Transvaginal bowel evisceration following robot-assisted radical cystectomy.

Transvaginal evisceration of the bowel has been found to most commonly occur following hysterectomy. To date, the reports of this complication following radical cystectomy are minimal. Herein, we report a case of transvaginal bowel evisceration 45 days following robotic-assisted radical cystectomy (RARC) in a postmenopausal woman.

INTRODUCTION

Transvaginal bowel evisceration is a complication that has been found to occur in postmenopausal women in such pelvic surgeries as hysterectomy, uterine prolapse, and proctectomy.[1] There are some risk factors for this complication such as vaginal vault infection, hematoma, early sexual intercourse, steroid use, or increased intra-abdominal pressure. There have been minimal reports of this complication following radical cystectomy.[2] Herein, we present a postmenopausal female who was found to have transvaginal bowel evisceration following robotic-assisted radical cystectomy (RARC). We attribute this complication to a thinned out vaginal wall from previous childbirth, and deviations from normal intrapelvic pressures postoperative.

CASE REPORT

A 75-year-old female underwent successful RARC, pelvic lymph node dissection, radical hysterectomy, bilateral salpingo-oophorectomy, resection of anterior vagina en bloc, and intracorporeal ileal conduit urinary diversion for a large, high-grade transitional cell carcinoma invading the left lateral/anterior wall of the bladder. The specimen was retrieved through the vagina. After retrieval, the anterior vaginal wall was closed using several V-Loc™ sutures. The integrity of the reconstruction was tested and found to be watertight. Of note, the suture line was closely examined during insertion of vaginal packing, and no significant findings were found. Surgical pathology found high-grade urothelial carcinoma involving the right, lateral, and dome of the bladder with pathologic stage T3bN1Mx. Patient's hospital stay was uneventful and she was discharged on postoperative day (POD) 6.

On POD 34, the patient reported passing a significant amount of watery vaginal discharge. She reported to be using 3–4 pads per day but denied vaginal bleeding, fever, and/or nausea. Laboratory tests were ordered and found to be not significant. At this time, the patient was referred to a female pelvic reconstruction and voiding dysfunction specialist regarding the vaginal discharge.

On POD 45, before meeting with the female reconstruction specialist, the patient presented to her local hospital with reports of developing a large bulge in her vagina and complained of abdominal pain, nausea, and nonbilious vomit. Her last bowel movement was over 24 h ago and was unable to recall flatulence. Imaging was obtained and found prolapse of small bowel into the perineum and small bowel obstruction (SBO) [Figure 1a and b]. Laboratory values also demonstrated an elevated white blood cell count. The patient was transferred to our facility where physical examination was positive for a mass covered in a blood clot bulging from the vagina [Figure 2]. The patient underwent immediate exploratory laparotomy. Initial findings reported multiple adhesions, which were released until the component of the small intestine that protruded through the vaginal cuff was found. Bowel was protruding through a 1.5 cm size hole near the apex of the vagina. A small portion of the vaginal cuff was released to locate the afferent and efferent loops of bowel through the exposed hernia. The herniated bowel segment was approximately 15 cm and was resected. This was followed by an anatomic side-to-side and functional end-to-end stapled anastomosis.

Figure 1

Preoperative computed tomography images demonstrating small bowel herniation through the vagina. (a) Transverse slice. (b) Coronal slide

Figure 2

Protrusion of small bowel through vagina on physical examination

On POD 4, the patient began passing loose stools, and on POD 5, bowel movements were more solid. Her hospital stay was uneventful, and she was discharged on POD 6. The patient had a series of uneventful follow-up visits without complaints of clinical bowel obstruction or vaginal discharge. On 2-year follow-up of RARC, the patient reports to be doing well with no complaints.

DISCUSSION

A rare postoperative complication of hysterectomy is vaginal evisceration. Risk factors for this complication include elderly, postmenopausal women, vaginal surgery cases, and multiparity.[3] Other factors may include trauma due to coitus, obstetric procedures, and a history of irradiation.[2] Hysterectomy is the most common surgical procedure that may lead to vaginal evisceration. Out of 85 reported cases of vaginal evisceration, 50–70% of patients had undergone at least one vaginal operation with approximately 25% of the eviscerations occurring postabdominal hysterectomy.[3] Transvaginal evisceration may occur spontaneously in postmenopausal women of older age with increased abdominal pressure[3] or a past surgical history of vaginal, abdominal, or laparoscopic hysterectomy with a mean onset of 36.8 months after surgery.[3] This is believed to be attributed to the postmenopausal tissue of the vulva and vagina becoming thinner, drier, and less elastic[4] with diminished vascularity making it more prone to rupture.[3]

Bowel evisceration is a surgical emergency and requires immediate treatment. The mortality rate from this condition is 6–10% due primarily to septicemia and thromboembolism. Emergent surgical intervention is necessary to reduce morbidity and mortality.

Thirty and 90-day complications after RARC are significant at approximately 41% and 48%, respectively.[5] Reoperation within 90 days is mainly related to fascial dehiscence, SBO or partial SBO, urine leak, and bleeding.[5] Vaginal complications following radical cystectomy include fistulization between bowel and vagina, vaginal prolapse, and sexual dysfunction. Chhabra and Hegde first reported on transvaginal bowel evisceration 3 months following open radical cystectomy.[2] In our experience, this complication occurred following RARC, which to our knowledge has not been previously reported. We believe this complication may have began around POD 34, and got worse due to deviations from normal pelvic pressure by POD 45, requiring visitation to a local hospital.

CONCLUSION

We report a case of transvaginal small bowel evisceration following RARC. This complication may have occurred to the patient's thinned out vaginal wall due from previous childbirth, as well as deviations from normal intrapelvic pressures postoperative.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.