Laparoscopic pelvic organ prolapse repair by mesh interposition following radical cystectomy.

INTRODUCTION: The present study aims to introduce laparoscopic treatment by the interposition of polypropylene mesh for a pelvic organ prolapse in females following radical cystectomy for treating muscle-invasive bladder carcinoma. CASE
PRESENTATION: The patients included two women aged 77 and 79 years with symptomatic enterocele following radical cystectomy and ileal conduit urinary diversion. We performed laparoscopic sacrospinous colpopexy using polypropylene and polypropylene/ePTFE composite meshes.
CONCLUSION: No recurrent prolapse occurred during 26 and 14 months of follow-up after the operation. No severe perioperative complications were noted. This is a first report on cases of laparoscopic sacrospinous colpopexy for post-cystectomy pelvic organ prolapse. Our procedure could be safely performed in two patients with post-cystectomy pelvic organ prolapse.

body mass index

ileal conduit

laparoscopic sacrospinous colpopexy

muscle‐invasive bladder cancer

pelvic organ prolapse

POP quantification

radical cystectomy

Keynote message

Laparoscopic treatment by the interposition of polypropylene mesh for a POP in two females following RC was performed. No recurrent prolapse occurred during 26 and 14 months of follow‐up after the operation, and no severe perioperative complications were noted. LSSC is thought to be safely performed in the patients with post‐cystectomy POP.

Case presentation

We present two cases of women with POP following RC for treating MIBC. Both patients were removed bladder with urethra, anterior vaginal wall, bilateral ovary, and uterine by a traditional manner of cystectomy. For both patients, POP treatment involved a polypropylene mesh and a polypropylene/ePTFE composite mesh, and both patients exhibited good clinical courses.

Case 1

A 79‐year‐old woman who had previously undergone RC and IC urinary diversion for MIBC (pT3cN0M0) at the age of 78 presented with a stage IV enterocele (POP‐Q) and superficial vaginal ulceration. Her BMI was 18. LSSC was performed according to the following protocol:

The patient was placed in the 15° Trendelenburg position under general anesthesia. The Trendelenburg position maintains the intestinal loops outside the pelvic cavity. We used four trocars on the umblical top, halfway between the umblicus and the pubic symphysis, the left ileac fossa, and the right ileac fossa. The first step of the operation involved the dissection of the intestinal and colonic adhesions in the pelvic floor. The vaginal apex was especially strongly adhered to the colon in the pelvic floor and was safely dissected. The rectovaginal space was dissected to an anorectal angle in the middle and until the levator ani muscle (puborectalis muscle) fascia on each lateral side was reached. In this case, the left ureter was on the promontrium of the sacrum, and we performed LSSC, not laparoscopic sacrocolpopexy.

Two self‐cut sheets of polypropylene mesh (Gynemesh™; Gynecare, Ethicon Inc., Somerville, NJ, USA) were fixed from the tip end of each dissected postvesical and rectovaginal space to the vaginal vault or the cervical stump. Another tip end of the mesh was ligated to the sacrospinous ligament (Fig. 1). Polypropylene/ePTFE composite mesh (Composix™; Bard Inc., Murray Hill, NJ, USA), which has reasonable characteristics for promoting tissue growth and minimizing the risk of bowel adhesion, was used to cover the polypropylene mesh interposing on the pelvic floor (Fig. 2). This reconstructive structure did not interfere with IC in the pelvis (Fig. 3). The total operation time was 120 min, and blood loss was approximately 25 mL.

Figure 1

Two self‐cut sheets of polypropylene mesh (Gynemesh™) were interposed on the anterior and posterior vagina, and solidly attached to the sacrospinous ligament. The right side of the sacrospinous ligament is indicated by the white arrow. The check arrow indicates two self‐cut sheets of polypropylene mesh. P; pubic bone, V; vagina, R; rectum.

Figure 2

Polypropylene/ePTFE composite mesh (Composix™) covered the polypropylene mesh interposing on the pelvic floor (white arrow). P; pubic bone, V; vagina, R; rectum.

Figure 3

Overview of the post‐surgical pelvis. IC is indicated by the black arrow.

On Day 7 after the operation, the patient was discharged from our hospital. A small mesh erosion occurred 3 months after the operation. The eroded part of the mesh was cut during an outpatient clinic visit, and local estrogen therapy was administered. POP symptoms, a pelvic pain, and constipation did not occur during 18 months of follow‐up.

Case 2

A 77‐year‐old woman who had previously undergone RC and IC for MIBC (pT3cN0M0) at the age of 76 presented with POP‐Q stage IV enterocele and superficial vaginal ulceration. Her BMI was 27. LSSC was performed, as previously described. Total operation time was 153 min, and blood loss was 10 mL.

On Day 5 after the operation, the patient was discharged from our hospital. She experienced no post‐surgical complications. POP symptoms, a pelvic pain, and constipation were absent up to 4 months after the operation.

Discussion

RC has been a standard surgical approach for treating MIBC. In female patients, RC sometimes requires the removal of not only the bladder but also the uterus, ovaries, and a segment of the anterior vaginal wall. This surgical procedure may weaken pelvic floor muscle structures, and the small intestine or large bowels may herniate through the anterior or posterior vaginal wall forming an enterocele. Theoretically, POP occurs more commonly in female patients following RC; however, there are few reports regarding post‐cystectomy POP.1, 2, 3 In patients who undergo RC for MIBC, oncologic clinical outcomes are generally focused upon post‐operatively, and the quality of life affected by surgical complications, including POP, may escape attention.4 In this manuscript, we reported two successful cases of LSSC in patients with post‐cystectomy POP.

Transvaginal repair using native tissue in cases of anterior enterocele, although not attempted by us, would be technically difficult for several reasons. First, some anatomic mechanisms predispose post‐cystectomy women to POP. Specifically, the endopelvic fascia overlying the pelvic floor is usually partially excised during RC. Second, a uterosacral ligamentous injury may result in inadequate native tissue repair. In previous reports in which different cases of patients with POP following RC and IC were presented, one woman received fascial repair without mesh reinforcement, the other patients received transvaginal repair using biological meshes and colpocleisis.4, 5 There has been no consensus regarding surgical procedures for post‐cystectomy POP, and the usage of biological mesh for pelvic repair is controversial.6 Generally, abdominal approach to the sacrum may be more reasonable than transvaginal approaches. In the previous prospective randomized study, subjective and objective success rates were higher (although the difference did not rise to the level of statistical significance) in the group of patients with abdominal sacral colpopexy compared to a group of patients with vaginal sacrospinous colpopexy for vaginal vault prolapse.7 To our knowledge, there is no report of LSSC performed in patients with post‐cystectomy POP. We presented two cases of LSSC in patients with POP following RC and IC.

Mesh erosion is a late complication of abdominal sacral colpopexy with a reported incidence of 3–7.6%.7, 8, 9, 10 Lower rates of erosion have been identified with monofilament polypropylene mesh.11 Polypropylene/ePTFE composite mesh may be useful for treating peritoneal defects of the pelvic floor. The composite mesh merges ease of use with excellent tissue integration and minimization of visceral attachment risk.

Conclusions

Surgical repair of POP in women who have undergone RC and IC may be difficult and challenging. The present cases demonstrated the usefulness of a laparoscopic approach with fundamental advantages.

Conflict of interest

The authors declare no conflict of interest.