We presented four cases of high-grade pelvic organ prolapse in women who underwent radical cystectomy for bladder cancer, with relevant clinical, radiographic, and surgical data. All four women reported a bulge sensation in the vagina and a physical exam confirmed pelvic organ prolapse. Three had radiographic findings consistent with high-grade enterocele at rest, yet none of the radiology reports indicated this finding. Three experienced prolonged intra-abdominal pressure rise post-radical cystectomy that may have further weakened the pelvic floor, while the fourth had a history of pelvic floor weakness requiring prolapse surgery.
Screening for post cystectomy enterocele can be performed by asking the simple question, “Do you ever feel a bulge or that something is falling out of the vagina?” The administration of this single validated question would have identified all four cases of postoperative enterocele in our series and is sensitive to detect most women who are experiencing pelvic organ prolapse. Attention to the pelvic floor on cross-sectional imaging with identification of features that indicate weakness, such as herniation of intestinal contents below the pubococcygeal line, will identify and/or confirm high-grade enterocele. Familiarity with risk factors for POP and intraoperative identification of weakened vaginal wall support opens up the opportunity for prevention. Together, urologic oncologists and pelvic reconstructive surgeons can determine if and when modifications to the standard surgical technique for pelvic exenteration are needed to prevent post-operative enterocele and preserve pelvic floor integrity.
Written by: Alan P Cruz, Raju Chelluri, Parvati Ramchandani, Thomas J Guzzo, Ariana L Smith
University of Michigan Medical School, Ann Arbor, MI., Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA., Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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