Post-Cystectomy Enterocele: A Case Series and Review of the Literature

Women with muscle-invasive bladder cancer undergo radical cystectomy often with anterior exenteration, significantly disrupting the pelvic floor. These women are at risk for pelvic organ prolapse. Our objective was to present a case series and literature review on post-radical cystectomy pelvic organ prolapse to heighten awareness of the symptoms, imaging findings, and risk factors associated with this complication while discussing methods of prevention. The genesis of this project was Dr. Smith being referred, in a short time frame, a few women with this complication and our subsequent discovery of the paucity of literature on this subject. We hoped to shed light on this in a multi-disciplinary fashion; i.e. make this relevant for Urologic Oncologists and Female Reconstructive Surgeons and spurn debate on how to prevent this issue. Additionally, we hoped to identify a simple means to screen for this condition post-radical cystectomy.

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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