Expanding the limits of vaginal surgery: Transvaginal vesicolithotomy for an incarcerated procidentia: A case report and literature review.

Bladder stones are rare in women. This report presents the case of a woman with a massive bladder stone and incarcerated procidentia. The 75-year-old woman presented to the outpatient clinic with procidentia and recurrent urinary tract infections. Preoperative imaging led to the diagnosis of cystolithiasis. After multidisciplinary counseling the patient underwent a vaginal hysterectomy with bilateral oophorectomy and transvaginal vesicolithotomy. A bladder biopsy was performed to rule out any malignancy. After three days, the patient was discharged with a Foley catheter; 15 days later, the bladder catheter was removed. She had an uncomplicated postoperative course. The presence of cystolithiasis and pelvic organ prolapse remains a challenge both in diagnosis and in treatment. The literature lacks solid evidence on the optimal management of these cases. Although there are no recommendations or consensus for their treatment, it seems that the one-step vaginal approach is preferable to the abdominal route.

Two Rings, Two Recoveries: Exploring the Thiersch Method in Complicated Cases.

Rectal prolapse, characterized by the protrusion of rectal mucosa or full-thickness tissue through the anal canal, significantly impacts quality of life, necessitating prompt intervention upon diagnosis. This case report presents the management of rectal prolapse in two cases admitted to our institution presenting with complaints of a prolapsing anal mass and many associated comorbidities and their subsequent surgical management using the Thiersch procedure. Following the procedure, both patients were monitored postoperatively, discharged once vitally stable, and kept on regular follow-up. Surgery is the primary therapy for rectal prolapse, and while various surgical techniques address rectal prolapse, anal encirclement procedures like the Thiersch procedure have been largely replaced by newer abdominal or perineal approaches. However, it is a valuable option for select patient populations. The Thiersch procedure is an ideal modality for treating high-risk patients with rectal prolapse or those patients with poor compliance for more extensive procedures. It can also be used temporarily until a further definitive treatment is planned later in the future.

HPV-independent cervical cancer associated with non-reducible pelvic organ prolapse: A case report.

•The presence of concomitant non-reducible prolapse and cervical cancer is rare.•Treatment of cervical cancer complicated by non-reducible prolapse must be individualized.•The role prolapse may play in the development of HPV-negative cervical cancer is unclear.

An innovative surgical treatment method in persistent rectal prolapse: Ventral abdomino-rectosigmoidopexy through tube sigmoidostomy combined with Ekehorn's rectopexy.

OBJECTIVE: Herein, the results of the cases, who underwent surgical repair with or without ventral abdomino-rectosigmoidopexy through tube sigmoidostomy combined with Ekehorn's rectopexy due to recurrent rectal prolapse, were discussed. METHODS: The demographic characteristics, surgical technique, and results of children who were operated in the department of Pediatric Surgery for rectal prolapse between 2004 and 2022 were retrospectively analyzed. RESULTS: In 18 years, six pediatric cases (2 females [33%] and 4 males [67%]) were operated for persistent rectal prolapse. The mean operative age of the patients was 7.5 years (2.1-17), and all had severe rectal prolapse. Some of these patients were followed up in other centers and their rectal prolapse continued despite diet changes, toilet behavior training, and the treatment of sclerosing agents. Rectal trimming was applied to one of the first two patients who were operated for anal atresia and recurrence did not occur. In the second case who underwent laparoscopic colon pull-through, Ekehorn rectopexy was performed alone and no recurrence was observed also in this case. Considering that rectosigmoid colon adhesions formed on the anterior abdominal wall due to colostomy opening-closing may provide ventral sigmoidopexy, it was decided to offer the option of applying both methods together. Three of the next four cases were diagnosed with cystic fibrosis. All four underwent ventral abdomino-rectosigmoidopexy through tube sigmoidostomy combined with Ekehorn's rectopexy. Ekehorn's butterfly sutures were removed on 15th day and Foley catheters on 21st day. Three cases with cystic fibrosis were uneventful. However, a 14-year-old girl with a history of sexual abuse relapsed 6 months later. CONCLUSION: Ventral abdomino-rectosigmoidopexy through tube sigmoidostomy combined with Ekehorn's rectopexy is a successful and unique method in terms of providing intestinal fixation. It may be the primary option for definitive surgical treatment of persistent rectal prolapse.

Gangrenous Small Bowel Due to Reposition of Procidentia in an Elderly Woman.

Gynecologists are familiar with procidentia, a severe form of pelvic organ prolapse (POP) that includes herniation of the anterior, posterior, and apical compartments of the vagina, through the introitus. Usually, women with POP present with concerns of something coming out of the vagina, heaviness, discharge through the vagina, urinary complaints, and, rarely bowel, complaints. Intestinal obstruction secondary to procidentia is a rare complication and is seldom reported in the literature. We report one such case where an elderly woman presented with the primary concerns of constipation, retention of urine, and multiple episodes of vomiting. Clinical history revealed that herniated tissue protruding outside the vaginal introitus was reposited inside the vagina two days ago. Clinical examination and investigations were suggestive of intestinal obstruction, secondary to the reposition of procidentia. Exploratory laparotomy revealed gangrene of the terminal ileum. Right hemicolectomy with ileo-colic anastomosis was done, which saved the woman's life. Reposition of the prolapsed uterus was thought to be the probable reason, leading to obstructed and gangrenous small bowel. As this case illustrates, the chronology of symptoms and signs and progression of disease should be appropriately interpreted to diagnose and manage such potentially life-threatening conditions.

When prolapse cannot be reduced: incarcerated procidentia due to pelvic mass.

INTRODUCTION AND HYPOTHESIS: Our objective is to demonstrate a surgical approach to the treatment of incarcerated procidentia with obstructed ureters due to a pelvic mass. METHODS: A 61-year-old woman presented with constipation, vaginal swelling, and difficulty voiding. On examination she had complete procidentia, which could not be reduced with gentle pressure. On imaging the prolapse appeared to contain a large pelvic mass measuring 11.5 cm in its greatest diameter, with features consistent with a mature teratoma. She was also noted to have bilateral ureteral obstruction and prominent hydronephrosis. After unsuccessful prolapse reduction under anesthesia, Bovie electrocautery was used to perform a posterior colpotomy. The obstructing mass was dissected away from the uterus and its connecting pedicle transected. The prolapse could then be reduced and a robotic hysterectomy performed. RESULTS: Pathology showed multiple pelvic masses including an 8-cm necrotic cystic nodule most consistent with uterine fibroids and a 4.5-cm mature cystic teratoma with associated seromucinous cystadenoma of the left ovary. Bilateral nephrostomy tubes were placed postoperatively. CONCLUSION: Incarcerated procidentia is an uncommon occurrence, which in rare cases may be due to a pelvic mass. Surgical management may be required with colpotomy for removal of the pelvic mass in order to reduce the prolapse and resolve the case.

Pelvic Organ Prolapse.

Pelvic organ prolapse (POP) is defined as the descent of one or more of the anterior and posterior vaginal walls, uterus (cervix), or apex of the vagina (vaginal vault or cuff scar after hysterectomy). Although POP can be asymptomatic, if the bulge extends beyond the opening of the vagina, it can have a significant impact on a woman's quality of life. Findings include vaginal bulging toward or through the vaginal introitus that the patient may feel, palpate, or see with a mirror. If a woman is bothered by her prolapse, she should be offered both nonsurgical and surgical treatments.

The utility of the Altemeier procedure in strangulated rectal procidentia secondary to rectal cancer. A case report.

INTRODUCTION AND IMPORTANCE: Altemeier rectosigmoidectomy has been cited in the literature as a suitable approach for incarcerated rectal prolapse when a large segment of bowel is involved. However, the literature is devoid of cases that employed the technique as an oncological procedure for rectal carcinoma. For this reason, this case report heralds a new perspective on an old technique. CASE PRESENTATION: We describe the case of a male in his 6th decade who presented with stage four rectal cancer. Computed tomography imaging showed a rectal mass at the rectosigmoid junction with pelvic lymphadenopathy and a solitary hepatic lesion in segment two of the liver. While admitted to the hospital a 16 cm segment of bowel containing the mass prolapsed and became incarcerated, eventually becoming necrotic. A modification of the Altemeier procedure was performed along with a diverting ileostomy and hepatic wedge resection of the solitary metastases. Histological assessment of the surgical specimens confirmed that adequate resection margins were obtained with one of twenty-one lymph nodes positive for malignancy. He is currently being followed up in the outpatient oncology clinic and has commenced adjuvant chemotherapy. CLINICAL DISCUSSION: Synchronous excision of rectal carcinoma with hepatic metastasectomy is a feasible surgery even in the emergency setting and can offer improved patient survival. CONCLUSION: The combination of both an abdominal and perineal approach was suitable for this patient given his improved quality of life and negative pathological margins.

Incarcerated Rectal Procidentia: A Case Report and Review.

Rectal procidentia is an uncommon perineal disease that is rare in males. There is no specific medical role in treatment of rectal procidentia and surgical intervention is the treatment of choice. Various surgical approaches have been performed, but there is no consensus on which procedure is most effective in terms of patient condition, recurrence rate, bowel function, and risk. This case presentation of a healthy male patient with experience of uncomplicated reducible rectal prolapse and a history of chronic constipation. Presented with complicated rectal prolapse in the presence of incarcerated rectal prolapse after a failed trial with conservative maneuvers, he ended up with abdominal approach sigmoidectomy and posterior mesh rectopexy.

Teaching the art of LeFort colpocleisis: a moderate-fidelity, low-cost simulation model.

The objective was to demonstrate the build and use of a low-cost, moderate-fidelity simulation model for LeFort colpocleisis. We a present a video demonstrating the creation of a LeFort colpocleisis model, the mounting of this model to a pre-existing vaginal hysterectomy simulator (SimVaHT), and the use of the model to teach the steps of the LeFort colpocleisis procedure. This LeFort colpocleisis model is easy to make, from readily available materials, and is inexpensive. It can help trainees to enhance their intraoperative learning.

Histology-specific FGFR2 alterations and FGFR2-TACC2 fusion in mixed adenoid cystic and neuroendocrine small cell carcinoma of the uterine cervix.

Neuroendocrine small cell carcinoma of the uterine cervix portends a dismal prognosis with limited treatment options. Rarely, tumors of mixed-lineage appear in gynecologic malignancies. Here, we report a 77-year-old woman who presented with complete uterine prolapse and 4-month history of vaginal bleeding. Histopathologic evaluation revealed a mixed adenoid cystic carcinoma and neuroendocrine small cell carcinoma of the uterine cervix. The tumor was PD-L1 and HPV 35 positive. The patient was treated with up-front surgery and adjuvant radiation. Independent, histology-specific alterations in FGFR2 and a FGFR2-TACC2 fusion were identified. Progression of disease occurred within 6 months for which she received chemotherapy and immunotherapy. However, the patient expired within a year. We comprehensively review how screening for and targeting of FGFR alterations in recurrent and metastatic cervical cancer might serve as a touchstone for future treatment regimens.

Cervical carcinoma in the setting of uterovaginal prolapse: comparing standard versus tailored management.

OBJECTIVES: Cervical cancer in the setting of uterovaginal prolapse is exceedingly rare. Altered anatomy can complicate treatment of underlying cancer. We first present a rare case of cervical cancer with invasion of uterovaginal prolapse as well as a systematic review of similar reported cases in the literature. The objective of this study was to compare the practice patterns and outcomes regarding cervical cancer with invasion of procidentia. METHODS: We conducted a systematic search of online databases (PubMed, Embase, Medline and the Cochrane Library) from 1990 to 2018 of all the cases of cervical cancer associated with stage III-IV uterovaginal prolapse. Patient demographics, pathology, surgical management, chemotherapy, radiation and disease-free survival were compared. RESULTS: Fifteen reported cases of cervical cancer in the setting of procidentia were identified (squamous cell carcinoma-14, clear cell carcinoma-1). The mean age at diagnosis was 74 years (range 54-89). Thirteen percent (n = 2) of cases presented with FIGO stage I disease, 67% (n = 10) with stage II, and 20% (n = 3) with stage III. All cases had stage III-IV uterovaginal prolapse. 73% (11) were treated surgically including nine patients who underwent vaginal hysterectomy. Among patients who underwent primary surgery, 7% (1) received adjuvant chemotherapy, 33% (5) adjuvant radiotherapy and 21% (3) both adjuvant chemotherapy and radiation. 33% (5) of surgical cases included procedures to address the pelvic organ prolapse (colpoclesis (n = 3), uterosacral suspension (n = 1) and anterior posterior repair (n = 1)). Two patients died from the disease within 12 months, one patient died from other causes within 1 month, and the remainder of patients were free of disease at last reported follow-up (Table 1). CONCLUSIONS: Cervical cancer in the setting of stage III-IV uterovaginal prolapse can be managed successfully with standard treatment strategies (primary surgery with adjuvant therapy as necessary versus chemoradiation). When patients are surgical candidates, techniques to address the underlying prolapse can be used for symptomatic improvement.

Video of uterovaginal procidentia repair incorporating a high extraperitoneal uterosacral vault suspension.

INTRODUCTION AND HYPOTHESIS: Women with high-grade uterovaginal prolapse have a higher incidence of levator injury, larger levator hiatal defects, and are at a greater risk of recurrent prolapse after pelvic organ prolapse (POP) surgery. RCOG guidelines have recommended prophylactic sacrospinous suspension at the time of vaginal hysterectomy, whenever there is a marked uterovaginal prolapse. The aim of the video is to describe our surgical approach at the time of surgery for advanced POP, and describe the technique for modified McCall high extraperitoneal vault suspension. METHODS: We have modified the McCall culdoplasty by extending the dissection of the middle portion of the uterosacral/cardinal ligaments so that the sutures can be placed higher and more laterally extraperitoneally to re-support the vaginal cuff at the time of a vaginal hysterectomy. RESULTS: The video highlights the surgical technique used for apical support at the time of surgery for advanced POP. CONCLUSIONS: This video demonstrates our modified McCall technique for vault suspension at the time of vaginal surgery for advanced POP. This technique could be considered an alternative technique to other modes of apical support.

Surgical Treatment of Rectal Prolapse: A 10-Year Experience at a Single Institution.

Purpose: Despite the plethora of surgical options, there is no consensus regarding the best treatment for rectal prolapse. This study is aimed at evaluating our experience with its treatment and outcomes. Methods: We retrospectively reviewed rectal prolapse patients' characteristics, clinical presentation, surgical procedure, average length of hospital stay, morbidity, mortality, and recurrence over a 10 year period at our institution. Results: A total of 46 patients underwent rectal prolapse repair at our institution over a 10 year period. Of the 39 patients with primary rectal prolapse, 18 patients had an abdominal procedure, while 21 patients underwent a perineal approach. Operative duration was significantly longer in abdominal procedures, of which 16 cases were performed laparoscopically. Length of hospital stay and recurrence were not statistically significant between the 2 groups. In patients with recurrent rectal prolapse, more than 80% of the initial surgeries were done using the perineal approach. An abdominal approach was utilized in the management of 75% of recurrences. Conclusion: An abdominal repair may be preferable in the treatment of recurrent rectal prolapse. Minimally invasive techniques may be feasible and can provide a safe alternative to perineal procedures in elderly patients.

Surgical Treatment of Rectal Prolapse: A 10-Year Experience at a Single Institution

PURPOSE: Despite the plethora of surgical options, there is no consensus regarding the best treatment for rectal prolapse. This study is aimed at evaluating our experience with its treatment and outcomes.METHODS: We retrospectively reviewed rectal prolapse patients' characteristics, clinical presentation, surgical procedure, average length of hospital stay, morbidity, mortality, and recurrence over a 10 year period at our institution.RESULTS: A total of 46 patients underwent rectal prolapse repair at our institution over a 10 year period. Of the 39 patients with primary rectal prolapse, 18 patients had an abdominal procedure, while 21 patients underwent a perineal approach. Operative duration was significantly longer in abdominal procedures, of which 16 cases were performed laparoscopically. Length of hospital stay and recurrence were not statistically significant between the 2 groups. In patients with recurrent rectal prolapse, more than 80% of the initial surgeries were done using the perineal approach. An abdominal approach was utilized in the management of 75% of recurrences.CONCLUSION: An abdominal repair may be preferable in the treatment of recurrent rectal prolapse. Minimally invasive techniques may be feasible and can provide a safe alternative to perineal procedures in elderly patients.