Anterior enterocele after cystectomy: case report and review of the literature.

PURPOSE: Anterior enterocele is a rare but potentially serious complication after cystectomy with heterogeneous treatment options. METHODS: Here we report on the management of a 71-year-old patient with recurrence of anterior enterocele after cystectomy and provide a systematic review of the literature using the PubMed/MEDLINE database. RESULTS: The 71-year-old patient with recurrence of anterior enterocele after cystectomy was successfully treated with colpocleisis and anterior colporrhaphy at the Department of Gynecology and Gynecological Oncology, University Hospital Bonn. The use of a synthetic mesh was not needed. At 16-month follow-up postoperatively, the patient was asymptomatic and had no signs of recurrence. n = 14 publications including n = 39 patients were identified for the systematic review including case reports and reviews. The median duration of developing an anterior enterocele after cystectomy was 9 months (range 3 months to 8 years). Patients had a median age of 71 years (range 44-84). In all cases, a surgical approach was described using a wide variety of surgical procedures. In total, 36% of all patients developed a recurrence with an average time period of 7 months after primary surgery. A rare complication represents a vaginal evisceration with the need of urgent surgery. Furthermore, the occurrence of a fistula is a possible long-term complication. CONCLUSION: Anterior enterocele after cystectomy is a rare complication requiring an individual and interdisciplinary treatment.

Resolution of symptoms of rectal prolapse after repair of vaginal prolapse: A report of two cases.

Pelvic organ prolapse (POP) is a very common problem that can affect any aspect of the pelvic floor. Often, vaginal and rectal prolapse occur simultaneously. Prior case reports have suggested resolution of symptoms of rectal prolapse in those with concomitant rectal and vaginal prolapse; however, the overall body of evidence is limited. We present the cases of two patients who had complete resolution of their symptoms of rectal prolapse after repair of a concomitant vaginal prolapse. Both patients underwent a traditional rectocele repair and perineoplasty, and subsequently reported complete resolution of their symptoms of rectal prolapse, which persisted at their six-month post-operative visits. The second patient ultimately canceled a previously scheduled rectopexy with colorectal surgery. Perhaps a rectocele repair with perineoplasty is limiting rectal mobility, and therefore eliminating its ability to prolapse or intussuscept and cause bothersome symptoms. We suggest that those with concomitant vaginal and rectal prolapse desiring corrective surgery first undergo a less invasive vaginal repair. Post-operative re-evaluation of the symptoms rectal prolapse might then demonstrate that a more invasive rectal prolapse repair, which may involve a colon resection and prolonged hospital stay, was not in fact needed. Further prospective and randomized study is needed to determine the long-term outcomes of concomitant rectal and vaginal prolapse in those who first undergo a vaginal repair.

A case of laparoscopically assisted transperineal repair of anterior enterocele dehiscence with small bowel evisceration after robot-assisted radical cystectomy.

We herein report a case of successful laparoscopically assisted transperineal repair of anterior enterocele dehiscence with small bowel evisceration after robot-assisted radical cystectomy. A 75-year-old woman underwent robot-assisted radical cystectomy with anterior vaginectomy and urethrectomy for bladder cancer (pTisN0M0). Vaginal reconstruction was performed using the posterior vaginal wall. Four months after surgery, she presented with small bowel evisceration due to anterior enterocele dehiscence. She underwent laparoscopically assisted transperineal repair. The anterior enterocele dehiscence did not occur at the vaginal closure site but instead between the vaginal wall and posterior pubic bone. No recurrence had developed at 2 months postoperatively.

[Imaging of the pelvic floor (MR defecography) : The surgeon's perspective]. / Bildgebung des Beckenbodens (MR-Defäkographie) : Die Sicht der Chirurgie.

BACKGROUND: Magnetic resonance defecography (MRD) plays a central role in diagnosing pelvic floor functional disorders by visualizing the entire pelvic floor along with pelvic organs and providing functional assessment of the defecation process. A shared understanding between radiology and surgery regarding indications and interpretation of findings is crucial for optimal utilization of MRD. OBJECTIVES: This review aims to explain the indications for MRD from a surgical perspective and elucidate the significance of radiological findings for treatment. It intends to clarify for which symptoms MRD is appropriate and which criteria should be followed for standardized results. This is prerequisite to develop interdisciplinary therapeutic approaches. MATERIALS AND METHODS: A comprehensive literature search was conducted, including current consensus guidelines. RESULTS: MRD can provide relevant findings in the diagnosis of fecal incontinence and obstructed defecation syndrome, particularly in cases of pelvic floor descent, enterocele, intussusception, and pelvic floor dyssynergia. However, rectocele findings in MRD should be interpreted with caution in order to avoid overdiagnosis. CONCLUSION: MRD findings should never be considered in isolation but rather in conjunction with patient history, clinical examination, and symptomatology since morphology and functional complaints may not always correlate, and there is wide variance of normal values. Interdisciplinary interpretation of MRD results involving radiology, surgery, gynecology, and urology, preferably in the context of pelvic floor conferences, is recommended.

Complicated enterocele: timely resolution with bowel resection via a vaginal approach: case report.

Background: Enterocele is an uncommon, serious condition that requires accurate and early diagnosis to prevent complications such as intestinal obstruction, incarceration, and strangulation, with consequent intestinal ischemia, necrosis, and evisceration. We report a rare case of a patient with a voluminous enterocele and initial signs of intestinal ischemia who underwent urgent vaginal surgery. Case description: An 80-year-old woman presented with a voluminous mass protruding from the vagina, associated abdominopelvic pain, a 10-day history of bowel sub-occlusion, and numerous episodes of profuse vaginal bleeding. She was diagnosed with an enterocele with early signs of complications. Owing to her advanced clinical condition and comorbidities, we opted for an urgent vaginal procedure. Intestinal loops with initial signs of ischemia were resected via a transvaginal approach, leading to good clinical outcomes. She was discharged on postoperative day 5. Conclusions: This rare case highlights a surgical emergency that was managed with transvaginal resection of the intestine. Early identification of the initial signs of complications allowed for this less invasive approach, resulting in reduced morbidity and length of hospital stay.

Australian trends in the treatment of pelvic organ prolapse in the non-mesh era.

BACKGROUND: To assess the contemporary trends in the types and incidence of pelvic organ prolapse (POP) surgery in Australia after the removal of transvaginal mesh from the Australian market. METHODS: This was a retrospective Australian cohort study utilizing three large Governmental databases covering all private and public POP procedures in Australia. All females ≥25 years old undergoing POP procedures between 2005 and 2021 were included. RESULTS: From 2005-2006 to 2020-2021 there have been a total of 408 881 POP procedures in Australia. The total number of procedures peaked in 2005-2006 at 537.8 procedures per 100 000 age-standardized female population, decreasing by an average of 3.5% per year to 329.0 procedures per 100 000 in 2018-2019, an overall 38.8% decrease (P < 0.001). A sudden growth in private operative procedures was noted between 2019-2020 and 2020-2021, from 218.2 to 268.6 procedures per 100 000 population, a 23.1% increase (P < 0.001). Laparoscopic and abdominal POP repair has seen a 115.8% increase from 13.7 procedures to 29.6 per 100 000 between 2005-2006 and 2020-2021. Over the last 15 years, the most common age group to undergo a procedure has changed from the 55 to 64 years demographic to a later decade of 65 to 74 years. CONCLUSION: Over the last 15 years, the total number of POP procedures performed has significantly decreased. There has however been a recent rise in interventions seen in the private sector and the utilization of laparoscopic or abdominal POP repair has increased, which has implications for procedural credentialing to ensure patient safety.

Translabial ultrasound for pelvic organ prolapse.

Pelvic organ prolapse (POP) is a significant public health concern in women and a common cause of gynecological surgery in elderly women. The prevalence of POP has increased with an increase in the aging population. POP is usually diagnosed based on pelvic examination. However, an imaging study may be necessary for more accurate diagnosis. Translabial ultrasound (TLUS) was used to assess diverse types of POP, particularly posterior-compartment POP. It is beneficial to distinguish between true and false rectocele, and detect the rectocele as clinically apparent. TLUS can also establish whether the underlying cause is a problem of the rectovaginal septum, perineal hypermobility, or isolated enterocele. TLUS also plays a role in differentiating POP from conditions that mimic POP. It is a simple, inexpensive, and non-harmful diagnostic modality that is appropriate for most gynecologic clinics.

Is posterior compartment prolapse associated with anal incontinence?

OBJECTIVE: It has been claimed that manifestations of posterior compartment prolapse, such as rectocele, enterocele and intussusception, are associated with anal incontinence (AI), but this has not been studied while controlling for anal sphincter trauma. We aimed to investigate this association in women with intact anal sphincter presenting with pelvic floor dysfunction. METHODS: This retrospective study analyzed 1133 women with intact anal sphincter presenting to a tertiary urogynecological center for pelvic floor dysfunction between 2014 and 2016. All women underwent a standardized interview, including assessment of symptoms of AI, clinical examination and three-/four-dimensional transperineal ultrasound. Descent of the rectal ampulla, true rectocele, enterocele, intussusception and anal sphincter trauma were diagnosed offline. RESULTS: Mean age was 54.1 (range, 17.6-89.7) years and mean body mass index was 29.4 (range, 14.7-67.8) kg/m2 . AI was reported by 149 (13%) patients, with a median St Mark's anal incontinence score of 12 (interquartile range, 1-23). Significant posterior compartment prolapse was seen in 693 (61%) women on clinical examination. Overall, 638 (56%) women had posterior compartment prolapse on imaging: 527 (47%) had a true rectocele, 89 (7.9%) had an enterocele and 26 (2.3%) had an intussusception. Women with ultrasound-diagnosed enterocele had a significantly higher rate of AI (23.6% vs 12.3%; odds ratio (OR), 2.21 (95% CI, 1.31-3.72); P = 0.002), but when adjusted for potential confounders, this association was no longer significant (OR, 1.56 (95% CI, 0.82-2.77); P = 0.134). CONCLUSION: In women without anal sphincter trauma, posterior compartment prolapse, whether diagnosed clinically or by imaging, was not shown to be associated with AI. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Rectocele: Incidental or important? Observe or operate? Contemporary diagnosis and management in the multidisciplinary era.

BACKGROUND: More common in older women than younger women, rectoceles may be secondary to pelvic floor weakness and/or pelvic floor dysfunction with impaired rectal evacuation. Rectoceles may be small (<2 cm), medium (2-4 cm), or large (>4 cm). Arguably, large rectoceles are more likely to be associated with symptoms (e.g., difficult defecation). It can be challenging to ascertain the extent to which a rectocele is secondary to pelvic floor dysfunction and/or whether a rectocele, rather than associated pelvic floor dysfunction, is responsible for symptoms. Surgical repair should be considered when initial treatment measures (e.g., bowel modifying agents and pelvic floor biofeedback therapy) are unsuccessful. PURPOSE: We summarize the clinical features, diagnosis, and management of rectoceles, with an emphasis on outcomes after surgical repair. This review accompanies a retrospective analysis of outcomes after multidisciplinary, transvaginal rectocele repair procedures undertaken by three colorectal surgeons in 215 patients at a large teaching hospital in the UK. A majority of patients had a large rectocele. Some patients also underwent an anterior levatorplasty and/or an enterocele repair. All patients were jointly assessed, and some patients underwent surgery by colorectal and urogynecologic surgeons. In this cohort, the perioperative data, efficacy, and harms outcomes are comparable with historical data predominantly derived from retrospective series in which patients had a good outcome (67%-78%), symptoms of difficult defecation improved (30%-50%), and patients had a recurrent rectocele 2 years after surgery (17%). Building on these data, prospective studies that rigorously evaluate outcomes after surgical repair are necessary.

Surgical anatomy of the vaginal vault.

AIM: Vaginal vault (VV) surgery should be a key part of surgery for a majority of pelvic organ prolapse (POP). The surgical anatomy of the VV, the upper most part of the vagina, has not been recently subject to a dedicated examination and description. METHODS: Cadaver studies were performed in (i) 10 unembalmed cadaveric pelves (observation); (ii) 2 unembalmed cadaveric pelves (dissection); (iii) 5 formalinized hemipelves (dissection). The structural outline and ligamentous supports of the VV were determined. Further confirmation of observations in post-hysterectomy patients were from a separate study on 300 consecutive POP repairs, 46% of whom had undergone prior hysterectomy. RESULTS: The VV is equivalent to the Level I section of the vagina, measured posteriorly from the top of the posterior vaginal wall (apex or highest part of the vagina) to 2.5 cm below this point. It comprises the anterior fornix (through which cervix protrudes or is removed at hysterectomy), posterior fornix and two lateral fornices. Before hysterectomy, the posterior aspects of the cervix and upper vagina are supported by the uterosacral (USL) and cardinal ligaments (CL), the distal segments of which fuse together to form a cardinal-uterosacral ligament complex (cardinal utero-sacral complex), around 2-3 cm long. Post---hysterectomy, there is some residual USL support to the anterior fornix but the posterior fornix has no ligamentous support and is thus more vulnerable to prolapse. CONCLUSION: Effective management of VV prolapse will need to be part of most POP repairs. Enhanced understanding of the surgical anatomy of the vaginal vault allows more effective planning of those POP surgeries.

Reappraising the Role of Enterocele in the Obstructed Defecation Syndrome: Is Radiological Impaired Rectal Emptying Significant in Enterocele?

Objectives: The role of enterocele in the obstructed defecation syndrome (ODS) has remained to be controversial, as patients with enterocele frequently exhibit multiple risk factors, including aging, parity, concomitant different abnormalities, previous histories of pelvic surgery, and incomplete emptying of the rectum. Thus, in this study, we aimed to investigate the association between enterocele and ODS using multivariate analysis. Methods: Between June 2013 and June 2021, 336 women underwent defecography as they had symptoms of ODS. Of those, 293 women (87%) who had anatomical abnormalities were included in this study. Results: Enterocele was detected in 104 (36%) patients. More women with enterocele had histories of hysterectomy compared to those without enterocele (29% vs. 10%, P < 0.0001). The frequency of radiological incomplete emptying was found to be significantly lower in women with enterocele (36%) than in those without enterocele (50%), whereas the mean (95% confidence interval) ODS scores in women with enterocele were significantly higher than those without enterocele [12.1 (11.0-13.3) versus 10.8 (10.5-11.5), P = 0.023]. As per the results of our multivariate analysis, it was determined that the presence of enterocele was associated with higher ODS scores (P = 0.028). However, the small differences in the mean score (1.3) would be clinically negligible. The specific radiological type of enterocele which compressed the rectal ampulla at the beginning of defecation was not associated with the increased ODS scores. Conclusions: The presence of enterocele may not be a primary cause of ODS. Other anatomical abnormalities combined with enterocele, or the hernia itself, may have a role in causing ODS.

Vaginal enterocele after cystectomy: A case report.

BACKGROUND: After undergoing radical cystectomy combined with hysterectomy, female patients may suffer from pelvic organ prolapse due to the destruction of pelvic structures, which mainly manifests as the prolapse of tissues of the vulva to varying degrees and can be accompanied by symptoms, such as bleeding and inflammation. Once this complication is present, surgical intervention is needed to resolve it. Therefore, preventing and managing this complication is especially important. CASE SUMMARY: The postoperative occurrence of acute enterocele is rare, and a case of acute small bowel vaginosis 2 mo after radical cystectomy with hysterectomy is reported. When the patient was admitted, physical examination revealed that the small bowel was displaced approximately 20 cm because of vaginocele. A team of gynecological, general surgery, and urological surgeons was employed to return the small bowel and repair the lacerated vaginal wall during the emergency operation. Eventually, the patient recovered, and no recurrence was seen in the half year of follow-up. CONCLUSION: We review the surgical approach for such patients, analyze high-risk factors for the disease and suggest corresponding preventive measures.

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.

Rare Presentation of Incarcerated Incisional Richter's Hernia of the Cecum.

Richter's hernia, also called a partial enterocele, involves a protrusion of peritoneum with subsequent strangulation or incarceration of only part of the lumen of the anti-mesenteric portion of the small bowel through a fascial defect. We report a rare presentation of incarcerated incisional Richter's hernia of the cecum in a 39-year-old female. The patient presented with acute abdominal pain that gradually improved. Physical examination revealed right lower quadrant tenderness and nodularity just above an abdominoplasty scar. Subsequent computed tomography scan demonstrated a 1 cm by 1 cm hypovascular pocket arising from the cecum with protrusion into the anterior abdominal wall. The hernia was successfully repaired surgically with resolution of symptoms. It is essential for clinicians to be mindful of the diagnosis of Richter's hernia on the differential for abdominal pain as the risk of detrimental outcomes increases with delayed surgical intervention.

Importance of Translabial Ultrasound for the Diagnosis of Pelvic Organ Prolapse and Its Correlation with the POP-Q Examination: Analysis of 363 Cases.

The incidence of pelvic organ prolapse (POP) is increasing in our aging society. We aimed to evaluate the clinical usefulness of translabial ultrasound (TLUS) by comparing the findings of POP-Q examination and TLUS in advanced POP patients and we also aimed to evaluate the prevalence of rectocele and enterocele on the TLUS. We analyzed the TLUS and POP-Q exam findings of 363 symptomatic POP patients who visited our clinic from March 2019 to April 2021. We excluded three patients who had conditions mimicking POP, as revealed by the TLUS. The most common POP type was anterior compartment POP (68.61%), followed by apical compartment (38.61%) and posterior compartment (16.11%) POP. Agreement between the POP-Q exam and TLUS was tested using Cohen's kappa (κ). p values < 0.05 were considered statistically significant. The incidence of rectocele or enterocele was only 1.67% (6/360) and there was no rectocele or enterocele in most patients (246/252, 96.63%) when the POP-Q exam revealed posterior compartment POP, suggesting that they only had posterior vaginal wall relaxation. The positive predictive value of the POP-Q exam for detecting rectocele or enterocele (as revealed by TLUS) was only 2.38%, whereas the negative predictive value was 100%. In conclusion, the application of TLUS is useful in the diagnosis of POP, especially for differentiation of true POP from conditions mimicking POP. The correlation between the POP-Q exam and TLUS is low, especially in posterior compartment POP, and therefore, patients with POP-Q exam findings suggesting posterior compartment POP should undergo TLUS to check for rectocele or enterocele. The use of TLUS in the diagnosis of POP patients can improve the accuracy of the diagnosis of POP patients in conjunction with a POP-Q exam.

Role of Preoperative and Postoperative Pelvic Floor Distress Inventory-20 in Evaluation of Posthysterectomy Vault Prolapse.

BACKGROUND: Posthysterectomy vault prolapse is a common problem after vaginal or abdominal hysterectomy. The objective was to assess the role of Pelvic Floor Distress Inventory 20 (PFDI-20) in evaluation of vault prolapse. MATERIALS AND METHODS: Prospective study in 20 women with posthysterectomy vault prolapse of Stage 2 and above. The outcome measure was to calculate PFDI-20 score in all cases before surgical intervention and to recalculate it again in 6 months after different surgical procedures for vault prolapse and to statistically compare the PFDI-20 score in different types of surgery over 4 years period at a tertiary referral hospital for surgical treatment. Prolapse was classified using Pelvic Organ Prolapse Quantification and intraoperative findings. All women were operated for vault prolapse as per hospital protocol and stage of prolapse by either vaginal sacrospinous fixation or abdominal sacrocolpopexy. RESULTS: Mean age, parity, and body mass index were 54.8 years, 3.5, and 22.71 kg/m2 respectively. Preceding surgery was vaginal hysterectomy in 75% women and abdominal hysterectomy in 25% women. Complaints were bulge or mass feeling at perineum (100%), pressure in lower abdomen and perineum (55%), and constipation (60%). The type of prolapse was vault prolapse (100%), cystocele (100%), rectocele (100%), and enterocele (45%). The range of PFDI-20 was 88-152 with mean being 123.50 ± 22.71 before surgery while its range decreased significantly to 80-126 with mean being 106.40 ± 16.45 after surgery (P < 0.01). Mean postoperative PFDI-20 score was 107.40 in vaginal sacrospinous fixation group and was 105.30 in abdominal sacrocolpopexy group and was not statistically different (P = 0.18). CONCLUSION: PFDI-20 score can be used to see the adverse impact of vault prolapse on pelvic floor and to assess the beneficial effect of different types of surgeries on the score.

Evisceración de intestino delgado por periné posterior como presentación de hernia interrecto-vaginal: reporte de un caso / Evisceration of the small intestine through the posterior perineum aspresentation of interrecto-vaginal hernia: a case report

Introducción. El enterocele es causado por un defecto herniario del piso pélvico, siendo el más común la hernia interrecto-vaginal. Se produce por un debilitamiento del piso pélvico, por diversos factores, entre ellos, las cirugías en la región pélvica, el estreñimiento crónico o las patologías que aumentan la presión intraabdominal, el antecedente de prolapso rectal o vaginal, y también, factores congénitos. Presentación de caso. Paciente femenina de 84 años de edad, con antecedentes de un parto eutócico y múltiples procedimientos quirúrgicos, entre ellos histerectomía hace 40 años y rectosigmoidectomía por enfermedad diverticular complicada hace 6 años, quien cuatro meses antes presenta constipación crónica, que empeora en los días previos a su ingreso, con dolor perineal intenso y salida de asas intestinales a nivel de la región perineal, que la obliga a consultar a Urgencias. Al encontrarse con asas intestinales expuestas, con cambios de coloración, es intervenida quirúrgicamente con resultado satisfactorio, postquirúrgico inmediato optimo y seguimiento por consulta externa por 3 meses sin evidencia de recidiva. Discusión. La hernia interrecto-vaginal tiene una incidencia baja y una presentación clínica variada. El único tratamiento es quirúrgico

Introduction. The enterocele is produced by an hernia defect of the pelvic floor, being the most common the interrecto-vaginal hernia. It is produced by weakness of the pelvic floor for multiples factors, among them surgeries of the pelvic region, chronic constipation or pathologies that increase intra-abdominal pressure, a history of rectal or vaginal prolapse, and congenital factors. Case report. A 84-year-old female patient, with a history of eutocic delivery and multiple surgical procedures, including hysterectomy 40 years ago and rectosigmoidectomy for complicated diverticular disease 6 years ago, presented four months earlier with chronic constipation, which worsens in the days before her admission, with intense perineal pain and exit of intestinal loops at the level of the perineal region, which forced her to consult the emergency room. At examination the intestinal loops were found exposed, with color changes, she underwent surgery with satisfactory results, optimal immediate postoperative and outpatient follow-up for 3 months with no evidence of recurrence. Discussion. Interrecto-vaginal hernia has a low incidence and a varied clinical presentation. The only treatment is surgery

Easy way for elytrocele treatment by the vaginal route without mesh (with video).

Since elytrocele/enterocele may occur between 0.1% to 10% after hysterectomy, surgical techniques to repair elytrocele should be learnt to master. We propose the step-by-step description of the vaginal technique: dissection and resection of the peritoneal sac followed by a mini-invasive posterior transvaginal sacrospinous colpopexy.

[linical case: enterocele after radical cystectomy with heterotopic bladder plastic surgery].

CLINICAL CASE: The article presents a clinical case of a 58-year-old patient T.N.V with enterocele following radical cystectomy with heterotopic neobladder.