Oregon Health and Science University, Department of Urology, Portland, OR.
Urology. 2020 Sep;143:268. doi: 10.1016/j.urology.2020.05.029. Epub 2020 Jun 2.
Pelvic organ prolapse is an increasingly reported complication following anterior pelvic exenteration and usually consists of an anterior enterocele. We present the surgical management of a peritoneal-vaginal fistula in a woman who presented with an acute enterocele 16 months following vaginal sparing, robot-assisted laparoscopic anterior pelvic exenteration.
Our patient is an 85-year-old female with history of upper tract urothelial carcinoma who underwent a left nephroureterectomy in 2008, and vaginal sparing robot-assisted laparoscopic anterior pelvic exenteration for BCG-refractory carcinoma in situ of the bladder in August 2016. She presented in November 2017 with new onset vaginal bleeding and discharge. On physical examination, she had a dehisced vaginal cuff apex with a bulging enterocele. There were no signs of active evisceration or strangulation. The patient was no longer sexually active and desired surgical treatment. At the time of surgery, a mature peritoneal-vaginal fistula was identified, and the fistula and prolapse were surgically managed with colpectomy and colpocleisis.
Intraoperatively found to have a partial vaginal cuff dehiscence covered with granulation tissue, resulting in a 5 mm peritoneal-vaginal fistula. The granulation-covered enterocele sac was trimmed, dissected free, closed, and reduced with serial purse-string sutures. In this fashion, the sutures were used to not only reduce the fistula, but to also perform a colpocleisis and colpectomy. The colpocleisis and colpectomy were performed due to lack of supportive apical vaginal structures and patient desire. The serial purse-string sutures not only provided additional apical support, but also reduced the likelihood of fistula recurrence by covering the peritoneum.
Transvaginal peritoneal-vaginal fistula repair with serial purse-string sutures and partial colpectomy provides a technique for repair in patients who do not have supportive apical tissue following exenterative surgery. The ideal prevention of this problem at the time of cystectomy and management for when it occurs remains unclear.
盆腔器官脱垂是前盆腔切除术后越来越常见的并发症，通常包括前肠膨出。我们报告了一位女性患者的手术治疗方法，她在阴道保留、机器人辅助腹腔镜前盆腔切除术 16 个月后出现急性肠膨出，并伴有急性肠膨出。
我们的患者是一位 85 岁的女性，患有上尿路尿路上皮癌，2008 年行左肾输尿管切除术，2016 年 8 月因卡介苗难治性膀胱原位癌行阴道保留机器人辅助腹腔镜前盆腔切除术。她于 2017 年 11 月出现新发阴道出血和分泌物。体格检查时，阴道残端顶点有裂开，膨出肠膨出。没有明显的内脏脱出或绞窄迹象。患者不再有性生活，希望接受手术治疗。手术时发现成熟的腹膜-阴道瘘，采用结肠切除术和阴道封闭术治疗瘘管和脱垂。
术中发现阴道残端部分裂开，覆盖肉芽组织，导致 5 毫米的腹膜-阴道瘘。切除肉芽覆盖的肠膨出囊，游离、闭合，并通过连续荷包缝合线缩小。这样，缝线不仅用于缩小瘘管，还用于进行阴道封闭术和结肠切除术。由于缺乏支持的阴道顶端结构和患者的意愿，进行阴道封闭术和结肠切除术。连续荷包缝合线不仅提供了额外的顶端支撑，还通过覆盖腹膜减少了瘘管复发的可能性。
经阴道腹膜-阴道瘘修补术联合连续荷包缝合线和部分结肠切除术为前盆腔切除术患者提供了一种在没有支持性顶端组织时进行修复的技术。在膀胱切除术时预防这一问题的理想方法和发生时的处理方法仍不清楚。
