Radiation Oncology/Toxicity/Vagina

Vagina

Vaginal Cuff Dehiscence After Hysterectomy

• Rare event, reported at 0.1-0.3% after total hysterectomy
  • Total laparoscopic hysterectomy appears to have higher rate (~5%) than total abdominal hysterectomy (~0.1%) or total vaginal hysterectomy (~0.3%)
• Predisposition
  • Premenopausal women: Vaginal cuff infections or wound hematomas
  • Post-menopausal women: Vaginal surgery for genital prolapse or complicated pelvic operations
  • High-grade enterocele, vaginal vault prolapse and severe cuff atrophy contribute to the weakening of the vaginal apex
  • Cuff radiation may compromise tissue vascularity and weaken the vaginal apex
• Triggers
  • Physical triggers: Intercourse, other sexual practices, vaginal brachytherapy
  • Pressure triggers: Valsalva (coughing, straining to pass stool)
  • Spontaneous: Even many years after hysterectomy
• Signs and symptoms
  • Pelvic pain
  • Vaginal bleeding
  • Egress of abdominal or pelvic viscera
  • A variety of other small-bowel symptoms
  • Severity of symptoms related to elapsed time between event and presentation
• Extruded body parts
  • Small bowel (commonly distal/ terminal ileum)
  • Omentum
  • Appendix
  • Fallopian tube
• Management
  • Fluid therapy
  • Wrapping the bowel with moist saline pads
  • Early antibiotic therapy
  • Surgical repair
    • Vaginal, transabdominal, or combined approach
    • Choice depends on bowel viability, the ability to reduce the prolapsed bowel, and the need for and extent of vaginal repair or reconstruction
    • The decision to proceed with the definitive repair primarily or to delay until resolution of inflammation depends on the viability of the tissues

• Pittsburgh
  • 2007 (2000-2006) PMID 17478361 -- "Incidence and patient characteristics of vaginal cuff dehiscence after different modes of hysterectomies." (Hur HC, J Minim Invasive Gynecol. 2007 May-Jun;14(3):311-7.)
    • Retrospective. 7286 hysterectomies (7039 total and 247 supracervical) performed by abdominal (TAH), vaginal (TVH), laparoscopic-assisted vaginal (LAVH), or laparoscopic hysterectomy (TLH)
    • Outcome: vaginal cuff dehiscence after total hysterectomy 0.14% (10/7286). However, incidence 4.9% after total laparoscopic hysterectomy, 0.3% after total vaginal hysterectomy, and 0.1% after total abdominal hysterectomy
    • Characteristics: median age 39 years, median time-to-dehiscence 11 weeks. 6/10 had both cuff dehiscence and bowel evisceration. 6/10 reported first post-op intercourse as the trigger event. 50% smoked cigarettes
    • Conclusion: TLH may be associated with an increased risk of vaginal cuff dehiscence
  • 1996 PMID 8784315 -- "Vaginal evisceration: presentation and management in postmenopausal women." (Kowalski LD, J Am Coll Surg. 1996 Sep;183(3):225-9.)
    • Retrospective. 3 cases. Literature review further 57 cases.
    • Risk factors: postmenopausal 41/60 (68%), previous vaginal surgery (73%), presence of enterocele (63%). Most managed by primary repair, either immediately or delayed
    • Conclusion: Vaginal evisceration seen with obstetrical or post-coital trauma, but in postmenopausal women also history of vaginal surgery and pelvic support disorder. Hypoestrogenism, atrophy, and devascularization from prior surgery seem to play a significant role

• Bologna; 2006 (1995-2001) PMID 16154253 -- "Transvaginal evisceration after hysterectomy: is vaginal cuff closure associated with a reduced risk?" (Iaco PD, Eur J Obstet Gynecol Reprod Biol. 2006 Mar 1;125(1):134-8. Epub 2005 Sep 8.)
  • Retrospective. 3593 patients, treated with hysterectomy (63% abdominal, 33% vaginal, 4% laparoscopic). Closed cuff 40%, open cuff 60%
  • Outcome: vaginal evisceration in 0.3% (10/3593); no difference by route of surgery (abdominal 0.26% vs vaginal 0.25% vs laparoscopic 0.79%), no difference by type of vaginal cuff closure (closed 0.4% vs opened 0.2%)
  • Trigger event: intercourse 40%, application of vaginal cylinder 20%, spontaneously 40%. Mean time to evisceration 20 months (2-62 months)
  • Conclusion: In young patients, sexual intercourse is the main trigger event; in elderly patients, evisceration is a spontaneous event

• NHS; 2006 (UK) PMID 17130054 -- "Vibrator in the peritoneal cavity: a case of post-hysterectomy vaginal vault evisceration." (Velchuru VR, J Obstet Gynaecol. 2006 Nov;26(8):826-7.)
  • Case report of an unusual presentation.

• Lille; 2003 (France) PMID 12798729 -- "Vaginal evisceration after hysterectomy: the repair by a laparoscopic and vaginal approach with a omental flap." (Narducci F, Gynecol Oncol. 2003 Jun;89(3):549-51.)
  • Case report. 2 patients, 2nd patient with endometrial cancer IB, applicator for vaginal brachytherapy inserted through vaginal cuff with resulting small bowel evisceration

• 1907 No PMID -- "Rupture of the vaginal wall with protrusion of small intestines in a woman 63 years of age: Replacement, suture, recovery." (McGregor AN, J Obstet Gynaecol Br Emp 1907;11:252-8.)
  • Initial report