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