EP343 - Strangulated Sigmoid Colon within Vaginal Vault Prolapse in a patient with prior Radical Cystectomy and Hysterectomy: a case report.

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Purpose/Background: Vaginal vault prolapse is a complication after hysterectomy that can be treated with conservative therapy or surgical intervention. To our knowledge, we report the first case in the literature of sigmoid colon strangulation secondary to its herniation within a prolapsed vaginal vault.

Methods/Interventions: Data was obtained from medical records.

Results/Outcomes: We present a 70-year-old female with history of T2DM, COPD, chronic constipation, and bladder cancer for which she underwent robotic-assisted radical cystectomy, pelvic lymphadenectomy, total hysterectomy, bilateral salpingo-oophorectomy, and ileal conduit creation in January 2018. She presented to the Emergency Room on May 2024 with a 1-month history of a prolapsing vaginal mass with associated pain that worsened in the last 24 hours. Vital signs were: BP 162/71 mmHg, HR 91 bpm, Temp 36.9°C, RR 19 bpm, and O2 Sat 100% on room air. On exam, the abdomen was soft, tender, non-distended, and non-peritonitic, with a reducible ileal conduit parastomal hernia. The pelvis had a complete procidentia of the vaginal vault with necrotic areas on the vaginal mucosa. The vaginal bulge was firm and tender to palpation (Figure 1). Labs included Hgb 10.4 g/dL, WBC 14.5 THOU/mcL, platelets 416 THOU/mL, BUN 31 mg/dL, Cr 1.22 mg/dl, Na 133 mEq/L, K 4.0 mEq/L, HCO3 22 mmol/L. CT of the abdomen/pelvis with IV contrast showed pelvic prolapse with an incarcerated sigmoidocele with severe surrounding edema (Figure 2). The patient was taken emergently to the operating room for exploratory laparotomy by general surgery. Upon entry to the abdomen, the incarcerated sigmoid colon was successfully reduced with external and internal traction. Inspection of the reduced sigmoid showed marked inflammation but no bowel necrosis. The vaginal prolapse was likewise reduced. Inspection of the vaginal cuff demonstrated a large necrotic and perforated segment. Given the redundancy and weight of the sigmoid colon, associated with the patient’s weakened pelvic floor and history of chronic constipation, the decision was made to perform a sigmoidectomy to prevent recurrent sigmoid incarceration. A stapled end-to-side anastomosis was created. This was followed by a flexible sigmoidoscopy, that demonstrated an intact and widely patent anastomosis with no signs of leaks. Next, the gynecologic surgeons resected the necrotic portions of the vaginal cuff followed by cuff re-closure using 0-Vicryl in a running configuration. The Urogynecology team then noted a rectocele just proximal to the hymen, reproduced with gentle abdominal pressure. Therefore, they proceeded with imbrication of the proximal vaginal apex and posterior vaginal fibromucosal layer with several interrupted 3-0 Vicryl sutures. This resulted in reduction of the redundant vagina, vaginal caliber, and an expected decrease in the risk for recurrent vaginal prolapse. Patient did well and was discharged on postoperative day 5. Pathology report described a 26 cm segment of sigmoid colon with acute inflammation, ulceration, and fibrous serosal adhesions with viable margins of resection, negative for dysplasia or malignancy, and vaginal cuff debridement with fragments of squamous mucosa with extensive acute inflammation, ulceration, and reactive changes, negative for dysplasia or malignancy. Patient was seen at the 2-week outpatient follow-up and continued to recover well.

Conclusion/Discussion: Sigmoid colon strangulation within vaginal vault prolapse can be successfully managed with emergent multidisciplinary operative intervention.