Introduction: Female cystectomy disrupts all levels of pelvic organ support, putting patients at increased risk for pelvic organ prolapse (POP). Incidence of post-cystectomy POP ranges 6-20%, although it is likely underreported. Management of POP following cystectomy can be complicated by factors such as hostile abdomen, poor tissue quality, and foreshortened vaginal length. There remains a paucity of data on techniques to reduce risk of post-cystectomy POP as well as management of cystectomy patients with POP at baseline. Herein we present a case of uterosacral ligament plication at time of benign robotic cystectomy in a patient with baseline POP.
Methods: A 78-year-old woman presents with mixed urinary incontinence and severe painful bladder spasms refractory to prior suprapubic tube with bladder neck closure, intradetrusor onabotulinumtoxinA, and pharmacotherapy. After extensive counseling, she elects robotic cystectomy with urinary diversion. Her history is also significant for symptomatic stage IIB POP with the vaginal vault apex just past the introitus. In light of her multiple other comorbidities, she elects uterosacral ligament plication at time of benign cystectomy given its minimal added operative time and morbidity.
Results: Following cystectomy, the uterosacral ligaments are plicated bilaterally with two 0 PDS running sutures. This results in a well-supported vaginal vault. At 1-month follow-up, her chronic pelvic pain and bladder spasm symptoms have resolved, and her apex remains well-supported.
Conclusions: Uterosacral ligament plication at time of cystectomy is feasible in patients with concomitant POP while adding little morbidity. This technique has potential as a prophylactic maneuver against post-cystectomy prolapse, though prospective study is needed.
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