# Radiation Oncology/Toxicity/Vagina

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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