Investigation of risk factors for vaginal dehiscence and development of small bowel evisceration after robot-assisted radical cystectomy for female bladder cancer and an improved vaginal reconstruction technique to prevent its onset

Investigation of risk factors for vaginal dehiscence and development of small bowel evisceration after robot-assisted radical cystectomy for female bladder cancer and an improved vaginal reconstruction technique to prevent its onset | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Investigation of risk factors for vaginal dehiscence and development of small bowel evisceration after robot-assisted radical cystectomy for female bladder cancer and an improved vaginal reconstruction technique to prevent its onset Satoshi Fukata, Ayano Kawaguchi, Rie Yoshimura, Hideo Fukuhara, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4460461/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Jul, 2024 Read the published version in Journal of Robotic Surgery → Version 1 posted 7 You are reading this latest preprint version Abstract Introduction Transvaginal organ prolapse, such as small bowel evisceration, is a rare complication after radical cystectomy (RC) in female patients with invasive bladder cancer, However, it often requires emergency surgical repair. Here, we describe our experience with such a case and a review of similar previously reported cases, along with evaluation of the risk factors. We also propose a vaginal reconstruction technique to prevent this complication during robot-assisted laparoscopic radical cystectomy (RARC). Methods A total of 178 patients who underwent laparoscopic radical cystectomy (LRC) or RARC were enrolled, 34 of whom (19%) were female. One of the 34 female patients had transvaginal small bowel evisceration after RARC. We evaluated our case and six such previously reported cases, to determine vaginal reconstruction techniques during RARC to prevent this complication postoperatively. Results Median age of these cases was 73 (51-80) years, and all patients were postmenopausal. The median time to small bowel evisceration was 14 (6-120) weeks postoperatively. In addition, we changed the methods of the vaginal reconstruction technique during RARC from the conventional side-to-side closure technique to the improved caudal-to-cephalad closure technique. Since implementing this change, we have not experienced any cases of vaginal vault dehiscence or organ prolapse. Conclusions Transvaginal small bowel evisceration after RC can easily become severe. Therefore, all possible preventive measures should be taken during RARC. We believe that our vaginal reconstruction techniques might reduce the risk of developing this complication. Postoperative vaginal failure robot-assisted radical cystectomy transvaginal bowel evisceration vaginal reconstruction technique Figures Figure 1 Figure 2 Figure 3 Introduction Radical cystectomy (RC) is the standard surgical treatment for invasive bladder cancer. In Japan, the surgical method has evolved from open radical cystectomy (ORC) to laparoscopic radical cystectomy (LRC), and further to robot-assisted radical cystectomy (RARC). RARC is currently widely performed in Japan. In female patients undergoing RC, the standard surgical approach involves en bloc removal of the bladder, urethra, uterus and anterior vaginal wall. This procedure increases the postoperative risk of vaginal prolapse and organ prolapse secondary to vaginal dehiscence (e.g., small bowel evisceration) due to weakening of pelvic support structures. Although it is rare for the disease to progress to small bowel evisceration, it requires emergency surgical repair since the condition is associated with a high risk of serious complications, such as infections, peritonitis, intestinal necrosis and intestinal obstruction. There are various risk factors for the occurrence of this complication. Parra et al. have identified factors such as advanced age, postmenopause, history of vaginal surgery, and parity as risk factors [ 1 ]. At our institution, we have also experienced transvaginal small bowel evisceration after RARC. We performed a literature search for previous reviews on vaginal dehiscence and bowel evisceration after RC, but found very little information. Therefore, we reviewed reported cases of vaginal small bowel evisceration after RC, including our case. Furthermore, we examined and implemented effective vaginal reconstructive techniques to prevent postoperative small bowel evisceration. The purpose of this study was to describe this reconstructive technique and evaluate its effectiveness. Materials and Methods All patients who underwent LRC or RARC for invasive bladder cancer at our institution between September 2009 and March 2023 were analyzed retrospectively, among whom female patients were analyzed for patient background characteristics, surgical outcomes, and postoperative complications. At our institution, LRC was performed between September 2009 and March 2018, and RARC was performed after April 2018. Urinary diversions were performed by extracorporeal urinary diversion (ECUD) in all cases undergoing LRC, and by intracorporeal urinary diversion (ICUD) in RARC cases performed after December 2019. The da Vinci® Xi Surgical System was used in all RARC cases. We compared and discussed female patients with postoperative transvaginal small bowel evisceration from among previously reported cases, including our own case, and reviewed the associated risk factors. Next, after experiencing a case of postoperative transvaginal small bowel evisceration, we improved our vaginal reconstructive technique during RARC in an attempt to prevent the occurrence of postoperative transvaginal organ prolapse. Conventional reconstruction procedure (a) After detachment of the bladder, uterus and ureters from adjacent tissue, the posterior vaginal fornix is incised to open the vaginal wall. The vaginal wall incision is extended toward the urethra, and the bladder and anterior vaginal wall are released and the vagina is opened wide. (b) The tissues around the urethra and anterior vaginal wall are incised. The bladder, urethra and anterior vaginal wall are transvaginally removed en bloc. With this conventional method, only a small amount of the vaginal wall can be preserved, potentially leading to large defects in the vagina, especially at the vaginal apex (back of the urethra) (Fig. 1 a). (c) The residual vaginal walls on both sides are folded craniocaudally, and continuous sutures are placed in the transverse axis using 3-0V-lok (side-to-side) sutures. Next, the cavity of the vaginal apex is closed vertically (Fig. 1 b). Application of excessive tension on the vaginal reconstruction lesion makes it difficult to achieve complete closure, such that it is not strong enough to support the abdominal pressure. If the vaginal wall defect on the dorsal side of the urethra becomes too large, the strength of the vaginal wall at the site of closure cannot be maintained. This appears to increase the risk of developing postoperative organ prolapse (Fig. 1 c). Taking these problems into consideration, we improved the vaginal reconstruction technique, as described below. Improved reconstruction procedure (a) The ureters are dissected from the bladder on both sides, and the vesico-vaginal space is dissected as much as possible from both sides before opening the vaginal wall. This makes it possible to open the vaginal wall from the posterior vaginal fornix toward the urethra, making the incision as close to the bladder as possible. During this step, inadvertent electrocoagulation on the vaginal wall and paravaginal tissues should be avoided in order to maintain the blood supply to the vagina as much as possible. (b) Since dissection of the vaginal apex and urethra is generally difficult because of the presence of strong adhesions, the space between the urethra and anterior vaginal wall is stripped as much as possible, and forceps are passed between the anterior vaginal wall and the urethra. This process enables separation of the posterior surface of the urethra and the anterior vaginal wall (Fig. 2 a). The procedure also allows more of the vaginal wall to be preserved, especially the anterior vaginal wall on the back of the urethra, enabling a stronger reconstruction than with the conventional technique (Fig. 2 b). (c) We perform the reconstruction as a roll shape using a continuous caudal-to-cephalad suture. In other words, the residual vaginal walls are brought together in the midline and closed longitudinally from the cranial side (posterior vaginal fornix) to the caudal side (vaginal apex) (Fig. 2 c). This technique allows the vagina to be reconstructed in a tubular shape, allowing easier and more robust reconstruction of the vagina (Fig. 2 d). We analyzed and compared the surgical outcomes and prophylactic efficacy between 20 patients who underwent the conventional reconstruction technique and 14 patients who underwent the improved reconstruction technique. The Fisher test and Mann-Whitney U test were used to test each factor between the two groups. EZR version 1.36 software (Saitama Medical Center, Jichi Medical University) was used for statistical analysis. P values of < 0.05 were considered significant for all analyses. Statement of ethics The research protocol was approved by the ethics review board of Kochi University (Registration number: ERB-103405). Since this was a retrospective study using a database, the ethics committee waived the need for patient informed consent. Results Between September 2009 and March 2023, a total of 175 patients underwent RC, 77 of which were LRC and 98 were RARC. Of them, 34 patients (19%) were female (LRC: 13, RARC: 21). The characteristics and surgical outcomes of the 34 female patients and 141 male patients are shown in Table 1 . Median age was 75 (59–88) years in females and 74 (44–88) years in males, with no significant difference between them (P = 0.64). All the female patients were postmenopausal at the time of surgery. Median BMI was 23.1 (15.5–34.1) kg/m 2 in females vs 23.2 (16.8-35.59) kg/m 2 in males, indicating no significant difference between them (P = 0.68). LRC was performed in 13 females and 64 males, and RARC was performed in 21 females and 77 males (P = 0.565). Median total surgical time was 548 (333–950) minutes in females vs 541 (314–850) minutes in males, which was not significantly different (P = 0.36). Median pneumoperitoneum time was significantly longer in females than in males (360 (135–655) minutes vs 308 (86–660) minutes, respectively (P = 0.04)). Median robotic console time was significantly longer in females versus males (409 (177–607) minutes vs 260 (126–543) minutes, respectively (P = 0.03)). It should be noted that the large range of pneumoperitoneum and console times are due to the fact that performance of urinary diversion by ICUD takes a longer time. Blood loss was 190 (50-2970) ml in females vs 350 (10-2730) ml in males, with no significant difference between them (P = 0.08). Postoperative hospital stay was 25 (15–63) days in females vs 25 (11–76) days in males (P = 0.54). In female cases, complications observed included vaginal prolapse in one case (3%), and transvaginal small bowel evisceration in one case (3%). The patient who developed small bowel evisceration was 80 years old at RARC, had a BMI of 23.1 kg/m 2 , and the ileal conduit was created using ICUD for urinary diversion. Total surgical time was 557 minutes, pneumoperitoneum time was 490 minutes, console time was 370 minutes, and blood loss was 370 ml. She developed transvaginal small bowel evisceration 17 weeks after RARC. The prolapsed small bowel was necrotic, and was complicated by intestinal obstruction and peritonitis (Fig. 3 ). A gastrointestinal surgeon urgently removed the necrotic small bowel and performed vaginal closure and reinforcement. Since then, she has had no recurrence. However, she also had an abdominal wall scar hernia after RARC, for which she underwent surgical repair. Table 1 Patient characteristics and surgical outcomes in the 34 female patients and 141 male patients who underwent LRC or RARC for bladder cancer Female Male p value* Number 34 (19%) 141 (81%) Age (years) 74 (59–88) 74 (44–88) 0.64 BMI (kg/m 2 ) 23.1 (15.5–34.1) 23.2 (16.8–35.5) 0.68 Surgical procedure [n] LRC 13 64 0.565 RARC 21 77 Urinary diversion [n] Uretrocutaneostomy 3 7 0.08 Ileal conduit 31 120 Neobladder 0 14 Total surgical time [min] 548 (333–950) 541 (314–850) 0.36 Pneumoperitoneum time [min] 371 (135–655) 308 (86–660) 0.04 Robotic console time [min] 409 (177–607) 260 (126–543) 0.03 Blood loss [ml] 190 (50-2970) 350 (10-2730) 0.08 Duration of hospitalization [days] 25 (15–63) 25 (11–76) 0.54 Complications [n] Vaginal prolapse 1 Urinoma 1 1 Pelvic abscess 1 Ventral hernia 1 Bowel evisceration 1 *Mann–Whitney U test or Fisher's exact test LRC: laparoscopic radical cystectomy, RARC: robot-assisted radical cystectomy. Next, we reviewed our case of transvaginal small bowel evisceration after RC, along with six previously reported cases. The results are shown in Table 2 [ 2 – 4 , 5 , 6 ]. Median patient age was 73 (51–80) years and BMI was 24.4 (23–28) kg/m 2 . The initial surgical procedure was open radical cystectomy (ORC) in one case, LRC in one case, RARC in four cases and unclear in one case. The onset of small bowel evisceration was at a median interval of 17 (6-120) weeks after RC. The repair method was transvaginal in three cases and transabdominal in four. At the time of RC, the sutures used for vaginal reconstruction were 2 − 0 PDS in one case, 3 − 0 V-Loc sutures in two and unknown in three cases. In our case, 3 − 0 V-Loc sutures had been used. None of the cases had recurrence after the repair surgery. Complications other than transvaginal organ prolapse were observed in two cases of parastomal hernia and two cases of abdominal wall scar hernia. Our case was also complicated by abdominal wall scar hernia before the onset of vaginal small bowel evisceration. Table 2 Review of previous cases of transvaginal small bowel evisceration after radical cystectomy and our case Case Reference Age (years) Menopause BMI (kg/m 2 ) Surgery Sutures Time to prolapse (wks) Repair approach Other complications 1 Frank et al, 73 + 24.4 RARC 2 − 0 PDS 14 Transvaginal Parastomal hernia 2 Frank et al, 73 + 28.9 RARC 3 − 0 V-Loc 120 Transvaginal Parastomal & ventral hernia 3 Chopra et al, 75 + Unknown RARC V-Loc 6 Transabdominal - 4 Chhabra et al, 51 + Unknown ORC Unknown 12 Transabdominal - 5 Meguro et al 79 + 17.9 LRC Unknown 52 Transabdominal - 6 Hassan et al, 78 + Unknown Unknown Unknown 96 Transvaginal - 7 Our case 80 + 23.1 RARC 3 − 0 V-Loc 17 Transabdominal Ventral hernia Median 75 23.75 17 ORC: open radical cystectomy, LRC: laparoscopic radical cystectomy, RARC: robot-assisted radical cystectomy PDS: polydioxanone, V-Loc: barbed suture (V-Loc™, Covidien) Since our experience with that case, we have so far performed RARC on 14 cases at our institution, after improving the vaginal reconstruction technique used during RC. We investigated the surgical outcomes of 20 cases performed before application of the improved technique and 14 cases performed after improvement of the technique (Table 3 ). Median patient age in the pre-improvement group was 75 (59–88) years, while that of the post-improvement group was 75 (61–83) years, with no significant difference between them (P = 0.861). BMI was 22.3 (15–28) kg/m 2 vs 26.2 (19–34) kg/m 2 , indicating a significantly higher BMI in the post-improvement group (P = 0.04). In the pre-improvement group, 13 cases underwent LRC and seven cases underwent RARC, while in the post-improvement group, 14 cases underwent RARC, indicating a significant difference in the numbers of the types of surgeries pre-and post-application of the improved technique (P = 0.00016). The reason for this is that all patients underwent RARC after 2019 at our institution. In the pre-improvement group, there was one case of ureterocutaneostomy and 19 cases of ileal conduit, while in the post-improvement group, there were two and 12 cases, respectively, of the two procedures, with no significant difference between them (P = 0.555). In the pre-improvement group, ECUD was performed in 17 cases and ICUD in three, while in the post-improvement group, ECUD was performed in two cases and ICUD in 10; i.e., significantly more ICUDs were performed in the post-improvement group (P = 0.001). The total surgical time was 550 (433–950) minutes in the pre-improvement group and 543 (333–685) minutes in the post-improvement group, which was not significantly different (P = 0.39). In addition, there was no significant difference in pneumoperitoneum time, which was 324 (135–655) minutes and 413 (177–607) minutes, respectively, in the pre- and post-improvement groups (P = 0.69). Console time in RARC cases was 315 (186–485) minutes in the pre-improvement group and 429 (177–607) minutes in the post-improvement group, with no significant difference (P = 0.76), although there was a trend toward longer console times in the post-improvement group. The reason for this is that there were more ICUD cases in the post-improvement group. Blood loss was 435 (70-2970) ml and 135 (50–300) ml, respectively, with significantly less bleeding in the post-improvement group (P = 0.008). The change in technique, thus, did not increase blood loss. No complications of vaginal prolapse or postoperative organ prolapse were observed in the 14 post-improvement cases, and all patients are currently doing well. Table 3 Comparison of the surgical outcomes of 20 cases pre-improvement and 14 cases post-improvement of the vaginal reconstruction technique used during radical cystectomy. Pre-improvement Post-improvement p value* Number of cases 20 14 Age (years) 75 (59–88) 75 (61–83) 0.861 BMI (kg/m 2 ) 22.3 (15–28) 26.2 (19–34) 0.039 Surgical procedure LRC 13 0 0.00016 RARC 7 14 Urinary diversion Uretrocutaneostomy 1 2 0.555 Ileal conduit 19 12 Neobladder 0 0 ECUD 17 4 0.001 ICUD 3 10 Total surgical time (min) 550 (433–950) 548 (333–685) 0.39 Pneumoperitoneum time (min) 324 (135–655) 413 (177–641) 0.69 Robotic console time (min) 315 (186–485) 429 (177–607) 0.76 Blood loss (ml) 435 (70-2970) 135 (50–300) 0.008 Duration of hospitalization (days) 30 (14–63) 18 (15–53) 0.007 Complications Urinoma 1 1 Pelvic abscess 1 Ventral hernia 1 0 Vaginal prolapse 1 Bowel evisceration 1 0 *Mann–Whitney U test or Fisher's exact test LRC: laparoscopic radical cystectomy, RARC: robot-assisted radical cystectomy, ECUD: extracorporeal urinary diversion, ICUD: intracorporeal urinary diversion Discussion In this study, total surgical time was not significantly different between males and females (P = 0.36), although pneumoperitoneum time and robotic console time were significantly longer in females (P = 0.04 and 0.03, respectively). This could be because RC in females generally requires en bloc removal of the bladder, urethra, uterus and anterior vaginal wall, followed by vaginal reconstruction; hence, the time is prolonged due to more surgical steps than in males. Thus, RC in females generally involves removing all anterior pelvic organs and vaginal reconstruction. Therefore, there is an increased risk of transvaginal organ prolapse, such as small bowel evisceration due to weakening of the anterior pelvic support tissue. Transvaginal small bowel evisceration after RC is a rare, but serious complication, that requires emergency surgical treatment. The mortality rate from this complication is estimated to be 6–10% [ 3 ]. In a multicenter cohort study in Japan, Kanno et al. reported that seven of 100 female patients underwent emergency surgery for bowel evisceration due to vaginal dehiscence after LRC, which is higher than the rate after hysterectomy. Median patient age in their study was 82 years (range: 77–87 years), and the median onset time of vaginal dehiscence was 147 days (range: 67-1240 days). Older age is considered a risk factor for the development of vaginal dehiscence [ 5 ]. In addition, Chhabra et al. identified factors such as postmenopausal status, history of prior vaginal surgery, and multi parturition as risk factors of vaginal dehiscence [ 3 ]. Menopause is thought to cause the tissues of the vulva and vagina to become thinner, dryer and less elastic, which further reduces blood flow to the vaginal walls, making them more susceptible to rupture [ 4 , 7 ]. Other reported risk factors include smoking, trauma from intercourse, obstetric procedures, history of radiation therapy, pelvic floor defects, poor wound healing, chronic steroid administration, and malnutrition [ 8 – 12 ]. There have been six previous reports of transvaginal small bowel evisceration after RC, showing that it is a rare complication with only few reported cases [ 2 – 4 , 5 , 6 ]. In our case and the six previously reported cases, median patient age was 75 years, median BMI was 23.7 kg/m 2 , and bowel evisceration occurred 17 weeks after surgery. There was a tendency toward development of this complication in elderly cases and those who underwent RARC. The repair approach was transvaginal in two cases and transabdominal in three cases. It is often necessary to partially resect the prolapsed small bowel, and gastrointestinal surgeons generally find it easier to perform the procedure through a transabdominal approach. Evaluation also showed that many cases were complicated by fragility of the abdominal wall, as well as fragility of the pelvic floor. Thus, in addition to organ prolapse, many cases are complicated by abdominal wall herniation, suggesting that sarcopenia might be a risk factor for the development of this condition. Sarcopenia is also associated with weakness of the pelvic floor muscles [ 13 ]. In addition, menopause also causes a decrease in estrogen secretion, which might further increase the risk of sarcopenia progression. Although none of the seven patients who developed vaginal dehiscence was severely obese, it is possible that obesity and postoperative malnutrition are also factors contributing to the occurrence of this complication. As for the frequency of occurrence postoperative transvaginal organ prolapse, the details are unknown because of the small number of reports, although, in general, since bladder cancer occurs more often in older people, women who undergo RC are necessarily older and postmenopausal. It is assumed that these patients are at a high risk of developing postoperative transvaginal organ prolapse. Many patients with cancer have sarcopenia and malnutrition as a complication. In addition, it is inevitable that the anterior pelvic organs (bladder, urethra, uterus and anterior vaginal wall) are almost completely removed during surgery, which results in abdominal pressure being exerted directly on the reconstructed vaginal wall. Therefore, the risk of developing transvaginal organ prolapse after RC is equal to or greater than that following obstetric and gynecological surgery. Of the seven cases examined in this study, two cases developed dehiscence more than one year after surgery, while it developed as early as 6 months after surgery in four cases, suggesting that many cases develop dehiscence relatively soon after surgery. Our case was 80 years old, the oldest of the reported cases, and developed dehiscence 17 weeks after RARC. Although we could not identify any factors that affected surgical outcomes, we thought that the risk factors include a history of previous hysterectomy, old age and menopause. In addition, this case was complicated by ventral hernia at the abdominal wound, suggesting that sarcopenia was also a likely predisposing factor for transvaginal organ prolapse in our case. We believe that it is important to perform appropriate vaginal reconstruction at the time of initial RC for women at risk, to prevent the onset of vaginal dehiscence. Various surgical techniques to prevent postoperative vaginal dehiscence have been reported, including bilateral vaginal uterosacral ligament suspension, vertical sutures, preservation of the length of the vaginal apex, and incision with minimal coagulation to preserve blood flow to the vaginal wall [ 14 , 15 ]. Cronin et al. suggested that surgical techniques to prevent vaginal dehiscence include the use of a monopolar electrocautery during vaginal wall excision, two-layer suturing, ensuring adequate tissue margins during reconstruction, and the use of bidirectional barbed sutures, such as V-Loc sutures [ 16 ]. We considered several surgery-related risk factors as potentially predisposing to the risk of vaginal dehiscence, and examined procedures that could eliminate these factors, such as: 1. Since there is little residual vaginal wall, the vaginal wall is easily detached due to the undue tension exerted on it when the opening is closed; 2. Impaired blood flow to the vaginal wall due to careless electrocoagulation in the surrounding tissue; 3. Reconstruction in a way that makes dehiscence easy (side to side); and 4. Changes in the anatomical position of the vagina due to surgery (disappearance of the flap valve mechanism of the vagina). Cerqui et al. discussed this change in the anatomical position of the vagina, suggesting that it could be due to deviation from normal conditions in the maintenance of pelvic pressure distribution [ 17 ]. Under normal circumstances, the upper vaginal axis is parallel to the elevator plates and oriented perpendicular to the direction of abdominal pressure. In other words, by tilting the upper vaginal canal in a cephalic-dorsal direction and maintaining it cephalad to the levator plate, it is supported by the pelvic floor muscles (levator plate) even when abdominal pressure increases, which helps to prevent prolapse (flap valve mechanism of the vagina). However, after RC, the anatomical relationship of the vagina changes and the normal axis of the vagina might also change, with positioning of the vagina in a more vertical position. As a result, abdominal pressure is directed towards the axis parallel to the vaginal fornix, making the vaginal reconstruction more susceptible to dehiscence (disappearance of the flap valve mechanism of the vagina) [ 17 , 18 ]. Frank et al. pointed out two basic problems in dissection after anterior pelvic organ removal. The first problem is total absence of the bladder and associated anterior vaginal wall. A defect in the anterior vaginal canal allows the abdominal contents to come into direct contact with this point of weakness. Second, there is a near-lack of reliable anatomical fixation points for reconstruction of the pelvic floor muscles and vaginal canal[ 4 ]. The authors of that study showed two methods for vaginal wall reconstruction. One is the method of folding the vaginal wall in a craniocaudal direction and closing it on the horizontal axis (clam shell method (i.e., side to side)). The other is a method of closing the residual vaginal walls along the same axis as the body axis (i.e., cranial to caudal) [ 4 ]. We initially attempted the clam shell method (Fig. 1 ), although, in this method, since the residual vaginal walls are folded down, the original cylindrical shape of the vagina is disturbed, resulting in unreasonable tension on the vaginal wall. This might also lead to disruption of blood flow to the remaining tissues. Therefore, after experiencing a case of small bowel evisceration, we changed the method to forming the residual vaginal wall into a roll shape to preserve the original shape of the vagina as much as possible. This procedure is similar to the caudal-to-cephalad method (Fig. 2 ). This results in the original form of the vagina and its anatomical positional relationship being maintained, so that the flap valve mechanism, which is particularly important for preservation of pelvic organ function, can be maintained as much as possible. Furthermore, by maintaining the original shape of the vaginal canal against abdominal pressure, blood flow to the vaginal wall is also not likely to be obstructed. To perform this procedure, it is necessary to separate the space between the bladder and the anterior vaginal wall as much as possible, preserving the vaginal wall, rather than inadvertently cutting off the vaginal wall when the bladder is released. It is also important to avoid electrocoagulation of the vaginal wall and paravaginal tissues to maintain blood flow. In addition, we believe that preservation of the anterior vaginal wall at the vaginal apex, that is, at the back of the urethra, is particularly important for strong vaginal reconstruction. Inadvertently and extensively resecting the vaginal wall can create large defects that make subsequent vaginal reconstruction difficult or impossible. We believe that this increases the risk of postoperative vaginal dehiscence and transvaginal prolapse. Therefore, we dissected the gap between the urethra and the anterior vaginal wall, preserving as much of the anterior vaginal wall as possible. After changing to this procedure, we have not experienced any occurrence of postoperative vaginal or other organ prolapse at our institution. However, caution is required when bladder cancer is located near the anterior vaginal wall, such as at the posterior bladder wall or bladder neck. In such cases, if the anterior vaginal wall is inadvertently preserved too much, it might lead to residual cancer at the resection margin, leading to a pathological diagnosis of a positive resection margin. Recognizing the location of the tumor and preoperative simulation of the extent of resection is important to ensure cancer control. Methodological limitations In this study, the reviewed cases were only those found in our literature search. We believe that there could be many more cases that have not been published, and that the actual number of cases of transvaginal small bowel evisceration after RC is much higher. However, the exact number of cases and incidence is unclear. In addition, the 34 cases enrolled in this study were a mixture of cases with different techniques, including LRC and RARC. Furthermore, the improved reconstructive techniques described here were performed during RARC, and we do not guarantee that the same procedures can be performed during ORC or LRC. Conclusion Transvaginal organ prolapse, such as small bowel evisceration, is a rare complication after RC, but can easily become severe. Emergency surgery is essential for its treatment, which increases the physical burden on the patient. Therefore, all possible measures to prevent its occurrence should be taken during RC. We believe that the risk of developing this disorder can be reduced by using the vaginal reconstruction technique described here. In the future, we should collect more cases performed by our technique to examine its preventive effects. Declarations Funding Sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflict of Interest Statement The authors have no conflicts of interest to declare. Author Contributions All authors contributed to the study conception and design. Material preparations were performed by Satoshi Fukata , Ayano Kawaguchi . Data collections were performed by Satoshi Fukata , Ayano Kawaguchi, Rie Yoshimura, Hideo Fukuhara, Takashi Karashima . Data analyses were performed by Satoshi Fukata . Prepared figures 1-3 were performed by Satoshi Fukata , Ayano Kawaguchi . The first draft of the manuscript was written by Satoshi Fukata and critical revision of the manuscript was performed by K eiji I noue . All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Ethics approval This is an observational study. The research protocol was approved by the ethics review board of Kochi University (Registration number:ERB-103405). Since this was a retrospective study using a database, the ethics committee waived the need for patient informed consent. Consent to participate Informed consent was obtained from all individual participants included in the study. Consent to publish The authors affirm that human research participants provided informed consent for publication of the images in Figure(s) 1a, 1b, 1c, 2a, 2b, 2c, 2d, 3a and 3b. Data Availability Statement The data that support the findings of this study are not publicly available since they contain information that could compromise the privacy of research participants, but are available from the first author (S.F.) upon reasonable request. Acknowledgements The authors would like to thank the patients, research facilities, and research staff who participated in this study. References Parra RS, Rocha JJ, Feres O (2010). Spontaneous transvaginal small bowel evisceration: A case report. Clinics (Sao Paulo) 65:559–61. Sameer Chopra, Arjuna Dharmaraja, Hooman Djaladat (2016). Transvaginal bowel evisceration following robot-assisted radical cystectomy. Indian J Urol. 32(4): 320–322.doi: 10.4103/0970-1591.189714 Chhabra S, Hegde P (2013). Spontaneous transvaginal bowel evisceration. Indian J Urol.29:139–41. Frank C. Lin, Andrew Medendorp, Michelle Van Kuiken, Steven A. Mills, Christopher M. Tarnay (2019). Vaginal Dehiscence and Evisceration After Robotic-assisted Radical Cystectomy: A Case Series and Review of the Literature. Urology. 134:90–96. doi: 10.1016/j.urology.2019.09.009 . Kanno T, Ito K, Sawada A et al (2019). Complications and reoperations after laparoscopic radical cystectomy in a Japanese multicenter cohort. Int. J. Urol. 26: 493–8. Wan Amir Wan Hassan, Vignesh Narasimhan, Asiri Arachchi, Thomas Manolitsas, William Teoh (2021). 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Iaco PD, Ceccaroni M, Alboni C et al (2006). Transvaginal evisceration after hysterectomy: is vaginal cuff closure associated with a reduced risk? Eur. J. Obstet. Gynecol. Reprod. Biol. 125: 134–8. Rávida R L Silva, Janaína F V Coutinho, Camila T M Vasconcelos, José Ananias Vasconcelos Neto, Rachel Gabriel B Barbosa et al (2021). Prevalence of sarcopenia in older women with pelvic floor dysfunction. Eur J Obstet Gynecol Reprod Biol 263:159–163. doi: 10.1016/j.ejogrb.2021.06.037 . Kashani S, Gallo T, Sargent A, Elsahwi K, Silasi DA, Azodi M (2012). Vaginal cuff dehiscence in robotic-assisted total hysterectomy. JSLS.16: 530–6. Robinson BL, Liao JB, Adams SF, Randall TC (2009). Vaginal cuff dehiscence after robotic total laparoscopic hysterectomy. Obstet. Gynecol. 114: 369–71. Cronin B, Sung VW, Matteson KA (2012). Vaginal cuff dehiscence: risk factors and management. Am. J. Obstet. Gynecol.206: 284–8. Cerqui AJ, Haran M, Collier SM (1998). A case of transvaginal evisceration. Aust N Z J Obstet Gynaecol. 38:229–31. M TAKEYAMA (2020). EVIDENCE OF PELVIC ORGAN PROLAPSE AND ITS TREATMENT. J Jpn Surg Assoc 81(2), 209–220 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 02 Jul, 2024 Read the published version in Journal of Robotic Surgery → Version 1 posted Editorial decision: Revision requested 21 Jun, 2024 Reviews received at journal 21 Jun, 2024 Reviewers agreed at journal 26 May, 2024 Reviewers invited by journal 25 May, 2024 Editor assigned by journal 25 May, 2024 Submission checks completed at journal 23 May, 2024 First submitted to journal 22 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4460461","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":308854098,"identity":"5a733f7e-0ce7-49ae-8a43-b7a479082900","order_by":0,"name":"Satoshi Fukata","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+klEQVRIiWNgGAWjYBACxgYGhg8MB0BM5sNA4gAPVIINnxbGGUAtEkBFycRpAemCauExBmkh7DDmaQcYm3nO2NXx95/5bPCh5o4Mg0QC44cfDHx5OK2YnQDUciNZQuJG7ubEGcee8QC1MEv2MLAV49aS//0xzwdmCYYbvJsP8zYc5rG/kcAgDfRLYgNeWz7US8ifP/MYrAVky2/CWm4cljA4kMOcDNXCRtCWxjlnjktuvJFmbDjjGFALz8M2yx4D3H4xBGppeHOsml/u/OHHEh9qDtszsCcfvvGj4hjOEDPEYj0oRRgcS8ClRR6XRA1OLaNgFIyCUTDiAADTx1ZpLlYgSAAAAABJRU5ErkJggg==","orcid":"","institution":"Kochi University","correspondingAuthor":true,"prefix":"","firstName":"Satoshi","middleName":"","lastName":"Fukata","suffix":""},{"id":308854099,"identity":"7ac9627d-684a-44ea-9ad5-6f8d6543620a","order_by":1,"name":"Ayano Kawaguchi","email":"","orcid":"","institution":"Kochi University","correspondingAuthor":false,"prefix":"","firstName":"Ayano","middleName":"","lastName":"Kawaguchi","suffix":""},{"id":308854100,"identity":"49e023dd-22ba-494b-bcbd-54efabc45bd6","order_by":2,"name":"Rie Yoshimura","email":"","orcid":"","institution":"Kochi University","correspondingAuthor":false,"prefix":"","firstName":"Rie","middleName":"","lastName":"Yoshimura","suffix":""},{"id":308854102,"identity":"744b61d8-f6cc-42f1-a287-de0222e44526","order_by":3,"name":"Hideo Fukuhara","email":"","orcid":"","institution":"Kochi University","correspondingAuthor":false,"prefix":"","firstName":"Hideo","middleName":"","lastName":"Fukuhara","suffix":""},{"id":308854104,"identity":"f7b094b2-f6d6-4803-8247-39f51a7952f3","order_by":4,"name":"Takashi Karashima","email":"","orcid":"","institution":"Kochi University","correspondingAuthor":false,"prefix":"","firstName":"Takashi","middleName":"","lastName":"Karashima","suffix":""},{"id":308854106,"identity":"9a335e9e-6fad-41fa-b175-6ec1718f6370","order_by":5,"name":"Keiji Inoue","email":"","orcid":"","institution":"Kochi University","correspondingAuthor":false,"prefix":"","firstName":"Keiji","middleName":"","lastName":"Inoue","suffix":""}],"badges":[],"createdAt":"2024-05-22 11:11:39","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4460461/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4460461/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11701-024-02035-0","type":"published","date":"2024-07-02T15:44:50+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":57944349,"identity":"6adb9c2f-c214-4163-a5c4-5c920df1612a","added_by":"auto","created_at":"2024-06-07 19:09:49","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":555877,"visible":true,"origin":"","legend":"\u003cp\u003eConventional reconstructive steps for the anterior vaginal wall during RARC. There is little residual vaginal wall and the defect is wide open (a). The suture needle is inserted into the cranial end of the residual vaginal wall, the thread is taken out of the body through the vaginal opening, and, by pulling it, the vaginal wall is folded back in the craniocaudal direction (b) and anastomosis is performed (c). This results in a large defect in the vaginal wall at the apex of the vagina, so that the left and right vaginal walls cannot be brought together. This makes it difficult to securely close the wound, making it impossible to form a strong wound.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4460461/v1/b072c45588f7fd9414fb2353.jpeg"},{"id":57944350,"identity":"3001aed3-70d9-43f2-b8e1-6f0bc828b530","added_by":"auto","created_at":"2024-06-07 19:09:49","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":685366,"visible":true,"origin":"","legend":"\u003cp\u003eImproved reconstructive steps for the anterior vaginal wall during RARC. The anterior vaginal wall should be preserved as much as possible. In particular, the anterior vaginal wall along the back of the urethra is separated from the urethra and preserved as much as possible (a). Much of the residual vaginal wall is left after cystectomy (b). With this technique, the residual vaginal wall can be formed into a roll, and the vaginal apex can also be tightly closed (c, d).\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4460461/v1/c3980400d67a5ffc6108b1d2.jpeg"},{"id":57944348,"identity":"3e854f56-f78c-4ec0-b843-65f02f6d0c0a","added_by":"auto","created_at":"2024-06-07 19:09:49","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":456381,"visible":true,"origin":"","legend":"\u003cp\u003eMacroscopic (a) and computed tomography imaging findings in our case \u003cstrong\u003e(b)\u003c/strong\u003e. Bowel evisceration from the vaginal dehiscence site is observed.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4460461/v1/03522ce9665cb6f1fa58073e.jpeg"},{"id":59508381,"identity":"1ad7eed7-499c-4247-ac79-5aaa6e0ce4a5","added_by":"auto","created_at":"2024-07-02 15:44:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2469412,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4460461/v1/1d8f5d16-d0ce-471b-8df7-3b7dcd9322c1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Investigation of risk factors for vaginal dehiscence and development of small bowel evisceration after robot-assisted radical cystectomy for female bladder cancer and an improved vaginal reconstruction technique to prevent its onset","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRadical cystectomy (RC) is the standard surgical treatment for invasive bladder cancer. In Japan, the surgical method has evolved from open radical cystectomy (ORC) to laparoscopic radical cystectomy (LRC), and further to robot-assisted radical cystectomy (RARC). RARC is currently widely performed in Japan.\u003c/p\u003e \u003cp\u003eIn female patients undergoing RC, the standard surgical approach involves en bloc removal of the bladder, urethra, uterus and anterior vaginal wall. This procedure increases the postoperative risk of vaginal prolapse and organ prolapse secondary to vaginal dehiscence (e.g., small bowel evisceration) due to weakening of pelvic support structures. Although it is rare for the disease to progress to small bowel evisceration, it requires emergency surgical repair since the condition is associated with a high risk of serious complications, such as infections, peritonitis, intestinal necrosis and intestinal obstruction. There are various risk factors for the occurrence of this complication. Parra et al. have identified factors such as advanced age, postmenopause, history of vaginal surgery, and parity as risk factors [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. At our institution, we have also experienced transvaginal small bowel evisceration after RARC. We performed a literature search for previous reviews on vaginal dehiscence and bowel evisceration after RC, but found very little information. Therefore, we reviewed reported cases of vaginal small bowel evisceration after RC, including our case. Furthermore, we examined and implemented effective vaginal reconstructive techniques to prevent postoperative small bowel evisceration. The purpose of this study was to describe this reconstructive technique and evaluate its effectiveness.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eAll patients who underwent LRC or RARC for invasive bladder cancer at our institution between September 2009 and March 2023 were analyzed retrospectively, among whom female patients were analyzed for patient background characteristics, surgical outcomes, and postoperative complications. At our institution, LRC was performed between September 2009 and March 2018, and RARC was performed after April 2018. Urinary diversions were performed by extracorporeal urinary diversion (ECUD) in all cases undergoing LRC, and by intracorporeal urinary diversion (ICUD) in RARC cases performed after December 2019. The da Vinci\u0026reg; Xi Surgical System was used in all RARC cases. We compared and discussed female patients with postoperative transvaginal small bowel evisceration from among previously reported cases, including our own case, and reviewed the associated risk factors. Next, after experiencing a case of postoperative transvaginal small bowel evisceration, we improved our vaginal reconstructive technique during RARC in an attempt to prevent the occurrence of postoperative transvaginal organ prolapse.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eConventional reconstruction procedure\u003c/h2\u003e \u003cp\u003e(a) After detachment of the bladder, uterus and ureters from adjacent tissue, the posterior vaginal fornix is incised to open the vaginal wall. The vaginal wall incision is extended toward the urethra, and the bladder and anterior vaginal wall are released and the vagina is opened wide. (b) The tissues around the urethra and anterior vaginal wall are incised. The bladder, urethra and anterior vaginal wall are transvaginally removed en bloc. With this conventional method, only a small amount of the vaginal wall can be preserved, potentially leading to large defects in the vagina, especially at the vaginal apex (back of the urethra) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea). (c) The residual vaginal walls on both sides are folded craniocaudally, and continuous sutures are placed in the transverse axis using 3-0V-lok (side-to-side) sutures. Next, the cavity of the vaginal apex is closed vertically (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb). Application of excessive tension on the vaginal reconstruction lesion makes it difficult to achieve complete closure, such that it is not strong enough to support the abdominal pressure. If the vaginal wall defect on the dorsal side of the urethra becomes too large, the strength of the vaginal wall at the site of closure cannot be maintained. This appears to increase the risk of developing postoperative organ prolapse (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ec). Taking these problems into consideration, we improved the vaginal reconstruction technique, as described below.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eImproved reconstruction procedure\u003c/h2\u003e \u003cp\u003e(a) The ureters are dissected from the bladder on both sides, and the vesico-vaginal space is dissected as much as possible from both sides before opening the vaginal wall. This makes it possible to open the vaginal wall from the posterior vaginal fornix toward the urethra, making the incision as close to the bladder as possible. During this step, inadvertent electrocoagulation on the vaginal wall and paravaginal tissues should be avoided in order to maintain the blood supply to the vagina as much as possible. (b) Since dissection of the vaginal apex and urethra is generally difficult because of the presence of strong adhesions, the space between the urethra and anterior vaginal wall is stripped as much as possible, and forceps are passed between the anterior vaginal wall and the urethra. This process enables separation of the posterior surface of the urethra and the anterior vaginal wall (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea). The procedure also allows more of the vaginal wall to be preserved, especially the anterior vaginal wall on the back of the urethra, enabling a stronger reconstruction than with the conventional technique (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb). (c) We perform the reconstruction as a roll shape using a continuous caudal-to-cephalad suture. In other words, the residual vaginal walls are brought together in the midline and closed longitudinally from the cranial side (posterior vaginal fornix) to the caudal side (vaginal apex) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ec). This technique allows the vagina to be reconstructed in a tubular shape, allowing easier and more robust reconstruction of the vagina (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ed). We analyzed and compared the surgical outcomes and prophylactic efficacy between 20 patients who underwent the conventional reconstruction technique and 14 patients who underwent the improved reconstruction technique. The Fisher test and Mann-Whitney U test were used to test each factor between the two groups. EZR version 1.36 software (Saitama Medical Center, Jichi Medical University) was used for statistical analysis. \u003cem\u003eP\u003c/em\u003e values of \u0026lt;\u0026thinsp;0.05 were considered significant for all analyses.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatement of ethics\u003c/h2\u003e \u003cp\u003e The research protocol was approved by the ethics review board of Kochi University (Registration number:\u003c/p\u003e \u003cp\u003eERB-103405). Since this was a retrospective study using a database, the ethics committee waived the need for patient informed consent.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eBetween September 2009 and March 2023, a total of 175 patients underwent RC, 77 of which were LRC and 98 were RARC. Of them, 34 patients (19%) were female (LRC: 13, RARC: 21). The characteristics and surgical outcomes of the 34 female patients and 141 male patients are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Median age was 75 (59\u0026ndash;88) years in females and 74 (44\u0026ndash;88) years in males, with no significant difference between them (P\u0026thinsp;=\u0026thinsp;0.64). All the female patients were postmenopausal at the time of surgery. Median BMI was 23.1 (15.5\u0026ndash;34.1) kg/m\u003csup\u003e2\u003c/sup\u003e in females vs 23.2 (16.8-35.59) kg/m\u003csup\u003e2\u003c/sup\u003e in males, indicating no significant difference between them (P\u0026thinsp;=\u0026thinsp;0.68). LRC was performed in 13 females and 64 males, and RARC was performed in 21 females and 77 males (P\u0026thinsp;=\u0026thinsp;0.565). Median total surgical time was 548 (333\u0026ndash;950) minutes in females vs 541 (314\u0026ndash;850) minutes in males, which was not significantly different (P\u0026thinsp;=\u0026thinsp;0.36). Median pneumoperitoneum time was significantly longer in females than in males (360 (135\u0026ndash;655) minutes vs 308 (86\u0026ndash;660) minutes, respectively (P\u0026thinsp;=\u0026thinsp;0.04)). Median robotic console time was significantly longer in females versus males (409 (177\u0026ndash;607) minutes vs 260 (126\u0026ndash;543) minutes, respectively (P\u0026thinsp;=\u0026thinsp;0.03)). It should be noted that the large range of pneumoperitoneum and console times are due to the fact that performance of urinary diversion by ICUD takes a longer time. Blood loss was 190 (50-2970) ml in females vs 350 (10-2730) ml in males, with no significant difference between them (P\u0026thinsp;=\u0026thinsp;0.08). Postoperative hospital stay was 25 (15\u0026ndash;63) days in females vs 25 (11\u0026ndash;76) days in males (P\u0026thinsp;=\u0026thinsp;0.54). In female cases, complications observed included vaginal prolapse in one case (3%), and transvaginal small bowel evisceration in one case (3%). The patient who developed small bowel evisceration was 80 years old at RARC, had a BMI of 23.1 kg/m\u003csup\u003e2\u003c/sup\u003e, and the ileal conduit was created using ICUD for urinary diversion. Total surgical time was 557 minutes, pneumoperitoneum time was 490 minutes, console time was 370 minutes, and blood loss was 370 ml. She developed transvaginal small bowel evisceration 17 weeks after RARC. The prolapsed small bowel was necrotic, and was complicated by intestinal obstruction and peritonitis (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). A gastrointestinal surgeon urgently removed the necrotic small bowel and performed vaginal closure and reinforcement. Since then, she has had no recurrence. However, she also had an abdominal wall scar hernia after RARC, for which she underwent surgical repair.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient characteristics and surgical outcomes in the 34 female patients and 141 male patients who underwent LRC or RARC for bladder cancer\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (19%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e141 (81%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74 (59\u0026ndash;88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e74 (44\u0026ndash;88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI (kg/m\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.1 (15.5\u0026ndash;34.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.2 (16.8\u0026ndash;35.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurgical procedure [n]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLRC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.565\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eRARC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUrinary diversion [n]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eUretrocutaneostomy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eIleal conduit\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNeobladder\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal surgical time [min]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e548 (333\u0026ndash;950)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e541 (314\u0026ndash;850)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePneumoperitoneum time [min]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e371 (135\u0026ndash;655)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e308 (86\u0026ndash;660)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRobotic console time [min]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e409 (177\u0026ndash;607)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e260 (126\u0026ndash;543)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBlood loss [ml]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e190 (50-2970)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e350 (10-2730)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration of hospitalization [days]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (15\u0026ndash;63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 (11\u0026ndash;76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComplications [n]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eVaginal prolapse\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eUrinoma\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePelvic abscess\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eVentral hernia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBowel evisceration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*Mann\u0026ndash;Whitney U test or Fisher's exact test\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eLRC: laparoscopic radical cystectomy, RARC: robot-assisted radical cystectomy.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eNext, we reviewed our case of transvaginal small bowel evisceration after RC, along with six previously reported cases. The results are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Median patient age was 73 (51\u0026ndash;80) years and BMI was 24.4 (23\u0026ndash;28) kg/m\u003csup\u003e2\u003c/sup\u003e. The initial surgical procedure was open radical cystectomy (ORC) in one case, LRC in one case, RARC in four cases and unclear in one case. The onset of small bowel evisceration was at a median interval of 17 (6-120) weeks after RC. The repair method was transvaginal in three cases and transabdominal in four. At the time of RC, the sutures used for vaginal reconstruction were 2\u0026thinsp;\u0026minus;\u0026thinsp;0 PDS in one case, 3\u0026thinsp;\u0026minus;\u0026thinsp;0 V-Loc sutures in two and unknown in three cases. In our case, 3\u0026thinsp;\u0026minus;\u0026thinsp;0 V-Loc sutures had been used. None of the cases had recurrence after the repair surgery. Complications other than transvaginal organ prolapse were observed in two cases of parastomal hernia and two cases of abdominal wall scar hernia. Our case was also complicated by abdominal wall scar hernia before the onset of vaginal small bowel evisceration.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eReview of previous cases of transvaginal small bowel evisceration after radical cystectomy and our case\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMenopause\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSurgery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSutures\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTime to prolapse (wks)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eRepair approach\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eOther complications\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrank et al,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRARC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2\u0026thinsp;\u0026minus;\u0026thinsp;0 PDS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTransvaginal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eParastomal hernia\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrank et al,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRARC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u0026thinsp;\u0026minus;\u0026thinsp;0 V-Loc\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTransvaginal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eParastomal \u0026amp; ventral hernia\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChopra et al,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRARC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eV-Loc\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTransabdominal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChhabra et al,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eORC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTransabdominal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMeguro et al\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLRC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTransabdominal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHassan et al,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTransvaginal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOur case\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRARC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u0026thinsp;\u0026minus;\u0026thinsp;0 V-Loc\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTransabdominal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eVentral hernia\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedian\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e75\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e23.75\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e17\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eORC: open radical cystectomy, LRC: laparoscopic radical cystectomy, RARC: robot-assisted radical cystectomy\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003ePDS: polydioxanone, V-Loc: barbed suture (V-Loc\u0026trade;, Covidien)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSince our experience with that case, we have so far performed RARC on 14 cases at our institution, after improving the vaginal reconstruction technique used during RC. We investigated the surgical outcomes of 20 cases performed before application of the improved technique and 14 cases performed after improvement of the technique (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Median patient age in the pre-improvement group was 75 (59\u0026ndash;88) years, while that of the post-improvement group was 75 (61\u0026ndash;83) years, with no significant difference between them (P\u0026thinsp;=\u0026thinsp;0.861). BMI was 22.3 (15\u0026ndash;28) kg/m\u003csup\u003e2\u003c/sup\u003e vs 26.2 (19\u0026ndash;34) kg/m\u003csup\u003e2\u003c/sup\u003e, indicating a significantly higher BMI in the post-improvement group (P\u0026thinsp;=\u0026thinsp;0.04). In the pre-improvement group, 13 cases underwent LRC and seven cases underwent RARC, while in the post-improvement group, 14 cases underwent RARC, indicating a significant difference in the numbers of the types of surgeries pre-and post-application of the improved technique (P\u0026thinsp;=\u0026thinsp;0.00016). The reason for this is that all patients underwent RARC after 2019 at our institution. In the pre-improvement group, there was one case of ureterocutaneostomy and 19 cases of ileal conduit, while in the post-improvement group, there were two and 12 cases, respectively, of the two procedures, with no significant difference between them (P\u0026thinsp;=\u0026thinsp;0.555). In the pre-improvement group, ECUD was performed in 17 cases and ICUD in three, while in the post-improvement group, ECUD was performed in two cases and ICUD in 10; i.e., significantly more ICUDs were performed in the post-improvement group (P\u0026thinsp;=\u0026thinsp;0.001). The total surgical time was 550 (433\u0026ndash;950) minutes in the pre-improvement group and 543 (333\u0026ndash;685) minutes in the post-improvement group, which was not significantly different (P\u0026thinsp;=\u0026thinsp;0.39). In addition, there was no significant difference in pneumoperitoneum time, which was 324 (135\u0026ndash;655) minutes and 413 (177\u0026ndash;607) minutes, respectively, in the pre- and post-improvement groups (P\u0026thinsp;=\u0026thinsp;0.69). Console time in RARC cases was 315 (186\u0026ndash;485) minutes in the pre-improvement group and 429 (177\u0026ndash;607) minutes in the post-improvement group, with no significant difference (P\u0026thinsp;=\u0026thinsp;0.76), although there was a trend toward longer console times in the post-improvement group. The reason for this is that there were more ICUD cases in the post-improvement group. Blood loss was 435 (70-2970) ml and 135 (50\u0026ndash;300) ml, respectively, with significantly less bleeding in the post-improvement group (P\u0026thinsp;=\u0026thinsp;0.008). The change in technique, thus, did not increase blood loss. No complications of vaginal prolapse or postoperative organ prolapse were observed in the 14 post-improvement cases, and all patients are currently doing well.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of the surgical outcomes of 20 cases pre-improvement and 14 cases post-improvement of the vaginal reconstruction technique used during radical cystectomy.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePre-improvement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePost-improvement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of cases\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75 (59\u0026ndash;88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75 (61\u0026ndash;83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.861\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI (kg/m\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.3 (15\u0026ndash;28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.2 (19\u0026ndash;34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.039\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurgical procedure\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eLRC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.00016\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eRARC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUrinary diversion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eUretrocutaneostomy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.555\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eIleal conduit\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNeobladder\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eECUD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eICUD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal surgical time (min)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e550 (433\u0026ndash;950)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e548 (333\u0026ndash;685)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.39\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePneumoperitoneum time (min)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e324 (135\u0026ndash;655)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e413 (177\u0026ndash;641)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRobotic console time (min)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e315 (186\u0026ndash;485)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e429 (177\u0026ndash;607)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBlood loss (ml)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e435 (70-2970)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e135 (50\u0026ndash;300)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration of hospitalization (days)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (14\u0026ndash;63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18 (15\u0026ndash;53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComplications\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eUrinoma\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePelvic abscess\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eVentral hernia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eVaginal prolapse\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eBowel evisceration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*Mann\u0026ndash;Whitney U test or Fisher's exact test\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eLRC: laparoscopic radical cystectomy, RARC: robot-assisted radical cystectomy, ECUD: extracorporeal urinary diversion, ICUD: intracorporeal urinary diversion\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, total surgical time was not significantly different between males and females (P\u0026thinsp;=\u0026thinsp;0.36), although pneumoperitoneum time and robotic console time were significantly longer in females (P\u0026thinsp;=\u0026thinsp;0.04 and 0.03, respectively). This could be because RC in females generally requires en bloc removal of the bladder, urethra, uterus and anterior vaginal wall, followed by vaginal reconstruction; hence, the time is prolonged due to more surgical steps than in males. Thus, RC in females generally involves removing all anterior pelvic organs and vaginal reconstruction. Therefore, there is an increased risk of transvaginal organ prolapse, such as small bowel evisceration due to weakening of the anterior pelvic support tissue.\u003c/p\u003e \u003cp\u003eTransvaginal small bowel evisceration after RC is a rare, but serious complication, that requires emergency surgical treatment. The mortality rate from this complication is estimated to be 6\u0026ndash;10% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In a multicenter cohort study in Japan, Kanno et al. reported that seven of 100 female patients underwent emergency surgery for bowel evisceration due to vaginal dehiscence after LRC, which is higher than the rate after hysterectomy. Median patient age in their study was 82 years (range: 77\u0026ndash;87 years), and the median onset time of vaginal dehiscence was 147 days (range: 67-1240 days). Older age is considered a risk factor for the development of vaginal dehiscence [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In addition, Chhabra et al. identified factors such as postmenopausal status, history of prior vaginal surgery, and multi parturition as risk factors of vaginal dehiscence [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Menopause is thought to cause the tissues of the vulva and vagina to become thinner, dryer and less elastic, which further reduces blood flow to the vaginal walls, making them more susceptible to rupture [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Other reported risk factors include smoking, trauma from intercourse, obstetric procedures, history of radiation therapy, pelvic floor defects, poor wound healing, chronic steroid administration, and malnutrition [\u003cspan additionalcitationids=\"CR9 CR10 CR11\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. There have been six previous reports of transvaginal small bowel evisceration after RC, showing that it is a rare complication with only few reported cases [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In our case and the six previously reported cases, median patient age was 75 years, median BMI was 23.7 kg/m\u003csup\u003e2\u003c/sup\u003e, and bowel evisceration occurred 17 weeks after surgery. There was a tendency toward development of this complication in elderly cases and those who underwent RARC. The repair approach was transvaginal in two cases and transabdominal in three cases. It is often necessary to partially resect the prolapsed small bowel, and gastrointestinal surgeons generally find it easier to perform the procedure through a transabdominal approach. Evaluation also showed that many cases were complicated by fragility of the abdominal wall, as well as fragility of the pelvic floor. Thus, in addition to organ prolapse, many cases are complicated by abdominal wall herniation, suggesting that sarcopenia might be a risk factor for the development of this condition. Sarcopenia is also associated with weakness of the pelvic floor muscles [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In addition, menopause also causes a decrease in estrogen secretion, which might further increase the risk of sarcopenia progression. Although none of the seven patients who developed vaginal dehiscence was severely obese, it is possible that obesity and postoperative malnutrition are also factors contributing to the occurrence of this complication. As for the frequency of occurrence postoperative transvaginal organ prolapse, the details are unknown because of the small number of reports, although, in general, since bladder cancer occurs more often in older people, women who undergo RC are necessarily older and postmenopausal. It is assumed that these patients are at a high risk of developing postoperative transvaginal organ prolapse.\u003c/p\u003e \u003cp\u003eMany patients with cancer have sarcopenia and malnutrition as a complication. In addition, it is inevitable that the anterior pelvic organs (bladder, urethra, uterus and anterior vaginal wall) are almost completely removed during surgery, which results in abdominal pressure being exerted directly on the reconstructed vaginal wall. Therefore, the risk of developing transvaginal organ prolapse after RC is equal to or greater than that following obstetric and gynecological surgery. Of the seven cases examined in this study, two cases developed dehiscence more than one year after surgery, while it developed as early as 6 months after surgery in four cases, suggesting that many cases develop dehiscence relatively soon after surgery. Our case was 80 years old, the oldest of the reported cases, and developed dehiscence 17 weeks after RARC. Although we could not identify any factors that affected surgical outcomes, we thought that the risk factors include a history of previous hysterectomy, old age and menopause. In addition, this case was complicated by ventral hernia at the abdominal wound, suggesting that sarcopenia was also a likely predisposing factor for transvaginal organ prolapse in our case.\u003c/p\u003e \u003cp\u003eWe believe that it is important to perform appropriate vaginal reconstruction at the time of initial RC for women at risk, to prevent the onset of vaginal dehiscence. Various surgical techniques to prevent postoperative vaginal dehiscence have been reported, including bilateral vaginal uterosacral ligament suspension, vertical sutures, preservation of the length of the vaginal apex, and incision with minimal coagulation to preserve blood flow to the vaginal wall [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Cronin et al. suggested that surgical techniques to prevent vaginal dehiscence include the use of a monopolar electrocautery during vaginal wall excision, two-layer suturing, ensuring adequate tissue margins during reconstruction, and the use of bidirectional barbed sutures, such as V-Loc sutures [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. We considered several surgery-related risk factors as potentially predisposing to the risk of vaginal dehiscence, and examined procedures that could eliminate these factors, such as: 1. Since there is little residual vaginal wall, the vaginal wall is easily detached due to the undue tension exerted on it when the opening is closed; 2. Impaired blood flow to the vaginal wall due to careless electrocoagulation in the surrounding tissue; 3. Reconstruction in a way that makes dehiscence easy (side to side); and 4. Changes in the anatomical position of the vagina due to surgery (disappearance of the flap valve mechanism of the vagina). Cerqui et al. discussed this change in the anatomical position of the vagina, suggesting that it could be due to deviation from normal conditions in the maintenance of pelvic pressure distribution [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Under normal circumstances, the upper vaginal axis is parallel to the elevator plates and oriented perpendicular to the direction of abdominal pressure. In other words, by tilting the upper vaginal canal in a cephalic-dorsal direction and maintaining it cephalad to the levator plate, it is supported by the pelvic floor muscles (levator plate) even when abdominal pressure increases, which helps to prevent prolapse (flap valve mechanism of the vagina). However, after RC, the anatomical relationship of the vagina changes and the normal axis of the vagina might also change, with positioning of the vagina in a more vertical position. As a result, abdominal pressure is directed towards the axis parallel to the vaginal fornix, making the vaginal reconstruction more susceptible to dehiscence (disappearance of the flap valve mechanism of the vagina) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Frank et al. pointed out two basic problems in dissection after anterior pelvic organ removal. The first problem is total absence of the bladder and associated anterior vaginal wall. A defect in the anterior vaginal canal allows the abdominal contents to come into direct contact with this point of weakness. Second, there is a near-lack of reliable anatomical fixation points for reconstruction of the pelvic floor muscles and vaginal canal[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The authors of that study showed two methods for vaginal wall reconstruction. One is the method of folding the vaginal wall in a craniocaudal direction and closing it on the horizontal axis (clam shell method (i.e., side to side)). The other is a method of closing the residual vaginal walls along the same axis as the body axis (i.e., cranial to caudal) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. We initially attempted the clam shell method (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), although, in this method, since the residual vaginal walls are folded down, the original cylindrical shape of the vagina is disturbed, resulting in unreasonable tension on the vaginal wall. This might also lead to disruption of blood flow to the remaining tissues. Therefore, after experiencing a case of small bowel evisceration, we changed the method to forming the residual vaginal wall into a roll shape to preserve the original shape of the vagina as much as possible. This procedure is similar to the caudal-to-cephalad method (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This results in the original form of the vagina and its anatomical positional relationship being maintained, so that the flap valve mechanism, which is particularly important for preservation of pelvic organ function, can be maintained as much as possible. Furthermore, by maintaining the original shape of the vaginal canal against abdominal pressure, blood flow to the vaginal wall is also not likely to be obstructed. To perform this procedure, it is necessary to separate the space between the bladder and the anterior vaginal wall as much as possible, preserving the vaginal wall, rather than inadvertently cutting off the vaginal wall when the bladder is released. It is also important to avoid electrocoagulation of the vaginal wall and paravaginal tissues to maintain blood flow. In addition, we believe that preservation of the anterior vaginal wall at the vaginal apex, that is, at the back of the urethra, is particularly important for strong vaginal reconstruction. Inadvertently and extensively resecting the vaginal wall can create large defects that make subsequent vaginal reconstruction difficult or impossible. We believe that this increases the risk of postoperative vaginal dehiscence and transvaginal prolapse. Therefore, we dissected the gap between the urethra and the anterior vaginal wall, preserving as much of the anterior vaginal wall as possible. After changing to this procedure, we have not experienced any occurrence of postoperative vaginal or other organ prolapse at our institution. However, caution is required when bladder cancer is located near the anterior vaginal wall, such as at the posterior bladder wall or bladder neck. In such cases, if the anterior vaginal wall is inadvertently preserved too much, it might lead to residual cancer at the resection margin, leading to a pathological diagnosis of a positive resection margin. Recognizing the location of the tumor and preoperative simulation of the extent of resection is important to ensure cancer control.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eMethodological limitations\u003c/h2\u003e \u003cp\u003eIn this study, the reviewed cases were only those found in our literature search. We believe that there could be many more cases that have not been published, and that the actual number of cases of transvaginal small bowel evisceration after RC is much higher. However, the exact number of cases and incidence is unclear. In addition, the 34 cases enrolled in this study were a mixture of cases with different techniques, including LRC and RARC. Furthermore, the improved reconstructive techniques described here were performed during RARC, and we do not guarantee that the same procedures can be performed during ORC or LRC.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTransvaginal organ prolapse, such as small bowel evisceration, is a rare complication after RC, but can easily become severe. Emergency surgery is essential for its treatment, which increases the physical burden on the patient. Therefore, all possible measures to prevent its occurrence should be taken during RC. We believe that the risk of developing this disorder can be reduced by using the vaginal reconstruction technique described here. In the future, we should collect more cases performed by our technique to examine its preventive effects.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Sources\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparations\u0026nbsp;were performed by\u0026nbsp;\u003cem\u003eSatoshi Fukata\u003c/em\u003e,\u003cem\u003e\u0026nbsp;Ayano Kawaguchi\u003c/em\u003e. Data collections\u0026nbsp;were performed by\u0026nbsp;\u003cem\u003eSatoshi Fukata\u003c/em\u003e,\u003cem\u003e\u0026nbsp;Ayano Kawaguchi, Rie Yoshimura, Hideo Fukuhara, Takashi Karashima\u003c/em\u003e. Data\u0026nbsp;analyses were performed by\u0026nbsp;\u003cem\u003eSatoshi Fukata\u003c/em\u003e.\u0026nbsp;\u0026nbsp;Prepared figures 1-3 were performed by\u003cem\u003e\u0026nbsp;Satoshi Fukata\u003c/em\u003e,\u003cem\u003e\u0026nbsp;Ayano Kawaguchi\u003c/em\u003e.\u0026nbsp;\u0026nbsp;The first draft of the manuscript was written by\u0026nbsp;\u003cem\u003eSatoshi Fukata\u003c/em\u003e and\u0026nbsp;critical revision of the manuscript was performed by \u003cem\u003eK\u003c/em\u003e\u003cem\u003eeiji\u0026nbsp;\u003c/em\u003e\u003cem\u003eI\u003c/em\u003e\u003cem\u003enoue\u003c/em\u003e\u003cem\u003e.\u0026nbsp;\u003c/em\u003eAll authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis is an observational study.\u0026nbsp;The research protocol was approved by the ethics review board of Kochi University (Registration number:ERB-103405). Since this was a retrospective study using a database, the ethics committee waived the need for patient informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors affirm that human research participants provided informed consent for publication of the images in\u0026nbsp;\u003cem\u003eFigure(s) 1a, 1b, 1c, 2a, 2b, 2c, 2d, 3a and 3b.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are not publicly available since they contain information that could compromise the privacy of research participants, but are available from the first author (S.F.) upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the patients, research facilities, and research staff who participated in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eParra RS, Rocha JJ, Feres O (2010). Spontaneous transvaginal small bowel evisceration: A case report. Clinics (Sao Paulo) 65:559\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSameer Chopra, Arjuna Dharmaraja, Hooman Djaladat (2016). Transvaginal bowel evisceration following robot-assisted radical cystectomy. Indian J Urol. 32(4): 320\u0026ndash;322.doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/0970-1591.189714\u003c/span\u003e\u003cspan address=\"10.4103/0970-1591.189714\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChhabra S, Hegde P (2013). Spontaneous transvaginal bowel evisceration. Indian J Urol.29:139\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrank C. Lin, Andrew Medendorp, Michelle Van Kuiken, Steven A. Mills, Christopher M. Tarnay (2019). Vaginal Dehiscence and Evisceration After Robotic-assisted Radical Cystectomy: A Case Series and Review of the Literature. Urology. 134:90\u0026ndash;96. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.urology.2019.09.009\u003c/span\u003e\u003cspan address=\"10.1016/j.urology.2019.09.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKanno T, Ito K, Sawada A \u003cem\u003eet al\u003c/em\u003e (2019). Complications and reoperations after laparoscopic radical cystectomy in a Japanese multicenter cohort. Int. J. Urol. 26: 493\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWan Amir Wan Hassan, Vignesh Narasimhan, Asiri Arachchi, Thomas Manolitsas, William Teoh (2021). Small bowel evisceration from vagina.J Surg Case Rep. 8: rjab343.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNikolopoulos I, Khan H, Janakan G, Kerwat R (2013). Laparoscopically assisted repair of vaginal evisceration after hysterectomy. \u003cem\u003eBMJ Case Rep\u003c/em\u003e pii: Bcr2013009897.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHur HC, Guido RS, Mansuria SM, Hacker MR, Sanfilippo JS, Lee TT (2007). Incidence and patient characteristics of vaginal cuff dehiscence after different modes of hysterectomies. J. Minim. Invasive Gynecol. 14: 311\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUccella S, Bogani G, Ghezzi F (2012). Vaginal cuff dehiscence after laparoscopic and robotic hysterectomy: is endoscopic colporraphy a waste of time? \u003cem\u003eAm. J. Obstet. 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Biol. 125: 134\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eR\u0026aacute;vida R L Silva, Jana\u0026iacute;na F V Coutinho, Camila T M Vasconcelos, Jos\u0026eacute; Ananias Vasconcelos Neto, Rachel Gabriel B Barbosa \u003cem\u003eet al\u003c/em\u003e (2021). Prevalence of sarcopenia in older women with pelvic floor dysfunction. Eur J Obstet Gynecol Reprod Biol 263:159\u0026ndash;163. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ejogrb.2021.06.037\u003c/span\u003e\u003cspan address=\"10.1016/j.ejogrb.2021.06.037\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKashani S, Gallo T, Sargent A, Elsahwi K, Silasi DA, Azodi M (2012). Vaginal cuff dehiscence in robotic-assisted total hysterectomy. JSLS.16: 530\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRobinson BL, Liao JB, Adams SF, Randall TC (2009). Vaginal cuff dehiscence after robotic total laparoscopic hysterectomy. Obstet. Gynecol. 114: 369\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCronin B, Sung VW, Matteson KA (2012). Vaginal cuff dehiscence: risk factors and management. Am. J. Obstet. Gynecol.206: 284\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCerqui AJ, Haran M, Collier SM (1998). A case of transvaginal evisceration. Aust N Z J Obstet Gynaecol. 38:229\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eM TAKEYAMA (2020). EVIDENCE OF PELVIC ORGAN PROLAPSE AND ITS TREATMENT. J Jpn Surg Assoc 81(2), 209\u0026ndash;220\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Postoperative vaginal failure, robot-assisted radical cystectomy, transvaginal bowel evisceration, vaginal reconstruction technique","lastPublishedDoi":"10.21203/rs.3.rs-4460461/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4460461/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e Transvaginal organ prolapse, such as small bowel evisceration, is a rare complication after radical cystectomy (RC) in female patients with invasive bladder cancer, However, it often requires emergency surgical repair. Here, we describe our experience with such a case and a review of similar previously reported cases, along with evaluation of the risk factors. We also propose a vaginal reconstruction technique to prevent this complication during robot-assisted laparoscopic radical cystectomy (RARC).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e A total of 178 patients who underwent laparoscopic radical cystectomy (LRC) or RARC were enrolled, 34 of whom (19%) were female. One of the 34 female patients had transvaginal small bowel evisceration after RARC. We evaluated our case and six such previously reported cases, to determine vaginal reconstruction techniques during RARC to prevent this complication postoperatively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e Median age of these cases was 73 (51-80) years, and all patients were postmenopausal. The median time to small bowel evisceration was 14 (6-120) weeks postoperatively. In addition, we changed the methods of the vaginal reconstruction technique during RARC from the conventional side-to-side closure technique to the improved caudal-to-cephalad closure technique. Since implementing this change, we have not experienced any cases of vaginal vault dehiscence or organ prolapse.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003eTransvaginal small bowel evisceration after RC can easily become severe. Therefore, all possible preventive measures should be taken during RARC. We believe that our vaginal reconstruction techniques might reduce the risk of developing this complication.\u003c/p\u003e","manuscriptTitle":"Investigation of risk factors for vaginal dehiscence and development of small bowel evisceration after robot-assisted radical cystectomy for female bladder cancer and an improved vaginal reconstruction technique to prevent its onset","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-07 19:09:44","doi":"10.21203/rs.3.rs-4460461/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-21T22:21:01+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-21T11:17:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"174784349750555013857612638920512834195","date":"2024-05-26T06:25:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-26T00:29:37+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-26T00:24:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-23T11:50:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Robotic Surgery","date":"2024-05-22T11:10:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"b11dbba5-23b0-45f6-9b7f-93aca72f2e2a","owner":[],"postedDate":"June 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-07-02T15:44:50+00:00","versionOfRecord":{"articleIdentity":"rs-4460461","link":"https://doi.org/10.1007/s11701-024-02035-0","journal":{"identity":"journal-of-robotic-surgery","isVorOnly":false,"title":"Journal of Robotic Surgery"},"publishedOn":"2024-07-02 15:44:50","publishedOnDateReadable":"July 2nd, 2024"},"versionCreatedAt":"2024-06-07 19:09:44","video":"","vorDoi":"10.1007/s11701-024-02035-0","vorDoiUrl":"https://doi.org/10.1007/s11701-024-02035-0","workflowStages":[]},"version":"v1","identity":"rs-4460461","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4460461","identity":"rs-4460461","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}