Sigmoid volvulus is an uncommon but significant cause of large bowel obstruction, typically associated with anatomical predispositions. Robotic-assisted laparoscopic prostatectomy (RALP) is a well-established surgical approach for localized prostate cancer, yet its association with postoperative sigmoid volvulus remains undocumented. We present the first known case of recurrent sigmoid volvulus following RALP.

Our patient was a 73-year-old male who presented with an elevated PSA of 15.4 ng/ml on a background of long-standing metabolic syndrome, osteoarthritis and two previous cerebrovascular accidents (CVA). Transperineal biopsy diagnosed Gleason 9 (G4+5), grade group 5 prostate cancer of the right posterior lobe. A staging PSMA PET scan confirmed high local prostate avidity and no metastasis. An uncomplicated anterior RALP was performed with minimal lateral mobilization of the sigmoid mesocolon to make space. The final histopathology demonstrated a pT3a stage cancer with clear surgical margins. Postoperatively he was discharged with paracetamol, laxatives and enoxaparin.

19-days following RALP the patient presented to the emergency department (ED) with a three-day history of obstipation, distension and reduced oral intake. Abdominopelvic CT revealed sigmoid volvulus (Figure 1). Flexible sigmoidoscopy confirmed sigmoid volvulus and decompression was performed with no complications. Two months after discharge, the patient presented again to ED with a similar three-day history of obstipation and progressive abdominal distension. Abdominopelvic CT and flexible sigmoidoscopy confirmed sigmoid volvulus again. One month later an elective anterior resection of the sigmoid colon was performed to prevent recurrence of symptoms following his urological procedure.

This case suggests a possible association between RALP and sigmoid volvulus, potentially influenced by intraoperative positioning, pneumoperitoneum, and mesenteric mobilization. After exclusion of more benign causes of intestinal obstruction, sigmoid volvulus may occur in patients who undergo lateral peritoneal release to mobilize the sigmoid colon. Consideration may be needed to laterally repair any sigmoid released during dissection in RALP.