As robot-assisted radical cystectomy (RARC) becomes more widespread, there are many cases of postoperative anterior enterocele (AE). We also experienced two cases of AE. In this report, we describe an innovative method to prevent AE.

In conventional RARC, the vaginal wall is partially resected when the bladder and uterus are en bloc removed, and the remaining vaginal wall is reconstructed sutured together. Because the vaginal wall is more easily dissected in robot-assisted surgery than in open surgery, much of the vaginal wall is preserved, but it is thin and has poor vascular supply. In addition, it is assumed that postoperative AE is increasing because thin vaginal walls are difficult to suture due to pneumoperitoneum. In the present report, we have devised a method based on sacrocolpopexy and uterosacral ligament suspension. First, a subtotal hysterectomy was performed, and the cervix was preserved. Next, an intestinal spatula was placed through the vagina and a dissection between the bladder and the vaginal wall was performed, and then cystectomy was to be performed. The vaginal wall is therefore preserved without incision. After cystectomy, the cervix was suture-fixed to the bilateral uterosacral ligament.

We have performed this method in five cases so far. No AE has occurred more than one year after surgery.

This method can preserve the vaginal wall in a normal state and is considered a useful method for preventing AE due to the suspension of the vaginal canal by fixing the cervix to the uterosacral ligament and the flap valve effect (Fig 1 and 2 C&D).