Vaginal prolapse is a common long-term complication of female cystectomy which has traditionally been underreported in cystectomy studies. In recent studies specifically looking at vaginal complications the long term prolapse rate was estimated between 20-80% of all female patients undergoing cystectomy. Suspension of the vaginal vault using native tissue, sutures or mesh are well described treatments for prolapse but use of any of these techniques prophylactically during cystectomy are not well described. We aimed to describe our technique of native tissue vaginal suspension during robotic female cystectomy and assess if it is associated with any adverse outcomes for those patients. We also aimed to assess predictive factors for when this technique is not possible to be performed.

We analysed our prospective, institutional database of >1000 cystectomies at Guys Hospital, London for all female cystectomies. We limited our date range from Oct 2023 to May 2024, as this is when all robotic procedures were reliably recorded on our cloud database to assess whether a native tissue vaginal suspension was performed. We then compared females who underwent native tissue vaginal suspension to those who did not during cystectomy in terms of demographics, surgical operating time, blood loss and complications. Statistical analysis was performed using SPSS 24.0

Twenty-one female cystectomies over this 8-month period were available for analysis. Median age was 71 years (Range 29-80), BMI 30.4 (Range 13-40), and indications for cystectomy were urothelial cancer (57%), squamous cell carcinoma (10%), and benign/premalignant conditions (33%). 81% of cases were performed robotically for both the cystectomy and urinary diversion. Eight females underwent native tissue suspension of the vagina where the round ligament is divided close to its insertion of the uterus and mobilised to the deep inguinal ring. Following removal of the bladder, uterus, fallopian tubes +/- ovaries via the vaginal incision, the vagina is reconstructed with a 2-0 barbed suture. The round ligament is then secured to the reconstructed vaginal using a 2-0 vicryl suture, suspending the vaginal vault to prevent vaginal prolapse. Native tissue vaginal suspension was not associated with any increase in blood loss (262ml vs. 305ml), total operating time (362.5 min vs. 348mins), length of stay 14.8 days (Range 5-34 days) vs. 15.6 days (Range 7-29 days). Complication rates were similar- Clavien I-II (50% vs. 46%), Clavien III-V (12% vs. 23%). In the cancer cases the suspension technique was not associated with a positive surgical margin (0% vs. 7%).

We describe a simple technique of native tissue vaginal suspension for prevention of vaginal prolapse following female cystectomy. This technique is not associated with any adverse outcomes or significant increase in operating time. Long term follow-up will be required to determine the durability of this technique for preventing vaginal prolapse.