Efficacy of the Mercedes‐Benz closure technique for vaginal reconstruction in female robot‐assisted radical cystectomy

Abstract

Introduction Vaginal reconstruction using the posterior vaginal wall is required following radical cystectomy in women with resection of the uterus, adnexa, and anterior vaginal wall. Roll closure and clamshell closure are two widely known techniques. Of these, clamshell closure is recommended because roll closure has a high likelihood of breakdown or a resultant canal that is too narrow for sexual intercourse. In clamshell closure, however, folding the posterior vaginal wall anteriorly can be difficult. Therefore, we devised Mercedes‐Benz closure, in which the vaginal wall is sutured from three directions to form a Mercedes‐Benz shape, for anastomosis without tension on the vaginal wall. The present study was performed to investigate the efficacy of this alternative surgical technique for vaginal reconstruction. Methods Twenty‐six patients who underwent vaginal reconstruction following robot‐assisted radical cystectomy were divided into two groups: 15 underwent clamshell closure and 11 underwent Mercedes‐Benz closure. The patients' characteristics and surgical outcomes were compared between the two groups. Results There were no significant differences in clinical characteristics, including age, body mass index, and prior abdominal surgery between the two groups. The median vaginal reconstruction time tended to be longer in the Mercedes‐Benz closure group than in the clamshell closure group (35.0 vs. 27.0 min, p = 0.102). No complications associated with vaginal reconstruction were identified. Conclusion The surgical outcomes were comparable between Mercedes‐Benz closure and clamshell closure. If vaginal reconstruction with clamshell closure is difficult, Mercedes‐Benz closure is a valuable alternative technique.

A case of laparoscopically assisted transperineal repair of anterior enterocele dehiscence with small bowel evisceration after robot-assisted radical cystectomy

“…Radical cystectomy in women classically involves removal of the bladder, urethra, and anterior vaginal wall along with the uterus and adnexa. 3 In anterior vaginectomy and urethrectomy, the periurethral fascia and ligamentous support of the pubic symphysis are disrupted. 1 Vaginal reconstruction using the posterior vaginal wall is commonly required following radical cystectomy in women.…”

“…To avoid vaginal dehiscence, the vaginal wall should be closed very tightly and carefully so that no tension is placed on it. 3 We previously reported use of the Mercedes-Benz closure technique to achieve this goal in vaginal reconstruction. 3 Thus, although we have focused on surgical techniques for vaginal reconstruction, our research indicates that surgical techniques alone are insufficient to prevent the occurrence of an anterior enterocele.…”

“… 3 We previously reported use of the Mercedes-Benz closure technique to achieve this goal in vaginal reconstruction. 3 Thus, although we have focused on surgical techniques for vaginal reconstruction, our research indicates that surgical techniques alone are insufficient to prevent the occurrence of an anterior enterocele. In the present case, the small bowel evisceration did not occur at the vaginal closure site, but between the vaginal wall and the posterior pubic bone.…”

“…The Mercedes-Benz closure technique was performed for vaginal reconstruction using the posterior vaginal wall. 3 No perioperative complications occurred, and the patient was discharged on postoperative day 20. However, 3 months after surgery, she complained of a bulge sensation in the vagina, and physical examination confirmed a ping-pong ball-sized anterior enterocele ( Fig.…”