Recurrent sigmoid volvulus after robotic-assisted laparoscopic prostatectomy





Abstract


A 73-year-old man underwent uncomplicated robotic-assisted laparoscopic prostatectomy (RALP). Nineteen days later, he developed constipation, obstipation, and distension. Imaging confirmed sigmoid volvulus, and he was subsequently managed with endoscopic detorsion. Recurrence occurred two months later, requiring colectomy.


Sigmoid volvulus has not been reported after RALP. RALP may contribute to sigmoid volvulus due to operative patient positioning, pneumoperitoneum, and mesenteric mobilization. Clinicians should be aware of this potential complication, particularly in elderly patients with predisposing anatomical factors. Consideration may be needed to laterally repair any sigmoid released during dissection in RALP.


1


Introduction


Sigmoid volvulus is a condition characterized by torsion of the sigmoid mesentery around its pedicle, leading to a closed-loop obstruction. It accounts for 2 %–5 % of all large bowel obstructions in Western countries. Contributing factors to its development include a ‘longer-than-wide’ mesentery (dolichomesentery), narrowing of the sigmoid mesenteric base, and redundancy of the sigmoid colon—pathological changes commonly associated with aging. Other risk factors include living at high altitudes (>5000 feet), chronic constipation and a high-fiber vegetable diet. ,


Robot-assisted laparoscopic prostatectomy (RALP) is a widely performed procedure for clinically localized prostate cancer, surpassing open prostatectomy in popularity. In England, RALP accounted for 85.1 % of prostatectomies, and in the United States, 78.1 % between 2005 and 2017. Compared to open prostatectomy, RALP offers benefits such as reduced blood loss, quicker recovery, shorter hospital stays, less post-operative pain, and lower complication rates. Despite its overall low complication rate, RALP may still lead to minor bleeding, lymphocele, erectile dysfunction, urinary incontinence, postoperative transient ileus, and intestinal injuries such as colorectal perforation. However, the association between RALP and unusual postoperative complications, such as recurrent sigmoid volvulus remains poorly documented.


Our report aims to present the first case to our knowledge of recurrent sigmoid volvulus following RALP and educate clinicians about the possibility of unusual bowel complications following this urological procedure proposing a pathophysiology on how this complication may have occurred and risk factors that could have facilitated the development of such complication.


2


Case presentation


2.1


Patient background


Our patient was a 73-year-old male diagnosed with localized prostatic cancer on a background of long-standing metabolic syndrome, osteoarthritis, peptic ulcer disease and two previous cerebrovascular accidents (CVA). His regular medications were aspirin, telmisartan, rosuvastatin, esomeprazole, empagliflozin and metformin. He had no known allergies. He was an ex-smoker and drank one bottle of wine a night.


2.2


Prostate cancer diagnosis


The patient was referred to urology with an elevated PSA of 15.4 ng/ml, which was an increase from 8.13 ng/ml performed the year prior. Multiparametric MRI (mpMRI) demonstrated no lesion and a transperineal prostate biopsy (TPB) revealed 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. The final histopathology demonstrated a pT3a stage cancer with clear surgical margins.


2.3


RALP and discharge


RALP was performed under general anesthetic in the 27-degrees trendelenburg position with a zero-degree telescope. A 24F rectal tube and 18F indwelling catheter (IDC) were inserted during the procedure. Hasson port was passed supraumbilically and insufflated to 10 mmHg with the remaining ports inserted under vision. The sigmoid colon was minimally released laterally to drop the bowel away from the working peritoneal space. There were no adhesions observed and the sigmoid was normal in appearance and attachment. The space of retzius was accessed and a routine prostatectomy was performed. Bladder neck was spared, bilateral nerve sparing was not performed, dorsal venous complex was cut and oversewn. Prior to vesicourethral anastomosis a negative rectal leak test with 60ml air was performed via a syringe, with insufflated air then removed and the rectal tube left open at the end till removal at case completion. The anastomosis was watertight with a negative 180 ml leak test. Total operative time was 160 minutes and estimated blood loss measured at 250 ml. The patient was discharged after two days and postoperative care included analgesia on demand, laxatives for three-days and enoxaparin venous thromboembolism (VTE) prophylaxis.


2.4


ED presentation


19-days following RALP the patient presented to the emergency department (ED) with a three-day history of obstipation and reduced oral intake. He also presented with a two-day history of nausea, one episode of vomiting and back pain relieved by lying supine. He denied any abdominal pain, urinary symptoms, fevers or chills. He also denied any recent opioid use and was using paracetamol when required following RALP.


On examination his vitals were normal. His abdomen appeared very distended, however non-tender to light and deep palpation. There was no guarding or peritonism. Bowel sounds were hyperactive on auscultation. Digital rectal examination revealed an empty rectum with no blood or fecal matter.


2.5


Sigmoid volvulus diagnosis & management


The patient was admitted, and an abdominal & pelvis contrast-enhanced CT was performed revealing volvulus of the sigmoid colon ( Figs. 1–4 ). Flexible sigmoidoscopy confirmed a sigmoid volvulus 30 cm of insertion of the scope. There was no masses or blood, and the mucosa appeared normal and healthy. The patient underwent sigmoid detorsion and the colon was decompressed with insertion of a rectal tube. There were no procedural complications during the flexible sigmoidoscope. Postoperatively, he was commenced on regular metoclopramide, cetirizine, analgesia and osmotic laxatives. Postoperative stay was complicated by euglycemic ketoacidosis thus, seven days later the patient was discharged.




Fig. 1


Sigmoid Volvulus Axial CT abdomen/pelvis.

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May 7, 2025 | Posted by in UROLOGY | Comments Off on Recurrent sigmoid volvulus after robotic-assisted laparoscopic prostatectomy

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