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Urol Case Rep
Urol Case Rep
Urology Case Reports
2214-4420
Elsevier

S2214-4420(24)00188-8
10.1016/j.eucr.2024.102834
102834
Trauma and Reconstruction
Transrectal bladder prolapse in a male managed with a robotic-assisted laparoscopic cystoprostosacropexy
Patel Saawan D.
Williams Cheyenne
Roberson Daniel S.
Mucksavage Phillip
Smith Ariana L. ariana.smith@pennmedicine.upenn.edu
⁎
Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, 800 Spruce St, Philadelphia, PA, 19107, USA
⁎ Corresponding author. University of Pennsylvania Perelman School of Medicine, 800 Walnut Street 19th Floor, Philadelphia, PA, 19107, USA.| ariana.smith@pennmedicine.upenn.edu
03 9 2024
11 2024
03 9 2024
57 10283420 8 2024
27 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Pelvic floor disorders frequently occur as the result of excessive straining from chronic constipation or the trauma of vaginal childbirth, making them more common in women. We present a 62-year-old male with bladder prolapse through the anterior rectal wall in the setting of longstanding bladder holding behavior and excessive straining to void. We performed a novel robotic-assisted laparoscopic cystoprostosacropexy by anchoring the bladder and prostate to the sacrum to prevent bladder descent. Postoperatively, the bladder prolapse resolved with return of normal urinary function. This case underscores the potential of innovative surgical techniques in managing complex pelvic floor disorders in males.
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pmc1 Introduction

The pelvic floor functions to support pelvic organs and prevent downward herniation of the bladder, prostate, uterus, and intestines with increases in intra-abdominal pressure. Pelvic organ prolapse (POP) occurs when the pelvic floor support is weakened due to prolonged or excessive straining or trauma, such as that seen with chronic constipation and vaginal childbirth.1 The occurrence of POP is much less common in male anatomy compared to female anatomy, as the male anatomy benefits from additional pelvic support (e.g., the prostate gland), which resists herniation through the pelvic diaphragm. To our knowledge, only one previous report describes bladder prolapse pathology in the setting of male anatomy.2 Here, we present the case of a 62-year-old male with a bothersome bladder prolapse through the anterior rectal wall.

2 Case presentation

A 62-year-old male with a history of longstanding, bladder holding behavior presented to our institution with increased difficulty emptying his bladder and worsening bladder prolapse per rectum. At the age of 43, the patient began experiencing urinary hesitancy and straining to void. He had a notable history of prolonged bladder holding due to occupational demands and heavy weight training (e.g., squatting, deadlifting), but he had no history of constipation or defecatory dysfunction. At the age of 48, an outside hospital urologist diagnosed him with benign prostatic hyperplasia (BPH) with incomplete bladder emptying. Prostate-specific antigen (PSA) levels remained within age-appropriate limits, and clinical evaluation showed no concern for pelvic malignancy. He underwent transurethral resection of the prostate (TURP) which temporarily improved his voiding dynamics and bladder emptying. However, by the age of 54, his condition regressed with incomplete bladder emptying and significant straining to void to the point of experiencing a vasovagal episode with subsequent rib fracture in one instance. Trials of bethanechol, tamsulosin, and silodosin did not improve his symptoms. The patient also reported that during episodes of straining to urinate, a tissue bulge through his anus was apparent, and with digital reduction, he experienced improved urinary flow. He also frequently passed small soft stools while straining to urinate and denied constipation or prolapse of tissue with bowel movements. After completing urination and cessation of straining, the anorectal bulge reduced inside his anal canal. On physical exam during Valsalva, a grade IV, full-thickness anorectal prolapse was noted. Given the degree of symptoms, he was instructed to begin clean intermittent catheterization (CIC) which he adhered to intermittently.

At the age of 56, a colorectal surgeon evaluated him for anorectal prolapse and performed a laparoscopic sigmoid resection and rectal prolapse repair. This procedure temporarily improved his anorectal bulge and his voiding symptoms, but within two years, symptoms recurred necessitating a return to CIC. Upon return of voiding symptoms, a dynamic magnetic resonance imaging (MRI) revealed an extensive bladder prolapse into the anorectal space with 20 % of the bladder below the pubococcygeal line (PCL). An outside urologist placed transprostatic implants (i.e., Urolift) to address his straining with urination and again temporary improvement was seen. Over five years, his condition again deteriorated with return of the anorectal bulge and straining to void; his post-void residual (PVR) increased from 16mL to 205mL. He experienced recurrent syncopal episodes secondary to excessive straining to urinate, and the anorectal prolapse remained outside his anus after voiding. He denied constipation, prolapse of the anorectal tissue during bowel movements, or prolapse during physical activity and weightlifting. Subsequent MRI (Fig. 1) revealed worsening bladder prolapse with 50 % of the bladder below the PCL. Video urodynamic testing revealed a straining pattern during an attempt to void with no detrusor activity seen. The bladder was smooth appearing with significant posterior descent with an attempt at voiding. The non-invasive maximum flow rate was measured at 13mL/s with a straining staccato pattern and PVR of 250mL. The patient reported normal bladder sensations during filling, normal bladder compliance, and a cystometric capacity of 647mL. He was instructed to start pelvic floor physical therapy and to resume CIC to avoid all straining with voiding attempts. He was not satisfied with this solution and continued to volitionally void with straining; he failed to make progress with pelvic floor therapy.Fig. 1 Pre-operative MRI sagittal views of bladder prolapse upon Valsalva maneuver. (A) At rest. (B) Mid-Valsalva with yellow arrowing indicating posterior bladder prolapse into the anterior rectal wall. (C) Full Valsalva with bladder prolapse through the anterior rectal wall and anus. Arrow indicates contrast filled bladder prolapse protruding through the anus, well below the PCL. (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)

Fig. 1

Given the patient's persistent bothersome symptoms, we offered surgical repair of the bladder prolapse, acknowledging the unique nature of his pathology and the likelihood that he would need ongoing CIC for his atonic bladder. We performed a novel robotic-assisted laparoscopic cystoprostosacropexy. During the procedure, we carefully dissected posterior to the bladder and prostate to the distal apex of the prostate, remaining above the rectum within a previously violated Denonvilliers' plane. A biologic Alloderm graft was used to anchor the bladder and posterior prostate to the anterior sacrum to support the bladder in the pelvic cavity and strengthen the plane between the bladder and anterior rectal wall (Fig. 2). Alloderm, a biologic substrate derived from a cadaveric dermis, was selected over synthetic mesh to reduce the risk of infection and lower the risk of erosion into adjacent organs.3 We anchored the Alloderm using a combination of absorbable polyglactin 910 (Vicryl) on the bladder and prostate and non-absorbable polytetrafluoroethylene (Gore-Tex®) sutures on the sacrum.Fig. 2 Final Alloderm biologic graft placement. (A) Distal Alloderm attachment to the distal apex of the prostate; Alloderm is folded back toward the midline to reinforce support under the narrow prostate gland. (B) Alloderm segment posterior to the bladder is spread in a single layer to support the broad base of the bladder and tapered toward the sacral promontory. (C) Proximal Alloderm attachment to anterior sacral promontory with 2–0 polytetrafluoroethylene (Gore-Tex®) sutures securing Alloderm to the anterior longitudinal ligament.

Fig. 2

At 3 weeks post-op, we removed his indwelling foley catheter, and he resumed CIC. Computed tomography (CT) confirmed the approximation of the bladder to the sacrum (Fig. 3). Voiding cystourethrogram (VCUG) demonstrated complete bladder emptying and no evidence of bladder prolapse (Fig. 4). The patient denied straining to void during the VCUG. At 2 months post-op, he resumed all daily activities and stopped CIC, as he experienced ease in emptying with a PVR of 2mL. Given the reduced outlet resistance after TURP and Urolift procedures, it is possible that restoration of bladder support to the normal anatomic position allowed for effective bladder emptying by pelvic relaxation. Additional urodynamics would be needed to determine if bladder contractility returned with anatomic restoration. The patient declined additional testing.Fig. 3 Post-operative CT with foley in place. (A) Axial view; yellow arrow demonstrating the plane between the bladder and the rectum where the Alloderm is secured. (B) Sagittal view; yellow arrow demonstrating approximation of the bladder to the sacral promontory. (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)

Fig. 3

Fig. 4 Post-operative VCUG. (A) Sagittal view of filling phase with a smooth posterior wall. (B) Sagittal view of voiding phase; yellow arrow indicates resolution of the posterior descent of the bladder into the rectal wall. (C) Post-void coronal view with near complete volitional emptying of the bladder around the catheter in the absence of straining. (For interpretation of the references to color in this figure legend, the reader is referred to the Web version of this article.)

Fig. 4

3 Discussion

To the best of our knowledge, this is the second reported case of a male bladder prolapse through the anterior rectal wall and the first to be treated with this novel surgical approach. This case implicates supraphysiologic stress as the cause of bladder prolapse through the anterior rectal wall in a male patient. Weakening of bladder support and the anterior rectal wall may have occurred slowly over time as the result of prolonged bladder holding with overstretching of the bladder, heavy weightlifting (e.g., squatting, deadlifting), and excessive straining to urinate. Because the patient's initial presentation was to an outside institution, we do not have a clear timeline of the development of the bladder prolapse in relation to his urinary symptoms. The timeline of his symptoms and sensation of the bulge per rectum suggest the excessive straining to void led to the progression of the bladder prolapse through the rectum. The previous sigmoid resection and rectopexy are thought to have provided some initial improvement, possibly due to inflammation at the surgical site and scar tissue formation. However, since the bladder support was not addressed and the patient continued to strain while urinating, the bladder prolapse recurred. Our decision to perform a laparoscopic cystoprostosacropexy was inspired by the use of sacrocolpopexy in treating female cystoceles.4 We extrapolated from these established techniques to address the unique anatomical and functional challenges in this male patient. We acknowledge the uncertainty of the causative relationship between the anatomical defect and functional impairment. The patient was counseled to avoid excessive straining of any kind and to resume CIC if any urinary difficulty returned.

Given the limited literature on treatment options for such abnormal anatomy, this case presented a unique challenge. The previous case report of a male rectal bladder prolapse followed a similar course: urinary retention followed by a TURP, subsequent rectal prolapse for which he underwent a Thiersch procedure, and development of bladder prolapse for which he received a cystoprostatectomy.2 Another report of transrectal bladder prolapses in two dogs with pelvic fractures and rectal lacerations also described herniation of the bladder through the rectal laceration.5

4 Conclusion

In this pioneering case, robotic-assisted laparoscopic cystoprostosacropexy provided effective management of a male cystocele, serving as a testament to the potential for surgical innovation to improve patient quality of life in novel presentations of pelvic floor disorders.

CRediT authorship contribution statement

Saawan D. Patel: Data curation, Writing – original draft, Writing – review & editing. Cheyenne Williams: Validation, Writing – review & editing. Daniel S. Roberson: Validation, Writing – review & editing. Phillip Mucksavage: Supervision, Writing – review & editing. Ariana L. Smith: Conceptualization, Supervision, Validation, Writing – review & editing.
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References

1 Schaffer J.I. Wai C.Y. Boreham M.K. Etiology of pelvic organ prolapse Clin Obstet Gynecol 48 3 Sep. 2005 639 10.1097/01.grf.0000170428.45819.4e 16012231
2 Kirmiz S.W. Livingston A.J. Luchtefeld M.A. Brede C.M. Noyes S.L. Lane B.R. My bladder is hanging out of my anus': successful management of first reported case of male transanal bladder prolapse Urol. Case Rep. 4 Nov. 2015 17 19 10.1016/j.eucr.2015.10.010 26793568
3 Buinewicz B. Rosen B. Acellular cadaveric dermis (AlloDerm): a new alternative for abdominal hernia repair Ann Plast Surg 52 2 Feb. 2004 188 194 10.1097/01.sap.0000100895.41198.27 14745271
4 Lucot J.-P. Safety of vaginal mesh surgery versus laparoscopic mesh sacropexy for cystocele repair: results of the prosthetic pelvic floor repair randomized controlled trial Eur Urol 74 2 Aug. 2018 167 176 10.1016/j.eururo.2018.01.044 29472143
5 Crivellenti L.Z. Silveira M.P. Silva A.N. Borin-Crivellenti S. Raposo T.M.M. Honsho D.K. Transrectal bladder prolapse secondary to pelvic fracture in two dogs J Small Anim Pract 55 8 2014 424 426 10.1111/jsap.12212 24697605
