Vaginal cuff dehiscence and bowel evisceration as a late-onset complication of vaginal vault prolapse: a case report

BACKGROUND: Vaginal cuff dehiscence (and evisceration, VCDE) after hysterectomy is a rare, but potentially serious complication. Current medical literature describes the most critical risk factors for VCDE after hysterectomy as surgical technique, use of thermal energy, early mechanical stress (especially sexual intercourse), infection, smoking, and obesity. There is currently no evidence regarding a potential association between VCDE and anti-HER2 therapy. We report a late-onset VCDE in a patient receiving combined antihormonal and anti-HER2 therapy, and discuss the hypothesis-generating question of a potential association, as well as the bowel-preserving surgical management. CASE PRESENTATION: We report the case of an 81-year-old White woman with hormone receptor-positive breast cancer receiving antihormonal therapy with anti-HER2 treatment and recurrent vaginal vault prolapse who presented with acute vaginal evisceration of the small bowel. She had undergone a vaginal hysterectomy for pelvic organ prolapse 3 years earlier. Emergency surgical management was performed via laparotomy with repositioning of the small bowel, vaginal cuff closure, and concomitant sacrocolpopexy. One week later, re-laparotomy was required due to an open abdomen associated with paralytic small bowel ileus; bowel resection was not necessary. The last follow-up was carried out 21 months postoperatively. The patient was asymptomatic and showed no evidence of recurrent prolapse. CONCLUSIONS: This case highlights a rare late-onset VCDE in a patient receiving combined antihormonal and anti-HER2 therapy, a clinical context not previously described. While causality cannot be established, this report raises the hypothesis of a potential association between targeted therapy and impaired tissue integrity.