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International Journal of Gynaecology... May 2024The average lifespan has increased over time due to improvements in quality of life, leading to an aging population that stays healthy for longer. Pelvic organ prolapse... (Review)
Review
Literature review, surgical decision making algorithm, and AGREE II-S comparison of national and international recommendations and guidelines in pelvic organ prolapse surgery.
The average lifespan has increased over time due to improvements in quality of life, leading to an aging population that stays healthy for longer. Pelvic organ prolapse (POP), whether uterine or vaginal, is a problem that severely impairs quality of life and imposes significant restrictions. The present study provides the reader with a summary of the many surgical techniques used in POP surgery, comparing international guidelines, offering an algorithm that is simple to understand, and allows the reader to quickly choose the table that includes the best surgical therapy for each individual. Using relevant keywords, the writers searched the PubMed and Scopus databases for relevant publications from 2000 to April 2023. Studies with cases of oncologic disorders or prior hysterectomy performed for another reason were not included in the analysis. Ten distinct international guidelines are highlighted and examined in the present study. We used the Appraisal of Guidelines for Research and Evaluation II-S (AGREE II-S) method to assess their quality, and incorporated the results into the conclusion. Worldwide, anterior colporrhaphy is the preferred method of treating anterior compartment abnormalities, and mesh is virtually always used when recurrence occurs (which happens in about half of the cases). Worldwide, posterior colporrhaphy is commonly used to repair posterior compartment abnormalities. Only a few national guidelines (the Iranian guideline, Acta Obstetricia et Gynecologica Scandinavica [AOGS], and the German-speaking countries) permit the use of mesh or xenograft in cases of recurrence. There is agreement on the abdominal approach (sacrocolpopexy) with mesh for treating apical deformities. Sacrospinous-hysteropexy is the standard method used to guide the vaginal approach; mesh is typically used to aid in this process. There are just three recommendations that do not include vaginal operations: HSE, AOGS, and Iran. Of obliteration techniques, colpocleisis is unquestionably the best. In conclusion, our analysis highlights the significance of customized methods in POP surgery, taking into account the requirements and preferences of each patient. To choose the best surgical therapy, criteria and patient features must be carefully considered.
PubMed: 38760975
DOI: 10.1002/ijgo.15614 -
Techniques in Coloproctology Oct 2023Determine predictors of success for transvaginal rectocoele repair (TVRR). Primary aim is to establish predictors of successful treatment analysing patients'...
PURPOSE
Determine predictors of success for transvaginal rectocoele repair (TVRR). Primary aim is to establish predictors of successful treatment analysing patients' characteristics, baseline symptoms, pelvic floor test results and pre-operative conservative treatment.
METHODS
Retrospective single institution study in a tertiary referral centre for pelvic floor disorders. 207 patients underwent TVRR for symptomatic rectocoele. Information about symptoms related to obstructive defaecation, anal incontinence and vaginal prolapse, results of pelvic floor investigations, multimodality conservative management and variation in surgical technique have been recorded. Symptom related information have been collected at surgical follow-up.
RESULTS
115 patients had residual symptoms after surgical repair of rectocoele, while 97 were symptoms free. Factors associated with residual symptoms after surgical repair are previous proctological procedures, urge AI symptoms, absence of vaginal bulge symptoms, use of transanal irrigation and having a concomitant enterocoele repair during procedure.
CONCLUSION
Factors able to predict a less favourable outcome after TVRR in patients with concomitant ODS are previous proctological procedures, presence of urge AI, short anal canal length on anorectal physiology, seepage on defaecating proctography, use of transanal irrigation, absence of vaginal bulge symptoms and enterocoele repair during surgery. These information are important for a tailored decision making process and to manage patients' expectations before surgical repair.
Topics: Female; Humans; Rectocele; Retrospective Studies; Constipation; Defecography; Fecal Incontinence; Treatment Outcome
PubMed: 37212926
DOI: 10.1007/s10151-023-02822-1 -
Journal of Gynecology Obstetrics and... Dec 2023Pelvic organ prolapse (POP) is a common condition affecting women, characterized by the descent of pelvic organs such as the vagina and uterus. While POP may not always...
Pelvic organ prolapse (POP) is a common condition affecting women, characterized by the descent of pelvic organs such as the vagina and uterus. While POP may not always cause symptoms, it can significantly impact a woman's quality of life. Diagnosis is typically made through clinical examination, and treatment options range from pelvic-floor physical therapy to surgery. Anterior sacrospinous ligament fixation (ASSLF) has emerged as a viable technique for treating apical prolapse vaginally. This procedure involves attaching the cervix or vaginal vault to the sacrospinous ligament, providing satisfactory results in the short term. Compared to the posterior approach, ASSLF shows similar efficacy, shorter operative time, and potentially fewer complications. Vaginal surgery offers advantages such as lower morbidity and cost, ability to address other pelvic conditions simultaneously, and suitability for managing recurrences. The presented case involves a 72-year-old woman with stage 3 cystocele, stage 3 hysterocele, stage 1 rectocele, and severe voiding dysfunction. After unsuccessful attempts with a pessary, surgical intervention becomes necessary. An instructive video article has been created to standardize the essential steps of ASSLF and facilitate resident education. The video demonstrates ten surgical steps, including installation/exposure, anterior vaginal wall infiltration, median anterior colpotomy, vesico-vaginal dissection, paravesical dissection, sacrospinous ligament suture, cystocele correction, colpotomy and vaginal wall repair, uterine anterior isthmus suture and sacrospinous ligament fixation, and colporrhaphy final closure. In conclusion, POP is a prevalent condition that can be effectively managed through techniques like ASSLF. Vaginal surgery offers several advantages, and proper training and standardization of surgical steps contribute to successful outcomes and resident education.
Topics: Female; Humans; Aged; Cystocele; Quality of Life; Pelvic Organ Prolapse; Vagina; Ligaments
PubMed: 37821046
DOI: 10.1016/j.jogoh.2023.102677 -
Journal of Clinical Medicine Sep 2023Laparoscopic ventral mesh rectopexy (VMR) is the standard procedure for the treatment of posterior pelvic organ prolapse. Despite significant functional improvement and...
Laparoscopic ventral mesh rectopexy (VMR) is the standard procedure for the treatment of posterior pelvic organ prolapse. Despite significant functional improvement and anatomical corrections, severe complications related to mesh augmentation can occur in a few proportions of patients. In order to decrease the number of rare but severe complications, we developed a variant of the conventional VMR without any rectal fixation and using a robotic approach with biological mesh. The aim of this study was to compare the results of laparoscopic ventral rectopexy with synthetic mesh (LVMRS) to those of robotic ventral rectopexy with biological mesh (RVMRB). Methods: Between 2004 and 2021, patients operated on for VMR in our unit were identified and separated into two groups: LVMRS and RVMRB. The surgical technique for both groups consisted of VMR without any rectal fixation, with mesh distally secured on the levator ani muscles. 269 patients with a mean age of 62 years were operated for posterior pelvic floor disorder: rectocele (61.7%) and external rectal prolapse (34.6%). 222 (82.5%) patients received LVMRS (2004-2015), whereas 47 were operated with RVMRB (2015-2021). Both groups slightly differed for combined anterior fixation proportion (LVMRS 39% vs. RVMRB 6.4%, < 0.001). Despite these differences, the length of stay was shorter in the RVMRB group (2 vs. 3 days, < 0.001). Postoperative complications were comparable in the two groups (1.8 vs. 4.3%, = 0.089) and mainly consisted of minor complications. Functional outcomes were favorable and similar in both groups, with an improvement in bulging, obstructed defecation symptoms, and fecal incontinence (NS in subgroup analysis). In the long term, there were no mesh erosions reported. The overall recurrence rate was 11.9%, and was comparable in the two groups (13% LVMRS vs. 8.5, = 0.43). VMR without rectal fixation is a safe and effective approach in posterior organ prolapse management. RVMRB provides comparable results in terms of recurrence and functional results, with avoidance of unabsorbable material implantation.
PubMed: 37685818
DOI: 10.3390/jcm12175751 -
Journal of Clinical Medicine Feb 2024Pelvic organ prolapse constitutes a prevalent condition associated with a considerable impact on the quality of life. The utilization of transvaginal mesh surgery for...
BACKGROUND
Pelvic organ prolapse constitutes a prevalent condition associated with a considerable impact on the quality of life. The utilization of transvaginal mesh surgery for managing POP has been a subject of extensive debate. Globally, trends in TVM surgery experienced significant shifts subsequent to warnings issued by the FDA.
METHODS
This study aims to explore temporal patterns in transvaginal mesh surgery in the German healthcare system. A comprehensive analysis was conducted on in-patient data from the German Federal Statistical Office spanning 2006 to 2021. A total of 1,150,811 operations, each associated with specific codes, were incorporated into the study. Linear regression analysis was employed to delineate discernible trends.
RESULTS
The trends in transvaginal mesh surgery within the anterior compartment exhibited relative stability ( = 0.147); however, a significant decline was noted in all other compartments (posterior: < 0.001, enterocele surgery: < 0.001). A subtle increasing trend was observed for uterine-preserving transvaginal mesh surgery ( = 0.045).
CONCLUSION
Surgical trends over the specified timeframe demonstrate how POP management has evolved globally. Notably, despite observed fluctuations, transvaginal mesh surgery remains a viable option, particularly for specific cases with a high risk of relapse and contraindications to alternative surgical approaches.
PubMed: 38398300
DOI: 10.3390/jcm13040987 -
International Journal of Colorectal... Aug 2023To compare perioperative results of laparoscopic and robotic ventral mesh rectopexy for pelvic floor disorders at the beginning of the surgical experience.
PURPOSE
To compare perioperative results of laparoscopic and robotic ventral mesh rectopexy for pelvic floor disorders at the beginning of the surgical experience.
METHODS
Between 2017 and 2022, the first 30 laparoscopic ventral mesh rectopexies and the first 30 robotic ventral mesh rectopexies at the beginning of the experience of 2 surgeons were retrospectively analyzed. Perioperative (demographic characteristics, surgical indication, conversion rate, operative time), and postoperative (complications, length of stay, unplanned reintervention) data were compared between groups.
RESULTS
Demographic characteristics were similar between groups. Conversion rate was lower (0 vs 17%, p = 0.05), but the operative time was significantly longer (182 [146-290] vs 150 [75-240] minutes, p < 0.0001) during robotic procedure when compared with laparoscopic approach. In terms of learning curve, the number of procedures to obtain the same operative time between the 2 approaches was 15. Postoperative results were similar between groups, in terms of pain (visual analogic scale = 2 [0-8] vs 4 [0-9], p = 0.07), morbidity (17 vs 3%, p = 0.2), and unplanned reintervention (1 vs 0%, p = 0.99). Mean length of stay was significantly reduced after robotic approach when compared with laparoscopic approach (3 [2-10] vs 5 [2-11] days, p < 0.01). Functional results were better after robotic than laparoscopic ventral mesh rectopexy, with higher satisfaction rate (93 vs 75%, p = 0.05), and reduced recurrence rate (0 vs 14%, p = 0.048).
CONCLUSION
Despite longer operative time at the beginning of the learning curve, robotic ventral mesh rectopexy was associated with similar or better perioperative results than laparoscopic ventral mesh rectopexy.
Topics: Humans; Female; Robotic Surgical Procedures; Retrospective Studies; Pelvic Floor Disorders; Surgical Mesh; Laparoscopy; Postoperative Complications
PubMed: 37589810
DOI: 10.1007/s00384-023-04511-9 -
International Urogynecology Journal Nov 2023Given the younger age of cervical cancer patients and improved postoperative survival, postoperative quality of life should be a reason for concern, particularly given...
INTRODUCTION AND HYPOTHESIS
Given the younger age of cervical cancer patients and improved postoperative survival, postoperative quality of life should be a reason for concern, particularly given the prevalence of pelvic floor dysfunction. High uterosacral ligament suspension (HUS) has been deemed the more consistently successful surgery for the treatment of mid-pelvic abnormalities. HUS intraoperatively prevents pelvic floor dysfunction effectively.
METHODS
We demonstrate the steps of surgery using surgical video and photographs. The uterosacral ligament is fan shaped and connected to the fascial and extraosseous membranes on the surface of the anterior sacral foramen of the 2nd, 3rd, and 4th sacral vertebrae. Given that the uterosacral ligament was fan-shaped, the fan-shaped suture with three stitches was more compatible with the original anatomy.
RESULTS
Thirty patients with HUS who underwent thorough hysterectomy had no complications, operation time 230.82 ± 43.61 min, and blood loss 62.32 ± 37.25 ml. The urinary catheter was successfully removed 1 week after the operation, and no pelvic organ prolapse, including vaginal anterior and posterior wall prolapse, or rectocele, occurred after 3 years of follow-up.
CONCLUSION
The uterosacral ligament fulfills the role of supporting, pulling, and suspending the uterus. We should exploit the advantage of fully exposing the uterosacral ligament in radical hysterectomy. Performing HUS to prevent pelvic organ prolapse following radical hysterectomy is a procedure worthy of investigation and promotion.
Topics: Female; Humans; Gynecologic Surgical Procedures; Hysterectomy; Hysterectomy, Vaginal; Ligaments; Neoplasm Recurrence, Local; Pelvic Organ Prolapse; Quality of Life; Treatment Outcome; Uterus
PubMed: 37417994
DOI: 10.1007/s00192-023-05592-4 -
American Journal of Surgery Mar 2024Stapled transanal rectal resection is the most surgical procedure used for obstructed defecation syndrome, rectal prolapse, rectocele and rectal intussusception...
INTRODUCTION
Stapled transanal rectal resection is the most surgical procedure used for obstructed defecation syndrome, rectal prolapse, rectocele and rectal intussusception worldwide. The aim of this study is to report our experience and long time consequences and to offer a new medico-legal perspective.
MATERIALS AND METHODS
We retrospective review medical charts of patients treated between 2006 and 2021 b y the same team directed by the same senior surgeon. We consider major complications and long time sequelaeses as main object for the discussion. Inclusion and exclusion criteria were created. IRB approved the study. After revision a medico-legal perspective was done based on major complications.
RESULTS
During the study period 1726 patients, ages between 18 and 71 years old, were treated with 1280 STARR procedures and 446 "Longo" [was stopped on 2012]; all procedures were performed by the senior surgeon and visited by the team at the same control visit at 7days, 30 days and 12 and 18 months after surgery. All patients had 100 % compliance at 30 days, while 85 % had long time visit (more than 18 months). During the study period 6 % (104 subjects) of patients had minor complications while 1 patient (42 yrs female) reported total fecal incontinence after 18 months (0,05 %). This patient had mental disorder treated with drugs unknown before surgery and long time mental disorder after surgery. We focused on this last case to discuss long time complication DISCUSSION: This survey reports some interesting clinical data; respect to standard complications minor complications such as pain, bleeding and anal discomfort represent less than 10 % of procedures that is a good results in this perineal surgery. For those working with rectal mucosal prolapse, obstructed defecation syndrome, rectocele or rectal intussusception is essential to distinguish these diagnosis to have a good counselling with patient before surgery (at least 1 month before). It is essential to check these patients with a close follow-up especially after surgery, to avoid any other mental discomfort related to fecal incontinence; long time fecal incontinence, without anatomical disorders as our case, could be associated and related to drugs consumption or mental disorder, or perineal insensitivity due to surgical procedure. In conclusion it is essential to have good clinical practice to suggest STARR procedure, having idea about different diseases, different surgical approaches and different long time complications.
Topics: Humans; Female; Adolescent; Young Adult; Adult; Middle Aged; Aged; Rectocele; Intussusception; Defecation; Constipation; Fecal Incontinence; Treatment Outcome; Surgical Stapling; Rectal Prolapse; Rectum; Digestive System Surgical Procedures
PubMed: 38042721
DOI: 10.1016/j.amjsurg.2023.11.016 -
BMC Medical Imaging Oct 2023This study explored using an improved ultrasound (US) for quantitative evaluation of the degree of pelvic organ prolapse(POP).
OBJECTIVE
This study explored using an improved ultrasound (US) for quantitative evaluation of the degree of pelvic organ prolapse(POP).
DESIGN
A transluminal probe was used to standardize ultrasound imaging of pelvic floor organ displacements. A US reference line was fixed between the lower edge of the pubic symphysis and the central axis of the pubic symphysis at a 30°counterclockwise angle.
METHOD
Points Aa, Ba, C and Bp on pelvic organ prolapse quantification (POP-Q) were then compared with the points on pelvic floor ultrasound (PFUS).
RESULTS
One hundred thirteen patients were included in the analysis of the standard US plane. Correlations were good in the anterior and middle compartments (PBN:Aa, ICC = 0.922; PBB:Ba, ICC = 0.923; and PC:C, ICC = 0.925), and Bland-Altman statistical maps corresponding to the average difference around the 30°horizontal line were close to 0. Correlations were poor in the posterior compartment (PRA:Bp, ICC = 0.444). However, eight (7.1%) cases of intestinal hernia and 21 (18.6%) cases of rectocele were diagnosed.
CONCLUSIONS
Introital PFUS using an intracavitary probe, which is gently placed at the introitus of the urethra and the vagina, may be accurately used to evaluate organ displacement. The application of a 30°horizontal line may improve the repeatability of the US diagnosis of POP.
Topics: Humans; Female; Pelvic Organ Prolapse; Genital Diseases, Female; Pelvic Floor; Ultrasonography
PubMed: 37904129
DOI: 10.1186/s12880-023-01013-6 -
Techniques in Coloproctology Jun 2024Patient selection is extremely important in obstructed defecation syndrome (ODS) and rectal prolapse (RP) surgery. This study assessed factors that guided the... (Observational Study)
Observational Study
Analysis of factors that indicated surgery in 400 patients submitted to a complete diagnostic workup for obstructed defecation syndrome and rectal prolapse using a supervised machine learning algorithm.
BACKGROUND
Patient selection is extremely important in obstructed defecation syndrome (ODS) and rectal prolapse (RP) surgery. This study assessed factors that guided the indications for ODS and RP surgery and their specific role in our decision-making process using a machine learning approach.
METHODS
This is a retrospective analysis of a long-term prospective observational study on female patients reporting symptoms of ODS who underwent a complete diagnostic workup from January 2010 to December 2021 at an academic tertiary referral center. Clinical, defecographic, and other functional tests data were assessed. A supervised machine learning algorithm using a classification tree model was performed and tested.
RESULTS
A total of 400 patients were included. The factors associated with a significantly higher probability of undergoing surgery were follows: as symptoms, perineal splinting, anal or vaginal self-digitations, sensation of external RP, episodes of fecal incontinence and soiling; as physical examination features, evidence of internal and external RP, rectocele, enterocele, or anterior/middle pelvic organs prolapse; as defecographic findings, intra-anal and external RP, rectocele, incomplete rectocele emptying, enterocele, cystocele, and colpo-hysterocele. Surgery was less indicated in patients with dyssynergia, severe anxiety and depression. All these factors were included in a supervised machine learning algorithm. The model showed high accuracy on the test dataset (79%, p < 0.001).
CONCLUSIONS
Symptoms assessment and physical examination proved to be fundamental, but other functional tests should also be considered. By adopting a machine learning model in further ODS and RP centers, indications for surgery could be more easily and reliably identified and shared.
Topics: Humans; Female; Middle Aged; Rectal Prolapse; Retrospective Studies; Constipation; Aged; Supervised Machine Learning; Syndrome; Defecation; Adult; Prospective Studies; Defecography; Patient Selection; Algorithms; Clinical Decision-Making
PubMed: 38918256
DOI: 10.1007/s10151-024-02951-1