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Journal of Neurogastroenterology and... Jan 2020Colon transit time (CTT) test is regarded as the gold standard for evaluating colon transit function. Fluoroscopic defecography (FD) is a dynamic radiologic test to...
BACKGROUND/AIMS
Colon transit time (CTT) test is regarded as the gold standard for evaluating colon transit function. Fluoroscopic defecography (FD) is a dynamic radiologic test to assess anorectal function. The aim is to evaluate the value of FD in constipated children with abnormal CTT test results.
METHODS
Fifty-one children (27 girls) with a mean age of 9.8 ± 3.2 years who met Rome III criteria for constipation and older than 5 years with abnormal CTT test results underwent FD.
RESULTS
Of 51 children, 27 (52.9%) showed positive findings on FD, including pelvic floor dyssynergia (PFD) (10/27, 37.0%), structural abnormality (15/27, 55.6%) (rectocele 53.3%, intussusception 33.3%, and both 13.4%), and both PFD and rectocele (2/27, 7.4%). In terms of CTT test subtype, of 35 children who had outlet obstruction type in CTT test, 19 (54.2%) had positive findings, including PFD (8/19, 42.1%), structural abnormality (9/19, 47.4%) (rectocele 55.6%, intussusception 22.2%, and both 22.2%), and both PFD and rectocele (2/19, 10.5%). Of the 16 children who had slow transit type of CTT test, 8 (50.0%) had positive findings, including PFD (2/8, 25.0%) and structural abnormality (6/8, 75.0%). Of the 6 children who had structural abnormality, 3 (50.0%) had rectocele and 3 (50.0%) had intussusception. For the 2 children (2/16, 12.5%) who had PFD, puborectalis muscle relax failure was found on FD. Puborectalis muscle relax failure was treated with biofeedback and medication. In the minor abnormalities, medication continued without additional therapeutic modalities.
CONCLUSIONS
FD was valuable for both diagnoses of underlying causes and interpretation of CTT test results in children with abnormal CTT test results. Therefore, this study suggests that FD and CTT tests should be incorporated into logical thinking for constipation in children.
PubMed: 31715093
DOI: 10.5056/jnm18201 -
International Journal of Gynaecology... Feb 2020The FIGO Working Group (FWG) in Pelvic Floor Medicine and Reconstructive Surgery (2012-2015) established a consensus among international opinion leaders in evaluating... (Review)
Review
BACKGROUND
The FIGO Working Group (FWG) in Pelvic Floor Medicine and Reconstructive Surgery (2012-2015) established a consensus among international opinion leaders in evaluating current evidence and providing practice recommendations.
OBJECTIVES
To provide an update of the previous clinical opinion report on conservative and surgical treatment of posterior compartment prolapse.
SEARCH STRATEGY
Search of evidence was performed using Pubmed, Embase, and Cochrane Library databases up to August 2018.
SELECTION CRITERIA
Controlled trials on posterior colporrhaphy, site-specific defect, transanal, abdominal, laparoscopic, and mesh repair.
DATA COLLECTION AND ANALYSIS
Collective consensus on surgical outcomes was based on a decision-making process during meetings and multiple group consultations.
MAIN RESULTS
Basic evaluation and conservative treatment precede surgical management. Surgical techniques are performed by vaginal, transperineal, transanal, abdominal, or laparoscopic approach. The transvaginal surgical route without mesh appears superior to the transanal route. No conclusions can be drawn based on clinical studies or randomized controlled trials of posterior colporrhaphy and laparoscopic rectopexy.
CONCLUSIONS
Management of rectocele should include patients' history, quality of life questionnaires, and, in case of complex anorectal symptoms, imaging and functional studies. Evidence on the best type of posterior vaginal wall repair is still scarce. Randomized controlled trials are needed to determine the best approach to achieve safe, effective, and long-term anatomical and functional outcomes.
Topics: Consensus; Female; Gynecologic Surgical Procedures; Humans; Laparoscopy; Pelvic Organ Prolapse; Quality of Life; Randomized Controlled Trials as Topic; Plastic Surgery Procedures; Surgical Mesh
PubMed: 31628853
DOI: 10.1002/ijgo.13006 -
International Urogynecology Journal Sep 2021Symptoms of obstructed defecation (OD) and anatomical abnormalities of the posterior compartment are prevalent in urogynecological patients. The aim of this study was to...
INTRODUCTION AND HYPOTHESIS
Symptoms of obstructed defecation (OD) and anatomical abnormalities of the posterior compartment are prevalent in urogynecological patients. The aim of this study was to determine whether perineal hypermobility is an independent predictor of OD, as is the case for rectocele, enterocele and rectal intussusception.
METHODS
This is a retrospective study of 2447 women attending a tertiary urodynamic center between September 2011 and December 2016. The assessment included a structured interview, urodynamic testing, a clinical examination and 4D transperineal ultrasound. After exclusion of previous pelvic floor surgery and defined anatomical abnormalities of the anorectum, 796 patients were left for analysis. Perineal hypermobility was defined as rectal descent ≥ 15 mm below the symphysis pubis, determined in stored ultrasound volume datasets offline, using proprietary software, blinded to all other data. Any association between perineal hypermobility and symptoms of obstructed defecation was tested for by chi-square (X) test.
RESULTS
For the 796 patients analyzed, median age was 52 (range, 16-88) years with a mean BMI of 27 (range, 15-64) kg/m. Average vaginal parity was two (range, 0-8). Reported OD symptoms in this group included sensation of incomplete emptying in 335 (42%), straining at stool in 300 (37%) and digitation in 83 (10%). At least one of those symptoms was reported by 424 (53%) women; 153 showed perineal hypermobility. There was no significant association between perineal hypermobility and OD symptoms on univariate testing.
CONCLUSIONS
We found no evidence of an independent association between perineal hypermobility and obstructed defecation.
Topics: Constipation; Defecation; Female; Humans; Middle Aged; Pregnancy; Rectocele; Retrospective Studies; Ultrasonography
PubMed: 33635352
DOI: 10.1007/s00192-021-04734-w -
Updates in Surgery Jun 2021Robot-assisted surgery is safe and effective to treat the complex pelvic organs prolapse (C-POP). The present study analyzes all the robotic procedures and their...
Robot-assisted surgery is safe and effective to treat the complex pelvic organs prolapse (C-POP). The present study analyzes all the robotic procedures and their advantages in the treatment of C-POP performed in a Proctologic and Pelvic Floor Clinical Centre. All the patients affected by C-POP who had robot-assisted surgery were retrospective analyzed. The anatomical and functional outcomes were respectively evaluated through POP-Q grading system and Wexner score about constipation and incontinence. The satisfaction rate was investigated using a five-point scale. From September 2014 to December 2018, 229 women underwent robotic surgery. The follow-up was 12 months. There were no robot-related complications. One hematoma (4.5%) of the recto-vaginal space occurred after Robotic Ventral Rectopexy with Folded Mesh (R-VRP-FM). In the robotic assisted lateral suspension (R-ALS) group there was one case of anterior vaginal wall mesh exposure (0.9%). After the robotic ventral rectopexy (R-VRP) the recurrence rate of external rectal prolapse, internal rectal prolapse, rectocele and enterocele was respectively 6.6, 9.5, 7.4 and 9.5%. After R-VRP-FM only one cystocele (14%) and one partial rectal prolapse (25%) recurred. Vaginal bulge symptoms resolution rate was 95.4%. The mean Wexner constipation score significantly decreased after R-VRP and R-VRP-FM. Vaginal bulge symptoms improved in 98.3% of cases with any apical prolapse recurrence after robotic abdominal colposacropexy. Success rate after R-ALS was 99.1% and 96.4% for apical and anterior prolapse respectively. Robotic assistance makes some surgical steps easier and more precise and this may result in less morbidity and better results.
Topics: Female; Humans; Laparoscopy; Pelvic Organ Prolapse; Retrospective Studies; Robotic Surgical Procedures; Surgical Mesh; Treatment Outcome
PubMed: 33387168
DOI: 10.1007/s13304-020-00913-4 -
Outcomes of a modified Bresler procedure for the treatment of rectocele with rectal intussusception.Gastroenterology Report Dec 2020Obstructed defecation syndrome (ODS) is a condition that is frequently caused by rectocele and rectal intussusception. This study aimed to evaluate the effectiveness of...
BACKGROUND
Obstructed defecation syndrome (ODS) is a condition that is frequently caused by rectocele and rectal intussusception. This study aimed to evaluate the effectiveness of a modified Bresler procedure for the treatment of ODS. The outcomes of this modified procedure were compared with the stapled transanal rectal resection (STARR) procedure.
METHODS
We performed a retrospective analysis of the clinical data from 76 female patients who presented with ODS between June 2014 and June 2016. The patients were divided into two treatment groups, namely Modified and STARR. Patients in the Modified group (=36) underwent the modified Bresler procedure, which involved posterior rectal-wall resection using a circular tubular stapler with multilevel purse-string sutures. Patients in the STARR group (=40) underwent the standard STARR procedure. We analysed post-operative complications, Wexner constipation scores (WCS), rectocele depths, and four-point post-operative satisfaction scales.
RESULTS
Patients in the Modified group exhibited shorter operative times and fewer post-operative complications (both <0.05). At 12 months post-operatively, both the Modified and STARR groups displayed a significant improvement in the Wexner constipation score and the depth of rectocele. The post-operative WCS for the Modified group were significantly improved compared to those for the STARR group (<0.05), while there was no significant difference in the rectocele depth between the two groups (>0.05). Post-operative interviews at post-operative 12 months showed that patients in the Modified group had a better satisfaction (=0.05).
CONCLUSIONS
Our modified procedure may be an effective treatment strategy for patients experiencing ODS caused by rectocele and rectal intussusception, with fewer complications and effective relief of symptoms.
PubMed: 33442479
DOI: 10.1093/gastro/goaa027 -
Urology Apr 2021To present a case series and literature review on post radical cystectomy (RC) pelvic organ prolapse (POP) to heighten awareness of the symptoms, imaging findings, and... (Review)
Review
OBJECTIVE
To present a case series and literature review on post radical cystectomy (RC) pelvic organ prolapse (POP) to heighten awareness of the symptoms, imaging findings, and risk factors associated with this complication and discuss opportunities for prevention. Women with muscle invasive bladder cancer undergo RC with anterior exenteration, significantly disrupting the pelvic floor. These women are at risk for POP.
METHODS
We present 4 cases of high-grade POP in women who underwent RC for bladder cancer. We reviewed the literature by conducting a Boolean search in PubMed with the terms "("radical cystectomy") AND ("enterocele" OR "pelvic organ prolapse" OR "rectocele" OR "vaginal vault prolapse")."
RESULTS
All 4 women reported a bulge sensation in the vagina and physical exam confirmed POP. Three had radiographic findings consistent with high-grade enterocele at rest. Three experienced prolonged intra-abdominal pressure rise post-RC that may have further weakened pelvic floor support, while the fourth had a history of surgery for high-grade POP. Nine articles on POP following RC were identified. Four focused on treatment and 3 focused on prevention.
CONCLUSION
Administration of a single validated question would have identified all 4 cases of postoperative enterocele and is sensitive to detect most women who are experiencing POP. Attention to the pelvic floor on cross-sectional imaging with identification of features that indicate POP, such as herniation of intestinal contents below the pubo-coccygeal line, will identify and/or confirm high-grade enterocele. Familiarity with risk factors for POP and identification of weakened vaginal wall support opens up the opportunity for prevention.
Topics: Aged; Cystectomy; Female; Hernia; Humans; Pelvic Organ Prolapse; Postoperative Complications; Risk Factors; Urinary Bladder Neoplasms
PubMed: 32512108
DOI: 10.1016/j.urology.2020.03.063 -
Academic Radiology Sep 2023Most women with endometrial cancer (EC) have an excellent prognosis and may be cured. However, treatment-related pelvic functional impacts may affect long-term quality...
RATIONALE AND OBJECTIVES
Most women with endometrial cancer (EC) have an excellent prognosis and may be cured. However, treatment-related pelvic functional impacts may affect long-term quality of life. To better understand these concerns, we explored correlations between patient-reported outcomes and pelvic magnetic resonance imaging (MRI) features in women treated for EC.
MATERIALS AND METHODS
Women with histologic diagnosis of EC were consented preoperatively and completed the validated Female Sexual Function Index (FSFI) and Pelvic Floor Dysfunction Index (PFDI) questionnaires at preoperative, 6-week, and 6-month follow-up visits. Pelvic MRIs with dynamic pelvic floor sequences were performed at 6 weeks and 6 months.
RESULTS
A total of 33 women participated in this prospective pilot study. Only 53.7% had been asked about sexual function by providers while 92.4% thought they should have been. Sexual function became more important to women over time. Baseline FSFI was low, declined at 6 weeks, and climbed above baseline at 6 months. Hyperintense vaginal wall signal on T2-weighted images (10.9 vs. 4.8, p = .002) and intact Kegel function (9.8 vs. 4.8, p = .03) were associated with higher FSFI. PFDI scores trended toward improved pelvic floor function over time. Pelvic adhesions on MRI were associated with better pelvic floor function (23.0 vs. 54.9, p = .003). Urethral hypermobility (48.4 vs. 21.7, p = .01), cystocele (65.6 vs. 24.8, p < .0001), and rectocele (58.8 vs. 18.8, p < .0001) predicted worse pelvic floor function.
CONCLUSION
Use of pelvic MRI to quantify anatomic and tissue changes may facilitate risk stratification and response assessment for pelvic floor and sexual dysfunction. Patients articulated the need for attention to these outcomes during EC treatment.
Topics: Female; Humans; Quality of Life; Prospective Studies; Pilot Projects; Magnetic Resonance Imaging; Endometrial Neoplasms; Patient Reported Outcome Measures; Surveys and Questionnaires
PubMed: 37100674
DOI: 10.1016/j.acra.2023.03.031 -
Surgery Dec 2022Patients with obstructed defecation syndrome may present with a wide spectrum of disorders. The iceberg diagram, which focuses on the underlying occult diseases, has...
BACKGROUND
Patients with obstructed defecation syndrome may present with a wide spectrum of disorders. The iceberg diagram, which focuses on the underlying occult diseases, has been proposed for an accurate diagnosis. The iceberg diagram deals with lesions, which, if neglected, may worsen the prognosis. The aim of this study was to evaluate the effect of using the iceberg diagram on the clinical results.
METHODS
Patients operated for obstructed defecation syndrome based on the iceberg diagram between 2008 and 2018 were evaluated pre- and postsurgery. All patients underwent psychosomatic assessment, abdominal and perineal examination, proctoscopy, vaginoscopy, transanal ultrasound, and defecography. Postoperative complications were also evaluated.
RESULTS
Of the 80 operated patients, 73 were females; median age was 47 (range 26-78) years. All had a rectal internal mucosal prolapse and 85% had a rectocele. The most frequent occult diseases were functional (mental distress [46%]) or organic (colpo-cysto-enterocele [44%]). Surgery was tailored according to the iceberg diagram with prolapsectomy and rectocele repair the most commonly used among 8 different procedures. A total of 14% of patients had a postoperative complication. Median follow-up was 72 months. Obstructed defecation syndrome score significantly decreased from 10.5 ± 4.8 (mean + standard deviation) to 3.4 ± 3.6 (P < .01) and 68% of patients reported to be either improved or cured.
CONCLUSION
The use of the iceberg diagram in obstructed defecation syndrome patients assists in identifying latent "submerged lesions' that may negatively impact the functional outcome of surgery. A clinical approach to patients with obstructed defecation syndrome tailored according to the iceberg diagram allows the identification of occult lesions and to achieve good long-term results.
Topics: Female; Humans; Adult; Middle Aged; Aged; Male; Rectocele; Defecography; Defecation; Syndrome; Postoperative Complications; Constipation; Treatment Outcome
PubMed: 36208984
DOI: 10.1016/j.surg.2022.05.030 -
Colorectal Disease : the Official... Feb 2020This study aimed to assess the functional outcome of transanal repair of rectocele using patient symptom scores and quality of life (QOL) instruments.
AIM
This study aimed to assess the functional outcome of transanal repair of rectocele using patient symptom scores and quality of life (QOL) instruments.
METHOD
Patients who underwent transanal repair for symptomatic rectocele between February 2012 and August 2017 were included. This study was a retrospective analysis of prospectively collected data. A standard questionnaire including the Constipation Scoring System (CSS), the Fecal Incontinence Severity Index (FISI) and QOL instruments [Patient Assessment of Constipation (PAC)-QOL, Fecal Incontinence QOL Scale, Short-Form 36 Health Survey (SF-36)] was administered before and after the operation. Physiological assessment and proctography were performed before and after the operation.
RESULTS
Thirty patients were included. The median follow-up was 36 (6-72) months. Postoperative proctography showed a reduction in rectocele size [34 mm (14-52 mm) vs 10 mm (0-28 mm), P < 0.0001]. Physiological assessment showed no significant postoperative changes. Constipation was improved in 15/21 patients (71%) at 1 year and 14/20 patients (70%) at the mid-term follow-up. The CSS score reduced at 3 months [12 (8-12) vs 6 (1-12), P < 0.0001] and remained significantly reduced over time until the mid-term follow-up. Faecal incontinence was improved in two-thirds patients at 1 year. Four patients developed new-onset faecal incontinence. All the PAC-QOL scale scores significantly improved over time until 1 year, while two of the eight SF-36 scale scores showed significant postoperative improvement.
CONCLUSION
Transanal repair for rectocele improves constipation and constipation-specific QOL.
Topics: Adult; Aged; Aged, 80 and over; Constipation; Fecal Incontinence; Female; Humans; Middle Aged; Pelvic Floor; Postoperative Complications; Prospective Studies; Quality of Life; Rectocele; Rectum; Retrospective Studies; Severity of Illness Index; Surveys and Questionnaires; Transanal Endoscopic Surgery; Treatment Outcome
PubMed: 31454453
DOI: 10.1111/codi.14833 -
Asian Journal of Endoscopic Surgery Jan 2022Posterior compartment pelvic floor prolapse (PCPFP) leads to anatomical distortion and functional impairment. Definitive management involves surgery. Ventral mesh...
BACKGROUND
Posterior compartment pelvic floor prolapse (PCPFP) leads to anatomical distortion and functional impairment. Definitive management involves surgery. Ventral mesh rectopexy (VMR) has gained increasing popularity in the West as it emerges as a durable approach. Existing literature and evidence on safety and efficacy of PCPFP surgery in the Asian population remains sparse. Our study aims to review our institution's experience in surgery for PCPFP.
METHODS
All cases of PCPFP surgery in Singapore General Hospital between 2014 to 2019 were studied.
RESULTS
Eighty-three patients had surgery performed for PCPFP, with the majority (83%) in the last 3 years. Median age was 63 years and 92% were female. Most patients (64%) had obstructive defecation symptoms, while the remaining had fecal incontinence, rectal bleeding, or anal discomfort. Main anatomical indication for surgery was external rectal prolapse (48%). Other indications were rectocele and/or rectal intussusception. The majority (66%) had abdominal rectopexy, while 28 underwent Delorme's procedure. Forty-five of the 50 VMRs were minimally invasive. Patients undergoing rectopexy were observed to be younger. Median length of stay was 3 days. Nine patients had early operative complications of which ileus was most common. Median length of follow-up was 12 months. The majority (93%) had initial symptom satisfaction. Eleven patients had anatomical recurrence with a median length of 9 months to development. There was no significant difference in outcomes between abdominal vs perineal approach, or laparoscopic vs robotic VMR.
CONCLUSION
Surgery for PCPFP has gained acceptance in our Asian institution with good symptom improvement, alongside low morbidity and recurrence.
Topics: Female; Humans; Laparoscopy; Middle Aged; Postoperative Complications; Rectal Prolapse; Rectum; Surgical Mesh; Treatment Outcome
PubMed: 34448361
DOI: 10.1111/ases.12978