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Radiologie (Heidelberg, Germany) Nov 2023Magnetic resonance defecography (MRD) plays a central role in diagnosing pelvic floor functional disorders by visualizing the entire pelvic floor along with pelvic... (Review)
Review
BACKGROUND
Magnetic resonance defecography (MRD) plays a central role in diagnosing pelvic floor functional disorders by visualizing the entire pelvic floor along with pelvic organs and providing functional assessment of the defecation process. A shared understanding between radiology and surgery regarding indications and interpretation of findings is crucial for optimal utilization of MRD.
OBJECTIVES
This review aims to explain the indications for MRD from a surgical perspective and elucidate the significance of radiological findings for treatment. It intends to clarify for which symptoms MRD is appropriate and which criteria should be followed for standardized results. This is prerequisite to develop interdisciplinary therapeutic approaches.
MATERIALS AND METHODS
A comprehensive literature search was conducted, including current consensus guidelines.
RESULTS
MRD can provide relevant findings in the diagnosis of fecal incontinence and obstructed defecation syndrome, particularly in cases of pelvic floor descent, enterocele, intussusception, and pelvic floor dyssynergia. However, rectocele findings in MRD should be interpreted with caution in order to avoid overdiagnosis.
CONCLUSION
MRD findings should never be considered in isolation but rather in conjunction with patient history, clinical examination, and symptomatology since morphology and functional complaints may not always correlate, and there is wide variance of normal values. Interdisciplinary interpretation of MRD results involving radiology, surgery, gynecology, and urology, preferably in the context of pelvic floor conferences, is recommended.
Topics: Female; Humans; Defecography; Pelvic Floor; Magnetic Resonance Imaging; Rectocele; Pelvic Floor Disorders; Surgeons
PubMed: 37831101
DOI: 10.1007/s00117-023-01213-9 -
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 -
Radiologie (Heidelberg, Germany) Nov 2023Dynamic magnetic resonance imaging (MRI) of the pelvic floor plays a key role in imaging complex pelvic floor dysfunction. The simultaneous detection of multiple... (Review)
Review
BACKGROUND
Dynamic magnetic resonance imaging (MRI) of the pelvic floor plays a key role in imaging complex pelvic floor dysfunction. The simultaneous detection of multiple findings in a complex anatomic setting renders correct analysis and clinical interpretation challenging.
OBJECTIVES
The most important aspects (anatomy of the pelvic floor, three compartment model, morphological and functional analysis, reporting) for a successful clinical use of dynamic MRI of the pelvic floor are summarized.
MATERIALS AND METHODS
Review of the scientific literature on dynamic pelvic MR imaging with special consideration of the joint recommendations provided by the expert panel of ESUR/ESGAR in 2016.
RESULTS
The pelvic floor is a complex anatomic structure, mainly formed by the levator ani muscle, the urethral support system and the endopelvic fascia. Firstly, morphological changes of these structures are analysed on the static sequences. Secondly, the functional analysis using the three compartment model is performed on the dynamic sequences during squeezing, straining and defecation. Pelvic organ mobility, pelvic organ prolapse, the anorectal angle and pelvic floor relaxation are measured and graded. The diagnosis of cystoceles, enteroceles, rectoceles, the uterovaginal as well as anorectal decent, intussusceptions and dyssynergic defecation should be reported using a structured report form.
CONCLUSIONS
A comprehensive analysis of all morphological and functional findings during dynamic MRI of the pelvic floor can provide information missed by other imaging modalities and hence alter therapeutic strategies.
Topics: Humans; Defecography; Pelvic Floor; Rectocele; Hernia; Magnetic Resonance Imaging
PubMed: 37783986
DOI: 10.1007/s00117-023-01223-7 -
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 -
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 -
Colorectal Disease : the Official... Oct 2023The aim of this work was to determine the range of normal imaging features during total pelvic floor ultrasound (TPFUS) (transperineal, transvaginal, endovaginal and...
AIM
The aim of this work was to determine the range of normal imaging features during total pelvic floor ultrasound (TPFUS) (transperineal, transvaginal, endovaginal and endoanal) and defaecation MRI (dMRI).
METHOD
Twenty asymptomatic female volunteers (mean age 36.5 years) were prospectively investigated with dMRI and TPFUS. Subjects were screened with symptom questionnaires (ICIQ-B, St Mark's faecal incontinence score, obstructed defaecation syndrome score, ICIQ-V, BSAQ). dMRI and TPFUS were performed and interpreted by blinded clinicians according to previously published methods.
RESULTS
The subjects comprised six parous and 14 nulliparous women, of whom three were postmenopausal. There were three with a rectocoele on both modalities and one with a rectocoele on dMRI only. There was one with intussusception on TPFUS. Two had an enterocoele on both modalities and one on TPFUS only. There were six with a cystocoele on both modalities, one on dMRI only and one on TPFUS only. On dMRI, there were 12 with functional features. Four also displayed functional features on TPFUS. Two displayed functional features on TPFUS only.
CONCLUSION
This study demonstrates the presence of abnormal findings on dMRI and TPFUS without symptoms. There was a high rate of functional features on dMRI. This series is not large enough to redefine normal parameters but is helpful for appreciating the wide range of findings seen in health.
Topics: Female; Humans; Adult; Rectocele; Pelvic Floor; Pelvic Floor Disorders; Ultrasonography; Hernia
PubMed: 37574701
DOI: 10.1111/codi.16709 -
Facts, Views & Vision in ObGyn Jun 2023Laparoscopic mesh sacrohysteropexy has been established as an effective, safe, and popular technique to treat uterine prolapse. Nevertheless, recent controversies...
BACKGROUND
Laparoscopic mesh sacrohysteropexy has been established as an effective, safe, and popular technique to treat uterine prolapse. Nevertheless, recent controversies regarding the role of synthetic mesh in pelvic reconstructive surgery have triggered a trend towards meshless procedures. Other laparoscopic native tissue prolapses techniques such as uterosacral ligament plication and sacral suture hysteropexy have been previously described in literature.
OBJECTIVES
To describe a meshless minimally invasive technique with uterine preservation, which incorporates steps from the above-mentioned procedures.
MATERIALS AND METHODS
We present a case of a 41-year-old patient with stage II apical prolapse and stage III cystocele and rectocele, who was keen to proceed to surgical management preserving her uterus and avoiding the use of a mesh implant. The narrated video demonstrates the surgical steps of our technique of laparoscopic suture sacrohysteropexy.
MAIN OUTCOME MEASURES
Objective (i.e., anatomic) and subjective (i.e., functional) surgical success on follow-up assessment at least 3 months post-surgery, similarly to every prolapse procedure.
RESULTS
Excellent anatomical result and resolution of prolapse symptoms at follow-up appointments.
CONCLUSIONS
Our technique of laparoscopic suture sacrohysteropexy seems a logical progression in prolapse surgery, responding to patients' wishes for minimally invasive meshless procedures with uterine preservation while at the same time achieving excellent apical support. Its long-term efficacy and safety need to be carefully assessed before it becomes established in clinical practice.
LEARNING OBJECTIVE
To demonstrate a laparoscopic uterine-sparing technique to treat uterine prolapse without the use of a permanent mesh.
PubMed: 37436056
DOI: 10.52054/FVVO.15.2.075 -
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