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Polski Przeglad Chirurgiczny Oct 2019Rectal prolapse (RP) is often seen in patients over the age of fifty, particularly women. These patients frequently suffer from other concomitant pathologies like...
Rectal prolapse (RP) is often seen in patients over the age of fifty, particularly women. These patients frequently suffer from other concomitant pathologies like rectocele, sigmoidocele, cystocele, or even enterocele. Rectopexy with a mesh has been an established treatment for rectal prolapse. The utilization of the robotic system allows for a successful repair within a confined pelvic space, especially for precise suture placement when working with the mesh. A 77-year-old female presented with obstructed defecation syndrome (ODS) symptoms found to be caused by a progressive rectal prolapse. Her pre-operative ODS score was 9/20. Pelvic floor evaluation revealed concomitant rectocele and sigmoidocele. The patient was offered a robotic-assisted rectopexy with mesh placement to address the three concomitant pathologies. During the procedure, a posterior mesorectal mobilization with autonomic nerves preservation was performed to address the posterior leading edge of the prolapse. Subsequently, the vagina was separated from the anterior portion of the rectum and dissected down to the levator ani muscles and the perineal body. This allowed for the affixation of a polypropylene mesh to the anterior portion of the rectum. Anterior suspension of the mobilized rectum with the mesh addressed all three pathologies. No recurrence or complications occurred at two-year follow up. The patients ODS score decreased to 1/20.
Topics: Aged; Digestive System Surgical Procedures; Fecal Incontinence; Female; Humans; Rectal Prolapse; Rectocele; Rectum; Robotics; Surgical Mesh; Treatment Outcome
PubMed: 31702576
DOI: 10.5604/01.3001.0013.5069 -
Neurourology and Urodynamics Jan 2020Oxygen plays a crucial role in wound healing after prolapse surgery. Trauma to the vaginal vasculature might limit the delivery of oxygen to the surgical wound, which...
AIMS
Oxygen plays a crucial role in wound healing after prolapse surgery. Trauma to the vaginal vasculature might limit the delivery of oxygen to the surgical wound, which may negatively affect wound healing and regeneration of connective tissue. This possibly increases the future risk of recurrence. We aimed to determine the effects of vaginal prolapse surgery on the microcirculation of the vaginal wall.
METHODS
We evaluated the vaginal microcirculation in healthy participants without known vascular disease undergoing anterior and/or posterior colporrhaphy. We used incident dark-field imaging for in vivo assessment before and after (1 day, 2 weeks, and 6 weeks) surgery. We studied perfusion (microvascular flow index [MFI]), angioarchitecture (morphology/layout of microvessels) and capillary density.
RESULTS
Ten women were included. Interindividual differences were observed 1 day postoperatively with regard to perfusion and angioarchitecture. Microvascular flow at the surgical site was absent or significantly reduced in some participants, whereas normal microvascular flow was observed in others (MFI range 0-3). Perfusion and angioarchitecture had been restored in all participants after 6 weeks (MFI range 2-3), regardless of the extent of vascular trauma 1 day postoperatively.
CONCLUSIONS
The difference in the extent of vascular trauma between women undergoing seemingly identical surgical procedures suggests that some individuals are more susceptible to vascular trauma than others. Delivery of oxygen to the wound and subsequent wound healing may be compromised in these cases, which could be related to the development of anatomical recurrence. Future studies should investigate whether there is a relationship between the vaginal microvasculature and the recurrence of prolapse.
Topics: Aged; Female; Gynecologic Surgical Procedures; Humans; Microcirculation; Microvessels; Middle Aged; Pelvic Organ Prolapse; Recurrence; Surgical Mesh; Vagina
PubMed: 31691336
DOI: 10.1002/nau.24203 -
Journal of the Formosan Medical... Dec 2019The most suitable surgical technique for pelvic organ prolapse (POP) remains undetermined. The aim of this study was to compare clinical outcomes of the tailored... (Comparative Study)
Comparative Study Observational Study
BACKGROUND/PURPOSE
The most suitable surgical technique for pelvic organ prolapse (POP) remains undetermined. The aim of this study was to compare clinical outcomes of the tailored transvaginal mesh (TVM) surgery and vaginal native tissue repair (NTR) surgery for POP.
METHODS
Between November 2011 and August 2014, medical records of 339 women receiving POP surgeries were reviewed.
RESULTS
Compared with the NTR group (n = 169), the use of TVM surgery (n = 170) was a predictor for longer operation time (coefficient = 25.2 min, P < 0.001) and larger blood loss (coefficient = 79.9 mL, P < 0.001) by multivariable analysis. However, a higher recurrence rate of cystoceles (log-rank test, P = 0.001) was found in the NTR group, compared with the TVM group; but not apical prolapse (P = 0.32) or rectocele (P = 0.45). Multivariable analysis revealed that the TVM surgery (hazard ratio = 0.24, 95% confidence interval = 0.09-0.64, P = 0.004) and old age (hazard ratio = 1.07, 95% confidence interval = 1.02-1.11, P = 0.005) were independent predictors for the recurrence of cystoceles. Based on the receiver operating characteristic curve (ROC) analysis, the cut-off age value was 64 years with an ROC area of 0.65. In women with intact uterus (n = 162), the recurrence rate of cystoceles was lower in the TVM group (log-rank test, P = 0.0001), compared with the NTR group. However, there was no between-group difference in the recurrence rate of cystoceles in women with prior or concomitant hysterectomy (n = 177, P = 0.17).
CONCLUSION
In women with intact uterus, the TVM group has a lower recurrence rate of cystoceles than the NTR group. In addition, old age, especially more than 64 years old, is a risk factor for cystocele recurrence.
Topics: Aged; Female; Humans; Middle Aged; Multivariate Analysis; Pelvic Organ Prolapse; ROC Curve; Recurrence; Retrospective Studies; Risk Factors; Surgical Mesh; Taiwan; Treatment Outcome; Urinary Incontinence; Urologic Surgical Procedures
PubMed: 31542332
DOI: 10.1016/j.jfma.2019.08.034 -
Geburtshilfe Und Frauenheilkunde Sep 2019The aim of this study was to determine the effectiveness of a newly developed anchoring system for unilateral sacrospinous ligament fixation (USSLF) and bilateral...
The aim of this study was to determine the effectiveness of a newly developed anchoring system for unilateral sacrospinous ligament fixation (USSLF) and bilateral sacrospinous ligament fixation (BSSLF) procedures. Ninety-three patients with pelvic prolapse who were treated surgically with the Anchorsure System between 2013 and 2018 were included in the study. USSLF was performed in 52 patients (group 1), and BSSLF was performed in 41 patients (group 2). Pelvic organ prolapse was assessed preoperatively and 6 months postoperatively. There were no significant differences between groups 1 and 2 with regard to age, parity, and demographic characteristics. Anatomical improvement rates were similar, irrespective of the type of SSLF used. No bleeding requiring blood transfusion or organ injuries occurred in any patient. Three patients in the group that received BSSLF developed small asymptomatic cystoceles (grade 1 to 2); there was no recurrence of rectoceles or enteroceles. Mild cystocele was found in 1 patient from the USSLF group. There was no significant difference between the groups with respect to the recurrence of cystocele. Recurrence of vaginal vault prolapse was found in 2 patients from the USSLF group (3.84%). There was no significant difference between the groups with regard to recurrence. Febrile morbidity, clinical outcomes, blood loss, duration of operation, intraoperative complications, and length of hospital stay were similar for the two groups. Unilateral and bilateral SSLF techniques produce similar clinical outcomes. USSLF and BSSLF performed using the new anchoring system are safe and effective methods to treat pelvic organ prolapse.
PubMed: 31523098
DOI: 10.1055/a-0846-5726 -
Therapeutic Advances in Urology 2019Our aim was to investigate longer-term surgical and quality of life (QOL) outcomes in a cohort of women undergoing robotic-assisted laparoscopic sacrocolpopexy (RALS)...
BACKGROUND
Our aim was to investigate longer-term surgical and quality of life (QOL) outcomes in a cohort of women undergoing robotic-assisted laparoscopic sacrocolpopexy (RALS) for pelvic organ prolapse (POP).
METHODS
We performed a retrospective cohort study at a single institution of female patients undergoing RALS with and without concomitant robotic-assisted laparoscopic hysterectomy, urethral sling, and rectocele repair. Scores from the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) surveys were used to evaluate QOL outcomes. Clinical improvement was defined by a decrease in a patient's PFDI and PFIQ postoperative score by ⩾70%.
RESULTS
Clinical improvement was seen in 62.6% by the PFIQ and in 64% by the PFDI survey. Younger patient age (OR 0.92, = 0.011) and worse preoperative American Urological Association (AUA) Quality of Life score (OR 1.42, = 0.046) were associated with clinical improvement. Within the PFIQ, 35.6% of patients saw clinical improvement with their bowel symptoms, compared with bladder (54.1%, < 0.001) and prolapse (45.6%, = 0.053) symptoms. Within the PFDI, 45.5% of patients reached clinical improvement with their bowel symptoms, compared with bladder (56.7%, = 0.035) and prolapse (62.6%, < 0.001) symptoms. Of the patients who had a rectocele repair, 46.3% reached clinical improvement in their CRADI-8 score, and 51% saw clinical improvement in the bowel portion of the PDFI.
CONCLUSIONS
Significantly fewer patients reached clinical improvement within the portions of the surveys that focus on bowel symptoms, compared with symptoms related to urination and POP. Of those that had a concomitant rectocele repair, approximately half reached clinical improvement with their bowel symptoms.
PubMed: 31447937
DOI: 10.1177/1756287219868593 -
International Braz J Urol : Official... 2019To compare the intermediate-term follow-up results of laparoscopic pectopexy and vaginal sacrospinous fi xation procedures. (Comparative Study)
Comparative Study Observational Study
OBJECTIVE
To compare the intermediate-term follow-up results of laparoscopic pectopexy and vaginal sacrospinous fi xation procedures.
MATERIALS AND METHODS
Forty-three women who had vaginal sacrospinous fixations (SSF) using Dr. Aksakal's Desta suture carrier and 36 women who had laparoscopic pectopexies were re-examined 7 to 43 months after surgery. The PISQ-12 and P-QOL questionnaires were answered by all of the women.
RESULTS
The apical descensus relapse rates did not differ between the groups (14% in the SSF vs. 11.1% in the pectopexy group). The de novo cystocele rates were higher in the SSF group (25.6% in the SSF vs. 8.3% in the pectopexy group). There were no significant differences in the de novo rectocele numbers between the groups. The treatment satisfaction rates were high in both groups (93% in the SSF vs. 91.7% in the pectopexy group), which was not statistically significant. Moreover, the postoperative de novo urge and stress urinary incontinence rates did not differ; however, the postoperative sexual function scores (PISQ-12) (36.86±3.15 in the SSF group vs. 38.21±5.69 in the pectopexy group) were better in the pectopexy group. The general P-QOL scores were not signifi cantly different between the surgery groups.
CONCLUSION
The vaginal sacrospinous fixation maintains its value in prolapse surgery with the increasing importance of native tissue repair. The new laparoscopic pectopexy technique has comparable positive follow-up results with the conventional sacrospinous fixation procedure.
Topics: Aged; Female; Humans; Laparoscopy; Middle Aged; Patient Satisfaction; Pelvic Organ Prolapse; Quality of Life; Reproducibility of Results; Retrospective Studies; Surveys and Questionnaires; Treatment Outcome; Vagina
PubMed: 31408288
DOI: 10.1590/S1677-5538.IBJU.2019.0103 -
International Urogynecology Journal Aug 2020Robotic abdominal lateral suspension (RALS) is an innovative mini-invasive surgical technique that allows treating apical and anterior prolapse. The safety and efficacy...
INTRODUCTION AND HYPOTHESIS
Robotic abdominal lateral suspension (RALS) is an innovative mini-invasive surgical technique that allows treating apical and anterior prolapse. The safety and efficacy of this strategy have not yet been tested.
METHODS
We completed a prospective case series of 115 RALS to treat apical and anterior prolapse stage III or IV, with no or minimal (stage I) posterior defect. Clinical evaluation was performed with a simplified POP quantification system (POP-Q). Mean follow-up was 28 ± 4 months. Primary outcomes were objective and subjective cure; secondary outcomes were reoperation rate for recurrence, erosion rate and complications. Objective cure was defined as POP-Q ≤ 1. Subjective cure was defined as absence of vaginal bulge. Patient's satisfaction was measured using the Patient Global Impression of Improvement Scale (PGI-I).
RESULTS
There was a significant improvement in POP-Q score in all treated compartments with an objective cure rate of 88.7% for the anterior and 93.1% for the apical compartment (p < 0.0001). Subjective cure rate was 82%. The emergence of de novo high rectoceles was not significant in the cohort, as much as the development of de novo stress or urge urinary incontinence. Reoperation rate for POP was 11.3% (8 recurrent cystoceles without apical descent and 5 apical and anterior relapses). No postoperative complications of Clavien-Dindo grade ≥ 3a were seen. Mesh exposure rate was 0.9%; 58.2% patients compiled a PGI-I score at 18-24 months post-surgery, reporting high satisfaction rates.
CONCLUSIONS
RALS is highly effective at a mid-term follow-up for the treatment of advanced apical and anterior POP.
Topics: Female; Gynecologic Surgical Procedures; Humans; Neoplasm Recurrence, Local; Pelvic Organ Prolapse; Prospective Studies; Robotic Surgical Procedures; Surgical Mesh; Treatment Outcome
PubMed: 31388718
DOI: 10.1007/s00192-019-04069-7 -
Research and Reports in Urology 2019Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) affect many women in their lifetime. In this review, we describe and evaluate the latest treatment... (Review)
Review
Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) affect many women in their lifetime. In this review, we describe and evaluate the latest treatment options for SUI and POP, including the controversy around transvaginal mesh (TVM) use. Growing evidence supports the utilization of pelvic floor muscle training as first-line treatment for both SUI and POP. Vaginal pessaries continue to be an effective and reversible option to manage SUI and POP symptoms. The midurethral sling remains the gold standard for surgical treatment of SUI, although patients and clinicians should acknowledge the potentially serious complications of TVM. Burch urethropexy and pubovaginal sling offer good SUI cure and may be preferred in women wishing to avoid mesh implants; however, their operative morbidities and more challenging surgical approach may limit their use. Site-specific cystocele or rectocele repairs may be indicated for isolated anterior or posterior vaginal compartment prolapse; however, in women with more severe POP, evidence supports using a vaginal native-tissue repair involving apical suspension as the primary surgical technique. Although abdominal and laparoscopic sacrocolpopexies are both effective in treating POP, their failure and mesh complication rates increase with time. There is insufficient evidence to support the widespread use of uterine-preserving surgical POP repairs at present due to the lack of long-term data. Routine TVM use is not recommended in POP surgeries and should only be considered on a case-by-case basis by trained surgeons, primarily in women with multiple risk factors for POP recurrence. In general, clinicians should individualize SUI and POP treatment options for women based on their symptoms, comorbidities, and risk factors for mesh-related complications.
PubMed: 31355157
DOI: 10.2147/RRU.S191555 -
Asian Journal of Surgery Jan 2020Rectocele is often associated with chronic constipation. Various surgical techniques have been described to repair rectoceles, but the results vary. The aim of this... (Comparative Study)
Comparative Study
BACKGROUND
Rectocele is often associated with chronic constipation. Various surgical techniques have been described to repair rectoceles, but the results vary. The aim of this study was to compare the outcomes of transanal repair (TAR) and transanal repair with posterior colporrhaphy (TAR + PC).
METHODS
While 44 patients underwent TAR, 49 patients underwent TAR + PC for surgical repair of rectocele. Patients were followed up 3 months post-surgery for anorectal physiological changes. From the entire cohort of patients who underwent the surgical repair, 22 patients who underwent TAR and 25 patients who underwent TAR + PC agreed to participate in the 3-year post-treatment check-up.
RESULTS
Out of the 22 patients who underwent TAR, 3 patients (13.6%) scored more than 15 on the constipation scoring system (CSS), while 1 out of 25 patients who underwent TAR + PC scored more than 15 on the CSS 3 months post-treatment, which is considered as recurrence (p = 0.237). With 7 patients from the TAR group (31.8%) and 2 patients from the TAR + PC group (8.0%) showing recurrence of rectocele at 3-year post-treatment follow-up, this study found that TAR + PC had a much lower rate of recurrence than TAR. Furthermore, TAR + PC was found to be more effective than TAR in terms of rectal sensation, sensory threshold (p = 0.001), and early defecation urge (p = 0.003).
CONCLUSIONS
TAR + PC can help alleviate some symptoms by restoring the rectal sensation and improving the rectovaginal septum. It can be inferred that the addition of a simple treatment method can lead to a lower rate of recurrence.
Topics: Anal Canal; Constipation; Female; Follow-Up Studies; Gynecologic Surgical Procedures; Humans; Middle Aged; Rectocele; Rectum; Secondary Prevention; Time Factors; Treatment Outcome
PubMed: 31036477
DOI: 10.1016/j.asjsur.2019.04.001 -
Neurogastroenterology and Motility Jul 2019During proctography, rectal emptying is visually estimated by the reduction in rectal area. The correlation between changes in rectal area, which is a surrogate measure... (Comparative Study)
Comparative Study
BACKGROUND
During proctography, rectal emptying is visually estimated by the reduction in rectal area. The correlation between changes in rectal area, which is a surrogate measure of volume, is unclear. Our aims were to compare the change in rectal area and volume during magnetic resonance (MR) proctography and to compare these parameters with rectal balloon expulsion time (BET).
METHODS
In 49 healthy and 46 constipated participants, we measured BET and rectal area and volume with a software program before and after participants expelled rectal gel during proctography.
KEY RESULTS
All participants completed both tests; six healthy and 17 constipated patients had a prolonged (>60 seconds) BET. During evacuation, the reduction in rectal area and volume was lower in participants with an abnormal than a normal BET (P < 0.01). The reduction in rectal area and volume were strongly correlated (r = 0.93, P < 0.001) and equivalent for identifying participants with abnormal BET. Among participants with less evacuation, the reduction in rectal area underestimated the reduction in rectal volume. A rectocele larger than 2 cm was observed in eight of 18 (44%) participants in whom the difference between change in volume and area was ˃10% but only 14 of 77 (18%) participants in whom the difference was ≤10% (P = 0.03).
CONCLUSIONS
Measured with MR proctography, the rectal area is reasonably accurate for quantifying rectal emptying and equivalent to rectal volume for distinguishing between normal and abnormal BET. When evacuation is reduced, the change in rectal area may underestimate the change in rectal volume.
Topics: Adult; Constipation; Defecation; Female; Humans; Magnetic Resonance Imaging; Male; Manometry; Rectum
PubMed: 31025437
DOI: 10.1111/nmo.13608