The influence of BMI, smoking, and age on vaginal erosions after synthetic mesh repair of pelvic organ prolapses. A multicenter study.

PubMed

Araco, Francesco; Gravante, Gianpiero; Sorge, Roberto; Overton, John; De Vita, Davide; Primicerio, Mario; Dati, Stefano; Araco, Placido; Piccione, Emilio

2009-01-01

To study the influence of body mass index (BMI), smoking, and age on the risk of vaginal erosions after mesh repair of pelvic prolapses. Retrospective study. Three university and community hospitals. Patients that underwent mesh correction of prolapses between 2002 and 2007. Excluded were those with stress urinary incontinence, ongoing clinical infections, with a complete antibiotic course in the last six months and with systemic diseases affecting tissue oxygenation. Revision of medical notes. Risk contributions for age, smoking, and BMI on the occurrence of vaginal erosions. Data were collected from 460 patients. Postoperative erosions were present in 7%. BMI greater than 30 conferred a 10.1-fold increase in the risk of developing erosions, smoking a 3.7-fold increase, and age greater than 60 years a 2.2-fold increase. A cut-off value of seven pack years was determined for smoking where the risk associated with light smokers was similar to that of non-smokers. BMI, smoking, and age are important risk factors for pelvic organ prolapse surgery. Our data could be used to stratify patients according to their risk so that preventative measures can be taken in high-risk patients.

Long term subjective cure rate, urinary tract symptoms and dyspareunia following mesh augmented anterior vaginal wall prolapse repair.

PubMed

Weintraub, A Y; Friedman, T; Baumfeld, Y; Neuman, M; Krissi, H

2015-12-01

The aim of this study was to assess patient-centered long term outcomes following anterior vaginal repair with mesh. In January 2015, we identified 124 women who underwent anterior pelvic floor repair with mesh between January 2006 and February 2009. Patient records were reviewed and demographic, clinical, intra-operative and post-operative follow-up data retrieved. Telephone interviews were conducted to access information on clinical outcomes. Associations between baseline characteristics and long term symptoms were assessed by multivariable logistic regression models. Seventy-nine women were reached and consented to participate. Patients were interviewed 79-104 months after surgery. Their mean age at the time of surgery was 62.48 ± 9.53 years; all had stage III cystocele with a mean POP Q point Ba of 5.32 ± 1.47. Twenty-four (30%) had a previous hysterectomy and 26 (33%) had a previous pelvic organ prolapse or stress urinary incontinence operation. At telephone interviews, recurrence of prolapse symptoms was reported by 11 (13.9%) patients, mostly in the posterior compartment. Only 6 needed a corrective procedure. One patient had her mesh removed due to dyspareunia. Eleven (13.9%) reported lower urinary tract symptoms other than prolapse, as follows: stress urinary incontinence (1), overactive bladder (8) and dyspareunia (2). Long term rates of recurrent prolapse, dyspareunia and lower urinary tract symptoms were low for patients who underwent anterior vaginal wall mesh augmentation surgery for symptomatic cystoceles. Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.

Prolapse and continence surgery in countries of the Organization for Economic Cooperation and Development in 2012.

PubMed

Haya, Nir; Baessler, Kaven; Christmann-Schmid, Corina; de Tayrac, Renaud; Dietz, Viviane; Guldberg, Rikke; Mascarenhas, Teresa; Nussler, Emil; Ballard, Emma; Ankardal, Maud; Boudemaghe, Thierry; Wu, Jennifer M; Maher, Christopher F

2015-06-01

The purpose of this study was to report the rates and types of pelvic organ prolapse (POP) and female continence surgery performed in member countries of the Organization for Economic Co-operation and Development (OECD) in 2012. The published health outcome data sources of the 34 OECD countries were contacted for data on POP and female continence interventions from 2010-2012. In nonresponding countries, data were sought from national or insurer databases. Extracted data were entered into an age-specific International Classification of Disease, edition 10 (ICD-10)-compliant Excel spreadsheet by 2 authors independently in English-speaking countries and a single author in non-English-speaking countries. Data were collated centrally and discrepancies were resolved by mutual agreement. We report on 684,250 POP and 410,352 continence procedures that were performed in 15 OECD countries in 2012. POP procedures (median rate, 1.38/1000 women; range, 0.51-2.55 prolapse procedures/1000 women) were performed 1.8 times more frequently than continence procedures (median rate, 0.75/1000 women; range, 0.46-1.65 continence procedures/1000 women). Repairs of the anterior vaginal compartment represented 54% of POP procedures; posterior repairs represented 43% of the procedures, and apical compartment repairs represented 20% of POP procedures. Median rate of graft usage was 15.7% of anterior vaginal repairs (range, 3.3-25.6%) and 8.5% (range, 3.2-17%) of posterior vaginal repairs. Apical compartment repairs were repaired vaginally at a median rate of 70% (range, 35-95%). Sacral colpopexy represented a median rate of 17% (range, 5-65%) of apical repairs; 61% of sacral colpopexies were performed minimally invasively. Between 2010 and 2012, there was a 3.7% median reduction in transvaginal grafts, a 4.0% reduction in midurethral slings, and a 25% increase in sacral colpopexies that were performed per 1000 women. Midurethral slings represented 82% of female continence surgeries. The 5-fold variation in the rate of prolapse interventions within OECD countries needs further evaluation. The significant heterogeneity (>10 times) in the rates at which individual POP procedures are performed indicates a lack of uniformity in the delivery of care to women with POP and demands the development of uniform guidelines for the surgical management of prolapse. In contrast, the midurethral slings were the standard female continence surgery performed throughout OECD countries in 2012. Copyright © 2015 Elsevier Inc. All rights reserved.

The role of nurses in the management of women with pelvic organ prolapse.

PubMed

Richardson, Karen; Hagen, Suzanne

Pelvic organ prolapse is a common female complaint, with 50% of women experiencing some degree of pelvic relaxation, although not all have any symptoms. Prolapse is found most commonly in the anterior vaginal walls. Posterior vaginal wall and apical prolapse are the other, less common, categories. There are a large number of potential risk factors, but increased age, parity and body mass index are most consistently reported. A variety of symptoms may be experienced, including a feeling of something coming down, pelvic heaviness, urinary, bowel and sexual dysfunction. Two main treatment options exist, conservative management (pessary or pelvic floor rehabilitation) or surgical repair, however the evidence-base for treatment is weak. The specialist nurse is well-placed to contribute to the initial assessment, management and ongoing support of women with prolapse.

Bladder function after sacrospinous hysteropexy and vaginal wall repair in women with uterovaginal prolapse.

PubMed

Sayed Ahmed, Waleed A; Taha, Omima T; Hamdy, Mostafa A; Ibrahim, Zakia M; Elshahat, Amal M

2018-05-01

To evaluate the impact of repair of uterovaginal prolapse using sacrospinous hysteropexy and vaginal wall repair on the bladder function. The study was conducted at the urogynecology clinic of Suez Canal University Hospitals, Ismailia from January 2014 to March 2016. This study included women with a diagnosis of uterovaginal prolapse and wishing to preserve their uteri. Bladder function was evaluated through assessment of urological symptoms using a standardized questionnaire - the urogenital distress inventory (UDI-6) - in addition to urodynamic studies just before and six-months after the sacrospinous hysteropexy ± associated vaginal wall repair operation. Twenty-seven patients completed the study with a mean age of 36.5 ± 4 years. Only 3 women had sacrospinous hysteropexy with no additional procedures. Other procedures included anterior colporrhaphy (12), posterior colporrhaphy (9) and perineorrhaphy (15). Based on UDI-6, there was no significant difference between the pre- and post-operative symptoms of stress urinary incontinence (SUI) [8/27 (29.6%) vs. 9/27 (33.3%) respectively; p value = 0.7]. The pre- and post-operative symptoms of urge urinary incontinence were also insignificantly different [13/27 (48.1%) vs. 15/27 (55.5%); p value = 0.5]. The total score of UDI-6 increased from 24.5 ± (14.2) to 32.8 ± (29.4) which was not statistically significant (p value = 0.12). Urodynamically, voiding dysfunction was found less frequently after the operation, however the difference was statistically insignificant [9/27 (33.3%) vs. 8/27 (29.6%); p value = 0.7]. Sacrospinous hysteropexy and associated vaginal wall repair do not affect the bladder function either subjectively or objectively. Copyright © 2018. Published by Elsevier B.V.

Geriatric Pelvic Organ Prolapse Surgery: Going the Extra Mile.

PubMed

Krishnan, Seethalakshmi

2017-12-01

To assess the quality of life in geriatric patients after reconstructive and obliterative vaginal surgery for advanced pelvic organ prolapse (POP). Prospective observational study was conducted between January 2009 and December 2014 at the department of Urogynaecology, Government Kasturbha Gandhi Hospital. A total of 424 women (between the age group of 60 and 94 years) with advanced pelvic organ prolapse underwent vaginal hysterectomy along with vaginal apical suspension procedures which were McCalls culdoplasty (35.02%), sacrospinous ligament suspension (8.3%), high uterosacral ligament suspension (26.2%), iliococcygeus fixation (4.6%) for stage 3-4 POP. Abdominal sacrocolpopexy (3.2%) was done for stage 3-4 vaginal vault prolapse. Patients with medical comorbidities underwent Leeforts partial colpocleisis (8.1%) and total colpocleisis (2%) for stage 3 and 4 POP. Site-specific repair (12.5%) was done for stage 3/4 cystocele and rectocele. The main outcomes measured were subjective cure (no prolapse), subjective improvements in pelvic floor symptoms as per the pelvic floor impact questionnaire, and objective cure (no prolapse of vaginal segment on maximum straining). Mean age of the patient was 64.29 years. The major complication rates were less than 1%. 85% were examined at 3 and 12 months. The subjective cure rate at 12 months is 92% and the objective cure rate is 94.5%. The geriatric patients who underwent either reconstructive or obliterative procedures were relieved of their preoperative symptoms and their quality of life had greatly improved.

Gluteo-vaginal fistula after posterior intravaginal slingplasty: a case report.

PubMed

Grynberg, Michael; Teyssedre, Jacques; Staerman, Frederic

2009-07-01

In patients with posthysterectomy prolapse of the vaginal vault, the posterior intravaginal slingplasty (posterior IVS, Tyco Healthcare, USA) has been suggested as an alternative to traditional vaginal vault suspensions. The goal of this technique is to recreate the uterosacral ligaments and to reinforce the rectovaginal fascia with the use of prosthetic material. We report the case of a 53-year-old woman with a history of 27 months of perineal suppurative discharge after she underwent a vaginal vault prolapse and rectocele repair using a posterior IVS (Tyco Healthcare, USA). The IVS tape was reinforced by interposing a rectovaginal monofilament polypropylene mesh (Parietex, Sofradim, France). Imaging studies and surgical exploration confirmed infection of the IVS mesh with the formation of a gluteo-vaginal fistula while the rectovaginal mesh was intact.

Is vaginal mesh a stimulus of autoimmune disease?

PubMed

Chughtai, Bilal; Sedrakyan, Art; Mao, Jialin; Eilber, Karyn S; Anger, Jennifer T; Clemens, J Quentin

2017-05-01

Polypropylene mesh has been used as a means of reinforcing weak tissues in women with pelvic organ prolapse and stress urinary incontinence. We sought to investigate a potential link between the development of systemic/autoimmune disorders and synthetic polypropylene mesh repairs. New York State Department of Health Statewide Planning and Research Cooperative System data were utilized to conduct this retrospective cohort study. Adult women undergoing surgery for pelvic organ prolapse with vaginally implanted mesh from January 2008 through December 2009 in inpatient and ambulatory surgery settings in New York State were identified. Two separate control cohorts were created to compare outcomes, including a screening colonoscopy cohort and a vaginal hysterectomy cohort for benign gynecologic conditions (without pelvic organ prolapse repair or sling). Patients in the mesh cohort were individually matched to the control cohorts based on demographics, comorbidities, and procedure date. The development of systemic/autoimmune disease was determined before and after matching for 1-year, 2-year, 3-year, and entire follow-up (up to 6 years until December 2014) and differences between groups were evaluated. A total of 2102 patients underwent mesh-based pelvic organ prolapse surgery from January 2008 through December 2009. In the control cohorts, 37,298 patients underwent colonoscopy and 7338 underwent vaginal hysterectomy. When patients were matched based on demographics, comorbidities, and procedure time, mesh-based surgery was not associated with an increased risk of developing autoimmune disease at any of the evaluated time periods. Mesh-based vaginal surgery was not associated with the development of systemic/autoimmune diseases. These data refute claims against mesh as a cause of systemic disease. Copyright © 2016 Elsevier Inc. All rights reserved.

Incidence of Extrusion Following Type I Polypropylene Mesh “Kit” Repairs in the Correction of Pelvic Organ Prolapse

PubMed Central

Lukban, James C.; Beyer, Roger D.; Moore, Robert D.

2012-01-01

Introduction and Hypothesis. We sought to determine the mesh extrusion (vaginal exposure) rates and subject outcomes following IntePro (Type I polypropylene) mesh “kit” repairs for vaginal prolapse. Methods. Data were pooled from two prospective multicenter studies evaluating the safety and efficacy of the Perigee and Apogee (American Medical Systems, Minnetonka, Minn, USA) to treat anterior and posterior/apical prolapses, respectively. Extrusions involving the anterior compartment (AC) or posterior compartment/apex (PC/A) were recorded. Results. Two hundred sixty women underwent mesh placement, with a total of 368 mesh units inserted (173 in the AC and 195 in the PC/A). Extrusions were noted in 13 (7.5%) of AC implants and 27 (13.8%) of PC/A implants through 12 months. No difference was seen between those with and without extrusion in regard to anatomic cure, postoperative painor quality of life at 1 year. Conclusions. Extrusion had no apparent effect on short-term outcomes. Given the unknown long-term sequellae of vaginal mesh exposure, a thorough assessment of risks and benefits of transvaginal mesh placement should be considered at the time of preoperative planning. PMID:22190952

Laparoscopic-assisted tension-free vaginal mesh: an innovative approach to placing synthetic mesh: transvaginally for surgical correction of pelvic organ prolapse.

PubMed

Watanabe, Toyohiko; Inoue, Miyabi; Ishii, Ayano; Yamato, Toyoko; Yamamoto, Masumi; Sasaki, Katsumi; Kobayashi, Yasuyuki; Araki, Motoo; Uehara, Shinya; Saika, Takashi; Kumon, Hiromi

2012-01-01

Polypropylene mesh implants for the correction of pelvic organ prolapse (POP) are now available in Japan. We developed an innovative approach for correcting POP by placing polypropylene mesh transvaginally with laparoscopic assistance. From June 2007 through March 2010, sixteen consecutive patients with symptomatic stage 2 or 3 pelvic organ prolapse underwent the laparoscopic-assisted tension-free vaginal mesh procedure at Okayama University Hospital. All patients were evaluated before and at 1, 3, 6, and 12 months after surgery. Female sexual function was also evaluated with the Female Sexual Function Index (FSFI). The procedure was performed successfully without significant complications. Fifteen of 16 patients were considered anatomically cured (93.8%) at 12 months postoperatively. One patient with a recurrent stage 3 vaginal vault prolapse required sacral colpopexy six months postoperatively. Total FSFI scores improved significantly from 10.3 ± 1.3 at baseline to 18.0 ± 1.2 at 12 months after surgery. The laparoscopic-assisted trans-vaginal mesh is a safe, effective, and simple procedure for POP repairs. The procedure not only restores anatomic relationships but also improves sexual function.

Transvaginal prolapse repair with or without the addition of a midurethral sling in women with genital prolapse and stress urinary incontinence: a randomised trial.

PubMed

van der Ploeg, J M; Oude Rengerink, K; van der Steen, A; van Leeuwen, J H S; Stekelenburg, J; Bongers, M Y; Weemhoff, M; Mol, B W; van der Vaart, C H; Roovers, J-P W R

2015-06-01

To compare transvaginal prolapse repair combined with midurethral sling (MUS) versus prolapse repair only. Multi-centre randomised trial. Fourteen teaching hospitals in the Netherlands. Women with symptomatic stage two or greater pelvic organ prolapse (POP), and subjective or objective stress urinary incontinence (SUI) without prolapse reduction. Women were randomly assigned to undergo vaginal prolapse repair with or without MUS. Analysis was according to intention to treat. The primary outcome at 12 months' follow-up was the absence of urinary incontinence (UI) assessed with the Urogenital Distress Inventory and treatment for SUI or overactive bladder. Secondary outcomes included complications. One hundred and thirty-four women were analysed at 12 months' follow-up (63 in MUS and 71 in control group). More women in the MUS group reported the absence of UI and SUI; respectively 62% versus 30% UI (relative risk [RR] 2.09; 95% confidence interval [CI] 1.39-3.15) and 78% versus 39% SUI (RR 1.97; 95% CI 1.44-2.71). Fewer women underwent treatment for postoperative SUI in the MUS group (10% versus 37%; RR 0.26; 95% CI 0.11-0.59). In the control group, 12 women (17%) underwent MUS after prolapse surgery versus none in the MUS group. Severe complications were more common in the MUS group, but the difference was not statistically significant (16% versus 6%; RR 2.82; 95% CI 0.93-8.54). Women with prolapse and co-existing SUI are less likely to have SUI after transvaginal prolapse repair with MUS compared with prolapse repair only. However, only 17% of the women undergoing POP surgery needed additional MUS. A well-informed decision balancing risks and benefits of both strategies should be tailored to individual women. © 2015 Royal College of Obstetricians and Gynaecologists.

[Are there selection criteria between abdominal approach and vaginal route for genital prolapse surgical management?].

PubMed

Cour, F; Vidart, A

2016-07-01

The never ending debate over the surgical approach of genital prolapse repair (abdominal versus vaginal route) is as passionate as ever. The available literature may support a multidisciplinary analysis of our expert daily practice. Our purpose was to define selection criteria for surgical approach between abdominal and vaginal route in the management of genital prolapse by reviewing the literature. Systematically review of the literature concerning comparative anatomical and functionnal results of surgery of pelvic organ prolaps by vaginal or abdominal route. We were confronted to the lack of data in the literature, with few prospective randomized comparative studies. Many limitations were identified such as small populations in the studies, no description of sub-population, multiplicity of surgical procedures. Moreover, vaginal route was compared to sacral colpopexy by open abdominal approach, whereas laparoscopic sacrocolpopexy is now recommended. Only one prospective randomized comparative trial assessed laparoscopic sacrocolpopexy and vaginal approach, in which was used a mesh withdrawn from the market. The lack of available randomized trials makes it impossible to define HAS compliant guidelines on this topic. However, selection criteria for each surgical approach and technique were drawn from experts' advices. © 2016 Published by Elsevier Masson SAS. © 2016 Elsevier Masson SAS. Tous droits réservés.

First report of vaginal prolapse in a bitch treated with oestrogen.

PubMed

Sarrafzadeh-Rezaei, F; Saifzadeh, S; Mazaheri, R; Behfar, M

2008-06-01

Vaginal prolapse is the protrusion of edematous vaginal tissue into and through the opening of the vulva occurring during the pro-oestrus and oestrus stages of the sexual cycle. True vaginal prolapse may occur near parturition, as the concentration of serum progesterone declines and the concentration of serum oestrogen increases. In a bitch, true vaginal prolapse is a very rare condition. This case report describes an 18-month-old crossbreed bitch, weighing 40 kg presented with type III vaginal prolapse. The patient had developed vaginal prolapse after receiving oestrogen in order to oestrus induction. Subsequent to unsuccessful attempts for repositioning, ovariohysterectomy (OHE), circumferential excision of the prolapsed tissue and finally vulvoplasty were performed. There was no evidence of recurrence of the prolapse during 30 days after surgery. This case report describes type III vaginal prolapse as an unusual side effect of oestrus induction hormonal therapy in the bitch.

Vaginal prolapse with urinary bladder incarceration and consecutive irreducible rectal prolapse in a dog.

PubMed

Ober, Ciprian-Andrei; Peștean, Cosmin Petru; Bel, Lucia Victoria; Taulescu, Marian; Cătoi, Cornel; Bogdan, Sidonia; Milgram, Joshua; Schwarz, Guenter; Oana, Liviu Ioan

2016-09-22

True vaginal prolapse is a rare condition in dogs and it is occasionally observed in animals with constipation, dystocia, or forced separation during breeding. If a true prolapse occurs, the bladder, the uterine body and/or distal part of the colon, may be present in the prolapse. A 2-year-old intact non pregnant Central Asian Shepherd dog in moderate condition, was presented for a true vaginal and rectal prolapse. The prolapses were confirmed by physical examination and ultrasonography. Herniation of the urinary bladder was identified within the vaginal prolapse. The necrotic vaginal wall was resected, the urinary bladder was reduced surgically and fixed to the right abdominal wall to prevent recurrence. Rectal resection and anastomosis was necessary to correct the rectal prolapse. Recurrence of the prolapses was not observed and the dog recovered completely after the surgical treatment. In our opinion, extreme tenesmus arising from constipation may have predisposed to the vaginal prolapse with bladder incarceration and secondarily to rectal prolapse. In the young female dog, true vaginal prolapse with secondary involvement of the urinary bladder and irreducible rectal prolapse is an exceptionally rare condition.

True vaginal prolapse in a bitch.

PubMed

Alan, M; Cetin, Y; Sendag, S; Eski, F

2007-08-01

Frequently, vaginal fold prolapse is the protrusion of edematous vaginal tissue into and through the opening of the vulva occurring during proestrus and estrus stages of the sexual cycle. True vaginal prolapse may occur near parturition, as the concentration of serum progesterone declines and the concentration of serum oestrogen increases. In the bitch, this type of true vaginal prolapse is a very rare condition. This short communication describes a 5-year-old female, cross-breed dog in moderate condition, weighing 33 kg, with distocia and true vaginal prolapse. Abdominal palpation and transabdominal ultrasonography revealed live and dead foetuses in the uterine horns. One dead and four live fetuses were removed from uterus by cesarean section. The ovariohysterectomy was performed after repositioning the vaginal wall with a combination of traction from within the abdomen and external manipulation through the vulva. Re-occurrence of a vaginal prolapse was not observed and the bitch recovered completely after the surgical therapy. Compared to other vaginal disorders, vaginal prolapse is an uncommon condition in the bitch. In the present case, extreme tenesmus arising from distocia may have predisposed to the vaginal prolapse. The cause of dystocia was probably the disposition of the first foetus. We concluded that the vaginal prolapse was the result of dystocia in the present case.

Effects of Preoperative Local Estrogen in Postmenopausal Women With Prolapse: A Randomized Trial

PubMed Central

Good, Meadow M.; Roshanravan, Shayzreen M.; Shi, Haolin; Schaffer, Joseph I.; Singh, Ravinder J.; Word, R. Ann

2014-01-01

Context: Pelvic organ prolapse (POP) increases in prevalence with age; recurrence after surgical repair is common. Objective: The objective of the study was to determine the effects of local estrogen treatment on connective tissue synthesis and breakdown in the vaginal wall of postmenopausal women planning surgical repair of POP. Design: This was a randomized trial. Setting: The study was conducted at an academic tertiary medical center. Patients or Other Participants: Postmenopausal women with a uterus and symptomatic anterior and/or apical prolapse at stage 2 or greater participated in the study. Intervention: Estrogen (Premarin) or placebo cream for 6 weeks preoperatively was the intervention. Main Outcome Measures: Full-thickness anterior apical vaginal wall biopsies were obtained at the time of hysterectomy and analyzed for mucosa and muscularis thickness, connective tissue synthesis, and degradation. Serum levels of estrone and 17β-estradiol were analyzed at baseline and the day of surgery using highly sensitive liquid chromatography-tandem mass spectrometry. Results: Fifteen women per group (n = 30 total) were randomized; 13 per group underwent surgery. Among drug-adherent participants (n = 8 estrogen, n = 13 placebo), epithelial and muscularis thickness was increased 1.8- and 2.7-fold (P = .002 and P =.088, respectively) by estrogen. Collagen types 1α1 and 1α2 mRNA increased 6.0- and 1.8-fold in the vaginal muscularis (P < .05 for both); collagen type Ia protein increased 9-fold in the muscularis (P = .012), whereas collagen III was not changed significantly. MMP-12 (human macrophage elastase) mRNA was suppressed in the vaginal mucosa from estrogen-treated participants (P = .011), and matrix metalloprotease-9 activity was decreased 6-fold in the mucosa and 4-fold in the muscularis (P = .02). Consistent with menopausal norms, serum estrone and 17β-estradiol were low and did not differ among the two groups. Conclusions: Vaginal estrogen application for 6 weeks preoperatively increased synthesis of mature collagen, decreased degradative enzyme activity, and increased thickness of the vaginal wall, suggesting this intervention improves both the substrate for suture placement at the time of surgical repair and maintenance of connective tissue integrity of the pelvic floor. PMID:24947034

Vaginal prolapse repair using the Prolift kit: a registry of 100 successive cases.

PubMed

Simon, Marie; Debodinance, Philippe

2011-09-01

To evaluate anatomical, functional outcomes and complications inherent to the treatment of pelvic organ prolapse by implantation of polypropylene mesh, using the Prolift kit. Single-center observational study of 100 successive patients enrolled in a registry, who underwent Prolift prolapse repair. Data on prior treatments, associated procedures and per- and post-operative complications were collected and the patients were seen after 2, 6 and 12 months. Anatomical outcomes were assessed using the International Continence Society Pelvic Organ Prolapse Quantification (ICS POP-Q) system. Function was assessed in terms of urinary and digestive problems, and impact on sex life. Failure was defined as relapse of POP-Q Grade 2 or more. Of the 100 patients, 32 had an anterior, 14 a posterior, 54 a total Prolift; 53 had concomitant urinary incontinence surgery. At 6 and 12 months respectively, 8% and 12% of the patients were lost to follow-up. Mean operating time was 39.8 min. With respect to peri-operative complications, there was no bladder or rectal damage but three patients experienced bleeding (≥ 300 ml) without needing transfusion. POP-Q Grades before surgery were: Grades III-IV cystocele in 65.7% of the anterior Prolift patients; Grades II-III rectocele in the posterior; and 77.8% of total were Grade III and 11.1% Grade IV. The incidence of recurrence was 3.6% at Month 6 and 10.2% at Month 12. Significant (p<0.05) improvements were seen in median scores for the various POP-Q items. With respect to functional problems, stress urinary incontinence was cured in 92% of the patients but 7.7% reported new-onset urinary incontinence after one year. One case of vaginal exposure after one year was observed and major or symptomatic mesh retraction was observed in 8%. New-onset dyspareunia was reported by 11.1% of the patients. These results confirm the feasibility of using the Prolift kit in the repair of prolapse via a vaginal approach and the low per- and post-operative morbidity associated with that technique. Nevertheless, longer-term evaluation is required to confirm the results. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Transvaginal single-incision mesh reconstruction for recurrent or advanced anterior vaginal wall prolapse.

PubMed

Marschke, J; Hengst, L; Schwertner-Tiepelmann, N; Beilecke, K; Tunn, R

2015-05-01

Single-incision transvaginal mesh for reconstruction of Level I and II prolapses in women with recurrent or advanced prolapse. We evaluated functional, anatomical, sonomorphological and quality-of-life outcome. Data were collected retrospectively for preoperative parameters and at follow-up visits. Anatomical cure was assessed with vaginal examination using the ICS-POP-Q system; introital-ultrasound scan for postvoidal residual and description of mesh characteristics was performed. We applied a visual analogue scale (VAS) and the German Pelvic Floor Questionnaire to assess quality-of-life. Seventy women with cystocele (III: 61.3%/IV: 16%), all post-hysterectomy and in majority (81.4%) after previous cystocele repair, were operated using a single-incision transvaginal technique. Overall anatomical success rate was 95.7% with significant improvement in quality-of-life (p < 0.0001). Mesh erosion occurred in 5.7%, one patient presented symptomatic vaginal vault prolapse. Postvoidal residual declined significantly (58 vs. 2.9%). Sonographic mesh length was 55.7% of implanted mesh with a wide range of mesh position, but no signs of mesh dislocation. There was no de novo dyspareunia reported, one case of preoperative existing dyspareunia worsened. No severe adverse event was observed. We hereby present a trial of a high-risk group of patients requiring reconstruction of anterior and apical vaginal wall in mostly recurrent prolapse situation. Our data support the hypothesis of improved anatomical and functional results and less mesh shrinkage caused by the single-incision technique with fixation in sacrospinous ligament in combination with modification in mesh quality compared to former multi-incision techniques.

Outcomes following vaginal prolapse repair and mid urethral sling (OPUS) trial--design and methods.

PubMed

Wei, John; Nygaard, Ingrid; Richter, Holly; Brown, Morton; Barber, Matthew; Xiao Xu; Kenton, Kimberly; Nager, Charles; Schaffer, Joseph; Visco, Anthony; Weber, Anne

2009-04-01

The primary aims of this trial are to determine whether the use of a concomitant prophylactic anti-incontinence procedure may prevent stress urinary incontinence symptom development in women undergoing vaginal prolapse surgery and to evaluate the cost-effectiveness of this prophylactic approach. To present the rationale and design of a randomized controlled surgical trial (RCT), the Outcomes following vaginal Prolapse repair and mid Urethral Sling (OPUS) Trial highlighting the challenges in the design and implementation. The challenges of implementing this surgical trial combined with a cost-effectiveness study and patient preference group are discussed including the study design, ethical issues regarding use of sham incision, maintaining the masking of study staff, and pragmatic difficulties encountered in the collection of cost data. The trial is conducted by the NICHD-funded Pelvic Floor Disorders Network. The ongoing OPUS trial started enrollment in May 2007 with a planned accrual of 350. The use of sham incision was generally well accepted but the collection of cost data using conventional billing forms was found to potentially unmask key study personnel. This necessitated changes in the study forms and planned timing for collection of cost data. To date, the enrollment to the patient preference group has been lower than the limit established by the protocol suggesting a willingness on the part of women to participate in the randomization. Given the invasive nature of surgical intervention trials, potential participants may be reluctant to accept random assignment, potentially impacting generalizability. Findings from the OPUS trial will provide important information that will help surgeons to better counsel women on the benefits and risks of concomitant prophylactic anti-incontinence procedure at the time of vaginal surgery for prolapse. The implementation of the OPUS trial has necessitated that investigators consider ethical issues up front, remain flexible with regards to data collection and be constantly aware of unanticipated opportunities for unmasking. Future surgical trials should be aware of potential challenges in maintaining masking and collection of cost-related information.

Outcomes and complications of trans-vaginal mesh repair using the Prolift™ kit for pelvic organ prolapse at 4 years median follow-up in a tertiary referral centre.

PubMed

Khan, Zainab A; Thomas, Lee; Emery, Simon J

2014-12-01

To evaluate the anatomical, functional and post-operative outcomes of polypropylene mesh (Prolift™) in the surgical management of pelvic organ prolapse (POP). A single-centre observational study of 106 successive patients, who underwent Prolift™ mesh repair (POP ≥ 2) with a median follow-up of 4 years, was performed. Outcomes of interest measured included patient demographics, intra and post-operative complications, concomitant procedures for POP or urinary incontinence. Using the Baden-Walker classification, grade ≥2 prolapses in the operated compartment were deemed as surgical failure. Validated questionnaires including ICIQ-VS and ICIQ-UI were used to assess functional outcome. Of the 106 patients, 56 had an anterior, 36 a posterior and 14 a total Prolift™. 101 patients were available for follow-up (median 4 years). 82 women underwent a clinical follow-up whilst 19 underwent a telephonic follow-up. Peri-operative bladder injury was noted in 2 (1.9 %) cases. Six (5.6 %) patients developed mesh exposure post-operatively. Re-operation rates for recurrent prolapse in the operated compartment were 2.8 % (n = 3). At follow-up, prolapse recurrence in the operated compartment was noted in another 7.3 % (n = 6) patients. Combining re-operations for POP and recurrences noted during follow-up, the revised failure rate was 10.1 % (n = 9). De novo prolapse in the non-operated compartment occurred in 19.5 % (n = 16) women. Our study demonstrates that Prolift™ vaginal mesh surgery offers anatomical cure rates of 89.9 %. A higher rate of de novo recurrence in the non-operated compartment was noted suggesting that surgical correction in one compartment may exacerbate recurrence in other compartments.

Necrotising fasciitis after hysterectomy and concomitant transvaginal mesh repair in a patient with pelvic organ prolapse.

PubMed

Pushkar, Dmitry Y; Vasilchenko, Mikhail I; Kasyan, George R

2013-10-01

Necrotising fasciitis is a severe form of soft tissue infection. Herein, we present an unreported complication of the transvaginal repair of a pelvic organ prolapse (POP) with trocar-guided polypropylene mesh and a concomitant hysterectomy. A 61-year-old Caucasian female who had been using an intrauterine device (IUD) for 30 years presented with a stage 3 pelvic organ prolapse. A genital ultrasound examination confirmed the presence of an IUD, but found no endometrial abnormalities. The surgical management was limited to a transvaginal hysterectomy and simultaneous anterior vaginal wall repair augmented with trocar-guided mesh. A morphological examination of the removed uterus confirmed the presence of the intrauterine device and additionally found endometrial cancer (T1N0M0), which was not revealed during the preoperative ultrasound. Within 6 days of the surgery, she developed anaerobic bilateral necrotising fasciitis on both thighs. Non-clostridial streptococci were identified in the wound. After 18 days of intensive care, the patient died of fatal coagulopathy.

The Role of the Surgeon on Outcomes of Vaginal Prolapse Surgery With Mesh.

PubMed

Eilber, Karyn S; Alperin, Marianna; Khan, Aqsa; Wu, Ning; Pashos, Chris L; Clemens, J Quentin; Anger, Jennifer T

Adverse outcomes after surgery for pelvic organ prolapse (POP) with mesh are often attributed to the mesh material with little attention paid to the influence of surgeon factors. We used a national data set to determine whether surgeon case volume and specialty influenced vaginal prolapse surgery outcomes with mesh. Public Use File data on a 5% random national sample of female Medicare beneficiaries were obtained from the Centers for Medicare and Medicaid Services. Women with a diagnosis of POP who underwent surgery with mesh between 2007 and 2008 were identified by relevant International Classification of Diseases, 9th Revision, Clinical Modification and Current Procedural Terminology, 4th Edition procedure codes. Outcomes were compared by surgeon case volume and specialty. From 2007 to 2008, 1657 surgeries for POP were performed with mesh. Low-, intermediate-, and high-volume surgeons performed 881 (53%), 408 (25%), and 368 (22%) of the cases with mesh, respectively. The cumulative reoperation rates for low-, intermediate-, and high-volume providers were 6%, 2%, and 3%, respectively. The difference in reoperation rates between low and intermediate and low- and high-volume surgeons was statistically significant (P = 0.007 and 0.003, respectively). There was no significant difference in reoperation rates between gynecologists and urologists when vaginal mesh was implanted for POP surgery. Low-volume surgeons performed most of the vaginal prolapse repairs with mesh and had significantly higher reoperation rates. Surgeon experience must be a consideration when reporting mesh-related complications of POP surgery.

Bilateral sacrospinous fixation without hysterectomy: 18-month follow-up

PubMed Central

Şentürk, Mehmet Baki; Güraslan, Hakan; Çakmak, Yusuf; Ekin, Murat

2015-01-01

Objective The aim of this study was to evaluate the results of bilateral sacrospinous fixation (SSF), which was performed with surgical mesh interposition and bilateral vaginal repair. Material and Methods Twenty-two patients underwent SSF between 2010 and 2012, and the results were evaluated retrospectively. The results at preoperative and postoperative 6th, 12th, and 18th months of the pelvic organ prolapse quantification system (POP-Q) and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12) were compared using Friedman and Wilcoxon Signed Ranks tests. Values of p<0.05 and <0.01 were considered statistically significant. Results According to the POP-Q, significant healing was observed on all vaginal vault points (p=0.001), and no prolapse was observed until the 18-month follow-up stage. There were also prominent patients who felt satisfactory with respect to their sexual life according to PISQ-12 (p=0.001). Conclusion This technique appears to provide an adequate clinical resolution, and it may be the primary surgical option for women with pelvic organ prolapse. PMID:26097393

Use of Concomitant Stress Incontinence Surgery at Time of Pelvic Organ Prolapse Surgery Since Release of the 2011 Notification on Serious Complications Associated with Transvaginal Mesh.

PubMed

Drain, Alice; Khan, Aqsa; Ohmann, Erin L; Brucker, Benjamin M; Smilen, Scott; Rosenblum, Nirit; Nitti, Victor W

2017-04-01

There is controversy regarding the performance of concomitant anti-incontinence procedures at the time of pelvic organ prolapse repair. Data support improvement in stress urinary incontinence with a concomitant sling but increased adverse events. We assessed trends in preoperative stress urinary incontinence evaluation, concomitant anti-incontinence procedure at pelvic organ prolapse surgery and postoperative anti-incontinence procedures at our institution before and after the 2011 FDA (U.S. Food and Drug Administration) Public Health Notification pertaining to vaginal mesh. We retrospectively reviewed the records of patients who underwent pelvic organ prolapse surgery from 2009 to 2015. Preoperative workup included assessment of subjective stress urinary incontinence and/or evaluation for leakage with reduction of pelvic organ prolapse on physical examination, urodynamics or a pessary trial. The percentages of concomitant and postoperative anti-incontinence procedures were compared before and after the 2011 FDA notification. A total of 775 women underwent pelvic organ prolapse repair. The percentage of anti-incontinence procedures at pelvic organ prolapse repair decreased from 54.8% to 38.0% after the FDA notification (p = 0.002) while the incidence of preoperative objective stress urinary incontinence on examination, urodynamics and pessary trials remained constant. The incidence of postoperative anti-incontinence procedures within 1 year of the index surgery remained low. We found a decrease in the incidence of concomitant anti-incontinence procedures at the time of pelvic organ prolapse repair following the 2011 FDA notification despite no significant decline in subjective stress urinary incontinence or demonstrable stress urinary incontinence on preoperative evaluation. Further analysis is warranted to assess the impact of the FDA notification on treatment patterns in women with pelvic organ prolapse and stress urinary incontinence. Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Vaginal prolapse repair with or without a midurethral sling in women with genital prolapse and occult stress urinary incontinence: a randomized trial.

PubMed

van der Ploeg, J Marinus; Oude Rengerink, Katrien; van der Steen, Annemarie; van Leeuwen, Jules H Schagen; van der Vaart, C Huub; Roovers, Jan-Paul W R

2016-07-01

We compared pelvic organ prolapse (POP) repair with and without midurethral sling (MUS) in women with occult stress urinary incontinence (SUI). This was a randomized trial conducted by a consortium of 13 teaching hospitals assessing a parallel cohort of continent women with symptomatic stage II or greater POP. Women with occult SUI were randomly assigned to vaginal prolapse repair with or without MUS. Women without occult SUI received POP surgery. Main outcomes were the absence of SUI at the 12-month follow-up based on the Urogenital Distress Inventory and the need for additional treatment for SUI. We evaluated 231 women, of whom 91 randomized as follows: 43 to POP surgery with and 47 without MUS. A greater number of women in the MUS group reported absence of SUI [86 % vs. 48 %; relative risk (RR) 1.79; 95 % confidence interval (CI) 1.29-2.48]. No women in the MUS group received additional treatment for postoperative SUI; six (13 %) in the control group had a secondary MUS. Women with occult SUI reported more urinary symptoms after POP surgery and more often underwent treatment for postoperative SUI than women without occult SUI. Women with occult SUI had a higher risk of reporting SUI after POP surgery compared with women without occult SUI. Adding a MUS to POP surgery reduced the risk of postoperative SUI and the need for its treatment in women with occult SUI. Of women with occult SUI undergoing POP-only surgery, 13 % needed additional MUS. We found no differences in global impression of improvement and quality of life.

Mesh for prolapse surgery: Why the fuss?

PubMed

Rajshekhar, Smita; Mukhopadhyay, Sambit; Klinge, Uwe

2015-06-01

Pelvic organ prolapse is a common gynaecological problem. Surgical techniques to repair prolapse have been constantly evolving to reduce the recurrence of prolapse and need for reoperation. Grafts made of synthetic and biological materials became popular in the last decade as they were intended to provide extra support to native tissue repairs. However, serious complications related to use of synthetic meshes have been reported and there is increasing medico-legal concern about mesh use in prolapse surgery. Some mesh products already have been withdrawn from the market and the FDA has introduced stricter surveillance of new and existing products. Large randomized studies comparing mesh with non-mesh procedures are lacking which creates uncertainty for the surgeon and their patients.The small cohorts of the RCTs available with short follow-up periods just allow the conclusion that the mesh repair can be helpful in the short to medium term but unfortunately are not able to prove safety for all patients. In particular, current clinical reports cannot define for which indication what material may be superior compared to non-mesh repair.Quality control through long-term individual and national mesh registries is needed to keep a record of all surgeons using mesh and all devices being used, monitoring their effectiveness and safety data. Meshes with better biocompatibility designed specifically for use in vaginal surgery may provide superior clinical results, where the reduction of complications may allow a wider range of indications. © The Author(s) 2015.

Vaginal fold prolapse during the last third of pregnancy, followed by normal parturition, in a bitch.

PubMed

Gouletsou, Pagona G; Galatos, Apostolos D; Apostolidis, Kosmas; Sideri, Aikaterini I

2009-06-01

This article describes a 1.5-year-old female, Greek Hound dog, weighing 16 kg, presented with a type III vaginal prolapse which occurred during the last third of pregnancy. Trans-abdominal ultrasonography revealed four live foetuses in the uterine horns. The animal was hospitalized and 4 days later gave birth without any interference. Three days later, resection of the prolapsed tissue was performed and the bitch recovered completely. Recurrence of a type I vaginal prolapse was observed 4 months later, during subsequent oestrus. This case is unusual because, although vaginal fold prolapse is mainly seen during proestrus/oestrus or during parturition, it was first noticed 47 days after mating and 13 days before parturition. Furthermore, even though the prolapse of vaginal fold was of type III and of considerable size, parturition proceeded normally. Finally, even though resection of the prolapsed tissue was performed 3 days after parturition, recurrence of vaginal fold oedema (type I) was observed in the subsequent oestrus.

Chronic vaginocervical prolapse with visceral incarceration in a dog.

PubMed

McNamara, P S; Harvey, H J; Dykes, N

1997-01-01

A bitch was presented for a vaginal prolapse of five years' duration. The prolapse was confirmed by physical examination and evaluated by contrast radiography. Herniation of the uterine body, urinary bladder, and distal aspect of the colon was identified within the prolapse. The prolapse was reduced surgically, and an ovariohysterectomy, cystopexy, and colopexy were performed. Compared to other vaginal disorders, vaginal prolapse is an uncommon condition in the bitch. The secondary involvement of abdominal viscera appears to be exceptionally rare.

Evidence-based outcomes for mesh-based surgery for pelvic organ prolapse.

PubMed

Mettu, Jayadev R; Colaco, Marc; Badlani, Gopal H

2014-07-01

In light of all the recent controversy regarding the use of synthetic mesh for pelvic organ prolapse, we did a retrospective review of the evidence-based outcomes and complications for its use. A total of 18 of the most recent studies in the last 5 years were selected. Studies selected were prospective randomized or quasi-randomized controlled trials that included surgical operations for pelvic organ prolapse for this review. Additionally, Cochrane review and meta-analysis of outcomes and complication were also analyzed. In terms of outcomes, the definition of successful surgery is currently being debated. Synthetic mesh provides superior anatomical and subjective cure rates compared with native tissue repair. Success rates varied greatly depending on the nature of prolapse and surgical approach. Furthermore, recurrence rates for mesh-based surgery are significantly lower than that for native tissue repair. The main unique complication of mesh is exposure and was reported in a mean of 11.4% of patients, with 6.8% of patients requiring surgical partial excision of mesh. Mesh significantly improves anatomical outcomes with sacrocolpopexy and vaginal repair. Mesh does create the unique complication which can be reduced with training and proper patient selection. Further development of better materials is vital rather than reverting to tissue-based repair. Ultimately, the decision to use mesh should be based upon a patient's personal goals and preferences after an informed conversation with her physician.

Under what circumstances should stress incontinence surgery be performed at the same time as prolapse surgery? ICI-RS 2015.

PubMed

Khullar, Vik; Anding, Ralf; Robinson, Dudley; Castro-Diaz, David; Dmochowski, Roger; Cardozo, Linda

2017-04-01

An International Consultation on Incontinence-Research Society (ICI-RS) Think Tank in 2015 discussed and evaluated the evidence of when stress incontinence surgery should be performed with prolapse surgery and highlighted evidence gaps, with the aim of recommending further clinical and research proposals. A review of the literature assessing randomized studies where women with vaginal prolapse have been randomized to vaginal prolapse surgery with or without continence surgery were evaluated. The different clinical presentations were also evaluated and their impact on outcome was critically reviewed. There are three symptomatic groups of women with vaginal prolapse who are treated. The first group is continent women with vaginal prolapse. The second group has stress urinary incontinence (SUI) and vaginal prolapse. The last group has vaginal prolapse and have been found through testing to have occult SUI. The studies have reported a range of outcomes for each of these groups. There are different outcomes based on the surgical method used to correct the prolapse and also the different continence surgical techniques. There are insufficient studies to allow firm conclusions to be drawn. The economic impact of the different management pathways is also discussed although costs vary according to different national medical funding systems. There is considerable uncertainty about the optimal method of managing women with vaginal prolapse and stress incontinence due to the different surgical techniques available. In particular the group of women with occult SUI are a challenge as the optimal diagnostic method has not yet been defined. © 2017 Wiley Periodicals, Inc.

Clinical approach to vaginal/vestibular masses in the bitch.

PubMed

Manothaiudom, K; Johnston, S D

1991-05-01

The most common causes of vaginal/vestibular masses in the bitch are vaginal prolapse, vaginal neoplasia, and urethral neoplasia protruding into the vaginal vault. Other possible causes are clitoral enlargement, vaginal polyps, uterine prolapse, and vaginal abscessation or hematoma. Vaginal prolapse usually can be distinguished from neoplasia by the age of the patient, the time of occurrence during the estrous cycle, and the site of origin of the mass. Prolapse usually occurs in bitches under 4 years of age during proestrus, estrus, or at the end of diestrus and usually arises from the floor of the vagina, except for urethral tumors that protrude from the external urethral orifice. Appropriate diagnostic workup of bitches with vaginal vestibular masses includes complete history and physical examination, vaginal cytologic and vaginoscopic examination, retrograde vaginography or urethrocystography, serum progesterone and estradiol concentrations, and, in the case of suspect neoplasms, surgical or excision biopsy of the mass.

Transanal repair of rectocele and full rectal mucosectomy with one circular stapler: a novel surgical technique.

PubMed

Regadas, F S P; Regadas, S M M; Rodrigues, L V; Misici, R; Silva, F R; Regadas Filho, F S P

2005-04-01

We present a new surgical stapling technique for treatment of rectocele when associated with internal mucosal prolapse or haemorrhoids using only one circular mechanical stapler. Eight female patients, mean age 53 years (range, 42-70), complaining of obstructed defecation with vaginal digitation because of rectocele associated with internal mucosal prolapse underwent transanal repair of rectocele and rectal mucosectomy using one circular stapler between April and July 2004. A running horizontal mattress suture was placed through the base of the rectocele including mucosa, submucosa and the muscle layer of the whole anterior anorectal junction wall. The prolapsed mucosa and the muscular layer were then excised with an electrical scapel. A continuous pursestring rectal mucosa suture was placed 0.5 cm before the previous anterior mucosa and muscle layers resected wound, including the anorectal junction wall which was kept separate from the posterior vaginal wall by a Babcock forceps. Posteriorly, the pursestring suture included only mucosal and submucosal layers. The stapled suture was positioned between normal anterior rectal wall and the anal canal, 0.5 cm above the pectinate line. The stapler was then closed, fired and withdrawn. One patient complained of a perianal hematoma on the seventh postoperative day, requiring surgical excision. Postoperative defecography showed correction of the rectocele and outlet obstruction disappeared in all patients. This novel combined manual-stapled technique for rectocele and rectal internal mucosal prolapse seems to be a safe procedure and the preliminary results are encouraging. Further investigations have to be performed to assess long-term outcome in a larger number of patients.

Association Between the Amount of Vaginal Mesh Used With Mesh Erosions and Repeated Surgery After Repairing Pelvic Organ Prolapse and Stress Urinary Incontinence.

PubMed

Chughtai, Bilal; Barber, Matthew D; Mao, Jialin; Forde, James C; Normand, Sharon-Lise T; Sedrakyan, Art

2017-03-01

Mesh, a synthetic graft, has been used in pelvic organ prolapse (POP) repair and stress urinary incontinence (SUI) to augment and strengthen weakened tissue. Polypropylene mesh has come under scrutiny by the US Food and Drug Administration. To examine the rates of mesh complications and invasive reintervention after the placement of vaginal mesh for POP repair or SUI surgery. This investigation was an observational cohort study at inpatient and ambulatory surgery settings in New York State. Participants were women who underwent transvaginal repair for POP or SUI with mesh between January 1, 2008, and December 31, 2012, and were followed up through December 31, 2013. They were divided into the following 4 groups based on the amount of mesh exposure: transvaginal POP repair surgery with mesh and concurrent sling use (vaginal mesh plus sling group), transvaginal POP repair with mesh and no concurrent sling use (vaginal mesh group), transvaginal POP repair without mesh but concurrent sling use for SUI (POP sling group), and sling for SUI alone (SUI sling group). The primary outcome was the occurrence of mesh complications and repeated invasive intervention within 1 year after the initial mesh implantation. A time-to-event analysis was performed to examine the occurrence of mesh erosions and subsequent reintervention. Secondary analyses of an age association (<65 vs ≥65 years) were conducted. The study identified 41 604 women who underwent 1 of the 4 procedures. The mean (SD) age of women at their initial mesh implantation was 56.2 (13.0) years. The highest risk of erosions was found in the vaginal mesh plus sling group (2.72%; 95% CI, 2.31%-3.21%) and the lowest in the SUI sling group (1.57%; 95% CI, 1.41%-1.74%). The risk of repeated surgery with concomitant erosion diagnosis was also the highest in the vaginal mesh plus sling group (2.13%; 95% CI, 1.76%-2.56%) and the lowest in the SUI sling group (1.16%; 95% CI, 1.03%-1.31%). The combined use of POP mesh and SUI mesh sling was associated with the highest erosion and repeated intervention risk, while mesh sling alone had the lowest erosion and repeated intervention risk. There is evidence for a dose-response relationship between the amount of mesh used and subsequent mesh erosions, complications, and invasive repeated intervention.

Clinical effectiveness and cost-effectiveness of surgical options for the management of anterior and/or posterior vaginal wall prolapse: two randomised controlled trials within a comprehensive cohort study - results from the PROSPECT Study.

PubMed

Glazener, Cathryn; Breeman, Suzanne; Elders, Andrew; Hemming, Christine; Cooper, Kevin; Freeman, Robert; Smith, Anthony; Hagen, Suzanne; Montgomery, Isobel; Kilonzo, Mary; Boyers, Dwayne; McDonald, Alison; McPherson, Gladys; MacLennan, Graeme; Norrie, John

2016-12-01

The use of mesh in prolapse surgery is controversial, leading to a number of enquiries into its safety and efficacy. To compare synthetic non-absorbable mesh inlay, biological graft and mesh kit with a standard repair in terms of clinical effectiveness, adverse effects, quality of life (QoL), costs and cost-effectiveness. Two randomised controlled trials within a comprehensive cohort (CC) study. Allocation was by a remote web-based randomisation system in a 1 :1 : 1 ratio (Primary trial) or 1 : 1 : 2 ratio (Secondary trial), and was minimised on age, type of prolapse repair planned, need for a concomitant continence procedure, need for a concomitant upper vaginal prolapse procedure and surgeon. Participants and outcome assessors were blinded to randomisation; participants were unblinded if they requested the information. Surgeons were not blinded to allocated procedure. Thirty-five UK hospitals. Primary study : 2474 women in the analysis (including 1348 randomised) having primary anterior or posterior prolapse surgery. Secondary study : 398 in the analysis (including 154 randomised) having repeat anterior or posterior prolapse surgery. CC3 : 215 women having either uterine or vault prolapse repair. Anterior or posterior repair alone, or with mesh inlay, biological graft or mesh kit. Prolapse symptoms [Pelvic Organ Prolapse Symptom Score (POP-SS)]; prolapse-specific QoL; cost-effectiveness [incremental cost per quality-adjusted life-year (QALY)]. Primary trials : adjusting for baseline and minimisation covariates, mean POP-SS was similar for each comparison {standard 5.4 [standard deviation (SD) 5.5] vs. mesh 5.5 (SD 5.1), mean difference (MD) 0.00, 95% confidence interval (CI) -0.70 to 0.71; standard 5.5 (SD 5.6) vs. graft 5.6 (SD 5.6), MD -0.15, 95% CI -0.93 to 0.63}. Serious non-mesh adverse effects rates were similar between the groups in year 1 [standard 7.2% vs. mesh 7.8%, risk ratio (RR) 1.08, 95% CI 0.68 to 1.72; standard 6.3% vs. graft 9.8%, RR 1.57, 95% CI 0.95 to 2.59]. There were no statistically significant differences between groups in any other outcome measure. The cumulative mesh complication rates over 2 years were 2 of 430 (0.5%) for standard repair (trial 1), 46 of 435 (10.6%) for mesh inlay and 2 of 368 (0.5%) for biological graft. The CC findings were comparable. Incremental costs were £363 (95% CI -£32 to £758) and £565 (95% CI £180 to £950) for mesh and graft vs. standard, respectively. Incremental QALYs were 0.071 (95% CI -0.004 to 0.145) and 0.039 (95% CI -0.041 to 0.120) for mesh and graft vs. standard, respectively. A Markov decision model extrapolating trial results over 5 years showed standard repair had the highest probability of cost-effectiveness, but results were surrounded by considerable uncertainty. Secondary trials : there were no statistically significant differences between the randomised groups in any outcome measure, but the sample size was too small to be conclusive. The cumulative mesh complication rates over 2 years were 7 of 52 (13.5%) for mesh inlay and 4 of 46 (8.7%) for mesh kit, with no mesh exposures for standard repair. In women who were having primary repairs, there was evidence of no benefit from the use of mesh inlay or biological graft compared with standard repair in terms of efficacy, QoL or adverse effects (other than mesh complications) in the short term. The Secondary trials were too small to provide conclusive results. Women in the Primary trials included some with a previous repair in another compartment. Follow-up is vital to identify any long-term potential benefits and serious adverse effects. Long-term follow-up to at least 6 years after surgery is ongoing to identify recurrence rates, need for further prolapse surgery, adverse effects and cost-effectiveness. Current Controlled Trials ISRCTN60695184. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 20, No. 95. See the NIHR Journals Library website for further project information.

Quantification of Pelvic Organ Prolapse in Mice: Vaginal Protease Activity Precedes Increased MOPQ Scores in Fibulin 5 Knockout Mice1

PubMed Central

Wieslander, Cecilia K.; Rahn, David D.; McIntire, Donald D.; Acevedo, Jesús F.; Drewes, Peter G.; Yanagisawa, Hiromi; Word, R. Ann

2008-01-01

Two mouse models of pelvic organ prolapse have been generated recently, both of which have null mutations in genes involved in elastic fiber synthesis and assembly (fibulin 5 and lysyl oxidase-like 1). Interestingly, although these mice exhibit elastinopathies early in life, pelvic organ prolapse does not develop until later in life. In this investigation we developed and validated a tool to quantify the severity of pelvic organ prolapse in mice, and we used this tool prospectively to study the role of fibulin 5, aging, and vaginal proteases in the development of pelvic organ prolapse. The results indicate that >90% of Fbln5−/− mice develop prolapse by 6 mo of age, even in the absence of vaginal delivery, and that increased vaginal protease activity precedes the development of prolapse. PMID:18987327

Static Mechanical Loading Influences the Expression of Extracellular Matrix and Cell Adhesion Proteins in Vaginal Cells Derived From Premenopausal Women With Severe Pelvic Organ Prolapse.

PubMed

Kufaishi, Hala; Alarab, May; Drutz, Harold; Lye, Stephen; Shynlova, Oksana

2016-08-01

Primary human vaginal cells derived from women with severe pelvic organ prolapse (POP-HVCs) demonstrate altered cellular characteristics as compared to cells derived from asymptomatic women (control-HVCs). Using computer-controllable Flexcell stretch unit, we examined whether POP-HVCs react differently to mechanical loading as compared to control-HVCs by the expression of extracellular matrix (ECM) components, cell-ECM adhesion proteins, and ECM degrading and maturating enzymes. Vaginal tissue biopsies from premenopausal patients with Pelvic Organ Prolapse Quantification System stage ≥3 (n = 8) and asymptomatic controls (n = 7) were collected during vaginal hysterectomy or repair. Human vaginal cells were isolated by enzymatic digestion, seeded on collagen (COLI)-coated plates, and stretched (24 hours, 25% elongation). Total RNA was extracted, and 84 genes were screened using Human ECM and Adhesion Molecules polymerase chain reaction array; selected genes were verified by quantitative reverse transcription-polymerase chain reaction. Stretch-conditioned media (SCM) were collected and analyzed by protein array, immunoblotting, and zymography. In mechanically stretched control-HVCs, transcript levels of integrins (ITGA1, ITGA4, ITGAV, and ITGB1) and matrix metalloproteinases (MMPs) 2, 8, and 13 were downregulated (P < .05); in POP-HVCs, MMP1, MMP3, and MMP10, ADAMTS8 and 13, tissue inhibitor of metalloproteinases (TIMPs) 1 to 3, ITGA2, ITGA4, ITGA6, ITGB1, contactin (CNTN1), catenins (A1 and B1), and laminins (A3 and C1) were significantly upregulated, whereas COLs (1, 4, 5, 6, 11, and 12) and LOXL1 were downregulated. Human vaginal cells massively secrete MMPs and TIMPs proteins; MMP1, MMP8, MMP9 protein expression and MMP2 gelatinase activity were increased, whereas TIMP2 decreased in SCM from POP-HVCs compared to control-HVCs. Primary human vaginal cells derived from women with severe pelvic organ prolapse and control-HVCs react differentially to in vitro mechanical stretch. Risk factors that induce stretch may alter ECM composition and cell-ECM interaction in pelvic floor tissue leading to the abatement of pelvic organ support and subsequent POP development. © The Author(s) 2016.

Biomechanical Properties of The Vaginal Wall: Effect of Pregnancy, Elastic Fiber Deficiency, and Pelvic Organ Prolapse

PubMed Central

Rahn, David D.; Ruff, Matthew D.; Brown, Spencer A.; Tibbals, Harry F.; Word, R. Ann

2009-01-01

Objectives To identify pregnancy-induced changes in biomechanical properties of the vaginal wall and compare these with Fibulin-5 knockout mice (Fbln5-/-) with and without prolapse. Study Design Mid-vaginal segments of nonpregnant and late-pregnant wild type (WT), Fbln5-/- with prolapse, and Fbln5-/- mice without prolapse were studied. Tissue length at failure, maximal strain, maximal stress, and tissue stiffness were determined. Results Compared with nonpregnant mice, vaginas of pregnant and Fbln5-/- (with prolapse) mice exhibited decreased maximal stress, increased distensibility and strain, and decreased stiffness. Tissues from Fbln5-/- mice without prolapse were similar to nonpregnant WT animals. Conclusions Pregnancy confers remarkable changes in the vaginal wall including increased distensibility and decreased stiffness and maximal stress. Elastinopathy alone is insufficient to cause significant changes in these properties, but prolapse confers additional alterations in distensibility and stiffness similar to those observed in pregnancy. These changes may contribute to the poor durability of many restorative surgical procedures for prolapse. PMID:18455541

Failure of Pelvic Organ Support in Mice Deficient In Fibulin-3

PubMed Central

Rahn, David D.; Acevedo, Jesús F.; Roshanravan, Shayzreen; Keller, Patrick W.; Davis, Elaine C.; Marmorstein, Lihua Y.; Word, R. Ann

2009-01-01

Fibulin-5 is crucial for normal elastic fiber synthesis in the vaginal wall; more than 90% of fibulin-5-knockout mice develop pelvic organ prolapse by 20 weeks of age. In contrast, fibulin-1 and -2 deficiencies do not result in similar pathologies, and fibulin-4-knockout mice die shortly after birth. EFEMP1 encodes fibulin-3, an extracellular matrix protein important in the maintenance of abdominal fascia. Herein, we evaluated the role of fibulin-3 in pelvic organ support. Pelvic organ support was impaired significantly in female Efemp1 knockout mice (Fbln3−[supi]/−), and overt vaginal, perineal, and rectal prolapse occurred in 26.9% of animals. Prolapse severity increased with age but not parity. Fibulin-5 was up-regulated in vaginal tissues from Fbln3−[supi]/− mice regardless of prolapse. Despite increased expression of fibulin-5 in the vaginal wall, pelvic organ support failure occurred in Fbln3−[supi]/− animals, suggesting that factors related to aging led to prolapse. Elastic fiber abnormalities in vaginal tissues from young Fbln3−[supi]/− mice progressed to severe elastic fiber disruption with age, and vaginal matrix metalloprotease activity was increased significantly in Fbln3−[supi]/− animals with prolapse compared with Fbln3−[supi]/− mice without prolapse. Overall, these results indicate that both fibulin-3 and -5 are important in maintaining pelvic organ support in mice. We suggest that increased vaginal protease activity and abnormal elastic fibers in the vaginal wall are important components in the pathogenesis of pelvic organ prolapse. PMID:19095964

Do patients prefer mesh or anterior colporrhaphy for primary correction of anterior vaginal wall prolapse: a labelled discrete choice experiment.

PubMed

Notten, K J B; Essers, B A; Weemhoff, M; Rutten, A G H; Donners, J J A E; van Gestel, I; Kruitwagen, R F P M; Roovers, J P W R; Dirksen, C D

2015-05-01

We investigated patients' preferences for anterior colporrhaphy or mesh surgery as surgical correction of anterior vaginal wall prolapse. Labelled discrete choice experiment. Three Dutch teaching hospitals. Women with anterior vaginal wall prolapse Pelvic Organ Prolapse Quantification stage 2 or more, indicated for anterior colporrhaphy (n = 100). Discrete choice experiments are an attribute-based survey method for measuring preferences. In this experiment, women were asked to choose between two treatment scenarios, mesh surgery or anterior colporrhaphy. These surgical treatments differed in four treatment attributes: (i) recurrence rate, (ii) exposure rate, (iii) infection rate, (iv) dyspareunia. Data were analysed using a multinomial logit model. Women's preferences for anterior colporrhaphy or mesh surgery for the repair of vaginal wall prolapse. All treatment attributes, i.e. recurrence, exposure, infection and dyspareunia, proved to be significant in the woman's decision to choose mesh surgery (P < 0.001), while only two attributes out of three, recurrence and infection, were significant for anterior colporrhaphy (P < 0.001). The relative importance data showed that with regards to the four statistically significant attributes for mesh, dyspareunia was the most important attribute, and of the two significant attributes for anterior colporrhaphy, the risk of infection. Based on the attributes and levels in our discrete choice experiment, anterior colporrhaphy was preferred in 74% as a primary correction of anterior vaginal wall prolapse, followed by a preference for mesh in 26% of all choices. This study showed that next to the risk of recurrence, other aspects like risk of infection, dyspareunia and exposure play a role in the woman's preference for a surgical treatment. In addition, our results indicate that anterior colporrhaphy is preferred in the majority of the choices, followed by a preference for mesh surgery in a quarter of all choice sets. However, these results represent the average preference of a sample of women and cannot be taken as the preference of each individual. In the medical decision-making context, information from the current study should be personalised to fit patient's unique circumstances. For patients to construct their own, individual preferences, they should be well informed about the existence and magnitude of the potential benefits and risks related to either anterior colporrhaphy or mesh surgery. © 2014 Royal College of Obstetricians and Gynaecologists.

Transrectal Mesh Erosion Requiring Bowel Resection.

PubMed

Kemp, Marta Maria; Slim, Karem; Rabischong, Benoît; Bourdel, Nicolas; Canis, Michel; Botchorishvili, Revaz

To report a case of a transrectal mesh erosion as complication of laparoscopic promontofixation with mesh repair, necessitating bowel resection and subsequent surgical interventions. Sacrocolpopexy has become a standard procedure for vaginal vault prolapse [1], and the laparoscopic approach has gained popularity owing to more rapid recovery and less morbidity [2,3]. Mesh erosion is a well-known complication of surgical treatment for prolapse as reported in several negative evaluations, including a report from the US Food and Drug Administration in 2011 [4]. Mesh complications are more common after surgeries via the vaginal approach [5]; nonetheless, the incidence of vaginal mesh erosion after laparoscopic procedures is as high as 9% [6]. The incidence of transrectal mesh exposure after laparoscopic ventral rectopexy is roughly 1% [7]. The diagnosis may be delayed because of its rarity and variable presentation. In addition, polyester meshes, such as the mesh used in this case, carry a higher risk of exposure [8]. A 57-year-old woman experiencing genital prolapse, with the cervix classified as +3 according to the Pelvic Organ Prolapse Quantification system, underwent laparoscopic standard sacrocolpopexy using polyester mesh. Subtotal hysterectomy and bilateral adnexectomy were performed concomitantly. A 3-year follow-up consultation demonstrated no signs or symptoms of erosion of any type. At 7 years after the surgery, however, the patient presented with rectal discharge, diagnosed as infectious rectocolitis with the isolation of Clostridium difficile. She underwent a total of 5 repair surgeries in a period of 4 months, including transrectal resection of exposed mesh, laparoscopic ablation of mesh with digestive resection, exploratory laparoscopy with abscess drainage, and exploratory laparoscopy with ablation of residual mesh and transverse colostomy. She recovered well after the last intervention, exhibiting no signs of vaginal or rectal fistula and no recurrence of pelvic floor descent. Her intestinal transit was reestablished, and she was satisfied with the treatment. None of the studies that represent the specific female population submitted to laparoscopic promontofixation with transrectal mesh erosion describe the need for more than one intervention or digestive resection [9-12]. Physicians dealing with patients submitted to pelvic reconstructive surgeries with mesh placement should be aware of transrectal and other nonvaginal erosions of mesh, even being rare events. Moreover, they should perform an active search for unusual gynecologic and anorectal signs and symptoms. Most importantly, patients undergoing mesh repair procedures must be warned of the risks of the surgery, including the possibility of several subsequent interventions. Copyright © 2017 AAGL. Published by Elsevier Inc. All rights reserved.

Laparoscopic promontofixation for the treatment of recurrent sigmoid neovaginal prolapse: case report and systematic review of the literature.

PubMed

Kondo, William; Ribeiro, Reitan; Tsumanuma, Fernanda Keiko; Zomer, Monica Tessmann

2012-01-01

Prolapse of a sigmoid neovagina, created in patients with congenital vaginal aplasia, is rare. In correcting this condition, preservation of coital function and restoration of the vaginal axis should be of primary interest. A 34-year-old woman with vaginal agenesis underwent vaginoplasty using sigmoid colon. Almost 6 years after the initial operation, she started complaining of a bearing-down sensation and an increase in vaginal discharge. She underwent 2 open surgeries and one vaginal surgery to treat the prolapse with no success. She came to our service and at vaginal examination the neovagina protruded approximately 5 cm beyond the hymen. The prolapse was treated successfully using a laparoscopic approach to suspend the neovagina to the sacral promontory (laparoscopic promontofixation). Prolapse of an artificially created vagina is a rare occurrence, without a standard treatment. Laparoscopy may be an alternative approach to restore the neovagina without compromising its function. Copyright © 2012 AAGL. Published by Elsevier Inc. All rights reserved.

Does the Vaginal Flora Modify When a Synthetic Mesh is Used for Genital Prolapse Repair in Postmenopausal Women? A Pilot, Randomized Controlled Study.

PubMed

de Castro, Edilson Benedito; Brito, Luiz Gustavo Oliveria; Giraldo, Paulo César; Teatin Juliato, Cássia Raquel

2018-01-10

The vaginal flora from postmenopausal women with pelvic organ prolapse (POP) is different from younger women. We hypothesized that the decision of a surgical route using a mesh would modify the vaginal flora. The purpose of this study was to analyze the vaginal flora from postmenopausal women that were submitted to abdominal sacrocervicopexy or vaginal sacrospinous fixation. A pilot, randomized controlled study with 50 women aged 55 to 75 years (n = 25; abdominal sacrocervicopexy + subtotal hysterectomy; n = 25 vaginal sacrospinous fixation + vaginal hysterectomy) was performed. A polyvinylidene mesh was used in both arms. The vaginal content analysis was collected before and 60 days after the surgery. The type of flora, the presence of lactobacilli/leukocytes, and the Nugent criteria were analyzed. Most of the women were white (80%), with at least 1 comorbidity (69.9%), did not present sexual activity (60%), and presented advanced stage 4 POP. Two thirds of women presented a type 3 flora, and half of them did not present lactobacilli (48.3%). About the Nugent criteria, 51.7% presented normal flora, 46.6% found altered flora, and 1.7% had bacterial vaginosis. There were no differences about the type of flora (P = 1), number of lactobacilli (P = 0.9187), Nugent criteria (P = 0.4235), inflammation (P = 0.1018), and bacterial vaginosis (P = 0.64) before and after surgery in both groups. In this pilot study, the use of synthetic mesh by vaginal or abdominal route did not affect the vaginal flora in postmenopausal women operated on by POP surgery.

Assessment of posterior vaginal wall prolapse: comparison of physical findings to cystodefecoperitoneography.

PubMed

Altman, Daniel; López, Annika; Kierkegaard, Jonas; Zetterström, Jan; Falconer, Christian; Pollack, Johan; Mellgren, Anders

2005-01-01

The aim of the present study was to compare clinical and radiological findings when assessing posterior vaginal wall prolapse. Defecography can be used to complement the clinical evaluation in patients with posterior vaginal wall prolapse. Further development of the defecography technique, using contrast medium in the urinary bladder and intraperitoneally, have resulted in cystodefecoperitoneography (CDP). Thirty-eight women underwent clinical examination using the pelvic organ prolapse quantification system (POP-Q) followed by CDP. All patients answered a standardized bowel function questionnaire. Statistical analysis measuring correlation between POP-Q and CDP using Pearson's correlation coefficient (r) and Spearman's rank order correlation coefficient (rs) demonstrated a poor to moderate correlation, r=0.49 and rs=0.55. Although there was a strong association between large rectoceles (>3 cm) at CDP and symptoms of rectal emptying difficulties (p<0.001), severity and prevalence of bowel dysfunction showed poor coherence with clinical prolapse staging and findings at radiological imaging. Vaginal topography and POP-Q staging predict neither radiological size nor visceral involvement in posterior vaginal wall prolapse. Radiological evaluation may therefore be a useful complement in selected patients.

Fast track vaginal surgery.

PubMed

Ottesen, Marianne; Sørensen, Mette; Rasmussen, Yvonne; Smidt-Jensen, Steen; Kehlet, Henrik; Ottesen, Bent

2002-02-01

Our aim was to describe the need for postoperative hospitalization after vaginal surgery for utero-vaginal prolapse with well-defined charts for postoperative care. A prospective, descriptive study. Consecutive women admitted for first-time vaginal surgery for utero-vaginal prolapse at a public university hospital in Copenhagen, Denmark, underwent surgery and postoperative care in a fast track setting from September 15, 1999 to June 15 2000. A multimodal rehabilitation model with emphasis on information, standardized general anesthesia, reduced surgical distress, optimized pain-relief, early oral nutrition and ambulation, minimal use of indwelling catheter and vaginal packing. Postoperative hospital stay, complications, re-admission, success rate, patients' satisfaction and acceptability. Forty-one women with a median age of 69 years (range, 44-88 years) were included. All underwent anterior and/or posterior vaginal repair. Nineteen (46.3%) underwent vaginal hysterectomy, and eight (19.5%) underwent the Manchester procedure. Postoperative hospital stay was median 24 hr. Only three (7.3%) were discharged later than 48 hr. No re-admissions occurred. The most frequent complications were urinary retention exceeding 450 ml, and urinary tract infection (12.2%, and 9.8%, respectively). Short-term success rate was 97.6%. Patients' satisfaction rates were 85.4-95.1%. The median score of acceptability was 10 on a 0-10 points scale. The need for postoperative hospitalization was median 24 hr after vaginal surgery in a fast track setting, independently of the complexity of the procedure performed. Short-term success rate, satisfaction rates, and acceptability were all excellent. Follow up has been established to evaluate long-term success rates and recurrence.

[Utilize the simplified POP-Q system in the clinical practice of staging for pelvic organ prolapse: comparative analysis with standard POP-Q system].

PubMed

Zhang, H; Zhu, L; Xu, T; Lang, J H

2016-07-25

To determine the association between simplified pelvic organ prolapse quantification system(S-POP-Q)and the standard pelvic organ prolapse quantification system(POP-Q)in describing pelvic organ prolapse. This was an observational study. From Jan. 2010 to Jan. 2014, 256 subjects with pelvic floor disorder symptoms underwent two exams: a POP-Q exam and a S-POP-Q exam. For the S-POP-Q system, vaginal segments of the exam were defined using points Ba, Bp, C, and D. For the POP-Q system vaginal segments of the exam were defined using points Aa, Ba, Ap, Bp, C, and D. The inter-system consistency between the overall ordinal stages, the anterior vaginal wall stages, the posterior vaginal wall stages, the cervix stages, the posterior fornix or vaginal cuff stages from each two kind of exam were compared. The Kendall tau-b correlation coefficient for overall stage was 0.81, the Kendall tau-b correlation coefficients were 0.81, 0.81, 0.85, 0.88 for the anterior vaginal wall, for the posterior vaginal wall, for the cervix, for the posterior fornix or vaginal cuff, respectively. There is almost perfect association between S-POP-Q and POP-Q in describing pelvic organ prolapse.

Vaginal surgery for pelvic organ prolapse using mesh and a vaginal support device.

PubMed

Carey, M; Slack, M; Higgs, P; Wynn-Williams, M; Cornish, A

2008-02-01

To describe a new surgical procedure for pelvic organ prolapse using mesh and a vaginal support device (VSD) and to report the results of surgery. A prospective observational study. Two tertiary referral Urogynaecology practices. Ninety-five women with International Continence Society pelvic organ prolapse quantification stage 2 or more pelvic organ prolapse who underwent vaginal surgery using mesh augmentation and a VSD. Surgery involved a vaginal approach with mesh reinforcement and placement of a VSD for 4 weeks. At 6 and 12 months, women were examined for prolapse recurrence, and visual analogue scales for satisfaction were completed. Women completed quality-of-life (QOL) questionnaires preoperatively and at 6 and 12 months. Objective success of surgery at 6 and 12 months following surgery. Secondary outcomes were subjective success, complications, QOL outcomes and patients' satisfaction. Objective success rate was 92 and 85% at 6 and 12 months, respectively. Subjective success rate was 91 and 87% at 6 and 12 months, respectively. New prolapse in nonrepaired compartments accounted for 7 of 12 (58%) failures at 12 months. Two of 4 mesh exposures required surgery. Sexual dysfunction was reported by 58% of sexually active women preoperatively and 23% at 12 months. QOL scores significantly improved at 12 months compared with baseline (P < 0.0001). Vaginal surgery using mesh and a VSD is an effective procedure for pelvic organ prolapse. However, further studies are required to establish the role of the surgery described in this study.

Definitions of apical vaginal support loss: a systematic review.

PubMed

Meister, Melanie R L; Sutcliffe, Siobhan; Lowder, Jerry L

2017-03-01

We sought to identify and summarize definitions of apical support loss utilized for inclusion, success, and failure in surgical trials for treatment of apical vaginal prolapse. Pelvic organ prolapse is a common condition affecting more than 3 million women in the US, and the prevalence is increasing. Prolapse may occur in the anterior compartment, posterior compartment or at the apex. Apical support is considered paramount to overall female pelvic organ support, yet apical support loss is often underrecognized and there are no guidelines for when an apical support procedure should be performed or incorporated into a procedure designed to address prolapse. A systematic literature search was performed in 8 search engines: PubMed 1946-, Embase 1947-, Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Review Effects, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Proquest Dissertations and Theses, and FirstSearch Proceedings, using key words for apical pelvic organ prolapse and apical suspension procedures through April 2016. Searches were limited to human beings using human filters and articles published in English. Study authors (M.R.L.M., J.L.L.) independently reviewed publications for inclusion based on predefined variables. Articles were eligible for inclusion if they satisfied any of the following criteria: (1) apical support loss was an inclusion criterion in the original study, (2) apical support loss was a surgical indication, or (3) an apical support procedure was performed as part of the primary surgery. A total of 4469 publications were identified. After review, 35 articles were included in the analysis. Prolapse-related inclusion criteria were: (1) apical prolapse (n = 20, 57.1%); (2) overall prolapse (n = 8, 22.8%); or (3) both (n = 6, 17.1%). Definitions of apical prolapse (relative to the hymen) included: (1) apical prolapse >-1 cm (n = 13, 50.0%); (2) apical prolapse >+1 cm (n = 7, 26.9%); (3) apical prolapse >50% of total vaginal length (-[total vaginal length/2]) (n = 4, 15.4%); and (4) cervix/apex >0 cm (n = 2, 7.7%). Sixteen of the 35 studies (45.7%) required the presence of symptoms for inclusion. A measurement of the apical compartment (relative to the hymen) was used as a measure of surgical success or failure in 17 (48.6%) studies. Definitions for surgical success included: (1) prolapse stage >2 in each compartment (n = 5, 29.4%); (2) prolapse >-[total vaginal length/2] (n = 2, 11.8%); (3) apical support >-[total vaginal length/3] (n = 1, 5.9%); (4) absence of prolapse beyond the hymen (n = 1, 5.9%); and (5) point C at ≥-5 cm (n = 2, 11.8%). Surgical failure was defined as: (1) apical prolapse ≥0 cm (n = 2, 11.8%); (2) apical prolapse ≥-1 cm (n = 2, 11.8%); (3) apical prolapse >-[total vaginal length/2] (n = 3, 17.6%); and (4) recurrent apical prolapse surgery (n = 1, 5.9%). Ten (28.6%) of the 35 studies also included symptomatic outcomes in the definition of success or failure. Among randomized, controlled surgical trials designed to address apical vaginal support loss, definitions of clinically significant apical prolapse for study inclusion and surgical success or failure are either highly variable or absent. These findings provide limited evidence of consensus and little insight into current expert opinion. Copyright © 2016 Elsevier Inc. All rights reserved.

Prolapse repair using the Elevate™ kit: prospective study on 70 patients.

PubMed

Azaïs, H; Charles, C Jean; Delporte, P; Debodinance, P

2012-10-01

The aim of this study was to examine the anatomical and functional results of prolapse repair by a vaginal approach using the Elevate kit. This was a prospective study of 70 patients presenting with symptomatic urogenital prolapse. Twenty Elevate Anterior, 16 Posterior, and 34 Anterior and Posterior repair systems were placed. Perioperative and postoperative complications were assessed. The patients were interviewed at 2 months and 1 year post-surgery. Recurrences were recorded in 21 patients (31.3%) at the 1-year follow-up. However, at the 1-year follow-up, there were 14 cases (20.9%) of direct recurrence (two anterior, two posterior, and ten combined anterior and posterior) compared with seven cases (10.4%) of indirect recurrence. Of the 21 failures (stage ≥ 2), 13 were stage 2 with the leading edge above the hymen. None of the patients underwent revision surgery. The exposure rate was 4.5%. The anterior and posterior shrinkage rates were 68.7% and 31.9%, respectively. There were four cases of de novo dyspareunia. Patients reported a significant decrease in the impact of pelvic floor distress on the PFIQ-7 questionnaire, but an improvement on the PFDI-20. There was no improvement in sexual function (PISQ-12). The Elevate™ kit is associated with satisfactory functional results. However, the anatomical results require ongoing evaluation.

Vaginal Changes Due to Varying Degrees of Rectocele Prolapse: A Computational Study.

PubMed

Chanda, Arnab; Meyer, Isuzu; Richter, Holly E; Lockhart, Mark E; Moraes, Fabia R D; Unnikrishnan, Vinu

2017-10-01

Pelvic organ prolapse (POP), downward descent of the pelvic organs resulting in a protrusion of the vagina, is a highly prevalent condition, responsible for 300,000 surgeries in the U.S. annually. Rectocele, a posterior vaginal wall (PVW) prolapse of the rectum, is the second most common type of POP after cystocele. A rectocele usually manifests itself along with other types of prolapse with multicompartment pelvic floor defects. To date, the specific mechanics of rectocele formation are poorly understood, which does not allow its early stage detection and progression prediction over time. Recently, with the advancement of imaging and computational modeling techniques, a plethora of finite element (FE) models have been developed to study vaginal prolapse from different perspectives and allow a better understanding of dynamic interactions of pelvic organs and their supporting structures. So far, most studies have focused on anterior vaginal prolapse (AVP) (or cystocele) and limited data exist on the role of pelvic muscles and ligaments on the development and progression of rectocele. In this work, a full-scale magnetic resonance imaging (MRI) based three-dimensional (3D) computational model of the female pelvic anatomy, comprising the vaginal canal, uterus, and rectum, was developed to study the effect of varying degrees (or sizes) of rectocele prolapse on the vaginal canal for the first time. Vaginal wall displacements and stresses generated due to the varying rectocele size and average abdominal pressures were estimated. Considering the direction pointing from anterior to posterior side of the pelvic system as the positive Y-direction, it was found that rectocele leads to negative Y-direction displacements, causing the vaginal cross section to shrink significantly at the lower half of the vaginal canal. Besides the negative Y displacements, the rectocele bulging was observed to push the PVW downward toward the vaginal hiatus, exhibiting the well-known "kneeling effect." Also, the stress field on the PVW was found to localize at the upper half of the vaginal canal and shift eventually to the lower half with increase in rectocele size. Additionally, clinical relevance and implications of the results were discussed.

Iliococcygeus fixation for the treatment of apical vaginal prolapse: efficacy and safety at 5 years of follow-up.

PubMed

Serati, Maurizio; Braga, Andrea; Bogani, Giorgio; Leone Roberti Maggiore, Umberto; Sorice, Paola; Ghezzi, Fabio; Salvatore, Stefano

2015-07-01

Sacrocolpopexy is considered the gold standard treatment for vaginal vault prolapse. However, the vaginal approach is very common, with 80-90 % of procedures being performed via this route. The aim of this study was to evaluate the safety and efficacy of iliococcygeus (ICG) fixation in the treatment of vaginal vault prolapse, with a minimum follow-up of 5 years. We prospectively enrolled women with symptomatic vaginal vault prolapse (Pelvic Organ Prolapse Quantification [POP-Q] stage ≥2) who were treated with ICG fixation. Subjective success was defined in the case of Patient Global Impression of Improvement ≤ 2 and an absence of bulging symptoms. Objective success was defined as stage of prolapse < 2 in all compartments. Overall success rate was defined as women without prolapse symptoms, PGI-I ≤ 2, stage of prolapse < 2, and no need for other surgery. All women filled in the Prolapse Quality of Life (P-QOL) questionnaire both at the preoperative visit and at every follow-up visit. Multiple logistic regression was performed to identify factors involved in the risk of recurrent POP. After a median (range) follow-up of 68.8 (60-92) months the subjective, objective, and overall cure rates were 88.6 % (39 out of 44), 84.1 % (37 out of 44), and 84.1 % (37 out of 44) respectively. Only preoperative stage IV vault descensus independently predicted POP recurrence after iliococcygeus fixation (OR: 8.78 [95 % CI: 1.31-9.42]; p < 0.001). Iliococcygeus fixation is a safe and effective surgical technique for the treatment of vaginal vault prolapse with long-lasting effectiveness.

Results of surgical excision of urethral prolapse in symptomatic patients.

PubMed

Hall, Mary E; Oyesanya, Tola; Cameron, Anne P

2017-11-01

Here, we present the clinical presentation and surgical outcomes of women with symptomatic urethral prolapse presenting to our institution over 20 years, and seek to provide treatment recommendations for management of symptomatic urethral prolapse and caruncle. A retrospective review of medical records from female patients who underwent surgery for symptomatic urethral prolapse from June 1995 to August 2015 was performed. Surgical technique consisted of a four-quadrant excisional approach for repair of urethral prolapse. A total of 26 patients were identified with a mean age of 38.8 years (range 3-81). The most common presentations were vaginal bleeding, hematuria, pain, and dysuria. All patients underwent surgical excision of urethral prolapse via a standard approach. Follow-up data was available in 24 patients. Six patients experienced temporary postoperative bleeding, and one patient required placement of a Foley catheter for tamponade. One patient experienced temporary postoperative urinary retention requiring Foley catheter placement. Three patients had visible recurrence of urethral prolapse, for which one later underwent re-excision. Surgical excision of urethral prolapse is a reasonable treatment option in patients who have tried conservative management without relief, as well as in those who present with severe symptoms. Possible complications following excision include postoperative bleeding and recurrence, and patients must be counseled accordingly. In this work, we propose a treatment algorithm for symptomatic urethral prolapse. © 2017 Wiley Periodicals, Inc.

Role of robotics in managing mesh and suture complications of prior pelvic organ prolapse surgery.

PubMed

Wilkinson, Michael N; O'Sullivan, Orfhlaith E; O'Reilly, Barry A

2017-03-01

Robotic surgery is proving essential in providing a minimally invasive approach to complex urogynaecological cases. This video highlights the diversity and complexity of cases performed using the robot-assisted approach. The robot-assisted approach was utilised for excellent effect in two complex urogynaecological cases. In the first case the entire left arm of an intravesically placed TVT was removed using a combined vaginal and robotic approach. The second case involved removing four paravaginal sutures, one of which breeched the bladder and was encrusted with calculus. These were placed during a laparoscopic paravaginal repair 2 years previously. She had a concomitant vaginal hysterectomy, Mc Calls culdoplasty and anterior wall repair. The robot-assisted approach allows for excellent access to the pelvis and retropubic space facilitating the surgical management of complex urogynaecology cases.

Complications of pelvic organ prolapse surgery and methods of prevention.

PubMed

de Tayrac, Renaud; Sentilhes, Loic

2013-11-01

The aim was to review complications associated with pelvic organ prolapse surgery. Every 4 years and as part of the Fifth International Collaboration on Incontinence we reviewed the English-language scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials [RCT] or systematic reviews), level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 (case reports). The highest level of evidence was utilised by the committee to make evidence-based recommendations based upon the Oxford grading system. Grade A recommendation usually depends on consistent level 1 evidence. Grade B recommendation usually depends on consistent level 2 and/or 3 studies, or "majority evidence" from RCTs. Grade C recommendation usually depends on level 4 studies or "majority evidence from level 2/3 studies or Delphi processed expert opinion. Grade D "no recommendation possible" would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi. Transvaginal mesh has a higher re-operation rate than native tissue vaginal repairs (grade A). If a synthetic mesh is placed via the vaginal route, it is recommended that a macroporous polypropylene monofilament mesh should be used. At sacral colpopexy mesh should not be introduced or sutured via the vaginal route and silicone-coated polyester, porcine dermis, fascia lata and polytetrafluoroethylene meshes are not recommended as grafts. Hysterectomy should also be avoided (grade B). There is no evidence to recommend routine local or systemic oestrogen therapy before or after prolapse surgery using mesh. The first cases should be undertaken with the guidance of an experienced surgeon in the relevant technique (grade C). Expert opinion suggests that by whatever the surgical route pre-operative urinary tract infections are treated, smoking is ceased and antibiotic prophylaxis is undertaken. It is recommended that a non-absorbable synthetic mesh should not be inserted into the rectovaginal septum when a rectal injury occurs. The placement of a non-absorbable synthetic mesh into the vesicovaginal septum may be considered after a bladder injury has been repaired, if the repair is considered to be satisfactory. It is possible to perform a hysterectomy in association with the introduction of a non-absorbable synthetic mesh inserted vaginally, but this is not recommended routinely.

Randomized controlled trial of postoperative belladonna and opium rectal suppositories in vaginal surgery.

PubMed

Butler, Kristina; Yi, John; Wasson, Megan; Klauschie, Jennifer; Ryan, Debra; Hentz, Joseph; Cornella, Jeffrey; Magtibay, Paul; Kho, Roseanne

2017-05-01

After vaginal surgery, oral and parenteral narcotics are used commonly for pain relief, and their use may exacerbate the incidence of sedation, nausea, and vomiting, which ultimately delays convalescence. Previous studies have demonstrated that rectal analgesia after surgery results in lower pain scores and less intravenous morphine consumption. Belladonna and opium rectal suppositories may be used to relieve pain and minimize side effects; however, their efficacy has not been confirmed. We aimed to evaluate the use of belladonna and opium suppositories for pain reduction in vaginal surgery. A prospective, randomized, double-blind, placebo-controlled trial that used belladonna and opium suppositories after inpatient or outpatient vaginal surgery was conducted. Vaginal surgery was defined as (1) vaginal hysterectomy with uterosacral ligament suspension or (2) posthysterectomy prolapse repair that included uterosacral ligament suspension and/or colporrhaphy. Belladonna and opium 16A (16.2/60 mg) or placebo suppositories were administered rectally immediately after surgery and every 8 hours for a total of 3 doses. Patient-reported pain data were collected with the use of a visual analog scale (at 2, 4, 12, and 20 hours postoperatively. Opiate use was measured and converted into parenteral morphine equivalents. The primary outcome was pain, and secondary outcomes included pain medication, antiemetic medication, and a quality of recovery questionnaire. Adverse effects were surveyed at 24 hours and 7 days. Concomitant procedures for urinary incontinence or pelvic organ prolapse did not preclude enrollment. Ninety women were randomly assigned consecutively at a single institution under the care of a fellowship-trained surgeon group. Demographics did not differ among the groups with mean age of 55 years, procedure time of 97 minutes, and prolapse at 51%. Postoperative pain scores were equivalent among both groups at each time interval. The belladonna and opium group used a mean of 57 mg morphine compared with 66 mg for placebo (P=.43) in 24 hours. Patient satisfaction with recovery was similar (P=.59). Antiemetic and ketorolac use were comparable among groups. Subgroup analyses of patients with prolapse and patients <50 years old did not reveal differences in pain scores. The use of belladonna and opium suppositories was uncomplicated, and adverse effects, which included constipation and urinary retention, were similar among groups. Belladonna and opium suppositories are safe for use after vaginal surgery. Belladonna and opium suppositories did not reveal lower pain or substantially lower narcotic use. Further investigation may be warranted to identify a population that may benefit optimally from belladonna and opium use. Copyright © 2016 Elsevier Inc. All rights reserved.

Anovulvar cleft and vaginal prolapse-hyperplasia in a bitch.

PubMed

Mostachio, G Q; Vicente, W R R; Cardilli, D J; Pires, E A; Toniollo, G H

2007-12-01

This report presents the case of a nine-month-old bitch with incomplete occlusion of the skin and mucosa between the anus and dorsal commissure of the vulva. This anomaly, known as anovulvar cleft, was associated with a vaginal prolapse-hyperplasia. Anovulvar cleft is a rare condition in bitches and is caused by incomplete closure of the dorsal urogenital folds. Anovulvar cleft can lead to clitoritis, abrasion, dryness and devitalisation of the smooth exposed mucosa. Surgery can correct the condition. In the present study, surgical resection of the hyperplasic vaginal tissue associated with perineoplasty using an inverted V-shaped incision showed excellent results. An ovariohysterectomy was also performed to prevent recurrence of the vaginal prolapse-hyperplasia.

Chronic vaginal prolapse during pregnancy in a bitch.

PubMed

Memon, M A; Pavletic, M M; Kumar, M S

1993-01-15

A 4-year-old bitch was referred with chronic vaginal prolapse. It was first noticed during estrus, about 58 days prior to referral. Artificial insemination (AI) was performed twice after reducing the prolapse manually. Abdominal radiography (53 to 55 days after AI) was performed by the attending veterinarian and the bitch was determined to be not pregnant. Serum progesterone and estradiol concentrations were 1.38 ng/ml and 1.79 pg/ml, respectively. With the bitch under general anesthesia, the vaginal prolapse was partially reduced and a hysteropexy was performed. Six days after surgery, the bitch delivered a live male pup. It is recommended that bitches so affected should not be bred, and that those not required for breeding should be ovariectomized.

Vaginal fold prolapse in a dog with pyometra and ovarian papillary cystadenocarcinoma.

PubMed

Zedda, Maria-Teresa; Bogliolo, Luisa; Ariu, Federica; Ledda, Mauro; Falchi, Laura; Pinna-Parpaglia, Maria-Luisa; Pau, Salvatore

2016-04-01

A 7-year-old 42-kg (92.4-lb) sexually intact nulliparous female Italian Mastiff was examined because of a history of vaginal prolapse during diestrus. A physical examination revealed vaginal fold prolapse. Abdominal ultrasonography revealed an enlarged uterus with hypoechogenic content, corpora lutea in the ovaries, and a cyst in the right ovary. Hematologic abnormalities included leukocytosis, neutrophilia, mild anemia, and low Hct. Progesterone and estradiol concentrations were 9.36 ng/mL and 30.42 pg/mL, respectively, in serum and 72.72 ng/mL and 792 pg/mL, respectively, in the ovarian cystic fluid. Ovariohysterectomy was performed; the prolapsed tissue was repositioned by external manipulation and maintained in situ by temporary apposition of the vulvar lips with a retention suture. Anatomic and histologic examinations of the excised tissues revealed pyometra and papillary cystadenocarcinoma in the right ovary. The vaginal hyperplasia completely regressed at 35 days after surgery; 5 months after surgery, the dog's general condition was considered good. Findings in this case were indicative of a hormonally active ovarian papillary cystadenocarcinoma in a female dog in diestrus. Hormone production by the cystadenocarcinoma was the predisposing factor that induced pyometra, mucosal hyperplasia, and vaginal fold prolapse in the dog. On the basis of these concurrent disorders, ovariohysterectomy was an appropriate treatment.

Complex sacral abscess 8 years after abdominal sacral colpopexy.

PubMed

Collins, Sarah A; Tulikangas, Paul K; LaSala, Christine A; Lind, Lawrence R

2011-08-01

Sacral colpopexy is an effective, durable repair for women with apical vaginal or uterovaginal prolapse. There are few reports of serious complications diagnosed in the remote postoperative period. A 74-year-old woman presented 8 years after undergoing posthysterectomy abdominal sacral colpopexy using polypropylene mesh. Posterior vaginal mesh erosion had been diagnosed several months before presentation. She suffered severe infectious complications including an infected thrombus in the inferior vena cava, sacral osteomyelitis, and a complex abscess with presacral and epidural components. Surgical exploration revealed an abscess cavity surrounding the mesh. Although minor complications commonly occur after sacral colpopexy using abdominal mesh, serious and rare postoperative infectious complications may occur years postoperatively.

What's new in the functional anatomy of pelvic organ prolapse?

PubMed

DeLancey, John O L

2016-10-01

Provide an evidence-based review of pelvic floor functional anatomy related to pelvic organ prolapse. Pelvic organ support depends on interactions between the levator ani muscle and pelvic connective tissues. Muscle failure exposes the vaginal wall to a pressure differential producing abnormal tension on the attachments of the pelvic organs to the pelvic sidewall. Birth-induced injury to the pubococcygeal portion of the levator ani muscle is seen in 55% of women with prolapse and 16% of women with normal support. Failure of the lateral connective tissue attachments between the uterus and vagina to the pelvic wall (cardinal, uterosacral, and paravaginal) are strongly related with prolapse (effect sizes ∼2.5) and are also highly correlated with one another (r ∼ 0.85). Small differences exist with prolapse in factors involving the vaginal wall length and width (effect sizes ∼1). The primary difference in ligament properties between women with and without prolapse is found in ligament length. Only minor differences in ligament stiffness are seen. Pelvic organ prolapse occurs because of injury to the levator ani muscles and failure of the lateral connections between the pelvic organs to the pelvic sidewall. Abnormalities of the vaginal wall fascial tissues may play a minor role.

Effect of vaginal distention on elastic fiber synthesis and matrix degradation in the vaginal wall: potential role in the pathogenesis of pelvic organ prolapse

PubMed Central

Rahn, D. D.; Acevedo, J. F.; Word, R. A.

2008-01-01

Matrix metalloprotease (MMP) activity is increased in the postpartum vagina of wild-type (WT) animals. This degradative activity is also accompanied by a burst in elastic fiber synthesis and assembly. The mechanisms that precipitate these changes are unclear. The goals of this study were to determine how vaginal distention (such as in parturition) affects elastic fiber homeostasis in the vaginal wall and the potential significance of these changes in the pathogenesis of pelvic organ prolapse. Vaginal distention with a balloon simulating parturition resulted in increased MMP-2 and MMP-9 activity in the vaginal wall of nonpregnant and pregnant animals. This was accompanied by visible fragmented and disrupted elastic fibers in the vaginal wall. In nonpregnant animals, the abundant amounts of tropoelastin and fibulin-5 in the vagina were not increased further by distention. In contrast, in pregnant animals, the suppressed levels of both proteins were increased 3-fold after vaginal distention. Distention performed in fibulin-5-deficient (Fbln5−/−) mice with defective elastic fiber synthesis and assembly induced accelerated pelvic organ prolapse, which never recovered. We conclude that, in pregnant mice, vaginal distention results in increased protease activity in the vaginal wall but also increased synthesis of proteins important for elastic fiber assembly. Distention may thereby contribute to the burst of elastic fiber synthesis in the postpartum vagina. The finding that distention results in accelerated pelvic organ prolapse in Fbln5−/− animals, but not in WT, indicates that elastic fiber synthesis is crucial for recovery of the vaginal wall from distention-induced increases in vaginal protease activity. PMID:18635445

A new operation technique for uterine prolapse: Vaginally-assisted laparoscopic sacrohysteropexy

PubMed Central

Sanverdi, İlhan; Kılıççı, Çetin; Polat, Mesut; Özkaya, Enis; Kılıç, Sami Gökhan; Dizdar, Merve; Karateke, Ateş

2017-01-01

Objective: To describe the new surgical technique and report the safety and feasibility of vaginally-assisted laparoscopic sacrohysteropexy (VALSH). Materials and Methods: Thirty-three women with stage 3 or more uterine prolapse underwent VALSH operation. Patients were followed up for 12 months for mesh-related complications and improvements of symptoms. The operation had three sections; 1st laparoscopic, 2nd vaginal, 3rd laparoscopic. Results: The mean age, gravidity, and parity of the study population were 46.5 years (range, 25-68 years), 4.3 (1-9), and 2.9 (1-6), respectively. The mean duration of operation was 59.5 min (range, 20-120 min). There were significant differences between the pre- and post-operative values of pelvic organ prolapse quantification parameters, which were favorable in the latter evaluation (p<0.001); total vaginal length was preserved after surgery (p>0.05). Conclusion: VALSH is a safe and minimally-invasive procedure in uterovaginal prolapse, with favorable anatomic and functional outcomes at 12 months post-operatively. PMID:29085709

Vaginal sacrospinous colpopexy and laparoscopic sacral colpopexy for vaginal vault prolapse.

PubMed

Marcickiewicz, J; Kjöllesdal, M; Engh, M Ellström; Eklind, S; Axén, C; Brännström, M; Stjerndahl, J-H

2007-01-01

Vaginal sacrospinous colpopexy (VSC) and laparoscopic sacral colpopexy (LSC) both correct vault prolapse. The present study compares the perioperative course and long-term results of VSC and LSC. This retrospective study of post-hysterectomy vault prolapse involved 111 patients operated with either VSC (n=51) or LSC (n=60). The median time for the postoperative follow-up visit was 33.6 (range: 13-60) months for the LSC group and 38.4 (range: 7-108) months for the VSC group. Prolapse grade as well as the patient's satisfaction was recorded at the follow-up visit. Operation time was significantly shorter in the VSC group (median: 62 min) compared to the LSC group (median: 129 min). The rate of perioperative complications was low in both groups. There were 3 laparotomies in the LSC group, due to perioperative complications. The inpatients days were similar, with 3.7 days (1-18) and 4.0 days (2-21) in the VSC and the LSC group, respectively. Surgery for the recurrence of vault prolapse at any time before the follow-up visit did not occur in the VSC group, but occurred in 7 patients in the LSC group. At the follow-up visit, there was no recurrence of vault prolapse in either group. The subjective success rate was 82% in the VSC and 78% in the LSC group. This study indicates that VSC and LSC are two equally effective surgical procedures to correct vaginal vault prolapse, but the LSC technique requires a longer operating time.

Robotic-assisted sacrocolpopexy for pelvic organ prolapse.

PubMed

White, Wesley M; Pickens, Ryan B; Elder, Robert F; Firoozi, Farzeen

2014-11-01

The demand for surgical correction of pelvic organ prolapse is expected to grow as the aging population remains active and focused on quality of life. Definitive correction of pelvic organ prolapse can be accomplished through both vaginal and abdominal approaches. This article provides a contemporary reference source that specifically addresses the historical framework, diagnostic algorithm, and therapeutic options for the treatment of female pelvic organ prolapse. Particular emphasis is placed on the role and technique of abdominal-based reconstruction using robotic technology and the evolving controversy regarding the use of synthetic vaginal mesh. Copyright © 2014 Elsevier Inc. All rights reserved.

Mesh, graft, or standard repair for women having primary transvaginal anterior or posterior compartment prolapse surgery: two parallel-group, multicentre, randomised, controlled trials (PROSPECT).

PubMed

Glazener, Cathryn Ma; Breeman, Suzanne; Elders, Andrew; Hemming, Christine; Cooper, Kevin G; Freeman, Robert M; Smith, Anthony Rb; Reid, Fiona; Hagen, Suzanne; Montgomery, Isobel; Kilonzo, Mary; Boyers, Dwayne; McDonald, Alison; McPherson, Gladys; MacLennan, Graeme; Norrie, John

2017-01-28

The use of transvaginal mesh and biological graft material in prolapse surgery is controversial and has led to a number of enquiries into their safety and efficacy. Existing trials of these augmentations are individually too small to be conclusive. We aimed to compare the outcomes of prolapse repair involving either synthetic mesh inlays or biological grafts against standard repair in women. We did two pragmatic, parallel-group, multicentre, randomised controlled trials for our study (PROSPECT [PROlapse Surgery: Pragmatic Evaluation and randomised Controlled Trials]) in 35 centres (a mix of secondary and tertiary referral hospitals) in the UK. We recruited women undergoing primary transvaginal anterior or posterior compartment prolapse surgery by 65 gynaecological surgeons in these centres. We randomly assigned participants by a remote web-based randomisation system to one of the two trials: comparing standard (native tissue) repair alone with standard repair augmented with either synthetic mesh (the mesh trial) or biological graft (the graft trial). We assigned women (1:1:1 or 1:1) within three strata: assigned to one of the three treatment options, comparison of standard repair with mesh, and comparison of standard repair with graft. Participants, ward staff, and outcome assessors were masked to randomisation where possible; masking was obviously not possible for the surgeon. Follow-up was for 2 years after the surgery; the primary outcomes, measured at 1 year and 2 years, were participant-reported prolapse symptoms (i.e. the Pelvic Organ Prolapse Symptom Score [POP-SS]) and condition-specific (ie, prolapse-related) quality-of-life scores, analysed in the modified intention-to-treat population. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN60695184. Between Jan 8, 2010, and Aug 30, 2013, we randomly allocated 1352 women to treatment, of whom 1348 were included in the analysis. 865 women were included in the mesh trial (430 to standard repair alone, 435 to mesh augmentation) and 735 were included in the graft trial (367 to standard repair alone, 368 to graft augmentation). Because the analyses were carried out separately for each trial (mesh trial and graft trial) some women in the standard repair arm assigned to all treatment options were included in the standard repair group of both trials. 23 of these women did not receive any surgery (15 in the mesh trial, 13 in the graft trial; five were included in both trials) and were included in the baseline analyses only. Mean POP-SS at 1 year did not differ substantially between comparisons (standard 5·4 [SD 5·5] vs mesh 5·5 [5·1], mean difference 0·00, 95% CI -0·70 to 0·71; p=0·99; standard 5·5 [SD 5·6] vs graft 5·6 [5·6]; mean difference -0·15, -0·93 to 0·63; p=0·71). Mean prolapse-related quality-of-life scores also did not differ between groups at 1 year (standard 2·0 [SD 2·7] vs mesh 2·2 [2·7], mean difference 0·13, 95% CI -0·25 to 0·51; p=0·50; standard 2·2 [SD 2·8] vs graft 2·4 [2·9]; mean difference 0·13, -0·30 to 0·56; p=0·54). Mean POP-SS at 2 years were: standard 4·9 (SD 5·1) versus mesh 5·3 (5·1), mean difference 0·32, 95% CI -0·39 to 1·03; p=0·37; standard 4·9 (SD 5·1) versus graft 5·5 (5·7); mean difference 0·32, -0·48 to 1·12; p=0·43. Prolapse-related quality-of-life scores at 2 years were: standard 1·9 (SD 2·5) versus mesh 2·2 (2·6), mean difference 0·15, 95% CI -0·23 to 0·54; p=0·44; standard 2·0 (2·5) versus graft 2·2 (2·8); mean difference 0·10, -0·33 to 0·52; p=0·66. Serious adverse events such as infection, urinary retention, or dyspareunia or other pain, excluding mesh complications, occurred with similar frequency in the groups over 1 year (mesh trial: 31/430 [7%] with standard repair vs 34/435 [8%] with mesh, risk ratio [RR] 1·08, 95% CI 0·68 to 1·72; p=0·73; graft trial: 23/367 [6%] with standard repair vs 36/368 [10%] with graft, RR 1·57, 0·95 to 2·59; p=0·08). The cumulative number of women with a mesh complication over 2 years in women actually exposed to synthetic mesh was 51 (12%) of 434. Augmentation of a vaginal repair with mesh or graft material did not improve women's outcomes in terms of effectiveness, quality of life, adverse effects, or any other outcome in the short term, but more than one in ten women had a mesh complication. Therefore, follow-up is vital to identify any longer-term potential benefits and serious adverse effects of mesh or graft reinforcement in vaginal prolapse surgery. UK National Institute of Health Research. Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY license. Published by Elsevier Ltd.. All rights reserved.

Pelvic Organ Prolapse Repair with Mesh: Mid-Term Efficacy and Complications.

PubMed

Mateu Arrom, Laura; Errando Smet, Carlos; Gutierrez Ruiz, Cristina; Araño, Pedro; Palou Redorta, Joan

2018-06-06

Our aim was to assess the efficacy and complications of pelvic organ prolapse (POP) correction with transvaginal mesh (TVM). We retrospectively assessed patients who had undergone a repair of an apical (primary or recurrent) or recurrent POP using TVM in our department since 2007. Meshes used were Prolift®, Elevate®, and Surelift®. Satisfaction with surgery was assessed on a 0-10 scale. A total of 83 patients were included (33 Prolift®, 36 Elevate®, 14 Surelift®), with a mean age of 67.8 ± 9.7 years. Eighteen (21.6%) patients underwent a recurrent POP correction. Follow-up was 49 ± 34 months. Twelve (14.4%) symptomatic recurrences were identified, 3 of which required further surgery. Satisfaction was 8.7. Four (4.8%) vaginal exposures were detected, 2 of which required partial mesh removal. Three (3.6%) cases of dyspareunia and 1 (1.2%) case of mild pelvic pain were reported, which did not require further treatment. The use of TVM for apical or recurrent POP repair is effective and is associated with a high satisfaction rate while complications are infrequent. © 2018 S. Karger AG, Basel.

Paravaginal defect: anatomy, clinical findings, and imaging

PubMed Central

Arenholt, Louise T.S.; Pedersen, Bodil Ginnerup; Glavind, Karin; Glavind-Kristensen, Marianne; DeLancey, John O.L.

2017-01-01

Introduction and Hypothesis The paravaginal defect has been a topic of active discussion concerning 1) what it is; 2) how to diagnose it; 3) its role in anterior vaginal wall prolapse; and 4) if and how to repair it. The aim of this article is to review the existing literature on the paravaginal defect and to discuss its role in the anterior vaginal wall support system, with an emphasis on anatomy and imaging. Methods Articles related to paravaginal defects were identified through a PUBMED search ending July 1, 2015. Results The support of the anterior vaginal wall is a complex system involving the levator ani muscle, the arcus tendineus fascia pelvis (ATFP), the pubocervical fascia, and the uterosacral/cardinal ligaments. Studies conclude that physical examination is inconsistent in detecting paravaginal defects. Ultrasound (US) and magnetic resonance imaging (MRI) have been used to describe patterns in the appearance of the vagina and bladder when a paravaginal defect is suspected. Different terms have been used (e.g. “sagging of bladder base,” “loss of tenting”), which all represent changes in the support of the pelvic floor but which could be due to both paravaginal defects and levator ani defects. Conclusion Paravaginal support plays a role in the support of the anterior vaginal wall, but we still do not know the degree to which it contributes to the development of prolapse. Both MRI and US are useful in the diagnosis of paravaginal defects, but further studies are needed to evaluate their use. PMID:27640064

Malignant mixed Mullerian tumour of the prolapsed cervix: A case report.

PubMed

Massinde, Anthony N; Rumanyika, Richard R; Kihunrwa, Albert; Rambau, Peter; Magoma, Moke

2012-04-01

Malignant mixed Mullerian tumour is a rare gynaecological tumour commonly presenting with vaginal bleeding, abdominal pain or mass in the uterine cavity, cervix or vagina. The neoplasms are commonly seen in postmenopausal women although it has been observed in younger women. Ovaries and the corpus of the uterus are commonly involved, whereas involvement of the cervix and vagina is rare. A 37 year-old Tanzania lady para 7 with a previous history of two genital polypectomies presented with history of recurrent vaginal mass which was associated with abnormal vaginal bleeding and foul smelling discharge. Vaginal examination revealed a prolapsed uterus with giant fungating cervical mass which was ulcerated, friable, and bled easily on touch. Impression was grade three uterine prolapse with infected cervical polyp/cervical sarcoma. Excision of the tumour through trans-vaginal hysterectomy was performed, no lymphadenopathy was found, no adnexa abnormalities, and no involvement of the vaginal wall. Histological diagnosis of Malignant mixed Mullerian tumour of the cervix was made. Patient recovery was unremarkable; however she was lost to follow up. The patient's mass was initially suspected to be prolapsed uterus with decubitus ulcer but the histological results were of a malignant condition. Lack of clear management guidelines for some rare mixed tumours remains a challenge for clinicians in low resource settings.

Towards rebuilding vaginal support utilizing an extracellular matrix bioscaffold.

PubMed

Liang, Rui; Knight, Katrina; Easley, Deanna; Palcsey, Stacy; Abramowitch, Steven; Moalli, Pamela A

2017-07-15

As an alternative to polypropylene mesh, we explored an extracellular matrix (ECM) bioscaffold derived from urinary bladder matrix (MatriStem™) in the repair of vaginal prolapse. We aimed to restore disrupted vaginal support simulating application via transvaginal and transabdominal approaches in a macaque model focusing on the impact on vaginal structure, function, and the host immune response. In 16 macaques, after laparotomy, the uterosacral ligaments and paravaginal attachments to pelvic side wall were completely transected (IACUC# 13081928). 6-ply MatriStem was cut into posterior and anterior templates with a portion covering the vagina and arms simulating uterosacral ligaments and paravaginal attachments, respectively. After surgically exposing the correct anatomical sites, in 8 animals, a vaginal incision was made on the anterior and posterior vagina and the respective scaffolds were passed into the vagina via these incisions (transvaginal insertion) prior to placement. The remaining 8 animals underwent the same surgery without vaginal incisions (transabdominal insertion). Three months post implantation, firm tissue bands extending from vagina to pelvic side wall appeared in both MatriStem groups. Experimental endpoints examining impact of MatriStem on the vagina demonstrated that vaginal biochemical and biomechanical parameters, smooth muscle thickness and contractility, and immune responses were similar in the MatriStem no incision group and sham-operated controls. In the MatriStem incision group, a 41% decrease in vaginal stiffness (P=0.042), a 22% decrease in collagen content (P=0.008) and a 25% increase in collagen subtypes III/I was observed vs. Sham. Active MMP2 was increased in both Matristem groups vs. Sham (both P=0.002). This study presents a novel application of ECM bioscaffolds as a first step towards the rebuilding of vaginal support. Pelvic organ prolapse is a common condition related to failure of the supportive soft tissues of the vagina; particularly at the apex and mid-vagina. Few studies have investigated methods to regenerate these failed structures. The overall goal of the study was to determine the feasibility of utilizing a regenerative bioscaffold in prolapse applications to restore apical (level I) and lateral (level II) support to the vagina without negatively impacting vaginal structure and function. The significance of our findings is two fold: 1. Implantation of properly constructed extracellular matrix grafts promoted rebuilding of level I and level II support to the vagina and did not negatively impact the overall functional, morphological and biochemical properties of the vagina. 2. The presence of vaginal incisions in the transvaginal insertion of bioscaffolds may compromise vaginal structural integrity in the short term. Copyright © 2017 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.

Changes in pelvic organ prolapse mesh mechanical properties following implantation in rats.

PubMed

Ulrich, Daniela; Edwards, Sharon L; Alexander, David L J; Rosamilia, Anna; Werkmeister, Jerome A; Gargett, Caroline E; Letouzey, Vincent

2016-02-01

Pelvic organ prolapse (POP) is a multifactorial disease that manifests as the herniation of the pelvic organs into the vagina. Surgical methods for prolapse repair involve the use of a synthetic polypropylene mesh. The use of this mesh has led to significantly higher anatomical success rates compared with native tissue repairs, and therefore, despite recent warnings by the Food and Drug Administration regarding the use of vaginal mesh, the number of POP mesh surgeries has increased over the last few years. However, mesh implantation is associated with higher postsurgery complications, including pain and erosion, with higher consecutive rates of reoperation when placed vaginally. Little is known on how the mechanical properties of the implanted mesh itself change in vivo. It is assumed that the mechanical properties of these meshes remain unchanged, with any differences in mechanical properties of the formed mesh-tissue complex attributed to the attached tissue alone. It is likely that any changes in mesh mechanical properties that do occur in vivo will have an impact on the biomechanical properties of the formed mesh-tissue complex. The objective of the study was to assess changes in the multiaxial mechanical properties of synthetic clinical prolapse meshes implanted abdominally for up to 90 days, using a rat model. Another objective of the study was to assess the biomechanical properties of the formed mesh-tissue complex following implantation. Three nondegradable polypropylene clinical synthetic mesh types for prolapse repair (Gynemesh PS, Polyform Lite, and Restorelle) and a partially degradable polypropylene/polyglecaprone mesh (UltraPro) were mechanically assessed before and after implantation (n = 5/ mesh type) in Sprague Dawley rats for 30 (Gynemesh PS, Polyform Lite, and Restorelle) and 90 (UltraPro and Polyform Lite) days. Stiffness and permanent extension following cyclic loading, and breaking load, of the preimplanted mesh types, explanted mesh-tissue complexes, and explanted meshes were assessed using a multi-axial (ball-burst) method. The 4 clinical meshes varied from each other in weight, thickness, porosity, and pore size and showed significant differences in stiffness and breaking load before implantation. Following 30 days of implantation, the mechanical properties of some mesh types altered, with significant decreases in mesh stiffness and breaking load, and increased permanent extension. After 90 days these changes were more obvious, with significant decreases in stiffness and breaking load and increased permanent extension. Similar biomechanical properties of formed mesh-tissue complexes were observed for mesh types of different preimplant stiffness and structure after 90 days implantation. This is the first study to report on intrinsic changes in the mechanical properties of implanted meshes and how these changes have an impact on the estimated tissue contribution of the formed mesh-tissue complex. Decreased mesh stiffness, strength, and increased permanent extension following 90 days of implantation increase the biomechanical contribution of the attached tissue of the formed mesh-tissue complex more than previously thought. This needs to be considered when using meshes for prolapse repair. Crown Copyright © 2016. Published by Elsevier Inc. All rights reserved.

Complex rectovaginal fistulas after pelvic organ prolapse repair with synthetic mesh: a multidisciplinary approach to evaluation and management.

PubMed

Choi, Judy M; Nguyen, Vian; Khavari, Rose; Reeves, Keith; Snyder, Michael; Fletcher, Sophie G

2012-01-01

The use of synthetic mesh for transvaginal pelvic organ prolapse (POP) repair is associated with the rare complication of mesh erosion into hollow viscera. This study presents a single-institution series of complex rectovaginal fistulas (RVFs) after synthetic mesh-augmented POP repair, as well as strategies for identification and management. Institutional review board approval was obtained for this retrospective study. Data were collected and analyzed on all female patients undergoing RVF repair from 2000 to 2011 at our institution. Thirty-seven patients underwent RVF repair at our multidisciplinary center for restorative pelvic medicine. Of these, 10 (27.0%) were associated with POP repairs using mesh. The POP repairs resulting in RVF were transvaginal repair with mesh (n = 8), laparoscopic sacrocolpopexy with concomitant traditional posterior repair (n = 1), and robotic-assisted laparoscopic sacrocolpopexy (n = 1). Time to presentation was an average of 7.1 months after POP repair. Patients underwent a mean of 4.4 surgeries for definitive RVF repair, with 40% of patients requiring a bowel diversion (3 temporary ileostomies and 1 long-term colostomy). Mean follow-up time after last surgery was 9.2 months. On follow-up, 1 patient has a persistent fistula with vaginal mesh extrusion. One patient has persistent pelvic pain. This series highlights the significant impact of synthetic mesh complications in the posterior compartment. These complications should be cautionary for synthetic graft use by those with limited experience, particularly when an alternate choice of traditional repair is available. When symptoms of RVF are present, collaboration with a colon and rectal specialist should be initiated as soon as possible for evaluation and definitive repair.

What’s new in the functional anatomy of pelvic organ prolapse?

PubMed Central

DeLancey, John O. L.

2017-01-01

Purpose of Review Provide an evidence-based review of pelvic floor functional anatomy related to pelvic organ prolapse. Recent Findings Pelvic organ support depends on interactions between the levator ani muscle and pelvic connective tissues. Muscle failure exposes the vaginal wall a pressure differential producing abnormal tension on the attachments of the pelvic organs to the pelvic side-wall. Birth-induced injury to the pubococcygeal portion of the levator ani muscle is seen in 55% of women with prolapse and 16% of women with normal support. Failure of the connective tissue attachments between the uterus and vagina to the pelvic wall (cardinal, uterosacral, paravaginal) are strongly related with prolapse (effect sizes ~2.5) and are also highly correlated with one another (r ~0.85). Small differences exist with prolapse in factors involving the vaginal wall length and width (effect sizes ~1). The primary difference in ligament properties between women with and without prolapse is found in ligament length. Only minor differences in ligament stiffness are seen. Summary Pelvic organ prolapse occurs due to injury to the levator ani muscles and failure of the connections between the pelvic organs to the pelvic sidewall. Abnormalities of the vaginal wall fascial tissues may play a minor role. PMID:27517338

[Impact of colpocleisis on body image in women with severe pelvic organ prolapse].

PubMed

Zhang, Ying-hui; Lu, Yong-xian; Liu, Xin; Liu, Jing-xia; Shen, Wen-jie; Wang, Wen-ying; Ge, Jing; Zhao, Ying; Niu, Ke

2011-06-01

To investigate the impact of colpocleisis on body image in women with severe pelvic organ prolapse (POP). From Oct. 2005 to Feb. 2010, 60 POP patients with stage III and IV by POP quantitation system underwent total or partial colpocleisis. Patients received body image evaluation before and 1 year after operation. One year after operation, 52 (87%, 52/60) patients completed body image evaluation. Before and 1 year after operation, the ratio of answer "Not at all" of questions such as "Have you felt less physically attractive as a result of your vaginal prolapse?", "Have you been feeling less feminine as a result of your vaginal prolapse?", "Did you find it difficult to look at yourself naked?", "Have you been feeling less sexually attractive as a result of your vaginal prolapse?", "Have you felt dissatisfied with your body?" were 25% and 96% (P < 0.01), 21% and 96% (P < 0.01), 37% and 67% (P = 0.018), 29% and 96% (P < 0.01), 12% and 83% (P < 0.01), respectively, indicating significant improvement on body image after operation for patients treated by colpocleisis. Women underwent colpocleisis for severe POP could not decrease their body image as a result of the disability of vaginal intercourse.

Genital hiatus size is associated with and predictive of apical vaginal support loss.

PubMed

Lowder, Jerry L; Oliphant, Sallie S; Shepherd, Jonathan P; Ghetti, Chiara; Sutkin, Gary

2016-06-01

Recognition and assessment of apical vaginal support defects remains a significant challenge in the evaluation and management of prolapse. There are several reasons that this is likely: (1) Although the Pelvic Organ Prolapse-Quantification examination is the standard prolapse staging system used in the Female Pelvic Medicine and Reconstructive Surgery field for reporting outcomes, this assessment is not used commonly in clinical care outside the subspecialty; (2) no clinically useful and accepted definition of apical support loss exists, and (3) no consensus or guidelines address the degree of apical support loss at which an apical support procedure should be performed routinely. The purpose of this study was to identify a simple screening measure for significant loss of apical vaginal support. This was an analysis of women with Pelvic Organ Prolapse-Quantification stage 0-IV prolapse. Women with total vaginal length of ≥7 cm were included to define a population with "normal" vaginal length. Univariable and linear regression analyses were used to identify Pelvic Organ Prolapse-Quantification points that were associated with 3 definitions of apical support loss: the International Consultation on Incontinence, the Pelvic Floor Disorders Network revised eCARE, and a Pelvic Organ Prolapse-Quantification point C cut-point developed by Dietz et al. Linear and logistic regression models were created to assess predictors of overall apical support loss according to these definitions. Receiver operator characteristic curves were generated to determine test characteristics of the predictor variables and the areas under the curves were calculated. Of 469 women, 453 women met the inclusion criterion. The median Pelvic Organ Prolapse-Quantification stage was III, and the median leading edge of prolapse was +2 cm (range, -3 to 12 cm). By stage of prolapse (0-IV), mean genital hiatus size (genital hiatus; mid urethra to posterior fourchette) increased: 2.0 ± 0.5, 3.0 ± 0.5, 4.0 ± 1.0, 5.0 ± 1.0, and 6.5 ± 1.5 cm, respectively (P < .01). Pelvic Organ Prolapse-Quantification points B anterior, B posterior, and genital hiatus had moderate-to-strong associations with overall apical support loss and all definitions of apical support loss. Linear regression models that predict overall apical support loss and logistic regression models predict apical support loss as defined by International Continence Society, eCARE, and the point C; cut-point definitions were fit with points B anterior, B posterior, and genital hiatus; these 3 points explained more than one-half of the model variance. Receiver operator characteristic analysis for all definitions of apical support loss found that genital hiatus >3.75 cm was highly predictive of apical support loss (area under the curve, >0.8 in all models). Increasing genital hiatus size is associated highly with and predictive of apical vaginal support loss. Specifically, the Pelvic Organ Prolapse-Quantification measurement genital hiatus of ≥3.75 cm is highly predictive of apical support loss by all study definitions. This simple measurement can be used to screen for apical support loss and the need for further evaluation of apical vaginal support before planning a hysterectomy or prolapse surgery. Copyright © 2015 Elsevier Inc. All rights reserved.

[Indications of mesh in surgical treatment of pelvic organ prolapse by vaginal route: expert consensus from the French College of Gynecologists and Obstetricians (CNGOF)].

PubMed

Deffieux, X; Sentilhes, L; Savary, D; Letouzey, V; Marcelli, M; Mares, P; Pierre, F

2013-11-01

To determine the indications and contraindications concerning prosthetic surgery by vaginal route for pelvic organ prolapse. Literature review and rating of proposals using a formal consensus method. Before surgery for genital prolapse, the patient should be counselled about the different existing techniques (abdominal and vaginal surgery with and without mesh), the reasons why the surgeon offered her the placement of a synthetic mesh and also other nonsurgical treatments (pelvic floor rehabilitation and pessary). The intervention must be preceded by an assessment of bothersome pelvic, urinary, digestive and sexual symptoms. For the surgical treatment of cystocele, the use of a synthetic mesh placed by vaginal route is not recommended routinely. It should be discussed on a case by case considering the risk/benefit ratio. In patients presenting with cystocele recurrence, the placement of a synthetic mesh is a reasonable option, in order to reduce the risk of cystocele recurrence. With the exception of a few situations (rectocele recurrence), the placement of a synthetic mesh is not recommended as first-line therapy for the surgical treatment of rectocele by vaginal route. In case of uterine or vaginal vault prolapse, repositioning the vaginal vault or uterus using synthetic mesh arms is not recommended as first-line surgical therapy. Surgeons should implement established preventive recommendations that may reduce the risk of complications. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

A case of vaginal cancer with uterine prolapse.

PubMed

Kim, Hwi-Gon; Song, Yong Jung; Na, Yong Jin; Choi, Ook-Hwan

2013-12-01

Primary vaginal cancer combined with uterine prolapse is very rare. We present a case of 80-year-old postmenopausal women complaints of something coming out per vagina for the past 20 years, along with blood stained discharge, foul odor leukorrhea, and severe pelvic pain for the last 3 months. A 4 × 5 cm ulcer was present on middle third of vaginal wall with marked edema and ulceration of surrounding tissue. The prolapse was reduced under intravenous sedation in operating room. On gynecologic examination, uterus was normal in size, no adnexal mass was examined, and both parametrium were thickened. Papanicolaou smear was normal. Biopsy of the ulcer at vaginal wall revealed invasive squamous cell carcinoma of vagina. Magnetic Resonance Imaging of abdomen and pelvis showed left hydronephrosis and liver metastasis. Positron emission tomography (PET)/computed tomography (CT) revealed metastasis to lung, liver and iliac bone. She died from progression of disease one month after diagnosis.

Factors affecting the feasibility of bilateral salpingo-oophorectomy during vaginal hysterectomy for uterine prolapse.

PubMed

Dain, Lena; Abramov, Yoram

2011-08-01

About 15% of all hysterectomies are performed for pelvic organ prolapse, generally through the transvaginal approach. However, concomitant bilateral salpingo-oophorectomy (BSO) is not always feasible through this approach, because the adnexae are sometimes inaccessible. To identify factors affecting the feasibility of performing BSO during transvaginal hysterectomy for uterine prolapse. We reviewed charts of all women undergoing vaginal hysterectomy for uterine prolapse in our institution between December 2005 and November 2009, at which time BSO was uniformly attempted in all patients. One hundred and seventy-two women who underwent vaginal hysterectomy were identified, of whom 134 (78%) underwent concomitant BSO. Women in whom BSO was feasible were younger (60.6±10.1 vs 65.6±8.6 years, P<0.02) and had a higher prevalence of advanced prolapse, including stage IV cystocele (68% vs 38%, P=0.01), stage III-IV rectocele (40% vs 11%, P=0.003) and stage IV uterine prolapse (64% vs 25%, P=0.0005). The feasibility of BSO was primarily dependent on the stage of pelvic organ prolapse and patients' age. Relaxation of the adnexae because of weakness of the infundibulo-pelvic ligaments may accompany severe pelvic organ prolapse and may potentially explain the feasibility of BSO in these women. © 2011 The Authors. Australian and New Zealand Journal of Obstetrics and Gynaecology © 2011 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Vaginal Vault Suspension at Hysterectomy for Prolapse – Myths and Facts, Anatomical Requirements, Fixation Techniques, Documentation and Cost Accounting

PubMed Central

Graefe, F.; Marschke, J.; Dimpfl, T.; Tunn, R.

2012-01-01

Vaginal vault suspension during hysterectomy for prolapse is both a therapy for apical insufficiency and helps prevent recurrence. Numerous techniques exist, with different anatomical results and differing complications. The description of the different approaches together with a description of the vaginal vault suspension technique used at the Department for Urogynaecology at St. Hedwig Hospital could serve as a basis for reassessment and for recommendations by scientific associations regarding general standards. PMID:25278621

[Evolution of clinical practices in the surgical management of pelvic organ prolapse in a "vaginalist" team over the period 2010-2015: A paradigm shift towards pluripotency].

PubMed

Baubil, F; Guerby, P; Léonard, F; Rimailho, J; Parant, O; Tanguy le Gac, Y; Chantalat, E; Vidal, F

2018-06-22

To determine whether the 2011 FDA alert and French Guidelines have impacted the routine surgical practice in the management of pelvic organ prolapse in a "vaginalist" team over the period 2010-2015. Retrospective study involving all patients undergoing surgical management of anterior and/or apical symptomatic pelvic organ prolapse during the civil years 2010 and 2015. Both naive and relapsed prolapses were eligible. Overall, 338 patients were included: 187 in 2010 and 151 in 2015. Among patients with naive prolapse, we observed a significant increase in the number of laparoscopic sacrocolpopexies (11.1% in 2010 versus 34.4% in 2015, P=0.001) and a significant decline in the use of native tissue repair (67.6% in 2010 versus 39% in 2015, P=0.001). While the number of transvaginal meshes did not decline over the study period, their indications displayed a significant evolution towards a restricted use to advanced stages. We did not observe any difference regarding the treatment of recurred pelvic organ prolapse. Vaginal route remained the preferred approach in this indication. In our "vaginalist" team, routine practice has significantly evolved over the period 2010-2015, resulting in a diversification of the healthcare offer. This paradigm shift towards pluripotency is mandatory, since patients' preference should also drive the choice of both surgical route and technique. Copyright © 2018. Published by Elsevier Masson SAS.

Prolapse repair with and without apical resuspension-Practice patterns among certifying American urologists.

PubMed

Liu, Joceline S; Nettey, Oluwarotimi; Vo, Amanda X; Hofer, Matthias D; Flury, Sarah C; Kielb, Stephanie J

2017-02-01

To examine surgeon characteristics in certifying urologists performing prolapse surgeries. Anterior compartment prolapse is often associated with apical prolapse, with high rates of recurrence when anterior repair is performed without apical resuspension. Six-month case log data of certifying urologists between 2003 and 2013 was obtained from the American Board of Urology (ABU). Cases with a CPT code for common prolapse repairs in females ≥18 years were analyzed. Among 2,588 urologists logging at least one prolapse surgery and a total of 30,983 surgeries, 320 (1.0% of all cases) uterosacral ligament suspension, 3,673 (11.9%) sacrospinous ligament suspension, and 2,618 (8.4%) abdominal sacrocolpopexy were identified. The remaining 14,585 cases were logged as anterior repair. 54.7% of anterior repairs did not include apical suspension. The proportion of anterior repairs without apical suspension has decreased from 77.7% in 2004 to 41.4% in 2012 (P < 0.001). Female subspecialists before 2011 performed anterior repair without apical suspension in 58.5%, versus 70.3% by all others. Since 2011 there has been a decrease in number of anterior repairs without apical suspension, notably in those applying for Female Pelvic Medicine and Reconstructive Surgery (FPMRS) certification (17.1% vs. 30.7% by all other urologists, P < 0.001); nonacademically affiliated urologists are 2.1 times more likely to report anterior repair without apical suspension than academically affiliated colleagues (P < 0.001). The proportion of prolapse repairs reported as anterior repairs without apical suspension is decreasing, although it remains a substantial portion. Recent log year, FPMRS, and academic affiliation were associated with prolapse repairs addressing apical support. Neurourol. Urodynam. 36:344-348, 2017. © 2015 Wiley Periodicals, Inc. © 2015 Wiley Periodicals, Inc.

Erosions on a prolapsed uterine in an old woman: an unusual manifestation of pemphigus vulgaris.

PubMed

Ramezani, Ali; Ghandi, Narges; Akhyani, Maryam; Daneshpazhooh, Maryam; Naraghi, Zahra S; Chams-Davatchi, Cheyda

2009-09-15

Vaginal involvement in pemphigus vulgaris has previously been described. In all those cases a pelvic examination was needed to explore the lesions. We describe a patient with pemphigus vulgaris who had pemphigus erosions on a prolapsed uterus (i.e., on the everted surface of vagina). The patient had widespread lesions of pemphigus in other mucosal and cutaneous sites. Biopsy, antibodies against desmoglein 1 and 3, and direct and indirect immunofluorescence were confirming. The erosions on the prolapsed uterus were resistant to treatment; other mucosal and cutaneous lesions responded rapidly to prednisolone and azathioprine. After lowering the dose of prednisolone the patient was referred to a gynecologist for a vaginal hysterectomy. This case was unique because her vaginal lesions could be easily examined and followed.

Should asymptomatic anterior pelvic organ prolapse be corrected to treat irritative urinary symptoms?

PubMed

Sutherland, Suzette E

2010-09-01

In clinical practice, women seen with pelvic organ prolapse (POP) often present with a variety of pelvic floor symptoms: urinary incontinence, irritative or overactive bladder symptoms, fecal urgency or incontinence, obstructive voiding, sexual disorders, pelvic and perineal pain, and vaginal bulging. Among these, the only symptom reliably associated with clinically relevant POP that will resolve following vaginal reconstructive surgery is the visualization and/or sensation of a vaginal bulge. Most other symptoms often attributed to POP at best have only weak correlations with worsening pelvic anatomical support. Specifically, with respect to the anterior and/or apical vaginal compartment, there does not appear to be a correlation between irritative overactive bladder symptoms and the presence or degree of anterior vaginal wall prolapse. Furthermore, no other symptoms, urinary or otherwise, are reliably influenced by correction of anatomical defects of pelvic support, especially in the otherwise asymptomatic patient with POP without vaginal bulge. A review of the recent literature underscores the realization that the relationship between pelvic floor symptoms and anatomy is incompletely and poorly understood. With this in mind, there does not seem to be any absolute justification for the surgical correction of otherwise asymptomatic pelvic support defects.

Effect of Uterosacral Ligament Suspension vs Sacrospinous Ligament Fixation With or Without Perioperative Behavioral Therapy for Pelvic Organ Vaginal Prolapse on Surgical Outcomes and Prolapse Symptoms at 5 Years in the OPTIMAL Randomized Clinical Trial.

PubMed

Jelovsek, J Eric; Barber, Matthew D; Brubaker, Linda; Norton, Peggy; Gantz, Marie; Richter, Holly E; Weidner, Alison; Menefee, Shawn; Schaffer, Joseph; Pugh, Norma; Meikle, Susan

2018-04-17

Uterosacral ligament suspension (ULS) and sacrospinous ligament fixation (SSLF) are commonly performed pelvic organ prolapse procedures despite a lack of long-term efficacy data. To compare outcomes in women randomized to (1) ULS or SSLF and (2) usual care or perioperative behavioral therapy and pelvic floor muscle training (BPMT) for vaginal apical prolapse. This 2 × 2 factorial randomized clinical trial was conducted at 9 US medical centers. Eligible participants who completed the Operations and Pelvic Muscle Training in the Management of Apical Support Loss Trial enrolled between January 2008 and March 2011 and were followed up 5 years after their index surgery from April 2011 through June 2016. Two randomizations: (1) BPMT (n = 186) or usual care (n = 188) and (2) surgical intervention (ULS: n = 188 or SSLF: n = 186). The primary surgical outcome was time to surgical failure. Surgical failure was defined as (1) apical descent greater than one-third of total vaginal length or anterior or posterior vaginal wall beyond the hymen or retreatment for prolapse (anatomic failure), or (2) bothersome bulge symptoms. The primary behavioral outcomes were time to anatomic failure and Pelvic Organ Prolapse Distress Inventory scores (range, 0-300). The original study randomized 374 patients, of whom 309 were eligible for this extended trial. For this study, 285 enrolled (mean age, 57.2 years), of whom 244 (86%) completed the extended trial. By year 5, the estimated surgical failure rate was 61.5% in the ULS group and 70.3% in the SSLF group (adjusted difference, -8.8% [95% CI, -24.2 to 6.6]). The estimated anatomic failure rate was 45.6% in the BPMT group and 47.2% in the usual care group (adjusted difference, -1.6% [95% CI, -21.2 to 17.9]). Improvements in Pelvic Organ Prolapse Distress Inventory scores were -59.4 in the BPMT group and -61.8 in the usual care group (adjusted mean difference, 2.4 [95% CI, -13.7 to 18.4]). Among women who had undergone vaginal surgery for apical pelvic organ vaginal prolapse, there was no significant difference between ULS and SSLF in rates of surgical failure and no significant difference between perioperative behavioral muscle training and usual care on rates of anatomic success and symptom scores at 5 years. Compared with outcomes at 2 years, rates of surgical failure increased during the follow-up period, although prolapse symptom scores remained improved. clinicaltrials.gov Identifier: NCT01166373.

Surgeon-tailored polypropylene mesh as a needleless single-incision sling versus TVT-O for the treatment of female stress urinary incontinence: a comparative study.

PubMed

ElSheemy, Mohammed S; Fathy, Hesham; Hussein, Hussein A; Hussein, Eman A; Hassan, Sarah Mohamed

2015-06-01

To compare safety and efficacy of surgeon-tailored polypropylene mesh through needleless single-incision technique (STM) versus tension-free vaginal tape-obturator (TVT-O) aiming to decrease cost of treatment of stress urinary incontinence (SUI). This is important in developing countries due to limited healthcare resources. A retrospective cohort study was done at Urology and Gynecology Departments (dual-center), Cairo University, from January 2011 to August 2013. STM was inserted in 72 females, while TVT-O was inserted in 48 females. Females evaluated by cough stress test, stress and urge incontinence quality of life questionnaire (SUIQQ), Q max and abdominal leak point pressure (ALPP) were included. Different factors were compared between both groups using paired t, Wilcoxon's signed rank, McNemar, Chi-square, Fisher's exact, independent t or Mann-Whitney tests. Age, parity, previous surgeries, ALPP, intrinsic sphincter deficiency (ISD), associated prolapse and associated prolapse repair were comparable in both groups. No significant difference was found between both groups in postoperative complications (except groin pain), cure, SUIQQ indices improvement and Q max decline. In total, 65 (90 %) cured, 6 (8 %) improved while failure was detected in one (1 %) patient in STM group, while 42 (87 %) cured, 4 (8 %) improved and failure was detected in two (4 %) patients in TVT-O group. Presence of ISD (p = 0.565), urgency (p = 0.496), UUI (p = 0.531), previous surgeries (p = 0.345), associated urogenital prolapse (p = 0.218) or associated prolapse repair (p = 0.592) did not lead to any significant difference in outcome between both groups. Cost of mesh decreased from US$500 (TVT-O) to US$10 (STM). Outcome of STM is comparable to TVT-O. Furthermore, STM is more economic.

Defecatory dysfunction and fecal incontinence in women with or without posterior vaginal wall prolapse as measured by pelvic organ prolapse quantification (POP-Q).

PubMed

Augusto, Kathiane Lustosa; Bezerra, Leonardo Robson Pinheiro Sobreira; Murad-Regadas, Sthela Maria; Vasconcelos Neto, José Ananias; Vasconcelos, Camila Teixeira Moreira; Karbage, Sara Arcanjo Lino; Bilhar, Andreisa Paiva Monteiro; Regadas, Francisco Sérgio Pinheiro

2017-07-01

Pelvic Floor Dysfunction is a complex condition that may be asymptomatic or may involve a loto f symptoms. This study evaluates defecatory dysfunction, fecal incontinence, and quality of life in relation to presence of posterior vaginal prolapse. 265 patients were divided into two groups according to posterior POP-Q stage: posterior POP-Q stage ≥2 and posterior POP-Q stage <2. The two groups were compared regarding demographic and clinical data; overall POP-Q stage, percentage of patients with defecatory dysfunction, percentage of patients with fecal incontinence, pelvic floor muscle strength, and quality of life scores. The correlation between severity of the prolapse and severity of constipation was calculated using ρ de Spearman (rho). Women with Bp stage ≥2 were significantly older and had significantly higher BMI, numbers of pregnancies and births, and overall POP-Q stage than women with stage <2. No significant differences between the groups were observed regarding proportion of patients with defecatory dysfunction or incontinence, pelvic floor muscle strength, quality of life (ICIQ-SF), or sexual impact (PISQ-12). POP-Q stage did not correlate with severity of constipation and incontinence. General quality of life perception on the SF-36 was significantly worse in patients with POP-Q stage ≥2 than in those with POP-Q stage <2. The lack of a clinically important association between the presence of posterior vaginal prolapse and symptoms of constipation or anal incontinence leads us to agree with the conclusion that posterior vaginal prolapse probably is not an independent cause defecatory dysfunction or fecal incontinence. Copyright © 2017 Elsevier B.V. All rights reserved.

Tactile Imaging Markers to Characterize Female Pelvic Floor Conditions.

PubMed

van Raalte, Heather; Egorov, Vladimir

2015-08-01

The Vaginal Tactile Imager (VTI) records pressure patterns from vaginal walls under an applied tissue deformation and during pelvic floor muscle contractions. The objective of this study is to validate tactile imaging and muscle contraction parameters (markers) sensitive to the female pelvic floor conditions. Twenty-two women with normal and prolapse conditions were examined by a vaginal tactile imaging probe. We identified 9 parameters which were sensitive to prolapse conditions ( p < 0.05 for one-way ANOVA and/or p < 0.05 for t -test with correlation factor r from -0.73 to -0.56). The list of parameters includes pressure, pressure gradient and dynamic pressure response during muscle contraction at identified locations. These parameters may be used for biomechanical characterization of female pelvic floor conditions to support an effective management of pelvic floor prolapse.

Tactile Imaging Markers to Characterize Female Pelvic Floor Conditions

PubMed Central

van Raalte, Heather; Egorov, Vladimir

2015-01-01

The Vaginal Tactile Imager (VTI) records pressure patterns from vaginal walls under an applied tissue deformation and during pelvic floor muscle contractions. The objective of this study is to validate tactile imaging and muscle contraction parameters (markers) sensitive to the female pelvic floor conditions. Twenty-two women with normal and prolapse conditions were examined by a vaginal tactile imaging probe. We identified 9 parameters which were sensitive to prolapse conditions (p < 0.05 for one-way ANOVA and/or p < 0.05 for t-test with correlation factor r from −0.73 to −0.56). The list of parameters includes pressure, pressure gradient and dynamic pressure response during muscle contraction at identified locations. These parameters may be used for biomechanical characterization of female pelvic floor conditions to support an effective management of pelvic floor prolapse. PMID:26389014

Animal models of female pelvic organ prolapse: lessons learned

PubMed Central

Couri, Bruna M; Lenis, Andrew T; Borazjani, Ali; Paraiso, Marie Fidela R; Damaser, Margot S

2012-01-01

Pelvic organ prolapse is a vaginal protrusion of female pelvic organs. It has high prevalence worldwide and represents a great burden to the economy. The pathophysiology of pelvic organ prolapse is multifactorial and includes genetic predisposition, aberrant connective tissue, obesity, advancing age, vaginal delivery and other risk factors. Owing to the long course prior to patients becoming symptomatic and ethical questions surrounding human studies, animal models are necessary and useful. These models can mimic different human characteristics – histological, anatomical or hormonal, but none present all of the characteristics at the same time. Major animal models include knockout mice, rats, sheep, rabbits and nonhuman primates. In this article we discuss different animal models and their utility for investigating the natural progression of pelvic organ prolapse pathophysiology and novel treatment approaches. PMID:22707980

Evaluation of current synthetic mesh materials in pelvic organ prolapse repair.

PubMed

Kanagarajah, Prashanth; Ayyathurai, Rajinikanth; Gomez, Christopher

2012-06-01

With increasing use of synthetic material in pelvic organ prolapse repair, the reporting and incidence of associated complications also have increased. The role of synthetic mesh in pelvic organ prolapse repair remains controversial and it is a therapeutic dilemma whether to continue its use in patients with poor native tissues, despite the recent public safety notification provided by the U.S. Food and Drug Administration. In this article, we review the biomaterials used in pelvic organ prolapse repair and discuss the outcomes and associated complications, paying emphasis to the benefits and the risks.

Ablative dual-phase Erbium:YAG laser treatment of atrophy-related vaginal symptoms in post-menopausal breast cancer survivors omitting hormonal treatment.

PubMed

Mothes, A R; Runnebaum, M; Runnebaum, I B

2018-05-01

First evaluation of dual-phase vaginal Er:YAG laser to omit hormonal treatment for atrophy-related symptoms in post-menopausal breast cancer survivors following prolapse surgery. Patients with a history of breast cancer at the time of surgery for pelvic organ prolapse were offered non-hormonal vaginal Er:YAG laser treatment when complaining of atrophy-related genitourinary syndrome of menopause. A single 10-min course of dual-phase protocol of pulsed Er:YAG laser (2940 nm, fractional ablative and thermal mode, fluence according to tissue thickness). Follow-up included subjective satisfaction, vaginal pH, vaginal health index (VHI), and complications after 6 weeks. A total of 16 breast cancer survivors (age 71 years, SD 7) had been seeking treatment for pelvic floor symptoms related to vaginal atrophy at follow-up visits after prolapse surgery. All ablative vaginal Er:YAG laser outpatient procedures were successfully completed, all patients returned to daily activities without a need for analgetic medication. Evaluation was performed after 8.3 (SD 2.5) weeks. Pre-laser VHI scored 16 (SD 4.6) and post-laser VHI 20 (SD 3) with p = 0.01. Patients were satisfied in 94% (n = 15) regarding symptom relief. Breast cancer survivors with atrophy-related complaints after pelvic floor surgery may benefit from vaginal application of this innovative dual protocol of Er:YAG laser technology as a non-hormonal treatment approach.

Small Bowel Prolapse (Enterocele)

MedlinePlus

... heavy lifting Being overweight or obese Pregnancy and childbirth Pregnancy and childbirth are the most common causes of pelvic organ ... of developing small bowel prolapse include: Pregnancy and childbirth. Vaginal delivery of one or more children contributes ...

Vaginal hysterectomies in patients without uterine prolapse: ten-year experience.

PubMed

Cheung, K W; Pun, T C

2013-08-01

To review the results of vaginal hysterectomies in patients without uterine prolapse. Retrospective chart review. University affiliated hospital, Hong Kong. All patients who had vaginal hysterectomies in the absence of uterine prolapse from 1999 to 2005 inclusive (first period) and 2006 to 2009 inclusive (second period). The number of such hysterectomies, indications, operative procedures, complications, use of preoperative gonadotropin-releasing hormone agonist, and concomitant vaginal salpingo-oophorectomies performed. In all, 94 and 98 patients fulfilling the necessary inclusion criteria within the two respective periods underwent vaginal hysterectomy. The indications for hysterectomy in the respective groups were similar, and 89 (95%) and 90 (92%) of the patients were Chinese. The respective proportions having additional procedures were 11% versus 23% (P=0.018) and the respective vaginal bilateral salpingo-oophorectomy rates were 1% versus 15% (P<0.001). The vault haematoma rate decreased significantly in the second period (from 12% to 1%; P=0.002). There were no significant differences between the periods with respect to mean operative blood losses, uterine weights, and operating times. The use of gonadotropin-releasing hormone agonist resulted in reduced mean uterine sizes (12 weeks vs 10 weeks; P=0.041). A decreasing trend in mean operating times and blood losses was also observed after such use. Vaginal hysterectomy and bilateral salpingo-oophorectomies were successfully performed in 12 (80%) patients without laparoscopic assistance. For this procedure, a learning curve was also evident. Surgeons' experience can influence the complication rate and the chance of successful vaginal salpingo-oophorectomy. More liberal use of gonadotropin-releasing hormone agonist may further reduce the complication rate and allow more vaginal hysterectomies.

Pelvic Floor Disorders After Childbirth: Effect of Episiotomy, Perineal Laceration, and Operative Birth

PubMed Central

Handa, Victoria L.; Blomquist, Joan L.; McDermott, Kelly C.; Friedman, Sarah; Muñoz, Alvaro

2011-01-01

Objective To investigate whether episiotomy, perineal laceration, and operative delivery are associated with pelvic floor disorders after vaginal childbirth. Methods This is a planned analysis of data for a cohort study of pelvic floor disorders. Participants who had experienced at least one vaginal birth were recruited 5–10 years after delivery of their first child. Obstetric exposures were classified by review of hospital records. At enrollment, pelvic floor outcomes, including stress incontinence, overactive bladder, anal incontinence, and prolapse symptoms were assessed with a validated questionnaire. Pelvic organ support was assessed using the Pelvic Organ Prolapse Quantification system. Logistic regression analysis was used to estimate the relative odds of each pelvic floor disorder by obstetric history, adjusting for relevant confounders. Results Of 449 participants, 71 (16%) had stress incontinence, 45 (10%) had overactive bladder, 56 (12%) had anal incontinence, 19 (4%) had prolapse symptoms and 64 (14%) had prolapse to or beyond the hymen on examination. Forceps delivery increased the odds of each pelvic floor disorder considered, especially overactive bladder (odds ratio 2.92, 95% confidence interval 1.44, 5.93) and prolapse (odds ratio 1.95, 95% confidence interval 1.03, 3.70). Episiotomy was not associated with any of these pelvic floor disorders. In contrast, women with a history of more than one spontaneous perineal laceration were significantly more likely to have prolapse to or beyond the hymen (odds ratio 2.34, 95% confidence interval 1.13, 4.86). Our multivariable results suggest that one additional woman would develop prolapse for every 8 women who experienced at least one forceps birth (versus delivering all her children by spontaneous vaginal birth). Conclusion Forceps deliveries and perineal lacerations, but not episiotomies, were associated with pelvic floor disorders 5–10 years after a first delivery. PMID:22227639

Robotic Single-Site Sacrocolpopexy Using Barbed Suture Anchoring and Peritoneal Tunneling Technique: Tips and Tricks.

PubMed

Guan, Xiaoming; Ma, Yingchun; Gisseman, Jordan; Kleithermes, Christopher; Liu, Juan

2017-01-01

To demonstrate the tips and tricks of a simpler technique for single-site sacrocolpopexy using barbed suture anchoring and retroperitoneal tunneling to make the procedure more efficient and reproducible. Step-by-step description of surgical tutorial using a narrated video (Canadian Task Force classification III). Academic tertiary care hospital. Patient with Stage III uterine prolapse. Sacrocolpopexy is increasing utilized since the FDA warning about complications of vaginal mesh surgery. It is the gold standard for repair of apical prolapse. However, there is great variation in the sacrocolpopexy procedure techniques and they have not been standardized. Traditional single-site laparoscopic sacrocolpopexy is very challenging as the procedure time is long and suturing is difficult. The advantages of suturing with wristed needle drivers in robotic single-site surgery simplify this complex procedure. Furthermore, using barbed suture anchoring and peritoneal tunneling technique potentially decreases the surgeon's learning curve and makes the procedure reproducible. In this video, we demonstrate a supracervial hysterectomy with a stepwise explanation of the correct technique for performing a robotic single incision sacrocolpopexy. Sacrocolpopexy is increasing used since the US Food and Drug Administration warning about complications of vaginal mesh surgery. It is the gold standard for repair of apical prolapse. However, a great variation exists in the sacrocolpopexy procedure techniques that need to be standardized. Traditional single-site laparoscopic sacrocolpopexy is very challenging because the procedure time is long and suturing is difficult. The advantages of suturing with wristed needle drivers in robotic single-site surgery simplify this complex procedure. Furthermore, using the barbed suture anchoring and peritoneal tunneling technique potentially decreases the surgeon's learning curve and makes the procedure reproducible. In this video, we demonstrate a supracervical hysterectomy with a stepwise explaation of the correct technique for performing a robotic single-incision sacrocolpopexy. The possibility of using the barbed suture and peritoneal tunneling technique with wristed needle drivers in robotic single-site sacrocolpopexy offers the possibility of an effective, safe, reproducible, and cosmetic surgical option. Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.

Incidence and Management of De Novo Lower Urinary Tract Symptoms After Pelvic Organ Prolapse Repair.

PubMed

Tran, Henry; Chung, Doreen E

2017-09-12

Pelvic organ prolapse (POP) is a significant problem with many options for surgical correction. Following prolapse surgery, de novo lower urinary tract symptoms (LUTS) are not uncommon. We review the current literature on de novo lower urinary tract symptoms following POP repair and discuss the role of urodynamics in the evaluation of the prolapse patient. Patients with occult stress urinary incontinence (SUI) appear to be at higher risk of developing de novo SUI after POP repair. Prolapse reduction in patients undergoing urodynamic evaluation is important. Different types of POP repair influence rates of de novo SUI. Also, prophylactic anti-incontinence procedures at time of POP repair appear to lower the incidence of de novo SUI, but at the cost of increased risk of complications and morbidity. Pre-existing overactive bladder (OAB) symptoms may either improve or persist, and de novo OAB can develop. The specific role of urodynamic study testing for POP is still being determined. Increasingly, women are seeking surgical treatment for POP. Aside from complications related to surgery in general, proper patient counseling is important regarding the risk of development of de novo voiding problems following surgery. Despite a growing body of literature looking at de novo voiding symptoms after prolapse repair, more studies are still needed.

Rectocele

MedlinePlus

... heavy lifting Being overweight or obese Pregnancy and childbirth The muscles, ligaments and connective tissue that support ... naturally more likely to develop posterior vaginal prolapse. Childbirth. If you have vaginally delivered multiple children, you ...

One-year prospective comparison of vaginal pessaries and surgery for pelvic organ prolapse using the validated ICIQ-VS and ICIQ-UI (SF) questionnaires.

PubMed

Lone, Farah; Thakar, Ranee; Sultan, Abdul H

2015-09-01

Vaginal pessaries, pelvic floor exercises and surgery are treatment options for women with symptomatic pelvic organ prolapse (POP). The aim of this study was to compare the outcomes of pessaries and surgery in women with symptomatic POP using the validated International Consultation on Incontinence Questionnaire-Vaginal Symptoms (ICIQ-VS) and Urinary Incontinence (ICIQ-UI) Short Form (SF). Women attending the Urogynecology clinics with symptomatic POP were recruited. All women were treated using either a vaginal pessary or surgery. Outcomes were evaluated and then compared at 1 year using the validated ICIQ-VS and ICIQ-UI (SF) questionnaires. A total of 287 women with symptomatic prolapse were recruited. 269 women completed the questionnaires at baseline and 183 at 1 year. At 1 year, improvement was noted in quality of life (QOL), frequency of urinary leak and vaginal symptoms in both groups except for the symptom of vaginal soreness in the pessary group and the symptom of a tight vagina in the surgery group. However, both these symptoms were not bothersome. Women who underwent surgery demonstrated an improvement in faecal evacuation and sex life. There was an overall statistically significant improvement in vaginal, sex, QOL and urinary symptom scores in both groups. No statistically significant difference was noted between the surgery and the pessary groups. Using validated questionnaires 1 year after treatment, women with symptomatic POP report improvement in vaginal, bowel, urinary and quality of life scores when treated with either pessary use or surgery. No statistically significant difference was noted in the two groups.

A Multi-Compartment 3-D Finite Element Model of Rectocele and Its Interaction with Cystocele

PubMed Central

Luo, Jiajia; Chen, Luyun; Fenner, Dee E.; Ashton-Miller, James A.; DeLancey, John O. L.

2015-01-01

We developed a subject-specific 3-D finite element model to understand the mechanics underlying formation of female pelvic organ prolapse, specifically a rectocele and its interaction with a cystocele. The model was created from MRI 3-D geometry of a healthy 45 year-old multiparous woman. It included anterior and posterior vaginal walls, levator ani muscle, cardinal and uterosacral ligaments, anterior and posterior arcus tendineus fascia pelvis, arcus tendineus levator ani, perineal body, perineal membrane and anal sphincter. Material properties were mostly from the literature. Tissue impairment was modeled as decreased tissue stiffness based on previous clinical studies. Model equations were solved using Abaqus v 6.11. The sensitivity of anterior and posterior vaginal wall geometry was calculated for different combinations tissue impairments under increasing intraabdominal pressure. Prolapse size was reported as POP-Q point at point Bp for rectocele and point Ba for cystocele. Results show that a rectocele resulted from impairments of the levator ani and posterior compartment support. For 20% levator and 85% posterior support impairments, simulated rectocele size (at POP-Q point: Bp) increased 0.29 mm/cm H2O without apical impairment and 0.36 mm/cm H2O with 60% apical impairment, as intraabdominal pressures increased from 0 to 150 cm H2O. Apical support impairment could result in the development of either a cystocele or rectocele. Simulated repair of posterior compartment support decreased rectocele but increased a preexisting cystocele. We conclude that development of rectocele and cystocele depend on the presence of anterior, posterior, levator and/or or apical support impairments, as well as the interaction of the prolapse with the opposing compartment. PMID:25757664

Intraoperative cervix location and apical support stiffness in women with and without pelvic organ prolapse.

PubMed

Swenson, Carolyn W; Smith, Tovia M; Luo, Jiajia; Kolenic, Giselle E; Ashton-Miller, James A; DeLancey, John O

2017-02-01

It is unknown how initial cervix location and cervical support resistance to traction, which we term "apical support stiffness," compare in women with different patterns of pelvic organ support. Defining a normal range of apical support stiffness is important to better understand the pathophysiology of apical support loss. The aims of our study were to determine whether: (1) women with normal apical support on clinic Pelvic Organ Prolapse Quantification, but with vaginal wall prolapse (cystocele and/or rectocele), have the same intraoperative cervix location and apical support stiffness as women with normal pelvic support; and (2) all women with apical prolapse have abnormal intraoperative cervix location and apical support stiffness. A third objective was to identify clinical and biomechanical factors independently associated with clinic Pelvic Organ Prolapse Quantification point C. We conducted an observational study of women with a full spectrum of pelvic organ support scheduled to undergo gynecologic surgery. All women underwent a preoperative clinic examination, including Pelvic Organ Prolapse Quantification. Cervix starting location and the resistance (stiffness) of its supports to being moved steadily in the direction of a traction force that increased from 0-18 N was measured intraoperatively using a computer-controlled servoactuator device. Women were divided into 3 groups for analysis according to their pelvic support as classified using the clinic Pelvic Organ Prolapse Quantification: (1) "normal/normal" was women with normal apical (C < -5 cm) and vaginal (Ba and Bp < 0 cm) support; (2) normal/prolapse had normal apical support (C < -5 cm) but prolapse of the anterior or posterior vaginal walls (Ba and/or Bp ≥ 0 cm); and (3) prolapse/prolapse had both apical and vaginal wall prolapse (C > -5 cm and Ba and/or Bp ≥ 0 cm). Demographics, intraoperative cervix locations, and apical support stiffness values were then compared. Normal range of cervix location during clinic examination and operative testing was defined by the total range of values observed in the normal/normal group. The proportion of women in each group with cervix locations within and outside the normal range was determined. Linear regression was performed to identify variables independently associated with clinic Pelvic Organ Prolapse Quantification point C. In all, 52 women were included: 14 in the normal/normal group, 11 in the normal/prolapse group, and 27 in the prolapse/prolapse group. At 1 N of traction force in the operating room, 50% of women in the normal/prolapse group had cervix locations outside the normal range while 10% had apical support stiffness outside the normal range. Of women in the prolapse/prolapse group, 81% had cervix locations outside the normal range and 8% had apical support stiffness outside the normal range. Similar results for cervix locations were observed at 18 N of traction force; however the proportion of women with apical support stiffness outside the normal range increased to 50% in the normal/prolapse group and 59% in the prolapse/prolapse group. The prolapse/prolapse group had statistically lower apical support stiffness compared to the normal/normal group with increased traction from 1-18 N (0.47 ± 0.18 N/mm vs 0.63 ± 0.20 N/mm, P = .006), but all other comparisons were nonsignificant. After controlling for age, parity, body mass index, and apical support stiffness, cervix location at 1 N traction force remained an independent predictor of clinic Pelvic Organ Prolapse Quantification point C, but only in the prolapse/prolapse group. Approximately 50% of women with cystocele and/or rectocele but normal apical support in the clinic had cervix locations outside the normal range under intraoperative traction, while 19% of women with uterine prolapse had normal apical support. Identifying women whose apical support falls outside a defined normal range may be a more accurate way to identify those who truly need a hysterectomy and/or an apical support procedure and to spare those who do not. Copyright © 2016 Elsevier Inc. All rights reserved.

Correlation of pelvic organ prolapse quantification system scores with obstetric parameters and lower urinary tract symptoms in primiparae postpartum.

PubMed

Liang, Ching-Chung; Tseng, Ling-Hong; Horng, Shang-Gwo; Lin, I-wen; Chang, Shuenn-Dhy

2007-05-01

This study investigated the correlation between results of the pelvic organ prolapse quantification (POPQ) system at 3 days and at 2 months postpartum with obstetric parameters and lower urinary tract symptoms (LUTS) in 125 primiparae with vaginal delivery. The clinical characteristics, prevalence of pregnancy-related LUTS, and POPQ scores were evaluated. Regarding the relationship of obstetric parameters with POPQ scoring, the gh was found positively correlated with the body mass index and vaginal laceration at 2 months postpartum. The POPQ evaluation did not find the LUTS to be significantly related to the prolapse score. The mean scores of points C and D were significantly increased, and gh, pb, and tvl were significantly decreased between the initial and 2-month follow-up scores. Our results revealed that a decrease in vaginal size is the principal change during the first 2 months postpartum and that with the exception of gh, neither the obstetric parameters nor the LUTS were associated with the POPQ scoring system.

[Sacrospinous colpopexy complications].

PubMed

Estrade, J-P; Agostini, A; Roger, V; Dallay, D; Blanc, B; Cravello, L

2004-10-01

To evaluate complications of sacrospinous ligament fixation. Monocentric retrospective study. Department of Obstetrics & Gynecology, La Conception University Hospital, Marcella. Between January 1991 and September 2002, 277 women (mean age 64.9 years, range 37 to 92 years) underwent a sacrospinous ligament fixation; 91% had a menopausal status, and 15.5% used hormone replacement therapy. 33.2% of the patients had prior hysterectomy, 28.9% had a history of surgery for prolapse, and 18.8% had associated symptoms of stress urinary incontinence. In all cases, sacrospinous ligament fixation was performed under visual control using conventional stitch. Sacrospinous ligament fixation was combined with the following procedures: anterior vaginal repair (N =137), additional incontinence surgery (N =31), vaginal hysterectomy (N =137), levator myorraphy (N =203). Intraoperative complications, postoperative complications, long-term painful symptoms. Intraoperative complications were represented by 1 case of vascular wound and four rectal injuries. Main postoperative complications were vaginal haematomas (N =6) and abscesses (N =2). Long-term symptoms were perineal pain, sciatic neuralgia, and dyspareunia. There was no surgical mortality, and we noted low rates of major complications. Sacrospinous ligament fixation assumes high priority in our therapeutic regimen.

The Quality of Health Information Available on the Internet for Patients With Pelvic Organ Prolapse.

PubMed

Solomon, Ellen R; Janssen, Kristine; Krajewski, Colleen M; Barber, Matthew D

2015-01-01

This study aimed to assess the quality of Web sites that provide information on pelvic organ prolapse using validated quality measurement tools. The Google search engine was used to perform a search of the following 4 terms: "pelvic organ prolapse," "dropped bladder," "cystocele," and "vaginal mesh." The DISCERN appraisal tool and JAMA benchmark criteria were used to determine the quality of health information of each Web site. Cohen κ was performed to determine interrater reliability between reviewers. Kruskal-Wallis and Wilcoxon rank sum tests were used to compare DISCERN scores and JAMA criteria among search terms. Interrater reliability between the two reviewers using DISCERN was κ = 0.71 [95% confidence interval (CI), 0.68-0.74] and using JAMA criteria was κ = 0.98 (95% CI, 0.74-1.0). On the basis of the DISCERN appraisal tool, the search term "vaginal mesh" had significantly lower Web site quality than "pelvic organ prolapse" and "cystocele," respectively [mean difference of DISCERN score, -14.65 (95% CI, -25.50 to 8.50, P < 0.0001) and -12.55 (95% CI, -24.00 to 7.00, P = 0.0007)]. "Dropped bladder" had significantly lower Web site quality compared to "pelvic organ prolapse" and "cystocele," respectively (mean difference of DISCERN score, -9.55 (95% CI, -20.00 to 3.00, P = 0.0098) and -7.80 (95% CI, -18.00 to 1.00, P = 0.0348). Using JAMA criteria, there were no statistically significant differences between Web sites. Web sites queried under search terms "vaginal mesh" and "dropped bladder" are lower in quality compared with the Web sites found using the search terms "pelvic organ prolapse" and "cystocele."

Benign intestinal glandular lesions in the vagina: a possible correlation with implantation.

PubMed

Lu, Weiwei; Zhang, Xiaofei; Lu, Bingjian

2016-06-17

Enteric-type glandular lesions are extremely rare in the vagina. Their histological origin remains a matter of speculation at present. We review two rectal mucosal prolapse-like polyps and one intestinal-type adenosis in the vagina. Case 1, a 64-year-old woman, presented with a vaginal polypoid lesion with a size of 4 × 3 × 3 cm. Case 2, an 8-year-old girl, had a 1.5 × 1.5 × 0.8-cm pedunculated polyp in the vaginal navicular fossa and a clinically suspected rectovaginal fistula. Case 1 and 3 had an obsolete severe perineal laceration. On histopathological examination, cases 1 and 2 resembled rectal mucosal prolapse or inflammatory cloacogenic polyp (rectal mucosal prolapse-like polyp). Case 3 had an incidental intestinal-type adenosis in the removed vaginal wall. Immunohistochemistry confirmed the intestinal differentiation in all 3 lesions by showing diffuse CDX2-positive, CK20-positive, and scattered chromogranin A-positive neuroendocrinal cells in the lower compartment of the crypt. In summary, we report herein three unusual cases of benign intestinal-type glandular lesions in the vagina including two rectal mucosal prolapse-like polyps and one case of intestinal-type adenosis, and discuss possibilities for their histogenetic basis.

Characterizing Pelvic Organ Prolapse in Adult Spina Bifida Patients.

PubMed

Liu, Joceline S; Vo, Amanda X; Doolittle, Johnathan; Hamoui, Nabeel; Lewicky-Gaupp, Christina; Kielb, Stephanie J

2016-11-01

To report the distribution of pelvic organ prolapse (POP) stages in adult spina bifida (SB) patients. The severity of POP in the SB population has not been previously reported. Retrospective review of SB patients ≥18 years with a documented POP quantification examination between 2006 and 2014 were included. Patient demographics, gestation, parity, POP quantification examinations and prolapse symptoms were obtained. Thirty-three SB patients were identified with a mean age of 33.2 years. Five patients (15.2%) had stage 0 prolapse, 12 (36.4%) had stage 1, 12 (36.4%) had stage 2, 3 (9.1%) had stage 3, and 1 (3.0%) had stage 4. Of the 16 patients with advanced POP (stage 2 prolapse or greater), only 6 patients (37.5%) reported symptoms related to POP. All 6 symptomatic patients endorsed sensation of a vaginal bulge. Two of the 6 patients also reported dyspareunia. Additionally, 1 patient with advanced POP presented with vaginal bulge, noted by a caregiver, and cervical bleeding, but was otherwise asymptomatic. Twenty-four patients (72.7%) were nulliparous, and 12 of the 24 nulliparous patients (50%) demonstrated prolapse. Despite young age and frequent nulliparity, patients with SB are more likely to have POP than the general population. Additionally, the majority of SB patients with prolapse are asymptomatic. Assessment of pelvic organ prolapse should be included in the evaluation of adult SB females due to the low rate of symptoms even in the setting of advanced stage prolapse and potential impact on both urinary and bowel function. Copyright © 2016 Elsevier Inc. All rights reserved.

External cephalic version in premature rupture of membranes: a systematic review.

PubMed

Quist-Nelson, Johanna; Landers, Kathryn; McCurdy, Rebekah; Berghella, Vincenzo

2017-09-01

External cephalic version (ECV) increases the likelihood of a vaginal delivery in patients with breech presentation. Our objective was to determine the rate of cephalic vaginal delivery in women undergoing ECV after PROM. We performed a systematic review of all case reports, case series and clinical trials of patients undergoing an ECV after PROM ≥ 24 weeks. Maternal demographics and outcome data were obtained. The primary outcome was rate of cephalic vaginal delivery. Statistical analysis was performed for continuous outcomes by calculating mean and standard deviations for appropriate variables. The systematic review yielded six papers with 13 case reports and no clinical trials of ECV after PROM. The rate of success to cephalic presentation was 46.1% (six of 13 cases), with a subsequent vaginal delivery rate of 23.1% (three of 13 cases). The rate of umbilical cord prolapse was 33.3% (two of six cases). ECV after PROM has been reported in 13 cases in the literature. For the cases reported, 46.1% of ECV were successful in turning to cephalic position, but only 23.1% resulted in a vaginal delivery. There was a 33.3% incidence of umbilical cord prolapse. Given the high rate of umbilical cord prolapse, it would be imperative to offer an ECV in the setting of PROM only at an institution that has the ability to perform the indicated emergent cesarean delivery and only after appropriate counseling.

Physical examination of the female internal and external genitalia with and without pelvic organ prolapse: A review.

PubMed

Pahwa, Avita K; Siegelman, Evan S; Arya, Lily A

2015-04-01

Pelvic organ prolapse, a herniation of pelvic organs through the vagina, is a common condition in older women. Pelvic organ prolapse distorts vaginal anatomy making pelvic examination difficult. A clinician must accurately identify anatomic landmarks both in women presenting with symptoms of prolapse and in women noted to have coincidental prolapse during routine gynecologic examination. We present a systematic approach to the female pelvic examination including anatomic landmarks of the external genitalia, vagina, and uterus in women with normal support as well as changes that occur with pelvic organ prolapse. Knowledge and awareness of normal anatomic landmarks will improve a clinician's ability to identify defects in pelvic support and allow for better diagnosis and treatment of pelvic organ prolapse. © 2014 Wiley Periodicals, Inc.

Ovine multiparity is associated with diminished vaginal muscularis, increased elastic fibres and vaginal wall weakness: implication for pelvic organ prolapse

PubMed Central

Emmerson, Stuart; Young, Natharnia; Rosamilia, Anna; Parkinson, Luke; Edwards, Sharon L.; Vashi, Aditya V.; Davies-Tuck, Miranda; White, Jacinta; Elgass, Kirstin; Lo, Camden; Arkwright, John; Werkmeister, Jerome A.; Gargett, Caroline E.

2017-01-01

Pelvic Organ Prolapse (POP) is a major clinical burden affecting 25% of women, with vaginal delivery a major contributing factor. We hypothesised that increasing parity weakens the vagina by altering the extracellular matrix proteins and smooth muscle thereby leading to POP vulnerability. We used a modified POP-quantification (POP-Q) system and a novel pressure sensor to measure vaginal wall weakness in nulliparous, primiparous and multiparous ewes. These measurements were correlated with histological, biochemical and biomechanical properties of the ovine vagina. Primiparous and multiparous ewes had greater displacement of vaginal tissue compared to nulliparous at points Aa, Ap and Ba and lower pressure sensor measurements at points equivalent to Ap and Ba. Vaginal wall muscularis of multiparous ewes was thinner than nulliparous and had greater elastic fibre content. Collagen content was lower in primiparous than nulliparous ewes, but collagen organisation did not differ. Biomechanically, multiparous vaginal tissue was weaker and less stiff than nulliparous. Parity had a significant impact on the structure and function of the ovine vaginal wall, as the multiparous vaginal wall was weaker and had a thinner muscularis than nulliparous ewes. This correlated with “POP-Q” and pressure sensor measurements showing greater tissue laxity in multiparous compared to nulliparous ewes. PMID:28374826

Graft and mesh use in vaginal surgery.

PubMed

Rizvi, Raheela Mohsin; Chughtai, Novera Ghayoor

2017-12-01

Pelvic organ prolapse and urinary incontinence are among the most common chronic disorders in women. These are common problems whose pathogenesis remains unclear. As life expectancy increases, significantly greater number of women now present with pelvic organ prolapse and urinary incontinence requiring surgical intervention. Currently, the lifetime risk of undergoing prolapse or continence surgery is one in 11, and up to 30% of patients will require repeat reconstructive surgery and repeat surgery for incontinence in 10%. In an attempt to improve surgical outcomes and to preserve vaginal capacity and coital function, a number of synthetic and biological prostheses have been developed. This review aims to look at the role of graft and mesh in vaginal surgery. We conducted a search for English-language articles published during 1997 to 2016, using MEDLINE, PubMed and United States' National Library of Medicine databases. We reviewed around 50 papers but referenced only 30 for this article. The literature review provided us a new insight regarding safety of mesh. Polypropylene mesh is safe for vaginal surgery if used by experienced surgeons. The safety of mesh becomes compromised in the hands of commercial surgical kit providers. All the new mesh tailored kits should undergo evidence-based trials and then can be safely used worldwide.

Real-time measurement of the vaginal pressure profile using an optical-fiber-based instrumented speculum.

PubMed

Parkinson, Luke A; Gargett, Caroline E; Young, Natharnia; Rosamilia, Anna; Vashi, Aditya V; Werkmeister, Jerome A; Papageorgiou, Anthony W; Arkwright, John W

2016-12-01

Pelvic organ prolapse (POP) occurs when changes to the pelvic organ support structures cause descent or herniation of the pelvic organs into the vagina. Clinical evaluation of POP is a series of manual measurements known as the pelvic organ prolapse quantification (POP-Q) score. However, it fails to identify the mechanism causing POP and relies on the skills of the practitioner. We report on a modified vaginal speculum incorporating a double-helix fiber-Bragg grating structure for distributed pressure measurements along the length of the vagina and include preliminary data in an ovine model of prolapse. Vaginal pressure profiles were recorded at 10 Hz as the speculum was dilated incrementally up to 20 mm. At 10-mm dilation, nulliparous sheep showed higher mean pressures ( 102 ± 46 ?? mmHg ) than parous sheep ( 39 ± 23 ?? mmHg ) ( P = 0.02 ), attributable largely to the proximal (cervical) end of the vagina. In addition to overall pressure variations, we observed a difference in the distribution of pressure that related to POP-Q measurements adapted for the ovine anatomy, showing increased tissue laxity in the upper anterior vagina for parous ewes. We demonstrate the utility of the fiber-optic instrumented speculum for rapid distributed measurement of vaginal support.

Real-time measurement of the vaginal pressure profile using an optical-fiber-based instrumented speculum

NASA Astrophysics Data System (ADS)

Parkinson, Luke A.; Gargett, Caroline E.; Young, Natharnia; Rosamilia, Anna; Vashi, Aditya V.; Werkmeister, Jerome A.; Papageorgiou, Anthony W.; Arkwright, John W.

2016-12-01

Pelvic organ prolapse (POP) occurs when changes to the pelvic organ support structures cause descent or herniation of the pelvic organs into the vagina. Clinical evaluation of POP is a series of manual measurements known as the pelvic organ prolapse quantification (POP-Q) score. However, it fails to identify the mechanism causing POP and relies on the skills of the practitioner. We report on a modified vaginal speculum incorporating a double-helix fiber-Bragg grating structure for distributed pressure measurements along the length of the vagina and include preliminary data in an ovine model of prolapse. Vaginal pressure profiles were recorded at 10 Hz as the speculum was dilated incrementally up to 20 mm. At 10-mm dilation, nulliparous sheep showed higher mean pressures (102±46 mmHg) than parous sheep (39±23 mmHg) (P=0.02), attributable largely to the proximal (cervical) end of the vagina. In addition to overall pressure variations, we observed a difference in the distribution of pressure that related to POP-Q measurements adapted for the ovine anatomy, showing increased tissue laxity in the upper anterior vagina for parous ewes. We demonstrate the utility of the fiber-optic instrumented speculum for rapid distributed measurement of vaginal support.

Pelvic organ prolapse (POP) surgery: the evidence for the repairs.

PubMed

Gomelsky, Alex; Penson, David F; Dmochowski, Roger R

2011-06-01

What is known on the subject? and What does the study add? Substantial experience of the outcomes has been gathered regarding the acute and sub-acute experience with various types of corrective procedures for POP. These include long-term POP correction as well as more recent recognition of improvement in functional disorders associated with POP such as UI, colorectal dysfunction, and sexual dysfunction. Long-term follow-up is available for some of the older types of interventions and current multicentre trials are being accrued with longer term follow-up for new interventions including mesh-type repairs. The study adds a condensed and summarized version of the current literature regarding the various interventions for POP and also provides an overview of the current controversies and areas where knowledge is incomplete and in need of further elaboration for definitive answers regarding optimization of surgical care for POP. Our aim is to summarise the available data on the transvaginal placement of synthetic mesh for pelvic organ prolapse (POP) repair, with a focus on the outcomes and complications of commercial POP-repair kits. As the stability and durability of autologous tissues may be questionable, nonabsorbable, synthetic materials are an attractive alternative for providing additional support during POP surgery. These materials are not novel, and most have been used for many years in surgical applications, e.g. hernia repairs. While theoretically appealing, the implantation of synthetic mesh in the pelvis may be associated with inherent adverse consequences, such as erosion, extrusion, and infection. Additionally, the routine use of these materials may carry potential long-term complications, such as dyspareunia, chronic pelvic pain, and vaginal distortion. The success and failure of mesh-augmented POP repair is related not only to the synthetic material itself, but also to patient- and surgeon-related factors. Recent warnings by the USA Food and Drug Administration and other groups regarding adverse events further complicate the decision to use synthetic mesh. © 2011 THE AUTHORS; BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.

Cusp repair in aortic valve reconstruction: does the technique affect stability?

PubMed

Aicher, Diana; Langer, Frank; Adam, Oliver; Tscholl, Dietmar; Lausberg, Henning; Schäfers, Hans-Joachim

2007-12-01

Cusp prolapse may be an isolated cause of aortic regurgitation or may exist in conjunction with dilatation of the proximal aorta. Prolapse can be corrected by central plication, triangular resection, or pericardial patch implantation. We retrospectively analyzed our results with these techniques. From October 1995 to December 2006, 604 patients (aged 3-86 years) underwent aortic valve repair. Cusp prolapse was found in 427 patients (246 tricuspid, 181 bicuspid). Prolapse was corrected by central plication (n = 275) or triangular resection (n = 80). A pericardial patch was implanted for pre-existing cusp defects or after excision of calcium (n = 72). One cusp was repaired in 198 patients; the remaining patients underwent repair of 2 (n = 189) or 3 cusps (n = 40). In 102 patients more than one technique was used, and the patients were allocated to the group of the assumedly more complex repair (central plication < triangular resection < pericardial patch plasty). Cumulative follow-up was 1238 patient-years (mean 35 +/- 27 months). Hospital mortality was 2.6% (11/427). Actuarial freedom from aortic regurgitation of grade II or more at 5 years was 92% (central plication), 90% (triangular resection), and 90% (pericardial patch plasty). Thirteen patients were reoperated on, with prolapse as the most common reason for failure (n = 7); 6 underwent re-repair. Freedom from reoperation at 5 years was 95% (central plication), 94% (triangular resection), and 94% (pericardial patch plasty). Freedom from valve replacement at 5 years was 97% (central plication), 99% (triangular resection), and 98% (pericardial patch plasty). In aortic valve repair, cusp prolapse can be treated reliably by central plication. In the presence of more complex disease, triangular resection or pericardial patch plasty may be used without compromising midterm durability.

Local repair of stoma prolapse: Case report of an in vivo application of linear stapler devices.

PubMed

Monette, Margaret M; Harney, Rodney T; Morris, Melanie S; Chu, Daniel I

2016-11-01

One of the most common late complications following stoma construction is prolapse. Although the majority of prolapse can be managed conservatively, surgical revision is required with incarceration/strangulation and in certain cases laparotomy and/or stoma reversal are not appropriate. This report will inform surgeons on safe and effective approaches to revising prolapsed stomas using local techniques. A 58 year old female with an obstructing rectal cancer previously received a diverting transverse loop colostomy. On completion of neoadjuvant treatment, re-staging found new lung metastases. She was scheduled for further chemotherapy but incarcerated a prolapsed segment of her loop colostomy. As there was no plan to resect her primary rectal tumor at the time, a local revision was preferred. Linear staplers were applied to the prolapsed stoma in step-wise fashion to locally revise the incarcerated prolapse. Post-operative recovery was satisfactory with no complications or recurrence of prolapse. We detail in step-wise fashion a technique using linear stapler devices that can be used to locally revise prolapsed stoma segments and therefore avoid a laparotomy. The procedure is technically easy to perform with satisfactory post-operative outcomes. We additionally review all previous reports of local repairs and show the evolution of local prolapse repair to the currently reported technique. This report offers surgeons an alternative, efficient and effective option for addressing the complications of stoma prolapse. While future studies are needed to assess long-term outcomes, in the short-term, our report confirms the safety and effectiveness of this local technique.

Trends in management of pelvic organ prolapse among female Medicare beneficiaries.

PubMed

Khan, Aqsa A; Eilber, Karyn S; Clemens, J Quentin; Wu, Ning; Pashos, Chris L; Anger, Jennifer T

2015-04-01

In the last decade, many new surgical treatments have been developed to achieve less-invasive approaches to prolapse management. However, limited data exist on how the patterns of care for women with pelvic organ prolapse (POP) may have changed over the last decade, and whether mesh implantation techniques have influenced the type of specific compartment repair performed. We used a national data set to analyze the temporal trends in patterns of care for women with POP. Data were obtained from Public Use Files from the Centers for Medicare and Medicaid Services for a 5% random sample of national beneficiaries with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of POP from 1999 through 2009. Current Procedural Terminology, 4th Edition and International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes were used to evaluate nonsurgical and surgical management trends for this cohort. Types of surgery were categorized by prolapse compartment and combinations of repairs. After 2005, when applicable codes became available, mesh or graft repairs were also analyzed. Over the study time period, the number of women with a diagnosis of POP in any 1 year in our 5% sample of Medicare beneficiaries remained relatively stable (range, 21,245-23,268 per year). Rates of pessary insertion were also consistent at 11-13% over the study period. Of the women with a prolapse diagnosis, 14-15% underwent surgical repair, and there was little change over time in surgical management patterns based on compartment. Most commonly, multiple compartments were repaired simultaneously. There was a rapid increase in mesh use such that in 2009, 41% of all women who underwent surgery (5.8% of the total cohort) had mesh or graft inserted in their repair. Hysterectomy rates for prolapse decreased over time. Rates of vault suspension at the time of hysterectomy for prolapse were low; however, they showed a relative increase over time (22% in 1999 to 26% in 2009). Patterns and rates of prolapse repairs remained relatively unchanged from 1999 through 2009, with an exception of a rapid rise in mesh use. These data suggest that the majority of mesh techniques were used for augmentation purposes only, but did not result in an increase in apical repairs performed in the United States. There remains a disappointingly low rate of vault suspension repairs concomitantly at time of hysterectomy for POP. Copyright © 2015. Published by Elsevier Inc.

Trends in management of pelvic organ prolapse among female Medicare beneficiaries

PubMed Central

Khan, Aqsa A.; Eilber, Karyn S.; Clemens, J. Quentin; Wu, Ning; Pashos, Chris L.; Anger, Jennifer T.

2016-01-01

OBJECTIVE In the last decade, many new surgical treatments have been developed to achieve less-invasive approaches to prolapse management. However, limited data exist on how the patterns of care for women with pelvic organ prolapse (POP) may have changed over the last decade, and whether mesh implantation techniques have influenced the type of specific compartment repair performed. We used a national data set to analyze the temporal trends in patterns of care for women with POP. STUDY DESIGN Data were obtained from Public Use Files from the Centers for Medicare and Medicaid Services for a 5% random sample of national beneficiaries with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of POP from 1999 through 2009. Current Procedural Terminology, 4th Edition and International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes were used to evaluate nonsurgical and surgical management trends for this cohort. Types of surgery were categorized by prolapse compartment and combinations of repairs. After 2005, when applicable codes became available, mesh or graft repairs were also analyzed. RESULTS Over the study time period, the number of women with a diagnosis of POP in any 1 year in our 5% sample of Medicare beneficiaries remained relatively stable (range, 21,245–23,268 per year). Rates of pessary insertion were also consistent at 11–13% over the study period. Of the women with a prolapse diagnosis, 14–15% underwent surgical repair, and there was little change over time in surgical management patterns based on compartment. Most commonly, multiple compartments were repaired simultaneously. There was a rapid increase in mesh use such that in 2009, 41% of all women who underwent surgery (5.8% of the total cohort) had mesh or graft inserted in their repair. Hysterectomy rates for prolapse decreased over time. Rates of vault suspension at the time of hysterectomy for prolapse were low; however, they showed a relative increase over time (22% in 1999 to 26% in 2009). CONCLUSION Patterns and rates of prolapse repairs remained relatively unchanged from 1999 through 2009, with an exception of a rapid rise in mesh use. These data suggest that the majority of mesh techniques were used for augmentation purposes only, but did not result in an increase in apical repairs performed in the United States. There remains a disappointingly low rate of vault suspension repairs concomitantly at time of hysterectomy for POP. PMID:25446663

Elastin density: Link between histological and biomechanical properties of vaginal tissue in women with pelvic organ prolapse?

PubMed

de Landsheere, Laurent; Brieu, Mathias; Blacher, Silvia; Munaut, Carine; Nusgens, Betty; Rubod, Chrystèle; Noel, Agnès; Foidart, Jean-Michel; Nisolle, Michelle; Cosson, Michel

2016-04-01

The aim of the study was to correlate histological and biomechanical characteristics of the vaginal wall in women with pelvic organ prolapse (POP). Tissue samples were collected from the anterior [point Ba; POP Questionnaire (POP-Q)] and/or posterior (point Bp; POP-Q) vaginal wall of 15 women who underwent vaginal surgery for POP. Both histological and biomechanical assessments were performed from the same tissue samples in 14 of 15 patients. For histological assessment, the density of collagen and elastin fibers was determined by combining high-resolution virtual imaging and computer-assisted digital image analysis. For biomechanical testing, uniaxial tension tests were performed to evaluate vaginal tissue stiffness at low (C0) and high (C1) deformation rates. Biomechanical testing highlights the hyperelastic behavior of the vaginal wall. At low strains (C0), vaginal tissue appeared stiffer when elastin density was low. We found a statistically significant inverse relationship between C0 and the elastin/collagen ratio (p = 0.048) in the lamina propria. However, at large strain levels (C1), no clear relationship was observed between elastin density or elastin/collagen ratio and stiffness, likely reflecting the large dispersion of the mechanical behavior of the tissue samples. Histological and biomechanical properties of the vaginal wall vary from patient to patient. This study suggests that elastin density deserves consideration as a relevant factor of vaginal stiffness in women with POP.

Vaginal Approaches Using Synthetic Mesh to Treat Pelvic Organ Prolapse.

PubMed

Moon, Jei Won; Chae, Hee Dong

2016-02-01

Pelvic organ prolapse (POP) is a very common condition in elderly women. In women with POP, a sacrocolpopexy or a vaginal hysterectomy with anterior and posterior colporrhaphy has long been considered as the gold standard of treatment. However, in recent decades, the tendency to use a vaginal approach with mesh for POP surgery has been increasing. A vaginal approach using mesh has many advantages, such as its being less invasive than an abdominal approach and easier to do than a laparoscopic approach and its having a lower recurrence rate than a traditional approach. However, the advantages of a vaginal approach with mesh for POP surgery must be weighed against the disadvantages. Specific complications that have been reported when using mesh in POP procedures are mesh erosion, dyspareunia, hematomas, urinary incontinence and so on, and evidence supporting the use of transvaginal surgery with mesh is still lacking. Hence, surgeons should understand the details of the surgical pelvic anatomy, the various surgical techniques for POP surgery, including using mesh, and the possible side effects of using mesh.

Male-to-female transsexualism: laparoscopic pelvic floor repair of prolapsed neovagina.

PubMed

Condous, George; Jones, Robert; Lam, Alan M

2006-06-01

The incidence of prolapse of the neovagina after male-to-female gender reassignment surgery is unknown. We present the first case of laparoscopic total pelvic floor repair in a male-to-female transsexual. This surgical procedure combined an understanding of the anatomy of the male pelvis with the principles of laparoscopic pelvic floor repair in the XX female.

Urethral pressure reflectometry in women with pelvic organ prolapse: a study of reproducibility.

PubMed

Khayyami, Yasmine; Lose, Gunnar; Klarskov, Niels

2017-05-01

The mechanism of continence in women with pelvic organ prolapse (POP) before and after surgery remains unknown. Urethral pressure reflectometry (UPR) separates women with stress urinary incontinence (SUI) from continent women by measuring urethral opening pressure at an abdominal pressure of 50 cmH 2 O (P O-Abd 50 ). UPR can help identify women with POP at risk of postoperative de novo SUI. The aim of this study was to investigate the reproducibility of UPR in women with POP. Women with anterior or posterior vaginal wall prolapse were recruited for this prospective, observational study from our outpatient clinic. The women were examined with UPR on two occasions. Measurements were done at rest, and during squeezing and straining. Statistical analyses were performed using SAS 9.4. A Bland-Altman analysis with limits of agreement and coefficients of variation was used to determine the level of agreement between measurements. Paired t tests were used to estimate the difference; a two-tailed P value of <0.05 was considered significant. We recruited 19 women with anterior vaginal wall prolapse and 11 women with posterior vaginal wall prolapse. There were no significant differences in the opening pressures at rest or during squeezing or in the values of P O-Abd 50 . P O-Abd 50 showed limits of agreement of 15.3 cmH 2 O and a coefficient of variation of 9.9 %. UPR was found to be a highly reproducible method in women with POP. UPR may be used in future studies to help reveal urodynamic features predictive of postoperative de novo SUI in women with POP.

Relationship between intra-abdominal pressure and vaginal wall movements during Valsalva in women with and without pelvic organ prolapse: technique development and early observations.

PubMed

Spahlinger, D M; Newcomb, L; Ashton-Miller, J A; DeLancey, J O L; Chen, Luyun

2014-07-01

To develop and test a method for measuring the relationship between the rise in intra-abdominal pressure and sagittal plane movements of the anterior and posterior vaginal walls during Valsalva in a pilot sample of women with and without prolapse. Mid-sagittal MRI images were obtained during Valsalva while changes in intra-abdominal pressure were measured via a bladder catheter in 5 women with cystocele, 5 women with rectocele, and 5 controls. The regional compliance of the anterior and posterior vagina wall support systems were estimated from the ratio of displacement (mm) of equidistant points along the anterior and posterior vaginal walls to intra-abdominal pressure rise (mmHg). The compliance of both anterior and posterior vaginal wall support systems varied along different regions of vaginal wall for all three groups, with the highest compliance found near the vaginal apex and the lowest near the introitus. Women with cystocele had more compliant anterior and posterior vaginal wall support systems than women with rectocele. The movement direction differs between cystocele and rectocele. In cystocele, the anterior vaginal wall moves mostly toward the vaginal orifice in the upper vagina, but in a ventral direction in the lower vagina. In rectocele, the direction of the posterior vaginal wall movement is generally toward the vaginal orifice. Movement of the vaginal wall and compliance of its support is quantifiable and was found to vary along the length of the vagina. Compliance was greatest in the upper vagina of all groups. Women with cystocele demonstrated the most compliant vaginal wall support.

Dynamic half Fourier acquisition, single shot turbo spin-echo magnetic resonance imaging for evaluating the female pelvis.

PubMed

Gousse, A E; Barbaric, Z L; Safir, M H; Madjar, S; Marumoto, A K; Raz, S

2000-11-01

We assessed the merit of dynamic half Fourier acquisition, single shot turbo spin-echo sequence T2-weighted magnetic resonance imaging (MRI) for evaluating pelvic organ prolapse and all other female pelvic pathology by prospectively correlating clinical with imaging findings. From September 1997 to April 1998, 100 consecutive women 23 to 88 years old with (65) and without (35) pelvic organ prolapse underwent half Fourier acquisition, single shot turbo spin-echo sequence dynamic pelvic T2-weighted MRI at our institution using a 1.5 Tesla magnet with phased array coils. Mid sagittal and parasagittal views with the patient supine, relaxed and straining were obtained using no pre-examination preparation or instrumentation. We evaluated the anterior vaginal wall, bladder, urethra, posterior vaginal wall, rectum, pelvic floor musculature, perineum, uterus, vaginal cuff, ovaries, ureters and intraperitoneal organs for all pathological conditions, including pelvic prolapse. Patients underwent a prospective physical examination performed by a female urologist, and an experienced radiologist blinded to pre-imaging clinical findings interpreted all studies. Physical examination, MRI and intraoperative findings were statistically correlated. Total image acquisition time was 2.5 minutes, room time 10 minutes and cost American $540. Half Fourier acquisition, single shot turbo spin-echo T2-weighted MRI revealed pathological entities other than pelvic prolapse in 55 cases, including uterine fibroids in 11, ovarian cysts in 9, bilateral ureteronephrosis in 3, nabothian cyst in 7, Bartholin's gland cyst in 4, urethral diverticulum in 3, polytetrafluoroethylene graft abscess in 3, bladder diverticulum in 2, sacral spinal abnormalities in 2, bladder tumor in 1, sigmoid diverticulosis in 1 and other in 9. Intraoperative findings were considered the gold standard against which physical examination and MRI were compared. Using these criteria the sensitivity, specificity and positive predictive value of MRI were 100%, 83% and 97% for cystocele; 100%, 75% and 94% for urethrocele; 100%, 54% and 33% for vaginal vault prolapse; 83%, 100% and 100% for uterine prolapse; 87%, 80% and 91% for enterocele; and 76%, 50% and 96% for rectocele. Dynamic half Fourier acquisition, single shot turbo spin-echo MRI appears to be an important adjunct in the comprehensive evaluation of the female pelvis. Except for rectocele, pelvic floor prolapse is accurately staged and pelvic organ pathology reliably detected. The technique is rapid, noninvasive and cost-effective, and it allows the clinician to visualize the whole pelvis using a single dynamic study that provides superb anatomical detail.

Gluteo-vaginal sinus formation complicating posterior intravaginal slingplasty followed by successful IVS removal. A case report and review of the literature.

PubMed

Mikos, Themistoklis; Tsalikis, Tryfon; Papanikolaou, Alexios; Pournaropoulos, Fotios; Bontis, John N

2008-03-01

Posterior intravaginal slingplasty (IVS) is a technique used for the treatment of apical prolapse. Type III meshes have been mostly used with this technique. In this article, a case of bilateral gluteo-vaginal sinus tract formation that complicated a posterior vaginal slingplasty with a type III mesh is presented. At 3 months follow-up, the patient complained for bulking through the vagina, continuous offensive vaginal discharge, and constant pain at the buttocks. She had prolapse recurrence, and there was defective healing at the gluteal entry points of the posterior IVS. Ten months after the initial surgery, she underwent a laparotomic subtotal hysterectomy and sacrocervicopexy with prolene type I mesh. At the same time, the posterior mesh was removed allowing the surgeon to discover communication of the canal of the mesh extending from gluteal incisions to the vagina epithelium. The sinus tract was managed surgically with excision of the surrounding tissues. There was no recurrence or other complications at 2 months follow-up.

Primary invasive carcinoma of the vagina after Le Fort partial colpocleisis for stage IV pelvic organ prolapse: a case report.

PubMed

Cho, Moon Kyoung; Kim, Chul Hong; Kim, Yoon Ha

2011-11-01

We present here the case report of a postmenopausal woman who complained of recurrent pus-like vaginal discharge and perianal pain 1 year after Le Fort colpocleisis, which was subsequently identified as a primary invasive carcinoma of the vagina. Biopsy confirmed a squamous cell carcinoma in the vagina, and the disease was classified as stage III according to FIGO staging. The patient received pelvic radiotherapy. This case emphasizes that differential diagnosis of recurrent vaginal discharge that presents remote from obliterative procedure for pelvic organ prolapse should consider not only pyometra, but also other causes.

Is sensory urgency part of the same spectrum of bladder dysfunction as detrusor overactivity?

PubMed

Haylen, Bernard T; Chetty, Naven; Logan, Vanessa; Schulz, Serena; Verity, Louise; Law, Matthew; Zhou, Jialun

2007-02-01

It has been suggested that the urogynecological diagnosis of sensory urgency is an early form of detrusor overactivity and may be just earlier in the spectrum of disease. The former term is generally defined as increased perceived bladder sensation during filling, a low first desire to void and low bladder capacity in the absence of recorded urinary tract infection (UTI) or detrusor overactivity. The aims of this study are to determine the prevalence and associations of sensory urgency in comparison with detrusor overactivity, and whether sensory urgency is shown to be in the same spectrum of bladder dysfunction as detrusor overactivity. Five hundred and ninety-two women attending for an initial urogynecological/urodynamic assessment took part in this prospective study. In addition to a full clinical assessment, all women underwent free uroflowmetry, residual urine volume measurement (by vaginal ultrasound) and multichannel filling and voiding cystometry. Data were separated into those having (1) sensory urgency or (2) detrusor overactivity. Apart from prevalence figures, comparative associations were sought for (3) age; (4) parity; (5) presenting symptoms; (6) presence of at least one (medically) documented UTI in the previous 12 months; (7) two or more (recurrent) documented UTIs in the previous 12 months; (8) prior hysterectomy; (9) prior continence surgery; (10) menopause; (11) menopause and HRT use; (12) sign of clinical stress leakage; (13) retroverted uterus; (14) anterior vaginal wall prolapse; (15) uterine prolapse; (16) posterior vaginal wall prolapse; (17) apical vaginal prolapse; (18, 19) maximum, average urine flow rate (MUFR, AUFR) centiles, Liverpool Nomograms; (20) median residual urine volume (RUV) in milliliters; (21, 22) voiding difficulty: VD1,VD2 (MUFR, AUFR under 10th centile Liverpool Nomogram and/or RUV >30 ml); (23) diagnosis of urodynamic stress incontinence and (24) diagnosis of uterine and/or vaginal prolapse (grade >0). The prevalence of sensory urgency was 13%. The only differences in the clinical and urodynamic profiles of it and detrusor overactivity were (1) significantly increased prevalence of the symptom of urge incontinence and (2) (by definition) abnormal detrusor contractions during filling cystometry in women with detrusor overactivity. Overall, sensory urgency and detrusor overactivity appear to be part of the same spectrum of bladder dysfunction.

Indications, Contraindications, and Complications of Mesh in Surgical Treatment of Pelvic Organ Prolapse

PubMed Central

Ellington, David R.; Richter, Holly E.

2013-01-01

Women are seeking care for pelvic organ prolapse (POP) in increasing numbers and a significant proportion of them will undergo a second repair for recurrence. This has initiated interest by both surgeons and industry to utilize and design prosthetic mesh materials to help augment longevity of prolapse repairs. Unfortunately, the introduction of transvaginal synthetic mesh kits for use in women was done without the benefit of Level 1 data to determine its utility compared to native tissue repair. This report summarizes the potential benefit/risks of transvaginal synthetic mesh use for POP and recommendations regarding its continued use. PMID:23563869

Laparoscopic correction of right transverse colostomy prolapse.

PubMed

Gundogdu, Gokhan; Topuz, Ufuk; Umutoglu, Tarik

2013-08-01

Colostomy prolapse is a frequently seen complication of transverse colostomy. In one child with recurrent stoma prolapse, we performed a loop-to-loop fixation and peritoneal tethering laparoscopically. No prolapse had recurred at follow-up. Laparoscopic repair of transverse colostomy prolapse seems to be a less invasive method than other techniques. © 2013 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd.

Vaginal disorders.

PubMed

Soderberg, S F

1986-05-01

Chronic vaginitis is the most common vaginal disorder. Dogs with vaginitis show no signs of systemic illness but often lick at the vulva and have purulent or hemorrhagic vaginal discharges. Vaginitis is most commonly secondary to a noninfectious inciting factor such as congenital vaginal anomalies, clitoral hypertrophy, foreign bodies, trauma to the vaginal mucosa, or vaginal tumors. Inspection of the caudal vagina and vestibule both visually and digitally will often reveal the source of vaginal irritation. Vaginal cytology is used to establish the stage of the estrous cycle as well as distinguish uterine from vaginal sources of discharge. Vaginal cultures are used to establish the predominant offending organism associated with vaginal discharges and may be used as a guide for selection of a therapeutic agent. Vaginitis is best managed by removing the inciting cause and treating the area locally with antiseptic douches. Congenital malformations at the vestibulovaginal or vestibulovulvar junction may prevent normal intromission. Affected bitches may be reluctant to breed naturally because of pain. Such defects are detected best by digital examination. Congenital vaginal defects may be corrected by digital or surgical means. Prolapse of tissue through the lips of the vulva may be caused by clitoral hypertrophy, vaginal hyperplasia, or vaginal tumors. Enlargement of clitoral tissue is the result of endogenous or exogenous sources of androgens. Treatment of this condition includes removal of the androgen source and/or surgical removal of clitoral tissue. Vaginal hyperplasia is detected during proestrus or estrus of young bitches. Hyperplastic tissue will regress during diestrus. Tissue that is excessively traumatized and/or prolapse of the entire vaginal circumference may be removed surgically. Ovariohysterectomy may be used to prevent recurrence. Vaginal tumors are detected most often in older intact bitches. Such tumors are generally of smooth muscle or fibrous tissue origin and benign. Surgical excision of the tumor combined with ovariohysterectomy is usually curative.

Massive prolapsed haemorrhoids managed by ablation and correction in a poor resourced area

PubMed Central

Weledji, Elroy Patrick; Enow Orock, George; Aminde, Leopold

2013-01-01

More recently some patients with rectal mucosal prolapse and obstructive defaecation have been treated with the procedure for prolapse and haemorrhoids. We report a case of symptomatic chronic circumferentially prolapsed haemorrhoids that had several failed attempts at surgical repair. This was finally managed by ablation and correction of the associated rectal mucosal prolapse by a modified ‘Delorme's procedure akin to a stapled anopexy. PMID:24968428

Surgical outcomes and quality of life post-synthetic mesh-augmented repair for pelvic organ prolapse in the Chinese population.

PubMed

Sun, Xiuli; Zhang, Xiaowei; Wang, Jianliu

2014-02-01

To investigate the surgical outcomes, urinary incontinence and quality of life (QOL) of patients with pelvic organ prolapse after synthetic mesh-augmented repair in the Chinese population. This is a retrospective study of women who underwent synthetic mesh-augmented repair. Surgical outcomes were investigated by recurrence rate of prolapse and Organ Prolapse Quantification, and QOL by Pelvic Floor Impact Questionnaire-7 (PFIQ-7) and Pelvic Floor Distress Inventory-20 (PFDI-20). The sex life quality was evaluated by Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-31 (PISQ-31). Eighty-three patients completed the entire study. Anatomical success was 90.36%. Of patients with preoperative stress urinary incontinence, 91.89% claimed that the incontinence symptoms were completely relieved. The 6-month PFDI-20 and PFIQ-7 scores were significantly decreased, indicating that improved QOL occurs. However, the PISQ-31 showed no significant difference between preoperative and postoperative data in sex life quality. The synthetic polypropylene mesh is effective in treating POP and may improve QOL with no significant difference in the sexual life postoperatively. De novo stress urinary incontinence may occur after synthetic mesh-augmented repair. © 2013 The Authors. Journal of Obstetrics and Gynaecology Research © 2013 Japan Society of Obstetrics and Gynecology.

On the Biomechanics of Vaginal Birth and Common Sequelae

PubMed Central

Ashton-Miller, James A.; DeLancey, John O.L.

2010-01-01

Approximately 11% of U.S. women undergo surgery for pelvic floor dysfunction, including genital organ prolapse and urinary and fecal incontinence. The major risk factor for developing these conditions is giving vaginal birth. Vaginal birth is a remarkable event about which little is known from a biomechanical perspective. We first review the functional anatomy of the female pelvic floor, the normal loads acting on the pelvic floor in activities of daily living, and the functional capacity of the pelvic floor muscles. Computer models show that the stretch ratio in the pelvic floor muscles can reach an extraordinary 3.26 by the end of the second stage of labor. Magnetic resonance images provide evidence that show that the pelvic floor regions experiencing the most stretch are at the greatest risk for injury, especially in forceps deliveries. A conceptual model suggests how these injuries may lead to the most common form of pelvic organ prolapse, a cystocele. PMID:19591614

Uterosacral ligament vaginal vault suspension: anatomy, outcome and surgical considerations.

PubMed

Yazdany, Taji; Bhatia, Narender

2008-10-01

With aging populations, primary pelvic organ and recurrent pelvic organ prolapse have become a large-scale public health concern. Surgical options for patients include both abdominal and vaginal approaches, each with its own safety and efficacy profiles. This review summarizes the most recent anatomic, surgical and outcome data for uterosacral ligament vault suspension. It offers data on methods to avoid complications and difficult surgical scenarios. Uterosacral ligament suspension allows reattachment of the vaginal vault high within the pelvis. New modifications in technique including the extraperitoneal and laparoscopic approaches allow surgeons more freedom when planning surgery. Five-year data on the durability of the procedure make it a viable surgical option. As a technique widely used by many pelvic reconstructive surgeons, uterosacral ligament vault suspension provides a safe, anatomically correct and durable approach to uterine and vault prolapse. It requires advanced surgical training and an intimate understanding of pelvic anatomy to avoid and identify ureteral injury.

Vaginosacral colpopexy (VSC)--a new modification of the Mc Call operation using vaginosacral ligaments as autologous sliding grafts in posthysterectomy vault prolapse.

PubMed

Antovska, S V; Dimitrov, D G

2006-01-01

The effect of a new modification of the Mc Call operation, vaginosacral colpopexy (VSC) was evaluated in the group of 32 patients. Due to our bad experience with transabdominal lumbosacral colpopexy, we tried to find out another solution. VSC using the mobilized vaginosacral ligaments as sliding grafts (two sutures through the vaginosacral ligaments and posterior vaginal wall and the third suture through the uterosacral ligaments) for vault prolapse was performed in the group of 32 patients. Before operation, the median stage of prolapse was: stage III (range, 0-IV) for anterior site; stage II (range, 0-IV) for posterior site; stage I (range, 0-IV) of the apical segment, and stage III (range 0-IV) for the most severe segment of prolapse. The mean follow-up was 24.5 months (range 9-42 months). There were no intraoperative injuries of the bladder, ureter, rectum or small bowel. At the final follow-up, the mean stage of the prolapse was following: stage 0 (range, 0-III) for anterior site, posterior site and the most severe segment of prolapse; and stage 0 (range, 0-I) of the apical segment. The total vaginal length (tvl) increased significantly (p < 0.001) (Valsalva maneuver) (Vm) and (p < 0.001) (Pozzi maneuver) (Pm) from the preoperative mean value of 3.20 +/- 1.18 (Vm) and 2.70 +/- 0.92 (Pm) to (- 8.33 +/- 0.77) (Vm) and (-7.82 +/- 0.89) (Pm). All 8 patients with genuine stress incontinence, became continent. 3 of 4 patients with potential urinary incontinence required Marshal-Marchetti operation for persistent stress incontinence. VSC seems to be quick, safe and effective procedure for vault prolapse (Tab. 5, Fig. 8, Ref. 31).

Apical sling: an approach to posthysterectomy vault prolapse.

PubMed

Alas, Alexandriah N; Pereira, Ines; Chandrasekaran, Neeraja; Devakumar, Hemikaa; Espaillat, Luis; Hurtado, Eric; Davila, G Willy

2016-09-01

This video demonstrates a transvaginal technique for vaginal vault suspension using an apical sling suspended from the sacrospinous ligaments. This was a retrospective review of apical sling procedures performed from July 2013 to November 2014. The technique is started by marking the vaginal apex. A posterior dissection is performed and the sacrospinous ligaments are identified after dissection into the pararectal space. A 10-cm piece of monofilament, inelastic polypropylene tape is attached to the underside of the vaginal apex. Polypropylene sutures are placed into the sacrospinous ligament and threaded though the lateral edges of the apical sling and tied down, restoring apical support. Finally, the vaginal epithelium is closed. A total of 67 women underwent an apical sling procedure with 70 % (47/67) completing 6 months follow-up. The subjective cure rate ("cured" or "greatly improved") was 78.7 % and the objective cure rate (anatomical success, defined as apical prolapse stage ≤1) was 100 % (47 patients). Our apical sling sacrospinous ligament fixation approach is a unique, minimal mesh approach using a tape commonly used for midurethral slings to suspend the vaginal apex. We achieved high anatomical success and patient satisfaction.

Vaginal prolapse surgery with transvaginal mesh: results of the Austrian registry.

PubMed

Bjelic-Radisic, V; Aigmueller, T; Preyer, O; Ralph, G; Geiss, I; Müller, G; Riss, P; Klug, P; Konrad, M; Wagner, G; Medl, M; Umek, W; Lozano, P; Tamussino, K; Tammaa, A

2014-08-01

Several mesh repair systems for pelvic organ prolapse (POP) were introduced into clinical practice with limited data on safety, complications or success rates, and impact on sexual function. The Austrian Urogynecology Working Group initiated a registry to assess the use of transvaginal mesh devices for POP repair. We looked at perioperative data, as well as outcomes at 3 and 12 months. Between 2006 and 2010 a total of 20 gynecology departments in Austria participated in the Transvaginal Mesh Registry. Case report forms were completed to gather data on operations, the postoperative course, and results at 3 and 12 months. A total of 726 transvaginal procedures with 10 different transvaginal kits were registered. Intra- and perioperative complications were reported in 6.8%. The most common complication was increased intraoperative bleeding (2.2%). Bladder and bowel perforation occurred in 6 (0.8%) and 2 (0.3%) cases. Mesh exposure was seen in 11% at 3 and in 12% at 12 months. 24 (10%) previously asymptomatic patients developed bowel symptoms by 1 year. De novo bladder symptoms were reported in 39 (10%) at 3 and in 26 (11%) at 12 months. Dyspareunia was reported by 7% and 10% of 265 and 181 sexually active patients at 3 and 12 months postoperatively respectively. The 6.8% rate of intra- and perioperative complications is in line with previous reports. Visceral injury was rare. The 12% rate of mesh exposure is consistent with previous series.

Vaginal wall weakness in parous ewes: a potential preclinical model of pelvic organ prolapse.

PubMed

Young, Natharnia; Rosamilia, Anna; Arkwright, John; Lee, Joseph; Davies-Tuck, Miranda; Melendez, Joan; Werkmeister, Jerome; Gargett, Caroline E

2017-07-01

Ewes develop pelvic organ prolapse (POP) and may be a suitable model for preclinical studies evaluating cell-based therapies for POP. The aim of this study was to establish a clinical score of vaginal weakness and to compare POP Quantification System (POP-Q) values in conscious nulliparous and parous ewes and determine whether ewes are a suitable POP model. Ewes (n = 114) were examined while conscious, without sedation, and standing in a V conveyer by adapting the human POP-Q measurement. Ovine POP was defined as descent to the introitus from POP-Q points Aa 3 cm above the introitus on the anterior wall, Ap 3 cm above the introitus on the posterior wall, or increased Ba anterior wall descent above the urethra (≥0). A test-retest showed good inter- and intrarater reliability. There was no evidence of tissue mobility at Aa, Ap, Ba (all -3 cm) in nulliparous ewes (n = 14). In contrast, multiparous ewes had a median of -1 and interquartile range (IQR) (-2 to 0) for Aa, [0 (-1 to 0)] for Ap and [0 (-2.75 to 0)] for Ba (n = 33; P < 0.0001 in comparison with nulliparous) ewes. Ovine vaginal displacement was seen in 50.9 % of parous ewes and was strongly associated with parity (P = 0.003). A modified POP-Q in conscious ewes was established showing that the vaginal wall of parous animals has similar regions of weakness as do women and may be similarly related to parity. Ewes appear to be a representative preclinical model of human vaginal prolapse.

Fallopian tube prolapse following hysterectomy.

PubMed

Fan, Qing-bo; Liu, Zhu-feng; Lang, Jing-he; Sun, Da-wei; Leng, Jin-hua; Zhu, Lan; Ning, Liu

2006-03-01

To investigate the clinical diagnosis, treatment, and prevention of fallopian tube prolapse (FTP) after hysterectomy. A total of 7949 patients received hysterectomy from January 1983 to August 2005 in Peking Union Medical College Hospital, and 9 cases (including 1 case from other hospital) of FTP after hysterectomy were involved during this period. All of them were diagnosed according to pathological results and were followed up. The symptoms, diagnosis, and treatment of the FTP patients were analyzed retrospectively. The incidence of FTP after hysterectomy was 0.1% (8/7949), with the incidence of FTP after transabdominal hysterectomy being 0.06% (4/6229), after trans-vaginal hysterectomy being 0.5% (4/780), after laparoscopic assistant vaginal hysterectomy being 0 (0/940). There was no symptom in 3 cases. The pelvic examination revealed the typical prolapsed fimbrial end of a fallopian tube in 3 cases and the other 6 cases revealed red granulation tissue. All of them were excised vaginally and cauterized. The results were proved by pathological examination. No recurrence was reported during follow-up. FTP is a rare complication after hysterectomy. The prognosis is well after proper diagnosis and treatment Fixation of accessories onto the pelvic wall and complete peritonealization at the time of hysterectomy are the most important methods to prevent FTP after hysterectomy.

Pelvic Organ Support in Animals with Partial Loss of Fibulin-5 in the Vaginal Wall

PubMed Central

Shi, Haolin; Balgobin, Sunil; Montoya, T. Ignacio; Yanagisawa, Hiromi; Word, R. Ann

2016-01-01

Compromise of elastic fiber integrity in connective tissues of the pelvic floor is most likely acquired through aging, childbirth-associated injury, and genetic susceptibility. Mouse models of pelvic organ prolapse demonstrate systemic deficiencies in proteins that affect elastogenesis. Prolapse, however, does not occur until several months after birth and is thereby acquired with age or after parturition. To determine the impact of compromised levels of fibulin-5 (Fbln5) during adulthood on pelvic organ support after parturition and elastase-induced injury, tissue-specific conditional knockout (cKO) mice were generated in which doxycycline (dox) treatment results in deletion of Fbln5 in cells that utilize the smooth muscle α actin promoter-driven reverse tetracycline transactivator and tetracycline responsive element-Cre recombinase (i.e., Fbln5f/f/SMA++-rtTA/Cre+, cKO). Fbln5 was decreased significantly in the vagina of cKO mice compared with dox-treated wild type or controls (Fbln5f/f/SMA++-rtTA/Cre-/-). In controls, perineal body length (PBL) and bulge increased significantly after delivery but declined to baseline values within 6–8 weeks. Although overt prolapse did not occur in cKO animals, these transient increases in PBL postpartum were amplified and, unlike controls, parturition-induced increases in PBL (and bulge) did not recover to baseline but remained significantly increased for 12 wks. This lack of recovery from parturition was associated with increased MMP-9 and nondetectable levels of Fbln5 in the postpartum vagina. This predisposition to prolapse was accentuated by injection of elastase into the vaginal wall in which overt prolapse occurred in cKO animals, but rarely in controls. Taken together, our model system in which Fbln5 is conditionally knock-downed in stromal cells of the pelvic floor results in animals that undergo normal elastogenesis during development but lose Fbln5 as adults. The results indicate that vaginal fibulin-5 during development is crucial for baseline pelvic organ support and is also important for protection and recovery from parturition- and elastase-induced prolapse. PMID:27124299

Pelvic Organ Support in Animals with Partial Loss of Fibulin-5 in the Vaginal Wall.

PubMed

Chin, Kathleen; Wieslander, Cecilia; Shi, Haolin; Balgobin, Sunil; Montoya, T Ignacio; Yanagisawa, Hiromi; Word, R Ann

2016-01-01

Compromise of elastic fiber integrity in connective tissues of the pelvic floor is most likely acquired through aging, childbirth-associated injury, and genetic susceptibility. Mouse models of pelvic organ prolapse demonstrate systemic deficiencies in proteins that affect elastogenesis. Prolapse, however, does not occur until several months after birth and is thereby acquired with age or after parturition. To determine the impact of compromised levels of fibulin-5 (Fbln5) during adulthood on pelvic organ support after parturition and elastase-induced injury, tissue-specific conditional knockout (cKO) mice were generated in which doxycycline (dox) treatment results in deletion of Fbln5 in cells that utilize the smooth muscle α actin promoter-driven reverse tetracycline transactivator and tetracycline responsive element-Cre recombinase (i.e., Fbln5f/f/SMA++-rtTA/Cre+, cKO). Fbln5 was decreased significantly in the vagina of cKO mice compared with dox-treated wild type or controls (Fbln5f/f/SMA++-rtTA/Cre-/-). In controls, perineal body length (PBL) and bulge increased significantly after delivery but declined to baseline values within 6-8 weeks. Although overt prolapse did not occur in cKO animals, these transient increases in PBL postpartum were amplified and, unlike controls, parturition-induced increases in PBL (and bulge) did not recover to baseline but remained significantly increased for 12 wks. This lack of recovery from parturition was associated with increased MMP-9 and nondetectable levels of Fbln5 in the postpartum vagina. This predisposition to prolapse was accentuated by injection of elastase into the vaginal wall in which overt prolapse occurred in cKO animals, but rarely in controls. Taken together, our model system in which Fbln5 is conditionally knock-downed in stromal cells of the pelvic floor results in animals that undergo normal elastogenesis during development but lose Fbln5 as adults. The results indicate that vaginal fibulin-5 during development is crucial for baseline pelvic organ support and is also important for protection and recovery from parturition- and elastase-induced prolapse.

[Pelvic floor and pregnancy].

PubMed

Fritel, X

2010-05-01

Congenital factor, obesity, aging, pregnancy and childbirth are the main risk factors for female pelvic floor disorders (urinary incontinence, anal incontinence, pelvic organ prolapse, dyspareunia). Vaginal delivery may cause injury to the pudendal nerve, the anal sphincter, or the anal sphincter. However the link between these injuries and pelvic floor symptoms is not always determined and we still ignore what might be the ways of prevention. Of the many obstetrical methods proposed to prevent postpartum symptoms, episiotomy, delivery in vertical position, delayed pushing, perineal massage, warm pack, pelvic floor rehabilitation, results are disappointing or limited. Caesarean section is followed by less postnatal urinary incontinence than vaginal childbirth. However this difference tends to disappear with time and following childbirth. Limit the number of instrumental extractions and prefer the vacuum to forceps could reduce pelvic floor disorders after childbirth. Ultrasound examination of the anal sphincter after a second-degree perineal tear is useful to detect and repair infra-clinic anal sphincter lesions. Scientific data is insufficient to justify an elective cesarean section in order to avoid pelvic floor symptoms in a woman without previous disorders. Copyright 2010 Elsevier Masson SAS. All rights reserved.

Utilization of apical vaginal support procedures at time of inpatient hysterectomy performed for benign conditions: a national estimate.

PubMed

Ross, Whitney Trotter; Meister, Melanie R; Shepherd, Jonathan P; Olsen, Margaret A; Lowder, Jerry L

2017-10-01

Apical vaginal support is considered the keystone of pelvic organ support. Level I evidence supports reestablishment of apical support at time of hysterectomy, regardless of whether the hysterectomy is performed for prolapse. National rates of apical support procedure performance at time of inpatient hysterectomy have not been well described. We sought to estimate trends and factors associated with use of apical support procedures at time of inpatient hysterectomy for benign indications in a large national database. The National (Nationwide) Inpatient Sample was used to identify hysterectomies performed from 2004 through 2013 for benign indications. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to select both procedures and diagnoses. The primary outcome was performance of an apical support procedure at time of hysterectomy. Descriptive and multivariable analyses were performed. There were 3,509,230 inpatient hysterectomies performed for benign disease from 2004 through 2013. In both nonprolapse and prolapse groups, there was a significant decrease in total number of annual hysterectomies performed over the study period (P < .0001). There were 2,790,652 (79.5%) hysterectomies performed without a diagnosis of prolapse, and an apical support procedure was performed in only 85,879 (3.1%). There was a significant decrease in the proportion of hysterectomies with concurrent apical support procedure (high of 4.0% in 2004 to 2.5% in 2013, P < .0001). In the multivariable logistic regression model, increasing age, hospital type (urban teaching), hospital bed size (large and medium), and hysterectomy type (vaginal and laparoscopically assisted vaginal) were associated with performance of an apical support procedure. During the study period, 718,578 (20.5%) inpatient hysterectomies were performed for prolapse diagnoses and 266,743 (37.1%) included an apical support procedure. There was a significant increase in the proportion of hysterectomies with concurrent apical support procedure (low of 31.3% in 2005 to 49.3% in 2013, P < .0001). In the multivariable logistic regression model, increasing age, hospital type (urban teaching), hospital bed size (medium and large), and hysterectomy type (total laparoscopic and laparoscopic supracervical) were associated with performance of an apical support procedure. This national database study demonstrates that apical support procedures are not routinely performed at time of inpatient hysterectomy regardless of presence of prolapse diagnosis. Educational efforts are needed to increase awareness of the importance of reestablishing apical vaginal support at time of hysterectomy regardless of indication. Copyright © 2017 Elsevier Inc. All rights reserved.

Relationship of advanced glycation end products and their receptor to pelvic organ prolapse

PubMed Central

Chen, Yisong; Huang, Jian; Hu, Changdong; Hua, Keqin

2015-01-01

Objective: The aims of this study are to detect levels of AGEs and RAGE and SNPs for RAGE in vaginal tissues of women with POP and rats in a repair location, and to explore the relationship between AGEs-RAGE pathway and POP. Methods: This study involved human vaginal tissues in fornix from 44 women with POP and 46 women without POP who were assigned to pelvic floor reconstruction or LAVH. The proteins of AGEs, collagen I, and RAGE were detected by immunohistochemistry and Western blot with appropriate primary antibodies. The entire RAGE gene of 24 women with POP and 25 controls were sequenced, and SNPs within were detected. Then, sixty 8-week-old female Sprague-Dawley rats subjected to abdominal defect were divided into three surgical pelvic floor reconstruction repair groups (n = 20/group): A, repair with non-absorable prolene mesh; B, repair with absorbable SIS mesh; and C, a no repair control group. 3, 9, 15, and 21 months after operation, rats were sacrificed and the expression of AGEs, RAGE and collagen I in the tissues of repair location were detected in the various experimental groups. Statistical analysis included comparison of means (Student’s t-test) and proportions (Chi-square test or Fisher test). Results: By both immunohistochemistry and Western blot, patients with POP showed higher protein expression of AGEs of POP than controls (P < 0.05). In contrast, the expression of collagen I was lower in POP patients than in the control group (P < 0.05). No differences in the expression of RAGE between the POP patients and controls were observed (P > 0.05). In POP patients, the expression of collagen I decreased particularly in patients ≥ 60 years old (P < 0.05), but there were no different in the expression of AGEs and RAGE dependent on age (P > 0.05). RAGE gene sequence variance analysis identified 18 variable loci, but only two of these were potential SNPs: rs184003 (1806), rs55640627 (2346) (P < 0.05). Both rs184003 and rs55640627 are both intronic variants, indicating that they may not influence the structure of RAGE. In rat surgical repair model, group B showed a greater extent of abdominal prolapse than groups A and C (P < 0.05). Consistent with this, the expression of AGEs in group B was higher than groups A and C (P < 0.05), and collagen I in group B was lower than the two others, further supporting our notion that AGEs are inversely related to type I collagen content. Conclusions: In summary, this study demonstrates that AGEs and RAGE might play important roles in the physiopathology of POP. Further studies are required to explore mechanisms of how AGEs-RAGE pathway may contribute to tissue degeneration and fragility in POP. PMID:26045736

Two parallel, pragmatic, UK multicentre, randomised controlled trials comparing surgical options for upper compartment (vault or uterine) pelvic organ prolapse (the VUE Study): study protocol for a randomised controlled trial.

PubMed

Glazener, Cathryn; Constable, Lynda; Hemming, Christine; Breeman, Suzanne; Elders, Andrew; Cooper, Kevin; Freeman, Robert; Smith, Anthony R B; Hagen, Suzanne; McDonald, Alison; McPherson, Gladys; Montgomery, Isobel; Kilonzo, Mary; Boyers, Dwayne; Goulao, Beatriz; Norrie, John

2016-09-08

One in three women who have a prolapse operation will go on to have another operation, though not necessarily in the same compartment. Surgery can result in greater impairment of quality of life than the original prolapse itself (such as the development of new-onset urinary incontinence, or prolapse at a different site). Anterior and posterior prolapse surgery is most common (90 % of operations), but around 43 % of women also have a uterine (34 %) or vault (9 %) procedure at the same time. There is not enough evidence from randomised controlled trials (RCTs) to guide management of vault or uterine prolapse. The Vault or Uterine prolapse surgery Evaluation (VUE) study aims to assess the surgical management of upper compartment pelvic organ prolapse (POP) in terms of clinical effectiveness, cost-effectiveness and adverse events. VUE is two parallel, pragmatic, UK multicentre, RCTs (Uterine Trial and Vault Trial). Eligible for inclusion are women with vault or uterine prolapse: requiring a surgical procedure, suitable for randomisation and willing to be randomised. Randomisation will be computer-allocated separately for each trial, minimised on: requiring concomitant anterior and/or posterior POP surgery or not, concomitant incontinence surgery or not, age (under 60 years or 60 years and older) and surgeon. Participants will be randomly assigned, with equal probability to intervention or control arms in either the Uterine Trial or the Vault Trial. Uterine Trial participants will receive either a vaginal hysterectomy or a uterine preservation procedure. Vault Trial participants will receive either a vaginal sacrospinous fixation or an abdominal sacrocolpopexy. Participants will be followed up by postal questionnaires (6 months post surgery and 12 months post randomisation) and also reviewed in clinic 12 months post surgery. The primary outcome is the participant-reported Pelvic Organ Prolapse Symptom Score (POP-SS) at 12 months post randomisation. Demonstrating the efficacy of vault and uterine prolapse surgeries is relevant not only to patients and clinicians but also to health care providers, both in the UK and globally. Current controlled trials ISRCTN86784244 (assigned 19 October 2012), and the first subject was randomly assigned on 1 May 2013.

Synthetic Graft Augmentation in Vaginal Prolapse Surgery: Long-Term Objective and Subjective Outcomes.

PubMed

Meyer, Isuzu; McGwin, Gerald; Swain, Thomas A; Alvarez, Mitchell D; Ellington, David R; Richter, Holly E

2016-01-01

To report long-term objectives and subjective outcomes in women who underwent prolapse surgery with a synthetic graft augmentation. Retrospective analysis (Canadian Task Force classification II-3). University hospital in the southeastern United States. Women with symptomatic pelvic organ prolapse who underwent transvaginal graft augmentation using the Prolift mesh system between July 2006 and December 2008 for a minimum 5-year follow-up. Subjects completed the Pelvic Floor Distress Inventory (PFDI-20), the Pelvic Floor Impact Questionnaire (PFIQ-7), the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ), and the Patient Satisfaction Questionnaire. Subjects also underwent postoperative physical examination with Pelvic Organ Prolapse Quantification (POP-Q) and vaginal pain/stricture assessment. Long-term postoperative findings were compared with preoperative baseline data. Of 208 eligible subjects, 70 completed the questionnaires only, and 48 of these 70 provided both postoperative examination and questionnaire data. The mean duration of follow-up was 7.0 ± 0.7 years (range, 5.8-8.1 years). POP-Q measurements of Ba (point B anterior), Bp (B posterior), C (cervix), GH (genital hiatus), PB (perineal body), and overall pelvic organ prolapse stage were significantly improved (all p < .001 except for PB, p = .006). PFIQ-7 (total, Urinary Impact Questionnaire, and Pelvic Organ Prolapse Impact Questionnaire) and PFDI-20 (total, Urinary Distress Inventory, and Pelvic Organ Prolapse Distress Inventory) scores significantly improved (all p < .001). No differences were noted in the colorectal-anal subscales (Colorectal-Anal Impact Questionnaire and Colorectal-Anal Distress Inventory) and PISQ scores at >5-year follow-up (all p > .05). Satisfaction rates were 15.7% for not at all, 35.7% for somewhat, and 48.6% for completely satisfied. Complications included graft exposure (n = 3; 6%) and dyspareunia (n = 25; 36%). Women undergoing transvaginal prolapse surgery using a synthetic graft continue to have positive objective and subjective outcomes, leading to significantly improved quality of life at a minimum 5-year follow-up. Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.

Dysregulation of Protease and Protease Inhibitors in a Mouse Model of Human Pelvic Organ Prolapse

PubMed Central

Budatha, Madhusudhan; Silva, Simone; Montoya, Teodoro Ignacio; Suzuki, Ayako; Shah-Simpson, Sheena; Wieslander, Cecilia Karin; Yanagisawa, Masashi; Word, Ruth Ann; Yanagisawa, Hiromi

2013-01-01

Mice deficient for the fibulin-5 gene (Fbln5−/−) develop pelvic organ prolapse (POP) due to compromised elastic fibers and upregulation of matrix metalloprotease (MMP)-9. Here, we used casein zymography, inhibitor profiling, affinity pull-down, and mass spectrometry to discover additional protease upregulated in the vaginal wall of Fbln5−/− mice, herein named V1 (25 kDa). V1 was a serine protease with trypsin-like activity similar to protease, serine (PRSS) 3, a major extrapancreatic trypsinogen, was optimum at pH 8.0, and predominantly detected in estrogenized vaginal epithelium of Fbln5−/− mice. PRSS3 was (a) localized in epithelial secretions, (b) detected in media of vaginal organ culture from both Fbln5−/− and wild type mice, and (c) cleaved fibulin-5 in vitro. Expression of two serine protease inhibitors [Serpina1a (α1-antitrypsin) and Elafin] was dysregulated in Fbln5−/− epithelium. Finally, we confirmed that PRSS3 was expressed in human vaginal epithelium and that SERPINA1 and Elafin were downregulated in vaginal tissues from women with POP. These data collectively suggest that the balance between proteases and their inhibitors contributes to support of the pelvic organs in humans and mice. PMID:23437119

Characteristics of women with continued use of vaginal pessaries.

PubMed

Lewthwaite, Barbara J; Staley, Doug; Girouard, Lise; Maslow, Ken

2013-01-01

Vaginal pessaries have been shown to be a safe, effective treatment for pelvic organ prolapse, and in some cases, female urinary incontinence. There are limited data that predict long-term pessary use; therefore, the aim of this retrospective, exploratory study was to describe selected characteristics of women using a pessary for 12 months or longer in a nurse-run clinic.

Conventional fascial technique versus mesh repair for advanced pelvic organ prolapse: Analysis of recurrences in treated and untreated compartments.

PubMed

Damiani, G R; Riva, D; Pellegrino, A; Gaetani, M; Tafuri, S; Turoli, D; Croce, P; Loverro, G

2016-01-01

117 women with severe pelvic organ prolapse (POP; stage > 2) were enrolled to elucidate a 24-month outcome of POP surgery, using conventional or mesh repair with 3 techniques. 59 patients underwent conventional repair and 58 underwent mesh repair. Two types of mesh were used: a trocar-guided transobturator polypropylene (Avaulta, Bard Inc.) and a porcine dermis mesh (Pelvisoft, Bard Inc.). Women with recurrences, who underwent previous unsuccessful conventional repair, were randomised. Primary outcome was the evaluation of anatomic failures (prolapse stage > 1) in treated and untreated compartments. Anatomic failure was observed in 11 of 58 patients (19%; CI 8.9-29) in the mesh group and in 16 of 59 patients (27.1%; p value = 0.3) in the conventional group. 9 of 11 failures in the mesh group (15.5%; CI 6.2-24.8) were observed in the untreated compartment (de novo recurrences), 14.3% in Pelvisoft and 16.7% in Avaulta arm, while only 1 recurrence in the untreated compartment (1.7%) was observed in the conventional group (odds ratio 10.6, p = 0.03).

Extracellular matrix regenerative graft attenuates the negative impact of polypropylene prolapse mesh on vagina in rhesus macaque.

PubMed

Liang, Rui; Knight, Katrina; Barone, William; Powers, Robert W; Nolfi, Alexis; Palcsey, Stacy; Abramowitch, Steven; Moalli, Pamela A

2017-02-01

The use of wide pore lightweight polypropylene mesh to improve anatomical outcomes in the surgical repair of prolapse has been hampered by mesh complications. One of the prototype prolapse meshes has been found to negatively impact the vagina by inducing a decrease in smooth muscle volume and contractility and the degradation of key structural proteins (collagen and elastin), resulting in vaginal degeneration. Recently, bioscaffolds derived from extracellular matrix have been used to mediate tissue regeneration and have been widely adopted in tissue engineering applications. Here we aimed to: (1) define whether augmentation of a polypropylene prolapse mesh with an extracellular matrix regenerative graft in a primate sacrocolpopexy model could mitigate the degenerative changes; and (2) determine the impact of the extracellular matrix graft on vagina when implanted alone. A polypropylene-extracellular matrix composite graft (n = 9) and a 6-layered extracellular matrix graft alone (n = 8) were implanted in 17 middle-aged parous rhesus macaques via sacrocolpopexy and compared to historical data obtained from sham (n = 12) and the polypropylene mesh (n = 12) implanted by the same method. Vaginal function was measured in passive (ball-burst test) and active (smooth muscle contractility) mechanical tests. Vaginal histomorphologic/biochemical assessments included hematoxylin-eosin and trichrome staining, immunofluorescent labeling of α-smooth muscle actin and apoptotic cells, measurement of total collagen, collagen subtypes (ratio III/I), mature elastin, and sulfated glycosaminoglycans. Statistical analyses included 1-way analysis of variance, Kruskal-Wallis, and appropriate post-hoc tests. The host inflammatory response in the composite mesh-implanted vagina was reduced compared to that following implantation with the polypropylene mesh alone. The increase in apoptotic cells observed with the polypropylene mesh was blunted in the composite (overall P < .001). Passive mechanical testing showed inferior parameters for both polypropylene mesh alone and the composite compared to sham whereas the contractility and thickness of smooth muscle layer in the composite were improved with a value similar to sham, which was distinct from the decreases observed with polypropylene mesh alone. Biochemically, the composite had similar mature elastin content, sulfated glycosaminoglycan content, and collagen subtype III/I ratio but lower total collagen content when compared to sham (P = .011). Multilayered extracellular matrix graft alone showed overall comparable values to sham in aspects of the biomechanical, histomorphologic, or biochemical endpoints of the vagina. The increased collagen subtype ratio III/I with the extracellular matrix graft alone (P = .033 compared to sham) is consistent with an ongoing active remodeling response. Mesh augmentation with a regenerative extracellular matrix graft attenuated the negative impact of polypropylene mesh on the vagina. Application of the extracellular matrix graft alone had no measurable negative effects suggesting that the benefits of this extracellular matrix graft occur when used without a permanent material. Future studies will focus on understanding mechanisms. Copyright © 2016. Published by Elsevier Inc.

Extracellular matrix regenerative graft attenuates the negative impact of polypropylene prolapse mesh on vagina in rhesus macaque

PubMed Central

Liang, Rui; Knight, Katrina; Barone, William; Powers, Robert W.; Nolfi, Alexis; Palcsey, Stacy; Abramowitch, Steven; Moalli, Pamela A.

2016-01-01

BACKGROUND The use of wide pore lightweight polypropylene mesh to improve anatomical outcomes in the surgical repair of prolapse has been hampered by mesh complications. One of the prototype prolapse meshes has been found to negatively impact the vagina by inducing a decrease in smooth muscle volume and contractility and the degradation of key structural proteins (collagen and elastin), resulting in vaginal degeneration. Recently, bioscaffolds derived from extracellular matrix have been used to mediate tissue regeneration and have been widely adopted in tissue engineering applications. OBJECTIVE Here we aimed to: (1) define whether augmentation of a polypropylene prolapse mesh with an extracellular matrix regenerative graft in a primate sacrocolpopexy model could mitigate the degenerative changes; and (2) determine the impact of the extracellular matrix graft on vagina when implanted alone. STUDY DESIGN A polypropylene-extracellular matrix composite graft (n = 9) and a 6-layered extracellular matrix graft alone (n = 8) were implanted in 17 middle-aged parous rhesus macaques via sacrocolpopexy and compared to historical data obtained from sham (n = 12) and the polypropylene mesh (n = 12) implanted by the same method. Vaginal function was measured in passive (ball-burst test) and active (smooth muscle contractility) mechanical tests. Vaginal histomorphologic/ biochemical assessments included hematoxylin-eosin and trichrome staining, immunofluorescent labeling of α-smooth muscle actin and apoptotic cells, measurement of total collagen, collagen subtypes (ratio III/ I), mature elastin, and sulfated glycosaminoglycans. Statistical analyses included 1-way analysis of variance, Kruskal-Wallis, and appropriate posthoc tests. RESULTS The host inflammatory response in the composite mesh-implanted vagina was reduced compared to that following implantation with the polypropylene mesh alone. The increase in apoptotic cells observed with the polypropylene mesh was blunted in the composite (overall P < .001). Passive mechanical testing showed inferior parameters for both polypropylene mesh alone and the composite compared to sham whereas the contractility and thickness of smooth muscle layer in the composite were improved with a value similar to sham, which was distinct from the decreases observed with polypropylene mesh alone. Biochemically, the composite had similar mature elastin content, sulfated glycosaminoglycan content, and collagen subtype III/I ratio but lower total collagen content when compared to sham (P = .011). Multilayered extracellular matrix graft alone showed overall comparable values to sham in aspects of the biomechanical, histomorphologic, or biochemical end-points of the vagina. The increased collagen subtype ratio III/I with the extracellular matrix graft alone (P = .033 compared to sham) is consistent with an ongoing active remodeling response. CONCLUSION Mesh augmentation with a regenerative extracellular matrix graft attenuated the negative impact of polypropylene mesh on the vagina. Application of the extracellular matrix graft alone had no measurable negative effects suggesting that the benefits of this extra-cellular matrix graft occur when used without a permanent material. Future studies will focus on understanding mechanisms. PMID:27615441

Simple versus complex degenerative mitral valve disease.

PubMed

Javadikasgari, Hoda; Mihaljevic, Tomislav; Suri, Rakesh M; Svensson, Lars G; Navia, Jose L; Wang, Robert Z; Tappuni, Bassman; Lowry, Ashley M; McCurry, Kenneth R; Blackstone, Eugene H; Desai, Milind Y; Mick, Stephanie L; Gillinov, A Marc

2018-07-01

At a center where surgeons favor mitral valve (MV) repair for all subsets of leaflet prolapse, we compared results of patients undergoing repair for simple versus complex degenerative MV disease. From January 1985 to January 2016, 6153 patients underwent primary isolated MV repair for degenerative disease, 3101 patients underwent primary isolated MV repair for simple disease (posterior prolapse), and 3052 patients underwent primary isolated MV repair for complex disease (anterior or bileaflet prolapse), based on preoperative echocardiographic images. Logistic regression analysis was used to generate propensity scores for risk-adjusted comparisons (n = 2065 matched pairs). Durability was assessed by longitudinal recurrence of mitral regurgitation and reoperation. Compared with patients with simple disease, those undergoing repair of complex pathology were more likely to be younger and female (both P values < .0001) but with similar symptoms (P = .3). The most common repair technique was ring/band annuloplasty (3055/99% simple vs 3000/98% complex; P = .5), followed by leaflet resection (2802/90% simple vs 2249/74% complex; P < .0001). Among propensity-matched patients, recurrence of severe mitral regurgitation 10 years after repair was 6.2% for simple pathology versus 11% for complex pathology (P = .007), reoperation at 18 years was 6.3% for simple pathology versus 11% for complex pathology, and 20-year survival was 62% for simple pathology versus 61% for complex pathology (P = .6). Early surgical intervention has become more common in patients with degenerative MV disease, regardless of valve prolapse complexity or symptom status. Valve repair was associated with similarly low operative risk and time-related survival but less durability in complex disease. Lifelong annual echocardiographic surveillance after MV repair is recommended, particularly in patients with complex disease. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Long-term outcomes of synthetic transobturator nonabsorbable anterior mesh versus anterior colporrhaphy in symptomatic, advanced pelvic organ prolapse surgery.

PubMed

Lo, Tsia-Shu; Pue, Leng Boi; Tan, Yiap Loong; Wu, Pei-Ying

2014-02-01

Anterior vaginal mesh (AVM) combined with sacrospinous ligament fixation (SSF) yields better long-term success rates over anterior colporrhaphy (AC) in advanced pelvic organ prolapse (POP) surgery, with a low rate of mesh-related complications. Medical records of 198 patients who underwent surgery for POP between January 2006 and March 2010 were reviewed retrospectively. Patients' assessment at baseline and third-year postoperative follow-up were analyzed. SSF plus AC or AVM was performed for apical and anterior compartment repair. Primary outcome was objective cure [Pelvic Organ Prolapse Quantification (POP-Q) stage ≤ 1)], and subjective cure defined as negative response to questions 2 and 3 on the POPDI-6. Secondary outcomes were complications, symptoms severity and quality of life as measured with validated questionnaires. Post-operative data were available for 186 patients, 72 in AC group and 114 in AVM group were analyzed. The mean age, parity and operating time in AVM group were significantly higher as compared to AC group. The overall objective and subjective cure rate in AVM group was significantly higher than AC group (90.3 % and 88.6 % versus 73.6 % and 70.8 %, with P value = 0.003 and 0.002 respectively). Mesh exposure rate was 3.5 %. Improvement in both POPDI-6 and PISQ-12 in AVM group was statistically significant compared to AC group. Transobturator synthetic nonabsorbable AVM combined with SSF yielded a favorable and sustainable result over 5 years as compared to traditional AC, both in anatomical and subjective success rate. Mesh related morbidities were low and acceptable.

'Cupid and Psyche': a novel technique for robotic hysterosacropexy in the treatment of pelvic organ prolapse.

PubMed

Dal Moro, Fabrizio; Calpista, Arturo; Mancini, Mariangela

2016-01-01

The purpose of any surgical repair of pelvic organ prolapse (POP) is to restore pelvic anatomy, preserving urinary, intestinal and sexual functions while avoiding complications. We present a novel robotic approach to hysterosacropexy (HSP) in the treatment of POP. In our technique (named 'Cupid and Psyche', recalling as it does the famous sculpture by Canova), the two branches of the MESH encircle the uterus from behind, lifting and supporting it.The aim of this technique is to resolve POP, minimizing the risk of vaginal erosion: the posterior 'embrace' of the uterus limits the direct contact of the mesh with the vagina, thus reducing any risk of erosion/extrusion at this level. We performed 10 cases of robotic HSP. All procedures are completed robotically. Median operative time (skin-to-skin) is 125 min [interquartile range (IQR) 85-145], including port placement, robot docking and console time. We have never had any cases of intraoperative or postoperative complications.With regard to short-term follow-up, analysis of outcomes is limited; in any case, we have never had any cases of MESH erosion or other complications, and no sexually active woman complained of dyspareunia. Maintaining sufficient motility of the vagina is another advantage of 'Cupid and Psyche', avoiding as it does any negative effects on patients' later sexual activity, granting more natural motility of both uterus and vagina but resolving the prolapse.Further prospective studies comparing the long-term functional outcomes of the various HSP techniques are needed to confirm these findings.

Laparoscopic hysteropexy: the initial results of a uterine suspension procedure for uterovaginal prolapse.

PubMed

Price, Natalia; Slack, A; Jackson, S R

2010-01-01

The aim of this study was to evaluate the outcome of laparoscopic hysteropexy, a surgical technique for the management of uterine prolapse, involving suspension of the uterus from the sacral promontory using bifurcated polypropylene mesh. The investigation was designed as a prospective observational study (clinical audit). The study was undertaken at a tertiary referral urogynaecology unit in the UK. The participants comprised 51 consecutive women with uterovaginal prolapse, who chose laparoscopic hysteropexy as one of the available surgical options. The hysteropexy was conducted laparoscopically in all cases. A bifurcated polypropylene mesh was used to suspend the uterus from the sacral promontory. The two arms of the mesh were introduced through bilateral windows created in the broad ligaments, and were sutured to the anterior cervix; the mesh was then fixed to the anterior longitudinal ligament over the sacral promontory, to elevate the uterus. Cure of the uterine prolapse was evaluated subjectively using the International Consultation on Incontinence Questionnaire for vaginal symptoms (ICIQ-VS), and objectively by vaginal examination using the Baden-Walker halfway system and the pelvic organ prolapse quantification (POP-Q) scale. Operative and postoperative complications were also assessed. The mean age of the 51 women was 52.5 years (range 19-71 years). All were sexually active, and at least three of them expressed a strong desire to have children in the future. All were available for follow-up in clinic at 10 weeks, and 38 have completed the questionnaires. In 50 out of 51 women the procedure was successful, with no objective evidence of uterine prolapse on examination at follow-up; there was one failure. Significant subjective improvements in prolapse symptoms, sexual wellbeing and related quality of life were observed, as detected by substantial reductions in the respective questionnaire scores. Laparoscopic hysteropexy is both a feasible and an effective procedure for correcting uterine prolapse without recourse to hysterectomy. It allows restoration of the length of the vagina without compromising its calibre, and is therefore likely to have a favourable functional outcome.

Rectal prolapse repair - series (image)

MedlinePlus

... the body through the anus. The rectum is anchored in position by ligaments. When these ligaments weaken, the rectum can move out of its normal position, downward, and pass through the anus. This is called rectal prolapse.

Regional variation in tissue composition and biomechanical properties of postmenopausal ovine and human vagina.

PubMed

Ulrich, Daniela; Edwards, Sharon L; Letouzey, Vincent; Su, Kai; White, Jacinta F; Rosamilia, Anna; Gargett, Caroline E; Werkmeister, Jerome A

2014-01-01

There are increasing numbers of reports describing human vaginal tissue composition in women with and without pelvic organ prolapse with conflicting results. The aim of this study was to compare ovine and human posterior vaginal tissue in terms of histological and biochemical tissue composition and to assess passive biomechanical properties of ovine vagina to further characterise this animal model for pelvic organ prolapse research. Vaginal tissue was collected from ovariectomised sheep (n = 6) and from postmenopausal women (n = 7) from the proximal, middle and distal thirds. Tissue histology was analyzed using Masson's Trichrome staining; total collagen was quantified by hydroxyproline assays, collagen III/I+III ratios by delayed reduction SDS PAGE, glycosaminoglycans by dimethylmethylene blue assay, and elastic tissue associated proteins (ETAP) by amino acid analysis. Young's modulus, maximum stress/strain, and permanent strain following cyclic loading were determined in ovine vagina. Both sheep and human vaginal tissue showed comparable tissue composition. Ovine vaginal tissue showed significantly higher total collagen and glycosaminoglycan values (p<0.05) nearest the cervix. No significant differences were found along the length of the human vagina for collagen, GAG or ETAP content. The proximal region was the stiffest (Young's modulus, p<0.05), strongest (maximum stress, p<0.05) compared to distal region, and most elastic (permanent strain). Sheep tissue composition and mechanical properties showed regional differences along the postmenopausal vaginal wall not apparent in human vagina, although the absolute content of proteins were similar. Knowledge of this baseline variation in the composition and mechanical properties of the vaginal wall will assist future studies using sheep as a model for vaginal surgery.

Alteration of apoptosis-related genes in postmenopausal women with uterine prolapse.

PubMed

Saatli, Bahadir; Kizildag, Sefa; Cagliyan, Erkan; Dogan, Erbil; Saygili, Ugur

2014-07-01

We aimed to compare expression levels of antiapoptotic and proapoptotic genes in parametrial and vaginal tissues from postmenopausal women with and without pelvic organ prolapse (POP). We hypothesized that the expression of genes that induce apoptosis may be altered in vaginal and parametrial tissues in postmenopausal women with POP. Samples of vaginal and parametrial tissues were obtained from postmenopausal women with (n = 10) and without (n = 10) POP who underwent vaginal or abdominal hysterectomy. Expression levels of antiapoptotic (BCL-2, BCL-XL) and proapoptotic (BAX, BAD) genes were studied by real-time reverse-transcription polymerase chain reaction (RT-PCR). Gene expression levels of BCL-2 (P < 0.001), BCL-XL (P < 0.001), BAX (p = 0.001), and BAD (p = 0.004) were all higher in vaginal tissues from the POP group compared with the non-POP group. Similarly, gene expression levels of BCL-2 (p < 0.001), BCL-XL (p < 0.001), BAX (p < 0.001), and BAD (p < 0.001) in parametrial tissues were also significantly higher in the POP group compared with the non-POP group. Additionally, expression levels of BCL-2 (p = 0.05), BCL-XL (p < 0.05), BAX (p = 0.05), and BAD (p = 0.07) in the POP group were higher in parametrial tissue than in vaginal tissue samples. Antiapoptotic and proapoptotic gene expression levels differed significantly between postmenopausal women with and without POP. Bcl-2 family genes were overexpressed in the parametrium of patients with POP compared with vaginal tissue, suggesting that the processes responsible for POP have a greater effect on parametrial tissue than vaginal tissue during the development of POP.

The epidemiology of pelvic floor disorders and childbirth: an update

PubMed Central

Hallock, Jennifer L.; Handa, Victoria L.

2015-01-01

SYNOPSIS Using a life span model, this article presents new scientific findings regarding risk factors for pelvic floor disorders (PFDs), with a focus on the role of childbirth in the development of single or multiple co-existing PFDs. Phase I of the life span model includes predisposing factors such as genetic predisposition and race. Phase II of the model includes inciting factors such as obstetric events. Prolapse, urinary incontinence (UI) and fecal incontinence (FI) are more common among vaginally parous women, although the impact of vaginal delivery on risk of FI is less dramatic than for prolapse and UI. Finally, Phase III includes intervening factors such as age and obesity. Both age and obesity are associated with prevalence of PFDs. The prevention and treatment of obesity is an important component to PFD prevention. PMID:26880504

Robotic artificial chordal replacement for repair of mitral valve prolapse.

PubMed

Brunsting, Louis A; Rankin, J Scott; Braly, Kimberly C; Binford, Robert S

2009-07-01

Artificial chordal replacement (ACR) has emerged as a superior method of mitral valve repair with excellent early and late efficacy. It is also ideal to combine with robotic techniques for correction of mitral prolapse, and this article presents a current method of robotic Gore-Tex ACR. Patients with isolated posterior leaflet prolapse are approached with the fourth-generation DaVinci robotic system and endoaortic balloon occlusion. A pledgetted anchor stitch is placed in a papillary muscle, and a 2-o Gore-Tex suture is passed through the anchor pledget. After full annuloplasty ring placement, the Gore-Tex suture is woven into the prolapsing segment and positioned temporarily with robotic forceps. Chordal length is then "adjusted" by lengthening or shortening the temporary knot over 1-cm increments as the valve is tested by injection of cold saline into the ventricle. After achieving good leaflet position and valve competence, the chord is tied permanently. The "adjustable" ACR procedure preserves leaflet surface area and produces a competent valve in the majority of patients. Postoperative transesophageal echo shows a large surface area of coaptation. Patient recovery is facilitated by the minimally invasive approach, while long-term stability of similar open ACR techniques have been excellent with a 2% to 3% failure rate over 10 years of follow-up. Robotic Gore-Tex ACR without leaflet resection is a reproducible procedure that simplifies mitral repair for prolapse. The outcomes observed in early robotic applications have been excellent. It is suggested that most patients with simple prolapse might validly be approached in this manner.

[Anatomy of the levator ani muscle and implications for obstetrics and gynaecology].

PubMed

Nyangoh Timoh, K; Bessede, T; Zaitouna, M; Peschaud, F; Chevallier, J-M; Fauconnier, A; Benoit, G; Moszkowicz, D

2015-01-01

Pelvic floor disorders include urogenital and anorectal prolapse, urinary and faecal incontinence. These diseases affect 25% of patients. Most of time, treatment is primarily surgical with a high post-operative risk of recurrence, especially for pelvic organ prolapse. Vaginal delivery is the major risk factor for pelvic floor disorders through levator ani muscle injury or nerve damage. After vaginal delivery, 20% of patients experiment elevator ani trauma. These injuries are more common in case of instrumental delivery by forceps, prolonged second phase labor, increased neonatal head circumference and associated anal sphincter injuries. Moreover, 25% of patients have temporary perineal neuropathy. Recently, pelvic three-dimensional reconstructions from RMI data allowed a better understanding of detailed levator ani muscle morphology and gave birth to a clear new nomenclature describing this muscle complex to be developed. Radiologic and anatomic studies have allowed exploring levator ani innervation leading to speculate on the muscle and nerve damage mechanisms during delivery. We then reviewed the levator ani muscle anatomy and innervation to better understand pelvic floor dysfunction observed after vaginal delivery. Copyright © 2015. Published by Elsevier SAS.

Treatment strategies for pelvic organ prolapse: a cost-effectiveness analysis.

PubMed

Hullfish, Kathie L; Trowbridge, Elisa R; Stukenborg, George J

2011-05-01

To compare the relative cost effectiveness of treatment decision alternatives for post-hysterectomy pelvic organ prolapse (POP). A Markov decision analysis model was used to assess and compare the relative cost effectiveness of expectant management, use of a pessary, and surgery for obtaining months of quality-adjusted life over 1 year. Sensitivity analysis was conducted to determine whether the results depended on specific estimates of patient utilities for pessary use, probabilities for complications and other events, and estimated costs. Only two treatment alternatives were found to be efficient choices: initial pessary use and vaginal reconstructive surgery (VRS). Pessary use (including patients that eventually transitioned to surgery) achieved 10.4 quality-adjusted months, at a cost of $10,000 per patient, while VRS obtained 11.4 quality-adjusted months, at $15,000 per patient. Sensitivity analysis demonstrated that these baseline results depended on several key estimates in the model. This analysis indicates that pessary use and VRS are the most cost-effective treatment alternatives for treating post-hysterectomy vaginal prolapse. Additional research is needed to standardize POP outcomes and complications, so that healthcare providers can best utilize cost information in balancing the risks and benefits of their treatment decisions.

[The Life Impacts and Symptom Distress in Women With Pelvic Organ Prolapse Syndrome Before Pelvic Reconstruction Surgery].

PubMed

Ko, I-Chen; Lo, Tsia-Shu; Lu, Yu-Ying; Tsao, Lee-Ing

2017-02-01

The decision whether or not to undergo pelvic reconstructive surgery is difficult for women suffering from pelvic organ prolapse. However, little research has examined the symptom distress and life impacts that these women face prior to this surgery. Thus, it is crucial that gynecology nurses learn about these life impacts and symptom distresses in order to help these women make the best decisions with regard to surgery. To explore the life impacts and degree of symptom distress in pre-surgery women with pelvic organ prolapse; to explore the relationships between demographic data and the variables of life impact and degree of symptom distress; and to identify the factors that relate to the explainable variance in the life impacts of these women. A cross-sectional and correlational research design was used and a total of 110 women with pelvic organ prolapse who had not yet undergone pelvic reconstruction surgery were recruited in the gynecological clinics of one medical center in Taiwan. Daytime urination frequency was the most prevalent urinary tract symptom noted by the participants; vaginal protrusion was the most prevalent pelvis-related symptom noted; and depression and anxiety were the most prevalent life impacts noted. Moreover, greater lower-urinary-tract symptom distress was associated with greater pelvic-symptom distress. Furthermore, greater lower urinary tract and pelvic symptom distresses were associated with a greater negative impact on life. Education background and pelvis-related symptoms were the explained variances in pre-surgery life impacts. Women with pelvic organ prolapse should pay particular attention to symptoms that include: daytime urinary frequency, vaginal protrusion, and emotional problems including depression and anxiety. Education background and level of symptom distress should be taken into consideration when caring for the life impacts of this vulnerable group of women.

Forceps delivery is associated with increased risk of pelvic organ prolapse and muscle trauma: a cross-sectional study 16-24 years after first delivery.

PubMed

Volløyhaug, I; Mørkved, S; Salvesen, Ø; Salvesen, K Å

2015-10-01

To study possible associations between mode of delivery and pelvic organ prolapse (POP) and pelvic floor muscle trauma 16-24 years after first delivery and, in particular, to identify differences between forceps and vacuum delivery. This was a cross-sectional study including 608 women who delivered their first child in 1990-1997 and were examined with POP quantification (POP-Q) and pelvic floor ultrasound in 2013-2014. Outcome measures were POP ≥ Stage 2 or previous prolapse surgery, levator avulsion and levator hiatal area on Valsalva. Univariable and multivariable logistic regression analyses and ANCOVA were applied to identify outcome variables associated with mode of delivery. Comparing forceps to vacuum delivery, the adjusted odds ratios (aOR) were 1.72 (95% CI, 1.06-2.79; P = 0.03) for POP ≥ Stage 2 or previous prolapse surgery and 4.16 (95% CI, 2.28-7.59; P < 0.01) for levator avulsion. Hiatal area on Valsalva was larger, with adjusted mean difference (aMD) of 4.75 cm(2) (95% CI, 2.46-7.03; P < 0.01). Comparing forceps with normal vaginal delivery, the adjusted odds ratio (aOR) was 1.74 (95% CI, 1.12-2.68; P = 0.01) for POP ≥ Stage 2 or surgery and 4.35 (95% CI, 2.56-7.40; P < 0.01) for levator avulsion; hiatal area on Valsalva was larger, with an aMD of 3.84 cm(2) (95% CI, 1.78-5.90; P < 0.01). Comparing Cesarean delivery with normal vaginal delivery, aOR was 0.06 (95% CI, 0.02-0.14; P < 0.01) for POP ≥ Stage 2 or surgery and crude OR was 0.00 (95% CI, 0.00-0.30; P < 0.01) for levator avulsion; hiatal area on Valsalva was smaller, with an aMD of -8.35 cm(2) (95% CI, -10.87 to -5.84; P < 0.01). No differences were found between vacuum and normal vaginal delivery. We found that mode of delivery was associated with POP and pelvic floor muscle trauma in women from a general population, 16-24 years after their first delivery. Forceps was associated with significantly more POP, levator avulsion and larger hiatal areas than were vacuum and normal vaginal deliveries. There were no statistically significant differences between vacuum and normal vaginal deliveries. Cesarean delivery was associated with significantly less POP and pelvic floor muscle trauma than were normal or operative vaginal delivery. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Diagnosis of cystocele--the correlation between clinical and radiological evaluation.

PubMed

Altman, Daniel; Mellgren, Anders; Kierkegaard, Jonas; Zetterström, Jan; Falconer, Christian; López, Annika

2004-01-01

In patients with genital prolapse involving several compartments simultaneously, radiologic investigation can be used to complement the clinical assessment. Contrast medium in the urinary bladder enables visualization of the bladder base at cystodefecoperitoneography (CDP). The aim of the present study was to evaluate the correlation between clinical examination using the Pelvic Organ Prolapse Quantification system (POP-Q) and CDP. Thirty-three women underwent clinical assessment and CDP. Statistical analysis using Pearson's correlation coefficient ( r) demonstrated a wide variability between the current definition of cystocele at CDP and POP-Q ( r=0.67). An attempt to provide an alternative definition of cystocele at CDP had a similar outcome ( r=0.63). The present study demonstrates a moderate correlation between clinical and radiologic findings in patients with anterior vaginal wall prolapse. It does not support the use of bladder contrast at radiologic investigation in the routine preoperative assessment of patients with genital prolapse.

Interlabial masses in little girls: review and imaging recommendations

DOE Office of Scientific and Technical Information (OSTI.GOV)

Nussbaum, A.R.; Lebowitz, R.L.

1983-07-01

When an interlabial mass is seen on physical examination in a little girl, there is often confusion about its etiology, its implications, and what should be done next. Five common interlabial masses, which superficially are strikingly similar, include a prolapsed ectopic ureterocele, a prolapsed urethra, a paraurethral cyst, hydro(metro)colpos, and rhabdomyosarcoma of the vagina (botryoid sarcoma). A prolapsed ectopic ureterocele occurs in white girls as a smooth mass which protrudes from the urethral meatus so that urine exits circumferentially. A prolapsed urethra occurs in black girls and resembles a donut with the urethral meatus in the center. A paraurethral cystmore » is smaller and displaces the meatus, so that the urinary stream is eccentric. Hydro(metro)colpos from hymenal imperforation presents as a smooth mass that fills the vaginal introitus, as opposed to the introital grapelike cluster of masses of botryoid sarcoma. Recommendations for efficient imaging are presented.« less

Preoperative Prolapse Stage as Predictor of Failure of Sacrocolpopexy.

PubMed

Aslam, Muhammad F; Osmundsen, Blake; Edwards, Sharon R; Matthews, Catherine; Gregory, William T

2016-01-01

Our aim was to determine if there was a correlation between the preoperative prolapse stage and postoperative recurrence of prolapse 1 year after sacrocolpopexy. Our null hypothesis is that the preoperative stage of prolapse does not increase the risk of recurrence. This is a multicenter cohort study from 3 centers. We included subjects who underwent robotic-assisted sacrocolpopexy and completed a standardized 1-year follow-up from 2009-2014. All subjects underwent a complete preoperative evaluation and completed 12 months of follow-up with the pelvic organ prolapse quantification examination. We compared those subjects who met the definition of recurrence with those who did not, analyzing the following covariates: stage of prolapse using International Continence Society (ICS) definitions, individual pelvic organ prolapse quantification points, age, body mass index, race, exogenous estrogen use, menopause, smoking, vaginal parity, cesarean section, and performance of concomitant procedures. We defined recurrence as any prolapse beyond the hymen. We had 125 women from 3 centers who met our criteria, with 23.2% of them having recurrence at 1 year. We found that recurrence increased as the preoperative ICS stage of prolapse increased (P = <0.001 in the univariate model). In the multivariate model, using logistic regression, we found that the risk of recurrence of pelvic organ prolapse increased as the presurgery clinical stage increased with an odds ratio of 3.8 (95% confidence interval, 1.5-9) when controlling for age, menopausal status, and genital hiatus (P = 0.004). Much like a higher stage of disease in oncology, we found that increasing stage of prolapse preoperatively increased the risk of recurrence at 1 year after sacrocolpopexy.

Synthetic mesh in the surgical repair of pelvic organ prolapse: current status and future directions.

PubMed

Keys, Tristan; Campeau, Lysanne; Badlani, Gopal

2012-08-01

In light of the recent Food and Drug Administration public health notification regarding complications associated with transvaginally placed mesh for pelvic organ prolapse (POP) repair, we review recent literature to evaluate current outcomes and complication data, analyze the clinical need for mesh on the basis of genetic and biochemical etiologies of POP, and investigate trends of mesh use via an American Urological Association member survey. Mesh-based techniques show better anatomic results than traditional repair of anterior POP, but subjective outcomes are equivalent. Further research and Level I evidence are required before mesh-based repair of POP can be standardized. Adequate surgical training and patient selection should decrease complication rates. Published by Elsevier Inc.

[Traumatically caused prolapse of the vaginal mucosa and retroflexion of the bladder in the bitch].

PubMed

Arbeiter, K; Bucher, A

1994-02-01

Four years after having been heavily injured in the perineal region by a firearm the presented bitch showed dysuria and signs of intense irritation. Clinical and radiological examinations revealed the fact of a partial loss of the vaginal channel and supporting tissues, consequently leading to a retroflexion of the bladder into the extroverted part of the vagina. The bitch recovered completely after a plastic operation.

A simple teaching tool for training the pelvic organ prolapse quantification system.

PubMed

Geiss, Ingrid M; Riss, Paul A; Hanzal, Engelbert; Dungl, Andrea

2007-09-01

The pelvic organ prolapse quantification (POPQ) system is currently the most common and specific system describing different prolapse stages. Nevertheless, its use is not yet accepted worldwide in routine care. Our aim was to develop a simple teaching tool for the POPQ system capable of simulating different stages of uterovaginal prolapse for use in medical education with hands on training. We constructed a moveable and flexible tool with an inverted Santa Claus' cap, which simulated the vaginal cuff and the tassel at the end representing the cervix. A wooden embroidery frame fixed the cap and served as the hymen, the reference point for all measurements. Inside the cap, we sewed buttons to define the anatomic landmark points Aa and Ap located 3 cm distal from the frame. After explaining the device to the students, we used the three-by-three grid for recording the quantitative description of the pelvic organ support. First, each student had to demonstrate a specific prolapse with his cap device. Then, a prolapse was simulated on the cap, and the student had to take the relevant measurements and record them in the POPQ grid. The main training effect to understand the POPQ system seems to be the possibility for each trainee to simulate a three-dimensional prolapse with this flexible vagina model.

Surgical Updates in the Treatment of Pelvic Organ Prolapse.

PubMed

Geynisman-Tan, Julia; Kenton, Kimberly

2017-04-28

Pelvic organ prolapse affects approximately 8% of women, and the demand for pelvic organ prolapse surgery is expected to increase by nearly 50% over the next 40 years. The surgical techniques used to correct pelvic organ prolapse have evolved over the last 10 years, with multiple well-designed studies addressing the risks, outcomes, reoperation rates, and optimal surgical approaches. Here we review the most recent evidence on the route of access, concomitant procedures, and synthetic materials for augmenting the repair. Ultimately, this review highlights that there is no optimal method for correcting pelvic organ prolapse and that the risks, benefits, and approaches should be discussed in a patient-centered, goal-oriented approach to decision-making.

A novel approach to mesh revision after sacrocolpopexy.

PubMed

Dawson, Melissa L; Rebecca, Rinko; Shah, Nima M; Whitmore, Kristene E

2016-01-01

Pelvic organ prolapse (POP) is the herniation of pelvic organs to or beyond the vaginal walls. POP affects 50% of parous women; of those women, 11% will need surgery based on bothersome symptoms. Transvaginal mesh has been used for vaginal augmentation since the 1990s. Complications from mesh use are now more prominent, and include chronic pelvic pain, dyspareunia, vaginal mesh erosion, and urinary and defecatory dysfunction. Presently, there is no consensus regarding treatment of these complications. Reported herein are two cases of women with defecatory dysfunction and pain after sacrocolpopexy who underwent mesh revision procedures performed with both urogynecologic and colorectal surgery.

Experimental study and constitutive modeling of the viscoelastic mechanical properties of the human prolapsed vaginal tissue.

PubMed

Peña, Estefania; Calvo, B; Martínez, M A; Martins, P; Mascarenhas, T; Jorge, R M N; Ferreira, A; Doblaré, M

2010-02-01

In this paper, the viscoelastic mechanical properties of vaginal tissue are investigated. Using previous results of the authors on the mechanical properties of biological soft tissues and newly experimental data from uniaxial tension tests, a new model for the viscoelastic mechanical properties of the human vaginal tissue is proposed. The structural model seems to be sufficiently accurate to guarantee its application to prediction of reliable stress distributions, and is suitable for finite element computations. The obtained results may be helpful in the design of surgical procedures with autologous tissue or prostheses.

Pelvic floor symptoms and severity of pelvic organ prolapse in women seeking care for pelvic floor problems.

PubMed

Espuña-Pons, Montserrat; Fillol, Manuel; Pascual, María A; Rebollo, Pablo; Mora, Ana M

2014-06-01

The aim of the study was to estimate whether POP severity is related to lower urinary tract symptoms (LUTS) and symptoms of sexual difficulties, when evaluated with validated questionnaires. Multicentric cross-sectional study of 521 women seeking care for PFD in 35 specialized urogynecological clinics. Patients answered the EPIQ to detect symptoms of PFD. The severity of urinary incontinence and the OAB symptoms were measured by ICIQ-UI SF and BSAQ. POP anatomic severity was measured by the anatomic stage of each compartment, determined in pelvic examination in accordance with the IUGA-ICS terminology. A maximum POP stage (M-POP-S) was assigned to each patient: Group A, patients with no POP (stage 0-I); group B, M-POP-S stage II; and group C, M-POP-S stage III-IV. Pelvic examination demonstrated anatomic POP in 224 patients (stage from II to IV). 288 women (56.25%) were classified in group A (no prolapse); 102 (19.92%) group B (stage II); and 122 (28.83%) group C (stage III-IV). Several associations were found between studied variables and M-POP-S (age<55 years, menopause, number of vaginal deliveries, symptom of vaginal bulge, feeling of a bulge makes it difficult to have sexual relations, symptoms of stress urinary incontinence, nocturia and voiding difficulties), but the only variables independently associated were age, symptom of vaginal bulge and difficulty in having sexual relations due to feeling of a bulge. In patients seeking care for PFD, LUTS are not independently associated to the prolapse stage. Copyright © 2014. Published by Elsevier Ireland Ltd.

A case of pelvic organ prolapse in the setting of cirrhotic ascites.

PubMed

Shah, Nima M; Ginzburg, Natasha; Whitmore, Kristene

2016-01-01

Ascites is commonly found in patients with liver cirrhosis. Although conservative therapy is often the ideal choice of care with these patients who also have symptomatic pelvic organ prolapse, this may fail and surgical methods may be needed. Literature is limited regarding surgical repair of prolapse in the setting of ascites. The authors present the surgical evaluation and management of a 63-year-old woman with recurrent ascites from liver cirrhosis who failed conservative therapy. With adequate multidisciplinary care and medical optimization, this patient underwent surgical therapy with resolution of her symptomatic prolapse and improved quality of life.

Biomechanical paradigm and interpretation of female pelvic floor conditions before a treatment

PubMed Central

Lucente, Vincent; van Raalte, Heather; Murphy, Miles; Egorov, Vladimir

2017-01-01

Background Further progress in restoring a woman’s health may be possible if a patient with a damaged pelvic floor could undergo medical imaging and biomechanical diagnostic tests. The results of such tests could contribute to the analysis of multiple treatment options and suggest the optimal one for that patient. Aim To develop a new approach for the biomechanical characterization of vaginal conditions, muscles, and connective tissues in the female pelvic floor. Methods Vaginal tactile imaging (VTI) allows biomechanical assessment of the soft tissue along the entire length of the anterior, posterior, and lateral vaginal walls at rest, with manually applied deflection pressures and with muscle contraction, muscle relaxation, and Valsalva maneuver. VTI allows a large body of measurements to evaluate individual variations in tissue elasticity, support defects, as well as pelvic muscle function. Presuming that 1) the female pelvic floor organs are suspended by ligaments against which muscles contract to open or close the outlets and 2) damaged ligaments weaken the support and may reduce the force of muscle contraction, we made an attempt to characterize multiple pelvic floor structures from VTI data. Results All of the 138 women enrolled in the study were successfully examined with the VTI. The study subjects have had normal pelvic support or pelvic organ prolapse (stages I–IV). The average age of this group of subjects was 60±15 years. We transposed a set of 31 VTI parameters into a quantitative characterization of pelvic muscles and ligamentous structures. Interpretation of the acquired VTI data for normal pelvic floor support and prolapse conditions is proposed based on biomechanical assessment of the functional anatomy. Conclusion Vaginal tactile imaging allows biomechanical characterization of female pelvic floor structures and tissues in vivo, which may help to optimize treatment of the diseased conditions such as prolapse, incontinence, atrophy, and some forms of pelvic pain. PMID:28831274

Ultrasound in the investigation of posterior compartment vaginal prolapse and obstructed defecation.

PubMed

Dietz, H P; Beer-Gabel, M

2012-07-01

Recent developments in diagnostic imaging have made gynecologists, colorectal surgeons and gastroenterologists realize as never before that they share a common interest in anorectal and pelvic floor dysfunction. While we often may be using different words to describe the same phenomenon (e.g. anismus/vaginismus) or attributing different meanings to the same words (e.g. rectocele), we look after patients with problems that transcend the borders of our respective specialties. Like no other diagnostic modality, imaging helps us understand each other and provides new insights into conditions we all need to learn to investigate better in order to improve clinical management. In this review we attempt to show what modern ultrasound imaging can contribute to the diagnostic work-up of patients with posterior vaginal wall prolapse, obstructed defecation and rectal intussusception/prolapse. In summary, it is evident that translabial/perineal ultrasound can serve as a first-line diagnostic tool in women with such complaints, replacing defecation proctography and MR proctography in a large proportion of female patients. This is advantageous for the women themselves because ultrasound is much better tolerated, as well as for healthcare systems since sonographic imaging is much less expensive. However, there is a substantial need for education, which currently remains unmet. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

[Vaginal mesh operations in the urogynecological practice after the FDA warnings. Use or not to use mesh?

PubMed

Fekete, Zoltán; Körösi, Szilvia; Németh, Gábor

2018-03-01

The prevalence of pelvic organ prolapse (POP) with aging is escalating alarmingly, and now becoming a growing epidemic among the elderly. Synthetic transvaginal mesh (TVM) has been employed with increasing popularity in the treatment of POP until the end of the last decade. After the U.S. Drug and Food Administration (FDA) warnings in the years 2008 and 2011, the number of vaginal mesh operations has decreased dramatically. The aim of the study was to evaluate and compare the anti-POP effectivity, the anti-stress incontinence (anti-SUI) efficacy, and the late (36 months) post-operative complications of the anterior vaginoplasty and the TVM operations. We analysed the clinical data from 120 patients with stage II-III anterior prolapse and concomitant SUI who had undergone surgery at a tertiary referral centre in Hungary between January 2013 and January 2014. Sixty patients underwent Kelly-Stoeckel vaginoplasty and the other 60 cases had TVM operation. The surgical complications were classified using the Clavien-Dindo (CD) classification system. The anti-POP (91.6% vs. 63.3%; p<0.001) and the anti-SUI efficacy (90% vs. 55%, p<0.001) were significantly higher in the TVM group than in the vaginoplasty group, while the overall extrusion rate was found 8.3% after a 3-year follow-up. The Clavien-Dindo score (CD) proved that the early post-operative complication profile was similar among the TVM patients as compared to the vaginoplasty group (p = 0.405). Vaginal mesh surgery represents an effective procedure for prolapse and concomitant SUI with a decreased risk of short- and long-term complications. Orv Hetil. 2018; 159(10): 397-404.

Hemorrhoidal artery ligation (HAL) and rectoanal repair (RAR): retrospective analysis of 408 patients in a single center.

PubMed

Scheyer, M; Antonietti, E; Rollinger, G; Lancee, S; Pokorny, H

2015-01-01

Rectoanal repair (RAR), which combines doppler-guided hemorrhoidal artery ligation (HAL) and mucopexy via lifting of the hemorrhoidal prolapse, offers a minimally invasive alternative to conventional hemorrhoidectomy. Patients with grade II hemorrhoids were treated with HAL, and patients with grade III and IV hemorrhoids were treated with the RAR procedure by two surgeons. Postoperative follow-up was performed clinically and by proctoscopy after 8 weeks routinely, and long-term follow-up was performed using a standardized postal questionnaire. The overall complication rate was 29% (n = 118). After short-term follow-up, 26% (n = 106) of patients reported recurrent or persistent prolapsing piles, while 21% (n = 86) of patients had recurrent bleeding. After long-term follow-up, 24% (n = 98) of patients reported prolapsing piles, 3% (n = 12) bleeding, 3% (n = 12) pruritus, and 2% (n = 8) anal pain, while 20% (n = 82) complained of persistent mixed symptoms. HAL and RAR provide prolonged relief for patients with hemorrhoidal disease whose main symptoms are bleeding, pruritus and pain but not for patients with prolapse as an initial indication.

Anterior vaginal wall repair (surgical treatment of urinary incontinence) - slideshow

MedlinePlus

... page: //medlineplus.gov/ency/presentations/100110.htm Anterior vaginal wall repair (surgical treatment of urinary incontinence) - series— ... to slide 4 out of 4 Overview The vaginal opening lies just below the urethral opening, and ...

Laparoscopic promontofixation for pelvic organ prolapse: a 10-year single center experience in a series of 501 patients.

PubMed

Bacle, Julien; Papatsoris, Athanasios G; Bigot, Pierre; Azzouzi, Abdel-Rahmene; Brychaet, Pierre-Emmanuel; Piussan, Jean; Mandron, Eric

2011-12-01

To assess the long-term outcomes of laparoscopic promontofixation (LP) for the treatment of pelvic organ prolapse (POP). A total of 501 consecutive patients with POP were included in this prospective study. The patients' mean age was 63.23 (36-90) years, their mean body mass index was 25.14 (15-36) and their mean number of deliveries was 3.3 (0-14). A POP grade ≥3 was diagnosed in 70.4% of the patients and 38.9% of them had a history of abdominal surgery. The patients underwent a Bonney test and urodynamic study. In cases of stress urinary incontinence (SUI), the patients underwent the simultaneous insertion of a tension-free vaginal tape. A prolapse quality of life questionnaire was sent to all patients. The mean operative time was 97.4 min (50-210) and there were 1.7% cases of intra-operative complications. The mean hospitalization time was 3.7 days (1-13 days). During the mean follow-up of 20.7 months (3-120), 91 (17.8%) complications were recorded, including constipation (5.5%), SUI (3.5%), vaginal erosion (2.4%), and urge incontinence (2%). Recurrences were recorded in 11.5% of the patients within an average time of 37.2 months. Risk factors for recurrence were the use of the polypropylene mesh compared with the polyester mesh (P<0.0001), an intra-operative hysterectomy (P=0.02), and bleeding (P=0.049). There was a statistical significant (P<0.001) improvement in most of the symptoms in the prolapse quality of life questionnaire. LP is safe with effective long-term results, with low recurrence and morbidity rates, and a good quality of life. © 2011 The Japanese Urological Association.

Estrogen receptor expression and vessel density in the vagina wall in postmenopausal women with prolapse.

PubMed

Lara, Lúcia Alves da Silva; Ribeiro da Silva, Alfredo; Rosa-e-Silva, Julio Cesar; Silva-de-Sá, Marcos Felipe; Rosa-e-Silva, Ana Carolina Japur de Sá

2014-04-01

After menopause, critically estrogen low levels result in modifications in vaginal wall. This cross-sectional study aims to determine whether there is a change in the number of vessels in the lamina propria of the vagina after menopause in parallel to the ER-alpha expression on the vaginal wall. Twelve women who underwent a genital surgery for genital prolapse up to grade II were selected. They were divided into two groups: a premenopausal group (PG) consisting of six women who were 18-40 years old with FSH levels =12 mIU/ml and regular cycles, and a menopausal group (MG) consisting of six women at least one year after menopause who were <65 years old with FSH levels =40 mIU/ml. Slides were stained for ER-alpha immunohistochemistry, and an endothelial cell marker CD3 was used to label vessels which were identified by using a system for morphometry. The number of vessels was significantly higher in the PG than in the MG both on the anterior wall (PG: 1.055 ± 145.8 vessels/mm(2), MG: 346.6 ± 209.9 vessels/mm(2), p<0.0001) and on the posterior wall (PG: 1064 ± 303.3 vessels/mm(2), MG: 348.6 ± 167.3 vessels/mm(2), p=0.0005). The ER-alpha score was significantly higher in the PG than the score for the MG on both the anterior and posterior walls (PG: 6.0 ± 0.52, MG: 2.5 ± 0.89, p=0.007; PG: 5.8 ± 0.79, MG: 2.7 ± 0.95, p=0.03, respectively). There was a positive correlation between the ER-alpha score and the vessel concentration on the anterior (r=0.6656, p=0.018) and posterior (r=0.6738, p=0.016) vaginal walls. Age was strongly negatively correlated with vessel concentration on the vaginal walls (respectively r=-0.9033, p<0.0001, r=-0.7440, p=0.0055). Therefore, postmenopausal women with genital prolapse have a smaller number of vessels on the vaginal wall compared to normoestrogenic controls with the same pathological condition. Hypoestrogenism and advancing age are factors that are associated to these changes. Copyright © 2014 Elsevier Ltd. All rights reserved.

Reproductive history and progression of lower urinary tract symptoms in women: results from a population-based cohort study.

PubMed

Maserejian, Nancy N; Curto, Teresa; Hall, Susan A; Wittert, Gary; McKinlay, John B

2014-04-01

To examine whether reproductive history and related conditions are associated with the development and persistence of lower urinary tract symptoms (LUTS) other than urinary incontinence in a racially and/or ethnically diverse population-based sample of women. The Boston Area Community Health Survey enrolled 3201 women aged 30-79 years of black, Hispanic, or white race and/or ethnicity. Baseline and 5-year follow-up interviews were completed by 2534 women (conditional response rate, 83.4%). The association between reproductive history factors and population-weighted estimates of LUTS progression and persistence was tested using multivariable logistic regression models. Between baseline and 5-year follow-up, 23.9% women had LUTS progression. In age-adjusted models, women who had delivered ≥2 childbirths had higher odds of LUTS progression, but the association was completely accounted for by vaginal child delivery (eg, 2 vaginal childbirths vs none, multivariable-adjusted odds ratio = 2.21; 95% CI, 1.46-3.35; P <.001). No increased odds of LUTS progression were found for women with only 1 vaginal delivery or who only had cesarean section(s). Uterine prolapse was associated with higher odds of LUTS progression (multivariable-adjusted odds ratio = 3.05; 95% CI, 1.43-6.50; P = .004). Gestational diabetes was associated with approximately twice the odds of LUTS progression, but only among younger women (interaction P = .003). In this cohort study, ≥2 vaginal child deliveries, uterine prolapse, and among younger women, gestational diabetes were robust predictors of LUTS progression. Clinicians should assess the presence of bothersome urinary frequency, urgency, and voiding symptoms among women who have had multiple vaginal childbirths or gestational diabetes. Copyright © 2014 Elsevier Inc. All rights reserved.

Perineal colostomy prolapse: a novel application of mesh sacral pexy.

PubMed

Landen, S; Ursaru, D; Delugeau, V; Landen, C

2018-01-01

Full thickness colonic prolapse following pseudocontinent perineal colostomy has not been previously reported. Possible contributing factors include a large skin aperture at the site of the perineal stoma, the absence of anal sphincters and mesorectal attachments and the presence of a perineal hernia. A novel application of sacral pexy combined with perineal hernia repair using two prosthetic meshes is described.

Multiplanar visualization in 3D transthoracic echocardiography for precise delineation of mitral valve pathology.

PubMed

Kuppahally, Suman S; Paloma, Allan; Craig Miller, D; Schnittger, Ingela; Liang, David

2008-01-01

A novel multiplanar reformatting (MPR) technique in three-dimensional transthoracic echocardiography (3D TTE) was used to precisely localize the prolapsed lateral segment of posterior mitral valve leaflet in a patient symptomatic with mitral valve prolapse (MVP) and moderate mitral regurgitation (MR) before undergoing mitral valve repair surgery. Transesophageal echocardiography was avoided based on the findings of this new technique by 3D TTE. It was noninvasive, quick, reproducible and reliable. Also, it did not need the time-consuming reconstruction of multiple cardiac images. Mitral valve repair surgery was subsequently performed based on the MPR findings and corroborated the findings from the MPR examination.

Advances in the surgical management of prolapse.

PubMed

Slack, Alex; Jackson, Simon

2007-03-01

Prolapse is an extremely common condition, for which 11% of women will have a surgical procedure at some point in their lives. The recurrence rate after most of the traditional surgical procedures is high and upto 29% of women who have had surgery for prolapse will require a further operation. In order to improve the surgical outcome, there is currently much interest in the use of grafts to augment traditional repairs and new procedures have been developed using specifically developed grafts. These have been combined with minimally invasive surgical techniques in an attempt to reduce surgical morbidity. These procedures may improve the outcome of surgery for prolapse. However, there is currently a lack of long-term data from randomized trials to demonstrate their effectiveness and safety.

Mitral valve repair using ePTFE sutures for ruptured mitral chordae tendineae: a computational simulation study.

PubMed

Rim, Yonghoon; Laing, Susan T; McPherson, David D; Kim, Hyunggun

2014-01-01

Mitral valve (MV) repair using expanded polytetrafluoroethylene sutures is an established and preferred interventional method to resolve the complex pathophysiologic problems associated with chordal rupture. We developed a novel computational evaluation protocol to determine the effect of the artificial sutures on restoring MV function following valve repair. A virtual MV was created using three-dimensional echocardiographic data in a patient with ruptured mitral chordae tendineae (RMCT). Virtual repairs were designed by adding artificial sutures between the papillary muscles and the posterior leaflet where the native chordae were ruptured. Dynamic finite element simulations were performed to evaluate pre- and post-repair MV function. Abnormal posterior leaflet prolapse and mitral regurgitation was clearly demonstrated in the MV with ruptured chordae. Following virtual repair to reconstruct ruptured chordae, the severity of the posterior leaflet prolapse decreased and stress concentration was markedly reduced both in the leaflet tissue and the intact native chordae. Complete leaflet coaptation was restored when four or six sutures were utilized. Computational simulations provided quantitative information of functional improvement following MV repair. This novel simulation strategy may provide a powerful tool for evaluation and prediction of interventional treatment for RMCT.

Impact of parity on ewe vaginal mechanical properties relative to the nonhuman primate and rodent.

PubMed

Knight, Katrina M; Moalli, Pamela A; Nolfi, Alexis; Palcsey, Stacy; Barone, William R; Abramowitch, Steven D

2016-08-01

Parity is the leading risk factor for the development of pelvic organ prolapse. To assess the impact of pregnancy and delivery on vaginal tissue, researchers commonly use nonhuman primate (NHP) and rodent models. The purpose of this study was to evaluate the ewe as an alternative model by investigating the impact of parity on the ewe vaginal mechanical properties and collagen structure. Mechanical properties of 15 nulliparous and parous ewe vaginas were determined via uniaxial tensile tests. Collagen content was determined by hydroxyproline assay and collagen fiber thickness was analyzed using picrosirius red staining. Outcome measures were compared using Independent samples t or Mann-Whitney U tests. ANOVA (Gabriel's pairwise post-hoc test) or the Welch Alternative for the F-ratio (Games Howell post-hoc test) was used to compare data with previously published NHP and rodent data. Vaginal tissue from the nulliparous ewe had a higher tangent modulus and tensile strength compared with the parous ewe (p < 0.025). The parous ewe vagina elongated 42 % more than the nulliparous ewe vagina (p = 0.015). No significant differences were observed in collagen structure among ewe vaginas. The tangent modulus of the nulliparous ewe vagina was not different from that of the NHP or rodent (p = 0.290). Additionally, the tangent moduli of the parous ewe and NHP vaginas did not differ (p = 0.773). Parity has a negative impact on the mechanical properties of the ewe vagina, as also observed in the NHP. The ewe may serve as an alternative model for studying parity and ultimately prolapse development.

Hydronephrosis Presenting 6 Months After Sacral Colpopexy: Case Report and Literature Review.

PubMed

Weber LeBrun, Emily; Santamaria, Estefania; Moy, Louis

The aim of this study was to describe a case of uterovaginal prolapse managed with robotic-assisted sacral colpopexy complicated by severe right-sided hydronephrosis despite normal intraoperative cystoscopy. A 68-year-old woman presented with a worsening vaginal bulge over the past 2 years. Tricompartment stage 2 uterovaginal prolapse, with dominant cystocele and skin erosion at the posterior fourchette from prolapse friction, was identified on physical examination, and the patient underwent pelvic reconstructive surgery, including sacral colpopexy. The patient was discharged on postoperative day 4 after being treated for a urinary tract infection. At her 6-week postoperative visit, the patient demonstrated normal vaginal support. She presented 6 months postoperatively with right-sided hydronephrosis with an almost imperceptible stricture where the right iliac vessels cross the pelvic brim, demonstrating a delayed manifestation of ureteral injury. She underwent open ureteroscopy, ureteroneocystostomy with vesicopsoas hitch, and ureteral stent placement. Ureteroscopy demonstrated a very mild narrowed caliber of the ureter just above the sacroiliac joint without overt obstruction. Follow-up intravenous pyelogram demonstrated no evidence of damage or obstruction. At nearly 1-year follow-up, the patient remained asymptomatic and had normal renal function. This case demonstrates the challenges of an uncommon, but highly morbid, complication of pelvic reconstructive surgery. Even when adequate visualization of the ureters and delicate ureteral dissection is achieved throughout surgery, occult injuries can still occur. Surgeons should maintain a high index of suspicion of ureteral injury when evaluating patients for late presentations of postoperative complications.

[Laparoscopic approach for artificial urinary sphincter implantation in women with severe urinary stress incontinence].

PubMed

Trolliet, S; Mandron, E; Lang, H; Jacqmin, D; Saussine, C

2013-09-01

To evaluate, feasibility, efficacy and morbidity of laparoscopic artificial urinary sphincter (AUS) implantation in women with severe stress urinary incontinence. Twenty-six women with severe stress urinary incontinence were treated between October 2007 and January 2012 by laparoscopic implantation of an AUS AMS 800 (American medical Systems, Inc., Minnetonka, Minnesota). For 18 patients AUS was primary implanted and, for eight, AUS was revised for a mechanical failure. Three patients had a concomitant laparoscopic vaginal prolapse repair. Mean value was for age 64 years, BMI 27.8kg/m2, and mean maximal urethral closure pressure was 26.75cm of water. Most of the patients (88%) had a history of pelvic or incontinence surgery. The study was a retrospective analysis of operative parameters, complications and functional results. Three conversions in open surgery and five bladder injuries were described. Mean operative time was 149 minutes. Bladder catheter was removed at a mean of day 3.8. Mean post-operative stay was 5 days. Early postoperative complications consist in eight acute transient urinary retentions, two pump migrations, and one vaginal injury. Late post-operative complications consist in one vaginal erosion. Explantation of AUS was performed for these last two patients. Mean follow-up was 20 months. Sixteen patients are totally continent, five have a social continence (1 pad/day) and three need more than one pad/day. Our results compare favorably to literature either for laparoscopic or conventional approach with a limited learning curve. Laparoscopic implantation of AUS in women with severe stress urinary incontinence was feasible and efficient. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

Mitral Valve Repair Using ePTFE Sutures for Ruptured Mitral Chordae Tendineae: A Computational Simulation Study

PubMed Central

Rim, Yonghoon; Laing, Susan T.; McPherson, David D.; Kim, Hyunggun

2013-01-01

Mitral valve repair using expanded polytetrafluoroethylene (ePTFE) sutures is an established and preferred interventional method to resolve the complex pathophysiologic problems associated with chordal rupture. We developed a novel computational evaluation protocol to determine the effect of the artificial sutures on restoring mitral valve function following valve repair. A virtual mitral valve was created using three-dimensional echocardiographic data in a patient with ruptured mitral chordae tendineae. Virtual repairs were designed by adding artificial sutures between the papillary muscles and the posterior leaflet where the native chordae were ruptured. Dynamic finite element simulations were performed to evaluate pre- and post-repair mitral valve function. Abnormal posterior leaflet prolapse and mitral regurgitation was clearly demonstrated in the mitral valve with ruptured chordae. Following virtual repair to reconstruct ruptured chordae, the severity of the posterior leaflet prolapse decreased and stress concentration was markedly reduced both in the leaflet tissue and the intact native chordae. Complete leaflet coaptation was restored when four or six sutures were utilized. Computational simulations provided quantitative information of functional improvement following mitral valve repair. This novel simulation strategy may provide a powerful tool for evaluation and prediction of interventional treatment for ruptured mitral chordae tendineae. PMID:24072489

The efficacy of pelvic floor muscle training for pelvic organ prolapse: a systematic review and meta-analysis.

PubMed

Li, Chunbo; Gong, Yuping; Wang, Bei

2016-07-01

Our objective was to assess the effectiveness of pelvic floor muscle training (PFMT) as a treatment for women with pelvic organ prolapse (POP) or as an adjunct to prolapse surgery. Relevant literature sources were searched using databases including PubMed, Ovid, Web of Science, Scopus, ClinicalTrials.gov, EBSCO, CINAHL, the Cochrane Central Register of Controlled Trials, CNKI, VIP, Wanfang, and CBM until 5 July 2015. Eligible studies were restricted to randomized controlled trials (RCT). The available data were pooled using Review Manager version 5.2. For data deemed not appropriate for synthesis, a narrative overview was conducted. In total, 13 studies with 2,340 patients were included. Our results indicated women receiving PFMT gained a greater improvement than controls in prolapse symptom score [mean difference (MD) -3.07, 95 % confidence interval (CI) -3.91 to -2.23] and POP stages [risk ratio (RR) 1.70, 95 % CI 1.19-2.44]. The number of women who said their prolapse was getting better was higher (RR 5.48, 95 % CI 2.19-13.72) and other discomfort syndromes, such as vaginal, bladder, and rectum, were lower in the PFMT groups than in controls. Meanwhile, women after PFMT had greater improvement in muscle strength and endurance but did not show a significant difference for further treatment needs. In addition, the results evaluating PFMT as an adjunct to prolapse surgery were inconclusive because of the variability in methods of measuring outcome. Our meta-analysis demonstrated women who received PFMT showed a greater subjective improvement in prolapse symptoms and an objective improvement in POP severity.

Estrogen Alters Remodeling of the Vaginal Wall after Surgical Injury in Guinea Pigs1

PubMed Central

Balgobin, Sunil; Montoya, T. Ignacio; Shi, Haolin; Acevedo, Jesus F.; Keller, Patrick W.; Riegel, Matthew; Wai, Clifford Y.; Word, Ruth Ann

2013-01-01

ABSTRACT Loss of pelvic organ support (i.e., pelvic organ prolapse) is common in menopausal women. Surgical reconstruction of pelvic organ prolapse is plagued with high failure rates. The objective of this study was to determine the effects of estrogen on biomechanical properties, lysyl oxidase (LOX), collagen content, and histomorphology of the vagina with or without surgical injury. Nulliparous ovariectomized guinea pigs were treated systemically with either 50 μg/kg/day estradiol (E2,) or vehicle. After 2 wk, vaginal surgery was performed, and animals were treated with either beta-aminopropionitrile (BAPN, an irreversible LOX inhibitor), or vehicle to determine the role of LOX in recovery of the vaginal wall from injury with or without E2. Estradiol resulted in (i) significant growth, increased smooth muscle, and increased thickness of the vagina, (ii) increased distensibility without compromise of maximal force at failure, and (iii) increased total and cross-linked collagen. In the absence of E2, BAPN resulted in decreased collagen and vaginal wall strength in the area of the injury. In contrast, in E2-treated animals, increased distensibility, maximal forces, and total collagen were maintained despite BAPN. Interestingly, LOX mRNA was induced dramatically (9.5-fold) in the injured vagina with or without E2 at 4 days. By 21 days, however, LOX levels declined to near baseline in E2-deprived animals. LOX mRNA levels remained strikingly elevated (12-fold) at 21 days in the estrogenized vagina. The results suggest that prolonged E2 induced increases in LOX, and collagen cross-links may act to sustain a matrix environment that optimizes long-term surgical wound healing in the vagina. PMID:24174572

Impact of parity on ewe vaginal mechanical properties relative to the nonhuman primate and rodent

PubMed Central

Knight, Katrina M.; Moalli, Pamela A.; Nolfi, Alexis; Palcsey, Stacy; Barone, William R.

2016-01-01

Introduction and hypothesis Parity is the leading risk factor for the development of pelvic organ prolapse. To assess the impact of pregnancy and delivery on vaginal tissue, researchers commonly use nonhuman primate (NHP) and rodent models. The purpose of this study was to evaluate the ewe as an alternative model by investigating the impact of parity on the ewe vaginal mechanical properties and collagen structure. Methods Mechanical properties of 15 nulliparous and parous ewe vaginas were determined via uniaxial tensile tests. Collagen content was determined by hydroxyproline assay and collagen fiber thickness was analyzed using picrosirius red staining. Outcome measures were compared using Independent samples t or Mann–Whitney U tests. ANOVA (Gabriel’s pairwise post-hoc test) or the Welch Alternative for the F-ratio (Games Howell post-hoc test) was used to compare data with previously published NHP and rodent data. Results Vaginal tissue from the nulliparous ewe had a higher tangent modulus and tensile strength compared with the parous ewe (p < 0.025). The parous ewe vagina elongated 42 % more than the nulliparous ewe vagina (p = 0.015). No significant differences were observed in collagen structure among ewe vaginas. The tangent modulus of the nulliparous ewe vagina was not different from that of the NHP or rodent (p = 0.290). Additionally, the tangent moduli of the parous ewe and NHP vaginas did not differ (p = 0.773). Conclusions Parity has a negative impact on the mechanical properties of the ewe vagina, as also observed in the NHP. The ewe may serve as an alternative model for studying parity and ultimately prolapse development. PMID:26872644

Mesh abdominal wall hernia surgery is safe and effective-the harm New Zealand media has done.

PubMed

Kelly, Steven

2017-10-06

Patients in New Zealand have now developed a fear of mesh abdominal wall hernia repair due to inaccurate media reporting. This article outlines the extensive literature that confirms abdominal wall mesh hernia repair is safe and effective. The worsening confidence in the transvaginal mesh prolapse repair should not adversely affect the good results of mesh abdominal wall hernia repair. New Zealand general surgeons are well trained in providing modern hernia surgery.

Long-term clinical outcomes with the retropubic tension-free vaginal tape (TVT) procedure compared to Burch colposuspension for correcting stress urinary incontinence (SUI).

PubMed

Holdø, Bjørn; Verelst, Margareta; Svenningsen, Rune; Milsom, Ian; Skjeldestad, Finn Egil

2017-11-01

The retropubic tension-free vaginal tape (TVT) procedure replaced Burch colposuspension as the primary surgical method for stress urinary incontinence (SUI) and mixed urinary incontinence (MUI) in women in our department in 1998. In this study we compared the short-term and long-term clinical outcomes of these surgical procedures. Using a case series design, we compared the last 5 years of the Burch procedure (n = 127, 1994-1999) with the first 5 years of the retropubic TVT procedure (n = 180, 1998-2002). Information from the medical records was transferred to a case report form comprising data on perioperative and long-term complications as well as recurrence of UI, defined as bothersome UI or UI in need of repeat surgery. Other endpoints were rates of perioperative and late complications and the rates of prolapse surgery after primary surgery. The data were analyzed with the chi-squared and t tests and survival analysis using SPSS. The cumulative recurrence rate of SUI in women with preoperative SUI was significantly higher after the Burch procedure, but no difference was observed in women with MUI. There were no significant differences in rates of perioperative and late complications. At 12 years there was a significant increase in rates of repeat surgery for incontinence and prolapse in women after the Burch procedure. The long-term efficacy of TVT surgery was superior to that of Burch colposuspension in women with SUI. In addition, the rate of late prolapse surgery was significantly higher after the Burch procedure.

Long-term follow-up after LeFort colpocleisis: patient satisfaction, regret rate, and pelvic symptoms.

PubMed

Song, Xiaochen; Zhu, Lan; Ding, Jing; Xu, Tao; Lang, Jinghe

2016-06-01

The aim of the study was to evaluate long-term patient satisfaction, regret rate, and pelvic symptoms in older women who underwent LeFort colpocleisis. A retrospective cohort study of women who underwent LeFort colpocleisis at least 3 years before was conducted. Records were reviewed for participant characteristics, comorbid conditions, and complications. The Patient Global Impression of Change (PGI-C) questionnaire and the Chinese version of the Pelvic Floor Distress Inventory-short form 20 (PFDI-20) were used to evaluate self-perceived quality of life. Regret was assessed by one additional question: "Do you regret choosing to have vaginal closure surgery for prolapse (Yes/No)?" LeFort colpocleisis accounted for 7.3% (42/572) of all the prolapse surgeries. Thirty-five of the women (83.3%) who responded were considered for statistical evaluation. Twenty-nine (82.9%) had at least one comorbid condition. After a median 5-year (range 3-7) follow-up period, no woman had experienced prolapse recurrence requiring a second surgery. No woman regretted having had the surgery. The satisfaction rate was 94.3%, with postoperative overactive bladder syndrome accounting for one "neither satisfied nor dissatisfied" woman and vaginal hematoma for another. Pelvic symptoms improved significantly from baseline (PFDI-20, preoperative 60.5 ± 29.5) to postoperative (14.1 ± 20.0, P < 0.001). After long-term follow-up, LeFort colpocleisis still had a high satisfaction rate, a low regret rate, and a positive impact on pelvic symptoms.

Thermosensitive hydrogels deliver bioactive protein to the vaginal wall

PubMed Central

Good, Meadow M.; Montoya, T. Ignacio; Shi, Haolin; Zhou, Jun; Huang, YiHui; Tang, Liping; Acevedo, Jesus F.

2017-01-01

The pathophysiology and natural history of pelvic organ prolapse (POP) are poorly understood. Consequently, our approaches to treatment of POP are limited. Alterations in the extracellular matrix components of pelvic support ligaments and vaginal tissue, including collagen and elastin, have been associated with the development of POP in animals and women. Prior studies have shown the protease MMP-9, a key player of ECM degradation, is upregulated in vaginal tissues from both mice and women with POP. On the other hand, fibulin-5, an elastogenic organizer, has been found to inhibit MMP-9 in the vaginal wall. Hence, we hypothesized that prolonged release of fibulin-5 may delay progression of POP. To test the hypothesis, oligo (ethylene glycol)-based thermosensitive hydrogels were fabricated, characterized and then used to deliver fibulin-5 to the vaginal wall and inhibit MMP-9 activity. The results indicate that hydrogels are cell and tissue compatible. The hydrogels also prolong the ½ life of fibulin-5 in cultured vaginal fibroblasts and in the vaginal wall in vivo. Finally, fibulin-5-containing hydrogels resulted in incorporation of fibulin-5 into the vaginal matrix and inhibition of MMP-9 for several weeks after injection. These results support the idea of fibulin-5 releasing hydrogel being developed as a new treatment for POP. PMID:29073153

A comparison of abdominal and vaginal hysterectomies in Benghazi, Libya.

PubMed

Agnaeber, K; Bodalal, Z

2013-08-01

We performed a comparative study between abdominal and vaginal hysterectomies using clinical data from Al-Jamhouria hospital (one of the largest maternity hospitals in Eastern Libya). Various parameters were taken into consideration: the rates of each type (and their subtypes); average age of patients; indications; causes; postoperative complications; and duration of stay in the hospital afterwards. Conclusions and recommendations were drawn from the results of this study. In light of the aforementioned parameters, it was found that: (1) abdominal hysterectomies were more common than vaginal hysterectomies (p < 0.001); (2) patients admitted for abdominal hysterectomies are younger than those admitted for vaginal hysterectomies (p < 0.001); (3) the most common indication for an abdominal hysterectomy was menstrual disturbances, while for vaginal hysterectomies it was vaginal prolapse; (4) the histopathological cause for abdominal and vaginal hysterectomies were observed and the most common were found to be leiomyomas and atrophic endometrium; (5) there was no significant difference between the two routes in terms of postoperative complications; (6) patients who were admitted for abdominal hysterectomies spent a longer amount of time in the hospital (p < 0.01). It was concluded that efforts should be made to further pursue vaginal and laparoscopic hysterectomies as a viable option to the more conventional abdominal route.

Defining normal apical vaginal support: a relook at the POSST study.

PubMed

Patnam, Radhika; Edenfield, Autumn; Swift, Steven

2018-06-16

The purpose of this study is to reanalyze data from the original 2005 Pelvic Organ Support Study (POSST) data set to define normal values for apical Pelvic Organ Prolapse Quantification (POP-Q) points C and D and total vaginal length (TVL) in an asymptomatic population of women. In this retrospective observational data-set review, patient were >18 years presenting for annual gynecologic exams to six centers in the United States. Data included demographics, questions about prolapse symptoms, and POP-Q points. Means and standard deviations were determined for each POP-Q point in the total population. The data set comprised 1011 women; 59 were excluded because they met criteria for having POP or were missing data. This left 948 for study. Mean age of our study population was 42 ± 14 years, and 45.6% were white, 25.1% black, and 25.2% Hispanic. One hundred fifty-six had a prior hysterectomy. Mean values with standard deviations (SD) for POP-Q values are as following: point C (vaginal cuff) -7.3 ± 1.5 cm, point C (cervix) -5.9 ± 1.5, point D -8.7 cm ± 1.5 cm, TVL (no hysterectomy) 9.8 cm ± 1.3 cm, and TVL (hysterectomy) 8.9 cm ± 1.5 cm. This data suggests normal values for POP-Q apical points in a population of patient with annual gynecological exams.

Tissue response to collagen containing polypropylene meshes in an ovine vaginal repair model.

PubMed

Darzi, Saeedeh; Urbankova, Iva; Su, Kai; White, Jacinta; Lo, Camden; Alexander, David; Werkmeister, Jerome A; Gargett, Caroline E; Deprest, Jan

2016-07-15

Pelvic Organ Prolapse (POP) is the herniation of pelvic organs into the vagina. Despite broad acceptance of mesh use in POP surgical repair, the complication rate is unacceptable. We hypothesized that collagen-containing polypropylene (PP) mesh types could modulate mesh-tissue integration and reduce long-term inflammation, thereby reducing mesh-associated complications. This study compared the long-term tissue response to an unmodified PP mesh and two collagen containing meshes in an ovine model which has similar pelvic anatomy and vaginal size to human. Three commercially available macroporous PP meshes, uncoated PP mesh (Avaulta Solo) (PP), the same textile PP mesh layered with a sheet of cross-linked porcine acellular matrix (Avaulta Plus) (PP-ACM) and a different yet also macroporous PP (Sofradim) mesh coated with solubilized atelocollagen (Ugytex) (PP-sCOL) were implanted in the ovine vagina and tissue explanted after 60 and 180days. The macrophage phenotype and response to implanted meshes, and vascularity were quantified by immunostaining and morphometry. We quantified changes in extracellular matrix composition biochemically and collagen organisation and percentage area around the interface of the mesh implants by Sirius Red birefringence and morphometry. PP-ACM induced a more sustained inflammatory response, indicated by similar CD45(+) leukocytes but reduced CD163(+) M2 macrophages at 60days (P<0.05). PP-sCOL increased Von Willebrand Factor (vWF)-immunoreactive vessel profiles after 60days. At the micro-molecular level, collagen birefringence quantification revealed significantly fewer mature collagen fibrils (red, thick fibrils) at the mesh-tissue interface than control tissue for all mesh types (P<0.001) but still significantly greater than the proportion of immature (green thin fibrils) at 60days (P<0.05). The proportion of mature collagen fibrils increased with time around the mesh filaments, particularly those containing collagen. The total collagen percent area at the mesh interface was greatest around the PP-ACM mesh at 60days (P<0.05). By 180days the total mature and immature collagen fibres at the interface of the mesh filaments resembled that of native tissue. In particular, these results suggest that both meshes containing collagen evoke different types of tissue responses at different times during the healing response yet both ultimately lead to physiological tissue formation approaching that of normal tissue. Pelvic organ prolapse (POP) is the descent of the pelvic organs to the vagina. POP affects more than 25% of all women and the lifetime risk of undergoing POP surgery is 19%. Although synthetic polypropylene (PP) meshes have improved the outcome of the surgical treatment for POP, there was an unacceptable rate of adverse events including mesh exposure and contracture. It is hypothesized that coating the PP meshes with collagen would provide a protective effect by preventing severe mesh adhesions to the wound, resulting in a better controlled initial inflammatory response, and diminished risk of exposure. In this study we assessed the effect of two collagen-containing PP meshes on the long-term vaginal tissue response using new techniques to quantify these tissue responses. Copyright © 2016 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.

Tissue-engineering with muscle fiber fragments improves the strength of a weak abdominal wall in rats.

PubMed

Jangö, Hanna; Gräs, Søren; Christensen, Lise; Lose, Gunnar

2017-02-01

Alternative approaches to reinforce the native tissue in patients with pelvic organ prolapse (POP) are needed to improve surgical outcome. Our aims were to develop a weakened abdominal wall in a rat model to mimic the weakened vaginal wall in women with POP and then evaluate the regenerative potential of a quickly biodegradable synthetic scaffold, methoxypolyethylene glycol polylactic-co-glycolic acid (MPEG-PLGA), seeded with autologous muscle fiber fragments (MFFs) using this model. In an initial pilot study with 15 animals, significant weakening of the abdominal wall and a feasible technique was established by creating a partial defect with removal of one abdominal muscle layer. Subsequently, 18 rats were evenly divided into three groups: (1) unrepaired partial defect; (2) partial defect repaired with MPEG-PLGA; (3) partial defect repaired with MPEG-PLGA and MFFs labeled with PKH26-fluorescence dye. After 8 weeks, we performed histopathological and immunohistochemical testing, fluorescence analysis, and uniaxial biomechanical testing. Both macroscopically and microscopically, the MPEG-PLGA scaffold was fully degraded, with no signs of an inflammatory or foreign-body response. PKH26-positive cells were found in all animals from the group with added MFFs. Analysis of variance (ANOVA) showed a significant difference between groups with respect to load at failure (p = 0.028), and post hoc testing revealed that the group with MPEG-PLGA and MFFs showed a significantly higher strength than the group with MPEG-PLGA alone (p = 0.034). Tissue-engineering with MFFs seeded on a scaffold of biodegradable MPEG-PLGA might be an interesting adjunct to future POP repair.

Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a multicentre randomised controlled trial.

PubMed

Hagen, Suzanne; Stark, Diane; Glazener, Cathryn; Dickson, Sylvia; Barry, Sarah; Elders, Andrew; Frawley, Helena; Galea, Mary P; Logan, Janet; McDonald, Alison; McPherson, Gladys; Moore, Kate H; Norrie, John; Walker, Andrew; Wilson, Don

2014-03-01

Pelvic organ prolapse is common and is strongly associated with childbirth and increasing age. Women with prolapse are often advised to do pelvic floor muscle exercises, but evidence supporting the benefits of such exercises is scarce. We aimed to establish the effectiveness of one-to-one individualised pelvic floor muscle training for reducing prolapse symptoms. We did a parallel-group, multicentre, randomised controlled trial at 23 centres in the UK, one in New Zealand, and one in Australia, between June 22, 2007, and April 9, 2010. Female outpatients with newly-diagnosed, symptomatic stage I, II, or III prolapse were randomly assigned (1:1), by remote computer allocation with minimsation, to receive an individualised programme of pelvic floor muscle training or a prolapse lifestyle advice leaflet and no muscle training (control group). Outcome assessors, and investigators who were gynaecologists at trial sites, were masked to group allocation; the statistician was masked until after data analysis. Our primary endpoint was participants' self-report of prolapse symptoms at 12 months. Analysis was by intention-to-treat analysis. This trial is registered, number ISRCTN35911035. 447 eligible patients were randomised to the intervention group (n=225) or the control group (n=222). 377 (84%) participants completed follow-up for questionnaires at 6 months and 295 (66%) for questionnaires at 12 months. Women in the intervention group reported fewer prolapse symptoms (ie, a significantly greater reduction in the pelvic organ prolapse symptom score [POP-SS]) at 12 months than those in the control group (mean reduction in POP-SS from baseline 3.77 [SD 5.62] vs 2.09 [5.39]; adjusted difference 1.52, 95% CI 0.46-2.59; p=0.0053). Findings were robust to missing data. Eight adverse events (six vaginal symptoms, one case of back pain, and one case of abdominal pain) and one unexpected serious adverse event, all in women from the intervention group, were regarded as unrelated to the intervention or to participation in the study. One-to-one pelvic floor muscle training for prolapse is effective for improvement of prolapse symptoms. Long-term benefits should be investigated, as should the effects in specific subgroups. Chief Scientist Office of the Scottish Government Health and Social Care Directorates, New Zealand Lottery Board, and National Health and Medical Research Council (Australia). Copyright © 2014 Elsevier Ltd. All rights reserved.

Successful vaginal birth after caesarean section in patient with Ehler-Danlos syndrome type 2.

PubMed

Maraj, Hemant; Mohajer, Michelle; Bhattacharjee, Deepannita

2011-12-01

We present the case of a 31-year-old woman with Ehler-Danlos syndrome (EDS) type 2. She had a previous caesarean section and went on to have an uncomplicated vaginal birth in her last pregnancy. To our knowledge, this is the first case of a successful vaginal birth after caesarean section in a patient with EDS. EDS is a multisystem disorder involving a genetic defect in collagen and connective-tissue synthesis and structure. It is a heterogeneous group of 11 different inherited disorders. Obstetric complications in these patients include miscarriages, stillbirths, premature rupture of the membranes, preterm labour, uterine prolapse, uterine rupture and severe postpartum haemorrhage. There has been much controversy over the appropriate mode of delivery. Abdominal deliveries are complicated by delayed wound healing and increased perioperative blood loss. Vaginal deliveries may be complicated by tissue friability causing extensive perineal tears, pelvic floor and bladder lesions. Our case highlights that in specific, controlled situations it is possible to have a vaginal delivery even after previous caesarean section in patients with EDS.

Successful vaginal birth after caesarean section in patient with Ehler-Danlos syndrome type 2

PubMed Central

Maraj, Hemant; Mohajer, Michelle; Bhattacharjee, Deepannita

2011-01-01

We present the case of a 31-year-old woman with Ehler-Danlos syndrome (EDS) type 2. She had a previous caesarean section and went on to have an uncomplicated vaginal birth in her last pregnancy. To our knowledge, this is the first case of a successful vaginal birth after caesarean section in a patient with EDS. EDS is a multisystem disorder involving a genetic defect in collagen and connective-tissue synthesis and structure. It is a heterogeneous group of 11 different inherited disorders. Obstetric complications in these patients include miscarriages, stillbirths, premature rupture of the membranes, preterm labour, uterine prolapse, uterine rupture and severe postpartum haemorrhage. There has been much controversy over the appropriate mode of delivery. Abdominal deliveries are complicated by delayed wound healing and increased perioperative blood loss. Vaginal deliveries may be complicated by tissue friability causing extensive perineal tears, pelvic floor and bladder lesions. Our case highlights that in specific, controlled situations it is possible to have a vaginal delivery even after previous caesarean section in patients with EDS. PMID:27579117

Preservation of the bicuspid aortic valve.

PubMed

Schäfers, Hans-Joachim; Aicher, Diana; Langer, Frank; Lausberg, Henning F

2007-02-01

Bicuspid anatomy of the aortic valve is a common reason for aortic regurgitation and is associated with aortic dilatation in more than 50% of patients. We have observed different patterns of aortic dilatation and used different approaches preserving the valve. Between October 1995 and February 2006, a regurgitant bicuspid valve was repaired in 173 patients. The aorta was normal in 57 patients who underwent isolated repair. Aortic dilatation mainly above commissural level (n = 38) was treated by separate valve repair plus supracommissural aortic replacement. In 78 patients, aortic dilatation involved the root and was treated by root remodeling. Hospital mortality and perioperative morbidity were low in all three groups. Myocardial ischemia was significantly shorter in repair plus aortic replacement than remodeling (p < 0.001). Freedom from aortic regurgitation II or greater at 5 years varied between 91% and 96%. Freedom from reoperation at 5 years was 97% after remodeling, but only 53% after repair plus aortic replacement (p = 0.33). Symmetric prolapse was the most frequent cause for reoperation. The long-term stability of bicuspid aortic valve repair is excellent in the absence of aortic pathology. In the presence of aortic dilatation, root remodeling leads to equally stable valve durability. In patients with less pronounced root dilatation, separate valve repair plus aortic replacement may be a less complex alternative. Symmetric prolapse should be avoided if the ascending aorta is replaced.

Safety of Synthetic Glue Used for Laparoscopic Prolapse Treatment.

PubMed

Sarasa Castelló, Núria; Toth, Alexandra; Canis, Michel; Botchorishvilli, Revaz

2017-12-29

We detected mesh erosion and serious postoperative complications in 3 women after performing laparoscopic promontofixation (LPF) using glue for mesh fixation. Glue, largely used in hernia surgery repair, is proposed by some gynecologic surgeons because it saves time and is easier to use than traditional sutures. We report 3 cases of postoperative complications after LPF in which glue had been used and provide research in the published literature about the use of glue in LPF. A research of glue use in gynecology mesh fixation was performed through PubMed on October 2016. The search was done using the Medical Subject Heading terms "POP" & "Laparoscopy" & "surgical Mesh" and the word either "glue" or "adhesive. Only 2 articles were found: Willecocq et al [1] and Estrade et al [2]. Neither study focused on postoperative complications. In this publication, we accurately edited video surgeries with an instructive purpose. University Hospital of Clermont-Ferrand, France. Patient A, a 65-year-old woman, complained of pelvic pain and vaginal discharge 1 month after LPF (polypropylene mesh and glue had been used). Wall mesh exposure and purulent discharge were noted. She received antibiotics and underwent mesh ablation surgery; debris of the glue was easily identified. Patient B, a 65-year-old lady with previous hysterectomy consulted for a bulging feeling in her vagina (classification: cystocele +2; rectocele +3 stage). An LPF was performed using polypropylene soft nonabsorbable mesh and glue. One month later, an apical defect of vaginal epithelialization was detected; she received long estrogenic local treatment but had to undergo surgery when presenting malodorous discharge and mesh exposure. The exposed mesh was removed, and pieces of glue were identified, having avoided mesh attachment. Patient C had a previous abdominal hysterectomy and promontofixation using a polyester mesh with glue. She consulted to us for vaginal mesh erosion covered with purulent discharge 3.5 years after LPF in another center. At the surgery, 1 cm of the prosthesis was identified in the vagina, dissected, and sutured. One year later, she consulted for dyspareunia and purulent discharge; vaginal rigid mesh exposure with an epithelization defect and inflammatory signs was seen. During laparoscopy, prosthetic exposition and glue debris on the prosthesis were identified. In all 3 cases, debris of glue were identified in the no integrated mesh area. The suggested reasons of exposure can be the excessive amount of surgical glue applied. Moreover, a large amount of glue may be impairing tissue ingrowth through the mesh pores, causing low fibrosis and poor tissue integration [3]. Glue seems to prevent fibrosis from occurring. Its use in pelvic organ prolapse laparoscopic mesh fixation should be done with caution. No prospective studies reporting long-term comorbidities and results have been published. Copyright © 2017 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.

Comparison of laparoscopy-assisted hysterectomies with conventional hysterectomies.

PubMed

Abdollahi, Seddigheh F; Bahlouli, Abolfazl; Mostafa, Parvin G; Rasooli, Susan; Morteza, Ghojazadeh

2009-06-01

To compare operative and early postoperative outcomes of laparoscopic-assisted vaginal hysterectomy (LAVH) and laparoscopy assisted supracervical hysterectomy (LASH) with conventional hysterectomy by laparotomy or vaginally, including patients undergoing total or subtotal hysterectomy for benign gynecologic disease. Three different methods of hysterectomies: laparoscopic, vaginal, and abdominal, were compared at the Department of Obstetrics and Gynecology of Tabriz University of Medical Sciences, Tabriz, Iran, including all patients with indication of uterus removal for benign uterine disease from January 2005 to December 2007. The regional medical research ethics committee approved the study. A total of 288 hysterectomies were performed: 165 (57.3%) abdominal hysterectomy, 85 (29.5%) vaginal hysterectomy, and 38 (13.2%) laparoscopic-assisted hysterectomy. Laparoscopy assisted hysterectomy (LAVH, LASH) was associated with significantly lower early postoperative pain scores and complication rates, less blood loss, short hospital stay, and resulted in lower hospital charge with reusable devices statistically (p=0.03). Laparoscopy is preferred to abdominal hysterectomy by laparotomy and to vaginal hysterectomy. Though vaginal hysterectomy had less complications and rapid recovery and patient satisfaction as compared with abdominal, but it was limited for multiparous patients with some degree of pelvic organ prolapse.

The feasibility of transvaginal robotic surgery in the repair of pelvic organ prolapse.

PubMed

Yaghnam, Ibrahim; Thomas, Dominique; Rosenblatt, Peter; Chughtai, Bilal

2017-08-01

Pelvic organ prolapse (POP), the descent of one or more pelvic organs, occurs in an estimated 40 to 60% of parous women. Conventional transvaginal surgery for POP has been plagued with high failure rates. The purpose was to determine the safety and feasibility of robotic transvaginal POP surgery. The da Vinci Surgical Robot, SI was used in the POP surgical procedures. There were two cadavers (aged 18 and 78 years of age; BMI 17.2 and 19.2 respectively). POP-Q scores before intervention were stage 1 for both cadavers. The visualization of anatomical landmarks and the placement of sutures at these locations were successful. Robotic transvaginal POP is a feasible option for POP surgery. Further studies are warranted to determine the role of robotic transvaginal POP repair.

[Analysis of mesh related complications after trans-vaginal mesh-augmented pelvic floor reconstruction surgery].

PubMed

Zhang, Kun; Han, Jin-song; Zhu, Fu-li; Yao, Ying

2012-09-01

To evaluate the complications after trans-vaginal mesh-augmented pelvic floor reconstruction in treatment of pelvic organ prolapse (POP). From February 2007 to October 2009, vaginal mesh procedures were performed on 91 women with POP stage III-IV in Peking University Third Hospital. The operative complications were studied. Ninety patients underwent successful surgery among 91 patients. Follow-up rate was 94% (85/90) at a median follow-up of 28.4 (15 - 44) months. One patient underwent intraoperative organ injuries, and 10 patients had postoperation mesh-related complications. The rate of mesh-related complications was 2% (2/85), 2% (2/85), 4% (3/85), 4% (3/85) on 6, 6 - 12, 12 - 24 and more than 24 months following up, respectively. Seven patients underwent conservative treatment and the symptoms were improved. Three patients underwent the second surgery, and the symptoms were cured or relieved. The incidence of mesh-related complications was low, and interventions were effective in vaginal mesh procedure.

The dynamic cardiac biosimulator: A method for training physicians in beating-heart mitral valve repair procedures.

PubMed

Leopaldi, Alberto M; Wrobel, Krzysztof; Speziali, Giovanni; van Tuijl, Sjoerd; Drasutiene, Agne; Chitwood, W Randolph

2018-01-01

Previously, cardiac surgeons and cardiologists learned to operate new clinical devices for the first time in the operating room or catheterization laboratory. We describe a biosimulator that recapitulates normal heart valve physiology with associated real-time hemodynamic performance. To highlight the advantages of this simulation platform, transventricular extruded polytetrafluoroethylene artificial chordae were attached to repair flail or prolapsing mitral valve leaflets. Guidance for key repair steps was by 2-dimensional/3-dimensional echocardiography and simultaneous intracardiac videoscopy. Multiple surgeons have assessed the use of this biosimulator during artificial chordae implantations. This simulation platform recapitulates normal and pathologic mitral valve function with associated hemodynamic changes. Clinical situations were replicated in the simulator and echocardiography was used for navigation, followed by videoscopic confirmation. This beating heart biosimulator reproduces prolapsing mitral leaflet pathology. It may be the ideal platform for surgeon and cardiologist training on many transcatheter and beating heart procedures. Copyright © 2017 The American Association for Thoracic Surgery. All rights reserved.

Microbial cultures in open globe injuries in southern India.

PubMed

Gupta, Arvind; Srinivasan, Renuka; Kaliaperumal, Subashini; Setia, Sajita

2007-07-01

To determine the risk factors leading to positive intraocular culture in patients with open globe injury. A prospective interventional study involving 110 eyes of 110 patients of more than 15 years of age, presenting with open globe injury, was undertaken. Emergency repair of the injured globe was done. Prolapsed intraocular tissue or aqueous humour was sent for microbial work up before repair. In endophthalmitis cases intravitreal antibiotics were given according to the antimicrobial sensitivity. Chi-square and logistic regression analysis were used to determine the risk factors. Fifty-six patients showed microbial contamination. Bacteria were cultured in 42 patients and fungi in 14 patients. Nineteen patients developed endophthalmitis, of which 18 patients showed microbial growth initially. In univariate analysis, initial visual acuity (<6/360, P = 0.002), presence of uveal tissue prolapse (P < 0.001), vitreous prolapse (P < 0.001) and length of laceration (>8 mm, P < 0.001) were significantly associated with positive microbial culture, however, in the multivariate stepwise logistic regression delay in surgical intervention (>72 h, P < 0.001), uveal tissue prolapse (P = 0.004) and corneosclearal laceration (>8 mm, P = 0.013) were associated with increased risk of positive microbial culture. Six patients had intraocular foreign body but were culture negative. Age, gender, site of injury and presence of cataract did not significantly affect the culture positivity. Microbial contamination is a risk factor for the development for endophthalmitis. Despite the high frequency of microbial contamination, it develops only in few cases. Systemic antibiotics, virulence of the organism and host factors play a role in the manifestation of endophthalmitis. Prophylaxis with intraocular antibiotics should be strongly considered in cases with poor vision at presentation, larger corneoscleral laceration, delayed surgical intervention and uveal tissue or vitreous prolapse.

Evaluation of a transvaginal mesh delivery system for the correction of pelvic organ prolapse: subjective and objective findings at least 1 year after surgery.

PubMed

Culligan, Patrick J; Littman, Paul M; Salamon, Charbel G; Priestley, Jennifer L; Shariati, Amir

2010-11-01

We sought to track objective and subjective outcomes ≥1 year after transvaginal mesh system to correct prolapse. This was a retrospective cohort study of 120 women who received a transvaginal mesh procedure (Avaulta Solo, CR Bard Inc, Covington, GA). Outcomes were pelvic organ prolapse quantification values; Pelvic Floor Distress Inventory, Short Form 20/Pelvic Floor Impact Questionnaire, Short Form 7 scores; and a surgical satisfaction survey. "Surgical failure" was defined as pelvic organ prolapse quantification point >0, and/or any reports of vaginal bulge. Of 120 patients, 116 (97%) were followed up for a mean of 14.4 months (range, 12-30). In all, 74 patients had only anterior mesh, 21 only posterior mesh, and 21 both meshes. Surgical cure rate was 81%. Surgical failure was more common if preoperative point C ≥+2 (35% vs 16%; P = .04). Mesh erosion and de novo pain occurred in 11.7% and 3.3%, respectively. Pelvic Floor Distress Inventory, Short Form 20/Pelvic Floor Impact Questionnaire, Short Form 7 scores improved (P < .01). Objective and subjective improvements occurred at ≥1 year, yet failure rates were high when preoperative point C was ≥+2. Copyright © 2010 Mosby, Inc. All rights reserved.

Mitral valve prolapse

MedlinePlus

... and lungs. The provider may feel a thrill (vibration) over the heart, and hear a heart murmur ( ... many heart medicines that may be used to control this condition. You may need surgery to repair ...

Isolated nonpulsatile enophthalmos in neurofibromatosis: An uncommon entity

PubMed Central

Singh, Swati; Mulay, Kaustubh; Mittal, Vikas

2017-01-01

Isolated enophthalmos is a rarely observed entity in neurofibromatosis (NF). A 12-year-old male presented with right lower eyelid fat prolapse and enophthalmos for the past 7 years. There was no history of antecedent trauma/surgery. Computed tomography of orbit revealed an ill-defined intraconal hyperdense lesion located between lateral and inferior rectus along with an enlarged inferior orbital fissure (IOF). Superior orbital fissure was minimally widened without prolapse of any intracranial contents. Excision biopsy along with repair of widened IOF was performed through inferior transconjunctival route. Histopathology was suggestive of plexiform neurofibroma with positivity for S-100 and epithelial membrane antigen. No associated cutaneous lesions were present. Nonpulsatile enophthalmos with eyelid fat prolapse can be a presenting sign of NF. PMID:29044092

Isolated nonpulsatile enophthalmos in neurofibromatosis: An uncommon entity.

PubMed

Singh, Swati; Mulay, Kaustubh; Mittal, Vikas

2017-10-01

Isolated enophthalmos is a rarely observed entity in neurofibromatosis (NF). A 12-year-old male presented with right lower eyelid fat prolapse and enophthalmos for the past 7 years. There was no history of antecedent trauma/surgery. Computed tomography of orbit revealed an ill-defined intraconal hyperdense lesion located between lateral and inferior rectus along with an enlarged inferior orbital fissure (IOF). Superior orbital fissure was minimally widened without prolapse of any intracranial contents. Excision biopsy along with repair of widened IOF was performed through inferior transconjunctival route. Histopathology was suggestive of plexiform neurofibroma with positivity for S-100 and epithelial membrane antigen. No associated cutaneous lesions were present. Nonpulsatile enophthalmos with eyelid fat prolapse can be a presenting sign of NF.

Textile properties of synthetic prolapse mesh in response to uniaxial loading.

PubMed

Barone, William R; Moalli, Pamela A; Abramowitch, Steven D

2016-09-01

Although synthetic mesh is associated with superior anatomic outcomes for the repair of pelvic organ prolapse, the benefits of mesh have been questioned because of the relatively high complication rates. To date, the mechanisms that result in such complications are poorly understood, yet the textile characteristics of mesh products are believed to play an important role. Interestingly, the pore diameter of synthetic mesh has been shown to impact the host response after hernia repair greatly, and such findings have served as design criteria for prolapse meshes, with larger pores viewed as more favorable. Although pore size and porosity are well-characterized before implantation, the changes in these textile properties after implantation are unclear; the application of mechanical forces has the potential to greatly alter pore geometries in vivo. Understanding the impact of mechanical loading on the textile properties of mesh is essential for the development of more effective devices for prolapse repair. The objective of this study was to determine the effect of tensile loading and pore orientation on mesh porosity and pore dimensions. In this study, the porosity and pore diameter of 4 currently available prolapse meshes were examined in response to uniaxial tensile loads of 0.1, 5, and 10 N while mimicking clinical loading conditions. The textile properties were compared with those observed for the unloaded mesh. Meshes included Gynemesh PS (Ethicon, Somerville, NJ), UltraPro (Artisyn; Ethicon), Restorelle (Coloplast, Minneapolis, MN), and Alyte Y-mesh (Bard, Covington, GA). In addition to the various pore geometries, 3 orientations of Restorelle (0-, 5-, 45-degree offset) and 2 orientations of UltraPro (0-, 90-degree offset) were examined. In response to uniaxial loading, both porosity and pore diameter dramatically decreased for most mesh products. The application of 5 N led to reductions in porosity for nearly all groups, with values decreasing by as much as 87% (P < .05). On loading to 10 N of force, nearly all mesh products that were tested were found to have porosities that approached 0% and 0 pores with diameters >1 mm. In this study, it was shown that the pore size of current prolapse meshes dramatically decreases in response to mechanical loading. These findings suggest that prolapse meshes, which are more likely to experience tensile forces in vivo relative to hernia repair meshes, have pores that are unfavorable for tissue integration after surgical tensioning and/or loading in urogynecologic surgeries. Such decreases in pore geometry support the hypothesis that regional increases in the concentration of mesh leads to an enhanced local foreign body response. Although pore deformation in transvaginal meshes requires further characterization, the findings presented here provide a mechanical understanding that can be used to recognize potential areas of concern for complex mesh geometries. Understanding mesh mechanics in response to surgical and in vivo loading conditions may provide improved design criteria for mesh and a refinement of surgical techniques, ultimately leading to better patient outcomes. Copyright © 2016 Elsevier Inc. All rights reserved.

Validation of the traditional Chinese version of the prolapse quality of life questionnaire (P-QOL) in a Mandarin-speaking Taiwanese population.

PubMed

Chuang, Fei-Chi; Chu, Li-Ching; Kung, Fu-Tsai; Huang, Kuan-Hui

2016-10-01

To validate the traditional Chinese translated version of the prolapse quality of life questionnaire (P-QOL). The P-QOL questionnaire was translated into traditional Chinese characters and administered to women recruited from gynecologic outpatient clinics of Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan. After the test-retest reliability and internal consistency were established in a pilot study, all participants completed the P-QOL questionnaire and were examined in the lithotomy position using the Pelvic Organ Prolapse Quantification System (POP-Q). The construct validity was assessed by comparing symptom scores and quality-of-life domain scores between symptomatic and asymptomatic women. Of the 244 women recruited, 159 were symptomatic for pelvic organ prolapse, and 85 were asymptomatic. The test-retest reliability confirmed a significant positive monotonic correlation between the total scores of each domain (n = 30, Spearman's rho was from 0.411 to 0.888, p < 0.05 of all). All items achieved a Cronbach α > 0.80 showing good internal consistency. Among the 18 symptom questions, the scores differed significantly between symptomatic and asymptomatic women for 12/18 symptom questions. These 12 questions referred to the prolapse/vaginal symptoms. All the quality of life domains differed significantly (p < 0.05) between symptomatic and asymptomatic women except for the domain of sleep/energy (p = 0.108). The traditional Chinese language version of the P-QOL is a reliable instrument for the assessment of symptom severity and impact on quality of life in women with pelvic organ prolapse. Copyright © 2016. Published by Elsevier B.V.

Vaginal estrogen: a dual-edged sword in postoperative healing of the vaginal wall.

PubMed

Ripperda, Christopher M; Maldonado, Pedro Antonio; Acevedo, Jesus F; Keller, Patrick W; Akgul, Yucel; Shelton, John M; Word, Ruth Ann

2017-07-01

Reconstructive surgery for pelvic organ prolapse is plagued with high failure rates possibly due to impaired healing or regeneration of the vaginal wall. Here, we tested the hypothesis that postoperative administration of local estrogen, direct injection of mesenchymal stem cells (MSCs), or both lead to improved wound healing of the injured vagina in a menopausal rat model. Ovariectomized rats underwent surgical injury to the posterior vaginal wall and were randomized to treatment with placebo (n = 41), estrogen cream (n = 47), direct injection of MSCs (n = 39), or both (n = 43). MSCs did not survive after injection and had no appreciable effects on healing of the vaginal wall. Acute postoperative administration of vaginal estrogen altered the response of the vaginal wall to injury with decreased stiffness, decreased collagen content, and decreased expression of transcripts for matrix components in the stromal compartment. Conversely, vaginal estrogen resulted in marked proliferation of the epithelial layer and increased expression of genes related to epithelial barrier function and protease inhibition. Transcripts for genes involved in chronic inflammation and adaptive immunity were also down-regulated in the estrogenized epithelium. Collectively, these data indicate that, in contrast to the reported positive effects of preoperative estrogen on the uninjured vagina, acute administration of postoperative vaginal estrogen has adverse effects on the early phase of healing of the stromal layer. In contrast, postoperative estrogen plays a positive role in healing of the vaginal epithelium after injury.

Vaginal estrogen: a dual-edged sword in postoperative healing of the vaginal wall

PubMed Central

Ripperda, Christopher M.; Maldonado, Pedro Antonio; Acevedo, Jesus F.; Keller, Patrick W.; Akgul, Yucel; Shelton, John M.; Word, Ruth Ann

2017-01-01

Abstract Objective: Reconstructive surgery for pelvic organ prolapse is plagued with high failure rates possibly due to impaired healing or regeneration of the vaginal wall. Here, we tested the hypothesis that postoperative administration of local estrogen, direct injection of mesenchymal stem cells (MSCs), or both lead to improved wound healing of the injured vagina in a menopausal rat model. Methods: Ovariectomized rats underwent surgical injury to the posterior vaginal wall and were randomized to treatment with placebo (n = 41), estrogen cream (n = 47), direct injection of MSCs (n = 39), or both (n = 43). Results: MSCs did not survive after injection and had no appreciable effects on healing of the vaginal wall. Acute postoperative administration of vaginal estrogen altered the response of the vaginal wall to injury with decreased stiffness, decreased collagen content, and decreased expression of transcripts for matrix components in the stromal compartment. Conversely, vaginal estrogen resulted in marked proliferation of the epithelial layer and increased expression of genes related to epithelial barrier function and protease inhibition. Transcripts for genes involved in chronic inflammation and adaptive immunity were also down-regulated in the estrogenized epithelium. Conclusions: Collectively, these data indicate that, in contrast to the reported positive effects of preoperative estrogen on the uninjured vagina, acute administration of postoperative vaginal estrogen has adverse effects on the early phase of healing of the stromal layer. In contrast, postoperative estrogen plays a positive role in healing of the vaginal epithelium after injury. PMID:28169915

Surgery Videos: MedlinePlus

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... 2009) Mitral Valve Prolapse Minimally Invasive Heart Surgery: Robot Assisted Mitral Valve Repair (Baptist Health South Florida, ... Center, Merriam, KS, 05/04/2012) Kidney Cancer Robot Assisted Partial Nephrectomy Using Fluorescence (Shawnee Mission Medical ...

[Treatment of Urinary incontinence associated with genital prolapse: Clinical practrice guidelines].

PubMed

Cortesse, A; Cardot, V; Basset, V; Le Normand, L; Donon, L

2016-07-01

Prolapse and urinary incontinence are frequently associated. Patente (or proven) stress urinary incontinence (SUI) is defined by a leakage of urine that occurs with coughing or Valsalva, in the absence of any prolapse reduction manipulation. Masked urinary incontinence results in leakage of urine occurring during reduction of prolapse during the clinical examination in a patient who does not describe incontinence symptoms at baseline. The purpose of this chapter is to consider on the issue of systematic support or not of urinary incontinence, patent or hidden, during the cure of pelvic organs prolapse by abdominal or vaginal approach. This work is based on an systematic review of the literature (PubMed, Medline, Cochrane Library, Cochrane database of systematic reviews, EMBASE) for meta-analyzes, randomized trials, registries, literature reviews, controlled studies and major not controlled studies, published on the subject. Its implementation has followed the methodology of the HAS on the recommendations for clinical practice, with a scientific argument (with the level of evidence, NP) and a recommendation grade (A, B, C, and professional agreement). In case of patent IUE, concomitant treatment of prolapse and SUI reduces the risk of postoperative SUI. However, the isolated treatment of prolapse can treat up to 30% of preoperative SUI. Concomitant treatment of SUI exposed to a specific overactive bladder and dysuria morbidity. The presence of a hidden IUE represents a risk of postoperative SUI, but there is no clinical or urodynamic test to predict individually the risk of postoperative SUI. Moreover, the isolated treatment of prolapse can treat up to 60% of the masked SUI. Concomitant treatment of the hidden IUE therefore exposes again to overtreatment and a specific overactive bladder and dysuria morbidity. In case of overt or hidden urinary incontinence, concomitant treatment of SUI and prolapse reduces the risk of postoperative SUI but exposes to a specific overactive bladder and dysuria morbidity (NP3). The isolated treatment of prolapse often allows itself to treat preoperative SUI. We can suggest not to treat SUI (whether patent or hidden) at the same time, providing that women are informed of the possibility of 2 stages surgery (Grade C). © 2016 Published by Elsevier Masson SAS. © 2016 Elsevier Masson SAS. Tous droits réservés.

Elevate and Uterine Preservation: Two-Year Results.

PubMed

Stanford, Edward J; Moore, Robert D; Roovers, Jan-Paul W R; VanDrie, Douglas M; Giudice, Thomas P; Lukban, James C; Bataller, Eduardo; Sutherland, Suzette E

2015-01-01

To evaluate efficacy of the Elevate Anterior and Apical (EAA) in the repair of pelvic organ prolapse (POP) when performed after previous hysterectomy and with or without uterine preservation during POP surgery. One hundred forty-two women with anterior vaginal prolapse and/or apical descent ≥ stage II were enrolled. The primary outcome was treatment failure defined as > stage II POP-Q during follow-up using the Last observed Failure Carried Forward method. Three sub-groups were analysed: baseline previous hysterectomy (N = 61); concomitant hysterectomy (N = 29), and preserved uterus/no hysterectomy (N = 51). Demographics, primary and secondary outcomes, and extrusion were compared between the groups. A P value less than 0.05 was considered statistically significant. Anatomic success shows significant and durable improvement at 24 months. The success for the apical compartment ranged between 93.8% and 100%. Success was slightly lower for the anterior compartment (70.8-89.1%). No statistically significant difference between the 3 subgroups. Age was the only patient characteristic to be found different between the 3 subgroups. In addition, there was no difference in overall intraoperative complications (P = 0.263). Mesh extrusion was found in all groups: 3 of 61 (4.9%) had previous hysterectomy; 4 of 29 (13.8%) had concomitant hysterectomy; and 1 of 51 (2.0%) had uterus preserved (P = 0.094). There appears to be a trend toward higher extrusion when a hysterectomy was performed with the EAA. Anatomic success and complications for the EAA do not appear to be significantly impacted when the uterus is removed before or during surgery or preserved. There may be a trend toward increased mesh extrusion when a hysterectomy is performed. However, larger cohort studies are needed to determine if concomitant hysterectomy impact extrusion.

In vitro differentiation of endometrial regenerative cells into smooth muscle cells: Α potential approach for the management of pelvic organ prolapse.

PubMed

Chen, Xiuhui; Kong, Xianchao; Liu, Dongzhe; Gao, Peng; Zhang, Yanhua; Li, Peiling; Liu, Meimei

2016-07-01

Pelvic organ prolapse (POP), is a common condition in parous women. Synthetic mesh was once considered to be the standard of care; however, the use of synthetic mesh is limited by severe complications, thus creating a need for novel approaches. The application of cell-based therapy with stem cells may be an ideal alternative, and specifically for vaginal prolapse. Abnormalities in vaginal smooth muscle (SM) play a role in the pathogenesis of POP, indicating that smooth muscle cells (SMCs) may be a potential therapeutic target. Endometrial regenerative cells (ERCs) are an easily accessible, readily available source of adult stem cells. In the present study, ERCs were obtained from human menstrual blood, and phase contrast microscopy and flow cytometry were performed to characterize the morphology and phenotype of the ERCs. SMC differentiation was induced by a transforming growth factor β1-based medium, and the induction conditions were optimized. We defined the SMC characteristics of the induced cells with regard to morphology and marker expression using transmission electron microscopy, western blot analysis, immunocytofluorescence and RT-PCR. Examining the expression of the components of the Smad pathway and phosphorylated Smad2 and Smad3 by western blot analysis, RT-PCR and quantitative PCR demonstrated that the 'TGFBR2/ALK5/Smad2 and Smad3' pathway is involved, and both Smad2 and Smad3 participated in SMC differentiation. Taken together, these findings indicate that ERCs may be a promising cell source for cellular therapy aimed at modulating SM function in the vagina wall and pelvic floor in order to treat POP.

Association of compartment defects in anorectal and pelvic floor dysfunction with female outlet obstruction constipation (OOC) by dynamic MR defecography.

PubMed

Li, M; Jiang, T; Peng, P; Yang, X-Q; Wang, W-C

2015-04-01

Chronic constipation affects more than 17% of the global population worldwide, and up to 50% of patients were outlet obstruction constipation (OOC). Women and the elderly are most likely to be affected, due to female-specific risk factors, such as menopause, parity and multiparity. The aim of our study was to investigate the association of compartment defects in anorectal and pelvic floor dysfunction with female outlet obstruction constipation (OOC) by MR defecography. Fifty-six consecutive women diagnosed with outlet obstruction constipation from October 2009 to July 2011 were included. They were categorized into the following groups: anorectal disorder only group (27 patients) and anorectal disorder plus multi-compartment pelvic disorder group (29 patients). Relevant measurements were taken at rest, during squeezing and straining. Anismus was significantly more common in the anorectal disorder group compared to the multi-compartment pelvic disorder group. Conversely, rectocele, rectal prolapse, and descending perineum were significantly more common in the multi-compartment pelvic disorder group compared to the anorectal disorder group. Of the total 56 OOC patients, 34 (60.7%) exhibited anismus and 38 (67.9%) rectocele. Among the anismus patients, there were 8 patients (23.5%) with combined cystocele, and 6 patients (17.6%) with combined vaginal/cervical prolapse. Among the rectocele patients, there were 23 patients (60.5%) with combined cystocele and 18 patients (47.4%) with combined vaginal/cervical prolapse. With respect to anorectal defects, 13 anismus patients (38.2%) were with signal posterior pelvic defects, 4 rectocele patients (10.5%) presented with signal posterior pelvic defects. Inadequate defecatory propulsion due to outlet obstruction constipation is often associated with multi-compartment pelvic floor disorders, whereas not about dyssynergic defecation.

Conceptual framework for patient-important treatment outcomes for pelvic organ prolapse.

PubMed

Sung, Vivian W; Rogers, Rebecca G; Barber, Matthew D; Clark, Melissa A

2014-04-01

To develop a comprehensive conceptual framework representing the most important outcomes for women seeking treatment for pelvic organ prolapse (POP). Twenty-five women with POP were recruited and participated in four semi-structured focus groups to refine and assess the content validity of a conceptual framework representing patient-important outcomes for POP. Specifically, the focus groups addressed the following three aims: (1) to evaluate the content and appropriateness of domains in our framework; (2) to identify gaps in the framework; and (3) to determine the relative importance of our framework domains from the patient perspective. Sessions were transcribed, coded, and qualitatively and quantitatively analyzed using analytic induction and deductive analysis to identify themes and domains relevant to women with POP. Our focus groups confirmed the importance of vaginal bulge symptoms (discomfort, bother, and adaptation), and the overarching domains and subdomains of physical (physical function and participation), social (social function, relationships, and sexual function), and mental health (emotional distress, preoccupation, and body image). Patients ranked outcomes in the following order of importance: (1) the resolution of vaginal bulge symptoms, (2) improvement in physical function; (3) improvement in sexual function; (4) improvement in body image perception; and (5) improvement in social function. We developed a conceptual framework for patient important outcomes of women seeking treatment for POP. This framework can improve the transparency and interpretation of POP study findings from the patient perspective. Vaginal bulge and its associated discomfort are most important for the definition of POP treatment success from the patient perspective. © 2013 Wiley Periodicals, Inc.

Overlapping sphincteroplasty and posterior repair.

PubMed

Crane, Andrea K; Myers, Erinn M; Lippmann, Quinn K; Matthews, Catherine A

2014-12-01

Knowledge of how to anatomically reconstruct extensive posterior-compartment defects is variable among gynecologists. The objective of this video is to demonstrate an effective technique of overlapping sphincteroplasty and posterior repair. In this video, a scripted storyboard was constructed that outlines the key surgical steps of a comprehensive posterior compartment repair: (1) surgical incision that permits access to posterior compartment and perineal body, (2) dissection of the rectovaginal space up to the level of the cervix, (3) plication of the rectovaginal muscularis, (4) repair of internal and external anal sphincters, and (5) reconstruction of the perineal body. Using a combination of graphic illustrations and live video footage, tips on repair are highlighted. The goals at the end of repair are to: (1) have improved vaginal caliber, (2) increase rectal tone along the entire posterior vaginal wall, (3) have the posterior vaginal wall at a perpendicular plane to the perineal body, (4) reform the hymenal ring, and (5) not have an overly elongated perineal body. This video provides a step-by-step guide on how to perform an overlapping sphincteroplasty and posterior repair.

Ultrasonographic patterns in patients with obstructed defaecation.

PubMed

Brusciano, L; Limongelli, P; Pescatori, M; Napolitano, V; Gagliardi, G; Maffettone, V; Rossetti, G; del Genio, G; Russo, G; Pizza, F; del Genio, A

2007-08-01

Anal ultrasound is helpful in assessing organic anorectal lesions, but its role in functional disease is still questionable. The purpose of the present study is to assess anal-vaginal-dynamic perineal ultrasonographic findings in patients with obstructed defecation (OD) and healthy controls. Ninety-two consecutive patients (77 women; mean age 51 years; range 21-71) with symptoms of OD were retrospectively evaluated. All patients underwent digital exploration, endoanal and endovaginal ultrasound (US) with rotating probe. Forty-one patients underwent dynamic perineal US with linear probe. Anal manometry and defaecography were performed in 73 and 43 patients, respectively. Ultrasonographic findings of 92 patients with symptoms of OD were compared to 22 healthy controls. Anismus was defined on US when the difference in millimetres between the distance of the inner edge of the puborectalis muscle posteriorly and the probe at rest and on straining was less then 5 mm. Sensitivity and specificity were calculated by assuming defaecography as the gold standard for intussusception and rectocele and proctoscopy for rectal internal mucosal prolapse. Since no gold standard for the diagnosis of anismus was available in the literature, the agreement between anal US and all other diagnostic procedures was evaluated. The incidence of anismus resulted significantly higher (P < 0.05) in OD patients than healthy controls on anal (48 vs 22%), vaginal (44 vs 21%), and dynamic perineal US (53 vs 22%). A significantly higher incidence of rectal internal mucosal prolapse was observed in OD patients when compared to healthy controls on both anal (61.9 vs 13.6%, P < 0.0001) and dynamic perineal US (51.2 vs.9% P = 0.001). For the diagnosis of rectal internal mucosal prolapse, anal US had a 100% sensitivity and specificity. For diagnosis of rectal intussusception, anal US had an 83.3% sensitivity and 100% specificity and perineal US had a 66.6% sensitivity and 100% specificity. In the diagnosis of anismus, anal ultrasonography resulted in agreement with perineal and vaginal US, manometry, defaecography, and digital exam (P < 0.05). Other lesions detected by US in patients with OD include solitary rectal ulcer, rectocele and enterocele. Damage of internal and/or external sphincter was diagnosed at anal US in 19/92 (20%) patients, all continent and with normal manometric values. Anal, vaginal and dynamic perineal ultrasonography can diagnose or confirm many of the abnormalities seen in patients with OD. The value of the information obtained by this non-invasive test and its role in the diagnostic algorithm of OD is yet to be defined.

The Role of Synthetic and Biologic Materials in the Treatment of Pelvic Organ Prolapse

PubMed Central

Brown, Ramon A.; Ellis, C. Neal

2014-01-01

Pelvic organ prolapse is a significant medical problem that poses a diagnostic and management dilemma. These diseases cause serious morbidity in those affected and treatment is sought for relief of pelvic pain, rectal bleeding, chronic constipation, obstructed defecation, and fecal incontinence. Numerous procedures have been proposed to treat these conditions; however, the search continues as colorectal surgeons attempt to find the procedure that would optimally treat these conditions. The use of prosthetics in the repair of pelvic organ prolapse has become prevalent as the benefits of their use are realized. While advances in biologic mesh and new surgical techniques promise improved functional outcomes with decreased complication rates without de novo symptoms, the debate concerning the best prosthetic material, synthetic or biologic, remains controversial. Furthermore, laparoscopic ventral mesh rectopexy has emerged as a procedure that could potentially fill this role and is rapidly becoming the procedure of choice for the surgical treatment of pelvic organ prolapse. PMID:25435827

The role of synthetic and biologic materials in the treatment of pelvic organ prolapse.

PubMed

Brown, Ramon A; Ellis, C Neal

2014-12-01

Pelvic organ prolapse is a significant medical problem that poses a diagnostic and management dilemma. These diseases cause serious morbidity in those affected and treatment is sought for relief of pelvic pain, rectal bleeding, chronic constipation, obstructed defecation, and fecal incontinence. Numerous procedures have been proposed to treat these conditions; however, the search continues as colorectal surgeons attempt to find the procedure that would optimally treat these conditions. The use of prosthetics in the repair of pelvic organ prolapse has become prevalent as the benefits of their use are realized. While advances in biologic mesh and new surgical techniques promise improved functional outcomes with decreased complication rates without de novo symptoms, the debate concerning the best prosthetic material, synthetic or biologic, remains controversial. Furthermore, laparoscopic ventral mesh rectopexy has emerged as a procedure that could potentially fill this role and is rapidly becoming the procedure of choice for the surgical treatment of pelvic organ prolapse.

Graft-versus-Host Disease-Associated Vulvovaginal Symptoms after Bone Marrow Transplantation.

PubMed

Chung, Christopher P; Sargent, Rachel E; Chung, Nadia T; Lacey, James V; Wakabayashi, Mark T

2016-02-01

We conducted a retrospective review to assess the prevalence of graft-versus-host disease (GVHD)-associated gynecologic conditions among bone marrow transplantation (BMT) patients at City of Hope Medical Center. We calculated the associations among the estimated risks of various gynecologic complications, including vaginal stenosis, by performing chi-square tests and t-test statistics. Between 2010 and 2014, 180 patients were referred to the gynecologic clinic after their BMT. One hundred twenty-four patients (69%) had GVHD; among these patients, 51 (41%) experienced dyspareunia and 43 (35%) had vaginal stenosis. GVHD patients were significantly more likely to have vaginal stenosis (P < .0001), more likely to have used a vaginal dilator (P = .0008), and less likely to have urinary incontinence (UI) than those without GVHD (P < .001). There was no difference in developing pelvic organ prolapse (POP) in patients with or without GVHD (P = .4373). GVHD was a common complication after allogenic BMT. Patients with BMT were more likely to have vulvovaginal symptoms, such as dyspareunia and pelvic pain. Patients with GVHD are at high risk for vaginal stenosis requiring the use of a vaginal dilator. However, they are at low risk for developing UI and POP. Copyright © 2016 American Society for Blood and Marrow Transplantation. Published by Elsevier Inc. All rights reserved.

Assessment of female sexual function among women with pelvic organ prolapse or urinary incontinence via an Arabic validated short-form sexual questionnaire.

PubMed

Shaaban, Mohamed M; Abdelwahab, Hassan A; Ahmed, Magdy R; Shalaby, Essam

2014-01-01

To assess female sexual function among women with pelvic organ prolapse or urinary incontinence via an Arabic, validated, short-form sexual questionnaire (PISQ-12). The present study was conducted among women attending Suez Canal University Hospital, Ismailia, Egypt, between September 2009 and August 2011. In the pilot study, 42 women completed the final version of the Arabic PISQ-12 at recruitment and then 2 weeks later, and the data were compared to evaluate reliability and internal consistency. The formal comparative study included 154 premenopausal sexually active women: 80 control women, and 74 women with some degree of pelvic prolapse with or without stress incontinence. All participants had a vaginal examination and completed the questionnaire. The main outcome measures were the mean questionnaire scores within its 3 domains (behavioral, physical, and partner-related). The test-retest reliability and internal consistency of the Arabic PISQ-12 were excellent. Validity was approved by an expert panel. The case group had a significantly lower mean total questionnaire score (31.07 ± 4.2 vs 34.7 ± 6.2; P<0.05) but a higher partner-related score (9.0 ± 2.4 vs 8.4 ± 2.5; P<0.05). The Arabic version of PISQ-12 was shown to be an effective and objective method of evaluating sexual function among patients with pelvic organ prolapse. © 2013.

[Pyometra and persistent hymen in an alpaca].

PubMed

Egloff, C; Gerspach, C; Rütten, M; Dettwiler, M; Reichler, I; Bleul, U

2013-01-01

A 3-year-old female alpaca was referred to the hospital because of tenesmus. Clinical examination revealed a habitual vaginal prolapse with tenesmus during urination and defecation. On vaginoscopic examination a persistent hymen was detected. Ultrasonography of the caudal abdomen showed an echogenic fluid-filled uterus. A diagnostic laparotomy led to diagnosis of pyometra. Following ovariohysterectomy, the recovery was uneventful. One and a half years later the alpaca was again admitted to the hospital because of colic. Based on the findings, a tentative prognosis was provided and the alpaca was euthanized at the request of the owner. At necropsy, a haemorrhagic infarction of a jejunal loop was found due to incarceration in a fibrous adhesion between the vaginal stump and small intestine.

Short-term outcomes of the transvaginal minimal mesh procedure for pelvic organ prolapse.

PubMed

Takazawa, Naoko; Fujisaki, Akiko; Yoshimura, Yasukuni; Tsujimura, Akira; Horie, Shigeo

2018-03-01

This study aimed to evaluate the clinical outcomes and complications of transvaginal minimal mesh repair without using commercially available kits for treatment of pelvic organ prolapse (POP). This retrospective cohort study involved 91 women who underwent surgical management of POP with originally designed small mesh between July 2014 and August 2015. This mesh is 56% smaller than the mesh widely used in Japan, and it has only two arms delivered into each right and left sacrospinous ligament. The main study outcome was the anatomic cure rate defined as recurrence of POP quantification (POP-Q) stage II or more. We also assessed changes in the overactive bladder symptom score (OABSS) and prolapse quality of life questionnaire (P-QOL) and evaluated adverse events. Finally, we compared patient backgrounds between the patients with and without recurrence. Prolapse recurred in 10 of 91 patients (11.0%), and all patients with recurrence were diagnosed as POP-Q stage II. As adverse events, only mesh erosion occurred in two (2.2%) and pelvic pain in one (1.1%) of the 91 patients. The OABSS and P-QOL were significantly improved by the operation. When we compared patient backgrounds between the patients with and without recurrence, body mass index was the only factor influencing affecting recurrence. Transvaginal minimal mesh repair resulted in successful outcomes with low mesh-related complications and anatomic recurrence at one year. Furthermore, significant improvement in QOL was offered by this procedure. Our minimal mesh technique should be considered as one treatment option for the management of POP.

Short-term outcomes of the transvaginal minimal mesh procedure for pelvic organ prolapse

PubMed Central

Takazawa, Naoko; Fujisaki, Akiko; Yoshimura, Yasukuni; Tsujimura, Akira

2018-01-01

Purpose This study aimed to evaluate the clinical outcomes and complications of transvaginal minimal mesh repair without using commercially available kits for treatment of pelvic organ prolapse (POP). Materials and Methods This retrospective cohort study involved 91 women who underwent surgical management of POP with originally designed small mesh between July 2014 and August 2015. This mesh is 56% smaller than the mesh widely used in Japan, and it has only two arms delivered into each right and left sacrospinous ligament. The main study outcome was the anatomic cure rate defined as recurrence of POP quantification (POP-Q) stage II or more. We also assessed changes in the overactive bladder symptom score (OABSS) and prolapse quality of life questionnaire (P-QOL) and evaluated adverse events. Finally, we compared patient backgrounds between the patients with and without recurrence. Results Prolapse recurred in 10 of 91 patients (11.0%), and all patients with recurrence were diagnosed as POP-Q stage II. As adverse events, only mesh erosion occurred in two (2.2%) and pelvic pain in one (1.1%) of the 91 patients. The OABSS and P-QOL were significantly improved by the operation. When we compared patient backgrounds between the patients with and without recurrence, body mass index was the only factor influencing affecting recurrence. Conclusions Transvaginal minimal mesh repair resulted in successful outcomes with low mesh-related complications and anatomic recurrence at one year. Furthermore, significant improvement in QOL was offered by this procedure. Our minimal mesh technique should be considered as one treatment option for the management of POP. PMID:29520390

Management of occult stress urinary incontinence with prolapse surgery.

PubMed

Al-Mandeel, H; Al-Badr, A

2013-08-01

Pelvic organ prolapse (POP) and stress urinary incontinence (SUI), are two common health-related conditions, each affecting up to 50% women worldwide. Stress urinary incontinence only observed after the reduction of co-existent prolapse is called occult SUI (OSUI), and is found in up to 80% of women with advanced POP. Although there is no consensus on how to diagnose OSUI, there are several reported methods to better diagnose. Counseling symptomatically continent women with POP concerning the potential risk for developing SUI postoperatively cannot be overstated. Evidence suggests that positive OSUI in symptomatically continent women who are planning to have POP repair is associated with a high risk of POSUI, furthermore, adding continence procedure is found to reduce postoperative SUI. Therefore, adding continence surgery at the time of POP surgery in patients who are found to have OSUI preoperatively is advocated.

Postpartum pelvic floor muscle training and pelvic organ prolapse--a randomized trial of primiparous women.

PubMed

Bø, Kari; Hilde, Gunvor; Stær-Jensen, Jette; Siafarikas, Franziska; Tennfjord, Merete Kolberg; Engh, Marie Ellstrøm

2015-01-01

Pelvic organ prolapse (POP) is a common and distressing condition. The aim of the present study was to evaluate the effect of pelvic floor muscle training (PFMT) on prevention and treatment of symptoms and signs of POP in primiparous postpartum women. This was a parallel group assessor blind randomized controlled trial. One hundred seventy-five primiparous postpartum women, mean age 29.8 years (standard deviation 4.1), stratified on major levator ani defects or no defect diagnosed by 3-/4-dimensional ultrasound, participated in a 4-month PFMT starting at 6-8 weeks' postpartum or control. All participants had thorough individual instruction and assessment of ability to perform correct pelvic floor muscle contractions. The PFMT group followed a supervised, weekly group training program and performed 3 sets of 8-12 daily maximal contractions at home. Main outcome was POP stage II or greater assessed by POP quantification and bladder neck position assessed by 3-/4- dimensional transperineal ultrasonography. Secondary outcome was symptoms of vaginal bulge using International Consultation on Incontinence Vaginal Symptoms questionnaire. Ninety-six percent of the intervention group adhered to ≥80% of both group and home training sessions. At postintervention, there was no significant risk difference in POP (rational ratio, 1.62; 95% confidence interval, 0.55-4.75), bladder neck position or symptoms of vaginal bulging. No effect was found of postpartum PFMT on POP in primiparous women. More randomized controlled trials are needed before strong conclusions can be drawn on the effect of PFMT on POP in the particular population. Copyright © 2015 Elsevier Inc. All rights reserved.

The scientific basis for the use of biomaterials in stress urinary incontinence (SUI) and pelvic organ prolapse (POP).

PubMed

Colaco, Marc; Mettu, Jayadev; Badlani, Gopal

2015-06-01

To review the scientific and clinical literature to assess the basis for the use of biomaterials in stress urinary incontinence (SUI) and pelvic organ prolapse (POP). Pelvic floor diseases (PFDS), such as SUI and POP, are common and vexing disorders. While synthetic mesh-based repairs have long been considered an option for PFD treatment, and their efficacy established in randomised clinical trials, safety of its use has recently been called into question. Using the PubMed, MEDLINE and Medical Subject Headings (MeSH) databases, we performed a critical review of English-language publications that contained the following keywords: 'pelvic organ prolapse', 'stress urinary incontinence', 'mesh', 'biomaterial', 'collagen', 'elastin' and 'extracellular matrix'. After reviewing for relevance for mesh use in the pelvis by two independent reviewers with a third available in the case of disagreement, a total of 60 articles were included in the present review. We found that many of the potential causes of PFDs are due to altered metabolism of patient extracellular matrix (specifically collagen, elastin, and their respective enzymes) and as such, repairs using native tissue may suffer from the same abnormalities leading to a subsequent lack of repair integrity. However, mesh use is not without its unique risks. Several publications have suggested that biomaterials may undergo alteration after implantation, but these findings have not been demonstrated in the normal milieu. While the decision for the use of synthetic mesh is scientifically sound, its benefits and risks must be discussed with the patient in an informed decision-making process. © 2014 The Authors. BJU International © 2014 BJU International.

Risk factors for the breakdown of perineal laceration repair after vaginal delivery.

PubMed

Williams, Meredith K; Chames, Mark C

2006-09-01

The purpose of this study was to identify risk factors that are associated with the breakdown of perineal laceration repair in the postpartum period. We conducted a retrospective, case-control study to review perineal laceration repair breakdown in patients who were delivered between September 1995 and February 2005 at the University of Michigan. Bivariate analysis with chi-square test and t-test and stepwise logistic regression analysis were performed. Fifty-nine cases and 118 control deliveries were identified from a total of 14,124 vaginal deliveries. Risk factors were longer second stage of labor (142 vs 87 minutes; P = .001), operative vaginal delivery (odds ratio, 3.6; 95% CI, 1.8-7.3), mediolateral episiotomy (odds ratio, 6.9; 95% CI, 2.6-18.7), third- or fourth-degree laceration (odds ratio, 3.1; 95% CI, 1.5-6.4), and meconium-stained amniotic fluid (odds ratio, 3.0; 95% CI, 1.1-7.9). Previous vaginal delivery was protective (odds ratio, 0.38; 95% CI, 0.18-0.84). Logistic regression showed the most significant factor to be an interaction between operative vaginal delivery and mediolateral episiotomy (odd ratio, 6.36; 95% CI, 2.18-18.57). The most significant events were mediolateral episiotomy, especially in conjunction with operative vaginal delivery, third- and fourth-degree lacerations, and meconium.

Loop technique.

PubMed

Seeburger, Joerg; Noack, Thilo; Winkfein, Michael; Ender, Joerg; Mohr, Friedrich Wilhelm

2010-01-01

The loop technique facilitates mitral valve repair for leaflet prolapse by implantation of Gore-Tex neo-chordae. The key feature of the technique is a premade bundle of four loops made out of one suture. The loops are available in different lengths ranging from 10 to 26 mm. After assessment of the ideal length of neo-chordae with a caliper the loops are then secured to the body of the papillary muscle over an additional felt pledget. In the following step, the free ends of the loops are distributed along the free margin of the prolapsing segment using one additional suture for each loop.

Robot-Assisted Ventral Mesh Rectopexy for Rectal Prolapse: A 5-Year Experience at a Tertiary Referral Center.

PubMed

van Iersel, Jan J; Formijne Jonkers, Hendrik A; Paulides, Tim J C; Verheijen, Paul M; Draaisma, Werner A; Consten, Esther C J; Broeders, Ivo A M J

2017-11-01

Laparoscopic ventral mesh rectopexy is being increasingly performed internationally to treat rectal prolapse syndromes. Robotic assistance appears advantageous for this procedure, but literature regarding robot-assisted ventral mesh rectopexy is limited. The primary objective of this study was to assess the safety and effectiveness of robot-assisted ventral mesh rectopexy in the largest consecutive series of patients to date. This study is a retrospective cross-sectional analysis of prospectively collected data. The study was conducted in a tertiary referral center. All of the patients undergoing robot-assisted ventral mesh rectopexy for rectal prolapse syndromes between 2010 and 2015 were evaluated. Preoperative and postoperative (mesh and nonmesh) morbidity and functional outcome were analyzed. The actuarial recurrence rates were calculated using the Kaplan-Meier method. A total of 258 patients underwent robot-assisted ventral mesh rectopexy (mean ± SD follow-up = 23.5 ± 21.8 mo; range, 0.2 - 65.1 mo). There were no conversions and only 5 intraoperative complications (1.9%). Mortality (0.4%) and major (1.9%) and minor (<30 d) early morbidity (7.0%) were acceptably low. Only 1 (1.3%) mesh-related complication (asymptomatic vaginal mesh erosion) was observed. A significant improvement in obstructed defecation (78.6%) and fecal incontinence (63.7%) were achieved for patients (both p < 0.0005). At final follow-up, a new onset of fecal incontinence and obstructed defecation was induced or worsened in 3.9% and 0.4%. The actuarial 5-year external rectal prolapse and internal rectal prolapse recurrence rates were 12.9% and 10.4%. This was a retrospective study including patients with minimal follow-up. No validated scores were used to assess function. The study was monocentric, and there was no control group. Robot-assisted ventral mesh rectopexy is a safe and effective technique to treat rectal prolapse syndromes, providing an acceptable recurrence rate and good symptomatic relief with minimal morbidity. See Video Abstract at http://links.lww.com/DCR/A427.

Transvaginal postpartum manual removal of a prolapsed submucous leiomyoma, initially diagnosed hybrid predominantly intramural.

PubMed

Elgonaid, Wael; Belkhir, Reem; Boama, Vincent

2017-08-11

We present a rare case of a large infarcted submucous fibroid removed manually after a normal vaginal delivery. This patient was known to have a large postero-fundal hybrid predominantly intramural uterine fibroid, measuring 11 x 10 cm in diameter and diagnosed 2 years prior to last conception. Thirty-five days postpartum, she presented with severe lower abdominal pain and foul smell per vaginum. Abdominal examination revealed a very tender bulky uterus at 24 weeks size, and vaginal examination revealed a big fleshy smelly mass with friable surface just bulging from a dilated cervix. Examination under anaesthesia revealed a very foul smelly large pedunculated submucous fibroid that was felt through a dilated cervix. It was deliverable vaginally, so the submucous leiomyoma was removed manually, a procedure similar to manual removal of placenta. Histopathology examination confirmed an infarcted massive fibroid. © BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Effects of horizontal vs vertical vaginal cuff closure techniques on vagina length after vaginal hysterectomy: a prospective randomized study.

PubMed

Cavkaytar, Sabri; Kokanali, Mahmut Kuntay; Topcu, Hasan Onur; Aksakal, Orhan Seyfi; Doganay, Melike

2014-01-01

To compare the effects of horizontal and vertical vaginal cuff closure techniques on vagina length after vaginal hysterectomy. Prospective randomized study (Canadian Task Force classification I). Teaching and research hospital, a tertiary center. Fifty-two women with POP-Q stage 0 or 1 uterine prolapse were randomized into 2 groups using vertical (n = 26) or horizontal (n = 26) vaginal cuff closure. All patients underwent vaginal hysterectomy. Vagina length in the 2 groups was compared preoperatively, immediately after surgery, and at 6 weeks postoperatively. Mean (SD) preoperative vagina length in the horizontal and vertical groups was similar (7.87 [0.92] cm vs 7.99 [0.78] cm; p = .41). Immediately postoperatively, the vagina was significantly shorter in the horizontal group than in the vertical group (6.61 [0.89] cm vs 7.51 [0.74] cm; p < .001). At 6 weeks postoperatively, the vagina was still significantly shorter in the horizontal group (6.55 [0.89] cm vs 7.42 (0.73) cm; p < .001). The mean difference in vagina length before and after surgery was also significantly higher in the horizontal group than in the vertical group (-1.26 [0.12] cm vs 0.49 [0.11] cm; p < .001). Vertical cuff closure during vaginal hysterectomy seems to preserve vagina length better than does horizontal cuff closure. Copyright © 2014 AAGL. Published by Elsevier Inc. All rights reserved.

[The incidence and prevalence of complications after urogynaecological and reconstructive pelvic floor prosthetic surgery and management of these complications in women].

PubMed

Martan, A; Svabík, K; Masata, J

2007-12-01

The aim of this article is to review the incidence and prevalence of complications after prosthetic surgery for POP (pelvic organ prolaps) and USI (urodynamic stress incontinence) and to introduce diagnostic and therapeutic advice into clinical practice. Review article. Gynecological and Obstetric Clinic, 1st LF UK and VFN, Prague. Summary of complications, recent findings, opinions and specific diagnostic and therapeutic recommendations with special focus to vaginal erosion, post-operative voiding difficulties, persisting leakage of urine and de novo urgency. In the last decade the surgical treatment of female USI by prosthetic slings procedures has been shown to be effective with high cure rate and low morbidity. Similary, prosthetic reconstruction of pelvic organ prolapse through the different compartments has been introduced into clinical practice with good anatomical and promising functional results. The article is structured to the different sections, describing the epidemiology and management of complications after prosthetic slings procedures and after vaginal prosthetic treatment of pelvic organ prolapse. The effect of various operations of pelvic floor and USI using synthetic implants may differ, depending on the material of the implant used. Current recommendation for the implants material: a light-weight, flexible polypropylene; Amid's classification: type 1, i.e macro-porous, monofilament material. The advantage of surgical treatment of pelvic floor defect using implants comprises a low percentage of recurrence of the descensus.

The genital prolapse of Australopithecus Lucy?

PubMed

Chene, Gautier; Lamblin, Gery; Lebail-Carval, Karine; Chabert, Philippe; Marès, Pierre; Coppens, Yves; Mellier, Georges

2015-07-01

The female bony pelvis has to fulfil opposing functions: it has to be sufficiently closed to support the pelvic viscera in the upright position, while remaining sufficiently open to allow vaginal delivery. We aim to give an evolutionary perspective and the possible evolution of the bony pelvis from Lucy to the modern female with the implications in terms of genital prolapse. Thirteen pelvimetric measurements were performed on 178 bony pelves: 1 fossil pelvis from Australopithecus Lucy, 128 female Caucasian modern adult pelves and 49 female Catarrhine pelves (29 gorillas and 20 chimpanzees). Lucy's pelvis shape was the most transversely oval, short and broad, termed platypelloid. Modern female pelves were transversely oval only at the inlet. A protruding ischial spine, fairly small ischial tuberosities and a sacral concavity made Lucy closer to Homo sapiens and less like the great apes. In the last group, pelvic planes were anteroposteriorly oval, except in the gorilla, where the outlet was round or slightly transversely oval. The subpubic angle was narrowest in Lucy, whereas it was greater than 90° in the great apes. The female pelvis is involved in both visceral support and parturition and represents a compromise. The narrower pelvis of Australopithecus Lucy provided protection against genital prolapse, but resulted in complex obstetrical mechanics. From an evolutionary perspective, the pelvis of Homo sapiens became modified to make parturition easier, but increased the risk of genital prolapse: the ilia became wide open laterally and the sacrum broadened with a shorter distance between the sacroiliac and coxofemoral joints.

Minimally invasive or conventional edge-to-edge repair for severe mitral regurgitation due to bileaflet prolapse in Barlow's disease: does the surgical approach have an impact on the long-term results?

PubMed

De Bonis, Michele; Lapenna, Elisabetta; Del Forno, Benedetto; Di Sanzo, Stefania; Giacomini, Andrea; Schiavi, Davide; Vicentini, Luca; Latib, Azeem; Pozzoli, Alberto; Pappalardo, Federico; La Canna, Giovanni; Alfieri, Ottavio

2017-07-01

To evaluate whether the adoption of a right minithoracotomy operative approach had an impact on the long-term results of edge-to-edge (EE) repair compared to conventional sternotomy in patients with Barlow's disease and bileaflet prolapse. We assessed the long-term results of 104 patients with Barlow's disease treated with a minimally invasive EE technique. An equal number of patients had a conventional median sternotomy EE repair for the same disease and were used as a control group. The inverse probability of treatment weighting was used to create comparable distributions of the covariates that were significantly different at baseline in the two groups. We performed a comparative analysis of the groups. No hospital deaths were observed. Follow-up was 99.5% complete (median 11.3 years). The cumulative incidence function (CIF) of cardiac death at 12 years, with noncardiac death as a competing risk, showed no difference between the two groups ( P  = 0.87). At 12 years, the CIF of recurrent MR ≥ 3+, with death as the competing risk, was 7% in the sternotomy group and 5% in the minimally invasive group ( P  = 0.30), and the CIF of recurrence of MR ≥ 2+ was 15 and 14%, respectively ( P  = 0.63). The type of surgical approach was not a predictor of cardiac death, reoperation, recurrent MR ≥ 3+ or recurrent MR ≥ 2+. A minimally invasive approach does not have a negative impact on the effectiveness and long-term durability of the EE repair for bileaflet prolapse in Barlow's disease. Long-term outcomes are excellent, and valvular performance remains stable over time with no evidence of mitral stenosis. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Mechanisms of tricuspid regurgitation in patients with hypoplastic left heart syndrome undergoing tricuspid valvuloplasty.

PubMed

Bautista-Hernandez, Victor; Brown, David W; Loyola, Hugo; Myers, Patrick O; Borisuk, Michele; del Nido, Pedro J; Baird, Christopher W

2014-09-01

Tricuspid regurgitation (TR) remains a risk factor for morbidity and mortality through staged palliation in patients with hypoplastic left heart syndrome (HLHS). Reports on the mechanisms associated with TR in patients with HLHS are limited. Thus, we sought to describe our experience with tricuspid valve (TV) repair in these patients, focusing on the mechanisms of TR and corresponding surgical techniques. We performed a retrospective single-center review (January 2000 to December 2012) of patients with HLHS undergoing TV repair and completing Fontan circulation. We evaluated the pre- and postoperative echocardiograms, intraoperative findings, and surgical techniques used. A total of 53 TV repairs were performed in 35 patients with HLHS completing staged palliation. TV repairs were performed at stage II in 15, between stage II and III in 4, at stage III in 27, and after stage III in 7. The surgical techniques for valvuloplasty included annuloplasty (38%), anteroseptal (AS) commissuroplasty (66%), anterior papillary muscle repositioning (11%), multiple commissuroplasties (9%), septal-posterior commissuroplasty (9%), and fenestration closure (4%). The predominant jet of TR emanated along the AS commissure in 68% of the cases. All patients survived the procedure and were discharged. Preoperative echocardiography showed a dilated TV annulus on the lateral dimension, anteroposterior dimension, and area that was significantly reduced after TV repair (P < .0001). The preoperative mean TR, as assessed by lateral (P = .002) and anteroposterior (P = .005) vena contracta, was also significantly reduced after TV repair. TV repair did not significantly affect right ventricular systolic function immediately after surgery (P = .17) or at the most recent follow-up visit (P = .52). Patients with anterior leaflet prolapse were at increased risk of worse outcomes, including moderate or greater right ventricular dysfunction (P = .02). Patients requiring reoperation for TV repair were younger (6.3 vs 28.1 months, P < .0001) at the initial operation. One patient died of heart failure. Freedom from TV replacement and transplant-free survival were both 97% at the most recent follow-up point. TR in patients with HLHS commonly emanates from the AS commissure. The associated mechanisms are often annular dilatation and anterior leaflet prolapse. Preoperative anterior leaflet prolapse was associated with worse outcomes. Annuloplasty, closure of the AS commissure, and repositioning of the anterior papillary muscle are effective in addressing TR in the short- and mid-term in this challenging population. Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Data for free--can an electronic medical record provide outcome data for incontinence/prolapse repair procedures?

PubMed

Steidl, Matthew; Zimmern, Philippe

2013-01-01

We determined whether a custom computer program can improve the extraction and accuracy of key outcome measures from progress notes in an electronic medical record compared to a traditional data recording system for incontinence and prolapse repair procedures. Following institutional review board approval, progress notes were exported from the Epic electronic medical record system for outcome measure extraction by a custom computer program. The extracted data (D1) were compared against a manually maintained outcome measures database (D2). This work took place in 2 phases. During the first phase, volatile data such as questionnaires and standardized physical examination findings using the POP-Q (pelvic organ prolapse quantification) system were extracted from existing progress notes. The second phase used a progress note template incorporating key outcome measures to evaluate improvement in data accuracy and extraction rates. Phase 1 compared 6,625 individual outcome measures from 316 patients in D2 to 3,534 outcome measures extracted from progress notes in D1, resulting in an extraction rate of 53.3%. A subset of 3,763 outcome measures from D1 was created by excluding data that did not exist in the extraction, yielding an accuracy rate of 93.9%. With the use of the template in phase 2, the extraction rate improved to 91.9% (273 of 297) and the accuracy rate improved to 100% (273 of 273). In the field of incontinence and prolapse, the disciplined use of an electronic medical record template containing a preestablished set of key outcome measures can provide the ideal interface between required documentation and clinical research. Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Correction of anterior mitral prolapse: the parachute technique.

PubMed

Zannis, Konstantinos; Mitchell-Heggs, Laurens; Di Nitto, Valentina; Kirsch, Matthias E W; Noghin, Milena; Ghorayeb, Gabriel; Lessana, Arrigo

2012-04-01

To evaluate a new surgical technique for the correction of anterior mitral leaflet prolapse. From October 2006 to November 2011, 44 consecutive patients (28 males, mean age 55 ± 13 years) underwent mitral valve repair because of anterior mitral leaflet prolapse. Echocardiography was performed to evaluate the distance from the tip of each papillary muscle to the annular plane. A specially designed caliper was used to manufacture a parachute-like device, by looping a 4-0 polytetrafluoroethylene suture between a Dacron strip and Teflon felt pledget, according to the preoperative echocardiographic measurements. This parachute was then used to resuspend the anterior mitral leaflet to the corresponding papillary muscle. Of the 44 patients, 35 (80%) required concomitant posterior leaflet repair. Additional procedures were required in 16 patients (36%). The preoperative logistic European System for Cardiac Operative Risk Evaluation was 4.3 ± 6.9. The clinical and echocardiographic follow-up were complete. The total follow-up was 1031 patient-months and averaged 23.4 ± 17.2 months per patient. The overall mortality rate was 4.5% (n = 2). Also, 2 patients (4.5%) with recurrent mitral regurgitation required mitral valve replacement, 1 on the first postoperative day and 1 after 13 months. In the latter patient, histologic analysis showed complete endothelialization of the Dacron strip. At follow-up, all non-reoperated survivors (n = 40) were in New York Heart Association class I, with no regurgitation in 40 patients (93%) and grade 2+ mitral regurgitation in 3 (7%). This technique offers a simple and reproducible solution for correction of anterior leaflet prolapse. Echocardiography can reliably evaluate the length of the chordae. However, the long-term results must be evaluated and compared with other surgical strategies. Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

[POP-Q indication points, Aa and Ba, involve in diagnosis and prognosis of occult stress urinary incontinence complicated with pelvic organ prolapse].

PubMed

Liu, Cheng; Wu, Wenying; Yang, Qing; Hu, Ming; Zhao, Yang; Hong, Li

2015-06-01

To investigate the correlation between pelvic organ prolapse quantitation (POP-Q) indication points and the incidence of occult stress urinary incontinence (OSUI) and its impact on prognosis. Retrospective study medical records of 93 patients with pelvic organ prolapse (POP) staged at III-IV, of which underwent pelvic reconstruction operations with Prolift system from Jan. 2007 to Sept. 2012. None of these patients had clinical manifestations of stress urinary incontinence (SUI) before surgery, and in which 44 patients were included in study group (POP complicated with OSUI) because they were identified with OSUI, another 49 patients as control group (simple POP). Follow-up and collecting datas including POP-Q, stress test, urodynamic recordings, incidence of de novo SUI, statistic analyzing by logistic regression and receiver operating characteristic curve (ROC). (1) The study group had a much higher incidence of 30% (13/44) on de novo SUI than that of control group (4%, 2/49; P < 0.01). (2) Vaginal delivery (OR = 5.327, 95% CI: 1.120-25.347), constipation (OR = 5.789, 95% CI: 1.492-22.459), preoperative OSUI (OR = 13.695, 95% CI: 2.980-62.944), anterior vaginal wall prolapse (OR = 6.115, 95% CI: 1.231-30.379) were identified as dependent risk factors for de novo SUI by logistic regression analysis. (3) For POP patients that complicated with OSUI, we chose a cutoff value of +1.5 cm for Aa point as the threshold to predicting incidence of de novo SUI according to ROC curve, area under the curve (AUC) was 0.889 (P < 0.05), the sensitivity reached 88.9% and specificity was 73.9%. According to ROC curve of Ba point, a cutoff value of +2.5 cm was chosen as the threshold to predicting incidence of de novo SUI post-operation, it had a sensitivity of 66.7% and specificity of 82.6%, AUC was 0.766 (P < 0.05). Pre-operative OSUI is a dependent risk factor of de novo SUI for advanced POP patients. Aa and Ba points are correlated with preoperative OSUI, and it is worthy to be considered as a risk predictor on forecasting the incidence of de novo SUI post pelvic reconstruction surgery.

Management of Labor and Delivery After Fetoscopic Repair of an Open Neural Tube Defect.

PubMed

Kohn, Jaden R; Rao, Vibha; Sellner, Allison A; Sharhan, Dina; Espinoza, Jimmy; Shamshirsaz, Alireza A; Whitehead, William E; Belfort, Michael A; Sanz Cortes, Magdalena

2018-06-01

To report labor, delivery, and neonatal outcomes in a cohort of women delivering neonates who had undergone fetoscopic neural tube defect repair. We conducted a retrospective cohort study from April 2014 to January 2018. All patients met Management of Myelomeningocele Study eligibility criteria. We included patients with completed second-trimester fetoscopic neural tube defect repair (laparotomy, uterine exteriorization, and minimally invasive access through two or three uterine ports) followed by standardized management of labor and delivery at our institution. Outcomes included rates of vaginal delivery, term delivery, and intrapartum cesarean delivery as well as obstetric and neonatal outcomes after oxytocin. Complications of interest included preterm prelabor rupture of membranes, chorioamnionitis, uterine dehiscence or rupture, 5-minute Apgar score less than 7, and neonatal acidosis (umbilical artery pH less than 7.15). Thirty-four patients had fetoscopic repair, followed by 17 vaginal deliveries (50%, 95% CI 32-68%). Median gestational age was 38 1/7 weeks at vaginal delivery (range 26 0/7-40 2/7 weeks of gestation) and 37 1/7 weeks of gestation at cesarean delivery (range 25 5/7-40 5/7 weeks of gestation); 62% of deliveries occurred at term. Eight patients had prelabor cesarean delivery: three nonurgent and five urgent (for nonreassuring fetal heart tracings). Twenty-six patients labored; six were induced and 20 labored spontaneously. Of the latter, five were augmented. Of 26 laboring patients, 17 delivered vaginally and nine underwent urgent cesarean delivery (35%, 95% CI 17-56%; seven nonreassuring fetal heart tracings and two breech). There were no cases of uterine rupture or dehiscence. Most (94%, 95% CI 80-99%) had normal 5-minute Apgar scores; one neonate (3%, 95% CI 0-15%) had acidosis but normal Apgar scores. Our data regarding trial of labor, use of low-dose oxytocin, and vaginal delivery after prenatal fetoscopic neural tube defect repair are reassuring. Importantly, fetoscopic repair may permit delivery at advanced gestational ages.

Vaginal rupture and evisceration in a dog.

PubMed

Prassinos, Nikitas N; Adamama-Moraitou, Katerina K; Ververidis, Haralabos N; Anagnostou, Tilemachos L; Kladakis, Stefanos E

2010-09-01

A 1.5-year-old German Shepherd mixed breed dog was admitted with mild haemorrhage from the vulva and a perineal mass of 24-hour duration, which had been first observed immediately after parturition. Parturition had occurred at low ambient temperature, and only one puppy survived out of the seven oversized fetuses. The dog was in poor body condition, dehydrated, hypothermic, depressed, non-ambulatory and in a state of shock. Intestinal loops, the urinary bladder and the uterine horns and body were protruding from the vulva. A true vaginal prolapse was also observed. The abdominal viscera were flushed with warm sterile saline solution, protected and maintained wet. The laboratory findings included moderate anaemia, leukocytosis, hypoalbuminaemia, azotaemia and elevated liver enzyme activities. Stabilisation of the dog's general condition was attempted before surgery. Antimicrobial and analgesic drugs were also administered. After exploratory laparotomy the protruding organs, which were in good condition, were reduced. A recent rupture in the vaginal wall, approximately 6 cm long, was observed. Ovariohysterectomy and partial vaginectomy were performed. The preoperative course of therapy was continued, but the bitch died 12 hours later. The probable cause of vaginal rupture and evisceration in this bitch was tenesmus and/or trauma due to the oversized fetuses.

[Sexual outcome after pelvic reconstructive surgery].

PubMed

Fatton, B; Savary, D; Velemir, L; Amblard, J; Accoceberry, M; Jacquetin, B

2009-02-01

Sexual well-being is an important parameter of women's health and quality of live. Sexual disorders may occur in women with pelvic organ prolapse and/or stress urinary incontinence and also after pelvic reconstructive surgery. Sexual dysfunction after POP or SUI surgery has been poorly documented but new condition specific questionnaires have been developed to help us to better evaluate such consequences. This paper reports available data and highlights more specifically consequences of surgery with mesh reinforcement which is, currently, an important issue particularly when performing by vaginal approach.

Comparing different tissue-engineered repair materials for the treatment of pelvic organ prolapse and urinary incontinence: which material is better?

PubMed

Wang, Xiaojuan; Chen, Yisong; Fan, Zhongyong; Hua, Keqin

2018-01-01

Synthetic non-absorbable meshes are widely used to augment surgical repair of pelvic organ prolapse (POP) and stress urinary incontinence (SUI), but these meshes are associated with serious complications. This study compares the attachment and extracellular matrix (ECM) production of adipose-derived stem cells (ADSCs) on different biodegradable nanomaterials to develop tissue engineered repair materials. Rat ADSCs were isolated and cultured on electrospun poly-L-lactic acid (PLA) and electrospun poly(L-lactide)-trimethylene carbonate-gycolide (PLTG) terpolymers for 1 and 2 weeks. Samples were tested for cell proliferation (cell counting kit-8), microstructure, and morphology (scanning electron microscopy), production of ECM components (immunostaining for collagen I, collagen III, and elastin) and biomechanical properties (uniaxial tensile methods). The ADSCs showed good attachment and proliferation on both PLA and PLTG scaffolds. The production of collagen I and collagen III on both scaffolds was greater at 14 days than at 7 days and was greater on PLTG scaffolds than on PLA scaffolds, but these differences were not significant. The addition of ADSCs onto scaffolds led to a significant increase in the biomechanical properties of both PLA and PLTG scaffolds compared with unseeded scaffolds. These data support the use of both PLA and PLTG as tissue-engineered repair materials for POP or SUI.

Lymphangiosarcoma in a 3.5-year-old Bullmastiff bitch with vaginal prolapse, primary lymph node fibrosis and other congenital defects.

PubMed

Williams, J H; Birrell, J; Van Wilpe, E

2005-09-01

Lymphangiosarcoma is an extremely rare tumour in dogs with only 16 cases reported in the literature. Lymphoedema, which may be primary due to defects in the lymphatic system, or secondary to various other pathologies, often precedes malignancy. Of the 16 canine reports, only 1 dog was confirmed as having had prior primary lymphoedema due to aplasia of the popliteal lymph nodes. A case of lymphangiosarcoma is described in a 3.5-year-old purebred, Bullmastiff bitch which presented with vaginal blood 'spotting' for 3 weeks after cessation of oestrus, during which intromission by the male had been unsuccessful. During ovariohysterectomy a large multicystic, proliferative, spongy, fluid-filled, brownish-red mass surrounding the cervix and projecting into the abdominal space was removed with the cervix, and a diagnosis of lymphangiosarcoma made on histological and electron microscopic examination of the tissue. Ultrastructurally, no basement membrane or pericytes were found, only some of the neoplastic endothelial cells were linked by tight junctions while there were gaps between others, and neither micropinocytotic vesicles nor Weibel-Palade bodies occurred in the cells examined. Very few of the endothelial cells lining the many interlinking, tortuous maze of channels, stained slightly positive immunohistochemically for factor VIII-related antigen. The channels were filled mostly with serous fluid, and occasionally mixed leucocytes and some erythrocytes. The endothelium was often associated with underlying blocks of collagenous material, as well as loosely-arranged aggregates of lymphocytes, other mononuclear cells and occasional neutrophils in the connective tissue septae and more prominently perivascularly. The bitch was discharged on antibiotic treatment but returned 2 weeks later with apparent prolapsed vagina which failed to reduce over the next week. Laparotomy revealed the tumour to have spread extensively in the caudal abdomen to involve the broad ligament and the ventral rectal serosa, and the 'prolapsed' tissue was found to be expanded vaginal wall. The bitch was euthanased and necropsied, Histological examination confirmed lymphangiosarcomatous invasion of the submucosal and muscular layers of the retroperitoneal, traumatised, prolapsed part of the vagina, the urethra and the ventral rectal wall. The broad ligament was diffusely invaded with tumour which had proliferated into the caudal abdominal space, and 3 small intra-trabecular foci of tumour were found in the right popliteal lymph node near the hilus. Mitotic figures were generally scarce. There was mild subcutaneous oedema of the ventral trunk extending from the axillae to the inner proximal thighs, which had not been evident clinically, and the lymph nodes (peripheral more so than internal) microscopically showed marked trabecular and perivascular fibrosis especially in hilar regions. Other congenital defects were hepatic capsular and central venous fibrosis with lymphatic duplication and dilatation in all areas of connective tissue, ventrally-incongruous half-circular tracheal rings, and multifocal renal dysplasia affecting the right kidney. There was locally-extensive subacute pyelonephritis of the left kidney.

Posterior repair with perforated porcine dermal graft.

PubMed

Taylor, G Bernard; Moore, Robert D; Miklos, John R; Mattox, T Fleming

2008-01-01

To compare postoperative vaginal incision separation and healing in patients undergoing posterior repair with perforated porcine dermal grafts with those that received grafts without perforations. Secondarily, the tensile properties of the perforated and non-perforated grafts were measured and compared. This was a non-randomized retrospective cohort analysis of women with stage II or greater rectoceles who underwent posterior repair with perforated and non-perforated porcine dermal grafts (Pelvicol(TM) CR Bard Covington, GA USA). The incidence of postoperative vaginal incision separation (dehiscence) was compared. A secondary analysis to assess graft tensile strength, suture pull out strength, and flexibility after perforation was performed using standard test method TM 0133 and ASTM bending and resistance protocols. Seventeen percent of patients (21/127) who received grafts without perforations developed vaginal incision dehiscence compared to 7% (5/71) of patients who received perforated grafts (p = 0.078). Four patients with vaginal incision dehiscence with non-perforated grafts required surgical revision to facilitate healing. Neither tensile strength or suture pull out strength were significantly different between perforated and non-perforated grafts (p = 0.81, p = 0.29, respectively). There was no difference in the flexibility of the two grafts (p = 0.20). Perforated porcine dermal grafts retain their tensile properties and are associated with fewer vaginal incision dehiscences.

Sexual function in women following transvaginal mesh procedures for the treatment of pelvic organ prolapse.

PubMed

Liang, Ching-Chung; Lo, Tsia-Shu; Tseng, Ling-Hong; Lin, Yi-Hao; Lin, Yu-Jr; Chang, Shuenn-Dhy

2012-10-01

Synthetic mesh kits recently adopted in pelvic reconstructive surgeries have achieved great surgical efficacy, but the effects of transvaginal synthetic mesh procedures on women's sexual function are still controversial. This study was conducted to demonstrate sexual function in women before and after surgery with transvaginal mesh (TVM) repair for pelvic organ prolapse (POP). A total of 93 sexually active women scheduled for correcting POP with synthetic mesh kits were recruited. In addition to urogynecological history, pelvic examination by the Pelvic Organ Prolapse Quantification system, and urodynamic testing, consenting participants were asked to complete the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) to evaluate sexual function before and after surgery. At the 3-month urodynamic studies, among the 25 patients with coexistent urodynamic stress incontinence (USI) who had undergone a concomitant transobturator suburethral tape procedure (TOT), 1 (4 %) had persistent USI; 8 of 68 (11.8 %) patients with a negative pessary test developed postoperative USI. Six-month prolapse recurrence rates following TVM alone and TVM with concomitant TOT were 9 and 12 %, respectively. The total PISQ-12 score after surgery showed worse results in the TVM alone group but not in the TVM with concomitant TOT group. The individual scores of PISQ-12 after surgery demonstrated prolapse-related items improved in both TVM groups; sexual function worsened in dyspareunia and behavior domains. Our data revealed that transvaginal synthetic mesh procedures for the treatment of POP generated favorable clinical outcomes, but situations might worsen in dyspareunia and behavior domains, thereby invoking a negative emotional reaction during intercourse after surgery.

[Pelvic floor muscle training and pelvic floor disorders in women].

PubMed

Thubert, T; Bakker, E; Fritel, X

2015-05-01

Our goal is to provide an update on the results of pelvic floor rehabilitation in the treatment of urinary incontinence and genital prolapse symptoms. Pelvic floor muscle training allows a reduction of urinary incontinence symptoms. Pelvic floor muscle contractions supervised by a healthcare professional allow cure in half cases of stress urinary incontinence. Viewing this contraction through biofeedback improves outcomes, but this effect could also be due by a more intensive and prolonged program with the physiotherapist. The place of electrostimulation remains unclear. The results obtained with vaginal cones are similar to pelvic floor muscle training with or without biofeedback or electrostimulation. It is not known whether pelvic floor muscle training has an effect after one year. In case of stress urinary incontinence, supervised pelvic floor muscle training avoids surgery in half of the cases at 1-year follow-up. Pelvic floor muscle training is the first-line treatment of post-partum urinary incontinence. Its preventive effect is uncertain. Pelvic floor muscle training may reduce the symptoms associated with genital prolapse. In conclusion, pelvic floor rehabilitation supervised by a physiotherapist is an effective short-term treatment to reduce the symptoms of urinary incontinence or pelvic organ prolapse. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

Defecography by digital radiography: experience in clinical practice.

PubMed

Gonçalves, Amanda Nogueira de Sá; Sala, Marco Aurélio Sousa; Bruno, Rodrigo Ciotola; Xavier, José Alberto Cunha; Indiani, João Mauricio Canavezi; Martin, Marcelo Fontalvo; Bruno, Paulo Maurício Chagas; Nacif, Marcelo Souto

2016-01-01

The objective of this study was to profile patients who undergo defecography, by age and gender, as well as to describe the main imaging and diagnostic findings in this population. This was a retrospective, descriptive study of 39 patients, conducted between January 2012 and February 2014. The patients were evaluated in terms of age, gender, and diagnosis. They were stratified by age, and continuous variables are expressed as mean ± standard deviation. All possible quantitative defecography variables were evaluated, including rectal evacuation, perineal descent, and measures of the anal canal. The majority (95%) of the patients were female. Patient ages ranged from 18 to 82 years (mean age, 52 ± 13 years): 10 patients were under 40 years of age; 18 were between 40 and 60 years of age; and 11 were over 60 years of age. All 39 of the patients evaluated had abnormal radiological findings. The most prevalent diagnoses were rectocele (in 77%) and enterocele (in 38%). Less prevalent diagnoses were vaginal prolapse, uterine prolapse, and Meckel's diverticulum (in 2%, for all). Although defecography is performed more often in women, both genders can benefit from the test. Defecography can be performed in order to detect complex disorders such as uterine and rectal prolapse, as well as to detect basic clinical conditions such as rectocele or enterocele.

Use and risks of surgical mesh for pelvic organ prolapse surgery in women in New York state: population based cohort study.

PubMed

Chughtai, Bilal; Mao, Jialin; Buck, Jessica; Kaplan, Steven; Sedrakyan, Art

2015-06-02

To assess the use of mesh in pelvic organ prolapse surgery, and compare short term outcomes between procedures using and not using mesh. All inclusive, population based cohort study. Statewide surgical care captured in the New York Statewide Planning and Research Cooperative System. Women who underwent prolapse repair procedures in New York state from 2008 to 2011. 90 day safety events and reinterventions within one year, after propensity score matching. Categorical, time to event, and subgroup analyses (<65 and ≥ 65 year age groups) were conducted. Of 27,991 patients in total, 7338 and 20, 653 underwent prolapse repair procedures with and without mesh, respectively. Mesh use increased by 44.7%, from 1461 procedures in 2008 to 2114 procedures in 2011. Most patients in the cohort were younger than 65 years (62.3% (n=17,424/27, 991)). However, more patients were aged 65 years and older in the mesh group than in the non-mesh group (44.3% (n=3249) v 35.4% (n=7318)). Complications after surgery were not common, irrespective of the use or non-use of mesh. After propensity score matching, patients who received the surgery with mesh had a higher chance of having a reintervention within one year (mesh 3.3% v no mesh 2.2%, hazard ratio 1.47 (95% confidence interval 1.21 to 1.79)) and were more likely to have urinary retention within 90 days (mesh 7.5% v no mesh 5.6%, risk ratio 1.33 (95% confidence interval 1.18 to 1.51)), compared with those who received surgery without mesh. In subgroup analyses based on age, mesh use was associated with an increased risk of reintervention within one year in patients under age 65 years, and increased risk of urinary retention in patients aged 65 years and over. Despite multiple warnings released by the US Food and Drug Administration since 2008, use of mesh in pelvic organ prolapse surgery continues to grow. In this statewide comprehensive study, mesh procedures were associated with an increased risk of reinterventions within one year and urinary retention after surgery. © Chughtai et al 2015.

The use of a surgical assist device to reduce glove perforations in postdelivery vaginal repair: a randomized controlled trial.

PubMed

Bebbington, M W; Treissman, M J

1996-10-01

Our purpose was to compare the effectiveness of a surgical assist device, SutureMate, to decrease glove perforations during postdelivery vaginal repair. This was a prospective randomized trial. After delivery surgeons who needed to perform vaginal repair were randomized to use the surgical assist device or to perform the repair in the usual fashion. After the repair, gloves were collected and the operator was asked to complete a standardized data form that was submitted with the gloves. The gloves were tested for perforations within 24 hours by the Food and Drug Administration-approved hydrosufflation technique. Comparisons were made with chi(2) statistics with p < 0.01 taken as being statistically significant with the use of a Bonferoni adjustment for multiple comparisons. A total of 476 glove sets were evaluated. The use of the surgical assist device significantly reduced the overall glove perforation rate from 28.3% in the control arm to 8.4% in the study arm (p = 0.0001). Rates of perforation varied with level of training and expertise but fell in all groups that used the device. Family physicians had the highest perforation rate in the control arm and benefited most from the device. A total of 76% of perforations were located in the thumb, index, and second fingers of the nondominant hand. Perforations were recognized in only 16% of the glove sets. The level of satisfaction with the device was mixed, but overall 50% of operators indicated that they were either satisfied or very satisfied with the device. The rate of glove perforation in postdelivery vaginal repair is high. The surgical assist device significantly reduced the rate of glove perforations.

Feminizing genitoplasty in adult transsexuals: early and long-term surgical results.

PubMed

Goddard, Jonathan C; Vickery, Richard M; Qureshi, Assad; Summerton, Duncan J; Khoosal, Deenesh; Terry, Tim R

2007-09-01

To examine the early and late surgical outcomes of feminizing genitoplasty (FG) in adult transsexuals in a UK single surgeon practice over a 10-year period. Computerized and manual databases were searched over the period 1994-2004 to identify patients who had undergone male to female FG. Case-notes were retrieved and analysed to identify epidemiological data, the number and type of perioperative problems, early results at outpatient review, late occurring problems and patient satisfaction. A telephone questionnaire was then conducted targeting all FG patients in our series. The questions were directed at identifying surgical complications, outcome and patient satisfaction. In all, 233 case-notes were identified and 222 (95%) were retrieved. All patients had penectomy, urethroplasty and labiaplasty, 207 (93%) had formation of a neoclitoris, and 202 (91%) had a skin-lined neovagina. The median (range) age was 41 (19-76) years. The median hospital stay was 10 (6-21) days. A record of the first outpatient visit was available in 197 (84.5%) cases. The median time to follow up was 56 (8-351) days. Over all, 82.2% had an adequate vaginal depth, with a median depth of 13 (5-15) cm and 6.1% had developed vaginal stenosis. Three (1.7%) patients had had a vaginal prolapse, two (1.1%) had a degree of vaginal skin flap necrosis and one (0.6%) was troubled with vaginal hair growth. In 86.3% of the patients the neoclitorizes were sensitive. There was urethral stenosis in 18.3% of the patients and 5.6% complained of spraying of urine. Minor corrective urethral surgery was undertaken in 36 patients including 42 urethral dilatations, and eight meatotomies were performed. At the first clinic visit 174 (88.3%) patients were 'happy', 13 (6.6%) were 'unhappy' and 10 (5.1%) made no comment. Of the 233 patients, we successfully contacted 70 (30%). All had had penectomy and labioplasty, 64 (91%) had a clitoroplasty and 62 (89%) a neovagina. The median age was 43 (19-76) years and the median follow up was 36 (9-96) months. Overall, 63 (98%) had a sensate neoclitoris, with 31 (48%) able to achieve orgasm; nine (14%) were hypersensitive. Vaginal depth was considered adequate by 38 (61%) and 14 (23%) had or were having regular intercourse. Vaginal hair growth troubled 18 (29%), four (6%) had a vaginal prolapse and two (3%) had vaginal necrosis. Urinary problems were reported by 19 (27%) patients, of these 18 (26%) required revision surgery, 14 (20%) complained of urinary spraying, 18 (26%) had an upward directed stream and 16 (23%) had urethral stenosis. The patients deemed the cosmetic result acceptable in 53 (76%) cases and 56 (80%) said the surgery met with their expectations. This is largest series of early results after male to female FG. Complications are common after this complex surgery and long-term follow-up is difficult, as patients tend to re-locate at the start of their 'new life' after FG. There were good overall cosmetic and functional results, with a sustained high patient satisfaction.

Preclinical animal study and human clinical trial data of co-electrospun poly(l-lactide-co-caprolactone) and fibrinogen mesh for anterior pelvic floor reconstruction

PubMed Central

Wu, Xujun; Wang, Yuru; Zhu, Cancan; Tong, Xiaowen; Yang, Ming; Yang, Li; Liu, Zhang; Huang, Weihong; Wu, Feng; Zong, Honghai; Li, Huaifang; He, Hongbing

2016-01-01

Synthetic and biological materials are commonly used for pelvic floor reconstruction. In this study, host tissue response and biomechanical properties of mesh fabricated from co-electrospun poly(l-lactide-co-caprolactone) (PLCL) and fibrinogen (Fg) were compared with those of polypropylene mesh (PPM) in a canine abdominal defect model. Macroscopic, microscopic, histological, and biomechanical evaluations were performed over a 24-week period. The results showed that PLCL/Fg mesh had similar host tissue responses but better initial vascularization and graft site tissue organization than PPM. The efficacy of the PLCL/Fg mesh was further examined in human pelvic floor reconstruction. Operation time, intraoperative blood loss, and pelvic organ prolapse quantification during 6-month follow-up were compared for patients receiving PLCL/Fg mesh versus PPM. According to the pelvic organ prolapse quantification scores, the anterior vaginal wall 3 cm proximal to the hymen point (Aa point), most distal edge of the cervix or vaginal cuff scar point (C point), and posterior fornix point (D point) showed significant improvement (P<0.01) at 1, 3, and 6 months for both groups compared with preoperatively. At 6 months, improvements at the Aa point in the PLCL/Fg group were significantly more (P<0.005) than the PPM group, indicating that, while both materials improve the patient symptoms, PLCL/Fg mesh resulted in more obvious improvement. PMID:26893556

Pelvic floor muscle training for secondary prevention of pelvic organ prolapse (PREVPROL): a multicentre randomised controlled trial.

PubMed

Hagen, Suzanne; Glazener, Cathryn; McClurg, Doreen; Macarthur, Christine; Elders, Andrew; Herbison, Peter; Wilson, Don; Toozs-Hobson, Philip; Hemming, Christine; Hay-Smith, Jean; Collins, Marissa; Dickson, Sylvia; Logan, Janet

2017-01-28

Pelvic floor muscle training can reduce prolapse severity and symptoms in women seeking treatment. We aimed to assess whether this intervention could also be effective in secondary prevention of prolapse and the need for future treatment. We did this multicentre, parallel-group, randomised controlled trial at three centres in New Zealand and the UK. Women from a longitudinal study of pelvic floor function after childbirth were potentially eligible for inclusion. Women of any age who had stage 1-3 prolapse, but had not sought treatment, were randomly assigned (1:1), via remote computer allocation, to receive either one-to-one pelvic floor muscle training (five physiotherapy appointments over 16 weeks, and annual review) plus Pilates-based pelvic floor muscle training classes and a DVD for home use (intervention group), or a prolapse lifestyle advice leaflet (control group). Randomisation was minimised by centre, parity (three or less vs more than three deliveries), prolapse stage (above the hymen vs at or beyond the hymen), and delivery method (any vaginal vs all caesarean sections). Women and intervention physiotherapists could not be masked to group allocation, but allocation was masked from data entry researchers and from the trial statistician until after database lock. The primary outcome was self-reported prolapse symptoms (Pelvic Organ Prolapse Symptom Score [POP-SS]) at 2 years. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01171846. Between Dec 21, 2008, and Feb 24, 2010, in New Zealand, and Oct 27, 2010, and Sept 5, 2011, in the UK, we randomly assigned 414 women to the intervention group (n=207) or the control group (n=207). One participant in each group was excluded after randomisation, leaving 412 women for analysis. At baseline, 399 (97%) women had prolapse above or at the level of the hymen. The mean POP-SS score at 2 years was 3·2 (SD 3·4) in the intervention group versus 4·2 (SD 4·4) in the control group (adjusted mean difference -1·01, 95% CI -1·70 to -0·33; p=0·004). The mean symptom score stayed similar across time points in the control group, but decreased in the intervention group. Three adverse events were reported, all of which were in the intervention group (one women had a fall, one woman had a pain in her tail bone, and one woman had chest pain and shortness of breath). Our study shows that pelvic floor muscle training leads to a small, but probably important, reduction in prolapse symptoms. This finding will be important for women and caregivers considering preventive strategies. Wellbeing of Women charity, the New Zealand Continence Association, and the Dean's Bequest Fund of Dunedin School of Medicine. Copyright © 2017 Elsevier Ltd. All rights reserved.

Döderlein-Krönig vaginal hysterectomy: an alternative to the traditional Heaney hysterectomy.

PubMed

Stone, Daniel E; Malik, Shazia A; Doerhman, Pooja; Videla, Felipe L

2015-05-01

The aim of this study was to demonstrate the surgical steps of performing the Döderlein-Krönig hysterectomy. A video recording was made of the hysterectomy using an alternative technique described by Drs. Döderlein and Krönig in 1906. The patient in the video had stage 3 prolapse and desired surgical correction. The video demonstrates an exam under anesthesia, an anterior colpotomy, delivery of the uterine fundus through the colpotomy, and completion of the hysterectomy. The surgery was performed by a urogynecologist and a resident physician. The patient tolerated the procedure well and had no symptom recurrence at her 1-year follow-up visit. This video was presented at the 2014 International Urogynecological Association Annual Meeting in Washington, DC, as a nondiscussed video poster. This video can assist and educate others in using this technique for performing a hysterectomy. Possible benefits of this approach include decreased blood loss and improved visualization, especially in women with pelvic organ prolapse.

Echocardiographic versus histologic findings in Marfan syndrome.

PubMed

Gu, Xiaoyan; He, Yihua; Li, Zhian; Han, Jiancheng; Chen, Jian; Nixon, J V Ian

2015-02-01

This retrospective study attempted to establish the prevalence of multiple-valve involvement in Marfan syndrome and to compare echocardiographic with histopathologic findings in Marfan patients undergoing valvular or aortic surgery. We reviewed echocardiograms of 73 Marfan patients who underwent cardiovascular surgery from January 2004 through October 2009. Tissue histology was available for comparison in 29 patients. Among the 73 patients, 66 underwent aortic valve replacement or the Bentall procedure. Histologic findings were available in 29 patients, all of whom had myxomatous degeneration. Of 63 patients with moderate or severe aortic regurgitation as determined by echocardiography, 4 had thickened aortic valves. The echocardiographic findings in 18 patients with mitral involvement included mitral prolapse in 15. Of 11 patients with moderate or severe mitral regurgitation as determined by echocardiography, 4 underwent mitral valve repair and 7 mitral valve replacement. Histologic findings among mitral valve replacement patients showed thickened valve tissue and myxomatous degeneration. Tricuspid involvement was seen echocardiographically in 8 patients, all of whom had tricuspid prolapse. Two patients had severe tricuspid regurgitation, and both underwent repair. Both mitral and tricuspid involvement were seen echocardiographically in 7 patients. Among the 73 patients undergoing cardiac surgery for Marfan syndrome, 66 had moderate or severe aortic regurgitation, although their valves manifested few histologic changes. Eighteen patients had mitral involvement (moderate or severe mitral regurgitation, prolapse, or both), and 8 had tricuspid involvement. Mitral valves were most frequently found to have histologic changes, but the tricuspid valve was invariably involved.

The 'respect rather than resect' principle in mitral valve repair: the lateral dislocation of the P2 technique.

PubMed

Zanobini, Marco; Ricciardi, Gabriella; Mammana, Francesco Liborio; Kassem, Samer; Poggio, Paolo; Di Minno, Alessandro; Cavallotti, L; Saccocci, Matteo

2017-09-01

Leaflet resection represents the reference standard for surgical treatment of mitral valve (MV) regurgitation. New approaches recently proposed place emphasis on respecting, rather than resecting, the leaflet tissue to avoid the drawbacks of the 'resection' approach. The lateral dislocation of mid portion of mitral posterior leaflet (P2) technique for MV repair is a nonresectional technique in which the prolapsed P2 segment is sutured to normal P1 segment. Our study evaluates the effectiveness of this technique. We performed the procedure on seven patients. Once ring annular sutures were placed, the prolapsed P2 segment was dislocated toward the normal P1 segment with a rotation of 90° and without any resection. If present, residual clefts between P2 and P3 segments were closed. Once the absence of residual mitral regurgitation is confirmed by saline pressure test, ring annuloplasty was completed. The valve was evaluated using transesophageal echocardiography in the operating room and by transthoracic echocardiography before discharge. At the last follow-up visit, transthoracic echocardiography revealed no mitral regurgitation and normal TRANSVALVULAR gradients. The lateral dislocation of P2 is an easily fine-tuned technique for isolated P2 prolapse, with the advantage of short aortic cross-clamp and cardiopulmonary bypass times. We think it might be very favorable in older and frail patients. Long-term follow-up is necessary to assess the durability of this technique.

Transapical off-pump mitral valve repair. First experience with the NeoChord system in Poland (report of two cases).

PubMed

Wróbel, Krzysztof; Kurnicka, Katarzyna; Zygier, Marcin; Dyk, Wojciech; Wojdyga, Ryszard; Zieliński, Dariusz; Jarzębska, Małgorzata; Juraszyński, Zbigniew; Lichodziejewska, Barbara; Pruszczyk, Piotr; Biederman, Andrzej; Speziali, Giovanni; Kasten, Uwe

2017-01-01

Artificial chord implantation to repair a flail or prolapsing mitral valve leaflet requires open heart surgery and cardiopulmonary bypass. Transapical off-pump artificial chordae implantation is a new surgical technique proposed to treat degenerative mitral valve regurgitation. The procedure is performed using the NeoChord DS1000 system (NeoChord, Inc., St. Louis Park, MN, USA), which facilitates both implantation and lenght adjustment of the artificial chordae under two (2D)- and three (3D)-dimensional transoesophageal echocardiographic (TEE) guidance on a beating heart. Two male patients aged 60 and 55 years with severe mitral regurgitation due to posterior leaflet prolapse underwent transapical off-pump artificial chordae implantation on September 3, 2015. The procedure was performed by left minithoracotomy under general anaesthesia in a cardiac surgical theatre, using 2D and 3D TEE guidance. Early procedural success as confirmed by 3D TEE was achieved in both patients, with implantation of 6 artificial chordae in the first patient and 3 artificial chordae in the second patient. Both procedures were uneventful, and no postoperative complications were noted. The patients were discharged home on the 8th and 6th postoperative day, respectively. The NeoChord DS1000 system allows both implantation and lenght adjustment of artificial chordae under 2D and 3D TEE guidance on a beating heart. Our initial experience in 2 patients with posterior mitral leaflet prolapse indicates that the procedure is feasible and safe.

Significance of preoperative calculation of uterine weight as an indicator for preserving the uterus in pelvic reconstructive surgery

PubMed Central

Sheng, Qingsong; Ma, Ning; Huang, Huijuan; Xu, Bo; He, Chunni; Song, Yanfeng

2015-01-01

Recently, increasing evidence has shown that uterus preservation is beneficial for pelvic organ prolapse (POP) patients, both physiologically and psychologically. However, the preoperative indicators for uterus preservation have rarely been examined. The current study was designed to determine the relationship between the preoperative evaluated uterus weight and the operation selection (preserving the uterus or not) in pelvic reconstructive surgery (PRS) using vaginal meshes. First, in a series of 96 patients undergoing hysterectomy, the uterine weight was calculated by preoperative ultrasound measurements, and was then compared with the postoperative actual weight of the uterus. Subsequently, in a series of 65 patients undergone PRS using vaginal meshes and preserving the uterus, the uterine weight was calculated by preoperative ultrasound measurements. Lastly, in a series of 43 patients with a uterine weight > 56.12 g who had undergone PRS using vaginal meshes, the operation success rate in patients with a preserved uterus was compared to patients for whom the uterus was not preserved. The results showed that uterus weight can be evaluated by ultrasound and used as a preoperative indicator for whether the uterus should be preserved or not in PRS when using vaginal meshes. It was indicated that preoperative evaluation of uterine weight is beneficial for surgical planning and guidance. PMID:25755793

TRREMS procedure (transanal repair of rectocele and rectal mucosectomy with one circular stapler): a prospective multicenter trial.

PubMed

Cruz, José Vinicius; Regadas, Francisco Sergio P; Murad-Regadas, Sthela Maria; Rodrigues, Lusmar Veras; Benicio, Fernando; Leal, Rogério; Carvalho, César G; Fernandes, Margarete; Roche, Lucimar M C; Miranda, Antônio Carlos; Câmara, Lucia; Pereira, Joaquim Costa; Parra, Antonio Mallén; Leal, Vilmar Moura

2011-01-01

Since anorectocele is usually associated with mucosa prolapse and/or rectal intussusceptions, it was developed a stapled surgical technique using one circular stapler. To report the results of Transanal Repair of Rectocele and Rectal Mucosectomy with one Circular Stapler (TRREMS procedure) in the treatment of anorectocele with mucosa prolapse in a prospective multicenter trial. It was conducted by 14 surgeons and included 75 female patients, mean aged 49.6 years, with symptoms of obstructed defecation due to grade 2 (26.7%) and grade 3 (73.3%) anorectocele associated with mucosa prolapse and/or rectal intussusception (52.0%) and an average validated Wexner constipation score of 16. All patients were evaluated by a proctological examination, cinedefecography, anal manometry and colonic transit time. The TRREMS procedure consists of the manual removal of the rectocele wall with circumferential rectal mucosectomy performed with a circular stapler. The mean follow-up time was 21 months. All patients presented obstructed defecation and they persisted with symptoms despite conservative treatment. The mean operative time was 42 minutes. In 13 (17.3%) patients, bleeding from the stapled line required hemostatic suture. Stapling was incomplete in 2 (2.6%). Forty-nine patients (65.3%) required 1 hospitalization day, the remainder (34.7%) 2 days. Postoperatively, 3 (4.0%) patients complained of persistent rectal pain and 7 (9.3%) developed stricture on the stapled suture subsequently treated by stricturectomy under anesthesia (n = 1), endoscopic stricturectomy with hot biopsy forceps (n = 3) and digital dilatation (n = 3). Postoperative cinedefecography showed residual grade I anorectoceles in 8 (10.6%). The mean Wexner constipation score decreased significantly from 16 to 4 (0-4: n = 68) (6: n = 6) (7: n = 1) (P<0.0001). Current trial results suggest that TRREMS procedure is a safe and effective technique for the treatment of anorectocele associated with mucosa prolapse. The stapling technique is low-cost as requires the use of a single circular stapler.

Minimally invasive mitral valve repair in osteogenesis imperfecta.

PubMed

Tagliasacchi, Isabella; Martinelli, Luigi; Bardaro, Leopoldo; Chierchia, Sergio

2017-10-01

Osteogenesis imperfecta is a disorder of the connective tissue that affects several structures including heart valves. However, cardiac surgery is associated with high mortality and morbidity rates. In a 48-year-old man with osteogenesis imperfecta and mitral valve prolapse, we performed the first successful mitral valve repair by right anterior mini-thoracotomy. At the 1-year follow-up, he was asymptomatic and echocardiography confirmed the initial success. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Defecography by digital radiography: experience in clinical practice*

PubMed Central

Gonçalves, Amanda Nogueira de Sá; Sala, Marco Aurélio Sousa; Bruno, Rodrigo Ciotola; Xavier, José Alberto Cunha; Indiani, João Mauricio Canavezi; Martin, Marcelo Fontalvo; Bruno, Paulo Maurício Chagas; Nacif, Marcelo Souto

2016-01-01

Objective The objective of this study was to profile patients who undergo defecography, by age and gender, as well as to describe the main imaging and diagnostic findings in this population. Materials and Methods This was a retrospective, descriptive study of 39 patients, conducted between January 2012 and February 2014. The patients were evaluated in terms of age, gender, and diagnosis. They were stratified by age, and continuous variables are expressed as mean ± standard deviation. All possible quantitative defecography variables were evaluated, including rectal evacuation, perineal descent, and measures of the anal canal. Results The majority (95%) of the patients were female. Patient ages ranged from 18 to 82 years (mean age, 52 ± 13 years): 10 patients were under 40 years of age; 18 were between 40 and 60 years of age; and 11 were over 60 years of age. All 39 of the patients evaluated had abnormal radiological findings. The most prevalent diagnoses were rectocele (in 77%) and enterocele (in 38%). Less prevalent diagnoses were vaginal prolapse, uterine prolapse, and Meckel's diverticulum (in 2%, for all). Conclusion Although defecography is performed more often in women, both genders can benefit from the test. Defecography can be performed in order to detect complex disorders such as uterine and rectal prolapse, as well as to detect basic clinical conditions such as rectocele or enterocele. PMID:28100932

Current Developments and Perspectives on the Diagnosis and Treatment of Urinary Incontinence and Genital Prolapse in Women

PubMed Central

Naumann, G.; Kölbl, H.

2012-01-01

As a key area of gynaecology, urogynaecology has undergone impressive changes in the past few years. Together with the high prevalence of functional pelvic floor disorders, modern anaesthesia procedures and the introduction of new, innovative minimally invasive operation techniques have led to a dramatic increase in the number of operations for incontinence and prolapses. The increasingly subtle diagnostic options, such as, e. g., 2D and 3D sonography of the pelvic floor provide unambiguous findings and facilitate decision making. Tension-free vaginal slings in retro-pubic, trans-obturator or single-incision techniques show a high success rate with few complications and have almost completely replaced the more invasive abdominal surgical techniques for the operative management of stress incontinence. Especially for recurrent prolapse the use of alloplastic nets leads to a markedly improved anatomic and functional outcome. In spite of the euphoria about modern operation techniques and novel net materials, in-depth knowledge of pelvic floor anatomy, sufficient surgical experience and unequivocal guideline-conform indications are mandatory for satisfactory treatment outcomes. The afflicted women must be informed in detail about alternative procedures and more emphasis should be placed on conservative therapy. Novel surgical techniques should be monitored by registers or clinical trials. The professional society is called upon to improve the training curricula for pelvic floor surgery. PMID:25308980

[Imaging of pelvic organ prolapse].

PubMed

Lapray, Jean-François

2013-01-01

Colpocystodefecography (CCD) and dynamic MRI with defecography (MRId) allow an alternation between filling and emptying the hollow organs and the maximum abdominal strain offered by the defecation. When applied in imaging these two principles reveal the masked or underestimated prolapses at the time of the physical examination. A rigorous application of the technique guarantees almost equivalent results from the two examinations. The CCD provides voiding views and improved analysis of the anorectal pathology (intussusception, anismus) but involves radiation and a more invasive examination. MRId has the advantage of providing continuous visibility of the peritoneal compartment, and a multiplanar representation, enabling an examination of the morphology of the pelvic organs and of the supporting structures, with the disadvantage of still necessitating a supine examination, resulting sometimes in an incomplete or impossible evacuation. The normal and abnormal results (cystoptosis, vaginal vault prolapse, enterocele, anorectal intussuception, rectocele, descending perineum, urinary and fecal incontinence) and the respective advantages and limits of the various imaging methods are detailed. Dynamic perineal and introital ultrasound remains more limited in the appreciation of posterior colpoceles and especially in anorectal disorders, than CCD or MRId. Endoanal ultrasound is the first line morphological evaluation of the anal sphincter. Transvaginal and introital ultrasound can detect some complications of suburethral tapes and meshes. Morphological and dynamic imaging are essential complementary tools to the physical examination, especially when a precise anatomic assessment is required to understand the functional complaint or when a reintervention is needed.

Vaginal Repair of Cesarean Section Scar Diverticula that Resulted in Improved Postoperative Menstruation.

PubMed

Zhou, Jieru; Yao, Min; Wang, Husheng; Tan, Weilin; Chen, Pin; Wang, Xipeng

2016-01-01

Owing to the increase in cesarean sections (C-sections) worldwide, long-term complications such as postmenstrual spotting, chronic pelvic pain, and C-section scar ectopic pregnancies have created a new medical era of gynecologic disease. A new type of vaginal repair is evaluated to repair C-section diverticulum (CSD) and rebuild the muscular layer to improve symptoms of abnormal uterine bleeding and decrease the risk of uterine rupture. Retrospective cohort study (Canadian Task Force classification II-2). University hospital. A total of 121 patients with CSD diagnoses by transvaginal ultrasound (TVU) presented with postmenstrual spotting between June 2012 and March 2015. All patients had undergone at least 1 C-section delivery and had no history of postmenstrual spotting before undergoing C-section. Vaginal excision and suture of CSD. The mean duration of menstruation was 14.87 ± 3.46 days preoperatively and decreased to 8.22 ± 2.73 days at 1 month after surgery, 8.89 ± 2.67 days at 3 months after surgery, and 9.02 ± 2.47 days at 6 months after surgery (p < .01). The length, width, depth, and thickness of the remaining muscular layer (TRM) at 1 month, 3 months, and 6 months assessed by TVU also improved significantly after surgery (p < .05). However, postoperative menstruation and imaging data did not differ markedly between 3 months and 6 months, suggesting that follow-up at 3 months represents an adequate endpoint for evaluating the effectiveness of surgery. At 6 months, 80.3% of patients (94 of 117) reached ≤10 days of menstruation. Further study revealed that a TRM at 6 months of ≥8.5 mm measured by TVU (relative risk [RR], 6.418; 95% confidence interval [CI], 1.478-28.443) and an interval between CS and vaginal repair of ≤2.5 years (RR, 12.0; 95% CI, 1.541- 93.454) were good prognostic factors associated with surgery. Vaginal repair of CSD improved the symptoms of postmenstrual spotting and anatomically corrected the scars. An interval between C-section and a surgery of ≤2.5 years was optimal for vaginal repair, and a TRM at 6 months of ≥8.5 mm represented the standard healing of CSD. Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.

Bilateral pedicled myocutaneous vertical rectus abdominus muscle flaps to close vesicovaginal and pouch-vaginal fistulas with simultaneous vaginal and perineal reconstruction in irradiated pelvic wounds.

PubMed

Horch, Raymund E; Gitsch, G; Schultze-Seemann, W

2002-09-01

Chronic postoperative pouch-vaginal and vesicovaginal fistulas after hysterectomy and irradiation to treat advanced cervical cancer do not respond to conventional treatment because of the low vascularity in the irradiated area. We present the successful repair of these complications in a female patient, in whom several vaginal and abdominal approaches had been tried and had resulted not only in failure but also in tissue loss and fibrosis and persisting fistulas. First, a synchronous vaginoabdominal approach using a vertical myocutaneous distally based rectus abdominis myocutaneous flap was used successfully to close a pouch-vaginal fistula and simultaneously reconstruct the posterior vaginal wall. In a second approach, the persisting vesicovaginal fistula was closed by a right rectus abdominis myocutaneous flap while simultaneously reconstructing the anterior vaginal wall, closing the enterocutaneous stoma and performing an appendicovesicostomy as a continence channel for catheterization. Despite unfavorable local wound situations, including an enterocutaneous stoma through the rectus abdominis and various previous incision lines, the transfer of axially well-vascularized tissue can solve these problem wounds. Consecutive bilateral use of the rectus abdominis flap may be necessary to deal with extensive pelvic wounds. This technique should be considered as one repair modality in irradiated pelvic wounds with fistulas. Previous enterostomy is not a contraindication to the use of this flap.

Anatomic characteristics of bileaflet mitral valve prolapse--Barlow disease--in patients undergoing mitral valve repair.

PubMed

Rostagno, Carlo; Droandi, Ginevra; Rossi, Alessandra; Bevilacqua, Sergio; Romagnoli, Stefano; Montesi, Gian Franco; Stefàno, Pier Luigi

2014-01-01

Barlow disease is a still challenging pathology for the surgeon. Aim of the present study is to report anatomic abnormalities of mitral valve in patients undergoing mitral valve repair. Between January 1st, 2007, and December 31st, 2010, 85 consecutive patients (54 men and 31 women, mean age 59 +/- 14 years--range: 28-85 years) with the features of a Barlow mitral valve disease underwent mitral repair Forty seven percent of patients were in New York Heart Association functional class III or IV. Preoperative transesophageal echocardiography was compared with anatomical findings at the moment of surgery. Transthoracic echocardiography diagnosis of Barlow disease according to the criteria described by Carpentier was confirmed at anatomical inspection. Annular calcifications were found in 28 patients while 7 patients presented single or multiple clefts. A flail posterior mitral leaflet was detected in 32 subjects, while a flail anterior leaflet in 8. Elongation of chordae tendineae was demonstrated in 45 patients and chordal rupture in 31. All patients showed at trans esophageal echocardiography the typical features of Barlow disease. Seventy-seven (90.6%) patients had severe mitral valve regurgitation, in the remaining 9.4% it was moderate to severe. Transesophageal echocardiography failed to identify clefts in 2/7 and chordal rupture in 4/31. bileaflet prolapse > 2 mm, billowing valve with excess tissue and thickened leaflets > or = 3 mm, and severe annular dilatation, are characteristics of Barlow disease, however the identification of the associated and complex abnormalities of mitral valve is necessary to obtain optimal valve repair.

Risk of recurrence, subsequent mode of birth and morbidity for women who experienced severe perineal trauma in a first birth in New South Wales between 2000 –2008: a population based data linkage study

PubMed Central

2013-01-01

Background Severe perineal trauma occurs in 0.5-10% of vaginal births and can result in significant morbidity including pain, dyspareunia and faecal incontinence. The aim of this study is to determine the risk of recurrence, subsequent mode of birth and morbidity for women who experienced severe perineal trauma during their first birth in New South Wales (NSW) between 2000 – 2008. Method All singleton births recorded in the NSW Midwives Data Collection between 2000–2008 (n=510,006) linked to Admitted Patient Data were analysed. Determination of morbidity was based upon readmission to hospital within a 12 month time period following birth for a surgical procedure falling within four categories: 1. Vaginal repair, 2. Fistula repair, 3. Faecal and urinary incontinence repair, and 4. Rectal/anal repair. Women who experienced severe perineal trauma during their first birth were compared to women who did not. Results 2,784 (1.6%) primiparous women experienced severe perineal trauma during this period. Primiparous women experiencing severe perineal trauma were less likely to have a subsequent birth (56% vs 53%) compared to those not who did not (OR 0.9; CI 0.81-0.99), however there was no difference in the subsequent rate of elective caesarean section (OR 1.2; 0.95-1.54), vaginal birth (including instrumental birth) (OR 1.0; CI 0.81-1.17) or normal vaginal birth (excluding instrumental birth) (OR 1.0; CI 0.85-1.17). Women were no more likely to have a severe perineal tear in the second birth if they experienced this in the first (OR 0.9; CI 0.67-1.34). Women who had a severe perineal tear in their first birth were significantly more likely to have an ‘associated surgical procedure’ within the ≤12 months following birth (vaginal repair following primary repair, rectal/anal repair following primary repair, fistula repair and urinary/faecal incontinence repair) (OR 7.6; CI 6.21-9.22). Women who gave birth in a private hospital compared to a public hospital were more likely to have an ‘associated surgical procedure’ in the 12 months following the birth (OR 1.8; CI 1.54-1.97), regardless of parity, birth type and perineal status. Conclusion Primiparous women who experience severe perineal trauma are less likely to have a subsequent baby, more likely to have a related surgical procedure in the 12 months following the birth and no more likely to have an operative birth or another severe perineal tear in a subsequent birth. Women giving birth in a private hospital are more likely to have an associated surgical procedure in the 12 months following birth. PMID:23565655

Pelvic fracture urethral injuries in girls.

PubMed

Podestá, M L; Jordan, G H

2001-05-01

Injuries to the female urethra associated with pelvic fracture are uncommon. They may vary from urethral contusion to partial or circumferential rupture. When disruption has occurred at the level of the proximal urethra, it is usually complete and often associated with vaginal laceration. We retrospectively reviewed the records of a series of girls with pelvic fracture urethral stricture and present surgical treatment to restore urethral continuity and the outcome. Between 1984 and 1997, 8 girls 4 to 16 years old (median age 9.6) with urethral injuries associated with pelvic fracture were treated at our institutions. Immediate therapy involved suprapubic cystostomy in 4 cases, urethral catheter alignment and simultaneous suprapubic cystostomy in 3, and primary suturing of the urethra, bladder neck and vagina in 1. Delayed 1-stage anastomotic repair was performed in 1 patient with urethral avulsion at the level of the bladder neck and in 5 with a proximal urethral distraction defect, while a neourethra was constructed from the anterior vaginal wall in a 2-stage procedure in 1 with mid urethral avulsion. Concomitant vaginal rupture in 7 cases was treated at delayed urethral reconstruction in 5 and by primary repair in 2. The surgical approach was retropubic in 3 cases, vaginal-retropubic in 1 and vaginal-transpubic in 4. Associated injuries included rectal injury in 3 girls and bladder neck laceration in 4. Overall postoperative followup was 6 months to 6.3 years (median 3 years). Urethral obliteration developed in all patients treated with suprapubic cystostomy and simultaneous urethral realignment. The stricture-free rate for 1-stage anastomotic repair and substitution urethroplasty was 100%. In 1 girl complete urinary incontinence developed, while another has mild stress incontinence. Retrospectively the 2 incontinent girls had had an associated bladder neck injury at the initial trauma. Two recurrent vaginal strictures were treated successfully with additional transpositions of lateral labial flaps. This study emphasizes that combined vaginal-partial transpubic access is a reliable approach for resolving complex obliterative urethral strictures and associated urethrovaginal fistulas or severe bladder neck damage after traumatic pelvic fracture injury in female pediatric patients. Although our experience with the initial management of these injuries is limited, we advocate early cystostomy drainage and deferred surgical reconstruction when life threatening clinical conditions are present or extensive traumatized tissue in the affected area precludes immediate ideal surgical repair.

First uses of HAART 300 rings for aortic valve repair in Poland - 4 case studies.

PubMed

Juściński, Jacek H; Koprowski, Andrzej; Kołaczkowska, Magdalena; Kowalik, Maciej M; Rogowski, Jan A; Rankin, James S

2018-03-01

Aortic valve reconstructions using geometric annuloplasty rings HAART 300/200 open new era in aortic valve surgery. The HAART technology resizes, reshapes, stabilizes and simplifies aortic valve repair. The HAART aortic repair rings are designed to be implanted directly into aortic annulus (under aortic valve leaflets). We present first in Poland 4 cases of aortic valve reconstructions using geometric annuloplasty rings HAART 300. Two patients had type IA aortic insufficiency (due to El-Khoury classification) - they were treated by HAART 300 ring insertion and ascending aorta prosthesis implantation. Third patient, Marfan with type IB aortic insufficiency was repaired by HAART 300 ring implantation followed by remodeling (Yacoub) procedure. Fourth patient with type II aortic insufficiency (due to RCC prolapse) was repaired by HAART 300 implantation and cusp plication. All patients shows good results on 6 months postoperative 3D TTE examinations. Presented technique is reproducible and simplify aortic valve reconstructions.

[Is the use of synthetic mesh by vaginal route decrease the risk of cystocele recurrence? Clinical practice guidelines].

PubMed

Le Normand, L; Deffieux, X; Donon, L; Fatton, B; Cour, F

2016-07-01

The use of prosthetic surgery by vaginal route has been widely used to try to reduce the risk of prolapse recurrence in the surgical treatment of vaginal cystoceles. Specific complications including type of erosion have led to randomized studies comparing surgery by vaginal route with and without use of Mesh. This work is based on a systematic review of the literature (PubMed, Medline, Cochrane Library, Cochrane database of systemactic reviews, EMBASE) for meta-analyzes, randomized trials, registries, literature reviews, controlled studies and major not controlled studies, published on the subject. Its implementation has followed the methodology of the HAS on the recommendations for clinical practice, with a scientific argument (with the level of evidence, NP) and a recommendation grade (A, B, C, and professional agreement (AP)). The use of inter-vesicovaginal synthetic mesh improves the anatomical result compared to the autologous surgery for the treatment of cystocele (NP1). However, there is no difference in the functional outcome and there is an increase in the number of reoperations related to specific complications, including vaginal erosions. If the use of inter-vesicovaginal synthetic mesh improves the anatomical result compared to the autologous surgery for the treatment of cystocele (NP1), no difference in functional outcome and the increased number of related reoperations specific complications including vaginal erosions, do not argue for the systematic use of mesh in the treatment of primary cystocele. It must be discussed case by case basis taking into account a risk-benefit uncertain at long-term (grade B). Its use should be supported by additional studies focused on specific populations at risk of recurrence. © 2016 Published by Elsevier Masson SAS. © 2016 Elsevier Masson SAS. Tous droits réservés.

Histological study on the effects of microablative fractional CO2 laser on atrophic vaginal tissue: an ex vivo study.

PubMed

Salvatore, Stefano; Leone Roberti Maggiore, Umberto; Athanasiou, Stavros; Origoni, Massimo; Candiani, Massimo; Calligaro, Alberto; Zerbinati, Nicola

2015-08-01

Microablative fractional CO2 laser has been proven to determine tissue remodeling with neoformation of collagen and elastic fibers on atrophic skin. The aim of our study is to evaluate the effects of microablative fractional CO2 laser on postmenopausal women with vulvovaginal atrophy using an ex vivo model. This is a prospective ex vivo cohort trial. Consecutive postmenopausal women with vulvovaginal atrophy managed with pelvic organ prolapse surgical operation were enrolled. After fascial plication, the redundant vaginal edge on one side was treated with CO2 laser (SmartXide2; DEKA Laser, Florence, Italy). Five different CO2 laser setup protocols were tested. The contralateral part of the vaginal wall was always used as control. Excessive vagina was trimmed and sent for histological evaluation to compare treated and nontreated tissues. Microscopic and ultrastructural aspects of the collagenic and elastic components of the matrix were studied, and a specific image analysis with computerized morphometry was performed. We also considered the fine cytological aspects of connective tissue proper cells, particularly fibroblasts. During the study period, five women were enrolled, and 10 vaginal specimens were finally retrieved. Four different settings of CO2 laser were compared. Protocols were tested twice each to confirm histological findings. Treatment protocols were compared according to histological findings, particularly in maximal depth and connective changes achieved. All procedures were uneventful for participants. This study shows that microablative fractional CO2 laser can produce a remodeling of vaginal connective tissue without causing damage to surrounding tissue.

Application of the low-level laser therapy for the treatment of vaginitis

NASA Astrophysics Data System (ADS)

Passeniouk, A. N.; Mikhailov, V. A.

2000-06-01

Vaginitis is the most common female infectious disease. Females suffering from this disorder are annually increasing in number. There are a lot of modalities of treatment of vaginitis, but because of drug allergy and microbe's stability to drug the treatment of vaginitis is difficult. Our study compares the efficacy of laser-therapy with drug therapy in the treatment of non-specific vaginitis and vaginal candidiasis. Thirty women reci4eed the LLLT by local action with antiseptic liquid daily during ten days, 20 women received metronidazole and fluconozole and vaginal application of metronidazole. The results suggest that local laser-therapy is able to remove sights of vaginitis more efficiently and faster than drug therapy. Repair of normal vaginal microflora, which is the best indicator of recovery, was significantly at a faster rate in laser-therapy group. There were no report of adverse reaction with vaginal laser- therapy, whereas there were women on drug therapy who reported side effects. In conclusion, vaginal aser-therapy with antiseptic liquid is a suitable, effective, safe and chip alternative to drug therapy in the treatment of vaginitis.

Giant primary vaginal calculus secondary to vesicovaginal fistula with partial vaginal outlet obstruction in a 12-year-old girl.

PubMed

Chen, Shushang; Ge, Rong; Zhu, Lingfeng; Yang, Shunliang; Wu, Weizhen; Yang, Yin; Tan, Jianming

2011-10-01

A vesicovaginal fistula with vagina obstruction associated with vaginal calculi is an extremely rare medical condition. We report a giant primary vaginal calculus resulting from vesicovaginal fistula with partial vaginal outlet obstruction secondary to perineum trauma and surgery in a 12-year-old girl. Episiotomy was performed and the adhesive labia minora was split. After the removal of a giant calculus in the vagina, approximately 8 cm in diameter, the fistula tract was completely excised, followed by the repair of the vesicovagina fistula and the vagina. The patient was symptom-free at 6-month follow-up examination. Copyright © 2011 Elsevier Inc. All rights reserved.

Transthoracic echocardiography in patients undergoing mitral valve repair: comparison of new transthoracic 3D techniques to 2D transoesophageal echocardiography in the localization of mitral valve prolapse.

PubMed

Gripari, Paola; Mapelli, Massimo; Bellacosa, Ilaria; Piazzese, Concetta; Milo, Maria; Fusini, Laura; Muratori, Manuela; Ali, Sarah Ghulam; Tamborini, Gloria; Pepi, Mauro

2018-02-26

Successful mitral valve (MV) repair for degenerative mitral regurgitation (DMR) is mainly related to surgical expertise and MV anatomy. Although 2D echocardiography, specifically transoesophageal (TOE), provides precise information regarding MV anatomy, recent advancements in matrix technology meant a decisive step forward to the point where segmental MV analysis can be accurately performed from a noninvasive 3D transthoracic (TTE) approach. The aims of this study were: (a) to evaluate the feasibility and time required for real-time 3D TTE in a large consecutive cohort of patients with severe DMR in the assessment of MV anatomy; (b) to compare the accuracy of 3D TTE and 2D TOE versus surgical inspection in the recognition and localization of all components of the MV leaflets; (c) to establish the added diagnostic value of 3D colourDoppler examination to pure 3D morphologic evaluation. 149 consecutive patients with severe DMR underwent complete 3D TTE before surgery and 2D TOE in the operating room. Echocardiographic data obtained by the different techniques were compared with surgical inspection. 3D TTE was feasible in a relatively short time (8 ± 4 min), with good (49%) and optimal (33%) imaging quality in the majority of cases. 3D TTE had significant better overall accuracy compared to 2D TOE (93 and 91%, p < 0.05, respectively). 2D TOE was significantly more specific than 3D TTE in the identification of A3 prolapse (99 vs. 96%). The colourDoppler mode did not improve significantly the accuracy of 3D TTE, albeit it determined a better sensitivity in the detection of A2 prolapse if compared to 2D TOE (95 vs. 85%). 3D TTE with or without colourDoppler is a feasible and useful method in the analysis of MV prolapse; it allows a preoperative and noninvasive description of the pathology as accurate as the 2D TOE.

Reprogramming of fibroblasts from older women with pelvic floor disorders alters cellular behavior associated with donor age.

PubMed

Wen, Yan; Wani, Prachi; Zhou, Lu; Baer, Tom; Phadnis, Smruti Madan; Reijo Pera, Renee A; Chen, Bertha

2013-02-01

We aimed to derive induced pluripotent stem cell (iPSC) lines from vaginal fibroblasts from older women with pelvic organ prolapse. We examined the effect of donor age on iPSCs and on the cells redifferentiated from these iPSCs. Vaginal fibroblasts were isolated from younger and older subjects for reprogramming. iPSCs were generated simultaneously using an excisable polycistronic lentiviral vector expressing Oct4, Klf4, Sox2, and cMyc. The pluripotent markers of iPSCs were confirmed by immunocytochemistry and quantitative reverse transcription-polymerase chain reaction (qRT-PCR). Spectral karyotyping was performed. The ability of the iPSCs to differentiate into three germ layers was confirmed by embryoid body and teratoma formation. Senescence marker (p21, p53, and Bax) expressions were determined by qRT-PCR and Western blot. The iPSCs were redifferentiated to fibroblasts and were evaluated with senescence-associated β-galactosidase (SA) activity and mitotic index using time-lapse dark-field microscopy. iPSCs derived from both the younger and older subjects expressed pluripotency markers and showed normal karyotype and positive teratoma assays. There was no significant difference in expression of senescence and apoptosis markers (p21, p53, and Bax) in iPSCs derived from the younger subject compared with the older subject. Furthermore, fibroblasts redifferentiated from these iPSCs did not differ in SA activity or mitotic index. We report successful derivation of iPSCs from women with pelvic organ prolapse. Older age did not interfere with successful reprogramming. Donor age differences were not observed in these iPSCs using standard senescence markers, and donor age did not appear to affect cell mitotic activity in fibroblasts redifferentiated from iPSCs.

Safety and long-term efficacy of fractional CO2 laser treatment in women suffering from genitourinary syndrome of menopause.

PubMed

Behnia-Willison, Fariba; Sarraf, Sara; Miller, Joseph; Mohamadi, Behrang; Care, Alison S; Lam, Alan; Willison, Nadia; Behnia, Leila; Salvatore, Stefano

2017-06-01

To evaluate the safety and long-term efficacy of fractional CO 2 laser treatment in reducing the severity of symptoms of genitourinary syndrome of menopause (GSM) in menopausal women. 102 women presenting with symptomatic GSM were treated with the fractional CO 2 laser (MonaLisa Touch, DEKA) system across a series of treatments delivered at intervals of six or more weeks. The Australian Pelvic Floor Questionnaire was used to gather data on sexual function and side-effects at three time-points across the study period (prospective panel design study). Wilcoxon signed-rank tests were used to detect statistically and clinically significant changes in sexual function and side-effects occurring from pre- to post-treatment. The primary outcome of this study was an improvement of the symptoms of GSM. The secondary outcome included bladder function and prolapse symptoms. A total of 102 women suffering from moderate to severe GSM were recruited. Eighty-four percent experienced significant improvement in their symptoms after CO 2 laser treatment. Scores on measures of sexual function, dyspareunia, and bothersomeness of sexual issues were improved from pre-treatment to long-term (12-24 month) follow-up. Furthermore, there were improvements on measures of bladder function (P=0.001), prolapse (P=0.001), vaginal sensation (P=0.001), vaginal lubrication (P<0.001) and urge incontinence (P=0.003) from the pre-treatment assessment to the second assessment (i.e. after the third treatment). In this study, fractional microablative CO 2 laser treatment was associated with an improvement in symptoms of GSM and sexual function. Copyright © 2017. Published by Elsevier B.V.

DETERIORATION IN BIOMECHANICAL PROPERTIES OF THE VAGINA FOLLOWING IMPLANTATION OF A HIGH STIFFNESS PROLAPSE MESH

PubMed Central

Feola, Andrew; Abramowitch, Steven; Jallah, Zegbeh; Stein, Suzan; Barone, William; Palcsey, Stacy; Moalli, Pamela

2012-01-01

Objective Define the impact of prolapse mesh on the biomechanical properties of the vagina by comparing the prototype Gynemesh PS (Ethicon, Somerville, NJ) to 2 new generation lower stiffness meshes, SmartMesh (Coloplast, Minneapolis, MN) and UltraPro (Ethicon). Design A study employing a non-human primate model Setting University of Pittsburgh Population 45 parous rhesus macaques Methods Meshes were implanted via sacrocolpexy after hysterectomy and compared to Sham. Because its stiffness is highly directional UltraPro was implanted in two directions: UltraPro Perpendicular (less stiff) and UltraPro Parallel (more stiff), with the indicated direction referring to the blue orientation lines. The mesh-vaginal complex (MVC) was excised en toto after 3 months. Main Outcome Measures Active mechanical properties were quantified as contractile force generated in the presence of 120 mM KCl. Passive mechanical properties (a tissues ability to resist an applied force) were measured using a multi-axial protocol. Results Vaginal contractility decreased 80% following implantation with the Gynemesh PS (p=0.001), 48% after SmartMesh (p=0.001), 68% after UltraPro parallel (p=0.001) and was highly variable after UltraPro perpendicular (p =0.16). The tissue contribution to the passive mechanical behavior of the MVC was drastically reduced for Gynemesh PS (p=0.003) but not SmartMesh (p=0.9) or UltraPro independent of the direction of implantation (p=0.68 and p=0.66, respectively). Conclusions Deterioration of the mechanical properties of the vagina was highest following implantation with the stiffest mesh, Gynemesh PS. Such a decrease associated with implantation of a device of increased stiffness is consistent with findings from other systems employing prostheses for support. PMID:23240801

Deterioration in biomechanical properties of the vagina following implantation of a high-stiffness prolapse mesh.

PubMed

Feola, A; Abramowitch, S; Jallah, Z; Stein, S; Barone, W; Palcsey, S; Moalli, P

2013-01-01

To define the impact of prolapse mesh on the biomechanical properties of the vagina by comparing the prototype Gynemesh PS (Ethicon) to two new-generation lower stiffness meshes, SmartMesh (Coloplast) and UltraPro (Ethicon). A study employing a nonhuman primate model. University of Pittsburgh, PA, USA. Forty-five parous rhesus macaques. Meshes were implanted via sacrocolpopexy after hysterectomy and compared with sham. Because its stiffness is highly directional, UltraPro was implanted in two directions: UltraPro Perpendicular (less stiff) and UltraPro Parallel (more stiff), with the indicated direction referring to the position of the blue orientation lines relative to the longitudinal axis of the vagina. The mesh-vaginal complex (MVC) was excised in toto after 3 months. Active mechanical properties were quantified as the contractile force generated in the presence of 120 mmol/l KCl. Passive mechanical properties (a tissue's ability to resist an applied force) were measured using a multiaxial protocol. Vaginal contractility decreased by 80% following implantation with the Gynemesh PS (P = 0.001), 48% after SmartMesh (P = 0.001), 68% after UltraPro Parallel (P = 0.001) and was highly variable after UltraPro Perpendicular (P = 0.16). The tissue contribution to the passive mechanical behaviour of the MVC was drastically reduced for Gynemesh PS (P = 0.003), but not for SmartMesh (P = 0.9) or UltraPro independent of the direction of implantation (P = 0.68 and P = 0.66, respectively). Deterioration of the mechanical properties of the vagina was highest following implantation with the stiffest mesh, Gynemesh PS. Such a decrease associated with implantation of a device of increased stiffness is consistent with findings from other systems employing prostheses for support. © 2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2013 RCOG.

[Laparoscopic promontofixation].

PubMed

Romero Selas, E; Mugnier, C; Piechaud, P T; Gaston, R; Hoepffner, J-L; Hanna, S; Cusomano, S

2010-11-01

The pathology of the pelvic floor, including the urinary incontinence, the anal incontinence and the genital prolapse, is very dominant, concerning approximately a third of the adult women. It is fundamental that this musculature supports a good function, because of the weakness of the pelvic floor produces urinary incontinence, cysto and rectocele, genital prolapses and sexual dysfunctions. The above mentioned pathology can be corrected by laparoscopic promontofixation, whatever the previous history of pelvic surgery, including the placing of prosthetic material. In this article we describe the above mentioned intervention. Preoperative care is standardized and is accompanied by antibiotic prophylaxis, preventive antithrombotic treatment and in the event of a history of pelvic surgery, a digestive preparation. Positioning of the patient must plan a 30° Trendelenbourg position. After the introduction the trocars, initial surgery comprises anterior dissection of promontory after incision of the posterior peritoneum with the patient placed beforehand in a Trendelembourg position. After that, we make interrectovaginal dissection to free the whole posterior surface of the vagina. This is followed by the installation of a posterior mesh pre-cut in an arc. After intervesical vaginal dissection, the anterior prosthesis comprising a precut polyester mesh is fixed avoiding excess traction. The end of the surgery involves careful reperitonization of all the prosthetic parts. Possible specific surgical complications are vascular and visceral wounds. RESULTS Y CONCLUSIONS: The technique allows the correction of the dysfunction of the pelvic floor and incontinence with good anatomical and functional results. Postoperative secondary haemorrhage and gastrointestinal occlusion may occur. Occurrence of an inflammatory syndrome and low back pain suggests spondylodicitis and MRI should be performed. Vaginal erosion on the prosthesis may occur after several months and seems relatively independent of the prosthetic material used.

Anesthesia and perioperative management of a pneumonectomized dog.

PubMed

Anagnostou, Tilemahos L; Pavlidou, Kiriaki; Savvas, Ioannis; Kazakos, George M; Papazoglou, Lysimachos G; Ververidis, Haralabos N; Raptopoulos, Dimitris

2012-01-01

Although left- or right-sided pneumonectomy is tolerated by normal dogs, complications impacting the respiratory, cardiovascular, and gastrointestinal systems are not uncommon. Pneumonectomy in dogs results in secondary changes in the remaining lung, which include: decreased compliance and vital capacity; and increased pulmonary vascular resistance potentially leading to right ventricular hypertrophy. Such alterations make the anesthetic management of an animal with one lung particularly challenging. This report describes a dog with a history of left pneumonectomy due to Aspergillus fumigatus pneumonia 3 yr before presentation. The dog presented with a vaginal wall prolapse, and surgical resection of the protruding vaginal wall, ovariectomy, and prophylactic gastropexy were performed. Anesthesia was induced with midazolam, fentanyl, and propofol and was maintained with isoflurane using intermittent positive pressure ventilation and a constant rate infusion of fentanyl. Epidural anesthesia was also used. Recovery and postoperative management were uncomplicated. Intensive hemodynamic and respiratory monitoring and appropriate response and treatment of any detected abnormalities, taking into consideration the pathophysiologic alterations occurring in a pneumonectomized animal, are required for successful perianesthetic management.

Obstetrical anal sphincter laceration and anal incontinence 5-10 years after childbirth

PubMed Central

EVERS, Emily C.; BLOMQUIST, Joan L.; MCDERMOTT, Kelly C.; HANDA, Victoria L.

2012-01-01

Objective To investigate the long-term impact of anal sphincter laceration on anal incontinence. Study Design Five to ten years after first delivery, anal incontinence and other bowel symptoms were measured using the Epidemiology of Prolapse and Incontinence Questionnaire and the short form of the Colorectal-Anal Impact Questionnaire. Obstetrical exposures were assessed with review of hospital records. Symptoms and quality of life impact were compared between 90 women with at least one anal sphincter laceration, 320 who delivered vaginally without sphincter laceration and 527 who delivered by cesarean. Results Women who sustained an anal sphincter laceration were most likely to report anal incontinence (odds ratio 2.32; 95% confidence interval 1.27, 4.26) and reported the greatest negative impact on quality of life. Anal incontinence and quality of life scores were similar between women who delivered by cesarean and those who delivered vaginally without sphincter laceration. Conclusion(s) Anal sphincter laceration is associated with anal incontinence 5-10 years after delivery. PMID:22831810

Restoration of continence following rectopexy for rectal prolapse and recovery of the internal anal sphincter electromyogram.

PubMed

Farouk, R; Duthie, G S; Bartolo, D C; MacGregor, A B

1992-05-01

Twenty-two patients with full-thickness rectal prolapse underwent ambulatory fine wire electromyography of the internal and sphincter (IAS), external and sphincter and puborectalis, together with anorectal manometry, using a computerized system. Examinations were performed both before and 3 to 4 months after rectopexy. The median (interquartile range (i.q.r.)) preoperative IAS electromyogram (EMG) frequency was 0.18 (0.05-0.31) Hz and the median (i.q.r.) preoperative resting anal pressure was 28 (15-64) cmH2O. An improvement in the IAS EMG frequency, median (i.q.r.) 0.29 (0.19-0.38) Hz (P less than 0.03), and resting anal pressure, median (i.q.r.) 41 (20-72) cmH2O (P less than 0.05), was recorded after operation, but these variables remained significantly lower than those found in normal controls: median (i.q.r.) IAS EMG frequency 0.44 (0.36-0.48) Hz and median (i.q.r.) resting anal pressure 92 (74-98) cmH2O. We suggest that repair of the prolapse allows the IAS to recover by removing the cause of persistent rectoanal inhibition.

Vaginal vault suspension during hysterectomy for benign indications: a prospective register study of agreement on terminology and surgical procedure.

PubMed

Bonde, Lisbeth; Noer, Mette Calundann; Møller, Lars Alling; Ottesen, Bent; Gimbel, Helga

2017-07-01

Several suspension methods are used to try to prevent pelvic organ prolapse (POP) after hysterectomy. We aimed to evaluate agreement on terminology and surgical procedure of these methods. We randomly chose 532 medical records of women with a history of hysterectomy from the Danish Hysterectomy and Hysteroscopy Database (DHHD). Additionally, we video-recorded 36 randomly chosen hysterectomies. The hysterectomies were registered in the DHHD. The material was categorized according to predefined suspension methods. Agreement compared suspension codes in DHHD (gynecologists' registrations) with medical records (gynecologists' descriptions) and with videos (reviewers' categorizations) respectively. Whether the vaginal vault was suspended (pooled suspension) or not (no suspension method + not described) was analyzed, in addition to each suspension method. Regarding medical records, agreement on terminology was good among patients undergoing pooled suspension in cases of hysterectomy via the abdominal and vaginal route (agreement 78.7, 92.3%). Regarding videos, agreement on surgical procedure was good among pooled suspension patients in cases of hysterectomy via the abdominal, laparoscopic, and vaginal routes (agreement 88.9, 97.8, 100%). Agreement on individual suspension methods differed regarding both medical records (agreement 0-90.1%) and videos (agreement 0-100%). Agreement on terminology and surgical procedure regarding suspension method was good in respect of pooled suspension. However, disagreement was observed when individual suspension methods and operative details were scrutinized. Better consensus of terminology and surgical procedure is warranted to enable further research aimed at preventing POP among women undergoing hysterectomy.

The effect of water immersion delivery on the strength of pelvic floor muscle and pelvic floor disorders during postpartum period: An experimental study.

PubMed

Zhao, Yun; Xiao, Mei; Tang, Fei; Tang, Wan; Yin, Heng; Sun, Guo-Qiang; Lin, Yin; Zhou, Yong; Luo, Yan; Li, Lu-Man; Tan, Zhi-Hua

2017-10-01

Water immersion delivery is a non-pharmacological approach to ease labor pain. This paper aims to investigate the effect of water immersion delivery on increasing strength of pelvic floor muscle (PFM) and relieving pelvic floor disorders (PFDs) during postpartum period. A total of 2749 vaginal-delivery primiparas in postpartum 6-8 weeks were selected as research objects. Based on the modes of delivery, 600 patients were assigned into water immersion delivery group, 2149 were assigned into conventional delivery group. The scales of PFM strength and pelvic organ prolapsed (POP) were determined by specially trained personnel using digital palpation, and the symptoms of stress urinary incontinence (SUI) were investigated by questionnaire survey. The weak PFM strength was improved by doing Kegel exercise at home for 6-8 weeks. We found that ①The rate of episiotomy in water immersion delivery group was 77.50% (465/600), which was lower than that in conventional delivery group (84.69%, 1820/2149) (P < .01); The primiparas without having an episiotomy have higher PFM strength than those having an episiotomy for both groups (P < .01). ②There was a negative correlation between the scale of PFM strength and SUI or POP, wherein the r-values were -0.135 and -0.435, respectively (P < .01). ③The rate of SUI was 6.50% (39/600) in water immersion delivery group and 6.89% (148/2149) in the conventional delivery group, wherein the intergroup difference was not significant (P > .05); ④The rates of vaginal wall prolapsed and uterus prolapsed were 29.83% (179/600) and 2.83% (17/600) in water immersion delivery group and 30.95% (665/2149) and 4.37% (94/2149) in the conventional delivery group, wherein the intergroup difference was not significant (P > .05). ⑤After Kegel exercise, the strength of PFM was promoted (P < .01). Water immersion delivery has been proved to a beneficial alternative method for conventional delivery method. This delivery mode is associated with fewer episiotomy rate, and avoiding episiotomy is beneficial for maintaining PFM strength of women in postpartum 6-8 weeks. The strength of PFM during postpartum period can be improved by doing Kegel exercise at home.

The effect of water immersion delivery on the strength of pelvic floor muscle and pelvic floor disorders during postpartum period

PubMed Central

Zhao, Yun; Xiao, Mei; Tang, Fei; Tang, Wan; Yin, Heng; Sun, Guo-Qiang; Lin, Yin; Zhou, Yong; Luo, Yan; Li, Lu-Man; Tan, Zhi-Hua

2017-01-01

Abstract Background: Water immersion delivery is a non-pharmacological approach to ease labor pain. This paper aims to investigate the effect of water immersion delivery on increasing strength of pelvic floor muscle (PFM) and relieving pelvic floor disorders (PFDs) during postpartum period. Methods: A total of 2749 vaginal-delivery primiparas in postpartum 6-8 weeks were selected as research objects. Based on the modes of delivery, 600 patients were assigned into water immersion delivery group, 2149 were assigned into conventional delivery group. The scales of PFM strength and pelvic organ prolapsed (POP) were determined by specially trained personnel using digital palpation, and the symptoms of stress urinary incontinence (SUI) were investigated by questionnaire survey. The weak PFM strength was improved by doing Kegel exercise at home for 6-8 weeks. Results: We found that ①The rate of episiotomy in water immersion delivery group was 77.50% (465/600), which was lower than that in conventional delivery group (84.69%, 1820/2149) (P < .01); The primiparas without having an episiotomy have higher PFM strength than those having an episiotomy for both groups (P < .01). ②There was a negative correlation between the scale of PFM strength and SUI or POP, wherein the r-values were −0.135 and −0.435, respectively (P < .01). ③The rate of SUI was 6.50% (39/600) in water immersion delivery group and 6.89% (148/2149) in the conventional delivery group, wherein the intergroup difference was not significant (P > .05); ④The rates of vaginal wall prolapsed and uterus prolapsed were 29.83% (179/600) and 2.83% (17/600) in water immersion delivery group and 30.95% (665/2149) and 4.37% (94/2149) in the conventional delivery group, wherein the intergroup difference was not significant (P > .05). ⑤After Kegel exercise, the strength of PFM was promoted (P < .01). Conclusion: Water immersion delivery has been proved to a beneficial alternative method for conventional delivery method. This delivery mode is associated with fewer episiotomy rate, and avoiding episiotomy is beneficial for maintaining PFM strength of women in postpartum 6-8 weeks. The strength of PFM during postpartum period can be improved by doing Kegel exercise at home. PMID:29019880

Incontinence after primary repair of obstetric anal sphincter tears is related to relative length of reconstructed external sphincter: a case-control study.

PubMed

Norderval, S; Røssaak, K; Markskog, A; Vonen, B

2012-08-01

To determine if anatomic primary repair with end-to-end reconstruction of the external anal sphincter (EAS) in its full length combined with separate repair of coexisting internal anal sphincter (IAS) tear, when present, results in less incontinence and better anal sphincter integrity compared with conventional primary end-to-end repair in which the IAS is not actively reconstructed. Women who sustained third- or fourth-degree obstetric tears were included prospectively in the study following anatomic primary repair. Women treated with conventional primary repair prior to the study period comprised the control group. Three-dimensional endoanal ultrasonography (3D-EAUS) images were classified according to the EAUS defect score, and incontinence according to St Mark's score. Sixty-three women were included in the study group and 61 in the control group, with mean follow-up times of 11 and 21 months, respectively. Among women who had not delivered vaginally prior to the tear, St Mark's score ≥ 3 was reported by 9.6% (5/52) in the study group and 37.5% (15/40) in the control group at follow-up (P = 0.002). The corresponding numbers among women who had previously delivered vaginally were 36.4% (4/11) and 42.9% (9/21), respectively (non-significant). St Mark's score correlated with the EAUS defect score (P = 0.017). An EAS defect exceeding 50% of the sphincter length was significantly less common in the study group, and in a multivariable logistic regression model, mode of repair (anatomic vs conventional) was the only factor explaining the difference in EAS sphincter length between the two groups (P = 0.007). Improved continence status after anatomic primary repair was associated with a better longitudinal reconstruction of the EAS, while the integrity of the IAS did not differ between the groups. Women with a history of vaginal delivery prior to the sphincter tear had an inferior outcome regardless of mode of repair. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Defining patients' knowledge and perceptions of vaginal mesh surgery.

PubMed

Brown, Lindsay K; Fenner, Dee E; Berger, Mitchell B; Delancey, John O L; Morgan, Daniel M; Patel, Divya A; Schimpf, Megan O

2013-01-01

Given recent government investigations and media coverage of the controversy regarding mesh surgery, we sought to define patients' knowledge and perceptions of vaginal mesh surgery. An anonymous survey was distributed to a convenience sample of new patients at urogynecology and female urology clinics at a single medical center during April to June 2012. The survey assessed patients' demographics, information sources, and beliefs and concerns regarding mesh surgery. The Fisher's exact test was used to identify predictors of patients' beliefs regarding mesh. Logistic and linear regressions were used to identify predictors of aversion to surgery and higher concern regarding future surgery. One hundred sixty-four women completed the survey; 62.2% (102/164) indicated knowledge of mesh surgery for prolapse and/or incontinence and were included in subsequent analyses. The mean ± SD age was 58.0 ± 12.5 years, and 24.5% reported prior mesh surgery. The most common information source was television commercials (57.8%); only 23.5% of the women reported receiving information from a medical professional. Participants indicated the following regarding vaginal mesh: class-action lawsuit in progress (55/102 [54.0%]), causes pain (47/102 [47.1%]), possibility of rejection (35/102 [34.3%]), can cause bleeding and become exposed vaginally (30/102 [29.4%]), and should be removed owing to recall (28/102 [27.5%]). Of these women, 22.1% (19/86) indicated they would not consider mesh surgery. On multivariable logistic regression, level of concern, information from friends/family, and knowledge of class-action lawsuit predicted aversion to mesh surgery. Nearly two thirds of new patients had knowledge of vaginal mesh surgery. We identified considerable misinformation and aversion to future mesh surgery among these women.

Effects of mesh-related complications in vaginal surgery on quality of life.

PubMed

Kowalik, Claudia R; Lakeman, Mariëlle M E; de Kraker, Alyde T; Roovers, Jan Paul W R

2018-06-16

Vaginal mesh surgery is subject of debate due to the impact of mesh-related complications on patient's lives. Not all of these complications are symptomatic. Restoration of the anatomy and improvement of pelvic floor function as a result may counter the experienced discomfort related to adverse events. We hypothesized that health-related quality of life (HR-QoL) is comparable in women after vaginal mesh surgery regardless of the presence or absence of a mesh-specific complication. This was a cross-sectional study of 128 women who had vaginal mesh surgery in a Dutch university hospital between 2007 and 2012. HR-QoL was measured in women with and without mesh complications using standardized QoL questionnaires Urogenital Distress Inventory-6 (UDI-6), Incontinence Impact Questionnaire (IIQ), Defecation Distress Inventory (DDI), and Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12). Complications were scored according to the International Urogynecological Association (IUGA) complication classification. Comparisons between groups were performed with Student's t test and analysis of variance (ANOVA) test. In 29 (23%) women, a mesh-related complication occurred. The domain scores of the UDI-6, DDI, IIQ, and PISQ showed no statistically significant differences between women with and without a mesh-related complication. A post hoc analysis showed similar HR-QoL for those in whom the complication had been resolved and those with persistent symptoms of the complication. Mesh surgery imposes specific complications. When counseling patients about the potential adverse events related to vaginal mesh surgery, it is important to inform them that mesh-related complications do not negatively affect QoL related to micturition, defecation, and sexual functioning.

[Development of better tolerated prosthetic materials: applications in gynecological surgery].

PubMed

Debodinance, P; Delporte, P; Engrand, J B; Boulogne, M

2002-10-01

Meshes have come to be widely used for surgical repair of the dysfunctional pelvic floor. The problem to date has been mesh intolerance. History. The first meshes were made with silver filigrees or stainless steel. Non-metallic and non-absorbable synthetic prostheses include nylon, silastic, polytetrafluoroethylene as well as expansive polyester and polypropylene forms. Most of the absorbable prostheses are made of polyglycolic acid and polyglactine 910. Classification. Four groups of biomaterials can be described according to pore size. Mechanical and biological properties. The mechanical properties of meshes have been tested industrially for resistance, pliability, elasticity and ductile qualities. These properties depend on type of tissue structure (woven or knitted) and the type of fiber used (mono and multi-filaments). The goal is to obtain a "silent" material, i.e. a material which does not trigger a host tissue reaction. Introducing the foreign body induces a "scarring" response. This fibroblastic reaction replaces the inflammatory reaction, leading to progressive colonization of the prosthesis. The major risk is infection caused by a disturbance of the inflammatory phase and bacterial development. Bacteria can be trapped in fibrotic tissue, with the risk of delayed infection. Immunological reactions may have an additive effect. These problems are not encountered with absorbable meshes. An ideal implant material must: not undergo physical modification by tissue fluids, be chemically inert, not trigger inflammatory or foreign body cell response in body tissues, be noncarcinogenic and nonallergenic, be capable of resisting mechanical stress and sterilization, and be able to be manufactured in the necessary shape. Polyester, polypropylene and expansive polytetrafluoroethylene fulfill these criteria. The ideal mesh. Eleven criteria are proposed. Complications for hernia repair. Infection and seroma are the most frequent complications with micro-porous meshes. Macro-porous meshes can cause erosive phenomena and adhesions. Retraction of synthetic tissues is observed in 20 to 30% of cases. Meshes in gynecology. In gynecology surgery, meshes made their first appearance in trans-abdominal sacrocolpopexy and slings. A detailed review of complications found in 32 articles studying slings and 22 studying sacrocolpopexy with approximately 10 types of meshes shows that intolerance of slings has oscillated between 1% with Prolene and 31% with Gore-Tex; for abdominal sacrocolpopexy the rate was between 1.7% with Prolene and 20% with Teflon. Rejection phenomena appear during the first year and are proportional to the surface area of the synthetic tissue and the proximity of the vaginal scar. New materials have been proposed over the last ten years for prolapse surgery, notably for cystocele, which accounts for 70% of all repair procedures. Nearly fifteen studies have reported a level of intolerance reaching 6%, the large majority of the meshes used being Prolene meshes. Our personal experience with 87 repair procedures has led us to the conclusion that Prolene is the most adapted mesh, allowing free tension between the bladder and the anterior vaginal wall. Continuous evaluation is needed to study these replacement materials which should in theory, improve the rate of recurrence, which is at present 20% with classic procedures not using a mesh.

Comparison of the Effects of Lidocaine Prilocaine Cream (EMLA) and Lidocaine Injection on Reduction of Perineal Pain During Perineum Repair in Normal Vaginal Delivery

PubMed Central

Kargar, Roxana; Aghazadeh-Nainie, Afsaneh; Khoddami-Vishteh, Hamid Reza

2016-01-01

Objective: To compare the efficacy of EMLA cream and lidocaine injection to reduce pain during episiotomy repair. Materials and methods: A total of 46 primiparous women with normal pregnancy who referred for normal vaginal delivery and needed episiotomy repair were selected and randomly divided into two groups. For EMLA group, one hour before the estimated time of delivery, 5g of EMLA cream was applied to perinealmediolateral incision, and after the delivery of the fetus and placenta, again 5g of EMLA cream was applied to healthy skin around the episiotomy for repair. In the other group, lidocaine 2% was used before episiotomy and for its repair, too. Results: Only 8 people (19%) were in need of further analgesia. The mean ± SD of pain during repair of episiotomy on the VAS scale in all cases was 4.2 ± 2.3 cm. Most people (97%) were satisfied with their episiotomy repair. Comparing the two groups of EMLA and lidocaine, there was no difference between the two groups in terms of the duration of episiotomy repair, need for further analgesia, pain on the VAS scale, and satisfaction with the repair method. Conclusion: The findings of this study showed that the use of EMLA cream in the site of episiotomy incision in primiparous women can induce a level of analgesia equal to that of lidocaine, and cause a similar level of satisfaction. PMID:27385970

Physical activity and pelvic floor muscle training in patients with pelvic organ prolapse: a pilot study.

PubMed

Ouchi, Mifuka; Kato, Kumiko; Gotoh, Momokazu; Suzuki, Shigeyuki

2017-12-01

The details of the physical activity in patients with mild to moderate pelvic organ prolapse (Pmoderate pelvic organ prolapse (POP) remain under-studied. The purpose of the present study was to investigate objective physical activity levels and the changes in pelvic floor muscle(PFM) strength, symptoms and quality of life (QOL) between before and after PFM training (PFMT) in patients with POP. In a prospective pilot study, 29 patients with stage II or III POP completed approximately 16 weeks of PFMT. A reliable activity monitor was used to measure physical activity parameters including step counts, activity and total calories expended, and duration at each intensity level. Maximum vaginal squeeze pressure, POP symptoms and QOL were assessed. Changes in these outcome measures were compared before and after PFMT. The step counts per day (mean ± SD) of women with POP was 7,272.9 ± 3,091.7 before PFMT and 7,553.4 ± 2,831.0 after PFMT. There was no significant change between before and PFMT. PFM strength was significantly increased after PFMT. POP-related symptoms including stress urinary incontinence, frequency, postmicturition dribble and interference with emptying the bowels were significantly improved. The QOL scores for general health, physical limitations, emotion, and severity measures were significantly improved after PFMT. Although PFMT changed PFM strength symptoms, and QOL, there were no changes for any physical activity parameters before and after PFMT. This is probably because the physical activity levels in patients with mild to moderate POP were almost same as in age-matched healthy women.

Female Pelvic Floor Biomechanics: Bridging the Gap

PubMed Central

Easley, Deanna C.; Abramowitch, Steven D.; Moalli, Pamela A.

2017-01-01

Purpose of review The pelvic floor is a complex assembly of connective tissues and striated muscle that simultaneously counteract gravitational forces, inertial forces, and intraabdominal pressures while maintaining the position of the pelvic organs. In 30% of women, injury or failure of the pelvic floor results in pelvic organ prolapse (POP). Surgical treatments have high recurrence rates, due, in part, to a limited understanding of physiologic loading conditions. It is critical to apply biomechanics to help elucidate how altered loading conditions of the pelvis contribute to the development of pelvic organ prolapse and to define surgeries to restore normal support. Recent findings Evidence suggests the ewe is a potential animal model for studying vaginal properties and that uterosacral and cardinal ligaments experience significant creep, which may be affecting surgical outcomes. A new method of measuring ligament displacements in vivo was developed, and finite element models that simulate urethral support, pelvic floor dynamics, and the impact of episiotomies on the pelvic floor were studied. Summary This review highlights some contributions over the past year, including mechanical testing and the creation of models, which are used to understand pelvic floor changes with loading, and the impact of surgical procedures, to illustrate how biomechanics is being utilized. PMID:28267057

Application of Tissue Engineering to Pelvic Organ Prolapse and Stress Urinary Incontinence.

PubMed

Chapple, Christopher R; Osman, Nadir I; Mangera, Altaf; Hillary, Christopher; Roman, Sabiniano; Bullock, Anthony; Macneil, Sheila

2015-05-01

Synthetic or biological materials can be used for the surgical repair of pelvic organ prolapse (POP) or stress urinary incontinence (SUI). While non-degradable synthetic mesh has a low failure rate, it is prone to complications such as infection and erosion, particularly in the urological/gynecological setting when subject to chronic influences of gravity and intermittent, repetitive strain. Biological materials have lower complication rates, although allografts and xenografts have a high risk of failure and the theoretical risk of infection. Autografts are used successfully for the treatment of SUI and are not associated with erosion; however, can lead to morbidity at the donor site. Tissue engineering has thus become the focus of interest in recent years as researchers seek an ideal tissue remodeling material for urogynecological repair. Herein, we review the directions of current and future research in this exciting field. Electrospun poly-L-lactic acid (PLA) and porcine small intestine submucosa (SIS) are two promising scaffold material candidates. Adipose-derived stem cells (ADSCs) appear to be a suitable cell type for scaffold seeding, and cells grown on scaffolds when subjected to repetitive biaxial strain show more appropriate biomechanical properties for clinical implantation. After implantation, an appropriate level of acute inflammation is important to precipitate moderate fibrosis and encourage tissue strength. New research directions include the use of bioactive materials containing compounds that may help facilitate integration of the new tissue. More research with longer follow-up is needed to ascertain the most successful and safe methods and materials for pelvic organ repair and SUI treatment. © 2015 Wiley Publishing Asia Pty Ltd.

The Role of Chronic Mesh Infection in Delayed-Onset Vaginal Mesh Complications or Recurrent Urinary Tract Infections: Results From Explanted Mesh Cultures.

PubMed

Mellano, Erin M; Nakamura, Leah Y; Choi, Judy M; Kang, Diana C; Grisales, Tamara; Raz, Shlomo; Rodriguez, Larissa V

2016-01-01

Vaginal mesh complications necessitating excision are increasingly prevalent. We aim to study whether subclinical chronically infected mesh contributes to the development of delayed-onset mesh complications or recurrent urinary tract infections (UTIs). Women undergoing mesh removal from August 2013 through May 2014 were identified by surgical code for vaginal mesh removal. Only women undergoing removal of anti-incontinence mesh were included. Exclusion criteria included any women undergoing simultaneous prolapse mesh removal. We abstracted preoperative and postoperative information from the medical record and compared mesh culture results from patients with and without mesh extrusion, de novo recurrent UTIs, and delayed-onset pain. One hundred seven women with only anti-incontinence mesh removed were included in the analysis. Onset of complications after mesh placement was within the first 6 months in 70 (65%) of 107 and delayed (≥6 months) in 37 (35%) of 107. A positive culture from the explanted mesh was obtained from 82 (77%) of 107 patients, and 40 (37%) of 107 were positive with potential pathogens. There were no significant differences in culture results when comparing patients with delayed-onset versus immediate pain, extrusion with no extrusion, and de novo recurrent UTIs with no infections. In this large cohort of patients with mesh removed for a diverse array of complications, cultures of the explanted vaginal mesh demonstrate frequent low-density bacterial colonization. We found no differences in culture results from women with delayed-onset pain versus acute pain, vaginal mesh extrusions versus no extrusions, or recurrent UTIs using standard culture methods. Chronic prosthetic infections in other areas of medicine are associated with bacterial biofilms, which are resistant to typical culture techniques. Further studies using culture-independent methods are needed to investigate the potential role of chronic bacterial infections in delayed vaginal mesh complications.

Management of obstructed defecation.

PubMed

Podzemny, Vlasta; Pescatori, Lorenzo Carlo; Pescatori, Mario

2015-01-28

The management of obstructed defecation syndrome (ODS) is mainly conservative and mainly consists of fiber diet, bulking laxatives, rectal irrigation or hydrocolontherapy, biofeedback, transanal electrostimulation, yoga and psychotherapy. According to our experience, nearly 20% of the patients need surgical treatment. If we consider ODS an "iceberg syndrome", with "emerging rocks", rectocele and rectal internal mucosal prolapse, that may benefit from surgery, at least two out of ten patients also has "underwater rocks" or occult disorders, such as anismus, rectal hyposensation and anxiety/depression, which mostly require conservative treatment. Rectal prolapse excision or obliterative suture, rectocele and/or enterocele repair, retrograde Malone's enema and partial myotomy of the puborectalis muscle are effective in selected cases. Laparoscopic ventral sacral colporectopexy may be an effective surgical option. Stapled transanal rectal resection may lead to severe complications. The Transtar procedure seems to be safer, when dealing with recto-rectal intussusception. A multidisciplinary approach to ODS provides the best results.

Management of obstructed defecation

PubMed Central

Podzemny, Vlasta; Pescatori, Lorenzo Carlo; Pescatori, Mario

2015-01-01

The management of obstructed defecation syndrome (ODS) is mainly conservative and mainly consists of fiber diet, bulking laxatives, rectal irrigation or hydrocolontherapy, biofeedback, transanal electrostimulation, yoga and psychotherapy. According to our experience, nearly 20% of the patients need surgical treatment. If we consider ODS an “iceberg syndrome”, with “emerging rocks”, rectocele and rectal internal mucosal prolapse, that may benefit from surgery, at least two out of ten patients also has “underwater rocks” or occult disorders, such as anismus, rectal hyposensation and anxiety/depression, which mostly require conservative treatment. Rectal prolapse excision or obliterative suture, rectocele and/or enterocele repair, retrograde Malone’s enema and partial myotomy of the puborectalis muscle are effective in selected cases. Laparoscopic ventral sacral colporectopexy may be an effective surgical option. Stapled transanal rectal resection may lead to severe complications. The Transtar procedure seems to be safer, when dealing with recto-rectal intussusception. A multidisciplinary approach to ODS provides the best results. PMID:25632177

Trocar-guided trans-vaginal mesh surgery for pelvic organ prolapse: effects on urinary continence and anatomical and functional outcomes. A prospective observational study.

PubMed

Natale, F; Costantini, E; La Penna, C; Illiano, E; Balsamo, R; Carbone, A; Cervigni, M

2017-03-01

Primary objective of this study was to assess the effects of trocar-guided transvaginal mesh surgery (TVM) on cure and prevention rates for incontinence, without concomitant surgery for Stress Urinary Incontinence (SUI). Our secondary objectives were anatomical outcomes, relief of symptoms and effect on quality of life (QoL). This prospective observational study evaluated women who underwent TVM for symptomatic stage >2 Pelvic Organ Prolapse (POP). SUI was evaluated objectively using the cough stress test with prolapse reduced. SUI and urge urinary incontinence (UUI) were subjectively evaluated using ICIQ-SF. Anatomical cure was defined as stage <2 at POP-Q. McNemar chi-square test; paired t-test; Mann-Whitney test. Seventy-two patients reached final evaluation (mean follow-up 72 months). In the 40 pre-op continent patients, 34 (85%) remained continent postoperatively and 6 (15%) showed de novo SUI. Only 1 patient chose to undergo subsequent TVT. The number needed to treat was 6 to prevent 1 women developing de novo objective SUI and 39 to prevent 1 woman having to undergo SUI surgery. In the 32 pre-op incontinent patients, 18 (56.3%) became continent postoperatively. Only 1 patient chose to undergo subsequent TVT. UUI was present in 44 patients pre-operatively and 15 (20.8%) post-operatively (1 de novo). Forty-four patients (61.1%) were continent post-operatively for SUI and UUI. We observed a significant improvement in storage, voiding, post-micturition and prolapse-related symptoms. The anatomical cure rate was 87.5% for the anterior compartment and 90.3%.for the apical segment. The apical recurrence was 8.3% in the patients previously hysterectomised, 18.8% in the patients with uterus preservation and 0% in the patients with concomitant hysterectomy. QoL scores improved in all domains except sleep and personal relationships. We observed mesh exposure in 10 patients (13.9%), in 5 of whom it was associated with a concomitant hysterectomy CONCLUSIONS: TVM showed excellent results in terms of continence and can be performed without contemporary anti-incontinence surgery, for both continent and incontinent women. Patients should have pre-operative counselling before POP surgery. For severe uterine prolapse the Perigee™ System should be employed with concomitant hysterectomy because uterus preservation is associated with significantly higher apical recurrence rates. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Post-traumatic female urethral reconstruction.

PubMed

Blaivas, Jerry G; Purohit, Rajveer S

2008-09-01

Post-traumatic urethral damage resulting in urethrovaginal fistulas or strictures, though rare, should be suspected in patients who have unexpected urinary incontinence or lower urinary tract symptoms after pelvic surgery, pelvic fracture, a long-term indwelling urethral catheter, or pelvic radiation. Careful physical examination and cystourethroscopy are critical to diagnose and assess the extent of the fistula. A concomitant vesicovaginal or ureterovaginal fistula should also be ruled out. The two main indications for reconstruction are sphincteric incontinence and urethral obstruction. Surgical correction intends to create a continent urethra that permits volitional, painless, and unobstructed passage of urine. An autologous pubovaginal sling, with or without a Martius flap at time of reconstruction, should be considered. The three approaches to urethral reconstruction are anterior bladder flaps, posterior bladder flaps, and vaginal wall flaps. We believe vaginal flaps are usually the best option. Options for vaginal repair of fistula include primary closure, peninsula flaps, bilateral labial pedicle flaps, and labial island flaps. Outcomes are optimized by using exacting surgical principles during repair and careful postoperative management by an experienced reconstructive surgeon.

Traumatic Tricuspid Regurgitation.

PubMed

Cheng, Yan; Yao, Lei; Wu, Shengjun

2017-05-31

Traumatic tricuspid regurgitation is a rare and progressive disease. Early diagnosis and surgical valve repair are very important. A 57-year-old male was referred to our hospital with a history of blunt chest trauma. Three-dimensional echocardiography showed severe tricuspid regurgitation and demonstrated two main anterior leaflet chordaes of the tricuspid valve rupture and the whole anterior leaflet prolapsed. The diagnosis was severe tricuspid regurgitation due to leaflet chordae rupture secondary to blunt chest trauma. Surgical repair of the tricuspid valve was performed in this patient. At 3-month follow-up, the right ventricle was decreased in size with significantly improved right ventricular function. The signs and symptoms of right heart failure were relieved. In this case, 3-dimensional transthoracic echocardiography enabled fast and non-invasive evaluation of the spatial destruction of the tricuspid valve and subvalvular apparatus to assist in the planning of valve repair.

Vesicovaginal fistula repair with rectus abdominus myofascial interposition flap.

PubMed

Reynolds, W Stuart; Gottlieb, Lawrence J; Lucioni, Alvaro; Rapp, David E; Song, David H; Bales, Gregory T

2008-06-01

Complex, recurrent vesicovaginal fistulas (VVFs) can be very challenging to repair and often require interposition of nonirradiated, well-vascularized tissue between the urinary system and vagina. We report our experience using a rectus abdominus myofascial (RAM) interposition flap for VVF repair. A retrospective analysis was performed to identify patients who had undergone VVF repair with RAM interposition. Data were collected focusing on preoperative patient characteristics, etiology of VVF, intraoperative parameters, including surgical techniques, and postoperative patient outcomes. We used a RAM interposition flap for VVF repair in 5 patients. All VVFs had developed postoperatively; no patient had received radiotherapy. VVF developed after total abdominal hysterectomy (TAH) or radical cystectomy in 3 and 2 cases, respectively. Both cases of VVF after radical cystectomy occurred in conjunction with orthotopic diversion (neobladder-vaginal fistula). In 3 patients with post-TAH VVF, a total of five previous failed repairs were attempted before RAM interposition. In 1 patient with a neobladder-vaginal fistula, who had received adjuvant chemotherapy, RAM interposition failed, and the patient ultimately required cutaneous urinary diversion after two subsequent failed attempts at repair (68 months of follow-up). The remaining 4 patients (80%) had no evidence of recurrent VVF or voiding abnormalities at a mean follow-up of 19 months (range 8 to 32). Rectus abdominus muscle can be a successful interposition flap during repair of complex, recurrent VVF. In our experience, this has been successful in most cases, particularly in younger patients with nonmalignant processes.

Update on laparoscopic, robotic, and minimally invasive vaginal surgery for pelvic floor repair.

PubMed

Ross, J W; Preston, M R

2009-06-01

Advanced laparoscopic surgery marked the beginning of minimally invasive pelvic surgery. This technique lead to the development of laparoscopic hysterectomy, colposuspension, paravaginal repair, uterosacral suspension, and sacrocolpopexy without an abdominal incision. With laparoscopy there is a significant decrease in postoperative pain, shorter length of hospital stay, and a faster return to normal activities. These advantages made laparoscopy very appealing to patients. Advanced laparoscopy requires a special set of surgical skills and in the early phase of development training was not readily available. Advanced laparoscopy was developed by practicing physicians, instead of coming down through the more usual academic channels. The need for special training did hinder widespread acceptance. Nonetheless by physician to physician training and society training courses it has continued to grow and now has been incorporated in most medical school curriculums. In the last few years there has been new interest in laparoscopy because of the development of robotic assistance. The 3D vision and 720 degree articulating arms with robotics have made suture intensive procedures much easier. Laparosco-pic robotic-assisted sacrocolpopexy is in the reach of most surgeons. This field is so new that there is very little data to evaluate at this time. There are short comings with laparoscopy and even with robotic-assisted procedures it is not the cure all for pelvic floor surgery. Laparoscopic procedures are long and many patients requiring pelvic floor surgery have medical conditions preventing long anesthesia. Minimally invasive vaginal surgery has developed from the concept of tissue replacement by synthetic mesh. Initially sheets of synthetic mesh were tailored by physicians to repair the anterior and posterior vaginal compartment. The use of mesh by general surgeons for hernia repair has served as a model for urogynecology. There have been rapid improvements in biomaterials and specialized kits have been developed by industry. The purpose of this article is to present an update in urogynecologic laparoscopy, robotic surgery, and minimally invasive vaginal surgery.

[Laparoscopic sacrocolpopexy for pelvic organ prolapse: guidelines for clinical practice].

PubMed

Wagner, L; Meurette, G; Vidart, A; Warembourg, S; Terassa, J-B; Berrogain, N; Ragni, E; Le Normand, L

2016-07-01

Open sacrocolpopexy have demonstrated its efficiency in surgical treatment of pelvic organ prolapse with an important backward on a large number of patients. Laparoscopic sacrocolpopexy reproduced the same surgical technique with reduced morbidity and may benefits from the recent development of robotic. Numerous technical variants have been developped around the original procedure but results seems not ever equivalent. Our objectives are to establish practical recommendations issues from the data of the litterature on the various technical aspects of this technique. This work leans on an exhaustive lecture of the literature concerning meta analyses, randomized tries, registers, controlled studies and the largest non controlled studies published on the subject. Recommendations were developed by a multidisciplinary workgroup then reread and amended by an also multidisciplinary group of proofreaders (urologists, gynecologists, gastroenterologists and surgeons). The methodology follows at best the recommendations of the HAS with a scientific argument for every question (accompanied with the level of proof, NP) and the recommendations, the officers (In, B, C and agreement of experts) and validated at the end of the phase of review. Surgical treatment of uro-genital prolapse by abdominal route classically associated hystero and anterior vaginopexy on the sacral ligament with a synthethic mesh. There are no argument to systematically associated a posterior vaginopexy to prevent secondary rectocele (level C). The consensual indication of laparoscopic rectopexy is represented by symptomatic rectal prolapse, the anatomical and functional results of which are the best estimated (level C). The surgical treatment of rectocele, elytrocele and enterocele with a posterior vaginopexy is not well estimated (level 3). Thus, it is not possible to conclude on the results of a posterior vaginal fixation with a mesh in these indications (AP). In the absence of colpocèle, the interest brought by the posterior vaginal mesh is not established (level 3). There is no comparative studies which allows to conclude on the type and mode of fixation of the prostheses of sacrocolpopexy. We would only report the most common practices without other conclusion. The anterior mesh is usually fixed upper on the anterior part of uterus cervix and lower on the anterior vaginal wall. These fixations are most of the time made by suture and on the promontory with non absorbable suture. The great majority of the authors recommend to make a peritonisation of prostheses to limit the risk of post-operative occlusion. It is now recommended to use only 2 kind of not absorbable prostheses: type I (macroporous polypropylene) or type III (polyester) and not to use any more prostheses type II (PTFE, Silicone) (level C) because of a high rate of mesh erosion: PTFE (9 %) or Silicone (19%) (level 3). Biological prostheses are no more recommended, because of short and medium-term lower anatomical results (level B). Anatomical and functional results are not stastistically differents between laparotomy and coelioscopy (NP1) but the comparison of tong-term results between both ways is not yet established. Coelioscopy allows significant reduction of blood losses, hospital stay and return to normal activity (level 1). Furthemore, there is a higher level of post-operative complications in laparotomy (level 1). When sacrocolpopexy is indicated, coelioscopy is thus recommended (level B). During coelioscopic sacrocolpopexy, anatomical and functional result have not shown any significance difference when using or no a robotics assistance but real randomised studies does not exist (level 2). In comparison to coelioscopy, robotic seems not to improve post-operative consequences and not to decrease the rate of complications of sacrocolpopexy (level 3). Robotic assistance cannot be yet recommended when a coelioscopic sacrocolpopexy is indicated (rank B). Sacrocolpopexy using not absorbable meshes allows to cure pelvic organ prolapses with very good results with few complications in terms of prothetic exposure and infection and thus is now considered as the referent prothetic surgical technique in this indication. Thus, it seems very important to establish clear recommendations on the numerous operating technical variants which developed around the original technique. © 2016 Published by Elsevier Masson SAS. © 2016 Elsevier Masson SAS. Tous droits réservés.

Contrast Media Delivery in the Assessment of Anomalous Left Coronary Artery From the Pulmonary Artery.

PubMed

Saade, Charbel; Al-Hamra, Salam; Al-Mohiy, Hussain; El-Merhi, Fadi

2016-05-01

A patient with a history of mitral valve prolapse and regurgitation that was corrected with a mitral ring repair 15 years earlier received a diagnosis of anomalous left coronary artery arising from the pulmonary artery and underwent repair. Coronary computed tomography angiography (CTA) was employed to image the patient before surgical intervention. Synchronizing contrast media administration to opacify the right coronary artery in the arterial phase and the left coronary artery in the venous phase required a test-bolus approach. Matching compromised cardiovascular dynamics with patient-specific contrast media administration protocols was improved considerably with the use of a test-bolus technique during electrocardiography-gated coronary CTA.

Assessment of the psychometric properties of the Short-Form Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) following surgical placement of Prolift+M: a transvaginal partially absorbable mesh system for the treatment of pelvic organ prolapse.

PubMed

Roy, Sanjoy; Mohandas, Anita; Coyne, Karin; Gelhorn, Heather; Gauld, Judi; Sikirica, Vanja; Milani, Alfredo L

2012-04-01

Impairment of sexual function is a significant problem among women suffering from pelvic organ prolapse (POP). Because anatomical measures of POP do not always correspond with patients' subjective reports of their condition, patient-reported outcome measures may provide additional valuable information regarding the experiences of women who have undergone surgery. The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) is a validated, widely used condition-specific questionnaire focused on sexual function among patients with POP or urinary incontinence. This study aims to report sexual function outcomes as measured by PISQ-12 and to evaluate the psychometric characteristics of the questionnaire following surgical mesh implant for the treatment of POP. The PISQ-12 was used to measure sexual function, while a set of other measures, namely, Pelvic Organ Prolapse Quantification, Patient Global Impression of Change, Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and Surgical Satisfaction Questionnaire, was used for validation. Data for the study were collected from a prospective multicenter, single-arm study of surgical POP repair via the transvaginal placement of a partially absorbable mesh system. For baseline, month 3, and month 12 following POP surgery, several psychometric properties of the PISQ-12 were evaluated, including internal consistency (Cronbach's alpha), concurrent validity, discriminant validity, and responsiveness. As measured by the PISQ-12 questionnaire, statistically significant improvements were observed in the composite summary score as well as all three subscale scores at 1 year. The PISQ-12 generally demonstrated good psychometric properties including internal consistency reliability, validity, and responsiveness. The PISQ-12 items had good distributional properties at baseline, with substantial ceiling effects at follow-up visits reflecting improvements experienced by the patients. The PISQ-12 is a valid measure of sexual function in studies involving patients with POP. © 2012 International Society for Sexual Medicine.

Delayed vaginal and urethral mesh exposure: 10 years after TVT surgery.

PubMed

Khanuengkitkong, Siwatchaya; Lo, Tsia-Shu; Dass, Anil Krishna

2013-03-01

Delayed mesh exposure after tension-free vaginal tape (TVT) procedure is rare. We report a case of mesh exposure into the vagina and urethra that developed 10 years after TVT surgery. A 58-year-old postmenopausal woman presented with mixed urinary incontinence. She was investigated, and her stress urinary incontinence was cured with a TVT procedure 10 years ago. She was then scheduled follow-up annually. Two years postsurgery, a granulation tissue was observed and excised at the vaginal incision site. Vaginal examination 10 years postsurgery showed vaginal mesh erosion 0.5 cm from urethral meatus. Cystoscopy revealed concomitant urethral erosion at the posterior urethral wall. Mesh excision was performed, and urethra and vagina were repaired in layers. Postoperative recovery was uneventful. This finding shows that, although rare, complications can occur even after 10 years of TVT surgery.

Vaginal resection and anastomosis for treatment of vestibulovaginal stenosis in 4 dogs with recurrent urinary tract infections.

PubMed

Kieves, Nina R; Novo, Roberto E; Martin, Robert B

2011-10-01

CASE DESCRIPTION-4 dogs were evaluated because of recurrent urinary tract infections. CLINICAL FINDINGS-All dogs had recurrent urinary tract infections and similar clinical signs; 3 dogs had urinary incontinence. Digital vaginal examination revealed vestibulovaginal stenosis in all dogs, which was confirmed by results of contrast vaginourethrography. From image measurements, the vestibulovaginal ratio (ratio of the height of the vestibulovaginal junction to the maximum height of the vagina on a lateral vaginourethrogram) was calculated for each dog. Three dogs had severe stenosis (vestibulovaginal ratio, < 0.20; severe stenosis is defined as a vestibulovaginal ratio < 0.20), whereas the fourth dog had moderate stenosis (vestibulovaginal ratio, 0.24; ratio range for moderate stenosis is 0.20 to 0.25). TREATMENT AND OUTCOME-All dogs were anesthetized for surgical correction of the vestibulovaginal stenosis. Vaginal resection and anastomosis of the stenosis was performed in all 4 dogs, with 1 dog also undergoing episioplasty. Complete resolution of clinical signs was apparent in 3 dogs; 1 dog had postoperative complications including pollakiuria and stranguria, which resulted in rectal and vaginal prolapse. This dog underwent ovariohysterectomy, after which clinical signs resolved. All dogs had resolution of urinary tract infections at the time of follow-up (6 to 8 months after surgery). CLINICAL RELEVANCE-Resection and anastomosis may resolve recurrent urinary tract infections in dogs with severe or moderate vestibulovaginal stenosis. Episiotomy was not necessary for success of surgical treatment, and overall, that procedure increased morbidity, the severity of intraoperative hemorrhage, and duration of surgery.

Laparoscopic repair of vesicovaginal fistulae with a transperitoneal approach at Universitas Gadjah Mada Urological Institute: a case report.

PubMed

Soeroharjo, Indrawarman; Khalilullah, Said Alfin; Danarto, Raden; Yuri, Prahara

2018-02-25

A vesicovaginal fistula is an abnormal fistulous tract extending between the bladder and the vagina that allows the continuous involuntary discharge of urine into the vaginal vault. In addition, the sequelae from these fistulae have a profound effect on the patients in view of their physical, psychological, and social dimensions. The treatment of vesicovaginal fistula is surgical in most cases and the choice of the repair technique is controversial. We evaluated the benefits of a laparoscopic approach in a patient with vesicovaginal fistulae. Here, we present our first experience using a simplified laparoscopic approach technique to repair vesicovaginal fistulae in our country. A 46-year-old Javanese woman presented with urinary incontinence following an abdominal hysterectomy 3 months earlier and received laparoscopic repair. A cystoscopy was performed to confirm the fistula orifice and a stent was inserted into the fistula tract from her bladder to her vagina. A tamponade was inserted into her vagina up to the vaginal apex, to be able to identify the vagina. She had adhesions; therefore, adhesiolysis was performed using a combination of sharp and blunt dissection to expose the vaginal stump and the superior aspect of her bladder. A simple cystotomy was performed and extended to include the fistulae site, and then the defect was repaired by using a running stitch. A second layer of closure was performed in an imbricating fashion with the same suture. The vagina defect was not closed separately but covered with an omental flap. This procedure takes approximately 2.5 hours; estimated blood loss was minimal and there were no intraoperative complications. She had no recurrent symptoms 6 months after surgery. Our case report concludes that the simplified laparoscopic approach to vesicovaginal fistulae is a viable option for successful repair and that it reduces the size of bladder opening, causes minimal bleeding, and gives successful relief.

Successful use of botulinum toxin type a in the treatment of refractory postoperative dyspareunia.

PubMed

Park, Amy J; Paraiso, Marie Fidela R

2009-08-01

Refractory dyspareunia presents a challenging therapeutic dilemma. A woman with defecatory dysfunction and dyspareunia presented with stage 2 prolapse. She underwent laparoscopic and vaginal pelvic floor reconstruction with excision of endometriosis. The patient experienced increased dyspareunia and de novo vaginismus postoperatively that were refractory to trigger point injections, physical therapy, and medical and surgical management. She underwent botulinum toxin type A injections into her levator ani muscles, which allowed her to have sexual intercourse again after 2 years of apareunia with no recurrence of pain for 12 months. Injecting botulinum toxin into the levator ani muscles shows promise for postoperative patients who develop vaginismus and do not respond to conservative therapy.

Autologous buccal mucosa graft augmentation for foreshortened vagina.

PubMed

Grimsby, Gwen M; Bradshaw, Karen; Baker, Linda A

2014-05-01

Vaginal foreshortening after pelvic surgery or radiotherapy may lead to dyspareunia and decreased quality of life. Unfortunately, little literature exists regarding treatment options for this debilitating problem. Autologous buccal mucosal grafting has been previously reported for creation of a total neovagina and the repair of postvaginoplasty vaginal stenosis. Autologous buccal mucosa offers several advantages as a replacement material for vaginal reconstruction. Vaginal and oral buccal mucosa are both hairless, moist, nonkeratinized stratified squamous epithelia. Buccal mucosa has a dense layer of elastic fibers, imparting both elasticity and strength, and acquires a robust neovascularity with excellent graft take. The graft material is readily available and donor site scars are hidden in the mouth. A 60-year-old woman had vaginal foreshortening to 4.5 cm 15 years after radical hysterectomy and brachytherapy for endometrial cancer. She was unable to have intercourse despite attempted vaginal dilation. Her foreshortened vagina was successfully augmented with autologous buccal mucosa grafting at the apex, increasing her vaginal length to 8 cm and permitting pain-free intercourse. Even in the face of an altered surgical field after radical hysterectomy and radiation, autologous buccal mucosa is an option for vaginal reconstruction for vaginal foreshortening.

Bulbocavernous myocutaneous flap: a new technique in repair of recurrent urethrovaginal fistula.

PubMed

Candiani, P; Campiglio, G L; Ceresoli, A; Zanetti, G; Colombo, F; Canclini, L; Austoni, E

1993-12-01

This paper describes the case of a recurrent post-partum urethrovaginal fistula. The extent of the vaginal tissues loss and the perilesional scarring made the direct closure of the defect non practicable. After suturing the urethra, the anterior vaginal wall was reconstructed with an island bulbocavernous musculocutaneous flap raised from the left labium majus. Nineteen months after surgery the flap healed well without peri urethral suffusion.

Putting POP-Q to the test: does C - D = cervical length?

PubMed

Williams, Kathryn S; Rosen, Lisa; Pilkinton, Marjorie L; Dhariwal, Laura; Winkler, Harvey A

2018-06-01

We investigated the correlation between calculated cervical length (CCL) and gross specimen cervical length (GCL) after total vaginal hysterectomy (TVH) at the time of surgery for pelvic organ prolapse (POP). This was a retrospective chart review of patients who had undergone TVH with reconstructive surgery for POP between 2013 and 2015. Patients without an intact specimen or documented cervical length in the pathology report were excluded. CCL was defined as the absolute difference between Pelvic Organ Prolapse Quantification (POP-Q) points C and D. GCL was obtained from the pathology report as the distance from the external to the internal os. The Bland-Altman method was used to assess the accuracy of POP-Q measurements with a priori ranges. Symptom severity was evaluated using the PFDI-20 questionnaire. Analysis of variance was used to model both GCL and CCL as a function of prolapse stage and the leading compartment. The final analysis included 202 subjects. Of the CCL measurements, 56.93% were within ±2 cm of GCL, while 36.14% were within ±1 cm. POP stage was significantly associated with GCL (P < 0.0024). CCL was significantly longer in patients with stage 4 POP (3.57 cm, 95% CI 3.13-4.00) than in those with stage 2 POP (P < 0.0017; mean 2.68 cm, 95% CI 2.45-2.92) and stage 3 POP (P < 0.0300; mean 2.94 cm, 95% CI 2.73-3.15). There were no significant correlations between PFDI scores and CCL or GCL. The agreement between POP-Q CCL (|C - D|) and GCL decreases with increasing POP-Q stage. There was no correlation between POP symptom severity and GCL or CCL. GCL significantly increased with increasing POP stage.

Can we predict urinary stress incontinence by using demographic, clinical, imaging and urodynamic data?

PubMed

Wlaźlak, Edyta; Surkont, Grzegorz; Shek, Ka L; Dietz, Hans P

2015-10-01

It has been claimed that urethral hypermobility and resting urethral pressure can largely explain stress incontinence in women. In this study we tried to replicate these findings in an unselected cohort of women seen for urodynamic testing, including as many potential confounders as possible. This study is a retrospective analysis of data obtained from 341 women. They attended for urodynamic testing due to symptoms of pelvic floor dysfunction. We excluded from the analysis women with a history of previous anti-incontinence and prolapse surgery. All patients had a standardised clinical assessment, 4D transperineal pelvic floor ultrasound and multichannel urodynamic testing. Urodynamic stress incontinence (USI) was diagnosed by multichannel urodynamic testing. Its severity was subjectively graded as mild, moderate and severe. Candidate variables were: age, BMI, symptoms of prolapse, vaginal parity, significant prolapse (compartment-specific), levator avulsion, levator hiatal area, Oxford grading, midurethral mobility, maximum urethral pressure (MUP), maximum cough pressure and maximum Valsalva pressure reached. On binary logistic regression, the following parameters were statistically significant in predicting urodynamic stress incontinence: age (P=0.03), significant rectocele (P=0.02), max. abdominal pressure reached (negatively, P<0.0001), midurethral mobility (P=0.0004) and MUP (negatively, P<0.0001). On multivariate analysis, accounting for multiple interdependencies, the following predictors remained significant: max. abdominal pressure reached (negatively, P<0.0001), cough pressure (P=0.006), midurethral mobility (P=0.003) and MUP (negatively, P<0.0001), giving an R(2) of 0.24. Mid-urethral mobility and MUP are the main predictors of USI. Demographic and clinical data are at best weak predictors. Our results suggest the presence of major unrecognised confounders. Copyright © 2015. Published by Elsevier Ireland Ltd.

Pelvic floor morphometry and function in women with and without puborectalis avulsion in the early postpartum period.

PubMed

Cyr, Marie-Pierre; Kruger, Jennifer; Wong, Vivien; Dumoulin, Chantale; Girard, Isabelle; Morin, Mélanie

2017-03-01

Pelvic floor muscles are subject to considerable stretching during vaginal birth. In 13-36% of women, stretching results in avulsion injury whereby the puborectalis muscle disconnects from its insertion points on the pubis bone. Until now, few studies have investigated the effect of this lesion on pelvic floor muscles in the early postpartum period. The primary aim of this study was to compare pelvic floor muscle morphometry and function in primiparous women with and without puborectalis avulsion in the early postpartum period. Our secondary objective was to compare the 2 groups for pelvic floor disorders and impact on quality of life. In all, 52 primiparous women diagnosed with (n = 22) or without (n = 30) puborectalis avulsion injury were assessed at 3 months postpartum. Pelvic floor muscle morphometry was evaluated with 3-/4-dimensional transperineal ultrasound at rest, maximal contraction, and Valsalva maneuver. Different parameters were measured in the midsagittal and axial planes: bladder neck position, levator plate angle, anorectal angle, and levator hiatus dimensions. The dynamometric speculum was used to assess pelvic floor muscle function including: passive properties (passive forces and stiffness) during dynamic stretches, maximal strength, speed of contraction, and endurance. Pelvic floor disorder-related symptoms (eg, urinary incontinence, vaginal and bowel symptoms) and impact on quality of life were evaluated with the International Consultation on Incontinence Questionnaire and the Pelvic Floor Impact Questionnaire-Short Form. Pelvic Organ Prolapse Quantification was also assessed. In comparison to women without avulsion, women with avulsion presented an enlarged hiatus area at rest, maximal contraction, and Valsalva maneuver (P ≤ .013) and all other ultrasound parameters were found to be significantly altered during maximal contraction (P ≤ .014). They showed lower passive forces at maximal and 20-mm vaginal apertures as well as lower stiffness at 20-mm aperture (P ≤ .048). Significantly lower strength, speed of contraction, and endurance were also found in women with avulsion (P ≤ .005). They also presented more urinary incontinence symptoms (P = .040) whereas vaginal and bowel symptoms were found to be similar in the 2 groups. Pelvic Organ Prolapse Quantification revealed greater anterior compartment descent in women with avulsion (P ≤ .010). The impact of pelvic floor disorders on quality of life was found to be significantly higher in women with avulsion (P = .038). This study confirms that pelvic floor muscle morphometry and function are impaired in primiparous women with puborectalis avulsion in the early postpartum period. Moreover, it highlights specific muscle parameters that are altered such as passive properties, strength, speed of contraction, and endurance. Copyright © 2016 Elsevier Inc. All rights reserved.

Laparoscopy-like operative vaginoscopy: a new approach to manage mesh erosions.

PubMed

Billone, Valentina; Amorim-Costa, Célia; Campos, Sara; Rabischong, Benoĭt; Bourdel, Nicolas; Canis, Michel; Botchorishvili, Revaz

2015-01-01

Mesh erosion through the vagina is the most common complication of synthetic mesh used for pelvic organ prolapse repair. However, conventional transvaginal mesh excision has many technical limitations. We aimed at creating and describing a new surgical technique for transvaginal removal of exposed mesh that would enable better exposition and access, thus facilitating optimal treatment. A step-by-step video showing the technique. A university tertiary care hospital. Five patients previously submitted to pelvic organ prolapse repair using synthetic mesh, presenting mesh erosion through the vagina. Mesh excision using a laparoscopy-like operative vaginoscopy in which standard laparoscopic instruments are used through a single-incision laparoscopic surgery port device placed in the vagina. In all cases, a very good exposure of the mesh was achieved, a minimal tissue traction was required, and the procedures were performed in a very ergonomic way. All the patients were discharged on the same day of the surgery and had a painless postoperative course. So far, there have been no cases of relapse. This seems to be a simple, cheap, and valuable minimally invasive technique with many advantages in comparison with the conventional approach. More cases and time are necessary to access its long-term efficacy. It may possibly be used for the management of other conditions. Copyright © 2015 AAGL. Published by Elsevier Inc. All rights reserved.

Female urethral injuries associated with pelvic fracture: a systematic review of the literature.

PubMed

Patel, Devin N; Fok, Cynthia S; Webster, George D; Anger, Jennifer T

2017-12-01

To review systematically the literature on female urethral injuries associated with pelvic fracture and to determine the optimum management of this rare injury. Using Meta-analysis of Observational Studies in Epidemiology criteria, we searched the Cochrane, Pubmed and OVID databases for all articles available before 30 June 2016 using the terms 'female pelvic fracture urethroplasty', 'female urethral distraction', 'female pelvic fracture urethral injury' and 'female pelvic fracture urethra girls.' Two authors of this paper independently reviewed the titles, abstracts, and articles in duplicate. We identified 162 individual articles from the databases. Fifty-one articles met our criteria for full review, including 158 female patients with urethral trauma. Of these injuries, 83 (53%) were managed with immediate repair; 17/83 (20%) via primary alignment and 66/83 (80%) via anastomotic repair. The remaining 75/158 (47%) were managed with delayed repair. Rates of urethral stenosis and fistula were highest after primary alignment. Urethral integrity appears to be similar after both primary anastomosis and delayed repair; however, patients experienced significantly more incontinence and vaginal stenosis after delayed repair. Patients who underwent delayed urethral repair were more likely to undergo more extensive reconstructive surgery than those who underwent primary repair. The optimum management of female urethral distraction defects is based on very-low-quality literature. Based on our review of the available literature, primary anastomotic repair of a female urethral distraction defect via a vaginal approach as soon as the patient is haemodynamically stable appears to be optimal. © 2017 The Authors BJU International © 2017 BJU International Published by John Wiley & Sons Ltd.

Mitral valve reconstruction in Barlow disease: long-term echographic results and implications for surgical management.

PubMed

Jouan, Jérôme; Berrebi, Alain; Chauvaud, Sylvain; Menasché, Philippe; Carpentier, Alain; Fabiani, Jean-Noël

2012-04-01

Owing to the complexity of the underlying lesions, Barlow disease remains a challenge for surgeons performing mitral valve repair. We aimed to assess whether our most recent results involving several surgeons were comparable with those of a previous experience in which mitral valve repair was performed by a more limited group of surgeons. From September 2000 to January 2007, 200 patients with Barlow disease (135 men and 65 women; mean age, 56 ± 13 years) were referred to our institution for surgical treatment of their mitral regurgitation. We retrospectively analysed the mitral lesions characteristics, the surgical techniques used, and clinical outcomes. Follow-up echocardiograms were biannually reviewed. Lesions comprised annular dilatation, excess tissue, and leaflet prolapse in all cases. The most frequent prolapsed segments were P2 (88.5%; n = 177) and A2 (55.5%; n = 111). Annular calcifications and restrictive valvular motion were associated in 20% (n = 40). Repair was feasible in 94.7% (n = 179/189) of non-redo interventions. Immediate postoperative echocardiography showed residual mitral regurgitation greater than 1+ in 6 cases; these patients were all reoperated on within the next months. Operative mortality was 1.5% (n = 3). Mean follow-up was 77.5 ± 25.6 months. At 8 years postoperatively, overall survival was 88.6% ± 3.1%, freedom from reintervention was 95.3% ± 1.7%, and freedom from late recurrent moderate mitral regurgitation (>2+) was 90.2% ± 3.1% Provided that the fundamental principles of mitral valve reconstruction are respected, the surgical techniques are highly reproducible with good long-term results, similar to those published during the pioneering phase of this surgery. Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

[Study on reductive surgery for pelvic organ prolapse concomitant with anti-incontinence sling for treatment of occult stress urinary incontinence].

PubMed

Zhang, Xiaolong; Lu, Yongxian; Shen, Wenjie; Liu, Jingxia; Ge, Jing; Liu, Xin; Zhao, Ying; Niu, Ke; Zhang, Yinghui; Wang, Wenying; Qiu, Chengli

2014-06-01

To evaluate the clinical outcome of anti-incontinence sling in the treatment of occult stress urinary incontinence (OSUI) during reductive surgery for advanced pelvic organ prolapse (POP). From Jun. 2003 to Dec. 2012, 78 patients with OSUI underwent reductive surgery for advanced POP such as high uterosacral ligament suspension, sacrospinous ligament suspension and sacral colpopexy in the First Affiliated Hospital, General Hospital of People's Liberation Army. Among them, 41 patients received reductive surgery alone was enrolled in non-concomitant anti-incontinence group and the other 37 patients who underwent same surgery with tension-free vaginal tape (TVT) or tension-free vaginal tape-obturator technique (TVT-O) was in anti-incontinence group. The patient's demography, objective and subjective outcomes, as well as complications and injures were compared between the two groups. The pelvic organ prolapse quantitation (POP-Q) was used to evaluate the objective outcomes of POP. Urinary distress inventory (UDI-6) and incontinence impact questionnaire short form (IIQ-7) were used to evaluate the subjective outcomes of stress urinary incontinence (SUI). Compared with the non-concomitant anti-incontinence group, the objective outcomes of reductive surgery exhibited no significant differences (100%, 78/78), and only the operation time of anti-incontinence group slightly increased 16 minutes. The occurrence rate of postoperative SUI was 12% (5/41), 15% (6/41), 17% (7/41) respectively after the operation at 2-month, 6-month and 12-month follow up in the non-concomitant anti-incontinence group; and the occurrence rate of the anti-incontinence group was 3% (1/37), 3% (1/37), 3% (1/37); but none of patients in the two groups require further surgery for stress urinary incontinence. Mean score of UDI-6 and IIQ-7 in all the patients decreased significantly after operation at 2-month, 6-month and 12-month follow up (all P < 0.01). However, there was no statistic difference between the two groups (P > 0.05). It is still difficult to make decision for concomitant anti-incontinence procedure in those patients with OSUI, who are undergoing reductive surgery because of advanced POP. Whether the patients will benefit more from anti-incontinence sling depends largely on strict preoperative evaluation for the severity of SUI. The patients with severe SUI are supposed to benefit most from anti-incontinence sling. However, a two-step approach to correct the postoperative stress urinary incontinence is also reasonable.

Foley catheter guide use during midurethral slings: does it make a difference?

PubMed

Miranne, Jeannine Marie; Dominguez, Aurora; Sokol, Andrew Ian; Gutman, Robert Eric; Iglesia, Cheryl Bernadette

2015-06-01

Our objective was to evaluate whether foley catheter guide use decreased the risk of cystotomy and urethrotomy during retropubic midurethral sling placement. This retrospective cohort study included all women undergoing retropubic synthetic midurethral sling placement at a single academic institution between January 2011 and September 2012. Patients were divided into groups based on whether or not the foley catheter guide was used during surgery. The primary outcome was the incidence of cystotomy. A total of 310 patients underwent retropubic midurethral sling placement. The foley catheter guide was used in 76/310 cases (24.5%). The mean age was 57 ± 11 and mean body mass index was 28 ± 7. More patients in the no-guide group had preoperative urgency (70% versus 58%, p = 0.049), anterior prolapse (95% versus 78%, p < 0.0001), and concomitant prolapse surgery (65% versus 51%, p = 0.03). There was no difference in preoperative urgency urinary incontinence, medical comorbidities, previous surgical history, intraoperative time, blood loss, or postoperative voiding dysfunction rates between groups. Fourteen of the 310 patients (4.5%) had cystotomies: 1/76 (1.3%) in the foley catheter guide group and 13/234 (5.6%) in the no-guide group (p = 0.12). No patients had urethrotomies. On multiple logistic regression, there was no difference in the odds of cystotomy between groups after adjusting for previous prolapse and anti-incontinence surgery, concomitant prolapse repair, level of first assistant, and retropubic local anesthesia use (AOR = 0.2 [95% CI 0.02-1.7]). Foley catheter guide use did not decrease the risk of intraoperative lower urinary tract injury during retropubic midurethral sling placement. Larger prospective studies are needed to confirm this finding.

Pelvic fracture-associated urethral injuries in girls: experience with primary repair.

PubMed

Dorairajan, Lalgudi N; Gupta, Harendra; Kumar, Santosh

2004-07-01

To present our experience with four urethral injuries in females accompanying a pelvic fracture, managed with primary repair or realignment of the urethra. There were three teenage girls and one adult (22 years old). All the patients had complete urethral injuries associated with a pelvic fracture from accidents. They were managed by immediate suprapubic cystostomy followed by repair or realignment of the urethra over a catheter on the same day. The catheter was removed after 3 weeks and a voiding cysto-urethrogram taken. Thereafter they were followed with regular urethral calibration. All patients voided satisfactorily with a good stream; three were fully continent and the fourth had transient stress urinary incontinence. One patient needed dilatation at 2 months and another visual internal urethrotomy at 5 months. At a mean (range) follow-up of 33 (9-60) months all the patients had a normal voiding pattern and were continent; none developed vaginal stenosis. Primary repair of the urethra, and if that is impossible, simple urethral realignment over a catheter, is the procedure of choice for managing female urethral injury associated with a pelvic fracture. The procedure has the additional advantage of reducing the risk of vaginal stenosis.

Robot-assisted versus open sacrocolpopexy: a cost-minimization analysis.

PubMed

Elliott, Christopher S; Hsieh, Michael H; Sokol, Eric R; Comiter, Craig V; Payne, Christopher K; Chen, Bertha

2012-02-01

Abdominal sacrocolpopexy is considered a standard of care operation for apical vaginal vault prolapse repair. Using outcomes at our center we evaluated whether the robotic approach to sacrocolpopexy is as cost-effective as the open approach. After obtaining institutional review board approval we performed cost-minimization analysis in a retrospective cohort of patients who underwent sacrocolpopexy at our institution between 2006 and 2010. Threshold values, that is model variable values at which the most cost effective approach crosses over to an alternative approach, were determined by testing model variables over realistic ranges using sensitivity analysis. Hospital billing data were also evaluated to confirm our findings. Operative time was similar for robotic and open surgery (226 vs 221 minutes) but postoperative length of stay differed significantly (1.0 vs 3.3 days, p <0.001). Base case analysis revealed an overall 10% cost savings for robot-assisted vs open sacrocolpopexy ($10,178 vs $11,307). Tornado analysis suggested that the number of institutional robotic cases done annually, length of stay and cost per hospitalization day in the postoperative period were the largest drivers of cost. Analysis of our hospital billing data showed a similar trend with robotic surgery costing 4.2% less than open surgery. A robot-assisted approach to sacrocolpopexy can be equally or less costly than an open approach. This depends on a sufficient institutional robotic case volume and a shorter postoperative stay for patients who undergo the robot-assisted procedure. Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Health-related quality of life and outcomes after surgical treatment of complications from vaginally placed mesh.

PubMed

Hokenstad, Erik D; El-Nashar, Sherif A; Blandon, Roberta E; Occhino, John A; Trabuco, Emanuel C; Gebhart, John B; Klingele, Christopher J

2015-01-01

We aimed to report on health-related quality of life after surgical excision of vaginally placed mesh for treatment of pelvic organ prolapse and to identify predictors of successful surgical management. We identified patients who underwent surgery for treatment of complications from vaginally placed mesh from January 1, 2003, through December 31, 2011, and conducted a follow-up survey. Logistic regression models were used to identify predictors of successful treatment. We identified 114 patients who underwent surgery for mesh-related complications and 68 underwent mesh excision. Of the 68 patients, 44 (64.7%) completed the survey. Of the 44 responders, 41 returned their consent form and were included in the analysis. Only 22 (54%) patients reported a successful outcome after mesh excision. Of 29 (71%) sexually active patients, 23 had dyspareunia before mesh excision and only 3 patients reported resolution of dyspareunia after excision. We reported a multivariable model for predicting successful surgical outcome with an area under the curve for the receiver operator characteristic of 0.781. In this model, complete excision of mesh, new overactive bladder symptoms after mesh placement, and a body mass index higher than 30 kg/m were associated with successful patient-reported outcomes; adjusted odds ratios (95% confidence intervals) were 5.46 (1.10-41.59), 7.76 (1.18-89.55), and 8.41 (1.35-92.41), respectively. Only half of the patients who had surgery for vaginally placed mesh complications reported improvement after surgery, with modest improvement in dyspareunia. Patients who had complete mesh excision, new overactive bladder symptoms, and obesity were more likely to report improvement.

Physical and cultural determinants of postpartum pelvic floor support and symptoms following vaginal delivery: a protocol for a mixed-methods prospective cohort study

PubMed Central

Nygaard, Ingrid E; Clark, Erin; Clark, Lauren; Egger, Marlene J; Hitchcock, Robert; Hsu, Yvonne; Norton, Peggy; Sanchez-Birkhead, Ana; Shaw, Janet; Sheng, Xiaoming; Varner, Michael

2017-01-01

Introduction Pelvic floor disorders (PFDs), including pelvic organ prolapse (POP), stress and urgency urinary incontinence, and faecal incontinence, are common and arise from loss of pelvic support. Although severe disease often does not occur until women become older, pregnancy and childbirth are major risk factors for PFDs, especially POP. We understand little about modifiable factors that impact pelvic floor function recovery after vaginal birth. This National Institutes of Health (NIH)-funded Program Project, ‘Bridging physical and cultural determinants of postpartum pelvic floor support and symptoms following vaginal delivery’, uses mixed-methods research to study the influences of intra-abdominal pressure, physical activity, body habitus and muscle fitness on pelvic floor support and symptoms as well as the cultural context in which women experience those changes. Methods and analysis Using quantitative methods, we will evaluate whether pelvic floor support and symptoms 1 year after the first vaginal delivery are affected by biologically plausible factors that may impact muscle, nerve and connective tissue healing during recovery (first 8 weeks postpartum) and strengthening (remainder of the first postpartum year). Using qualitative methods, we will examine cultural aspects of perceptions, explanations of changes in pelvic floor support, and actions taken by Mexican-American and Euro-American primipara, emphasising early changes after childbirth. We will summarise project results in a resource toolkit that will enhance opportunities for dialogue between women, their families and providers, and across lay and medical discourses. We anticipate enrolling up to 1530 nulliparous women into the prospective cohort study during the third trimester, following those who deliver vaginally 1 year postpartum. Participants will be drawn from this cohort to meet the project's aims. Ethics and dissemination The University of Utah and Intermountain Healthcare Institutional Review Boards approved this study. Data are stored in a secure password-protected database. Papers summarising the primary results and ancillary analyses will be published in peer-reviewed journals. PMID:28073797

Correlation processing of polarization inhomogenous images in laser diagnostics of biological tissues

NASA Astrophysics Data System (ADS)

Trifonyuk, L.

2012-10-01

The model of interaction of laser radiation with biological tissue as a two-component amorphous-crystalline matrix was proposed. The processes of formation of polarization of laser radiation are considered, taking into account birefringence network protein fibrils. Measurement of the coordinate distribution of polarization states in the location of the laser micropolarimetr was conducted .The results of investigating the interrelation between the values of correlation (correlation area, asymmetry coefficient and autocorrelation function excess) and fractal (dispersion of logarithmic dependencies of power spectra) parameters are presented. They characterize the coordinate distributions of polarization azimuth of laser images of histological sections of women's reproductive sphere tissues and pathological changes in human organism. The diagnostic criteria of the prolapse of the vaginal tissue arising are determined.

Pregnancy and childbirth after repair of obstetric fistula in sub-Saharan Africa: Scoping Review.

PubMed

Delamou, Alexandre; Utz, Bettina; Delvaux, Therese; Beavogui, Abdoul Habib; Shahabuddin, Asm; Koivogui, Akoi; Levêque, Alain; Zhang, Wei-Hong; De Brouwere, Vincent

2016-11-01

To synthesise the evidence on pregnancy and childbirth after repair of obstetric fistula in sub-Saharan Africa and to identify the existing knowledge gaps. A scoping review of studies reporting on pregnancy and childbirth in women who underwent repair for obstetric fistula in sub-Saharan Africa was conducted. We searched relevant articles published between 1 January 1970 and 31 March 2016, without methodological or language restrictions, in electronic databases, general Internet sources and grey literature. A total of 16 studies were included in the narrative synthesis. The findings indicate that many women in sub-Saharan Africa still desire to become pregnant after the repair of their obstetric fistula. The overall proportion of pregnancies after repair estimated in 11 studies was 17.4% (ranging from 2.5% to 40%). Among the 459 deliveries for which the mode of delivery was reported, 208 women (45.3%) delivered by elective caesarean section (CS), 176 women (38.4%) by emergency CS and 75 women (16.3%) by vaginal delivery. Recurrence of fistula was a common maternal complication in included studies while abortions/miscarriage, stillbirths and neonatal deaths were frequent foetal consequences. Vaginal delivery and emergency C-section were associated with increased risk of stillbirth, recurrence of the fistula or even maternal death. Women who get pregnant after repair of obstetric fistula carry a high risk for pregnancy complications. However, the current evidence does not provide precise estimates of the incidence of pregnancy and pregnancy outcomes post-repair. Therefore, studies clearly assessing these outcomes with the appropriate study designs are needed. © 2016 John Wiley & Sons Ltd.

Predictors and outcome of surgical repair of obstetric fistula at a regional referral hospital, Mbarara, western Uganda

PubMed Central

2011-01-01

Background Obstetric fistula although virtually eliminated in high income countries, still remains a prevalent and debilitating condition in many parts of the developing world. It occurs in areas where access to care at childbirth is limited, or of poor quality and where few hospitals offer the necessary corrective surgery. Methods This was a prospective observational study where all women who attended Mbarara Regional Referral Hospital in western Uganda with obstetric fistula during the study period were assessed pre-operatively for social demographics, fistula characteristics, classification and outcomes after surgery. Assessment for fistula closure and stress incontinence after surgery was done using a dye test before discharge Results Of the 77 women who were recruited in this study, 60 (77.9%) had successful closure of their fistulae. Unsuccessful fistula closure was significantly associated with large fistula size (Odds Ratio 6 95% Confidential interval 1.46-24.63), circumferential fistulae (Odds ratio 9.33 95% Confidential interval 2.23-39.12) and moderate to severe vaginal scarring (Odds ratio 12.24 95% Confidential interval 1.52-98.30). Vaginal scarring was the only factor independently associated with unsuccessful fistula repair (Odds ratio 10 95% confidential interval 1.12-100.57). Residual stress incontinence after successful fistula closure was associated with type IIb fistulae (Odds ratio 5.56 95% Confidential interval 1.34-23.02), circumferential fistulae (Odds ratio 10.5 95% Confidential interval 1.39-79.13) and previous unsuccessful fistula repair (Odds ratio 4.8 95% Confidential interval 1.27-18.11). Independent predictors for residual stress incontinence after successful fistula closure were urethral involvement (Odds Ratio 4.024 95% Confidential interval 2.77-5.83) and previous unsuccessful fistula repair (Odds ratio 38.69 95% Confidential interval 2.13-703.88). Conclusions This study demonstrated that large fistula size, circumferential fistulae and marked vaginal scarring are predictors for unsuccessful fistula repair while predictors for residual stress incontinence after successful fistula closure were urethral involvement, circumferential fistulae and previous unsuccessful fistula repair. PMID:22151960

Predictors and outcome of surgical repair of obstetric fistula at a regional referral hospital, Mbarara, western Uganda.

PubMed

Kayondo, Musa; Wasswa, Ssalongo; Kabakyenga, Jerome; Mukiibi, Nozmo; Senkungu, Jude; Stenson, Amy; Mukasa, Peter

2011-12-07

Obstetric fistula although virtually eliminated in high income countries, still remains a prevalent and debilitating condition in many parts of the developing world. It occurs in areas where access to care at childbirth is limited, or of poor quality and where few hospitals offer the necessary corrective surgery. This was a prospective observational study where all women who attended Mbarara Regional Referral Hospital in western Uganda with obstetric fistula during the study period were assessed pre-operatively for social demographics, fistula characteristics, classification and outcomes after surgery. Assessment for fistula closure and stress incontinence after surgery was done using a dye test before discharge Of the 77 women who were recruited in this study, 60 (77.9%) had successful closure of their fistulae. Unsuccessful fistula closure was significantly associated with large fistula size (Odds Ratio 6 95% Confidential interval 1.46-24.63), circumferential fistulae (Odds ratio 9.33 95% Confidential interval 2.23-39.12) and moderate to severe vaginal scarring (Odds ratio 12.24 95% Confidential interval 1.52-98.30). Vaginal scarring was the only factor independently associated with unsuccessful fistula repair (Odds ratio 10 95% confidential interval 1.12-100.57). Residual stress incontinence after successful fistula closure was associated with type IIb fistulae (Odds ratio 5.56 95% Confidential interval 1.34-23.02), circumferential fistulae (Odds ratio 10.5 95% Confidential interval 1.39-79.13) and previous unsuccessful fistula repair (Odds ratio 4.8 95% Confidential interval 1.27-18.11). Independent predictors for residual stress incontinence after successful fistula closure were urethral involvement (Odds Ratio 4.024 95% Confidential interval 2.77-5.83) and previous unsuccessful fistula repair (Odds ratio 38.69 95% Confidential interval 2.13-703.88). This study demonstrated that large fistula size, circumferential fistulae and marked vaginal scarring are predictors for unsuccessful fistula repair while predictors for residual stress incontinence after successful fistula closure were urethral involvement, circumferential fistulae and previous unsuccessful fistula repair.

[TECHNIQUES IN MITRAL VALVE REPAIR VIA A MINIMALLY INVASIVE APPROACH].

PubMed

Ito, Toshiaki

2016-03-01

In mitral valve repair via a minimally invasive approach, resection of the leaflet is technically demanding compared with that in the standard approach. For resection and suture repair of the posterior leaflet, premarking of incision lines is recommended for precise resection. As an alternative to resection and suture, the leaflet-folding technique is also recommended. For correction of prolapse of the anterior leaflet, neochordae placement with the loop technique is easy to perform. Premeasurement with transesophageal echocardiography or intraoperative measurement using a replica of artificial chordae is useful to determine the appropriate length of the loops. Fine-tuning of the length of neochordae is possible by adding a secondary fixation point on the leaflet if the loop is too long. If the loop is too short, a CV5 Gore-Tex suture can be passed through the loop and loosely tied several times to stack the knots, with subsequent fixation to the edge of the leaflet. Finally, skill in the mitral valve replacement technique is necessary as a back-up for surgeons who perform minimally invasive mitral valve repair.

Pelvic floor dysfunction in the immediate puerperium, and 1 month and 3 months after vaginal or cesarean delivery.

PubMed

Colla, Cássia; L Paiva, Luciana; Ferla, Lia; B Trento, Maria J; M P de Vargas, Isadora; A Dos Santos, Bianca; Ferreira, Charles F; L Ramos, José G

2018-06-07

To identify and assess postpartum pelvic floor dysfunction (PFD) between vaginal delivery, elective cesarean delivery (ECD), and intrapartum cesarean delivery (ICD). The present prospective observational study included women aged at least 18 years with no history of pelvic surgery or lower urinary tract malformation, and who had not undergone pelvic floor muscle (PFM) training in the preceding 12 months, who underwent delivery at Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil between August 1, 2016, and May 31, 2017. Participants were assessed at 48 hours (phase 1), 1 month (phase 2), and 3 months (phase 3) after delivery. Assessments included the International Consultation on Incontinence Questionnaire, Short Form (ICIQ-SF); the Jorge-Wexner anal incontinence scale; a self-rated visual analog scale for pelvic pain; the pelvic organ prolapse quantification (POP-Q) system; and a PFM perineometer. A total of 227 women were assessed in phase 1 (141 vaginal deliveries; 28 ICDs; and 58 ECDs), 79 in phase 2, and 41 in phase 3. The ICIQ-SF, Jorge-Wexner scale, visual analog scale, and perineometer measurements did not identify significant differences in relation to the type of delivery (P>0.05). The type of delivery was not associated with differences in the short-term development of postpartum PFD. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Anterior vaginal wall repair

MedlinePlus

... 11th ed. Philadelphia, PA: Elsevier; 2016:chap 83. Review Date 5/23/2016 Updated by: Jennifer Sobol, ... the Michigan Institute of Urology, West Bloomfield, MI. Review provided by VeriMed Healthcare Network. Also reviewed by ...

Repair of a ruptured globe using topical anesthesia.

PubMed

Auffarth, Gerd U; Vargas, Luis G; Klett, Jens; Völcker, Hans E

2004-03-01

We present a 76-year-old patient who had ocular trauma with dehiscence of the wound and scleral rupture with a prolapsed iris, ciliary body, intraocular lens, and vitreous after uneventful cataract surgery with a self-sealing sclerocorneal tunnel incision. General anesthesia was not possible because the patient had a history of lung cancer with extensive emphysema and unstable coronary disease. Local retrobulbar or peribulbar anesthesia was not considered because of the risk for further extrusion of intraocular contents. Topical anesthesia was applied with a 10.0 mm x 2.5 mm cellulose sponge soaked in oxybuprocaine 0.4% (Novesine) placed under the upper and lower lid for 20 minutes. Surgical repair of a 14.0 mm scleral wound was achieved without complication or pain during the procedure.

Comparison of candidate scaffolds for tissue engineering for stress urinary incontinence and pelvic organ prolapse repair.

PubMed

Mangera, Altaf; Bullock, Anthony J; Roman, Sabiniano; Chapple, Christopher R; MacNeil, Sheila

2013-09-01

To identify candidate materials which have sufficient potential to be taken forward for an in vivo tissue-engineering approach to restoring the tissue structure of the pelvic floor in women with stress urinary incontinence (SUI) or pelvic organ prolapse (POP). Oral mucosal fibroblasts were seeded onto seven different scaffold materials, AlloDerm ( LifeCell Corp., Branchburg, NJ, USA), cadaveric dermis, porcine dermis, polypropylene, sheep forestomach, porcine small intestinal submucosa (SIS) and thermoannealed poly(L) lactic acid (PLA) under both free and restrained conditions. The scaffolds were assessed for: cell attachment using AlamarBlue and 4,6-diamidino-2-phenylindole (DAPI); contraction using serial photographs; and extracellular matrix production using Sirius red staining, immunostaining and scanning electron microscopy. Finally the biomechanical properties of all the scaffolds were assessed. Of the seven, there were two biodegradable scaffolds, synthetic PLA and natural SIS, which supported good cell attachment and proliferation. Immunostaining confirmed the presence of collagen I, III and elastin which was highest in SIS and PLA. The mechanical properties of PLA were closest to native tissue with an ultimate tensile strength of 0.72 ± 0.18 MPa, ultimate tensile strain 0.53 ± 0.16 and Young's modulus 4.5 ± 2.9 MPa. Scaffold restraint did not have a significant impact on the above properties in the best scaffolds. These data support both PLA and SIS as good candidate materials for use in making a tissue-engineered repair material for SUI or POP. © 2013 BJU International.

Family history associated with pelvic organ prolapse in young women.

PubMed

Alcalay, Menachem; Stav, Kobi; Eisenberg, Vered H

2015-12-01

Pelvic organ prolapse (POP) among young women is a relatively rare disorder with a unique clinical background. The objective of our study was to investigate the relative risk factors for POP and the relationship between family history and POP development in young women. In a retrospective longitudinal study we investigated 26 young patients (age <45 years) who underwent POP surgery and compared them to a control group of 26 patients (age >55 years) who underwent similar surgery and were matched with regard to parity. All women were interviewed for family history of POP, POP surgery among first-degree relatives, and hernia repair. Family history of POP was five times more prevalent among women in the study group than in the control group (46 % vs. 8 %, P < 0.01). Moreover, POP surgery among the first-degree relatives was significantly more prevalent in the study group (23.1 % vs. 3.8 %, p < 0.05). The prevalence of a family history of POP in more than one first-degree relative (11.5 % vs. 3.84 %, p = 0.3) and the family history of hernia repair among first-degree relatives (11.5 % vs. 15.4 %) did not differ between the groups. A family history of POP is significantly more common in younger affected women than in older affected women. We suggest that future genetic studies should concentrate on this specific population.

Impact of Parturition on Chemokine Homing Factor Expression in the Vaginal Distention Model of Stress Urinary Incontinence

PubMed Central

Lenis, Andrew T.; Kuang, Mei; Woo, Lynn L.; Hijaz, Adonis; Penn, Marc S.; Butler, Robert S.; Rackley, Raymond; Damaser, Margot S.; Wood, Hadley M.

2015-01-01

Purpose Human childbirth simulated by vaginal distention is known to increase the expression of chemokines and receptors involved in stem cell homing and tissue repair. We hypothesized that pregnancy and parturition in rats contributes to the expression of chemokines and receptors after vaginal distention. Materials and Methods We used 72 age matched female Lewis rats, including virgin rats with and without vaginal distention, and delivered rats with and without vaginal distention. Each rat was sacrificed immediately, or 3 or 7 days after vaginal distention and/or parturition, and the urethra was harvested. Relative expression of chemokines and receptors was determined by real-time polymerase chain reaction. Mixed models were used with the Bonferroni correction for multiple comparisons. Results Vaginal distention up-regulated urethral expression of CCL7 immediately after injury in virgin and postpartum rats. Hypoxia inducible factor-1α and vascular endothelial growth factor were up-regulated only in virgin rats immediately after vaginal distention. CD191 expression was immediately up-regulated in postpartum rats without vaginal distention compared to virgin rats without vaginal distention. CD195 was up-regulated in virgin rats 3 days after vaginal distention compared to virgin rats without vaginal distention. CD193 and CXCR4 showed delayed up-regulation in virgin rats 7 days after vaginal distention. CXCL12 was up-regulated in virgin rats 3 days after vaginal distention compared to immediately after vaginal distention. Interleukin-8 and CD192 showed no differential expression. Conclusions Vaginal distention results in up-regulation of the chemokines and receptors expressed during tissue injury, which may facilitate the spontaneous functional recovery previously noted. Pregnancy and delivery up-regulated CD191 and attenuated the expression of hypoxia inducible factor-1α and vascular endothelial growth factor in the setting of vaginal distention, likely by decreasing hypoxia. PMID:23022009

A retrospective comparison of two vaginal mesh kits in the management of anterior and apical vaginal prolapse: long-term results for apical fixation and quality of life.

PubMed

Lamblin, Gery; Gouttenoire, Chloé; Panel, Laure; Moret, Stéphanie; Chene, Gautier; Courtieu, Christophe

2016-12-01

To compare apical correction in stage ≥3 cystocele between two mesh kits. This was a retrospective, nonrandomized study that compared two groups matched on anterior/apical POP-Q stage: 84 received Elevate Ant™ single-incision mesh (Elevate Ant group) and 42 Perigee™ transvaginal mesh (Perigee group). Follow-up at 1 and 2 years comprised objective (POP-Q) and subjective (PFDI-20, PFIQ-7, PISQ-12) assessments. The primary endpoint was objective success: 2-year apical POP-Q stage ≤1. Secondary endpoints were anterior POP-Q stage, subjective results and complications. Groups were comparable in terms of age (66.6 and 64.7 years, respectively; p = 0.19), BMI (both 25.4 kg/m 2 ; p = 0.93), and history of hysterectomy (7.2 % and 14.3 %; p = 0.21) or prolapse surgery (12 % and 14.3 %; p = 0.72). Operative time was shorter in the Elevate Ant group (54.1 vs. 62.5 min; p = 0.048), and the 2-year objective apical success rate was higher (92.9 % vs. 66.7 %; p < 0.0001), with better point C correction (-5 vs. -3.8; p = 0.006). Function improved in both groups, with significantly better PFIQ-7 (p = 0.03) and PFDI-20 (p = 0.02) scores in the Elevate Ant group at 2 years. Vaginal exposure was not seen in the Elevate Ant group but occurred in two patients in the Perigee group (p = 0.33). Factors associated with success were age >65 years (OR 7.16, 95 % CI 1.83 - 27.97) and treatment with Elevate Ant mesh (OR 10.16, 95 % CI 2.78 - 37.14). Postoperative stress urinary incontinence rate was greater with the Elevate Ant group (29.8 % and 16.7 %; p = 0.11). The use of the Elevate Ant mesh was associated with significantly better apical correction at 2 years. Function improved in both groups, but with a significantly better PFDI-20 score in the Elevate Ant group at 1 and 2 years. The postoperative stress urinary incontinence rate, however, tended to be greater in the Elevate Ant group. The results need confirming with longer follow-up of these cohorts and in randomized studies.

COMPUTATIONAL MITRAL VALVE EVALUATION AND POTENTIAL CLINICAL APPLICATIONS

PubMed Central

Chandran, Krishnan B.; Kim, Hyunggun

2014-01-01

The mitral valve (MV) apparatus consists of the two asymmetric leaflets, the saddle-shaped annulus, the chordae tendineae, and the papillary muscles. MV function over the cardiac cycle involves complex interaction between the MV apparatus components for efficient blood circulation. Common diseases of the MV include valvular stenosis, regurgitation, and prolapse. MV repair is the most popular and most reliable surgical treatment for early MV pathology. One of the unsolved problems in MV repair is to predict the optimal repair strategy for each patient. Although experimental studies have provided valuable information to improve repair techniques, computational simulations are increasingly playing an important role in understanding the complex MV dynamics, particularly with the availability of patient-specific real-time imaging modalities. This work presents a review of computational simulation studies of MV function employing finite element (FE) structural analysis and fluid-structure interaction (FSI) approach reported in the literature to date. More recent studies towards potential applications of computational simulation approaches in the assessment of valvular repair techniques and potential pre-surgical planning of repair strategies are also discussed. It is anticipated that further advancements in computational techniques combined with the next generations of clinical imaging modalities will enable physiologically more realistic simulations. Such advancement in imaging and computation will allow for patient-specific, disease-specific, and case-specific MV evaluation and virtual prediction of MV repair. PMID:25134487

Role of Imaging Techniques in Percutaneous Treatment of Mitral Regurgitation.

PubMed

Li, Chi-Hion; Arzamendi, Dabit; Carreras, Francesc

2016-04-01

Mitral regurgitation is the most prevalent valvular heart disease in the United States and the second most prevalent in Europe. Patients with severe mitral regurgitation have a poor prognosis with medical therapy once they become symptomatic or develop signs of significant cardiac dysfunction. However, as many as half of these patients are inoperable because of advanced age, ventricular dysfunction, or other comorbidities. Studies have shown that surgery increases survival in patients with organic mitral regurgitation due to valve prolapse but has no clinical benefit in those with functional mitral regurgitation. In this scenario, percutaneous repair for mitral regurgitation in native valves provides alternative management of valvular heart disease in patients at high surgical risk. Percutaneous repair for mitral regurgitation is a growing field that relies heavily on imaging techniques to diagnose functional anatomy and guide repair procedures. Copyright © 2016 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.

Factors associated with the failure of obstetric fistula repair in Guinea: implications for practice.

PubMed

Delamou, Alexandre; Delvaux, Therese; Beavogui, Abdoul Habib; Toure, Abdoulaye; Kolié, Delphin; Sidibé, Sidikiba; Camara, Mandian; Diallo, Kindy; Barry, Thierno Hamidou; Diallo, Moustapha; Leveque, Alain; Zhang, Wei-Hong; De Brouwere, Vincent

2016-11-08

The prevention and treatment of obstetric fistula still remains a concern and a challenge in low income countries. The objective of this study was to estimate the overall proportions of failure of fistula closure and incontinence among women undergoing repair for obstetric fistula in Guinea and identify its associated factors. This was a retrospective cohort study using data extracted from medical records of fistula repairs between 1 January 2012 and 30 September 2013. The outcome was the failure of fistula closure and incontinence at hospital discharge evaluated by a dye test. A sub-sample of women with vesicovaginal fistula was used to identify the factors associated with these outcomes. Overall, 109 women out of 754 (14.5 %; 95 % CI:11.9-17.0) unsuccessful repaired fistula at discharge and 132 (17.5 %; 95 % CI:14.8-20.2) were not continent. Failure of fistula closure was associated with vaginal delivery (AOR: 1.9; 95 % CI: 1.0-3.6), partially (AOR: 2.0; 95 % CI: 1.1-5.6) or totally damaged urethra (AOR: 5.9; 95 % CI: 2.9-12.3) and surgical repair at Jean Paul II Hospital (AOR: 2.5; 95 % CI: 1.2-4.9). Women who had a partially damaged urethra (AOR: 2.5; 95 % CI: 1.5-4.4) or a totally damaged urethra (AOR: 6.3; 95 % CI: 3.0-13.0) were more likely to experience post-repair urinary incontinence than women who had their urethra intact. At programmatic level in Guinea, caution should be paid to the repair of women who present with a damaged urethra and those who delivered vaginally as they carry greater risks of experiencing a failure of fistula closure and incontinence.

Surgical Repair of an Impalement Genital Injury from an Inline Skating Accident in a 7-Year-Old Prepubertal Girl: A Case Report.

PubMed

Csorba, Roland; Engel, Joerg B; Wieg, Christian

2017-02-01

In girls who present with vaginal trauma, sexual abuse is often the primary diagnosis. The differential diagnosis must include patterns and the mechanism of injury that differentiate accidental injuries from inflicted trauma. A 7-year-old prepubertal girl presented to the emergency department with genital bleeding after a serious accidental impaling injury from inline skating. After rapid abduction of the legs and a fall onto the blade of an inline skate this child incurred an impaling genital injury consistent with an accidental mechanism. The dramatic genital injuries when repaired healed with almost imperceptible residual evidence of previous trauma. To our knowledge, this case report represents the first in the medical literature of an impaling vaginal trauma from an inline skate and describes its clinical and surgical management. Copyright © 2016 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.

Large Urethro-Vesico-Vaginal Fistula due to a Vaginal Foreign Body in a 22-Year-Old Woman: Case Report and Literature Review.

PubMed

D'Elia, Carolina; Curti, Pierpaolo; Cerruto, Maria Angela; Monaco, Carmelo; Artibani, Walter

2015-01-01

In the non-industrialized countries of Africa and Asia obstetric fistulas are more frequently caused by prolonged labour, whereas in countries with developed healthcare systems they are generally the result of complications of gynaecological surgery or, rarely, benign pathologies like inflammation or foreign bodies. A 22-year-old woman was brought to the gynaecology clinic because of foul-smelling vaginal discharge. On pelvic examination a ring-like foreign body was impacted between the anterior and posterior vaginal wall. MRI scan confirmed the presence of a cylindrical foreign body in the vagina and the patient revealed that she had 'involuntarily' inserted a plastic bubble bath cap into the vagina. At surgery removal of the cap was difficult and at the end of the manoeuver evidence of a huge urethro-vesico-vaginal fistula occurred. The patient was discharged with bilateral ureteral stents and suprapubic catheter. After 3 months we performed an end-to-end anastomotic urethroplasty to repair the urethral avulsion and restored the bladder/trigonal and vaginal/cervical defects with 3 layers of sutures; 3 months later the patient had no complaints. Complex genital fistulas represent an extremely debilitating morbidity. In our case, a vaginal approach was successful, but the choice between an abdominal or vaginal approach depends on the surgeon's experience and training. © 2015 S. Karger AG, Basel.

[Reconstructive treatment of female urethral estenosis secondary to erosion by suburethral tape].

PubMed

Angulo, J C; Mateo, E; Lista, F; Andrés, G

2011-04-01

Female urethral stricture secondary to erosión by suburethral sling is an unfrequent problem of difficult solution. Ventral vaginal rotation flaps or buccal mucosa dorsal grafts are not useful because this type of stricture is very proximal (close to the bladder neck) and the vagina is thinned. We present our experience to manage this problem using excision of disease urethral tract, associated to bladder mucosa flap and vaginal sling using transverse vaginal flap to repair the weakened vaginal wall. Three females with urethral stricture secondary to urethral erosion of their sling were treated with a technique of combined urethroplasty with bladder flap and vaginal reinforcement with pediculated vaginal flap transferred in a mini-sling fashion. Two of the patients suffered chronic urinary retention and preoperative placement of urethral catheter was not possible. The patients were evaluated 12, 36 and 55 months after surgery, respectively. Surgery was performed without complications. Results were satisfactory in all the patients, reaching good micturition postoperative caliber and being without incontinence at follow-up. Patients with suburethral erosion by a synthetic sling and secondary severe urethral stricture need total extirpation of the mesh and complete reconstruction of the urethro-vaginal septum. Tension-free urethral suture and use of vaginal sling with the technique here described are two useful technical tips for this problem. Copyright © 2011 AEU. Published by Elsevier Espana. All rights reserved.

[Relevance between expectations before treatment, new symptoms and satisfaction after treatment in patients with pelvic organ prolapse].

PubMed

Wang, Yu; Han, Jinsong; Zhang, Kun; Zhu, Fuli; Yang, Junfang; Wang, Yiting

2015-09-01

To investigate the relevance between expectations before treatment, new symptoms and satisfaction after treatment of the pelvic organ prolapse (POP) patients. Made a collection of 75 cases of POP patients at Peking University Third Hospital, who were affected by the POP symptoms and came to our clinic for treatment from January to December in 2013. Prospectively investigate the patients' expectations before treatment, which were the most troubling symptoms to be solved. According to treatment we divided the patients into surgery and pessary groups. Two groups were followed up with the degree to achieve the desired goals using patient global impression of improvement (PGI-I), new symptoms and satisfaction after treatment, try to find the relevance between expectations before treatment, new symptoms and satisfaction after treatment. There were 47 (63%, 47/75) patients in the surgical group and 28 (37%, 28/75) patients in the pessary group. The top three problems for patients were friction when walking (25%, 19/75), dysuria (23%, 17/75) and the feeling of vaginal prolapse (19%, 14/75). The follow-up rate was of 93% (70/75), follow-up time was (5 ± 4) months. Satisfaction score after treatment of surgical group was higher than that of pessary group [(4.9 ± 0.4) versus (4.0 ± 1.3) scores, P < 0.01]. There was no statistically significant difference between two groups of PGI-I score [(6.7 ± 0.6) versus (6.6 ± 0.9) scores, P = 0.886]. The top three new symptoms after treatment were increased secretion, urinary incontinence and dysuria. PGI-I and satisfaction scores was relevant (P = 0.021). The availability of new symptoms and satisfaction scores was relevant (P = 0.001). When achieving higher expectations to the treatment and no more new symptoms, the satisfaction score after treatment is higher.

The safety and efficacy of the "inside-out" trans-obturator TVT in elderly versus younger stress-incontinent women: a prospective study of 353 consecutive patients.

PubMed

Groutz, Asnat; Cohen, Aviad; Gold, Ronen; Pauzner, David; Lessing, Joseph B; Gordon, David

2011-03-01

To analyze the safety and efficacy of the trans-obturator tension-free vaginal tape (TVT-O) in elderly versus younger stress-incontinent women. Ninety-seven consecutive elderly, aged 70 and older, and 256 younger women (mean age 75 and 55 years, respectively) who underwent TVT-O for urodynamically confirmed stress urinary incontinence (SUI) were prospectively enrolled. Concomitant pelvic organ prolapse (POP) repair was performed in 90% of the elderly and 70% of the younger women. The surgical procedures, as well as all pre- and postoperative clinical and urodynamic evaluation, were performed in one university-affiliated medical center. Main outcome measures were operative complications, early and late postoperative morbidity, postoperative urodynamically confirmed SUI (symptomatic, or asymptomatic), persistent, or de novo overactive bladder (OAB) and bladder outlet obstruction (BOO). Mean follow-up of the patients was 30 ± 17 months (range 3-58 months). Early and late postoperative morbidity was similar in both groups, except for significantly more cases of postoperative recurrent UTI's among elderly women (13.7% vs. 6.2%). The incidence of persistent urodynamically confirmed overt SUI was similar in both age groups (5%). However, asymptomatic urodynamic SUI was significantly more common among elderly patients (19% vs. 3.7%, P<0.05). The incidence of persistent OAB was similar in elderly and younger patients (68% and 62%, respectively), while de novo OAB was significantly more common in elderly patients (11.9% vs. 4.7%, P<0.05). TVT-O is safe and efficient for both elderly and younger stress-incontinent women. However, elderly patients are in increased risk for postoperative recurrent UTI's as well as de novo OAB. Copyright © 2010 Wiley-Liss, Inc.

Sexual satisfaction in the elderly female population: A special focus on women with gynecologic pathology.

PubMed

Ratner, Elena S; Erekson, Elisabeth A; Minkin, Mary Jane; Foran-Tuller, Kelly A

2011-11-01

SEXUAL FUNCTION IN AGING WOMEN: Sexuality is an integral part of human expressions. Mental health plays a major role in sexuality. Several psychological interventions are proposed to increase the sexual quality of life in older women with diverse gynecologic pathology. A biopsychosocial approach utilizing brief strategies can be easily implemented in clinics to help women of all ages increase their sexual quality of life. THE IMPACT OF FEMALE PELVIC FLOOR DISORDERS ON SEXUAL FUNCTION IN OLDER WOMEN: Female pelvic floor disorders include urinary incontinence, pelvic organ prolapse, and fecal incontinence. These disorders increase dramatically with increasing age. Urinary incontinence has been demonstrated to have a negative impact on a woman's sexual function. Among sexually active older women with urinary incontinence, 22% report being moderately or extremely worried that sexual activity would cause urine loss. An increased prevalence of sexual distress [9% (6/76) vs. 1.3% (2/216), p=0.005] has been reported in sexually active women over 40 years old with urinary incontinence. Treatment of urinary incontinence can improve sexual function in older women. Among sexually active women (N=53) who underwent midurethral slings procedures for the correction of urinary incontinence, increased coital frequency, decrease fear of incontinence with coitus, decreased embarrassment due to incontinence was reported six months after surgery. Pelvic organ prolapse, a hernia of the vagina resulting in a visible vaginal bulge, has also been associated with a negative impact on sexual function. Women with advanced pelvic organ prolapse (POP-Q stage III or IV) have been demonstrated to have decreased body image reporting that they are more self-conscious about their appearance [adjusted odds ratio (AOR) 4.7; 95% confidence interval (CI) 2.9, 51], feel less feminine (AOR 4.0; 95% CI 1.2, 15) and less sexually attractive (AOR 4.6; 95% CI 1.4, 17) compared with women who have normal pelvic support. Both vaginal and abdominal approaches to surgical correction of pelvic organ prolapse have been demonstrated to improve sexual function. MENTAL HEALTH: Mental health plays a major role in older woman's sexuality. Sexual interest and satisfaction is tied to emotional expressivity, women's self-worth, feelings of depression and loneliness as well as cognitive function. Research has shown that both general practitioners and specialists lack training in sexual assessments. Behavioral health specialists, such as a psychologist, can play an integral role in helping to facilitate communication between the patient and the provider. A main focus of communication training is to facilitate open and genuine conversation between the provider and the patient. Providers are encouraged to ask open ended questions while patients are encouraged to discuss symptoms while coping with an internal state of anxiety. Despite the known prevalence of sexual dysfunction among older women, few studied empirically based interventions have been published with these women. This speaks to the general assumption among medical professionals that having the "sex talk" in older women with gynecological pathology is not important or relevant. A biopsychosocial approach utilizing some of the aforementioned brief strategies can be easily implemented in comprehensive gynecology clinics in order to help women of all ages increase their sexual quality of life. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Sexual satisfaction in the elderly female population: A special focus on women with gynecologic pathology

PubMed Central

Ratner, Elena S.; Erekson, Elisabeth A.; Minkin, Mary Jane; Foran-Tuller, Kelly A.

2013-01-01

Sexual function in aging women Sexuality is an integral part of human expressions. Mental health plays a major role in sexuality. Several psychological interventions are proposed to increase the sexual quality of life in older women with diverse gynecologic pathology. A biopsychosocial approach utilizing brief strategies can be easily implemented in clinics to help women of all ages increase their sexual quality of life. The impact of female pelvic floor disorders on sexual function in older women Female pelvic floor disorders include urinary incontinence, pelvic organ prolapse, and fecal incontinence. These disorders increase dramatically with increasing age. Urinary incontinence has been demonstrated to have a negative impact on a woman’s sexual function. Among sexually active older women with urinary incontinence, 22% report being moderately or extremely worried that sexual activity would cause urine loss. An increased prevalence of sexual distress [9% (6/76) vs. 1.3% (2/216), p=0.005] has been reported in sexually active women over 40 years old with urinary incontinence. Treatment of urinary incontinence can improve sexual function in older women. Among sexually active women (N=53) who underwent midurethral slings procedures for the correction of urinary incontinence, increased coital frequency, decrease fear of incontinence with coitus, decreased embarrassment due to incontinence was reported six months after surgery. Pelvic organ prolapse, a hernia of the vagina resulting in a visible vaginal bulge, has also been associated with a negative impact on sexual function. Women with advanced pelvic organ prolapse (POP-Q stage III or IV) have been demonstrated to have decreased body image reporting that they are more self-conscious about their appearance [adjusted odds ratio (AOR) 4.7; 95% confidence interval (CI) 2.9, 51], feel less feminine (AOR 4.0; 95% CI 1.2, 15) and less sexually attractive (AOR 4.6; 95% CI 1.4, 17) compared with women who have normal pelvic support. Both vaginal and abdominal approaches to surgical correction of pelvic organ prolapse have been demonstrated to improve sexual function. Mental health Mental health plays a major role in older woman’s sexuality. Sexual interest and satisfaction is tied to emotional expressivity, women’s self-worth, feelings of depression and loneliness as well as cognitive function. Research has shown that both general practitioners and specialists lack training in sexual assessments. Behavioral health specialists, such as a psychologist, can play an integral role in helping to facilitate communication between the patient and the provider. A main focus of communication training is to facilitate open and genuine conversation between the provider and the patient. Providers are encouraged to ask open ended questions while patients are encouraged to discuss symptoms while coping with an internal state of anxiety. Despite the known prevalence of sexual dysfunction among older women, few studied empirically based interventions have been published with these women. This speaks to the general assumption among medical professionals that having the “sex talk” in older women with gynecological pathology is not important or relevant. A biopsychosocial approach utilizing some of the aforementioned brief strategies can be easily implemented in comprehensive gynecology clinics in order to help women of all ages increase their sexual quality of life. PMID:21943557

Optimal surgical management of severe tricuspid regurgitation in cardiac transplant patients.

PubMed

Filsoufi, Farzan; Salzberg, Sacha P; Anderson, Curtis A; Couper, Gregory S; Cohn, Lawrence H; Adams, David H

2006-03-01

Severe tricuspid regurgitation (TR) with signs of right-sided heart failure is rare after orthotopic heart transplantation (OHT). In some instances, this condition will require surgical correction using reconstructive surgery or prosthetic valve replacement. Repair techniques of atrioventricular valves are now well described. However, the results of the different surgical procedures in this setting have not been widely reported and may depend on the type of valvular dysfunction and lesions present. Herein we report our experience in a group of patients requiring surgical correction of symptomatic severe TR after OHT. We reviewed our transplant experience during the period from July 1992 to July 1999 (n = 138 cardiac transplants). Eight patients (5.8%) developed symptomatic severe TR requiring surgical correction after a mean duration of 21 months after OHT. Patients were divided into 2 groups based on the mechanism of regurgitation using Carpentier's functional classification. In Group 1 (n = 4), the mechanism of tricuspid regurgitation was Carpentier's Type I, secondary to annular dilation. In Group 2 (n = 4) the mechanism of TR was leaflet prolapse (Type II), due to chordal rupture after biopsy injury. Initially, tricuspid valve integrity was surgically restored in all 8 patients with either valve repair (n = 6) or replacement (n = 2). In Group 1, 2 patients underwent valve repair using a ring annuloplasty and 2 patients underwent valve replacement with a bioprosthetic valve (n = 1) or pulmonary allograft (n = 1). In Group 2, all patients underwent valve repair using a variety of techniques in combination with tricuspid annuloplasty. During the follow-up period, 3 of the 6 (50%) primary repairs (1 patient in Group 1 and 2 in Group 2) failed and required replacement with a bioprosthesis at 8 days, 14 days and 4 years, respectively. The pulmonary allograft failed secondary to valvular stenosis and was replaced with a bioprosthesis after 10 months. Overall, no failures occurred in any of the 5 bioprosthetic valves placed at the primary operation (n = 1) or after failed tricuspid repair/pulmonary allograft (n = 4), after a mean follow-up of 55 months. TR requiring surgical correction after OHT is a rare condition and requires a tailored surgical strategy. This strategy should take into account the mechanism of valve dysfunction and specific valvular lesions. In patients with Type I dysfunction secondary to annular dilation, valve repair with a remodeling annuloplasty should be performed; however, in the presence of any residual TR on transesophageal echocardiography (TEE) at the completion of cardiopulmonary bypass (CPB), a valve replacement with a bioprosthesis is warranted during the same procedure. In patients with Type II dysfunction with leaflet prolapse and biopsy-induced chordal injury, a bioprosthetic valve replacement seems a reliable surgical option.

Finite element analysis for edge-to-edge technique to treat post-mitral valve repair systolic anterior motion.

PubMed

Zhong, Qi; Zeng, Wenhua; Huang, Xiaoyang; Zhao, Xiaojia

2014-01-01

Systolic anterior motion of the mitral valve is an uncommon complication of mitral valve repair, which requires immediate supplementary surgical action. Edge-to-edge suture is considered as an effective technique to treat post-mitral valve repair systolic anterior motion by clinical researchers. However, the fundamentals and quantitative analysis are vacant to validate the effectiveness of the additional edge-to-edge surgery to repair systolic anterior motion. In the present work, finite element models were developed to simulate a specific clinical surgery for patients with posterior leaflet prolapse, so as to analyze the edge-to-edge technique quantificationally. The simulated surgery procedure concluded several actions such as quadrangular resection, mitral annuloplasty and edge-to-edge suture. And the simulated results were compared with echocardiography and measurement data of the patients under the mitral valve surgery, which shows good agreement. The leaflets model with additional edge-to-edge suture has a shorter mismatch length than that of the model merely under quadrangular resection and mitral annuloplasty actions at systole, which assures a better coaptation status. The stress on the leaflets after edge-to-edge suture is lessened as well.

Physical and cultural determinants of postpartum pelvic floor support and symptoms following vaginal delivery: a protocol for a mixed-methods prospective cohort study.

PubMed

Nygaard, Ingrid E; Clark, Erin; Clark, Lauren; Egger, Marlene J; Hitchcock, Robert; Hsu, Yvonne; Norton, Peggy; Sanchez-Birkhead, Ana; Shaw, Janet; Sheng, Xiaoming; Varner, Michael

2017-01-10

Pelvic floor disorders (PFDs), including pelvic organ prolapse (POP), stress and urgency urinary incontinence, and faecal incontinence, are common and arise from loss of pelvic support. Although severe disease often does not occur until women become older, pregnancy and childbirth are major risk factors for PFDs, especially POP. We understand little about modifiable factors that impact pelvic floor function recovery after vaginal birth. This National Institutes of Health (NIH)-funded Program Project, 'Bridging physical and cultural determinants of postpartum pelvic floor support and symptoms following vaginal delivery', uses mixed-methods research to study the influences of intra-abdominal pressure, physical activity, body habitus and muscle fitness on pelvic floor support and symptoms as well as the cultural context in which women experience those changes. Using quantitative methods, we will evaluate whether pelvic floor support and symptoms 1 year after the first vaginal delivery are affected by biologically plausible factors that may impact muscle, nerve and connective tissue healing during recovery (first 8 weeks postpartum) and strengthening (remainder of the first postpartum year). Using qualitative methods, we will examine cultural aspects of perceptions, explanations of changes in pelvic floor support, and actions taken by Mexican-American and Euro-American primipara, emphasising early changes after childbirth. We will summarise project results in a resource toolkit that will enhance opportunities for dialogue between women, their families and providers, and across lay and medical discourses. We anticipate enrolling up to 1530 nulliparous women into the prospective cohort study during the third trimester, following those who deliver vaginally 1 year postpartum. Participants will be drawn from this cohort to meet the project's aims. The University of Utah and Intermountain Healthcare Institutional Review Boards approved this study. Data are stored in a secure password-protected database. Papers summarising the primary results and ancillary analyses will be published in peer-reviewed journals. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Consensus Statement of the European Urology Association and the European Urogynaecological Association on the Use of Implanted Materials for Treating Pelvic Organ Prolapse and Stress Urinary Incontinence.

PubMed

Chapple, Christopher R; Cruz, Francisco; Deffieux, Xavier; Milani, Alfredo L; Arlandis, Salvador; Artibani, Walter; Bauer, Ricarda M; Burkhard, Fiona; Cardozo, Linda; Castro-Diaz, David; Cornu, Jean Nicolas; Deprest, Jan; Gunnemann, Alfons; Gyhagen, Maria; Heesakkers, John; Koelbl, Heinz; MacNeil, Sheila; Naumann, Gert; Roovers, Jan-Paul W R; Salvatore, Stefano; Sievert, Karl-Dietrich; Tarcan, Tufan; Van der Aa, Frank; Montorsi, Francesco; Wirth, Manfred; Abdel-Fattah, Mohamed

2017-09-01

Surgical nonautologous meshes have been used for several decades to repair abdominal wall herniae. Implantable materials have been adopted for the treatment of female and male stress urinary incontinence (SUI) and female pelvic organ prolapse (POP). A consensus review of existing data based on published meta-analyses and reviews. This document summarises the deliberations of a consensus group meeting convened by the European Association of Urology (EAU) and the European Urogynecological Association, to explore the current evidence relating to the use of polypropylene (PP) materials used for the treatment of SUI and POP, with reference to the 2016 EAU guidelines (European Association of Urology 2016), the European Commission's SCENIHR report on the use of surgical meshes (SCENIHR 2015), other available high-quality evidence, guidelines, and national recommendations. Current data suggest that the use of nonautologous durable materials in surgery has well-established benefits but significant risks, which are specific to the condition and location they are used for. Various graft-related complications have been described-such as infection, chronic pain including dyspareunia, exposure in the vagina, shrinkage, erosion into other organs of xenografts, synthetic PP tapes (used in SUI), and meshes (used in POP)-which differ from the complications seen with abdominal herniae. When considering surgery for SUI, it is essential to evaluate the available options, which may include synthetic midurethral slings (MUSs) using PP tapes, bulking agents, colposuspension, and autologous sling surgery. The use of synthetic MUSs for surgical treatment of SUI in both male and female patients has good efficacy and acceptable morbidity. Synthetic mesh for POP should be used only in complex cases with recurrent prolapse in the same compartment and restricted to those surgeons with appropriate training who are working in multidisciplinary referral centres. Synthetic slings can be safely used in the surgical treatment of stress incontinence in both male and female patients. Patients need to be aware of the alternative therapy and potential risks and complications of this therapy. Synthetic mesh for treating prolapse should be used only in complex cases with recurrent prolapse in specialist referral centres. Copyright © 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Rupture of the female urethra in childhood.

PubMed

Williams, D I

1975-01-01

Rupture of the female urethra is a rare disorder, but perhaps more liable to occur in childhood than in adult life. As in the male, it can follow a fractured pelvis, but the level of the rupture is not simply in the membranous region, and is frequently much higher with destruction of the urethra over a considerable length. The vagina is always involved, so that almost inevitably there is a urethra-vaginal fistula. In the low lesions the bladder and urethral function may be adequate, but stenosis of the vaginal introitus can result in a considerable hydrocolpos, leading to a spurious form of incontinence. In the higher lesions true incontinence can occur, and there may be stricturing of the urethra above or below the urethro-vaginal fistula. Methods of surgical repair are discussed.

[Neovagina with intestine: 13 cases].

PubMed

Parente, A; Molina, E; Cerdá, J; Cañizo, A; Rodriguez, A; Laín, A; Fanjul, M; Vázquez, J

2008-01-01

The absence or hipoplasia vaginal can turn out to be isolated, associated with ambiguous genitalia, or as anatomical variant in a syndrome of sewer. The fundamental aim in the creation of a new vagina is: to obtain a good aesthetic result, to fulfil functional criteria (elasticity, sensibility, physiological inclination) and to improve the quality of life of the patients avoiding the use of molds and minimizing the morbidity of the zones donors. In this work let's sense beforehand our experience in the accomplishment of neovaginas with intestine. We analyze the clinical record of 13 patients treated surgically in the last ten years. We differentiate two groups according to the age, the diagnosis and the type of surgery: a) the first group of 8 patients present syndrome of insensibility to the androgens (4), syndrome of Rokitansky (2), extrofia of sewer (1) and mixed gonadal disgenesia (1). This group of patients were controlled in the adolescence by an average of age of 19 years (11-35 years), they fulfilling a neovagina with sigma; b) the second group of 5 patients with sewer (3), extrofia of sewer (1) and congenital suprarrenal hiperplasia (1). This group was controlled prematurely by a middle ages of one year (4 months-3 years). The intestinal segment used as neovagina was sigma (2), ileon (2) and rectum (1), and was performed during the surgical correction of her congenital malformation. Two patients have presented intestinal obstruction in the postoperatory immediate one. Four patients have needed removal of a small vaginal prolapse, and three have needed vaginal transitory expansions for introit stenosis. The long-term evolution has been favorable with an excellent aesthetic aspect. Four patients recount sexual fully satisfactory relations. We believe that the neovagina with sigma is at present the best option in patients with absence or hipoplasia vaginal. The advantages are the possibility of precocious and one time correction, a neovagina of dimensions and oiling adapted without need of expansions or molds, an aesthetic excellent aspect, and sexual satisfactory sexual relations.

Validation of the International Consultation on Incontinence Questionnaire-Vaginal Symptoms (ICIQ-VS) in two south- Asian languages.

PubMed

Ekanayake, Chanil D; Pathmeswaran, Arunasalam; Herath, Rasika P; Perera, H Suharshi S; Patabendige, Malitha; Wijesinghe, Prasantha S

2017-12-01

The multifaceted nature of pelvic floor disorders means that a systematic evaluation is required for optimal treatment outcome. It is also generally acknowledged that a valid tool is necessary to objectively assess symptoms reported by affected women. The International Consultation on Incontinence Questionnaire-Vaginal Symptoms (ICIQ-VS) questionnaire was translated to Sinhala and Tamil and a validation study carried out among women attending gynecology clinics at North Colombo Teaching Hospital, Ragama, and the district general hospitals Mannar and Vavuniya. Content validity was assessed by the level of missing answers, which was < 4% and 2% for each item in Sinhala and Tamil, respectively. Construct validity was assessed by the ability of the questionnaire to differentiate between patients and controls. Both differentiated patients from controls on vaginal symptoms score (VSS) (p < 0.001), sexual symptoms score (SSS) (p < 0.01), and quality of life (QoL) (p < 0.001). There was a strong positive correlation between Pelvic Organ Prolapse Quantification (POP-Q) scores and VSS (Sinhala r s  = 0.64, p < 0.001, Tamil r s  = 0.65, p < 0.001), and QoL (Sinhala r s  = 0.49, p < 0.001, Tamil r s  = 0.60, p < 0.001). Internal consistency as assessed using Cronbach's coefficient alpha: 0.78 (0.76-0.78) and 0.83 (0.80-0.84) in Sinhala and Tamil, respectively. Test-retest reliability was assessed by weighted kappa scores (Sinhala 0.58-0.88 and Tamil 0.76-0.90). Both questionnaires were sensitive to change and showed that VSS and QoL improved following surgery (Wilcoxon matched-pairs signed-rank test p < 0.001). The validated Sinhala and Tamil translations of ICIQ-VS will be useful for assessing vaginal and sexual symptoms among women speaking Sinhala and Tamil.

Local Oestrogen for Pelvic Floor Disorders: A Systematic Review

PubMed Central

Weber, M. A.; Kleijn, M. H.; Langendam, M.; Limpens, J.; Heineman, M. J.; Roovers, J. P.

2015-01-01

Objective The decline in available oestrogen after menopause is a possible etiological factor in pelvic floor disorders like vaginal atrophy (VA), urinary incontinence (UI), overactive bladder (OAB) and pelvic organ prolapse (POP). This systematic review will examine the evidence for local oestrogen therapy in the treatment of these pelvic floor disorders. Evidence Acquisition We performed a systematic search in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and the non-MEDLINE subset of PubMed from inception to May 2014. We searched for local oestrogens and VA (I), UI/OAB (II) and POP (III). Part I was combined with broad methodological filters for randomized controlled trials (RCTs) and secondary evidence. For part I and II two reviewers independently selected RCTs evaluating the effect of topical oestrogens on symptoms and signs of VA and UI/OAB. In part III all studies of topical oestrogen therapy in the treatment of POP were selected. Data extraction and the assessment of risk of bias using the Cochrane Risk of Bias Tool was undertaken independently by two reviewers. Evidence Synthesis The included studies varied in ways of topical application, types of oestrogen, dosage and treatment durations. Objective and subjective outcomes were assessed by a variety of measures. Overall, subjective and urodynamic outcomes, vaginal maturation and vaginal pH changed in favor of vaginal oestrogens compared to placebo. No obvious differences between different application methods were revealed. Low doses already seemed to have a beneficial effect. Studies evaluating the effect of topical oestrogen in women with POP are scarce and mainly assessed symptoms and signs associated with VA instead of POP symptoms. Conclusion Topical oestrogen administration is effective for the treatment of VA and seems to decrease complaints of OAB and UI. The potential for local oestrogens in the prevention as well as treatment of POP needs further research. PMID:26383760

Techniques to reduce perineal pain during spontaneous vaginal delivery and perineal suturing: a UK survey of midwifery practice.

PubMed

Sanders, Julia; Peters, Tim J; Campbell, Rona

2005-06-01

To investigate use of pharmacological and non-pharmacological methods of perineal analgesia used by midwives during the second stage of labour and perineal repair in the UK. Postal survey. Self-complete questionnaires were sent to Heads of Midwifery in all 219 maternity units in the UK. Information was requested on the number and type of deliveries undertaken in the previous year and on the midwifery procedures used to provide pain relief immediately before delivery and for perineal repair. Details were also sought on local anaesthetics given before episiotomy or perineal repair. 207 completed questionnaires were returned providing information on 210 maternity units. Midwives reported using a variety of non-pharmacological analgesic methods to control pain at the end of the second stage of labour. Hot packs were used in 70 (33%) maternity units, cold packs in 44 (21%) and perineal massage in 109 (52%). Midwives in 131 (62%) maternity units used injectable local anaesthetics to control perineal pain. All units advocated use of local anaesthetic before episiotomy or perineal repair, but the reported doses used varied widely. The literature on levels of pain experienced immediately before spontaneous vaginal delivery and during perineal repair is sparse, but what evidence exists suggests that, for some women, these occasions are accompanied by severe pain. Findings from this survey show that there is considerable variation in what midwives provide to control pain. Formal evaluation of the perineal analgesia offered to women during the second stage of labour is urgently required.

Vulvovaginitis and other common vulvar disorders in children.

PubMed

Rome, Ellen S

2012-01-01

Vulvovaginitis, labial adhesions, and other vulvar disorders occur commonly in children and can provoke high anxiety in both the parent and child. Performed correctly, the pediatric gynecologic examination can diagnose and treat, educate and reassure both parent and child. This examination requires patience, sensitivity, direct communication with the child as well as with the parent, and an open manner that inspires trust in both parties to manage a potentially anxiety-provoking situation. This chapter will review common vulvar disorders, including vulvovaginitis, lichen sclerosis et atrophicus, bubble bath vaginitis, labial adhesions, urethral prolapse, and other common problems. A discussion of childhood sexual abuse is beyond the scope of this chapter, with appropriate references available elsewhere. Practical pearls will be offered to make this exam easy for the primary care clinician and/or subspecialist. Copyright © 2012 S. Karger AG, Basel.

Ovariohysterectomy in the Bitch

PubMed Central

Bencharif, Djemil; Amirat, Lamia; Garand, Annabelle; Tainturier, Daniel

2010-01-01

Ovariohysterectomy is a surgical procedure widely employed in practice by vets. It is indicated in cases of pyometra, uterine tumours, or other pathologies. This procedure should only be undertaken if the bitch is in a fit state to withstand general anaesthesia. However, the procedure is contradicated if the bitch presents a generalised condition with hypothermia, dehydration, and mydriasis. Ovariohysterectomy is generally performed via the linea alba. Per-vaginal hysterectomy can also be performed in the event of uterine prolapse, if the latter cannot be reduced or if has been traumatised to such an extent that it cannot be replaced safely. Specific and nonspecific complictions can occur as hemorrhage, adherences, urinary incontinence, return to oestrus including repeat surgery. After an ovariectomy, bitches tend to put on weight, it is therefore important to inform the owner and to reduce the daily ration by 10%. PMID:20224801

Biomaterials for Pelvic Floor Reconstructive Surgery: How Can We Do Better?

PubMed Central

Osman, Nadir I.; Bissoli, Julio; Bullock, Anthony J.; Chapple, Chris R.

2015-01-01

Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) are major health issues that detrimentally impact the quality of life of millions of women worldwide. Surgical repair is an effective and durable treatment for both conditions. Over the past two decades there has been a trend to enforce or reinforce repairs with synthetic and biological materials. The determinants of surgical outcome are many, encompassing the physical and mechanical properties of the material used, and individual immune responses, as well surgical and constitutional factors. Of the current biomaterials in use none represents an ideal. Biomaterials that induce limited inflammatory response followed by constructive remodelling appear to have more long term success than biomaterials that induce chronic inflammation, fibrosis and encapsulation. In this review we draw upon published animal and human studies to characterize the changes biomaterials undergo after implantation and the typical host responses, placing these in the context of clinical outcomes. PMID:25977927

Premeasured Chordal Loops for Mitral Valve Repair.

PubMed

Gillinov, Marc; Quinn, Reed; Kerendi, Faraz; Gaudiani, Vince; Shemin, Richard; Barnhart, Glenn; Raines, Edward; Gerdisch, Marc W; Banbury, Michael

2016-09-01

Premeasured expanded polytetrafluoroethylene chordal loops with integrated sutures for attachment to the papillary muscle and leaflet edges facilitate correction of mitral valve prolapse. Configured as a group of 3 loops (length range 12 to 24 mm), the loops are attached to a pledget that is passed through the papillary muscle and tied. Each of the loops has 2 sutures with attached needles; these needles are passed through the free edge of the leaflet and then the sutures are tied to each other, securing the chordal loop to the leaflet. Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Tricuspid and Mitral Valve Regurgitation with Bi-fascicular Block Following a Horse Kick.

PubMed

Kokubun, Tomoki; Oikawa, Masayoshi; Ichijo, Yasuhiro; Matsumoto, Yoshiyuki; Yokokawa, Tetsuro; Nakazato, Kazuhiko; Sato, Yoshiyuki; Takase, Shinya; Shinjo, Hiroharu; Yokoyama, Hitoshi; Suzuki, Hitoshi; Saitoh, Shu-Ichi; Takeishi, Yasuchika

2018-06-01

A 40-year-old man was transferred to our hospital following an isolated horse kick injury to the anterior chest wall. The case showed bi-fascicular block, severe tricuspid valve regurgitation due to ruptured chordae tendineae of the anterior leaflet, moderate mitral valve regurgitation due to prolapse of mitral anterior leaflet, and hypokinetic motion of the inferior septal wall. Both tricuspid and mitral insufficiency were completely repaired by a surgical operation. Fortunately, these injuries were not fatal in this case, but the comprehensive assessment of cardiac damage and careful observation are important for managing patients with cardiac injury.

Mitral valve prolapse and hyperthyroidism: effect of patient selection.

PubMed

Zullo, M A; Devereux, R B; Kramer-Fox, R; Lutas, E M; Brown, W T

1985-11-01

Patients with mitral valve prolapse and hyperthyroidism have common symptoms; the most outstanding symptom is palpitation. To determine whether or not common symptoms contributed to the reported association of these conditions, we evaluated 220 patients with symptomatic mitral valve prolapse and 216 first-degree relatives in 72 families; 65 relatives with mitral valve prolapse and 151 relatives without mitral valve prolapse, all greater than or equal to 16 years of age. Thirty subjects, aged 49 +/- 13 years (p less than 0.025 vs entire study group), had thyroid disease (23 subjects had definite thyroid disease, seven subjects had probable); 27 of 30 subjects with thyroid disease (90%) were female (p less than 0.005). The age- and sex-adjusted prevalence of hyperthyroidism was significantly higher in probands with mitral valve prolapse than in family members without mitral valve prolapse (3.5% vs 0%, p = 0.03), while an intermediate prevalence of hyperthyroidism (2.2%) was observed in family members with mitral valve prolapse. Thus, the prevalence of hyperthyroidism is increased among symptomatic patients with mitral valve prolapse as compared to family members without mitral valve prolapse, but the prevalence of thyroid conditions is similar among family members with or without this condition. These findings are explained by the effect of common symptoms on clinical detection of both mitral valve prolapse and hyperthyroidism.

[Acquired caustic vagina stenosis: Surgical outcomes of 21 cases].

PubMed

Séni, K; Horo, A G; Koffi, A; Aka, K E; Fomba, M; Koné, M

2016-03-01

To document epidemiology, causes, anatomical varieties and surgical management outcomes of caustic acquired vagina stenosis. Retrospective study of 21 patients involved from 1996 to 2012 at the department of obstetrics and gynecology of Yopougon's teaching hospital in Abidjan, Côte d'Ivoire. Vaginal stenosis due to genital malformation, vaginal irradiation of pelvic tumours, repair of bladder and vaginal fistulae or intersexual disorders were excluded. The prevalence was 0.14/1000 admissions, mean age was 32.1 years, mean gravidity was 1.76 and mean parity was 1.1. Vaginal stenosis seat and extent were variable and 100 % had a caustic origin by use of traditional medicine vaginal pessaire. Of the patients, 95.2 % underwent surgical treatment followed by several dilations sessions with glass dilators. Successful surgical outcome allowing coitus was achieved in 47.6 % of cases with 52.4 % failure. Acquired caustic vagina stenosis are frequently occurring and are a public health problem related to ignorance. Health education and establishment of expert centers with exchange of experiences in West Africa should be able to improve surgical outcomes. Copyright © 2016. Published by Elsevier SAS.

Repair-oriented classification of aortic insufficiency: impact on surgical techniques and clinical outcomes.

PubMed

Boodhwani, Munir; de Kerchove, Laurent; Glineur, David; Poncelet, Alain; Rubay, Jean; Astarci, Parla; Verhelst, Robert; Noirhomme, Philippe; El Khoury, Gébrine

2009-02-01

Valve repair for aortic insufficiency requires a tailored surgical approach determined by the leaflet and aortic disease. Over the past decade, we have developed a functional classification of AI, which guides repair strategy and can predict outcome. In this study, we analyze our experience with a systematic approach to aortic valve repair. From 1996 to 2007, 264 patients underwent elective aortic valve repair for aortic insufficiency (mean age - 54 +/- 16 years; 79% male). AV was tricuspid in 171 patients bicuspid in 90 and quadricuspid in 3. One hundred fifty three patients had type I dysfunction (aortic dilatation), 134 had type II (cusp prolapse), and 40 had type III (restrictive). Thirty six percent (96/264) of the patients had more than one identified mechanism. In-hospital mortality was 1.1% (3/264). Six patients experienced early repair failure; 3 underwent re-repair. Functional classification predicted the necessary repair techniques in 82-100% of patients, with adjunctive techniques being employed in up to 35% of patients. Mid-term follow up (median [interquartile range]: 47 [29-73] months) revealed a late mortality rate of 4.2% (11/261, 10 cardiac). Five year overall survival was 95 +/- 3%. Ten patients underwent aortic valve reoperation (1 re-repair). Freedoms from recurrent Al (>2+) and from AV reoperation at 5 years was 88 +/- 3% and 92 +/- 4% respectively and patients with type I (82 +/- 9%; 93 +/- 5%) or II (95 +/- 5%; 94 +/- 6%) had better outcomes compared to type III (76 +/- 17%; 84 +/- 13%). Aortic valve repair is an acceptable therapeutic option for patients with aortic insufficiency. This functional classification allows a systematic approach to the repair of Al and can help to predict the surgical techniques required as well as the durability of repair. Restrictive cusp motion (type III), due to fibrosis or calcification, is an important predictor for recurrent Al following AV repair.

The IUGA/ICS classification of synthetic mesh complications in female pelvic floor reconstructive surgery: a multicenter study.

PubMed

Miklos, John R; Chinthakanan, Orawee; Moore, Robert D; Mitchell, Gretchen K; Favors, Sheena; Karp, Deborah R; Northington, Gina M; Nogueiras, Gladys M; Davila, G Willy

2016-06-01

The objective was to report patterns of sling and transvaginal mesh-related complications using the IUGA/ICS classification of prosthesis-related complications. This was a retrospective chart review of all patients who underwent surgical removal of sling, transvaginal mesh, and sacrocolpopexy for mesh-related complications from 2011 to 2013 at three tertiary referral centers. The International Urogynecological Association (IUGA)/International Continence Society (ICS) classification system was utilized. We identified 445 patients with mesh complications, 506 pieces of synthetic mesh were removed, and 587 prostheses-related complications were classified. 3.7 % of patients had viscus organ penetration or vaginal exposure as their presenting chief complaint and 59.7 % were classified as not having any vaginal epithelial separation or category 1. The most common category was spontaneous pain (1Be: 32.5 %) followed by dyspareunia (1Bc: 14.7 %). The sling group was 20 % more likely to have pain compared with the pelvic organ prolapse (POP) mesh group (OR 1.2, 95 % CI 0.8-1.6). The most commonly affected site (S2) was away from the suture line (49 %). Compared with the sling group, the POP group had a higher rate of mesh exposure, which mostly occurred at the suture line area. The majority of patients presented with mesh-related complications more than 1 year post-insertion (T4; average 3.68 ± 2.47 years). Surgeons should be aware that patients with vaginal mesh complications routinely exhibit complications more than 1 year after the implantation with pain as the most common presenting symptom.

Vaginal cones or balls to improve pelvic floor muscle performance and urinary continence in women post partum: A quantitative systematic review.

PubMed

Oblasser, Claudia; Christie, Janice; McCourt, Christine

2015-11-01

the vaginal use of cones or balls aims to increase muscle performance and thereby prevent or treat urinary incontinence. To date, no systematic review has focused on the effectiveness of these devices specifically during the postpartum period. The objectives of this review were: to compare the effectiveness of vaginal cones or balls for improvement of pelvic floor muscle performance and urinary continence in the postpartum period to no treatment, placebo, sham treatment or active controls; to gather information on effect on perineal descent or pelvic organ prolapse, adverse effects and economical aspects. quantitative systematic review. 14 scientific databases (including PubMed and CINAHL) and the world-wide web; experts were contacted for published and unpublished data. studies had to be randomised/quasi-randomised trials and have female participants up to one year after childbirth. The intervention is compared to no treatment, placebo, sham treatment or active controls. Outcome measures relate to pelvic floor muscle performance or urinary incontinence. Studies were selected, 'risk of bias' assessed, and data extracted by two reviewers independently with inter-reviewer agreement. one study met the inclusion criteria; its original data were re-analysed. In an intention-to-treat analysis, compared with the control group, the cone group showed a statistically significant lower rate of urinary incontinence; compared with the exercise group, the prevalence was similar. However, the validity of the analysis is limited. the evidence gained from this systematic review is very limited. The use of cones may be helpful for urinary incontinence after childbirth, but further research is needed. Copyright © 2015 Elsevier Ltd. All rights reserved.

Anatomic distribution of nerves and microvascular density in the human anterior vaginal wall: prospective study.

PubMed

Li, Ting; Liao, Qinping; Zhang, Hong; Gao, Xuelian; Li, Xueying; Zhang, Miao

2014-01-01

The presence of the G-spot (an assumed erotic sensitive area in the anterior wall of the vagina) remains controversial. We explored the histomorphological basis of the G-spot. Biopsies were drawn from a 12 o'clock direction in the distal- and proximal-third areas of the anterior vagina of 32 Chinese subjects. The total number of protein gene product 9.5-immunoreactive nerves and smooth muscle actin-immunoreactive blood vessels in each specimen was quantified using the avidin-biotin-peroxidase assay. Vaginal innervation was observed in the lamina propria and muscle layer of the anterior vaginal wall. The distal-third of the anterior vaginal wall had significantly richer small-nerve-fiber innervation in the lamina propria than the proximal-third (p = 0.000) and in the vaginal muscle layer (p = 0.006). There were abundant microvessels in the lamina propria and muscle layer, but no small vessels in the lamina propria and few in the muscle layer. Significant differences were noted in the number of microvessels when comparing the distal- with proximal-third parts in the lamina propria (p = 0.046) and muscle layer (p = 0.002). Significantly increased density of nerves and microvessels in the distal-third of the anterior vaginal wall could be the histomorphological basis of the G-spot. Distal anterior vaginal repair could disrupt the normal anatomy, neurovascular supply and function of the G-spot, and cause sexual dysfunction.

Robotic-assisted vesicovaginal fistula repair using an extravesical approach without interposition grafting.

PubMed

Kelly, Erin; Wu, Maria Y; MacMillan, J Barry

2018-03-01

Post-hysterectomy vesicovaginal fistula (VVF) is rare. In addition to conventional abdominal and vaginal approaches, robotic-assisted VVF repairs have recently been described. We present a case of an extravesical, robotic-assisted VVF repair, without placement of an interposition graft performed in a Canadian teaching center. A 51-year-old woman presented with urinary incontinence 5 days after laparoscopic hysterectomy. Computed tomography cystogram, cystoscopy, and methylene blue dye test, confirmed a VVF above the bladder trigone. The patient underwent a robotic-assisted VVF repair 3 months after presentation, without complication. An abdominal, extravesical approach was used. Operative time was 116 min and repeat CT cystogram showed no evidence of persistent. We have demonstrated that a VVF repair, using a robotic-assisted, extravesical approach without interposition graft placement, can be safe, less invasive and have a successful outcome at 1 year of follow-up.

Variation in the Reported Management of Canine Prolapsed Nictitans Gland and Feline Herpetic Keratitis.

PubMed

White, Constance N; Jones, Gareth; Baker, Sarah; Dean, Rachel S; Brennan, Marnie L

2018-06-01

Treatment variation in medicine may be driven by evidence gaps, clinician factors, and patient preferences. Although well-documented in human medicine, variation in clinical management is relatively unexplored in veterinary practice. Clinical vignette questionnaires were administered to a cross section of general practitioners (GPs) and veterinarians with postgraduate training in ophthalmology (PGs) to survey recommended management of canine prolapsed nictitans gland ("cherry eye", PNG) and feline herpesvirus (FHV-1) keratitis. The majority of veterinarians (96.2%) suggested surgical replacement of cherry eye, with a pocketing technique being the most frequently nominated procedure. GPs were more likely to suggest gland excision in the event of surgical failure, while PGs more frequently nominated techniques incorporating a periosteal anchor for salvage repair. Most respondents managed FHV-1 keratitis with topical antibiotics (76.4%), with a minority suggesting topical antivirals (32.2%). GPs favoured topical acyclovir whilst PGs more frequently recommended topical trifluorothymidine. A significantly larger proportion of PGs nominated systemic famciclovir and lysine supplement for FHV-1 keratitis. This survey revealed moderate treatment variation for these conditions, both between and within practitioner groups. Additional research is needed to assess the reasons for this variation, particularly for conditions in which high quality evidence is scant.

Successful surgical treatment of intramural aortoatrial fistula, severe aortic regurgitation, mitral prolapse, and tricuspid insufficiency in a patient with Ehlers-Danlos syndrome type IV.

PubMed

Jiang, Shengli; Gao, Changqing; Ren, Chonglei; Zhang, Tao

2012-06-01

Patients with Ehlers-Danlos syndrome (EDS) type IV, an inherited connective tissue disorder, are predisposed to vascular and digestive ruptures, and arterial ruptures account for the majority of deaths. A 31-year-old man with EDS presented with an intramural aortoatrial fistula, severe aortic regurgitation, mitral valve prolapse, and severe tricuspid valve insufficiency combined with a severely dilated left ventricle. Determining the best surgical option for the patient was not easy, especially regarding the course of action for the aortic root with a tear in the sinus of Valsalva. The fistula tract was closed at the aorta with suture and with a patch in the right atrium, the mitral valve was repaired with edge-to-edge suture and then annuloplasty with a Cosgrove ring, the aortic valve was replaced with a mechanical prosthesis, and a modified De Vega technique was used for the tricuspid valvuloplasty. The postoperative course was uncomplicated, and the patient was discharged 2 weeks later. The considerations made to arrive at the chosen surgical course of action in this complex case are reviewed.

Pregnancy after orthotopic continent urinary diversion.

PubMed

Kennedy, W A; Hensle, T W; Reiley, E A; Fox, H E; Haus, T

1993-10-01

Continent urinary diversion has become a common form of bladder management for the female exstrophy patient in whom primary reconstruction has failed. Reported are the results of successful pregnancies in four young adult females, who had previously undergone a flap vaginoplasty as part of earlier management and more recently a continent right colonic urinary reservoir with a perineal stoma (Indiana pouch). Pregnancy in each of these patients was characterized by several urinary tract infections, cervical prolapse and mild to severe maternal hydronephrosis. All of the patients had some degree of difficulty with clean intermittent catheterization. One patient required an indwelling catheter with prolonged bed rest. Maternal hydronephrosis resolved after delivery in all instances. All four patients delivered their infants by way of cesarean section, either emergently for maternal or fetal distress or electively. Cervical prolapse did not resolve in three patients and will require surgical repair. After delivery, all patients returned to their previous pattern of clean intermittent catheterization without loss of continence. All the infants delivered were healthy with appropriate weights and high Apgar scores (more than 8). Orthotopic (perineal stoma) continent urinary diversion is not a contraindication to pregnancy. However, our experience mandates delivery by cesarean section with close monitoring for maternal or fetal distress during gestation.

[Complications associated with the use of polypropylene mesh in women under colposacropexy].

PubMed

Aguilera-Maldonado, Lizzete Verónica; Jiménez-Vieyra, Carlos Ramón; Solís-Moreno, Tania Kristal

2015-10-01

There have been numerous surgical procedures and modi fied in the hope of obtaining a lasting cure for pelvic organ prolapse These surgeries were performed using the traditionally native tissues of the patient. In an effort to reduce morbidity, improve surgical outcomes and reduce the complexity of these operations, we used a growing number of synthetic mesh repairs and biomaterials used tissue from cadaver or animal. To evaluate the frequency of complications associated with the use of polypropylene mesh in women undergoing colposacropexy. Retrospective, observational and descriptive study conducted at the Hospitalde Ginecología y Obstetricia 3 IMSS (Mexico) between 1 January 2006 and 15 February 2013. The main risk factors associated with pelvic organ prolapse were considered, comorbidity and complications directly linked to the procedure. With respect to the related complications colposacropexy procedure using polypropylene mesh were documented in 20 of 67 patients which corresponded to 30%. A number of complications have been associated with the use of meshes between these include: extrusion, erosion, pelvic pain, dyspareunia, bladder or bowel condition, but one aspect is poorly evaluated sexual dysfunction without to definitely plays an important role in the field bio-psychosocial.

Aortic valve repair leads to a low incidence of valve-related complications.

PubMed

Aicher, Diana; Fries, Roland; Rodionycheva, Svetlana; Schmidt, Kathrin; Langer, Frank; Schäfers, Hans-Joachim

2010-01-01

Aortic valve replacement for aortic regurgitation (AR) has been established as a standard treatment but implies prosthesis-related complications. Aortic valve repair is an alternative approach, but its mid- to long-term results still need to be defined. Over a 12-year period, 640 patients underwent aortic valve repair for regurgitation of a unicuspid (n=21), bicuspid (n=205), tricuspid (n=411) or quadricuspid (n=3) aortic valve. The mechanism of regurgitation involved prolapse (n=469) or retraction (n=20) of the cusps, and dilatation of the root (n=323) or combined pathologies. Treatment consisted of cusp repair (n=529), root repair (n=323) or a combination of both (n=208). The patients were followed clinically and echocardiographically; follow-up was complete in 98.5% (cumulative follow-up: 3035 patient years). Hospital mortality was 3.4% in the total patient cohort and 0.8% for isolated aortic valve repair. The incidences of thrombo-embolism (0.2% per patient per year) and endocarditis (0.16%per patient per year) were low. Freedom from re-operation at 5 and 10 years was 88% and 81% in bicuspid and 97% and 93% in tricuspid aortic valves (p=0.0013). At re-operation, 13 out of 36 valves could be re-repaired. Freedom from valve replacement was 95% and 90% in bicuspid and 97% and 94% in tricuspid aortic valves (p=0.36). Freedom from all valve-related complications at 10 years was 88%. Reconstructive surgery of the aortic valve is feasible with low mortality in many individuals with aortic regurgitation. Freedom from valve-related complications after valve repair seems superior compared to available data on standard aortic valve replacement. Copyright 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Extracellular matrix integrity: a possible mechanism for differential clinical effects among selective estrogen receptor modulators and estrogens?

PubMed

Cox, David A; Helvering, Leah M

2006-03-09

Recent gene microarray studies have illustrated heterogeneity in gene expression changes not only between estrogens and selective estrogen receptor modulators (SERMs), but also across different SERM molecules. In ovariectomized rats, this phenomenon was observed with respect to a number of genes involved in collagen turnover and extracellular matrix (ECM) integrity in the uterus and vaginal tissues. Preliminary mechanistic data suggest that these effects on ECM integrity may have relevance in the context of the effect of estrogens and some SERMs to increase the risk of pelvic organ prolapse and the incidence of urinary incontinence in postmenopausal women. Given the pivotal role of ECM integrity and collagen turnover in other tissues and disease states, these processes may provide a fruitful target for future research into the mechanisms for the heterogeneous pharmacology of estrogens and SERMs across different cell types and target tissues.

Predictors of recurrence of prolapse after procedure for prolapse and haemorrhoids.

PubMed

Festen, S; Molthof, H; van Geloven, A A W; Luchters, S; Gerhards, M F

2012-08-01

The procedure for prolapse and haemorrhoids (PPH) is an effective surgical therapy for symptomatic haemorrhoids. Compared with haemorrhoidectomy, meta-analysis has shown PPH to be less painful, with higher patient satisfaction and a quicker return to work, but at the cost of higher prolapse recurrence rates. This is the first report describing predictors of prolapse recurrence after PPH. A cohort of patients with symptomatic haemorrhoids, treated with PPH in our hospital between 2002 and 2009, was retrospectively analysed. Multivariate analysis was performed to identify patient-related and perioperative predictors associated with persisting prolapse and prolapse recurrence. In total, 159 consecutively enrolled patients were analysed. Persistence and recurrence of prolapse was observed in 16% of the patients. Increased surgical experience showed a trend towards lower recurrence rates. Multivariate analysis identified female gender, long duration of PPH surgery and the absence of muscle tissue in the resected specimen as independent predictors of postoperative persistence of prolapse of haemorrhoids. The absence of prior treatment with rubber band ligation (RBL) as well as increased PPH experience at the hospital showed a trend towards a higher rate of prolapse recurrence. In order to reduce recurrence of prolapse, PPH should be performed by a surgeon with adequate PPH experience, patients should be treated with RBL prior to PPH and a resection of mucosa with underlying muscle fibres should be strived for. © 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland.

Cloacal Prolapse in Raptors: Review of 16 Cases.

PubMed

Dutton, Thomas A G; Forbes, Neil A; Carrasco, Daniel Calvo

2016-06-01

Sixteen cases of cloacal prolapse in raptors were reviewed in this study. Colonic prolapse was the most common presentation (56% of cases). Red-tailed hawks ( Buteo jamaicensis ) were overrepresented, comprising 66% of colonic prolapse cases. In cases of colonic prolapse, postsurgical stricture formation was a commonly identified complication after resection and anastomosis of the colon. A novel technique was used in 2 cases of colonic prolapse, in which sterile, semirigid rubber tubing was placed in the distal colon and removed per-cloaca at the end of the procedure; this facilitated a secure, fluid-tight anastomosis while maintaining sufficient intestinal lumen. Oviductal prolapse (31% of cases) was associated with the most guarded prognosis (40% treatment success). Cloacoliths were treated successfully in 2 birds (13% of cases) by minimally invasive per-cloacal manual removal.

Management of patients with rectocele, multiple pelvic floor dysfunctions and obstructed defecation syndrome.

PubMed

Murad-Regadas, Sthela Maria; Regadas, Francisco Sergio P; Rodrigues, Lusmar Veras; Fernandes, Graziela Olivia da Silva; Buchen, Guilherme; Kenmoti, Viviane T

2012-01-01

Management of patients with obstructed defecation syndrome is still controversial. To analyze the efficacy of clinical, clinical treatment followed by biofeedback, and surgical treatment in patients with obstructed defecation, rectocele and multiple dysfunctions evaluated with echodefecography. The study included 103 females aged 26-84 years with obstructed defecation, grade-II/III rectocele and multiple dysfunctions on echodefecography. Patients were distributed into three treatment groups and constipation scores were assigned. Group I: 34 (33%) patients with significant improvement of symptoms through clinical management only. Group II: 14 (14%) with improvement through clinical treatment plus biofeedback. Group III: 55 (53%) referred to surgery due to treatment failure. Group I: 20 (59%) patients had grade-II rectocele, 14 (41%) grade-III. Obstructed defecation syndrome was associated with intussusception (41%), mucosal prolapse (41%), anismus (29%), enterocele (9%) or 2 dysfunctions (23%). The average constipation score decreased significantly from 11 to 5. Group II: 11 (79%) grade-II rectocele, 3 (21%) grade-III, associated with intussusception (7%), mucosal prolapse (43%), anismus (71%) or 2 dysfunctions (29%). There was significant decrease in constipation score from 13 to 6. Group III: 8 (15%) grade-II rectocele, 47 (85%) grade-III, associated with intussusception (42%), mucosal prolapse (40%) or 2 dysfunctions (32%). The constipation score remained unchanged despite clinical treatment and biofeedback. Twenty-three underwent surgery had a significantly decrease in constipation score from 12 to 4. The remaining 32 (31%) patients which 22 refused surgery, 6 had low anal pressure and 4 had slow transit. Approximately 50% of patients with obstructed defecation, rectocele and multiple dysfunctions presented a satisfactory response to clinical treatment and/or biofeedback. Surgical repair was mainly required in patients with grade-III rectocele whose constipation scores remained high despite all efforts.

Bio-Thiersch as an Adjunct to Perineal Proctectomy Reduces Rates of Recurrent Rectal Prolapse.

PubMed

Eftaiha, Saleh M; Calata, Jed F; Sugrue, Jeremy J; Marecik, Slawomir J; Prasad, Leela M; Mellgren, Anders; Nordenstam, Johan; Park, John J

2017-02-01

The rates of recurrent prolapse after perineal proctectomy vary widely in the literature, with incidences ranging between 0% and 50%. The Thiersch procedure, first described in 1891 for the treatment of rectal prolapse, involves encircling the anus with a foreign material with the goal of confining the prolapsing rectum above the anus. The Bio-Thiersch procedure uses biological mesh for anal encirclement and can be used as an adjunct to perineal proctectomy for rectal prolapse to reduce recurrence. The aim of this study was to evaluate the Bio-Thiersch procedure as an adjunct to perineal proctectomy and its impact on recurrence compared with perineal proctectomy alone. A retrospective review of consecutive patients undergoing perineal proctectomy with and without Bio-Thiersch was performed. Procedures took place in the Division of Colon and Rectal Surgery at a tertiary academic teaching hospital. Patients who had undergone perineal proctectomy and those who received perineal proctectomy with Bio-Thiersch were evaluated and compared. All of the patients with rectal prolapse received perineal proctectomy with levatorplasty, and a proportion of those patients had a Bio-Thiersch placed as an adjunct. The incidence of recurrent rectal prolapse after perineal proctectomy alone or perineal proctectomy with Bio-Thiersch was documented. Sixty-two patients underwent perineal proctectomy (8 had a previous prolapse procedure), and 25 patients underwent perineal proctectomy with Bio-Thiersch (12 had a previous prolapse procedure). Patients who received perineal proctectomy with Bio-Thiersch had a lower rate of recurrent rectal prolapse (p < 0.05) despite a higher proportion of them having had a previous prolapse procedure (p < 0.01). Perineal proctectomy with Bio-Thiersch had a lower recurrence over time versus perineal proctectomy alone (p < 0.05). This study was limited by nature of being a retrospective review. Bio-Thiersch as an adjunct to perineal proctectomy may reduce the risk for recurrent rectal prolapse and can be particularly effective in patients with a history of previous failed prolapse procedures.

Uterine prolapse with an interesting vascular anomaly in a cheetah: a case report.

PubMed

Nöthling, J O; Knesl, O; Irons, P; Lane, E

2002-12-01

A 5-year-old cheetah suffered a complete prolapse of the left uterine horn after the birth of her second litter. Two attempts to reduce the prolapse transvaginally failed. The animal was hospitalized 13 days after the prolapse first occurred, and an ovariohysterectomy was performed to resolve the prolapse. The prolapsed uterine horn had been mutilated: its tip, together with the ipsilateral ovary was absent. Laparotomy revealed no sign of recent or past hemorrhage or adhesions, or any signs of the left ovarian artery or left ovarian vein in the remnants of the left mesovarium. A large vein crossed the uterine body from the left uterine horn to join the right uterine vein, presumably serving as the only route of venous drainage for the prolapsed uterine horn. A possible cause for the prolapse is excessive mobility of the uterus due to prior rupture of its mesial support. The animal died 24 days after surgery due to chronic renal failure, as a result of severe renal amyloidosis.

Body image perceptions in women with pelvic organ prolapse: a qualitative study.

PubMed

Lowder, Jerry L; Ghetti, Chiara; Nikolajski, Cara; Oliphant, Sallie S; Zyczynski, Halina M

2011-05-01

To describe perceptions of prolapse-specific body image in women with symptomatic prolapse. Women with symptomatic pelvic organ prolapse quantification stage ≥ II prolapse participated in semistructured focus groups or self-report questionnaire. Transcripts were independently reviewed and body image themes were identified and confirmed by consensus. Twenty-five women participated in focus groups and 27 in online questionnaires. Transcript analysis revealed 3 central themes and 25 body-image related subthemes. Women living with prolapse were more likely to feel self-conscious, isolated, "different," less feminine, and less attractive. Women often changed sexual intimacy practices because of embarrassment or discomfort, and many avoided intimacy all together. Prolapse greatly affected women's personal and professional activities causing some women to adjust routines or stop activities. Women reported loss of interest in activities, distraction while performing daily/work-related tasks, and embarrassment when asking for help with activities. Themes identified in this qualitative study demonstrate the profound effect of prolapse on a woman's body image. Copyright © 2011 Mosby, Inc. All rights reserved.

Advances in basic science methodologies for clinical diagnosis in female stress urinary incontinence.

PubMed

Abdulaziz, Marwa; Deegan, Emily G; Kavanagh, Alex; Stothers, Lynn; Pugash, Denise; Macnab, Andrew

2017-06-01

We provide an overview of advanced imaging techniques currently being explored to gain greater understanding of the complexity of stress urinary incontinence (SUI) through better definition of structural anatomic data. Two methods of imaging and analysis are detailed for SUI with or without prolapse: 1) open magnetic resonance imaging (MRI) with or without the use of reference lines; and 2) 3D reconstruction of the pelvis using MRI. An additional innovative method of assessment includes the use of near infrared spectroscopy (NIRS), which uses non-invasive photonics in a vaginal speculum to objectively evaluate pelvic floor muscle (PFM) function as it relates to SUI pathology. Advantages and disadvantages of these techniques are described. The recent innovation of open-configuration magnetic resonance imaging (MRO) allows images to be captured in sitting and standing positions, which better simulates states that correlate with urinary leakage and can be further enhanced with 3D reconstruction. By detecting direct changes in oxygenated muscle tissue, the NIRS vaginal speculum is able to provide insight into how the oxidative capacity of the PFM influences SUI. The small number of units able to provide patient evaluation using these techniques and their cost and relative complexity are major considerations, but if such imaging can optimize diagnosis, treatment allocation, and selection for surgery enhanced imaging techniques may prove to be a worthwhile and cost-effective strategy for assessing and treating SUI.

Laparoscopic Sacral Colpopexy: The "6-Points" Technique.

PubMed

Schaub, Marie; Lecointre, Lise; Faller, Emilie; Boisramé, Thomas; Baldauf, Jean-Jacques; Wattiez, Arnaud; Akladios, Cherif Youssef

To illustrate laparoscopic sacral colpopexy for pelvic organ prolapse, a new method using a simplified mesh fixation technique, with only 6 fixing points. Step-by-step explanation of the surgery using video (educative video). The video was approved by the local institutional review board. University Hospital of Strasbourg, France (Canadian Task Force Classification III). Women with multicompartment prolapse. We first dissected the promontorium and vertically incise the posterior parietal peritoneum on the right pelvic sidewall up the pouch of Douglas. We then dissect the rectovaginal septum up to the anal cap, laterally exposing the puborectalis muscle on each side. Middle rectal vessels can be coagulated and cut without increasing the risk of digestive disorders (especially constipation), but it is preferable to conserve them if the space is sufficient for suture. Then, we dissect the vesicovaginal space and realized the subtotal hysterectomy. Finally, we realized the fastening of the anterior and posterior meshes. The particularity is that we performed only 6 points for fixing the meshes: 1 on the puborectalis muscle on each side without tension (to reduce the risk of mesh contracture, dyspareunia, and chronic pelvic pain), 1 for the fixing of the anterior mesh on the anterior vaginal wall at the level of the bladder neck, and 1 on each side of the cervix for the reconstitution of the pericervical ring gathering together the anterior mesh, the pubocervical fascia, and the insertion of the uterosacral ligament at the level of the cervix and the posterior mesh. The sixth stitch fastened 1 of 2 meshes to the anterior paravertebral ligament at the level of the sacral promontory. We finished with the peritonization. The duration of surgery lasts approximately 120 minutes in well-experienced hands. Based on our experience the 6-point technique was relatively simple (few laparoscopic stiches) with few operative difficulties and was also associated with a low rate of reintervention. Surgical management of middle compartment prolapse could be performed quickly and efficiently under laparoscopy with the "6-points" technique. Copyright © 2017 AAGL. Published by Elsevier Inc. All rights reserved.

Is it necessary to diagnose levator avulsion on pelvic floor muscle contraction?

PubMed

Dietz, H P; Pattillo Garnham, A; Guzmán Rojas, R

2017-02-01

Avulsion of the levator ani muscle commonly occurs at vaginal birth. This condition is usually diagnosed by translabial ultrasound (TLUS) during pelvic floor muscle contraction (PFMC). Some patients are unable to achieve a satisfactory PFMC and in these cases avulsion is assessed at rest. The aim of this study was to validate the diagnosis of levator avulsion by means of TLUS at rest. This was a retrospective study of 233 women seen at a tertiary urogynecological center. All women underwent four-dimensional TLUS in the supine position and after voiding. Volumes were obtained on maximal PFMC and at rest. Analysis of the volumes was performed with the observer blinded against all clinical data. Avulsion was defined as an abnormal levator ani muscle insertion that was visible in at least three consecutive axial plane slices, at and above the level of minimal hiatal dimensions, at 2.5-mm intervals. We examined the correlation between both assessment methods using Cohen's kappa coefficient and tested the association of each method with female pelvic organ prolapse on clinical examination, organ descent on ultrasound and hiatal ballooning. In total, datasets from 202 women were available for analysis. The correlation between a diagnosis of avulsion in volumes obtained at rest and those on PFMC was moderate, with a kappa value of 0.583 (95% CI, 0.484-0.683). Agreement for defects visualized on single slices was moderate, with a kappa value of 0.556 (95% CI, 0.520-0.591). When avulsion diagnoses at rest and on PFMC were tested against symptoms of prolapse, and prolapse on clinical examination and on ultrasound, neither of the two methods was superior. Although tomographic ultrasound imaging during PFMC enhances tissue discrimination, this may not translate to superior diagnostic performance. Hence, volumes obtained at rest may be used in women unable to contract their pelvic floor. The diagnosis of levator avulsion by tomographic pelvic floor ultrasound is equally valid when performed at rest or on PFMC. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Stimulation of TLRs by LMW-HA induces self-defense mechanisms in vaginal epithelium.

PubMed

Dusio, Giuseppina F; Cardani, Diego; Zanobbio, Laura; Mantovani, Martina; Luchini, Patrizia; Battini, Lorenzo; Galli, Valentina; Diana, Angela; Balsari, Andrea; Rumio, Cristiano

2011-07-01

The innate immune system is present throughout the female reproductive tract and functions in synchrony with the adaptive immune system to provide protection in a way that enhances the chances for fetal survival, while protecting against potential pathogens. Recent data show that activation of Toll-like receptor (TLR)2 and 4 by low-molecular weight hyaluronic acid (LMW-HA) in the epidermis induces secretion of the antimicrobial peptide β-defensin 2. In the present work, we show that LMW-HA induces vaginal epithelial cells to release different antimicrobial peptides, via activation of TLR2 and TLR4. Further, we found that LMW-HA favors repair of vaginal epithelial injury, involving TLR2 and TLR4, and independently from its classical receptor CD44. This wound-healing activity of LMW-HA is dependent from an Akt/phosphatidylinositol 3 kinase pathway. Therefore, these findings suggest that the vaginal epithelium is more than a simple physical barrier to protect against invading pathogens: on the contrary, this surface acts as efficient player of innate host defense, which may modulate its antimicrobial properties and injury restitution activity, following LMW-HA stimulation; this activity may furnish an additional protective activity to this body compartment, highly and constantly exposed to microbiota, ameliorating the self-defense of the vaginal epithelium in both basal and pathological conditions.

Uterovaginal Anastomosis for Cases of Cryptomenorrhea Due to Cervical Atresia with Vaginal Aplasia: Benefits and Risks.

PubMed

Zayed, M; Fouad, R; Elsetohy, K A; Hashem, A T; AbdAllah, A A; Fathi, A I

2017-12-01

The objective of this study was to assess short-term benefits and risks of utero-vaginal anastomosis done for cases of cryptomenorrhea due to cervical atresia with vaginal aplasia. Prospective study. Surgical procedures were done between December 2013 and September 2015 at the department of Obstetrics and Gynecology, Cairo University Hospital. Five patients who had cryptomenorrhea due to cervical atresia associated with vaginal aplasia were included. Utero-vaginal anastomoses were performed in 2 stages; a stage of McIndoe vaginoplasty and a stage of excision of the atretic cervical tissue and anastomosing the uterus to the neovagina. Follow-up was done by gynecological and ultrasound examination in a duration ranged from 12 to 36 months. Occurrence of regular menstrual flow and relief of the severe cyclic pain. All patients had relief of the severe cyclic pain. Four patients had regular menstrual flow. One patient developed occlusion of the track after 1 year and needed dilatation once. Three patients developed low vaginal stenosis without occlusion of the track. One patient had rectal injury repaired without causing postoperative morbidity. Uterovaginal anastomosis is a promising conservative management option for cervical atresia with vaginal aplasia, which has benefits but is not free of risks. Long-term follow-up is still needed to judge its feasibility. We recommend performing McIndoe vaginoplasty as a starting stage before the anastomosis preferably in a separate setting. Copyright © 2017 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.

Genitourinary tract injuries in girls.

PubMed

Okur, H; Küçïkaydin, M; Kazez, A; Turan, C; Bozkurt, A

1996-09-01

To evaluate lower genitourinary tract injuries in girls and to propose guidelines for the investigation and initial management of this unusual injury. The hospital records of 38 girls (aged 2-13 years) treated in our institution because of lower genitourinary (LG) tract injury between 1988 and 1995 were reviewed retrospectively. Urethral ruptures were detected in six patients, but the most frequent injuries were to the vulva (63%) and vagina (53%). There were pelvic fractures in eight patients and femoral fractures in a further five. Eight patients had concomitant anorectal lacerations. Vaginal and perineal lacerations were repaired primarily and a temporary urethral catheter was placed for a mean of 3 days. Partial urethral disruptions were repaired primarily over a stenting catheter in three patients. In one case, vaginal laceration and proximal complete rupture of the urethra was managed through a transvaginal approach with end-to-end urethral anastomosis over a stenting catheter. There was a complete rupture of the distal urethra and avulsion of the external meatus in two cases and these patients were managed by urethral advancement and meatoplasty. Perineal physical signs did not reflect the severity of the lesions and cystovaginoscopy allowed localization of lacerations in some cases. Primary repair was possible in all cases. Three patients (8%) had wound infection after surgery. One patient had temporary urinary incontinence which was managed conservatively and one patient had faecal incontinence which needed secondary surgery. All female paediatric patients with suspected LG tract injury should undergo examination under anaesthesia to determine the degree of injury or possible concomitant injury to the urethra, bladder or rectum. Primary repair of these injuries is recommended.

Lifetime physical activity and female stress urinary incontinence.

PubMed

Nygaard, Ingrid E; Shaw, Janet M; Bardsley, Tyler; Egger, Marlene J

2015-07-01

We sought to estimate whether moderate/severe stress urinary incontinence (SUI) in middle-aged women is associated with overall lifetime physical activity (including leisure, household, outdoor, and occupational), as well as lifetime leisure (recreational), lifetime strenuous, and strenuous activity during the teen years. Recruitment for this case-control study was conducted in primary-care-level family medicine and gynecology clinics. A total of 1538 enrolled women ages 39-65 years underwent a Pelvic Organ Prolapse Quantification examination to assess vaginal support. Based on Incontinence Severity Index scores, cases had moderate/severe and controls had no/mild SUI. We excluded 349 with vaginal descent at/below the hymen (pelvic organ prolapse), 194 who did not return questionnaires, and 110 with insufficient activity data for analysis. In all, 213 cases were frequency matched 1:1 by age group to controls. Physical activity was measured using the Lifetime Physical Activity Questionnaire, in which women recall activity from menarche to present. We created separate multivariable logistic regression models for activity measures. SUI odds increased slightly with overall lifetime activity (odds ratio [OR], 1.20 per 70 additional metabolic equivalent of task-h/wk; 95% confidence interval [CI], 1.02-1.41), and were not associated with lifetime strenuous activity (OR, 1.11; 95% CI, 0.99-1.25). In quintile analysis of lifetime leisure activity, which demonstrated a nonlinear pattern, all quintiles incurred about half the odds of SUI compared to reference (second quintile; P = .009). Greater strenuous activity in teen years modestly increased SUI odds (OR, 1.37 per 7 additional h/wk; 95% CI, 1.09-1.71); OR, 1.75; 95% CI, 1.15-2.66 in sensitivity analysis adjusting for measurement error. The predicted probability of SUI rose linearly in women exceeding 7.5 hours of strenuous activity/wk during teen years. Teen strenuous activity had a similar effect on SUI odds when adjusted for subsequent strenuous activity during ages 21-65 years. In middle-aged women, a slight increased odds of SUI was noted only after substantially increased overall lifetime physical activity. Increased lifetime leisure activity decreased and lifetime strenuous activity appeared unrelated to SUI odds. Greater strenuous activity during teen years modestly increased SUI odds. Copyright © 2015 Elsevier Inc. All rights reserved.

The modified Altemeier procedure for a loop colostomy prolapse.

PubMed

Watanabe, Makoto; Murakami, Masahiko; Ozawa, Yoshiaki; Uchida, Marie; Yamazaki, Kimiyasu; Fujimori, Akira; Otsuka, Koji; Aoki, Takeshi

2015-11-01

Loop colostomy prolapse is associated with an impaired quality of life. Surgical treatment may sometimes be required for cases that cannot be closed by colon colostomy because of high-risk morbidities or advanced disease. We applied the Altimeter operation for patients with transverse loop colostomy. The Altemeier operation is therefore indicated for rectal prolapse. This technique involves a simple operation, which includes a circumferential incision through the full thickness of the outer and inner cylinder of the prolapsed limb, without incising the abdominal wall, and anastomosis with sutures using absorbable thread. We performed the Altemeier operation for three cases of loop stomal prolapse. Those patients demonstrated no postoperative complications (including obstruction, prolapse recurrence, or hernia). Our findings suggest that this procedure is useful as an optional surgical treatment for cases of transverse loop colostomy prolapse as a permanent measure in patients with high-risk morbidities or advanced disease.

Randomised trial of mitral valve repair with leaflet resection versus leaflet preservation on functional mitral stenosis (The CAMRA CardioLink-2 Trial).

PubMed

Chan, Vincent; Chu, Michael W A; Leong-Poi, Howard; Latter, David A; Hall, Judith; Thorpe, Kevin E; de Varennes, Benoit E; Quan, Adrian; Tsang, Wendy; Dhingra, Natasha; Yared, Kibar; Teoh, Hwee; Chu, F Victor; Chan, Kwan-Leung; Mesana, Thierry G; Connelly, Kim A; Ruel, Marc; Jüni, Peter; Mazer, C David; Verma, Subodh

2017-05-30

The gold-standard treatment of severe mitral regurgitation (MR) due to degenerative disease is valve repair, which is surgically performed with either a leaflet resection or leaflet preservation approach. Recent data suggest that functional mitral stenosis (MS) may occur following valve repair using a leaflet resection strategy, which adversely affects patient prognosis. A randomised comparison of these two approaches to mitral repair on functional MS has not been conducted. This is a prospective, multicentre randomised controlled trial designed to test the hypothesis that leaflet preservation leads to better preservation of mitral valve geometry, and therefore, will be superior to leaflet resection for the primary outcome of functional MS as assessed by 12-month mean mitral valve gradient at peak exercise. Eighty-eight patients with posterior leaflet prolapse will be randomised intraoperatively once deemed by the operating surgeon to feasibly undergo mitral repair using either a leaflet resection or leaflet preservation approach. Secondary end points include comparison of repair strategies with regard to mitral valve orifice area, leaflet coaptation height, 6 min walk test and a composite major adverse event end point consisting of recurrent MR ≥2+, death or hospital readmission for congestive heart failure within 12 months of surgery. Institutional ethics approval has been obtained from all enrolling sites. Overall, there remains clinical equipoise regarding the mitral valve repair strategy that is associated with the least likelihood of functional MS. This trial hopes to introduce high-quality evidence to help surgical decision making in this context. NCT02552771. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Evolving Techniques for Mitral Valve Reconstruction

PubMed Central

Galloway, Aubrey C.; Grossi, Eugene A.; Bizekis, Costas S.; Ribakove, Greg; Ursomanno, Patricia; Delianides, Julie; Baumann, F. Gregory; Spencer, Frank C.; Colvin, Stephen B.

2002-01-01

Objective To analyze the effectiveness of new techniques of mitral valve reconstruction (MVR) that have evolved over the last decade, such as aggressive anterior leaflet repair and minimally invasive surgery using an endoaortic balloon occluder. Summary Background Data MVR via conventional sternotomy has been an established treatment for mitral insufficiency for over 20 years, primarily for the treatment of patients with posterior leaflet prolapse. Methods Between June 1980 and June 2001, 1,195 consecutive patients had MVR with ring annuloplasty. Conventional sternotomy was used in 843 patients, minimally invasive surgery in 352 (since June 1996). Anterior leaflet repair was performed in 374 patients, with increasing use over the last 10 years. Follow-up was 100% complete (mean 4.6 years, range 0.5–20.5). Results Hospital mortality was 4.7% overall and 1.4% for isolated MVR (1.1% for minimally invasive surgery vs. 1.6% for conventional sternotomy;P = .4). Multivariate analysis showed the factors predictive of increased operative risk to be age, NYHA functional class, concomitant procedures, and previous cardiac surgery. The 5-year results for freedom from cardiac death, reoperation, and valve-related complications among the 782 patients with degenerative etiology are, respectively, as follows (P > .05 for all end points): for anterior leaflet repair, 93%, 94%, 90%; for no anterior leaflet repair, 91%, 92%, 91%; for minimally invasive surgery, 97%, 89%, 93%; and for conventional sternotomy, 93%, 94%, 90%. Conclusions These findings indicate that late results of MVR after minimally invasive surgery and after anterior leaflet repair are equivalent to those achievable with conventional sternotomy and posterior leaflet repair. These options significantly expand the range of patients suitable for mitral valve repair surgery and give further evidence to support wider use of minimally invasive techniques. PMID:12192315

Pelvic organ prolapse in jimma university specialized hospital, southwest ethiopia.

PubMed

Akmel, Menur; Segni, Hailemariam

2012-07-01

Pelvic organ prolapse is the down ward descent of female organs including the bladder, small and large bowel resulting in protrusion of the vagina, uterus or both. It is a disorder exclusive to women and one of the most common indications for gynecologic surgery. This hospital based retrospective descriptive study was conducted to assess the magnitude of pelvic organ prolapse and risk factors for it. All cases of pelvic organ prolapse admitted and treated in Jimma University Specialized Hospital from July 1, 2008 to June 30, 2011 were included. The collected data were analyzed using SPSS computer software version 16.0. Chi-square test was used and was considered to be significant when p<0.05. Pelvic organ prolapse accounted for 40.7% of major gynecologic operations. Mean age of patients was 42.43 ± 10.4 years and there was a significant association between prolapse and age of patients (p <0.05). Mean parity of patients was 6.5± 2.64 with a significant association between prolapse and parity (p < 0.05). Majority of them (80.6%) lived in rural area and there was a significant association between prolapse and residence area. Farmers accounted for 68.2% of the patients and there was a significant association between prolapse and occupation (p < 0.05). Risk factors identified were chronic cough (20.9%), constipation (30.2%) with some having more than one risk factor while none was identified in 59.7%. Prolapse is common among rural, farmer, parous and older women where most of them delivered at home with prolonged labor. Age, parity and occupation were associated with the stage of prolapse. Awareness creation on risk factors of pelvic organ prolapse and use of contraception to reduce parity is recommended. Health institution delivery should be advocated to minimize the rate of home deliveries and hence of prolonged labor.

Simultaneous Delorme's procedure and inter-sphinteric prosthetic implant for the treatment of rectal prolapse and faecal incontinence: preliminary experience and literature review.

PubMed

Cavazzoni, Emanuel; Rosati, Emanuele; Zavagno, Valentina; Graziosi, Luigina; Donini, Annibale

2015-02-01

Rectal prolapse is a distressing condition affecting mostly elderly patients and females. Delorme's procedure is frequently performed since it offers good results and is burdened by a particularly low morbidity. Faecal Incontinence is associated with prolapse in a large percentage of patients, due to the sphincter damage caused by the prolapsed rectum through the anal canal. Prolapse resection is often ineffective in treating incontinence, and further specific procedures are frequently required. At present, no data are available on combined Delorme's procedure with the implant of Bulking Agents for the simultaneous treatment of rectal prolapse and faecal incontinence. Three patients affected by complete external rectal prolapse underwent simultaneous Delorme's procedure with application of six polyacrylonitrile prosthetic cylinders in the inter-sphinteric space (Gate Keeper™, THD, Correggio Italy). Follow up was at 3,6 and 12 months. Gate Keeper procedure required a short operative time; no morbidity or complications were experienced. Prolapse was successfully treated in all patients and the mean Vaizey's incontinence score value dropped from pre-operative 19.3 to 9.3 after 3 months. All patients experienced a reduction of incontinence episodes and an improvement in daily activities and lifestyle. Gate Keeper implant is feasible and safe when associated to surgical procedures like Delorme's prolapse resection. Preliminary results are positive even if a study with a larger numbers of patients is needed to confirm the efficacy. A simultaneous treatment of faecal incontinence should be always considered when performing surgery for rectal prolapse. The present manuscript describes a simultaneous combination of two surgical techniques to treat rectal prolapse and faecal incontinence. To date, there are no published data on a similar approach. The paper underlies the importance of treating faecal incontinence when performing surgery for rectal prolapse. Copyright © 2015 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

Vaginal-sparing ventral buccal mucosal graft urethroplasty for female urethral stricture: A novel modification of surgical technique.

PubMed

Hoag, Nathan; Gani, Johan; Chee, Justin

2016-07-01

To present a novel modification of surgical technique to treat female urethral stricture (FUS) by a vaginal-sparing ventral buccal mucosal urethroplasty. Recurrent FUS represents an uncommon, though difficult clinical scenario to manage definitively. A variety of surgical techniques have been described to date, yet a lack of consensus on the optimal procedure persists. We present a 51-year-old female with urethral stricture involving the entire urethra. Suspected etiology was iatrogenic from cystoscopy 17 years prior. Since then, the patient had undergone at least 25 formal urethral dilations and periods of self-dilation. In lithotomy position, the urethra was dilated to accommodate forceps, and ventral urethrotomy carried out sharply, exposing a bed of periurethral tissue. Buccal mucosa was harvested, and a ventral inlay technique facilitated by a nasal speculum, was used to place the graft from the proximal urethra/bladder neck to urethral meatus without a vaginal incision. Graft was sutured into place, and urethral Foley catheter inserted. The vaginal-sparing ventral buccal mucosal graft urethroplasty was deemed successful as of last follow-up. Flexible cystoscopy demonstrated patency of the repair at 6 months. At 10 months of follow-up, the patient was voiding well, with no urinary incontinence. No further interventions have been required. This case describes a novel modification of surgical technique for performing buccal mucosal urethroplasty for FUS. By avoiding incision of the vaginal mucosa, benefits may include reduced: morbidity, urinary incontinence, and wound complications including urethro-vaginal fistula.

Successful resolution of a preputial prolapse in an alpaca using medical therapy

PubMed Central

Koziol, Jennifer H.; Edmondson, Misty A.; Wolfe, Dwight F.; Bayne, Jenna E.

2015-01-01

A 2-year-old intact male alpaca was presented for a post-breeding preputial prolapse of 5 days duration. The internal lamina of the prepuce was prolapsed approximately 6 cm and the exposed preputial epithelium was edematous and necrotic. Following 7 days of medical treatment, resolution of the preputial prolapse was achieved. PMID:26130840

Bicornuate uterine horns with complete cervical-vaginal agenesis and congenital vesicouterine fistula.

PubMed

Kumar, Santosh; Singh, S K; Mavuduru, Ravi; Naveen, A; Agarwal, M M; Vanita, Jain; Mandal, A K

2008-05-01

We present a case of bicornuate uterine horns with complete cervico-vaginal agenesis and associated congenital uterovaginal fistula. The patient presented with cyclical hematuria, amenorrhea, and abdominal lump. The vagina was blind-ending. The cystoscopic examination during cyclical hematuria revealed bloody efflux through a small fistula on the posterior wall of the urinary bladder. The magnetic resonance imaging (MRI) showed bicornuate uterus and cervical agenesis. Hysterectomy and repair of the uterovesical fistula was done. The vagina was reconstructed using an amniotic mould. The report underlies the importance of MRI in diagnosing complexity of such rare anomalies. It also stresses for the need of hysterectomy if cervicovaginal agenesis is present.

All in the family: matrimonial mitral valve clicks.

PubMed

Desser, K B; Bokhari, S I; Benchimol, A; Romney, D

1981-05-01

Mitral valve clicks with or without late systolic murmurs were detected in genetically unrelated marital partners of 5 families. The first family represented 2 successive nonconsanguineous marital unions with 3 generations of mitral valve clicks. The second family included 1 natural and 2 adopted children with clinical and echographic evidence of mitral valve prolapse. The third family was comprised of asymptomatic parents, both with nonejection clicks and mitral valve prolapse, whose daughter presented 3 years previously with syncope, palpitations, and combined mitral and tricuspid valve prolapse. The fourth family had 3 members with auscultatory and ultrasonic manifestations of billowing mitral valve, whereas the fourth member had "silent mitral valve prolapse." The fifth family represented a mother with auscultatory and echographic evidence of mitral valve prolapse; her 14-year-old daughter had both mitral and tricuspid valve prolapse, whereas the son had a bicuspid aortic valve. Both children were products of a prior marriage, and her husband has symptomatic mitral valve prolapse. We conclude that matrimonial mitral valve prolapse probably reflects the purported (6--10%) prevalence of this disorder in the general population. The consequences of such marital union on progeny is currently unclear and warrants future investigation.

Prevalence of severe pelvic organ prolapse in relation to job description and socioeconomic status: a multicenter cross-sectional study.

PubMed

Woodman, Patrick J; Swift, Steven E; O'Boyle, Amy L; Valley, Michael T; Bland, Deirdre R; Kahn, Margie A; Schaffer, Joseph I

2006-06-01

The aim of this study was to determine if certain occupations or socioeconomic levels are associated with pelvic organ prolapse. Investigators at six American sites performed pelvic organ prolapse quantification examinations on women presenting for routine gynecologic care. Between September 1999 and March 2002, 1,004 patients were examined. Severe pelvic organ prolapse was defined as the leading edge being 1 cm or more beyond the hymeneal ring. The data was analyzed with the Kruskal-Wallis analysis of variance, Bonferroni test, multiple logistic regression, and descriptive statistics. The prevalence of severe pelvic organ prolapse in our group was 4.3%. Women who were laborers/factory workers had significantly more severe prolapse than the other job categories (p < 0.001). Women with annual income of Dollars 10,000 or less had significantly more severe pelvic organ prolapse than other income groups (p < 0.001). These differences persisted even when controlling for age, race, number of deliveries, body mass index >30, and smoking status (all p < 0.001). Laborers/factory worker jobs and an annual household income of Dollars 10,000 or less are associated with severe pelvic organ prolapse.

Intestinal Perforation Following Ileoscopy Through a Prolapsed Stoma in an Pediatric Intestinal Transplant Recipient With an Unrecognized Parastomal Hernia

PubMed Central

Yeh, Joanna; Hall, Theodore R.; Agopian, Vatche G.; Farmer, Douglas G.; Marcus, Elizabeth A.; Venick, Robert S.; Wozniak, Laura J.

2016-01-01

Ileoscopy with mucosal biopsy is fundamental in the management and surveillance of inflammatory bowel disease patients and intestinal transplant recipients. There is a paucity of data describing the risks of ileoscopy in the presence of a prolapsed stoma. Parastomal hernias are frequently associated with prolapsed stomas. We report the first case of perforation during ileoscopy in the setting of a prolapsed stoma and unrecognized parastomal hernia. Recognition of parastomal hernia associated with stoma prolapse is of paramount importance in patients undergoing ileoscopy as it may increase the risk of perforation. PMID:27807575

Vaginal Migration of Ventriculoperitoneal Shunt Catheter and Cerebrospinal Fluid Leak as a Complication of Hysterectomy.

PubMed

Houten, John K; Smith, Shiela; Schwartz, Amit Y

2017-08-01

Ventriculoperitoneal (VP) shunting is a common neurosurgical procedure to treat hydrocephalus that diverts cerebrospinal fluid from the cerebral ventricles to the peritoneal cavity for reabsorption. The distal catheter may potentially migrate through any potential or iatrogenic opening in the peritoneal cavity. Increasingly successfully management of childhood hydrocephalus and adult-onset conditions leading to hydrocephalus, such as subarachnoid hemorrhage, is leading many adult female patients harboring VP shunts needing to undergo hysterectomy. Hysterectomy creates a potential defect though which a VP shunt catheter may migrate. It is not known whether the hysterectomy cuff closure technique may affect the likelihood of distal catheter migration though the repair site. We report the case of a 38-year-old woman with a VP shunt who underwent laparoscopic hysterectomy via an open vaginal cuff technique who subsequently presented with vaginal cerebrospinal fluid leakage secondary to migration of the distal shunt catheter through the hysterectomy cuff. Vaginal migration of the distal VP shunt catheter is a possible complication of hysterectomy. The authors postulate that an open cuff hysterectomy closure technique may increase the risk of catheter migration, an issue that may be better understood with further investigation. Copyright © 2017 Elsevier Inc. All rights reserved.

Vaginal anomalies and atresia associated with imperforate anus: diagnosis and surgical management.

PubMed

Pandya, Kartikey A; Koga, Hiroyuki; Okawada, Manabu; Coran, Arnold G; Yamataka, Atsuyuki; Teitelbaum, Daniel H

2015-03-01

The association of vaginal atresia (or Mayer-Rokitansky-Kuster-Hauser Syndrome) with imperforate anus is rare and can present significant diagnostic and therapeutic challenges. This study describes clinical characteristics, surgical treatment and outcomes in this group of complex children. Records of 20 patients were retrospectively analyzed from two pediatric surgical centers. Five patients were excluded from the long-term analysis due to inadequate information, leaving long-term follow-up in 15 patients. Mean follow-up was 10 years (range 1-31.1 years). The diagnosis of vaginal atresia was made pre-operatively in 12 out of 15 patients, and in three patients it was identified during the anoplasty. The anorectal malformations were rectoperineal (N=2), rectovestibular (N=6), recto-bladder neck (N=1) and imperforate anus without fistula (N=6). Satisfactory surgical repair was performed in 13 patients, while one continues to stool through a low perineal fistula awaiting definitive surgery and another underwent a colostomy and mucous fistula. Delayed vaginal reconstruction was due to a failure to identify the problem prior to anoplasty (N=3). Long-term results demonstrated that anorectal continence was much worse than initially appreciated, and many had associated urinary incontinence. Overall stooling score was far lower than in a separate group of children with imperforate anus without vaginal atresia (Levitt and Peña, 2007). Vaginal atresia with imperforate anus is a rare and an extensive pre-operative workup of females with imperforate anus must include assessment of vagina patency. Vaginal reconstruction and anorectal continuity can be performed in a variety of approaches, but long-term continence is often not optimal. We propose a pathway for management of this difficult genito-anorectal disorder. Copyright © 2015 Elsevier Inc. All rights reserved.

Uterine Prolapse

MedlinePlus

... during bowel movements Family history of weakness in connective tissue Being Hispanic or white Complications Uterine prolapse is ... You might experience: Anterior prolapse (cystocele). Weakness of connective tissue separating the bladder and vagina may cause the ...

Experiences and expectations of women with urogenital prolapse: a quantitative and qualitative exploration.

PubMed

Srikrishna, S; Robinson, D; Cardozo, L; Cartwright, R

2008-10-01

To explore the expectations and goals of women undergoing surgery for urogenital prolapse using both a quantitative quality of life approach exploring symptom bother and a qualitative interview-based approach exploring patient goals and expectations. Prospective observational study. Tertiary referral centre for urogynaecology. Forty-three women with symptomatic pelvic organ prolapse were recruited from the waiting list for pelvic floor reconstructive surgery. All women were assessed with a structured clinical interview on an individual basis. The data obtained were transcribed verbatim and then analysed thematically based on the grounded theory. Individual codes and subcodes were identified to develop a coding framework. The prolapse quality-of-life (pQoL) questionnaire was used to determine the impact of pelvic organ prolapse on the woman's daily life. We arbitrarily classified 'bother' as minimal, mild, moderate and marked if scores ranged from 0 to 25, 25-50, 50-75 and 75-100, respectively. The degree of prolapse was objectively quantified using the pelvic organ prolapse quantification (POP-Q) system. Quantitative data were analysed using SPSS. Ethical approval was obtained from the Kings College Hospital Ethics Committee. Quantitative data from POP-Q, subjective data from pQoL, qualitative data based on the structured clinical interview. Forty-three women were recruited over the first 1 year of the study. Their mean age was 56 years (range 36-78) and mean parity was 2 (range 0-6). The mean ordinal stage of the prolapse was 2 (range stages 1-4). Quantitative analysis of the pQoL data suggested that the main domains affected were prolapse impact on life (mean score 74.71) and personal relationships (mean score 46.66). Qualitative analysis based on the clinical interview suggested that these women were most affected by the actual physical symptoms of prolapse (bulge, pain and bowel problems) as well by the impact prolapse has on their sexual function. While disease-specific QoL questionnaires allow broad comparisons to be made assessing patient bother, they may lack the sensitivity to assess individual symptoms. A qualitative approach may individualize patient care and ultimately improve patient satisfaction and overall outcome when treating women complaining of urogenital prolapse.

A comparison between stabilization exercises and pelvic floor muscle training in women with pelvic organ prolapse.

PubMed

Özengin, Nuriye; Ün Yıldırım, Necmiye; Duran, Bülent

2015-03-01

This study aimed to compare the effectiveness of stabilization exercises and pelvic floor muscle training in women with stage 1 and 2 pelvic organ prolapse. In a total 38 women with pelvic organ prolapse whose average age was 45.60 years, pelvic floor muscles were evaluated with electromyography, and prolapse with pelvic organ prolapse quantification system, and the quality of life with prolapse quality of life questionnaire. Afterwards, the subjects were divided into two groups; stabilization exercise group (n=19) and pelvic floor muscle training group (n=19). Stabilization exercise group were given training for 8 weeks, 3 times a week. Pelvic floor muscle training group were given eight-week home exercises. Each group was assessed before training and after eight weeks. An increase was found in the pelvic muscle activation response in the 2 groups (p≤0.05). There was no difference in EMG activity values between the groups (p>0.05). A difference was found in the values Aa, Ba and C in subjects of each group (p≤0.05), and the TVL, Ap, Bp and D values of subjects in pelvic floor muscle training group (p≤0.05) in the before and after pelvic organ prolapse quantification system assessment, however, no difference was found between the groups (p≤0.05). A positive difference was found in the effect of prolapse sub parameter in each of the two groups, and in general health perception sub parameter in subjects of stabilization exercise group (p<0.05) in the prolapse quality of life questionnaire. It was concluded that both training programs increased the pelvic floor muscle strength, provided a decline in prolapse stages. Stabilization exercise has increased general health perception unlike home training, thus, these exercises can be added to the treatment of women with prolapse.

A comparison between stabilization exercises and pelvic floor muscle training in women with pelvic organ prolapse

PubMed Central

Özengin, Nuriye; Ün Yıldırım, Necmiye; Duran, Bülent

2015-01-01

Objective: This study aimed to compare the effectiveness of stabilization exercises and pelvic floor muscle training in women with stage 1 and 2 pelvic organ prolapse. Materials and Methods: In a total 38 women with pelvic organ prolapse whose average age was 45.60 years, pelvic floor muscles were evaluated with electromyography, and prolapse with pelvic organ prolapse quantification system, and the quality of life with prolapse quality of life questionnaire. Afterwards, the subjects were divided into two groups; stabilization exercise group (n=19) and pelvic floor muscle training group (n=19). Stabilization exercise group were given training for 8 weeks, 3 times a week. Pelvic floor muscle training group were given eight-week home exercises. Each group was assessed before training and after eight weeks. Results: An increase was found in the pelvic muscle activation response in the 2 groups (p≤0.05). There was no difference in EMG activity values between the groups (p>0.05). A difference was found in the values Aa, Ba and C in subjects of each group (p≤0.05), and the TVL, Ap, Bp and D values of subjects in pelvic floor muscle training group (p≤0.05) in the before and after pelvic organ prolapse quantification system assessment, however, no difference was found between the groups (p≤0.05). A positive difference was found in the effect of prolapse sub parameter in each of the two groups, and in general health perception sub parameter in subjects of stabilization exercise group (p<0.05) in the prolapse quality of life questionnaire. Conclusions: It was concluded that both training programs increased the pelvic floor muscle strength, provided a decline in prolapse stages. Stabilization exercise has increased general health perception unlike home training, thus, these exercises can be added to the treatment of women with prolapse. PMID:28913034

Expression of fibulin-5 in the skin of patients with rectal prolapse.

PubMed

Joshi, H M; Gosselink, M P; Smyth, E A; Hompes, R; Cunningham, C; Lindsey, I; Urban, J; Jones, O M

2015-11-01

Components of connective tissue other than collagen have been found to be involved in patients with rectal prolapse. The organization of elastic fibres differs between controls and subsets of patients with rectal prolapse, and their importance for maintaining the structural and functional integrity of the pelvic floor has been demonstrated in transgenic mice, with animals which have a null mutation in fibulin-5 (Fbln5(i/i)) developing prolapse. This study aimed to compare fibulin-5 expression in the skin of patients with and without rectal prolapse. Between January 2013 and February 2014, skin specimens were obtained during surgery from 20 patients with rectal prolapse and from 21 without prolapse undergoing surgery for other indications. Fibroblasts from the skin were cultured and the level of fibulin-5 expression was determined on cultured fibroblasts, isolated from these specimens by quantitative real-time polymerase chain reaction. Immunohistochemistry was performed on fixed tissue specimens to assess fibulin-5 expression. Fibulin-5 mRNA expression and fibulin-5 staining intensity were significantly lower in young male patients with rectal prolapse compared with age-matched controls [fibulin-5 mean ± SD mRNA relative units, 1.1 ± 0.41 vs 0.53 ± 0.22, P = 0.001; intensity score, median (range), 2 (0-3) vs 1 (0-3), P = 0.05]. There were no significant differences in the expression of fibulin-5 in women with rectal prolapse compared with controls. Fibulin-5 may be implicated in the aetiology of rectal prolapse in a subgroup of young male patients. Colorectal Disease © 2015 The Association of Coloproctology of Great Britain and Ireland.

Efficacy and pregnancy outcomes of laparoscopic single sheet mesh sacrohysteropexy.

PubMed

Pandeva, Ivilina; Mistry, Minesh; Fayyad, Abdalla

2017-03-01

To evaluate outcomes following laparoscopic single sheet mesh sacrohysteropexy for the management of uterine prolapse. One hundred and fifty-nine women underwent the procedure between August 2010 and August 2014. One hundred and forty-four patients completed the follow up assessment. At each visit, the prolapse symptoms were assessed using the prolapse quality-of-life (P-QOL) questionnaire and objectively with the use of the Pelvic Organ Prolapse Quantification (POPQ) score. The subjective outcomes were also evaluated with the use of the Patient Global Impression of Improvement (PGII) questionnaires. Perioperative complications and further surgery for prolapse were evaluated. Women who conceived following the procedure were evaluated for pregnancy outcomes and prolapse recurrence. Pre-operatively, 85% (135/159) had uterine prolapse ≥ stage 2. Postoperatively, 95.1% (137/144) of women had anatomical success rate defined as stage 0 uterine descent. Eighty-two percent (118/144) of women reported cure of prolapse symptoms and feeling "much better" or "very much better" on postoperative PGII assessment. Eight women (5%) became pregnant following the laparoscopic sacrohysteropexy- seven had full term pregnancies and one had a miscarriage. Six out of the seven (86%) had stage 0 apical prolapse and PGII of "much better" at 6 months postpartum. One patient had symptomatic prolapse recurrence and underwent perineorrhaphy at 3 years. Laparoscopic single sheet mesh sacrohysteropexy is associated with subjective and objective improvement in prolapse symptoms and QoL that is maintained up to 48 months. Laparoscopic sacrohysteropexy can be offered to women desiring future fertility; however, further research is needed to advise on best surgical approach in women of childbearing age. Neurourol. Urodynam. 36:787-793, 2017. © 2016 The Authors. Neurourology and Urodynamics Published by Wiley Periodicals, Inc. © 2016 The Authors. Neurourology and Urodynamics Published by Wiley Periodicals, Inc.

Delivery-associated presence of supramolecular fibronectin-fibrin complexes in puerperal and cord plasma.

PubMed

Lis-Kuberka, Jolanta; Berghausen-Mazur, Marta; Kątnik-Prastowska, Iwona; Orczyk-Pawiłowicz, Magdalena

2018-05-15

The variable fibronectin (FN) molecular forms are known to be engaged in coagulation and fibrinolysis pathways as well as tissue remodeling and repair processes. Some of them seem to be indispensable molecules within intensive biological processes associated with delivery. The aim of the study was to evaluate the FN molecular status in maternal and cord plasma after vaginal birth and cesarean section (C-section). The study included nonpregnant women's plasma samples (n = 31) and puerperal and cord plasma samples collected from 49 mothers who delivered healthy newborns at term by vaginal birth (n = 25) and C-section (n = 24). The maternal and cord plasma FN concentrations and presence and relative ratios of different FN-fibrin complexes were determined by ELISA and sodium dodecyl sulfate (SDS) -agarose immunoblotting, respectively. FN concentration in puerperal plasma after vaginal birth (232.08 ± 71.8 mg/L) and C-section (228.17 ± 71.2 mg/L) was significantly higher than in the plasma of nonpregnant women (190.00 ± 48.75 mg/L). In contrast, FN concentration in cord plasma of the C-section group (101.95 ± 30.3 mg/L) was significantly lower than that of the vaginal birth group (121.80 ± 22.2 mg/L). Immunoblotting of puerperal and cord plasma distinguished the most abundant dimeric plasma FN form, the 220-280-kDa FN degradation products and 750-1900-kDa FN-fibrin complexes, which occurred more frequently and in higher amounts in puerperal and cord plasma groups than the nonpregnant women group, although independently of the mode of delivery. Occurrence and relative amount of delivery-associated FN-fibrin complexes in both puerperal and cord plasmas might be bound with the physiological adaptive mechanisms reducing the risk of hemorrhage and intensive remodeling and repair processes after delivery.

Efficacy of early skin-to-skin contact on the rate of exclusive breastfeeding in term neonates: a randomized controlled trial.

PubMed

Sharma, Amit

2016-09-01

Despite multiple benefits of breast milk, the rates of exclusive breastfeeding in developing countries are low. To evaluate the efficacy of early skin -to -skin contact (SSC) on the rate of exclusive breastfeeding (EBF) at 6 weeks of age among term neonates born by vaginal delivery. Term neonates born by vaginal delivery and did not require any resuscitation were randomized at birth to SSC (n=100) and control (n=100) group. Immediately after clamping the umbilical cord, SSC group neonates were placed on the bare bosom of mother and control group neonates were placed under a radiant warmer for a period of 45 minutes each while mothers underwent management of the third stage of labor and episiotomy repair. Pain experienced by mother during episiotomy repair was recorded using a numerical pain scale The primary outcome evaluated was the rate of exclusive breastfeeding at 6 weeks of postnatal age. A significantly higher proportion of neonates were exclusively breastfeed at 6 weeks of age in the SSC group than in the control group (72% vs. 57.6%, p=0.04, relative risk: 1.3, 95% confidence interval: 1.0 -1.6). The pain score during episiotomy repair in mothers of the SSC group was significantly lower than the control group (4.74±0.85 versus 5.34±0.81; P <0.01). Early SSC significantly improved the rate of exclusively breastfeeding at 6 weeks of age among healthy term neonates. An important additional effect was a decrease in the amount of pain that mothers in the SSC group experienced during episiotomy repair.

Surgical management of colorectal injuries: colostomy or primary repair?

PubMed

Papadopoulos, V N; Michalopoulos, A; Apostolidis, S; Paramythiotis, D; Ioannidis, A; Mekras, A; Panidis, S; Stavrou, G; Basdanis, G

2011-10-01

Several factors have been considered important for the decision between diversion and primary repair in the surgical management of colorectal injuries. The aim of this study is to clarify whether patients with colorectal injuries need diversion or not. From 2008 to 2010, ten patients with colorectal injuries were surgically treated by primary repair or by a staged repair. The patients were five men and five women, with median age 40 years (20-55). Two men and two women had rectal injuries, while 6 patients had colon injuries. The mechanism of trauma in two patients was firearm injuries, in two patients was a stab injury, in four patients was a motor vehicle accident, in one woman was iatrogenic injury during vaginal delivery, and one case was the transanal foreign body insertion. Primary repair was possible in six patients, while diversion was necessary in four patients. Primary repair should be attempted in the initial surgical management of all penetrating colon and intraperitoneal rectal injuries. Diversion of colonic injuries should only be considered if the colon tissue itself is inappropriate for repair due to severe edema or ischemia. The role of diversion in the management of unrepaired extraperitoneal rectal injuries and in cases with anal sphincter injuries is mandatory.

Age and cellular context influence rectal prolapse formation in mice with caecal wall colorectal cancer xenografts.

PubMed

Tommelein, Joke; Gremonprez, Félix; Verset, Laurine; De Vlieghere, Elly; Wagemans, Glenn; Gespach, Christian; Boterberg, Tom; Demetter, Pieter; Ceelen, Wim; Bracke, Marc; De Wever, Olivier

2016-11-15

In patients with rectal prolapse is the prevalence of colorectal cancer increased, suggesting that a colorectal tumor may induce rectal prolapse. Establishment of tumor xenografts in immunodeficient mice after orthotopic inoculations of human colorectal cancer cells into the caecal wall is a widely used approach for the study of human colorectal cancer progression and preclinical evaluation of therapeutics. Remarkably, 70% of young mice carrying a COLO320DM caecal tumor showed symptoms of intussusception of the large bowel associated with intestinal lumen obstruction and rectal prolapse. The quantity of the COLO320DM bioluminescent signal of the first three weeks post-inoculation predicts prolapse in young mice. Rectal prolapse was not observed in adult mice carrying a COLO320DM caecal tumor or young mice carrying a HT29 caecal tumor. In contrast to HT29 tumors, which showed local invasion and metastasis, COLO320DM tumors demonstrated a non-invasive tumor with pushing borders without presence of metastasis. In conclusion, rectal prolapse can be linked to a non-invasive, space-occupying COLO320DM tumor in the gastrointestinal tract of young immunodeficient mice. These data reveal a model that can clarify the association of patients showing rectal prolapse with colorectal cancer.

Aortic valve repair using a differentiated surgical strategy.

PubMed

Langer, Frank; Aicher, Diana; Kissinger, Anke; Wendler, Olaf; Lausberg, Henning; Fries, Roland; Schäfers, Hans-Joachim

2004-09-14

Reconstruction of the aortic valve for aortic regurgitation (AR) remains challenging, in part because of not only cusp or root pathology but also a combination of both can be responsible for this valve dysfunction. We have systematically tailored the repair to the individual pathology of cusps and root. Between October 1995 and August 2003, aortic valve repair was performed in 282 of 493 patients undergoing surgery for AR and concomitant disease. Root dilatation was corrected by subcommissural plication (n=59), supracommissural aortic replacement (n=27), root remodeling (n=175), or valve reimplantation within a graft (n=24). Cusp prolapse was corrected by plication of the free margin (n=157) or triangular resection (n =36), cusp defects were closed with a pericardial patch (n=16). Additional procedures were arch replacement (n=114), coronary artery bypass graft (n=60) or mitral repair (n=24). All patients were followed-up (follow-up 99.6% complete), and cumulative follow-up was 8425 patient-months (mean, 33+/-27 months).Results- Eleven patients died in hospital (3.9%). Nine patients underwent reoperation for recurrent AR (3.3%). Actuarial freedom from AR grade > or =II at 5 years was 81% for isolated valve repair, 84% for isolated root replacement, and 94% for combination of both; actuarial freedom from reoperation at 5 years was 93%, 95%, and 98%, respectively. No thromboembolic events occurred, and there was 1 episode of endocarditis 4.5 years postoperatively. Aortic valve repair is feasible even for complex mechanisms of AR with a systematic and individually tailored approach. Operative mortality is low and mid-term durability is encouraging. The incidence of valve-related morbidity is low compared with valve replacement.

Creation of an acellular vaginal matrix for potential vaginal augmentation and cloacal repair.

PubMed

Greco, K V; Jones, L G; Obiri-Yeboa, I; Ansari, T

2018-05-21

our aim was to use porcine vagina to create a vaginal matrix and test its cellular biocompatibility. vagina was harvested from pigs and de-cellularised (DC) using a combination of detergents (Triton x-100 and sodium deoxycholate) and enzymes (DNAse/RNAse). the presence of cellular material, collagen structural integrity and basement membrane proteins were assessed histologically. To address cytocompatibility, porcine adipose derived-mesenchymal stem cells (AD-MSC) were harvested from abdominal fat together with vaginal epithelial cells (VEC) and seeded onto the mucosal aspect of the vaginal scaffold. Both cells populations were seeded individually and assessed histologically at days 3 and 10. MAIN OUTCOMES/RESULTS: the combination of enzymes and detergents resulted in a totally acellular matrix with very low DNA amount (control= 97.5ng/μl ± 10.8 vs DC= 40.1 ng/μl ±0.33 p=0.02). The extra cellular matrix (ECM) showed retention of collagen fibres and elastin and a 50% retention in glycosaminoglycan content; (control= 1.18μg/mg ± 0.28 DC = 1.35μg/mg ± 0.1 p=0.03) and an intact basement membrane (positive for both laminin and collagen IV). Seeded scaffolds showed cell attachment with both AD-MSC and VEC at days 3 and 10. it is possible to generate an acellular porcine vaginal matrix capable of supporting cells to reconstruct the vagina for future pre-clinical testing, and holds promise for creating clinically relevant sized tissue for human application. Copyright © 2018. Published by Elsevier Inc.

Vaginal-sparing ventral buccal mucosal graft urethroplasty for female urethral stricture: A novel modification of surgical technique

PubMed Central

Gani, Johan; Chee, Justin

2016-01-01

Purpose To present a novel modification of surgical technique to treat female urethral stricture (FUS) by a vaginal-sparing ventral buccal mucosal urethroplasty. Recurrent FUS represents an uncommon, though difficult clinical scenario to manage definitively. A variety of surgical techniques have been described to date, yet a lack of consensus on the optimal procedure persists. Materials and Methods We present a 51-year-old female with urethral stricture involving the entire urethra. Suspected etiology was iatrogenic from cystoscopy 17 years prior. Since then, the patient had undergone at least 25 formal urethral dilations and periods of self-dilation. In lithotomy position, the urethra was dilated to accommodate forceps, and ventral urethrotomy carried out sharply, exposing a bed of periurethral tissue. Buccal mucosa was harvested, and a ventral inlay technique facilitated by a nasal speculum, was used to place the graft from the proximal urethra/bladder neck to urethral meatus without a vaginal incision. Graft was sutured into place, and urethral Foley catheter inserted. Results The vaginal-sparing ventral buccal mucosal graft urethroplasty was deemed successful as of last follow-up. Flexible cystoscopy demonstrated patency of the repair at 6 months. At 10 months of follow-up, the patient was voiding well, with no urinary incontinence. No further interventions have been required. Conclusions This case describes a novel modification of surgical technique for performing buccal mucosal urethroplasty for FUS. By avoiding incision of the vaginal mucosa, benefits may include reduced: morbidity, urinary incontinence, and wound complications including urethro-vaginal fistula. PMID:27437540

Vaginal vault dehiscence after robotic hysterectomy for gynecologic cancers: search for risk factors and literature review.

PubMed

Drudi, Laura; Press, Joshua Z; Lau, Susie; Gotlieb, Raphael; How, Jeffrey; Eniu, Ioana; Drummond, Nancy; Brin, Sonya; Deland, Claire; Gotlieb, Walter H

2013-06-01

Vaginal vault dehiscence following robotic-assisted hysterectomy for gynecologic cancer may be attributed to surgical techniques and postoperative therapeutic interventions. We searched for risk factors in patients with gynecologic cancers and complemented this with a literature review. Evaluation of prospectively gathered information on all consecutive robotic surgeries for gynecologic cancers was performed in a tertiary academic cancer center between December 2007 and March 2012. The literature was reviewed for articles relevant to "gynecologic oncology" and "robotics" with "vaginal cuff dehiscence" in the English and French languages. Respective authors were contacted to complete relevant information. Seven dehiscences were identified of 441 cases with established gynecologic cancers. The closures in these 7 were performed using interrupted 1-Vicryl (Ethicon Inc) (3/167; 1.8%), combination of interrupted 1-Vicryl and 1-Biosyn (Covidien Inc) (3/156, 1.9%), and V-Loc (Covidien Inc) (1/118, 0.8%) sutures. Associated risk factors included adjuvant chemotherapy and/or brachytherapy, early resumption of sexual activity, and low body mass index (mean, 23 ± 3.23 kg/m²). Dehiscences occurred regardless of suturing by staff or trainees. Review of operative videos did not reveal a detectable etiologic factor, such as excessive cautery damage to the vaginal cuff or shallow tissue sutured. All 7 colporrhexis repairs were performed through a vaginal approach without the need of laparoscopy or laparotomy. Postoperative chemotherapy, brachytherapy, and early resumption of sexual activities are risk factors for vaginal vault dehiscence. Surgical technique, particularly the use of delayed absorbable sutures, deserves further evaluation.

Highly differentiated keratinizing squamous cell cancer of the cervix: a rare, locally aggressive tumor not associated with human papillomavirus or squamous intraepithelial lesions.

PubMed

Morrison, C; Catania, F; Wakely, P; Nuovo, G J

2001-10-01

The purpose of this study is to report an unusual variant of cervical squamous cell carcinoma, not associated with either human papillomavirus infection or antecedent squamous intraepithelial lesions. Five women had a diagnosis of invasive cervical cancer discovered at hysterectomy performed for prolapse (two cases), leiomyoma (one case), or a vaginal fistula (two cases). The women ranged in age from 47 to 78 years (mean 59 years). Four of the five had a history of normal Papanicolaou (Pap) smears; the other had a Pap smear diagnosis of atypical squamous cells of undetermined significance (ASCUS). All had large cervical tumors (two with parametrial involvement and one with vaginal involvement) that showed extensive keratin formation, an inverted pattern of growth, and, except for one case, minimal cytologic atypia. There was extensive hyperkeratosis and parakeratosis adjacent to each tumor; none had evidence of squamous intraepithelial lesion. Human papillomavirus testing by polymerase chain reaction in situ hybridization and reverse-transcribed polymerase chain reaction in situ was negative in each case, compared with a detection rate of 107 of 108 (99%) for squamous intraepithelial lesion-associated cervical squamous cell and adenocarcinomas. Two of the women died of extensive local recurrence; two other women were recently diagnosed. We conclude that highly differentiated keratinizing squamous cell carcinoma of the cervix is a rare entity not associated with human papillomavirus infection or squamous intraepithelial lesion and thus difficult to detect on routine cervical cancer screening.

Predicting obstetric anal sphincter injuries in a modern obstetric population.

PubMed

Meister, Melanie R L; Cahill, Alison G; Conner, Shayna N; Woolfolk, Candice L; Lowder, Jerry L

2016-09-01

Perineal lacerations are common at the time of vaginal delivery and may predispose patients to long-term pelvic floor disorders, such as urinary incontinence and pelvic organ prolapse. Obstetric anal sphincter injuries, which are the most severe form of perineal lacerations, result in disruption of the anal sphincter and, in some cases, the rectal mucosa during vaginal delivery. Long-term morbidity, including pain, pelvic floor disorders, fecal incontinence, and predisposition to recurrent injury at subsequent delivery may result. Despite several studies that have reported risk factors for obstetric anal sphincter injuries, no accurate risk prediction models have been developed. The purpose of this study was to identify risk factors and develop prediction models for perineal lacerations and obstetric anal sphincter injuries. This was a nested case control study within a retrospective cohort of consecutive term vaginal deliveries at 1 tertiary care facility from 2004-2008. Cases were patients with any perineal laceration that had been sustained during vaginal delivery; control subjects had no lacerations of any severity. Secondary analyses investigated obstetric anal sphincter injury (3rd- to 4(th)-degree laceration) vs no obstetric anal sphincter injury (0 to 2(nd)-degree laceration). Baseline characteristics were compared between groups with the use of the chi-square and Student t test. Adjusted odds ratios and 95% confidence intervals were calculated with the use of multivariable logistic regression. Prediction models were created and model performance was estimated with receiver-operator characteristic curve analysis. Receiver-operator characteristic curves were validated internally with the use of the bootstrap method to correct for bias within the model. Of the 5569 term vaginal deliveries that were recorded during the study period, complete laceration data were available in 5524 deliveries. There were 3382 perineal lacerations and 249 (4.5%) obstetric anal sphincter injuries. After adjusted analysis, significant predictors for laceration included nulliparity, non-black race, longer second stage, nonsmoking status, higher infant birthweight, and operative delivery. Private health insurance, labor induction, pushing duration, and regional anesthesia were not statistically significant in adjusted analyses. Significant risk factors for obstetric anal sphincter injury were similar to predictors for any laceration; nulliparity and operative vaginal delivery had the highest predictive value. Area under the curve for the predictive ability of the models was 0.70 for overall perineal laceration, and 0.83 for obstetric anal sphincter injury. When limited to primiparous patients, 1996 term vaginal deliveries were recorded. One hundred ninety-two women sustained an obstetric anal sphincter injury; 1796 women did not. After adjusted analysis, significant predictors for laceration included non-black race, age, obesity, and nonsmoking status. In secondary analyses, significant predictors for obstetric anal sphincter injury included non-black race, nonsmoking status, longer duration of pushing, operative vaginal delivery, and infant birthweight. Area under the curve for the predictive ability of the models was 0.60 for any laceration and 0.77 for obstetric anal sphincter injury. Significant risk factors for sustaining any laceration and obstetric anal sphincter injury during vaginal deliveries were identified. These results will help identify clinically at-risk patients and assist providers in counseling patients about modifications to decrease these risks. Copyright © 2016 Elsevier Inc. All rights reserved.

A modified repair technique for tricuspid incompetence in Ebstein's anomaly.

PubMed

Hetzer, R; Nagdyman, N; Ewert, P; Weng, Y G; Alexi-Meskhisvili, V; Berger, F; Pasic, M; Lange, P E

1998-04-01

A modified technique for tricuspid valve repair in Ebstein's anomaly restructures the valve mechanism at the level of the true tricuspid anulus by using the most mobile leaflet for valve closure without plication of the atrialized chamber. Midterm results of this therapeutic approach for patients with Ebstein's anomaly and tricuspid valve incompetence are reported. Between October 1988 and April 1997, the incompetent tricuspid valve was repaired with our technique in 19 patients (12 female, 7 male; 2 to 54 years, mean 21 years). The indication for operation was congestive heart failure of various degrees in all patients. Tricuspid incompetence was grade II in two patients, grade III in 14, and grade IV in three. Associated congenital malformations were simultaneously repaired (interatrial communication in 18, ventricular septal defect in two, pulmonary stenosis in two, mitral valve prolapse in one). Follow-up ranged between 10 and 103 months (median 28 months) and was complete for all patients. There were no operative deaths. One patient with active endocarditis and pulmonary abscess died 2 months after the operation of recurrent sepsis; there were no late deaths. During follow-up, New York Heart Association functional class improved from 2.8 before the operation to 1.9 without recurrent cyanosis, and tricuspid incompetence decreased from a mean grade of 3.1 to one of 0.9, without any echocardiographic deterioration of the tricuspid valve function or right ventricular dilation. Our technique allows tricuspid valve repair in patients with Ebstein's anomaly, even in cases usually reserved for primary valve replacement, without late functional deterioration.

The effect of prolapse repair on urinary flow rates and the relationship to changes in the ultrasound appearance of the bladder neck.

PubMed

Duckett, Jonathan; Chakani, Dorothy

2013-12-01

To assess whether specific changes in bladder neck morphology, caused by an anterior repair operation, are associated with resolution of overactive bladder and improved urinary flow rates. Sixty-four women with urgency documented on the urgency perception scale (UPS) underwent an anterior repair. Their preoperative flow studies were compared to those 8 weeks postoperatively. Flow rates were compared in those women who reported improved or cured urgency to those who reported no effect. Resolution of urgency was correlated with the change in bladder neck angulation (posterior urethrovesical angle-PUA). 55% (35/64) women reported no urgency after the anterior repair. A further 19% (12/64) were improved and 26% (17/64) were no better. Patients who were cured or improved showed a significant increase in their flow rates after surgery (mean flow=15 before and 17.6 ml/s after) (Mann-Whitney p=0.04). There was a significant change (increase in the PUA angle/straightening of the angle between the bladder and urethra) from a mean value of 123 degrees (SD 49.3) preoperatively to a mean value of 146.8 (SD 29.2) post operatively (p<0.001). Despite an increase in PUA, this was not correlated with an increase in the maximum flow rate centile (p=0.45, r=0.10). An anterior repair results in increased maximum urinary flow rates but this does not correlate to changes in the appearance of the bladder neck. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Fetoscopic Open Neural Tube Defect Repair: Development and Refinement of a Two-Port, Carbon Dioxide Insufflation Technique.

PubMed

Belfort, Michael A; Whitehead, William E; Shamshirsaz, Alireza A; Bateni, Zhoobin H; Olutoye, Oluyinka O; Olutoye, Olutoyin A; Mann, David G; Espinoza, Jimmy; Williams, Erin; Lee, Timothy C; Keswani, Sundeep G; Ayres, Nancy; Cassady, Christopher I; Mehollin-Ray, Amy R; Sanz Cortes, Magdalena; Carreras, Elena; Peiro, Jose L; Ruano, Rodrigo; Cass, Darrell L

2017-04-01

To describe development of a two-port fetoscopic technique for spina bifida repair in the exteriorized, carbon dioxide-filled uterus and report early results of two cohorts of patients: the first 15 treated with an iterative technique and the latter 13 with a standardized technique. This was a retrospective cohort study (2014-2016). All patients met Management of Myelomeningocele Study selection criteria. The intraoperative approach was iterative in the first 15 patients and was then standardized. Obstetric, maternal, fetal, and early neonatal outcomes were compared. Standard parametric and nonparametric tests were used as appropriate. Data for 28 patients (22 endoscopic only, four hybrid, two abandoned) are reported, but only those with a complete fetoscopic repair were analyzed (iterative technique [n=10] compared with standardized technique [n=12]). Maternal demographics and gestational age (median [range]) at fetal surgery (25.4 [22.9-25.9] compared with 24.8 [24-25.6] weeks) were similar, but delivery occurred at 35.9 (26-39) weeks of gestation with the iterative technique compared with 39 (35.9-40) weeks of gestation with the standardized technique (P<.01). Duration of surgery (267 [107-434] compared with 246 [206-333] minutes), complication rates, preterm prelabor rupture of membranes rates (4/12 [33%] compared with 1/10 [10%]), and vaginal delivery rates (5/12 [42%] compared with 6/10 [60%]) were not statistically different in the iterative and standardized techniques, respectively. In 6 of 12 (50%) compared with 1 of 10 (10%), respectively (P=.07), there was leakage of cerebrospinal fluid from the repair site at birth. Management of Myelomeningocele Study criteria for hydrocephalus-death at discharge were met in 9 of 12 (75%) and 3 of 10 (30%), respectively, and 7 of 12 (58%) compared with 2 of 10 (20%) have been treated for hydrocephalus to date. These latter differences were not statistically significant. Fetoscopic open neural tube defect repair does not appear to increase maternal-fetal complications as compared with repair by hysterotomy, allows for vaginal delivery, and may reduce long-term maternal risks. ClinicalTrials.gov, https://clinicaltrials.gov, NCT02230072.

The prevalence and treatment pattern of clinically diagnosed pelvic organ prolapse: a Korean National Health Insurance Database-based cross-sectional study 2009-2015.

PubMed

Yuk, Jin-Sung; Lee, Jung Hun; Hur, Jun-Young; Shin, Jung-Ho

2018-01-22

The study aim was to evaluate the prevalence of pelvic organ prolapse using claim data of South Korea and to evaluate treatment patterns. The Korea National Health Insurance Corporation pay medical costs for most diseases. This study used Health Insurance Review & Assessment Service-National Inpatient Sample (HIRA-NIS) 2009-2015. Pelvic organ prolapse was defined by diagnostic code (N81.x). Of the approximately 4.5 million women included in HIRA-NIS 2009-2015, 10,305 women were selected as having pelvic organ prolapse, and the mean age of the pelvic organ prolapse group was 63.9 ± 0.2 years. The prevalence of pelvic organ prolapse was 180 ± 4 per 100,000 population in women older than 50 years old. In logistic regression analysis, constipation increased the prevalence of all pelvic organ prolapse (odds ratio, 4.04; 95% confidence interval, 3.52-4.63; P < 0.01). The number of women requiring pessary only and surgery only were 26 ± 2 per 100,000 population and 89 ± 1 per 100,000 population, respectively, for women over 50 years of age. The prevalence of pelvic organ prolapse was quite lower than in previous studies. Surgery peaked at approximately 70 years of age. Pessary increased dramatically among women after the age of 65.

[Hysterectomies at the Conakry university hospitals: social, demographic, and clinical characteristics, types, indications, surgical approaches, and prognosis].

PubMed

Baldé, I S; Sy, T; Diallo, B S; Diallo, Y; Mamy, M N; Diallo, M H; Bah, E M; Diallo, T S; Keita, N

2014-01-01

The objectives of this study were to calculate the frequency of hysterectomies at the Conakry university hospitals (Donka Hospital and Ignace Deen Hospital), describe the women's social, demographic, and clinical characteristics, and identify the key indications, the surgical techniques used, and the prognosis. This was a 2-year descriptive study, retrospective for the first year (May 2011-April 2012) and prospective for the second (May 2012-April 2013), of 333 consecutive hysterectomies performed in the obstetrics and gynecology departments of these two hospitals. Hysterectomy is one of the surgical procedures most commonly performed in these departments (following cesarean deliveries), with frequency of 4.4% interventions. The profile of the women undergoing this surgery was that of a woman aged younger than 49 years (61%), married (75.7%), multiparous (33%), of childbearing age (61%), and with no history of abdominal or pelvic surgery (79.6%). Nearly all hysterectomies were total (95%, compared with 5% subtotal; the approach was abdominal in 82.25% of procedures and vaginal in 17.75%. The most common indication for surgery was uterine fibroids (39.6%), followed by genital prolapse (22.2%), and obstetric emergencies (17.8%). The average duration of surgery was 96 minutes for abdominal and 55 minutes for vaginal hysterectomies. The principal intraoperative complication was hemorrhage (12.31%), and the main postoperative complication parietal suppuration (21.02%). The average length of hospital stay was 10.3 days for abdominal hysterectomies and 7.15 days for vaginal procedures. We recorded 14 deaths for a lethality rate of 4.2%; most of these deaths were associated with hemorrhagic shock during or after an obstetric hysterectomy (93%). Hysterectomy remains a common intervention in developing countries. Its indications are common during the pregnancy and postpartum period, with high morbidity and mortality rates. Improving obstetric coverage could reduce its indications.

Characterization of Pelvic Floor Symptoms in Women of Northeastern Liberia

PubMed Central

Bowling, C. Bryce; Munoz, Oxana; Gerten, Kimberly A.; Mann, MerryLynn; Taryor, Rebecca; Norman, Andy M.; Szychowski, Jeff M.; Richter, Holly E.

2013-01-01

Objective To characterize prevalence and quality of life (QoL) impact of urinary incontinence (UI), fecal incontinence (FI), and pelvic organ prolapse (POP) symptoms in women of Liberia. Methods A questionnaire addressing symptoms and QoL impact of UI, FI and POP was administered to women in a community setting in Ganta, Liberia. Questionnaires were analyzed to determine prevalence rates, QoL impact, and risk factors for these conditions. Results 424 participants were surveyed; 1.7% reported UI, 0.10% reported any form of FI, and 3.3% reported some degree of POP symptoms. QoL responses varied among symptom groups. Previous hysterectomy, cesarean delivery, vaginal deliveries, and body mass index had no significant association with UI, FI, or POP. Participants with UI symptoms were more likely to report FI symptoms (p=0.002). Conclusion Prevalence rates for UI, FI and POP in this population are low; there was a significant association of FI symptoms in subjects with UI. PMID:20206351

TVT-O vs TVT: a randomized trial in patients with different degrees of urinary stress incontinence.

PubMed

Araco, F; Gravante, G; Sorge, R; Overton, J; De Vita, D; Sesti, F; Piccione, E

2008-07-01

TVT-O and TVT were compared in patients stratified according the severity of Stress Urinary Incontinence (SUI). Those patients with intrinsic sphincter deficiencies, overactive bladders, associated prolapses, neurovegetative disorders and recurrent SUI or under rehabilitative/medical therapies were all excluded. There were 208 women included. Operating times were longer, and postoperative pain greater for TVT (p < 0.001). TVT produced longer hospitalizations in severe SUI patients (p < 0.001). After 1 year of follow-up, incontinence was cured in all mild SUI patients with both techniques, in all severe SUI patients when treated with TVT and in 66% of them when treated with TVT-O (p < 0.001). Vaginal perforations occurred during the TVT-O (p = 0.01), bladder perforations during TVT (p = NS), bladder obstructions in mild SUI patients after TVT (p < 0.001). The severity of SUI is an important parameter that influences results after TVT-O and TVT, and could be used to guide surgeons in selecting the most effective intervention.

Rectoanal repair versus suture haemorrhoidopexy: a comparative study on suture mucopexy procedures for high-grade haemorrhoids.

PubMed

Theodoropoulos, G E; Michalopoulos, N V; Linardoutsos, D; Stamopoulos, P; Flessas, I; Tsamis, D; Zografos, G C

2012-06-01

The isolated application of Doppler-guided haemorrhoidal artery ligation (DGHAL) may fail due to the increased reprolapse rate for high-grade haemorrhoids. DGHAL has been combined with a proctoscopic-assisted transanal rectal mucopexy of the prolapsing tissue. The technique is called rectoanal repair (RAR) and is an evolution of various mucopexy and suture haemorrhoidopexy (SHP) techniques. A prominent external component may require minimal (muco-) cutaneous excision (MMCE) of protruding anoderm or minor cutaneous excision of skin tags. Fifty-seven patients with symptomatic Goligher grade III and IV haemorrhoids underwent DGHAL followed by either RAR or SHP. In 26 cases, the addition of MMCE was necessary. No significant differences were observed between the two approaches with regards to pain scores measured with visual analogue scale (VAS). On postoperative day 1, mean pain score at rest was 5.81 (±2.23 SD) after SHP versus 5.08 (±2.35 SD) after RAR, while mean pain score at first defecation was 7.31 (±1.6 SD) versus 7.52 (±1.83 SD). There was no difference in the duration of analgesic requirements, postoperative complications and residual prolapse between the 2 procedures. The addition of MMCE did not affect postoperative pain nor analgesic requirements. With the exception of 8 patients who still had with skin tags or minimal protrusion, the remaining of patients (86 %) were asymptomatic and recurrence-free at an average follow-up of 20 months. Overall, 94.8 % of patients stated that they were satisfied with the results, and 91.2 % that they would repeat it if necessary. Performance of either SHP or RAR after DGHAL is a safe and effective surgical tactic for advanced grade haemorrhoids. Our initial results do not confirm any superiority of RAR over traditional SHP.

Minimal access treatment of pectus carinatum: a preliminary report.

PubMed

Hock, András

2009-04-01

Unlike the minimal access repair of pectus excavatum (PE), a minimal access repair of pectus carinatum (PC) has not been established. This initial experience reports the correction of PC using a minimal access technique in five patients. The procedure was performed by insertion of a pectus bar through either bilateral or only left midaxillary incision. The pectus bar was placed so that the elevated sternum could be depressed. Thoracoscopy was not employed during the procedures and no stabiliser plates were used. On completion of the procedure, a chest tube was inserted into the thoracic cavity to evacuate the air from the thoracic cavity followed by wound closure. The operation time ranged from 75 to 110 min. The chest tube was removed on the second postoperative day and the patients were discharged between the fifth and seventh postoperative day. There was one dislocation in which the bar was finally removed, and in three patients a prolapse of the end of the strut through intercostal space necessitated refixation using wires. Despite a small series, this method offers a minimal access repair of PC, which is comparable to the technique used for PE. The invasiveness of our method is obviously far less, than of those different open surgical techniques performed worldwide presently. Our postoperative results warrant the application of this technique in patients with PC.

[Study on concomitant surgical correction of pelvic organ prolapse and TVT-O for treatment of stress urinary incontinence].

PubMed

Wang, Su-mei; Zhang, Zhen-yu; Liu, Chong-dong; Wang, Shu-zhen

2013-07-01

To investigate the necessity, safety and efficacy of transobturator tension-free vaginal tape (TVT-O) for treatment of stress urinary incontinence (SUI) during transvaginal corrective operation of pelvic organ prolapse (POP). From Jan. 2005 to Dec. 2010, 92 patients undergoing transvaginal pelvic reconstruction surgery for correction of POP concomitant TVT-O for treatment of SUI in Department of Obstetrics and Gynecology affiliated to Beijing Chaoyang Hospital as concomitant surgery group were enrolled in this retrospective study matched with 90 patients with mild SUI without SUI surgery as non-concomitant surgery group and 120 patients without SUI as control group.Variable clinical index, clinical efficacy and complications were compared among those three groups. Compared with those in the other two groups, the mean age [(62 ± 11) years] was lower (P = 0.007,0.038), the operation time only slightly increased (12.8 min and 12.9 min respectively) significantly in concomitant TVT-O group. The bleeding loss and the length of staying hospital after operation all exhibited no significant differences within three groups (P > 0.05). The effective rate for SUI was 96.7% (89/92) in concomitant TVT-O group, corrective operation of POP was ineffective for 74.4% (67/90) SUI, 9.2% (11/120) patients presented new SUI in the patients without SUI preoperatively. TVT-O is a simple, safe and effective method in the treatment of SUI, which is more suitable for performing simultaneously during the corrective operation of POP.Efficacy of SUI correction was limited in those patients undergoing only pelvic reconstructive surgery. However, a preventive anti-incontinence procedure is not recommended because of the lower incidence in POP patients without SUI preoperatively.

Semi-closed bilateral partial miotomy of the puborectalis for anismus: a pilot study: Partial miotomy of the puborectalis for anismus.

PubMed

Asciore, L; Pescatori, L C; Pescatori, M

2015-12-01

Anismus or non relaxing puborectalis muscle (PRM) may cause obstructed defecation (OD). Reported surgical treatment is partial miotomy, followed by sepsis, bleeding, and incontinence. The aim of the present study was to investigate on the feasibility and outcome of a modified mini-invasive operation. Consecutive patients with anismus and OD not responding to medical therapy, excluding multiparous females, patients with anal incontinence, recto-rectal intussusception, and disordered psychological pattern. Semi-closed bilateral partial division of PRM, pulled down through 1-cm perianal incisions, was performed. Concomitant significant rectal mucosal prolapse and rectocele, when present, were treated. OD was evaluated using a validated score and anal/vaginal ultrasound (US) was performed pre -and postoperatively. A control group of seven patients with normal bowel habit was also investigated. Eight patients (seven females), median age 48 years (range 29-71) were operated. Six also had significant mucosal prolapse and rectocele. All were followed up for a median of 12 months (range 2-40). None of them had postoperative sepsis or bleeding. One had just one occasional episode of mild anal incontinence. Symptoms improved in 6 or 75 % and, OD score decreased from 19.6 ± 1.0 to 9.2 ± 2.0 (mean ± s.e.m.), P = 0.007. No patient had anismus after surgery and PRM relaxation changed from 0 to 5.9 ± 0.8 mm being 6.6 ± 1.5 mm in controls. Semi-closed bilateral partial division of PRM achieves muscle's relaxation on straining in all patients without any significant postoperative complication. Further studies are needed prior to consider it a validated procedure.

Effectiveness and cost-effectiveness of pessary treatment compared with pelvic floor muscle training in older women with pelvic organ prolapse: 2-year follow-up of a randomized controlled trial in primary care.

PubMed

Panman, Chantal M C R; Wiegersma, Marian; Kollen, Boudewijn J; Berger, Marjolein Y; Lisman-van Leeuwen, Yvonne; Vermeulen, Karin M; Dekker, Janny H

2016-12-01

We investigated the effectiveness and cost-effectiveness of pessary treatment compared with pelvic floor muscle training (PFMT) in women with pelvic organ prolapse over a 2-year period. Randomized controlled trial with women (≥55 y) with symptomatic pelvic organ prolapse, identified by screening. Participants were recruited from 20 primary care practices (October 2009-December 2012). Primary outcome was the difference in change of pelvic floor symptoms (PFDI-20 score) between groups over 24 months. Secondary outcomes included prolapse, urinary, and anorectal symptoms; quality of life; costs; sexual functioning; prolapse stage; pelvic floor muscle function; and participants' perceived symptom improvement. There was a nonsignificant difference in the primary outcome between pessary treatment (n = 82) and PFMT (n = 80) with a mean difference of -3.7 points (95% CI, -12.8 to 5.3; P = 0.42) in favor of pessary treatment. A significantly greater improvement in the prolapse symptom score was, however, seen with pessary treatment (mean difference -3.2 points [95% CI, -6.3 to -0.0; P = 0.05]). Direct medical costs over the 2-year study were $309 and $437 per person for pessary treatment and PFMT, respectively. In older women with symptomatic prolapse, there was no significant difference between pessary treatment and PFMT in reducing pelvic floor symptoms, but specific prolapse-related symptoms did improve more with pessary treatment. Pessary treatment was preferable in the cost-effectiveness analysis. When counseling women for prolapse treatment it should, however, be taken into account that pessary fitting fails in a considerable portion of women and that pessary treatment was associated with more side effects compared with PFMT.

The clover technique for the treatment of complex tricuspid valve insufficiency: midterm clinical and echocardiographic results in 66 patients.

PubMed

Lapenna, Elisabetta; De Bonis, Michele; Verzini, Alessandro; La Canna, Giovanni; Ferrara, David; Calabrese, Maria Chiara; Taramasso, Maurizio; Alfieri, Ottavio

2010-06-01

This study assesses the results of the 'clover technique' (suturing together the middle point of the free edges of the tricuspid leaflets) for the treatment of tricuspid regurgitation (TR) due to severe prolapse or tethering. From 2001, 66 patients with severe TR due to prolapsing or tethered leaflets underwent 'clover repair'. Annuloplasty was associated in 64 patients (97%). The aetiology of TR was degenerative in 52 cases (79%), post-traumatic in eight (12%) and secondary to dilated cardiomyopathy (DCM) in six (9%). The main mechanism of TR was prolapse/flail of one leaflet in 15 patients (23%), of two leaflets in 31 (47%) and of all three leaflets in 14 (21%). The remaining six patients (9%) presented with severe leaflets' tethering. Four deaths (6%) occurred during hospitalisation and one patient died 3.6 years after surgery. Survival was 91 + or - 4.1% at 5 years. Follow-up of the 62 hospital survivors was 100% complete (mean length 3.5 + or - 1.6 years, range 13 months-7.1 years). At the last echocardiogram, no or mild TR was detected in 55 (88.7%) patients, moderate (2+/4+) in six (9.6%) and severe (4+/4+) in one patient (1.6%). Mean tricuspid valve area and gradient were 4.3 + or - 0.6 cm(2) and 2.8 + or -1.4 mmHg. In six patients, stress echocardiography was performed and no signs of tricuspid stenosis were detected. At the multivariable analysis, the degree of TR at hospital discharge was identified as the only predictor of TR > or = 2+ at follow-up. Midterm clinical and echocardiographic results confirm the role of the 'clover technique' in the surgical treatment of TR due to lesions, which are unlikely to be effectively treatable by annuloplasty alone. Copyright 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Strangulation of giant rectal prolapse.

PubMed

El Moussaoui, Imad; Limbga, Augustin; Dika, Manke; Mehdi, Abdelilah

2018-01-01

Introduction Rectal prolapse is the complete protrusion of the rectum through the anal canal, incarceration rarely complicates rectal prolapse. Even more rarely, it becomes strangulated and gangrenous, necessitating emergency surgery. Case presentation We present the first reported case of strangulated acute rectal prolapse as the first manifestation of rectal prolapse. The patient was a 26-year-old man who presented with a 20×6 cm semi-spherical mass extra-anally. Rectosigmoidectomy with sacral rectopexy was performed, resecting 20 cm of the incarcerated rectum and sigmoid colon. The postoperative course was uneventful with a good final result after colostomy closure and continuity restoration. Conclusion The successful treatment of this patient illustrates the value of surgery in this difficult and unusual case scenario of rectal incarceration.

Frequency of anal sphincter rupture at delivery in Sweden and Finland--result of difference in manual help to the baby's head.

PubMed

Pirhonen, J P; Grenman, S E; Haadem, K; Gudmundsson, S; Lindqvist, P; Siihola, S; Erkkola, R U; Marsal, K

1998-11-01

Anal sphincter rupture is a serious complication of vaginal delivery and almost half the affected women have persistent defecatory symptoms despite adequate primary repair. During the past decade, the incidence of anal sphincter ruptures has been increasing in Sweden and is currently estimated to occur in 2.5% of vaginal deliveries. The aim of the study was to report the frequency of anal sphincter ruptures in two university hospitals in two Scandinavian countries, Malmö in Sweden and Turku in Finland, and analyze the potential determinants. Retrospective analysis of a population of 30,933 deliveries (26,541 vaginal) during the years 1990 to 1994. The incidence of anal sphincter ruptures in Malmö, Sweden was 2.69%, and in Turku, Finland 0.36%. There were no significant population differences for the known risk factors (fetal weight, nulliparity or fetal head circumference). However, there is a difference in manual support given to the perineum and to the baby's head when crowning through the vaginal introitus between Malmö and Turku. The proportion of operative vaginal deliveries and abnormal presentations was significantly higher in Turku reflected in the lower Apgar score at 5 minutes and longer duration of second phase of labor. When high risk deliveries (operative vaginal delivery, abnormal presentation and newborns over 4,000 g) were excluded, the risk for anal sphincter ruptures was estimated to be 13 times higher in Malmö than in Turku. The difference in the incidence of anal sphincter rupture between Malmö, Sweden and Turku, Finland may be due to the difference in manual control of the baby's head when crowning.

Female Sexual Function Following Surgical Treatment of Stress Urinary Incontinence: Systematic Review and Meta-Analysis.

PubMed

Bicudo-Fürst, Maria Cláudia; Borba Leite, Pedro Henrique; Araújo Glina, Felipe Placco; Baccaglini, Willy; de Carvalho Fürst, Rafael Vilhena; Bezerra, Carlos Alberto; Glina, Sidney

2018-04-01

The impact of surgery for stress urinary incontinence (SUI) on female sexual function has received attention in the medical literature, but not in a structured manner. To assess the most recent evidence on the impact of surgical management for female SUI on female sexual function. The review and meta-analysis of available articles published in Medline, Cochrane, LILACS, SCOPUS, Web of Science, CINHAL, and EMBASE included prospective randomized and non-randomized studies that assessed patients who underwent surgical treatment for UI through 2 validated questionnaires: the Pelvic Organ Prolapse Urinary Incontinence Sexual Questionnaire (PISQ-12) and the Female Sexual Function Index (FSFI). The following terms were searched: (urinary incontinence OR female OR woman OR women) AND (suburethral slings OR transobturator tape* OR transobturator suburethral tape OR trans-obturator tape* OR urethral sling* OR midurethral sling* OR mid-urethral sling* OR "standard midurethral slings" OR tensionless vaginal tape* OR mini sling* OR Burch* OR "Burch colposuspension" OR "urologic surgical procedures" OR "tension-free vaginal tape" OR pubovaginal sling) AND (sexual behavior OR "Female Sexual Function Index" OR FSFI OR sexual function OR "Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire" OR PISQ-12). 1,043 articles were retrieved; 9 studies were included for qualitative analysis and 4 were included for meta-analysis. 25 articles were excluded because they used questionnaires other than the FSFI and PISQ-12. Meta-analysis of 2 studies composed of 411 women who underwent to retropubic and transobturator sling intervention and completed the PISQ-12 questionnaire showed an increase in sexual function of 2.40 points after transobturator compared with retropubic sling intervention (95% CI = -2.48 to -2.32; I 2  = 35%, P < .00001). However, 2 other studies composed of 183 women comparing the same techniques, but using the FSFI, did not show a statistically significant difference (95% CI = -1.77 to 3.78; I 2  = 0%, P = .48). The impact of UI surgery on sexual function is uncertain because of the imprecision of the effect and inconsistency among studies. Only limited evidence on the impact of the transobturator vs the retropubic sling was found. Bicudo-Fürst MC, Borba Leite PH, Araújo Glina FP, et al. Female Sexual Function Following Surgical Treatment of Stress Urinary Incontinence: Systematic Review and Meta-Analysis. Sex Med Rev 2018;6:224-233. Copyright © 2017. Published by Elsevier Inc.

Penetrating keratoplasty for treatment of corneal protrusion in a great horned owl (Bubo virginianus).

PubMed

Andrew, Stacy E; Clippinger, Tracy L; Brooks, Dennis E; Helmick, Kelly E

2002-09-01

A young adult great horned owl (Bubo virginianus) was examined following presumed trauma. The owl had soft tissue injury to its left wing as well as corneal protrusion, lens subluxation, and iridodialysis of the right eye. The bird's eye was treated surgically with a large, rectangular penetrating keratoplasty. Following escape from housing, the bird was found with partial wound dehiscence and iris prolapse 12 days post operation. Surgical repair was performed and healing progressed for 14 days, at which time the transplant dehisced and the globe was exenterated. The patient rehabilitated well until escaping from its cage again 4 weeks later, at which time it sustained an open comminuted humeral fracture and was euthanized.

Atrioventricular valve repair in patients with functional single-ventricle physiology: impact of ventricular and valve function and morphology on survival and reintervention.

PubMed

Honjo, Osami; Atlin, Cori R; Mertens, Luc; Al-Radi, Osman O; Redington, Andrew N; Caldarone, Christopher A; Van Arsdell, Glen S

2011-08-01

This study was to determine whether atrioventricular valve repair modifies natural history of single-ventricle patients with atrioventricular valve insufficiency and to identify factors predicting survival and reintervention. Fifty-seven (13.5%) of 422 single-ventricle patients underwent atrioventricular valve repair. Valve morphology, regurgitation mechanism, and ventricular morphology and function were analyzed for effect on survival, transplant, and reintervention with multivariate logistic and Cox regression models. Comparative analysis used case-matched controls. Atrioventricular valve was tricuspid in 67% and common in 28%. Ventricular morphology was right in 83%. Regurgitation mechanisms were prolapse (n = 24, 46%), dysplasia (n = 18, 35%), annular dilatation (n = 8, 15%), and restriction or cleft (n = 2, 4%). Postrepair insufficiency was none or trivial in 14 (26%), mild in 33 (61%), and moderate in 7 (13%). Survival in repair group was lower than in matched controls (78.9% vs 92.7% at 1 year, 68.7% vs 90.6% at 3 years, P = .015). Patients with successful repair and normal ventricular function had equivalent survival to matched controls (P = .36). Independent predictors for death or transplant included increased indexed annular size (P = .05), increased cardiopulmonary bypass time (P = .04), and decreased postrepair ventricular function (P = .01). Ventricular dilation was a time-related factor for all events, including failed repair. Survival was lower in single-ventricle patients operated on for atrioventricular valve insufficiency than in case-matched controls. Patients with little postoperative residual regurgitation and preserved ventricular function had equivalent survival to controls. Lower grade ventricular function and ventricular dilation correlated with death and repair failure, suggesting that timing of intervention may affect outcome. Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Simple repair approach for mitral regurgitation in Barlow disease.

PubMed

Ben Zekry, Sagit; Spiegelstein, Dan; Sternik, Leonid; Lev, Innon; Kogan, Alexander; Kuperstein, Rafael; Raanani, Ehud

2015-11-01

Mitral valve repair for myxomatous Barlow disease is a challenging procedure requiring complex surgery with less than optimal results. The use of ring-only repair has been previously reported but never analyzed or followed-up. We investigated this simple valve repair approach for patients with Barlow disease and multisegment involvement causing mainly central jet. Of 572 patients who underwent mitral valve repair for mitral regurgitation at our medical center, 24 with Barlow disease (aged 47 ± 14 years; 46% male) underwent ring-only repair. Patients were characterized by severely enlarged mitral valve annulus, multisegment prolapse involving both leaflets, and demonstrated mainly a central wide regurgitant jet. Surgical technique included only the implantation of a large mitral annuloplasty ring. Early and late outcome results were compared with those of the remaining patients who underwent conventional mitral valve repair for degenerative disease (controls). All ring-only patients presented with moderate-severe/severe mitral regurgitation (vena contracta, 0.6 ± 0.1 cm; regurgitation volume, 52 ± 17 mL), with mainly a central jet and almost preserved ejection fraction (59% ± 6%). Cardiopulmonary bypass and crossclamp times were significantly shorter compared with controls (P < .0001). At follow-up (ring-only, 38 ± 36 months and controls, 36 ± 29 months), there were no late deaths in the ring-only group compared with 19 (4%) in the controls. Late follow-up revealed New York Heart Association functional class I or II in 95% of ring-only patients, compared with 90% of controls. Freedom from recurrent moderate or severe mitral regurgitation was 100% and 89% in the ring-only and control groups, respectively. Mitral annuloplasty for Barlow disease patients with multisegment involvement and mainly central regurgitant jet is both simple and reproducible with excellent late outcomes. Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

COMPARISON OF ARTIFICIAL NEOCHORDAE AND NATIVE CHORDAL TRANSFER IN THE REPAIR OF A FLAIL POSTERIOR MITRAL LEAFLET: AN EXPERIMENTAL STUDY

PubMed Central

Padala, Muralidhar; Cardinau, Benedicte; Gyoneva, Lazarina I.; Thourani, Vinod H.

2013-01-01

BACKGROUND Surgical reconstruction of a flail posterior leaflet is a routine mitral valve repair, the techniques for which have evolved from leaflet resection to leaflet preservation. Artificial ePTFE neochordae are frequently used to stabilize the flail leaflet, and seldom translocation of the native secondary chordae of the valve to the leaflet free edge is used. In this study, we sought to investigate the efficacy of the two techniques to correct posterior leaflet prolapse and reduce mitral regurgitation, and quantify the acute post-repair leaflet kinematics. METHODS Adult porcine mitral valves (N =7) were studied in a pulsatile left heart experimental model in which isolated P2 flail was mimicked by marginal chordal transection. Baseline conditions were established in each valve under normal conditions (control), and followed by induction of isolated P2 flail by transecting the two marginal chordae on the posterior leaflet free edge (disease). The flail posterior leaflet was reconstructed using artificial neochordae (repair 1) and then native chordal translocation (repair 2). Reduction in leaflet flail, changes in mitral regurgitation fraction, leaflet coaptation length, and posterior leaflet mobility were measured using B-mode echocardiography or color doppler. RESULTS At baseline, all the valves were competent with no mitral regurgitation. After transection of the marginal chordae on the posterior leaflet, isolated P2 flail was evident with 13.7±13% regurgitation. Reconstruction with artificial neochordae eliminated leaflet flail and reduced mitral regurgitation to 3.2± 2.8%, and with chordal translocation leaflet flail was corrected and mitral regurgitation was measured at 2.3±2.6%. Using either repair techniques, leaflet coaptation and mobility of the repaired leaflets were adequate and comparable to the baseline measurements. CONCLUSIONS Comparable reduction leaflet flail and regurgitation, and restoration of physiological leaflet coaptation with the two techniques indicates that under acute conditions, use of artificial neochordae or native chordal translocations have similar benefits. PMID:23291143

Reduction of uterine prolapse in a sow by laparotomy.

PubMed

Raleigh, P J

1977-01-29

In the past, total uterine prolapse in the sow has been regarded as a grave condition because manipulative reposition through the vulva and vagina is extremely difficult, if not impossible, and amputation is merely a salvage procedure with a mortality rate approaching 100 percent. Laparotomy as a means of facilitating reduction of the prolapse in the sow appears to have been overlooked although it is a standard procedure in dogs and cats. This report describes a case of uterine prolapse in a sow successfully treated by laparotomy.

Incidence of mitral valve prolapse in one hundred clinically stable newborn baby girls: an echocardiographic study.

PubMed

Chandraratna, P A; Vlahovich, G; Kong, Y; Wilson, D

1979-09-01

Clinical and echocardiographic examinations were performed on 100 clinically stable, newborn baby girls. Mitral valve prolapse was noted on the echocardiograms of seven babies. Three subjects had systolic clicks, two of whom had systolic murmurs following the click. The four other babies who had echocardiographic evidence of mitral valve prolapse had no abnormal auscultatory signs. Of the 93 babies without evidence of mitral prolapse, 91 had normal echocardiograms and auscultatory features; one was noted to have a murmur consistent with a ventricular septal defect, and another had an eccentric aortic valve on the echocardiogram which was suggestive of a bicuspid aortic valve. Serial studies on our group of subjects will yield useful information regarding the natural history of mitral valve prolapse.

Superficial Dorsal Venous Rupture of the Penis: False Penile Fracture That Needs to be Treated as a True Urologic Emergency.

PubMed

Truong, Hong; Ferenczi, Basil; Cleary, Ryan; Healy, Kelly A

2016-11-01

A 38-year-old man with history of repaired penile fracture presented with rapid detumescence, penile pain, and ecchymosis during vaginal sexual intercourse concerning for recurrent fracture. Surgical exploration revealed ruptured superficial dorsal vein of the penis, which was subsequently ligated. Patients with traumatic penile vascular injuries often present with clinical features indistinguishable from a true penile fracture. Gradual detumescence and an absence of characteristic popping sound may indicate a vascular injury but they cannot safely rule out a true penile fracture. Both true and false penile fractures require emergent surgical exploration and repair to prevent long-term complications. Copyright © 2016 Elsevier Inc. All rights reserved.

[Rectal mucosal prolapse syndrome: study of cases. Hospital Daniel A Carrion, Lima, Peru, 2010-2013].

PubMed

Arévalo Suarez, Fernando; Cárdenas Vela, Irene; Rodríguez Rodríguez, Kriss; Pérez Narrea, María Teresa; Rodríguez Vargas, Omar; Montes Teves, Pedro; Monge Salgado, Eduardo

2014-04-01

to describe the clinical, endoscopic, and histological characteristics of rectal mucosal prolapse syndrome, formerly known as Solitary rectal ulcer, in patients from a general hospital. All patient diagnosed as rectal mucosal prolapse syndrome during 2010-2013 was selected; the medical history war reviewed and the histological slides were reevaluated by two pathologists. 17 cases of rectal mucosal prolapse syndrome were selected, the majority were males under 50 years, the most common clinical findings were rectal bleeding (82%) and constipation (65%), the endocopic findings were heterogeneous,: erythema (41%), ulcers (35%) and elevated lesions (29%). All cases presented fibromuscularhyperplasia in lamina propia and crypt distortion in the microscopic evaluation. In our study of rectal mucosal prolapse syndrome. The most common clinical findings were rectal bleeding and constipation. Erythematous mucosa was the most common endoscopic finding.

Prolapse-related knowledge and attitudes toward the uterus in women with pelvic organ prolapse symptoms.

PubMed

Good, Meadow M; Korbly, Nicole; Kassis, Nadine C; Richardson, Monica L; Book, Nicole M; Yip, Sallis; Saguan, Docile; Gross, Carey; Evans, Janelle; Harvie, Heidi S; Sung, Vivian

2013-11-01

The objective of the study was to describe the basic knowledge about prolapse and attitudes regarding the uterus in women seeking care for prolapse symptoms. This was a cross-sectional study of English-speaking women presenting with prolapse symptoms. Patients completed a self-administered questionnaire that included 5 prolapse-related knowledge items and 6 benefit-of-uterus attitude items; higher scores indicated greater knowledge or more positive perception of the uterus. The data were analyzed using descriptive statistics and multiple linear regression. A total of 213 women were included. The overall mean knowledge score was 2.2 ± 1.1 (range, 0-5); 44% of the items were answered correctly. Participants correctly responded that surgery (79.8%), pessary (55.4%), and pelvic muscle exercises (34.3%) were prolapse treatment options. Prior evaluation by a female pelvic medicine and reconstructive surgery specialist (beta = 0.57, P = .001) and higher education (beta = 0.3, P = .07) was associated with a higher mean knowledge score. For attitude items, the overall mean score was 15.1 (4.7; range, 6-30). A total of 47.4% disagreed with the statement that the uterus is important for sex. The majority disagreed with the statement that the uterus is important for a sense of self (60.1%); that hysterectomy would make me feel less feminine (63.9%); and that hysterectomy would make me feel less whole (66.7%). Previous consultation with a female pelvic medicine and reconstructive surgery specialist was associated with a higher mean benefit of uterus score (beta = 1.82, P = .01). Prolapse-related knowledge is low in women seeking care for prolapse symptoms. The majority do not believe the uterus is important for body image or sexuality and do not believe that hysterectomy will negatively affect their sex lives. Copyright © 2013 Mosby, Inc. All rights reserved.

Robotic sacrocolpoperineopexy with ventral rectopexy for the combined treatment of rectal and pelvic organ prolapse: initial report and technique.

PubMed

Reddy, Jhansi; Ridgeway, Beri; Gurland, Brooke; Paraiso, Marie Fidela R

2011-09-01

The objective of our study is to describe the peri-operative and early postoperative surgical outcomes following robotic sacrocolpoperineopexy with ventral rectopexy for the combined treatment of rectal and pelvic organ prolapse. This was a retrospective cohort study of ten women with symptomatic Stage 2 or greater pelvic organ prolapse and concomitant rectal prolapse who desired combined robotic surgery, at a single institution. The mean age of the subjects was 55.3 ± 19.2 years (range 19-86)  and the mean body mass index was 25.8 ± 5.7 kg/m(2). Preoperatively, the women had Stage 2 or greater pelvic organ prolapse and the average length of rectal prolapse was 2.1 ± 1.9 cm. There were no conversions to conventional laparoscopy or laparotomy. The mean operating room time was 307 ± 45 min with an estimated blood loss of 144 ± 68 ml. The average length of stay was 2.4 ± 0.8 days. Preliminary data suggest that robotic sacrocolpoperineopexy with ventral rectopexy is a feasible procedure with minimal operative morbidity for the combined treatment of rectal and pelvic organ prolapse. Longer follow-up is needed to ensure favorable long-term subjective and objective outcomes.

The significance of organ prolapse in gastroschisis.

PubMed

Koehler, Shannon M; Szabo, Aniko; Loichinger, Matt; Peterson, Erika; Christensen, Melissa; Wagner, Amy J

2017-12-01

The aim of this study was to evaluate the incidence and importance of organ prolapse (stomach, bladder, reproductive organs) in gastroschisis. This is a retrospective review of gastroschisis patients from 2000 to 2014 at a single tertiary institution. Statistical analysis was performed using a chi-square test, Student's t test, log-rank test, or Cox regression analysis models. All tests were conducted as two-tailed tests, and p-values <0.05 were considered statistically significant. One hundred seventy-one gastroschisis patients were identified. Sixty-nine (40.6%) had at least one prolapsed organ besides bowel. The most commonly prolapsed organs were stomach (n=45, 26.3%), reproductive organs (n=34, 19.9%), and bladder (n=15, 8.8%). Patients with prolapsed organs were more likely to have simple gastroschisis with significant decreases in the rate of atresia and necrosis/perforation. They progressed to earlier enteral feeds, discontinuation of parenteral nutrition, and discharge. Likewise, these patients were less likely to have complications such as central line infections, sepsis, and short gut syndrome. Gastroschisis is typically described as isolated bowel herniation, but a large portion have prolapse of other organs. Prolapsed organs are associated with simple gastroschisis, and improved outcomes most likely due to a larger fascial defect. This may be useful for prenatal and postnatal counseling of families. Case Control/Retrospective Comparative Study. Level III. Copyright © 2017 Elsevier Inc. All rights reserved.

Metatranscriptome Analysis of the Vaginal Microbiota Reveals Potential Mechanisms for Protection against Metronidazole in Bacterial Vaginosis.

PubMed

Deng, Zhi-Luo; Gottschick, Cornelia; Bhuju, Sabin; Masur, Clarissa; Abels, Christoph; Wagner-Döbler, Irene

2018-06-27

Bacterial vaginosis (BV) is a prevalent multifactorial disease of women in their reproductive years characterized by a shift from the Lactobacillus species-dominated microbial community toward a taxonomically diverse anaerobic community. For unknown reasons, some women do not respond to therapy. In our recent clinical study, among 37 women diagnosed with BV, 31 were successfully treated with metronidazole, while 6 still had BV after treatment. To discover possible reasons for the lack of response in those patients, we performed a metatranscriptome analysis of their vaginal microbiota, comparing them to the patients who responded. Seven of 8 clustered regularly interspaced short palindromic repeat (CRISPR)-associated (Cas) genes of Gardnerella vaginalis were highly upregulated in nonresponding patients. Cas genes, in addition to protecting against phages, might be involved in DNA repair, thus mitigating the bactericidal effect of DNA-damaging agents such as metronidazole. In the second part of our study, we analyzed the vaginal metatranscriptomes of four patients over 3 months and showed high in vivo expression of genes for pore-forming toxins in L. iners and of genes encoding enzymes for the production of hydrogen peroxide and d-lactate in L. crispatus IMPORTANCE Bacterial vaginosis is a serious issue for women in their reproductive years. Although it can usually be cured by antibiotics, the recurrence rate is very high, and some women do not respond to antibiotic therapy. The reasons for that are not known. Therefore, we undertook a study to detect the activity of the complete microbiota in the vaginal fluid of women who responded to antibiotic therapy and compared it to the activity of the microbiota in women who did not respond. We found that one of the most important pathogens in bacterial vaginosis, Gardnerella vaginalis , has activated genes that can repair the DNA damage caused by the antibiotic in those women that do not respond to therapy. Suppressing these genes might be a possibility to improve the antibiotic therapy of bacterial vaginosis. Copyright © 2018 Deng et al.

Reasons for delay in decision making and reaching health facility among obstetric fistula and pelvic organ prolapse patients in Gondar University hospital, Northwest Ethiopia.

PubMed

Adefris, Mulat; Abebe, Solomon Mekonnen; Terefe, Kiros; Gelagay, Abebaw Addis; Adigo, Azmeraw; Amare, Selamawit; Lazaro, Dorothy; Berhe, Aster; Baye, Chernet

2017-08-22

Obstetric fistula and pelvic organ prolapse remain highly prevalent in sub-Saharan Africa, where women have poor access to modern health care. Women having these problems tend to stay at home for years before getting treatment. However, information regarding the reasons contributing to late presentation to treatment is scarce, especially at the study area. The objective of this study was to assess the reasons whywomen with obstetric fistula and pelvic organ prolapse at Gondar University Hospital delay treatment. A hospital based cross-sectional study was conducted among 384 women. Delay was evaluated by calculating symptom onset and time of arrival to get treatment at Gondar University Hospital. Regression analysis was conducted to elicit predictors of delay for treatment. Of the total 384 participants, 311 (80.9%) had pelvic organ prolapse and 73(19.1%) obstetric fistula. The proportion of women who delayed treatment of pelvic organ prolapse was 82.9% and that of obstetric fistula 60.9%. Fear of disclosing illness due to social stigma (AOR = 2; 1.03, 3.9) and lack of money (AOR = 1.97; 1.01, 3.86) were associated with the delay of treatment for pelvic organ prolapse,while increasing age (AOR =1.12; 1.01, 1.24) and divorce (AOR = 16.9; 1.75, 165.5) were were responsible for delaying treatment forobstetric fistula. A large numberof women with pelvic organ prolapse and obstetric fistula delayed treatment. Fear of disclosure due to social stigma and lack of moneywere the major factors that contributed to thedelay to seek treatment for pelvic organ prolapse,while increasing age and divorce were the predictors for delaying treatment for obstetric fistula.

Absorbable synthetic versus catgut suture material for perineal repair

PubMed Central

Kettle, Christine

2014-01-01

Background Approximately 70% of women will experience some degree of perineal trauma following vaginal delivery and will require stitches. This may result in perineal pain and superficial dyspareunia. Objectives The objective of this review was to assess the effects of absorbable synthetic suture material as compared with catgut on the amount of short and long term pain experienced by mothers following perineal repair. Search strategy We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register. Selection criteria Randomised trials comparing absorbable synthetic (polyglycolic acid and polyglactin) with plain or chromic catgut suture for perineal repair in mothers after vaginal delivery. Data collection and analysis Trial quality was assessed independently by two reviewers. Data were extracted by one reviewer and checked by the second reviewer. Main results Eight trials were included. Compared with catgut, the polyglycolic acid and polyglactin groups were associated with less pain in first three days (odds ratio 0.62, 95% confidence interval 0.54 to 0.71). There was also less need for analgesia (odds ratio 0.63, 95% confidence interval 0.52 to 0.77) and less suture dehiscence (odds ratio 0.45, 95% confidence interval 0.29 to 0.70). There was no significant difference in long term pain (odds ratio 0.81, 95% confidence interval 0.61 to 1.08). Removal of suture material was significantly more common in the polyglycolic acid and polyglactin groups (odds ratio 2.01, 95% confidence interval 1.56 to 2.58). There was no difference in the amount of dyspareunia experienced by women. Authors’ conclusions Absorbable synthetic suture material (in the form of polyglycolic acid and polyglactin sutures) for perineal repair following childbirth appears to decrease women’s experience of short-term pain. The length of time taken for the synthetic material to be absorbed is of concern. A trial addressing the use of polyglactin has recently been completed and this has been included in this updated review. PMID:10796081

Liposomal Bupivacaine During Robotic Colpopexy and Posterior Repair: A Randomized Controlled Trial.

PubMed

Yeung, Jennifer; Crisp, Catrina C; Mazloomdoost, Donna; Kleeman, Steven D; Pauls, Rachel N

2018-01-01

To evaluate the effect of liposomal bupivacaine on postoperative pain among patients undergoing robotic sacrocolpopexy with posterior repair. This was a randomized, patient-blinded, placebo-controlled trial of women undergoing robotic sacrocolpopexy with posterior repair. Liposomal bupivacaine or normal saline placebo was injected into laparoscopic and vaginal incisions at completion of surgery. Perioperative care was standardized. Visual analog scales were collected at 4, 18, and 24 hours postoperatively in hospital. Starting on postoperative day 1, participants completed twice-daily pain scales and a pain medication diary up until the evening of postoperative day 3. The primary outcome was a 20-mm change in the visual analog scale 18 hours postoperatively. Secondary measures included additional pain scores, satisfaction, and narcotic use. Sample size calculation revealed that 32 patients per arm were required to detect the 20-mm difference with 90% power and an α of 0.05. To allocate for dropout, a goal of 70 was set. Between March 2015 and April 2016, 100 women were screened and 70 women were enrolled: 35 women were randomized to liposomal bupivacaine and 35 to placebo, of whom 64 (91%) were included in the final analysis: 33 liposomal bupivacaine and 31 placebo. No difference in demographics, surgical data, or satisfaction between groups was noted. Median VAS at 18 hours after surgery was not statistically different in those who received liposomal bupivacaine compared with normal saline (15 mm compared with 20 mm; P=.52). Other pain scales and total morphine equivalents were also similar (P=.90). In this study of robotic sacrocolpopexy with posterior repair, there were no differences in pain scores or narcotic use between liposomal bupivacaine and placebo injected into laparoscopic and vaginal incisions. Given its lack of clinical benefit, routine use of liposomal bupivacaine is not supported for this surgical intervention. ClinicalTrials.gov, NCT02449915.

[Surgical treatment of prolapse by abdominal route and effort-related urinary incontinence].

PubMed

Wagner, L; Fatton, B; Delmas, V; Haab, F; Costa, P

2009-12-01

Stress urinary incontinence is often associated with prolapse. The suburethral tapes have modified the indication for a preventive treatment of incontinence. The tapes are necessary in case of patent or masked incontinence, discussed in case of potential incontinence. The diagnosis of incontinence is done on questions to the patient, clinical exam, more than in urodynamic study. There is no absolute sign allowing to predict postoperative incontinence after surgery for prolapse. A continent woman can be incontinent postoperatively. If a potential incontinence is treated in the same as the prolapse, the patient must be informed of risk of obstruction and/or urgency.

Emergent presentation of decompensated mitral valve prolapse and atrial septal defect.

PubMed

Kang, Jessie; Das, Bijon

2015-05-01

Mitral valve prolapse is not commonly on the list of differential diagnosis when a patient presents in the emergency department (ED) in severe distress, presenting with non-specific features such as abdominal pain, tachycardia and dyspnea. A healthy 55-year-old man without significant past medical history arrived in the ED with a unique presentation of a primary mitral valve prolapse with an atrial septal defect uncommon in cardiology literature. Early recognition of mitral valve prolapse in high-risk patients for severe mitral regurgitation or patients with underlying cardiovascular abnormalities such as an atrial septal defect is crucial to prevent morbid outcomes such as sudden cardiac death.

Shared research priorities for pessary use in women with prolapse: results from a James Lind Alliance Priority Setting Partnership

PubMed Central

Hagen, Suzanne; McClurg, Doreen; Pollock, Alex

2018-01-01

Objectives To identify the shared priorities for future research of women affected by and clinicians involved with pessary use for the management of prolapse. Design A priority setting project using a consensus method. Setting A James Lind Alliance Pessary use for prolapse Priority Setting Partnership (JLA Pessary PSP) conducted from May 2016 to September 2017 in the UK. Participants The PSP was run by a Steering Group of three women with experience of pessary use, three experienced clinicians involved with management of prolapse, two researchers with relevant experience, a JLA adviser and a PSP leader. Two surveys were conducted in 2016 and 2017. The first gathered questions about pessaries, and the second asked respondents to prioritise a list of questions. A final workshop was held on 8 September 2017 involving 10 women and 13 clinician representatives with prolapse and pessary experience. Results A top 10 list of priorities for future research in pessary use for prolapse was agreed by consensus. Conclusions Women with experience of pessary use and clinicians involved with prolapse management have worked together to determine shared priorities for future research. Aligning the top 10 results with existing research findings will highlight the gaps in current evidence and signpost future research to areas of priority. Effective dissemination of the results will enable research funding bodies to focus on gathering the evidence to answer the questions that matter most to those who will be affected. PMID:29705767

Spontaneous intrapartum vesicouterine fistula.

PubMed

Kaaki, Bilal; Gyves, Michael; Goldman, Howard

2006-02-01

Vesicouterine fistulae as an obstetrical complication have been reported only in women with a history of cesarean. We present a patient with no such history who developed a vesicouterine fistula after vaginal delivery. A 43-year-old gravida 5 at term with no history of cesarean presented in the latent phase of labor. Gross hematuria was noted intrapartum, and a foley catheter was placed. A cystogram showed an extraperitoneal bladder perforation. The patient had urinary incontinence despite Foley catheter drainage. The diagnosis of vesicouterine fistula was made by cystoscopy and fistulogram. The patient had a successful repair at 3 months. This is a rare case of a vesicouterine fistula developing during a pregnancy with no previous cesarean. Accurate diagnosis is essential because surgical repair has an excellent outcome.

Prevention and management of pelvic organ prolapse

PubMed Central

Giarenis, Ilias

2014-01-01

Pelvic organ prolapse is a highly prevalent condition in the female population, which impairs the health-related quality of life of affected individuals. Despite the lack of robust evidence, selective modification of obstetric events or other risk factors could play a central role in the prevention of prolapse. While the value of pelvic floor muscle training as a preventive treatment remains uncertain, it has an essential role in the conservative management of prolapse. Surgical trends are currently changing due to the controversial issues surrounding the use of mesh and the increasing demand for uterine preservation. The evolution of laparoscopic and robotic surgery has increased the use of these techniques in pelvic floor surgery. PMID:25343034

Women seeking treatment for advanced pelvic organ prolapse have decreased body image and quality of life.

PubMed

Jelovsek, J Eric; Barber, Matthew D

2006-05-01

Women who seek treatment for pelvic organ prolapse strive for an improvement in quality of life. Body image has been shown to be an important component of differences in quality of life. To date, there are no data on body image in patients with advanced pelvic organ prolapse. Our objective was to compare body image and quality of life in women with advanced pelvic organ prolapse with normal controls. We used a case-control study design. Cases were defined as subjects who presented to a tertiary urogynecology clinic with advanced pelvic organ prolapse (stage 3 or 4). Controls were defined as subjects who presented to a tertiary care gynecology or women's health clinic for an annual visit with normal pelvic floor support (stage 0 or 1) and without urinary incontinence. All patients completed a valid and reliable body image scale and a generalized (Short Form Health Survey) and condition-specific (Pelvic Floor Distress Inventory-20) quality-of-life scale. Linear and logistic regression analyses were performed to adjust for possible confounding variables. Forty-seven case and 51 control subjects were enrolled. After controlling for age, race, parity, previous hysterectomy, and medical comorbidities, subjects with advanced pelvic organ prolapse were more likely to feel self-conscious (adjusted odds ratio 4.7; 95% confidence interval 1.4 to 18, P = .02), less likely to feel physically attractive (adjusted odds ratio 11; 95% confidence interval 2.9 to 51, P < .001), less likely to feel feminine (adjusted odds ratio 4.0; 95% confidence interval 1.2 to 15, P = .03), and less likely to feel sexually attractive (adjusted odds ratio 4.6; 95% confidence interval 1.4 to 17, P = .02) than normal controls. The groups were similar in their feeling of dissatisfaction with appearance when dressed, difficulty looking at themselves naked, avoiding people because of appearance, and overall dissatisfaction with their body. Subjects with advanced pelvic organ prolapse suffered significantly lower quality of life on the physical scale of the SF-12 (mean 42; 95% confidence interval 39 to 45 versus mean 50; 95% confidence interval 47 to 53, P < .009). However, no differences between groups were noted on the mental scale of the SF-12 (mean 51; 95% confidence interval 50 to 54 versus mean 50; 95% confidence interval 47 to 52, P = .56). Additionally, subjects with advanced pelvic organ prolapse scored significantly worse on the prolapse, urinary, and colorectal scales and overall summary score of Pelvic Floor Distress Inventory-20 than normal controls (mean summary score 104; 95% confidence interval 90 to 118 versus mean 29; 95% confidence interval 16 to 43, P < .0001), indicating a decrease in condition-specific quality of life. Worsening body image correlated with lower quality of life on both the physical and mental scales of the SF-12 as well as the prolapse, urinary, and colorectal scales and overall summary score of Pelvic Floor Distress Inventory-20 in subjects with advanced pelvic organ prolapse. Women seeking treatment for advanced pelvic organ prolapse have decreased body image and overall quality of life. Body image may be a key determinant for quality of life in patients with advanced prolapse and may be an important outcome measure for treatment evaluation in clinical trials.

Surgical treatment of female stress urinary incontinence with a trans-obturator-tape (T.O.T.) Uratape: short term results of a prospective multicentric study.

PubMed

Costa, P; Grise, P; Droupy, S; Monneins, F; Assenmacher, C; Ballanger, P; Hermieu, J F; Delmas, V; Boccon-Gibod, L; Ortuno, C

2004-07-01

The aim of the study was to assess the efficacy and safety of a new minimally invasive surgical procedure using the Trans-Obturator-Tape Uratape to treat female stress urinary incontinence. 183 women with stress urinary incontinence (SUI) associated with urethral hypermobility, underwent the T.O.T. procedure (October 2001 to March 2003). 26 patients were previously operated for incontinence. 26 patients were operated at the same time for their genital prolapse. Mean age was 56 years (29-87). 50/183 patients were having mixed incontinence. A non-elastic, polypropylene tape (UraTape, Mentor-Porgès) with a silicon coated central part was placed under the mid-urethra. The surgical placement technique utilises a trans-obturator percutaneous approach. All patients underwent post-operative clinical examination, cough-stress test (full bladder), uroflowmetry, and post-voiding residual assessment. Mean follow-up was 7 months (1-21). At 1 year follow-up 80.5% of the patients were completely cured and 7.5% were improved. The overall peri-operative complication rate was 2.2% with no vascular, nerve or bowel injury. 6 patients (3.3%) had post-operative urinary retention. The present multicentric study confirms the results obtained by the instigator of the technique, E. Delorme, and allows us to consider T.O.T. as an effective and safe technique for the treatment of female stress urinary incontinence, alone or in combination with prolapse repair. Copyright 2004 Elsevier B.V.

Applications of diagnostic ultrasonography in small ruminant reproductive management.

PubMed

Scott, P R

2012-02-01

Modern portable ultrasound machines provide the veterinary clinician with an inexpensive and non-invasive method to further examine the reproductive tract of both male and female sheep on farm which should take no more than 5 min with the results available immediately. Unlike cattle, ultrasound examination of the ovaries is not undertaken because failure to cycle during the normal season is rare in sheep and there are no common ovarian conditions causing acyclicity. Accurate diagnosis of foetal number has greatly improved the nutritional management of late gestation ewes over the past 30 years. Late gestation nutritional supply in response to foetal demand greatly reduces perinatal lamb mortality by ensuring lamb birthweight and ewe colostrum accumulation. The contents of vaginal prolapse have been determined using ultrasonography which has led to an improved method for correction. A retained foetus when second stage labour is considered to have been completed, and uterine torsion, can be identified during ultrasound examination allowing timely correction. Ultrasonographic examination of palpable scrotal abnormalities can provide much useful information particularly in the diagnosis of epididymitis, orchitis and testicular atrophy. Copyright © 2012 Elsevier B.V. All rights reserved.

The Amnioscope Strikes Back as a Useful Device for Pinhole Amniotomy in the Management of Polyhydramnios

PubMed Central

Koyama, Shinsuke; Tomimatsu, Takuji; Kanagawa, Takeshi; Tsutsui, Tateki; Kimura, Tadashi

2011-01-01

Polyhydramnios is associated with many serious maternal complications such as placental abruption or cord prolapse at rupture of membranes, uterine dysfunction at delivery, and postpartum hemorrhage. When considering uterine dysfunction caused by overstretched uterine muscles, active artificial amniotomy for more efficient labor seems to be a preferred obstetric management, but the potential adverse complications make obstetricians hesitate to perform this procedure. In such a challenging situation, a new strategy is required. We recently performed pinhole artificial amniotomy using an amnioscope in four women with polyhydramnios, not only to accelerate of labor but also to more slowly and safely reduce amniotic fluid volume. We had no complications using this procedure, and all women were able to have a vaginal delivery without postpartum hemorrhage and neonatal asphyxia. Pinhole artificial amniotomy using an amnioscope may be more convenient and safer than conventional artificial amniotomy. The significance of the amnioscope has been practically nil in modern obstetric management. In this pilot clinical study, we identified a new value for the amnioscope as a promising device for safer amniotomy in women with polyhydramnios. PMID:23705096

Hysterectomy for complications after uterine artery embolization for leiomyoma: results of a Canadian multicenter clinical trial.

PubMed

Pron, Gaylene; Mocarski, Eva; Cohen, Marsha; Colgan, Terence; Bennett, John; Common, Andrew; Vilos, George; Kung, Rose

2003-02-01

To determine the complication-related hysterectomy rate after uterine artery embolization (UAE) for symptomatic uterine leiomyomas. Prospective, multicenter, nonrandomized, single-arm clinical trial (Canadian Task Force classification II-2). Eight Ontario University-affiliated teaching and community hospitals. Five hundred fifty-five women. Polyvinyl alcohol particles were delivered through a catheter into uterine arteries under fluoroscopic guidance. Prospective follow-up investigations consisted of telephone interviews, ultrasound examinations, and reviews of pathology and surgery reports. Median follow-up was 8.1 months, and all but five patients had complete 3-month follow-up. At 3 months, eight women (1.5%, 95% CI 0.6-2.8) underwent complication-related hysterectomy. Half of the surgeries were performed at institutions other than where UAE had been performed. Indications for hysterectomies were infections (2), postembolization pain (4), vaginal bleeding (1), and prolapsed leiomyoma (1). The 3-month complication rate resulting in hysterectomy after UAE in a large cohort of women was low. Hysterectomy after UAE is an important measure of safety and a key outcome measure of this new therapy.

Treatment of rectal prolapse in children with cow milk injection sclerotherapy: 30-year experience

PubMed Central

Zganjer, Mirko; Cizmic, Ante; Cigit, Irenej; Zupancic, Bozidar; Bumci, Igor; Popovic, Ljiljana; Kljenak, Antun

2008-01-01

AIM: To evaluate the role and our experience of injection sclerotherapy with cow milk in the treatment of rectal prolapse in children. METHODS: In the last 30 years (1976-2006) we made 100 injections of sclerotherapy with cow milk in 86 children. In this study we included children who failed to respond to conservative treatment and we perform operative treatment. RESULTS: In our study we included 86 children and in all of the patients we perform cow milk injection sclerotherapy. In 95.3% (82 children) of patients sclerotherapy was successful. In 4 (4.7%) patients we had recurrent rectal prolapse where we performed operative treatment. Below 4 years we had 62 children (72%) and 24 older children (28%). In children who needed operative treatment we performed Thiersch operation and without any complications. CONCLUSION: Injection sclerotherapy with cow milk for treatment rectal prolapse in children is a simple and effective treatment for rectal prolapse with minimal complications. PMID:18205264

[Implants for genital prolapse : Contra mesh surgery].

PubMed

Hampel, C

2017-12-01

Alloplastic transvaginal meshes have become very popular in the surgery of pelvic organ prolapse (POP) as did alloplastic suburethral slings in female stress incontinence surgery, but without adequate supporting data. The simplicity of the mesh procedure facilitates its propagation with acceptance of higher revision and complication rates. Since attending physicians do more and more prolapse surgeries without practicing or teaching alternative techniques, expertise in these alternatives, which might be very useful in cases of recurrence, persistence or complications, is permanently lost. It is doubtful that proper and detailed information about alternatives, risks, and benefits of transvaginal alloplastic meshes is provided to every single prolapse patient according to the recommendations of the German POP guidelines, since the number of implanted meshes exceeds the number of properly indicated mesh candidates by far. Although there is no dissent internationally about the available mesh data, thousands of lawsuits in the USA, insolvency of companies due to claims for compensation and unambiguous warnings from foreign urological societies leave German urogynecologists still unimpressed. The existing literature in pelvic organ prolapse exclusively focusses on POP stage and improvement of that stage with surgical therapy. Instead, typical prolapse symptoms should trigger therapy and improvement of these symptoms should be the utmost treatment goal. It is strongly recommended for liability reasons to obtain specific written informed consent.

Physical therapy intervention in women with urinary incontinence associated with pelvic organ prolapse.

PubMed

Knorst, Mara R; Cavazzotto, Karilena; Henrique, Magali; Resende, Thais L

2012-04-01

Urinary incontinence (UI) is a prevalent condition that affects women of all ages. Pelvic organ prolapse in conjunction with UI is a common occurrence. To assess the effect of pelvic prolapse on the outcome of physical therapy treatment for women with UI. The study included 48 women aged between 35 and 78 years who underwent anamnesis and measurement of pelvic floor strength (bi-digital test and perineometry). The physical therapy intervention consisted of transvaginal electrical stimulation and pelvic floor exercise for up to 15 weekly sessions. The majority of the women had normal delivery and 2.6±1.5 children (range=0-7). Pelvic prolapse was observed in 72.4% of the women who had normal delivery, in 100% of those who had cesarean section, and in 77.8% of those who had both normal and cesarean deliveries. 48% of the women had mixed UI, 39.5% had stress UI, and 12.5% had urge UI. The duration of symptoms varied from 2 to 28 years (7.9±5.3). In the participants with and without prolapse, a significant difference was observed in the pre- and post-treatment comparisons for the pelvic floor muscles. The pre- and post-treatment perineometry showed a significant increase only in the women with prolapse (p=0.048). 87.5% of the participants became continent. The physical therapy treatment was effective in treating and/or curing the symptoms of UI, whether or not associated with pelvic prolapse, regardless of the clinical type of incontinence. Clinical Trial Registration (Brazilian Clinical Trial Registry): RBR-3p5s66.

Treatment-seeking behaviour and social status of women with pelvic organ prolapse, 4th-degree obstetric tears, and obstetric fistula in western Uganda.

PubMed

Krause, Hannah G; Natukunda, Harriet; Singasi, Isaac; Hicks, Sylvia S W; Goh, Judith T W

2014-11-01

This study looks at a trilogy of women's health issues including severe pelvic organ prolapse, unrepaired 4th degree obstetric tears and obstetric fistula, all of which can cause significant suffering in the lives of women and their families. Women undergoing surgery for severe pelvic organ prolapse, unrepaired 4th degree obstetric tears and obstetric fistulae, were interviewed to assess their perceptions of what caused their condition, subsequent impact on their social situation and sexual activity, and whether they had sought treatment previously. One hundred fifty women participated in the survey, including 69 undergoing surgery for genito-urinary fistula, 25 with faecal incontinence only (including 24 women with unrepaired 4th degree obstetric tears and 1 woman with an isolated rectovaginal fistula), and 56 women with severe pelvic organ prolapse. All groups of women were exposed to abandonment by their families with 42 % of women with genito-urinary fistula, 21 % with unrepaired 4th degree obstetric tear, and 25 % of women with severe pelvic organ prolapse rejected by their husbands. Most of the women had actively sought treatment for their condition with no success due to unavailability of treatment or misinformation. This study confirms the social stigma associated with obstetric fistula, however also highlights the social stigma faced by women suffering with severe pelvic organ prolapse and unrepaired 4th degree obstetric tears in western Uganda. There is an urgent need for education and training in obstetric management and pelvic organ prolapse management in such areas of limited resources.

Shared research priorities for pessary use in women with prolapse: results from a James Lind Alliance Priority Setting Partnership.

PubMed

Lough, Kate; Hagen, Suzanne; McClurg, Doreen; Pollock, Alex

2018-04-28

To identify the shared priorities for future research of women affected by and clinicians involved with pessary use for the management of prolapse. A priority setting project using a consensus method. A James Lind Alliance Pessary use for prolapse Priority Setting Partnership (JLA Pessary PSP) conducted from May 2016 to September 2017 in the UK. The PSP was run by a Steering Group of three women with experience of pessary use, three experienced clinicians involved with management of prolapse, two researchers with relevant experience, a JLA adviser and a PSP leader. Two surveys were conducted in 2016 and 2017. The first gathered questions about pessaries, and the second asked respondents to prioritise a list of questions. A final workshop was held on 8 September 2017 involving 10 women and 13 clinician representatives with prolapse and pessary experience. A top 10 list of priorities for future research in pessary use for prolapse was agreed by consensus. Women with experience of pessary use and clinicians involved with prolapse management have worked together to determine shared priorities for future research. Aligning the top 10 results with existing research findings will highlight the gaps in current evidence and signpost future research to areas of priority. Effective dissemination of the results will enable research funding bodies to focus on gathering the evidence to answer the questions that matter most to those who will be affected. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Falling out: authoritative knowledge and women's experiences with pelvic organ prolapse.

PubMed

Low, Lisa Kane; Tumbarello, Julie A

2012-01-01

Despite the high prevalence of pelvic organ prolapse, many women suffer in silence, lacking the language and opportunity to describe their condition. There are limited descriptions of women's experiences with pelvic organ prolapse in the literature. This qualitative study addressed the knowledge and experience of women with pelvic organ prolapse. Semistructured interviews were conducted with 13 women who had been previously diagnosed with pelvic organ prolapse. Transcripts of the interviews were reviewed and coded using a process of content analysis compared against the framework of authoritative knowledge, developed by Brigitte Jordan. By applying the concept of authoritative knowledge, we identified 3 themes of how women construct understanding about pelvic organ prolapse and how they demonstrate deference to the authoritative knowledge of medical providers. First, we found through women's narratives that authoritative knowledge was held by the health care provider and is considered consequential and legitimate by all participants. Second, women reported that the health care provider's authoritative knowledge was valued over personal, experiential knowledge. Finally, women described how they work with their health care providers to create a system of authoritative knowledge as they seek treatment for or discuss their condition. Throughout the narratives, women's experiences are not legitimized by the women or the medical community, perpetuating the "hidden" nature of these conditions. This analysis provides qualitative evidence of Jordan's authoritative knowledge: women and health care providers contribute to dimensions of authoritative knowledge surrounding pelvic organ prolapse. Despite what women experience, the health care provider's definition and understanding of pelvic organ prolapse is seen as legitimate and consequential. Because of their construction of their condition, and the power dynamic at play, women are silenced, and their expertise about their bodies is delegitimized, limiting their active participation in seeking care for this condition. © 2012 by the American College of Nurse-Midwives.

Falling Out: Authoritative Knowledge and Women’s Experience with Pelvic Organ Prolapse

PubMed Central

Low, Lisa Kane; Tumbarello, Julie A.

2014-01-01

Introduction Despite the high prevalence of pelvic organ prolapse many women suffer in silence, lacking the language and opportunity to describe their condition. There are limited descriptions of women’s experiences with pelvic organ prolapse in the literature. This qualitative study addressed the knowledge and experience of women with pelvic organ prolapse. Methods Semi-structured interviews were conducted with 13 women who had been previously diagnosed with pelvic organ prolapse. Transcripts of the interviews were reviewed and coded using a process of content analysis compared against the framework of authoritative knowledge, developed by Bridgitte Jordan. Results By applying the concept of “authoritative knowledge,” we identified three themes of how women construct understanding about their pelvic organ prolapse and how they demonstrate deference to the authoritative knowledge of medical providers. First, we found through women’s narratives that authoritative knowledge was held by the health care provider and is considered consequential and legitimate by all participants. Second, women reported that the health care provider’s authoritative knowledge was valued over personal, experiential knowledge. Finally, women describe how they work with their health care providers to create a system of authoritative knowledge as they seek treatment for or discuss their condition. Throughout the narratives, women’s experiences are not well acknowledged by themselves or the medical community, perpetuating the “hidden” nature of these conditions. Discussion This analysis provides qualitative evidence of Jordan’s authoritative knowledge: women and health care providers contribute to dimensions of authoritative knowledge surrounding pelvic organ prolapse. Despite what women experience, the health care provider’s definition and understanding of pelvic organ prolapse is seen as legitimate and consequential. Because of their construction of their condition, and the power dynamic at play, women are silenced and their expertise about their body is delegitimized, limiting their active participation in seeking care for this condition. PMID:22954080

Bone marrow mesenchymal stem cells could acquire the phenotypes of epithelial cells and accelerate vaginal reconstruction combined with small intestinal submucosa.

PubMed

Li, Yanan; Liu, Fangfang; Zhang, Zhiqiang; Zhang, Mingle; Cao, Shanjin; Li, Yachai; Zhang, Lin; Huang, Xianghua; Xu, Yanfang

2015-11-01

Grafting material for vaginal reconstruction commonly includes the bowel, peritoneum, skin, and amniotic membrane. Bone marrow mesenchymal stem cells (MSCs) have the potential of multilineage differentiation into a variety of cells and have been widely explored in tissue engineering. In the current study, we examined whether MSCs could be differentiated to vaginal epithelial cells (VECs) upon co-culturing with VECs. We also examined whether Wnt/β-catenin signaling pathway is implicated in such differentiation. Co-culture of MSCs with VECs using a transwell insert system (with no direct contact) induced the expression of VECs marker AE1/AE3 in MSCs. MSCs combined with small intestinal submucosa (SIS) scaffold were implanted in place of the native vagina in rats to observe the implications for vaginal reconstruction in vivo. Anatomic repair of neovagina was assessed by histological staining for H/E and Masson's Trichrome. GSK-3β and β-catenin, main members of Wnt/β-catenin signaling pathway, in MSCs were increased upon co-culturing with VECs. Exposure of co-cultured MSCs to a Wnt/β-catenin signaling activator, lithium chloride (LiCl, 20 µM) increased phosphorylated GSK-3β and β-catenin and enhanced expression of AE1/AE3. In vivo-grafted cells displayed significant matrix infiltration and expressed epithelial markers in neovagina. These findings suggest that MSCs could acquire the phenotype of VECs when co-cultured with VECs, possibly via activation of Wnt/β-catenin signaling. MSCs provide an alternative cell source for potential use in vaginal tissue engineering. © 2015 International Federation for Cell Biology.

Neurological outcomes by mode of delivery for fetuses with open neural tube defects: A systematic review and meta-analysis.

PubMed

Tolcher, Mary C; Shazly, Sherif A; Shamshirsaz, Alireza A; Whitehead, William E; Espinoza, Jimmy; Vidaeff, Alex C; Belfort, Michael A; Nassr, Ahmed A

2018-06-20

Controversy exists regarding the optimal mode of delivery for fetuses with open neural tube defects. To compare neurological outcomes among infants with open neural tube defects who underwent vaginal compared to caesarean delivery. Electronic databases MEDLINE, EMBASE, Scopus, and Clinicaltrials. gov were searched from inception to November 2017. Eligible studies included observational or randomised studies comparing vaginal and caesarean delivery in pregnancies with fetal open neural tube defects who did not undergo prenatal repair. Two reviewers independently reviewed abstracts and full text articles. Outcomes were compared between vaginal and caesarean delivery and prelabour caesarean versus labour. The primary outcome was motor-anatomic level difference. Secondary outcomes included shunt requirement, sac disruption, meningitis, and ambulation at 2 years. Meta-analysis was performed and mean difference or odds ratios with 95% confidence interval calculated. Of 201 abstracts identified in the primary search, 9 studies (672 women) met eligibility criteria. Comparing vaginal and caesarean delivery, there was no significant difference in motor-anatomic level difference (mean difference -0.10, 95% CI -0.58-0.38; I 2 =57%). The vaginal delivery group was less likely to require a shunt or have sac disruption (OR 0.37, 95% CI 0.14-0.95 and OR 0.46, 95% CI 0.23-0.90, respectively). Comparisons by prelabour caesarean versus labour showed no significant difference in motor-anatomic level difference (OR 1.29, 95% CI -0.63-3.21) or ambulation at 2 years (OR 2.13, 95% CI 0.35-13.12). Caesarean delivery was not associated with improved neurological outcomes among fetuses with open neural tube defects. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Valve repair for traumatic tricuspid regurgitation.

PubMed

Maisano, F; Lorusso, R; Sandrelli, L; Torracca, L; Coletti, G; La Canna, G; Alfieri, O

1996-01-01

The review of six cases of valve repair for traumatic tricuspid regurgitation in our institution and 74 in the literature in order to assess effective methods of treating this lesion. Tricuspid valve regurgitation is a rare complication of blunt chest trauma. Optimal treatment for this condition is still controversial ranging from long-term medical therapy to early surgical correction. We followed the cases of six consecutive patients with post-traumatic tricuspid incompetence who were successfully treated with reparative techniques. All patients were male and their ages ranged from 18 years to 42 years. Valve regurgitation was always secondary to blunt chest trauma due to motor vehicle accident. The mechanism of valve insufficiency was invariably anterior leaflet prolapse due to chordal or papillary muscle rupture associated with annular dilatation. Surgical procedures included Carpentier ring implant (5 patients), Bex posterior annuloplasty (1 patient), implant of artificial chordae (4 patients), papillary muscle reinsertion (2 patients), commissuroplasty (1 patient) and "artificial double orifice" technique (1 patient). Tricuspid insufficiency improved in all patients after the correction. No complications were recorded and all patients were asymptomatic at the follow-up. Since post-traumatic tricuspid regurgitation is effectively correctable with reparative techniques, early operation is recommended to relieve symptoms and to prevent right ventricular dysfunction.

Clinical and functional evaluation of patients with rectocele and mucosal prolapse treated with transanal repair of rectocele and rectal mucosectomy with a single circular stapler (TRREMS)

PubMed Central

Regadas, F. S. P.; Regadas, S. M. M.; Veras, L. R.

2010-01-01

Background The aim of the present study was to make a preoperative and postoperative clinical and functional evaluation of patients who underwent transanal repair of rectocele and rectal mucosectomy with a single circular stapler (TRREMS procedure) as treatment for obstructed defecation syndrome (ODS) caused by rectocele and rectal mucosal prolapse (RMP). Methods This prospective study included 35 female patients, 34 multiparous and one nulliparous, with an average age of 47.5 years (range 31–67 years), rectocele grade II (n = 13/37.1%) or grade III (n = 22/62.9%), associated with RMP. The study parameters included ODS, constipation, functional continence scores and pre- and postoperative cinedefecographic findings. Results The average preoperative ODS score, the constipation score and the functional continence score were significantly reduced after surgery from 10.63 to 2.91 (p = 0.001), 15.23 to 4.46 (p = 0.001) and 2.77 to 1.71 (p = 0.001), respectively. Between the first and the eighth postoperative day, the average visual analog scale pain score fell from 5.23 to 1.20 (p = 0.001). Satisfaction with treatment outcome was 79.97, 86.54, 87.65 and 88.06 at 1, 3, 6 and 12 months, respectively. Cinedefecography revealed average reductions in rectocele size from 19.23 ± 8.84 mm (3–42) to 6.68 ± 3.65 mm (range 0–7) at rest and from 34.89 ± 12.30 mm (range 20–70) to 10.94 ± 5.97 mm (range 0–25) during evacuation (both P = 0.001). Conclusion The TRREMS procedure is a safe and efficient technique associated with satisfactory anatomic and functional results and with a low incidence of postoperative pain and complications. PMID:20957403

Ex vivo hydrodynamics after central and paracommissural edge-to-edge technique: A further step toward transcatheter tricuspid repair?

PubMed

Stock, Sina; Bohm, Heidemarie; Scharfschwerdt, Michael; Richardt, Doreen; Meyer-Saraei, Roza; Tsvelodub, Stanislav; Sievers, Hans-Hinrich

2018-03-01

Transcatheter approaches in heart valve disease became tremendously important and are currently established in the aortic position, but transcatheter tricuspid repair is still in its beginning and remains challenging. Replicating the surgical edge-to-edge technique, for example, with the MitraClip System (Abbott Vascular, Santa Clara, Calif), represents a promising option and has been reported successfully in small numbers of cases. However, up to now, few data considering the edge-to-edge technique as a transcatheter approach are available. This study aims to determine the ex vivo hydrodynamics after the central and paracommissural edge-to-edge technique in different pathologies. Because of basal or apical dislocation of papillary muscles, leaflet prolapse or tethering was simulated in porcine tricuspid valves mounted on a flexible holding device. Central and paracommissural edge-to-edge techniques were evaluated successively in these pathologies. Regurgitant volume and mean transvalvular gradient were determined in a pulse duplicator. In this ex vivo model, the isolated edge-to-edge technique reduced tricuspid regurgitation. In the prolapse model, regurgitant volume decreased significantly after central edge-to-edge technique (from 49.4 ± 13.6 mL/stroke to 39.3 ± 14.1 mL/stroke). In the tethering model, both the central and the paracommissural edge-to-edge techniques led to a significant decrease (from 48.7 ± 13.9 to 43.6 ± 15.6 and to 41.1 ± 13.8 mL/stroke). In all cases, the reduction of regurgitant volume was achieved at the cost of significantly increased mean transvalvular gradient. This study provides a reduction of tricuspid regurgitation after the edge-to-edge technique in the specific experimental setup. Whether this reduction is sufficient to treat tricuspid regurgitation successfully in clinical practice remains to be established. Transcatheter approaches need to be evaluated further, probably with regard to concomitant annuloplasty for higher reduction of tricuspid regurgitation. Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Influence of mitral valve repair versus replacement on the development of late functional tricuspid regurgitation.

PubMed

Rajbanshi, Bijoy G; Suri, Rakesh M; Nkomo, Vuyisile T; Dearani, Joseph A; Daly, Richard C; Burkhart, Harold M; Stulak, John M; Joyce, Lyle D; Li, Zhuo; Schaff, Hartzell V

2014-11-01

To study the determinants of functional tricuspid regurgitation (TR) progression after surgical correction of mitral regurgitation, including the influence of mitral valve (MV) repair (MVr) versus replacement (MVR) for degenerative mitral regurgitation. From January 1995 to January 2006, 747 adults with MV prolapse underwent isolated MVr (n=683) or MVR (n=64; mechanical in 32). The mean age was 60.8 years, and 491 were men (66.0%). Moderate preoperative functional TR was present in 115 (15.4%). The MVR group had a greater likelihood of New York Heart Association class III or IV (75.0% vs 34.4%, P<.001), atrial fibrillation (20.3% vs 8.3%, P=.002), a lower left ventricular ejection fraction (61.0% vs 65.2%, P<.003), and a higher pulmonary artery pressure (50.1 vs 41.2 mm Hg, P=.001). The patients were monitored for a mean of 6.9 years (MVr) or 7.7 years (MVR; P=.075). During late follow-up, no difference was found between the groups in the development of moderately severe or severe TR: 1 to 5 years (3.0% vs 3.3%, P=.91) and >5 years (6.1% vs 6.5%; P=.93). The univariate predictors of severe TR after 5 years were older age (hazard ratio [HR], 1.1; P=.011), female gender (HR, 6.86; P=.005), higher pulmonary artery pressure (HR, 1.05; P=.022), and larger left atrial size (HR, 2.11; P=.035). Two patients (0.26%) who had undergone initial MVr required reoperation for late functional TR. Another 2 patients had had the tricuspid valve addressed concurrent with reoperation for MVr failure. No tricuspid reoperations were required in the MVR group. The risk of TR progression was low after MVr or MVR for MV prolapse. Timely MV surgery before the development of left atrial dilatation or pulmonary hypertension could further decrease the risk of TR progression during follow-up. Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis.

PubMed

Keag, Oonagh E; Norman, Jane E; Stock, Sarah J

2018-01-01

Cesarean birth rates continue to rise worldwide with recent (2016) reported rates of 24.5% in Western Europe, 32% in North America, and 41% in South America. The objective of this systematic review is to describe the long-term risks and benefits of cesarean delivery for mother, baby, and subsequent pregnancies. The primary maternal outcome was pelvic floor dysfunction, the primary baby outcome was asthma, and the primary subsequent pregnancy outcome was perinatal death. Medline, Embase, Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were systematically searched for published studies in human subjects (last search 25 May 2017), supplemented by manual searches. Included studies were randomized controlled trials (RCTs) and large (more than 1,000 participants) prospective cohort studies with greater than or equal to one-year follow-up comparing outcomes of women delivering by cesarean delivery and by vaginal delivery. Two assessors screened 30,327 abstracts. Studies were graded for risk of bias by two assessors using the Scottish Intercollegiate Guideline Network (SIGN) Methodology Checklist and the Risk of Bias Assessment tool for Non-Randomized Studies. Results were pooled in fixed effects meta-analyses or in random effects models when significant heterogeneity was present (I2 ≥ 40%). One RCT and 79 cohort studies (all from high income countries) were included, involving 29,928,274 participants. Compared to vaginal delivery, cesarean delivery was associated with decreased risk of urinary incontinence, odds ratio (OR) 0.56 (95% CI 0.47 to 0.66; n = 58,900; 8 studies) and pelvic organ prolapse (OR 0.29, 0.17 to 0.51; n = 39,208; 2 studies). Children delivered by cesarean delivery had increased risk of asthma up to the age of 12 years (OR 1.21, 1.11 to 1.32; n = 887,960; 13 studies) and obesity up to the age of 5 years (OR 1.59, 1.33 to 1.90; n = 64,113; 6 studies). Pregnancy after cesarean delivery was associated with increased risk of miscarriage (OR 1.17, 1.03 to 1.32; n = 151,412; 4 studies) and stillbirth (OR 1.27, 1.15 to 1.40; n = 703,562; 8 studies), but not perinatal mortality (OR 1.11, 0.89 to 1.39; n = 91,429; 2 studies). Pregnancy following cesarean delivery was associated with increased risk of placenta previa (OR 1.74, 1.62 to 1.87; n = 7,101,692; 10 studies), placenta accreta (OR 2.95, 1.32 to 6.60; n = 705,108; 3 studies), and placental abruption (OR 1.38, 1.27 to 1.49; n = 5,667,160; 6 studies). This is a comprehensive review adhering to a registered protocol, and guidelines for the Meta-analysis of Observational Studies in Epidemiology were followed, but it is based on predominantly observational data, and in some meta-analyses, between-study heterogeneity is high; therefore, causation cannot be inferred and the results should be interpreted with caution. When compared with vaginal delivery, cesarean delivery is associated with a reduced rate of urinary incontinence and pelvic organ prolapse, but this should be weighed against the association with increased risks for fertility, future pregnancy, and long-term childhood outcomes. This information could be valuable in counselling women on mode of delivery.

Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis

PubMed Central

Keag, Oonagh E.; Stock, Sarah J.

2018-01-01

Background Cesarean birth rates continue to rise worldwide with recent (2016) reported rates of 24.5% in Western Europe, 32% in North America, and 41% in South America. The objective of this systematic review is to describe the long-term risks and benefits of cesarean delivery for mother, baby, and subsequent pregnancies. The primary maternal outcome was pelvic floor dysfunction, the primary baby outcome was asthma, and the primary subsequent pregnancy outcome was perinatal death. Methods and findings Medline, Embase, Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were systematically searched for published studies in human subjects (last search 25 May 2017), supplemented by manual searches. Included studies were randomized controlled trials (RCTs) and large (more than 1,000 participants) prospective cohort studies with greater than or equal to one-year follow-up comparing outcomes of women delivering by cesarean delivery and by vaginal delivery. Two assessors screened 30,327 abstracts. Studies were graded for risk of bias by two assessors using the Scottish Intercollegiate Guideline Network (SIGN) Methodology Checklist and the Risk of Bias Assessment tool for Non-Randomized Studies. Results were pooled in fixed effects meta-analyses or in random effects models when significant heterogeneity was present (I2 ≥ 40%). One RCT and 79 cohort studies (all from high income countries) were included, involving 29,928,274 participants. Compared to vaginal delivery, cesarean delivery was associated with decreased risk of urinary incontinence, odds ratio (OR) 0.56 (95% CI 0.47 to 0.66; n = 58,900; 8 studies) and pelvic organ prolapse (OR 0.29, 0.17 to 0.51; n = 39,208; 2 studies). Children delivered by cesarean delivery had increased risk of asthma up to the age of 12 years (OR 1.21, 1.11 to 1.32; n = 887,960; 13 studies) and obesity up to the age of 5 years (OR 1.59, 1.33 to 1.90; n = 64,113; 6 studies). Pregnancy after cesarean delivery was associated with increased risk of miscarriage (OR 1.17, 1.03 to 1.32; n = 151,412; 4 studies) and stillbirth (OR 1.27, 1.15 to 1.40; n = 703,562; 8 studies), but not perinatal mortality (OR 1.11, 0.89 to 1.39; n = 91,429; 2 studies). Pregnancy following cesarean delivery was associated with increased risk of placenta previa (OR 1.74, 1.62 to 1.87; n = 7,101,692; 10 studies), placenta accreta (OR 2.95, 1.32 to 6.60; n = 705,108; 3 studies), and placental abruption (OR 1.38, 1.27 to 1.49; n = 5,667,160; 6 studies). This is a comprehensive review adhering to a registered protocol, and guidelines for the Meta-analysis of Observational Studies in Epidemiology were followed, but it is based on predominantly observational data, and in some meta-analyses, between-study heterogeneity is high; therefore, causation cannot be inferred and the results should be interpreted with caution. Conclusions When compared with vaginal delivery, cesarean delivery is associated with a reduced rate of urinary incontinence and pelvic organ prolapse, but this should be weighed against the association with increased risks for fertility, future pregnancy, and long-term childhood outcomes. This information could be valuable in counselling women on mode of delivery. PMID:29360829

Silicone rubber band treatment of rectal prolapse.

PubMed

Jackaman, F R; Francis, J N; Hopkinson, B R

1980-09-01

Fifty-two patients with rectal prolapse have been treated by the silicone rubber band perianal suture technique and satisfactory results have been obtained in 46 (89%). Eleven patients required reoperation to achieve this result. The procedure is a minor one, with little morbidity and no mortality. Provided that faecal impaction can be avoided in patients having this operation a successful outcome, can be expected. It is recommended especially for the frail and elderly with rectal prolapse.

[A case of lipoma of the stomach prolapsing into the duodenal bulb and causing a duodenal ulcer].

PubMed

Yamane, Tateki; Uchiyama, Kan; Furuya, Toru; Ishii, Takayuki; Omura, Nobuo; Nakano, Masataka; Fukamachi, Shinsuke; Suwa, Tatsushi; Okusa, Toshifumi

2009-11-01

We report a case of lipoma in the antrum of the stomach which prolapsed into the duodenal bulb and caused a duodenal ulcer, which was speculated to have been induced by the friction of its tip against the duodenal mucosa. Although the duodenal ulcer healed after the administration of a proton pump inhibitor, the symptoms of epigastric discomfort continued, which was suggested to be due to the prolapse. Therefore, a laparoscopic operation was conducted. The incidence of lipoma of the stomach is rare, and cases of its prolapse into the duodenum are few. Furthermore, it is extremely rare for it to cause a duodenal ulcer. Because these features made this case clinically interesting, we report it here.

Nigeria task force alerts public to fistula hazards.

PubMed

1994-01-01

Nigeria's National Task Force on Vesico-vaginal Fistula has published a booklet to draw public attention to the problem of fistulae. The 20-page booklet explains how fistulae happen and what can be done to prevent them. It makes clear that early marriage and early pregnancy are major causes of fistulae that lead to the social rejection of many young women. The booklet tells the story of two girls in a series of color pictures with accompanying text in Hausa and English. One girl is given in marriage to an older man at the age of nine, becomes pregnant before she is fully grown, suffers obstructed labor, is denied obstetric care and is left with a vesico-vaginal fistula. With urine leaking from her bladder through her vagina, she smells constantly of urine and is thrown out of the house by her husband. Her parents also reject her and she is reduced to begging until one day she hears of a hospital where fistulae can be repaired. After the repair she is warned that if she has any more babies they must be delivered in a hospital. The other girl is not given away in marriage but goes to school, graduates from university and marries a man of her choice. She becomes pregnant only when her body is fully developed, attends the antenatal clinic, has an easy labor and safe delivery. full text

Complex anal fistulas: plug or flap?

PubMed

Muhlmann, Mark D; Hayes, Julian L; Merrie, Arend E H; Parry, Bryan R; Bissett, Ian P

2011-10-01

Rectal mucosal advancement flaps (RMAF) and fistula plugs (FP) are techniques used to manage complex anal fistulas. The purpose of this study was to review and compare the results of these methods of repair. A retrospective review of all complex anal fistulas treated by either a RMAF or a FP at Auckland City Hospital from 2004 to 2008. Comparisons were made in terms of successful healing rates, time to failure and the use of magnetic resonance imaging. Overall, 70 operations were performed on 55 patients (55.7% male). The mean age was 44.9 years. Twenty-one patients (30%) had had at least one previous unsuccessful repair. Indications for repair included 57 high cryptoglandular anal (81%), 4 Crohn's anal (6%), 7 rectovaginal (10%), 1 rectourethral (1%) and 1 pouch-vaginal fistula (1%). All patients were followed up with a mean of 4.5 months. Forty-eight RMAFs (69% of total) were performed with 16 successful repairs (33%). Twenty-two FPs (31% of total) were performed with 7 successful repairs (32%, P = 0.9). In failed repairs, there was no difference in terms of mean time to failure (RMAF 4.8 months versus FP 4.1 months, P = 0.62). Magnetic resonance imaging was performed in 21 patients (37%) before the repair. The success rate in these patients was 20%. The results of treatment of complex anal fistulas are disappointing. The choice of operation of either a RMAF or a FP did not alter the poor healing rates of about one third of patients in each group.