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Wang X, Zhuang X, Zhang L, Lu Y. Changes in bowel symptoms after different pelvic organ prolapse surgeries among elderly women at the 1-year follow up. Int J Gynaecol Obstet 2023; 163:854-861. [PMID: 37465949 DOI: 10.1002/ijgo.14966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 06/30/2023] [Accepted: 06/10/2023] [Indexed: 07/20/2023]
Abstract
OBJECTIVE To investigate the prevalence of bowel symptoms in patients with pelvic organ prolapse (POP), to evaluate the changes in bowel symptoms after different POP surgeries, and to identify risk factors for unrelieved bowel symptoms. METHODS This was an observational prospective cohort study conducted at Peking University First Hospital from 2020 to 2021. Demographic, clinical, and therapeutic data were collected. Participants underwent POP Quantification examination and completed the Pelvic Floor Distress Inventory-20 questionnaire at baseline and 1 year postoperatively. RESULTS The prevalence of bowel symptoms and bothersome bowel symptoms in women with POP was 46.38% and 24.40%, respectively. Surgical correction of prolapse was associated with significant relief in bowel symptoms (P < 0.05). Colpocleisis may relieve bowel symptoms better than reconstructive surgeries (41% vs. 31%, P = 0.048). However, 35% of women had at least one bowel symptom at the 1-year follow up. A long perineal body (Pb) and levator ani muscle injury were found to be predictors of unrelieved bowel symptoms in patients undergoing colpocleisis and those undergoing reconstructive surgery, respectively (odds ratio [OR] 2.306, 95% confidence interval [CI] 1.112-4.783, P = 0.025 and OR 3.245, 95% CI 1.266-8.317, P = 0.014, respectively), and perineoplasty was a protective factor for women who underwent colpocleisis (OR 0.102, 95% CI 0.025-0.417, P = 0.001) CONCLUSION: Women with POP have a high prevalence of bowel symptoms. Although bowel symptoms can be relieved after POP surgeries, one-third of women still experience bowel symptoms. A long Pb and levator ani muscle injury were associated with unrelieved bowel symptoms, while perineoplasty was a protective factor.
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Affiliation(s)
- Xiaoxiao Wang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Xinrong Zhuang
- Department of Obstetrics and Gynecology, Affiliated Hospital of Chengde Medical University, HeBei, China
| | - Lei Zhang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
| | - Ye Lu
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing, China
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Ferrari L, Cuinas K, Hainsworth A, Darakhshan A, Schizas A, Kelleher C, Williams AB. Preoperative predictors of success after transvaginal rectocoele repair. Tech Coloproctol 2023; 27:859-866. [PMID: 37212926 DOI: 10.1007/s10151-023-02822-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 05/04/2023] [Indexed: 05/23/2023]
Abstract
PURPOSE Determine predictors of success for transvaginal rectocoele repair (TVRR). Primary aim is to establish predictors of successful treatment analysing patients' characteristics, baseline symptoms, pelvic floor test results and pre-operative conservative treatment. METHODS Retrospective single institution study in a tertiary referral centre for pelvic floor disorders. 207 patients underwent TVRR for symptomatic rectocoele. Information about symptoms related to obstructive defaecation, anal incontinence and vaginal prolapse, results of pelvic floor investigations, multimodality conservative management and variation in surgical technique have been recorded. Symptom related information have been collected at surgical follow-up. RESULTS 115 patients had residual symptoms after surgical repair of rectocoele, while 97 were symptoms free. Factors associated with residual symptoms after surgical repair are previous proctological procedures, urge AI symptoms, absence of vaginal bulge symptoms, use of transanal irrigation and having a concomitant enterocoele repair during procedure. CONCLUSION Factors able to predict a less favourable outcome after TVRR in patients with concomitant ODS are previous proctological procedures, presence of urge AI, short anal canal length on anorectal physiology, seepage on defaecating proctography, use of transanal irrigation, absence of vaginal bulge symptoms and enterocoele repair during surgery. These information are important for a tailored decision making process and to manage patients' expectations before surgical repair.
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Affiliation(s)
- Linda Ferrari
- Pelvic Floor Unit, Mitchener Ward, St Thomas' Hospital, Guy's and St Thomas NHS Foundation Trust, Westminster Bridge Road, London, SE17EH, UK.
| | - Karina Cuinas
- Pelvic Floor Unit, Mitchener Ward, St Thomas' Hospital, Guy's and St Thomas NHS Foundation Trust, Westminster Bridge Road, London, SE17EH, UK
| | - Alison Hainsworth
- Pelvic Floor Unit, Mitchener Ward, St Thomas' Hospital, Guy's and St Thomas NHS Foundation Trust, Westminster Bridge Road, London, SE17EH, UK
| | - Amir Darakhshan
- Pelvic Floor Unit, Mitchener Ward, St Thomas' Hospital, Guy's and St Thomas NHS Foundation Trust, Westminster Bridge Road, London, SE17EH, UK
| | - Alexis Schizas
- Pelvic Floor Unit, Mitchener Ward, St Thomas' Hospital, Guy's and St Thomas NHS Foundation Trust, Westminster Bridge Road, London, SE17EH, UK
| | - Cornelius Kelleher
- Pelvic Floor Unit, Mitchener Ward, St Thomas' Hospital, Guy's and St Thomas NHS Foundation Trust, Westminster Bridge Road, London, SE17EH, UK
| | - Andrew Brian Williams
- Pelvic Floor Unit, Mitchener Ward, St Thomas' Hospital, Guy's and St Thomas NHS Foundation Trust, Westminster Bridge Road, London, SE17EH, UK
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Martoccia A, Al Salhi Y, Fuschi A, Rera OA, Suraci PP, Scalzo S, Antonioni A, Valenzi FM, Sequi MB, De Nunzio C, Lombardo R, Sciarra A, Di Pierro G, Bozzini G, Asimakopoulos AD, Finazzi Agrò E, Zucchi A, Gubiotti M, Cervigni M, Carbone A, Pastore AL. Robot-Assisted Sacrocolpopexy versus Trans-Vaginal Multicompartment Prolapse Repair: Impact on Lower Bowel Tract Function. Biomedicines 2023; 11:2105. [PMID: 37626605 PMCID: PMC10452351 DOI: 10.3390/biomedicines11082105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/05/2023] [Accepted: 07/21/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND This study evaluated the effectiveness, safety, and possible changes in bowel symptoms after multicompartment prolapse surgery by comparing two different surgical approaches, transvaginal mesh surgery with levatorplasty (TVMLP) and robot-assisted sacrocolpopexy (RSC). METHODS All patients underwent pelvic (POP-Q staging system) and rectal examination to evaluate anal sphincter tone in the lithotomy position with the appropriate Valsalva test. The preoperative evaluation included urodynamics and pelvic magnetic resonance defecography. Patient Global Impression of Improvement (PGI-I) at follow-up measured subjective improvement. All patients completed Agachan-Wexner's questionnaire at 0 and 12 months of follow-up to evaluate bowel symptoms. RESULTS A total of 73 cases were randomized into the RSC group (36 cases) and TVMLP group (37 cases). After surgery, the main POP-Q stage in both groups was stage I (RCS 80.5% vs. TVMLP 82%). There was a significant difference (p < 0.05) in postoperative anal sphincter tone: 35%. The TVMLP group experienced a hypertonic anal sphincter, while none of the RSC group did. Regarding subjective improvement, the median PGI-I was 1 in both groups. At 12 months of follow-up, both groups exhibited a significant improvement in bowel symptoms. CONCLUSIONS RSC and TVMLP successfully corrected multicompartment POP. RSC showed a greater improvement in the total Agachan-Wexner score and lower bowel symptoms.
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Affiliation(s)
- Alessia Martoccia
- Urology Unit, Department of Medical-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, “Sapienza” University of Rome, 04100 Latina, Italy; (A.M.); (Y.A.S.); (A.F.); (O.A.R.); (P.P.S.); (S.S.); (A.A.); (F.M.V.); (M.B.S.); (M.C.); (A.C.)
| | - Yazan Al Salhi
- Urology Unit, Department of Medical-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, “Sapienza” University of Rome, 04100 Latina, Italy; (A.M.); (Y.A.S.); (A.F.); (O.A.R.); (P.P.S.); (S.S.); (A.A.); (F.M.V.); (M.B.S.); (M.C.); (A.C.)
| | - Andrea Fuschi
- Urology Unit, Department of Medical-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, “Sapienza” University of Rome, 04100 Latina, Italy; (A.M.); (Y.A.S.); (A.F.); (O.A.R.); (P.P.S.); (S.S.); (A.A.); (F.M.V.); (M.B.S.); (M.C.); (A.C.)
| | - Onofrio Antonio Rera
- Urology Unit, Department of Medical-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, “Sapienza” University of Rome, 04100 Latina, Italy; (A.M.); (Y.A.S.); (A.F.); (O.A.R.); (P.P.S.); (S.S.); (A.A.); (F.M.V.); (M.B.S.); (M.C.); (A.C.)
| | - Paolo Pietro Suraci
- Urology Unit, Department of Medical-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, “Sapienza” University of Rome, 04100 Latina, Italy; (A.M.); (Y.A.S.); (A.F.); (O.A.R.); (P.P.S.); (S.S.); (A.A.); (F.M.V.); (M.B.S.); (M.C.); (A.C.)
| | - Silvio Scalzo
- Urology Unit, Department of Medical-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, “Sapienza” University of Rome, 04100 Latina, Italy; (A.M.); (Y.A.S.); (A.F.); (O.A.R.); (P.P.S.); (S.S.); (A.A.); (F.M.V.); (M.B.S.); (M.C.); (A.C.)
| | - Alice Antonioni
- Urology Unit, Department of Medical-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, “Sapienza” University of Rome, 04100 Latina, Italy; (A.M.); (Y.A.S.); (A.F.); (O.A.R.); (P.P.S.); (S.S.); (A.A.); (F.M.V.); (M.B.S.); (M.C.); (A.C.)
| | - Fabio Maria Valenzi
- Urology Unit, Department of Medical-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, “Sapienza” University of Rome, 04100 Latina, Italy; (A.M.); (Y.A.S.); (A.F.); (O.A.R.); (P.P.S.); (S.S.); (A.A.); (F.M.V.); (M.B.S.); (M.C.); (A.C.)
| | - Manfredi Bruno Sequi
- Urology Unit, Department of Medical-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, “Sapienza” University of Rome, 04100 Latina, Italy; (A.M.); (Y.A.S.); (A.F.); (O.A.R.); (P.P.S.); (S.S.); (A.A.); (F.M.V.); (M.B.S.); (M.C.); (A.C.)
| | - Cosimo De Nunzio
- Department of Urology, Sant’Andrea Hospital, Sapienza University of Rome, 00189 Rome, Italy; (C.D.N.); (R.L.)
| | - Riccardo Lombardo
- Department of Urology, Sant’Andrea Hospital, Sapienza University of Rome, 00189 Rome, Italy; (C.D.N.); (R.L.)
| | - Alessandro Sciarra
- Policlinico Umberto I, Department of Urology, Sapienza University of Rome, 00161 Rome, Italy; (A.S.); (G.D.P.)
| | - Giovanni Di Pierro
- Policlinico Umberto I, Department of Urology, Sapienza University of Rome, 00161 Rome, Italy; (A.S.); (G.D.P.)
| | - Giorgio Bozzini
- Department of Urology, ASST Lariana-Sant’Anna Hospital, 22100 Como, Italy;
| | - Anastasios D. Asimakopoulos
- Urology Unit, Fondazione PTV Policlinico Tor Vergata University Hospital, 00133 Rome, Italy; (A.D.A.); (E.F.A.)
| | - Enrico Finazzi Agrò
- Urology Unit, Fondazione PTV Policlinico Tor Vergata University Hospital, 00133 Rome, Italy; (A.D.A.); (E.F.A.)
| | | | | | - Mauro Cervigni
- Urology Unit, Department of Medical-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, “Sapienza” University of Rome, 04100 Latina, Italy; (A.M.); (Y.A.S.); (A.F.); (O.A.R.); (P.P.S.); (S.S.); (A.A.); (F.M.V.); (M.B.S.); (M.C.); (A.C.)
| | - Antonio Carbone
- Urology Unit, Department of Medical-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, “Sapienza” University of Rome, 04100 Latina, Italy; (A.M.); (Y.A.S.); (A.F.); (O.A.R.); (P.P.S.); (S.S.); (A.A.); (F.M.V.); (M.B.S.); (M.C.); (A.C.)
| | - Antonio Luigi Pastore
- Urology Unit, Department of Medical-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, “Sapienza” University of Rome, 04100 Latina, Italy; (A.M.); (Y.A.S.); (A.F.); (O.A.R.); (P.P.S.); (S.S.); (A.A.); (F.M.V.); (M.B.S.); (M.C.); (A.C.)
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Sun G, de Haas RJ, Trzpis M, Broens PMA. A possible physiological mechanism of rectocele formation in women. Abdom Radiol (NY) 2023; 48:1203-1214. [PMID: 36745205 PMCID: PMC10115871 DOI: 10.1007/s00261-023-03807-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 02/07/2023]
Abstract
BACKGROUND We aimed to determine the anorectal physiological factors associated with rectocele formation. METHODS Female patients (N = 32) with severe constipation, fecal incontinence, or suspicion of rectocele, who had undergone magnetic resonance defecography and anorectal function tests between 2015 and 2021, were retrospectively included for analysis. The anorectal function tests were used to measure pressure in the anorectum during defecation. Rectocele characteristics and pelvic floor anatomy were determined with magnetic resonance defecography. Constipation severity was determined with the Agachan score. Information regarding constipation-related symptoms was collected. RESULTS Mean rectocele size during defecation was 2.14 ± 0.88 cm. During defecation, the mean anal sphincter pressure just before defecation was 123.70 ± 67.37 mm Hg and was associated with rectocele size (P = 0.041). The Agachan constipation score was moderately correlated with anal sphincter pressure just before defecation (r = 0.465, P = 0.022), but not with rectocele size (r = 0.276, P = 0.191). During defecation, increased anal sphincter pressure just before defecation correlated moderately and positively with straining maneuvers (r = 0.539, P = 0.007) and defecation blockage (r = 0.532, P = 0.007). Rectocele size correlated moderately and positively with the distance between the pubococcygeal line and perineum (r = 0.446, P = 0.011). CONCLUSION Increased anal sphincter pressure just before defecation is correlated with the rectocele size. Based on these results, it seems important to first treat the increased anal canal pressure before considering surgical rectocele repair to enhance patient outcomes.
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Affiliation(s)
- Ge Sun
- Anorectal Physiology Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30 001, 9700 RB, Groningen, The Netherlands
| | - Robbert J de Haas
- Department of Radiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30 001, 9700 RB, Groningen, The Netherlands
| | - Monika Trzpis
- Anorectal Physiology Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30 001, 9700 RB, Groningen, The Netherlands.
| | - Paul M A Broens
- Anorectal Physiology Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30 001, 9700 RB, Groningen, The Netherlands.,Division of Pediatric Surgery, Department of Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30 001, 9700 RB, Groningen, The Netherlands
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Thorsen AJ. Management of Rectocele with and without Obstructed Defecation. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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The Effect of Preoperative Fiber on Postoperative Bowel Function After Pelvic Reconstructive Surgery: A Randomized Controlled Trial. Female Pelvic Med Reconstr Surg 2022; 28:554-560. [PMID: 35649241 DOI: 10.1097/spv.0000000000001203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
IMPORTANCE There are limited studies evaluating the effect of preoperative interventions on postoperative bowel function after prolapse surgery. OBJECTIVE The objective of this study was to evaluate if preoperative fiber intake reduces time to first bowel movement after surgery for pelvic organ prolapse. STUDY DESIGN We performed a randomized controlled trial of women undergoing pelvic organ prolapse surgery between July 2019 and May 2021. Participants were recruited at their preoperative visit and randomized to receive either 3.4 g psyllium fiber supplementation twice a day for 1 week before surgery or no fiber supplementation before surgery. Postoperative bowel regimen was standardized for both groups. Participants completed a bowel diary for their first postoperative bowel movement after surgery characterized by the Bristol Stool Scale and any associated pain or urgency. The primary outcome was time to first bowel movement. Secondary outcomes included pain associated with first bowel movement. RESULTS Eighty-four patients were enrolled in the study. Seventy-one patients had complete data for primary analysis, with 35 patients in the intervention group and 36 patients in the control group. Demographic and perioperative characteristics were similar between the groups. There was no difference found between the groups with respect to time to first bowel movement (control: 68.3 [SD, 25] hours vs intervention: 66.5 [SD, 23] hours, P = 0.749). There was no difference found with pain associated with first bowel movement (visual analog scale median [interquartile range] control: 2.0 [0.0-4.0] vs intervention: 2.0 [1.0-4.0]; P = 0.655). CONCLUSIONS Preoperative fiber supplementation before prolapse surgery does not improve time to first bowel movement after surgery.
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The impact of transvaginal, mesh-augmented level one apical repair on anorectal dysfunction due to pelvic organ prolapse. Int Urogynecol J 2022; 33:3261-3273. [DOI: 10.1007/s00192-022-05151-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 02/18/2022] [Indexed: 12/12/2022]
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Cortes ARB, Hayashi T, Nomura M, Sawada Y, Tokiwa S, Nagae M. Medium term anatomical and functional outcomes following modified laparoscopic sacrocolpopexy. Int Urogynecol J 2022; 33:3111-3121. [PMID: 35089412 DOI: 10.1007/s00192-022-05076-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/26/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION AND HYPOTHESIS We evaluated the anatomical and functional outcomes following modified laparoscopic sacrocolpopexy (LSC) utilizing deep dissection of the vaginal walls and distal mesh fixation at the anterior and posterior compartments. We hypothesized that anatomical and functional outcomes improve after this modified LSC technique. METHODS This was a retrospective study of all women (n = 240) who underwent LSC for pelvic organ prolapse (POP) from January to December 2017 in a tertiary center. POP-Q staging, validated questionnaires (International Consultation on Incontinence Questionnaire-Short Form [ICIQ-SF] and Pelvic Floor Distress Inventory Questionnaire-Short Form), and uroflowmetry were used to evaluate the anatomical and functional outcomes. Statistical analyses were performed using McNemar test and repeated measures analysis of variance with Fisher's least significant difference post hoc (p < 0.05). RESULTS The anatomical success rate is 96%, with a prolapse recurrence rate of 3.8% at 3-year follow-up. Bulge symptoms and anatomical compartments were significantly improved after LSC. Clinically, there were significant improvements after LSC in voiding dysfunction and bowel symptoms. Also, there was a significant increase in stress urinary incontinence and non-significant decrease in mixed urinary incontinence and urge urinary incontinence. ICIQ-SF and Colorectal-Anal Distress Inventory 8 scores were significantly lower after LSC, signifying improvement in incontinence and bowel symptoms. CONCLUSION Our modified LSC technique is safe and effective in restoring level 1 and level 2 supports, without adverse effects on urinary and bowel function. Bladder and bowel symptoms have also been found to keep improving over time.
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Affiliation(s)
- Auran Rosanne B Cortes
- Urogynecology Center, Kameda Medical Center, 929 Higashicho, Kamogawa, Chiba, 296-0041, Japan. .,Department of Obstetrics and Gynecology, Dr. Paulino J. Garcia Memorial Research and Medical Center, Mabini Street Extension, Cabanatuan City, Nueva Ecija, 3100, Philippines.
| | - Tokumasa Hayashi
- Urogynecology Center, Kameda Medical Center, 929 Higashicho, Kamogawa, Chiba, 296-0041, Japan
| | - Masayoshi Nomura
- Urogynecology Center, Kameda Medical Center, 929 Higashicho, Kamogawa, Chiba, 296-0041, Japan
| | - Yugo Sawada
- Urogynecology Center, Kameda Medical Center, 929 Higashicho, Kamogawa, Chiba, 296-0041, Japan
| | - Shino Tokiwa
- Urogynecology Center, Kameda Medical Center, 929 Higashicho, Kamogawa, Chiba, 296-0041, Japan
| | - Mika Nagae
- Urogynecology Center, Kameda Medical Center, 929 Higashicho, Kamogawa, Chiba, 296-0041, Japan
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BEDEL A, AGOSTINI PA, NETTER DA, PIVANO DA, Caroline DRAMBEAUD, TOURETTE DC. Midline Rectovaginal Fascial Plication: Anatomical and Functional Outcomes at One Year. J Gynecol Obstet Hum Reprod 2022; 51:102327. [DOI: 10.1016/j.jogoh.2022.102327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 01/16/2022] [Accepted: 01/24/2022] [Indexed: 11/30/2022]
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d'Altilia N, Mancini V, Falagario U, Chirico M, Illiano E, Balzarro M, Annese P, Busetto GM, Bettocchi C, Cormio L, Sanguedolce F, Schiavina R, Brunocilla E, Costantini E, Carrieri G. Are Two Meshes Better than One in Sacrocolpopexy for Pelvic Organ Prolapse? Comparison of Single Anterior versus Anterior and Posterior Vaginal Mesh Procedures. Urol Int 2021; 106:282-290. [PMID: 34839298 DOI: 10.1159/000519818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 09/20/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Sacrocolpopexy (SC) is the main treatment option for the repair of anterior and apical pelvic organ prolapse (POP). Indications and technical aspects are not standardized, and the question remains whether it is necessary to place a mesh on both anterior and posterior vaginal walls, particularly in cases with only minor or no posterior compartment prolapse. The present study aimed to compare the anatomical and functional outcomes of single anterior mesh only versus anterior and posterior mesh procedures in SC. MATERIALS AND METHODS Our prospectively maintained database on POP was used to identify patients who had undergone either abdominal or mini-invasive SC from January 2006 to October 2019. Patients with symptomatic or unmasked stress urinary incontinence (SUI) were not included in the study and were treated using the pubo-vaginal cystocele sling procedure. Objective outcomes included clinical evaluation of pre-existing or de novo POP by the halfway system and POP-q classifications, as well as the development of de novo SUI. Subjective outcomes were assessed using the Pelvic Floor Impact Questionnaire (PFIQ-7) with questions on bladder, bowel, and vaginal functions. Persistent or de novo constipation and overactive bladder were defined as bowel symptoms and urinary urgency/frequency/urinary incontinence after surgery. RESULTS Ninety-five women with symptomatic anterior and apical POP underwent SC. Forty-one patients were treated with only anterior vaginal mesh (group A), and 54 with anterior and posterior mesh (group B). There were no differences between the pre- and post-operative characteristics of the 2 groups. In group B, there were 2 blood transfusions, 1 wound dehiscence, and 3 mesh erosions/extrusion after abdominal SC (Clavien-Dindo II), and in group A, there was 1 ileal lesion after laparoscopic SC (Clavien-Dindo III). There were no differences between the 2 groups in either anatomical or functional outcomes during 3 years of follow-up. CONCLUSIONS SC with single anterior vaginal mesh has similar results to SC with combined anterior/posterior mesh, regardless of the surgical approach. The single anterior mesh may reduce the risk of complications (mesh erosion/extrusion), and offers better subjective outcomes with improved quality of life. Anterior/posterior mesh may be justified in the presence of clinically significant posterior POP.
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Affiliation(s)
- Nicola d'Altilia
- Department of Urology and Renal Transplantation, University of Foggia, Policlinico Riuniti di Foggia, Foggia, Italy
| | - Vito Mancini
- Department of Urology and Renal Transplantation, University of Foggia, Policlinico Riuniti di Foggia, Foggia, Italy
| | - Ugo Falagario
- Department of Urology and Renal Transplantation, University of Foggia, Policlinico Riuniti di Foggia, Foggia, Italy
| | - Marco Chirico
- Department of Urology and Renal Transplantation, University of Foggia, Policlinico Riuniti di Foggia, Foggia, Italy
| | - Ester Illiano
- Andrology and Urogynecology Clinic, Santa Maria Terni Hospital, University of Perugia, Perugia, Italy
| | - Matteo Balzarro
- Department of Urology, University of Verona, Azienda Ospedaliero-Universitaria, Verona, Italy
| | - Pasquale Annese
- Department of Urology and Renal Transplantation, University of Foggia, Policlinico Riuniti di Foggia, Foggia, Italy
| | - Gian Maria Busetto
- Department of Urology and Renal Transplantation, University of Foggia, Policlinico Riuniti di Foggia, Foggia, Italy
| | - Carlo Bettocchi
- Department of Urology and Renal Transplantation, University of Foggia, Policlinico Riuniti di Foggia, Foggia, Italy
| | - Luigi Cormio
- Department of Urology and Renal Transplantation, University of Foggia, Policlinico Riuniti di Foggia, Foggia, Italy
| | - Francesca Sanguedolce
- Department of Pathology, University of Foggia, Policlinico Riuniti di Foggia, Foggia, Italy
| | - Riccardo Schiavina
- Department of Urology, University of Bologna, S-Orsola-Malpighi Hospital, Bologna, Italy
| | - Eugenio Brunocilla
- Department of Urology, University of Bologna, S-Orsola-Malpighi Hospital, Bologna, Italy
| | - Elisabetta Costantini
- Andrology and Urogynecology Clinic, Santa Maria Terni Hospital, University of Perugia, Perugia, Italy
| | - Giuseppe Carrieri
- Department of Urology and Renal Transplantation, University of Foggia, Policlinico Riuniti di Foggia, Foggia, Italy
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Harvey MA, Chih HJ, Geoffrion R, Amir B, Bhide A, Miotla P, Rosier PFWM, Offiah I, Pal M, Alas AN. International Urogynecology Consultation Chapter 1 Committee 5: relationship of pelvic organ prolapse to associated pelvic floor dysfunction symptoms: lower urinary tract, bowel, sexual dysfunction and abdominopelvic pain. Int Urogynecol J 2021; 32:2575-2594. [PMID: 34338825 DOI: 10.1007/s00192-021-04941-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/11/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION AND HYPOTHESIS This article from Chapter 1 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) establishes the prevalence of lower urinary tract disorders, bowel symptoms, vulvo-vaginal/lower abdominal/back pain and sexual dysfunction in women with POP. METHODS An international group of nine urogynecologists/urologists and one medical student performed a search of the literature using pre-specified search terms in Ovid, MEDLINE, Embase and CINAHL from January 2000 to March 2019. Publications were eliminated if not relevant or they did not include clear definitions of POP or the symptoms associated with POP. Definitions of POP needed to include both a physical examination finding using a validated examination technique and the complaint of a bothersome vaginal bulge. Symptoms were categorized into symptom groups for ease of evaluation. The Specialist Unit for Review Evidence (SURE) was used to evaluate for quality of the included articles. The resulting list of articles was used to determine the prevalence of various symptoms in women with POP. Cohort studies were used to evaluate for possible causation of POP as either causing or worsening the symptom category. RESULTS The original search yielded over 12,000 references, of which 50 were used. More than 50% of women with POP report lower urinary tract symptoms. Cohort studies suggest that women with POP have more obstructive lower urinary tract symptoms than women without POP. Pain described in various ways is frequently reported in women with POP, with low back pain being the most common pain symptom reported in 45% of women with POP. In cohort studies those with POP had more pain complaints than those without POP. Sexual dysfunction is reported by over half of women with POP and obstructed intercourse in 37-100% of women with POP. Approximately 40% of women have complaints of bowel symptoms. There was no difference in the median prevalence of bowel symptoms in those with and without POP in cohort studies. CONCLUSIONS The prevalence of lower urinary tract disorders, bowel symptoms, vulvo-vaginal/lower abdominal/back pain and sexual dysfunction in women with POP are common but inconsistently reported. There are few data on incidence of associated symptoms with POP, and cohort studies evaluating causality are rare or inconsistent. Obstructive voiding, lower abdominal and pelvic pain, and sexual dysfunction are most frequently associated with POP.
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Affiliation(s)
- Marie-Andrée Harvey
- Department of Obstetrics and Gynecology Queen's University, Victory 4, Kingston Health Science Centre, 76 Stuart St, Kingston, Ontario, K7L 2V7, Canada.
| | - Hui Ju Chih
- Department of Obstetrics and Gynecology Queen's University, Victory 4, Kingston Health Science Centre, 76 Stuart St, Kingston, Ontario, K7L 2V7, Canada
| | - Roxana Geoffrion
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, Canada
| | - Baharak Amir
- Department of Obstetrics & Gynecology, Division of Urogynecology and Pelvic Floor Surgery, Dalhousie University, Halifax, Canada
| | - Alka Bhide
- Department of Obstetrics and Gynecology, Imperial College Healthcare NHS Trust, London, UK
| | - Pawel Miotla
- 2nd Department of Gynecology, Medical University of Lublin, Lublin, Poland
| | - Peter F W M Rosier
- Department of Urology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ifeoma Offiah
- Department Obstetrics and Gynecology, Derriford Hospital Healthcare, NHS Trust, Plymouth, UK
| | - Manidip Pal
- Department of Obstetrics and Gynecology College of Medicine & JNM Hospital, WBUHS, Kalyani, India
| | - Alexandriah Nicole Alas
- Department of Obstetrics and Gynecology, University of Texas Health Sciences, San Antonio, TX, USA
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Kikuchi JY, Muñiz KS, Handa VL. Surgical Repair of the Genital Hiatus: A Narrative Review. Int Urogynecol J 2021; 32:2111-2117. [PMID: 33606054 DOI: 10.1007/s00192-021-04680-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION AND HYPOTHESIS An enlarged genital hiatus (GH) is associated with the development of prolapse and may be associated with prolapse recurrence following surgery; however, there is insufficient evidence to support surgical reduction of the GH as prophylaxis against future prolapse. The objective of this review is (1) to review the association between GH size and pelvic organ prolapse and (2) to discuss the existing literature on surgical procedures that narrow the GH. METHODS A literature search was performed in the PubMed search engine, using the keyword "genital hiatus." Articles were included if they addressed any of the following topics: (1) normative GH values; (2) associations between the GH and prolapse development or recurrence; (3) surgical alteration of the GH; (4) indications, risks or benefits of surgical alteration of the GH. RESULTS An enlarging GH has been observed prior to the development of prolapse. Multiple studies show that an enlarged pre- and/or postoperative GH is associated with an increased risk of recurrent prolapse following prolapse repair surgery. There are limited data on the specific risks of GH alteration related to bowel and sexual function. CONCLUSIONS GH size and prolapse appear to be strongly associated. Because GH size appears to be a risk factor for pelvic organ prolapse, the GH size should be carefully considered at the time of surgery. Surgeons should discuss with their patients the risks and potential benefits of additional procedures designed to reduce GH size.
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Affiliation(s)
- Jacqueline Y Kikuchi
- Department of Gynecology and Obstetrics, Division of Female Pelvic Medicine and Reconstructive Surgery, Johns Hopkins University School of Medicine, 4940 Eastern Ave, Baltimore, MD, 21224, USA.
| | - Keila S Muñiz
- Department of Gynecology and Obstetrics, Division of Female Pelvic Medicine and Reconstructive Surgery, Johns Hopkins University School of Medicine, 4940 Eastern Ave, Baltimore, MD, 21224, USA
| | - Victoria L Handa
- Department of Gynecology and Obstetrics, Division of Female Pelvic Medicine and Reconstructive Surgery, Johns Hopkins University School of Medicine, 4940 Eastern Ave, Baltimore, MD, 21224, USA
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Early postpartum physical activity and pelvic floor support and symptoms 1 year postpartum. Am J Obstet Gynecol 2021; 224:193.e1-193.e19. [PMID: 32798462 DOI: 10.1016/j.ajog.2020.08.033] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/27/2020] [Accepted: 08/11/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Risks of pelvic organ prolapse and urinary incontinence increase after the first vaginal delivery. During the early postpartum period, a time of active regeneration and healing of the pelvic floor, women may be particularly vulnerable to greater pelvic floor loading. OBJECTIVE This prospective cohort study aimed to determine whether objectively measured moderate to vigorous physical activity in the early postpartum period predicts pelvic floor support and symptoms 1 year after the first vaginal birth. STUDY DESIGN We enrolled nulliparous women in the third trimester, later excluding those who had a cesarean or preterm delivery. Participants wore triaxial wrist accelerometers at 2 to 3 weeks and 5 to 6 weeks postpartum for ≥4 days. Primary outcomes, assessed 1 year postpartum, included (1) pelvic floor support on Pelvic Organ Prolapse Quantification examination, dichotomized as maximal vaginal descent of <0 cm (better support) vs ≥0 cm (worse support); and (2) pelvic floor symptom burden, considered positive with report of ≥1 bothersome symptom in ≥2 of 6 domains, assessed using the Epidemiology of Prolapse and Incontinence Questionnaire. The primary predictor was average daily moderate to vigorous physical activity. Because we could not eliminate women with pelvic floor changes before pregnancy, we modeled prevalence, rather than risk, ratios for each outcome using modified Poisson regression. RESULTS Of 825 participants eligible after delivery, 611 completed accelerometry and 1-year follow-up; 562 completed in-person visits, and 609 completed questionnaires. The mean age was 28.9 years (standard deviation, 5.01). The mean for moderate to vigorous physical activity measured in minutes per day was 57.3 (standard deviation, 25.4) and 68.1 (standard deviation, 28.9) at 2 to 3 weeks and 5 to 6 weeks, respectively. One year postpartum, 53 of 562 participants (9.4%) demonstrated worse vaginal support and 330 of 609 participants (54.2%) met criteria for pelvic floor symptom burden. In addition, 324 (53.1%), 284 (46.6%), 144 (23.6%), and 25 (4.1%) reported secondary outcomes of stress urinary incontinence, overactive bladder, anal incontinence, and constipation, respectively, and 264 (43.4%), 250 (41.0%), and 89 (14.6%) reported no, mild, or moderate to severe urinary incontinence, respectively. The relationship between moderate to vigorous physical activity and outcomes was not linear. On the basis of plots, we grouped quintiles of moderate to vigorous physical activity into 3 categories: first and second quintiles combined, third and fourth quintiles combined, and fifth quintile. In final multivariable models, compared with women in moderate to vigorous physical activity quintiles 3 and 4, those in the lower 2 (prevalence ratio, 0.55; 95% confidence interval, 0.31-1.00) and upper quintile (prevalence ratio, 0.70; 95% confidence interval, 0.35-1.38)) trended toward lower prevalence of worse support. However, we observed the reverse for symptom burden: compared with women in quintiles 3 and 4, those in the lower 2 (prevalence ratio, 1.20; 95% confidence interval, 1.02-1.41) and upper quintile prevalence ratio 1.34 (95% confidence interval, 1.11-1.61) demonstrated higher prevalence of symptom burden. Moderate to vigorous physical activity did not predict any of the secondary outcomes. The presence of a delivery factor with potential to increase risk for levator ani muscle injury did not modify the effect of moderate to vigorous physical activity on outcomes. CONCLUSION Except for support, which was worse in women with moderately high levels of activity, early postpartum moderate to vigorous physical activity was either protective or had no effect on other parameters of pelvic floor health. Few women performed substantial vigorous activity, and thus, these results do not apply to women performing strenuous exercise shortly after delivery.
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Genital Prolapse Surgery: What Options Do We Have in the Age of Mesh Issues? J Clin Med 2021; 10:jcm10020267. [PMID: 33450901 PMCID: PMC7828306 DOI: 10.3390/jcm10020267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/08/2021] [Accepted: 01/11/2021] [Indexed: 12/16/2022] Open
Abstract
Here, we describe the current laparoscopic procedures for prolapse surgery and report data based on the application of these procedures. We also evaluate current approaches in vaginal prolapse surgery. Debates concerning the use of meshes have seriously affected vaginal surgery and threaten to influence reconstructive laparoscopic surgery as well. We describe the option of using autologous tissue in combination with the laparoscopic approach. Study data and problematic issues concerning the existing techniques are highlighted, and future options addressed.
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Noé GK, Schiermeier S, Papathemelis T, Fuellers U, Khudyakov A, Altmann HH, Borowski S, Morawski PP, Gantert M, De Vree B, Tkacz Z, Ugarteburu RG, Anapolski M. Prospective International Multicenter Pelvic Floor Study: Short-Term Follow-Up and Clinical Findings for Combined Pectopexy and Native Tissue Repair. J Clin Med 2021; 10:jcm10020217. [PMID: 33435323 PMCID: PMC7827325 DOI: 10.3390/jcm10020217] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/06/2021] [Accepted: 01/07/2021] [Indexed: 12/27/2022] Open
Abstract
Efforts to use traditional native tissue strategies and reduce the use of meshes have been made in several countries. Combining native tissue repair with sufficient mesh applied apical repair might provide a means of effective treatment. The study group did perform and publish a randomized trial focusing on the combination of traditional native tissue repair with pectopexy or sacrocolpopexy and observed no severe or hitherto unknown risks for patients (Noé G.K. J Endourol 2015;29(2):210–215). The short-term follow-up of this international multicenter study carried out now is presented in this article. Material and Methods: Eleven clinics and 13 surgeons in four European counties participated in the trial. In order to ensure a standardized approach and obtain comparable data, all surgeons were obliged to follow a standardized approach for pectopexy, focusing on the area of fixation and the use of a prefabricated mesh (PVDF PRP 3 × 15 Dynamesh). The mesh was solely used for apical repair. All other clinically relevant defects were treated with native tissue repair. Colposuspension or TVT were used for the treatment of incontinence. Data were collected independently for 14 months on a secured server; 501 surgeries were registered and evaluated. Two hundred and sixty-four patients out of 479 (55.1%) returned for the physical examination and interview after 12–18 months. Main Outcome and Results: The mean duration of follow-up was 15 months. The overall success of apical repair was rated positively by 96.9%, and the satisfaction score was rated positively by 95.5%. A positive general recommendation was expressed by 95.1% of patients. Pelvic pressure was reduced in 95.2%, pain in 98.0%, and urgency in 86.0% of patients. No major complications, mesh exposure, or mesh complication occurred during the follow-up period. Conclusion: In clinical routine, pectopexy and concomitant surgery, mainly using native tissue approaches, resulted in high satisfaction rates and favorable clinical findings. The procedure may also be recommended for use by general urogynecological practitioners with experience in laparoscopy.
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Affiliation(s)
- Günter K. Noé
- Department of Obstetrics and Gynecology, University of Witten-Herdecke, Rheinlandclinics Dormagen, 41540 Dormagen, Germany;
- Correspondence:
| | - Sven Schiermeier
- Department of Obstetrics and Gynecology, University Witten-Herdecke, 258452 Witten, Germany;
| | - Thomas Papathemelis
- Department of Obstetrics and Gynecology, St. Marien Hospital Amberg, 92224 Amberg, Germany;
| | - Ulrich Fuellers
- Private Department of Surgical Gynecology, Krefeld (GTK) Germany, 47800 Krefeld, Germany; (U.F.); (A.K.)
| | - Alexander Khudyakov
- Private Department of Surgical Gynecology, Krefeld (GTK) Germany, 47800 Krefeld, Germany; (U.F.); (A.K.)
| | - Harald-Hans Altmann
- Department of Obstetrics and Gynecology, Regiomed Clinics Coburg, 96450 Coburg, Germany;
| | - Stefan Borowski
- Department of Obstetrics and Gynecology, Clinic Links der Weser, 28277 Bremen, Germany;
| | - Pawel P. Morawski
- Department of Obstetrics and Gynecology, Helios Clinic Bad Sarow, 15526 Bad Saarow, Germany;
| | - Markus Gantert
- Department of Obstetrics and Gynecology, St. Franziskus Hospital Ahlen, 59227 Ahlen, Germany;
| | - Bart De Vree
- Department of Obstetrics and Gynecology, ZNA Middelheim Antwerp, 2020 Antwerpen, Belgium;
| | - Zbigniew Tkacz
- Department of Obstetrics and Gynecology, NHS Tayside Dundee, Dundee DD1 9SY, UK;
| | - Rodrigo Gil Ugarteburu
- Department of Obstetrics and Gynecology, University Hospital de Cabueñes, 33394 Gijon, Spain;
| | - Michael Anapolski
- Department of Obstetrics and Gynecology, University of Witten-Herdecke, Rheinlandclinics Dormagen, 41540 Dormagen, Germany;
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American Urogynecologic Society Best-Practice Statement on Evaluation of Obstructed Defecation. Female Pelvic Med Reconstr Surg 2019; 24:383-391. [PMID: 30365459 DOI: 10.1097/spv.0000000000000635] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The symptoms of constipation and obstructed defecation are common in women with pelvic floor disorders. Female pelvic medicine and reconstructive surgery specialists evaluate and treat women with these symptoms, with the initial consultation often occurring when a woman has the symptom or sign of posterior compartment pelvic organ prolapse (including rectocele or enterocele) or if a rectocele or enterocele is identified in pelvic imaging. This best-practice statement will review techniques used to evaluate constipation and obstructed defecation, with a special focus on the relationship between obstructed defecation, constipation, and pelvic organ prolapse.
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Gillor M, Langer S, Dietz HP. Long-term subjective, clinical and sonographic outcomes after native-tissue and mesh-augmented posterior colporrhaphy. Int Urogynecol J 2019; 30:1581-1585. [DOI: 10.1007/s00192-019-03921-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 03/05/2019] [Indexed: 12/26/2022]
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Posterior Compartment Surgery Provides No Differential Benefit for Defecatory Symptoms Before or After Concomitant Mesh-Augmented Apical Suspension. Female Pelvic Med Reconstr Surg 2019; 24:183-187. [PMID: 29319557 DOI: 10.1097/spv.0000000000000538] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to determine the value of posterior compartment surgery during concomitant mesh-augmented apical suspension by comparing obstructed defecatory symptoms after laparoscopic sacrocolpopexy (LSC) with LSC with posterior repair (LSC + PR) and laparoscopic sacrocolpoperineopexy (LSCP) procedures. METHODS This was a retrospective cohort study of women who underwent LSC, LSC + PR, and LSCP between July 2007 and July 2016 at a tertiary referral center in Indianapolis, Ind. Our primary outcome was differential change in Colorectal-Anal Distress Inventory (CRADI-8) and Colorectal-Anal Impact Questionnaire (CRAIQ-7) scores between the groups including patient-specific symptoms of splinting, straining, incomplete emptying, and pain with defecation. Our secondary outcomes were the rates of postoperative persistent, new, and resolved obstructed defecation symptoms. Anatomic outcomes were also compared between the groups as measured by change in Pelvic Organ Prolapse Quantification System points Ap, GH, and PB. RESULTS A total of 312 women were included in the study (47 LSC, 133 LSC + PR, and 132 LSCP), with a median follow-up time of 366 days. The majority of patients who underwent surgery had stage III pelvic organ prolapse (61%). Baseline demographics were similar between groups, including preoperative CRADI-8 and CRAIQ-7 scores. All surgical groups demonstrated improvement in CRADI-8 and CRAIQ-7 scores postoperatively (P < 0.001). However, despite differential change in Pelvic Organ Prolapse Quantification System points Ap, GH, and PB, there was no change in CRADI-8 and CRAIQ-7 scores or rates of persistent, new, and resolved symptoms of splinting to defecate, incomplete emptying, and pain with defecation between the groups. The only factor that seemed to be differentially improved by the addition of a posterior compartment repair was postoperative straining. There was a greater rate of de novo straining in the LSC group compared with LSCP (P = 0.01) (LSC + PR v LSCP, P = NS, for both). CONCLUSIONS We cannot recommend posterior compartment surgery as providing any patient-centered benefit beyond improved cosmesis because the addition of perineal body stabilization either before (LSCP) or posterior repair after (LSC + PR) concomitant mesh-augmented apical suspension did not differentially affect bowel symptoms compared with LSC alone.
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Grossi U, Horrocks EJ, Mason J, Knowles CH, Williams AB. Surgery for constipation: systematic review and practice recommendations: Results IV: Recto-vaginal reinforcement procedures. Colorectal Dis 2017; 19 Suppl 3:73-91. [PMID: 28960924 DOI: 10.1111/codi.13781] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
AIM To assess the outcomes of recto-vaginal reinforcement procedures in adults with chronic constipation. METHOD Standardised methods and reporting of benefits and harms were used for all CapaCiTY reviews that closely adhered to PRISMA 2016 guidance. Main conclusions were presented as summary evidence statements with a summative Oxford Centre for Evidence-Based Medicine (2009) level. RESULTS Forty-three articles were identified, providing data on outcomes in 3346 patients. Average length of procedures ranged between 20 and 169 min, and length of stay between 1 and 15 days. Complications typically occurred after 7-17% of procedures (range 0-61%). Post-operative bleeding was uncommon (0-4%) as well as haematoma or sepsis (0-2%). Fistulation did not occur in most studies. Two procedure-related deaths were observed for 3209 patients. Although inconsistent, 78% of patients reported a satisfactory or good outcome, with 30-50% experiencing reduced symptoms of straining, incomplete emptying or reduced vaginal digitation. About 17% of patients developed anatomical recurrence. Considering measures of harm and global satisfaction rating scales, there was insufficient evidence to prefer one type of procedure over another. There was no evidence to support better outcomes based on selection of patients with a particular size or grade of rectocoele. CONCLUSION Evidence supporting recto-vaginal reinforcement procedures is currently derived from observational studies and comparisons, with only one high quality study. Large trials are needed to inform future clinical decision making.
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Affiliation(s)
- U Grossi
- National Bowel Research Centre, Blizard Institute, Queen Mary University of London, London, UK
| | - E J Horrocks
- National Bowel Research Centre, Blizard Institute, Queen Mary University of London, London, UK
| | - J Mason
- Health Economics, University of Warwick, Coventry, UK
| | - C H Knowles
- National Bowel Research Centre, Blizard Institute, Queen Mary University of London, London, UK
| | - A B Williams
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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- National Institute for Health Research: Chronic Constipation Treatment Pathway, London, UK
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- Affiliate section of the Association of Coloproctology of Great Britain and Ireland, London, UK
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Abstract
Pelvic floor dysfunction and fecal incontinence is a common and debilitating condition in women, particularly as women age, and often goes under-reported to health care providers. It is important for providers to ask patients about possible symptoms. An algorithm for evaluation and treatment is presented. Current and future therapies are described and discussed.
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Grimes CL, Overholser RH, Xu R, Tan-Kim J, Nager CW, Dyer KY, Menefee SA, Diwadkar GB, Lukacz ES. Measuring the impact of a posterior compartment procedure on symptoms of obstructed defecation and posterior vaginal compartment anatomy. Int Urogynecol J 2016; 27:1817-1823. [PMID: 27230408 DOI: 10.1007/s00192-016-3046-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 05/05/2016] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND HYPOTHESIS We hypothesized that there would be a significant difference in changes in obstructed defecation symptoms and posterior compartment prolapse between women who underwent posterior vaginal wall prolapse repair (PR) and those who did not. METHODS This was a two-site prospective cohort study of women undergoing prolapse or incontinence surgery in which a PR was, or was not, performed at the discretion of the surgeon. Women were assessed using validated obstructed defecation questionnaires and standardized examination measures (including POP-Q, measurement of transverse gh, and assessment for a rectovaginal pocket and laxity) prior to pelvic surgery and 12 weeks after surgery. RESULTS Of 68 women who underwent surgery, 43 had PR. The PR group had higher obstructed defecation symptoms and greater posterior compartment prolapse at baseline. At 12 weeks, obstructed defecation symptoms had improved significantly more in the PR group than in the no PR group (all p < 0.03). Anatomic outcomes showed greater improvement in point Bp in the PR group (-3.4 vs. -0.7 no PR, p < 0.001) and resolution of the rectovaginal pocket (86 % vs. 42 %, p = 0.002). There were no significant changes in obstructed defecation symptoms or anatomic outcomes from baseline in the no PR group, while the PR group showed significantly improved obstructed defecation symptoms and anatomic outcomes after repair (p < 0.001 for both). CONCLUSIONS Significant improvements in obstructed defecation symptoms and posterior compartment prolapse were seen after PR, but not in women who did not receive PR. Obstructed defecation symptoms, Bp and rectovaginal pocket were the measures best able to demonstrate improvement after PR. We recommend the use of these measures to assess the impact of surgery in the posterior compartment.
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Affiliation(s)
- Cara L Grimes
- Department of Obstetrics and Gynecology, Columbia University Medical Center, 622 West 168th Street, PH 16, Room 127, New York, NY, 10032, USA.
| | - Rosanna H Overholser
- San Diego Clinical and Translational Research Institute, UC San Diego Health System, San Diego, CA, USA
| | - Ronghui Xu
- Department of Family and Preventive Medicine and Department of Mathematics, UC San Diego Health System, San Diego, CA, USA
| | - Jasmine Tan-Kim
- Division of Female Pelvic Medicine and Reconstructive Surgery, Kaiser Permanente, San Diego, CA, USA
| | - Charles W Nager
- Department of Reproductive Medicine, Division of Female Pelvic Medicine and Reconstructive Surgery, UC San Diego Health System, La Jolla, CA, USA
| | - Keisha Y Dyer
- Division of Female Pelvic Medicine and Reconstructive Surgery, Kaiser Permanente, San Diego, CA, USA
| | - Shawn A Menefee
- Division of Female Pelvic Medicine and Reconstructive Surgery, Kaiser Permanente, San Diego, CA, USA
| | - Gouri B Diwadkar
- Division of Female Pelvic Medicine and Reconstructive Surgery, Kaiser Permanente, San Diego, CA, USA
| | - Emily S Lukacz
- Department of Reproductive Medicine, Division of Female Pelvic Medicine and Reconstructive Surgery, UC San Diego Health System, La Jolla, CA, USA
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Brown H, Grimes C. Current Trends in Management of Defecatory Dysfunction, Posterior Compartment Prolapse, and Fecal Incontinence. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2016; 5:165-171. [PMID: 27547494 DOI: 10.1007/s13669-016-0148-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
While it would be our hope to report that there have been significant gains in the understanding of the correlation between the posterior vaginal compartment and defecatory dysfunction in the last year, this is not the case. Instead, we review the highlights of management of posterior vaginal compartment and defecatory dysfunction including 1) defining and understanding the patient's symptoms; 2) considering systemic disorders, motility dysfunction, and mechanical causes that may be contributing; 3) encouraging conservative management as first-line therapy; and 4) recognizing which surgical options are likely to improve specific symptoms. This is then followed by an update on treatment options for fecal incontinence, which we now prefer to refer to as accidental bowel leakage. We are able to report on five exciting and innovative treatment approaches for accidental bowel leakage. As the scientific community increases focus on patient-centered outcomes, we are likely on the verge of having a greater understanding of how treatment options for posterior compartment prolapse and defecatory dysfunction can improve patient symptoms. This year, we can report that strong evidence based recommendations simply do not exist, and this area is ripe for future investigation.
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Affiliation(s)
- Heidi Brown
- University of Wisconsin-Madison School of Medicine & Public Health, Departments of Obstetrics & Gynecology and Urology, Female Pelvic Medicine & Reconstructive Surgery Section, 600 Highland Avenue, Box 6188 (H4/656), Madison, WI 53792, , Fax:
| | - Cara Grimes
- Columbia University Medical Cnter, Department of Obstetrics and Gynecology, Section of Female Pelvic Medicine and Reconstructive Surgery, 622 West 168 Street, PH 16, Room 127, New York, NY 10032, Phone:212-305-0189
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Bergman I, Söderberg MW, Kjaeldgaard A, Ek M. Does the choice of suture material matter in anterior and posterior colporrhaphy? Int Urogynecol J 2016; 27:1357-65. [DOI: 10.1007/s00192-016-2981-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Accepted: 02/10/2016] [Indexed: 11/29/2022]
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Abstract
Pelvic organ prolapse is highly prevalent, and negatively affects a woman’s quality of life. Women with bothersome prolapse may be offered pessary management or may choose to undergo corrective surgery. In choosing the most appropriate surgical procedure, there are many factors to consider. These may include the location(s) of anatomic defects, the severity of prolapse symptoms, the activity level of the woman, and concerns regarding the durability of the repair. In many instances, women and their surgeons are challenged to weigh the risks and benefits of native tissue versus mesh-augmented repairs. Though mesh-augmented repairs may offer better durability, they are also associated with unique complications, such as mesh erosion. Furthermore, newer surgical techniques of mesh placement via abdominal or vaginal routes may result in different outcomes compared to traditional techniques. Biologic grafts may also be considered to improve durability of a surgical repair, while avoiding potential complications of synthetic mesh. In this article, we review many of the clinical challenges that gynecologic surgeons face in the surgical management of vaginal prolapse. Furthermore, we review data that can help guide decision making when treating women with pelvic organ prolapse.
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Affiliation(s)
- Nazema Y Siddiqui
- Division of Urogynecology and Reconstructive Surgery, Duke University Medical Center, Durham, NC, USA
| | - Autumn L Edenfield
- Division of Urogynecology and Reconstructive Surgery, Duke University Medical Center, Durham, NC, USA
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Sung VW, Rardin CR, Raker CA, LaSala CA, Myers DL. Changes in bowel symptoms 1 year after rectocele repair. Am J Obstet Gynecol 2012; 207:423.e1-5. [PMID: 22835490 PMCID: PMC3484201 DOI: 10.1016/j.ajog.2012.06.054] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 04/30/2012] [Accepted: 06/27/2012] [Indexed: 02/07/2023]
Abstract
OBJECTIVE We sought to evaluate changes in bowel symptoms after rectocele repair and identify risk factors for persistent symptoms. STUDY DESIGN We conducted ancillary analysis of a randomized surgical trial for rectocele repair. Subjects underwent examinations and completed questionnaires for bowel symptoms at baseline and 12 months postoperatively. Outcomes included resolution, persistence, or de novo bowel symptoms. We used multiple logistic regression to identify risk factors for bowel symptom persistence. RESULTS A total of 160 women enrolled: 139 had baseline bowel symptoms and 85% had 12-month data. The prevalence of bowel symptoms decreased after rectocele repair (56% vs 23% splinting, 74% vs 37% straining, 85% vs 19% incomplete evacuation, 66% vs 14% obstructive defecation; P < .001 for all). On multiple logistic regression, a longer history of splinting was a risk factor for persistent postoperative splinting (adjusted odds ratio, 2.25; 95% confidence interval, 1.02-4.93). CONCLUSION Bowel symptoms may improve after rectocele repair, but almost half of women will have persistent symptoms.
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Affiliation(s)
- Vivian W Sung
- Division of Urogynecology, Department of Obstetrics and Gynecology, Alpert Medical School of Brown University, Providence, RI, USA
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Functional bowel disorders and pelvic organ prolapse: a case-control study. Female Pelvic Med Reconstr Surg 2012; 16:209-14. [PMID: 22453343 DOI: 10.1097/spv.0b013e3181e4f270] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES : To compare the relative frequencies of constipation and other functional bowel disorders between patients with and without pelvic organ prolapse (POP). METHODS : This was a case-control study design. Cases were patients with stage 3-4 POP presenting to a urogynecology clinic and controls were patients presenting to a general gynecology or women's health clinic for annual examinations with stage 0-1 vaginal support. Constipation disorders were defined using responses to the Rome II Modular Questionnaire for functional bowel disorders as well as predefined defecatory disorders. RESULTS : 128 cases and 127 controls were enrolled. After controlling for race, education, and comorbidities, women with POP were more likely to report symptoms consistent with outlet constipation, including straining during a bowel movement (odds ratio [OR] 3.9, confidence interval [CI] 2.1-7.3), feeling of incomplete rectal emptying (OR 4.0, CI 2.1-7.7), a sensation that stool cannot be passed (OR 3.4, CI 1.7-6.7), and splinting (OR 2.7, CI 1.3-5.7). In spite of this, cases were just as likely to meet the criteria for functional constipation or irritable bowel syndrome (IBS) with constipation as controls but more likely to meet the criteria for IBS-any type (OR 3.8, CI 1.6-9.1) as women with POP reported more discomfort or pain in the abdomen (OR 3.4 CI 1.6-7.1) and >3 bowel movements per day (OR 2.9, CI 1.3-6.3). CONCLUSIONS : Patients with POP are more likely to have symptoms of outlet constipation and other functional bowel disorders compared with patients without POP. The Rome II criteria may not be an appropriate classification system for functional bowel disorders in patients with advanced POP.
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Gomelsky A, Dmochowski RR. Posterior-compartment repair: a urology perspective. Urol Clin North Am 2012; 39:371-6. [PMID: 22877720 DOI: 10.1016/j.ucl.2012.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The prevalence of posterior-compartment prolapse (rectocele) is not known. The authors have found that operative repair symptomatically improved a majority of patients with impaired defecation associated with a large rectocele, but this improvement was likely related at least in part to factors other than the size of the rectocele. Multiple surgical techniques are available for rectocele repair, and the literature is not clear regarding indications for each type of surgical intervention. This article reviews the literature regarding various types of posterior-compartment repair, and draws conclusions regarding their absolute efficacy and relative efficacy in comparison with one another.
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Affiliation(s)
- Alex Gomelsky
- Department of Urology, Louisiana State University Health Sciences Center, Shreveport, LA 71130, USA.
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Porcine subintestinal submucosal graft augmentation for rectocele repair: a randomized controlled trial. Obstet Gynecol 2012; 119:125-33. [PMID: 22183220 DOI: 10.1097/aog.0b013e31823d407e] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To estimate the effect of porcine subintestinal submucosal graft augmentation on improving anatomic and subjective rectocele repair outcomes compared with native tissue repair. METHODS We conducted a randomized controlled trial at two sites, including women with at least stage 2 symptomatic rectocele. Anatomic and subjective outcomes (vaginal bulge and defecatory) were collected 12 months postoperatively, including blinded Pelvic Organ Prolapse Quantification (POP-Q) examinations. Anatomic failure was defined as points Ap or Bp -1 or greater on POP-Q. Subjective failure was defined as no improvement or worsening of symptoms. We estimated number needed to treat and adjusted odds ratios (ORs). Assuming graft use is associated with 93% anatomic success, 63 women per group would be needed to detect a 20% difference at α=.05 and β=.20. RESULTS One hundred sixty women were randomized; 137 had 12-month anatomic data (67 graft; 70 control). There was no difference in anatomic failure (12% compared with 9%, P=.5), vaginal bulge symptom failure (3% compared with 7%, P=.4, number needed to treat=26) or defecatory symptom failure (44% compared with 45%, P=.9, number needed to treat=91) for graft compared with control, respectively. Both groups reported improvement in vaginal bulge and defecatory symptoms (P<.05 for all). On multiple logistic regression, graft use was not associated with a decreased odds of anatomic failure (adjusted OR 1.36, 95% confidence interval [CI] 0.44-4.25), vaginal bulge symptoms (adjusted OR 0.46, 95% CI 0.08-2.68), or defecatory symptoms (adjusted OR 0.98, 95% CI 0.48-2.03). CONCLUSION Although rectocele repair by either approach is associated with improved symptoms, subintestinal submucosal graft augmentation was not superior to native tissue for anatomic or subjective outcomes at 12 months. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, www.clinicaltrials.gov, NCT00321867.
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Transischioanal trans-sacrospinous ligament rectocele repair with polypropylene mesh: a prospective study with assessment of rectoanal function. Int Urogynecol J 2012; 24:81-9. [DOI: 10.1007/s00192-012-1813-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2011] [Accepted: 04/22/2012] [Indexed: 11/25/2022]
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Letouzey V, Panel L, Courtieu C. [Rectocele repair with porcine dermal collagen implant associated with infracoccygeal sacropexy]. Prog Urol 2012; 22:240-4. [PMID: 22516787 DOI: 10.1016/j.purol.2012.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 12/12/2011] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate an infracoccygeal colpopexy procedure by tension-free synthetic tape for vaginal apical prolapse associated with a posterior mesh procedure using porcine dermal graft for rectocele repair. METHODS A retrospective study concerning 35 women. The surgical procedure included rectocele repair with porcine dermal collagen implant (porcine dermal matrix, native) associated with transgluteal infracoccygeal sacropexy using a polypropylene sling. RESULTS Median follow up was 48 months (42-54). A vaginal hysterectomy was associated in 43% and a cure of cystocele was associated in 63% of cases. No intra-operative complication was noted. The prevalence of dyschesia decreased from 25% (eight patients) preoperatively to 3% (one patient) postoperatively. No cases of de novo dyspareunia was noted. Five (14%) patients had a recurrent prolapse (two cases of rectocele stage 2, one case of grade 3 rectocele associated with a cystocele, a case of uterine prolapse associated with cystocele and one case of recurrent isolated uterine prolapse). Among them, three patients (9%) required a re-intervention for prolapse recurrence. No vaginal mesh exposure was observed. Perineal pain was reported by 12 (33%) patients at one month follow-up, but no patient complained with perineal pain one year follow-up. CONCLUSION Infracoccygeal sacropexy associated with rectocele repair using porcine dermal collagen implant was associated with satisfactory results at medium term follow-up.
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Affiliation(s)
- V Letouzey
- Service de gynécologie obstétrique, CHU Caremeau, place du Professeur-Robert-Debré, 30000 Nîmes cedex, France.
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Grimes CL, Lukacz ES. Posterior vaginal compartment prolapse and defecatory dysfunction: are they related? Int Urogynecol J 2012; 23:537-51. [PMID: 22222672 DOI: 10.1007/s00192-011-1629-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Accepted: 12/06/2011] [Indexed: 02/07/2023]
Abstract
While posterior vaginal compartment prolapse and defecatory dysfunction are highly prevalent conditions in women with pelvic floor disorders, the relationship between anatomy and symptoms, specifically obstructed defecation, is incompletely understood. This review discusses the anatomy of the posterior vaginal compartment and definitions of defecatory dysfunction and obstructed defecation. A clinically useful classification system for defecatory dysfunction is highlighted. Available tools for the measurement of symptoms, physical findings, and imaging in women with posterior compartment prolapse are discussed. Based on a critical review of the literature, we investigate and summarize whether posterior compartment anatomy correlates with function. Definitions of obstructed defecation and significant posterior compartment prolapse are proposed for future exploration.
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Affiliation(s)
- Cara L Grimes
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Reproductive Medicine, University of California-San Diego, La Jolla, CA, USA.
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Dua A, Radley S, Brown S, Jha S, Jones G. The effect of posterior colporrhaphy on anorectal function. Int Urogynecol J 2011; 23:749-53. [PMID: 22113259 DOI: 10.1007/s00192-011-1603-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Accepted: 10/28/2011] [Indexed: 01/24/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The objective of this study is to determine the effect of posterior colporrhaphy on bowel symptoms. METHODS Comprehensive pelvic floor data were collected prospectively for 60 women undergoing posterior colporrhaphy. The electronic Personal Assessment Questionnaire-Pelvic Floor (ePAQ-PF) was completed at initial assessment and 3-6 months post-operatively. The bowel dimension of ePAQ-PF computes domain scores for IBS, constipation, evacuation, continence and QoL on a scale of 0-100. Preoperative bowel domain scores were compared with post-operative scores (Student t test). RESULTS Significant improvement was seen in bowel evacuation (42%), continence (37%) and bowel-related QoL (61%) scores. IBS score improved by 28%, but this did not reach significance. There was no significant change noted in constipation (0.5%). All individual symptoms relating to bowel evacuation and continence improved significantly other than painful evacuation and incontinence to solid stool. CONCLUSIONS Bowel evacuation and continence improve significantly 3-6 months following posterior colporrhaphy and are associated with parallel improvement in QoL.
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Affiliation(s)
- Anupreet Dua
- Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Glossop Road, Sheffield, S10 2SF, UK.
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Patel M, O’Sullivan DM, LaSala CA. Constipation symptoms before and after vaginal and abdominal pelvic reconstructive surgery. Int Urogynecol J 2011; 22:1413-9. [DOI: 10.1007/s00192-011-1489-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 06/14/2011] [Indexed: 01/14/2023]
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Goes JCS, Bates D. Periareolar mastopexy with FortaPerm. Aesthetic Plast Surg 2010; 34:350-8. [PMID: 20336456 DOI: 10.1007/s00266-009-9462-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2009] [Accepted: 11/16/2009] [Indexed: 01/06/2023]
Abstract
BACKGROUND Recurrent ptosis is a common sequel of mastopexy. The use of mesh as an adjunct to the double-skin technique was developed to reduce the incidence of recurrent ptosis. The optimal mesh needs to strike the right balance between persistence, inflammation, biocompatibility, and incorporation without interfering with mammography or presenting a long-term infection risk. This study investigated the ability of a biologic tissue matrix, FortaPerm, to achieve these goals. METHODS Women undergoing mastopexy were enrolled in this prospective observational study. The study participants were evaluated at multiple time points for 5 years. Efficacy was assessed primarily by photographic evaluation and secondarily by mammography, patient and physician global assessments, and patient pain assessments. RESULTS Five women ages 17-41 years were enrolled in this study. At 12 months, 80% of the patients (4/5), and at 5 years, 66% of the patients (2/3) had no asymmetry or ptosis. Mammographic evaluation of the breasts was not affected by the presence of the FortaPerm, and there were no abnormal findings. In two patients, FortaPerm was associated with bilateral seromas associated with extrusion of small amounts of the FortaPerm material in the absence of surrounding inflammation. CONCLUSIONS FortaPerm achieved excellent initial aesthetic outcomes and long-term maintenance of the breast position with no evidence of ptosis 5 years postoperatively for a majority of the patients. FortaPerm did not interfere with mammography, presented no long-term safety concerns, and produced satisfactory results for all patients relative to appearance of the scar as well as shape and firmness of the breasts.
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Cortesse A, Haab F, Costa P, Delmas V. [Cure of rectocele by vaginal way]. Prog Urol 2009; 19:1080-5. [PMID: 19969279 DOI: 10.1016/j.purol.2009.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Accepted: 10/26/2009] [Indexed: 12/22/2022]
Abstract
Rectocele is a rectal hernia through the posterior vaginal wall. There is three levels of rectocele. High rectocele is caused by the uterosacral and cardinal ligaments stretching; it needs prerecti fascia placation with a sacrofixation of an associated prolapsus of uterus or vaginal vault. The middle rectocele is linked with a rectovaginal fascia defect; the preferential choice for middle rectocele is midline fascial plication; superior myoraphy gives dyspareunia. The inferior rectocele results of a destruction of the perineal body; the treatment is a myoraphy with vulvoraphy. Complete rectocele would be an indication for a posterior mesh.
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Affiliation(s)
- A Cortesse
- Service d'Urologie, Hôpital Saint-Louis, AP-HP, 1 Avenue Claude-Vellefaux, 75010 Paris, France.
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Effects of colpocleisis on bowel symptoms among women with severe pelvic organ prolapse. Int Urogynecol J 2009; 21:461-6. [PMID: 19960182 DOI: 10.1007/s00192-009-1062-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Accepted: 11/15/2009] [Indexed: 10/20/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Our objective was to evaluate bowel symptoms after colpocleisis. METHODS This was a planned ancillary analysis of a prospective, colpocleisis cohort study of 152 women. Those with baseline and 1-year questionnaires (Colorectal-Anal Distress Inventory (CRADI) and the Colorectal-Anal Impact Questionnaire (CRAIQ)) were included. "Bothersome" CRADI symptoms (score>2("moderately", "quite a bit")) were identified. CRADI and CRAIQ scores were compared, and postoperative symptom resolution and new symptom development were measured. RESULTS Of 121 (80%) subjects with complete data, mean age was 79.2 +/- 5.4 years and all had stage 3-4 prolapse. Procedures performed: partial colpocleisis (61%), total colpocleisis (39%), levator myorrhaphy (71%), and perineorrhaphy (97%). Bothersome bowel symptom(s) were present in 77% at baseline (obstructive (17-26%), incontinence (12-35%) and pain/irritation (3-34%)). All bothersome obstructive and most bothersome incontinence symptoms were less prevalent 1 year after surgery. CRADI and CRAIQ scores significantly improved. The majority of bothersome symptoms resolved (50-100%) with low rates of de novo symptoms (0-14%). CONCLUSIONS Most bothersome bowel symptoms resolve after colpocleisis, especially obstructive and incontinence symptoms, with low rates of de novo symptoms.
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Abstract
The pelvic floor is a highly complex structure made up of skeletal and striated muscles, support and suspensory ligaments, fascial coverings and an intricate neural network. Its dual role is to provide support for the pelvic viscera (bladder, bowel and uterus) and maintain functional integrity of these organs. In order to maintain good pelvic floor function, this elaborate system must work in a highly integrated manner. When this system if damaged, pelvic floor failure ensues. The aetiology is inevitably multi-factorial, and seldom as a consequence of a single aetiological factor. It can affect one or all the three compartments of the pelvic floor, often resulting in prolapse and functional disturbance of the bladder (urinary incontinence and voiding dysfunction), rectum (faecal incontinence), vagina and/or uterus (sexual dysfunction). This compartmentalisation of the pelvic floor has resulted in the partitioning of patients into urology, colo-rectal surgery or gynaecology, respectively, depending on the patients presenting symptoms. In complete pelvic floor failure, all three compartments are inevitably damaged resulting in apical prolapse, with associated organ dysfunction. It is clear that in this state, the patient needs the clinical input of at least two of the three pelvic floor clinical specialities. Whilst the primary clinical aim is to correct the anatomy, it must also be to preserve or restore pelvic floor function. As a consequence, these patients need careful clinical assessment, appropriate investigations, and counselling before embarking on a well-defined management pathway. The latter includes behavioural and lifestyle changes, conservative treatments (pelvic support pessaries, physiotherapy and biofeedback), pharmacotherapy, minimally invasive surgery (intravaginal slingoplasty, sacrospinous fixation and mid-urethral tapes) and radical specialised surgery (open or laparoscopic sacrocolpopexy). It is not surprising that in this complex group of patients, a multi-disciplinary approach is not only essential, but also critical, if good clinical care and governance is to be ensured.
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El-Azab AS, Abd-Elsayed AA, Imam HM. Patient reported and anatomical outcomes after surgery for pelvic organ prolapse. Neurourol Urodyn 2009; 28:219-24. [DOI: 10.1002/nau.20626] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Jones GL, Radley SC, Lumb J, Farkas A. Responsiveness of the electronic Personal Assessment Questionnaire-Pelvic Floor (ePAQ-PF). Int Urogynecol J 2009; 20:557-64. [DOI: 10.1007/s00192-008-0790-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2008] [Accepted: 12/07/2008] [Indexed: 10/21/2022]
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Savary D, Fatton B, Velemir L, Amblard J, Jacquetin B. [What about transvaginal mesh repair of pelvic organ prolapse? Review of the literature since the HAS (French Health Authorities) report]. ACTA ACUST UNITED AC 2008; 38:11-41. [PMID: 18996650 DOI: 10.1016/j.jgyn.2008.09.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2008] [Revised: 09/14/2008] [Accepted: 09/25/2008] [Indexed: 11/30/2022]
Abstract
The French Health Authorities' (HAS) report of November 2006 concluded that the use of mesh at the time of transvaginal repair of pelvic organ prolapse (POP) should be limited to clinical research. This review intends to analyse and comment the recent data on this topic. A review on PubMed, on a personal database and actualisation until May 2008 has been performed choosing French or English language series concerning prolapse surgery with mesh disposed by the vaginal route. It includes six randomised controlled trials comparing transvaginal repair of POP with or without mesh: four about cystocele, one about rectocele and one about apical prolapse. Both surgical techniques and recurrence criteria are poorly standardised. The four randomised trials focusing on cystocele repair support the anatomical superiority of techniques using mesh, with similar functional results with or without mesh reinforcement. In the other indications, the results remain unclear or controversial. According to the randomised trials, the complications rate, except mesh exposure, is similar with and without mesh. However there are some specific complications when using mesh, such as mesh infection, mesh exposure or shrinkage and visceral extrusion. We recommend using vaginal reinforcement mesh with specific care in selected patients and we suggest some guidelines to be proposed for consensus at concerned French scientific societies.
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Affiliation(s)
- D Savary
- Unité d'urogynécologie, service de maternité, hôpital Hôtel-Dieu, CHU de Clermont-Ferrand, Clermont-Ferrand cedex 1, France.
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Miedel A, Tegerstedt G, Mörlin B, Hammarström M. A 5-year prospective follow-up study of vaginal surgery for pelvic organ prolapse. Int Urogynecol J 2008; 19:1593-601. [PMID: 18696002 DOI: 10.1007/s00192-008-0702-z] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2008] [Revised: 06/03/2008] [Accepted: 07/19/2008] [Indexed: 10/21/2022]
Abstract
The objective of this study was to evaluate anatomic, functional, short- and long-term outcome of vaginal surgery for pelvic organ prolapse. This was a prospective observational study of 185 consecutive women planned for vaginal prolapse reconstructive surgery. Stage of prolapse, urinary incontinence (UI), bowel and mechanical symptoms were assessed preoperatively and at 1, 3 and 5 years postoperatively. The mean follow-up time was 53 months. The anatomic recurrence rate was 41.1% but less than half of them were symptomatic. Anterior compartment was most prone for recurrence and the majority of the recurrences took place within the first year. UI remained at the same level at 1-year follow-up. De novo urge occurred in 22.6% and de novo stress incontinence in 6.0%. An improvement was seen in difficulty in emptying bowel 1 year after surgery (54%). Patients were primarily cured from mechanical symptoms. Re-operation rate was 9.7%; if additional operation for incontinence was included, it was13.5%.
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Affiliation(s)
- Ann Miedel
- Department of Clinical Science and Education, Södersjukhuset, Section of Obstetrics and Gynaecology, Karolinska Institutet, 118 83, Stockholm, Sweden.
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