[Myostimulating effect of comprehensive application of general magnetotherapy, fractional CO2 laser, electro-myostimulation and special complex of exercise in patients with rectoceleal after open-peconstructure]. / Miostimuliruyushchii effekt kompleksnogo primeneniya obshchei magnitoterapii, fraktsionnogo CO2-lazera, elektromiostimulyatsii i spetsial'nogo kompleksa LFK u patsientok s rektotsele posle rekonstruktivno-plasticheskikh operatsii.

The article presents data on the treatment of 200 women of childbearing, peri - and menopausal age with rectocele of II-III degree, which were divided into 4 groups comparable in clinical and functional characteristics: 1-50 patients who, after surgical treatment of rectocele, underwent a complex consisting of a course of General magnetic therapy, 2 intra-vascular procedures of fractional microablative CO2 laser therapy, electromyostimulation with the pelvic floor muscles and a special complex of therapeutic physical education; comparison 1, which included 50 patients who underwent the above-mentioned complex of rehabilitation measures without General magnetotherapy; comparison of 2-50 patients after surgical treatment of rectocele, who in the late postoperative period (one month after the operation) underwent a set of rehabilitation measures, including a course of electromyostimulation with the biological connection of the pelvic floor muscles, consisting of 10 daily procedures and a special complex of physical therapy and a control group - 50 patients after surgical treatment of rectocele, who in the late postoperative period were treated with symptomatic therapy, including painkillers and antispasmodics, which served as a background for all other groups. As a result of the research, it was found that the developed rehabilitation complexes have a pronounced myostimulating effect, and can be recommended for wide use in rehabilitation programs for postoperative management of patients with rectocele.

The relationship between obstructed defecation and true rectocele in patients with pelvic organ prolapse.

We aimed to investigate the prevalence of true rectocele and obstructed defecation (OD) in patients with pelvic organ prolapse (POP), to investigate the correlation between true rectocele and OD, and to understand the diagnostic value of translabial ultrasound (TLUS) in the diagnosis of true rectocele. The patients who scheduled for POP surgery were enrolled in this study. Patients who had previous reconstructive pelvic surgery or repair of rectocele were excluded. Birmingham Bowel and Urinary symptoms questionnaires and Longo's obstructed defecation syndrome scoring system were used to assess the bowel symptoms of patients. TLUS was used to evaluate anatomical defects. P value <0.05 was considered statistically significant, and confidence intervals were set at 95%. 279 patients were included into this study. The prevalence rate of OD was 43%, and the average value of ODS score was 6.67. 17% patients presented straining at stool, 33% presented incomplete emptying, 13% presented digitations, and 12% required laxatives or enema. The prevalence rate of true rectocele was 23%. Defecation symptoms were significantly correlated with age, levator-ani hiatus, levator-ani muscle injury and true rectocele. Logistic regression showed that true rectocele and increased levator-ani hiatus were independent risk factors of OD. True rectocele was significantly correlated with straining at stool, digitation, incomplete emptying and requirement of laxatives or enema.In POP patients, the prevalence rate of true rectocele and OD was 23% and 43%, respectively. True rectocele was related to OD. TLUS was a valuable approach in anatomical evaluation of POP.

Long-term comparison of physiologic anorectal changes and recurrence between transanal repair and transanal repair with posterior colporrhaphy in rectocele.

BACKGROUND: Rectocele is often associated with chronic constipation. Various surgical techniques have been described to repair rectoceles, but the results vary. The aim of this study was to compare the outcomes of transanal repair (TAR) and transanal repair with posterior colporrhaphy (TAR + PC). METHODS: While 44 patients underwent TAR, 49 patients underwent TAR + PC for surgical repair of rectocele. Patients were followed up 3 months post-surgery for anorectal physiological changes. From the entire cohort of patients who underwent the surgical repair, 22 patients who underwent TAR and 25 patients who underwent TAR + PC agreed to participate in the 3-year post-treatment check-up. RESULTS: Out of the 22 patients who underwent TAR, 3 patients (13.6%) scored more than 15 on the constipation scoring system (CSS), while 1 out of 25 patients who underwent TAR + PC scored more than 15 on the CSS 3 months post-treatment, which is considered as recurrence (p = 0.237). With 7 patients from the TAR group (31.8%) and 2 patients from the TAR + PC group (8.0%) showing recurrence of rectocele at 3-year post-treatment follow-up, this study found that TAR + PC had a much lower rate of recurrence than TAR. Furthermore, TAR + PC was found to be more effective than TAR in terms of rectal sensation, sensory threshold (p = 0.001), and early defecation urge (p = 0.003). CONCLUSIONS: TAR + PC can help alleviate some symptoms by restoring the rectal sensation and improving the rectovaginal septum. It can be inferred that the addition of a simple treatment method can lead to a lower rate of recurrence.

Long-term subjective, clinical and sonographic outcomes after native-tissue and mesh-augmented posterior colporrhaphy.

INTRODUCTION AND HYPOTHESIS: Our primary objective was to describe long-term outcomes after posterior colporrhaphy with and without mesh augmentation. METHODS: This was a retrospective study including 93 patients after posterior colporrhaphy (native tissue in 39 and synthetic mesh augmented in 54). The indication was symptoms of prolapse with clinical posterior vaginal wall prolapse. Mesh augmentation and concomitant prolapse operations were performed at the surgeon's discretion. Patients underwent interview, clinical examination and 4D pelvic floor ultrasound. Imaging analysis was done with the reviewer blinded against all other data. Generalized linear modeling was used to compare groups with logistic regression for binary and linear regression for continuous outcomes. RESULTS: Patients were seen on average 5.3 years after surgery and described persistent symptoms of prolapse in 32% and of obstructed defecation in 33%. Clinical recurrence (Bp ≥ -1) was seen in 20%, while sonographic recurrence (rectal ampulla descent to ≥ 15 mm below the symphysis pubis) was noted in 12%. A true rectocele was diagnosed in 33% of patients. No major differences in outcomes were found between those who underwent native tissue and those who had a mesh-augmented repair. CONCLUSIONS: Mesh augmentation was not superior to native tissue posterior colporrhaphy, and both were only moderately effective in eliminating a true rectocele and symptoms of obstructed defecation 5 years after reconstructive surgery.

Resección rectal por vía perineal mediante engrapadora lineal: experiencia inicial de una nueva técnica para el tratamiento del rectocele anterior / Rectal resection perineally via a linear stapler: initial experience of a new technique for the treatment of the anterior rectocele

Introducción: Analizar los resultados a corto y mediano plazo del tratamiento del rectocele anterior mediante la resección rectal transperineal con engrapadora lineal y refuerzo del tabique rectovaginal con malla. Prospectivo de casos consecutivos. Pacientes y método: Entre 01 de abril de 2008 y 31 de Marzo de 2010, 12 pacientes fueron tratados en nuestra institución por presentar diagnóstico de Rectocele Anterior. Los pacientes fueron evaluados por cirujanos entrenados; sometidos a manometría anorrectal y estudios imagenológicos dinámicos. Se realizó una técnica de Resección Rectal por vía perineal con engrapadora lineal y la aplicación de malla. Se aplicaron distintos scores para evaluar los resultados. Resultados: El 100% fueron sexo femenino, edad promedio 44,6 años. El tiempo promedio de cirugía fue 164 minutos (r: 135-180). No hubo complicaciones intraoperatorias. La estadía media hospitalaria fue 2,6 días. La morbilidad fue del 16,6% (2) y no hubo mortalidad relacionada al procedimiento. La evaluación basal del score ODS mostró un promedio de 19.16, mientras el promedio determinado al 7 y 21 día postoperatorio fue 0,5 y 0,16 respectivamente (P = 0,001). La evaluación del estreñimiento usando el score PAC-SYM mostró un resultado basal promedio de 17,08, mientras que al 7 y 21 día postoperatorio fue 3,25 y 1,32 respectivamente (P = 0,002). El cuestionario de Satisfacción a los 6 meses mostró mejoría significativa respecto al valor basal (p = 0,001). Conclusión: Esta nueva técnica permite restaurar el tabique rectovaginal resecando el defecto rectal. Los resultados funcionales obtenidos son favorables, con baja morbilidad y pocas complicaciones relacionadas al uso de mallas. (AU)

Objective: To analyze short and mid-term results of anterior rectocele treatment by trans perineal rectal resection with linear stapler and rectovaginal septum reinforcement with mesh. Patients and methods: Between 01April 2008 and 31 March 2010, 12 patients were treated at our institution with diagnosis of Anterior Rectocele. Patients were evaluated by trained surgeons, underwent anorectal manometry and dynamic images studies. We performed a novel technique called "Stapled Perineal Rectocele resection". Different scores were applied to evaluate the results. Results: 100% were female, average age 44.6 years. The mean surgical time was 164 minutes (r: 135-180). There were no intraoperative complications. The average hospital stay was 2.6 days. The morbidity was 16.6% (2) and there was no procedure-related mortality. Baseline of ODS showed an average score of 19.16, while the average determined at 7 and 21 days postoperatively was 0.5 and 0.16 respectively (P = 0.001). The assessment of constipation using the PAC-SYM score showed a mean baseline of 17.08 results, while at 7 and 21 days after surgery was 3.25 and 1.32 respectively (P = 0.002). The patient satisfaction score after six months showed significant improvement from baseline (p = 0.001). Conclusion: The novel technique restores rectovaginal septum and extirpates the rectal defect. The functional results are favorable, with low morbidity and few complications related to the use of mesh. (AU)

Laparoscopic ventral rectopexy in patients with fecal incontinence associated with rectoanal intussusception: prospective evaluation of clinical, physiological and morphological changes.

BACKGROUND: Physiological changes after laparoscopic ventral rectopexy (LVR) in patients with rectoanal intussusception (RAI) remain unclear. This study was undertaken to evaluate physiological and morphological changes after LVR for RAI, and to study clinical outcomes following LVR with special reference to fecal incontinence (FI). METHODS: The study was conducted on patients who had LVR for RAI between February 2012 and December 2016 at our institution Patients with RAI and FI were included in the study. Patients with RAI and obstructed defecation and those with RAI and neurologic FI were not included. The patients had anorectal manometry preoperatively, and 3, 6, and 12 months postoperatively. Defecography was performed before and 6 months after the procedure. FI was evaluated using the Fecal Incontinence Severity Index (FISI). RESULTS: There were 34 patients (median age 77 years (range 60-93) years). Thirty-two patients (94%) were female and the median number of vaginal deliveries was 2 (range 0-5). Neither maximum resting pressure nor maximum squeeze pressure increased postoperatively. There was an overall increase in both defecatory desire volume (median preoperative 75 ml vs. 90 ml at 12 months; p = 0.002) and maximum tolerated volume (median preoperative 145 ml vs.175 ml at 12 months; p = 0.002). Postoperatively, RAI was eliminated in all patients but one, although 13 had residual rectorectal intussusception found at defecography. There was an overall reduction in both rectocele size (median preop 29 mm vs. postop 10 mm; p = 0.008) and pelvic floor descent (median preop 26 mm vs. postop 20 mm; p = 0.005). Twelve months after surgery, a reduction of at least 50% was observed in the FISI score for 31 incontinent patients (91%). CONCLUSIONS: LVR for RAI produced adequate improvement of FI, and successful anatomical correction of RAI was confirmed by postoperative proctography. Postoperative increase in the rectal volume may have a positive effect on continence.

Rectocele plication: description of a novel surgical technique and review of clinical results.

INTRODUCTION AND HYPOTHESIS: A rectocele is the bulging of the anterior rectal wall into the posterior vaginal compartment. The route of surgical repair can be transvaginal, transrectal or abdominal. The aim of this retrospective study is to describe a novel transvaginal surgical procedure and investigate the associated subjective and objective clinical outcomes. METHODS: Database records were retrieved for all women who underwent a rectocele plication for the period from January 2010 until December 2015 in a referral urogynecology unit with a minimum follow-up period of 12 months. This transvaginal technique entails a plication of the anterior rectal wall by suturing of the rectal muscularis layer. Clinical findings and quality of life (QOL) metrics were evaluated and reported on. RESULTS: One hundred thirty-nine women met the initial inclusion criteria with full data available for 123. The presenting symptoms included a vaginal bulge in 73 (52.5%), overactive bladder (OAB) in 73 (52.5%), obstructed defecation (OD) in 49 (35.3%) and anal incontinence (AI) in 35 (25.2%). The majority of women (n = 72, 51.8%) had stage 3-4 posterior prolapse. The mean follow-up period was 27 ± 15 months. The postoperative symptoms were significantly improved for all, except AI (p = 0.43). There was a significant improvement in posterior prolapse (p < 0.001) with the majority of women noted to have a stage 0 or 1 (n = 109; 88.6%) posterior prolapse at follow-up. CONCLUSIONS: The rectocele plication is a novel surgical technique with good subjective and objective clinical outcomes in the medium term.

Stapled transanal rectal resection with contour transtar for obstructed defecation syndrome: lessons learned after more than 3 years of single-center activity.

BACKGROUND: Obstructed defecation syndrome is a widespread and disabling disease. OBJECTIVE: We aim to evaluate the safety and efficacy of stapled transanal rectal resection performed with a new dedicated curved device in the treatment of obstructed defecation syndrome. DESIGN: A retrospective review of 187 stapled transanal rectal resections performed from June 2007 to February 2011 was conducted. SETTINGS: The entire study was conducted at a university hospital. PATIENTS: : All the patients with symptomatic obstructed defecation syndrome and the presence of a rectocele and/or a rectorectal or rectoanal intussusception, in the absence of sphincter contractile deficiency, were included in the treatment protocol. INTERVENTIONS: All procedures were performed with the use of the Contour Transtar device. We analyzed the functional results of this technique, the incidence and features of the surgical and functional complications, and ways to prevent or treat them. MAIN OUTCOME MEASURES: Constipation was graded by using the Agachan-Wexner constipation score; use of aids to defecate and patient satisfaction were assessed preoperatively and 6 months after surgery. Intraoperative and postoperative complications were also investigated. RESULTS: The constipation intensity was statistically reduced from the preoperative mean value of 15.8 (± 4.9) to 5.2 (± 3.9) at 6 months after surgery (p < 0.0001). Of the 151 (80.3%) patients who took laxatives and the 49 (26.2%) who used enemas before treatment, only 25 (13.2%; p < 0.0001) and 7 (3.7%; p < 0.0001) continued to do so after surgery. None of the 17 (9.1%) patients who had previously helped themselves with digitations needed to continue this practice. Almost all patients showed a good satisfaction rate (3.87/5) after the procedure. LIMITATIONS: Limitations are the short follow-up of 1 year and the design of the study that may introduce potential selection bias. CONCLUSIONS: The results of this study show that stapled transanal rectal resection performed with the use of the Contour Transtar is a safe and effective procedure to treat obstructed defecation syndrome.

[Laparoscopic resection rectopexy as treatment for obstructive defecation syndrome]. / Die laparoskopische Resektionsrektopexie zur Therapie des obstruktiven Defäkationssyndroms.

Anorectal outlet obstruction constitutes one form of chronic constipation. Combinations of morphological alterations of the pelvis, the pelvic floor and the colorectum are nearly always evident. The goal of the diagnostic work-up is to identify those patients who will profit from a surgical intervention. Resection rectopexy aims at restoring the physiological anatomy thereby ameliorating the functional interaction of structures effected with the laparoscopic approach entailing all advantages of minimally invasive surgery. Besides a detailed description of the surgical technique used and an algorithm for indications to operate we present our results after 19 years of experience. Throughout this period, 264 laparoscopic resection rectopexies for outlet obstruction were performed. With a mean follow-up of 58.2 months the rate of improvement of obstructive symptoms was 79.5 % (n = 128 of 161 available for follow-up). Present studies suggest that (laparoscopic) resection rectopexy entails better results in comparison to non-resecting procedures and procedures with the implantation of allogenic material. Certainly, in order to achieve these results a correct patient selection and an expertise in laparoscopic surgery are essential. Both the perioperative and the functional results of our own collective fortify the advantages of laparoscopic resection rectopexy in patients with an outlet obstruction.

Prevalence of and risk factors for pelvic organ prolapse and lower urinary tract symptoms among women in rural Nepal.

OBJECTIVE: To evaluate the prevalence and associated risk factors of pelvic organ prolapse (POP) and lower urinary tract symptoms (LUTS) among women seeking healthcare services in 3 discrete rural areas in Nepal. METHODS: A cross-sectional study was conducted using a Nepalese-specific questionnaire to obtain demographic and personal information. Urinary symptoms were examined using the Urogenital Distress Inventory Short form questionnaire, while POP severity was staged according to the POP-Q system. The χ(2) test and multivariate logistic regression analysis were used to determine POP risk factors. RESULTS: Of the 174 women included in the analysis, 106 (60.9%) had stage II POP or greater. In all, 93 women (53.4%) had cystocele, 63 (36.2%) had rectocele, and 37 (21.3%) had uterine prolapse. Univariate analysis identified high parity; young age at first delivery; menopause; squatting or standing position during delivery; and early return to work after delivery as risk factors for POP. Multivariate logistic regression revealed that delivery in a lying position presented a lower risk for cystocele than squatting or standing (odds ratio 0.34; P<0.01). CONCLUSION: Both LUTS and POP are common among women in rural Nepal. Cystocele is the most frequent, advanced, and symptomatic form of POP observed in this population.

Influence of age, mode of delivery and parity on the prevalence of posterior pelvic floor dysfunctions / Influência da idade, tipo de parto e paridade na prevalência das disfunções do assoalho pélvico no compartimento posterior

CONTEXT: The correlation between vaginal delivery, age and pelvic floor dysfunctions involving obstructed defecation is still a matter of controversy. OBJECTIVES: To determine the influence of age, mode of delivery and parity on the prevalence of posterior pelvic floor dysfunctions in women with obstructed defecation syndrome. METHODS: Four hundred sixty-nine females with obstructed defecation syndrome were retrospectively evaluated using dynamic 3D ultrasonography to quantify posterior pelvic floor dysfunctions (rectocele grade II or III, rectal intussusception, paradoxical contraction/non-relaxation of the puborectalis and entero/ sigmoidocele grade III). In addition, sphincter damage was evaluated. Patients were grouped according to age (<50y x >50y) and stratified by mode of delivery and parity: group I (<50y): 218 patients, 75 nulliparous, 64 vaginal delivery and 79 only cesarean section and group II (>50y): 251 patients, 60 nulliparous, 148 vaginal delivery and 43 only caesarean section. Additionally, patients were stratified by number of vaginal deliveries: 0 - nulliparous (n = 135), 1 - vaginal (n = 46), >1 - vaginal (n = 166). RESULTS: Rectocele grade II or III, intussusception, rectocele + intussusception and sphincter damage were more prevalent in Group II (P = 0.0432; P = 0.0028; P = 0.0178; P = 0.0001). The stratified groups (nulliparous, vaginal delivery and cesarean) did not differ significantly with regard to rectocele, intussusception or anismus in each age group. Entero/sigmoidocele was more prevalent in the vaginal group <50y and in the nulliparous and vaginal groups >50y. No correlation was found between rectocele and the number of vaginal deliveries. CONCLUSION: Higher age (>50 years) was shown to influence the prevalence of significant rectocele, intussusception and sphincter damage in women. However, delivery mode and parity were not correlated with the prevalence of rectocele, intussusception and anismus in women with obstructed defecation.

CONTEXTO: A correlação entre parto vaginal, idade e disfunções do assoalho pélvico em pacientes com evacuação obstruída permanece ainda controverso. OBJETIVO: Determinar a influência da idade, tipo de parto e paridade na prevalência de disfunções do assoalho pélvico posterior em mulheres com evacuação obstruída. MÉTODOS: Quatrocentas e sessenta e nove mulheres com evacuação obstruída foram avaliadas, retrospectivamente, utilizando ultrassonografia tridimensional dinâmica para quantificar disfunções do assoalho pélvico posterior (retocele grau II ou III, intussuscepção retal, anismus e entero/sigmoidocele grau III) e presença de lesão esfincteriana. As pacientes foram agrupadas de acordo com a idade (<50 anos e >50 anos) e estratificadas por tipo de parto e paridade em grupo I (<50 anos): incluindo 218 pacientes (75 nulíparas, 64 com partos vaginais e 79 apenas com operações cesarianas) e grupo II (>50 anos): incluindo 251 pacientes (60 nulíparas, 148 com partos vaginais e 43 apenas com cesarianas). Além disso, as pacientes foram estratificadas por número de partos vaginais em nulíparas (n = 135), com um parto vaginal (n = 46) e com mais de um parto vaginal (n = 166). RESULTADOS: Retocele, intussuscepção, associação de intussuscepção e retocele e lesão esfinceriana foram mais prevalentes no grupo II (P = 0,0432, P = 0,0028, P = 0,0178, P = 0,0001). Não houve diferença significante na prevalência de retocele, intussuscepção ou anismus em relação ao tipo de parto e paridade, em cada faixa etária. Êntero/sigmoidocele foi mais prevalente em pacientes com parto vaginal no grupo I e em nulíparas e com parto vaginal no grupo II. Nenhuma correlação foi encontrada entre prevalência de retocele e número de partos vaginais. CONCLUSÃO: A idade superior a 50 anos está associada a maior prevalência de retocele, intussuscepção e lesão esfincteriana, no entanto, a paridade e o tipo de parto não se correlacionam com a prevalência de intussuscepção, retocele e anismus em mulheres com evacuação obstruída.

Symptomatic vaginal enterocele associated with malfunctioning ventriculoperitoneal shunt and cerebrospinal ascites.

Abdominal pseudocyst formation is a rare adult complication associated with ventriculoperitoneal (VP) shunts. Presenting symptoms are primarily abdominal and include distention, pain and anorexia, and secondarily neurological with signs and symptoms of shunt malfunction. We describe a case of VP shunt-related pseudocyst formation presenting as symptomatic pelvic organ prolapse with stage 4 enterocele 4 years after VP shunt placement. The patient's vaginal enterocele enlarged and became more symptomatic as intra-abdominal cyst formation expanded. Symptomatic relief of pelvic floor symptomatology including resolution of exteriorized prolapse was established by conservative measures and eventual VP shunt revision and removal. VP shunt malfunction may present as symptomatic pelvic organ prolapse and may require shunt removal or revision for resolution of symptoms.

A novel technique for the management of advanced uterine/vault prolapse: extraperitoneal sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: Abdominal sacrocolpopexy is the gold standard for advanced uterovaginal/cuff prolapse repair; however, early and late bowel complications are of concern. We report our experience with extraperitoneal sacrocolpopexy (ESCP). METHODS: Twenty-three patients who underwent ESCP between 2007 and 2010 were analyzed in this retrospective cohort study. Preoperative assessment included Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Floor Impact (PFIQ-7) questionnaires, and pelvic examination according to Pelvic Organ Prolapse Quantification (POP-Q) system. Pre-operative findings were compared with postoperative values at the last follow-up using the Wilcoxon sign test. RESULTS: Mean operation time was 86 ± 20 min. Twenty patients were discharged within 24 h. With a mean follow-up of 20 months, objective and subjective cure rates were 91.3% and 86.9%, respectively. No postoperative complications were evident with significant improvement in POP-Q, PFDI-20, and PFIQ-7 scores. CONCLUSIONS: ESCP is a safe and effective sacrocolpopexy procedure that can potentially eliminate the risk of gastrointestinal complications.

Rectocele and anal sphincter defect - surgical anatomy and combined repair.

This study reports on the surgical anatomy and technique of perineal repair in a selected group of parous women with faecal incontinence and/or difficulty in evacuation. Anal sphincter muscle damage is usually attributed to childbirth, although most of these women present for the first time years later. Consecutive patients with the above symptoms were examined clinically and then investigated with a perineal ultrasound scan. During the perineal operation for repair, further investigation by transillumination and measurements with calipers were done in 50 patients. All patients received routine postoperative care, and were followed up for at least 6 months. From 1995 to 2009 a total of 117 patients, all female, underwent perineal repair by a single surgeon. The age range was 24 - 82 years. In the last 50 consecutive patients, transillumination was positive prior to repair in all, and negative after. The average thickness of the rectocele wall was 2.4 mm prior to repair and 4.8 mm after. In all patients a rectocele was found in conjunction with the anal sphincter defect. The results of combined repair were satisfactory in 109 of 117 patients (93%). A rectocele consists of rectal mucosa, and represents a pulsion diverticulum of the lower anterior rectum. The mucosa herniates through a defect in the midline in the lower anterior rectal muscle wall. This defect then extends into the internal and external anal sphincters. It is a consistent finding in women with faecal incontinence due to anal sphincter disruption. If the anterior rectal muscle wall is repaired first, anal sphincter repair is facilitated.

Abdominal mesh sacrocolpopexy for recurrent triple-compartment pelvic organ prolapse.

OBJECTIVE: To report the short- and intermediate- term outcome of safety and efficacy after abdominal-mesh sacrocolpopexy (MSC) for recurrent anterior, posterior and vault ('triple-compartment') pelvic organ prolapse (POP). PATIENTS AND METHODS: In a database review we identified non-neurogenic women who had MSC for recurrent triple-compartment POP and with a >or=6-month cystographic follow-up. The preoperative evaluation included a history, physical examination, Urogenital Distress Inventory (UDI-6) and visual analogue quality-of-life (QoL) questionnaires, urodynamic studies, and a standing lateral voiding cysto-urethrogram (VCUG) with rest-strain views. All surgery as performed by the same surgeon, using polypropylene (Marlex) mesh. Perioperative data, the VCUG at 6 months, and interval pelvic examinations were recorded. RESULTS: Between 2000 and 2006, 29 postmenopausal women (Caucasian, mean age 64 years, sd 11) underwent MSC. The mean (sd, range) operative duration was 228 (75, 170-340) min, the estimated blood loss 150 (100) mL and the inpatient stay 3 (1) days. At a mean (sd) follow-up of 23 (16) months, the physical examination showed no evidence of POP of grade >or=2, with mean POP-Quantification scores of -2.8 (0.4), -2.9 (0.4) and -9.3 (0.8) for points A(a), A(p) and C, respectively. Two patients (8%) had evidence of grade >or=2 cystocele at the 6-month VCUG. After MSC, four of the six UDI and the QoL scores were significantly lower at the last follow-up than at baseline, with no change in sexual or defecatory function. CONCLUSIONS: The objective and subjective improvement at the short and intermediate follow-up after MSC suggest that this is a safe and effective treatment for recurrent triple-compartment POP.

Effect of weight change on natural history of pelvic organ prolapse.

OBJECTIVE: To evaluate the relationship between change in weight and pelvic organ prolapse (POP) progression/regression in women during a 5-year period. METHODS: Postmenopausal women with uteri (N=16,608), ages 50 to 79, who were enrolled in the Women's Health Initiative (WHI) Estrogen plus Progestin Clinical Trial between 1993 and 1998 were included in this secondary analysis. Baseline pelvic examination, repeated annually, assessed uterine prolapse, cystocele, and rectocele using the WHI Prolapse Classification System. Statistical analyses included univariate and multiple logistic regression methods. RESULTS: During the 5-year time period, the majority of women (9,251, 55.7%) gained weight (mean 4.43 kg, +/-5.95 kg), and the overall rate of prolapse (WHI Prolapse Classification System: grades 1-3) increased from 40.9% at baseline to 43.8% at year 5 of evaluation. Controlling for age, parity, race, and other health/physical variables, being overweight (body mass index [BMI] between 25 and 29.9) or obese (BMI of at least 30) at baseline was associated with progression in cystocele, rectocele, and uterine prolapse compared with women with healthy BMIs (BMI is calculated as weight (kg)/[height (m)]). Specifically, the risk of prolapse progression in overweight and obese women as compared with the participants with healthy BMIs increased by 32% and 48% for cystocele, by 37% and 58% for rectocele, and by 43% and 69% for uterine prolapse, respectively. Adjusting for women with prolapse at baseline and baseline BMI, a 10% weight change was associated with minimal change in overall POP. Specifically, a 10% weight loss was associated with a borderline worsening of uterine prolapse (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.88-0.97) and a minimal regression of cystocele (OR 1.03, 95% CI 1.00-1.05) and rectocele (OR 1.04, 95% CI 1.01-1.07). CONCLUSION: Being overweight or obese is associated with progression of POP. Weight loss does not appear to be significantly associated with regression of POP, suggesting that damage to the pelvic floor related to weight gain might be irreversible. LEVEL OF EVIDENCE: II.

Levator trauma is associated with pelvic organ prolapse.

OBJECTIVE: To estimate the risk of prolapse associated with levator avulsion injury among a urogynaecological clinic population. DESIGN: Retrospective observational study. SETTING: Tertiary urogynaecological unit. SAMPLE: A total of 934 women seen for interview, examination using the pelvic organ prolapse quantification (POP-Q) staging system and imaging of the levator ani muscle by four-dimensional translabial ultrasound. METHODS: Retrospective review of charts and stored imaging data. MAIN OUTCOME MEASURES: Pelvic organ prolapse stage II and higher and presence of defects of the levator ani muscle. RESULTS: After exclusion of 137 women with a history of anti-incontinence or prolapse surgery, and a further exclusion of 16 women in whom either examination or imaging was impossible, we compared prolapse and imaging data in 781 women. Mean age was 53 years (range 15-89 years), and median parity was 2 (range 0-12). Women reported stress incontinence (76%), urge incontinence (69%), frequency (47%), nocturia (49%) and symptoms of prolapse (38%). Significant prolapse (stage II or higher) was diagnosed in 415 (53%) women, and 181 (23%) women were found to have levator avulsion defects. Prolapse was seen in 150/181 (83%) women with avulsion and in 265/600 (44%) women without avulsion, giving a relative risk (RR) of 1.9 (95% CI 1.7-2.1). The association was strongest for cystocele (RR 2.3, 95% CI 2.0-2.7) and uterine prolapse (RR 4.0, 95% CI 2.5-6.5). CONCLUSIONS: Women with levator avulsion defects were about twice as likely to show pelvic organ prolapse of stage II or higher than those without. This effect is mainly due to an increased risk of cystocele and uterine prolapse.

Transvaginal excision of a retrorectal tumor presenting as rectocele.

Tumors occupying the retrorectal (presacral) space are uncommon and heterogeneous. It is estimated that an average of two patients with retrorectal tumors will be diagnosed per year in a standard metropolitan area. They are usually asymptomatic and diagnosed during routine physical examination incidentally. Our case was admitted with complaints of a swelling in her vagina, constipation, and difficulty in emptying her bowels. The diagnosis and treatment utilizing transvaginal approach in this case is discussed in comparison with the literature. Up to our knowledge, this is the first case presenting as rectocele and second case of retrorectal tumor surgically treated using transvaginal approach.