Surgical Correction of the Genital Hiatus at the Time of Sacrocolpopexy-Are Concurrent Posterior Repairs Cost-Effective?

OBJECTIVE: The objective was to perform a cost-effectiveness analysis of posterior repair performed at the time of sacrocolpopexy (SCP). METHODS: We used TreeAge Pro to construct a decision model comparing laparoscopic hysterectomy with SCP with and without concurrent posterior repair (SCP and SCP + PR). Using a time horizon of 1 year, we modeled prolapse recurrence, prolapse retreatment, and complications, including rectal injury, rectovaginal hematoma requiring surgical take-back, and postoperative dyspareunia. Costs included index surgery, surgical retreatment, and complications. We modeled effectiveness as quality-adjusted life years (QALYs). Cost-effectiveness was defined using the incremental cost-effectiveness ratio and willingness to pay of $100,000/QALY. Sensitivity analyses were performed. RESULTS: Sacrocolpopexy was the dominant strategy with a cost of $65,714 and an effectiveness of 0.84. It was cost-effective at willingness to pay threshold less than $100,000/QALY. The SCP + PR costs more ($75,063) with lower effectiveness (0.83). The effectiveness of the 2 strategies was similar, differing only by 0.01 QALY, which is less than the minimally important difference for utilities. Tornado plots showed CEA results were most influenced by the cost of SCP, cost of SCP + PR, and probability of dyspareunia after SCP. In 1-way sensitivity analyses, the model outcome would change only if the cost of SCP was increased by 12.8% or if the cost of SCP + PR decreased by 14.5%. For dyspareunia, our model would only change if the probability of dyspareunia after SCP alone was 75.9% (base case, 18.6%), whereas the probability of dyspareunia after SCP + PR was 26.8%. CONCLUSION: In this cost-effectiveness analysis, SCP without concurrent PR was the dominant strategy.

Transperineal ultrasound assessment of fetal head elevation by maneuvers used for managing umbilical cord prolapse.

OBJECTIVE: To assess objectively the degree of fetal head elevation achieved by different maneuvers commonly used for managing umbilical cord prolapse. METHODS: This was a prospective observational study of pregnant women at term before elective Cesarean delivery. A baseline assessment of fetal head station was performed with the woman in the supine position, using transperineal ultrasound for measuring the parasagittal angle of progression (psAOP), head-symphysis distance (HSD) and head-perineum distance (HPD). The ultrasonographic measurements of fetal head station were repeated during different maneuvers, including elevation of the maternal buttocks using a wedge, knee-chest position, Trendelenburg position with a 15° tilt and filling the maternal urinary bladder with 100 mL, 300 mL and 500 mL of normal saline. The measurements obtained during the maneuvers were compared with the baseline measurements. RESULTS: Twenty pregnant women scheduled for elective Cesarean section at term were included in the study. When compared with baseline (median psAOP, 103.6°), the knee-chest position gave the strongest elevation effect, with the greatest reduction in psAOP (psAOP, 80.7°; P < 0.001), followed by filling the bladder with 500 mL (psAOP, 89.9°; P < 0.001) and 300 mL (psAOP, 94.4°; P < 0.001) of normal saline. Filling the maternal bladder with 100 mL of normal saline (psAOP, 96.1°; P = 0.001), the Trendelenburg position (psAOP, 96.8°; P = 0.014) and elevating the maternal buttocks (psAOP, 98.3°; P = 0.033) gave modest elevation effects. Similar findings were reported for HSD and HPD. The fetal head elevation effects of the knee-chest position, Trendelenburg position and elevation of the maternal buttocks were independent of the initial fetal head station, but that of bladder filling was greater when the initial head station was low. CONCLUSIONS: To elevate the fetal presenting part, the knee-chest position provides the best effect, followed by filling the maternal urinary bladder with 500 mL then 300 mL of fluid, respectively. Filling the bladder with 100 mL of fluid, the Trendelenburg position and elevation of the maternal buttocks have modest effects. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Assessment of the Safety and Efficacy of Prolapsed Orbital Fat Resection During Involutional Entropion Repair.

PURPOSE: To assess the recurrence rate of involutional entropion in patients treated with a combined approach including a modified Bick procedure, excision of preseptal orbicularis muscle, and conservative resection of prolapsed orbital fat. METHODS: A retrospective chart review of patients undergoing repair of involutional entropion with the combined procedure including orbital fat resection and a second group with standard entropion repair without orbital fat resection was performed. Only patients with follow-up greater than 6 months were included in the study. RESULTS: Seventy eyelids of 54 patients met all inclusion criteria for the combined procedure group over a 9-year period from 2008 to 2016. Average follow-up was 46.9 months. There was a documented recurrence of entropion in 1 eyelid during the follow-up period (1.4%). The remaining 69 cases had successful subjective and objective results without need for any additional procedures. In the group undergoing entropion repair without fat resection, 22 eyelids of 19 patients had the required follow-up period with a recurrence rate of 4.5% (p > 0.05). CONCLUSIONS: The authors demonstrate good surgical success with a combined approach of a modified Bick procedure, preseptal orbicularis excision, and conservative orbital fat resection. Conservative fat resection during entropion repair was found to be safe, and the combined procedure was found to be effective with a rate of recurrent entropion of 1.4% on extended follow-up.The authors propose that orbital fat prolapse contributes to the mechanics of involutional entropion and that conservative orbital fat resection during surgical repair of entropion can be done safely, resulting in low recurrence rates.

Prolapse of Orbital Fat through the Inferior Orbital Fissure: Description, Prevalence, and Assessment of Possible Pathologic Associations.

BACKGROUND AND PURPOSE: A few patterns of orbital fat prolapse have been described. Some are associated with disease, and others may mimic a neoplasm. We have observed prolapse of orbital fat into the infratemporal fossa via the inferior orbital fissure on MR imaging. The clinical relevance of this finding, if any, is unknown. The purposes of this study were to describe the MR imaging appearance of orbital fat prolapse through the inferior orbital fissure, to estimate the prevalence of this finding, and to assess possible pathologic associations. MATERIALS AND METHODS: For this retrospective study of 228 orbital MR imaging examinations, 3 neuroradiologists independently assessed the presence of prolapse on high-resolution T1-weighted images. Discrepancies were resolved by consensus, and interobserver agreement was calculated. Patient demographics, indications for imaging, and pertinent clinical history were recorded. One-way analysis of variance and the Fisher exact test were used to assess possible associations between prolapse and specific patient characteristics. RESULTS: Orbital fat prolapse through the inferior orbital fissure was observed in 20/228 patients (9%). This finding was unilateral in 11 patients (55%) and bilateral in 9 patients (45%). There was no significant association with age, sex, obesity, Graves disease, hypercortisolism, prior orbital trauma, proptosis, or enophthalmos. Interobserver agreement was 90%. CONCLUSIONS: Prolapse of orbital fat into the infratemporal fossa via the inferior orbital fissure is a relatively common finding on orbital MR imaging that has no identified pathologic association. Neuroradiologists should recognize this finding so as not to report it as pathologic.

Prolapse of the Pipeline embolization device in aneurysms: incidence, management, and outcomes.

OBJECTIVE The Pipeline embolization device (PED) is frequently used in the treatment of anterior circulation aneurysms, especially around the carotid siphon, with generally excellent results. However, the PED has its own unique technical challenges, including the occurrence of device foreshortening or migration leading to prolapse into the aneurysm. The authors sought to determine the incidence of this phenomenon, the rescue strategies, and outcomes. METHODS Four institutional databases of neuroendovascular procedures were reviewed for cases of intracranial aneurysms treated with PEDs. Patient and aneurysm data as well as angiographic imaging were reviewed for all cases involving device prolapse into the aneurysm. RESULTS A total of 413 intracranial aneurysms were treated with PEDs during the study period, by 5 neurointerventionalists. Large and giant aneurysms (≥ 2 cm) accounted for 32 of these aneurysms. Among these 32 PEDs, prolapse into the aneurysm occurred in 3 patients, with 1 of these PEDs successfully rescued and the other 2 left in situ. No patients suffered any severe complications. The 2 patients in whom the PEDs were left in situ remained on antiplatelet therapy. CONCLUSIONS The PED may foreshorten or migrate during or after deployment, leading to prolapse into the aneurysm. This phenomenon appears to be associated with large and giant aneurysms, vessel tortuosity, short landing zones, and use of balloon angioplasty. Future study and follow-up is needed to further evaluate this phenomenon, but some of the observations and techniques described in this paper may help to prevent or salvage prolapsed devices.

Quantitative assessment of tissue prolapse on optical coherence tomography and its relation to underlying plaque morphologies and clinical outcome in patients with elective stent implantation.

BACKGROUND: Tissue prolapse (TP) is sometimes observed after percutaneous coronary intervention (PCI), but its clinical significance remains unclear. We investigated the relationship between TP volume on optical coherence tomography (OCT) after PCI and underlying plaque morphologies and the impact of TP on clinical outcomes. METHODS: We investigated 178 native coronary lesions with normal pre-PCI creatine kinase-myocardial band (CK-MB) values (154 lesions with stable angina; 24 with unstable angina). TP was defined as tissue extrusion from stent struts throughout the stented segments. All lesions were divided into tertiles according to TP volume. The differences in plaque morphologies and 9-month clinical outcomes were evaluated. RESULTS: TP volume was correlated with lipid arc (r=0.374, p<0.0001) and fibrous cap thickness (r=-0.254, p=0.001) at the culprit sites. The frequency of thin-cap fibroatheroma (TCFA) was higher in the largest TP tertile (≥ 1.38 mm(3)) (p=0.015). In multivariate analysis, right coronary artery lesion (odds ratio [OR]: 2.779; p=0.005), lesion length (OR: 1.047; p=0.003), and TCFA (OR: 2.430; p=0.022) were related to the largest TP tertile. Lesions with post-PCI CK-MB elevation (>upper reference limit) had larger TP volume than those without (1.28 [0.48 to 3.97] vs. 0.70 [0.16 to 1.64] mm(3), p=0.007). The prevalence of cardiac events during the 9-month follow-up was not significantly different according to TP volume. CONCLUSIONS: TP volume on OCT was related to plaque morphologies and instability, and post-PCI myocardial injury, but not to worse 9-month outcomes.

Assessment of indications and clinical outcome for the endoscopy-assisted combined subciliary/transantral approach in treatment of complex orbital floor fractures.

BACKGROUND: The treatment of complex orbital floor fractures with extensive orbital prolapse remains a surgical challenge in craniomaxillofacial traumatology and is still controversially discussed. Reduction of orbital tissue via a transcutaneous or transconjunctival approach alone can be very difficult and lead to unsatisfying results. METHODS: Over a 3-year-period, we enrolled 13 patients who underwent endoscopy-assisted reconstruction of isolated orbital floor fractures via a combined subciliary and transantral approach. Patient data, imaging and ophthalmologic examination were reviewed prospectively. RESULTS: Ten patients underwent primary surgical treatment, 3 patients had secondary surgical treatment because of unsatisfactory results of primary surgical intervention. All patients had an uneventful postoperative course without ophthalmologic deterioration, no further surgical procedures were necessary. CONCLUSIONS: The additional use of an endoscopy-assisted transantral approach provides a reliable treatment modality in selected cases. To our knowledge, this is the only study of patients treated with a combined subciliary and transantral approach. Special emphasis was given to postoperative functional results, a short algorithm for use of an additional transantral endoscopy-assisted approach is presented.

Stapled hemorrhoidopexy, an innovative surgical procedure for hemorrhoidal prolapse: cost-utility analysis.

AIM: To undertake full economic evaluation of stapled hemorrhoidopexy (PPH) to establish its cost-effectiveness and investigate whether PPH can become cost-saving compared to conventional excisional hemorrhoidectomy (CH). METHODS: A cost-utility analysis in hospital and health care system (UK) was undertaken using a probabilistic, cohort-based decision tree to compare the use of PPH with CH. Sensitivity analyses allowed showing outcomes in regard to the variations in clinical practice of PPH procedure. The participants were patients undergoing initial surgical treatment of third and fourth degree hemorrhoids within a 1-year time-horizon. Data on clinical effectiveness were obtained from a systematic review of the literature. Main outcome measures were the cost per procedure at the hospital level, total direct costs from the health care system perspective, quality adjusted life years (QALY) gained and incremental cost per QALY gained. RESULTS: A decrease in operating theater time and hospital stay associated with PPH led to a cost saving compared to CH of GBP 27 (US $43.11, €30.50) per procedure at the hospital level and to an incremental cost of GBP 33 (US $52.68, €37.29) after one year from the societal perspective. Calculation of QALYs induced an incremental QALY of 0.0076 and showed an incremental cost-effective ratio (ICER) of GBP 4316 (US $6890.47, €4878.37). Taking into consideration recent literature on clinical outcomes, PPH becomes cost saving compared to CH for the health care system. CONCLUSIONS: PPH is a cost-effective procedure with an ICER of GBP 4136 and it seems that an innovative surgical procedure could be cost saving in routine clinical practice.

Dynamic magnetic resonance imaging for assessment of minimally invasive pelvic floor reconstruction with polypropylene implant.

INTRODUCTION: The purpose of the study was to assess the usefulness of dynamic MRI in patients with pelvic organ prolapse after pelvic floor repair with polypropylene mesh. MATERIALS AND METHODS: Fifteen consecutive patients (mean age 66.5 years) who were scheduled for either anterior (n=9) or posterior (n=6) pelvic floor repair were prospectively evaluated by clinical assessment and dynamic MRI 1 day before and 3 months after surgery. MRI diagnoses and MRI measurements of relevant anatomical points at rest and on straining were analysed before and after surgery. RESULTS: At follow-up assessment 93.3% of all patients were clinically cured. Dynamic MRI showed newly developed (n=6) or increased (n=6) pelvic organ prolapse in 80% (n=12) of all patients 3 months after pelvic floor repair. Most of them (n=11; 91.7%) affected the untreated pelvic floor compartment. On straining anatomical points of reference in the anterior pelvic floor compartment were significantly (p<0.05) elevated after anterior repair and rectal bulging was significantly (p=0.036) reduced after posterior pelvic floor repair. CONCLUSIONS: In this study dynamic MRI could verify the effective support of anterior and posterior pelvic floor structures by anterior and posterior polypropylene implant respectively. But dynamic MRI demonstrates if one compartment of the pelvic floor is repaired another compartment frequently (73.3%) develops dysfunction. These results did not correspond to clinical symptoms on short-term follow-up (3 months). Studies with long-term follow-up are necessary to prove if dynamic MRI can reliably identify clinically significant pelvic organ prolapse after pelvic floor repair before the onset of symptoms.

Ileal pouch prolapse: prevalence, management, and outcomes.

AIM: The study aim is to review the prevalence, management, and outcomes for patients diagnosed with ileal pouch prolapse after restorative proctocolectomy. MATERIALS AND METHODS: Patients were identified retrospectively from a prospectively maintained pouch database. Parameters analyzed included presenting symptoms, indications for pouch surgery, type of ileal pouch-anal anastomosis, treatment modalities, and outcomes. RESULTS: Of 3,176 patients who underwent ileal pouch surgery, 11 were diagnosed with pouch prolapse (0.3%). Seven had full-thickness prolapse and four mucosal prolapse. Six were male, and five were female. Indication for index surgery was ulcerative colitis (nine patients), familial adenomatous polyposis (one patient), and colonic inertia (one patient). Median age at pouch prolapse was 34 years. Median time from index surgery to prolapse diagnosis was 2 years. Two patients with mucosal prolapse responded to conservative management; two required mucosal excisions. An abdominal approach was successful in four out of seven patients with full thickness prolapse. The three failures subsequently underwent continent ileostomy formation and prompted us to add biological mesh to future pouchpexy repairs. CONCLUSIONS: Pouch prolapse is rare, and there are no obvious predisposing factors. Mucosal prolapse may be treated by stool bulking or a local perineal procedure. Full thickness prolapse requires definitive surgery and is associated with risk of pouch loss.

Early postoperative complications following ostomy surgery: a review.

This article reviews early postoperative complications in adults undergoing ostomy surgery. Whether the ostomy is the result of an emergent or elective procedure, the WOC nurse and staff nurses are responsible for monitoring and ensuring quality healthcare for the patient. Nevertheless, many patients undergoing ostomy surgery experience a complication during the early postoperative period. Early postoperative complications not only influence immediate postoperative care but may also impact quality of life for the person living with an ostomy. Keen assessment skills, early recognition of signs and symptoms of a complication, and prompt interventions are crucial to maintaining a viable stoma and a successful surgical outcome.

Optical coherence tomography assessment of the acute effects of stent implantation on the vessel wall: a systematic quantitative approach.

OBJECTIVE: To observe and characterise vessel injury after stenting using optical coherence tomography (OCT), to propose a systematic OCT classification for periprocedural vessel trauma, to evaluate its frequency in stable versus unstable patients and to assess its clinical impact during the hospitalisation period. SETTING: Stenting causes vessel injury. DESIGN AND INTERVENTIONS: All consecutive patients in whom OCT was performed after stent implantation were included in the study. Qualitative and quantitative assessment of tissue prolapse, intra-stent dissection and edge dissection were performed. RESULTS: Seventy-three patients (80 vessels) were analysed. Tissue prolapse within the stented segment was visible in 78/80 vessels (97.5%). Median number of tissue prolapse sites was 8 (IQR 4-19), mean (SD) area 1.04 (0.9) mm(2). Intra-stent dissection flaps were visible in 69/80 vessels (86.3%) (median number 3 (IQR 1.25-6), maximum flap length 450 (220) microm). Fifty-five out of 80 vessels (68.8%) showed dissection cavities (median number 2 (IQR 0-4.75), maximum depth 340 (170) microm). Edge dissection was visible in 20 vessels (mean (SD) length flap 744 (439) microm). The frequency of tissue prolapse or intra-stent dissection was similar in stable and unstable patients (95.6% vs 100%, p = 0.5 for tissue prolapse; 91.1% vs 82.9%, p = 0.3 for intra-stent dissection). There were no events during the hospitalisation period. CONCLUSIONS: OCT allows a detailed visualisation of vessel injury after stent implantation and enables a systematic classification and quantification in vivo. In this study, frequency of tissue prolapse or intra-stent dissections after stenting was high, irrespective of the clinical presentation of the patients, and was not associated with clinical events during hospitalisation.

Significant linkage evidence for a predisposition gene for pelvic floor disorders on chromosome 9q21.

Predisposition factors for pelvic floor disorders (PFDs), including pelvic organ prolapse (POP), stress urinary incontinence (SUI), urge urinary incontinence (UUI), and hernias, are not well understood. We assessed linkage evidence for PFDs in mostly sister pairs who received treatment for moderate-to-severe POP. We genotyped 70 affected women of European descent from 32 eligible families with at least two affected cases by using the Illumina 1 million single-nucleotide polymorphism (SNP) marker set. Parametric linkage analysis with general dominant and recessive models was performed by the Markov chain Monte Carlo linkage analysis method, MCLINK, and a set of SNPs was formed, from which those in high linkage disequilibrium were eliminated. Significant genome-wide evidence for linkage was identified on chromosome 9q21 with a HLOD score of 3.41 under a recessive model. Seventeen pedigrees (53%) had at least nominal evidence for linkage on a by-pedigree basis at this region. These results provide evidence for a predisposition gene for PFDs on chromosome 9q.

[Effectiveness evaluation of polypropylene mesh in the repair of urogenital prolapse in 106 patients]. / Valoración de la eficacia de la malla de polipropileno en la reparación del prolapso urogenital en 106 pacientes.

OBJECTIVE: To evaluate the efficacy and security of polypropylene meshes in the repair of urogenital prolapse. MATERIAL AND METHOD: Retrospective and non-randomized study in 106 patients which had different kinds of urogenital prolapse repaired using polypropylene meshes between April 2005 and January 2007. The follow-up was carried out by two visits to the hospital, 2 and 6 months after surgery. The variables analyzed were age, parity, menopause presence, kind of surgical technique, surgical time, time at hospital and complications. Afterwards, the information was analyzed descriptively. RESULTS: Average age was 64.4 years. The rate of multiparity and menopause women was 91.51% and 92.45% respectively. The most used surgical technique was the anterior mesh with tension-free band (34.90%), to repair the associated urinary incontinence. The rate of intraoperatory complications was 2.83%, immediate complications was 37.73% and late complications was 21.69%. The success rate after 6 months was 80-100% depending on the technique. CONCLUSIONS: There is a low rate of intraoperatory and 6 months after the repair in the reconstructive surgery of pelvic floor for the urogenital prolapses using polypropylene meshes, which makes this technique a secure and effective option for the treatment of this problem.

Ultrasound assessment of pelvic organ prolapse: the relationship between prolapse severity and symptoms.

OBJECTIVE: At present little information is available to help define whether a certain degree of pelvic organ prolapse is clinically relevant. We performed a retrospective study to define cut-offs for significant pelvic organ descent on the basis of prolapse symptoms. METHODS: At a tertiary urogynecological center, 735 women with symptoms of lower urinary tract dysfunction and prolapse were seen for interview, clinical examination, multi-channel urodynamics and ultrasound imaging, while supine and after voiding, for prolapse quantification. Women with multi-compartment prolapse, i.e. those in whom no compartment was clearly dominant were excluded. Receiver-operator statistics were used to test pelvic organ descent as a predictor of prolapse symptoms. RESULTS: Mean age was 55.1 years, mean parity 2.8 (range, 0-12). Symptoms of prolapse were reported by 188 women (25.6%). Seventy-four showed a symptomatic multi-compartment prolapse and were excluded, 56 symptomatic women had cystoceles and 48 had rectoceles. Symptomatic cystoceles descended on average to 23.8 mm below the symphysis pubis and symptomatic rectoceles to 21.4 mm below the symphysis pubis. Descent was strongly associated with symptoms of prolapse (both, P < 0.001). Receiver-operating characteristics (ROC) statistics suggested a cut-off of 10 mm below the symphysis pubis for cystocele, and 15 mm below the symphysis pubis for rectocele. ROC curves were similar for both compartments (area under the curve, 0.857 and 0.821, respectively). CONCLUSIONS: Descent of the bladder to > or = 10 mm and of the rectum to > or = 15 mm below the symphysis pubis are strongly associated with symptoms, and these values are proposed as cut-offs for the diagnosis of significant prolapse on the basis of ROC statistics.

Perineal hernia in women : assessment with evacuation fluoroscopic cystocolpoproctography.

The aim of this study is to assess the usefulness of fluoroscopic cystocolpoproctography in the treatment of female pelvic organ prolapse. The presence or absence of rectocele, enterocele, sigmoidocele, and the cystocele on cystocolpoproctography was retrospectively analyzed in 46 consecutive patients. A rectocele was detected in 4.5% of the patients, postvaginal hernia in 19.7%, cystocele in 3.0%, complete rectal prolapse in 53.0%, massive rectal prolapse in 10.6%, and incomplete rectal prolapse in 4.5% of the patients on cystocolpoproctography. Perineal hernia can include a combination of cystocele, rectocele, uterine prolapse, enterocele and rectal prolapse. Accurate diagnosis of the coexisting abnormalities is essential in planning reconstructive procedures so that the risks of recurrence and reoperation can be minimized. Fluoroscopic cystocolpoproctography provides direct visualization and quantification of female pelvic organ prolapse, information that usually can only be inferred by physical examination.

Long-term anatomical and functional assessment of trans-vaginal cystocele repair using a tension-free polypropylene mesh.

We report a case series of 63 women with cystocele who underwent the same trans-vaginal procedure between October 1999 and October 2002. The polypropylene mesh (GyneMesh, Gynecare, Ethicon, France) was placed from the retropubic space to the inferior part of the bladder in a tension-free fashion. Patients were followed up for 24 to 60 months, with a mean follow-up of 37 months. Fifty-five patients returned for follow-up (87.3%). At follow-up, 49 women were anatomically cured (89.1%), five women had stage 2 anterior vaginal wall prolapse (9.1%), and one had a recurrent stage 3 (1.8%). Functional results and sexual function were also investigated. Fifty-three women had significant improvement in their quality of life (96.4%). There were a total of three cases of local pain around a mesh shrinkage (5.5%) and five vaginal erosions of the mesh (9.1%). Four out of 24 patients had dyspareunia (16.7%). In conclusion, the vaginal repair of anterior vaginal wall prolapse reinforced with a polypropylene mesh was efficient at 2 to 5 years follow-up. However, the first generation of polypropylene mesh we used was responsible for high rates of local complications and dyspareunia. Therefore, the polypropylene mesh has to be improved (lower weight) and the technique has to be documented by a randomized controlled trial before we could recommend its use in clinical practice.