[Influence of complex rehabilitation programs on the uterine blood flow in patients of different age after plastic surgery for rectocele]. / Vliyanie reabilitatsionnykh kompleksnykh programm na pokazateli matochnogo krovotoka po dannym 3D-ekhodopplerografii u patsientok raznykh vozrastnykh grupp posle plasticheskoi operatsii po povodu rektotsele.

OBJECTIVE: To develop the optimized complex programs, including general magnetotherapy, fractional microablative therapy with a CO2 laser, electromyostimulation with biofeedback of the pelvic floor muscles, and a special exercise therapy complex in late rehabilitation programs for women of different age after reconstructive plastic surgery for rectocele. MATERIAL AND METHODS: There were 200 women of childbearing, peri- and menopausal age with rectocele grade II-III and 20 healthy women of comparable age. All patients were divided into 4 groups by 50 womes: main group, two comparison groups and control group. Surgical treatment of rectocele was followed by long-term postoperative rehabilitation including symptomatic therapy, general magnetotherapy, and electromyostimulation with biofeedback of the pelvic floor muscles, intra-vaginal fractional microablative therapy with a CO2 laser and special complex of therapeutic physical education. RESULTS: General magnetotherapy in early (1 day) postoperative period and complex rehabilitation in long-term postoperative period (within a month after surgery) including 2 procedures of intra-vaginal microablative fractional therapy with carbon dioxide laser, electromyostimulation with biological connection of the pelvic floor muscles and special complex of therapeutic physical education ensured more significant improvement of uterine blood flow regardless age and baseline disorders in the uterine arteries in patients with rectocele. In our opinion, this is primarily due to vasoactive effects of general magnetotherapy, recovery of circulation via relief of spasm in the arteries and arterioles, improved vein contractility and venous outflow. These processes combined with electrical stimulation and therapeutic exercises of pelvic floor muscle followed by their reinforcement, as well as fractional microablative therapy ensured significant vascular effect.

Test-retest reliability of internal pudendal artery blood flow using color Doppler ultrasound in healthy women.

INTRODUCTION AND HYPOTHESIS: The internal pudendal artery (IPA) is one of the main arteries supplying the pelvic floor muscles (PFMs) and vulvo-vaginal tissues. Its assessment with color Doppler ultrasound has been documented previously, but the reliability of IPA measurements has never been assessed. This study evaluates the test-retest reliability of IPA blood flow parameters measured by color Doppler ultrasound under two conditions: at rest and after a PFM contraction task. METHODS: Twenty healthy women participated in this study. One observer performed two measurement sessions using a clinical ultrasound system with a curved-array probe on the participant's gluteal area. IPA measurements were repeated: at rest and after a PFM contraction task. Peak systolic velocity (PSV), time-averaged maximum velocity (TAMX), end-diastolic velocity (EDV), pulsatility index (PI), and resistance index (RI) were measured. Test-retest reliability was assessed using a paired t test, intraclass correlation coefficient (ICC), and Bland and Altman plots. RESULTS: There was no significant difference for all IPA blood flow measurements between the two repeated sessions. At rest, reliability was excellent for PSV and TAMX and the variability between measurements, as per Bland and Altman plots, was small. After PFM contractions, reliability was excellent for PSV and TAMX and fair to good for PI. The variability between measurements was small for PSV and acceptable for TAMX and PI. EDV and RI parameters did not perform as well. CONCLUSION: The assessment of IPA blood flow with color Doppler ultrasound to evaluate vascular change in women is reliable.

Cadaveric Nerve and Artery Proximity to Sacrospinous Ligament Fixation Sutures Placed by a Suture-Capturing Device.

OBJECTIVE: To simulate sacrospinous ligament fixation on cadaveric specimens, describe the surrounding retroperitoneal anatomy, and estimate the risk to nerves and arteries for the purposes of optimizing safe suture placement. METHODS: Sacrospinous ligament fixation was performed on eight fresh-tissue female cadavers using a Capio ligature capture device. Distances from placed sutures to the following structures were measured: ischial spine; fourth sacral root; pudendal nerve; the nerve to coccygeus muscle; the nerve to levator ani muscle; inferior gluteal artery; and internal pudendal artery. Periligamentous anatomy was examined in an additional 17 embalmed cadaver dissections. RESULTS: Sacrospinous ligament length was not seen to differ significantly between sides. The fourth sacral spinal nerve was seen most commonly associated with the medial third of the ligament, whereas the pudendal nerve and the nerves to coccygeus and levator ani muscles were associated with the lateral third. The inferior gluteal artery was seen leaving the greater sciatic foramen a median 15.8 mm (range 1.8-48.0, CI 14.9-22.3) above the ligament, whereas the internal pudendal artery exited just above the ischial spine. The two sets of sutures were placed 20.5 mm (range 9.2-34.4, CI 19.7-24.7) and 24.8 mm (range 12.4-46.2, CI 24.0-30.0) medial to the ischial spine, respectively. No structures were directly damaged by placed sutures. The nerves to coccygeus and levator ani were closest and arteries farthest from the placed sutures. CONCLUSION: The middle segment of the sacrospinous ligament has the lowest incidence of nerves and arteries associated with it. This study confirms that the nerves supplying the pelvic floor muscles are at a higher risk from entrapment than the pudendal nerve.

MRI visible Fe3O4 polypropylene mesh: 3D reconstruction of spatial relation to bony pelvis and neurovascular structures.

INTRODUCTION AND HYPOTHESIS: To demonstrate mesh magnetic resonance imaging (MRI) visibility in living women, the feasibility of reconstructing the full mesh course in 3D, and to document its spatial relationship to pelvic anatomical structures. METHODS: This is a proof of concept study of three patients from a prospective multi-center trial evaluating women with anterior vaginal mesh repair using a MRI-visible Fe3O4 polypropylene implant for pelvic floor reconstruction. High-resolution sagittal T2-weighted (T2w) sequences, transverse T1-weighted (T1w) FLASH 2D, and transverse T1w FLASH 3D sequences were performed to evaluate Fe3O4 polypropylene mesh MRI visibility and overall post-surgical pelvic anatomy 3 months after reconstructive surgery. Full mesh course in addition to important pelvic structures were reconstructed using the 3D Slicer® software program based on T1w and T2w MRI. RESULTS: Three women with POP-Q grade III cystoceles were successfully treated with a partially absorbable MRI-visible anterior vaginal mesh with six fixation arms and showed no recurrent cystocele at the 3-month follow-up examination. The course of mesh in the pelvis was visible on MRI in all three women. The mesh body and arms could be reconstructed allowing visualization of the full course of the mesh in relationship to important pelvic structures such as the obturator or pudendal vessel nerve bundles in 3D. CONCLUSIONS: The use of MRI-visible Fe3O4 polypropylene meshes in combination with post-surgical 3D reconstruction of the mesh and adjacent structures is feasible suggesting that it might be a useful tool for evaluating mesh complications more precisely and a valuable interactive feedback tool for surgeons and mesh design engineers.

Can 3D power Doppler identify levator ani vascularization at its pubic insertion?

INTRODUCTION AND HYPOTHESIS: The levator ani is the most important muscle in the pelvic floor. This pilot study using 3D power Doppler aimed to identify normal vascularization of the puborectalis/pubovisceralis muscle at its insertion in nulliparous and premenopausal women. METHODS: Forty nulliparous and premenopausal women were evaluated at the Gynecological Unit of a tertiary hospital. All women underwent a translabial ultrasound (US) with 3D power Doppler. Pubic insertion of the puborectalis/pubovisceralis muscle was assessed in the axial plane, and vascularization index (VI), flow index (FI), and vascularization-flow index (VFI) were calculated bilaterally. Volumes were analyzed offline by two independent observers, and interobserver agreement and correlation between variables was calculated. RESULTS: A high, statistically significant, correlation was found between the three US indices on each side (p < 0.005). No correlation was found between the US index and either of the demographic parameters of body mass index [(BMI), p > 0.241], or age (p > 0.398). The degree of correlation between the same index on the different sides was not statistically significant. CONCLUSION: Puborectalis/pubovisceralis muscle vascularization at its insertion can be identified using 3D Doppler US, but values differ substantially from those of the contralateral side.

Maternal floor infarction/massive perivillous fibrin deposition: a manifestation of maternal antifetal rejection?

OBJECTIVE: Massive perivillous fibrin deposition (MPFD) and maternal floor infarction (MFI) are related placental lesions often associated with fetal death and fetal growth restriction. A tendency to recur in subsequent pregnancies has been reported. This study was conducted to determine whether this complication of pregnancy could reflect maternal antifetal rejection. METHODS: Pregnancies with MPFD were identified (n = 10). Controls consisted of women with uncomplicated pregnancies who delivered at term without MPFD (n = 175). Second-trimester maternal plasma was analyzed for panel-reactive anti-HLA class I and class II antibodies. The prevalence of chronic chorioamnionitis, villitis of unknown etiology, and plasma cell deciduitis was compared between cases and controls. Immunohistochemistry was performed on available umbilical vein segments from cases with MPFD (n = 4) to determine whether there was evidence of complement activation (C4d deposition). Specific maternal HLA-antibody and fetal HLA-antigen status were also determined in paired specimens (n = 6). Plasma CXCL-10 concentrations were measured in longitudinal samples of cases (n = 28 specimens) and controls (n = 749 specimens) by ELISA. Linear mixed-effects models were used to test for differences in plasma CXCL-10 concentration. RESULTS: (i) The prevalence of plasma cell deciduitis in the placenta was significantly higher in cases with MPFD than in those with uncomplicated term deliveries (40% versus 8.6%, P = 0.01), (ii) patients with MPFD had a significantly higher frequency of maternal anti-HLA class I positivity during the second trimester than those with uncomplicated term deliveries (80% versus 36%, P = 0.01); (iii) strongly positive C4d deposition was observed on umbilical vein endothelium in cases of MPFD, (iv) a specific maternal antibody against fetal HLA antigen class I or II was identified in all cases of MPFD; and 5) the mean maternal plasma concentration of CXCL-10 was higher in patients with evidence of MPFD than in those without evidence of MFPD (P < 0.001). CONCLUSION: A subset of patients with MPFD has evidence of maternal antifetal rejection.

[Rectal cancer and Trousseau syndrome. Case report]. / Síndrome de Trousseau y cáncer de recto. Informe de un caso.

BACKGROUND: The Trousseau syndrome, first described in 1865, is the relationship of venous thromboembolisms and cancer. We present a case with rectal cancer and Trousseau syndrome. CLINICAL CASE: Female 40 years old, went to the Coloproctology Service for painless bleeding. A computed tomography report showed a tumor of 5 by 6 cm up 5 cm from the anal margin. Ultra-low anterior resection with colonic reservoir and loop ileostomy surgery was performed. The pathology report showed a semidiferenciate adenocarcinoma of the rectum and we established the stage as T3N0M0. Within 72 hours of her operation, she experienced sudden hypotension and painful abdominal distention. A second surgery was done finding necrosis of the colon from the splenic angle until the colonic reservoir with thrombi in the left colic artery, ischemic signs of bilateral fallopian tubes, ovaries, uterus, pelvic floor and the small intestine, 40 cm before ileostomy and ileon. Left hemicolectomy and colostomy was done. She was taken to intensive care where continuous administration of heparin was given; she died within 5 days because of multiorgan failure. CONCLUSIONS: The mechanism for this syndrome was unknown but there are several hypotheses, suggesting that hematological cancer patients are at an increased risk of deep vein thrombosis. Pancreatic cancer is the most common presentation with this syndrome (in 50% of cases). We suggested continuing with the standards of prevention of thromboembolism.

antecedentes: el síndrome de Trousseau se describió por primera vez en 1865; es la relación entre tromboembolismo venoso y cáncer. Objetivo: informar el caso de una paciente con cáncer de recto y síndrome de Trousseau. Caso clínico: paciente femenina de 40 años de edad que acudió al servicio de Coloproctología por rectorragia indolora. La TAC reportó un tumor de 5 por 6cm y del margen anal a 5cm. Se efectuó resección anterior ultrabaja, con reservorio colónico e ileostomía de protección. El reporte de patología fue de: adenocarcinoma semidiferenciado del recto, con clasificación T3N0M0. A las 72 horas del postoperatorio tuvo hipotensión arterial súbita y distensión abdominal dolorosa. En la reintervención quirúrgica se encontró: necrosis del colon desde el ángulo esplénico hasta el reservorio colónico, con trombos en meso, signos de isquemia en el útero, trompa de Falopio y ovarios, piso pélvico y 40 cm de intestino delgado, antes de la ileostomía e íleon. Se realizó hemicolectomía izquierda y colostomía. Se trasladó a la unidad de terapia intensiva donde continuó con la administración de heparina; falleció a los cinco días por insuficiencia multiorgánica. Conclusiones: el mecanismo de este síndrome se desconoce pero existen varias hipótesis: se ha sugerido que los cánceres hematológicos son los que tienen mayor riesgo de trombosis venosa profunda. El cáncer de páncreas se relaciona con este síndrome en 50% de los casos. Se sugiere continuar con las normas de prevención del tromboembolismo.

Anatomic relationships of single-incision midurethral slings.

OBJECTIVE: The objective of the study was to evaluate the anatomic relationships of anchor points of single-incision midurethral slings with 2 common placement trajectories. STUDY DESIGN: In 30 female pelvic halves, a probe was introduced through a suburethral tunnel following 45° and 90° angle trajectories. The corresponding anchor points were tagged. Distances to the obturator canal, accessory obturator vessels, dorsal vein of clitoris, and external iliac vein were recorded. RESULTS: Both suburethral tunnel trajectories and their respective anchor points remained caudad to the obturator internus muscle in 100% of dissections. The closest distance between either anchor point to the obturator canal was 1.6 cm. The closest distance from the 45° and 90° anchor points to the accessory obturator vessels was 1.6 and 1.5 cm, respectively. CONCLUSION: The anchor points of single-incision midurethral slings are in close proximity to vascular structures that could be injured with inadvertent entry into the retropubic space.

Ex vivo pharmacology of surgical samples of the uterosacral ligament. Part II: Effects of oxytocin and relaxin on arteries and vascular plexus.

AIMS: The uterosacral ligament (USL) contains prominent vessels, the function of which is unknown. Here we study the relationship between smooth muscle of the USL and the vascular bundles. METHODS: Native samples of arteries and vascular bundles were mounted in a perfusion chamber under the stereomicroscope. The effects of noradrenalin, carbachol, oxytocin, and relaxin were monitored by digital time-lapse video and quantified by image processing. RESULTS: Arteries were adrenergic and the smooth muscle in the adventitia cholinergic. Relaxin-2 shifted the dose response curve of noradrenalin to the right and widened the arterial lumen within 30 min. Oxytocin induced contraction of the adventitial smooth muscle leading to a slow opening of the artery. In a vascular bundle the differential pattern of both reactivities was demonstrated. CONCLUSIONS: In the USL the smooth muscle extends into the adventitial layer of blood vessels and forms a functional unit with the vascular plexus, which is regulated by relaxin and oxytocin.

Perfil clínico, funcional e sociodemográfico das pacientes com incontinência urinária atendidas em um serviço público de fisioterapia uroginecológica / Clinical, functional and sociodemographic profile of patients with urinary incontinence attended at public service of urogynecologic physiotherapy

Introdução: Alguns fatores estão associados ao desenvolvimentoda incontinência urinária (IU), porém, existem poucos estudosque descrevem o perfil das mulheres com IU que procuram assistênciafisioterapêutica. Objetivo: Caracterizar e investigar possíveiscorrelações entre o perfil sociodemográfico e o diagnóstico clínico efuncional das mulheres com IU atendidas em um serviço público deFisioterapia Uroginecológica. Material e métodos: Foram levantadosos dados: idade, escolaridade, raça, profissão, tipo de IU, estadohormonal, presença de contração muscular perineal e função dacontração muscular do assoalho pélvico (escala Perfect), por meio defichas de avaliação de 452 pacientes. Para a análise estatística utilizou--se os testes Qui-quadrado, exato de Fisher, t de Student, ANOVAcom pós-teste de Tukey. Resultados: A maioria das pacientes era daraça branca e se encontrava no período pós-menopausa. A maiormédia de idade foi encontrada no grupo de pacientes com IU deurgência. Os tipos mais frequentes de IU foram IU de esforço e IUmista. As pacientes que exerciam a profissão de empregada domésticaapresentaram menor endurance do que as pacientes que exerciamatividade profissional na posição sentada (p < 0,05). Conclusão: Opresente estudo permitiu caracterizar e observar correlações entreo perfil sociodemográfico e o diagnóstico clínico e funcional daspacientes.

Introduction: Some factors are associated with the developmentof urinary incontinence (UI), however, there are very few studies thatdescribe the profile of women with UI who seek physical therapy assistance.Purpose: To characterize and investigate possible correlationsbetween the sociodemographic profile and clinical and functionaldiagnosis of women with UI attended at a public urogynecologicalphysical therapy service. Methods: The following data were collected:age, education, race, occupation, type of incontinence, hormonalstatus, presence of perineal muscle contraction and the pelvicfloor muscle function (Perfect scale), by analysis of 452 patientsdossiers. For statistical analyses Chi-square test, Fisher exact test,Student t test and Anova (with Tukey posttest) were used. Results:Most patients were white and were in the postmenopausal period.The eldest patients were those with urge urinary incontinence. Themost frequent type of UI was stress urinary incontinence and mixedurinary incontinence. The housekeepers had lower endurance thanpatients with sedentary job (p < 0.05). Conclusion: Were observedcorrelations between the sociodemographic profile and the clinicaland functional diagnosis of the patients.

Combined ischemic and neuropathic insult to the anal canal in an animal model of obstetric-related trauma.

BACKGROUND: Childbirth, in particular, when it involves instrumental vaginal delivery, can result in direct trauma to the external anal sphincter muscle. In addition, a global injury to the pelvic floor, including neurovascular injury to the anal sphincter complex, may occur. OBJECTIVE: The aims of this study were to determine whether sensory drive from the anal canal and oxygenation of the external anal sphincter were compromised during simulated labor in a validated animal model of obstetric trauma. DESIGN: Fifteen female Wister rats were operated on. Group 1 (n = 5) underwent pelvic balloon compression for 1 hour to simulate increased pelvic pressure during childbirth. Somatosensory cortical potentials, evoked by electrically stimulating the anal canal, were tracked. In group 2 (sham), the balloons were not inflated. In group 3, tissue PO2 values of the external anal sphincter and femoral arterial blood flow were measured simultaneously during the period of balloon inflation. RESULTS: The peak amplitude of cortical evoked potentials was reduced (from 11.8 ± 1.5 µV to 3.1 ± 1.1 µV) during pelvic compression (p = 0.002, ANOVA). During this period, arterial blood flow to the hindlimb and the external anal sphincter tissue PO2 decreased by 20% (p < 0.001) and 60% (p < 0.001). CONCLUSION: Pelvic compression that mimics obstetric trauma is associated with diminished anocortical drive. This neural insult may be compounded by concomitant ischemia of the external anal sphincter.

Surgical anatomy of urogenital diaphragm and course of its vessels in exstrophy-epispadias.

OBJECTIVES: To report the surgical anatomy of the muscles of the urogenital diaphragm and the pattern of its vessels in the classic exstrophy bladder and incontinent epispadias. METHODS: A total of 11 patients, 9 with unoperated classic exstrophy and 2 with incontinent epispadias, who were >5 years old at presentation, were selected for the present study. Magnetic resonance imaging of the pelvis was performed using a 3.0 T magnetic resonance imaging scanner and an 8-channel coil. Computed tomography was performed for 5 patients using a multidetector row helical computed tomography scanner. Angiograms of the vessels of the urogenital diaphragm were also obtained using magnetic resonance imaging and computed tomography. RESULTS: A central perineal body was seen in all the patients, with attachment of the bulbospongiosus anteriorly, superficial transverse perinei laterally, and anal sphincter posteriorly. At the root of corpora, the ischiocavernosus muscle was also seen. The triangle among the ischiocavernosus, bulbospongiosus, and superficial transverse perinei muscle was accentuated and contained the perineal artery, indirectly indicating the course of the perineal nerve. The dorsal penile artery was nearer to the posterior edge of the ischiopubic ramus, before coursing on the lateral aspect of the anterior segment of the corpora. The deep transverse perinei muscle and laid open external urethral sphincter were also seen in the proximal planes of the urogenital diaphragm. CONCLUSIONS: First, all the muscles of the urogenital diaphragm, including the external urethral sphincter, were present in the exstrophy bladder. Second, the perineal artery and its sphincteric branches were in the triangular space between the ischiocavernosus, bulbospongiosus, and superficial transverse perinei muscle. Finally, the dorsal penile artery ran along the inner edge of the ischiopubic ramus before lying on lateral aspect of the corpora.

Sexual steroids in urogynecology.

The decline in sex hormone levels that accompanies the menopause has substantial effects on the tissues of the urogenital system, leading to atrophic changes. These changes can have negative effects on sexual and urinary function. The authors evaluate the repercussion of hypoestrogenism and sexual steroids on some elements of the pelvic floor and lower urinary tract. They summarize their research work and review significant published papers. They emphasize the changes in urinary mucosae, periurethral vessels, muscular layer, connective tissue, gene expression, autonomic nervous system receptors, as well as the main clinical aspects involved.

A serious bleeding complication with injury of the corona mortis with the TVT-Secur procedure.

We report a serious complication following a TVT-Secur procedure due to injury of the corona mortis requiring a surgical intervention for removal of 1 l of clotted blood from the space of Retzius. The corona mortis is an anomaly of the vessel combining the obturator and epigastric arteries passing over the superior pubic ramus, well known to hernia and orthopedic surgeons but probably less well known to gynecological surgeons.

Simultaneous measurement of pelvic floor muscle activity and vaginal blood flow: a pilot study.

INTRODUCTION: Dyspareunia, defined as persistent or recurrent genital pain associated with sexual intercourse, is hypothesized to be related to pelvic floor hyperactivity and to diminished sexual arousal. Empirical research to support these hypotheses is scarce and concentrates mostly on the role of either pelvic floor activity or genital arousal in female dyspareunia. Currently, however, there is no measurement device to assess pelvic floor activity and genital response simultaneously. AIM: The aim of this study was to investigate the validity of a new device that enables simultaneous measurement of pelvic floor activity and genital response in women. MAIN OUTCOME MEASURES: Genital arousal measured as vaginal pulse amplitude, and vaginal surface electromyogram (EMG). METHOD: Thirty sexually functional women participated. To investigate the accuracy of genital response measurement with the adapted photoplethysmograph, and the sensitivity of the device for involuntary changes in pelvic floor activity, vaginal pulse amplitude and vaginal surface EMG were monitored during exposure to emotional, including erotic, films. In addition, vaginal surface EMG was monitored during instructed pelvic floor contractions. RESULTS: The genital data obtained during emotional films proved accurate measurement of genital response. EMG values during the emotional films indicated limited sensitivity of the device for small, involuntary changes in pelvic floor activity due to emotional state. The EMG measurements during the instructed pelvic floor contractions proved sensitivity of the new probe to voluntary pelvic floor activity. CONCLUSION: It is concluded that following improvement of the sensitivity of the EMG measurement for small, involuntary changes in pelvic floor activity, the device will be a valuable tool in research on superficial dyspareunia.

[Endovascular procedures in case of cancers engaging the vessels of the small pelvis].

Cervix cancer is quite common nowadays. Its progress is followed by painful symptomatology, urosepsis, lymphedem, flebothrombosis and ischemia of the lower limbs. The surgical treatment and the following chemotherapy and radiotherapy causes proliferation of the fibroid tissue, which embraces and presses the vessels of the small pelvis. We are to depict two clinical cases in which the choice of the percutaneous transluminal angioplasty and the implementation of a covered stent - graft is preferable to the open surgery. During the predilatation with a balloon catheter, our first patient suffered of a vessel rupture, visualized on the intraoperative angiogram. The rupture of vessel during angioplasty usually demands open surgical correction, but endovascular procedure can provide a fast, efficient, and less aggressive method. Covered stent-grafts are applicable for both treatment and stabilization of vessel lesions.

Anatomical conditions for pelvic floor reconstruction with polypropylene implant and its application for the treatment of vaginal prolapse.

OBJECTIVE: The purpose of the surgical treatment of vaginal prolapse is not only the restoration of the anatomy but also of the visceral functioning. To maintain the quality of life for patients with recurrent vaginal prolapse, to reduce the failure rates of operations and to avoid a colpectomy or a colpocleisis at the same time, synthetic materials have been introduced in transvaginal reconstructive surgery of the pelvic floor. The TVM Group from France described the reconstruction of the pelvic floor with polypropylene implants in 2004. The aim of this study is to determine the anatomical position of the polypropylene implants after reconstruction of each compartment of the pelvic floor and to determine the relation of the implants to the major neighbouring neurovascular structures on the basis of corpse dissections. STUDY DESIGN: Following the technique of the TVM Group from France we present the pelvic floor reconstruction using Gynecare Prolift* (Ethicon, Sommerville, NJ, USA). To reach the aims of the study, anatomical dissections of the pelvic floor on three specially preserved anatomical specimens are performed after the placement of the implants. RESULTS: The anatomical dissections show that every defect in all three compartments of the pelvic floor can be repaired by using polypropylene implants. Between the implants and the major neighbouring neurovascular structures a safe distance exists with slight individual differences. CONCLUSION: The pelvic floor reconstruction using polypropylene implants is a treatment option especially for the surgical correction of the recurrent vaginal prolapse. If the surgeon has thorough anatomical knowledge and performs the surgical technique in the recommended manner, injuries of the major neighbouring neurovascular structures will be avoided. Clinical studies will analyze the long-term results after pelvic floor reconstruction using polypropylene implants.

Intravenous immunoglobulin in antiphospholipid syndrome and maternal floor infarction when standard treatment fails: a case report.

Obstetrical antiphospholipid syndrome (APS) is associated with maternal and fetal morbidity and mortality. Standard treatment with low-dose acetylsalicylic acid and unfractionated heparin has achieved up to a 70 to 80% likelihood of success. Conversely, up to 30% of women with APS will have further pregnancy losses, despite treatment. Intravenous immunoglobulin (IVIG) may be a promising adjuvant when standard treatment fails. We present a case of a 35-year-old woman with obstetrical APS and maternal floor infarction in prior pregnancy losses who continued to have further unsuccessful pregnancies despite standard treatment with acetylsalicylic acid and unfractionated heparin. On an investigational basis, she was prescribed concomitant IVIG and had two subsequent healthy newborns. IVIG appears to be promising in obstetrical patients with APS who are refractory to standard treatment. Prior history of maternal floor infarction may be a prognostic indicator for triple therapy for obstetrical APS.