Pelvic floor function after third and fourth degree perineal lacerations: a case-control study on quality of life.

BACKGROUND: The primary aim of this study was to compare the quality of life between women with obstetric anal sphincter injury (OASI) and women with intact perineum or minor vaginal tears following their first vaginal birth through a validated urogynaecological questionnaire. As a secondary aim, we wanted to identify the specific symptoms for pelvic floor dysfunction after a vaginal birth. METHODS: One hundred thirty-three cases (III- and IV-degree vaginal tears) and 133 controls (intact perineum or I- and II-degree vaginal tear) were asked to fill the PFDI-20 condition-specific and quality of life survey at three and 12 months after vaginal delivery. The survey evaluates pelvic floor dysfunction symptoms through three subsections: the Pelvic Organ Prolapse Distress Inventory (POPDI), the Colorectal-Anal Distress Inventory (CRADI), and Urinary Distress Inventory, (UDI). The scoring system ranges from 0 (no distress) to 100 (maximum distress) for each subsection, subsequently summed up to obtain the summary score (0 to 300). The patients recruited were asked to complete the survey at 3- and 12-months follow-up visit. Accordingly, data collection started. Categorical variables were subjected to Chi-square test or Fisher's Exact test. Quantitative variables were compared through Student's t-test or Mann-Whitney test. RESULTS: All surveys have shown statistically significant differences when comparing the cases to the control group. Consequently, PFDI-20 has shown a strong correlation between III- and IV-grade lacerations and pelvic floor dysfunction persistence at 12 months after delivery. Intestinal symptoms were the most reported disturbances among women with previous OASI. CONCLUSIONS: Major vaginal tears have demonstrated to have a strong impact on women's quality of life up to a follow-up of 12 months. The use of PFDI-20 questionnaire is a useful and valid tool in the diagnosis and follow-up of genital prolapse, fecal and urinary incontinence in primiparous women with a history of OASI. Thus, its application in clinical practice can help offering the most adequate rehabilitative treatment.

[A study on the surgical efficacy of modified laparoscopic levator ani muscle external abdominoperineal resection for the treatment of ultra-low rectal cancer patients].

Objective: Exploring the surgical effectiveness and post-operative recovery of modified laparoscopic levator ani muscle external abdominoperineal resection (L-ELAPE) in the treatment of ultra-low rectal cancer patients. Methods: In a retrospective study conducted at the Oncology Department of Xinxiang Central Hospital and the Fourth Clinical College of Xinxiang Medical University, we analyzed 107 patients with ultra-low rectal cancer who underwent surgical treatment from April 2017 to April 2022. Among them, 54 patients in the modified group were treated using the L-ELAPE technique, while 53 patients in the conventional group underwent the traditional ELAPE surgery. We compared the surgical operation metrics, post-operative pathological results, quality of life, and incidence of complications between the two groups. Results: The age of 54 patients in the modified group was (56.8±7.2) years old, with 53.7% (29 cases) being male; The age of 53 patients in the conventional group was (54.5±5.9) years old, with males accounting for 45.3% (24 cases). There was no statistically significant difference in surgical time between the modified group and the conventional group (P>0.05); The surgical bleeding volume, drainage tube placement time, first postoperative anal exhaust time, and hospitalization time of the modified group patients were (143.2±26.7) ml, (61.9±11.4) h, (5.5±1.6) d, and (10.5±2.2) d, respectively, which were shorter than those in the conventional group's (185.0±31.5) ml, (74.8±14.0) h, (6.4±1.7) d, and (12.2±2.8) d (all P values<0.05). There was no statistically significant difference in postoperative pathological TNM staging, vascular infiltration rate, nerve invasion rate, number of lymph nodes cleaned, and tumor differentiation degree between the two groups of patients (all P values>0.05); The incidence of surgical complications in the modified group was 7.41% (4 cases), lower than that in the conventional group (P<0.05) with 24.53%(13 cases). One month after surgery, the physiological health score of the modified group patients was (35.6±4.7) score, which was higher than the conventional group's (32.8±5.1) score (P<0.05). Conclusion: For patients with ultra-low rectal cancer, the use of the L-ELAPE treatment, compared to conventional methods, can effectively promote post-operative recovery and reduce the rate of surgical complications, which, to some extent, contributes to improving the post-operative quality of life for the patients.

[Dynamic magnetic resonance imaging of the pelvic floor: clinical application]. / Dynamische Magnetresonanztomographie des Beckenbodens: Klinische Anwendung.

BACKGROUND: Dynamic magnetic resonance imaging (MRI) of the pelvic floor plays a key role in imaging complex pelvic floor dysfunction. The simultaneous detection of multiple findings in a complex anatomic setting renders correct analysis and clinical interpretation challenging. OBJECTIVES: The most important aspects (anatomy of the pelvic floor, three compartment model, morphological and functional analysis, reporting) for a successful clinical use of dynamic MRI of the pelvic floor are summarized. MATERIALS AND METHODS: Review of the scientific literature on dynamic pelvic MR imaging with special consideration of the joint recommendations provided by the expert panel of ESUR/ESGAR in 2016. RESULTS: The pelvic floor is a complex anatomic structure, mainly formed by the levator ani muscle, the urethral support system and the endopelvic fascia. Firstly, morphological changes of these structures are analysed on the static sequences. Secondly, the functional analysis using the three compartment model is performed on the dynamic sequences during squeezing, straining and defecation. Pelvic organ mobility, pelvic organ prolapse, the anorectal angle and pelvic floor relaxation are measured and graded. The diagnosis of cystoceles, enteroceles, rectoceles, the uterovaginal as well as anorectal decent, intussusceptions and dyssynergic defecation should be reported using a structured report form. CONCLUSIONS: A comprehensive analysis of all morphological and functional findings during dynamic MRI of the pelvic floor can provide information missed by other imaging modalities and hence alter therapeutic strategies.

[Dynamic magnetic resonance imaging of the pelvic floor: Technical aspects]. / Dynamische Magnetresonanztomographie des Beckenbodens: Technische Aspekte.

BACKGROUND: Dynamic magnetic resonance imaging (MRI) of the pelvic floor plays a key role in imaging complex pelvic floor dysfunction. High-quality examination is crucial for diagnostic benefit but can be technically challenging. OBJECTIVES: The most important technical aspects (patient selection, patient preparation, MRI technology, MRI scan protocol, success control) for obtaining a state-of-the-art dynamic MRI of the pelvic floor are summarized. MATERIALS AND METHODS: Review of the scientific literature on dynamic pelvic MR imaging with special consideration of the joint recommendations provided by the expert panels of European Society of Urogenital Radiology/European Society of Gastrointestinal and Abdominal Radiology (ESUR/ESGAR) in 2016 and Society of Abdominal Radiology (SAR) in 2019. RESULTS: Examination with at least 1.5 T and a surface coil after rectal instillation of ultrasound gel is clinical standard. Dynamic MRI in a closed magnet with the patient in supine position is the most widespread technique. No clinically significant pathologies of the pelvic floor are missed compared to the sitting position in an open magnet. The minimum scan protocol should encompass static, high-resolution T2-imaging (i.e., T2-TSE) in three planes and dynamic sequences with high temporal resolution in sagittal (and possibly axial) plane (i.e., steady-state or balanced steady-state free precession) during squeezing, straining and evacuation. Detailed patient instruction and practicing prior to the scan improve patients' compliance and hence diagnostic quality. CONCLUSIONS: A technically flawless dynamic MRI of the pelvic floor according to these standards can provide information missed by other imaging modalities and hence alter therapeutic strategies.

[Imaging of the pelvic floor (MR defecography) : The surgeon's perspective]. / Bildgebung des Beckenbodens (MR-Defäkographie) : Die Sicht der Chirurgie.

BACKGROUND: Magnetic resonance defecography (MRD) plays a central role in diagnosing pelvic floor functional disorders by visualizing the entire pelvic floor along with pelvic organs and providing functional assessment of the defecation process. A shared understanding between radiology and surgery regarding indications and interpretation of findings is crucial for optimal utilization of MRD. OBJECTIVES: This review aims to explain the indications for MRD from a surgical perspective and elucidate the significance of radiological findings for treatment. It intends to clarify for which symptoms MRD is appropriate and which criteria should be followed for standardized results. This is prerequisite to develop interdisciplinary therapeutic approaches. MATERIALS AND METHODS: A comprehensive literature search was conducted, including current consensus guidelines. RESULTS: MRD can provide relevant findings in the diagnosis of fecal incontinence and obstructed defecation syndrome, particularly in cases of pelvic floor descent, enterocele, intussusception, and pelvic floor dyssynergia. However, rectocele findings in MRD should be interpreted with caution in order to avoid overdiagnosis. CONCLUSION: MRD findings should never be considered in isolation but rather in conjunction with patient history, clinical examination, and symptomatology since morphology and functional complaints may not always correlate, and there is wide variance of normal values. Interdisciplinary interpretation of MRD results involving radiology, surgery, gynecology, and urology, preferably in the context of pelvic floor conferences, is recommended.

Research progress in pelvic floor ultrasound for assessing the morphology and function of levator ani muscle in women. / ç›†åº•è¶ å£°è¯„ä¼°å¥³æ€§è‚›æè‚Œå½¢æ€åŠåŠŸèƒ½çš„ç ”ç©¶è¿›å±•.

Pelvic floor ultrasound can clearly visualize the position and morphology of pelvic floor organs, observe the pelvic organ prolapse in real-time, and quantify and analyze the degree of the levator ani muscle injury, which is the most common imaging method to assess the morphology and function of the levator ani muscle to date. The different ultrasound imaging techniques provide a variety of indicators, each with its own advantages and limitations.Furthermore, two-dimensional ultrasound is the basis of imaging, but it fails to detect cross-sectional images of the pelvic floor; three-dimensional ultrasound can acquire the axial plane of the levator hiatus; tomographic ultrasound imaging allows real-time observation of the levator ani muscle injury; shear wave elastography can provide a quantitative assessment of the contractility and elastic characteristics of the levator ani muscle in real-time. It is of great significance to summarize the basic principles of various ultrasound imaging techniques, summarize the ultrasound image characteristics of levator ani muscle and its hiatus in different populations and different states, and explore the cut-off values and diagnostic criteria-related ultrasound parameters for improving the diagnostic efficiency of pelvic floor ultrasound for levator ani muscle injury, leading to reducing missed diagnosis and misdiagnosis of lesions.

Four-dimensional reconstruction and characterization of bladder deformations.

BACKGROUND AND OBJECTIVE: Pelvic floor disorders are prevalent diseases and patient care remains difficult as the dynamics of the pelvic floor remains poorly understood. So far, only 2D dynamic observations of straining exercises at excretion are available in the clinics and 3D mechanical defects of pelvic organs are not well studied. In this context, we propose a complete methodology for the 3D representation of non-reversible bladder deformations during exercises, combined with a 3D representation of the location of the highest strain areas on the organ surface. METHODS: Novel image segmentation and registration approaches have been combined with three geometrical configurations of up-to-date rapid dynamic multi-slice MRI acquisitions for the reconstruction of real-time dynamic bladder volumes. RESULTS: For the first time, we proposed real-time 3D deformation fields of the bladder under strain from in-bore forced breathing exercises. The potential of our method was assessed on eight control subjects undergoing forced breathing exercises. We obtained average volume deviations of the reconstructed dynamic volume of bladders around 2.5% and high registration accuracy with mean distance values of 0.4 ± 0.3 mm and Hausdorff distance values of 2.2 ± 1.1 mm. CONCLUSIONS: The proposed framework provides proper 3D+t spatial tracking of non-reversible bladder deformations. This has immediate applicability in clinical settings for a better understanding of pelvic organ prolapse pathophysiology. This work can be extended to patients with cavity filling or excretion problems to better characterize the severity of pelvic floor pathologies or to be used for preoperative surgical planning.

[Clinical study of using basement membrane biological products in pelvic floor reconstruction during pelvic exenteration].

Objective: To investigate the value of reconstruction of pelvic floor with biological products to prevent and treat empty pelvic syndrome after pelvic exenteration (PE) for locally advanced or recurrent rectal cancer. Methods: This was a descriptive study of data of 56 patients with locally advanced or locally recurrent rectal cancer without or with limited extra-pelvic metastases who had undergone PE and pelvic floor reconstruction using basement membrane biologic products to separate the abdominal and pelvic cavities in the Department of Anorectal Surgery of the Second Affiliated Hospital of Naval Military Medical University from November 2021 to May 2022. The extent of surgery was divided into two categories: mainly inside the pelvis (41 patients) and including pelvic wall resection (15 patients). In all procedures, basement membrane biologic products were used to reconstruct the pelvic floor and separate the abdominal and pelvic cavities. The procedures included a transperitoneal approach, in which biologic products were used to cover the retroperitoneal defect and the pelvic entrance from the Treitz ligament to the sacral promontory and sutured to the lateral peritoneum, the peritoneal margin of the retained organs in the anterior pelvis, or the pubic arch and pubic symphysis; and a sacrococcygeal approach in which biologic products were used to reconstruct the defect in the pelvic muscle-sacral plane. Variables assessed included patients' baseline information (including sex, age, history of preoperative radiotherapy, recurrence or primary, and extra-pelvic metastases), surgery-related variables (including extent of organ resection, operative time, intraoperative bleeding, and tissue restoration), post-operative recovery (time to recovery of bowel function and time to recovery from empty pelvic syndrome), complications, and findings on follow-up. Postoperative complications were graded using the Clavien-Dindo classification. Results: The median age of the 41 patients whose surgery was mainly inside the pelvis was 57 (31-82) years. The patients comprised 25 men and 16 women. Of these 41 patients, 23 had locally advanced disease and 18 had locally recurrent disease; 32 had a history of chemotherapy/immunotherapy/targeted therapy and 24 of radiation therapy. Among these patients, the median operative time, median intraoperative bleeding, median time to recovery of bowel function, and median time to resolution of empty pelvic syndrome were 440 (240-1020) minutes, 650 (200-4000) ml, 3 (1-9) days, and 14 (5-105) days, respectively. As for postoperative complications, 37 patients had Clavien-Dindo < grade III and four had ≥ grade III complications. One patient died of multiple organ failure 7 days after surgery, two underwent second surgeries because of massive bleeding from their pelvic floor wounds, and one was successfully resuscitated from respiratory failure. In contrast, the median age of the 15 patients whose procedure included combined pelvic and pelvic wall resection was 61 (43-76) years, they comprised eight men and seven women, four had locally advanced disease and 11 had locally recurrent disease. All had a history of chemotherapy/ immunotherapy and 13 had a history of radiation therapy. The median operative time, median intraoperative bleeding, median time to recovery of bowel function, and median time to relief of empty pelvic syndrome were 600 (360-960) minutes, 1600 (400-4000) ml, 3 (2-7) days, and 68 (7-120) days, respectively, in this subgroup of patients. Twelve of these patients had Clavien-Dindo < grade III and three had ≥ grade III postoperative complications. Follow-up was until 31 October 2022 or death; the median follow-up time was 9 (5-12) months. One patient in this group died 3 months after surgery because of rapid tumor progression. The remaining 54 patients have survived to date and no local recurrences have been detected at the surgical site. Conclusion: The use of basement membrane biologic products for pelvic floor reconstruction and separation of the abdominal and pelvic cavities during PE for locally advanced or recurrent rectal cancer is safe, effective, and feasible. It improves the perioperative safety of PE and warrants more implementation.

The Impact of Pelvic Floor Physical Therapy on Bladder and Bowel Function After Obstetric Anal Sphincter Injury.

IMPORTANCE: Women with obstetric anal sphincter injury (OASI) are at increased risk of pelvic floor disorders. No standard of care exists for management of pelvic floor dysfunction after OASI. OBJECTIVES: The aims of this study were to evaluate the impact of pelvic floor physical therapy (PFPT) on bladder and bowel function after OASI and to describe adherence to PFPT. STUDY DESIGN: A retrospective cohort study of women with OASI presenting at a postpartum care clinic from 2017 to 2021 was conducted. Women were grouped according to PFPT attendance. Urinary Distress Inventory 6 (UDI-6) and Fecal Incontinence Severity Index (FISI) were administered at baseline and 6 months. RESULTS: A total of 430 women with OASI presented to a postpartum care clinic, of which 137 (31.9%) attended PFPT, and 293 (68.1%) did not attend. Baseline and 6-month questionnaires were completed by 169 women: 52 (30.8%) in the PFPT group and 117 (69.2%) in the non-PFPT group. Baseline UDI-6 and FISI scores were higher in the PFPT group. Improvement in UDI-6 was not different between groups (-5.8 ± 14.9 vs -3.7 ± 10.8, P = 0.36). The non-PFPT group had greater worsening of FISI compared with PFPT group (9.8 ± 15.2 vs 1.1 ± 11.5, P < 0.001). Sixty-six percent (n = 136) of women referred to PFFT attended at least 1 session, of which 32.4% (n = 44) completed all sessions. Completely adherent women were referred to PFPT earlier (18.5 vs 28.5 days postpartum, P = 0.027). CONCLUSIONS: Women in both the PFPT and non-PFPT groups reported improvement in bladder leakage 6 months after OASI. Women who did not attend PFPT had significant worsening of bowel leakage. Early referral to PFPT in women with pelvic floor dysfunction following OASI should be considered.

[Effect of pelvic peritoneum reconstruction on the prognosis of patients underwent laparoscopic low anterior resection of rectal adenocarcinoma].

Objective: To investigate the effect of pelvic peritoneum reconstruction on the prognosis of patients underwent laparoscopic low anterior resection of rectal adenocarcinoma. Methods: This retrospective cohort study included 97 patients who underwent laparoscopic low anterior resection of rectal adenocarcinoma in General Surgery Department, the First Affiliated Hospital of Soochow University from January 2017 to June 2021. According to the implementation of pelvic peritoneum reconstruction, the subjects were divided into study group (48 patients underwent pelvic peritoneum reconstruction after laparoscopic resection) and control group (49 patients not underwent pelvic peritoneum reconstruction). The two groups were compared in terms of Wexner score of anal function, anorectal manometry results, normal rate of defecation sensation, pelvic floor anatomical structure and postoperative complications. Five-year survival analysis was performed. Results: Patients in the study group and the control group were (61.25±10.38) years old and (59.47±11.40) years old (P>0.05). The proportions of male patients were 60.4% (29 cases) and 55.1% (27 cases) (P>0.05) in the study group and control group, respectively. At 3, 6 and 12 months after surgery, Wexner scores of anal function in the study group were lower than those in the control group [(14.29±2.07) vs (16.33±2.18), P<0.001; (9.57±2.34) vs (11.26±2.85), P=0.002; (5.41±1.36) vs (7.86±1.95), P<0.001, respectively]. The anal resting pressure and anal systolic pressure of the study group were higher than those of the control group [(56.29±7.31) mmHg vs (52.88±6.65) mmHg, P=0.018; (129.33±17.36) mmHg vs (110.45±15.22) mmHg, P<0.001, respectively] (1 mmHg=0.133 kPa). The rectal sensory volume, rectal maximum tolerance volume, and the length of anal high-pressure area in the study group were greater than those in the control group [(32.15±4.38) vs (29.76±4.29), P=0.008; (209.57±40.27) vs (184.39±37.56), P=0.002; (3.07±0.52) vs (2.80±0.49), P=0.010, respectively]. At 3 and 6 months after surgery, the normal rates of defecation sensation in the study group were 47.9% (23 cases) and 70.8% (34 cases), respectively, higher than those in the control group [26.5% (13 cases) and 51.0% (25 cases)] (P=0.029 and 0.046, respectively). The detection rate of intestinal tube accumulation in the study group was lower than that in the control group [12.5% (6 cases) vs 38.9% (19 cases)] (P=0.003). There was no significant difference in the total incidence of complications (anastomotic leakage, abdominal infection, intestinal obstruction, pendant pneumonia and urinary tract infection) between the two groups [18.8% (9 cases) vs 24.5% (12 cases)] (P=0.493). There was no significant difference in 5-year cumulative survival rate between the study group and the control group (71.6% vs 68.2%, P=0.309). Conclusion: Pelvic peritoneum reconstruction can improve postoperative anal function and reduce intestinal tube accumulation in patients underwent laparoscopic low anterior resection of rectal adenocarcinoma with high safety and feasibility.

Longitudinal changes in pelvic organ support among primiparas with postpartum pelvic organ prolapse: A follow-up magnetic resonance imaging study.

OBJECTIVE: To quantify morphological changes of pelvic floor in primiparas with postpartum pelvic organ prolapse (POP) during the early postpartum period. METHODS: A total of 309 primiparas underwent pelvic floor magnetic resonance imaging (MRI) at 6 weeks postpartum. Those primiparas diagnosed with postpartum POP by MRI criterion were followed up at 3 and 6 months postpartum. Normal primiparas were enrolled in the control group. The puborectal hiatus line, muscular pelvic floor relaxation line, levator hiatus area, iliococcygeus angle, levator plate angle, uterus-pubococcygeal line, and bladder-pubococcygeal line were assessed on MRI. Longitudinal changes in pelvic floor measurements between the two groups were compared by repeated-measures analysis of variance. RESULTS: Compared with the control group, enlarged puborectal hiatus line, levator hiatus area, and RICA and decreased uterus-pubococcygeal line were observed at rest in the POP group (all P < 0.05). All of the pelvic floor measurements were significantly different in the POP group compared with the control group at the maximum Valsalva maneuver (all P < 0.05). All of the pelvic floor measurements showed no significant change over time in both the POP and control groups (all P > 0.05). CONCLUSIONS: Postpartum POP accompanied by poor pelvic floor support will persist in the early postpartum period.

Colonoscopic findings in patients with pelvic floor dysfunction.

BACKGROUNDY: Colonoscopy is often performed in the initial workup of pelvic floor dysfunction, even in the absence of red flag symptoms. Current guidelines suggest colonoscopy is only required in the presence of rectal bleeding, diarrhoea or change in bowel habit. The aim of this study was to evaluate the prevalence of significant pathology found at colonoscopy in patients with pelvic floor dysfunction. METHODS: Retrospective chart review was performed on all patients presenting to a functional colorectal outpatient clinic between May 2018 and August 2019. Information was collected on presenting symptoms, whether colonoscopy had been performed within 5 years, quality of bowel preparation, withdrawal time, number of polyps detected, histology, presence of diverticular disease, colorectal malignancy, inflammatory bowel disease, solitary rectal ulcer or rectal prolapse. RESULTS: There were 260 patients seen within the study period, of which 67% had undergone recent colonoscopy within the last 5 years. The mean age was 53 and 219 (84%) patients were female. Average withdrawal time was 13 min. Polyps were found in 48.7% and adenomas in 32.4% of all colonoscopies. The adenoma detection rate was 32.7%. None of the colonoscopies found evidence of malignancy. A new diagnosis of inflammatory bowel disease was discovered in two patients. CONCLUSION: There was low rates of serious pathology such as malignancy or inflammatory bowel disease in patients referred to a functional clinic. However, colonoscopy is still useful in workup of pelvic floor dysfunction, as many patients have erratic bowel habits or vague symptoms, and will have adenomas found.

Management of female pelvic organ prolapse-Summary of the 2021 HAS guidelines.

When a patient presents with symptoms suggestive of pelvic organ prolapse (POP), clinical evaluation should include an assessment of symptoms, their impact on daily life and rule out other pelvic pathologies. The prolapse should be described compartment by compartment, indicating the extent of the externalization for each. The diagnosis of POP is clinical. Additional exams may be requested to explore the symptoms associated or not explained by the observed prolapse. Pelvic floor muscle training and pessaries are non-surgical conservative treatment options recommended as first-line therapy for pelvic organ prolapse. They can be offered in combination and be associated with the management of modifiable risk factors for prolapse. If the conservative therapeutic options do not meet the patient's expectations, surgery should be proposed if the symptoms are disabling, related to pelvic organ prolapse, detected on clinical examination and significant (stage 2 or more of the POP-Q classification). Surgical routes for POP repair can be abdominal with mesh placement, or vaginal with autologous tissue. Laparoscopic sacrocolpopexy is recommended for cases of apical and anterior prolapse. Autologous vaginal surgery (including colpocleisis) is a recommended option for elderly and fragile patients. For cases of isolated rectocele, the posterior vaginal route with autologous tissue should be preferentially performed over the transanal route. The decision to place a mesh must be made in consultation with a multidisciplinary team. After the surgery, the patient should be reassessed by the surgeon, even in the absence of symptoms or complications, and in the long term by a primary care or specialist doctor.

Electrospun nanofiber mesh with connective tissue growth factor and mesenchymal stem cells for pelvic floor repair: Long-term study.

Pelvic organ prolapse (POP) affects many women, with an estimated lifetime risk of surgical intervention of 18.7%. There is a need for alternative approaches as the use of synthetic nondegradable mesh was stopped due to severe adverse events, and as current methods for pelvic floor repair have high POP recurrence rates. Thus, we hypothesized that electrospun degradable meshes with stem cells and growth factor were safe and durable for the long term in elderly rats. In an abdominal repair model, electrospun polycaprolactone (PCL) meshes coated with connective tissue growth factor (CTGF)/PEG-fibrinogen (PF) and rat mesenchymal stem cells were implanted in elderly female rats and removed after in average 53 weeks (53-week group). Collagen amount and production were quantified by qPCR and Western blotting. Moreover, histological appearance and biomechanical properties were evaluated. Results were compared with previous results of young rats with identical mesh implanted for 24 weeks (24-week group). The 53-week group differed from the 24-week group in terms of (1) reduced collagen III, (2) strong reduction in foreign body response, and (3) altered histological appearance. We found comparable biomechanical properties, aside from higher, not significant, mean tissue stiffness in the 53-week group. Lastly, we identified mesh components 53 weeks after implantation. This study provides new insights into future POP repair in postmenopausal women by showing how CTGF/PF-coated electrospun PCL meshes with stem cells exhibit sufficient support, biocompatibility, and no mesh-related complications long term in an abdominal repair model in elderly rats.

Research progress in pelvic floor ultrasound for assessing the morphology and function of levator ani muscle in women / 中南大学学报(医学版)

Pelvic floor ultrasound can clearly visualize the position and morphology of pelvic floor organs, observe the pelvic organ prolapse in real-time, and quantify and analyze the degree of the levator ani muscle injury, which is the most common imaging method to assess the morphology and function of the levator ani muscle to date. The different ultrasound imaging techniques provide a variety of indicators, each with its own advantages and limitations.Furthermore, two-dimensional ultrasound is the basis of imaging, but it fails to detect cross-sectional images of the pelvic floor; three-dimensional ultrasound can acquire the axial plane of the levator hiatus; tomographic ultrasound imaging allows real-time observation of the levator ani muscle injury; shear wave elastography can provide a quantitative assessment of the contractility and elastic characteristics of the levator ani muscle in real-time. It is of great significance to summarize the basic principles of various ultrasound imaging techniques, summarize the ultrasound image characteristics of levator ani muscle and its hiatus in different populations and different states, and explore the cut-off values and diagnostic criteria-related ultrasound parameters for improving the diagnostic efficiency of pelvic floor ultrasound for levator ani muscle injury, leading to reducing missed diagnosis and misdiagnosis of lesions.

Clinical study of using basement membrane biological products in pelvic floor reconstruction during pelvic exenteration / 中华胃肠外科杂志

Objective: To investigate the value of reconstruction of pelvic floor with biological products to prevent and treat empty pelvic syndrome after pelvic exenteration (PE) for locally advanced or recurrent rectal cancer. Methods: This was a descriptive study of data of 56 patients with locally advanced or locally recurrent rectal cancer without or with limited extra-pelvic metastases who had undergone PE and pelvic floor reconstruction using basement membrane biologic products to separate the abdominal and pelvic cavities in the Department of Anorectal Surgery of the Second Affiliated Hospital of Naval Military Medical University from November 2021 to May 2022. The extent of surgery was divided into two categories: mainly inside the pelvis (41 patients) and including pelvic wall resection (15 patients). In all procedures, basement membrane biologic products were used to reconstruct the pelvic floor and separate the abdominal and pelvic cavities. The procedures included a transperitoneal approach, in which biologic products were used to cover the retroperitoneal defect and the pelvic entrance from the Treitz ligament to the sacral promontory and sutured to the lateral peritoneum, the peritoneal margin of the retained organs in the anterior pelvis, or the pubic arch and pubic symphysis; and a sacrococcygeal approach in which biologic products were used to reconstruct the defect in the pelvic muscle-sacral plane. Variables assessed included patients' baseline information (including sex, age, history of preoperative radiotherapy, recurrence or primary, and extra-pelvic metastases), surgery-related variables (including extent of organ resection, operative time, intraoperative bleeding, and tissue restoration), post-operative recovery (time to recovery of bowel function and time to recovery from empty pelvic syndrome), complications, and findings on follow-up. Postoperative complications were graded using the Clavien-Dindo classification. Results: The median age of the 41 patients whose surgery was mainly inside the pelvis was 57 (31-82) years. The patients comprised 25 men and 16 women. Of these 41 patients, 23 had locally advanced disease and 18 had locally recurrent disease; 32 had a history of chemotherapy/immunotherapy/targeted therapy and 24 of radiation therapy. Among these patients, the median operative time, median intraoperative bleeding, median time to recovery of bowel function, and median time to resolution of empty pelvic syndrome were 440 (240-1020) minutes, 650 (200-4000) ml, 3 (1-9) days, and 14 (5-105) days, respectively. As for postoperative complications, 37 patients had Clavien-Dindo < grade III and four had ≥ grade III complications. One patient died of multiple organ failure 7 days after surgery, two underwent second surgeries because of massive bleeding from their pelvic floor wounds, and one was successfully resuscitated from respiratory failure. In contrast, the median age of the 15 patients whose procedure included combined pelvic and pelvic wall resection was 61 (43-76) years, they comprised eight men and seven women, four had locally advanced disease and 11 had locally recurrent disease. All had a history of chemotherapy/ immunotherapy and 13 had a history of radiation therapy. The median operative time, median intraoperative bleeding, median time to recovery of bowel function, and median time to relief of empty pelvic syndrome were 600 (360-960) minutes, 1600 (400-4000) ml, 3 (2-7) days, and 68 (7-120) days, respectively, in this subgroup of patients. Twelve of these patients had Clavien-Dindo < grade III and three had ≥ grade III postoperative complications. Follow-up was until 31 October 2022 or death; the median follow-up time was 9 (5-12) months. One patient in this group died 3 months after surgery because of rapid tumor progression. The remaining 54 patients have survived to date and no local recurrences have been detected at the surgical site. Conclusion: The use of basement membrane biologic products for pelvic floor reconstruction and separation of the abdominal and pelvic cavities during PE for locally advanced or recurrent rectal cancer is safe, effective, and feasible. It improves the perioperative safety of PE and warrants more implementation.

Técnica de reconstrucción de ligamentos pélvicos según la Teoría Integral / Pelvic Ligament Reconstruction Technique According to Integral Theory

La patología de piso pélvico es una entidad multifactorial con un conjunto de síntomas ginecológicos, urinarios, fecales y de sensibilidad pelviperineal. La Teoría Integral de la Continencia propone un tratamiento holístico con la reconstrucción de los ligamentos del piso pélvico. La presente técnica propuesta constituye una alternativa quirúrgica que permite dar respuesta de forma global a los síntomas que refieren las pacientes. Método: Reconstrucción de los ligamentos pubouretrales, cardinales y úterosacros con acortamiento de su longitud y colocación de cinta de malla de polipropileno que permita la formación de colágeno y mejore los resultados a largo plazo. Resultados: Se incluyeron 15 pacientes con prolapso de órganos pélvicos, incontinencia urinaria, vulvodinia, nocturia, alteración del vaciamiento vesical y nocturia. Se realizó seguimiento al 1, 3 y 6 años. Se obtuvo diferencia estadísticamente significativa al año en la incontinencia urinaria de esfuerzo, dolor pélvico, alteración del vaciamiento y nocturia y prolapso ( p = 0,33, 0,033, 0,002 y 0,001 respectivamente). En el seguimiento a 6 años se evaluó el 20 % de la muestra inicial, 2 pacientes con recidiva de la alteración del vaciamiento y la incontinencia urinaria, ninguna con recidiva de prolapso. Vulvodinia: Se incluyeron 2 pacientes las cuales no tuvieron el síntoma a los 3 años de seguimiento. Conclusiones: La técnica propuesta es una alternativa para el tratamiento de la patología del piso pélvico y requiere aumentar el tamaño de la muestra para aumentar el aprendizaje de la técnica y tener mayor evidencia estadística de sus resultados a corto y largo plazo(AU)

Pelvic floor pathology is a multifactorial entity with a set of gynecological, urinary, fecal and pelviperineal sensitivity symptoms. The Integral Theory of Continence proposes a holistic treatment with the reconstruction of the ligaments of the pelvic floor. This proposed technique constitutes a surgical alternative that allows a global response to the symptoms reported by the patients. Method: Reconstruction of the pubourethral, cardinal and uterosacral ligaments with shortening of their length and placement of polypropylene mesh tape that allows collagen formation and improves long-term results. Results: 15 patients with pelvic organ prolapse, urinary incontinence, vulvodynia, nocturia, impaired bladder emptying and nocturia were included. Follow-up was performed at 1, 3 and 6 years. A statistically significant difference was obtained at one year in stress urinary incontinence, pelvic pain, impaired voiding, and nocturia and prolapse (p = 0.33, 0.033, 0.002, and 0.001, respectively). At 6-year follow-up, 20% of the initial sample was evaluated, 2 patients with recurrence of impaired voiding and urinary incontinence, none with recurrence of prolapse. Vulvodynia: 2 patients were included who did not have the symptom at 3 years of follow-up. Conclusions: The proposed technique is an alternative for the treatment of pelvic floor pathology. A larger sample is necessary to improve the learning curve of this technique and achieve greater statistical evidence of its outcomes at short and long term(AU)

Comparison of the Perineal Body Between Chinese Women With Pelvic Organ Prolapse and Women With Normal Support by Magnetic Resonance Imaging With 3-Dimensional Reconstruction.

OBJECTIVE: This study aimed to determine whether the perineal body (PB) is different between women with and without prolapse and to analyze its association with prolapse. METHODS: This cross-sectional observational study was performed in a tertiary-level urology department and included patients with stage II-IV pelvic organ prolapse (POP) and normal controls with all points 1 cm or more above the hymen. The patients underwent supine midsagittal magnetic resonance imaging (MRI) at rest and during the maximum Valsalva maneuver. Perineal mobility and PB length, height, perimeter, and area were measured; in addition, the genital hiatus and PB were measured according to the definition of the Pelvic Organ Prolapse Quantification system. Univariate associations of POP with characteristics were assessed using the chi-square test or Fisher exact test for categorical variables and the t test for continuous variables. Multivariate logistic regression analysis was used to estimate the adjusted odds ratios and 95% confidence intervals. RESULTS: Seventy-two controls and 130 patients were analyzed. The PB length, height, and area measurements were significantly lower in the POP group. The perineal mobility in different directions was significantly higher in the POP group. Multivariate analysis demonstrated that the PB area and perineal mobility in the ventral-dorsal and cranio-caudal directions were associated with POP. CONCLUSIONS: Our data suggest that a smaller PB area and greater dorsal or caudal mobility are associated with prolapse.

Application of depithelized gracilis adipofascial flap for pelvic floor reconstruction after pelvic exenteration.

BACKGROUND: Pelvic exenteration is a radical surgery performed in selected patients with locally advanced or recurrent pelvic malignancy. It involves radical en bloc resection of the adjacent anatomical structures affected by the tumor. The authors sought to evaluate the clinical application of a depithelized gracilis adipofascial flap for pelvic floor reconstruction after pelvic exenteration. METHODS: A total of 31 patients who underwent pelvic floor reconstruction with a gracilis adipofascial flap after pelvic exenterationat Peking University Third Hospital from 2014 to 2022 were enrolled in the study. The postoperative follow-up durations varied from 4 to 12 months. RESULTS: The survival rate of the flap was 96.77% with partial flap necrosis in one case. The total incidence of postoperative complications associated with the flap was 25.81%, with an incidence of 6.45% in the donor site and 19.35% in the recipient site. All complications were early complications, including postoperative infection and flap necrosis. All patients recovered after treatments, including anti-infectives, dressing change, debridement, and local flap repair. Long-term follow-up showed good outcomes without flap-related complications. CONCLUSIONS: A depithelized gracilis adipofascial flap can be applied for pelvic floor reconstruction after pelvic exenteration. The flap is an ideal and reliable choice for pelvic floor reconstruction with few complications, an elevated survival rate, sufficient volume, and mild effects on the function of the donor site.

Magnetic resonance imaging evaluation of the effectiveness of FemiCushion in pelvic organ prolapse.

AIMS: FemiCushion (FC) is a supportive device for pelvic organ prolapse (POP), but its effectiveness has not been evaluated with imaging studies. This study utilized magnetic resonance imaging (MRI) to evaluate the anatomic changes induced by FC use in patients with severe POP. METHODS: This prospective study examined patients with stage 3 or 4 POP who underwent treatment with FC and received a diagnostic MRI. Measurements were made in the midsagittal plane at rest and during straining with and without FC. The vertical distances from the lowest points of the anterior and posterior vaginal wall (A; P), uterine cervix or vaginal stump (C), and perineal body (PB) to the Pelvic Inclination Correction System line were measured, along with the lengths of the urogenital (UGH) and levator hiatus (LH). RESULTS: Twelve patients were included in the study. The median age was 72 (range, 56-84) years. All reference points were positioned significantly higher with the FC than without the FC (median ΔA: 11 mm, p = 0.005; ΔC: 14 mm, p = 0.011; ΔP: 6 mm, p = 0.008; ΔPB: 7 mm, p = 0.002). Median UGH and LH lengths during straining were significantly shorter with the FC than without the FC (UGH: 44 mm vs. 53 mm, p = 0.002; LH: 60 vs. 65 mm, p = 0.021). CONCLUSIONS: This is the first report on the use of MRI to measure the performance of FC. Our study demonstrates that FC effectively repositioned the organs involved in POP.