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1.
Zhonghua Wei Chang Wai Ke Za Zhi ; 23(1): 92-95, 2020 Jan 25.
Artigo em Chinês | MEDLINE | ID: mdl-31958939

RESUMO

Extralevator abdominoperineal excision (ELAPE) has been suggested to potentially improve oncological outcomes in advanced low rectal cancer patients. However, the urogenital function impairment as one of the main complications deteriorates the quality of life in these patients. The key point to prevent urogenital function impairment is to avoid autonomic nerve injury, including the superior and inferior hypogastric nerve plexus and neurovascular bundle. Three areas should be especially focused during surgery, including the posterolateral aspect of the prostate during the separation of the rectum from prostate, the lateral wall of ischioanal fossa and the area in front of anal canal. Previous presumption supposed that extended resection, though promoting oncologic outcomes, might lead to enlarged injury to surrounding vessels and nerves that deteriorated patients' urogenital function. But recent studies show that postoperative urogenital function outcomes of rectal cancer patients who underwent ELAPE are not inferior to conventional APE after the induction of minimal invasive approaches including laparoscopic and robotic surgery. Their quality of life can be comparable with patients who underwent conventional APE, and are even better in some particular area. Moreover, as further improvement of ELAPE procedure has been made, the concept of individualized ELAPE addressed the importance of personalized surgical procedure based on tumor stage and location, dedicating to avoid injury to vessels and nerves through preserving more surrounding tissues. Urogenital function outcomes, as part of postoperative outcomes, get more and more attention in recent years. We review current studies on urogenital function after ELAPE from anatomy to clinical research, in order to raise surgeons' attention of nerve preservation technique and to improve their understanding of ELAPE procedure.


Assuntos
Sistema Nervoso Autônomo/lesões , Traumatismos dos Nervos Periféricos/prevenção & controle , Protectomia/efeitos adversos , Protectomia/métodos , Neoplasias Retais/cirurgia , Sistema Urogenital/inervação , Sistema Nervoso Autônomo/cirurgia , Humanos , Diafragma da Pelve/lesões , Diafragma da Pelve/cirurgia , Períneo , Traumatismos dos Nervos Periféricos/etiologia , Protectomia/normas , Qualidade de Vida , Resultado do Tratamento , Sistema Urogenital/lesões , Sistema Urogenital/cirurgia
2.
Medicine (Baltimore) ; 99(1): e16791, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31895764

RESUMO

The present study aimed to investigate the feasibility of vaginal delivery combined with vaginal tightening surgery and perineal body repair.From January 2017 to April 2017, 5 cases underwent vaginal delivery combined with vaginal tightening surgery and perineal body repair. We retrospectively analyzed the clinical data.The incisions of 5 cases were all primary healing; vulva form was improved, and there were no postoperative hematoma, infection or vaginal mucosa prolapse. Sexual function was improved to different degrees. The pelvic muscle force test showed that both the type I and type II myofiber scores were increased.It is feasible to perform vaginal delivery combined with vaginal tightening surgery and perineal body repair, which is a safe and effective method for improving sex life and pelvic floor function.


Assuntos
Parto Obstétrico/efeitos adversos , Vagina/cirurgia , Adulto , Feminino , Humanos , Lacerações/etiologia , Lacerações/cirurgia , Diafragma da Pelve/fisiopatologia , Diafragma da Pelve/cirurgia , Períneo/lesões , Períneo/cirurgia , Gravidez , Qualidade de Vida , Vagina/fisiopatologia , Vulva/cirurgia
3.
BJOG ; 127(1): 88-97, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31544327

RESUMO

OBJECTIVE: To assess the short-term incidence of serious complications of surgery for urinary incontinence or pelvic organ prolapse. DESIGN: Prospective longitudinal cohort study using a surgical registry. SETTING: Thirteen public hospitals in France. POPULATION: A cohort of 1873 women undergoing surgery between February 2017 and August 2018. METHODS: Preliminary analysis of serious complications after a mean follow-up of 7 months (0-18 months), according to type of surgery. Surgeons reported procedures and complications, which were verified by the hospitals' information systems. MAIN OUTCOME MEASURES: Serious complication requiring discontinuation of the procedure or subsequent surgical intervention, life-threatening complication requiring resuscitation, or death. RESULTS: Fifty-two women (2.8%, 95% CI 2.1-3.6%) experienced a serious complication either during surgery, requiring the discontinuation of the procedure, or during the first months of follow-up, necessitating a subsequent reoperation. One woman also required resuscitation; no women died. Of 811 midurethral slings (MUSs), 11 were removed in part or totally (1.4%, 0.7-2.3%), as were two of 391 transvaginal meshes (0.5%, 0.1-1.6%), and four of 611 laparoscopically placed mesh implants (0.7%, 0.2-1.5%). The incidence of serious complications 6 months after the surgical procedure was estimated to be around 3.5% (2.0-5.0%) after MUS alone, 7.0% (2.8-11.3%) after MUS with prolapse surgery, 1.7% (0.0-3.8%) after vaginal native tissue repair, 2.8% (0.9-4.6%) after transvaginal mesh, and 1.0% (0.1-1.9%) after laparoscopy with mesh. CONCLUSIONS: Early serious complications are relatively rare. Monitoring must be continued and expanded to assess the long-term risk associated with mesh use and to identify its risk factors. TWEETABLE ABSTRACT: Short-term serious complications are rare after surgery for urinary incontinence or pelvic organ prolapse, even with mesh.


Assuntos
Diafragma da Pelve/cirurgia , Prolapso de Órgão Pélvico/cirurgia , Telas Cirúrgicas/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Colposcopia/efeitos adversos , Colposcopia/mortalidade , Colposcopia/estatística & dados numéricos , Feminino , França/epidemiologia , Humanos , Incidência , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/mortalidade , Pessoa de Meia-Idade , Prolapso de Órgão Pélvico/mortalidade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Estudos Prospectivos , Sistema de Registros , Slings Suburetrais/efeitos adversos , Slings Suburetrais/estatística & dados numéricos , Telas Cirúrgicas/estatística & dados numéricos , Centros Cirúrgicos/estatística & dados numéricos , Adulto Jovem
5.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(10): 937-942, 2019 Oct 25.
Artigo em Chinês | MEDLINE | ID: mdl-31630490

RESUMO

The anorectum is a complex region, whose anatomic structure is the basis and premise of intersphincteric resection (ISR) for low rectal cancer. With the development of pelvic surgery and minimally invasive surgery, the anatomic approaches, surgical planes, extent of excision and reconstruction strategies of ISR have been better understood. Surgeons can furthest preserve anal function as well as adhere to the principles of radical resection. However, the anatomy of the anorectum has not been fully understood. We hope further exploration of the anal canal anatomy, including the perirectal fascia, rectourethral muscle, anococcygeal ligament, hiatal ligament, levator ani muscle, internal and externals phincter, intersphincteric nerves, conjointed longitudinal muscle, intersphincteric spaces and the surgical approaches, by reviewing relevant literatures combined with the experiences of our clinical practice and applied anatomy, will help to improve the accuracy of the surgeries and increase the oncologic and functional outcomes of ISR.


Assuntos
Canal Anal/patologia , Canal Anal/cirurgia , Pelve/cirurgia , Neoplasias Retais/patologia , Neoplasias Retais/cirurgia , Canal Anal/anatomia & histologia , Canal Anal/inervação , Fáscia/anatomia & histologia , Humanos , Diafragma da Pelve/anatomia & histologia , Diafragma da Pelve/patologia , Diafragma da Pelve/cirurgia , Pelve/anatomia & histologia , Pelve/patologia
7.
Zhonghua Fu Chan Ke Za Zhi ; 54(9): 608-614, 2019 Sep 25.
Artigo em Chinês | MEDLINE | ID: mdl-31550777

RESUMO

Objective: To investigate the similarities and differences between Chinese International Urogynecological Association (IUGA) members and international IUGA members on the treatment of pelvic organ prolapse (POP) and stress urinary incontinence (SUI) with polypropylene (PP) mesh and sling. Methods: Questionnaires were sent to Chinese IUGA members by Email. The contents of the questionnaires included POP mesh, SUI slings, abdominal sacrocolpopexy (ASC), complications, patients' awareness of rights protection, litigation and database use.Chi-square test was used to compare the proportion of Chinese IUGA members and international IUGA members to the problem alternatives. Results: A total of 31 Chinese IUGA members (100%, 31/31) responded to the questionnaire. All Chinese IUGA members (100%, 31/31) recognized and used PP sling to treat SUI, 98% (917/936) of international IUGA members had used and continued to use PP sling. For ASC surgery, 81% (25/31) of Chinese IUGA members and 82% (768/936) of international IUGA members agreed with and implemented the operation (P=0.841), while 94% (29/31) of Chinese IUGA members and 72% (674/936) of international IUGA members had the same or increased surgical volume as before (P=0.019). For the treatment of POP by transvaginal implantation of PP mesh, Chinese IUGA members had significant differences with international IUGA members in terms of whether they had used (P=0.002), were using (P<0.001), reasons for not using mesh (P<0.001), and indications of mesh implantation (P<0.001). Totally 81% (25/31) of Chinese IUGA members used various databases for monitoring and follow-up, while only 62% (580/936) of international IUGA members used databases, but there was no statistical difference (P=0.092). Conclusion: There are great differences in the concept and clinical application of transvaginal PP mesh implantation for POP between Chinese IUGA members and international IUGA members.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/métodos , Ginecologia/estatística & dados numéricos , Diafragma da Pelve/cirurgia , Prolapso de Órgão Pélvico/cirurgia , Polipropilenos , Telas Cirúrgicas , Incontinência Urinária por Estresse/cirurgia , Feminino , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Humanos , Masculino , Padrões de Prática Médica , Procedimentos Cirúrgicos Reconstrutivos , Inquéritos e Questionários , Incontinência Urinária por Estresse/fisiopatologia
8.
Zhonghua Fu Chan Ke Za Zhi ; 54(7): 445-451, 2019 Jul 25.
Artigo em Chinês | MEDLINE | ID: mdl-31365956

RESUMO

Objective: To assess the five-year effect of the transvaginal high uterosacral ligament suspension (HUS) with or without additional concomitant native-tissue anterior and (or) posterior repair in women suffering from middle compartment defect. Methods: A retrospective review of records identified 79 women who underwent transvaginal HUS with or without additional concomitant native-tissue anterior and (or) posterior repair from January 2007 to January 2018 in Fourth Medical Center, General Hospital of People's Liberation Army. The middle compartment defects were predominant in these patients with point C no less than point Ba or Bp if accompanied with anterior or posterior vaginal wall prolapse. Follow-up visits were performed 2,6 and 12 months after surgery and then annually. Anatomic results of pelvic organ prolapse (POP) was established by pelvic examination using pelvic organ prolapse quantitation system (POP-Q) staging. Funtional results were obtained by patient global impression of improvement (PGI-I) scale in POP, pelvic floor distress inventory-short form 20 (PFDI-20) and pelvic floor impact questionnaire short form (PFIQ-7). Surgical success required the fulfillment of all 3 criteria: (1) anterior or posterior vaginal wall prolapsed leading edge of 0 cm or less and apex of 1/2 total vaginal length or less; (2) the absence of POP symptoms as reported on the PFDI-20 question No.3 ( "Do you usually have a bulge or something falling out that you can see or feel in your vaginal area?" ); and (3) no prolapse reoperations or pessary use during the study period. Results: Of 79 women, 51(65%, 51/79) women completed the five-year follow-up during the study period. The median follow-up time was 5.2 years (2.8-8.3 years). The overall surgery success rate was 86% (44/51) according to above all 3 criteria. Prolapse recurrence rates were isolated anterior 8% (4/51), isolated apical 0, isolated posterior 2% (1/51) and multiple compartments 4% (2/51). Seven women (14%,7/51) developed anterior or posterior prolapse beyond the hymen with the leading edge≤1 cm. No apical prolapsed occurred. None of recurrent women underwent retreatment,including either surgery or pessary usage at last follow-up. The subjective satisfaction rate was 90% (46/51). There was a 1% (1/79) rate of intraoperative ureteral kinking and 3% (2/79) rate of postoperative morbidity. Conclusions: The transvaginal HUS for middle compartment defect offers good long-term anatomical results with excellent vault suspension. With additional concomitant native-tissue anterior and (or) posterior repair, it will be a reconstructive surgery for the majority of moderate-to-severe POP. It is minimal traumatic and worthy of being popularized for clinical application.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/métodos , Ligamentos/cirurgia , Prolapso de Órgão Pélvico/cirurgia , Vagina/cirurgia , China , Feminino , Humanos , Diafragma da Pelve/cirurgia , Prolapso de Órgão Pélvico/patologia , Pessários , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Sacro/cirurgia , Slings Suburetrais , Resultado do Tratamento
10.
Biomed Res Int ; 2019: 9051963, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31080834

RESUMO

Background: Pelvic organ prolapses (POP) and overactive bladder (OAB) may coexist and both negatively impact quality of life in women. The correlation between POP and OAB remains unclear, but these patients may have the OAB resolution after the surgical treatment of POP. Aim of our study was to assess the anatomical results and the effect on OAB symptoms in women who underwent laparoscopic lateral suspension for POP. Materials and Methods: This prospective study included all women with apical POP who underwent surgical repair with laparoscopic uterine lateral suspension from January 2016 to December 2017. The baseline and the 1-year follow-up included post-void residual measurement, urinalysis, vaginal examination, OAB symptoms evaluation, and administration of questionnaires (PFDI-20, UDI 6). Results: 64 women underwent laparoscopic lateral suspension for uterine prolapse and 78.1% had concomitant anterior vaginal wall defect. At 1-year follow-up the anatomic success rates were 84.4% for the apical and 76.2% for the anterior compartment. The comparison between OAB symptoms before and after the surgical procedure showed the resolution of OAB in 76% of the women, while de novo OAB was present in 2.6%. With the questionnaires 95.3% (61/64) of our patients were satisfied after the POP repair. We documented a trend in ameliorating of OAB regardless of the POP-Q stage. However, the Pearson test showed this correlation as statistically significant only in women with anterior vaginal wall defect stage III and apical stage II. No patient had vaginal exposure of the polypropylene mesh. Conclusion: Our data show how laparoscopic lateral suspension is an effective procedure for apical and anterior vaginal wall defects. This study provides further evidence for the concept that OAB in women with POP >II stage improves after a successful POP surgery. These women may benefit from a resolution of OAB and POP symptoms with the improvement of patient's quality of life.


Assuntos
Laparoscopia/métodos , Prolapso de Órgão Pélvico/complicações , Prolapso de Órgão Pélvico/cirurgia , Bexiga Urinária Hiperativa/complicações , Bexiga Urinária Hiperativa/cirurgia , Adulto , Idoso , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Satisfação do Paciente , Diafragma da Pelve/cirurgia , Prolapso de Órgão Pélvico/psicologia , Estudos Prospectivos , Qualidade de Vida , Telas Cirúrgicas , Inquéritos e Questionários , Resultado do Tratamento , Bexiga Urinária Hiperativa/patologia , Bexiga Urinária Hiperativa/psicologia , Prolapso Uterino/cirurgia , Vagina/cirurgia
11.
Ann Surg Oncol ; 26(8): 2514-2515, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31102088

RESUMO

BACKGROUND: Robotic surgery is increasingly performed for low rectal cancer.1 A redundant sigmoid colon makes retraction and pelvic dissection challenging. We present a 'pelvis-first' approach to robotic proctectomy where pelvic dissection occurs prior to colonic mobilization. METHODS: A 26-year-old woman was diagnosed with a clinical T3N1 rectal adenocarcinoma at 3 cm from the anal verge. The patient had Lynch syndrome, with a germline mutation in the PMS2 gene. A near-complete clinical response was observed after neoadjuvant chemoradiation (NCRT), and the patient wished to delay surgery and permanent colostomy. Additional FOLFOX was administered and led to a complete clinical response. After 2.5 months of watchful delay of surgery, the tumor regrew, and the patient then underwent robotic abdominoperineal resection (APR). RESULTS: Initial exploration revealed a highly redundant sigmoid colon. A pelvis-first approach was undertaken. The colon was left tethered and outside of the pelvis during the pelvic dissection. The levator ani was divided transabdominally. Vascular dissection and left colon mobilization were completed after pelvic dissection.2 The specimen was removed transanally, obviating the need for abdominal incision. An end colostomy was created laparoscopically, and the perineum was closed primarily after omental flap. The patient recovered without complications. CONCLUSIONS: The 'pelvis-first' approach to proctectomy is advantageous for patients with a highly redundant sigmoid colon. Transabdominal division of the levator ani during APR ensures excellent circumferential margin. Although Lynch syndrome-associated rectal cancer can show excellent response to NCRT,3 patients undergoing watchful delay of surgery require close monitoring and prompt triggering of salvage proctectomy when tumor regrowth is observed.4,5.


Assuntos
Adenocarcinoma/cirurgia , Colo/cirurgia , Diafragma da Pelve/cirurgia , Protectomia/métodos , Neoplasias Retais/cirurgia , Robótica/métodos , Adenocarcinoma/patologia , Adulto , Colo/patologia , Feminino , Humanos , Diafragma da Pelve/patologia , Prognóstico , Neoplasias Retais/patologia
12.
BJOG ; 126(8): 1065-1073, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30924606

RESUMO

OBJECTIVE: Robot-assisted surgery is a recognised treatment for pelvic-organ prolapse. Many of the surgical subgroup outcomes for apical prolapse are reported together, leading to a paucity of homogenous data. DESIGN: Prospective observational cohort study (NCT01598467, clinicaltrials.gov) assessing outcomes for homogeneous subgroups of robot-assisted apical prolapse surgery. SETTING: Two European tertiary referral hospitals. POPULATION: Consecutive patients undergoing robot-assisted sacrocolpopexy (RASC) and supracervical hysterectomy with sacrocervicopexy (RSHS). METHODS: Anatomical cure (simplified Pelvic Organ Prolapse Quantification, sPOPQ, stage 1), subjective cure (symptoms of bulge), and quality of life (Pelvic Floor Impact Questionnaire, PFIQ-7). MAIN OUTCOME MEASURES: Primary outcome: anatomical and subjective cure. SECONDARY OUTCOMES: surgical safety and intraoperative variables. RESULTS: A total of 305 patients were included (RASC n = 188; RSHS n = 117). Twelve months follow-up was available for 144 (RASC 76.6%) and 109 (RSHS 93.2%) women. Anatomical success of the apical compartment occurred for 91% (RASC) and in 99% (RSHS) of the women. In all compartments, the success percentages were 67 and 65%, respectively. Most recurrences were in the anterior compartment [15.7% RASC (symptomatic 12.1%); 22.9% RSHS (symptomatic 4.8%)]. Symptoms of bulge improved from 97.4 to 17.4% (P < 0.0005). PFIQ-7 scores improved from 76.7 ± 62.3 to 13.5 ± 31.1 (P < 0.0005). The duration of surgery increased significantly for RSHS [183.1 ± 38.2 versus 145.3 ± 29.8 (P < 0.0005)]. Intraoperative complications and conversion rates were low (RASC, 5.3 and 4.3%; RSHS, 0.0 and 0.0%). Four severe postoperative complications occurred after RASC (2.1%) and one occurred after RSHS (1.6%). CONCLUSIONS: This is the largest reported prospective cohort study on robot-assisted apical prolapse surgery. Both procedures are safe, with durable results. TWEETABLE ABSTRACT: European bi-centre trial concludes that robot-assisted surgery is a viable approach to managing apical prolapse.


Assuntos
Colposcopia/métodos , Histerectomia/métodos , Diafragma da Pelve/cirurgia , Prolapso de Órgão Pélvico/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Idoso , Colo do Útero/cirurgia , Feminino , Humanos , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Sacro/cirurgia , Centros de Atenção Terciária , Resultado do Tratamento
13.
Medicine (Baltimore) ; 98(8): e14616, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30813190

RESUMO

Hysterectomy is a potential risk factor for subsequent surgery for pelvic organ prolapse, especially when the prolapse exists before hysterectomy. Women without prolapse before hysterectomy may also experience prolapse after hysterectomy. This study aimed to describe a surgical modification of laparoscopic colposuspension with round ligaments after hysterectomy in women without preexisting genital prolapse and to evaluate the initial surgical results in these patients.We reviewed data of 54 patients who underwent laparoscopic hysterectomy with colposuspension with unilateral or bilateral round ligaments after hysterectomy at Chia-Yi Chang Gung Memorial Hospital from July 2012 to March 2015. Vaginal length was measured before and after colposuspension after complete hysterectomy. Preoperative characteristics of the patients, perioperative quality, postoperative outcomes, and vaginal length differences were analyzed.Vaginal length increased by a mean of 2.59 cm after colposuspension. The mean extra-operative time needed for laparoscopic colposuspension was about 10 minutes. No severe complications were reported in our patients, and we did not find any cystocele after completing vaginal cuff suspension to the round ligament.The vaginal apex level was maintained in our modified laparoscopic hysterectomy. Therefore, laparoscopic colposuspension with round ligaments is a promising option as a routine, first-line standard procedure in younger women without genital prolapse to maintain an acceptable vaginal length after laparoscopic hysterectomy.


Assuntos
Histerectomia/métodos , Laparoscopia/métodos , Prolapso de Órgão Pélvico/prevenção & controle , Ligamento Redondo do Útero/cirurgia , Vagina/cirurgia , Adulto , Feminino , Humanos , Histerectomia/efeitos adversos , Laparoscopia/efeitos adversos , Pessoa de Meia-Idade , Diafragma da Pelve/cirurgia , Prolapso de Órgão Pélvico/etiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos
14.
Eur J Obstet Gynecol Reprod Biol ; 236: 154-159, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30927707

RESUMO

OBJECTIVE: To evaluate the effectiveness of infiltration with ropivacaine 0.5% on controlling postoperative pain in women undergoing vaginal hysterectomy (VH) and pelvic floor repair for prolapse stage > II. STUDY DESIGN: This double-blind randomized 1:1 placebo-controlled trial included 59 women. Thirty millilitres of ropivacaine 0.5% or placebo was infiltrated in the round and uterosacral ligaments and in the perineal body. Primary outcomes included postoperative pain intensity at rest and during cough (measured using 10-cm visual analogue scale), and proportion of patients reporting moderate/severe pain. Secondary outcomes included morphine consumption and assessment of nausea, vomiting and sedation. Outcomes were compared between groups at 2, 4, 8 and 24 h postoperatively. Statistical (p-values) and clinical significance {effect size [Cliff's delta] [95% confidence interval (CI)] and odds ratio (95% CI)} of results were assessed. Outcomes are presented as median (min-max) and n (%). RESULTS: Pain intensity was lower after ropivacaine infiltration compared with placebo at 2 and 4 h postoperatively at rest [0.5 (0.1-7.2) vs 1.1 (0.2-9.3) (p = 0.007) and 1.3 (0.1-5.1) vs 3.1 (0.1-9.8) (p = 0.02), respectively] and during cough [0.9 (0.1-8.9) vs 1.9 (0.1-10) (p = 0.03) and 1.6 (0.1-4.7) vs 3.2 (0.3-9.6) (p = 0.009), respectively]. The proportion of patients with moderate/severe pain was significantly less after ropivacaine infiltration compared with placebo at 2, 4 and 8 h postoperatively at rest [4% vs 32% (p = 0.03), 16% vs 44% (p = 0.03) and 12% vs 40% (p = 0.02), respectively] and during cough [8% vs 40% (p = 0.008), 16% vs 52% (p = 0.007) and 20% vs 52% (p = 0.02), respectively]. Patients in the ropivacaine group consumed significantly less morphine compared with those in the placebo group up to 24 h postoperatively [4 (0-17) mg vs 7 (0-19) mg (p = 0.02)]. The incidence of nausea and vomiting was 3 (12%) and 0-2 (0-8%) in the ropivacaine group, compared with 1-7 (4-28%) and 1-4 (4-16%) in the placebo group. No significant difference was found in the proportion of patients using morphine, proportion of patients reporting the presence of nausea/vomiting, and the intensity of sedation between the groups (all p > 0.05). CONCLUSION: Local infiltration with ropivacaine 0.5% significantly reduces postoperative pain and morphine consumption in patients undergoing VH and pelvic floor repair for advanced pelvic organ prolapse.


Assuntos
Anestésicos Locais/uso terapêutico , Histerectomia Vaginal/métodos , Dor Pós-Operatória/prevenção & controle , Diafragma da Pelve/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Ropivacaina/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Método Duplo-Cego , Feminino , Humanos , Pessoa de Meia-Idade , Resultado do Tratamento
15.
J Urol ; 202(2): 406-412, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30840542

RESUMO

PURPOSE: We determined the safety and efficacy of intraoperative magnetic resonance imaging guided surgical reconstruction of bladder exstrophy for the identification of the urogenital diaphragm fibers and the thickened muscular attachments between the posterior urethra, bladder plate and pubic rami. MATERIALS AND METHODS: Institutional review board and U.S. Food and Drug Administration approval was obtained for the use of Brainlab (Munich, Germany) intraoperative magnetic resonance imaging guided navigation of the pelvic floor anatomy during closure of classic bladder exstrophy and cloacal exstrophy at our institution. Preoperative pelvic 3-dimensional magnetic resonance imaging was obtained 1 day before closure in patients undergoing pelvic osteotomies. Intraoperative registration was performed after preoperative planning with a pediatric radiologist using 5 anatomical landmarks immediately before initiation of surgery. Accuracy of pelvic anatomy identification was assessed by 2 pediatric urological surgeons and 1 pediatric radiologist. RESULTS: In 43 patients with classic bladder exstrophy and 4 patients with cloacal exstrophy closed at our institution, Brainlab technology was used successfully to navigate and guide the dissection of the pelvic floor intraoperatively. In all patients there was 100% accuracy in the correlation of gross anatomical landmarks with 3-dimensional magnetic resonance imaging identified landmarks intraoperatively, and all patients had successful closure without any major complications. CONCLUSIONS: Brainlab intraoperative 3-dimensional magnetic resonance imaging guided pelvic floor navigation and dissection is an effective way to accurately identify pelvic anatomy during classic bladder exstrophy and cloacal exstrophy closure. This technology offers a unique opportunity for surgical skill education in this complex reconstructive operation.


Assuntos
Extrofia Vesical/diagnóstico por imagem , Extrofia Vesical/cirurgia , Imagem Tridimensional , Imagem por Ressonância Magnética , Diafragma da Pelve/diagnóstico por imagem , Diafragma da Pelve/cirurgia , Cirurgia Assistida por Computador , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Imagem por Ressonância Magnética/métodos , Masculino , Resultado do Tratamento , Procedimentos Cirúrgicos Urológicos/efeitos adversos , Procedimentos Cirúrgicos Urológicos/métodos
16.
J Minim Invasive Gynecol ; 26(5): 816-825, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30708118

RESUMO

OBJECTIVE: To determine the effect of bariatric surgery (BS) on the prevalence of pelvic floor dysfunctions (PFD), specifically on urinary incontinence (UI), pelvic organ prolapse (POP), and fecal incontinence (FI). DATA SOURCES: A systematic review (PROSPERO registration no. CRD42017068452) with a literature search was performed using the PubMed, Scopus, and SciELO databases for all publications related to BS and PFD, with no language restrictions, from inception to September 2018. METHODS OF STUDY SELECTION: Two authors screened for study eligibility and extracted data. Only prospective cohorts assessing women with morbid obesity and the prevalence of PFD before and after BS in multiple academic and private centers were included. UI, POP, and FI were defined according to the International Urogynecological Association/International Continence Society joint consensus, and diagnosis was made based on self-report or questionnaires. TABULATION, INTEGRATION, AND RESULTS: Our search strategy retrieved 957 results. Of those, 28 studies were included for full analysis, and 20 studies (n = 3684 patients) were selected for final analysis. The main reasons for exclusion were missing data before and after BS (n = 7) and combined data of men and women who underwent BS (n = 1). Laparoscopic Roux-en-Y gastric bypass was the most common surgical technique. Pooled analysis (16 studies) showed that women had a mean body mass index reduction of 12.90 kg/m2 after treatment (95% confidence interval [CI], -14.82 to -10.97; p < .0001). The relative risk reduction was 67% (n = 19; odds ratio [OR], 0.33; 95% CI, 0.26-0.41; p < .0001) for UI, 52% (n = 5; OR, 0.48; 95% CI, 0.22-1.07; p = .07) for POP, and 20% (n = 9; OR, 0.80; 95% CI, 0.53-1.21; p = .29) for FI. Funnel plots for UI and FI did not suggest any publication bias. With regard to the standardized questionnaires for PFD, the International Consultation on Incontinence-Short Form, Pelvic Floor Impact Questionnaire-7 and its subscale Colorectal-Anal Impact Questionnaire-7, Pelvic Floor Distress Inventory-20, and its subscale Urinary Distress Inventory-6 showed statistically significantly lower scores. Sexual function, represented by the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12, showed no statistically significant improvement after surgery. CONCLUSION: BS has a significant impact on reducing UI, but FI and POP, in obese women.


Assuntos
Cirurgia Bariátrica/métodos , Obesidade Mórbida/complicações , Diafragma da Pelve/cirurgia , Prolapso de Órgão Pélvico/complicações , Índice de Massa Corporal , Incontinência Fecal/epidemiologia , Feminino , Humanos , Obesidade Mórbida/cirurgia , Distúrbios do Assoalho Pélvico/epidemiologia , Distúrbios do Assoalho Pélvico/cirurgia , Prolapso de Órgão Pélvico/fisiopatologia , Prolapso de Órgão Pélvico/cirurgia , Prevalência , Estudos Prospectivos , Fatores de Risco , Comportamento Sexual , Inquéritos e Questionários , Incontinência Urinária/cirurgia , Perda de Peso
17.
Eur J Obstet Gynecol Reprod Biol ; 235: 42-48, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30784826

RESUMO

OBJECTIVE: To compare the effects and complications of caesarean section (CSD) and vaginal delivery (VD) for pelvic floor function of parturients. METHODS: Multiple databases were searched for full-text articles regarding the clinical effects and complications of CSD and VD. Review Manager 5.0 was used for meta-analyses, sensitivity analysis and bias analysis. RESULTS: In total, 4491 patients were included in nine studies that met the eligibility criteria. Of these, 1527 women underwent CSD and 2944 women had a VD. The meta-analyses suggested significant differences in pelvic floor muscle strength [mean difference (MD) -11.94, 95% confidence interval (CI) -12.48 to -11.39, p < 0.00001, p for heterogeneity <0.00001, I² = 93%], vaginal muscle voltage (MD -9.45, 95% CI -9.73 to -9.16, p < 0.00001, p for heterogeneity <0.00001, I² = 94%), maximum urinary flow rate (MD -5.67, 95% CI -5.94 to -5.39, p < 0.00001, p for heterogeneity <0.00001, I² = 96%), stress urinary incontinence [odds ratio (OR) 0.45, 95% CI 0.37-0.55, p < 0.00001, p for heterogeneity = 0.79, I² = 0%] and pelvic organ prolapse (OR 0.59, 95% CI 0.50-0.70, p < 0.00001, p for heterogeneity = 0.24, I² = 23%) between the CSD group and the VD group. CONCLUSION: This study demonstrated that CSD is the preferred mode of delivery for pregnant woman in terms of pelvic floor function.


Assuntos
Cesárea/efeitos adversos , Parto Obstétrico/efeitos adversos , Distúrbios do Assoalho Pélvico/etiologia , Diafragma da Pelve/fisiopatologia , Parto Obstétrico/métodos , Feminino , Humanos , Força Muscular , Razão de Chances , Parto , Diafragma da Pelve/cirurgia , Gravidez , Vagina/fisiopatologia
18.
Dis Colon Rectum ; 62(2): 196-202, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30640835

RESUMO

BACKGROUND: Ischiorectal fossa tumors are rare. OBJECTIVE: This study reviews a single institution's series of ischiorectal tumors with comparison against presacral tumors and assesses the utility of preoperative biopsy and angioembolization. DESIGN: This is a retrospective study. SETTINGS: This study was conducted at a quaternary referral center. PATIENTS: All patients with ischiorectal tumor treated between February 1995 and April 2017 were retrospectively reviewed. Tumors extending secondarily into the ischiorectal fossa and inflammatory pathologies were excluded. INTERVENTIONS: Preoperative biopsy, neoadjuvant therapy, angioembolization, and surgical excision of these tumors were reviewed. MAIN OUTCOME MEASURES: Demographic, perioperative, pathological, and oncologic outcomes were evaluated. RESULTS: Twenty-four patients (15 female; median age 54) were identified. Two-thirds were symptomatic. Forty-six percent had a palpable mass. All patients had CT and/or MRI. Fifty percent had a preoperative biopsy, of which 83% were diagnostic, and management was altered in 50%. All patients underwent surgical excision. Fifty-five percent had local excision, 38% had radical pelvic excision, and 8% had total mesorectal excision. Two patients had preoperative angioembolization. Both had successful R0 local excision. Morbidity occurred in 25%, with 1 major complication. There was no 30-day mortality. Histopathology demonstrated 17 soft tissue tumors (3 malignant), 2 GI stromal tumors, 1 neuroendocrine tumor, 1 Merkel cell carcinoma, 1 basaloid carcinoma, 1 epidermal cyst, and 1 lipoma. R0 resection was achieved in 75%. All patients were alive after a median follow-up of 33 months. Four patients developed recurrence at a median 10 months postoperatively. All recurrences were malignant, and 75% had had a R1 resection. LIMITATIONS: This study is limited by its small numbers. The quaternary institution source may introduce bias. CONCLUSIONS: Ischiorectal fossa tumors are heterogeneous and more likely to be malignant than presacral tumors. Biopsy can be useful if a malignant diagnosis is suspected and changes management in 50% of cases. Preoperative embolization may be useful for large vascular tumors. R0 resection is important to minimize recurrence. See Video Abstract at http://links.lww.com/DCR/A779.


Assuntos
Embolização Terapêutica , Tumores do Estroma Gastrointestinal/terapia , Terapia Neoadjuvante , Neoplasias Pélvicas/terapia , Neoplasias de Tecidos Moles/terapia , Procedimentos Cirúrgicos Operatórios , Adulto , Idoso , Biópsia , Carcinoma de Célula de Merkel/diagnóstico por imagem , Carcinoma de Célula de Merkel/patologia , Carcinoma de Célula de Merkel/terapia , Procedimentos Cirúrgicos do Sistema Digestório , Cisto Epidérmico/diagnóstico por imagem , Cisto Epidérmico/patologia , Cisto Epidérmico/terapia , Feminino , Tumores do Estroma Gastrointestinal/diagnóstico por imagem , Tumores do Estroma Gastrointestinal/patologia , Humanos , Lipoma/diagnóstico por imagem , Lipoma/patologia , Lipoma/terapia , Imagem por Ressonância Magnética , Masculino , Mesentério/cirurgia , Pessoa de Meia-Idade , Tumores Neuroendócrinos/diagnóstico por imagem , Tumores Neuroendócrinos/patologia , Tumores Neuroendócrinos/terapia , Duração da Cirurgia , Diafragma da Pelve/cirurgia , Neoplasias Pélvicas/diagnóstico por imagem , Neoplasias Pélvicas/patologia , Tomografia por Emissão de Pósitrons , Cuidados Pré-Operatórios , Procedimentos Cirúrgicos Reconstrutivos , Reto/cirurgia , Estudos Retrospectivos , Neoplasias de Tecidos Moles/diagnóstico por imagem , Neoplasias de Tecidos Moles/patologia , Tomografia Computadorizada por Raios X
19.
J Reconstr Microsurg ; 35(6): 425-429, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30658351

RESUMO

BACKGROUND: The purpose of this study is to describe our experience and outcomes in oncoplastic pelvic reconstruction for patients who underwent either vertical rectus abdominis musculocutaneous (VRAM) or omental flap following abdominoperineal resection (APR) at a single tertiary care institution. METHODS: All patients who underwent pelvic reconstruction following APR with either VRAM or omental flaps from January 1992 to January 2017 were retrospectively reviewed. Patient demographics and relevant comorbidities including chemotherapy and radiation therapy data were collected and analyzed. In addition, margin status at the time of oncologic resection was analyzed. Flap-specific data were collected for each approach. Oncologic data collected included cancer type, stage at time of APR, and rate of tumor recurrence within the flap. RESULTS: A total of 562 patients were identified who underwent pelvic reconstruction with either VRAM or omental pedicle flaps. Of these, 274 (48.8%) underwent VRAM reconstruction and 288 (51.2%) underwent omental flap reconstruction. All margins were negative at time of cancer ablation surgery. Complications data included: seroma (VRAM = 2 [0.36%]; omentum = 32 [5.69%], p < 0.0001), wound dehiscence (VRAM = 31 [5.52%]; omentum = 17 [3.02%], p = 0.022), abscess (VRAM = 4 [0.71%]; omentum = 27 [4.8%], p < 0.0001), cellulitis (VRAM = 2 [0.36%]; omentum = 10 [1.78%], p = 0.025). Statistical comparison of tumor recurrence between these two reconstructive approaches showed a significantly higher recurrence rate in omental flaps compared with VRAM flaps (p = 0.000127). CONCLUSION: The results of this study suggest a significantly higher tumor recurrence rate in omental flap pelvic reconstruction compared with VRAM flaps. This knowledge has the potential to influence surgical planning and flap selection in pelvic reconstruction.


Assuntos
Neoplasias Abdominais/cirurgia , Omento/transplante , Diafragma da Pelve/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Neoplasias Retais/cirurgia , Reto do Abdome/transplante , Retalhos Cirúrgicos/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Complicações Pós-Operatórias , Estudos Retrospectivos
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