Mid-term functional and quality of life outcomes of robotic and laparoscopic ventral mesh rectopexy: multicenter comparative matched-pair analyses.

BACKGROUND: The aim of this study was to compare patients' mid-term functional and quality of life (QoL) outcomes following robotic ventral mesh rectopexy (RVMR) and laparoscopic ventral mesh rectopexy (LVMR). METHODS: The data of consecutive female patients who underwent minimally invasive ventral mesh rectopexy for external or symptomatic internal rectal prolapse at 3 hospitals in Finland between January 2011 and December 2016 were retrospectively collected. Patients were matched by age and diagnosis at a 1:1 ratio. A disease-related symptom questionnaire was sent to all living patients at follow-up in July 2018. RESULTS: After a total of 401 patients (RVMR, n = 187; LVMR, n = 214) were matched, 152 patients in each group were included in the final analyses. The median follow-up times were 3.3 (range 1.6-7.4) years and 3.0 (range 1.6-7.6) years for the RVMR and LVMR groups, respectively. The postoperative QoL measures did not differ between the groups. Compared with the LVMR group, the RVMR group had lower postoperative Wexner Incontinence Score (median 5 vs. median 8; p < 0.001), experienced significant ongoing incontinence symptoms less often (30.6% vs. 49.0%; p < 0.001) and reported less postoperative faecal incontinence discomfort evaluated with the visual analogue scale (median 11 vs. median 39; p = 0.005). RVMR patients had a shorter hospital stay (2.2 days vs. 3.8 days; p < 0.001) but experienced more frequent de novo pelvic pain (31.8% vs. 11.8%; p < 0.001). CONCLUSION: RVMR and LVMR patients had equal functional and QoL outcomes. Those who underwent RVMR had lower mid-term anal incontinence symptom scores but suffered more frequent de novo pelvic pain.

Redo ventral rectopexy: is it worthwhile?

BACKGROUND: Minimally invasive ventral mesh rectopexy (VMR) is a widely used surgical treatment for posterior pelvic organ prolapse; however, evidence of the utility of revisional surgery is lacking. Our aim was to assess the technical details, safety and outcomes of redo minimally invasive VMR for patients with external rectal prolapse (ERP) recurrence or relapsed symptoms of internal rectal prolapse (IRP). METHODS: This is a retrospective cohort study of patients with recurrent ERP or symptomatic IRP who underwent redo minimally invasive VMR between 2011 and 2016. The study was conducted at three hospitals in Finland. Data collected retrospectively included patient demographics, in addition to perioperative and short-term postoperative findings. At follow-up, all living patients were sent a questionnaire concerning postoperative disease-related symptoms and quality of life. RESULTS: A total of 43 redo minimally invasive VMR were performed during the study period. The indication for reoperation was recurrent ERP in 22 patients and relapsed symptoms of IRP in 21 patients. In most operations (62.8%), the previously used mesh was left in situ and a new one was placed. Ten (23.3%) patients experienced complications, including 2 (4.7%) mesh-related complications. The recurrence rate was 4.5% for ERP. Three patients out of 43 were reoperated on for various reasons. One patient required postoperative laparoscopic hematoma evacuation. Patients operated on for recurrent ERP seemed to benefit more from the reoperation. CONCLUSIONS: Minimally invasive redo VMR appears to be a safe and effective procedure for treating posterior pelvic floor dysfunction with acceptable recurrence and reoperation rates.

Restored pelvic anatomy is preserved after laparoscopic and robot-assisted ventral rectopexy: MRI-based 5-year follow-up of a randomized controlled trial.

AIM: Our aim was to compare the long-term anatomical outcomes between robot-assisted ventral mesh rectopexy (RVMR) and laparoscopic ventral mesh rectopexy (LVMR) for external or internal rectal prolapse. METHOD: This study is a follow-up of a single-centre randomized controlled trial (RCT). Thirty patients were randomly allocated to RVMR (n = 16) or LVMR (n = 14). The primary end-point was maintenance of the restored pelvic anatomy 5 years after the operation, as assessed by magnetic resonance (MR) defaecography. Secondary outcome measures included the Pelvic Organ Prolapse Quantification (POP-Q) measures and functional results assessed using symptom questionnaires. RESULTS: Twenty-six patients (14 RVMR and 12 LVMR) completed the 5-year follow-up and were included in the study. The MRI results, POP-Q measurements and symptom-specific quality of life measures did not differ between the RVMR and LVMR groups. The MRI measurements of the total study population remained unchanged between 3 months and 5 years. In the Pelvic Floor Distress Inventory (PFDI-20), the RVMR group had lower symptom scores (mean 96.0, SD 70.7) than the LVMR group (mean 160.6, SD 58.9; P = 0.004). In the subscales of pelvic organ prolapse (POPDI-6) (mean 23.2, SD 24.3 vs mean 52.4, SD 22.4; P = 0.001) and the Colorectal-Anal Distress Inventory (CRADI-8) (mean 38.4, SD 23.3 vs mean 58.6, SD 25.4; P = 0.009), the patients in the RVMR group had significantly better outcomes. CONCLUSION: After VMR, the corrected anatomy was preserved. There were no clinically significant differences in anatomical results between the RVMR and LVMR procedures 5 years after surgery based on MR defaecography. However, functional outcomes were better after RMVR.

A prospective pilot study on MRI visibility of iron oxide-impregnated polyvinylidene fluoride mesh after ventral rectopexy.

BACKGROUND: Magnetic resonance imaging (MRI) provides excellent information about pelvic anatomy after ventral rectopexy, but the position of the conventional mesh is not seen constantly. Iron oxide-impregnated polyvinylidene fluoride (PVDF) meshes are proven to have MRI visibility in hernia or vaginal reconstructive surgery. This prospective pilot study was designed to assess the visualization, position, and shape of the magnetic resonance (MR)-visible synthetic pelvic mesh used in minimally invasive ventral rectopexy. METHODS: Eight patients with pelvic organ prolapse were recruited for laparoscopic (LVMR) or robotic-assisted ventral mesh rectopexy (RVMR) with a synthetic MR-visible PVDF mesh. A follow-up visit was scheduled at 3 months after surgery. MR imaging was performed to evaluate the position and dimensions of the mesh and anatomical result. The visibility of the mesh in each sequence was assessed subjectively. RESULTS: The visibility of the mesh was best on T1-weighted flash images. The mesh was also well visualized on T2-weighted sagittal images. T2-weighted images, in general, provided best visualization of the surrounding anatomical structures and enabled assessment of the mesh fixation. CONCLUSIONS: T2 sagittal and T1-weighted flash images provide the best information about the position and integrity of the iron oxide-impregnated PVDF mesh after LVMR or RVMR with a short examination time.

Autologous and homologous fibrinogen sealants: adhesive strength.

The adhesive strength of autologous fibrinogen sealants prepared from the individual patient's blood with the help of ammonium sulphate or polyethylene glycol was compared to that of a homologous commercial fibrinogen sealant. The concentration of the fibrinogen harvested by each method was measured. The bonding power measurements were carried out by gluing pieces of human dura, rat skin, or cotton cloth together. The commercial fibrinogen sealant yielded the highest concentration of fibrinogen and also proved to be the strongest of the glues tested. The PEG glue was better than the AS glue. Humidity did not have a significant influence on adhesive strength, nor did deep-freezing worsen the properties of the fibrinogen sealants. In addition to the commercial products, the self-made fibrinogen glues, especially the PEG glue, were also strong enough for otolaryngological use.

Treatment of mandibular fractures. Need for rigid internal fixation.

The treatment of 200 mandibular fractures was evaluated retrospectively with special reference to the need for rigid internal fixation (AO-plating), as indicated by the ASIF organization. It was shown that the treatment was most typically intermaxillary fixation (50%) followed by Gunning-type splints (17%), wire (16%) and plate (6%) osteosynthesis, while 11% received no active treatment. Complications during splinting were most common among patients treated by osteosynthesis via an extra-oral approach. Most of the fractures (73%) were estimated to be anatomically suitable for AO-plating. One fifth (22%) had relative indications for the use of rigid internal fixation, and 59% had absolute indications, mostly due to simultaneous condylar and corpus (body) fractures or due to fractures in the angle region.

A comparison of three vibrators in static posturography: the effect of vibration amplitude on body sway.

In static posturography, proprioception is often disturbed using vibrators applied bilaterally to the calf muscles. The effect of vibrator amplitude on body sway was compared in static posturography using bilateral vibrators on the calf muscles of 30 healthy male military conscripts at frequencies of 50 and 90 Hz. Postural stability was measured in terms of BSV (body sway velocity), and maximal displacements of the centre of force (MAXY, MAXX) in the anterio-posterior and lateral directions. In comparing the effects of vibration to base stance without vibration, BSV seemed to be the most sensitive parameter. A vibration of 50 and 90 Hz significantly influenced BSV values with the two most eccentric loads, an effect which could not be confirmed using any other parameter. This result could be obtained even with a small amplitude (around 0.7 mm free/0.3 mm fixed) in our healthy subjects. The BSV effects may be even more pronounced in clinical work with patients and postural disorders. Thus, when proprioceptive stimulations is used in posturographic measurements, differences in the tested magnitude of the stimulation amplitude with a constant frequency will significantly affect postural stability, even in healthy subjects.

Immediate correction of congenital nasal deformities; follow-up of 8 years.

A total of 4724 newborns was screened for congenital nasal deformities. Altogether 91 (1.9%) pathological, screening-positive cases were found. Because of refusal to participate, 3 pathological cases were lost leaving 88 cases. The first 55 screening positive newborns were left without treatment while an attempt was made by an otolaryngologist to correct the remaining 33 cases within a week from delivery. Eighty-two newborns of those who passed the screening tests were analyzed as a control group. In 1987, at the age of 8 years the case and control children were interviewed by mailed questionnaire and invited to be re-examined by an ENT-surgeon. Forty-seven of the not corrected, 21 of the corrected cases and 61 controls came to the re-examination. The luxated septal cauda tended to be straight both spontaneously as well as after active treatment. The few mid-septal pathologies (vomerine junction) in the corrected group were resistant to the treatment attempted. The mid-septal deformities found in the follow-up were connected with frequent antibiotic prescriptions but not respiratory infections. No increase in frequency of otitis media or sinusitis was noticed. The immediate treatment of nasal deformities did not significantly affect the clinical status of the nose at the follow-up. Thus the benefit of immediate treatment on nasal deformities in newborns and screening to find them remains questionable.

Radiography of the maxillary sinus mucosal surface with Tantalum.

Experiments were made with powdered Tantalum insufflated through a puncture trocar into 12 healthy maxillary sinuses and into 8 diseased sinuses. The spread of the powder was good enough to depict all the surfaces of the sinus if there was no secretion, irrespective of mucosal changes, but unsatisfactory if the sinus contained secretion. The Tantalum powder did not cause any harm to the patients and the clearance of this contrast medium gave additional information on the functional capacity of the sinus.

Does posturography differentiate malingerers from vertiginous patients?

Voluntary, simulated vertigo and acute vertigo due to vestibular neuritis were examined by means of static posturography in 81 tests to evaluate the extent to which intentional malingering can be detected. Thirty healthy, normal subjects were first instructed to stand as still as possible on a static force platform and then to simulate dizziness. The true cases consisted of 21 patients with vestibular neuritis. The parameters analyzed included body sway velocity (BSV), body sway area of ellipse (BSE), and the Romberg quotient. Both the simulated and pathological posturographic BSV and BSE values differed from normal values under all test conditions, but they did not differ from each other, whereas the simulated values could be differentiated from the pathological ones with the Romberg quotient based on BSV. Five staff members of our audiological department were able to differentiate between the simulations and pathological cases quite well, with a median sensitivity of 0.77 and a specificity of 0.71 in a blinded test. A posturographic measurement, even performed once, can be useful to some extent for detecting simulation, but more investigation and development of the analysis system is required to obtain more specific results. For the present, the results obtained by trained observation of the subject in the test situation are at least as reliable as those obtained through the analysis of statistical measurements.

The repeatability of posturographic measurements and the effects of sleep deprivation.

The repeatability of posturographic measurements and the effects of sleep deprivation on them were investigated in 23 volunteers over a period of four months. Postural stability was studied by evaluating body sway velocity and the maximal and average vibration-induced shifts of the centre of pressure in the anterio-posterior and lateral directions. The posturographic test was performed with and without exposure of the calf muscles to vibration. Subjects were tested both with their eyes open and closed, and the measurements were performed weekly during the first month and once every month thereafter. The interindividual results differed more than the intraindividual ones, indicating that posturographic measurements are most suitable for functional monitoring in one person's tests. The dispersion of the results did not diminish with time, nor did the body sway decrease. The findings suggest that no learning takes place in nontrained persons. In the second part of the research, measurements were performed twice after the subjects had been awake the previous night or 24 hours. Postural stability did not deteriorate in this situation.

Effect of positioning of the feet in posturography.

Static posturography has been developed from a basic research test to a widely used clinical tool for evaluating dizzy patients. Before any actual standardization can be achieved, however, several aspects of the test situations have to be evaluated, including the position of the feet. The quantitative significance of the standing position in posturographic measurements was evaluated with healthy volunteers studied under visual and nonvisual conditions, using 4 foot positions: heels together with the toes 30 degrees apart or at an angle of the volunteer's own choice, and the feet parallel and either 0 or 10 cm apart were studied separately. Each measurement was characterized in terms of 5 parameters (body sway velocity, vibration-induced shift of centre of force in anteroposterior and lateral directions, and maximum displacement of centre of force in the same directions). Body sway velocities were smallest when the feet were parallel and 10 cm apart. Although the position chosen by the subject was usually more stable than that with the toes 30 degrees apart, the difference was nonsignificant. According to our results, the standing position is not crucial in posturographic measurements provided that the distance between the heels is determined, and the subject can just as well choose the angle between the feet if the heels are kept together.

Static posturography and intravenous alcohol.

Twelve health subjects were assessed using static posturography before and after intravenous alcohol infusion in a double-blind experiment. The dose was 0.5 g ethanol per kg body weight in 15 minutes, which raised the blood alcohol concentration to a level of approximately 1 mg/mL. Among other parameters, the average body sway velocity (BSV) and area of body sway (BSA) were measured. BSV was the most sensitive parameter for detecting increased body sway after alcohol infusion, and a significant effect of alcohol on its values was seen at 0.46 to 1.0 mg/mL alcohol concentrations. The second best indicator was the BSA. There was a positive correlation between the BSV and the BSA. The other parameters were not affected. The Romberg quotient remained constant during the alcohol test. The test battery used was relevant to distinguish the effect of alcohol on balance. In this study, acute blood alcohol concentrations of around 0.5 to 1.0 mg/mL affected BSV more significantly than BSA. The authors do not, however, recommend the test for forensic purposes in examining drivers with alcohol in their blood, as there is too much interindividual dispersion in the results.

Ear protection against water-borne infection: an objective evaluation.

Eight different ear plug materials were tested, in 5 ears each, in artificial shallow underwater conditions for 30 minutes, in order to determine their efficacy in sealing the ear canals to avoid water-borne infections in ear canals and open middle ears. Most of the plugs tested would meet everyday requirements for protection, but the polymeric foam plugs, treated with petroleum jelly, and moldable plastic materials were most effective in protecting both the middle ear and the ear canal skin.

Assessment of bone conduction prosthesis in situ.

Conventional and bone anchored bone conduction hearing aids can be tested with skull simulating devices and the individual adjustment rely on time consuming psychoacoustic audiometry in free-field which can be quite demanding for the patient. A method is presented in which the hearing aid induced skull vibrations are collected with an acceleromotor and recorded on a digital audio tape. The recordings are analysed with Fast Fourier 'Transformation (FFT) by using a signal processor. The free-field test signal can be either narrow-band or white noise. Changes in frequency characteristics can be easily monitored with white noise as signal, harmonic distortion and dynamic response can be analysed reliably by using pure tones. The inter-individual comparisons can be made when calibration is based on skull vibrations at the individual bone-conduction hearing thresholds. Two case reports are presented and discussed.

Diagnostic delays in vestibular schwannoma.

OBJECTIVES: The literature on delays in vestibular schwannoma diagnosis is from the era before the routine use of magnetic resonance imaging. We evaluated such diagnostic delays and their impact on tumour size and on pre- and post-treatment morbidity, in a relatively recent patient series. STUDY DESIGN: Retrospective review. METHODS: A two-centre study was conducted, including 91 consecutive vestibular schwannoma patients diagnosed between 1992 and 2006. Data on the presenting symptom and the initial medical visit were obtained from primary care records completed at the time of the initial visit; data on the tumour and the clinical course were obtained from review of the hospital chart. Data on diagnostic delays were available for 59 patients. RESULTS: The median patient, professional and total diagnostic delays were three, four and 14 months, respectively. Unilateral hearing loss as the presenting symptom predicted an lengthened total diagnostic delay. Diagnostic delay had no impact on the tumour size at time of diagnosis or on the pre- and post-treatment morbidity. CONCLUSIONS: Delays in the diagnosis of vestibular schwannoma have shortened since the introduction of magnetic resonance imaging. Longer diagnostic delays do not seem to have significant consequences.

Speech recognition in noise. Development of a computerized test and preparation of test material.

In adaptable, Finnish language, "speech in noise" test was developed using a personal computer equipped with a sound card. each of the 1000 test items stored as a separate digitized wave form file on the hard disk of a personal computer consisted of disyllabic words on one stereo track and synchronized speech noise on the other. Because only a few randomly selected words are presented in this test for SRTN (speech recognition threshold in noise or S/N ratio corresponding to 50% recognition) the selection and equalization of test material is considered to be crucial to the achievement of reproducible results in short time. Equalization of the test items (word + noise) in accordance with degree of difficulty, by adapting the noise signal to the properties of the corresponding word, and selection of 510 of the initial 1,000 recordings with the smallest SDs are described. The effect of this procedure on the test-retest reliability of testing SRTN is evaluated. Despite contrary expectations, the procedure appears to have no effect on the reliability of the speech recognition threshold in noise (SD from 1.5 to 1.7 dB).

[Causes and mechanisms in dizziness]. / Orsaker och mekanismer vid yrsel.

A feeling of vertigo ensues if the senses mediate contradictory information, or if the information is misinterpreted in the brain. Long-term, and repeated vertigo are common, particularly in the elderly. Often it is a matter of benign positional vertigo but the root cause may be organic disease or a functional disorder. In most cases the diagnosis is made at anamnesis but, as this survey shows, vertigo may sometimes be difficult to investigate and its causal connections obscure.

Finnish speech in noise test: long-term reproducibility.

A computerized adaptive Finnish speech in noise test was developed recently. As part of the test's evaluation process the long-term stability of speech recognition threshold in noise (SRTN) was determined. The non-operated ears of 164 stapes surgery patients were assessed preoperatively and at 1, 7 and 19 months postoperatively. Short-term and long-term repeatability were equal. The absolute intraindividual differences were 1.5 dB on average.

Intratympanic gentamycin in severe Ménière's disease.

From 1982 to 1987, 20 patients with disabling attacks of vertigo and severe hearing loss due to unilateral Ménière's disease were treated with local intratympanic gentamycin. In 18 patients control of vertiginous attacks was achieved. Hearing deteriorated in 8 patients. In spite of complete control of attacks a disabling ablation type of unsteadiness and dizziness affected 7 patients. Two patients required additional treatment after 5-8 months remission. Intratympanic gentamycin seems to be a less useful method of treating severe unilateral Ménière's disease than previously stated. It is, however, a possible alternative to surgical labyrinthectomy with a fair chance of residual hearing preservation.