Dynamic pelvic magnetic resonance imaging and cystocolpoproctography alter surgical management of pelvic floor disorders

PURPOSE: Pelvic organ prolapse results in a spectrum of progressively disabling disorders. Despite attempts to standardize the clinical examination, a variety of imaging techniques are used. The purpose of this study was to evaluate dynamic pelvic magnetic resonance imaging and dynamic cystocolpoproctography in the surgical management of females with complex pelvic floor disorders. METHODS: Twenty-two patients were identified from The Johns Hopkins Pelvic Floor Disorders Center database who had symptoms of complex pelvic organ prolapse and underwent dynamic magnetic resonance, dynamic cystocolpoproctography, and subsequent multidisciplinary review and operative repair. RESULTS: The mean age of the study group was 58 ± 13 years, and all patients were Caucasian. Constipation (95.5 percent), urinary incontinence (77.3 percent), complaints of incomplete fecal evacuation (59.1 percent), and bulging vaginal tissues (54.4 percent) were the most common complaints on presentation. All patients had multiple complaints with a median number of 4 symptoms (range, 2–8). Physical examination, dynamic magnetic resonance imaging, and dynamic cystocolpoproctography were concordant for rectocele, enterocele, cystocele, and perineal descent in only 41 percent of patients. Dynamic imaging lead to changes in the initial operative plan in 41 percent of patients. Dynamic magnetic resonance was the only modality that identified levator ani hernias. Dynamic cystocolpoproctography identified sigmoidoceles and internal rectal prolapse more often than physical examination or dynamic magnetic resonance. CONCLUSIONS: Levator ani hernias are often missed by physical examination and traditional fluoroscopic imaging. Dynamic magnetic resonance and cystocolpoproctography are complementary studies to the physical examination that may alter the surgical management of females with complex pelvic floor disorders.Presented at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, June 24 to 29, 2000.No reprints are available.     

Treatment of enterocele by obliteration of the pelvic inlet

PURPOSE: Enterocele is defined as a herniation of the peritoneal sac between the vagina and the rectum. This hernial sac contains either sigmoid colon or small bowel. It is well known that enteroceles are associated with symptoms of pelvic discomfort. It is unclear whether enteroceles contribute to evacuation difficulties. Controversies also exist regarding their treatment of choice. The aim of the present prospective study was to evaluate the impact of obliteration of the pelvic inlet on evacuation difficulties and on symptoms of pelvic discomfort. METHODS: From October 1994 to August 1996 20 females (median age, 53; range, 41–73 years) with symptomatic enterocele diagnosed on evacuation proctography underwent obliteration of the pelvic inlet with a nonabsorbable Mersilene® mesh. All patients presented with pelvic discomfort, characterized by feelings of prolapse (n=20), pelvic pressure (n=16), lower abdominal pain (n=13), and false urge to defecate (n=15). Symptoms of obstructed defecation were noted in 15 patients. Six months after repair, evacuation proctography with opacification of the small bowel and the vagina was repeated. RESULTS: The median duration of follow-up was 25 (range, 10–34) months. A persistent or recurrent enterocele was observed in none of the patients. All symptoms of pelvic discomfort disappeared except feelings of a false urge to defectate, which persisted in 27 percent of cases. Symptoms of obstructed defecation persisted in all patients with evacuation difficulties. CONCLUSIONS: In patients with pelvic discomfort enterocele should be considered as a possible causative factor. It is unlikely that this abnormality contributes to the problem of obstructed defecation. In patients with a symptomatic enterocele, obliteration of the pelvic inlet with a Mersilene® mesh is an adequate treatment.Read at the XVIIth Biennial Congress of the International Society of University Colon and Rectal Surgeons, Malmö, Sweden, June 7 to 11, 1998.     

Recurrent rectal prolapse

PURPOSE: The aim of this study was to assess the clinical and functional outcome of surgery for recurrent rectal prolapse and compare it with the outcome of patients who underwent primary operation for rectal prolapse. METHODS: All patients who underwent surgery for rectal prolapse were evaluated for age, gender, procedure, anorectal manometry and electromyography findings, and morbidity. The results for patients who underwent surgery for recurrent rectal prolapse were compared with a group of patients matched for age, gender, surgeon, and procedure who underwent primary operations for rectal prolapse. RESULTS: A total of 115 patients underwent surgery for rectal prolapse. Twenty-seven patients, 10 initially operated on at this institution and 17 operated on elsewhere, underwent surgery for recurrent rectal prolapse. These 27 patients were compared with 27 patients with primary rectal prolapse operated on in our department. In the recurrent rectal prolapse group, prior surgery included rectopexy in 7 patients, Delorme's procedure in 7 patients, perineal rectosigmoidectomy in 7 patients, anal encirclement procedure in 4 patients, and resection rectopexy in 2 patients. Operations performed for recurrence were perineal rectosigmoidectomy in 14 patients, resection rectopexy in 8 patients, rectopexy in 2 patients, pelvic floor repair in 2 patients, and Delorme's procedure in 1 patient. There were no statistically significant differences between the groups in preoperative incontinence score (recurrent rectal prolapse, 13.6±7.8vs. rectal prolapse, 12.7±7.2; range, 0–20) or manometric or electromyography findings, and there were no significant differences in mortality (0vs. 3.7 percent), mean hospital stay (5.4±2.5vs. 6.9±2.8 days), anastomotic complications (anastomotic stricture (0vs. 7.4 percent), anastomotic leak (3.7vs. 3.7 percent) and wound infection (3.7vs. 0 percent)), postoperative incontinence score (2.8±4.8vs. 1.5±2.7), or recurrence rate (14.8vs. 11.1 percent) between the two groups at a mean follow-up of 23.9 (range, 6–68) and 22 (range, 5–55) months, respectively. The overall success rate for recurrent rectal prolapse was 85.2 percent. CONCLUSION: The outcome of surgery for rectal prolapse is similar in cases of primary or recurrent prolapse. The same surgical options are valid in both scenarios.Funded in part by a generous grant from the Eleanor Naylor Dana Charitable Trust Fund and the Caporella Family.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, June 22 to 26, 1997.     

Perineal descent and levator ani hernia: a dynamic magnetic resonance imaging study

PURPOSE: Patients with symptomatic pelvic organ prolapse often have multifocal pelvic floor defects that are not always evident of physical examination. In this study, dynamic magnetic resonance imaging of symptomatic patients with pelvic floor prolapse demonstrated unsuspected levator ani hernia. This study was designed to identify any specific symptoms and/or physical findings associated with these hernias.METHODS: Eighty consecutive patients with pelvic organ prolapse, fecal and/or urinary incontinence, or chronic constipation received standardized questionnaires, physical examination, and dynamic magnetic resonance imaging. Fishers exact test was used to compare symptoms and examination findings between patients with or without levator ani hernia.RESULTS: Twelve patients (15 percent) were found to have unilateral (n = 8) or bilateral (n = 4) levator ani hernias on dynamic magnetic resonance imaging. No one specific symptom was directly associated with the presence of a levator ani hernia. Furthermore, levator ani hernias were not found more frequently in patients with previous pelvic floor surgery. Perineal descent on physical examination was associated with the finding of a levator ani hernia in nine patients (P = 0.02). Although not statistically significant, there was a trend toward a lower incidence of levator ani hernia in females using estrogen replacement therapy (P = 0.06).CONCLUSIONS: Patients with symptomatic pelvic organ prolapse and perineal descent on physical examination may have a levator ani hernia. Although the significance of levator ani hernia needs to be determined, the recurrence rate after the surgical management of pelvic organ prolapse remains unacceptably high, and ongoing investigation of all associated abnormalities is warranted.Data were obtained from the Johns Hopkins Pelvic Floor Database. Poster presentation at The American Society of Colon and Rectal Surgery Meeting, Boston, Massachusetts, June 24 to 29, 2000.     

Surgical treatment of recurrent complete rectal prolapse

PURPOSE: Complete recurrent rectal prolapse (RRP) after initial prolapse surgery is well described. Our aim was to examine the possible causes for RRP, to learn of the operations performed most frequently, and to examine the outcome following recurrence surgery. METHODS: Patients with RRP were reviewed retrospectively from 1963 to 1993. RESULTS: A total of 24 patients (19 females) had RRP. Of these, 29 operations were performed; three patients had 2 RRP operations, and one patient had 3 RRP operations. Median age was 56 (range, 18–88) years. Median follow-up and median duration to recurrence were 6.75 (range, 0.08–17) years and 2 (range, 0.1–29) years. One patient had RRP at the end of the follow-up period. RRP occurred after 15 abdominal and 9 perineal operations. Treatment for RRP included 25 abdominal and 4 perineal operations. Causes for RRP were identified in 41 percent of cases and was most often attributable to problems with the mesh following the Ripstein procedure. Preoperative incontinence and constipation were largely unchanged by RRP operation. CONCLUSION: RRP occurred most commonly because of problems with the mesh, but no etiologic factor was found in the majority of patients. Abdominal operations were performed more frequently than perineal approaches for RRP. Elimination of prolapse can be obtained, but bowel dysfunction still remains in 60 percent of patients.     

Laparoscopic surgery for rectal prolapse and outlet obstruction

PURPOSE: The aim of this study was to assess the outcome of both laparoscopic suture rectopexy and resection-rectopexy in the treatment of complete and incomplete rectal prolapse, outlet obstruction, or both. METHODS: Data from surgery were collected prospectively. Semiannual follow-up was performed by assessment of recurrence, continence, and constipation using patients' history, physical examination, continence score, and anorectal manometry. Statistical analysis was performed by chi-squared test and Student'st-test (P<0.05 was accepted as statistically significant). RESULTS: Between September 1992 and February 1997, 72 patients (68 females) with a mean age of 62 (range, 23–88) years were treated laparoscopically. Indications for surgery were rectal prolapse in 21 patients, rectal prolapse combined with outlet obstruction in 36 patients, and outlet obstruction alone in 15 patients. Standard procedure was a laparoscopic suture rectopexy. A sigmoid resection was added in 40 patients. Mean duration of surgery was 227 (range, 125–360) minutes for rectopexy and 258 (range, 150–380) minutes for resection-rectopexy. Conversion was necessary in 1.4 percent (n=1). Overall complication rate was 9.7 percent (n=7) and mortality rate was 0 percent. Mean postoperative hospitalization was 15 (range, 6–47) days. All patients with a minimal follow-up of two years (n=53) could be enrolled in a prospective follow-up study (mean follow-up, 30 months). No recurrence of rectal prolapse had to be recognized. Sixty-four percent of patients with incontinence before surgery were continent or had improved continence. In patients experiencing constipation preoperatively, constipation was improved or completely removed in 76 percent. No additional symptoms of constipation occurred after surgery. CONCLUSION: Laparoscopic procedures in the treatment of pelvic floor disorders,e.g., rectal prolapse or outlet obstruction, lead to acceptable functional results. However, follow-up has to be extended and long-term results of recurrence, continence, and constipation have to be evaluated.     

Management of Recurrent Rectal Prolapse: Surgical Approach Influences Outcome

Introduction Recurrent rectal prolapse is an unresolved problem and the optimal treatment is debated. This study was designed to review patterns of care and outcomes in a large cohort of patients after surgery for recurrent prolapse. Methods From 685 patients who underwent operative repair for full-thickness external rectal prolapse, we identified 78 patients (70 females; mean age, 66.9 years) who underwent surgery for recurrence. We reviewed the subsequent management and outcomes for these 78 patients. Results Mean interval to their first recurrence was 33 (range, 1–168) months. There were significantly more re-recurrences after reoperation using a perineal procedure (19/51) compared with an abdominal procedure (4/27) for their recurrent rectal prolapse (P = 0.03) at a mean follow-up of nine (range, 1–82) months. Patients undergoing abdominal repair of recurrence were significantly younger than those who underwent perineal repair (mean age, 58.5 vs. 71.5 years; P < 0.01); however, there was nosignificant difference between the two groups with regard to the American Society of Anesthesiologists classification (P = 0.89). Eighteen patients had surgery for a second recurrence, with perineal repairs associated with higher failure rates (50 vs. 8 percent; P = 0.07). Finally, when combining all repairs, the abdominal approach continued to have significantly lower recurrence rates (39 vs. 13 percent; P < 0.01). Conclusions The re-recurrence rate after surgery for recurrent rectal prolapse is high, even at a relatively short follow-up interval. Our data suggest that abdominal repair of recurrent rectal prolapse should be undertaken if the patient's risk profile permits this approach. Read at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005.     

Functional results of operative treatment of rectal prolapse over an 11-year period

PURPOSE: A variety of surgical procedures have been developed to treat rectal prolapse, but there is still no consensus on the operation of choice. The aim of this study was to evaluate the functional results of operative treatment of rectal prolapse during an 11-year period in our department. METHODS: All patients treated for complete rectal prolapse during an 11-year period, from 1985 to 1995, in a single university hospital were included. Of the 123 patients, 22 were men, and the mean age was 59 (range, 15–88) years. The medical records of all patients were reviewed retrospectively, and a questionnaire on bowel symptoms before and after surgery was sent to all 95 living patients. RESULTS: The majority of the procedures (91 percent) were performed by abdominal approach, and the most frequently used open technique was posterior rectopexy with mesh (78 percent). Of the incontinent patients, 35 (63 percent), all those less than 40 years of age and 64 percent of those 40 years or older, were continent postoperatively (P=0.0001) after a median follow-up of five (range, 1–72) months. According to the questionnaire, after a median follow-up of 85 (range, 16–144) months, only 38 percent of the incontinent patients in the mesh or suture group, 78 percent of patients less than 40 years of age (n=18), and 52 percent of those 40 years or older (n=47) claimed to be continent postoperatively. The proportion of patients with constipation was greater after the operation than preoperatively (P=0.02) and more patients used medication for constipation after than before the operation (P=0.0001). The overall complication rate was 15 percent, and the mortality rate was 1 percent (1/123). In the mesh or suture group there were 6 (6 percent) recurrent complete prolapses and 11 (12 percent) mucous prolapses. CONCLUSION: Posterior rectopexy with mesh gave good results in our hands. Older age and longer follow-up seem to have a negative effect on the functional outcome of the operation and on the recurrence rate.Supported by a grant from the Medical Research Fund of the Tampere University Hospital.     

Anal Continence After Rectocele Repair

INTRODUCTION: Rectocele may be associated with both chronic constipation and anal incontinence. Several different surgical procedures have been advocated for rectocele repair. The aim of the present study was to evaluate anorectal function and clinical outcome in a consecutive series of patients who underwent selected endorectal or transperineal surgery for rectocele for whom operative treatment was determined by clinical and proctographic features. Attention was paid to the cohort of rectocele patients presenting with incontinence as a leading symptom. METHODS: Sixty consecutive patients with symptomatic rectocele underwent surgical treatment at our institution. Fifty-eight of the patients were female (mean age 56; range, 21–70 years). Incontinence was graded according to a previously reported scoring system that accounts for the type and frequency of incontinence episodes. Preoperative anorectal manometry was performed using an open perfused polyethylene probe. Rectal sensation was recorded by balloon distention. Endoanal ultrasonography was performed with a 7.5-MHz probe. Preoperative defecography was performed at rest and on maximal squeeze and straining. Patients with obstructed defecation as their principal symptom, with associated mucosal rectal prolapse, underwent an endorectal procedure. For patients with associated anal incontinence (Grade B2 or greater), and without a rectal mucosal prolapse, a transperineal approach was performed with either an anterior external overlapping sphincteroplasty or levatorplasty. The median follow-up was 48 (range, 9–122) months. RESULTS: There was no operative mortality. Postoperative complications occurred in 18 patients (30 percent). Of 43 patients with incontinence, 34 (79 percent) were available for postoperative evaluation. None were fully continent. However, in 25 patients (73.5 percent), continence improved after surgery; half had only mucus soiling or loss of gas. Incontinence scores decreased (i.e., improved) from 4.8 ± 0.9 to 3.9 ± 0.9 (P = 0.002). A significant improvement was found both after transanal and perineal procedures. Only ten initially continent patients were available for postoperative assessment. All patients stated that they had clinical improvement in constipation. Their preoperative mean anal resting pressure was 62.5 ± 3.9 (standard error of the mean) mmHg, with a postoperative mean of 75.5 ± 7 mmHg. The preoperative mean squeeze pressure was 83.1 ± 8.5 mmHg, with a mean postoperative squeeze pressure of 88.5 ± 7.9 mmHg (P = not significant). The maximal tolerable volumes were all within normal limits, confirming the proctographic evidence that there were no cases of megarectum in our patient series. The pudendal nerve terminal motor latency was abnormal in all but two patients with incontinence (mean pudendal nerve terminal motor latency = 3.1; range, 1.2–4 milliseconds). Rectoceles recurred in six patients (10 percent): five after a Block procedure and one after a Sarles-type operation. The postoperative endosonographic appearance varied according to the nature of the procedure performed. CONCLUSION: There are few data concerning patients with rectocele who have associated anal incontinence, however, surgical decision analysis resulted in improvement in both constipation and incontinence in the majority of our patients with rectocele. Nevertheless, because none of the patients gained full continence postoperatively, pelvic floor rehabilitation might be also needed to achieve better sphincter function in patients with incontinence.     

Feasibility and Functional Outcome of Laparoscopic Sacrocolporectopexy for Combined Vaginal and Rectal Prolapse

Purpose  Prolapse of multiple pelvic organs causes a variety of symptoms that impair a patient’s quality of life. A laparoscopic procedure is described that uses a mesh fixation of the mid-compartment vagina to the sacrum with additional rectopexy to correct both the anatomical deformities and the dysfunction of the posterior compartment. Methods  Patients with significant rectal and vaginal prolapse with or without rectocele were recruited. A thorough preoperative physiological assessment of each of the compartments of the pelvic floor was carried out. Patients also completed the Pelvic Floor Distress Inventory before and six months after surgery. Results  Ten patients underwent the procedure of laparoscopic sacrocolporectopexy (median age 47 years, interquartile range 43–53). No mortality or morbidity occurred. Median global distress inventory scores were significantly lower postoperatively (8.3, interquartile range 0–20.8 vs. 37.5, interquartile range 16.6–60.4) P = 0.012. All three median subscales were also significantly lower postoperatively. The procedure corrected associated rectoceles and descent of the perineum on straining. Conclusion  The described laparoscopic procedure of mesh sacrocolpopexy with rectopexy was safe and feasible and conferred good symptomatic improvement in pelvic floor dysfunction. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Complete rectal prolapse

Optional treatment for complete rectal prolapse remains controversial. PURPOSE: We reviewed our experience over a 19-year period to assess trends in choice of operation, recurrence rates, and functional results. METHODS: We identified 372 patients who underwent surgery for complete rectal prolapse between 1976 and 1994. Charts were reviewed and follow-up (median, 64; range, 12–231 months) was obtained by mailed questionnaire (149 patients; 40 percent) and telephone interview (35 patients; 9 percent). Functional results were obtained from 184 responders (49 percent). RESULTS: Median age of patients was 64 (11–100) years, and females outnumbered males by nine to one. One-hundred and eighty-eight patients (51 percent) were lost to follow-up; 183 patients (49 percent) underwent perineal rectosigmoidectomy, and 161 patients (43 percent) underwent abdominal rectopexy with bowel resection. The percentage of patients who underwent perineal rectosigmoidectomy increased from 22 percent in the first five years of the study to 79 percent in the most recent five years. Patients undergoing perineal rectosigmoidectomy were more likely to have associated medical problems as compared with patients undergoing abdominal rectopexy (61vs. 30 percent,P=0.00001). There was no significant difference in morbidity, with 14 percent for perineal rectosigmoidectomyvs. 20 percent for abdominal rectopexy. Abdominal procedures were associated with a longer length of stay as compared with perineal rectosigmoidectomy (8vs. 5 days,P=0.001). Perineal procedures, however, had a higher recurrence rate (16vs. 5 percent,P=0.002). Functional improvement was not significantly different, and most patients were satisfied with treatment and outcome. CONCLUSIONS: We conclude that abdominal rectopexy with bowel resection is associated with low recurrence rates. Perineal rectosigmoidectomy provides lower morbidity and shorter length of stay, but recurrence rates are much higher. Despite this, perineal rectosigmoidectomy has appeal as a lesser procedure for elderly patients or those patients in the high surgical risk category. For younger patients, the benefits of perineal rectosigmoidectomy being a lesser procedure must be weighed against a higher recurrence rate.Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996, and at the Tripartite Meeting, London, United Kingdom, July 8 to 10, 1996.     

Morbid Obesity Adversely Impacts Pelvic Floor Function in Females Seeking Attention for Weight Loss Surgery

Purpose This study was designed to determine the impact of excess body mass on the prevalence of pelvic floor disorders in morbidly obese females. Methods A total of 358 morbidly obese females (body mass index (BMI) ≥ 35 kg/m²) completed two validated, condition-specific, quality of life questionnaires of pelvic floor dysfunction, which assessed stress/impact in three main domains of pelvic floor disorders: pelvic organ prolapse, colorectal-anal, and urogenital incontinence. Prevalence and severity scores in the study population were compared with data from 37 age-matched nonobese controls (BMI ≤ 35 kg/m²). Results Mean age was 43 ± 11 years vs. 42 ± 12 years, and mean BMI was 50 ± 10 kg/m² vs. 26 ± 4 kg/m² (p = 0.02) in the study and control groups, respectively. Parity and past obstetric history were similar between the groups. Pelvic floor disorders were prevalent in 91 percent of the morbidly obese females compared with 22 percent in the control group (p < 0.001). Scores were statistically significantly higher in the study group for all studied stress/impact domains (p < 0.001 and p = 0.001, respectively). Further stratifications in the study group revealed a significant impact on pelvic floor disorders with increased age (p < 0.003 and p < 0.009 for stress/impact mean scores, respectively) and the presence of other comorbidities (p< 0.008, p < 0.03 for stress/impact prevalence, respectively). Additional increases in BMI > 35 kg/m² did not show increased adverse impacts on pelvic floor disorders symptoms. Conclusion More than 90 percent of morbidly obese females experience some degree of pelvic floor disorders, and 50 percent of these females report that symptoms adversely impact quality of life. In morbidly obese females, obesity is as important as obstetric history in predicting pelvic floor dysfunction. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 3 to 7, 2006.     

Abdominal colporectopexy with pelvic cul-de-sac closure

PURPOSE: Rectal prolapse and posthysterectomy vaginal vault prolapse often occur together and constitute a management problem. This article describes a combined colorectal and gynecologic approach to surgical management and reports the follow-up results of treatment. METHOD: Patients who presented with both rectal and gynecologic symptoms of prolapse subsequent to hysterectomy and were found on clinical examination to have overt and/or occult prolapse of both the rectum and the vaginal vault were considered suitable for a combined operative procedure. This consisted of an abdominal mesh rectopexy, abdominal closure of the pelvic cul-de-sac (enhanced by intravaginal endoscopic transillumination), and a colpopexy attaching forward extensions of the same mesh to the apex of the anatomically restored and reinforced vaginal vault. The operation was also accompanied by a colporrhaphy if prolapse of the lower one-third of the vagina was still evident on completion of the abdominal procedures. RESULTS: Eighty-nine patients underwent combined surgery. Sixty of these patients had a concurrent vaginal repair. The mean follow-up time was approximately five years. There were no perioperative deaths, and the morbidity rate was 9 percent. No injury occurred to the urinary tract, and no wound or pelvic infections were evident. There was no recurrence of either the rectal or vaginal vault prolapse. Improvement occurred in all major symptoms, especially in pelvic pain. CONCLUSIONS: The problem of coexisting rectal and posthysterectomy vaginal vault prolapse can be corrected by combined abdominal colporectopexy and closure of the pelvic cul-de-sac. For 89 patients this operation provided considerable relief of symptoms, with no evidence of recurrence of rectal or vaginal vault prolapse at follow-up.     

全骨盆底悬吊术在女性骨盆底功能重建中的应用

目的探讨利用全骨盆底网片悬吊术治疗女性盆腔脏器脱垂并进行骨盆底重建的可行性和有效性。方法对2005年1月至2006年6月确诊为盆腔脏器脱垂的53例患者采用蝶形聚丙烯网片进行经阴道全骨盆底悬吊术,根据临床检查及主诉对手术前后脱垂情况进行评估,观察疗效并定期随访。结果手术时间平均97min,出血量平均160ml,53例均在术后2～6d出院,术后1、3、9、12个月随访,根据国际尿控协会制定的盆腔脏器脱垂定量分度法客观评估子宫脱垂、阴道前后壁膨出等症状全部得到纠正,无复发、无阴道扭曲和缩短、无性生活障碍,满意度达94．3％。结论全骨盆底网片悬吊术是经阴道的微创手术,对盆腔脏器脱垂患者在保留子宫的同时进行骨盆底功能重建,复发率低,值得临床进一步推广。     

Anal Sphincter Injury After Forceps Delivery: Myth or Reality?

PURPOSE: This study was designed to estimate the prevalence of anal sphincter injury after forceps delivery in a large population of females managed by trained obstetricians in a French hospital and to identify factors predictive for anal sphincter injury. METHODS: We performed a prospective study of healthy females older than 18 years with no history of anal incontinence, anorectal abnormalities, or anorectal surgery after their first vaginal delivery. All females were interviewed using a standardized questionnaire concerning intestinal transit and continence status. Physical examination and endoanal ultrasonography were performed after delivery. RESULTS: Between November 1999 and November 2000, 93 females were included in the study after their first forceps delivery. Eleven patients (11.8 percent) had a partial defect involving the external sphincter, visible on ultrasonography. One patient (1.1 percent) had a partial defect of external sphincter with complete defect of internal sphincter (sequelae of primary repair of a third-degree perineal tear). Seventeen patients (18.2 percent) had flatus incontinence, and four patients (4.3 percent) had liquid stool incontinence. A high daily number of stools was significantly associated with sphincter defect visible on ultrasonography (P = 0.02). The development of anal incontinence was not related to sphincter defect on ultrasonography. There was a strong association between perineal tear and sphincter defect visible on ultrasonography (odds ratio, 4.5 (range, 1.2–16.7)). CONCLUSIONS: Anal sphincter injury after forceps delivery was identified in <13 percent of our large population of healthy females. Our study does not confirm previous observations that anal sphincter injury is common after forceps delivery; previously published studies may have overestimated the prevalence of this condition. The only factor with significant predictive value for anal sphincter injury was perineal tear. Anal endosonography should be recommended after obstetric perineal tear.Presented at the Journées Francophones de Pathologie Digestive, Nantes, France, March 25 to 27, 2002 (abstract published in Gastroenterol Clin Biol 2002;26:A33)     

Complications of absorbable pelvic mesh slings following surgery for rectal carcinoma

PURPOSE: To evaluate the intraoperative, postoperative, and long-term complications of an absorbable pelvic mesh sling after surgery for rectal carcinoma. METHODS: A retrospective review of medical records from April 8, 1991, through April 8, 1996. RESULTS: Twenty patients with a mean age of 57 (range, 37–79) years underwent pelvic mesh sling placement. The tumor stages were as follows: Stage I, 5; Stage II, 2; Stage III, 11; and Stage IV, 1. A recurrent perianal basal cell carcinoma was not included in the staging group. Surgery consisted of 18 abdominoperineal resections, 1 total proctocolectomy, and one Hartmann's procedure. Mean follow-up was 18 (range, 2–49) months. There were no intraoperative complications related to mesh placement. Twenty-nine complications occurred in 14 patients during the immediate postoperative period. Five were possibly mesh-related and included a pelvic abscess, perineal seroma, toxic perineal wound, pulmonary embolus, and lower extremity deep venous thrombosis, respectively. A mild postoperative ileus developed in 17 patients (85 percent), and a diet was initiated at a mean of seven (range, 4–24) days. Fourteen patients received postoperative radiotherapy with a mean dose of 5,339 (range, 2,500–7,020) cGy delivered in 180-cGy fractions. There were 14 immediate complications caused by radiotherapy in 11 patients, but only two patients required delays in treatment. Two patients had diarrhea alone, six developed perineal dermatitis alone, and three patients had both diarrhea and perineal dermatitis. All patients with diarrhea had received chemoradiation. One patient developed a partial small-bowel obstruction following radiation. CONCLUSIONS: Absorbable pelvic mesh sling placement can be performed with minimum morbidity and is recommended following surgery for rectal cancer when radiation is anticipated as part of multimodality therapy.     

Complications and Sexual Function After Vaginectomy for Anorectal Tumors

Purpose The objective of this study was to determine complication rates and functional outcomes of females who underwent vaginectomy during anorectal tumor resection and to determine whether flap reconstruction of the vagina improves sexual function. Methods A retrospective review was performed of all females who underwent multivisceral resections involving the vagina for anorectal tumors at two academic hospitals from 1985 to 2004. Living patients were contacted, and a 25-question telephone questionnaire was administered. Results Fifty-four patients were identified. Nineteen patients had flap reconstruction of the vagina and 35 had primary repair. Eighty-three percent of patients experienced surgical complications, including perineal wound complications in 33 percent (14/42) of those with perineal incisions and vaginal complications in 41 percent (22/54) of the cohort. There was a nonsignificant decrease in perineal wound complications when flap reconstruction was performed (22 vs. 42 percent). Twenty-three patients completed the questionnaire (96 percent of those eligible). Six patients were able to have sexual intercourse after surgery and nine were not. Reasons for inability to have sexual intercourse were: inadequate vaginal capacity (n = 4), pain (n = 2), and chronic wound or fistula (n = 3). No living patients who had flap reconstruction were able to have sexual intercourse. Only 20 percent of patients remembered a preoperative discussion of possible sexual effects of surgery; however, overall quality of life was preserved. Conclusions Anorectal tumor resections involving the vagina are associated with a high rate of complications, including inability to have intercourse after surgery, even with flap reconstruction. Females should be counseled regarding potential loss of sexual function. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, May 1 to 5, 2004. Presented at the meeting of the Canadian Association of General Surgeons, Podium Presentation, Ottawa, Ontario, September 9 to 11, 2004. Reprints are not available.     

Delorme's procedure for complete rectal prolapse in severely debilitated patients

PURPOSE: This study was designed to assess the results of a minimally invasive surgical procedure for the correction of complete rectal prolapse in a poor surgical risk group. METHODS: Over a ten-year period, 40 patients underwent 41 Delorme operations when advanced age and/or poor overall health mitigated against an abdominal approach. Mean age was 82 (range, 30–100) years. Eighty-eight percent were females. Surgery was performed in the prone jackknife position utilizing intravenous sedation and local anesthesia. RESULTS: Follow-up ranges from 1 year to 2 years (mean, 47 months). There have been 9 recurrences in 8 patients (22 percent). Mean time to recurrence was 13 months (range, 1 month to 6 years). One death occurred in an 81-year-old patient within 24 hours of surgery from cardiopulmonary arrest. Minor complications occurred in 25 percent of patients. CONCLUSION: Satisfactory prolapse repair was safely performed in 78 percent of this high-risk group. Pitfalls in performing this procedure relate primarily to associated perineal and colonic conditions. Most prominent among these conditions are weak or absent anal sphincter tone, perineal descent, and previous sphincter injury. Extensive diverticular disease may prohibit effective and complete proximal mucosectomy. An inadequate mucosectomy sets the stage for early recurrence of prolapse.     

Prolift全盆底修补系统在老年女性全盆底重建术中的应用

目的通过对Prolift全盆底修补系统在老年女性盆腔器官脱垂治疗中的应用及近期疗效的评估,探讨治疗盆腔器官脱垂的手术方式。方法选取2009年1月至2010年12月间南京市妇幼保健院妇科收治的因盆腔器官脱垂行盆底修复重建手术的老年女性患者共43例。其中采用Prolift全盆底修补系统行全盆底重建手术24例（A组）,传统的阴道前后壁修补手术19例（B组）。比较2组患者的一般资料、围手术期和随访情况,并进行统计学分析。结果 2组患者的年龄、体质量、孕产次、阴道壁脱垂程度差异无显著性（P〉0.05）。2组患者的手术时间、术中出血量、尿管留置天数、术后残余尿和住院时间比较,差异无显著性（P〉0.05）。2组术后随访率均为100%。A、B组术后复发各为0和3例,A组复发率明显低于B组（P〈0.05）;A组发生性生活不适者3例,略高于B组的1例,但无显著性差异（P〉0.05）;A组补片侵蚀2例（8.33%）,2组均未发生直肠、输尿管等周围脏器及明显血管神经损伤。结论 Prolift用于阴道前后壁脱垂患者的全盆底重建手术,手术安全可行,近期疗效明显优于传统的阴道前后壁修补术。