Symptomatic vaginal enterocele associated with malfunctioning ventriculoperitoneal shunt and cerebrospinal ascites

Abdominal pseudocyst formation is a rare adult complication associated with ventriculoperitoneal (VP) shunts. Presenting symptoms are primarily abdominal and include distention, pain and anorexia, and secondarily neurological with signs and symptoms of shunt malfunction. We describe a case of VP shunt-related pseudocyst formation presenting as symptomatic pelvic organ prolapse with stage 4 enterocele 4 years after VP shunt placement. The patient's vaginal enterocele enlarged and became more symptomatic as intra-abdominal cyst formation expanded. Symptomatic relief of pelvic floor symptomatology including resolution of exteriorized prolapse was established by conservative measures and eventual VP shunt revision and removal. VP shunt malfunction may present as symptomatic pelvic organ prolapse and may require shunt removal or revision for resolution of symptoms.     

In vitro assessment of back pressure on ventriculoperitoneal shunt valves

Background: Whereas there are case reports of laparoscopy in patients with ventriculoperitoneal shunts, there are no studies assessing the potential failure of shunt valves with the increased intra-abdominal pressure of laparoscopy. This study aims to assess this factor. Methods: An in vitro model was used to assess the potential for retrograde failure of ventriculoperitoneal shunt valves in a commonly used shunt. Nine shunts were subjected to graded increases in back pressure and observed for retrograde valve leak. Results: None of the shunts tested showed any signs of leak associated with the increased back pressure. However, disruption of shunt seals was noted in seven of the nine shunts, occurring at the minimal pressure of 80 mmHg. Conclusions: There appears to be minimal risk of retrograde failure of the valve system in the ventriculoperitoneal shunt tested. However, tests on different types of ventriculoperitoneal shunts would be needed to confirm these results if laparoscopy is to be considered safe in patients with ventriculoperitoneal shunts in situ. Received: 2 February 1998/Accepted: 6 July 1998     

Recent advances in robotic surgery in female urology

Pelvic organ prolapse and lower urinary tract fistulas are two disorders frequently managed in female urology. New techniques have been adapted and improved to decrease morbidity and improve clinical outcomes of these disorders. The adaptation of minimally‐invasive approaches for the management of pelvic organ prolapse and lower urinary tract fistulas began with laparoscopy. However, laparoscopic surgery has not gained widespread popularity as a result of the associated technical challenges, such as intracorporeal suturing and pelvic dissection. Robotic surgery has been widely carried out in urological oncology since 2001, and has been widely adapted because of its advantages over conventional laparoscopy for the management of pelvic organ prolapse and lower urinary tract fistulas. The current literature has shown the safety, feasibility and favorable clinical outcomes of robotic surgery for the treatment of these disorders. Robotic surgery in the management of pelvic organ prolapse and lower urinary tract fistula repairs might offer a promising advancement and benefits. However, further long‐term data should be followed to assess the durability of this newer, and minimally‐invasive approach.     

Apical vault repair, the cornerstone or pelvic vault reconstruction

Pelvic organ prolapse remains a difficult problem for pelvic reconstructive surgery. Before new surgical procedures can be developed a good understanding of pelvic anatomy is necessary. It is widely held that the etiology of pelvic organ prolapse is secondary to stretch neuropathy following childbirth and chronic cough or constipation. Several transvaginal and transabdominal procedures have been developed over the years. With the increasing use of laparoscopy, a new variation on existing culdeplasty techniques has been developed. Following anatomical principles, the apical vault repair reestablishes the pericervical ring at the vaginal apex. The incorporation of pubocervical fascia, uterosacral-cardinal ligament and the rectovaginal fascia provides a strong anchor for the vaginal apex. In addition, the repair should help prevent future transverse cystocele, rectocele, enterocele and apical vault prolapse. Early outcome studies suggest that the apical vault repair should be used routinely with laparoscopic urethropexy, laparoscopic hysterectomy and the repair of pelvic organ prolapse. Good apical vault support is considered the cornerstone of pelvic reconstruction.     

Risks, symptoms, and management of pelvic nerve damage secondary to surgery for pelvic organ prolapse: a report of 95 cases

Introduction and hypothesis  

This study aims to report pelvic nerve damage secondary to surgical treatment of pelvic organ prolapse and the role of laparoscopy in the diagnosis and treatment of such nerve damage.     

Female incontinence: a review of biomaterials and minimally invasive techniques

PURPOSE OF REVIEW: This article discusses the various grafts or biomaterials, minimally invasive techniques, and recent advances for the treatment of female stress urinary incontinence and pelvic organ prolapse. RECENT FINDINGS: The studies reviewed in this paper compared certain biologic grafts to synthetic grafts in clinical trials and histopathological studies. Data from long-term outcome studies for tension-free vaginal tape are evaluated. As tension-free vaginal tape is the foremost technique for stress urinary incontinence correction, many of the newer modalities such as transobturator tape and laparoscopy are compared with it. Immediate and long-term complications from mesh use in stress urinary incontinence and pelvic organ prolapse repair are examined. Correction of prolapse may eventually entail the use of specially designed 'kits' that allow total pelvic floor reconstruction with a single piece of mesh. SUMMARY: Although biological grafts are initially efficacious, the trend is to use synthetic grafts in repair of stress urinary incontinence and pelvic organ prolapse. Midurethral slings continue to be the front-line therapeutic modality for stress urinary incontinence. After analysis of long-term data, other surgical techniques may gain popularity. With increasing use of synthetic grafts, however, long-term complications such as de-novo urgency, erosion, and dyspareunia need to be assessed.     

Robotic sacrocolpoperineopexy with ventral rectopexy for the combined treatment of rectal and pelvic organ prolapse: initial report and technique

The objective of our study is to describe the peri-operative and early postoperative surgical outcomes following robotic sacrocolpoperineopexy with ventral rectopexy for the combined treatment of rectal and pelvic organ prolapse. This was a retrospective cohort study of ten women with symptomatic Stage 2 or greater pelvic organ prolapse and concomitant rectal prolapse who desired combined robotic surgery, at a single institution. The mean age of the subjects was 55.3 ± 19.2 years (range 19–86)  and the mean body mass index was 25.8 ± 5.7 kg/m². Preoperatively, the women had Stage 2 or greater pelvic organ prolapse and the average length of rectal prolapse was 2.1 ± 1.9 cm. There were no conversions to conventional laparoscopy or laparotomy. The mean operating room time was 307 ± 45 min with an estimated blood loss of 144 ± 68 ml. The average length of stay was 2.4 ± 0.8 days. Preliminary data suggest that robotic sacrocolpoperineopexy with ventral rectopexy is a feasible procedure with minimal operative morbidity for the combined treatment of rectal and pelvic organ prolapse. Longer follow-up is needed to ensure favorable long-term subjective and objective outcomes.     

Laparoscopic techniques for the repair of vaginal vault prolapse: Determining if less is more

Repair of vaginal vault prolapse remains a surgical challenge. Abdominal, vaginal, and combined procedures have been described. The ideal operation remains elusive with regard to outcomes, morbidity, and economics. As an extension of the abdominal approach, laparoscopy continues to gain favor as an access method and as a surgical advancement. Recent studies highlight a number of laparoscopic techniques for restoration of apical support that demonstrate feasibility and encouraging results. Further study is necessary to determine if the minimally invasive nature of laparoscopy can duplicate or surpass standard abdominal and vaginal approaches to the repair of pelvic organ prolapse.     

Relationship between Stress Urinary Incontinence and Pelvic Organ Prolapse

We investigated the objective coexisting rate of stress urinary incontinence and pelvic organ prolapse, and also compared the treatment outcomes in patients who had both conditions, treated by a corrective operation on the basis of a precise preoperative evaluation. We reviewed 97 cases who underwent urodynamic studies and evaluation of the prolapse according to the Pelvic Organ Prolapse Quantification (POP-Q) system from among patients who were admitted for treatment of either stress urinary incontinence or pelvic organ prolapse. A Burch urethropexy, either alone or with a parvaginal repair, was done to correct the stress urinary incontinence, as well as additional operations to correct prolapse of stage II or more. The patients were evaluated postoperatively for the stress urinary incontinence and the degree of prolapse at every visit. Nineteen of 30 (63.3%) patients who were admitted with stress urinary incontinence had a coexisting pelvic organ prolapse, most often of the anterior wall. In 42 of 67 (62.7%) cases admitted with pelvic organ prolapse there was a coexisting stress urinary incontinence. A total of 61 patients who had both conditions were followed for 12 months postoperatively. The recurrence rate of stress urinary incontinence and prolapse (all of which were stage II) was 3.3% and 18.0%, respectively. It was noted that the greater the preoperative stage, the higher the recurrence rate (stage II 4.35%; stage III 25.0%; stage IV 33.6%). The coexisting rates of pelvic organ prolapse in patients having stress urinary incontinence, and stress urinary incontinence in patients having a pelvic organ prolapse, were both high. Therefore, when a preoperative evaluation that simultaneously considers both conditions and the correcting surgery is based on this evaluation, the recurrence rates of both conditions could be lowered.     

改良全盆底重建手术治疗女性盆腔器官脱垂35例疗效观察

目的评价改良盆底重建术治疗盆腔脏器脱垂的临床效果。方法盆腔脏器脱垂定量(POP-Q)分度为Ⅲ～Ⅳ度35例患者行改良盆底重建术,观察手术时间、术中出血量、住院时间等围手术期指标,以POP-Q分度为客观疗效评价指标,以临床症状消失为主观治愈指标。术后定期随访,观察疗效。结果手术平均时间(55士20.2)min、术中平均出血(100±40.2)ml,术后住院平均(4.5±1.5)d,术后随访3～18个月、中位随访时间6个月,客观治愈率94%(33/35),主观有效率91%(32/35)。术后仅1例发生网片侵蚀,3例发生排尿困难,2例发生性交痛,2例发生急迫性尿失禁。结论改良盆底重建术是治疗盆腔脏器脱垂的有效术式,保留子宫同时加强盆底组织,手术简单、安全、微创、经济,远期疗效有待进一步观察。     

Abdominal sacral colpopexy: Surgical pearls and outcomes

Vaginal vault prolapse is a challenging form of pelvic organ prolapse that occurs in combination with cystocele, rectocele, or enterocele in nearly 75% of affected patients. Clinical presentation will vary depending on the associated defects. Any successful therapy for vaginal vault prolapse will depend on a thorough evaluation of the vaginal compartments and concomitant lower urinary tract function. Surgical correction of vaginal vault prolapse can be achieved through a variety of vaginal or abdominal approaches. This review focuses on the abdominal approach for vaginal vault prolapse surgery. We review outcomes of abdominal sacral colpopexy (ASC) and available comparisons to vaginal vault suspension. We address the role of laparoscopy and robotics in ASC and examine the outcomes of such procedures. We also discuss available literature on the management of the lower urinary tract in combination with ASC.     

女性盆底器官脱垂伴尿失禁患者的尿动力学特征

目的 探讨女性盆底器官脱垂伴尿失禁患者膀胱储尿期和排尿期的尿动力学参数变化. 方法对182例女性尿失禁和盆底器官脱垂患者进行尿动力学检查,其中尿失禁140例,尿失禁伴盆底器官脱垂42例.在统一标准下行尿动力学检查测定膀胱灌注量、排尿量、膀胱顺应性、最大尿流率、最大尿流率逼尿肌压、最小尿流率逼尿肌压、尿道阻力因子(URA)、膀胱梗阻指数(OBI)以及归-化逼尿肌收缩力,评价女性尿失禁患者盆底器官脱垂对膀胱储尿功能和排尿功能的影响. 结果 尿失禁组与尿失禁伴盆底器官脱垂组患者尿失禁病程[(58.1±75.4)与(41.9±55.4)个月]、膀胱灌注量[(295.3±95.8)与(276.5±80.8)ml]、膀胱顺应性[(77.7±122.1)与(51.5±61.9)ml/cm H2O]、最大尿流率[(15.8±12.5)与(14.7±13.9)ml/s]、最小尿流率逼尿肌压[(3.2±5.8)与(2.8±5.5)ml/cm H2O]、归-化逼尿肌收缩力[(7.5±12.8)与(8.2±13.8)cm H2O]相比差异均无统计学意义(P>0.05);而年龄[(58.7±12.2)与(67.1±8.3)岁]、排尿量[(269.2±145.2)与(248.9±135.1)ml]、最大尿流率逼尿肌压[(20.4±16.2)与(25.7±21.3)cm H2O]、URA[(11.3±9.5与(14.8±12.6)cm H2O]、OBI[(15.6±14.5)与(21.7±20.1)cm H2O]2组相比差异有统计学意义(P<0.05).结论高龄女性尿失禁患者更可能伴有盆底器官脱垂,而盆底器官脱垂对膀胱储尿功能无影响,但可影响排尿期相关参数,增加膀胱出口阻力和膀胱残余尿量.     

Laparoscopic cholecystectomy in patients with ventriculoperitoneal (VP) shunts

Increased intracranial pressure is often relieved by a ventriculoperitoneal shunt. The shunt has a one-way valve which can withstand pressures of 300 mmHg and prevent reflux of intraabdominal fluid. We have utilized laparoscopy for cholecystectomy in four patients with VP shunts. In all patients the peritoneal cavity was free of adhesions. When CO₂ insufflation pressure was as high as 10–15 mmHg cerebrospinal fluid was still noted to flow from the end of the shunts. In three patients the entire procedure was performed laparoscopically. In the fourth patient the procedure was converted to an open cholecystectomy because of extensive inflammation surrounding a gangrenous gallbladder. Postoperatively the shunts remained intact and functional. There were no central nervous system sequelae. None of the shunts became infected. Elective laparoscopic cholecystectomy in patients with VP shunts can be done safely without a need for clamping or other manipulation of the shunt.     

Pelvic organ prolapse after uterine artery embolization for uterine myoma

Uterine artery embolization (UAE) is gaining popularity as a treatment modality in patients with symptomatic uterine fibroids who do not desire fertility. Complications of this procedure can be serious and disabling. A 50-year-old woman presented with stage II uterovaginal prolapse after UAE for symptomatic uterine fibroids. Pelvic organ prolapse developed 16 months after the initial procedure. Surgical correction was performed. This is the first case report of pelvic organ prolapse after UAE. Normal prior gynecological examinations, and absence of pelvic pressure symptoms, indicate that pelvic organ prolapse had occurred subsequent to UAE.     

Evaluation of Current Synthetic Mesh Materials in Pelvic Organ Prolapse Repair

With increasing use of synthetic material in pelvic organ prolapse repair, the reporting and incidence of associated complications also have increased. The role of synthetic mesh in pelvic organ prolapse repair remains controversial and it is a therapeutic dilemma whether to continue its use in patients with poor native tissues, despite the recent public safety notification provided by the U.S. Food and Drug Administration. In this article, we review the biomaterials used in pelvic organ prolapse repair and discuss the outcomes and associated complications, paying emphasis to the benefits and the risks.     

女性便秘与盆腔器官脱垂关系的动态磁共振评估(附43例报告)

目的分析女性便秘与盆腔器官脱垂的关系。方法对43例经临床诊断为盆底功能障碍性疾病的女性患者行动态磁共振检查,在动态磁共振上根据HMO分度系统进行盆腔器官脱垂的分度和直肠前突深度的测量,并行便秘严重度CSS评分,两者进行相关性分析。结果女性便秘的严重度与膀胱脱垂分度的相关系数为0.018(P=0.91),与子宫脱垂分度的相关系数为0.042(P=0.80),与直肠脱垂分度的相关系数为0.350(P=0.02),与直肠前突深度的相关系数为0.599(P=0.009)。结论女性便秘的严重度与盆腔器官脱垂中直肠脱垂的关系密切相关,与直肠前突深度相关性较好。     

Anterior enterocele: a report of three cases

Anterior enterocele is an uncommon finding in patients with pelvic organ prolapse. We reviewed 490 consecutive operations for pelvic organ prolapse . Three anterior enteroceles were identified in a series of 193 enterocele repairs (1.6%). The presentation and treatment of each of these patients is reviewed.This revised version was published online in June 2004 with corrections to the title.     

Laparoscopic guidance or revision of ventriculoperitoneal shunts in children.

BACKGROUND: Ventriculoperitoneal shunt is the preferred treatment for hydrocephalus. Known complications include infection, obstruction, and disconnection with the fractured fragment migrating in the peritoneal cavity. We report 17 cases of laparoscopic evaluation and revision of ventriculoperitoneal shunts in children. METHODS: From January 2000 through October 2002, we retrospectively reviewed our experience with laparoscopy and ventriculoperitoneal shunts. RESULTS: Laparoscopy was performed in 17 children with a malfunctioning shunt, presumed shunt dislodgment or disconnection, reinsertion of a shunt after externalization, and primary shunt placement. Six patients (35%) were converted to an open laparotomy due to dense adhesions. Eleven patients (65%) underwent successful laparoscopic-assisted ventriculoperitoneal shunt placement: 5/11 (45%) had lysis of adhesions or pseudocyst marsupialization with repositioning of a functional shunt, or both; 3/11 (27%) had successful retrieval of a disconnected catheter with reinsertion of a new catheter; 2/11 (18%) had laparoscopic confirmation of satisfactory placement and function, requiring no revision; 1/11 (9%) had an initial shunt placed with laparoscopic guidance due to the obesity. Operative time for the laparoscopic procedure ranged from 30 minutes to 60 minutes. All laparoscopic procedures used 1-mm or two 5-mm ports. Perioperatively, no adverse neurological sequelae occurred due to the pneumoperitoneum. CONCLUSIONS: Laparoscopic guidance or revision of ventriculoperitoneal shunts permits (1) direct visualization of catheter insertion within the peritoneal cavity, (2) satisfactory positioning, (3) lysis of adhesions or marsupialization with catheter repositioning, or both, and (4) retrieval of fractured catheters.     

Liver transplant in a patient with a ventriculoperitoneal shunt.

There are no published accounts of patients with ventriculoperitoneal shunts undergoing liver transplantation in the literature. Because patients with ventriculoperitoneal shunts are prone to infections, this may be a theoretical contraindication to transplantation. We present a case of a patient with cirrhosis who had a ventriculoperitoneal shunt placed many years prior to transplantation. The patient had no neurological complications and the shunt was intact and functioning. Prior to transplantation, the patient underwent a ventriculoperitoneal to ventriculopleural shunt conversion that was reversed posttransplantation. Apart from some minor complications, the patient has done remarkably well from a graft and neurological perspective. In conclusion, patients who have ventriculoperitoneal shunts may be considered for liver transplantation as the risk of infectious and neurological complications is low and there are no deleterious effects on graft survival.