Validation of the Pelvic Organ Prolapse Quantification Index (POP-Q-I): a novel interpretation of the POP-Q system for optimization of POP research

Even though very precise at describing pelvic organ position, our criticism to the Pelvic Organ Prolapse Quantification (POP-Q) system is its limited ability to quantify the prolapse itself, since it still classifies prolapse into four stages, almost the same way as Baden and Walker (Clin Obstet Gynecol 15(4):1070-1072, 1972) did in 1972. As a result, the same grade can include a wide prolapse intensity range. The objective of this study was to assess inter-observer reliability in the Pelvic Organ Prolapse Quantification Index (POP-Q-I; Lemos et al., Int Urogynecol J 18(6):609-611, 2007) on a prospective randomized trial. Fifty consecutive women were prospectively examined by two members of the urogynecology staff, blinded to each other's results. Spearman's rank correlation was used to assess inter-observer reliability. Excellent correlation coefficients were observed, with an overall coefficient of 96.5% (CI: 0.889-1.042; p < 0.0001). The POP-Q-I is a method that makes POP research more efficient by directly measuring prolapse as a continuous variable, which is statistically more powerful than the categorical variables proposed by the POP-Q system. This study suggests that the POP-Q-I is applicable to clinical POP research.     

Hemicorporectomy: back to front

Hemicorporectomy involves amputation of the pelvis and lower extremities by disarticulation through the lumbar spine with concomitant transection of the aorta, inferior vena cava, and spinal cord, as well as creation of conduits for diversion of the urinary and fecal streams. A review of the literature reveals that the surgical technique has been relatively unchanged since 1960. The standard anterior to posterior approach is associated with significant blood loss and morbidity, likely contributing to lengthy hospital stay. Herein, we describe our back-to-front approach to hemicorporectomy, involving early division of the vertebral structures and spinal cord, pre-empting engorgement of Batson's plexus, thus minimizing blood loss. In addition, this approach greatly improves exposure of the pelvic vessels, allowing for a technically less challenging and safer procedure.     

宫腔镜联合腹腔镜检查不孕症168例分析

目的探讨宫、腹腔镜联合检查不孕症的诊断价值.方法回顾性分析1999年6月～2003年10月宫、腹腔镜联合检查168例不孕症的临床资料.结果宫腔镜检查发现异常宫腔79例（79/168,47.0%）,其中子宫内膜增生、内膜息肉46例（46/79,58.2%）.腹腔镜检查发现盆腔器质性病变99例,其中慢性盆腔炎、子宫内膜异位症和多囊卵巢共85例（85/99,85.9%）;宫、腹腔镜检均正常15例,均异常39例.宫腔镜下行输卵管通畅检查,输卵管单侧或双侧不通90例（90/168,53.6% ）;腹腔镜检查输卵管单侧或双侧不通78例（78/168,46.4%）.结论宫腔镜联合腹腔镜检查不孕症能够提供准确的诊断依据.     

The Delorme repair for full-thickness rectal prolapse: a retrospective review

Background

The purpose of this study was to assess our colorectal surgical training program experience with the Delorme procedure for complete rectal prolapse.

Methods

Consecutive patients were identified from a surgical database and evaluated by chart review.

Results

Seventy-six patients with a mean follow-up period of 3.6 years were included. Outcomes included a recurrence rate of 14.5%, an overall complication rate of 25%, and a surgical site-specific complication rate of 8%. For patients younger than 50 years old (mean age, 36 y; range, 19-49 y), the recurrence rate was 8% with a mean follow-up period of 4.1 years. Their total complication rate was 15%, with no surgery site-specific complications.

Conclusions

Our results are consistent with previously published experiences in that most preoperative evacuatory symptoms resolve with repair of the prolapse, and serious complications are uncommon. The observation that recurrence and complication rates may be lower in younger medically fit patients suggests the Delorme repair need not be restricted specifically to older, medically unfit patients.     

A Pelvic Ring Fracture Complicated by Acute Traumatic Obstructed Direct Inguinal Hernia

Abstract A young male motorcyclist presented to the Pelvic Unit with an open-book fracture of his pelvis and an acute obstructed direct inguinal hernia. He was managed operatively and made an excellent recovery. Traumatic abdominal wall hernias are rare. This is a unique combination of injuries that the trauma surgeon should be aware of.     

Control of severe hemorrhage using C-clamp and arterial embolization in hemodynamically unstable patients with pelvic ring disruption

Introduction

Hemorrhage is the leading cause of death in patients with a pelvic fracture. The majority of blood loss derives from injured retroperitoneal veins and broad cancellous bone surfaces. The emergency management of multiply injured patients with pelvic ring disruption and severe hemorrhage remains controversial. Although it is well accepted that the displaced pelvic ring injury must be rapidly reduced and stabilized, the methods by which control of hemorrhagic shock is achieved remain under discussion. It has been proposed to exclusively use external pelvic ring stabilization for control of hemorrhage by producing a ‘tamponade effect’ of the pelvis. However, the frequency of clinically important arterial bleeding after external fixation of the pelvic ring remains unclear. We therefore undertook this retrospective review to attempt to answer this one important question: How frequently is arterial embolization necessary to control hemorrhage and restore hemodynamic stability after external pelvic ring fixation?

Materials and methods

We performed a retrospective review of 55 consecutive patients who presented with unstable types B and C pelvic ring fractures. Those patients designated as being in hemorrhagic shock (defined as a systolic blood pressure less than 90 mmHg after receiving 2 L of intravenous crystalloid) were treated by application of the pelvic C-clamp. Patients who remained in hemorrhagic shock, or were determined to be in severe shock (defined as mandatory catecholamines or more than 12 blood transfusions over 2 h), underwent therapeutic angiography within 24 h in order to control bleeding.

Results

Fourteen patients were identified as being hemodynamically unstable (ISS 30.1±11.3 points) and were treated with a C-clamp. In those patients with persistent hemodynamic instability, arterial embolization was performed. After C-clamp application, 5 of 14 patients required therapeutic angiography to control bleeding. Two patients died, one from multiple sources of bleeding and the other from an open pelvic fracture (total mortality 2/14, 14%).

Conclusions

Although the C-clamp is effective in controlling hemorrhage, one must be aware of the need for arterial embolization to restore hemodynamic stability in a select subgroup of patients.

     

Levator defects can be detected by 2D translabial ultrasound

Introduction and hypothesis  Childbirth-related morphological abnormalities or defects of the puborectalis muscle (“avulsion”) can be diagnosed by magnetic resonance imaging and three-dimensional (3D) ultrasound, but neither method is universally available. In this study, we tested validity and reproducibility of a new method for diagnosing levator avulsion by 2D translabial ultrasound. Methods  Seventy-five women were examined for major morphological abnormalities of the puborectalis muscle by palpation, 2D and 3D ultrasound (US). For 2D US, we used an oblique parasagittal translabial approach. The operator using 2D US was blinded against all other findings. Results  Agreement between observers for diagnosis of avulsion by 2D US was 87% (Cohen’s kappa 0.56, CI 0.33–0.80). Agreement between tomographic 3D US and 2D US was 87% (kappa 0.61, CI 0.45–0.77). Conclusions  Defects of the puborectalis muscle can be diagnosed with 2D US. The finding of a discontinuity between the hyperechogenic muscle and the pelvic sidewall is moderately reproducible and agrees moderately well with palpation and 3D US.     

The prevalence of pelvic organ prolapse symptoms and signs and their relation with bladder and bowel disorders in a general female population

Introduction and hypothesis  In selected populations, pelvic organ prolapse (POP) was associated with bladder/bowel symptoms, but data on the general female population are lacking. Our aim was to obtain normative data on the prevalence of POP and pelvic floor dysfunction (PFD) symptoms and signs and to identify associations. Methods  Validated questionnaires on POP and PFD (urogenital distress inventory, (UDI) and defaecation distress inventory (DDI)) were sent to a general population of 2,979 women (aged 45–85 years). Data were analysed using the Kruskal–Wallis test, chi square test and Spearman’s rank correlation coefficient. Results  Response rate was 62.7%. Associations between POP stage and parity (0.002) and vaginal bulging (<0.001) are significant. Anatomical locations of POP and PFD symptoms correlated significantly with incontinence of flatus, feeling anal prolapse, manual evacuation of stool, vaginal bulging, constipation and pain during faecal urge (p ≤ 0.005). Conclusions  Strategies should be developed to alleviate obstructive bowel disorders associated with POP. Summary  POP was strongly associated with obstructive bowel disorders. Therefore, preventive strategies should be developed.     

U-shaped sacral fractures: Surgical treatment and quality of life

Background

U-shaped sacral fractures are rare and highly unstable pelvic ring fractures. They are not recognised in the standard classification systems of these fractures. The fracture pattern is associated with significant neurological injury and can lead to progressive deformity and chronic pain if not diagnosed and treated properly. In recent years a variety of surgical strategies have been shown to facilitate early mobilisation and reduce early mortality as compared to non-operative strategies. Poor evidence, however, has hampered the development of a standard treatment algorithm. As for the long-term morbidity, the influence of operative treatment may be difficult to assess due to associated injury. However, evidence exists that there is a significant effect on the long-term morbidity.

Objective

To assess the injury characteristics, choice of treatment and quality of life of U-shaped sacral fractures.

Methods

Eight polytraumatised patients with U-shaped sacral fractures were identified over a 7-year period and evaluated retrospectively. They were analysed for fracture classification, associated injury, and injury severity. Clinical and Radiological results were evaluated. Neurological outcome was retrospectively classified by Gibbons’ criteria. Long-term quality of life outcome was evaluated using the EuroQoL-6D questionnaire.

Results

The study population consists of five women and three men; with a median age of 29 years. All patients sustained severe associated injury. The Injury Severity Score ranged from 17 to 45 (median 23). The median time between trauma and definitive internal fixation was 4 days (range, 2-22 days). Definitive fixation included either percutaneous iliosacral screws (n = 2), transsacral plate osteosynthesis (n = 1) or triangular osteosynthesis with (n = 4) or without transsacral plating (n = 1). Early postoperative mobilisation and early partial weight-bearing were encouraged when possible. Follow-up ranged from 5 to 65 months (median, 36 months). Pain, mood disorders and mobility problems mainly influenced patients’ present general health status.

Conclusion

U-shaped sacral fractures present a rare and heterogeneous injury. Operative treatment depended mainly on fracture type, associated spinal fractures, and the surgeon's preference. Long-term quality of life is dominated by pain, mood disorders and moderate mobility problems.     

后尿道损伤不同术式处理后尿道狭窄发生率的Meta分析

目的 比较早期尿道会师加牵引术(即早期复位术)及早期耻骨上膀胱造瘘加延期尿道吻合术(即延期尿道成形术)处理骨盆骨折致后尿道损伤的疗效.方法 收集1966年至2006年Medline、荷兰医学文摘、中国生物医学文摘、Cochrane图书馆临床对照试验资料库与骨盆骨折导致后尿道损伤处理的有关文献,由2位评价者按相关限定条件进行筛选,选出符合纳入标准文献,使用RevMan 4.2软件进行Meta分析.结果 共10篇文献470例患者资料纳入分析,其中采用早期复位术249例、延期成形术221例.2种术式术后尿道狭窄发生率比较,OR一0.27,95%CI 0.08～0.86,P=0.03,差异有统计学意义;早期复位术术后狭窄需要再次行尿道吻合术者低于延期成形术,OR=0.25,95%,CI 0.08～0.74,P=0.01,差异有统计学意义.结论 早期复位术术后尿道狭窄的发生率低,治疗容易.本Meta分析不能排除分组时产生的偏倚,如尿道损伤的严重程度.