Anterior Suspension Research Articles

Ovarian repositioning in pediatric cancer patients: Flexible techniques accommodate pelvic radiation fields

Treatments for childhood cancer and consequent long-term survival rates continue to improve. As the success of these therapies advances, premature ovarian failure and sterility have become an increasingly evident long-term morbidity. Abdominal and pelvic radiation have been specifically shown to induce early menopause and decreased fertility. In order to minimize radiation injury, we utilized novel techniques to reposition ovaries in two girls with pelvic tumors prior to initiation of pelvic radiation. One girl with a sacral Ewing sarcoma underwent laparoscopic anterior suspension of the ovaries, using a simple and easily reversible technique. The second patient, who underwent hysterectomy for a recurrent uterine rhabdomyosarcoma, underwent widely lateral and cephalad repositioning of the ovaries. Both procedures were well tolerated, with no significant morbidity. In both cases the ovaries were moved well beyond the planned radiation field. We propose that open or laparoscopic ovarian repositioning in children is a simple, flexible, and reversible option to reduce radiation injury to the ovaries in pediatric cancer patients.

Anterior or posterior sacrospinous vaginal vault suspension: long-term anatomic and functional evaluation

OBJECTIVE: To compare vaginal anatomy and sexual function after the conventional posterior and anterior sacrospinous vault suspension. METHODS: A retrospective repeated measures cohort study included all 168 consecutive sacrospinous vault suspension procedures between July 1990 and February 1997. The posterior suspension ( n = 92) used a posterior vaginal incision and pararectal dissection. Anterior suspension ( n = 76) involved an anterior rather than posterior vaginal incision, retropubic perforation, and dissection of a paravaginal-paravesical rather than pararectal space to accommodate the vaginal vault. Two polytetrafluoroethylene (00) sutures anchored the anterior vaginal cuff (for the anterior sacrospinous suspension) or the posterior vaginal cuff (for the posterior sacrospinous suspension) to the ligament. Postoperative evaluation included an examination using the pelvic organ prolapse quantitative system, assessment of vaginal width and axis, and symptom questionnaire. RESULTS: Total vaginal length and apical suspension were slightly greater after the anterior suspension, and recurrent anterior vaginal relaxation was less likely. No differences were found in maximal dilator size or apical narrowing between the two groups. New onset dyspareunia was reported by two subjects in the anterior vault suspension group, and two in the posterior vault suspension group. Three of these four cases of de novo dyspareunia were attributable to either severe atrophy or recurrent prolapse, and none to vaginal narrowing or shortening. CONCLUSION: After anterior sacrospinous vault suspension, vaginal length and apical suspension were slightly increased, and recurrent anterior vaginal prolapse decreased compared with the posterior sacrospinous suspension technique. Upper vaginal caliber and sexual function appear well preserved using either technique.

Anterior or Posterior Sacrospinous Vaginal Vault Suspension

In Brief OBJECTIVE To compare vaginal anatomy and sexual function after the conventional posterior and anterior sacrospinous vault suspension. METHODS A retrospective repeated measures cohort study included all 168 consecutive sacrospinous vault suspension procedures between July 1990 and February 1997. The posterior suspension (n = 92) used a posterior vaginal incision and pararectal dissection. Anterior suspension (n = 76) involved an anterior rather than posterior vaginal incision, retropubic perforation, and dissection of a paravaginal-paravesical rather than pararectal space to accommodate the vaginal vault. Two polytetrafluoroethylene (00) sutures anchored the anterior vaginal cuff (for the anterior sacrospinous suspension) or the posterior vaginal cuff (for the posterior sacrospinous suspension) to the ligament. Postoperative evaluation included an examination using the pelvic organ prolapse quantitative system, assessment of vaginal width and axis, and symptom questionnaire. RESULTS Total vaginal length and apical suspension were slightly greater after the anterior suspension, and recurrent anterior vaginal relaxation was less likely. No differences were found in maximal dilator size or apical narrowing between the two groups. New onset dyspareunia was reported by two subjects in the anterior vault suspension group, and two in the posterior vault suspension group. Three of these four cases of de novo dyspareunia were attributable to either severe atrophy or recurrent prolapse, and none to vaginal narrowing or shortening. CONCLUSION After anterior sacrospinous vault suspension, vaginal length and apical suspension were slightly increased, and recurrent anterior vaginal prolapse decreased compared with the posterior sacrospinous suspension technique. Upper vaginal caliber and sexual function appear well preserved using either technique. Anterior sacrospinous vaginal vault suspension results in anatomic and functional outcomes similar to the conventional posterior approach, and may reduce the risk of recurrent anterior compartment prolapse.

Excision of Urethral Diverticulum

Urethral diverticula result in most cases from inflammatory conditions of the periurethral glands. Most are the result of repeated infection and obstruction of the periurethral glands. Initially, a suburethral cyst is formed by both the inflammatory process of infection and by the pressures created within an obstructed periurethral gland. These cysts subsequently rupture into the urethral lumen. The resulting draining abscess cavity is eventually epithelialized, and thus a urethral diverticulum is formed. Very rarely, they are congenital or traumatic following urethroscopy or urethrotomy. Open surgical procedures such as anterior colporrhaphy or bladder neck suspension surgery may damage the periurethral fascia and create a traction diverticulum.

The stabilizing sling for the long head of the biceps tendon in the rotator cuff interval. A histoanatomic study.

A histoanatomic study of the rotator cuff interval was done in 13 cadaveric specimens to investigate the relation of its ligamentous structures to the long head of the biceps tendon, with a special focus on revealing a stabilizing function. After macroscopic evaluation, the lateral half of the rotator cuff interval capsule was cut into three sections: medial, middle, and lateral. These sections were embedded in methacrylate, and then serial sections were made and stained for polarized light microscopy. The superior glenohumeral ligament was seen to form a fold having the macroscopic appearance of a U-shaped anterior suspension sling for the long head of the biceps tendon. Microscopic evaluation revealed an important role of the fasciculus obliquus in the roof of this sling. Fibers of the supraspinatus tendon join the posterosuperior part of the sling. The subscapularis tendon is not involved in this suspensory mechanism. As a result of these observations, we determined that the superior glenohumeral ligament and the fasciculus obliquus are the most important ligamentous reinforcements of a stabilizing sling for the long head of the biceps tendon in the rotator cuff interval. Their histologic appearance indicates they function to protect the long head of the biceps against anterior shearing stress. A lesion of this sling might lead to anterior instability of the biceps tendon.

The wide exposure anterior suspension technique in tympanoplasty

Otolaryngology–Head and Neck SurgeryVolume 121, Issue S2 p. P195-P196 Abstract The wide exposure anterior suspension technique in tympanoplasty Jeffery J Kuhn, Jeffery J Kuhn Virginia Beach, VASearch for more papers by this author Jeffery J Kuhn, Jeffery J Kuhn Virginia Beach, VASearch for more papers by this author First published: 11 December 2016 https://doi.org/10.1016/S0194-5998(99)80367-2AboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume121, IssueS2August 1999Pages P195-P196 RelatedInformation

Innominate artery compression of the trachea: diagnosis and treatment by anterior suspension. A 25-year experience.

Suspension of the innominate artery to the sternum has been a widely accepted therapy for the relief of tracheal compression. Recently, reimplantation of the innominate artery has been advocated as a superior operative procedure. While generally successful, arterial transfer carries the risk of early bleeding and stroke, and the potential for late stenosis at the anastomotic site. Between 1969 and 1994, 25 infants and children at our institution received diagnoses of innominate artery compression and were treated by anterior suspension. All presented with stridor and one third had a history of suspected or proven apnea. Twenty-four children had excellent results, while 1 required resuspension after stridor returned. There were no major complications. Our series strongly supports the belief that anterior suspension of the innominate artery is a successful and reliable operation with minimal morbidity and mortality. More complex procedures are rarely indicated.

Inter‐ and intra‐observer variation of colpo‐cysto‐urethrography diagnoses

To evaluate the reliability of diagnosing type of bladder suspension defect in incontinent women by means of voiding colpo-cysto-urethrography (CCU), 93 CCU-series with exposures at rest, coughing, withholding and voiding were diagnosed. Three senior and one junior radiologists, a gynecologist and a urologist diagnosed the CCU-series twice with 3-6 months interval. The main diagnostic possibilities were anterior bladder suspension defects, posterior defects and normal, which were in accordance with general practice of choosing an abdominal suspension operation for the anterior suspension defects and a vaginal operation for the posterior defects. The intra-observer agreement varied between 99% and 72%, i.e. 1/5 to 1/4 of the patients changed from one main diagnostic group to another at the two examinations. The inter-observer agreement varied between 43% and 60%. Information of clinical patient data, given to the two clinicians, did not change their CCU-diagnoses significantly. We concluded, that CCU should not be recommended as a routine for evaluation of type of suspension defect since the intra-inter-observer variation was around 25% and 50% respectively. CCU might still be useful preoperatively in selected cases, since it gives an excellent visualisation of bladder base anatomy.

Anterior cricoid suspension and tracheal stomal closure for children with cricoid collapse and peristomal tracheomalacia following tracheostomy

Anterior cricoid suspension and tracheal stomal closure for children with cricoid collapse and peristomal tracheomalacia following tracheostomy

Vaginal ultrasonography versus colpo-cysto-urethrography in the evaluation of female urinary incontinence

To compare the information of bladder neck suspension given by colpo-cysto-urethrography (CCU) and vaginal ultra-sonography (US), 44 women with various grades of incontinence were examined by both methods. The criteria for evaluation of incontinence for each method were applied on both procedures. CCU-diagnoses of type of bladder neck descent were compared as well as US-measurements of bladder neck position and mobility in relation to the symphysis pubis during rest, Valsalva and withholding. The interobserver agreement of diagnoses was 58%, which is comparable to interobserver agreement for CCU. The measurements of bladder neck suspension by bladder to symphysis (BS)-distance and rotation-angle in relation to the symphysis pubis, revealed almost identical results for the two procedures. The US-measurements had a better accuracy than the CCU measurements. Furthermore, hypermobility of the bladder neck was related to grade of incontinence and to diagnoses including anterior suspension defects. Presence of a cysto- or rectocele affected the size of the rotation angles. Patients with a cystocele had a 16o larger rotation angle by both procedures. Presence of a rectocele increased the rotation angle, measured by US, but decreased the angles, measured by CCU. Furthermore, the ability to withhold was decreased, when the patient had a rectocele. Since the same information of bladder neck suspension is provided by the two methods, and since the US-criteria revealed a better accuracy and a good clinical reliability, ultrasonography is recommended for evaluation of bladder neck anatomy - also for practical and economical reasons.

Glossopexia--evaluation of a new surgical method for treating obstructive sleep apnea syndrome.

Uvulopalatopharyngoglossoplasty, UPPGP, is a modification of the uvulopalatopharyngoplasty, UPPP, technique, originally used for surgical treatment of the obstructive sleep apnea syndrome. The first method seems to be the more successful. However, polysomnography performed after UPPGP showed that about 35% of the patients still had obstructive apnea periods during sleep. Eight of these patients were reoperated with a new technique which is a combination of partial tongue resection and anterior suspension of the tongue (glossopexia). After glossopexia all the patients were subjectively relieved of their symptoms. However, polysomnography carried out postoperatively demonstrated that only 2 patients were objectively cured. The authors want to stress the necessity of meticulous polysomnographical registration pre- and postoperatively. Subjective and objective parameters recorded before and after surgery are discussed.

Reliability of Voiding Colpo-Cysto-Urethrography in Female Urinary Stress Incontinence before and after Treatment

Voiding colpo-cysto-urethrography was performed in 52 consecutive female patients with genuine urinary stress incontinence before treatment and in 50 of the patients after treatment. The patients were randomized to either pelvic floor training or surgery. Surgery included a colposuspension operation in patients with an anterior suspension defect and a vaginal repair in patients with a posterior suspension defect. All pre- and posttreatment examinations were reevaluated blindly by one observer 4 to 6 years later. The pretreatment radiologic reevaluation was in agreement with the original classification in 79 per cent and not in agreement in 21 per cent. Pelvic floor training did not change the degree of suspension defect systematically. The effect of squeezing was significantly improved following pelvic floor training. A colposuspension gave rise to a typical radiologic configuration of the bladder and urethra. A vaginal repair was not detectable radiologically and it did not correct a posterior descent. The degree of descent and the degree of incontinence were not correlated and it was not possible radiologically to distinguish treatment failures from treatment success.

Reliability of voiding colpo-cysto-urethrography in female urinary stress incontinence before and after treatment

Voiding colpo-cysto-urethrography was performed in 52 consecutive female patients with genuine urinary stress incontinence before treatment and in 50 of the patients after treatment. The patients were randomized to either pelvic floor training or surgery. Surgery included a colposuspension operation in patients with an anterior suspension defect and a vaginal repair in patients with a posterior suspension defect. All pre- and posttreatment examinations were reevaluated blindly by one observer 4 to 6 years later. The pretreatment radiologic reevaluation was in agreement with the original classification in 79 per cent and not in agreement in 21 per cent. Pelvic floor training did not change the degree of suspension defect systematically. The effect of squeezing was significantly improved following pelvic floor training. A colposuspension gave rise to a typical radiologic configuration of the bladder and urethra. A vaginal repair was not detectable radiologically and it did not correct a posterior descent. The degree of descent and the degree of incontinence were not correlated and it was not possible radiologically to distinguish treatment failures from treatment success.

Manofluorography of deglutition after supraglottic laryngectomy.

Manofluorography (mano: manometry, fluoro: videofluoroscopy, graphy: picture) provides a simultaneous display of manometry and fluoroscopy on one video screen. This study uses manofluorography to analyze the swallowing patterns of nine patients who had undergone supraglottic laryngectomy. The results show that during swallowing the pharyngeal mechanism for preventing aspiration depends upon three processes: (1) tight lingual-laryngeal contact, (2) coordination of the swallowing reflex, and (3) tongue base and pharyngeal constrictor clearing of the hypopharynx and laryngeal inlet. Anterior suspension of the larynx under the tongue base serves to improve lingual-laryngeal contact. This close contact during deglutition protects the airway from the bolus and also opens the postcricoid region, aiding bolus passage into the esophagus. Impairment of the swallowing reflex, which can cause severe aspiration before the swallowing reflex is triggered, can be rehabilitated by swallowing therapy. Minor aspiration is commonly caused by impaired clearing of the superior hypopharynx after supraglottic laryngectomy.

Colposuspension compared with levator ani muscle repair for correction of female stress urinary incontinence

A total of 70 women with stress urinary incontinence were randomly allocated to either colposuspension or transperitoneal levator ani repair. Preoperatively, 92% of the patients had anterior suspension defects on colpocystourethrography. At follow-up after \(2{\raise0.5ex\hbox{$\scriptstyle 1$}\kern-0.1em/\kern-0.15em\lower0.25ex\hbox{$\scriptstyle 2$}}\) years the subjective results of the operation, urinary flow rate, cystometry, colpocystourethrography and operative complications were evaluated. In the colposuspended group, 81% of the patients were continent or had improved continence versus 50% in the levator ani repair group. Both operations carried some operative complications. It was concluded that colposuspension was superior to the levator ani repair for operative correction of anterior suspension defects in stress incontinent women.

The value of colpo-cysto-urethrography in female stress- and urge incontinence and following operation.

The value of colpo-cysto-urethrography (CCU) in female stress- and urge incontinence was measured. In a prospective series of 172 consecutive females with stress- or urge incontinence, CCU was performed and assessed with regard to no suspension defects, anterior defects, or posterior defects, respectively. Six months following operative repair for stress incontinence, CCU was repeated in 97 patients and compared with operative success. CCU was of minor value in the differentiation between stress- and urge incontinence. In stress incontinence, CCU was of greater value for the preoperative planning of operative technique, vaginal or abdominal, but could be omitted when pelvic examination did not disclose genital prolapse, as this excluded posterior suspension defects at CCU. Postoperative CCU was of minor value, and poorly correlated to operative success or failure. Stress incontinence with anterior suspension defects was best treated by abdominal colposuspension, even when complicated by genital prolapse. With no suspension defect at CCU, vaginal and abdominal repair were equally good alternatives. Posterior suspension defects had the lowest cure rate.

Anterior bladder suspension defects in the female. Radiological classification with urodynamic evaluation. Anatomically corrective operations.

Colpo-cysto-urethrography, urodynamic and cystometric examinations were performed in 420 patients from the departments of urology and gynecology. One hundred and ninty-eight patients displayed displacement of the urethro-vesical junction in the anterior and inferior direction. Three grades of displacement were established. The mildest form, grade 1, was visible only during a cough. The intermediate form, grade 2, was present even at rest. The severest form, grade 3, involved a displacement of the anterior vaginal wall, resulting in anterior bladder descent during cough and/or micturition. Stress incontinence was a complaint in 82 per cent of the women. The pathology is shown to be laxity of the arcus tendineus fasciae pelvis, which normally exerts a pull on the bladder neck in a postero-cranial direction. In seven cases anatomically corrective operations on this ligament were performed, resulting in a normal bladder base in an anatomically correct position. The operation is complicated and not suited for routine use.

The anterior vaginal suspension operation: A report of 110 cases

A modified operative procedure based upon the principles and original technique of the Marshall-Marchetti-Krantz procedure has been discussed in view of enlarging the use of the anterior type of suspension operation as a primary procedure in the correction of stress incontinence. The use of the operation in various clinical situations and with various abdominal and pelvic operative methods is presented. The utilization of a modified lithotomy position of the patient during operation is emphasized, especially in combined abdominal hysterectomy and anterior vaginal suspension. The use of permanent suture is suggested, and placing of these sutures in the form of a T to suspend the dome of the vagina (giving rise to the name of the procedure) is discussed in a series of 110 cases. Both catgut and permanent sutures have been used. The permanent sutures used have for the most part been silk. The drawback of postoperative wound complications is observed. Increased care in carrying out the procedure has lowered this incidence by more than 50 per cent. The use of a drain for the first 24 hours after operation completely obviates this problem.Improved results over vaginal operations from below are reported and these are notably in the preservation of vaginal length, preservation of mobility of the urethra and bladder neck, and prevention of the usual postoperative complaints referrable to a heavy, painful, fixed anterior vaginal wall. Restoration of a functional vagina in cases in which its function has been impaired, such as postoperative shortening and scarring, or in instances of excessive anterior vaginal wall relaxation is noted in many of these cases. The adaptation of the anterior vaginal suspension operation to most cases of anterior vaginal wall relaxation is demonstrated.There have been some failures (but none have been recorded so far in this series) in cases in which permanent sutures have been used. A possible permanent obliteration of cystocele is discussed and the possibility of its recurrence is considered, although none have as yet been seen. The follow-up time is from 6 weeks to 2 1/2years. A very few individuals are not completely continent but have been improved, and these are all in the group in which catgut suture was used for the repair. It is hoped that further follow-up and further adaptation of the anterior suspension principle to the correction of anterior vaginal wall relaxation problems, including stress incontinence, will prove to be as effective as a recent series has apparently shown.15 Increased interest in the problems of vaginal relaxation will stimulate even more experience with the anterior suspension type of surgical procedure as a possible solution to this unfortunate, debilitating, embarrassing, and nerve-racking complaint.