Intact External Sphincter Research Articles

Novel anal sphincter saving procedure with partial excision of levator-ani muscle in rectal cancer invading ipsilateral pelvic floor

PurposeTumors at the level of the anorectal junction had required total levator-ani muscle excision to achieve an adequate resection margin. However, in the cases of tumor invading ipsilateral levator-ani muscle and intact external sphincter, en bloc resection of rectum with levator-ani muscle including tumor would be possible. This hemilevator excision (HLE) technique enables preserving the anal sphincter function while obtaining oncologic clearance and avoiding permanent colostomy in those patients. This study aimed to evaluate the surgical outcomes and feasibility of HLE.MethodsData on 13 consecutive patients who underwent HLE for pathologically proven low rectal cancer were retrospectively collected. All 13 patients presented low rectal cancer at the anorectal ring level that was suspected to invade or abut to the ipsilateral side of the levator-ani muscle.ResultsA secure resection margin was achieved in all cases, and anastomotic leakage occurred in 2 patients. During follow-up, 3 patients experienced tumor recurrence (2 systemic and 1 local). Among 6 patients who underwent diverting ileostomy closure after the index operation, 2 complained of fecal incontinence. The other 4 patients without fecal incontinence showed <10 times of bowel movement per day. Accessing their incontinence scale, mean Wexner score was 9.4.ConclusionHLE is a novel sphincter-preserving technique that can be a treatment option for low rectal cancer invading ipsilateral levator-ani muscle, which has been an indication for abdominoperineal resection (APR) or extralevator APR. However, the long-term oncologic and functional outcomes of this procedure still need to be assessed to confirm its validity.

1523 THERAPY OF REFRACTORY POSTOPERATIVE URINARY STRESS INCONTINENCE BY THE USE OF AUTOLOGOUS SKELETAL MUSCLE-DERIVED CELLS (MDC)

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Incontinence - Evaluation & Therapy I1 Apr 20101523 THERAPY OF REFRACTORY POSTOPERATIVE URINARY STRESS INCONTINENCE BY THE USE OF AUTOLOGOUS SKELETAL MUSCLE-DERIVED CELLS (MDC) Christoph Eimer, Holger Gerullis, Roman Karig, Peter Goretzki, Albert Ramon, and Thomas Otto Christoph EimerChristoph Eimer Neuss, Germany More articles by this author , Holger GerullisHolger Gerullis Neuss, Germany More articles by this author , Roman KarigRoman Karig Neuss, Germany More articles by this author , Peter GoretzkiPeter Goretzki Neuss, Germany More articles by this author , Albert RamonAlbert Ramon Bad Aachen, Germany More articles by this author , and Thomas OttoThomas Otto Neuss, Germany More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.2367AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Urinary stress incontinence (USI) caused by morphological injury of the external urethral sphincter is refractory to conservative treatment. According to §4a of the German Pharmaceutical Law (AMG) we treated patients suffering from postoperative refractory grade III USI by transplantation of MDC. Patients were sent to our clinic from all parts of Germany. METHODS In general or local anaesthesia muscle tissue is extracted from the deltoid muscle (sample size 5x5mm, 2 samples/patient). The muscle tissue is converted into a primary cell culture separating individual cells and expanding them. Prior to the transplantation MDC are stored in physiological soda solution. Under visual guidance the cells are endoscopically injected into/around the lesion of the sphincter. RESULTS 222 men aged 70 years (56-81) from 32 different hospitals in Germany were included. 60% (132/222) of the patients were followed-up for at least 12 months after MDC transplantation- the time span necessary for sufficient evaluation of the transplantation process. The average time since iatrogenic sphincter injury was 43 months (12-192). After a medium of 59 days (16-122) following the muscle biopsy transplantation of MDC was performed. 11.18x106 (0.21-29.23x106) of MDC are transplanted. 11,3 % (9.5-13.1%) of these cells are identified immunocytochemically as satellite cells (positive for MyoD1, α-sarcomeric actin, α-smooth-muscle actin). Reversible AE′s grade I were observed in 11% of the patients (15/132). After a minimum follow-up of 12 months (12-61) 18 patients (13.6%) were completely continent, 51 patients (38,6%) showed improvement from grade III USI to grade I (less than 100ml/24h uncontrolled urine loss). The treatment effect can be observed 4,7 months (2-9) after transplantation of MDC and remains stable during follow-up. 63/132 (48%) patients have no change regarding grade III incontinence. Control cystoscopy showed a morphologically intact external sphincter in 15% (20/63) of the patients despite lacking improvement of USI. CONCLUSIONS Transplantation of MDC for the repair of iatrogenic damage of the external urinary sphincter and consecutive grade III USI is a safe procedure. In 52% (69/132) of the patients this method is efficient in distinctively reducing incontinence or even healing it. Disadvantages are the expenditure of time between treatment and efficacy of about 7 months, the cost situation, and the legal restrictions prohibiting us the initiation of GCP- conform clinical trials. © 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e587 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Christoph Eimer Neuss, Germany More articles by this author Holger Gerullis Neuss, Germany More articles by this author Roman Karig Neuss, Germany More articles by this author Peter Goretzki Neuss, Germany More articles by this author Albert Ramon Bad Aachen, Germany More articles by this author Thomas Otto Neuss, Germany More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Outcome of primary repair of obstetric anal sphincter rupture using the overlap technique

Grade III and IV anal sphincter ruptures after vaginal delivery are an increasing problem. We assessed the outcome of an overlap technique in primary repair. In this retrospective observational study, from 2002 to 2004, 61 consecutive women with grade III and IV obstetric tears were included. Of the 61 women, 42 had complete rupture of the external sphincter and underwent sphincter repair using standardised overlap technique. The outcome was assessed by clinical examination, Wexner questionnaire, and endoanal ultrasonography (EAUS), after a median follow-up of 9.4 months. Main outcome measure was continence following primary repair. At follow-up, 64% of the patients had no symptoms of anal incontinence. A total of 29% experienced occasional incontinence to flatus, 1 patient (2%) experienced occasional incontinence to liquid stools, and 1 patient to liquid or normal stools. EAUS revealed intact external sphincter in 29 of the 35 patients (83%). In 6 patients (17%), EAUS showed partial discontinuity of the sphincter muscle. The results show that the primary overlap technique in the repair of anal sphincter rupture following vaginal delivery is highly successful.

Anterior anal sphincter repair in patients with obstetric trauma.

Anterior sphincter repair for faecal incontinence related to obstetric trauma was performed in 55 patients: 32 with incontinence after delivery and 23 with late onset. Anal endosonography and physiological tests were performed before and after surgery. After a median of 15 (range 6-36) months, 42 patients had improved, 11 had not improved and two were awaiting colostomy closure. The postoperative squeeze pressure was increased (by 20 versus 5 cmH2O, P = 0.05) and the external sphincter was more frequently intact (32 of 35 versus five of 11, P = 0.003) in those with a good outcome. Patients with an intact external sphincter had higher postoperative squeeze pressures (50 versus 20 cmH2O, P = 0.004). Patients with late-onset incontinence were older than those who developed incontinence soon after delivery (median 59 versus 32 years, P < 0.001) and had longer pudendal nerve terminal motor latencies (2.3 versus 2.1 ms, P = 0.03). Failure of repair is related to persistent external sphincter defects. Late-onset incontinence, even with a prolonged pudendal nerve terminal motor latency, does not preclude a good outcome.

Fecal Incontinence.

Fecal incontinence is a socially devastating clinical condition. Initial symptomatic treatment includes exclusion of foods that precipitate the problem, increased use of fiber, and drug therapy with loperamide. Persistence of incontinence after these lifestyle modifications requires the physician to evaluate the internal and external anal sphincters. Anal endosonography and manometry provide an evaluation of sphincter structure and function. If an isolated muscle defect is seen, sphincteroplasty can be tried. If this surgical procedure is not indicated, biofeedback may be an option. Biofeedback should be considered for patients with neurogenic fecal incontinence, a weak but structurally intact external sphincter, or a decreased ability to perceive rectal distention. Muscle transposition to create a neosphincter should be offered only by surgeons with extensive experience performing this surgery. Because of the cosmetic sequela of colostomy, this surgery is often considered as a last-step procedure, despite being safe and effective.

Accuracy and reliability of transanal ultrasound for anterior anal sphincter injury.

Although transanal ultrasound has rapidly become the test of choice for the diagnosis of anal sphincter injury, the accuracy and reliability of this technique are unknown. This study evaluates the accuracy and reliability of transanal ultrasound for anterior (obstetric-related) anal sphincter injury. Sixty-two women underwent transanal ultrasound with hard-copy images obtained at 0.5-cm intervals from the anal verge to 2.5 cm into the anal canal. All transanal ultrasound procedures were also recorded on videotape. Two experienced ultrasonographers blinded as to the patients' clinical history and examination independently reviewed the images and videotape recordings for the presence or absence of anal sphincter injury. The accuracy of transanal ultrasound in 22 incontinent women with known anal sphincter injury was 100 percent. The accuracy of transanal ultrasound in 20 nulliparous women with intact anal sphincters was only 35 percent but improved to 50 percent after the "real time" videotape was reviewed (P = 0.16) and further improved to 85 percent when interpretation was limited to the distal 1.5 cm of the anal canal (P = 0.004). In these nulliparous women, intact internal sphincters were more accurately predicted than intact external sphincters (95 vs. 85 percent; P = 0.24). Measurement agreement between the two ultrasonographers was 68 percent (fair; kappa, 0.26) but significantly improved to 78 percent (moderate; kappa, 0.48; P = 0.0001) when interpretation was limited to the distal 1.5 cm of the anal canal. Overall clinical agreement (final scan interpretation) was good (81 percent agreement; kappa, 0.61). Agreement was better for the internal sphincter (74 percent; fair; kappa, 0.36) than the external sphincter (61 percent; poor; kappa, 0.17; P = 0.0002). Although transanal ultrasound can accurately identify anterior anal sphincter injury when present, transanal ultrasound falsely identifies sphincter injury in at least 5 to 25 percent of normal anal sphincters. Only fair agreement in the interpretation of transanal ultrasound exists between experienced ultrasonographers. Both the accuracy and reliability of transanal ultrasound are significantly improved by limiting transanal ultrasound to the distal 1.5 cm of the anal canal.

Rectal manometry, computed tomography, and functional results of anal atresia surgery

Children with anal atresia often have compromised function. This is especially common with the anatomic "high lesion." Twenty-five patients have been studied using clinical evaluation, computed tomography (CT), and manometry to make an objective evaluation. The patients were an average of 9.6 years old; the male-to-female ratio was 3:2. Thirty-three percent had acceptable bowel function as defined by a continence score of 1 or 2. Only two (11%) had an abnormal sacrum. The mean rectal pressure was 20 cm H2O and 5 patients (23%) had a normal rectal relaxation reflex. Thirty percent had CT scans that demonstrated an intact external sphincter and puborectalis. In comparing the objective criteria and clinical results no technique could predict continence. CT demonstrated no significant group (P = .046 to .659) and manometry demonstrated no significant group (P = .082 to .752). We found no objective criteria that could evaluate the patient's clinical result or dictate therapy.

Surgical correction of anal incontinence.

Seventy-six operative procedures for anal incontinence performed at the Lahey Clinic Medical Center between 1964 and 1985 were reviewed. Etiologic factors, findings on preoperative physical examination, and functional results are reported for 61 procedures in the four categories of simple anterior reefing, anterior reefing with perineal body reconstruction and anoplasty skin closure, posterior proctopexy, and Dacron Silastic sling insertion. In women with anterior sphincter defects, combining anoplasty skin closure and deep external sphincter plication gives superior functional results over superficial reefing, especially when there is attenuation of the rectovaginal septum and perineal body. The posterior proctopexy is most useful in patients with intact external sphincters and incontinence without recognizable cause or after abdominal repair of rectal prolapse.

Post-prostatectomy incontinence.

Urinary continence is maintained by the smooth-muscled system of the "internal sphincter". The striated external sphincter is not primarily responsible for continence. One of the chief functions of the external sphincter is the initiation of voluntary micturition. Its other functions are: random interruption of the urinary stream, reflex control during an increase in intra-abdominal pressure (such as coughing, sneezing, larghing, lifting) complete emp;ying of the urethra after micturition and stabilization of the posterior urethra in the urogenital diaphragm. After prostatectomy an intact external sphincter is important in order to support the smooth-muscled system which continues to be primarily responsible for continence to function as efficiently as possible. In approximately 90% of all postprostatectomy incontinences the external sphincter is intact and this cames a good prognosis following our correcture surgery without the need for prostheses. Only in rare post-prostatectomy incontinence cases (aprox. 10%) is the external sphincter also injured. Incontinence surgery according to our method has not been satisfactory in these cases.

Urinary continence in absence of intact external sphincter : N. J. Nemoy and D. E. Govan. J. Urol. 102:200–204, August 1969

Urinary continence in absence of intact external sphincter : N. J. Nemoy and D. E. Govan. J. Urol. 102:200–204, August 1969

Urinary Continence in the Absence of an Intact External Sphincter

Urinary Continence in the Absence of an Intact External Sphincter