Internal Sphincter Research Articles

Organic changes of anal sphincter in complicated rectal fistulas

Aim. To evaluate the diagnostic significance of structural changes in the anal sphincter (AS) in patients with complex rectal fistulas (CRF).Materials and Methods. This study analyzed the results of examination and surgical treatment of 87 patients with rectal fistulas. Following a comprehensive assessment, the structural changes in the anal sphincter (SCAS) among patients with complex rectal fistulas were classified into several categories. The first subgroup included 16 patients (18.4%) with complex rectal fistulas accompanied by inflammatory infiltration of the anal sphincter (reactive sphincteritis, RS). The second subgroup consisted of 24 patients (27.6%) who exhibited fibrotic changes in the anal sphincter (anal sphincter pectenosis, ASP). The third subgroup comprised 17 patients (19.5%) with complex rectal fistulas and defects (diastasis of AS muscles) in the anal sphincter fibers. The fourth subgroup served as the comparison group, consisting of 30 patients (34.5%) with complex rectal fistulas but without organic changes in the AS.Results and Discussion. The primary complaint among all patients with complex rectal fistulas was the presence of a fistula opening with purulent discharge, although additional symptoms varied depending on the type of structural changes in the AS. The study demonstrated that ultrasound showed a sensitivity of 87%, specificity of 69%, and overall accuracy of 92% in diagnosing rectal fistulas, consistent with data reported by other researchers. On ultrasound, reactive sphincteritis presented as a homogeneous or heterogeneous structure of anal sphincter fibers with varying shapes and sizes, characterized by hyperechogenicity intimately adjacent to fluid accumulations (or intersphincteric localization), filled with contents of varying degrees of echogenicity depending on the stage of inflammation. The ultrasound characteristics of anal sphincter pectenosis (ASP) differed from RS, showing a decrease in sphincter fiber volume and deformation of the AS with retraction of the muscular ring. Defects in the internal sphincter were characterized by varying degrees of hypoechogenicity, with lengths ranging from 0.3 to 1.2 cm, and were more frequently observed along the posterior rectal wall.Conclusions. Complex rectal fistulas are often associated with organic changes in the structure of the anal sphincter, manifesting as reactive sphincteritis, anal sphincter pectenosis, and defects in the muscle fibers of the external anal sphincter. The clinical course of the disease in patients with ASP is influenced by both the type of rectal fistula and the nature and severity of SCAS.

Effectiveness of 0.3 % nifedipine gel combined with 2.0 % lidocaine and BTA 80 U in treatment of chronic anal fissure. Pilot randomized study. Preliminary results

AIM: to improve the results of chronic anal fissure treatment. PATIENTS AND METHODS: the study included 22 patients randomized by random numbers generation method into 2 groups. Eleven patients were included in main group and were treated with 0.3 % nifedipine + 2.0 % lidocaine gel, 11 patients of the control group received injections of botulinum toxin A into the internal anal sphincter at a dose of 80 U (BTA 80). RESULTS: by day 30, there was a decrease of maximal resting pressure in anal canal (MRPAC) in both the main and control groups [p = 0.015 and p = 0.004, respectively] and the average resting pressure in anal canal (ARPAC) [p = 0.01 and p = 0.02, respectively]. There was no difference between the groups in pain severity both after stool and during the day (p = 0.5 and p = 0.6, respectively). On day 60, the defect was epithelized in 6/11 (54.6 %) patients of the study group and in 9/11 (81.8 %) patients of the BTA 80 group [p = 0.36], respectively. The reason of treatment failure in 4/11 (36.4 %) patients of the main group and 2/11 (18.2 %) patients of the control group was a preserved internal sphincter spasm. It was found that these patients used a lower amount of the drug product — 2.2 (1.8; 2.5) mg/day compared to 2.4 (1.9; 2.7) mg/day in other patients. On the day 30 after surgical treatment, complaints about gas incontinence were registered in 1/11 (9.1 %) patients of the main group and 1/11 (9.1 %) patients of the control group [p = 1]. Such a complication as external hemorrhoid thrombosis occurred only in 1/11 (9.1 %) patients in the BTA 80 group [p = 0.87]. CONCLUSION: the study results show that gel containing 0.3 % nifedipine and 2 % lidocaine produces an effect on the tone of the internal sphincter comparable to BTA. However, the lack of accurate dosage of the drug product and/or low patient compliance reduce the effectiveness of treatment and make the use of BTA preferable for medical relaxation of the internal sphincter.

Rethinking Fistula Preservation in Anorectal Malformation Surgery: A Histopathological Perspective.

This study aims to assess the histopathological characteristics of the fistulous tissue in males with anorectal malformation (ARM) to determine its suitability for use in constructing a neoanus. This prospective observational study included male ARM patients with recto-urethral fistula. All other types were excluded. The tissue specimens comprised 0.5-2.0 cm of the most distal part of the rectal pouch and the fistulous tissue. Hematoxylin and eosin-stained sections were prepared. Histological features viz. internal sphincter, anal grand and crypts, ganglion cells, presence of subepithelial fibrosis, thickened nerve trunks, and metaplasia were evaluated. Of 65 patients of ARM admitted, 24 met the inclusion criteria. Gross and microscopic internal sphincter was not found in any sample. The anal mucosa was visualized in all cases; however, crypts were irregular and distorted architecture was seen in 4 (16.67%) samples. Urothelial metaplasia was identified in 10 (41.67%) cases. Adequate ganglion cells were seen only in 6 (25%) samples. Significant submucosal fibrosis was seen in all samples. Thickened nerve trunks were identified in 4 (16.67%) samples. All normal anal histological features could not be found together in the fistula tissue. With the absence of normal features, such as internal anal sphincter muscles, and the presence of abnormal histopathological features, such as subepithelial fibrosis, thickened nerve trunks, and metaplasia there are high chances of abnormal bowel function like constipation if the fistulous tissue is used for neoanus construction. It may have an impact on the quality of life of patients.

The impact of plasma-rich platelet injection to perianal sphincters on incontinence and quality of life in patients with rectal cancer after low anterior or intersphincteric resection: a prospective cohort study

BackgroundIncontinence is not rare after rectal cancer surgery. Platelet-rich plasma may promote tissue repair and generation but has never been tested for the treatment of anal incontinence. This study evaluated the impact of platelet-rich plasma injection on the severity of incontinence and quality of life after low rectal cancer surgery.MethodsThis is a prospective cohort proof of concept study in a colorectal cancer institution. Patients had undergone low anterior or intersphincteric resection for low rectal cancer and had a Wexner score > 4. Ten milliliters of platelet-rich plasma were injected into the internal and external sphincters under endoanal ultrasound (EAUS) guidance. Primary outcome measure was > 2 point improvement in Wexner score (improved group). The patients were assessed with endo-anal ultrasound examination, manometry, the Wexner Questionnaire and SF-36 Health Surveys, and patients were asked whether they used pads and antidiarrheal medications before and 6 months after PRP injection.ResultsOf 20 patients included in the study, 14 (70%) were men, and the average age was 56.8 (SD = 9.5) years. No statistically significant difference was found in Wexner scores before and after PRP injection (p = 0.66). Seven (35%) patients experienced a > 2 point improvement in Wexner score. Rectal manometry demonstrated improved squeezing pressure (p = 0.0096). Furthermore, physical functioning scoring (p = 0.023), role limitation (p = 0.016), emotional well-being (p = 0.0057) and social functioning (p = 0.043) domains on the SF-36 questionnaire improved. One (5%) and three (15%) patients stopped using pads and antidiarrheal medications.ConclusionPlatelet-rich plasma injection does not restore Wexner scores, but more than one-third of patients may benefit from this application with an improvement of > 2 points in their scores. Platelet-rich plasma injection may improve squeezing pressure and certain life quality measures for incontinent patients after rectal cancer surgery.

The analysis of different types of anorectal abscesses was conducted using the MRI 3D reconstruction technique

It has not yet been proven whether sepsis affects the tissue around the anal canal. To address this issue, we established three-dimensional models for various types of anorectal abscesses and utilize 3D reconstruction of Magnetic Resonance Imaging scans to assess the extent of muscle damage caused by anorectal abscesses. Patients diagnosed with anorectal abscess, selected from January 2019 to January 2022 underwent pre- and post-operative scanning of pelvic floor and perianal tissues. The aforementioned structures were segmented for the reconstruction of a three-dimensional visual model and measurement of volumes for the abscess as well as the internal and external sphincters and levator ani muscle. The study included a total of 42 patients. Three-dimensional visualization models were created for different types of anorectal abscesses, including perianal, intersphincteric, ischiorectal, and supralevator abscesses. No statistically significant differences were observed in the volume of the internal sphincter, external sphincter, and levator ani muscle between pre- and post-operative patients. The 3D model of anorectal abscess, reconstructed from MRI data, offers a precise and direct visualization of the anatomical structures associated with various types of anorectal abscesses. The infection did not result in any damage to the internal and external anal sphincter and levator ani muscle.

Granular Cell Tumor of the Anal Canal: Case Report and Literature Review

AbstractGranular cell tumors (GCTs) are rare benign neoplasms that can occur anywhere in the body but are most commonly found in the head and neck region. These tumors are often asymptomatic and are incidentally discovered during routine rectal examination. In some cases, symptoms may include bleeding, pain, and a palpable mass. Imaging studies such as colonoscopy, ultrasound, magnetic resonance imaging (MRI), or computed tomography can be used to characterize and measure the tumor. Treatment typically involves local resection, with or without adjuvant radiotherapy, depending on the size, location, and pathological characteristics of the tumor. The prognosis for GCTs of the anal canal is generally good, with few cases of recurrence or metastasis reported, but long-term follow-up is recommended due to the potential for late recurrence or malignant transformation. The present study reports a 39-year-old female patient who presented with anal itching associated with protrusion of a perianal mass and who underwent treatment between November 2022 and December 2023. The MRI scan revealed a nodular image in its caudal aspect with involvement of the internal sphincter between 12 and 5 o'clock, which was successfully resected. Histopathology was compatible with GCT, and the patient had a satisfactory recovery and was discharged. In conclusion, GCTs of the anal canal are rare and extremely unusual tumors that can be difficult to diagnose and manage, requiring a multidisciplinary approach for optimal management.

Interstitial cell of Cajal-like cells (ICC-LC) exhibit dynamic spontaneous activity but are not functionally innervated in mouse urethra

Urethral smooth muscle cells (USMC) contract to occlude the internal urethral sphincter during bladder filling. Interstitial cells also exist in urethral smooth muscles and are hypothesized to influence USMC behaviours and neural responses. These cells are similar to Kit+ interstitial cells of Cajal (ICC), which are gastrointestinal pacemakers and neuroeffectors. Isolated urethral ICC-like cells (ICC-LC) exhibit spontaneous intracellular Ca2+ signalling behaviours that suggest these cells may serve as pacemakers or neuromodulators similar to ICC in the gut, although observation and direct stimulation of ICC-LC within intact urethral tissues is lacking. We used mice with cell-specific expression of the Ca2+ indicator, GCaMP6f, driven off the endogenous promoter for Kit (Kit-GCaMP6f mice) to identify ICC-LC in situ within urethra muscles and to characterize spontaneous and nerve-evoked Ca2+ signalling. ICC-LC generated Ca2+ waves spontaneously that propagated on average 40.1 ± 0.7 μm, with varying amplitudes, durations, and spatial spread. These events originated from multiple firing sites in cells and the activity between sites was not coordinated. ICC-LC in urethra formed clusters but not interconnected networks. No evidence for entrainment of Ca2+ signalling between ICC-LC was obtained. Ca2+ events in ICC-LC were unaffected by nifedipine but were abolished by cyclopiazonic acid and decreased by an antagonist of Orai Ca2+ channels (GSK-7975A). Phenylephrine increased Ca2+ event frequency but a nitric oxide donor (DEA-NONOate) had no effect. Electrical field stimulation (EFS, 10 Hz) of intrinsic nerves, which evoked contractions of urethral rings and increased Ca2+ event firing in USMC, failed to evoke responses in ICC-LC. Our data suggest that urethral ICC-LC are spontaneously active but are not regulated by autonomic neurons.

Internal urethral sphincter reconstruction with anterior bladder neck tube for robotic and laparoscopic radical prostatectomy: improving early return of continence.

In recent years, despite several surgical techniques having been applied, the early incontinence rate after radical prostatectomy (RP) remains high. In this study, we reconstructed an internal urethral sphincter (IUS) with anterior bladder neck tube (ABNT) to improve early return of continence and find a more effective technique for early urinary incontinence after RP. In this study, 96 previous patients who did not receive an ABNT between October 2018 and May 2020 were compared as historical controls (the control group). A total of 210 consecutive patients underwent robotic or laparoscopic RP with ABNT between May 2020 and February 2023 (the ABNT group). The inclusion criteria included Eastern Cooperative Oncology Group (ECOG) score 0-1 and localized prostate cancer (clinical stages cT1-3, cN0, cM0). The exclusion criteria included patients with diabetes, neurologic diseases, previous pelvic operations, symptoms of urinary incontinence, prior radiation, focal therapy, or androgen deprivation therapy for prostate cancer. ABNT was reconducted with a U-shaped flap from the anterior wall of the bladder neck, and was then anastomosed with the urethra. In the control group, the bladder outlet was directly anastomosed with the urethra. Continence, as defined if 0 pads were used per day and International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) score ≤6, was assessed at 1, 4, 8, 12, and 24 weeks after catheter removal. At 2 weeks after catheter removal, urethral pressure profilometry (UPP) and upright urethrography were performed to evaluate the function of ABNT in the ABNT group. More patients in the ABNT group were continent than those in the control group at 1 week (85.2% vs. 22.9%, P<0.001), 4 weeks (91.4% vs. 27.1%, P<0.001), 8 weeks (95.2% vs. 40.6%, P<0.001), 12 weeks (100% vs. 71.9%, P<0.001), and at 24 weeks (100% vs. 87.5%, P<0.001) after catheter removal. Stricture was presented in 5.2% and 2.1% (P=0.34) in the ABNT group and control group, respectively. UPP showed that a functional IUS was reconstructed with ABNT. Upright urethrography showed that the ABNT was filled with contrast medium in the urination period and with no contrast medium during the storage period and interruption of urination. The ABNT technique significantly improved early return of continence in comparison with the no ABNT technique, especially the immediate continence. The ABNT technique reconstructed the functional IUS with acceptable urethral stricture. The limitations of the present study include that the comparison was conducted retrospectively with a historical cohort and lack of randomization, and the single center setting. A prospective, randomized, and multicenter evaluation is expected.

Rectovaginal Fistula Due To Chronic Perineal Tear; A Case Report

An abnormal connection that exists between two epithelial surfaces or lumens of the rectum that reaches into the vagina is known as a recto-vaginal fistula (RVF). RVF is one unfortunate consequence of the underlying condition, such as trauma or surgery. According to the patient recap of the urogynecology clinic at M Djamil Hospital Padang (2023), from January to September, 6 patients had cases of rectovaginal fistula that needed to be repaired. Treatment of the underlying condition, the fistula, and its associated complications all fall under the umbrella of RVF management. Given that obstetrics, procedure is still the main cause in this case, the role of the field of urogynecology in the management of surgical interventions is important to maintain the quality of life of a woman. In this case report we present a case report of a 24-year-old woman with rectovaginal fistula and anal incontinence caused by chronic total perineal tear. The patient complained of feces discharge from the vagina since giving spontaneous birth to the first. Physical examination found defects in the internal sphincter (IAS) and external sphincter (EAS) at 11 until 14 o'clock. The patient then underwent sphincteroplasty and perineorrhaphy and showed improvement after surgical intervention

Modern methods of treatment of anal stenosis

Objective. To develop and put into practice a new combined method of anal stenosis surgical treatment based on laser plastic surgery of tissues with a diode laser. Assess the effectiveness of the technique based on the analysis of immediate and long-term results, postoperative complications, peculiarities of technical implementation, and features of the quality of patients` life. Materials and methods. The study involved 68 patients with anal stricture after the anal and (or) rectal surgery. All patients underwent laser correction of postoperative scar tissue. According to indications, botulinum toxin was injected into the internal sphincter and (or) PRP autoplasma perarectally. Surgery was performed under intravenous anesthesia with the addition of tumescent anesthesia or local anesthesia. Laser radiation from a diode device with a wavelength of 1.56 microns and a power of 10 W was applied. Results. There are no restrictions on laser correction of anal stenosis regardless of the type and complexity of anal stenosis, it is technically easy to use, minimizes the risk of postoperative complications and relapse of the disease, and has a highly effective treatment result. Conclusions. The technique is characterized by versatility and ease of use, highly effective results, high quality of patients` life, and it can be used routinely on an outpatient basis.

Dilip's Transmucosal Internal Sphincterotomy: A Simplified Approach to Lateral Internal Sphincterotomy for Fissure in Ano.

Fissure in ano is a prevalent and painful condition, typically treated by lateral internal sphincterotomy after conservative measures fail. Dilip's transmucosal internal sphincterotomy introduces a simplified approach that reduces the risk of damaging the external sphincter, making it particularly suitable for less experienced surgeons. This innovation offers a less invasive method with minimal risk of incontinence, providing a safer, more accessible option. Transmucosal internal sphincterotomy simplifies the internal sphincterotomy process, offering a tailored approach that eliminates the need for extensive dissection. This method allows surgeons complete control over the internal sphincter bundle, facilitating a precise, customizable cut without the risks associated with traditional internal sphincterotomy, especially in obese patients where the intersphincteric groove is not visible, leading to potentially harmful blind incisions. The procedure is performed under saddle block anesthesia with the patient in the lithotomy position. A distinctive approach involving the use of retractors and stay sutures allows the internal sphincter to be made prominent and secured without extensive dissection. The division of the internal sphincter is achieved through a minimal mucosal incision, requiring no closure and significantly reducing postoperative pain and complications. Between December 2020 and February 2022, 124 patients received transmucosal internal sphincterotomy, showing significant benefits with a median operative time of 7 minutes and low postoperative pain. With a 2.5% infection rate effectively managed and a 3% transient incontinence rate, the majority healed within 9 weeks. Recurrence was rare at 1.6%. Transmucosal internal sphincterotomy presents significant advantages over traditional internal sphincterotomy, including reduced pain, lower risk of complications, such as hematoma, abscess, or fistula formation, and the absence of painful postoperative nodules. The success of transmucosal internal sphincterotomy suggests that it should be incorporated into surgical education, offering a less daunting and more reproducible method for treating fissure in ano that is especially beneficial for junior surgeons and improving patient outcomes.

3D endoanal ultrasound versus external phased array MRI in detection and evaluation of anal sphincteric lesions

BackgroundThe anal sphincteric complex is formed by internal and external sphincters making two partially overlapping tubes around the anal canal. Anal sphincteric lesions represent a spectrum of entities with different patients’ presentations and surgical managements. Endoanal ultrasound has an increasing role in detection and evaluation of anal sphincteric lesions as compared to MRI of the anal canal. The aim of this work was to compare between the 3D EAUA and external phased array MRI in detection and evaluation of anal sphincteric lesions.ResultsThere is almost perfect agreement of 97.92% (Κw = 0.972) between 3D EAUS and external phased array MRI in the detection of the internal anal sphincter lesions and fair agreement of 66.67% (Κw = 0.37) in the detection of the external anal sphincteric lesions.Conclusions3D EAUS and external phased array MRI are comparable imaging techniques in the detection of the internal anal sphincter lesions, while the MRI could detect more external sphincteric lesions than EAUS.

Application value of laparoscopic double stapler firings and double stapling technique combined with rectal eversion and total extra-abdominal resection in the sphincter-preserving resection of low rectal cancer

Objectives: To investigate the application value of laparoscopic double stapler firings and double stapling technique combined with rectal eversion and total extra-abdominal resection (LDER) in the anal preservation treatment of low rectal cancer. Methods: Inclusion criteria: (1) age was 18-70; (2) the distance of the lower tumor edge from the anal verge was 4-5 cm; (3) primary tumor with a diameter ≤3 cm; (4) preoperative staging of T1~2N1~2M0; (5) "difficult pelvis", defined as ischial tuberosity diameter<10 cm or body mass index>25 kg/m2; (6) patients with strong intention for sphincter preservation; (7) no preoperative treatment (e.g., chemotherapy, radiotherapy, molecular targeted therapy, or immunotherapy); (8) no lateral lymph node enlargement; (9) no previous anorectal surgery; (10) patients with good basic condition who could tolerate surgery. Exclusion criteria: (1) previously suffered from malignant tumors of the digestive tract or currently suffering from malignant tumors out of the digestive tract; (2) patients with preoperative anal dysfunction (Wexner score ≥ 10), or fecal incontinence. The specific surgical steps are as follows: the distal end of the rectum was dissected to the level of the interspace between internal and external sphincters of anal canal. Five centimeters proximal to the tumor, the mesorectum was ligated, and a liner stapler was used to transect the rectum. The distal rectum with the tumor were then everted and extracted through the anus. The rectum was transected 0.5-1.0 cm distal to the tumor with a linear stapler. Full thickness suture was used to reinforce the stump of the rectum, which was then brought back into the pelvic cavity. Finally, an end-to-end anastomosis between the colon and the rectum was performed. A retrospective descriptive study was performed of the clinical and pathological data of 12 patients with T1-T2 stage low rectal cancer treated with LDER at Henan Provincial People's Hospital from January 2020 to December 2022. Results: All 12 patients successfully completed LDER with sphincter preservation, without conversion to open surgery or changes in surgical approach. The median surgical time was 272 (155-320) minutes, with a median bleeding volume of 100 (50-200) mL. No protective stoma was performed, and all patients received R0 resection. The average hospital stay was 9 (7-15) days. There were no postoperative anastomotic leakage or perioperative deaths. All 12 patients received postoperative follow-up, with a median follow-up of 12 months (6-36 months) and a Wexner score of 8 (5-14) at 6 months postoperatively. There was no tumor recurrence or metastasis during the follow-up period. Conclusions: LDER is safe and effective for the treatment of low rectal cancer.

Raktamokshana by Jalauka in the management of Shophayukta Charmakeela Arsha w.s.r. to inflamed sentinel tag: A case study

Chronic fissure in a no is characterized by a sentinel tag externally between which lies the slightly indurated anal ulcer overlying the fibers of the internal sphincter. Chronic fissure is an inflamed &amp; indurated margin and a sentinel tag at its inferior margin, which is edematous &amp; acts like a guard. It causes repeated infections, discomfort, burning sensation. Charmakeela arshas is an immovable growth in exterior skin, correlated with sentinel pile. Here the shophayukta charmakeela arshas (inflamed sentinel piles) are treated with jalauka. Jalauka has sheetha and madhuraguna because it helps to remove excess doshas from inflamed sentinel piles and helps to reduce pain and swelling. Jalaukavacharana done on inflamed pile mass for 3 days of interval of 1 day, other oral medications, avagaha sweda (sitzbath) and local application. This paper elaborates upon the effect of jalaukavacharana in the management of inflamed sentinel pile.

P519 Assessment of anal sphincter complex in pregnant patients with non-active perianal Crohns disease

Abstract Background Pregnant IBD patients are more likely to undergo Cesarean delivery (CS).. Active perianal Crohn’s disease (PCD) is the only Crohns - related indication for CS. The rationale for CS in this group is that active PCD damages the sphincters and therefore a vaginal delivery may exacerbate the damage to the point of fecal incontinence. Pregnant PCD patients with non-active PCD are commonly not offered CS. We suspect that lack of active PCD does not necessarily attest for the physiological function of the anal complex sphincter and that vaginal delivery may exacerbate their condition to the point of incontinence. Therefore, we conducted a prospective trial to examine, prior to delivery, the anatomy and physiology of the sphincter complex in our cohort and weather pregnant patients with non-active PCD suffer from sphincter damageMethods All consecutive pregnant patients with Non-active PCD were enlisted. Patients underwent physical examination, anal manometry and Trans Rectal Ultra Sound (TRUS) before conception or during pregnancy before delivery. Active PCD was defined as: Perianal abscess, fistulas with active drainage, severe fissures and stricture. Non active PCD was defined as history of prior PCD, history of surgery for perianal fistula or old scars from previous abscess drainage. Results There were 13 patients who were enlisted to our study. Table 1 describes the TRUS, Manometry and pregnancy details. There were 9 patients (69%) with evidence of sphincter damage in our cohort including external and/or internal sphincter of at least 30 degrees of the muscle radius. Of them, 6 had posterior damage and 4 had anterior damage. In Manometry all patients had either normal or satisfying results. Three patients were strongly recommended to choose CS due to the sphincter damage. Conclusion patients with non-active PCD and future intent to deliver should be assessed routinely regarding their sphincter complex status. This should include TRUS, manometry and clinical evaluation. We discuss with each patient the advantages and disadvantages of vaginal delivery versus CS, weighing the risk of repeated CS (mainly placenta previa and accreta) against the risk of incontinence. Maternal age, Obstetrical history and estimated fetal weight at delivery are the main factors to consider. Although it is still unclear if detected muscle injury affect clinical incontinence, it is our practice to recommend CS for patients with significant muscle damage. We emphasize our recommendation specifically in patients with anterior damage because potentially delivery damage would be to the same area

The association of anal sphincter morphology and somatotype characteristics with the pathogenesis of hemorrhoidal disease

Objective: This study aims to evaluate the changes that may occur in the morphology of the anal sphincter muscles in hemorrhoidal disease. The relationship between the somatotype features of individuals and the disease were also evaluated. Materials and Methods: The study was conducted with 76 stage IV hemorrhoidal disease patients and 75 controls. Internal (IAS) and external (EAS) anal sphincter muscle thicknesses were measured at the middle anal canal level and in four quadrants (anterior, posterior, right, left), puborectalis muscle thicknesses were measured at the upper anal canal level and in two quadrants (right, left) by using 3D-endoanal ultrasonography (3D-EAUSG). Anal triangle dimensions were measured with a digital caliper and the area was calculated with the relevant formula. Somatotype features of individuals were determined according to the Heath-Carter formula. Results: It was observed that the external anal sphincter muscle thicknesses were higher in the right and posterior quadrants of the patients compared to the control group. The internal anal sphincter muscle thicknesses were thicker in the right and anterior quadrants in the patient group. Somatotype features of individuals in the patient and control groups were similar. Conclusions: The thickenings in some quadrants of the anal sphincter muscles in the patient group can be considered as a result of hemorrhoidal disease. However, the fact that there is no difference in terms of the mean value cannot confirm its relationship with the disease. Therefore, it can be concluded that individual somatotype differences do not have any effect on the pathogenesis of hemorrhoidal disease.

Intersphincteric resection of low rectal cancer: a retrospective study

Background The use of sphincter-saving resection without a permanent stoma in place of abdominoperineal resection (APR) has been one of the greatest advancements in the area of surgical therapy for low rectal cancer. Aim To assess the oncological and functional outcomes of inter-sphincteric resection of low rectal cancer in order to achieve radicality and a standard of living. Patients and methods At the hospitals affiliated with Menoufia University, a retrospective analysis was done. Forty patients with rectum cancer who were undergoing general surgery at Menoufia University Hospitals were the subject of this investigation. We comprised: older than 18 years old, sexes of both genders, low rectum and anal canal, with internal sphincter or rectal wall restriction on magnetic resonance imaging, differentiated tumour, tumour diameter of 1–5, and good continence. Results Mean operative time was 261.8 (±96.6 SD), the mean blood loss was 185.8 (±156.5 SD). Mean postoperative hospital stay was 11.2 (±4.1S D), the mean pain severity 1 h postoperatively was 5.5 (±1.0 SD), the mean 1 day postoperatively was 5.9 (±1.5 SD), the mean 5 day postoperatively was 3.3 (±1.2 SD), there were three with Anastomotic leakage, two with wound infection, two with hemorrhage, one with urinary tract infection, one with ileus. Regarding complications, mean score of micturition problems was 28.2 (±4.1 SD), the mean GIT symptoms was 32.2 (±3.1 SD), the mean weight loss was 5.5 (±1.0 SD), the mean CTX side effects was 13.9 (±1.5 SD), the mean body image was 70.3±6.2. Conclusion The intersphincteric resection approach improves the rate of sphincter preservation while maintaining oncological and functional results. Symptom-specific quality of life may be adversely affected by preoperative radiation.

The bladder neck preservation in robot assisted radical prostatectomy: Surgical and pathological outcome.

The post-prostatectomy incontinence is influenced by multiple elements, anatomic components and biological factors. The bladder neck preservation, more accurate during robot assisted radical prostatectomy, works on two anatomic components responsible for post-prostatectomy continence. The bladder neck preservation spares the internal sphincter, which is responsible for passive continence, and results in earlier return to continence and lower rates of post-prostatectomy incontinence. Moreover, this surgical technique spares the zone of urothelium coaptation and provides primary resistance to the urine to maintain postprostatectomy continence. The potential risk of bladder neck positive surgical margins (PSM) may prevent the usage of the bladder neck preservation. The purpose of this study is to evaluate the surgical and pathological outcome in prostate cancer patients underwent robot assisted radical prostatectomy with bladder neck preservation. Prospectively, we have collected demographic, clinical, surgical and pathological data of prostate cancer patients underwent robot assisted radical prostatectomy with bladder neck preservation, from January 2014 to December 2016, in Urological Clinic of the University of Padua. Moreover, it was valued the presence of alterations or continuous solutions of specimen external capsule, attributable to the surgical technique of bladder neck preservation, by microscopic and macroscopic pathological analysis. According to D'Amico risk classification, 40 patients (45.4%) had a low risk neoplasia, 35 patients (39.8%) had an intermediate risk neoplasia, 13 patients (14.8%) had an high risk neoplasia. The median prostatic volume, valued on specimen, was 30.84 cc (21.5-44.75 cc). The median prostatic weight, valued on specimen, was 51 gr (36-67 gr). The pathological stage of disease was pT2a in 11 cases (12.5%), pT2b in 37 cases (42.1%), pT3a in 28 cases (31.8%), pT3b in 12 cases (13.6%). The pathological stage of lymph node involvement was pNx in 17 cases (19.3%), pN0 in 66 cases (75%), pN1 in 5 cases (5.7%). The prostate cancers diagnosed had a Gleason score at specimen of 6 in 10 cases (10.4%), 7 (3+4) in 30 cases (34.1%), 7 (4+3) in 20 cases (22.7%), 8 in 19 cases (21.6%) and 9 in 9 cases (10.2%). The prostatic base was involved by neoplasia in 14 patients (15.9%); of these, 5 patients (35.7%) had bladder neck PSM. The patients with bladder neck PSM had: a pathological stage of disease as pT3a in 2 cases (40%) and pT3b in 3 cases (60%); a pathological stage of lymph node involvement as pN0 in 2 cases (40%) and pN1 in 3 cases (60%); a Gleason score at specimen of 8 in 3 cases (60%) and 9 in 2 cases (40%); multiple PSM. Nobody had alterations or continuous solutions of specimen external capsule, attributable to surgical technique of bladder neck preservation. The bladder neck preservation, during robot assisted radical prostatectomy, is a safe oncological procedure resulting in a good functional outcome, about post-prostatectomy continence, working on two anatomic components responsible for post-prostatectomy continence. The bladder neck PSM are linked to neoplasia with adverse pathological features, rather than the bladder neck preservation.

Long-term outcome after SphinKeeper® surgery for treating fecal incontinence—who are good candidates?

PurposeThe efficacy of the novel SphinKeeper® procedure for the treatment of fecal incontinence (FI) is not yet well defined. This study aimed to assess long-term functional outcomes after SphinKeeper® surgery.MethodsWe included 32 patients with FI (28 female), who were operated at a tertiary referral center between August 2018 and September 2021. Functional outcome and quality of life were evaluated prospectively using validated questionnaires before and after surgery. Additionally, endoanal ultrasound and anal manometry were conducted prior and after SphinKeeper® implantation. Predictive parameters for treatment success were defined.ResultsThe mean follow-up time was 22.62 ± 8.82 months. The St. Mark’s incontinence score decreased significantly after surgery (median preoperative = 19 (IQR 17–22) versus median last follow-up = 12 (IQR 8–16), p = 0.001). Similarly, physical short-form health survey showed a significant improvement after SphinKeeper® implantation (p = 0.011).Patients with a higher degree of internal sphincter defect showed an improved objective therapy success (r = 0.633, p = 0.015) after SphinKeeper® operation, whereas the type and severity of FI had no impact on the functional outcome. Notably, a higher number of dislocated prostheses (r = 0.772, p = 0.015) showed a significant correlation with reduced improvement of incontinence.ConclusionThe SphinKeeper® procedure showed a significant long-term functional improvement in over half of the patients. Patients with a higher internal sphincter defect benefited most, whereas dislocation of the prostheses was associated with less favorable results.

Mathematical Model of Anal Canal for Anal Fistula Surgery

Abstract: Purpose: Surgery is necessary for the treatment of an anal fistula. However, excision of some sphincter muscle would compromise sphincter integrity or function, which is the cause of a reduced success rate in the long term. In order to develop an appropriate surgical plan, a mathematical model that describes the relationship between the internal pressure of the anal canal and the structure of anal sphincters is required.&#x0D; Methods: The anatomical structure of the anal canal and the corresponding sphincter pressure can be measured by endoanal ultrasound (EAUS) imaging and manometry, respectively. Length-tension relationships for skeletal and smooth muscles, two major components of the external and internal anal sphincter, respectively, were reviewed first. &#x0D; Results: Based on the information about the internal and external sphincters, two mathematical models, the thick-wall cylinder model and the two-layer model, have been created, from which the influence of complete or partial excision of the sphincter muscle can be estimated.&#x0D; Conclusions: The proposed thick-wall cylinder and two-layer models could describe the relationship between the internal anal canal pressure and the structure of anal sphincters, from which the influence of complete or partial excision of the sphincter muscle may be estimated.