Levator Ani Research Articles

Clinical Evidence Regarding Spermidine–Hyaluronate Gel as a Novel Therapeutic Strategy in Vestibulodynia Management

Background: Vestibulodynia (VBD) represents a summation and overlapping of trigger factors (infections, hormonal disturbances, allergies, genetic aspects, psychological vulnerability, and others) with broad individual variability. As there are no standard treatment options for VBD, the disease is still in need of appropriate therapeutic tools. Objectives: A prospective observational trial was performed to confirm the efficacy of a topical gel containing a spermidine–hyaluronate complex (UBIGEL donna™) as either a stand-alone or companion treatment through a multicenter study on a large sample population. Methods: For women with VBD (n = 154), the treatment consisted of approximately two months (4 + 4 weeks) of applications according to the posology of UBIGEL. Evaluation of symptoms was performed on relevant clinical endpoints: dyspareunia and vulvovaginal pain/burning by a visual scale (VAS); vestibular trophism by a vestibular trophic health (VeTH) score; vulvoscopy through a cotton swab test; and the level of hypertonic pelvic floor by a physical graded assessment of levator ani hypertonus. Results: A total of 154 patients treated with UBIGEL donna™ showed significant improvements across all five evaluated parameters, including pain, dyspareunia, swab test results, muscle hypertonicity, and vestibular trophism. Pain and dyspareunia scores decreased by 46.5% and 33.5%, respectively, while significant improvements were also observed in the other parameters (p < 0.0001). These improvements were consistent across various stratifications, including age and disease duration. Conclusions: The findings of the present study suggest that UBIGEL donna™ is effective in alleviating pain and dyspareunia, as well as reducing vestibular hypersensitivity in women with VBD. Although UBIGEL donna™ alone cannot serve as a comprehensive substitute for all recommended therapies, we suggest that multimodal therapy strategies may be crucial for attaining substantial improvement in any aspect of the condition.

Extrauterine Causes of Severe and Concealed Postpartum Bleeding: Clinical Aspects and Challenges

Abstract Objective To describe the challenges in diagnosing concealed postpartum bleeding, a rare but potentially life-threatening condition, and to highlight key factors in identifying and managing this condition. Methods We reviewed clinical cases and diagnostic approaches where concealed postpartum bleeding was suspected, focusing on the role of imaging, serologic markers, and angiography. We examined instances of hemodynamic instability, the utility of pelvic space analysis via computed tomography, and the limitations of digital angiography, particularly in identifying bleeding sources in the posterior iliac internal artery division. Results Concealed postpartum bleeding often originates from venous damage or, less commonly, arterial injury. Hemodynamic instability was noted to occur periodically, despite negative findings on vaginal examination and ultrasound, leading to diagnostic delays. Digital angiography often yields negative results when the focus is limited to the anterior division of the internal iliac artery. Bleeding typically arises from damage to the vaginal muscular layer or levator ani muscle, both supplied by branches of the internal pudendal artery (posterior iliac division). In some cases, laparotomy also failed to locate the source due to the bleeding being in the subperitoneal spaces. Conclusion Concealed postpartum bleeding presents a diagnostic challenge due to intermittent hemodynamic instability and often negative imaging results. A detailed pelvic space analysis and awareness of posterior iliac internal artery involvement are crucial. Advanced expertise, along with serologic markers of hidden bleeding, is essential for timely diagnosis and management.

6979 Effect of Orchiectomy on Muscle Growth and Differentiation Factors in Male Mice With Kidney Disease

Abstract Disclosure: O. Marks: None. J. Bruno: None. D. Wu: None. A. Patwardhan: None. Y. Komaru: None. G. Ling: None. E. Kefalogianni: None. R. Aurora: None. S.S. Dhindsa: None. A. Herrlich: None. Background: Sarcopenia and frailty are major clinical concerns in participants with chronic kidney disease (CKD). In males, an additional factor contributes to the development of sarcopenia. Around half of the men with CKD have subnormal serum testosterone (T) concentrations. The mechanisms that underlie the effect of low T concentrations on muscle growth in CKD are not known. In this study, we performed orchiectomy in male mice with kidney disease and evaluated the expression and protein content of the following muscle growth and differentiation factors. Methods: Forty mice were divided into 4 groups: 1) renal injury, induced by ischemia-induced reperfusion (IRI, N=11) at 2 months of age; 2) orchidectomy (ORX), performed 4 weeks after IRI (IRI + ORX, N=9); 3) sham-IRI and ORX (sham-ORX, N=8); and 4) sham-sham surgery (N=12). The mice were sacrificed when they were ∼7 months old (mean age 206±13 days). Gastrocnemius and levator ani muscles were harvested to measure expression by RT-qPCR of muscle catabolism markers (Atrogin-1 and ubiquitin ligase MuRF1), muscle growth inhibitors, myostatin and myogenic regulatory factor (Mrf4), fibroblast growth factor-2 (FGF2, a stimulator of satellite stem cells) and its receptor FGFR2, androgen receptor (AR) and IGF-1. Results: The mean BUN (blood urea nitrogen) at the time of sacrifice was higher in the IRI/ORX (32±4 mg/dl) and IRI/Sham (26±5 mg/dl) groups as compared to sham-sham (21±5 mg/dl, p<0.05 for both). There was a significant reduction (p<0.05) in the expression of myostatin (by 41%), Mrf4 (29%), atrogin-1 (51%) and MuRF1 (32%) in gastrocnemius muscle from the ORX-IRI and ORX-sham groups, while there was no difference in FGF2 and FGFR2, as compared to sham-sham group. Data from levator ani muscle (the most androgen sensitive muscle in mammals) showed increases in AR (64%) and Atrogin-1 (66%); and decreases in IGF-1 (88%) and myostatin (86%) in ORX-IRI and ORX-sham groups. Consistent with the mRNA expression, we found a drastic decline in protein content of myostatin in gastrocnemius (85%) in ORX-IRI and ORX-sham groups as compared to sham-sham (p=0.04). Conclusions: These data show that ORX in mice with renal injury is associated with changes in muscle growth and differentiation factors. Myostatin was the most affected gene, with 41-86% decline in mRNA and protein. These data are informative for attempts to develop treatments for sarcopenia in patients with kidney disease. Limitations: Our experimental model differs in some respects from hypogonadal men with CKD. ORX results in complete elimination of T, and thus much lower T concentrations than in men with kidney disease. There is a recovery of kidney function after IRI. We sacrificed the mice 5 months after renal injury was inflicted. Hence, the effect of IRI on muscle growth genes may have been different immediately following IRI. Thus, the impact of ORX was more apparent than of IRI in our study. Presentation: 6/1/2024

6979 Effect of Orchiectomy on Muscle Growth and Differentiation Factors in Male Mice With Kidney Disease

Abstract Disclosure: O. Marks: None. J. Bruno: None. D. Wu: None. A. Patwardhan: None. Y. Komaru: None. G. Ling: None. E. Kefalogianni: None. R. Aurora: None. S.S. Dhindsa: None. A. Herrlich: None. Background: Sarcopenia and frailty are major clinical concerns in participants with chronic kidney disease (CKD). In males, an additional factor contributes to the development of sarcopenia. Around half of the men with CKD have subnormal serum testosterone (T) concentrations. The mechanisms that underlie the effect of low T concentrations on muscle growth in CKD are not known. In this study, we performed orchiectomy in male mice with kidney disease and evaluated the expression and protein content of the following muscle growth and differentiation factors. Methods: Forty mice were divided into 4 groups: 1) renal injury, induced by ischemia-induced reperfusion (IRI, N=11) at 2 months of age; 2) orchidectomy (ORX), performed 4 weeks after IRI (IRI + ORX, N=9); 3) sham-IRI and ORX (sham-ORX, N=8); and 4) sham-sham surgery (N=12). The mice were sacrificed when they were ∼7 months old (mean age 206±13 days). Gastrocnemius and levator ani muscles were harvested to measure expression by RT-qPCR of muscle catabolism markers (Atrogin-1 and ubiquitin ligase MuRF1), muscle growth inhibitors, myostatin and myogenic regulatory factor (Mrf4), fibroblast growth factor-2 (FGF2, a stimulator of satellite stem cells) and its receptor FGFR2, androgen receptor (AR) and IGF-1. Results: The mean BUN (blood urea nitrogen) at the time of sacrifice was higher in the IRI/ORX (32±4 mg/dl) and IRI/Sham (26±5 mg/dl) groups as compared to sham-sham (21±5 mg/dl, p<0.05 for both). There was a significant reduction (p<0.05) in the expression of myostatin (by 41%), Mrf4 (29%), atrogin-1 (51%) and MuRF1 (32%) in gastrocnemius muscle from the ORX-IRI and ORX-sham groups, while there was no difference in FGF2 and FGFR2, as compared to sham-sham group. Data from levator ani muscle (the most androgen sensitive muscle in mammals) showed increases in AR (64%) and Atrogin-1 (66%); and decreases in IGF-1 (88%) and myostatin (86%) in ORX-IRI and ORX-sham groups. Consistent with the mRNA expression, we found a drastic decline in protein content of myostatin in gastrocnemius (85%) in ORX-IRI and ORX-sham groups as compared to sham-sham (p=0.04). Conclusions: These data show that ORX in mice with renal injury is associated with changes in muscle growth and differentiation factors. Myostatin was the most affected gene, with 41-86% decline in mRNA and protein. These data are informative for attempts to develop treatments for sarcopenia in patients with kidney disease. Limitations: Our experimental model differs in some respects from hypogonadal men with CKD. ORX results in complete elimination of T, and thus much lower T concentrations than in men with kidney disease. There is a recovery of kidney function after IRI. We sacrificed the mice 5 months after renal injury was inflicted. Hence, the effect of IRI on muscle growth genes may have been different immediately following IRI. Thus, the impact of ORX was more apparent than of IRI in our study. Presentation: 6/1/2024

12565 Expression Of Sex Hormone Receptors In Levator Ani Muscle Tissue From Patients With Pelvic Organ Prolapse

Abstract Disclosure: T. You: None. A. Halle: None. W. Xu: None. T. Potluri: None. H. Nguyen: None. S.E. Bulun: None. J. Julia Geynisman-Tan: None. H. Zhao: None. Introduction: Women with pelvic floor disorders usually have weakened pelvic floor muscles, which may cause urinary incontinence, fecal incontinence, and pelvic organ prolapse (POP). Histologically, the pelvic floor musculature in POP patients displays increased fibrosis and muscle atrophy. However, the underlying molecular mechanism for POP has not been fully investigated. We and others found that estrogen causes pelvic skeletal muscle fibrosis and inguinal hernias in male animal models. Additionally, clinical trials from the Women's Health Initiative showed women receiving estrogen-only or estrogen plus progestin treatment had statistically significant increases in the risk for urinary incontinence. However, the role of estrogen, progesterone, androgen, and their receptor expression in pelvic floor muscle is not well studied. Methods: TruCut biopsy needles were used to obtain levator ani (LA, the major pelvic floor muscle) biopsies from four groups of patients undergoing surgery: (i) 5 premenopausal women with stage II/III POP (age 38-52 years), (ii) 5 postmenopausal women with stage III POP (59-75 years), (iii) 5 age and parity matched premenopausal controls, and (iv) 5 age and parity matched postmenopausal controls. The control patients did not have any POP (stage 0) or only had sole stress urinary incontinence. H&E staining, Masson’s trichrome staining, and immunohistochemistry (IHC) staining for estrogen receptor α (ERα), progesterone receptor (PGR), and androgen receptor (AR) were performed in LA muscle tissue. Standard patient demographics (age, parity, and diagnosis) were collected. Results: We used H&E staining to morphologically assess stromal cells and myofibers obtained from LA muscle biopsies. Masson’s trichrome staining showed extracellular matrix deposition in the LA muscle from women with or without POP. In addition, we found ERα was present in the stromal cells from nearly every LA biopsy using IHC staining. ERα expression (H-Score) was similar in four groups of patients. ERα IHC staining was absent in LA myofibers. AR was highly expressed in stromal cells in all LA muscles and weakly expressed in myofibers in ∼70% of LA tissues. AR expression (H-Score) was significantly decreased in postmenopausal women with stage III pelvic organ prolapse. PGR was only expressed in a small portion of the LA sample (30%), with PGR exclusively expressed in the stroma of the LA muscle. Conclusion: Our findings indicate that sex hormone receptors (ERα, AR, and PGR) are present in LA muscle stroma, providing the foundation to further define the roles of sex steroid hormones in pelvic organ prolapse. Presentation: 6/3/2024

Castration Levels of Testosterone Results in Atrophy of Androgen-Sensitive Perineal Muscles: A Potential Biomarker for Male Hypogonadism

ObjectivesTo evaluate MRI-based measurements of androgen-sensitive perineal/pelvic muscles in men with prostate cancer before and after androgen deprivation therapy (ADT) as a novel imaging marker for end-organ effects of hypogonadism. Diagnosing hypogonadism or testosterone deficiency (TD) requires both low serum testosterone and clinical symptoms, such as erectile dysfunction and reduced libido. However, the non-specific nature of many TD symptoms makes it challenging to initiate therapy. Objective markers of TD help to better identify patients who may benefit from testosterone supplementation; however, current markers, such as low bone mineral density, lack sensitivity. Previous studies suggest that decreased bulbocavernosus-muscle (BCM) thickness may be associated with TD, although it remains unclear if this is a correlative relationship. MethodsData was prospectively collected for patients with intermediate/high-risk localized prostate cancer enrolled in a phase II trial (NCT02430480). Patients received ADT before prostatectomy and underwent prostate MRI pre-/post-ADT. BCM, ischiocavernosus-muscle (ICM), and levator-ani-muscle (LAM) measurements were made using T2W-MRI. Paired t-tests evaluated changes in BCM/ICM/LAM width, and linear regression analyses evaluated relationships between changes in testosterone and muscle width. ResultsThirty-eight consecutive patients with pre-/post-ADT MRIs were analyzed. Baseline testosterone was 286.5ng/dl, and 36/38 patients had post-ADT testosterone <50ng/dL. Pre-ADT and post-ADT measurements of the bilateral BCM/ICM/LAM width were 7.16mm/7.95mm/5.53mm and 5.68mm/6.71mm/4.89mm, respectively (p<0.001). Decreases in testosterone predicted reduction in combined perineal muscle (BCM+ICM) width (p=0.032). ConclusionsAndrogen deprivation led to significant and relatively rapid decreases in BCM/ICM/LAM thickness. This objective biomarker of low testosterone states may help identify patients who will potentially benefit from testosterone replacement.

141 - Prostatic urethral length, membranous urethral length and levator ani muscle thickness in preoperative MRI are associated with the risk of post-prostatectomy incontinence.

141 - Prostatic urethral length, membranous urethral length and levator ani muscle thickness in preoperative MRI are associated with the risk of post-prostatectomy incontinence.

Long-term follow-up after laparoscopic reparation of pelvic organ prolapses in a large teaching gynecological center

ObjectiveTo provide a description of laparoscopic approach to correct pelvic organ prolapses and evaluate the risk factors associated with the prolapse recurrence Study designWe retrospectively analyzed 418 patients with symptomatic pelvic organ prolapse who underwent a laparoscopic reparation at our university center from 2010 to 2020. Prolapses were assessed by Baden-Walker system (stage I–IV). The association between the potential prognostic factors and the recurrence was analyzed using Cox regression. ResultsWe included 418 patients. Most patients (97.6 %) had at least one vaginal delivery and 92 (22 %) had a previous prolapse surgery. In 29.74 % of cases levator ani muscle avulsion was observed. We performed a cervicosacropexy in 336 (80.38 %) cases, a sacrohysteropexy in 13 (3.11 %), and a sacrocolpopexy in 69 (16.5 %). Also, concomitantly, 66 (15.79 %) patients with stress and occult urinary incontinence underwent TOT surgery. Surgical complications were low (9.51 %) and the majority were minor. Median follow-up was 37 months (IQR 10.5, 61.4 months), and the global recurrence rate was 9.57 %. Only 4.06 % of cases required reintervention. In Cox regression analysis only levator ani muscle avulsion remained as a recurrence-associated factor. ConclusionOur series is one of the largest and with the longest follow-up. Recurrence rate was low, and comparable to other large series. The only independent factor related to recurrence was the levator ani muscle avulsion.

313 - Levator ani deficiency and pelvic floor dysfunction one year postpartum: a prospective nested case-control study

313 - Levator ani deficiency and pelvic floor dysfunction one year postpartum: a prospective nested case-control study

98 - Levator ani avulsion in patients with pelvic organ prolapse: first steps in sonographic diagnosis in a regional hospital

98 - Levator ani avulsion in patients with pelvic organ prolapse: first steps in sonographic diagnosis in a regional hospital

Elevating precision: A thorough investigation of multiparametric prostate MRI for prolonged insights into early continence prediction after robot-assisted laparoscopic prostatectomy

BackgroundWhile radical prostatectomy stands out as one of the most effective curative treatments for prostate cancer, it does come with annoying side effects, such as urinary incontinence (UI). We aimed to investigate the predictability of UI using MRI measurements, along with clinical and disease-related variables. MethodsWe included 191 patients who underwent robot-assisted laparoscopic radical prostatectomy between July 2020 and October 2022 in the study. Preoperative MRIs of the patients are re-evaluated by an experienced uroradiologist, and membranous urethral length (MUL), urethra wall thickness, levator ani thickness, outer levator distance, Lee's apex shape, intravesical prostate protrusion length, prostate apex depth, and pubic height measurements were made. Additionally, retrospective data on patients' age, BMI, PSA, PSA density, prostate volume, IPSS, clinical stage, and nerve-sparing status were collected. Patients were categorized into two groups based on continence status in the third postoperative month: continent or incontinent. The definition of UI was accepted as the use of one or more pads per day. ResultsUI was observed in 38.21 % of the patients in the postoperative third month. Among MRI measurements, only MUL showed a significant relationship with UI (p < 0.001). IPSS (p = 0.004) and Clinical Stage (p < 0.001) were also significantly associated with continence status. Logistic regression analysis identified BMI (p = 0.023; CI 0.73–0.97), IPSS (p = 0.002; CI 1.03–1.17), MUL (p = 0.001; CI 0.66–0.90), and Clinical Stage (p < 0.001; CI 1.53–2.71) as significant predictors. In Multivariable Regression analysis, Clinical Stage emerged as the most powerful predictor of UI (p < 0.001). ConclusionsExcept for MUL, MRI measurements may not predict postoperative UI. A combination of IPSS, clinical stage, and MUL effectively informs patients about postoperative outcomes. These findings contribute to enhancing preoperative counseling for patients undergoing radical prostatectomy.

Beyond breathless: a case of air infiltrating every cavity

Hawaii attracts 10 million tourists annually, with non-residents accounting for 9% of trauma cases, half of which are water-related. We experienced a SCUBA tank injury, causing extensive trauma from pressurized air release. A 53-year-old female, post-Scuba diving, fell onto a SCUBA tank, causing rapid pressurized air discharge. She presented with perineal pain, bloating, and extensive subcutaneous emphysema. CT revealed air in every possible cavity. Thoracostomies and exploratory laparotomy performed, revealing an 80-90% anal sphincter transection. An overlapping anal sphincteroplasty with diverting loop ileostomy was performed. Recovery was uncomplicated. This unique case involves a traumatic SCUBA tank air release causing extensive damage. The patient avoided direct anorectal entry, preventing catastrophic damage but sustained an anal sphincter complex injury. Air likely entered the peritoneum through the levator ani, causing pneumoperitoneum and pneumothoracies. The extensive damage emphasizes the need for safe water sports practices. The patient’s recovery highlights the human body’s resilience in unique situations.

Perineal-First Approach in Robotic Abdominoperineal Resection.

Although abdominoperineal resection (APR) is required for rectal cancer invading the levator ani muscle, its curative outcomes remain poorer than those of other rectal surgeries.1-3 In particular, the anatomic complexity around the anterior wall of the rectum increases the technical difficulty during APR, resulting in a high frequency of margin involvement that causes local recurrence. In this video, we present the technical details of a robotic perineal-first APR approach. For a 46year-old man, locally advanced rectal cancer invading the levator ani muscles was diagnosed. Although total neoadjuvant therapy (8 cycles of induction FOLFOXIRI followed by chemoradiotherapy 50.4 Gy) decreased the tumor size, invasion was suspected still to remain. Therefore, robotic APR was performed. Written informed consent was obtained from the patient. For the perineal-first approach, we created a circular incision around the anus, then divided the fat tissues of the ischiorectal fossa until the levator ani muscle was exposed on both sides. Posterior and anterior dissections were performed along the coccyx and external anal sphincter, respectively. After placement of a lap protector to maintain air-tightness, the robotic approach was initiated. Posterior dissection was performed along the coccyx, then was connected to the already-dissected space created earlier by the perineal approach. Next, the levator ani muscle was divided from the dorsal to the lateral side. Finally, anterior dissection was performed along the prostate, followed by division of the rectourethral muscle, the smooth muscle fibers running vertically. The creation of the already-dissected space on the perineal side offers advantages of robotic manipulation from the abdominal side, especially anterior dissection. We performed robotic APR using the perineal-first approach for 17 consecutive patients (12 men and 5 women) between 2019 and 2023. All 17 patients achieved complete total mesorectal excision with negative margins. The mean time required for the perineal approach was about 25 min. In anterior dissection using the robotic approach, division of the smooth muscle fibers at the perineal body (i.e., rectourethral muscle in males4 or muscular intermingling in females5) was reproducibly performed in both males and females. Robotic APR with a perineal-first approach can be advantageous in ensuring surgical margin safety (especially for the anterior aspect of the rectum).

Laparoscopic Ultralow Anterior Resection Using a New Articulating Device.

Laparoscopic surgery offers several advantages, but it can be challenging to perform in confined spaces, such as the narrow and deep pelvis, due to poor vision and instrument collisions. Conventional laparoscopic instruments are rigid and straight, which can restrict optimal access to the target organ. Although the use of robotic surgical platforms with flexible wrists has significantly reduced movement restrictions and surgeon fatigue, their high cost remains a barrier to widespread adoption. Recent technological advancements in laparoscopic instruments have led to the development of an articulating flexible hand-held device that enables greater dexterity and easier access to difficult anatomical locations. This technology has the potential to improve surgical outcomes by using multiple degrees of freedom to perform complex surgical procedures with greater precision. The ArtiSential® product line comprises over 30 end-effectors, such as scissors, hooks, and graspers. The benefits of this device are evident throughout the total mesorectal excision, especially when approaching the left lateral side of the mesorectum (the side opposite the surgeon) or the deepest part of the pelvis around the levator ani muscle. The Samsung Medical Center Institutional Review Board approved this study (2022-01-174). A 79-year-old male with rectal cancer located 9 cm from the anal verge underwent an laparoscopic ultralow anterior resection using ArtiSential®. There were no intraoperative complications. The pathologic results showed that the tumor was at pT3N0 stage. The patient was discharged without any complications. The articulating device can be effectively used for laparoscopic surgery, but has some challenges related to the bulky handpiece and learning curve. A multicenter prospective cohort study to compare the outcomes of articulating laparoscopic surgery and robotic surgery for patients with rectal cancer is oncoing (clinicaltrials.gov number: NCT05566249).

Training program for radiologists for improving the multidisciplinary approach for the treatment of rectal cancer

BACKGROUND: Diagnosis and treatment of patients with colorectal cancer is a multidisciplinary task. The transition to a new edition of clinical guidelines for the treatment of colorectal cancer in 2024, while maintaining the routine approach to MR staging of malignant neoplasms of this localization, reduces the level of continuity between medical specialists. AIM: To improve the quality and completeness of MR diagnostics of malignant neoplasms of the rectum to ensure continuity and improve the multidisciplinary approach. MATERIALS AND METHODS: A retrospective analysis of the completeness of compliance with the parameters of TNM8 (2017) and the MRI subclassification T3 of rectal cancer was carried out on 137MRI scans of the pelvic organs and protocols with conclusions to them. Based on the results of the analysis, educational training and a conclusion template for radiologists were developed and conducted, after which the MR images were re-evaluated. Before and after the training, the most fully evaluated MRI scans by radiologists were provided to medical experts to form a "second opinion". The results obtained made it possible to calculate the absolute and relative number of consensuses (coinciding in all parameters of the conclusions) and to identify cases of rectal cancer restaging that require changes in treatment tactics. RESULTS: Before the educational training, only 11% of MRI scans and their reports met the requirements of the modern protocol. After the training, 78% of the images were completed in compliance with all requirements. Particular difficulties and the majority of "discrepancies" in conclusions arose when determining the depth of tumor invasion into the mesorectal tissue; measuring the distance from the tumor and/or affected lymph node to the mesorectal fascia or edge of the levator ani muscle and identifying signs of extramural vascular invasion. It was not possible to achieve complete consensus in all cases on these parameters. CONCLUSION: The analysis of MRI scans of the pelvic organs, the development and implementation of educational training to improve the interpretation of medical images, made it possible to significantly improve the staging of rectal cancer and ensure proper continuity in the implementation of a multidisciplinary approach

Comparison of non-invasive magnetomyography to Brink score for assessment of pelvic floor muscle strength.

Objective.Levator ani muscles undergo significant stretching and micro-trauma at childbirth. The goal was to assess the neuromuscular integrity of this muscle group by means of magnetomyography (MMG) and correlate with Brink score-a commonly used digital assessment of pelvic floor muscle strength.Approach.Non-invasive MMG data was collected on 22 pregnant women during rest and voluntary contraction of the pelvic-floor muscles (Kegels). The mean amplitude and power spectral density (PSD) of the Kegels were correlated to Brink pressure score.Main Results.The modified Brink pressure score demonstrated medium correlations (⩾0.3) with MMG amplitude and PSD with the average Kegel of medium intensity and rest. Data showed that the 'resting state' of the pelvic floor is, in actuality, quite dynamic and may have implications for pelvic floor disorder propensity postpartum.Significance.These results confirm the ability of non-invasive MMG to reliably capture pelvic floor contraction as these signals correlate with clinical measure.

Lone-Star retractor perineal exposure method for laparoscopic abdominal perineal resection of rectal cancer.

The abdominal perineal resection (APR), historically referred to as Mile's procedure, stands as a time-honored surgical intervention for rectal cancer management. Advancements in surgical techniques and the advent of neoadjuvant therapies have significantly improved the rate of sphincter preservation among patients afflicted with rectal cancer, including those with ultralow rectal cancer. Despite these improvements, APR maintains its irreplaceable role in the clinical landscape, particularly for cases involving low rectal cancer with encroachment on the external anal sphincter or levator ani muscles. Optimal perineal exposure stands as a pivotal phase in APR, given that the precision of this maneuver is directly correlated with both the safety of the surgery and the patient's subsequent long-term prognosis. To evaluate the value of Lone-Star retractor (LSR) perineal exposure method in the treatment for laparoscopic APR of rectal cancer. We reviewed the records of 38 patients with rectal cancer at Anqing Municipal Hospital from January 2020 to December 2023, including 20 patients who underwent the APR procedure with a LSR perineal exposure method (LSR group) and 18 patients who underwent the APR procedure with a conventional perineal exposure method (control group). In the LSR group, following incision of the skin and subcutaneous tissue, the LSR was placed and dynamically adjusted according to the surgical plane to fully expose the perineal operative field. A total of 38 patients underwent laparoscopic APR, none of whom were found to have distant metastasis upon intraoperative exploration. Perineal blood loss, the postoperative hospital stays and the wound pain scores in the LSR group were significantly lower than those in the control group. A single surgeon completed the perineal operation significantly more often in the LSR group than in the control group (P < 0.05). The incidence of infection via the perineal incision in the LSR group was significantly lower than that in the control group (P < 0.05). No cases of distant metastasis or local recurrence were found among the patients at the postoperative follow-up. The application of the LSR technique might be helpful for performing perineal exposure during APR for rectal cancer and could reduce the incidence of perineal complications, shorten the postoperative hospital stay, improve postoperative pain, and allow one surgeon to perform the perineal operation.

Effectiveness of Pelvic Floor Muscle Training for Treating Faecal Incontinence

The purpose of this study is to examine the effect of pelvic floor muscle training on faecal incontinence. Faecal incontinence is a condition in which stool leaks from the anus involuntarily or uncontrollably. Faecal incontinence is common in elderly people and patients with underlying diseases, but the pathophysiology of faecal incontinence is diverse, and treatment methods must be varied accordingly. Among the known treatment methods, in this study, we focused on pelvic floor muscle training, which can be performed in daily life. The literature was searched for papers that present existing knowledge and address current perspectives. Extracted studies included papers that report scientific consensus. After reviewing the literature, it appears that it is possible to effectively train patients to defecate twice a day, approximately 30 min after breakfast and dinner, by having them attempting to defecate, even when there is no such urge. Pelvic floor muscle training can improve urinary and faecal incontinence by strengthening the contractile force of the pelvic floor muscles such as the external anal sphincter and levator ani. However, the specific types of faecal incontinence patients that can effectively benefit from pelvic floor muscle training is unclear. It is important for patients to understand the pelvic floor muscle training program and to develop sufficient motivation to continue training at home.

Association of pre-pregnancy body mass index and gestational weight gain on postpartum pelvic floor muscle morphology and function in Chinese primiparous women: A retrospective cohort study.

Our study aimed to investigate the association between maternal pre-pregnancy body mass index (BMI), gestational weight gain (GWG), and impaired pelvic floor muscle (PFM) morphology and function during the early postpartum period. This retrospective cohort study was conducted at Shanghai First Maternity and Infant Hospital from December 2020 to December 2022. A total of 1118 primiparous women with singleton pregnancies who underwent vaginal deliveries and participated in postpartum PFM assessments were included. Maternal pre-pregnancy BMI and GWG were considered as exposures. PFM morphology and function impairment were the primary outcomes. PFM morphology impairment, defined as levator ani muscle avulsion, was assessed using transperineal ultrasound. PFM function impairment, manifested as diminished PFM fiber strength, was assessed through vaginal manometry. Multivariable logistic regression analysis was employed to calculate adjusted odds ratios (aOR) with 95% confidence intervals (CI). Restricted cubic spline models were used to validate and visualize the relationship. Women with lower pre-pregnancy BMI were at an increased risk of levator ani muscle avulsion (aOR = 1.73, 95% CI: 1.10-2.70, P = 0.017), particularly when combined with excessive GWG during pregnancy (aOR = 3.20, 95% CI: 1.15-8.97, P = 0.027). Lower pre-pregnancy BMI was also identified as an independent predictor of PFM weakness (aOR = 1.53, 95% CI: 1.08-2.16, P = 0.017 for type I fiber injuries). Notably, regardless of the avulsion status, both underweight and overweight/obese women faced an elevated risk of reduced PFM strength (aOR = 1.74, 95% CI: 1.17-2.59, P = 0.006 for underweight women with type I fiber injuries; aOR = 1.67, 95% CI: 1.06-2.64, P = 0.027; and aOR = 1.73, 95% CI: 1.09-2.76, P = 0.021 for overweight/obese women with type I and type II fibers injuries, respectively). Both lower and higher pre-pregnancy BMI, as well as excessive GWG, were strongly associated with PFM impairments. These findings highlighted the critical importance of comprehensive weight management throughout pregnancy to effectively promote women's pelvic health.

Clinically significant changes in anal sphincter hiatal area in patients with gestational diabetes mellitus and pelvic organ prolapse.

The prevalence of pelvic organ prolapse (POP) increases with age and parity. Specifically, the prevalence of POP among women aged 20 to 39 is 9.7%, while it rises to 49% among women over 80 years old. Additionally, as the number of deliveries increases, the prevalence of POP also rises accordingly, with a rate of 12.8% for women with one delivery history, 18.7% for those with two deliveries, and 24.6% for women with three or more deliveries. It causes immense suffering for pregnant women. To evaluate the relationship between the levator ani muscle's hiatus (LH) area and POP in patients with gestational diabetes mellitus (GDM) using perineal ultra-sound. The study cohort comprised 104 patients aged 29.8 ± 3.7 years who sought medical care at our institution between January 2021 and June 2023. All were singleton pregnancies consisting of 75 primiparas and 29 multiparas, with an average parity of 1.7 ± 0.5. According to the POP diagnostic criteria, the 104 subjects were divided into two groups with 52 members each: POP group (patients with GDM combined with POP) and non-POP group (patients with GDM without POP). Perineal ultrasound was used to measure differences in the anteroposterior diameter, transverse diameter, and LH area. Receiver operating characteristic curves were drawn to determine the optimal cutoff values for the LH anteroposterior diameter, transverse diameter, and area for diagnosing POP. Statistically significant increase in the LH area, anteroposterior diameter, and lateral diameter were observed in the POP group compared with the non-POP group (P < 0.05). Both groups exhibited markedly elevated incidence rates of macrosomia and stress urinary incontinence. For the POP group, the area under the curve (AUC) for the LH area was 0.906 with a 95% confidence interval (CI): 0.824-0.988. The optimal cutoff was 13.54cm², demonstrating a sensitivity of 83.2% and a specificity of 64.4%. The AUC for the anteroposterior diameter reached 0.836 with a 95%CI: 0.729-0.943. The optimal cutoff was 5.53 cm with a sensitivity of 64.2% and a specificity of 73.4%. For the lateral diameter, its AUC was 0.568 with a 95%CI: 0.407-0.729. The optimal cutoff was 4.67 cm, displaying a sensitivity of 65.9% and a specificity of 69.3%. Logistic regression analysis unveiled that age, body weight, number of childbirths, total number of pregnancies, and gestational weight gain constituted the independent risk factors for the cooccurrence of GDM and POP. Three-dimensional perineal ultrasonography of LH size and shape changes can effectively diagnose POP. Age, weight, number of births, number of pregnancies, and weight gain during pregnancy are independent risk factors affecting the cooccurrence of GDM and POP. GDM can increase the LH area in patients, and an enlarged LH leads to an increased incidence of POP.