Pelvic Floor Reconstruction Research Articles

Prevalence, bother, and impact on pelvic floor muscles of vaginal noise among middle-aged women

BackgroundVaginal noise (VN) is a natural phenomenon that arises when air is forced into the vagina and then expelled as the vaginal wall muscles naturally contract. It has been described as involuntarily passing gas from the vagina. VN is a symptom of pelvic floor (PF) dysfunction and can cause social and psychological issues. Data on it is limited, and women rarely voluntarily report it. So, this study was conducted to determine the prevalence, bother, and relation between VN and PF muscle dysfunction.Material and methodsIt was a cross-sectional study that included females with age ranges from 30 to 60 years old, body mass index (BMI) ranges from 18 to 30 kg/m2, married, single, virgin, nulliparous, and multiparous women; those with previous one or more vaginal deliveries or cesarean sections (CS) or history of anterior and/or posterior vaginal wall prolapses; and those who had undergone medical interventions such as vaginal surgeries (e.g., pelvic floor reconstruction, hysterectomy), stress urinary incontinence, urge incontinence, and fecal incontinence. The Vaginal Wind Questionnaire, Pelvic Floor Impact Questionnaire-Short Form 7 (PFIQ-7), and Pelvic Floor Bother Questionnaire were used as methods of evaluating the VN prevalence and bother and its relation to PF dysfunction.ResultsIt was noted that there was a 76.3% prevalence of VN and 75% bother among the study population. Eighty-eight percent of them did not seek any treatment, and VN occurred in 84.3% of females with pelvic floor muscle weakness.ConclusionVN is common in middle-aged Egyptian women, most frequently occurring with sexual intercourse, vaginal delivery, and pelvic floor muscle weakness.

Preserving Essential Skills: The Future of Vaginal Hysterectomy Training in Urogynaecology.

This study aimed to evaluate the training and self-assessed proficiency of surgeons in the surgical management of pelvic organ prolapse (POP). We focused on the factors that influence decision-making, the surgical techniques employed, the training received, and the management of complications. A cross-sectional survey. An electronic questionnaire. European Urogynaecological Association (EUGA) and International Urogynecological Association (IUGA) members. A total of 33 questions evaluating surgeon preference regarding vaginal surgeries. Demographics, surgical selection, proficiency and technique, and training methods. There were 471 respondents, of which 273 (58%) dedicated more than 50% of their week to urogynaecology. 250 (53%) had completed a fellowship, with 215 (86%) of those fellowships being in urogynaecology and pelvic floor reconstruction. A preference for hysterectomy in cases of uterine descent was noted by 297 (63%) respondents, influenced mainly by patient preference, age, and prolapse anatomical score. A total of 443 (94%) were proficient in vaginal hysterectomy, with two-thirds performing 30 or fewer procedures annually; 212 (45%) reporting a decrease in the number of procedures over the last decade. Additionally, 373 (79%) respondents believed that 10-30 cases were needed to achieve and maintain proficiency. Vaginal hysterectomy remains a key component in uterine prolapse repair. However, with the rise of uterine-sparing prolapse repairs, the decision-making process may be influenced by multiple factors, including surgical training. Emphasis should be placed on training and maintaining proficiency in both traditional and novel techniques.

Application of modified extralevator abdominoperineal excision for low rectal cancer resection.

Laparoscopic ELAPE surgery has been carried out in our center for a long time, and some modifications have been made in clinical practice. In this study, we compared conventional ELAPE operation with modified ELAPE operation to investigate the efficacy and safety of modified ELAPE operation. We retrospectively analyzed the data from 339 patients with low rectal cancer undergoing abdominoperineal resection from 2017 to 2021 in the Department of General Surgery, Qilu Hospital of Shandong University. Patients were classified into modified ELAPE groups (199 patients) and conventional ELAPE groups (140 patients). Total operation time, reconstruction time, postoperative hospital stay, total cost, intraoperative data, postoperative short-term and long-term complications and tumor recurrence were compared. The baseline characteristics were comparable between the two groups. Total operation time was less with modified ELAPE group compared to conventional ELAPE group (190.6 ± 33.1min vs 230.1 ± 51.6min, P = 0.022). Pelvic floor reconstruction time was also less with modified ELAPE group compared to conventional ELAPE group (4.3 ± 1.2min vs 11.9 ± 1.7min, P = 0.004). Positive CRM was observed in 11 and 9 patients in modified ELAPE groups and conventional ELAPE groups (P = 0.744). IOP occurred in 12 and 7 patients in modified ELAPE group and conventional ELAPE group (P = 0.701). Total cost was also less with modified ELAPE group compared to conventional ELAPE group (9004 ± 1146 USD vs 10,336 ± 2047 USD, P = 0.031). The incidence of parastomal hernia was less with modified ELAPE group compared to conventional ELAPE group (7/199 vs 22/140, P < 0.001). Three-year follow-up data did not show any difference in overall survival rate or local occurrence between the two groups. Modified ELAPE surgery is technically safe and feasible, and oncologically comparable to that of conventional ELAPE surgery, which can be considered for popularization and application.

The Efficacy of Platelet-Rich Plasma in Pelvic Floor Reconstruction Surgery : A Scoping Review of Literature

The Efficacy of Platelet-Rich Plasma in Pelvic Floor Reconstruction Surgery : A Scoping Review of Literature

Preparation and Performance of a Novel Polyurethane Microporous Film on Polypropylene Medical Mesh Surface

This study aims to develop a medical patch surface material featuring a microporous polyurethane (PU) membrane and to assess the material's properties and biological performance. The goal is to enhance the clinical applicability of pelvic floor repair patch materials. PU films with a microporous surface were prepared using PU prepolymer foaming technology. The films were produced by optimizing the PU prepolymer isocyanate index (R value) and the relative humidity (RH) of the foaming environment. The surface morphology of the PU microporous films was observed by scanning electron microscopy, and the chemical properties of the PU microporous films, including hydrophilicity, were analyzed using infrared spectroscopy, Raman spectroscopy, and water contact angle measurements. In vitro evaluations included testing the effects of PU microporous film extracts on the proliferation of L929 mouse fibroblasts and observing the adhesion and morphology of these fibroblasts. Additionally, the effect of the PU microporous films on RAW264.7 mouse macrophages was studied. Immune response and tissue regeneration were assessed in vivo using Sprague Dawley (SD) rats. The PU films exhibited a well-defined and uniform microporous structure when the R value of PU prepolymer=1.5 and the foaming environment RH=70%. The chemical structure of the PU microporous films was not significantly altered compared to the PU films, with a significantly lower water contact angle ([55.7±1.5]° ) compared to PU films ([69.5±1.7]° ) and polypropylene (PP) ([ 104.3±2.5]°), indicating superior hydrophilicity. The extracts from PU microporous films demonstrated good in vitro biocompatibility, promoting the proliferation of L929 mouse fibroblasts. The surface morphology of the PU microporous films facilitated fibroblast adhesion and spreading. The films also inhibited the secretion of tumor necrosis factor-α (TNF-α) and interleukin (IL)-1β by RAW264.7 macrophages while enhancing IL-10 and IL-4 secretion. Compared to 24 hours, after 72 hours of culture, the expression levels of TNF-α and IL-1β were reduced in both the PU film and PU microporous film groups and were significantly lower than those in the PP film group (P<0.05), with the most notable decreases observed in the PU microporous film group. IL-10 and IL-4 levels increased significantly in the PU microporous film group, surpassing those in the PP film group (P<0.01), with the most pronounced increase in IL-4. The PU microporous film induced mild inflammation with no significant fibrous capsule formation in vivo. After 60 days of implantation, the film partially degraded, showing extensive collagen fiber growth and muscle formation in its central region. The PU microporous film exhibits good hydrophilicity and biocompatibility. Its surface morphology enhances cell adhesion, regulates the function of RAW264.7 macrophages, and promotes tissue repair, offering new insights for the design of pelvic floor repair and reconstruction patch materials.

Vaginal Hysterectomy and Pelvic Organ Prolapse: History and Recent Developments.

Vaginal hysterectomy (VH) was described as far back as 120 CE. However, it was not till the mid-1900s when reconstructive procedures were introduced to mitigate the risk of, or treat, pelvic organ prolapse in relation to VH. Furthermore, routine hysterectomy, particularly VH, has long been advocated in prolapse surgery. However, this indication is now questionable. Literature review to provide an overview of current evidence and experts' opinion regarding the relationship between VH and pelvic organ prolapse. The review presents a historical perspective on the role of VH in the management of pelvic organ prolapse, the current debate on the usefulness of the procedure in this context, a practical guide on operative techniques used during VH and the impact of recent surgical developments on its use. Vaginal hysterectomy is a well-established technique that is still superior to laparoscopic hysterectomy for benign gynecological disease, although more surgically challenging. However, it is possible that some contemporary techniques, such as vaginal natural orifice transluminal endoscopic surgery, may overcome some of these challenges, and hence increase the number of hysterectomies performed via the vaginal route. Although patients should be counselled about uterine-sparing reconstructive surgery, vaginal hysterectomy continues to be a major surgical procedure in reconstructive pelvic floor surgery. Therefore, it is prudent to continue to train residents in vaginal surgical skills to ensure that they continue to provide safe, cost-effective, and comprehensive patient care.

Combined Robotic and Vaginal Surgery for Pelvic Exenteration Due to Vaginal Sarcoma Relapse in an Obese Woman

Pelvic exenteration (PE) is an aggressive surgical procedure that implies a large hard-to-fill pelvic defect. Different reconstruction techniques were proposed to improve abdominal organ support and reduce complications (infections, pelvic organs herniation, vaginal stump dehiscence, bowel prolapse and obstruction) [1], with conflicting results [2]. Because of young age and survival greater than 50% at 5 years in patients with no residual tumor after surgery [3], a new approach with better clinical results to pelvic reconstruction is needed. The aim of this surgical film is to present an unusual presentation of vaginal sarcoma, successfully managed with a minimally invasive approach, and to illustrate our contextual multilayer technique of pelvic reconstruction using a combination of pedicled omental flap (POF) and human acellular dermal matrix (HADM). Tertiary level academic hospital. A 42-year-old obese patient with recurrent and symptomatic myxoid leiomyosarcoma, previously underwent vaginal-assisted laparoscopic surgery at a primary care center for the removal of a vaginal swelling. The multidisciplinary board determined anterior PE as the optimal therapeutic approach. Given the patient's body mass index (33 kg/m2), young age, and the favorable outcomes of robotic surgery in obese patients compared with other approaches [3,4], we proposed a combined robotic and vaginal surgery for both exenteration and reconstructive procedures [5]. During surgery, we initially explored the abdominal cavity to exclude macroscopic metastasis, followed by anterior PE. Urinary diversion was achieved with a Bricker ileal conduit by means of an ileoileal laterolateral anastomosis and an uretero-ileo-cutaneostomy. The pelvic dead space was partially filled with a POF on the left gastroepiploic artery. Subsequently, the pelvic defect was covered by a 15 × 10 mm HADM inlay inserted circumferentially at the pelvic brim, fixed with a barbed thread suture on residual pelvic structures. The final pathology confirmed the recurrence of myxoid leiomyosarcoma and indicated tumor-free resection margins. The intraoperative and postoperative periods were uneventful. The patient was discharged 14 days after surgery and underwent adjuvant doxorubicin- and dacarbazine-based chemotherapy, which was initiated 45 days after the surgery. Currently the patient is asymptomatic and disease free at the sixth month of follow-up. Robotic PE proves to be a feasible technique in obese patients, reducing postoperative hospital stay and complications. The contextual pelvic floor reconstruction with a POF and HADM supports abdominal viscera, diminishing interorgan adhesions and bowel prolapse. VIDEO ABSTRACT.

Trends and focal points in pelvic floor reconstruction for pelvic organ prolapse: A bibliometric analysis.

This study aims to investigate the current research trends and focal points in the field of pelvic floor reconstruction for the management of pelvic organ prolapse (POP). To achieve this objective, a bibliometric analysis was conducted on relevant literature using the Citespace database. The analysis led to the creation of a knowledge map, offering a comprehensive overview of scientific advancements in this research area. The study included a total of 607 publications, revealing a consistent increase in articles addressing pelvic floor reconstruction for POP treatment. Most articles originated from the United States (317 articles), followed by Chinese scholars (40 articles). However, it is important to note that the overall number of articles remains relatively low. The organization with the highest publication frequency was the Cleveland Clinic in Ohio, where Matthew D. Barber leads the academic group. Barber himself has the highest number of published articles (18 articles), followed by Zhu Lan, a Chinese scholar (10 articles). Key topics with high frequency and mediated centrality include stress urinary incontinence, quality of life, impact, and age. The journal with the largest number of papers from both domestic and international researchers is INT UROGYNECOL J. The study's hotspots mainly focus on the impact of pelvic floor reconstruction on the treatment and quality of life of POP patients. The United States leads in this field, but there is a lack of cooperation between countries, institutions, and authors. Moving forward, cross-institutional, cross-national, and cross-disciplinary exchanges and cooperation should be strengthened to further advance the field of pelvic floor reconstructive surgery for POP research.

Perioperative Hypothermia in Elderly Patients During Pelvic Floor Reconstruction Surgery: An Observational Study.

The potential predictors of pelvic floor reconstruction surgery hypothermia remain unclear. This prospective cohort study was aimed at identifying these predictors and evaluating the outcomes associated with perioperative hypothermia. Elderly patients undergoing pelvic floor reconstruction surgery were consecutively enrolled from April 2023 to September 2023. Perioperative temperature was measured at preoperative (T1), every 15min after the start of anesthesia (T2), and 15min postoperative (T3) using a temperature probe. Perioperative hypothermia was defined as a core temperature below 36°C at any point during the procedure. Multivariate logistic regression analysis was conducted to determine factors associated with perioperative hypothermia. A total of 229 patients were included in the study, with 50.7% experiencing hypothermia. Multivariate analysis revealed that the surgical method involving pelvic floor combined with laparoscopy, preoperative temperature < 36.5°C, anesthesia duration ≥ 120min, and the high levels of anxiety were significantly associated with perioperative hypothermia. The predictive value of the multivariate model was 0.767 (95% CI, 0.706 to 0.828). This observational prospective study identified several predictive factors for perioperative hypothermia in elderly patients during pelvic floor reconstruction surgery. Strategies aimed at preventing perioperative hypothermia should target these factors. Further studies are required to assess the effectiveness of these strategies, specifically in elderly patients undergoing pelvic floor reconstruction surgery.

Harvest of large fascia lata autograft: Outcomes in 108 patients.

Due to the reclassification of transvaginal mesh as a high-risk device, there has been renewed interest in the use of fascia lata in pelvic floor reconstruction. Here we report our experience in 108 patients who underwent large fascia lata harvest for pelvic organ prolapse (POP) repair. Our primary objective was to highlight the postoperative morbidity of the large fascia lata harvest in patients who underwent POP repair using fascia lata autograft. Surgery involved harvesting a fascia lata graft through a small lateral upper thigh incision and was used for either autologous transvaginal POP repair or autologous sacrocolpopexy. To prevent seroma, a temporary Jackson-Pratt drain was intraoperatively placed and a mild compression wrap was applied to the area for 4-6 weeks postoperatively. Patient demographics were obtained preoperatively, while physical exam findings and postoperative outcomes related to the fascia lata harvest were collected at sequential follow up visits. One-hundred eight patients underwent 111 large fascia lata harvests for either transvaginal or abdominal/robotic POP repair from July 2016 to January 2022. Mean follow-up was 19.6 months (range: 1-65) with 38 patients having 24 months or more of follow-up. Mean Visual Analog Pain (VAP) score was 1 (range: 0-10). Sixteen patients developed asymptomatic thigh bulges, 16 patients developed harvest site seromas (of which 14 resolved), and 59 patients experienced mild, non-bothersome paresthesia near the incision. Large fascia lata harvest offers a robust autograft for transvaginal or transabdominal POP repair with minimal morbidity. Harvest site complications are minor and typically resolve with expectant management. This technique can be safely utilized in patients who desire graft-augmented repair of POP without the use of synthetic mesh, allograft, or xenograft.

Puerarin-Loaded Electrospun Patches with Anti-Inflammatory and Pro-Collagen Synthesis Properties for Pelvic Floor Reconstruction.

Pelvic organ prolapse (POP) is one of the most common pelvic floor dysfunction disorders worldwide. The weakening of pelvic connective tissues initiated by excessive collagen degradation is a leading cause of POP. However, the patches currently used in the clinic trigger an unfavorable inflammatory response, which often leads to implantation failure and the inability to simultaneously reverse progressive collagen degradation. Therefore, to overcome the present challenges, a new strategy is applied by introducing puerarin (Pue) into poly(l-lactic acid) (PLLA) using electrospinning technology. PLLA improves the mechanical properties of the patch, while Pue offers intrinsic anti-inflammatory and pro-collagen synthesis effects. The results show that Pue is released from PLLA@Pue in a sustained manner for more than 20days, with a total release rate exceeding 80%. The PLLA@Pue electrospun patches also show good biocompatibility and low cytotoxicity. The excellent anti-inflammatory and pro-collagen synthesis properties of the PLLA@Pue patch are demonstrated both in vitro in H2O2-stimulated mouse fibroblasts and in vivo in rat abdominal wall muscle defects. Therefore, it is believed that this multifunctional electrospun patch integrating anti-inflammatory and pro-collagen synthesis properties can overcome the limitations of traditional patches and has great prospects for efficient pelvic floor reconstruction.

Monocytic profile of patients after pelvic floor reconstruction

Monocytic profile of patients after pelvic floor reconstruction

Унилатеральная гибридная хирургическая реконструкция тазового дна. Модифицированная лоскутная методика

Sacrospinous fixation is one of the most studied treatments for pelvic organ prolapse (POP), but the prevention of implantrelated complications remains unresolved. To isolate the mesh materials from the incision line and to prevent the development of chronic pelvic pain syndrome due to rigid fixation, a modification of hybrid pelvic floor reconstruction was performed, where a U-shaped vascularized vaginal flap acts as the main fixation point of the mesh implant. Objective. To study the efficacy and safety of a modified flap technique for unilateral hybrid pelvic floor surgical reconstruction. Patients and methods. A database of 128 case histories was generated. Inclusion criteria: apical anterior prolapse (POP-Q: Ba, C ≥ 0), hybrid pelvic floor surgical reconstruction using mesh endoprosthesis and vascularized vaginal flap performed between May 2020 and September 2022. The variables under study included POP stage, results of the PFDI-20, PISQ-12, and ICIQ-SF questionnaires, intraoperative complications. Patients who underwent surgery were invited for consultation. The following parameters were evaluated: POP stage, presence of mesh erosion, de novo dyspareunia, de novo chronic pelvic pain, de novo functional disorders (an overactive or atonic bladder, stress urinary incontinence (SUI), defecation disorders), repeat surgeries for POP and SUI. The PFDI-20, PISQ-12, and ICIQ-SF questionnaires were filled in. Satisfaction with treatment was assessed using the PGI-I scale. Four patients underwent contrast-enhanced magnetic resonance imaging of the pelvic organs. Results. The results showed a significant improvement in the quality of life after surgery in 113 (96.6%) cases. Only 3 (2.6%) patients had persistent POP symptoms. Of the 117 patients with baseline moderate or severe urinary incontinence, 45 (38.5%) showed improvement in 41 (91.1%) cases. Assessment of the quality of sexual life showed improvement in 27 (77.1%) of 35 patients, and 4 patients returned to sexual activity after surgery. Satisfaction with the results of treatment was noted in 109 (93.2%) patients. Conclusion. Flap modification for unilateral hybrid pelvic floor surgical reconstruction is an effective and safe method of preventing the development of implant-related complications in the correction of POP. Key words: pelvic organ prolapse, mesh implant, vaginal flap

Central Sensitisation Syndrome: A Frequent Finding in Women with Pelvic Floor Symptoms Without Evident Urogenital Prolapse.

Women with central sensitisation syndrome (CSS) experience poorer subjective post-operative outcomes even after successful pelvic floor reconstruction. This study tests the hypothesis that women with pelvic floor symptoms (PFS) without relevant pelvic organ prolapse (POP), are more likely to have CSS. A questionnaire was sent to women who participated in the POP-UP study in 2017. The POP-UP study evaluated POP in 247 women 16years after laparoscopic or vaginal hysterectomy. POP-Q data and Pelvic Floor Distress Inventory (PFDI-20) results were used and supplemented with CSS-specific questionnaires. A Central Sensitisation Inventory (CSI) score above 40 implicates CSS. Women were divided into groups based on POP beyond the hymen in relation to the PFDI-20 score. Outcomes of women with PFS and without POP (called 'group 1') were compared with the rest of the cohort (groups 2-4; women without PFS and/or with POP). A total of 136 women were included in the analysis. A CSI score above 40 was present in 16 out of 42 women of group 1 (37%) versus 11 out of 93 women of groups 2-4 (12%), p < 0.0001. Passive coping was more prevalent in group 1 (p = 0.039), and more deviations in somatisation, depression, anxiety and distress were found in group 1 (p values of < 0.0001, 0.018, 0.003 and 0.002 respectively). This study suggests that CSS might be more prevalent in women with PFS without relevant POP. More awareness of CSS and valid individual counselling may overcome unnecessary surgery for POP and help in setting realistic expectations.

Outcomes of Abdominal Apical Suspension Using Mesh in a Tertiary Training Hospital: A Seven-year Retrospective Review.

Pelvic organ prolapse (POP) is an inconvenience that can affect a woman's well-being. Reconstructive pelvic floor surgery involves repairing defects in the endopelvic fascia and pelvic floor musculature as close to the physiologic and anatomic norm. The cornerstone of successful prolapse repair is a strong apical support. The aim of the study is to determine the outcomes of abdominal sacrocolpopexy (ASC) and abdominal sacrohysteropexy (ASH) in the Philippines. The study utilized a descriptive study design to compare the pre-operative and post-operative Pelvic Organ Prolapse Quantification Score (POP-Q Score), presence of mesh complications, and urinary/bowel symptoms in patients operated within 2010-2016 in a Philippine tertiary training hospital. Based on recovered charts and inclusion/exclusion criteria, this study sampled 34 of 50 patient records. Statistical measures of median and range were used to describe pre-operative and post-operative POP-Q scores in any two follow-ups within 6-, 12-, 18-, and 24-month interval. The objective success rate and incidence of urinary/bowel symptoms were described using frequencies and percentages. Presence of any mesh erosion was noted for each follow-up. McNemar's test was applied to assess the comparative occurrence of each symptom comparing between the pre-operative and first follow-up periods. ASC had a success rate of 73.7% at six months and 56.3% at 12 months post-surgery. ASH showed an 84.6% success rate at six months and 71.4% at 12 months. Apical support has a 97% success rate without affecting the anterior or posterior compartments. Out of 20 ASC patients, 5 (25%) exhibited anterior compartment descent, whereas two out of 14 ASH patients (14.2%) had the same condition. It is observed that the anterior vaginal wall has the higher tendency to descend after reconstructive surgery, independent of route or technique. In addition, not all patients with surgical prolapse beyond -1 experienced symptomatic vaginal bulges. Overall, a notable decrease in the occurrence of urine symptoms was seen after the surgery. No mesh erosion was seen within the initial two years of follow-up but there was a single reported instance of abdominal hernia, an uncommon consequence. This study demonstrated that ASC and ASH have good success rate in apical support; however, descent of the anterior or posterior compartment diminishes the overall success rate in terms of over-all objective POP-Q score. Both resulted to improvement in symptoms with minimal complications.

Pelvic exenteration for late complications of radiation-induced pelvic injury: a preliminary study

Objective: To investigate the safety and efficacy of total pelvic exenteration (TPE) for treating late complications of radiation-induced pelvic injury. Methods: This was a descriptive case series study. The inclusion criteria were as follows: (1) confirmed radiation-induced pelvic injury after radiotherapy for pelvic malignancies; (2) late complications of radiation-induced pelvic injury, such as bleeding, perforation, fistula, and obstruction, involving multiple pelvic organs; (3) TPE recommended by a multidisciplinary team; (4) patient in good preoperative condition and considered fit enough to tolerate TPE; and (5) patient extremely willing to undergo the procedure and accept the associated risks. The exclusion criteria were as follows: (1) preoperative or intraoperative diagnosis of tumor recurrence or metastasis; (2) had only undergone diversion or bypass surgery after laparoscopic exploration; and (3) incomplete medical records. Clinical and follow-up data of patients who had undergone TPE for late complications of radiation-induced pelvic injury between March 2020 and September 2022 at the Sixth Affiliated Hospital of Sun Yat-sen University were analyzed. Perioperative recovery, postoperative complications, perioperative deaths, and quality of life 1 year postoperatively were recorded. Results: The study cohort comprised 14 women, nine of whom had recto-vagino-vesical fistulas, two vesicovaginal fistulas, one ileo-vesical fistula and rectal necrosis, one ileo-vesical and rectovaginal fistulas, and one rectal ulcer and bilateral ureteral stenosis. The mean duration of surgery was 592.1±167.6 minutes and the median blood loss 550 (100-6000) mL. Ten patients underwent intestinal reconstruction, and four the Hartmann procedure. Ten patients underwent urinary reconstruction using Bricker's procedure and 7 underwent pelvic floor reconstruction. The mean postoperative hospital stay was 23.6±14.9 days. Seven patients (7/14) had serious postoperative complications (Clavien-Dindo IIIa to IVb), including surgical site infections in eight, abdominopelvic abscesses in five, pulmonary infections in five, intestinal obstruction in four, and urinary leakage in two. Empty pelvis syndrome (EPS) was diagnosed in five patients, none of whom had undergone pelvic floor reconstruction. Five of the seven patients who had not undergone pelvic floor reconstruction developed EPS, compared with none of those who had undergone pelvic floor reconstruction. One patient with EPS underwent reoperation because of a pelvic abscess, pelvic hemorrhage, and intestinal obstruction. There were no perioperative deaths. During 18.9±10.1 months of follow-up, three patients died, two of renal failure, which was a preoperative comorbidity, and one of COVID-19. The remaining patients had gradual and significant relief of symptoms during follow-up. QLQ-C30 assessment of postoperative quality of life showed gradual improvement in all functional domains and general health at 1, 3, and 6 months postoperatively (all P<0.05). Conclusions: TPE is a feasible procedure for treating late complications of radiation-induced pelvic injury combined with complex pelvic fistulas. TPE is effective in alleviating symptoms and improving quality of life. However, the indications for this procedure should be strictly controlled and the surgery carried out only by experienced surgeons.

A New Technique for Pelvic and Vaginal Reconstruction in Abdominoperineal Rectal Excision: Combination of Gluteus Maximus Flap and Fasciocutaneous Flap.

Resection of advanced rectal cancer might result in significant tissue loss, including pelvic floor and parts of the vaginal wall. Pelvic floor reconstruction using a musculocutaneous flap offers optimized healing abilities and the possibility of vaginal reconstruction. In Skåne University Hospital, two different flap techniques are used to reconstruct the perineum: the vertical rectus abdominis musculocutaneous flap and the gluteus maximus (GM) flap. A combination of a GM flap and a fasciocutanous flap, referred to locally as a GM special (GMS) flap, is used for posterior vaginal wall reconstruction in women undergoing abdominoperineal resections including parts of or the total posterior vaginal wall. The GMS flap was introduced through a national collaboration in Sweden in 2013. The aim of this article is to offer a detailed description and illustrations of the surgical technique used to construct the GMS flap, focusing on the posterior vaginal wall reconstruction. In our experience, the GMS flap is a resilient and cosmetically appealing choice that is technically easily harvested. The flap has acceptable morbidity and long-term results with adequate neovaginal measurements. Collaborative work is further encouraged.

Comparison of long-term clinical outcomes between transvaginal mesh and pelvic floor reconstruction with native tissue repair in the treatment of advanced pelvic organ prolapse

Objective: To study the long-term clinical effect of transvaginal mesh (TVM) and pelvic floor reconstruction with native tissue repair (NTR) in the treatment of advanced pelvic organ prolapse (POP). Methods: Totally 207 patients with advanced POP who were treated in Hunan Provincial Maternal and Child Health Care Hospital from Jan. 2016 to Sep. 2019 were enrolled. The patient's pelvic organ prolapse quantification were all at degree Ⅲ or above, and they all complained for different degree of symptoms. They were divided into two groups according to the different surgical methods, TVM group and NTR group. In TVM group, the mesh was implanted through the vagina for pelvic floor reconstruction, while in NTR group, the traditional transvaginal hysterectomy combined with uterosacral ligament suspension and anterior and posterior wall repair, as well as perineal body repair were performed. The median follow-up time was 60 months, during the follow up time, 164 cases (79.2%, 164/207) had completed follow-up, including 76 cases in TVM group and 88 cases in NTR group. The perioperative data and complication rates of the two groups were compared, and the subjective and objective outcomes of the two groups at 1, 3 and 5 years were observed, respectively. The objective efficacy was evaluated by three composite criteria, namely: (1) the distance from the farthest end of the prolapse of the anterior and posterior wall of the vagina to the hymen is ≤0 cm, and the descending distance of the top is ≤1/2 of the total length of the vagina; (2) determine the disappearance of relevant POP symptoms according to "Do you often see or feel vaginal mass prolapse？"; (3) no further operation or pessary treatment was performed due to prolapse. If the above three criteria were met at the same time, the operation is successful; otherwise, it was recurrence. The subjective efficacy was evaluated by the pelvic floor distress inventory-short form 20 (PFDI-20) and pelvic floor impact questionnaire-short form 7 (PFIQ-7). Results: The median follow-up time of the two groups was 60 months (range: 41-82 months). Five years after the operation, the subjective and objective cure rates of TVM group were 89.5% (68/76) and 94.7% (72/76), respectively. The subjective and objective cure rates in NTR group were 80.7% (71/88) and 85.2% (75/88), respectively. There were significant differences in the subjective and objective cure rates between the two groups (χ2=9.869, P=0.002; χ2=3.969, P=0.046). The recurrence rate of TVM group was 5.3% (4/76), and that of NTR group was 14.8% (13/88). There was a significant difference between the two groups (P=0.046). The postoperative PFDI-20 and PFIQ-7 scores of the two groups were significantly lower than those before surgery, and there were significant differences of the two groups before and after surgery (all P<0.05). Postoperative mesh exposure in TVM group was 1.3% (1/76). Conclusions: The long-term outcomes between the two groups show that the subjective and objective outcomes of pelvic floor reconstruction in TVM group are significantly higher than those in NTR group, and the recurrence rate is significantly lower than that in NTR group. TVM has certain advantages in the treatment of advanced POP.

Complications after abdominal surgery and breast implant pelvic positioning: case report and literature review.

The recommended treatment for patients with locally advanced colorectal cancer (CRC) or other pelvic neoplasms often comprises extensive abdominal surgery and radiation therapy (RT). The major complications of these treatments are radiation enteritis and empty pelvis syndrome, which is the displacement of bowel loops in the pelvic dead space created after the intervention. To avoid these complications, diverse methods of pelvic floor reconstruction have been attempted, one of them being the silicon breast prosthesis pelvic placement. Since literature is scarce on complications secondary to breast implant placement in the pelvis, we consider our case an unusual presentation of this entity offering the availability of novel information.

Resection rectopexy as part of the multidisciplinary approach in the management of complex pelvic floor disorders.

Pelvic floor disorders are frequently caused byan organ prolapse involving multiple pelvic floor compartments. In such cases, a multidisciplinary strategy for diagnostic work-up and therapy is required. All patients who underwent transabdominal rectopexy/resection rectopexy alone or in combination with simultaneous gynecological pelvic floor reconstruction at our institution between 01/2006 and 12/2021 were included in this retrospective study. The study aimed to evaluate the functional outcome and postoperative complications. Two hundred and eighty seven patients were assigned to one of the following groups: PG1- patient group one: after resection rectopexy (n=141); PG2- after ventral rectopexy (n=8); PG3- after combined resection rectopexy and sacro (cervico)colpopexy (n=62); PG4- after combined resection rectopexy and trans-vaginal pelvic floor repair (n=76). The duration of follow-up was 14months for PG1 (median, IQR 37months), 11months for PG2 (mean, SD 9months), 7months for PG 3 (median, IQR 33months), and 12months for PG 4 (median, IQR 51 Months). The surgical procedure resulted in improvement of symptoms related to obstructed defecation in 56.4 % (22/39) of the patients in PG1, 25 % in PG2 (1/4), 62.5 % (20/32) in PG3, and 71.8 % (28/39) in PG4. "De novo" constipation was reported by 2.4 % (2/141) of patients from PG1. Improvement in fecal incontinence symptoms was reported by 69 % (40/58) of patients in PG1, 100 % in PG2 (2/2), 93.1 % (27/29) in PG3, and 87.2 % (34/39) in PG4. The recurrence rate for external rectal prolapse was 7.1 % in PG1, 50 % in PG2 (1/2), 2.7 % in PG3, and 6.3 % in PG4. A significant difference in terms of severe morbidity (grade≥ IIIb) and mortality could not be determined between the non-interdisciplinary (PG1 with PG2) and interdisciplinary surgery (PG3 with PG4) (p=0.88, p=0.499). Based on our results, we can assume that combined surgery is as feasible as rectal surgery alone. In our study, combined interventions were effective and not associated with an increased risk of postoperative complications.