Pelvic Floor Reconstructive Surgery Research Articles

Vaginal Packing After Pelvic Floor Reconstructive Surgery: Does the Soaking Agent Used for Packing (Bupivacaine, Estrogen or Saline) Impact Post-operative Pain Scores?”

Study ObjectiveVaginal packing is traditionally placed after pelvic floor reconstructive surgery (PFRS) to prevent hematoma formation. We seek to determine if there is a difference in post-operative pain scores after PFRS if vaginal packing is soaked with estrogen cream, bupivacaine, or saline. The primary outcome was pain as measured by a visual analog scale (VAS) at 2 hours, 6 hours, and 1 day post-operatively. Secondary outcomes include change in hemoglobin, urinary retention and length of stay (LOS) in hospital. DesignProspective cohort study SettingTertiary care academic teaching hospital. All PFRS performed by fellowship-trained urogynecologists. ParticipantsConsenting patients undergoing PFRS. InterventionsAt the completion of surgery, gauze packing soaked with either estrogen cream 0.25% bupivacaine with 1% epinephrine, or normal saline was placed inside the vagina and removed on post-operative day 1. ResultsWe included 210 patients (74 estrogen, 66 bupivacaine, 70 saline). There was no significant difference in mean post-operative pain scores between the groups (estrogen, bupivacaine, saline-soaked vaginal packs respectively) at 2 hours (2.66±2.25, 2.30±2.17, 2.24±2.07; p=.4656), 6 hours (2.99±2.38, 2.52±2.30, 2.36±2.01; p=.2181) or on post operative day 1 (1.89±2.01 vs. 2.08±2.15 vs. 2.44±2.19; p=.2832) as measured by VAS scores (0-10). There was no difference in the secondary outcomes of change in pre-/post-operative hemoglobin (21.8±10.73g/L, 20.09±11.55g/L, 21.7±9.62g/L, p=.68), urinary retention (37%, 45% and 48%, p=.45), LOS (1.05±0.46 days, 1.02±0.12, 1.03±0.24, p=.97) or in-hospital opioid usage during admission (represented in morphine milligram equivalents (median (IQR1, IQR3), Kruskal-Wallis test): 11.25mg (0,33), 7.5mg (0, 22.5) and 15mg (0, 33.88) p =0.41. ConclusionThere was no difference found between soaking vaginal packing with estrogen cream, bupivacaine, or saline after PFRS with respect to post-operative pain scores, LOS, in-hospital opioid usage, or urinary retention. Saline-soaked packing is an equivalent alternative to estrogen or bupivacaine vaginal packing. Clinical Trial RegistrationNCT03266926. Registered February 1, 2017. https://clinicaltrials.gov/study/NCT03266926

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

New horizons in gynecological surgery: first-year experience with HUGO™ robotic-assisted surgery system at two tertiary referral robotic centers

AbstractThe HUGO™ robotic-assisted surgery system (RAS, Medtronic, CA) consists of a 3D open console, four independent carts, and an integrated laparoscopic and robotic tower. Approved in 2021, it represents a novel alternative platform for robotic procedures. The aim of our study is to report the first-year experience with this system for gynecological procedures at two tertiary referral robotic centers. We prospectively collected and retrospectively analyzed data from patients underwent gynecological robot-assisted surgery with the HUGO™ RAS, at San Paolo University Hospital (Milan, Italy), and Onze Lieve Vrouw (OLV) Hospital (Aalst, Belgium), March 2022–April 2023. Demographic characteristics, intraoperative settings, and perioperative outcomes were investigated. A total of 32 procedures were performed: 20 (62.5%) hysterectomies, 7 (21.9%) adnexal surgeries, and 5 (15.6%) pelvic floor reconstructive surgeries. In 2022 and 2023, 13 (40.6%) and 19 (59.4%) procedures were carried out, respectively. The median docking time was 8 min (IQR 5.8–11.5). The median console and skin-to-skin time was 52.5 min (IQR 33.8–94.2) and 108.5 min (IQR 81.5–157.2), respectively. No intraoperative complications occurred. Two conversions to laparoscopy managed without any additional complications were needed. To the best of our knowledge, this is the first global series of gynecological procedures performed with the HUGO™ RAS. Our preliminary findings showed the system’s feasibility reporting promising results. The observed upward trend in the total number of procedures during the analyzed period is encouraging. Further studies are needed to assess a standardized method in the gynecological field with the novel platform.

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.

The Pathogenesis of Mesh-induced Inflammatory Response and Pain: Rationale for Development of New Mesh

Chronic postoperative pain (CPP) in mesh hernia repair (MHR) may complicate the postoperative course. The cause of CPP may be multifactorial - surgical technique, patient-intrinsic factors, and mesh. Polypropylene (PP) mesh is the most widely used material for MHR. Despite its advantages, it has been associated with severe complications in urogynecology leading to a partial mesh ban. PP is not inert and causes foreign body reactions (FBR), corrosion, and loss in biocompatibility. Pain is a hallmark of mesh-induced complications. The pathogenesis of pain is related to an immune response with neutrophils, T cells, and macrophages, major players in mesh-associated fibrosis and pain. Pain may be caused by mesh implantation-induced nerve entrapment, compression, and severe inflammation, relevant for both nociceptive and neuropathic pain. Compression neuropathy has been associated with preoperative pain and chronic postoperative pain in mesh and non-mesh repairs. The mesh may induce FBR changes causing clinical complications and pain. Increased mesh vicinity innervation induced by fibrosis may be responsible for chronic postoperative pain. An aggressive immune response in pelvic floor reconstructive surgery degrades PP. T cells and macrophages may protect against or induce degradation and pain. The main point to eliminate pain is to develop a mesh, that provides long-term corrosion resistance, and biocompatibility. This may be achieved by coating PP mesh with a thin layer of Titanium oxide or meshes of pure titanium. Titanium is considered to be bio-inert providing corrosion resistance and biocompatibility. However, depending on the location and surface of the mesh (roughness, hydrophilicity), there may be a macrophage-neutrophil-induced inflammatory response causing fibrosis and cicatrization. Based on the structure, location, and production Titanium may demonstrate beneficial effects concerning corrosion, oxidation, FBR, and biocompatibility. To improve outcomes in MHR the analysis of cellular immune response concerning mesh properties, composite endpoints, pain, and physical function may be necessary.

Impact of childbirth on pelvic floor dysfunction in women who have undergone previous pelvic floor reconstructive surgery: systematic review and meta-analysis.

The aim of the study was to perform a systematic review and meta-analysis of the impact of pregnancy and childbirth (vaginal delivery [VD]) or cesarean section (CS) on the recurrence of pelvic floor disorders in women who had previously undergone pelvic floor reconstructive surgery for pelvic organ prolapse (POP) or stress urinary incontinence (SUI), to facilitate future evidence-based counseling. PubMed, Cochrane, Embase, BJOG, Scopus, etc. were screened, from 1990 to date. Inclusion criteria included cohort studies, case-control studies, case series, and case reports that reported on the primary outcome measure of the review. Exclusion criteria included studies on surgical procedures whose outcomes are unlikely to be impacted by pregnancy and childbirth or are obsolete. Meta-analysis was performed using Review Manager 5.3. Seven papers on midurethral slings (MUS; 181 women in both VD and CS groups respectively) and three papers on different hysteropexy techniques (47 and 29 women in the VD and CS groups respectively), were included in the meta-analysis. No difference was seen between the two groups regarding the recurrence of SUI in women who had previously undergone MUS surgery (OR: 1.18 [0.66, 2.09]; Z = 0.56; p = 0.58) or the recurrence of POP following hysteropexy using various apical suspension procedures (OR: 1.81 [0.04, 80.65]; Z = 0.31; p = 0.76). There are insufficient data to support meta-analyses for individual MUS sub-types or hysteropexy procedures. Current literature does not demonstrate a protective effect of CS in preventing recurrent SUI in women who had undergone MUS surgery for SUI. When hysteropexy is considered irrespective of the apical suspension procedure employed, the incidence of recurrent POP appears similar after CS and VD.

Electrical stimulation plus biofeedback improves urination function, pelvic floor function, and distress after reconstructive surgery: a randomized controlled trial

PurposeThis study is aimed at assessing the effect of postoperative electrical stimulation (ES) plus biofeedback therapy on patient rehabilitation after pelvic floor reconstructive surgery.MethodsPatients with pelvic organ prolapse (POP) who had received pelvic floor reconstructive surgery were randomly allocated to the intervention group and the control group at a 1:1 ratio. Patients in the control group received routine postoperative nursing care. Patients in the intervention group underwent ES plus biofeedback therapy. The outcomes included the recovery of urination function, the improvement of pelvic floor muscle (PFM) strength, and the change of Pelvic Floor Distress Inventory Questionnaire-20 (PFDI-20) scores. The study outcomes were evaluated at pre-intervention (T0, 2 months after surgery), 3 months after surgery (T1), and 6 months after surgery (T2).ResultsA total of 60 patients with POP were included in this study. For the urination function evaluation, the intervention group had a higher recovered rate than the control group at the time point of T2 (p = 0.038). For the EMG results, the changes of flick-max and tonic-mean values from T0 to T2 were much higher in the intervention group comparing to the control group. Corresponding to the EMG results, digital palpation showed that intervention group had a much higher proportion of patients who had elevated PFM strength. Furthermore, the intervention group also had more significant PFDI-20 score improvements compared with control group.ConclusionsPostoperative ES plus biofeedback therapy could significantly improve urination function, PFM strength, and patient’s reported QoL.Trial registrationClinical registration number: hiCTR2000032432.

Chinese experts consensus on the complications registry of female pelvic floor reconstructive surgery with prosthesis

Chinese experts consensus on the complications registry of female pelvic floor reconstructive surgery with prosthesis

MP07-15 LANGUAGE-RELATED DISPARITIES IN ACUTE POSTOPERATIVE PAIN MANAGEMENT FOLLOWING PELVIC FLOOR RECONSTRUCTIVE SURGERY

You have accessJournal of UrologyCME1 Apr 2023MP07-15 LANGUAGE-RELATED DISPARITIES IN ACUTE POSTOPERATIVE PAIN MANAGEMENT FOLLOWING PELVIC FLOOR RECONSTRUCTIVE SURGERY Grace K. Sarris, Fatima A. Khan, Nachiketh S. Prakash, Raveen Syan, Lauren Martin, and Katherine Amin Grace K. SarrisGrace K. Sarris More articles by this author , Fatima A. KhanFatima A. Khan More articles by this author , Nachiketh S. PrakashNachiketh S. Prakash More articles by this author , Raveen SyanRaveen Syan More articles by this author , Lauren MartinLauren Martin More articles by this author , and Katherine AminKatherine Amin More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003222.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Current literature suggests racial/ethnic disparities exist in acute pain management, where minority patients are often less likely to receive opioid medication. Lower English proficiency is correlated with minority race/ethnicity in the United States, however limited data exists on this relationship with opioid administration during post anesthesia care unit (PACU) stay. This study investigates predictors of opioid use in PACU following female pelvic floor reconstructive surgery (FPMRS). METHODS: A retrospective chart review of 3,511 patients who underwent FPMRS was performed. Continuous and categorical variables were analyzed using a t-test and chi-squared test, respectively. Non-parametric data was analyzed using Wilcoxon rank-sum tests. A Multinomial logistic regression model was fitted to identify independent predictors. A p-value <0.05 was considered statistically significant. RESULTS: Sociodemographic details off 155 women who underwent FPMRS are outlined in Table 1. Spanish as a preferred language (aOR 0.16, 95% CI: 0.03-0.88) shows a decreased likelihood of receiving opioids in the PACU. Prolapse stage 1 (aOR 19.65, 95% CI: 1.17-327.57) and 4 (aOR 92.03, 95% CI (1.13-7435) and previous smokers (aOR 8.15, 95% CI: 1.35-49.160) were associated with an increased likelihood of receiving opioids in PACU. Patient race, parity, menopausal status, BMI, and diagnosis of hypertension, diabetes or chronic pain were not predictive of receiving opioids in the PACU (Table 2). CONCLUSIONS: Our results showed Spanish speaking patients are more likely to receive opioids in the PACU. Previously reported disparities in postoperative opioid use including race and ethnicity did not appear to exist in our unique Hispanic minority-majority patient population. Instead, our study implicates the importance of communication in acute postoperative pain management. The etiology of this language-related disparity is complex and future studies to investigate are warranted. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e90 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Grace K. Sarris More articles by this author Fatima A. Khan More articles by this author Nachiketh S. Prakash More articles by this author Raveen Syan More articles by this author Lauren Martin More articles by this author Katherine Amin More articles by this author Expand All Advertisement PDF downloadLoading ...

Robot-assisted pelvic floor reconstructive surgery: an international Delphi study of expert users

BackgroundRobotic surgery has gained popularity for the reconstruction of pelvic floor defects. Nonetheless, there is no evidence that robot-assisted reconstructive surgery is either appropriate or superior to standard laparoscopy for the performance of pelvic floor reconstructive procedures or that it is sustainable. The aim of this project was to address the proper role of robotic pelvic floor reconstructive procedures using expert opinion.MethodsWe set up an international, multidisciplinary group of 26 experts to participate in a Delphi process on robotics as applied to pelvic floor reconstructive surgery. The group comprised urogynecologists, urologists, and colorectal surgeons with long-term experience in the performance of pelvic floor reconstructive procedures and with the use of the robot, who were identified primarily based on peer-reviewed publications. Two rounds of the Delphi process were conducted. The first included 63 statements pertaining to surgeons’ characteristics, general questions, indications, surgical technique, and future-oriented questions. A second round including 20 statements was used to reassess those statements where borderline agreement was obtained during the first round. The final step consisted of a face-to-face meeting with all participants to present and discuss the results of the analysis.ResultsThe 26 experts agreed that robotics is a suitable indication for pelvic floor reconstructive surgery because of the significant technical advantages that it confers relative to standard laparoscopy. Experts considered these advantages particularly important for the execution of complex reconstructive procedures, although the benefits can be found also during less challenging cases. The experts considered the robot safe and effective for pelvic floor reconstruction and generally thought that the additional costs are offset by the increased surgical efficacy.ConclusionRobotics is a suitable choice for pelvic reconstruction, but this Delphi initiative calls for more research to objectively assess the specific settings where robotic surgery would provide the most benefit.

Preemptive Infiltration of Local Anesthetics During Vaginal Hysterectomy: A Systematic Review and Meta-analysis of Randomized Controlled Trials

(Abstracted from Urogynecology 2022;28:667–678) Undergoing pelvic floor reconstructive surgery bears a lifetime risk between 14% and 19%, with a significantly higher risk in elderly and postmenopausal women. The traditional preferred surgical approach for pelvic floor disorders (PFDs) is vaginal hysterectomy (VH) with or without pelvic floor repair.

Enhanced Recovery Protocols in Urogynecologic and Pelvic Floor Reconstructive Surgery: A Systematic Review and Meta-Analysis.

The implementation of Enhanced Recovery After Surgery (ERAS) protocols may optimize the clinical outcome of surgical patients, by reducing the length of hospital stay (LOS) and improving the quality of recovery. This study aims to evaluate the impact of ERAS protocols in the intraoperative and postoperative course of patients undergoing pelvic floor reconstructive surgery. A systematic search of PubMed/MEDLINE, Embase, and the Cochrane Library was conducted up to January 2022, using the Systematic Reviews and Meta-analyses guidelines. Search terms, such as ERAS, urogynecology, sacrocolpopexy were tailored to each database as necessary. Statistical analysis was performed using the RevMan 5.4 software. Confidence intervals (CI) were set at 95%. Mean difference and risk ratio were used in the analysis, and the results were calculated using the random effect model. Six studies that reported outcomes of 1,153 women were included. The ERAS protocols were implemented in 553 women, whereas the remaining 600 received standard perioperative care. A significantly shorter LOS (mean difference, -16.17 hours; 95% CI, -24.07 to -8.26 hours; P < 0.0001) and a higher proportion of patients discharged within 24 hours postoperatively was observed in ERAS patients compared with non-ERAS controls (risk ratio, 3.08; 95% CI, 2.00-4.75; P < 0.00001). Operative time, estimated blood loss, complications, and readmission rates did not differ between the 2 groups. Our analysis showed that ERAS protocols have a favorable impact on the perioperative course of urogynecologic populations. More research is required to determine those key components of ERAS protocols, specifically applicable and more beneficial to women with pelvic floor disorders.

Mid-term efficacy of surgical treatments for post-hysterectomy vaginal vault prolapse: a retrospective study

The surgical treatment of post-hysterectomy vaginal vault prolapse (PHVP) has been reported in several clinical studies, but mostly are short-term studies. This study aims to explore the mid-term efficacy of surgical treatments for PHVP. A total of 138 PHVP patients underwent surgery from January 2005 to January 2020 at the Fourth Medical Center of PLA General Hospital, Beijing. The clinical data of 119 patients who completed follow-up were retrospectively analyzed. Both groups of patients are diagnosed Pelvic Organ Prolapse Quantification system (POP-Q) III-IV stage of prolapse, with obvious prolapse-related symptoms and requiring surgical treatment. Among them, pelvic floor reconstruction surgery (RPS) was performed in patients who wanted to retain vaginal function and colpocleisis were used for frail patients who cannot tolerate RPS. We used the POP-Q scores for the objective efficacy evaluation, and use the Pelvic Floor Distress Inventory-Short Form 20 (PFDI-20) and Pelvic Floor Impact Questionnaire-7 (PFIQ-7) to evaluate the subjective symptom during follow up. Among them, 61 patients underwent pelvic floor RPS (Group R), and 58 received colpocleisis (Group C). The surgeries in both groups were successfully completed, the median follow-up time after surgery was 4.3 years (0.25-13 years) and 5.3 years (0.33-15 years), respectively; the overall surgical success rate was 86.9% (53/61) and 100% (58/58), respectively; the subjective satisfaction rate was 90.2% (55/61) and 91.4% (53/58), respectively; and the PFDI-20 and PFIQ-7 scores in both groups were significantly improved compared with the preoperative levels (P<0.05). In Group R, 6 cases (9.8%, 6/61) were dissatisfied after surgery; in Group C, 5 cases (8.6%, 5/58) were dissatisfied after surgery. Reconstructive surgery and colpocleisis have a good mid-term effect on PHVP, with good outcome and few complications. The surgeon is expected to ascertain an appropriate surgical procedure based on the characteristics of the patient, the degree and the location of prolapse, in order to achieve the best surgical efficacy and minimize the damage.

Feasibility of combining pelvic reconstruction with gynecologic oncology-related surgery.

At our institution, every patient seen by the gynecologic oncology service is screened for pelvic floor dysfunction. This study was aimed at determining if a combined surgical approach by gynecologic oncology and urogynecology services at our institution was feasible and safe for this patient population. We performed a retrospective review of patients undergoing combined surgery by gynecologic oncology and urogynecology services at our institution from 2013 to 2021. Perioperative variables, postoperative adverse events, and long-term outcomes were assessed, and descriptive statistics were performed. From 20 December 2013 to 29 January 2021, a total of 102 patients underwent concurrent surgical repair of pelvic organ prolapse and/or stress urinary incontinence. Seventy-three patients (71.6%) had normal/benign pathologic conditions, and 29 (28.4%) had premalignant/malignant pathologic conditions. Ten patients (9.8%) had a postoperative complication, including reoperation for exposed midurethral sling (4.9%), urinary retention requiring midurethral sling release (2.9%), reoperation for hemoperitoneum (1.0%), and anemia requiring blood transfusion (1.0%). Nine complications occurred in patients with benign/normal pathologic conditions (12.3%), and one complication occurred in patients with pre-malignant/malignant pathologic conditions (3.4%). In our single-institution experience, concurrent gynecologic oncology and pelvic floor reconstructive surgery were safe and feasible in combination with no reported major morbidity events.

Clinical and pelvic floor ultrasound characteristics of pelvic organ prolapse recurrence after transvaginal mesh pelvic reconstruction

BackgroundRecurrence of pelvic organ prolapse (POP) after transvaginal mesh (TVM) implantation pelvic floor reconstruction surgery remains an unresolved problem in clinical practice. In this retrospective observational study, clinical and pelvic floor ultrasound (PFUS) parameters were analyzed in order to identify high-risk factors of POP recurrence.MethodsThe clinical and PFUS data from September 2013 to November 2019 of patients who underwent TVM were retrospectively analyzed. The patients with prolapse recurrence on postoperative follow-up diagnosed by PFUS were selected as case group, the clinical and PFUS parameters of them were compared with the control group in which the patients had no sign of prolapse recurrence. Univariate and multivariate regression analyses were performed based on age, BMI, gravidity, parity, surgical history (non-POP hysterectomy and incontinence-or-POP surgery), preoperative POP stage, follow-up in years, levator avulsion and hiatal area (HA) on Valsalva.ResultsAltogether 102 patients entered the study and the median interval between PFUS and TVM surgery was 2.5 years. Univariate analysis showed that levator avulsion and HA were significantly different between case group and control; multivariate regression analysis showed that only HA was related to prolapse recurrence after TVM (OR = 1.202, 95% CI 1.100–1.313, P < 0.001). The area under the ROC curve was 0.775 (95% CI 0.684–0.867, P < 0.001).ConclusionsHiatal area on Valsalva was related to prolapse recurrence after TVM surgery and it is an important parameter for postoperative follow-up of TVM surgery.

Трудности и ошибки диагностики вторичного гипокортицизма у больных старческого возраста

Adrenal insufficiency is a relatively rare condition, especially among individuals older than 65 years. Therefore, the specific manifestations of primary and secondary adrenal insufficiency are understudied in elderly patients. The article elucidates new data on the senile physiological hyperplasia of the zona fasiculata of the adrenal cortex: human aging is tightly linked to an increasing secretion of glucocorticoids. A clinical case of secondary adrenal insufficiency due to empty sella syndrome (ESS) and hydrocephalus in a senile patient is described. The patient’s medical history included two key elements aggravating the adrenal insufficiency: adrenalectomy and chemotherapy with platinum derivatives which could have impact on the adrenal glands. The specific symptoms experienced by the patient and the clinical course of the disease correlated with the residual secretion of adrenocorticotropic hormone (ACTH), cerebral disorders (ESS) and the compensatory secretion of corticotropin releasing factor. The clinical presentation of adrenal insufficiency was vague and atypical. In addition, it was found that the patient had hyposecretion of anabolic androgenic steroids. In turn, it caused a muscle hypotrophy and facilitated the recurrence of pelvic organ prolapse after the earlier performed pelvic floor reconstructive surgery. In such clinical cases the treatment should be aimed at improving the state of the hypothalamic-pituitary system and increasing the production of endogenous corticotropin releasing factor, ACTH, and cortisol. Androgen replacement therapy in androgen-deficient elderly patients has not been developed. KEYWORDS: secondary adrenal insufficiency, adrenocorticotropic hormone; empty sella syndrome, glucocorticoids. FOR CITATION: Tereshchenko I.V. Difficulties and diagnostic errors in old patients with secondary adrenal insufficiency. Russian Medical Inquiry. 2022;6(9):534–537 (in Russ.). DOI: 10.32364/2587-6821-2022-6-9-534-537.

Shared decision-making in urology and female pelvic floor medicine and reconstructive surgery.

Shared decision-making (SDM) is a hallmark of patient-centred care that uses informed consent to help guide patients with making complex health-care decisions. In SDM, patients and providers work together to determine the best course of action based on both the current available evidence and the patient's values and preferences. SDM not only provides a framework for the legal and ethical obligations providers need to fulfil for informed consent, but also leads to improved knowledge of treatment options and satisfaction of decision-making for patients. Tools such as decision aids have been developed to support SDM for complex decisions. Several decision aids are available for use in the field of urology and female pelvic medicine and reconstructive surgery, but these decision aids are also associated with barriers to SDM implementation including patient, provider and systematic challenges. However, solutions to such barriers to SDM include continued development of SDM tools to improve patient engagement, expand training of providers in SDM communication models and a process to encourage implementation of SDM.

Quality of Sexual Life after Native Tissue versus Polypropylene Mesh Augmented Pelvic Floor Reconstructive Surgery.

There are still controversies around reconstructive surgeries used in POP treatment. The aim of this study was to compare the QoSL after VNTR vs. TVM surgery due to POP via the use of PISQ-12 and FSFI questionnaires. The study included a group of 121 sexually active patients qualified for reconstructive surgery due to symptomatic POP, and 50 control. The average results of PISQ-12 before and after surgery were compared using the t-test. The significance of the mean differences in demographic groups was measured using the t-test for independent samples and one-way ANOVA. The results in the demographic groups were compared using the Mann–Whitney U test and the Kruskal–Wallis test. Fifty-eight women had VNTR, while 63 had TVM. Results of PISQ-12 revealed significant improvement in the sexual life after reconstructive surgery (27.24 vs. 32.43; p < 0.001, t = 8.48) both after VNTR and TVM. There were no significant differences in the assessment of the QoSL according to PISQ-12 and FSFI results between both analyzed groups of patients (PISQ-12: VNTR vs. TVM; t-test p = 0.19 and FSFI: VNTR vs. TVM; Mann–Whitney U test p = 0.54). VNTR is the treatment of choice in the case of uncomplicated primary POP.

Robotic Assisted Pudendal Neurolysis for Severe Pudendal Neuralgia

<h3>Study Objective</h3> To demonstrate robotic assisted pudendal neurolysis surgery in a patient with severe pudendal neuralgia. <h3>Design</h3> Patient followed until 6-month postoperative visit. <h3>Setting</h3> Video collected while patient in dorsal lithotomy position with steep Trendelenburg under general anesthesia in the operating room. <h3>Patients or Participants</h3> 60-year-old female with long history of chronic pelvic pain and pudendal neuralgia after multiple pelvic floor reconstructive surgeries at an outside facility. <h3>Interventions</h3> Robotic assisted pudendal neurolysis in a patient desiring additional treatment for her pudendal neuralgia after multiple other therapies. <h3>Measurements and Main Results</h3> Improvement in pain assessed via patient reported pain at both pre- and postoperative visits. Patient reported improved pain at both her 4-week and 6-month postoperative visits. <h3>Conclusion</h3> This video demonstrates robotic assisted pudendal neurolysis surgery in a patient desiring further treatment for her severe pudendal neuralgia. The patient reported improved pain at her postoperative visits. Robotic assisted pudendal neurolysis is a viable option for patients suffering from severe and refractory pudendal neuralgia.