Pelvic Surgery Research Articles

Knowledge and concern towards endometriosis among Lebanese women: a cross-sectional study.

Endometriosis is a prevalent disease among women worldwide, including the Middle East. Insufficient knowledge about the disease causes delayed diagnosis which could result in major complications, particularly infertility. Thus, being aware of the symptom's aids in prompt diagnosis and treatment. Furthermore, no research has been done in Lebanon to assess the Lebanese women's knowledge about endometriosis. To determine the understanding and concerns of Lebanese women about endometriosis which aids in identifying knowledge gaps and misconceptions so that they can be addressed. A cross-sectional study was conducted between February and March 2024 among Lebanese females, who completed the authors' online questionnaire assessing knowledge and concern about endometriosis and its associated symptoms, Multivariable logistic regression analysis was used to explore the relationship between score of knowledge and different characteristics of patients. A survey of 725 Lebanese women (mean age 32.5 years, SD = 9.5) revealed low knowledge (25.9%) about endometriosis origin, symptoms, and treatment. Over 60% were unaware of endometriosis symptoms, while 9.9% mistakenly believed menstrual cramps indicated the disease. Younger age (< 35 years), higher education (Master's degree or above), professional occupation, lower pregnancy and live birth rates, and no history of abortion, endometriosis, pelvic inflammatory disease, uterine or ovarian conditions, and pelvic surgeries were significantly associated with greater knowledge of endometriosis. Lebanese women's knowledge of endometriosis is limited. This highlights how crucial medical education and awareness initiatives are in addressing the issue in Lebanon. Greater awareness of endometriosis will encourage Lebanese women to seek medical advice and consultation, resulting in earlier detection and treatment.

Inclusion of Muscle Forces Affects Finite Element Prediction of Compression Screw Pullout but Not Fatigue Failure in a Custom Pelvic Implant

Custom implants used for pelvic reconstruction in pelvic sarcoma surgery face a high complication rate due to mechanical failures of fixation screws. Consequently, patient-specific finite element (FE) models have been employed to analyze custom pelvic implant durability. However, muscle forces have often been omitted from FE studies of the post-operative pelvis with a custom implant, despite the lack of evidence that this omission has minimal impact on predicted bone, implant, and fixation screw stress distributions. This study investigated the influence of muscle forces on FE predictions of fixation screw pullout and fatigue failure in a custom pelvic implant. Specifically, FE analyses were conducted using a patient-specific FE model loaded with seven sets of personalized muscle and hip joint contact force loading conditions estimated using a personalized neuromusculoskeletal (NMS) model. Predictions of fixation screw pullout and fatigue failure—quantified by simulated screw axial forces and von Mises stresses, respectively—were compared between analyses with and without personalized muscle forces. The study found that muscle forces had a considerable influence on predicted screw pullout but not fatigue failure. However, it remains unclear whether including or excluding muscle forces would yield more conservative predictions of screw failures. Furthermore, while the effect of muscle forces on predicted screw failures was location-dependent for cortical screws, no clear location dependency was observed for cancellous screws. These findings support the combined use of patient-specific FE and NMS models, including loading from muscle forces, when predicting screw pullout but not fatigue failure in custom pelvic implants.

Development and Validation of a Simulation Model for Ureteral Stent Placement.

Currently, there are no validated training models for cystoscopy with ureteral stent placement. The objectives of this study were to develop and validate a novel endoscopic simulation model for training in ureteral stent placement. A low-cost, low-fidelity training model was developed to simulate ureteral stent placement. Recruited participants were divided into 3 groups: novices (postgraduate year 3/4 gynecology residents), advanced learners (urogynecology and reconstructive pelvic surgery fellows), and experts (urology residents, urogynecology faculty, and urology faculty). Construct validity was measured using de-identified video-recorded performances on the model, which were evaluated by 2 expert reviewers using validated scales (Global Operative Assessment of Laparoscopic Skills [GOALS], Global Rating Scale [GRS]) and procedure-specific metrics. The model was created using a hollow Styrofoam sphere, plastic tubing from a retropubic sling, and a silicone pacifier. Thirty-six surgeons were assessed performing the procedure using the model with cystoscopic equipment. The experts (n = 12) performed significantly better than the advanced learners (n = 17) and novices (n = 7) in total scores (max 75, median [IQR]: 75 [75-75], 61 [56.5-68.5], 45 [43-46], respectively; P < 0.001) and within each individual scale domain. Increasing experience with ureteral stent placement had a significant correlation (P < 0.001) with better performance on the model. A minimum total passing score of 63 was established. On post simulation assessment, most participants "agreed" or "strongly agreed" that the model closely approximates the feel of ureteral stent placement. This ureteral stenting simulation model is easy to construct, affordable, and reproducible. The model is valid and reliable for practicing the procedure in preparation for live surgery.

Intraoperative ICG-fluorescence imaging of ureteral defect: case report and literature review

Iatrogenic ureteral injury is the most frequent trauma during pelvic surgery. Due to the peculiarities of this topographic region, assessment of ureteral wall perfusion is critical for prevention of ischemic complications.In modern surgical practice, assessing local ureteral perfusion is often based on the surgeon’s subjective opinion. Intraoperative angiography with indocyanine green (indocyanine green, ICG) has been shown to be an adequate reflection of tissue perfusion and potentially influence the outcome of surgery.Currently, there are insufficient data regarding the use of ICG in iatrogenic ureteral injury. In this article, we describe a successful ICG fluorescence-guided middle third ureteroplasty in a 92-year-old patient with uterine cancer who underwent a simple hysterectomy. We also review the literature on this topic. The literature search for the review was performed using the PubMed database.Based on currently available data, the use of ICG for defect detection and control during ureteral resection is feasible and safe. However, the significance of this procedure should be evaluated in further studies.

Surgical Recovery Among Patients With Chronic Pain Undergoing Pelvic Reconstructive Surgery.

Limited data exist on postoperative recovery among patients with chronic pain undergoing pelvic reconstructive surgical procedures. The objective of this study was to evaluate if patients with versus without self-reported chronic pain experience different recovery after pelvic reconstructive surgery. From September 2022 to May 2023, this prospective cohort study enrolled patients with and without chronic pain, who were undergoing vaginal or laparoscopic procedures for pelvic organ prolapse. Preoperative pain was assessed using the Brief Pain Inventory (BPI) and Pepper Assessment Tool for Disability (PAT-D). Postoperative recovery was evaluated at 2, 4, and 12 weeks using the Postdischarge Surgical Recovery (PSR) scale, Global Surgical Recovery (GSR) index, and PAT-D questionnaire. The primary outcome was PSR scores at 4 weeks postoperatively. Ninety patients were recruited, with 43 reporting chronic pain and 47 without. Demographics were similar. Patients with chronic pain had higher preoperative BPI and PAT-D scores. Perioperative outcomes and hospital stay were similar. Patients with chronic pain used more postoperative opioids in the hospital (27.0 ± 27.8 vs 24.3 ± 60.3 morphine milligram equivalents [MME]; P = 0.03) and at home (40.1 ± 54.7 vs 19.9 ± 39.0 MME; P = 0.03). The PSR scores at 4 weeks were not significantly different. No differences were observed in PSR or GSR scores at all time points. Patients with chronic pain had a higher PAT-D score at 12 weeks. Fewer chronic pain patients returned to work by 12 weeks and desired more time off work. Patients with and without chronic pain had similar surgical outcomes and recovery. However, chronic pain patients required more postoperative opioid pain medication and preferred more time off work.

Adverse Events after Pelvic Organ Prolapse Surgery in Older Women with Atrial Fibrillation

Adverse Events after Pelvic Organ Prolapse Surgery in Older Women with Atrial Fibrillation

STRIVE pilot trial: a protocol for a multicentre pragmatic internal pilot randomised controlled trial of Structured TRaining to Improve fitness in a Virtual Environment (STRIVE) before surgery

IntroductionHome-based, virtually-supported care models may represent the most efficient and scalable approach to delivering prehabilitation services. However, virtual approaches to prehabilitation are understudied. This manuscript describes the protocol for an...

Health related outcomes of patients with serious traumatic injury: Results of a longitudinal follow-up program delivered by trauma clinicians

IntroductionThe routine collection of long-term patient health outcomes after serious traumatic injury at the health service level is uncommon. In 2019, we implemented the longitudinal Trauma Service Follow Up (TSFU) program at a level I trauma centre. Delivered by the trauma service clinicians involved in inpatient care, it assesses quality of life and disability. This study reports the 6- and 12-month outcomes of the first two years of operation of the TSFU program. MethodsThis is a prospective cohort study of seriously injured adult trauma patients admitted to a level I trauma centre with 6- and 12-months post-discharge outcome assessments. Outcomes were quality of life and function/disability as measured using the EQ-5D-5L and WHODAS 2.0 validated instruments. Changes from 6 to 12 months were assessed using generalised estimating equations methods. Logistic regression models were used to identify factors associated with ongoing problems at each time point. ResultsFive-hundred and eight seriously injured patients were eligible for the TSFU program with follow-up rates over 80 % at both 6- and 12-month timepoints. At six months, ongoing problems with pain (69.9 %), anxiety and depression (49 %) and carrying out usual activities (57.5 %) were highly prevalent; at 12 months problems with pain (61.4 %) and anxiety and depression (43.8 %) persisted. Lower extremity and/or pelvic surgery was associated with ongoing pain, odds ratio (OR) = 3.77 (95 % CI 1.54–9.21, p=0.01), anxiety and depression (OR 1.95, 95 % CI 1.09–3.48, p=0.02) and problems carrying out their usual activities (OR 3.19, 95 % CI 0.75–13.5, p=0.11) at six months. These patterns mostly persisted at 12 months. Similar associations between surgical intervention and high levels of disability were evident at both time points. ConclusionPersistent impairments in physical and emotional health continues to affect many people following serious traumatic injury. The collection of longitudinal health outcomes by trauma clinicians enables identification of factors that contribute to disability and a reduction in quality of life. This in turn can drive quality improvement initiatives within the hospital trauma system. Longitudinal follow-up programs may provide a platform to provide ongoing specialist trauma-informed care after hospital discharge.

Voiding Dysfunction inTransgender Patients: What We Know and What We Do Not Know.

Transgender and non-binary patients (TGNB) undergoing gender affirming genital surgery may experience perioperative voiding dysfunction. This review aims to outline and analyze literature about gender affirming pelvic surgery urinary complications, evaluation, and treatment. If a patient is seeking bottom surgery, then urinary goals and pre-operative symptoms should be discussed with respect to variable post-operative outcomes. Urologists should also be aware of the effect that gender affirming hormone therapy has on urinary symptoms. Urethral strictures and urethrocutaneous fistulae occur after feminizing and masculinizing procedures and may manifest as LUTS. Although there is no standardized approach for managing post-operative voiding issues, we present available options. The evaluation of TGNB patients is ideally affirming and tailored to the patient. Long-term urinary and voiding outcomes measurements after vaginoplasty and phalloplasty are also needed, as current validated questionnaires do not capture these symptoms well in TGNB patients.

Pericapsular Nerve Group (PENG) Block in Pediatric Patients Undergoing Hip and Pelvic Surgical Procedures: An Educational Focused Review.

Hip disorders in infants and children may result from congenital, infectious, developmental, inflammatory, neoplastic, and traumatic etiologies. Postoperative pain management associated with hip pathologies can be challenging especially due to complex innervation of the hip and surrounding structures. Given the adverse effect profile of systemic opioids, regional anesthesia offers an excellent alternative with more beneficial adverse effect profile. Various peripheral regional anesthetic techniques have been reported with variable results regarding analgesia and differing adverse effect profiles. The pericapsular nerve group (PENG) block is a novel motor-sparing regional anesthetic technique where the local anesthetic agent is deposited in the musculofascial plane between the psoas tendon and the pubic ramus. The main target is the genicular branches of the femoral, obturator, and accessory obturator nerve, which innervate the hip capsule. The anatomy involved with PENG block is reviewed and previous reports of PENG block in pediatric-aged patients, including single shot or continuous catheter techniques, are reviewed.

Occupational Radiation Exposure During Intraoperative 3-Dimensional Fluoroscopy in Pelvis and Acetabular Surgery.

To quantify the occupational radiation exposure with a 3-dimensional (3D) fluoroscopic machine during routine use in pelvic and acetabular surgery and to determine whether the additional radiation exposure encountered with the 3D fluoroscopic spin is within previously accepted limits. Prospective cohort study. Level I trauma center. All patients undergoing 3D fluoroscopy intraoperatively during pelvis (OTA/AO 61B,C) or acetabular (OTA/AO 62A-C) surgery between April 2021 and July 2021. Radiation dose at standardized locations around the operating room during the spin portion of the 3D fluoroscopy. Seventy-six 3D spins were performed on 69 patients during the study period. The average emitted radiation dose from the machine for the routine fluoroscopy portion of the case was 74.5 mGy. The average displayed radiation dose in the air for the spin portion of the case was 39.9 mGy, an average of 53.6% less radiation than the routine fluoroscopy portion. For the spin portion, the average radiation exposure seen by the patient was 3.42 mGy (centered on the patient) and the average maximal exposure in the room was 0.062 mGy. Minimal radiation was detected outside the operating room doors. The radiation exposure encountered by operating room personnel with 3D fluoroscopy appears to be within safe occupational limits. The marginal increase in radiation exposure during pelvic and acetabular surgery should not discourage the use of 3D imaging intraoperatively. Level IV, Case Series.

Literature review, surgical decision making algorithm, and AGREE II-S comparison of national and international recommendations and guidelines in pelvic organ prolapse surgery.

The average lifespan has increased over time due to improvements in quality of life, leading to an aging population that stays healthy for longer. Pelvic organ prolapse (POP), whether uterine or vaginal, is a problem that severely impairs quality of life and imposes significant restrictions. The present study provides the reader with a summary of the many surgical techniques used in POP surgery, comparing international guidelines, offering an algorithm that is simple to understand, and allows the reader to quickly choose the table that includes the best surgical therapy for each individual. Using relevant keywords, the writers searched the PubMed and Scopus databases for relevant publications from 2000 to April 2023. Studies with cases of oncologic disorders or prior hysterectomy performed for another reason were not included in the analysis. Ten distinct international guidelines are highlighted and examined in the present study. We used the Appraisal of Guidelines for Research and Evaluation II-S (AGREE II-S) method to assess their quality, and incorporated the results into the conclusion. Worldwide, anterior colporrhaphy is the preferred method of treating anterior compartment abnormalities, and mesh is virtually always used when recurrence occurs (which happens in about half of the cases). Worldwide, posterior colporrhaphy is commonly used to repair posterior compartment abnormalities. Only a few national guidelines (the Iranian guideline, Acta Obstetricia et Gynecologica Scandinavica [AOGS], and the German-speaking countries) permit the use of mesh or xenograft in cases of recurrence. There is agreement on the abdominal approach (sacrocolpopexy) with mesh for treating apical deformities. Sacrospinous-hysteropexy is the standard method used to guide the vaginal approach; mesh is typically used to aid in this process. There are just three recommendations that do not include vaginal operations: HSE, AOGS, and Iran. Of obliteration techniques, colpocleisis is unquestionably the best. In conclusion, our analysis highlights the significance of customized methods in POP surgery, taking into account the requirements and preferences of each patient. To choose the best surgical therapy, criteria and patient features must be carefully considered.

Mesh-associated pain syndrome: predictors for continence and prolapse mesh removal surgery in a single centre

ObjectiveOver the last two decades one of the main surgical treatment for stress urinary incontinence (SUI) and pelvic organ prolapse (POP) surgery was the insertion of non-absorbable mesh to restore continence and prolapse respectively. Over time complications arose including mesh-associated pain syndrome (MAPS), mesh exposure, mesh, erosion, chronic bladder/vaginal infections, and dyspareunia. Consequently, women chose surgical mesh removal to counter these problems. However, little is known about the demographics, medical co-morbidities, mesh types involved and the timing from mesh insertion to mesh removal. This retrospective study will look at which of these factors may be closely associated with mesh removal surgery.DesignRetrospective evaluation.SettingFemale Pelvic Medicine and Reconstructive Surgery (FPMRS) Clinic at University College London Hospitals NHS Foundation Trust.PopulationAll patients presenting to the FPMRS Clinic between June 2011 to December 2019, requesting mesh removal surgery with a history of MAPS and other mesh complications were included in this study.MethodsPatient demographics including age, ethnicity, obstetric history, and medical co-morbidities; type of mesh/anatomical route used; onset of symptoms; and time from insertion to removal were recorded.Main Outcome MeasuresDetermination of correlation coefficients between patient demographics, patient reported symptoms and mesh removal surgery.ResultsThree hundred and forty-five women with a history of MAPS were included in the study. Women in the 40–60 year old cohort accounted for 54.4% of mesh removal surgery; 54.8% had a BMI under 30 and almost 90% were Caucasian. 96.5% had had children, with over 77% having had a vaginal delivery. 91.9% of patients reported other health conditions including 18.8% with a concomitant history of mental health problems and 15.4% with a history of heart disease. Over 80% of women undergoing mesh removal surgery had a continence mesh (49% retropubic and 32% obturator continence mesh) removed, whereas 20% had an abdominal prolapse and/or vaginal prolapse mesh removed. The average time from mesh insertion to mesh removal was seven years, with the prevalence of mesh removal surgery averaging 85% (range 50–100%) depending on the comorbidity determined.ConclusionsAll women presented to the clinic with a history of MAPS and other comorbidities which may have influenced their decision to pursue mesh removal surgery. There were no specific predictors, other than chronic pain associated with mesh, determining which women underwent surgery, though those with continence mesh were more likely to do so.

11663 Prophylactic Ureteral Stents in Complex Pelvic Surgery and Rates of Acute Kidney Injury

11663 Prophylactic Ureteral Stents in Complex Pelvic Surgery and Rates of Acute Kidney Injury

Intra-Ureteral Indocyanine Green (ICG) Dye Use During Complex Pelvic Surgery: A Surgical Tutorial and Guide

Intra-Ureteral Indocyanine Green (ICG) Dye Use During Complex Pelvic Surgery: A Surgical Tutorial and Guide

Giant benign mesenteric cysts (mesothelioma and lymphangioma): A report of two cases

Introduction and importanceMesenteric cysts are a rare group of intra-abdominal tumors located in the mesentery or omentum, most of this lesion are asymptomatically but occasionally presents with non-specific symptoms, which makes diagnosis difficult. Case presentationWe present two cases of giant mesenteric cyst in our Institution, the first case is a women of 23 years with previous gynecologic surgery with chronic abdominal pain and large abdominal mass CT showed a giant intraabdominal 30 × 25 × 15 cm, the patient went to laparotomy and a large mesenteric tumor found. The Histopathology reported a Benign cyst mesothelioma (BCM). The second case is a 47 year male with intermittent abdominal pain and abdominal CT shows a 20x21x15 cm tumor. Laparotomy was performed. Histopathology reported a large lymphangioma. Clinical discussionBCM tumors are rare intrabdominal lesions often diagnosed in premenopausal women. Its etiopathogenesis is still unclear, associated risk factors are endometriosis, pelvic inflammatory disease and previous pelvic surgery. Lymphangiomas are an infrequent cyst tumors. It results from a failure in the evolutionary development of the lymphatic system, often localized in the head and neck and its localization in the abdomen is even rare. The definitive diagnosis is made by histopathology. ConclusionMesenteric cysts diagnosis if often challenge due to nonspecific symptoms and significant overlap in imaging appearance between the different entities, its diagnosis should be in mind when encounter a cystic abdominal tumor, surgical complete removal of this tumors is the optimal treatment to prevent recurrence and complications.

Continuous infusion of piperacillin/tazobactam optimizes intraoperative antibiotic exposure in patients undergoing elective pelvic exenteration surgery.

Patients undergoing elective pelvic exenteration surgery who receive piperacillin/tazobactam as surgical prophylaxis are at risk of suboptimal intraoperative antibiotic exposure. With this work, we aimed to study the plasma pharmacokinetics of piperacillin and tazobactam in this population to provide dosing recommendations that optimize antibiotic exposure. We developed a prospective, observational, pharmacokinetic study of piperacillin/tazobactam in patients undergoing pelvic exenteration. Population pharmacokinetic analysis and Monte Carlo simulations were performed with Monolix and Simulx software. Probabilities of target attainment of different dosing regimens against the minimum inhibitory concentration (MIC) breakpoints (8 and 16 mg/L) were calculated. Twelve patients were included in the study, with a median age of 50.0 years [interquartile interval (45.3-57.5)] and a median weight of 79.0 kg (61.3-88.3). Median surgical time was 10.5 h (9.8-11.7). A two-compartment linear model best fitted piperacillin and tazobactam data (190 plasma samples). Monte Carlo simulations showed that a lower dose of 2 g/0.25 g loading dose followed by 4 g/0.5 g q8h by continuous infusion provided ≥90% probability of target attainment for MIC = 16 mg/L for most of the patients. For non-continuous infusion regimens, only the 2-hourly bolus re-dosing achieved intraoperative concentrations of piperacillin ≥16 mg/L. Patients with weights ≥ 100 kg and glomerular filtration rates ≥ 120 mL/min required 4 g/0.5 g q6h by continuous infusion after a loading dose. In conclusion, continuous infusion of lower doses of piperacillin/tazobactam is as adequate as the 2-hourly re-dosing recommended by the current guidelines for surgical prophylaxis in pelvic exenteration. Patients with higher weights and glomerular filtration rates are at greater risk of inadequate exposure.

Patient Perception of Prolapse Condition Questionnaire: A Validated Patient-Reported Outcome Measure.

Identifying patient-reported outcome measures allows management of urogenital prolapse to be tailored to reflect symptom bother and expectations of treatment. We devised a new single-item questionnaire, the Patient Perception of Prolapse Condition (PPPC), based on the Patient Perception of Bladder Condition (PPBC). The aim was to evaluate the criterion validity, test/re-test reliability and responsiveness of the PPPC. Women attending a tertiary urogynaecology clinic were recruited. At visit 1, patients completed the Prolapse Quality of Life (P-QOL) and PPPC questionnaires, and underwent a Pelvic Organ Prolapse Quantification (POP-Q) examination. This allowed assessment of criterion validity using Spearman's rank correlation (rho) of the PPPC against validated subjective and objective outcomes. At visit 2, within the next 6weeks, PPPC was repeated to assess test/re-test reliability using Cronbach's alpha (α). In those undergoing pelvic floor surgery, responsiveness of the PPPC was assessed at visit 3 by correlating PPPC and P-QOL scores 6weeks post-operatively. A total of 178 patients attended visit 1, 60 attended visit 2 and 58 attended visit 3. At visit 1, there were moderate correlations between the PPPC and both objective (POP-Q: rho = 0.385, p < 0.01, CI 0.192-0.549) and subjective (P-QOL: rho = 0.635, p < 0.01, CI 0.493-0.744) measures confirming criterion validity. Test/re-test reliability was high (α = 0.89). Correlation with post-operative PPPC and P-QOL confirmed moderate responsiveness (rho = 0.54, p < 0.01). The PPPC, a novel single-item patient-reported measure of prolapse condition, demonstrated good criterion validity, test/re-test reliability and responsiveness. These findings support the use of the PPPC as a global assessment of prolapse condition.

Staged operations of acquired lymphangiectasia of the vulva: 10 cases clinical analysis

Objective: To investigate the characteristics, diagnosis and therapeutic effect of acquired lymphangiectasia of the vulva (ALV). Methods: A retrospective analysis of clinicopathological and follow-up data was conducted on the patients treated in Capital Medical University Affiliated Beijing Shijitan Hospital due to female ALV from July 2009 to July 2023. The patients who completed the staged operations [partial labiectomy and reconstruction + thoracic ductplasty and (or) perineal lymphovenous anastomosis] were included in the study and followed up. The improvement of perineal swelling, blister range, fluid leakage volume and frequency were evaluated through outpatient visits by the symptom rating scale of ALV (hereinafter referred to as the symptom rating scale) before and after surgery. Results: A total of 48 patients were treated due to ALV from July 2009 to July 2023, of which 98% (47/48) were postoperative pelvic malignant tumors and 94% (45/48) had a history of radiotherapy. A total of 10 patients with ALV who completed the staged operations were included in this study. (1) Clinical characteristics and diagnosis: 10 patients had a median age of 60 years old (50, 63 years old ). The median duration from cervical cancer surgery and radiation therapy to vulvar swelling was 1.5 years (0.0, 2.0 years), and the median duration from vulvar swelling to blister formation and leakage was 0.0 years (0.0, 4.8 years). Seven patients (7/10) had a history of recurrent erysipelas; 7 patients (7/10) had the most severe symptom (widespread blisters, persistent fluid leakage, and large amount of fluid leakage); noncontrast magnetic resonance lymphography (NCMRL) showed edema signals in the perineal region of all the patients, and increase of agent in the perineal region was observed in lymphoscintigram (LS). (2) Surgical treatment and postoperative pathological examination: of the 10 ALV patients who completed staged surgical treatment, 6 cases (6/10) were diagnosed with thoracic duct outlet obstruction and underwent thoracic ductplasty and partial labiectomy and reconstruction. Perineal lymphovenous anastomosis and partial labiectomy and reconstruction were performed in 4 cases (4/10) without thoracic duct outlet obstruction. Postoperative routine pathological examination of 10 patients (10/10) showed dermal papilla lymphangiectasia. Immunohistochemical tests were performed on 5 patients, all of which were positive for D2-40 and negative for CD34. (3) Efficacy: 8 patients completed the postoperative follow-up, and the median follow-up time was 31.0 months (17.5, 78.3 months). The perineal swelling and the blister fluid leakage were all significantly improved after the staged operations. All indexes of the symptom rating scale, including the degree of perineal swelling, blister range, fluid leakage volume and frequency, were significantly improved in 8 follow-up patients, and 3 (3/8) of them were cured; the median symptom score decreased significantly from 11.0 before surgery to 3.0 after surgery (P<0.001). The incidence of erysipelas was significantly reduced from 7/10 before surgery to 2/8 after surgery (P=0.035). Conclusions: The main causes of female ALV are pelvic tumor surgery and radiotherapy. The clinical diagnosis is made from relevant medical history, clinical manifestations, LS and magnetic resonance imaging. The diagnosis is confirmed by histopathological findings. Pathological results show lymphangiectasia in the dermal papilla, and immunohistochemical staining show positive for D2-40 and negative for CD34. The effect of staged surgery on ALV is remarkable and even cured, and could effectively reduce the incidence of erysipelas.

Physiotherapists working with pessaries

Pessaries and the physiotherapy profession have evolved over the past 10 years, and pelvic health physiotherapists can now prescribe vaginal pessaries. Pelvic, Obstetric and Gynaecological Physiotherapy (POGP) is developing ways to support members with these skills. Globally, up to 50% of women will suffer from pelvic organ prolapse (POP) (Carroll et al. 2022), and this condition costs the UK National Health Service £45 million every year (PCWHF 2019). The most common symptom is a vaginal bulge. The National Institute for Health and Care Excellence guidelines recommend either doing nothing, or pelvic floor muscle exercises (PFMEs), vaginal pessaries or surgery (NICE 2019). Pessary services are provided in dedicated clinics, usually in general practice or secondary care. There has been an increase in physiotherapists delivering pessary care over the past decade: in 2013, it was reported that 1.4% were part of the pessary workforce compared to 5% in 2020 (Bugge et al. 2013; Brown et al. 2021). Currently, ineffective patient pathways, poor service provision and lack of training are barriers to treatment. Poorly designed patient pathways are frustrating, and women are often required to return to primary or secondary care to get a referral to a pessary clinic. Physiotherapists are well placed to offer a pessary alongside PFMEs since it is part of the range of conservative treatment options. They also build strong a rapport with their patients because of the therapeutic nature of the treatment sessions, and typically, offer longer appointments than postnatal period. A prospective multicentre trial demonstrated the acceptability of and compliance with using a pessary immediately after childbirth irrespective of any pelvic floor dysfunction or mode of delivery (Baessler et al. 2019). The majority of women used the pessary to treat the symptoms of POP. Further work is required to investigate pessary use and the prevention of pelvic floor dysfunction in this cohort of women. The results of the TOPSY [Treatment Of Prolapse with Self-care pessarY] trial (Hagen et al. 2023) highlighted that pessary self-management is cost-effective and reduces complications. This is excellent news because physiotherapists are well placed to teach women pessary self-management because of: generally longer appointments; and the well-established rapport built up over time while teaching PFMEs. Despite women reporting that pessary use during exercise relieves their symptoms, this is an under-researched area. The impact of exercise on POP, and whether there are any protective factors involved that prevent its progression, are not fully understood. There also remains a gap in the evidence with regard to the use of PFMEs and vaginal pessaries. Research proposals are currently in development to address this. A pessary course is being developed by POGP, and this will be launched in 2024 alongside a mentoring programme as part of the pessary accreditation scheme jointly written with the United Kingdom Continence Society. Further governance documents have been created by the Physiotherapists Working with Pessaries subgroup of POGP, including a standard operating procedure, emergency out-of-hours statement, note proformas and template letters (POGP 2024).