Perineal Technique Research Articles

Facilitators and Barriers to Implementation of Perineal Techniques: A Scoping Review Applying the Consolidated Framework for Implementation Research.

To summarise the barriers and facilitators to the clinical implementation of perineal techniques and to provide evidence-based insights for decision-making based on existing research. A scoping review. Nine electronic databases (PubMed, Cochrane Library, Embase, CINAHL, ProQuest, CNKI, WanFang, VIP and SinoMed) were systematically searched on 4 February 2024. This study followed Joanna Briggs Institute's scoping review methodology. The barriers and facilitators identified in the included studies were mapped to the domains of the Consolidated Framework for Implementation Research (CFIR): intervention characteristics, outer setting, inner setting, characteristics of individuals and process. A total of 18 studies were finally included and analysed. The most frequently identified facilitator was theoretical education for midwives (inner setting). Common barriers included: lack of time to implement perineal techniques (intervention characteristics); labour pain and women's stress due to insufficient understanding of the birthing process, as well as women's reluctance to receive the perineal techniques (outer setting); risk factors for OASIS (inner setting); insufficient theoretical education for midwives and inadequate prenatal education for pregnant women (inner setting) and concerns about potential medical disputes among performers (characteristics of individuals). Many of the factors influencing the implementation of perineal techniques identified in this review are modifiable. Developing implementation strategies based on these factors can promote the successful implementation of these perineal techniques in clinical settings. This scoping review could serve as a reference framework for health authorities in developing strategies to promote the use of perineal techniques in clinical practice. Existing research has primarily focused on the outer setting, inner setting and characteristics of individuals implementing perineal techniques. Therefore, there is a need for more high-quality studies focusing on intervention characteristics and the implementation process. This study followed the PRISMA extension for scoping reviews. Not applicable.

Perineal techniques during the second stage of labour for reducing perineal trauma and postpartum complications.

Perineal techniques during the second stage of labour for reducing perineal trauma and postpartum complications.

El uso de la cirugía robótica para el tratamiento de estenosis uretrales y contracturas del cuello vesical: una revisión sistemática

The use of robotic surgery for the management of urethral strictures and bladder neck contractures: a systematic reviewObjective: The aim of this systematic review is to offer a comprehensive view of the current use of robotic surgery for the treatment of urethral strictures and bladder neck contractures.Methods: A systematic review of the current literature was conducted through the Medline and NCBI PubMed, Embase databases in December 2023. Keywords used were “robotic” and “robotic-assisted” combined with “urethroplasty”, “urethral stricture”, and “bladder neck contracture”. All papers published after 2000, concerning studies conducted on humans for urethral strictures and bladder neck contractures managed with robotic surgery were considered for the review. Only procedures involving a direct approach to urethra/bladder neck and/or graft harvesting for urethroplasty have been included.Results: A total of 275 articles were evaluated after the strategy search and only 11 articles were considered eligible for the final analysis. The studies included a series of between a minimum of 1 and a maximum of 104 patients, for a total of 203 patients. The robotic surgery was performed mainly for the treatment of bladder neck contracture and posterior urethra. In some reports, the robotic system was used for graft harvesting, subsequently used with an open perineal technique. The follow-up presented in the different studies is very heterogeneous. However, most studies have high success rates, with recurrence and redo surgery rates generally below 20%. Likewise, post-procedure incontinence rates are low.Conclusions: The outcomes presented in the literature, combined with the minimally invasive nature, suggest a possible growing role for robotic surgery in the coming years in the treatment of these diseases.

Rectal Prolapse Surgery: Balancing Effectiveness and Safety in Abdominal and Perineal Approaches.

The event in which the entire thickness of the rectumprotrudes through the anal canal is called rectal prolapse. This ailment is common in the elderly population and especially in females. It causes some disastrous symptoms, including incontinence to feces and flatus, constipation, and discomfort, because of the weakness in the anorectal junction, making it mandatory for surgical correction. Over time, several surgical techniques have been developed; these are broadly classified into two categories: abdominal and perineal techniques. However, the best approach for surgery that minimizes recurrence while maximizing patient quality of life is still up for debate. A comprehensive review was conducted adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines; a systematic search of the PubMed Database was performed to identify studies published between 2000 and 2024 with the keywords ((Rectal Prolapse) AND ("Perineal" OR "Laparotomy")). The inclusion criteria were focused on studies comparing the outcomes between surgical approaches at the abdominal and perineal locations, particularly on the recurrence rate, postoperative complications, and functional outcomes. In total, 21 studies were included in the review: these ranged from retrospective analysis and prospective studies to a multicentric randomized trial. In this review, abdominal approaches, particularly in the form of laparoscopic rectopexy, consistently demonstrated improved results compared to perineal techniques, with a much lower recurrence rate. The rates of mortality and morbidity were also remarkably lower in laparoscopic operations, which were advocated for suitable patients. However, perineal approaches, while still producing higher rates of recurrence, are a valuable alternative for elderly and high-risk patients due to their being relatively less invasive. Laparoscopic rectopexy can be considered a better surgical method for rectal prolapse, as it has a lower recurrence rate and better functional outcomes. In contrast, perineal approaches will have their place in the management of rectal prolapse, given patient selection for patients at high risk with regard to surgery. Future research should be directed toward multicenter trials with long-term outcomes in order further to fine-tune surgery strategy and criteria for patient selection.

Surgical and Functional Outcome of Laparoscopic Vaginal Suspension Combined with Suture Rectopexy for Management of Pelvic Organ Prolapse

Abstract Purpose Laparoscopic techniques to treat pelvic organ prolapse are gaining popularity around the globe due to their low recurrence rates and better functional results compared to perineal techniques. However, the optimum surgical procedures are not yet determined. In the current research, we suggest a novel surgical approach, laparoscopic vaginal suspension with suture rectopexy, to treat multiorgan pelvic prolapse. Methods This prospective cohort trial was conducted from March 2018 to March 2022 and comprised 35 females with multiorgan pelvic organ prolapse with obstructed defecation symptoms. A residual rectal prolapse was still present despite the manual reduction of uterine prolapse. Patients' conditions before and after the operation were monitored regarding the obstructed defecation score, sexual function, need for laxatives, anorectal manometry pressures, anorectal sensations, and recurrence. The mean follow-up duration was one year. Results Modified Longo score for obstructed defecation significantly decreased at six and twelve months after surgery. Additionally, a significant reduction was reported in the number of patients who needed laxatives at six and twelve months after surgery. Anorectal manometry pre- and post-surgery showed a significant elevation in the mean squeeze pressure and a decline in all rectal sensations. All parameters of the female sexual function scoring system increased postoperatively. No recurrence was reported during follow-up. Conclusion For multiorgan pelvic prolapse, laparoscopic vaginal suspension combined with suture rectopexy has excellent functional outcomes, minimal morbidity, and low cost.

Effects of different techniques during the second stage of labour on reducing perineal laceration: An overview of systematic reviews.

To summarize the evidence on the effects of different techniques during the second stage of labour on reducing perineal laceration depending on available systematic reviews to provide optimal evidence for decision-making. Preventing perineal laceration has been considered an important part of improving women's health. Various techniques have been used to prevent perineal laceration during the second stage of labour. However, systematic reviews evaluating the effects of different techniques on reducing perineal laceration show inconsistent results. Overview of systematic reviews. Five English and four Chinese databases were systematically searched for relevant systematic reviews and meta-analyses published between 1 January 2016 and 31 August 2021. The quality of the included reviews was assessed by the AMSTAR 2 tool. A narrative synthesis was conducted to report the results of moderate-to-high quality systematic reviews. The overview was reported according to the PRISMA statement. Eighteen reviews were included, of which four reviews had moderate-to-high methodological quality. Perineal massage and warm compresses significantly decreased the incidence of third- or fourth-degree perineal laceration (moderate-quality evidence). Hands-off technique had no impact on perineal laceration (low-to-moderate quality evidence). Ritgen's manoeuvre could reduce the incidence of first-degree perineal laceration but increase the incidence of second-degree perineal laceration (very low-quality evidence). Spontaneous pushing (low-quality evidence) and delayed pushing (moderate-quality evidence) had no impact on the incidence of third- or fourth-degree perineal laceration. Upright positions did not increase the risk of third- or fourth-degree perineal laceration (very low- to low-quality evidence) but increased the risk of second-degree perineal laceration for women without epidural analgesia (low-quality evidence). Perineal massage and warm compresses could be the better choice for preventing perineal laceration in the second stage of labour. Midwives and obstetricians could use perineal massage and warm compresses to prevent perineal laceration and should consider women's preferences and experience with perineal techniques.

EDITORIAL COMMENT

Reconstruction of the posterior urethra following prostate cancer therapies such as radical prostatectomy or radiotherapy has traditionally been discouraged due to difficulties achieving an anastomosis, significant morbidity, including hemorrhage, rectal injury, ureteral injury and low success rates. However, there has been a growing experience of successful reconstruction of the posterior urethra using open, perineal, and abdominal perineal techniques.1 More recently the Trauma and Urologic Reconstructive Network of Surgeons reported encouraging results with the use of the robotic platform for reconstruction for vesicourethral anastomotic stenosis (VUAS) and recalcitrant bladder neck stenosis (BNS).

Comparison of Perineal Closure Techniques after Extended Abdominoperineal Resections for Anal Cancer

Comparison of Perineal Closure Techniques after Extended Abdominoperineal Resections for Anal Cancer

Creation of Neovagina Using Complete Laparoscopic Dissection

Study Objective Exclusive laparoscopic dissection for creation of neovagina in MRKH Design Video with step-by-step description of technique Setting Department of Gynaecology at BLK Max Superspeciality Hospital, a tertiary care teaching hospital in Delhi, India Patients or Participants 27-year-old patient with MRKH syndrome, married for 6 months came for creation of neo-vagina Interventions Neovagina was created using complete laparoscopic dissection. Measurements and Main Results The surgery required lesser time than combined laparoscopic-perineal approach. The operation duration was 25 minutes. Blood loss was 20 ml. The vaginal lumen accommodated the vaginal mould well and patient could very comfortably change the vaginal mould herself from 4th day onwards. Conclusion For creation of neovagina, MacIndoe's method had been gold standard for many years. Combined laparoscopic and perineal technique with peritoneal pull through has become popular due to minimal morbidity. In this video, we show the technique of complete laparoscopic dissection right up to skin at vaginal dimple. As this dissection is completely under vision, it minimises the risk of damage to the bladder and rectum, which is not uncommon with perineal dissection. In addition, few medial fibers of levator ani can be divided under vision with this technique which avoids cicatrisation of vagina in future. Exclusive laparoscopic dissection for creation of neovagina in MRKH Video with step-by-step description of technique Department of Gynaecology at BLK Max Superspeciality Hospital, a tertiary care teaching hospital in Delhi, India 27-year-old patient with MRKH syndrome, married for 6 months came for creation of neo-vagina Neovagina was created using complete laparoscopic dissection. The surgery required lesser time than combined laparoscopic-perineal approach. The operation duration was 25 minutes. Blood loss was 20 ml. The vaginal lumen accommodated the vaginal mould well and patient could very comfortably change the vaginal mould herself from 4th day onwards. For creation of neovagina, MacIndoe's method had been gold standard for many years. Combined laparoscopic and perineal technique with peritoneal pull through has become popular due to minimal morbidity. In this video, we show the technique of complete laparoscopic dissection right up to skin at vaginal dimple. As this dissection is completely under vision, it minimises the risk of damage to the bladder and rectum, which is not uncommon with perineal dissection. In addition, few medial fibers of levator ani can be divided under vision with this technique which avoids cicatrisation of vagina in future.

Efficacy of transcutaneous perineal electrostimulation versus intracavitary anal electrostimulation in the treatment of urinary incontinence after a radical prostatectomy: randomized controlled trial study protocol

BackgroundRadical prostatectomy is the gold standard treatment for men with localized prostate cancer. This technique is associated with post-operative urinary incontinence. Pelvic floor physiotherapy is a conservative, painless and economical treatment for this specific situation. Kegel exercises and perineal electrostimulation are common techniques to train pelvic floor muscles. The perineal electrostimulation can be applied to the patient with surface electrodes or by an intra-cavitary anal probe. This study proposes that transcutaneous perineal electrostimulation is as effective as intra-cavitary electrostimulation in reducing urinary incontinence secondary to radical prostatectomy. The main objective is to compare the efficacy of the treatment with transcutaneous perineal electrostimulation versus the same intra-cavitary treatment to reduce the magnitude of urinary incontinence after radical prostatectomy, and the impact on the quality of life.MethodsThis single-blind equivalence randomized controlled trial will include 70 man who suffer urinary incontinence post radical prostatectomy. Participants will be randomized into surface electrodes group and intra-anal probe group. The groups will receive treatment for 10 consecutive weeks. Outcomes include changes in the 24-h Pad Test, and ICIQ-SF, SF-12 and I-QoL questionnaires. Clinical data will be collected at baseline, 6 and 10 weeks after the first session, and 6 months after the end of treatment.DiscussionThe results will allow us to prescribe the most beneficial perineal electrostimulation technique in the treatment of urinary incontinence derived from radical prostatectomy.Trial registrationClinicalTrials.gov Identifier: NCT03587402. 27/06/2018

EFFECT OF UTILIZING HANDS-ON VERSUS OFF METHOD DURING DELIVERY OF FETAL HEAD ON OCCURRENCE OF PERINEAL TEAR

Most vaginal births are associated with some forms of trauma to the genital tract.The morbidity associated with perineal tear is significant, especially when it comes tothird- and fourth-degree tears. Different perineal techniques and interventions are beingused to prevent perineal tear such as hands on and hands off techniques. Aim: This studywas carried out to evaluate the effect of utilizing hands on versus off method duringdelivery of fetal head on occurrence of perineal tear. Design: Randomized clinical trialstudy design was used. Setting: This study was carried out at Sherbeen General Hospital,Dakahlia Governorate Egypt on 130 parturient women in the 2nd stage of labor, who wereselected by purposive sample technique and divided into two equal sample size (65). Inhands-on method group, the researcher put one hand above fetal head to maintaindownward direction toward perineum and guarding the perineum by placing the otherhand against it. In hands-off method group in which the delivery occurs without touchingthe fetal head or perineum. Two tools were used to collect the necessary data namely sociodemographicand current obstetrical data, evaluation check list to clarify perinealcondition after delivery. Results: 72.3% of hands on parturient women group had perinealtear during labor compared with 80% of hands off group, there was statistically significantdifference between hands on and hands off groups regarding degree of perineal tear(p=0.033). This study concluded that hands-on technique had significant effect ondecreasing rate, lowering degree of perineal tears and need to repair than hands-offtechnique. This study recommended that relevant nursing curriculum must entail a detailedportion about the correct manner of performing hands-on technique to increase the chanceof perineal integrity during the second stage of labor.

A multicentre study on the effect of moderate perineal protection technique: a new technique for perineal management in labour

We conducted a large-sample study in six midwifery centres to estimate the effectiveness of Moderate Perineal Protection technique during spontaneous delivery. 31,249 women accepted the traditional technique were selected as control group, and 57,056 women accepted the Moderate Perineal Protection technique as the observation group. There was no significant difference in demographic characteristics between the two groups. The perineal episiotomy rate decreased (22.913% vs. 32.161%, p < .05), the perineal integrity significantly increased (43.505% vs. 36.384%, p < .05) and perineal trauma reduced in the observation group when compared to the control group (54.630% vs. 61.239% in first degree tears, and 1.826% vs. 2.340% in second degree tears, p < .05). The neonatal asphyxia rate in the observation group was lower than that in the control group (p < .05). The observation group also had a higher rate of total satisfaction, lower VAS score for perineal pain, shorter postpartum hospitalisation days, lower rate of postpartum urinary retention and postpartum incontinence (p < .05). We concluded that the Moderate Perineal Protection technique is safe, effective and worth promoting widely.Impact statementWhat is already known on this subject? In order to reduce the episiotomy rate and reduce perineal injury, some researches have been carried out and some perineal techniques have been evaluated, but there are still many aspects to improve.What the results of this study add? Moderate Perineal Protection technique can effectively reduce episiotomy rate, protect perineal integrity, improve neonatal outcomes and increase maternal satisfaction.What the implications are of these findings for clinical practice and/or further research? The Moderate Perineal Protection technique is an effective and safe technique worth clinical promoting widely. Further research could focus on the long-term effects of Moderate Perineal Protection technique, such as pelvic floor injury and long-term mother–child outcomes.

Impact of electronic and blended learning programs for manual perineal support on incidence of obstetric anal sphincter injuries: a prospective interventional study

BackgroundObstetric anal sphincter injuries (OASIS) are associated with anal incontinence, dyspareunia and perineal pain. Bimanual perineal support technique (bPST) prevents OASIS. The aim of this study was to assess the effect of two different bPST training-methods on OASIS incidence.MethodsThis is a prospective-interventional quality improvement study conducted in two Palestinian maternity units between June 1 2015 and December 31 2016. Women having spontaneous or operative vaginal-delivery at ≥24 gestational-weeks or a birthweight of ≥1000 g (n = 1694) were recruited and examined vaginally and rectally immediately after vaginal birth by a trained assessor. Data on baseline OASIS incidence were collected during Phase-1 of the study. Subsequently, birth attendants in both maternity units were trained in bPST using two training modalities. A self-directed electronic-learning (e-learning) using an animated video was launched in phase-2 followed by a blended learning method (the animated e-learning video+ structured face-to-face training) in phase-3. OASIS incidence was monitored during phases-2 and 3. Variations in OASIS incidence between the three phases were assessed using Pearson-χ2-test (or Fisher’s-Exact-test). The impact of each training-method on OASIS incidence was assessed using logistic-regression analysis.ResultsA total of 1694 women were included; 376 in phase-1, 626 in phase-2 and 692 in phase-3. Compared to Phase-1, OASIS incidence was reduced by 45% (12.2 to 6.7%, aOR: 0.56, CI; 0.35–0.91, p = 0.018) and 74% (12.2 to 3.2%, aOR, 0.29, CI; 0.17–0.50, p < 0.001) in phases-2 and 3, respectively. There was also a significant reduction in OASIS incidence by 52% from phase-2 to phase-3 (6.7% (42/626) to 3.2% (22/692), p = 0.003).These reductions reached statistical significance among parous-women only (aOR: 0.18, CI; 0.07–0.49, p = 0.001) after the first training method tested in phase-2. However, the reduction was significant among both primiparous (aOR: 0.39, CI; 0.21–0.74, p = 0.004) and parous-women (aOR: 0.11, CI; 0.04–0.32, p < 0.001) after implementing the blended learning method in phase-3.ConclusionThe animated e-learning video had a positive impact on reducing OASIS incidence. However, this reduction was enhanced by the use of a blended learning program combining both e- learning and face-to-face training modalities.Study registration numberClinicalTrialo.gov identifier: NCT02427854, date: 28 April 2015.

Transanal endorectal approach for the treatment of idiopathic rectal prolapse in children: Experience with the modified Delorme's procedure

BackgroundPersistent or recurrent idiopathic rectal prolapse in children requires surgical intervention. Several techniques have been used to repair this problem. However, recurrence and complications continue to be a challenge in the management of this condition. Here we report our experience in using the modified Delorme's procedure to treat such patients. MethodsWe conducted a retrospective observational study of patients with idiopathic rectal prolapse who underwent the modified Delorme's procedure during 2013–2017. We analyzed the clinical characteristics of the patients and the recurrence and complication rates during a follow-up of 15–68 months. ResultsWe included 14 patients. The age at operation ranged from 2 to 17 years, and the length of the prolapse was 3–15 cm. There were no intraoperative or postoperative complications. All patients achieved postoperative fecal control, and there were no recurrences. ConclusionThe modified Delorme's procedure was effective for the treatment of idiopathic rectal prolapse. There were no recurrences or complications. Because it is a perineal technique, the procedure avoids the risk of nerve injury that exists for transabdominal methods.

A novel application of the lotus petal flap in high-risk perineal urethrostomy: principles and outcomes

Introduction: Perineal urethrostomy is a valuable technique in the management of complex anterior urethral strictures, as well as following penectomy or urethrectomy. Traditional techniques that employ perineal or scrotal skin flaps have documented failure rates of up to 30 per cent. Current techniques for salvage have only modest success, leaving patients few options other than permanent suprapubic catheter or cystectomy and ileal conduit formation. Results: We present a new method of perineal urethrostomy using perforator-based lotus petal flaps in cases which were high risk or unsuitable for traditional perineal urethrostomy techniques, or where traditional strategies had failed. All patients demonstrated continent voiding at a minimum of 22 months follow-up, with patency confirmed by flexible cystoscopy. No complications were encountered.**Conclusion**: Utilisation of lotus petal flaps in high-risk cases of perineal urethrostomy will lead to significant improvements in patient outcomes. The availability of larger amounts of soft tissue coverage will obviate the need for compromise on either resection of involved urethra, or calibre and inset of urethrostomy. This will subsequently minimise the rates of failure, reduce the requirement for urinary diversion procedures and lead to improved quality of life.

Perineal techniques during the second stage of labour for reducing perineal trauma.

Perineal techniques during the second stage of labour for reducing perineal trauma.

EFFECTIVENESS OF HANDS OFF VERSUS HANDS ON TECHNIQUES ON PERINEAL TRAUMA AND PERINEAL PAIN AMONG PARTURIENT MOTHERS

Background: Labor is the process by which the fetus and the placenta leave the uterus. Delivery can occur in two ways, vaginally or by a cesarean delivery. The majority of women who have a vaginal birth will sustain perineal trauma from a spontaneous perineal tear or episiotomy or both.Aim: This study aims to assess the effectiveness of hands off versus hands on techniques on perineal trauma and perineal pain among parturient mothers in selected hospitals, Kerala.Methods: The research design adopted in this study was true experimental post test only design. The study was conducted in 3 hospitals at Kerala such as Karothukuzhiyil hospital Pvt, Lakshmi hospital Pvt and Carmal hospital Pvt. Sample size was computed by power analysis based on the previous studies and it would be a total of 90 samples, with 30 parturient mothers in each groups. Simple random sampling technique (Lottery method) was adopted for the selection of parturient mothers into the study. Perineal trauma was assessed by the scale given by Royal College of Obstetrics and Gynaecology (RCOG), 2001, and visual analogue scale (Combined numerical and categorical pain scale) was used to assess the perineal pain of parturient mothers.Results: The results showed that, there was extremely significant difference found in perineal trauma and perineal pain of parturient mothers between study group I and study II at p=0.000 level. The mean scores of study group I was lesser than the mean scores of study group II. Conclusion: Different perineal techniques and interventions such as hands on technique, hands off technique, perineal massage, warm compresses etc can be widely used by midwives and birth attendants to prevent perineal trauma during labour. Key words: hands off technique, hands on technique, perineal trauma and perineal pain

Evaluation and surgical treatment of rectal prolapse: an international survey

Validated guidelines for the surgical and non-surgical treatment of rectal prolapse (RP) do not exist. The aim of this international questionnaire survey was to provide an overview of the evaluation, follow-up and treatment of patients with an internal or external RP. A 36-question questionnaire in English about the evaluation, treatment and follow-up of patients with RP was distributed amongst surgeons attending the congresses of the European Association for Endoscopic Surgery and the European Society of Coloproctology in 2010. It was subsequently sent to all the members of the American Society of Colon and Rectal Surgeons and the European Society of Coloproctology by e-mail. In all, 391 surgeons in 50 different countries completed the questionnaire. Evaluation, surgical treatment and follow-up of patients with RP differed considerably. For healthy patients with an external RP, laparoscopic ventral rectopexy was the most popular treatment in Europe, whereas laparoscopic resection rectopexy was favoured in North America. There was consensus only on frail and/or elderly patients with an external prolapse, with a preference for a perineal technique. After failure of conservative therapy, internal RP was mostly treated by laparoscopic resection rectopexy in North America. In Europe, laparoscopic ventral rectopexy and stapled transanal rectal resection were the most popular techniques for these patients. The treatment of RP differs between surgeons, countries and regions. Guidelines are lacking. Prospective comparative studies are warranted that may result in universally accepted protocols.

Rectal Prolapse in the Elderly: Trends in Surgical Management and Outcomes from the American College of Surgeons National Surgical Quality Improvement Program Database

Full thickness rectal prolapse (FTRP) is managed with an abdominal or perineal operation. Traditionally, the approach has been determined by patient age and comorbidities. Our aim was to determine operative trends and outcomes for repair of FTRP in elderly patients using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. We queried the ACS NSQIP database from 2006 to 2009 for patients with FTRP who were 70 years of age or older. Patients were grouped according to type of surgical repair: laparoscopic (LR), open (OR), or perineal (PR) technique. We reviewed demographics, operative trends of surgical technique, and short-term outcomes for each group. A total of 816 patients were analyzed; 596 (73%) PR, 130 (16%) OR, and 90 (11%) LR patients. Patients who received OR and LR had lower mean American Society of Anesthesiologists (ASA) scores than PR patients (2.6, 2.5, and 2.7, respectively, p < 0.001). The percentage of LR and OR procedures decreased as age increased by decade; the inverse was seen for PR (p < 0.001). The distribution of operative techniques has not changed from year to year. Length of stay was significantly shorter for LR (3.77 days) and PR (3.44 days) patients vs OR patients (6.23 days) (p = 0.01). Complication rates were 2.22%, 8.72%, and 12.31% for LR, PR, and OR, respectively (p = 0.021). Open surgery was the only factor associated with an increased complication rate, with an odds ratio of 6.29 (95% CI 1.38 to 28.6, p < 0.02). Despite the appeal of perineal proctectomy in the elderly and debilitated patient, the approach to FTRP is slowly evolving in the era of laparoscopic surgery. Laparoscopic repair of FTRP in the elderly is associated with improved short-term outcomes when compared with OR and PR.

Perineal warm compress reduces risk of third- and fourth- degree tears and should be part of second stage care

Commentary on: V Aasheim, AB Nilsen, M Lukasse, et al.. Perineal techniques during the second stage of labour for reducing perineal trauma.Cochrane Database Syst Rev2011:CD006672.