Posterior Wall Defect Research Articles

Calcium phosphate cement–based vertebroplasty compared with conservative treatment for osteoporotic compression fractures: a matched case–control study

Few studies have been conducted to compare vertebroplasty and conservative treatment for osteoporotic vertebral compression fractures (OVCFs). To investigate the effects of calcium phosphate cement (CPC)-based vertebroplasty on relief of pain and augmentation of the fractured vertebral body (VB), the authors compared the results of CPC-assisted vertebroplasty with those of conservative treatment alone. Two groups of patients were examined: the vertebroplasty group (30 consecutive patients with primary OVCF) and the control group (30 patients matched for age, sex, interval from injury to treatment, and grade of the posterior wall defects of the fractured VB). Outcome measures included the visual analog scale (VAS) score of back pain and analgesic requirements, and the radiographically documented rate of the VB kyphosis. The follow-up duration was more than 12 months (mean 17 months). The mean VAS score at 12 months after injury was 0.67 cm in the vertebroplasty group and 1.97 cm in the control group, and the mean improvement rates in the VAS scores were 91.6 and 73.6%, respectively (p < 0.0001). The mean duration of analgesic requirement was 8.3 days in the vertebroplasty group and 62.2 days in the control group (p = 0.0005). The mean kyphosis rate at 12 months after injury was 72.9% in the vertebroplasty group and 58% in the control group, and the mean recovery rate of kyphosis was +8.4 and -21%, respectively (p < 0.0001). The authors conclude that CPC-assisted vertebroplasty provides better clinical and radiological results than conservative treatment for primary OVCF.

Traumatic Optic Nerve Avulsion

A 10-year-old boy presented with optic nerve avulsion associated with ptosis and limitation of elevation and adduction secondary to blunt ocular trauma. At the initial examination the funduscopic view was hazy because of concurrent vitreous hemorrhage. Ultrasonography revealed a posterior ocular wall defect and a hypolucent area in the region of the optic nerve head.

Paravaginal Repair Using White??s Technique (Bilateral Incision Approach)???Revisited

Abstract This study was undertaken to describe and evaluate the outcome of bilateral paravaginal repair using White's technique, which is different from the commonly used technique in its incision and approach. This was carried out as part of site-specific fascial defects repair in treating women with primary or recurrent grade II or more of anterior vaginal wall prolapse. Retrospective observational study with follow up objective and subjective assessment. At Weston General Hospital NHS Trust, Weston-super-Mare, U.K., 47 women presented with anterior vaginal wall prolapse of grade II or more according to the halfway grading system described by Baden and Walker. They were all treated with bilateral paravaginal repair, White's technique, as part of other site-specific fascial defect repair between the years 1995 and 2002. Forty-seven women underwent vaginal bilateral paravaginal repair using White's technique. Diagnosis of anterior vaginal wall prolapse resulting from paravaginal defects was made using Baden and Walker criteria. The degree of the prolapse was assessed and graded preoperatively using the halfway system. All women were followed up after surgery. The mean length of follow up was 29.1 months. Operative complications were recorded. The anatomic support of the anterior vaginal wall, the vaginal vault, and upper vaginal wall were objectively assessed using this system. Subjective assessment was made through patient satisfaction questionnaire. Objective failure was defined as recurrent anterior vaginal wall prolapse or prolapse of other sites to grade I or greater. Subjectively, failure was defined as persistence of prolapse symptoms, urinary symptoms, coital and bowel dysfunction. The mean age of women included in this study was 60.1 years. Preoperatively, all women presented with various degrees of anterior vaginal wall prolapse with concurrent vault and or upper posterior wall defect. The postoperative objective assessment was made using the halfway system. Anterior vaginal wall was supported at grade zero in 40 women (85.1%). Vault and upper posterior vaginal wall were supported at grade zero in 45 patients (95.7%). Recurrence of anterior vaginal wall prolapse occurred in 7 women (14.9%), 2 of whom 7 had recurrence of vaginal vault prolapse (4.3%). Prolapse symptoms completely subsided in 42 women. The overall subjective satisfaction rate was 88.5%. Urinary symptoms generally improved postoperatively and dyspareunia was rare. There was no significant change in bowel symptoms. Complications included one case of intraoperative bleeding. Nine women had delayed resumption of normal voiding. Bilateral vaginal paravaginal repair using White's technique is an effective and safe treatment of anterior vaginal wall prolapse resulting from a paravaginal defect. This method provides easy and adequate exposure to the paravaginal space. It has a good subjective and objective outcome.

Sacrospinous mesh colpopexy: a new technique for vaginal suspension

A novel new approach to correct vaginal vault prolapse using a Prolene mesh sling suspended between both sacrospinous ligaments is described. The technique utilises reusable equipment and the mesh repair is easily extended to repair posterior vaginal wall defects concurrently.

Immediate vulvar and vaginal reconstruction using the gluteal-fold flap: long-term results

The gluteal-fold flap was used to reconstruct vulvar and posterior vaginal wall defects in 40 patients. This is a fasciocutaneous, islanded flap based on the internal pudendal artery and vein perforators. The flap is robust and has the advantage of being away from the pathway of carcinoma spread. In addition it has minimal donor-site morbidity as the scar is hidden in a natural crease.

The accuracy of clinical evaluation of posterior vaginal wall defects.

We retrospectively reviewed 106 cases of defect-directed rectocele repair. Preoperative standardized evaluation of rectovaginal septum support was performed. Support defects were identified at surgery by visually identifying breaks in the rectovaginal fascia. Clinical and surgical findings were compared using the chi2 test. Logistic regression analysis was used to identify predictive variables. Clinical examination concurred with surgical findings in 59.4% (63/106) and differed in 40.6% (43/106). Predictors of agreement between clinical examination and intraoperative findings were the presence of multiple defects in the rectovaginal fascia at surgery (OR 4.42, 95% CI 1.89, 10.35) and stage II or III prolapse (OR 0.0007, 95% CI 0.00059, 0.003 and 0.0003, 95% CI 0.00033, 0.0017, respectively). The sensitivity and positive predictive value for all defects was less than 40%. The inaccuracy of clinical examination emphasizes the need to develop new clinical and/or imaging methods to evaluate posterior vaginal support defects.

Changes in muscle strength and pain in response to surgical repair of posterior abdominal wall disruption followed by rehabilitation

Background: Posterior abdominal wall deficiency (PAWD) is a tear in the external oblique aponeurosis or the conjoint tendon causing a posterior wall defect at the medial end of the inguinal...

Posterior vaginal wall defects and their relation to measures of pelvic floor neuromuscular function and posterior compartment symptoms

Objective: The purpose of this study was to describe the pelvic floor neuromuscular function and posterior compartment symptoms in patients with posterior vaginal wall prolapse. Study Design: Two hundred twenty-seven women who were referred to a urogynecology and urology clinic were enrolled prospectively. Each patient completed a health history questionnaire and standardized physical examination that specifically graded uterovaginal prolapse according to the pelvic organ prolapse quantification system. Results: Sixty-nine women had a pelvic organ prolapse quantification system point (most dependent portion of the posterior vaginal wall during straining as measured from the hymeneal ring) of ≤−1. Older age, a history of hysterectomy, a genital hiatus of >3 cm (48% vs 24%; P =.002), and perineal descent of ≥2 cm (14% vs 5%; P =.042) were significantly more common in women with posterior vaginal prolapse. When women with posterior prolapse and symptomatic complaints were compared with asymptomatic women with prolapse, a perineal descent of ≥2 cm (21% vs 0%; P =.004) was significantly more common in the symptomatic group. Conclusion: Pelvic floor neuromuscular function should be related to posterior vaginal prolapse and symptoms; however, only perineal descent appears associated strongly with both symptoms and prolapse in this population. (Am J Obstet Gynecol 2002;187:1443-9.)

Rectocele repair: when and how?

Pelvic organ prolapse repair poses a unique challenge to the reconstructive pelvic surgeon. Traditional levator plication has been promoted for the past century and has recently been shown to create unsatisfactory functional results, among them dyspareunia. In an attempt to improve both functional and quality-of-life outcomes, new methods for posterior vaginal wall defect repair have been developed and are now undergoing critical evaluation. We present a review of posterior vaginal wall repair with a focus on new anatomic concepts and site-specific rectocele repair.

Candidate's thesis: Revision tympanoplasty utilizing fossa triangularis cartilage.

A small percentage of fascia graft tympanoplasties fail. Cartilage tympanoplasty has a reputation for excellent graft healing but potentially sacrifices maximum hearing improvement and creates difficulty in postoperative follow-up resulting from opacity and immobility. We sought to use a tissue thicker than fascia but thinner than tragal cartilage to repair tympanic membranes that had failed previous fascia grafting. Our hypothesis was that use of the thinner cartilage would maintain the excellent healing rate and resistance to chronic negative pressure while improving hearing and mobility. The study is a retrospective review of all patients who received a total cartilage graft tympanoplasty after experiencing a failed standard fascia graft tympanoplasty. No previous operative series on impedance testing following cartilage grafting was identified in the literature. Standard audiologic and tympanometric parameters were obtained in all patients. Tragal and fossa triangularis cartilage were statistically analyzed for thickness and weight. Surgical indications included patients who had chronic otologic disease that resulted in recurrent tympanic membrane perforation, atelectasis, or cholesteatoma. The tympanic membrane and any posterior canal wall defect were completely replaced with cartilage. Preoperative and postoperative audiometric and impedence tympanometry measurements were compared. Triangularis fossa cartilage is thinner and has less mass than tragal cartilage. Complete data were obtained on 83 of 159 patients to make up this study. The success rate for tympanic membrane integrity measured by tympanometry was 100% at a minimum 2-year follow-up in all ears included in the study. Hearing results are reported collectively and include all types of ossiculoplasty. The largest closure of air-bone gap was at 1000 Hz, followed by 2000, 500, and 4000 Hz. The patient's best hearing level was most frequently at 2000 Hz. Impedence testing showed a large shift in tympanogram configuration from B to C, indicating that cartilage grafts heal with integrity and measurable mobility although stiffened compared with normal. Fossa triangularis cartilage is thinner and has less mass than tragal cartilage. This creates a relatively mobile neotympanic membrane that can be monitored postoperatively by standard tympanometry, and allows for excellent hearing results. Recurrent tympanic membrane perforation or atelectasis with or without bony canal erosion that has failed standard fascia graft tympanoplasty can be successfully repaired with fossa triangularis cartilage graft tympanoplasty. Primary surgical use of cartilage graft tympanoplasty should be considered in patients with high-risk otologic disease, since fossa triangularis cartilage is thick enough to resist prolonged negative middle ear pressure and the hearing results with fossa triangularis cartilage shield graft tympanoplasty are comparable to those reported with fascia grafting. In patients with type A or C tympanogram results following successful fossa triangularis cartilage grafts, standard impedance testing can be used to clinically evaluate tympanic membrane mobility and help identify the presence of middle ear disease. However primary placement of a tympanostomy tube should be performed in patients with granulation tissue in the middle ear at time of tympanoplasty. Further study is needed to determine the ideal thickness of cartilage for tympanic membrane reconstruction.

Surgical management of the apical vaginal defect.

To review the etiology, presentation, imaging techniques and current surgical management of the apical vaginal defect. Urologists are increasingly managing urinary incontinence and prolapse of the anterior and posterior compartment but most refer the management of the apical defect to gynecologists. A variety of abdominal and vaginal repairs are commonly utilized to repair the apical defect, often based on the surgeon's preference. Of the abdominal repairs, abdominal sacral colpopexy with mesh remains the gold standard. Laparoscopic techniques, although feasible, have not gained widespread acceptance. Of the vaginal restorative procedures there are proponents for uterosacral ligament vault suspension, iliococcygeus and sacrospinous ligament fixation. The uterosacral ligament vault suspension is the most anatomic of the repairs and hence least likely to create a predisposition to future anterior or posterior vaginal wall defects or compromise vaginal function. In rare instances where restorative procedures are discouraged and sexual function is no longer desired, obliterative procedures, which are better tolerated, may be more appropriate. The best approach for restoration of vaginal apical support remains controversial with abdominal and vaginal routes commonly utilized. A single approach or procedure based on the surgeon's preference is not always optimal. Procedure selection should be individualized based on the patient's age, comorbidities, prior surgical history and level of physical and sexual activity. The transvaginal uterosacral ligament vaginal vault suspension is increasingly our procedure of choice for management of the apical defect due to its versatility, reduced postoperative morbidity and excellent short-term results.

An alternative approach to the repair of cystoceles and rectoceles

Purpose: We present an alternative approach to repair severe or recurrent central anterior wall defects and high posterior wall defects. Background: Pelvic prolapse is one of the most common problems with which a gynecologist deals. One in nine women in the United States suffers from prolapse. Of those who undergo surgery, 25–30% will have a recurrence. It long has been recognized that the patient tissue available for repair often is less than optimal. Implantable material was used as early as 1955 in an attempt to improve the strength and longevity of the repair. Unfortunately, these materials often resulted in infection, sinus formation, or erosion. A better understanding of anatomy has improved our ability to recognize and repair these defects, especially paravaginal defects in the anterior compartment and site-specific defects in the posterior compartment. However, severe or recurrent central anterior defects and high posterior (Level I) defects have little or no supportive tissue to use in the repair. Results and Conclusions: Fifty women have undergone this alternative procedure to repair cystocele and rectocele from January through October 2000, using donor collagen. The use of donor collagen in the repair of these defects has resulted in no infections or erosions, and there has been no evidence of recurrence during our initial follow-up.

CSF rhinorrhoea: the place of endoscopic sinus surgery

Cerebrospinal fluid (CSF) rhinorrhoea has been managed by both neurosurgeons and otorhinolaryngologists, with neurosurgeons often choosing an intracranial approach and otorhinolaryngologists an extracranial approach. Recently, transnasal endoscopic techniques have been introduced that significantly reduce the morbidity of surgical repair when compared with previous techniques. The sense of smell was preserved in all patients who underwent an endoscopic repair of their CSF leak where it was present preoperatively. The results of transnasal endoscopic repair now make it the treatment of choice for most anterior cranial and sphenoid CSF leaks, with the exception of defects in posterior wall of the frontal sinus or defects larger than 5 cm. It is vital that a diagnosis of a CSF leak is confirmed by immunofixation of beta 2 transferrin as unilateral rhinorrhoea can masquerade as a CSF leak. We illustrate our experience with 78 patients who were referred with a diagnosis of CSF rhinorrhoea.

鼻性頭蓋内膿よう例

We report a rare case of intracranial complication originating from the frontal sinusitis. The patient was a 32 year-old-male who initially presented with a high fever and anumb feeling in his head. A sudden onset of right upper limb dyskinesia appeared several days after the initial symptoms. Magnetic resonance imaging (MRI) was useful to reveal an epidural abscess in the frontal region of the head and a subdural abscess near the falx cerebri. These Lesions ware considered to arise from the direct extension of the frontal sinusitis via a posterior wall defect of the frontal sinus, and phlebitis of the diploic vein around the frontal sinus. The intracranial abscess and frontal sinusitis ware eliminated using Neurosurgical and Otolaryngological techniques.Even with the development of antibiotics, this condition can still be fatal; thus, we suggest that it is important to increase physician's awareness of this condition.

Laparoscopic management of genital prolapse: lateral suspension with two meshes

ObjectiveTo report our experience with a new laparoscopic technique to treat genital prolapse.SubjectsProspective longitudinal case study of 35 women with genital prolapse treated between June 1997 and January 1999.InterventionThe technique involves the use of two composite meshes, one of which is applied to the upper portion of the anterior wall of the vagina and the other to the upper portion of the posterior vaginal wall and posterior aspect of the cervix if present. The lateral ends of the two meshes are pulled trough a retroperitoneal tunnel and fixed to the aponeurosis of the external oblique muscle above the iliac crest. Depending on the patient's symptoms and clinical findings, ancillary procedures (i.e. urethropexy, repair of the pouch of Douglas) may be necessary.ResultsThe average operating time was 254 ± 45 min (range 180–360). The total rate of complications was 20% (seven cases). The mean duration of hospital stay was 4.8 ± 1.2 days (range 3–8). With regard to the anatomical results: the mean postoperative follow up was 5 ± 4.6 months; results were excellent in 80% of cases. The remaining 20% had moderate posterior vaginal wall defect. With regard to the functional results: the mean follow‐up was 10.5 ± 4.6 months; 90.9% of the patients were satisfied; the functional defects were persistent urinary stress incontinence in 6.6% cases, urgency in 6.6% cases, frequency in 6.6% cases, constipation in 9.1% cases; the rate of dyspareunia in patients who were sexually active was 10.3%.ConclusionThis technique presents the advantage of providing complete treatment for prolapse using laparoscopic surgery without having to approach the promontory or having to carry out extensive reperitonealization.

Chest wall stabilization with synthetic reabsorbable materials as originally published in 1992: Updated in 1999 by

Chest wall stabilization with synthetic reabsorbable materials as originally published in 1992: Updated in 1999 by

The Effect of Posterior Wall Support Defects on Urodynamic Indices in Stress Urinary Incontinence

In Brief Objective To determine if posterior vaginal wall defects affect urodynamic indices and mask stress urinary incontinence. Methods Ninety women with grade 0, 1, 2, or 3 posterior wall defects were evaluated prospectively by complete urodynamics to assess their urinary complaints. None had severe anterior or apical support defects. Urethral pressure profilometry and cough stress test were performed with the posterior wall in the unretracted position and then with the posterior wall retracted using a split speculum. Analysis of covariance was used to compare adjusted mean differences in maximum urethral closure pressure, functional urethral length, and units of leakage volume during the cough stress test in the unretracted and retracted positions among the posterior wall grade groups. Results In women with grade 3 posterior wall defects, there were significant changes from the unretracted to the retracted position in maximum urethral closure pressure of −7.0 cm H2O, (99% confidence interval [CI] −12.4, −1.6), functional urethral length of −0.3 cm (99% CI −0.5, −0.1), and leak volume units of +0.7 (99% CI 0.4, 1.0) during the cough stress test. There were four women with grade 3 posterior wall defects who demonstrated potential stress incontinence when their posterior wall was retracted. Conclusion A grade 3 posterior wall defect may artificially raise maximum urethral closure pressure, increase functional urethral length, and mask urinary stress incontinence during a cough stress test. Women with grade 3 posterior wall defects should be tested with the posterior wall retracted during urodynamic evaluation. Grade three posterior wall defects may affect urodynamic indices and mask potential stress urinary incontinence.

The Effect of Posterior Wall Support Defects on Urodynamic Indices in Stress Urinary Incontinence

Objective: To determine if posterior vaginal wall defects affect urodynamic indices and mask stress urinary incontinence. Methods: Ninety women with grade 0, 1, 2, or 3 posterior wall defects were evaluated prospectively by complete urodynamics to assess their urinary complaints. None had severe anterior or apical support defects. Urethral pressure profilometry and cough stress test were performed with the posterior wall in the unretracted position and then with the posterior wall retracted using a split speculum. Analysis of covariance was used to compare adjusted mean differences in maximum urethral closure pressure, functional urethral length, and units of leakage volume during the cough stress test in the unretracted and retracted positions among the posterior wall grade groups. Results: In women with grade 3 posterior wall defects, there were significant changes from the unretracted to the retracted position in maximum urethral closure pressure of −7.0 cm H 2O, (99% confidence interval [CI] −12.4, −1.6), functional urethral length of −0.3 cm (99% CI −0.5, −0.1), and leak volume units of +0.7 (99% CI 0.4, 1.0) during the cough stress test. There were four women with grade 3 posterior wall defects who demonstrated potential stress incontinence when their posterior wall was retracted. Conclusion: A grade 3 posterior wall defect may artificially raise maximum urethral closure pressure, increase functional urethral length, and mask urinary stress incontinence during a cough stress test. Women with grade 3 posterior wall defects should be tested with the posterior wall retracted during urodynamic evaluation.

In vitro Characteristics of a Glass Ionomer Cement

Glass ionomer cements were first described by Wilson and Kent and have been used in dentistry since 1969. It has been recommended for bridging ossicular chain defects, fixation of ossicular chain prosthesis, anchoring of cochlear implants, mastoid obliteration, and repair of tegmen and posterior canal wall defects. The biocompatability and stability of this material over time is vital to its usefulness in neurotologic surgery. The purpose of this study was to assess the stability of a glass ionomer cement in the presence of bacteria and in different pH environments. We demonstrated that bacteria readily adhere to the surface and their presence is associated with accelerated loss of matrix. We found the cement to be susceptible to low pH and to release a visible cloud of debris upon contact with fluid. Calcium concentration in the solution was elevated at all pH levels. Although we are able to demonstrate these findings in vitro the clinical relevance is unclear. There have been several cases of aseptic meningitis possibly due to intracranial release of components of the cement. Until further studies are done use of the cement in contact with cerebral spinal fluid should be avoided. This cement, or a similar material, would be useful in neurotologic surgery but prior to widespread use further testing should be done to assess safety.

Tumours of the posterior pharyngeal wall: the use of the platysma flap.

Posterior pharyngeal will tumours are infrequent neoplasms with a very poor prognosis. The 5 year survival rate range from 3% to 32%. Most authors agree that the treatment of choice is surgery with post-operative radiotherapy. The results of treatment of 36 patients (tumour excision plus bilateral neck dissection and post-operative radiotherapy) in which the posterior pharyngeal wall defect was closed with a platysma myocutaneous flap were compared with other forms of repair (13 patients). The 5 year survival rate was 17.2% in the whole group. Laryngeal voice was achieved in 79% of patients having a platysma flap reconstruction. The platysma myocutaneous flap is very satisfactory for the repair of the posterior pharyngeal wall as it is easy to perform, it is oncologically safe and its functional results match well with other forms of reconstruction, with the advantage of laryngeal preservation.