Posterior Wall Research Articles

Acetabular fractures in geriatric patients: epidemiology, pathomechanism, classification and treatment options.

The incidence of geriatric acetabular fractures has shown a sharp increase in the last decades. The majority of patients are male, which is different to other osteoporotic fractures. The typical pathomechanism generally differs from acetabular fractures in young patients regarding both the direction and the amount of force transmission to the acetabulum via the femoral head. Geriatric fractures very frequently involve anterior structures of the acetabulum, while the posterior wall is less frequently involved. The anterior column and posterior hemitransverse (ACPHT) fracture is the most common fracture type. Superomedial dome impactions (gull sign) are a frequent feature in geriatric acetabular fractures as well. Treatment options include nonoperative treatment, internal fixation and arthoplasty. Nonoperative treatment includes rapid mobilisation and full weighbearing under analgesia and is advisable in non- or minimally displaced fractures without subluxation of the hip joint and without positive gull sign. Open reduction and internal fixation of geriatric acetabular fractures leads to good or excellent results, if anatomic reduction is achieved intraoperatively and loss of reduction does not occur postoperatively. Primary arthroplasty of geriatric acetabular fractures is a treatment option, which does not require anatomic reduction, allows for immediate postoperative full weightbearing and obviates several complications, which are associated with internal fixation. The major issue is the fixation of the acetabular cup in the fractured bone. Primary cups, reinforcement rings or a combination of arthroplasty and internal fixation may be applied depending on the acetabular fracture type.

An unusual occurrence of a four-headed psoas major: a case report.

While many structures within the human body demonstrate anatomical variations, this is not typically the case for the iliopsoas muscle complex. However, the present paper describes a case of an anomalous psoas major composed of four different muscular heads in a 78-year-old male cadaver. During a routine dissection of the right posterior abdominal wall, an unusual psoas major was observed, measured and photographed. The psoas major was found to possess four muscular heads, otherwise the anatomy of the wall was normal. The presence of so many heads could interfere with the functions of the psoas major muscle. Therefore this anatomical variation merits further study.

Decreased plasma ELABELA level as a novel screening indicator for heart failure: a cohort and observational study.

The predictive power of B-type natriuretic peptide (BNP) and left ventricular ejection fraction (LVEF) is limited by its low specificity in patients with heart failure (HF). Discovery of more novel biomarkers for HF better diagnosis is necessary and urgent. ELABELA, an early endogenous ligand for the G protein-coupled receptor APJ (Apelin peptide jejunum, Apelin receptor), exhibits cardioprotective actions. However, the relationship between plasma ELABELA and cardiac function in HF patients is unclear. To evaluate plasma ELABELA level and its diagnostic value in HF patients, a total of 335 patients with or without HF were recruited for our monocentric observational study. Plasma ELABELA and Apelin levels were detected by immunoassay in all patients. Spearman correlation analysis was used to analyze the correlation between plasma ELABELA or Apelin levels and study variables. The receiver operating characteristic curves were used to access the predictive power of plasma ELABELA or Apelin levels. Plasma ELABELA levels were lower, while plasma Apelin levels were higher in HF patients than in non-HF patients. Plasma ELABELA levels were gradually decreased with increasing New York Heart Association grade or decreasing LVEF. Plasma ELABELA levels were negatively correlated with BNP, left atrial diameter, left ventricular end-diastolic diameter, left ventricular end-systolic diameter, and left ventricular posterior wall thickness and positively correlated with LVEF in HF patients. In contrast, the correlation between plasma Apelin levels and these parameters is utterly opposite to ELABELA. The diagnostic value of ELABELA, Apelin, and LVEF for all HF patients was 0.835, 0.673, and 0.612; the sensitivity was 62.52, 66.20, and 32.97%; and the specificity was 95.92, 67.23, and 87.49%, respectively. All these parameters in HF patients with preserved ejection fraction were comparable to those in total HF patients. Overall, plasma ELABELA levels were significantly reduced and negatively correlated with cardiac function in HF patients. Decreased plasma ELABELA levels may function as a novel screening biomarker for HF. A combined assessment of BNP and ELABELA may be a good choice to increase the accuracy of the diagnosis of HF.

Catheter ablation for persistent atrial fibrillation: patterns of recurrence and impact on quality of life and health care utilisation.

Patterns of atrial fibrillation (AF) recurrence post catheter ablation for persistent AF are not well described. This study aimed to describe the pattern of AF recurrence seen following catheter ablation for persistent AF (PsAF) and the implications for healthcare utilisation and quality of life. This was a post-hoc analysis of the CAPLA study, an international, multi-centre study that randomised patients with symptomatic PsAF to pulmonary vein isolation plus posterior wall isolation or pulmonary vein isolation alone. Patients underwent twice daily single lead ECG, implantable device monitoring or three monthly Holter monitoring. 154 of 333 (46.2%) patients (median age 67.3 years, 28% female) experienced AF recurrence at 12-month follow-up. Recurrence was paroxysmal in 97 (63%) patients and persistent in 57 (37%). Recurrence type did not differ between randomisation groups (p=0.508). Median AF burden was 27.4% in PsAF recurrence and 0.9% in paroxysmal AF (PAF) recurrence (p<0.001). Patients with PsAF recurrence had lower baseline left ventricular ejection fraction (PsAF 50% vs PAF 60%, p<0.001) and larger left atrial volume (PsAF 54.2±19.3 ml/m² vs PAF 44.8±11.6 ml/m², p=0.008). Healthcare utilisation was significantly higher in PsAF (45 patients [78.9%]) vs PAF recurrence (45 patients [46.4%], p<0.001) and lowest in those without recurrence (17 patients [9.5%], p<0.001). Patients without AF recurrence had greater improvements in quality of life as assessed by the Atrial Fibrillation Effect on Quality-of-Life (AFEQT) questionnaire (Δ33.3±25.2 points) compared to those with PAF (Δ24.0±25.0 points, p=0.012) or PsAF (Δ13.4±22.9 points, p<0.001) recurrence. AF recurrence is more often paroxysmal after catheter ablation for PsAF irrespective of ablation strategy. Recurrent PsAF was associated with higher AF burden, increased healthcare utilisation and antiarrhythmic drug use. The type of AF recurrence and AF burden may be considered important endpoints in clinical trials investigating ablation of PsAF.

Surgical treatment outcomes of acetabular posterior wall and posterior column fractures using 3D printing technology and individualized custom-made metal plates: a retrospective study.

Fractures involving the posterior acetabulum with its rich vascular and neural supply present challenges in trauma orthopedics. This study evaluates the effectiveness of 3D printing technology with the use of custom-made metal plates in the treatment of posterior wall and column acetabular fractures. A retrospective analysis included 31 patients undergoing surgical fixation for posterior wall and column fractures of the acetabulum (16 in the 3D printing group, utilizing 3D printing for a 1:1 pelvic model and custom-made plates based on preoperative simulation; 15 in the traditional group, using conventional methods). Surgical and instrument operation times, intraoperative fluoroscopy frequency, intraoperative blood loss, fracture reduction quality, fracture healing time, preoperative and 12-month postoperative pain scores (Numeric Rating Scale, NRS), hip joint function at 6 and 12 months (Harris scores), and complications were compared. The surgical and instrument operation times were significantly shorter in the 3D printing group (p < 0.001). The 3D printing group exhibited significantly lower intraoperative fluoroscopy frequency and blood loss (p = 0.001 and p < 0.001, respectively). No significant differences were observed between the two groups in terms of fracture reduction quality, fracture healing time, preoperative pain scores (NRS scores), and 6-month hip joint function (Harris scores) (p > 0.05). However, at 12 months, hip joint function and pain scores were significantly better in the 3D printing group (p < 0.05). Although the incidence of complications was lower in the 3D printing group (18.8% vs. 33.3%), the difference did not reach statistical significance (p = 0.433). Combining 3D printing with individualized custom-made metal plates for acetabular posterior wall and column fractures reduces surgery and instrument time, minimizes intraoperative procedures and blood loss, enhancing long-term hip joint function recovery. 12/04/2023;Trial Registration No. ChiCTR2300070438; http://www.chictr.org.cn .

Evaluation of Neuromuscular Morphometry of the Vaginal Wall Using Protein Gene Product 9.5 (Pgp 9.5) and Smooth Muscle α-Actin (Sma) in Patients with Posterior Vaginal Wall Prolapse

Evaluation of Neuromuscular Morphometry of the Vaginal Wall Using Protein Gene Product 9.5 (Pgp 9.5) and Smooth Muscle α-Actin (Sma) in Patients with Posterior Vaginal Wall Prolapse

MR defecography in assessing stress urinary incontinence with or without symptomatic pelvic organ prolapse.

Utilize magnetic resonance defecography (MRD) to analyze the primary pelvic floor dysfunctions in patients with stress urinary incontinence (SUI) associated with pelvic organ prolapse (POP), and in SUI patients with asymptomatic POP. We performed MRD in both SUI and POP subjects. As a primary analysis, the functional MR parameters were compared between the isolated POP and POP combined SUI groups. As a secondary analysis, the functional MR data were compared between the POP combined SUI and the SUI with asymptomatic POP (isolated SUI) groups. MRD noted the main characteristics of SUI combined moderate or severe POP, including the shorter closed urethra length (1.87cm vs. 2.50cm, p < 0.001), more prevalent urethral hypermobility (112.31° vs. 85.67°, p = 0.003), bladder neck funneling (48.28% vs. 20.51%, p = 0.020), lower position of vesicourethral junction (2.11cm vs. 1.67cm, p = 0.030), and more severe prolapse of the posterior bladder wall (6.26cm vs. 4.35cm, p = 0.008). The isolated SUI patients showed the shortest length of the closed urethra (1.56cm vs. 1.87cm, p = 0.029), a larger vesicourethral angle (153.80° vs. 107.58°, p < 0.001), the more positive bladder funneling (84.85% vs. 48.28%, p = 0.002) and a special urethral opening sign (45.45% vs. 3.45%, p < 0.001). Patients with SUI accompanying POP primarily exhibit excessive urethral mobility and a shortened urethral closure. SUI patients with asymptomatic POP mainly show dysfunction of the urethra and bladder neck, characterized by the opening of the urethra and bladder neck and a shortened urethral closure.

Pulmonary Vein Isolation for Atrial Fibrillation: Comparison of a Very High-Power Very Short-Duration (vHPvSD) Ablation Protocol Versus a Hybrid Ablation Approach—Procedural and Mid-Term Outcome Data

Background: Pulmonary vein isolation (PVI) using radiofrequency ablation (RFA) is a standard-of-care treatment in the rhythm control strategy of symptomatic atrial fibrillation (AF). Ablation protocols, varying in the power and duration of energy delivery, have changed rapidly in recent years. Very high-power very short-duration ablation (vHPvSD) is expected to shorten procedural times compared to conventional ablation approaches. However, the existing data suggest that this might come at the cost of lower first-pass isolation rates, a predictor of poor ablation long-term outcomes. This study aims to compare a vHPvSD protocol to a hybrid strategy, in which the power and duration of the energy transfer are adapted depending on the anatomical location. Methods: We retrospectively analyzed procedural and outcome data from 93 patients (55 vHPvSD vs. 38 hybrid) scheduled for de novo pulmonary vein isolation. A vHPvSD ablation protocol (90 Watt (W), 4 seconds (s)) was compared to a hybrid protocol using vHPvSD on the posterior wall and 50 W HPSD (high-power short-duration) ablation guided by the Ablation Index along the remaining spots. Results: Ablation times were significantly shorter in the vHPvSD cohort (5.4 min. vs. 14.2 min, p &lt; 0.001), thus resulting in a significant reduction in the overall procedural duration (91 min vs. 106 min, p = 0.003). The non-significant slightly higher first-pass isolation rates in the vHPvSD cohort (85% vs. 76%, p = 0.262) did not affect freedom from AF 6 months after the procedure (83% vs. 87%, p = 0.622). Conclusion: vHPvSD helps in shortening the PVI procedural duration, thus neither affecting first-pass isolation rates nor freedom from atrial tachyarrhythmia recurrence at 6 months after the index procedure.

Fundal Anterior to Posterior Hysterotomy and Cesarean Myomectomy in Fibroid Uterus

Fibroids are a common benign tumor located in the female reproductive tract and affect up to 10 percent of women, leading to challenges during cesarean section. Few cases of myomectomy at the time of cesarean section have been described and most describe uteri with only a few fibroids present. Our case describes a 39 year old G1P0101female with extensive fibroids including large fibroids located at the lower uterine segment. This patient underwent cesarean section and myomectomy at 27 weeks and five days gestation with a fundal, vertical hysterotomy, extending from the anterior to posterior wall of uterus. This is the first case described in the literature of a cesarean section performed on a uterus with innumerable intramural fibroids and first case documented of a fundal, anterior to posterior hysterotomy.

The use of hyaluronic acid based bulking agent for stress urinary incontinence in women: A prospective controlled study

Background. Paraurethral injection of bulking agents in women is one of the minimally invasive technologies for the treatment of stress urinary incontinence (SUI). The effectiveness and safety of this method depend on the properties of injected substance. Aim. To evaluate the results of paraurethral injections of 1,4-butanediol diglycidyl ether crosslinked high-density hyaluronic acid (EsteFILL® intim) in the treatment of SUI in women of reproductive and perimenopausal age. Materials and methods. We examined 18 patients aged 45.8±5.0 years with mild SUI in combination with grade I–II genital prolapse. After general clinical and special studies (urination diaries, King and PISQ-12 questionnaires, cough test, complex urodynamic study, urethrovesical segment and pelvic floor ultrasound with compression elastography) paraurethral injection of 4.0 ml EsteFILL® intim drug was performed. The results of therapy were studied 1 and 6 months after the procedure. Results. It was found that the injection of the drug contributed to an increase in the stiffness of paraurethral tissues by 1.5 times within 6 months after injection. According to the results of elastography before treatment, the average value of the strain ratio of paraurethral tissues of the proximal posterior wall of the urethra was 0.66±0.46 (0.42–0.91), after 1 and 6 months – 0.99±0.45 (0.76–1.23) and 1.00±0.36 (0.78–1.22) respectively; p=0.009 and 0.018. The effectiveness of EsteFILL® intim drug in the treatment of mild SUI in women after 1 and 6 months according to the results of a cough test was 88.2 and 71.4%, according to urination diaries – 88.9 and 66.7% respectively. During the entire observation period the patients noted a decrease in the degree of discomfort due to SUI and an improvement in the quality of life. Conclusion. Paraurethral injection of EsteFILL® intim drug helps to increase the stiffness of the urethra supporting structures in patients with SUI. This method of treating SUI is effective for women of reproductive and perimenopausal age with mild severity disease, who do not plan surgical treatment, are interested in achieving a quick result of therapy and are informed that the effect decreases over time after the procedure.

Impact of Posterior Wall Isolation DuringAF Ablation on the Incidence ofLeft Atrial Flutter.

Linear and complex electrogram ablation (LCEA) beyond pulmonary vein isolation (PVI) is associated with an increase in left atrial macro-re-entrant tachycardias (LAMTs). Posterior wall isolation (PWI) is increasingly performed to improve AF ablation outcomes. However, the impact of PWI on the incidence of LAMT is unknown. The purpose of this study was to establish the incidence of LAMT following PVI alone vs PVI+ PWI vs PVI+ PWI+ LCEA. Consecutive patients undergoing catheter ablation for AF or LAMT post-AF ablation between 2008 and 2022 from 4 electrophysiology centers were reviewed with a minimum follow-up of 12months. In total, 5,619 (4,419 index, 1,100 redo) AF ablation procedures were performed in 4,783 patients (mean age 60.9 ± 10.6 years, 70.7% men). Over a mean follow-up of 6.4 ± 3.8 years, 246 procedures for LAMT were performed in 214 patients at a mean of 2.6 ± 0.6 years post-AF ablation. Perimitral (52.8% of patients), roof-dependent (27.1%), PV gap-related (17.3%), and anterior circuits (8.9%) were most common, with 16.4% demonstrating multiple circuits. The incidence of LAMT was significantly higher following PVI+ PWI (6.2%) vs PVI alone (3.0%; P< 0.0001) and following PVI+ PWI+ LCEA vs PVI+ PWI (12.5%; P = 0.019). Conduction gaps in previous ablation lines were responsible for LAMT in 28.4% post-PVI alone, 35.3% post-PVI+ PWI (P = 0.386), and 81.8% post-PVI+ PWI+ LCEA (P< 0.005). The incidence of LAMT following PVI+ PWI is higher than with PVI alone but significantly lower than with more extensive atrial substrate modification. Given a low frequency of LAMT following PWI, empiric mitral isthmus ablation is not justified and may be proarrhythmic.

PRACTICE OF USING IMPLANTS IN GYNECOLOGICAL SURGICAL INTERVENTIONS (SCIENTIFIC LITERATURE REVIEW)

Introduction. The use of implants during surgical interventions in gynecology can contribute to the anatomical restoration of the genital organs. The most commonly used implants in gynecology are polypropylene meshes, which promote tissue ingrowth, thus restoring reproductive organs. One of the reasons for using implants in gynecology is pelvic organ prolapse, including uterine prolapse, anterior or posterior vaginal wall prolapse, and vaginal vault prolapse. Synthetic implants are often utilized to reinforce surgical interventions for gynecological disorders, with better indicators of anatomical success in the long term. The aim of the research is to investigate the biomechanical properties of implants in gynecology as effective means for the surgical restoration of female reproductive organs. Materials and methods. Bibliosemantic, comparative, and systematic analysis methods were employed. The proposed recommendations were developed based on the analysis of contemporary literature, results of randomized trials, and meta-analyses dedicated to studying the impact of implants in surgical interventions in gynecological practice. Results. The analyzed results indicate that the optimal supportive framework of implants for gynecological surgery, particularly in the treatment of prolapse, should aim to facilitate the formation of a new matrix for fascial reinforcement, thereby minimizing the development of scar tissue. Conclusions. The primary objective of using implants in gynecological surgical interventions is to search for optimal designs to complement vaginal surgery. This is essential for prolonging treatment outcomes, increasing patient satisfaction, and reducing complications.

Early-stage hypopharyngeal squamous cell carcinoma treated with radical radiotherapy at a uniform dose of 70Gy in 35 fractions: a single-center study.

Hypopharyngeal squamous cell carcinoma (HSCC) is often undetected until advanced stages, which contributes to poor survival rates. Recent advances in diagnostic techniques have enhanced the feasibility of early detection, and this study evaluated the efficacy and safety of radical radiotherapy that specifically targets early stage HSCC. This retrospective cohort study consecutively analyzed patients with clinical stage I or II HSCC between December 2008 and February 2023. These patients underwent radical radiotherapy with a uniform dose of 70 Gy delivered in 35 fractions to the primary site, followed by elective nodal irradiation. We assessed clinical outcomes, including overall survival (OS), disease-free survival (DFS), and 5-year locoregional control (LRC). Multivariate analyses were performed to identify the independent prognostic factors for OS. The 5-year OS rate of the entire cohort was 80.7% (95% confidence interval [CI] = 66.5-89.4%), with no significant difference between patients with clinical stage I and II HSCC. Stratified by subsite, the 5-year OS for pyriform sinus, posterior pharyngeal wall, and postcricoid region were 81.6, 68.2, and 100%, respectively. The ECOG-Performance status (PS) was identified as an independent risk factor for OS (hazard ratio [HR] = 8.457; 95% CI 1.325-53.970; p = 0.024). DFS at 5 years was 66.4%, with local recurrence being the most frequent, and LRC rate at 5 years was 79.3%. Acute and late-phase toxicities were predominantly mild to moderate, with no grade 3 or higher toxicities reported. This study supports radical radiotherapy as an effective approach for optimal tumor control in patients with early stage HSCC. Despite the limitations of this study, including its retrospective design and single-center confinement, our results revealed the effectiveness and feasibility of radical radiotherapy in the management of early stage HSCC.

Left ventricular global longitudinal strain is worse in BRCA mutation positive breast cancer patients prior to cancer treatment and premature menopause.

Breast cancer patients with mutations in human tumor suppressor genes BRCA1 and BRCA2 are at higher risk of cardiovascular disease (CVD) than the general population, as they are frequently exposed to cardiotoxic chemotherapy, anti-estrogen therapy, radiation, and/or oophorectomy for cancer-related treatment and prophylaxis. Animal and cell culture models suggest that BRCA mutations may play an independent role in heart failure. We sought to evaluate cardiac structure and function in female BRCA1 and BRCA2 mutation carriers with breast cancer compared to BRCA wildtype women with breast cancer. We performed a 1:2 age- and hypertension-matched retrospective cohort study comparing BRCA1 and BRCA2 mutation carriers (n = 38) versus BRCA wildtype controls (n = 76) with a new diagnosis of breast cancer. Echocardiographic data were obtained within 6months of breast cancer diagnosis and prior to chemotherapy, anti-estrogen therapy, radiation, or oophorectomy. Left ventricular global longitudinal strain (LV-GLS), a highly sensitive marker of LV function, was measured using QLab 15 (Philips Healthcare). In the total cohort of 114 patients with a new diagnosis of breast cancer, the median age was 45 ± 11years and the prevalence of hypertension was 8%. There were no differences in traditional cardiovascular disease risk factors between cases and controls. BRCA carriers had lower LV-GLS (-18.1% ± 4.7% vs. -20.1% ± 3.8%, p = 0.02) and greater right atrial area (12.9cm2 ± 2.7cm2 vs. 11.8cm2 ± 2.0cm2, p = 0.04) compared to controls; however, both LV-GLS and right atrial area were within the normal range. Compared to controls, BRCA carriers had a trend toward worse LV posterior wall thickness (0.89cm ± 0.15cm vs. 0.83cm ± 0.16cm, p = 0.06) although not statistically significant. In women with newly diagnosed breast cancer and prior to treatment, LV-GLS was worse in BRCA1 and BRCA2 mutation carriers compared to those with BRCA wildtype. These findings suggest that BRCA mutations may be associated with subtle changes in cardiac function. Whether differences in GLS translate to increased cardiovascular risk in women with BRCA mutations needs to be further characterized.

A case report: Posterior acetabular deficiency treated with femoral head autograft and hybrid total hip arthroplasty

As a choice for treating acetabular deficiencies, total hip arthroplasty (THA) is beset with many drawbacks, particularly in relation to untreated fractures and post-surgery complications. Furthermore, it is hard to ensure long-term fixation of the acetabular shell. In our case, a 52-year-old male manual laborer presented with complaints of a painful limp of the left lower limb with gross restriction of movements in the left hip joint. Previously, the patient had undergone open reduction and posterior acetabular wall plate fixation 2 years back and implant exit had been done 1 year before due to complaints of pain. We treated the patient with hybrid THA. To rectify the acetabular defect, we used a femoral head autograft, securing it with screws, and supporting it with a plate posteriorly. After 1 year, there was good graft consolidation sans acetabular component displacement as evidenced by radiography. A Harris hip score of 79.7 indicated good functionality. Therefore, hybrid THA with reconstruction is a good option for treating post-traumatic arthritis with acetabular wall deficiencies. Although the procedure is difficult to carry out, it yields better results in terms of lessened pain, enhanced stability, and better functionality.

Young patient with a giant gastric bronchogenic cyst: A case report and review of literature

BACKGROUND Gastric bronchogenic cysts (BCs) are extremely rare cystic masses caused by abnormal development of the respiratory system during the embryonic period. Gastric bronchial cysts are rare lesions that were first reported in 1956; as of 2023, only 33 cases are available in the PubMed online database. BCs usually have no clinical symptoms in the early stage, and imaging findings also lack specificity. Therefore, they are difficult to diagnose before histopathological examination. CASE SUMMARY A 34-year-old woman with respiratory distress presented at our hospital. Endoscopic ultrasound revealed an anechoic mass between the spleen, left kidney and gastric fundus, with hyperechogenic and soft elastography textures and with a size of approximately 6.5 cm × 4.0 cm. Furthermore, a computed tomography scan demonstrated high density between the posterior stomach and the spleen and the left kidney, with uniform internal density and a small amount of calcification. The maximum cross section was approximately 10.1 cm × 6.1 cm, and the possibility of a cyst was high. Because the imaging findings did not suggest a malignancy and because the patient required complete resection, she underwent laparotomy surgery. Intraoperatively, this cystic lesion was found to be located in the posterior wall of the large curvature of the fundus and was approximately 8 cm × 6 cm in size. Finally, the pathologists verified that the cyst in the fundus was a gastric BC. The patient recovered well, her symptoms of chest tightness disappeared, and the abdominal drain was removed on postoperative day 6, after which she was discharged on day 7 for 6 months of follow-up. She had no tumor recurrence or postoperative complications during the follow-up. CONCLUSION This is a valuable report as it describes an extremely rare case of gastric BC. Moreover, this was a very young patient with a large BC in the stomach.

The impact of maxillary dimensions on determining surgical approach of fungal ball in the maxillary sinus

Endoscopic middle meatal antrostomy (MMA) is commonly used for maxillary sinus (MS) fungal ball removal. For challenging cases involving anterior or inferior recess, an additional inferior meatal approach (IMA) might be needed. We analyzed the differences in MS dimensions on CT scans according to the surgical approach to suggest preoperative variables that could facilitate an additional IMA. CT scans of 281 adult patients who underwent ESS for the MS fungal ball (139 MMA, 62 MMA & IMA) were evaluated for comparative analysis of 8 MS measurements based on the surgical approach. Complete removal was achieved in all cases. Age and sex didn't differ significantly (p > 0.05). The maximum distances between the anterior–posterior walls, the inferior ostium border to the lateral recess, and the ostium to the inferior wall of the MS were statistically greater in the MMA & IMA group compared to the MMA group (p = 0.003, p = 0.005, and p = 0.010, respectively), especially among females. This study underscores the clinical importance of specific measurements—anterior to posterior wall, medial wall to lateral recess, and ostium to inferior wall of the maxillary sinus—for guiding optimal surgical approaches in MS lesions.

Diagnosis and treatment of retrorectal cystic hamartoma: clinical case

Background. Retrorectal tumors are a rare group of tumors that can be benign or malignant in origin; in most cases, they are asymptomatic. They mainly arise in the presacral space, which is limited by Waldeyer’s fascia posteriorly, the rectal fascia proper anteriorly, the ureters and lateral ligaments of the rectum laterally, the levator ani muscles and coccyx inferiorly, and the transition of the pelvic peritoneum between the second and third sacral segments superiorly. Magnetic resonance imaging (MRI) is crucial for diagnosis and surgical planning. Most retrorectal tumors require surgical treatment without preoperative biopsy. Here, we present a case of a retrorectal cystic hamartoma that was treated with surgery.Clinical case. Patient N., 45 years old, presented with suspected pelvic malformation. The patient reported experiencing pain in the sacrum area since May 2023, with no history of trauma. She sought medical help at a local polyclinic, where an ultrasound of the pelvic organs revealed a pelvic mass. The patient was then referred to an oncologist at the Multidisciplinary Clinical Medical Center “Medical City”. Physical examination showed no specific features, except upon rectal examination, where a non-displaced tumor measuring up to 2 cm was palpated along the posterior rectal wall. MRI of the pelvic organs confirmed the presence of a mass behind the lower ampullary rectum. Surgical treatment was subsequently performed, and the diagnosis of teratoma was confirmed through morphological and immunohistochemical studies.Conclusion. Early comprehensive diagnostics and an experienced surgical team are key factors for successful treatment of patients with retrorectal tumors.

Three-Year Outcomes of a Randomized Clinical Trial of Perioperative Vaginal Estrogen as Adjunct to Native Tissue Vaginal Apical Prolapse Repair

As the muscular and connective tissue components of the vagina are estrogen-responsive, clinicians may recommend vaginal estrogen to optimize tissues preoperatively and as a possible means to reduce prolapse recurrence, but long-term effects of perioperative intravaginal estrogen on surgical prolapse management are uncertain. To compare the efficacy of perioperative vaginal estrogen vs. placebo cream in reducing composite surgical treatment failure 36 months following native tissue transvaginal prolapse repair. This is the extended follow-up of a randomized superiority trial conducted at 3 tertiary US sites. Postmenopausal patients with bothersome anterior/apical vaginal prolapse were randomized 1:1 to 1g conjugated estrogen cream (0.625mg/g) or placebo, inserted vaginally twice-weekly for ≥5wk preoperatively and continued twice-weekly for 12mo postoperatively. All participants underwent a vaginal hysterectomy (if uterus present) and standardized uterosacral or sacrospinous ligament suspension at surgeon discretion. The primary report's outcome was time-to-failure by 12mo postoperatively defined by a composite outcome of objective prolapse of the anterior or posterior walls beyond the hymen or the vaginal apex descending below one-third the total vaginal length; subjective bulge symptoms; and/or retreatment. After 12mo, participants could choose to use-or not use-vaginal estrogen for atrophy symptom bother. Secondary outcomes included pelvic organ prolapse quantification (POP-Q) points, subjective prolapse symptom severity using the Patient Global Impression of Severity (PGI-S), Patient Global Impression of Improvement (PGI-I), and prolapse-specific subscales of the Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Floor Impact Questionnaire (PFIQ-7). Data were analyzed as intent-to-treat and "per-protocol" (i.e., ≥50% of expected cream use per medication diary). Of 206 postmenopausal patients, 199 were randomized and 186 underwent surgery; 164 (88.2%) provided 36-month data. Mean (SD) age was 65 (6.7) years; characteristics were similar at baseline between groups. Composite surgical failure rates were not significantly different for the estrogen vs. placebo groups through 36 months with model-estimated failure rates of 32.6% (95% CI: 21.6-42.0%) vs. 26.8% (95% CI: 15.8-36.3%), respectively, adjusted hazard ratio, 1.55 (95% CI: 0.90-2.66), P=0.11. Results were similar for the per-protocol analysis. Objective/anatomic failures were more common than subjective/symptomatic failures, combined objective and subjective failures, or retreatment. Using the PGI-I, 75 of 80 (94%) estrogen and 72 of 76 (95%) placebo participants providing 36-month data reported they were much- or very much better 36 months after surgery, P>0.99; these data include reporting from 51 of the 55 "surgical failures". POP-Q measurements, PGI-S scores, and prolapse subscale scores of the PFDI-20 and PFIQ-7 all significantly improved for both estrogen and placebo groups from baseline to 36 months postoperatively without differences between groups. Of the 160 providing data on vaginal estrogen usage at 36 months postoperatively, 40 of 82 (49%) originally assigned to estrogen were using prescribed vaginal estrogen, and 47 of 78 (60%) assigned to placebo were using vaginal estrogen, P=0.15. Adjunctive perioperative vaginal estrogen applied ≥5wk preoperatively and 12mo postoperatively did not improve surgical success rates 36 months after uterosacral or sacrospinous ligament suspension prolapse repair. Patient perception of improvement remained very high at 36 months.

Video X-ray micturition. Note how the downward angulation of the levator plate opens out the posterior urethral wall. Also, how the detrusor spasms to empty.

Video X-ray micturition. Note how the downward angulation of the levator plate opens out the posterior urethral wall. Also, how the detrusor spasms to empty.