Technique For Prolapse Research Articles

The comparative effectiveness of pelvic floor muscle training and hypopressive breathing techniques for pelvic organ prolapse: A systematic review and pooled analysis of randomized controlled trials

BackgroundPelvic floor (PF) disorder affects 25 ​% of females, often progressing to Pelvic Organ Prolapse (POP). PF muscle training (PFMT) and hypopressive breathing (HB) are conservative techniques used to repair pelvic muscles. This study analyzes the comparative efficacy of PFMT and HB for POP. MethodsA systematic review was conducted and seven records were included in the pooled analysis, which compared PF outcomes between HB and PFMT. ResultsPFMT (d ​= ​2.14 and d ​= ​1.07) demonstrated a larger effect size compared to HB (d ​= ​1.24 and d ​= ​0.78) for sEMG contractility and the Modified Oxford Scale, respectively. The Pelvic Floor Disability Index (PFDI-20) found a lower effect size of PFMT (d ​= ​0.558) compared to HB (d ​= ​0.961). ConclusionsPFMT was found to improve PF strength (Oxford) more than HB, while HB had a greater effect on quality of life (PFDI-20). Results were insignificant for contractility.

Reduced port laparoscopic rectopexy for full-thickness rectal prolapse

BackgroundLaparoscopic rectopexy is an established treatment option for full-thickness rectal prolapse. Recently, reduced port surgery (RPS) has emerged as a novel concept, offering reduced postoperative pain and improved cosmetic outcomes compared with conventional multiport surgery (MPS). This study aimed to evaluate the feasibility and safety of RPS for full-thickness rectal prolapse.MethodsFrom October 2012 to December 2018, 37 patients (MPS: 10 cases, RPS: 27 cases) underwent laparoscopic rectopexy for full-thickness rectal prolapse. Laparoscopic posterior mesh rectopexy (Wells procedure) is the standard technique for full-thickness rectal prolapse at our hospital. RPS was performed using a multi-channel access device, with an additional 12-mm right-hand port. Short-term outcomes were retrospectively compared between MPS and RPS.ResultsNo significant differences were observed between MPS and RPS in the median operative time, the median blood loss volume, the postoperative complication rates, and median hospital stay duration after surgery.ConclusionReduced port laparoscopic posterior mesh rectopexy may serve as an effective therapeutic option for full-thickness rectal prolapse. However, to establish the superiority of RPS over MPS, a prospective, randomized, controlled trial is warranted.

Image-Based Computational Fluid Dynamics to Compare Two Repair Techniques for Mitral Valve Prolapse

Objective The treatment of mitral valve prolapse involves two distinct repair techniques: chordal replacement (Neochordae technique) and leaflet resection (Resection technique). However, there is still a debate in the literature about which is the optimal one. In this context, we performed an image-based computational fluid dynamic study to evaluate blood dynamics in the two surgical techniques.Methods We considered a healthy subject (H) and two patients (N and R) who underwent surgery for prolapse of the posterior leaflet and were operated with the Neochordae and Resection technique, respectively. Computational Fluid Dynamics (CFD) was employed with prescribed motion of the entire left heart coming from cine-MRI images, with a Large Eddy Simulation model to describe the transition to turbulence and a resistive method for managing valve dynamics. We created three different virtual scenarios where the operated mitral valves were inserted in the same left heart geometry of the healthy subject to study the differences attributed only to the two techniques.Results We compared the three scenarios by quantitatively analyzing ventricular velocity patterns and pressures, transition to turbulence, and the ventricle ability to prevent thrombi formation. From these results, we found that the operative techniques affected the ventricular blood dynamics in different ways, with variations attributed to the reduced mobility of the Resection posterior leaflet. Specifically, the Resection technique resulted in turbulent forces, related with the risk of hemolysis formation, up to 640 Pa, while the other two scenarios exhibited a maximum of 240 Pa. Moreover, in correspondence of the ventricular apex, the Resection technique reduced the areas with low velocity to 15%, whereas the healthy case and the Neochordae case maintained these areas at 30 and 48%, respectively. Our findings suggest that the Neochordae technique developed a more physiological flow with respect to the Resection technique.ConclusionResection technique gives rise to a different direction of the mitral jet during diastole increasing the ability to washout the ventricular apex preventing from thrombi formation, but at the same time it promotes turbulence formation that is associated with ventricular effort and risk of hemolysis.

A Modified McCall Culdoplasty in Pelvic Organ Prolapse Surgery: Anatomical and Functional Outcomes.

The aim of this study was to evaluate anatomical and functional outcomes of a modified McCall culdoplasty compared with the traditional technique for pelvic organ prolapse. This prospective clinical observational study was conducted in a secondary referral urogynecological center between October 2021 and October 2022. A modified McCall culdoplasty was performed in 85 patients (group A). It was characterized by dissection of uterosacral ligaments up to the ischial spines, their shortening and attachment to the vaginal apex and both the rectovaginal and the vesicovaginal fascia. Outcomes were compared with those of a group of 86 patients (group B) who underwent the traditional culdoplasty between September 2020 and September 2021. Primary outcome was prolapse recurrence. Secondary endpoints included subjective outcomes, vaginal length, quality of life, and urinary and anal incontinence. Statistical analysis was conducted using Fisher's exact, Mann-Whitney U, and Student's t tests. At 12months, prolapse recurrence occurred in 2.5% (CI 0.7-8.8%) of patients in group A and in 6.7% (CI 2.9-14.7%) in group B. Postoperative vaginal length was 8.3 ± 0.78cm in group A and 6.4 ± 1.1cm in group B (p < 0.001). The Patient Global Impression of Improvement questionnaire revealed that 76 patients (96.2%) in group A versus 64 (85%) in group B were very satisfied (p < 0.03). Both groups showed an improvement in urinary symptoms and quality of life. The modified McCall culdoplasty showed successful anatomical and functional outcomes, with a tendency towards lower recurrence rates than the traditional McCall procedure. Further long-term studies are needed to confirm our data.

Subjective Long-Term Outcomes After Vaginal Native Tissue Hysteropexy: Cohort Study.

There are still doubts about long-term satisfaction rates of native tissue uterine preserving surgical techniques for pelvic organ prolapse. The objective of this study was to compare long-term subjective success rates and satisfaction rates between vaginal sacrospinous hysteropexy (SSHP) and vaginal hysterectomy with uterosacral ligament suspension (VH-USLS). This was a retrospective single-center, observational matched cohort study in women receiving either SSHP or VH-USLS between 2004 and 2021. Primary outcome was overall subjective success (combined outcome of absence of bulge nor retreatment, and satisfaction with operation) at least 12 months after surgery. Satisfaction with the operation was defined as a combined Patient Global Impression of Improvement rating ≤ 2 and a patient satisfaction score ≥7. Of 583 patients, 192 patients could be matched (SSHP, 96; VH-USLS, 96), with 55% (SSHP, 60; VH-USLS, 45) participating at the telephone interview. Mean follow-up time was 77 months for VH-USLS, and 36 months for SSHP, respectively. No difference in overall subjective success rates was found between the groups (45% VH-USLS and 51% SSHP; P = 0.54). Overall satisfaction was similar between both groups (70% vs 71%, P = 0.90). Logistic regression found no influence of duration of follow-up and the overall subjective success rate. Both procedures would be recommended to a relative or friend by a large majority of patients (88% vs 85%, P = 0.761). Operative time and hospitalization time were significantly shorter in the SSHP group. No serious complications were reported. Overall success rates did not differ between both procedures after at least 1 year of follow-up with relatively high satisfaction rates. Sacrospinous hysteropexy had shorter operative time and shorter duration of hospitalization.

Novel Repair Technique for Oral and Anal Side Stoma Prolapse of a Loop Colostomy With the Stapled Modified Altemeier Method Using Indocyanine Green Fluorescence Imaging.

Stoma prolapse is a common complication in the late phase after stoma creation. With advances in chemotherapy, a double-orifice colostomy or ileostomy and chemotherapy are used to treat primary unresectable colorectal cancer. Preoperative therapy with a double-orifice colostomy or ileostomy is performed to aid primary colorectal cancer miniaturization. Therefore, the number of stoma prolapses will likely increase in the future. Previous reports on the repair of stoma prolapse focused on unilateral stoma prolapse of loop colostomy, and there are no reports about the bilateral stoma prolapse of loop colostomy or ileostomy. We report a novel repair technique for oral and anal side (bilateral) stoma prolapse of a loop colostomy with the stapled modified Altemeier method using indocyanine green (ICG) fluorescence imaging considering the distribution of marginal artery in preventing marginal artery injury which has considerable clinical significance. Our novel technique for the oral and anal side prolapse of a loop colostomy is considered effective and safe.

Transvaginal extraperitoneal single-port laparoscopic sacrocolpopexy for apical prolapse after total/subtotal hysterectomy: Chinese surgeons' initial experience.

To introduce a novel technique of transvaginal extraperitoneal single-port laparoscopic sacrocolpopexy (ESLS) for apical prolapse and to evaluate the feasibility and short-term outcomes of this technique. Sixteen patients were enrolled to undergo ESLS between January 2020 and May 2021. Perioperative outcomes were included. Short-term results were assessed by Pelvic Floor Distress Inventory-20 (PFDI-20), Pelvic Organ Prolapse Quantification (POP-Q) scores, mesh exposure and prolapse recurrence. A total of 14/16 cases (87.5%) were successfully completed. The mean operation time was 118min (range 85-160), and the mean blood loss was 68ml (range 20-100). The mean postoperative visual analog scale (VAS) pain score at 24h was 0.7. No intraoperative complications occurred except for one patient who developed subcutaneous emphysema. All patients gained a significant improvement in both physical prolapse and quality of life at 12 months after surgery, and there was no mesh exposure or prolapse recurrence. Our experience showed that transvaginal ESLS is a feasible and effective technique for apical prolapse with a previous hysterectomy. However, this technique should be performed by surgeons with extensive experience both in vaginal surgery and laparoscopic single-port surgery.

Alfieri versus conventional repair for bileaflet mitral valve prolapse

ObjectiveMitral valve repair for bileaflet prolapse can be complex, involving multiple chords or resection. The Alfieri technique for bileaflet disease is simple but may be associated with mitral stenosis or recurrent mitral regurgitation. Outcomes of patients with bileaflet prolapse undergoing mitral valve repair using the Alfieri versus conventional chord/resection techniques were compared. MethodsAdults undergoing mitral valve repair for bileaflet prolapse for degenerative disease from 2017 to 2023 were stratified by repair technique. Outcomes including operative mortality and echocardiogram data were compared. Time to event analysis was used to characterize freedom from recurrent mitral regurgitation (moderate or greater mitral regurgitation). ResultsAmong 188 patients with bileaflet prolapse, 37% (70) were repaired with the Alfieri and the remaining patients were repaired with chords/resection. Compared with chords/resection, patients undergoing the Alfieri had shorter cardiopulmonary bypass and crossclamp times. Operative mortality (0% [0/70] vs 2% [2/118], P = .27) was similar between both techniques. The mean mitral gradient was low and similar for the Alfieri versus chords/resection (3 vs 3, P = .34). Development of recurrent mitral regurgitation at 2 years, incorporating the competing risk of death and mitral reintervention, was 4.3% (95% CI, 1.5%-9.3%) for the Alfieri technique and 5.8% (95% CI, 2.2%-11.8%) for chord/resection (P = .83). ConclusionsBoth the Alfieri and chord/resection techniques had low rates of recurrent mitral regurgitation at 2 years. The mitral valve gradient was low and similar regardless of technique; thus, those who received the Alfieri technique did not have an increased rate of mitral stenosis. The Alfieri may be an underused technique for bileaflet prolapse.

Old meets new: vNOTES retroperitoneal promontory fixation in conjunction with the uterus preserving Manchester procedure.

The Manchester procedure is a classic native tissue prolapse technique with low recurrence and low complication rate. vNOTES (vaginal natural orifice transluminal endoscopic surgery) is a vaginal approach to enter the intra or retroperitoneal space, with the guidance of endoscopic visualization. Different studies have shown women to prefer uterus-preserving correction of prolapse over hysterectomy, as they worry about complications, impact on sexual function and self- sense. At the same time, an increasing caution and awareness of mesh related complications has evolved, giving a need for the development of additional non-mesh uterus preserving surgical techniques for prolapse. The aim with the video is to show a new surgical technique for prolapse, combining the Manchester procedure with vNOTES retroperitoneal non-mesh promontory hysteropexy.

Comparison of laparoscopic pectopexy with the standard laparoscopic sacropexy for apical prolapse: an exploratory randomized controlled trial

To compare laparoscopic pectopexy with the standard laparoscopic sacropexy in women with symptomatic apical prolapse. An interim analysis of an exploratory randomized controlled trial with the primary objective of comparing mesh fixation time and secondary objectives were to compare total operating time, blood loss, and intra-operative and post-operative complications. Additionally, patients completed the Prolapse Quality of Life (P-QOL) and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) questionnaires before surgery and during six months follow-up visit to evaluate the overall improvement in quality of life and sexual function. Patient Global Impression of Improvement (PGI-I) score was calculated on the 7-10th day post-operatively and then at six months to assess the level of improvement. The study included 30 patients; 15 underwent laparoscopic sacropexy, and 15 underwent laparoscopic pectopexy. Baseline characteristics were comparable in both groups. The mean duration of mesh fixation was significantly less with laparoscopic pectopexy (45.00±11.34 minutes) than laparoscopic sacropexy (54.67±9.35 minutes) (p=0.019). The total operating time and blood loss tended to be less in the pectopexy group, but not significantly so. Only one patient in the pectopexy group had a bladder injury. No patient in either group had any post-operative complications. One case in each group had a relapse of apical prolapse. All the domains of PISQ-12, P-QOL, and PGI-I scores improved significantly after both procedures. Laparoscopic pectopexy is a safe, feasible, and comfortable alternative procedure to the standard sacropexy for apical prolapse. We noted significantly less mesh fixation time and less operating time, while blood loss tended to be less with laparoscopic pectopexy than with laparoscopic sacropexy. Post-operative parameters were comparable between techniques. Both corrective techniques for prolapse improved the PGI-I, P-QOL, and PISQ-12 scores.

Long-term outcomes and quality of life after Manchester procedure for pelvic reconstructive surgery in women with cervical elongation

ObjectiveNative-tissue techniques for Pelvic Organ Prolapse (POP) repairs, such as the Manchester Procedure (MP), have recently been revitalized. However, there are conflicting opinions regarding correcting cervical elongation support by the MP, and the risk of possible poor outcomes and postoperative complications.Therefore, this study aimed to investigate anatomical and patient-reported outcomes during one year after MP. DesignProspective cohort study. SettingThis study was conducted on women who underwent the MP for cervical elongation between 2010 and 2020. PatientsWomen with apical compartment prolapse up to stage 3 due to cervical elongation. InterventionsManchester Procedure. MeasurementsPre and postoperative evaluations by POP Quantification (POP-Q) system were performed, and patients filled out the quality-of-life questionnaires including Pelvic Floor Distress Inventory Short Form 20 (PFDI-20), and POP/Urinary Incontinence Sexual Questionnaire (PISQ-12) before and 12 months after the procedure. Anatomical outcomes were measured by POP-Q and the changes in POP-related symptoms were evaluated and reported. Main Results33 participants were recruited in the study. Significant anatomical improvements were obtained in all compartments after the surgery. After 12 months in POP-Q examination, the mean (±SD) of Ba was changed from +1.82 (±1.71) to −1.18 (±1.50), C was changed from −1.25 (±2.81) to −6 (±1.82), and D from −6.30 (±1.42) to −7.1 (±1.25) respectively (P < 0.001). POP-Q stage 0–1 was obtained inof7% in the apical compartment (C < −1), but only in 45.4% in the anterior compartment (Ba < −1). A significant reduction in symptom scores was obtained for PFDI-20 (P < 0.01) and PISQ-12 (P = 0.011). ConclusionsOur findings suggest that the MP provides adequate apical support with improvement in anatomic and subjective findings for patients with cervical elongation.

Long-term outcomes of cable-suspended suture technique versus conventional suture for anterior vaginal wall prolapse: a retrospective cohort study

BackgroundAnterior colporrhaphy (AC) is a conventional surgical repair technique for cystocele but with high recurrence rate. We present a novel technique: Cable-suspended structure (CSS) by non-absorbable suture combined with "bridge" formation in surgical treatment of cystocele. This study aimed to evaluate and compare the long-term outcome of CSS technique for anterior vaginal wall repair with AC.MethodsA retrospective review was performed on patients who underwent anterior vaginal wall repair between January 2012 and March 2017 at our center. All the patients were under a follow-up survey. The primary outcomes were objective cure (anterior prolapse POP-Q ≤ stage 1) and subjective cure (no symptoms of bulge or retreatment for prolapse). Secondary outcomes included quality of life (QOL) and patients’ satisfaction, outcomes of site-specific POP-Q points Aa, Ba and C, as well as postoperative complications.ResultsOf 91 included participants, 43 underwent AC and 48 underwent CSS. The proportion of sarcrospinous ligament fixation in the CSS group was higher than in the AC group (81.4% vs. 77.1%, P < 0.05). At a median follow-up of 69 months, the CSS group showed significantly higher objective cure rate compared with the AC group (72.9% vs. 51.2%, odds ratio 2.57, 95%CI 1.07–6.16). After adjusting for sarcrospinous ligament fixation, the CSS group still significantly showed higher objective cure rate (adjusted odds ratio 2.88, 95%CI 1.16–7.21). The proportion of the patients with POP-Q 0 stage in the CSS group was particularly higher than the AC group (25% vs. 7.0%, P = 0.025). There was no difference between the groups with respect to subjective cure, patients’ satisfaction and postoperative complication.ConclusionsThe CSS technique showed better objective outcome than AC, however, subjective cure rate did not significantly differ between the two. Future prospective trial with large-scale should confirm the effectiveness and safety of CSS in sexually active women.

Lateral suspension with V-NOTES for the treatment of pelvic organ prolapse with the Salman-KetenciGencer technique.

Pelvic organ prolapse (POP) is a common morbidity and 10-20% of the patients need surgical correction. Sacrocolpopexy or sacrohysteropexy procedures are satisfactory but still difficult. Lateral suspension (LS) as a safe and simple technique has become an alternative technique recently. Vaginal natural orifice transluminal endoscopic surgery (V-NOTES) is also a new modality and LS using V-NOTES has not been performed previously and should be promising. This prospective observational pilot study was conducted with a total of 38 women with stage 3 and 4 POP according to the Pelvic Organ Prolapse Quantification grading system (POP-Q). Lateral suspension via V-NOTES was performed with the Salman-KetenciGencer technique using a mesh for POP. The preoperative and postoperative 6-month POP-Q stages together with Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) scores were recorded and compared. Comparison of the preoperative and postoperative 6-month POP-Q stages of the patients were statistically significant except for the total vaginal length (p<0.01). Compared with the preoperative total and subscale scores of PISQ-12, the postoperative values were considerably improved (p<0.001). With the Salman-KetenciGencer technique not only good anatomical but also good functional results were obtained with V-NOTES. Surgeons may focus on uterine sparing while using the Salman-KetenciGencer technique for apical prolapse owing to the higher rate of complications related to the colposuspension and better sexual results after the cervicosuspension.

Management of Pelvic Organ Prolapse with or without Hysterectomy Via Transvaginal Robotic Notes High Uterosacral Ligament

<h3>Study Objective</h3> To demonstrate stepwise techniques for the successful use of the robotic-assisted transvaginal natural orifice transluminal endoscopy surgery high uterosacral ligament suspension (RvNOTES-HUS) technique for pelvic organ prolapse with and without uterine preservation. <h3>Design</h3> Stepwise demonstration with narrated video footage (Canadian Task Force classification III). <h3>Setting</h3> An academic tertiary care hospital. <h3>Patients or Participants</h3> Case 1: 62-year-old G0P0 with a symptomatic stage Ⅱ anterior vaginal prolapse and Stage Ⅱ uterine prolapse. Preoperative vaginal length was measured at 9cm. Case 2: 42-year-old G3P2 with a symptomatic fibroid uterus with stage Ⅱ anterior vaginal prolapse and Stage Ⅱ uterine prolapse. Preoperative vaginal length was measured at 8cm. <h3>Interventions</h3> Since the approval of the robotic platforms in gynecologic surgery by the Food and Drug Administration in 2005¹, robotic assisted surgery has been proliferating in the treatment of benign gynecological diseases including sacrocolpopexy, hysterectomy, myomectomy and endometriosis resection^2-5. In recent years, publications have demonstrated the feasibility and safety of traditional laparoscopic assisted high uterosacral ligament suspension for pelvic organ prolapse with long term follow up^6-8. However, robotic assisted RvNOTES-HUS has yet to be investigated in a publication. Utilizing the RvNOTES-HUS technique with or without uterine preservation operations greatly reduces the difficulty of intraperitoneal suture for the surgeon and postoperative pain for the patient. <h3>Measurements and Main Results</h3> Case 1: Procedure was successfully performed with a postoperative vaginal length of 8cm. Pain level was 4/10 in the first week, 2/10 in the second, 0/10 in the third. POP was stage 0. Case 2: Procedure was successfully performed with a postoperative vaginal length of 7cm. She had one day of post-operative pain. POP was stage 0. <h3>Conclusion</h3> RvNOTES-HUS is a practical technique in women with uterine prolapse while choosing whether to preserve the uterus. This technique allows for the better exposure of the ureter, while the articulating robotic joints allow for increased precision of dissection and suturing.

Endoscopic Lumbar Discectomy Using Side-Viewing Conical Working Tube: An Institutional Experience

Abstract Objective The paradigm of surgical therapy for spinal disease especially for lumbar disc herniation (LDH) has gradually shifted from the traditional open surgeries to minimal invasive spinal surgeries. Endoscopic discectomy has been performed widely using various devices and techniques. In this study we present our experience of endoscopic discectomy using a unique device with separate side-viewing channel. Methods Twenty-six patients with LDH treated between March 2015 and April 2018 using the unique conical working tube with separate side-viewing endoscopic channel have been retrospectively analyzed. Their preoperative and postoperative Oswestry Disability Index (ODI) and Macnab scores were used to evaluate the outcome with a mean follow-up of 37.04 months. Results There were 18 males and 8 females with age ranging from 19 to 72 years (mean, 38.4 years). The follow-up ranged from 25 to 60 months with mean of 37.04 months. The mean preoperative ODI score was 72.4, which decreased to a mean of 7.6 and the outcome evaluated by Macnab criteria was 65.3% excellent, 19.2% good, 11.5% fair, and 3.8% poor. One patient underwent second surgery. None of the patients had to change their occupation postoperatively. Complications that occurred were dural tear in one patient and transient foot paresis in one, which improved spontaneously. Conclusion Endoscopic discectomy using conical working tube is a safe and effective technique for lumbar disc prolapse. The long-term results are comparable to the conventional techniques.

Single-Incision vs. Multiport Robotic Sacrocolpopexy: 126 Consecutive Cases at a Single Institution.

Robot-assisted laparoscopic sacrocolpopexy (RSC) has gained popularity as a method for easier intracorporeal suturing than conventional laparoscopic sacrocolpopexy. However, few studies have compared multiport RSC (MP-RSC) and single-incision RSC (SI-RSC). We aimed to compare perioperative outcomes between these techniques for advanced pelvic organ prolapse (POP). We analyzed 126 patients who underwent RSC for POP quantification (all stage III to IV) between March 2019 and May 2021 at Seoul Asan Medical Center. We prospectively collected operation-related data, including total operation time (OT; from skin incision to closure) and perioperative outcomes. A total of 106 and 20 patients underwent MP-RSC and SI-RSC, respectively. The mean ages were 57.49 ± 10.89 and 56.20 ± 10.30 years in the MP-RSC and SI-RSC groups, respectively. The mean total OT was significantly shorter for MP-RSC than for SI-RSC (105.43 ± 24.03 vs. 121.10 ± 26.28 min). The OT difference was 15.67 min (95% confidence interval, 3.90–25.85, p = 0.009). No statistically significant differences were observed in terms of perioperative variables (estimated blood loss, hospital stay) and postoperative adverse events (POP recurrence, mesh erosion). SI-RSC had comparable intraoperative and postoperative outcomes to MP-RSC, with additional cosmetic benefits. MP-RSC had significantly shorter OT than SI-RSC.

Mitral repair with leaflet preservation versus leaflet resection and ventricular reverse remodeling from a randomized trial

ObjectivesIn the Canadian Mitral Research Alliance (CAMRA) Trial CardioLink-2 leaflet resection versus preservation techniques for posterior leaflet prolapse was investigated and no difference was shown in their effect on mean mitral gradient at peak exercise at 12 months postoperatively. The purpose of this subanalysis was to evaluate the effect of the 2 strategies on left ventricular (LV) reverse remodeling after repair. MethodsA total of 104 patients were randomized to either a leaflet resection or leaflet preservation strategy. Echocardiograms, performed at baseline (preoperative), predischarge, and 12 months postoperatively, were analyzed in a blinded fashion at a core laboratory. ResultsAll patients underwent successful mitral repair. At discharge, 3 patients showed moderate mitral regurgitation, whereas the remainder showed mild or less regurgitation. Compared with the baseline echocardiogram, the indexed end diastolic volume was reduced at the discharge echocardiogram (P < .0001) and was further reduced at the 12-month echocardiogram (P = .01). In contrast, the indexed end systolic volume did not significantly change from baseline assessed at the predischarge echocardiogram (P = .32) but improved at 12 months postoperatively (P < .0001), resulting in a corresponding improvement in ejection fraction at 12 months (P < .0001). The type of mitral repair strategy had no significant effect on LV reverse remodeling trends. ConclusionsThe mitral repair strategies used did not influence postoperative LV reverse remodeling, which occurred in stages. Although LV end diastolic dimensions recovered before discharge, improvements in LV end systolic dimension were evident 12 months after repair.

Surgical Techniques for Rectal Prolapse

Complete rectal prolapse or rectal procidentia is a debilitating disease that presents with fecal incontinence, constipation, and rectal discharge. Definitive surgical techniques described for this disease include perineal procedures such as mucosectomy and rectosigmoidectomy, and abdominal procedures such as rectopexy with or without mesh and concomitant resection. The debate over these techniques regarding the lowest recurrence and morbidity rates, and the best functional outcomes for constipation or incontinence, has been going on for decades. The heterogeneity of available studies does not allow us to draw firm conclusions. This article aims to review the surgical techniques for complete rectal prolapse based on the current evidence base regarding surgical and functional outcomes.

Short-term outcomes of anterior approach sacrospinous ligament fixation for apical vaginal prolapse - A retrospective study.

Vaginal sacrospinous fixation and sacrospinous hysteropexy (SSF/SSHP) are highly effective procedures for apical compartment prolapse. The established technique is the posterior vaginal approach. The alternative anterior approach through an anterior vaginal incision, although occasionally mentioned in the literature, is less well established. However, this approach is a more appropriate route if posterior vaginal surgery is not indicated. The aim of this paper is to review surgical outcomes of anterior approach in our centre and to compare outcomes of SSF vs SSHP. Retrospective case note review of 60 patients who underwent anterior SSF for prolapse between 2009-2017 was performed. Preoperative and postoperative symptoms and findings were recorded. Anterior SSF involved an anterior vaginal incision and paravaginal access to the ligament for dissection and fixation to either the cervix or vault. SSF was performed in 39 patients, out of which 8 underwent vaginal hysterectomy concomitantly. SSHP for uterine prolapse was performed in 21 patients. There were no cases of recurrent apical prolapse in the cohort at mean follow-up of 1 year. No intra-operative visceral injuries were observed. Recurrence of anterior wall prolapse and postoperative voiding dysfunction was observed in 8.3% and short-term buttock pain in 6.6% of patients. Anterior approach SSF and SSHP is a safe and effective technique for apical prolapse and is the recommended route when posterior vaginal surgery is not required.

Laparoscopic excision and re-attachment of sacrocolpopexy mesh.

Two cases are described and surgical techniques for recurrent pelvic organ prolapse after minimally invasive sacrocolpopexy are demonstrated at an academic affiliated hospital in patients with recurrent pelvic organ prolapse after minimally invasive sacrocolpopexy. A laparoscopic approach was taken for surgical intervention, with excision of prior detached vaginal mesh and re-attachment of new sacrocolpopexy mesh. Two patients presented with recurrent pelvic organ prolapse after failed surgical treatment. The first case is a 68-year-old vaginal multipara with recurrent pelvic organ prolapse status post laparoscopic supracervical hysterectomy, sacrocolpopexy, and mid-urethral sling performed at an outside institution. Preoperative physical examination revealed stage 3 prolapse. Mesh was loosely attached to the cervix. After surgical correction, postoperative physical examination revealed stage 1 prolapse at the 6-week postoperative visit. The second case is a 62-year old vaginal multipara with recurrent pelvic organ prolapse status post-total laparoscopic hysterectomy and sacrocolpopexy at an outside institution. Preoperative physical examination revealed stage 2 prolapse. The mesh was loosely attached to the vagina. After surgical correction, postoperative physical examination revealed stage 0 prolapse at the 6-week postoperative visit. Both patients reported improvement in symptoms and overall quality of life. Surgical management of recurrent pelvic organ prolapse after failed initial sacrocolpopexy procedure can be safely accomplished laparoscopically through identification of points of mesh detachment, anatomical landmarks, removal of the prior vaginal portion of the mesh, and attachment of a new surgical mesh to either the sacrum or the sacral portion of the mesh.