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PubMed1986

Pathological anatomy of ventricular septal defect associated with aortic valve prolapse and regurgitation.

In an attempt to clarify the pathogenetic morphology of aortic regurgitation (AR) due to prolapse of the aortic valve (prolapsing AR) associated with ventricular septal defect (VSD), 201 specimens from Japanese autopsy series with isolated VSD were examined. Among these hearts, there were 128 cases (64%) of infundibular VSD (IVSD); 29 of them (14%) showed AR due to prolapsed cusp, of which nine cases developed a large aneurysm of the sinus of Valsalva. Another 32 cases (16%) had varying degrees of prolapse but without AR and were considered to show the prodrome of prolapsing AR. These 61 cases (30%) were examined with special reference to the type of septal alignment, location of the defect, relation of the defect to the aortic valve, and anomalies of the aortic valve and sinus of Valsalva. There were two principal forms in this syndrome: The common form, i.e., simple punched-hole IVSD with normal septal alignment in 82% (50/61) of cases, and a rare form, i.e., malalignment IVSD in 18% (11/61) of cases. The latter included Eisenmenger-type IVSD due to anteriorly deviated outlet septum (10/11 cases) and coarctation-type IVSD due to posteriorly deviated septum (1/11). Both forms had several subtypes according to the location of the defect, i.e., subpulmonic, muscular, perimembranous, and total IVSD. The relevant anatomical findings of the common form of the syndrome were: There was no septal malalignment with a normal aortic valve position. The VSD was a simple muscular defect in any part of the infundibular septum between the pulmonary valve above and the membranous septum below, the majority of cases (80%), however, showed subpulmonic IVSD. The annulus and sinus of Valsalva wall of the right coronary cusp, which is normally supported firmly by this septum, became exposed in the muscle defect and were poorly supported. The majority of cases showed a normally formed aortic valve but with poor support. The muscular defect was relatively large, but the functioning VSD was usually less than moderate in size with a half-moon shape below the denuded sinus of Valsalva wall and annulus. The functioning VSD appeared to become narrower depending on the degree of prolapse into the defect, resulting in a crescent-moon or slit-like shape, and it may close in rare cases. The major anatomical findings of the rare form were: There was mild to moderate dextroposition (or levoposition) of the aortic valve due to a septal malalignment.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗
PubMed1984

Rectopexy to the promontory for the treatment of rectal prolapse. Report of 257 cases.

From 1953 to 1982, 257 patients with complete rectal prolapse were operated upon. To the procedure described by Orr, we have added mobilization of the rectum prior to its suspension and eliminated the pouch of Douglas, and nylon strips have been used for suspension in most patients. There were 57 male and 200 female patients. Ages ranged from 11 to 90 years. Sixty-one patients had already undergone surgery for rectal prolapse with another procedure and prolapse had recurred. The postoperative course was uneventful in 96 per cent of patients. Two patients, aged 79 to 83 years, died of cardiac failure. Follow-up of 115 patients ranged from five to 23 years. Recurrent rectal prolapse was observed in 4.3 per cent of the patients in whom nylon strips were used to suspend the rectum. In 136 patients anal incontinence was associated with rectal prolapse. Normal continence was restored in 84.1 per cent of 107 patients with rectopexy alone and in 64.2 per cent of 14 patients who underwent rectopexy and anal sphincter repair. It is concluded that rectopexy to the promontory with nylon strips after mobilization of the rectum is a safe and efficient procedure for the treatment of rectal prolapse.

Adolescent↗
PubMed1981

Results of treatment for rectal prolapse and fecal incontinence.

Fifty-six patients were treated for rectal prolapse or incontinence. Rectal prolapse was present in 32 patients and was associated with fecal incontinence in 24 (75 per cent). Incontinence without prolapse was present in 24 patients, 12 of whom were less than 40 years old. Rectopexy was used for treatment of rectal prolapse. Surgical treatment of fecal incontinence was by postanal repair; external sphincter reconstruction and surgery was advised only if control of diarrhea and electrical therapy had been of no benefit. Rectopexy was completely successful at controlling rectal prolapse in all cases, and only four of the 20 (20 per cent) patients with incontinence and prolapse remained incontinent after rectopexy alone. Incontinence was completely controlled by postanal repair in 58 per cent of patients and by external sphincter repair alone or in combination with postanal repair in 67 per cent. Using a combination of therapies 45 of 48 patients who were initially incontinent were improved (94 per cent), and 42 of the patients have complete control of defecation (87 per cent).

Adult↗
PubMedDate not supplied

Abdominal hysterectomy and Burch colposuspension for uterovaginal prolapse.

The recurrence rate for prolapse in patients who underwent abdominal hysterectomy and sacrocolposuspension for genital prolapse were determined. Patient records were reviewed and 58 patients who had undergone abdominal hysterectomy for genital prolapse and sacrocolposuspension with mesh were included. The patients' median age was 47.0 years and parity 3. Preoperatively, 25 patients (43%) presented with bladder symptoms, 17 (29%) with bowel symptoms and 45 (78%) with something protruding through the vagina. All patients underwent hysterectomy, of which 51 (88%) were subtotal. Colposuspension was performed by inserting a mesh from the mid-vagina to the sacrum (S1). A Burch colposuspension was performed in 50 patients (87%). The median follow-up was 20 months. Six patients (10%) developed recurrent prolapse, of which five (9%) underwent repeat surgery. There were no mesh erosions. The recurrence rate for prolapse was low, indicating that abdominal hysterectomy with sacrocolposuspension is an excellent option for uterovaginal prolapse.

Adult↗
PubMed2005

Severity of pelvic organ prolapse associated with measurements of pelvic floor function.

This study tested the hypothesis that clinical measurements of the superficial perineum and of pelvic floor muscle (PFM) function correlate with the severity of pelvic organ prolapse. This retrospective cross-sectional study assessed 1037 women in an academic urogynecologic practice. Greatest descent of prolapse, by the Pelvic Organ Prolapse Quantification system, was correlated with two assessments of levator function--the Oxford grading scale and levator hiatus (LH) size measured by digital examination. Correlations were calculated using Pearson's correlation for continuous variables and Kendall's tau-b. Severity of prolapse correlated moderately with genital hiatus (GH) (r = 0.5, p<0.0001) and with LH (transverse r = 0.4, p < 0.0001; longitudinal r = 0.5, p < 0.0001), but weakly with the Oxford grading scale (r = -0.16, p < 0.0001). LH correlated with GH (r = 0.5, p < 0.0001) but not with perineal body (r = 0.06, p = 0.06). Both GH and LH size are associated with the severity of prolapse. LH size correlates more strongly to prolapse severity than assessment of PFM function by the Oxford grading scale.

Adult↗
PubMed2005

Concomitant pelvic organ prolapse surgery with TVT procedure.

The aim of this study is to evaluate the efficacy and feasibility of concomitant pelvic reconstructive surgery with tension-free vaginal tape (TVT) procedure to treat pelvic organ prolapse women with urodynamic stress incontinence (USI) or occult USI. Seventy-five women with pelvic organ prolapse and diagnosed as USI or occult USI were enrolled in this study. All patients with USI or occult USI underwent TVT treatment under general anesthesia, combined with transvaginal total hysterectomy (VTH), anterior-posterior colporrhaphy (APC), and/or right sacrospinous ligament suspension (SSS) reconstructive surgeries. The subjective assessment was evaluated by using a visual analog scale (VAS) score and a urinary symptomatic questionnaire. The objective assessment was carried out with a 1-h pad test, cough stress test, and urodynamic examination. Of the 75 patients, 35 patients with grade III uterine prolapse underwent VTH and APC, 30 patients with grade IV uterine prolapse underwent VTH, SSS, and APC, and the other 10 patients who had previous hysterectomy with total vaginal vault prolapse underwent SSS and APC. The mean follow-up interval was 25 months (12-42 months). The mean hospitalization was 5.9 days and the mean catheterization time was 3.8 days. The subjective success rate for the treatment of urine incontinence was 88%, and the objective complete cure rate was 84%. The rate of postoperative complications with persistent urinary urgency, de novo detrusor overactivity, dysfunctional voiding, and tape erosion were 50, 8, 12, and 1.3%, respectively. There were no bladder perforations during the TVT procedure and no perioperative complications requiring conversion to laparotomy. Pelvic organ prolapse women with USI or occult USI can be treated by reconstructive surgeries combined with a TVT procedure to treat and prevent postoperative USI.

Adult↗
PubMed2006

Optimizing pelvic organ prolapse research.

For many years, researchers on this field have suffered from the lack of an efficient method for describing pelvic organ prolapse. Struggling to solve this problem, the International Continence Society has proposed a pelvic organ prolapse quantification (POP-Q) system [Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JO, Klarskov P, Shull B, Smith ARB, Am J Obstet Gynecol, 175(1):1956-1962, 1996], which was validated as a precise and reproducible technique for describing pelvic organ position. However, even though very precise at describing pelvic organ position, our critic to this system is its limited ability to quantify the prolapse itself, since it still classifies prolapse into four grades, almost the same way as Baden and Walker did in 1972. As a result, the same grade can include a wide prolapse intensity range. The objective of this paper is to propose a method that makes POP research more efficient by directly measuring prolapse as a continuous variable that requires lesser number of subjects in order to achieve statistical significance.

Anthropometry↗
PubMed2007

A simple teaching tool for training the pelvic organ prolapse quantification system.

The pelvic organ prolapse quantification (POPQ) system is currently the most common and specific system describing different prolapse stages. Nevertheless, its use is not yet accepted worldwide in routine care. Our aim was to develop a simple teaching tool for the POPQ system capable of simulating different stages of uterovaginal prolapse for use in medical education with hands on training. We constructed a moveable and flexible tool with an inverted Santa Claus' cap, which simulated the vaginal cuff and the tassel at the end representing the cervix. A wooden embroidery frame fixed the cap and served as the hymen, the reference point for all measurements. Inside the cap, we sewed buttons to define the anatomic landmark points Aa and Ap located 3 cm distal from the frame. After explaining the device to the students, we used the three-by-three grid for recording the quantitative description of the pelvic organ support. First, each student had to demonstrate a specific prolapse with his cap device. Then, a prolapse was simulated on the cap, and the student had to take the relevant measurements and record them in the POPQ grid. The main training effect to understand the POPQ system seems to be the possibility for each trainee to simulate a three-dimensional prolapse with this flexible vagina model.

Disease Progression↗
PubMed1999

A retrospective comparison of abdominal sacrocolpopexy with Burch colposuspension versus sacrospinous fixation with transvaginal needle suspension for the management of vaginal vault prolapse and coexisting stress incontinence.

The objective of this study was to compare the surgical outcome of abdominal sacrocolpopexy and Burch colposuspension with sacrospinous fixation and transvaginal needle suspension in the management of vaginal vault prolapse and coexisting stress incontinence. One hundred and seventeen women with vaginal vault prolapse and coexisting stress incontinence were surgically managed over a 7-year period. The first 61 consecutive women who underwent sacrospinous fixation and transvaginal needle suspension comprised the vaginal group, and the following 56 consecutive women who underwent abdominal sacrocolpopexy and Burch colposuspension comprised the abdominal group. Office records were reviewed to assess the presence of recurrent prolapse and urinary incontinence during postoperative follow-up. Objective follow-up was available for 101 women. Mean duration of follow-up was 24.0 +/- 15 months for the vaginal group, and 23.1 +/- 12.6 months for the abdominal group. The incidence of recurrent prolapse to or beyond the hymen (33% vs. 19%, P=0.0505) and lower urinary tract symptoms (26% vs. 13%, P = 0.0506) were significantly higher in the vaginal group than in the abdominal group. Our data suggest that the combined abdominal approach has a lower incidence of recurrent prolapse and lower urinary tract symptoms than the combined vaginal approach in managing vaginal vault prolapse and coexisting stress incontinence.

Adult↗
PubMed2001

Urogenital prolapse and atrophy at menopause: a prevalence study.

For 285 subjects referred to a menopause clinic data were prospectively collected on the time elapsed since the onset of menopause (menopausal age), sexual activity, dyspareunia, smoking, chronic cough and constipation. Prolapse and atrophy were sought on examination. FSH assay confirmed menopausal status. We found an anterior wall prolapse in 51% of the subjects, of which 6% were protruding beyond the introitus. Posterior wall prolapse was present in 27% and apical prolapse in 20%; none was protruding beyond the introitus. No trend was noted between prolapse and menopausal age. Atrophy was evident in 34% of the women, and this was related to menopausal age (P<0.001). Forty per cent of the sexually active women admitted to dyspareunia, of which 2/3 were superficial. This correlated with advancing menopausal age (P<0.02). In conclusion, genital prolapse was frequent in the population of postmenopausal women, predominantly cystocele, but the prevalence did not correlate with menopausal age.

Adult↗
PubMed2005

Revision of prolapsed feeding gastrostomy with a modified Janeway 'gastric tube'.

After creation of open or percutaneous endoscopic gastrostomy, gastric prolapse and leak of gastric contents may cause serious skin rash and infection which are often difficult to treat. We present four patients in whom these problems were solved with gastrostomy revision by a modified Janeway 'gastric tube' technique. The patients were aged 7 months and 7, 10 and 16 years at the time of the revision. The underlying conditions were hypoxic encephalopathy with epilepsy, infantile spasm and epilepsy with arthrogryposis, dystonic tetraplegy, and total colon aganglionosis. All patients had gastrostomy prolapse with peristomal skin rash and cellulitis. Prior to modified Janeway revision, the four patients had undergone a total of 16 failed attempts to cure the prolapse. At the operation, the previous gastrostomy was detached and closed. A longitudinal gastric tube of 6 cm was created along the greater curvature with a GIA stapler and brought through the abdominal wall leaving 3-5 cm of free intra-abdominal gastric tube. A balloon catheter was left for 6 weeks, and replaced with a long Mickey tube according to patient's or caretaker's preference. There were no surgical complications. Hospitalisation after revision was median 6 (range 4-11) days. Six weeks after the revision, prolapse, leak and peristomal infections were cured in all patients, and feeding through the gastrostomy presented no problems. One patient underwent minor excision of excess stomal mucosa. Two patients opted for Mickey tube, two for a feeding catheter. A median of 9 (6-16) months after the revision, all patients have a functioning gastrostomy without prolapse or leak. Modified Janeway 'gastric tube' revision is feasible and, within short to medium term follow-up, controls efficiently gastrostomy prolapse and leak.

Adolescent↗
PubMed2006

Laparoscopic uterosacral ligaments plication for the treatment of uterine prolapse.

OBJECTIVE: To present preliminary results of a simple, minimally interventional, uterus-sparing procedure for uterine prolapse repair. METHODS: This prospective study was undertaken on women with symptomatic uterine prolapse >/=2nd stage, who declined hysterectomy at the time of prolapse surgery. A 10 mm laparoscope and three 5 mm ancillary trocars were used to perform the procedure. The uterosacral ligament was invested with a nonabsorbable suture. A total of three helical type sutures were placed full-thickness in the uterosacral ligament, beginning in the distal third of the ligament. The ends of the suture were tied with an extra-corporeal knot-tying technique on each side, thus shortening the ligaments. Finally, the round ligaments were plicated to restore the uterus to its correct anatomic position. No additional surgical procedure was performed concomitantly. RESULTS: Ten patients underwent laparoscopic uterosacral ligaments plication for the treatment of symptomatic uterine prolapse. The median (range) patients age was 45.5 years (36-66). Five (50%) patients were premenopausal and 3 (60%) had not completed their family. The median operating time was 22.5 min (20-45). No intraoperative complications occurred. The median follow-up time was 21 months (range 15-33). The median postoperative difference in POP-Q point C was -3 cm (range 0 to -5). Eight (80%) patients were objectively cured at the last follow-up evaluation and all of them reported a complete resolution of their symptoms. Two women had prolapse recurrence and underwent vaginal hysterectomy 7 and 24 months after primary surgery, respectively. CONCLUSION: Laparoscopic uterosacral ligaments plication is a minimally invasive and straightforward simple procedure that appears to be a safe and effective treatment option for women with uterovaginal prolapse who desire uterine preservation.

Adult↗
PubMed2005

Laparoscopically-assisted resection rectopexy for rectal prolapse: ten years' experience.

PURPOSE: This study has been undertaken to audit a single-center experience with laparoscopically-assisted resection rectopexy for full-thickness rectal prolapse. The clinical outcomes and long-term results were evaluated. METHODS: The data were prospectively collected for the duration of the operation, time to passage of flatus postoperatively, hospital stay, morbidity, and mortality. For follow-up, patients received a questionnaire or were contacted. The data were divided into quartiles over the study period, and the differences in operating time and length of hospital stay were tested using the Kruskal-Wallis test. RESULTS: Between March 1992 and October 2003, a total of 117 patients underwent laparoscopic resection rectopexy for rectal prolapse. The median operating time during the first quartile (representing the early experience) was 180 minutes compared with 110 minutes for the fourth quartile (Kruskal-Wallis test for operating time = 35.523, 3 df, P < 0.0001). Overall morbidity was 9 percent (ten patients), with one death (<1 percent). One patient had a ureteric injury requiring conversion. One minor anastomotic leak occurred, necessitating laparoscopic evacuation of a pelvic abscess. Altogether, 77 patients were available for follow-up. The median follow-up was 62 months. Eighty percent of the patients reported alleviation of their symptoms after the operation. Sixty-nine percent of the constipated patients experienced an improvement in bowel frequency. No patient had new or worsening symptoms of constipation after surgery. Two (2.5 percent) patients had full-thickness rectal prolapse recurrence. Mucosal prolapse recurred in 14 (18 percent) patients. Anastomotic dilation was performed for stricture in five (4 percent) patients. CONCLUSIONS: Laparoscopically-assisted resection rectopexy for rectal prolapse provides a favorable functional outcome and low recurrence rate. Shorter operating time is achieved with experience. The minimally invasive technique benefits should be considered when offering rectal prolapse patients a transabdominal approach for repair, and emphasis should now be on advanced training in the laparoscopic approach.

Adult↗
PubMed2006

Management of recurrent rectal prolapse: surgical approach influences outcome.

INTRODUCTION: Recurrent rectal prolapse is an unresolved problem and the optimal treatment is debated. This study was designed to review patterns of care and outcomes in a large cohort of patients after surgery for recurrent prolapse. METHODS: From 685 patients who underwent operative repair for full-thickness external rectal prolapse, we identified 78 patients (70 females; mean age, 66.9 years) who underwent surgery for recurrence. We reviewed the subsequent management and outcomes for these 78 patients. RESULTS: Mean interval to their first recurrence was 33 (range, 1-168) months. There were significantly more re-recurrences after reoperation using a perineal procedure (19/51) compared with an abdominal procedure (4/27) for their recurrent rectal prolapse (P = 0.03) at a mean follow-up of nine (range, 1-82) months. Patients undergoing abdominal repair of recurrence were significantly younger than those who underwent perineal repair (mean age, 58.5 vs. 71.5 years; P < 0.01); however, there was nosignificant difference between the two groups with regard to the American Society of Anesthesiologists classification (P = 0.89). Eighteen patients had surgery for a second recurrence, with perineal repairs associated with higher failure rates (50 vs. 8 percent; P = 0.07). Finally, when combining all repairs, the abdominal approach continued to have significantly lower recurrence rates (39 vs. 13 percent; P < 0.01). CONCLUSIONS: The re-recurrence rate after surgery for recurrent rectal prolapse is high, even at a relatively short follow-up interval. Our data suggest that abdominal repair of recurrent rectal prolapse should be undertaken if the patient's risk profile permits this approach.

Abdomen↗
PubMed1987

Echocardiographic mitral valve prolapse in ballet dancers: a function of leanness.

To determine the prevalence of mitral valve prolapse in ballet dancers by echocardiography and to establish which anthropometric measurements best predict the presence of mitral valve prolapse, we compared 44 professional dancers (22 men and 22 women) with 52 controls (24 men and 28 women). Forty-eight percent (21 of 44) of dancers had echocardiographic mitral valve prolapse compared with 10% (5 of 52) of controls (p less than 0.01). The dancers weighed less than the controls and had significantly smaller bony diameters and body circumferences. However, only ponderal index was predictive of mitral valve prolapse in both dancers and controls. Thus, echocardiographic mitral valve prolapse is associated with low body weight relative to height and neither to ballet dancing nor to a distinct body habitus. Echocardiographic mitral valve prolapse may represent a normal variant in the majority of asymptomatic, thin subjects without auscultatory findings.

Adult↗
PubMed1978

Stress myocardial imaging in mitral leaflet prolapse syndrome.

Mitral leaflet prolapse syndrome has been associated with anginal chest pain, atypical chest pain, electrocardiographic abnormalities and positive stress electrocardiograms. These features overlap those of ischemic heart disease. Furthermore, coronary artery disease is frequently associated with mitral leaflet prolapse. This study evaluated the usefulness of stress myocardial scintigraphy in distinguishing these two disorders. Thirty-two patients with an angiographic diagnosis of mitral leaflet prolapse were studied. Of the 22 patients (8 men and 14 women, mean age 48 years) with a normal coronary arteriogram, 5 had "typical" angina pectoris, 6 had resting electrocardiographic abnormalities and 6 had a positive stress electrocardiogram; all 22 patients had a normal stress myocardial scintigram. Of the 10 patients (7 men and 3 women, mean age 55 years) with at least 70 percent stenosis of one coronary artery, 6 had "typical" angina pectoris, 1 had resting electrocardiographic abnormalities and 7 had a positive stress electrocardiogram. Nine of these 10 patients had one or more demonstrable perfusion defects on stress myocardial scintigrams. It is concluded that mitral leaflet prolapse syndrome is not associated with regional myocardial ischemia as demonstrated with stress scintigraphy, and that stress scintigraphy, a noninvasive technique, is useful in distinguishing the mitral prolapse syndrome from mitral prolapse associated with coronary artery disease.

Adult↗
PubMed1985

Normal catecholamine and hemodynamic responses to orthostatic tilt in subjects with mitral valve prolapse. Correlation with psychologic testing.

Various functional abnormalities of the autonomic nervous system have been reported in symptomatic patients with mitral valve prolapse. It has also been suggested that mitral valve prolapse may be a component of a neurovascular endocrine abnormality and a marker for anxiety. Eleven consecutive patients with mitral valve prolapse (six men and five women), five of whom were asymptomatic, were studied. In comparison with 11 control subjects matched for age and sex who underwent 60-degree upright tilt, there was no significant difference between plasma norepinephrine levels, heart rate, and blood pressure, before, during, and after tilting. Psychologic testing for anxiety neurosis in both groups showed no significant difference on any of these measurements. There was therefore no evidence of autonomic dysfunction or neurosis in the patients with mitral valve prolapse. This variance with the findings of other investigators is probably related to their study of patient groups skewed by a disproportionate number of symptomatic females; the patients in the study reported herein are more representative of mitral valve prolapse in the general population. The symptoms attributed to mitral valve prolapse are quite likely adrenergically mediated and precipitated by anxiety, but this probably represents a coincidence of two common conditions encountered in medical practice.

Adult↗
PubMed1983

The effect of uterovaginal prolapse on urethrovesical pressure dynamics.

Complete urodynamic evaluations were performed on patients with severe uterovaginal prolapse with the prolapse protruding and after reduction with a pessary. These results were compared with those from patients with genuine stress incontinence without prolapse. There was a significant increase in urethral closure pressure in patients with prolapse on the assumption of a more erect posture or on Valsalva maneuver. The opposite relationship was observed in patients with genuine stress incontinence in whom the urethral closure pressure significantly decreased under similar conditions. These results strongly suggest that the mechanism of continence in patients with significant prolapse is urethral obstruction. Reduction of the prolapse with a pessary can differentiate those patients who will require urethrovesical neck suspension.

Adult↗