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PubMed2001

The Altemeier repair: outpatient treatment of rectal prolapse.

PURPOSE: Rectal prolapse typically occurs in elderly patients, who are often poor surgical candidates because of the presence of multiple comorbidities. Abdominal approaches to procidentia have low recurrence rates but are associated with higher rates of morbidity and mortality. Perineal rectosigmoidectomy (Altemeier repair) is a safe and effective approach to the treatment of rectal prolapse and can be done as an outpatient procedure. In this article, the results of a series of 63 consecutive Altemeier repairs are presented. METHODS: Between February 1993 and December 1999, 63 patients (61 females) underwent Altemeier repair of rectal prolapse. The mean patient age was 79 years. Preoperative, intraoperative, and postoperative data were collected and analyzed for all patients. RESULTS: Median follow-up was 20.8 months. Seventy percent of patients were given a regional or local anesthetic. The average resected specimen length was 11.6 cm, and 83 percent of anastomoses were stapled. Sixty-two percent of patients were discharged home on the day of surgery, and 80 percent were home within 24 hours. Complications occurred in 10 percent of patients, but there was no perioperative mortality. There was a 6.4 percent recurrence rate, and all recurrences were successfully treated with repeat Altemeier repair. All 63 patients had complete objective resolution of prolapse, and 87 percent had subjective improvement after repair. CONCLUSIONS: Altemeier repair of rectal prolapse is safe, produces minimal discomfort, and does not require a general anesthetic. It is ideally suited to be done on an outpatient basis, as was done in the majority of patients in our series. The recurrence rate is slightly higher than with abdominal resections, but morbidity and cost are lower, and repeat perineal resections are easily and safely performed.

Adult↗
PubMed2000

Schistosomal pelvic floor myopathy contributes to the pathogenesis of rectal prolapse in young males.

PURPOSE: Rectal prolapse is common in young males in Egypt. The role of schistosomiasis in the pathogenesis of rectal prolapse is not clearly defined. The purpose of this work is to study changes in the pelvic floor muscles in patients of rectal prolapse associated with schistosomiasis. METHODS: This study included 33 male patients with rectal prolapse of whom 27 patients with schistosomiasis and 6 patients free from schistosomiasis. Biopsies were taken from the pelvic floor muscle during surgery. The prepared sections were examined for histopathologic structural changes, for ultrastructural changes (by using electron microscopy) and after immunohistochemical staining by using anti-IgG and anti-IgM antibodies. RESULTS: The muscles from the patients without schistosomiasis had no histologic or EM changes and showed negative staining for IgG and IgM. Myopathic changes were found in the group of patients with schistosomiasis, including increased variation in the fiber diameter in 66.6 percent of patients, degenerative changes in 59.26 percent of patients, fiber splitting and fragmentation in 44.4 percent of patients, and endomysial fatty changes in 55.5 percent of patients. Ultrastructural study revealed starting loss of striation and margination of the nucleus in 70.37 percent of patients, distorted myofibrillar pattern in 51.85 percent of patients, disturbed endoplasmic reticulum and increased glycogen granules in all patients, the mitochondria are irregularly arranged with electron dense matrix in 40.74 percent of patients, and prominent nuclear sap in 13.72 percent of patients. The muscles of all the schistosomal patients showed a positive cytoplasmic staining for immunoglobulin G, of them only 12 patients showed positive staining for IgM. CONCLUSION: Patients with schistosomiasis suffer from pelvic floor myopathic changes that may contribute to the pathogenesis of rectal prolapse in young males. The immunohistochemical findings suggest immunologic mechanism for this myopathy.

Adolescent↗
PubMed1999

Selection criteria for internal rectal prolapse repair by Delorme's transrectal excision.

PURPOSE: The aim of this study was to review our results of Delorme's transrectal excision for internal rectal prolapse, with a view to determining preoperative selection criteria associated with a satisfactory outcome. METHODS: Between 1992 and 1998, 20 patients with internal rectal prolapse underwent Delorme's transrectal excision. The last patient was excluded from the study because of a follow-up period shorter than six months. The remaining 19 patients were prospectively followed up and classified into two groups according to their preoperative selection criteria. Group I consisted of eight patients operated on between January 1992 and October 1993 who were selected for surgery after medical treatment during a three-month period failed to improve symptoms. Initial results were reviewed, with a follow-up of at least six months, to assess predictive criteria correlating with poorer surgical outcome. These adverse criteria were used to exclude patients from selection into Group II, which included 11 patients operated on between June 1994 and June 1997. In each group the degree of improvement of symptoms was graded: Grade 1 = complete improvement with resolution of all symptoms; Grade 2 = significant improvement with resolution of dyschezia but not of other symptoms; Grade 3 = no improvement; and Grade 4 = worsened condition or reoperation. The two groups were compared according to ultimate outcomes. RESULTS: Of the Group I patients, three had preoperative chronic diarrhea, one had proximal internal rectal prolapse with rectosacral separation at defecography, and the other two were incontinent to liquid stool. An additional patient had incontinence to liquid stool but no diarrhea. Three other patients had major perineal descent (>9 cm). Results were Grade 1 for one patient, Grade 2 for one patient, Grade 3 for five patients, and Grade 4 for one patient (subsequent abdominal rectopexy). Data review showed that proximal internal prolapse with rectosacral separation at defecography, preoperative chronic diarrhea, fecal incontinence, and descending perineum (>9 cm on straining) were associated with a poorer outcome (Grades 3 and 4). These adverse criteria were used to exclude patients from selection into Group II. In this group results were Grade 1 for seven patients and Grade 2 for four patients. During the course of follow-up (mean, 43; standard deviation, 19; range, 8-73 months), outcome was better in Group II (P = 0.007). CONCLUSION. These data suggest that a favorable outcome can be achieved after Delorme's transrectal excision for internal rectal prolapse by applying stringent patient-selection criteria.

Adult↗
PubMed1999

Laparoscopic surgery for rectal prolapse and outlet obstruction.

PURPOSE: The aim of this study was to assess the outcome of both laparoscopic suture rectopexy and resection-rectopexy in the treatment of complete and incomplete rectal prolapse, outlet obstruction, or both. METHODS: Data from surgery were collected prospectively. Semiannual follow-up was performed by assessment of recurrence, continence, and constipation using patients' history, physical examination, continence score, and anorectal manometry. Statistical analysis was performed by chi-squared test and Student's t-test (P < 0.05 was accepted as statistically significant). RESULTS: Between September 1992 and February 1997, 72 patients (68 females) with a mean age of 62 (range, 23-88) years were treated laparoscopically. Indications for surgery were rectal prolapse in 21 patients, rectal prolapse combined with outlet obstruction in 36 patients, and outlet obstruction alone in 15 patients. Standard procedure was a laparoscopic suture rectopexy. A sigmoid resection was added in 40 patients. Mean duration of surgery was 227 (range, 125-360) minutes for rectopexy and 258 (range, 150-380) minutes for resection-rectopexy. Conversion was necessary in 1.4 percent (n = 1). Overall complication rate was 9.7 percent (n = 7) and mortality rate was 0 percent. Mean postoperative hospitalization was 15 (range, 6-47) days. All patients with a minimal follow-up of two years (n = 53) could be enrolled in a prospective follow-up study (mean follow-up, 30 months). No recurrence of rectal prolapse had to be recognized. Sixty-four percent of patients with incontinence before surgery were continent or had improved continence. In patients experiencing constipation preoperatively, constipation was improved or completely removed in 76 percent. No additional symptoms of constipation occurred after surgery. CONCLUSION: Laparoscopic procedures in the treatment of pelvic floor disorders, e.g., rectal prolapse or outlet obstruction, lead to acceptable functional results. However, follow-up has to be extended and long-term results of recurrence, continence, and constipation have to be evaluated.

Adult↗
PubMed1999

Sigmoid colon cancer presenting as complete rectal prolapse: report of a case.

We describe herein the unusual case of a 76-year-old woman who was diagnosed as having sigmoid colon cancer after presenting with complete rectal prolapse. The rectal prolapse was considered to have been caused by constipation accelerated by the colon cancer. The relationship between colorectal cancer and rectal prolapse has not yet been clarified; however, this case report suggests that rectal prolapse can present as a symptom of colorectal cancer. Thus, patients with a sudden onset of rectal prolapse should be screened for colorectal cancer.

Aged↗
PubMedDate not supplied

Anal sphincteric pressure studies in complete rectal prolapse.

Anal sphincteric pressure studies of patients with complete rectal prolapse demonstrated that: 1) The resting yield pressure of the internal anal sphincter in patients with complete rectal prolapse was not significantly different from that of control subjects. Thus, it seems to have no role in the etiology of prolapse. 2) The maximal sphincteric pressure of the external anal sphincter was significantly less in patients with prolapse than in controls. This suggested weakness in the effective functional power of the external anal sphincter in complete prolapse. 3) Anal continence could be achieved by the ability to maintain full contraction of the external anal sphincter for more than 40 seconds, which was the minimum for control subjects. Incontinent patients could not do this.

Adolescent↗
PubMedDate not supplied

A clinical profile of mitral valve prolapse syndrome.

Clinical, radiologic, electrocardiographic and 2-dimensional echocardiographic findings of fifty cases of mitral valve prolapse syndrome attending the Pediatric Cardiology clinic of I.C.H. and Childrens Hospital, Medical College, Kottayam over a period of ten years from 1980-1989 are presented. Mitral valve prolapse syndrome (MVPS) accounted for 2% of cardiac problems attending our pediatric cardiology clinic. Isolated MVPS constituted 64% of the cases. The common causes of secondary MVPS were Marfan Syndrome-18%, Atrial Septal Defect-10% and Rheumatic fever-8%. Associations of MVPS included Pectus excavatum (8%), Isolated arachnodactyly (2%) and Straight back syndrome (2%). 2-D echocardiogram demonstrated prolapse of both leaflets of Mitral valve in 44%, Isolated posterior mitral valve leaflet prolapse in 32% and Isolated anterior mitral valve leaflet prolapse in 24% of cases. No complications were seen during follow up.

Echocardiography, Doppler↗
PubMed1999

Relationship between surgically induced neuropathy and outcome of pelvic organ prolapse surgery.

The aim of the study was to determine whether surgically induced perineal neuropathy relates to the outcome of surgery for the correction of pelvic organ prolapse. Perineal nerve terminal motor latencies (PeNTML) were obtained in 31 women prior to and following transvaginal surgery for the correction of pelvic organ prolapse consisting of bilateral sacrospinous ligament vault suspension and bilateral paravaginal cystocele repair. Mean follow-up was 32 months (range 12-60). Surgical outcome was defined as optimal (asymptomatic, with the apex of the vagina above the levator plate with no tissue protruding beyond the hymen in the upright position with maximum Valsalva), or suboptimal (apical descent of > 50%, or any vaginal wall protrusion beyond the hymen in the upright position with maximum Valsalva). Surgically induced neuropathy was defined as an increase of 0.6 ms or more in the averaged right and left PeNTML measurements following the surgery. All women had preoperative symptomatic prolapse and the mean preoperative PeNTML was prolonged compared to established normals. Using strict definitions, 11 women had optimal outcome and 20 had suboptimal outcome. The outcome groups were similar with respect to age, weight, parity, degree of preoperative prolapse and preoperative perineal neuropathy. Eleven women had surgically induced perineal neuropathy. This was associated with suboptimal outcome compared to optimal outcome (P = 0.03). The relative risk of suboptimal outcome with surgically induced neuropathy was 1.82 (95% CI 1.13-2.93). It was concluded that a relationship exists between the outcome of organ prolapse surgery and surgically induced perineal neuropathy as measured by PeNTML. Such neuropathy may play a role in failed pelvic reconstructive surgery.

Female↗
PubMed2004

Assessment of posterior vaginal wall prolapse: comparison of physical findings to cystodefecoperitoneography.

The aim of the present study was to compare clinical and radiological findings when assessing posterior vaginal wall prolapse. Defecography can be used to complement the clinical evaluation in patients with posterior vaginal wall prolapse. Further development of the defecography technique, using contrast medium in the urinary bladder and intraperitoneally, have resulted in cystodefecoperitoneography (CDP). Thirty-eight women underwent clinical examination using the pelvic organ prolapse quantification system (POP-Q) followed by CDP. All patients answered a standardized bowel function questionnaire. Statistical analysis measuring correlation between POP-Q and CDP using Pearson's correlation coefficient (r) and Spearman's rank order correlation coefficient (rs) demonstrated a poor to moderate correlation, r=0.49 and rs=0.55. Although there was a strong association between large rectoceles (>3 cm) at CDP and symptoms of rectal emptying difficulties (p<0.001), severity and prevalence of bowel dysfunction showed poor coherence with clinical prolapse staging and findings at radiological imaging. Vaginal topography and POP-Q staging predict neither radiological size nor visceral involvement in posterior vaginal wall prolapse. Radiological evaluation may therefore be a useful complement in selected patients.

Adult↗
PubMed2005

Prolapse of neovagina created with labia minora: a case report.

Prolapse of a neovagina created in patients with congenital vaginal aplasia is rare. A 55-year-old woman with a neovagina was referred for management of complete prolapse and stress urinary incontinence. At the age of 19 she had undergone surgery for creation of a neovagina using the labia minora. She accepted vaginal surgical treatment to correct her prolapse. A posterior intravaginal slingplasty was successfully performed, associated with tension-free vaginal tape through the obturator foramens. There is no other case of prolapse of a labia minora neovagina described in the literature. The common procedures were not adapted in this case. Indeed, the vaginal tissues were extremely fragile, making the dissection more difficult. The vaginal approach sounded interesting to us to correct this prolapse.

Female↗
PubMed2005

Laparoscopic sacral suture hysteropexy for uterine prolapse.

This study aims to describe and review a new method of uterine conservation in pelvic reconstruction for women with uterine prolapse. This is a prospective study of women who have undergone laparoscopic sacral suture hysteropexy. Structured questions, visual analogue patient satisfaction score (VAS), and vaginal examination were undertaken. Follow-up was performed by non-surgical reviewers. From July 2001 until August 2003, a total of 81 women underwent laparoscopic sacral suture hysteropexy for uterine prolapse. At a mean of 20.3 months follow-up, 76 women (93.8%) were available for questioning and 57 (70.3%) attended for examination. Sixty-five women (87.8%) had no symptoms of pelvic floor prolapse, 54 women (94.7%) had no objective evidence of uterine prolapse, and 61 women (82.4%) were satisfied with their surgery (VAS > or = 80%). Laparoscopic sacral suture hysteropexy attaches the posterior cervix to the sacral promontory via the right uterosacral ligament. Follow-up data of laparoscopic sacral suture hysteropexy indicate it to be an effective method in the management of uterine prolapse.

Adult↗
PubMed2005

The development of pelvic organ prolapse after colposuspension: a prospective, long-term follow-up study on the prevalence and predisposing factors.

The objectives of this prospective study were to determine the prevalence of pelvic organ prolapse (POP) after colposuspension and to investigate possible preoperative and operative risk factors. Seventy-seven women who underwent colposuspension between 1996 and 1997 were investigated. POP was assessed before colposuspension using the pelvic organ prolapse quantification system (POPQ). Women were reassessed at one and seven to eight years (or when referred with symptomatic POP). By seven to eight years, of the 77 women, 29 (38%) had developed symptomatic prolapse, 29 (38%) had asymptomatic prolapse, 7 (9%) had no symptoms and no prolapse, and 12 (15%) could not be assessed. POP at one year was significantly associated with the presence of posterior vaginal descent before colposuspension (odds ratio 3.07, 95% CI 1.10-8.60, p = 0.03). No variable reached statistical significance by eight years postcolposuspension. In conclusion, this is the first study to assess POP prospectively using a validated method before and after colposuspension. The results add support to the view that there is an association between colposuspension and the development of symptomatic POP (requiring surgery).

Adult↗
PubMed2005

Familial transmission of genitovaginal prolapse.

Some females with little to no risk factors develop prolapse, while other females with multiple risk factors do not. It appears that some women may have a predisposition for prolapse in the setting of equivalent risk factors. We identified 10 patients younger than 55 years old with a family history of prolapse. Their average age was 37 years (range 27-51), the mean number of deliveries was 1.8, and their mean birth weight was 8 lbs. Genetic analysis of the inheritance pattern within these families demonstrated that pelvic organ prolapse segregated in a dominant fashion with incomplete penetrance in these families. Both maternal and paternal transmissions were observed. The relative risk to siblings of affected patients was five times that of the risk for the general population. Further investigation of these families may identify a genetic defect responsible for prolapse.

Adult↗
PubMed2006

Prolapse repair by vaginal route using a new protected low-weight polypropylene mesh: 1-year functional and anatomical outcome in a prospective multicentre study.

The aim of this study was to evaluate the anatomical and functional results of a low-weight polypropylene mesh coated with an absorbable film in prolapse surgery by vaginal route. We have conducted a prospective multicentre study in 13 gynaecological and urological units. There were 230 patients requiring repair for anterior or posterior vaginal prolapse included. The present report is based on the analysis of the first 143 patients evaluated after at least 10 months follow-up. All patients were operated by the vaginal route using a specially designed mesh (Ugytex, Sofradim, France). Prolapse severity were evaluated using the Pelvic Organ Prolapse staging system. Symptoms and quality of life were evaluated preoperatively and during follow-up using the validated Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) self-questionnaires. Mean age was 63 years (37-91). Anterior, posterior and anterior-posterior repair with the mesh were performed in 67 (46.9%), 11 (7.7%) and 65 (45.4%) patients, respectively. With a mean follow-up of 13 months (10-19), 132 patients were considered anatomically cured (92.3%) with a recurrence rate of 9 of 132 for cystocele (6.8%) and 2 of 76 for rectocele (2.6%). Nine vaginal erosions occurred (6.3%), six of them necessitated another procedure by simple excision. The rate of de novo dyspareunia was 12.8%. At follow-up, improvement of PFDI and PFIQ scores were highly significant (p<0.0001). The use of low-weight polypropylene mesh coated with a hydrophilic absorbable film for vaginal repair of genital prolapse seems to decrease local morbidity while maintaining low recurrence rates.

Adult↗
PubMed2006

Transvaginal repair of genital prolapse: preliminary results of a new tension-free vaginal mesh (Prolift technique)--a case series multicentric study.

Our goal was to report the preliminary results of a transvaginal mesh repair of genital prolapse using the Prolift system. This retrospective multicentric study includes 110 patients. All patients had a stage 3 (at the hymen) or stage 4 (beyond the hymen) prolapse. Total mesh was used in 59 patients (53.6%), an isolated anterior mesh in 22 patients (20%) and an isolated posterior mesh in 29 patients (26.4%). We report one bladder injury sutured at surgery and two haematomas requiring secondary surgical management. At 3 months, 106 patients were available for follow-up. Mesh exposure occurred in five patients (4.7%), two of them requiring a surgical management. Granuloma without exposure occurred in three patients (2.8%). Failure rate (recurrent prolapse even asymptomatic or low grade symptomatic prolapse) was 4.7%. According to the perioperative and immediate post-operative results, Prolift repair seems to be a safe technique to correct pelvic organ prolapse. Anatomical and functional results must be assessed with a long-term follow-up to confirm the effectiveness and safety of the procedure.

Adult↗
PubMed2006

Quality of life after surgery for genital prolapse in elderly women: obliterative and reconstructive surgery.

The objective of this study was to determine if obliterative and reconstructive vaginal surgery for advanced pelvic organ prolapse improve quality of life in elderly women. Women age 65 years or older with stage 3 or 4 pelvic organ prolapse who desired surgical correction were prospectively enrolled. The subjects underwent either obliterative or reconstructive vaginal surgery based on their personal preference and sexual expectations. The subjects received a pelvic organ prolapse quantitation examination and completed the pelvic floor distress inventory (PFDI), the pelvic floor impact questionnaire (PFIQ), the SF-36, and the Beck depression inventory preoperatively, 6 and 12 months after surgery. Seventy-nine subjects were enrolled, 70 of whom completed follow-up: 30 in the obliterative group and 40 in the reconstructive group. Both groups demonstrated significant improvements in the pelvic organ prolapse, urinary, and colorectal scales of the PFDI and PFIQ 6 and 12 months after surgery with no differences between the two treatment groups. In addition, there were significant and clinically important improvements noted in the bodily pain, vitality, social functioning, role-emotional, and mental health summary scales of the SF-36 in both groups after surgery, with no significant difference between groups. In appropriately selected elderly women, both obliterative and reconstructive vaginal surgery for advanced pelvic organ prolapse significantly improved health-related quality of life.

Aged↗
PubMed2006

Conservation of the prolapsed uterus is a valid option: medium term results of a prospective comparative study with the posterior intravaginal slingoplasty operation.

It has been reported that, by the age of 80, the risk of women to undergo surgery for the treatment of pelvic organ prolapse (POP) exceeds 10%, a percentage expected to increase with the rise in life expectancy. The vaginal approach for POP reconstructive operations is associated with fewer complications and results in a shorter rehabilitation period than the abdominal route, whereas hysterectomy is widely performed concomitantly whenever the uterus is significantly prolapsed. However, there is no clear evidence supporting the role of hysterectomy in improving surgery outcome. We present our experience with a new minimally invasive procedure--the posterior intravaginal slingplasty (PIVS) for correction of advanced uterine prolapse--at the same time, comparing additive vaginal hysterectomy to uterine preservation, to evaluate the therapeutic significance of hysterectomy when vaginal apical prolapse is reconstructed with PIVS. Seventy-nine women presenting with moderate to severe uterine prolapse were enrolled into the current PIVS study. Vaginal hysterectomy was concomitantly performed upon patient's request (44 patients), whereas those wishing to preserve their uterus underwent reconstructive surgery only (35 patients). No intraoperative or postoperative major complications were recorded during an average follow-up of 29.8 months: One patient (1.3%) presented with surgical failure, whereas 71 (89.9%) of the operated patients reported satisfaction with the therapeutic results. Bladder overactivity symptoms declined from three thirds of the patients preoperatively to below 10% postoperatively. Ten (12.7%) patients had vaginal tape protrusion; all underwent segmental tape resection at the out-patient clinic. Because the PIVS procedure does not require either laparotomy or deep transvaginal dissection, as previously required for operative intervention, the hospitalization period was relatively short: 4.2 days for the hysterectomy group and 1.5 for the non-hysterectomy group. Other statistically significant differences between the hysterectomy and non-hysterectomy groups were the average ages (63.5 vs 51.0 years, respectively) and concomitant surgery (87% vs 69%, respectively, the higher percentage due to additive amputation of elongated uterine cervices). No other significant differences were recorded. The current results support the previously reported efficacy, safety, and simplicity of the PIVS procedure as well as the legitimacy of uterine preservation. Moreover, unstable bladder symptoms were found to be improved after this operation. However, long-term data are required to be able to draw solid conclusions concerning the superiority of the discussed operation.

Adult↗
PubMed2002

Pubic bone anchoring devices for the surgical treatment of urinary stress incontinence in patients with severe genital prolapse.

The aim of this study was to test a surgical technique for the treatment of stress urinary incontinence associated with genital prolapse through a transvaginal suspension anchored to the pubic bone. Thirty-seven patients with severe genital prolapse and urodynamically proven stress incontinence were operated on with this procedure from February 1998 to May 2000. Preoperatively a detailed history, pelvic examination and urodynamic studies were carried out. The degree of prolapse was assessed pre- and postoperatively in the lithotomy position in accordance with the classification proposed by Baden and Walker [8]. Two titanium bone screws with no. 1 polypropylene sutures attached to them and a battery-operated screw inserter are used to fix the vaginal sutures to the pubic bone bilaterally. The procedure is performed transvaginally with no abdominal or suprapubic incisions. Objective outcomes were assessed by symptom assessment, clinical examination and a full urodynamic evaluation at 6 months postoperatively, and annually by clinical evaluation. Subjective outcomes were assessed by directly interviewing the patients about their postoperative urinary symptoms and asking them to classify their level of satisfaction. An objective cure rate (no objective loss of urine during coughing in the absence of a simultaneous detrusor contraction) at the 6-month postoperative urodynamic evaluation was observed in 23 of 37 patients (62%). Recurrent anterior vaginal wall prolapse (grade 2) had developed in 7 of 37 patients (27%). Subjectively, 73% of the patients expressed satisfaction with the procedure. Early results using two bone screws into the pubis to fix the periurethral and perivesical tissues and vagina to the posterior surface of the pubic bone were disappointing. Based on our results we have abandoned the use of this procedure to correct stress incontinence associated with severe genital prolapse.

Aged↗