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PubMed2000

Abdominal sacral colpopexy and abdominal enterocele repair in the management of vaginal vault prolapse.

Vaginal vault prolapse and enterocele represent challenging forms of female pelvic organ relaxation. These conditions are most commonly associated with other pelvic organ defects. Proper diagnosis and management is essential to achieve long-term successful outcomes. Physical examination should be carried out in the lithotomy and standing positions (if necessary) in order to detect a loss of vaginal vault support. With proper identification of the vaginal cuff, one should assess the degree of mobility of the vaginal cuff with a Valsalva maneuver. If there is significant descent of the vaginal cuff, vaginal vault prolapse is present, and correction should be considered. The abdominal sacral colpopexy is an excellent means to provide vaginal vault suspension. This procedure entails suspension of the vaginal cuff to the sacrum with fascia or synthetic mesh. This procedure should always be accompanied by an abdominal enterocele repair and cul-de-sac obliteration. In addition, many patients require surgical procedures to correct stress urinary incontinence, which is either symptomatic or latent (occurs postoperatively after prolapse correction). Complications include: mesh infection, mesh erosion, bowel obstruction, ileus, and bleeding from the presacral venous complex. If the procedure is carried out using meticulous technique, few complications occur and excellent long-term reduction of vaginal vault prolapse and enterocele are achieved. The purpose of this article is to review the preoperative evaluation of women with pelvic organ prolapse, and provide a detailed description of the surgical technique of an abdominal sacral colpopexy.

Aged↗
PubMed2000

Anterior approach bilateral sacrospinous ligament fixation for vaginal vault prolapse.

The sacrospinous ligament fixation (SSLF) was first described as a unilateral fixation; however, bilateral fixation, when possible, allows a symmetrical vaginal reconstruction and provides additional vaginal vault support. We evaluated the outcome of treating total vault prolapse using a bilateral SSLF through an anterior vaginal approach. From July 1996 to July 1999, 28 patients (mean age 67) underwent bilateral SSLF procedures through an anterior vaginal approach. All patients had either grade 3 or 4 vault prolapse, and all patients had associated enteroceles, cystoceles, and rectoceles. All patients underwent fluorourodynamic evaluation including an abdominal leak point pressure (ALPP) with reduction of the vaginal prolapse. A pubovaginal sling was performed in 25 patients and all 28 patients underwent an anterior colporrhaphy, rectocele, and enterocele repair. A vaginal paravaginal repair was performed in 22 cases. At a mean follow-up of 17 months (range 5 to 35), 27 of 28 patients were cured, 1 patient had an asymptomatic unilateral grade 1 vault prolapse, 2 patients had developed small asymptomatic cystoceles and there had been no recurrence of rectoceles or enteroceles. Stress incontinence had been cured in all patients; however, 2 patients continued to have mild urge incontinence requiring <1 pad per day. Two patients complained of transient gluteal pain. We believe the anterior approach bilateral SSLF is a safe procedure with excellent medium term results in women with grade 3 to 4 vaginal prolapse.

Aged↗
PubMed2003

Value of express T2-weighted pelvic MRI in the preoperative evaluation of severe pelvic floor prolapse: a prospective study.

OBJECTIVES: To report our prospective experience with extended-phase conjugate-symmetry rapid spin-echo sequence (EXPRESS) magnetic resonance imaging (MRI) of the female pelvis in the preoperative staging of severe pelvic floor prolapse (PFP). Severe PFP represents a significant diagnostic and reconstructive challenge for clinicians. Although the clinical utility of dynamic MRI has already been demonstrated, EXPRESS MRI has not been prospectively studied in the evaluation of PFP. METHODS: Between January 1999 and December 2001, 31 consecutive female patients with severe PFP were referred to our institution. Twenty of them underwent EXPRESS dynamic pelvic MRI. The physical examination, MRI, and intraoperative findings were statistically correlated. RESULTS: The mean age of the 20 patients undergoing preoperative EXPRESS MRI was 67 years. The mean duration of prolapse was 6.1 years. All 20 patients underwent surgery for symptomatic PFP with or without associated voiding dysfunction. No postoperative complications or recurrent PFP had occurred at a median follow-up of 19 months. Significant correlations were found between the preoperative pelvic examination findings and operative findings of cystourethrocele and vaginal cuff prolapse, and significant correlations were found between MRI findings and operative findings of enterocele, cystourethrocele, vaginal cuff prolapse, and uterine prolapse. CONCLUSIONS: EXPRESS MRI can accurately stage PFP. The technique is rapid, precise, and noninvasive. Practitioners should consider obtaining dynamic, rapid-sequence sagittal pelvic MRI scans in cases of severe PFP when the diagnosis is not clear before surgery. More accurate preoperative information may ultimately result in improved long-term surgical outcomes and guide the refinement of surgical techniques.

Adult↗
PubMedDate not supplied

Nontraumatic prolapse of the orbital contents into the ethmoid sinus: evaluation with screening sinus CT.

PURPOSE: The purpose of this study is to evaluate the incidence and CT features of nontraumatic prolapse of the orbital content into the ethmoid sinus, which may be a cause of orbital complication of ethmoidectomy. MATERIALS AND METHODS: CT of 1,024 consecutive patients with subjective sinonasal symptoms who underwent screening sinus CT were reviewed and analyzed. The 573 men and 451 women were between the ages of 5 and 79 years old. The patients with a history of sinus surgery of facial trauma were excluded from this study. The incidence and CT features of dehiscence and/or bowing of the lamina papyracea with prolapse of the orbital content in each age group and differences between the age groups were analyzed. RESULTS: Ethmoidal prolapse of the orbital content was found in 67 patients (6.5%). There was a tendency of increasing incidence with increasing age. The incidence in the juvenile age group was significantly low (1.9%) as compared with that of adult. Four patients (0.4%) had bilateral lesions. Twenty-nine lesions showed prolapse of moderate to severe degree, and deformity of the medial rectus muscle on coronal CT image was associated in 21 lesions. Inflammatory change of adjacent ethmoid sinus was indicated in 19 lesions, and there was no statistical difference in incidence from that of the opposite side. CONCLUSIONS: The incidence of nontraumatic prolapse of the orbital content is far beyond general expectations, and detailed structural information with CT for this anatomic alteration may be important before endoscopic sinus surgery to avoid possible complication. The higher incidence in adult may suggest age-related acquired etiologic factors besides congenital dehiscence or weakness of the lamina papyracea.

Adolescent↗
PubMed2003

Validation of an Italian version of the prolapse quality of life questionnaire.

OBJECTIVE: To validate the italian translated version of the prolapse quality of life questionnaire (P-QOL). STUDY DESIGN: The P-QOL questionnaire was translated into Italian and administered to women recruited from a gynaecology outpatient clinic. All women completed a P-QOL questionnaire at the time of the visit, and were examined in left lateral position using the ICS prolapse score. A second P-QOL questionnaire was posted and completed by women 1 week later. The validity was assessed by measuring levels of missing data, comparing symptom scores with objective prolapse stages and between affected and asymptomatic women. The reliability was assessed by testing internal consistency and stability using 1-week test retest analysis. RESULTS: 132 symptomatic and 61 asymptomatic women were studied. The number of missing items was 2%. P-QOL domain scores were significantly different between symptomatic and asymptomatic women (P<0.001). Severity according to P-QOL strongly correlated with the prolapse size (P<0.01, rho>0.5). All items achieved a Cronbach alpha greater than 0.8. The test retest reliability confirmed a highly significant correlation between the total scores for each domain. CONCLUSION: The Italian version of the P-QOL questionnaire has been validated, providing a reliable, easily comprehensible and valid instrument for the symptomatic assessment of Italian-speaking women with uterovaginal prolapse.

Adult↗
PubMed1986

Mitral valve prolapse: definition and implications in athletes.

Mitral valve prolapse is probably the most common cardiac valve disorder, affecting approximately 5% of the population. Although it is genetically determined, its clinical manifestations do not usually become evident before adulthood. In the setting of a cardiology referral center, a mitral valve prolapse syndrome, consisting of nonspecific symptoms, repolarization changes on the electrocardiogram and arrhythmias, has been identified. However, doubt has recently been expressed about the existence of such a syndrome. The prognosis of mitral valve prolapse is generally favorable but infrequent complications do occur and include transient ischemic attacks, progression of mitral regurgitation with or without ruptured chordae tendineae, infective endocarditis and sudden death. The symptoms and the complications are not usually related to physical activity. A permissive attitude toward participation of patients with mitral valve prolapse in competitive athletics is probably warranted; however, it would appear reasonable to disqualify athletes with mitral valve prolapse in the following circumstances: history of syncope; disabling chest pain; complex ventricular arrhythmias, particularly if induced or worsened by exercise; significant mitral regurgitation; prolonged QT interval; Marfan's syndrome; and family history of sudden death.

Adolescent↗
PubMed1999

Intermediate-term durability of bicuspid aortic valve repair for prolapsing leaflet.

OBJECTIVE: To determine the durability of repair of a bicuspid aortic valve with leaflet prolapse, and to identify factors associated with repair failure. METHODS: From November 1988 to January 1997, 94 patients with a bicuspid aortic valve and regurgitation from leaflet prolapse had aortic valve repair. In 66 patients, the repair employed triangular resection of the prolapsing leaflet. The remainder underwent mid-leaflet plication of the prolapsing leaflet. Mean age was 38 +/- 10 years and 93% were male. Median follow-up was 5.5 years (range 0.2-9 years). Factors associated with aortic valve competence and durability were identified by multivariable logistic and hazard function analyses. RESULTS: Early valve competence was more difficult to achieve in patients with large, poor functioning ventricles (P = 0.02). Aortic valve reoperation was necessary in 12 patients that included three re-repairs and nine aortic valve replacements. Freedom from reoperation was 95, 87 and 84% at 1, 5 and 7 years, respectively. The instantaneous risk of reoperation was highest immediately after operation, and fell rapidly to approximately 2% per year and less after 2 years. The only risk factor identified was the presence of residual aortic regurgitation (trace to mild in 35 cases) on immediate intraoperative post-repair transesophageal echocardiography. Late aortic regurgitation did not progress detectably across time (P = 0.3). There were no deaths, early or late. CONCLUSION: Bicuspid aortic valve repair for prolapsing leaflet is a safe procedure with good intermediate-term outcome. However, any residual aortic regurgitation jeopardizes repair durability and initial repair achievement is more difficult in patients with dilated, poor functioning ventricles.

Adolescent↗
PubMed2002

The vaginal-psoas suspension repair of uterovaginal prolapse.

BACKGROUND: This article introduces a novel technique for the abdominal suspension of the prolapsed vagina. A Gore-Tex (WL Gore & Associates, Flagstaff, AZ) graft interposition between the vaginal apex and the right psoas muscle is performed under direct visualization to effect the repair. STUDY DESIGN: Between June 1998 and June 2001, seven consecutive cases of uterovaginal prolapse were repaired abdominally using the vaginal-psoas technique as outlined here. Patients were followed postoperatively for recurrent prolapse, urinary incontinence, and the development of new or progressive pelvic support defects. RESULTS: The mean operative time was 134 minutes, and the mean blood loss was 160mL for all procedures. One patient was lost to followup after 2 months. The remaining six patients have a median followup of 22 months (range 4 to 36 months), and in these patients, there have been no instances of recurrent prolapse or urinary dysfunction. One patient developed a progression of her rectocele. There were no peroperative or postoperative complications directly related to the procedure. Specifically, there were no instances of hemorrhage, transfusion, small bowel obstruction, graft erosion, or genitofemoral neuropathy. CONCLUSIONS: The vaginal-psoas colposuspension appears to be a simple, efficacious technique for the repair of uterovaginal prolapse. No significant morbidity directly related to the procedure has occurred to date. Further studies with longer followup will be required in the future before definitive conclusions can be reached.

Aged↗
PubMed2003

Tension-free vaginal tape procedure on genuine stress incontinent women with coexisting genital prolapse.

OBJECTIVE: To study the efficacy of performing the tension-free vaginal tape (TVT) procedure concurrently with vaginal pelvic relaxation surgeries in the management of genuine stress incontinence with genital prolapse. MATERIALS AND METHODS: Fifty-eight women were surgically managed. Various vaginal pelvic reconstructive surgeries for prolapses were completed before the TVT procedure. Pre-operative and postoperative urodynamic studies, 1-h pad tests and symptom analysis were evaluated 1 year postoperatively. Surgical procedures and patient outcomes are discussed. RESULTS: Objective data available for 55 patients. Fifty (91%) were dry 1 year postoperatively. The concurrent pelvic surgeries included vaginal total hysterectomies, anterior colporrhaphies, posterior colporrhaphies and sacrospinous ligament fixations. No major surgical complications occurred. The average blood loss was 134 ml, the average operating time for the TVT procedure was 21 min, and the average postoperative hospital stay was 3.4 days. All patients voided spontaneously with adequate volumes of postvoid residual urine before being discharged. Two patients had a recurrent prolapse. Urodynamic parameters showed no significant differences before and after the surgery, except that the parameters related to voiding dysfunction were improved in the patients with severe cystocele. De nova detrusor instability was observed in one patient. CONCLUSIONS: The tension-free vaginal tape procedure performed with concurrent vaginal pelvic relaxation surgery is safe and effective for genuine stress incontinence and pelvic prolapse. Concomitant procedures also appear to relieve bladder outlet obstructions caused by severe prolapse.

Adult↗
PubMed1993

Iris prolapse; who? When? Why?

A 12-month period was reviewed to identify the incidence of iris prolapse following cataract surgery, and any predisposing factors. Of 1408 routine manual extracapsular cataract extractions, 29 eyes (2.06%) sustained an iris prolapse. Iris prolapse was commoner in Asian patients and when less experienced surgeons were operating. Twenty-five per cent of cases occurred in patients with obstructive airways disease or post-operative cough. Thirty-four per cent of iris prolapses were identified on the first post-operative day and 86% within 2 weeks. Prolapse probably occurs because of raised intraocular pressure in association with poor wound construction or closure. More emphasis should be given to wound construction and closure during surgical training, with extra diligence when operating on patients likely to cough postoperatively. Clinicians must ensure non-English speaking patients understand about ocular aftercare following cataract surgery.

Cataract Extraction↗
PubMed1997

Post-operative iris prolapse following phacoemulsification and extracapsular cataract surgery.

PURPOSE: This study retrospectively compared and contrasted iris prolapse occurring following extracapsular cataract extraction and phacoemulsification. METHODS: The clinical notes of all patients who had undergone iris prolapse repair in the last 5 years at Southampton Eye Unit were recalled. Sixty-five patients (mean age 73 years; 41.6% male, 58.4% female) were identified out of a total of 7252 cataract operations performed (5983 extracapsular, 1269 phacoemulsification). RESULTS: Fifty-nine (93.3%) iris prolapses occurred following extracapsular surgery (83% had corneal incisions, 17% limbal). We identified 3 cases of phaco-related prolapse each of which occurred where the scleral tunnel had been extended to enable insertion of a 7.0 mm optic intraocular lens but had not been sutured. Overall, the average best corrected visual acuity achieved was 6/9. CONCLUSION: The authors conclude that although iris prolapse is much less common following phacoemulsification, all scleral sections that are extended should be sutured.

Aged↗
PubMed1980

[Reconstructive surgery on eyeball injuries with iris prolapse (author's transl)].

Whereas before the Second World War eyeball injuries involving iris prolapse were treated by excision, it is customary nowadays in almost all cases to attempt restoration of the iris. The authors deal briefly with the various views on when restoration of the iris should be performed, how long after injury it can still be carried out, and the kind of suture and material used. They then describe their operating technique in cases of injury to the cornea and the eyeball in general with iris prolapse, and report their results in 21 cases of cornea injury with iris prolapse and nine cases, also with iris prolapse, where the injury extended to the sclera. Details are given of the time elapsing between injury and operation, the final degree of vision regained, and the aesthetic result. The authors' final conclusion is that in cases of iris prolapse as a result of injury to the cornea and the eyeball in general, an attempt should be made to achieve restoration, with antibiotic treatment given at the same time.

Adolescent↗
PubMed2001

Assessment and grading of pelvic organ prolapse by use of dynamic magnetic resonance imaging.

OBJECTIVE: Our purpose was to assess and compare a new technique of grading pelvic organ prolapse by using dynamic magnetic resonance imaging with the clinical staging proposed by the International Continence Society. STUDY DESIGN: In a cross-sectional study, 20 patients with pelvic organ prolapse underwent dynamic magnetic resonance imaging. Clinical staging (according to the International Continence Society) was compared with staging by magnetic resonance imaging. A new reference line, the midpubic line, was drawn on the magnetic resonance image to correspond to the hymenal ring marker used in the clinical staging. The levator-vaginal angle and the area of the genital hiatus were measured to indicate vaginal supports. Ten nulliparous, symptom-free women were studied as control subjects. RESULTS: The proposed staging by magnetic resonance imaging showed good correlation with the clinical staging (kappa = 0.61). Magnetic resonance imaging improved clinical assessment by its ability to measure the actual pelvic organ descent and to delineate prolapse of the pouch of Douglas accurately. The midpubic line was a useful reference line for grading prolapse on magnetic resonance imaging. The levator-vaginal angle and the area of the genital hiatus are useful in assessing vaginal support at different anatomic levels. CONCLUSIONS: This new method of grading by magnetic resonance imaging uses the same landmarks as the clinical grading, and this uniformity of approach allows an objective assessment of the results of surgical correction of pelvic organ prolapse.

Adult↗
PubMed2001

Two- and 3-dimensional MRI comparison of levator ani structure, volume, and integrity in women with stress incontinence and prolapse.

OBJECTIVE: The aim of this study was to identify imaging markers for genuine stress incontinence and pelvic organ prolapse by using magnetic resonance imaging and reconstructed 3-dimensional models. STUDY DESIGN: Thirty women were studied, 10 with prolapse, 10 with genuine stress incontinence, and 10 asymptomatic volunteers. Axial and sagittal T1 and T2 weighted pelvic magnetic resonance scans were obtained with the patient in the supine position. Source images were measured to determine levator hiatus height, bladder neck to pubococcygeal line, levator plate angle, and perineal descent at rest and maximum Valsalva. Manual segmentation and surface modeling was applied to build 3-dimensional models of the organs. The 3-dimensional models were measured to determine levator muscle volume, shape and hiatus width, distance between symphysis and levator sling muscle, posterior urethrovesical angle, bladder neck descent, and levator plate angle. RESULTS: The 3 groups of subjects were comparable in age, parity, and body mass index. In the control, genuine stress incontinence, and prolapse groups, the menopausal rate was 40%, 60%, and 55% (P =.7). In the same order, significant mean 2-dimensional measures were: resting bladder neck descent of 24, 17, and 3 mm (P <.005), straining levator plate angle of -4.3, -11.5, and -31 degrees (P =.01), straining levator hiatus height of 48.5, 51.1, and 65.3 mm (P <.005), and straining perineal descent of 17.2, 22.5, 27.2 mm (P =.02). Similarly ordered mean 3-dimensional parameters showed levator volumes of 32.2, 23.3, and 18.4 cm(3) (P <.005); hiatus widths of 25.7, 34.7, and 40.3 mm (P <.005); left levator sling muscle gaps of 15.6, 20.3, and 23.8 mm (P =.03), right levator sling muscle gaps of 15.6, 22.5, and 30.8 mm, (P = 0.003), and levator shape (90%, 40%, and 20% dome shaped; P <.005). CONCLUSION: Both 2-dimensional magnetic resonance images and 3-dimensional models yield findings that differ among asymptomatic subjects compared with those with genuine stress incontinence and prolapse. Our 3-dimensional data demonstrate a statistically significant continuum in levator volume, shape, and integrity across groups of asymptomatic, genuine stress incontinence, and prolapse subjects.

Adult↗
PubMed2002

Laparoscopic versus open Burch retropubic urethropexy: comparison of morbidity and costs when performed with concurrent vaginal prolapse repairs.

OBJECTIVE: The purpose of this study was to determine the morbidity and cost that are associated with laparoscopic and open Burch retropubic urethropexy when they are performed with concurrent vaginal prolapse repairs. STUDY DESIGN: We conducted a retrospective study of all patients who had undergone laparoscopic (n = 76) or open (n = 143) Burch retropubic urethropexy with at least 1 concurrent vaginal repair for symptomatic prolapse. We compared demographic data, level of prolapse, operative and postoperative details, medical and surgical histories, complications, and hospital charges. RESULTS: The group with open retropubic urethropexy had an older age, greater degree of prolapse, fewer concurrent hysterectomies, and a greater number of vaginal procedures than the group with laparoscopic retropubic urethropexy. There were minimal differences in complications and no differences in the estimated blood loss, operative time, hemoglobin change, hospitalization, or hospital charges between the 2 groups. CONCLUSION: Traditional benefits of laparoscopic retropubic urethropexy were not apparent when vaginal prolapse repairs were performed.

Aged↗
PubMed2002

A comparison of preoperative and intraoperative evaluations for patients who undergo site-specific operation for the correction of pelvic organ prolapse.

OBJECTIVE: We compared preoperative and intraoperative assessments of pelvic organ prolapse to ascertain whether differences existed. STUDY DESIGN: This study is a retrospective analysis of information that was collected of 193 women who underwent reconstructive operation for pelvic organ prolapse between January 1994 and April 1999 by the senior author (B. L. S.) in this institution. Support for the urethra, bladder, cervix or vaginal cuff, cul-de-sac, and rectum were assessed with the Baden-Walker halfway system before and during the operations. RESULTS: Preoperative and intraoperative assessments were significantly correlated (Spearman rank order correlation, 0.85-0.94). A comparison of the assessments revealed significantly greater prolapse at the urethra, cervix/cuff, cul-de-sac, and rectum on intraoperative evaluation (P <or=.00007). CONCLUSION: Intraoperative evaluation of women who are to undergo reconstructive operation for pelvic organ prolapse may reveal greater prolapse at selected sites than previously noted in up to 32% of patients.

Cervix Uteri↗
PubMed2002

Morphometric properties of the posterior vaginal wall in women with pelvic organ prolapse.

OBJECTIVE: Our purpose was to analyze the morphometric properties of the posterior vaginal wall and compare the smooth muscle distribution in the posterior vaginal muscularis in women with and without pelvic organ prolapse. STUDY DESIGN: Specimens were taken from the apex of the posterior vaginal wall after hysterectomy from 15 women with pelvic organ prolapse and from 8 healthy control subjects. Smooth muscle cells of the posterior vaginal wall were identified by immunohistochemistry with antibodies to smooth muscle alpha-actin. Morphometric analysis was performed on histologic cross-sections of the posterior vaginal wall to determine the fractional area of nonvascular smooth muscle in the muscularis. The innervation pattern of the vaginal wall was determined by use of S100 immunostaining. Statistical comparisons between two groups were conducted by a Student t test. Comparisons between multiple groups were conducted with a one-way analysis of variance followed by a post-hoc Student-Neuman-Keuls test. RESULTS: The fractional area of nonvascular vaginal smooth muscle in the muscularis of women with posterior wall prolapse was significantly decreased compared with that of healthy control subjects. Nerve bundles were located in the deep vaginal muscularis and adventitia of the posterior vaginal wall. In women with posterior wall prolapse, nerve bundles were smaller and fewer in number. CONCLUSION: Morphologic features of the posterior vaginal wall are significantly altered in women with posterior wall prolapse compared with asymptomatic control subjects.

Actins↗
PubMed2006

Can pelvic floor muscle training prevent and treat pelvic organ prolapse?

BACKGROUND AND METHODS: Pelvic floor muscle dysfunction may cause urinary and fecal incontinence, pelvic organ prolapse (POP), pain, and sexual disturbances. The aim of the present study is to review the literature on the effectiveness of pelvic floor muscle training (PFMT) to prevent and treat POP, and the possible theories and mechanisms on how PFMT could prevent or reverse prolapse. RESULTS: No studies were found on prevention of POP. One uncontrolled study and one low-quality RCT were found in the treatment of prolapse. The results showed a positive effect of PFMT in severe, but not in mild prolapse. A review is presented of the main hypothesis of mechanisms on how PFMT may be effective. The two mechanisms are morphological changes occurring after strength training and use of a conscious contraction during increase in abdominal pressure in daily activities. CONCLUSIONS: In addition to the theory of functional anatomy and exercise science, one randomized controlled trial (RCT) is supportive for a positive effect of PFMT in the treatment of POP. There is an urgent need for more RCT with high methodological quality, use of valid and reproducible methods to assess degree of prolapse, and appropriate training protocols to evaluate the effect of PFMT in the prevention and treatment of POP.

Exercise Therapy↗