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PubMed2005

Repair of aortic leaflet prolapse: the "sliding leaflet technique".

Valve-preserving aortic replacement has become an accepted therapeutic option for aortic dilatation with normal valve leaflets. The presence of a leaflet prolapse often induces the choice of a composite graft repair. In these cases, however, the repair of a leaflet prolapse is possible and represents a valuable alternative to a prosthetic valve. The conventional techniques of repair of a cusp prolapse are designed to restore coaptation through a reduction of free margin length. The sliding leaflet technique is an alternative procedure conceived to repair the prolapsed valve cusp by remodeling both the free margin and the annular insertion.

Aorta↗
PubMed2006

Mitral valve repair for anterior leaflet prolapse with expanded polytetrafluoroethylene sutures.

BACKGROUND: This study was a long-term Doppler echocardiographic assessment of mitral valve repair for anterior mitral leaflet prolapse using expanded polytetrafluoroethylene sutures. METHODS: Between April 1992 and December 2003, we performed mitral valve repair using expanded polytetrafluoroethylene sutures in 204 patients (mean age, 54.6 years) with severe mitral regurgitation (MR) having anterior mitral leaflet prolapse. The cause of valve disease was degenerative in 181 patients (88.7%). Postoperative serial transthoracic echocardiographic studies were performed in all hospital survivors. Residual MR flow detected by color Doppler echocardiography was classified according to the maximum regurgitant jet area. RESULTS: The 30-day mortality of 204 patients was 1.4% (3 deaths). There were 12 late deaths and 14 reoperations in this series. Kaplan-Meier survival and freedom from reoperation at 12 years were 84.6% +/- 4.0% and 89.9% +/- 2.9%, respectively. Postoperative transthoracic echocardiographic assessment after discharge (mean follow-up, 4.2 +/- 3.0 years) showed less than mild regurgitation (maximum regurgitant jet area < 4.0 cm2) in 80.9% of the patients. Overall, freedom from severe MR (maximum regurgitant jet area > or = 7.0 cm2) estimates at 12 years were 88.1% +/- 3.1%. Freedom from severe MR at 12 years for 114 patients with no MR (maximum regurgitant jet area = 0 cm2) on intraoperative transesophageal echocardiography and 77 patients with MR was 95.3% +/- 2.1% and 82.9% +/- 5.1%, respectively (p = 0.033). CONCLUSIONS: Twelve-year echocardiographic follow-up demonstrates good long-term results of chordal replacement with expanded polytetrafluoroethylene sutures for anterior mitral leaflet prolapse. To avoid recurrence of regurgitation, a significantly high level of competence of the valve is essential in the repair of anterior mitral leaflet prolapse.

Adolescent↗
PubMed2006

Gore-Tex mesh pelvic occlusion and secondary colpopexy: A new surgical technique for posthysterectomy vaginal vault prolapse.

OBJECTIVE: This article presents and discusses a new surgical abdominal technique for the treatment of posthysterectomy vaginal vault prolapse. METHOD: It provides support of the peritoneal surface of the pelvic floor by means of a Gore-Tex mesh, which closes this space. The vaginal vault is fixed to the centre of the mesh. STUDY DESIGN: Descriptive study. RESULTS: Sixteen patients with vaginal vault prolapse were operated on and postoperative follow-up time ranged from 16 to 46 months. There was only one case in which the mesh had to be removed due to infection and posterior erosion of the vaginal wall, and no cases of recurrent vaginal vault prolapse. CONCLUSION: A Gore-Tex mesh, placed at the top of the vaginal vault and extending across the pelvic floor, can effectively treat posthysterectomy vault prolapse.

Adult↗
PubMed2005

Uterus preservation in surgical correction of urogenital prolapse.

OBJECTIVE: This study aimed to evaluate the efficacy of colposacropexy with uterine preservation as therapy for uterovaginal prolapse. Surgical techniques, efficacy and overall results are described. METHODS: In this prospective, controlled study, 34 of the 72 consecutive patients with symptomatic uterovaginal prolapse were treated with colposacropexy with uterus conservation (hysterocolposacropexy, HSP) and the other 38 with hysterectomy followed by sacropexy (CSP). Anchorage was achieved with two rectangular meshes in CSP and with one posterior rectangular and one anterior Y-shaped mesh in HSP. Check-ups were scheduled at 3, 6 and 12 months and then yearly. Pre-operative patient characteristics, operative and post-operative events and follow-up results were recorded. Mean follow-up was 51 months (range 12-115). RESULTS: No significant differences emerged in demographic and clinical characteristics between the HSP and CSP groups. Mean operating times, intra-operative blood loss and hospital stay were significantly less after HSP (p<0.001). At follow-up success rates were similar in the two groups in terms of uterine and upper vaginal support (100%). Recurrent low-grade cystoceles developed in 1/38 (2.6%) in the CSP group and in 5/34 (14.7%) in the HSP group (p=NS), recurrent low-grade rectocele developed in 6/38 (15.8%) and in 3/34 (8.8%) patients respectively (p=NS). No patient required surgery for recurrent vault or uterus prolapse. Urodynamic results showed that pressure/flow parameters improved significantly (p<0.001) in both groups. Thirty-one of the 34 patients (91%) in the HSP group and 33/38 (86.8%) in the CSP group were satisfied and would repeat surgery again. CONCLUSIONS: Colposacropexy provides a secure anchorage, restoring an anatomical vaginal axis and a good vaginal length. HSP can be safely offered to women who request uterine preservation. Whether the uterus was preserved or not, patients had similar results in terms of prolapse resolution, urodynamic outcomes, improvements in voiding and sexual dysfunctions. HSP has shorter operating times and less blood loss.

Aged↗
PubMed2005

[Practicability of the vaginal prolapse surgery in the elderly woman].

OBJECTIVE: To evaluate the vaginal prolapse cure in the elderly woman. PATIENTS AND METHODS: A retrospective study is carried out on 38 patients of more than 80 years, operated for a vaginal genital prolapse cure between November 1997 and October 2004. The patients' general state of health, the type of analgesia, the operative type and time, the per- and postoperative complications and the evolution of the patients one month after the intervention, had been assessed. RESULTS: The average age of the patients was 84.2 (80-95). The patients' general state of health, according to the ASA classification was about 55.3% ASA II, and about 44.7% ASA III. The anaesthesia was general in 92.1% and spinal in 7.9%. The operating type was vaginal hysterectomy associated to a Marion-Kelly and a posterior perineorrhaphy in 68.4%; and a simple vaginal hysterectomy, associated more or less to the installation of a TVT in 13.1%; an intervention of Lefort, a case of Richter and a case of simple colpectomy in 10.5%. The average operative time is about 43 minutes. The peroperative complications can be summed up in a conversion in laparotomy due to haemorrhage, and a case of ligation of the right urethra. The transfer in an intensive care unit during 24 hours is necessary only for one case in 38. The postoperative complications are in one case death at eleventh day as a result of a pulmonary embolism, and a case of temporospatial disorientation and a prolapse relapse at 6 months. The duration of stay in hospital is about 7 days (2-18). The surgery did not affect the autonomy of the patients at one month. DISCUSSION AND CONCLUSION: Vaginal prolapse concerning the elderly woman is workable in quite common practice; it involves a good cooperation between anaesthetist and surgeon. The vital risk is really present but relative. This functional surgery must not be delayed by the installation of a pessary which must be used only for the inoperable patients.

Aged, 80 and over↗
PubMed2006

Ventricular septal defect closure in right coronary cusp prolapse and aortic regurgitation complicating VSD in the outlet septum: which treatment is most appropriate?

BACKGROUND: There is currently not a standardized technique for the sizing and shaping of surgical closure of the ventricular septal defect (VSD) patch in patients with right coronary aortic cusp prolapse and aortic regurgitation (AR) complicating VSD in the outlet septum. METHODS: Forty-six VSD patients who had aortic valve prolapse were divided into groups DC (direct closure, n=19), and SPC (small patch closure, n=27). Preoperative and postoperative echocardiography with Doppler color flow interrogation was performed on all patients. RESULTS: In the DC group, among seven patients who had aortic valve prolapse but no AR preoperative, one patient developed AR during postoperative follow-up period. In the remaining 12 patients who had mild AR associated with aortic valve prolapse prior to the procedure, AR was diminished in four and unchanged in six patients. However, AR was aggravated in two patients who required further operations for AV repair or replacement. In the SPC group, among the eight patients who had no preoperative AR, AR progressed in one patient postoperatively. In the remaining 19 patients who had mild AR, AR was diminished in 15 and unchanged in four. The outcome from the operative procedure was significantly better in the SPC group than DC group with mild preoperative AR (chi(2)=7.82; P<0.05). CONCLUSIONS: Small patch closure for this type of VSD is safer and more reliable in improving mild AR than that of direct closure, especially in patients with mild AR.

Adolescent↗
PubMed2004

Colposacrosuspension for severe genital prolapse.

OBJECTIVE: A descriptive study of 140 patients with severe genital prolapse managed by colposacrosuspension with mesh interposition and a modified Burch colposuspension. METHODS: A laparotomy was performed with mobilization of the rectum and exploration of the rectovaginal septum. Vaginally, a longitudinal incision was made in the posterior vaginal wall which was completely separated from the rectum. A perineal repair was done, whereafter a strip of Vypro (Johnson & Johnson, Brussels, Belgium) mesh was inserted from the perineum to the sacrum at S1. It was fixated to the perineum and vagina while the rectum was elevated and attached to the mesh. Where a perineal repair was deemed not necessary, the mesh extended from the mid-vagina to the sacrum. A second mesh strip was placed anteriorly of the vagina, covering the upper third of the vagina and extending to the sacrum. After closure of the pelvic peritoneum, covering the mesh, a modified Burch colposuspension was performed. Follow-up was done at 6 weeks, 6 months and yearly thereafter. RESULTS: The median age was 61 years with a median parity of 3. All patients presented with grade 2 (extending to the vaginal introitus) or 3 (outside the vaginal introitus) prolapse. Approximately one-third had urinary incontinence and a similar proportion complained of difficulty in defecation. All the patients underwent colposacrosuspension with the mesh extending to the perineum in 67% of the patients. A Burch colposuspension was performed in 79% of the women. Postoperatively, 97% of the patients were followed for 1-29 months with a median of 8.5 months (mean 10.2 months). Recurrent prolapse, grade 2 or 3, developed in 11 patients (8%) and 17 patients (12%) developed urinary incontinence, needing a transvaginal tape procedure. Removal of the mesh was necessary in one patient (0.7%). CONCLUSION: Colposacrosuspension for severe genital prolapse delivered satisfactory short-term results. It is, however, a major surgical procedure and elderly or compromised patients may require less invasive procedures.

Adult↗
PubMed2006

Characterization of plaque prolapse after drug-eluting stent implantation in diabetic patients: a three-dimensional volumetric intravascular ultrasound outcome study.

OBJECTIVES: The aim of this research was to evaluate the plaque prolapse (PP) phenomenon after bare-metal (BMS) and drug-eluting stent (DES) implantation in patients with diabetes mellitus using 3-dimensional volumetric intravascular ultrasound (IVUS). BACKGROUND: Plaque prolapse has been observed in up to 22% of patients treated with BMS. Diabetic patients have a larger atherothrombotic burden and may be more prone to have PP. However, the incidence of PP and its clinical impact after DES implantation is unknown. METHODS: Three-dimensional IVUS was performed after intervention and at 9-month follow-up in 168 patients with diabetes (205 lesions) treated with bare BX Velocity stents ((BX Velocity/Sonic, Cordis, Johnson & Johnson) (BMS, n = 65), sirolimus-eluting stents (Cypher, Cordis) (SES, n = 69), and paclitaxel-eluting stents (Taxus, Boston Scientific, Natick, Massachusetts) (PES, n = 71). Intravascular ultrasound data at the sites of PP were compared with stented segments without PP in each lesion. Outcomes were evaluated at 9- and 12-month follow-up. RESULTS: There were 42 sites of PP (BMS = 11, SES = 11, PES = 20, p = NS) in 34 stented segments of 205 (16.6%) lesions. Plaque prolapse was more frequent in the right coronary artery and in chronic total occlusion lesions. Post-procedure PP volume was 1.95 mm3 in BMS, 2.96 mm3 in SES, and 4.53 mm3 in PES. At follow-up, tissue volume increased at PP sites in both BMS and PES, but not after SES. Neointimal proliferation was similar between PP and non-PP sites. Stent thrombosis and restenosis rates were similar between PP and non-PP lesions. CONCLUSIONS: The incidence of PP after implantation of new generation tubular stents in patients with diabetes remains high. Drug-eluting stent implantation was not associated with increased risk of PP. Plaque prolapse was not associated with stent thrombosis or increased neointimal proliferation.

Aged↗
PubMed2005

A short-form questionnaire identified genital organ prolapse.

OBJECTIVE: We constructed a simple questionnaire that, with a minimum of questions, could accurately and reliably identify women with genital organ prolapse. STUDY DESIGN AND SETTING: Two hundred women with confirmed genital organ prolapse and 199 outpatients with various gynecologic symptoms but no objective prolapse answered 13 questions perceived to be valuable for the diagnosis. With stepwise backward logistic regression, the discriminatory ability of a successively abbreviated set of questions was assessed. The resulting short questionnaire was tested in a new population-based sample of 282 women participating in a screening survey. RESULTS: A final five-item questionnaire retained 94% of the predictive value of all 13 questions and had 92.5% sensitivity and 94.5% specificity in the first group of women. When the questionnaire was used in the subsequent population-based survey, the sensitivity and specificity values were 66.5% and 94.2%, respectively. Most missed cases had stage I prolapse. CONCLUSION: Although the sensitivity of the test was moderate, the specificity, and hence the ability to rule in cases, was satisfactory. The test is suitable for case finding in epidemiologic studies.

Adult↗
PubMed2006

The manchester-fothergill procedure as a fertility sparing alternative for pelvic organ prolapse in young women.

Although reproductive organ prolapse typically affects older, parous women, a certain population of children and adolescents, primarily adolescents with congenital spinal defects, are also at risk. The Manchester-Fothergill procedure was first performed in 1888 by Dr. Archibald Donald of Manchester, England. Although this is a well-described procedure in historic texts, the practical application is not often employed, and modern surgical texts rarely describe how to perform this surgery. It is crucial to educate younger physicians about the technical aspects of this procedure so as not to lose this operation as an alternative surgical approach. We present a case of recurrent uterine prolapse after a prior laparoscopic uterine suspension procedure. In order to address recurrent prolapse, which was accompanied by cervical elongation, this young woman elected to have additional surgical management with the Manchester-Fothergill procedure. We describe the procedure in detail, accompanied by photographs taken during the operation to fully illustrate the extent of this patient's condition and to document the surgical technique. The Manchester Fothergill procedure is an additional fertility-sparing surgical approach to treatment of pelvic organ prolapse.

Adult↗
PubMed2005

Ptosis and orbital fat prolapse after posterior sub-Tenon's capsule triamcinolone injection.

PURPOSE: To describe the occurrence of orbital fat prolapse and blepharoptosis after posterior sub-Tenon (PST) triamcinolone injection. DESIGN: Retrospective review of consecutive case series. PARTICIPANTS: Patients with ptosis and orbital fat herniation after PST triamcinolone injection. METHODS: Charts of all patients with ptosis and orbital fat herniation presenting after PST triamcinolone injection to the oculoplastics service of the Cole Eye Institute between 1999 and 2003 were reviewed. Charts were reviewed for patient age, indication, dates of injections, time to patient complaint or time to referral for ptosis, and marginal reflex distance (MRD1). MAIN OUTCOME MEASURES: Ptosis and orbital fat herniation after PST triamcinolone injection. RESULTS: Eleven patients with a history of ipsilateral PST triamcinolone injections were seen with ptosis and orbital fat prolapse. Ten charts were available for review. Mean patient age was 64 years (range, 45-78 years). Patients underwent 1 to 9 ipsilateral injections, and 2 patients underwent bilateral injections. Patients were seen for ptosis evaluation on average 22.5 months (range, 3-56 months) after the initial injection, and 6.6 months (range, 0-20 months) after the most recent injection. All patients demonstrated significant orbital fat prolapse in conjunction with statistically significant ptosis (P = 0.016). Tissue was obtained in 3 cases. Histologic findings in 1 case showed orbital fat infiltrated by histiocytes that seemed to contain phagocytosed material. CONCLUSIONS: Posterior sub-Tenon triamcinolone injection may cause ptosis associated with orbital fat prolapse. This finding may be a relatively common complication of PST triamcinolone injection. We recommend counseling patients about this risk before PST triamcinolone injection.

Adipose Tissue↗
PubMed2004

Transvaginal surgery in the octogenarian using cadaveric fascia for pelvic prolapse and stress incontinence: minimal one-year results compared to younger patients.

OBJECTIVES: To evaluate prospectively our transvaginal surgery experience in octogenarian women and compare the results with those in younger patients. As our population has aged, the treatment of incontinence and prolapse in women older than 80 years, known as octogenarians, has become a significant clinical issue. METHODS: To date, our prospective database includes 455 women who have undergone transvaginal sling surgery using nonfrozen cadaveric fascia lata with or without concurrent prolapse repair. Of these, 51 (11%) were at least 80 years old at surgery. Complete follow-up was defined as pelvic examination findings, validated questionnaire responses (incontinence and quality of life), and SEAPI (Stress, Emptying, Anatomy, Protection, and Instability) score. The outcomes analysis was focused on the 31 octogenarian women with a minimum of 1 year of complete follow-up and compared their data with the data of 234 younger women with an identical minimal follow-up time. RESULTS: The mean octogenarian age was 83 years (maximal age 93). The mean octogenarian questionnaire and examination follow-up was administered at 21.4 months and 17.5 months, respectively. Of the 31 octogenarians, 17 (55%) reported continence improvement of greater than 70%, and 28 (90%) had no symptomatic recurrent prolapse. Compared with younger patients, no statistically significant difference in outcome parameters was identified. The rates of persistent urgency and urgency in dissatisfied patients were greater in octogenarian women, but did not reach statistical significance. Statistically significant improvement in the octogenarian quality-of-life measures was demonstrated. No perioperative complications occurred. CONCLUSIONS: Transvaginal incontinence and/or prolapse surgery may be safely performed in octogenarian women, with resultant improvement in quality-of-life measures. Although outcomes after transvaginal surgery were comparable between octogenarian and younger women, persistent urgency may predict dissatisfaction in the octogenarian population.

Age Factors↗
PubMed2001

Chordal plication and free edge remodeling for mitral anterior leaflet prolapse repair: 8-year follow-up.

BACKGROUND: Chordal suture plication and free edge remodeling represent a personal technique for the repair of anterior leaflet prolapse. We report the results of an 8-year experience. METHODS: Sixty-one patients with degenerative mitral regurgitation caused by prolapse of the anterior leaflet (11) or both leaflets (50) underwent anterior leaflet prolapse repair. Twenty patients who had associated cardiac procedures are included. RESULTS: There were two perioperative deaths. Postoperative mitral regurgitation fell to 0.4 +/- 0.7 versus 3.7 +/- 0.4 preoperative (p < 0.0001). Mean follow-up was 40.5 months. There were 3 late deaths and 3 mitral reoperations (1 of 3 repairs, 2 of 3 replacements). Thromboembolism and endocarditis occurred in 1 patient each. Actuarial overall survival, freedom from cardiac death, and freedom from mitral reoperation at 92 months were 85.1% +/- 7.9%, 88.9% +/- 7.7%, and 94.6% +/- 3.0%, respectively. CONCLUSIONS: Our technique of anterior leaflet prolapse repair appears effective, safe, and durable at mid- to long-term follow-up, and may be used in the presence of extensive disease of both leaflets.

Adult↗
PubMed1997

Synthetic sling for genital prolapse in young women.

OBJECTIVE: The aim is to repair uterine prolapse in young women, utilizing synthetic tape (Merselene). It is a prospective study demonstrating an operative procedure for correction of uterine prolapse in young women. This procedure was performed in three post-graduate teaching hospitals: Institute of Obstetrics and Gynaecology, Gandhi Hospital and Niloufer Hospital, Hyderabad, India. METHOD: Through an abdominal approach, the Merselene tape was fixed on the posterior surface of the uterus and anchored to the anterior longitudinal ligament, over the sacral promontory. This procedure was performed on 19 women in the age group 17-27 years, two of whom were unmarried virgins. RESULTS: The procedure rectified the descent of the uterus and kept it anteverted. In one of the cases, exploration at cesarean section showed that the sling was intact. There were no significant intraoperative or postoperative complications. Recurrence of prolapse was not reported in any of these cases. CONCLUSION: This technique is a relatively simple method for correction of uterine prolapse in young women. The Merselene tape is inert, strong, flexible, effectively supports the uterus, and remains retroperitoneal.

Adolescent↗
PubMed1987

Multiple-flap anoplasty in the treatment of rectal prolapse after pull-through operations for imperforate anus.

Rectal prolapse is a frequent complication after pull-through operations for high imperforate anus. Mucosal prolapse causes soiling, occasional bleeding, and pain. Simple resection of the redundant mucosa is unsatisfactory and leads to frequent recurrences or strictures. In 1982, Millard and Rowe reported a technique designed to correct rectal prolapse using two perineal flaps, thus providing a skin-lined anal canal. We have operated on two patients using the same technique. A three-flap anoplasty was used in nine other patients. With an average follow-up of 13 months, none of out patients presented recurrence of the prolapse or a significant stenosis. This procedure is safe and physiologically sound. The skin-lined anal canal provides some sensation where it is lacking. The functional and esthetic results are gratifying and we are now using the three-flap anoplasty as a primary procedure in the correction of high imperforate anus.

Adolescent↗
PubMed1989

Posterior sagittal anorectoplasty for pediatric recurrent rectal prolapse.

The recent use of the posterior sagittal anorectoplasty for repair of high imperforate anus has demonstrated several advantages: elimination of laparotomy, more direct approach, easier division of rectourethral fistula, more exact identification of the muscles of fecal continence, proper relocation of anorectum within these muscles and sphincters, and virtual elimination of postoperative anal prolapse. It is this latter advantage that attracted us to use this procedure for the repair of a recurrent rectal prolapse in a 1-year-old girl who also had a recurrent bladder exstrophy. The latter probably contributed to her constantly pushing out her rectum, which easily admitted two fingers. Two attempts were made to repair the rectal prolapse using the subcutaneous Thiersch's perianal technique; however, each was successful for only 6 weeks. When her recurrent bladder exstrophy was repaired, we also repaired her recurrent rectal prolapse using the posterior sagittal anorectoplasty. The midline sacrococcygeal incision was carried down to but not through the external sphincter, and the patulous rectum was plicated back to a normal size. Reapproximation of the levator sling and lower muscle complex then incorporated the plicated rectum. Both repairs remain intact after 1 year.

Anal Canal↗
PubMed1997

Prolapse of urethral mucosa in white female children: experience with 58 cases.

In the 15 years from 1981, 58 white girls were treated for urethral prolapse. They were grouped into those with partial prolapse (n = 17) and those with circular prolapse (n = 41). Medical treatment was successful in 20 patients with 5 recurrences, 2 of whom ultimately required operation. Lack of response to medical treatment resulted in a further 38 patients undergoing surgery. Four girls had complications: bleeding (n = 1) urethral stenosis (n = 2) and recurrence (n = 1). These complications were treated successfully. Pathological changes in prolapsed urethral mucosa are discussed in this report.

Child↗
PubMed1994

Prolapsed vesicostomy results in a strangulated bowel herniation: a rare complication of cutaneous vesicostomy.

A 3-year-old girl presented with a prolapsed cutaneous vesicostomy, and symptoms and signs of acute intestinal obstruction. The vesicostomy had been performed when she was 19 months old for bilateral vesicoureteral reflux. Postoperatively, prolapse of the bladder from the stoma occurred almost daily. The prolapsed part retracted naturally when the patient was relaxed and reclining. Intestinal obstruction was due to strangulated herniation of the bowel into the prolapsed bladder via the stoma of vesicostomy. Treatment consisted of manual reduction and the stoma of the vesicostomy was revised with the patient under general anesthesia.

Child, Preschool↗