便秘是一种常见的疾病，但有关其定义和发病机制的认识尚不统一。由于肠道传输时间并不是一个常数，不同时间测的数值有很大差异，不应作为便秘诊断的参数，其时间延长经常因出口梗阻型便秘所致，而非便秘的初始原因。由于便秘病人需要通过增加腹内压和盆腔内压力，产生排便的刺激，导致道格拉斯窝加深、肠疝、直肠内套叠、膀胱膨出、子宫及阴道脱垂及会阴过度下降等功能性改变，继而出现解剖学改变。直肠内脱垂分为两种类型：直肠长度和结构正常的直肠脱垂；以及伴有直肠肌层延长等结构改变的直肠脱垂，通过经肛吻合器直肠切除术（STARR）切除直肠脱垂及直肠膨出，可以明显改善这些功能性和解剖性变化。

Ventral rectopexy has become increasingly used in the surgical management of rectal prolapse. There is a need for a contemporary evaluation of the role of the procedure and a description of its use in clinical practice.

Background: This work had its origins in the 1990s, when women having collagen-creating midurethral slings for stress urinary incontinence (SUI) and uterosacral slings for uterine prolapse began reporting cure or improvement in co-occurring fecal incontinence, obstructive defecation, and chronic pelvic pain. Summary: We briefly describe anatomical etiopathogenesis to explain how the same collagen-creating ligament repair system using a common ligament-based diagnostic system, can treat pelvic symptoms from 3 disciplines: Urology, Gynecology, Coloproctology. Collagen-induced laxity in ligaments and vagina diminishes contractile forces required by pelvic muscles to close urethra and anus for continence, open them for evacuation, and stretch the bladder base and rectum like a trampoline to prevent stretch receptors prematurely activating micturition and defecation reflexes. These are perceived cortically as bladder or fecal “urge to go.” The pictorial algorithm summarizes common ligament pathogeneses for prolapse/bladder/bowel/pain dysfunctions which can be confirmed by mechanical support of PUL for relief of urine loss on coughing, and uterosacral ligaments (USL) for relief of urge and chronic pelvic pain. The same minimally invasive ligament repairs used for SUI, prolapse, pain/bladder dysfunctions were demonstrated by X-ray defecography controlled studies to cure fecal incontinence, obstructive defecation, anterior rectal wall intussusception and descending perineal syndrome (as shown in 16 case managements in 3 disciplines; video: <ext-link ext-link-type=\"uri\" xlink:href=\"https://youtu.be/a6jJQXDx71U?si=MLdo3Yq9kAZ82RVb\" xmlns:xlink=\"http://www.w3.org/1999/xlink\">https://youtu.be/a6jJQXDx71U?si=MLdo3Yq9kAZ82RVb</ext-link>). Key Messages: Symptom relief can be achieved using standard operations which repair PUL or USL even with minimal prolapse. Whether the surgery is done laparoscopically or vaginally is of little consequence, as the same structure is repaired.

Fecal incontinence is a challenging condition of diverse etiology and devastating psychosocial impact. Multiple mechanisms may be involved in its pathophysiology, such as altered stool consistency and delivery of contents to the rectum, abnormal rectal capacity or compliance, decreased anorectal sensation, and pelvic floor or anal sphincter dysfunction. A detailed clinical history and physical examination are essential. Anorectal manometry, pudendal nerve latency studies, and electromyography are part of the standard primary evaluation. The evaluation of idiopathic fecal incontinence may require tests such as cinedefecography, spinal latencies, and anal mucosal electrosensitivity. These tests permit both objective assessment and focused therapy. Appropriate treatment options include biofeedback and sphincteroplasty. Biofeedback has resulted in 90 percent reduction in episodes of incontinence in over 60 percent of patients. Overlapping anterior sphincteroplasty has been associated with good to excellent results in 70 to 90 percent of patients. The common denominator between the medical and surgical treatment groups is the necessity of pretreatment physiologic assessment. It is the results of these tests that permit optimal therapeutic assignment. For example, pudendal nerve terminal motor latencies (PNTML) are the most important predictor factor of functional outcome. However, even the most experienced examiner's digit cannot assess PNTML. In the absence of pudendal neuropathy, sphincteroplasty is an excellent option. If neuropathy exists, however, then postanal or total pelvic floor repair remain viable surgical options for the treatment of idiopathic fecal incontinence. In the absence of an adequate sphincter muscle, encirclement procedures using synthetic materials or muscle transfer techniques might be considered. Implantation of a stimulating electrode into the gracilis neosphincter and artificial sphincter implantation are other valid alternatives. The final therapeutic option is fecal diversion. This article reviews the current status of the etiology and incidence of incontinence as well as the evaluation and treatment of this disabling condition.

Existing scales for assessing faecal incontinence have not been validated against clinical assessment, or with regard to reproducibility. They also fail to take into account faecal urgency, and the use of antidiarrhoeal medications.To establish the validity, and sensitivity to change, of existing scales and a newly designed incontinence scale.(1) Twenty three patients (21 females, median age 57 years) were prospectively evaluated by two independent clinical observers, using three established scales (Pescatori, Wexner, American Medical Systems), a newly devised scale which also includes details about urgency and antidiarrhoeal drugs, and by a 28 day diary. (2) A further 10 female patients were assessed by the same scales before and after surgery for faecal incontinence.(1) Assessments by two independent clinicians correlated well. All four scales and a diary card correlated highly and significantly with the clinical impression, with the new scale reaching the highest correlation (r=0.79, p<0.001). (2) All except one score changed significantly in response to surgical treatment; the new scale showed the greatest change, at the highest level of significance (p=0.004), and correlated best with the clinicians' assessment of change (r=0.94, p<0.001).Existing scales for the assessment of faecal incontinence correlate well with careful clinical impression of severity, and serve as useful and reproducible measures for comparison of patients and treatments. A newly devised scale has shown high clinical validity and utility.

To develop short forms of 2 valid and reliable condition-specific quality-of-life questionnaires for women with disorders of the pelvic floor including urinary incontinence, pelvic organ prolapse, and fecal incontinence (Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire).Data from the 100 women who contributed to the development and validation of the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire long forms were used to develop the short-form questionnaires. All subsets regression analysis was used to find the items in each scale that best predicted the scale score on the respective long form. When different items appeared equivalent, a choice was made on item content. After development, the short forms and the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire long forms were administered preoperatively to 45 women with pelvic floor disorders scheduled to undergo surgery to evaluate the correlation between short and long forms in a second independent population. The short forms were readministered 3 to 6 months postoperatively to assess the responsiveness of the instruments.The short-form version of the Pelvic Floor Distress Inventory has a total of 20 questions and 3 scales (Urinary Distress Inventory, Pelvic Organ Prolapse Distress Inventory, and Colorectal-Anal Distress Inventory). Each short-form scale demonstrates significant correlation with their long-form scales (r=.86, r=.92, and r=.93, respectively, P<.0001). For the Pelvic Floor Impact Questionnaire short form, the previously developed short form for the Incontinence Impact Questionnaire-7 was used as a template. The 7 items identified in the previously developed Incontinence Impact Questionnaire-7 short form correlate highly with the Incontinence Impact Questionnaire long form (r=.96, P<.0001) as well as the long forms of the Colorectal-Anal Impact Questionnaire scale (r=.96, P<.0001) and the Pelvic Organ Prolapse Impact Questionnaire (r=.94, P<.0001). All subsets regression analysis did not identify any items or combination of items that correlated substantially better for any of the 3 scales. The scales of the Pelvic Floor Distress Inventory-20 and Pelvic Floor Impact Questionnaire-7 maintained their excellent correlation to the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire long forms in the second independent sample (r=.88 to.94 for scales of Pelvic Floor Distress Inventory-20; r=.95 to.96 for scales of Pelvic Floor Impact Questionnaire-7, P<.0001 for all). The test-retest reliability of each scale was good to excellent (intraclass correlation coefficient 0.70 to 0.93, P<.001 for all scales). The scales and summary scores of the Pelvic Floor Distress Inventory-20 and Pelvic Floor Impact Questionnaire-7 demonstrated moderate to excellent responsiveness 3 to 6 months after surgery.The Pelvic Floor Distress Inventory-20 and Pelvic Floor Impact Questionnaire-7 are valid, reliable, and responsive short forms of 2 condition-specific quality-of-life questionnaires for women with pelvic floor disorders.

Many operations have been described for the management of rectal prolapse. Despite an overall recurrence rate of greater than 15 percent, few reviews address how to deal with this problem. This report summarizes our experience with recurrent rectal prolapse and includes suggestions for reoperative management of failed repairs from both abdominal and perineal approaches.Fourteen patients (3 male) ranging in age from 22 to 92 (mean, 68) years underwent operative correction of recurrent rectal prolapse. Average time from initial operation to recurrence was 14 (range, 6-60) months. Initial operations (before recurrence) were as follows: perineal proctectomy and levatorplasty (10), anal encirclement (2), Delorme's procedure (1), and anterior resection (1). Operative procedures performed for recurrence were as follows: perineal proctectomy and levatorplasty (7), sacral rectopexy (abdominal approach; 3), anterior resection with rectopexy (2), Delorme's procedure (1), and anal encirclement (1). Average length of follow-up was 50 (range, 9-115) months.No further episodes of complete rectal prolapse were observed during this period. Preoperatively, three patients were noted to be incontinent to the extent that necessitated the use of perineal pads. The reoperative procedures failed to restore fecal continence in any of these three individuals. One patient died in the postoperative period after anal encirclement from an unrelated cause.Surgical management of recurrent rectal prolapse can be expected to alleviate the prolapse, but not necessarily fecal incontinence. Perineal proctectomies can be safely repeated. Resectional procedures may result in an ischemic segment between two anastomoses, unless the surgeon can resect a previous anastomosis in the repeat procedure. Nonresectional procedures such as the Delorme's procedure should be strongly considered in the management of recurrent rectal prolapse if a resectional procedure was performed initially and failed.

Altemeier's procedure is infrequently applied in European countries and because of the small number of patients treated in each center, its long-term reliability is uncertain.Medical records of 93 patients (median age, 77 years) undergoing perineal rectosigmoidectomy associated with levatorplasty in 72 patients (78 percent) were reviewed; 65 patients (70 percent) suffered from major fecal incontinence.There was no postoperative mortality. Eight (8.6 percent) major complications were observed (3 pelvic hematomas, 1 anastomotic dehiscence, 1 sigmoid perforation, 1 pararectal abscess, and 2 late anal strictures), and 13 (14 percent) minor complications. At a mean follow-up of 41 (range, 12-112) months the complete recurrence rate was 18 percent (17 patients); these patients were treated with a repeat Altemeier's procedure (6 patients), Delorme's operation (1 patient), Wells' rectopexy (1 patient), postanal repair (1 patient), anal bulking agents (2 patients), and sacral nerve stimulation (2 patients). Anal manometry significantly improved postoperatively. Incontinence improved postoperatively in 30 cases (28 percent), deteriorated in 2 patients, while 4 patients developed minor incontinence.Perineal rectosigmoidectomy for rectal prolapse is a relatively safe and effective treatment, in particular, for frail, older patients, with a low postoperative morbidity, but the recurrence rate is not negligible and restoration of continence is unpredictable.

Established in 1987, the EuroQol Group initially comprised a network of international, multilingual and multidisciplinary researchers from seven centres in Finland, the Netherlands, Norway, Sweden and the UK. Nowadays, the Group comprises researchers from Canada, Denmark, Germany, Greece, Japan, New Zealand, Slovenia, Spain, the USA and Zimbabwe. The process of shared development and local experimentation resulted in EQ-5D, a generic measure of health status that provides a simple descriptive profile and a single index value that can be used in the clinical and economic evaluation of health care and in population health surveys. Currently, EQ-5D is being widely used in different countries by clinical researchers in a variety of clinical areas. EQ-5D is also being used by eight out of the first 10 of the top 50 pharmaceutical companies listed in the annual report of Pharma Business (November/December 1999). Furthermore, EQ-5D is one of the handful of measures recommended for use in cost-effectiveness analyses by the Washington Panel on Cost Effectiveness in Health and Medicine. EQ-5D has now been translated into most major languages with the EuroQol Group closely monitoring the process.

To assess the sensitivity to within person change over time of an outcome measure for practitioners in primary care that is applicable to a wide range of illness.Comparison of a new patient generated instrument, the measure yourself medical outcome profile (MYMOP), with the SF-36 health profile and a five point change score; all scales were completed during the consultation with' practitioners and repeated after four weeks. 103 patients were followed up for 16 weeks and their results charted; seven practitioners were interviewed.Established practice of the four NHS general practitioners and four of the private complementary practitioners working in one medical centre.Systematic sample of 218 patients from general practice and all 47 patients of complementary practitioners; patients had had symptoms for more than seven days.Standardised response mean and index of responsiveness; view of practitioners.The index of responsiveness, relating to the minimal clinically important difference, was high for MYMOP: 1.4 for the first symptom, 1.33 for activity, and 0.85 for the profile compared with < 0.45 for SF-36. MYMOP's validity was supported by significant correlation between the change score and the change in the MYMOP score and the ability of this instrument to detect more improvement in acute than in chronic conditions. Practitioners found that MYMOP was practical and applicable to all patients with symptoms and that its use increased their awareness of patients' priorities.MYMOP shows promise as an outcome measure for primary care and for complementary treatment. It is more sensitive to change than the SF-36 and has the added bonus of improving patient-practitioner communication.

The development of robotic assistance has made dissection and suturing in the deep pelvis much easier. The augmented quality of the images and the articulation of the robotic arms have also enabled a more precise dissection. The aim of this study is to present the data on robotic-assisted ventral mesh rectopexy procedures in a university hospital and examine the literature in terms of mesh erosion.The electronic databases Pubmed, Embase and Cochrane were searched. Studies from January 2004 until January 2023 in the English language were included. Studies which included fewer than 10 patients were excluded. Laparoscopic or robotic-assisted ventral mesh rectopexies were included. Mesh erosion rates following laparoscopic or robotic-assisted ventral mesh rectopexies were measured.Overall, the systematic review presents 5911 patients from 43 studies who underwent laparoscopic ventral mesh rectopexy compared with 746 patients treated with robotic-assisted ventral mesh rectopexy from six studies and our centre. Mesh erosion was rare in both groups; however, the prevalence was greater in the laparoscopy group (0.90% vs. 0.27%).The mesh erosion rates are very low with robotic-assisted ventral mesh rectopexy. For precise results, more studies and experience in robotic surgery are required.© 2024 The Authors. Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.

Robot-assisted ventral mesh rectopexy is considered a valid option in the treatment of rectal prolapse. However, it involves higher costs than the laparoscopic approach. The aim of this study is to determine if less expensive robotic surgery for rectal prolapse can be safely performed.

Concerns have been raised regarding the potential risk of mesh complications after laparoscopic ventral rectopexy.This study aimed to determine the risk of mesh and nonmesh morbidity after laparoscopic ventral rectopexy and to compare the safety of synthetic meshes with biological grafts.This was a retrospective review.The study used data collated from prospective pelvic floor databases in 5 centers (3 in the United Kingdom, 1 in Australia, and 1 in Italy).All of the patients undergoing laparoscopic ventral rectopexy over a 14-year period (1999-2013) at these centers were included in the study.The primary outcome was mesh morbidity, classified as vaginal erosion, rectal erosion, rectovaginal fistula, or perineal erosion. Secondary outcomes were nonmesh morbidity.A total of 2203 patients underwent surgery; 1764 (80.1%) used synthetic mesh and 439 (19.9%) used biological grafts. There were 2 postoperative deaths (0.1%). Forty-five patients (2.0%) had mesh erosion, including 20 vaginal, 17 rectal, 7 rectovaginal fistula, and 1 perineal. Twenty-three patients (51.1%) required treatment for minor erosion morbidity (local excision of stitch/exposed mesh), and 18 patients (40.0%) were treated for major erosion morbidity (12 laparoscopic mesh removal, 3 mesh removal plus colostomy, and 3 anterior resection). Erosion occurred in 2.4% of synthetic meshes and 0.7% of biological meshes. The median time to erosion was 23 months. Nonmesh complications occurred in 11.1% of patients.This was a retrospective study including patients with minimal follow-up. The study was unable to determine whether patients will develop future erosions, currently have asymptomatic erosions, or have been treated in other institutions for erosions.Laparoscopic ventral rectopexy is a safe operation. Mesh erosion rates are 2% and occasionally require resectional surgery that might be reduced by the use of biological graft. An international ventral mesh registry is recommended to monitor mesh problems and to assess whether type of mesh has any impact on functional outcomes or the need for revisional surgery for nonerosion problems.

Ventral mesh rectopexy (VMR) is a surgical option to treat rectal prolapse with pelvic floor dysfunction (PFD). Using synthetic surgical glue to fix the mesh to the anterior rectal wall after ventral dissection could be advantageous in comparison with sutured or stapled fixation. This study aimed to evaluate the safety and efficacy of synthetic surgical glue for mesh fixation compared with suture mesh fixation in VMR.This observational cohort study is a retrospective analysis conducted in a University Hospital Pelvic Surgery Center. All consecutive female patients (n = 176) who underwent laparoscopic or laparotomic VMR between January 2009 and December 2014 were included. Two groups were defined based on mesh fixation technique of the rectal wall: VMR with synthetic glue (n = 66) and VMR with suture (n = 110). The recurrence-free survival after VMR was determined by Kaplan-Meier method and multivariate analysis by Cox regression. Short-term postoperative complications, postoperative symptom improvement, the need for complementary treatment postoperatively, and procedure length were evaluated.A total of 176 females patients (mean age, 58.6 ± 13.7 years) underwent VMR with synthetic mesh. Mean recurrence-free survivals after VMR were 17.16 (CI 95% 16.54-17.80) and 17.33 (CI 95% 16.89-17.77) months in the glue group and the suture group, respectively (p > 0.05). Cox regression identified an independent effect on the recurrence risk of the external rectal prolapse, alone, or in combination with other anatomical abnormalities (HR = 0.37; CI 95% 0.14-0.93; p = 0.03). There was no significant difference of short-term postoperative morbidity, procedure length, postoperative symptom improvement, or need for complementary treatment postoperatively between suture versus glue groups (all p > 0.05).Use of glue to fix the mesh in VMR was safe and had no impact on outcomes. External prolapse was the unique significant predictive factor for recurrence.

We updated anatomic theories of pelvic organ support to determine pathophysiology in various forms of cystocele.PubMed/MEDLINE, ScienceDirect, Cochrane Library, and Web of Science databases were searched using the terms pelvic floor, cystocele, anatomy, connective tissue, endopelvic fascia, and pelvic mobility. We retrieved 612 articles, of which 61 matched our topic and thus were selected. Anatomic structures of bladder support and their roles in cystocele onset were determined on the international anatomic classification; the various anatomic theories of pelvic organ support were reviewed and a synthesis was made of theories of cystocele pathophysiology.Anterior vaginal support structures comprise pubocervical fascia, tendinous arcs, endopelvic fascia, and levator ani muscle. DeLancey's theory was based on anatomic models and, later, magnetic resonance imaging (MRI), establishing a three-level anatomopathologic definition of prolapse. Petros's integral theory demonstrated interdependence between pelvic organ support systems, linking ligament-fascia lesions, and clinical expression. Apical cystocele is induced by failure of the pubocervical fascia and insertion of its cervical ring; lower cystocele is induced by pubocervical fascia (medial cystocele) or endopelvic fascia failure at its arcus tendineus fasciae pelvis attachment (lateral cystocele).Improved anatomic knowledge of vaginal wall support mechanisms will improve understanding of cystocele pathophysiology, diagnosis of the various types, and surgical techniques. The two most relevant theories, DeLancey's and Petros's, are complementary, enriching knowledge of pelvic functional anatomy, but differ in mechanism. Three-dimensional digital models could integrate and assess the mechanical properties of each anatomic structure.

Laparoscopic ventral mesh rectopexy (LVMR) has proved effective in the treatment of internal and external rectal prolapse. The present meta-analysis aimed to determine the predictive factors of recurrence of full-thickness external rectal prolapse after LVMR.An organized, systematic search of electronic databases including PubMed/Medline, Embase, Scopus, and Cochran library was conducted in adherence to PRISMA guidelines. Studies that reported the outcome of LVMR in patients with full-thickness external rectal prolapse were included according to predefined criteria. A meta-regression analysis and sub-group meta-analyses were performed to recognize the patient and technical factors that were associated with higher recurrence rates.Seventeen studies comprising 1242 patients of a median age of 60 years were included. The median operation time was 122.3 min. Conversion to open surgery was required in 22 (1.8%) patients. The weighted mean complication rate across the studies was 12.4% (95% CI 8.4-16.4) and the weighted mean rate of recurrence of full-thickness external rectal prolapse was 2.8% (95% CI 1.4-4.3). The median follow-up duration was 23 months. Male gender (SE = 0.018, p = 0.008) and length of the mesh (SE = - 0.007, p = 0.025) were significantly associated with full-thickness recurrence of rectal prolapse. The weighted mean rates of improvement in fecal incontinence and constipation after LVMR were 79.3% and 71%, respectively.LVMR is an effective and safe option in treatment of full-thickness external rectal prolapse with low recurrence and complication rates. Male patients and length of the mesh may potentially have a significant impact on recurrence of rectal prolapse after LVMR.

Laparoscopic ventral mesh rectopexy (LVR) is an emerging technique for selected patients with rectal prolapse and obstructed defaecation syndrome. Data are insufficient to conclude which type of mesh affords the greatest benefit. Our aim was to compare the outcomes of LVR using a non-cross-linked biologic versus a permanent mesh.Twenty nine cases of LVR with permanent mesh were matched based on age and surgical indication with an equal number of patients using biologic mesh. Cases were retrospectively reviewed from a prospectively maintained database. Symptom resolution, patient satisfaction and recurrence of prolapse were measured among those who underwent LVR with either a biologic (Biodesign(®), Cook Medical) or polypropylene mesh.Age, American Society of Anesthesiologists (ASA) class, surgical indication and primary symptoms were not different between the two groups. After a median follow-up of 15.4 months, all patients reported being either completely or partially satisfied. Rates of complete or partial symptom resolution (p = 0.26) or satisfaction (p = 0.27) did not differ between groups. After LVR, similar rates of additional procedures were performed in the biologic (21 %) and the permanent (28 %) mesh group. Among patients with full-thickness prolapse (n = 33), there were five cases (15 %) of recurrence, one in the biologic group and four in the permanent mesh group (p = 0.37). There were no mesh-related complications in either group.LVR using a non-cross-linked biologic mesh appears to have comparable rates of symptom improvement and patient satisfaction in the short term. Longer follow-up will be required to determine if prolapse recurrence depends on mesh type.

There has been increasing concern and scrutiny in the use of mesh for certain pelvic organ prolapse procedures. However, mesh erosion was often associated with sites of suture fixation of the mesh to the rectum or vagina. Thus, in response to this finding, we replaced our suture material with absorbable monofilament suture.The purpose of this study was to compare the rates of mesh-related complications after laparoscopic ventral mesh rectopexy, according to the type of suture used in fixation of mesh.This was retrospective cohort study.This study was performed at a high-volume, tertiary care center. It was conducted using a prospective database including patients who underwent laparoscopic ventral mesh rectopexy over a 7-year period.A total of 495 cases were included; 296 (60%) laparoscopic ventral mesh rectopexies were performed using a nonabsorbable suture compared with 199 (40%) with an absorbable suture in a case-matched analysis. In addition, 151 cases of laparoscopic ventral mesh rectopexy with nonabsorbable were matched based on age, sex, and time of follow-up, with an equal number of patients using absorbable monofilament suture.Primary outcome was symptomatic mesh erosion after rectopexy. Secondary outcomes included other mesh-related complications and/or reoperations.The erosion rate was 2% (6/495) in the nonabsorbable suture group, including 4 erosions into the rectum and 2 into the vagina. There was no erosion in the group with absorbable suture. This difference was maintained after matching: after a median follow-up of 6 (12) months, there was no erosion in the absorbable suture group versus 3.3% erosion (n = 5) in the nonabsorbable suture group (p = 0.03).This study was limited by its retrospective design.Mesh-related complications are reduced using absorbable sutures compared with nonabsorbable sutures when performing laparoscopic ventral mesh rectopexy with synthetic mesh without an increase in rectopexy failures. See Video Abstract at http://links.lww.com/DCR/B49. IMPACTO DEL TIPO DE SUTURA EN LA TASA DE EROSIóN DESPUéS DE LA RECTOPEXIA VENTRAL LAPAROSCóPICA CON MALLA: UN ESTUDIO DE CASOS EMPAREJADOS: Ha habido una creciente preocupación y escrutinio en el uso de la malla para ciertos procedimientos de prolapso de órganos pélvicos. Sin embargo, la erosión de la malla a menudo se asoció con sitios de fijación de sutura de la malla al recto o la vagina. Por lo tanto, en respuesta a este hallazgo, reemplazamos nuestro material de sutura con sutura de monofilamento absorbible.Comparar las tasas de complicaciones relacionadas con la malla después de la rectopexia laparoscópica de malla ventral, de acuerdo al tipo de sutura utilizada en la fijación de la malla.Este fue un estudio de cohorte retrospectivo.Este estudio se realizó en un centro de atención de tercer nivel de alto volumen. Se realizó utilizando una base de datos prospectiva que incluía pacientes que se sometieron a una rectopexia de malla ventral laparoscópica durante un período de 7 años.Se incluyeron un total de 495 casos; 296 (60%) rectopexias de malla ventral laparoscópica utilizando una sutura no reabsorbible en comparación con 199 (40%) con una sutura absorbible en un análisis de casos emparejados. Además, 151 casos de rectopexia ventral laparoscópica con malla no absorbible se emparejaron según la edad, el sexo y el tiempo de seguimiento con un número igual de pacientes que usaban sutura de monofilamento absorbible.La medida de resultado primaria fue la erosión sintomática de la malla después de la rectopexia. La medida de resultado secundarias incluyeron otras complicaciones y/o reoperaciones relacionadas con la malla.La tasa de erosión fue del 2% (6/495) en el grupo de sutura no absorbible; 4 erosiones en el recto y 2 en la vagina. No hubo erosión en el grupo con sutura absorbible. Esta diferencia se mantuvo después del emparejamiento: después de una mediana de seguimiento de 6 (12) meses, no hubo erosión en el grupo de sutura absorbible versus 3.3% de erosión (n = 5) en el grupo de sutura no absorbible (p = 0.03).Este estudio estuvo limitado por su diseño retrospectivo.Las complicaciones relacionadas con la malla se reducen utilizando suturas absorbibles en comparación con las suturas no absorbibles cuando se realiza la rectopexia de malla ventral laparoscópica con malla sintética, sin un aumento en los fracasos de rectopexia. Vea el Resumen del Video en http://links.lww.com/DCR/B49.

Ventral mesh rectopexy (laparoscopic and robotic) is a common and well established treatment of rectal prolapse. Although described as safe and effective, complications, especially mesh-associated ones are often mentioned. Additionally, there is no consensus regarding the mesh type and fixation method as well as the materials used for this purpose. The aim of this systematic review was to identify the total amount of complications and of those the mesh-associated ones.Pubmed, Web of Science and Cochrane Central Register were screened for complications in general and in detail regarding the mesh(es) and a systematic review was performed.Following qualitative evaluation, 40 studies were identified for further investigation. Across 6269 patients, complications were found in 9.2% (622 patients). Mesh-related complications were described in 1.4% (88 patients) of which 64.8% were erosions, 11.4% fistulas and 13.6% mesh releases. The complication rate according to the different materials were low with 1% in biological and synthetic meshes and 1.8% in not further described or mixed mesh type. Non-absorbable material to fixate the mesh was most frequently used to fixate the mesh.Laparoscopic ventral mesh rectopexy is a safe operation with a low-complication rate, regardless of mesh type.© 2024. The Author(s).

Complications associated with pelvic organ prolapse (POP) surgery using a synthetic non-absorbable mesh are uncommon (<5%) but may be severe and may hugely diminish the quality of life of some women. In drawing up these multidisciplinary clinical practice recommendations, the French National Authority for Health (Haute Autorité de santé, HAS) conducted an exhaustive review of the literature concerning the diagnosis, prevention, and management of complications associated with POP surgery using a synthetic mesh. Each recommendation for practice was allocated a grade (A,B or C; or expert opinion (EO)), which depends on the level of evidence (clinical practice guidelines).Each patient must be informed concerning the risks associated with POP surgery (EO).Vaginal infiltration using a vasoconstrictive solution is not recommended during POP surgery by the vaginal route (grade C). The placement of vaginal packing is not recommended following POP surgery by the vaginal route (grade C). During laparoscopic sacral colpopexy, when the promontory seems highly dangerous or when severe adhesions prevent access to the anterior vertebral ligament, alternative surgical techniques should be discussed per operatively, including colpopexy by lateral mesh laparoscopic suspension, uterosacral ligament suspension, open abdominal mesh surgery, or surgery by the vaginal route (EO).When a bladder injury is diagnosed, bladder repair by suturing is recommended, using a slow resorption suture thread, plus monitoring of the permeability of the ureters (before and after bladder repair) when the injury is located at the level of the trigone (EO). When a bladder injury is diagnosed, after bladder repair, a prosthetic mesh (polypropylene or polyester material) can be placed between the repaired bladder and the vagina, if the quality of the suturing is good. The recommended duration of bladder catheterization following bladder repair in this context of POP mesh surgery is from 5 to 10 days (EO).After ureteral repair, it is possible to continue sacral colpopexy and place the mesh if it is located away from the ureteral repair (EO).Regardless of the approach, when a rectal injury occurs, a posterior mesh should not be placed between the rectum and the vagina wall (EO). Concerning the anterior mesh, it is recommended to use a macroporous monofilament polypropylene mesh (EO). A polyester mesh is not recommended in this situation (EO).After vaginal wall repair, an anterior or a posterior microporous polypropylene mesh can be placed, if the quality of the repair is found to be satisfactory (EO). A polyester mesh should not be used after vaginal wall repair (EO).Regardless of the surgical approach, intravenous antibiotic prophylaxis is recommended (aminopenicillin + beta-lactamase inhibitor: 30 min before skin incision +/- repeated after 2 h if surgery lasts longer) (EO). When spondylodiscitis is diagnosed following sacral colpopexy, treatment should be discussed by a multidisciplinary group, including especially spine specialists (rheumatologists, orthopedists, neurosurgeons) and infectious disease specialists (EO). When a pelvic abscess occurs following synthetic mesh sacral colpopexy, it is recommended to carry out complete mesh removal as soon as possible, combined with collection of intraoperative bacteriological samples, drainage of the collection and targeted antibiotic therapy (EO). Non-surgical conservative management with antibiotic therapy may be an option (EO) in certain conditions (absence of signs of sepsis, macroporous monofilament polypropylene type 1 mesh, prior microbiological documentation and multidisciplinary consultation for the choice of type and duration of antibiotic therapy), associated with close monitoring of the patient.Peritoneal closure is recommended after placement of a synthetic mesh by the abdominal approach (EO).Preoperative urodynamics is recommended in women presenting with urinary symptoms (bladder outlet obstruction symptoms, overactive bladder syndrome or incontinence) (EO). It is recommended to remove the bladder catheter at the end of the procedure or within 48 h after POP surgery (grade B). Bladder emptying and post-void residual should be checked following POP surgery, before discharge (EO). When postoperative urine retention occurs after POP surgery, it is recommended to carry out indwelling catheterization and to prefer intermittent self-catheterization (EO).Before POP surgery, the patient should be asked about risk factors for prolonged and chronic postoperative pain (pain sensitization, allodynia, chronic pelvic or non-pelvic pain) (EO). Concerning the prevention of postoperative pain, it is recommended to carry out a pre-, per- and postoperative multimodal pain treatment (grade B). The use of ketamine intraoperatively is recommended for the prevention of chronic postoperative pelvic pain, especially for patients with risk factors (preoperative painful sensitization, allodynia, chronic pelvic or non-pelvic pain) (EO). Postoperative prescription of opioids should be limited in quantity and duration (grade C). When acute neuropathic pain (sciatalgia or pudendal neuralgia) resistant to level I and II analgesics occurs following sacrospinous fixation, a reintervention is recommended for suspension suture removal (EO). When chronic postoperative pain occurs after POP surgery, it is recommended to systematically seek arguments in favor of neuropathic pain with the DN4 questionnaire (EO). When chronic postoperative pelvic pain occurs after POP surgery, central sensitization should be identified since it requires a consultation in a chronic pain department (EO). Concerning myofascial pain syndrome (clinical pain condition associated with increased muscle tension caused by myofascial trigger points), when chronic postoperative pain occurs after POP surgery, it is recommended to examine the levator ani, piriformis and obturator internus muscles, so as to identify trigger points on the pathway of the synthetic mesh (EO). Pelvic floor muscle training with muscle relaxation is recommended when myofascial pain syndrome is associated with chronic postoperative pain following POP surgery (EO). After failure of pelvic floor muscle training (3 months), it is recommended to discuss surgical removal of the synthetic mesh, during a multidisciplinary discussion group meeting (EO). Partial removal of synthetic mesh is indicated when a trigger point is located on the pathway of the mesh (EO). Total removal of synthetic mesh should be discussed during a multidisciplinary discussion group meeting when diffuse (no trigger point) chronic postoperative pain occurs following POP surgery, with or without central sensitization or neuropathic pain syndromes (EO).When de novo postoperative dyspareunia occurs after POP surgery, surgical removal of the mesh should be discussed (EO).To reduce the risk of vaginal mesh exposure, when hysterectomy is required during sacral colpopexy, subtotal hysterectomy is recommended (grade C). When asymptomatic vaginal macroporous monofilament polypropylene mesh exposure occurs, systematic imaging is not recommended. When vaginal polyester mesh exposure occurs, pelvic +/- lumbar MRI (EO) should be used to look for an abscess or spondylodiscitis, given the greater risk of infection associated with this type of material. When asymptomatic vaginal mesh exposure of less than 1 cm2 occurs in a woman with no sexual intercourse, the patient should be offered observation (no treatment) or local estrogen therapy (EO). However, if the patient wishes, partial excision of the mesh can be offered. When asymptomatic vaginal mesh exposure of more than 1 cm2 occurs or if the woman has sexual intercourse, or if it is a polyester prosthesis, partial mesh excision, either immediately or after local estrogen therapy, should be offered (EO). When symptomatic vaginal mesh exposure occurs, but without infectious complications, surgical removal of the exposed part of the mesh by the vaginal route is recommended (EO), and not systematic complete excision of the mesh. Following sacral colpopexy, complete removal of the mesh (by laparoscopy or laparotomy) is only required in the presence of an abscess or spondylodiscitis (EO). When vaginal mesh exposure recurs after a first reoperation, the patient should be treated by an experienced team specialized in this type of complication (EO).For women presenting with vaginal exposure to non-absorbable suture thread following POP surgery with mesh reinforcement, the suture thread should be removed by the vaginal route (EO). Removal of the surrounding mesh is only recommended when vaginal mesh exposure or associated abscess is diagnosed.When bladder mesh exposure occurs, removal of the exposed part of the mesh is recommended (grade B). Both alternatives (total or partial mesh removal) should be discussed with the patient and should be debated during a multidisciplinary discussion group meeting (EO).Copyright © 2024 Elsevier B.V. All rights reserved.

The aim of this work was to assess the relationship between pelvic pain and rectal prolapse both before prolapse surgery and in the long term after ventral mesh rectopexy (VMR).

Ventral mesh rectopexy (VMR) is a widely accepted surgical treatment for rectal prolapse. Both synthetic and biologic mesh are used. No consensus exists on the preferred type of mesh material. The aim of this systematic review and meta-analysis was to establish an overview of the current literature on mesh-related complications and recurrence after VMR with synthetic or biologic mesh to aid evidence-based decision making in preferred mesh material.

This study aimed to evaluate factors that contribute to the recurrence of external rectal prolapse (ERP) following laparoscopic ventral rectopexy (LVR).All patients who underwent LVR using synthetic meshes between 2011 and 2018 were prospectively included. A standard questionnaire including the Fecal Incontinence Severity Index (FISI) and Constipation Scoring System (CSS) was administered preoperatively and postoperatively. Defecography was performed 6 months postoperatively. Univariate and backward stepwise multivariate Cox analysis was performed to determine the prognostic factors of recurrence.In total, 132 patients with a median follow-up of 46 months were included. The overall recurrence rate was 6.8% (n = 9), as confirmed by defecography at 6 months in six of the patients. None of the patients developed mesh erosion. FISI and CSS scores were significantly reduced at 3 months and remained significantly reduced for 3 years. Multivariate analyses revealed that the predictors of recurrence included male sex (hazards ratio, 11.3; 95% confidence interval, 3.0-43.0) and age >80 years (hazards ratio, 10.7; 95% confidence interval, 1.3-86.3). Eight patients with recurrence underwent surgery via Delorme's procedure (n = 7) and posterior rectopexy (n = 1). Two patients with new-onset rectoanal intussusception and one with uncorrected sigmoidocoele underwent repeat LVR.LVR is effective in treating ERP with low morbidity and low recurrence. Male patients and patients older than 80 years are at increased risk of recurrence. Hence, the LVR technique should be modified or coupled with other perineal procedures when treating ERP, especially in male patients.Copyright © 2021 by The Japan Society of Coloproctology.

Minimally invasive ventral mesh rectopexy (VMR) is a widely used surgical treatment for posterior pelvic organ prolapse; however, evidence of the utility of revisional surgery is lacking. Our aim was to assess the technical details, safety and outcomes of redo minimally invasive VMR for patients with external rectal prolapse (ERP) recurrence or relapsed symptoms of internal rectal prolapse (IRP).This is a retrospective cohort study of patients with recurrent ERP or symptomatic IRP who underwent redo minimally invasive VMR between 2011 and 2016. The study was conducted at three hospitals in Finland. Data collected retrospectively included patient demographics, in addition to perioperative and short-term postoperative findings. At follow-up, all living patients were sent a questionnaire concerning postoperative disease-related symptoms and quality of life.A total of 43 redo minimally invasive VMR were performed during the study period. The indication for reoperation was recurrent ERP in 22 patients and relapsed symptoms of IRP in 21 patients. In most operations (62.8%), the previously used mesh was left in situ and a new one was placed. Ten (23.3%) patients experienced complications, including 2 (4.7%) mesh-related complications. The recurrence rate was 4.5% for ERP. Three patients out of 43 were reoperated on for various reasons. One patient required postoperative laparoscopic hematoma evacuation. Patients operated on for recurrent ERP seemed to benefit more from the reoperation.Minimally invasive redo VMR appears to be a safe and effective procedure for treating posterior pelvic floor dysfunction with acceptable recurrence and reoperation rates.

Pregnancy and childbirth are considered risk factors for pelvic organ prolapse (POP). The long latency between obstetric events and morbidity hinders the establishment of cause-effect relationships. Recently, intermediate outcomes such as organ descent and levator avulsion (LA) have been identified. We aimed to assess the effect of obstetric events on symptoms and signs of POP and on LA.We systematically reviewed the literature by searching PubMed/MEDLINE, Embase and Cochrane Library. We included studies in women examining associations between obstetric events and symptoms and signs of POP and LA, assessed through questionnaires, clinical examination and pelvic floor imaging. Two reviewers evaluated the studies for eligibility and for methodological quality/susceptibility to bias. We extracted study results and clustered them by outcome: symptoms of POP (sPOP), clinical findings of POP (cPOP) and LA. When appropriate, we performed a random-effect meta-analysis and reported the summary odds ratios (OR) with 95% confidence intervals. Heterogeneity across studies was assessed using the I statistic.The first vaginal delivery was a risk factor for POP as measured by sPOP (OR: 2.65 [1.81-3.88]), cPOP (OR: 4.85 [2.15-10.94]) and in association with LA (OR: 41.6 [4.13- 419.41]). Forceps delivery was a risk factor for POP as measured by sPOP (OR: 2.51 [1.34-4.69]), cPOP (OR: 1.68 [1.21-2.34]) and in association with LA (OR: 5.92 [3.75-9.34]). Birth exclusively by caesarean was protective for sPOP (OR: 0.38 [0.29-0.51]) and for cPOP (OR: 0.29 [0.20-0.41]) and it did not confer any additional risk compared to nulliparity.This review confirms a strong aetiological link between vaginal birth and POP, with the first vaginal and forceps delivery being the main determinants.

Ileal pouch-anal anastomosis is a restorative option for patients with ulcerative colitis (UC) requiring surgery. The primary outcome of this study was the relative risk of infertility in females with UC undergoing restorative proctocolectomy compared to the same patients before undergoing restorative proctocolectomy (RPC). Infertility was defined as the inability to conceive after 1 year of regular sexual intercourse without contraception.A systematic review and meta-analysis were performed to include all relevant articles from 1946 from MEDLINE, EMBASE and Cochrane central register of controlled trials. Studies included reported on the fertility rate of a cohort with UC and also reported the rate after RPC in those within the cohort who underwent surgery. This study was registered on PROSPERO (CRD42021259745).13 studies met the inclusion criteria and accounted for 793 patients pre-pouch and 802 post-pouch. The mean and median age of the patients at analysis was 36.8 and 32.7 years respectively; and the median duration of follow-up following IPAA was 110.4 (68-139) months. Our results highlighted that following RPC the relative risk of infertility was 4.17 ([1.99, 8.74] 95% CI) compared with patients before RPC who had ulcerative colitis.The findings of this meta-analysis provide an update on previous meta-analysis published over a decade ago and results remain congruent. This suggests that despite advancements in surgical techniques the risk to fertility remains similar to a decade ago. However, further high qualities studies are needed to try and decipher independent risk factors associated with a decrease in infertility.This article is protected by copyright. All rights reserved.

Pelvic organ prolapse(POP) has an adverse impact on quality of life with lifetime risk of surgery varying from 11 to 20%. Conditions such as fibromyalgia (FMS), chronic fatigue syndrome (CFS/ME) and irritable bowel syndrome (IBS), collectively known as central sensitivity syndromes (CSS), may affect the outcome of POP surgery. The aim of this article is to compare the outcomes of vaginal POP surgery between women with and without CSS.This was a prospective cohort study. The validated Central Sensitisation Inventory (CSI) was used to identify women with CSS. Subjective and objective outcomes were compared between the two groups using POP-SS, Expectation and satisfaction/"EGGS", pain scores and the POP quantification system (POP-Q). A non-parametric test was used for analysis.Seventy-eight women were recruited. Complete data were available in 62 patients; 23 patients had evidence of CSS and 39 did not. Women with CSS had significantly higher pre- and post-operative POP-SS scores than those without (p < 0.0005, p = 0.004). Seventeen (73.9%) women with CSS compared to 38 (97.4%) women without CSS demonstrated improvement of a minimum 6 points on the POP-SS scale; however, this was not stastically significant. McGill's pain scores were higher in women with CSS both pre- and post-surgery. Ninety-five per cent of women without CSS achieved their goals and were satisfied with the surgery compared to 69.5% of women with CSS (p < 005).There is a less favourable outcome of POP surgery in women with CSS compared to those without in terms of persistence of symptoms, pain and overall satisfaction.

Rectal prolapse is considered rare in men but the prevalence can be high in certain populations. It is unclear which surgical approach offers lower recurrence rates and better functional outcomes in men. The aim was to determine the recurrence rates, complications, and functional outcomes after prolapse surgery in men.MEDLINE, EMBASE, and Scopus databases were systematically searched to identify studies on outcomes following surgical management of full-thickness rectal prolapse in men (>18years of age) published between 1951 and September 2022. Outcomes of interest included recurrence rate after surgery, bowel function, urinary function, sexual function, and postoperative complications. Prospero registered: CRD42021252719.Twenty-eight studies involving 1,751 men were included. Two papers focused exclusively on men. Twelve studies employed a mixture of abdominal approaches, 10 employed perineal approaches, and 6 compared both. Recurrence rate varied across studies ranging from 0-34%. Sexual and urinary function were poorly reported but the incidence of dysfunction appears low.Outcomes of rectal prolapse surgery in men are poorly studied with small sample sizes and variable outcomes reported. There is insufficient evidence to recommend a specific repair approach based on the recurrence rate and functional outcomes. Further studies are required to identify the optimal surgical approach for rectal prolapse in men.This article is protected by copyright. All rights reserved.