OBJECTIVETo evaluate clinical effectiveness of total pelvic floor reconstruction surgery for repair of severe pelvic organ prolapse.

METHODSWe retrospectively analyzed the clinical data of 21 patients with severe pelvic organ prolapse. The anatomical outcomes were evaluated by Pelvic Organ Prolapse Quantitation, functional effectiveness by Prolapse Quality of Life method, and sexual function and operation-related complications were also analyzed.

RESULTSAll surgical operations were accomplished successfully by the same surgeon. No impairment of bladder, urethra, rectum, or great vessels was noted, and no patient required blood transfusion. The mean operation duration was (63±19) minutes, and the mean intra-operative blood loss was (143±72) ml. One patients experienced post-operative urinary retention for 7 days, and the remaining 20 patients were able to micturate spontaneously 1-2 day after surgery. The post-operative morbidity rate was 14.3%. Three patients (14.3%) experienced mesh erosion. Of 12 patients who were sexually active, two patients suffered from algopareunia from dyspareunia, one from de novo overactive bladder, and one from stress urinary incontinence Questionnaire scores showed that the overall post operative quality of life was improved significantly (P=0.000), while quality of sexual life significantly degraded (P=0.044) The anatomic cure rate was 95.2% (20/21), and the patient subjective satisfaction rate was 85.7% (18/21)

CONCLUSIONSThe total pelvic floor reconstruction is a safe and effective approach for the repair of severe pelvic organ prolapse, although its functional effectiveness is not as notable as anatomical outcomes However, the complications such as mesh erosion, low urinary tract symptoms, algopareunia, and dyspareunia should be carefully managed.

Aged ; Humans ; Middle Aged ; Pelvic Floor ; surgery ; Pelvic Organ Prolapse ; surgery ; Retrospective Studies ; Treatment Outcome

Abdomen/surgery* ; Humans ; Laparoscopy/methods* ; Pelvic Floor/surgery* ; Perineum/surgery* ; Proctectomy ; Rectal Neoplasms/surgery*

Objective: To compare the morbidity of perineum-related complication between biological mesh and primary closure in closing pelvic floor defects following extralevator abdominoperineal excision (ELAPE). Methods: A literature search was performed in PubMed, Embase, Cochrane Library, Web of Science, Wanfang database, Chinese National Knowledge Infrastructure, VIP database, and China Biological Medicine database for published clinical researches on perineum-related complications following ELAPE between January 2007 and August 2020. Literature inclusion criteria: (1) study subjects: patients undergoing ELAPE with rectal cancers confirmed by colonoscopy pathological biopsy or surgical pathology; (2) study types: randomized controlled studies or observational studies comparing the postoperative perineum-related complications between the two groups (primary perineal closure and reconstruction with a biological mesh) following ELAPE; (3) intervention measures: biological mesh reconstruction used as the treatment group, and primary closure used as the control group; (4) outcome measures: the included literatures should at least include one of the following postoperative perineal complications: overall perineal wound complications, perineal wound infection, perineal wound dehiscence, perineal hernia, chronic sinus, chronic perineal pain (postoperative 12-month), urinary dysfunction and sexual dysfunction. Literature exclusion criteria: (1) data published repeatedly; (2) study with incomplete or wrong original data and unable to obtain original data. Two reviewers independently performed screening, data extraction and assessment on the quality of included studies. Review Manager 5.3 software was used for meta-analysis. The mobidities of perineum-related complications, including overall perineal wound (infection, dehiscence, hernia, chronic sinus) and perineal chronic pain (postoperative 12-month), were compared between the two pelvic floor reconstruction methods. Finally, publication bias was assessed, and sensitivity analysis was used to evaluate the stability of the results. Results: A total of five studies, including two randomized controlled studies and three observational controlled studies, with 650 patients (399 cases in the biological mesh group and 251 cases in primary closure group) were finally included. Compared with primary closure, biological mesh reconstruction had significantly lower ratio of perineal hernia (RR=0.37, 95%CI: 0.21-0.64, P<0.001). No significant differences in ratios of overall perineal wound complication, perineal wound infection, perineal wound dehiscence, perineal chronic sinus and perineal chronic pain (postoperative 12-month) were found between the two groups (all P>0.05). Conclusion: Compared with primary closure, pelvic floor reconstruction following ELAPE with biological mesh has the advantage of a lower incidence of perineal hernia.
Humans ; Pelvic Floor/surgery* ; Perineum/surgery* ; Proctectomy ; Rectum/surgery* ; Surgical Mesh

Intersphincteric resection (ISR) involves the anatomy of hiatal ligament, internal and external sphincter and conjoined longitudinal muscle. The hiatal ligament is actually a branch of the longitudinal muscle of rectum, shown as an uneven ring attached to the levator ani muscle. The internal sphincter is the end of the circular muscle of rectum which begins at the level of hiatal ligament formation. The distance from the upper boundary of internal sphincter to dentate line is significantly different among individuals. Although there is adipose tissue in the space between the internal and external sphincters, no evidence of mesentery structure in the anal canal is found as in the rectum. The conjoined longitudinal muscle is the remaining branch of the longitudinal muscle, whose return passes through the external sphincter and ends at the anococcygeal ligament/coccyx after reaching the anal margin. The synergistic action of conjoined longitudinal muscle and the hiatal ligament participates in the defecation process. The individualized difference of ISR-related anatomy affects the operation, especially the anastomosis.
Anal Canal/surgery* ; Anastomosis, Surgical ; Humans ; Pelvic Floor ; Rectal Neoplasms ; Rectum/surgery*

OBJECTIVE: To observe and verify the key anatomies of DeLancey's three levels of vaginal support theory through laparoscopic surgery by space dissection technique. METHODS: The features and stress performance of related anatomies were observed and analyzed in laparoscopic type C hysterectomy and pelvic lymphadenectomy for cervical cancer by natural space exposures. RESULTS: The main ligament-like structure at level Ⅰ was the uterosacral ligament, which acted as the main apical fixation in the sacral direction, while the cardinal ligament was mainly composed of vascular system, lymph-vessels and loose connective tissue around them, lacking the tough connective tissue structures, which was connected to the internal iliac vascular system. There were no strong ligaments connected to the tendinous arch of pelvic fascia (ATFP) at the lateral side of vaginal wall at level Ⅱ. ATFP was the edge of the superior fascia of pelvic diaphragm, which was bounded by the fascia of the obturator. Its surface was smooth and close to the levator ani muscle and fuses with the vaginal fascia in about one thirds of middle lower segments of the vagina. When the ureter tunnel is separated, dense connective structures can be found in both anterior and posterior walls near the intersection of the ureter across uterine artery, fixing the bilateral angle of the bladder triangle, starting from the cervix and vagina and ending in the tunica muscularis vesicae urinariae. CONCLUSIONS Based on the laparoscopic anatomy, the pelvic floor fascia ligament support above the levator ani muscle can be considered mainly around the vagina, and fascial ligament above the levator ani muscle can be simply considered as two parallel planes forming a "double hammock" structure, which may provide more anatomic data for pelvic floor reconstruction.
Female ; Humans ; Laparoscopy ; Ligaments ; anatomy & histology ; Pelvic Floor ; Urinary Bladder ; Vagina ; anatomy & histology ; surgery

Extralevator abdominoperineal excision (ELAPE) has been described to improve the outcomes of advanced low rectal cancer, probably because of more pelvic dissection and less positive circumferential resection margin (CRM). Recent improvements of ELAPE have focused on the reconstruction of the large pelvic defect. Different approaches have been focused on the reconstruction including primary closure, uterus retroversion, omentoplasty, myocutaneous flaps, and biological mesh. The optimal method is still controversial. Recent reviews showed that the perineal wound complications of biological mesh reconstruction were comparable to those of myocutaneous flaps. Moreover reviews suggested the use of biologic materials to close the perineal defect because it offers a significant cost saving mostly attributable to reduction in hospital length of stay. The combination of different techniques may be the best way to reconstruct the pelvic defect following ELAPE.
Digestive System Surgical Procedures ; methods ; Humans ; Pelvic Floor ; surgery ; Perineum ; surgery ; Reconstructive Surgical Procedures ; methods ; Rectal Neoplasms ; surgery ; Rectum ; surgery

The efficacy of laparoscopic total mesorectum excision (TME) has been confirmed by many clinical trials and guidelines. But two issues on laparoscopic TME are still questioned, including the integrity of specimen membrane of TME and the incidence of postoperative sexual dysfunction. According to my experiences and the primary results of the multicenter clinical trial (LASRE, clinicaltrials.gov identifier: NCT01899547) conducted by me, the integrity of the specimen membrane of laparoscopic TME is not inferior to the open TME. With the further understanding of surgical membrane anatomy, the quality of surgical specimen after laparoscopic TME could be improved, and the incidence of postoperative sexual dysfunction could be lowered. With the combination of my laparoscopic experiences and the theory of surgical membrane anatomy, this article introduces the peri-rectal space dissection during TME and its relationship with the membrane anatomy for reference. It suggests that laparoscopic TME should be performed with the guidelines of surgical membrane anatomy: (1) To cut membrane bridge of left para-rectal furrow and enter left retroperitoneal space; (2) Along the autonomic nerve, to separate retrorectal space first, then rectal front space, and bilateral rectal space finally; (3) To cut anterior lobe of Denonvilliers fascia using U shape 0.5 to 1 cm away from the bottom of seminal vesicle, if existence of tumor invasion in fascia, to separate downward in front; (4) To separate mesorectum to the edge of hiatus of levator ani muscle and then bare.
Adult ; Autonomic Pathways ; Digestive System Surgical Procedures ; Dissection ; Fascia ; Female ; Humans ; Laparoscopy ; Male ; Mesocolon ; surgery ; Pelvic Floor ; Rectal Neoplasms ; surgery

Female ; Humans ; Consensus ; East Asian People ; Pelvic Floor/surgery* ; Prostheses and Implants ; Registries ; Plastic Surgery Procedures/adverse effects* ; Prosthesis Implantation

Aged ; Fatal Outcome ; Female ; Granulosa Cell Tumor ; secondary ; surgery ; Humans ; Kidney Neoplasms ; secondary ; Middle Aged ; Ovarian Neoplasms ; pathology ; surgery ; Pelvic Floor ; Pelvic Neoplasms ; secondary ; Time Factors

OBJECTIVETo evaluate the clinical outcome of a novel approach for pelvic floor reconstruction using synthetic mesh (modified total pelvic floor reconstruction) for treatment of pelvic organ prolapse.

METHODSModified total pelvic floor reconstruction was performed in 30 patients with severe pelvic organ prolapse (including vault prolapse). The clinical outcome of each patient was assessed.

RESULTSThe mean operation time was (74.2 +/- 21.5) minutes, and the mean blood loss was (103.3 +/- 40.1) ml. Among them, 23 patients (76.7%) were able to micturate spontaneously the next morning after surgery, with residual urine less than 100 ml. The mean post-operative hospital stay was (4.2 +/- 1.8) days. All patients were followed up for a medium of 6 months. Totally 93.3% and 96.7% of patients were objectively (according to Pelvic Organ Prolapse Quantitive Examination score) and subjectively (according to Prolapse Quality of Life) cured, respectively. During follow-up, only one patient was found to have asymptomatic erosion, and de novo urgent urinary incontinence was seen in 6.7% of patients. The most prominent complication was dyspareunia (66.7%). Although the post-operative sexual function was reported to be worse, no significant difference between patients' pre- and post-operative Pelvic Organ Prolapse/ Urinary Incontinence Sexual Function Questionnaire-12 scores was noted.

CONCLUSIONModified total pelvic floor reconstruction is a safe, effective, and micro-invasive approach for severe pelvic organ prolapse repair; however, dyspareunia remains a main concern.

Blood Loss, Surgical ; Dyspareunia ; etiology ; Humans ; Pelvic Floor ; surgery ; Pelvic Organ Prolapse ; complications ; surgery ; Postoperative Complications ; Quality of Life ; Reconstructive Surgical Procedures ; adverse effects ; methods ; Surveys and Questionnaires ; Treatment Outcome