Summary of experience with patterning cropped and shaped mesh repair for perineal hernia after abdominoperineal excision in rectal cancer / 中华外科杂志

Objective: To examine the patterning cropped and shaped mesh repair for perineal hernia after abdominoperineal excision (APE) in rectal cancer. Methods: The clinical data of 8 patients with perineal hernia after APE who accepted surgical treatment in the Department of Hepatopancreatobiliary and Hernia Surgery, the First Affiliated Hospital of Fujian Medical University from March 2017 to December 2022 were retrospectively reviewed. There were 3 males and 5 females, aged (67.6±7.2) years (range: 56 to 76 years). Eight patients developed a perineal mass at (11.3±2.9) months (range: 5 to 13 months) after APE. After surgical separation of adhesion and exposing the pelvic floor defect, a 15 cm×20 cm anti-adhesion mesh was fashioned as a three-dimensional pocket shape to fit the pelvic defect, then fixed to the promontory or sacrum and sutured to the pelvic sidewalls and the anterior peritoneum, while two side slender slings were tailored in front of the mesh and fixed on the pectineal ligament. Results: The repair of their perineal hernias went well, with an operating time of (240.6±48.8) minutes (range: 155 to 300 minutes). Five patients underwent laparotomy, 3 patients tried laparoscopic surgery first and then transferred to laparotomy combined with the perineal approach. Intraoperative bowel injury was observed in 3 patients. All patients did not have an intestinal fistula, bleeding occurred. No reoperation was performed and their preoperative symptoms improved significantly. The postoperative hospital stay was (13.5±2.9) days (range: 7 to 17 days) and two patients had postoperative ileus, which improved after conservative treatment. Two patients had a postoperative perineal hernia sac effusion, one of them underwent placement of a tube to puncture the hernia sac effusion due to infection, and continued irrigation and drainage. The postoperative follow-up was (34.8±14.0) months (range: 13 to 48 months), and 1 patient developed recurrence in the seventh postoperative month, no further surgery was performed. Conclusions: Surgical repair of the perineal hernia after APE can be preferred transabdominal approach, routine application of laparoscopy is not recommended, combined abdominoperineal approach can be considered if necessary. The perineal hernia after APE can be repaired safely and effectively using the described technique of patterning cropped and shaped mesh repair.

Higher symptom score, larger residual rectocele, and lower rectal compliance predict failure of improvement after surgical treatment of rectocele

Background: Rectocele is a frequent finding in women and is usually asymptomatic. However, it is sometimes associated with symptoms of obstructed defecation syndrome (ODS). While most patients with ODS due to rectocele respond well to conservative treatment, some may require surgical treatment. The aim of the study was to determine the predictors of failure of symptom improvement after rectocele repair. Methods: The study included adult women with rectocele who underwent surgical treatment by transperineal repair (TPR) or transvaginal repair (TVR). The preoperative and postoperative assessment was done using the Wexner constipation score, anorectal manometry, and defecography. Results: A total of 93 female patients with a mean age of 43.7 years were included. Among them, 65.6% of patients underwent TPR and 34.4% underwent TVR; 22 (23.7%) patients reported failure of significant improvement in ODS symptoms after surgery. The independent predictors of failure of improvement were higher preoperative Wexner score (odds ratio, OR: 1.4, 95% confidence interval, CI: 1.09-1.84, p = 0.009), larger residual rectocele after repair (OR: 2.95, 95% CI: 1.43-6.08, p = 0.003), and lower postoperative maximum tolerable volume (OR: 0.949, 95% CI: 0.907-0.992, p = 0.02). The predictive cutoff point for the preoperative Wexner score was 15. Conclusions: Patients with a preoperative Wexner score higher than 15 and larger residual rectocele after surgery may experience little improvement in symptoms after rectocele repair. Although TPR was associated with a poorer relief of symptoms than did TVR; it was not an independent predictor of failure. (AU)

Reconstituição cirúrgica do períneo após o parto: um estudo qualitativo de uma prática pedagógica / Surgical reconstitution of the perineum after delivery: a qualitative study of a pedagogical practice

Resumo Descreve-se uma atividade pedagógica com estudantes do Mestrado e Pós-Licenciatura em Enfermagem de Saúde Materna e Obstetrícia, aplicando princípios da prática simulada na realização da sutura perineal após o parto. Este procedimento causa muita insegurança e gera grande ansiedade nos estudantes, quando iniciam estágio em bloco de partos. Os objetivos deste artigo são desenvolver competências psicomotoras nos estudantes para a reconstituição cirúrgica perineal; aumentar a autoconfiança dos estudantes para o procedimento. Metodologia qualitativa, com 2 momentos de recolha de dados aplicados a dois cursos. Questionário com perguntas abertas, sessão de "focus group" e filmagem. Análise de conteúdo das respostas às perguntas abertas e verbatim do "focus group". Como Resultados destaca-se uma estreita relação entre a simulação e o desenvolvimento de competências. Os estudantes salientaram a importância da atividade pedagógica na aquisição de competências de sutura, reforço da autoconfiança e na diminuição da ansiedade inicial. O uso da investigação qualitativa permitiu identificar o impacto da prática simulada no desenvolvimento de competências dos estudantes, identificar aspetos a aperfeiçoar na metodologia, contribuindo para a melhoria das práticas pedagógicas.

Abstract A pedagogical activity with Master's Degree and Postgraduate students in Maternal Health and Obstetrics Nursing is described, applying principles of simulated practice in perineal suturing after delivery. This procedure causes a lot of insecurity and generates great anxiety in the students, when they start the internship in a delivery room. Objectives: to develop the psychomotor skills in students for perineal surgical reconstruction; increase students' self-confidence to perform the procedure. Methodology: qualitative, with 2 moments of data collection applied to two courses. Questionnaire with open questions, focus group session and filming. Content analysis of the answers to the questions and verbatim of the focus group. Results: a close relationship was observed between simulation and skills development. Conclusion: the students emphasized the importance of the pedagogical activity in the acquisition of suturing skills, improving their self-confidence and reducing the initial anxiety. The use of the qualitative research allowed identifying the impact of the simulated practice on the development of the students' skills and to identify aspects to be improved, contributing to the progress of pedagogical practices.

Biological mesh versus primary closure for pelvic floor reconstruction following extralevator abdominoperineal excision: a meta-analysis / 中华胃肠外科杂志

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.

Evisceración del intestino delgado estrangulado en una anciana con douglascele / Evisceration of the impacted small bowel in an elderly with douglascele

Se presenta el caso clínico de una anciana de 86 años de edad con evisceración del intestino delgado a través del periné. Se efectuó la exploración quirúrgica urgente del abdomen y se observó la perforación del fondo del saco de Douglas y la salida de 50 cm de intestino delgado estrangulado, de manera que se realizó la resección intestinal de todo el segmento afectado y anastomosis termino-terminal. Luego se reparó el defecto del fondo del saco de Douglas con una plastia perineal, para lo cual se utilizó una malla de polipropileno. Este proceder es una buena alternativa para el tratamiento quirúrgico en quienes presentan hernias perineales, pues permite un cierre mejor, disecar el saco herniario y reducirlo adecuadamente.

The case report of a 86 years elderly is presented with evisceration of the small bowel through the perineum. The urgent surgical exploration of the abdomen was carried out and it was observed the perforation of the Douglas pouch and the 50 cm prominence of impacted small bowel, so that the bowel resection of the whole affected segment and end to end anastomosis was carried out. Then the Douglas pouch defect was repaired with a perineal plasty, for which a polypropylene mesh was used. This procedure is a good alternative for the surgical treatment in those who present perineal hernias, because it allows a better closing, to dissect the hernial sack and to reduce it appropriately.

Quiste epidérmico gigante de región perianal: reporte de un caso / Giant epidermal cyst of the perianal region: a case report

Introducción: Quiste epidermoide de inclusión es una lesión dérmica benigna frecuente, predominante en hombres de 30-40 años, originada por secuestro de restos epidérmicos, oclusión pilosebácea o implantación traumática de elementos epiteliales en la dermis.Caso clínico: Paciente femenino de 75 años de edad la cual presenta tumoración perineal de 4 años de evolución, con aumento progresivo en el último año ocasionando disconfort. Resonancia magnética nuclear, muestra lesión quística. Escisión quirúrgica incluyendo capsula en su totalidad. Anatomía patológica, quiste de inclusión epidérmica. Control a los 6 meses sin evidencia de recidiva.Conclusión: El quiste epidérmico gigante de inclusión perineal es raro, por lo cual hay que descartar otras patologías similares. El tratamiento quirúrgico debe evitar la escisión fraccionada e incluir la capsula en forma completa, de lo contrario la recidiva es una constante.

Introduction: The epidermoid inclusion cyst is a frequent benign dermal lesion, predominantly in men aged 30-40, caused by sequestration of epidermal remains, pilosebaceous occlusion or traumatic implantation of epithelial elements in the dermis.Case report: A 75-year-old female patient who has 4 years of evolution perineal tumor with a progressive increase in size in the last year causing discomfort. MRI shows a cyst lesion. Surgical excision including capsule. Pathological anatomy, epidermoid inclusion cyst. Following at 6 months without evidence of recurrence.Conclusion: The giant epidermoid cyst of perineum is rare, therefore we must rule out other similar pathologies. Surgical treatment should avoid fractional excision and include the capsule completely, otherwise recurrence is a constant.

Sepsis por celulitis necrotizante en paciente embarazada con sindrome antifosfolípido en tratamiento / Necrotizing sepsis cellulitis pregnant patient with antiphospholipid syndrome treatment

Introducción: El término ''síndrome antifosfolipídico'' (SAF) describe la asociación de los anticuerpos antifosfolipídicos (AAF) con un cuadro clínico de hipercoagulabilidad caracterizado por trombosis a repetición y abortos recurrentes. Objetivo: Presentar un caso de celulitis severa de periné en paciente con SAF y tratamiento con hidroxicloroquina. Caso clínico: Paciente de 39 años con embarazo de término con SAF tratado con hidroxicloroquina y anticoagulación que desarrolló una infección severa de partes blandas del periné que fue tratado con interrupción del embarazo, drenaje agresivo del periné y tratamiento antibiótico extenso con buena evolución. Conclusión: La asociación del tratamiento con hidroxicloroquina, embarazo y una complicación séptica es incierta. El tratamiento con inmunosupresión no es estándar y podría haber favorecido el mal pronóstico del cuadro clínico. (AU)

Objetive: To present a case of severe perineal cellulitis in a pregnant patient with Antiphospholipid syndrome treated wiht hidroxicloroquine. Case report: A 39 years old female pregnant patient with AFS treated with hidroxicloroquine and heparin developed severe perineal infection with systemic impairment. Final treatment included aggressive perineal drainage in multiple sessions, pregnancy delivered and systemic treatment with wide spectrum antibiotics and general measures. Discusion and Conclusion: Treatment with hidroxicloroquine, pregnancy and septic complication is infrequent. This approach is not standard and it could favored worst prognostic of the general syndrome. (AU)

Perineal repair after abdominoperineal excision with rectus abdominis myocutaneous flap / Reconstrução do períneo após amputação abdominoperineal com retalho pediculado do músculo reto abdominal

ABSTRACT Background: Abdominoperineal excision of the rectum (APR) remains the only potential curative treatment for very low rectal adenocarcinoma and squamous cell carcinoma of the anus. Yet, it implies a significant perineal exenteration and has set the attention on the perineal reconstruction. Aim: To present technique used in one case of APR for anal cancer, with resection of the vaginal posterior wall with large perineal defect which has called for the necessity of a flap for reconstruction Method: To cover the large perineal defect and reconstruct the posterior vaginal wall was perform a standardized and reproducible surgical technique using oblique rectus abdominis myocutaneous (ORAM) flap. The overlying skin of this flap is thick and well vascularized by both superficial branches and perforators of the superior epigastric artery and the deep inferior epigastric artery which serves as the vascular pedicle for the ORAM flap. Results: This procedure was applied in a 65-year-old woman with recurrent squamous cell carcinoma of the anus infiltrating the posterior wall of the vagina. Was performed an APR with en-bloc resection of the vaginal posterior wall in order to achieve tumor-free margins. Postoperative course was uneventful and she was discharged home at postoperative day 9. Final pathological report confirmed the oncological adequacy of the procedure (R0) and showed a rypT4N0 lesion. Conclusion: Flap reconstruction is an effective way to cover the perineal wound reducing both perineal complication rate and wound healing delay. The ORAM is particularly interesting for female whose tumors require resection and subsequent reconstruction of the posterior wall of the vagina.

RESUMO Racional: A amputação abdominoperineal do reto (APR) continua sendo o único tratamento curativo nos casos de adenocarcinoma retal muito baixo e carcinoma espinocelular do ânus. No entanto, implica em exenteração perineal significativa e exige atenção na reconstrução perineal. Objetivo: Propor, ilustrando com um caso clinico, proposta de APR para câncer anal com ressecção da parede posterior da vagina com cobertura do grande defeito perineal através de reconstrução com retalho miocutâneo oblíquo do reto abdominal (ORAM). Método: Para cobrir o defeito e reconstruir a parede vaginal posterior, realizou-se técnica de retalho miocutâneo oblíquo do reto abdominal (ORAM). A pele subjacente desse retalho por ser espessa e bem vascularizada por ramos perforantes superficiais da artéria epigástrica superior e pela artéria epigástrica inferior profunda serviu como pedículo vascular. Resultado: Este procedimento foi aplicado em uma mulher de 65 anos com recidiva de carcinoma espinocelular do ânus infiltrado na parede posterior da vagina. Foi realizada APR com ressecção em bloco da parede posterior vaginal com o objetivo de obter margens livres de tumor. O pós-operatório transcorreu sem intercorrências e a paciente recebeu alta hospitalar no 9° dia pós-operatório. O relatório patológico final confirmou a adequação oncológica do procedimento (R0) e mostrou uma lesão rypT4N0 de 6,5 cm. Conclusão: A reconstrução perineal com utilização de retalho é maneira eficaz de fechar a ferida operatória, reduzindo a taxa de complicações perineais e o atraso na cicatrização. O retalho de tipo ORAM é particularmente interessante para mulheres cujos tumores requerem ressecção e subsequente reconstrução da parede posterior da vagina.

Perineal outcomes and its associated variables of water births versus non-water births: a cross-sectional study / Desfechos perineais e as variáveis associadas no parto na água e no parto fora da água: estudo transversal

Abstract Objectives: to describe the perineal outcomes of women who had delivered in water and out of water. Methods: a cross-sectional and quantitative study developed in a public hospital in Setúbal, Portugal. The population was of women who participated in the "Water Birth Project" in the period from 2011 to 2014, which gave birth in water and out of water. 104 women were selected according to established inclusion criteria. The groups were compared according to the following variables: demographics, obstetric information, delivery care and perineal outcomes. The data were analyzed in the Stata(r) software, with descriptive and bivariate statistics (chi-square and Fisher's test). Results: the medical records of 73 women who gave birth in water and 31 women who gave birth out of water were studied. Water deliveries were significantly associated with fewer perineal lacerations, lower rates of episiotomy, and shorter delivery time. Conclusions: the results of the study suggest that childbirth in water has a protective effect against severe third or fourth degree perineal tears, during fetal expulsion in water.

Resumo Objetivos: descrever os resultados perineais de mulheres que tiveram parto na água e fora da água. Métodos: estudo transversal e quantitativo desenvolvido em um hospital público de Setúbal, Portugal. A população foi de mulheres que participaram do "Projeto Parto na Água", no período de 2011 a 2014, que deram à luz na água e fora da água. Foram selecionadas para o estudo 104 mulheres de acordo com os critérios de inclusão estabelecidos. Os grupos foram comparados de acordo com as seguintes variáveis: demografia, informação obstétrica, assistência ao parto e resultados perineais. Os dados foram analisados no software Stata(r), com estatísitica descritiva e bivariada (qui-quadrado e teste de Fisher). Resultados: foram estudados os prontuários de 73 mulheres que deram à luz na água e 31 mulheres que deram à luz fora da água. Os partos na água foram significativamente associados a menos lacerações perineais, menores taxas de episiotomia e menor tempo de parto. Conclusão: os resultados do estudo sugerem que o parto na água tem um efeito protetor contra lacerações perineais severas de terceiro ou de quarto grau durante a expulsão fetal na água.

Technique and results of the first six cases of anal sphincteroplasty with Deoti's flap for complex anatomical deformity of the perineum / Técnica e resultados dos primeiros seis casos de esfincteroplastia anal com retalho Deoti para deformidade anatômica complexa do períneo

ABSTRACT Objectives: Anal sphincteroplasty with Deoti's flap is a recently published procedure for the treatment of fecal incontinence with severe perineal deformity. The aim of this study is to report six cases of patients, analyzing their results in fecal incontinence questionnaires and proposing a new scale to better assess our technique's main objective, the reconstruction of the perianal anatomy. Methods: Six patients were submitted to anal sphincteroplasty with Deoti's flap and follow-up was performed every six months. Functional results and Quality of Life were measured by Wexner Score and Fecal Incontinence Quality of Life Scale, respectively. Results: All operations were carried out without failure to perform Deoti's flap rotation. The sample presented medians of 18.5 and 3.5 on Wexner Score, before and after surgery, respectively. In the Fecal Incontinence Quality of Life Scale, the medians before and after surgery are, respectively, 1.75 and 3.35 (Scale 1), 1.54 and 2.60 (Scale 2), 2.35 and 3.28 (Scale 3), 1.49 and 3.33 (Scale 4). The p-values were 0.0173 for Wexner Score and 0.0260, 0.0411, 0.0368 and 0.0952 for Scales 1, 2, 3 and 4 of Fecal Incontinence Quality of Life Scale, respectively. All patients presented sustained improvement in Wexner Score and in quality of life questionnaire (in all scales of Fecal Incontinence Quality of Life Scale). Conclusions: Deoti's surgical flap with sphincteroplasty successfully reconstructs complex anatomical deformities of the perineum. Current questionnaires to assess fecal incontinence may not evaluate properly the anatomical result of the technique, thus we propose a visual scale. In addition, sphincteroplasty with Deoti's flap may have longer-term outcomes in functional results than sphincteroplasty alone.

RESUMO Objetivos: A esfincteroplastia anal com retalho Deoti é um procedimento publicado recentemente para o tratamento de deformidade perineal grave. O objetivo deste estudo é relatar seis pacientes, analisando seus resultados em questionários de incontinência fecal e propondo uma nova escala para avaliar melhor o objetivo principal da nossa técnica, a reconstrução da anatomia perianal. Métodos: Seis pacientes foram submetidos à esfincteroplastia anal com retalho de Deoti e o acompanhamento foi realizado a cada seis meses. Os resultados funcionais e a qualidade de vida foram medidos pelas Escalas Wexner Score e FIQL, respectivamente. Resultados: Não houve falhas na rotação do retalho Deoti. A amostra apresentou medianas de 18,5 e 3,5 na Wexner Score, antes e depois da cirurgia, respectivamente. Na Escala FIQL, as medianas antes e depois da cirurgia são, respectivamente, 1,75 e 3,35 (Escala 1); 1,54 e 2,60 (Escala 2); 2,35 e 3,28 (Escala 3); 1,49 e 3,33 (Escala 4). Os valores de p foram 0,0173 para Wexner Score e 0,0260; 0,0411; 0,0368 e 0,0952 para Escalas 1; 2; 3 e 4 de FIQL, respectivamente. Todos os pacientes apresentaram melhora sustentada na pontuação de Wexner e no questionário de qualidade de vida (em todas as escalas do FIQL). Conclusões: O retalho de Deoti com esfincteroplastia reconstrói com sucesso as deformidades anatômicas complexas do períneo. Os questionários atuais para avaliar a incontinência fecal podem não avaliar adequadamente o resultado anatômico da técnica, por isso propomos uma escala visual. Além disso, a esfincteroplastia com retalho de Deoti pode apresentar resultados funcionais mais duradouros do que a esfincteroplastia isolada.

Reconstrucción perineal con colgajo miocutáneo vertical de recto anterior del abdomen luego de amputación abdomino perineal extraelevador. Una alternativa factible para el cirujano colorrectal / Perineal reconstruction with vertical myocutaneous flap of the anterior rectus abdominis after extra-elevating perineal abdominal amputation. A feasible alternative for the colorectal surgeon

Las complicaciones perienales luego de la amputación abdominoperineal son frecuentes y clínicamente relevantes en términos de estadía hospitalaria, costos, calidad de vida y los resultados oncológicos. La utilización creciente de radioterapia pre operatoria y la incorporación gradual a la técnica extra-elevador, ha llevado a un aumento en la morbilidad perineal. Es por elloque la búsqueda de una técnica confiable y con buenos resultados para el cierre perineal se hace necesaria. Se han publicado muchas series que describen diferentes técnicas de cierre del defecto perineal, pero faltan estudios clínicos de alta calidad que indiquen cuál es la mejor opción. Cuando la proctectomía resulta en un amplio defecto perineal, el colgajo vertical del recto del abdomen parece ser la mejor opción. Presentamos dos casos de tumores anorectales localmente avanzados en los que se realizó una amputación abdominoperineal extraelevador con posterior reconstrucción perineal con colgajo de recto anterior y, a su vez, describimos la técnica quirúrgica. (AU)

Perineal complications after abdominoperineal amputation are frequent and clinically relevant in terms of hospital stay, costs, quality of life and oncological results. The growing utilization of pre-operative radiotherapy and the gradual incorporation to the extra-elevator technique, has leaded to an increase in perineal morbidity. That is why the search for a reliable technique with good postoerative outcomes for the perineal closure is necessary. Many series describing different closure techniques of the perineal defect have been published, but high quality clinical studies have to indicate which the best option is. When the proctectomy results in a wide perineal defect, the vertical rectus abdominis flap seems to be the best option. We presented two cases of locally advanced anorectal tumors in which an extraelevatory abdominoperineal amputation was carried out with posterior perineal reconstruction with vertical rectus abdomins flap and we described the surgical technique. (AU)

Synthetic mesh repair of an anterior perineal hernia following robotic radical urethrocystectomy

ABSTRACT Introduction: Perineal hernia is a protrusion of intra-abdominal viscera through a defect in the pelvic floor and is a rare but challenging complication after extensive abdominoperineal surgery. There have been small series published after colorectal exenteration, but no cases have been reported after radical cystectomy and urethrectomy. Case Presentation: A 68 years old woman developed an anterior perineal hernia, with no vaginal prolapse, after an anterior exenteration for bladder cancer. A perineal approach with the use of a synthetic polypropylene mesh was chosen to resolve the condition. After 6 months of follow-up, the patient has no symptoms or recurrence of the anterior perineal hernia. Conclusion: To our knowledge, this case is the first report of perineal hernia after radical urethrocystectomy. Although being a case report, this article describes a potential and challenging complication after extensive anterior pelvic surgery, that could increase its incidence in the future. Literature review shows that whether perineal, abdominal or combined approach is chosen, surgery must respect hernia repair principles.

Perianal leiomyoma / Leiomioma de localização perianal

Abstract Leiomyomas are smooth muscle tumors and may occur in places where these fibers are present, while the anorectal location is rare. They are commonly incidental imaging findings and in most cases, patients are asymptomatic. The therapeutic recommendation is tumor resection and postoperative follow-up. Case report: a 38-year-old Black woman had, one year ago, a swelling in perianal right region, which showed slow and progressive growth. She denied bowel habit alterations, local pain, hematochezia, or tenesmus. Proctologic examination showed a fibroelastic, regular, mobile, painless nodule measuring 10 cm at its largest diameter in the right perianal region, next to the anal verge. The soft tissue ultrasound image identified a solid, hypoechoic, and discreetly vascularized nodule in the perianal, superficial right gluteal region that did not reach the adjacent muscles. A complete resection of perineal tumor was carried out in the ventral position. Histological and immunohistochemical analyses disclosed a leiomyoma with a positive finding for actin smooth muscle and negative for desmin. She is currently asymptomatic and undergoing outpatient follow-up.

Resumo Os leiomiomas são tumores da musculatura lisa podendo ocorrer nos locais onde essas fibras estão presentes, sendo rara a localização anorretal. Na maioria dos casos os pacientes são assintomáticos, sendo comumente achados de exame de imagem. A recomendação terapêutica é a ressecção tumoral e o seguimento pós-operatório. Relato do caso: mulher, 38 anos, negra. Há um ano, apresentou abaulamento em região perianal direita, de crescimento lento e progressivo. Negava alteração do hábito intestinal, dor local, hematoquezia, puxo ou tenesmo. Ao exame proctológico, apresentava nodulação fibroelástica, regular, móvel, indolor, com 10 cm de diâmetro em região perianal à direita, próxima à borda anal. Realizou ultrassonografia de partes moles que identificou imagem nodular, sólida, hipoecogênica e discreta vascularização em parte superficial perianal e glútea direita, não envolvendo musculatura adjacente. Foi submetida à ressecção completa do tumor via perineal, em posição ventral. O laudo histológico e imuno-histoquímico revelou leiomioma, com achado positivo para actina de músculo liso e negativo para desmina. Atualmente está assintomática, em seguimento ambulatorial.

Single stage: dorsolateral onlay buccal mucosal urethroplasty for long anterior urethral strictures using perineal route

ABSTRACT Objective To assess the outcome of single stage dorsolateral onlay buccal mucosal urethroplasty for long anterior urethral strictures (>4cm long) using a perineal incision. Materials and Methods From August 2010 to August 2013, 20 patients underwent BMG urethroplasty. The cause of stricture was Lichen sclerosis in 12 cases (60%), Instrumentation in 5 cases (25%), and unknown in 3 cases (15%). Strictures were approached through a perineal skin incision and penis was invaginated into it to access the entire urethra. All the grafts were placed dorsolaterally, preserving the bulbospongiosus muscle, central tendon of perineum and one-sided attachement of corpus spongiosum. Procedure was considered to be failure if the patient required instrumentation postoperatively. Results Mean stricture length was 8.5cm (range 4 to 12cm). Mean follow-up was 22.7 months (range 12 to 36 months). Overall success rate was 85%. There were 3 failures (meatal stenosis in 1, proximal stricture in 1 and whole length recurrent stricture in 1). Other complications included wound infection, urethrocutaneous fistula, brownish discharge per urethra and scrotal oedema. Conclusion Dorsolateral buccal mucosal urethroplasty for long anterior urethral strictures using a single perineal incision is simple, safe and easily reproducible by urologists with a good outcome.

Rectosigmoidectomía perineal para el tratamiento del prolapso rectal completo / Perineal rectosigmoidectomy for the treatment of rectal prolapse

Objetivo: Presentamos nuestra experiencia en el tratamiento quirúrgico de esta patología con la técnica de la rectosigmoidectomía perineal. Material y método: Se trata de una serie retrospectiva, consecutiva de 17 pacientes. Resultados: Predomina el género femenino y el promedio de edad es de 62 años. La morbilidad alcanza el 23%, aunque casi toda de menor gravedad, con solo un paciente reoperado. La recidiva es del 6%, con mejoría de los síntomas en un 88%. Conclusión: Concluimos que es una técnica segura, con una morbilidad controlada y con buenos resultados a mediano plazo con un adecuado control de la recidiva y mejoría de la continencia en un alto porcentaje de los pacientes.

Aim: We present our experience with perineal rectosigmoidectomy for the treatment of rectal prolapse. Material and method: It is a retrospective, consecutive series of 17 patients. Results: Predominantly female and the average age is 62 years. Morbidity reached 23%, but almost all less serious, with only one reoperation. Recurrence is 6%, and the improvement in continence is 88%. Conclusion: We conclude that it is a safe technique with a controlled morbidity and good results with low recurrence and improvement of continence in a high percentage of patients.

Complex reconstruction of the perineal and gluteal regions after resection of a large squamocellular carcinoma of the anal margin: a case report / Reconstrução complexa de regiões glútea e perineal após ressecção de extenso carcinoma escamocelular de borda anal: relato de caso

Perineal and gluteal regions may be affected by a wide spectrum of diseases, and the treatment may require extensive surgery and cause functional, aesthetic, and psychosocial damages at various levels. Wounds in the extensive perineal and gluteal regions after surgical treatment of neoplasia may represent a challenge in local reconstruction. Size, location, and availability of tissue around the lesion may hinder wound primary closure, requiring the use of one or more flaps. This article reports a case of reconstruction of the perineal and gluteal regions after oncological resection at the plastic surgery service of the Hospital das Clínicas at the Federal University of Minas Gerais. The muscle and fasciocutaneous flaps of the gluteus maximus and myocutaneous of the semimembranosus were used.

As regiões glútea e perineal podem ser afetadas por um variado espectro de doenças, cujo tratamento pode demandar extensas mutilações e acarretar em prejuízo funcional, estético e psicossocial em variados graus. Feridas extensas da região perineal e glútea após o tratamento cirúrgico de neoplasias podem representar um desafio para a reconstrução local. Tamanho, localização e disponibilidade de tecido em torno da lesão são fatores que podem impedir o seu fechamento primário, tornando necessário o uso de um ou mais retalhos. Este artigo relata um caso de reconstrução de períneo e região glútea após ressecção oncológica, no serviço de Cirurgia Plástica do Hospital das Clínicas da Universidade Federal de Minas Gerais (UFMG). Foram utilizados os retalhos muscular e fasciocutâneo de glúteo máximo e miocutâneo de semimembranoso.

Perineostomy: the last oportunity

Objective To review the technique and outcome of perineal urethrostomy or urethral perineostomy and to identify factors related to the procedure failure. Material and methods We studied 17 patients who underwent perineal urethrostomy between 2009-2013 in a single hospital. Success was defined as no need for additional surgical treatment or urethral dilatation. We reviewed the clinical data related to age, weight, previous urethral surgery, diabetes, hypertension, ischemic cardiopathy, lichen sclerosus and other causes and studied their association with the procedure failure (univariate analysis). We completed the analysis with a multivariate test based on binary regression. Results The average follow-up was 39.41 months. From all the causes, we found Lichen Sclerosus in 35%, idiopathic etiology in 29% and prior hypospadia repair in 18%. Postoperative failure occurred in 3 patients, with a final success of 82.4%. The binary regression model showed as independent risk factors ischemic cardiopathy (OR: 2.34), and the presence of Lichen Sclerosis (OR: 3.21). Conclusions The success rate with the perineal urethrostomy technique shows it to be a valid option above all when we preserve the urethral blood supply and plate. Lichen sclerosus and ischemic vascular problems are risk factors to re-stenosis. .

Is Radical Perineal Prostatectomy a Viable Therapeutic Option for Intermediate- and High-risk Prostate Cancer?

The aim of this study was to investigate a single-institution experience with radical perineal prostatectomy (RPP), radical retropubic prostatectomy (RRP) and minimally invasive radical prostatectomy (MIRP) with respect to onco-surgical outcomes in patients with intermediate-risk (IR; PSA 10-20 ng/mL, biopsy Gleason score bGS 7 or cT2b-2c) and high-risk (HR; PSA >20 ng/mL, bGS > or =8, or > or =cT3) prostate cancer (PCa). We retrospectively reviewed data from 2,581 men who underwent radical prostatectomy for IR and HR PCa (RPP, n = 689; RRP, n = 402; MIRP, n = 1,490 [laparoscopic, n = 206; robot-assisted laparoscopic, n = 1,284]). The proportion of HR PCa was 40.3%, 46.8%, and 49.5% in RPP, RRP, and MIRP (P < 0.001), respectively. The positive surgical margin rate was 23.8%, 26.1%, and 18.7% (P = 0.002) overall, 17.5%, 17.8%, and 8.8% (P < 0.001) for pT2 disease and 41.9%, 44.4%, and 40.0% (P = 0.55) for pT3 disease in men undergoing RPP, RRP, and MIRP, respectively. Biochemical recurrence-free survival rates among RPP, RRP, and MIRP were 73.0%, 70.1%, and 76.8%, respectively, at 5 yr (RPP vs. RPP, P = 0.02; RPP vs. MIRP, P = 0.23). Furthermore, comparable 5-yr metastases-free survival rates were demonstrated for specific surgical approaches (RPP vs. RPP, P = 0.26; RPP vs. MIRP, P = 0.06). RPP achieved acceptable oncological control for IR and HR PCa.

Perineal colostomy: an alternative to avoid permanent abdominal colostomy: operative technique, results and reflection / Colostomia perineal: uma alternativa para evitar a colostomia abdominal definitiva: técnica operatória, resultados e reflexão

BACKGROUND: The most common injury to indicate definitive stoma is rectal cancer. Despite advances in surgical treatment, the abdominoperineal resection is still the most effective operation in radical treatment of malignancies of the distal rectum invading the sphincter and anal canal. Even with all the effort that surgeons have to preserve anal sphincters, abdominoperineal amputation is still indicated, and a definitive abdominal colostomy is necessary. This surgery requires patients to live with a definitive abdominal colostomy, which is a condition that modify body image, is not without morbidity and has great impact on the quality of life. AIM: To evaluate the technique of abdominoperineal amputation with perineal colostomy with irrigation as an alternative to permanent abdominal colostomy. METHOD: Retrospective analysis of medical records of 55 patients underwent abdominoperineal resection of the rectum with perineal colostomy in the period 1989-2010. RESULTS: The mean age was 58 years, 40 % men and 60 % women. In 94.5% of patients the indication for surgery was for cancer of the rectum. In some patients were made three valves, other two valves and in the remaining no valve at all. Complications were: mucosal prolapse, necrosis of the lowered segment and stenosis. CONCLUSION: The abdominoperineal amputation with perineal colostomy is a good therapeutic option in the armamentarium of the surgical treatment of rectal cancer. .

RACIONAL: O câncer de reto é o agravo mais frequente para a indicação do estoma abdominal definitivo. Apesar dos avanços no tratamento cirúrgico, a amputação abdominoperineal ainda é a operação indicada mais efetiva nesta indicação com invasão de esfíncter e de canal anal, o que impõe aos pacientes colostomia abdominal definitiva, condição que altera a imagem corporal e grande repercussão na qualidade de vida. OBJETIVO: Avaliar a técnica de amputação abdominoperineal mais colostomia perineal com irrigação como alternativa à colostomia abdominal definitiva. MÉTODO: Análise retrospectiva de prontuário médico de cinquenta e cinco pacientes submetidos à amputação abdominoperineal do reto mais colostomia perineal no período de 1989 a 2010. RESULTADOS: A média de idade foi de 58 anos sendo 40% em homens e 60% em mulheres. Em 94,5% dos pacientes a indicação cirúrgica foi por câncer de reto. Em alguns foram confeccionadas três válvulas, em outros duas e nos demais não foi confeccionada nenhuma válvula. As complicações foram: prolapso mucoso, necrose do segmento abaixado e estenose. CONCLUSÃO: A técnica de amputação abdominoperineal mais colostomia perineal é boa opção terapêutica no arsenal do tratamento cirúrgico do câncer de reto. .

Amputación abdominoperineal extraelevador como tratamiento de neoplasias anorrectales localmente avanzadas. Experiencia inicial / Extralevator abdominoperineal resection as treatment of locally advanced anorectal neoplasias. Initial experience

Introducción: la amputación abdominoperineal (AAP) fue durante muchas años el tratamiento de elección para los tumores de recto bajo y especialmente aquellos con compromiso del aparato esfinteriano. Algunas modificaciones a la técnica original, sugieren el aumento de la radicalidad a través de una resección cilíndrica (amputación abdominoperineal extraelevador). Esta estrategia permite ampliar los márgenes de resección circunferencial, con menor posibilidad de perforación o apertura tumoral, permitiendo así una menor recidiva local y mejores resultados oncológicos. El siguiente trabajo tiene por objetivo exponer los aspectos técnicos más relevantes y los resultados de la experiencia inicial con esta variante técnica. Diseño: Serie de casos. Pacientes y métodos: se analizaron todos los pacientes sometidos a una amputación abdominoperineal extraelevador (AAPE) intervenidos en el Sanatorio Güemes, en el período comprendido desde mayo 2011 hasta septiembre del 2013. Fueron analizadas variables: demográficas, índice ASA (American Society of Anesthesiologist), índice de masa corporal (IMC), distancia del tumoral margen anal, tipo de cirugía, estadía hospitalaria y la morbilidad perioperatoria. Resultados: se incluyeron 5 pacientes, 4 de ellos pertenecían al sexo masculino. La media de edad fue de 61 años mientras que para el IMC fue de 29,8. Solamente en 1 paciente se realizó el abordaje laparoscópico. El tiempo operatorio medio fue de 266 minutos. La estadía hospitalaria en promedio fue de 8,6 días. Se registraron las siguientes complicaciones: dehiscencia parcial de colgajo cutáneo en 2 pacientes, fistula uretral (1 paciente) y eventración de la incisión mediana (1 paciente). El seguimiento medio de la serie fue de1 5 (8-24) meses. No hubo mortalidad en la serie. Un paciente presento una recidiva local...

Background: abdominoperineal resection (APR) has been, for many years, the treatment of choice for low rectal tumors, or those with sphincter involvement. In recent years, technical modifications (extralevator abdominoperineal resection) were performed, increasing the radicality of the original surgery. Thus oncologic outcomes were improved, with a decrease in the values of tumor perforation, circumferential resection margins involvement and a consequent lower local recurrence rates. This paper attempts to show the initial experience in this type of procedure. Design: Case series. Patients and methods: all patients who underwent extralevator abdominoperineal resection (EAPR) in the Sanatorio Güemes in the period from May 2011 to September 2013 were included. The variables analyzed were: demographic, ASA index (American Society of Anesthesiologist), body mass index (BMI), tumor distance from the anal verge, type of surgery, hospital stay, and intraoperative and postoperative complications. Results: five extralevator abdominoperineal resection were performed in 4 males. The mean age was 61 years and the mean BMI was 29.8. Only 1 laparoscopic approach was performed. The mean operative time was 266 min. The hospital stay was 8.6 days. The postoperative complications were: partial flap dehiscence (2 patients), urethral fistula (1 patient) and median incision hernia (1 patient). The median follow-up was 15 (8-24) months. Only one patient had a local recurrence...