Descending perineal syndrome cure by deep transversus perinei ligament repair: surgical options.

Descending perineal syndrome (DPS) was described by Parks et al. as descent of the anus on straining, typically 3-4 cm below a line drawn from the coccyx to the lower end of the. DPS is associated with obstructed defecation, with increased bulging of the perineum with straining, although perineal descent can also be seen at rest. In their review, Chaudhry and Tarnay stated: "It is controversial whether surgical management is even an option for patients with DPS". The deep transversus perinei (DTP) ligaments are the suspensory ligaments of the perineal body (PB). DTP are approximately 4 cm long. They attach behind the upper 2/3 and lower 1/3 of the descending ramus. If, at childbirth, the PB is overstretched and displaced laterally and inferiorly, the DTP lengthens. DPS is described as descent of the anus on straining, typically 3-4 cm below a line drawn from the coccyx to the lower end of the symphysis. DPS is associated with obstructed and often, assisted defecation, with increased bulging of the perineum with straining descent of the anus on straining. The surgical methodology begins as a standard PB repair which dissects the rectum from the vagina and PB and approximates the displaced components of the PB. We added an additional step: identifying the DTPs, shortening and reinforcing them with the Tissue Fixation System (TFS) minisling or No. 2 polyester sutures. High cure rates for obstructed defecation were achieved with the TFS minisling, and initial results using No. 2 polyester sutures are favourable. The key messages from both operations is DPS is caused by stretching and elongation of DPS ligaments, and these are surgically repairable.

Chronic pelvic pain of "unknown origin" in the female.

The remit of this review is confined to the experimental scientific works and surgeries based on the Integral Theory Paradigm (ITP). Chronic pelvic pain (CPP) is a major societal problem which is said to occur in up to 20% of women. The pathogenesis of CPP of "unknown origin" is said to be unknown and CPP is said to be incurable. According to the ITP, however, CPP is said to be mainly caused by the inability of loose or weak uterosacral ligaments (USLs) to mechanically support visceral nerve plexuses (VPs), T11-L2 and S2-4. These fire off de novo impulses, interpreted by the cortex as pain coming from the end organs. CPP, when it occurs simultaneously in multiple pelvic sites, is associated with uterine/apical prolapse (often minimal) and bladder symptoms such as overactive bladder (OAB), nocturia, retention. This combination of symptoms was described in 1993 as the "posterior fornix syndrome" (PFS). As such, CPP when associated with the PFS, is potentially curable by surgical repair of USLs. However, patients with CPP generally complain only of one symptom, CPP. This is known as the "Pescatori iceberg" effect. Other PFS symptoms are "under the surface" and must be sought out by direct questioning. The diagnostic algorithm is helpful in locating other associated symptoms. Definitive diagnosis of CPP, caused by USL laxity, is immediate alleviation of pain by mechanical support of USLs by using the speculum test or by tampons in the posterior fornix. Treatment of CPP can be non-surgical, by strengthening USLs by squatting exercises, supporting USLs mechanically with tampons or USL surgery. Coexisting bladder symptoms are (variously) improved or cured. URL for CPP https://www.pelviperineology.org/volume/36/issue/3.

Normative values of the internal genital organs of the female pelvis in transvaginal and transabdominal ultrasound.

AIM: To conduct a systemic review of published data on reference values for both transabdominal and transvaginal ultrasound in gynecology. MATERIALS AND METHODS: Literature from 1970 to 2020 of reference values for the female pelvis in healthy subjects was reviewed. According to the determination of reference intervals for laboratory values reference values are generally determined using 95%-reference intervals and their associated 90%-confidence intervals. The list of articles was supplemented with extensive crosschecking of the reference lists of all retrieved articles. RESULTS: A total of 33 studies were included and analyzed. The diagnostic performance of transvaginal ultrasound (TVUS) has a higher sensitivity and specificity than transabdominal ultrasound (TAUS) for high quality imaging of the uterus and the bilateral adnexa. The length of normal uterus is about 50-80 mm in fertile age. There is no consensus about the cut off value of the thickness of the endometrium in asymptomatic postmenopausal women, while a measurement of >5 mm and postmenopausal bleeding is suspect and requires further examination. The distribution of normal ovarian volumes is narrow with small volumes in postmenopausal women. CONCLUSION: Normal values are helpful in delimiting the pathological changes in the female pelvis. While sonomorphologic criteria are more important than the ovarian size for the assessment of ovarian masses and reference values of the uterus in adults have little impact on routine practice, normative values in pediatric patients are important for the detection of pathologies. Normative values of the internal genital organs in females are sufficiently validated; still further research is required to assess the role of normative values in routine clinical practice and in sonographic screening for endometrial and ovarian cancer.

Colorectal resection in endometriosis patients: correlation between histopathological findings and postoperative outcome.

INTRODUCTION: Endometriosis is associated with a high number of chronic pelvic pain and reduced quality of life. Colorectal resections in case of bowel involvement of endometriosis are associated with an unneglectable morbidity in young and healthy patients. There is no linear correlation established between the degree of symptoms and stage of endometriosis. The aim of this study was to correlate the histological findings to preoperative pain scores in colorectal resected patients with endometriosis. METHODS: Twenty-five patients who underwent laparoscopic colorectal resection for endometriosis between 2014 and 2019 were included in this retrospective study. Pain level was assessed preoperatively and postoperatively via phone call in May 2020. Histopathology was correlated to preoperative symptoms and postoperative outcome. RESULTS: Average follow-up time was 38.68 months (± 19.92). Preoperative VAS-score was 8.32 (± 1.70). We observed a significant reduction of pain level in all patients after surgery (p ≤ 0.005). Pain levels were equal regarding the presence of satellite spots and various degrees of infiltration depth. The resection margins were clear in all patients. Postoperative complications occurred in 6 cases (24%) and anastomotic leakage was observed in 3 patients (12%). Average VAS-score at time of follow-up was 1.70 (± 2.54). CONCLUSION: Our data demonstrate that adequate colorectal resection leads to reduction of pain and an increase of quality of life irrespective of histopathological findings. An experienced team is necessary to improve intraoperative outcome and to reduce postoperative morbidity in case of complication.

A biomechanically based concept for a stronger obstetric anal sphincter repair.

INTRODUCTION AND HYPOTHESIS: This study emanates from the ISPP OASIS and fecal incontinence study group at the 2018 annual meeting of the International Society for Pelviperineology (ISPP) in Bucharest, Romania. The aim was to analyze the biomechanical factors leading to the breakdown of anal sphincter repair and to suggest a more robust technique for external anal sphincter (EAS) repair. METHODS: Our starting point was what happens to the EAS wound repair site during defecation following EAS repair, with special reference to the process of wound healing. RESULTS: We concluded that a graft no more than 1 × 1.5 cm sutured across the EAS tear line would mechanically support the tear line, vastly reduce the internal centrifugal forces acting on it during defecation, thereby giving the wound time to heal. Three different grafts were discussed, autologous, biological, and mesh. Also analyzed were the effects on EAS muscle contractility of overly tight repair and overly loose sphincter repair, the latter occasioned by the tearing out of sutures and repair by secondary intention. CONCLUSIONS: We have analyzed causes of sphincter repair failure, introduced a graft method, preferably autologous, for the prevention thereof and supported ultrasound assessment, rather than the absence of fecal incontinence as the criterion for success of EAS repair. Although based on well-established biomechanical principles, our proposal at this stage remains unproven. Our hope is that these concepts will be challenged, clarified, and tested, preferably in a randomized controlled trial.

Chronic pelvic pain of unknown origin may be caused by loose uterosacral ligaments failing to support pelvic nerve plexuses - a critical review.

INTRODUCTION: Chronic pelvic pain of unknown origin (CPPU) affects the quality of life (QoL) of up to 20% of women. The 2005 Cochrane Review, based on randomized controlled trials (RCTs), stated that the pathogenesis of CPPU is poorly understood and its treatment is empirical and ineffective. Totally ignored were the high cure rates from uterosacral ligament (USL) repair, the principal subject of this review. MATERIAL AND METHODS: We carried out a review of literature on USL causation, diagnosis, and treatment of CPPU, selecting only the literature relevant to USL. RESULTS: The first mention of CPPU being caused by lax USLs was in the pre-WWII German literature by Heinrich Martius. In 1993, CPPU was described as one of the 4 pillars of the posterior fornix syndrome (PFS- CPPU, urgency, nocturia, abnormal bladder emptying). Cure/improvement of CPPU was reported by widely geographically separated surgical groups using squatting-based pelvic floor exercises and by shortening and reinforcing USLs with tension tapes, literally a reverse transvaginal tape. Patients can potentially be cured either by native tissue ligament repair or in older women a posterior sling can be tested using a speculum test or even menstrual tampons. CONCLUSIONS: This technology, based on USL pathogenesis, which can be tested for potential cure, non-surgical or surgical, offers hope for women for a condition previously considered incurable. Chronic pelvic pain, bladder and bowel incontinence occur in predictable symptom groupings, which are associated with apical prolapse. USL repair, whether native tissue or (preferably) using a posterior sling has the potential to improve clinical practice, QoL for women and open new research directions.

Cure of Underactive and Overactive Bladder Symptoms in Women by 1,671 Apical Sling Operations Gives Fresh Insights into Pathogenesis and Need for Definition Change.

INTRODUCTION: To check evidence that symptoms identical with those constituting "underactive bladder" (UAB) and "overactive bladder" (OAB) are caused by apical prolapse and cured by repair thereof. MATERIAL AND METHODS: After repair of apical prolapse by mesh tape reinforcement of lax uterosacral ligaments (USL) data form 1,671 women were retrospectively examined to determine the presence of OAB and UAB symptoms and to check, how many were cured surgically. Thereby 3 different techniques were performed: elevate (n = 277), "Posterior IVS" (n = 1,049), and TFS cardinal (CL)/USL (n = 345). RESULTS: Symptoms identical with those comprising UAB and OAB were cured in up to 80% of cases following surgical repair of the CL/USL complex. CONCLUSIONS: These symptoms may be consistent with symptoms of the posterior fornix syndrome, which comprises 4 main symptoms: micturition difficulties, urge/frequency, nocturia, chronic pelvic pain, all consequent on USL laxity. Surgical cure of OAB and UAB is inconsistent with existing definitions, which imply pathogenesis of the detrusor muscle itself. A reconsideration and reformulation of existing definitions may be required. Altering UAB definition to "bladder emptying difficulties" and return to former definitions for OAB such as "detrusor" or "bladder instability" may help to restore compatibility with surgical cure of these conditions.

The mechanics of urethral closure, incontinence and midurethral sling repair. Part 2 further experimental validation (1993-2003).

IN: Part 1, The original 1990 science behind the MUS, the hypothesized closure mechanisms, and the prototype MUS itself were presented. The next phase of MUS development began in 1990 in collaboration with the late Ulf Ulmsten. It had two arms Further development of the prototype MUS. Further anatomical, imaging, urodynamic studies to validate the role of PUL in the closure mechanisms. A second series of prototype MUS operations performed under LA/sedation resulted in a permanently implanted polypropylene sling and the MUS as is known today. The tape was elevated until no urine leaked on coughing. This demonstrated that the artificial PUL neoligament needed to be at a specific length to work. Anatomical, EMG and video ultrasound, and X-ray studies confirmed three directional muscles contracted pubourethral (PUL) and uterosacral (USL) ligaments. The contribution of the horseshoe shaped rhabdosphincter (RS) to continence was directly tested with pressure measurements under live surgery conditions. It was concluded that the RS was responsible for pressure generation but not continence. Continence was a consequence of intraurethral resistance to flow created by the distal and proximal urethral closure mechanisms, both governed ultimately by the Law of Poiseuille. CONCLUSIONS: The key element in curing USI is creation of a competent PUL using the collagenous neoligament surgical principle described in Part 1. This creates a firm insertion point for the three directional muscle forces, restoring their contractile strength and closure.

The mechanics of urethral closure, incontinence and midurethral sling repair. Part 1 original experimental studies. (1990).

AIMS: To summarize the mechanics of urethral closure, incontinence, and midurethral sling repair, a work in 3 parts Part 1. Original scientific studies (1990). Part 2. Experimental validation of reliance of the closure mechanisms on a competent PUL (1993-2003). Part 3. Surgery (1990-2016). METHODS: Part1. Two unrelated observations in the mid 1980s led to the discovery of the MUS: a hemostat applied on one side of the midurethral area of the vagina, controlled urine loss on coughing without bladder neck elevation; an implanted Teflon tape cause a collagenous reaction. It was hypothesized that urinary stress incontinence (USI) was caused by collagen loss in the pubourethral ligament (PUL) and a tape implanted in the exact position of PUL would reinforce it and cure USI. A tape removable at 6 weeks was configured as an inverted "U" in the vagina and lowered sequentially. RESULTS: At a certain point, the patient was continent on coughing but was able to pass urine freely. This proved the mechanism for continence was not obstructive. Post-op xrays showed no elevation of bladder neck. This invalidated Enhorning's Theory. Ultrasound showed closure of distal urethra from behind and descent of vaginal fornix on straining. This indicated there were two closure mechanisms, distal urethral, and bladder neck. Three months following sling removal, there was a 50% failure rate. CONCLUSIONS: The 1990 results indicated a permanent sling was required for the MUS. Further proofs were required for the proposed musculoelastic mechanisms.

The mechanics of urethral closure, incontinence, and midurethral sling repair Part 3 surgical applications (1990-2016).

Part 3 briefly summarizes further development in midurethral sling (MUS) instruments and technique following the 1990 prototype operations, then critically examines the whole MUS surgical methodology, 1990 to present day. The aim is to identify positive and negative aspects of these methodologies which can be usefully applied to improve current MUS surgery. ANIMAL EXPERIMENTS: 1987-1988 proved that a collagenous neoligament could be formed by implantation of a tape. There was a wide variation in tissue reaction to implanted tapes. Inflamamatory tissue reaction was very different from bacterial infection and was safe even when a sinus is formed. MUS METHODOLOGY: The key factor in avoiding major vessel and nerve injuries is to penetrate the perianal membrane with scissors, insert the applicator. Importantly, this reveals any bleeding which could otherwise accumulate in the Space of Retzius and only be controlled by digital pressure. The balance between too tight (retention) and too loose (incontinence) is analyzed in terms of the exponential relationship between urethral diameter and urine flow; why elastic tapes are more likely to cause post-operative urinary retention; how to minimize retention by tightening against an indwelling No18 Foley catheter; the importance of routinely repairing the distal closure mechanism with purse string suture to external ligaments, fascial layer of vagina; why minislings avoid most of the serious MUS complication; why a tensioned minisling allows greater precision when tightening the sling and how anchors and individually knitted tapes give hope that tape erosions may decrease.

Knowledge of urethral closure mechanics helps to optimize surgical methodology of the midurethral sling operation.

The mechanism for urinary continence is not obstructive. Ultrasound and video data indicate that 3 striated muscle forces contract in opposite directions around a competent pubourethral ligament (PUL) to close the distal urethra and bladder neck. If PUL is loose, both mechanisms are invalidated, because striated muscles need a firm insertion point to function efficiently. The patient now loses urine on effort. Referring back to original research, the various steps involved in a midurethral sling operation are analysed with a view to optimizing surgical results. These include an analysis of what causes postoperative urinary retention, why the components of the distal closure mechanism need repair and simple steps to avoid nerve and blood vessel injury.

Retention of urine in women is alleviated by uterosacral ligament repair: implications for Fowler's syndrome.

INTRODUCTION: The aim of this study was to independently evaluate idiopathic urinary retention and other known Fowler's syndrome (FS) descriptions in 24 women treated for posterior fornix syndrome (PFS) by reinforcement of the uterosacral ligaments (USL) using the tissue fixation system (TFS). MATERIAL AND METHODS: The main inclusion criterion was: idiopathic urinary retention with post-void residual urines (PVR) >100 ml. RESULTS: The mean patient age was 63 years (range 32-87). Except for peak urine flow, features typical of FS were statistically improved (p 0.015 to <0.0001), pre-op mean with post-op mean in brackets: PVR 272 ml (34 ml); abnormal emptying symptoms n = 24 (18/24 cured or 80% improved); natural bladder volume 598 ml (301 ml); emptying time 50 seconds (20 seconds): peak flow 42 ml/sec (37 ml/sec); chronic pelvic pain n = 18 (14/18 >80% improved); maximal urethral closure pressure >90 cm (n = 4) 93 cm H2O (75 cm); frequency (14/14 improved); nocturia 110 episodes (33 episodes). CONCLUSIONS: Functional disorders typical of FS, also present in posterior fornix syndrome, principally idiopathic urinary retention, were cured/improved by USL sling repair. Suggested anatomical pathway: lax USLs weaken the backward muscular forces, unbalancing bladder neck and urethral closure. Compensatory forward-acting closure muscles narrow the distal urethra, causing urinary flow difficulties, and retention. This functional imbalance can be relieved by posterior sling repair. We suggest that, rather than spasm from the (weak) rhabdosphincter (Fowler's syndrome), USL weakness is the most likely cause of idiopathic urinary retention in women.

Pathways to causation and surgical cure of chronic pelvic pain of unknown origin, bladder and bowel dysfunction - an anatomical analysis.

INTRODUCTION: Current thinking is that chronic pelvic pain of unknown origin (CPPU) is poorly understood and its treatment is empirical and ineffective. According to the Integral Theory System (ITS), however, CPPU is secondary to uterosacral ligament (USL) laxity which is associated with bladder and bowel symptoms and all are potentially curable by surgical reinforcement of USLs. MATERIAL AND METHODS: We applied the ITS to anatomically explain the pathogenesis and cure of these conditions. RESULTS: The first mention of CPPU being caused by lax USLs was in the pre- WWII German literature by Heinrich Martius. CPPU was first described in the English literature in 1993 as one of the four pillars of the posterior fornix syndrome (PFS) (CPPU, urgency, nocturia and abnormal bladder emptying). Surgical cure/improvement of CPPU was achieved by shortening and reinforcing USLs initially with USL ligament plication and later with tensioned tapes because of deteriorating cure rates. Non-invasive 'simulated operations' which support USLs in the posterior fornix help predict USL causation. CONCLUSIONS: USL tapes cure/improve CPPU, bladder and bowel dysfunctions by reinforcing the USLs against which the 3 directional forces contract. Weak suspensory ligaments may invalidate these forces to cause incontinence, emptying and pain symptoms, all of which can be potentially reversed by using tapes to reinforce the damaged ligaments, as demonstrated.

The posterior intravaginal slingplasty operation: results of the Austrian registry.

OBJECTIVE: We set up a registry to assess complications and short-term results of the posterior intravaginal slingplasty operation. STUDY DESIGN: A total of 14 gynecology departments in Austria completed questionnaires addressing the patient's history, the operation itself and the postoperative course. In the follow-up we asked for information on tape exposure and functional and anatomical results. RESULTS: Fourteen centers entered a total of 577 patients operated between 2001 and 2006. 560 (97%) posterior slingplasty operations were done in conjunction with other procedures. Intraoperative complications were reported for 16 (2.8%) procedures. Postoperatively five hematomas required reoperation. 496 (86%) patients were available for follow-up after a median of 7 weeks (range, 1-156). 54 (9.4%) patients required reoperation. Vaginal tape exposure was seen in 50 (8.7%) women. Physicians assessed the functional and anatomical results as excellent or good in 83% and 88% of patients, respectively. CONCLUSION: Despite the limitations of a registry and the high rate of concomitant procedures, this study provides data on the complications and results of the posterior intravaginal slingplasty operation.

The Tissue Fixation System provides a new structural method for cystocoele repair: a preliminary report.

BACKGROUND: A new reconstruction principle that uses tensioned tapes instead of large mesh is described for cystocoele repair. AIM: To apply this method to patients with central, paravaginal and cervical ring defects. METHODS: Ninety patients, mean age 63 years (29-83) and mean weight 73 kg (52-117 kg), underwent cystocoele repair using the Tissue Fixation System (TFS). Tapes were applied as a retro-obturator U-sling (n=29), transversely between both arcus tendineus fascia pelvis (ATFP) ligaments (n=45), along the path of the cardinal ligament in patients with cervical ring defects (n=12), and longitudinally along the ATFP ligament (n=4). RESULTS: At mean eight months review (three to 15 months), two failures were reported. There was one haematoma that drained spontaneously at seven days, and there were no erosions. Mean hospital stay was one a half days for the Australian group (one to seven days) and five days (four to eight days) for the European group. After using single U-sling, one patient required intermittent catheterisation for seven days before she could pass urine freely. In one patient the bladder was perforated during dissection laterally towards the ATFP; the perforation was successfully repaired. CONCLUSIONS: The tensioned tape operation is simple and accurate, and appears to work well in the short term. Longer-term studies are required.