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Query: UMLS:C0033377 (prolapse)
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A new technique using cadaveric fascia lata for the simultaneous repair of a cystocele and placement of a pubovaginal sling by means of a transvaginal approach is described, and our early results are reported. We refer to this as the cadaveric prolapse repair with sling (CaPS). Fifty patients, ages 37 to 90 years, underwent a new technique for simultaneous cystocele repair and transvaginal pubovaginal sling using a single piece of cadaveric fascia. Maximum follow-up was 6 months (range 1 to 6). A 6 x 8 cm segment of cadaveric fascia lata is placed transvaginally to repair the defect through which the bladder herniates into the vagina and to provide sling support at the bladder neck/proximal urethra. The sling is anchored to the pubic bone with transvaginal bone anchors. The remainder of the fascia is then secured to the medial edge of the levator muscles/pubocervical fascia bilaterally and at the vaginal cuff or cervix with absorbable sutures to reduce the cystocele. Patients are being evaluated with preoperative and postoperative stress, emptying, anatomy, protection, instability (SEAPI) scores as well as with grading of the prolapse based on a 3-grade anatomic classification system. Presenting symptoms have included stress urinary incontinence (SUI) in 13 (26%), urge incontinence in 4 (8%), mixed incontinence in 6 (12%), and pelvic prolapse in 20 (40%). These symptoms are not mutually exclusive; some patients presented with a combination of symptoms. The mean SEAPI scores were 5.51 preoperatively and 0.63 postoperatively, representing a significant improvement (P <0.001). Of the 40 patients whose prolapse was quantified, 1 patient (2.5%) had a minimal cystocele, 16 (40.0%) had moderate cystoceles, and 23 (57.5%) had large cystoceles. After the CaPS, 36 (72%) were completely dry, 3 (6%) had persistent SUI, 1 (2%) had de novo urinary incontinence (UI), 3 (6%) had persistent UI, and 1 (2%) had mixed incontinence. No patient had permanent urinary retention. Transvaginal placement of cadaveric fascia for concomitant sling and cystocele repair provides material of excellent strength for the repair without relying on the inherently weak tissues in the patient with pelvic prolapse. Thus far, the early results with CaPS are extremely encouraging. Long-term follow-up is underway to evaluate the efficacy of this procedure.
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PMID:A new technique for cystocele repair and transvaginal sling: the cadaveric prolapse repair and sling (CAPS). 1111 57

We retrospectively studied 77 laparoscopic sacral colpopexies performed from June 1996 to May 1998. Suspension was reinforced with two strips of synthetic mesh. Five patients had previously undergone hysterectomy and 4 others had experienced failure of surgery for prolapse of the uterus. Laparoscopy was performed in 83 women with symptomatic prolapse of the uterus. Six cases required conversion to laparotomy because of technical difficulties. All other 77 patients underwent laparoscopic sacropexy using anterior and posterior mesh reinforcement. Subtotal laparoscopic hysterectomy was associated in 60 cases, laparoscopic Burch colposuspension in 74 and levator myorraphy using the vaginal approach in 55. Operative time decreased from 292 to 180 minutes as the surgeon gained experience. The main operative complications were one rectal and two bladder injuries. Three patients required reoperations for haematoma or hemorrhage. One patient complained of chronic inflammation of the cervix and another experienced rejection of the posterior mesh 6 months after the operation. Mean follow up was 343 days. Three other patients required reoperation: one for a 3(rd) degree cystocele and two for recurrent stress incontinence. The conclusion of this study is that laparoscopic sacrocolpopexy is feasible. Operative time and postoperative complications are related to the surgeon's experience but remain comparable to those noted in laparotomy. Long term assessment is required to confirm the results of this procedure.
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PMID:[Laparoscopic sacral colpopexy: short-term results and complications in 83 patients]. 1113 10

Genital prolapse is a common problem in women. The wide variety of surgical techniques used to treat this problem demonstrate how difficult it is to manage. Laparoscopic surgery offers a new approach. It allows a good view of the anterior and posterior compartments so that a global approach for the prolapse is possible by the same surgical route. Traditional promontofixation can be combined with a new approach to the posterior compartment. Laparoscopic promontofixation through installation of an intervesicouterine prosthesis for the treatment of hysterocele and cystocele is associated with paravaginal repair of lateral defects and a Burch anterior colposuspension for urinary stress incontinence. When combined with laparoscopic treatment of rectocele by myorrhaphy and reinforcement of the fascia by means of a prosthesis, it provides a complete range of treatment for all types of feminine prolapse. After 20 years of experience through laparotomy, promontofixation using a triangle has been carried out by laparoscopy at the authors' center since 1991 in an attempt to eliminate the cystocele by solidly anchoring the uterus and bladder floor to the promontory. This laparoscopic technique follows the usual steps for pelvic prolapse repair: 1. Total or subtotal hysterectomy or suspension of the uterus is performed in such a way that it returns to normal physiologic position, and a solid subvesical floor is created. 2. The physiologic axis of the vagina is restored by creating a strong, low posterior point of support and by performing culdoplasty. 3. Evident or latent stress incontinence is treated. It would be pointless to treat the hysterocele on its own because, once the prolapse has been cured, the subvesical mass will disappear and allow urinary incontinence to appear. 4. Reconstruction of the posterior rectovaginal support structures seems to be mandatory and is carried out in almost all cases. The first phase of the laparoscopic approach to pelvic prolapse allowed the authors to explore the technical aspects. Several approaches are possible by laparoscopy. Herein, the authors report 8 years of technical research and assessment. This experience confirms the tremendous potential of laparoscopic surgery for the treatment of all aspects of this pathology by the same route. Stress incontinence, cystocele, hysterocele, rectocele, or enterocele can be treated. The operative time is longer than with the open route, and the surgeon must be highly experienced. Based on their experience, the authors are discovering new concepts. More data are required before a conclusion can be drawn concerning this promising new approach.
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PMID:Promontofixation for the treatment of prolapse. 1127 60

For 285 subjects referred to a menopause clinic data were prospectively collected on the time elapsed since the onset of menopause (menopausal age), sexual activity, dyspareunia, smoking, chronic cough and constipation. Prolapse and atrophy were sought on examination. FSH assay confirmed menopausal status. We found an anterior wall prolapse in 51% of the subjects, of which 6% were protruding beyond the introitus. Posterior wall prolapse was present in 27% and apical prolapse in 20%; none was protruding beyond the introitus. No trend was noted between prolapse and menopausal age. Atrophy was evident in 34% of the women, and this was related to menopausal age (P<0.001). Forty per cent of the sexually active women admitted to dyspareunia, of which 2/3 were superficial. This correlated with advancing menopausal age (P<0.02). In conclusion, genital prolapse was frequent in the population of postmenopausal women, predominantly cystocele, but the prevalence did not correlate with menopausal age.
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PMID:Urogenital prolapse and atrophy at menopause: a prevalence study. 1137 7

Over a 2-year period 45 patients with bilateral paravaginal support defects underwent vaginal paravaginal repair. Postoperative evaluations were conducted and anatomic outcome was determined by vaginal examination, with grading of vaginal wall support. Functional outcome was assessed by a standardized quality of life questionnaire, voiding dairy and standing stress test with a full bladder. Thirty-five patients had long-term follow-up with a mean of 1.6 years (range 1-85). The recurrence rates for displacement cystocele, enterocele and rectocele were 3% (1/35), 20% (7/35) and 14% (5/35), respectively. In no patients did vault prolapse develop or recur. Subjective or objective evidence of persistent stress urinary incontinence was found in 57% of patients (12/21). Vaginal paravaginal repair is a safe and effective technique for the surgical correction of anterior vaginal wall prolapse but has limited applicability in the surgical correction of genuine stress incontinence.
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PMID:Anatomic and functional outcome of vaginal paravaginal repair in the correction of anterior vaginal wall prolapse. 1137 18

Pelvic organ prolapse is abnormal displacement of the pelvic organs from their normal anatomical position. Patients may present with a variety of symptoms, including pain, incontinence, constipation, urinary retention, and defecatory dysfunction. Any combination of cystocele, rectocele, enterocele, sigmoidocele, peritoneocele, and prolapse of the vagina and uterus may occur. Therefore, accurate preoperative evaluation of each organ is important for proper surgical planning. Compared with physical examination and other imaging modalities, advantages of magnetic resonance imaging (MRI) include a global multiplanar view of the pelvis, and the lack of ionizing radiation and invasive procedures. Subsecond MRI techniques have not only shortened the imaging time to minimize motion artifacts but provide the capability for dynamic MRI. In this pictorial essay, we describe fast MRI techniques, MRI findings, and the associated clinical findings in patients with pelvic organ prolapse. We also refer to limitations of MRI.
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PMID:Fast magnetic resonance imaging of pelvic organ prolapse. 1138 91

Pelvic floor dysfunction encompasses a variety of fascial and anatomic defects that can include a combination of cystocele, rectocele, uterine prolapse, enterocele and vault prolapse. Accurate diagnosis of the coexisting abnormalities is essential in planning reconstructive procedures so that the risks of recurrence and reoperation can be minimized. At this time, dynamic magnetic resonance imaging is the study of choice to evaluate the female pelvis and delineate the possible components of pelvic floor dysfunction.
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PMID:Diagnostic imaging of pelvic floor dysfunction. 1142 5

Despite an improved understanding of pelvic anatomy and organ function and advances in surgical techniques, long-term success rates in pelvic surgery are still variable (3-59%), but can reach up to 92% in the case of associated procedures. The major causes of recurrent pelvic prolapse after corrective surgery are related to patient factors, such as poor tissues, impaired healing processes and chronic pathological increases in intra-abdominal pressure. Other causes of failure are, however, probably related to surgical techniques: the use of weak or insufficient sutures, or suboptimal performance of the surgery. In line with progress in the surgical correction of abdominal hernias, the use of synthetic mesh in pelvic reconstructive surgery also seems to guarantee its reliability, especially when autologous tissue is of poor quality or insufficient quantity. Moreover, the use of artificial mesh may simplify a surgical procedure, reducing operative time and the need for additional techniques. This review evaluates the main properties of synthetic biomaterials, their complications and the most common procedures involved in the use of synthetic mesh: the abdominal sacral colpopexy and transvaginal cystocele repair.
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PMID:The use of synthetics in the treatment of pelvic organ prolapse. 1142 6

Pelvic organ prolapse of the female is a common disease with age dependent increase in incidence. The committee for standardisation of the International Continence Society recently suggested to avoid classical terms such as cystocele, rectocele or enterocele for the description of prolapse and to replace them by defined landmarks. The "Pelvic Organ Prolapse Quantification" (POPQ) was developed and five different grades of prolapse were defined. This is a true gain for scientific documentation but needs some effort to be implemented in routine practical work. Previous normal vaginal delivery is statistically highly correlated with prolapse, followed by climacteric involution, constitutional factors, physical work, chronic bronchitis, and overweight respectively. The diagnosis is confirmed by clinical examination. Defects of the supportive structures can be precisely assessed with dynamic magnetic resonance imaging. Time will show whether this costly method will become part of routine diagnostic procedures. A patient with moderate prolapse or few complaints may be treated conservatively with pelvic floor training or electrotherapy. Modern pessaries are tried as first line therapy or for patients unwilling to undergo surgery. Local estrogen application should routinely be prescribed for perimenopausal patients. In the last decade laparoscopic techniques have been established in addition to standard methods of pelvic floor reconstruction. These techniques do not follow a new surgical strategy but realise the minimal invasive approach to established methods of pelvic floor reconstruction. Of note, laparoscopic fixation is very convenient for young women who want to preserve their uterus. Long time follow up is not available for most techniques.
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PMID:[Pelvic organ prolapse]. 1183 46

The aim of the study was to prospectively evaluate pre- and postoperative findings of cystodefecoperitoneography (CDP) and to correlate the findings to the clinical examination in patients with genital prolapse. Twenty-five female patients were investigated both pre- and postoperatively with a standardized questionnaire, clinical examination and CDP, including contrast medium in the rectum, vagina, bladder, small bowel and peritoneal cavity. At preoperative clinical examination a rectocele was diagnosed in 24 patients, a cystocele in 7 and an enterocele in 2. At the preoperative CDP a rectocele was diagnosed in 21 patients, a cystocele in 22 patients and a peritoneocele in 9, of which six contained small bowel (i.e. an enterocele). Surgery was performed according to the clinical findings. At the postoperative clinical examination no rectocele was diagnosed, a cystocele was diagnosed in 3 patients and an enterocele in 1. Postoperative CDP showed a rectocele in 4 patients, a cystocele in 24 and a peritoneocele in 7 patients, of which three contained small bowel (i.e. an enterocele). CDP may complement the clinical assessment of patients with genital prolapse, in particular to confirm or detect defects involving the posterior compartment. The radiologic definition of cystocele needs further evaluation.
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PMID:Cystodefecoperitoneography in patients with genital prolapse. 1199 1


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