D. M. J. Oom

Assessment of posterior compartment prolapse: a comparison of evacuation proctography and 3D transperineal ultrasound.

Introduction  Evacuation proctography (EP) is considered to be the gold standard investigation for the diagnosis of posterior compartment prolapse. 3D transperineal ultrasound (3DTPUS) imaging of the pelvic floor is a noninvasive investigation for detection of pelvic floor abnormalities. This study compared EP with 3DTPUS in diagnosing posterior compartment prolapse.

Enterocele repair by abdominal obliteration of the pelvic inlet: long-term outcome on obstructed defaecation and symptoms of pelvic discomfort

Objective  Enterocele is defined as a herniation of the peritoneal sac between the vagina and the rectum. This may contain either sigmoid colon or small bowel. It has been reported that enterocele is associated with obstructed defaecation and symptoms of pelvic discomfort. The aim of the present study was to evaluate the long‐term effect of enterocele repair.

Detection of anal sphincter defects in female patients with fecal incontinence: a comparison of 3-dimensional transperineal ultrasound and 2-dimensional endoanal ultrasound.

BACKGROUND: Endoanal ultrasound is widely used for the detection of external and internal anal sphincter defects in patients with fecal incontinence. Recently, 3-dimensional transperineal ultrasound has been introduced as a noninvasive imaging method for the detection of these sphincter defects. OBJECTIVE: This study was designed to assess agreement between 3-dimensional transperineal ultrasound and 2-dimensional endoanal ultrasound regarding the detection of anal sphincter defects in women with fecal incontinence. DESIGN: This study was designed as a prospective observational study. SETTINGS: The study took place in a university hospital. PATIENTS: Between October 2008 and June 2009, all women with concerns of fecal incontinence underwent 2-dimensional endoanal ultrasound as well as 3-dimensional transperineal ultrasound. MAIN OUTCOME MEASURES: The main outcome measures are the presence of external and internal anal sphincter defects. RESULTS: Fifty-five patients were included. External and internal anal sphincter defects were observed with 2-dimensional endoanal ultrasound in 27 (49%) and 15 (27%) patients. Three-dimensional transperineal ultrasound detected an external and internal sphincter defect in 19 (35%) and 16 (29%) patients. The Cohen &kgr; coefficient for the detection of external (&kgr; = 0.63) and internal (&kgr; = 0.78) anal sphincter defects was good. LIMITATIONS: This study’s limitations include the absence of a surgical examination as the reference standard in the determination of sphincter defects. CONCLUSION: This study shows good agreement between 3-dimensional transperineal ultrasound and 2-dimensional endoanal ultrasound regarding the detection of anal sphincter defects. Based on these data, 3-dimensional transperineal ultrasound might be considered as a valuable alternative noninvasive investigation method.

Anterior sphincteroplasty for fecal incontinence: A single center experience in the era of sacral neuromodulation

PURPOSE: Anterior sphincteroplasty is the surgical treatment of choice for patients with fecal incontinence associated with an external anal sphincter defect. Recently it has been reported that patients with such a defect may also benefit from sacral neuromodulation. The success of this technique raises the question whether anterior sphincteroplasty still deserves a place in the surgical treatment of fecal incontinence. This study investigated the outcome of anterior sphincteroplasty in a large cohort of patients. METHODS: A consecutive series of 172 patients underwent anterior overlapping sphincteroplasty. A standardized questionnaire concerning current continence status, overall satisfaction, and quality of life was used to assess the outcome. RESULTS: Follow-up data were obtained from 75% of the 160 patients who were still alive at the time of the survey. After a median follow-up of 111 (range, 12–207) months, the outcome was still good to excellent in 44 patients (37%). In 28 patients (23%), the outcome was classified as moderate because these patients still experienced regular incontinence for stool. However, they were satisfied with their outcome because their incontinence episodes had been reduced by 50% or more. The outcome was poor in 40% of the patients. Predictors of worse outcome were older age (≥50 years) at surgery, deep wound infection, and isolated external anal sphincter defects. Patients with follow-up of five or more years had the same outcome as patients with follow-up of fewer than five years. CONCLUSION: Anterior sphincteroplasty results in an acceptable to excellent long-term outcome in 60% of patients, especially in those under the age of 50 years at surgery.

Obliteration of the fistulous tract with BioGlue ® adversely affects the outcome of transanal advancement flap repair

BackgroundTransanal advancement flap repair (TAFR) is useful in the treatment of high transsphincteric fistulas. Initially, promising results were reported. More recent studies have indicated that TAFR fails in one out of three patients. In almost all of our patients with a failure, we have observed healing of the flap except at the site of the original internal opening. A possible explanation for this remarkable finding might be persistent inflammation in the fistulous tract, finding a way out through the original internal opening. The question is whether obliteration of the fistulous tract by local installation at a surgical adhesive, can prevent persistent inflammation to break through the original opening. The aim of this pilot study was to investigate whether concomitant instillation of BioGlue could improve the healing rate following TAFR for high transsphincteric fistulas.MethodsBetween March 2006 and April 2006 a consecutive series of eight patients (four men, four women; median age 46 years) with a high transsphincteric fistula underwent TAFR after instillation of BioGlue in the fistulous tract. All patients were seen in the outpatient department for postoperative evaluation.ResultsFistula healing was observed in only one patient (12.5%). All other patients experienced one or more of the following complications: prolonged severe pain (n=5), discharge of great amounts of purulent liquid from the external opening (n=3) and abscess formation (n=2), necessitating incision and drainage. Because of this unexpected outcome we decided to terminate the study prematurely.ConclusionsOur findings indicate that obliteration of the fistulous tract with BioGlue adversely affects the outcome of TAFR for high transsphincteric fistulas.

Puborectal sling interposition for the treatment of rectovaginal fistulas

AbstractBackgroundSeveral techniques are available for the surgical treatment of rectovaginal fistulas, however often the results are rather disappointing. Interposition of healthy, well vascularized tissue may be the key to rectovaginal fistula healing. The present study was aimed at evaluating the outcome of puborectal sling interposition in the treatment of rectovaginal fistulas.MethodsBetween 2001 and 2004, 26 consecutive patients (median age, 40.5 years; range, 15–69 years) with a rectovaginal fistula underwent a puborectal sling interposition. The etiology of the fistulas was: obstetric injury (n=11), complications after prior surgery (n=2), bartholinitis (n=4), cryptoglandular perineal abscess (n=2), inflammatory bowel disease (n=2) and idiopathic causes (n=5). The patients received a questionnaire about fecal continence (before and after surgery) and dyspareunia (after surgery).ResultsThe median follow-up was 14 months. The recto-vaginal fistula healed in 16 (62%) of 26 patients. In patients who had undergone one or more previous repairs, the healing rate was only 31% versus 92% in patients without previous repairs (p<0.01). The median Rockwood fecal incontinence severity index score did not change as a result of the surgery. Seventeen percent of patients experienced painful intercourse before the operation; after the procedure this problem was encountered by 57% of the patients.ConclusionsThe puborectal sling interposition is only successful in patients without previous repairs and in those with an uneventful postoperative course, however dyspareunia is a major drawback of this procedure.

Required length of follow‐up after transanal advancement flap repair of high transsphincteric fistulas

Objective  Repair of high perianal fistulas presents a major surgical challenge. Transanal advancement flap repair (TAFR) provides a useful tool in the treatment of these fistulas. Initially promising results have been reported. More recent studies indicate that TAFR fails in one out of three patients. The aim of the present study was to determine the appropriate length of follow‐up needed to assess the healing rate after TAFR of high transsphincteric fistulas.

Anterior sphincteroplasty for fecal incontinence: is the outcome compromised in patients with associated pelvic floor injury?

INTRODUCTION: It has been shown that vaginal delivery may result not only in sphincter defects, but also in pelvic floor injury. However, the influence of this type of injury on the etiology of fecal incontinence and its treatment is unknown. The present study was aimed to assess the prevalence of pelvic floor injury in patients who underwent anterior sphincteroplasty for the treatment of fecal incontinence and to determine the impact of this type of injury on the outcome of this procedure. METHODS: Women who underwent anterior sphincteroplasty in the past were invited to participate in the present study. With transperineal ultrasound, which has been developed recently, pelvic floor integrity was examined in 70 of 117 patients (60%). Follow-up was obtained from a standardized questionnaire. RESULTS: The median time period between anterior sphincteroplasty and the current assessment was 106 (range, 15–211) months. Pelvic floor injury was diagnosed in 43 patients (61%). Despite the prior sphincteroplasty, an external anal sphincter defect was found in 20 patients (29%). Outcome did not differ, neither between patients with and those without pelvic floor injury, nor between patients with and those without an adequate repair. However, patients with an adequate repair and an intact pelvic floor did have a better outcome than patients with one or both abnormalities. CONCLUSION: The majority of female patients with incontinence who were eligible for anterior sphincteroplasty have concomitant pelvic floor injury. Based on the present study, it seems unlikely that this type of injury itself has an impact on the outcome of anterior sphincteroplasty.

Rectocele repair by anterolateral rectopexy: long-term functional outcome

Introduction  Rectoceles are frequently associated with feelings of pelvic discomfort and symptoms of obstructed defaecation (OD). Repair by a transvaginal or transanal approach might result in de novo dyspareunia in up to approximately 40% of the cases. This study was designed to investigate whether anterolateral rectopexy provides an adequate rectocele repair without dyspareunia as a side effect.

OC261: Comparison of defecography and 3D/4D translabial ultrasound in patients with pelvic organ prolapse and/or evacuation disorders

Objectives: Magnetic resonance imaging (MRI) is the gold standard for the investigation of pelvic floor anatomy and function. The objective of this study was to compare biometric measures obtained by 3D ultrasound and MRI. Methods: In this prospective study, translabial 3D ultrasound and multiplanar MRI were used to assess pelvic floor anatomy in 27 nulliparous female volunteers. 3D ultrasound was performed using a GE Kretz Voluson 730/730 Expert system; MR images were obtained using a Siemens MAGNETOM Avanto 1.5-T scanner. All subjects were imaged supine and after voiding for both modalities. Data were acquired at rest, on pelvic floor muscle contraction and on maximal Valsalva. Results: All subjects were asymptomatic for pelvic floor dysfunction. Mean age was 29.3 (21–41) years, mean body mass index was 22.4 (18–29). Measures of hiatal diameters and areas obtained on MRI and 3D ultrasound were distributed normally. Sagittal hiatal diameters correlated at r = 0.533, P = 0.005 at rest, with ranges of 3.8–6.0 cm for MRI and 3.9–5.7 cm for ultrasound. On Valsalva, these figures were r = 0.658, P < 0.001, with ranges of 2.9–8.0 cm on MRI and 3.7–7.3 cm on ultrasound. On pelvic floor muscle contraction, the correlation was r = 0.503, P = 0.01 with ranges of 3.0–5.9 cm on MRI and 3.1–4.7 cm on ultrasound. As regards area measurements, correlations were r = 0.648 at rest and r = 0.542 on Valsalva (P < 0.01). Ranges were 9.1–18.1 on MRI vs. 9.2–17.8 on ultrasound at rest and 6.53–36.5 cm2 on MRI vs. 10.7–27.9 cm2 on ultrasound on Valsalva. There was a tendency for larger MRI measurements on Valsalva (P < 0.01 for area and midsagittal diameter). Repeatability measures were good to excellent for both methods. Conclusions: In this study of 3D ultrasound and MRI of the levator hiatus, correlations between methods were moderate but highly significant. MRI seemed to yield higher measurements on Valsalva, suggesting difficulties in identifying the plane of minimal dimensions during maneuvers that led to displacement of this plane.