Functional and sexual outcomes following surgical vaginal introital reduction

OBJECTIVE

Surgical introital reduction procedures are commonly performed for the treatment of vaginal laxity (VL), yet poorly studied. The aim of this study was to assess clinical outcomes following surgical vaginal introital reduction for VL.

METHODS

This was an ambidirectional cohort study conducted in a single urogynecology center. All sexually active women who had vaginal introital surgical reduction for VL between March 2015 and September 2020 were included in this study. VL was defined as a genital hiatus distance ≥4cm according to the POP-Q classification, associated with symptoms of laxity. The primary endpoint was sexual health assessed by the Pelvi-Perineal Surgery Sexuality Questionnaire (PPSSQ), while the secondary endpoints included postoperative pain, perioperative complications, rate of dyspareunia, patient satisfaction and success rate based on the Patient Global Improvement Index (PGI-I) and Vaginal Laxity Questionnaire (VLQ).

RESULTS

Of the 27 patients sent the questionnaires, 23 sexually active patients returned the completed ones and were included in the study. Participants had a mean age and BMI of 41 years (range 24-74) and 21.3 (range 17.6-31.9) respectively. The most prevalent preoperative symptom was feeling of VL in 82.6% followed by bulging sensation in 47.8%. Preoperative dyspareunia was reported in 8/23 (34.8%). Surgical interventions involved perineorrhaphy with (n=14) or without (n=9) levator ani plication. The PPSSQ mean sexual health score was 86.7/100 (SD 5.8; range 16.7-93.3) and the mean discomfort and pain score was 27.5/100 (SD 26.0; range 0-80). Postoperative sexuality was reported to better, identical or worse in 16 (69.6%), 2 (8.7%) and 5 (21.7%) patients respectively. On PGI-I, patients reported feeling much better, better, slightly better and no change in 10 (43.5%), 5 (21.7%), 5 (21.7%) and 3 (13.0%) respectively. None of the women reported feeling worse. The overall post-operative complication rate was 3/23 (13.0%), including a perineal hematoma, and two cases of reoperation for narrow introitus. De novo dyspareunia was reported by 11/18 (61.1%) patients, occurring often or more in 4/18 (22.2%) patients, due to narrow introitus (n=2), enlarge introitus (n=1) and vaginal dryness (n=1).

CONCLUSION

Vaginal introital reduction surgery is a viable treatment option for symptoms of vaginal laxity after failure of conservative measures. However, patients should be made aware of the risk of de novo dyspareunia.

LEVEL OF EVIDENCE: 4

Does Rectocele Repair Combined with Other Perineal Surgeries Affect Outcome Compared to Solo Rectocele Repair?

OBJECTIVES

Rectocele is common in female patients. To date, there is no literature comparing outcomes of rectocele repairs in combination with other perineal surgeries. We aim to analyze perioperative morbidity and mortality as well as long-term outcome of rectocele repair in combination with other perineal surgeries (RR combination) and compare this with solo rectocele repair (solo RR).

DESIGN

The type of study was case-control. Data of patients who received solo rectocele repair or rectocele repair in combination with other perineal surgeries between January 2011 and December 2015 were identified and reviewed in a prospectively maintained and IRB-approved database. Ninety-eight patients were included, including 41 patients in the solo RR group and 57 patients in the RR combination group. The demographics, characteristics of patients, short-term complications, long-term complications, and morbidity of the 2 groups were observed.

METHODS

The demographics, characteristics of patients, short-term complications, long-term complications, and morbidity of the 2 groups were compared, respectively. Covariate adjustment was analyzed by multivariate logistic and Cox regression analysis.

RESULTS

Ninety-eight patients with a median age of 57 were included, involving 41 patients in the solo RR group and 57 patients in the RR combination group. Other than the operative approach (p < 0.01), demographics and preoperative characteristics of the 2 groups were comparable. All variables, including length of stay, estimated blood loss, self-limiting rectal bleeding, transfusion, urinary retention, rectal stricture, rectal and perineal infection, rectovaginal abscess, reoperation, effective resolution of obstructive defecation symptoms, residual symptoms rate, and recurrence rate, were comparable among the 2 groups except for operative time (p = 0.03).

LIMITATIONS

This study is a single-center study, which may cause bias. In addition, the sample size is limited. Staging of rectocele and routine imaging studies were not performed.

CONCLUSIONS

Rectocele repair in combination with other perineal surgeries is feasible, and outcomes are comparable with solo rectocele repair. Transanal versus transvaginal repairs appear to have no influence on outcomes.

The Thiel cadaveric model for pelvic floor surgery: Best rated in transferable simulation-based training for postgraduate studies

OBJECTIVE

To determine whether the Thiel cadaveric model is better and more realistic than other surgical simulation techniques for learning pelvic floor and perineal surgical procedures according to the opinions of urogynecologists and surgeons participating in international postgraduate pelvic floor surgery courses using cadavers embalmed by the Thiel method.

STUDY DESIGN

An observational prospective study was performed in urogynecologists and surgeons attending international postgraduate pelvic floor and perineal surgery courses using cadavers embalmed by the Thiel method. A survey was completed by the participants after finishing the course. Based on the answers collected, we analyzed the differences, including in the satisfaction degree and teaching level for each surgical procedure, between different surgical simulation models that the participants had already used and the Thiel simulation method employed.

RESULTS

The students recognized that Thiel cadavers present more similarities to patients than other simulation methods. The Thiel cadaveric method was considered by most responders to be the best for the simulation of surgical procedures on the pelvic floor and perineum. Most of the surgeons surveyed recommended conducting these courses with Thiel cadavers for different colleagues in other specialties as a reliable simulation method for training for difficult surgical procedures.

CONCLUSIONS

Participants in the course on pelvic floor surgery in Thiel cadavers recognized that this is the most realistic model for surgical simulation and the best way to gain confidence, self-determination and precise surgical skills for performing pelvic floor and perineal surgery.

Perianal minimally invasive surgery (PAMIS) for rectal stump resection after previous colectomy

PURPOSE

Resection of a long rectal stump after previous colectomy or Hartmann procedure often requires a combined transperitoneal and transperineal approach because of limited access through a perineal incision alone. Risks associated with this procedure include iatrogenic injury to bowels, nerves, ureters, vessels and sexual organs. This study reports on the feasibility and safety of perianal minimally invasive surgery (PAMIS) for the resection of long rectal stumps that would otherwise require a combined transperitoneal and perianal approach.

METHODS

PAMIS utilizes standard laparoscopic equipment and a single access port to dissect the rectal stump following the mesorectal fascia into the pelvis after excision of the anal canal. Three PAMIS procedures were performed between February and April 2016. Feasibility, safety and outcome were analysed.

RESULTS

Three patients with previous colectomy and ostomy creation due to colitis ulcerosa (n = 2) and idiopathic enteropathy (n = 1) underwent PAMIS. The rectal stump length ranged between 10 and 19 cm. The median postoperative length of stay was 9 (range 6 to 11) days and the median operating time was 90 (range 80 to 120) min. There were no perioperative complications.

CONCLUSION

PAMIS is a feasible, safe and efficient procedure for rectal stump resection avoiding the transperitoneal approach for pelvic dissection.

Anterior perineal fistulectomy in repairing H-type rectovestibular fistula with a normal anus in female children

The purpose of this study was to review a 7-year operative experience of anterior perineal fistulectomy in repairing H-type rectovestibular fistula with a normal anus in female children. From January 2007 to December 2013, 105 female children with H-type rectovestibular fistula and a normal anus underwent anterior perineal fistulectomy in the Department of General Surgery, Beijing Children's Hospital, Capital Medical University. Clinical data were retrospectively analyzed. Patients' age ranged from 6 months to 13 years 10 months, with an average age 5 years 2 months. The clinical feature of this disease was a definite history of vestibular infection at about 30 days after birth and leakage of gas or loose stool through vestibular fistular orifice after the infection was controlled. All patients had a normal anus. Follow-up through telephone or outpatient visits from 6 months to 7 years (median, 5.2 years), showed that all the patients were continent and had regular bowel movements. Among the 105 patients, 97 (92.4%) gained primary healing with a satisfactory appearance; 8 (7.6%) patients relapsed, among which 5 healed after hip bathing treatment within 3 weeks, 2 required another anterior perineal fistulectomy 7 months later and were cured, and the last one had another anterior perineal fistulectomy 1 year 10 months later but relapsed again, which healed after hip bathing treatment within 3weeks after the second surgery. Anterior perineal fistulectomy is a simple, safe and reliable surgical method to treat H-type rectovestibular fistula with a normal anus.