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TFS repair of rectocele. The TFS sling restores the anatomy of the posterior vaginal wall by shortening the uterosacral (USL) ligaments and fascia, and re-approximating the laterally displaced perineal body (PB).
Source publication
The Integral System is a total care management system based on the Integral Theory which states 'prolapse and symptoms of urinary stress, urge, abnormal bowel & bladder emptying, and some forms of pelvic pain, mainly arise, for different reasons, from laxity in the vagina or its supporting ligaments, a result of altered connective tissue'.
The orga...
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Purpose
Provoked vulvodynia (PV) is the most common cause of vulvar pain and dyspareunia. Although its etiology is unknown, it has been associated with musculoskeletal dysfunction. The inability of the lax uterosacral ligaments (USLs) to support the adjoining T11/L2 and S2-4 nerve plexuses is considered to cause PV. This study aimed to determine wh...
Citations
... Stress urinary incontinence (SUI) is an involuntary loss of urine that occurs due to an increase in intra-abdominal pressure, which can be caused by a slight or vigorous movement or physical effort, such as laughing, coughing, sneezing, and running [1]. Stress urinary incontinence (SUI) can have various underlying etiologies, including inadequate pelvic organ support, alterations in the urethral closure mechanism, or a prolapse of the anterior vaginal wall [2,3]. According to the current guidelines, the first step in the treatment of SUI, especially in situations where there is no evidence of internal urethral sphincter insufficiency, is pelvic floor muscle training (PFMT), broadly defined as urogynecological rehabilitation with lifestyle changes [4]. ...
Background: Stress urinary incontinence (SUI) causes both physical and psychological problems to women and their partners. Recently, vaginal radiofrequency (RF) application, as well as the administration of non-crosslinked hyaluronic acid (NCLHA) together with calcium hydroxyapatite (CaHA), has attracted attention for SUI treatment. The current, comparative study evaluated the efficacy and safety of these technologies acting separately and in a combined treatment. Methods: Sixty women with mild to moderate SUI, aged between 46 and 76 years (mean age 63.2) were divided into three groups intended for different treatments: group I, RF vaginal treatment only, group II, NCLHA plus CaHA periurethral injection only, group III, combined treatment including a single periurethral injection of NCLHA plus CaHA followed by four vaginal applications of RF at intervals of 3–5 days. The clinical effects of the treatments were evaluated by ICIQ-LUTSqol (Polish version) and UDI-6. Results: The obtained results suggest that the symptoms of SUI and the quality of life of the patients improved significantly in each group after the therapies compared to the pre-treatment levels and were more persistent in the third HA + RF group compared to the HA or the RF group.
... In addition to the similar results of machine reference analysis, four different new results are found based on the current research progress and the results of manual analysis. First, the fine diagnosis of three cavities and three levels is the basis for effective treatment (Petros, 2011;Chen et al., 2021); Second, imaging research may be one of the important directions to overcome mesh complications (Gavlin et al., 2020;Mahoney et al., 2020;Ram et al., 2021); Third, clinical research is an effective method to find answers to clinical questions, especially the clinical prediction model based on real world data (Barber and Maher, 2013;Weber LeBrun et al., 2018;Morcos et al., 2021); Finally, the new direction of tissue engineering technology and pelvic floor research is worthy of our expectation and further exploration (Hennes et al., 2021;Laursen et al., 2022). To our knowledge, this is the first in-depth bibliometric analysis of pelvic floor mesh surgery, there are several limitations that need to be explained. ...
Aims: In recent decades, extensive attention has been paid to the application of mesh to repair pelvic floor defects. However, a large body of related literature has not been system summarized. The purpose of this study is to summarize and visualize the literature on pelvic organ prolapse (POP) repair with mesh using bibliometrics.
Methods: Medical literature regarding POP repair with mesh were searched and obtained in the Web of Science™ Core (WoSCC) database from 2001 to 2021. Microsoft Excel 2020, CiteSpace and VOSviewer were used to conduct the bibliometric and knowledge-map analysis.
Results: In the past 20 years, a total of 2,550 articles and reviews have been published in 35 journals, and the published and cited results show a growing trend. Cosson M and International Urogynecology Journal were the authors and journals with the highest output, respectively. The United States, France and the United Kingdom are among the top three countries/organizations in relevant publications in worldwide. 584 key words in the literature are divided into 8 clusters, which are mainly related to prolapse type, risk factors, surgical methods, imaging, quality of life and bioengineering. Using clinical research and tissue engineering technology to reduce mesh complications is the current hot spot in this field.
Conclusion: Reasonable application of mesh and avoiding mesh complications are still the most concerned topics in POP research. Although clinical research, surgical improvement, biological mesh and bioengineering technology have shown promising results, it is still urgent to carry out clinical transformation application research.
... SUI has a strong negative impact on the psychological, social, relational, and health condition of patients [2]. The aetiology of SUI can depend on multiple factors, such as an insufficient support of the pelvic organs, change in the intrinsic urethral closure mechanism, or a suspension of the anterior vaginal wall [3,4]. Conservative options include pelvic floor exercises and biofeedback. ...
Background and Objectives: This retrospective study investigates the action of a bipolar, temperature controlled, endovaginal RF handpiece for the treatment of mild, moderate, and severe stress urinary incontinence with a minimally invasive approach. Stress urinary incontinence (SUI) is a common condition resulting in involuntary urine leakage, with an associated social and psychological impact. SUI is the most common type of urinary incontinence in women. Materials and Methods: We retrospectively studied 54 patients for this study. The bipolar radiofrequency energy used in all patients was 50 W, with temperatures maintained between 41 °C and 44 °C. Two sessions were performed four weeks apart. In order to monitor all patients before the first treatment and 4 months after the second treatment, the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) was used. Paired Student’s t test was used to elaborate the statistical data. Results: The average frequency of urine leak improved from “2–3 times a week” (2.1 ± 1.3 points before the treatment) to “once a week” (0.8 ± 1.3 points 4 MFU post-treatment). The average volume improved from “small/moderate quantity” (3.2 ± 1.6 points before the treatment) to “none” (0.9 ± 1.4 points 4 MFU post-treatment). No adverse events or side effects were found. Conclusion: Our preliminary results represent a good starting point to check the effectiveness and validity of the bipolar radiofrequency temperature-controlled method in the treatment of SUI.
... Petros's integral theory/system [7][8][9][10] proposes that the shared origin of PFDs does not originate at the musculature, but instead with the loss of connective tissue integrity due to the same repetitive intraabdominal mechanical stresses highlighted by De Lancey and Ashton-Miller: elevated body mass index, hysterectomy, vaginal birth, increased parity, etc. [7,8]. The result is an increase in vaginal and ligament laxity [9]. ...
... The result is an increase in vaginal and ligament laxity [9]. Without strong, supportive connective tissue for pelvic floor muscles to contract against, the muscles are weakened and provide insufficient force to counter increased intraabdominal pressure [10]. The main evidence to support this theory are successful surgical interventions that aim to recreate the supporting role of the connective tissue without intervening on the muscle [9,11]. ...
Pelvic floor disorders (PFDs) will affect most women during their lifetime. Sequelae such as pelvic organ prolapse, stress urinary incontinence, chronic pain and dyspareunia significantly impact overall quality of life. Interventions to manage or eliminate symptoms from PFDs aim to restore support of the pelvic floor. Pessaries have been used to mechanically counteract PFDs for thousands of years, but do not offer a cure. By contrast, surgically implanted grafts or mesh offer patients a more permanent resolution but have been in wide use within the pelvis for less than 30 years. In this perspective review, we provide an overview of the main theories underpinning PFD pathogenesis and the animal models used to investigate it. We highlight the clinical outcomes of mesh and grafts before exploring studies performed to elucidate tissue level effects and bioengineering considerations. Considering recent turmoil surrounding transvaginal mesh, the role of pessaries, an impermanent method, is examined as a means to address patients with PFDs.
... Additional support to the uterus comes from the broad (round and ovarian) ligament. Together, these suspensory structures hold the uterus and upper vagina in proper positions over the levator plate: damage or weakness in this complex may result in abnormal bladder emptying and uterine prolapse (Petros [240] vagina dorso-ventrally between the bladder and the rectum. Superiorly, it is continuous with the downward reflections of the paracolpium that changes its configuration and forms a direct lateral attachments of the mid third of the vagina to the pelvic side walls at levator and fascial arches, ATFP anteriorly and ATFR posteriorly. ...
Female pelvic floor dysfunctions (PFDs) such as incontinence and prolapse are observed
in multiparous elderly females caused by denervation injuries during childbirth and progressive tissue remodeling after menopause. With continuously increasing average life
expectancy, these disorders have become an important public health issue that require high costs for the treatment and a standardized study. Minimally invasive surgery has become a more frequent repair procedure for which more than 20 million implants are implanted worldwide every year. However, serious postoperative mesh relative complications are reported.
This thesis reviews the static, functional and dynamic anatomy of the female pelvic floor.
A detail methodology to construct a realistic computer model from sheet plastination of
a female cadaver pelvic floor has been described. Based on the published literature and
multi-disciplinary communication with surgeons and urologist, a most complete form of
3D finite element (FE) model has been constructed, which considers smoothed NURBS
based surfaces for frictionless contacts between organs and internal self-contact of the
hollow organs. Further, an isotropic, hyperelastic, incompressible multiscale modeling of
the soft connective tissues is adopted. In addition, transversely isotropic and non-linear
Humphrey’s constitutive model has been implemented to describe the passive stretching
of the pelvic skeletal muscle without neural excitation. Similarly, for the experimented
surgical meshes with different pore characteristics and stress-strain curves, linearly elastic
orthotropic and non-linear hyperelastic models are fitted and used in the numerical study.
Various FE analyses are performed to investigate pathophysiological situations and surgical treatments using mesh implants to compare their biofunctionality and to optimize
the preferred surgery. Hence, the presented models and the modeling approaches included
in this thesis facilitate the work of surgeons and urologists by a biomechanical study of
female PFDs.
... Level I refers to the intermingling fibres of the cardinal/uterosacral ligament complex which attaches the upper vagina, cervix, and lower uterine segment to the obturator muscle/sacrum, piriformis, and coccygeus, respectively ( Figure 2). Laxity in this complex may result in abnormal bladder emptying and uterine prolapse [36]. Level II supports the middle one-half of the vagina to the levator ani muscles and provides a firm base for bladder neck and urethra. ...
... Petros [36] hypothesized that the backward pull of the levator plate from the muscle fibres during pelvic manoeuvres widens the levator hiatus and causes organ descent. In numerical studies, the ligaments, the levator plate, and the coccygeus muscles connected to the coccyx are completely constrained in all directions. ...
After menopause, decreased levels of estrogen and progesterone remodel the collagen of the soft tissues thereby reducing their stiffness. Stress urinary incontinence is associated with involuntary urine leakage due to pathological movement of the pelvic organs resulting from lax suspension system, fasciae, and ligaments. This study compares the changes in the orientation and position of the female pelvic organs due to weakened fasciae, ligaments, and their combined laxity. A mixture theory weighted by respective volume fraction of elastin-collagen fibre compound (5%), adipose tissue (85%), and smooth muscle (5%) is adopted to characterize the mechanical behaviour of the fascia. The load carrying response (other than the functional response to the pelvic organs) of each fascia component, pelvic organs, muscles, and ligaments are assumed to be isotropic, hyperelastic, and incompressible. Finite element simulations are conducted during Valsalva manoeuvre with weakened tissues modelled by reduced tissue stiffness. A significant dislocation of the urethrovesical junction is observed due to weakness of the fascia (13.89 mm) compared to the ligaments (5.47 mm). The dynamics of the pelvic floor observed in this study during Valsalva manoeuvre is associated with urethral-bladder hypermobility, greater levator plate angulation, and positive Q-tip test which are observed in incontinent females.
... The vertical arrows became asymmetric, which translated into a backward and downward displacement The increase in abdominal pressure with straining leads to an asymmetrical deformation of the bladder, and hence a downward and rearward displacement of the urine, as well as forward propulsion of the horizontal segment of the anterior vaginal walls (a downward and rearward tilt). This motion was visualized radiologically by placing clips and by opacification [4], and it is outlined in the various versions of the integral theory [5][6][7]. ...
An intravaginal device to prevent urinary incontinence was devised based on the notions of the ‘viscoelasticity of the anterior vaginal’ wall. As the anterior vaginal wall can be divided into segments with differing viscoelastic properties, this device is comprised of two parts: a rigid component to treat the urethral side, and a flexible ring-shaped component to exploit thee lastic properties of the anterior vaginal wall in its horizontal portion under the bladder. The resulting device has the potential to address each stage of bladder function in women: straining, bladder filling, and micturition. These specifications ensure that the device is effective and well tolerated by patients. This is hence a new therapeutic approach for the managementof female urinary incontinence. The high efficiency of the device is a validation of the physiological notion of differential viscoelastic properties of the pelvis (and the anterior vaginal wall) on either side of the vaginal cap.
... To develop numerical models of the pelvic system, research has concentrated on the anatomical structures easily identifiable with anatomical knowledge 10,11,29 and in medical images. 18,21,35 Such numerical models are improved by the introduction of structures that are not observable through medical imaging, such as fasciae and ligaments. ...
... Anatomical supporting structures such as ligaments and fasciae, which are not visible on the clinical images, are introduced in the 3D model in accordance with anatomic literature 10,11,29 and an iterative optimization process 23,30,35 in order to obtain numerical simulation in agreement with MRI-analysis of the displacement and strain fields. 18,21 We used digital image correlation to estimate the organ displacement fields. ...
The woman pelvic system involves multiple organs, muscles, ligaments, and fasciae where different pathologies may occur. Here we are most interested in abnormal mobility, often caused by complex and not fully understood mechanisms. Computer simulation and modeling using the finite element (FE) method are the tools helping to better understand the pathological mobility, but of course patient-specific models are required to make contribution to patient care. These models require a good representation of the pelvic system geometry, information on the material properties, boundary conditions and loading. In this contribution we focus on the relative influence of the inaccuracies in geometry description and of uncertainty of patient-specific material properties of soft connective tissues. We conducted a comparative study using several constitutive behavior laws and variations in geometry description resulting from the imprecision of clinical imaging and image analysis. We find that geometry seems to have the dominant effect on the pelvic organ mobility simulation results. Provided that proper finite deformation non-linear FE solution procedures are used, the influence of the functional form of the constitutive law might be for practical purposes negligible. These last findings confirm similar results from the fields of modeling neurosurgery and abdominal aortic aneurysms.
Background
Pelvic floor muscle training (PFMT) has emerged as a potential intervention to improve post–total hysterectomy (TH) sexual function. Electromyographic (EMG) biofeedback is an adjunct that may improve outcomes.
Aim
In this study we aimed to compare the EMG biofeedback–assisted PFMT and PFMT alone for improving sexual function in women after TH.
Methods
For this prospective study we enrolled women undergoing TH in our hospital between January 2022 and April 2023. Participants were divided according to the treatment they selected: EMG biofeedback–assisted PFMT or PFMT alone.
Outcomes
The primary study outcome was change in patient sexual function evaluated by use of the Female Sexual Function Index. Secondary outcomes were changes in anxiety and depression evaluated with the Hospital Anxiety and Depression Scale score and pelvic floor muscle strength was evaluated with the Glazer assessment performed from before to after treatment.
Results
A total of 73 patients were included, with 38 patients treated with Electromyographic biofeedback–assisted pelvic floor muscle training. After treatment, sexual function was significantly improved compared to baseline in all patients (all P < .001). Compared to patients with pelvic floor muscle training, the changes in total Female Sexual Function Index scores from before to after treatment in patients with Electromyographic biofeedback–assisted pelvic floor muscle training were significantly higher (all P < .05). There were no significant differences between the 2 groups in the changes in the Glazer score and Hospital Anxiety and Depression Scale scores from before to after treatment (both P > .05).
Clinical Translation
The results demonstrate that Electromyographic biofeedback–assisted pelvic floor muscle training may be used to improve the sexual function of patients following TH.
Strengths and Limitations
This study is limited by its single-center design, small sample size, lack of randomization, and absence of estrogen monitoring in enrolled participants.
Conclusions
Electromyographic biofeedback–assisted pelvic floor muscle training appears to be more effective than pelvic floor muscle training alone in improving sexual function among patients after total hysterectomy.
Introduction: Pelvic static disorders have a major impact on patients’ quality of life, constituting a real public health problem, despite the fact that they are not life-threatening. Pelvic static disorders are characterized by varying degrees of damage to the structures of the pelvic floor, which leads to the appearance of some anatomical-clinical entities, the most common of which are urinary incontinence and pelvic organ prolapse. There is no consensus regarding the optimal treatment of pelvic static disorders, reconstruction techniques being extremely numerous, from classic techniques, which use the patients’ own tissues to laparoscopic techniques and those using alloplastic materials
Methods: In the Surgery Clinic I of SCJU Constanța, 89 surgical interventions for the correction of uterine prolapse and 22 interventions for the correction of vaginal vault prolapse were performed on a group of 327 patients, using both reconstructive and obliterative surgical techniques
Results: The best anatomical success rate was achieved by performing laparoscopic colposuspension by the lateral suspension procedure, followed by laparoscopic sacrocolpopexy and colposuspension at the sacrospinous ligaments
Conclusions: Hystero/colposuspension is a lateral fixation procedure that fulfills the four major goals of surgical prolapse cure: reduction of prolapse, absence of functional symptoms, patient satisfaction, and avoidance of complications. The technique is simple, requires a short operative time with minimal operative trauma, rapid postoperative recovery with a high degree of satisfaction in terms of quality of life and early socio-professional integration of the patients.
