Pelvic Floor Dysfunction (PFD), called Pelvic Floor Defects (PelvicFloorDe-Feets) or Relaxati-onofPelvicSupports, is a common and frequent disease in middle-aged and elderly women, with an incidence of about 40%, The number of cases increases with each year, which seriously affects the quality of life and physical and mental health of patients.
First, the classification of female pelvic floor dysfunctional diseases
1, stress urinary incontinence (SUI): stress urinary incontinence refers to the state of involuntary flow of urine when the abdominal pressure increases (such as: coughing, sneezing, laughing, exercise, etc.). Urinary incontinence affects the quality of life of patients, making many elderly people unable to take care of themselves and causing great stress to families. Beijing, Guangzhou and other places in China reported that the prevalence of female incontinence is 18.1% to 57.5%, up to 50% of postmenopausal women, becoming one of the most common chronic diseases threatening women’s health.
2, pelvic organ prolapse (POP): pelvic organ prolapse includes anterior vaginal wall prolapse, uterine prolapse, vaginal vault prolapse, posterior vaginal wall prolapse, rectal prolapse, etc.. Uterine prolapse is a common gynecological disease. According to statistics, the majority of uterine prolapse occurs in married women who have given birth, but it is also occasionally seen in unmarried people. Prolapse occurs most often at the age of 40 to 60. In rural areas of China, it is one of the diseases closely related to maternal health and quality of obstetrics. With the increase of human life expectancy, uterine prolapse is not uncommon in large and medium-sized cities.
II. Surgical approaches to female pelvic floor dysfunctional disorders
The traditional surgical treatment of pelvic floor dysfunctional diseases has been available for a long time and is widely carried out in domestic hospitals. In recent years, with the continuous development and updating of medical materials and surgical equipment, new treatment methods have emerged. At the same time, due to the continuous improvement of people’s living standards, new requirements for medical services, many of the traditional conservative treatment of pelvic floor diseases such as stress urinary incontinence more surgical treatment, and has achieved good results. The existing surgical modalities can be broadly divided into the following.
1, urogenital diaphragmatic plasty: including anterior vaginal wall repair, urethral folding, etc.
2.Postpubic urethral fixation suspension: including MMK (Marshall-Marchetti-Krantz procedure) which fixes the paraurethral tissues in the pubic symphysis and Burch procedure which fixes the paraurethral tissues in Cooper’s ligament.
3, Needle suspension: including Peregra, Stamey, Gittes and Raz.
4, lower urethral suspension: including fascial suspension (AlbridgeStuddiford procedure and MilliaRead procedure) and composite medical material sling procedure. With the development of modern biotechnology, the material of the sling has been greatly improved, which has revolutionized urinary incontinence surgery, and various minimally invasive procedures have emerged, such as vaginal tension-free urethral suspension (TVT), transvaginal urethral suspension (IVS), suprapubic tension-free suspension belt (SPARC), transconjunctival urethral suspension (TOT), reverse transconjunctival urethral suspension (TVT- O), etc.
5. Procedures for female pelvic organ prolapse include: anterior-posterior vaginal wall repair, anterior-posterior vaginal wall repair and hysterectomy, transvaginal hysterectomy with vaginal wall repair, vaginal closure, transvaginal anal levator suture, posterior fornixoplasty, secondary (total) hysterectomy with suspension, posterior transvaginal suspension belt, modified posterior transvaginal wall suspension, PRO-LIFT pelvic floor repair device and polypropylene mesh total pelvic floor suspension, etc.
In addition, periurethral bulkingagents are also used as a conservative procedure in clinical practice.
Common surgical complications
There are many kinds of pelvic floor reconstruction surgeries, and along with the emergence of various new surgeries and new materials, inevitable surgical complications have become a major obstacle to the promotion of many new surgical methods. In clinical practice, there are still many issues to be explored in the prevention and management of complications. Common surgical complications and preventive measures include.
1. efficacy-related complications: the treatment effect after surgery differs too much from the treatment expected before surgery or brings new problems due to surgery, such as ineffective or insignificant results after surgery for stress urinary incontinence, or causes urinary retention or difficulty in urination.
Postoperative dysuria is one of the most common complications of stress urinary incontinence surgery, and the incidence of urinary retention is about 10%. In order to reduce its occurrence, the following points must be noted before surgery: (1) pay attention to the special history of preoperative urinary difficulties and urodynamic examination, such as preoperative history of incomplete urination, drenching, interrupted and delayed urination, and even urinary retention, etc., and vulvovaginal atrophy in the physical examination, which is prone to urinary disorders after surgery, should be given great attention, and should not only pay attention to the symptoms of stress urinary incontinence and ignore the other medical history. Preoperative urodynamic interrogation for stress urinary incontinence is important, especially urinary flow rate, filling phase forceps activity, forceps pressure and residual urine determination are involved in the assessment of surgical prognosis. (2) Those with preoperative instability of the forceps, high forceps pressure, reduced urinary flow rate (<25 ml/s), and positive residual urine (>80 ml) are prone to postoperative voiding disorders, so urethral suspension should be chosen with caution, and the tension of suspension should be controlled during surgery, and should not be suspended too tightly. Sometimes the decrease in urinary flow rate may also occur in cases of overfilled bladder, reduced urine volume and suppressed urination, and attention should be paid to the difference. (3) For patients who already have voiding disorders, in addition to detailed medical history and performing physical examination and urodynamic examination, they should be recorded in detail in the medical record, talk fully before surgery and sign an informed consent form so that patients can be fully prepared for possible postoperative problems, even including learning to self-catheterize in case of postoperative.
If urinary disorders occur after surgery, different measures should be taken according to their severity. Mild postoperative voiding disorders are mainly caused by intraoperative bladder urethra edema, spasm, infection, etc.; some may be caused by a slight preoperative weakening of the forceps muscle, and due to the increased resistance of the urethra after surgery, the function of the forceps muscle to overcome urethral resistance needs to be established over a period of time. These symptoms of voiding disorders are mostly transient and can be recovered in about a month, and do not require special treatment, and can be treated symptomatically with anti-inflammatory and antispasmodic drugs as well as physical therapy. When urinary retention occurs after surgery, suprapubic cystostomy drainage is recommended to help reduce urethral edema, shorten the time from catheterization to detachment, and also facilitate observation of recovery of voiding function and assessment of residual urine. The literature reports that cholinergic receptor agonists such as carbachol, urocholine, and bronstimine may be used to increase contraction of the detrusor muscle and improve urinary retention. In severe postoperative dyspareunia and urinary retention, which have failed with conservative treatment, transvaginal sling release can be performed by partial cut and lengthening of the sling, complete cut, and release of periurethral scar and adhesions. In some cases, the incontinence recurs after the release, but in some cases, the sling is cut completely and the incontinence does not recur after the operation, and the scar that may be formed has some therapeutic effect. Cystoscopy and urethroscopy should be performed prior to release surgery to clarify the cause of obstruction and the site of obstructive stricture.
Other complications of stress urinary incontinence surgery, such as pelvic floor muscle exercises for those with too loose a suspension can help improve symptoms; excessive bladder activity occurs several months after surgery, tolterodine tartrate and electrical stimulation of the pelvic floor muscle can improve symptoms; postoperative incontinence, instability of the forced urinary muscle is its common cause, in addition to cystometry and other tests, cystoscopy should be performed to understand the position and movement of the bladder neck The cystoscopy should be performed to understand the position and movement of the bladder neck in addition to cystometry and other tests. A few recurrences are due to urethral instability, mostly due to retropubic hemorrhage, hematoma, hematoma mechanization, and fibrosis, resulting in urethral wall stiffness and incomplete sphincter closure. In addition, the experience and skill of the surgeon is important and should usually be operated by a trained and experienced surgeon, which is the key to reducing complications and ensuring a successful operation.
Common complications after uterine prolapse and anterior and posterior vaginal wall bulge repair include postoperative vaginal hypertightness, difficulty with intercourse, pain, and postoperative recurrence. A comprehensive assessment of pelvic floor problems is required before surgery, and a comprehensive surgical plan should be used to solve the problem in one operation if possible, while avoiding new anatomical and functional problems or discomfort caused by the surgery. Patients who complain of vaginal tightness, pain, lower abdominal cramps, etc. should consider whether to repair the problem surgically, whether there is local infection, whether there is leaching of the implant material, whether the patient is psychologically healthy, etc., and deal with the specific situation accordingly.
2, organ damage complications: the surgical treatment of pelvic floor dysfunctional diseases is mainly vaginal surgery, due to the small surgical field of view, most cases are non-direct vision surgery, and most rely on special surgical equipment, such as improper operation, often can cause organ damage, such as common bladder, urethra, vascular, nerve, intestinal injury of. The literature reports that the incidence of bladder perforation is 3.8% to 10.0%, urethral injury is 0.07%, retropubic hematoma is 1.9% to 3.0%, large vessel injury is 0.01% to 0.07%, intestinal injury is 0.007%, and the above injuries require caesarean section in about 0.3% of cases. The majority of these injuries can be solved by conservative or local surgical repair. The procedure of middle and posterior surgery is improving faster, and the one with more accumulated medical records is posterior IVS. Other procedures are reported more frequently, but it is difficult to see large samples of reported data, especially the occurrence of complications of transcatheter surgery, rectal injury is one of the more serious complications of posterior surgery injury, and there are also pararectal gap hematoma, vulvar nerve injury, etc.
Familiarity with the local anatomy of the pelvic floor, proper placement of surgical positions, and necessary surgical techniques are the main measures to prevent the occurrence of organ injuries. The occurrence of surgical injuries is difficult to avoid completely, but the key is to detect and deal with them in a timely manner, mostly with a perfect outcome. If hematuria occurs during surgery especially after puncture, or if there is a large amount of fluid leakage from the trauma, or if the patient shows severe symptoms of vagal excitation such as slowed heart rate and lowered blood pressure, bladder perforation or injury should be considered, and timely cystoscopy can help confirm the diagnosis. Bladder injury can be healed, generally can be conservative treatment, do not need to repair, retain a catheter for at least seven days, the application of antibiotics to prevent infection. Urethral injuries require more help from a urologist. Vascular injuries are less common, but large vessel injuries can be fatal and have been reported in the literature, requiring open abdominal treatment in emergencies, and vascular interventional embolization is also feasible. Small retropubic and pararectal interstitial hematomas can be observed, with appropriate use of hemostatic drugs and local compression to stop bleeding. Intestinal injuries must be repaired to avoid serious consequences. Nerve injuries caused by puncture are mostly blunt injuries, rarely disconnected injuries, and corresponding symptoms may occur after surgery, but they are mostly reversible. In recent years, there has been an increase in closed-hole surgery that relies on closed-hole as the suspension force point in anterior surgery, and its bony suspension is more reliable than previous soft tissue surgery in terms of efficacy, which is the development direction of pelvic floor suspension surgery, and the injury and consequences caused by closed-hole perforation are still under close observation.
3, material compatibility complications: new methods of surgical treatment of pelvic floor dysfunctional diseases are mostly related to medical implant materials, which are mostly synthetic polypropylene chemical materials in addition to very few biological materials, such materials are used in human tissue compatibility is very good, but due to differences in material processing, weaving methods and mesh size, can cause rejection and other reactions in some patients. Rejection usually occurs 3-6 months after surgery. Rejection is manifested as the implanted mesh penetrates the mucosa, and there is a gap between the mesh and the surrounding group, which cannot be fused with human tissue. On examination, local bleeding, polyp formation and mesh are seen. The only treatment is removal of the mesh. Exposure is the exposure of the mesh outside the vaginal mucosa, the part under the mucosa is compatible with the tissue, no polyp usually grows around the exposed part, and a round or oval pit forms in the surrounding mucosa, mostly without infection. The reasons for the formation are related to the type of material, thin separation of the vaginal wall, excessive tension in the vaginal wall suture, and malnutrition of the patient, or the exposure may have already occurred during surgical puncture. When there is no infection, there are mostly no clinical symptoms and it can be left untreated. If the mesh enters in the direction of the mucosal surface of the tissues and organs, symptoms of impaction may occur when the mesh penetrates, such as repeated hematuria in the bladder section and blood in the stool and irritation of the bowel when the mesh impaction reaches the rectum. Once the diagnosis is confirmed, the mesh should be removed and the need for repair should be determined on a case-by-case basis to avoid genital fistula.
4. Infection-related complications: Infection can easily occur when the implanted mesh is incompatible with the tissue and forms an abscess cavity along the week of the mesh, which repeatedly persists and forms a sinus tract, with symptoms such as chronic bleeding and increased secretions, and fever when drainage is poor. In clinical management, antibiotics and local cleaning and disinfection should be actively used for a short period of time, and the mesh should be removed after treatment is ineffective and repeatedly occurs, and can be cured after adequate drainage.
5, complications caused by other diseases: pelvic dysfunctional disease patients are mostly middle-aged and elderly women, many patients with serious medical and surgical diseases, such as hypertension, heart disease, liver and kidney disease, diabetes mellitus, etc., perioperative period is very prone to life-threatening adverse consequences, because medical and surgical diseases before and after the operation of the literature reported more accidents, pelvic dysfunctional disease itself is not critical to the lives of patients, the operation of The purpose is only to improve the patient’s quality of life. When there are serious medical and surgical diseases that are not under control, surgical risk assessment is performed before individualized surgical plans are developed, and if not, it is recommended to suspend surgery.
There have been breakthroughs in pelvic floor repair and reconstructive surgery in recent years and treatment outcomes are improving, but the optimal surgical protocol for pelvic floor reconstructive surgery is still a topic to be explored and researched by modern surgeons engaged in pelvic floor reconstructive surgery. Some instruments suitable for vaginal or pelvic floor surgery also need to be improved to solve the confusion of surgery in this area. There are still many difficulties in the treatment of pelvic organ prolapse, which require the joint efforts of multidisciplinary surgeons to continuously improve the treatment results, increase the success rate and reduce the complications of surgery.