Perineal descent (PD) is a sign of connective tissue weakness of the pelvic floor, it can be measured mechanically or radiologically. Joint hypermobility can be a sign of a generalised connective tissue abnormality, there is an increased incidence of pelvic organ prolapse and faecal incontinence amongst patients with heritable connective tissues diseases. To explore the relevance of PD and the relationship between connective tissue abnormality and pelvic floor dysfunction five studies were performed.A new mechanical device for the measurement of PD, the laser commode, and the established mechanical device, the perineometer were compared to the current gold standard method of measurement, defaecating proctography in 68 subjects. The laser commode provided a mean overall PD measurement closer to that of proctography than the perineometer but the repeatability and reproducibility of the measurements were not accurate enough for the laser commode to be used either in the subsequent parts of this research project or in a clinical setting.Perineal descent was measured using proctography and joint hypermobility was measured using the Beighton score in 70 females with pelvic floor dysfunction. No correlation was found between PD and joint mobility.A review of 323 proctograms of females with pelvic floor dysfunction found an association between PD and rectal prolapse but no association between either PD and rectocele formation or PD and rectal intussusception. The Pelvic Floor Distress Inventory questionnaires of 133 females were correlated with their proctography findings. There was no association between PD and any of the clinical symptoms. Biopsies from the rectus sheath and pelvic floor fascia of 19 females with rectal prolapse were compared to those of 8 normal controls. There was no difference in collagen or elastin content between the groups but participant numbers were small. The pelvic floor fascia of the rectal prolapse group showed a higher percentage of well organised elastin than that of the control group but this did not reach statistical significance. Perineal descent does not appear to be a consistent indicator of severe pelvic floor connective tissue abnormality or injury. This study has furthered our understanding of perineal descent and the relationships between this finding and other pelvic floor disorders caused by connective tissue weakness. Future work will focus on further histological analysis of tissue from patients with rectal prolapse in combination with the use of more sensitive methods to establish the presence of an underlying connective tissue abnormality.

Diss. (sammanfattning) Stockholm : Karol. inst., 2005. / Härtill 5 uppsatser.

Abstract Rectal prolapse and internal rectal prolapse with symptoms of obstructed defecation and/or faecal incontinence are debilitating conditions. Often, symptoms coexist from other pelvic compartments, reducing quality of life. Robot-assisted surgery with its advanced features may offer better conditions in narrow pelvic space to correct rectal prolapses with rectopexy operation. In this thesis, we compared robot-assisted and laparoscopic techniques during the early learning curve in a ‘matched-pairs’ feasibility study (n = 30, follow-up three months) and in a prospective randomized series (n = 33, follow-up 24 months). The long-term functional results were assessed in a retrospective multicenter study with cross-sectional questionnaire assessment (n = 508, median follow-up 44 months). In the randomised series, as demonstrated with MR defecography, ventral rectopexy corrects the posterior compartment defects, external and internal rectal prolapses and recto-enteroceles. The operation restores the posterior and middle compartment anatomy and reduces pelvic organ mobility with a minor impact on the anterior compartment. Pelvic floor dysfunction and symptom-specific quality of life is improved after rectopexy; specifically, the colorectal-anal and the pelvic organ prolapse subscales in the questionnaires showed improvement. We found equality between robot-assisted rectopexy and laparoscopic rectopexy in most relevant outcome measures, which does not justify the added cost of the routine use of robots in rectopexy operations. The health-related quality of life and cost-utility analysis in our cohort indicated, however, that in long-term the technique may be cost-effective. The functional results are retained in the long term. The rate of recurrences (7.1%) and complications (10%) are acceptable and mesh-related complications (1.4%) are rare. Denovo symptoms, such as the urge to defecate or urinary incontinence, may arise, while urinary symptoms may be alleviated. In the long-run, patients with external rectal prolapse benefit more than patients with internal rectal prolapse. In part, the results of this thesis support using a multidisciplinary approach in examining patients with posterior pelvic floor dysfunction. Furthermore, the indications for robotic use in rectopexy operations need to be explored in larger patient samples. / Tiivistelmä Rektumprolapsi ja peräsuolen sisäinen tuppeuma eli interni prolapsi aiheuttavat hankalia oireita, kuten ulostusvaikeuksia, ulosteinkontinenssia ja lantion kipua. Elämänlaatua heikentäviä oireita esiintyy usein samanaikaisesti myös muissa lantion osissa. Robottiavusteinen kirurgia tarjoaa paremmat leikkausolosuhteet lantion ahtaassa tilassa tehtävään rektopeksialeikkaukseen ja mahdollisesti edut voivat näkyä leikkaustuloksessa. Tässä väitöskirjassa vertailimme robottiavusteista ja laparoskooppista leikkaustekniikkaa oppimiskäyrän alkuvaiheessa käyttökelpoisuustutkimuksessa kaltaistetussa parivertailuasetelmassa (n = 40, seuranta-aika 3 kk) sekä prospektiivisessa randomoidussa tutkimussarjassa (n = 33, seuranta-aika 24 kk). Monikeskustutkimuksessa (n = 508, seuranta-ajan mediaani 44 kk) selvitimme laajassa aineistossa laparoskooppisen ventraalisen rektopeksian pitkäaikaistuloksia liittämällä aineiston analyysiin poikkileikkauskyselytutkimuksen tulokset. Randomoidussa sarjassa MR-defekografialla todennettiin, että rektopeksialeikkauksen jälkeen peräsuolen sisäinen tuppeuma, rektoseele ja enteroseele korjaantuvat. Rektopeksialeikkaus palauttaa lantion taka- ja keskiosan anatomian, vähentää elinten dynaamista liikkuvuutta ja parantaa lantionpohjan toimintaa sekä oireisiin liittyvää elämänlaatua, erityisesti suolioireiden ja gynekologisten laskeumaoireiden osalta. Robottiavusteinen ja laparoskooppinen tekniikka olivat samanvertaisia perioperatiivisten parametrien, komplikaatioiden, anatomisten ja toiminnallisten tulosten suhteen. Vaikka kustannusvertailussa kalliimpi robottikirurgia voi osoittautua kustannustehokkaaksi pitkäaikaisseurannassa, yhdenvertaiset tulokset eivät oikeuta menetelmää rutiinikäyttöön. Retrospektiivisen tutkimuksen poikkileikkauskyselyn mukaan toiminnalliset tulokset säilyvät pitkäaikaisseurannassa, residiivien (7,1 %) ja komplikaatioiden (10 %) määrä on hyväksyttävä ja verkkoon liittyviä komplikaatioita esiintyy vähän (1,4 %). Leikkauksen jälkeen ilmenee myös uusia oireita, kuten ulostuspakkoa tai virtsankarkailua. Toisaalta virtsankarkailuoire voi korjaantuakin. Pitkäaikaisseurannassa totaalin rektumprolapsin vuoksi leikatut potilaat hyötyvät leikkauksesta enemmän kuin oireisen internin prolapsin vuoksi leikatut. Osa väitöskirjatyön tuloksista tukee moniammatillisen lähestymistavan käyttöä potilaiden arvioinnissa. Jatkossa robottikirurgian käytön indikaatioita rektopeksialeikkauksissa tulisi arvioida isommissa potilasaineistoissa.