CHIRURGIA COMBINATA GINECOLOGICA E RETTALE CON APPROCCIO TRANSPERINEALE PER IL TRATTAMENTO DELLE DISFUNZIONI COMPLESSE DEL PAVIMENTO PELVICO. RISULTATI FUNZIONALI E QUALITÀ DI VITA

Lucia Morganti1, Francesca Gubbiotti1, Simona Ascanelli1, Ruby Martinello2, Gennaro Scutiero2, Giorgio Cremonini2, Pantaleo Greco2
1Clinica Chirurgica, Università degli Studi di Ferrara
2Clinica Ostetrica e Ginecologica, Università degli Studi di Ferrara

Topic: Disfunzioni complesse del pavimento pelvico

Purpose: To evaluate clinical outcomes and quality of life (QoL) in patients with complex pelvic floor disorders (PFDs) treated by a multidisciplinary group with anterior or posterior vaginal wall repair with or without vaginal hysterectomy (VAHY) associated to stapled trans-anal rectal resection (STARR).
Methods: Retrospective cohort study including all patients with complex PFDs managed by a multidisciplinary and interprofessional pelvic floor team, receiving combined STARR and uro-gynecologic surgery at our institution over a two-year period. Patient’s clinical outcomes and QoL before and after the combined surgical treatment was evaluated by submitting Pelvic Floor Disorders Distress Inventory (PFDI) and Pelvic Floor Disorders Impact Questionnaire (PFIQ), respectively. For functional evaluation, preoperative and postoperative obstructed defecation syndrome scores and anorectal manometry were employed.
Results: Between December 2012 and December 2014, 18 consecutive patients underwent combined STARR and anterior or posterior vaginal wall repair with or without VAHY. PFDI, PFIQ and obstructed defecation syndrome scores were all improved after combined surgical repair (p <0,0001) (Table 1). At postoperative anorectal manometry, rectal compliance increased (p=0.03) while mean resting pressure and squeeze pressure did not vary significantly (Table 2). No patients required re-operation at 22-month follow up, while one patient had a prolapse recurrence one year after the operation.
Conclusions: These preliminary data support the multidisciplinary interprofessional management of complex PFDs to achieve good clinical outcomes and QoL in patients undergoing trans-perineal surgery. A multidisciplinary approach may help the decision-making process for complex PFDs and may reduce single-specialist management failure.

Table 1. The clinical outcomes and health-related QoL of patients with complex PFDs who underwent combined surgical repair by a multidisciplinary team.

 

Before Surgery
[Median (IQR 75-25)]

After Surgery
[Median (IQR 75-25)]

p

Pelvic Floor Distress Inventory – PFDI (range 0-300)

170.6 (163.5-192.7)

88.0 (68.8-123.7)

<0.0001

Pelvic Organ Prolapse QuantificationPOP-Q (grade 0-4)

2.0 (2.0-3.0)

0 (0-1.0)

<0.0001

Obstructed Defecation Syndrome – ODS (range 0-31)

24.0 (18.0-26.0)

10.5 (6.0-11.0)

<0.0001

Wexner Scale Constipation scoring system (range 0-30)

21.0 (17.0-21.0)

12.0 (7.0-13.0)

<0.0001

Cleveland Clinic Incontinence ScoreCCIS (0-20)

5.0 (3.0-9.0)

8.0 (3.0-9.0)

0.4258

Pelvic Floor Impact Questionnaire – PFIQ  (range 0-300)

197.4 (156.6-213.9)

107.1 (80.5-137.2)

<0.0001

 

Table 2. Functional results of patients with complex PFDs who underwent combined surgical repair by a multidisciplinary team.

 

Before Surgery
[Median (IQR 75-25)]

After Surgery
[Median (IQR 75-25)]

p

Medium Anal Resting Pressure

34.5 (26.0-45.0)

34 (28.0-45.0)

0.67

Maximum Anal  Resting Pressure

65.0 (49.0-81.0)

63.5 (55.0-78.0)

0.55

Medium Anal Squeeze Pressure

34.5 (25.0-53.0)

41.0 (30.0-51.0)

0.1

Maximum Anal Squeeze Pressure

89.0 (60.0-120.0)

90.0 (62.0-130.0)

0.37

Rectal Compliance

7.6 (4.0-15.0)

11.2 (5.8-15.0)

0.03

Medium and maximum anal resting pressure are expressed in mmHg, with respectively normal value of > 20 mmHg, and between 50-80 mmHg; Medium and maximum anal squeeze pressure are expressed in mmHg, with respectively normal value of >20 mmHg, and between 100-180 mmHg; Rectal Compliance has normal value of 15-16, expressed in ml/cmH2O

 

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