Search Results (507)

Background/Objectives: Pelvic organ prolapse (POP) is increasingly recognized as a localized extracellular matrix (ECM) remodeling disorder. Conventional clinical predictors do not fully explain interindividual variation in tissue quality or surgical durability. This study aimed to characterize the ECM failure phenotype in surgically obtained pelvic support tissue and to derive an exploratory tissue-based ECM Vulnerability (ECM-V) score. Methods: This single-center exploratory translational biomarker derivation study included 121 women: 60 undergoing primary reconstructive surgery for POP with or without concomitant stress urinary incontinence, and 61 benign gynecological controls. Standardized intraoperative anterior vaginal wall biopsies and preoperative plasma samples were obtained. Seven ECM biomarkers (COL1, COL3, ELN, MMP1, MMP2, MMP3, MMP9) were quantified in both compartments. Receiver operating characteristics (ROC) analysis adjusted logistic regression and stratified 10-fold cross-validation were performed. An exploratory integer-weighted ECM-V score was derived from COL3, MMP2 and MMP9 tissue values. Results: Tissue biomarkers demonstrated substantially stronger discrimination than plasma biomarkers. Surgical cases showed reduced COL1 (AUC 0.898) and ELN (AUC 0.846), elevated COL3 (AUC 0.818), MMP2 (AUC 0.958) and MMP9 (AUC 0.977) (all p < 0.001). The compact COL3-MMP2-MMP9 tissue model achieved a cross-validated AUC of 0.986 ± 0.035, substantially outperforming the best plasma model (AUC 0.719). The ECM-V score demonstrated derivation-level AUC of 0.995, sensitivity of 0.967 and specificity of 0.967. Tissue MMP9 and MMP2 correlated strongly with POP-Q severity and validated symptom scores (rho up to 0.806, p < 0.001). Conclusions: Women undergoing primary POP surgery demonstrate a distinct localized ECM failure phenotype. The exploratory COL3-MMP2-MMP9 framework provides a biologically coherent basis for the ECM-V score requiring prospective validation with longitudinal recurrence outcomes. Full article

Carotid artery stenting (CAS) is an established revascularization option for patients with carotid disease at high surgical risk. Periprocedural cerebral embolization remains a clinical concern, and plaque prolapse, the extrusion of atherosclerotic material through the stent struts into the lumen, has emerged as an actionable mechanism directly linked to embolic events and adverse neurological outcomes. This narrative review provides a structured, practice-oriented framework addressing one specific question: how can plaque prolapse be prevented during CAS? Drawing on prospective registries, comparative cohort studies and intravascular imaging analyses based on optical coherence tomography (OCT) and intravascular ultrasound (IVUS), we discuss the main determinants of prolapse risk, plaque morphology, procedural variables and device selection, converging on dual-layer micromesh stent (DLMS) technology as the most advanced device-based solution available. Pooled clinical data indicate a 30-day stroke rate of approximately 1.4% when DLMSs are used in combination with embolic protection, and OCT studies confirm reduced prolapse compared with single-layer stents. Prevention requires an integrated strategy combining lesion-specific characterisation, optimised technique and tailored device selection, while standardised imaging definitions and adequately powered randomised trials with hard clinical endpoints remain research priorities. Full article

Apical pelvic organ prolapse (POP) is characterized by descent of the uterus or post-hysterectomy vaginal vault resulting from failure of level I pelvic support and represents a major contributor to pelvic floor dysfunction and recurrent prolapse surgery. Loss of apical support is frequently associated with anterior and posterior compartment defects, leading to vaginal bulge symptoms, pelvic pressure, urinary and bowel dysfunction, sexual dysfunction, and reduced quality of life. This narrative review summarizes current knowledge on POP, from molecular mechanisms and emerging biomarkers to contemporary surgical management, with particular emphasis on sacrocolpopexy and robotic-assisted approaches. A literature search of PubMed, Scopus, Google Scholar, and Consensus identified peer-reviewed studies published up to February 2026. Evidence demonstrates that POP has a multifactorial and polygenic background involving extracellular matrix remodeling, connective tissue integrity, smooth muscle dysfunction, and altered level of protein expression. Several candidate biomarkers, including single-nucleotide polymorphisms, circulating proteins, metabolites, and imaging-based parameters, show potential for risk prediction and earlier diagnosis, although routine clinical implementation remains limited. Sacrocolpopexy remains the gold standard for apical prolapse repair because of superior anatomical outcomes, low recurrence, and significant quality-of-life improvement. Laparoscopic and robotic-assisted sacrocolpopexy provide comparable efficacy with reduced blood loss, shorter hospitalization, and faster recovery. The objective success rate is usually over 90%. Complications are very rare and typically include mesh erosion in 2–4% of cases and the need for reoperation in 6% of cases. Our own experience shows that, for a group of surgeons, the learning curve for the laparoscopic approach reached a plateau after a total of 30 operations. Robotic platforms may facilitate complex pelvic dissection and shorten the learning curve, although higher procedural costs remain a major limitation. Full article

Objective: To assess the anatomical and clinical outcomes of a novel, mesh-free cerclage pectopexy technique that uses the round ligament for apical support following total laparoscopic hysterectomy in women with stage II uterine prolapse. Methods: This retrospective observational study included 120 women with stage II uterine prolapse who underwent total laparoscopic hysterectomy followed by laparoscopic non-mesh pectopexy between October 2023 and August 2024. In this procedure, the distal portion of each round ligament was fixed to the pectineal ligament using Ethibond sutures. Multiple plicating stitches were then placed to reinforce the ligament’s tensile strength, creating a biological suspension bridge between the pectineal ligament and the vaginal cuff. All patients were examined preoperatively and at 1, 3, 6, and 12 months postoperatively using the POP-Q system. Anatomical success was defined as an apical stage ≤ I at 12 months. Results: At the twelve-month follow-up, anatomical success was achieved in 95 percent of patients, with six cases of apical recurrence. POP-Q measurements showed significant improvement from baseline, and total vaginal length was preserved. Functional outcomes, including postoperative pain and dyspareunia, were favorable. Early complications were uncommon, and no intraoperative or mesh-related complications occurred. Conclusion: Round-ligament-based non-mesh cerclage pectopexy provides reliable apical support with minimal surgical morbidity following total laparoscopic hysterectomy. This technique appears to provide effective apical support with low surgical morbidity while avoiding synthetic mesh. Preservation of vaginal length and favorable short-term clinical outcomes were observed; however, longer-term comparative studies are required. Future prospective studies combining this procedure with other minimally invasive suspension techniques, such as McCall culdoplasty or uterosacral plication, may broaden its applicability to more advanced prolapse cases. Full article

Hemorrhoidal disease is a common anorectal condition that may require treatment when bleeding, prolapse or persistent symptoms fail to respond to conservative or office-based therapy. Radiofrequency ablation (RFA) has emerged as a minimally invasive, tissue-sparing technique for symptomatic internal hemorrhoids, based on controlled delivery of high-frequency energy into hemorrhoidal tissue. The resulting thermal effect induces coagulative necrosis, fibrosis, mucosal fixation and progressive reduction in hemorrhoidal volume, without excisional removal of anoderm or rectal mucosa. This narrative review summarizes the mechanism, technical principles, clinical advantages, comparative evidence and remaining uncertainties surrounding RFA, with particular attention to the Rafaelo procedure and related radiofrequency-based approaches. Current evidence suggests that RFA may reduce postoperative pain, analgesic requirements, wound-related morbidity, hospital stay and time to return to normal activity compared with conventional hemorrhoidectomy, while maintaining acceptable short- and mid-term symptom control in selected patients, especially those with grade II–III internal hemorrhoids. However, available studies remain heterogeneous in design, technique, patient selection, outcome definitions and follow-up duration. The relationship between modern probe-based RFA and earlier radiofrequency-based approaches, including Ellman surface coagulation, Celon bipolar radiofrequency-induced thermotherapy and radiofrequency-assisted hemorrhoidectomy, remains insufficiently standardized in the literature. Further randomized trials, standardized outcome reporting, long-term recurrence data and cost-effectiveness analyses are required to define the optimal indications and therapeutic position of RFA. Full article

Background/Objectives: Pelvic organ prolapse (POP) management requires precise patient selection for surgical techniques to balance clinical efficacy and safety. The primary aim of this study was to evaluate the role of preoperative 3D/4D transperineal ultrasound in the risk stratification of POP recurrence. We analyzed the impact of levator ani muscle (LAM) injuries, specifically avulsion and ballooning, as identified by ultrasound, on both anatomical and subjective success rates, comparing native tissue repair versus mesh-augmented surgery. Methods: A prospective, multicenter observational study was conducted over a five-year period, January 2021 to December 2024 (recruitment), with follow-up completed in December 2025, ensuring a minimum follow-up of 12 months for all participants. The cohort included 276 women scheduled for primary surgery for symptomatic POP stage ≥ 2. Prior to intervention (116 underwent native tissue repair and 160 received mesh), all patients underwent 3D/4D transperineal ultrasound for standardized volume acquisition. Using this preoperative functional imaging technique, we measured the hiatal area and diagnosed the presence of hiatal ballooning (≥25.0 cm²) or levator muscle avulsion. Results: Ultrasound assessment revealed significant differences in surgical success based on the diagnosed baseline site-specific defects. Hiatal ballooning was the sonographic finding that demonstrated the greatest impact on risk stratification. Among patients with preoperative ballooning, mesh use significantly reduced both subjective recurrence (5.7% vs. 21.4%, p = 0.001) and objective recurrence (21.4% vs. 35.7%, p = 0.040) compared to native tissue repair. Furthermore, in women without ultrasound-documented avulsion, mesh also decreased objective recurrence (17.9% vs. 33.0%, p = 0.024). Multivariate analysis, adjusted for age, BMI, menopausal status, and parity, confirmed that, after stratifying by these preoperative ultrasound findings, a native tissue approach remains the primary independent predictor of surgical failure (OR 1.752 for objective recurrence; p = 0.041). Conclusions: In conclusion, native tissue repair was identified as the primary independent predictor of surgical failure. While 3D/4D transperineal ultrasound helps identify high-risk phenotypes such as hiatal ballooning, these sonographic findings did not maintain independent significance in the multivariate model. Therefore, ultrasound should be considered a complementary tool for surgical planning rather than a definitive predictor of recurrence. Full article

Background: Perioperative outcomes in pelvic organ prolapse (POP) surgery remain difficult to predict due to substantial heterogeneity in both surgical techniques and patient characteristics. Existing studies typically evaluate these factors in isolation, limiting their ability to support individualized risk stratification. This study introduces a stratified analytical framework to disentangle the relative impact of procedural and patient-related determinants across common vaginal reconstructive approaches. Methods: A retrospective cohort of 376 women undergoing POP surgery between 2020 and 2025 was analyzed. Patients were stratified into three procedure groups: sacrospinous fixation with mid-urethral sling (SFM + TOT/TVT), anterior and posterior repair with sling (A&P + TOT/TVT), and isolated anterior and posterior repair (A&P alone). Key outcomes included intraoperative blood loss, length of hospitalization, postoperative hospital stay and catheterization time. Within-group predictors were assessed using stratified odds ratios and synthesized via a random-effects model. Results: Procedure type was consistently associated with recovery-related outcomes, although it explained only a modest proportion of outcome variability. Patients undergoing A&P repair exhibited significantly prolonged hospitalization (8.00 vs. 6.29 and 6.94 days), postoperative recovery (4.99 vs. 3.48 and 4.17 days), and catheterization duration (3.31 vs. 2.33 and 2.86 days) (all p < 0.001). In contrast, intraoperative blood loss was primarily driven by patient-specific factors, including concomitant hysterectomy, prolapse severity, obesity, age, and obstetric history. Prolonged hospitalization was strongly associated with combined procedural complexity and clinical burden, while catheterization duration was influenced by postoperative complications and parity. Conclusions: This study demonstrates that perioperative outcomes in POP surgery arise from distinct and interacting domains: procedural factors predominantly shape recovery trajectories, whereas patient characteristics govern intraoperative risk. The proposed stratified random-effects framework enables integrated evaluation across heterogeneous surgical groups and provides an exploratory basis for identifying domains that may inform future individualized perioperative risk models. Full article

Background: Pelvic organ prolapse (POP) is a prevalent condition that often requires surgical correction of apical support. Vaginal approaches that restore anatomy while minimizing synthetic material are of increasing clinical interest. Bilateral sacrospinous colposuspension with sling has been proposed as a minimally invasive technique; however, evidence from large clinical cohorts remains limited. Objectives: This study aimed to evaluate the anatomical, functional, and safety outcomes of this procedure in women with symptomatic advanced POP. Methods: This retrospective single-center cohort study included 235 consecutive women who underwent bilateral sacrospinous colposuspension with sling for symptomatic POP between 2018 and 2024. The primary outcomes were anatomical success (Baden stage ≤ II) and functional success (absence of vaginal bulge symptoms). Secondary outcomes included urinary, bowel, and sexual function, patient satisfaction, and postoperative complications classified according to the Clavien–Dindo system. Results: At a median follow-up of 20 months, anatomical success was achieved in 87.1% of patients and functional success in 93.6%. Significant improvements were observed in POP-Q points Ba and C (p < 0.001). Among symptomatic patients, stress urinary incontinence improved in 66%, urgency in 63%, and constipation in 71%. Overall morbidity was low (5.5%), with most complications classified as Clavien–Dindo grade I–II. Mesh extrusion occurred in 2.1% of cases, and reintervention was required in 2.1%. Functional recurrence was observed in 6.4% of patients, with 26% requiring surgical reintervention. Patient satisfaction was high (median score: 9/10). Conclusions: These findings support bilateral sacrospinous colposuspension with sling as a safe and effective vaginal approach for symptomatic advanced POP; however, the retrospective design and absence of a control group should be considered when interpreting the results. Full article

Background/Objectives: Sacrospinous ligament fixation (SSLF) is a well-established native tissue vaginal procedure for uterine/vault prolapse. Despite favorable success rates, the procedure presents technical challenges due to the deep operative field and proximity to critical neurovascular structures. To review current evidence regarding anatomical considerations, surgical technique, fixation strategies, suture materials, device-assisted methods, and perioperative complications in SSLF. Methods: A structured narrative review of the contemporary literature was conducted, focusing on comparative and systematic studies evaluating unilateral versus bilateral fixation, anterior versus posterior approach, suture type and number, and suture-capturing or anchor-based devices. Anatomical, functional, and safety outcomes were critically analyzed. Results: SSLF achieves favorable anatomical success rates with significant symptom improvement. Meticulous knowledge of sacrospinous ligament anatomy is critical to reduce bleeding and neuropathic complications. Unilateral fixation remains the most common technique, while bilateral fixation may benefit selected patients. According to the available evidence, the anterior approach may better preserve vaginal length, although it may be associated with longer operative time and short-term urinary morbidity. Absorbable and permanent sutures appear to provide comparable anatomical durability, while placement of two sutures remains the most commonly used fixation strategy. Device-assisted techniques may facilitate suture placement but require advanced anatomical expertise. Conclusions: SSLF is a safe and effective suspension procedure when individualized and meticulously performed. Further randomized studies evaluating long-term anatomical and patient-reported outcomes are warranted. Full article

Background: Pelvic organ prolapse (POP) significantly impacts women’s quality of life. Two established surgical approaches exist: laparoscopic sacropexy (LSC) and vaginal sacrospinous fixation (SSLF). This study compared surgical outcomes, complication rates, and quality of life between these techniques. Methods: This retrospective monocentric study included 58 patients treated between 2020 and 2023: 41 underwent LSC, and 17 underwent SSLF with vaginal hysterectomy. All procedures were performed by a single surgeon. Primary outcomes included operative time, complications, and hospital stay. Quality of life was assessed using the German Pelvic Floor Questionnaire (Deutscher Beckenboden-Fragebogen), King’s Health Questionnaire (KHQ), and patient satisfaction surveys. Results: Patient groups differed significantly in ASA scores (p = 0.023) and comorbidities, with SSLF patients showing higher morbidity. LSC demonstrated longer operative times (91 (75–115) vs. 73 (61–87) min, p = 0.05) but significantly fewer complications (0% vs. 17.6%, p = 0.02). Both methods showed significant improvements in bladder function, prolapse symptoms, and pelvic floor dysfunction scores (all p < 0.001). A within-group improvement in sexual function scores was observed in the LSC group (p = 0.002) but not in the SSLF group (p = 0.5); the between-group comparison of change scores was not significant (p = 0.8). No significant differences were found between groups regarding hospital stay duration or overall patient satisfaction (LSC: 95% vs. SSLF: 87% satisfied, p > 0.05). Conclusions: Both surgical approaches effectively treat POP with high patient satisfaction. LSC was associated with fewer observed complications and a within-group improvement in sexual function scores; SSLF was associated with shorter operative time and was applied in patients with higher morbidity. These associations may partly reflect baseline differences between groups and are considered hypothesis-generating. SSLF remains suitable for patients with higher morbidity when minimizing operative time and avoiding Trendelenburg positioning is advantageous. Full article

Background/Objectives: Medial upper eyelid fullness resulting from septal fat prolapse during infrabrow blepharoplasty has not been consistently addressed. However, the potential benefit of medial septal fat excision in enhancing the medial contour remains unclear. This study aimed to evaluate the efficacy and safety of medial septal fat excision during infrabrow blepharoplasty. Methods: This retrospective comparative cohort study included 488 patients who underwent infrabrow blepharoplasty with at least 6 months of follow-up. The patients were divided into the excision (n = 358) and non-excision (n = 130) groups based on the medial septal fat excision status. Medial fullness was graded using a standardized 4-point photographic scale. The primary outcome was the change in medial fullness grade (Δ). Analyses were performed at the patient level, selecting the eye with higher preoperative grade. Analysis of covariance was used to adjust for baseline differences. A subgroup analysis was performed for patients with mild baseline fullness (grades 1–2). Results: The excision group demonstrated significantly greater improvement in medial fullness. After adjustment for baseline differences, postoperative scores were significantly lower in the excision group, with an adjusted mean difference of −0.395. Subgroup analysis confirmed superior improvement in the excision subgroup. The complication rates were low and comparable between the groups (15.4% vs. 10.0%), with no increase in major adverse events. Conclusions: Medial septal fat excision during infrabrow blepharoplasty significantly enhances medial upper eyelid contour without increasing complication rates. This approach is a safe and effective adjunct for addressing medial fat bulging. Full article

Background: Endoscopic sacrocolpopexy (ESC) is a widely performed procedure for pelvic organ prolapse, with laparoscopic sacrocolpopexy (LSC) and robotic-assisted sacrocolpopexy (RSC) approaches. However, suturing to the anterior longitudinal ligament at the sacral promontory carries a risk of massive hemorrhage due to presacral vascular injury. This study aimed to determine the frequency of presacral venous variations considered clinically relevant during suturing at the promontory and to explore their association with perioperative outcomes using contrast-enhanced three-dimensional computed tomography (3D-CT). Methods: Among 319 consecutive ESC cases performed between 2014 and 2025, 265 patients who underwent preoperative contrast-enhanced CT were retrospectively analyzed in this single-center cohort study. Two vascular findings were defined as clinically significant: (1) anomalous drainage of the internal iliac vein into the contralateral common iliac vein and (2) a clearly visualized median sacral vein on 3D reconstruction. The clinical impact of vascular abnormalities was evaluated using surgical time, blood loss, and perioperative complication rates as indicators. Student’s t-test was used for comparing continuous variables, and the chi-squared test was used for comparing categorical variables. The data for this study were retrospectively collected from electronic medical records, anonymized, and then analyzed. Results: Anomalous internal iliac vein drainage was observed in 11.3% (30/265), and a visible median sacral vein was observed in 10.2% (27/265). Overall, 17.7% (47/265, CI: 13.2–22.2%) of patients had at least one clinically significant variation. There were no significant differences between the groups in terms of age, parity, BMI, operative time, blood loss, or perioperative complication rates. No cases required transfusion. Conclusions: Clinically significant presacral vein mutations were present in approximately 1 in 6 patients. The main findings of this study are that clinically significant presacral vascular mutations are relatively frequent (17.7%) in ESC and that there was no significant difference in perioperative outcomes between patients with and without vascular mutations. Clinically relevant presacral vascular variations are relatively common in ESC. Preoperative contrast-enhanced 3D-CT may support risk assessment and surgical planning. Full article

Background: Reintervention after mitral valve repair represents a relevant clinical challenge, yet the mechanisms and timing of repair failure remain incompletely defined. Understanding how the interval between index repair and reoperation affects failure mechanisms and the feasibility of repeat repair may help refine surgical strategies. Methods: We retrospectively analyzed 194 patients undergoing repeat mitral valve surgery between 2010 and 2025 after prior repair. Median age was 70 years and 61.3% were male. Patients were stratified by time to reoperation: 0–5 years (n = 91), 6–10 years (n = 42), and >10 years (n = 61). Median left ventricular ejection fraction was 58%, atrial fibrillation prevalence 32.5%, minimally invasive approach 21.6%, and EuroSCORE II 4.8%. Results: Baseline characteristics and operative risk were comparable across groups. However, mechanisms of repair failure differed significantly. Early failures were more commonly due to recurrent leaflet prolapse (47.8%), whereas late failures showed a higher incidence of mitral stenosis (63.9%). The rate of repeat mitral repair decreased over time, being higher in early failures compared with intermediate and late failures (17.6% vs. 14.3% vs. 8.2%). Conclusions: Timing of mitral repair failure is associated with distinct mechanisms and influences surgical management. Early failures are more frequently related to prolapse recurrence and are more amenable to re-repair, whereas late failures are characterized by structural degeneration and more often require valve replacement. Full article

Mitral valve prolapse represents the most common cause of primary mitral regurgitation in Western countries and has traditionally been viewed as a disorder driven by valvular incompetence and chronic volume overload. Within this paradigm, left ventricular enlargement was expected to correlate with regurgitant severity. However, patients with myxomatous bileaflet prolapse often exhibit left ventricular dilatation disproportionate to the degree of regurgitation, leading to the hypothesis of an intrinsic myocardial disease process. Cardiovascular magnetic resonance imaging has challenged this concept through the identification of doming volume, a previously unrecognized systolic blood compartment located between the mitral annular plane and the ventricular surface of prolapsing leaflets. This volume is mechanically coupled to ventricular contraction and contributes to total ventricular volume load independently of transvalvular regurgitation. Recognition of doming volume provides a physiological explanation for excessive ventricular remodeling observed in bileaflet prolapse and Barlow disease. Doming volume has important implications for imaging assessment. Its common exclusion from echocardiographic volumetric measurements may result in underestimation of left ventricular end-systolic volume, overestimation of ejection fraction, and underestimation of regurgitant burden, contributing to discordance between echocardiographic and cardiovascular magnetic resonance-derived measurements. Cardiovascular magnetic resonance enables comprehensive assessment, allowing accurate quantification of ventricular volumes, mitral regurgitation severity, doming volume, and myocardial tissue characteristics. Integration of doming volume into the evaluation of mitral valve prolapse improves physiological consistency between imaging findings and ventricular remodeling. However, further evidence is required before doming volume assessment can be incorporated into operative clinical indications or decision-making thresholds. Full article