Clinical Anatomic Study, Imaging Diagnosis And Treatment Of Pelvic Reconstruction Surgery (Prolift^TM Technique) On Female Pelvic Floor Dysfunction

Objective:The purpose of this reasearch was to identify the difference between the Prolift^TM technique(total pelvic floor reconstruction surgery) and the modified Prolift technique(modified pelvic floor reconstruction surgery) for the treatment of female pelvic floor dysfunction through the study on anatomical dissection,dynamic magnetic resonance imaging(MRI) and the clinical practice.Meanwhile,recommended a security path for each surgical procedure.Methods:Twelve fresh cadavers were randomized to the Prolift^TM technique group or the modified Prolift technique group,each group had six bodies. After the puncture surgical procedures was finished according to the Prolift^TM technique or the modified Prolift technique,anatomical dissections of the pelvic floor on twelve fresh specimens are performed. Distances between cannula(Prolift^TM technique) or string(modified Prolift technique) and the major neighbouring neurovascular and visceral structures both inside and outside the pelvic area were measured. Comparative study of 20 patients before and after each of the pelvic reconstruction surgery on dynamic MRI was performed and analyzed during the past years.Outcomes of 168 cases(16 cases of Prolift^TM surgery and 152 cases of the modified Prolift surgery) were analyze with prospective study.Results1.The anterior and posterior cannula(Prolift^TM technique) or string (modified Prolift technique) were below the level of clitoris when it perforated the obturator foramen area.The distance between the posterior cannula(Prolift^TM technique) or string(modified Prolift technique) and the anterior or posterior branch of obturator nerves were similar,all P＞0.05.2.The posterior cannula(Prolift^TM technique) and string(modified Prolift technique) were closer to the posterior branch of obturator vessels[(0.60±0.36cm) and(0.78±0.10cm)]than the anterior cannula(Prolift^TM technique) and string(modified Prolift technique) to the anterior branch of obturator vessels[(1.58±0.05cm) and(1.58±0.05cm)],but no significant difference between the two group.(all P＞0.05).3.The length of the vaginal from the perforation of the needle through the ischiorectal fossa or posterior area of obturator to the hymen was more longer in the Prolift^TM technique[(7.38±0.15cm) and(5.63±0.15cm)] than in the modified Prolift technique[(5.88±0.23cm) and(4.83±0.05cm)] (all P＜0.01).4.The distance between the cannula(Prolift^TM technique) and the caudal artery(0.88±0.10cm) was more closer than that the string(modified Prolift technique) and the caudal artery(2.95±0.09cm)(all P＜0.01).5.The sacrotuberous and sacrospinous ligaments were overlapping integration to sacrotuber-sacrospinous complex at the point near the ischial spine for 1.30±0.12cm.The caudal edge of sacrotuberous ligament was lower than the sacrospinous ligament.6.66.7%cannula(Prolift^TM technique) and 16.7%string(modified Prolift technique) perforated through the sacrotuber-sacrospinous complex,while 25%cannula(Prolift^TM technique) and 75%string(modified Prolift technique) perforated through the iliococcygeus.Significant difference could be found between the two group(all P＜0.05).7.Direction should be changed according to the direct of the finger in the vaginal after anterior or posterior needle punctured into the inside of the pelvis to avoid the damage to the bladder or urithral in Prolift^TM technique.Cornering should be avoid when the needles punctured through the ischiorectal fossa.8.It would be safe for the helical needles punctured both anterior and posterior region of the anterior vaginal wall through the obturator area which had an 45°angle with the sagittal plane in modified Prolift technique.Cornering should be avoid when the needles punctured through the ischiorectal fossa.9.The consistency of the diagnosis with dynamic MRI on the anterior pelvic prolapse reached to the rate of 95 percent with that clinical examination,while the consistency droped to the rate of 25 percent with that clinical examination on the posterior pelvic prolapse. 10.Significant difference could be found in the length of the line H and line M in Prolift^TM group and in the length of the line H in modified Prolift group after the surgery.11.Three patients were diagnosed mild POP through dynamic MRI,one in Prolift^TM group and 2 in modified Prolift group after the surgery.12.Of the 168 cases,134 cases(80%) finished one time follow-up at outpatient clinic after the surgery for one year.The cure rate were 100% and 94.1%in Prolift^TM and modified Prolift group.No serious complications had been found during and after the surgeries.Conclusions1.Damage to the obturator nerves could be avoid if the anterior and posterior cannula(Prolift^TM technique) or string(modified Prolift technique) below the level of clitoris when it perforated the obturator foramen area.2.Compare with the anterior cannula(Prolift^TM technique) or string (modified Prolift technique),it would be easier to cause damage on the posterior branch of obturator vessels for the posterior cannula(Prolift^TM technique) or string(modified Prolift technique),but it seldom cause serious bleeding or hematoma.3.Rare articles report the damage to the caudal artery during the Prolift^TM operation.We found it would be easier to make damage to the caudal artery in the Prolift^TM operation than in the modified Prolift operation in our research.4.Through we found the puncture length in the vaginal was longer in the Prolift^TM than in the modified Prolift,it did not had an obvious effect on the clinical outcomes.5.As we know,it was the first time that we proposed the concept of sacrotuber-sacrospinous complex and we also found that the needle of the Prolift^TM perforate the sacrotuber-sacrospinous complex or sacrotuberous ligament more often than sacrospinous ligament report in the article.6.Low risk of damage could be happen if the pelvic reconstruction operation followed the right and recommended procedures.7.It was the first time to compare the qualification of the POP through both the clinical examination and the dynamic MRI and the result was that the diagnosis on anterior pelvic prolapse was prior to the diagnosis on posterior pelvic prolapse with dynamic MRI.8.In our dynamic MRI research,we found that both surgery could improved the hiatal enlargement and only Prolift^TM could improved the pelvic foor descent.Both surgeries could have good efficiency on the treatment of POP.9.Dynamic MRI was more objective and comprehensive on the diagnosis of POP than the clinical diagnosis.For the cost of dynamic MRI examination was high,more evidence-based medicine work should be done to make sure that if it was a good examination performed in POP before or after the surgery.10.Clinical research have proved that Both Protift^TM and modified Prolift techniques could have good efficiency and safety for the treatment of POP.11.As it is too much expensive for the mesh kits of Prolift^TM,Prolift^TM technique could not be popular used for the treatment of POP in China now.Modified Prolift had lower cost but had the same efficiency on the treatment of POP with Prolift^TM.So it will do good for the Chinese women with POP using the modified Prolift technique.