Laser hemorrhoidoplasty versus conventional hemorrhoidectomy for grade II/III hemorrhoids: a systematic review and meta-analysis

Purpose This study compared the short- and long-term clinical outcomes of laser hemorrhoidoplasty (LH) vs. conventional hemorrhoidectomy (CH) in patients with grade II/III hemorrhoids. Methods PubMed/Medline and the Cochrane Library were searched for randomized and nonrandomized studies comparing LH against CH in grade II/III hemorrhoids. The primary outcomes included postoperative use of analgesia, postoperative morbidity (bleeding, urinary retention, pain, thrombosis), and time of return to work/daily activities. Results Nine studies totaling 661 patients (LH, 336 and CH, 325) were included. The LH group had shorter operative time (P0.999) and prolapse (P=0.240), and the likelihood of complete resolution at 12 months, were similar (P=0.240). Conclusion LH offers more favorable short-term clinical outcomes than CH, with reduced morbidity and pain and earlier return to work or daily activities. Medium-term symptom recurrence at 12 months was similar. Our results should be verified in future well-designed trials with larger samples

Operative and diagnostic strategies in pelvic floor disease and incontinence

Introduction: Pelvic floor disease affects many patients, with age, female gender and multiparity being significant associations. This can present clinically as pelvic organ prolapse, internal and external rectal mucosal intussuception, obstructed defecation syndrome, rectocele, cystocele and urinary/faecal incontinence. Diagnostic and treatment strategies for the management of such disorders is significantly varied, and evidence for current surgical management is poor. This thesis explores diagnostic and operative strategies currently regarded as state of the art and examines a novel method of pelvic floor assessment using MRI-based statistical shaped modelling. Methods: Meta-analysis in accordance with Cochrane collaboration guidelines was performed to assess laparoscopic versus open techniques for urinary incontinence, as well as endoanal ultrasound (EUS) scanning versus MRI in the assessment of faecal incontinence. The efficacy of sacral nerve stimulation (SNS) was reviewed. In addition, decision analysis was performed to assess the cost-effectiveness of delayed versus immediate anal sphincter repairs, and current operative treatments for end-stage faecal incontinence, and operative strategies for end-stage incontinence. MRI-based statistical shaped biomechanical modelling was performed to assess normal pelvic floors in comparison with patients with obstructed defecation syndrome. 15 asymptomatic volunteers aged 18 to 60 years were scanned and compared against 7 with obstructed defecation (ODS). Finally, 7 patients who were treated surgically for ODS were reassessed 6 months post-operation. Results: There were significant benefits to laparoscopic colposuspension for urinary incontinence. EUS was superior to MRI at detecting internal sphincter lesions, but not for external sphincter lesions. Immediate sphincter repairs were more cost-effective than delayed repairs. The artificial bowel sphincter and end stoma were more acceptable to both patient and institution than dynamic graciloplasty. Patients with obstructed defecation had significantly more irregular levator muscles with wider levator hiatus. Pressure during straining was concentrated in the posterior aspect of the hiatus, potentially contributing to the rectal neuropathy noted in obstructed defecation. Conclusions: Sacral nerve stimulation is an effective treatment for faecal incontinence. The artificial bowel sphincter and end stoma were cost-effective long-term strategies for end-stage faecal incontinence. A new technique for dynamic imaging and functionally assessing pelvic floor musculature has been developed and is showing promise as an adjunct to conventional assessment. Conventional defecating proctography does not provide the dynamic and functional assessment provided by this technique, and may translate well into a means of functional radiological assessment in the future

Operative and diagnostic strategies in pelvic floor disease and incontinence

Introduction: Pelvic floor disease affects many patients, with age, female gender and multiparity being significant associations. This can present clinically as pelvic organ prolapse, internal and external rectal mucosal intussuception, obstructed defecation syndrome, rectocele, cystocele and urinary/faecal incontinence. Diagnostic and treatment strategies for the management of such disorders is significantly varied, and evidence for current surgical management is poor. This thesis explores diagnostic and operative strategies currently regarded as state of the art and examines a novel method of pelvic floor assessment using MRI-based statistical shaped modelling. Methods: Meta-analysis in accordance with Cochrane collaboration guidelines was performed to assess laparoscopic versus open techniques for urinary incontinence, as well as endoanal ultrasound (EUS) scanning versus MRI in the assessment of faecal incontinence. The efficacy of sacral nerve stimulation (SNS) was reviewed. In addition, decision analysis was performed to assess the cost-effectiveness of delayed versus immediate anal sphincter repairs, and current operative treatments for end-stage faecal incontinence, and operative strategies for end-stage incontinence. MRI-based statistical shaped biomechanical modelling was performed to assess normal pelvic floors in comparison with patients with obstructed defecation syndrome. 15 asymptomatic volunteers aged 18 to 60 years were scanned and compared against 7 with obstructed defecation (ODS). Finally, 7 patients who were treated surgically for ODS were reassessed 6 months post-operation. Results: There were significant benefits to laparoscopic colposuspension for urinary incontinence. EUS was superior to MRI at detecting internal sphincter lesions, but not for external sphincter lesions. Immediate sphincter repairs were more cost-effective than delayed repairs. The artificial bowel sphincter and end stoma were more acceptable to both patient and institution than dynamic graciloplasty. Patients with obstructed defecation had significantly more irregular levator muscles with wider levator hiatus. Pressure during straining was concentrated in the posterior aspect of the hiatus, potentially contributing to the rectal neuropathy noted in obstructed defecation. Conclusions: Sacral nerve stimulation is an effective treatment for faecal incontinence. The artificial bowel sphincter and end stoma were cost-effective long-term strategies for end-stage faecal incontinence. A new technique for dynamic imaging and functionally assessing pelvic floor musculature has been developed and is showing promise as an adjunct to conventional assessment. Conventional defecating proctography does not provide the dynamic and functional assessment provided by this technique, and may translate well into a means of functional radiological assessment in the future.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

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10.1016/j.jpainsymman.2020.06.016Journal of Pain and Symptom Managemen