Mesh-enhanced reconstruction that parallels the female urogenital diaphragm: a surgical technique and case study

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Clinical trial number: not applicable. pelvic floor reconstruction pelvic organ prolapse transvaginal mesh pelvic floor hernia(PFH) Figures Figure 1 Figure 2 Brief Summary Mesh-enhanced reconstruction parallel to the female urogenital diaphragm is a safe and effective surgery for preventing pelvic floor hernia and pelvic cavity syndrome. Introduction The anatomical and functional defects of the female urogenital diaphragm have been shown to present complications such as recurrence and pelvic floor hernia(PFH), after certain surgical treatments. The existing mesh pelvic floor reconstruction surgery, such as the Prolift procedure, has played a positive role in the functional repair of the pelvic floor, but there are currently few reports [ 1 , 2 , 3 ] on the surgical treatment of anatomical or functional defects in large areas of the urogenital diaphragm.Based on this, we believed that it was necessary to improve the surgical method and designed this surgical method. We have included two specific patients with whom we communicated about this study and who signed an informed consent form. We adopted a design that included parallel enhanced reconstruction of a urethral diaphragm mesh and provided follow-up for eight years and fourteen months, respectively. Our results confirmed satisfactory efficacy and these data, together with a review of the literature, are presented in the following analysis report. Mesh material: For the pelvic floor repair, we used the polypropylene mesh Pelvimesh® manufactured by Herniamesh SRL (Italy), with specification PM1015, cut to size according to the requirements of the intraoperative situation in a rectangular patch. Cases information Case 1 The condition at admission A woman aged 51 years presented with a urethral neoplasm and hematuria for 6 months. Physical examination at admission showed that the vulva and clitoris were hardened, and a cauliflower-like neoplasm was observed growing in clusters on the inner side of the right labia majora. Multiple cauliflower-shaped red nodules also obstructed the external urethral orifice, with a maximum size of approximately 2.5 × 1.5 cm and a fragile texture that bled easily on palpation. Palpation of the vaginal wall was uneven with a hard texture; the entire urethra appeared stiff and we palpated new nodules at the anterior part of the cervix. Based on imaging data and cystoscopy, the clinical diagnosis was stage D urethral cancer. Tumour invasion included the entire urethra, vulva, clitoris, anterior vaginal wall, cervix and bladder wall. Surgical protocol On 13 February 2017, we used a routine disinfectant drape to perform an abdominal and perineal dual pathway surgery under general anaesthesia. Excisional surgery The scope of tissue and organ resection and lymph node dissection surgery included 1. total urethrectomy; 2. cystectomy; 3. vaginectomy; 4. hysterectomy; 5. affected labia and clitoris resection; 6. inguinal and pelvic lymph node dissection; 7. pelvic floor affected muscle skin resection. Anatomical and functional reconstructive surgery The aim was to ensure normal excretory and defecatory functions and to maintain as close to normal body structures as possible. 1. Rectal bladder replacement; 2. Sigmoidostomy; 3. Vulvar reconstruction; and 4. Pelvic floor parallel mesh patch reconstruction. Almost all of the urogenital diaphragm muscle tissue was removed, leaving an empty area without muscle support, and the support and lifting functions of the pelvic floor were almost completely lost. We designed the artificial mesh to strengthen the pelvic floor, with the aim of preventing pelvic floor hernias after surgery. Surgical design for mesh-enhanced reconstructive surgery The anatomical position of mesh implantation followed DeLancey's three levels of vaginal support theory [ 4 ] at levels I–II, and the anatomical layer we selected was below the parietal peritoneum. Intermittent multiple non-absorbable sutures were sewn and fixed around the perimeter, and the front of the mesh was affixed to the arcuate pubic ligament and the posterior pubic ligament. Both sides were attached to the connective tissue of the muscular fascia of the pubococcygeus, fascia of the obturator internus, and arcus tendineus fascia pelvis (ATFP); with the posterior portion attached to the posterior segment of the ATFP and the anterior sacrosciatic ligaments. We ensured that the mesh was securely sutured, forming a framework parallel to that of the urogenital diaphragm. Postoperative recovery Postoperative recovery was uneventful, and urine and feces could be successfully evacuated through the newly established pathway. The status of the pelvic floor was followed for 8 years without any abnormal conditions such as herniation, and normal daily activities were performed. Case 2 The first hospitalisation process The condition at admission A 65-year-old female was admitted to our hospital with a vaginal mass that had been present for eight years and had become increasingly symptomatic over the past three years. The woman had two vaginal deliveries, both with perineal lacerations. Additionally, the couple had sexual intercourse at least weekly. A physical examination on admission revealed that her uterus was prolapsed through the vaginal opening, with an apparently elongated cervix. Pelvic Organ Prolapse Quantification (POP-Q) measurements were as follows: Aa, + 3; Ba, + 7; C, + 8; Ap, + 3; Bp, + 7; D, + 7; Gh, 8; Pb, 0.7; and tvl, 10. The perineal body could be seen as an irregular healing scar, was extremely short, and almost fused to the anus; and we noted an obvious external hemorrhoidal mass. Preoperative diagnosis 1. Pelvic organ prolapse (anterior vaginal wall prolapse stage IV, uterine prolapse stage IV, and posterior vaginal wall prolapse stage IV); 2. the left kidney after DJ tube placement; and 3. double hydronephrosis. Surgical protocol Surgical treatment on May 15, 2023 included anterior pelvic mesh(polypropylene mesh Pelvimesh®, with specification PM41230)repair and reconstruction, cervical circumcision, and perineal body repair. Postoperative follow-up Early recovery after surgery was good, and household activities resumed normally one month later. While the patient's condition appeared normal three months after surgery, a new mass was observed in the vaginal opening six months after surgery, prompting the patient to seek medical attention again. The second hospitalisation process The condition on admission : A mass was seen prolapsing from the vaginal opening, we instructed the patient to perform a physical examination after walking abdominal pressure boosting, and the results were as follows: the anterior pelvic status was mild, with the prolapsed uterus in the anterior wall outside the hymenal ring, and the uterus was seen to prolapse in the middle and posterior pelvis. The posterior wall of the uterus and the vaginal mucosa were rotated forward and upward with the anterior lip of the cervix as the origin, and the prolapse of the posterior wall reached stage IV. The pelvic floor muscles were extremely relaxed, the anal sphincter was also relaxed, and contractility was reduced. The POP-Q measurements were as follows (the data in parentheses represent the data prior to the first surgery): Aa, 1(3); Ba, 2(7); C, 2(8); Ap, 3(3); Bp, 8(7); D, 10(7); Gh, 8(8); Pb, 0.7(0.7); and tvl, 8(10). Physical examination revealed laxity of the pelvic floor muscles, decreased pelvic floor support, and a markedly enlarged genital hiatus. The pelvic floor tissue was loosely organized and the anal sphincter were loose. From the analysis of the situation of the POP-Q data, the anterior vaginal wall and the anterior cervix were relatively short, which was probably due to the implantation of the anterior pelvic mesh, which was used to strengthen the anterior vaginal wall for stabilization and also played a role in lifting. The posterior pelvis lacked support and increased its degree of freedom, so in this uterine prolapse the anterior pelvis was rotated and pushed forward, resulting in a forward-rotating prolapse. Preoperative diagnosis : Preoperative diagnosis: We diagnosed postoperative recurrence of stage IV POP. Figure 1 : Recurrence after first surgery (photo used with the patient's permission). Surgical procedure protocol After communication with the patient and her family members, she was willing to undergo surgical treatment. Surgical treatment on 20 December, The surgical design and implementation plan were as follows. 1. After completion of a transvaginal hysterectomy, the peritoneum of the organ layer on the surface of the uterus was folded and sutured to strengthen the peritoneum of the pelvic floor. During hysterectomy, attention was paid to the anatomical separation of the uterosacral ligament for subsequent pelvic floor reconstruction as a possible suture fixation point. 2. After determining the suspension position of the vaginal stump in the uterosacral ligament and the anterior sacrospinal ligament, a single thread non-absorbable suture was applied. Two stitches were pre-sewn on each side of the bilateral uterosacral ligament and sacrospinal ligament near the sacrum. Then, after pelvic floor reinforcement and reconstruction with mesh, the reserve non-absorbable suture was sutured and tied to the vaginal stump, and the vaginal stump was placed under (i.e. outside) the mesh. 3. A mesh was implanted at the bottom of the pelvic cavity outside the peritoneum to reinforce the urogenital diaphragm. The anterior suture was attached to the pubovesical ligament, posterior pubic ligament and arcuate pubic ligament on both sides of the bladder. Bilateral fixation was to connective tissues such as the bilateral pubococcygeal fascia, obturator fascia and pelvic fascia tendon arches. The posterior part was connected to the posterior segment of the pelvic fascia tendineae and the sacrospinal ligament, and the anterior wall of the rectum was also sutured intermittently and fixed with mesh to ensure a firm suture and to form a frame parallel to the urogenital diaphragm. 4. Repair of the posterior vaginal wall and vaginal formation,We taking into account the very short perineal body and the presence of external haemorrhoids, we started from the top of the residual posterior vaginal wall, cut away the excess vaginal wall tissue and proceeded downwards to separate the vaginal-rectal gap at the lower end of the vagina. We inserted a polypropylene mesh into the gap and secured the mesh to the surface of the rectum with three non-absorbable sutures at the lower end of the mesh. After being laid flat on both sides, the mesh was fixed to the surface fascia on both sides of the rectum with a non-absorbable suture. The end of the mesh was then fixed and sutured to the remaining end of the vagina, and we sutured the vaginal wound with absorbable thread, tightened the vaginal wall appropriately, and - taking into account the needs of sexual activity - ensured that there was sufficient space for vaginal dilation during suturing. 5. After suturing the vaginal stump with absorbable suture, the non-absorbable suture line reserved for the uterosacral and sacrospinal ligaments was sutured tightly to the uterus close to the sacrum to suspend the vaginal stump. 6. After surgery, the vagina was filled with Vaseline iodoform imitation cylindrical gauze. To ensure the effectiveness of the tamponade, the insertion technique was gradually pushed into the vagina from the front to the back. When the body of the gauze had reached the end of the vagina, it was compressed and pushed backwards and upwards. We never rotated the gauze as we advanced it, so as not to cause the mesh to pile up or shift. This packing ensured that the mesh was stretched in the posterior wall and that the tissues in the rectovaginal space adhered closely together; and that the reconstructed urogenital diaphragm tissue was lifted upward as the mesh was pushed upward to ensure that the mesh adhered closely to the tissues to eliminate any dead space. Postoperative measures and follow-up: The tamponade was removed five days after surgery, and the patient resumed a normal diet five days after surgery and was discharged one week later, with the recovery process proceeding smoothly.The patient was advised to avoid all factors that would increase abdominal pressure for three months after surgery.An eight-month follow-up visit revealed that the patient's urinary reflex was good, the vagina exhibited enough space, and the vaginal mucosa was smooth and flat, showing an overall acceptable condition. Please refer to Figure 2, which shows the follow-up results eight months after the second surgery. The clinical-diagnosis and treatment-research plans of the two patients complied with the requirements of the Helsinki Declaration. The surgical implementation plan and the use of mesh implantation were fully explained and communicated to the patients and their families, ensuring their informed consent. Discussion The authors concluded that contemporary surgical management of pelvic floor dysfunction is not limited to the diagnosis and treatment of current symptoms; it must also take into account the likelihood of recurrence, the occurrence of postoperative pelvic floor hernias(PFH), the timely prediction of outcomes, and the development of interventions. PFH and EPS have been recognised as potential complications of pelvic floor surgery, further research is required to determine the full extent of these complications. In this article, we review the relevant literature and discuss it in the context of our case. It was previously hypothesised that PFH was a rare disease. However, there have now been several reports of complications arising from abdominal perineal resection (APR) during abdominal surgery [ 5 – 8 ] . This type of PFH is primarily characterised by a posterior pelvic floor hernia. There have also been reports of complications arising from female pelvic floor surgery [ 9 ] . In the absence of high-grade clinical diagnosis or treatment evidence, the clinical diagnosis and treatment of PFH remains uncertain [ 5 – 8 , 10 , 11 ] . It is suggested that possible PFH and EPS be considered during the performance of pelvic and pelvic floor surgery. Some surgical designs for patients with PFH and EPS have been considered and implemented by surgeons during operations [ 1 , 2 , 10 , 11 ] . Prevention and treatment of PFH Prevention Domansky et al [ 12 ] conducted a comparative study on the use of myoplasty for closing a pelvic floor defect after extralevator abdominoperineal excision of the rectum. Their results showed that the incidence of postoperative pelvic floor complications was higher in patients undergoing simple plastic surgery of the peritoneal wound compared to those undergoing pelvic floor myoplasty surgery. Treatment Although surgical intervention is the only effective means to prevent and treat PFH, there is currently no consensus on the surgical approach [ 3 , 5 – 8 , 12 ] . The treatment of PFH includes muscle tissue flap repair and reconstruction [ 12 , 13 ] , biological patch repair and reconstruction [ 14 , 15 ] , artificial mesh repair and reconstruction, and tissue flap combined with artificial patch reconstruction surgery [ 16 ] . Literature suggests that artificial mesh (polypropylene) is becoming a mainstream repair material [15~17] . Surgical approach The current literature focuses on therapeutic repair and reconstruction of PFH, with most reports covering abdominal surgery, particularly posterior pelvic hernia repairs.Surgical approaches include transabdominal surgery, transabdominal perineal combined surgery, and pelvic floor surgery. There is no recognised best plan [ 18 ] , and reports suggest that the perineal approach is the optimal approach for repairing perineal hernias. The two patients in our group were assigned to undergo surgery within the ready-made surgical area from the perspective of preventing PFH, without the need for additional surgical incisions and in accordance with the principle of minimal trauma. Theoretical and clinical analysis of surgical design An examination of pelvic floor anatomy and functional analysis of cases Case 1 was characterised by a significant pelvic cavity and pelvic floor area deficit as a result of resection.The increased probability of EPS and PFH necessitated consideration of pelvic floor muscle repair of the pelvic floor. We performed reconstructive surgery with parallel mesh repair of the genitourinary septum. Postoperatively, it was ascertained that the reconstructed pelvic floor exhibited adequate carrying capacity, spanning from anatomical recovery to functional recovery. Case 2 suffered from recurrent POP with anterior reinforcement, anterior rotation of the uterus after prolapse, prolongation of the genital fissure, extreme laxity of the pelvic floor muscles and extreme shortening of the perineal body. Hysterectomy, vaginal suspension and reconstruction with urogenital diaphragm mesh reinforcement were performed. Management of the vaginal stump was the highest priority in this case and we chose to fix it to the sacrospinous ligament with non-absorbable sutures during vaginal suspension. The rest of the management was based on the experience of case 1. Conception and design guided by the theory of pelvic floor dysfunction The mesh, which was placed in a parallel orientation to the urinary diaphragm, was designed according to the integral theory [ 22 , 23 ] of organ-muscle relationship. The reconstructed pelvic floor was closer to the natural anatomical state. The mesh was placed between the first horizontal layer, the parietal peritoneum, and the pelvic floor muscles to form a "sandwich" by suturing them to achieve fusion, thereby strengthening the pelvic floor, reducing erosion exposure, and serving as a vaginal suspension-support point [ 24 ] .The posterior pelvis should be treated accordingly when necessary. Reliable mesh suspension-fixation point with regard to tissue strength The key to the success of the operation was ensuring that the mesh remained flat and securely fixed. The mesh fixation was solid and reliable and the plane stable and not drifting or folding, to maintain the tension and elasticity and to function as a hammock. According to the above principle, the peripheral fixation position was the ligament in the pelvic wall around the interrupted multi-point suture fixation. And the mesh was sutured to the outer rectal tissue with 2–3 non-absorbable sutures to prevent the formation of a gap between the rectum and the mesh. This ensured that the mesh was stitched firmly together, and that it ultimately formed a parallel state with the urinary diaphragm. Care must be taken in the suspension of the vaginal stump after hysterectomy; it must be sutured to a strong ligament around the pelvis. Anteriorly, it can be fixed to the severed ends of the round uterine ligaments [ 25 ] . Key points of the surgical operation: 1.The mesh sutured and fixed at multiple points to the pelvic floor peritoneum to prevent it from floating or shifting after surgery. 2.The sutures between the mesh and the surrounding ligaments should be multipoint suture fixation at different levels to distribute the pressure and prevent tearing. 3. The incision was closed with the necessary penetrating sutures between the perineal skin and the mesh to eliminate the dead space between. In summary, Mesh-enhanced reconstruction parallel to the female urogenital diaphragm maybe was an effective surgical method that leads to overall improvement in pelvic floor dysfunction, which has clinical value for preventing PFH and EPS. We only studied 2 cases in this article, and the follow-up time varied.We will select appropriate cases in the future to further expand clinical use and follow-up. Abbreviations abdominal perineal resection ..................................................APR arcus tendineus fascia pelvis ..................................................ATFP empty-pelvis syndrome .............................................................EPS empty-pelvis syndrome..............................................................EPS Mesh enhanced reconstruction parallel to female urogenital diaphragm........................................................................MRP-FUD pelvic floor hernia.....................................................................PFH Pelvic organ prolapse................................................................POP Pelvic organ prolapse quantification ..................................POP-Q Declarations Ethics approval and consent to participate:This article describes the Innovative surgical methods and procedures accepted and agreed to by the patients and approved by the Medical Ethics Committee of the Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China. (Approval No. 2025020), and was conducted in accordance with the tenets of the Helsinki Declaration of 1964 and its subsequent amendments or equivalent ethical standards. Informed consent was waived by our Institutional Review Board because of the retrospective nature of our study. Consent for publication. Consent for publication: •Written informed consent for publication of clinical details and/or clinical images was obtained from the patient. Availability of data and materials:Not applicable Conflict of interest: All authors declare that they have no conflicts of interest. Funding:The authors declare no funding source. Authors' contributions: • Y Liu: Data collection , Patient follow-up，Manuscript writing • ZJ Li: Patient follow-up，Manuscript writing • K Qian: Patient follow-up • ZG Luo: Surgical design, Data Collection, Manuscript writing Acknowledgments: We thank LetPub (www.letpub.com.cn) for its linguistic assistance during the preparation of this manuscript. References M. A ,S. 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Petros P E P , Ulmsten U I .An integral theory of female urinary incontinence. Experimental and clinical considerations[J].Acta obstetricia et gynecologica Scandinavica. Supplement, 1990, 153(153):7-31.DOI:10.1111/j.1600-0412.1990.tb08027.x. Delancey JOL. Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol. 1994 Jun;170(6):1713-20; discussion 1720-3. Kaba M. Uterosacral ligament dissection during McCall culdoplasty to prevent ureteral kinking, and round ligament fixation to support vaginal vault: a new surgical technique.McCall Med Sci Discov. 2022;9(9):485–7. https://doi.org/10.36472/msd.v9i9.810. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6950357","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":498263200,"identity":"887ec22b-f938-4e6c-bea8-61d923f5410e","order_by":0,"name":"Yi Liu","email":"","orcid":"","institution":"University of South China","correspondingAuthor":false,"prefix":"","firstName":"Yi","middleName":"","lastName":"Liu","suffix":""},{"id":498263201,"identity":"dde617ae-1173-40c5-b7b3-46989f1376bf","order_by":1,"name":"Zhijun Li","email":"","orcid":"","institution":"University of South China","correspondingAuthor":false,"prefix":"","firstName":"Zhijun","middleName":"","lastName":"Li","suffix":""},{"id":498263202,"identity":"5caa2e56-1b97-46e9-8c1f-13e8f858fca4","order_by":2,"name":"Kun Qian","email":"","orcid":"","institution":"University of South China","correspondingAuthor":false,"prefix":"","firstName":"Kun","middleName":"","lastName":"Qian","suffix":""},{"id":498263203,"identity":"d798bf90-a50c-4ed5-a7f2-6ebeab5b91d8","order_by":3,"name":"Zhigang Luo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIiWNgGAWjYBACNvbm4x8SKiR42JiZD0CEDhDQwsdzLI3hwxkbOX52tgTitMhJ5JgxzmxLM5bs5zEgTgubRFraYx62w4kbDvN8k/xRwyDHdyOB8XMBPi08j48b8/CAtPBuk+Y5xmAseSOBWXoGPi3saQnSPBJQLYwNDIkbbiSwMfPg08KQYyDNYwB22DPJnw0M9YS1cOSYSc5IAHq/mYdNgreBIcGAoBaeY8kGHw4AA5mZzdia55iE4cwzD5ul8WmRb28++CDxHzAq+Q8/vPmjxkae73jywc/4tKADCSAGBsIoGAWjYBSMAsoAAEE6SbcCdmIiAAAAAElFTkSuQmCC","orcid":"","institution":"University of South China","correspondingAuthor":true,"prefix":"","firstName":"Zhigang","middleName":"","lastName":"Luo","suffix":""}],"badges":[],"createdAt":"2025-06-22 15:23:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6950357/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6950357/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88756292,"identity":"7757b335-1faf-49e8-b055-5da7d6113f5e","added_by":"auto","created_at":"2025-08-11 07:16:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":853769,"visible":true,"origin":"","legend":"\u003cp\u003eRecurrence after the first surgery\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6950357/v1/05cce17cf565e4735ebce5a3.png"},{"id":88754128,"identity":"e6d63900-4a8c-4625-ace8-41e54d969bb1","added_by":"auto","created_at":"2025-08-11 07:08:09","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":461217,"visible":true,"origin":"","legend":"\u003cp\u003eFollow-up results eight months after the second surgery\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6950357/v1/7567d8cb9145d304cd779f45.png"},{"id":91851955,"identity":"f3340072-9a82-4dee-8dbc-72ec08f366fb","added_by":"auto","created_at":"2025-09-22 11:25:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2814089,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6950357/v1/fb4e58dd-aabe-4aa1-9b71-958124667404.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Mesh-enhanced reconstruction that parallels the female urogenital diaphragm: a surgical technique and case study","fulltext":[{"header":"Brief Summary","content":"\u003cp\u003eMesh-enhanced reconstruction parallel to the female urogenital diaphragm is a safe and effective surgery for preventing pelvic floor hernia and pelvic cavity syndrome.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eThe anatomical and functional defects of the female urogenital diaphragm have been shown to present complications such as recurrence and pelvic floor hernia(PFH), after certain surgical treatments. The existing mesh pelvic floor reconstruction surgery, such as the Prolift procedure, has played a positive role in the functional repair of the pelvic floor, but there are currently few reports\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e on the surgical treatment of anatomical or functional defects in large areas of the urogenital diaphragm.Based on this, we believed that it was necessary to improve the surgical method and designed this surgical method.\u003c/p\u003e\u003cp\u003e We have included two specific patients with whom we communicated about this study and who signed an informed consent form. We adopted a design that included parallel enhanced reconstruction of a urethral diaphragm mesh and provided follow-up for eight years and fourteen months, respectively. Our results confirmed satisfactory efficacy and these data, together with a review of the literature, are presented in the following analysis report.\u003c/p\u003e\u003cp\u003eMesh material: For the pelvic floor repair, we used the polypropylene mesh Pelvimesh\u0026reg; manufactured by Herniamesh SRL (Italy), with specification PM1015, cut to size according to the requirements of the intraoperative situation in a rectangular patch.\u003c/p\u003e"},{"header":"Cases information","content":"\u003cp\u003e\u003cstrong\u003eCase 1\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eThe condition at admission\u003c/strong\u003e\u003cp\u003eA woman aged 51 years presented with a urethral neoplasm and hematuria for 6 months. Physical examination at admission showed that the vulva and clitoris were hardened, and a cauliflower-like neoplasm was observed growing in clusters on the inner side of the right labia majora. Multiple cauliflower-shaped red nodules also obstructed the external urethral orifice, with a maximum size of approximately 2.5 \u0026times; 1.5 cm and a fragile texture that bled easily on palpation. Palpation of the vaginal wall was uneven with a hard texture; the entire urethra appeared stiff and we palpated new nodules at the anterior part of the cervix.\u003c/p\u003e\u003c/p\u003e\u003cp\u003eBased on imaging data and cystoscopy, the clinical diagnosis was stage D urethral cancer. Tumour invasion included the entire urethra, vulva, clitoris, anterior vaginal wall, cervix and bladder wall.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSurgical protocol\u003c/strong\u003e\u003cp\u003eOn 13 February 2017, we used a routine disinfectant drape to perform an abdominal and perineal dual pathway surgery under general anaesthesia.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eExcisional surgery\u003c/strong\u003e\u003cp\u003eThe scope of tissue and organ resection and lymph node dissection surgery included 1. total urethrectomy; 2. cystectomy; 3. vaginectomy; 4. hysterectomy; 5. affected labia and clitoris resection; 6. inguinal and pelvic lymph node dissection; 7. pelvic floor affected muscle skin resection.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAnatomical and functional reconstructive surgery\u003c/strong\u003e\u003cp\u003eThe aim was to ensure normal excretory and defecatory functions and to maintain as close to normal body structures as possible. 1. Rectal bladder replacement; 2. Sigmoidostomy; 3. Vulvar reconstruction; and 4. Pelvic floor parallel mesh patch reconstruction. Almost all of the urogenital diaphragm muscle tissue was removed, leaving an empty area without muscle support, and the support and lifting functions of the pelvic floor were almost completely lost. We designed the artificial mesh to strengthen the pelvic floor, with the aim of preventing pelvic floor hernias after surgery.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSurgical design for mesh-enhanced reconstructive surgery\u003c/strong\u003e\u003cp\u003eThe anatomical position of mesh implantation followed DeLancey's three levels of vaginal support theory\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e at levels I\u0026ndash;II, and the anatomical layer we selected was below the parietal peritoneum. Intermittent multiple non-absorbable sutures were sewn and fixed around the perimeter, and the front of the mesh was affixed to the arcuate pubic ligament and the posterior pubic ligament. Both sides were attached to the connective tissue of the muscular fascia of the pubococcygeus, fascia of the obturator internus, and arcus tendineus fascia pelvis (ATFP); with the posterior portion attached to the posterior segment of the ATFP and the anterior sacrosciatic ligaments. We ensured that the mesh was securely sutured, forming a framework parallel to that of the urogenital diaphragm.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003ePostoperative recovery\u003c/strong\u003e\u003cp\u003ePostoperative recovery was uneventful, and urine and feces could be successfully evacuated through the newly established pathway. The status of the pelvic floor was followed for 8 years without any abnormal conditions such as herniation, and normal daily activities were performed.\u003c/p\u003e\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eCase 2\u003c/h2\u003e\u003cdiv id=\"Sec4\" class=\"Section3\"\u003e\u003ch2\u003eThe first hospitalisation process\u003c/h2\u003e\u003cp\u003e\u003cstrong\u003eThe condition at admission\u003c/strong\u003e\u003cp\u003eA 65-year-old female was admitted to our hospital with a vaginal mass that had been present for eight years and had become increasingly symptomatic over the past three years. The woman had two vaginal deliveries, both with perineal lacerations. Additionally, the couple had sexual intercourse at least weekly. A physical examination on admission revealed that her uterus was prolapsed through the vaginal opening, with an apparently elongated cervix.\u003c/p\u003e\u003c/p\u003e\u003cp\u003ePelvic Organ Prolapse Quantification (POP-Q) measurements were as follows: Aa, +\u0026thinsp;3; Ba, +\u0026thinsp;7; C, +\u0026thinsp;8; Ap, +\u0026thinsp;3; Bp, +\u0026thinsp;7; D, +\u0026thinsp;7; Gh, 8; Pb, 0.7; and tvl, 10. The perineal body could be seen as an irregular healing scar, was extremely short, and almost fused to the anus; and we noted an obvious external hemorrhoidal mass.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003ePreoperative diagnosis\u003c/strong\u003e\u003cp\u003e1. Pelvic organ prolapse (anterior vaginal wall prolapse stage IV, uterine prolapse stage IV, and posterior vaginal wall prolapse stage IV); 2. the left kidney after DJ tube placement; and 3. double hydronephrosis.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSurgical protocol\u003c/strong\u003e\u003cp\u003eSurgical treatment on May 15, 2023 included anterior pelvic mesh(polypropylene mesh Pelvimesh\u0026reg;, with specification PM41230)repair and reconstruction, cervical circumcision, and perineal body repair.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003ePostoperative follow-up\u003c/strong\u003e\u003cp\u003eEarly recovery after surgery was good, and household activities resumed normally one month later. While the patient's condition appeared normal three months after surgery, a new mass was observed in the vaginal opening six months after surgery, prompting the patient to seek medical attention again.\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\n\u003ch3\u003eThe second hospitalisation process\u003c/h3\u003e\n\u003cp\u003e\u003cb\u003eThe condition on admission\u003c/b\u003e: A mass was seen prolapsing from the vaginal opening, we instructed the patient to perform a physical examination after walking abdominal pressure boosting, and the results were as follows: the anterior pelvic status was mild, with the prolapsed uterus in the anterior wall outside the hymenal ring, and the uterus was seen to prolapse in the middle and posterior pelvis. The posterior wall of the uterus and the vaginal mucosa were rotated forward and upward with the anterior lip of the cervix as the origin, and the prolapse of the posterior wall reached stage IV. The pelvic floor muscles were extremely relaxed, the anal sphincter was also relaxed, and contractility was reduced. The POP-Q measurements were as follows (the data in parentheses represent the data prior to the first surgery): Aa, 1(3); Ba, 2(7); C, 2(8); Ap, 3(3); Bp, 8(7); D, 10(7); Gh, 8(8); Pb, 0.7(0.7); and tvl, 8(10).\u003c/p\u003e\u003cp\u003ePhysical examination revealed laxity of the pelvic floor muscles, decreased pelvic floor support, and a markedly enlarged genital hiatus. The pelvic floor tissue was loosely organized and the anal sphincter were loose. From the analysis of the situation of the POP-Q data, the anterior vaginal wall and the anterior cervix were relatively short, which was probably due to the implantation of the anterior pelvic mesh, which was used to strengthen the anterior vaginal wall for stabilization and also played a role in lifting. The posterior pelvis lacked support and increased its degree of freedom, so in this uterine prolapse the anterior pelvis was rotated and pushed forward, resulting in a forward-rotating prolapse.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePreoperative diagnosis\u003c/b\u003e: Preoperative diagnosis: We diagnosed postoperative recurrence of stage IV POP. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e: Recurrence after first surgery (photo used with the patient's permission).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSurgical procedure protocol\u003c/strong\u003e\u003cp\u003eAfter communication with the patient and her family members, she was willing to undergo surgical treatment. Surgical treatment on 20 December, The surgical design and implementation plan were as follows.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e1. After completion of a transvaginal hysterectomy, the peritoneum of the organ layer on the surface of the uterus was folded and sutured to strengthen the peritoneum of the pelvic floor. During hysterectomy, attention was paid to the anatomical separation of the uterosacral ligament for subsequent pelvic floor reconstruction as a possible suture fixation point.\u003c/p\u003e\n\u003cp\u003e2. After determining the suspension position of the vaginal stump in the uterosacral ligament and the anterior sacrospinal ligament, a single thread non-absorbable suture was applied. Two stitches were pre-sewn on each side of the bilateral uterosacral ligament and sacrospinal ligament near the sacrum. Then, after pelvic floor reinforcement and reconstruction with mesh, the reserve non-absorbable suture was sutured and tied to the vaginal stump, and the vaginal stump was placed under (i.e. outside) the mesh. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3. A mesh was implanted at the bottom of the pelvic cavity outside the peritoneum to reinforce the urogenital diaphragm. The anterior suture was attached to the pubovesical ligament, posterior pubic ligament and arcuate pubic ligament on both sides of the bladder. Bilateral fixation was to connective tissues such as the bilateral pubococcygeal fascia, obturator fascia and pelvic fascia tendon arches. The posterior part was connected to the posterior segment of the pelvic fascia tendineae and the sacrospinal ligament, and the anterior wall of the rectum was also sutured intermittently and fixed with mesh to ensure a firm suture and to form a frame parallel to the urogenital diaphragm.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4. Repair of the posterior vaginal wall and vaginal formation,We\u0026nbsp;\u003c/p\u003e\n\u003cp\u003etaking into account the very short perineal body and the presence of external haemorrhoids, we started from the top of the residual posterior vaginal wall, cut away the excess vaginal wall tissue and proceeded downwards to separate the vaginal-rectal gap at the lower end of the vagina. We inserted a polypropylene mesh into the gap and secured the mesh to the surface of the rectum with three non-absorbable sutures at the lower end of the mesh. After being laid flat on both sides, the mesh was fixed to the surface fascia on both sides of the rectum with a non-absorbable suture. The end of the mesh was then fixed and sutured to the remaining end of the vagina, and we sutured the vaginal wound with absorbable thread, tightened the vaginal wall appropriately, and - taking into account the needs of sexual activity - ensured that there was sufficient space for vaginal dilation during suturing.\u003c/p\u003e\n\u003cp\u003e5. After suturing the vaginal stump with absorbable suture, the non-absorbable suture line reserved for the uterosacral and sacrospinal ligaments was sutured tightly to the uterus close to the sacrum to suspend the vaginal stump.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e6. After surgery, the vagina was filled with Vaseline iodoform imitation cylindrical gauze. To ensure the effectiveness of the tamponade, the insertion technique was gradually pushed into the vagina from the front to the back. When the body of the gauze had reached the end of the vagina, it was compressed and pushed backwards and upwards. We never rotated the gauze as we advanced it, so as not to cause the mesh to pile up or shift. This packing ensured that the mesh was stretched in the posterior wall and that the tissues in the rectovaginal space adhered closely together; and that the reconstructed urogenital diaphragm tissue was lifted upward as the mesh was pushed upward to ensure that the mesh adhered closely to the tissues to eliminate any dead space.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative measures and follow-up:\u003c/strong\u003eThe tamponade was removed five days after surgery, and the patient resumed a normal diet five days after surgery and was discharged one week later, with the recovery process proceeding smoothly.The patient was advised to avoid all factors that would increase abdominal pressure for three months after surgery.An eight-month follow-up visit revealed that the patient\u0026apos;s urinary reflex was good, the vagina exhibited enough space, and the vaginal mucosa was smooth and flat, showing an overall acceptable condition. Please refer to Figure 2, which shows the follow-up results eight months after the second surgery.\u003c/p\u003e\n\u003cp\u003eThe clinical-diagnosis and treatment-research plans of the two patients complied with the requirements of the Helsinki Declaration. The surgical implementation plan and the use of mesh implantation were fully explained and communicated to the patients and their families, ensuring their informed consent.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe authors concluded that contemporary surgical management of pelvic floor dysfunction is not limited to the diagnosis and treatment of current symptoms; it must also take into account the likelihood of recurrence, the occurrence of postoperative pelvic floor hernias(PFH), the timely prediction of outcomes, and the development of interventions.\u003c/p\u003e\u003cp\u003ePFH and EPS have been recognised as potential complications of pelvic floor surgery, further research is required to determine the full extent of these complications. In this article, we review the relevant literature and discuss it in the context of our case.\u003c/p\u003e\u003cp\u003eIt was previously hypothesised that PFH was a rare disease. However, there have now been several reports of complications arising from abdominal perineal resection (APR) during abdominal surgery \u003csup\u003e[\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. This type of PFH is primarily characterised by a posterior pelvic floor hernia. There have also been reports of complications arising from female pelvic floor surgery \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn the absence of high-grade clinical diagnosis or treatment evidence, the clinical diagnosis and treatment of PFH remains uncertain \u003csup\u003e[\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. It is suggested that possible PFH and EPS be considered during the performance of pelvic and pelvic floor surgery. Some surgical designs for patients with PFH and EPS have been considered and implemented by surgeons during operations \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\n\u003ch3\u003ePrevention and treatment of PFH\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003ePrevention\u003c/strong\u003e\u003cp\u003eDomansky et al\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003econducted a comparative study on the use of myoplasty for closing a pelvic floor defect after extralevator abdominoperineal excision of the rectum. Their results showed that the incidence of postoperative pelvic floor complications was higher in patients undergoing simple plastic surgery of the peritoneal wound compared to those undergoing pelvic floor myoplasty surgery.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eTreatment\u003c/strong\u003e\u003cp\u003eAlthough surgical intervention is the only effective means to prevent and treat PFH, there is currently no consensus on the surgical approach \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. The treatment of PFH includes muscle tissue flap repair and reconstruction \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e, biological patch repair and reconstruction \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e, artificial mesh repair and reconstruction, and tissue flap combined with artificial patch reconstruction surgery \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. Literature suggests that artificial mesh (polypropylene) is becoming a mainstream repair material \u003csup\u003e[15~17]\u003c/sup\u003e.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSurgical approach\u003c/strong\u003e\u003cp\u003eThe current literature focuses on therapeutic repair and reconstruction of PFH, with most reports covering abdominal surgery, particularly posterior pelvic hernia repairs.Surgical approaches include transabdominal surgery, transabdominal perineal combined surgery, and pelvic floor surgery. There is no recognised best plan\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e, and reports suggest that the perineal approach is the optimal approach for repairing perineal hernias. The two patients in our group were assigned to undergo surgery within the ready-made surgical area from the perspective of preventing PFH, without the need for additional surgical incisions and in accordance with the principle of minimal trauma.\u003c/p\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eTheoretical and clinical analysis of surgical design\u003c/h2\u003e\u003cp\u003e\u003cstrong\u003eAn examination of pelvic floor anatomy and functional analysis of cases\u003c/strong\u003e\u003cp\u003eCase 1 was characterised by a significant pelvic cavity and pelvic floor area deficit as a result of resection.The increased probability of EPS and PFH necessitated consideration of pelvic floor muscle repair of the pelvic floor. We performed reconstructive surgery with parallel mesh repair of the genitourinary septum. Postoperatively, it was ascertained that the reconstructed pelvic floor exhibited adequate carrying capacity, spanning from anatomical recovery to functional recovery. Case 2 suffered from recurrent POP with anterior reinforcement, anterior rotation of the uterus after prolapse, prolongation of the genital fissure, extreme laxity of the pelvic floor muscles and extreme shortening of the perineal body. Hysterectomy, vaginal suspension and reconstruction with urogenital diaphragm mesh reinforcement were performed. Management of the vaginal stump was the highest priority in this case and we chose to fix it to the sacrospinous ligament with non-absorbable sutures during vaginal suspension. The rest of the management was based on the experience of case 1.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConception and design guided by the theory of pelvic floor dysfunction\u003c/strong\u003e\u003cp\u003eThe mesh, which was placed in a parallel orientation to the urinary diaphragm, was designed according to the integral theory\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e of organ-muscle relationship. The reconstructed pelvic floor was closer to the natural anatomical state. The mesh was placed between the first horizontal layer, the parietal peritoneum, and the pelvic floor muscles to form a \"sandwich\" by suturing them to achieve fusion, thereby strengthening the pelvic floor, reducing erosion exposure, and serving as a vaginal suspension-support point\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e.The posterior pelvis should be treated accordingly when necessary.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eReliable mesh suspension-fixation point with regard to tissue strength\u003c/strong\u003e\u003cp\u003eThe key to the success of the operation was ensuring that the mesh remained flat and securely fixed. The mesh fixation was solid and reliable and the plane stable and not drifting or folding, to maintain the tension and elasticity and to function as a hammock. According to the above principle, the peripheral fixation position was the ligament in the pelvic wall around the interrupted multi-point suture fixation. And the mesh was sutured to the outer rectal tissue with 2\u0026ndash;3 non-absorbable sutures to prevent the formation of a gap between the rectum and the mesh. This ensured that the mesh was stitched firmly together, and that it ultimately formed a parallel state with the urinary diaphragm. Care must be taken in the suspension of the vaginal stump after hysterectomy; it must be sutured to a strong ligament around the pelvis. Anteriorly, it can be fixed to the severed ends of the round uterine ligaments \u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003c/p\u003e\u003cp\u003eKey points of the surgical operation:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e1.The mesh sutured and fixed at multiple points to the pelvic floor peritoneum to prevent it from floating or shifting after surgery.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e2.The sutures between the mesh and the surrounding ligaments should be multipoint suture fixation at different levels to distribute the pressure and prevent tearing.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e3. The incision was closed with the necessary penetrating sutures between the perineal skin and the mesh to eliminate the dead space between.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eIn summary, Mesh-enhanced reconstruction parallel to the female urogenital diaphragm maybe was an effective surgical method that leads to overall improvement in pelvic floor dysfunction, which has clinical value for preventing PFH and EPS.\u003c/p\u003e\u003cp\u003eWe only studied 2 cases in this article, and the follow-up time varied.We will select appropriate cases in the future to further expand clinical use and follow-up.\u003c/p\u003e\u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eabdominal perineal resection ..................................................APR\u003c/p\u003e\n\u003cp\u003earcus tendineus fascia pelvis ..................................................ATFP\u003c/p\u003e\n\u003cp\u003eempty-pelvis syndrome .............................................................EPS\u003c/p\u003e\n\u003cp\u003eempty-pelvis syndrome..............................................................EPS\u003c/p\u003e\n\u003cp\u003eMesh enhanced reconstruction parallel to female urogenital diaphragm........................................................................MRP-FUD\u003c/p\u003e\n\u003cp\u003epelvic floor hernia.....................................................................PFH\u003c/p\u003e\n\u003cp\u003ePelvic organ prolapse................................................................POP\u003c/p\u003e\n\u003cp\u003ePelvic organ prolapse quantification ..................................POP-Q\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u0026nbsp;Ethics approval and consent to participate:This article describes the Innovative surgical methods and procedures accepted and agreed to by the patients and approved by the Medical Ethics Committee of the Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, China. (Approval No. 2025020), and was conducted in accordance with the tenets of the Helsinki Declaration of 1964 and its subsequent amendments or equivalent ethical standards. Informed consent was waived by our Institutional Review Board because of the retrospective nature of our study. Consent for publication.\u003c/p\u003e\n\u003cp\u003eConsent for publication:\u003c/p\u003e\n\u003cp\u003e•Written informed consent for publication of clinical details and/or clinical images was obtained from the patient.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials:Not applicable\u003c/p\u003e\n\u003cp\u003eConflict of interest: All authors declare that they have no conflicts of interest.\u003c/p\u003e\n\u003cp\u003eFunding:The authors declare no funding source.\u003c/p\u003e\n\u003cp\u003eAuthors' contributions:\u003c/p\u003e\n\u003cp\u003e•\u0026nbsp;Y Liu: Data collection , Patient follow-up，Manuscript writing\u003c/p\u003e\n\u003cp\u003e• ZJ Li: Patient follow-up，Manuscript writing\u003c/p\u003e\n\u003cp\u003e• K Qian: Patient follow-up\u003c/p\u003e\n\u003cp\u003e• ZG Luo: Surgical design, Data Collection, Manuscript writing\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgments: We thank LetPub (www.letpub.com.cn) for its linguistic assistance during the preparation of this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eM. 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Uterosacral ligament dissection during McCall culdoplasty to prevent ureteral kinking, and round ligament fixation to support vaginal vault: a new surgical technique.McCall Med Sci Discov. 2022;9(9):485\u0026ndash;7. https://doi.org/10.36472/msd.v9i9.810.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"pelvic floor reconstruction, pelvic organ prolapse, transvaginal mesh, pelvic floor hernia(PFH)","lastPublishedDoi":"10.21203/rs.3.rs-6950357/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6950357/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe anatomical and functional defects of the female urogenital diaphragm have been shown to present complications such as recurrence, pelvic floor hernia(PFH), and empty-pelvis syndrome(EPS);after certain surgical treatments. which should be taken seriously in clinical practice and necessary preventive measures should be taken.Based on two cases of defects/severe weakness of the urinary diaphragm, we designed a Mesh enhanced reconstruction parallel to female urogenital diaphragm(MRP-FUD), and our postoperative follow-up results were favorable. the parallel mesh used to enhance reconstructive surgery of the female urogenital diaphragm could also be used to supplement and enhance the anatomical and functional defects of the female basin, and thus exhibits potential clinical value.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number: \u003c/strong\u003enot applicable.\u003c/p\u003e","manuscriptTitle":"Mesh-enhanced reconstruction that parallels the female urogenital diaphragm: a surgical technique and case study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-11 07:08:04","doi":"10.21203/rs.3.rs-6950357/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fa06ed94-4d90-4325-8ec9-94a0f1f4f905","owner":[],"postedDate":"August 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-22T11:23:23+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-11 07:08:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6950357","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6950357","identity":"rs-6950357","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}