This review describes our experience with native tissue repair of the visceral pelvic fascia, the perineum, and anal sphincters in women. We propose that complex repair of the pelvic floor should consider vaginal support in all three anatomical Delancey's levels, together with more caudal structures-the external and internal anal sphincters. Original illustrations were created to facilitate the understanding of the complex anatomy of common multi-level defects. As the integrity of connective tissue adds to various aspects of the delicate function of the female pelvic floor, it is complete and as perfect as possible repair is a common goal of both gynecologists and colorectal specialists.

• Klíčová slova
• anatomy, birth trauma, endopelvic fascia, incontinence, obstetric anal sphincter injury, pelvic organ prolapse, proctology,
• MeSH
• anální kanál * chirurgie   MeSH
• fascie MeSH
• gynekologické chirurgické výkony * metody   MeSH
• lidé MeSH
• onemocnění dna pánevního * chirurgie   MeSH
• pánevní dno * chirurgie   MeSH
• perineum chirurgie   MeSH
• prolaps pánevních orgánů * chirurgie   MeSH
• vagina chirurgie   MeSH
• Check Tag
• lidé MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH
• přehledy MeSH

INTRODUCTION AND HYPOTHESIS: Injury of the levator ani muscle (LAM) is a significant risk factor for pelvic organ prolapse (POP). The puborectalis (PRM) and pubovisceral (PVM) subdivisions are level III vaginal support structures. The null hypothesis was that there is no significant difference in patterns of LAM subdivisions in healthy nulliparous women. Secondarily, we evaluated the presence of different LAM injury in a POP-symptomatic cohort. METHODS: This retrospective magnetic resonance imaging study included: 64 nulligravidae without any pelvic floor dysfunction (PFD) and 526 women of various parity with symptomatic POP. Primary outcome was PVM and PRM morphology on the axial planes: the attachment site on the pubic bone, and the visible separation/border between the PVM and PRM. The attachment was scored as "normal" or "abnormal". The "abnormal" attachment was divided in two types: "type I"-loss of the muscle substance, but preservation of the overall muscle architecture-and "type II"-muscle detachment from the pubic bone. RESULTS: The puboanal muscle (PAM) subdivision was evaluated as a representative part of the PVM. The PAM and PRM attachments and separation were distinguished in all asymptomatic nulliparae. PAM and PRM attachments did not significantly differ. POP group characteristics were parity 1.9 ± 0.8, instrumental delivery 5.6%, hysterectomy or POP surgery 60%, all Pelvic Organ Prolapse Quantification (POP-Q) stages, LAM defect 77.6% (PRM: 77.1%; PAM: 51.3%). Type I injuries were more frequent (PRM 54.7%; PAM 53.9%) compared with type II (PRM 29.4%; PAM 42.1%). CONCLUSIONS: A LAM defect was present in 77.6% of women with symptomatic POP. In PRM and PAM subdivisions type I injury was more frequent than type II.

• Klíčová slova
• Attachment patterns, Levator ani muscle, Level III, Magnetic resonance imaging,
• MeSH
• lidé MeSH
• magnetická rezonanční tomografie MeSH
• pánevní dno zranění   MeSH
• prolaps pánevních orgánů * diagnostické zobrazování   etiologie   MeSH
• retrospektivní studie MeSH
• těhotenství MeSH
• vagina * diagnostické zobrazování   MeSH
• Check Tag
• lidé MeSH
• těhotenství MeSH
• ženské pohlaví MeSH
• Publikační typ
• časopisecké články MeSH

INTRODUCTION AND HYPOTHESIS: It is reported that almost one in five women will need some form of pelvic organ prolapse surgery in their lifetime, with anterior wall repair accounting for nearly half of these. Cystoceles occur secondary to defect(s) in one or more of the vaginal wall support mechanisms, including its lateral paravaginal attachments. Paravaginal defects are very common in women presenting with cystocele, thus highlighting the importance of paravaginal defect repair for optimal cystocele correction in the majority of cases. Although there are several paravaginal defect repair procedures, some entail complex techniques, whereas others rely on the use of transvaginal mesh, which is currently not permitted in many countries. METHODS: In this video article we present a novel trans-obturator native tissue paravaginal defect repair for the management of cystocele. RESULTS: This procedure has the advantages of avoiding complex transabdominal paravaginal defect repair, the controversial use of transvaginal mesh, or a single-point fixation to an arcus tendineus fasciae pelvis that might be difficult to identify. CONCLUSION: We believe that the trans-obturator cystocele repair procedure offers several advantages over existing paravaginal defect repair alternatives.

• Klíčová slova
• Arcus tendineus fasciae pelvis, Cystocele, Native tissue, Obturator paravaginal, Repair, Transobturator,
• MeSH
• břicho MeSH
• chirurgické síťky MeSH
• cystokéla * chirurgie   MeSH
• fascie MeSH
• lidé MeSH
• prolaps pánevních orgánů * chirurgie   MeSH
• vagina chirurgie   MeSH
• Check Tag
• lidé MeSH
• ženské pohlaví MeSH
• Publikační typ
• audiovizuální média MeSH
• časopisecké články MeSH