function. First of all, I'm Roger Goldberg. I'm one of the course co-directors with Miles. He's really the guy who's put this all together. But I'm at University of Chicago Endeavor Health. Spent the better part of really most of my career, if not all of it, trying to focus not only on clinical practice, but also innovating new solutions. It's just part of the DNA of how we think at our institution. And a lot of that is done vaginally, although we do use all methods, robotics. My partners do straight stick. But we do a lot of vaginal surgery. You'll see later on this morning with grafts and mesh. And it may fit or not fit your practice, but I'll share with you what we do. And hopefully it'll just provide some additional dimension. This is some of the most interesting work that I've come across in my career. I find it incredibly exciting. It's a whole new patient population that's right under our nose. Those women that have bowel dysfunction, whether that's obstructive defecation or rectal prolapse, these patients you're seeing every day, or at least every week. And as you're a gynecologist, just like with incontinence 30 years ago, we as women's health providers really weren't taking care of this. I think this is where we belong. And so we've developed diagnostic techniques and new solutions that I think are really, in my opinion, have the possibility of changing that reality. I don't know if I'm out of range here. So my financial disclosures are in the brochure. Are you going to have to advance for me? OK. Sorry. OK. No problem. So you can just move it along. If you want to unfold each slide, that's perfectly fine. So why should you care? About 30% of women in the world have constipation. And about 50% of those cases are categorized as obstructed defecation, or ODS. That means about 18% of women, this is published literature, have ODS. Among patients with pelvic organ prolapse, some of the published literature suggests the rates are as high as 68%. That's probably a loose definition. Not all those women are horribly bothered. Some of them might be miscategorized as slow motility. But these patients are there. Whether we say this is inflated or right on target, we have an opportunity here. There's no question this is a major quality of life impact. If you talk to women, especially with bad ODS, this can be their number one problem. Right up there with incontinence and prolapse and other pelvic abnormalities, I like to call this the hidden PFD that we need to start paying attention to. And we're really, in this room, we're the ones best positioned to change the reality. So this is an evacuation problem. ODS, if you don't mind unfolding this whole slide, ODS is an evacuation problem. It's truly a pelvic floor disorder in that this is a physical detachment, which results in the rectum coming loose in many cases, not all. But it's often a physical loosening of the rectum, sort of an apical defect of the rectum, kind of like apical defect of the uterovaginal supports. And that results in breakdown of the physics. Stools get trapped in these pockets. The rectum's moving as the woman tries to evacuate. And then you have straining and splinting and positional changes and often multiple bowel movements per day. As opposed to the upper tract constipation, where a woman might skip three, four days between movements, here you have a woman who never feels empty. She's always got to do something, lean forward, use a squatty potty, push with her fingers. And that's very frustrating. Next slide. Yeah. Splinting, you probably all know, is placement of the finger around the vagina, perineum, or buttocks. And you can find women that do this vaginally or around the buttock area, sometimes even on the front end. Next slide. So what's causing this patient's ODS? So we see this patient every day. She's got a little posterior defect. 61 years old, not a huge prolapse, but it's there. Never feels empty. She's going all the time and splinting to complete her bowel movements. Well, when I was growing up as a young attending, I would counsel these women that, ma'am, you've got a rectocele. And I thought in my mind, surely that's where the stool's pocketing. I can see it. There's a bulge right there at the surface. Turns out the plot thickened. That's not exactly what's going on. Next slide. All the potential causes need to be considered. Sure, occasionally, when we fix a rectocele, the patient will improve. It is sometimes the actual vaginal pelvic organ prolapse. Once in a while, we'll have a dyssynergia, a patient who truly has a discoordination between relaxation and the mechanics of exiting. But I would argue that in many, if not most cases, this is a physical abnormality. And I'll show you how we've come about that conclusion. Typically, over the years, the mantra was fix the rectocele. And we would all hope for the best. Next slide. But we've had it all wrong. Posterior coporaphy cures the vaginal bulge. But it generally, generally is not reliable in improving bowel function. And we've known this for decades. It goes back to the research from the 1980s. Next. Here are just some examples. Stuart Stanton, 1997, looked at posterior coporaphy. Decreased vaginal bulge symptoms beautifully. But ODS and defecatory symptoms were actually more common in this particular study. Ingrid Nygaard is just an example. I'm just pulling out of the literature, looking at the long-term sacrocopalpexy care study outcomes. And posterior coporaphy offered no improvement even in that context of ASC patients undergoing posterior coporaphy had no particular benefit to stool exit. So we decided, really, this all came about when I took in a fellow who's since become my partner. And she was already kind of a widely published author and upcoming expert in pelvic floor imaging. And we sat together and we said, well, let's get us going on some ultrasound research. Let's get going on some ultrasound research. And let's try to understand, if we can, if we can get a little bit closer to this underlying defect in a way that would be diagnosable for the average woman without using necessarily MRI. And can we come about better solutions? So our premise was that we've been ignoring the ODS. We've been blaming the wrong defects. Well, what are the right defects? And our feeling was that rectal support was the key. And so we went looking for that defect with ultrasound. And then, of course, to innovate a better cure, which is, as I mentioned, that's usually our goal, is to try to see if we can apply minimally invasive vaginal tools to cure this forgotten PFD. Can you play this? I don't know. This is just an example. This is one of my patients who I had her bear down. This is very different than what we were looking at in the previous slide with that small rectocele. Here you see a descent, peroneal descent. And we know peroneal descent is a proxy for levator ani injury. If the peroneum descends two centimeters below the tuberosities, you can call that, quote unquote, peroneal hypermobility. And we know that that reflects a levator structure that's ballooning. We also know, now that we've ultrasounded thousands of these women with rectal support defects, typically this is going to often overlay with rectal motion, rectal hypermobility that starts to affect bowel dysfunction. This is not a one-to-one match. These phenotypes are very different from patient to patient. But as you start to examine patients in the office, I would encourage you, don't just look at your POPQ points. Look for this peroneal ballooning for this global pelvic floor relaxation, because that's going to give you at least a mental insight of what might be going on inside. Go ahead. Next slide, please. Oh, actually, I'm controlling. And here's just an example. Then take it one step further. You'll start to see that some of these patients with peroneal ballooning pay attention to the anus and the rectal supports. And you'll start to see not hemorrhoids. That's what often they're described as when you take the history. But you're starting to see early rectal prolapse, or even worse. This is not our revelation. I mean, we know that rectal support defects exist. And that's been described with various names. We call it rectal hypermobility, because it goes along nicely with our verbiage in this field. But intussusception, rectal folding, incomplete rectal prolapse, as opposed to complete. And we know that those defects are purported to start about 6 to 8 centimeters up the rectum. So again, sort of an apical defect to the rectum, resulting in support loss. But the supports are very analogous to the vagina and the uterovaginal compartments, because they have other components. They have posterior components, just like our, let's say, uterosacral ligaments. Well, the rectosacral fascia is a thick fascial reflection that's bolstering the rectum in the posterior dimension towards the sacrum. There are lateral components, just like our paravaginal supports. The rectum needs to be suspended, or should be suspended, ideally, with the lateral ligaments that extend from the pelvic sidewall to the lateral aspect. And then there are anterior attachments that are weaker, but they're there. The denoviase fascia, which is sort of the vaginal side attachment of the rectum. And sometimes in surgery, you might find yourself playing with those supports or seeing that there's more of a defect in that rectovaginal space. And we'll get to that in a minute. One of the reasons we've, I think, done such a poor job of identifying these women is there's really a lack of a good, feasible, cost-effective diagnostic test. And I overheard yesterday, there was some chatter about MRI deficography. And I had a patient just the other day that sounded like what I was overhearing, where they described this massive or advanced rectocele. And this patient freaked out. She had had prior surgery. She came into the office. Her exam looked perfect. So first of all, with MRI, there's some discoordination between the anatomic definitions they're using and what we're seeing, as opposed to ultrasound in the office when you're doing it, where we can really correlate the physical exam to exactly what we're seeing. As John Delancey said, it's like opening the hood of a car. You can see the inner workings of what's moving. Well, you can do that in real time with the patient valve salving, correlating that with your POPQ, and what you can do as a physician or as a surgeon. So using these real-time dynamic clips in the office has been a game changer for us. I was very skeptical. When I got my institution to buy Dr. Rastami a 3D ultrasound machine, I thought this was a research tool. I thought we'd be staring at levator defects and pondering and postulating and publishing on the podium just for research purposes. That wasn't interesting to me. But we found now our real-life defects, just like our vaginal defects, but we couldn't see them before. And they're just in a deeper plane. They're easily seen with dynamic video clips. You don't even need the 3D, although that's an incredibly interesting technology to have for diagnosing other things, like anal sphincter defects and finding mesh if you don't know where it is. But it's really these dynamic clips that show you the story. We started to just ultrasound a lot, a lot of women. We started to look at how this correlates with ODS. We found an incredibly predictable point of detachment, about 8 centimeters up the rectum. And this was an apical defect of the rectum that didn't vary a lot. So you either had a good attached proximal rectum or you didn't. And that correlated with function. So here's abnormal rectal motion. And the right side of the screen here is a pointer. And the right side of the screen is the lower end of the screen here is the rectal tube. Right side is the anus. Left side is the cul-de-sac, basically. And so you can move this slide along if you want. I think you just, oh, sorry, that's me. Let me do this next one. This might show a little bit better. So here you can see a control. So you can see the rectal tube aligned on the bottom. I would point if I could. But there's really little motion with the patient fell salving. The left side of the screen here is staying fairly static, the left side of the tube, as opposed to abdominal constipation, which is actually exactly the same. So you have a lot of women that are constipated. You have them bare down. And the rectum on the left side of the screen doesn't move at all. But the pattern that became interesting was, all right, let's take our ODS group. And the left side of the screen on the bottom starts to deflect sometimes all the way. Well, the entire rectum is collapsing inside the body. This could be a patient with zero rectocele. This could be a 39-year-old with a minus 3 posterior points. And so we were like, huh, this is really a totally separate plane of motion. And this is correlating with incredible statistical power to function. So we developed a measure that we've published since, which is quantifying this deflection of the rectum. It's called compression ratio. And it's simply a percentage shortening of the rectum. So it's like 100%, 0%, and anywhere in between. And we call it compression ratio because our biomechanical engineer we were working with at UPIT thought this looked like kind of a crushed can. And so that's been a really nice thing, even research-wise. And it's now involved in our surgical decision-making. As we found that a compression ratio of greater than 50%, these tend to be the women that we would consider for surgery. And I'll get to surgery in a minute because this is a clinical course, but this is all the back story. This is just some of the statistical power that ODS was up to 31 times more likely among women with a high compression ratio. And then we started to stratify compression ratio and found that severity of ODS was in each strata correlating with higher and lower numbers. So higher compression ratio, worse ODS. More likely to be a possible surgical candidate, or at least to be discussed. Interestingly, in our work, just like Stanton, just like in the CARE study that I showed you, rectocele was zeroed out. It had absolutely no correlation. Once we did our multivariate analysis, there was no effect of rectoceles at all. You could have a big outie in the posterior compartment. It had no bearing on emptying. And that was fascinating. So it just didn't seem to be part of the story statistically in this large cohort that we were studying. So getting to the repair, you'll see in the second talk that I give today that we've done a lot of work on sacrospinous-based methods. And most of those, all of those to this point had been used for vaginal surgery. But as I was looking at this defect of the rectum, and we were looking at its anatomic position, and even correlating with MRI validation, I was like, God, this rectum, the apical detached part of the rectum, it looks like it wants to be on the sacrospinous ligament. It's right there. It was literally a distance of one centimeter. And so the sacrospinous just seemed like the right support. We thought about developing slicker abdominal repairs, but it was unavoidable that this was the right anatomic position. In fact, it was the better posterior deflection as compared to ventral mesh rectopexy. It was putting the rectum exactly where it wants to be. And so we got to work. We ran a trial. And we, again, this is some of the MRI work that we had done in the biomechanical modeling, showing that this was the spot that we were going to use, the sacrospinous ligament. And so this was the right apical rectal support. The goals were safety. I mean, this is the rectum. We're not used to handling the rectum on a daily basis. So we don't want to injure the rectum. We want this to be quick and minimally invasive. That's kind of our mantra. Eliminate the risk of mesh, if possible, and ability to combine with POP surgery. And again, covering that short distance. The key is finding the right part of the rectum and standardizing the depth and not injuring the rectum in the process. And we're working on better and better methods for that all the time. So this is a case study. I'm actually going to show you a different patient's video. But this was a 53-year-old early in when we were presenting. Typical case, she was straining with more than 50% of her bowel movements. Dynamic ultrasound here showing a high compression ratio. Having bowel movements all throughout the day and splinting all the time. She opted for sacrospinous rectopexy. In this slide, I kept in here just to show you her rectum then being stabilized with the low compression ratio and total resolution of her ODS. No surgery is perfect, but this case series now, we're looking at five-year outcomes. It's been amazing. So we're seeing now, I think, 84% at five years. And I'll show you how we're moving the techniques along. This is interesting. So this is a 39-year-old. I know that's pretty young. But she actually flew in to us because one of my colleagues knew that we were doing this work. She has EDS, is done having her kids, has rectal bulging, and bad, bad ODS. Not a lot of prolapse, but very lax, sort of just more of a widened introitus. And this is a really pared-down video. But she's done great. This was about, I think, a year and a half ago now. I talked to her recently. And she has no ODS, no rectal prolapse at the present time. So this is just, at the time, using the Capio. And this is a bilateral approach, posterior approach. These are PDS sutures. And you'll see, in her case, we did the rectopexy, which she was so mobile that there was an opportunity. Sometimes it can be quite hard. Obviously, here, rectal injury, proper depth, proper position. We're working on standardizing all of that. The rectum in the middle, as well. A lot of people ask, well, is it just these two lateral attachments? No. In a patient like this, with such laxity, there could be a number of other techniques that we'll use. The midline, where you may, remember the denoviase fascia I was talking about? You may reestablish some connectivity between the rectum and the apex. As well as, sometimes, you'll even find lateral defects for real rectal prolapse that we will stabilize laterally toward the levator. So having done a lot of this now, we're sort of working through the details. And this is still a work in progress. This isn't something that I'm saying at a clinical course, go start doing on Monday. So don't feel that way. The purpose of this is really to suggest this is where the field should be moving, and we should do it safely. Sorry, I thought this video was a little bit more edited down. But you can see the final outcome here. She's done great. And she's back in St. Louis. And I talked to her a couple of months ago, and she's had a really awesome outcome so far. So that was a nice visual case with her laxity. We've published some of this, and I won't go into too much. I'll just get to the other videos and leave a little time for Q&A. The original study involved a cohort up till 2020. This was a bilateral technique that's published, if you care to look, with one-year outcomes. That was everyone who had reached one year. Very safe, very effective. And the incomplete straining was highly correlated with the stabilization according to the compression ratio. So it all did seem to pan out as expected. Long-term follow-up was recently reported. 190 patients with up to five-year follow-up. 87% was the reported subjective improvement. So that was higher than I just guesstimated a minute ago. And 77% with the compression ratio being objectively better according to criteria. There were two rectal injuries. So this is a surgery. These were both on the approach. These were both during the dissection. They didn't happen to be my cases, but it could happen to me. So we have to be humble about this is not the vagina. It is the rectum. And so it's a reality that we have to just operate carefully and refine these techniques before we necessarily advocate them for everybody. I'm going to show you now something really cool. This is an advanced rectal prolapse that we did. And this was sort of an emerging approach that I won't get into today. But I just want to show you more as an example of where we think the ball could be bouncing. This is an older woman. We had two similar cases like this on the same day. She had no other options. There wasn't a colorectal that would operate on her. She was absolutely miserable. Her family said, we will gladly enroll for any reasonable minimally invasive surgery that will help grandma. And we're just working with them. It's just a different setup here, which again, I won't get into today. But it's just to show you how we're trying to integrate things and improve techniques. So this is just a, sorry, I can't fast forward. But this should be a very quick video once we get these in. This woman was very severe. I think we did. This is a different system, unrelated to that, though, to answer your question. This particular system, we used about at least two anchors on each side. I'd have to look back to see. And then also lateral rectal support, I think. But it was mostly the apical lift here with the two anchors on each side. Here's this. Yes, here's the second one. I mainly just want to show you the outcome here, because this is not a technique that's available at this time. But it's sort of a depth-controlled system. So these patients, as you may well be aware, they just don't have anywhere to run. I mean, less so these ladies. The colorectals will usually be willing to help a woman like this. But they're often not medically appropriate at that stage. Whereas the ODS, which is the same phenomenon, it's just a lesser degree of sliding. The ODS, these patients usually get no help at all. I'll just wait for my partner to tie down a few stitches. And I just kind of want to show you the end. She's done amazing. She's still within the first year of follow-up. But that's her outcome. I mean, proof of concept, if nothing else. Look what we just did as vaginal surgeons. I mean, we had a colorectal surgeon in the room. His mind was like blowing up. It was like the emoji. He was like, I cannot believe what I just saw. So will she hold up at five years? We don't know yet. But will we need to incorporate other elements of the principle to make sure she does hold up long term? Maybe. Or maybe there's scars. But I can tell you that, with the first five years of experience, nothing's perfect. But this is kind of an unbelievable cohort. So I'll move on beyond that. So I guess I want to say, as I conclude here, that I've shown you kind of the wow factor of the new surgeries that we're trying to develop and put safely into the hands of everybody. But as Holly was alluding to, this is a comprehensive approach to a very, very complicated situation. I always tell patients, the bowels are not the bladder. We've got an upper track. We've got a lower track. As human adults, we are all going to have to play detective with how our bowels are working. This has to do with how you're processing foods. It has to do with, yes, pelvic supports. But it really has to do with your fiber intake, your exercise, your activity, pelvic fitness, so much. So every single patient that leads to that kind of surgery, they've gone through that comprehensive view. And that starts with, is it up or is it lower? If it is isolated, lower. Like, no, this is a woman who tries to defecate six times a day. She never feels empty. I'm always splinting. You've probably got a good candidate in your hand. But a lot of these women will be ruled out as abdominal constipation. And those are women that are skipping two, three, four days at a time. And get good at all those medications that Dr. Richter was talking about. Don't be scared to become a little bit more of an expert and confident in prescribing these, quote, unquote, GI medicines. The reason is, the GIs aren't really prescribing them, because they're not seeing these patients. So we need to be the ones to kind of push that left side of the algorithm. And that's critically important, because you never want to operate on somebody unless they're likely to benefit. But if they have no dyssynergia, which I've found that to be a very small part of my population, because maybe because we deal with pelvic floor weakness, then if they wind up in this last category, I should mention, virtually everybody does physical therapy. Nobody goes to surgery without that. But if all else has failed, then we think we're honing in on some rectopexy options that will hopefully be applicable to the average. I say average. None of us are average. We're all exceptional. To the gynecologists, not to waiting to see if we're lucky that we have the compassionate women's health-focused colorectal at our institution. We know that's rare. This should be in our hands, and we should be helping these women. So in summary, this is a pelvic floor condition. It's very analogous to an apical defect of the vagina and the uterus. It has those lateral, apical, and posterior supports. It all makes sense to us in the language that we understand. Rectal hypermobility is urethral hypermobility. It's uterus-sacral hypermobility. We just need to learn how to fix it with a reasonable morbidity. We should be the experts. And again, rectoceles, I repair them every day, but that's really more of a vaginal cosmesis. It's not really, for the most part, it's not really going to be a reliable strategy for repairing ODS. And then the ultrasonography, I really am a believer in that now. It's not an inexpensive purchase, but it is very revealing. Even as a skeptic, as I started to now get comfortable doing ultrasound, including 3D, it's just a nice tool to have in the office, obviously, depending on what your focus is. It's not worth it for a once-every-three-month evaluation, but really great if it just becomes more part of your regular offering. Patient comes in now for an initial patient visit, and if she drove a distance and I want to learn everything on the first day, I can roll in the ultrasound machine. It gives you a lot of flexibility, as opposed to MRI defecography. So thank you. I'd be happy to stay in touch if anybody has any questions. Thank you. We have a mic here if anybody has questions. Thank you, Roger. This is so great. I have a patient who I did sacral colopixy and posterior repair about a year and a half ago. And then she had abdominal constipation after, went to GI. They sent to colorectal. Colorectal didn't want to do anything. And then she got sent back to me after she had a defecogram showing a little anterior rectocele and an enterocele. So when you look on exam, the POPU, not much. Then you do a rectal exam, maybe a little bit more, but still ODS symptoms. So of course, she's in pelvic PT. I said, let's book surgery like five months from now. Let's do good at least three months of pelvic PT. And if things are better, maybe cancel. I can do a repeat rectocele repair, but we've got to stop a vicious cycle of chicken and the egg with abdominal constipation and other pelvic floor issues. But this is just fascinating because I feel like this might be right up her alley. I'm a couple of questions besides if I was going to do a repeat rectocele repair. When you do this, it seems like you would also close the gap in an enterocele when you do that rectopexy. Or if something presented in a defecogram with enterocele, do you approach that differently? Well, let me say I haven't done what I used to consider an enterocele repair, like ligating the sac. I haven't done that in a very, very long time. And I don't know that that was a conscious decision to stop doing that. But I feel like these sacrospinous-based suspensions sort of snap shut the cul-de-sac because whether it's the rectum or the vagina, you really are kind of getting this posterior deflection. And enterocele is almost by definition being corrected in the process. But I think you're right. First of all, we've seen these cases because we're now attracting some of these referrals. But the anterior deflection of the ASC opens the trap door a little bit, I think. And so even though probably if we put in our robot or laparoscope, it's not going to look like much happening. I think the anterior deflection has given the rectum more opportunity to move. It was probably right on that edge to begin with. Yeah, because the apex is well-supported, but it's almost like a pulsion enterocele, right? And then the MRI, fascinatingly, always diagnoses it incorrectly as a rectocele. But I don't think that's what's going on. It's more rectal motion and deflection vertically. It's not like bulging into the vagina. It's actually just sliding. So that's case by case. But we've seen those patients. We've been able to help them. And as far as in a conscious way, repairing an enterocele, making that one of our surgical goals, not really. The enterocele, though, is a big part of this story. So I wouldn't rule it out. On these scans, you'll see rectal motion, sometimes with the big accompanying enterocele. So I would say, yes, fix it, whether that's just that it looks like it's been fixed by virtue of the rectopexy, or close and ligate the sac if you feel that it's clinically appropriate. But those are real case by case. When you do the rectopexies, you're doing about half the thickness of a rectum? Yeah, that's where it gets nuanced. We've been doing this now for five years. And some of these corners are dark and deep. And you've got a finger in the rectum. We're probably, with my fellows no less, they're usually in there operating as well, at least on one side. So there is variability to rectal thickness. We're working on techniques right now to standardize all that. I would say, really, as somebody who's tried to teach and develop techniques in the past, I would say this is not like a one-off. I wouldn't necessarily do this if you're not doing a lot of sacrospinous, and if you're not dedicated to getting really good at it. Because the rectal thickness is critical. We've had a few rectal injuries. Those patients did fine, but that's not a small consequence. But I anticipate if you do rectal injuries, it's primary closure just like a colorectal would do. And do you fix that just with Vicryl? I mean, yes. I mean, you do a double layer, exactly. Obviously, our patients have done well. We had two in the series. It was learning curve, basically, with one of our partners. But yeah, I mean, there's nothing magical, I guess, about fixing a rectal injury. But it is more consequential than a bladder injury, for example, if that healing doesn't occur properly. Great. Thank you. Are you using PDS? Yeah, we're using PDS for all these, exactly. Thank you. Yeah. It's Capio. So that's a 2-0. Yeah, me. Any other questions? OK, well, I am a believer in this, because I think many of us have seen these patients. And similar to Andrea's story, and I've approached a couple of those patients by doing the thing that I talked about yesterday, essentially like a posterior uphold with a graft, which functionally is now occurring to me is doing a lot of this, but just not attaching to the rectum. So I guess I'm just curious about that. I have just, out of trying to find solutions, done that, where I put a bilateral sacrospinous with a graft essentially across the middle of it. What are your thoughts about that versus stitching into the rectum? So we're working on that. I mean, that's part of this overall project is to see. I mean, the non-mesh cases have done so well that right now there's not a huge impetus to suddenly switch gears. Could be that seven-year outcomes show that you just don't have enough durability, but 87% at five years so far without any of the risks of mesh is pretty compelling. Mesh against the rectum is obviously going to have different, even if it's a net of one, if you have a few of those complications, that's more of an issue. I'm not talking about permanent mesh. I'm saying a biologic graft. Graft, yeah, and that too. So that's part of the discussion. Again, it's just been the strength of the native tissue outcomes that has slowed us in making some kind of quick pivot to using the biologics. Probably the risk benefit there is going to be less of an issue, and we're planning to do a cohort with that in mind.

obstructed defecation syndrome

pelvic floor disorders

minimally invasive surgery

sacrospinous rectopexy

rectal support

ultrasound diagnostics

gynecological care