Is levator avulsion a predictor of cystocele recurrence following anterior vaginal mesh placement?

A Randomized Clinical Trial Comparing Dubuisson Laparoscopic Lateral Suspension with Laparoscopic Sacropexy for Pelvic Organ Prolapse: Short-Term Results

BACKGROUND

Laparoscopic sacrocolpopexy (LSC) is the gold standard for the treatment of apical prolapse, although dissection of the promontory may be challenging. Laparoscopic lateral suspension (LLS) with mesh is an alternative technique for apical repair with similar anatomical and functional outcomes, according to recent studies. The purpose of this study was to compare these operative techniques.

METHODS

Women with uterine Pelvic Organ Prolapse Quantification (POP-Q) stage 2 were enrolled in this prospective study and were randomly allocated to the LLS or LSC group. At the 12-month follow-up, primary measures included both anatomical and functional outcomes. Perioperative parameters and complications were recorded.

RESULTS

A total of 93 women were randomized, 48 in the LLS group and 45 in the LSC group, with 2 women lost to follow-up in both groups. LSC anatomic success rates were 81.82% for the apical compartment and 95.22% for the anterior compartment. LLS anatomic success rates for the apical and anterior compartments were 90% and 92.30%, respectively. The mean operative time for LLS was 160.3 min, while for LSC it was 168.3 min. The mean blood loss was 100 mL in both procedures. Conversion to laparotomy was necessary in three women. Mesh erosion was not observed in any of the cases. In terms of the complication, Clavien-Dindo grade 1 was observed in two patients in the LLS group and a complication rated grade 3b was observed in one patient in LSC group.

CONCLUSIONS

LLS is a good alternative to LSC, with promising anatomical and quality-of-life results.

Validation of a built-in software in automatically reconstructing the tomographic images of the levator ani muscle

INTRODUCTION AND HYPOTHESIS

Transperineal ultrasound (TPUS) is an effective tool for evaluating the integrity of the levator ani muscle (LAM). Several operating steps are required to obtain the standard multi-slice image of the LAM, which is experience dependent and time consuming. This study was aimed at evaluating the feasibility and reproducibility of the built-in software, Smart-pelvic™, in reconstructing standard tomographic images of LAM from 3D/4D TPUS volumes.

METHODS

This study was conducted at a tertiary teaching hospital, enrolling women who underwent TPUS. Tomographic images of the LAM were automatically reconstructed by Smart-pelvicTM and rated by two experienced observers as standard or nonstandard. The anteroposterior diameter (APD) of the levator hiatus was also measured on the mid-sagittal plane of the automatically and manually reconstructed images. The APD measurements of each approach were compared using Bland-Altman plots, and interclass correlation coefficient (ICC) was used to evaluate intra- and inter-observer reproducibility. Meanwhile, the time taken for the reconstruction process of both methods was also recorded.

RESULTS

The ultrasound volume of a total of 104 patients were included in this study. Using Smart-pelvicTM, the overall success rate of the tomographic image reconstruction was 98%. Regarding measurements of APD, the ICC between the automatic and manual reconstruction methods was 0.99 (0.98, 0.99). The average time taken for reconstruction per case was 2.65 ± 0.52 s and 22.08 ± 3.45 s, respectively.

CONCLUSIONS

Using Smart-pelvicTM to reconstruct tomographic images of LAM is feasible, and it can promote TPUS by reducing operator dependence and improving examination efficiency in a clinical setting.

Risk factors for the recurrence of pelvic organ prolapse: a meta-analysis

Female pelvic organ prolapse (POP) is a common condition, which has a high recurrence rate after reconstructive surgery, and the risk factors for POP recurrence are unclear. The aim of this study was to perform a meta-analysis to determine risk factors for POP recurrence. A thorough search of PubMed, Medline, EMBASE, Cochrane Central Register of Controlled Trials, and China Academic Journal Network Publishing Database was conducted for relevant publications until 29 October 2022, without language restrictions. A total of 29 studies involving 6597 patients were included, and the recurrence rate of POP after surgery was 37.7%. Significant OR and CI were found for levator avulsion (OR: 2.46, 95% CI: 1.80-3.36), preoperative stage ≥ III (OR: 1.87, 95% CI: 1.53-2.27), hiatal area on Valsalva manoeuvre (OR: 1.08, 95% CI: 1.03-1.12) and previous pelvic floor surgery (OR: 1.60, 95% CI: 1.07-2.39). Levator avulsion, preoperative stage ≥ III, hiatal area on Valsalva manoeuvre and previous pelvic floor surgery are significant risk factors for POP recurrence.IMPACT STATEMENTWhat is already known on this subject? It has been reported that genetic factors, parity, obesity, birth-induced injury during delivery, etc. are risk factors for POP development and recurrence after operation.What do the results of this study add? There are few literatures about the risk factors of POP recurrence at present. Our research has increased the information regarding risk factors for POP recurrence.What are the implications of these findings for clinical practice and/or further research? Our study provides an overview of the risk factors affecting POP recurrence and their contribution (OR, CI) to POP recurrence, which provides valuable evidence-based basis for clinical decision-making in POP treatment and prevention of POP recurrence.

Summary: 2021 International Consultation on Incontinence Evidence-Based Surgical Pathway for Pelvic Organ Prolapse

(1) Background: There is wide variation in the reported prevalence rates for pelvic organ prolapse (POP). There is also wide variation in the rate at which surgical interventions for pelvic organ prolapse are performed, as well as the type of interventions undertaken. As part of the International Consultation on Incontinence (ICI), our committee was tasked to produce evidence-based pathways for the surgical management of POP, any associated stress urinary incontinence (SUI), and bowel dysfunction. (2) Methods: To enable us to generate such evidence, we undertook a thorough search for the POP surgery-related, English-language scientific literature published up to April 2021. (3) Results: The committee evaluated the literature and made recommendations based on the Oxford grading system. (4) Conclusions: This review serves to provide a summary of the 2021 ICI surgical management of an evidence-based prolapse pathway and outline the evidence used to inform this guidance.

Is levator ani avulsion a risk factor for prolapse recurrence? A systematic review and meta-analysis

Introduction and hypothesis

Levator ani muscle avulsion as a risk factor for prolapse recurrence is not well established. This systematic review was aimed at evaluating the correlation between levator ani avulsion and postoperative prolapse recurrence with meta-analysis, specifically, the risk of subjective or objective prolapse recurrence and reoperation.

Methods

The protocol was registered in the International Prospective Register of Systematic Reviews (registration number CRD42021256675). A systematic literature search was conducted using PubMed, EMBASE and Cochrane Database of Systematic Reviews to identify all peer-reviewed studies that described levator avulsion in women and investigated operative and postoperative outcomes. All peer-reviewed, English-language cohort studies in those with and without levator avulsion with a minimum of 3 months’ follow-up were included. Pooled unadjusted and adjusted odds ratios were calculated for subjective recurrence, objective recurrence and rates of re-operation. The Cochrane Collaboration Risk of Bias In Non-Randomized Studies (RoBINS) and The Grading of Recommendations Assessment, Development and Evaluation (GRADE) tools were used to assess the quality of the studies included.

Results

Twelve studies with a total of 2,637 subjects and a follow-up period 0.3–6.4 years were identified. There were insufficient data to report a pooled adjusted risk for subjective recurrence and reoperation. On low to moderate quality-adjusted data, the pooled odds of objective recurrence was not significantly associated with levator ani avulsion (aOR 1.68; 95% CI 0.78–3.66).

Conclusion

Levator ani avulsion has not been confirmed as a risk factor for objective prolapse recurrence. Further evidence is needed to investigate the correlation between levator ani avulsion and the risk of subjective recurrence and reoperation.

Supplementary information

The online version contains supplementary material available at 10.1007/s00192-022-05217-2

Four-Dimensional Introital Ultrasound in Assessing Perioperative Pelvic Floor Muscle Functions of Women with Cystoceles

PURPOSE

 Research on the use of ultrasound to explore the pelvic floor in women is rarely done with introital ultrasound. This study aimed to investigate the performance of four-dimensional (4D) introital ultrasound in the perioperative assessment of pelvic floor muscle (PFM) function in women with cystocele.

MATERIALS AND METHODS

 The reliability and agreement of ultrasound measurements were determined by intraclass correlation coefficients (ICC) with 95 % confidence interval and Bland-Altman analysis in 20 women. The validity of ultrasound parameters was assessed by correlating squeezing ultrasound measurements with the modified Oxford scale (MOS) in 317 women. 4D introital ultrasound data of 241 women with (n = 29) and without (n = 212) postoperative cystocele at the 12-month postoperative assessment were retrospectively analyzed. Levator avulsion was diagnosed using tomographic ultrasound imaging. Involuntary and voluntary PFM functions were explored by dynamic changes in the bladder neck and genital hiatus, respectively, upon coughing and squeezing on 4D introital ultrasound.

RESULTS

 The ICC for the reliability of all tested ultrasound parameters was good to very good. The changes and change ratios of most ultrasound measurements from resting to squeezing were fairly correlated with MOS. Women with postoperative cystocele demonstrated more rates of complete levator avulsion [41.3 % vs. 4.7 %, P < 0.001, odds ratio (OR) 14.26, 95 % confidence interval (CI) 4.88-42.42] and fewer rates of capable voluntary PFM contraction (65.5 % vs. 92.5 %, P < 0.001, OR 0.16, 95 % CI 0.06-0.43) than those without postoperative cystocele postoperatively.

CONCLUSION

 4D introital ultrasound is feasible to assess perioperative PFM function in women with cystocele.

[Diagnostic testing of female urinary incontinence: dos and dont's]

Urinary incontinence causes significant limitations in quality of life and reduces mental and physical health. It is a widespread and chronic disease. About 200 million people are affected by urinary incontinence worldwide. Females are more often affected than males. For the therapy of female urinary incontinence various conservative and surgical treatment measures are available. A comprehensive diagnostic work-up is crucial for effective and successful use of those therapeutical measures. The current paper gives a review of diagnostic options for female urinary incontinence: from non-invasive up to invasive investigations. It presents potential pitfalls and possibilities for improving the diagnostic work-up.

Levator ani muscle avulsion: Digital palpation versus tomographic ultrasound imaging

OBJECTIVE

To determine the diagnostic performance of digital palpation of levator ani muscle (LAM) avulsion compared with translabial tomographic ultrasound imaging (TUI).

METHODS

A cross-sectional study, incorporating 195 women involved in a longitudinal cohort study. Palpation for levator integrity was performed, followed by a four-dimensional translabial ultrasound. LAM avulsion defects were diagnosed in the presence of puborectalis muscle detachment from its insertion. Post-processing analysis of ultrasound volumes for LAM integrity on TUI was performed blinded against palpation findings. Agreement between methods was assessed using Cohen's κ.

RESULTS

In all, 388 paired assessments of LAM bilaterally, were available. Sixteen (8.2%) unilateral avulsion defects were detected on palpation. Sonographically, 31 (16%) were diagnosed with avulsions: 4.6% bilateral and 11.3% unilateral. An overall agreement of 91% was observed between digital palpation and TUI, yielding a Cohen's κ of 0.32 (95% confidence interval 0.15-0.48) demonstrating "fair agreement": and implying 25% sensitivity, 98% specificity, 63% positive predictive value, and 92% negative predictive value. Analysis of the first and last 20 palpations showed no change in performance during the 13-day study period.

CONCLUSION

Assessment of LAM avulsion defects by digital palpation is feasible but may require substantial training. Confirmation by imaging is crucial, especially if the diagnosis of avulsion may influence clinical management.

Women with advanced pelvic organ prolapse and levator ani muscle avulsion would significantly benefit from mesh repair surgery

OBJECTIVES

Mesh repair surgery for pelvic organ prolapse (POP) has been suspended in some countries owing to concerns about its associated complications. However, mesh repair has been shown to reduce the risk of prolapse recurrence after surgery. In view of this controversy, our aim was to assess the incidence of subjective and objective recurrence of POP following mesh repair surgery vs native-tissue repair in women with Stage-III or Stage-IV POP.

METHODS

This was a prospective observational study of women who presented with Stage-III or Stage-IV POP and received primary prolapse surgery between 2013 and 2018. Transperineal ultrasound was performed before the operation and volumes were analyzed offline to assess the presence of levator ani muscle (LAM) avulsion. All women were counseled on either mesh repair or native-tissue reconstruction. The mesh-repair group was followed up for up to 5 years and the native-tissue-repair group for up to 2 years after the operation. Prolapse symptoms and POP quantification (POP-Q) staging were assessed at follow-up. Subjective recurrence of POP was defined as symptoms of prolapse (vaginal bulge sensation or dragging sensation) reported by the patient. Objective recurrence was defined as POP-Q ≥ Stage II. The subjective and objective recurrences of prolapse were compared between women with and those without mesh use. Multivariate regression analysis was used to identify risk factors for the recurrence of POP.

RESULTS

A total of 154 Chinese women with Stage-III or Stage-IV prolapse were recruited. Of these, 104 (67.5%) underwent mesh repair (transabdominal in 57 women and transvaginal in 47 women) and 50 (32.5%) had native-tissue repair surgery. Ninety-five (61.7%) women had LAM avulsion. Both the subjective POP recurrence rate (4.8% vs 20.0%; P = 0.003) and the objective recurrence rate (20.2% vs 46.0%; P = 0.001) were significantly lower in the mesh-repair group than in the native-tissue-repair group. On multivariate logistic regression analysis, mesh repair was associated significantly with a reduced risk of subjective recurrence (odds ratio (OR), 0.20 (95% CI, 0.07-0.63)) and of objective recurrence (OR, 0.16 (95% CI, 0.07-0.55)) of prolapse. On subgroup analysis of women with LAM avulsion, mesh repair significantly reduced the risk of subjective recurrence (OR, 0.24 (95% CI, 0.07-0.87)) and objective recurrence (OR, 0.23 (95% CI, 0.09-0.57)) of POP. The incidence of mesh-related complications was low, and mesh exposure could be treated conservatively or by minor surgery.

CONCLUSIONS

Mesh repair surgery, compared with native-tissue repair, was associated with a 5-fold reduction in the risk of subjective recurrence and a 6-fold reduction in the risk of objective recurrence of prolapse in women with Stage-III or Stage-IV POP. In women with concomitant LAM avulsion, mesh repair surgery was associated with a 4-fold reduction in both objective and subjective recurrence of POP. The rate of mesh-related complications was low, and mesh exposure could be treated conservatively or by minor surgery. The benefit of mesh surgery for these high-risk women appears to outweigh the risks of mesh complications, and it could be a treatment option for this group of women. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Ultrasound imaging of slings and meshes in urogynecology

Imaging is used increasingly in urogynecology. One of the main applications is in the assessment of synthetic implants. Ultrasound is particularly useful for this purpose as most such implants appear highly echogenic on ultrasound but are not visible using other imaging techniques. The worldwide success of synthetic mid-urethral slings, introduced in the late 90s, led to the subsequent introduction of transvaginal mesh in 2003-2004. Widespread use of synthetic implants for both urinary incontinence and prolapse has caused a rise in implant-related complications and increasing negative publicity and litigation, with many products removed from the market. It is not surprising that there is increasing demand for the assessment and evaluation of sling and mesh implants using imaging. This review article discusses the role of translabial/transperineal ultrasound in the evaluation of synthetic implants used in the treatment of urinary incontinence and pelvic organ prolapse. The discussion focuses on those applications of the technique that are useful for surgeons dealing with patients after mesh and/or sling placement. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Long-term follow-up of native tissue anterior vaginal wall repair: does the POP-Q stage really reflect patients' satisfaction rate?

INTRODUCTION

Anterior colporrhaphy (AC) is one of the most commonly performed surgical procedures for pelvic organ prolapse treatment; however, there are only few data in the literature regarding its long-term outcomes. Our aim was to assess the long-term efficacy and satisfaction rate after AC.

METHODS

Patients who underwent AC at our institution from 2011 to 2014 were invited to this follow-up study, which took place in January-February 2019. Medical history and gynaecological examination with POP-Q assessment were performed. Patients filled out validated questionnaires UIQ-7, CRAIQ-7, POPIQ-7, PFIQ-7, POPDI-6, CRADI-8, and UDI-6 and evaluated their satisfaction with the procedure. Objective success was defined as anterior wall prolapse stage 0 or 1 assessed by the POP-Q system. Subjective success was defined as the absence of bulging sensation or a sense of falling out that can be felt or seen in the vaginal area. Data were analysed using descriptive statistics and non-parametric tests.

RESULTS

Seventy out of 137 (51.1%) patients attended the follow-up. Mean follow-up period up was 74.1 ± 12.6 months. Two patients were excluded from the analysis because they had another surgical procedure due to central compartment prolapse. Of the remaining patients, 50 had AC and 18 had AC and posterior colporrhaphy (PC). Objective success rate was 13.2% and subjective success rate was 68.7%. Almost all patients (98.5%) were satisfied with the procedure. In the group of patients with objective recurrence, 66.1% had no prolapse symptoms.

CONCLUSION

Despite having a low objective success rate, patients' satisfaction with AC is very high.

Impact of levator muscle avulsions on Manchester procedure outcomes in pelvic organ prolapse surgery

INTRODUCTION

Levator ani muscle avulsions potentially increase recurrence after anterior colporrhaphies. We aimed at evaluating the impact of avulsions on anatomical and patient-reported outcomes 1 year after the Manchester procedure for primary anterior compartment pelvic organ prolapse.

MATERIAL AND METHODS

Prospective cohort study of 189 women undergoing the Manchester procedure between October 2014 and January 2017. Avulsions were diagnosed by transperineal ultrasound. Women with and without avulsions were compared for 1-year postoperative outcomes; Pelvic Organ Prolapse Quantification measurements, subjective satisfaction (1-worse to 4-cured), failure (new prolapse treatment), response to validated questionnaires on pelvic floor distress and sexual function, and a composite outcome (subjectively cured and optimal anterior compartment outcome (stage 0-I)). Optimal mid-compartment outcome was defined as cervix ≥5 cm above the hymen. Factors potentially associated with poor anatomical outcomes (anterior compartment stage ≥II) or pelvic floor distress were analyzed using regression analyses.

RESULTS

Fewer women with avulsions (present in 50.8%) obtained optimal mid-compartment outcomes (88.2% vs 77.1%; P = 0.05). The groups were otherwise similar in terms of mid-compartment reduction, anterior compartment results, failure rate, subjective satisfaction, pelvic floor/sexual symptoms, and combined optimal subjective and anatomical outcome. Only preoperative anterior compartment stage ≥III was associated with poor anatomical outcome (P < 0.01). A high preoperative symptom score was associated with a high postoperative symptom score (P < 0.001).

CONCLUSIONS

Although fewer women with avulsions obtained optimal mid-compartment results, avulsions had no impact on other anatomical or symptomatic outcomes 1 year after the Manchester procedure for primary anterior compartment prolapse.

Concordance of tomographic ultrasound and multiplanar ultrasound in detecting levator ani muscle injury in patients with pelvic organ prolapse

Aim

To compare the evaluations of evaluate levator ani muscle injury (LAMI) by tomographic ultrasound imaging (TUI) and multiplanar (MP) ultrasound in patients with pelvic organ prolapse (POP).

Method

This retrospective analysis studied women who underwent International Continence Society POP quantification examination between October 2015 and June 2016. LAMI was assessed by both TUI and MP ultrasounds. Concordance of these two testing results was analyzed. Their correlations with clinical symptoms were also studied.

Results

A total of 135 women were included. All the patients with POP had a minimal LAMI depth ≥ 7 mm. Two examinations, TUI and MP, had satisfactory concordance (k = 0.71, P < 0.01). Depth of LAMI in the coronal plane demonstrated good agreement with TUI scores (r = 0.84; P < 0.01). After controlling for age, BMI, and parity, to have clinically significant POP and POP symptoms, the odds ratios (ORs) for the depth of LAMI in the coronal plane were 1.31 (95% CI 1.19–1.44) and 1.25 (95% CI 1.14–1.36), and for TUI scores were 1.72 (95% CI 1.37–2.17) and 1.63 (95% CI 1.31–2.03). Receiver operating characteristic curve analyses showed a cutoff depth of 7 mm of LAMI yielded a sensitivity of 62% and specificity of 80% for POP symptoms.

Conclusions

TUI and MP had satisfactory concordance in detecting LAMI and correlated with clinical symptoms of POP.

Short-term outcomes of the transvaginal minimal mesh procedure for pelvic organ prolapse

Purpose

This study aimed to evaluate the clinical outcomes and complications of transvaginal minimal mesh repair without using commercially available kits for treatment of pelvic organ prolapse (POP).

Materials and Methods

This retrospective cohort study involved 91 women who underwent surgical management of POP with originally designed small mesh between July 2014 and August 2015. This mesh is 56% smaller than the mesh widely used in Japan, and it has only two arms delivered into each right and left sacrospinous ligament. The main study outcome was the anatomic cure rate defined as recurrence of POP quantification (POP-Q) stage II or more. We also assessed changes in the overactive bladder symptom score (OABSS) and prolapse quality of life questionnaire (P-QOL) and evaluated adverse events. Finally, we compared patient backgrounds between the patients with and without recurrence.

Results

Prolapse recurred in 10 of 91 patients (11.0%), and all patients with recurrence were diagnosed as POP-Q stage II. As adverse events, only mesh erosion occurred in two (2.2%) and pelvic pain in one (1.1%) of the 91 patients. The OABSS and P-QOL were significantly improved by the operation. When we compared patient backgrounds between the patients with and without recurrence, body mass index was the only factor influencing affecting recurrence.

Conclusions

Transvaginal minimal mesh repair resulted in successful outcomes with low mesh-related complications and anatomic recurrence at one year. Furthermore, significant improvement in QOL was offered by this procedure. Our minimal mesh technique should be considered as one treatment option for the management of POP.

Risk factors for prolapse recurrence: systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

Female pelvic organ prolapse (POP) is a common condition, with a lifetime risk for surgery of 10-20%. Prolapse procedures are known to have a high reoperation rate. It is assumed that etiological factors for POP may also be risk factors for POP recurrence after surgery. There are few reviews available evaluating risk factors for prolapse and recurrence or recently updated meta-analysis on this topic. Our aim was to perform a systematic review and quantitative meta-analysis to determine risk factors for prolapse recurrence after reconstructive surgery.

METHODS

Four electronic databases (MEDLINE, PubMed, EMBASE, and Google Scholar) were searched between 1995 and 1 January 2017, with no language restrictions.

RESULTS

Twenty-five studies met inclusion criteria for a total of 5082 patients with an average recurrence rate of 36%. Variables on which a meta-analysis could be performed were body mass index (BMI) (n = 12), age (n = 11), preoperative stage (n = 9), levator avulsion (n = 8), parity (n = 8), constipation/straining (n = 6), number of compartments involved (n = 4), prior hysterectomy (n = 4), familiy history (n = 3), and several other predictors evaluated in only three studies. The following meta- analyses identified significant predictors: levator avulsion [odds ratio (OR) 2.76, P < 0.01], preoperative stage 3-4 (OR 2.11, P < 0.001), family history (OR 1.84, P = 0.006), and hiatal area (OR 1.06/cm2, P = 0.003).

CONCLUSIONS

Levator avulsion, prolapse stage, and family history are significant risk factors for prolapse recurrence.

Recent Advances in Understanding Pelvic-Floor Tissue of Women With and Without Pelvic Organ Prolapse: Considerations for Physical Therapists

Pelvic organ prolapse is a fairly common condition that imposes significant symptoms, diminished quality of life, social burden, financial expense, and surgical risk on women. As evidence supporting the benefit of pelvic-floor muscle training in nonsurgical management of pelvic organ prolapse grows, physical therapists are becoming a provider of choice interacting with women affected by pelvic organ prolapse. This perspective article will review recent research on tissue characteristics of 3 key components of pelvic organ support: skeletal muscle, ligament, and vaginal wall. This information will be summarized as implications for physical therapists. An improved understanding of pelvic-floor tissue in women with and without pelvic organ prolapse will provide a more comprehensive appreciation of the interaction of multiple systems in the disorder.

Levator Ani Muscle Defects in Patients With Surgical Failure

INTRODUCTION

The objective of the study was to use a well-described system of measuring levator ani (LA) muscle defects from magnetic resonance images to evaluate whether major defects are correlated to an increased risk of surgical failure.

METHODS

A retrospective cohort study performed on patients who underwent laparoscopic uterosacral ligament suspension from 2010 to 2012. Surgical failure was defined as a composite score of anatomic bulge beyond the hymen with sensation of bulge or repeat treatment of prolapse via pessary or surgery by 1-year follow-up. Levator ani muscle defects were graded by a score of 0 (no defect), 1 (<50% muscle bulk missing), 2 (>50% muscle bulk missing), or 3 (complete loss of muscle). Total score is the sum from both graded sides, with 0 classified as having no defect, 1 to 3 classified as having minor defects, and 4 to 6 classified as having major defects. Dichotomous values of LA major defects were compared against dichotomous values of surgical outcomes via a contingency table. Fisher exact test was then performed to correlate major defects to surgical success/failure. P value of less than 0.05 was considered statistically significant.

RESULTS

Sixty-six women met the inclusion criteria. Thirteen (19.6%) patients met the criteria for surgical failure at 1 year. Of the 13, 54% (7) had a major defect, and 46% (6) had a minor or no defect (odds ratio, 1.31; 95% confidence interval, 0.39-4.41; P = 0.762).

CONCLUSIONS

We did not find a statistical correlation to surgical failure after a laparoscopic uterosacral ligament suspension with LA muscle defects on preoperative magnetic resonance images within this specific patient population.

Diagnosis and Therapy of Female Pelvic Organ Prolapse. Guideline of the DGGG, SGGG and OEGGG (S2e-Level, AWMF Registry Number 015/006, April 2016)

Aims: The aim was to establish an official interdisciplinary guideline, published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). The guideline was developed for use in German-speaking countries. In addition to the Germany Society of Gynecology and Obstetrics, the guideline has also been approved by the Swiss Society of Gynecology and Obstetrics (SGGG) and the Austrian Society of Gynecology and Obstetrics (OEGGG). This is a guideline published and coordinated by the DGGG. The aim is to provide evidence-based recommendations obtained by evaluating the relevant literature for the diagnostic, conservative and surgical treatment of women with female pelvic organ prolapse with or without stress incontinence. Methods: We conducted a systematic review together with a synthesis of data and meta-analyses, where feasible. MEDLINE, Embase, Cinahl, Pedro and the Cochrane Register were searched for relevant articles. Reference lists were hand-searched, as were the abstracts of the Annual Meetings of the International Continence Society and the International Urogynecological Association. We included only abstracts of randomized controlled trials that were presented and discussed in podium sessions. We assessed original data on surgical procedures published since 2008 with a minimum follow-up time of at least 12 months. If the studies included descriptions of perioperative complications, this minimum follow-up period did not apply. Recommendations: The guideline encompasses recommendations for the diagnosis and treatment of female pelvic organ prolapse. Recommendations for anterior, posterior and apical pelvic organ prolapse with or without concomitant stress urinary incontinence, uterine preservation options, and the pros and cons of mesh placements during surgery for pelvic organ prolapse are presented. The recommendations are based on an extensive and systematic review and evaluation of the current literature and include the experiences and specific conditions in Germany, Austria and Switzerland.

Does it matter whether levator avulsion is diagnosed pre- or postoperatively?

OBJECTIVE

Levator ani muscle avulsion is found in 15-30% of parturients and is associated with recurrence of pelvic organ prolapse (POP) following surgery, although most published evidence on recurrence relates to postoperative diagnosis. We performed a study to determine whether a diagnosis of avulsion after pelvic floor surgery can be used as a proxy for preoperative diagnosis.

METHODS

This was a retrospective study of 207 patients who were seen before and after surgery for POP between February 2007 and May 2013. All assessments included a three/four-dimensional transperineal tomographic ultrasound examination. Volume data were stored and analyzed at a later date by an operator who was blinded against all clinical data. The primary outcome measure was agreement between preoperative and postoperative diagnoses of avulsion, as evaluated by Cohen's kappa. Secondary outcome measures were the associations of pre- and postoperative diagnoses of levator avulsion with prolapse recurrence, defined as International Continence Society POP-Q Stage ≥ 2 in any compartment.

RESULTS

Mean follow-up after surgery was 1.3 (range, 0.3-5.5) years. Levator avulsion was found preoperatively in 111 (53.6%) patients and postoperatively in 109 (52.7%). The kappa value for the association between pre- and postoperative avulsion was 0.864 (95% CI, 0.796-0.933), signifying high agreement. The odds ratio of prolapse recurrence in women with a preoperative diagnosis of avulsion was 2.5 (95% CI, 1.3-4.5) and in those with a postoperative diagnosis it was 2.3 (95% CI, 1.3-4.2).

CONCLUSIONS

The diagnosis of levator avulsion by tomographic pelvic floor ultrasound is equally valid before and after pelvic reconstructive surgery for POP, and both diagnoses show excellent agreement. This implies that a postoperative diagnosis of avulsion can be used as a proxy for preoperative diagnosis. Hence, avulsion can be identified postoperatively and used for subgroup analysis in prospective surgical intervention trials to define high-risk patients. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Estimated levator ani subtended volume: a novel assay for predicting surgical failure after uterosacral ligament suspension

BACKGROUND

Levator ani muscle complex plays an important role in pelvic support and defects or laxity in this muscle complex contributes to pelvic organ prolapse and recurrence after surgical repair.

OBJECTIVE

The purpose of this study was to determine whether estimated levator ani subtended volume can predict surgical outcomes for laparoscopic bilateral uterosacral ligament suspension.

STUDY DESIGN

A retrospective cohort study was performed in patients who underwent laparoscopic uterosacral ligament suspension from 2010-2012. Only patients with a preoperative pelvic magnetic resonance image were included. Surgical failure was defined as a composite score that included the presence of anatomic bulge beyond the hymen with sensation of vaginal bulge or repeat treatment for prolapse via pessary or surgery by 1-year follow-up evaluation. Standard protocol pelvic magnetic resonance imaging measurements pubococcygeal line, H-line, and M-line were collected along with the calculation of the width of the levator ani hiatus. Estimated levator ani subtended volume was calculated for each subject. An optimal cutoff point was calculated and compared against categoric values of surgical success/failure. A Fisher exact test, an area under receiver operating characteristics curve, and logistic regression analysis were performed. A probability value of <.05 was considered statistically significant.

RESULTS

Ninety-three women underwent laparoscopic bilateral uterosacral ligament suspension during study period. Of these, 66 women had a standardized preoperative pelvic magnetic resonance image per institutional protocol. Thirteen patients (19.6%) met the criteria for surgical failure by 1 year. An optimal cutoff point of 38.5 was calculated by Liu's method for optimization. Among the patients with defined surgical failures, 84.6% (11/13) had an estimated levator ani subtended volume above cutoff point of 38.5. Among the patients with defined surgical success, 39.6% (21/53) had an estimated levator ani subtended volume above the cutoff point (84.6% vs 39.6%; P = .0048) with a significant odds ratio of 8.38 (95% confidence interval, 1.69-41.68; P = .009). An area under receiver operating characteristics curve of 0.725 (95% confidence interval, 0.603-0.847), sensitivity of 84.6% (95% confidence interval, 54.6%-98.1%), and specificity of 60.4% (95% confidence interval, 46%-73.5%) at 38.5 were predictors of surgical success/failure by 1 year. Logistic regression analysis demonstrated no significant confounders among age, body mass index, stage, or parity.

CONCLUSIONS

Estimated levator ani subtended volume may predict surgical failure for laparoscopic bilateral uterosacral ligament suspension. Patients with a calculated estimated levator ani subtended volume above 38.5 on a preoperative pelvic magnetic resonance imaging were associated with an increased risk for surgical failure by 1 year, regardless of age, body mass index, stage, or parity. Future investigation that will include repeatability, reliability analysis, and a prospective study is warranted.

The association between different measures of pelvic floor muscle function and female pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

We aimed to compare palpatory and translabial ultrasound (TLUS) measurements of pelvic floor muscle (PFM) function with symptoms and signs of female pelvic organ prolapse (FPOP) to determine a possible association.

METHODS

We analysed data from 726 women with a mean age of 56 (SD 13.7, range 18-88) years, seen for symptoms of pelvic floor dysfunction between August 2011 and April 2013. The examination included a standardised interview and clinical assessment of FPOP with Pelvic Organ Prolapse Quantification (POP-Q) measurements, Modified Oxford Scale (MOS) grading and 4D TLUS.

RESULTS

Symptoms of prolapse were reported in 51.4% (373 out of 726) with a mean bother score of 5.8 (SD 2.91, range 0-10). A clinically significant POP (Incontinence Society [ICS]-POP-Q stage ≥ 2) in any compartment was diagnosed in 77.1%. Mean MOS was 2.4 (SD 1.1, range 0-5). Significant POP on TLUS was seen in 54.6% (389 out of 712). TLUS volumes at rest and on maximal PFM contraction were analysed on a desktop PC, to assess the degree of bladder neck (BN) cranioventral shift and levator antero-posterior (AP) diameter reduction, blinded against other data. Mean cranioventral BN shift was 7.11 (SD 4.36, range 0.32-25.32) mm and mean levator AP diameter reduction was 8.6 (SD 4.8, range 0.3-31.3) mm. MOS was strongly associated with subjective and objective POP (P ≤ 0.001), whereas this was not true for TLUS measurements of tissue displacement.

CONCLUSION

The MOS seems to be a more valid measure of PFM function than sonographically determined BN displacement or reduction of hiatal AP diameter observed on PFM contraction.

The association between vaginal parity and hiatal dimensions: a retrospective observational study in a tertiary urogynaecological centre

OBJECTIVE

Vaginal childbirth has a substantial effect on pelvic organ supports, which may be mediated by levator ani (LA) avulsion or hiatal overdistension. Although the impact of a first vaginal delivery on the hiatus has been investigated, little is known about the effect of subsequent births. This study was designed to evaluate the association between vaginal parity and hiatal dimension.

DESIGN

Retrospective observational study.

SETTING

A tertiary urogynaecological unit in Australia.

POPULATION

A total of 780 archived data sets of women seen for symptoms of lower urinary tract and pelvic floor dysfunction.

METHODS

Standardised in-house interview and assessment using the International Continence Society (ICS) pelvic organ prolapse quantification (POP-Q), and four-dimensional translabial ultrasound. Offline analysis for hiatal dimensions was undertaken blinded to history and clinical examination.

MAIN OUTCOME MEASURES

Hiatal area on maximum Valsalva.

RESULTS

Of 780 women, 64 were excluded because of missing ultrasound volumes, leaving 716 for analysis: 96% (n = 686) were parous, with a median parity of three (interquartile range, IQR 2-3), and 91.2% (n = 653) were vaginally parous. Levator avulsion was found in 21% (n = 148). The mean hiatal area on Valsalva was 29 cm(2) (SD 9.4 cm(2) ). On one-way anova, vaginal parity was significantly associated with hiatal area (P < 0.001). Most of the effect seems to occur with the first delivery. Subsequent deliveries do not seem to have any significant effect on hiatal dimensions. This remained true after controlling for potential confounding factors using multivariate regression analysis (P = 0.0123).

CONCLUSIONS

Vaginal parity was strongly associated with hiatal area on Valsalva. Most of this effect seems to be associated with the first vaginal delivery.

The levator ani muscle during pregnancy and major levator ani muscle defects diagnosed postpartum: a three- and four-dimensional transperineal ultrasound study

OBJECTIVE

To investigate associations between levator hiatus area and levator ani muscle function during pregnancy and major levator ani muscle defects postpartum.

DESIGN

Observational prospective cohort study.

SETTING

University hospital, Norway.

SAMPLE

A cohort of 234 nulliparous women at 21 and 37 weeks of gestation, and at 6 weeks postpartum.

METHODS

Ultrasound measurements of the levator hiatus at rest, during pelvic floor muscle contraction, and during the Valsalva manoeuvre were taken at 21 and 37 weeks of gestation. Levator ani muscle function was estimated as the percentage changes in levator ani muscle length from rest to contraction, and the level of muscle stretch during the Valsalva manoeuvre. Major levator ani muscle defects were diagnosed at 6 weeks postpartum using tomographic ultrasound imaging.

MAIN OUTCOME MEASURES

Associations between ultrasound measurements antepartum and major levator ani muscle defects postpartum.

RESULTS

Women with major levator ani muscle defects postpartum had significantly smaller levator hiatus area at rest and during the Valsalva manoeuvre at mid-pregnancy (mean difference 1.03 cm(2) , 95% CI 0.31-1.76; 2.92 cm(2) , 95% CI 1.77-4.07), and at 37 weeks of gestation (mean difference 1.47 cm(2) , 95% CI 0.62-2.32; 2.84 cm(2) , 95% CI 0.88-4.80), than women without such defects. They also had significantly less shortening of the levator ani muscle during contraction at 37 weeks of gestation.

CONCLUSIONS

Smaller levator hiatus area at rest and during the Valsalva manoeuvre at mid and late pregnancy, and less shortening of the levator ani muscle during contraction at 37 weeks of gestation, are associated with major levator ani muscle defects postpartum.

ACR Appropriateness Criteria pelvic floor dysfunction

Pelvic floor dysfunction is a common and potentially complex condition. Imaging can complement physical examination by revealing clinically occult abnormalities and clarifying the nature of the pelvic floor defects present. Imaging can add value in preoperative management for patients with a complex clinical presentation, and in postoperative management of patients suspected to have recurrent pelvic floor dysfunction or a surgical complication. Imaging findings are only clinically relevant if the patient is symptomatic. Several imaging modalities have a potential role in evaluating patients; the choice of modality depends on the patient's symptoms, the clinical information desired, and the usefulness of the test. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions; they are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals, and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Imaging of slings and meshes

The popularity of imaging in pelvic floor medicine continues to increase. Among the various modalities, ultrasound is superior as it is cheap, safe, easily accesible and simple, resulting in high patient compliance. It is the only technique that allows imaging of modern wide-weave polypropylene sling or mesh implants, and imaging of such implants is commonly required due to the popularity of surgical techniques that involve the placement of slings and meshes. This review article will discuss the role of translabial ultrasound in the evaluation of synthetic implants used in the treatment of urinary incontinence and pelvic organ prolapse.

Three-dimensional transperineal ultrasound for imaging mesh implants following sacrocolpopexy

OBJECTIVE

To characterize, using three-dimensional (3D) transperineal ultrasound, the appearance, position and dimensions of mesh implants following minimally invasive abdominal sacrocolpopexy.

METHODS

In women who underwent sacrocolpopexy, mesh was evaluated at rest and on maximal Valsalva, on all 3D orthogonal planes and rendered views. Mesh dimensions were obtained by 3D processing in the midsagittal and coronal planes (anterior, posterior and sacral arm) and were analyzed offline, the operator blinded to clinical data.

RESULTS

Overall, 62 women, mean age 58.4 (range, 42-79) years were evaluated at a median of 9 (range, 1-26) months following surgery. The anterior arm of the mesh was caudal to the lowermost point of descent of the anterior compartment in 56 (90.3%) women, was equally positioned in five (8.1%) and was cranial in one. The posterior arm was caudal in 44 (71%) women, was equally positioned in 16 (25.8%) and was cranial in two (3.2%). The Y connection and the sacral arm of the mesh could not be adequately seen because of physical limitations of ultrasound (lower resolution at greater depth), large recurrent rectoceles, echogenic stools or folding of mesh remnants. Folding of the mesh was seen in 46 (74.2%) women, folding of the anterior arm in five (8.1%) and folding of the posterior arm in 23 (37.1%). Folding occurred caudally in 26 (41.9%) women, proximally in 11 (17.7%) and in both areas in nine (14.5%). There were no erosions.

CONCLUSION

Mesh visualization following minimally invasive abdominal sacrocolpopexy procedures using transperineal 3D/four-dimensional (4D) ultrasound is feasible. Studies are needed to evaluate the correlation between ultrasound measures and prolapse recurrence or mesh erosion.

Recent studies of genetic dysfunction in pelvic organ prolapse: the role of collagen defects

Gynaecologists are becoming increasingly aware that women with a family history of prolapse are at an increased risk of prolapse refractory to treatment. In the past five years, several genetic mutations have been shown to correlate with increased prolapse susceptibility. These mutations can result in disordered collagen metabolism, which weaken the fascial support of the pelvic organs. This review examines the contemporary evidence regarding the role of collagen in prolapse.