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García-Mejido JA, García-Jimenez R, Fernández-Conde C, García-Pombo S, Fernández-Palacín F, Sainz-Bueno JA. The Application of Shear Wave Elastography to Determine the Elasticity of the Levator Ani Muscle and Vaginal Tissue in Patients With Pelvic Organ Prolapse. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:913-921. [PMID: 38284137 DOI: 10.1002/jum.16422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/08/2024] [Accepted: 01/15/2024] [Indexed: 01/30/2024]
Abstract
OBJECTIVES The changes of the extracellular matrix of the connective tissue have significantly contributed to the incidence of pelvic organ prolapse (POP). It seems reasonable that sonoelastography could be a useful tool to evaluate the elasticity of pelvic floor tissue in patients with POP and compare it to those without POP. The main aim of this pilot study was to determine if there are differences in the elasticity of the levator ani muscle (LAM) and vaginal tissue between patients with and without POP. METHODS Prospective observation study, including 60 patients (30 with POP and 30 without POP). Sonoelastography was performed to evaluate the elasticity (in kilopascals, kPa) of the following regions of interest: vagina at the level of middle third of the urethra; vagina at the level of the bladder trigone; vagina in the anterior and posterior fornix; vagina at the level of middle third of the anorectal canal; posterior third of the LAM. RESULTS A total of 60 patients completed the study (30 with POP, 30 without POP). In the POP group, 18/30 (60%) had an anterior vaginal wall prolapse, 3/30 (10%) a uterine prolapse, 15/30 (50%) a rectocele, and 6/30 (20%) a enterocele. Patients with POP had higher elasticity in all anatomical study areas, with statistically significant differences in the anterior fornix (13.6 vs 11.2 kPa; P: .012). A multiple regression (controlling age, menopausal stage, and parity) allowed to detect statistically significant differences in the elasticity of the middle third of the urethra (P: .03) and the middle third of the anorectal canal (P: .019). CONCLUSION It is possible to evaluate the elasticity of the LAM and vaginal tissue using sonoelastography, detecting a higher elasticity in patients with POP than in those without POP.
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Affiliation(s)
- José Antonio García-Mejido
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Seville, Seville, Spain
| | | | | | - Sara García-Pombo
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
| | | | - José Antonio Sainz-Bueno
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Seville, Seville, Spain
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García-Mejido JA, Martín-Martinez A, García-Jimenez R, González-Diaz E, Núñez-Matas MJ, Fernández-Palacín F, Carballo-Rastrilla S, Fernández-Fernández C, Sainz-Bueno JA. Is the Presence of Levator Ani Muscle Avulsion Relevant for the Diagnosis of Uterine Prolapse? JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:265-272. [PMID: 37853913 DOI: 10.1002/jum.16356] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/23/2023] [Accepted: 10/01/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVE To determine if the addition of the assessment of levator ani muscle (LAM) avulsion to the measurement of the difference in the pubis-uterine fundus distance between rest and with the Valsalva maneuver could increase the diagnostic capacity of ultrasound for uterine prolapse (UP). METHODS This multicenter, observational and prospective study included 145 patients. Ultrasound assessment was performed, establishing the diagnosis of UP as a difference between the pubic-uterine fundus distance at rest and during the Valsalva maneuver ≥15 mm (standard technique), while LAM avulsion was defined as an abnormal LAM insertion in three central slices using multislice ultrasound. A binary multivariate logistic regression model was made using nonautomated methods to predict surgical UP (general population, premenopausal, and postmenopausal patients), including the difference between the pubis-uterine fundus distance at rest and with the Valsalva maneuver as well as LAM avulsion. RESULTS A total of 143 patients completed the study. The addition of LAM avulsion criteria to the standard dynamic distance-based protocol for the diagnosis of UP resulted in a higher sensitivity for the general population (79.7 vs 68.1%) as well as for premenopausal (89.3 vs 79.9%) and postmenopausal patients (76 vs 66.1%). In contrast, the standard technique showed a higher specificity than the model based on the standard technique associated with LAM avulsion for the general population (89.2 vs 74.3%) and premenopausal women (91.7 vs 63.2%). For postmenopausal patients, the model based on the standard technique associated with LAM avulsion had a higher sensitivity (76 vs 66.1%) and specificity (91.7 vs 86.8%) than the ultrasound diagnosis of UP. CONCLUSION The implementation of the assessment of LAM avulsion in the ultrasound diagnosis of UP is useful in postmenopausal patients, increasing sensitivity and specificity relative to the ultrasound assessment based only on the difference between the pubis-uterine fundus distance at rest and with the Valsalva maneuver.
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Affiliation(s)
- José Antonio García-Mejido
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Seville, Seville, Spain
| | - Alicia Martín-Martinez
- Department of Obstetrics and Gynecology, University Healthcare Complex of Gran Canaria, Gran Canaria, Spain
| | - Rocío García-Jimenez
- Obstetrics and Gynecology Department, Juan Ramon Jiménez Hospital, Huelva, Spain
| | - Enrique González-Diaz
- Department of Obstetrics and Gynecology, University Healthcare Complex of Leon (CAULE), Leon, Spain
| | - María José Núñez-Matas
- Department of Obstetrics and Gynecology, Virgen de la Victoria University Hospital of Malaga, Malaga, Spain
| | | | - Sonia Carballo-Rastrilla
- Department of Obstetrics and Gynecology, University Healthcare Complex of Gran Canaria, Gran Canaria, Spain
| | | | - José Antonio Sainz-Bueno
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Seville, Seville, Spain
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García-Mejido JA, Martín-Martinez A, González-Diaz E, Núñez-Matas MJ, Fernández-Palacín A, Carballo-Rastrilla S, Fernández-Fernández C, García-Jimenez R, Sainz-Bueno JA. Is It Possible to Diagnose Surgical Uterine Prolapse With Transperineal Ultrasound? Multicenter Validation of Diagnostic Software. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:2673-2681. [PMID: 37421644 DOI: 10.1002/jum.16303] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/24/2023] [Accepted: 06/23/2023] [Indexed: 07/10/2023]
Abstract
OBJECTIVES To validate an ultrasound software that uses transperineal ultrasound to diagnose uterine prolapse (UP). METHODS Multicenter, observational and prospective study with 155 patients that had indications for surgical intervention for dysfunctional pelvic floor pathology. Each patient underwent an examination with Pozzi tenaculum forceps was performed in the operating room with the patient anesthetized, followed by surgical correction of stages II-IV UP. Transperineal ultrasound was used to assess the difference in the pubis-uterine fundus measurement. With a multivariate logistic regression binary model (with the measurement ultrasound at rest, the Valsalva maneuver and age) using nonautomated methods to predict UP. With the purpose of evaluating the model, a table with coordinates of the receiver operating characteristic (ROC) curve, after which sensitivity and specificity were assessed. RESULTS A total of 153 patients were included (73 with a diagnosis of surgical UP). It was obtained from the AUC (0.89) of the probabilities predicted by the model (95% confidence interval, 0.84-0.95; P < .0005). Based on the ROC curve for the model, obtaining a sensitivity of 91.8% and a specificity of 72.7%, values that were superior to those for the clinical exam for surgical UP (sensitivity: 80.8%; specificity: 71.3%). CONCLUSIONS We validated software that uses transperineal ultrasound of the pelvic floor and patient age to generate a more reliable diagnosis of surgical UP than that obtained from clinical examinations.
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Affiliation(s)
- José Antonio García-Mejido
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Seville, Seville, Spain
| | - Alicia Martín-Martinez
- Department of Obstetrics and Gynecology, University Healthcare Complex of Gran Canaria, Gran Canaria, Spain
| | - Enrique González-Diaz
- Department of Obstetrics and Gynecology, University Healthcare Complex of Leon (CAULE), Leon, Spain
| | - María José Núñez-Matas
- Department of Obstetrics and Gynecology, Virgen de la Victoria University Hospital of Malaga, Malaga, Spain
| | - Ana Fernández-Palacín
- Biostatistics Unit, Department of Preventive Medicine and Public Health, University of Seville, Seville, Spain
| | - Sonia Carballo-Rastrilla
- Department of Obstetrics and Gynecology, University Healthcare Complex of Gran Canaria, Gran Canaria, Spain
| | | | - Rocío García-Jimenez
- Department of Obstetrics and Gynecology, Juan Ramón Jimenez Hospital, Seville, Spain
| | - José Antonio Sainz-Bueno
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Seville, Seville, Spain
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García-Mejido JA, Martín-Martinez A, González-Diaz E, Núñez-Matas MJ, Fernández-Palacín A, Carballo-Rastrilla S, Fernández-Fernández C, Sainz-Bueno JA. Identification of Surgical Uterine Prolapse in Premenopausal Patients With Clinical or Ultrasound Criteria? A Multicenter Comparative Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:2269-2275. [PMID: 37163226 DOI: 10.1002/jum.16248] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/13/2023] [Accepted: 04/19/2023] [Indexed: 05/11/2023]
Abstract
OBJECTIVES It is unknown whether diagnosing uterine prolapse (UP) via ultrasound or surgical criteria is superior. Our objective is to determine whether the diagnostic capacity of ultrasound with surgical criteria differs from that of surgical criteria only. METHODS This was a multicenter prospective observational study with 54 premenopausal patients with surgical criteria for a dysfunctional pelvic floor pathology who were consecutively recruited for 1 year. Clinical UP with surgical criteria was defined when UP stage II-IV was identified (during pelvic floor consultation), and UP diagnosed by ultrasound with surgical criteria was established when a difference ≥15 mm was found between rest and Valsalva applied to the pubis-uterine fundus. The sensitivity, specificity and positive and negative predictive values were determined to evaluate clinical and ultrasound methodologies as diagnostic tests. RESULTS UP diagnosed by ultrasound with surgical criteria presented better sensitivity (78.57 vs 35.71%), specificity (92.11 vs 81.58%), positive predictive value (61.83 vs 23.99%), and negative predictive value (96.35 vs 11.37%) than UP diagnosed by surgical criteria only. CONCLUSION Ultrasound with surgical criteria is superior to surgical criteria alone when diagnosing UP.
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Affiliation(s)
- José Antonio García-Mejido
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Seville, Seville, Spain
| | - Alicia Martín-Martinez
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Gran Canarias, Gran Canarias, Spain
| | - Enrique González-Diaz
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Leon (CAULE), León, Spain
| | - María José Núñez-Matas
- Department of Obstetrics and Gynecology, University Hospital Virgen de la Victoria of Malaga, Malaga, Spain
| | - Ana Fernández-Palacín
- Biostatistics Unit, Department of Preventive Medicine and Public Health, University of Seville, Seville, Spain
| | - Sonia Carballo-Rastrilla
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Gran Canarias, Gran Canarias, Spain
| | - Camino Fernández-Fernández
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Leon (CAULE), León, Spain
| | - José Antonio Sainz-Bueno
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Seville, Seville, Spain
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Wang R, Tunitsky-Bitton E. How does office assessment of prolapse compare to what is seen in the operating room? Int Urogynecol J 2023; 34:167-174. [PMID: 35648182 PMCID: PMC9157481 DOI: 10.1007/s00192-022-05239-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 04/19/2022] [Indexed: 01/14/2023]
Abstract
INTRODUCTION AND HYPOTHESIS It is not known whether the measurements of pelvic organ assessment under anesthesia accurately estimate prolapse severity. We compared Pelvic Organ Prolapse Quantification (POP-Q) measurements in the office to exams under anesthesia. METHODS We prospectively enrolled patients undergoing prolapse surgery between February 2020 and July 2020. POP-Qs at rest and with Valsalva were performed at pre- and postoperative visits. POP-Q under anesthesia was performed, without traction, at the start of case (pre-surgical), following apical suspension, and at the end of case (post-surgical). Primary outcome was change in POP-Q between the office and operating room. Due to the COVID-19 pandemic, additional patients were recruited to maintain the follow-up time frame. RESULTS Out of 66 patients, 63 underwent surgery and 33 had postoperative exams within 6 weeks. Mean age was 61.3 ± 11.9 years, and mean BMI was 28.4 ± 6.5 kg/m2. Preoperative Aa, Ba, C, Ap, Bp, and D with Valsalva had greater descent than pre-surgical measurements. However, preoperative Gh with Valsalva (4.1 ± 1.3 cm) was not different from pre-surgical Gh (4.0 ± 1.0 cm) (P = 0.60). Postoperative Aa, Ba, Ap, Bp, and D were not different from post-surgical measurements. In contrast, postoperative Gh at rest (2.3 ± 0.7 cm) and with Valsalva (2.4 ± 0.8 cm) were both narrower than post-surgical Gh (2.8 ± 0.6 cm) (P < 0.05). Gh was also narrowed after apical suspension (3.6 ± 1.0 cm, P = 0.005) prior to posterior repair. CONCLUSIONS Surgeons should rely on preoperative POP-Q for surgical decisions. Gh should be reassessed after apical suspension, and further correction should consider that Gh may be exaggerated compared to the measurement postoperatively when the patient is awake.
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Affiliation(s)
- Rui Wang
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Hartford Hospital, Hartford, CT, USA
| | - Elena Tunitsky-Bitton
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Hartford Hospital, Hartford, CT, USA.
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Wang X, He D, Feng F, Ashton-Miller JA, DeLancey JOL, Luo J. Multi-label classification of pelvic organ prolapse using stress magnetic resonance imaging with deep learning. Int Urogynecol J 2022; 33:2869-2877. [PMID: 35083500 PMCID: PMC9325920 DOI: 10.1007/s00192-021-05064-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 12/05/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION AND HYPOTHESIS We aimed to develop a deep learning-based multi-label classification model to simultaneously diagnose three types of pelvic organ prolapse using stress magnetic resonance imaging (MRI). METHODS Our dataset consisted of 213 midsagittal labeled MR images at maximum Valsalva. For each MR image, the two endpoints of the sacrococcygeal inferior-pubic point line were auto-localized. Based on this line, a region of interest was automatically selected as input to a modified deep learning model, ResNet-50, for diagnosis. An unlabeled MRI dataset, a public dataset, and a synthetic dataset were used along with the labeled image dataset to train the model through a novel training strategy. We conducted a fivefold cross-validation and evaluated the classification results using precision, recall, F1 score, and area under the curve (AUC). RESULTS The average precision, recall, F1 score, and AUC of our proposed multi-label classification model for the three types of prolapse were 0.84, 0.72, 0.77, and 0.91 respectively, which were improved from 0.64, 0.53, 0.57, and 0.83 from the original ResNet-50. Classification took 0.18 s to diagnose one patient. CONCLUSIONS The proposed deep learning-based model were demonstrated feasible and fast in simultaneously diagnosing three types of prolapse based on pelvic floor stress MRI, which could facilitate computer-aided prolapse diagnosis and treatment planning.
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Affiliation(s)
- Xinyi Wang
- University of Michigan-Shanghai Jiao Tong University Joint Institute, Shanghai Jiao Tong University, Shanghai, 200240, China
| | - Da He
- University of Michigan-Shanghai Jiao Tong University Joint Institute, Shanghai Jiao Tong University, Shanghai, 200240, China
| | - Fei Feng
- University of Michigan-Shanghai Jiao Tong University Joint Institute, Shanghai Jiao Tong University, Shanghai, 200240, China
| | - James A Ashton-Miller
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, 48109, USA
| | - John O L DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Jiajia Luo
- Biomedical Engineering Department, Peking University, Beijing, 100191, China.
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García-Mejido JA, Ramos-Vega Z, Fernández-Palacín A, Borrero C, Valdivia M, Pelayo-Delgado I, Sainz-Bueno JA. Predictive Model for the Diagnosis of Uterine Prolapse Based on Transperineal Ultrasound. Tomography 2022; 8:1716-1725. [PMID: 35894009 PMCID: PMC9326672 DOI: 10.3390/tomography8040144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/22/2022] [Accepted: 06/30/2022] [Indexed: 11/27/2022] Open
Abstract
We want to describe a model that allows the use of transperineal ultrasound to define the probability of experiencing uterine prolapse (UP). This was a prospective observational study involving 107 patients with UP or cervical elongation (CE) without UP. The ultrasound study was performed using transperineal ultrasound and evaluated the differences in the pubis−uterine fundus distance at rest and with the Valsalva maneuver. We generated different multivariate binary logistic regression models using nonautomated methods to predict UP, including the difference in the pubis−uterine fundus distance at rest and with the Valsalva maneuver. The parameters were added progressively according to their simplicity of use and their predictive capacity for identifying UP. We used two binary logistic regression models to predict UP. Model 1 was based on the difference in the pubis−uterine fundus distance at rest and with the Valsalva maneuver and the age of the patient [AUC: 0.967 (95% CI, 0.939−0.995; p < 0.0005)]. Model 2 used the difference in the pubis−uterine fundus distance at rest and with the Valsalva maneuver, age, avulsion and ballooning (AUC: 0.971 (95% CI, 0.945−0.997; p < 0.0005)). In conclusion, the model based on the difference in the pubis−uterine fundus distance at rest and with the Valsalva maneuver and the age of the patient could predict 96.7% of patients with UP.
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Affiliation(s)
- José Antonio García-Mejido
- Department of Obstetrics and Gynecology, Valme University Hospital, 41014 Seville, Spain; (C.B.); (M.V.); (J.A.S.-B.)
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Seville, 41009 Seville, Spain
- Correspondence: (J.A.G.-M.); (A.F.-P.)
| | - Zenaida Ramos-Vega
- Department of Obstetrics and Gynecology, Nuestra Señora de la Merced Hospital, 41640 Seville, Spain;
| | - Ana Fernández-Palacín
- Biostatistics Unit, Department of Preventive Medicine and Public Health, University of Seville, 41009 Seville, Spain
- Correspondence: (J.A.G.-M.); (A.F.-P.)
| | - Carlota Borrero
- Department of Obstetrics and Gynecology, Valme University Hospital, 41014 Seville, Spain; (C.B.); (M.V.); (J.A.S.-B.)
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Seville, 41009 Seville, Spain
| | - Maribel Valdivia
- Department of Obstetrics and Gynecology, Valme University Hospital, 41014 Seville, Spain; (C.B.); (M.V.); (J.A.S.-B.)
| | - Irene Pelayo-Delgado
- Department of Obstetrics and Gynecology, Ramón y Cajal University Hospital, 28034 Madrid, Spain;
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Alcalá de Henares, 28871 Madrid, Spain
| | - José Antonio Sainz-Bueno
- Department of Obstetrics and Gynecology, Valme University Hospital, 41014 Seville, Spain; (C.B.); (M.V.); (J.A.S.-B.)
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Seville, 41009 Seville, Spain
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García-Mejido JA, González-Diaz E, Ortega I, Borrero C, Fernández-Palacín A, Sainz-Bueno JA. 2D ultrasound diagnosis of middle compartment prolapse: a multicenter study. Quant Imaging Med Surg 2022; 12:959-966. [PMID: 35111597 DOI: 10.21037/qims-21-707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 09/22/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Recently, a specific methodology has been defined, using transperineal ultrasound, for the differential diagnosis of middle compartment prolapse [uterine prolapse (UP) or cervical elongation (CE) without UP] based on the difference in the pubis-uterine fundus distance at rest and with the Valsalva maneuver, with a cutoff point of 15 mm. The objective of this study was to validate the diagnostic utility of a ≥15 mm difference between the pubis-uterine fundus distance at rest and during the Valsalva maneuver to define UP in a multicenter study. METHODS This prospective multicenter observational study included 94 patients (UP =51; CE without UP =43). The clinical examination was based on the International Continence Society Pelvic Organ Prolapse Quantification (ICS POP-Q) system for assessing pelvic organ prolapse (POP) and patients were candidates for corrective surgery of the middle compartment of the pelvic floor (correction of UP or CE without UP). The ultrasound study was performed by transperineal ultrasound (B-mode) with the patient undergoing dorsal lithotomy. The distance evaluation was performed in relation to the posteroinferior pubic margin in the midsagittal plane, with reference to the uterine fundus (established as the most distal hyperechogenic) line from the pubis to the uterine fundus at rest and with the Valsalva maneuver. We defined UP detected using UP as a difference of ≥15 mm between the pubis-uterine fundus distance at rest and with the Valsalva maneuver. Agreement between the clinical and ultrasound diagnosis of UP was assessed using the Cohen kappa coefficient of agreement and its 95% CIs. RESULTS The ultrasound diagnosis of global UP at the three centers showed very good agreement, with a kappa index of 0.826 (0.71, 0.94). The agreement of ultrasound with the clinical diagnosis of UP using the ICS POP-Q system was very good for each of the hospitals [Hospital 1: 0.814 (0.64, 0.98), Hospital 2: 0.847 (0.64, 1) and Hospital 3: 0.824 (0.59, 1)]. CONCLUSIONS A difference of ≥15 mm between the pubis-uterine fundus distance at rest and during the Valsalva maneuver for the diagnosis of UP presents very good agreement with the results of clinical evaluation with the ICS POP-Q system.
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Affiliation(s)
- José Antonio García-Mejido
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain.,Department of Obstetrics and Gynecology, University of Seville, Seville, Spain
| | - Enrique González-Diaz
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Leon (CAULE), León, Spain
| | - Ismael Ortega
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Gran Canarias, Gran Canarias, Spain
| | - Carlota Borrero
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain.,Department of Obstetrics and Gynecology, University of Seville, Seville, Spain
| | - Ana Fernández-Palacín
- Biostatistics Unit, Department of Preventive Medicine and Public Health, University of Seville, Seville, Spain
| | - José Antonio Sainz-Bueno
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain.,Department of Obstetrics and Gynecology, University of Seville, Seville, Spain
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Chaudhuri S, Vaitheeswari J. Correlation of preoperative and intraoperative assessment of pelvic organ prolapse by pelvic organ prolapse quantification system. Int J Gynaecol Obstet 2021; 157:466-470. [PMID: 34424996 DOI: 10.1002/ijgo.13894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/24/2021] [Accepted: 08/20/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To correlate the measurements of pelvic organ quantification (POP-Q) score obtained preoperatively with Valsalva maneuver with POP-Q score obtained intraoperatively under anesthesia in the assessment of pelvic organ prolapse. METHODS A prospective observational study included 25 women attending gynecology outpatient department with symptomatic pelvic organ prolapse in Midnapore Medical College, India and planned for vaginal operative treatment between March 2019 and February 2020. The preoperative examination was performed in the outpatient department using the POP-Q system with Valsalva maneuver and final examination was performed under spinal anesthesia with mechanical traction. The correlation was performed using the preoperative and intraoperative measurements. RESULTS All intraoperative POP-Q measurements showed a significantly higher descent compared with preoperative measurements (mean difference Aa 0.72 cm, Ba 1.08 cm, C 1.66 cm, Ap 0.26 cm, Bp 1.6 cm, D 1.6 cm, Gh 0.6 cm,) except for Pb and Tvl. Among all nine measurements, the greatest difference between the preoperative and intraoperative values was observed for points C, D, and Bp. CONCLUSION Preoperative POP-Q scores significantly differed when assessed intraoperatively under spinal anesthesia with traction. The patient should be informed that the surgical plan may change depending on the intraoperative findings. Our study is an alert for both surgeons and patients.
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Affiliation(s)
- Snehamay Chaudhuri
- Department of Obstetrics and Gynecology, Midnapore Medical College, Paschim Midnapore, West Bengal, India
| | - Jayamoorthy Vaitheeswari
- Department of Obstetrics and Gynecology, Midnapore Medical College, Paschim Midnapore, West Bengal, India
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García-Mejido JA, Ramos-Vega Z, Armijo-Sánchez A, Fernández-Palacín A, García-Jimenez R, Sainz JA. Differential diagnosis of middle compartment pelvic organ prolapse with transperineal ultrasound. Int Urogynecol J 2021; 32:2219-2225. [PMID: 33484288 DOI: 10.1007/s00192-020-04646-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/09/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to identify the best parameter (pubis-cervix measurement, pubis-uterine fundus measurement or pubis-pouch of Douglas measurement) on transperineal ultrasound, based on the difference between measurements taken at rest and with the Valsalva maneuver, for presurgical differential diagnosis between uterine prolapse (UP) and cervical elongation (CE) without UP. METHODS A prospective observational study of 60 consecutively recruited patients who underwent corrective surgery of the middle compartment (UP or CE without UP). A transperineal ultrasound was performed, and the descent of the pelvic organ was measured in relation to the posteroinferior margin of the pubis in the midsagittal plane, referencing the uterine fundus, pouch of Douglas and the cervix at rest and with the Valsalva test. RESULTS Receiver operating characteristic (ROC) curves were constructed for the three evaluated measures, based on the difference between rest and Valsalva, for the diagnosis of UP. For the pubis-cervix distance, an area under the curve (AUC) of 0.59 was obtained; for the pubis-uterine fundus distance, the AUC was 0.81; and for the pubis-pouch of Douglas distance, the AUC was 0.69. Based on the best AUC (the difference in the pubis-uterine fundus distance at rest and with the Valsalva maneuver), a cut-off point of 15 mm was established for the diagnosis of UP (sensitivity: 75%; specificity: 95%; positive predictive value: 86%; and negative predictive value: 89%). CONCLUSION A difference of ≥15 mm in the pubis-uterine fundus distance at rest and with the Valsalva maneuver is useful for differentiating UP from CE without UP by ultrasound.
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Affiliation(s)
- José Antonio García-Mejido
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain.
- Department of Obstetrics and Gynecology, University of Seville, Seville, Spain.
| | - Zenaida Ramos-Vega
- Department of Obstetrics and Gynecology, Nuestra Señora de la Merced Hospital, Seville, Spain
| | | | - Ana Fernández-Palacín
- Biostatistics Unit, Department of Preventive Medicine and Public Health, University of Seville, Seville, Spain
| | - Rocío García-Jimenez
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
| | - José Antonio Sainz
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
- Department of Obstetrics and Gynecology, University of Seville, Seville, Spain
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Kieserman-Shmokler C, Swenson CW, Chen L, Desmond LM, Ashton-Miller JA, DeLancey JO. From molecular to macro: the key role of the apical ligaments in uterovaginal support. Am J Obstet Gynecol 2020; 222:427-436. [PMID: 31639371 DOI: 10.1016/j.ajog.2019.10.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 09/05/2019] [Accepted: 10/12/2019] [Indexed: 01/22/2023]
Abstract
To explain the pathophysiology of pelvic organ prolapse, we must first understand the complexities of the normal support structures of the uterus and vagina. In this review, we focus on the apical ligaments, which include the cardinal and uterosacral ligaments. The aims of this review are the following: (1) to provide an overview of the anatomy and histology of the ligaments; (2) to summarize the imaging and biomechanical studies of the ligament properties and the way they relate to anterior and posterior vaginal wall prolapse; and (3) to synthesize these findings into a conceptual model for the progression of prolapse.
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12
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Standardized terminology of apical structures in the female pelvis based on a structured medical literature review. Am J Obstet Gynecol 2020; 222:204-218. [PMID: 31805273 DOI: 10.1016/j.ajog.2019.11.1262] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 11/04/2019] [Accepted: 11/17/2019] [Indexed: 12/13/2022]
Abstract
The objectives of this study were to review the published literature and selected textbooks, to compare existing usage to that in Terminologia Anatomica, and to compile standardized anatomic nomenclature for the apical structures of the female pelvis. MEDLINE was searched from inception until May 30, 2017, based on 33 search terms generated by group consensus. Resulting abstracts were screened by 11 reviewers to identify pertinent studies reporting on apical female pelvic anatomy. Following additional focused screening for rarer terms and selective representative random sampling of the literature for common terms, accepted full-text manuscripts and relevant textbook chapters were extracted for anatomic terms related to apical structures. From an initial total of 55,448 abstracts, 193 eligible studies were identified for extraction, to which 14 chapters from 9 textbooks were added. In all, 293 separate structural terms were identified, of which 184 had Terminologia Anatomica-accepted terms. Inclusion of several widely used regional terms (vaginal apex, adnexa, cervico-vaginal junction, uretero-vesical junction, and apical segment), structural terms (vesicouterine ligament, paracolpium, mesoteres, mesoureter, ovarian venous plexus, and artery to the round ligament) and spaces (vesicocervical, vesicovaginal, presacral, and pararectal) not included in Terminologia Anatomica is proposed. Furthermore, 2 controversial terms (lower uterine segment and supravaginal septum) were identified that require additional research to support or refute continued use in medical communication. This study confirms and identifies inconsistencies and gaps in the nomenclature of apical structures of the female pelvis. Standardized terminology should be used when describing apical female pelvic structures to facilitate communication and to promote consistency among multiple academic, clinical, and surgical disciplines.
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Berger MB, Kolenic GE, Fenner DE, Morgan DM, DeLancey JOL. Structural, functional, and symptomatic differences between women with rectocele versus cystocele and normal support. Am J Obstet Gynecol 2018; 218:510.e1-510.e8. [PMID: 29409787 DOI: 10.1016/j.ajog.2018.01.033] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 01/19/2018] [Accepted: 01/23/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Prolapse of the anterior and posterior vaginal walls has been generally associated with apical descent and levator ani muscle defects. However, the relative contributions of these factors to the pathophysiology of descent in the different vaginal compartments is not well understood. Furthermore, symptoms uniquely associated with prolapse in these compartments have not been well characterized. OBJECTIVES The objectives of the study were to compare the associations between the following: (1) apical support, (2) levator ani muscles, and (3) pelvic floor symptoms in women with posterior-predominant prolapse, anterior-predominant prolapse, and normal support. STUDY DESIGN This is a cross-sectional study with 2 case arms: 60 women with posterior prolapse, 90 with anterior prolapse, and a referent control arm with 103 asymptomatic subjects with normal support, determined from pelvic organ prolapse quantification examinations. Levator muscle defects were graded from magnetic resonance imaging. Vaginal closure forces above resting were measured with an instrumented speculum during maximal contraction. Pelvic floor symptoms were measured via the Pelvic Floor Distress Inventory-Short Form. RESULTS Mean point C location in controls was -6.9 cm [1.5] (mean [standard deviation]); and was higher in posterior prolapse (-4.7 cm [2.7], 2.2 cm below controls) than the anterior prolapse group (-1.2 cm [4.1]; 5.6 cm below controls, P < .001 for all comparisons). Normal-appearing muscles (ie, muscle without a visible defect) occurred at similar frequencies in posterior prolapse (45%) and controls (51%, P = .43) but less often in anterior prolapse (28%, P ≤ .03 for pairwise comparisons). Major levator ani defects occurred at similar rates in women with posterior (33%) and anterior prolapse (42%, P = .27) but less often in controls (16%, P ≤ .012 for both pairwise comparisons). Similarly, there were significant differences in generated vaginal closure forces across the 3 groups, with the prolapse groups generating weaker closure forces than the control group (P = .004), but the differences between the 2 prolapse groups were not significant after controlling for prolapse size (P = .43). Pelvic floor symptoms were more severe for the posterior (mean Pelvic Floor Distress Inventory score, 129) and anterior prolapse groups (score, 128) than the controls (score, 40.2, P < .001 for both comparisons); the difference between the 2 prolapse groups was not significant (P = .83). CONCLUSION Posterior-predominant prolapse involves an almost 3-fold less apical descent below normal than anterior-predominant vaginal prolapse. Levator ani defects and muscle impairment also have a lower impact. Pelvic floor symptoms reflect the presence and size of prolapse more than the predominant lax vaginal compartment.
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Affiliation(s)
- Mitchell B Berger
- Pelvic Floor Research Group, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI.
| | - Giselle E Kolenic
- Pelvic Floor Research Group, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Dee E Fenner
- Pelvic Floor Research Group, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Daniel M Morgan
- Pelvic Floor Research Group, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - John O L DeLancey
- Pelvic Floor Research Group, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
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Ruiz-Zapata AM, Feola AJ, Heesakkers J, de Graaf P, Blaganje M, Sievert KD. Biomechanical Properties of the Pelvic Floor and its Relation to Pelvic Floor Disorders. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.eursup.2017.12.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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15
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Weber LeBrun EE. Update on Surgical Treatments for Pelvic Organ Prolapse. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2017. [DOI: 10.1007/s13669-017-0221-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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