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Omouri A, Rapacchi S, Duclos J, Niddam R, Bellemare ME, Pirró N. 3D Observation of Pelvic Organs with Dynamic MRI Segmentation: A Bridge Toward Patient-Specific Models. Int Urogynecol J 2024:10.1007/s00192-024-05817-0. [PMID: 38801556 DOI: 10.1007/s00192-024-05817-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 04/24/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION AND HYPOTHESIS Female pelvic organ prolapses are common, but their treatment is challenging. Notably, diagnosis and understanding of these troubles remain incomplete. Tridimensional observations of displacement and deformation of the pelvic organs during a strain could support a better understanding and help to develop comprehensive tools for preoperative planning. METHODS The present feasibility study evaluates tridimensional dynamic MRI in 12 healthy volunteers. Tridimensional acquisitions were approximated using five intersecting slices, each recorded twice per second. MRI was performed during rest and strain, with intrarectal and intravaginal contrast gel. Subject-specific dynamic 3D models were built for each volunteer through segmentation. RESULTS For each volunteer, pelvic organs could be segmented in three dimensions with a rate of acquisition of two cycles per second on five slices, allowing for a fluid observation of displacements and deformations during strain. Manual segmentation of a full strain required 2 h and 33 min on average. The upper limit of the rectum and the pelvic floor were the most difficult structures to identify. This technique is limited by its time-consuming manual segmentation, which impedes its implantation for routine clinical use. This method must be tried in patients with pelvic organ prolapse. CONCLUSIONS This multi-planar acquisition technique applied during a dynamic MRI allows for observation of displacement and deformations of pelvic organs during a strain.
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Affiliation(s)
- Adel Omouri
- Aix-Marseille Univ-Service de Chirurgie Digestive et Oncologique-Hôpital de la Timone, 264, Rue Saint-Pierre, 13005, Marseille, France.
| | - Stanislas Rapacchi
- CNRS, CRMBM, Aix-Marseille Univ, 27 Boulevard Jean Moulin, 13005, Marseille, France
| | - Julie Duclos
- Aix-Marseille Univ-Service de Chirurgie Digestive et Oncologique-Hôpital de la Timone, 264, Rue Saint-Pierre, 13005, Marseille, France
| | - Raphaël Niddam
- Aix-Marseille Univ-Service de Chirurgie Digestive et Oncologique-Hôpital de la Timone, 264, Rue Saint-Pierre, 13005, Marseille, France
| | - Marc-Emmanuel Bellemare
- Laboratoire d'Informatique Et Systèmes, équipe I&M - UMR CNRS 7020, Aix-Marseille Université-CNRS, 52, Avenue Escadrille Normandie Niémen, 13397, Marseille Cedex 20, France
| | - Nicolas Pirró
- Aix-Marseille Univ-Service de Chirurgie Digestive et Oncologique-Hôpital de la Timone, 264, Rue Saint-Pierre, 13005, Marseille, France
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Barbier H, Carberry CL, Karjalainen PK, Mahoney CK, Galán VM, Rosamilia A, Ruess E, Shaker D, Thariani K. International Urogynecology consultation chapter 2 committee 3: the clinical evaluation of pelvic organ prolapse including investigations into associated morbidity/pelvic floor dysfunction. Int Urogynecol J 2023; 34:2657-2688. [PMID: 37737436 PMCID: PMC10682140 DOI: 10.1007/s00192-023-05629-8] [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: 05/01/2023] [Accepted: 07/22/2023] [Indexed: 09/23/2023]
Abstract
INTRODUCTION AND HYPOTHESIS This manuscript from Chapter 2 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) reviews the literature involving the clinical evaluation of a patient with POP and associated bladder and bowel dysfunction. METHODS An international group of 11 clinicians performed a search of the literature using pre-specified search MESH terms in PubMed and Embase databases (January 2000 to August 2020). Publications were eliminated if not relevant to the clinical evaluation of patients or did not include clear definitions of POP. The titles and abstracts were reviewed using the Covidence database to determine whether they met the inclusion criteria. The manuscripts were reviewed for suitability using the Specialist Unit for Review Evidence checklists. The data from full-text manuscripts were extracted and then reviewed. RESULTS The search strategy found 11,242 abstracts, of which 220 articles were used to inform this narrative review. The main themes of this manuscript were the clinical examination, and the evaluation of comorbid conditions including the urinary tract (LUTS), gastrointestinal tract (GIT), pain, and sexual function. The physical examination of patients with pelvic organ prolapse (POP) should include a reproducible method of describing and quantifying the degree of POP and only the Pelvic Organ Quantification (POP-Q) system or the Simplified Pelvic Organ Prolapse Quantification (S-POP) system have enough reproducibility to be recommended. POP examination should be done with an empty bladder and patients can be supine but should be upright if the prolapse cannot be reproduced. No other parameters of the examination aid in describing and quantifying POP. Post-void residual urine volume >100 ml is commonly used to assess for voiding difficulty. Prolapse reduction can be used to predict the possibility of postoperative persistence of voiding difficulty. There is no benefit of urodynamic testing for assessment of detrusor overactivity as it does not change the management. In women with POP and stress urinary incontinence (SUI), the cough stress test should be performed with a bladder volume of at least 200 ml and with the prolapse reduced either with a speculum or by a pessary. The urodynamic assessment only changes management when SUI and voiding dysfunction co-exist. Demonstration of preoperative occult SUI has a positive predictive value for de novo SUI of 40% but most useful is its absence, which has a negative predictive value of 91%. The routine addition of radiographic or physiological testing of the GIT currently has no additional value for a physical examination. In subjects with GIT symptoms further radiological but not physiological testing appears to aid in diagnosing enteroceles, sigmoidoceles, and intussusception, but there are no data on how this affects outcomes. There were no articles in the search on the evaluation of the co-morbid conditions of pain or sexual dysfunction in women with POP. CONCLUSIONS The clinical pelvic examination remains the central tool for evaluation of POP and a system such as the POP-Q or S-POP should be used to describe and quantify. The value of investigation for urinary tract dysfunction was discussed and findings presented. The routine addition of GI radiographic or physiological testing is currently not recommended. There are no data on the role of the routine assessment of pain or sexual function, and this area needs more study. Imaging studies alone cannot replace clinical examination for the assessment of POP.
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Affiliation(s)
- Heather Barbier
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Cassandra L Carberry
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University/Women & Infants Hospital, Providence, RI, USA
| | - Päivi K Karjalainen
- Department of Obstetrics and Gynecology, Hospital Nova of Central Finland, Jyväskylä, Finland
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
- Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | | | | | - Anna Rosamilia
- Urogynaecologist and Reconstructive Pelvic Floor Surgeon, Cabrini Hospital, Malvern, Victoria, Australia.
- Monash Health, Monash University Department of O&G, Hudson Institute of Medical Research, Melbourne, Australia.
| | - Esther Ruess
- Department of Obstetrics and Gynecology, University Hospital of Basel, Basel, Switzerland
| | - David Shaker
- Rural Clinical School Rockhampton Australia, Mater Private Hospital Rockhampton Australia, University of Queensland, St Lucia, Australia
| | - Karishma Thariani
- Fellowship in Urogynaecology & Pelvic Reconstructive Surgery, Consultant Urogynaecologist, Centre for Urogynaecology & Pelvic Health, New Delhi, India
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Peng J, Li S, Wang L, Yang L, Nai M, Xu Q, Jin Y, Liu P, Li L. Comparison of efficacy between laparoscopic pectopexy and laparoscopic high uterosacral ligament suspension in the treatment of apical prolapse-short term results. Sci Rep 2023; 13:18519. [PMID: 37898708 PMCID: PMC10613309 DOI: 10.1038/s41598-023-45871-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 10/25/2023] [Indexed: 10/30/2023] Open
Abstract
To compare the clinical efficacy of laparoscopic pectopexy and laparoscopic high uterosacral ligament suspension in women suffering from apical prolapse. The clinical data of 170 patients with apical prolapse (POP-Q score ≥ II) treated in the Third Affiliated Hospital of Zhengzhou University from January 2018 to July 2020 were retrospectively analyzed to assess the clinical efficacy of three surgical methods [laparoscopic pectopexy with uterine preservation, laparoscopic pectopexy with hysterectomy, laparoscopic high uterosacral ligament suspension (LHUSLS) with hysterectomy]. Patients were divided into three groups depending on Surgical methods: laparoscopic uterine pectopexy group (n = 23), laparoscopic pectopexy with hysterectomy group (n = 78) and LHUSLS with hysterectomy group (n = 69). The POP-Q points before and after operation were analyzed. The operation-related indices, perioperative periods and post-operative complications were compared. 1. The operation time of laparoscopic uterine pectopexy group was the shortest (p < 0.05). There was no significant difference in the incidence of apical prolapse and new stress urinary incontinence among the three groups during the follow-up period (p > 0.05). 2. The POP-Q points (Aa, Ba, C) in the three groups were better than those before operation (p < 0.05). Laparoscopic pectopexy with hysterectomy group had better Ap, Bp and C points and a longer TVL than LHUSLS with hysterectomy group (p < 0.05). 3. The postoperative PFDI-20, PFIQ-7 and PISQ-12 scores of the three groups were significantly improved than those before operation (p < 0.05). The PISQ-12 scores in laparoscopic uterine pectopexy group were significantly higher than that in the other two groups one year after operation (p < 0.05). The study concludes that laparoscopic pectopexy and LHUSLS can significantly improve the quality of life and sexual function for patients with apical prolapse. One year after operation, laparoscopic pectopexy has a more satisfactory anatomical reduction than LHUSLS with hysterectomy. The laparoscopic uterine pectopexy group had lower postoperative complications and better sexual function than that with hysterectomy group. Laparoscopic pectopexy should be used for the treatment of apical prolapse (POP-Q score ≥ II) patients who aim to better clinical efficacy and sexual function improvement.
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Affiliation(s)
- Juan Peng
- The Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Zhengzhou Key Laboratory of Endometrial Disease Prevention and Treatment, Zhengzhou, China
| | - Shuqing Li
- The Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Luwen Wang
- The Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Li Yang
- The Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Zhengzhou Key Laboratory of Endometrial Disease Prevention and Treatment, Zhengzhou, China
| | - Manman Nai
- The Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qingqing Xu
- The Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuxi Jin
- The Department of Obstetrics and Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Peng Liu
- The Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lei Li
- The Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
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Cheng W, English E, Horner W, Swenson CW, Chen L, Pipitone F, Ashton-Miller JA, DeLancey JOL. Hiatal failure: effects of pregnancy, delivery, and pelvic floor disorders on level III factors. Int Urogynecol J 2023; 34:327-343. [PMID: 36129480 PMCID: PMC10171831 DOI: 10.1007/s00192-022-05354-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 08/28/2022] [Indexed: 01/26/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The failure of the levator hiatus (LH) and urogenital hiatus (UGH) to remain closed is not only associated with pelvic floor disorders, but also contributes to recurrence after surgical repair. Pregnancy and vaginal birth are key events affecting this closure. An understanding of normal and failed hiatal closure is necessary to understand, manage, and prevent pelvic floor disorders. METHODS This narrative review was conducted by applying the keywords "levator hiatus" OR "genital hiatus" OR "urogenital hiatus" in PubMed. Articles that reported hiatal size related to pelvic floor disorders and pregnancy were chosen. Weighted averages for hiatal size were calculated for each clinical situation. RESULTS Women with prolapse have a 22% and 30% larger LH area measured by ultrasound at rest and during Valsalva than parous women with normal support. Women with persistently enlarged UGH have 2-3 times higher postoperative failure rates after surgery for prolapse. During pregnancy, the LH area at Valsalva increases by 29% from the first to the third trimester in preparation for childbirth. The enlarged postpartum hiatus recovers over time, but does not return to nulliparous size after vaginal birth. Levator muscle injury during vaginal birth, especially forceps-assisted, is associated with increases in hiatal size; however, it only explains a portion of hiatus variation-the rest can be explained by pelvic muscle function and possibly injury to other level III structures. CONCLUSIONS Failed hiatal closure is strongly related to pelvic floor disorders. Vaginal birth and levator injury are primary factors affecting this important mechanism.
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Affiliation(s)
- Wenjin Cheng
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.
- Beaumont Hospital Dearborn, Department of Obstetrics and Gynecology, 18101 Oakwood Blvd, Dearborn, MI, 48124, USA.
| | - Emily English
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Michigan Medicine, University of Michigan Health-West, Grand Rapids, MI, USA
| | - Whitney Horner
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Carolyn W Swenson
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Division of Urogynecology and Pelvic Reconstructive, University of Utah, Salt Lake City, UT, USA
| | - Luyun Chen
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Fernanda Pipitone
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
- Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | - James A Ashton-Miller
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - John O L DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
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El-Sayegh B, Cacciari LP, Primeau FL, Sawan M, Dumoulin C. The state of pelvic floor muscle dynamometry: A scoping review. Neurourol Urodyn 2023; 42:478-499. [PMID: 36478202 DOI: 10.1002/nau.25101] [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: 10/25/2021] [Revised: 10/01/2022] [Accepted: 11/14/2022] [Indexed: 12/12/2022]
Abstract
AIMS To discuss the advantages and limitation of the different pelvic floor muscle (PFM) dynamometers available, both in research and industry, and to present the extent of variation between them in terms of structure, functioning, psychometric properties, and assessment procedures. METHODS We identified relevant studies from four databases (MEDLINE, Compendex, Web of Science, and Derwent Innovations Index) up to December 2020 using terms related to dynamometry and PFM. In addition, we conducted a hand search of the bibliographies of all relevant reports. Peer-reviewed papers, conference proceedings, patents and user's manuals for commercial dynamometers were included and assessed by two independent reviewers. RESULTS One hundred and one records were included and 23 PFM dynamometers from 15 research groups were identified. From these, 20 were considered as clinical dynamometers (meant for research settings) and three as personal dynamometers (developed by the industry). Overall, significant heterogeneity was found in their structure and functioning, which limits development of normative data for PFM force in women. Further research is needed to assess the psychometric properties of PFM dynamometers and to standardize assessment procedures. CONCLUSION This review points up to the heterogeneity of existing dynamometers and methods of assessing PFM function. It highlights the need to better document their design and assessment protocol methods. Additionally, this review recommends standards for new dynamometers to allow the establishment of normalized data.
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Affiliation(s)
- Batoul El-Sayegh
- Department of Electrical and Computer Engineering, Polytechnique of Montreal, Montreal, Québec, Canada.,Research Center of the Institut Universtaire de Gériatrie de Montréal, Montréal, Québec, Canada
| | - Licia P Cacciari
- Research Center of the Institut Universtaire de Gériatrie de Montréal, Montréal, Québec, Canada.,School of Rehabilitation, Université de Montréal, Montréal, Québec, Canada
| | - Francois L Primeau
- Department of Electrical and Computer Engineering, Polytechnique of Montreal, Montreal, Québec, Canada
| | - Mohamad Sawan
- School of Engineering, Westlake University and Institute of Advanced Study, Westlake Institute for Advanced Study, Hangzhou, China
| | - Chantal Dumoulin
- Research Center of the Institut Universtaire de Gériatrie de Montréal, Montréal, Québec, Canada.,School of Rehabilitation, Université de Montréal, Montréal, Québec, Canada
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6
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Chen L, Schmidt P, DeLancey JO, Swenson CW. Analysis of long-term structural failure after native tissue prolapse surgery: a 3D stress MRI-based study. Int Urogynecol J 2022; 33:2761-2772. [PMID: 34626202 PMCID: PMC8993938 DOI: 10.1007/s00192-021-04925-5] [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: 03/26/2021] [Accepted: 06/12/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND HYPOTHESIS We sought to identify postoperative structural failure sites associated with long-term prolapse recurrence and their association with symptoms and satisfaction. METHODS Women who had a research MRI prior to native-tissue prolapse surgery were recruited for examination, 3D stress MRI, and questionnaires. Recurrence was defined by Pelvic Organ Prolapse Quantification System (POP-Q)Ba/Bp > 0 or C > -4. Measurements were performed at rest and maximum Valsalva ("strain") including vaginal length, apex location, urogenital hiatus (UGH), and levator hiatus (LH). Measures were compared between subjects and to women with normal support. Failure frequency was the proportion of women with measurements outside the normal range. Symptoms and satisfaction were measured using validated questionnaires. RESULTS Thirty-one women participated 12.7 years after surgery-58% with long-term success and 42% with recurrence. Failure site comparisons between success and failure were: impaired mid-vaginal paravaginal support (62% vs. 28%, p = 0.01), longer vaginal length (54% vs. 22%, p = 0.03), and enlarged urogenital hiatus (54% vs. 22%, p = 0.03). Apical paravaginal location had the lowest failure frequency (recurrence: 15% vs. success: 7%, p = 0.37). Patient satisfaction was high (recurrence: 5.0 vs. success: 5.0, p = 0.86). Women with bothersome bulge symptoms had a 33% larger UGH strain on POP-Q (p = 0.01), 8.7% larger resting UGH (p = 0.046), 11.5% larger straining LH (p = 0.01), and 9.3% larger resting LH (p = 0.01). CONCLUSIONS Abnormal low mid-vaginal paravaginal location (Level II), long vaginal length (Level II), and large UGH (Level III) were associated with long-term prolapse recurrence. Patient satisfaction was high and unrelated to anatomical recurrence. Bothersome bulge symptoms were associated with hiatus enlargement.
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Affiliation(s)
- Luyun Chen
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.
- Pelvic Floor Research Group, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA.
| | - Payton Schmidt
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - John O DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Carolyn W Swenson
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
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Liu JJ, Wang YZ, Chen N, Wang QN, Liu L, Li Y, Lei L, Wu Y. Hypothesis generation: Quantitative research to levator ani muscle injury based on MRI texture analysis. J Obstet Gynaecol Res 2022; 48:3269-3278. [PMID: 36167929 DOI: 10.1111/jog.15440] [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: 04/17/2022] [Revised: 09/09/2022] [Accepted: 09/11/2022] [Indexed: 11/30/2022]
Abstract
AIM Patients with pelvic organ prolapse (POP) mostly have injury to the levator ani muscle (LAM). We aimed to assess LAM injury in POP patients by quantifying texture feature (TF) ratios between the LAM and the obturator internus muscle (OIM) using texture analysis. METHODS This study retrospectively enrolled 32 participants, including 24 patients with POP and eight people with normal pelvic floor muscles. TFs of the LAM and the OIM were extracted using LIFEx version 6.30, and an independent samples t-test was performed to determine TF ratios characterizing LAM injury. After dimension reduction and binary logic analysis, the optimal TF ratio was obtained and the LAM injury quantitative evaluation was proposed. Spearman's correlation was performed to explore the correlations between TF ratios and clinical characteristics. We compared the diagnostic performance of quantitative evaluation and visual evaluation. RESULTS There were significant differences in 13 TF ratios between the POP and control groups. The area under the receiver operating characteristic curve of the integrated TF ratio was 0.948. Integrated TF ratio was significantly correlated with body mass index, pregnancies, and vaginal deliveries but had no correlation with LAM volume, hiatal area or abortions. Compared with the visual evaluation, the diagnostic accuracy of the quantitative evaluation had improved by 63.2% and 14.3% in the "minor defect" and "major defect" categories, respectively. CONCLUSION The integrated TF ratio can be used as a new quantifiable index to characterize LAM injury. The TF evaluation provides a potential role in LAM injury noninvasive diagnostic.
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Affiliation(s)
- Jing Jing Liu
- Faculty of Biomedical Engineering and Imaging Medicine, Army Medical University, Chongqing, China
| | - Yan Zhou Wang
- Department of Gynecology and Obstetrics, First Affiliated Hospital of Army Medical University, Chongqing, China
| | - Na Chen
- Faculty of Biomedical Engineering and Imaging Medicine, Army Medical University, Chongqing, China
| | - Qian Nan Wang
- Faculty of Biomedical Engineering and Imaging Medicine, Army Medical University, Chongqing, China
| | - Li Liu
- Faculty of Biomedical Engineering and Imaging Medicine, Army Medical University, Chongqing, China
| | - Ying Li
- Faculty of Biomedical Engineering and Imaging Medicine, Army Medical University, Chongqing, China
| | - Ling Lei
- Department of Gynecology and Obstetrics, First Affiliated Hospital of Army Medical University, Chongqing, China.,Department of Gynecology, The People Hospital of Anshun, Anshun City, China
| | - Yi Wu
- Faculty of Biomedical Engineering and Imaging Medicine, Army Medical University, Chongqing, China
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Serrano S, Henriques A, Valentim-Lourenço A, Pereira I. Levator ani muscle avulsion in patients with pelvic floor dysfunction – does it help in understanding pelvic organ prolapse? Eur J Obstet Gynecol Reprod Biol 2022; 279:140-145. [DOI: 10.1016/j.ejogrb.2022.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 09/22/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022]
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9
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Legan M, Barbič M, Osredkar J, Blaganje M. Association of vitamin D deficiency and pelvic organ prolapse in postmenopausal women: a cross-sectional study. Womens Midlife Health 2022; 8:9. [PMID: 35927747 PMCID: PMC9354377 DOI: 10.1186/s40695-022-00078-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 07/14/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Vitamin D is vital for skeletal integrity as well as optimal muscle work. High incidence and prevalence of vitamin D deficiency as well as pelvic organ prolapse are found in postmenopausal women, thus raising the question of whether the entities could be related. METHODS We compared 50 postmenopausal women aged 50 to 75 years with pelvic organ prolapse (POP) with 48 women of same age without POP. The clinical assessment of the disorder was performed using the Pelvic Organ Prolapse Quantification system (POP-Q). An anamnestic questionnaire was filled out by the participants on their anthropometric data, life habits, reproductive history, previous and actual diseases. A blood sample was collected for determination of 25-OH-vitamin D as well as calcium and phosphorus concentrations. RESULTS The group with POP and the control group were comparable in body mass index, physical activity, life habits and general health, but differed significantly in parity (being higher in POP) and vitamin D blood level concentrations, being lower in POP patients. A significantly higher prevalence of vitamin D deficiency (25-OH-vitamin D < 50 nmol/l) was found in the POP group compared to controls. Taking into account the confounding variables the logistic regression model confirmed the significant role of vitamin D for POP. CONCLUSIONS Vitamin D deficiency might be an important systemic factor associated to pelvic organ prolapse. The determination of vitamin D levels in postmenopausal women and replenishing its deficiency might also be of importance for the pelvic floor.
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Affiliation(s)
- Mateja Legan
- Division of Gynaecology, University Medical Centre Ljubljana, Zaloška 7, 1000, Ljubljana, Slovenia
| | - Matija Barbič
- Division of Gynaecology, University Medical Centre Ljubljana, Zaloška 7, 1000, Ljubljana, Slovenia
| | - Joško Osredkar
- Institute of Clinical Chemistry and Clinical Biochemistry, Zaloška 7, 1000, Ljubljana, Slovenia
| | - Mija Blaganje
- Division of Gynaecology, University Medical Centre Ljubljana, Zaloška 7, 1000, Ljubljana, Slovenia.
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10
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Vargas Maldonado D, Chen AH, Gebhart JB. Transvaginal Approach to Surgery for Pelvic Organ Prolapse. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2022.0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Darlene Vargas Maldonado
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Anita H. Chen
- Department of Medical and Surgical Gynecology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - John B. Gebhart
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Khatri G, Bhosale PR, Robbins JB, Akin EA, Ascher SM, Brook OR, Dassel M, Glanc P, Henrichsen TL, Learman LA, Sadowski EA, Saphier CJ, Wasnik AP, Maturen KE. ACR Appropriateness Criteria® Pelvic Floor Dysfunction in Females. J Am Coll Radiol 2022; 19:S137-S155. [PMID: 35550798 DOI: 10.1016/j.jacr.2022.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 02/19/2022] [Indexed: 10/18/2022]
Abstract
Pelvic floor disorders including pelvic organ prolapse (POP), urinary dysfunction, defecatory dysfunction, and complications after pelvic floor surgery are relatively common in the female population. Imaging tests are obtained when the initial clinical evaluation is thought to be incomplete or inconclusive or demonstrates findings that are discordant with patients' symptoms. An integrated imaging approach is optimal to evaluate the complex anatomy and dynamic functionality of the pelvic floor. Fluoroscopic cystocolpoproctography (CCP) and MR defecography are considered the initial imaging tests of choice for evaluation of POP. Fluoroscopic voiding cystourethrography is considered the initial imaging test for patients with urinary dysfunction. Fluoroscopic CCP and MR defecography are considered the initial imaging test for patients with defecatory dysfunction, whereas ultrasound pelvis transrectal is a complementary test in patients requiring evaluation for anal sphincter defects. MRI pelvis without and with intravenous contrast, MRI pelvis with dynamic maneuvers, and MR defecography are considered the initial imaging tests in patients with suspected complications of prior pelvic floor surgical repair. Transperineal ultrasound is emerging as an important imaging tool, in particular for screening of pelvic floor dysfunction and for evaluation of midurethral slings, vaginal mesh, and complications related to prior pelvic floor surgical repair. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Gaurav Khatri
- Division Chief, Body MRI; Associate Division Chief, Abdominal Imaging, UT Southwestern Medical Center, Dallas, Texas; Program Director, Body MRI Fellowship.
| | | | | | - Esma A Akin
- George Washington University Hospital, Washington, District of Columbia
| | - Susan M Ascher
- Georgetown University Hospital, Washington, District of Columbia
| | - Olga R Brook
- Section Chief of Abdominal Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Mark Dassel
- Director Endometriosis and Chronic Pelvic Pain, Cleveland Clinic, Cleveland, Ohio; American College of Obstetricians and Gynecologists
| | - Phyllis Glanc
- University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Lee A Learman
- Dean, Virginia Tech Carilion School of Medicine, Roanoke, Virginia; American College of Obstetricians and Gynecologists
| | - Elizabeth A Sadowski
- University of Wisconsin, Madison, Wisconsin; and ACR O-RADS MRI Education Subcommittee Chair
| | - Carl J Saphier
- Women's Ultrasound, LLC, Englewood, New Jersey; American College of Obstetricians and Gynecologists
| | - Ashish P Wasnik
- Division Chief, Abdominal Radiology, University of Michigan, Ann Arbor, Michigan
| | - Katherine E Maturen
- Associate Chair for Ambulatory Care and Specialty Chair, University of Michigan, Ann Arbor, Michigan
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12
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Schmidt P, Chen L, DeLancey JO, Swenson CW. Preoperative level II/III MRI measures predicting long-term prolapse recurrence after native tissue repair. Int Urogynecol J 2022; 33:133-141. [PMID: 34043048 PMCID: PMC8626527 DOI: 10.1007/s00192-021-04854-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/09/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION AND HYPOTHESIS To identify preoperative level II/III MRI measures associated with long-term recurrence after native tissue prolapse repair. METHODS Women who previously participated in pelvic floor research involving MRI prior to undergoing primary native tissue prolapse repair were recruited to return for repeat examination and MRI. Recurrence was defined by POP-Q (Ba/Bp > 0 or C > -4), repeat surgery, or pessary use. Preoperative MR images were used to perform five level II/III measurements including a new levator plate (LP) shape analysis at rest and maximal Valsalva. Principal component analysis (PCA) was used to evaluate LP shape variations. Principal component scores calculated for two independent shape variations were noted. RESULTS Thirty-five women were included with a mean follow-up of 13.2 ± 3.3 years. Nineteen (54%) were in the success group. There were no statistical differences between success versus recurrence groups in demographic, clinical, or surgical characteristics. Women with recurrence had a larger preoperative resting levator hiatus [median 6.4 cm (IQR 5.7, 7.1) vs. 5.8 cm (IQR 5.3, 6.3), p = 0.03]. This measure was associated with increased odds of recurrence (OR 8.2, CI 1.4-48.9, p = 0.02). Using PCA, preoperative LP shape PC1 scores were different between success and recurrence groups (p = 0.02), with a more dorsally oriented LP shape associated with recurrence. CONCLUSIONS Larger preoperative levator hiatus at rest and a more dorsally oriented levator plate shape were associated with prolapse recurrence at long-term follow-up. For every 1 cm increase in preoperative resting levator hiatus, the odds of long-term prolapse recurrence increases 8-fold.
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Affiliation(s)
- Payton Schmidt
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA.
| | - Luyun Chen
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, 48109, USA
| | - John O DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - Carolyn W Swenson
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA
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13
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Schmidt P, Cox CK, DeLancey JO, Suresh S, Horner W, Chen L, Swenson CW. Does preoperative resting genital hiatus size predict surgical outcomes? J Obstet Gynaecol Res 2021; 47:4023-4029. [PMID: 34412156 DOI: 10.1111/jog.14993] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/18/2021] [Accepted: 08/09/2021] [Indexed: 11/27/2022]
Abstract
AIM To determine whether preoperative genital hiatus at rest is predictive of medium-term prolapse recurrence. METHODS We conducted a retrospective study of women who underwent native tissue prolapse surgery from 2002 to 2017 with pelvic organ prolapse quantification data including resting genital hiatus at one of three time points: preoperatively, 6 weeks, and ≥1 year postoperatively. Demographics and clinical data were abstracted from the chart. Prolapse recurrence was defined by anatomic outcomes (Ba > 0, Bp > 0, and/or C ≥ -4) or retreatment. Descriptive statistics, bivariate analyses, and logistic regression analyses were performed. RESULTS Of the 165 women included, 36 (21.8%) had prolapse recurrence at an average of 1.5 years after surgery. Preoperative resting genital hiatus did not differ between women with surgical success versus recurrence (3.5 cm [interquartile range, IQR 2.25, 4.0) vs 3.5 cm (IQR 3.0, 4.0), p = 0.71). Point Bp was greater in the recurrence group at every time point. Preoperative Bp (odds ratio [OR] 1.24, confidence interval [CI] [1.06-1.45], p = 0.01) and days from surgery (OR 1.001, CI [1.000-1.001], p < 0.01) were independently associated with recurrence. Preoperative genital hiatus at rest and strain were significantly larger among women who underwent a colpoperineorrhaphy (rest: 4.0 [3.0, 4.5] cm vs 3.5 [3.0, 4.0] cm, p < 0.01; strain: 6.0 [4.0, 6.5] cm vs 5.0 [4.0, 6.0] cm, p = 0.01). CONCLUSIONS Preoperative genital hiatus at rest was not associated with prolapse recurrence when the majority of women underwent colpoperineorrhaphy. Preoperative Bp was more predictive of short-term prolapse recurrence. For every 1 cm increase in point Bp, there is a 24% increased odds of recurrence.
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Affiliation(s)
- Payton Schmidt
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Caroline K Cox
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - John O DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Shriya Suresh
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Whitney Horner
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Luyun Chen
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Carolyn W Swenson
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
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14
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Contemporary Review of MRI in Benign Genitourinary Pelvic Medicine: What Every Urologist Should Know. CURRENT BLADDER DYSFUNCTION REPORTS 2021. [DOI: 10.1007/s11884-021-00631-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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15
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Dahal S, Kuang M, Rietsch A, Butler RS, Ramamurthi A, Damaser MS. Quantitative Morphometry of Elastic Fibers in Pelvic Organ Prolapse. Ann Biomed Eng 2021; 49:1909-1922. [PMID: 33768411 DOI: 10.1007/s10439-021-02760-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 02/22/2021] [Indexed: 12/17/2022]
Abstract
Pelvic organ prolapse (POP) is common among older women who have delivered children vaginally. While the pathophysiology is not fully delineated, POP can occur in part from insufficient repair of disrupted elastic matrix fibers. Quantification of structural changes to elastic fibers has not been described previously for POP. The goal of this paper is to present a validated technique for morphometric analysis of elastic fibers in vaginal tissue cultures from lysyl oxidase like-1 knock out (LOXL1 KO) mice with POP. The effect of LOXL1 KO, effect of POP, effect of culture, and effect of elastogenic treatment on the changes in elastin fiber characteristics were tested using vaginal tissues from wild type multiparous (WT), LOXL1 KO multiparous prolapsed (POP) and LOXL1 KO multiparous non-prolapsed (NP) mice. Our results show significantly higher mean aspect ratio, maximum diameter and perimeter length in POP compared to NP after 3 weeks of tissue culture. Further, treatment of POP tissues in culture with growth factors with previously documented elastogenic effects caused a significant increase in the mean area and perimeter length of elastic fibers. This technique thus appears to be useful in quantifying structural changes and can be used to assess the pathophysiology of POP and the effect of elastogenic treatments with potential for POP.
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Affiliation(s)
- Shataakshi Dahal
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave. ND20, Cleveland, OH, 44195, USA
| | - Mei Kuang
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave. ND20, Cleveland, OH, 44195, USA
- Advanced Platform Technology Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - Anna Rietsch
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave. ND20, Cleveland, OH, 44195, USA
- Advanced Platform Technology Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - R S Butler
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Anand Ramamurthi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave. ND20, Cleveland, OH, 44195, USA
- Department of Biomedical Engineering, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, OH, USA
| | - Margot S Damaser
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave. ND20, Cleveland, OH, 44195, USA.
- Advanced Platform Technology Center, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.
- Department of Biomedical Engineering, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, OH, USA.
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
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16
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Chen L, Xie B, Fenner DE, Duarte Thibault ME, Ashton-Miller JA, DeLancey JO. Structural failure sites in posterior vaginal wall prolapse: stress 3D MRI-based analysis. Int Urogynecol J 2021; 32:1399-1407. [PMID: 33704534 DOI: 10.1007/s00192-021-04685-2] [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: 10/16/2020] [Accepted: 01/10/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to identify structural failure sites in rectocele by comparing women with and those without posterior vaginal wall prolapse and accessing their relative contribution to rectocele size based on stress MRI-based measurements. METHODS We studied three-dimensional stress MRI at maximal Valsalva of 25 women with (cases) and 25 without (controls) posterior vaginal prolapse of similar age and parity. Vaginal wall factors (posterior wall length and width); attachment factors (paravaginal posterior wall location, posterior fornix height, and perineal height); and hiatal factors (hiatal size and levator ani defects) were measured using Slicer 4.3.0® and a custom Python program. Stepwise linear regression was used to assess the relative contribution of all factors to the posterior prolapse size. RESULTS We identified three primary factors with large effect sizes of 2 or greater: two attachment factors-posterior paravaginal descent and perineal height; and one hiatal factor-genital hiatus size. These were the strongest predictors of the presence and size of rectocele, the most common failure sites, found in 60-76% of cases; and highly correlated with one another (r = 0.72-0.84, p < .001). Longer vaginal length, wider distal vagina, lower posterior fornix, and larger levator ani hiatus had smaller effect sizes and were less likely to fall outside the norm (20-24%) than the three primary factors. When considering all the supporting factors, the combination of perineal height, posterior fornix height, and vaginal length explained 73% of the variation in rectocele size. CONCLUSIONS Lower perineal and lateral posterior vaginal location and enlarged genital hiatus size were strong predictors of rectocele occurrence and size and correlated highly.
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Affiliation(s)
- Luyun Chen
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA. .,Pelvic Floor Research Group, University of Michigan, Ann Arbor, MI, USA.
| | - Bing Xie
- Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, China
| | - Dee E Fenner
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA.,Pelvic Floor Research Group, University of Michigan, Ann Arbor, MI, USA
| | - Mary E Duarte Thibault
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA.,Pelvic Floor Research Group, University of Michigan, Ann Arbor, MI, USA
| | - James A Ashton-Miller
- Pelvic Floor Research Group, University of Michigan, Ann Arbor, MI, USA.,Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - John O DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA.,Pelvic Floor Research Group, University of Michigan, Ann Arbor, MI, USA
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17
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Kilic D, Guler T, Gokbel I, Gokbel DA, Ceylan DA, Sivaslioglu A. EFFECTS OF ISOLATED POSTERIOR VAGINAL WALL PROLAPSE ON LOWER URINARY TRACT SYMPTOMS. J Gynecol Obstet Hum Reprod 2021; 50:102095. [PMID: 33592348 DOI: 10.1016/j.jogoh.2021.102095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 12/12/2020] [Accepted: 02/04/2021] [Indexed: 11/27/2022]
Abstract
AIM To investigate the effects of isolated posterior vaginal compartment prolapse to lower urinary tract symptoms (LUTS). MATERIALS-METHODS Patients who were admitted with any kind of LUTS and diagnosed with posterior compartment defects were retrospectively analyzed at urogynecology units of 2 different tertiary referral centers. Patients were included in the analysis if they had isolated posterior vaginal compartment defects with no clinically significant anterior and apical compartment defects. The control group consisted of patients with no pelvic organ prolapse (POP). All pelvic examinations were performed by the same 2 specialists. The responses to a detailed LUTS questionnaire in the unit were assessed. RESULTS Of the 340 women with posterior POP, 280 were excluded from the analysis due to combined anterior and/or apical POP with posterior POP and stage 4 POP. When we compared the symptoms between the control group and the remaining 60 patients with isolated posterior POP, there was a statistically significant difference in urge, frequency, nocturia, abnormal emptying, vaginal winding, difficult stool passage (p = 0.031, p < 0.001, p < 0.001, p = 0.022, p = 0.041, and p = 0.039, respectively). CONCLUSION Women with posterior POP should be carefully examined not only for anorectal or bulging symptoms but also for LUTS.
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Affiliation(s)
- Derya Kilic
- Department of Obstetrics and Gynecology, Pamukkale University, Denizli, Turkey.
| | - Tolga Guler
- Department of Obstetrics and Gynecology, Pamukkale University, Denizli, Turkey
| | - Ismail Gokbel
- Department of Obstetrics and Gynecology, Mugla Sitki Kocman University, Mugla, Turkey
| | - Deniz Akin Gokbel
- Department of Obstetrics and Gynecology, Mugla Sitki Kocman University, Mugla, Turkey
| | - Deniz Aydin Ceylan
- Department of Obstetrics and Gynecology, Pamukkale University, Denizli, Turkey
| | - Akin Sivaslioglu
- Department of Obstetrics and Gynecology, Mugla Sitki Kocman University, Mugla, Turkey
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18
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Siahkal SF, Iravani M, Mohaghegh Z, Sharifipour F, Zahedian M, Nasab MB. Investigating the association of the dimensions of genital hiatus and levator hiatus with pelvic organ prolapse: a systematic review. Int Urogynecol J 2021; 32:2095-2109. [PMID: 33523259 DOI: 10.1007/s00192-020-04639-0] [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: 07/16/2020] [Accepted: 12/02/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND HYPOTHESIS Pelvic organ prolapse (POP) is a very common and distressing problem that affects women's quality of life. This systematic review aimed to investigate the association of the dimensions of the genital hiatus and levator hiatus at rest and Valsalva with POP. METHODS The Cochrane Library, PubMed, Scopus, Embase and Web of Science were searched on 25 April 2020. All data were analyzed using Review Manager 5.3. RESULTS Of the 1288 papers reviewed, 21 (n = 5145: 2909 women with POP and 2236 controls) were considered for meta-analysis. Compared with the normal pelvic floor group, the urogenital hiatus size in the POP group was significantly higher at rest (mean difference: 0.49; 95% CI: [0.43, 0.55], P < 0.00001) and at Valsalva (mean difference: 0.79; 95% CI: [0.70, 0.89], P < 0.00001). Also, the levator ani hiatus size in the POP group was significantly higher at rest (mean difference: 0.52, 95% CI: [0.25, 0.78], P < 0.0001) and at Valsalva (mean difference: 1.01; 95% CI: [0.73,1.28], P < 0.00001) compared with that in the normal pelvic floor group. CONCLUSION This systematic review showed that the sizes of the urogenital hiatus and levator ani hiatus and area of the levator hiatus in the POP group were significantly higher than those in the normal pelvic floor groups in both positions (rest or Valsalva maneuver). Also, in the POP group, the levator hiatus length at rest was significantly lower than that in the Valsalva maneuver.
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Affiliation(s)
- Shahla Faal Siahkal
- Department of Midwifery, Marand Branch, Islamic Azad University, Marand, Iran
| | - Mina Iravani
- Reproductive Health Promotion Research Center, Midwifery and Reproductive Health Department, Nursing and Midwifery School, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Zeynab Mohaghegh
- Unit of Family Health, Health Deputy of Tehran University of Medical Science, Tehran, Iran
| | - Foruzan Sharifipour
- Midwifery Department, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Maryam Zahedian
- Nursing and Midwifery School, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Maryam Beheshti Nasab
- Reproductive Health Promotion Research Center, Midwifery Department, Nursing and Midwifery School, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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19
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English EM, Chen L, Sammarco AG, Kolenic GE, Cheng W, Ashton-Miller JA, DeLancey JO. Mechanisms of hiatus failure in prolapse: a multifaceted evaluation. Int Urogynecol J 2021; 32:1545-1553. [PMID: 33399905 DOI: 10.1007/s00192-020-04651-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 12/10/2020] [Indexed: 12/26/2022]
Abstract
INTRODUCTION AND HYPOTHESIS We investigated whether factors influencing pelvic floor hiatal closure are inter-related or independent, hypothesizing that (1) hiatus size is moderately correlated with levator defect, pelvic floor muscle strength, and change in hiatus size with contraction and (2) urogenital hiatus (UGH) and levator hiatus (LH) measures are similar in patients with anterior wall (AW) and posterior wall (PW) prolapse. METHODS This cross-sectional case-control study included subjects with AW prolapse (n = 50), PW prolapse (n = 50), and normal support (n = 50). Hiatus measurements and levator defects were assessed on MRI, and vaginal closure force was measured with an instrumented speculum. Pearson correlation coefficients and simple and multivariable linear regression models were performed. RESULTS During contraction, LH narrowed 47% more in the PW compared to AW group (p = 0.001). With straining, LH lengthened 34% more in the PW than AW group (p < 0.001). With straining, UGH and LH lengthening was greater by 72% and 44% in those with major compared to no/minor defect (p < 0.001 and p = 0.004). Contraction strength explained, at most, 4% of UGH (r = 0.17) or LH (r = 0.20) shortening during contraction (r = 0.17 and r = 0.20, respectively), indicating that these factors are largely independent. After controlling for prolapse size, resting UGH and levator defect status were associated with straining UGH (p < 0.001, p = 0.004), but muscle strength and resting tone were not. CONCLUSIONS Hiatus measures are complex and differ according to prolapse occurrence and type. They are, at best, only weakly correlated with pelvic floor muscle strength and movement during contraction.
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Affiliation(s)
- Emily M English
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Luyun Chen
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.,Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Anne G Sammarco
- Department of Obstetrics and Gynecology, Rush University Medical Center, Chicago, IL, USA
| | - Giselle E Kolenic
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Wenjin Cheng
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.,Department of Obstetrics and Gynecology, Peking University People's Hospital, Beijing, China
| | | | - John O DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA. .,L4000 University Hospital South, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA.
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20
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Ignjatovic I, Potic M, Basic D, Dinic L, Skakic A. Laparoscopic minimally invasive sacrocolpopexy or hysteropexy and transobturator tape combined with native tissue repair of the vaginal compartments in patients with advanced pelvic organ prolapse and incontinence. Int Urogynecol J 2020; 32:967-974. [PMID: 32897460 DOI: 10.1007/s00192-020-04519-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/24/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The aim of the study was to evaluate hysterectomized and non-hysterectomized patients with prolapse and incontinence. Laparoscopic sacrohysteropexy (LSHP) and minimally invasive sacrocolpopexy (LMSCP) were done in combination with transobturator tape (TOT) and native tissue repair of the anterior and posterior vaginal compartments in patients with pelvic organ prolapse (POP) and occult, stress, or urinary incontinence (SUI). The hypothesis is that both methods are successful. METHODS A total of 81 patients with POP were evaluated: 44 had vaginal vault prolapse (POPQ points Ba, C, and Bp were 1.2, 2.6, and 0.4, respectively) and 37 had uterine prolapse (POPQ points Ba, C, and Bp were 1.8, 1.7, and 1.3, respectively). LMSCP (which means less dissection of the vagina in its upper third and avoiding possible collision with the ureters anteriorly or the rectum posteriorly) was performed in patients with vault prolapse, whereas patients with uterine prolapse underwent LSHP. Transobturator tape (TOT) was placed in all patients to treat symptomatic and occult urinary incontinence. Systematic anterior and posterior colporrhaphy was performed in both groups. RESULTS Both groups showed anatomic (p < 0.0001) and symptomatic improvement (p < 0.001-p < 0.05). Voiding was significantly improved after surgery without postoperative incontinence (p < 0.001). There was no significant difference between groups regarding duration of surgery (p = 0.06), hospital stay (p = 0.13), blood loss (0.83), Clavien-Dindo grade 3 (p = 0.87), and Clavien-Dindo grade 1-2 (p = 0.92) complications. CONCLUSION Minimally invasive LSCP or LSHP combined with TOT and native tissue repair of the anterior and posterior vaginal compartment is a successful treatment for POP.
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Affiliation(s)
- Ivan Ignjatovic
- Clinic of Urology, Clinical Center Nis, Bulevar Zorana Djindjica 48, Nis, Serbia.
| | - Milan Potic
- Clinic of Urology, Clinical Center Nis, Bulevar Zorana Djindjica 48, Nis, Serbia
| | - Dragoslav Basic
- Clinic of Urology, Clinical Center Nis, Bulevar Zorana Djindjica 48, Nis, Serbia
| | - Ljubomir Dinic
- Clinic of Urology, Clinical Center Nis, Bulevar Zorana Djindjica 48, Nis, Serbia
| | - Aleksandar Skakic
- Clinic of Urology, Clinical Center Nis, Bulevar Zorana Djindjica 48, Nis, Serbia
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21
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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: 17] [Impact Index Per Article: 4.3] [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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García-Mejido JA, Martín-Martínez A, González-Diaz E, Fernández-Fernández C, Ortega I, Medina M, Fernández-Corona A, Fernández-Palacín A, Sainz JA. Malmström vacuum or Kielland forceps: which causes more damage to pelvic floor? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:257-263. [PMID: 31332857 DOI: 10.1002/uog.20404] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 07/01/2019] [Accepted: 07/03/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To determine whether differences exist in the rate of levator ani muscle (LAM) avulsion between women who had undergone either Malmström vacuum delivery (MVD) or Kielland forceps delivery (KFD), allowing for potential confounding factors. METHODS This was a prospective observational study of nulliparous women undergoing instrumental delivery using Malmström vacuum extractor or Kielland forceps, at two hospital centers in Spain. Fetal head position (anterior, posterior or transverse) and fetal head station (low or mid) were assessed by ultrasound and digital examination, respectively. Avulsion was defined on tomographic ultrasound imaging as an abnormal insertion of the LAM in the three central slices from the plane of minimal hiatal dimensions. RESULTS In total, 414 patients were included in the study (212 MVD and 202 KFD). We observed a higher rate of LAM avulsion in the KFD group (KFD 49.5% vs MVD 32.5%; P = 0.001). When the results were evaluated according to fetal head position and station, we observed no differences in LAM avulsion. The crude odds ratio (OR) for the difference in avulsion between women in the KFD and MVD groups was 2.03 (95% CI, 1.36-3.03). However, when adjusted for duration of second stage of labor, fetal head circumference and fetal head station, the OR was no longer statistically significant (OR, 2.14 (95% CI, 0.95-4.85); P = 0.068). CONCLUSION When potential confounding factors are taken into account, the rate of LAM avulsion does not differ between women according to whether they have undergone KFD or MVD. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- J A García-Mejido
- Department of Obstetrics and Gynecology, Valme University Hospital, Seville, Spain
- Department of Obstetrics and Gynecology, University of Seville, Seville, Spain
| | - A Martín-Martínez
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Gran Canarias, Gran Canarias, Spain
| | - E González-Diaz
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Leon (CAULE), Leon, Spain
| | - C Fernández-Fernández
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Leon (CAULE), Leon, Spain
| | - I Ortega
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Gran Canarias, Gran Canarias, Spain
| | - M Medina
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Gran Canarias, Gran Canarias, Spain
| | - A Fernández-Corona
- Department of Obstetrics and Gynecology, Complejo Asistencial Universitario de Leon (CAULE), Leon, Spain
| | - A Fernández-Palacín
- Biostatistics Unit, Department of Preventive Medicine and Public Health, University of Seville, Seville, Spain
| | - J A 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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Comparison of measurement systems for posterior vaginal wall prolapse on magnetic resonance imaging. Int Urogynecol J 2019; 30:1269-1277. [PMID: 30972442 DOI: 10.1007/s00192-019-03939-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 03/20/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION AND HYPOTHESIS A wide variety of reference lines and landmarks have been used in imaging studies to diagnose and quantify posterior vaginal wall prolapse without consensus. We sought to determine which is the best system to (1) identify posterior vaginal wall prolapse and its appropriate cutoff values and (2) assess the prolapse size. METHODS This was a secondary analysis of sagittal maximal Valsalva dynamic MRI scans from 52 posterior-predominant prolapse cases and 60 comparable controls from ongoing research. All eight existing measurement lines and a new parameter, the exposed vaginal length, were measured. Expert opinions were used to score the prolapse sizes. Simple linear regressions, effect sizes, area under the curve, and classification and regression tree analyses were used to compare these reference systems and determine cutoff values. Linear and ordinal logistic regressions were used to assess the effectiveness of the prolapse size. RESULTS Among existing parameters, "the perineal line-internal pubis," a reference line from the inside of the pubic symphysis to the front tip of the perineal body (cutoff value 0.9 cm), had the largest effect size (1.61), showed the highest sensitivity and specificity to discriminate prolapse with area under the curve (0.91), and explained the most variation (68%) in prolapse size scores. The exposed vaginal length (cutoff value 2.9) outperformed all the existing lines, with the largest effect size (2.09), area under the curve (0.95), and R-squared value (0.77). CONCLUSIONS The exposed vaginal length performs slightly better than the best of the existing systems, for both diagnosing and quantifying posterior prolapse size. Performance characteristics and evidence-based cutoffs might be useful in clinical practice.
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Nyhus MØ, Salvesen KÅ, Volløyhaug I. Association between pelvic floor muscle trauma and contraction in parous women from a general population. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:262-268. [PMID: 30084230 DOI: 10.1002/uog.19195] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 07/13/2018] [Accepted: 07/16/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To study possible associations between pelvic floor muscle contraction, levator ani muscle (LAM) trauma and/or pelvic organ prolapse (POP) ≥ Stage 2 in parous women recruited from a general population. METHODS This was a secondary analysis of data from a cross-sectional study of 608 parous women from a general population examined using the POP quantification system (POP-Q) and three-dimensional/four-dimensional transperineal ultrasound for identification of LAM macrotrauma (avulsion) and microtrauma (distension of levator hiatal area > 75th percentile on Valsalva maneuver). Muscle contraction was assessed using the modified Oxford scale (MOS), perineometry and ultrasound measurement of proportional change of anteroposterior hiatal diameter and levator hiatal area at rest and on pelvic floor muscle contraction. The Mann-Whitney U-test was used to study associations between pelvic floor muscle contraction, LAM trauma and POP. RESULTS Women with macrotrauma (n = 113) had significantly weaker median pelvic floor muscle contraction, as measured using MOS and perineometry, than did women with an intact LAM (n = 493) (contraction strength was 1.5 (range, 0.0-5.0) vs 3.5 (range, 0.0-5.0) on MOS, and vaginal squeeze pressure was 15.0 (range, 0.0-78.0) cmH2 O vs 28.0 (range, 0.0-129.0) cmH2 O on perineometry; P < 0.001). This was also demonstrated by ultrasound measurement, with a proportional change in hiatal area of 19.9% (range, 4.1-48.0%) vs 34.0% (range, 0.0-64.0%) (P < 0.001) and proportional change in anteroposterior diameter of 16.2% (range, -5.7 to 42.6%) vs 26.0% (range, -3.4 to 49.4%) (P < 0.001). No statistically significant difference between women with (n = 65), and those without (n = 378), microtrauma was found after excluding women with macrotrauma. Women with POP had weaker muscle contraction than those without; in those with POP-Q ≥ 2 (n = 275) compared with those with POP-Q < 2 (n = 333), muscle contraction strength was 3.0 (range, 0.0-5.0) vs 3.5 (range, 0.0-5.0) on MOS, vaginal squeeze pressure was 21.0 (range, 0.0-98.0) cmH2 O vs 28.0 (range, 3.0-129.0) cmH2 O on perineometry, proportional change in hiatal area was 29.6% (range, 0.0-60.9%) vs 33.8% (range, 0.0-64.4%) and proportional change in anteroposterior diameter was 22.8% (range, -5.7 to 49.4%) vs 25.7% (range, -3.4 to 49.4%) (P < 0.001 for all). CONCLUSIONS LAM macrotrauma was associated with weaker pelvic floor muscle contraction measured using palpation, perineometry and ultrasound. Women with POP had weaker contraction than did women without POP. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M Ø Nyhus
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Obstetrics and Gynecology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - K Å Salvesen
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Obstetrics and Gynecology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - I Volløyhaug
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Obstetrics and Gynecology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Abstract
Native tissue anterior compartment prolapse repair remains an important surgical procedure for pelvic prolapse. Native tissue repair has been well-studied and is successful in relieving vaginal bulge symptoms and reducing prolapse within the vagina. Native tissue cystocele repair has been performed safely since the advent to modern vaginal surgery for prolapse. Reoperation rates are low and the contribution of apical support in the durability of vaginal wall defect repair surgery has been well-established. Native tissue cystocele repair addresses symptom relief for women, and should continue to be a part of pelvic floor reconstructive surgery.
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Affiliation(s)
- Katherine Amin
- Female Pelvic Medicine and Reconstructive Surgery, Section of Urology, Virginia Mason Medical Center, 1100 9th Avenue, C7-URO, Seattle, WA 98101, USA
| | - Una Lee
- Female Pelvic Medicine and Reconstructive Surgery, Section of Urology, Virginia Mason Medical Center, 1100 9th Avenue, C7-URO, Seattle, WA 98101, USA.
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