Comparison between the Valsalva maneuver and intraoperative traction measurements in pelvic organ prolapse assessment

In-plane and out-of-plane deformations of gilt utero-sacral ligaments

The uterosacral ligaments (USLs) are supportive structures of the uterus and apical vagina. The mechanical function of these ligaments within the pelvic floor is crucial not only in normal physiological conditions but also in reconstructive surgeries for pelvic organ prolapse. Discrepancies in their anatomical and histological description exist in the literature, but such discrepancies are likely due to large variations of these structures. This makes mechanical testing very challenging, requiring the development of advanced methods for characterizing their mechanical properties. This study proposes the use of planar biaxial testing, digital image correlation (DIC), and optical coherence tomography (OCT) to quantify the deformations of the USLs, both in-plane and out-of-plane. Using the gilts as an animal model, the USLs were found to deform significantly less in their main direction (MD) of in vivo loading than in the direction perpendicular to it (PD) at increasing equibiaxial stresses. Under constant equibiaxial loading, the USLs deform over time equally, at comparable rates in both the MD and PD. The thickness of the USLs decreases as the equibiaxial loading increases but, under constant equibiaxial loading, the thickness increases in some specimens and decreases in others. These findings could contribute to the design of new mesh materials that augment the support function of USLs as well as noninvasive diagnostic tools for evaluating the integrity of the USLs.

Correlation of preoperative and intraoperative assessment of pelvic organ prolapse by pelvic organ prolapse quantification system

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.

Mechanics of Uterosacral Ligaments: Current Knowledge, Existing Gaps, and Future Directions

The uterosacral ligaments (USLs) are important anatomical structures that support the uterus and apical vagina within the pelvis. As these structures are over-stretched, become weak, and exhibit laxity, pelvic floor disorders such as pelvic organ prolapse occur. Although several surgical procedures to treat pelvic floor disorders are directed toward the USLs, there is still a lot that is unknown about their function. This manuscript presents a review of the current knowledge on the mechanical properties of the USLs. The anatomy, microstructure, and clinical significance of the USLs are first reviewed. Then, the results of published experimental studies on the in vivo and ex vivo, uniaxial and biaxial tensile tests are compiled. Based on the existing findings, research gaps are identified and future research directions are discussed. The purpose of this exhaustive review is to help new researchers navigate scientific literature on the mechanical properties of the USLs. The use of these structures remains very popular in reconstructive surgeries that restore and augment the support of pelvic organs, especially as synthetic surgical mesh implants continue to be highly controversial.

Could the Valsalva manoeuvre be an alternative to the tenaculum for intrauterine device insertion?

OBJECTIVES

This study investigated whether the Valsalva manoeuvre (VM) could be an alternative to use of the tenaculum for intrauterine device (IUD) insertion. The aims were to establish whether VM could provide good patient comfort and enable the insertion to be performed successfully with adequate pain control in cases where the cervix could not be passed spontaneously.

METHODS

Women who attended the outpatient clinic of Alanya Education and Research Hospital between November 2017 and December 2020 for IUD insertion were randomly assigned to the VM (n = 52) or tenaculum (n = 55) group. Insertion in the latter group was carried out by grasping the cervix with a single-toothed tenaculum. In the VM group, no tenaculum was used to grasp the cervix; instead, the woman was asked to perform VM during insertion.

RESULTS

IUD insertion success rates were similar between the groups. Procedural anxiety scores were slightly higher in the tenaculum group. Pain scores measured during the procedure were significantly higher in the tenaculum group compared with the VM group. Severe pain was reported by 58.2% of women in the tenaculum group, whereas 57.7% of women in the VM group reported no pain.

CONCLUSION

In cases where an IUD cannot be passed through the cervical canal spontaneously, the procedure should be attempted using VM before using a tenaculum. The use of VM may lead to lower pain and anxiety levels as well as increased patient comfort.

Perioperative changes in superficial pelvic organ prolapse quantification system measurements after prolapse surgery

OBJECTIVES

To evaluate the values of perineal body (PB) and genital hiatus (GH) before and after posterior repair. We also evaluated the introital surface area (ISA)-a sum of transverse and longitudinal GH measurements.

METHODS

This secondary analysis of a prospective case series included 94 women undergoing posterior vaginal prolapse surgery at a consultant urogynecology clinic between October 3, 2011, and October 2, 2014. Patients were examined in clinic using the pelvic organ prolapse quantification system with Valsalva maneuver, and in theatre pre- and postoperatively with traction.

RESULTS

Immediately postoperatively, a statistically significant change (all P<0.001) was noted for GH (mean difference -0.59 cm), PB (-0.56 cm), and ISA (-0.87 cm) compared with preoperative measurement. This effect was maintained for GH (-0.42 cm) and PB (-0.40 cm) at 2 months' follow-up (both P<0.001), and for PB alone (-0.43 cm; P=0.04) at 8 months. ISA had a moderate correlation with GH (r=0.55).

CONCLUSIONS

Posterior repair significantly improved PB length at months 2 and 8, and GH length at month 2. ISA did not correlate with prolapse stage. Changes in GH were not maintained beyond postoperative month 2.