Imaging of slings and meshes

[Imaging of the pelvic floor : The gynaecological perspective]

BACKGROUND

Pelvic floor dysfunction is common in women.

OBJECTIVES

To describe the role of ultrasound in the urogynecological examination and imaging of the pelvic floor.

MATERIALS AND METHODS

Analysis and summary of current recommendations and literature on the role of pelvic floor ultrasound.

RESULTS

Pelvic floor ultrasound is a dynamic and real-time imaging modality. It is readily available, allows for a realistic assessment of anatomy and morphology, and poses minimal patient burden.

CONCLUSIONS

Pelvic floor ultrasound is of great value in preoperative diagnostics as well as in the postoperative management of complications.

Clinical application of a fixed reference line in the ultrasound quantitative diagnosis of female pelvic organ prolapse

OBJECTIVE

This study explored using an improved ultrasound (US) for quantitative evaluation of the degree of pelvic organ prolapse(POP).

DESIGN

A transluminal probe was used to standardize ultrasound imaging of pelvic floor organ displacements. A US reference line was fixed between the lower edge of the pubic symphysis and the central axis of the pubic symphysis at a 30°counterclockwise angle.

METHOD

Points Aa, Ba, C and Bp on pelvic organ prolapse quantification (POP-Q) were then compared with the points on pelvic floor ultrasound (PFUS).

RESULTS

One hundred thirteen patients were included in the analysis of the standard US plane. Correlations were good in the anterior and middle compartments (PBN:Aa, ICC = 0.922; PBB:Ba, ICC = 0.923; and PC:C, ICC = 0.925), and Bland-Altman statistical maps corresponding to the average difference around the 30°horizontal line were close to 0. Correlations were poor in the posterior compartment (PRA:Bp, ICC = 0.444). However, eight (7.1%) cases of intestinal hernia and 21 (18.6%) cases of rectocele were diagnosed.

CONCLUSIONS

Introital PFUS using an intracavitary probe, which is gently placed at the introitus of the urethra and the vagina, may be accurately used to evaluate organ displacement. The application of a 30°horizontal line may improve the repeatability of the US diagnosis of POP.

Sonographic assessment of compression effect on urethra following transobturator MUS

INTRODUCTION AND HYPOTHESIS

The aim of this study was to investigate the relationship between compression effect exerted by the sling on the urethra using translabial ultrasound and the prognosis of sling surgery in women for stress urinary incontinence (SUI).

METHODS

We retrospectively reviewed 151 women with SUI who had undergone either a TVT-Abbrevo (n = 81) or TVT-O (n = 70) procedure. Preoperative and 12-month postoperative assessments including sonographic data, urinary symptoms and signs were compared. Objective and subjective success rates were assessed at 12 months postoperatively.

RESULTS

Overall, 140 patients (92.7%) were objectively cured and 138 patients (91.4%) were subjectively cured of SUI 12 months after the operation with no significant differences between groups (p > 0.05). After both the TVT-Abbrevo and TVT-O procedures, the shortest distance between the tape and the urethral cavity line (TU) on straining (objective cure 4.1 mm vs. 4.5 mm, subjective cure 4.1 mm vs. 4.4 mm), the changes of the angle (∆) between the two arms of the sling (objective cure 15.8° vs. 20.8°, subjective cure 16.5° vs. 21.3°) and the gap between the sling and symphysis pubis (objective cure 9.9 mm vs. 12.1 mm, subjective cure 9.8 mm vs. 12.4 mm) were significantly smaller in the success group (p < 0.05). Analysis of ultrasound measurements in women reporting success and those reporting failure of the procedure showed the ∆TU (objective cure 1.6 mm vs. 0.9 mm, subjective cure 1.6 mm vs. 1.0 mm) and the angle on straining (objective cure 93.4° vs. 89.2°, subjective cure 94.3° vs. 88.9°) to be significantly bigger (p < 0.05). However, none of the assessed sonographic variables showed any significant differences between the TVT-Abbrevo and TVT-O groups.

CONCLUSIONS

The change in distance between the tape and urethral cavity line in the center of the urethra in the mid-sagittal plane after straining is an effective indicator of the compression effect exerted by the sling on the urethra after a mid-urethral sling (MUS) procedure and may contribute to both objective and subjective cure rates postoperatively.

Management and Follow-Up Practices of Women With Recurrent Stress Urinary Incontinence Following Transobturator Mid-urethral Synthetic Sling Procedure: A 6-Year Retrospective Monocentric University-Based Study

Purpose: The purpose of this study is to evaluate the efficacy of management and follow-up practices in repeat retropubic mid-urethral synthetic sling (MUS) procedure after transobturator tape/tension-free vaginal tape-obturator (TOT/TVT-O) failure, and to clarify the possible etiology of recurrent stress urinary incontinence.

Methods: The charts of all women patients who underwent tension-free vaginal tape (TVT) slings after previous failed transobturator MUS procedures between February 2012 and November 2018 at a single center were reviewed retrospectively. The transperineal ultrasound was performed to assess the pre-operative or post-operative urethral mobility and location of the slings. Furthermore, some essential evaluations were also made, mainly including medical history, physical examination, 1 h pad test, and urodynamic study. Finally, primary outcomes were evaluated according to the above items at 3, 6, and 12 months after the second operation, respectively.

Results: Thirty-five patients were included in the primary transobturator MUS sling procedure. At the 6 months follow-up, 32 (91.42%) patients were socially continent and negative in 1 h pad test. The transperineal ultrasound measurement results revealed that the bladder neck descent (BND) values were significantly decreased after the repeat sling operation, and better urinary continence function was observed according to the post-operative urodynamic study. Multifactorial etiologies resulted in recurrent stress urinary incontinence (SUI), including poor surgical technique, inadequate sling tension when treating ISD, and inappropriate sling position. Then the detail of the surgical procedure varied with the results of pre-operative evaluations, affecting the validity of the second sling.

Conclusion: Recurrent SUI has resulted from multi factors, pre-operative urodynamic study and transperineal ultrasound might be valuable tools to guide repeat sling operation and predict post-operative outcomes. A repeat TVT procedure may be regarded as a remedial measure for a failed transobturator MUS operation.

Translabial Ultrasound for Assessment of Synthetic Midurethral Sling Complications

ABSTRACT

Translabial ultrasound (TLUS) is an inexpensive, noninvasive imaging modality traditionally used for assessment of pelvic organ prolapse. The utility of TLUS has recently been expanded to the evaluation of synthetic midurethral slings (MUS) surgically implanted for management of stress urinary incontinence. The purpose of this article is to familiarize radiologists with translabial ultrasound technique and provide a technical protocol for TLUS execution because it can be optimized for imaging and assessment of MUS, including identification of MUS configuration and recognition of common complications. This article provides example images of transobturator and retropubic slings and their associated complications, as visualized on TLUS. Accurate imaging and assessment of MUS is helpful in the evaluation of the patient presenting with symptoms suspicious for sling-related complications and in the planning of surgical revision.

International Urogynecological Consultation: clinical definition of pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

This segment of Chapter 1 of the International Urogynecology Consultation (IUC) on pelvic organ prolapse (POP) reviews the literature on the clinical definition of POP with the intent of creating standard terminology.

METHODS

An international group containing nine urogynecologists and one university-based medical librarian performed a search of the literature using pre-specified search terms in PubMed, Embase, and Scopus. Publications were eliminated if not relevant to the clinical definition of POP, and those articles remaining were evaluated for quality using the Specialist Unit for Review Evidence (SURE). The resulting list of articles was used to inform a comprehensive review and creation of the clinical definition of POP.

RESULTS

The original search yielded 31,931 references, of which 167 were used by the writing group. Ultimately, 78 are referenced in the manuscript.

CONCLUSIONS

The clinical definition of POP for this review of the literature is: "anatomical prolapse with descent of at least one of the vaginal walls to or beyond the vaginal hymen with maximal Valsalva effort WITH the presence either of bothersome characteristic symptoms, most commonly the sensation of vaginal bulge, or of functional or medical compromise due to prolapse without symptom bother."

Ultrasound evaluation of anterior transvaginal mesh for pelvic organ prolapse: correlation to 5-year clinical outcomes

Introduction and hypothesis

Vaginal prolapse mesh may effectively restore vaginal anatomy. The aim of this study was to investigate how the in vivo mesh position correlates to clinical outcomes.

Methods

Seventy-one women operated on using Uphold mesh for apical pelvic organ prolapse (POP-Q, C ≥ stage II) were examined 5 years after surgery by introital-perineal 2D ultrasound in a midsagittal plane at rest and Valsalva. The horizontal line and pubis symphysis were considered the reference for all measures. Ultrasound measures were statistically compared to clinical outcomes: POP-Q, Pelvic Floor Distress Inventory (PFDI-20) and subscales [Pelvic Organ Distress Inventory (PODI-6), and Urinary Distress Inventory (UDI-6)] and the VAS scale for pain.

Results

Original mesh length was preserved by 86% and correlated to improved pain as estimated by VAS scale (r 0.321). Valsalva was associated with a lowering of the superior and inferior mesh margins by 7.3 and 6.1 mm, respectively (p < 0.001) but a reduction of total mesh length by only 1 mm (30.2 ± 5.2 to 29.2 ± 4.7 mm, p < 0.001). Mobility of the anterior vaginal wall (bladder neck and midurethra) at Valsalva was parallel to downward movement of the mesh inferior margin (r 0.346 and 0.314) but inversely correlated to total UDI-6 (r − 0.254 and − 0.263). Mobility of the midurethra was inversely correlated to bladder emptying (PFDI-20 Question 19, r − 0.245).

Conclusions

Five years after surgery, preserved original length of the mesh with apical support was correlated to improved anatomical and patient-reported outcomes. Mesh support to the vaginal apex was associated with improved bladder emptying and total urinary distress outcomes but not stress urinary incontinence.

Meshy business: MRI and ultrasound evaluation of pelvic floor mesh and slings

Pelvic floor disorders are a complex set of conditions including but not limited to stress urinary incontinence and pelvic organ prolapse that generally affect older and multiparous women. Of the several surgical options available for treatment of these conditions, synthetic mid-urethral slings for stress urinary incontinence and vaginal mesh for pelvic organ prolapse are amenable to imaging evaluation by ultrasound and magnetic resonance imaging techniques. Ultrasound can evaluate the sub- and immediate peri-urethral portions of sling due to its ability to differentiate synthetic material from native tissues with real-time imaging, while MRI is able to better depict the global pelvic floor anatomy and assess the more distant components of mesh and slings material. Given the high prevalence of pelvic floor disorders and complications after surgical repair, it is important that radiologists familiarize themselves with normal and abnormal imaging findings after these procedures. This article provides a review of the spectrum of imaging findings in patients after pelvic floor repair with synthetic mid-urethral slings and vaginal mesh.

Pelvic floor ultrasound: when, why, and how?

Pelvic floor disorders are a significant medical issue, reportedly affecting nearly one in four women in the United States. Nonetheless, until the last decade, there has been relatively limited imaging research into this highly prevalent disorder. The three major imaging modalities utilized to assess pelvic floor function are ultrasound, MRI and fluoroscopy. Pelvic floor ultrasound is a rapidly emerging technique which takes advantage of the widespread availability of ultrasound, the non-invasive and relatively inexpensive approach and the incorporation of real-time imaging and software advances which permit 3-D volume imaging. Pelvic floor ultrasound provides the opportunity to optimize patient counseling and enhance pre-operative planning by providing an anatomic and functional roadmap for the referring clinician. We recommend the consideration of pelvic floor ultrasound, as described here, as an addition to the imaging armamentarium available to physicians and surgeons serving this patient population.

Association between 3D endovaginal and 2D perineal pelvic floor ultrasound findings and symptoms in women presenting with mid-urethral sling complications

OBJECTIVES

To present the characteristics of women attending a tertiary urogynecology pelvic floor scan clinic with mid-urethral sling (MUS) complications and examine the association between patient symptoms and findings on two-dimensional (2D) perineal and three-dimensional (3D) endovaginal ultrasound.

METHODS

This was a cross-sectional study of all women with MUS complications referred to a specialist pelvic floor ultrasound clinic between October 2016 and October 2018. Detailed history was obtained regarding their symptoms and time of onset. All patients underwent 2D perineal and 3D endovaginal ultrasound assessment. The association between patient symptoms and ultrasound findings was evaluated using logistic regression analysis. Only symptomatic women with a single MUS, without other pelvic floor mesh, prior mesh excision or bulking agents, were included in the regression analysis.

RESULTS

A total of 311 women with a history of MUS surgery were seen during the study period. Vaginal and/or non-vaginal pain was reported by 80% of patients and this was the primary presenting complaint in 59% of the patients. One-third of the patients reported symptoms starting within 4 weeks after surgery. The data of 172 patients were included in the regression analysis. MUS position within the rhabdosphincter was significantly associated with voiding dysfunction (odds ratio (OR), 10.6 (95% CI, 2.2-50.9); P = 0.003). Voiding dysfunction was highest in those with C-shaped MUS both at rest and on Valsalva maneuver (OR, 3.2 (95% CI, 1.3-7.6); P < 0.001). MUS position in the distal third of the urethra was significantly associated with a higher rate of recurrent urinary tract infection (OR, 2.9 (95% CI, 1.3-6.3); P = 0.01).

CONCLUSIONS

Pelvic floor ultrasound can provide insight into the position and shape of the MUS, which could explain some patient symptoms and guide management or surgical planning. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

The prevalence of incidental uterine venous plexus thrombosis in women attending a gynecology clinic

BACKGROUND

The uterine venous plexus (UVP) is an unusual site for venous thrombosis (VT). Our aim was to determine the prevalence of UVP thrombosis (UVPT) and identify associated risk factors.

METHODS

We conducted a cross-sectional study on consecutive nonpregnant women attending our general gynecology clinic with a wide variety of presenting symptoms over a 16-month period. All women underwent a transvaginal ultrasound scan which involved detailed examination of the uterine venous plexus. Women diagnosed with incidental UVPT had thrombophilia screening, lower limb venous duplex imaging, and specialist hematological review. Logistic regression was used to examine associations between various risk factors and UVPT.

RESULTS

We screened 1383 women, 39 of whom had an incidental UVPT, giving a prevalence of 3.0% (95% confidence interval [CI], 2.1%-4.1%). Multivariate analysis showed positive associations between multiparity (odds ratio [OR] 5.75 [95% CI 2.10, 15.7]), recent surgery (OR 3.10 [95% CI 1.19, 8.07]), presence of leg varicose veins (OR 3.15 [95% CI 1.32, 7.49]), and a family history of venous thromboembolism (OR 8.74 [1.65, 46.4]) and negative associations between postmenopausal status (OR 0.36 [95% CI 0.13, 0.95]) and the development of UVPT. Thrombophilia was detected in 12.8% women diagnosed with UVPT.

CONCLUSIONS

The prevalence of incidental UVPT in a general gynecology population was 3.0%. Several demographic and clinical factors were found to be associated with UVPT. This could help to identify women at risk of this condition, and facilitate its early detection and development of evidence-based management strategies.

The Use of Imaging for Synthetic Midurethral Slings

Ultrasound and magnetic resonance imaging can be used to image midurethral slings, which have may have complications such as pain. There is considerable misunderstanding regarding the utility of the different modalities. This article aims to review the current literature to identify the benefits and limitations of each imaging modality and identify the place that each should have for patients with midurethral sling complications. A literature search was performed, and all relevant articles were identified and reviewed. Different imaging modalities are complementary, but more research is required in this area.

Do we have adequate data to construct a valid algorithm for management of synthetic midurethral sling complications? ICI-RS 2019

BACKGROUND

Synthetic midurethral sling (MUS) procedures, purported for the last two decades as the gold standard surgical treatment for stress urinary incontinence, have been in creasingly scrutinized in recent years with regard to the rate and severity of complications.

METHODS

During the International Consultation on Incontinence Research Society meeting held in Bristol, UK, in 2019, a multidisciplinary panel held a think tank and discussed the contemporary evidence pertaining to the classification, investigation, and treatment of MUS complications.

RESULTS

The current classification system of mesh-related complications was discussed, and shortcomings were identified. The lack of a standardized clinical pathway was noted, and the value of clinical investigations and surgical treatments was difficult to fully evaluate. The paucity of high-level evidence was a common factor in all discussions, and the difficulties with setting up relevant randomized-controlled trials were highlighted.

CONCLUSIONS

The outcome of the think-tank discussions is summarized with a set of recommendations designed to stimulate future research.

3D reconstruction of MR-visible Fe3 O4 -mesh implants: Pelvic mesh measurement techniques and preliminary findings

AIMS

To develop MR-based measurement technique to evaluate the postoperative dimension and location of implanted magnetic resonance (MR)-visible meshes.

METHODS

This technique development study reports findings of six patients (A-F) with cystoceles treated with anterior vaginal MR-visible Fe₃ O₄ -polypropylene implants. Implanted meshes were reconstructed from 3 months and/or 1 year postsurgical MR-images using 3D Slicer®. Measurements including mesh length, distance to the ischial spines, pudendal, and obturator neurovascular bundles and urethra were obtained using software Rhino® and a custom Matlab® program. The range of implanted mesh length and their placements were reported and compared with mesh design and implantation recommendations. With the anterior/posterior-mesh-segment-ratio mesh shrinkage localization was evaluated.

RESULTS

Examinations were possible for patients A-D 3 months and for A, C, E, and F 1 year postsurgical. The mesh was at least 40% shorter in all patients 3 months and/or 1 year postoperatively. A, B showed shrinkage in the anterior segment, D, E in the posterior segment (Patients C, F not applicable due to intraoperative mesh trimming). Patient E presented pain in the area of mesh shrinkage. In Patient C posterior mesh fixations were placed in the iliococcygeal muscle rather than sacrospinous ligaments. Arm placement less than 20 mm from the pudendal neurovascular bundles was seen in all cases. The portion of the urethra having mesh underneath it ranged from 19% to 55%.

CONCLUSIONS

MRI-based measurement techniques have been developed to quantify implanted mesh location and dimension. Mesh placement variations possibly correlating with postoperative complications can be illustrated.

Translabial Ultrasound Evaluation of Pelvic Floor Structures and Mesh in the Urology Office and Intraoperative Setting

BACKGROUND

Translabial ultrasound (TUS) can provide an inexpensive alternative imaging modality for evaluating pelvic floor structures and synthetic slings as mesh can be difficult to identify on pelvic exam or cystoscopy, patients may be unable to provide an accurate history of previous pelvic surgery, and cross-sectional imaging with computed tomography and magnetic resonance imaging can be inadequate for evaluating synthetic slings.

OBJECTIVE

To demonstrate the use of TUS in the evaluation of female pelvic floor structures and mesh.

METHODS

Translabial ultrasound can be used in the Urology clinic or intraoperative setting using a curvilinear transducer. Following identification of anatomic landmarks in the various planes of the pelvic floor, TUS can evaluate for pelvic floor disorders and the type and location of synthetic mesh material. Artifacts, such as air pockets in the vagina or rectum and the hypoechoic pubic symphysis, are also considered.

RESULTS

Real-time imaging allows for dynamic examination of pelvic organ prolapse and urethral hypermobility that can contribute to pelvic exam findings. Bladder ultrasound can help evaluate for lesions, calculi, and even mesh erosion. Translabial ultrasound can also be used to differentiate hyperechoic retropubic and transobturator slings by identifying the position of sling arms and the appearance of the sling at different planes. Evaluation with TUS can demonstrate sling disruption, folding, urethral impingement, and erosion into pelvic floor structures. This can be particularly useful in patients presenting with pain, recurrent infections, or voiding dysfunction in which problems with mesh may not be easily identified on pelvic exam or cystoscopy. This imaging modality can complement a patient's history, aid in preoperative planning, and enable intraoperative identification of mesh slings.

CONCLUSION

Translabial ultrasound provides a quick, readily available, and easy-to-learn imaging modality for evaluating pelvic floor structures and mesh in the office or intraoperative setting.

Erosion of Polytetrafluoroethylene (Gore-tex) Sling Over 20 Years After Placement for Stress Urinary Incontinence

As synthetic material has evolved to improve both the efficacy and biocompatibility of suburethral slings, soft polypropylene slings are currently the gold standard for treatment of stress urinary incontinence. However, reports of complications beyond 10 years are limited and patients can nevertheless present with erosion and other complications from other sling materials that have been used in the past. We present a case of synthetic sling erosion 21 years after placement of a polytetrafluoroethylene sling (Gore-tex).