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Duran P, Sesillo FB, Cook M, Burnett L, Menefee SA, Do E, French S, Zazueta-Damian G, Dzieciatkowska M, Saviola AJ, Shah MM, Sanvictores C, Osborn KG, Hansen KC, Shtrahman M, Christman KL, Alperin M. Proregenerative extracellular matrix hydrogel mitigates pathological alterations of pelvic skeletal muscles after birth injury. Sci Transl Med 2023; 15:eabj3138. [PMID: 37531414 PMCID: PMC10460616 DOI: 10.1126/scitranslmed.abj3138] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/14/2023] [Indexed: 08/04/2023]
Abstract
Pelvic floor disorders, including pelvic organ prolapse and urinary and fecal incontinence, affect millions of women globally and represent a major public health concern. Pelvic floor muscle (PFM) dysfunction has been identified as one of the leading risk factors for the development of these morbid conditions. Childbirth, specifically vaginal delivery, has been recognized as the most important potentially modifiable risk factor for PFM injury; however, the precise mechanisms of PFM dysfunction after parturition remain elusive. In this study, we demonstrated that PFMs exhibit atrophy and fibrosis in parous women with symptomatic pelvic organ prolapse. These pathological alterations were recapitulated in a preclinical rat model of simulated birth injury (SBI). The transcriptional signature of PFMs after injury demonstrated an impairment in muscle anabolism, persistent expression of genes that promote extracellular matrix (ECM) deposition, and a sustained inflammatory response. We also evaluated the administration of acellular injectable skeletal muscle ECM hydrogel for the prevention of these pathological alterations. Treatment of PFMs with the ECM hydrogel either at the time of birth injury or 4 weeks after injury mitigated PFM atrophy and fibrosis. By evaluating gene expression, we demonstrated that these changes are mainly driven by the hydrogel-induced enhancement of endogenous myogenesis, ECM remodeling, and modulation of the immune response. This work furthers our understanding of PFM birth injury and demonstrates proof of concept for future investigations of proregenerative biomaterial approaches for the treatment of injured pelvic soft tissues.
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Affiliation(s)
- Pamela Duran
- Shu Chien-Gene Lay Department of Bioengineering, University of California San Diego, La Jolla, CA 92093, USA
- Sanford Consortium for Regenerative Medicine, University of California San Diego, La Jolla, CA 92037, USA
| | - Francesca Boscolo Sesillo
- Sanford Consortium for Regenerative Medicine, University of California San Diego, La Jolla, CA 92037, USA
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Female Pelvic Medicine and Reconstructive Surgery, University of California San Diego, La Jolla, CA 92093, USA
| | - Mark Cook
- Department of Integrative, Biology and Physiology, University of Minnesota, Minneapolis, MN 55455, USA
| | - Lindsey Burnett
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Female Pelvic Medicine and Reconstructive Surgery, University of California San Diego, La Jolla, CA 92093, USA
| | - Shawn A. Menefee
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Kaiser Permanente, San Diego, CA 92110, USA
| | - Emmy Do
- Department of Biology, University of California San Diego, La Jolla, CA 92093, USA
| | - Saya French
- Department of Biology, University of California San Diego, La Jolla, CA 92093, USA
| | - Gisselle Zazueta-Damian
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Kaiser Permanente, San Diego, CA 92110, USA
| | - Monika Dzieciatkowska
- Department of Biochemistry and Molecular Genetics, School of Medicine, University of Colorado, Aurora, CO 80045, USA
| | - Anthony J. Saviola
- Department of Biochemistry and Molecular Genetics, School of Medicine, University of Colorado, Aurora, CO 80045, USA
| | - Manali M. Shah
- Shu Chien-Gene Lay Department of Bioengineering, University of California San Diego, La Jolla, CA 92093, USA
| | - Clyde Sanvictores
- Department of Physics, University of California San Diego, La Jolla, CA 92093, USA
| | - Kent G. Osborn
- Center for Veterinary Sciences and Comparative Medicine, Division of Comparative Pathology and Medicine, University of California San Diego, La Jolla, CA 92093, USA
| | - Kirk C. Hansen
- Department of Biochemistry and Molecular Genetics, School of Medicine, University of Colorado, Aurora, CO 80045, USA
| | - Matthew Shtrahman
- Sanford Consortium for Regenerative Medicine, University of California San Diego, La Jolla, CA 92037, USA
- Department of Neurosciences, University of California San Diego, La Jolla, CA 92093, USA
| | - Karen L. Christman
- Shu Chien-Gene Lay Department of Bioengineering, University of California San Diego, La Jolla, CA 92093, USA
- Sanford Consortium for Regenerative Medicine, University of California San Diego, La Jolla, CA 92037, USA
| | - Marianna Alperin
- Sanford Consortium for Regenerative Medicine, University of California San Diego, La Jolla, CA 92037, USA
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Female Pelvic Medicine and Reconstructive Surgery, University of California San Diego, La Jolla, CA 92093, USA
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van den Noort F, van der Vaart CH, Grob ATM, van de Waarsenburg MK, Slump CH, van Stralen M. Deep learning enables automatic quantitative assessment of puborectalis muscle and urogenital hiatus in plane of minimal hiatal dimensions. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:270-275. [PMID: 30461079 PMCID: PMC6772057 DOI: 10.1002/uog.20181] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 10/12/2018] [Accepted: 11/15/2018] [Indexed: 05/05/2023]
Abstract
OBJECTIVES To measure the length, width and area of the urogenital hiatus (UH), and the length and mean echogenicity (MEP) of the puborectalis muscle (PRM), automatically and observer-independently, in the plane of minimal hiatal dimensions on transperineal ultrasound (TPUS) images, by automatic segmentation of the UH and the PRM using deep learning. METHODS In 1318 three- and four-dimensional (3D/4D) TPUS volume datasets from 253 nulliparae at 12 and 36 weeks' gestation, two-dimensional (2D) images in the plane of minimal hiatal dimensions with the PRM at rest, on maximum contraction and on maximum Valsalva maneuver, were obtained manually and the UH and PRM were segmented manually. In total, 713 of the images were used to train a convolutional neural network (CNN) to segment automatically the UH and PRM in the plane of minimal hiatal dimensions. In the remainder of the dataset (test set 1 (TS1); 601 images, four having been excluded), the performance of the CNN was evaluated by comparing automatic and manual segmentations. The performance of the CNN was also tested on 117 images from an independent dataset (test set 2 (TS2); two images having been excluded) from 40 nulliparae at 12 weeks' gestation, which were acquired and segmented manually by a different observer. The success of automatic segmentation was assessed visually. Based on the CNN segmentations, the following clinically relevant parameters were measured: the length, width and area of the UH, the length of the PRM and MEP. The overlap (Dice similarity index (DSI)) and surface distance (mean absolute distance (MAD) and Hausdorff distance (HDD)) between manual and CNN segmentations were measured to investigate their similarity. For the measured clinically relevant parameters, the intraclass correlation coefficients (ICCs) between manual and CNN results were determined. RESULTS Fully automatic CNN segmentation was successful in 99.0% and 93.2% of images in TS1 and TS2, respectively. DSI, MAD and HDD showed good overlap and distance between manual and CNN segmentations in both test sets. This was reflected in the respective ICC values in TS1 and TS2 for the length (0.96 and 0.95), width (0.77 and 0.87) and area (0.96 and 0.91) of the UH, the length of the PRM (0.87 and 0.73) and MEP (0.95 and 0.97), which showed good to very good agreement. CONCLUSION Deep learning can be used to segment automatically and reliably the PRM and UH on 2D ultrasound images of the nulliparous pelvic floor in the plane of minimal hiatal dimensions. These segmentations can be used to measure reliably UH dimensions as well as PRM length and MEP. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- F. van den Noort
- Robotics and Mechatronics, Faculty of Electrical Engineering, Mathematics and Computer Science, Technical Medical CenterUniversity of TwenteEnschedeThe Netherlands
- Department of Reproductive Medicine and GynecologyUniversity Medical CenterUtrechtThe Netherlands
| | - C. H. van der Vaart
- Department of Reproductive Medicine and GynecologyUniversity Medical CenterUtrechtThe Netherlands
| | - A. T. M. Grob
- Multi‐modality Medical Imaging, Faculty of Science and Technology, Technical Medical CenterUniversity of TwenteEnschedeThe Netherlands
| | - M. K. van de Waarsenburg
- Department of Reproductive Medicine and GynecologyUniversity Medical CenterUtrechtThe Netherlands
| | - C. H. Slump
- Robotics and Mechatronics, Faculty of Electrical Engineering, Mathematics and Computer Science, Technical Medical CenterUniversity of TwenteEnschedeThe Netherlands
| | - M. van Stralen
- Imaging DivisionUniversity Medical Center UtrechtUtrechtThe Netherlands
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Comparing 3-Dimensional Ultrasound to 3-Dimensional Magnetic Resonance Imaging in the Detection of Levator Ani Defects. Female Pelvic Med Reconstr Surg 2019; 24:295-300. [PMID: 28953075 DOI: 10.1097/spv.0000000000000485] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The aim of this study was to compare the detection of levator ani defects (LAD) between 3-dimensional (3D) ultrasound (US) and 3D magnetic resonance imaging (MRI). METHODS This is a secondary analysis of the Pelvic Floor Nerve Injury Following Childbirth Study. Nulliparous women underwent a standardized protocol of pelvic floor evaluations between January 2008 and December 2013, prior to pregnancy (V1) and at 2 points postpartum: 6 weeks (V2) and 6 months (V3). Those women who underwent a high-resolution 3D MRI pelvic floor sequence were selected. Comparisons were made to concomitantly acquired 3D perineal US. Eight tomographic slices were examined in the axial plane, each side independently scored with 0 (no defect) or 1 (defect). A similar tomographic approach was applied to the MRI. For both MRI and US, the right and left sides were each scored. A total score of 0 to 8 was given to each side. A dichotomous variable "complete LAD" was defined. Cohen κ was used as a measurement of agreement of complete LAD between MRI and US. Kendall τ b was used to correlate total scores. RESULTS On the right side, 80 (90%) of 89 pairs were in agreement (concordant in the diagnosis or not of a "defect"). On the left side, 72 (81%) of 89 pairs were in agreement. Correlations (Cohen κ) of complete LAD were 0.65 (P < 0.001) on the right and 0.37 (P < 0.001) on the left. Correlations of total scores were 0.47 (P < 0.001) on the right and 0.41 (P < 0.001) on the left. CONCLUSIONS Moderate agreement was found between 3D US and 3D MRI LAD detection. More LADs and discordance were seen on the left.
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Da Silva AS, Asfour V, Digesu GA, Cartwright R, Fernando R, Khullar V. Levator Ani avulsion: The histological composition of this site. A cadaveric study. Neurourol Urodyn 2018; 38:123-129. [PMID: 30375038 DOI: 10.1002/nau.23847] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 07/25/2018] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The sonographic appearance of a levator muscle "avulsion" representing the literal detachment of the pubovisceral muscle (PVM) enthesis has been contested. The nature of the levator ani "avulsion" is still not fully understood. It is known, that the tensile strength of a tendon is dependent on collagen with increased synthesis of collagen occurring in tissue with increased mechanical load levels. This study aims to perform a quantitative histological evaluation of the PVM enthesis with or without the imaging finding of levator ani "avulsion" to determine if there is a difference in the proportion of muscle and collagen. METHOD Three-dimensional translabial ultrasound for PVM "avulsion" was performed on cadavers using a GE Voluson I with a 5-9 MHz electronic probe. Cadavers were meticulously dissected to identify the presence or absence of an anatomical avulsion. The PVM enthesis was excised for further histopathological processing and treated with three different colorations. Quantitative analysis using ImageJ software was conducted to compare tissue composition in samples with or without sonographic "avulsion." All stages were performed by two separate investigators blinded to each other's results. The results were analyzed using SPSS v24, IBM. RESULTS Twenty-three PVM enthesis with histological staining were procured. Ultrasonographic "avulsions" were seen in 5/23 PVM enthesis. No anatomical avulsions were seen. There was no difference in the overall muscle or collagen content (Kruskal-Wallis, P = 0.864). The mean organized skeletal muscle content was 23% in the sonographic "avulsion" group versus 62% in the no "avulsion" group (Kruskall-Walis, P = 0.02). "Avulsions" were associated with a disorganized appearance at histology. CONCLUSION The tissue composition relating to the proportion of muscle and collagen was not significantly different in specimens with or without sonographic "avulsions." However, morphological differences were observed in the organization of the muscle fibres, which requires further evaluation.
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Affiliation(s)
- Ana Sofia Da Silva
- Department of Urogynaecology, St. Mary's Hospital, London, United Kingdom.,Institute of Women's Health, University College London, London, United Kingdom
| | - Victoria Asfour
- Department of Urogynaecology, St. Mary's Hospital, London, United Kingdom
| | | | - Rufus Cartwright
- Department of Urogynaecology, St. Mary's Hospital, London, United Kingdom
| | - Ruwan Fernando
- Department of Urogynaecology, St. Mary's Hospital, London, United Kingdom
| | - Vik Khullar
- Department of Urogynaecology, St. Mary's Hospital, London, United Kingdom
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Abdul Jalil SS, Guzman Rojas R, Dietz HP. Does it matter whether levator avulsion is diagnosed pre- or postoperatively? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:516-519. [PMID: 26663519 DOI: 10.1002/uog.15837] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Revised: 11/27/2015] [Accepted: 12/07/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Levator ani muscle avulsion is found in 15-30% of parturients and is associated with recurrence of pelvic organ prolapse (POP) following surgery, although most published evidence on recurrence relates to postoperative diagnosis. We performed a study to determine whether a diagnosis of avulsion after pelvic floor surgery can be used as a proxy for preoperative diagnosis. METHODS This was a retrospective study of 207 patients who were seen before and after surgery for POP between February 2007 and May 2013. All assessments included a three/four-dimensional transperineal tomographic ultrasound examination. Volume data were stored and analyzed at a later date by an operator who was blinded against all clinical data. The primary outcome measure was agreement between preoperative and postoperative diagnoses of avulsion, as evaluated by Cohen's kappa. Secondary outcome measures were the associations of pre- and postoperative diagnoses of levator avulsion with prolapse recurrence, defined as International Continence Society POP-Q Stage ≥ 2 in any compartment. RESULTS Mean follow-up after surgery was 1.3 (range, 0.3-5.5) years. Levator avulsion was found preoperatively in 111 (53.6%) patients and postoperatively in 109 (52.7%). The kappa value for the association between pre- and postoperative avulsion was 0.864 (95% CI, 0.796-0.933), signifying high agreement. The odds ratio of prolapse recurrence in women with a preoperative diagnosis of avulsion was 2.5 (95% CI, 1.3-4.5) and in those with a postoperative diagnosis it was 2.3 (95% CI, 1.3-4.2). CONCLUSIONS The diagnosis of levator avulsion by tomographic pelvic floor ultrasound is equally valid before and after pelvic reconstructive surgery for POP, and both diagnoses show excellent agreement. This implies that a postoperative diagnosis of avulsion can be used as a proxy for preoperative diagnosis. Hence, avulsion can be identified postoperatively and used for subgroup analysis in prospective surgical intervention trials to define high-risk patients. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- S S Abdul Jalil
- Sydney Medical School Nepean, Nepean Hospital, Penrith, NSW, Australia
| | - R Guzman Rojas
- Sydney Medical School Nepean, Nepean Hospital, Penrith, NSW, Australia
- Departamento de Ginecología y Obstetricia, Facultad de Medicina, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile
- Departamento de Ginecología y Obstetricia, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - H P Dietz
- Sydney Medical School Nepean, Nepean Hospital, Penrith, NSW, Australia.
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