Do the anatomical defects associated with cystocele affect the outcome of the anterior repair? A clinical and radiological study

Recommended standardized terminology of the anterior female pelvis based on a structured medical literature review

BACKGROUND

The use of imprecise and inaccurate terms leads to confusion amongst anatomists and medical professionals.

OBJECTIVE

We sought to create recommended standardized terminology to describe anatomic structures of the anterior female pelvis based on a structured review of published literature and selected text books.

STUDY DESIGN

We searched MEDLINE from its inception until May 2, 2016, using 11 medical subject heading terms to identify studies reporting on anterior female pelvic anatomy; any study type published in English was accepted. Nine textbooks were also included. We screened 12,264 abstracts, identifying 200 eligible studies along with 13 textbook chapters from which we extracted all pertinent anatomic terms.

RESULTS

In all, 67 unique structures in the anterior female pelvis were identified. A total of 59 of these have been previously recognized with accepted terms in Terminologia Anatomica, the international standard on anatomical terminology. We also identified and propose the adoption of 4 anatomic regional terms (lateral vaginal wall, pelvic sidewall, pelvic bones, and anterior compartment), and 2 structural terms not included in Terminologia Anatomica (vaginal sulcus and levator hiatus). In addition, we identified 2 controversial terms (pubourethral ligament and Grafenberg spot) that require additional research and consensus from the greater medical and scientific community prior to adoption or rejection of these terms.

CONCLUSION

We propose standardized terminology that should be used when discussing anatomic structures in the anterior female pelvis to help improve communication among researchers, clinicians, and surgeons.

Evaluating maternal recovery from labor and delivery: bone and levator ani injuries

OBJECTIVE

We sought to describe occurrence, recovery, and consequences of musculoskeletal (MSK) injuries in women at risk for childbirth-related pelvic floor injury at first vaginal birth.

STUDY DESIGN

Evaluating Maternal Recovery from Labor and Delivery is a longitudinal cohort design study of women recruited early postbirth and followed over time. We report here on 68 women who had birth-related risk factors for levator ani (LA) muscle injury, including long second stage, anal tears, and/or older maternal age, and who were evaluated by MSK magnetic resonance imaging at both 7 weeks and 8 months' postpartum. We categorized magnitude of injury by extent of bone marrow edema, pubic bone fracture, LA muscle edema, and LA muscle tear. We also measured the force of LA muscle contraction, urethral pressure, pelvic organ prolapse, and incontinence.

RESULTS

In this higher-risk sample, 66% (39/59) had pubic bone marrow edema, 29% (17/59) had subcortical fracture, 90% (53/59) had LA muscle edema, and 41% (28/68) had low-grade or greater LA tear 7 weeks' postpartum. The magnitude of LA muscle tear did not substantially change by 8 months' postpartum (P = .86), but LA muscle edema and bone injuries showed total or near total resolution (P < .05). The magnitude of unresolved MSK injuries correlated with magnitude of reduced LA muscle force and posterior vaginal wall descent (P < .05) but not with urethral pressure, volume of demonstrable stress incontinence, or self-report of incontinence severity (P > .05).

CONCLUSION

Pubic bone edema and subcortical fracture and LA muscle injury are common when studied in women with certain risk factors. The bony abnormalities resolve, but levator tear does not, and is associated with levator weakness and posterior-vaginal wall descent.

Dynamic magnetic resonance imaging before and 6 months after laparoscopic sacrocolpopexy

INTRODUCTION AND HYPOTHESIS

The objective of this study was to correlate dynamic magnetic resonance imaging (MRI) with Pelvic Organ Prolapse Quantification (POP-Q) measurements and pelvic floor symptoms in order to determine the value of dynamic MRI for evaluating vaginal vault prolapse both before and 6 months after laparoscopic sacrocolpopexy.

METHODS

This was a prospective, single-center cohort study in 43 patients who underwent a modified laparoscopic sacrocolpopexy/hysteropexy operation using bone-anchor fixation and synthetic mesh. The study included dynamic MRI, POP-Q staging, and validated questionnaires before and 6 months after laparoscopic sacrocolpopexy. To assess MRI data, the pubococcygeal reference line and specifically defined anatomical landmarks for the separate compartments were used. Differences between pre- and postoperative measurements were evaluated with the Wilcoxon signed-rank test, and correlations at the 0.05 level were considered to be significant (Pearson correlation, two tailed).

RESULTS

At 6 months, a statistically significant improvement was seen in POP-Q staging for all compartments. Dynamic MRI measurements only revealed a significant improvement after surgery for the apical compartment. The correlation between (changes in) MRI measurements, POP-Q measurements, and validated questionnaires was poor.

CONCLUSIONS

The value of dynamic MRI for evaluating and documenting changes in vaginal vault support and position after laparoscopic sacrocolpopexy is limited due to the poor correlation with both POP-Q staging and pelvic floor symptoms.

Is levator avulsion a predictor of cystocele recurrence following anterior vaginal mesh placement?

OBJECTIVE

Levator avulsion has been shown to be a predictor of cystocele recurrence following anterior colporrhaphy. The aim of this study was to determine if levator avulsion is a risk factor for prolapse recurrence following anterior colporrhaphy with mesh.

METHODS

This was a retrospective analysis of data obtained from three surgical audits for subjective and objective outcomes following anterior colporrhaphy with mesh. Recurrence was defined as cystocele ≥ Stage 2 on the prolapse quantification system of the International Continence Society; symptoms of vaginal lump/bulge; or cystocele on ultrasound, defined as maximum bladder descent to ≥ 10 mm below the symphysis pubis. Levator avulsion was diagnosed using tomographic ultrasound imaging.

RESULTS

Two hundred and nine patients were followed up at a mean of 2.2 years (range, 3 months to 5.6 years) after anterior vaginal mesh placement. 24% (51/209) had recurrent prolapse symptoms, 33% (68/209) clinical cystocele recurrence ≥ Stage 2, and 26% (54/209) a recurrent cystocele on ultrasound. Twenty-eight out of 80 (35%) women with levator avulsion had significant sonographic cystocele recurrence (odds ratio (OR), 2.24 (95% confidence interval (CI), 1.13-4.43)). This finding was confirmed after adjusting for potential predictors of prolapse recurrence on multivariate logistic regression (OR, 2.13 (95% CI, 1.04-4.39); P = 0.04).

CONCLUSION

Levator avulsion doubles the risk of cystocele recurrence after anterior colporrhaphy with transobturator mesh.

Ultrasound changes in the relationship between the urethra and bladder neck caused by prolapse repair: feasibility and reliability of measurements

The objective of this study was to assess whether intraoperative transperineal ultrasound can be used to assess changes in the relationship between the urethra and bladder caused by a prolapse repair operation. The reliability of the measurements was also assessed. A total of 25 women having an anterior colporrhaphy operation had pre- and post-repair imaging using a standard bladder volume. There was a statistically significant change (p ≤ 0.04) in the posterior urethrovesical angle (PUA) from 115° (SD 37) before surgery, to 135° (SD 30) after surgery. There was no significant change (p = 0.93) in the anterior urethrovesical angle before 73° (SD 14) after surgery 73° (SD 14). Interclass correlation coefficients showed good reproducibility for all measurements. Ultrasound can be used to measure changes in the relationship of the urethra and bladder produced by anterior colporrhaphy. Clinically, the effect of these changes is to reduce the angulation of the urethra in relation to the bladder.

Diagnosing pubovisceral avulsions: a systematic review of the clinical relevance of a prevalent anatomical defect

The aims of this systematic literature review were to assess whether the detection of pubovisceral avulsions using magnetic resonance (MR) imaging or perineal ultrasonography was clinically relevant in women with pelvic floor dysfunction and to evaluate the relation with anatomy, symptoms, and recurrence after surgery. We performed a systematic literature review using three bibliographical databases (PubMed, Embase, and CINAHL) as data sources. Clinical studies were included in which pubovisceral avulsions were studied in relation to pelvic organ prolapse (POP) stage, pelvic floor symptoms, and/or recurrence of POP after surgery. Ultimately, 21 studies met the inclusion criteria. POP stage and recurrence of POP after surgery were strongly associated with pubovisceral avulsions. Contradictory results were found regarding the relation between pubovisceral avulsions and urinary symptoms and symptoms of anorectal dysfunction. Pubovisceral avulsions, as diagnosed by MR imaging or perineal ultrasonography, are associated with higher stages of POP and recurrence of POP after surgery.

Obstetric levator ani muscle injuries: current status

Levator ani muscle (LAM) injuries occur in 13-36% of women who have a vaginal delivery. Although these injuries were first described using magnetic resonance imaging, three-dimensional transperineal and endovaginal ultrasound has emerged as a more readily available and economic alternative to identify LAM morphology. Injury to the LAM is attributed to vaginal delivery resulting in reduced pelvic floor muscle strength, enlargement of the vaginal hiatus and pelvic organ prolapse. There is inconclusive evidence to support an association between LAM injuries and stress urinary incontinence and there seems to be a trend towards the development of fecal incontinence. Longitudinal studies with long-term follow-up assessing the LAM before and after childbirth are lacking. Furthermore, the consequence of LAM injuries on quality of life due to prolapse and/or urinary and fecal incontinence have not been evaluated using validated questionnaires. Direct comparative studies using the above-mentioned imaging modalities are needed to determine the true gold standard for the diagnosis of LAM injuries. This would enable consistency in definition and classification of LAM injuries. Only then could high-risk groups be identified and preventive strategies implemented in obstetric practice.

Intrapartum translabial three-dimensional ultrasound visualization of levator trauma

OBJECTIVES

The aim of this study was to visualize levator trauma by three-dimensional (3D) ultrasound performed during labor and soon after the crowning of the fetal head and to determine how often levator trauma occurs.

METHODS

This was a prospective, observational study of 66 women enrolled during the first stage of labor. The women underwent intrapartum 3D transperineal ultrasound examination during the first and second stages of labor and within 12 h after delivery. Volume datasets were acquired and analyzed to determine the presence of levator trauma.

RESULTS

Data from 10 of the 66 women were excluded from analysis-nine because they underwent Cesarean section in the first or second stage of labor and one because she underwent hysterectomy and no postpartum volumes were collected. Thus our study group comprised 56 women-35 nulliparous and 21 parous. A total of 504 volumes were collected in the 56 women (three volumes for each stage of labor). One hundred and twenty levator volumes were excluded from analysis, but volumes of acceptable quality were available for all three stages of labor in all women. Eleven (31.4%) of the 35 nulliparae had levator lesions detected postpartum and none of them had levator lesions before delivery. Five (23.8%) of the 21 parous women had a levator tear detected in their postpartum volumes. In two of these five women the levator tear was also present in both volumes taken during labor.

CONCLUSIONS

Visualization of the levator ani during labor by 3D ultrasound examination is feasible. Comparison of volumes obtained during labor and within the first 2 h after delivery supports the theory that crowning of the head is the immediate cause of avulsion of the levator ani muscle.

Tissue response to a new type of biomaterial implanted subcutaneously in rats

INTRODUCTION AND HYPOTHESIS

A new type of resorbable biomaterial intended for pelvic reconstruction was tested with respect to tissue regeneration and biocompatibility in rats. The biomaterial consisted of methoxypolyethyleneglycol-poly(lactic-co-glycolic acid) (MPEG-PLGA). Implants were pure, enriched with extra-cellular matrix (ECM) or estrogen.

METHODS

Ten implants of each type were tested for 3 and 8 weeks, respectively. Histological assessment of connective tissue organization, inflammation, vascularization, and thickness of regenerated tissue was undertaken.

RESULTS

All implants had a high degree of biocompatibility. ECM-enriched implants had significantly higher inflammatory scores compared to pure implants at 3 weeks. At 8 weeks, neither of the parameters differed significantly. No trace of the implants remained.

CONCLUSIONS

The MPEG-PLGA is highly biocompatible, degrades quickly, and seems inert in the process of tissue regeneration. Thus, it is hardly a candidate per se in reinforcement of pelvic reconstruction, but it could have a future role as carrier for stem cells.