Imaging of Pelvic Floor Reconstruction

Use of Magnetic Resonance Imaging in women with suspected complications following insertion of implants for pelvic organ prolapse and stress urinary incontinence surgery

OBJECTIVE

To evaluate the role of Magnetic Resonance Imaging (MRI) in women presenting with suspected implant complications following surgery for pelvic organ prolapse (POP) and stress urinary incontinence (SUI).

STUDY DESIGN

Retrospective single-centre cohort study in a designated tertiary referral centre. All women with vaginally and/or abdominally placed implants for POP or SUI who were referred with suspected mesh complications, and investigated with an MRI scan, between January 2018-October 2020 were included in the study.

RESULTS

97 women were identified over this time-period with a total of 123 implants, a median age of 55 years (Range: 34-79) and an average insertion to presentation time of 84 months (Range: 2-300). 78% (74) had one implant in situ, with the remainder having at least 2 in situ. Transobturator tapes (TVT-O/TOT) were the most common implants [35% (43)]. Chronic Pelvic or abdominal pain was the most common clinical symptom [73.2% (71/112 primary complaints)] with provoked tenderness on examination being the most common clinical finding [27.8% (32/115 clinical findings)]. MRI was more likely to detect abdominally placed implants [100% (all 30)] and Retropubic Tapes [89% (16/18)] when compared to Transvaginal POP implants [87.5% (28/32)] and TVT-O/TOT [67% (29/43)]. MRI identified both cases of Sacrocolpopexy mesh rupture as well as all 11 cases of infection (100%). In 91% (10/11) of these cases, MRI revealed the infection to be more widespread than clinical findings initially suspected. Cohen's Kappa demonstrated excellent correlation between MRI and surgical findings in cases with implant related infection, rupture and normal findings (κ = 1; z = 4.58; p = 0.00000459).

CONCLUSION(S)

MRI can be a useful tool in assessment and management of patients with complications from implants. MRI can detect infection that may be more extensive that is initially clinically apparent in the outpatient setting. Abdominal implants appear to be easier to detect than transvaginal meshes and trans obturator tapes.

Evaluation of Pelvic Floor Muscles in Pregnancy and Postpartum With Non-Invasive Magnetomyography

Objective: To record and characterize features of levator ani muscles (LAM) activity in pregnancy and postpartum using non-invasive and novel Magnetomyography (MMG) technique with amplitude and spectral parameters. Methods: Nulliparous women with uncomplicated pregnancies participated in the MMG data collection during rest and voluntary LAM contractions (Kegels) with modulated intensity in third trimester and approximately 2 months postpartum (PP). Simultaneous surface electromyography was recorded to document the recruitment of accessory muscles. Moderate strength Kegel (MK) MMG trials were analyzed. Amplitude and spectral parameters including root-mean square (RMS) amplitude, power spectrum density (PSD) and normalized PSD (rPSD) in three frequency bands (low, middle, high) were computed on MK epochs. Statistical comparisons between pregnancy and postpartum were calculated. Results: MMG recordings were measured from 10 pregnant women. Results showed decreased RMS and power between third trimester and postpartum, trending towards significance. rPSD values in the low frequency band decreased significantly (p = 0.028) from third trimester to postpartum, while significant increase was observed in the middle frequency band (p = 0.018). Conclusions: This study shows that MMG as non-invasive tool has the ability to detect and characterize changes of LAM activity with amplitude and spectral parameters during pregnancy and postpartum.

Twisting of transobturator midurethral slings: does it matter?

INTRODUCTION AND HYPOTHESIS

We assessed rotation/twisting of transobturator midurethral slings (TOTs) and tested for associations with de novo chronic pain and voiding dysfunction.

METHODS

A retrospective pilot study including patients seen after Monarc™ TOT surgery at a single tertiary hospital in 2005-2016. Patients underwent an interview, clinical examination, uroflowmetry and 4D pelvic floor ultrasound. Volume datasets were analyzed blinded against all other data. Sling rotation/twisting was evaluated in volumes obtained at rest. The sling axis was measured relative to the vertical in the midline and in the most lateral parasagittal slice. Total sling rotation was calculated by summation of absolute angle differences between midline and lateral angles. "Corkscrew" rotation was noted when direction of rotation was opposite on the contra-lateral side.

RESULTS

The study included 215 patients. Fifty-two (24%) were excluded, leaving 163. Mean age was 57 years (28-87; SD 12), mean BMI 29.4 kg/m² (18.3-47.4, SD 6). Follow-up was at a median of 17 months (IQR 11-27). Chronic de novo pain was reported by 15 women (9%; dyspareunia by 11 and pelvic/vaginal pain by 4). On imaging, mean total sling rotation was 144° (12-335, SD 56). In the majority (n = 103, 63%) it rotated counter-clockwise from its midline position and in 30 (18%) it rotated clockwise. "Corkscrew" rotation was noted in 30 (18%). De novo chronic pain was associated with lower BMI and vaginal sling exposure but not with sling rotation. The latter was not found to be associated with voiding dysfunction either.

CONCLUSIONS

Monarc™ TOTs rotate considerably throughout their course. The degree of twisting or rotation and its direction was not found to be associated with de novo postoperative chronic pain or voiding dysfunction.

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.

Mesh complications: best practice in diagnosis and treatment

Mesh was a promising, minimally invasive, and 'gold standard' treatment for urinary stress incontinence. Time has shown that complications from these devices can happen early, or even several years, after mesh placement and can be catastrophic. Pain, erosion, voiding dysfunction, infection, recurrent UTIs [urinary tract infections (UTIs)], fistulae, organ perforation, bleeding, vaginal scarring, neuromuscular alterations, LUTS (lower urinary tract symptoms), bowel complications and even immune disorders have been linked to mesh. Various tools, such as imaging, endoscopic and functional studies, are available for diagnosis of mesh complications. Since the spectrum of complications is wide, involvement of other specialties is usually beneficial in the diagnosis and management of these complications. There is still much to learn on the accuracy and utility of diagnostic studies in each type of complication. Evidence on the best diagnostic and treatment pathways for these complications is scarce but continuously growing as information is being reported, and we continue to gain expertise in dealing with patients affected by mesh. Treatment options include conservative and medical management initially and then open or minimally invasive surgical procedure approaches. This article will describe diagnostic and treatment pathways for mesh complications.