Assessment of Urinary Dysfunction After Midurethral Sling Placement: A Comparison of Two Voiding Trial Methods

STUDY OBJECTIVE

Temporary urinary retention after midurethral sling (MUS) surgery requiring indwelling catheter or self-catheterization usage is common. Different methods for assessment of immediate postoperative urinary retention have been described. This study aimed to compare postoperative voiding trial (VT) success after active vs passive VT in women undergoing MUS surgery.

DESIGN

Comparative retrospective cohort study.

SETTING

Female pelvic medicine and reconstructive surgery practice at a university-affiliated tertiary medical center.

PATIENTS

Patients with stress urinary incontinence who underwent surgical treatment during the study period were eligible for inclusion. Excluded were patients younger than the age of 18 years, combined cases with other surgical services, planned laparotomy, and a history of urinary retention and patients for whom their VT was performed on postoperative day 1. The cohort was divided into 2 groups: (1) patients who underwent an active retrofill of their bladder using a Foley catheter and (2) patients who were allowed to have a spontaneous void.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 285 patients met the inclusion criteria for the study. Of these subjects, 94 underwent an active VT and 191 underwent a passive VT. There were no statistically significant differences in immediate postoperative urinary retention (30.8% vs 29.3%; p = .79) or time from surgery end to VT (233.0 ± 167.6 minutes vs 203.1 ± 147.8 minutes; p = .13) between groups. Urinary retention, as defined by a failed VT, increased from 10% to 29.3% when MUS placement was accompanied by concomitant prolapse repair procedure. Multivariate logistic regression analysis revealed that undergoing a combined anterior and posterior colporrhaphy (odds ratio [OR], 5.13; p <.001) and undergoing an apical prolapse procedure (OR, 2.75; p = .004) were independently associated with immediate postoperative urinary retention whereas increased body mass index (OR, 0.89; p <.001) lowered likelihood of retention.

CONCLUSION

The method used to assess immediate postoperative urinary retention did not affect VT success. Concomitant combined anterior and posterior colporrhaphy and apical suspension were correlated with greater likelihood of VT failure whereas increased body mass index decreased odds of retention.

Pubococcygeal Line Versus H-line as MR Defecography Reference for Bladder Descent

INTRODUCTION AND HYPOTHESIS

Magnetic resonance defecography imaging techniques have been used widely to study pelvic floor function and diagnose pelvic organ prolapse (POP). The aim of this study was to investigate the diagnostic accuracy of the H-line to detect bladder descent compared with the current landmark, the pubococcygeal line (PCL).

METHODS

In this retrospective cohort study, patients who underwent MR defecography in our medical center and were diagnosed with moderate to severe cystocele by radiological measurements were recruited. One rest image and one maximum evacuation image for each subject were used for the following measurements: bladder base perpendicular distance from the genital hiatus (GH), indicative of clinically significant bladder descent, PCL as the current radiological reference line, and the H-line, or minimal levator hiatus line, indicative of pelvic floor muscle and connective tissue support. Subjects were categorized as having clinically significant cystocele if the "bladder base" reached within 1 cm or lower of the GH (stage II or higher cystocele). A comparison was performed to assess differences and predictive capabilities of the reference lines relative to the GH measure.

RESULTS

Seventy subjects were included, 30 with clinically significant bladder descent based on distance to GH. Women with bladder descent were older (64.0 ± 11.8 vs 51.2 ± 15.6, p < 0.001), had increased parity (3 [1-7] vs 2 [0-5], p = 0.009), and had a bladder that descended lower than the H-line at rest (1.9 ± 0.5 vs 2.2 ± 0.4, p = 0.003) and evacuation (-2.4 ± 1.6 vs -0.7 ± 1.1, p < 0.001). Multivariate regression analysis confirmed that age, length of the H-line at evacuation, the perpendicular distances between the H-line and the lowest bladder point at rest, and the PCL to the lowest bladder point at evacuation significantly correlated with bladder descent. Receiver operating characteristic analysis was used to identify a measurement threshold to diagnose clinically significant cystocele for both measurements, bladder base to the H-line: -1.2 (80.0, 72.5) area under the curve (AUC) 0.82, and bladder base PCL: -3.3 (77.8, 79.5) AUC 0.86.

CONCLUSION

Our data support the application of using the minimal levator hiatus plane and specifically the H-line as a reliable landmark to diagnose bladder descent using MR defecography imaging.

Sacrum and Coccyx Shape Changes During Pregnancy and After Delivery

Remodeling of the sacrum and coccyx to accommodate pregnancy and delivery has been hypothesized but not directly quantified. This study aimed to quantify the remodeling of the sacrum and coccyx by comparing midsagittal lengths, angles, curvature, and shape between nulliparous, pregnant, and parous women using both 2 and 3 dimensional measures. Ninety pelvic magnetic resonance images of the pelvis were retrospectively collected and segmented. Twelve length, angle, and curvature measurements were made using definitions from previous literature on the midsagittal plane to define the sacrum, coccyx, and combined sacrum-coccyx shape. These measures were followed by a statistical shape analysis, which returned modes of variation and principal component scores. A separate MANCOVA analysis was conducted for both the 2D and 3D measures. The 2D and 3D analyses agreed that pregnant women had a significantly straighter coccyx and combined sacrum/coccyx than nulliparous (9.1% and 5.6%, respectively) and parous (7.5% and 2.7%, respectively) subjects. All comparisons showed that, on average, a pregnant woman's sacrum and coccyx were significantly straighter than their nulliparous counterparts. Then after delivery, the sacrum/coccyx returned, but not completely back to a more curved configuration.

Quantifying the effect of an endo-vaginal probe on position of the pelvic floor viscera and muscles

INTRODUCTION AND HYPOTHESIS

Endovaginal ultrasound has long been hypothesized to have a significant effect on locations of what it visualizes. However, little work has directly quantified its effect. This study aimed to quantify it.

METHODS

This cross-sectional study consisted of 20 healthy asymptomatic volunteers who underwent both endovaginal ultrasound and MRI. The urethra, vagina, rectum, pelvic floor, and pubic bone were segmented in both ultrasound and MRI using 3DSlicer. Then, using 3DSlicer's transform tool the volumes were rigidly aligned based on the posterior curvature of the pubic bone. The organs were then split into thirds along their long axis to compare their distal, middle, and proximal sections. Using Houdini, we compared the location of the centroid of each of the urethra, vagina, and rectum and the surface-to-surface difference of the urethra and rectum. The anterior curvature of the pelvic floor was also compared. Normality of all variables was assessed by Shapiro-Wilk test.

RESULTS

The largest amount of surface-to-surface distance was observed in the proximal region for the urethra and rectum. Across all three organs, the majority of the deviation was in the anterior direction for geometries obtained from ultrasound versus those from MRI. For each subject, the trace defining the midline of the levator plate was more anterior for ultrasound compared to MRI.

CONCLUSIONS

While it has often been assumed that placing a probe in the vagina probably distorts the anatomy, this study quantified the distortion and displacement of the pelvic viscera. This allows for better interpretation of clinical and research findings based on this modality.

Effect of Squeeze, Cough, and Strain on Dynamic Urethral Function in Nulligravid Asymptomatic Women: A Cross-Sectional Cohort Study

IMPORTANCE

In the past, urethral shape, mobility, and urodynamics have been used to retrospectively demonstrate correlations with stress urinary incontinence. Our previous work has shown a relationship between urethral function and shape in symptomatic women.

OBJECTIVE

This study aimed to characterize the effect of pelvic floor squeeze and strain maneuvers on urethral shapes and pressure in a cohort of patients without pelvic floor disorders.

STUDY DESIGN

In this cross-sectional study, volunteers underwent dynamic pelvic floor ultrasound examination, and a modified urodynamic study. Urethral length, thickness, and proximal and distal swing angles were measured at rest, squeeze, and strain. The midsagittal urethral walls were traced so that a statistical shape model could be performed. Means and standard deviations of imaging and urodynamic measures were calculated.

RESULTS

Data from 19 participants were analyzed. On average during squeeze compared with rest, urethral length increased by 6%, thickness decreased by 42% (distal, P < 0.001), 10% (middle), and urethral pressure increased by 14%. Opposite shape changes-length decreased by 10% ( P = 0.001), thickness increased by 57% (distal, P < 0.001), 20% (middle, P < 0.001)-and increased urethral mobility were observed during strain, with larger pressure increases occurring (29%, P < 0.001). Fifty-one percent of the total shape variance described the differences between maneuvers. These differences were statistically different between groups ( P < 0.001 for comparisons, all others P > 0.05).

CONCLUSIONS

Dynamic ultrasound and urodynamics allow for the establishment of baseline ranges in urethral metrics (2-dimensional measures, shape, and pressure) and how they are altered during maneuvers. These data can allow for a more objective identification of incontinence via ultrasound and urodynamic testing.

Multimodal measurements of levator bowl volume in nulligravid asymptomatic women: endovaginal ultrasound versus MRI

INTRODUCTION AND HYPOTHESIS

Measurements of levator bowl volume using advanced imaging, may be predictive of pelvic floor muscle function. The aim of this study was to compare the volume of the levator bowl using both magnetic resonance imaging (MRI) and endovaginal ultrasound (EVU) of healthy asymptomatic women.

METHODS

All participants underwent a comprehensive interview including completion of the Pelvic Floor Distress Inventory Questionnaire-20 questionnaire, pelvic examination with a pelvic organ prolapse quantification evaluation, MRI, and EVU. The pelvic floor was segmented using Slicer and the MRI segmentations were trimmed using two methods: soft-tissue landmarks and the field of view (FOV) of the ultrasound volume. The levator bowl volume of the 3D segmented shapes was measured using Blender's 3D printing toolkit. Normality was tested using the Shapiro-Wilks test and comparisons were made using self-paired t tests.

RESULTS

The final analysis included 19 patients. Levator bowl volume measured via MRI was larger than that measured in EVU (46.1 ± 7.9 cm3 vs 27.4 ± 5.9 cm3, p<0.001). Reducing the FOV of the MRI to that of EVU caused the MRI volume to be much closer to the EVU volume (35.5 ± 3.3 cm3 vs 27.4 ± 5.9 cm3, p<0.001); however, it remained significantly larger.

CONCLUSION

Levator bowl volume measured using MRI was larger than that measured using EVU no matter the method of delineation of the levator muscles. Although EVU is safe, cheap, and easy to perform, it captures a smaller volume of levator bowel than MRI.

Morphological Variation in the Pelvic Floor Muscle Complex of Nulliparous, Pregnant, and Parous Women

Specific levator ani muscle imaging measures change with pregnancy and vaginal parity, though entire pelvic floor muscle complex (PFMC) shape variation related to pregnancy-induced and postpartum remodeling has never been quantified. We used statistical shape modeling to compute the 3D variation in PFMC morphology of reproductive-aged nulliparous, late pregnant, and parous women. Pelvic magnetic resonance images were collected retrospectively and PFMCs were segmented. Modes of variation and principal component scores, generated via statistical shape modeling, defined significant morphological variation. Nulliparous (have never given birth), late pregnant (3rd trimester), and parous (have given birth and not currently pregnant) PFMCs were compared via MANCOVA. The overall PFMC shape, mode 2, and mode 3 significantly differed across patient groups (p < 0.001, = 0.002, = 0.001, respectively). This statistical shape analysis described greater perineal and external anal sphincter descent, increased iliococcygeus concavity, and a proportionally wider mid-posterior levator hiatus in late pregnant compared to nulliparous and parous women. The late pregnant group was the most divergent, highlighting differences that likely reduce the mechanical burden of vaginal childbirth. This robust quantification of PFMC shape provides insight to pregnancy and postpartum remodeling and allows for generation of representative non-patient-specific PFMCs that can be used in biomechanical simulations.

Obstructed Defecation Symptom Severity and Degree of Rectal Hypermobility and Folding Detected by Dynamic Ultrasound

ABSTRACT

We used dynamic pelvic floor ultrasound to investigate the relationship between obstructed defecation symptom (ODS) severity and the degree of rectal hypermobility/folding. In this retrospective study, women who presented with ODS from October 2017 to January 2019 and underwent an interview, pelvic examination, and pelvic floor ultrasound were recruited. Patients were diagnosed with abdominal constipation, dyssynergia, or pelvic constipation. Pelvic constipation patients were categorized based on their reported frequency of incomplete emptying of stool (<50% or ≥50% of bowel movements) representing mild and severe ODS, respectively. Using dynamic ultrasound, rectal hypermobility was quantified via rectovaginal septum length at rest and Valsalva and its compression ratio, where shorter lengths and larger compression ratios are indicative of increased rectal hypermobility. One hundred twenty-one patients (41 with abdominal constipation, 7 with dyssynergia, and 73 with pelvic constipation) were included. Compression ratios were higher in women with severe versus mild ODS (17.36 ± 16.89 vs 36.38 ± 25.82, P = 0.0039). The risk of having severe symptoms was 4 times greater (odds ratio = 4.2, 95% confidence interval = 1.4 to 12.6, P = 0.01) among those with a high compression ratio (≥20%) after controlling for age, body mass index, and levator plate descent angle. Incomplete emptying was weakly, positively, linearly correlated with rectal hypermobility/folding (r = -0.2724, -0.3767 to 0.3922, and P = 0.0197, 0.0010, 0.0006, respectively). Women with more severe ODS experienced more rectal hypermobility/folding as measured via dynamic ultrasound-a cheaper, effective alternative to magnetic resonance defecography for evaluation of obstructed defecation.

Pelvic floor architectural defects in female patients with urge fecal incontinence versus passive fecal leakage: a dynamic ultrasound study

INTRODUCTION AND HYPOTHESIS

Fecal incontinence (FI) has two primary subtypes: urgency fecal incontinence (UFI) and passive fecal leakage (PFL). The pathophysiology underlying the subtypes is incompletely understood.

OBJECTIVES

To compare the bowel habits, physical examinations and pelvic floor anatomical defects in patients with UFI-dominant FI versus patients with PFL-dominant FI.

STUDY DESIGN

This is a retrospective cross-sectional study of female patients who presented with fecal incontinence symptoms to our tertiary urogynecology center. All subjects underwent a comprehensive history, physical examination, 3D-static pelvic floor ultrasound, and 2D-dynamic ultrasound of the posterior compartment. Patients with UFI-dominant FI were compared to patients with PFL-dominant FI.

RESULTS

One hundred forty-five patients were included in the analysis; 57 categorized as UFI-dominant FI, 69 PFL-dominant FI and 19 categorized as having "both" leakage patterns. In comparing bowel habits, patient with UFI-dominant FI had more frequent bowel movements (15.5 ± SD 13.0/week vs. 10.9 ± SD 7.6 /week, p = 0.022) and were more likely to have loose stools (48.2% vs. 26.1%, p = 0.01). No statistically significant differences were observed in the prevalence of external anal sphincter defect (11.3% vs. 17.2%, p = 0.38) or internal anal sphincter defect (11.3% vs. 19%, p = 0.26) between groups. Finally, patients with UFI-dominant FI had a higher incidence of rectal hypermobility (loss of rectal support on Valsalva) (58% vs. 36.9%, p = 0.025).

CONCLUSION

Patients with urge-predominant FI have increased frequency of bowel movements, looser stools, and increased rectal folding diagnosed via dynamic ultrasound as compared to patients with passive-dominant FI.

Urethral support in female urinary continence part 2: a computational, biomechanical analysis of Valsalva

INTRODUCTION AND HYPOTHESIS

In Part 1, we observed urethral mechanics during Valsalva that oppose current continence theories. In this study, we utilize a finite element model to elucidate the role of supportive tissues on the urethra during Valsalva. By determining the sensitivity of urethral motion and deformations to variations in tissue stiffnesses, we formulate new hypotheses regarding mechanisms of urethral passive closure.

METHODS

Anatomy was segmented from a nulliparous, continent woman at rest. The model was tuned such that urethral motion during Valsalva matched that observed in that patient. Urethra and surrounding tissue material properties were varied using Latin hypercube sampling to perform a sensitivity analysis. As in Part 1, urethral length, proximal and distal swinging, and shape parameters were measured at peak Valsalva for 50 simulations, and partial rank correlation coefficients were calculated between all model inputs and outputs. Cumulative influence factors determined which tissue properties were meaningfully influential (≥ 0.5).

RESULTS

The material properties of the urethra, perineal membrane, bladder, and paraurethral connective tissues meaningfully influenced urethral motion, deformation, and shape. Reduction of the urethral stiffness and/or the perineal membrane soft constraint resulted in simulated urethral motions and shapes associated with stress urinary incontinence in Part 1.

CONCLUSIONS

The data from Parts 1 and 2 suggest that connective tissues guide the controlled swinging motion and deformation of the urethra needed for passive closure during Valsalva. The swinging and kinking quantified in Part 1 and simulated in Part 2 are inconsistent with current continence theories.

Pelvic floor shape variations during pregnancy and after vaginal delivery

BACKGROUND AND OBJECTIVE

Strong evidence suggests that pelvic soft tissues soften during pregnancy to facilitate vaginal delivery while protecting against maternal birth injury. We hypothesized that these adaptations likely result in changes to the shape of the pelvic floor. Thus, this study aimed to compare midsagittal pelvic floor shapes from MRIs of nulliparous, gravid, and vaginally parous women using statistical shape modeling.

METHODS

A retrospective study of 22 nulliparous, 29 gravid (vaginally nulliparous), and 18 vaginally parous women who underwent pelvic MRI was performed. The pelvic floor was segmented from pubic symphysis to coccyx as a 2D polyline in the midsagittal plane. Once corresponding landmarks were computed and the variances between them determined by principal component analysis, the principal component scores were calculated for modes that explained variance greater than noise. These became the dependent variables in a MANOVA with univariate ANOVAs, linear regressions, and Benjamini-Hochberg corrections post hoc. Two initial statistical shape analyses were conducted to analyze differences based on gestational age (1^st/2^nd vs 3^rd trimester) and vaginal parity (VP1 vs VP2-4). There were significant differences based on gestational age, but not vaginal parity. Thus, the final statistical shape analysis evaluated pelvic floor shapes of nulliparous, 3rd trimester gravid, and all vaginally parous subjects.

RESULTS

In the final analysis, six modes described variance-a measure of shape variability-greater than noise. Groups differed significantly for modes 1, 2, and 4 (p < 0.001, p = 0.021, and p = 0.015, respectively) and only differed between the nulliparous and gravid groups (p < 0.001, p = 0.018, and p = 0.012, respectively). Anatomically, these modes described levator plate relaxation and level III support protrusion in gravid compared to nulliparous subjects while the parous group straddled the other two.

CONCLUSIONS

The shape of the pelvic floor changes significantly during pregnancy and some of those changes are present after vaginal delivery. The fact that the nulliparous and gravid groups differ while the parous is similar to both suggests that some parous women regain their nulliparous shape after pregnancy and delivery while others do not. This indicates that remodeling during pregnancy and/or injury during vaginal delivery can have lasting effects on the pelvic floor.

Statistical shape modeling of the pelvic floor to evaluate women with obstructed defecation symptoms

Obstructed defecation (OD) is common and may be related to compromised pelvic floor integrity. Magnetic resonance (MR) defecography and statistical shape modeling were used to define pelvic floor shape variations, hypothesizing that State (rest vs peak evacuation) and Group (control vs case) would significantly influence shape. 16 women underwent MR defecography (9 cases vs 7 controls). Midsagittal, 2D pelvic floors were segmented and aligned by corresponding points. Principal component scores were compared using a Two-Way Mixed MANOVA. Three modes described differences between State (p < 0.001) and Group (p = 0.023). The pelvic floor shape differed significantly between women with and without OD and during evacuation.

The role of conventional pelvic floor reconstructive surgeries in obstructed defecation symptoms change: CARE and OPTIMAL trials sub-analysis of 2-year follow-up data

INTRODUCTION AND HYPOTHESIS

The current study was aimed at addressing two questions: first, is any conventional vaginal prolapse repair effective in curing obstructed defecation symptoms, and second, is there evidence to suggest that a sacrocolpopexy will increase the risk of worsening or new-onset obstructed defecation symptoms?

METHODS

This is a sub-analysis of two major clinical trials performed by the Pelvic Floor Disorders Network: the Colpopexy and Urinary Reduction Efforts (CARE) trial and the Operations and Pelvic Muscle Training in the Management of Apical Support Loss (OPTIMAL) trial. Two-year follow-up data were included. Demographics, pelvic organ prolapse quantification examination, and symptoms were compared between first, two surgical arms in the OPTIMAL study and second, CARE and OPTIMAL datasets using Chi-squared test for categorical variables and Student's t test or Mann-Whitney U test for continuous variables.

RESULTS

A total of 353 subjects form the OPTIMAL study and 279 subjects from the CARE study met the inclusion criteria. Regardless of trial, obstructed defecation symptoms were present in more than half of the patients at the initial visit before the surgical intervention, and interestingly, about one third of the patients were symptomatic at the 24-month follow-up in all surgical groups.

CONCLUSION

The conventional vaginal prolapse surgeries, with or without posterior vaginal wall repair, improved obstructed defecation symptoms by 50%, but about 35% of patients were suffering from at least one of the aspects of obstructed defecation at the 24-month follow-up. It is also important to note that about a quarter of the patients experienced persisting or worsening of their obstructed defecation symptoms in the absence of anatomical failure.

Motion of the vaginal apex during strain and defecation

INTRODUCTION AND HYPOTHESIS

Although the main function of the suspensory ligaments of the vaginal apex is to prevent its descent toward the vaginal introitus, there remains limited information regarding its normal physiological motion. This study was aimed at quantifying the motion of the non-prolapsed vaginal apex during strain and defecation maneuvers.

METHODS

This study represents a sub-analysis of a parent study that was aimed at evaluating rectal mobility with regard to obstructed defecation symptoms. Patients with normal apical vaginal support who had undergone MR defecography were entered into the study. For each patient, midsagittal images at rest, maximum strain, and maximum evacuation were utilized. The location of the cervicovaginal junction, S4-S5 intervertebral disc, sacral promontory, and hymen were identified. Vectors were calculated from each of these landmarks to the vaginal apex to compare vector angles and magnitudes across subjects.

RESULTS

Twelve patients were included in this study. At rest, the vagina extends from the hymen, which is inferior and posterior to the inferior symphysis pubis, to the vaginal apex at an angle of 45.2° ± 14.5° relative to the pubococcygeal line. This angle became more acute with strain and even more so during maximum evacuation (14.1° ± 9.0°, p < 0.001). Differences in the vector magnitude, although not statistically significant, showed a trend indicating shorter lengths with maximum evacuation.

CONCLUSIONS

The vaginal apex is a highly mobile structure demonstrating significantly more mobility during defecation compared with strain. The data obtained contradict the general perception that the vaginal apex is relatively fixed within the pelvis of normally supported women.

Variability of the pubic arch architecture and its influence on the minimal levator hiatus area

OBJECTIVE

To investigate the association between the minimal levator hiatus (MLH) area at rest with its surrounding soft-tissue and bony structures in nulliparous asymptomatic women with a normal levator ani muscle.

METHODS

A subanalysis was undertaken of a prospective study of the appearance of the levator ani in asymptomatic nulliparous women conducted between September 2010 and September 2011. The subanalysis included women with a normal levator ani muscle. Three-dimensional ultrasonography volumes were used to obtain pelvic floor measurements.

RESULTS

The analysis included 56 women with mean age of 43.0±13.4years. The mean MLH area was 13.1±1.8cm(2) (range 9.0-17.3). The pubic arch angle had no influence on the MLH area (Pearson correlation coefficient r=0.13). Height and pubic arch length were positively correlated with the MLH area (r=0.26 [P=0.52] and r=0.50 [P<0.001], respectively).

CONCLUSION

The MLH size of nulliparous women varied widely and was positively correlated with the height and pubic arch length of the women. Therefore, caution is warranted when interpreting the MLH area as an indicator of a levator ani defect or a predictor of pelvic organ prolapse without taking a woman's pelvic bone characteristics into account.

How does 3D endovaginal ultrasound compare to magnetic resonance imaging in the evaluation of levator ani anatomy?

INTRODUCTION AND HYPOTHESIS

To compare magnetic resonance imaging (MRI) to 3D endovaginal ultrasound (EVUS) in the evaluation of major levator ani defects in women with pelvic floor disorders.

METHODS

A total of 21 subjects with pelvic floor with complaints of pelvic floor disorders were included in this study. EVUS imaging of the levator ani muscle (LAM) was performed in all subjects, and the LA muscle groups of interest evaluated were the puboanalis (PA), puborectalis (PR), and pubovisceralis (PV) muscles. The right and left subdivisions were evaluated separately, and classified as (i) normal, normal with only minor irregularities, grossly abnormal, or absent, or (ii) by the levator ani deficiency (LAD) score and classified by no defect (complete attachment of muscle to the pubic bone), <50% detachment or loss, >50% detachment or loss, and completely detached or complete muscle loss. Paired data were analyzed with McNemar's test or Bowker's test of symmetry.

RESULTS

When unilateral LAM subdivisions were classified as "normal," "normal with minor irregularity," "grossly abnormal," and "absent," there were no significant differences between MRI and EVUS by categorization of LAM defects. Comparing "normal" versus "abnormal," there was no difference between imaging modalities. When compared by LAD score evaluation, there were no differences in the categorization of unilateral defects between MRI and EVUS.

CONCLUSIONS

Endovaginal 3D US is comparable to MRI in its ability to identify both normal and abnormal LAM anatomy. Neurourol. Urodynam. 36:409-413, 2017. © 2015 Wiley Periodicals, Inc.

Levator Plate Upward Lift on Dynamic Sonography and Levator Muscle Strength

OBJECTIVES

To compare digital palpation with levator plate lift measured by endovaginal and transperineal dynamic sonography.

METHODS

Dynamic transperineal and endovaginal sonographic examinations were performed as part of multicompartmental pelvic floor functional assessment. Patients were instructed to perform Kegel contractions while a probe captured a video clip of levator plate movement at rest and during contraction in a 2-dimensional midsagittal posterior view. We measured the distance between the levator plate and the probe on endovaginal sonography as well as the distance between the levator plate and the gothic arch of the pubis on transperineal sonography. The change in diameter (lift) and levator plate lift ratio (lift/rest × 100) were calculated. Pelvic floor muscle strength was assessed by digital palpation and divided into functional and nonfunctional groups according to the Modified Oxford Scale. Mean differences in levator plate upward lift were compared by Modified Oxford Scale scores using Student t tests and analysis of variance.

RESULTS

Seventy-four women were available for analysis. The mean age was 55 (SD, 11.9) years. When measured by vaginal dynamic sonography, mean lift and lift/rest ratio values increased with increasing Modified Oxford Scale score (analysis of variance, P= .09 and .04, respectively). When scores were categorized to represent nonfunctional (0-1) and functional (2-5) muscle strength groups, the mean lift (3.2 versus 4.6 mm; P = .03) and lift/rest ratio (13% versus 20%; P = .01) values were significantly higher in women with functional muscle strength. All patients with lift of 30% or greater detected by vaginal sonography had functional muscle strength.

CONCLUSIONS

A greater levator plate lift ratio detected by dynamic endovaginal sonography was associated with higher muscle strength as determined by the Modified Oxford Scale. This novel measurement can be incorporated into sonographic evaluation of levator ani function.

Is a new high-resolution probe better than the standard probe for 3D anal sphincter and levator ani imaging?

The aim of our study was to determine the accuracy of a new three-dimensional (3D) endoluminal ultrasound probe in assessing the levator ani muscle and anal sphincter complex. A total of 85 patients who had undergone concurrent 3D endovaginal (EVUS) and 3D endoanal (EAUS) ultrasound with both the standard BK 2052 probe and the new high-definition BK 8838 probes were included. For EVUS volumes, the levator ani deficiency (LAD) scores were calculated for each probe. For the EAUS volumes, any defects in the external anal sphincter (EAS) and the internal anal sphincter (IAS) visualized with each probe were recorded. The 3D volumes were evaluated in a blinded fashion. Appropriate statistics were utilized to assess absolute agreements between each pair of imaging modalities. The mean age of the patient population was 59 years (SD ± 10.76), the mean body mass index (BMI) was 28.36 (SD ± 5.99), and the median parity was 2 (range 1, 7). In all, 93% of the patients were Caucasian, 31% had stage 0 or 1 prolapse, while 59% had stage 2 prolapse. The mean total LAD score obtained on EVUS with the standard and the new probes were 11.49 (SD ± 4.94) and 11.53 (SD ± 5.01), respectively, p = 0.3778. Among the 53 patients who had EAUS with both probes, exact agreement for visualization of EAS and IAS for the standard and the new probes was 83% and 98%, respectively. Both transducers can be used for endovaginal imaging of the levator ani muscles interchangeably. Both transducers can be used for endoanal imaging of anal sphincter complex interchangeably.

How well can levator ani muscle morphology on 3D pelvic floor ultrasound predict the levator ani muscle function?

INTRODUCTION AND HYPOTHESIS

The aim of our study was to assess the performance of levator ani muscle deficiency (LAD) evaluated by 3D endovaginal ultrasound (EVUS) to detect pelvic floor muscle function as assessed by digital examination.

METHODS

This cross-sectional study was conducted among 77 patients referred to our urogynecology clinic for pelvic floor dysfunction symptoms. Patients underwent physical examinations including digital pelvic muscle strength assessment using the Modified Oxford scale (MOS). EVUS volumes were evaluated and levator ani muscles were scored according to a validated LAD scoring system. MOS scores were categorized as nonfunctional (scores 0-1) and functional (scores 2-5).

RESULTS

Mean age of participants was 56 (SD ± 12.5) and 71% were menopausal. Overall, 32.5% had nonfunctional muscle strength and 44.2% were classified as having significant LAD. LAD identified by ultrasound had a sensitivity of 60% (95% CI 41 -79%) for detecting nonfunctional muscle and a specificity of 63% (95% CI 50 -77%) for detecting functional muscle. Overall, LAD demonstrated fair ability to discriminate between patients with and those without poor muscle function (area under the ROC curve = 0.70 [95% CI 0.58-0.83]). Among patients with an LAD score of 16-18, representing almost total muscle avulsion, 70% had nonfunctional MOS scores, whereas in patients with normal/minimal LAD (scores of 0-4), 89.5% had functional MOS scores.

CONCLUSIONS

Levator ani deficiency and MOS scales were moderately negatively correlated. Among patients with normal morphology or the most severe muscle deficiency, LAD scores can identify the majority of patients with functional or nonfunctional MOS scores respectively.

Clinical and ultrasonographic study of patients presenting with transvaginal mesh complications

AIM

The objective of this study was to investigate the clinical and ultrasonographic findings of women who had three-dimensional endovaginal ultrasound (EVUS) for the management of vaginal mesh complications.

METHODS

This was a retrospective study of patients that had EVUS due to mesh complications at a tertiary care center. The clinical charts were reviewed. The stored 3D volumes were reviewed regarding mesh information by two examiners independently. The predictive value of physical examination for detection of vaginal mesh was calculated. Patient outcomes were reviewed.

RESULTS

Seventy-nine patients presented to our center because of their, or their physicians' concern regarding mesh complications. Forty-one (51.9%) had vaginal/pelvic pain, and 51/62 (82.2%) of sexually active women experienced dyspareunia. According to ultrasonographic findings, mesh or sling was not demonstrated in six patients who believed they have had mesh/sling implantation. The positive predictive value for vaginal examination was 94.5% (95% CI: 84.9%-98.8%), negative predictive value was 12.5% (95% CI: 2.8%-32.4%), sensitivity was 72.2% (95% CI: 59.4%-81.2%), and specificity was 50.0% (95% CI: 12.4%-87.6%). Fifty-four patients were indicated for surgical treatment. Median postoperative review was 12 (range, 3-18) months and 38/53 (71.7%) patients were satisfied.

CONCLUSIONS

The most common complaints of vaginal mesh complications were pain and dyspareunia. EVUS appeared to be helpful for assessing mesh presence, location, and extent including planning for surgical intervention.

Robotic surgery training in gynecologic fellowship programs in the United States

BACKGROUND AND OBJECTIVES

The increasing use and acceptance of robotic platforms calls for the need to train not only established surgeons but also residents and fellow trainees within the context of the traditional residency and fellowship program. Our study aimed to clarify the current status of robotic training in gynecologic fellowship programs in the United States.

METHODS

This was a Web-based survey of four gynecology fellowship programs in the United States from November 2010 to March 2011. Programs were selected based on their geographic areas. A questionnaire with 43 questions inquiring about robotic surgery performance and training was sent to the programs and either a fellow or the fellowship director was asked to complete. Participation was voluntary.

RESULTS

We had 102 responders (18% respond rate) with an almost equal response rate from all four gynecologic fellowships, with a median response rate of 25% (range 21-29%). Minimally Invasive Surgery (MIS) and Gynecologic Oncology (Gyn Onc) fellowships had the highest rate of robotic training in their fellowship curriculum-95% and 83%, respectively. Simulator training was used as a training tool in 74% of Female Pelvic Medicine and Reconstructive Surgery (FPMRS); however, just 22% of Reproductive Endocrinology and Infertility fellowships had simulator training. Eighty-seven percent of Gyn Onc fellows graduate with >50 robotic cases, but this was 0% for Reproductive Endocrinology Infertility fellows.

CONCLUSION

Our study showed that the use of a robotic system was built into fellowship curriculum of >80% of MIS and Gyn Onc fellowship programs that were entered in our study. Simulator training has been used widely in Ob&Gyn fellowship programs as part of their robotic training curriculum.

Evaluation of vaginal cysts and masses by 3-dimensional endovaginal and endoanal sonography

The purpose of this pictorial essay is to describe the utility of 3-dimensional endovaginal and endoanal sonography in the assessment of vulvovaginal cysts and masses. It is accepted that compared with transabdominal pelvic sonography, transvaginal end-fire sonography provides improved resolution for visualization of female reproductive organs with fewer artifacts. To visualize the structures that are located in or lateral to the vaginal canal, side-fire 3-dimensional endovaginal or endoanal sonography can be used. This special technique has the advantage of maintaining the spatial anatomic relationship of any abnormality in the vagina.

Development of an in-house endoanal ultrasound teaching phantom

OBJECTIVES

The aim of this study was to construct an anatomically correct phantom for visualization of anal sphincter complex structures.

METHODS

To ake an endoanal ultrasound phantom, we experimented with a variety of commercially available materials to simulate hyperechoic, hypoechoic, and isoechoic tissue consistency. We created external anal sphincter muscle and the levator plate using stand-alone density gel and microbubbles to simulate the echogenicity of the muscles. A mold was created in a container, the muscles were inserted, and the mold was filled with high-density clear gel and allowed to fill. Once finished, the container was sealed tightly and stored for later use. To evaluate the accuracy of the model, 6 ultrasound imaging raters from different disciplines were included. The raters were administered a 6-item Internet-based interactive test using 2-dimensional images obtained from scanning the phantom. Rater agreement was determined. The Fleiss κstatistic was calculated to determine inter-rater reliability.

RESULTS

The raters identified the structures in 32 (89%) of 36 test questions. There was good to excellent agreement among the readers. Agreement rates for visualization of the external anal sphincter, perineal body, and internal anal sphincter were 67%, 83%, and 100%, respectively.

CONCLUSIONS

An endoanal phantom can be constructed as a simulator for endoanal sonography.

The determinants of minimal levator hiatus and their relationship to the puborectalis muscle and the levator plate

OBJECTIVE

To determine the muscles comprising the minimal levator hiatus.

DESIGN

Cross-sectional study.

SETTING

The University of Oklahoma Health Sciences Center, USA.

POPULATION

Eight female fresh frozen pelves and 80 nulliparouswomen.

METHODS

Three-dimensional endovaginal ultrasound was performed in eight fresh frozen female pelves. The structures of the levator hiatus were tagged with needles and the cadavers were dissected to identify the tagged structures. A group of 80 nullipara underwent 3D endovaginal ultrasound, and the minimal levator hiatus area, puborectalis area, and anorectal angle were assessed, and normal values were obtained.

MAIN OUTCOME MEASURES

Anatomic borders of minimal levator hiatus and normality in pelvic floor measurements.

RESULTS

The pubococcygeus forms the inner lateral border and anterior attachment of the minimal levator hiatus to the pubic bone. The puboanalis fibres are immediately lateral to pubococcygeus attachments. There are variable contributions of the puborectalis fibres lateral to the puboanalis attachment. The posterior border of the minimal levator hiatus is formed by the levator plate. Eighty community-dwelling nulliparous women underwent 3D endovaginal ultrasound. The median age was 47 years (range 22-70 years). The mean of minimal levator hiatus and puborectalis hiatus areas were 13.4 cm(2) (±1.89 cm(2) SD) and 14.8 cm(2) (±2.16 cm(2) SD). The mean anorectal and levator plate descent angles were 156° (±10.04° SD) and 15.9° (±8.28° SD).

CONCLUSION

Anterior and lateral borders of the minimal levator hiatus are formed mostly by pubococcygeus. The puborectalis, pubococcygeus, and iliococcygeus form the bulk of the levator plate.

Referral pattern for vaginal mesh and graft complications to the University of Oklahoma Pelvic and Bladder Health Clinic

OBJECTIVE

To evaluate the referral pattern to a tertiary care center for vaginal mesh complications following surgeries for pelvic organ support defect.

METHODS

This was a retrospective review of women presenting to our clinic for complications of vaginal mesh.

RESULTS

One hundred thirty three patients were included in the study. The median age was 58.4 years, median parity was two, and 95.4% were Caucasian. The pattern of referral was as follows: 10% continued care at the tertiary center where mesh or graft was initially inserted, 18% were referred by the surgeon who initially implanted the mesh or graft, 71% were referred from an outside secondary health care provider, and 1% was self referred.

CONCLUSION

The majority of patients presenting to our clinic with mesh vaginal mesh complications were referred by someone other than the implanting surgeon.

Surgical repair of bilateral levator ani muscles with ultrasound guidance

Separation of the levator ani muscles from pubic bone is a common major levator trauma that may occur in vaginal delivery and is associated with pelvic floor dysfunctions. We describe a novel ultrasound-guided technique to repair these muscles. A 33-year-old woman presented with a history of difficult vaginal delivery and complaint of numbness and weakness of the vagina. In evaluation, bilateral levator defects were diagnosed by physical examination, three-dimensional endovaginal ultrasound, and magnetic resonance imaging. With ultrasound guidance the detached ends of muscles were tagged and sutured to their insertion points at the pubic bone. The patient's normal anatomy was restored with the return to normal pelvic floor tone. A follow-up ultrasound showed restored levator anatomy at 3 months.