Levator Ani Research Articles

PD34-11 EFFECTS OF AGE AND MULTIPLE VAGINAL BIRTHS ON URINARY BLADDER, SPHINCTER STRUCTURE, FUNCTION AND PELVIC SUPPORT IN NONHUMAN PRIMATES

You have accessJournal of UrologyCME1 May 2022PD34-11 EFFECTS OF AGE AND MULTIPLE VAGINAL BIRTHS ON URINARY BLADDER, SPHINCTER STRUCTURE, FUNCTION AND PELVIC SUPPORT IN NONHUMAN PRIMATES J. Koudy Williams, Shannon Lankford, and Gopal Badlani J. Koudy WilliamsJ. Koudy Williams More articles by this author , Shannon LankfordShannon Lankford More articles by this author , and Gopal BadlaniGopal Badlani More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002585.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Both aging and childbirth are associated with lower urinary tract dysfunction. However, the relative contribution of urinary bladder, urinary sphincter dysfunction and pelvic support remains unclear. This study uses female nonhuman primates (which have a 28 day menstrual cycle, an upright sitting posture and pelvic bladder and urinary sphincter) to address this issue. METHODS: Eight older (17-19 years of age, who have had an average of 7 live vaginal births) cynomolgus monkeys were compared to 6 younger (5 years of age, nulliparous) monkeys. Sedated abdominal leak point pressures (ALPP) were performed as well as urodynamic measures of sphincter maximal pressures (MUP) at rest and during pudendal nerve stimulation. Urinary sphincters, bladders and pelvic support muscles (levator ani and coccygeus) were examined for collagen content Masson’s trichrome, and picosirius red staining) and collagen fiber characteristics using CT-FIRE analysis. RESULTS: Aging and multiple vaginal births did not affect resting MUP measures, but did reduce the increase in MUP during pudendal nerve stimulation seen in the younger nulliparous monkeys (p<0.05) (Table 1). Age and multiple births did not affect total sphincter or bladder collagen content (Table 1, p>0.05), but did increase collagen content and reduce muscle content in the pelvic support muscles (p<0.05) (Table 1). ALPP was significantly lower in the older multiparous group than the young nulliparous group Table 1, p< 0.05). CONCLUSIONS: Results in this highly translatable animal model indicate that Lower urinary tract dysfunction associated with age and multiple births may be more a result of reduced sphincter response to neuronal stimulation and reduced pelvic support rather than intrinsic urinary sphincter or bladder structural and functional pathology. Source of Funding: National Institutes of Health, NIDDK © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e564 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information J. Koudy Williams More articles by this author Shannon Lankford More articles by this author Gopal Badlani More articles by this author Expand All Advertisement PDF DownloadLoading ...

V07-06 RETZIUS-SPARING ROBOT-ASSISTED RADICAL PROSTATECTOMY IN HIGH-RISK PROSTATE CANCER PATIENTS

You have accessJournal of UrologyCME1 May 2022V07-06 RETZIUS-SPARING ROBOT-ASSISTED RADICAL PROSTATECTOMY IN HIGH-RISK PROSTATE CANCER PATIENTS Paolo Dell'Oglio, Stefano Tappero, Mattia Longoni, Carlo Buratto, Pietro Scilipoti, Silvia Secco, Alberto Olivero, Michele Barbieri, Erika Palagonia, Giancarlo Napoli, Elena Strada, Giovanni Petralia, Dario Di Trapani, Angelo Vanzulli, Aldo Massimo Bocciardi, and Antonio Galfano Paolo Dell'OglioPaolo Dell'Oglio More articles by this author , Stefano TapperoStefano Tappero More articles by this author , Mattia LongoniMattia Longoni More articles by this author , Carlo BurattoCarlo Buratto More articles by this author , Pietro ScilipotiPietro Scilipoti More articles by this author , Silvia SeccoSilvia Secco More articles by this author , Alberto OliveroAlberto Olivero More articles by this author , Michele BarbieriMichele Barbieri More articles by this author , Erika PalagoniaErika Palagonia More articles by this author , Giancarlo NapoliGiancarlo Napoli More articles by this author , Elena StradaElena Strada More articles by this author , Giovanni PetraliaGiovanni Petralia More articles by this author , Dario Di TrapaniDario Di Trapani More articles by this author , Angelo VanzulliAngelo Vanzulli More articles by this author , Aldo Massimo BocciardiAldo Massimo Bocciardi More articles by this author , and Antonio GalfanoAntonio Galfano More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002598.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Retzius-sparing (RS) robot assisted radical prostatectomy is a valid surgical treatment option for prostate cancer (PCa) patients. However, there is a lack of evidence on the feasibility of this approach in high-risk (HR) PCa patients. In this video we describe our RS-RARP technique for HRPCa patients. METHODS: We present the case of a 66 year-old patient with PSA of 13.8 ng/ml, cT3 on the left side at DRE, an MRI showing 16 mm PIRADS 5 on the left lobe and an ISUP 4 grade PCa at biopsy (17/21 cores). No distant metastases were found at total body CT and bone scan. Left extrafascial and interfascial right nerve sparing RS with extended lymph node dissection was performed with a four-arm da Vinci Si Surgical System at a high volume centre. After incision of the parietal peritoneum at the anterior surface of the Douglas pouch, dissection of the vasa deferentia, isolation of the seminal vesicles, the Denonvillier’s fascia is medially incised starting from an extrafascial layer and pushed upwards with the posterior surface of the prostate. The dissection is carried out forward to the prostatic apex. On the left side part of the perirectal fat is also pushed upwards with the specimen. Once isolated the posterior aspect of the prostate, a wide left extrafascial plane is carried out laterally to the levator ani fascia. A right unilateral inter-fascial nerve sparing is performed in a standard fashion. The bladder neck is dissected, the anterior surface of the gland is isolated, the Santorini plexus is partially resected. Finally, the apex is isolated from the urethra and the latter is incised. RESULTS: Operative time and estimated blood loss were 185 min and 150 ml. No intraoperative complications occurred. Final pathology revealed a ISUP 4 grade, pT3aN0R0. The patient was discharged on POD 2 and the suprapubic catheter was removed on POD 7. Follow-up period was uneventful and at 8 months from surgery PSA was undetectable and the urinary continence (UC) fully recovered. 340 HRPCa patients were treated with this technique at our centre. Final pathology reported 9.4% focal and 19.4% extended positive surgical margins. Median follow-up was 47 months. At 4 years of follow-up, BCR-free and additional treatment-free survival were 64 and 57%. The 2-year UC and erectile function recovery were respectively 85% and 50%. CONCLUSIONS: RS in HR-PCa patients is safe and allows optimal intra- peri- and postoperative, oncologic and functional outcomes. RS should be considered a valid surgical treatment option for HRPCa patients in expert hands. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e660 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Paolo Dell'Oglio More articles by this author Stefano Tappero More articles by this author Mattia Longoni More articles by this author Carlo Buratto More articles by this author Pietro Scilipoti More articles by this author Silvia Secco More articles by this author Alberto Olivero More articles by this author Michele Barbieri More articles by this author Erika Palagonia More articles by this author Giancarlo Napoli More articles by this author Elena Strada More articles by this author Giovanni Petralia More articles by this author Dario Di Trapani More articles by this author Angelo Vanzulli More articles by this author Aldo Massimo Bocciardi More articles by this author Antonio Galfano More articles by this author Expand All Advertisement PDF downloadLoading ...

Guidelines to diagnose and treat peri-levator high-5 anal fistulas: Supralevator, suprasphincteric, extrasphincteric, high outersphincteric, and high intrarectal fistulas.

Supralevator, suprasphincteric, extrasphincteric, and high intrarectal fistulas (high fistulas in muscle layers of the rectal wall) are well-known high anal fistulas which are considered the most complex and extremely challenging fistulas to manage. Magnetic resonance imaging has brought more clarity to the pathophysiology of these fistulas. Along with these fistulas, a new type of complex fistula in high outersphincteric space, a fistula at the roof of ischiorectal fossa inside the levator ani muscle (RIFIL), has been described. The diagnosis, management, and prognosis of RIFIL fistulas is reported to be even worse than supralevator and suprasphincteric fistulas. There is a lot of confusion regarding the anatomy, diagnosis, and management of these five types of fistulas. The main reason for this is the paucity of literature about these fistulas. The common feature of all these fistulas is their complete involvement of the external anal sphincter. Therefore, fistulotomy, the simplest and most commonly performed procedure, is practically ruled out in these fistulas and a sphincter-saving procedure needs to be performed. Recent advances have provided new insights into the anatomy, radiological modalities, diagnosis, and management of these five types of high fistulas. These have been discussed and guidelines formulated for the diagnosis and treatment of these fistulas for the first time in this paper.

Evaluation of Nursing Effect of Pelvic Floor Rehabilitation Training on Pelvic Organ Prolapse in Postpartum Pregnant Women under Ultrasound Imaging with Artificial Intelligence Algorithm.

This study was aimed at exploring the application value of ultrasound technology and rehabilitation training based on artificial intelligence algorithm in postpartum recovery of pelvic organ prolapse. Sixty patients diagnosed as mild and moderate pelvic organ prolapse by pelvic organ prolapse quantification evaluation were selected as the research objects. The patients were randomly divided into experimental group (30 cases) and control group (30 cases). The patients in the control group were given routine guidance and postpartum health education 42 days after delivery and given no pelvic floor rehabilitation training, waiting for natural recovery. 42 days after delivery, the patients in the experimental group received pelvic floor rehabilitation training based on the patients in the control group. All patients underwent ultrasonography, the convolution neural network (CNN) algorithm was used for image denoising and edge feature extraction, and the performance of the algorithm was evaluated by the Dice coefficient, positive predictive value, sensitivity, and Hausdorff distance. The thickness of levator ani muscle, anterior and posterior diameter of perineal hiatus, pelvic floor muscle strength, and imaging data were compared between the two groups. The results revealed that the thickness of levator ani muscle in the experimental group was significantly greater than that in the control group after one month and three months of treatment (0.633 ± 0.26 cm vs. 0.519 ± 0.234 cm, 0.7 ± 0.214 cm vs. 0.507 ± 0.168 cm, P < 0.05). After one month and three months of treatment, the anterior and posterior diameter of perineal fissure in the experimental group was obviously smaller than that in the control group (4.76 ± 0.513 cm vs. 5.002 ± 0.763 cm, 4.735 ± 0.614 cm vs. 4.987 ± 0.581 cm, P < 0.05). The pelvic floor muscle strength of the experimental group was remarkably higher than that of the control group after one month and three months of treatment (3.183 ± 1.47 vs. 2.41 ± 1.57, 3.365 ± 1.53 vs. 2.865 ± 1.69, P < 0.05). The ultrasonic image was clearer, the focus was more prominent, and the image quality was significantly improved after being processed by artificial intelligence algorithm. The Dice coefficient, positive predictive value, sensitivity, and Hausdorff distance of the proposed algorithm were better than those of the traditional algorithm. Thus, artificial intelligence algorithm had a good effect in ultrasonic image processing. Pelvic floor rehabilitation training had a good effect on postpartum nursing of patients with pelvic organ prolapse.

Why upright standing men urinate more efficiently than in supine position: A morphological analysis with real-time magnetic resonance imaging.

Few studies have examined the effects of body position on urination efficiency morphologically. We aimed to dissect out the anatomical changes of pelvic organs during urination in the upright and supine positions by a real-time magnetic resonance imaging (rtMRI) system. Thirteen healthy male volunteers aged 26-60 years were included in the study. The sagittal real-time two-dimensional images were taken to evaluate urinary efficiency, along with change in six morphological indices at the time of storage and the beginning of voiding, in both upright ant supine positions. Urination was more efficient in upright position than in supine position, as expressed by higher average rate of bladder emptying (9.9 ± 4.2 vs. 6.8 ± 2.9 ml/s, p < 0.05) and also by fewer participants showing significant residual urine (1/13 vs. 7/13, p < 0.05). At the onset of voiding in standing position, the levator ani (LA) muscle moves downward and backward followed by descent of the bladder neck and rotation of the prostate around the symphysis. Such changes were expressed by two morphological indices. One was posterior vesicourethral angle at the start of voiding, 152 ± 7 versus 140 ± 1 in upright and supine position (p < 0.05). The other index was the change in angle between the LA line and pubo-coccygeal line in upright and supine position, 9.4 ± 9.9 versus 1.6 ± 7.9 before voiding (p < 0.05) and 30.2 ± 14.0 versus 17.3 ± 12.9 after the start of voiding (p < 0.05). The dynamic relaxation of LA seemed to be a key movement that enables more efficient urination in standing position than in supine position.

Simultaneous Integrated Boost Volumetric Modulated Arc Therapy for Rectal Cancer: Long-Term Results after Protocol-Based Treatment.

Background Volumetric modulated arc therapy (VMAT) with simultaneous integrated boost (SIB) is an advanced form of radiotherapy (RT) technology. The purpose of this study was to report long-term treatment outcomes in patients with locally advanced rectal cancer undergoing VMAT-SIB based concurrent chemoradiotherapy (CRT). Methods Between January 2016 and January 2018, a total of 22 patients with operable stage II-III rectal adenocarcinoma were recruited for the pre-designed VMAT-SIB RT protocol. All patients underwent standard diagnostic and staging work-up. The RT target volumes included the following areas: PTV1 = mesorectum that contained gross tumors and enlarged lymph node regions and PTV2 = mesorectum and regional lymphatics from L4-5/S1 to 3-4 cm below the tumor or levator ani muscle, excluding PTV1. The VMAT-SIB dose prescription was as follows: PTV1 = 52.5 Gy/daily 2.1 Gy/25 fractions, PTV2 = 45 Gy/daily 1.8 Gy/25 fractions. Results The mean age of the study population was 64 (range, 18-84) years, and 15 (68.2%) patients were male. Radical operation (total mesorectal excision) was performed by either low anterior resection, ultralow anterior resection, or abdominal perineal resection. All five (22.7%) of the patients with confirmed increasing serum carcinoembryonic antigen (CEA) level at diagnosis showed normalization of serum CEA level after the planned treatment. Among 20 patients who underwent preoperative CRT and surgery, tumor down staging in T- and N-stages was achieved in 10 patients (50%) and 13 patients (65%), respectively, with 20% of ypT0/Tis. With a median follow-up of 54.2 (range, 22.6-61.1) months, the 5-year disease-free survival, overall survival, and local control rates were 64.6%, 81.8%, and 84.4%, respectively. Five patients developed distant metastasis and one developed local recurrence as a first event. Two cases with anastomosis site leakage, three with adhesive ileus, and two with abscess formation were observed during postoperative periods. Conclusions The current VMAT-SIB-based CRT protocol provided acceptable treatment and toxicity outcomes.

A biomechanical study of the birth position: a natural struggle between mother and fetus.

Birth trauma affects millions of women and infants worldwide. Levator ani muscle avulsions can be responsible for long-term morbidity, associated with 13-36% of women who deliver vaginally. Pelvic floor injuries are enhanced by fetal malposition, namely persistent occipito-posterior (OP) position, estimated to affect 1.8-12.9% of pregnancies. Neonates delivered in persistent OP position are associated with an increased risk for adverse outcomes. The main goal of this work was to evaluate the impact of distinct fetal positions on both mother and fetus. Therefore, a finite element model of the fetal head and maternal structures was used to perform childbirth simulations with the fetus in the occipito-anterior (OA) and OP position of the vertex presentation, considering a flexible-sacrum maternal position. Results demonstrated that the pelvic floor muscles' stretch was similar in both cases. The maximum principal stresses were higher for the OP position, and the coccyx rotation reached maximums of 2.17[Formula: see text] and 0.98[Formula: see text] for the OP and OA positions, respectively. Concerning the fetal head, results showed noteworthy differences in the variation of diameters between the two positions. The molding index is higher for the OA position, with a maximum of 1.87. The main conclusions indicate that an OP position can be more harmful to the pelvic floor and pelvic bones from a biomechanical point of view. On the other side, an OP position can be favorable to the fetus since fewer deformations were verified. This study demonstrates the importance of biomechanical analyses to further understand the mechanics of labor.

Quantification of 3/4D ultrasound pelvic floor changes induced by postpartum muscle training in patients with levator ani muscle avulsion: a parallel randomized controlled trial.

We believe that physiotherapy with muscle training (MT) of the postpartum pelvic floor may lead to a change in the clinical management of patients with avulsion of the puborectal portion of the levator ani muscle (LAM). Our objective is to assess whether physiotherapy with MT of the postpartum pelvic floor in patients with LAM avulsion produces changes in pelvic floor morphology evaluated by 3/4D transperineal ultrasound. This parallel randomized controlled trial (RCT) included 97 primiparous patients. A study was conducted in three parts. In the first part (3 months postpartum), primiparous patients with LAM avulsion were recruited, and the levator hiatus and the LAM areas were measured using 3/4D transperineal ultrasound. In the second part (3 to 6 months postpartum), patients were randomized into two groups, with one undergoing rehabilitation (experimental group) and another without rehabilitation (control group). At the end of 6 months, a new transperineal ultrasound was performed. In the third part (9 months postpartum), the levator hiatus and LAM dimensions were analyzed again. The RCT was registered at ClinicalTrials.gov (NCT03686956). Project PI16/01387 funded by Instituto de Salud Carlos III (Spain) integrated in the national I+D+i 2013-2016 and cofounded by the European Union (ERDF/ESF, "Investing in your future"). A total of 92 completed the study, including 46 patients in the experimental group and 46 in the control group. The experimental group had a greater LAM area at 6 months (9.2±1.9 vs. 7.6±2.1 cm2, P=0.008; 95% CI: 0.6-3.0) and 9 months after labor (9.4±2.7 vs. 7.6±2.0 cm2, P=0.012; 95% CI: 0.4-3.2), which was not observed at 3 months postpartum (8.3±1.6 vs. 7.5±2.3 cm2; P=0.183; 95% CI: 0.39-1.99). The levator hiatus area decreased more in the experimental group in almost all comparisons. The most significant change occurred from 3 to 6 months during the Valsalva maneuver (-3.92±5.12 vs. 0.45±3.06 cm2; P<0.005; 95% CI: 2.64-5.00). Women with a rehabilitated LAM through physiotherapy showed a significant reduction in the levator hiatus area during Valsalva while receiving in-person physical therapy (3 to 6 months after delivery). These differences did not persist once physical therapy was completed (6 to 9 months after delivery). ClinicalTrials.gov identifier NCT03686956.

Development and validation of a composite AI model for the diagnosis of levator ani muscle avulsion.

To assess the feasibility and reliability of a composite AI model for the diagnosis of levator ani muscle (LAM) avulsion of tomographic ultrasound imaging (TUI). Ultrasonic images of the pelvic floor from a total of 304 patients taken from January 2018 to October 2020 were included. All patients included underwent standardized interviews and transperineal ultrasound (TPUS). Transfer-learning and ensemble-learning methods were adopted to develop the proposed model on the basis of three classic convolutional neural networks (CNN). Confusion matrix (CM) and the ROC statistic were used to assess the effectiveness of the proposed model. Gradient-weighted class activation mappings (Grad-CAMs) were used to help enhance the interpretability of the proposed model. Of the 304 patients included, 208 were in the derivation cohort (108 LAM avulsion and 100 normal) and 96 (39 LAM avulsion and 57 normal) were in the validation cohort. The proposed model in LAM avulsion diagnosis outperformed other models and a junior clinician in both the test set of derivation cohort and the validation cohort, with accuracies of 0.95 and 0.81, and AUCs of 0.98 and 0.86, respectively. According to the heatmap of Grad-CAMs, the proposed model mainly localizes areas between the pubic symphysis and the bilateral insertion point of LAM when making a diagnosis, which is exactly the region of interest in clinical practice. The proposed model using ultrasonic images of the pelvic floor may be a promising tool in assisting the diagnosis of LAM avulsion in clinical practice. • First AI-assisted model for levator ani muscle avulsion diagnosis • Diagnosis accuracy of less-experienced clinicians could be improved using the proposed model.

Pelvic floor anatomy

: The pelvic floor is a complex mechanical apparatus composed by the levator ani, superficial perineal muscles, pelvic nerves, endopelvic fascia, and ligaments. The pelvic anatomy is somewhat challenging to both surgeons and anatomists. It is a narrow and deep region that encompasses intestinal, gynecologic, and urologic viscera, vessels, nerves, and fascial attachments. It is designed for content suspension and to promote coordinated action during bladder and rectal emptying. Support for the pelvic organs originates from connections to the pelvis and associated muscles. The pelvic muscles encompass five groups: levator ani, anal sphincter complex, pelvic sidewall, and anterior perineal muscles. Damage to structural and functional interactions of the pelvic floor can potentially lead to multi-compartmental dysfunction. Also, debilitating pelvic floor disorders such as pelvic organ prolapse and incontinence are usually related to injuries and deterioration of muscles, nerves, and ligaments that support and maintain normal pelvic function. The anorectum and pelvic floor are interconnected by the fascia and ligaments, which provide support for endopelvic viscera. In females, the pelvic floor is considered part of the birth canal and stretching and tearing of these structures during vaginal delivery are often underestimated causes of pelvic floor dysfunction. In addition, pelvic floor function can be affected by variation in bowel habits, particularly chronic excessive straining. Understanding pelvic floor anatomy is essential to fully diagnose and adequately treat these dysfunctions.

The impact of levator ani muscle trauma and contraction on recurrence after prolapse surgery

Introduction and hypothesisThe objective was to explore the impact of levator ani muscle (LAM) trauma and pelvic floor contraction on symptoms and anatomy after pelvic organ prolapse (POP) surgery.MethodsProspective study including 200 women with symptomatic POP ≥ grade 2 examined 3 months prior to and 6 months after surgery. Prolapse in each compartment was graded using the Pelvic Organ Prolapse Quantification (POP-Q) system, and women answered yes/no to a question about bulge sensation. Pelvic floor muscle contraction was assessed with transperineal ultrasound measuring proportional change in levator hiatal anteroposterior diameter from rest to contraction. LAM trauma was diagnosed using tomographic ultrasound imaging. Statistical analysis was performed using multivariate logistic regression analysis.ResultsA total of 183 women (92%) completed the study. Anatomical recurrence (POP ≥ grade 2) was found in 76 women (42%), and a bulge sensation was reported by 35 (19%). Ninety-two women (50%) had LAM trauma, and this was associated with increased risk of anatomical recurrence (OR 2.1 (95% CI 1.1–4.1), p = 0.022), but not bulge sensation (OR 1.1 (95% CI 0.5–2.4), p = 0.809). We found a reduced risk of bulge sensation for women with absent to weak contraction compared with normal to strong contraction (OR 0.4 (95% CI 0.1–0.9), p = 0.031), but no difference in risk for POP ≥ 2 after surgery (OR 1.5 (95% CI 0.8–2.9), p = 0.223).ConclusionsLevator ani muscle trauma was associated with increased risk of anatomical failure 6 months after POP surgery. Absent to weak pelvic floor muscle contraction was associated with reduced risk of bulge sensation after surgery.

The prediction of postoperative anorectal dysfunction after low anterior resection for lower rectal cancer by measuring the volume of defecation-related muscles.

Approximately 90% of patients are thought to develop bowel dysfunction after low anterior resection (LAR). Although some prognostic factors have been reported, the volumes of defecation-related muscles have not been examined. This retrospective study investigated the association between the preoperative volume of defecation-related muscles and major LARS. Forty-six patients who underwent LAR for rectal cancer between 2013 and 2020 in our institution were analyzed. They had no local residual tumor or local recurrence at the time of the study and no problems with their defecation function pre-operatively. Defecation-related muscle volume measurements were made before surgery, and the patients answered a low anterior resection syndrome (LARS) score questionnaire after surgery. The muscle volume was adjusted by the patient's height squared. Twenty-seven patients (58.7%) developed major LARS. In the univariate analysis, sex, lateral lymph node dissection, and diverting ileostomy as well as muscle volume of the external anal sphincter, pubococcygeal + iliococcygeus muscle, and puborectal muscle were associated with major LARS. In a multivariate analysis, pubococcygeal + iliococcygeus muscle (< 5.96ml/m2) was the only factor (p = 0.02). Measuring the volume of the defecation-related muscles may aid in predicting major LARS.

Multilevel musculo-fascial defect magnetic resonance study of female pelvic floor: retrospective case control study in women with pelvic floor dysfunction after the first vaginal delivery.

Magnetic resonance imaging (MRI) provides a detailed display of the pelvic floor structures responsible for normal pelvic floor anatomy. The aim of the study is to assess the appearance of musculo-fascial defects in women with pelvic floor dysfunction following first vaginal delivery. Analysis of axial T3 (Tesla 3) MRI scans from a case control study of symptomatic (n=149) and asymptomatic (n=60) women after first vaginal delivery. Presence and severity of pelvic organ support and attachment system defects in three axial pelvic planes were assessed. In the symptomatic group, major muscular defects were found in 67.1% (for pubovisceral muscle complex) and 87.9% (for iliococcygeal muscle). Only 6.7% of major pubovisceral and 35.0% of major iliococcygeal defects were identified in the controls (p=0.000). Prolapse patients had an odds ratio (OR) of 22.1 (95% CI 8.94-54.67) to have major pubovisceral muscle complex defect and OR of 4.9 (95% CI 1.51-15.71) to have major iliococcygeal muscle defect. Fascial defects were found in 60.4% and 83.2% the symptomatic group, respectively. Those with prolapse had an OR of 29.1 (95% CI 9.77-86.31) to have facial defect at the level of pubovisceral muscle complex and an OR of 16.9 (95% CI 7.62-37.69) to have fascial defect at the level of iliococcygeal muscle. Uterosacral ligaments detachment was associated with prolapse with an OR of 10.1 (95% CI 4.01-25.29). For the model based on combination on all MRI markers, the area under the receiver operating characteristic curve is 0.921. This study provides comprehensive data about first vaginal delivery-induced changes in the levator ani muscle and endopelvic fascial attachment system. These changes are seen also in asymptomatic controls, but they are significantly less expressed.

Pelvic Floor Muscle Strength in the First Trimester of Primipara: A Cross-Sectional Study.

Background: Pelvic floor muscle (PFM) weakness is associated with stress urinary incontinence. Pregnancy is an important risk factor for PFM weakness. Studies evaluating PFM strength in the first trimester of pregnancy are still lacking. Our study aimed to describe pelvic floor function of the primipara in the first trimester of gestation and investigate the risk factors for PFM weakness. Methods: Primiparas aged 20~40 years with a singleton pregnancy less than 14 weeks of gestation were recruited, and data were collected via questionnaires on items that were suggested as associated with PFM weakness, followed by Modified Oxford Scale (MOS) on genital hiatus and perineal body and pelvic floor ultrasound evaluation for the thickness of the left and right levator ani muscles (LAM), right–left diameter of the levator hiatus (LH), and LH area. Participants were divided into three groups by MOS >3, =3, and <3 for data analysis. Results: A total of 380 participants completed the questionnaires and examinational analysis, of whom, 228, 98, and 54 were divided into Group 1, Group 2, and Group 3, respectively. The three groups were significantly different in the number of gestations and abortions, toilet types, and the right–left diameter of the LH (p < 0.05). Logistic regressive analysis showed that squatting toilet dominant (OR = 3.025; 95% CI: 1.623~5.638; p < 0.001) and a larger right–left diameter of the LH (OR = 1.065; 95% CI: 1.026~1.105; p = 0.001) were significantly associated with PFM weakness. Conclusions: Squatting toilet dominancy and longer right–left diameter of the LH are significantly associated with PFM weakness in primiparas in the first trimester. Sitting toilets should be recommended to women, especially pregnant women. Trial registration: The trial has been registered at Chinese Clinical Trial Registry (registration number: ChiCTR2000029618).

Usefulness of transperineal shear wave elastography of levator ani muscle in women with stress urinary incontinence.

This study aimed to quantitatively assess the quality of levator ani muscle (LAM) using shear wave elastography (SWE) and to evaluate the association between the elasticity of LAM and stress urinary incontinence (SUI). The study population included 32 women with SUI and 34 women with normal pelvic support. The thickness of LAM, bladder neck descent (BND), and urethral funneling (UF) were assessed by transperineal ultrasound. LAM elasticity was measured by SWE at rest and during the maximal Valsalva maneuver. Age, menopause, BND, and UF showed a positive correlation with SUI. There was no significant between-group difference in the elastic modulus values of LAM at rest. The thickness of LAM in women with SUI was greater than that in control group at rest and during the maximal Valsalva maneuver (P < 0.001). The elastic modulus values of Emax and Emean were significantly increased from rest to the maximal Valsalva maneuver in all participants (56.24 vs 82.43kPa and 47.92 vs 72.37kPa, P < 0.001). The change of these variables from rest to the maximal Valsalva maneuver in the control group was more obvious than that in the SUI group (34.09 vs 17.87kPa and 31.55 vs 16.82kPa, P < 0.05). The elasticity of LAM, as quantified by SWE, may potentially be used as an index for predicting SUI.

The correlation between levator ani co-activation and fetal head regression on maternal pushing at term

Objective To assess the correlation between fetal head regression and levator ani muscle (LAM) co-activation under Valsalva maneuver. Study design This study was a secondary analysis of a prospective cohort study on the association between the angle of progression (AoP) and labor outcome. We scanned a group of nulliparous women at term before the onset of labor at rest and under maximum Valsalva maneuver. In addition to the previously calculated AoP, in the present study, we measured the anteroposterior diameter of LAM hiatus (APD) on each ultrasound image. LAM co-activation was defined as APD at Valsalva less than that at rest, whereas fetal head regression was defined as AoP at Valsalva less than that at rest. We calculated the correlation between the two phenomena. Finally, we examined various labor outcomes according to the presence, absence, or co-existence of these two phenomena. Results We included 469 women. A total of 129 (27.5%) women presented LAM co-activation while 50 (10.7%) showed head regression. Only 15 (3.2%) women showed simultaneous head regression and LAM co-activation. Women with coexisting LAM co-activation and head regression had the narrowest AoP at Valsalva in comparison with other study groups (p < .001). In addition, they had the highest risk of Cesarean delivery (40%) and longest first, second, and active second stage durations, although none of these reached statistical significance. Conclusion In nulliparous women at term before the onset of labor fetal head regression and LAM co-activation at Valsalva are two distinct phenomena that uncommonly coexist.

A prospective observational study on the influence of the difficulty of forceps application and the avulsion of the levator ani muscle

Background: To compare the rate of levator ani muscle (LAM) avulsion between normal deliveries (ND) and forceps deliveries (FD) and to determine whether the difficulty of forceps application in FD is related to the occurrence of LAM avulsion. Methods: This prospective observational study included 240 primiparous patients (125 ND and 115 FD). FD were classified according to the difficulty of forceps application. The application was considered difficult if the fetal head was in a transverse position or if it was midforceps (head engaged by the leading part was above +2 stations) with the fetal head in the occipito-posterior position; otherwise, the application was considered easy. Ultrasound evaluation was performed 6 months after delivery, and complete avulsion was diagnosed when there was abnormal insertion of the LAM in all three central slices. Results: There were statistically significant differences between the ND and FD groups in the presence of LAM avulsion (15.6% vs. 38.3%; p &lt; 0.0005), with a crude Odds Ratio (OR) of 3.36 and an adjusted OR of 4.219. However, there were no statistically significant differences in the LAM avulsion rates between the easy and difficult application groups (34.2% vs. 45.2%; p: 0.244). Conclusions: FD have higher rates of LAM avulsion than ND, although the difficulty of forceps application does not have an influence on the rates of LAM avulsion.

Estimated Levator Ani Subtended Volume: A Predictive Biomarker for Surgical Outcomes Following Native Tissue Apical Repair

The aim of the study was to investigate the clinical utility of estimated levator ani subtended volume (eLASV) as a prospective preoperative biomarker for prediction of surgical outcomes. This is a prospective case-control pilot study. Patients were recruited and gave consent between January 2018 and December 2020. Surgical failure was defined by composite score. The eLASV was calculated for each patient based on a previously published algorithm. Descriptive statistics, Fisher exact test, log-binomial regression, area under a receiver operating characteristics, Bland-Altman plot, Lin coefficient, and κ coefficient were all performed for analysis. Fifty-one patients gave consent, 31 completed preoperative magnetic resonance imaging, 27 underwent surgery (uterosacral ligament suspension), and 19 followed up for 1-year examination. Five patients (26.3%) were defined as surgical failure with median eLASV volume of 57.0 (interquartile range, 50.1-66.2). Fourteen patients (73.7%) were defined as surgical success with median eLASV of 28.2 (interquartile range, 17.2-24.3). Eighty percent of the surgical failure group (4/5) had elevated volume of eLASV, where only 14.3% of the success group (2/14) had an elevated volume (P = 0.0173). No confounders were found and unadjusted log-binomial regression suggested that patients with a high eLASV were 8.7 (95% confidence interval, 1.2-61.9) times more likely to experience surgical failure compared with those with low eLASV. The c-statistic (area under a receiver operating characteristics) was high at 0.829 along with Lin concordance coefficient of 0.949 (95% confidence interval, 0.891-0.977) for continuous data between the 2 interrater observer teams. In this small prospective pilot study, patients with elevated eLASV on a preoperative pelvic magnetic resonance imaging were associated with an increased risk for surgical failure at 1 year regardless of age, body mass index, stage, or parity.CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov, NCT03534830.

Levator ani asymmetry and deviation in high-type anorectal malformation evaluated by magnetic resonance imaging.

The levator ani (LA) complex in high-type imperforate anus (H-IA), low-type imperforate anus (L-IA), and Hirschsprung's disease (HD) patients as controls were documented using magnetic resonance imaging (MRI) and compared for symmetry. Mean left:right LA thickness ratio (LA ratio), and deviation of the LA from the pubococcygeal line (PCL; LA angle) were calculated from thin-slice MRI images (axial 2mm, coronal 2mm, and sagittal 3mm) of the puborectalis and pubococcygeus taken parallel to the PCL under sedation in H-IA (n=14), L-IA (n=16), and HD (n=9). MRI scans were performed between January 2018 and June 2021. LA were significantly thinner in H-IA (1.78±0.46mm) compared with L-IA (2.97±0.55mm) and controls (2.87±0.32mm), p<0.0001. LA ratio was significantly lower in H-IA (0.71±0.15) compared with L-IA (0.93±0.04), and controls (0.91±0.06), p<0.0001. Mean LA-angle was significantly different in H-IA, 10.8° (range 6°-19°), versus L-IA and controls, both zero degrees (range 0°-5°), p<0.0001, respectively. LA was confirmed to be significantly asymmetric in H-IA. Because outcome of surgical repair involving a midline incision, such as posterior sagittal anorectoplasty could be impaired, pediatric surgeons are advised to plan surgical intervention for H-IA carefully and appropriately.

Correlation between pelvic floor ultrasound parameters and vaginal pressures in nulliparous women: a subanalysis of the SUM-AN study.

Pelvic floor ultrasound is used as a validated technique for measuring levator ani dimensions. Vaginal manometry has been used in the past as a method to assess levator ani muscle (LAM) strength. Whether the combination of both methods can contribute to our understanding of pelvic floor pathophysiology has not yet been described. We hypothesized that as female pelvic floor muscular hiatus increases, the vaginal pressure and strength decrease. We recruited 20 asymptomatic nulliparous women ages 18-85 years. Minimal levator hiatus (MLH) area, anteroposterior/left-right (AP/LR) diameter ratio, the distance between levator plate and the pubic symphysis (LP-PS) while at rest and squeeze were measured using endovaginal ultrasound (US). Vaginal pressure at rest, squeeze (Kegel) and Valsalva were measured using 3D manometry. Logistic and linear regression analysis was performed to assess correlations. MLH area was negatively correlated with the sum of all the squeeze pressures produced on the four walls of the vagina (p = 0.049, R2 = 0.197). There was also a borderline negative correlation between MLH and the sum of rest pressures (p = 0.09, R2 = 0.15). AP/LR ratio was negatively correlated with the sum of squeeze pressures (p = 0.056, R2 = 0.197). LP-PS distances, both while at rest and during squeeze, were negatively correlated with the vaginal squeeze pressure (p = 0.046, R2 = 0.21; p = 0.011, R2 = 0.31, respectively). LP-V distance, both at rest and during squeeze, was negatively correlated with the sum of squeeze pressures on four vaginal walls (p = 0.02, R2 = 0.25; p = 0.005, R2 = 0.36, respectively). Stronger levator ani muscles, smaller MLH area and a more oval shape of pelvic floor hiatus as assessed by pelvic floor ultrasound are associated with higher squeeze vaginal pressures as assessed by 3D manometry.