Pelvic Organ Prolapse Quantification Measurements Research Articles

70: Dynamic magnetic resonance imaging of pelvic anatomy following vaginal reconstructive surgery: A prospective study

To describe the impact of native tissue vaginal reconstruction, including vaginal vault suspension, on pelvic anatomy using dynamic magnetic resonance imaging (MRI). This IRB approved prospective cohort study investigated women undergoing intraperitoneal vaginal vault suspension for symptomatic pelvic organ prolapse (POP) with native tissue reconstruction. Enrolled participants underwent dynamic pelvic MRI preoperatively and 3 months postoperatively. Radiographic and anatomic measurements were compared. The H-line (or levator hiatus) was defined as the distance from the pubic symphysis to the posterior anal canal and the M-line (or muscular pelvic floor relaxation) was defined as the decent of the levator plate from the pubococcygeal line (PCL). The PCL represented the level of the pelvic floor and was measured from the inferior border of the pubic symphysis to the last coccygeal joint. Our primary outcome was to compare preoperative MRI measurements to those following surgical treatment. Secondary outcomes were evaluated via validated patient questionnaires pre- and post-operatively. A total of 17 participants were enrolled, 14 completed the study and were included in our analysis. The mean age was 62 years; all participants were white. The majority of participants had Stage III POP, as defined by the Pelvic Organ Prolapse Quantification (POP-Q) scale. Twelve participants (85.7%) underwent a concomitant hysterectomy and 5 participants (35.7%) received a concomitant midurethral sling procedure. There was a significant improvement in several radiographic measurements with straining and/or defecation following vaginal reconstruction, including the H-line, M-line, anorectal angle, and the extent of apical and anterior compartment prolapse. There was no difference regarding pubococcygeal line (PCL), anorectal decent, extent of enterocele, or posterior compartment prolapse. POP-Q measurements improved significantly in all compartments with the exception of perineal body and total vaginal length. Regarding validated questionnaires, PFDI-20 scores improved significantly (102 preop vs. 30 postop, p<0.001) following surgery. While PFIQ-7 scores also improved, this finding did not achieve significance (55 preop vs 24 postop, p=0.164). Native tissue reconstruction with intraperitoneal vaginal vault suspension for symptomatic pelvic organ prolapse not only improves pelvic anatomy and function as defined by POP-Q measurements and PFDI scores, but is also associated with significantly improved measurements on dynamic MRI at 3 months postoperatively.

Vaginal hysterectomy with bilateral sacrospinous fixation plus an anterior mesh versus abdominal sacrocervicopexy for the treatment of primary apical prolapse in postmenopausal women: a randomized controlled study.

We compared vaginal hysterectomy with bilateral sacrospinous fixation plus an anterior polyvinylidene fluoride mesh versus abdominal sacrocolpopexy for the treatment of primary apical prolapse in postmenopausal women. A prospective, randomized, single-blind, parallel study [Registro Brasileiro de Ensaios Clinicos (REBEC) trial register code RBR-7t6rg2] was performed from October 2015 to May 2016. A total of 71 postmenopausal women with advanced pelvic organ prolapse (POP) and undergoing surgery were randomized to the abdominal sacrocolpopexy (ASC) (n= 36) or the vaginal sacrospinous fixation with anterior mesh (VSF-AM) (n= 35) groups. Pelvic Organ Prolapse Quantification (POP-Q) system classification was performed for objective assessment, and the International Consultation on Incontinence Questionnaire-Vaginal Symptoms (ICIQ-VS), International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), and International Consultation on Incontinence Questionnaire Overactive Bladder (ICIQ-OAB) questionnaires were filled out for subjective evaluation by women before and 1year after surgery. All procedures were performed by a single surgeon. Both groups had improvement in almost POP-Q points (except for vaginal length in the VSF-AM group) and all ICIQ scores. The ASC group had a longer operative time (129 versus 117min, p= 0.0038) and duration for return to activities (103 versus 57days, p< .05). Four women (11%) in the VSF-AM group were reoperated versus none from the ASC group (p =.05). Although the study did not achieve the planned recruitment, after 12months of follow-up, ASC did not differ from VSF-AM in objective and subjective scores (ICIQ questionnaires; POP-Q measurements). Recovery time was longer after open abdominal surgery.

Outcomes of colpectomy for uterovaginal and posthysterectomy vault prolapse: A comparative study between normal and overweight women

The objective of the study is to compare success and perioperative outcomes of colpectomy for severe prolapse between normal and overweight patients. This is a retrospective cohort study of 95 non-sexually active women undergoing colpectomy for severe prolapse between July 2010 and December 2015. Vaginal hysterectomy was performed for those with uterovaginal prolapse. Prolapse stage and location were identified according to Pelvic Organ Prolapse Quantification (POP-Q) measurements. Demographic data and perioperative outcomes were recorded. Patients were categorized into normal-weight and overweight groups according to World Health Organization body mass index classification for adults. During postoperative visit, prolapse symptoms and POP-Q measurements were re-evaluated. Objective cure was defined as prolapse at or above hymen, while subjective cure determined as resolution of prolapse sensation. One-third was determined as overweight. Objective cure was 81.1%, whereas subjective cure was 95.8%. Overweight patients significantly demonstrated poorer perioperative outcomes including increased blood loss, more advanced stage prolapse, and lower success rates. In conclusion, colpectomy is an effective repair procedure for non-sexually active women with severe prolapse due to low perioperative morbidities and favorable surgical outcomes. However, special precaution is required when performing this procedure in overweight women.

Impact of levator muscle avulsions on Manchester procedure outcomes in pelvic organ prolapse surgery.

Levator ani muscle avulsions potentially increase recurrence after anterior colporrhaphies. We aimed at evaluating the impact of avulsions on anatomical and patient-reported outcomes 1year after the Manchester procedure for primary anterior compartment pelvic organ prolapse. Prospective cohort study of 189 women undergoing the Manchester procedure between October 2014 and January 2017. Avulsions were diagnosed by transperineal ultrasound. Women with and without avulsions were compared for 1-year postoperative outcomes; Pelvic Organ Prolapse Quantification measurements, subjective satisfaction (1-worse to 4-cured), failure (new prolapse treatment), response to validated questionnaires on pelvic floor distress and sexual function, and a composite outcome (subjectively cured and optimal anterior compartment outcome (stage 0-I)). Optimal mid-compartment outcome was defined as cervix≥5cm above the hymen. Factors potentially associated with poor anatomical outcomes (anterior compartment stage ≥II) or pelvic floor distress were analyzed using regression analyses. Fewer women with avulsions (present in 50.8%) obtained optimal mid-compartment outcomes (88.2% vs 77.1%; P=0.05). The groups were otherwise similar in terms of mid-compartment reduction, anterior compartment results, failure rate, subjective satisfaction, pelvic floor/sexual symptoms, and combined optimal subjective and anatomical outcome. Only preoperative anterior compartment stage ≥III was associated with poor anatomical outcome (P<0.01). A high preoperative symptom score was associated with a high postoperative symptom score (P<0.001). Although fewer women with avulsions obtained optimal mid-compartment results, avulsions had no impact on other anatomical or symptomatic outcomes 1year after the Manchester procedure for primary anterior compartment prolapse.

Definition of apical descent in women with and without previous hysterectomy: A retrospective analysis.

BackgroundWhile normal pelvic organ support has been defined for women with intact uterus, this is not the case for post- hysterectomy vault descent. A recent systematic review found that definitions of apical prolapse are highly variable.ObjectivesTo investigate the relationship between prolapse symptoms and apical POP-Q measurements and establish cutoffs for ‘significant apical descent using receiver–operator characteristics (ROC) statistics.Study designRetrospective analysis of patients seen at a tertiary urogynecological unit. Evaluation included a standardized interview and clinical assessment using the Pelvic Organ Prolapse Quantification (POP-Q) system. ROC curves were prepared for the relationship between prolapse symptoms and POP-Q measure “C”.ResultsThe records of 3010 women were available for analysis. Prolapse symptoms were reported by 52.3% (n = 1573), with a mean bother of 5.9 (SD 3.0, range 0–10). POP-Q point “C” was associated with symptoms of prolapse (p <0.0001) and prolapse bother (p <0.0001) on both univariate and multivariate analysis. ROC curves for women with and without uterus were similar, although the relationship between apical descent and symptoms of prolapse was stronger for women with uterus (AUC 0.728 versus 0.678). After controlling for multi-compartment prolapse, the models improved, resulting in AUCs of 0.782 and 0.720. For prediction of prolapse symptoms, cutoffs were set at C = -5 (sensitivity 0.73, specificity 0.67 with uterus in situ, sensitivity 0.59, specificity, 0.73 after hysterectomy).ConclusionA cut- off for ‘significant central compartment descent’ of 5 cm above the hymen on Valsalva seems valid regardless of previous hysterectomy.

Laparoscopic Uterosacral Ligament Hysteropexy vs Total Vaginal Hysterectomy with Uterosacral Ligament Suspension for Anterior and Apical Prolapse: Surgical Outcome and Patient Satisfaction

To compare anatomic and clinical cure rates as well as patient satisfaction between uterine-preserving laparoscopic uterosacral ligament suspension and total vaginal hysterectomy with uterosacral ligament suspension in women with apical and anterior prolapse. Single-center clinical comparative retrospective cohort study. A female pelvic medicine and reconstructive surgery service at a tertiary teaching hospital. Women with pelvic organ prolapse who underwent surgical treatment for their condition between July 2010 and December 2015. All women underwent laparoscopic uterosacral ligament suspension or total vaginal hysterectomy with uterosacral ligament suspension for apical and anterior prolapse. Concomitant procedures included anterior and posterior repair, as well as a midurethral sling when indicated. Preoperative and postoperative Pelvic Organ Prolapse Quantification (POP-Q) measurements were obtained. The primary outcome was clinical cure rate. Secondary outcomes included anatomic cure rate and outcomes of site-specific POP-Q points Ba, C, and Bp for the whole cohort. Patient satisfaction was measured using the Patient Global Impression of Improvement questionnaire. During the study period, 106 women underwent transvaginal hysterectomy with uterosacral ligament suspension, and 53 women had laparoscopic uterosacral ligament suspension. At a mean follow-up of 14.7 ± 13.23 months for the vaginal group and 17.5 ± 15.84 months for the laparoscopic group (p = .29), there were significant improvements of POP-Q points Ba, C, and Bp (p < .0001 for all comparisons in both groups). The clinical cure rate was 96% in the vaginal group and 98% in the laparoscopic group (p = .50). The anatomic cure rate was 85.4% in the vaginal group and 93.75% in the laparoscopic group (p = .11) Patient satisfaction was high in both groups. In appropriately selected patients, laparoscopic uterosacral ligament suspension is a valid uterus-preserving option for women with anterior and apical prolapse, associated with high anatomic and clinical cure rates and patient satisfaction.

25: Pessary use and severity of pelvic organ prolapse over time: a retrospective study

To evaluate if long-term pessary use is associated with a change in pelvic organ prolapse (POP) severity and genital hiatus (GH) size. This is a retrospective study of women using pessaries for treatment of symptomatic POP and/or incontinence from January 2014 to April 2017 at a single urogynecology practice. Baseline and most recent pelvic organ prolapse quantification (POPQ) measurements and stages were recorded. The primary outcome was change in POPQ point GH. Secondary outcomes included change in POPQ stage, type of pessary (e.g., space-filling or support), size of pessary, number of pessary changes over time (e.g., size and/or type of pessary), and duration of use. Demographic characteristics were analyzed using descriptive statistics. Student t test and Mann-Whitney tests were used to compare categorical data as appropriate. Pearson’s and Spearman’s correlation coefficients were used where appropriate for evaluation of change over time. A total of 132 patients were included in the analysis. The cohort was predominantly non-Hispanic white (75%) women using pessaries for symptomatic POP greater than stage 2 (70.5%). All patients were post-menopausal. Median duration of pessary use was 39.5 months (IQR 17-64.5 months). POPQ point GH (r = -0.215, p = 0.014) and POPQ stage (r = -0.276, p = 0.001) decreased significantly as duration of pessary use increased. Compared to patients with baseline POPQ stage <3, those with baseline POPQ stages ≥3 had a significant decrease in GH as duration of pessary use increased (-0.5 cm vs. 0 cm, p <0.001). This relationship was not seen when comparing baseline GH <3 cm to those with baseline GH ≥3 cm. Patients underwent a significant number of changes in pessary type over time (p < 0.001); however, there was no significant change in the size of pessary over time (p = 0.191). Pessary use by women with pelvic organ prolapse causes a change in vaginal anatomy over time as seen by decreasing POPQ stage and point GH. Prospective studies are needed to further characterize and confirm these findings.

A comparison of pelvic organ prolapse and sexual function after abdominal and laparoscopic hysterectomy

Hysterectomy is one of the risk factors of pelvic organ prolapse (POP). There is no consensus on whether the route of hysterectomy affects the subsequent development of POP. The aim of the study was to assess POP and sexual function 1 year after a hysterectomy when comparing total abdominal hysterectomy (TAH) with total laparoscopic hysterectomy (TLH). The study applied the pelvic organ prolapse quantification (POP-Q) as the measure of POP and a short-form of the POP/Urinary Incontinence Sexual Function Questionnaire (PISQ-12). All patients that underwent either TAH or TLH due to benign causes between March 2016 and March 2017 at the tertiary hospital used for the study were included in our prospective cohort study. POP-Q measurements and PISQ-12 scores were assessed 1 year postoperatively. We included 182 patients in the clinical examinations. There were no statistically significant differences in demographic characteristics between the TAH and TLH groups. Also, there we no differences observed in the objective POP measurements between the two study groups. Results of the two groups' PISQ-12 scores were also similar. However, postoperative vaginal lengths were found to be significantly shorter in the patients who had undergone TAH compared with those who had undergone TLH. TAH and TLH are comparable regarding short-term objective pelvic organ prolapse. Although we found statistically a significant difference in vaginal lengths between the two groups, no clinical significance was found in terms of sexual function.

Anatomical Outcome and Patient Satisfaction After Laparoscopic Uterosacral Ligament Hysteropexy for Anterior and Apical Prolapse.

The aim of this study was to determine anatomical and clinical cure, as well as patient satisfaction in uterine-preserving laparoscopic uterosacral ligament suspension (LUSLS) in women with anterior and apical prolapse. This was a retrospective cohort study including all women who underwent LUSLS for anterior and apical prolapse between January 2012 and December 2015 at a tertiary-care university hospital. All women had LUSLS hysteropexy and anterior colporrhaphy. Pre- and postoperative pelvic organ prolapse quantification (POP-Q) measurements were taken. Prolapse symptoms were queried via standardized history. Patient satisfaction was measured by the Patient Global Impression of Improvement (PGI-I). Fifty-three women underwent the procedure during the study period. Follow-up data were available for 48 women. The mean preoperative POP-Q Ba point was 2.7 ± 1.6 and C point was -0.8 ± 2.8. At a mean follow-up of 17.5 ± 16.0 months with a median of 12 months (range, 1-54 months), there was a significant improvement of POP-Q points Ba, C, and Bp (P < 0.001 for all comparisons). Anatomical cure, defined as no prolapse of any POP-Q point at or below 1 cm above the hymen (-1), was 85.4%. Clinical cure, defined as a composite outcome of no prolapse outside the hymen, C point above total vaginal length/2, no prolapse symptoms, and no need for further treatment, was 95.8%. At a mean of 22.2 ± 12.4 months postoperatively, patient satisfaction was high, with 95.5% stating their condition was very much better (PGI-I-A) or much better (PGI-I-B). Laparoscopic uterosacral ligament suspension is a valid uterine-preserving option for women with anterior and apical prolapse, with high anatomical and clinical cure rates and patient satisfaction.

Open sacrocolpopexy and vaginal apical repair: retrospective comparison of success and serious complications.

We compared treatment success and adverse events between women undergoing open abdominal sacrocolpopexy (ASC) vs vaginal repair (VAR) using data from women enrolled in one of three multicenter trials. We hypothesized that ASC would result in better outcomes than VAR. Participants underwent apical repair of stage 2-4 prolapse. Vaginal repair included uterosacral, sacrospinous, and iliococcygeal suspensions; sacrocolpopexies were via laparotomy. Success was defined as no bothersome bulge symptoms, no prolapse beyond the hymen, and no retreatment up to 24months. Adverse events were collected at multiple time points. Outcomes were analyzed using longitudinal mixed-effects models to obtain valid outcome estimates at specific visit times, accounting for data missing at random. Comparisons were controlled for center, age, body mass index (BMI), initial Pelvic Organ Prolapse Quantification (POP-Q) stage, baseline scores, prior prolapse repair, and concurrent repairs. Of women who met inclusion criteria (1022 of 1159 eligibile), 701 underwent vaginal repair. The ASC group (n = 321) was older, more likely white, had prior prolapse repairs, and stage 4 prolapse (all p < 0.05). While POP-Q measurements and symptoms improved in both groups, treatment success was higher in the ASC group [odds ratio (OR) 6.00, 95% confidence interval (CI) 3.45-10.44). The groups did not differ significantly in most questionnaire responses at 12months and overall improvement in bowel and bladder function. By 24months, fewer patients had undergone retreatment (2% ASC vs 5% VAR); serious adverse events did not differ significantly through 6weeks (13% vs 5%, OR 2.0, 95% CI 0.9-4.7), and 12months (26% vs 13%, OR 1.6, 95% CI 0.9-2.9), respectively. Open sacrocolpopexy resulted in more successful prolapse treatment at 2years.

The Association of Abdominal Striae With Pelvic Organ Prolapse.

Our objective was to estimate the prevalence of abdominal wall striae among women with and without pelvic organ prolapse (POP) in a population with pelvic floor disorders. This cross-sectional study included nonpregnant women with urinary incontinence and POP presenting to a tertiary urogynecology practice between December 2012 and August 2013. Participants completed a nonvalidated questionnaire about striae, and the degree of abdominal wall striae was quantified on physical examination. Baseline demographics, clinical characteristics, and Pelvic Organ Prolapse Quantification (POP-Q) measurements were recorded. One hundred thirty-two women were approached for participation, of which 110 (83%) completed study questionnaires. Of these 110, 59 had POP defined at POP-Q stages 2-4, whereas 51 had normal pelvic support, POP-Q stages 0-1. The mean (SD) age was 55.5 (12) years, and most (78/110) were sexually active. Women with POP were more parous than women without POP (median 2 vs 1, respectively; P = 0.03). However, there was no difference in medical comorbidities, smoking status, or steroid use between groups (P > 0.05). More women with POP reported striae (42/59 [71%] vs 23/51 [45%], P = 0.006) and had quantifiable abdominal wall striae compared with women with normal support (39/59 [66%] vs 22/51 [44%], P = 0.02). On multivariate logistic regression, women with POP were 2.5 times more likely to have striae compared with women without POP after adjusting for skin type and smoking status (odds ratio, 2.5; 95% confidence interval, 1.03-6.06; P = 0.04). Women with POP are more likely to have striae compared with women without POP.

Dynamic 3T pelvic floor magnetic resonance imaging in women progressing from the nulligravid to the primiparous state.

The objective was to prospectively characterize dynamic pelvic 3-Tesla magnetic resonance imaging (dp3T MRI) findings in nulligravida women and characterize changes 6months after delivery in the same woman. In this prospective study, nulligravida women seeking assisted reproductive technology for pregnancy were recruited. After physical examination by Pelvic Organ Prolapse Quantification (POP-Q), Brink assessment and measures including the Pelvic Floor Distress Inventory-20 and Pelvic Floor Impact Questionnaire-7, pre-pregnancy dp3T MRI at rest, with strain, and evacuation were performed. Assessments were repeated ≥6months postpartum. Analysis included Welch and paired t tests for continuous variables, Fisher's exact test for differences in categorical outcomes, and paired t tests for postpartum symptoms. Nineteen subjects (mean±SD age, 31±5years) completed baseline clinical and dp3T MRI studies, 15 delivered and 10 (30.5±3years) completed pre-pregnancy and post-delivery clinical and dp3T MRI assessments. There were no significant changes in scores of validated questionnaires (all p>0.05) or on POP-Q measures post-delivery. Two (20%) subjects without pre-pregnancy levator tears had tears on MRI post-delivery. MRI measures of pelvic organ descent were increased post-delivery. Seventeen pelvic soft-tissue parameters increased by greater than 10% post-delivery, including 5 out of 70 (7.1%), 17 out of 110 (15.5%), and 50 out of 110 (45.5%) values exceeding thresholds at rest, strain, and evacuation respectively. Dynamic pelvic 3T MRI detected levator tears and increased pelvic organ descent, which can be directly attributed to pregnancy and delivery.

Putting POP-Q to the test: does C-D=cervical length?

We investigated the correlation between calculated cervical length (CCL) and gross specimen cervical length (GCL) after total vaginal hysterectomy (TVH) at the time of surgery for pelvic organ prolapse (POP). This was a retrospective chart review of patients who had undergone TVH with reconstructive surgery for POP between 2013 and 2015. Patients without an intact specimen or documented cervical length in the pathology report were excluded. CCL was defined as the absolute difference between Pelvic Organ Prolapse Quantification (POP-Q) points C and D. GCL was obtained from the pathology report as the distance from the external to the internal os. The Bland-Altman method was used to assess the accuracy of POP-Q measurements with a priori ranges. Symptom severity was evaluated using the PFDI-20 questionnaire. Analysis of variance was used to model both GCL and CCL as a function of prolapse stage and the leading compartment. The final analysis included 202 subjects. Of the CCL measurements, 56.93% were within ±2cm of GCL, while 36.14% were within ±1cm. POP stage was significantly associated with GCL (P<0.0024). CCL was significantly longer in patients with stage 4 POP (3.57cm, 95% CI 3.13-4.00) than in those with stage 2 POP (P<0.0017; mean 2.68cm, 95% CI 2.45-2.92) and stage 3 POP (P<0.0300; mean 2.94cm, 95% CI 2.73-3.15). There were no significant correlations between PFDI scores and CCL or GCL. The agreement between POP-Q CCL (|C-D|) and GCL decreases with increasing POP-Q stage. There was no correlation between POP symptom severity and GCL or CCL. GCL significantly increased with increasing POP stage.

Self-retaining support implant: an anchorless system for the treatment of pelvic organ prolapse—2-year follow-up

The search for an improved vaginal mesh prompted the development of a new anchorless implant. The objective was to report on outcome after 2years of a technique using a self-retaining support (SRS) implant. Patients with anterior vaginal wall prolapse, with/without apical prolapse, were recruited. Participants underwent surgical repair using the SRS device. Demographic data, pre-surgical Pelvic Organ Prolapse Quantification (POP-Q) scoring, quality of life (QoL) questionnaires (Pelvic Floor Distress Inventory Short Form 20 [PFDI-20], Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire 12 [PISQ-12]), and surgical data were collected. Patients were followed at 2weeks, 2, 6, 12, and 24months after surgery. Objective anatomical success was defined using the NIH criteria. Twenty women were recruited for the study with an average age of 62.1years and an average parity of 4.0 deliveries. Average BMI was 28. Pre-operative mean POP-Q measurements were Aa =1.40 (-1 to 3) cm, Ba =2.3 (-1 to 6) cm and C=0.4 (-7 to 6) cm. Surgical time averaged 31.2min. Estimated blood loss averaged 165ml. No intra-operative complications were observed. One case (5%) of frame erosion was documented 8months after surgery. At 2years' follow-up, mean POP-Q measurements were: Aa=-2.95 (-3 to -2) cm, Ba=-2.85 (-3 to -2) cm, and C point -6.90 (-10 to -3) cm. Seventeen (85%) patients had stage 0 and 3 patients (15%) had stage 1. No mesh erosions or chronic pelvic pain were documented at follow-up. The total PFDI score at follow-up was decreased by 92.8 points (p<0.0001). At 2years' follow-up, the SRS implant was found to be safe, showing no intra-operative or immediate post-operative complications. All women presented with POP-Q measurements of the anterior and apical compartment at normal value (Ba ≤ -2cm) and statistically significant subjective improvement.

Vaginal Sacral Colpopexy: A Natural Orifice Approach to a Gold Standard Procedure

Study ObjectiveA transvaginal approach to sacral colpopexy has a natural appeal to those interested in minimally invasive pelvic reconstructive surgery. Development of an effective technique has been frustrated because of the technical difficulty of confining the dissection and placement of mesh to the retroperitoneal space. The objective of this prospective study is to describe the technique and report the outcomes of a transvaginal, retroperitoneal sacral colpopexy. DesignProspective cohort study (Canadian Task Force Design classification II-2). SettingUrogynecology of Southern Alabama private practice. PatientsWomen with stage 2 or greater apical prolapse. InterventionsSurgical repair of apical prolapse using vaginal sacral colpopexy. Measurements and ResultsOver a 1-year period, 15 posthysterectomy patients with stage 2 or greater vaginal prolapse were recruited and consented to vaginal sacral colpopexy. Primary outcome was success of the repair, with success defined as a combination of objective and subjective parameters using pelvic organ prolapse quantification measures, and quality of life questionnaires. Secondary outcomes were complications and operating time. One case converted to a native tissue repair. The vaginal sacral colpopexy was completed in the remaining 14. Eleven patients have been followed for 1 year or longer. Two patients did not return after their 6-week examination because of chronic illness. They were contacted by telephone over 2 years after the surgery and expressed total satisfaction with the operation and the outcome. One patient was seen at 3 months and was noted to have an excellent anatomic result; however, a pelvic organ prolapse quantification evaluation was not done. She has been totally lost to further follow-up. There was 1 mechanical failure in which the titanium tacks securing the apex to the anterior longitudinal ligament dislodged and a second case with a stage 2 posterior compartment defect. One incidental cystotomy, and 1 incidental proctotomy occurred. These were both small, remote from the site of the vaginal mesh, and did not prevent completion of the procedure. There were no mesh-related complications. Mean operating time was 123 minutes. ConclusionIn this small pilot study, a transvaginal retroperitoneal sacral colpopexy is described and is demonstrated to be feasible and safe. Based on the experience gained, changes in technique have been implemented to prevent future mechanical tack failures. Assuming that these changes will be successful in preventing apical recurrence due to dislodgement of mesh from the anterior longitudinal ligament, a larger study is planned to determine efficacy. Inherent advantages of the transvaginal approach are discussed, including a favorable morbidity profile, full access to all compartments, short operating times, and decreased costs.

Anterior compartment descent: A new measure in the assessment of urethral hypermobility in women with urinary incontinence.

To introduce a new, simple, non-invasive test to quantify urethral hypermobility. We reviewed data of women with urinary incontinence who were examined at the Department for General Gynaecology and Urogynaecology, Clinic for Gynaecology and Perinatology, Maribor, Slovenia, between October 2010 and March 2014. Patients' age, diagnosis, results of the Q-tip test and Pelvic Organ Prolapse Quantification measurements were collected. In addition, a new parameter was defined as anterior compartment descent, a midline distance between the external urethral meatus and maximum descent of the anterior vaginal wall when performed the Valsalva maneuver. Statistical analysis was performed with spss software using the Mann-Whitney test, correlation, regression and receiver operating characteristic curve analysis. The analysis was also carried out separately for patients with anterior compartment prolapse stage 0 or I. A total of 472 women were included, 323 of them with anterior compartment prolapse stage 0 or I. Women with urethral hypermobility had significantly higher anterior compartment descent values than patients without urethral hypermobility (3.7 cm vs 2.6 cm, P < 0.001). A moderate correlation was found between anterior compartment descent and the Q-tip test (Spearman's rho = 0.55, P < 0.001). Age and anterior compartment descent were identified as independent variables for the presence of urethral hypermobility. When the cut-off value is set at 3.5 cm, anterior compartment descent represents a test for urethral hypermobility assessment with sensitivity of 65.2%, specificity of 88.6%, positive predictive value of 97.0% and negative predictive value of 30.7%. Anterior compartment descent values were also significantly higher in patients with anterior compartment prolapse stage 0 or I (3.4 ± 0.7 cm vs 2.6 ± 0.7 cm, P < 0.001). The anterior compartment descent could be a valuable tool for the assessment of urethral hypermobility. Further effort should be directed into the standardization of the technique, determination of the normal range of anterior compartment descent, and its intra- and interobserver reliability.

Defining Cervical Elongation: A Prospective Observational Study.

Our primary aim was to define cervical elongation (CE) using the following methods: (1) measurement of pathology specimen, (2)physician perception, (3) intraoperative estimate of anterior cervical length, and (4) office Pelvic Organ Prolapse Quantification (POP-Q) points C and D. Our secondary aim was to determine whether these definitions correlate with perioperative outcomes. Women undergoing vaginal hysterectomy and prolapse repair were enrolled. Office POP-Q measurements were collected. Estimates of cervical length were made based on points C minus D of the POP-Q and by manual exam using the surgeon's index and middle fingers. Cervical dimensions were measured from the pathology specimen at the end of the case. CE was defined as one standard deviation (SD) above the mean for each definition. Additional intraoperative data was collected to determine the surgeon perception of cervical anatomy. A total of 90 patients were enrolled during the study period. Our definitions for CE were as follows: (1) 5 cm (70 without and 20 with CE), (2) physician perception (67 without and 23 with CE), (3)3.4 cm (79 without and 11 with CE), and (4) 8.3 cm (77 without and 13 with CE). After controlling for uterine weight and the presence of fibroids, the operative time was the only outcome measure that remained elevated for patients with CE using our first definition (42.4 ± 20.1 without vs. 53.8 ± 19.2 with CE, P= 0.03). CE using our first definition was associated with a statistically significant increase in operative time in women undergoing hysterectomy at the time of prolapse repair.

Is Pelvic Floor Dysfunction an Independent Threat to Sexual Function? A Cross-Sectional Study in Women With Pelvic Floor Dysfunction

IntroductionPrior studies have reported an association of sexual dysfunction with pelvic floor dysfunction (PFD), but without defining causation. AimTo investigate predictors of sexual function in women with PFD, including pelvic organ prolapse, stress urinary incontinence, overactive bladder, obstructed defecation, and fecal incontinence. MethodsThis retrospective cross-sectional study included 755 women (mean age = 56 years, 68% postmenopausal) referred for PFD (2008–2013). Subjects underwent standardized history and examination, including demographics and assessment of pelvic floor function and sexual function using validated quality-of-life instruments. The physical examination included body mass index, Pelvic Organ Prolapse Quantification measurements, and pelvic muscle strength (Oxford scale). Proportional odds regression analysis tested patient characteristics, PFD, and other determinants of sexual dysfunction as predictors of sexual function. Main Outcome MeasuresThe Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Floor Impact Questionnaire (PFIQ-7) to assess PFD and the Short Personal Experiences Questionnaire to assess sexual function. ResultsThe prevalence of PFD included pelvic organ prolapse (72%), stress urinary incontinence (66%), overactive bladder (78%), fecal incontinence (41%), and obstructed defecation (70%). Most subjects (74%) had a sexual partner and most (56%) reported recent sexual intercourse. Participants reported a low level of sexual desire and sexual enjoyment and moderate levels of sexual arousal and orgasm. When stratified by sexual enjoyment, 46% enjoyed sex and this group had lower PFDI and PFIQ scores, reflecting less quality-of-life burden. Pelvic organ prolapse, obstructed defecation, and fecal incontinence were associated with not enjoying sex. However, when adjusted for other determinants of sexual dysfunction (eg, aging, dyspareunia, atrophy, and partner issues), these associations disappeared. ConclusionWomen with PFD also have a large burden of sexual dysfunction, although this appears to be mediated by factors not unique to PFD.

Real-time measurement of the vaginal pressure profile using an optical-fiber-based instrumented speculum.

Pelvic organ prolapse (POP) occurs when changes to the pelvic organ support structures cause descent or herniation of the pelvic organs into the vagina. Clinical evaluation of POP is a series of manual measurements known as the pelvic organ prolapse quantification (POP-Q) score. However, it fails to identify the mechanism causing POP and relies on the skills of the practitioner. We report on a modified vaginal speculum incorporating a double-helix fiber-Bragg grating structure for distributed pressure measurements along the length of the vagina and include preliminary data in an ovine model of prolapse. Vaginal pressure profiles were recorded at 10 Hz as the speculum was dilated incrementally up to 20 mm. At 10-mm dilation, nulliparous sheep showed higher mean pressures ( 102 ± 46 ?? mmHg ) than parous sheep ( 39 ± 23 ?? mmHg ) ( P = 0.02 ), attributable largely to the proximal (cervical) end of the vagina. In addition to overall pressure variations, we observed a difference in the distribution of pressure that related to POP-Q measurements adapted for the ovine anatomy, showing increased tissue laxity in the upper anterior vagina for parous ewes. We demonstrate the utility of the fiber-optic instrumented speculum for rapid distributed measurement of vaginal support.

Long-term outcomes of modified laparoscopic sacrocolpopexy for advanced pelvic organ prolapse: a 3-year prospective study.

The aim of the study was to evaluate the anatomical and functional outcomes of modified laparoscopic sacrocolpopexy (MLSC) for the treatment of advanced pelvic organ prolapse (POP). From May 2009 to September 2012, a consecutive prospective observational study of 30 participants was conducted to evaluate MLSC as a treatment for symptomatic advanced POP at Peking Union Medical College Hospital. The Pelvic Organ Prolapse Quantification (POP-Q) classification was used to determine the POP stage. Validated tools were used to evaluate symptoms (Pelvic Floor Distress Inventory, PFDI-20) and sexual function (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, PISQ-12). Measurements were recorded preoperatively and then at 3 months and yearly after surgery. We compared the follow-up results with the preoperative data. All participants completed a 3-year clinical follow-up routine. The anatomical results at 3 months showed significant improvements (P < 0.05) compared with the preoperative results based on the POP-Q measurements. This improvement remained significant after 3 years (P < 0.05). The anatomical cure rate was 100% and 96.7% at 3 months and 3 years after surgery, respectively. Pelvic floor function remained significantly improved after surgery compared with preceding surgery (P < 0.05) according to the following measures: PFDI-20 (106.2 vs 36.0), Pelvic Organ Prolapse Distress Inventory-6 (POPDI-6, 47.9 vs 13.7), Colorectal-Anal Distress Inventory-8 (CRADI-8, 29.2 vs 9.2), and Urinary Distress Inventory-6 (UDI-6, 29.2 vs 13.2). The participants maintained a high level of sexual function (PISQ-12: 29.0 vs 35.1, P < 0.05). One case of mesh exposure (3.3%) and two cases of de novo dyspareunia (8.7%) were observed. MLSC seems to be a safe and effective procedure that achieves good long-term anatomical and functional results.