Research progress in pelvic floor ultrasound for assessing the morphology and function of levator ani muscle in women / 中南大学学报(医学版)

Pelvic floor ultrasound can clearly visualize the position and morphology of pelvic floor organs, observe the pelvic organ prolapse in real-time, and quantify and analyze the degree of the levator ani muscle injury, which is the most common imaging method to assess the morphology and function of the levator ani muscle to date. The different ultrasound imaging techniques provide a variety of indicators, each with its own advantages and limitations.Furthermore, two-dimensional ultrasound is the basis of imaging, but it fails to detect cross-sectional images of the pelvic floor; three-dimensional ultrasound can acquire the axial plane of the levator hiatus; tomographic ultrasound imaging allows real-time observation of the levator ani muscle injury; shear wave elastography can provide a quantitative assessment of the contractility and elastic characteristics of the levator ani muscle in real-time. It is of great significance to summarize the basic principles of various ultrasound imaging techniques, summarize the ultrasound image characteristics of levator ani muscle and its hiatus in different populations and different states, and explore the cut-off values and diagnostic criteria-related ultrasound parameters for improving the diagnostic efficiency of pelvic floor ultrasound for levator ani muscle injury, leading to reducing missed diagnosis and misdiagnosis of lesions.

Understanding pelvic floor in women

Change from quadruped to erect posture has resulted in changes in the human pelvis. This has resulted in pelvis supporting the abdominal viscera. The bony pelvis is deficient on inferior aspect. Muscles covered by fascia on superior and inferior aspect. A good knowledge of pelvic floor is very basic and mandatory for any gynecologist as pelvic floor is crucial to support the pelvic organs and is required to maintain urinary and fecal continence.

Progresses of pelvic floor ultrasound in assessing levator ani muscle injury in postpartum women / 中国医学影像技术

The levator ani muscle is the most important component of the pelvic floor support system, and levator ani muscle injury (LAMI) is a leading cause of female pelvic floor dysfunction (FPFD). Early diagnosis of changes of levator ani muscle structure and function in postpartum women is vital in preventing the occurrence of FPFD. Progresses of pelvic floor ultrasound in assessment of levator ani muscle injury in postpartum women were reviewed in this article.

Investigation for method of observing major muscle groups of levator ani in female by transvaginal two‐dimensional sonography / 中华超声影像学杂志

To evaluate and discuss feasibility and value of the transvaginal two‐dimensional sonography in distinguishing the major muscle groups of levator ani ,including puborectalis and iliococcygeus ,by observing the morphology and contraction form of these muscles . Methods Total of 145 nulliparous women were chosen . T he major muscle groups of levator ani were observed by transvaginal two‐dimensional sonography . T he images of puborectalis and iliococcygeus were obtained both at rest and contracting . T he features of the sonogram and the direction of muscle contraction were summarized . T he consistency between two sonographers was analyzed by ICC . Results T ransvaginal two‐dimensional sonography could be used to observe and distinguish the major muscle groups of levator ani . Puborectalis was showed distinctly as thick and uniform hyperechoic linear zone . Iliococcygeus was showed as triangle zone with sparse hyperechoic lines ,with one angle pointing to the caudal .During contracting ,puborectalis moved from the dorsal to the ventral while iliococcygeus contracted from the caudal to the cephalic . T he consistency between two sonographers for distinguishing the morphology and contraction form between the puborectalis( ICC＝0 .93 ,0 .89 ) and ilococcygeus ( ICC＝0 .78 ,0 .75 ) were remarkably high . Conclusions T ransvaginal two‐dimensional sonography could be used to observe dynamically and distinguish the morphology and contraction form of the levator ani muscles ,including puborectalis and iliococcygeus . It is a convenient and reproducible method to help study mechanism of levator ani injury and provide fine radiological evidence of making individual treatment .

Transperineal three-dimensional ultrasound in evaluation on impact of different delivery modes on levator ani muscle elasticity in early postpartum women / 中国医学影像技术

Objective To evaluate the impact of different delivery ways on levator ani muscle elasticity in early postpartum women with transperineal three-dimensional ultrasound.Methods Totally 60 postpartum women (30 in spontaneous transvaginal delivery group and 30 in selective cesarean delivery group) and 30 non-fertile women (control group) were enrolled.All subjects underwent transperineal three-dimensional ultrasound.The images were acquired at rest,Valsalva and maximal levator ani muscle contraction,respectively,and then the area (A),circumference (C) of levator hiatus and the length (L) of levator ani muscle were measured.The difference values of A,C,L (△A,△C,△L)were calculated between contraction and rest,and the strain rate (ε) was calculated at contraction.The difference of A,C,L (△A',△C',△L') were calculated between Valsalva and rest,and strain rate (ε') was calculated at Valsalva.Results The △A,△C,△L,ε in spontaneous transviginal delivery group and selective cesarean delivery group were smaller than those in control group (all P＜0.05),and △A',△C',△L',ε'in spontaneous transviginal delivery group and selective cesarean delivery group were larger than those in control group (all P＜0.05),while there was no statistical difference between spontaneous transviginal delivery group and selective cesarean delivery group of △A,△C,△L,ε,△A',△C',△L'nor ε'(all P＞0.05).Conclusion The levator ani muscle elasticity decreases in the early postpartum women,and selective cesarean delivery has limited role in protection of levator ani muscle.

Analysis of the Effects of Different Delivery Methods on the Levator Ani Muscle of the Pelvic Floor by Transperineal Three - dimensional Ultrasound and TUI Imaging / 现代医院

Objective To investigate the effect of different delivery methods on the levator ani muscle of the pelvic floor by transperineal three-dimensional ultrasound and TUI imaging. Methods 200 cases of pregnant women from August2014 to August 2016 in our hospital were divided into selective cesarean section group (n = 85) and vaginal delivery group (n= 115). The vaginal group, according to the intraoperative lateral segmentation, was further divided into vaginal lateral incision group (n = 65) and vaginal delivery without lateral incision group (n = 50). At the same time, select 80 cases of nulliparous women (volunteers) as control group, relevant indicators by three-dimensional imaging and TUI imaging technique. Results The vaginal delivery without lateral incision group, lateral incision group vaginal delivery and cesarean section group levator hiatus diameter, anteroposterior diameter, perimeter and area were significantly higher than the control group(P＜0.05), and vaginal delivery side cut was significantly higher than the other three groups (P＜0.05), vaginal delivery in two sub-group and cesarean section group of levator ani muscle thickness were significantly lower than the control group(P＜0.05), vaginal delivery in two sub groups were significantly lower than that in the cesarean section group (P＜0. 05); vaginal delivery group of levator ani muscle injury rate was significantly higher than that in the cesarean section group (P＜0. 05); There was no significant difference in the rate of levator ani muscle injury in vaginal delivery group (P＞0.05). Conclusion Compared with cesarean section, vaginal delivery is more obvious in changing the morphology and integrity of levator ani muscle, and vaginal delivery is more obvious than that of vaginal incision.

Association between Magnetic Resonance Imaging Findings of the Pelvic Floor and de novo Stress Urinary Incontinence after Vaginal Delivery

OBJECTIVE: The study aimed to evaluate the contributions of levator ani muscle (LAM) injury, vesical neck movement, urethral length and mobility, and urethral sphincter dysfunction observed on magnetic resonance imaging (MRI) towards stress urinary incontinence (SUI) after vaginal delivery. MATERIALS AND METHODS: Fifty primiparous women after 6 months of delivery (15 with SUI and 35 without) and 35 nulliparous as continent controls underwent MRI at rest and Valsalva maneuver. A published levator ani scoring system was used to characterize morphological changes of LAM. The severity of the injury was divided into three categories as none, minor, and major. A series of common parameters including levator plate angle, iliococcygeal angle, and levator hiatus were used to describe the functional conditions of LAM. Urethral mobility was defined based on the rotation of the urethra between Valsalva and rest status. Vesical neck movement was evaluated by its distance to the pubococcygeal line. Urethral sphincter dysfunction was defined as the widening of the proximal urethra and/or funneling at the urethrovesical junction during Valsalva. RESULTS: Primiparous incontinent (PI) women had additional major levator ani defects (33.3% vs. 17.1%) while less minor defects (0.7% vs. 31.4%) than primiparous continent (PC) women. Vesical neck downward movement in PI women was more obvious than PC women (28.5 mm vs. 24.2 mm, p = 0.006). Urethral mobility was more active in primiparous women than in nulliparous continent controls (57.4 vs. 52.4), whereas no difference was observed on urethral mobility in the primiparous group (p = 0.25). Urethral sphincter dysfunction and funneling were present in 80% of PI women versus 22.9% in PC women (p < 0.001). CONCLUSION: The MRI findings revealed that de novo SUI was associated with major LAM injury, vesical neck downward movement as well as urethral sphincter dysfunction. Vesical neck funneling on sagittal images can be treated as a valuable predictor for SUI. The intervention for the PI should focus on the elevation of vesical neck, rehabilitation of LAM as well as recovery of the urethral sphincter muscle.

Determining "abnormal" levator hiatus distensibility using three-dimensional transperineal ultrasound in Chinese women / 医学前沿

The dimension of the levator hiatus is a possible predictor of pelvic organ prolapse (POP). This retrospective study investigated 360 women who went to urogynecological clinic for pelvic floor discomfort. Levator hiatus dimensions were obtained by three-dimensional transperineal ultrasound and results were compared between women with and without significantly objective prolapse (International Continence Society POP quantification, grade 2 or higher). Receiver operating characteristic (ROC) curve analyses were performed to determine valid screening index for detecting abnormal levator hiatus distensibility. Women with significantly objective prolapse had significantly higher levator hiatus dimensions than those without (all P < 0.001). ROC curve analyses confirmed that hiatal area (HA) of 19.5 cm during Valsalva maneuver can be used as single-screening index for abnormal levator hiatus distensibility with sensitivity of 0.80 and specificity of 0.70. In this study, we used a two-step method and achieved higher sensibility (0.80 vs. 0.87) without reducing specificity (0.70 vs. 0.71) compared with a single-screening index method. As a result, we suggest that HA ⩾ 19.5 cm during Valsalva maneuver is an indicator of abnormal levator hiatus distensibility in Chinese women and that the two-step method has higher sensitivity in detecting abnormal distensibility.

Feasibility study of MR T2-mapping for evaluating birth-related levator ani muscle injury / 实用放射学杂志

Objective To investigate MR T2-mapping in evaluating birth-related levator ani muscle injury.Methods 25 primiparas at 6 weeks after first vaginal delivery as primiparous group and 12 nulliparous volunteers as control group were prospectively studied. All the subjects underwent pelvic MRI including T2-mapping,mDIXON-T2 WI sequences.Levator ani muscle were divided into two subgroups:levator ani muscle injury group and non-injury group according to if there were edema,avulsion,or rupture in each levator ani muscle subdivisions[puborectal muscle(PRM);iliococcygeal muscle(ICM)],which were showed on mDIXON-T2 WI images.Two radiologists evaluated T2 values of PRM,ICM and observed artificial color images respectively.The consistency between two observers for T2 values of PRM,ICM were evaluated using the intraclass correlation coefficient (ICC ),the difference of T2 values in each levator ani muscle subdivisions among control group,non-injury group and muscle injury group were analyzed using ANOVA .Results There were 26 PRM injury cases and 24 non-injury cases in primiparous group on mDIXON-T2 WI images,and no ICM injured cases in our study.Inter-rater reliability for T2 values between two observers were good(ICC >0.75).T2 values in PRM injury group,non-injury group and control group were(62.78±1.23)ms,(49.75±3.17)ms,(49.96±4.37)ms respectively and the difference was significant. There were significant difference between PRM injury group and non-injury group,control group respectively(P =0.000,P =0.000). The T2 values of ICM in PRM injury group,non-injury group and control group were(70.80±6.50)ms,(62.41±7.32)ms,(62.78±6.91)ms and there were significant difference(P =0.000),meanwhile the difference between PRM injury group and non-injury group,control group were significant respectively(P =0.000,P =0.000).The color gradation of PRM in PRM injury group were mixed with blue, green,and yellow,and tone were lightened on T2-mapping artificial color images;ICM color gradation were uneven with green and yellow, a d tone were higher than those of control group and non-injurygroup.Conclusion T2-mapping can quantitatively assess birth-related levator ani muscle injury and T2-mapping artificial color images show the range and degree of levator ani muscle injury visually.It is hopeful to find micro lesions that T2 WI images are difficult to find.

Feasibility study of MR T2-mapping for evaluating birth-related levator ani muscle injury / 实用放射学杂志

Objective To investigate MR T2-mapping in evaluating birth-related levator ani muscle injury.Methods 25 primiparas at 6 weeks after first vaginal delivery as primiparous group and 12 nulliparous volunteers as control group were prospectively studied. All the subjects underwent pelvic MRI including T2-mapping,mDIXON-T2 WI sequences.Levator ani muscle were divided into two subgroups:levator ani muscle injury group and non-injury group according to if there were edema,avulsion,or rupture in each levator ani muscle subdivisions[puborectal muscle(PRM);iliococcygeal muscle(ICM)],which were showed on mDIXON-T2 WI images.Two radiologists evaluated T2 values of PRM,ICM and observed artificial color images respectively.The consistency between two observers for T2 values of PRM,ICM were evaluated using the intraclass correlation coefficient (ICC ),the difference of T2 values in each levator ani muscle subdivisions among control group,non-injury group and muscle injury group were analyzed using ANOVA .Results There were 26 PRM injury cases and 24 non-injury cases in primiparous group on mDIXON-T2 WI images,and no ICM injured cases in our study.Inter-rater reliability for T2 values between two observers were good(ICC >0.75).T2 values in PRM injury group,non-injury group and control group were(62.78±1.23)ms,(49.75±3.17)ms,(49.96±4.37)ms respectively and the difference was significant. There were significant difference between PRM injury group and non-injury group,control group respectively(P =0.000,P =0.000). The T2 values of ICM in PRM injury group,non-injury group and control group were(70.80±6.50)ms,(62.41±7.32)ms,(62.78±6.91)ms and there were significant difference(P =0.000),meanwhile the difference between PRM injury group and non-injury group,control group were significant respectively(P =0.000,P =0.000).The color gradation of PRM in PRM injury group were mixed with blue, green,and yellow,and tone were lightened on T2-mapping artificial color images;ICM color gradation were uneven with green and yellow, a d tone were higher than those of control group and non-injurygroup.Conclusion T2-mapping can quantitatively assess birth-related levator ani muscle injury and T2-mapping artificial color images show the range and degree of levator ani muscle injury visually.It is hopeful to find micro lesions that T2 WI images are difficult to find.

Progresses of ultrasound in evaluation of pelvic organ prolapse / 中国介入影像与治疗学

Ultrasonography can clearly show pelvic anatomic structures,as well as the location and length of mesh after pelvic floor reconstructive operation.The consistency of ultrasonic diagnosis of severe pelvic organ prolapse with pelvic organ prolapse quantitation is good.Furthermore,ultrasonography can provide imaging basis for evaluating the safety and efficacy of pelvic floor reconstruction.The progresses of ultrasound in diagnosis of severe pelvic organ prolapse and postoperative evaluation of pelvic floor reconstruction were reviewed in this article.

Novel anal sphincter saving procedure with partial excision of levator-ani muscle in rectal cancer invading ipsilateral pelvic floor

PURPOSE: Tumors at the level of the anorectal junction had required total levator-ani muscle excision to achieve an adequate resection margin. However, in the cases of tumor invading ipsilateral levator-ani muscle and intact external sphincter, en bloc resection of rectum with levator-ani muscle including tumor would be possible. This hemilevator excision (HLE) technique enables preserving the anal sphincter function while obtaining oncologic clearance and avoiding permanent colostomy in those patients. This study aimed to evaluate the surgical outcomes and feasibility of HLE. METHODS: Data on 13 consecutive patients who underwent HLE for pathologically proven low rectal cancer were retrospectively collected. All 13 patients presented low rectal cancer at the anorectal ring level that was suspected to invade or abut to the ipsilateral side of the levator-ani muscle. RESULTS: A secure resection margin was achieved in all cases, and anastomotic leakage occurred in 2 patients. During follow-up, 3 patients experienced tumor recurrence (2 systemic and 1 local). Among 6 patients who underwent diverting ileostomy closure after the index operation, 2 complained of fecal incontinence. The other 4 patients without fecal incontinence showed <10 times of bowel movement per day. Accessing their incontinence scale, mean Wexner score was 9.4. CONCLUSION: HLE is a novel sphincter-preserving technique that can be a treatment option for low rectal cancer invading ipsilateral levator-ani muscle, which has been an indication for abdominoperineal resection (APR) or extralevator APR. However, the long-term oncologic and functional outcomes of this procedure still need to be assessed to confirm its validity.

Observation on the Efficacy of Point Injection at Xialiao Point (BL 34) for Levator Ani Syndrome / 上海针灸杂志

Objective To observe the clinical efficacy of point injection at Xialiao point (BL 34) for levator ani syndrome. Methods A hundred levator ani syndrome patients were randomly allocated to a treatment group and a control group, 50 cases each. The treatment group received point injection at Xialiao point (BL 34) and the control group was intervened by biofeedback therapy. The Visual Analogue Scale (VAS), component scores of the MOS 36-item Short-From Health Survey (SF-36), anal resting and squeeze pressures were recorded in the two groups before and after the treatment. The therapeutic effects and therapy costs were compared between the two groups.Results The VAS, component scores of SF-36, anal resting and squeeze pressures were significantly changed after intervention in the two groups (P<0.05). After treatment, the VAS, a part of the SF-36 score [physiological function (PF), body pain (BP), vitality (VT) and social function (SF) scores], anal resting and squeeze pressures in the treatment group were significantly different from that in the control group (P<0.05). The total efficacy rate was 88.0% in the treatment group versus 80.0% in the control group, and the difference was statistically significant (P<0.05). The therapy costs in the treatment group were (327.31±13.42) RMB and (408.45±21.56) RMB in the control group, and the difference was statistically significant (P<0.01).Conclusions Point injection at Xialiao point (BL 34) is an effective method for levator ani syndrome.

Static and dynamic MRI evaluation before and after operation of pelvic organ prolapse / 实用放射学杂志

Objective To explore the value of static and dynamic MRI before and after operation of pelvic organ prolapse (POP). Methods 29 patients with POP (POP group)and 12 normal women (control group)underwent static and dynamic MRI.The morphologic changes of pelvic floor were observed on MR images.The measurements of bladder,uterus,Douglas pouch to pubococcygeal line (B-PCL,U-PCL,D-PCL),the puborectal hiatus line (H-line),muscular pelvic floor descent (M-line),the levator hiatus size (LHS),the levator plate angle (LPA),the iliococcygeus angle (ICA)and the urethral inclination angle (UA)were recorded on dynamic MR images.Results 19 cystoceles,28 uterine prolapses,4 rectoceles and 14 hernias of Douglas pouch were detected with MRI.29 cases of pelvic floor relaxation,27 cases of levator ani muscle defect and 24 cases of pubocervical fascial defect were found.The values of B-PCL,U-PCL, D-PCL,H-line,M-line,LHS,LPA,ICA and UA of POP group were larger than control group (P<0.01).The positions of pelvic organ returned to normal in 9 cases of 21 postoperative cases,while 12 cases remained prolapses.There was no displacement of mesh in 8 cases of mesh implant.The values of B-PCL,U-PCL,D-PCL,UA after operation were smaller than those before operation (P<0.05).Conclusion Static and dynamic MRI can evaluate morphological and functional changes of pelvic floor before and after operation of POP comprehensively,and may reveal those invisible pelvic floor dysfunction and postoperative remnant defects.

Observation of levator ani muscle contractility in postpartum women by ultrasound / 中华超声影像学杂志

Objective To evaluate the changes of levator ani muscle contractility in different postpartum periods by observing the contractility of postpartum women's levator ani muscle.Methods Forty-six postpartum women and 43 nulliparous women were included in the object.All of those went through translabial pelvic floor ultrasound examinations.Images of their levator hiatus would be recorded at the conditions of rest and contraction.The hiatal length (L)and the area (A)of levator hiatus were measured,then the differences were obtained between rest and contraction conditions,recording as ΔL andΔA.Relevant data were analyzed.Results There was no obvious statistical difference of L and A between the groups (P >0.05).The ΔL and ΔA of the 6-8 weeks were the minimum in this objective(P 0.05).Conclusions After delivery,the contractility of levator ani muscle became weaker,but could recovery effectively after about half a year.

Vaginal tightening surgery by strengthening the pelvic floor support / 中华医学美学美容杂志

Objective To explore the related pelvic floor anatomy to the pathological vaginal relaxation and key points of the vaginal tightening surgery.Methods The vaginal tightening surgery was performed in 24 cases of vaginal relaxation.The key points of this operation included levator ani muscle suturation and perineal body reconstruction,and anal sphincter reconstruction as in case of the muscle injury grade Ⅲ.Results The degree of levator ani muscle separation was positively correlated with that of vaginal relaxation in all the 24 cases.18 cases were followed up from 6 months to 2 years,and had no complications of rectovaginal fistula and infections.The average level of perineal body was increased from 2.3 cm to 3.5 cm.Vaginal length of 6 cm from vaginal orifice was proper with good tightness.The patients felt strong anal contraction,enhanced ability of vaginal tightening and improved quality of sex life.There were no more infections of genitourinary tract.Conclusions Through levator ani muscle suturation and perineal body reconstruction,it can get the vaginal tightening effect.

Dynamic MRI for assessment of the anatomical and functional significance of the bladder and urethra in female stress urinary incontinence / 局解手术学杂志

Astract:Objective To assess the anatomical and functional significance of the bladder and urethra in female SUI by dynamic MRI and urodynamic. Methods The clinical data were retrospectively analysed on 60 cases of female stress urinary incontinence from Feb 2011 to Nov 2013. All the women received pelvic floor dynamic MRI and Urodynamic study. Measured the urethral angle,the distance of the H line, M line and the descent of the bladder,cervical,anorectal junction from the PCL in the mid-sagittal dynamic MR image of the pelvic. Pearson 's correlation coefficient was used to examine the association among the distance of the H line,M line and the urethral angle,the descent of the bladder,cervical,anorectal junction from the PCL and the Urodynamic data. Results The distance of the H line,M line were significantly and positively associated with urethral angle and the descent of the bladder,cervical,anorectal junction from the PCL. The distance of the H line,M line were significantly and negatively associated with functional profile length, maximum urethral closure pressure,VLPP and detrusor opening pressure. Conclusion Pelvic floor dynamic MRI combined with Urodynamic study is useful for assessing the anatomical and func-tional significance of the bladder and urethra in female SUI.

The assessment of levator ani muscle contractility in postpartum women by three-dimensional ultrasound / 中华超声影像学杂志

Objective To assess the contractility of levator ani muscle in postpartum female using pelvic floor three-dimensional ultrasound and to provide an effective imaging basis for the change of levator ani muscle contractility in postpartum female.Methods Totally 75 postpartum women (55 underwent spontaneous vaginal delivery and 20 underwent selective cesarean delivery) and 40 nulliparas were examined by pelvic floor three-dimensional ultrasound.The images were obtained at rest and at maximal levator ani muscle contraction.The sagittal hiatal length (L) on the two-dimensional sagittal images,the area of levator hiatus (A) and the circumference of levator hiatus (C) were measured on the three-dimensional images,and the difference value between rest and contraction were calculated to get the △L,△A,△C.Then the △L,△A,△C between different groups were compared.Results The △L,△A,△C in spontaneous vaginal delivery group and selective cesarean delivery group were smaller than those in nulliparas group (P ＜0.05),and there was no statistical difference between spontaneous vaginal delivery and selective cesarean delivery group (P ＞ 0.05).Conclusions Three-dimensional ultrasound can effectively assess the the contractility of levator ani muscle,the levator ani muscle contractility of postpartum female was poorer than nulliparas,and between spontaneous vaginal delivery and selective cesarean delivery women there is no obvious difference.

Effects of levator ani muscle exposure in abdominal perineal resection for rectal cancer / 中华消化外科杂志

Objective To investigate the effects of levator ani muscle exposure in abdominal periueal resection for rectal cancer.Methods The clinical data of 109 patients with rectal cancer who were admitted to the First Affiliated Hospital of Nanjing Medical University from January 2001 to January 2008 were retrospectively analyzed.There were 55 patients received traditional procedure (conventional method group) and 54 patients received modified procedure with levator ani muscle exposure (levator ani muscle exposure group).The mesorectum was sharply dissected according to the total mesorectal excision principle.It is essential to remove the rectum along with the mesorectum up to the level of the levators.Preoperative bowel preparation,anesthesia,body position,abdominal incision,perineal incision and suture of the 2 groups were the same as Miles procedure.In the conventional method group,the superficial dissection was carried out with electrocautery or ultracision harmonic scalpel.The presacral space was entered by dividing the rectococcygeus muscle,commencing at the level of the tip of the coccygeus.The levators were then divided near the pelvic wall attachments and next procedures were performed without levator ani muscle exposure.In levator ani muscle exposure group,once the ischiorectal fat was cleared by electrocautery,the planes of levator ani muscle were identified and exposed after dividing the rectococcygeus muscle and next procedures were performed.The patients in stage Ⅰ only needed to follow-up; the patients in stage Ⅱ had to receive chemotherapy with following situation:poor differentiation,T4 stage,blood vessel or lymphatic invasion,number of lymph nodcs detected ＜ 12.Patients in stage Ⅲ or Ⅳ needed adjuvant chemotherapy.The follow-up evaluation included blood routine examination,hepatic and renal function examination,chest radiography,hepatobiliary ultrasonographic evaluation and determination of CEA levels (once every 3 months in the first year after operation,and once every 6 months after one year).Abdominal CT scan and colonoscopy should be employed every year.All the patients were followed up till December of 2012.All data were analyzed using the chi-square test or t test.The survival curve was drawn using the Kaplan-Meier method,and the prognosis was analyzed using the Log-rank test.Results The operation time were (60 ± 15)minutes and (30 ± 10) minutes in the conventional method group and the levator ani muscle exposure group,with significant difference between the 2 groups (t =3.936,P ＜ 0.05).The intraoperative blood loss were (300 ± 60) mL and (30±20) mL in the conventional method group and the levator ani muscle exposure group,with significant difference between the 2 groups (t =5.687,P ＜ 0.05).Three patients were with rectal injury,1 with urethral injury,1 with vaginal injury,and 10 with incision infection in the conventional method group.There were 9 patients with incision infection in the levator ani muscle exposure group.The course of chemotherapy was under 12 in 30 patients,and above 6 in 41 patients.The median time of follow-up of the patients was 56 months (range,15-95 months).Of the 109 patients,10 missed the follow-up,15 patients had local recurrence,30 had distal metastasis,and 35 patients died.The 1-,3-,5-year cumulative survival rates were 93.4％,76.0％ and 65.6％.The 5-year survival rates were 65.2％ and 66.3％ for patients in the conventional method group and the levator ani muscle exposure group,with no significant difference between the 2 groups (x2=4.210,P ＞0.05).Conclusion Levator ani muscle exposure method provides clearer vision of operational field,shorter operation time,less blood loss and less injury to the rectum or urinary tract (vagina).

A preliminary application of levator-urethra gap in evaluating levtor avulsion in postpartum women / 中华超声影像学杂志

Objective To study the change of levator urethra gap(LUG) in postpartum female using pelvic floor three-dimensional ultrasonography.Methods Totally 80 postpartum women and 30 nulliparas were examined by three-dimensional pelvic floor ultrasonography.The images were obtained at maximal pelvic floor muscle contraction,and then the morphology of puborectalis muscle on tomographic ultrasound imaging were observed and the right LUG and left LUG were measured.Results The puborectalis was intact in all nulliparas and 69 postpartum women.The puborectalis avulsion was find in 11 postpartum women.The LUG of postpartum group was greater than that of nullipara group (P ＜0.05).In postpartum group,the LUG of puborectalis avulsion was greater than that of intact puborectalis(P ＜0.05).There was no difference between the right LUG and left LUG in nullipara group and in the postpartum women with intact puborectalis (P ＞ 0.05).ConcIusions LUG is a good imaging parameter to evaluate the levator avulsion in postpartum women.