Urethral length and bladder neck behavior: can dynamic magnetic resonance imaging give the same results as introital ultrasound?

PURPOSE: To compare dynamic magnetic resonance imaging (dMRI) and introital ultrasound results with regard to urethral length measurements and the evaluation of bladder neck changes. METHODS: Retrospective analyses of urethral length measurements and detection of bladder neck changes (rotated/vertical bladder neck descent, urethral funneling) were conducted in women-scheduled for surgical treatment with alloplastic material-who had undergone introital ultrasound and dMRI presurgery and 3 months postsurgery. Measurement differences between both imaging modalities were evaluated by assessing the confidence interval for the difference in means between the datasets using bootstrap analysis. RESULTS: Based on data from 40 patients (320 image series), the urethra could be clearly measured on every pre- and postsurgical dMRI dataset but not on preoperative ultrasound images in nine women during Valsalva maneuver due to a large cystocele. The estimation of the mean difference distribution based on 500,000 bootstrap resamples indicated that the urethral length was measured shorter by dMRI pre- and postsurgery at rest and postsurgery during Valsalva maneuver (median 1.6-3.1 mm) but longer by dMRI (median 0.2 mm) during Valsalva maneuver presurgery. Rotated/vertical bladder neck descent and urethral funneling diagnoses showed concordance of 67-74% in the direct comparison of patients; the estimation of the concordance indicated poorer outcomes with 50-72%. CONCLUSIONS: Metric information on urethral length from dMRI is comparable to that from introital ultrasound. dMRI is more advantageous in cases with an extended organ prolapse. At present, dMRI does not give the same diagnosis on bladder neck changes as introital ultrasound does.

[Imaging for urinary incontinence]. / Bildgebung bei Harninkontinenz.

BACKGROUND: Ultrasonography and functional cine magnetic resonance imaging (MRI) are noninvasive and x-ray free tools, which are currently widely used in clinical diagnostics and scientific research of male and female urinary incontinence. The increasing use and improving techniques of modern imaging tools are closely linked to rapid development of minimally invasive surgery in patients with urinary incontinence and insights gained in continence mechanisms. METHODS: Whereas ultrasonography is a cost-efficient and readily available diagnostic tool for a routine use, the more expensive functional MRI, as a tool with more precise visualization of functional interactions and spatial representation of anatomical structures of the pelvic floor, is suitable for complex diagnostic purposes and scientific research. Both tools are already well established for evaluations of the female pelvic floor. For evaluation of the male pelvic floor, and in particular postprostatectomy incontinence, perineal ultrasonography and functional cine MRI are becoming increasingly evident. CONCLUSION: Further development of both imaging tools will contribute to new insights into the continence mechanism and improve the techniques of radical prostatectomy and minimally invasive surgery of male and female urinary incontinence in the future.

Anatomical Position of Four Different Transobturator Mesh Implants for Female Anterior Prolapse Repair.

Purpose: Polypropylene mesh implants are frequently used for pelvic floor reconstruction in women. Yet they vary in size and fixation. The purpose of this study is to compare four mesh products with regard to their anatomical positioning and functionality within the pelvic floor, to determine whether each mesh fits equally well in a female cadaver. Methods: One female pelvis was dissected, opening the retropubic space exposing the endopelvic fascia and demonstrating the arcus tendineus fasciae pelvis (ATFP). Anatomical parameters were measured before and after implanting four meshes via the transobturator approach. Results: The anterior fixation of the ATFP was found to be 5 mm lateral to the symphysis in this cadaver. The endopelvic fascia covered 54.6 cm2. The obturator nerve was located 35 mm from the white line. The distance of the proximal and lateral points of mesh fixation from the ischial spine or ATFP varied from 0 to 25 mm. The meshes varied in size and anatomical positioning. Conclusion: These observations demonstrate the necessity of developing optimally sized meshes and appropriate introducer techniques that can provide sufficient vaginal support. Surgeons, furthermore, need profound knowledge of anatomy, the patient's pelvic floor defect and the meshes available on the market.

Pelvic organ prolapse: does the postoperative course of mesh-repair surgery differ in elderly women when compared with younger patients?

Pelvic organ prolapse (POP) is a common disease in elderly women. Among a wide range of possibilities in POP surgery, the use of partially absorbable meshes appears to be very promising. The problem concerning POP therapy in elderly patients has not yet been not sufficiently investigated. We enrolled 64 patients with POP stages 3 and 4. All patients underwent mesh-repair surgery and afterwards were stratified into two age groups. Data obtained from anamnesis, pelvic organ prolapse quantification (POP-Q) scale, dynamic MRI and prolapse quality of life (P-QoL) questionnaire were analysed and compared between both age groups. A total of 64 patients completed the study protocol. Outcome of the surgery was promising and comparable between both age groups. One recurrence of prolapse and one mesh erosion was reported. P-QoL showed a good overall satisfaction. Our data show that the surgical correction of POP with use of polypropylene mesh in elderly women appears to be a successful method with an acceptable morbidity, adverse events rate and high satisfaction of the patients.

Validation of a German version of the P-QOL Questionnaire.

OBJECTIVE: The objective of this study was to validate the German version of the prolapse quality-of-life questionnaire (P-QOL). METHODS: The P-QOL questionnaire was translated into German and administered to women recruited from two gynecological outpatient clinics and seven gynecological practices. All women were examined in supine position using the Pelvic Organ Prolapse Quantification System of the International Continence Society. The validity was assessed by comparing symptom scores and quality-of-life scores between symptomatic and asymptomatic women. RESULTS: According to the English study, 140 symptomatic and 75 asymptomatic women were included. The total scores for each P-QOL domain were significantly different between symptomatic and asymptomatic women (p < 0.001). Seven symptom regarding questions showed significant differences (p < 0.05). CONCLUSION: The German version of P-QOL is a valid, reliable, and easily comprehensible instrument to assess quality of life and symptoms in German-speaking patients with urogenital prolapse.

[Results of balloon kyphoplasty in the treatment of osteoporotic vertebral compression fractures]. / Ergebnisse der Ballonkyphoplastie in der Behandlung von osteoporotischen Wirbelkörperfrakturen.

The aim of this study was to evaluate the reduction of pain, improvement of sagittal alignment, complications and intermediate term results of balloon kyphoplasty in the treatment of osteoporotic vertebral compression fractures (VCF). The study group consisted of 87 patients with 145 VCFs which were not responsive to non-operative treatment. All data were collected prospectively. Improvement of sagittal alignment (Cobb and kyphotic angles, anterior, middle and posterior height) was determined from CT scans. Pain was evaluated by means of a visual analogue scale (VAS). Postoperative CT scans revealed a significant reduction of the mean kyphotic angle of 5.7 degrees (range 2-24 degrees ) and a significant reduction of pain from 7.8+/-2.4 to 2.0+/-1.5 in the VAS (improvement of pain in 95.5% of patients). An asymptomatic leakage of cement was observed in 28 out of 145 vertebrae (19.3%). The outcome of 35 patients with 51 VCFs was evaluated after a mean of 13 (range 12-70) months (CT and VAS) and there was a persisting reduction of pain and no loss of reduction. In this group of patients new symptomatic fractures were evident in 4 and clinically asymptomatic (only seen on CT) fractures were detected in 5 out of 35 patients, 7 fractures were adjacent to and 2 fractures were remote from the initially treated level. In two patients an asymptomatic moderate loss of reduction was detected. These intermediate term results indicate that kyphoplasty reduces pain and improves sagittal alignment in patients with VCF. However, in 26% of patients new fractures occurred, predominantly in adjacent levels but approximately 50% of these fractures were clinically asymptomatic.

[MDCT after balloon kyphoplasty: analysis of vertebral body architecture one year after treatment of osteoporotic fractures]. / MDCT nach Ballonkyphoplastie: Analyse der Wirbelkörperarchitektur 1 Jahr nach Behandlung osteoporotischer Sinterungsfrakturen.

PURPOSE: To evaluate the value of MDCT in the monitoring of vertebral body architecture after balloon kyphoplasty and observe morphological changes of the vertebral body. MATERIAL AND METHODS: During a period of 26 months, 66 osteoporotic fractures of the vertebral bodies were treated with percutanous balloon kyphoplasty. The height of the vertebral body, width of spinal space, sagittal indices, kyphosis und COBB angle, and cement leakage were evaluated by computed tomography before and after treatment and in a long-term follow up. Statistical analysis was performed by calculating quantitative constant parameters of descriptive key data. In addition, parametric and distribution-free procedures were performed for all questions. RESULTS: After kyphoplasty, the treated vertebral bodies showed a significant gain in the height of the leading edge (0.15 cm; p < 0.0001) and in the central part of the vertebral body (0.17 cm; p < 0.0001). The height of the trailing edge did not change significantly. A corresponding gain in the sagittal index was found. The index remained stable during follow-up. Treated vertebral bodies as well as untreated references showed a comparable loss of height over the period of one year. The shape of the vertebral bodies remained stable. In comparison to these findings, treated vertebral bodies showed a reduced loss of height. A significant change in kyphosis und the COBB angle was noted. In total, pallacos leakage was detected in 71 % of cases. CONCLUSION: MDCT is an accurate method for evaluating vertebral body architecture after treatment with balloon kyphoplasty. Morphological changes in the vertebral bodies, and complications such as pallacos leakage and progression of osteoprosis can be accurately documented. The significant increase in the vertebral body height after treatment is closely correlated with a gain in the sagittal index and reduced kyphosis and COBB angle.