Long-term patient satisfaction with michigan four-wall sacrospinous ligament suspension for prolapse.

OBJECTIVE: To describe patient satisfaction after Michigan four-wall sacrospinous ligament suspension for prolapse and identify factors associated with satisfaction. METHODS: Four hundred fifty-three patients were asked to rate their satisfaction with surgery and complete validated quality-of-life instruments. Postoperative support was extracted from the medical record and assessed when possible. Factors independently associated with patients who were "highly satisfied" were identified with multivariable logistic regression. RESULTS: Sixty-two percent (242/392) reported how satisfied they were 8.0±1.7 years later. Fifty-seven percent had failed prior prolapse surgery, and 56% had a preoperative prolapse 4 cm or greater beyond the hymen. Ninety percent were satisfied; 76% were "completely" or "very" satisfied and they were considered "highly satisfied" for analysis. Fourteen percent reporting being "moderately" satisfied and they were considered among those "less satisfied." Women with lower scores on the postoperative Pelvic Floor Distress Inventory-20 were more likely to be "highly satisfied." Postoperative anatomic data were available for 67% (162/242) and vaginal support was observed at or above the hymen in 86%. Women with preoperative Baden Walker grade 3 or 4 prolapse were more likely than those with grade 2 prolapse to be "highly satisfied." Women with advanced postoperative prolapse (grade 3 or 4) were less likely and those with grade 2 support were as likely to be "highly satisfied" as those with grade 0 or 1 support. CONCLUSION: The Michigan four-wall sacrospinous ligament suspension is an anatomically effective approach to vault suspension with a high rate of long-term patient satisfaction. Postoperative vaginal support at the hymen does not negatively affect patient satisfaction. LEVEL OF EVIDENCE: III.

Self-reported natural history of recurrent prolapse among women presenting to a tertiary care center.

OBJECTIVE: To describe the characteristics of recurrent pelvic organ prolapse (POP). METHODS: A convenience sample of patients presenting with recurrent POP symptoms between October 2007 and February 2010 completed questionnaires. The survey focused on timing of recurrence(s), symptoms, and demographics. RESULTS: Ninety-seven women completed questionnaires. Thirty-four (35.1%) had undergone multiple prior treatments. Overall, 23 of 76 (30.3%) women had not informed their surgeon of the recurrence. Twenty-seven of 59 (45.8%) women reported that their symptoms were the same as before treatment, whereas 23 of 59 (39.0%) reported more severe symptoms. POP was considered to be persistent if symptoms returned within 3 months, and recurrent if symptom relief exceeded 3 months. After primary surgery, 28 of 79 (35.4%) cases were considered to be persistent, whereas 51 (64.6%) cases were recurrent. Similar percentages were seen after second and third treatments. CONCLUSION: Overall, 35% of participants experienced early return of symptoms. Almost one-third of participants had not informed their surgeon of the recurrence, indicating that there may not be an accurate self-assessment of outcome in the absence of careful follow-up.

Posterior vaginal prolapse shape and position changes at maximal Valsalva seen in 3-D MRI-based models.

INTRODUCTION AND HYPOTHESIS: Two-dimensional magnetic resonance imaging (MRI) of posterior vaginal prolapse has been studied. However, the three-dimensional (3-D) mechanisms causing such prolapse remain poorly understood. This discovery project was undertaken to identify the different 3-D characteristics of models of rectocele-type posterior vaginal prolapse (PVP(R)) in women. METHODS: Ten women with (cases) and ten without (controls) PVP(R) were selected from an ongoing case-control study. Supine, multiplanar MR imaging was performed at rest and maximal Valsalva. Three-dimensional reconstructions of the posterior vaginal wall and pelvic bones were created using 3D Slicer v. 3.4.1. In each slice the posterior vaginal wall and perineal skin were outlined to the anterior margin of the external anal sphincter to include the area of the perineal body. Women with predominant enteroceles or anterior vaginal prolapse were excluded. RESULTS: The case and control groups had similar demographics. In women with PVP(R) two characteristics were consistently visible (10/10): (1) the posterior vaginal wall displayed a folding phenomenon similar to a person beginning to kneel ("kneeling" shape) and (2) a downward displacement in the upper two thirds of the vagina. Also seen in some, but not all of the scans were: (3) forward protrusion of the distal vagina (6/10), (4) perineal descent (5/10), and (5) distal widening in the lower third of the vagina (3/10). CONCLUSIONS: Increased folding (kneeling) of the vagina and an overall downward displacement are consistently present in rectocele. Forward protrusion, perineal descent, and distal widening are sometimes seen as well.

Measurement of the 3D geometry of the fascial arches in women with a unilateral levator defect and "architectural distortion".

INTRODUCTION AND HYPOTHESIS: The arcus tendineus fascia pelvis (ATFP) and arcus tendineus levator ani (ATLA) are elements of anterior vaginal support. This study describes their geometry in women with unilateral levator ani muscle defects and associated "architectural distortion." METHODS: Fourteen subjects with unilateral defects underwent MRI. 3D models of the arcus were generated. The locations of these relative to an ilial reference line were compared between the unaffected and affected sides. RESULTS: Pronounced changes occurred on the defect sides' ventral region. The furthest point of the ATLA lays up to a mean of 10 mm (p = 0.01) more inferior and 6.5 mm (p = 0.02) more medial than that on the intact side. Similarly, the ATFP lays 6 mm (p = 0.01) more inferior than on the unaffected side. CONCLUSIONS: The ventral arcus anatomy is significantly altered in the presence of levator defects and architectural distortion. Alterations of these key fixation points will change the supportive force direction along the lateral anterior vaginal wall, increasing the risk for anterior vaginal wall prolapse.

3D analysis of cystoceles using magnetic resonance imaging assessing midline, paravaginal, and apical defects.

INTRODUCTION AND HYPOTHESIS: This study assesses relative contributions of "midline defects" (widening of the vagina) and "paravaginal defects" (separation of the lateral vagina from the pelvic sidewall). METHODS: Ten women with anterior predominant prolapse and ten with normal support underwent pelvic MR imaging. 3-D models of the anterior vaginal wall (AVW) were generated to determine locations of the lateral AVW margin, vaginal width, and apical position. RESULTS: The lateral AVW margin was farther from its normal position in cases than controls throughout most of the vaginal length, most pronounced midvagina (effect sizes, 2.2-2.8). Vaginal widths differed in the midvagina with an effect size of 1.0. Strong correlations between apical and paravaginal support were evident in mid- and upper vagina (r = 0.77-0.93). CONCLUSIONS: Changes in lateral AVW location were considerably greater than changes in vaginal width in cases vs controls, both in number of sites affected and effect sizes. These "paravaginal defects" are highly correlated with apical descent.

Perineal body anatomy in living women: 3-dimensional analysis using thin-slice magnetic resonance imaging.

OBJECTIVE: The objective of the study was to describe a framework for visualizing the perineal body's complex anatomy using thin-slice magnetic resonance (MR) imaging. STUDY DESIGN: Two millimeter thick MR images were acquired in 11 women with normal pelvic support and no incontinence/prolapse symptoms. Anatomic structures were analyzed in axial, sagittal, and coronal slices. Three-dimensional (3-D) models were generated from these images. RESULTS: Three distinct perineal body regions are visible on MR imaging: (1) a superficial region at the level of the vestibular bulb, (2) a midregion at the proximal end of the superficial transverse perineal muscle, and (3) a deep region at the level of the midurethra and puborectalis muscle. Structures are best visualized on axial scans, whereas craniocaudal relationships are appreciated on sagittal scans. The 3-D model further clarifies interrelationships. CONCLUSION: Advances in MR technology allow visualization of perineal body anatomy in living women and development of 3-D models that enhance our understanding of its 3 different regions: superficial, mid, and deep.

Magnetic resonance imaging-based three-dimensional model of anterior vaginal wall position at rest and maximal strain in women with and without prolapse.

INTRODUCTION AND HYPOTHESIS: Two-dimensional magnetic resonance imaging (MRI) demonstrates apical support and vaginal length contribute to anterior wall prolapse (AWP). This paper describes a novel three-dimensional technique to examine the vagina and its relationship to pelvic sidewalls at rest and Valsalva. METHODS: Twenty women (10 with AWP and 10 with normal support) underwent pelvic magnetic resonance imaging at rest and Valsalva. Three-dimensional reconstructions of the pelvic bones and anterior vaginal wall were created to assess morphologic changes occurring in prolapse. RESULTS: In women with AWP, Valsalva caused downward translation of the vagina along its length. A transition point separated a proximal region supported by levator muscles and a distal, unsupported region no longer in contact with the perineal body. In this latter region, sagittal and frontal plane "cupping" occurs. The distal vagina rotated inferiorly along an arc centered on the inferior pubis. CONCLUSION: Downward translation, cupping, and distal rotation are three novel characteristics of AWP demonstrated by this three-dimensional technique.

Structural position of the posterior vagina and pelvic floor in women with and without posterior vaginal prolapse.

OBJECTIVE: The objective of the study was to compare pelvic structure location on magnetic resonance imaging (MRI) during maximal Valsalva among women with posterior prolapse and those with normal support. STUDY DESIGN: Subjects (n=37) had posterior vaginal wall (PVW) prolapse of +1 cm or greater. All underwent midsagittal, dynamic MRI. Structure locations (distal vagina, apex, perineal body, external anal sphincter) were determined. PVW length, levator and urogenital hiatus diameters, and prolapse diameter were measured. RESULTS: Subjects had more caudal structures (P<.001) and larger hiatus diameters (P<.005); the posterior wall was longer, whereas the straight-line distance between the apex and distal vagina was shorter. In enteroceles, the apex was more ventrally displaced compared with rectoceles (P=.003). Unlike apical descent (r=-0.3; P=.1), PVW length and point Bp were correlated with MRI prolapse size (r=0.5; P=.002; r=0.7; P<.001, respectively). CONCLUSION: At maximal Valsalva on MRI, structures are more caudal in women with posterior prolapse. The posterior vaginal wall is longer; this length strongly correlates with prolapse size.

Anterior vaginal wall prolapse: assessment and treatment.

Assessment and management of anterior vaginal wall defects presents a unique surgical challenge. It is often the most common site of initial prolapse in women and the most common site of recurrence. This chapter discusses the anatomy, evaluation, and surgical approach to the treatment of anterior vaginal wall defects. We also review outcomes of various surgical approaches and discuss why the anterior vaginal wall presents such a challenge.

Anatomy of the perineal membrane as seen in magnetic resonance images of nulliparous women.

OBJECTIVE: Recent cadaver research demonstrates the perineal membrane's ventral and dorsal portions and close relationship to the levator ani muscle. This study seeks to show these relationships in women by magnetic resonance (MR) images. STUDY DESIGN: The subjects were 20 asymptomatic nulliparous women with normal pelvic examinations. MR images were acquired in multiple planes. Anatomical relationships from cadaver studies were examined in these planes. RESULTS: In the coronal plane the ventral perineal membrane forms an interconnected complex with the compressor urethrae, vestibular bulb, and levator ani. The dorsal part connects the levator ani and vaginal side wall via a distinct band to the ischiopubic ramus. In the sagittal plane the parallel position of perineal membrane and levator ani are seen. CONCLUSION: The perineal membrane's anatomical features can be seen in women with MR. The close relationship between the perineal membrane and levator ani is evident.

Comparison of bony dimensions at the level of the pelvic floor in women with and without pelvic organ prolapse.

OBJECTIVE: We sought to compare bony pelvis dimensions at the level of pelvic support in women with and without pelvic organ prolapse (POP). STUDY DESIGN: Pelvic floor dimensions of 42 white women with POP > 1 cm beyond the hymen were compared with 42 age- and parity-matched women with normal support. Bony landmarks relevant to connective tissue and levator attachments were identified on magnetic resonance imaging. Dimensions were independently measured by 2 examiners and averaged for each subject. RESULTS: Measurements (in centimeters) for patients and control subjects were as follows: interspinous diameter, 11.2 +/- 0.8 versus 11.1 +/- 0.7, P = .19; anterior-posterior outlet diameter, 11.7 +/- 0.7 versus 11.7 +/- 0.8, P = .71; pubic symphysis to ischial spine left, 9.5 +/- 0.5 versus 9.5 +/- 0.4, P = .91; pubic symphysis to ischial spine right, 9.5 +/- 0.4 versus 9.5 +/- 0.5, P = .81; sacrococcygeal junction to ischial spine left, 7.0 +/- 0.6 versus 7.0 +/- 0.5, P = .54; and sacrococcygeal junction to ischial spine right, 7.0 +/- 0.6 versus 6.9 +/- 0.4, P = .32. CONCLUSION: Bony pelvis dimensions are similar at the level of the muscular pelvic floor in white women with and without POP.

The relationship between superior attachment points for anterior wall mesh operations and the upper vagina using a 3-dimensional magnetic resonance model in women with normal support.

OBJECTIVE: We examined structural relationships between anterior mesh kit suspension points and the upper vagina in women with normal support. STUDY DESIGN: Eleven women with normal support underwent supine, multiplanar magnetic resonance pelvic imaging at rest and maximal Valsalva. Using 3-dimensional models generated from these images, anterior wall mesh kit anchoring points were identified along the arcus tendineus fascia pelvis. We then measured the percentage of anterior vagina above and posterior to superior suspension points. RESULTS: The anterior vagina extended above superior attachment points in 100% of women at rest and in 73% during Valsalva. It extended posterior to them in 82% and 100% (rest and Valsalva, respectively). The mean percentage of anterior vaginal length above superior anchoring sites was 40 +/- 14% at rest and 29 +/- 12% during Valsalva. CONCLUSION: The upper vagina lies above and posterior to superior suspension points in the majority of women with normal support.