K. J. Schweitzer

Mid-term clinical efficacy of a volumetric magnetic resonance-guided high-intensity focused ultrasound technique for treatment of symptomatic uterine fibroids

AbstractObjectiveTo assess the mid-term efficacy of magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) using a volumetric ablation technique for treating uterine fibroids.MethodsForty-six premenopausal women with 58 symptomatic uterine fibroids were prospectively included for MR-HIFU. After treatment, CE-MRI allowed measurement of the non-perfused volume (NPV) ratio, defined as the non-enhancing part of the fibroid divided by fibroid volume. Clinical symptoms and fibroid size on T2W-MRI were quantified at 3 and 6xa0months’ follow-up. The primary endpoint was a clinically relevant improvement in the transformed Symptom Severity Score (tSSS) of the Uterine Fibroid Symptom and Quality of Life questionnaire, defined as a 10-point reduction.ResultsVolumetric ablation resulted in a mean NPV ratio of 0.40 ± 0.22, with a mean NPV of 141 ± 135xa0cm3. Mean fibroid volume was 353 ± 269xa0cm3 at baseline, which decreased to 271 ± 225xa0cm3 at 6xa0months (Pu2009<u20090.001), corresponding to a mean volume reduction of 29xa0% ± 20xa0%. Clinical follow-up showed that 54xa0% (25/46) of the patients reported a more than 10-point reduction in the tSSS. Mean tSSS improved from 50.9 ± 18.4 at baseline to 34.7 ± 20.2 after 6xa0months (Pu2009<u20090.001).ConclusionVolumetric MR-HIFU is effective for patients with symptomatic uterine fibroids. At 6xa0months, significant symptom improvement was observed in 54xa0% of patients.Key Points• Volumetric MR-guided high-intensity focused ultrasound is a novel ablation technique for leiomyomatosis.n • We prospectively evaluated the outcome of volumetric MR-HIFU ablation for symptomatic fibroids.n • This study showed that volumetric MR-HIFU results in an effective treatment.n • A randomised controlled trial would set this technique in an appropriate context.

Ultrasound imaging of the pelvic floor: changes in anatomy during and after first pregnancy

To describe changes in the absolute values of levator hiatal dimensions and in the contractility and distensibility of the levator hiatus during pelvic floor contraction and Valsalva maneuver, using three/four‐dimensional (3D/4D) transperineal ultrasound in women during and after their first pregnancy.

Reliability of pelvic floor measurements on three- and four-dimensional ultrasound during and after first pregnancy: implications for training

To evaluate the reliability of measurements of the levator hiatus and levator–urethra gap (LUG) using three/four‐dimensional (3D/4D) transperineal ultrasound in women during their first pregnancy and 6 months postpartum, and to assess the learning process for these measurements.

Postoperative pain after adjustable single-incision or transobturator sling for incontinence: a randomized controlled trial.

OBJECTIVE: To compare postoperative pain scores and assess efficacy between an adjustable single-incision sling and a standard transobturator sling for stress urinary incontinence (SUI). METHODS: This single-blinded randomized controlled trial involved 156 women with clinically proven SUI. Women were allocated to receive either an adjustable single-incision or a transobturator sling. The primary outcome was postoperative pain score on a visual analog scale. Secondary outcomes were objective and subjective cure rates at 12 months, symptom bother scores, quality of life, and complications. RESULTS: The mean pain score in the first week postoperatively was significantly lower at all time points in the adjustable single-incision sling group compared with the transobturator sling group. Maximum difference in pain score was reported on the evening of the day of surgery; median pain score was 1.0 (interquartile range 2.0) in the adjustable sling group and 3.0 (interquartile range 4.5) in the transobturator sling group (Mann Whitney U test P<.001). There was no statistical difference in analgesic use. The objective cure rates in the adjustable single-incision sling and in the transobturator sling group were 90.8% and 88.6% (P=.760), and the subjective cure rates were 77.2% and 72.9% (P=.577), respectively. No difference in the complication rate was found. CONCLUSION: An adjustable single-incision sling for the treatment of SUI is associated with lower early postoperative pain scores but shows comparable cure rates with a transobturator at 12 months of follow-up. CLINICAL TRIAL REGISTRATION: Netherlands Trial Register, http://www.trialregister.nl, NTR: 2558. LEVEL OF EVIDENCE: I

Midline fascial plication under continuous digital transrectal control : which factors determine anatomic outcome?

Introduction and hypothesisThe aim of the study was to report anatomic and functional outcome of midline fascial plication under continuous digital transrectal control and to identify predictors of anatomic failure.MethodsProspective observational cohort. Anatomic success defined as POP-Q stageu2009≤u2009I of the posterior compartment. Validated questionnaires to measure bother and impact on quality of life. Logistic regression to identify risk factors for anatomic failure.ResultsTwo hundred thirty-three patients with posterior pelvic organ prolapse (POP) stageu2009≥u2009II underwent midline fascial plication under continuous digital transrectal control. Median follow-up was 14xa0months (12–35xa0months), and anatomic success was 80.3% (95% CI 75–86). Independent predictors of failure were posterior compartment POP stageu2009≥u2009III [OR 8.7 (95% CI 2.7–28.1)] and prior colposuspension [OR 5.6 (95% CI 1.1–27.8)]. Sixty-three percent of patients bothered by obstructed defaecation experienced relief after surgery.ConclusionsAnatomic and functional outcomes were good. Risk factors for anatomic failure were initial size of posterior POP (stageu2009≥u2009III) and prior colposuspension.

Association between levator hiatal dimensions on ultrasound during first pregnancy and mode of delivery

To determine the association between levator hiatal dimensions, measured using transperineal ultrasound, in women during their first pregnancy and the subsequent mode of delivery, stratified by the indication for intervention.

Measuring echogenicity and area of the puborectalis muscle: method and reliability.

To develop a semi‐automated method to assess puborectalis muscle echogenicity on three‐dimensional/four‐dimensional (3D/4D) volume transperineal ultrasound images using 4D View and Matlab® software and evaluate its intra‐ and interobserver reliability.

Associations between subjective overactive bladder symptoms and objective parameters on bladder diary and filling cystometry

Introduction and hypothesisA study was conducted to assess associations between different overactive bladder (OAB) symptoms and their outcomes on bladder diary and filling cystometry parameters.MethodsWe performed a retrospective cohort study in database of 6,876 Urinary Distress Inventories, 3,185 bladder diaries and 2,153 filling cystometries from women referred to our urogynecological center between 2003 and 2009. Women were dichotomized into two groups. Group I: those women without symptoms, and those with symptoms that were not bothersome. Group II: women with bothersome symptoms. Data obtained from bladder diaries were: daytime urinary frequency, nocturnal frequency, minimum voided volume, maximum voided volume, average voided volume, and incontinence episodes. From filling cystometries, volumes at first desire to void, normal desire to void, strong desire to void and maximum cystometric capacity, were extracted. Univariate and multiple linear regression analysis were performed to determine associations between OAB symptoms and bladder diary and filling cystometry measurements.ResultsAfter multivariate analysis the objective daytime frequency was most strongly associated with the frequency symptom (β 0.27, pu2009<u20090.05), night time frequency with the nocturia symptom (β 0.40, pu2009<u20090.05) and the number of incontinence episodes with the urge incontinence symptom (β 0.37, pu2009<u20090.05). Both frequency and nocturia symptoms were significantly associated with bladder diary and cystometry filling volumes, and their effect size was the same. The urgency symptom proved to be poorly associated with objective parameters.ConclusionsIn contrast to the frequency and nocturia symptom, the urgency symptom is poorly associated with objective parameters on bladder diary and filling cystometry. Therefore, the current practice of using frequency and incontinence episodes in outcome research of OAB trials is justified.

Diagnosing levator avulsions after first delivery by tomographic ultrasound: reliability between observers from different centers.

Introduction and hypothesisTo evaluate the interobserver reliability of diagnosing levator avulsions between observers from different centers using tomographic ultrasound imaging (TUI) in women after their first delivery.MethodsTransperineal ultrasound volume datasets of 40 women 6xa0months after their first delivery were analyzed by five observers from four different centers. Levator avulsions were diagnosed using TUI and datasets were assessed as optimal or suboptimal image quality and optimal or suboptimal pelvic floor contraction. Cohen’s kappa was used to evaluate the interobserver reliability of diagnosing levator avulsions for the total group, the group with optimal and suboptimal image quality, and the group with optimal and suboptimal pelvic floor contraction. Consensus on the presence or absence of avulsions was scored according to the number of observers who diagnosed an avulsion (0u2009=u2009consensus on the absence of avulsion, 1–4u2009=u2009avulsion diagnosed by 1 to 4 observers, 5u2009=u2009consensus on the presence of avulsion).ResultsFor the total group, the interobserver reliability varied widely, with kappa values ranging from −0.07 to 0.72. Analyzes in the subgroups showed comparable results. Of the women who potentially have an avulsion (avulsion diagnosed by at least one observer), consensus on the presence of an avulsion was reached in 0.0 to 20.0xa0%. Of the women who potentially have no avulsion (no avulsion diagnosed by at least one observer), consensus on the absence of an avulsion was reached in 46.7 to 85.7xa0%.ConclusionsDiagnosing levator avulsions using TUI in women 6xa0months after their first delivery is strongly observer-dependent and therefore not generalizable.

Changes in the mean echogenicity and area of the puborectalis muscle during pregnancy and postpartum

Introduction and hypothesisThree-dimensional (3D) and four-dimensional (4D) volume transperineal ultrasound imaging is increasingly used to assess changes in the dimensions of the pelvic floor during pregnancy and after delivery. Little is known with regard to the area of the puborectalis muscle and its structural changes. Echogenicity measurement, a parameter that provides information on the structure of muscles, is increasingly used in orthopaedics and neuromuscular disease evaluation. This study is aimed at assessing the changes in the mean echogenicity of the puborectalis muscle (MEP) and the puborectalis muscle area (PMA) during first pregnancy and after childbirth.MethodsThe MEP and PMA of 254 women during first pregnancy were measured at 12 and 36xa0weeks’ gestation and 6xa0months postpartum. To determine the effect of child-birth on MEP and PMA, the results at 6xa0months postpartum were separately analysed for vaginal deliveries, operative vaginal deliveries (ventouse) and caesarean section deliveries. Mean differences in MEP and PMA were analysed using ANOVA statistics.ResultsThe MEP at 6xa0months postpartum was, independent of manoeuvre, significantly (pu2009<u20090.001) lower than MEP values during pregnancy. After caesarean delivery, the PMA was significantly smaller at maximum pelvic floor contraction than PMA after vaginal delivery (pu2009=u20090.003) or operative vaginal delivery (pu2009=u20090.002).ConclusionOur study indicates that structural changes in the puborectalis muscle during and after pregnancy, as measured by MEP, occur and can be analysed. In addition, the mode of delivery affects the area of the puborectalis during contraction after delivery. For true volume analysis, as part of an assessment of contractility of the puborectalis muscle we will need 3D volume analysis.