Kim Notten

Avulsion of puborectalis muscle and other risk factors for cystocele recurrence: a 2-year follow-up study

Introduction and hypothesisThis study aimed to determine the relationship of recurrent cystocele with avulsion of puborectalis muscle and other risk factors.MethodsIn this prospective observational cohort study, 245 women undergoing anterior colporrhaphy were invited for a 2-year follow-up visit consisting of a questionnaire, physical examination, and translabial 3D ultrasonography. Women with and without recurrent cystocele were compared to identify recurrence risk factors.ResultsOf the 245 women, 156 agreed to the follow-up visit (63.7%). Objective recurrence rate was 80 of 156 (51.3%). Seventeen of the 156 (10.9%) reported subjective recurrence. Risk factors for anatomical recurrence were complete avulsion of puborectalis muscle (OR, 2.4; 95% CI, 1.3, 4.7), advanced preoperative stage (OR, 2.0; 95% CI, 1.0, 4.1), family history of prolapse (OR, 2.4; 95% CI, 1.2, 4.9), and sacrospinous fixation (OR, 6.5; 95% CI, 2.0, 21.2).ConclusionsRisk factors for anatomical cystocele recurrence after anterior colporrhaphy were complete avulsion of puborectalis muscle, advanced preoperative stage, family history of prolapse, and sacrospinous fixation.

Protocol for translabial 3D-ultrasonography for diagnosing levator defects (TRUDIL): a multicentre cohort study for estimating the diagnostic accuracy of translabial 3D-ultrasonography of the pelvic floor as compared to MR imaging.

BackgroundPelvic organ prolapse (POP) is a condition affecting more than half of the women above age 40. The estimated lifetime risk of needing surgical management for POP is 11%.In patients undergoing POP surgery of the anterior vaginal wall, the re-operation rate is 30%. The recurrence risk is especially high in women with a levator ani defect. Such defect is present if there is a partially or completely detachment of the levator ani from the inferior ramus of the symphysis. Detecting levator ani defects is relevant for counseling, and probably also for treatment. Levator ani defects can be imaged with MRI and also with Translabial 3D ultrasonography of the pelvic floor.The primary aim of this study is to assess the diagnostic accuracy of translabial 3D ultrasonography for diagnosing levator defects in women with POP with Magnetic Resonance Imaging as the reference standard. Secondary goals of this study include quantification of the inter-observer agreement about levator ani defects and determining the association between levator defects and recurrent POP after anterior repair. In addition, the cost-effectiveness of adding translabial ultrasonography to the diagnostic work-up in patients with POP will be estimated in a decision analytic model.Methods/DesignA multicentre cohort study will be performed in nine Dutch hospitals. 140 consecutive women with a POPQ stage 2 or more anterior vaginal wall prolapse, who are indicated for anterior colporapphy will be included. Patients undergoing additional prolapse procedures will also be included.Prior to surgery, patients will undergo MR imaging and translabial 3D ultrasound examination of the pelvic floor. Patients will be asked to complete validated disease specific quality of life questionnaires before surgery and at six and twelve months after surgery. Pelvic examination will be performed at the same time points.Assuming a sensitivity and specificity of 90% of 3D ultrasound for diagnosing levator defects in a population of 120 women with POP, with a prior probability of levator ani defects of 40%, we will be able to estimate predictive values with good accuracy (i.e. confidence limits of at most 10% below or above the point estimates of positive and negative predictive values).Anticipating 3% unclassifiable diagnostic images because of technical reasons, and a further safety margin of 10% we plan to recruit 140 patients.Trial registrationNederlands trial register NTR2220.

Translabial Three-Dimensional Ultrasonography Compared With Magnetic Resonance Imaging in Detecting Levator Ani Defects

OBJECTIVE: To assess the diagnostic performance of translabial three-dimensional ultrasonography in detecting major levator ani defects in women with pelvic organ prolapse compared with magnetic resonance imaging (MRI) and to assess the interobserver agreement in detecting levator ani defects with translabial three-dimensional ultrasonography. METHODS: In a multicenter cohort study, 140 women indicated for primary surgery of pelvic organ prolapse quantification stage II or more cystocele were included. Patients undergoing mesh surgery or concomitant stress incontinence surgery were excluded. All consenting patients underwent translabial three-dimensional ultrasonography and MRI of the pelvic floor before surgery. Two observers (out of a pool of four observers) assessed translabial three-dimensional ultrasound images; two other observers (out a pool of five observers) assessed MRIs for levator ani muscle damage. In case of disagreement, the images were discussed in a consensus meeting. RESULTS: Of the 135 scans, 45 major levator ani defects were detected on ultrasonogram (33.3%) and 32 were confirmed at MRI (23.7%). Of the 41 major levator ani defects detected on MRI, nine were missed at translabial three-dimensional ultrasonogram. Sensitivity was 0.78 (32 of 41) (95% confidence interval [CI] 0.65–0.91) and specificity was 0.86 (81 of 94) (95% CI 0.79–0.93) in detecting major levator ani defects with translabial three-dimensional ultrasonography compared with MRI. There was good agreement scoring levator ani defects on translabial three-dimensional ultrasonography, with a &kgr; of 0.67 (95% CI 0.58–0.76); agreement in recognizing major levator ani defects was moderate, with a &kgr; of 0.53 (95% CI 0.37–0.69). CONCLUSION: Translabial three-dimensional ultrasonography shows reasonable agreement with MRI in detecting major levator defects. Because of the moderate interobserver agreement, it will be difficult to implement ultrasonography in daily practice. CLINICAL TRIAL REGISTRATION: Netherlands Trial Register, www.trialregister.nl, NTR2220. LEVEL OF EVIDENCE:

Anatomical Cystocele Recurrence: Development and Internal Validation of a Prediction Model.

OBJECTIVE: To develop a prediction model that estimates the risk of anatomical cystocele recurrence after surgery. METHODS: The databases of two multicenter prospective cohort studies were combined, and we performed a retrospective secondary analysis of these data. Women undergoing an anterior colporrhaphy without mesh materials and without previous pelvic organ prolapse (POP) surgery filled in a questionnaire, underwent translabial three-dimensional ultrasonography, and underwent staging of POP preoperatively and postoperatively. We developed a prediction model using multivariable logistic regression and internally validated it using standard bootstrapping techniques. The performance of the prediction model was assessed by computing indices of overall performance, discriminative ability, calibration, and its clinical utility by computing test characteristics. RESULTS: Of 287 included women, 149 (51.9%) had anatomical cystocele recurrence. Factors included in the prediction model were assisted delivery, preoperative cystocele stage, number of compartments involved, major levator ani muscle defects, and levator hiatal area during Valsalva. Potential predictors that were excluded after backward elimination because of high P values were age, body mass index, number of vaginal deliveries, and family history of POP. The shrinkage factor resulting from the bootstrap procedure was 0.91. After correction for optimism, Nagelkerkes R2 and the Brier score were 0.15 and 0.22, respectively. This indicates satisfactory model fit. The area under the receiver operating characteristic curve of the prediction model was 71.6% (95% confidence interval 65.7–77.5). After correction for optimism, the area under the receiver operating characteristic curve was 69.7%. CONCLUSION: This prediction model, including history of assisted delivery, preoperative stage, number of compartments, levator defects, and levator hiatus, estimates the risk of anatomical cystocele recurrence.

OC10.01: Diagnosing levator defects on 3D transperineal ultrasound compared to MR imaging

Objectives: The purpose of this study was to compare volume and VOCAL cervical parameters obtained with trans-vaginal ultrasound between threatened preterm labour and short asymptomatic cervix pregnancies without treatment and delivering at term. Methods: Cervical volume, vascularisation index (VI), flow index (FI) and vascularisation flow index (VFI) were measured with a transvaginal ultrasound. One group were patients from 24 weeks to 34 weeks of gestation with diagnosis of threatened preterm birth. The other group were patients within the same gestational age with short asymptomatic cervix. Patients with premature rupture of membranes, fetal pathology and multiple gestations were excluded. Results: A total of 70 threatened preterm labour patients and 34 short cervix pregnancies were included. Both groups were homogeneous (P > 0.05) for gestational age at measurement (mean 30.6 vs. 31.1 gestational weeks), cervical length (mean 19.0 vs. 19.6 mm) and parity (35% parous in threatened preterm labour VS 45% in controls). Threatened preterm labour cases presented significantly lower cervical volume (13 vs. 18 cm3) and FI (30.2 vs. 33.4) than controls (P < 0.05) besides significantly higher values (P < 0.05) were found in VI (16.0 vs. 5.5) and VFI (4.8 VS 1.8). Conclusions: Assessment of cervical volume and VOCAL parameters show differences between threatened preterm labour and asymptomatic short cervix pregnancies. Further research is needed to assess their usefulness in the surveillance of short cervix pregnancies and applicability to clinical practice.

Comparison of translabial three-dimensional ultrasound with magnetic resonance imaging for measurement of levator hiatal biometry at rest

To compare translabial three‐dimensional (3D) ultrasound with magnetic resonance imaging (MRI) for the measurement of levator hiatal biometry at rest in women with pelvic organ prolapse, and to determine the interobserver reliability between two independent observers for ultrasound and MRI measurements.

Do patients prefer mesh or anterior colporrhaphy for primary correction of anterior vaginal wall prolapse: a labelled discrete choice experiment.

We investigated patients’ preferences for anterior colporrhaphy or mesh surgery as surgical correction of anterior vaginal wall prolapse.

Diagnostic Accuracy and Clinical Implications of Translabial Ultrasound for the Assessment of Levator Ani Defects and Levator Ani Biometry in Women With Pelvic Organ Prolapse: A Systematic Review

Objective The aim of this study was to assess the diagnostic accuracy and clinical implications of translabial 3-dimensional (3D) ultrasound for the assessment of levator ani defects and biometry in women with pelvic organ prolapse (POP). Methods We performed a systematic literature search through computerized databases including MEDLINE (via PubMed), EMBASE (via OvidSP), and the Cochrane Library using both medical subject headings and text terms from January 1, 2003, to December 25, 2015. We included articles that reported on POP status and diagnostic accuracy measurements with translabial 3D ultrasound or transperineal ultrasound for the detection of levator ani defects or for measuring pelvic floor biometry, that is, levator ani hiatus, or reported on the clinical relevance of using translabial 3D ultrasound for levator ani defects or measuring pelvic floor biometry in women with POP. Results Thirty-one articles were selected in accordance with parts of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines that can be applied to studies of diagnostic accuracy. Twenty-two articles (71%) are coauthored by 1 expert in this field. Detecting levator ani defects with translabial 3D ultrasound compared with magnetic resonance imaging showed a moderate to good agreement, whereas measuring hiatal biometry on translabial 3D ultrasound compared with magnetic resonance imaging showed a moderate to very good agreement. The interobserver agreement for diagnosing levator ani defects and measuring the levator hiatal area showed a moderate to very good agreement. Furthermore, levator ani defects increase the risk of cystocele and uterine prolapse, and levator ani defects are associated with recurrent POP. Finally, a larger hiatus was associated with POP and recurrent POP. Conclusions Translabial 3D ultrasound is reproducible for diagnosing levator ani defects and ballooning hiatus. Both levator ani defects and a larger hiatal area are, in a selected population of patients with pelvic floor dysfunction, associated with POP and recurrent POP. More research is needed concerning external validation because most data in this article are coauthored by 1 expert in this field.

Medical students’ perspective on training in anatomy

Gaining sufficient knowledge of anatomy is an important part of medical education. Factors that influence how well students learn anatomical structures include available sources, learning time and study assistance. This study explores the attitude of medical students with regard to studying anatomy and evaluates possibilities for improvement of training in anatomy. Twenty medical students participated in a focus group meeting. Based on this focus group, an online survey consisting of 27 questions was developed and distributed amongst medical students of Maastricht University, the Netherlands. A total of 495 medical students (both Bachelor and Master level) participated in this survey. Master students found studying anatomy less attractive than Bachelor students (36.8% of the Master students vs. 47.9% of the Bachelor students (p=.024)). Although most students responded that they thought it is important to study anatomy, 48% of all students studied anatomy less than 10h per study block of 8 weeks. Only 47.9% of the students rated their knowledge of anatomy as adequate. Students suggested that three-dimensional techniques would help improve their knowledge of anatomy. Therefore investing in three-dimensional tools could prove beneficial in the future.

Comparison of translabial three-dimensional ultrasound with magnetic resonance imaging for measurement of levator hiatal biometry at rest: Levator hiatus biometry on ultrasound and MRI

To compare translabial three‐dimensional (3D) ultrasound with magnetic resonance imaging (MRI) for the measurement of levator hiatal biometry at rest in women with pelvic organ prolapse, and to determine the interobserver reliability between two independent observers for ultrasound and MRI measurements.