Kindra Larson

Vaginal support as determined by levator ani defect status 6 weeks after primary surgery for pelvic organ prolapse

To evaluate whether major levator ani muscle defects were associated with differences in postoperative vaginal support after primary surgery for pelvic organ prolapse (POP).

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 bodys 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.

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

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 hypothesisTwo-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.MethodsTwenty 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.ResultsIn 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.ConclusionDownward translation, cupping, and distal rotation are three novel characteristics of AWP demonstrated by this three-dimensional technique.

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

OBJECTIVE Recent cadaver research demonstrates the perineal membranes 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 membranes anatomical features can be seen in women with MR. The close relationship between the perineal membrane and levator ani is evident.

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

Introduction and hypothesisTwo-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 (PVPR) in women.MethodsTen women with (cases) and ten without (controls) PVPR 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.ResultsThe case and control groups had similar demographics. In women with PVPR 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).ConclusionsIncreased 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.

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.

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.

Uterosacral and sacrospinous ligament suspension for restoration of apical vaginal support

Correction of apical vaginal prolapse has been described via abdominal, laparoscopic, and transvaginal approaches. The uterosacral and sacrospinous ligament suspension procedures are common transvaginal native tissue repairs to restore apical vaginal support. Preoperative evaluation, operative decision making, surgical techniques, and objective and subjective outcomes of each technique are reviewed.

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.