MRI analysis of the musculo-fascial component of pelvic floor in woman before planned vaginal reconstruction procedur for symptomatic pelvic organ prolapse


Authors: M. Němec 1 ;  L. Horčička 2;  M. Dibonová 1;  M. Krčmář 3,4;  I. Urbánková 3,4;  L. Krofta 3,4;  J. Feyereisl 3,4
Authors‘ workplace: Gynekologicko-porodnické oddělení, Nemocnice ve Frýdku-Místku, primář MUDr. M. Němec, MBA 1;  Gona s. r. o., Nestátní gynekologické zařízení, Praha, vedoucí MUDr. L. Horčička 2;  Ústav pro péči o matku a dítě, Praha, ředitel doc. MUDr. J. Feyereisl, CSc. 3;  3. lékařská fakulta Univerzity Karlovy, Praha 4
Published in: Ceska Gynekol 2018; 83(2): 84-93

Overview

Objective:
The aim of the study is to analyse the musculo-fascial component of the pelvic floor in symptomatic group of woman with pelvic organ prolapse before planned vaginal reconstruction using synthetic vaginal mesh.

Design:
Observational cohort study.

Setting:
Department of Obstetrics and Gynaecology, Hospital in Frýdek-Místek; GONA Ltd, Prague; Institute for Care of Mother and Child, Prague; 3rd Faculty of Medicine CHU Prague.

Methodology:
The study involved 285 female volunteers (6 nulliparous, all other patients gave birth vaginally at least once) that in the period 2008–2015 before the planned reconstructive vaginal operations have undergone a comprehensive urogynaecology examination supplemented by magnetic resonance imaging (MRI) of the pelvic floor. Assessed was musculofascial component of the pelvic floor containing -musculus levator ani (MLA), endopelvic fascia (EF) and sacrouterine ligaments (SUL). MLA and EF were evaluated at two levels. The first level corresponds to the puborectalis muscle (evaluation of MRI trauma stage and avulsion), the second level correspondes to the iliococcygeus muscule (evaluation only avulsion injury to the muscle).

Results:
Normal appereance of musculus puborectalis (level 1) was captured only in 25 (8.8) women. In 117 (41.1%) of women were present MRI minor trauma, 143 (50,2%) women were present with MRI major trauma. Avulsion of the muscle was captured in 85 cases (29.8%) at level 1 and in 165 cases (57.9%) in level 2. Preserved architecture of the EF was caught only 99 (34.7%) of the cases in level 1 and in 47 cases (16.5%) in level 2. Sacrouterine ligaments showed normal morphology in 100 cases (35.1%).

Conslusion:
Defects of musculofascial component of the pelvic floor is found frequently in women with symptomatic pelvic organ prolapse. Often a combination of defects MLA, EF and SUL are found. These comprehensive pelvic floor defects require careful urogynecological examination and planing operating methods with a view to minimizing the likelihood of recurrence of the descent. In indicated cases the use of the synthetic vaginal mesh is as a method of first choice.

Keywords:
pelvic organ prolapse, musculofascial component, mesh, MRI, avulsion


Sources

1. Betschart, C, Kim Jinyong, Miller, J., et al. Comparison of muscle fiber directions between different levator ani muscle subdivisions: in vivo MRI measurements in women. Int Urogynecol J, 2014, 25, 1263–1268.

2. Brányik, K., Krofta, L., Kraus, P., et al. Rekonstrukce defektu zadního a středního kompartmentu pomocí kotveného implantátu Prolift Posterior: kohortová studie s pětiletým folow–up. Čes Gynek, 2017, 82, 4, s. 268–276.

3. Bump, RC., Mattiasson, A., Bo, K., et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. AJOG, 1996, 175, p. 10–17.

4. DeLancey, JDM., Morgan, D., Ferner, E. Comparsion of levator ani muscle defects and function in women with and without pelvic organ prolapse. Obstet Gynecol, 2011, 109, p. 295–302.

5. DeLancey, JO., Kearney, R., Chou, Q., et al. The appereance of levator ani muscle abnormalities in magnetic resonance images after vaginal delivery. Obstet Gynecol, 2003, 101, p. 46–53 (PubMed:12517644).

6. DeLancey, JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol, 1992, 166, p. 1717.

7. DeLancey, JO. Surgery for cystocoele III: do all cystocoeles involve apical descent? Int Urogynecol J, 2012, 23, p. 665–667.

8. Dietz, HP., Lanzarone, V. Levator trauma after vaginal delivery. Obstet Gynecol, 2005, 106, p. 707–712.

9. Huebner, M., Marguiles, R., DeLancey, JO. Pelvic architectural distortion is associated with pelvic organprolapse. Int Urogynecol J Pelvic Floor Dysfunct, 2008, 19, p. 863–867.

10. Kearney, R., Sawhney, R., DeLancey, JO. Levator ani muscle anatomy evaluated by origin-insertion pairs. Obstet Gynecol, 2004, 104, p. 168.

11. Kraus, P., Krofta, L., Krčmář, M., et al. Řešení sestupu tří kompartmentů pomocí syntetického implantátu a sakrospinózní fixace: kohortová prospektivní studie s delkou folow-up pěti let. Čes Gynek, 2017, 82, 4, s. 277–286.

12. Lawson, JON. Pelvic anatomy. I. Pelvic floor muscles. Ann R Cooll Surg Engl, 1974, 54, p. 244–252.

13. Lien, KC., Mooney, B., DeLancey, JO., Ashton-Miller, JA. Levator ani muscle stretch induced by simulated vaginal birth. ObstetGynecol, 2004, 103, p. 31–40.

14. Maher, C., Feiner, B., Baessler, K., et al. Transvaginal mesh or grafts compared with native tissue repair for vaginal prolapse.Cochrane Database Syst Rev. 2016, 2:CD012079. Epub 2016 Feb 9.

15. Matthew, D., Barber, MHS. Surgical female urogenital anatomy, Up To Date, 2017, 30.

16. Miller, JM., Brandon, C., Jacobson, JA., et al. MRI findings in pantients considered high risk for pelvic floor injury studied serially post vaginal childbirth. Am J Roentgenol, 2010, 195, p. 786–791.

17. Morgan, DM., Kaur, G., Hsu, Y., et al. Does vaginal closure force differ in the supine and standing positions? Am J Obstet Gynecol, 2005, 192, p. 1722–1728.

18. Shafik, A., Doss, S., Asaad, S. Etiology of the resting myoelectric activity of the levator ani muscle: physioanatomic study with a new theory. World J Surg, 2003, 27, p. 309–314.

19. Singh, K., Jakab, M., Reid, WM., et al. Three-dimensional magnetic resonance imaging assessment of levator ani morphologic features in different grades of prolapse. Am J Obstet Gynecol, 2003, 188, p. 910.

20. Summers, A., Winkel, LA., Hussain, HK., DeLancey, JO. The relationship between anterior and apical compartment support. Am J Obstet Gynecol, 2006, 194, p. 1438–1443.

21. Umek, W., Morgan, DM., Ashton-Miller, JA., DeLancey, JO. Quantitative analysis of uterosacral ligament origin and insertion points by magnetic resonance imaging. Obstet Gynecol, 2004, 103, p. 447–451.

22. Wise, J. NICE to ban mesh for vaginal prolapse. BMJ, 2017, 359:j5523 doi:10.1136/bmj.j5523.

Labels
Paediatric gynaecology Gynaecology and obstetrics Neonatology Paediatrics Reproduction medicine
Login
Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.

Login

Don‘t have an account?  Create new account