Levator avulsion, prolapse stage, and family history are significant risk factors for prolapse recurrence.

Quantitative computed tomography analysis confirms lung recruitment with biologically variable ventilation in a porcine oleic acid injury model. Surfactant replacement with biologically variable ventilation provided no additional recruitment benefit and may in fact be harmful.

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KEYWORDS: 3D/4D ultrasound; pelvic floor; translabial ultrasound; vaginal laxity CONTRIBUTION What are the novel findings of this work? Our results show a clear, statistically significant increase in measures of pelvic floor distensibility in women complaining of vaginal laxity, supporting the growing evidence of an association between vaginal laxity and pelvic floor hyperdistensibility, and contributing to a method for objectively defining this condition. What are the clinical implications of this work?Since vaginal laxity is likely to be under-reported by patients, and given its association with pelvic floor hyperdistensibility, gynecologists should be sure to investigate sexual function, especially in women with a clinically wide hiatus or hiatal 'ballooning' on translabial ultrasound. ABSTRACT Objective To assess the predictive value of measures of levator hiatal distension at rest and on maximum Valsalva maneuver for symptoms of vaginal laxity.Methods This was a retrospective study of women seen at a tertiary urogynecological unit. All women underwent a standardized interview, clinical examination and four-dimensional translabial ultrasound examination. Area, anteroposterior diameter (APD) and coronal diameter (CD) of the levator hiatus were measured at rest and on maximum Valsalva maneuver in the plane of minimal hiatal dimensions using the rendered volume technique, by an operator blinded to all clinical data. The association between levator hiatal measurements and vaginal laxity was assessed, and receiver-operating-characteristics (ROC)-curve analysis was used to determine their predictive value.Results Data from 490 patients were analyzed. Mean age was 58 (range, 18-88) years, and vaginal laxity was reported by 111 (23%) women. Measurements obtained on maximum Valsalva were significantly larger in women who reported vaginal laxity than in those who did not, with mean levator hiatal area, APD and CD of 30.45 ± 8.74 cm 2 , 7.24 ± 1.16 cm and 5.60 ± 0.89 cm, respectively, compared with 24.84 ± 8.63 cm 2 , 6.64 ± 1.22 cm and 5.01 ± 0.97 cm in the no-laxity group (P < 0.001 for all). Measurements obtained at rest were not significantly different between the groups. Multiple logistic regression analysis controlling for age, body mass index, vaginal parity and levator avulsion confirmed these results. The best regression model for the prediction of vaginal laxity included age, vaginal parity and levator hiatal area on maximum Valsalva. ROC-curve analysis of levator hiatal measurements on maximum Valsalva in the prediction of vaginal laxity demonstrated areas under the curve of 0.68 (95% CI, 0.63-0.73) for area, 0.63 (95% CI, 0.57-0.68) for APD and 0.68 (95% CI, 0.62-0.73) for CD.Conclusions Levator hiatal area on maximum Valsalva seems to be the measure of levator ani distensibility that is most predictive of symptoms of vaginal laxity. Copyright

Objective Three-/four-dimensional translabial ultrasound (TLUS) is gaining popularity for the assessment of anal sphincter trauma, although repeatability data are lacking. This study aimed to determine the repeatability of tomographic ultrasound imaging (TUI) on TLUS for the diagnosis of external anal sphincter (EAS) trauma and compare the performance of a novice with that of an experienced investigator.Methods This was a retrospective study of archived ultrasound datasets of patients who presented with symptoms of pelvic floor dysfunction and were examined twice between 2012 and 2016 at an average interval of 260 (range, 1-1100) days. All volumes were obtained using a GE Medical Systems Voluson 730 Expert or E8 ultrasound system. Post-processing of volumes was performed independently by two investigators, one with over 1 year's experience and another with no prior experience in using TUI, who were blinded to clinical data, each other's results and the results obtained at the first timepoint. Significant trauma on EAS was diagnosed if four of the six TUI slices showed a defect of ≥ 30 • . Intra-and interobserver agreement were determined using Cohen's kappa (κ) and intraclass correlation coefficients.Results During the study period, 105 women underwent two TLUS assessments of the anal sphincter. Of these, 103 patients with ultrasound volumes available for both timepoints were included in the analysis. The novice investigator demonstrated average repeatability for assessment of significant EAS trauma and single-slice defect (κ, 0.30 and 0.22, respectively) despite relatively high agreement between measurements obtained at the two timepoints (84.5% and 79.3%, respectively). The experienced investigator demonstrated good to very good repeatability for significant EAS trauma and single-slice defect (κ, 0.91 and 0.78, respectively) between the Correspondence to: two assessments, which equates to 98.1% and 94.7% agreement, respectively. ConclusionThe repeatability of TLUS measurements for diagnosis of EAS trauma seems to be very good when imaging is undertaken with state-of-the-art equipment and the analysis is performed by an experienced observer; however, the performance of a novice investigator is much poorer.

Chronic peripheral nerve pain is a common problem that can arise from numerous causes, for which neurolysis is a therapeutic option. It is postulated that cryotherapy will have less adverse events than other methods of nerve ablation. A retrospective case series review was performed in patients who had undergone sonographically guided cryoneurolysis for Morton neuromas, postsurgical and posttraumatic neuromas, and idiopathic neuralgia. Fifteen of 20 patients had a positive response to cryoneurolysis, as did 2 of 4 patients with borderline symptoms for chronic regional pain syndrome. In view of our positive results, we believe that cryoneurolysis should be considered a reasonable option in performing neurolytic therapy.

Pigmented villonodular synovitis (PVNS) can recur after complete synovectomy and even after total joint replacement. In the authors' experience, there is a misconception that MRI may not be useful to diagnose PVNS in the setting of a total joint replacement due to dephasing artifact from metal. While there are case reports of PVNS in patients with total joint replacement diagnosed surgically, to our knowledge, diagnosis of recurrent PVNS by MRI following total joint replacement has not been reported. This report illustrates the utility of MRI in the diagnosis of recurrent PVNS following total joint replacement by reviewing two cases of pathologically correlated PVNS recurrence following arthroplasty, and two cases in which PVNS recurrence is strongly suspected, though pathological correlation is not available.

On comparing women with one, two, or three or more CS, we found no significant differences in any measured sonographic parameters of pelvic organ descent and pelvic floor muscle function. This implies that subsequent pregnancies after the first are unlikely to exert significant additional effects on pelvic floor functional anatomy.