Apical Descent in the Office and the Operating Room

Crosby, Elizabeth C.; Sharp, Kristen M.; Gasperut, Adrian; DeLancey, John O.L.; Morgan, Daniel M.

doi:10.1097/spv.0b013e31829c6365

Cited by 10 publications

(15 citation statements)

References 8 publications

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“…In fact, uterine location at rest in the OR was equal to or lower than the maximal Valsalva location seen in MRI for 90 % (17/19) of women. Although this comparison has not been previously reported, Crosby et al reported that cervix location is, on average, 3.5 cm lower in the OR under traction vs POP-Q exam in clinic during maximal Valsalva [13]. We hypothesized that conditional differences between the OR and MRI environments may help explain some of these findings.…”

Section: Discussionmentioning

confidence: 76%

Traction force needed to reproduce physiologically observed uterine movement: technique development, feasibility assessment, and preliminary findings

et al. 2016

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Introduction and hypothesis This study aimed to describe a novel strategy to determine the traction forces needed to reproduce physiologic uterine displacement in women with and without prolapse. Methods Participants underwent dynamic stress magnetic resonance imaging (MRI) testing as part of a study examining apical uterine support. Physiologic uterine displacement was determined by analyzing uterine location in images taken at rest and at maximal Valsalva. Force-displacement curves were calculated based on intraoperative cervical traction testing. The intraoperative force required to achieve the uterine displacement measured during MRI was then estimated from these curves. Women were categorized into three groups based on pelvic organ support: group 1 (normal apical and vaginal support), group 2 (normal apical support but vaginal prolapse present), and group 3 (apical prolapse). Results Data from 19 women were analyzed: five in group 1, five in group 2, and nine in group 3. Groups were similar in terms of age, body mass index (BMI), and parity. Median operating room (OR) force required for uterine displacement measured during MRI was 0.8 N [interquartile range (IQR) 0.62–3.22], and apical ligament stiffness determined using MRI uterine displacement was 0.04 N/mm (IQR 0.02–0.08); differences between groups were nonsignificant. Uterine locations determined at rest and during maximal traction were lower in the OR compared with MRI in all groups. Conclusions Using this investigative strategy, we determined that only 0.8 N of traction force in the OR was required to achieve maximal physiologic uterine displacement seen during dynamic (maximal Valsalva) MRI testing, regardless of the presence or absence of prolapse.

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Section: Discussionmentioning

confidence: 76%

Traction force needed to reproduce physiologically observed uterine movement: technique development, feasibility assessment, and preliminary findings

et al. 2016

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“…Foon et al, 3 in their 3-month follow-up study, reported that "intraoperative cervical traction" with apical prolapse < À1 cm did not inform them of the need to perform concurrent vaginal hysterectomy at the time of anterior repair. However, Crosby et al 12 reported that a C point > 5 cm (a threshold at which they would intervene) was evident in 33% of 206 women studied in their series. Surprisingly, this difference was more evident in women with lesser degrees of prolapse: 70.3% (57/81) with stage 1 prolapse versus 9.3% (4/43) with stage 2 prolapse, and 8.5% (7/82) with for stage 3 prolapse (p < 0.001).…”

Section: Discussionmentioning

confidence: 94%

“…12 This phenomenon may be attributed to (1) dynamic changes in vaginal pressure forces accentuating areas of fascial tears in other compartments following repair of one compartment, or (2) unrecognized defects at the completion of the initial prolapse repair procedure. 13e15 Some recurrences are purely anatomical and tend to remain asymptomatic when mild or moderate.…”

Section: Discussionmentioning

confidence: 98%

“…Surprisingly, this difference was more evident in women with lesser degrees of prolapse: 70.3% (57/81) with stage 1 prolapse versus 9.3% (4/43) with stage 2 prolapse, and 8.5% (7/82) with for stage 3 prolapse (p < 0.001). 12 Our study differs significantly from these aforementioned studies by taking it one step further along and explores the anatomical outcomes based on our intraoperative threshold (defined as ! À1 cm) or enterocele (defect > 3 cm measured in pelvis) for additional prolapse repair following concomitant hysterectomy and anterior compartment repair.…”

Section: Discussionmentioning

confidence: 99%

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Total hysterectomy and anterior vaginal wall suspension for concurrent uterine and bladder prolapses: Long-term anatomical results of additional vault and/or posterior compartment prolapse repair

2015

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Keywords:anterior vaginal wall suspension hysterectomy pelvic organ prolapse progression prolapse recurrence a b s t r a c t Objective: To review the long-term results of an intraoperative decision to repair or not repair associated vault and posterior compartment defects after total hysterectomy (TH) and anterior vaginal wall suspension (AVWS) for uterine and bladder prolapses. Methods: After gaining Institutional Review Board approval, the operative records of women receiving TH and AVWS concurrently with a minimum follow-up period of 6 months were reviewed. Two groups were identified: Group 1 (G1) underwent TH þ AVWS and intraoperative apical and/or posterior repairs, and Group 2 (G2) had TH þ AVWS alone. The definition of prolapse recurrence was Pelvic Organ ProlapsedQuantification ! Stage 2 and/or any reoperation for prolapse. Results: From 1998 to 2009, a total of 94 women were evaluated. At the mean 3 years follow-up, the rates of overall prolapse recurrence following initial surgeries between G1 and G2 were 30% and 24%, respectively. Additional operative repair for G1 and G2 was 18.5% and 16%, respectively. The progression rate for both groups was < 8%. The overall success for G1 and G2 was 70% and 76%, respectively. Conclusion: At long-term follow-up, nearly one in five apical recurrences in these two surgical groups was observed with stable results in the anterior compartment. The posterior compartment required the least surgical intervention.

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“…5,6 This difference may be partially explained by different environmental and loading conditions (i.e., Valsalva vs. traction, leg position, anesthesia, etc.) to which the apical ligaments are subjected.…”

Section: Introductionmentioning

confidence: 99%

Intraoperative cervix location and apical support stiffness in women with and without pelvic organ prolapse

Swenson

Smith

Luo

et al. 2017

American Journal of Obstetrics and Gynecology

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Background It is unknown how initial cervix location and cervical support resistance to traction, which we term “apical support stiffness,” compare in women with different patterns of pelvic organ support. Defining a normal range of apical support stiffness is important in order to better understand the pathophysiology of apical support loss. Objective(s) The aims of our study were to: 1) determine whether women with normal apical support on clinic Pelvic Organ Prolapse Quantification (POP-Q), but with vaginal wall prolapse (cystocele and/or rectocele), have the same intraoperative cervix location and apical support stiffness as women with normal pelvic support; and 2) determine whether all women with apical prolapse have abnormal intraoperative cervix location and apical support stiffness. A third objective was to identify clinical and biomechanical factors independently associated with clinic POP-Q point C. Study Design We conducted an observational study of women with a full spectrum of pelvic organ support scheduled to undergo gynecologic surgery. All women underwent a preoperative clinic exam, including the POP-Q. Cervix starting location and the resistance (stiffness) of its supports to being moved steadily in the direction of a traction force that increased from 0 to 18 N was measured intraoperatively using a computer-controlled servoactuator device. Women were divided into three groups for analysis according to their pelvic support as classified using the clinic POP-Q: 1) “Normal/Normal” was women with normal apical (C < -5 cm) and vaginal support (Ba and Bp < 0 cm); 2) “Normal/Prolapse” had normal apical support (C < -5 cm) but prolapse of the anterior or posterior vaginal walls (Ba and/or Bp ≥ 0 cm); and 3) “Prolapse/Prolapse” had both apical and vaginal wall prolapse (C > -5 cm and Ba and/or Bp ≥ 0 cm). Demographics, intraoperative cervix locations, and apical support stiffness values were then compared. “Normal range” of cervix location during clinic exam and operative testing was defined by the total range of values observed in the Normal/Normal group. The proportion of women in each group with cervix locations within and outside the normal range was determined. Linear regression was performed to identify variables independently associated with clinic POP-Q point C. Results Fifty-two women were included—14 in the Normal/Normal group, 11 in the Normal/Prolapse group, and 27 in the Prolapse/Prolapse group. At 1 N of traction force in the operating room, 50% of women in the Normal/Prolapse group had cervix locations outside the normal range while 10% had apical support stiffness outside the normal range. Of women in the Prolapse/Prolapse group, 81% had cervix locations outside the normal range and 8% had apical support stiffness outside the normal range. Similar results for cervix locations were observed at 18 N of traction force; however the proportion of women with apical support stiffness outside the normal range increased to 50% in the Normal/Prolapse group and 59% in the Prolapse/Prolapse g...

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Apical Descent in the Office and the Operating Room

Cited by 10 publications

References 8 publications

Traction force needed to reproduce physiologically observed uterine movement: technique development, feasibility assessment, and preliminary findings

Traction force needed to reproduce physiologically observed uterine movement: technique development, feasibility assessment, and preliminary findings

Total hysterectomy and anterior vaginal wall suspension for concurrent uterine and bladder prolapses: Long-term anatomical results of additional vault and/or posterior compartment prolapse repair

Intraoperative cervix location and apical support stiffness in women with and without pelvic organ prolapse

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