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

Abstract

Objective To evaluate whether major levator ani muscle defects were associated with differences in postoperative vaginal support after primary surgery for pelvic organ prolapse (POP). Methods A retrospective chart review of a subgroup of patients in the Organ Prolapse and Levator (OPAL) study. Of the 247 women recruited into OPAL, 107 underwent surgery for prolapse and were the cohort for the present analysis. Major levator ani defects were diagnosed when more than 50% of the pubovisceral muscle was missing on MRI. Postoperative vaginal support was assessed via POP-quantification system. Postoperative anatomic outcome was analyzed according to levator ani defect status, as determined by MRI. Results Support of the anterior vaginal wall 2 cm above the hymen occurred among 62% of women with normal levator ani muscles/minor defects and 35% of those with major defects. Support of the anterior wall 1 cm above the hymen occurred among 32% women with normal muscles /minor defects and 59% of those with major defects. Levator ani defects were not associated with differences in postoperative apical/posterior vaginal support. Conclusion Six weeks after primary surgery for prolapse, women with normal levator ani muscles/minor defects had better anterior vaginal support than those with major levator defects.

The use of 3‐dimensional ultrasound of the pelvic floor to predict recurrence risk after pelvic reconstructive surgery

“…As regards levator avulsion, our data are consistent with own results in unrelated data sets 23 and results obtained by others, 11 both on ultrasound and on magnetic resonance imaging. As regards excessive distensibility of the levator hiatus, there is no data in the world literature as this is, to the knowledge of the authors, the first study to demonstrate such a relationship.…”

“…5 Trauma or 'avulsion' of this muscle predisposes to prolapse of the anterior, central and posterior compartments, [6][7][8] and to prolapse recurrence after surgery. [9][10][11][12] Furthermore, there is some evidence that the size of the genital hiatus, or the hiatus of the levator ani muscle, may also be a predictor independently of avulsion, as patients with excessive hiatal distensibility of over 25 cm 2 on maximal valsalva seem to be at an increased risk of support failure. 13 Such imaging studies are supported by data from a clinical study showing that diminished levator ani contraction strength and a widened genital hiatus were associated with increased anatomical prolapse recurrence.…”

Imaging of slings and meshes

“…The impact of major levator defects has been confirmed on MRI. In a series of 83 women Morgan, et al reported poorer anterior vaginal support in patients with major levator defects 6 weeks after primary surgery for prolapse 55 . The predictive effect of avulsion in prolapse recurrence applies even in women after placement of anterior compartment mesh.…”

Diagnosis and Therapy of Female Pelvic Organ Prolapse. Guideline of the DGGG, SGGG and OEGGG (S2e-Level, AWMF Registry Number 015/006, April 2016)

“…The risk of recurrence appears to increase almost twofold in patients with levator defects (avulsion of the pubococcygeus muscle from the pubic rami) [67][68][69][70].…”