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Analysis of long-term structural failure after native tissue prolapse surgery: a 3D stress MRI-based study

Abstract

Introduction and hypothesis

We sought to identify postoperative structural failure sites associated with long-term prolapse recurrence and their association with symptoms and satisfaction.

Methods

Women who had a research MRI prior to native-tissue prolapse surgery were recruited for examination, 3D stress MRI, and questionnaires. Recurrence was defined by Pelvic Organ Prolapse Quantification System (POP-Q)Ba/Bp > 0 or C > -4. Measurements were performed at rest and maximum Valsalva (“strain”) including vaginal length, apex location, urogenital hiatus (UGH), and levator hiatus (LH). Measures were compared between subjects and to women with normal support. Failure frequency was the proportion of women with measurements outside the normal range. Symptoms and satisfaction were measured using validated questionnaires.

Results

Thirty-one women participated 12.7 years after surgery—58% with long-term success and 42% with recurrence. Failure site comparisons between success and failure were: impaired mid-vaginal paravaginal support (62% vs. 28%, p = 0.01), longer vaginal length (54% vs. 22%, p = 0.03), and enlarged urogenital hiatus (54% vs. 22%, p = 0.03). Apical paravaginal location had the lowest failure frequency (recurrence: 15% vs. success: 7%, p = 0.37). Patient satisfaction was high (recurrence: 5.0 vs. success: 5.0, p = 0.86). Women with bothersome bulge symptoms had a 33% larger UGH strain on POP-Q (p = 0.01), 8.7% larger resting UGH (p = 0.046), 11.5% larger straining LH (p = 0.01), and 9.3% larger resting LH (p = 0.01).

Conclusions

Abnormal low mid-vaginal paravaginal location (Level II), long vaginal length (Level II), and large UGH (Level III) were associated with long-term prolapse recurrence. Patient satisfaction was high and unrelated to anatomical recurrence. Bothersome bulge symptoms were associated with hiatus enlargement.

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References

  1. 1.

    Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol. 1997;89(4):501–6. https://doi.org/10.1016/S0029-7844(97)00058-6.

    CAS  Article  PubMed  Google Scholar 

  2. 2.

    Jelovsek JE, Barber MD. Women seeking treatment for advanced pelvic organ prolapse have decreased body image and quality of life. Am J Obstet Gynecol. 2006;194(5):1455–61. https://doi.org/10.1016/j.ajog.2006.01.060.

    Article  PubMed  Google Scholar 

  3. 3.

    Wu JM, Vaughan CP, Goode PS, Redden DT, Burgio KL, Richter HE, et al. Prevalence and trends of symptomatic pelvic floor disorders in US women. Obstet Gynecol. 2014;123(1):141–8. https://doi.org/10.1097/AOG.0000000000000057.

    Article  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Nygaard I, Brubaker L, Zyczynski HM, Cundiff G, Richter H, Gantz M, et al. Long-term outcomes following abdominal sacrocolpopexy for pelvic organ prolapse. JAMA. 2013;309(19):2016–24. https://doi.org/10.1001/jama.2013.4919.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  5. 5.

    Barber MD, Brubaker L, Burgio KL, Richter HE, Nygaard I, Weidner AC, et al. Comparison of 2 transvaginal surgical approaches and perioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial. JAMA. 2014;311(10):1023–34. https://doi.org/10.1001/jama.2014.1719.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Morgan DM, Larson K, Lewicky-Gaupp C, Fenner DE, DeLancey JO. Vaginal support as determined by levator ani defect status 6 weeks after primary surgery for pelvic organ prolapse. Int J Gynaecol Obstet. 2011;114(2):141–4. https://doi.org/10.1016/j.ijgo.2011.02.020.

    Article  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Berger MB, Kolenic GE, Fenner DE, Morgan DM, DeLancey JOL. Structural, functional, and symptomatic differences between women with rectocele versus cystocele and normal support. Am J Obstet Gynecol. 2018;218(5):510.e511–8. https://doi.org/10.1016/j.ajog.2018.01.033.

    Article  Google Scholar 

  8. 8.

    Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JO, Klarskov P, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175(1):10–7.

    CAS  Article  Google Scholar 

  9. 9.

    Trowbridge ER, Fultz NH, Patel DA, DeLancey JO, Fenner DE. Distribution of pelvic organ support measures in a population-based sample of middle-aged, community-dwelling African American and white women in southeastern Michigan. Am J Obstet Gynecol. 2008;198(5):548 e541–6. https://doi.org/10.1016/j.ajog.2008.01.054.

    Article  Google Scholar 

  10. 10.

    Sung VW, Kauffman N, Raker CA, Myers DL, Clark MA. Validation of decision-making outcomes for female pelvic floor disorders. Am J Obstet Gynecol. 2008;198(5):575.e571–6. https://doi.org/10.1016/j.ajog.2007.12.035.

    Article  Google Scholar 

  11. 11.

    Barber MD, Kuchibhatla MN, Pieper CF, Bump RC. Psychometric evaluation of 2 comprehensive condition-specific quality of life instruments for women with pelvic floor disorders. Am J Obstet Gynecol. 2001;185(6):1388–95. https://doi.org/10.1067/mob.2001.118659.

    CAS  Article  PubMed  Google Scholar 

  12. 12.

    Chen L, Lisse S, Larson K, Berger MB, Ashton-Miller JA, DeLancey JO. Structural failure sites in anterior Vaginal Wall prolapse: identification of a collinear triad. Obstet Gynecol. 2016;128(4):853–62. https://doi.org/10.1097/AOG.0000000000001652.

    Article  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Reiner CS, Williamson T, Winklehner T, Lisse S, Fink D, DeLancey JOL, et al. The 3D pelvic inclination correction system (PICS): a universally applicable coordinate system for isovolumetric imaging measurements, tested in women with pelvic organ prolapse (POP). Comput Med Imaging Graph. 2017;59:28–37. https://doi.org/10.1016/j.compmedimag.2017.05.005.

    Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Betschart C, Chen L, Ashton-Miller JA, Delancey JO. On pelvic reference lines and the MR evaluation of genital prolapse: a proposal for standardization using the pelvic inclination correction system. Int Urogynecol J. 2013;24(9):1421–8. https://doi.org/10.1007/s00192-013-2100-4.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Larson KA, Smith T, Berger MB, Abernethy M, Mead S, Fenner DE, et al. Long-term patient satisfaction with Michigan four-wall sacrospinous ligament suspension for prolapse. Obstet Gynecol. 2013;122(5):967–75. https://doi.org/10.1097/AOG.0b013e3182a7f0d5.

    Article  PubMed  Google Scholar 

  16. 16.

    Miedel A, Tegerstedt G, Morlin B, Hammarstrom M. A 5-year prospective follow-up study of vaginal surgery for pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(12):1593–601. https://doi.org/10.1007/s00192-008-0702-z.

    Article  PubMed  Google Scholar 

  17. 17.

    Fialkow MF, Newton KM, Weiss NS. Incidence of recurrent pelvic organ prolapse 10 years following primary surgical management: a retrospective cohort study. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(11):1483–7. https://doi.org/10.1007/s00192-008-0678-8.

    Article  PubMed  Google Scholar 

  18. 18.

    Haylen BT, Avery D, Chiu TL, Birrell W. Posterior repair quantification (PR-Q) using key anatomical indicators (KAI): preliminary report. Int Urogynecol J. 2014;25(12):1665–72. https://doi.org/10.1007/s00192-014-2433-7.

    Article  PubMed  Google Scholar 

  19. 19.

    Medina CA, Candiotti K, Takacs P. Wide genital hiatus is a risk factor for recurrence following anterior vaginal repair. Int J Gynaecol Obstet. 2008;101(2):184–7. https://doi.org/10.1016/j.ijgo.2007.11.008.

    Article  PubMed  Google Scholar 

  20. 20.

    Vaughan MH, Siddiqui NY, Newcomb LK, Weidner AC, Kawasaki A, Visco AG, et al. Surgical alteration of genital hiatus size and anatomic failure after vaginal vault suspension. Obstet Gynecol. 2018;131(6):1137–44. https://doi.org/10.1097/AOG.0000000000002593.

    Article  PubMed  Google Scholar 

  21. 21.

    Vakili B, Zheng YT, Loesch H, Echols KT, Franco N, Chesson RR. Levator contraction strength and genital hiatus as risk factors for recurrent pelvic organ prolapse. Am J Obstet Gynecol. 2005;192(5):1592–8. https://doi.org/10.1016/j.ajog.2004.11.022.

    Article  PubMed  Google Scholar 

  22. 22.

    Swenson CW, Masteling M, DeLancey JO, Nandikanti L, Schmidt P, Chen L. Aging effects on pelvic floor support: a pilot study comparing young versus older nulliparous women. Int Urogynecol J. 2020;31(3):535–43. https://doi.org/10.1007/s00192-019-04063-z.

    Article  PubMed  Google Scholar 

  23. 23.

    English EM, Chen L, Sammarco AG, Kolenic GE, Cheng W, Ashton-Miller JA, et al. Mechanisms of hiatus failure in prolapse: a multifaceted evaluation. Int Urogynecol J. 2021. https://doi.org/10.1007/s00192-020-04651-4.

  24. 24.

    Andrew BP, Shek KL, Chantarasorn V, Dietz HP. Enlargement of the levator hiatus in female pelvic organ prolapse: cause or effect? Aust N Z J Obstet Gynaecol. 2013;53(1):74–8. https://doi.org/10.1111/ajo.12026.

    Article  PubMed  Google Scholar 

  25. 25.

    Wong V, Shek KL, Korda A, Benness C, Pardey J, Dietz HP. A pilot study on surgical reduction of the levator hiatus-the puborectalis sling. Int Urogynecol J. 2019;30(12):2127–33. https://doi.org/10.1007/s00192-019-04062-0.

    Article  PubMed  Google Scholar 

  26. 26.

    Muñiz KS, Voegtline K, Olson S, Handa V. The role of the genital hiatus and prolapse symptom bother. Int Urogynecol J. 2020. https://doi.org/10.1007/s00192-020-04569-x.

  27. 27.

    Siff LN, Barber MD, Zyczynski HM, Rardin CR, Jakus-Waldman S, Rahn DD, et al. Immediate postoperative pelvic organ prolapse quantification measures and 2-year risk of prolapse recurrence. Obstet Gynecol. 2020;136(4):792–801. https://doi.org/10.1097/AOG.0000000000004043.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  28. 28.

    Hill AM, Shatkin-Margolis A, Smith BC, Pauls RN. Associating genital hiatus size with long-term outcomes after apical suspension. Int Urogynecol J. 2020;31(8):1537–44. https://doi.org/10.1007/s00192-019-04138-x.

    Article  PubMed  Google Scholar 

Download references

Funding

Investigator support was provided by National Institutes of Health (NIH) grant # R01 HD094954, R03 HD096189 and the National Institute of Child Health and Human Development (NICHD) WRHR Career Development Award #K12 HD065257. The NIH and NICHD played no role in the research design, data collection/analysis, decision to publish, or choice of journal for this manuscript.

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Correspondence to Luyun Chen.

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Appendix

Appendix

Table 2 Demographic and clinical data including POP-Q comparison of women with prolapse and normal controls
Table 3 Comparison of long-term follow-up mid-sagittal MRI measurements between women with success and recurrence

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Chen, L., Schmidt, P., DeLancey, J.O. et al. Analysis of long-term structural failure after native tissue prolapse surgery: a 3D stress MRI-based study. Int Urogynecol J (2021). https://doi.org/10.1007/s00192-021-04925-5

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Keywords

  • Long-term follow-up
  • MRI
  • Native tissue prolapse surgery
  • Prolapse recurrence
  • Structure failure