Short and long-term outcomes of the Manchester Procedure for Pelvic Organ Prolapse and the impact of major Levator Ani Muscle defects

High recurrence rates after Pelvic Organ Prolapse (POP) surgery have been reported and avulsions of the levator ani muscle (LAM) are believed to increase the risk. The aims of this thesis were to investigate long-term recurrence risks and postoperative outcomes after native tissue POP repairs, focusing on the “complete” (three compartment) Manchester Procedure. We wanted to estimate the prevalence of avulsions and their impact on baseline data and postoperative outcomes. Two cohorts were analyzed; Women treated with native tissue POP repairs from 2002 to 2005 (n=699) and a prospective cohort of 204 women scheduled for a Manchester Procedure between 2014 and 2017. This thesis finds that the Manchester Procedure provides lower long-term recurrence rates (2.8 vs. 8.9%) (p<0.01) and superior anatomical results (optimal outcome 86.7 vs.78.3%) (p=0.02) compared to “partial” repairs. Subjective satisfaction was overall excellent, 90- 96%. LAM avulsions were highly prevalent (50%), but not associated with preoperative symptoms or postoperative outcomes. Native tissue techniques like the Manchester Procedure ensure favorable outcomes and low recurrence risks independent of LAM integrity

The Manchester procedure: anatomical, subjective and sexual outcomes

Introduction and hypothesis Classical native-tissue techniques for pelvic organ prolapse (POP) repairs, such as the Manchester procedure (MP), have been revitalized because of vaginal mesh complications. However, there are conflicting opinions regarding sufficient apical (mid-compartment) support by the MP and concerns about the risk of dyspareunia. The aims of this study were therefore to investigate anatomical and patient-reported outcomes 1 year after MP. Methods Prospective cohort study of 153 females undergoing an MP for anterior compartment POP between October 2014 and June 2016. Pre- and 1-year postoperative evaluations included POP-Q measurements and the questionnaires Pelvic Floor Distress Inventory Short Form 20 (PFDI-20) and POP/Urinary Incontinence Sexual Questionnaire (PISQ-12). Results At 1 year, 97% (148/153) attended the follow-up. Significant anatomical improvements (p < 0.01) were obtained in all compartments. Mean Ba was −1.1 (± 1.4), mean C −5.9 (± 1.7) and mean D −7.0 (± 1.2) at follow-up. Point C ≤ −5 was present in 81.1%. POP-Q stage 0–1 was obtained in 99.3% in the mid-compartment (C < −1), but only in 48.6% in the anterior compartment (Ba < −1). A significant reduction in symptom scores was obtained for PFDI-20 (p < 0.01) and PISQ-12 (p = 0.01). No significant changes were seen in dyspareunia rates (q.5, PISQ-12), but 5.6% reported de novo dyspareunia. Concerning POP symptoms, 96.0% reported being cured or significantly improved. Conclusions The Manchester procedure provides adequate apical support, albeit inferior anatomical anterior compartment results, and 96.0% reported being subjectively cured or substantially better at 1-year follow-up, with no significant change in dyspareunia

The association between different measures of pelvic floor muscle function and female pelvic organ prolapse

Introduction and hypothesis: We aimed to compare palpatory and translabial ultrasound (TLUS) measurements of pelvic floor muscle (PFM) function with symptoms and signs of female pelvic organ prolapse (FPOP) to determine a possible association. Methods: We analysed data from 726 women with a mean age of 56 (SD 13.7, range 18–88) years, seen for symptoms of pelvic floor dysfunction between August 2011 and April 2013. The examination included a standardised interview and clinical assessment of FPOP with Pelvic Organ Prolapse Quantification (POP-Q) measurements, Modified Oxford Scale (MOS) grading and 4D TLUS. Results: Symptoms of prolapse were reported in 51.4% (373 out of 726) with a mean bother score of 5.8 (SD 2.91, range 0–10). A clinically significant POP (Incontinence Society [ICS]-POP-Q stage ≥ 2) in any compartment was diagnosed in 77.1%. Mean MOS was 2.4 (SD 1.1, range 0–5). Significant POP on TLUS was seen in 54.6% (389 out of 712). TLUS volumes at rest and on maximal PFM contraction were analysed on a desktop PC, to assess the degree of bladder neck (BN) cranioventral shift and levator antero-posterior (AP) diameter reduction, blinded against other data. Mean cranioventral BN shift was 7.11 (SD 4.36, range 0.32–25.32) mm and mean levator AP diameter reduction was 8.6 (SD 4.8, range 0.3–31.3) mm. MOS was strongly associated with subjective and objective POP (P ≤ 0.001), whereas this was not true for TLUS measurements of tissue displacement. Conclusion: The MOS seems to be a more valid measure of PFM function than sonographically determined BN displacement or reduction of hiatal AP diameter observed on PFM contraction

Levator ani defects and the severity of symptoms in women with anterior compartment pelvic organ prolapse

Introduction and hypothesis The aims of this study were to evaluate the prevalence of levator ani muscle (LAM) avulsions in a selected cohort of patients with primary anterior compartment pelvic organ prolapse (POP) and to assess whether LAM avulsions, as an independent factor, affect the degree of POP symptoms and sexual dysfunction. Additionally, clinical and demographic variables of women with and those without avulsions were compared. Methods We carried out a cross-sectional analysis of a prospective cohort study including 197 women scheduled for anterior compartment POP surgery. LAM avulsions were diagnosed on transperineal 4D ultrasound. Preoperative symptom severity and sexual dysfunction were evaluated using validated questionnaires (Pelvic Floor Disability Index [PFDI-20] and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-Short Form 12 [PISQ-12]). Linear regression was performed with avulsion as the main independent variable against total PFDI-20 and domain scores, bulge symptoms, and PISQ-12 score. Clinical and demographic variables for women with and without avulsions were compared using independent samples t test, Mann–Whitney U test or Chi-squared test. Results The prevalence of LAM avulsions was 50.3%. Avulsions were not associated with symptom severity or sexual dysfunction. “Chronic disease causing pain, fatigue or increased intra-abdominal pressure” was the only independent factor associated with all domains of the PFDI-20. Women with avulsions were younger at presentation, older at their first delivery, had lower BMI, and more often had a history of forceps delivery (p < 0.01). Conclusions LAM avulsions were highly prevalent in this preoperative POP cohort. Avulsions were not associated with the severity of POP symptoms or sexual dysfunction. Women with avulsions seem to require fewer additional cofactors for developing POP. This is a post-peer-review, pre-copyedit version of an article published in International Urogynecology Journal. The final authenticated version is available online at: http://dx.doi.org/10.1007/s00192-017-3390-

Association of urinary and anal incontinence with measures of pelvic floor muscle contractility

Objective: To assess the association between clinical and sonographic measures of pelvic floor muscle (PFM) function and symptoms of urinary and anal incontinence (AI). Methods: This was a retrospective study of women seen at a tertiary urogynecological unit. All women had undergone a standardized interview, clinical examination including Modified Oxford Scale (MOS) grading, urodynamic testing and four-dimensional translabial ultrasound (TLUS). Cranioventral shift of the bladder neck (BN) and reduction in the hiatal anteroposterior (AP) diameter were measured using ultrasound volumes acquired on maximal PFM contraction, blinded against all clinical data. Results: Data from 726 women with a mean age of 56 ± 13.7 (range, 18–88) years and a mean body mass index of 29 ± 6.1 (range, 17–55) kg/m2 were analyzed. Stress (SI) and urge (UI) urinary incontinence were reported by 73% and 72%, respectively, and 13% had AI. Mean MOS grade was 2.4 ± 1.1 (range, 0–5). Mean cranioventral BN shift on TLUS was 7.1 ± 4.4 (range, 0.3–25.3) mm; mean reduction in AP hiatal diameter was 8.6 ± 4.8 (range, 0.3–31.3) mm. On univariate analysis, neither MOS nor TLUS measures were strongly associated with symptoms of urinary incontinence or AI; associations were non-significant except for BN displacement/SI (7.3 mm vs 6.5 mm; P = 0.028), BN displacement/UI (6.85 vs 7.75; P = 0.019), hiatal AP diameter/AI (9.6 mm vs 8.5 mm; P = 0.047) and MOS/SI (2.42 vs 2.19; P = 0.013).Conclusions: In this large retrospective study we did not find any strong associations between sonographic or palpatory measures of PFM function and symptoms of urinary incontinence or AI