Defining mechanisms of recurrence following apical prolapse repair based on imaging criteria - 29/10/21
, Steven D. Abramowitch, PhD a, Mark E. Lockhart, MD, MPH c, Alison C. Weidner, MD d, Cecile A. Ferrando, MD, MPH, FACOG, FACS e, Charles W. Nager, MD f, Holly E. Richter, PhD, MD g, Charles R. Rardin, MD h, Yuko M. Komesu, MD i, Heidi S. Harvie, MD, MSCE, MBA j, Donna Mazloomdoost, MD, FACOG k, Amaanti Sridhar, MS l, Marie G. Gantz, PhD lOn behalf of the
Eunice Kennedy Shriver National Institute of Child Health and Human Development Pelvic Floor Disorders Network
Abstract |
Background |
Prolapse recurrence after transvaginal surgical repair is common; however, its mechanisms are ill-defined. A thorough understanding of how and why prolapse repairs fail is needed to address their high rate of anatomic recurrence and to develop novel therapies to overcome defined deficiencies.
Objective |
This study aimed to identify mechanisms and contributors of anatomic recurrence after vaginal hysterectomy with uterosacral ligament suspension (native tissue repair) vs transvaginal mesh (VM) hysteropexy surgery for uterovaginal prolapse.
Study Design |
This multicenter study was conducted in a subset of participants in a randomized clinical trial by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Pelvic Floor Disorders Network. Overall, 94 women with uterovaginal prolapse treated via native tissue repair (n=48) or VM hysteropexy (n=46) underwent pelvic magnetic resonance imaging at rest, maximal strain, and poststrain rest (recovery) 30 to 42 months after surgery. Participants who desired reoperation before 30 to 42 months were imaged earlier to assess the impact of the index surgery. Using a novel 3-dimensional pelvic coordinate system, coregistered midsagittal images were obtained to assess study outcomes. Magnetic resonance imaging–based anatomic recurrence (failure) was defined as prolapse beyond the hymen. The primary outcome was the mechanism of failure (apical descent vs anterior vaginal wall elongation), including the frequency and site of failure. Secondary outcomes included displacement of the vaginal apex and perineal body and change in the length of the anterior wall, posterior wall, vaginal perimeter, and introitus of the vagina from rest to strain and rest to recovery. Group differences in the mechanism, frequency, and site of failure were assessed using the Fisher exact tests, and secondary outcomes were compared using Wilcoxon rank-sum tests.
Results |
Of the 88 participants analyzed, 37 (42%) had recurrent prolapse (VM hysteropexy, 13 of 45 [29%]; native tissue repair, 24 of 43 [56%]). The most common site of failure was the anterior compartment (VM hysteropexy, 38%; native tissue repair, 92%). The primary mechanism of recurrence was apical descent (VM hysteropexy, 85%; native tissue repair, 67%). From rest to strain, failures (vs successes) had greater inferior displacement of the vaginal apex (difference, −12 mm; 95% confidence interval, −19 to −6) and perineal body (difference, −7 mm; 95% confidence interval, −11 to −4) and elongation of the anterior vaginal wall (difference, 12 mm; 95% confidence interval, 8–16) and vaginal introitus (difference, 11 mm; 95% confidence interval, 7–15).
Conclusion |
The primary mechanism of prolapse recurrence following vaginal hysterectomy with uterosacral ligament suspension or VM hysteropexy was apical descent. In addition, greater inferior descent of the vaginal apex and perineal body, lengthening of the anterior vaginal wall, and increased size of the vaginal introitus with strain were associated with anatomic failure. Further studies are needed to provide additional insight into the mechanism by which these factors contribute to anatomic failure.
Le texte complet de cet article est disponible en PDF.Key words : hysteropexy, magnetic resonance imaging, pelvic organ prolapse, prolapse surgery, transvaginal mesh, vaginal hysterectomy
Plan
| S.T.B. and P.A.M. contributed equally to this work. |
|
| A.S. and M.G.G. had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. |
|
| All of the authors reported receiving funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and the National Institutes of Health (NIH) Office of Research on Women’s Health (ORWH) and that the Boston Scientific Corporation provided partial support through a research grant to the Pelvic Floor Disorders Network (PFDN) Data Coordinating Center, RTI International. |
|
| P.A.M. reported serving as a consultant to Hologic, Inc and receiving research support from the NICHD. |
|
| S.T.A. reported receiving research support from the NICHD. |
|
| M.E.L. reported receiving personal fees from the American Institute of Ultrasound in Medicine as deputy editor for the Journal of Ultrasound in Medicine and book royalties from Elsevier and Oxford Publishers. |
|
| A.C.W. reported receiving personal fees as an assistant editor for the Obstetrical & Gynecological Survey and consultant to UroCure and research support from the NICHD. |
|
| C.E.F. reported receiving personal fees from Coloplast Corp; Boston Scientific Corporation; Medtronic USA, Inc; and Aesculap Inc. |
|
| C.W.N. reported receiving royalties for UpToDate. |
|
| H.E.R. reported receiving personal fees from the International Urogynecological Association and American College of Obstetricians and Gynecologists as an editor for the International Urogynecology Journal and Obstetrics and Gynecology Journal, respectively, and royalties from UpToDate. H.E.R. also reported receiving research support from Bluewind, Data and Safety Monitoring Board, Renovia, Allergan, the NICHD, and the National Institute of Aging. H.E.R. serves as a board member for the Worldwide Fistula Fund and American Urogynecologic Society. |
|
| C.R.R. reported receiving research support from Solace Therapeutics, Pelvalon, Foundation for Female Health Awareness, and the NICHD. |
|
| Y.M.K. reported receiving funding from Cook Myosite and research support from the NICHD. |
|
| The authors report no conflict of interest. |
|
| This study was conducted by the Eunice Kennedy Shriver NICHD-sponsored PFDN (grant number U10 HD054214, U10 HD041267, U10 HD041261, U10 HD069013, U10 HD069025, U10 HD069010, U10 HD069006, U10 HD054215, and U01 HD069031) and the NIH ORWH. Partial support for this study was supplied by Boston Scientific Corporation through a research grant to the PFDN Data Coordinating Center, RTI International. Research training support was provided by the National Institute of Biomedical Imaging and Bioengineering (NIBIB) (5T32EB003392-13) and the National Academies of Sciences, Engineering, and Medicine’s Ford Foundation Predoctoral Fellowship Program. The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the NIH or the Ford Foundation. |
|
| The NICHD project scientist (D.M.) for the PFDN at the time of this study had a role in the development of the protocol and management of the study and preparation, review, and approval of the manuscript. The funding of the study was managed by other NIH employees. The NIBIB and Ford Foundation had a role in providing research training support. Boston Scientific Corporation had no role in any aspects of this study. |
|
| Cite this article as: Bowen ST, Moalli PA, Abramowitch SD, et al. Defining mechanisms of recurrence following apical prolapse repair based on imaging criteria. Am J Obstet Gynecol 2021;225:506.e1-28. |
Vol 225 - N° 5
P. 506.e1-506.e28 - novembre 2021 Retour au numéro
Article précédent
- Subgroups of failure after surgery for pelvic organ prolapse and associations with quality of life outcomes: a longitudinal cluster analysis
- J. Eric Jelovsek, Marie G. Gantz, Emily S. Lukacz, Halina M. Zyczynski, Amaanti Sridhar, Caroline Kery, Rob Chew, Heidi S. Harvie, Gena Dunivan, Joseph Schaffer, Vivian Sung, R. Ed Varner, Donna Mazloomdoost, Matthew D. Barber, Eunice Kennedy Shriver National Institute of Child Health and Human Development Pelvic Floor Disorders Network
- Uptake and timing of risk-reducing salpingo-oophorectomy among patients with BRCA1 and BRCA2 mutations
- Maria J. Smith, Deanna Gerber, Anne Olsen, Olivia R. Khouri, Yuyan Wang, Mengling Liu, Julia Smith, Bhavana Pothuri
Bienvenue sur EM-consulte, la référence des professionnels de santé.
L’accès au texte intégral de cet article nécessite un abonnement.
Déjà abonné à cette revue ?