- Email: [email protected]
Functional cine magnetic resonance imaging in women after abdominal sacrocolpopexy
Functional Cine Magnetic Resonance Imaging in Women After Abdominal Sacrocolpopexy ANDREAS LIENEMANN, MD, DOROTHE´E SPRENGER, MD, CHRISTOPH ANTHUBER, MD, ANNE BARON, MD, AND MAXIMILIAN REISER, MD Objective: To evaluate whether functional cine magnetic resonance imaging (MRI) is a reliable method for verifying postoperative anatomy and function in women after abdominal sacrocolpopexy. Methods: We did postoperative functional cine MRI in 25 women who had sacrocolpopexies. Visibility of grafts and vaginal and sacral fixation points were assessed and correlated with intraoperative results. Ranges of vaginal movement were calculated and compared with results of postoperative gynecologic examinations. Results: Functional cine MRI achieved full view of vaginas in all cases. The mean vaginal axis was 142°. Grafts were entirely visible in 13 women, partly visible in nine, and not visible in three. Functional cine MRI defined exactly the sacral fixation points in 22 women. Compared with intraoperative results, functional cine MRI showed a higher level of fixation in nine of 11 women. Functional cine MRI defined exact vaginal fixations point in 15 of 25 women. According to the pubococcygeal reference line, the postoperative range of movement of the vaginal apex was 1.8 cm. Recurrent vaginal vault prolapses in three women were detected equally by functional cine MRIs and gynecologic examinations. In those cases, no parts of patches were seen on the images. Conclusion: Functional cine MRI provided reliable abdominal sacrocolpopexy follow-up data. It might help with individual surgical planning and augment understanding of benefits and flaws of various surgical approaches to repair of vaginal vault prolapse. (Obstet Gynecol 2001;97:81–5. © 2001 by The American College of Obstetricians and Gynecologists.)
Sacrocolpopexy is believed to be one of the most successful measures for treating symptomatic prolapse of the vaginal vault.1– 4 According to previous reports, the desired obliteration of the pouch of Douglas for correction and prevention of postoperative enteroceles also was achieved with it.5 Some investigators deFrom the Departments of Diagnostic Radiology and Obstetrics and Gynaecology, Klinikum Grosshadern, Ludwig-Maximilians-Universita¨t Mu¨nchen, Mu¨nchen, Germany.
VOL. 97, NO. 1, JANUARY 2001
scribed their experience with other techniques for treating vaginal vault prolapse, such as paravaginal defect repair or intraperitoneal vaginal vault fixation on the sacral portion of the sacrouterine ligaments.6 To rate surgical success one should have objective findings besides subjective criteria, especially for assessing anatomy-restoring surgery, or when different approaches are appropriate. Diagnostic imaging was done mainly by introital ultrasound and lateral colpocystorectography, which have advantages and drawbacks.7,8 Functional cine magnetic resonance imaging (MRI) allows complete and dynamic view of motility and interaction of all pelvic floor organs.9,10 Our study assessed the potential of functional cine MRI for depicting postoperative anatomy and function in women who had sacrocolpopexies, one of the most common treatments of vaginal vault prolapse.
Materials and Methods In 1998 and 1999 we examined 25 consecutive women (mean age 61.7 years; mean parity 2.5; mean height 164.2 cm; mean weight 66.8 kg) who had abdominal sacrocolpopexies. The average time between operation and gynecologic examination and functional cine MRI was 12 months. All women signed informed consent forms before participation. Sacrocolpopexies were done by the same surgeon (C.A.). Fixation of the vaginal vault on the anterior longitudinal ligament of the os sacrum was achieved with interpositioned patch.1 The surgeon chose the deepest accessible sacral fixation point for the patch, which was approximately 5– 6 cm below the promontorium. In cases with associated cystoceles or rectoceles, the vaginal fixation point of the patch was chosen to be the anterior or posterior vaginal wall only. A combined prolapse was treated with an anterior and posterior vaginal patch fixation. Polytetrafluoroethylene patches
0029-7844/01/$20.00 PII S0029-7844(00)01102-9
81
Table 1. Previous Pelvic Floor Surgery Procedure
n ⫽ 22
Anterior and posterior colporrhaphy Anterior colporrhaphy Posterior colporrhaphy Colposuspension Needle suspension Urethral sling Ventrofixation of vagina Suspension of vaginal vault (McCall procedure)
8 4 1 4 1 1 2 1
were used in 11 women, dura mater patches in 14. All women had longitudinal suturing of the peritoneum of the small pelvis (modified Moscowicz procedure). Twenty-two women had previous pelvic floor surgeries (Table 1). Postoperative gynecologic examination was done by two experienced gynecologists (C.A. and A.B.). Clinical assessment included documentation of patient complaints and physical examination using a bivalve speculum with women in the dorsal lithotomy position. Pelvic support was assessed with women straining maximally. Urethra and bladder, vaginal vault-cervix, and rectum were identified separately. Prolapse classification was graded using a modified version of the score proposed by the International Continence Society.11,12 We modified the score concerning the defined points Ba and Bp, which according to ICS classification indicate the most distal position of the anterior (Ba) and posterior (Bp) vaginal walls. In cases with no descent of the upper third of the vagina, after definition those points were defined by ⫺3, ie, identical to points Aa or Ba. In cases of high cystoceles approaching the hymenal fringe up to a distance of 3 cm, with the unmodified score point Ba also would have to be defined as ⫺3, rendering differentiation impossible. In the present study, in cases with no vaginal descent we defined the points Ba and Bp by ⫺6 instead of ⫺3. To determine the objective degree of stress urinary incontinence, the clinical cough stress test13 was used with the bladder filled to 400 mL. Intraoperative documentation of vaginal fixation points was made in all cases. Presumed exact sacral fixation points of patches were documented for 11 women. Functional cine MRI was done with a 1.5 Tesla superconductive magnet unit (Vision, Siemens, Erlangen, Germany). Opacification of vagina and rectum was achieved with sonography gel. The vagina was considered adequately filled when gel appeared at the orifice. The filling of the rectum was discontinued when women expressed discomfort. Urethra and bladder were not opacified. Examinations were done with women supine with
82 Lienemann et al
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their legs slightly spread apart. Absorbent pads prevented leakage of gel. No premedication was given. Functional cine MRI was done according to Lienemann et al9 using static axial and sagittal T2-weighted spin echo sequences and dynamic sagittal fast imaging with steady precession sequence (true-FISP). In cases in which the patch interposed between the vaginal vault and os sacrum, and not parallel to the sagittal midline, thus insufficiently visible, additional sequences were acquired to obtain a near-full longitudinal view of the patch. The patch on the axial image was used as a reference point. During examination, women were asked to relax their pelvic floor muscles, contract them slowly, relax again, then increase their intra-abdominal pressure by straining to defecate.9 Images were evaluated on a workstation by two experienced abdominal radiologists (D.S. and A.L.) who were blinded to results of surgery and physical examinations. In cases of disagreement, a consensus reading was done. Special attention was given to visibility, signal intensity, and sagittal diameter of interposed patches in all sequences, and to identification of vaginal (ventrally, dorsally, both, or vaginal apex) and sacral (vertebral body) fixation points of patches. The angle of the vaginal axis also was calculated. The pubococcygeal reference line was used in the dynamic sequences to assess orientation and vaginal stability. The reference line was drawn between the inferior rim of the pubic bone as visible on the sagittal image and the last visible intervertebral space seen at the coccygeal bone (Figure 1). Reliability of functional cine MRI for assessing the criteria was compared with clinical evaluation and intraoperative results.
Results Postoperative gynecologic examinations found stage I pelvic organ prolapses in 15 women, stage II prolapses in seven, and stage III prolapses in three. In the latter, quantitative description found recurrent vaginal vault prolapse. During surgery, patches were fixed ventrally to vaginal apexes in two cases, dorsally in ten cases, directly at the apex in two cases, and on both sides in 11 cases. Sacral fixation points could be estimated only in 11 women. In seven cases, patches were attached at S3, in three cases at S4 and in one S2 of the sacral bone. With functional cine MRI, the full length of the vagina was seen in all women. Vaginal axes were calculated on average 142° (range 124°–178°). The interposed patch between the vaginal apex and os sacrum could be entirely seen in 13 and partly in nine of 25 women. All patches except one were seen as rubber-
Obstetrics & Gynecology
Figure 1. A 79-year-old woman with a good result after abdominal sacrocolpopexy and colposuspension. a) Midsagittal image at rest: The polytetrafluoroethylene patch (arrows) interposed between the vaginal vault (arrowhead) and os sacrum (asterisk) is visible in full length. b) On straining, the patch maintains the vagina in virtually the same retroverted position as at rest, although sufficient vaginal mobility persists postoperatively. V ⫽ vagina; S ⫽ small bowel, pubococcygeal reference line.
band–like structures of low signal intensity. Mean diameters of the patches seen on sagittal images were always less than 1 cm. In one case the patch was broadened and surrounded by inflammatory tissue (Figure 2). In three of 25 women no part of patches could be seen on functional cine MRI. Regarding the material of the 11 polytetrafluoroethylene patches, six were entirely visible and three were partly visible. Seven of the 14 dura mater patches were
Figure 2. A 52-year-old woman who presented with lower abdominal pain and pyrexia 6 months after abdominal sacrocolpopexy. Parasagittal image on straining shows the polytetrafluoroethylene patch (arrows) interposed between the vaginal vault (arrowhead) and promontorium in full length. It appears to be thick with inhomogeneous signal. At surgery the patch was entirely surrounded by inflammatory granulation tissue.
VOL. 97, NO. 1, JANUARY 2001
entirely visible and six of them were partly visible in functional cine MRI. Functional cine MRI identified exact sacral fixation points of vaginas after sacrocolpopexy in 22 women, which was S1 in seven women, S2 in 12, and S3 in three. In the remaining three women, typical low-signal, Vshaped thickening of the presacral tissue could not to be identified. A direct comparison with intraoperative results could be done in 11 cases. In only two of those cases could an approximate correspondence between locations be stated. In each of the remaining nine cases, functional cine MRI showed more cranial locations of patches. That discrepancy amounted to the length of one vertebral body in four women and two vertebrae in five. The vaginal fixation point of a patch is localized on functional cine MRI by direct view of insertion point or circumscribed thickening of the vaginal wall (Figure 3). Those signs could be discerned on the ventral aspect of the vagina in five, the apex in three, the dorsal aspect in nine, and on both sides in eight women. The intraoperative presumption of vaginal fixation point of patches corresponded with fixation points found by functional MRI in only 15 of 25 women. Functional cine MRI found the postoperative mean distance between the vaginal vault and the pubococcygeal reference line at ⫹3.8 cm on relaxation (range 5.7– 0.5 cm) and ⫹2.2 cm on straining (range 4.7– ⫺3.2 cm). In three women with clinically verified vaginal vault reprolapse, functional cine MRI showed descent of the vaginal apex below the reference line
Lienemann et al
Magnetic Resonance Imaging
83
Figure 3. a) In this 41-year old woman, the dura mater patch is a band-like structure (arrows) of low to intermediate signal intensity. The sacral fixation point (asterisk) can be identified at the level of S3. Note the thickening of the dorsal vaginal wall that indicates the vaginal insertion point of the patch. V ⫽ vagina. b) This coronal oblique image of the same woman shows the patch (arrow) to be situated left laterally to the midsagittal orientation, between the rectum and the small bowel loops.
during straining. Also no part of patches could be identified.
Discussion Our technique of functional cine MRI provided objective, detailed visual information on pelvic organs in postoperatively altered topographic anatomy. Among women suffering pelvic floor descent and associated conditions, hitherto used methods of diagnostic imaging were introital or perineal ultrasound and lateral colpocystorectography.7 Advantages of ultrasound include availability, cost effectiveness, and short examination time. However, it has clear limitations when assessing the middle and posterior compartments. There is a strong operator dependency in it also. Roentgenologic methods are not commonly used, mostly because of exposure to radiation, superimposition of structures, and lack of visibility of the graft.8 There is very little published data on MRI evaluation after sacrocolpopexy. On dynamic MRI examinations an average of 2 months after sacrocolpopexy, Monga et al found higher positions of the vaginal vault during relaxation and on straining, and a significantly elevated rectum on straining in eight women. They recommended the method as a suitable instrument for objective pre- and postoperative imaging and to plan surgery.14 Goodrich et al and Osaza et al drew the same conclusion after assessing anatomic and topographic changes of pelvic organs before and after prolapse surgery.15,16 In contrast, our method used static and functional sequences to get an appropriate view of movement of the vagina. An important advantage of our method was generally good and full visibility of the patch inter-
84 Lienemann et al
Magnetic Resonance Imaging
posed between the vaginal vault and os sacrum. By using specially adjusted oblique sequences, we were able to view the patch interposed between the vaginal vault and os sacrum in 22 of 25 women (Figure 3). In three cases in which interposed patches could not be seen on functional cine MRI, we clinically and radiologically assessed a postoperative vaginal apex descent. Thus we hypothesize a correlation between patch visibility in MRI and its function, ie, its ability to keep the vaginal vault in the desired straight position. Another important advantage of our method is its ability to distinctly identify exact fixation points of patches on the os sacrum. That is crucial because the sacral fixation point defines the axis of the vagina and the hight of the cul-de-sac closure. In nine of 11 cases, clinically presumed sacral fixation points diverged from those on MRI examination. Images generally showed the vagina fixated at a steeper and possibly less physiologic14 angle than advocated by other investigators1– 4 and intraoperatively intended. One reason for that might be avoiding injuries to the presacral venous plexus by choosing a more cranial level of sacral fixation.
References 1. Anthuber C, Schu¨ssler B, Hepp H. Operative therapy of the vaginal vault prolapse—abdominal sacrocolpopexy. Gyna¨kologe 1996;153:652– 8. 2. Drutz HP, Cha LS. Massive genital and vault prolapse treated by abdominal-vaginal sacropexy with use of Marlex mesh: Review of the literature. Am J Obstet Gynecol 1987;156:387–92. 3. Iosif CS. Abdominal sacral colpopexy with use of synthetic mesh. Acta Obstet Gynecol Scand 1992;72:214 –7. 4. Valaitis S, Stanton SL. Sacrocolpopexy: A retrospective study of a clinician’s experience. Br J Obstet Gynaecol 1994;101:518 –22. 5. Angulo A, Kligman I. Retroperitoneal sacrocolpopexy for correc-
Obstetrics & Gynecology
6.
7.
8.
9.
10. 11.
12.
13.
14.
tion of prolapse of vaginal vault. Surg Gynecol Obstet 1989;175: 233–7. Richardson AC, Edmonds PB, Williams NL. Treatment of stress urinary incontinence due to paravaginal fascial defect. Obstet Gynecol 1981;57:357– 62. Ko¨lbl H, Bernaschek G, Wolf GA. Comparative study of perineal ultrasound scanning and urethrocystography in patients with genuine stress incontinence. Arch Gynecol Obstet 1988;244:39 – 45. Scha¨r G, Koechli OR, Fink D, Haller U. Diagnostic value of lateral urethrocystography and perineal sonography. Geburtsh Frauenheilk 1994;54:75–9. Lienemann A, Anthuber C, Baron A, Kohz P, Reiser M. Dynamic colpocystorectography assessing pelvic-floor descent. Eur Radiol 1997;7:1309 –17. DeLancey JOL. Anatomy and biomechanics of genital prolapse. Clin Obstet Gynecol 1993;36:897–909. Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey J, Klarskov P, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10 –7. Viereck V, Peschers M, Singer M, Schu¨ssler B. Metric quantification of female genital prolapse: A useful innovation in prolapse diagnostics? Geburtsh Frauenheilk 1997;57:177– 82. Schu¨ssler B, Alloussi S. About classification of stress-incontinence according to Ingelmann-Sundberg. Gynakol Rundsch 1983;29:19 – 22. Monga AK, Heron CW, Stanton SL. How does sacrocolpopexy affect bladder function and pelvic floor anatomy? A combined urodynamic and MRI approach. Neurourol Urodyn 1994;13:378 – 80.
VOL. 97, NO. 1, JANUARY 2001
15. Goodrich MA, Webb MJ, King BF, Bampton AEH, Campeau NG, Riederer SJ. Magnetic resonance imaging of pelvic floor relaxation: Dynamic analysis and evaluation of patients before and after surgical repair. Obstet Gynecol 1993;82:883–91. 16. Osaza H, Mori T, Togashi K. Study of uterine prolapse by magnetic resonance imaging: Topographical changes involving the levator ani muscle and the vagina. Gynecol Obstet Invest 1992;34:43– 8.
Address reprint requests to:
Andreas Lienemann, MD Ludwig-Maximilians University Department of Diagnostic Radiology Klinikum Grosshadern Marchioninistrasse 15 Munich, D-81377 Germany E-mail: [email protected]
Received May 22, 2000. Received in revised form July 27, 2000. Accepted September 21, 2000.
Copyright © 2001 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
Lienemann et al
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85
Sacrocolpopexy is believed to be one of the most successful measures for treating symptomatic prolapse of the vaginal vault.1– 4 According to previous reports, the desired obliteration of the pouch of Douglas for correction and prevention of postoperative enteroceles also was achieved with it.5 Some investigators deFrom the Departments of Diagnostic Radiology and Obstetrics and Gynaecology, Klinikum Grosshadern, Ludwig-Maximilians-Universita¨t Mu¨nchen, Mu¨nchen, Germany.
VOL. 97, NO. 1, JANUARY 2001
scribed their experience with other techniques for treating vaginal vault prolapse, such as paravaginal defect repair or intraperitoneal vaginal vault fixation on the sacral portion of the sacrouterine ligaments.6 To rate surgical success one should have objective findings besides subjective criteria, especially for assessing anatomy-restoring surgery, or when different approaches are appropriate. Diagnostic imaging was done mainly by introital ultrasound and lateral colpocystorectography, which have advantages and drawbacks.7,8 Functional cine magnetic resonance imaging (MRI) allows complete and dynamic view of motility and interaction of all pelvic floor organs.9,10 Our study assessed the potential of functional cine MRI for depicting postoperative anatomy and function in women who had sacrocolpopexies, one of the most common treatments of vaginal vault prolapse.
Materials and Methods In 1998 and 1999 we examined 25 consecutive women (mean age 61.7 years; mean parity 2.5; mean height 164.2 cm; mean weight 66.8 kg) who had abdominal sacrocolpopexies. The average time between operation and gynecologic examination and functional cine MRI was 12 months. All women signed informed consent forms before participation. Sacrocolpopexies were done by the same surgeon (C.A.). Fixation of the vaginal vault on the anterior longitudinal ligament of the os sacrum was achieved with interpositioned patch.1 The surgeon chose the deepest accessible sacral fixation point for the patch, which was approximately 5– 6 cm below the promontorium. In cases with associated cystoceles or rectoceles, the vaginal fixation point of the patch was chosen to be the anterior or posterior vaginal wall only. A combined prolapse was treated with an anterior and posterior vaginal patch fixation. Polytetrafluoroethylene patches
0029-7844/01/$20.00 PII S0029-7844(00)01102-9
81
Table 1. Previous Pelvic Floor Surgery Procedure
n ⫽ 22
Anterior and posterior colporrhaphy Anterior colporrhaphy Posterior colporrhaphy Colposuspension Needle suspension Urethral sling Ventrofixation of vagina Suspension of vaginal vault (McCall procedure)
8 4 1 4 1 1 2 1
were used in 11 women, dura mater patches in 14. All women had longitudinal suturing of the peritoneum of the small pelvis (modified Moscowicz procedure). Twenty-two women had previous pelvic floor surgeries (Table 1). Postoperative gynecologic examination was done by two experienced gynecologists (C.A. and A.B.). Clinical assessment included documentation of patient complaints and physical examination using a bivalve speculum with women in the dorsal lithotomy position. Pelvic support was assessed with women straining maximally. Urethra and bladder, vaginal vault-cervix, and rectum were identified separately. Prolapse classification was graded using a modified version of the score proposed by the International Continence Society.11,12 We modified the score concerning the defined points Ba and Bp, which according to ICS classification indicate the most distal position of the anterior (Ba) and posterior (Bp) vaginal walls. In cases with no descent of the upper third of the vagina, after definition those points were defined by ⫺3, ie, identical to points Aa or Ba. In cases of high cystoceles approaching the hymenal fringe up to a distance of 3 cm, with the unmodified score point Ba also would have to be defined as ⫺3, rendering differentiation impossible. In the present study, in cases with no vaginal descent we defined the points Ba and Bp by ⫺6 instead of ⫺3. To determine the objective degree of stress urinary incontinence, the clinical cough stress test13 was used with the bladder filled to 400 mL. Intraoperative documentation of vaginal fixation points was made in all cases. Presumed exact sacral fixation points of patches were documented for 11 women. Functional cine MRI was done with a 1.5 Tesla superconductive magnet unit (Vision, Siemens, Erlangen, Germany). Opacification of vagina and rectum was achieved with sonography gel. The vagina was considered adequately filled when gel appeared at the orifice. The filling of the rectum was discontinued when women expressed discomfort. Urethra and bladder were not opacified. Examinations were done with women supine with
82 Lienemann et al
Magnetic Resonance Imaging
their legs slightly spread apart. Absorbent pads prevented leakage of gel. No premedication was given. Functional cine MRI was done according to Lienemann et al9 using static axial and sagittal T2-weighted spin echo sequences and dynamic sagittal fast imaging with steady precession sequence (true-FISP). In cases in which the patch interposed between the vaginal vault and os sacrum, and not parallel to the sagittal midline, thus insufficiently visible, additional sequences were acquired to obtain a near-full longitudinal view of the patch. The patch on the axial image was used as a reference point. During examination, women were asked to relax their pelvic floor muscles, contract them slowly, relax again, then increase their intra-abdominal pressure by straining to defecate.9 Images were evaluated on a workstation by two experienced abdominal radiologists (D.S. and A.L.) who were blinded to results of surgery and physical examinations. In cases of disagreement, a consensus reading was done. Special attention was given to visibility, signal intensity, and sagittal diameter of interposed patches in all sequences, and to identification of vaginal (ventrally, dorsally, both, or vaginal apex) and sacral (vertebral body) fixation points of patches. The angle of the vaginal axis also was calculated. The pubococcygeal reference line was used in the dynamic sequences to assess orientation and vaginal stability. The reference line was drawn between the inferior rim of the pubic bone as visible on the sagittal image and the last visible intervertebral space seen at the coccygeal bone (Figure 1). Reliability of functional cine MRI for assessing the criteria was compared with clinical evaluation and intraoperative results.
Results Postoperative gynecologic examinations found stage I pelvic organ prolapses in 15 women, stage II prolapses in seven, and stage III prolapses in three. In the latter, quantitative description found recurrent vaginal vault prolapse. During surgery, patches were fixed ventrally to vaginal apexes in two cases, dorsally in ten cases, directly at the apex in two cases, and on both sides in 11 cases. Sacral fixation points could be estimated only in 11 women. In seven cases, patches were attached at S3, in three cases at S4 and in one S2 of the sacral bone. With functional cine MRI, the full length of the vagina was seen in all women. Vaginal axes were calculated on average 142° (range 124°–178°). The interposed patch between the vaginal apex and os sacrum could be entirely seen in 13 and partly in nine of 25 women. All patches except one were seen as rubber-
Obstetrics & Gynecology
Figure 1. A 79-year-old woman with a good result after abdominal sacrocolpopexy and colposuspension. a) Midsagittal image at rest: The polytetrafluoroethylene patch (arrows) interposed between the vaginal vault (arrowhead) and os sacrum (asterisk) is visible in full length. b) On straining, the patch maintains the vagina in virtually the same retroverted position as at rest, although sufficient vaginal mobility persists postoperatively. V ⫽ vagina; S ⫽ small bowel, pubococcygeal reference line.
band–like structures of low signal intensity. Mean diameters of the patches seen on sagittal images were always less than 1 cm. In one case the patch was broadened and surrounded by inflammatory tissue (Figure 2). In three of 25 women no part of patches could be seen on functional cine MRI. Regarding the material of the 11 polytetrafluoroethylene patches, six were entirely visible and three were partly visible. Seven of the 14 dura mater patches were
Figure 2. A 52-year-old woman who presented with lower abdominal pain and pyrexia 6 months after abdominal sacrocolpopexy. Parasagittal image on straining shows the polytetrafluoroethylene patch (arrows) interposed between the vaginal vault (arrowhead) and promontorium in full length. It appears to be thick with inhomogeneous signal. At surgery the patch was entirely surrounded by inflammatory granulation tissue.
VOL. 97, NO. 1, JANUARY 2001
entirely visible and six of them were partly visible in functional cine MRI. Functional cine MRI identified exact sacral fixation points of vaginas after sacrocolpopexy in 22 women, which was S1 in seven women, S2 in 12, and S3 in three. In the remaining three women, typical low-signal, Vshaped thickening of the presacral tissue could not to be identified. A direct comparison with intraoperative results could be done in 11 cases. In only two of those cases could an approximate correspondence between locations be stated. In each of the remaining nine cases, functional cine MRI showed more cranial locations of patches. That discrepancy amounted to the length of one vertebral body in four women and two vertebrae in five. The vaginal fixation point of a patch is localized on functional cine MRI by direct view of insertion point or circumscribed thickening of the vaginal wall (Figure 3). Those signs could be discerned on the ventral aspect of the vagina in five, the apex in three, the dorsal aspect in nine, and on both sides in eight women. The intraoperative presumption of vaginal fixation point of patches corresponded with fixation points found by functional MRI in only 15 of 25 women. Functional cine MRI found the postoperative mean distance between the vaginal vault and the pubococcygeal reference line at ⫹3.8 cm on relaxation (range 5.7– 0.5 cm) and ⫹2.2 cm on straining (range 4.7– ⫺3.2 cm). In three women with clinically verified vaginal vault reprolapse, functional cine MRI showed descent of the vaginal apex below the reference line
Lienemann et al
Magnetic Resonance Imaging
83
Figure 3. a) In this 41-year old woman, the dura mater patch is a band-like structure (arrows) of low to intermediate signal intensity. The sacral fixation point (asterisk) can be identified at the level of S3. Note the thickening of the dorsal vaginal wall that indicates the vaginal insertion point of the patch. V ⫽ vagina. b) This coronal oblique image of the same woman shows the patch (arrow) to be situated left laterally to the midsagittal orientation, between the rectum and the small bowel loops.
during straining. Also no part of patches could be identified.
Discussion Our technique of functional cine MRI provided objective, detailed visual information on pelvic organs in postoperatively altered topographic anatomy. Among women suffering pelvic floor descent and associated conditions, hitherto used methods of diagnostic imaging were introital or perineal ultrasound and lateral colpocystorectography.7 Advantages of ultrasound include availability, cost effectiveness, and short examination time. However, it has clear limitations when assessing the middle and posterior compartments. There is a strong operator dependency in it also. Roentgenologic methods are not commonly used, mostly because of exposure to radiation, superimposition of structures, and lack of visibility of the graft.8 There is very little published data on MRI evaluation after sacrocolpopexy. On dynamic MRI examinations an average of 2 months after sacrocolpopexy, Monga et al found higher positions of the vaginal vault during relaxation and on straining, and a significantly elevated rectum on straining in eight women. They recommended the method as a suitable instrument for objective pre- and postoperative imaging and to plan surgery.14 Goodrich et al and Osaza et al drew the same conclusion after assessing anatomic and topographic changes of pelvic organs before and after prolapse surgery.15,16 In contrast, our method used static and functional sequences to get an appropriate view of movement of the vagina. An important advantage of our method was generally good and full visibility of the patch inter-
84 Lienemann et al
Magnetic Resonance Imaging
posed between the vaginal vault and os sacrum. By using specially adjusted oblique sequences, we were able to view the patch interposed between the vaginal vault and os sacrum in 22 of 25 women (Figure 3). In three cases in which interposed patches could not be seen on functional cine MRI, we clinically and radiologically assessed a postoperative vaginal apex descent. Thus we hypothesize a correlation between patch visibility in MRI and its function, ie, its ability to keep the vaginal vault in the desired straight position. Another important advantage of our method is its ability to distinctly identify exact fixation points of patches on the os sacrum. That is crucial because the sacral fixation point defines the axis of the vagina and the hight of the cul-de-sac closure. In nine of 11 cases, clinically presumed sacral fixation points diverged from those on MRI examination. Images generally showed the vagina fixated at a steeper and possibly less physiologic14 angle than advocated by other investigators1– 4 and intraoperatively intended. One reason for that might be avoiding injuries to the presacral venous plexus by choosing a more cranial level of sacral fixation.
References 1. Anthuber C, Schu¨ssler B, Hepp H. Operative therapy of the vaginal vault prolapse—abdominal sacrocolpopexy. Gyna¨kologe 1996;153:652– 8. 2. Drutz HP, Cha LS. Massive genital and vault prolapse treated by abdominal-vaginal sacropexy with use of Marlex mesh: Review of the literature. Am J Obstet Gynecol 1987;156:387–92. 3. Iosif CS. Abdominal sacral colpopexy with use of synthetic mesh. Acta Obstet Gynecol Scand 1992;72:214 –7. 4. Valaitis S, Stanton SL. Sacrocolpopexy: A retrospective study of a clinician’s experience. Br J Obstet Gynaecol 1994;101:518 –22. 5. Angulo A, Kligman I. Retroperitoneal sacrocolpopexy for correc-
Obstetrics & Gynecology
6.
7.
8.
9.
10. 11.
12.
13.
14.
tion of prolapse of vaginal vault. Surg Gynecol Obstet 1989;175: 233–7. Richardson AC, Edmonds PB, Williams NL. Treatment of stress urinary incontinence due to paravaginal fascial defect. Obstet Gynecol 1981;57:357– 62. Ko¨lbl H, Bernaschek G, Wolf GA. Comparative study of perineal ultrasound scanning and urethrocystography in patients with genuine stress incontinence. Arch Gynecol Obstet 1988;244:39 – 45. Scha¨r G, Koechli OR, Fink D, Haller U. Diagnostic value of lateral urethrocystography and perineal sonography. Geburtsh Frauenheilk 1994;54:75–9. Lienemann A, Anthuber C, Baron A, Kohz P, Reiser M. Dynamic colpocystorectography assessing pelvic-floor descent. Eur Radiol 1997;7:1309 –17. DeLancey JOL. Anatomy and biomechanics of genital prolapse. Clin Obstet Gynecol 1993;36:897–909. Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey J, Klarskov P, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10 –7. Viereck V, Peschers M, Singer M, Schu¨ssler B. Metric quantification of female genital prolapse: A useful innovation in prolapse diagnostics? Geburtsh Frauenheilk 1997;57:177– 82. Schu¨ssler B, Alloussi S. About classification of stress-incontinence according to Ingelmann-Sundberg. Gynakol Rundsch 1983;29:19 – 22. Monga AK, Heron CW, Stanton SL. How does sacrocolpopexy affect bladder function and pelvic floor anatomy? A combined urodynamic and MRI approach. Neurourol Urodyn 1994;13:378 – 80.
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Address reprint requests to:
Andreas Lienemann, MD Ludwig-Maximilians University Department of Diagnostic Radiology Klinikum Grosshadern Marchioninistrasse 15 Munich, D-81377 Germany E-mail: [email protected]
Received May 22, 2000. Received in revised form July 27, 2000. Accepted September 21, 2000.
Copyright © 2001 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
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