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ORIGINAL RESEARCH |
From the Departments of Diagnostic Radiology and Obstetrics and Gynaecology, Klinikum Grosshadern, Ludwig-Maximilians-Universität München, München, Germany.
Address reprint requests to: Andreas Lienemann, MD Ludwig-Maximilians University Department of Diagnostic Radiology Klinikum Grosshadern Marchioninistrasse 15 Munich, D-81377 Germany E-mail: andreaslienemann{at}compuserve.com
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Abstract |
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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.
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 described 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.
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Materials and Methods |
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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 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
).
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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 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).
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Results |
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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-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.
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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, V-shaped 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.
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Discussion |
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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 interposed 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.
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Footnotes |
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Received May 22, 2000. Received in revised form July 27, 2000. Accepted September 21, 2000.
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References |
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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.[Medline]
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.[Medline]
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6. Richardson AC, Edmonds PB, Williams NL. Treatment of stress urinary incontinence due to paravaginal fascial defect. Obstet Gynecol 1981;57:357–62.
7. Kölbl 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.[Medline]
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9. Lienemann A, Anthuber C, Baron A, Kohz P, Reiser M. Dynamic colpocystorectography assessing pelvic-floor descent. Eur Radiol 1997;7:1309–17.[Medline]
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11. 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.[Medline]
12. Viereck V, Peschers M, Singer M, Schüssler B. Metric quantification of female genital prolapse: A useful innovation in prolapse diagnostics? Geburtsh Frauenheilk 1997;57:177–82.
13. Schüssler B, Alloussi S. About classification of stress-incontinence according to Ingelmann-Sundberg. Gynakol Rundsch 1983;29:19–22.
14. 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.
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.[Medline]
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