Mid- to Long-Term Magnetic Resonance Imaging Results of Two Prolapse Surgeries for Apical Defect: A Secondary Analysis of a Randomized Controlled Trial

Santos Junior, Luiz Carlos; Brito, Luiz Gustavo Oliveira; Castro, Edilson Benedito de; Dertkigil, Sergio; Juliato, Cassia Raquel Teatin

doi:10.1055/s-0040-1718441

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Original Article • Rev. Bras. Ginecol. Obstet. 43 (01) • Jan 2021 • https://doi.org/10.1055/s-0040-1718441 copy

Mid- to Long-Term Magnetic Resonance Imaging Results of Two Prolapse Surgeries for Apical Defect: A Secondary Analysis of a Randomized Controlled Trial

Resultados de ressonância magnética de médio a longo prazos de duas cirurgias de prolapso por defeito apical: Uma análise secundária de um ensaio clínico randomizado

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

Magnetic resonance imaging (MRI) has been considered another tool for use during the pre- and postoperative periods of the management of pelvic-organ prolapse (POP). However, there is little consensus regarding its practical use for POP and the association betweenMRI lines of reference and physical examination.We aimedto evaluate the mid- to long-term results of two surgical techniques for apical prolapse.

Methods

In total, 40 women with apical POP randomized from 2014 to 2016 underwent abdominal sacrocolpopexy (ASC group; n = 20) or bilateral vaginal sacrospinous fixation with an anterior mesh (VSF-AM group; n = 20). A physical examination using the POP Quantification System (POP-Q) for staging (objective cure) and the International Consultation on Incontinence Questionnaire-Vaginal Symptoms (ICIQ-VS: subjective cure), were applied and analyzed before and one year after surgery respectively. All MRI variables (pubococcigeous line [PCL], bladder base [BB], anorectal junction [ARJ], and the estimated levator ani subtended volume [eLASV]) were investigated one year after surgery. Significance was established at p < 0.05.

Results

After a mean 27-month follow-up, according to the MRI criteria, 60% of the women were cured in the VSF-AM group versus 45% in ASC group (p= 0.52). The POP-Q and objective cure rates by MRI were correlated in the anterior vaginal wall (p= 0.007), but no correlationwas foundwith the subjective cure. The eLASVwas largeramongthe patients with surgical failure, and a cutoff of ≥ 33.5mm3 was associated with postoperative failure (area under the receiver operating characteristic curve [ROC]: 0.813; p= 0.002).

Conclusion

Both surgeries for prolapse were similar regarding theobjective variables (POP-Q measurements and MRI cure rates). Larger eLASV areas were associated with surgical failure.

Keywords:
pelvic organ prolapse; magnetic resonance imaging; cross-sectional studies

Variables	ASC (n = 20)	VSF-AM (n = 20)	p-value
Age (years) – mean (±SD)	67.9 (4.9)	67.1 (4.82)	0.75
< 60 years	1	2
60–69 years	12	10
> 70 years	7	8
Pregnancies – mean (±SD)	4.85 (3.7)	5.4 (3)	0.28
Vaginal delivery – mean (±SD)	4.15 (3.39)	4.35 (3.08)	0.74
Body mass index (kg/m²) – mean (±SD)	27.06 (3.72)	25.79 (4.84)	0.26
Tobacco use (current or previous)	3	4	0.66
Menopause (years of age) – mean (±SD)	51.85 (3.67)	48.4 (4.25)	0.009
Preoperative POP-Q
Anterior			1.0
stages → 2	1	0
3	10	10
4	9	10
Apical			0.75
stages → 3	11	10
4	9	10
Posterior			0.79
stages → 0	1	2
1	31	2
2	6	3
3	3	3
4	9	10
GH – mean, in centimeters (±SD)	3.5 (1.08)	3.37 (1.72)	0.06
PB – mean, in centimeters (±SD)	2.15 (0.72)	2.05 (0.77)	0.77

Variables	VSF-M (n = 20)	ASC (n = 20)	p-value
Objective cure	13	15	0.49
Subjective cure	17	17	1.0
MRI measures
Bladder base – mean (±SD)	1.6 (1.8)	1.1 (1.6)	0.51
Vaginal vault – mean (±SD)	-0.08 (1.8)	-1.4 (1.0)	0.007
Anorectal junction – mean (±SD)	2.4 (0.9)	2.5 (1.0)	0.93
Rectocele – mean (±SD)	3.3 (0.6)	3.9 (0.9)	0.033
Bladder base MRI stage
Stages 0 and 1	13	14	0.73
Stage ≥2	7	6	0.73
Vaginal vault MRI stage
Stages 0 and 1	16	17	1.0
Stage ≥2	4	3	1.0
Anorectal junction MRI stage
Stage 0	14	14	1.0
Stage 1 or 2	6	6	1.0
Rectocele MRI stage
Stage 0 or 1	18	11
Stage 2	2	9	0.0013
MRI cure	12	9	0.52
Apical POP-Q
stage 0	12	14	0.74
stage 1	7	6
stage 2	1	0
Anterior (bladder)
stage 0	7	8	0.27
stage 1	2	2
stage 2	7	10
stage 3	4	0
Posterior (rectal)
stage 0	19	11	0.013
stage 1	0	4
stage 2	1	4
stage 3	0	1

Vaginal wall - n (%)	MRI failure	POP-Q Failure	p-value	Subjective failure	p-value
General	19 (47.5)	12 (30)	0.007^a a MRI general failure versus POP-Q general failure (Fisher exact test).	6 (15)	0.6^e e Subjective cure in the ICIQ-VS versus general MRI cure. 0.055^f f Subjective cure in the ICIQ-VS versus POP-Q general failure.
Anterior	13 (32.5)	11 (27.5)	0.02^b b Bladder base to PCL in the MRI (grade ≥ 2) versus POP-Q Ba > 0 (Fisher exact test).	6 (15)	0.31^g g Subjective cure in the ICIQ-VS versus POP-Q Ba > 0 (grade ≥ 2). 1.0^h h Subjective cure in the ICIQ-VS versus BB to PCL in the MRI.
Apical	7 (17.5)	0	^* * Vaginal vault to PCL in the MRI (stage ≥ 2) versus POP-Q C > 0 and subjective cure (ICIQ-VS questions 5a and 6a equal to zero) – homogenous sample, no test was made.	6 (15)	^* * Vaginal vault to PCL in the MRI (stage ≥ 2) versus POP-Q C > 0 and subjective cure (ICIQ-VS questions 5a and 6a equal to zero) – homogenous sample, no test was made.
Posterior
ARJ	12 (30)	2 (5)	0.08^c c Anorectal junction to PCL in the MRI (grade ≥ 1) versus POP-Q Bp > 0.	6 (15)	0.6ⁱ i Subjective cure in the ICIQ-VS versus ARJ to PCL in the MRI (grade ≥ 1).
Rectocele	11 (2.5)	2 (5)	0.47^d d Rectocele measure in the MRI (grade ≥ 2) versus POP-Q Bp > 0.		0.12^j j Subjective cure in the ICIQ-VS versus rectocele pouch stage in the MRI (grade ≥ 2).

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[1] Address for correspondence Cássia Raquel Teatin Juliato, MD, PhD, Universidade Estadual de Campinas, Rua Alexander Fleming 101, Cidade Universitária Zeferino Vaz, Campinas, SP, 13083-881, Brazil (e-mail: cjuliato@unicamp.br).