A unified pelvic floor conceptual model for studying morphological changes with prolapse, age, and parity.

Several 2-dimensional and 3-dimensional measurements have been used to assess changes in pelvic floor structures and shape. These include assessment of urogenital and levator hiatus dimensions, levator injury grade, levator bowl volume, and levator plate shape. We argue that each assessment reflects underlying changes in an individual aspect of the overall changes in muscle and fascial structures. Vaginal delivery, aging, and interindividual variations in anatomy combine to affect pelvic floor structures and their connections in different ways. To date, there is no unifying conceptual model that permits the evaluation of how these many measures relate to one another or that reflects overall pelvic floor structure and function. Therefore, this study aimed to describe a unified pelvic floor conceptual model to better understand how the aforementioned changes to the pelvic floor structures and their biomechanical interactions affect pelvic organ support with vaginal birth, prolapse, and age. In this model, the pelvic floor is composed of 5 key anatomic structures: the (1) pubovisceral, (2) puborectal, and (3) iliococcygeal muscles with their superficial and inferior fascia; (4) the perineal membrane or body; and (5) the anal sphincter complex. Schematically, these structures are considered to originate from pelvic sidewall structures and meet medially at important connection points that include the anal sphincter complex, perineal body, and anococcygeal raphe. The pubovisceral muscle contributes primarily to urogenital hiatus closure, whereas the puborectal muscle is mainly related to levator hiatus closure, although each muscle contributes to the other. Dorsally and laterally, the iliococcygeal muscle forms a shelflike structure in women with normal support that spans the remaining area between these medial muscles and attachments to the pelvic sidewall. Other features include the levator plate, bowl volume, and anorectal angle. The pelvic floor conceptual model integrates existing observations and points out evident knowledge gaps in how parturition, injury, disease, and aging can contribute to changes associated with pelvic floor function caused by the detachment of one or more important connection points or pubovisceral muscle failure.

Hiatal failure: effects of pregnancy, delivery, and pelvic floor disorders on level III factors.

INTRODUCTION AND HYPOTHESIS: The failure of the levator hiatus (LH) and urogenital hiatus (UGH) to remain closed is not only associated with pelvic floor disorders, but also contributes to recurrence after surgical repair. Pregnancy and vaginal birth are key events affecting this closure. An understanding of normal and failed hiatal closure is necessary to understand, manage, and prevent pelvic floor disorders. METHODS: This narrative review was conducted by applying the keywords "levator hiatus" OR "genital hiatus" OR "urogenital hiatus" in PubMed. Articles that reported hiatal size related to pelvic floor disorders and pregnancy were chosen. Weighted averages for hiatal size were calculated for each clinical situation. RESULTS: Women with prolapse have a 22% and 30% larger LH area measured by ultrasound at rest and during Valsalva than parous women with normal support. Women with persistently enlarged UGH have 2-3 times higher postoperative failure rates after surgery for prolapse. During pregnancy, the LH area at Valsalva increases by 29% from the first to the third trimester in preparation for childbirth. The enlarged postpartum hiatus recovers over time, but does not return to nulliparous size after vaginal birth. Levator muscle injury during vaginal birth, especially forceps-assisted, is associated with increases in hiatal size; however, it only explains a portion of hiatus variation-the rest can be explained by pelvic muscle function and possibly injury to other level III structures. CONCLUSIONS: Failed hiatal closure is strongly related to pelvic floor disorders. Vaginal birth and levator injury are primary factors affecting this important mechanism.

Does preoperative resting genital hiatus size predict surgical outcomes?

AIM: To determine whether preoperative genital hiatus at rest is predictive of medium-term prolapse recurrence. METHODS: We conducted a retrospective study of women who underwent native tissue prolapse surgery from 2002 to 2017 with pelvic organ prolapse quantification data including resting genital hiatus at one of three time points: preoperatively, 6 weeks, and ≥1 year postoperatively. Demographics and clinical data were abstracted from the chart. Prolapse recurrence was defined by anatomic outcomes (Ba > 0, Bp > 0, and/or C ≥ -4) or retreatment. Descriptive statistics, bivariate analyses, and logistic regression analyses were performed. RESULTS: Of the 165 women included, 36 (21.8%) had prolapse recurrence at an average of 1.5 years after surgery. Preoperative resting genital hiatus did not differ between women with surgical success versus recurrence (3.5 cm [interquartile range, IQR 2.25, 4.0) vs 3.5 cm (IQR 3.0, 4.0), p = 0.71). Point Bp was greater in the recurrence group at every time point. Preoperative Bp (odds ratio [OR] 1.24, confidence interval [CI] [1.06-1.45], p = 0.01) and days from surgery (OR 1.001, CI [1.000-1.001], p < 0.01) were independently associated with recurrence. Preoperative genital hiatus at rest and strain were significantly larger among women who underwent a colpoperineorrhaphy (rest: 4.0 [3.0, 4.5] cm vs 3.5 [3.0, 4.0] cm, p < 0.01; strain: 6.0 [4.0, 6.5] cm vs 5.0 [4.0, 6.0] cm, p = 0.01). CONCLUSIONS: Preoperative genital hiatus at rest was not associated with prolapse recurrence when the majority of women underwent colpoperineorrhaphy. Preoperative Bp was more predictive of short-term prolapse recurrence. For every 1 cm increase in point Bp, there is a 24% increased odds of recurrence.

Trends in surgical complexity and treatment modalities utilized in the management of ovarian cancer in an era of neoadjuvant chemotherapy.

OBJECTIVES: To investigate the impact of the increased use of neoadjuvant chemotherapy on the complexity of cytoreductive surgeries for ovarian cancer. METHODS: Using the National Cancer Database, we performed a retrospective cohort study of women diagnosed between 2004 and 2015 with stage III or IV epithelial ovarian cancer who underwent either primary cytoreductive surgery (PDS) followed by adjuvant chemotherapy, neoadjuvant chemotherapy (NACT) followed by interval debulking surgery. Cases were assigned a surgical complexity category as 1) Inadequate, 2) Low, 3) Moderate and, 4) High complexity. The primary outcome was the trend in surgical complexity over time. Secondary outcomes included temporal trends in treatment modality, perioperative mortality, and survival. RESULTS: At total of 52,582 (76.3%) underwent PDS and 16,307 (23.7%) underwent NACT. The utilization of NACT increased from 7.7% in 2004 to 27.8% in 2015 (p-trend < 0.001). Patients undergoing moderate complexity surgeries increased from 28.9% to 33.5% and high complexity surgeries from 26.3% to 30% (p-trend < 0.001, for both). Trends in increasing surgical complexity were seen in both NACT and PDS cohorts. This increase in surgical complexity was seen most profoundly at the high-volume centers. Overall 30-day mortality decreased from 3.4% in 2004 to 1.4% in 2015; and 90-day mortality decreased from 7.6% to 4%. During the same time, 5-year survival increased from 39.7% to 49%. CONCLUSIONS: Increase in the utilization of NACT is associated with decreased 30- and 90-day mortality and increase in five-year survival. Moreover, the overall complexity of ovarian cancer surgery has increased in both PDS and NACT cohorts.