Short and long-term outcomes of the Manchester Procedure for and the impact of major Levator Ani Muscle defects

PhD thesis by Sissel Hegdahl Oversand, MD 2018

Department of , Oslo University Hospital, Ullevål and University of Oslo, Faculty of Medicine, Norway

© Sissel Hegdahl Oversand, 2018

Series of dissertations submitted to the Faculty of Medicine, University of Oslo

ISBN 978-82-8377-335-4

All rights reserved. No part of this publication may be reproduced or transmitted, in any form or by any means, without permission.

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The pudendal nerves inervate the voluntary parts of the urethral and anal sphincters whereas the levator ani muscle complex receives its nerve supply from both the pudendal and direct sacral nerves. During the second stage of labor, the nerves to the anal sphincter undergo the most strain (8).

The connective tissue supports of and are commonly divided into 3 levels, as classified by DeLancey (see Figure 4) (9):

i. Level 1 supports the uterus and the upper vagina (= apical support), and is constituted by the cardinal and uterosacral ligaments.

ii. Level 2 provides lateral attachment to the mid-vagina by the adherence of the vagina to the aponeurosis of the levator ani and comprises the endopelvic fascia´s connections to the arcus tendineus fascia pelvis (“white line”). Figure 4: Levels of connective tissue support of uterus and vagina. iii. Level 3 keeps the Reprinted from DeLancey, JOL: Anatomic aspects of vaginal eversion after , urethra and the lower Am J Obstet Gynecol 1992; 166:1717, with permission. third of the vagina in place. Posteriorly, the vagina attaches to the perineal body and muscular fibers from the bulbospongiosus, transversus perinei and

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“The boat in dry dock” theory postulated by Norton provides a simple structural understanding of POP, particularly of uterine descent (46). The boat represents the pelvic organs, the water represents the pelvic floor muscles (PFM), and the moorings represent their fascia and ligamentous attachments to the pelvic sidewall. If the ligaments (“moorings”) are cut or the PFM tone (“water”) is reduced, increased strain will be put on the remaining structures and thereby increase the risk for POP (see Figure 7) (46).

Different types of POP can be explained by deficiencies at different levels of the pelvic organ support system, which is described and illustrated in 1.1 (see Figure 8) (9): i. A mid-compartment or apical prolapse is present when there is a prolapse of the uterine body, the vaginal vault (the bind-ending top of the vagina after total hysterectomy) or the after subtotal hysterectomy. Level 1 defects Figure 8: Above: Uterovaginal prolapse lead to mid- and anterior (involving all three compartments). compartment prolapses. Below: Anterior compartment prolapse. ii. An anterior compartment Reprinted from Haylen et al: An IUGA / ICS Joint Report on the Terminology for prolapse is the bulging of the Female Pelvic Organ Prolapse (POP), Neurourol Urodyn 2016; 35 (2):137-168, anterior vaginal wall into the with permission. vagina. It contains a

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 BA 

D=<L@= LGO9JF9?9AFKLL@=AJMK=  .@=K=O9JFAF?KAF 9<DALA?9LAGFK9?9AFKLE==KKAGF9DK9F<E9FM>9;LMJ=JK@9N=D=<LGL@=<=;DAF=AFMK=G> KQFL@=LA;E=K@=KAFN9?AF9DKMJ?=JQ   .@=J=9J=@GO=N=JKLADD;GFLJGN=JKA=K;GF;=JFAF?A>9F<O@=FLGMK= KQFL@=LA;E=K@=K9F<O@A;@CAFE=K@=KLG=EHDGQ M=LG @=L=JG?=F=ALQAFGML;GE=N9JA9:D=KJ=KMDLK>JGEKLML=FFGL ;GEH9J9:D=:MLL@=;MJJ=FL?=F=J9DJ=;GEE=F<9LAGFAKL@9L9HGKL=JAGJ ;GEH9JLE=FLE=K@ALK9F<L@9L9FL=JAGJ ;GEH9JLE=FLE=K@HD9;=E=FL@9N=DAEAL=<AFAF< L@9LOGE=FOAL@&'9NMDKAGFKK== @9N=9 J=;MJJ=F;=9>L=J*)*KMJ?=JQ9F<;D9AEL@9LN9?AF9DKQFL@=LA;E=K@AK AFL=J*)*KMJ?=JQJ=E9AFKMF;D=9J   DDE=K@LQH=K@9N=L@=AJ9GJE9F;=AFJ=?9J<LG9F9LGEA;9DJ=KMDLKO@=FMK=< N9?AF9DDQ:MLOAL@9@A?@JAKCG>E=K@;GEHDA;9LAGFK GEHDA;9LAGFK 9J=D=KK>J=IM=FLO@=FL@=E=K@AKHD9;=<9:GJE9F;=LGGL@=JE9L=JA9DKAF9:GJ9@QKL=J=;LGEQ@QKL=J=;LGEQ>GJ:=FA?FAF

 BB 

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 BC 

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 BD 

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 BE 

Mid- compartment POP Intact Previous uterus hysterectomy

Hysterectomy

Uterus-sparing Subtotal Total surgery

Abdominal/ Abdominal/ laparoscopic/ Vaginal laparoscopic/ Vaginal robotic robotic

Native tissue Synthetic vaginal Sacrospinous repairs mesh procedures Obliterative vault fixation procedures

Sacrohysteropexy McCalls Culdoplasty Uterosacral Sacrospinous ligament ligament suspension suspension Sacrocolpopexy

Manchester Sacrospinous hystero- LeFort´s Partial Procedure (cervico)pexy Colpocleisis

0.96,  DGO ;@9JLADDMKLJ9LAF?KGE=G>L@=E9FQHJG;=GJEA< ;GEH9JLE=FL*)* 

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 C@ 

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 DC 3.3. Anatomical evaluation tools

Pelvic Organ Prolapse Quantification (POP-Q) system (Appendix 1)(41, 51) Patients were examined preoperatively (Papers I-IV) and at one-year follow-up (Papers I, III-IV) in the dorsal lithotomy position with the head of the table elevated 30-45 degrees and the POP scored according to the standardized joint ICS /IUGA POP-Q system (41, 51). According to this system, each compartment is staged separately while the woman is performing maximum Valsalva (see Figure 14).

Figure 14: Prolapse staging (mid-compartment).

Reprinted from Haylen et al: An IUGA / ICS Joint Report on the Terminology for Female Pelvic Organ Prolapse (POP), Neurourol Urodyn 2016; 35 (2):137-168, with permission.

• Stage O: no prolapse demonstrated • Stage I: Most distal portion of the prolapse is more than 1 cm above the level of the hymen • Stage II: Most distal portion of the prolapse is 1 cm or less proximal or distal to the hymenal plane • Stage III: Most distal portion of the prolapse protrudes more than 1 cm below the plane of the hymen but protrudes no further than 2 cm less than the total vaginal length.

55

Stage IV: Vaginal eversion is essentially complete

The staging is based on six defined points measured on maximal Valsalva; Aa and Ba for the anterior compartment, C and D for the mid- compartment and Ap and Bp for the posterior compartment. Further three landmarks are measured at rest ; gh (genital hiatus), tvl (total vaginal length) and pb (perineal body), see Figure 15: POP-Q points and landmarks. Reprinted from Haylen et al: Figure 15. An IUGA / ICS Joint Report on the Terminology for Female Pelvic Organ Prolapse (POP), Neurourol Urodyn For the mid-compartment, C refers 2016; 35 (2):137-168, with permission. to the maximal descent of the cervix or vaginal cuff and D to the maximal descent of the vaginal posterior fornix. Ba refers to the maximal descent of the anterior compartment. The hymenal plane is in the POP-Q system defined as the zero (reference) level, with points proximal to the hymen being negative and points distal to the hymen being positive. For further details on the POP-Q system, see Appendix 1.

Stage ³ II was considered anatomically significant in our present study, as stage

56 

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 @?A 

PREOPERATIVELY 1 YEAR POSTOPERATIVELY

Dyspareunia * n=2 9.7% Dyspareunia n=4 5.3 % n=7 n=2

n=4 Sexually active No No Sexually active n=78 n=74 dyspareunia * n=57 90.3% dyspareunia n=71 94.7 % n=65

Did not Did not respond n=2 respond n=3 n=1 n=2

n=10 n=1

n=6

Sexually inactive Sexually inactive n= 70¬ n=63 n= 74

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