Short and long-term outcomes of the Manchester Procedure for Pelvic Organ Prolapse and the impact of major Levator Ani Muscle defects
PhD thesis by Sissel Hegdahl Oversand, MD 2018
Department of Gynaecology, 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.
Cover: Hanne Baadsgaard Utigard. Print production: Reprosentralen, University of Oslo. # " !$ !
." '& * &0# &)),(* &0#),!(-/**),.
& 0.),(#'/-& 0/&-#)(-
* &0#),!(*,)&*-
-/,!#&'(! ' (.) * &0#),!(*,)&*-
." '(" -. ,*,) /,
*)*-/,! ,3#(. ,(&+/.3)(.,)&
)/.)' ' -/, -#(*)*-/,! ,3
)-.^ .#0 ( -- *.# (.- & .#)( -/,!#&. (#+/ - (.)'#& 0&/.#)(.))&- *.# (. , *),. 0&/.#)(.))&- )/.)' ' -/, - (0196,6(8, 3(8420*(1498*42,7 !(80,386,5468,+498*42,7 42510*(80437 -..#-.#&(&3- -(*)1 ,&/&.#)(- & !#-&.#)((, - ," ."#- !$ ! -"),.(&)(! . ,' #&/, ,. - *, 0& ( ) &'0/&-#)(-(#'*.)(*, )* ,.#0 -../- #'*.) &'0/&-#)(-)()( 3 ,*)-.)* ,.#0 )/.)' - (.)'#&(*.# (. , *),. )/.)' -)( 3 , . , (.#0 .#--/ *)*, *#,-1#."'#( )/-)(." '(" -. , *,) /, ! ' ."))&)!#&)(-# ,.#)(-
B #89+=+,70.3(3+789+=54591(80437 07703.+(8( !,1:0* 6.(3!641(57,"9(380-0*(80437*(1,! !">>>>> $6(375,603,(1%186(7493+ "9,780433(06,7 $,1,5/43,038,6:0,; #86,3./87(3+10208(80437 #8(80780*(1(3(1=7,7 #-/--#)() , -/&.- ! " ! ! ** (#2#." * &0#),!(*,)&*- +/(.# #.#)(*)* + -3-. ' ** (#2." * &0# &)),#-., --#(0 (.),3-"),. ),' * # ** (#2." * &0#),!(*,)&*- /,#(,3#()(.#( ( - 2/&+/ -.#)((#, -"),. ),' *#-+ ** (#2-"),. ),'*"3-##(" %-. ),." *)*-/,! ,3 #(. ,(&+/.3)(.,)&, !#-.,3 *,.' (.) !3( )&)!3 )-&)/(#0 ,-#.3")-*#.& "
C .@=OGJCHJ=K=FL=<AFL@AK*@L@=KAKO9K;9JJA=<GML9LL@==H9JLE=FL G>!QF=;GDG?Q)KDG/FAN=JKALQ"GKHAL9D9F<9LL@= 9;MDLQG>'=)KDG:=LO==F 9F< AJKLG>9DD#OGMD<DAC=LGL@9FC>GJE=J"=9<G>L@=/JG?QF=;GDG?Q/FAL DD=FGJKL9<>GJ9O9C=FAF?EQAFL=J=KLAFL@=>A=D<O@AD= =FL@MKA9KLA;9DDQL=9;@AF?E=L@=HJAF;AHD=K9F<KCADDKG>*=DNA;)J?9F *JGD9HK=KMJ?=JQMKAF?F9LAN=LAKKM=J=H9AJK -@=O9K9DKGL@=GF=O@G KL9JL=<E=GFEQ9;9<=EA;;9J==J:Q9KCAF?E=LGAFN=KLA?9L=*=DNA; )J?9F*JGD9HK=KMJ?=JQGML;GE=KG>OGE=FJ=?AKL=J=<AFL@= =H9JLE=FL8KAFL=JF9DIM9DALQ;GFLJGDJ=?AKLJQO@A;@K@=AFLJG
D
HJ=H9J=<>GJ9DEGKL9FQL@AF?L@GM?@#OADDF=N=JBGAFQGM>GJ9K;A >A EGNA= 'QKAF;=J=?J9LALM<=9DKG?G=KLGEQ;G KMH=JNAKGJFF=LAF=-L9>>O@G OAL@@=J=PLJ9GJ
E
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he 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 uterus and vagina 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 hysterectomy, 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 22 =PL=JF9D9F9DKH@AF;L=JEMK;D=K &9L=J9DDQL@=N9?AF9>MK=KLGL@= D=N9LGJ9FAEMK;D=9F<9FL=JAGJDQLGL@=MJ=L@J99F<H=JA MJ=L@J9D ;GFF=;LAN=LAKKM=K DL=J9LAGFKG>L@=FGJE9DH=DNA;>DGGJ9F9LGEQE9Q;9MK=*=DNA; DGGJ QK>MF;LAGFL@9L;9F?AN=JAK=LG9OA<=J9F?=9F<<=?J==G>KQEHLGEK .@=EGKLHJ=N9D=FLE9FA>=KL9LAGFKAFL@=>=E9D=HGHMD9LAGF9J=*=DNA; )J?9F*JGD9HK=*)*9F</JAF9JQ9F<F9D#F;GFLAF=F;= .@= <=?J==G>E9FA>=KL9LAGFEA?@L:=:=LL=JMF<=JKLGG<9K9DA>= KH9F AFL=J9;LAGF:=LO==FHJ= <3=3 .,'*&"%-+$.-$+"'&+ 9E9?=LGL@=D=N9LGJ9FAEMK;D=&'>JGE;@AD<:AJL@O9K<=K;JA:=< :Q!9AF=Q9DJ=9 AB AFL=?JALQJ=KMDLAF?AF9EGJ=GH=FMJG?=FAL9D@A9LMKG;;MJK KL9F<9J AC 0.96, .J9FH=JAF=9D/DLJ9KGMF<AE9?=KG>AFL9;LD=N9LGJ9FAEMK;D=&' 9F<:AD9L=J9D&'9NMDKAGFK &'9NMDKAGFKE9Q:= AD 0.96,.GEG?J9H@A;/DLJ9KGMF<#E9?AF?./#AE9?=G>AFL9;L&' GMJ AE EMKL:=AFL=JHJ=L=<OAL@;9MLAGFKAF;=N9?AF9D@A9L9DKAR=AK;GJJ=D9L=< OAL@L@=OGE9FYK@=A?@L9F<HM:A;9J;@D=F?L@ 1GE=FOAL@&'9NMDKAGFK@9N= <3>3$."* &*'$(+ *=DNA;)J?9F*JGD9HK=@9KAEH9;L=<>=E9D=@=9DL@>GJL@GMK9F AF 0.96,_.@=:G9LAF AG “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 cervix 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 cystocele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id- 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 Colpocleisis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`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natomical 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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≥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`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≥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
A<=F;=#FL=JN9D & 9J
!QF=;GDG?Q)/" #FGJ<=JLG=KLAE9L= L@=AEH9;LG>&'9NMDKAGFKGFHJ= 9F<HGKLGH=J9LAN=GML;GE=KL@= ;G@GJLO9K=PL=F<=<LGAF;DM<= OGE=F
GJL@= HM:GJ=;L9D9F<HM:G;G;;Q?=9DEMK;D=K9KL@=K=EMK;D=K9J=D9J?=DQ ;GFLAFMGMK 0.96, .@=D=N9LGJ9FAEMK;D= K==F>JGE9:GN=L@=K9;J9D HJGEGFLGJQ#L@=HM:GN9?AF9D EMK;D=!&HM:G9F9DEMK;D= !9J;MKL=F
MJL@=J<=K;JA:=<:=DGO .@=L=JEN=KA;GN9?AF9D >9K;A9AKOA<=DQMK=<>GJL@=;GFF=;LAN=LAKKM=O@A;@G;;MHA=KL@= N=KA;GN9?AF9DKH9;=<=KHAL=KGE=9ML@GJK;D9AEAF?L@9LALAKFGL9LJM= >9K;A9 #FL@=GML=JH9JLKG>L@=H=DNA;>DGGJL@==F
A:JGEMK;MD9JKLJM;LMJ= ,=HJAFL=<>JGE=&9F;=Q=L9D-MJ?A;9D 9HHJG9;@=KLG*GKLG:KL=LJA;*=JAF=9DG
=;LK103 )78,8=3,*41 OAL@H=JEAKKAGF G>L@=N9?AF99F<L@=9FMK O@A;@HD9QK9FAEHGJL9FLJGD= AFE9AFL9AFAF?L@=AFL=?JALQG>L@=H=DNA;>DGGJ &9L=J9DDQL@=H=JAF=9D :G
A;A9DLJ9FKN=JK= H=JAF=9DEMK;D=K9F<>A:=JK>JGEL@=:MD:GKHGF?AGKMKEMK;D=9DKG>GJE H9JLG>L@AKKLJM;LMJ= .@=H=JAF=9D:G
A=D<'9?F=LA;,=KGF9F;=#E9?AF? ',#9F<.J9FKH=JAF=9D/DLJ9KGMF<.*/-9DDGOAF?>MJL@=J<=L9AD=< 9F9LGEA;9DCFGOD=AE9?AF? .@=E9AFJAKC>9;LGJ>GJE9BGJ&'<=>=;LK;9DD=<9NMDKAGFKAKN9?AF9D ;@AD<:AJL@ &'9NMDKAGFK9J=J9J=DQ<=K;JA:=<AFFMDDAH9JGMKOGE=FGJ 9>L=J;=K9J=9FK=;LAGF &GKKG>D=N9LGJ9FAEMK;MD9JLGF=9F<
GMF<9F)<
GMF<L@9L OGMD<<=;DAF=@QKL=J=;LGEQ>GJ *)*A>HJ=K=FL=<OAL@9F=IM9DDQ=>>A;A=FLML=JMK KH9JAF?GHLAGF
L=J AD=G;G;;Q?=GMK>AP9LAGFL@9F9>L=JK9;JGKHAFGMK>AP9LAGF AAA .@=ML=JGK9;J9DDA?9E=FLKML=JGK9;J9DDA?9E=FLKMKH=FKAGF MKM9DDQH=J>GJE=<AFLJ9H=JALGF=9DDQ :MLL@==PLJ9H=JALGF=9D 9DL=JF9LAN==PAKLK =KH=;A9DDQA>L@=;=JNAPAKAFL9;L #F'9QG ';9DDK;MD
L@=HJG;=
=JJ=<LG9K9L@J== ;GEH9JLE=FLHJG;=
L=JL@=EA< >A>LA=KALKHGHMD9JALQ<=;J=9K=< =KH=;A9DDQAFL@=/-E9AFDQ
L@=H=JAF=9D:G
L@=N9?AF9J=
L=JK@GJL=FAF?9F< J=HGKALAGFAF?G>L@=DA?9E=FLK -*-QEH@QKAK*M:AK D9<<=J//L=JMK0 09?AF9 /-DA?9E=FLK 9J
L@AK*@L@=KAK 9;;GJ
OGE=FO@G@9<J=;=AN=<*)*KMJ?=JQOAL@ F9LAN=LAKKM=J=H9AJL=;@FAIM=K9LGMJ=H9JLE=FL
=JLGL@=>DGO;@9JL A?MJ= AF*9H=J# .@==H9JLE=FL8KAFL=JF9DIM9DALQ;GFLJGDJ=?AKLJQ>GJ*)*KMJ?=JQ@9K :==FJMFFAF?KAF;= 9F<AF;DM<=KEMDLAHD=N9JA9:D=KG>O@A;@L@= >GDDGOAF?O=J==PLJ9;L=<>GJ*9H=J#<=EG?J9H@A;<9L9HJG;=
=:JM9JQ LGJMD=GML9FQ EAKK=<KMJ?=JQ>GJJ=;MJJ=FL*)*GJ;GEHDA;9LAGFKFGL=FL=J=<AFLGL@= IM9DALQ;GFLJGDJ=?AKLJQ #FGJ<=JLGA<=FLA>QH9LA=FLKOAL@J=H=9L*)* KMJ?=JA=KH=J>GJE=<9LGL@=J@GKHAL9DKL=D=H@GF=AFL=JNA=OKO=J= H=J>GJE=<:QL@=*@KLM<=FL>JGE MFLADL@==F<G> =:JM9JQ DDH9LA=FLKKLADD9DAN=O=J=;GFL9;L=<OAL@L@==P;=HLAGFG>OGE=F 9DJ=9
GJJ=;MJJ=FL*)*9LGMJ =H9JLE=FL ! 5,-17(*+ 5 8 1GE=FHJGKH=;LAN=DQAF;DM<=<>GJL@='* *)*.@='9F;@=KL=J *JG;=
GJEL@=:9KAK>GJ*9H=JK##
&'9NMDKAGFKGF:9K=DAF=<9L9 *9H=J##9KO=DD9KGFGF= Q=9JHGKLGH=J9LAN=GML;GE=K*9H=J#0 .@= AF;DMKAGFH=JAG<KL9JL=<AF);LG:=J 9F<=F<=<AF$9FM9JQ >GJ *9H=J###OAL@F OGE=FAF;DM<=<O@=J=9KL@=AF;DMKAGFH=JAG< O9K;GF;DM<=<AF$MF= >GJ*9H=J##9F<#0LGL9DDAF?F OGE=F AF;DM<=< -MJ?=JA=KO=J=H=J>GJE=<:=LO==F);LG:=J 9F<$MF= >GJ*9H=J###9F<MFLAD$9FM9JQ >GJ*9H=J#0 =L9AD=< GN=JNA=OKG>L@=KLM
DGO;@9JLKAF*9H=JK ## #0 DDH9LA=FLKJ=>=JJ=<LGL@=GMLH9LA=FL;DAFA;G>L@==H9JLE=FLG> !QF=;GDG?Q9L)/">GJHJ=GH=J9LAN==N9DM9LAGFG>*)*
=JJ=<9F<L@=OGE=FL@=J=>GJ=FGLG>>=J=<KLM
L@JGM?@GMJ*)*KMJ?=JQ AFL=JF9DIM9DALQ;GFLJGDJ=?AKLJQAFGJ<=JLG=FKMJ=L@9LL@=AF;DM<=<;G@GJL >=JKA?FA>A;9FLDQ>JGEL@=LGL9D;G@GJLMF<=J?GAF?*)*KMJ?=JQ 9LGMJ=H9JLE=FL
GJE=<9K9L@J==;GEH9JLE=FLHJG;=
L@=N9?AF9L@=J=:Q HJ=N=FLAF?J=;MJJ=F;= GJ9<=L9AD=<<=K;JAHLAGFG>L@='9F;@=KL=J*JG;=
GJL@=
9;LAGF9LL@=GF= Q=9J>GDDGO MH O9K=N9DM9L=<:QJ=KHGFK=LG9KAF?D=IM=KLAGFGFKM:B=;LAN=K9LAK>9;LAGF *9H=JK####9F<#0 *GKKA:D=;9L=?GJA;9DGHLAGFKO=J=MJ=< AEHJGN=<MF;@9F?=<GJ<=L=JAGJ9L=< OGJK= .@AKIM=KLAGFO@A;@O9K MK=<9K9KAEHD=E=9KMJ=G>L@=H9LA=FLYKGN=J9DDHGKLGH=J9LAN=LJ=9LE=FL K9LAK>9;LAGF@9KFGL:==FN9DA<9L=< $."$''*"+,*++ &.&,'*,!'*,'*%5=;7 5=;87((&"0=8 7GJH9LA=FL J=HGJL=< HJ=GH=J9LAN=9F<GF= Q=9JHGKLGH=J9LAN=KQEHLGEKG>H=DNA;>DGGJ
GJE=<>GJ*9H=J##AF;DM
$MDQ FG X -M;@KLMJGEJ=?AGF9D =L@A;9D;GEEALL===N9DM9LAGF 1JALL=FH9LA=FL;GFK=FLO9KFGL<==E=< F=;=KK9JQ>GJ*9H=J#KAF;=L@=IM9DALQ;GFLJGDH9J9E=L=JKO=J==N9DM9L=< GF9?JGMHD=N=D9F<>GJLJ=9LE=FL9DJ=9
GJ'=GJE=<;GFK=FLO9KG:L9AF=<>JGE9DDH9JLA;AH9FLK GFAF;DMKAGF .@=#FKLALMLAGF9D9L9*JGL=;LAGF)>>A;=J9L)KDG/FAN=JKALQ "GKHAL9D9HHJGN=<<9L9@9F
A;9FLDQDGO=J;MEMD9LAN=JAKCG>J=GH=J9LAGF;GEH9J=<LGH9JLA9D J=H9AJKH .@=D9LL=JO9K9DKGLJM=O@=F'9F;@=KL=J*JG;=
JGEL@= =H9JLE=FLaK*)*KMJ?=JQAFL=JF9DIM9DALQ;GFLJGDJ=?AKLJQAF;DM
>=J>JGEL@=HMJHGK=G>L@=J=?AKLJQKGL@9LAEHGJL9FLN9JA9:D=K9J= D9;CAF?9EGF?L@=J=?AKL=J=<N9JA9:D=K LGMJ=H9JLE=FLL@= AFL=JF9DIM9DALQ;GFLJGDJ=?AKLJQO9KK=LMHAF AFL@==J9G> AF;J=9KAF?HGHMD9JALQG>N9?AF9DKQFL@=LA;E=K@OAL@L@=AFL=FLAGFG> L=KLAF?L@==>>A;9;QG>F9LAN=LAKKM=J=H9AJHJG;=
A;HJ= 9F<HGKLGH=J9LAN= N9JA9:D=K9F<;GEH9J=OGE=FOAL@KAEAD9J:9K=DAF=9F9LGEA;9D*)* KM;@J=?AKLJA=KE9Q:=D=KKMK=>MD 1=L@=J=>GJ=<=;A<=<LGKL9JL9 HJGKH=;LAN=KLM
GJEAF?9,9F
K=D=;LAGF K9EHDAF?:A9K .G=FKMJ=L@9LL@=KLM
OGE=FFGLAF;DM<=<DAKL=<9K@9NAF?MF<=J?GF=9 HJAE9JQ'9F;@=KL=J*JG;=
DM=FLDQAF(GJO=?A9FGJ F?DAK@ HJGHGJLAGFG>FGF O=KL=JFAEEA?J9FLKO=J=L@=J=>GJ=KQKL=E9LA;9DDQ=P;DM<=< ):=KALQAK CFGOFLG:=@A?@DQHJ=N9D=FL9EGF?KGE=AEEA?J9FL?JGMHKAF(GJO9Q 9F<O9KL@=J=>GJ=L@GM?@LLG=PHD9AFL@AK'#