UOG Journal Club: Diagnosis of levator avulsion injury: a comparison of three methods

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This Journal Club presentation provides a summary and discussion of the following free access article published in UOG:

Diagnosis of levator avulsion injury: a comparison of three methods
H.P Dietz, F. Moegni, K.L. Shek
Volume 40, Issue 6, Date: December 2012, pages 693-698

It can be accessed here: http://onlinelibrary.wiley.com/doi/10.1002/uog.11190/abstract

Published in: Health & Medicine
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UOG Journal Club: Diagnosis of levator avulsion injury: a comparison of three methods

  1. 1. UOG Journal Club: December 2012 Diagnosis of levator avulsion injury: a comparison of three methods HP Dietz, F Moegni, KL Shek Volume 40, Issue 6, Date: December 2012, pages 693–698 Journal Club slides prepared by Dr Tommaso Bignardi (UOG Editor for Trainees)
  2. 2. Background• Levator avulsion is common after vaginal delivery and is strongly associated with prolapse and prolapse recurrence after reconstructive surgery• Levator avulsion can be diagnosed by vaginal palpation, 3D/4D translabial ultrasound or magnetic resonance imaging (MRI)• With the 3D ultrasound technique, data can be analysed as rendered volumes or else tomographic multislice imaging
  3. 3. Diagnosis of levator avulsion injury: a comparison of three methods Dietz et al., UOG 2012 The aim of this study was to compare assessment bydigital palpation and two ultrasound methods, one using rendered volumes and the other multislice imaging, for the diagnosis of levator avulsion
  4. 4. Diagnosis of levator avulsion injury: a comparison of three methods Dietz et al., UOG 2012 Patients and Methods• 266 women seen at a tertiary urogynecological unit• Each woman underwent an interview, vaginal examination and 3D/ 4D translabial ultrasound retrospective offline analysis of ultrasound volumes, blinded against clinical data, using two techniques rendered volumes tomographic ultrasound imaging (TUI)Agreement was evaluated between the ultrasound techniques and findings on digital palpationThe results were finally related to symptoms and signs of pelvic organ prolapse
  5. 5. Diagnosis of levator avulsion injury: a comparison of three methods Dietz et al., UOG 2012 Vaginal palpation The index finger is placed parallel to the urethra, with fingertip at the bladder neck. The fingertip is turned towards the inferior pubic ramus, whilst the patient is asked to contract the pelvic floor. The gap between urethra and muscle should be about one fingerbreadth. If no contractile tissue is palpated there will be room for two or more fingers between urethra and pelvic sidewall, and a diagnosis of avulsion is made.
  6. 6. Diagnosis of levator avulsion injury: a comparison of three methods Dietz et al., UOG 2012 Rendered volumes • Obtained on maximal pelvic floor contraction • Slice thickness of between 1.5 and 2.5 cm • Plane of minimal hiatal dimensions included in the ‘region of interest’
  7. 7. Diagnosis of levator avulsion injury: a comparison of three methods Dietz et al., UOG 2012 Tomographic ultrasound imaging (TUI)• Obtained during maximum pelvic floor contraction• Set of 8 slices in the axial plane at intervals of 2.5mm• Taken from 5mm caudad to 2.5mm cephalad of the plane of minimal hiatal dimensions
  8. 8. Diagnosis of levator avulsion injury: a comparison of three methods Dietz et al., UOG 2012 Results: Agreement between methodsMethods compared Agreement Cohen’s kappa (%) (95% CI)Palpation versus 86 0.43 (0.32–0.53)rendered volumeRendered volume 80 0.35 (0.26–0.44)versus TUIPalpation 87 0.56 (0.48–0.62)versus TUITUI, tomographic ultrasound imaging. CI, confidence interval
  9. 9. Diagnosis of levator avulsion injury: a comparison of three methods Dietz et al., UOG 2012 Results: Association with symptoms and signs of prolapseMethod Symptoms Significant Maximum Maximum of prolapse bladder hiatal area prolapse (POPQ stage 2+) descent on on Valsalva ultrasoundPalpation χ2 = 39.8 χ2 = 91.1 t = 4.22 t = -6.92 P< 0.001† P< 0.001† P< 0.001 P< 0.001*Rendered χ2 = 25.8 χ2 = 64.3 t = 2.73 t = -3.46volume P< 0.001* P< 0.001* P= 0.007* P< 0.001**Tomographic χ2 = 13.8 χ2 = 58.3 t = 3.78 t = -7.04ultrasound P< 0.001 P< 0.001 P< 0.001 P< 0.001*n=266 except for *n=259 and **n=252. All findings were blinded against each other,except for those marked with †.
  10. 10. Diagnosis of levator avulsion injury: a comparison of three methods Dietz et al., UOG 2012 Key findings• Vaginal palpation, rendered ultrasound volumes andmultislice imaging all seem to be moderately repeatableand they correlate moderately well with each other• Findings for all three methods are significantly associatedwith symptoms, signs and ultrasound findings of femalepelvic organ prolapse
  11. 11. Diagnosis of levator avulsion injury: a comparison of three methods Dietz et al., UOG 2012 Limitations• Retrospective analysis• Women with previous pelvic surgery not excluded• Palpation data obtained by senior author not consistentlyblinded to history and other clinical findings• These three methods need validation in other populations
  12. 12. Diagnosis of levator avulsion injury: a comparison of three methods Dietz et al., UOG 2012 Discussion points• Should the study of levator avulsion form part of routine investigations forwomen presenting with symptoms and/or signs of pelvic prolapse?• What are the clinical implications of diagnosing avulsion, especially priorto prolapse surgery?• Do the data presented in the study demonstrate the superiority ofultrasound techniques over digital palpation for diagnosing levatoravulsion?• How do the techniques investigated compare against MRI assessment?• How can we identify and counsel women at higher risk of recurrence afterpelvic reconstructive surgery?

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