Evaluation Of The Therapeutic Efficacy For Pelvic Organ Prolapse By Pelvic Floor Ultrasound And The Value Of Pelvic Floor Tele-ultrasound

PartⅠ:Evaluated the therapeutic effect of pelvic floor rehabilitation therapy on middle-aged and elderly patients with pelvic organ prolapse by pelvic floor ultrasound combined with other auxiliary inspectionsObjective:To evaluate the treatment effectiveness of pelvic floor rehabilitation therapy on middle-aged and elderly women through analyzing the pelvic floor parameters before and after treatment by transperineal pelvic floor ultrasound(PFUS),and combined with pelvic organ prolapse quantitation(POP-Q),pelvic floor muscle strength measurement,pelvic floor electromyography and the visual analogue scale(VAS)score of perineal pain.Methods:This retrospective study enrolled 44 middle-aged and elderly patients with POP-Q stageⅠ～II,who received biofeedback-electrical stimulation combined with pelvic floor muscle training(PFMT)from October 2020 to October 2021 in our hospital.Each patient received biofeedback-electrical stimulation twice a week for a total of 10times combined with PFMT at home for 30 minutes each morning and evening.Each patient underwent transperineal pelvic floor ultrasound,POP-Q staging,pelvic floor muscle strength assessment,pelvic floor electromyography and VAS score of perineal pain before and after treatment.The changes of pelvic floor parameters before and after treatment were observed to evaluate the therapeutic efficacy.Results:After treatment,bladder lowest-symphyseal distance(BLSD),cervix-symphyseal distance(CSD),rectal ampulla-symphyseal distance(RASD),bladder lowest descent(BLD)and hiatal area(HA)at Valsalva were significantly improved compared with before treatment,the differences were statistically significant(-1.50±10.34mm vs.2.36±10.31mm,P=0.001;12.36±11.37mm vs.15.84±8.28mm,P=0.019;-5.73±9.17mm vs.-1.70±7.72mm,P=0.002;24.80±9.65mm vs.21.18±10.34mm,P=0.014;21.57±6.30cm~2 vs.20.05±5.54cm~2,P=0.000).There were no statistically significant differences in other ultrasound parameters before and after treatment(P>0.05).Regards to the POP-Q system,there were statistically significant differences in Aa,Ba and C points(-1.55±0.82cm vs.-1.83±0.77cm,P=0.014;-1.18±1.02cm vs.-1.61±0.91cm,P=0.001;-4.43±1.47cm vs.-5.18±0.93cm,P=0.000),while there were no statistically significant differences in D,Ap,Bp points and POP-Q stage.After treatment,VAS score of four tenderness points of tendon arch fascia and levator ani muscle were significantly reduced(P=0.000,P=0.001,P=0.000,P=0.003),and the EMG values of class I and class II were improved(P=0.011,P=0.001).After treatment,30 patients(68.2%)subjective positive feedback with clinical symptoms improvement.Conclusions:For middle-aged and elderly patients with POP-Q stageⅠ～Ⅱ,biofeedback-electrical stimulation combined with PFMT is effective for pelvic floor tissue repair.The level of improvement is not enough to quantitative change POP-Q stage.PFUS is an effective tool,and the PFUS parameters on Valsalva can effectively reflect therapeutic effectiveness.Part Ⅱ: Pelvic floor ultrasound for analyzing the outcomes of pelvic floor surgery for the treatment of anterior compartment prolapse: A comparative study of transvaginal mesh and native-tissue repairObjective: To compare the outcomes of transvaginal mesh(TVM)and nativetissue repair(NTR)for the repair of anterior compartment prolapse.Methods: This retrospective study involved 90 patients with anterior compartment prolapse who underwent POP surgery between January 2018 and October 2020.TVM was used to treat 53 patients and 37 underwent NTR.All patients underwent a standardized interview,POP-Q,and four-dimensional PFUS before and after the surgery.The postoperative improvement,anatomic recurrence rate of the two surgical methods and mesh display rate of the TVM group were evaluated by transperineal PFUS.Objective anatomic recurrence was defined as maximum descent of the bladder ≥10 mm below the reference line(the inferior margin of the SP),or the uterus cervix or vaginal vault at the level of or below the reference line,or rectal ampulla ≥15 mm below the reference line.The secondary outcomes were subjective recurrence and complications.Results: Subjective recurrence was 9.43%(5/53)for TVM and 16.22%(6/37)for NTR(P = 0.522).Significant recurrence of prolapse on ultrasound occurred in five patients(9.43%)after TVM and 12(32.43%)after NTR;there was a significant difference between the TVM and NTR groups(P = 0.006).In the TVM group,the mesh was visible on ultrasound in each patient.The mesh exposure rate was 1.89%(1/53).At the maximum Valsalva status,BLSD,CSD/vaginal fornix-symphyseal distance(VFSD),RASD,BLD,URA and HA in two groups were significantly improved compared with that before surgery.The postoperative HA reduction in the TVM group,compared with the NTR group,was statistically significant(5.55 ± 4.71 cm2 vs.3.09 ± 5.61 cm2,P=0.027).The incidence of de novo stress urinary incontinence(SUI)was higher in the TVM group(20.75% vs.2.70%,P = 0.030).After surgery,there were significant differences between the two groups based on bladder descent(12.02 ± 8.64 mm vs.22.41 ± 13.95 mm,P = 0.000)and urethral rotation angle(25.26 ± 13.92° vs.40.27 ± 23.72°,P =0.001).Conclusion: PFUS is effective for evaluating postoperative outcomes.TVM facilitates a better anatomic cure than NTR for anterior compartment prolapse.Part Ⅲ: Real-time tele-ultrasound system to improve the quality of pelvic floor ultrasound examination by ultrasonography-naive operators: A pilot prospective studyPurpose: This exploratory prospective study was to investigate the feasibility of real-time tele-US for improving the quality of pelvic floor ultrasound by ultrasonography-naive operator,and to explore the application value of tele-US in practical teaching.Method: Two clinicians trainee A(TA),trainee B(TB)with similar medical theoretical knowledge in basic medicine,obstetrics and gynecology,and ultrasound,but no clinical experience in ultrasound,were selected as the research objects of this study.Before the test,the two trainees were trained in pelvic floor ultrasound theory and operation.A total of 56 patients were included.For each patient,TA,TB and onsite PFUS specialist performed scanning for three consecutive times with the same procedure.TA completed the examination independently,while TB was guided by PFUS specialist using real-time tele-US.Three operators were blind to each other.The quality of images and diagnostic consistency with on-site expert were compared between TA and TB,evaluated by the reviewers who were not on-site,according to images obtained by specialists as the gold standard.TB evaluated the effect of distance teaching through questionnaires in instrument adjustment,operation techniques,diagnostic confidence,improvement of professional knowledge and training of clinical thinking ability.The expert using tele-US evaluated the effect of distance teaching through questionnaires in whether trainee could understand the requirements and meet the requirements in operation.Result: The average examination time of TB was longer than TA(15.05±6.93 min/per vs.12.68±4.47 min/per,P=0.034).For the qualitative diagnosis of POP,TA achieved good inter-observer agreement with expert only in the diagnosis of anterior pelvic prolapse(Kappa=0.691),while TB achieved in the diagnosis of anterior,middle and posterior pelvic prolapse,urethral funneling and levator ani muscle avulsion(Kappa =0.887,0.674,0.638,0.739,1.000,respectively).For 10 PFUS quantitative features,TB achieved good inter-observer agreement(>0.75)with the expert on seven(7/10,70%),while TA only two(2/10,20%)(P=0.025).For image quality,TB was superior to TA in image depth,TGC,guidance of patient coordination,position of probe,the visibility of urethra,bladder and cervix,4D image post-processing(P=0.017,0.010,0.023,0.027,0.047,0.009,0.002 and 0.000,respectively).The Likert score comprehensive assessment score was higher for TB than for TA(3.96±0.82 vs.3.09±0.87,P<0.001).TB believed that the tele-US were helpful in instrument adjustment,operation technique,diagnostic confidence,improvement of pelvic floor professional knowledge and training of clinical thinking ability in 40(71.43%),34(60.71%),45(80.36%),39(69.64%)and 33(58.93%)of cases,respectively.The expert using tele-US believed that the cases of effective communication between teacher and trainee and trainee can meet the requirements in operation were 43(76.79%)and 39(69.64%),respectively.Conclusion: Tele-US can improve the quality of pelvic floor ultrasound performed by ultrasonography-naive operators.The preliminary results suggest that tele-US is expected to further improve the training effect of pelvic floor operation skills.