Mind the Gap: Changes in Levator Dimensions After Sacrocolpopexy

The aim of the study was to compare levator hiatus (LH) and levator area (LA) on transvaginal 3-dimensional (3D) ultrasound (US) and genital hiatus (GH) size by Pelvic Organ Prolapse Quantification (POP-Q) examination before and after minimally invasive sacrocolpopexy.

Women with prolapse (POP) beyond the hymen undergoing minimally invasive sacrocolpopexy without concomitant POP repairs completed Pelvic Floor Distress Inventory short form (PFDI), POP-Q, and transvaginal 3D US before and 14 weeks after surgery. Data were analyzed by 2 urogynecologists, blinded to US image sequence and to corresponding POP-Q scores.

Forty-three patients were enrolled; 35 with complete data are included. Patients had a mean ± SD age of 55 ± 11 years. Most were white (89%), vaginally parous (94%), postmenopausal (66%), sexually active (63%), and had stage 3 POP (86%). The majority (89%) had concomitant hysterectomy, and 60% had midurethral slings. At baseline, the mean ± SD PFDI and Prolapse subscale of the Pelvic Floor Distress Inventory scores were 98 ± 50 and 42 ± 22. The median (interquartile range) POP-Q stage decreased after surgery from 3 (3) to 0 (0-1, P < 0.001) and the mean ± SD PFDI scores decreased to 55 ± 42 (P = 0.002). At baseline, the mean ± SD GH and perineal body measurements were 3.5 ± 0.7 and 2.4 ± 0.6 cm. Although the GH size decreased by 0.5 cm after surgery, perineal body was unchanged. Levator hiatus remained unchanged between the baseline and 14-week visits (P = 0.07), whereas LA increased by 0.8 cm2 (P = 0.03). At 14 weeks, the change in LA was not correlated with the change in GH (ρ = -0.2, P = 0.2) or POP stage (ρ = -0.2, P = 0.9).

Restoring the apex with sacrocolpopexy alone reduces GH size on clinical examination; however, it does not impact the size of the underlying LH on US.