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Background: Black women are at an increased risk of developing uterine leiomyomas and experiencing worse disease prognosis than White women. Epidemiologic and molecular factors have been identified as underlying these disparities, but there remains a paucity of deep, multiomic analysis investigating molecular differences in uterine leiomyomas from Black and White patients., Objective: To identify molecular alterations within uterine leiomyoma tissues correlating with patient race by multiomic analyses of uterine leiomyomas collected from cohorts of Black and White women., Study Design: We performed multiomic analysis of uterine leiomyomas from Black (42) and White (47) women undergoing hysterectomy for symptomatic uterine leiomyomata. In addition, our analysis included the application of orthogonal methods to evaluate fibroid biomechanical properties, such as second harmonic generation microscopy, uniaxial compression testing, and shear-wave ultrasonography analyses., Results: We found a greater proportion of MED12 mutant uterine leiomyomas from Black women (>35% increase; Mann-Whitney U, P<.001). MED12 mutant tumors exhibited an elevated abundance of extracellular matrix proteins, including several collagen isoforms, involved in the regulation of the core matrisome. Histologic analysis of tissue fibrosis using trichrome staining and secondary harmonic generation microscopy confirmed that MED12 mutant tumors are more fibrotic than MED12 wild-type tumors. Using shear-wave ultrasonography in a prospectively collected cohort, Black patients had fibroids that were firmer than White patients, even when similar in size. In addition, these analyses uncovered ancestry-linked expression quantitative trait loci with altered allele frequencies in African and European populations correlating with differential abundance of several proteins in uterine leiomyomas independently of MED12 mutation status, including tetratricopeptide repeat protein 38., Conclusion: Our study shows that Black women have a higher prevalence of uterine leiomyomas harboring mutations in MED12 and that this mutational status correlates with increased tissue fibrosis compared with wild-type uterine leiomyomas. Our study provides insights into molecular alterations correlating with racial disparities in uterine leiomyomas and improves our understanding of the molecular etiology underlying uterine leiomyoma development within these populations., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Importance: FGM/C is common, effecting over 200 million women worldwide and has substantial associated morbidity. We seek improving the reversal procedure using ultrasound imaging., Objective: The use of peri- and intraoperative ultrasound imaging for reconstructive surgery following FGM/C for staging and surgical planning, with focus on the clitoral structures and blood flow., Study Design: This is a case series of patients with FGM/C who were evaluated and underwent reconstructive surgical management at a single institution between 2018 and 2022. Ultrasound examination with Doppler imaging was performed. The electronic medical record was queried for data regarding patient characteristics, examination and ultrasound findings, and surgical and postoperative course., Results: Seven patients are described in this case series who sustained the FGM/C with classifications ranging from Ia to IIIb. The primary complaints were dyspareunia or apareunia. Six of seven (86%) reported anorgasmia. Four of seven (57%) had prior vaginal deliveries, and one of seven (14%) was delivered only by cesarean sections, two of seven (29%) have not been able to have intercourse. Ultrasound examination was utilized to facilitate recognition of the anatomic structures during the reconstruction, and Doppler was used to evaluate the clitoral blood flow. Doppler was useful to delineate clitoral tissues from a closely involved periclitoral inclusion cyst, aiding in surgical excision while minimizing clitoral vascular or nerve injury. Postoperative anatomical restoration, sexual function, and alleviation of dyspareunia were excellent. None of the patients reported decreased sexual pleasure postoperatively., Conclusions: Ultrasound imaging with Doppler can be utilized to facilitate personalized approaches to optimize both anatomical and functional results in cases of genital reconstruction., (© 2024 International Federation of Gynecology and Obstetrics.)

Levator ani muscle (LAM) avulsion is a common complication of vaginal childbirth and is linked to several pelvic floor disorders. Diagnosing and treating these conditions require imaging of the pelvic floor and examination of the obtained images, which is a time-consuming process subjected to operator variability. In our study, we proposed using deep learning (DL) to automate the segmentation of the LAM from 3D endovaginal ultrasound images (EVUS) to improve diagnostic accuracy and efficiency. Over one thousand images extracted from the 3D EVUS data of healthy subjects and patients with pelvic floor disorders were utilized for the automated LAM segmentation. A U-Net model was implemented, with Intersection over Union (IoU) and Dice metrics being used for model performance evaluation. The model achieved a mean Dice score of 0.86, demonstrating a better performance than existing works. The mean IoU was 0.76, indicative of a high degree of overlap between the automated and manual segmentation of the LAM. Three other models including Attention UNet, FD-UNet and Dense-UNet were also applied on the same images which showed comparable results. Our study demonstrated the feasibility and accuracy of using DL segmentation with U-Net architecture to automate LAM segmentation to reduce the time and resources required for manual segmentation of 3D EVUS images. The proposed method could become an important component in AI-based diagnostic tools, particularly in low socioeconomic regions where access to healthcare resources is limited. By improving the management of pelvic floor disorders, our approach may contribute to better patient outcomes in these underserved areas.

Competing Interests: The authors have declared they have no conflicts of interest.

Introduction and Hypothesis: This study aimed to compare the difference in levator ani muscle (LAM) volumes between 'normal' and those with sonographically visualized LAM defects. We hypothesized that the 'muscle damage' group would have a significantly lower muscle volume., Methods: The study included patients who had undergone a 3D endovaginal ultrasound. The normal (NM) and damage (DM) muscle groups' architectural changes were evaluated based on anterior-posterior (AP), left-right (LR) diameter, and minimal levator hiatus (MLH) area. The puboanalis-puboperinealis (PA), puborectalis (PR), and pubococcygeus-iliococcygeus (PC) were manually segmented using 2.5 vs. 1.0 mm to find the optimal sequence and to compare the volumes between NM and DM groups. POPQs were compared between the NM and DM groups., Results: The 1.0-mm segmentation volumes created superior volume analysis. Comparing NM to the DM group showed no significant difference in LAM volume. Respectively, the mean total LAM volumes were 17.27 cm 3 (SD = 3.97) and 17.04 cm 3 (SD = 4.32), p = 0.79. The mean MLH measurements for both groups respectively were 10.06 cm 2 (SD = 2.93) and 12.18 cm 2 (SD = 2.93), indicating a significant difference (p = 0.01). POPQ analysis demonstrated statistically significant differences at Ba and Bp parameters suggesting that the DM group had worse prolapse (p = 0.05, 0.01, respectively)., Conclusions: While LAM volumes are similar, there is a significant difference in the physical architecture of the LAM and the POPQ parameters in muscle-damaged patients compared to the normal group., (© 2022. The International Urogynecological Association.)

Objectives: To determine whether transobturator slings follow a consistent path and whether there is an association between ultrasonographically visualized sling pattern or position with sling-related pain., Methods: This was a cross-sectional retrospective pilot study. We evaluated women who were presented to our clinic for pain or other urogynecologic symptoms following transobturator sling placement between 2009 and 2014. Patients had undergone a 3-dimensional endovaginal pelvic floor ultrasound, assessing minimal levator hiatus, antero-posterior diameter, left-right diameter, and the hiatal shape. The mesh patterns were categorized as seagull patterns (normal), lopsided, flat, and convoluted., Results: A total of 68 cases were reviewed. Fifty patients reported pain, and 18 did not. There were wide variations in the course of the slings. The sling center- minimal levator hiatus position ranged 14.8 mm below and 17.9 mm above the minimal levator hiatus. The lateral arm insertion points ranged between 17.1 mm below and 16.6 mm above the minimal levator hiatus. The right arm insertion points ranged between 9.6 mm below and 18.8 mm above the minimal levator hiatus. Thirty-five of 68 (70%) patients with pain and 13 of 18 (72.2%) without had abnormal sling patterns. The abnormal sling shape was not correlated with pain (P = 1). The levator shape trended toward a statistical significant correlation with sling shape abnormality (P = .084)., Conclusions: This population of women with transobturator sling complications demonstrated wide variations in anatomic paths. Neither the abnormal sling shape nor the distance of the center of the tape from the minimal levator hiatus level were correlated with pain., (© 2022 American Institute of Ultrasound in Medicine.)

There is an increasing interest in the applications of 3D ultrasound imaging of the pelvic floor to improve the diagnosis, treatment, and surgical planning of female pelvic floor dysfunction (PFD). Pelvic floor biometrics are obtained on an oblique image plane known as the plane of minimal hiatal dimensions (PMHD). Identifying this plane requires the detection of two anatomical landmarks, the pubic symphysis and anorectal angle. The manual detection of the anatomical landmarks and the PMHD in 3D pelvic ultrasound requires expert knowledge of the pelvic floor anatomy, and is challenging, time-consuming, and subject to human error. These challenges have hindered the adoption of such quantitative analysis in the clinic. This work presents an automatic approach to identify the anatomical landmarks and extract the PMHD from 3D pelvic ultrasound volumes. To demonstrate clinical utility and a complete automated clinical task, an automatic segmentation of the levator-ani muscle on the extracted PMHD images was also performed. Experiments using 73 test images of patients during a pelvic muscle resting state showed that this algorithm has the capability to accurately identify the PMHD with an average Dice of 0.89 and an average mean boundary distance of 2.25mm. Further evaluation of the PMHD detection algorithm using 35 images of patients performing pelvic muscle contraction resulted in an average Dice of 0.88 and an average mean boundary distance of 2.75mm. This work had the potential to pave the way towards the adoption of ultrasound in the clinic and development of personalized treatment for PFD.

Abstract: This clinical consensus statement on vaginal energy-based devices (EBDs) reflects an update by content experts from the American Urogynecologic Society's EBD writing group. In 2019, the American Urogynecologic Society's EBD writing group used a modified Delphi process to assess statements that were evaluated for consensus after a structured literature search. A total of 40 statements were assessed and divided into 5 categories: (1) patient criteria, (2) health care provider criteria, (3) efficacy, (4) safety, and (5) treatment considerations. Of the 40 statements that were assessed, 28 reached consensus and the remaining 12 did not. Lack of evidence was among the main reasons that vulvovaginal EBD treatment statements did not reach consensus. In March 2022, these statements were reassessed using the interim literature., Competing Interests: The other authors have declared they have no conflicts of interest., (Copyright © 2022 American Urogynecologic Society. All rights reserved.)

Objective: To evaluate the American College of Surgeons (ACS) surgical risk calculator's reliability in predicting outcomes in hysterectomies., Methods: This is a prospective cohort study at a large community-based hospital. Twenty-one preoperative and postoperative criteria were abstracted from the electronic medical record and entered into the online ACS calculator to determine a risk score. Logistical regression was used to determine the association between risk score and actual outcome. The prediction capability was analyzed with c-statistic, Hosmer-Lemeshow, and Brier score., Results: A total of 634 hysterectomies were performed during the study period from January to April 2019. Patients were predominantly 55 years old, white (53%) and overweight (body mass index 30). Predicted perioperative adverse events were significantly higher than actual adverse events across all domains. In all, 54/634 (8.5%) patients experienced postoperative urinary tract infection. C-statistics for return to operating room, renal failure, and readmission were 0.607 (95% C Statistic index [CI] 0.370-0.845), 0.882 (95% CI 0.802-0.962), 0.637 (95% CI 0.524-0.750), respectively. Brier scores approached one in all categorical domains., Conclusion: The ACS surgical risk calculator holds the promise of predicting postoperative complications or length of stay for patients undergoing hysterectomy. Further adjustment to this tool is required before it can be advocated for use in the clinical setting., (© 2021 International Federation of Gynecology and Obstetrics.)

Introduction and Hypothesis: Pelvic floor ultrasound is used as a validated technique for measuring levator ani dimensions. Vaginal manometry has been used in the past as a method to assess levator ani muscle (LAM) strength. Whether the combination of both methods can contribute to our understanding of pelvic floor pathophysiology has not yet been described. We hypothesized that as female pelvic floor muscular hiatus increases, the vaginal pressure and strength decrease., Methods: We recruited 20 asymptomatic nulliparous women ages 18-85 years. Minimal levator hiatus (MLH) area, anteroposterior/left-right (AP/LR) diameter ratio, the distance between levator plate and the pubic symphysis (LP-PS) while at rest and squeeze were measured using endovaginal ultrasound (US). Vaginal pressure at rest, squeeze (Kegel) and Valsalva were measured using 3D manometry. Logistic and linear regression analysis was performed to assess correlations., Results: MLH area was negatively correlated with the sum of all the squeeze pressures produced on the four walls of the vagina (p = 0.049, R 2  = 0.197). There was also a borderline negative correlation between MLH and the sum of rest pressures (p = 0.09, R 2  = 0.15). AP/LR ratio was negatively correlated with the sum of squeeze pressures (p = 0.056, R 2  = 0.197). LP-PS distances, both while at rest and during squeeze, were negatively correlated with the vaginal squeeze pressure (p = 0.046, R 2  = 0.21; p = 0.011, R 2  = 0.31, respectively). LP-V distance, both at rest and during squeeze, was negatively correlated with the sum of squeeze pressures on four vaginal walls (p = 0.02, R 2  = 0.25; p = 0.005, R 2  = 0.36, respectively)., Conclusions: Stronger levator ani muscles, smaller MLH area and a more oval shape of pelvic floor hiatus as assessed by pelvic floor ultrasound are associated with higher squeeze vaginal pressures as assessed by 3D manometry., (© 2022. The International Urogynecological Association.)

Objective: To compare the effects of 6% Pueraria mirifica vaginal gel with those of placebo gel on vaginal blood flow, vaginal maturation index (VMI), vaginal health index (VHI), endometrial thickness and genitourinary symptoms in postmenopausal women., Study Design: In a randomized, double-blinded, placebo-controlled study (TCTR20200624007), 72 postmenopausal women were randomized into the P. mirifica or the placebo gel group. Both groups were followed up at week 4 and week 12., Main Outcome Measure: Doppler ultrasonography pulsatility index (PI) and resistance index (RI), VMI, VHI, endometrial thickness and genitourinary symptoms were evaluated at baseline, at week 4 and week 12 of treatment., Results: Sixty-three participants completed the study. After 4 and 12 weeks of treatment, PI and RI had significantly decreased in the P. mirifica group compared with the placebo group. At week 12, PI in the P. mirifica group and in the placebo group were 3.03 + 1.09 and 6.88 + 2.16, respectively (p = 0.002). Similar changes were also demonstrated in the resistance indices. The P. mirifica group demonstrated a markedly higher mean VMI at week 12 compared with the placebo group, 55.19 ± 18.53 and 20.29 ± 28.46 (p = 0.012). In addition, all parameters of VHI based on the vaginal physical findings at week 12 in the P. mirifica group were significantly higher than in the placebo group (p < 0.001)., Conclusion: In this study, 6% P. mirifica vaginal gel for 12 weeks in postmenopausal women with GSM appeared to increase vaginal artery circulation and restore atrophic vaginal tissue., Clinical Trial Registration Number: TCTR20200624007., Competing Interests: The authors declare that they have no competing interests., (Copyright © 2022. Published by Elsevier B.V.)

Introduction and Hypothesis: The aim of this study is to develop and validate a new integral parameter, the Biomechanical Integrity score (BI-score), for the characterization of the female pelvic floor., Methods: A total of 253 subjects with normal and pelvic organ prolapse (POP) conditions were included in the multi-site observational, case-control study; 125 subjects had normal pelvic floor conditions, and 128 subjects had POP stage II or higher. A Vaginal Tactile Imager (VTI) was used to acquire and automatically calculate 52 biomechanical parameters for eight VTI test procedures (probe insertion, elevation, rotation, Valsalva maneuver, voluntary muscle contractions in two planes, relaxation, and reflex contraction). Statistical methods were applied (t-test, correlation) to identify the VTI parameters sensitive to the pelvic conditions., Results: Twenty-six parameters were identified as statistically sensitive to POP development. They were subdivided into five groups to characterize (1) tissue elasticity, (2) pelvic support, (3) pelvic muscle contraction, (4) involuntary muscle relaxation, and (5) pelvic muscle mobility. Every parameter was transformed to its standard deviation units against the patient age similar to T-score for bone density. Linear combinations with specified weights led to the composition of five component parameters for groups (1)-(5) and the BI-score in standard deviation units. The p-value for the BI-score has p = 4.3 × 10 -31 for POP versus normal conditions. A reference BI-score curve against age for normal pelvic floor conditions was defined., Conclusions: Quantitative transformations of the pelvic tissues, support structures, and functions under diseased conditions may be studied with the BI-score in future research and practical applications., (© 2022. The Author(s).)

Study Objective: The objective of this study was to determine the efficacy, safety, and healthcare resource use of laparoscopic radiofrequency ablation (LAP-RFA) compared with myomectomy in patients with symptomatic uterine leiomyomas (ULs)., Design: This was a secondary analysis of the original postmarket randomized, multicenter, longitudinal, comparative TRUST (Treatment Results of Uterine Sparing Technologies) United States trial in patients with symptomatic ULs. After the procedure, subjects were followed over a 12-month period., Setting: Multicenter trial, including hospitals with or without an academic affiliation, surgery centers, and fertility centers performing outpatient procedures for uterine myomas., Participants: A total of 57 patients were randomized to either LAP-RFA (n = 30) or myomectomy (n = 27)., Interventions: LAP-RFA or myomectomy (laparoscopic or abdominal)., Measurements and Main Results: The main outcome measures of this study were part of the secondary outcomes of the original TRUST trial. The primary outcome of this study was the reduction of UL symptoms and the improvement in patient-reported outcomes scores over time. Secondary outcomes included postprocedure hospitalization, length of stay, complications, reinterventions, and recovery time. There was a significant improvement in UL symptoms at 3 and 12 months after the procedure within each treatment group, and these improvements were similar between treatment groups. There was a significant reduction in UL symptoms per month between baseline and 12-months after the procedure for both LAP-RFA and myomectomy of 72% and 85%, respectively. A significant improvement was seen in all patient-reported outcomes scores over time for both groups. At 3 and 12 months after the procedure, the percentages of patients who were hospitalized in the LAP-RFA group were 74% and 49% lower than those of patients in the laparoscopic myomectomy group, respectively, with the 3-month difference being statistically significant. The length of hospital stay was significantly shorter in the LAP-RFA group compared with the myomectomy group (8.0 ± 5.7 hours vs 18.8 ± 14.6 hours; p < .05). Doctors recommended taking significantly less time off before returning to work for the patients in the LAP-RFA group compared with those in the myomectomy group (10.3 ± 5.1 days vs 14.5 ± 5.4 days; p < .05). The total number of days until back to normal activity was significantly lower in the LAP-RFA group compared with the myomectomy group (16.3 ± 15.2 days vs 26.5 ± 15.9 days; p < .05)., Conclusion: The results from this 12-month follow-up study suggest that LAP-RFA is a safe, effective, uterine-sparing alternative to laparoscopic myomectomy in the treatment of ULs. These data points build on previously published studies showing that LAP-RFA has lower healthcare resource use overall, including lower postprocedure hospitalization rate and shorter length of stay. In clinical practice, LAP-RFA is a promising treatment approach to ULs for women., (Copyright © 2022. Published by Elsevier Inc.)

Objective: To investigate how aging and menopausal status in absence of pregnancy and childbirth affect the elasticity of the bladder and urethra., Study Design: A single-center prospective observational study including nulliparous 10 pre- and 12 postmenopausal women. Data collection included baseline characteristics, physical examination data, questionnaire scores, PDFI and the Pelvic Floor Impact Questionnaire, and pelvic floor sonographic measurements as well as elastography measurements. The shear wave elastography (SWE) of tissue was measured using Kilopascal (kPa). The elastography measurements were taken over the rhabdosphincter, the suburethra smooth muscle, and the trigonal areas., Results: A total of 22 nulliparous subjects were enrolled in the study. The cohort's mean age was 43.5 years, the mean body mass index (BMI) was 26.8, and 86% were of Caucasian ethnicity. The postmenopausal group was older and with higher BMI (p < 0.001 and p = 0.05). They also had higher scores in all the questionnaires (p < 0.05 for all) and did not demonstrate prolapse in any compartments. The SWE results for the whole group were 35.2 kPa in the rhabdosphincter measuring point, 40.2 kPa in the sub-urethra point, and 20.6 kPa in the trigone point. Comparing the premenopause and postmenopause groups, we found lower measurements in the rhabdosphincter area and equivocal measurements for the suburethral zone. No statistically significant differences were found between the groups CONCLUSIONS: The elastic properties of the different bladder components and the urethra change with age and menopause. Using elastic properties of the tissues, we can further explore both stress urinary incontinence and overactive bladder., (© 2022 Wiley Periodicals LLC.)

We aimed to determine whether intraoperative ultrasound is a feasible tool for visualization of the pouch of Douglas (POD) to facilitate a safe vaginal entry for direct robotic vaginal trocar insertion for pelvic floor surgery. Endovaginal ultrasound-guided needle insertion of a trocar into the POD was performed in six fresh frozen female cadavers and a live sheep animal model. Using an endovaginal probe the POD was identified as a fluid-filled space clear of bowel or adhesions, then a Veress needle was also used to confirm POD localization. Access to the POD was achieved using a robotic trocar designed for this purpose. The animal study was approved by the Ethics Committee of Asaf-Harofe hospital. Direct visualization during laparoscopy in cadavers and open cadaveric dissections confirmed safe POD entry and accurate trocar placement. This method was found feasible in the development of a safe vaginal entry in both the animal and cadaveric model, possibly negating the need for laparoscopic umbilical observation., (© 2021. The Author(s), under exclusive licence to Springer-Verlag London Ltd. part of Springer Nature.)