title: Does it matter whether levator avulsion is diagnosed pre- or postoperatively?
abstract: OBJECTIVE
  Levator ani muscle avulsion is found in 15-30% of parturients and is associated with recurrence of pelvic organ prolapse (POP) following surgery, although most published evidence on recurrence relates to postoperative diagnosis. We performed a study to determine whether a diagnosis of avulsion after pelvic floor surgery can be used as a proxy for preoperative diagnosis.
  
  
  METHODS
  This was a retrospective study of 207 patients who were seen before and after surgery for POP between February 2007 and May 2013. All assessments included a three/four-dimensional transperineal tomographic ultrasound examination. Volume data were stored and analyzed at a later date by an operator who was blinded against all clinical data. The primary outcome measure was agreement between preoperative and postoperative diagnoses of avulsion, as evaluated by Cohen's kappa. Secondary outcome measures were the associations of pre- and postoperative diagnoses of levator avulsion with prolapse recurrence, defined as International Continence Society POP-Q Stage ≥ 2 in any compartment.
  
  
  RESULTS
  Mean follow-up after surgery was 1.3 (range, 0.3-5.5) years. Levator avulsion was found preoperatively in 111 (53.6%) patients and postoperatively in 109 (52.7%). The kappa value for the association between pre- and postoperative avulsion was 0.864 (95% CI, 0.796-0.933), signifying high agreement. The odds ratio of prolapse recurrence in women with a preoperative diagnosis of avulsion was 2.5 (95% CI, 1.3-4.5) and in those with a postoperative diagnosis it was 2.3 (95% CI, 1.3-4.2).
  
  
  CONCLUSIONS
  The diagnosis of levator avulsion by tomographic pelvic floor ultrasound is equally valid before and after pelvic reconstructive surgery for POP, and both diagnoses show excellent agreement. This implies that a postoperative diagnosis of avulsion can be used as a proxy for preoperative diagnosis. Hence, avulsion can be identified postoperatively and used for subgroup analysis in prospective surgical intervention trials to define high-risk patients. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
authors.affiliation: Sydney Medical School Nepean, Nepean Hospital, Penrith, NSW, Australia.
authors.forename: S S
authors.initials: SS
authors.lastname: Abdul Jalil
authors.affiliation: Sydney Medical School Nepean, Nepean Hospital, Penrith, NSW, Australia.|Departamento de Ginecología y Obstetricia, Facultad de Medicina, Clínica Alemana - Universidad del Desarrollo, Santiago, Chile.|Departamento de Ginecología y Obstetricia, Hospital Clínico de la Universidad de Chile, Santiago, Chile.
authors.forename: R
authors.initials: R
authors.lastname: Guzman Rojas
authors.affiliation: Sydney Medical School Nepean, Nepean Hospital, Penrith, NSW, Australia. hpdietz@bigpond.com.
authors.forename: H P
authors.initials: HP
authors.lastname: Dietz
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D008875:Middle Aged; D016017:Odds Ratio; D017773:Pelvic Floor / Q000000981:diagnostic imaging* / Q000293:injuries; D056887:Pelvic Organ Prolapse / Q000000981:diagnostic imaging / Q000601:surgery*; D011184:Postoperative Period; D011247:Pregnancy; D057234:Preoperative Period; D011446:Prospective Studies; D012189:Retrospective Studies; D014463:Ultrasonography / Q000379:methods*
keywords: avulsion; pelvic floor; prolapse; recurrence; translabial ultrasound