Pubocervical fascia (PF) is a common place of injury during labor and delivery, which in turn affects the apical and anterior support [1]. Therefore, we believe that the identification of PF injury before surgery is essential in the evaluation of pelvic organ prolapse (POP) patients. Our aim is the evaluation of the pubocervical fascia (PF) with endovaginal ultrasonography (EVUS) and correlating it with findings during ultrasonography robotic-assisted sacrocervicopexy and pubocervical fascia reconstruction (u-RALS-PFR).

A retrospective analysis was done in 110 women with symptomatic POP, each of whom underwent an initial pelvic floor ultrasonography (PFUS) evaluation. This pre-operative evaluation was done using perineal pelvic floor ultrasonography (pPFUS) and 3D-EVUS during Valsalva. We identified areas of pubocervical fascia weakness (PFW) based on the presence of any hypoechoic areas (HA) between the bladder floor and anterior vaginal wall. Several measurements were performed on the main HA—the hypoechoic area distance to pubic symphysis (HAD-PS), the hypoechoic area distance to bladder neck (HAD-BN), and the hypoechoic area distance to posterior bladder wall (HAD-PBW). These measurements were taken on sagittal view during EVUS with a mean bladder volume of 150-200cc (pre-void) and 8-55cc (post-void). We then correlated the PFW with its respective pelvic organ prolapse quantification staging (POP-Q stage). All participants underwent a standardized evaluation comprised of a structured urogynecologic history and physical examination with pelvic organ prolapse quantitative staging. Of the 110 women, 15 desired to undergo minimally invasive surgery with u-RALS-PFR. Ultimately, we were able to use our initial measurements to compare our office findings with the findings noted during surgery.

Median follow-up in the 110 women with complete data was 8 months. We used a quantitative measure of HA between the bladder and anterior vagina, during the Valsalva maneuver, and found a significant association between HA, POP-Q stages and the number of plications during surgery. The bigger the HA, the more severe the POP-Q stage on the anterior compartment and more plications on the pubocervical fascia. In our previous publication, we have described our plication technique during robotic sacrocervicopexy [2].

This finding supports our hypothesis that pubocervical fascia injury may present as HA during endovaginal ultrasonography and this allows us to plan the plication of the PF during robotic sacrocervicopexy.

Measures of hypoechoic areas obtained by sonographic imaging between the anterior vaginal wall and bladder floor are associated with severe POP-Q stage at the apical and anterior compartments, supporting our theory that pubocervical fascia injuries may present as hypoechoic areas during EVUS. This seems to correlate with the number of plications we do during robotic sacrocervicopexy and may prevent anterior compartment failures. This may open new applications for ultrasonography in the evaluation and treatment of POP.

Davila, H.H., Brown, K., Dara, P. et al. Robotic-assisted laparoscopic apical suspension: description of the spiral technique. J Robotic Surg (2018). https://doi.org/10.1007/s11701-018-0879-1.
Davila, H.H, Abdelhameed, S. Malave-Huerta D. et al. Ultrasonography and robotic-assisted laparoscopic sacrocervicopexy with pubocervical fascia reconstruction: comparison with standard technique. J Robotic Surg (2020). https://doi.org/10.1007/s11701-020-01051-0