Arcus Tendineus Fascia Pelvis 3D Ultrasound Anatomy in Cystocele vs. Controls

Objectives: The arcus tendinous fascia pelvis (ATFP) is a crucial supporting structure for the anterior wall. We hypothesized that ATFP was not seen properly in women with cystoceles compared to nullipara using 3D endovaginal ultrasound (EVUS).

Methods: This is a retrospective analysis of the Ultrasound Database Stress Inventory (UDSI) containing 3D ultrasound and pelvic floor assessment data. The minimal levator hiatus (MLH) plane was used as the reference point to measure levator ani muscle (LAM) volumes, including puboanalis (PA), puborectalis (PR), and pubococcygeus/iliococcygeus (PC/IC). We identified bilateral points of attachment of the endopelvic fascia of the levator ani muscle to the ATFP. We outlined the pubocervical fascia along the ATFP, obtaining the area in cm2 (Fig 1). We delineated the cephalad and caudal regions of the levator ani muscle (designated as areas 1 and 6, respectively). Connecting these two strategic points, a line of reference is drawn in the right-to-left direction. We recorded the visibility of ATFP, the pubocervical area, MLH area, and the LAM volume.

Results: We included 22 nullipara and 22 women with cystocele. The mean age for nullipara was 32.5 years, and for women with cystocele, 43. The mean parity for the cystocele women was 2.36. In the pelvic examination of nulliparous women, the mean of POP-Q (Aa, Ba, C, GH, PB, TVL, Ap, Bp, D), each with corresponding values: -2, -2.7, - 6.7, 2.07, 2.17, 8.28, -2.07, -2.7, -8.2; and for women with cystocele, was -0.27, -0.27, -3.1, 3.8, 2.5, 9.27, -0.73, -0.77, -5.3).
We observed intact ATFP on both sides in all nulliparous women. In the cystocele group, 12/22 (60%) had injured ATFP (unilateral or bilateral), indicating a significant difference in the presence of ATFP between the two groups (p < 0.001) (Fig 2).
The mean pubocervical area in nulliparous women was 8.79 cm² (SD1.1), while in women with cystocele, it was 8.0 cm² (SD1.6). For LAM volume, nulliparous women had a mean of 14.75 cm³ (SD2.6), and women with cystocele had a mean of 14.84 cm³ (SD3.3). Additionally, the mean MLH area was 11cm² (SD1.9) for nulliparous women and 13.7cm² (SD3.34) for women with cystocele. Our analysis revealed no statistically significant differences between the groups for the pubocervical area (P = 0.06) or LAM volume (P = 0.7). However, there was a notable discrepancy in MLH area measurements, with a significant difference observed between the two groups (P = 0.003).

Conclusions: 60% of cystoceles can be attributed to ATFP deficiency. A significant difference observed in the MLH area despite similar LAM volume suggests MLH association with cystocele presence.