Pelvic Anatomy Research Articles

Use of the flat panel detector fluoroscope reduces radiation exposure during periacetabular osteotomy

The Periacetabular Osteotomy is a technically demanding procedure that requires precise intraoperative evaluation of pelvic anatomy. Fluoroscopic images pose a radiation risk to operating room staff, scrubbed personnel, and the patient. Most commonly, a Standard Fluoroscope with an Image Intensifier is used. Our institution recently implemented the novel Fluoroscope with a Flat Panel Detector. The purpose of this study was to compare radiation dosage and accuracy between the two fluoroscopes. A retrospective review of a consecutive series of patients who underwent Periacetabular Osteotomy for symptomatic hip dysplasia was completed. The total radiation exposure dose (mGy) was recorded and compared for each case from the standard fluoroscope (n = 27) and the flat panel detector (n = 26) cohorts. Lateral center edge angle was measured and compared intraoperatively and at the six-week postoperative visit. A total of 53 patients (96% female) with a mean age and BMI of 17.84 (± 6.84) years and 22.66 (± 4.49) kg/m2 (standard fluoroscope) and 18.23 (± 4.21) years and 21.99 (± 4.00) kg/m2 (flat panel detector) were included. The standard fluoroscope averaged total radiation exposure to be 410.61(± 193.02) mGy, while the flat panel detector averaged 91.12 (± 49.64) mGy (p < 0.0001). The average difference (bias) between intraoperative and 6-week postoperative lateral center edge angle measurement was 0.36° (limits of agreement: − 3.19 to 2.47°) for the standard fluoroscope and 0.27° (limits of agreement: − 2.05 to 2.59°) for the flat panel detector cohort. Use of fluoroscopy with flat panel detector technology decreased the total radiation dose exposure intraoperatively and produced an equivalent assessment of intraoperative lateral center edge angle. Decreasing radiation exposure to young patients is imperative to reduce the risk of future comorbidities.

Pubourethral and uterosacral male analogues suggest parallel male/female pelvic anatomy and symptom pathogenesis.

The thesis that functional/dysfunctional male/female pelvic floor anatomy are parallel, originated from two studies: a successful retropubic perineal male sling for post-prostatectomy stress urinary incontinence (SUI) and discovery of a male uterosacral ligament (USL) analogue, we named "prostatosacral ligament" (PSL). In 25 out of the studied 27 males (92.6%), it starts on both sides of the median sulcus of the prostate the ligament passes lateral to the rectum being fused with the lateral margin of the mesorectum before leaving it as it thins out to be attached posteriorly similar to the USL. The ultrasound data during straining in men and women showed the same three oppositely acting muscle vectors contracting around analogous ligaments, puboprostatic ligament (PPL) (male), and pubourethral ligament (PUL) (female). Further parallels were pubovesical ligaments (PVLs) and arc of Gilvernet as part of the continence and micturition mechanisms. Impressive evidence for parallel anatomy came from the successful cure of 22 males with post-prostatectomy SUI using a perineal retropubic tissue fixation system (TFS) minisling applied to the PPL using a similar methodology to that used in the female for PUL midurethral sling repair for cure of SUI. Laparoscopic evidence confirmed the prostate as a male analogue of the cervix, and PSLs as analogues of USLs: PSL origin from the prostate attached laterally to the mesorectum and inserted into the sacrum. Histologically, PSLs had identical features with USLs: collagen, elastin, smooth muscle, blood vessels and nerves. Virtually identical symptoms for "chronic prostatitis" (CP) and "posterior fornix syndrome" (PFS), such as chronic pelvic pain, overactive bladder (OAB), abnormal emptying, gave birth to the hypothesis, of a common pathogenesis for "CP" and "PFS", USL (or PSL) laxity. If this could be proven by "simulated operations", "CP", at least in theory, may be potentially correctible by PSL repair.

Structural, functional, and dysfunctional pelvic anatomy.

The structural basis of the Integral Theory is holistic. Four main pelvic muscles interact holistically with five main pelvic ligaments to maintain pelvic organ structure and function. The vagina is structurally weak. The support it provides to the bladder base is contingent on being stretched by opposite pelvic muscle forces, much like a trampoline. Its main role is to transmit muscle forces to facilitate continence, evacuation and control of urgency. Therefore, as an organ that cannot regenerate, the vagina should be conserved, and not excised. The ligaments provide the main structural support for the organs and are the most vulnerable part of the anatomical system to injury because their structural collagen is depolymerized prior to labour, and stretched during labour. Further ligament weakening occurs after menopause due to collagen breakdown. Hence, collagen loss is the main cause of organ prolapse and lower urinary tract symptoms (LUTS). The strengthening of damaged ligaments, whether surgically or non-surgically, can improve or cure symptoms and prolapse. Because collagen loss in ligaments is a principal cause of dysfunction in older women, collagen-creating techniques are advised: precisely inserted tapes to create neoligaments, or wide-bore No. 2 or No. 3 polyester ligament sutures instead of dissolvable sutures.

Simple pelvimetry predicts the pelvic manipulation time in robot-assisted low and ultra-low anterior resection for rectal cancer.

This study explored the difficulty factors in robot-assisted low and ultra-low anterior resection, focusing on simple measurements of the pelvic anatomy. This was a retrospective analysis of the clinical data of 61 patients who underwent robot-assisted low and ultra-low anterior resection for rectal cancer between October 2018 and April 2023. The relationship between the operative time in the pelvic phase and clinicopathological data, especially pelvic anatomical parameters measured on X-ray and computed tomography (CT), was evaluated. The operative time in the pelvic phase was defined as the time between mobilization from the sacral promontory and rectal resection. Robot-assisted low and ultra-low anterior resections were performed in 32 and 29 patients, respectively. The median operative time in the pelvic phase was 126 (range, 31-332)min. A multiple linear regression analysis showed that a short distance from the anal verge to the lower edge of the cancer, a narrow area comprising the iliopectineal line, short anteroposterior and transverse pelvic diameters, and a small angle of the pelvic mesorectum were associated with a prolonged operative time in the pelvic phase. Simple pelvic anatomical measurements using abdominal radiography and CT may predict the pelvic manipulation time in robot-assisted surgery for rectal cancer.

Progress on treatment of acetabular quadrilateral plate injury

Acetabular quadrilateral plate injury has become a hot spot and focus in the field of orthopaedic trauma and pelvic floor function in recent years. Although there are five fracture types,they are all based on fracture morphology,without considering the pulling force of ligaments,joint capsular and muscles. A perfect classification needs to describe the displacement of bone mass in three-dimensional space to better guide reduction and fixation. The seven incision and exposure methods are still the traditional open-eye surgery,and how to protect the criss-crossing vascular neural network and pelvic organs is still the focus. Quadrilateral defect causes dislocation of artificial hip joint,and quantitative evaluation of quadrilateral defect volume and revision techniques are still a hot topic. In this paper,the viewpoints of three-dimensional network structure of acetabular pelvic vascular anatomy,anatomical surgical target channel and fixation anchor point of acetabular fracture reduction are proposed to design new techniques for accurate and minimally invasive surgical operations,in order to realize the requirements of rapid orthopedic rehabilitation.

Robotic-assisted uterine transposition followed by anatomic pelvic repositioning for a patient with intramural fibroids and rectal cancer

To report the first described case of robotic-assisted utero-ovarian transposition followed by anatomic repositioning in the pelvis and cervicovaginal anastomosis in a woman with uterine fibroids, which was performed for fertility preservation in the context of pelvic radiation for rectal cancer. Description of technique and live-action narrated surgical footage showing uterine transposition and repositioning. University hospital. A 36-year-old woman with a new diagnosis of cT3N2M0 rectal adenocarcinoma planned for neoadjuvant chemotherapy and pelvic radiation and desired fertility preservation permissive of future pregnancy. A transvaginal ultrasound revealed a 5-cm posterior leiomyoma and a normal endometrial cavity. The patient elected for utero-ovarian transposition before chemoradiation. The patient included in this video gave consent for publication and posting of the video online, including on social media, the journal website, scientific literature websites, and other applicable sites. Per institutional guidelines, an Institutional Review Board review was not required. Robotic-assisted utero-ovarian transposition was performed in an inpatient setting 2 weeks after ovarian stimulation and oocyte retrieval. She was given a gonadotropin-releasing hormone agonist for menstrual suppression after oocyte retrieval. The uterus and adnexa were transposed en bloc to the upper abdomen, with perfusion via retroflected infundibulopelvic ligaments. Intravenous indocyanine green was administered intraoperatively to visualize uterine perfusion. Three weeks postoperatively, the patient underwent surgical management of small bowel obstruction, which was successfully managed with laparoscopic adhesiolysis. The patient subsequently completed chemoradiation and had a complete response to the rectal tumor. She therefore elected for surveillance. Seven months after transposition and 2 months after completion of treatment, the patient underwent uncomplicated robotic-assisted utero-ovarian anatomic repositioning in the pelvis with cervicovaginal anastomosis. Chromopertubation confirmed tubal patency. Restoration of normal pelvic anatomy and resumption of reproductive physiology. At her 4-month postoperative visit, the cervix and vagina were normal in appearance. The patient reported the return of spontaneous menses and sexual activity without complications. This case is unique because of the presence of bulky intramural uterine fibroids. The described technique may be useful for selected cancer patients who desire to carry a pregnancy after pelvic radiation for cancer treatment, and demonstrates that patients considering utero-ovarian transposition need not be excluded solely on the basis of the presence of uterine fibroids.

Limb Salvage and Pelvic Reconstruction With Endoprosthesis After Pelvic Tumor Resection: A Narrative Review.

Periacetabular defects following tumor resection present formidable challenges in reconstruction and continue to pose clinical difficulties. Historically, treatment approaches leaned towards hindquarter amputation; however, due to associated morbidities and functional limitations, limb-sparing procedures gained prominence in the 1980s. Nevertheless, the intricacies of pelvic anatomy and the imperative of achieving wide surgical margins while preserving essential structures make pelvic tumor resection and subsequent reconstruction inherently complex. Various reconstruction modalities have been explored, including non-vascularized fibular grafts and prosthetic implants. Among these options, the LUMiC® endoprosthesis stands out as a promising solution for pelvic reconstruction post-tumor resection. Characterized by a modular design featuring a hydroxyapatite-coated stem and acetabular cup, this device has shown favorable implant survival rates in studies, despite encountering complications primarily associated with soft tissue failure, dislocation, and infection. Notably, the incidence of complications varies across studies. The Henderson classification system delineates these complications, encompassing soft tissue issues, aseptic loosening, periprosthetic fractures, infections, and tumor recurrence. Despite the encouraging functional outcomes associated with the LUMiC® endoprosthesis, it is not immune to limitations. Concerns persist regarding complications such as dislocation and infection, underscoring the imperative for further research to evaluate the long-term durability and reliability of this reconstructive approach. Moreover, advancements in surgical techniques, perioperative management, and the advent of navigation-assisted procedures hold promise for enhancing outcomes and mitigating complication rates in pelvic reconstruction surgeries.

Anthropometric Study Via Digital X-Rays of the Obturator Foramen in Surgical Treatment of Urine Incontinence in the South-Western Adult Female Population of Iran

Background: The trans-obturator tape (TOT) procedure is an efficient treatment option that provides support for the urethra in cases of stress urinary incontinence (SUI). Objectives: This research aimed to ascertain the accuracy of anthropometric parameters of the female pubic arch and the obturator foramen (OF) and their application in clinical anatomy. Methods: In this cross-sectional observational research conducted from October 2021 to September 2022, the morphometric characteristics of the pubic arch and the OF were measured on digital pelvic radiographs of 500 adult women from southwestern Iran. They were grouped into three age categories, namely, 18 - 34, 35 - 50, and more than 50 years old, and compared within and between the groups. Results: Significant differences were observed in computed parameter indices of the OF and pubic arch based on age. Parameters such as inter-obturator foramina distance, pubic symphysis length, pubic ramus width, and length increased significantly with age (P ≤ 0.05). Additionally, as women's ages increased, their subpubic angle decreased significantly (P = 0.001). However, other parameters, such as the OF area and the anterior urogenital triangle area, did not show a significant increase with age (P ≥ 0.05). These findings indicate that anatomical pelvic measurements change significantly with age in women. Conclusions: The present study revealed a wide range of variant bony pelvic anatomy in southwestern Iranian adult women, distinct from norms in other groups. Our findings could be utilized in surgical approaches and the production of trans-obturator kits by companies.

(038) Development of a Vaginal Dilator and Home Insemination Device for Cis-And Transgender People, Based on Actual Pelvic Anatomy

Abstract Introduction Genital gender-affirming surgery (gGAS) is a rapidly evolving surgical field. Specific to feminizing gGAS, one surgical option pertains to vaginoplasty with creation of a neovaginal canal. Given this canal is commonly lined with skin, peritoneum, or colon, women who undergo these procedures as part of their gender affirmation must commit to life-long self-dilation and douching to maintain canal patency and hygiene. Current commercially available dilators and douches are designed for cisgender anatomy, and are either straight, or, have an abrupt upward curve at the tip, inconsistent with neovaginal canal anatomy, which also lacks the elasticity of a cisgender woman’s vagina, making it sensitive to dilator shape, and douche nozzle length. In addition, many LGBTQ+ individuals with a uterus seek pregnancy without a male sexual partner, but few devices exist which cater to this specific population. Objective 1) To design a vaginal dilator which more accurately reflects pelvic and vaginal canal anatomy, 2) Design a novel dilator which combines dilation, douching, and depth measurement functions, and 3) Modify our new dilator-douche device for use with semen for home insemination by both cis- and transgender women, and, transgender men seeking to become pregnant. Methods A radio-opaque catheter was placed into the neovaginal canal of 12 transgender women who underwent vaginoplasty with canal creation. C-Arm fluoroscopy delineated canal curvature based on the catheter. In addition, gynecologic texts and instruments were examined to ascertain the shape of a cisgender woman’s vaginal canal. Based on these findings, a novel dilator was designed and 3-D printed. Results A smooth “S-shape” was found in the vaginal canal of both cis- and transgender women, consistent with the shape of cervical dilators. In cisgender women, the vaginal vault, which is elastic, is closer to the introitus than that of transgender women. The cervix is typically anteriorly located between 0.5 to 4cm proximal to the posterior fornix. Our vaginal dilators (Figure 1a) (five, each 8–12cm circumference) and insemination device (Figure 1b-c) (9cm circumference) reflect the same smooth S-shaped design. Our dilators have depth markings, side-wall grooves to allow air and liquid to pass, and, can be fitted with a douche-bulb to maintain hygiene. Our insemination device can accommodate a 10cc syringe and has a recessed anterior wall 0.5–4cm from the tip to deposit semen around the cervix for conception. Conclusions The design improvements shown with respect to this dilator-douche device should make dilation and douching more comfortable, improve hygiene, and, decrease the incidence of granulation tissue. Our inseminator offers a private, at-home means of achieving fertilization for both cisgender and transgender individuals. (U.S. Patent 11638808; Neovaginal and vaginal health devices) Disclosure No.

(172) Managing Proximal Perforation of Inflatable Penile Prosthesis in Pelvic Trauma

Abstract Introduction Corporal perforation is a complication that occurs secondary to misdirected or over-aggressive dilation or weakened tunica albuginea. One major risk factor is corporal fibrosis, as the corpora is more difficult to dilate, and sharp dissection or counter-incisions may be required. Fibrosis is most commonly observed in patients with history of infection, priapism, Peyronie’s disease, or multiple revision surgeries. In the setting of pelvic trauma, normal anatomical landmarks can be altered leading to proximal perforation during dilation. Proximal corporal perforation first manifests as unequal corporal measurements intraoperatively or palpable malposition of the cylinder into the perineum. Objective Herein we discuss the case of a 24-year-old male with erectile dysfunction secondary to pelvic trauma who presents one year postoperatively with malposition of his right cylinder due to proximal migration from altered pelvic anatomy. We aim to describe our surgical techniques that can be utilized to correct proximal perforation. Methods Physical exam and preoperative imaging revealed grossly malpositioned right prosthetic cylinder. We utilized the prior transverse penoscrotal incision to deliver the scrotal pump from the surgical capsule. Given normal appearance of reservoir on imaging and duration from initial placement, only the scrotal pump and cylinders were exchanged. Bilateral cylinders were explanted through vertical corporotomies. Proximal measurements of 20cm on the left and 24cm on the right were consistent with corporal perforation. The Windsock procedure was performed by placing a 2–0 PDS suture from out to in through the tunica albuginea, through the right rear-tip extender, then in to out back through the albuginea of corporotomy. After copious irrigation of corporal space, new cylinders were placed using the modified rear tip extender. A new scrotal pump was placed in anterior dependent position. The device cycled properly in symmetric position bilaterally before all tissue layers were closed. Results The patient was observed overnight and discharged on post-operative day 1 after passing void trial. He was noted to be doing well at his post-operative clinic visit 6 weeks later and has been cleared for sexual activity. Conclusions We describe a patient with challenging anatomy due to extensive pelvic fracture leading to corporal perforation and proximal migration of a prosthetic cylinder. Due to lack of a normal pubic tubercle, we performed the Windsock sling procedure to provide posterior support of the right cylinder to prevent future proximal migration. An alternate approach is to secure the prosthesis tubing via sutures to the corporotomies is also presented. A critical intraoperative maneuver is evaluating for equal dilator depth alignment to recognize proximal perforation. These techniques can be applicable to other patients with altered anatomy secondary or in the setting of proximal corporal perforation. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific.

(094) Evaluation of Female Sexuality After Vaginal Hysterectomy in a Cohort of Tunisian Women

Abstract Introduction Researchers indicate that hysterectomy might adversely affect pelvic anatomy and therefore female sexuality. However, only a few studies focused on evaluating female sexuality after vaginal hysterectomy. Objective This study aimed to evaluate female sexual function after a vaginal hysterectomy. Methods This was a monocentric prospective study conducted in the gynecology-obstetrics department of Ben Arous regional hospital over a period of 5 years [January 2016-December 2020]. We included all patients who underwent vaginal hysterectomy. Selected women received a preoperative evaluation of their sexual function using the Female sexual function index (FSFI). They were invited for two follow-ups at 12 and 24 months after surgery. The main outcomes measured were frequency of sexual intercourse, dyspareunia, orgasm, vaginal dryness, sexual desire, and FSFI scores. Results A total number of 109 women underwent vaginal hysterectomy over the study period. The mean age was 41 years ranging from 31 to 69 years. Only 79 patients completed the required follow-ups in order to evaluate their satisfaction and the impact of surgery on their sexuality. The percentage of women engaging in sexual intercourse increased significantly from 70.8% before vaginal hysterectomy (VH) to 77.21% and 75.9% at 12 and 24 months after respectively. The rate of dyspareunia dropped significantly from 40.5% before surgery to 5% and 3.8 % at 12 and 14 months after VH. The rate of women experiencing orgasm increased significantly from 63.2% before VH to 72.1% and 70.8 % after 12 and 24 months. Low sexual desire also decreased significantly from 10.1% before VH to 6.3% and 5% respectively at 12 and 24 months. The percentage of women experiencing satisfactory vaginal lubrication increased from 36.7% to 46.8% and 45.5%. Average FSFI significantly increased from 24.58 prior to the surgery to 26.82 and 27.55 at the 12 months and 24 months follow-ups respectively. Conclusions Female sexual function is a major cause of women's concern for scheduled hysterectomy. Our results showed a significant improvement in female sexual function after a vaginal hysterectomy. Therefore, the vaginal route for hysterectomy should be encouraged among middle-aged women as a minimally invasive technique that does not affect female sexual function or feminine shape. Disclosure No.

Reproductive outcome after in vitro fertilization in endometriosis - key factors and implications.

Endometriosis is a benign chronic disease with a major impact on a woman's quality of life, mainly due to painful physical symptoms. Endometriosis is also a common cause of infertility caused by low ovarian reserve, distorted pelvic anatomy, and severe local inflammation with a direct negative impact on the quality of oocytes, embryos, and endometrium. We conducted a retrospective study between January 2019 and December 2023, including women with a history of surgery for endometriosis who underwent in vitro fertilization (IVF) to achieve pregnancy. Their reproductive outcome was compared with a group of patients with documented tubal obstruction. The aim of our study was to identify the factors associated with a positive impact on the pregnancy rate, specifically age, anti-Mullerian hormone (AMH), ovarian stimulation protocol, and types of gonadotropins used. We analyzed a group of 175 patients with endometriosis compared with 189 patients with tubal obstruction. The average age was similar between the two groups but with a difference in the average AMH value (1.63 ± 1.09 ng/mL vs. 2.55 ± 1.67 ng/mL). The most utilized ovarian stimulation protocol in both groups was the short gonadotropin-releasing hormone (GnRH) antagonist. The clinical pregnancy rate was 27.2% in the endometriosis group and 54.7% in the tubal obstruction group. Our study revealed that treatment with corifollitropin alfa in the endometriosis group was associated with a higher clinical pregnancy rate. AMH and age proved to be significant independent factors for the reproductive outcome.

Pelvic Exenteration Surgery Outcomes Following Establishment of a Complex Pelvic Surgery Multidisciplinary Tertiary Unit

Background: Pelvic exenteration surgery (PES) is a complex operation associated with significant morbidity. PES requires sub-specialised multidisciplinary input along with expertise in complex pelvic surgery and anatomy. The majority of published data on PES comes from high volume units, however there is emerging evidence of comparable short and long-term outcomes in lower volume units where dedicated multidisciplinary teams are established. This study reports outcomes of PES in a lower volume centre with a collaborative multidisciplinary surgical approach. Methods: A retrospective review of patients who underwent PES for benign or malignant pathology at Liverpool and Macquarie University Hospitals between September 2015 and June 2022. Descriptive statistics were performed and KaplanMeier survival analysis for patients treated for malignancy with curative intent. Results: A total of 67 patients undergoing pelvic exenteration were included (53.8% female; with mean age 59 years). Indications for PES were colorectal cancer (56.7%), gynaecological cancer (22.4%), other malignancy (9.0%) and complex benign pathology (11.9%). Posterior or total pelvic exenteration was performed in 88.1%. Median hospital stay was 16 days. Clavien-Dindo grade III or IV complications occurred in 34.3%. There were two post-operative deaths (3.0%; one palliative intent). For patients treated with curative intent (n=51), R0 resection margin was achieved in 92.2%, and R1 margin in 7.8%. Estimated five-year disease-free survival was 57.1%, and five-year overall survival was 65.5%. Conclusion: Short and long-term outcomes of PES in a low volume unit with appropriate multidisciplinary expertise are comparable to published data on pelvic exenteration from higher volume units.

Pedicle screw accuracy placed with assistance of machine vision technology in patients with neuromuscular scoliosis.

Pedicle screws are the primary method of vertebral fixation in scoliosis surgery, but there are lingering concerns over potential malposition. The rates of pedicle screw malposition in pediatric spine surgery vary from 10% to 21%. Malpositioned screws can lead to potentially catastrophic neurological, vascular, and visceral complications. Pedicle screw positioning in patients with neuromuscular scoliosis is challenging due to a combination of large curves, complex pelvic anatomy, and osteopenia. This study aimed to determine the rate of pedicle screw malposition, associated complications, and subsequent revision from screws placed with the assistance of machine vision navigation technology in patients with neuromuscular scoliosis undergoing posterior instrumentation and fusion. A retrospective analysis of the records of patients with neuromuscular scoliosis who underwent thoracolumbar pedicle screw insertion with the assistance of machine-vision image guidance navigation was performed. Screws were inserted by either a staff surgeon, orthopaedic fellow, or orthopaedic resident. Post-operative ultra-low dose CT scans were used to assess pedicle screw accuracy. The Gertzbein classification was used to grade any pedicle breaches (grade 0, no breach; grade 1, <2 mm; grade 2, 2-4 mm; grade 3, >4 mm). A screw was deemed accurate if no breach was identified (grade 0). 25 patients were included in the analysis, with a mean age of 13.6 years (range 11 to 18 years; 13/25 (52.0%) were female. The average pre-operative supine Cobb angle was 90.0 degrees (48-120 degrees). A total of 687 screws from 25 patients were analyzed (402 thoracic, 241 lumbosacral, 44 S2 alar-iliac (S2AI) screws). Surgical trainees (fellows and orthopaedic residents) inserted 46.6% (320/687) of screws with 98.8% (4/320) accuracy. The overall accuracy of pedicle screw insertion was 98.0% (Grade 0, no breach). All 13 breaches that occurred in the thoracic and lumbar screws were Grade 1. Of the 44 S2AI screws placed, one screw had a Grade 3 breach (2.3%) noted on intra-operative radiographs following rod placement and correction. This screw was subsequently revised. None of the breaches resulted in neuromonitoring changes, vessel, or visceral injuries. Machine vision navigation technology combined with careful free-hand pedicle screw insertion techniques demonstrated high levels of pedicle screw insertion accuracy, even in patients with challenging anatomy.

Ultrasound-Based Prognostic Anatomical Parameters for Post-Prostatectomy Incontinence: A Systematic Review

Background: A number of assessment methods for the pelvic floor have been described. Male pelvic floor ultrasound is an accessible, noninvasive assessment tool. Objective: To evaluate current published literature on anatomical parameters on pre- and postoperative ultrasound imaging of the male pelvic floor and correlation with continence status following radical prostatectomy (RP). Methods: A comprehensive literature search was conducted using the PRISMA guidelines to identify publications up to November 2022. Exclusion criteria consisted of animal studies, non-English articles, case reports, reviews and abstracts or reports from conferences. A full-text review was performed on 12 papers using ultrasound to assess pelvic floor anatomy and correlation with continence status following RP. Results: A total of 18 anatomical parameters were evaluated using US. Membranous urethral length (MUL), striated urethral sphincter (SUS) morphology and activation were most commonly studied. Shorter pre- and postoperative MUL, decreased preoperative SUS thickness and vascularity, postoperative discontinuity of SUS muscle fibres and decreased SUS activation are associated with post-prostatectomy incontinence (PPI). There is a paucity of data comparing anatomical changes in men prior to and following RP. The benefits of transperineal ultrasound are that it is minimally invasive, accessible, provides dynamic imaging of all three striated muscle complexes simultaneously and includes a bony landmark to reference measures of pelvic floor muscle displacement. Conclusions: Ultrasound evaluation of the male pelvic floor is an evolving field as there is development in technology and understanding of pelvic floor anatomy. It is an accessible and dynamic imaging modality, which allows both morphological and functional assessment of pelvic floor anatomy and its role in PPI. MUL and SUS morphology and activation are associated with continence status following RP. Several other anatomical parameters that may predict PPI were identified. Current literature is limited by small, single-centre studies with heterogeneous cohorts and methodologies.

Challenges in cosmetic gynecology surgery: A case series

Background: Cosmetic and functional gynecology is a novel specialty that is rapidly gaining tractionacross the globe, particularly in Europe, Asia, and America. These intricate procedures enhance theesthetics and restore the physiological function of the genitalia. This relates very closely to womensexuality, dignity, self-esteem, and overall confidence. Self-esteem is often closely mirrored anddependent on a person’s perception of her genitalia, both functionally and more recently esthetically. Anincreasing number of gynecologists are gradually embracing this art of restoration as the demand rapidlyincreases among patients. The outcomes are sometimes not pleasing to the patients and may requirerevision.Case series: We present four case series of undesirable outcomes from labiaplasty andperineovaginoplasty. The surgical procedures had to be repeated in two instances because of spousaldemand or from the lady herself.Case 1: Reconstruction after Type IV female genital mutilation (FGM)A 46-year-old grand multipara with Type IV FGM presented with sexual dysfunction and psychosexualproblems arising from FGM. She requested reconstruction of the labia minora, restoration of the labiamajora, and perineovaginoplasty. Examination revealed partial clitoridectomy, a narrowed vaginalintroitus with the removal of the labia minora, and excision of the labia majora. The missing tissues madethe reconstruction technically difficult. Labia minora was reconstructed from the labia majora by thegrooving technique, and labia majora fat augmentation with perineoplasty was performed with goodoutcomes.Case 2: Perineoplasty revision.A 43-year-old, para 3+0, presented with complaints of lax vaginal muscles after her third delivery. All herdeliveries were normal, vertex. She sustained a second-degree perineal tear after her last delivery, whichwas repaired. She was started on Kegel’s exercises with no improvement. She had a perineoplasty donesuccessfully, but she healed with a small rent. A revision was performed with good results.Case 3: Perineoplasty revisionThe patient underwent vaginoperineoplasty, but the perineum healed with a little bump, which both thepatient and the spouse did not like. Revision of perineoplasty was performed with excellent outcomes.Case 4: Revision of an overly tight vagina after vaginoperineoplastyThe patient had previously undergone vaginoperineoplasty but felt it was not tight enough. However,three months after revision, the spouse complained of incomplete penetration, whereas the patientcomplained of pain at the fourchette. Another revision was performed to address their concerns withgood outcomes. Conclusion: Cosmetic gynecological procedures must achieve satisfactory outcomes and restore theclient’s genital esthetics and functionality. Although some procedures are technically challenging and mayrequire repeat procedures, patient satisfaction is key. Knowledge of pelvic anatomy and restoration techniques is a prerequisite for achieving acceptable outcomes. Counseling of the couple is an integralpart of cosmetic gynecology to manage expectations and rule out psychosocial causes.

Prepubic urethral transposition, with prostatic urethral anastomosis to penile urethra, after severe membrane urethral injury in dog - case report

Rupture of the membranous urethra caused by automobile trauma in dogs, accounting for only 5% of genitourinary tract injuries. The higher prevalence in male dogs is noteworthy due to pelvic anatomy and locomotion habits. Clinical signs include edema, anuria, hematuria, pain, and uroperitoneum, requiring an emergency approach. Diagnosis is usually based on history and imaging tests such as ultrasonography and urethrocystography. Treatment varies based on the location of the injury, with surgical intervention being crucial in complete tears. Prepubic urethral transposition with terminal anastomosis from the prostatic urethra to the penile urethra, although little used in veterinary medicine, presents benefits in male dogs, providing a new urinary path without significant aesthetic changes. The case report presents the successful application of this technique in a canine patient with rupture of the membranous urethra due to automobile trauma, aiming to establish an efficient urinary flow without complications and without compromising genital aesthetics.

(077) Development of a Vaginal Dilator and Home Insemination Device for Cis-And Transgender People, Based on Actual Pelvic Anatomy

Abstract Introduction Genital gender-affirming surgery (gGAS) is a rapidly evolving surgical field. Specific to feminizing gGAS, one surgical option pertains to vaginoplasty with creation of a neovaginal canal. Given this canal is commonly lined with skin, peritoneum, or colon, women who undergo these procedures as part of their gender affirmation must commit to life-long self-dilation and douching to maintain canal patency and hygiene. Current commercially available dilators and douches are designed for cisgender anatomy, and are either straight, or, have an abrupt upward curve at the tip, inconsistent with neovaginal canal anatomy, which also lacks the elasticity of a cisgender woman’s vagina, making it sensitive to dilator shape, and douche nozzle length. In addition, many LGBTQ+ individuals with a uterus seek pregnancy without a male sexual partner, but few devices exist which cater to this specific population. Objective 1) To design a vaginal dilator which more accurately reflects pelvic and vaginal canal anatomy, 2) Design a novel dilator which combines dilation, douching, and depth measurement functions, and 3) Modify our new dilator-douche device for use with semen for home insemination by both cis- and transgender women, and, transgender men seeking to become pregnant. Methods A radio-opaque catheter was placed into the neovaginal canal of 12 transgender women who underwent vaginoplasty with canal creation. C-Arm fluoroscopy delineated canal curvature based on the catheter. In addition, gynecologic texts and instruments were examined to ascertain the shape of a cisgender woman’s vaginal canal. Based on these findings, a novel dilator was designed and 3-D printed. Results A smooth “S-shape” was found in the vaginal canal of both cis- and transgender women, consistent with the shape of cervical dilators. In cisgender women, the vaginal vault, which is elastic, is closer to the introitus than that of transgender women. The cervix is typically anteriorly located between 0.5 to 4cm proximal to the posterior fornix. Our vaginal dilators (Figure 1a) (five, each 8-12cm circumference) and insemination device (Figure 1b-c) (9cm circumference) reflect the same smooth S-shaped design. Our dilators have depth markings, side-wall grooves to allow air and liquid to pass, and, can be fitted with a douche-bulb to maintain hygiene. Our insemination device can accommodate a 10cc syringe and has a recessed anterior wall 0.5-4cm from the tip to deposit semen around the cervix for conception. Conclusions The design improvements shown with respect to this dilator-douche device should make dilation and douching more comfortable, improve hygiene, and, decrease the incidence of granulation tissue. Our inseminator offers a private, at-home means of achieving fertilization for both cisgender and transgender individuals. (U.S. Patent 11638808; Neovaginal and vaginal health devices) Disclosure No.

(194) Midline Reservoir Placement of Infrapubic Inflatable Penile Prosthesis: A Step-by-Step Surgical Technique

Abstract Introduction Various alternative placements of inflatable penile prosthesis (IPP) reservoirs have been previously documented, differing from the traditional retroperitoneal placement in the Space of Retzius. Pelvic trauma, history of surgery in the pelvic region, and atypical anatomy can necessitate an alternative location for implantation of the IPP reservoir. The midline placement of the IPP reservoir provides numerous advantages in outcomes, patient experience, and versatility of implantation. This video demonstrates the surgical procedure for midline placement of the IPP reservoir. Objective We outline a surgical technique to place the IPP reservoir in an alternative midline location. Methods The patient was instructed to void his bladder prior to the procedure to circumvent Foley catheter insertion. A 2.5 cm-wide horizontal incision was made 2 finger widths cranially to the dorsal aspect of the base of the penis. The surgeon’s index finger was used for blunt dissection along the linea alba above the pubic tubercles. A tonsil clamp is used to pierce the rectus fascia at the midline, below the arcuate line, to leave a defect just wide enough to accommodate a 70 mm nasal speculum. The surgeon’s finger is used to assess the space to determine if a 9/10 mm Hegar dilator is necessary to expand the avascular space by sweeping it parallel to the fascia. The speculum is inserted and positioned with the blades pointed cranially parallel to the facial axis and the handles pointed superiorly. The reservoir is prepared and delivered into this space using a metal pediatric Yankauer suction tip through the open blades of the nasal speculum. A syringe filled with saline solution is connected to the reservoir tubing, and the fluid is transferred completely to the reservoir and the tubing is clamped. The tubes originating from the reservoir and implant cylinders are both clamped, trimmed to length, and connected to each other in a watertight fashion to permit the bidirectional flow of saline solution. Proper IPP cylinder inflation is tested prior to closing the incision. Results The reservoir is thus safely deployed cranially to the pubic bone and avoids interfering with the urinary bladder. No complications were observed in this patient, and he was discharged on the same day. Conclusions The midline surgical placement of the reservoir during the infrapubic implantation of an inflatable penile prosthesis is a safe and effective alternative placement for patients with prior pelvic surgery, injuries, or atypical pelvic anatomy. Patients with compromised pelvic, abdominal, or inguinal regions due to hernia repair, patulous inguinal rings, or dense lateral pelvic scarring stand to benefit the most from this reservoir placement. This procedure outlines the surgical steps of midline reservoir placement for new IPP implantation or relocation during a revision procedure. Disclosure No.

Reconstruction of Cloacal Defect: Switch Operation - A New Approach.

Reconstruction of a cloacal defect in a girl is often difficult and complicated.[1] This is most often done either by the sacro-perineal route or through the posterior sagittal route.[2] The procedures may involve total mobilization of the cloaca with or without the creation of a lower vagina with the help of a loop of vascularized bowel.[3] In our approach, such defects can be corrected using the lower anorectum for the creation of a lower vagina and abdominoperineal pull-through of the proximal divided bowel. This method can be used both in short and long common channel cloaca. We have used this procedure in one patient of posterior cloaca and four patients of anterior cloaca. These operations were done in patients of 1 year and 6 months to 4 years. Only one patient is waiting for the closure of the colostomy. In all the cases, the urethra, the vagina, and the anus were successfully separated. This operation restores normal pelvic anatomy and physiology with minimal mutilation of the pelvic floor.