Pelvic Region Research Articles

(006) Methamphetamine-Induced Vaginal Lubrication

Abstract Introduction Vaginal dryness is a frequent complaint, especially in post-menopausal women. The physiology underlying the production of vaginal lubrication in response to arousing stimuli is established; however, no current pharmacological agents successfully target mechanisms within this physiology. Previous research from our lab has demonstrated that female methamphetamine (meth) users experience the immediate production of excessive vaginal lubrication, accompanied by a warmth or flushing sensation spreading from the chest areas to the pelvic region, when using the drug intravenously (IV). The physiological source of this previously undescribed effect of meth could present a potential mechanism to enhance a woman’s natural production of vaginal lubrication, providing a potentially life-changing option to patients experiencing vaginal dryness. Objectives The purpose of the current study was to determine if vaginal lubrication induced by IV meth use reported in a previous study from our lab occurs in rats, and if this effect is dose-dependent. This study also sought to begin to uncover the mechanism behind this phenomenon. Methods Adult female Wistar rats (n=8) were implanted with chronic indwelling jugular catheters and allowed at least one week to recover from surgery. Rats anesthetized with isoflurane gas were intravenously infused with one of seven doses of meth ranging from 0.015-0.96 mg/kg meth or saline IV via the implanted catheter. Pre-weighed cotton-tipped swabs inserted into the vaginal canal collected fluid secreted following drug administration. The change in weight of the swab was taken as the weight of fluid produced. Consequent studies examined several signaling molecules in plasma known to have an influence on vaginal lubrication, including the steroid hormones estradiol, progesterone and testosterone, as well as the gaseous vasodilator nitric oxide. These molecules were measured at time points up to 60 minutes after meth administration. Results As hypothesized, meth increased vaginal lubrication in a dose-dependent manner. Doses of 0.06 and 0.24 mg/kg of meth induced significant increases in vaginal lubrication compared to saline. Further, compared to pre-meth levels, significant increases in estradiol were seen at two and 15 minutes after meth administration. Significant increases in progesterone, testosterone and nitric oxide were seen ten minutes after meth administration. Conclusions This study has far-reaching implications since the majority of women will experience vaginal dryness at least once, if not recurrently. The underlying mechanism of meth-induced vaginal lubrication, when elucidated, may provide a pharmacological target in treating not only meth use disorder, but also the millions of women suffering from vaginal dryness. Disclosure No.

Left Hindquarter Amputation due to High-Grade Pleomorphic Sarcoma of the Groin: A Case Report

Introduction:Hindquarter amputation or known as hemipelvectomy is a surgical technique that is primarily used for the eradication of malignant primary soft tissue and bone tumors of the pelvis, hip, and upper thigh regions. Occasionally, hindquarter amputation has been employed in the treatment of severe trauma, metastases, and infection. This case report aims to give a lesson in the case of the High-Grade Pleomorphic Sarcoma of the Groin because this is a very rare case and most patients are not willing to undergo amputation.Case Presentation: A 54-year-old male patient came with a complaint of a lump in the thigh. Initially, the lump was as big as a marble and has been getting bigger since last year. The size of the lump was approximately 30 x 30 x 30 cmConclusions: The most common indications for amputation in patients with the primary localized disease were extensive involvement of the limb-girdle, multiple muscle compartment involvement, multifocality, and unsuitability for limb-sparing surgery, typically due to lack of a salvage option. Hindquarter amputation was used as a treatment for 13% of all pelvic bone sarcomas where there is a realistic chance of control of symptoms or long-term survival.comas.

An unusual manifestation of neurofibromatosis – A case report of a vulval mass

Neurofibromatosis (NF) of the female genitalia is an uncommon manifestation. Selective involvement of the labium majus is quite rare. We describe a rare manifestation of a vulval plexiform neurofibroma without clitoral involvement in a post-pubertal girl. The patient had multiple café-au-lait spots over the neck, back, buttocks and thighs, a patch of pigmentation over the pelvis and inguinal region, axillary freckling, and a large hanging left vulval mass. On ultrasound, it showed hypoechoic nodules on a hyperechoic background with significant vascularity. Magnetic resonance imaging revealed T1-weighted (T1W) hypointense and T2-weighted (T2W) hyperintense, diffuse infiltrating lesion with few T2W hyperintense tubular and nodular areas, presence of “target sign,” and intense post-contrast enhancement. A biopsy confirmed it to be neurofibroma. The patient was diagnosed with NF type 1 and underwent surgical resection.

Undergraduate medical student perceptions and learning outcomes related to anatomy training using Thiel- and ethanol-glycerin-embalmed tissues.

Anatomical dissection is known to serve as an integral tool in teaching gross anatomy, including postgraduate training. A variety of embalming techniques exist, resulting in different haptic and optical tissue properties. This study aimed to objectify learning outcomes and medical student perceptions related to the use of two widely used embalming techniques, namely Thiel and ethanol-glycerin embalming. Between 2020 and 2022, first- and second-year medical students enrolled in the course on topographic anatomy participated in this study. Objective structured practical examinations were carried out for the head, neck, thorax, abdomen, pelvis, and extremity regions following regional dissection just before the oral examinations began. Six to ten numbered tags were marked in prosections of each region in Thiel- and ethanol-glycerin-embalmed specimens. Following the examinations, the students were surveyed regarding the suitability of the two embalming techniques with respect to preservation, colorfastness, tissue pliability, and the suitability in preparing for their anatomy examinations. Consistently higher scores were achieved for the thoracic and abdominal regions in ethanol-glycerin-embalmed specimens when compared to Thiel. No benefit was found for Thiel-embalmed upper or lower extremities. Tissues embalmed with ethanol-glycerin were rated higher for preservation and suitability to achieve the learning objectives, tissue pliability was rated higher for Thiel-embalmed tissues. Ethanol-glycerin embalming appears to offer certain advantages for undergraduate students in recognizing visceral structures, which may align with students' ideas on tissue suitability for their learning. Consequently, the benefits reported for Thiel embalming for postgraduate study unlikely reflect its suitability for novices.

An anthropomorphic body phantom for the determination of calibration factor in radionuclide treatment dosimetry.

The aim of this study is to create an inhomogeneous human-like phantom, whose attenuation and scattering effects are similar to the human body, as an alternative to the homogeneous phantoms traditionally used in calibration factor (CF) determination. The phantom was designed to include the thorax, abdomen and upper pelvis regions sized to represent a 75-kg male with a body mass index of 25. Measurements using Lu-177 with 50- and 100-mL lesion volumes were performed using inhomogeneous anthropomorphic body phantom (ABP) and homogeneous NEMA PET body phantom. There was a difference of 5.7% of Calibration Factor including attenuation and scatter effect between ABP and NEMA PET body phantom. Because it better reflects the attenuation and scatter effect, it is recommended to use a human-like inhomogeneous phantom for determination of CF instead of a homogeneous phantom.

Elective Nodal Irradiation for Oligorecurrent Nodal Prostate Cancer: Interobserver Variability in the PEACE V-STORM Randomized Phase 2 Trial

Consistency in delineation of pelvic lymph node regions for prostate cancer elective nodal radiation therapy is still challenging despite current guidelines. The aim of this study was to evaluate the interobserver variability in elective lymph node delineation in the PEACE V- STORM randomized phase 2 trial for oligorecurrent nodal prostate cancer. Twenty-three centers were asked to delineate the elective pelvic nodal clinical target volume (CTV) of a postoperative oligorecurrent nodal prostate cancer benchmark case using a modified Radiation Therapy Oncology Group (RTOG) 2009 template (upper limit at the L4/L5 interspace). Overall, intersection and overflow volumes, Dice coefficient, Hausdorff distance, and count maps merged with computed tomography images were analyzed. The mean volume including the 23 nodal CTVs was 430.4 ± 64.1 cm3, larger than the modified RTOG 2009 CTV reference volume (386.1 cm3). The intersection common volume between the modified reference RTOG 2009 and the 23 nodal CTVs was estimated at 83.9%, whereas the overflow volume was 23.4%, mainly located at the level of the presacral and the upper limit of the L4/L5 interspace. The mean Dice coefficient was 0.79 ± 0.02, whereas the mean Hausdorff distance was 27 ± 4.4 mm. In salvage radiation therapy treatment of oligorecurrent nodal prostate cancer, variations in elective lymph node volume delineation were mainly observed in the presacral and common iliac areas. Routine implementation and diffusion of available contouring guidelines together with a constant evaluation and evidence-based updating are expected to further decrease the existing variability in pelvic node contouring.

Fetal atomic bomb survivor dosimetry using the J45 series of pregnant female phantoms with realistic survivor exposure scenarios: comparisons to dose estimates in the DS02 system.

A significant source of information on radiation-induced biological effects following in-utero irradiation stems from studies of atomic bomb survivors who were pregnant at the time of exposure in Hiroshima, and to a lesser extent, from survivors in Nagasaki. Dose estimates to the developing fetus for these survivors have been assigned in prior dosimetry systems of the Radiation Effects Research Foundation as the dose to the uterine wall within the non-pregnant adult stylized phantom, originally designed for the dosimetry system DS86 and then carried forward in DS02. In a prior study, a new J45 (Japanese 1945) series of high-resolution phantoms of the adult pregnant female at 8weeks, 15weeks, 25weeks, and 38-weeks post-conception was presented. Fetal and maternal organ doses were estimated by computationally exposing the pregnant female phantom series to DS02 free-in-air cumulative photon and neutron fluences at three distances from the hypocenter at both Hiroshima and Nagasaki under idealized frontal (AP) and isotropic (ISO) particle incidence. In this present study, this work was extended using realistic angular fluences (480 directions) from the DS02 system for seven radiation source terms, nine different radiation dose components, and five shielding conditions. In addition, to explore the effects of fetal position within the womb, four new phantoms were created and the same irradiation scenarios were performed. General findings are that the current DS02 fetal dose surrogate overestimates values of fetal organ dose seen in the J45 phantoms towards the cranial end of the fetus, especially in the later stages of pregnancy. For example, for in-open exposures at 1000m in Hiroshima, the ratio of J45 fetal brain dose to DS02 uterine wall dose is 0.90, 0.82, and 0.70 at 15weeks, 25weeks, and 38-weeks, respectively, for total gamma exposures, and are 0.64, 0.44, and 0.37 at these same gestational ages for total neutron exposures. For organs in the abdominal and pelvic regions of the fetus, dose gradients across gestational age flatten and later reverse, so that DS02 fetal dosimetry begins to underestimate values of fetal organ dose as seen in the J45 phantoms. For example, for the same exposure scenario, the ratios of J45 fetal kidney dose to DS02 uterine wall dose are about 1.09 from 15 to 38weeks for total gamma dose, and are 1.30, 1.56, and 1.75 at 15weeks, 25weeks, and 38weeks, respectively, for the total neutron dose. Results using the new fetal positioning phantoms show this trend reversing for a head-up, breach fetal position. This work supports previous findings that the J45 pregnant female phantom series offers significant opportunities for gestational age-dependent assessment of fetal organ dose without the need to invoke the uterine wall as a fetal organ surrogate.

Network analysis of osteoporosis provides a global view of associated comorbidities and their temporal relationships.

Osteoporosis causes devastating fractures; however, its exact etiology remains unknown. Elucidating associated comorbidities and their temporal relationships could provide better insights into its pathogenesis. Comorbidity-network analysis was performed to obtain global view of these associations. We randomly selected 10000-patients with osteoporosis registered in the National-Health-Insurance Service cohort-database. These patients were identified using ICD-10 codes M81-M82, which represent osteoporosis without pathological fractures. Control group was created through propensity score matching. The comorbidities in each group were grouped into similar classifications to form "disease cluster"; 126 such clusters were identified. To create a comorbidity network, we selected disease clusters with high associations (i.e., odds ratios and relative risks ranked in the upper 50th percentile). To identify the temporal relationships between these clusters and osteoporosis, trajectories of directions were identified. Finally, we found 45 significant disease clusters. Of these, 14 disease clusters were related to fractures or injuries, while 10 were related to musculoskeletal diseases. Temporal analysis revealed that 15 disease clusters preceded osteoporosis; these included the following three with the strongest associations: "other fracture", "disorders of bone density and structure (M83-M85)", and "sequelae of injuries of neck and trunk (T91)". Thirty disease clusters followed osteoporosis; these included the following three with the strongest associations: "spine fracture," "spondylopathies (M45-M49)", and "pelvic region and thigh fracture,". We obtained a global view of the osteoporosis comorbidity network, which is otherwise difficult to achieve through study of individual diseases. Our findings will serve as the basic data for further studies.

FGFR1 gene fusions in a subset of pediatric mesenchymal tumors: Expanding the genetic spectrum of tumors sharing histologic overlap with infantile fibrosarcoma and "NTRK-rearranged" spindle cell neoplasms.

As the classification of kinase-driven spindle cell tumors continues to evolve, we describe the first series of pediatric mesenchymal tumors harboring FGFR1 gene fusions that share histologic overlap with infantile fibrosarcoma and "NTRK-rearranged" spindle cell neoplasms. Herein, we present three cases of FGFR1-rearranged pediatric mesenchymal tumors, including one case with FGFR1::PARD6B gene fusion and two cases with FGFR1::EBF2 gene fusion. The tumors involved infants ranging from 3 to 9 months in age with a male-to-female ratio of 2:1. All tumors involved the deep soft tissue of the gluteal, pelvic, or perirectal region. Histologically, the tumors comprised a cellular spindle cell neoplasm with primitive stellate cells, focal myxoid stroma, focal epithelioid features, no necrosis, and occasional mitotic figures (2-6 per 10 high-power field). By immunohistochemistry, the neoplastic cells focally expressed CD34 but lacked expression of S100 protein, SMA, desmin, myogenin, MyoD1, pan-TRK, and ALK. These three cases, including a case with long-term clinical follow-up, demonstrate that FGFR1 fusions occur in a subset of newly described pediatric kinase-driven mesenchymal tumors with locally aggressive behavior. Importantly, knowledge of these genetic alterations in this spectrum of pediatric tumors is key for diagnostic and targeted therapeutic purposes.

The effect of transverse friction massage on pain and quality of life in women with chronic pelvic pain: a quasi-experimental study

Background/Aims Chronic pelvic pain is defined as pain located to the pelvis or lower abdominal region, lasting for at least 6 months, and not associated with menstruation, coitus or pregnancy. The aim of this study was to investigate the feasibility and effectiveness of transverse friction massage on pain and quality of life in women with chronic pelvic pain. Methods A total of 20 women participated in this study. Eight sessions of transverse friction massage were performed twice a week for 4 weeks, with each session lasting 30 minutes. Pelvic floor muscles (in terms of tenderness, trigger point, spasm and scar presence) were evaluated by digital palpation by an expert physiotherapist. The outcome measures used were the visual analogue scale, the 36-item Short Form-36 Survey and the Beck Depression Inventory. Participants were evaluated before treatment, at the end of the treatment, and 4 weeks after the end of the treatment. Results Participants' mean age was 49.7 ± 0.31 years. There was a decrease in pain intensity and an increase in quality of life scores (P<0.001), but no statistically significant improvement in depression status at the end of the treatment (P>0.001). Four weeks after the end of the treatment, significant decreases in pain severity, quality of life and depression were observed (P<0.001). Conclusions Transverse friction massage is a feasible treatment option that can safely be used by physiotherapists to treat patients with chronic pelvic pain. It is inexpensive and can help to reduce pain and increase patients' quality of life. Randomised controlled trials are recommended to further confirm the findings from this study.

Automatic AI-based contouring of prostate MRI for online adaptive radiotherapy

Background and purposeMR-guided radiotherapy (MRgRT) online plan adaptation accounts for tumor volume changes, interfraction motion and thus allows daily sparing of relevant organs at risk. Due to the high interfraction variability of bladder and rectum, patients with tumors in the pelvic region may strongly benefit from adaptive MRgRT. Currently, fast automatic annotation of anatomical structures is not available within the online MRgRT workflow. Therefore, the aim of this study was to train and validate a fast, accurate deep learning model for automatic MRI segmentation at the MR-Linac for future implementation in a clinical MRgRT workflow. Materials and methodsFor a total of 47 patients, T2w MRI data were acquired on a 1.5 T MR-Linac (Unity, Elekta) on five different days. Prostate, seminal vesicles, rectum, anal canal, bladder, penile bulb, body and bony structures were manually annotated. These training data consisting of 232 data sets in total was used for the generation of a deep learning based autocontouring model and validated on 20 unseen T2w-MRIs. For quantitative evaluation the validation set was contoured by a radiation oncologist as gold standard contours (GSC) and compared in MATLAB to the automatic contours (AIC). For the evaluation, dice similarity coefficients (DSC), and 95% Hausdorff distances (95% HD), added path length (APL) and surface DSC (sDSC) were calculated in a caudal-cranial window of ± 4 cm with respect to the prostate ends. For qualitative evaluation, five radiation oncologists scored the AIC on the possible usage within an online adaptive workflow as follows: (1) no modifications needed, (2) minor adjustments needed, (3) major adjustments/ multiple minor adjustments needed, (4) not usable. ResultsThe quantitative evaluation revealed a maximum median 95% HD of 6.9 mm for the rectum and minimum median 95% HD of 2.7 mm for the bladder. Maximal and minimal median DSC were detected for bladder with 0.97 and for penile bulb with 0.73, respectively. Using a tolerance level of 3 mm, the highest and lowest sDSC were determined for rectum (0.94) and anal canal (0.68), respectively.Qualitative evaluation resulted in a mean score of 1.2 for AICs over all organs and patients across all expert ratings. For the different autocontoured structures, the highest mean score of 1.0 was observed for anal canal, sacrum, femur left and right, and pelvis left, whereas for prostate the lowest mean score of 2.0 was detected. In total, 80% of the contours were rated be clinically acceptable, 16% to require minor and 4% major adjustments for online adaptive MRgRT. ConclusionIn this study, an AI-based autocontouring was successfully trained for online adaptive MR-guided radiotherapy on the 1.5 T MR-Linac system. The developed model can automatically generate contours accepted by physicians (80%) or only with the need of minor corrections (16%) for the irradiation of primary prostate on the clinically employed sequences.

Factors Affecting Prostate Displacement During Volumetric Modulated Arc Therapy in Prone Position After High-Dose-Rate Brachytherapy for Prostate Cancer

In irradiating the prostate and pelvic lymph node regions, registration based on bony structures matches the pelvic lymph node regions but not necessarily the prostate position, and it is important to identify factors that influence prostate displacement. Therefore, we investigated factors influencing prostate displacement during volumetric modulated arc therapy after single-fraction high-dose-rate brachytherapy (HDR-BT) for prostate cancer and the trends in displacement for each fraction. Seventy patients who underwent pelvic volumetric modulated arc therapy of 46 Gy in the prone position 15 days after 13 Gy HDR-BT were included. Prostate displacement relative to bony structures was calculated using cone beam computed tomography. Systematic error (SE) and random error (RE) were evaluated in the right-left (RL), craniocaudal (CC), and anteroposterior (AP) directions. The association with clinical and anatomic factors on the planning computed tomography or magneticresonanceimaging was analyzed. Prostate volume change (PVC) was defined as the volume change at 2 days after HDR-BT. Displacement trends were individually examined from the first to 23rd fractions. The mean SE in the RL, CC, and AP directions was -0.01 mm, -2.34 mm, and -0.47 mm, respectively. The root mean square of the RE in the RL, CC, and AP directions was 0.44 mm, 1.14 mm, and 1.10 mm, respectively. SE in the CC direction was independently associated with bladder volume (P=.021, t statistic=2.352) and PVC (P < .001, t statistic=-8.526). SE in the AP direction was independently associated with bladder volume (P=.013, t statistic=-2.553), PVC (P < .001, t statistic=5.477), and rectal mean area (P=.008, t statistic=2.743). RE in the CC direction was independently associated with smoking (P=.035). RE in the AP direction was associated with PVC (P=.043). Gradual displacement caudally and posteriorly occurred during the irradiation period. Anatomic characteristics of the bladder, rectum, and prostate predict SE. Smoking and PVC predict RE. In particular, whether PVC is ≥140% affects setting internal margins.

Evaluation of the 2023 Kahramanmaras earthquake from the perspective of Plastic Surgery Department: A single-center experience.

The aim of this study was to evaluate the treatment management and demographic data of earthquake victims admitted to Plastic Surgery Department of our center after the 2023 Kahramanmaras earthquake. Between February 6th, 2023 and February 15th, 2023, a total of 120 patients (65 males, 55 females; mean age: 36.3±17.3 years; range, 85 to 88 years) who were consulted to the Plastic Surgery Department of our center were included. Demographic data of the patients, time to admission to the emergency room, removal time under the rubble, type of injury, emergency operation requirement, fasciotomy requirement, hyperbaric oxygen therapy administration, and length of stay in the intensive care unit were evaluated. After the first intervention, patients with compartment syndrome underwent emergency fasciotomy immediately. Perioperative laboratory values of the patients were followed closely to prevent the development of crush syndrome. Due to stay under the rubble, upper extremity soft tissue injury was seen in 46.2% of the patients. The pelvic and abdominal region were the least affected soft tissues in 1.7% patients. Fasciotomy was performed in 75 patients who stayed under the rubble. Hyperbaric oxygen therapy was applied to 21 of 75 patients who underwent fasciotomy. Amputation was performed in four patients, three of which were in the upper extremity and one in the lower extremity, during follow-up after fasciotomy. A total of 10.83% of the patients were treated conservatively and 11.67% of them were reconstructed with free flaps. Totally 7.5% of the patients who stayed under the rubble were hospitalized in our clinic for maxillofacial injuries. A total of 66.6% of these patients were treated surgically, while 33.3% of them were further treated conservatively. Proper triage, proper fasciotomy, and appropriate surgical interventions reduce the amputation rate, yielding clinically satisfactory results.

Treatment of adult deformity surgery by orthopedic and neurological surgeons: trends in treatment, techniques, and costs by specialty

BACKGROUND CONTEXTSurgery to correct adult spinal deformity (ASD) is performed by both neurological surgeons and orthopedic surgeons. Despite well-documented high costs and complication rates following ASD surgery, there is a dearth of research investigating trends in treatment according to surgeon subspeciality. PURPOSEThe purpose of this investigation was to perform an analysis of surgical trends, costs and complications of ASD operations by physician specialty using a large, nationwide sample. STUDY DESIGN/SETTINGRetrospective cohort study using an administrative claims database. PATIENT SAMPLEA total of 12,929 patients were identified with ASD that underwent deformity surgery performed by neurological or orthopedic surgeons. OUTCOME MEASURESThe primary outcome was surgical case volume by surgeon specialty. Secondary outcomes included costs, medical complications, surgical complications, and reoperation rates (30-day, 1-year, 5-year, and total). METHODSThe PearlDiver Mariner database was queried to identify patients who underwent ASD correction from 2010 to 2019. The cohort was stratified to identify patients who were treated by either orthopedic or neurological surgeons. Surgical volume, baseline characteristics, and surgical techniques were examined between cohorts. Multivariable logistic regression was employed to assess the cost, rate of reoperation and complication according to each subspecialty while controlling for number of levels fused, rate of pelvic fixation, age, gender, region and Charlson Comorbidity Index (CCI). Alpha was set to 0.05 and a Bonferroni correction for multiple comparisons was utilized to set the significance threshold at p ≤.000521. RESULTSA total of 12,929 ASD patients underwent deformity surgery performed by neurological or orthopedic surgeons. Orthopedic surgeons performed most deformity procedures accounting for 64.57% (8,866/12,929) of all ASD operations, while the proportion treated by neurological surgeons increased 44.2% over the decade (2010: 24.39% vs 2019: 35.16%; p<.0005). Neurological surgeons more frequently operated on older patients (60.52 vs 55.18 years, p<.0005) with more medical comorbidities (CCI scores: 2.01 vs 1.47, p<.0005). Neurological surgeons also performed higher rates of arthrodesis between one and six levels (OR: 1.86, p<.0005), three column osteotomies (OR: 1.35, p<.0005) and navigated or robotic procedures (OR: 3.30, p<.0005). Procedures performed by orthopedic surgeons had significantly lower average costs as compared to neurological surgeons (orthopedic surgeons: $17,971.66 vs neurological surgeons: $22,322.64, p=.253). Adjusted logistic regression controlling for number of levels fused, pelvic fixation, age, sex, region, and comorbidities revealed that patients within neurosurgical care had similar odds of complications to orthopaedic surgery. CONCLUSIONSThis investigation of over 12,000 ASD patients demonstrates orthopedic surgeons continue to perform the majority of ASD correction surgery, although neurological surgeons are performing an increasingly larger percentage over time with a 44% increase in the proportion of surgeries performed in the decade. In this cohort, neurological surgeons more frequently operated on older and more comorbid patients, utilizing shorter-segment fixation with greater use of navigation and robotic assistance.

(385) The Bulboclitoral Erectile Tissues: A Previously Unacknowledged Organ at Risk During Radiotherapy

Abstract Introduction Loss of sexual function can be a devastating side effect of the radiotherapy techniques used in the treatment of pelvic area tumors. Direct damage to the erectile tissues caused by off-target effects of radiation contributes to this loss of function. Advances in radiation techniques allow for greater tissue sparing, offering the potential to minimize tissue toxicity during treatments for pelvic cancers. In radiation oncology practice, specific attention is given to preserving sexual function in well characterized anatomic areas of male sexual function; however, preservation of clitoral structures involved in sexual function has not been well explored. Incorporating previously unacknowledged sexual structures such as the clitoris and vestibular bulbs (bulboclitoris for short) into radiotherapy treatment planning may improve our ability to preserve the function of these structures, including arousal and orgasm, after pelvic radiotherapy. Such an approach normalizes and affirms sexual pleasure as an important aspect of sexual health in cancer survivorship for women and gender-diverse persons. Objective We aim to explore the anatomic and radiologic characteristics of bulboclitoral sexual structures to shed light on their potential therapeutic applications in radiotherapy. Methods We evaluated the presence and configuration of the bulboclitoral erectile tissues and their proximity to other organs in a multi-modality study. The morphological characteristics were assessed in human cadaveric specimens using gross anatomic dissection and cross-sectioning as well as cross-sectional imaging using Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) (N=3). Results We present the CT, MRI, gross cross-sections, and 3D reconstruction of the bulboclitoral sexual structures. The presence and morphology of the female erectile tissues and adjacent structures are consistently demonstrated across modalities to inform anatomic delineation on radiotherapy planning scans. Conclusions The bulboclitoral erectile tissues are important structures in the pelvic region that have an essential role in sexual function. Attention to these previously unacknowledged structures has the potential to help improve patient outcomes in radiotherapy. In order to make this step, radiation oncologists can learn about the structures and their functions, and develop and apply advanced techniques to help preserve their integrity. Empowering radiotherapy clinicians with evidence for incorporating the anatomy, physiology and pathophysiology of organ function related to sexual pleasure in female persons with cancer provides an opportunity for tailored clinical decision-making and a more equitable distribution of advanced technologies that may preserve sexual function after cancer treatment. Disclosure No

Executive Functioning in Females Living With Chronic Pelvic Pain: A Pilot Study

Background: Chronic pelvic pain (CPP) is a musculoskeletal condition that is treated by physiotherapists. CPP refers to constant or intermittent pain in the pelvic region lasting at least 6 months in duration. Despite links between other chronic pain conditions and impaired executive functioning (EF), the relationship between CPP and EF has not been examined. Objectives: To examine (1) the feasibility of recruitment, retention of potential participants, and virtual data collection to discover; (2) whether EF assessment measures suggest the presence of EF impairment in participants living with CPP; and (3) how self-reported scores on pain catastrophizing, central sensitization, depression, anxiety, and stress among those living with CPP compare with normative data. Study Design: In this cross-sectional pilot study, participants were included if they self-identified as a female, reported living with CPP, and were 18 to 40 years of age. Method: Virtual interviews were conducted to administer the Central Sensitization Inventory, Pain Catastrophizing Scale, short version of the Depression, Anxiety, and Stress Scale, Oral Trail-Making Test, a phonemic verbal fluency FAS test, and the Executive Skills Questionnaire-Revised. Results: A total of 35 people participated in the study (60.34% of all interested potential participants). When compared with normative data, participants displayed difficulties on the verbal fluency FAS test and the Executive Skills Questionnaire-Revised. Conclusion: It is feasible to recruit and retain participants using virtual interviews to study EF in females living with CPP. Some assessment measures of EF indicated the presence of impairment. Central sensitization, catastrophizing, depression, anxiety, and stress scores were high.

Comparison of image quality, arterial depiction, and radiation dose between two rapid kVp-switching dual-energy CT scanners in CT angiography at 40-keV

PurposeTo compare the quantitative parameters and qualitative image quality of dual-energy CT angiography (CTA) between two rapid kVp-switching dual-energy CT scanners.Materials and methodsBetween May 2021 and March 2022, 79 participants underwent whole-body CTA using either Discovery CT750 HD (Group A, n = 38) or Revolution CT Apex (Group B, n = 41). All data were reconstructed at 40-keV and with adaptive statistical iterative reconstruction-Veo of 40%. The two groups were compared in terms of CT numbers of the thoracic and abdominal aorta, and the iliac artery, background noise, signal-to-noise ratio (SNR) of the artery, CT dose-index volume (CTDIvol), and qualitative scores for image noise, sharpness, diagnostic acceptability, and arterial depictions.ResultsThe median CT number of the abdominal aorta (p = 0.04) and SNR of the thoracic aorta (p = 0.02) were higher in Group B than in Group A, while no difference was observed in the other CT numbers and SNRs of the artery (p = 0.09–0.23). The background noises at the thoracic (p = 0.11), abdominal (p = 0.85), and pelvic (p = 0.85) regions were comparable between the two groups. CTDIvol was lower in Group B than in Group A (p = 0.006). All qualitative scores were higher in Group B than in Group A (p < 0.001–0.04). The arterial depictions were nearly identical in both two groups (p = 0.005–1.0).ConclusionIn dual-energy CTA at 40-keV, Revolution CT Apex improved qualitative image quality and reduced radiation dose.

An Open-Book Approach to Pelvic Dissection for the Male Genitourinary System.

Cadaveric dissections of the male pelvis are predominately conducted using either an anterior approach with the pelvis intact, or via pelvic hemi-section. The anterior approach leaves more tissue in-situ, but has limited visualization of retropubic structures, such as the prostate, seminal vesicles, vas deferens, and urethra. Hemi-section of the pelvis provides increased visualization at the expense of transecting midline structures. This article describes a novel cadaveric dissection, which offers enhanced visualization of pelvic structures in-situ. Using a posterior approach, the pelvis was dissected in an "open-book" manner, which fully exposed the posterior aspects of the prostate, seminal vesicles, ureters, and vas deferens. The delicate neurovascular bundle supplying these structures remained undisturbed. The visualization provided by this dissection correlated well with a coronal MRI of the pelvic region. This open-book dissection provides a novel posterior vantage point of the male genitourinary system, which can help medical students and residents solidify their understanding of anatomical relationships within the pelvis.

Optimization of in-brace corrective force in adolescents with Lenke type 5 curve using finite element model

BackgroundPelvic parameters have been taken into consideration for the evaluation of the outcomes of bracing in AIS. To discuss the stress required to correct the pelvic deformity related to Lenke5 adolescent idiopathic scoliosis (AIS) by finite element analysis, and provide a reference for the shaping of the pelvic region of the brace.MethodsAn three-dimensional (3D) corrective force on the pelvic area was defined. Computed tomography images were used to reconstruct a 3D model of Lenke5 AIS. Computer-aided engineering software Abaqus was used to implement finite element analysis. By adjusting the magnitude and position of corrective forces, coronal pelvic coronal plane rotation (PCPR) and Cobb angle (CA) of lumbar curve in the coronal plane, horizontal pelvic axial plane rotation, and apical vertebra rotation (AVR) were minimized to achieve the best effect on the spine and pelvic deformity correction. The proposed corrective conditions were divided into three groups: (1) forces applied on X-axis; (2) forces applied both in the X- and Y-axis; and (3) forces applied along the X-, Y-, and Z-axis at the same time.ResultsIn three groups, CA correction reduced by 31.5%, 42.5%, and 59.8%, and the PCPR changed to 12°, 13°, and 1° from 6.5°, respectively. The best groups of correction forces should simultaneously locate on the sagittal, transverse, and coronal planes of the pelvis.ConclusionsFor Lenke5 AIS, 3D correction forces can sufficiently reduce scoliosis and pelvic asymmetrical state. Force applied along the Z-axis is vital to correct the pelvic coronal pelvic tilt associated with Lenke5 AIS.

Open, Laparoscopic, and Robotic Approaches to Treat Colorectal Cancer: A Comprehensive Review of Literature.

Surgery is usually required to treat colorectal cancer (CRC). Medical technology has advanced, providing various approaches to tackle this disease. Different surgeries are available, such as laparoscopic surgery, single-incision laparoscopic surgery, natural orifice transluminal endoscopic surgery, and robotic surgery. Laparoscopic surgery has several benefits including reduced blood loss and shorter recovery time. It can also improve lung function and minimize complications. However, it requires more time to perform and has a higher risk of complications during the procedure. Robotic surgery provides a three-dimensional view of the surgical area allowing for greater precision in rectal surgeries and access to difficult-to-reach pelvic regions. This method utilizes robotics technology which reduces surgical time and speeds up recovery for patients. There are various surgical options available for treating CRC; however, laparoscopic surgery and robotic surgery offer unique advantages despite their own drawbacks. As technology continues to evolve, medical techniques will continue improving existing methods while providing new options resulting in better outcomes for patients. Compared to laparoscopy, robotic surgery has a lower rate of operative conversions and a shorter learning curve. However, it also has some drawbacks, such as a longer docking time, lack of tactile sensation, and higher cost. Therefore, the choice of surgical method should depend on patient characteristics, surgeon preference and expertise, and available resources. Currently, specialized centers offer robotic surgeries which are more expensive and take longer compared to open and laparoscopic approaches. Nonetheless, they are considered safe and feasible when compared to traditional surgery. Short-term outcomes for robotic surgeries are better, while long-term postoperative complicationrates remain similar. However, there is a need for additional well-defined randomized control trials conducted across multiple centers to validate the use of robotic surgery over open and laparoscopic approaches. Improving patient care and outcomes is the objective of this comprehensive literature overview on surgical approaches for CRC.