Pubic Arch Research Articles

Which Foetal-Pelvic Variables Are Useful for Predicting Caesarean Section and Instrumental Assistance

Objective: To assess the variables useful to predict caesarean delivery (CD) and instrumental assistance, through the analysis of a large number of foetal-pelvic variables, using discriminant analysis. Materials and Methods: One hundred and fourteen pregnant women were included in this single-centre prospective study. For each mother-foetus pair, 43 pelvic and 18 foetal variables were measured. Partial least squares-discriminant analysis was performed to identify foetal-pelvic variables that could statistically separate the 3 delivery modality groups: spontaneous vaginal delivery (SVD), CD, and instrument-assisted delivery (IAD). Results: For the SVD versus CD model, voluminous foetuses and women with a narrow pelvic inlet had a greater risk for requiring CD. The most efficient variables for discrimination were the transverse diameter and foetal weight. The antero-posterior inlet and obstetric conjugate were considered in this model, with the former being a useful variable but not the latter. For the SVD versus IAD model, the most important variables were the foetal variables, particularly the bi-parietal diameter. Women with a reduced antero-posterior outlet diameter and a narrow pubic arch were more at risk of requiring an IAD. Conclusion: The antero-posterior inlet was an efficient variable unlike the obstetric conjugate. The obstetric conjugate diameter should no longer be considered a useful variable in estimating the arrest of labour. Antero-posterior inlet diameter was a sagittal variable that should be taken into account. The comparison of sub-pubic angle and bi-parietal and antero-posterior outlet diameters was useful in identifying a risk of requiring instrumental assistance.

Epidemiology of Blunt Lower Urinary Tract Trauma With and Without Pelvic Fracture

To assess the contemporary epidemiology of blunt trauma lower urinary tract injury (LUTI) and to evaluate outcomes in patients with and without associated pelvic fracture (PF). Patients presenting to our level I trauma center with PF and/or LUTI from blunt trauma from 2000 to 2014 were identified in our institutional trauma registry. Demographics, mechanism of injury, fracture configurations, hospital course, and outpatient disposition were analyzed. Of 5518 PF patients, 233 (4.2%) had LUTI. Thirty-four patients had non-PF LUTI. There were 3.2% of men and 3.3% of women with PF who had bladder injuries (P = .94). Urethral injury was more common in men (2.0% vs 0.05%; relative risk 43.1). Pubic arch fractures were present in 87% of patients with urethral injuries, although only 1.5% of patients with pubic arch fractures had urethral injury. Isolated acetabular fractures were never associated with urethral injury and associated with only 2.6% of bladder injuries. Extraperitoneal bladder ruptures were more common in the PF group as compared to the non-PF LUTI group (39.1% vs 14.7%, P < .01). Intensive care unit length of stay and hospital length of stay for PF vs non-PF patients were 7.1 ± 8.1 vs 2.8 ± 5.3 days (P < .01) and 13.5 ± 13.4 vs 7.7 ± 8.4 days (P = .01), respectively. These data suggest that the contemporary incidence of PF LUTI is lower than previously reported. The presence of PF in patients with LUTI is associated with more severe overall injuries, longer hospital stays, and increased rates of inpatient complications.

Imaging of the pubic arch angle in prolonged second stage of labour with intrapartum translabial 3D ultrasound and its clinical significance

Imaging of the pubic arch angle in prolonged second stage of labour with intrapartum translabial 3D ultrasound and its clinical significance

OP28.11: The correlation between computed tomography measurements of the pubic arch angle and the intraspinous diameter in reproductive‐age women

OP28.11: The correlation between computed tomography measurements of the pubic arch angle and the intraspinous diameter in reproductive‐age women

Normal Range of Head-to-body Delivery Interval by Two-step Delivery.

Background:The one-step method was routine practices in China, scientific evidence to support this intervention is scarce. The purpose of this study was to observe the natural process of head-to-body delivery interval by waiting for at least one contraction (two-step) after head delivered in normal birth.Methods:From March 1 to March 30 in 2015 at Haikou Maternal and Child Hospital in China, normal vaginal birth with normal baby condition were recorded by video. Videotapes were transferred to computer then replayed and observed.Results:Ninety-two cases were enrolled in this study. The average head-to-body delivery interval by two-step delivery was 71.04 ± 61.02 s, (mean + 2 standard deviation = 193.07 s, 95% confidence interval [15.65–229.15] s). Fifty-one patients (51/92, 55.43%) were <60 s, 41 patients (41/92, 44.57%) were over 60 s. Shoulders delivered at the first contraction were 96.74% (89/92), 3.26% (3/92) had delivered by the second contraction. Shoulders emerged from perineum were 71.73% (66/92), 15.21% (14/92) transversely, and 13.04% (12/92) emerged from under pubic arch. Babies cried before the shoulder were 31.52% (29/92), cried after birth 52.17% (48/92), and 16.30% (15/92) did not cry after birth. Baby activities included as making faces, sucking, and bubbled from mouth and noses, and the lighter blue color of skin with good perfusion.Conclusions:The average time of head-to-body delivery interval was longer than 60 s by two-step delivery. Majority shoulders were delivered at the first contraction. Majority shoulders emerged from perineum rather from under pubic arch. The routine one-step method of shoulder delivery where the downward force applied is not necessary and is not the right direction. Baby's breath, making faces, sucking, bubble from noses and mouth, and the light blue color of the faces, all those signs during shoulder delivery indicated a normal live birth.

Variability of the pubic arch architecture and its influence on the minimal levator hiatus area

ObjectiveTo investigate the association between the minimal levator hiatus (MLH) area at rest with its surrounding soft-tissue and bony structures in nulliparous asymptomatic women with a normal levator ani muscle. MethodsA subanalysis was undertaken of a prospective study of the appearance of the levator ani in asymptomatic nulliparous women conducted between September 2010 and September 2011. The subanalysis included women with a normal levator ani muscle. Three-dimensional ultrasonography volumes were used to obtain pelvic floor measurements. ResultsThe analysis included 56 women with mean age of 43.0±13.4years. The mean MLH area was 13.1±1.8cm2 (range 9.0–17.3). The pubic arch angle had no influence on the MLH area (Pearson correlation coefficient r=0.13). Height and pubic arch length were positively correlated with the MLH area (r=0.26 [P=0.52] and r=0.50 [P<0.001], respectively). ConclusionThe MLH size of nulliparous women varied widely and was positively correlated with the height and pubic arch length of the women. Therefore, caution is warranted when interpreting the MLH area as an indicator of a levator ani defect or a predictor of pelvic organ prolapse without taking a woman’s pelvic bone characteristics into account.

High dose rate brachytherapy as monotherapy for localized prostate cancer: Our initial experience.

e626 Background: High dose rate (HDR) brachytherapy is an attractive treatment option for localized prostate cancer (CaP) as it allows for safe dose escalation and exploits the radiobiological advantage of using a high dose/fraction. We evaluate our early experience in using HDR monotherapy for localized CaP. Methods: Forty patients with low- to intermediate-risk CaP were treated from October 2013-July 2015. Patients had catheters placed transperineally under spinal anaesthesia, using transrectal ultrasound guidance. The clinical target volume [CTV: prostate ± seminal vesicles base] was outlined on a planning CT scan with the catheters and template in-situ. The CTV was grown by 3mm isotropically to obtain the planning target volume (PTV). The catheters were reconstructed and plan optimised according to pre-set dose constraints [DC]. Dose delivered was 19Gy/one fraction. Toxicity was assessed using RTOG criteria. Results: A range of volumes were implanted (20–120 cc, median: 37.5), using a median of 17 needles (range 13–20). Satisfactory implants were achieved in patients with volumes&gt;60cc by excluding pubic arch interference on the pre-implant MRI pelvis. All patients were discharged home within 24 hours, with two patients (5%) requiring re-catheterisation. Good dose coverage to the PTV was achieved: median D90 of 20.4Gy (DC&gt;19Gy), V100 of 95.1% (DC≥95%). Urethral and rectal sparing was satisfactory: urethral D10 of 21.23Gy (DC&lt;22Gy), rectal D2cc of 14Gy (DC&lt;15Gy). The median follow-up was 8 (1-22.6) months. Twenty-five patients, with at least 6 months follow-up showed a median PSA reduction of 80%. Thus far, one had biopsy proven recurrence. Only two patients had grade 3 urinary toxicity and one had grade 3 bowel toxicity at 2 weeks, which returned to baseline at 12 weeks. The IPSS score increased at 2-4 weeks after treatment, but returned to baseline after 3 months. Conclusions: Our initial experience with HDR monotherapy for localized CaP confirms this to be safe, with minimal acute complications. It is possible to implant volumes higher than 60cc, if adequate measures are taken. The early efficacy data for 19Gy is also promising.

Extensive Metoidioplasty as a Technique Capable of Creating a Compatible Analogue to a Natural Penis in Female Transsexuals.

To introduce the operative technique of "extensive metoidioplasty" (EM) in female transsexual surgery, for achieving an effective reconstruction of a male-appearing, normally functioning, fully sensate and erectile external genitalia. Ten female transsexuals (46 xx karyotype) between the ages of 20 and 40 years underwent EM as their sex reassignment surgical procedure with the mean operative time of 171 min (45-211, SD 19.55 min) between 2007 and 2014 in a general hospital in Tehran, Iran. Subjects were closely followed for the mean time of 68.4 months. All participants were thoroughly rehearsed about the nature of their surgical procedure and an informed written consent was obtained before surgery. We extensively detached the native clitoris to the point of a nearly complete detachment from its attachments to the pubic arch and approximated the originally divergent corporal bodies to each other. We were also able to increase the penile size by the application of PEP, a procedure which is in practice at our clinic. Postoperatively all ten patients achieved a mean penile length of 8.7 (6-12) cm and 7/10 (70 %) were capable of obtaining erection, rigid enough for intromission. We did not observe any significant postoperative complications. EM in association with the application of PEP could result in a natural-looking, erotically fully sensate and functional penis in majority of female transsexuals undergoing this procedure. This operative technique should be given serious considerations in well-informed female transsexual. Larger studies may be needed to validate this technique further. This journal requires that the authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Brachytherapy: state‐of‐the‐art radiotherapy in prostate cancer

Brachytherapy: state‐of‐the‐art radiotherapy in prostate cancer

Penile prosthesis implantation in a patient with congenital aphallia treated using the De Castro technique 10 years previously. Is it feasible?

Aphallia is a rare congenital abnormality with an incidence of 1 in 30 million births. In this video, we demonstrate implantation of a penile prosthesis in a neophallus performed 10 years previously in a patient aged 21. Through a midline perineal incision aiming to reach the inferior surface of the pubic arch, we created a 16-cm tunnel for prosthesis insertion into the neophallus. We dressed the prosthesis with a polypropylene mesh to give stability to the component and avoid its extrusion. We anchored the lateral mesh to the inferior aspect of the pubic arch with 2.0 vicryl sutures in both sides. The patient had an excellent initial outcome, without any complaints of pain or other inflammatory findings. We acknowledge limited clinical experience with this technique. Further psychological evaluation will confirm if patients can have pleasant sexual experiences.

Bromoderma caused by over‐the‐counter analgesic mimicking pyoderma gangrenosum

A 41-year-old Japanese woman was admitted to the emergency department of our hospital due to a seizure. She had been diagnosed with pyoderma gangrenosum 11 years ago without bone marrow disease, rheumatoid arthritis, or inflammatory bowel disease. Pyoderma with painful ulcers had repeatedly appeared on the arms, legs, face, and pubic arch despite treatment with systemic prednisolone and cyclosporine. She also had frequently complained about syncopal episodes, however, there was no evidence of neurological diseases, including epilepsy and endocrine diseases. On admission, the blood test revealed a negative anion gap, hyperchloremia, and neutrophilic leukocytosis. Since one of the major causes of negative anion gaps with hyperchloremia is bromide intoxication, we measured the serum bromide level and found that it was significantly high at 21 mg/dl. Bromide is not normaly detectable in healthy indivisuals. Furthermore, 296 empty sheets of over-the-counter(O-T-C) analgesic tablets containing bromide (Naronace: O-T-C analgesic in Japan, contain bromovalerylurea 100 mg/ tablet) were found in her house, suggesting that she had bromide intoxication. Repeated syncopal episodes may have been due to this intoxication. These findings forced us to reconsider the diagnosis of pyoderma gangrenosum in this case, because bromide causes the same clinical symptoms as pyoderma. In addition, we realized neutrophilic leukocytosis and hyperchloremia had been associated with exacerbation of the clinical symptoms for 11 years. Therefore, we examined the bromide level of the serum samples collected from the past 10 years and found that the bromide level had been as high as 112.7 mg/dl. In conclusion, we diagnosed this case with bromoderma caused by O-T-C analgesic mimicking pyoderma gangrenosum. After the patient stop taking the analgesic, the pyoderma rapidly disappeared, and the white blood cell count and the serum chloride level returned to normal levels, with no recurrence, even after the discontinuation of prednisolone and cyclosporine.

Customized Needle Guides for Inserting Non-Parallel Needle Arrangements in Prostate HDR Brachytherapy: A Phantom Study

Purpose: To evaluate the use of customized guides for inserting optimized, non-parallel arrangements of high-dose-rate (HDR) brachytherapy needles into prostate gelatin phantoms. Materials and Methods: Four prostate gelatin phantoms were constructed with prostate, urethra, bladder, rectum, penile bulb, and pubic arch anatomical structures. The target volume was the prostate, and the other structures were organs at risk (OAR). The anatomical structures were digitized, and a non-parallel needle arrangement was optimized for each phantom using Needle Planning by Integer Program (NPIP). The optimized needle arrangements contained 13-15 needles, which is less than the standard number currently used in our clinic. None of the optimized needles punctured any non-prostate structures. Inverse Planning by Integer Program (IPIP) was used to compute a dose plan for each optimized needle arrangement that conformed to the guidelines set in the Radiation Therapy Oncology Group (RTOG) 0321 dosimetric protocol. Customized needle guides were digitally created for each phantom to implant the corresponding optimized needle arrangement. The needle guides were 3D-printed in ABS plastic using a uPrint Plus 3D printer (StrataSys). The needle guides were mechanically registered to the phantoms. The needles were inserted into each phantom by a researcher without any clinical brachytherapy experience and without the assistance of trans-rectal ultrasound (TRUS) guidance. The phantoms and implanted needle arrangements were digitized, and another dose plan was computed for each implant. Compliance with the RTOG 0321 protocol, puncturing of OAR, and placement error were evaluated. Results: Three of the needle arrangements were implanted without puncturing any OAR. Due to placement error, one implanted needle arrangement punctured the penile bulb and urethra. We considered this case a failure, and we did not post-process it further. The successfully implanted needle arrangements met all the dose requirements in the RTOG 0321 protocol. The RMS placement error between the dwell positions in the planned and implanted needle arrangements was 3.6 mm, 4.5 mm, and 2.3 mm for the three cases. The majority of the error was along the needle insertion direction (i.e. the z-direction), which is most likely because templates do not restrict motion along this direction, and therefore is where error is the most user-dependent, or because the anatomy was digitized from 3 mm thick CT slices taken in the zdirection, and therefore registration in this direction is the most uncertain. Conclusions: Customized needle guides are a promising method for inserting optimized, non-parallel, brachytherapy needle arrangements. Although NPIP, IPIP, and 3D printers were used to construct the guides in this study, other planning and construction methods could be used without changing our fundamental workflow structure. However, the templatepatient registration and needle insertion workflow must still be improved to reduce placement error. This includes incorporating real-time TRUS guidance to monitor progress and avoid puncturing OAR, which we propose as future work.

Analysis of normal pelvis morphometry of modern Chinese southern Han female and its correlation with age

To analyze the normal pelvis morphometry of Chinese southern Han female and its correlation with age. From August 2009 to September 2011, 289 Han nationality females who received pelvis CT scan at Nanfang Hospital of Southern Medical University were eligible for the study. Their mean age was 43.5 years, with normal body development and no pelvic abnormality. The patients were divided into 3 age groups: 25 to 40 (n = 109), 41 to 50 (n = 115), and >50 years (n = 65). After constructing a three-dimensional digital model of the pelvis, the following parameters were measured, including transverse inlet diameter, posterior sagittal diameter of pelvic inlet, sagittal inlet, diagonal conjugate, biischial diameter, posterior sagittal diameter of midpelvis, sagittal midpelvic diameter, intertuberous distance, posterior sagittal diameter of outlet, angle of pubic arch, sagittal outlet, penal height, sacrum length and sacrum curvature. The relationship between all parameters and age was analyzed. (1) The posterior sagittal diameters of pelvic inlet of the 25 to 40 age group, 41 to 50 age group, >50 years age group were (53 ± 8), (51 ± 7), (48 ± 6) mm. The sagittal inlet of the three groups were (122 ± 8), (120 ± 9), (114 ± 8) mm. And the diagonal conjugate of the three groups were (135 ± 10), (132 ± 9), (127 ± 9) mm. All had significant differences among the three groups (P < 0.01) . (2) The posterior sagittal diameter of midpelvis of the three groups were (43 ± 6), (44 ± 6), (43 ± 7) mm, and the sagittal midpelvic diameter of the three groups were (119 ± 8), (120 ± 8), (119 ± 7) mm, with no significant difference among the three groups (P > 0.05). (3) The intertuberous distance of the three groups were (122 ± 11), (121 ± 10), (117 ± 11) mm, and the posterior sagittal diameter of outlet of the three groups were (56 ± 9), (58 ± 8), (57 ± 9) mm. There was no significant difference among the three groups (P > 0.05) .(4) Penal height of three groups were (31 ± 3), (33 ± 3), (34 ± 3) mm, there was with significant differences (P < 0.01) .(5) Pearson correlation analysis showed that penal height was positively correlated with age (r = 0.331, P < 0.05), while sagittal inlet, posterior sagittal diameter of inlet, diagonal conjugate, intertuberous distance, angle of pubic arch, sacrum length and sacrum curvature were negatively correlated with age (r = -0.120 to -0.343, P < 0.05). The shape of the pelvic inlet of Chinese southern Han female changed from sagittal elliptic into transverse elliptic form, and the posterior part of pelvic inlet became larger.Sacral concavity was increased and the pelvis became deeper. Mid pelvis and the pelvic outlet was almost unchanged, and showed no correlation with age.

1845 COMPARISON OF PELVIC ANATOMY AFTER CHILDBIRTH AND MENOPAUSE TO BEFORE CHILDBIRTH USING PELVIC MRI. AND NALYSIS OF PREDICTORS OF CYSTOCELE

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Female Urology (II)1 Apr 20131845 COMPARISON OF PELVIC ANATOMY AFTER CHILDBIRTH AND MENOPAUSE TO BEFORE CHILDBIRTH USING PELVIC MRI. AND NALYSIS OF PREDICTORS OF CYSTOCELE Mitsuharu Iwasaki, Nobuhiro Haga, Junya Hata, Yuuichi Satoh, Kouji Sagawa, Norio Takahashi, and Yoshiyuki Kojima Mitsuharu IwasakiMitsuharu Iwasaki Fukushima, Japan More articles by this author , Nobuhiro HagaNobuhiro Haga Fukushima, Japan More articles by this author , Junya HataJunya Hata Fukushima, Japan More articles by this author , Yuuichi SatohYuuichi Satoh Fukushima, Japan More articles by this author , Kouji SagawaKouji Sagawa Fukushima, Japan More articles by this author , Norio TakahashiNorio Takahashi Fukushima, Japan More articles by this author , and Yoshiyuki KojimaYoshiyuki Kojima Fukushima, Japan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2264AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES We measured various parameters representing the levator ani muscle and pelvic morphology from MRI images of Japanese female pelvis to clarify the changes due to aging and childbirth. Finally we analyzed statistically relevance to occurrence of cystocele and its grade. METHODS As levator ani muscle parameters, we measured levator ani muscle volume and the levator hiatus longitudinal and transverse diameter from MRI. As pelvic morphology parameters, we measured the distance between the ischium, pubic arch angle, the distance of obstetrical conjugate, and the distance between lower edge of the pubic bone and coccyx from MRI. Using these data, we compared the differences between the three groups, postmenopausal parous women with cystocele:GROUP1 (n= 29), postmenopausal parous women without cystocele:GROUP2 (n=26), and young nulliparous women:GROUP3 (n= 26). Furthermore, in addition to the Body Mass Index we analyzed the predictors of occurrence of cystocele and its grade. RESULTS Volume decrease of levator ani muscle and the increase in levator hiatus longitudinal and transverse diameter thought to be due to childbirth and aging was observed. It was thought the levator ani muscle volume reduction and increased levator hiatus transverse diameter were the risk factor for cystocele occurrence and its grade. Pelvic morphology and Body Mass Index, was not involved in the cystocele occurrence and its grade. CONCLUSIONS In Japanese women, it was found that the levator ani muscle volume reduction and increased levator hiatus transverse diameter were the risk factor for cystocele occurrence and its grade. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e757-e758 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mitsuharu Iwasaki Fukushima, Japan More articles by this author Nobuhiro Haga Fukushima, Japan More articles by this author Junya Hata Fukushima, Japan More articles by this author Yuuichi Satoh Fukushima, Japan More articles by this author Kouji Sagawa Fukushima, Japan More articles by this author Norio Takahashi Fukushima, Japan More articles by this author Yoshiyuki Kojima Fukushima, Japan More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Pubic arch angle in prolonged second stage of labor: clinical significance

To evaluate the clinical significance of the pubic arch angle (PAA) measured by transperineal ultrasound during prolonged second stage of labor. We evaluated prospectively 62 women ≥ 37 weeks of gestation with failure to progress in the second stage of labor. Transperineal ultrasound (transverse plane) was used to measure the pubic arch angle. Correlations with fetomaternal characteristics, mode of delivery and perinatal outcome were evaluated. The mean PAA was 101.1° (± 13.1°; range, 80°-135°). We found a negative correlation with maternal age. Patients with an occipitotransverse fetal position had a significantly smaller angle compared with those with occipitoanterior positions (94.3° ± 5.5° vs. 103.2° ± 14.8°, P < 0.05), as did those with operative deliveries compared with those with spontaneous vaginal delivery (97.1° ± 11.5° vs. 110.1° ± 14.0°, P < 0.05). The prediction of operative delivery in prolonged second stage of labor by receiver-operating characteristics curve using PAA alone yielded an area under the curve of 0.75. The predicted probability for operative delivery increased as PAA decreased, with an odds ratio of 0.933 for each decrease in angle of 1°. Our study suggests a correlation between the PAA and mode of delivery in prolonged second stage of labor. This may be used as an adjunctive parameter when considering delivery mode.

Does Anatomy of the Pubic Arch Interfere with the Maintaining of Erection?

There are men who suffer from unsustainable erections without any identified cause of erectile dysfunction, raising the question if anatomical alterations could be involved. Since early anatomical studies, it has been proposed that to achieve full penile rigidity, the blood must be blocked inside the penis by compression of the deep dorsal vein (DDV), the main venous collector under pubic symphysis. Using a recently developed caverno computed tomography (CT) scan technique, allowing the evaluation of the venous drainage of the corpora cavernosa (CC) during erection, we have studied some anatomical conditions of this important part of the erectile phenomenon. Puboischial rami angles were measured in axial CT images and calculated strictly on the upper insertion point of the CC, using axial submillimeter slices in 37 patients divided into 3 groups depending on the results of the caverno CT scan: (i) no leak; (ii) superficial veins leaking; and (iii) drainage through the DDV and/or preprostatic plexus. In addition same angles were measured in two randomly unselected populations of men (N = 30), and women (N = 23) who underwent pelvic CT scan for various reasons, unrelated to their sexual or genital condition. The angles made by both puboischial rami were measured in patients with and without veno-occlusive dysfunction and in unselected samples of men and women. There is a significantly wider angle made by both puboischial rami in men without complete erection and without evidence of anomalous venous drainage (group 3) (72.2° ± 4.7° standard deviation [SD]), compared with both men with normal erection (group 1) (57.5 ± 5° SD) P < 0.00001, and men with incomplete erection and evidence of anomalous drainage (group 2) (57.7 ± 6° SD) P < 0.00001. If confirmed in larger samples, these results raise new questions on the mechanism and the role of these significant anatomical variations, yet unknown, in maintaining or not full rigid erections.

Pubic arch anatomy might explain unsustainable erections

Pubic arch anatomy might explain unsustainable erections

A Cervical Cerclage Task Trainer for Maternal-Fetal Medicine Fellows and Obstetrics/Gynecology Residents

Performance of cervical cerclage is a difficult procedure for learners with limited operative experience. We present a task trainer for cervical cerclage, which can facilitate learner training in a preclinical environment. A simulated vagina is first fashioned out of polyvinyl chloride pipe material to allow an appropriately shaped pelvic structure. To simulate collapsible vaginal sidewalls, a foam covered with latex sheets is used to line the inside of the task trainer. A "cervix" is made by cutting cylinders approximately 2 in in diameter and 4 in in length in frozen cow muscle. After thawing, the cervical models are fastened to a semirigid foam disk with suture, which is used to secure the cervix inside the polyvinyl chloride pipe at the top of the simulated vagina. The full cervical cerclage task trainer is then secured in a holder to stabilize it in place. Placement of a cervical cerclage can then be practiced with standard vaginal cerclage instruments. Cervical cerclage can be practiced in a nonclinical environment using this model. Several aspects of the procedure can be modified including the amount of vaginal tissue, length and caliber of the vagina, and pubic arch angle. This model allows beginning learners sequential training of increasing difficulty. Faculty and trainees alike found the trainer to be useful and felt that it helped in the acquisition of the surgical skills needed for cerclage placement in a clinical setting. This low-cost task trainer can provide Maternal-fetal Medicine fellows and obstetric/gynecology residents the opportunity to practice cervical cerclage placement in a nonclinical environment. It may help physicians to obtain or maintain proficiency despite the relative low frequency of the procedure in modern obstetric practice.

Predicting pubic arch interference in prostate brachytherapy on transrectal ultrasonography-computed tomography fusion images

We investigated the usefulness of the fusion image created by transrectal ultrasonography (TRUS) and large-bore computed tomography (CT) for predicting pubic arch interference (PAI) during prostate seed brachytherapy. The TRUS volume study was performed in 21 patients, followed by large-bore computed tomography of patients in the lithotomy position. Then, we created TRUS-CT fusion images using a radiation planning treatment system. TRUS images in which the prostate outline was the largest were overlaid on CT images with the narrowest pubic arch. PAI was estimated in the right and left arch separately and classified to three grades: no PAI, PAI positive within 5 mm and PAI of >5 mm. If the estimated PAI was more than 5 mm on at least one side of the arch, we judged there to be a significant PAI. Brachytherapy was performed in 18 patients who were evaluated as not having significant PAI on TRUS. Intra-operative PAI was observed in one case, which was also detected with a fusion image. On the other hand, intra-operative PAI was not observed in one case that had been evaluated as having significant PAI with a fusion image. In the remaining three patients, TRUS suggested the presence of significant PAI, which was also confirmed by a fusion image. Intra-operative PAI could be predicted by TRUS-CT fusion imaging, even when it was undetectable by TRUS. Although improvement of the reproducibility of the patients’ position to avoid false-positive cases is warranted, TRUS-CT fusion imaging has the possibility that the uncertainty of TRUS can be supplemented.

WE‐A‐BRB‐01: Robotic Brachytherapy Demonstration: Implant of HDR Brachytherapy Needle Configuration Computer‐Optimized to Avoid Critical Structures Near the Bulb of the Penis

Purpose: To develop a robotic system to implant high dose rate brachytherapy (HDR‐BT) needle configurations meeting clinical dose objectives while avoiding puncture of non‐target structures. This system consists of (1) a robotic needle insertion device, (2) needle and dose planning software, and (3) a human with no clinical experience. Methods: Acubot‐RND is a joy‐stick controlled 7‐DoF stereotactic needle insertion robot with a remote center of motion (RCM) allowing needle pivot around the RCM point. For this project, a digital needle coordinate input and execution system was developed to replace the analog joy‐stick control. Custom pelvic phantoms were built, CT imaged, and contoured. A custom needle‐geometry optimization engine was used to generate a planned needle configuration (PNC) within the robot workspace and tailored to the phantom anatomy. Configurations of parallel and angulated needles (up to 53 deg. from parallel) were instructed to avoid puncture of the critical structures near the penile bulb (CSNB). The PNC was transferred to Acubot for sequential insertion. After each insertion, the robot released the needle in place. Needle stylets were passed through the needle and deposited in the phantom during needle retraction by the human user making the implanted needle configuration (INC). Results: Two phantoms were implanted using the robotic system. Post‐implant CT were obtained, puncture avoidance of the CSNB, pubic arch, and urethra confirmed, and the INC digitized for treatment plan generation. Satisfaction of RTOG‐0321 clinical dose objectives was verified and quantitatively compared against a phantom implant performed by an experienced physician. Conclusions: A clinically‐ relevant robotic brachytherapy workflow able to avoid the CSNB and guide needles behind the pubic arch while meeting clinical dose requirements was demonstrated. Operation of this system mitigates some reliance on brachytherapy implant expertise. This workflow is valid for both PPI and HDR‐BT. Supported by American Cancer Society Grant #IRG‐97‐150‐13.