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Tappy EE, Ramirez DMO, Stork AM, Carrick KS, Hamner JJ, Pruszynski JE, Corton MM. Somatic and autonomic nerve density of the urethra, periurethral tissue, and anterior vaginal wall: an immunohistochemical study in adult female cadavers. Int Urogynecol J 2023; 34:3023-3032. [PMID: 37796330 DOI: 10.1007/s00192-023-05645-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/18/2023] [Indexed: 10/06/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Retropubic procedures may disrupt nerves supplying the pelvic viscera; however, knowledge of pelvic neuroanatomy is limited. We sought to characterize somatic and autonomic nerve density within the urethra, periurethral tissue, and anterior vagina. METHODS Axial sections were obtained from pelvic tissue harvested from female cadavers ≤24 h from death at three anatomical levels: the midurethra, proximal urethra, and upper trigone. Periurethral/perivesical tissue was divided into medial and lateral sections, and the anterior vagina into middle, medial, and lateral sections. Double immunofluorescent staining for beta III tubulin (βIIIT), a global axonal marker, and myelin basic protein (MBP), a myelinated nerve marker, was performed. Threshold-based automatic image segmentation distinguished stained areas. Autonomic and somatic density were calculated as percentage of tissue stained with βIIIT alone, and with βIIIT and MBP respectively. Statistical comparisons were made using nonparametric Friedman tests. RESULTS Six cadavers, aged 22-73, were examined. Overall, autonomic nerve density was highest at the midurethral level in the lateral and middle anterior vagina. Somatic density was highest in the external urethral sphincter (midurethra mean 0.15%, SD ±0.11; proximal urethra 0.19%, SD ±0.19). Comparison of annotated sections revealed significant differences in autonomic density among the lateral, medial, and middle vagina at the midurethra level (0.71%, SD ±0.48 vs 0.60%, SD ±0.48 vs 0.70%, SD ±0.63, p=0.03). Autonomic density was greater than somatic density in all sections. CONCLUSIONS Autonomic and somatic nerves are diffusely distributed throughout the periurethral tissue and anterior vagina, with few significant differences in nerve density among sections analyzed. Minimizing tissue disruption near urethral skeletal muscle critical for urinary continence may prevent adverse postoperative urinary symptoms.
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Affiliation(s)
- Erryn E Tappy
- Department of Obstetrics and Gynecology, UT Southwestern Medical Center, 5323 Harry Hines Blvd G6.238, Dallas, TX, 75390, USA
| | - Denise M O Ramirez
- Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX, USA
| | - Abby M Stork
- Department of Obstetrics and Gynecology, UT Southwestern Medical Center, 5323 Harry Hines Blvd G6.238, Dallas, TX, 75390, USA
| | - Kelley S Carrick
- Department of Pathology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Jennifer J Hamner
- Department of Urogynecology, Indiana University Health, Carmel, IN, USA
| | - Jessica E Pruszynski
- Department of Obstetrics and Gynecology, UT Southwestern Medical Center, 5323 Harry Hines Blvd G6.238, Dallas, TX, 75390, USA
| | - Marlene M Corton
- Department of Obstetrics and Gynecology, UT Southwestern Medical Center, 5323 Harry Hines Blvd G6.238, Dallas, TX, 75390, USA.
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Zhang S, Yu H, Dong Z, Chen Y, Shan W, Zhang W, Tang H, Chen M, Wei W, Shi R, Xia B, Chen J. Laparoendoscopic single-site surgery for deep infiltrating endometriosis based on retroperitoneal pelvic spaces anatomy: a retrospective study. Sci Rep 2023; 13:10785. [PMID: 37402839 DOI: 10.1038/s41598-023-38034-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 07/01/2023] [Indexed: 07/06/2023] Open
Abstract
Transumbilical single-port laparoscopy is widely used in gynecological surgery. However, it is rarely used in the treatment of deep infiltrating endometriosis due to its own shortcomings and the complex condition of deep infiltrating endometriosis. The study aims to introduce a transumbilical single-port laparoscopic surgery based on retroperitoneal pelvic spaces anatomy, which can complete the operation of deep infiltrating endometriosis more easily. A retrospective analysis of 63 patients with deep infiltrating endometriosis treated by transumbilical single-port laparoscopy using this method was conducted. The operation duration was 120.00 (85.00 ± 170.00) (35-405) min, the estimated blood loss was 68.41 ± 39.35 ml, the postoperative hospital stay was 5.00 (4.00-6.00) days, and the incidence of postoperative complications was 4.76% (3/63). 1 patient was found to have intestinal injury during operation, 1 patient had ureteral injury after operation, and 1 patient had postoperative pelvic infection, with a recurrence rate of 9.52%. The postoperative scar score was 3.00 (3.00-4.00) and the postoperative satisfaction score was 9.00 (8.00-10.00). In summary, this study demonstrates the feasibility of transumbilical single-port laparoscopic surgery for deep infiltrating endometriosis based on retroperitoneal pelvic spaces anatomy. Hysterectomy, adenomyosis resection, etc. are also feasible with this method, boasting more obvious advantages. This method can make transumbilical single-port laparoscopy more widely used in deep infiltrating endometriosis.
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Affiliation(s)
- Shoufeng Zhang
- Dalian Medical University, Dalian, 116000, People's Republic of China
| | - Hongxia Yu
- Dalian Medical University, Dalian, 116000, People's Republic of China
| | - ZhiYong Dong
- Department of Obstetrics and Gynaecology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, People's Republic of China
| | - Yao Chen
- Bengbu Medical College, Bengbu, 233030, People's Republic of China
| | - Wulin Shan
- Bengbu Medical College, Bengbu, 233030, People's Republic of China
| | - Wendi Zhang
- Dalian Medical University, Dalian, 116000, People's Republic of China
| | - Huiming Tang
- Department of Obstetrics and Gynecology, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, 213000, Jiangsu Province, China
| | - Mengyue Chen
- Dalian Medical University, Dalian, 116000, People's Republic of China
| | - Weiwei Wei
- Department of Obstetrics and Gynecology, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, 213000, Jiangsu Province, China
| | - Ruxia Shi
- Department of Obstetrics and Gynecology, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, 213000, Jiangsu Province, China
| | - Bairong Xia
- Department of Gynecology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230031, People's Republic of China
| | - Jiming Chen
- Department of Obstetrics and Gynecology, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, 213000, Jiangsu Province, China.
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Tappy E, Pan E, Corton M. Robotic Burch colposuspension: anatomical and technical considerations. Int Urogynecol J 2023; 34:1653-1657. [PMID: 36745132 DOI: 10.1007/s00192-023-05452-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 01/06/2023] [Indexed: 02/07/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Up to 13.6% of women will undergo surgical treatment for stress urinary incontinence during their lifetime. Midurethral slings are the mainstay of stress incontinence treatment; however, diversity of surgical options is needed to serve the large number of patients desiring treatment. The Burch colposuspension remains a viable treatment option for appropriately selected patients. Currently, information on procedural standardization and tools for surgical training on robot-assisted colposuspension is limited. METHODS We describe a stepwise robotic approach aimed at enhancing procedural reproducibility, while decreasing risks of intraoperative injury and postoperative complications. We analyze perioperative outcomes of our technique in a retrospective cohort of patients who underwent robot-assisted colposuspension at our institution. RESULTS Seven key procedural steps are defined to optimize safe dissection in the retropubic space and to reduce the potential for surgical complications. These include methods of avoiding bladder, urethral, and neurovascular injury, as well as enhancing adequate suture fixation that prevents urethral obstruction and adverse postoperative urinary and pain-related symptoms. Surgical outcomes for 20 patients are reported and reveal low rates of perioperative complications. CONCLUSION Robot-assisted colposuspension requires thorough knowledge of the retropubic space and the application of standardized techniques may reduce the risk of injury and optimize procedure efficiency and reproducibility.
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Affiliation(s)
- Erryn Tappy
- UT Southwestern Medical Center, Dallas, TX, USA.
| | - Evelyn Pan
- UT Southwestern Medical Center, Dallas, TX, USA
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Xing D, Liang SX, Gao FF, Epstein JI. Mesonephric Adenocarcinoma and Mesonephric-like Adenocarcinoma of the Urinary Tract. Mod Pathol 2023; 36:100031. [PMID: 36788068 DOI: 10.1016/j.modpat.2022.100031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/19/2022] [Accepted: 09/21/2022] [Indexed: 01/19/2023]
Abstract
Given the association of mesonephric adenocarcinoma (MA) of the uterine cervix with florid mesonephric hyperplasia, one would expect MAs to rarely arise in other anatomical locations that harbor mesonephric remnants. In contrast, mesonephric-like adenocarcinoma (MLA) is thought to arise from Müllerian origin without an association with mesonephric remnants. The current case series characterizes 4 cases of MA arising in the urinary bladder (1 woman and 3 men), 1 case of MA in the perirenal region (woman), and 1 case of MLA in the ureter (woman). All cases displayed morphologic features similar to MA of the uterine cervix and MLA of the ovary and endometrium, characterized by predominant tubular and focal glandular/ductal architecture. Mesonephric remnants in the bladder wall were closely associated with adjacent MA in cases 1 and 4. MLA in case 6 was associated with mesonephric-like proliferations and endometriosis. All cases (6/6) were diffusely positive for Pax8, and all displayed a luminal pattern of CD10 staining, except case 4 for which CD10 immunostain was not available for review. Gata3 was either focally positive (cases 1, 2, and 6), negative (case 3), or diffusely positive (case 5). TTF-1 was diffusely expressed in cases 1 and 3 and negative in cases 2, 5, and 6. Although a KRAS G12C somatic mutation was detected in case 6, hotspot mutations in KRAS, NRAS, and PIK3CA were not present in other tested cases. Our study demonstrates that MAs and MLAs of the urinary tract share similar histopathogenesis, morphology, and immunophenotype to their counterparts in the female genital tract. We propose that, in the urinary tract, MA might be classified as a distinctive tumor that arises from mesonephric remnants or presumed Wolffian origin if they are not related to Müllerian-type precursors. The tumor displaying similar morphology and immunoprofile to MA but associated with Müllerian-type precursors should be classified as MLA.
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Affiliation(s)
- Deyin Xing
- Department of Pathology, The Johns Hopkins Medical Institutions, Baltimore, Maryland; Department of Oncology, The Johns Hopkins Medical Institutions, Baltimore, Maryland; Department of Gynecology and Obstetrics, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Sharon X Liang
- Department of Pathology, Allegheny Health Network/West Penn Hospital, Pittsburgh, Pennsylvania
| | - Faye F Gao
- Department of Pathology, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Jonathan I Epstein
- Department of Pathology, The Johns Hopkins Medical Institutions, Baltimore, Maryland; Department of Oncology, The Johns Hopkins Medical Institutions, Baltimore, Maryland; Department of Urology, The Johns Hopkins Medical Institutions, Baltimore, Maryland.
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Erdemoglu E, Öztürk V, Turan İ, Erdemoglu E. Vaginally Assisted Laparoscopic Urethrolysis and Mesh Excision after Tension-free Vaginal Tape. J Minim Invasive Gynecol 2021; 28:1975-1977. [PMID: 34224871 DOI: 10.1016/j.jmig.2021.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/10/2021] [Accepted: 06/25/2021] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE To present technique of vaginally assisted laparoscopic urethrolysis and mesh excision after tension-free vaginal tape. DESIGN Demonstration video. SETTING Despite the Food and Drug Administration's warning to limit the use of mesh, midurethral sling surgery (MUS) has not significantly decreased, but operations for complications have increased 3 times [1]. Urethral obstruction after MUS has an incidence of 2.7% to 11% [2] that requires resurgery, which ranges from pull-down, mesh excision to urethrolysis and is chosen by the surgeon's experience. Retropubic urethrolysis and mesh excision are reported to be more successful [3]. Urethrolysis can be performed by a retropubic, transvaginal, or suprameatal approach. Transvaginal mesh excision and urethrolysis are not satisfactory in all cases, and it might be difficult to identify the mesh if it is dislocated proximally or buried in dense fibrosis, which may increase urethral/bladder injuries. Although vaginal urethrolysis and mesh removal are usually preferred as the primary approach, there is no randomized controlled trial comparing retropubic and vaginal urethrolysis with/without mesh removal. Gynecologists should master each technique to provide individualized treatment. Laparoscopic urethrolysis has the advantage of the identification of neighboring structures and provides a safer operation (Fig. 1). Combined vaginal and laparoscopic approaches can be used to totally remove the mesh and for difficult surgeries at the junction of the retropubic urethra and the midurethra (Fig. 2). INTERVENTIONS (1) Timing of urethrolysis is controversial. Although urethral loosening or pulling down in the first few days and mesh excision in the first 15 days can be useful, urethrolysis can be chosen for delayed cases with marked fibrosis. Preoperative diagnostic cystoscopy to exclude urethral mesh erosion is essential. Intermittent catheterization until surgery should be done. (2) The technique is described in 5 steps. The arcus tendineus is an important landmark [4] (Fig. 3). CONCLUSION Laparoscopic urethrolysis for urinary obstruction after MUS can be a safe and successful procedure after failed vaginal approach or can be considered as a primary approach in select cases.
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Affiliation(s)
- Evrim Erdemoglu
- Department of Obstetrics and Gynecology, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey (all authors)..
| | - Volkan Öztürk
- Department of Obstetrics and Gynecology, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey (all authors)
| | - İlyas Turan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey (all authors)
| | - Ebru Erdemoglu
- Department of Obstetrics and Gynecology, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey (all authors)
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Roch M, Gaudreault N, Cyr MP, Venne G, Bureau NJ, Morin M. The Female Pelvic Floor Fascia Anatomy: A Systematic Search and Review. Life (Basel) 2021; 11:life11090900. [PMID: 34575049 PMCID: PMC8467746 DOI: 10.3390/life11090900] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/20/2021] [Accepted: 08/26/2021] [Indexed: 12/20/2022] Open
Abstract
The female pelvis is a complex anatomical region comprising the pelvic organs, muscles, neurovascular supplies, and fasciae. The anatomy of the pelvic floor and its fascial components are currently poorly described and misunderstood. This systematic search and review aimed to explore and summarize the current state of knowledge on the fascial anatomy of the pelvic floor in women. Methods: A systematic search was performed using Medline and Scopus databases. A synthesis of the findings with a critical appraisal was subsequently carried out. The risk of bias was assessed with the Anatomical Quality Assurance Tool. Results: A total of 39 articles, involving 1192 women, were included in the review. Although the perineal membrane, tendinous arch of pelvic fascia, pubourethral ligaments, rectovaginal fascia, and perineal body were the most frequently described structures, uncertainties were identified in micro- and macro-anatomy. The risk of bias was scored as low in 16 studies (41%), unclear in 3 studies (8%), and high in 20 studies (51%). Conclusions: This review provides the best available evidence on the female anatomy of the pelvic floor fasciae. Future studies should be conducted to clarify the discrepancies highlighted and accurately describe the pelvic floor fasciae.
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Affiliation(s)
- Mélanie Roch
- Research Center of the Centre Hospitalier Universitaire de Sherbrooke, Faculty of Medicine and Health Sciences, School of Rehabilitation, Université de Sherbrooke, Sherbrooke, QC J1H 5N4, Canada; (M.R.); (N.G.); (M.-P.C.)
| | - Nathaly Gaudreault
- Research Center of the Centre Hospitalier Universitaire de Sherbrooke, Faculty of Medicine and Health Sciences, School of Rehabilitation, Université de Sherbrooke, Sherbrooke, QC J1H 5N4, Canada; (M.R.); (N.G.); (M.-P.C.)
| | - Marie-Pierre Cyr
- Research Center of the Centre Hospitalier Universitaire de Sherbrooke, Faculty of Medicine and Health Sciences, School of Rehabilitation, Université de Sherbrooke, Sherbrooke, QC J1H 5N4, Canada; (M.R.); (N.G.); (M.-P.C.)
| | - Gabriel Venne
- Anatomy and Cell Biology, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC H3A 0C7, Canada;
| | - Nathalie J. Bureau
- Centre Hospitalier de l’Université de Montréal, Department of Radiology, Radio-Oncology, Nuclear Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC H3T 1J4, Canada;
| | - Mélanie Morin
- Research Center of the Centre Hospitalier Universitaire de Sherbrooke, Faculty of Medicine and Health Sciences, School of Rehabilitation, Université de Sherbrooke, Sherbrooke, QC J1H 5N4, Canada; (M.R.); (N.G.); (M.-P.C.)
- Correspondence:
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Abstract
The current World Health Organization (WHO) classification of adenocarcinoma of the urinary tract including the urethra includes uncommon Müllerian-derived carcinomas such as clear cell and endometrioid adenocarcinomas. The concept of primary mesonephric (Wolffian-derived) adenocarcinoma (MA) in the urethra (and urinary tract in general) is currently regarded as controversial as the term "mesonephric" had been also inaccurately applied in the past to label Müllerian-derived carcinomas, particularly clear cell adenocarcinoma. Further, pathologically well-documented or bona fide urethral MAs have not yet to be reported. Herein, we describe 2 examples of MA in elderly females that primarily presented in the urethra and manifested clinically with obstructive lower urinary tract symptoms. Both tumors exhibited histology similar to those in MAs of the female genital tract including the distinctive tubular proliferations with luminal eosinophilic materials. The first case, in addition, showed a variety of patterns including ductal (glandular), solid, fused/sieve-like tubules, dilated tubules, and spindled cells. The second case also showed a transition to the more irregular and poorly formed tubular proliferation of cells with greater nuclear atypia and with a desmoplastic response. Both tumors showed positivity for PAX8, GATA3, and luminal CD10, and 1 tumor analyzed harbored KRAS and ARID1A mutations. One patient received neoadjuvant chemotherapy and underwent resection but had local tumor recurrence and metastasis to the lungs and lumbar spine 12 months after presentation. In conclusion, MA, similar to those occurring in the female genital tract and distinct from the recognized Müllerian-derived carcinomas, may present primarily as urethral tumors. MA in the urethra probably shares a common pathogenesis with vaginal MA as both may originate from the same caudal loci of mesonephric remnants along the closely apposed anterior vaginal and posterior urethral walls. MA should be considered in future classifications for urethral tumors and we recommend that the confusing term "mesonephroid adenocarcinoma" should no longer be used.
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Laparoscopic surgical anatomy for pelvic floor surgery. Best Pract Res Clin Obstet Gynaecol 2018; 54:89-102. [PMID: 30554856 DOI: 10.1016/j.bpobgyn.2018.11.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 11/12/2018] [Indexed: 11/22/2022]
Abstract
Understanding anatomy is one of the pillars for performing a safe, effective, and efficient surgery, but recently, it is reported that there has been a decline in teaching anatomy during the preclinical years of medical school. There is also evidence that by the time a medical student becomes a clinician, a considerable proportion of the basic anatomy knowledge is lost. Hence, it is crucial for surgeons performing or assisting in pelvic floor surgery to revisit this integral clinical aspect of pelvic anatomy for performing a safe surgery. Pelvic organ prolapse repair, especially abdominal laparoscopic sacrocolpopexy, which is the gold standard of pelvic organ prolapse repair, presents a significant challenge to surgeons because the technique requires thorough and meticulous negotiation through abdomino-pelvic vascular structures and nerves supplying the pelvis, rectum, and ureters. The abdominal laparoscopic sacrocolpopexy surgery requires surgeons to have a deep understanding of anatomy to prevent potential life-threatening complications, which is as critical as it is for a pilot to understand the navigation route for a safe landing. This review is an extensive look and a great reminder to laparoscopic surgeons working in the pelvic cavity, especially those performing a pelvic floor surgery, about the anatomical safe routes for performing laparoscopic pelvic floor repairs. For easy reading and clear understanding, we have described step by step the safe anatomical journey a surgeon needs to take during laparoscopic sacrocolpopexy. We divided the technique into five critical anatomic locations (landmarks), which serves as our "flight map" for performing safe and efficient laparoscopic sacrocolpopexy.
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