Pelvic haematoma after Perigee™ procedure for cystocoele

Ultrasound imaging in urogynecology - state of the art 2016

The role of ultrasound imaging in urogynecology is not clearly defined. Despite significant developments in visualization techniques and interpretation of images, pelvic ultrasound is still more a tool for research than for clinical practice. Structures of the lower genitourinary tract and pelvic floor can be visualized from different approaches: transperineal, introital, transvaginal, abdominal or endoanal. According to contemporary guidelines and recommendations, the role of ultrasound in urogynecology is limited to the measurement of post-void residue. However, in many instances, including planning and audit of surgical procedures, management of recurrences or complications, ultrasound may be proposed as the initial examination of choice. Ultrasound may be used for assessment of bladder neck mobility before anti-incontinence procedures. On rare occasions it is helpful in recognition of pathologies mimicking vaginal prolapse such as vaginal cyst, urethral diverticula or rectal intussusception. In patients subjected to suburethral slings, causes of surgery failure or postsurgical voiding dysfunctions can be revealed by imaging. Many reports link the location of a tape close to the bladder neck to unfavorable outcomes of sling surgery. Some postoperative complications, such as urinary retention, mesh malposition, hematoma, or urinary tract injury, can be diagnosed by ultrasound. On the other hand, the clinical value of some applications of ultrasound in urogynecology, for example measurement of the bladder wall thickness as a marker of detrusor overactivity, has not been proved.

Determination of a Central Avascular Triangle within the Obturator Foramen: A Radioanatomic Study

PURPOSE

To map the vascular anatomy of the obturator foramen using fixed anatomic landmarks.

METHOD

Twenty obturator regions were dissected in 10 fresh female cadavers after vascular blue dye injection in five cadavers (50%). Furthermore, 104 obturator regions were reconstructed by angiotomodensitometry from 52 women under investigation for suspected arterial disease. The anatomy of the obturator region was mapped by measuring the distance of vascular structures from the middle of the two branches of the ischiopubic bone, which were used as fixed landmarks.

RESULTS

The bifurcation of the obturator artery was at a mean (SD) distance of 30.0 mm (4.5) from the middle of the ischiopubic branch (MISP). The anterior branch of the obturator vessels was 15.2 mm (10.1) from the MISP. The posterior branch of the obturator vessels was 5.5 mm (4.0) and 23.6 mm (8.7) from the middle of the outer edge of the obturator foramen (MOE) and the MISP, respectively. Using 5° and 95° percentiles of these measurements we defined a central avascular triangle.

CONCLUSIONS

Our data show that, beyond inter-individual variations, a central triangular avascular area can be identified in the obturator foramen between the posterior and anterior obturator artery using fixed landmarks.

How to manage peroperative haemorrhage when vaginally treating genital prolapse

Surgery of genital prolapse causes haemorrhagic complications in about 1% of cases. The pelvis is highly vascular and accessing the usual landmarks of vaginal surgery, in particular the sciatic spine, is delicate work. Meticulous dissection of closed spaces is often difficult, and exposure and haemostatic procedures will be challenging in the event of any bleeding complication. When fixing prosthesis to the sacrospinous ligament, the inferior gluteal artery and its coccygeal branch are at risk. Fixation to the sacrospinous ligament must be performed more than 25mm away from the sciatic spine and, if possible, must not transfixiate it. Safe insertion of prosthesis requires sufficient experience, and an adequate learning curve. Being aware of vascular anatomy allows one to understand and treat haemorrhagic incidents. Packing or selective embolization seem to be the two methods to adopt, depending on the severity of bleeding and the conditions of exposure on the one hand, and on the technical resources available for embolization, on the other. Hypogastric ligature appears to be ineffective in this context.