Caryl G. Salomon

Three dimensional virtual reality model of the normal female pelvic floor

The anatomy of the pelvic floor is complex and difficult to visualize from conventional two-dimensional anatomy pictures. The goal of this project was to establish the methods necessary to develop a static three-dimensional virtual reality model of the normal female pelvic floor from high-resolution magnetic resonance imaging (MRI) scans. An asymptomatic nulliparous 23-year-old female with no urinary incontinence symptoms underwent a high-resolution pelvic floor MRI scan. Selected pelvic floor structures were manually segmented: bladder, urethra, vagina, uterus, cervix, levator ani, obturator externus, obturator internus, and pubic bone. With high-resolution scans, accurate segmentation of the structures was possible. The completed models were displayed on an ImmersaDesk Virtual Reality system and three clinicians verified their accuracy. Stereovision glasses were used to enhance the model while a receiver tracked head position. Three-dimensional virtual reality models of the female pelvic floor can enhance our understanding of anatomy and physiology of this complex part of the body. They can be used as tools for both research and teaching, facilitating improved treatment of pelvic floor pathologies.

Reproducibility of Dynamic MR Imaging Pelvic Measurements : A Multi-institutional Study

PURPOSE To assess the reproducibility of bone and soft-tissue pelvimetry measurements obtained from dynamic magnetic resonance (MR) imaging studies in primiparous women across multiple centers. MATERIALS AND METHODS All subjects prospectively gave consent for participation in this institutional review board-approved, HIPAA-compliant study. At six clinical sites, standardized dynamic pelvic 1.5-T multiplanar T2-weighted MR imaging was performed in three groups of primiparous women at 6-12 months after birth: Group 1, vaginal delivery with anal sphincter tear (n = 93); group 2, vaginal delivery without anal sphincter tear (n = 79); and group 3, cesarean delivery without labor (n = 26). After standardized central training, blinded readers at separate clinical sites and a blinded expert central reader measured nine bone and 10 soft-tissue pelvimetry parameters. Subsequently, three readers underwent additional standardized training, and reread 20 MR imaging studies. Measurement variability was assessed by using intraclass correlation for agreement between the clinical site and central readers. Acceptable agreement was defined as an intraclass correlation coefficient (ICC) of at least 0.7. RESULTS There was acceptable agreement (ICC range, 0.71-0.93) for eight of 19 MR imaging parameters at initial readings of 198 subjects. The remaining parameters had an ICC range of 0.13-0.66. Additional training reduced measurement variability: Twelve of 19 parameters had acceptable agreement (ICC range, 0.70-0.92). Correlations were greater for bone (ICC, >or=0.70 in five [initial readings] and eight of nine [rereadings] variables) than for soft-tissue measurements (ICC, >or=0.70 in three [initial readings] of 10 and four [rereadings] of 10 readings, respectively). CONCLUSION Despite standardized central training, there is high variability of pelvic MR imaging measurements among readers, particularly for soft-tissue structures. Although slightly improved with additional training, measurement variability adversely affects the utility of many MR imaging measurements for multicenter pelvic floor disorder research.

Magnetic resonance assessment of pelvic anatomy and pelvic floor disorders after childbirth

To compare pelvic anatomy, using magnetic resonance imaging, between postpartum women with or without pelvic floor disorders. We measured postpartum bony and soft tissue pelvic dimensions in 246 primiparas, 6–12-months postpartum. Anatomy was compared between women with and without urinary or fecal incontinence, or pelvic organ prolapse; P < 0.01 was considered statistically significant. A deeper sacral hollow was significantly associated with fecal incontinence (P = 0.005). Urinary incontinence was marginally associated with a wider intertuberous diameter (P = 0.017) and pelvic arch (P = 0.017). There were no significant differences in pelvimetry measures between women with and without prolapse (e.g., vaginal or cervical descent to or beyond the hymen). We did not detect meaningful differences in soft tissue dimensions for women with and without these pelvic floor disorders. Dimensions of the bony pelvis do not differ substantially between primiparous women with and without postpartum urinary incontinence, fecal incontinence and prolapse.

Computed tomography of chronic nonpuerperal uterine inversion.

Uterine inversion is an unusual entity; chronic nonpuerperal inversion is rare. In this report we present a case of chronic nonpuerperal uterine inversion that was initially diagnosed as invasive endometrial carcinoma. The CT findings in this case are presented.

Measurements from image-based three dimensional pelvic floor reconstruction: a study of inter- and intraobserver reliability.

To describe inter‐ and intraobserver reliability of 3D measurements of female pelvic floor structures.

Fibroma of the testicular tunics: an unusual extratesticular intrascrotal mass.

Fibromas are rare, benign intrascrotal tumors. There are only a handful of case reports that specifically discuss these masses. 1-5 Here we present a case of fibroma of the testicular tunics and its imaging characteristics. The radiologic appearance of these tumors is variable; our goal is to familiarize the radiologist with the imaging characteristics of this clinical entity.

Randomized trial of medroxyprogesterone acetate for the prevention of endometrial pathology from adjuvant tamoxifen for breast cancer: SWOG S9630

The proliferative effect of adjuvant tamoxifen on the endometrium can potentially result in endometrial abnormalities, including cancer in postmenopausal women. We conducted a randomized, controlled trial to assess endometrial pathological diagnoses in postmenopausal women with early stage, ER-positive breast cancer without endometrial pathology at baseline. They were assigned to tamoxifen alone versus tamoxifen plus cyclical medroxyprogesterone acetate (MPA 10 mg for 14 days every 3 months) for 5 years. Endovaginal sonograms (EVS) +/− endometrial biopsies (EMB) were required at baseline, 2 and 5 years. Of 313 patients registered, 296 were eligible and 169 (57%; 89, tamoxifen; 80, tamoxifen+MPA) were evaluable (completed year-2 EVS, with an EMB if stripe width was ⩾5 mm). Sixty (67%) of these in the tamoxifen arm had an endometrial stripe width ⩾5 mm (and underwent subsequent EMB) compared with 48 (60%) in the tamoxifen+MPA arm (P=0.40). There were four cases of proliferative endometrium and one simple hyperplasia on the tamoxifen arm (6% (95% confidence interval (CI): 2–13%) among evaluable patients and one proliferative endometrium on the tamoxifen+MPA arm (P=0.11). The overall fraction with benign endometrial abnormalities at year 2 was 3.6% (6/169; 95% CI: 1.3–7.6%), with only 1 (of 102) new benign proliferative event at year 5. The event rate in both arms was much lower than projected, making treatment arm comparisons less informative. A normal endometrium prior to tamoxifen may provide reassurance regarding future endometrial events. However, validation in a larger trial is needed before changing practice in asymptomatic, postmenopausal women.

Transrectal ultrasound of the prostate bed after collagen injection

OBJECTIVE Transurethral injection of collagen (TCI) may be used to treat urinary incontinence following radical prostatectomy for prostate cancer. The transrectal ultrasound (TRUS) findings after TCI are described in this report. MATERIALS AND METHODS TRUS exams of four postprostatectomy patients who had undergone TCI were reviewed. Findings were correlated with pathologic specimens obtained at TRUS-guided core biopsy. These histologic specimens were compared with others from postprostatectomy patients who had not undergone TCI. RESULTS Well defined bladder apex masses of uniform echogenicity, hypoechoic to adjacent fat and muscle, were identified sonographically in all TCI patients. Masses from which positive biopsies were obtained were similar in appearance to those with no malignancy. Hypocellular fibrous tissue and foci of acellular loose connective tissue were identified in the biopsies of those patients who had undergone TCI. No acellular areas were identified in specimens from patients who had not had TCI. CONCLUSION Sequelae of TCI should be included in the differential diagnosis of perianastomotic masses in postprostatectomy patients. However, the need for biopsy is not obviated as residual or recurrent prostate carcinoma may coexist.