Jerome L. Buller

Uterosacral ligament: description of anatomic relationships to optimize surgical safety☆

Objective To determine the optimal site in the uterosacral ligament for suspension of the vaginal vault with regard to adjacent anatomy and suspension strength. Methods Fifteen female cadavers were evaluated between December 1998 and September 1999. Eleven hemisected pelves were dissected to better define the uterosacral ligament and identify adjacent anatomy. Ureteral pressure profiles with and without relaxing incisions were done on four fresh specimens. Suture pullout strengths also were assessed in the uterosacral ligament. Results The uterosacral ligament was attached broadly to the first, second, and third sacral vertebrae, and variably to the fourth sacral vertebrae. The intermediate portion of the uterosacral ligament had fewer vital, subjacent structures. The mean ± standard deviation distance from ureter to uterosacral ligament was 0.9 ± 0.4, 2.3 ± 0.9, and 4.1 ± 0.6 cm in the cervical, intermediate, and sacral portions of the uterosacral ligament, respectively. The distance from the ischial spine to the ureter was 4.9 ± 2.0 cm. The ischial spine was consistently beneath the intermediate portion but variable in location beneath the breadth of the ligament. Uterosacral ligament tension was transmitted to the ureter, most notably near the cervix. The cervical and intermediate portions of the uterosacral ligament supported more than 17 kg of weight before failure. Conclusion Our findings suggest that the optimal site for fixation is the intermediate portion of the uterosacral ligament, 1 cm posterior to its most anterior palpable margin, with the ligament on tension.

Dynamic pelvic magnetic resonance imaging and cystocolpoproctography alter surgical management of pelvic floor disorders

PURPOSE: Pelvic organ prolapse results in a spectrum of progressively disabling disorders. Despite attempts to standardize the clinical examination, a variety of imaging techniques are used. The purpose of this study was to evaluate dynamic pelvic magnetic resonance imaging and dynamic cystocolpoproctography in the surgical management of females with complex pelvic floor disorders. METHODS: Twenty-two patients were identified from The Johns Hopkins Pelvic Floor Disorders Center database who had symptoms of complex pelvic organ prolapse and underwent dynamic magnetic resonance, dynamic cystocolpoproctography, and subsequent multidisciplinary review and operative repair. RESULTS: The mean age of the study group was 58 ± 13 years, and all patients were Caucasian. Constipation (95.5 percent), urinary incontinence (77.3 percent), complaints of incomplete fecal evacuation (59.1 percent), and bulging vaginal tissues (54.4 percent) were the most common complaints on presentation. All patients had multiple complaints with a median number of 4 symptoms (range, 2–8). Physical examination, dynamic magnetic resonance imaging, and dynamic cystocolpoproctography were concordant for rectocele, enterocele, cystocele, and perineal descent in only 41 percent of patients. Dynamic imaging lead to changes in the initial operative plan in 41 percent of patients. Dynamic magnetic resonance was the only modality that identified levator ani hernias. Dynamic cystocolpoproctography identified sigmoidoceles and internal rectal prolapse more often than physical examination or dynamic magnetic resonance. CONCLUSIONS: Levator ani hernias are often missed by physical examination and traditional fluoroscopic imaging. Dynamic magnetic resonance and cystocolpoproctography are complementary studies to the physical examination that may alter the surgical management of females with complex pelvic floor disorders.

Anatomy of pelvic arteries adjacent to the sacrospinous ligament: importance of the coccygeal branch of the inferior gluteal artery

OBJECTIVE To describe the arterial vascular anatomy in the area of the sacrospinous ligament. METHODS Cadaver pelvises were dissected to reveal the anatomy of the sacrospinous ligament with emphasis on vascular and neuroanatomy. Flexible rulers were used to measure the coccygeal branch in five hemipelvises. RESULTS The pudendal vessels and nerve pass immediately medial and inferior to the ischial spine (within 0.5 cm of the spine) and behind the sacrospinous ligament. The pudendal artery lies anterior to the sacrotuberous ligament, which passes behind the ischial spine to its attachment at the posterior ischial tuberosity. The inferior gluteal artery originates from the posterior or the anterior branch of the internal iliac artery to pass behind the sciatic nerve and the sacrospinous ligament. There is a 3- to 5-mm window in which the inferior gluteal vessel is left uncovered above the top of the sacrospinous ligament and below the lower edge of the main body of the sciatic nerve plexus. The coccygeal branch of the inferior gluteal artery passes immediately behind the midportion of the sacrospinous ligament and pierces the sacrotuberous ligament in multiple sites. The main body of the inferior gluteal artery leaves the pelvis by passing posterior to the upper edge of the sacrospinous ligament and following the inferior portion of the sciatic nerve out of the greater sciatic foramen. CONCLUSION Sutures placed through the sacrospinous ligament at least 2.5 cm from the ischial spine along the superior border of the sacrospinous ligament and without transgressing the entire thickness are in an area generally free of arterial vessels.

Establishing a Mean Postvoid Residual Volume in Asymptomatic Perimenopausal and Postmenopausal Women

OBJECTIVE: To estimate mean postvoid residual (PVR) volumes among perimenopausal and postmenopausal women without significant lower urinary tract or pelvic organ prolapse symptoms. METHODS: Patients presenting for well-women encounters were offered study participation. Women with a history of urinary incontinence greater than twice per week, urinary retention, symptomatic pelvic organ prolapse, or neurologic disorders were excluded. Pelvic relaxation, if present, was characterized according to the pelvic organ prolapse quantification system. Within 10 minutes of spontaneously voiding, PVR volume was assessed with bladder ultrasonography. RESULTS: A total of 96 patients were enrolled; mean age was 60±11 years. The majority (80%) were postmenopausal; 30% had a previous hysterectomy. Most women (92%) had some degree of prolapse; the median stage was one, most commonly involving the anterior compartment (70%). The median PVR volume was 19 mL (range 0–145 mL); the mean PVR volume was 24±29 mL. Only 15% of patients had a PVR volume greater than 50 mL, and 95% had a PVR volume 100 mL or less. Only age 65 years or older was associated with a higher mean PVR volume; hormone therapy, vaginal atrophy, parity, and stage of asymptomatic prolapse did not affect PVR volumes. CONCLUSION: Most asymptomatic perimenopausal and postmenopausal women had a PVR volume less than 50 mL, which was unaffected by multiple factors that were thought to potentially affect bladder function. Establishing “normal” volumes in this population may aid in developing recommendations regarding appropriate bladder function and retention criteria for women who are symptomatic or those who have had pelvic floor surgery. LEVEL OF EVIDENCE: II

Pregnancy during Operation Iraqi Freedom/Operation Enduring Freedom

OBJECTIVE The purpose of this study was to evaluate pregnancy during war-time deployment. METHODS A retrospective review of gynecology visits was evaluated at Camp Doha, Kuwait, from August 2003 through April 2004. Of the 1,737 visits, 77 demonstrated a positive pregnancy test. These charts were evaluated for factors that may lead to important information for future deployments. RESULTS The average age of the female soldier with a positive pregnancy test in theater was 27 +/- 7 years. The primary presenting complaint was amenorrhea. Ninety-two percent had an ultrasound. Fifty-four percent of visits were active duty, followed by Reserve, National Guard, and civilian government employees. Ninety-two percent were administratively redeployed. Seventy-seven percent of the soldiers became pregnant in country. Twenty-three percent arrived in country pregnant. CONCLUSIONS Given the number of pregnancies before and during deployment, current screening procedures as well as new concepts in prevention need to be addressed.

Anatomical and histological examination of the porcine vagina and supportive structures: in search of an ideal model for pelvic floor disorder evaluation and management.

Objective: The objective of the study was to examine the anatomy and histology of the swine vagina and adjacent supportive structures in comparison to human tissues to determine the potential utility of this model for pelvic floor disorder evaluation and management. Methods: This is a descriptive study of the gross anatomy and histology of the swine vagina, uterosacral ligament, cardinal ligament, and rectovaginal space. Tissue was collected from 6 different sites in each of the 6 animals, processed, and stained with hematoxylin-eosin, Masson trichrome, and van Gieson and evaluated by both gynecologic and veterinary pathologists. Results: Porcine tissues were similar to the human vagina and supporting structures. The origin, insertion, and course of the uterosacral and cardinal ligaments appeared similar to those in humans. Histologically, both the porcine and human vagina and rectum consist of a mucosal, muscular, and adventitial layers. The swine vaginal smooth muscle is arranged in an inner circular and outer longitudinal manner. Collagen, elastin, and smooth muscle were identified in 5 sites. Collagen was highest in the cardinal compared with the uterosacral ligament (P = 0.03), whereas elastin was highest in the uterosacral ligament. The vaginal epithelium measured approximately 40 &mgr;m at the vaginal cuff and 50 to 200 &mgr;m at anterior and posterior vagina. The swine vagina appeared thinner and contained less elastin. The rectovaginal region contained a smooth muscle layer leading to a thin adventitial layer. Conclusions: The swine vagina and adjacent supportive structures appear to be grossly and histologically similar to human vaginal anatomy, and these similarities could lead to further investigation of the porcine model in the study of pelvic support and support disorders.

Pelvic Pain Presenting in a Combat Environment

OBJECTIVE The objective was to identify the incidence of pain disorders in the deployed female active duty population in support of Operation Iraqi Freedom. METHODS Retrospective chart review was completed on all patients who were seen for gynecologic services at Camp Doha, Kuwait, from September 2003 through March 2004. One thousand seven hundred thirty-seven patients were identified. Statistical analysis was performed. RESULTS Of the 1,737 patients seen during the study period, 150 patients were identified as having a pelvic pain disorder. These patients accounted for 14% of all patients seen for gynecologic services. Mean age was 28 +/- 8 years (range, 15-53 years). Pelvic pain of unclear etiology and cystitis were the most common diagnoses made accounting for 19% and 16% of encounters. CONCLUSIONS Acute pelvic pain disorders can be effectively managed in the combat environment. Optimization of predeployment regimens for management of pain is strongly recommended. Consideration should be given to making soldiers with chronic pelvic pain disorders that fail to respond to predeployment medical management nondeployable.

Laparoscopic colpotomy using monopolar electrocautery: does power really matter?

Objective The purpose of this study was to assess the extent and rate of vaginal tissue injury associated with the utilization of various monopolar electrosurgical power settings when laparoscopically transecting vaginal tissue. Methods This is an Institutional Animal Care and Use Committee–approved prospective, paired, single-blinded study. Externalized porcine vagina was transected using monopolar energy at 30, 50, and 80 W in the cut mode with laparoscopic Endo Shears. The slides were prepared and stained with both hematoxylin-eosin and Masson trichrome and were examined by board-certified veterinary pathologists blinded to the study. Results There were 18 swine; each animal was tested on all 3 power settings (n = 54). Tissue injury was measured to a mean (SD) of 767 (519) &mgr;m at 30 W, 690 (600) &mgr;m at 50 W, and 556 (470) &mgr;m at 80 W. When comparing the monopolar settings, the results were as follows: 30 versus 50 W (P = 0.33), 30 versus 80 W (P = 0.067), and 50 versus 80 W (P = 0.17). The mean (SD) time for complete transection was measured at each power setting (n = 18), with 35.8 (5.4) seconds for 30 W, 13.5 (5.5) seconds for 50 W, and 8.4 (5.1) seconds for 80 W (P < 0.001). There was a statistically significant difference in the mean (SD) rates of injury, with 20.8 (8.8) &mgr;m/s at 30 W, 39.8 (11.8) &mgr;m/s at 50 W, and 50.1 (19.2) &mgr;m/s at 80 W (P = 0.01). Conclusions Using various power settings of monopolar energy may not make a significant difference in swine vaginal tissue damage at the time of colpotomy. However, there was a significant difference in the times and rates at which tissue was transected when using higher powers. We recommend using the 50- or 80-W setting, as this will likely decrease surgical times without altering vaginal tissue damage.

Usability Study of a Novel, Self-Lighted, Disposable Speculum: Military Applications

STUDY DESIGN Data collected from a postutilization questionnaire were used to evaluate the usability of the OfficeSPEC disposable vaginal speculum, specifically the effectiveness, efficiency, and acceptability, in clinical, hospital, and austere environments. RESULTS Usability data analysis showed the OfficeSPEC speculum had an effectiveness rating of 4.6/5, efficiency rating of 4.5/5, and acceptability rating of 4.6/5; overall usability in deployed environments was favorable. The overall rankings were 3.4 for plastic, 4.2 for metal (p < 0.001), and 4.5 for OfficeSPEC (p < 0.001). Cost analysis of the OfficeSPEC placed the disposable speculum as a reasonable alternative with yearly cost of

Prevalence of perioperative complications among women undergoing reconstructive pelvic surgery

129,200, compared to traditional metal (