Rene R. Genadry

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.

The origin and clinical behavior of the parovarian tumor.

This study of 132 benign parovarian cysts and eight parovarian neoplasms demonstrated that the majority of such lesions are of paramesonephric or mesothelial origin. Furthermore, adnexal neoplasms, not histologically associated with the tube or ovary, may arise in such parovarian structures or de novo from the pelvic mesothelium.

Tubo-ovarian abscess: a retrospective review.

The charts of 160 patients with tubo-ovarian abscesses (TOAs) were reviewed. Patients were divided into two groups according to their response to initial medical therapy. Predictive factors were identified for the two groups. Prognosis was predictable on the basis of extent of disease at diagnosis and the initial response to medical therapy. There was no apparent association between a unilateral TOA and the use of an intrauterine contraceptive device. A minimum pregnancy rate of 8% was observed in patients maintaining reproductive function. No patient with a bilateral TOA conceived. Of all patients admitted to the hospital with TOA, 53% ultimately required surgical therapy. High residual morbidity and/or resultant infertility mandates more aggressive attempts at prevention.

Obstetric fistulas: a clinical review.

A high proportion of genitourinary fistulas have an obstetric origin. Obstetric fistulas are caused by prolonged obstructed labor coupled with a lack of medical attention. While successful management with prolonged bladder drainage has occasionally been reported, mature fistulas require formal operative repair, and it is crucial that the first repair is done properly. The literature reports 3 approaches to fistula repair: vaginal, abdominal, and combined vaginal and abdominal. Many authors report high success rates for the surgical closure of obstetric fistulas at the time of hospital discharge, without further evaluation of the repairs effect on urinary continence or subsequent quality of life. Data on obstetric fistulas are scarce, and thus many questions regarding fistula management remain unanswered. A standardized terminology and classification, as well as a data reporting system on the surgical management of obstetric fistulas and its outcomes, are critical steps that need to be taken immediately.

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.

Female urinary incontinence: pathophysiology, methods of evaluation and role of MR imaging

Urinary incontinence (UI) is one of the most common conditions that cause a significant psychosocial and hygienic problem in an aging female population. In this article we focus on the sphincteric type of stress UI in women, review the anatomy of the urethral sphincter and its support mechanism, and discuss methods of the evaluation of urethral function. Stress UI is the functional consequence of an anatomical abnormality, urethral hypermobility (UH) and intrinsic sphincter deficiency (ISD). Imaging plays an adjunct role to urodynamics in the assessment of women with UI. MR imaging due to its superior soft tissue contrast resolution contributes many findings that are predictive of UH, such as abnormal descent of the bladder neck, disruption of periurethral ligaments and vaginal attachments, and defects within the levator ani muscle. In ISD, MR imaging may show foreshortening or thinning of the sphincter muscle and bladder neck insufficiency manifested by funneling. MR imaging is ideal to evaluate the anatomy of the bladder neck and urethra; functional implications correlate well with functional studies and make MR imaging central to understanding the causes of stress UI and its thorough evaluation.

Controversies in Female Urethral Anatomy and their Significance for Understanding Urinary Continence: Observations and Literature Review

Abstract: To re-examine the anatomy of the female urethra and related structures, three female pelves serially sectioned in sagittal, coronal or transverse planes, and four sets of transverse histological slides of female urethras, were studied. The observations were assembled, rendered as illustrations, and correlated with published works to present an overall explanation of the gross and histological anatomy of the female pelvis and perineum as related to continence. The figures accompanying the text present the anatomy in a series of views in the three anatomical planes. The anatomical relationships of the paraurethral and paravaginal tissues are examined in relation to the conflicting nomenclature applied to these structures. The figures show the spatial relationships within the pelves and perineum that explain their effective function in urinary continence.

An anatomic classification of retovaginal septal defects

A classification of anatomic defects of the rectovaginal septum secondary to obstetric and/or surgical trauma is presented. Five distinct types are described on the basis of the location of the fistula and the associated anatomic alteration. A review of 57 patients based on this classification showed its applicability to preoperative management and surgical technique utilized.

Complex obstetric fistulas

Obstetric fistulas are rarely simple. Most patients in sub‐Saharan Africa and parts of Asia are carriers of complex fistulas or complicated fistulas requiring expert skills for evaluation and management. A fistula is predictably complex when it is greater than 4 cm and involves the continence mechanism (the urethra is partially absent, the bladder capacity is reduced, or both); is associated with moderately severe scarring of the trigone and urethrovesical junction; and/or has multiple openings. A fistula is even more complicated when it is more than 6 cm in its largest dimension, particularly when it is associated with severe scarring and the absence of the urethra, and/or when it is combined with a recto‐vaginal fistula. The present article reviews the evaluation methods and main surgical techniques used in the management of complex fistulas. The severity of the neurovascular alterations associated with these lesions, as well as inescapable limitations in staff, health facilities, and supplies, make their optimal management very challenging.

Secondary malignancies in benign cystic teratomas

Abstract Seventeen cases of secondary malignancy arising in benign cystic teratomas are described. All 17 cases contained elements of the preexisting benign cystic teratoma. Thirteen contained invasive squamous cell carcinoma alone. In situ squamous cell carcinoma was seen in 1 case. Three cases displayed invasive squamous cell carcinoma plus a mixed mesodermal tumor, a carcinoid in struma ovarii in thyroid tissue, and a follicular adenoma in thyroid tissue, respectively. These neoplasms occurred in women in the fifth decade of life and treatment in most cases was a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Survival was dependent upon clinical stage at the time of diagnosis and therapy.