Does a Uterine Manipulator Increase the Distance of the Ureter to the Cervix and/or Vagina? An Anatomical Cadaver Study.

STUDY OBJECTIVE: To determine whether advancing a manipulator increased the distance of the ureter to the cervix and/or vagina. DESIGN: Prospective. SETTING: Academic institution. PATIENTS: A total of 22 intact fresh-frozen female pelvises. INTERVENTIONS: A total of 6 ureteral distances were measured per pelvis. Included were the following measurements on each side: (1) from the lateral cervical wall to the ureter at the intersection with the uterine artery; (2) from the lateral cervical wall to the parametrial ureter; and (3) from the vagina to the ureter at the intersection with the uterine artery. All measurements were obtained with and without advancement of a uterine manipulator. MEASUREMENTS AND MAIN RESULTS: The average distance from the ureter to the cervix and vagina without advancing the manipulator was 2.8 and 3.1 cm, respectively, and the distance from the parametrial ureter to the cervix was 3.3 cm. When the manipulator was advanced, all ureteral distances increased by 0.8, 0.6, and 0.6 cm, respectively, in 12 of the 22 pelvises (55%). Advancing the manipulator did not increase at least 1 of the distances in 10 of the 22 pelvises (45%). The advancement of the manipulator lengthened the 2 shortest ureteral distances of 1 cm noted in 1 pelvis (4.5%) by 0.9 and 0.4 cm. CONCLUSION: The uterine manipulator increased the distance of the ureter to the cervix and vagina for all measurements in 55.5% of the pelvises. The greatest increase was 0.9 cm. The manipulator did not increase at least 1 of the distances in 10 of the 22 pelvises (45.4%).

3D Printing-Enabled Nanoparticle Alignment: A Review of Mechanisms and Applications.

3D printing (additive manufacturing (AM)) has enormous potential for rapid tooling and mass production due to its design flexibility and significant reduction of the timeline from design to manufacturing. The current state-of-the-art in 3D printing focuses on material manufacturability and engineering applications. However, there still exists the bottleneck of low printing resolution and processing rates, especially when nanomaterials need tailorable orders at different scales. An interesting phenomenon is the preferential alignment of nanoparticles that enhance material properties. Therefore, this review emphasizes the landscape of nanoparticle alignment in the context of 3D printing. Herein, a brief overview of 3D printing is provided, followed by a comprehensive summary of the 3D printing-enabled nanoparticle alignment in well-established and in-house customized 3D printing mechanisms that can lead to selective deposition and preferential orientation of nanoparticles. Subsequently, it is listed that typical applications that utilized the properties of ordered nanoparticles (e.g., structural composites, heat conductors, chemo-resistive sensors, engineered surfaces, tissue scaffolds, and actuators based on structural and functional property improvement). This review's emphasis is on the particle alignment methodology and the performance of composites incorporating aligned nanoparticles. In the end, significant limitations of current 3D printing techniques are identified together with future perspectives.

Vaginal Salpingectomy Techniques in the Presence of Ovarian Conservation.

STUDY OBJECTIVE: To demonstrate vaginal salpingectomy techniques in the presence of ovarian conservation. DESIGN: Technical video demonstrating 2 methods of Fallopian tube removal with illustrations (Canadian Task Force classification III). SETTING: The prevalence of salpingectomy at the time of hysterectomy has increased significantly since 1998 [1]. One reason for the increased rate of salpingectomy is the relationship of serous ovarian carcinomas to fimbrial serous tubal intraepithelial carcinomas [2]. A Swedish population-based study reported that salpingectomy is an effective measure to reduce ovarian cancer risk in the general population [3]. Prophylactic salpingectomy and delayed oophorectomy may be an acceptable alternative in some BRCA mutation carriers [4]. A retrospective cohort study of 425 vaginal hysterectomies showed that 88% of patients were able to successfully undergo concomitant salpingectomy [5]. Mayo Clinic Institutional Review Board approval was not required for this video article. INTERVENTION: Two methods of salpingectomy are demonstrated differing in the final disposition of the proximal Fallopian tube (segment). The 2 different methods are shown to increase clarity and understanding of the technique. CONCLUSION: Salpingectomy without concomitant removal of the ovaries at vaginal hysterectomy is a feasible and beneficial procedure.

Outcomes of Concurrent Breast and Gynecologic Risk Reduction Surgery.

BACKGROUND: Women considering risk reduction surgery after a diagnosis of breast/ovarian cancer and/or inherited cancer gene mutation face difficult decisions. The safety of combined breast and gynecologic surgery has not been well studied; therefore, we evaluated the outcomes for patients who have undergone coordinated multispecialty surgery. METHODS: We conducted a retrospective review of patients undergoing simultaneous breast and gynecologic surgery for newly or previously diagnosed breast cancer and/or an inherited cancer gene mutation during the same anesthetic at a single institution from 1999 to 2013. RESULTS: Seventy-three patients with a mean age of 50 years (range 27-88) were identified. Most patients had newly diagnosed breast cancer or ductal carcinoma in situ (62 %) and 28 patients (38 %) had an identified BRCA mutation. Almost all gynecologic procedures were for risk reduction or benign gynecologic conditions (97 %). Mastectomy was performed in 39 patients (53 %), the majority of whom (79 %) underwent immediate reconstruction. The most common gynecologic procedure involved bilateral salpingo-oophorectomy, which was performed alone in 18 patients (25 %) and combined with hysterectomy in 40 patients (55 %). A total of 32 patients (44 %) developed postoperative complications, most of which were minor and did not require surgical intervention or hospitalization. Two of the 19 patients who underwent implant reconstruction (11 %; 3 % of the entire cohort) had major infectious complications requiring explantation. CONCLUSION: Combined breast and gynecologic procedures for a breast cancer diagnosis and/or risk reduction in patients can be accomplished with acceptable morbidity. Concurrent operations, including reconstruction, can be offered to patients without negatively impacting their outcome.

Complications in robotic-assisted gynecologic surgery according to case type: a 6-year retrospective cohort study using Clavien-Dindo classification.

STUDY OBJECTIVE: To estimate the risk of postoperative complications in robotic-assisted gynecologic surgery according to case type. STUDY DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Mayo Clinic Arizona. PATIENTS: All 1155 patients who underwent robotic-assisted gynecologic surgery between March 2004 and December 2009 were included. Patients were primarily white (94.3%), with a mean (SD) age of 51.5 (15.4) years, and were overweight, with body mass index (BMI) of 27.2 (6.8). INTERVENTIONS: Risk of complications, overall and according to Clavien-Dindo grade, and incidence of specific complications were analyzed. Robotic-assisted gynecologic surgical procedures were categorized postoperatively according to case type as benign simple (e.g., oophorectomy, simple hysterectomy) in 552 (47.8%) patients, benign complex (e.g., excision of invasive endometriosis) in 262 (22.7%), urogynecologic in 121 (10.5%), and oncologic in 220 (19.1%). MEASUREMENTS AND MAIN RESULTS: Intraoperative complications occurred in 3.2% of patients. Postoperative complications of any type occurred in 18.4% of patients. Conversion to laparotomy was necessary in 2.7%. Urologic complications were more common in urogynecologic cases (5.8%) as compared with benign simple (0.5%), benign complex (2.7%), and oncologic (3.2%). Bleeding complications were most common in oncologic cases (5%). Clavien-Dindo grade ≥ 3 complications occurred in 5.2% of patients overall, and were >3-fold likely to occur in benign complex, urogynecologic, and oncologic cases than in benign simple cases. When adjusted for age, BMI, estimated blood loss, operative time, length of stay, and previous pelvic surgery, complications were nearly twice as common for benign complex (odds ratio [OR] 1.7; 95% confidence interval [CI], 1.1-2.7), urogynecologic (OR 1.9; 95% CI, 1.0-3.4), and oncologic (OR 1.9; 95% CI, 1.1-3.1) cases as for benign simple cases, although weakly significant. Case type, BMI, estimated blood loss, and length of stay remained important factors in predicting postoperative complications. CONCLUSION: The incidence of complications in robotic-assisted gynecologic surgery varies according to case type. Defining the role of patient and surgical variables such as case type in the occurrence of complications may help in identification of cases with increased risk, to improve patient counseling and surgical outcome.

The effect of rectal distension on bladder function in patients with overactive bladder.

AIMS: To investigate the effect of rectal distension on bladder sensation volumes and the number of detrusor contractions in patients with overactive bladder (OAB) symptoms. METHODS: A prospective randomized study included patients with OAB symptoms. Multichannel urodynamic studies were completed with and without rectal balloon distension. Bladder sensation volumes and detrusor contractions were compared. RESULTS: Twenty-six patients were included in the study. The mean age was 67 years and mean BMI was 28.3 kg/m(2) . Bladder sensation volumes were lower with rectal distention as follows: normal desire to void (139 ml SD, ±114 vs. 197 ml SD ±150, P = 0.01), strong desire to void (260 ml SD ±171 vs. 330 ml SD ±172, P = 0.01), and maximum cystometric capacity (326 ml SD ±183 vs. 403 ml SD ±180, P = 0.0001). There was no difference in the number of detrusor contractions or the bladder volume at which the first detrusor contraction had occurred with and without rectal distension. CONCLUSION: Rectal distention in patients with OAB symptoms significantly lowered bladder sensation volumes (normal desire, strong desire, and maximal capacity).

Incidence and characteristics of patients with vaginal cuff dehiscence after robotic procedures.

OBJECTIVE: To estimate the incidence and characteristics of patients with vaginal cuff dehiscence after robotic cuff closure. METHODS: We reviewed medical records from March 2004 to December 2008 of all patients with vaginal cuff dehiscence after a robotic simple and radical hysterectomy, trachelectomy, and upper vaginectomy using the robotic da Vinci Surgical System. RESULTS: Twenty-one of 510 patients were identified with vaginal cuff dehiscence (incidence 4.1%, 95% confidence interval 2.3-5.8%). In nine patients, the robotic procedure was performed for a gynecologic malignancy. Coitus was the triggering event in 10 patients. Patients most commonly presented with vaginal bleeding and sudden gush of watery vaginal discharge. Bowel evisceration was associated in six patients. Median time to presentation was 43 days or 6.1 weeks. Nineteen cases were repaired through a vaginal approach and one combined vaginal and laparoscopic. Three of 21 patients experienced a repeat dehiscence and required a second repair. CONCLUSION: Vaginal cuff dehiscence should be considered in patients with vaginal bleeding and sudden watery discharge after robotic cuff closure. The incidence is similar as previously reported for laparoscopic procedures. Contributing factors remain unknown but thermal effect and vaginal closure technique probably play major roles. LEVEL OF EVIDENCE: III.

Robotic-assisted sacrocolpopexy: technique and learning curve.

BACKGROUND: Laparoscopic sacrocolpopexy (LSCP) offers a minimally invasive approach for treating vaginal vault prolapse. The Da Vinci robotic surgical system may decrease the difficulty of the procedure. The objective of this study was to describe the surgical technique of robotic-assisted sacrocolpopexy (RASCP) and evaluate its feasibility, safety, learning curve, and perioperative complications. METHODS: Eighty patients underwent RASCP between November 2004 and June 2007. Robotic dissection of the planes between the bladder and vagina anteriorly and between the vagina and rectum posteriorly was performed. A peritoneal incision was made to expose the sacral promontory and extended down to the vaginal apex. A Y-shaped mesh was sutured to the anterior and posterior surfaces of the vagina. The tail end of the mesh was sutured to the sacral promontory. Intracorporeal knot tying was used in all sutures. The peritoneal incision was closed to cover the mesh using a running suture. RESULTS: Mean operative time was 197.9 [standard deviation (SD) 66.8] min. After completion of the first ten cases, mean operative time decreased by 25.4% [64.3 min, 95% confidence interval (CI) 16.1-112.4 min, p < 0.01]. Two (2.5%) patients had injury to the bladder, one (1.2%) patient had a small bowel injury, and one (1.2%) patient had a ureteric injury. Postoperatively, five (6%) patients developed vaginal mesh erosion, one (1.2%) patient developed a pelvic abscess, and one (1.2%) patient had postoperative ileus. Four (5%) cases were converted to laparotomy. Mean follow-up period was 4.8 months (range 1-24 months). CONCLUSIONS: RASCP is a feasible procedure with acceptable complication rates and short learning curve.

Open laparoscopic access technique: review of 2010 patients.

OBJECTIVE: We assessed safety and efficacy of an open laparoscopic entry technique. METHODS: A retrospective review of all patients undergoing laparoscopy via open laparoscopic access over an 8-year period from January 1, 1998 to December 31, 2006 is presented. RESULTS: During the study period, 2010 consecutive subjects underwent laparoscopy. Recorded intraoperative complications include enterotomy (0.1%) and failure to enter (0.1%). There were no instances of vascular injury related to entry. Recorded postoperative complications include hernia (0.9%), infection (2.5%), hematoma (0.05%), and noncosmetic healing (0.4%). A statistically significant association existed between obesity and postoperative hernia, and between previous abdominal surgery and postoperative infection. CONCLUSION: Though typically straightforward, initial entry is one of the most common causes of injury in laparoscopy. The predominant entry method of entry in gynecologic surgery remains a closed technique. This technique has unfortunately been demonstrated in multiple series to have the potential for visceral and vascular injury due to its blind insertion of Veress needles and trocars. The open laparoscopic technique is a safe and effective method of obtaining access to the abdominal cavity with no associated vascular injury.

A Case of Simultaneous Benign Metastasizing Leiomyomas and Disseminated Peritoneal Leiomyomatosis Following Endoscopic Power Morcellation for Uterine Disease.

Extrauterine spread of leiomyomas is rare and most commonly occurs in the lungs. We present a case of simultaneous metastatic leiomyomatosis to the lungs and peritoneal cavity following laparoscopic myomectomy with power morcellation. The patient presented to our institution for further management where she underwent a robotically assisted hysterectomy with bilateral salpingo-oophorectomy. Leiomyomatous implants measuring up to 2.4 cm were resected from bowel mesentery and bladder peritoneum. Subsequent serial computed tomography imaging confirmed stable pulmonary nodules without new intraperitoneal lesions. Increasing number of cases involving extrauterine spread of leiomyomas has been reported with the introduction of power morcellation. The exact pathogenesis is unknown but is likely multifactorial. We emphasize that although the incidence of spread of benign disease is low, it is important to recognize this phenomenon as we will likely continue to encounter similar cases in the coming years.

Ischiorectal abscess after sacrospinous ligament suspension.

An ischiorectal abscess in a 66-year-old patient was determined to be an uncommon complication of sacrospinous fixation. The abscess was diagnosed 9 months after the patient had a sacrospinous ligament suspension. She was treated successfully with perianal incision, drainage, and intravenous antibiotics.

Surgical treatment of vaginal vault prolapse: a historic summary and review of outcomes.

OBJECTIVES: This study aimed to review the history of surgical treatment of vaginal vault prolapse, its current treatments, and its outcomes. METHODS: A PubMed search was conducted using the following terms: vaginal vault prolapse, apical prolapse, surgical treatments, culdoplasty, uterosacral ligament fixation, and sacral colpopexy. RESULTS: Vaginal vault prolapse is a common condition with many surgical treatment options. Surgical principles and treatment of this condition dates back to the 19th century. Native tissue repairs such as McCall culdoplasty, uterosacral ligament fixation, and sacrospinous fixation have high overall success rates with restoring apical anatomy. Sacral colpopexy also has excellent success rates when mesh is needed to augment repairs. CONCLUSIONS: There are many options for the treatment of vaginal vault prolapse. Modifications have been made to the original procedures; however, the basic principles are still applicable and include attaching the vaginal apex to level 1 support.

Randomized trial of preemptive local analgesia in vaginal surgery.

Preemptive analgesia in vaginal surgery has had conflicting efficacy reported in the existing literature. This study was designed to clarify the usefulness of preemptive local analgesia (PLA) in patients undergoing vaginal hysterectomy. A prospective, randomized, double-blinded trial of PLA in 90 women undergoing vaginal hysterectomy was conducted. PLA consisted of 20 ml of 0.5% bupivacaine with 1:200,000 epinephrine injected in a paracervical-type fashion. Total narcotic use and pain (using a visual analog scale (VAS)) was recorded at 30 min, 3, 12, and 24 h postoperatively. The mean total dose of narcotic was significantly less in the PLA group versus the placebo group (P = 0.009) at every time point postoperatively. Additionally, the mean pain VAS 30 min and 3 h postoperatively was 43% (P = 0.003) and 33% (P = 0.02) lower, respectively, in the PLA group. PLA with bupivacaine prior to vaginal hysterectomy is associated with significantly lower pain scores and a reduction in narcotic use postoperatively.

Actinomyces meyeri osteomyelitis of the symphysis pubis following pubovaginal sling.

Previous reports of pubic osteomyelitis associated with bone anchors describe symptoms presenting 10 days to 12 months postoperatively with typical pathogens including Streptococcus, Staphylococcus, Citrobacter, and Pseudomonas (Fitzgerald et al., Int Urogynecol J 10:346-348, 1999 Enzler et al., J Bone Jt Surg Am 81-A(12):1736-1740, 1999; Graham and Dmochowski, J Urol 168:2055-2058, 2004; Fialkow et al., Urology 64(6):1127-1132, 2004; Matkov et al., J Urol 160(4):1427, 1998). This case illustrates the potential for protracted symptoms and delayed diagnosis of pubic osteomyelitis with the fastidious pathogen of Actinomyces meyeri.

Rectovaginal fistula after Posterior Intravaginal Slingplasty and polypropylene mesh augmented rectocele repair.

Posterior Intravaginal Slingplasty and mesh augmented rectocele repairs are procedures promoted for correction of vaginal relaxation. There is little data on the complications of these procedures alone or in combination. The first report of rectovaginal fistula after Posterior Intravaginal Slingplasty with graft augmented rectocele repair is presented. A 60-year-old female developed a rectovaginal fistula 3 months after undergoing a Posterior Intravaginal Slingplasty and mesh augmented rectocele repair for prolapse. Two attempts at correcting the fistula failed and there was a recurrence of her vault prolapse. She may now require diverting colostomy and repeat repair of her vault prolapse. The case report highlights the difficulties in treating a rectovaginal fistula that developed after Posterior Intravaginal Slingplasty and mesh augmented rectocele repair for vaginal vault prolapse. More data regarding complications associated with use of these procedures is needed prior to widespread use.

Histologic evaluation of human cadaveric fascia lata in a rabbit vagina model.

The purpose of this study was to evaluate the histologic response of human cadaveric fascia lata after vaginal implantation. Freeze-dried, gamma-irradiated cadaveric fascia lata from three lots was implanted between the rectovaginal membrane and vaginal epithelium in New Zealand white rabbits. Rabbits were killed at 2, 4, 8, and 12 weeks after implantation. At necropsy, gross findings were described and specimens for routine cultures were taken. Histologic evaluation determined graft integrity, neovascularization, inflammatory response, and host tissue incorporation. Nine rabbits were available for histologic analysis and 14 for gross and microbiologic analysis. Vaginal erosions occurred with three grafts. The remainder were adherent to the surrounding tissues. Erosion was associated with bacterial colonization of the graft. Autolysis of one graft occurred at 4 weeks. Over time, the inflammatory response decreased and neovascularization increased; by 12 weeks, the graft collagen was replaced by host collagen. Cadaveric fascia lata serves as scaffolding for host tissue incorporation with replacement by host collagen.

Management of stress urinary incontinence.

Although there is renewed interest in conservative therapies for stress urinary incontinence, such as pelvic floor exercises, electrical stimulation, and duloxetine therapy, surgery remains the primary choice in managing this condition. Surgical options include paravaginal defect repair, the Marshall-Marchetti-Krantz procedure, open and laparoscopic Burch urethropexy, and pubovaginal sling procedures. There is a growing trend in the United States toward use of the pubovaginal sling procedure as the primary operation for urinary incontinence due to less invasive techniques. Studies comparing the pubovaginal sling with open urethropexy have shown similar short-term cure rates. More large prospective, randomized studies are needed to assess long-term rates.

Changes in tensile strength of cadaveric human fascia lata after implantation in a rabbit vagina model.

PURPOSE: We determined changes in tensile properties after vaginal implantation of human cadaveric fascia lata. MATERIALS AND METHODS: Baseline tensile properties were determined for freeze-dried, gamma irradiated human cadaveric fascia lata from 3 separate lots. Fascial strips (2 x 0.5 cm.) from 2 lots were implanted between the rectovaginal membrane and vaginal mucosa in New Zealand white rabbits. The strips were excised en bloc 12 weeks after implantation. Tensile property measurements were repeated and compared with pre-implantation values. RESULTS: Pre-implantation interlot and intralot variability in baseline tensile properties was significant. After implantation there was an approximate 90% decrease in tensile strength from baseline values. There was no gross evidence of graft autolysis. CONCLUSIONS: The decrease in tensile strength of cadaveric fascial graft was significant after implantation in this model.

Effects of raloxifene hydrochloride on endometrial cancer cells in vitro.

OBJECTIVE: Determine effects of raloxifene hydrochloride, a selective estrogen receptor modulator (SERM), on growth and proliferation of an estrogen-responsive endometrial cancer cell line in vitro. MATERIALS AND METHODS: Studies were performed with Ishikawa endometrial adenocarcinoma cells, a well-differentiated cancer that expresses estrogen receptors and progesterone receptors. Raloxifene was purified as the hydrochloride salt. The four arms of the study were cells grown (1) without any further addition (control), (2) with estradiol only, (3) with raloxifene only, or (4) with estradiol and raloxifene. Three concentrations of estradiol (10, 100, 1000 pg/ml) and raloxifene (1, 10, 100 ng/ml) were used. After 1 week of culturing, the number of living cells for each experimental group was determined and expressed as a percentage of the control group. RESULTS: Cells treated with raloxifene 10 or 100 ng/ml alone grew significantly faster than control cells: 10 ng/ml [115.25%; SD, 11.05; 95% confidence interval (CI), 107.35-123.16; P = 0.002] and 100 ng/ml (111.14%; SD, 14.19; 95% CI, 100.98-121.29; P = 0.03). Estradiol 10 or 100 pg/ml did not stimulate cell growth, whereas cells treated with 1000 pg/ml grew significantly faster than control cells (114.69%; SD, 16.84; 95% CI, 102.65-126.74; P = 0.02). Raloxifene and estradiol together in any concentration did not affect cell growth. CONCLUSIONS: Raloxifene did not inhibit the growth of endometrial cancer cells in vitro. High concentrations even promoted cell growth. Estradiol in physiologic concentrations did not stimulate the growth of endometrial cancer cells in vitro.

Three-dimensional reconstruction of magnetic resonance images of the anal sphincter and correlation between sphincter volume and pressure.

OBJECTIVE: The purpose of this study was to assess the correlation between internal and external anal sphincter volumes and manometric anal pressures. STUDY DESIGN: Ten healthy nulliparous women underwent anal sphincter magnetic resonance imaging and anal manometry measurement. A 3-dimensional reconstruction of magnetic resonance images was accomplished with the use of 3-dimensional slicer. Sphincter volumes were measured 3 times by the same observer for each of 10 patients. The intrarater reliability was measured with the use of the intraclass correlation coefficient (ICC = sigma (2)(patients)/(sigma (2)(patients) + sigma (2)(error))) from a 2-way analysis of variance model with terms for patient and measurement trial. Measurements that were recorded on anal manometry included squeeze length, length of the high-pressure zone, and maximal resting and squeeze pressures. RESULTS: The mean volumes (+/- SD) were 18.77 +/- 4.64 cm(3), 13.82 +/- 3.8 cm(3), and 32.36 +/- 8.37 cm(3) for internal, external, and combined sphincters, respectively. Intrarater reliability was 98% for external sphincter volume (95% CI, 94%-99%), 98% for internal sphincter volume (95% CI, 94%-99%), and 99% for total volume (95% CI, 97%-100%). On the 3-dimensional images, the internal sphincter was found to be cylindric in shape, with an ellipse as a base. It is elongated in the anterior and posterior direction and flattened on the sides. The external sphincter was found to be funnel-shaped, being narrower caudad and widening in the cephalad direction. Similar to the internal sphincter, the external sphincter is elongated in the anteroposterior diameter. Volumes of the internal, external, and combined sphincters did not correlate with the maximum pressures at rest and squeeze. Correlations higher than r = 0.5 were observed for all 3 sphincter volume measurements versus high pressure zone at squeeze. The highest correlation, r = 0.66, was for internal sphincter volume versus high pressure zone at squeeze CONCLUSION: Three-dimensional reconstruction of the rectal sphincter musculature can be performed easily with 3-dimensional software. Measurements of the sphincter volumes have excellent intrarater reliability. Sphincter volumes do not correlate with pressures at rest or squeeze, but the internal sphincter volume correlates with the length of the high pressure zone at squeeze. Contrary to current generalized concepts, it is possible that the internal sphincter may play some role in generating the squeeze pressure. More research is necessary in applying 3-dimensional magnetic resonance image reconstruction in patients with different parity and continence status. Reconstruction of magnetic resonance images of the rectal sphincter musculature may prove to be beneficial in planning the treatment of patients with fecal incontinence.