Novel Use of the Falciform Ligament for MHV Reconstruction During Laparoscopic Hepatectomy of Colorectal Liver Metastasis.

BACKGROUND: Laparoscopic hepatectomy (LH) with oncological R0 resection combined with systemic therapy offers the best chance of cure for colorectal liver metastasis. However, tumors in vicinity of major hepatic veins require complex technique. Parenchyma-sparing resection with involved vein resection and peritoneal patch reconstruction could be an efficacious alternative to preserve liver volume for adjuvant chemotherapy and avoid venous congestion of the remnant liver.1,2 METHODS: A 64-year-old female, with history of colon cancer, had new diagnosis of liver metastatic tumor of S8 (2.8 cm), which was considering encroached on middle hepatic vein (MHV) with distal part patent. Thus margin-negative, parenchyma-sparing liver resection with involved vein resection and proximal MHV reconstruction was indicated for oncological radicality. RESULTS: With the patient in modified French position, we dissected falciform ligament and right coronary ligament to expose the crypt between right hepatic vein (RHV) and MHV. Intraoperative ultrasound localized the tumor and resection margin. Parenchymal dissection was performed caudally to cranially, left to right, to ligate dorsal branch of G8 (G8d) and V8 and expose main trunk of MHV. The involved side-wall of MHV was incised after the proximal and distal parts clamped. Peritoneal patch was harvested from falciform ligament to repair MHV side-wall before clamps released. The patient had an uneventful recovery and remained disease-free at 1 year postoperatively with patency of distal MHV by image. CONCLUSIONS: LH with MHV reconstruction by falciform ligament for metastatic lesion is technically demanding but feasible with oncological radicality and volume preservation for adjuvant chemotherapy.

SIRT1 as a potential therapeutic target in pelvic organ prolapse due to protective effects against oxidative stress and cellular senescence in human uterosacral ligament fibroblasts.

INTRODUCTION: The pathogenesis of pelvic organ prolapse (POP), an age-related disease, has not been fully elucidated. Therapeutic targets of POP are limited. Silencing information regulator 2 related enzyme 1 (SIRT1), a gene considered capable of regulating oxidative stress and cellular senescence, has been widely demonstrated involved in aging and age-related diseases. The present study aimed to explore the role of SIRT1 in POP in vivo and in vitro. METHODS: Expression levels of SIRT1 in uterosacral ligament (USL) tissues from patients with or without POP were measured using immunohistochemical assays. SRT1720, a SIRT1 agonist, was used to upregulate SIRT1, and hydrogen peroxide (H2O2) was used to establish an oxidative stress model in human uterosacral ligament fibroblasts (hUSLFs). The effects of SIRT1 on cell viability, apoptosis, senescence, and reactive oxygen species (ROS) levels were detected, respectively. Western blot assays were used to examine expression levels of apoptosis- and senescence-associated biomarkers. Unpaired Student's t test, Mann-Whitney U test, χ2 test, and one-way ANOVA were performed for determining statistically significant differences. RESULTS: Compared to the control group, expression levels of SIRT1 were downregulated in USL tissues and hUSLFs from patients with POP, and associated with stage (p < 0.05). hUSLFs of patients with POP had lower growth rates (p < 0.0001) than those of the control group, which were improved by upregulating SIRT1 (p < 0.05). The senescent proportion was higher in the POP group than the control group (43.63 ± 10.62% vs. 4.84 ± 5.32%, p < 0.0001), which could be reduced by upregulating SIRT1 (p < 0.0001). High ROS levels in the POP group were also alleviated by SRT1720. H2O2 exposure increased ROS levels, inhibited proliferation, and triggered apoptosis and senescence in hUSLFs of patients without POP in a concentration-dependent manner. Further, these damages were alleviated by pretreatment with SRT1720. CONCLUSIONS: SIRT1 is downregulated in patients with POP, and the development of SIRT1 activators or agonists may have applications in the treatment and prevention of POP through antioxidative stress and antisenescence effects.

Spontaneous tendon or ligament ruptures in patients undergoing dialysis: First pediatric case report and literature review.

Spontaneous tendon or ligament ruptures are quite rare and mostly associated with chronic systemic diseases such as diabetes mellitus, systemic lupus erythematosus, rheumatoid arthritis, and chronic kidney disease (CKD). In this study, we present the first documented case of a spontaneous rupture of the medial patellofemoral ligament (MPFL) in a pediatric patient. The patient was undergoing long-term peritoneal dialysis (PD) and had a history of severe secondary hyperparathyroidism. Additionally, we discussed spontaneous tendon and ligament ruptures associated with CKD or dialysis through a comprehensive literature review. This case report highlights the importance of recognizing that spontaneous tendon or ligament injuries are not exclusive to adults; children with CKD can also be affected. Several factors including poor parathyroid hormone (PTH) and metabolic acidosis control, prolonged CKD duration and presence of malnutrition play role in the pathogenesis. Early diagnosis is crucial as it allows for timely surgical intervention and leads to a favorable functional recovery.

Prospective diagnostic test accuracy of transvaginal ultrasound posterior approach for uterosacral ligament and torus uterinus deep endometriosis.

OBJECTIVE: To determine the diagnostic test accuracy of transvaginal ultrasound (TVS) using a standardized technique for the diagnosis of deep endometriosis (DE) of the uterosacral ligaments (USLs) and adjacent torus uterinus (TU). METHODS: This was a prospective diagnostic test accuracy study conducted at the McMaster University Medical Center Tertiary Endometriosis Clinic, Hamilton, ON, Canada. Consecutive participants were enrolled if they successfully underwent TVS and surgery by our team from 10 August 2020 to 31 October 2021. The index test was TVS using a standardized posterior approach performed and interpreted by an expert sonologist. The reference standard included direct surgical visualization on laparoscopy by the same person who performed and interpreted the ultrasound scans. Accuracy, sensitivity, specificity, positive and negative predictive values (PPV and NPV) and positive and negative likelihood ratios were calculated for the TVS posterior approach for each location using the reference standard. RESULTS: There were 54 consecutive participants included upon completion of laparoscopy and histological assessment. The prevalence of DE for the left USL, right USL and TU was 42.6%, 22.2% and 14.8%, respectively. Based on surgical visualization as the reference standard, TVS demonstrated an accuracy of 92.6% (95% CI, 82.1-97.9%), sensitivity of 82.6% (95% CI, 61.2-95.1%), specificity of 100% (95% CI, 88.8-100%), PPV of 100% and NPV of 88.6% (95% CI, 76.1-95.0%) for diagnosing DE in the left USL. For DE of the right USL, TVS demonstrated an accuracy of 94.4% (95% CI, 84.6-98.8%), sensitivity of 75.0% (95% CI, 42.8-94.5%), specificity of 100% (95% CI, 91.6-100%), PPV of 100% and NPV of 93.3% (95% CI, 84.0-97.4%). For DE of the TU, TVS demonstrated an accuracy of 100% (95% CI, 93.4-100%), sensitivity of 100% (95% CI, 63.1-100%), specificity of 100% (95% CI, 92.3-100%), PPV of 100% and NPV of 100%. CONCLUSIONS: We observed high diagnostic test accuracy of the evaluated standardized TVS technique for assessing DE of the USLs and TU. Further studies evaluating this technique should be performed, particularly with less experienced observers, before considering this technique as the standard approach. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Lax Uterosacral Ligament and Urge Urinary Incontinence: MRI Findings in Symptomatic Patients Versus Healthy Volunteers.

INTRODUCTION AND HYPOTHESIS: The objective was to explore the association between urge urinary incontinence (UUI) and lax uterosacral ligaments (USL) using MRI. METHODS: Sixty-seven female participants were recruited prospectively: 41 continent volunteers (control group) and 26 patients with UUI. Static proton density- and T2-weighted turbo spin echo sequences of MR images were used. A radiologist employed a standardized grid system to record structural observations of the USLs on sequentially numbered axial MR images and then applied a four-point grading scale to assess ligament visibility. MR images were interpreted by a radiologist and a urologist, and then validated by an expert radiologist. RESULTS: The comparison between the mean length of uterosacral ligaments in the control and UUI groups was highly statistically significant (p < 0.001). The mean length of the right USL was 38 ± 11 mm, and the left USL was 35 ± 12 mm in the UUI group. In the control group, the mean length of the USL was 22 ± 9 mm on the right side and 18 ± 9 mm on the left side, along their craniocaudal extent. The highest inter-observer agreement was on the level of origin and insertion (image numbers), whereas the lowest agreement was on the anatomical site of origin and insertion of the USL in both the control and UUI groups. CONCLUSIONS: The average length of USLs in patients with UUI is significantly longer than that in healthy continent women, indicating laxity. Our findings support the relationship between the laxity of the USL and UUI symptoms and have therapeutic implications.

Localized chondro-ossification underlies joint dysfunction and motor deficits in the Fkbp10 mouse model of osteogenesis imperfecta.

Osteogenesis imperfecta (OI) is a genetic disorder that features wide-ranging defects in both skeletal and nonskeletal tissues. Previously, we and others reported that loss-of-function mutations in FK506 Binding Protein 10 (FKBP10) lead to skeletal deformities in conjunction with joint contractures. However, the pathogenic mechanisms underlying joint dysfunction in OI are poorly understood. In this study, we have generated a mouse model in which Fkbp10 is conditionally deleted in tendons and ligaments. Fkbp10 removal substantially reduced telopeptide lysyl hydroxylation of type I procollagen and collagen cross-linking in tendons. These biochemical alterations resulting from Fkbp10 ablation were associated with a site-specific induction of fibrosis, inflammation, and ectopic chondrogenesis followed by joint deformities in postnatal mice. We found that the ectopic chondrogenesis coincided with enhanced Gli1 expression, indicating dysregulated Hedgehog (Hh) signaling. Importantly, genetic inhibition of the Hh pathway attenuated ectopic chondrogenesis and joint deformities in Fkbp10 mutants. Furthermore, Hh inhibition restored alterations in gait parameters caused by Fkbp10 loss. Taken together, we identified a previously unappreciated role of Fkbp10 in tendons and ligaments and pathogenic mechanisms driving OI joint dysfunction.

Diagnostic performance of high-resolution ultrasound in the evaluation of intrinsic and extrinsic wrist ligaments after trauma.

PURPOSE: To investigate the role of ultrasound (US) in the evaluation of intrinsic and extrinsic ligaments of the wrist with magnetic resonance arthrography (MRA) as the reference standard. MATERIALS AND METHODS: This prospective study included patients referred for MRA after wrist trauma. US examination was performed just before MRA. On the dorsal and palmar sides of the wrist, the intrinsic interosseus and midcarpal, extrinsic, and collateral ligaments were evaluated. MRA was performed on a 1.5-T unit. In the first 20 patients included, ligament thickness was independently assessed using US and MRA and thickness reproducibility was calculated. Ligament integrity was evaluated in all patients. RESULTS: 38 patients (22 men, 16 women; mean age: 38 years) were included. Ligament thickness reproducibility ranged between 44% for the palmar ulnocapitate ligament and 71% for the palmar scaphotriquetral ligament. US had a sensitivity, specificity, positive and negative predictive values, and accuracy of 100% in the identification of tears of the palmar (n=8) and dorsal (n=3) bands of the scapholunate ligament and the ulnar collateral ligament (n=3). It had a sensitivity of 100%, specificity of 97%, positive predictive value of 50%, negative predictive value of 100%, and accuracy of 97% in the identification of tears of the palmar ulnolunate ligament (n=1). CONCLUSION: Compared to MRA, US showed good reproducibility in the assessment of wrist ligament thickness and similar accuracy with respect to identifying tears of the scapholunate, palmar ulnolunate, and ulnar collateral ligaments.

Synthetic Ligament-Assisted Functional Soft-Tissue Reconstruction in Tumor-Related Proximal Femoral Replacements.

BACKGROUND: Soft-tissue functional reconstruction is important for restoring hip function in proximal femoral replacement for tumor resection. This study evaluated the functional outcome and postoperative complications of a specific synthetic ligament for soft-tissue functional reconstruction in proximal femoral replacement for tumor resection. METHODS: This cohort included 80 patients (40 men and 40 women, mean age, 40 years (range, 10 to 79)) who had benign invasive tumors (n = 13), primary malignant bone tumors (n = 40), or bone metastases (n = 27). Patients' medical records, imaging files, surgical details, and postoperative pathological diagnoses were collected. Tumor staging was performed with the Enneking staging criteria. Lower limb and hip functions were assessed using the Musculoskeletal Tumor Society scoring system and Harris Hip score, respectively. RESULTS: Mean postoperative Musculoskeletal Tumor Society and Harris Hip scores were 27 (range, 24 to 30) and 90 (range, 76 to 97), respectively, indicating satisfactory range of motion and stability. Trendelenburg gait was observed in 3 osteosarcoma patients (3.8%), and 6 patients showed unequal lower-limb lengths. Reoperations occurred in 5 cases, including 3 cases of deep vein thromboses and 1 case each of giant cell granuloma and periprosthetic infection. There were 27 patients who had bone metastases who did not require reoperation. CONCLUSIONS: The synthetic ligament reconstruction of the hip with proximal femoral replacement for tumor resection was associated with improved outcomes. Its implementation exhibits the potential to reduce postoperative incidences of hip dislocation and periprostheses infection, thereby warranting its prospective clinical application.

Hypertrophied medial parapatellar plica: a case of a medial plica anatomical variation with insertion to the inter-meniscal ligament in an adolescent athlete treated arthroscopically.

PURPOSE: The present study aims to report the arthroscopic, radiological and clinical appearance of a rare anatomical variation of a hypertrophied medial parapatellar plica with its response to arthroscopic treatment. CASE PRESENTATION: A 14-year-old female handball athlete presented with a history of left knee injury during her participation in a handball training session and subsequent locked knee at 20º flexion. Tenderness was located at the medial joint line. Plain radiographs of the injured knee were normal. The magnetic resonance imaging revealed a hypertrophic medial parapatellar plica and a horizontal tear of the medial meniscus. A standard knee arthroscopy was performed. An extremely hypertrophied medial plica was identified, covering a great part of the medial femoral condyle extending up to the femoral trochlea. Distally, it was attached into the inter-meniscal ligament. The plica was excised and the medial meniscus tear was repaired. At 1-month post-operatively, the patient was completely asymptomatic and at 3-months she returned to her weekly training routine. CONCLUSIONS: This study presented a rare anatomical variation of a hypertrophied medial parapatellar plica with atypical course in the medial patellofemoral compartment and insertion into the inter-meniscal ligament. In combination with a medial meniscus tear led to a locked knee. Arthroscopic medial meniscus repair and plica excision resulted in complete resolution of symptoms.

Mild endometriosis of the uterosacral ligaments: a retrospective study of magnetic resonance imaging performance for diagnosis.

RESEARCH QUESTION: What are the diagnostic performances of magnetic resonance imaging (MRI) scans when used to identify mild endometriosis of the uterosacral ligaments (USL)? DESIGN: Monocentric retrospective study of patients who underwent a pelvic MRI followed by laparoscopy for determination of endometriosis between January 2016 and December 2020. Patients were included whether endometriosis of USL was suspected or not, but patients presenting large lesions that left no doubt as to their endometriotic nature on the MRI were excluded. Six criteria for the description of USL on MRI were studied to determine their diagnostic performances in predicting the presence of endometriosis on laparoscopy as follows: asymmetry, thickening, irregularity, straightness, the presence of a nodule or a hypersignal T1 spot. RESULTS: Seventy-seven patients were included. Among the criteria, 'asymmetry' and 'thickening' had the highest sensitivities (0.69 [95% confidence interval 0.54-0.80] and 0.51 [0.40-0.63], respectively) but moderate specificities (0.52 [0.31-0.73] and 0.62 [0.50-0.72]). Conversely, 'irregularity', 'nodule', 'straightness' and 'hypersignal T1 spot' were associated with high specificities (0.81 [0.70-0.89], 0.96 [0.89-0.99], 0.95 [0.87-0.99] and 0.99 [0.93-1.00], respectively) but poor sensitivities (0.22 [0.14-0.33], 0.12 [0.06-0.21], 0.08 [0.03-0.16] and 0.08 [0.03-0.16], respectively). The presence of at least one criterion for the description of the USL was associated with good sensitivity (0.80 [0.66-0.89]) but poor specificity (0.35 [0.16-0.57]). CONCLUSIONS: The results suggest that the identification of minimal changes in the normal appearance of USL should not automatically lead to a conclusion of mild endometriosis at this location.

Primary endodermal sinus tumor originating from the sacral ligament: a case report and review of the literature.

BACKGROUND: Endodermal sinus tumor (EST) is a malignant tumor originating from the ovary or testis. In most case, ultrasound examination shows ovarian mass. But there is a special kind of extra-gonadal endodermal sinus tumor, which occur in organs other than gonads with insidious onset. Here we reported a case of endodermal sinus tumor, which originated from the sacral ligament presenting as an acute lower abdominal pain. CASE PRESENTATION: A 14-year-old girl was admitted to the hospital because of acute lower abdominal pain. The ultrasound showed a mass with 72 mm × 64 mm × 50 mm in Douglas, and there was no abnormality in bilateral ovaries and fallopian tubes. Laparoscopic exploration showed a large amount of blood clots in the pelvic cavity. After removal of the blood, we found rotten fish-like tissue in the left sacral ligament, rapid pathology suggested endodermal sinus tumor. After the operation, we retrospectively examined the value of alpha-fetoprotein (AFP), which was found to be elevated, and post-operative paraffin pathology confirmed the diagnosis. After four cycles of BEP chemotherapy, exploratory laparotomy was performed to remove the visible lesion, but postoperative pathology showed no abnormality. At the one-year follow-up, the patient remained recurrence-free. CONCLUSION: Extra-gonadal germ cell tumors are rarely reported. When young teenagers complain of acute lower abdominal pain with elevated AFP, but there was no lesion in bilateral ovaries and fallopian tubes, we must think about the possibility of endodermal sinus tumors. Accurate diagnosis facilitates complete resection of lesions and improves patient's outcomes.

Ultrasound Characteristics and Scanning Techniques of Uterosacral Ligaments for the Diagnosis of Endometriosis: A Systematic Review.

Endometriosis is a common and painful gynaecological condition that takes an average of 6.4years to diagnose. While laparoscopic surgery is the recommend gold standard in diagnosis of endometriosis, transvaginal ultrasound (TVS) is able to assist surgeons in the planning and management of patients, especially when there is limited visualisation in the posterior compartment. Uterosacral ligaments (USL) are located in the posterior compartment and are one of the first and most common places that endometriosis deposits, The International Deep Endometriosis Analysis (IDEA) group consensus, which are the current guidelines for DE imaging, recommends a thorough ultrasound assessment to identify endometriotic disease. This includes an assessment of anatomic structures in the posterior compartment including the USLs. However, IDEA does not explicitly articulate specifics of USL imaging and measurements on ultrasound. The primary aim of this review is to determine is to identify ultrasound techniques and characteristics of USLs in the diagnosis of deep infiltrative endometriosis (DE). The secondary aim is to describe and summarise these findings into normal and pathological findings. A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A population, interventions, comparator, and outcome framework was used to define a search strategy. Articles were screened using Covidence review management system, and data was extracted by two authors using a standardised and piolet-tested form. Quality assessment was conducted using the Critical Appraisal Skills Programme (CASP). Medline, Embase and Scopus and Google Scholar were searched yielding 250 articles, with 22 being included in the review. Analysis of the data demonstrated inconsistent reporting of ultrasound techniques and characteristics of USLs. Most (20/22) papers described abnormal criteria of USLs, only 5/22 papers determined what the normal USL appearance is or what techniques (11/22) were applied. Even though reporting was heterogeneous, there was a high level of tertiary centre participation with gynaecological experienced operators, therefore was a high level of agreement. Through review of the current literature, this study has investigated ultrasound techniques and characteristics of USLs for the diagnosis of DE. All papers included in this review reported presence of pathological sonographic findings of the USLs when DE was presented therefore it is recommended that USL examination become a part of TVS exams when DE is clinically suspected. This study also demonstrated that there was lack of data and no agreement when it comes to measuring USLs with DE. Even so, the current evidence demonstrates that scanning the USLs, and locating, identifying, and describing USL thickening and endometriotic nodules in the various locations using the described techniques and characteristics in this review has clinical value in early diagnosis.

Use of LARS for soft tissue function reconstruction during tumor-type hemi-shoulder replacement achieves a good prognosis: a retrospective cohort study.

BACKGROUND: Shoulder soft tissue function reconstruction during tumor-type hemishoulder replacement is an important step to restore shoulder function. This study evaluates the functional prognosis and postoperative complications of ligament advanced reinforcement system (LARS)-assisted soft tissue functional reconstruction in tumor-type hemi-shoulder replacement. MATERIALS AND METHODS: Twenty-two patients with an average age of 37.5 ± 17.8 years diagnosed with benign invasive tumors, primary malignant bone tumors, or bone metastases were enrolled in this study. The patient's medical records (history and surgical details), histological sections, imaging files, oncological prognosis, functional prognosis, and postoperative complications were collected. The upper limb function and shoulder joint function were evaluated using the Musculoskeletal Tumor Society (MSTS) system and American Shoulder and Elbow Surgeons (ASES) scoring criteria, respectively. RESULTS: Twenty-two patients comprising 12 males and 10 females were enrolled. Overall, 9 patients had preoperative pathological fractures. The mean lesion length was 8.6 ± 3.0 cm. The local recurrence was observed in 3 cases, including 2 cases of osteosarcoma and 1 case of MGCT. A further 4 cases had pulmonary metastasis, including 2 cases with local tumor recurrence. The average postoperative MSTS score was 25.8 ± 1.7, and the score of postoperative ASES was 85.7 ± 6.0, both of which showed satisfactory functional recovery. Two cases experienced postoperative complications requiring surgical intervention, including one periprosthetic fracture and one giant cell granuloma. Prosthesis dislocation occurred in 1 case. None of the cases of periprosthetic infection or postoperative complications resulted in implant failure. CONCLUSIONS: LARS-assisted soft tissue function reconstruction in benign and malignant proximal humerus tumors after a tumor-type hemi-shoulder replacement is an effective technical improvement, which can effectively repair the integrity of the joint capsule to restore joint stability, provide a medium for soft tissue attachment to rebuild the muscular dynamic system, and eliminate residual dead space around the prosthesis, effectively improving limb function and reduce postoperative infection complications.

Findings consistent with equine proximal suspensory desmitis can be reliably detected using computed tomography and differ between affected horses and controls.

The objective of this retrospective, observational, controlled study was to evaluate bone and soft tissue window CT images of the proximoplantar metatarsus III region in twenty horses with pain localized to the proximal suspensory ligament (PSL) and 20 horses with findings nonrelated to tarsal pain. All horses underwent CT and radiographic examination. Images were reviewed by three independent observers who graded the severity and localization of findings. Bone-related categories as well as soft tissue-related categories were evaluated. For the comparison of imaging findings in horses with and without proximal suspensory desmitis (PSD), mixed linear regression was performed. The intraclass correlation coefficient (ICC) was calculated to assess intraobserver agreement, and kappa statistics were employed to evaluate interobserver agreement. CT examination identified significantly more abnormalities in the diseased group. The scores for osseous exostosis (p = .015) and PSL enlargement (p = .004) were notably higher in PSD horses compared to controls. Intraobserver agreement was overall high (ICC .82-1.0), and interobserver agreement was substantial for the detection of mineralization (kappa = .61) and moderate for sclerosis (kappa = .43), exostosis (kappa = .43), and PSL enlargement (kappa = .48/.51). Measurements in the soft tissue window were significantly smaller than those in the bone window. Findings concurrent with PSD including osseous proliferation and sclerosis as well as soft tissue enlargement, mineralization, and avulsion can be reliably detected using CT. Findings from the current study supported the use of CT for evaluating horses with suspected PSD where high-field MRI is not available.

Ultrasonographic comparison of the intermediate patellar ligament in warmbloods versus quarter horses.

Striations are present on ultrasonography of the intermediate (middle) patellar ligament in the transverse plane, which can be confused with tears. Comparison to the contralateral limb is often performed to help differentiate anatomic variation from pathologic change. The purposes of this prospective, observational study were to describe the striation patterns in Warmbloods and Quarter Horses, determine if these patterns are bilaterally symmetrical, and compare striation characteristics between Warmbloods and Quarter Horses. The intermediate patellar ligaments of six Warmblood horses and six Quarter horses, free from clinical signs of hindlimb lameness and in full work, were examined ultrasonographically. Striation pattern, striation number, and the transverse-sectional areas for intermediate patellar ligaments were compared between Warmbloods and Quarter horses. Striation patterns were also compared for the left and right limbs of each horse. A significant difference between breeds was identified at the mid-portion of the intermediate patellar ligament when both left and right ligaments were included (P = 0.02) and when comparing the right intermediate patellar ligament (P = 0.02). There were no other significant breed differences, and a parallel pattern was the most common pattern type. Two-thirds of the horses in this study had bilaterally symmetrical patterns within the distal aspect of their intermediate patellar ligaments, while one-third of the population were asymmetric. These results show that comparison of the contralateral limb during ultrasonography to determine if changes within the distal aspect of the intermediate patellar ligament are normal striations versus tears may lead to misdiagnosis in one-third of horses, regardless of breed. Other signs of pathology on ultrasonography should be used instead.

Laparoscopic Ovarian Transposition with Extraperitonealization of the Infundibulopelvic Ligament for Cervical Cancer in Ten Steps.

Preservation of ovarian function is important for the physical and psychosexual well-being of young patients with cancer. Patients with pelvic malignancies such as cervical or rectal cancer planned for radiotherapy may benefit from ovarian transposition with the aim of moving the ovaries outside the radiation field.1 Different surgical techniques have been reported previously.2,3 With the present video, we aim to standardize the surgical technique of laparoscopic ovarian transposition in ten steps. We present the case of a 30-year-old nulliparous woman diagnosed with grade 3 squamous cell cervical carcinoma having a largest tumor diameter of 41 mm on magnetic resonance imaging (MRI) scan. The tumor was staged as FIGO 2018 stage IIIC1r with a common iliac lymphadenopathy reported on both MRI and positron emission tomography (PET)/computed tomography (CT) scan. The multidisciplinary team recommended exclusive chemoradiation extended to paraaortic area. The patient underwent laparoscopic bilateral salpingectomy and bilateral ovarian transposition with extraperitonealization of the infundibulopelvic ligament. The procedure was divided into the following ten steps: division of uteroovarian ligament, incision of lateral pelvic peritoneum, identification of ureter, incision of medial pelvic peritoneum, skeletonization of the infundibulopelvic ligament, retroperitoneal tunnel in paracolic gutter, creating the window (as high as possible), mobilization of the ovary without torsion, intraperitonealization of the ovary, and fix ovary with clips (Fig. 1). Surgical time was 30 min, with minimal estimated blood loss. No intra- or postoperative complication was recorded. The patient started radiotherapy 14 days after the procedure. In conclusion, we showed that laparoscopic ovarian transposition in cervical cancer before radiotherapy can be standardized in ten steps with encouraging perioperative results, making it an easily reproducible procedure. Ovarian function is reported to be preserved in 62-65% of cases undergoing ovarian transposition and radiation therapy.4,5 Fig. 1 Laparoscopic view of right ovary transposed below the liver edge after extraperitonealization of the infudibulopelvic ligament.

Primary tuberculous granuloma in the falciform ligament of liver.

Isolated tuberculous granuloma in the falciform ligament of the liver has never been reported. Here, we report a case of tuberculous granuloma in the falciform ligament of the liver of a 45-year-old woman who complained only of persistent right upper abdominal pain. On abdominal contrast-enhanced CT and MRI, it is difficult to distinguish benign from malignant masses. Imaging on 18 F-FDG PET/CT showed high uptake of 18 F-FDG in the lesion, which was thus considered more likely to be malignant. However, postoperative pathological examination showed granulomatous inflammation with caseous necrosis, which was diagnosed as tuberculosis.

Non-Hunner's Interstitial Cystitis Is Different from Hunner's Interstitial Cystitis and May Be Curable by Uterosacral Ligament Repair.

BACKGROUND: The posterior fornix syndrome (PFS) was first described in 1993 as a predictably occurring group of symptoms: chronic pelvic pain (CPP), urge, frequency, nocturia, emptying difficulties/urinary retention, caused by uterosacral ligament (USL) laxity, and cured by repair thereof. SUMMARY: Our hypothesis was that non-Hunner's interstitial cystitis (IC) and PFS are substantially equivalent conditions. The primary objective was to determine if there was a causal relationship between IC and pelvic organ prolapse (POP). The secondary objective was to assess whether other pelvic symptoms were present in patients with POP-related IC and if so, which ones? How often did they occur? A retrospective study was performed in 198 women who presented with CPP, uterine/apical prolapse (varying degrees), and PFS symptoms, all of whom had been treated by posterior USL sling repair. We compared their PFS symptoms with known definitions of IC, CPP, and bladder symptoms. To check our hypothesis for truth or falsity, we used a validated questionnaire, "simulated operations" (mechanically supporting USLs with a vaginal speculum test to test for reduction of urge and pain), transperineal ultrasound and urodynamics. KEY MESSAGES: 198 patients had CPP and 313 had urinary symptoms which conformed to the definition for non-Hunner's IC. The cure rate after USL sling repair was CPP 74%, urge incontinence 80%, frequency 79.6%, abnormal emptying 53%, nocturia 79%, obstructive defecation 80%. Our findings seem to support our hypothesis that non-Hunner's IC and PFS may be similar conditions; also, non-Hunner IC/BPS may be a separate or lesser disease entity from "Hunner lesion disease". More rigorous scientific investigation, preferably by RCT, will be required.

Cervical versus Utero-Ovarian Ligament Injection of the Tracer for the Pelvic Sentinel Lymph Node Mapping in Gynecologic Oncology: A Prospective Observational Study.

OBJECTIVE: In gynecologic oncology, the consolidated injection site for the pelvic sentinel lymph node mapping is the cervix. However, in apparent early-stage ovarian cancer, current trials map the pelvic area injecting the tracers in the utero-ovarian ligament. A different injection site is proposed based on a possible different lymphatic ovarian drainage through the utero-ovarian ligament and uterus and consequently a different pelvic sentinel lymph node mapping than the cervix; however, this was never proven. On that basis, this study aimed to investigate whether injecting the tracer in the utero-ovarian ligament map the same or a different pelvic sentinel lymph node than the cervix. DESIGN: A prospective observational study was conducted. METHODS: All consecutive women undergoing primary surgery for gynecologic malignancy with planned pelvic sentinel lymph node mapping were enrolled. The cervical injection was performed at 3 and 9 o'clock injecting indocyanine green. Bilateral utero-ovarian ligament injection was performed by injecting methylene blue. The probability of detecting the same sentinel lymph node (concordance rate) and the probability of detecting a different sentinel lymph node (discordance rate) in each hemipelvis were compared using McNemar's exact test. RESULTS: Out of 36 hemipelvis (18 patients), the overall detection rate with cervical indocyanine green injection was 86.1% (31/36) versus 52.8% (19/36) with utero-ovarian ligament methylene blue injection (p = 0.0004). Indocyanine green and methylene blue identified the same sentinel lymph node in all hemipelvis when sentinel lymph node mapping was obtained by both dyes (19/19; concordance rate 100%). No different or additional sentinel lymph nodes were identified by one of the two dyes (0/19; discordance rate 0%). The probability of detecting the same pelvic sentinel lymph node by the two injection sites was significantly higher than the probability of detecting a different pelvic sentinel lymph node (p < 0.0001). LIMITATIONS: The use of two different dyes with known different sentinel lymph node mapping performance impedes to evaluate differences in detection rate attributable to the two injection sites, limiting the comparison only in hemipelvis in which both dyes identified a sentinel lymph node. CONCLUSIONS: The cervix and utero-ovarian ligament are two sites for the tracer injection that have a higher probability of detecting the same than a different pelvic sentinel lymph node. Given the higher technical challenge in performing the utero-ovarian ligament injection, these results suggest that the injection of the tracer into the cervix could be a more reliable alternative for the pelvic sentinel lymph node mapping in ovarian cancer.

[Two-dimensional equivalent mechanical modeling and finite element analysis of normal female pelvic floor system].

Objective: To construct the geometric model of the pelvic floor by a two-dimensional equivalent mechanics method, and to explore the effect of the shape and position of pelvic floor organs and tissues on the biomechanical properties of the pelvic floor under different abdominal pressure. Methods: A 28-year-old healthy and symmetrical married infertile female volunteer was included. The pelvic floor tissue was scanned in the supine position using a 3.0T magnetic resonance scanner (Philips Company, Holland). Based on the method of magnetic resonance imaging (MRI) two-dimensional parameter measurement and computer aided design, the geometric model and finite element model of the female pelvic floor were established, and the biomechanical characteristics of the pelvic floor support system under different abdominal pressure were analyzed. Results: In this study, four different working conditions of the pelvic floor force were simulated under 60, 99, 168, and 208 cmH2O (1 cmH2O=0.098 kPa) abdominal pressure loads. The trend was as follows: under the abdominal pressure load, the retrograde flexion of the uterus occurred, the cervical, the middle and upper vaginal segment and the levator anus muscle had the characteristic change of mechanical axial direction pointing to the sacrum and coccyx, and the deformation of the levator anus muscle in the horizontal direction was greater than that in the vertical direction. With the increase of the abdominal pressure, the maximum stress values of the pelvic floor whole system of healthy subjects under four different working conditions were 0.194 3, 0.389 6, 0.557 1, and 0.627 5 MPa, respectively, and the maximum displacement values were 10, 14, 21 and 25 mm, respectively. The maximum stress values of the cervical and vaginal middle and upper segment were 0.111 7, 0.161 8, 0.250 6, and 0.304 1 MPa, respectively, and the maximum displacement values were 3, 6, 9, and 11 mm, respectively. The maximum stress of the perineal body was 0.063 4, 0.119 6, 0.235 2, and 0.288 0 MPa, and the maximum displacement was 1, 2, 4, and 5 mm. The maximum stress values of the levator anus muscle were 0.194 3, 0.389 6, 0.557 1, and 0.627 5 MPa, and the maximum displacement values were 2, 4, 7, and 8 mm, respectively. The maximum stress and maximum displacement of pelvic organs increased with the increase of the abdominal pressure under different working conditions. The stress axial relationship of normal female pelvic floor was that the middle and upper segment of uterus and vagina mainly acted on the sacrococcyx and the levator anus muscle, and the lower vaginal segment acts on the perineal body. Conclusions: The two-dimensional equivalent mechanical modeling and finite element analysis of the female pelvic floor system can accurately reflect the biomechanical characteristics of the female pelvic floor, and the resultant stress direction of the pelvic organs points to the sacrum and coccyx. The sacrum and coccyx, levator anus and perineal body play important stress supporting roles in the pelvic floor system.