A reappraisal of the deep uterine vein: a multimodal exploration with implications for pelvic surgery.

PURPOSE: Pelvic gynecological surgeries, whether for malignant or benign conditions, frequently result in functional complications due to injuries to the autonomic nervous system. Recognizing the deep uterine vein (DUV) as an essential anatomical reference can aid in preserving these structures. Despite its significance, the DUV is infrequently studied and lacks comprehensive documentation in Terminologia Anatomica. This research endeavors to elucidate a detailed characterization of the DUV. METHODS: We undertook a systematic literature review aligning with the "PRISMA" guidelines, sourcing from PUBMED and EMBASE. Our comprehensive anatomical examination encompassed cadaveric dissections and radio-anatomical evaluations utilizing the Anatomage® Table. RESULTS: The literary exploration revealed a consensus on the DUV's description based on both anatomical and surgical observations. It arises from the merger of cervical, vesical, and vaginal veins, coursing through the paracervix in a descending and rearward direction before culminating in the internal iliac vein. The hands-on anatomical study further delineated the DUV's associations throughout its course, highlighting its role in bifurcating the uterus's lateral aspect into two distinct zones: a superior vascular zone housing the uterine artery and ureter and an inferior nervous segment below the DUV representing the autonomic nerve pathway. CONCLUSION: A profound understanding of the subperitoneal space anatomy is paramount for pelvic surgeons to mitigate postoperative complications. The DUV's intricate neurovascular interplays underscore its significance as an indispensable surgical guide for safeguarding nerves and the ureter.

A systematic review of annotation for surgical process model analysis in minimally invasive surgery based on video.

BACKGROUND: Annotated data are foundational to applications of supervised machine learning. However, there seems to be a lack of common language used in the field of surgical data science. The aim of this study is to review the process of annotation and semantics used in the creation of SPM for minimally invasive surgery videos. METHODS: For this systematic review, we reviewed articles indexed in the MEDLINE database from January 2000 until March 2022. We selected articles using surgical video annotations to describe a surgical process model in the field of minimally invasive surgery. We excluded studies focusing on instrument detection or recognition of anatomical areas only. The risk of bias was evaluated with the Newcastle Ottawa Quality assessment tool. Data from the studies were visually presented in table using the SPIDER tool. RESULTS: Of the 2806 articles identified, 34 were selected for review. Twenty-two were in the field of digestive surgery, six in ophthalmologic surgery only, one in neurosurgery, three in gynecologic surgery, and two in mixed fields. Thirty-one studies (88.2%) were dedicated to phase, step, or action recognition and mainly relied on a very simple formalization (29, 85.2%). Clinical information in the datasets was lacking for studies using available public datasets. The process of annotation for surgical process model was lacking and poorly described, and description of the surgical procedures was highly variable between studies. CONCLUSION: Surgical video annotation lacks a rigorous and reproducible framework. This leads to difficulties in sharing videos between institutions and hospitals because of the different languages used. There is a need to develop and use common ontology to improve libraries of annotated surgical videos.

Comparison of early loosening vs delayed section of mid-urethral slings for postoperative voiding dysfunction.

INTRODUCTION AND HYPOTHESIS: Bladder outlet obstruction (BOO) is a common occurrence after midurethral sling (MUS) insertion and can result in acute or chronic urinary retention or de novo lower urinary tract symptoms (LUTS). However, the management of BOO after MUS is not standardised. The objective of this study was to compare two therapeutic strategies for suspected BOO after MUS. METHODS: Patients who had surgical revision for voiding dysfunction with a post-void residual (PVR) ≥100 ml after MUS in five centres between 2005 and 2020 were included in a retrospective study. Patients were divided into two groups: early sling loosening (EL) vs delayed section/excision of the sling (DS). RESULTS: Seventy patients were included: 38 in the EL group and 32 in the DS group. The postoperative complication rate was comparable in both groups (10.5% vs 12.5%; p = 0.99). At 3 months, the rate of withdrawal from self-catheterisation was similar in the two groups (92.1% vs 100%; p = 0.25) as was the PVR (57.5 vs 63.5 ml; p = 0.09). After a median follow-up of 9 months, there were significantly more patients with resolved voiding dysfunction in the EL group (63.2% vs 31.3%; p = 0.01). The rate of persistent/recurrent stress urinary incontinence (SUI) was higher in the DS group (21% vs 43.7%; p = 0.04). In multivariate analysis, the main predictive factor of recurrent SUI was DS (OR 2.87, 95% CI 1.01-8.60, p = 0.048). CONCLUSIONS: Early loosening of MUS in the case of postoperative voiding dysfunction offers better efficacy than DS of the sling, with a lower risk of recurrent/persistent SUI.

Anatomical Pitfalls of Excision of Deep Endometriosis Nodules of the Sciatic Nerve: A three-dimensional Reconstruction and Surgical Educational Video.

STUDY OBJECTIVE: To highlight the anatomical keys to safely performing an excision of deep endometriosis nodules of the sciatic nerve DESIGN: We present a didactic video combining an anatomical three-dimensional reconstruction of the pelvis using the Anatomage table and a surgical dissection video of the removal of deep endometriosis nodules of the left sciatic nerve [1]. The patient's approval was obtained. The patient consented that this surgical video be used for publication. SETTING: Tertiary referral center. INTERVENTIONS: To reach this specific area, we must localize precise anatomical pitfalls [2,3]. Taking the external iliac vessels as an anatomical plane of reference, we can divide anatomical structures into lateral and medial. During the first step of the procedure, we open the latero-pelvic peritoneum covering the external iliac artery. This step allows the identification of the lateral anatomic keys. Lateral anatomic keys are represented by: (1) the genito-femoral nerve, an element which is superficially situated between the psoas muscle and external iliac artery, and (2) the obturator nerve (Video Still 1), which is deep and is located within the ilio-lumbar fossa. To enter it, a dissection between the psoas muscle and external iliac artery and vein must be performed. At this point, particular attention must be paid to the obturator artery that runs below the obturator nerve. In this fossa, the lumbosacral trunk is easily identified just below the obturator nerve; it lies at this level on the iliac bone. Then the opening of the posterior leaf of the broad ligament is realized. Therefore, we access the medial anatomic keys: (1) the ureter, and (2) the umbilico-artery trunk with the umbilical and uterine artery. In the opening of the posterior leaf, we can find the obturator nerve and lumbosacral trunk again. Finally, following the umbilical artery (that is the first branch of the internal iliac artery), we discover the internal iliac artery and vein. A very careful dissection of these vessels must be done to avoid big hemorrhages, which can be life-threatening [4-6]. In the plane below the internal iliac artery and vein, we access the sacral roots S1, S2, and S3 (Video Still 2), which join the lumbosacral trunk (lying on the piriformis muscle) to form the ischiatic nerve [7]. At this level, the ischiatic nerve exits through the infra-piriform foramen behind the ischiatic spine and sacrospinous ligament toward the gluteal area in an oblique way [8]. Two other elements may be seen: the pudendal nerve exiting the pelvis behind the sacrospinous ligament in a craniocaudal way and the posterior femoral cutaneous nerve. During this dissection, the autonomous system must be spared as usual to avoid functional sequelae. CONCLUSION: Removal of deep endometriosis nodules of sciatic nerves is a challenging procedure. Because few surgeries are specifically dedicated to the sciatic area, the specific anatomy of the region is poorly taught and known. However, pelvic anatomical knowledge is indispensable to the safe removal of nodules of sciatic nerves. The main advantage of this anatomical 3D reconstruction is the possibility of visualizing the deep pelvic anatomy in a laparoscopic position. Surgeons must be aware of both somatic and autonomous pelvic nerve anatomy within the retroperitoneal spaces and the great vessels surrounding them.

Risk factors for stress urinary incontinence recurrence after midurethral sling revision.

OBJECTIVES: The purpose of this study was to report the rate of stress urinary incontinence (SUI) recurrence after sling revision, and to determine predictive factors of SUI recurrence. METHODS: We conducted a retrospective cohort study in a single academic center between 2005 and 2022, of patients who underwent sling revision. Four surgical techniques were used for sling revision (loosening, section, partial, and total excision). The primary endpoint was recurrence of SUI at 3 months postoperatively, and the other outcome of interest was the rate of subsequent anti-incontinence surgical procedure. RESULTS: Sixty-nine patients were included for analysis. SUI recurred in 46.4% of patients. Fifteen patients underwent a subsequent anti-incontinence procedure (21.8%). The time to revision was significantly longer in the group with recurrent SUI (median: 84.5 vs. 44.8 months; p = 0.004). The recurrence rate differed significantly depending on the revision technique: 7.7% after sling loosening, 22.2% after sling section, 60% after partial excision, and 66.7% after complete sling removal (p = 0.001). The risk of SUI recurrence was lower for those whose indication of reoperation was voiding dysfunction (27.3% vs. 66.7%; p = 0.002), and was higher for those who underwent a trans-obturator tap rather than a tension-free vaginal tape revision (68.4% vs. 35.7%; p = 0.02). In multivariate analysis, only the revision technique remained significantly associated with the risk of recurrence of SUI (complete excision vs. section: odds ratio = 4.66; p = 0.04). CONCLUSION: The risk of SUI recurrence may differ widely according to the techniques used, and it seems that the less extensive the surgical procedure is, the lower the risk is.

Efficacy of In Situ Methotrexate Injection in the Treatment of Nontubal Ectopic Pregnancies: A Retrospective Multicenter Study.

STUDY OBJECTIVE: Evaluation of the efficacy of different injection sites of methotrexate in the treatment of nontubal ectopic pregnancies. DESIGN: Retrospective multicenter study. SETTING: Multicenter, including 3 teaching hospitals, an intercommunal hospital, and a clinic. PATIENTS: A total of 106 patients with nontubal ectopic pregnancies, including 59 interstitial, 39 cesarean scar, and 8 cervical or isthmic. INTERVENTIONS: Overall, 58 patients received methotrexate via intramuscular injection (IM group), 35 received methotrexate via in situ injection (IS group), and 13 received a combination of both in situ and intramuscular injections of methotrexate (IS + IM group). MEASUREMENTS AND MAIN RESULTS: The main end point of this study was measured via the primary success rate (defined as a negative ß-human chorionic gonadotropin level without recourse to any additional treatment) of treatment with methotrexate according to injection site. The primary success rate was 46.55% in the IM group, 60% in the IS group, and 61.54% in the IS + IM group, respectively. In the multivariate analysis, the primary success rate of treatment was significantly correlated to the in situ injection of methotrexate, either solely or in conjunction with an intramuscular injection of methotrexate administered the following day, (odds ratio = 2.7; 95% confidence interval, 1.03-7.14). CONCLUSION: Solely an intramuscular injection of methotrexate is a less efficient first-line treatment strategy for the conservative management of nontubular ectopic pregnancy. The use of an in situ injection of methotrexate should therefore be preferred.

Relationship between uterine veins, ureter, and hypogastric nerve for uterine transplantation: An anatomic study.

Uterine transplantation is on the rise worldwide. In contrast to its arterial anatomy, venous drainage of the uterus is poorly defined in the literature. Our aim was to provide a standardized description of uterine veins through a multimodal approach to establish anatomical landmarks for the uterine transplantation surgeon. Data were obtained from: (1) an anatomical study of eight fresh female cadavers (16 hemipelves) studied separately by an extra fascial dissection from the iliac bifurcation to the uterine pedicle, with analysis of the urinary tract and nerve structures and (2) a virtual anatomical study from the Anatomage® Table comprising a high-fidelity virtual reconstruction of two deceased female subjects by imaging and anatomical methods. An inconstant duality of uterine veins was identified: a deep uterine vein of larger caliber and a superficial uterine vein observed in 25% of cases. A close relationship of the ureter passing posterior to the superficial uterine vein and anterior to the deep uterine vein was evident in the parametrium. The inferior hypogastric plexus was identified in all cases immediately behind the deep uterine vein. The data obtained from the fresh female cadavers were validated by the Anatomage® Table. We describe the close relationship of the uterine veins with the ureter and the inferior hypogastric plexus. This knowledge represents a surgical landmark to support the success of uterine transplantation by respecting both the graft and the safety of the living donor by limiting the risk of injuries during uterus procurement.

Relationships between pelvic nerves and levator ani muscle for posterior sacrocolpopexy: an anatomic study.

BACKGROUND: The placement of posterior mesh during pelvic organ prolapse laparoscopic surgery has been incriminated as responsible for postoperative adverse outcomes such as digestive symptoms, chronic pelvic pain, and sexual dysfunction. These complications may be related to neural injuries that occur during the fixation of the posterior mesh on the levator ani muscle. OBJECTIVES: The aim of our study was to describe the course of the autonomic nerves of the pararectal space and their anatomical relationship with the posterior mesh fixation zone on the levator ani muscle. STUDY DESIGN: Twenty hemi-pelvis specimens from 10 fresh female cadavers were dissected. We measured the distance between the posterior mesh fixation zone on the levator ani, and the nearest point of adjacent structures: the hypogastric nerve, inferior hypogastric plexus, uterosacral ligament, uterine artery, and ureter. Measurements were repeated starting from the inferior hypogastric plexus. RESULTS: Nerve fibers of the inferior hypogastric plexus spread out systematically above the superior aspect of the levator ani muscle. Median distance from the posterior mesh fixation zone and the inferior hypogastric plexus was around 2.8 (range 2.1-3.5) cm. CONCLUSIONS: The inferior hypogastric plexus lies above the superior aspect of the levator ani muscle. A short distance between the posterior mesh fixation zone on the levator ani muscle and inferior hypogastric plexus could explain in part postoperative digestive symptoms. These observations support the development of nerve-sparing procedures for posterior mesh placement in the context of pelvic organ prolapse repair and suggest that postoperative complications could be improved by changing the fixation zone.

Pelvic floor disorders and sexuality in women with ovarian cancer: A systematic review.

INTRODUCTION: Pelvic floor disorders (PFD) are common conditions impacting quality of life and sexuality may worsen after ovarian cancer therapies. Our objective was to describe the prevalence of PFD and sexuality in women with ovarian cancer (OC). METHODS: We reviewed articles indexed in the MEDLINE database until June 2020 and selected articles assessing UI, POP, FI and sexual dysfunction in a population of women with OC. RESULTS: Of 360 articles, 18 were included: four assessed UI, two assessed POP, three FI, and 13 sexual dysfunction. PFD findings were highly heterogeneous due to the definitions used and the populations studied. The prevalence of any type of UI in patients with OC before treatment is around 50%, and about 17% report feeling a bulge in their vagina. These rates are similar to those reported in women without cancer. Similarly, the main post-treatment UI scores were not significantly different from women without cancer. Fecal incontinence has been less studied in women with OC but reported as affecting 4% of patients preoperatively and 16% postoperatively. About half of the women are sexually active after surgical treatment with high reported rates of dyspareunia (40-80%) and vaginal dryness (60-80%). Compared with healthy women, some authors found that OC patients had greater problems with loss of desire and poorer sexual function scores; other authors did not find a significant difference. CONCLUSIONS: While PFD seem to be common in women after treatment for OC, the rates are not higher than in the general population. Overall, there is a higher prevalence of UI and sexual dysfunction compared with bowel dysfunction. More prospective studies are needed to explore the impact of gynecologic cancers and their treatments on pelvic floor function and pelvic health-related quality of life.

Systematic Nerve Sparing during Surgery for Deep-infiltrating Posterior Endometriosis Improves Immediate Postoperative Urinary Outcomes.

STUDY OBJECTIVE: Evaluate the feasibility and risk-benefit ratio of systematic nerve sparing by complete dissection of the inferior hypogastric nerves and afferent pelvic splanchnic nerves during surgery for deep-infiltrating endometriosis (DIE) on the basis of complication rates and postoperative bladder morbidity. DESIGN: Observational before (2012-2014)-and-after (2015-2017) study based on a prospectively completed database of all patients treated medically or surgically for endometriosis. SETTING: Unicentric study at the Centre Hospitalier Intercommunal de Poissy-St-Germain-en-Laye. PATIENTS: This study included patients undergoing laparoscopic surgery for DIE (pouch of Douglas resection with or without colpectomy or bilateral uterosacral ligament resection), with complete excision of all identifiable endometriotic lesions, with or without an associated digestive procedure, between 2012 and 2017. The exclusion criteria included prior history of surgery for DIE or colorectal DIE excision, unilateral uterosacral ligament resection, and bladder endometriotic lesions. INTERVENTIONS: For the patients in group 1 (2012-2014, n = 56), partial dissection of the pelvic nerves was carried out only if they were macroscopically caught in endometriotic lesions, without dissection of the pelvic splanchnic nerves. The patients in group 2 (2015-2017, n = 65) systematically underwent nerve sparing during DIE surgery, with dissection of the inferior hypogastric nerves and pelvic splanchnic nerves. MEASUREMENTS AND MAIN RESULTS: Both groups were comparable in terms of patient age, parity, body mass index, and previous abdominal surgery. The operating times were similar in both groups (228 ± 105 minutes in group 2 vs 219 ± 71 minutes in group 1), as were intra- and postoperative complication rates. Time to voiding was significantly longer in the patients in group 1 (p <.01), with 7 (12.9%) patients requiring self-catheterization in this group compared with no patients (0%) in group 2. The duration of self-catheterization for the 7 patients in group 1 was 28, 21, 3, 60, 21, 1 (stopped by the patient), and 28 days, respectively. Uroflowmetry on postoperative day 10 was abnormal in 5/25 patients in group 1 compared with 1/33 in group 2 (p = .031). CONCLUSION: Systematic and complete nerve sparing, including pelvic splanchnic nerve dissection, during surgery for posterior DIE improves immediate postoperative urinary outcomes, reducing the need for self-catheterization without increasing operating time or complication rates.

The male external urethral sphincter is autonomically innervated.

INTRODUCTION: The aim of the present study was to describe autonomic urethral sphincter (US) innervation using specific muscular and neuronal antibody markers and 3D reconstruction. MATERIAL AND METHODS: We performed en-bloc removal of the entire pelvis of three male human fetuses between 18 and 40 weeks. Serial whole mount sections (5 µm intervals) were stained and investigated. The sections were stained with Masson's trichrome and Eosin Hematoxylin, and immunostained with: anti-SMA antibody for smooth muscle; anti-S100 antibody for all nerves; and anti-PMP22 antibody, anti-TH antibody, anti-CGRP antibody, anti-NOS antibody for somatic, adrenergic, sensory and nitrergic nerve fibers, respectively. The slides were digitized for 3D reconstruction to improve topographical understanding. An animated reconstruction of the autonomic innervation of the US was generated. RESULTS: The external and internal US are innervated by autonomic nerves of the inferior hypogastric plexus (IHP). These nerves are sympathetic (positive anti-TH antibody), sensory (positive anti-CGRP antibody), and nitrergic (positive anti-NOS antibody). Some autonomic fibers run within the neurovascular bundles, posterolaterally. Others run from the IHP to the posteromedial aspect of the prostate apex, above an through the rectourethral muscle. The external US is also innervated by somatic nerves (positive anti-PMP22 antibody) arising from the pudendal nerve, joining the midline but remaining below the rectourethral. CONCLUSIONS: This study provides anatomical evidence of an autonomic component in the innervation of the external US that travels in the neurovascular bundle. During radical prostatectomy, the rectourethral muscle and the neurovascular bundles are to be preserved, particularly during apical dissection.

Smooth muscle of the male pelvic floor: An anatomic study.

Knowledge of the anatomy of the male pelvic floor is important to avoid damaging the pelvic floor muscles during surgery. We set out to explore the structure and innervation of the smooth muscle (SM) of the whole pelvic floor using male fetuses. We removed en-bloc the entire pelvis of three male fetuses. The specimens were serially sectioned before being stained with Masson's trichrome and hematoxylin and eosin, and immunostained for SMs, and somatic, adrenergic, sensory and nitrergic nerve fibers. Slides were digitized for three-dimensional reconstruction. We individualized a middle compartment that contains SM cells. This compartment is in close relation with the levator ani muscle (LAM), rectum, and urethra. We describe a posterior part of the middle compartment posterior to the rectal wall and an anterior part anterior to the rectal wall. The anterior part is split into (1) a centro-levator area of SM cells localized between the right and left LAM, (2) an endo-levator area that upholsters the internal aspect of the LAM, and (3) an infra-levator area below the LAM. All these areas are innervated by autonomic nerves coming from the inferior hypogastric plexus. The core and the infra-levator area receive the cavernous nerve and nerves supplying the urethra. We thus demonstrate that these muscular structures are smooth and under autonomic influence. These findings are relevant for the pelvic surgeon, and especially the urologist, during radical prostatectomy, abdominoperineal resection and intersphincteric resection. Clin. Anat., 2019. © 2019 Wiley Periodicals, Inc.

Perineal ultrasound for the measurement of urethral mobility: a study of inter- and intra-observer reliability.

INTRODUCTION AND HYPOTHESIS: Ultrasound measurement of urethral mobility is an attractive approach to directly visualize bladder neck descent (BND) during stress. BND assessed by transperineal ultrasound appears to be associated with stress urinary incontinence (SUI) severity. This study evaluated the inter- and intra-observer reliability of ultrasound BND measurement and its correlation with clinical examination. METHODS: We included 50 women from the multicenter randomized 3PN study ("Prenatal Perineal Prevention"). BND was measured by two operators either during pregnancy (at 20 weeks of gestation) or 2 months after delivery. Two measurements were taken by each operator. Intra-class coefficient correlations were used for analysis. Urethral mobility was clinically assessed by measuring the point Aa of the POP-Q classification during maximum strain (Valsalva maneuver) with an empty bladder. RESULTS: Ultrasound analysis showed high intra-observer reliability in the overall population: intraclass correlation coefficients (ICC) = 0.75 (0.59-0.85) and 0.73 (0.55-0.84) for each operator. Intra-observer agreements were considered moderate to high in the post- and antepartum groups. Inter-observer agreements were moderate in the antepartum period [ICC = 0.58 (0.26-0.78) for the first measurement and 0.68 (0.42-0.84) for the second] but low in the postpartum period [ICC = 0.15 (0.10-0.41) and 0.21 (0.10-0.58)]. Correlations between ultrasound and clinical measurements were considered low to moderate (Spearman coefficient, rho = 0.34 and 0.50 for post- and antepartum periods, respectively). CONCLUSIONS: Inter-observer reliability of ultrasound urethral mobility measurements by the transperineal route is moderate antepartum and low postpartum. The correlation with point Aa is low to moderate.

Fertility, Pregnancy, and Clinical Outcomes after Uterine Arteriovenous Malformation Management.

STUDY OBJECTIVE: To evaluate fertility, pregnancy, and clinical outcomes after uterine arteriovenous malformation (UAVM) management. DESIGN: Single-center retrospective study (Canadian Task Force classification III). SETTING: One referral center. PATIENTS: Twenty-two patients with a UAVM diagnosed by magnetic resonance angiography or computed tomography angiography and managed by expectant management (EM) or uterine arterial embolization (UAE) during the study period were included. INTERVENTIONS: Nine of 22 patients underwent first-intention EM and 13 first-line UAE. Three of 9 EM patients (33.3%) required emergency second-intention UAE for nonresolution of the UAVM and severe genital bleeding. MEASUREMENTS AND MAIN RESULTS: To analyze fertility according to management approach, we defined 2 groups: EM only group (n = 6) and UAE group (n = 16; women who underwent first- or second-intention UAE). Overall, the median age was 29 years (range, 17-43). The mean follow-up after UAVM management was 39 months (range, 1-116). The success rate of the UAE procedure was 87.5% (14/16). Eight of 12 women (66.7%) who wished to conceive became pregnant: 2 of 5 (33.3%) in the EM group and 6 of 7 (85.7%) in the UAE group (p = 1). Overall, 11 patients (50%) conceived: 3 in the EM group (50%) and 8 in the UAE group (50%) (p = .9). The live birth rate was 36.4% (8/22) for the whole population. There were no miscarriages or ectopic pregnancies. The 8 women (72.7%) wishing to conceive who became pregnant all delivered: 1 by cesarean section and 7 by vaginal delivery. Median duration of pregnancy was 39 weeks and 5 days. The remaining 3 women (i.e., women who conceived but did not wish to become pregnant) had therapeutic abortions. One complication was experienced in the EM group (small for gestational age newborn) and none in the UAE group (p = .3). Limitations include retrospective design and small sample size. CONCLUSION: UAE for UAVM is an effective and safe technique. It does not impair fertility, and obstetric prognosis is good.

Standardization of laparoscopic extrafascial hysterectomy: anatomic considerations to protect the ureter.

PURPOSE: To describe the procedure of laparoscopic extrafascial hysterectomy to avoid ureter injury. METHODS: Data were obtained from: (1) anatomic study of ten fresh female cadavers to measure the distance between the point where the ureter and uterine artery cross and the level of section of the ascending branch of the uterine artery during extrafascial dissection of the uterine pedicle and uterosacral ligament (Paris School of Surgery). The Wilcoxon test was used to compare measurements within each subject. P < 0.05 was considered to denote significance; (2) prospectively collected clinical data from women undergoing laparoscopic extrafascial hysterectomy from July 2006 to March 2014 at Poissy University Hospital, to describe the laparoscopic extrafascial hysterectomy technique with analysis of surgical complications using the Clavien-Dindo classification. RESULTS: Anatomic study: The mean (SD) distance between the point where the ureter and uterine artery cross and the level of the section of the ascending branch of the uterine artery were: 11.6 mm (5.2) in neutral position and 25 mm (7.5) after pulling the uterus laterally; and 25mm (8.9) after sectioning the ascending portion of the uterine pedicle and 38.6 mm (4.5) after complete uterine artery pedicle dissection through the uterosacral ligaments. After release of the ureter, the curve in front of the uterine artery disappeared. Clinical laparoscopic study: Sixty-eight patients underwent laparoscopic extrafascial hysterectomy. No ureteral complications occurred. CONCLUSION: Laparoscopic extrafascial hysterectomy is a safe and feasible procedure. Combined lateralization and elevation of the uterus, section of the ascending branch of the uterine artery, and its extrafascial dissection along the uterosacral ligament contribute to protecting the ureter during the procedure.

Detailed muscular structure and neural control anatomy of the levator ani muscle: a study based on female human fetuses.

BACKGROUND: Injury to the levator ani muscle or pelvic nerves during pregnancy and vaginal delivery is responsible for pelvic floor dysfunction. OBJECTIVE: We sought to demonstrate the presence of smooth muscular cell areas within the levator ani muscle and describe their localization and innervation. STUDY DESIGN: Five female human fetuses were studied after approval from the French Biomedicine Agency. Specimens were serially sectioned and stained by Masson trichrome and immunostained for striated and smooth muscle, as well as for somatic, adrenergic, cholinergic, and nitriergic nerve fibers. Slides were digitized for 3-dimensional reconstruction. One fetus was reserved for electron microscopy. We explored the structure and innervation of the levator ani muscle. RESULTS: Smooth muscular cell beams were connected externally to the anococcygeal raphe and the levator ani muscle and with the longitudinal anal muscle sphincter. The caudalmost part of the pubovaginal muscle was found to bulge between the rectum and the vagina. This bulging was a smooth muscular interface between the levator ani muscle and the longitudinal anal muscle sphincter. The medial (visceral) part of the levator ani muscle contained smooth muscle cells, in relation to the autonomic nerve fibers of the inferior hypogastric plexus. The lateral (parietal) part of the levator ani muscle contained striated muscle cells only and was innervated by the somatic nerve fibers of levator ani and pudendal nerves. The presence of smooth muscle cells within the medial part of the levator ani muscle was confirmed under electron microscopy in 1 fetus. CONCLUSION: We characterized the muscular structure and neural control of the levator ani muscle. The muscle consists of a medial part containing smooth muscle cells under autonomic nerve influence and a lateral part containing striated muscle cells under somatic nerve control. These findings could result in new postpartum rehabilitation techniques.

Comparison of Laparoscopic Discoid Resection and Segmental Resection for Colorectal Endometriosis Using a Propensity Score Matching Analysis.

STUDY OBJECTIVE: Our primary endpoint was to compare the intra- and postoperative complications, whereas secondary endpoints were the occurrence of voiding dysfunction and evaluation of the quality or life of segmental and discoid resection in patients with colorectal endometriosis. DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: Tenon University Hospital in Paris. PATIENTS: Thirty-one 31 patients who underwent a conservative surgery and 31 patients who underwent. INTERVENTIONS: The 2 groups were compared using propensity score matching (PSM) analysis, with a median follow-up of 247 days (8.2 months). MEASUREMENTS AND MAIN RESULTS: Discoid colorectal resection was associated with a shorter operating time (155 vs 180 minutes, p = .03) and hospital stay (7 vs 8 days, p = .002) than segmental colorectal resection; however, a similar intra- and postoperative complication rate was found. A higher rate of postoperative voiding dysfunction was observed in the segmental resection group (19% vs 45%, p = .03) as well as duration of voiding dysfunction requiring bladder self-catheterization longer than 30 days (0 vs 22%, p = .005). CONCLUSION: Our PSM analysis suggests the advantages of discoid resection because it results in a similar surgical complication rate to segmental resection but with advantages in operating time, hospital stay, and voiding dysfunction.

Magnetic Resonance Enterography to Assess Multifocal and Multicentric Bowel Endometriosis.

STUDY OBJECTIVE: To prospectively determine the accuracy of magnetic resonance enterography (MRE) compared with conventional magnetic resonance imaging (MRI) for multifocal (i.e., multiple lesions affecting the same digestive segment) and multicentric (i.e., multiple lesions affecting several digestive segments) bowel endometriosis. DESIGN: A prospective study (Canadian Task Force classification II-2). SETTING: Tenon University Hospital, Paris, France. PATIENTS: Patients with MRI-suspected colorectal endometriosis scheduled for colorectal resection from April 2014 to February 2016 were included. INTERVENTIONS: Patients underwent both 1.5-Tesla MRI and MRE as well as laparoscopically assisted and open colorectal resections. MEASUREMENTS AND MAIN RESULTS: The diagnostic performance of MRI and MRE was evaluated for sensitivity, specificity, positive and negative predictive values, accuracy, and positive and negative likelihood ratios (LRs). The interobserver variability of the experienced and junior radiologists was quantified using weighted statistics. Forty-seven patients were included. Twenty-two (46.8%) patients had unifocal lesions, 14 (30%) had multifocal lesions, and 11 (23.4%) had multicentric lesions. The sensitivity, specificity, positive LR, and negative LR for the diagnosis of multifocal lesions were 0.29 (6/21), 1.00 (23/24), 15.36, and 0.71 for MRI and 0.57 (12/21), 0.89 (23/25), 4.95, and 0.58 for MRE. The sensitivity, specificity, positive LR, and negative LR for the diagnosis of multicentric lesions were 0.18 (1/11), 1.00 (1/1), 15, and 0.80 for MRI and 0.46 (5/11), 0.92 (33/36), 5.45, and 0.60 for MRE. Lower accuracies for MRI compared with MRE to diagnose multicentric (p = .01) and multifocal lesions (p = .004) were noted. The interobserver agreement for MRE was good for both multifocality (κ = 0.80) and multicentricity (κ = 0.61). CONCLUSION: MRE has better accuracy for diagnosing multifocal and multicentric bowel endometriosis than conventional MRI.

Serum hCG threshold to assess medical abortion success.

OBJECTIVES: The main aim of the study was to establish a threshold for serum human chorionic gonadotropin (hCG) level that ruled out ongoing pregnancy after induced medical abortion (MA). The secondary aim was to discover risk factors for the need for uterine aspiration. METHODS: This prospective study included women who underwent MA with mifepristone-misoprostol at ≤9 weeks of gestation between 2012 and 2014. Serum hCG levels were measured 14-21 days after MA. The main outcome measure, ongoing pregnancy, was defined as the presence of an embryo with cardiac activity on transvaginal ultrasonography after MA. The receiver operating characteristic curve was plotted to determine the optimal serum hCG threshold. Risk factors for the need for uterine aspiration were calculated using multivariate logistic regression and expressed as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: The study included 814 women. Mean gestational age was 46.5 ± 7.4 days for ongoing pregnancies and 44.2 ± 4.8 days for MA success (p = .43). The ongoing pregnancy rate after MA was 0.9%. A serum hCG threshold ≥900 IU/l to diagnose ongoing pregnancy gave 100% sensitivity and 81.5% specificity, compared with 85.7% sensitivity and 83.5% specificity using a threshold ≥1000 IU/l. Independent risk factors for uterine aspiration requirement were: gravidity (OR 3.8; 95% CI 1.1, 13.2; p = .001), gestational age >6 weeks (OR 6.0; 95% CI 1.8, 6.0; p = .006) and previous surgical abortion (OR 2.4; 95% CI 1.1, 5.2; p < .001). CONCLUSION: Serum hCG measurement <900 IU/l, 14-21 days after MA, is an efficient strategy for excluding ongoing pregnancy after first trimester MA.

Organization of the fascia and aponeurosis in the lumbar paraspinal compartment.

PURPOSE: The thoracolumbar fascia (TLF) and the erector spinae aponeurosis (ESA) play significant roles in the biomechanics of the spine and could be a source of low back pain. Attachment, collagen fiber direction, size and biomechanical properties of the TLF have been well documented. However, questions remain about the attachment of the TLF and ESA in relation to adjoining tissues in the lumbosacral region. Moreover, quantitative data in relation to the ESA have rarely been examined. The aim of this study was to further investigate the anatomical features of the TLF and ESA and to determine the attachments and sliding areas of the paraspinal compartment through dissection. MATERIALS AND METHODS: In 10 fresh cadavers (6 females, 4 males, mean age: 77 ± 10 years), we determined (1) the gross anatomy of the ESA and the TLF (attachments and sliding areas) and (2) the structure of the ESA and the TLF (thickness, width, orientation of collagen fibers). The pennation angle between the axis of the ES muscle fibers and the axis of the collagen fibers of the ESA were also measured. RESULTS: The TLF is an irregular dense connective tissue with a mean thickness of 0.95 mm. The distance between the spinous processes line and the site where the neurovascular bundles pierced the TLF, depending on the vertebral level, ranged from 29 mm at L1 to 75 mm at L3. The ESA constituted a band of regular longitudinally oriented connective fibers (mean thickness: 1.85 mm). Muscles fibers of the ES were strongly diagonally attached to the ESA (mean pennation angle 8° for the iliocostalis and 14° for the longissimus). To a lesser extent, the superficial multifidi were attached to the ESA at the lumbar level close to the midline and at the sacral level. CONCLUSION: The ESA, at twice the thickness of the pTLF, was the thickest dense connective tissue of the paraspinal compartment. The ESA and the TLF circumscribed subcompartments and sliding areas between the TFL and the lumbar paraspinal muscles, between the ES and the multifidus, and between the longissimus and the iliocostalis.