Three-dimensional geometric morphometric sex determination of the whole and modeled fragmentary human pubic bone.

Sex determination of the human pelvis has traditionally been done through visual analyses of morphoscopic traits and there are limited metric methods available to forensic anthropologists to add metric credibility to these analyses. The goal of this research was to create an improved metric method using three-dimensional geometric morphometrics to determine sex from both whole and modeled fragmented human pubic bones. The sample consisted of n = 378 pubic bones from the University of New Mexico's Maxwell Museum Documented Skeletal Collection and eight landmarks were collected from each bone. Statistical analyses and machine learning algorithms were used to predict the accuracy of the method's ability to classify a bone as male or female on both whole and simulated fragmented remains; this included tests run on each possible landmark combination of three or more landmarks to simulate fragmented bones (218 combinations). The results of the whole bone analysis resulted in 95.35% testing accuracy. The results of the modeled fragmentary analysis consisted of 164 combinations which exhibit a 90% or higher accuracy in sex prediction; and twelve combinations which exhibit 96% or higher accuracy in sex prediction. In particular, two landmarks clustered around the ventral arc of the pubic bone performed the best, indicating this is the most sexually dimorphic portion of the bone. These results indicate that three-dimensional geometric morphometrics is a valid method to be applied to sex determination in forensic anthropology.

A novel nomogram for the delayed transperineal anastomotic urethroplasty based on relative position between the proximal urethra and the pubic ramus in pelvic fracture injury patients: a retrospective analysis.

PURPOSE: Many reconstructive urologists have observed that higher urethra injuries lead to potentially less successful repairs. This article introduces a novel prognostic factor for pelvic fracture caused urethral injury (PFUI) to predict stricture recurrence after delayed transperineal anastomotic urethroplasty (TAU) patients with PFUI based on urethra injury locations. MATERIALS AND METHODS: Patients who underwent suprapubic cystostomy tube placement and delayed TAU for PFUI by a single surgeon between 2009 and 2018 were screened. A total of 151 patients completed the follow-up. The relative location between the proximal urethra and the pubic ramus (PUE-PR), a novel stricture length classification method based on the anatomical landmark, was divided into a lower, middle, and upper group reflected by urethrogram. The nomogram was developed based on significant coefficients identified by multivariable Cox regression. RESULTS: Based on the relative position between the proximal urethra end and the pubic ramus (PUE-PR), 47 (31%), 66 (44%), and 38 (25%) patients were assigned to the lower, middle, and upper group, respectively. A total of 33 patients (22%) patients had a recurrence. The median (IQR) follow-up was 49 months (28-75). Smoking, endoscopic treatment history, and PUE-PR were identified as independent risk factors for stricture recurrence. The nomogram showed good discrimination with a C-index of 76.67%. The decision curve analysis (DCA) indicated that the model could bring more clinical net benefit when a threshold probability is larger than 8%. CONCLUSIONS: PUE-PR is a new prognostic factor for PFUI to predict stricture recurrence after TAU. A novel nomogram incorporating PUE-PR could be applied to facilitate the prediction of stricture recurrence after delayed TAU for PFUI.

Establishing reference values for the pubofemoral distance in normal infant medial hips by ultrasound.

BACKGROUND: Measuring the pubofemoral distance (PFD) is important for evaluating the effectiveness of hip reduction in the treatment of developmental dysplasia of the hip (DDH). However, reference PFD values have not been established in normal infants. PURPOSE: To investigate variations in PFD values measured in normal infant medial hips stratified by age, laterality, and gender. MATERIAL AND METHODS: A total of 240 infants diagnosed with Graf type Ia and/or Graf type Ib hips by ultrasonography were stratified into eight age groups: 0-1 month; 1-2 months; 2-3 months; 3-4 months; 4-5 months; 5-6 months; 6-7 months; and 7-12 months. The bilateral medial hips were scanned with transinguinal ultrasound. The PFD was defined as the distance between the lateral edge of the superior ramus of pubic bone and the medial edge of the femoral head. Inter-observer reproducibility was assessed. RESULTS: Among the 240 infants, there were 371 Graf type Ia hips and 109 Graf type Ib hips. Mean ± SD bilateral PFD values of eight groups were measured separately. There were no significant differences in mean PFD values for left or right hips (t = 0.946, P = 0.345) or mean bilateral PFD values in male and female infants (t = 1.445, P = 0.149). Mean PFD values increased linearly with age (left: r = 0.680, P < 0.0001; right: r = 0.682, P < 0.0001). Inter-observer reproducibility was excellent. CONCLUSION: This study established reference PFD values from the medial hip in infants aged 0-12 months. PFD values increased with age, but were not significantly influenced by laterality or gender. These data provide detailed information that can support follow-up of infants treated for DDH.

Spatial distribution of smooth muscle tissue in the female pelvic floor and surrounding the urethra and vagina.

Data regarding urethral supporting structures are insufficient for understanding the mechanism of stress urinary incontinence. Whether smooth muscle fibers contribute to urethral support and pelvic floor support structures is unclear. This study aimed to clarify the histological structures and spatial distributions of smooth muscle tissues surrounding the urethra and vagina. Using cadaveric specimens, macroscopic anatomical and histological evaluations were conducted. Six female cadavers were used for macroscopic observations. Ten female cadavers were used for histological observations. Three pelvises were cut in a plane vertical to the urethra, and the other pelvises were cut in a plane parallel to the urethra and vagina to observe tissues surrounding the urethra and vagina. The major tissue component around the proper muscle layer of the urethra was smooth muscle tissue, which mediated among the urethra, pubis, and levator ani. Smooth muscle tissues laterally extended the smooth muscle fibers, both superiorly and inferiorly toward the levator ani, with a few fibers inserted in the levator ani. Smooth muscle was found between the urethral walls and pubic bones. Smooth muscle may contribute to the mechanism of pelvic floor support.

Dual-sectored transurethral ultrasound for thermal treatment of stress urinary incontinence: in silico studies in 3D anatomical models.

The purpose of this study is to investigate the feasibility and performance of a stationary, non-focused dual-sectored tubular transurethral ultrasound applicator for thermal exposure of tissue regions adjacent to the urethra for treatment of stress urinary incontinence (SUI) through acoustic and biothermal simulations on 3D anatomical models. Parametric studies in a generalized tissue model over dual-sectored ultrasound applicator configurations (acoustic surface intensities, lateral active acoustic output sector angles, and durations) were performed. Selected configurations and delivery strategies were applied on 3D pelvic anatomical models. Temperature and thermal dose distributions on the target region and surrounding tissues were calculated. Endovaginal cooling was explored as a strategy to mitigate vaginal heating. The 75-90° dual-sectored transurethral tubular transducer (3.5 mm outer diameter (OD), 14 mm length, 6.5 MHz, 8.8-10.2 W/cm2) and 2-3-min sonication duration were selected from the parametric study for acoustic and biothermal simulations on anatomical models. The transurethral applicator with two opposing 75-90° active lateral tubular sectors can create two heated volumes for a total of up to 1.8 cm3 over 60 EM43 °C, with at least 10 mm radial penetration depth, 1.2 mm urethral sparing, and no lethal damage to the vagina and adjacent bone (< 60 EM43 °C). Endovaginal cooling can be applied to further reduce the vaginal wall exposure (< 15 EM43 °C). Simulations on 3D anatomical models indicate that dual-sectored transurethral ultrasound applicators can selectively heat pelvic floor tissue lateral to the mid-urethra in short treatment durations, without damaging adjacent vaginal and bone tissues, as a potential alternative treatment option for stress urinary incontinence. Graphical abstract Schema for in silico investigation of transurethral ultrasound thermal therapy applicator for minimally invasive treatment of SUI.

Medial Thigh Anatomy in Female Cadavers: Clinical Applications to the Transobturator Midurethral Sling.

BACKGROUND: Mesh resection for refractory pain after transobturator midurethral sling may require exploration of structures different than those involved in insertion. Our objective was to describe the muscular and neurovascular anatomy of the medial thigh compartment. METHODS: Dissections were performed in unembalmed female cadavers. Relationships of medial thigh structures were evaluated relative to the midpubic arch and obturator nerve. An out-to-in transobturator tape was passed in a subset of cadavers, and its relationships to the obturator nerve and adductor muscles were examined. Descriptive statistics were used for analyses. RESULTS: Sixteen cadavers were examined. The adductor longus muscle was a median of 37 mm (26-50) from the midpubic arch with tendon length of 26 mm (12-53) and width of 16 mm (14-29). The gracilis was 21 mm (17-26) from the midpubic arch with tendon length of 28 mm (15-56) and width of 45 mm (31-68). The obturator nerve was 58 mm (51-63) from the midpubic arch with width of 5 mm (4-7). No differences between measurements in the supine and lithotomy positions were noted. The transobturator tape was 42 mm (30-47) from the midpubic arch, 36 mm (30-44) from the obturator nerve, and 20 mm (5-31) from the closest obturator nerve branch. The transobturator sling passed through the gracilis muscle in all specimens with variable passage through the adductors longus (75%) and brevis (25%). CONCLUSIONS: Familiarity with the medial thigh is essential for surgeons utilizing transobturator midurethral slings. Risks of mesh excision should be weighed against benefits before extensive thigh dissection for pain-related indications.

Clinical Anatomy of the Puboprostatic Ligament for the Safe Guidance for the Prostate Surgery.

OBJECTIVE: To provide the anatomy of the puboprostatic ligament and related structures to save urogenital competence after prostatectomy. MATERIALS AND METHODS: Pelvic areas of 31 adult cadavers were dissected to figure out the shape, number, and location of the puboprostatic ligaments. RESULTS: The puboprostatic ligament was the most important support structure between the pubic bone and prostate gland. Puboprostatic ligaments were bilaterally single (61.3%), bilaterally double (19.4%), or mixed (19.4%). Ligaments were mostly I-shaped (53.8%). If ligaments had extra attachment to or from the arcuate line, the ligaments were λ-shaped (36.3%), or Y-shaped (8.8%). In one case, the ligament had a central fusion with an irregular shape. I-shaped puboprostatic ligaments were observed more frequently in specimens with double ligaments, while λ-shaped puboprostatic ligaments were observed more frequently in the cases with single ligaments. The average distance between both puboprostatic ligaments was 8.1 mm at the pubic site and 14.2 mm at the prostate site. The distance was narrower when the specimen had double puboprostatic ligaments on both sides. The neurovascular bundle ran beneath the puboprostatic ligament. If the ligament was the λ-shaped type, the neurovascular bundle frequently pierced the lateral band of the ligament. CONCLUSION: Puboprostatic ligaments hold and stabilize the prostate against the pubic bone. It is believed that a pelvis with bilateral, double puboprostatic ligaments would have advantages in urogenital competence. The morphologic data of the shape, multiplicity, and location of the PPLs would help to make a plan to approach the prostate.

MR imaging-anatomical-histological evaluation of the abdominal muscles, aponeurosis, and adductor tendon insertions on the pubic symphysis: a cadaver study.

PURPOSE: To perform an MR(magnetic resonance) imaging, anatomical, and histological evaluation of the abdominal muscles and adductor tendon insertions. METHOD: Four fresh cadaveric pelvis specimens were imaged at 3 T with the following imaging parameters: TE (echo time)/TR (repetition time): 20, 4090, slice thickness: 2 mm, FOV: 270 × 90, matrix size: 512. Anatomical slices were obtained with a band saw and photographed. MR images and photographs were evaluated by an anatomist and radiologist. Selected 3 mm thick slices were placed in formalin and decalcified, cut, placed on large slides, and stained with hematoxylin eosin stain (HES). RESULTS: The main adductor tendon insertions are: the anterosuperior aspect of the pubic bone for the adductor longus, the anteroinferior aspect of the pubic bone - for the adductor brevis, and the inferior aspect of the pubic bone for the adductor magnus. On histology, the adductor longus tendon fibers inserted perpendicularly into the bone at a fibrocartilage enthesis and cross connected along the anterior pubic ligament into the controlateral tendon. The rectus abdominis-pyramidalis unit was covered by a thin anterior and posterior aponeurosis. The posterior aponeurosis inserted into the superior aspect of the anterior pubic ligament, whereas the anterior aponeurosis fused distally with the adductor longus tendons. CONCLUSION: Our findings demonstrate the insertions of the adductor tendons, on the pubic ligament and pubic bone.Histologically, the adductor longus tendon fibers inserted perpendicularly into the bone through a fibrocartilage enthesis, and cross connected along the anterior pubic ligament into the contralateral tendon.

Correlation between the distance from the pubic symphysis to the sacrum with pelvic incidence.

INTRODUCTION: The distance between the pubic symphysis and sacrococcygeal joint has been noted as an important parameter in evaluating pelvic tilt in an anteroposterior (AP) radiograph. Similarly, pelvic incidence measures the sagittal balance of the pelvis and is influenced by pelvic rotation. The relationship between these 2 parameters is unknown and could affect interpretation of pelvic AP radiographs. METHODS: We reconstructed 248 cadaveric pelvises. Pelvic incidence was measured using a previously validated method. Pubic symphysis-sacrococcygeal joint (PSS) height was measured from the superior pubic tubercle to the sacrococcygeal joint. The pelvises were positioned so that the anterior pelvis lay flush with the surface. A ruler was zeroed on the pubic tubercles and a transverse projecting laser was used to measure the height to the sacrococcygeal joint. RESULTS: A total of 248 pelvises were reconstructed. Average age of death of the specimens was 33±6.0 years. 80% of the pelvises were male, 56% were Caucasian, and 44% African American. The mean PSS height was 2.2 ± 1.4 cm and mean PI was 44.3° ± 10.6°. Multiple regression analysis found PI and PSS height were not correlated (p = 0.144). Females had a larger PSS height than males (beta = 1.17, p < 0.001) and African Americans a larger PSS height than Caucasians (beta = 0.63, p < 0.001). CONCLUSIONS: This study provides useful information for clinicians in evaluating AP radiographs of the pelvis in that it supports the use of PSS height to judge the adequacy of a radiograph even in the context of abnormal pelvic incidence.

Penile dimensions: What are surgeons measuring?

Penile dimensions and related dissatisfaction, may have significant impact upon patients whom undergo andrological surgeries. Whilst penile dimension assessment is performed as part of the andrological evaluation, little is known regarding the surgeons' opinions nor contemporary practices. This study was designed to gain further insights into the opinions and practices of clinicians regarding penile measurement and is the first paper in the literature of its kind. The study was performed by inviting clinicians at andrological/urological conferences to participate in a voluntary 10 point survey concerning penile dimensions. Of 126 responses recorded, 56% (71/126) were andrologists. Of the responders, 45% (56/122) did not routinely perform penile measurement prior to treatment nor were they aware of the standardised method (93/123). The majority 64%(81/126) would measure the penile length from the pubic bone to the tip (79/123) with the penis in a stretched position (99/125). A goniometer was the most common way of assessing penile curvature (37/73) and the length would be measured mostly on the convex side (46/119). Responders felt that, from the patients perspective, a combination of length, girth and shape (51/123), or length only (50/123), were the more important aspects of penile dimensions. As responders were recruited based on their interest in andrological aspects of urology, it may not be representative of the general urological community. In conclusion, attitudes and methods of penile measurement are quite varied amongst surgeons, thus further discussion and investigation of this aspect of andrological care ought to occur.

Virtual Periacetabular Osteotomy and Anatomical Measurements.

OBJECTIVE: To report on a CT scan virtual periacetabular osteotomy (PAO) process to evaluate the potential risk of different PAO cutting planes. METHODS: A total of 123 patients (64 men and 59 women) underwent virtual PAO. We defined two retroacetabular cutting (RC) planes: the RC plane and the RC+ plane (10 mm posteriorly as compared to the RC plane). Subsequently, we measured the anatomical minimum distance between the acetabulum and the sciatic notch, the minimum distance between the acetabulum and the retroacetabular cutting plane (osteotomy of the posterior column), and the osteotomy length in the cranio-caudal direction. RESULTS: The mean (standard deviation [SD]) minimum distance between the acetabulum and the sciatic notch was 25.82 ± 3.52 mm (95% confidence intervals [CI], 25.36-26.25 mm). In men, the mean (SD) minimum distance between the acetabulum and sciatic notch (27.18 ± 3.47 mm; 95% CI, 26.56-27.78 mm) was significantly (3 mm) larger than in women (24.34 ± 2.92 mm; 95% CI, 23.82-24.89 mm; P < 0.001). The mean (SD) minimum distance between the acetabulum and the retroacetabular plane was significantly larger for the RC+ plane (6.97 ± 0.91 mm) than for the RC plane (P < 0.001). In men, this distance (10.23 ± 3.84 mm) was significantly (2.3 mm) larger than in women (7.94 ± 3.45 mm; P < 0.001). The mean (SD) osteotomy length was significantly larger for the RC+ plane (61.78 ± 6.75 mm) than for the RC plane (68.48 ± 6.65) mm; P < 0.001). All three evaluated parameters had significantly shorter lengths in women than in men. CONCLUSION: The safety space for PAO in women was narrower than in men. By shifting the RC plane 10 mm into the posterior direction, the RC+ plane provides a safer cutting distance and shorter osteotomy line in the PAO than the RC plan, which is important to avoid intraarticular penetration.

Assessing the fusion of the ischiopubic synchondrosis using predictive modeling.

Flaring of the ischiopubic synchondrosis at the time of fusion is a common clinical observation in pediatrics and represents a normal physiological process in skeletal maturation. When presenting unilaterally, this flaring can mimic a range of serious pathological conditions such as osteomyelitis, osteal tumors, and traumatic injury. An improved understanding of ischiopubic synchondrosis fusion is therefore critical to avoid potential misdiagnosis. Retrospective multi-slice computed tomography pelvic scans of Australian individuals aged neonate to 24 years (n = 184) were assessed using a novel five stage morphological classification system of the maturation and fusion of the ischiopubic synchondrosis. Maturation scoring was conducted using both multiplanar formatting views and volume-rendered reconstructions in OsiriX™. Maturational stage was strongly related to age (P < 0.001) with fusion of the ischiopubic synchondrosis observed between the ages of 4 and 9 years in females and 7 and 13 years for males. The highest probability of fusion in our Queensland Australian population based on multinomial regression predictive modeling was between 7 and 10 years of age. We documented three variants of fusion: pubic and ischial outgrowths, appearance of a secondary ossification center, and a fusiform-shaped enlargement. This study provides the first predictive modeling of the timing of fusion of the ischiopubic synchondrosis using a reliable morphological classification system. The significant variation in timing and progression of fusion of the ischiopubic synchondrosis reported in this study, will aid in minimizing misdiagnosis and unnecessary treatment in children presenting with asymmetrical or delayed ischiopubic synchondrosis anomalies. Clin. Anat. 32:851-859, 2019. © 2019 Wiley Periodicals, Inc.

The birth canal: correlation between the pubic arch angle, the interspinous diameter, and the obstetrical conjugate: a computed tomography biometric study in reproductive age women.

Background: Assessment of pelvic configuration is an important factor in the prediction of a successful vaginal birth. However, manual evaluation of the pelvis is practically a vanishing art, and imaging techniques are not available as a real-time bed-side tool. Unlike the obstetrical conjugate diameter (OC) and inter spinous diameter (ISD), the pubic arch angle (PAA) can be easily measured by transperineal ultrasound. Objectives: Three-dimensional computed tomography bone reconstructions were used to measure the three main birth canal diameters, evaluate the correlation between them, and establish the normal reference range for the inlet, mid-, and pelvic outlet. Study design: Measurements of the PAA, obstetric conjugate (OC), and ISD were performed offline using three-dimensional post processing reconstruction in bone algorithm application of the pelvis on examinations performed for suspected renal colic in nonpregnant reproductive age woman. The mean of two measurements was used for statistical analysis which included reproducibility of measurements, regression curve estimation between PAA, OC, and ISD, and calculation of the respective reference range centiles for each PAA degree. Results: Two hundred ninety-eight women comprised the study group. The mean ± SD of the PAA, ISD, and OC were 104.9° (±7.4), 103.8 mm (±7.3), and 129.9 mm (±8.3), respectively. The intra- and interobserver agreement defined by the intraclass correlation coefficient (ICC) was excellent for all parameters (range 0.905-0.993). A significant positive correlation was found between PAA and ISD and between PAA and OCD (Pearson's correlation = 0.373 (p < .001), and 0.163 (p = .022), respectively). The best regression formula was found with quadratic regression for inter spinous diameter (ISD): 34.122778 + (0.962182*PAA - 0.002830*PAA2), and linear regression for obstetric conjugate (OC): 110.638397 + 0.183156*PAA. Modeled mean, SD, and reference centiles of the ISD and OCD were calculated using the above regression models as function of the PAA. Conclusions: We report significant correlation between the three pelvic landmarks with greatest impact on the prediction of a successful vaginal delivery: the PAA which is easily measured sonographically and the ISD and OC which are not measurable by ultrasound. This correlation may serve as a basis for future studies to assess its utility and prognostic value for a safe vaginal delivery.

Specific-age group sex estimation of infants through geometric morphometrics analysis of pubis and ischium.

Sex determination of unknown individuals is one of the primary goals of Physical and Forensic Anthropology. The adult skeleton can be sexed using both morphological and metric traits on a large number of bones. The human pelvis is often used as an important element of adult sex determination. However, studies carried out about the pelvic bone in subadult individuals present several limitations due the absence of sexually dimorphic characteristics. In this study, we analyse the sexual dimorphism of the immature pubis and ischium bones, attending to their shape (Procrustes residuals) and size (centroid size), using an identified sample of subadult individuals composed of 58 individuals for the pubis and 83 for the ischium, aged between birth and 1year of life, from the Granada osteological collection of identified infants (Granada, Spain). Geometric morphometric methods and discriminant analysis were applied to this study. The results of intra- and inter-observer error showed good and excellent agreement in the location of coordinates of landmarks and semilandmarks, respectively. Principal component analysis performed on shape and size variables showed superposition of the two sexes, suggesting a low degree of sexual dimorphism. Canonical variable analysis did not show significant changes between the male and female shapes. As a consequence, discriminant analysis with leave-one-out cross validation provided low classification accuracy. The results suggested a low degree of sexual dimorphism supported by significant sexual dimorphism in the subadult sample and poor cross-validated classification accuracy. The inclusion of centroid size as a discriminant variable does not imply a significant improvement in the results of the analysis. The similarities found between the sexes prevent consideration of pubic and ischial morphology as a sex estimator in early stages of development. The authors suggest extending this study by analysing the different trajectories of shape and size in later ontogeny between males and females.

Postnatal Changes in Testicular Position Are Associated With IGF-I and Function of Sertoli and Leydig Cells.

Context: Despite clinical guidelines calling for repetitive examination of testicular position during childhood, little is known of normal changes in testicular position during childhood, let alone factors that control it. Objective: To assess changes in and factors associated with testicular position during childhood. Design: Testicular position (the distance from the pubic bone to the upper pole of the testes) at birth, 3 months, 18 months, 36 months, and 7 years and reproductive hormones at 3 months were measured. Setting: Prenatally recruited, prospective longitudinal birth cohort. Participants: A total of 2545 boys were recruited prenatally in a Danish-Finnish birth cohort and had a testicular position examination available. A subset of 680 Danish and 362 Finnish boys had serum reproductive hormone concentrations and insulin-like growth factor I (IGF-I) determined at 3 months. Main Outcome Measures: Testicular distance to pubic bone (TDP), serum reproductive hormone, and IGF-I concentrations. Results: TDP increased from birth to 3 months and decreased thereafter. Length, gestational age, weight for gestational age, and penile length were positively associated with larger TDP and thus lower testicular position in a linear mixed-effect model. Furthermore, IGF-I concentration, inhibin B/follicle-stimulating hormone ratio, and testosterone/luteinizing hormone ratio were all independently and positively associated with longer TDP. Conclusions: We provide longitudinal data on postnatal changes in TDP. TDP is dynamic and associated with Leydig and Sertoli cell function as well as with IGF-I levels during the first months of life at mini-puberty of infancy. TDP may thus be a useful biomarker of postnatal testicular function.

Metric Assessment of the Pubic Bone Using Known and Novel Data Points for Sex Estimation.

Biological sex estimation of skeletal remains is essential in forensic and archaeological analyses. Anthropologists most often use the pelvis, which is the most sexually dimorphic element both morphologically and metrically. While nonmetric pubic bone features have been studied extensively, few metric studies have examined this individual bone for dimorphism. For this study, three observers examined three previously identified and ten novel measurements of the pubic body on a modern sample of isolated pubic bones from the Maricopa County Forensic Science Center (FSC), in Phoenix, Arizona (n = 400). A relationship between pubic body measurements and biological sex was demonstrated, with significant correlations. Discriminant function analyses found that five measurements, four of which were novel, discriminated between males (89%) and females (86%). Observer experience level did not significantly impact the results. These five measurements were reliable and show promise for inclusion in metric methods for assessment of sex.

The prevalence and morphology of the corona mortis (Crown of death): A meta-analysis with implications in abdominal wall and pelvic surgery.

PURPOSE: Corona mortis is a highly variable vascular connection between the obturator and external iliac or inferior epigastric arteries or veins located behind the superior pubic ramus in the retropubic space (space of Retzius). Due to the significant variation in this collateral circulation, detailed anatomical knowledge of the corona mortis is vital to enhance the prevention of possible iatrogenic errors in hernia repair and other pubic surgical procedures. The aim of our meta-analysis was to provide comprehensive data on the prevalence, anatomical characteristics, and ethnic variations of the corona mortis vessel. METHODS: An extensive search was conducted through the major electronic databases to identify eligible articles. Data extracted included investigative method, prevalence of the corona mortis vessels among hemi-pelvises (overall, arterial only, venous only, and combined), distance from the corona mortis to pubic symphysis, and assessment of gender, side, laterality, and ethnicity subgroups. RESULTS: A total of 21 studies (n=2184 hemi-pelvises) were included in the meta-analysis. The overall prevalence of the corona mortis in hemi-pelvises is high (49.3%). A venous corona mortis is more prevalent than an arterial corona mortis (41.7% vs. 17.0%). The corona mortis is more common in Asia (59.3%) than in Europe (42.8%) and North America (44.3%). CONCLUSIONS: As a corona mortis is present in an about half of all hemi-pelvises, it is important to consider the possibilities of its presence when undertaking surgical procedures and plan accordingly to avoid injuries. All surgeons operating in the retropubic region should have a thorough understanding of the anatomical characteristics and surgical implications of a corona mortis.

Pubourethral Stump Angle Measured on Preoperative Magnetic Resonance Imaging Predicts Urethroplasty Type for Pelvic Fracture Urethral Injury Repair.

OBJECTIVE: To examine whether the type of delayed urethroplasty required for pelvic fracture urethral injury, which is not easily predicted from conventional urethrography findings, can be predicted from preoperative magnetic resonance imaging (MRI) results. PATIENTS AND METHODS: Records of 74 male patients with pelvic fracture urethral injury who underwent MRI of the pelvis at least 3 months after injury and, subsequently, delayed anastomotic urethroplasty were retrospectively analyzed. Pubourethral stump length (PUL) was defined as the distance between the distal end of the proximal urethral stump and the lower border of the inferior pubic ramus. Pubourethral stump angle (PUA) was defined as the angle between the long axis of the pubis and the line between the distal end of the proximal urethral stump and the lower border of the inferior pubic ramus. Both PUL and PUA were measured in sagittal T2-weighted MRI. RESULTS: Delayed urethroplasty was performed by a simple perineal approach in the 28 patients requiring only bulbar urethral mobilization with or without corporal splitting and by elaborate approach in the 46 additionally requiring inferior pubectomy or an abdominoperineal approach with urethral rerouting. The overall success rate defined as no recurrent stricture on urethroscopy was 94.6%. Disruption at the prostate apex, greater urethral gap length, longer PUL, and lower PUA were in univariate analysis significantly associated with an elaborate approach. In multivariate analysis, only low PUA was an independent predictor of the need for an elaborate approach. CONCLUSION: PUA measured on MRI is useful for predicting the type of reconstruction needed for urethral repair.

Is anatomic acetabular orientation related to pelvic morphology? CT analysis of 150 healthy pelvises.

BACKGROUND: Links between sagittal spinal alignment and acetabular orientation attract considerable research attention with the goal of optimising prosthetic cup position. However, whether pelvic incidence (PI) is related to anatomic acetabular orientation remains unknown. We therefore conducted a radiological study with the following objectives: to look for correlations between PI and anatomic acetabular parameters; to describe the sacro-pubic angle (SPA), defined by fixed bony pelvic landmarks, and its relations with acetabular anteversion; and to determine whether anatomical parameters (PI and SPA) correlate with demographic characteristics. HYPOTHESIS: PI correlates with anatomical acetabular parameters. MATERIALS AND METHODS: We conducted a computed tomography (CT) study of the pelvises of 150 patients free of degenerative disease. Three parameters were measured: anatomic acetabular orientation in the Lewinnek reference plane, PI, and the SPA subtended by the line connecting the midpoint of the sacral endplate to the pubic symphysis and the anterior pelvic plane. Statistical tests were performed to look for correlations among these parameters. RESULTS: Intra-observer and inter-observer reproducibility was considered highly satisfactory (inter-class correlation coefficient, >86% and >82%, respectively). Mean PI was 58.6°±10.2° (range, 32.8°-97.6°), with no significant differences between genders or across age groups. Mean SPA was 34.7°±5.5° (range, 18.3°-49.8°). Mean anatomic acetabular anteversion (AAA) was greater in females (23.4°; range, 11.5°-34.5°) than in males (20°; range, 7.5°-34.5°) (P<0.001). PI did not correlate with any of the acetabular parameters (PI/AAA, r=0.8 and P=0.33; PI/acetabular inclination on the horizontal, r=-0.96 and P=0.24). SPA correlated significantly with both PI (r=0.33 and P<0.001) and AAA (r=0.33 and P<0.001). DISCUSSION: This CT study of normal pelvises showed that AAA was significantly greater in females and that SPA correlated significantly with both PI and acetabular anteversion. SPA could serve to define the "theoretical" AAA of each individual patient and could thus be incorporated into surgical planning protocols or intra-operative guidance methods for hip replacement surgery. LEVEL OF EVIDENCE: IV, retrospective study with no control group.

Nature and Architecture of the Puboprostatic Ligament: A Macro- and Microscopic Cadaveric Study Using Epoxy Sheet Plastination.

OBJECTIVE: To investigate the nature and the architecture of the puboprostatic ligament (PPL) and its relationship with surroundings. MATERIALS AND METHODS: Six adult male cadaveric pelvises (age range, 46-87 years) were prepared as serial transverse (2 sets), coronal (1 set), or sagittal (3 sets) plastinated sections, and were examined under a stereoscope and a confocal microscope. The thickness of the section was 2.5 mm, the interval between 2 adjacent sections was about 0.9 mm, and a total of about 70 serial sections per set were collected. RESULTS: First, the musculotendinous sheet of the pubococcygeus contributed to the visceral endopelvic fascia, decussated in front of the detrusor apron, and fixed to the pubis. Second, anteriorly to the prostate, the detrusor apron split up into anterior, middle, and posterior layers, which contributed to the PPL, the fascial sheaths of the dorsal vascular complex, and the anterior fibromuscular stroma of the prostate, respectively. Third, the PPL originated from both the detrusor apron and the decussated and undecussated fibers of the pubococcygeus, and inserted onto the pubis. CONCLUSION: This study revealed the nature and the architecture of the PPL and its relationship with surroundings. These findings provide new insights in the "suspensory system" involving the urinary continence and may incite for future surgical techniques that aim to preserve the decussated pubococcygeus and the intactness of a pubococcygeus-detrusor apron complex during radical retropubic prostatectomy.