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International Journal of Surgery Case... Jul 2022Aggressive Angiomyxoma (AA) is an uncommon, locally infiltrative mesenchymal tumor that primarily originates from perineal and pelvic sites of women, particularly in the...
INTRODUCTION AND IMPORTANCE
Aggressive Angiomyxoma (AA) is an uncommon, locally infiltrative mesenchymal tumor that primarily originates from perineal and pelvic sites of women, particularly in the 4th decade of life with having an emphasized tendency for local recurrence, whereas it has a low tendency to metastasize. Patients often present with nonspecific symptoms such as painless visible mass that might be misdiagnosed with every mass in genital and pelvic sites in reproductive-age women.
CASE PRESENTATION
We describe a 31-year-old female presenting with an enlargement on the right labia majora. Ultrasound and magnetic resonance were carried out, and the mass was surgically excised completely and without complication. The diagnosis of AA was made based on characteristic histopathological features. The postoperative follow-up for recurrence is currently being continued.
CLINICAL DISCUSSION
Due to its rarity and lack of specificity in clinical and radiological examinations, the pre-operative misdiagnosis rate of AA is rather high. Hence, most cases are diagnosed on histology after initial surgical excision. Surgical management is the gold standard treatment for primary tumors; however, in case of local recurrences, treatment choices range from surgical resection to gonadotropin-releasing hormone (GnRH) agonist for tumors positive for estrogen and progesterone receptors.
CONCLUSION
Wide surgical resection is the gold standard treatment of AA; however, exceptions might occur due to the depth of tumor infiltration to adjacent viscera. Therefore, adjunct medical therapies can play a crucial role in treatment. In addition, long-term follow-up is necessary due to the high rate of local recurrences.
PubMed: 35716621
DOI: 10.1016/j.ijscr.2022.107313 -
Ethiopian Journal of Health Sciences Oct 2022Abdominopelvic vascular structures are exposed to be compressed by adjacent organs or might cause compression of the adjacent hollow viscera. Most of these conditions...
BACKGROUND
Abdominopelvic vascular structures are exposed to be compressed by adjacent organs or might cause compression of the adjacent hollow viscera. Most of these conditions are asymptomatic and they are detected on imaging incidentally. However, when they are symptomatic, they can lead to a variety of uncommon syndromes in the abdomen and pelvis. Aim of the study was to assess the prevalence of incidental abdominopelvic vascular compressions on computed tomography.
METHOD
A retrospective cross-sectional study was conducted. All the CT was performed using 64 slice machine. All computed tomography scan of the abdomen between January and April 2019 were evaluated. Data were collected by evaluating abdominal Computed Tomographic scans from Picture archiving and communication system (PACS). Statistical analysis was performed by using SPSS version 25.0 software.
RESULTS
Out of 623 multi detector abdominopelvic computed tomography (MDCT) performed between January 2019 and April 2019; a total of 513 (N = 513) patients were included in the study. This study group comprised of 277 (54 %) females and 236 male (46%) patients. Mean age was 38 ± 20 (mean ± SD). We identified 35(6.8%) participants with imaging features of Superior mesenteric artery (SMA) compressions and a 34(6.6%) with imaging features of nutcracker phenomenon. The celiac artery was compressed by median arcuate ligament (MAL) in 22(4.3%) of them.
CONCLUSION
Incidentally detected intraabdominal vascular compressions are common to asymptomatic patients. This result emphasizes that, vascular compression syndromes diagnosis should not be made on imaging alone.
Topics: Female; Humans; Male; Adolescent; Young Adult; Adult; Middle Aged; Retrospective Studies; Prevalence; Cross-Sectional Studies; Tomography, X-Ray Computed; Vascular Diseases; Abdomen
PubMed: 36339956
DOI: 10.4314/ejhs.v32i1.8S -
Quantifying the effect of an endo-vaginal probe on position of the pelvic floor viscera and muscles.International Urogynecology Journal Oct 2023Endovaginal ultrasound has long been hypothesized to have a significant effect on locations of what it visualizes. However, little work has directly quantified its...
INTRODUCTION AND HYPOTHESIS
Endovaginal ultrasound has long been hypothesized to have a significant effect on locations of what it visualizes. However, little work has directly quantified its effect. This study aimed to quantify it.
METHODS
This cross-sectional study consisted of 20 healthy asymptomatic volunteers who underwent both endovaginal ultrasound and MRI. The urethra, vagina, rectum, pelvic floor, and pubic bone were segmented in both ultrasound and MRI using 3DSlicer. Then, using 3DSlicer's transform tool the volumes were rigidly aligned based on the posterior curvature of the pubic bone. The organs were then split into thirds along their long axis to compare their distal, middle, and proximal sections. Using Houdini, we compared the location of the centroid of each of the urethra, vagina, and rectum and the surface-to-surface difference of the urethra and rectum. The anterior curvature of the pelvic floor was also compared. Normality of all variables was assessed by Shapiro-Wilk test.
RESULTS
The largest amount of surface-to-surface distance was observed in the proximal region for the urethra and rectum. Across all three organs, the majority of the deviation was in the anterior direction for geometries obtained from ultrasound versus those from MRI. For each subject, the trace defining the midline of the levator plate was more anterior for ultrasound compared to MRI.
CONCLUSIONS
While it has often been assumed that placing a probe in the vagina probably distorts the anatomy, this study quantified the distortion and displacement of the pelvic viscera. This allows for better interpretation of clinical and research findings based on this modality.
PubMed: 37145123
DOI: 10.1007/s00192-023-05557-7 -
Journal of Minimally Invasive Gynecology Jan 2020To illustrate the key steps involved in performing a supralevator pelvic exenteration robotically.
STUDY OBJECTIVE
To illustrate the key steps involved in performing a supralevator pelvic exenteration robotically.
DESIGN
Presentation of the steps involved in excising the pelvic viscera during robotic-assisted supralevator pelvic exenteration.
SETTING
Tertiary care academic center.
PATIENTS
A patient undergoing pelvic exenteration for uterine leiomyosarcoma.
INTERVENTIONS
Robotic total supralevator pelvic exenteration.
MEASUREMENTS AND MAIN RESULTS
In this woman undergoing pelvic exenteration for uterine leiomyosarcoma, the paravesical and pararectal spaces are shown, along with important pelvic landmarks, such as the major vessels and the ureters. Once the pararectal and paravesical spaces are identified, the parametrium in between is resected. The posterior dissection is then performed along the filmy presacral space to the level of the coccyx and levator muscles. Anteriorly, the bladder is dissected along the space of Retzius, and the urethra is transected. Once the pelvic organs are separated, the specimen is removed, and reconstruction of the pelvic floor is performed. The ileal conduit is created from a segment of small bowel approximately 20 cm from the terminal ileum measuring 15 cm long. The 2 ureters are spatulated and attached to the ileal conduit, and a stoma is created. The descending segment of colon is brought up through a separate stoma site on the other side of the abdomen to create the colostomy. The total operating time, including reconstruction with the ileal conduit, was 480 minutes, and the estimated blood loss was 250 mL.
CONCLUSION
Total pelvic exenteration can be safely performed robotically with appropriate understanding of the key steps and anatomic landmarks.
Topics: Dissection; Female; Gynecologic Surgical Procedures; Humans; Laparoscopy; Leiomyosarcoma; Pelvic Exenteration; Plastic Surgery Procedures; Robotic Surgical Procedures; Uterine Neoplasms; Viscera
PubMed: 31146031
DOI: 10.1016/j.jmig.2019.05.012 -
Anatomy of the vesicovaginal fascia and its relation to branches of the inferior hypogastric plexus.Clinical Anatomy (New York, N.Y.) Oct 2022The inferior hypogastric plexus (IHP) lies in the extraperitoneal pelvis, and supplies branches to pelvic and perineal viscera. In men, the rectoprostatic fascia...
The inferior hypogastric plexus (IHP) lies in the extraperitoneal pelvis, and supplies branches to pelvic and perineal viscera. In men, the rectoprostatic fascia (Denonvillier's fascia) forms a distinct double fascial layer between the seminal glands and the rectum. The hypogastric nerve projections to the prostate and seminal glands run anterior to this. An analagous fascial layer in women between the vagina and cervix posteriorly and the urinary bladder anteriorly has recently been described. The purpose of this study was to examine the anatomy of the vesicovaginal fascia (VVF) and to determine its relationship to the anterior branches of the IHP. This dissection study examined the fascial layers between the posterior urinary bladder and anterior vagina/cervix (VVF) in 15 female embalmed cadavers and three fresh specimens. Anterior branches of the IHP were identified and followed distally. The relationship between these nerve projections and the VVF was examined. In 16 dissection, the VVF was identified as a complete fascial plane extending beneath the vesicouterine pouch to the neck of the bladder inferiorly and to the endopelvic fascia laterally. Anterior projections from the hypogastric nerves and IHP maintained an extraperitoneal course passing anteriorly to the VVF towards the urinary bladder The VVF is a distinct fascial structure and projections of the hypogastric nerves pass anterior to this. This may have implications for nerve sparing hysterectomy.
Topics: Fascia; Female; Humans; Hypogastric Plexus; Male; Pelvis; Rectum; Urinary Bladder
PubMed: 35333406
DOI: 10.1002/ca.23858 -
Journal of Neuropathology and... Dec 2023Neural plasticity occurs within the central and peripheral nervous systems after spinal cord injury (SCI). Although central alterations have extensively been studied, it...
Neural plasticity occurs within the central and peripheral nervous systems after spinal cord injury (SCI). Although central alterations have extensively been studied, it is largely unknown whether afferent and efferent fibers in pelvic viscera undergo similar morphological changes. Using a rat spinal cord transection model, we conducted immunohistochemistry to investigate afferent and efferent innervations to the kidney, colon, and bladder. Approximately 3-4 weeks after injury, immunostaining demonstrated that tyrosine hydroxylase (TH)-labeled postganglionic sympathetic fibers and calcitonin gene-related peptide (CGRP)-immunoreactive sensory terminals sprout in the renal pelvis and colon. Morphologically, sprouted afferent or efferent projections showed a disorganized structure. In the bladder, however, denser CGRP-positive primary sensory fibers emerged in rats with SCI, whereas TH-positive sympathetic efferent fibers did not change. Numerous CGRP-positive afferents were observed in the muscle layer and the lamina propria of the bladder following SCI. TH-positive efferent inputs displayed hypertrophy with large diameters, but their innervation patterns were sustained. Collectively, afferent or efferent inputs sprout widely in the pelvic organs after SCI, which may be one of the morphological bases underlying functional adaptation or maladaptation.
Topics: Rats; Animals; Calcitonin Gene-Related Peptide; Viscera; Spinal Cord Injuries; Immunohistochemistry; Spinal Cord; Afferent Pathways
PubMed: 38102789
DOI: 10.1093/jnen/nlad108 -
Pain Apr 2022Clinical evidence indicates dorsal root ganglion (DRG) stimulation effectively reduces pain without the need to evoke paresthesia. This paresthesia-free anesthesia by...
Clinical evidence indicates dorsal root ganglion (DRG) stimulation effectively reduces pain without the need to evoke paresthesia. This paresthesia-free anesthesia by DRG stimulation can be promising to treat pain from the viscera, where paresthesia usually cannot be produced. Here, we explored the mechanisms and parameters for DRG stimulation using an ex vivo preparation with mouse distal colon and rectum (colorectum), pelvic nerve, L6 DRG, and dorsal root in continuity. We conducted single-fiber recordings from split dorsal root filaments and assessed the effect of DRG stimulation on afferent neural transmission. We determined the optimal stimulus pulse width by measuring the chronaxies of DRG stimulation to be below 216 µs, indicating spike initiation likely at attached axons rather than somata. Subkilohertz DRG stimulation significantly attenuates colorectal afferent transmission (10, 50, 100, 500, and 1000 Hz), of which 50 and 100 Hz show superior blocking effects. Synchronized spinal nerve and DRG stimulation reveals a progressive increase in conduction delay by DRG stimulation, suggesting activity-dependent slowing in blocked fibers. Afferents blocked by DRG stimulation show a greater increase in conduction delay than the unblocked counterparts. Midrange frequencies (50-500 Hz) are more efficient at blocking transmission than lower or higher frequencies. In addition, DRG stimulation at 50 and 100 Hz significantly attenuates in vivo visceromotor responses to noxious colorectal balloon distension. This reversible conduction block in C-type and Aδ-type afferents by subkilohertz DRG stimulation likely underlies the paresthesia-free anesthesia by DRG stimulation, thereby offering a promising new approach for managing chronic visceral pain.
Topics: Animals; Chronic Pain; Colorectal Neoplasms; Ganglia, Spinal; Mice; Paresthesia
PubMed: 34232925
DOI: 10.1097/j.pain.0000000000002395 -
The Journal of Surgical Research Nov 2023Optimal antimicrobial prophylaxis duration following gunshot wounds (GSW) to the abdomen with an associated orthopedic fracture is unknown. This study evaluated the...
INTRODUCTION
Optimal antimicrobial prophylaxis duration following gunshot wounds (GSW) to the abdomen with an associated orthopedic fracture is unknown. This study evaluated the safety and efficacy of short versus long courses of prophylactic antibiotics following penetrating hollow viscus injury with communicating orthopedic fracture.
METHODS
This retrospective study included adult patients admitted to the trauma service over a 20-y period who sustained an abdominal GSW with hollow viscus injury and communicating spine or pelvic fractures. Patients were stratified into cohorts based on prophylactic antibiotic duration: short course (SC, ≤48 h) and long course (>48 h). The primary outcome was the incidence of osteomyelitis and meningitis up to 1-y postinjury. Secondary outcomes included hospital length of stay and the incidence of multidrug-resistant organisms and Clostridioides difficile infections. Risk factors for osteomyelitis and meningitis were determined.
RESULTS
A total of 125 patients were included with 45 (36%) in the SC group. Median prophylactic antibiotic durations were SC, 1 (interquartile range [IQR], 1-2) versus long course, 7 (IQR, 5-7) d (P < 0.001). There was no difference in osteomyelitis and meningitis incidence (2 [4.4%] versus 4 [5%], P = 0.77). Median hospital length of stay (7 [IQR, 6-11] versus 9 [IQR, 6-15] d, P = 0.072) and incidence of multidrug-resistant organisms (6 [13.3%] versus 13 [16.3%], P = 0.86) and Clostridioides difficile infections (0 [0%] versus 1 [1.3%], P = 0.77) were similar between groups. There were no independent risk factors identified for osteomyelitis or meningitis.
CONCLUSIONS
A shorter course of antibiotic prophylaxis ≤48 h may be adequate following abdominal GSW that traverses a hollow viscus and results in pelvic fracture or spinal column injury.
Topics: Adult; Humans; Anti-Bacterial Agents; Wounds, Gunshot; Retrospective Studies; Wounds, Penetrating; Pelvis; Abdomen; Abdominal Injuries; Fractures, Bone; Antibiotic Prophylaxis; Spinal Injuries; Meningitis; Osteomyelitis
PubMed: 37354706
DOI: 10.1016/j.jss.2023.05.025 -
International Urogynecology Journal Dec 2023Retropubic procedures may disrupt nerves supplying the pelvic viscera; however, knowledge of pelvic neuroanatomy is limited. We sought to characterize somatic and...
INTRODUCTION AND HYPOTHESIS
Retropubic procedures may disrupt nerves supplying the pelvic viscera; however, knowledge of pelvic neuroanatomy is limited. We sought to characterize somatic and autonomic nerve density within the urethra, periurethral tissue, and anterior vagina.
METHODS
Axial sections were obtained from pelvic tissue harvested from female cadavers ≤24 h from death at three anatomical levels: the midurethra, proximal urethra, and upper trigone. Periurethral/perivesical tissue was divided into medial and lateral sections, and the anterior vagina into middle, medial, and lateral sections. Double immunofluorescent staining for beta III tubulin (βIIIT), a global axonal marker, and myelin basic protein (MBP), a myelinated nerve marker, was performed. Threshold-based automatic image segmentation distinguished stained areas. Autonomic and somatic density were calculated as percentage of tissue stained with βIIIT alone, and with βIIIT and MBP respectively. Statistical comparisons were made using nonparametric Friedman tests.
RESULTS
Six cadavers, aged 22-73, were examined. Overall, autonomic nerve density was highest at the midurethral level in the lateral and middle anterior vagina. Somatic density was highest in the external urethral sphincter (midurethra mean 0.15%, SD ±0.11; proximal urethra 0.19%, SD ±0.19). Comparison of annotated sections revealed significant differences in autonomic density among the lateral, medial, and middle vagina at the midurethra level (0.71%, SD ±0.48 vs 0.60%, SD ±0.48 vs 0.70%, SD ±0.63, p=0.03). Autonomic density was greater than somatic density in all sections.
CONCLUSIONS
Autonomic and somatic nerves are diffusely distributed throughout the periurethral tissue and anterior vagina, with few significant differences in nerve density among sections analyzed. Minimizing tissue disruption near urethral skeletal muscle critical for urinary continence may prevent adverse postoperative urinary symptoms.
Topics: Adult; Female; Humans; Urethra; Vagina; Pelvis; Cadaver; Autonomic Pathways
PubMed: 37796330
DOI: 10.1007/s00192-023-05645-8