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The objectives of this study were to review the published literature and selected textbooks, to compare existing usage to that in Terminologia Anatomica, and to compile standardized anatomic nomenclature for the apical structures of the female pelvis. MEDLINE was searched from inception until May 30, 2017, based on 33 search terms generated by group consensus. Resulting abstracts were screened by 11 reviewers to identify pertinent studies reporting on apical female pelvic anatomy. Following additional focused screening for rarer terms and selective representative random sampling of the literature for common terms, accepted full-text manuscripts and relevant textbook chapters were extracted for anatomic terms related to apical structures. From an initial total of 55,448 abstracts, 193 eligible studies were identified for extraction, to which 14 chapters from 9 textbooks were added. In all, 293 separate structural terms were identified, of which 184 had Terminologia Anatomica-accepted terms. Inclusion of several widely used regional terms (vaginal apex, adnexa, cervico-vaginal junction, uretero-vesical junction, and apical segment), structural terms (vesicouterine ligament, paracolpium, mesoteres, mesoureter, ovarian venous plexus, and artery to the round ligament) and spaces (vesicocervical, vesicovaginal, presacral, and pararectal) not included in Terminologia Anatomica is proposed. Furthermore, 2 controversial terms (lower uterine segment and supravaginal septum) were identified that require additional research to support or refute continued use in medical communication. This study confirms and identifies inconsistencies and gaps in the nomenclature of apical structures of the female pelvis. Standardized terminology should be used when describing apical female pelvic structures to facilitate communication and to promote consistency among multiple academic, clinical, and surgical disciplines.

Objective The aim of this study was to report subjective, long-term outcomes and describe patient demographics, presenting symptoms, perioperative management, and complications after overlapping sphincteroplasty repair for chronic fourth-degree lacerations (cloacal-like deformities). Methods In this retrospective study, hospital records were reviewed for women who underwent overlapping anal sphincteroplasty for a cloacal-like deformity of the perineum at a single institution from 1996 to 2013. Details including patient demographics, presenting symptoms, perioperative management, and complications were abstracted from the medical record. As a follow-up, subjects were contacted by telephone and were administered the validated Modified Manchester Health Questionnaire to assess anal continence status and anal incontinence-related quality of life since the time of surgery. Results Of 57 women who underwent an anal sphincteroplasty within the study period, 29 met inclusion criteria. Median parity was 3 (range, 1-7) and 24.5% reported a history of forceps or vacuum-assisted vaginal delivery. Presenting symptoms included fecal incontinence (58.6%), flatal incontinence (41%), sexual dysfunction (20.7%), and poor body self-image (3.4%). Thirteen (45%) women could be contacted by telephone and all agreed to participate. Overall, 46.2% of the 13 women who completed the Modified Manchester Health Questionnaire reported some form anal of incontinence, whereas 53.8% reported complete continence at a mean follow-up of 7.0 ± 3.6 years. Perioperative morbidity was uncommon, and postoperative antibiotics were used in 75.9% of cases for a median duration of 8.8 ± 3.3 days. Conclusions Perioperative morbidity after overlapping sphincteroplasty for cloacal-like deformities after obstetrical injury is rare. Although long-term complete anal continence may be difficult to achieve in all cases, good quality of life measures and low symptom severity were noted at a mean interval of 7 years after surgery.

OBJECTIVE:To quantify the distance of the dissection plane from the cervicovaginal junction to the anterior peritoneal reflection for vaginal hysterectomy.METHODS:This is a descriptive study examining the dissection plane for anterior colpotomy in 22 surgical patients undergoing vaginal hysterectomy

Background Knowledge of the retropubic space anatomy is essential for safe entry and surgical applications within this space. Objective The objectives of this study were to examine the gross and histologic anatomy of the retropubic urethra, paraurethral tissue, and urethrovaginal space and to correlate findings to retropubic procedures. Study Design Anatomic relationships of the retropubic urethra were examined grossly in unembalmed female cadavers. Measured distances included: lateral urethral wall to arcus tendineus fascia pelvis at the level of urethrovesical junction and at 1 cm distal. Other measurements included retropubic urethral length and distances from internal urethral opening to each ureteric orifice. Microscopic examination was performed at the same levels examined grossly in separate nulliparous specimens. Descriptive statistics were used for data analyses. Results In all, 25 cadavers were examined grossly. Median distance from lateral urethral wall to arcus tendineus fascia pelvis at the level of urethrovesical junction was 25 mm (range, 13–38 mm). At 1 cm distal, the median distance from aforementioned structures was 14 mm (10–26 mm). Median length of the retropubic urethra was 23 mm (range 15–30 mm). Four nulliparous specimens, ages 12 weeks, and 34, 47, and 52 years, were examined histologically. No histologic evidence of a discrete fascial layer between bladder/urethra and anterior vagina was noted at any level examined. Tissue between the urethra and the pelvic sidewall skeletal muscle was composed of dense fibrous tissue, smooth muscle bundles, scant adipose tissue, blood vessels, and nerves. The smooth muscle fibers of the vaginal muscularis interdigitated with skeletal muscle fibers in the pelvic sidewall at both levels examined. No histologic evidence of “pubourethral ligaments” within the paraurethral tissue was noticed. Conclusion A 2-cm “zone of safety” exists between the urethra and arcus tendineus fascia pelvis at the urethrovesical junction level. Suture or graft placement within this region should minimize injury to the urethra, pelvic sidewall muscles, and bladder. Knowledge that the shortest length of retropubic urethra was 1.5 cm and shortest urethra to arcus tendineus fascia pelvis distance was 1 cm highlights the importance of maintaining dissection and trocar entry site close to pubic bone to avoid bladder and/or urethral injury. Histologic analysis of paraurethral tissue supports the nonexistence of pubourethral ligaments.

Background The use of imprecise and inaccurate terms leads to confusion amongst anatomists and medical professionals. Objective We sought to create recommended standardized terminology to describe anatomic structures of the anterior female pelvis based on a structured review of published literature and selected text books. Study Design We searched MEDLINE from its inception until May 2, 2016, using 11 medical subject heading terms to identify studies reporting on anterior female pelvic anatomy; any study type published in English was accepted. Nine textbooks were also included. We screened 12,264 abstracts, identifying 200 eligible studies along with 13 textbook chapters from which we extracted all pertinent anatomic terms. Results In all, 67 unique structures in the anterior female pelvis were identified. A total of 59 of these have been previously recognized with accepted terms in Terminologia Anatomica, the international standard on anatomical terminology. We also identified and propose the adoption of 4 anatomic regional terms (lateral vaginal wall, pelvic sidewall, pelvic bones, and anterior compartment), and 2 structural terms not included in Terminologia Anatomica (vaginal sulcus and levator hiatus). In addition, we identified 2 controversial terms (pubourethral ligament and Grafenberg spot) that require additional research and consensus from the greater medical and scientific community prior to adoption or rejection of these terms. Conclusion We propose standardized terminology that should be used when discussing anatomic structures in the anterior female pelvis to help improve communication among researchers, clinicians, and surgeons.

This chapter discusses the potential pathophysiology of anal and/or fecal incontinence during pregnancy and the postpartum period and prevalence of such incontinence, appropriate assessment, and various treatment options. This chapter explains risk factors associated with fecal incontinence in first and subsequent pregnancies and the postpartum, including risks associated with obstetrical anal sphincter injuries, pudendal nerve injury, and chronic fourth-degree lacerations. Quality of life and impact on psychosocial factors, including sexual function, are also discussed. Case studies are provided to emphasize the role of the advanced practice nurse in assessment and treatment of fecal incontinence within this special population.

A comprehensive knowledge of the boundaries, contents, and interactions between surgical spaces is essential to safely and effectively perform mesh-augmented prolapse repairs and anti-incontinence procedures. This knowledge is also critical when managing intraoperative and postoperative complications such as bleeding, visceral injury, mesh erosion, exposure, or extrusion, and pelvic pain, groin pain, and dyspareunia. We present a detailed description of the surgical spaces entered during mesh augmented vaginal repair procedures and suggest strategies to avoid nerve and visceral injuries.

The objectives of this study were to estimate the rates of sonographically detected anal sphincter defects within 72 h of childbirth and to evaluate intra- and interobserver agreement using three-dimensional (3-D) endoanal sonography data. This is a prospective observational study of primiparous women delivered vaginally. Women without clinically identified anal sphincter lacerations underwent endoanal ultrasonography within 72 h of delivery. Intra- and interobserver agreement for diagnosis of sphincter defects using 3-D endoanal sonography data was calculated using kappa statistics. The rate of sphincter defects in 107 women undergoing 3-D endoanal sonography was 12 %. Characteristics of women with sonographically detected sphincter defects, compared to those without, included a significantly increased rate of clinically diagnosed second-degree lacerations (54 vs 20 %, p 0.008). The intra- and interobserver agreement for diagnosis of sphincter defects using 3-D endoanal sonography data was 0.82 [confidence interval (CI) 0.66–0.99] and 0.72 (CI 0.54–0.92), respectively. Anal sphincter defects detected using endoanal sonography are common, occurring in 12 % of primiparous women, and are significantly associated with other less severe perineal lacerations. Overall and combining sonographically detected defects with clinically diagnosed lacerations, we estimate that 17.8 % of primiparous women delivered vaginally sustain anal sphincter injuries. The intraobserver agreement for diagnosis of sphincter defects is very good and the interobserver agreement is good.

Reports of sensory neuropathy attributed to uterosacral ligament suspension (USLS) have emerged. The objectives of this study were to assess the rate of sensory neuropathy symptoms following transvaginal USLS at a single institution during a 5-year period and to describe the evaluation, management, and outcomes in these patients. A retrospective review of records identified 278 women who underwent transvaginal USLS during the study period. Inpatient and outpatient records within the first 4 weeks postsurgery were reviewed. Women with new-onset buttock and/or lower-extremity pain, numbness, weakness or a combination of these symptoms were identified. Demographic data, intraoperative data, and management modalities and outcomes were collected. Nineteen (6.8 %) women met criteria for inclusion. The most common symptom was buttock pain (73.7 % of cases). Pain radiation to the ipsilateral posterior thigh was present in 11 cases (57.9 %). The majority of women (73.7 %) reported pain symptoms on the right side. Conservative treatment modalities were initially implemented in all women. Four women (21 %) underwent suture removal a median of 1.75 months after USLS. Full symptom resolution was reported in 13 (68.4 %) women a median of 6 months after USLS. The remaining women experienced partial symptom resolution with ongoing conservative management. Sensory neuropathy is common in women who undergo transvaginal USLS. As quality of life may be significantly affected, any symptoms of buttock or lower-extremity pain in the immediate postoperative period warrant a thorough evaluation and close follow-up, with early suture removal consideration.

To assess the effectiveness of an instructional DVD on the anatomy and repair of anal sphincter lacerations to improve postgraduate trainees' understanding.A total of 71 obstetrics and gynecology trainees completed a pretest of third- and fourth-degree lacerations to assess baseline knowledge and perceptions. Question categories included anatomy, antibiotics, anesthesia, repair methods, complications, postoperative care, and risk factors. After 1 year of clinical experience, 67 trainees (94%) were randomly assigned into DVD (intervention) and non-DVD (control) groups. A post-test was administered 4 weeks later.In the DVD group (n=34), mean scores on the pretest versus the post-test were 65% vs 74% for postgraduate year (PGY)-1 (P=0.09); 72% vs 83% for PGY-2 (P=0.06); 67% vs 83% for PGY-3 (P=0.01); and 75% vs 87% for PGY-4 (P0.001). In the non-DVD group (n=33), mean scores did not change significantly for any year level. The increase in score from pretest to post-test was significantly different between the 2 groups, independent of year (P0.001). DVD group scores improved significantly over non-DVD group scores in anatomy (P=0.005) and repair methods (P=0.042) subscales.An educational video is an effective tool for improving understanding of third- and fourth-degree lacerations for physicians-in-training.

Background The primary aims of this trial are to determine whether the use of a concomitant prophylactic anti-incontinence procedure may prevent stress urinary incontinence symptom development in women undergoing vaginal prolapse surgery and to evaluate the cost-effectiveness of this prophylactic approach. Purpose To present the rationale and design of a randomized controlled surgical trial (RCT), the Outcomes following vaginal Prolapse repair and mid Urethral Sling (OPUS) Trial highlighting the challenges in the design and implementation. Methods The challenges of implementing this surgical trial combined with a cost-effectiveness study and patient preference group are discussed including the study design, ethical issues regarding use of sham incision, maintaining the masking of study staff, and pragmatic difficulties encountered in the collection of cost data. The trial is conducted by the NICHD-funded Pelvic Floor Disorders Network. Results The ongoing OPUS trial started enrollment in May 2007 with a planned accrual of 350. The use of sham incision was generally well accepted but the collection of cost data using conventional billing forms was found to potentially unmask key study personnel. This necessitated changes in the study forms and planned timing for collection of cost data. To date, the enrollment to the patient preference group has been lower than the limit established by the protocol suggesting a willingness on the part of women to participate in the randomization. Limitations Given the invasive nature of surgical intervention trials, potential participants may be reluctant to accept random assignment, potentially impacting generalizability. Conclusion Findings from the OPUS trial will provide important information that will help surgeons to better counsel women on the benefits and risks of concomitant prophylactic anti-incontinence procedure at the time of vaginal surgery for prolapse. The implementation of the OPUS trial has necessitated that investigators consider ethical issues up front, remain flexible with regards to data collection and be constantly aware of unanticipated opportunities for unmasking. Future surgical trials should be aware of potential challenges in maintaining masking and collection of cost-related information. Clinical Trials 2009; 6: 162—171. http://ctj.sagepub.com

Objective The objective of the study was to revisit the anatomical path of the tension-free vaginal tape and better describe its relationship to the perineal membrane and other important anatomic landmarks. Study design Dissections of the anterior perineal triangle, periurethral, and retropubic spaces were performed in 24 unembalmed female cadavers following placement of the tension-free vaginal tape to identify the sling's relationship to the perineal membrane, periurethral muscles, and the arcus tendineus fascia pelvis. Results In 100% of specimens, the device passed cephalad to the perineal membrane. The urethrovaginal sphincter muscle was perforated in 2 of the specimens. The sling passed lateral to the arcus tendineus and perforated the pubococcygeus muscle in 6 (25%) of the cadavers. In the remaining 18 (75%) specimens, the mesh was medial to the arcus tendineus and penetrated the periurethral connective tissue. Conclusion The assertion that the tension-free vaginal tape perforates the perineal membrane is incorrect.

This study was undertaken to assess the impact of interactive, computer-based versus conventional, paper-based format in student, resident, and fellow learning and retention of anatomy knowledge.Randomized longitudinal cohort design with scores repeated as pre-, post-, and follow-up tests. Subjects were randomly assigned to an anatomy module in computer-based (CD-ROM) format and 1 in paper-based format. A follow-up examination was administered 3 weeks after the posttest to evaluate retention of knowledge. Tests results were analyzed by using Student t tests and analysis of variance.Thirty-nine subjects completed all testing. Regardless of instructional method, pretest to posttest scores improved (P.01), and posttest to follow-up test scores decreased among all levels of training (P.01). Student satisfaction was highest with CD-ROM format.Improvement and retention of anatomy knowledge was not significantly different when comparing a new CD-ROM interactive approach with a traditional paper-based method.

Objective The objective of the study was to characterize the vascular anatomy over the superior pubic ramus. Study design Detailed dissections of the retropubic space were performed in 15 fresh female cadavers. Vessels crossing the superior pubic rami were inspected for width, course, communications, and relationship to the midline of the pubic symphysis and the obturator canal. Results Vessels 1 mm or greater in width connecting the obturator vessels and inferior epigastric or external iliac vessels were noted in 10 of 15 (66.7%) cadavers: 9 (60%) had veins, 5 (33.3 %) had arteries, and 4 (26.7%) had both. In all specimens, the vessels crossed over the superior pubic rami lateral to or at the level of the obturator canal, which was on average 5.4 cm from the midline of the pubic symphysis. Conclusion Communicating vessels crossing the superior pubic rami were present in the majority of specimens. Understanding this anatomy should aid the surgeon in avoiding vascular complications.

This study was undertaken to evaluate the impact of a pelvic dissection course on resident proficiency in surgical anatomy.Over a 1-year period, residents attended a course consisting of pretesting and posttesting, lectures, and pelvic dissection. Tests results were analyzed using paired Student t test, analysis of variance, and Kruskal-Wallis statistics.Of 42 residents, 24 completed all testing (study cohort). On written and practical examinations, resident scores improved a median of 42% and 29% (both P.0001). Postgraduate year (PGY) 2 demonstrated the greatest improvement on the practical and PGY-3s demonstrated the greatest improvement on the written. Baseline written and practical results discriminated PGY level (construct validity): PGY-2=PGY-3PGY-4 on written pretest, PGY-2PGY-3=PGY-4 on practical pretest. No difference between resident cohorts was seen in either posttest.Resident surgical anatomy proficiency is measurably improved by a comprehensive course.

OBJECTIVES The study aims were to characterize women with fecal incontinence (FI) and measure changes in FI severity and quality of life 3 and 12 months after treatment. METHODS This study is a secondary analysis of a multicenter study measuring adaptive behaviors among women with FI. Women included had a primary complaint of at least monthly FI over 3 consecutive months and planned FI treatment. Demographic and medical history data were obtained at baseline. Data were collected at baseline, 3 months, and 12 months after clinically selected, nonstandardized treatment. Validated questionnaires were as follows: Fecal Incontinence Severity Index, Modified Manchester Health Questionnaire, Pelvic Floor Disorders Inventory's Colorectal and Anal Distress Inventory, Pelvic Floor Impact Questionnaire's Colorectal and Anal Impact Questionnaire, and Medical Outcomes Study Short Form. Questionnaire score changes from baseline were compared using paired t tests at 3 and 12 months after treatment. RESULTS Of the 133 women enrolled, 90 women had treatment data at 3 months and 77 at 12 months. Nonsurgical therapies were the most common (78%) with anal sphincter repair in 22%. Fecal Incontinence Severity Index scores and Modified Manchester Health Questionnaire scores significantly improved 3 months after nonsurgical and surgical treatments (-8.8 ± 12.0 and -12.6 ± 19.2, respectively, P < 0.001), as did Colorectal-Anal Distress Inventory and Colorectal-Anal Impact Questionnaire scores (-52.7 ± 70.0 and -60.6 ± 70.0, respectively, P < 0.001) and Medical Outcomes Study Short Form mental health scores (4.2 ± 9.4, P = 0.001). Improvement persisted 12 months posttreatment. CONCLUSIONS In women seeking care for FI, symptom severity and condition-specific quality of life significantly improve within the first 3 months after FI treatment and are maintained up to 12 months.

Background Pneumomediastinum is a rare but potential complication of laparoscopy that is related to insufflation with carbon dioxide gas and may lead to life-threatening complications. Case A 76-year-old woman underwent robotic sacrocolpopexy to repair posthysterectomy prolapse without any apparent intraoperative complications. Postoperatively, she developed shortness of breath and tachycardia and was found to have subcutaneous emphysema and pneumomediastinum. Conclusion Pelvic surgeons should understand the risks associated with development of pneumomediastinum as well as associated signs and symptoms. In our case, pneumomediastinum likely developed as carbon dioxide tracked from the peritoneum into the mediastinum during prolonged robotic retroperitoneal surgery. Surgeons should have a low threshold to obtain radiographic tests in the early postoperative period, as close monitoring is essential to manage potentially life-threatening complications such as pneumothorax and cardiac arrest.

Background Reported rates of gluteal pain after sacrospinous ligament fixation range from 12–55% in the immediate postoperative period and from 4–15% 4–6 weeks postoperatively. The source of gluteal pain often is attributed to injury to the nerve to levator ani or pudendal nerve. The inferior gluteal nerve and other sacral nerve branches have not been examined thoroughly as potential sources of gluteal pain. Objectives The purpose of this study was to further characterize anatomy of the inferior gluteal nerve and other nerves that are associated with the sacrospinous ligament from a combined gluteal and pelvic approach and to correlate findings to sacrospinous ligament fixation. Study Design Dissections were performed in female cadavers that had not been embalmed with gluteal and pelvic approaches. From a pelvic perspective, the closest structure to the superior border of the sacrospinous ligament midpoint was noted, and the sacral nerves that perforated the ventral surface of coccygeus muscle were examined. From a gluteal perspective, the closest distances from ischial spine to the pudendal, inferior gluteal, posterior femoral cutaneous, and sciatic nerves were measured. In addition, the closest distance from the midpoint of sacrospinous ligament to the inferior gluteal nerve and the origin of this nerve were documented. The thickness and height of the sacrospinous ligament at its midpoint were measured. Sacral nerve branches that coursed between the sacrospinous and sacrotuberous ligaments were assessed from both a pelvic and a gluteal approach. Descriptive statistics were used for data analysis. Results Fourteen cadavers were examined. From a pelvic perspective, the closest structure to the superior border of sacrospinous ligament at its midpoint was the S3 nerve (median distance, 3 mm; range, 0–11 mm). Branches from S3 and/or S4 perforated the ventral surface of coccygeus muscles in 94% specimens. From a gluteal perspective, the closest structure to ischial spine was the pudendal nerve (median distance, 0 mm; range, 0–9 mm). Median closest distance from inferior gluteal nerve to ischial spine and to the midpoint of sacrospinous ligament was 28.5 mm (range, 6–53 mm) and 31.5 mm (range, 10–47 mm), respectively. The inferior gluteal nerve arose from dorsal surface of combined lumbosacral trunk and S1 nerves in all specimens; a contribution from S2 was noted in 46% of hemipelvises. At its midpoint, the sacrospinous ligament median thickness was 5 mm (range, 2–7 mm), and its median height was 14 mm (range, 3–22 mm). In 85% of specimens, 1 to 3 branches from S3 and/or S4 nerves pierced or coursed ventral to the sacrotuberous ligament and perforated the inferior portion of the gluteus maximus muscle. Conclusions Damage to the inferior gluteal nerve during sacrospinous ligament fixation is an unlikely source for postoperative gluteal pain. Rather, branches from S3 and/or S4 that innervate the coccygeus muscles and those coursing between the sacrospinous and sacrotuberous ligaments to supply gluteus maximus muscles are more likely to be implicated. A thorough understanding of the complex anatomy surrounding the sacrospinous ligament, limiting depth of needle penetration into the ligament, and avoiding extension of needle exit or entry point above the upper extent of sacrospinous ligament may reduce nerve entrapment and postoperative gluteal pain.

OBJECTIVE Although gynecologists perform a large number of surgeries in close proximity to the ureters and the urinary bladder, traditionally, Obstetrics and Gynecology resident physicians are not formally taught to perform cystoscopy. The primary objective was to document resident physicians' performance in diagnostic cystoscopic instrumentation and technique. The secondary objective was to examine if reported prior cystoscopic experience was associated with superior performance. METHODS Fifty-one postgraduate year 4 residents with reported experience with cystoscopy were evaluated using an operation-specific checklist and a global ratings scale based on the Objective Structured Assessment of Technical Skill model. Before evaluation, they attended a formal training session in cystoscopy, which included practice on a bench model of a simulated bladder. RESULTS Forty-three of the 51 residents were able to successfully perform a thorough diagnostic examination immediately after the course. Six of the 8 failures were re-evaluated 2 weeks later and successfully performed a complete examination at that time. Before the course, the residents had performed a mean of 12.2 cystoscopic examinations as the primary surgeon (median, 12; range, 2-33). The number of reported cystoscopic examinations performed before the course did not correlate with the ability to perform a thorough cystoscopic examination (r = -0.109; P = 0.496). CONCLUSIONS For this group of residents, there was poor correlation between the number of reported cystoscopic examinations and the ability to perform diagnostic cystoscopy. Trainees may not be able to determine when they have received enough instruction in hands-on training with models before acquisition of technical skills.

Normal physiologic function of the pelvic organs depends on the anatomic integrity and proper interaction among the pelvic structures, the pelvic floor support components, and the nervous system. Pelvic floor dysfunction includes urinary and anal incontinence; pelvic organ prolapse; and sexual, voiding, and defecatory dysfunction. Understanding the anatomy and proper interaction among the support components is essential to diagnose and treat pelvic floor dysfunction. The primary aim of this article is to provide an updated review of pelvic support anatomy with clinical correlations. In addition, surgical spaces of interest to the gynecologic surgeon and the course of the pelvic ureter are described. Several concepts reviewed in this article are derived and modified from a previous review of pelvic support anatomy.

Objective The objective of the study was to characterize the anatomy of the internal iliac artery (IIA) and its posterior division branches and to correlate these findings to IIA ligation. Study Design Dissections were performed in 54 female cadavers. Results Average length of IIA was 27.0 (range, 0-52) mm. Posterior division arteries arose from a common trunk in 62.3% (66 of 106) of pelvic halves. In the remaining specimens, branches arose independently from the IIA, with the iliolumbar noted as the first branch in 28.3%, lateral sacral in 5.7%, and superior gluteal in 3.8%. The average width of the first branch was 5.0 (range, 2-12) mm. In all dissections, posterior division branches arose from the dorsal and lateral aspect of IIA. The internal iliac vein was lateral to the artery in 70.6% (12 of 17) of specimens on the left and 93.3% (14 of 15) on the right. Conclusion Ligation of the IIA 5 cm distal from the common iliac bifurcation would spare posterior division branches in the vast majority of cases. Understanding IIA anatomy is essential to minimize intra-operative blood loss and other complications.

Objective The objective of the study was to characterize anatomic relationships of uterosacral ligament suspension (USLS) sutures. Study Design The relationship of USLS sutures to the ureters, rectal lumen, and sidewall neurovascular structures was examined in 15 unembalmed female cadavers. Results The mean distance of the proximal sutures to the ureters and rectal lumen was 14 mm (range, 0-33) and 10 mm (range, 0-33), respectively. The mean distance of the distal sutures to the ureters was 14 mm (range, 4-33) and to the rectal lumen 13 mm (range, 3-23). Right sutures were noted at the level of S1 in 37.5%, S2 in 37.5%, and S3 in 25% of specimens. Left sutures were noted at the level of S1 in 50%, S2 in 29.2%, and S3 in 20.8% of cadavers. Of 48 sutures passed, 1 entrapped the S3 nerve. Sutures perforated the pelvic sidewall vessels in 4.1% of specimens. Conclusion USLS sutures can directly injure the ureters, rectum, and neurovascular structures in the pelvic walls.

Objective The objective of the study was to assess whether cervical preservation at the time of hysterectomy may help prevent subsequent apical vaginal vault prolapse. Study Design Supracervical hysterectomies were performed in 12 unembalmed cadavers. Successive hanging weights of 1, 2, 3, and 4 kg were loaded against the cervical stump and distances moved were recorded. The same process was repeated after completion of a total hysterectomy. Results Average distances pulled with 1, 2, 3, and 4 kg of traction against the cervical stump were 17.8 ± 1.9, 24.1 ± 2.5, 29.0 ± 2.8, and 34.3 ± 3.5 mm, respectively. After total hysterectomy, these distances were 17.5 ± 2.5, 23.5 ± 2.6, 29.3 ± 3.1, and 34.5 ± 3.6 mm, respectively. Conclusion In unembalmed cadavers, it appears that total abdominal hysterectomy and supracervical hysterectomy provide equal resistance to forces applied to the vaginal apex.

Background Simple cysts of the female genital tract may become symptomatic and require surgical removal. Case A 20-year-old woman had complaints of a vaginal bulge, pelvic pressure, dyspareunia, and stress urinary incontinence. Two cystic masses were seen in the vagina. A magnetic resonance imaging scan revealed 2 additional larger cysts. Urodynamic evaluation was significant for stress incontinence at 200 mL and a Valsalva leak-point pressure of 51 cm H(2)0. The 2 smaller cysts were removed intact through a superficial incision. The larger cysts were intentionally ruptured and dissected out. Histologic examination revealed a low cuboidal or a ciliated columnar epithelium that stained positive with mucicarmine, consistent with mullerian origin. One year after surgical excision, the patient remained symptom free with no urinary incontinence and no recurrence of the cysts. Conclusion Magnetic resonance imaging was useful in delineating the course and anatomic arrangement of the vaginal cysts, but more importantly, identified another cyst that was not readily apparent at physical examination.

Objective The objective of the study was to evaluate the anatomic relationships of anchor points of single-incision midurethral slings with 2 common placement trajectories. Study Design In 30 female pelvic halves, a probe was introduced through a suburethral tunnel following 45 ° and 90 ° angle trajectories. The corresponding anchor points were tagged. Distances to the obturator canal, accessory obturator vessels, dorsal vein of clitoris, and external iliac vein were recorded. Results Both suburethral tunnel trajectories and their respective anchor points remained caudad to the obturator internus muscle in 100% of dissections. The closest distance between either anchor point to the obturator canal was 1.6 cm. The closest distance from the 45 ° and 90 ° anchor points to the accessory obturator vessels was 1.6 and 1.5 cm, respectively. Conclusion The anchor points of single-incision midurethral slings are in close proximity to vascular structures that could be injured with inadvertent entry into the retropubic space.

Objective The objective of the study was to determine whether bed delivery without stirrups reduces the incidence of perineal lacerations compared with delivery in stirrups. Study design In this randomized trial, we compared bed delivery without stirrups with delivery in stirrups in nulliparous women. The primary outcome was any perineal laceration (first through fourth degree). Results One hundred eight women were randomized to delivery without stirrups and 106 to stirrups. A total of 82 women randomized to no stirrups (76%) sustained perineal lacerations compared with 83 in women allocated to stirrups (78%) (P = .8). There was no significant difference in the severity of lacerations or in obstetric outcomes such as prolonged second stage of labor, forceps delivery, or cesarean birth. Similarly, infant outcomes were unaffected. Conclusion Our results do not incriminate stirrups as a cause of perineal lacerations. Alternatively, our findings of no difference in perineal lacerations suggest that delivering in bed without stirrups confers no advantages or disadvantages.

Objective We sought to characterize the distribution of the pudendal nerve branches and to correlate findings with injury risk related to common midurethral sling procedures. Study Design Dissections were performed in 18 female cadavers. Biopsies were obtained to confirm gross findings by histology. Results In all dissections, most of the clitoral and perineal nerves coursed caudal to the ventral portion of the perineal membrane. The inferior rectal nerve did not enter the pudendal canal in 44% (n = 8) of specimens. Nerve tissue was confirmed histologically in tissue sampled. Conclusion The clitoral and perineal branches of the pudendal nerve should be at low risk of direct nerve injury during midurethral slings and similar procedures as they course caudal to the ventral portion of the perineal membrane. The inferior rectal nerve might be at risk of injury during procedures that involve passage of needles through the ischioanal fossa.

Objective We sought to describe relationships of clinically relevant nerves and vessels of the anterior abdominal wall. Study Design The ilioinguinal and iliohypogastric nerves and inferior epigastric vessels were dissected in 11 unembalmed female cadavers. Distances from surface landmarks and common incision sites were recorded. Additional surface measurements were taken in 7 other specimens with and without insufflation. Results The ilioinguinal nerve emerged through the internal oblique: mean (range), 2.5 (1.1–5.1) cm medial and 2.4 (0–5.3) cm inferior to the anterior superior iliac spine (ASIS). The iliohypogastric emerged 2.5 (0–4.6) cm medial and 2.0 (0–4.6) cm inferior. Inferior epigastric vessels were 3.7 (2.6–5.5) cm from midline at the level of the ASIS and always lateral to the rectus muscles at a level 2 cm superior to the pubic symphysis. Conclusion Risk of anterior abdominal wall nerve and vessel injury is minimized when lateral trocars are placed superior to the ASISs and >6 cm from midline and low transverse fascial incisions are not extended beyond the lateral borders of the rectus muscles.