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Functional Anatomy of Pelvic Floor

Racial differences in pelvic morphology among asymptomatic nulliparous women as seen on three-dimensional magnetic resonance images.
Hoyte L, Thomas J, Foster RT, Shott S, Jakab M, Weidner AC
Am J Obstet Gynecol 2005 Dec;193(6):2035-40.

OBJECTIVE: Compare pelvic morphology between asymptomatic African-American and white nulliparous women. STUDY DESIGN: Resting supine T2-weighted magnetic resonance (MR) images were obtained in 12 African-American (AA) and 10 white American (WA) women without pelvic floor dysfunction. Three-dimensional models were reconstructed from the MR images by a masked investigator, and predefined bony and soft tissue pelvic floor parameters were measured and compared. Nonparametric statistics were used, with significance considered at P < .05. RESULTS: Subjects were similar in age and body mass index. Levator ani volume was significantly greater in the AA versus the WA group (mean = 26.8 vs 19.8 cm3, P = .002). The levator-symphysis gap was smaller in the AA (left-18.2, right-18.8 mm) versus the WA group (22.4, 22.6 mm, P = .003, .048) on the left and right. Significant differences were seen in bladder neck position, urethral angle, and the pubic arch angle. CONCLUSION: The increased muscle bulk and closer puborectalis attachment seen among the African-American nulliparous women may impact the development of pelvic floor dysfunction. These findings need further study.

Rectoceles and the anatomy of the posteriorvaginal wall: revisited.
Kleeman SD, Westermann C, Karram MM
Am J Obstet Gynecol 2005 Dec;193(6):2050-5.

OBJECTIVE: The purpose of this study was to histologically evaluate the posterior aspect of the pelvis, specifically, the relationship between the perineum, posterior vagina, anterior rectum, and all other intervening tissue. STUDY DESIGN: The perineum, posterior vaginal wall, and upper part of the rectum were removed en bloc from 4 fresh cadavers without pelvic prolapse. Length of the specimens ranged from 6 to 7.9 cm and width 3 to 4 cm. Seven to 26 serial sections were taken from each cadaver. Sections were stained with hematoxylin and eosin (H&E), Masson trichrome, and Verhoeff Von Gieson elastic stain. RESULTS: All 4 specimens showed dense connective tissue and no plane of cleavage for 3 to 3.5 cm proximally from the posterior forchette. Proximal to this, all 4 specimens showed space between the muscular wall of the vagina and the muscular wall of the rectum, which was composed of adipose tissue with discontinuous bands of fibrous tissue or loose areolar tissue. This appears to be a natural line of cleavage. Histologically, no evidence of fascia or a rectovaginal septum was identified. CONCLUSION: Histologically, there is no evidence of a distinct fascial layer between the posterior vaginal wall and anterior wall of the rectum. Clinically, it is the splitting of the adventitia and fibromuscular layers of the vagina that are used in defect-specific rectocele repairs to support the anterior rectal wall.

Anatomy of pudendal nerve at urogenital diaphragm--new critical site for nerve entrapment.
Hruby S, Ebmer J, Dellon AL, Aszmann OC
Urology 2005 Nov;66(5):949-52.

OBJECTIVES: To investigate the relations of the pudendal nerve in this complex anatomic region and determine possible entrapment sites that are accessible for surgical decompression. Entrapment neuropathies of the pudendal nerve are an uncommon and, therefore, often overlooked or misdiagnosed clinical entity. The detailed relations of this nerve as it exits the pelvis through the urogenital diaphragm and enters the mobile part of the penis have not yet been studied. METHODS: Detailed anatomic dissections were performed in 10 formalin preserved hemipelves under 3.5x loupe magnification. The pudendal nerve was dissected from the entrance into the Alcock canal to the dorsum of the penis. The branching pattern of the nerve and its topographic relationship were recorded and photographs taken. RESULTS: The anatomic dissections revealed that the pudendal nerve passes through a tight osteofibrotic canal just distal to the urogenital diaphragm at the entrance to the base of the penis. This canal is, in part, formed by the inferior ramus of the pubic bone, the suspensory ligament of the penis, and the ischiocavernous body. In two specimens, a fusiform pseudoneuromatous thickening was found. CONCLUSIONS: The pudendal nerve is susceptible to compression at the passage from the Alcock canal to the dorsum of the penis. Individuals exposed to repetitive mechanical irritation in this region are especially endangered. Diabetic patients with peripheral neuropathy can have additional compression neuropathy with decreased penile sensibility and will benefit from decompression of the pudendal nerve.

Pelvic anatomy and MRI.
Paramasivam S, Proietto A, Puvaneswary M
Best Pract Res Clin Obstet Gynaecol 2005 Nov 4;.

An in-depth knowledge of the anatomy of the pelvis and pelvic sidewall is necessary before a gynaecologist can even contemplate making an initial examination and start management in cases of pelvic pathology or malignancy. This chapter provides basic information on gross pelvic anatomy structures that are of clinical relevance and discusses their correlation with medical imaging, especially magnetic resonance imaging (MRI). MRI is an ideal non-invasive technique in the assessment of normal anatomy and tissue characterization of pelvic pathology. The excellent soft-tissue contrast and the ability to direct multiplanar imaging and to demonstrate blood vessels without the use of intravenous contrast make MRI superior to other imaging modalities in the evaluation of pelvic abnormalities. The anatomical relation of the visceral organs, the differential zonal anatomy of the corpus uteri and the cyclical endometrial changes during the menstrual cycle are well depicted with MRI.

Medical professionalism and the clinical anatomist.
Swick HM
Clin Anat 2005 Nov 29;.

Medical professionalism has become an important issue for medical education and practice. The core attributes of professionalism derive from the roles and responsibilities of professions and from the nature of medicine as a healing profession. In medical education, most of the focus on professionalism has been directed to the clinical arena, yet it is critically important that the attributes of professionalism be manifested in basic science courses-especially anatomy-as well as in clinical experiences, because the transformation from medical student to physician begins at the outset of medical school. Throughout history, anatomists have exemplified many of the attributes and values of professionalism, and clinical anatomists today still have much to offer. Anatomy faculty have an important responsibility to nurture and exemplify professionalism. Clin. Anat., 2006. (c) 2005 Wiley-Liss, Inc.

Attitudes of professional anatomists to curricular change.
Patel KM, Moxham BJ
Clin Anat 2005 Nov 21;.

Throughout the world, recent developments in medical curricula have led to marked changes in the teaching of gross anatomy. This change has involved decreasing curricular student contact time and the use of new methods for anatomical teaching. Some "modern" anatomists have welcomed the arrival of these novel methods while other, more "traditional," anatomists have fought to maintain the use of cadaveric dissection. Consequently, controversy over teaching methods has developed to the point that "modernist" and "traditionalist" views within the community of professional anatomists seem to have diverged such that the importance of gross anatomy in the medical curriculum is disputed and that cadaveric dissection by students is no longer the preferred method of teaching. This study tests this hypothesis using Thurstone and Chave attitude analyses to assess attitudes to educational change and the importance of anatomy in medicine and a matrix questionnaire that required professional anatomists to relate course aims to different teaching methods. In total, 112 completed questionnaires were received from anatomists who are employed at higher education institutions that use various teaching methods and who span the academic hierarchy. The results suggest that over 90% of anatomists favor educational change and approximately 98% of professional anatomists believe that gross anatomy has an important role to play in clinical medicine. A clear majority of the anatomists (69%) favored the use of human cadaveric dissection over other teaching methods (this method seeming to achieve a range of different course aims/objectives) (P < 0.001; Kruskal-Wallis). Using Kruskal-Wallis statistical tests, the order-of-preference for teaching methods was found to be as follows: 1Practical lessons using cadaveric dissection by students2Practical lessons using prosection3Tuition based upon living and radiological anatomy4Electronic tuition using computer aided learning (CAL)5Didactic teaching alone (e.g. lectures/class room-based tuition)6Use of models The preference for the use of human cadaveric dissection was evident in all groups of anatomists, whether "traditionalist" or "modernist" (P = 0.002, Chi-squared). These findings are therefore not consistent with our initial hypothesis. Clin. Anat., 2006. (c) 2005 Wiley-Liss, Inc.

Anatomy of the sigmoid colon, rectum, and the rectovaginal pouch in women with enterocele and anterior rectal wall procidentia.
Baessler K, Schuessler B
Clin Anat 2005 Nov 14;.

This study describes the anatomy of the rectovaginal pouch, the sigmoid colon, and rectum in women with posterior enterocele and anterior rectal wall procidentia. The anatomy of rectovaginal pouch, sigmoid colon, and rectum was described in 36 women with an enterocele (group A) and compared with those of 43 women (group B) without pelvic organ prolapse. Women with previous incontinence or prolapse surgery were excluded. The mean age in group A was 58 years (40-75) and in group B 35 years (19-64; P < 0.001). There were 15 nulliparas in group B. Nine women in group A had an internal anterior rectal wall procidentia, and one woman had an external anterior rectal wall procidentia. In group A, the rectovaginal pouch was significantly deeper, the sigmoid mesocolon at S1 shorter and showed more often a straight course (P < 0.05). These characteristics (termed "grande fosse pelvienne") were present in 23 women (64%) in group A and in 6 (14%) in group B, three of the latter were young nulliparas (P < 0.001). Age, parity, menopausal status, body mass index, constipation, and varicose veins were not associated with a grande fosse pelvienne. The typical anatomy in women with an enterocele and anterior rectal wall procidentia was a sigmoid colon with a straight course and a short mesentery at S1 and a rectovaginal pouch that covered more than half of the vaginal length. It may be a congenital condition and important in the development of an enterocele and rectal wall procidentia.

Magnetic resonance imaging and 3-dimensional analysis of external anal sphincter anatomy.
Hsu Y, Fenner DE, Weadock WJ, Delancey JO
Obstet Gynecol 2005 Dec;106(6):1259-65.

OBJECTIVE: To use magnetic resonance images of living women and 3-dimesional modeling software to identify the component parts and characteristic features of the external anal sphincter (EAS) that have visible separation or varying origins and insertions. METHODS: Detailed structural analysis of anal sphincter anatomy was performed on 3 pelvic magnetic resonance imaging (MRI) data sets selected for image clarity from ongoing studies involving nulliparous women. The relationships of anal sphincter structures seen in axial, sagittal, and coronal planes were examined using the 3-D Slicer 2.1b1 software program. The following were requirements for sphincter elements to be considered separate: 1) a clear and consistently visible separation or 2) a different origin or insertion. The characteristic features identified in this way were then evaluated in images from an additional 50 nulliparas for the frequency of feature visibility. RESULTS: There were 3 components of the EAS that met criteria as being "separate" structures. The main body (EAS-M) is separated from the subcutaneous external anal sphincter (SQ-EAS) by a clear division that could be observed in all (100%) of the MRI scans reviewed. The wing-shaped end (EAS-W) has fibers that do not cross the midline ventrally, but have lateral origins near the ischiopubic ramus. This EAS-W component was visible in 76% of the nulliparas reviewed. CONCLUSION: Three distinct external anal sphincter components can be identified by MRI in the majority of nulliparous women.

[PET-CT studies of the support system and continence function of pelvic organs The pivotal importance of Denonvilliers' fascia for surgical procedures.]
Stelzner F, Biersack HJ, von Mallek D, Reinhardt M
Chirurg 2005 Dec;76(12):1168-74.

Like all other organs in the chest or abdominal cavities, pelvic organs are not suspended by specialized ligaments such as those in the skeletomuscular system. In spite of this, the organs of the pelvis remain well suspended within their cavity even during evacuation. This support system for these organs consists of inconspicuous smooth muscle elements scattered throughout pelvic structural fat tissue and fascial structures, in particular Denonvilliers' fascia. We used PET-CT studies to identify spontaneous muscle activity in the pelvis, which is strongest at Denonvilliers' fascia. We were able to correlate continence function, filling, and evacuation of pelvic organs with this spontaneous muscle activity that leads to stiffening and relaxation of the muscular walls of these organs. During the course of different disease processes such as visceral prolapse, these pelvic support structures are prone to fail gradually. Surgical interventions should take the pelvic support system into account to avoid therapeutic errors.

Human muscle aging: ROS-mediated alterations in rectus abdominis and vastus lateralis muscles.
Marzani B, Felzani G, Bellomo RG, Vecchiet J, Marzatico F
Exp Gerontol 2005 Oct 5;.

Aging is related to the accumulation of reactive oxygen species (ROS)-mediated oxidative damage. Considering the heterogeneity of age-related changes and the involvement of muscles in different functions, we compared the aging process in different functional muscles. We studied age-related changes in rectus abdominis (RA) and vastus lateralis (VL) in subjects of different age (18-48- and 66-90-year-old). We analysed fiber distribution, antioxidant enzymatic systems: Mn and CuZn superoxide dismutase (MnSOD, CuZnSOD), glutathione peroxidase (GSHPx), catalase (CAT), as well as oxidative damage markers: lipoperoxide levels (LPO), carbonylated proteins (CP), reduced and oxidized glutathione (GSH, GSSG) content and the GSH/GSSG ratio. In the muscles analysed, type I fiber increases during aging with a consequent decrease in type II distribution. In the elderly group RA MnSOD showed higher activity than VL. Furthermore, in RA MnSOD was higher in the elder group than in the younger group. CuZnSOD, as well as GSHPx and CAT activities remained unchanged. LPO levels in VL increase with age; moreover, in the elderly group VL showed higher value than RA. CP, GSH and GSSG remained unchanged, while GSH/GSSG decreases in RA during aging. In conclusion, a relationship between aging and ROS seems to exist, but oxidative processes could evolve in different ways in muscles with different functions.

Stem cells, progenitors and myelin repair.
Zhao C, Fancy SP, Magy L, Urwin JE, Franklin RJ
J Anat 2005 Sep;207(3):251-8.

Remyelination, the process by which new myelin sheaths are restored to demyelinated axons, represents one of the most compelling examples of adult multipotent progenitor cells contributing to regeneration of the injured central nervous system (CNS). This process can occur with remarkable efficiency in both clinical disease, such as multiple sclerosis, and in experimental models, revealing an impressive ability of the adult CNS to repair itself. However, the inconsistency of remyelination in multiple sclerosis, and the loss of axonal integrity that results from its failure, makes enhancement of remyelination an important therapeutic objective. Identifying potential targets will depend on a detailed understanding of the cellular and molecular mechanisms of remyelination. In this article we address two important issues. First, we consider the nature of the cell or cells that respond to demyelination and generate new oligodendrocytes, identifying current areas of uncertainty and addressing the role of adult CNS stem and progenitor cells. Second, we discuss the concept of adult progenitor activation following demyelination, focusing on the increased expression of (1) olig transcription factors, (2) bone morphogenetic proteins and (3) fyn, a member of the src-family of tyrosine kinases.

Anatomical perspectives on adult neural stem cells.
Watts C, McConkey H, Anderson L, Caldwell M
J Anat 2005 Sep;207(3):197-208.

The concept of stem cells within the adult brain is not new. However, only recently have scientific techniques become sufficiently advanced to identify them although this remains problematic and the technology is still developing. Nevertheless, it is now generally recognized that stem cells are restricted to two germinal regions within the intact brain. From here they can migrate to specific destinations where they integrate with existing circuitry. Their identity remains controversial but a growing body of evidence suggests it may have an astrocytic phenotype. Within the germinal regions the stem cells are confined to a niche environment and are capable of responding to environmental signals generated locally in an autocrine or paracrine fashion. The niche environment is also modulated by more generalized systemic and physiological activity. These observations are exciting in their own right and form the basis of this review. They are also beginning to alter how we think about neural injury and disease and to impact on the development of novel therapies.

Electrospinning of collagen nanofibers: Effects on the behavior of normal human keratinocytes and early-stage wound healing.
Rho KS, Jeong L, Lee G, Seo BM, Park YJ, Hong SD, Roh S, Cho JJ, Park WH, Min BM
Biomaterials 2005 Sep 3;

Electrospinning of type I collagen in 1,1,1,3,3,3-hexafluoro-2-propanol (HFIP) to fabricate a biomimetic nanofibrous extracellular matrix for tissue engineering was investigated. The average diameter of collagen nanofibers electrospun from 8% collagen solution in HFIP was 460nm (range of 100-1200nm). The as-spun collagen nanofibrous matrix was chemically cross-linked by glutaraldehyde vapor with a saturated aqueous solution and then treated with aqueous 0.1m glycine to block unreacted aldehyde groups. With vapor phase cross-linking for 12h, porosity of the collagen matrix decreased from 89% to 71%. The collagen nanofibrous matrix showed good tensile strength, even in aqueous solution. Effects on cytocompatibility, cell behavior, cell and collagen nanofiber interactions, and open wound healing in rats were examined. Relatively low cell adhesion was observed on uncoated collagen nanofibers, whereas collagen nanofibrous matrices treated with type I collagen or laminin were functionally active in responses in normal human keratinocytes. Collagen nanofibrous matrices were very effective as wound-healing accelerators in early-stage wound healing. Our results indicate that cross-linked collagen nanofibers coated with ECM proteins, particularly type I collagen, may be a good candidate for biomedical applications, such as wound dressing and scaffolds for tissue engineering.

Electrospinning of collagen and elastin for tissue engineering applications.
Buttafoco L, Kolkman NG, Engbers-Buijtenhuijs P, Poot AA, Dijkstra PJ, Vermes I, Feijen J
Biomaterials 2005 Aug 17;.

Meshes of collagen and/or elastin were successfully prepared by means of electrospinning from aqueous solutions. Flow rate, applied electric field, collecting distance and composition of the starting solutions determined the morphology of the obtained fibres. Addition of PEO (M(w)=8x10(6)) and NaCl was always necessary to spin continuous and homogeneous fibres. Spinning a mixture of collagen and elastin resulted in fibres in which the single components could not be distinguished by SEM. Increasing the elastin content determined an increase in fibres diameters from 220 to 600nm. The voltage necessary for a continuous production of fibres was dependent on the composition of the starting solution, but always between 10 and 25kV. Under these conditions, non-woven meshes could be formed and a partial orientation of the fibres constituting the mesh was obtained by using a rotating tubular mandrel as collector. Collagen/elastin (1:1) meshes were stabilized by crosslinking with N-(3-dimethylaminopropyl)-N'-ethylcarbodiimide hydrochloride (EDC) and N-hydroxysuccinimide (NHS). This treatment afforded materials with a high thermal stability (T(d)=79 degrees C) without altering their original morphology. Upon crosslinking PEO and NaCl were fully leached out. Smooth muscle cells grew as a confluent layer on top of the crosslinked meshes after 14d of culture.

Microintegrating smooth muscle cells into a biodegradable, elastomeric fiber matrix.
Stankus JJ, Guan J, Fujimoto K, Wagner WR
Biomaterials 2005 Aug 8;.

Electrospinning permits fabrication of biodegradable elastomers into matrices that can resemble the scale and mechanical behavior of the native extracellular matrix. However, achieving high-cellular density and infiltration with this technique remains challenging and time consuming. We have overcome this limitation by electrospraying vascular smooth muscle cells (SMCs) concurrently with electrospinning a biodegradable, elastomeric poly(ester urethane)urea (PEUU). Trypan blue staining revealed no significant decrease in cell viability from the fabrication process and electrosprayed SMCs spread and proliferated similar to control unprocessed SMCs. The resulting SMC microintegrated PEUU constructs were cultured under static conditions or transmural perfusion. Higher cell numbers resulted with perfusion culture with 131% and 98% more viable cells versus static culture at days 4 and 7 (p<0.05). Fluorescent imaging and hematoxylin and eosin staining further illustrated high cell densities integrated between the elastomeric fibers after perfusion culture. SMC microintegrated PEUU was strong, flexible and anisotropic with tensile strengths ranging from 2.0 to 6.5MPa and breaking strains from 850 to 1700% dependent on the material axis. The ability to microintegrate smooth muscle or other cell types into a biodegradable elastomer fiber matrix embodies a novel tissue engineering approach that could be applied to fabricate high cell density elastic tissue mimetics, blood vessels or other cardiovascular tissues.

Age associated changes in erythrocyte membrane surface charge: Modulatory role of grape seed proanthocyanidins.
Sangeetha P, Balu M, Haripriya D, Panneerselvam C
Exp Gerontol 2005 Aug 30;.

Aging, a multifactorial process of enormous complexity is characterized by impairment of physio-chemical and biological aspects of cellular functions. It is closely associated with increased free radical production, which situation ultimately leads to devastation of normal cell function and membrane integrity. The present study was aimed to determine the effect of proanthocyanidins rich grape seed extract (GSP) on membrane surface charge density in erythrocytes during animal age associated oxidative stress. GSP (100mg/day/kg body weight) was administered orally for 15 and 30 days to young and aged rats. Significant decrease in surface charge levels with concomitant increase in protein carbonyls and decrease in glycoprotein, antioxidants status was noted in erythrocytes of aged rats when compared with young rat erythrocytes. Duration dependent supplementation of GSP increased the erythrocyte surface charge density to near normalcy in aged rats. Decrease in protein carbonyls level and increase in glycoproteins as well as antioxidant status was observed in aged rat erythrocytes on GSP treatment. Thus, from our results, we conclude that GSP is an effective anti-aging drug in preventing the oxidative stress associated loss of membrane surface charge, which thereby maintains the erythrocyte membrane integrity and functions in elderly.

Immunohistochemical evidence for the interaction between levator ani and pudendal motor neurons in the coordination of pelvic floor and visceral activity in the squirrel monkey.
Pierce LM, Reyes M, Thor KB, Dolber PC, Bremer RE, Kuehl TJ, Coates KW. Am J Obstet Gynecol 2005 May;192(5):1506-15.

OBJECTIVE: The purpose of this study was to characterize the spinal distribution of afferent and efferent pathways that innervate the levator ani (LA) muscle in the female squirrel monkey. STUDY DESIGN: Cholera toxin B (CTB) was injected unilaterally into the LA muscle of 5 monkeys to identify primary sensory neurons in the dorsal root ganglia (DRG) and motor neurons in the spinal cord that contribute fibers to the LA nerve. Fluoro-Gold (FG) was injected into the external anal sphincter of 2 of these animals to label pudendal motor neurons (1 of these animals underwent unilateral LA neurectomy before CTB injection). Spinal cord and DRG were processed for immunofluorescence 3 to 7 days after injections. RESULTS: Retrograde transport of CTB from the LA muscle labeled primary afferent neurons in the ipsilateral DRG, their central projections, and motor neurons in the medial portion of the ipsilateral ventral horn of the spinal cord (L7-S2 segments). Injection of FG into the external anal sphincter labeled cells in Onuf's nucleus, primarily in L7. Importantly, CTB-labeled LA motor neurons were virtually absent in Onuf's nucleus, where all pudendal motor neurons are located. CTB-labeled processes were observed within Onuf's nucleus, adjacent to FG-labeled pudendal motor neurons, and appeared to derive from dendrites of LA motor neurons that project into Onuf's nucleus. CONCLUSION: The LA muscle has a distinct innervation with very little or no contribution from the pudendal nerve. The intriguing labeling of LA neural elements within a nucleus that innervates the external urethral and anal sphincters (involved in pelvic visceral control) may represent a neuroanatomic substrate for physiologic integration of spinal and supraspinal inputs for the coordination of pelvic floor and visceral activity.

Vascular anatomy of the presacral space: a fresh tissue cadaver dissection.
Flynn MK, Romero AA, Amundsen CL, Weidner AC
Am J Obstet Gynecol 2005 May;192(5):1501-5.

OBJECTIVE: To assess variability in the vascular structures of the presacral space and to estimate the risk of injury because of blind suture placement during sacral colpopexy. STUDY DESIGN: Ten fresh frozen female cadavers were evaluated. Three 0-polyester sutures were placed blindly through the peritoneum and around the midline of the anterior longitudinal ligament. The presacral space was dissected and the sutures examined for injury to vessels. The midline of the anterior longitudinal ligament was marked from the promontory to its inferior edge, and measurements were taken to the leading edge of vessels proximal to the presacral space. On a template, all vessels larger than 2 mm were drawn to scale and overlaid on the template. RESULTS: Unequivocal vascular injury was found in 5 cadavers because of blind sutures. Four injuries occurred to the middle sacral artery and 1 to the left common iliac vein. There was significant variability in location of vessels, particularly on the left side of the ligament. CONCLUSIONS: The vascular pattern of the presacral space is variable, and major vessels may deviate significantly from their expected positions. Surgeons should carefully expose this space prior to placing sutures during sacral colpopexy.

Impaired expression of myogenic regulatory molecules in the pelvic floor muscles of murine embryos with anorectal malformations.
Aoi S, Shimotake T, Tsuda T, Deguchi E, Iwai N. J Pediatr Surg 2005 May;40(5):805-9.

Abstract Background/Purpose Recent biological studies have elucidated the molecular mechanism of muscle development, in which various regulatory factors (myogenic regulatory factors [MRFs]) play key roles during embryogenesis. To investigate the development of anorectal malformations (ARMs), we studied MRF expressions in myogenic cells in the pelvic floor using murine embryos affected with ARM. Methods Anorectal malformation embryos were obtained from the 10.5th embryonal day (E10.5) to the 7.0th postnatal day (D7.0) in a natural mutant strain (Sd/+, RSV/Le). Serial frozen sections were prepared for immunohistochemistry using specific antibodies to M-cadherin, myoD, Myogenin, myosin heavy chain, and alfa-actin molecule. Results In normal mice, embryonal caudal somites differentiated into myogenic stem cells and migrated to the pelvic floor between E11.0 and E14.0. In the ARM mice, however, caudal somites were irregularly arranged and MRF expressions in myogenic cells were markedly decreased in the dorsocaudal region at E11.5 to E13.0, leading to hypoplastic pelvic floor muscles. Conclusions The maldevelopment of pelvic floor muscles in ARM is derived from a deficient supply of myogenic stem cells, with impaired MRF expression. These results suggest that myogenic stem cells, available from bone marrow contents, may be used for postnatal muscle regeneration to reinforce the pelvic floor muscle function in children with ARM.

Elastin metabolism in pelvic tissues: is it modulated by reproductive hormones?
Chen B, Wen Y, Yu X, Polan ML. Am J Obstet Gynecol 2005 May;192(5):1605-13.

OBJECTIVE: The purpose of this study was to investigate the effect of relaxin on extracellular matrix protein expression in pelvic fibroblasts that were cultured from women with stress urinary incontinence compared with asymptomatic control subjects. STUDY DESIGN: Periurethral vaginal wall fibroblasts from premenopausal women with stress urinary incontinence and continent women (in both the proliferative and secretory phase of the menstrual cycle) were stimulated with increasing concentrations of relaxin (0-500 ng/mL). The supernatant was sampled for matrix metalloproteinase-2 and -9 by zymography. Tissue inhibitors of metalloproteinase-1 and -2 and alpha-1 antitrypsin were evaluated with Western blot. Total elastase activity was measured by generation of free amino groups from succinylated elastin. Increasing concentrations of alpha-1 antitrypsin were added to cell lysate to evaluate total elastase activity inhibition. RESULTS: Proliferative-phase stress urinary incontinence fibroblasts demonstrated an increase in matrix metalloproteinase-2 and no change in matrix metalloproteinase-9 and tissue inhibitors of metalloproteinase-1 and -2 expressions with increasing relaxin concentrations. Cells from control subjects showed increased expression of matrix metalloproteinase-2 and -9, but no change in tissue inhibitors of metalloproteinases. Secretory-phase stress urinary incontinence fibroblasts showed no response in matrix metalloproteinase or tissue inhibitors of metalloproteinase expressions with relaxin stimulation. Secretory-phase control fibroblasts reacted by increasing matrix metalloproteinase-2 and -9 and tissue inhibitors of metalloproteinase-2. With respect to total elastase activity and alpha-1 antitrypsin expression, increasing doses of relaxin appear to increase elastolytic activity in stress urinary incontinence cells by decreasing the expression of alpha-1 antitrypsin in proliferative phase cells or increasing the total elastase activity in secretory phase cells. Fibroblast total elastase activity was inhibited by increasing concentrations of alpha-1 antitrypsin. CONCLUSION: Elastase activity appears to be increased in relaxin-stimulated stress urinary incontinence fibroblasts by either decreased inhibitor (alpha-1 antitrypsin) production or increased elastase activity.

Morphology of the gluteal region in the female population 5 to 83 years of age.
Babuccu O, Kargi E, Hosnuter M, Babuccu B, Kiran S
Aesthetic Plast Surg 2004 Nov-Dec;28(6):405-11.

This study evaluated the development of gluteal region morphology in the female population 5 to 83 years of age. For the study, 132 female subjects were placed into four groups: prepubertal (ages 5 to 8 years; n = 10), pubertal (ages 9 to 14 years; n = 38) postpubertal (ages 15 to 41 years; n = 34), and menopausal-postmenopausal (older than 42 years; n = 29). The age, weight, and height of the subjects were routinely recorded, and body mass index was estimated. In addition, 11 measurements were performed on the gluteal region. The data were analyzed by Pearson and Spearmen correlation analyses using SSPS 11.0 for Windows. In the prepubertal group, the intergluteal sulcus and infragluteal sulci did not actively change. Weight gain was the major factor influencing the shape of the gluteal region, whereas age had no effect. In the puberty group, the gluteal region expanded in all directions. During this period, it was difficult to determine any specific relation between measurements because of significant correlation involving all parameters. However, it should be mentioned that among the four groups, only in pubertal group did age significantly affect the shape of the gluteal region. In other three groups, weight seemed to be a major determinant. In the pospubertal and menopausal-postmenopausal groups, the buttocks sagged with weight gain, contrary to the belief that this happens with aging. This causes movement of the infragluteal sulci in downward and lateral directions as well as lengthening of intergluteal sulcus.Although the gluteal shape is open to the effects of demographic factors such as ethnicity, feeding habits, and lifestyle, according to these findings, it might be advised that in the assessment of the gluteal region morphology, it would be better to consider its dynamic nature. Reshaping its only one part, which can be devastating unless the whole gluteal region and upper limb are addressed.

Visualization of the endopelvic fascia by transrectal three-dimensional ultrasound.
Reisinger E, Stummvoll W
Int Urogynecol J Pelvic Floor Dysfunct 2005 Apr 14;

The aim of our pilot study was to explore the feasibility of visualizing the endopelvic fascia by transrectal three-dimensional (3D) ultrasound. Transrectal 3D ultrasound was performed in 12 nulliparous women and 11 women with a history of vaginal delivery. A 6-10 MHz volume probe was used to examine the suburethral anterior vaginal wall. In all women, an echogenic layer was identified at an average of 3-5 mm from the vaginal surface. This echogenic layer was found to be contiguous to the lateral pelvic sidewall and uninterrupted in 10 of 12 nulliparous women, whereas gaps in this layer were identified in all 11 parous women. We hypothesize that this echogenic layer may represent the suburethral component of the endopelvic fascia. Depending on the number and localization of the interruptions in this echogenic layer, the mechanical support of the pelvic floor seems to be weakened corresponding to a higher incidence of descensus of the anterior vaginal wall, which frequently was associated with urinary incontinence.

[Physiology of the anal and urinary sphincter apparatus for continence]
Leroi AM, Le Normand L
Prog Urol 2005 Feb;15(1):123-48.

This report of the 27th congress of the Societe Internationale Francophone d'Urodynamique (SIFUD) describes the mechanisms which allow the anal and urethral sphincter apparatus to ensure faecal and urinary continence. It successively described sphincter anatomy, the structure and ultrastructure of its muscle components, its innervation, neurotransmission and functioning regimens at rest, on effort and on straining. This study illustrates the differences but also the similarities of functioning of these two sphincter apparatuses. This can explain the high frequency of associated urinary and anal incontinence.

Surgical anatomy of the cervical sympathetic trunk.
Kiray A, Arman C, Naderi S, Guvencer M, Korman E
Clin Anat 2005 Apr;18(3):179-85.

Lack of knowledge of the anatomy of the cervical sympathetic trunk (CST) may complicate surgical procedures on the cervical spine. This study aims to define linear and angular relations of the CST with respect to consistent structures around it, including the number and size of the cervical ganglia, the distances between the CST and the longus colli muscle and the anterior tubercles of the transverse processes of cervical vertebrae. Morphometric parameters of the 24 CSTs of 12 adults were measured on both sides. The CST had superior, middle, and inferior (or cervicothoracic) ganglia in 20.8% of specimens; superior and inferior (or cervicothoracic) ganglia in 45.8%; superior, middle, vertebral, inferior, or cervicothoracic ganglia in 12.5%, and superior, vertebral, inferior or cervicothoracic ganglia in 20.8% of specimens. The superior ganglion was observed in all specimens, the middle ganglion and vertebral ganglion were each observed in 33.3%. There was no difference between the number of superior and vertebral ganglia between the right and left sides. The average distance between the CST and the medial border of the ipsilateral longus colli muscle (LCM) was 17.2 mm at C3 and 12.4 mm at C7. As the CSTs converged caudally, the LCMs diverged. The average distance between the anterior tubercles of transverse processes of the cervical vertebrae and the lateral borders of the ipsilateral CST was 3.4 mm at C4, 3.2 mm at C5, and 3.9 mm at C6. The presence of a vertebral ganglion and variations, such as the localization of the CST within the carotid sheath, are important. The anatomical landmarks described should assist the spinal surgeon to avoid injury of the CST. Clin. Anat. 18:179-185, 2005. (c) 2005 Wiley-Liss, Inc.

Anatomical study of the pudendal nerve adjacent to the sacrospinous ligament.
Mahakkanukrauh P, Surin P, Vaidhayakarn P
Clin Anat 2005 Apr;18(3):200-5.

The pudendal nerve (S3-S5) is a major branch of the sacral plexus. After branching from the sacral plexus, the pudendal nerve travels through three main regions: the gluteal region, the pudendal canal, and the perineum. In the gluteal region, the pudendal nerve lies posterior to the sacrospinous ligament. The relationship of the pudendal nerve to the sacrospinous ligament has important clinical ramifications, but there is a lack of literature examining the variations in pudendal nerve anatomy in the gluteal region. This study investigates the pudendal nerve trunking in relation to the sacrospinous ligament in 37 cadavers (73 sides of pelves) of 21 males and 16 females, ranging from 18-83 years of age. Pudendal nerve trunking could be grouped into five types: Type I is defined as one-trunked (41/73; 56.2%), Type II is two-trunked (8/73; 11%), Type III is two-trunked with one trunk as an inferior rectal nerve piercing through the sacrospinous ligament (8/73; 11%), Type IV is two-trunked with one as an inferior rectal nerve not piercing through the sacrospinous ligament (7/73; 9.5%), and Type V is three-trunked (9/73; 12.3%). In summary, 56.2% of pudendal nerves adjacent to the sacrospinous ligament were one-trunked, 31.5% were two-trunked and 12.3% were three-trunked. Fifteen inferior rectal nerves originated independently from the S4 root and never joined the main pudendal nerve. Eight of fifteen inferior rectal nerves pierced through the sacrospinous ligament, perhaps making it prone for entrapment. We measured the average diameter of the main trunk of the pudendal nerve to be 4.67 +/- 1.17 mm. We also measured the average length of the pudendal nerve trunks before terminal branching to be 25.14 +/- 10.29 mm. There was no significant statistical difference in the average length, average diameter, number of trunks, and pudendal nerve variations between male and female or right or left sides of the pelves. A detailed study of pudendal nerve trunking in relationship to the sacrospinous ligament would be useful for instruction in basic anatomy courses and in relevant clinical settings as well. Clin. Anat. 18:200-205, 2005. (c) 2005 Wiley-Liss, Inc.

Anisotropy of human linea alba: A biomechanical study.
Grabetael D, Prescher A, Fitzek S, Keyserlingk DG, Axer H
J Surg Res 2005 Mar;124(1):118-125.

BACKGROUND: Recently, a new model of fiber architecture of the linea alba has been described consisting of an oblique fiber layer of intermingling oblique fibers, a transverse fiber layer containing mainly transverse fibril bundles, and a variable, small irregular fiber layer. In this study the morphological model was proven using direction-specific biomechanical measurements of the linea alba. MATERIAL AND METHODS: Thirty-one human abdominal walls were analyzed (16 male and 15 female). Six strips of collagen tissue with a width of 1 cm were exsected from each linea alba transversely, obliquely, and longitudinally according to the main fiber directions. An increasing force from 2 to 24 N was applied to these strips, and the corresponding strain represented by the relative elongation was measured, which allows the calculation of a direction-specific compliance of the tissue. RESULTS: The compliance is highest in longitudinal and smallest in transverse direction. In the infraumbilical part of the female linea alba the compliance was significantly smaller in the transverse direction than in the oblique direction. Moreover, the compliance in the transverse direction was significantly smaller in women than in men. CONCLUSIONS: A distinct anisotropy of morphological and biomechanical properties was demonstrated as well as sex-dependent differences. The compliance correlates with the distribution of fiber orientation in the linea alba. These biomechanical results constitute the functional correlation with the fiber morphology of the linea alba and correspond well to our earlier proposed model of fiber architecture.

Pressure-induced cellular senescence: A mechanism linking venous hypertension to venous ulcers(1).
Stanley AC, Fernandez NN, Lounsbury KM, Corrow K, Osler T, Healey C, Forgione P, Shackford SR, Ricci MA
J Surg Res 2005 Mar;124(1):112-7.

INTRODUCTION: Slow healing of ulcers in chronic venous insufficiency (CVI) has long been thought secondary to venous hypertension. Dermal fibroblasts isolated from venous ulcers have morphologies and protein production suggestive of premature aging. In this study, we hypothesized that neonatal fibroblasts (NNF) cultured under elevated pressure will demonstrate premature aging and that this effect will be augmented by an inflammatory mediator, transforming growth factor beta (TGF-beta). MATERIALS AND METHODS: A unique pressure incubator was used to culture NNF at atmospheric pressure (ATM), ATM + 30 mmHg, ATM + 60 mmHg, and ATM +120 mmHg. Some pressure-exposed NNF were also cultured with TGF- beta (1 ng/ml). Growth rates were determined by flow cytometry. Senescent cells were identified by staining with a marker for cellular senescence, beta-galactosidase (SA-beta-Gal). Light microscopy and digital imaging were used to evaluate cell morphology. Paired linear models and comparison of the slopes were used for statistical analysis of growth. chi(2) analysis was used to compare senescence rates. RESULTS: NNF cultured at ATM + 60 mmHg and ATM + 120 mmHg showed increased SA-beta-Gal activity (P < 0.05), and reduced growth rates (P < 0.05) at 11 days. These effects were not seen at ATM + 30 mmHg. NNF grown with TGF-beta did not show augmented SA-beta-Gal staining. CONCLUSIONS: Pressure-exposed NNF demonstrated an accelerated aging phenomenon similar to fibroblasts isolated from venous ulcers. This aging effect was directly related to the level of pressure. TGF-beta did not augment the aging effect. This study suggests that pressure elevations result in altered cell function and accelerated aging that may contribute to the slowed healing seen in patients with venous insufficiency.

Effect of vaginal distension on anorectal function: identification of the vagino-anorectal reflex.
Shafik A, Shafik I, El-Sibai O
Acta Obstet Gynecol Scand 2005 Mar;84(3):225-9.

Background. Sexual stimulation produces not only reflex changes in the female external and internal reproductive organs but also extragenital reactions. A mention of the response of the anal sphincters and the rectum to penile thrusting could not be traced in the literature. We investigated the hypothesis that the anal sphincters and the rectum respond to penile thrusting in a way that prevents gas and fecal leakage during sexual intercourse. Methods. The response of the external anal sphincter (EAS) and the internal anal sphincter (IAS) and the rectum to vaginal balloon (condom) distension was recorded in 23 healthy women (age: 33.7 +/- 7.3 years). The vaginal condom was inflated with air in increments of 50-300 ml, and the electromyographic (EMG) activity of the EAS and the IAS, as well as rectal pressure, was recorded. The test was repeated after separate anesthetization of the vagina, the rectum, the EAS and the IAS and after the use of normal saline instead of lidocaine. Results. Vaginal distension reduced the rectal pressure in the ratio of expansion of the vaginal volume up to a certain volume, beyond which the rectal pressure ceased to decline when more distending volume was added. Similarly, the internal sphincter EMG activity increased progressively on incremental vaginal distension increase until the 150-ml distension was reached after which more vaginal distension caused no further increase of the EMG activity; external sphincter EMG activity showed no response. Vaginal distension, while the vagina, the rectum, the EAS, and the IAS had been separately anesthetized, produced no significant change, but saline did. Conclusions. Vaginal balloon distension appears to effect rectal wall relaxation and increase of the internal sphincter tone. This seems to provide a mechanism to avoid rectal contents leakage during coitus. Rectal and internal sphincter response to vaginal distension is suggested to be mediated through a reflex we term 'vagino-anorectal reflex', which seems to be evoked by vaginal distension during penile thrusting. The reflex may prove of diagnostic significance in sexual disorders; further studies are needed in order to investigate this point.

Anatomics: the intersection of anatomy and bioinformatics.
Bard JB
J Anat 2005 Jan;206(1):1-16.

Abstract Computational resources are now using the tissue names of the major model organisms so that tissue-associated data can be archived in and retrieved from databases on the basis of developing and adult anatomy. For this to be done, the set of tissues in that organism (its anatome) has to be organized in a way that is computer-comprehensible. Indeed, such formalization is a necessary part of what is becoming known as systems biology, in which explanations of high-level biological phenomena are not only sought in terms of lower-level events, but are articulated within a computational framework. Lists of tissue names alone, however, turn out to be inadequate for this formalization because tissue organization is essentially hierarchical and thus cannot easily be put into tables, the natural format of relational databases. The solution now adopted is to organize the anatomy of each organism as a hierarchy of tissue names and linking relationships (e.g. the tibia is PART OF the leg, the tibia IS-A bone) within what are known as ontologies. In these, a unique ID is assigned to each tissue and this can be used within, for example, gene-expression databases to link data to tissue organization, and also used to query other data sources (interoperability), while inferences about the anatomy can be made within the ontology on the basis of the relationships. There are now about 15 such anatomical ontologies, many of which are linked to organism databases; these ontologies are now publicly available at the Open Biological Ontologies website ( from where they can be freely downloaded and viewed using standard tools. This review considers how anatomy is formalized within ontologies, together with the problems that have had to be solved for this to be done. It is suggested that the appropriate term for the analysis, computer formulation and use of the anatome is anatomics.

Ethics, transplantation, and the changing role of anatomists.
Satyapal KS
Clin Anat 2005 Feb 4;18(2):150-153.

Anatomists are regarded as custodians of cadaveric material donated to science. Almost every facet of medical science has experienced explosive advances. This has impacted directly on anatomists and their role. Increasingly, anatomists are raising concerns with regard to the treatment of human tissue (Jones,2002, Clin. Anat. 15:436-440). The Korperwelten (Bodyworlds) of Gunther von Hagens et al. (1987, Anat. Embryol. 175:411-421) has evoked considerable debate about the treatment of human cadavers. Thus far clinical anatomists have had little role to play in policy formulation, legislation, and ethical imperatives as applied to cadaveric donation for organ transplantation. Anatomists play an even more negligible role in the raging ethical controversy around live related/unrelated organ transplantation. Due to the critical international shortage of cadaveric donors, boundaries are being pushed to meet the needs of potential recipients (Ohler,2001, Prog. Transplant. 11:160-161). Constant reappraisal of these ethical and moral issues is therefore appropriate. Issues that relate to cultural and economic imperialism and pronouncements of international transplant societies may also require re-evaluation. The legislature governing the donation of human tissue in various countries is usually governed by a Human Tissue Act or its equivalent. In general, such acts are congruent with the Human Tissue Act (South Africa: Government Gazette 9, November 2001; No. 22824) that states "It is an offense to charge a fee in relation to the donation of human organs." In many countries, however, various lay press report that "the sale of body parts is now coming of age." Terms such as "rewarded gifting" and "donors" being transformed into "vendors" are opening a Pandora's Box (Nelson et al.,1993, "Financial incentives for organ donation: a report on the UNOS ethics committee payment subcommittee"). Cameron and Hoffenberg (1999, Kidney Int. 55:724-732) feel strongly that arguments in favour of the sale of organs are sufficiently cogent to warrant further discussion. Equally disturbing is the use of executed prisoners as organ donors. In the developing world there are additional socio-economic, indigenous and cultural, religious, and ethical issues to consider. In addition, strategies that are ethically sound and morally acceptable to expand the pool of living donors must keep pace with recent advances in medicine. A paradigm shift is required for anatomists to contribute to the international ethical debate, not only as custodians of the dead but also as protectors of the living. Their voices should be heard in transplantation and other forums, and contribute to the ethical debate as well as relevant evolving legislature. Clin. Anat. 18:150-153, 2005. (c) 2005 Wiley-Liss, Inc.

An embryological study of fetal development of the rectourethralis muscle--does it really exist?
Sebe P, Oswald J, Fritsch H, Aigner F, Bartsch G, Radmayr C
J Urol 2005 Feb;173(2):583-6.

PURPOSE: The so-called rectourethralis muscle is widely described in the urological literature. However, its description is subject to variations concerning extent and morphology. Moreover, little is known about its fetal development, which would allow a better understanding of the adult anatomy. The aim of this study was to investigate the morphology, extent and development of the rectourethralis muscle in fetal specimens. MATERIALS AND METHODS: A total of 15 normal human male fetuses were included in the study. Age ranged from 13th week of gestation to term. The histological study used plastination and standard and immunohistochemical techniques to identify the developing muscular structures in serial sections of the rectourethral space. Investigations in all 3 planes (coronal, sagittal and transverse) were performed. RESULTS: In all sections of the proximal aspect of the rectourethral space no developing muscle fibers could be identified leaving the anterior wall of the rectum to join the rhabdosphincter or the apical prostate. In the distal aspect of the rectourethral space an independent muscular structure located between the external muscular layer of the anorectal canal and the dorsal bundles of the rhabdosphincter could be clearly demonstrated. This structure consisted of connective, smooth and striated muscle tissue, and was deeply anchored to the apical perineal body. CONCLUSIONS: This study suggests that the so-called rectourethralis muscle is a misnomer in the urological literature. In the fetal period a developing muscular structure could be clearly identified as a part of the apical perineal body, which would correspond to the rectoperinealis muscle in the adult.

Pelvic organ support in pregnancy and postpartum.
O'boyle AL, O'boyle JD, Calhoun B, Davis GD
Int Urogynecol J Pelvic Floor Dysfunct 2005 Jan-Feb;16(1):69-72. Epub 2004 Jul 31.

The purpose of this study was to evaluate pelvic organ support during pregnancy and following delivery. This was a prospective observational study. Pelvic organ prolapse quantification (POPQ) examinations were performed during each trimester of pregnancy and in the postpartum. Statistical comparisons of POPQ stage and of the nine measurements comprising the POPQ between the different time intervals were made using Wilcoxon's signed rank and the paired t-test. Comparison of POPQ stage by mode of delivery was made using Fisher's exact test. One hundred thirty-five nulliparous women underwent 281 pelvic organ support evaluations. During both the third trimester and postpartum, POPQ stage was significantly higher compared to the first trimester (p<0.001). In the postpartum, POPQ stage was significantly higher in women delivered vaginally compared to women delivered by cesarean (p=0.02). In nulliparous pregnant women, POPQ stage appears to increase during pregnancy and does not change significantly following delivery. In the postpartum, POPQ stage may be higher in women delivered vaginally compared to women delivered by cesarean.

The bion device: a minimally invasive implantable ministimulator for pudendal nerve neuromodulation in patients with detrusor overactivity incontinence.
Bosch JL
Urol Clin North Am 2005 Feb;32(1):109-12.

Injectable neuromodulatory agents: botulinum toxin therapy.
Frenkl TL, Rackley RR
Urol Clin North Am 2005 Feb;32(1):89-99.

Neuromodulation for constipation and fecal incontinence.
Jarrett ME
Urol Clin North Am 2005 Feb;32(1):79-87.

Percutaneous neuromodulation.
Cooperberg MR, Stoller ML
Urol Clin North Am 2005 Feb;32(1):71-8.

Complications and troubleshooting of sacral neuromodulation therapy.
Hijaz A, Vasavada S
Urol Clin North Am 2005 Feb;32(1):65-9.

Expanding indications for neuromodulation.
Bernstein AJ, Peters KM
Urol Clin North Am 2005 Feb;32(1):59-63.

European experience with bilateral sacral neuromodulation in patients with chronic lower urinary tract dysfunction.
van Kerrebroeck EV, Scheepens WA, de Bie RA, Weil EH
Urol Clin North Am 2005 Feb;32(1):51-7.

Current indications for neuromodulation.
Daneshgari F, Moy ML
Urol Clin North Am 2005 Feb;32(1):37-40.

Surgical techniques of sacral implantation.
Chai TC
Urol Clin North Am 2005 Feb;32(1):27-35.

Selecting patients for sacral nerve stimulation.
Siegel SW
Urol Clin North Am 2005 Feb;32(1):19-26.

How sacral nerve stimulation neuromodulation works.
Leng WW, Chancellor MB
Urol Clin North Am 2005 Feb;32(1):11-8.

Neuromodulation in voiding dysfunction: a historical overview of neurostimulation and its application.
Fandel T, Tanagho EA
Urol Clin North Am 2005 Feb;32(1):1-10.

Neuromodulation: past, present, and future.
Steers WD
Urol Clin North Am 2005 Feb;32(1):xv-xvi.

Pelvic neuromodulation.
Daneshgari F
Urol Clin North Am 2005 Feb;32(1):xiii-xiv.

Pelvic neuromodulation.
Resnick MI
Urol Clin North Am 2005 Feb;32(1):xi.

Solitary fibrous tumor in the pelvic cavity with hypoglycemia: report of a case.
Nagase T, Adachi I, Yamada T, Murakami N, Morita K, Yoshino Y, Katayanagi K, Kurumaya H
Surg Today 2005;35(2):181-4.

A case of solitary fibrous tumor (SFT) in the pelvic cavity with hypoglycemia is reported. The patient was a 60-year-old man who was referred to our hospital for a closer examination of hypoglycemia. Computed tomography demonstrated a mass, measuring 14 x 9 cm in size, in the pelvic cavity. Magnetic resonance imaging showed the mass to have a low signal intensity on T1-weighted images and a high intensity on T2-weighted images. Laparotomy revealed no peritoneal dissemination nor lymph node metastasis. An en bloc excision of the tumor was performed with a good recovery, and the hypoglycemia disappeared. Histologically, the tumor was composed of spindle-shaped and oval cells in sarcoma, based on a moderate mitotic rate and cellularity. Immunohistochemically, the tumor was positive for CD34 and negative for keratin, alpha-smooth muscle actin, desmin, S100 protein, c-kit protein, and epithelial membrane antigen. Based on these findings, the tumor was diagnosed to be malignant SFT in the pelvic cavity.