bristolanatomycourse

The retropubic space in a nulliparous subject

2010-11-05T09:48:00.004Z

This view of the retropubic space in a nulliparous woman is 20 years old. The posterior surface of the pubis is clear. The anterior surface of the bladder is clear with the urethra passing beneath the two ligaments and the inferior border of the symphysis pubis
.

RF Zacharin christened them the pubourethral ligaments though there has always been some discussion about precise origins and insertions. Recent MR studies regularly describe them in detail. There are some variations with parity - as there are with uterosacral ligaments. In contrast to the uterosacrals these ligaments do not seem to reattach when they have been disrupted though the uterosacrals frequently reattach giving the impression of an intact lower genital tract - when it is anything but !

Do they contain nerves, and if so, where these nerves come from ?

Unusual uterosacral "defect" ?

2010-11-05T09:39:00.000Z

Another uterosacral defect demonstrating - almost a hernia - in the left uterosacral ligament. Again a Chinese patient delivered by forceps and presenting with chronic pelvic pain. The right uterosacral ligament is almost completely intact.

What is your advice to this patient ?

2010-11-05T09:35:00.000Z

More uterosacral injuries at laparoscopy. On this occasion a Chinese patient, delivered in Hangzhou - which is interesting because the CS rate is 60-70% and there are correspondlingly few vaginal deliveries. On this occasion there is absent of the left uterosacral ligament that is plastered against the left pelvic side wall. The right uterosacral ligament is almost intact. In this patient the features are clearly defined because of the prior procedure to remove the left ovarian endometrioma - by a second year resident. Peritoneal lavage with normal saline outlines the key anatomical features.

12th BAC will be held at St Georges,16 & 17th September, 2010

2010-05-31T08:24:00.005+01:00

The 12th BAC will take place at Department of Anatomy, St Georges, University of London on 16th and 17th September 2010.

Famous alumni of SGUL include Henry Gray and Robert Lee, who both made important contributions to gynaecology in the nineteenth century. In those days materials were stored in alcohol rather than formalin - the latter destroys fine anatomical detail. We hope to offer you material preserved so as to demonstrate important anatomical details on the course .

The local Course Organiser is Mr Paul Carter, Consultant in Obstetrics & Gynaecology, and the Gynecare Guest Lecture will be given by Miss Michelle Fynes, Consultant in Urogynaecology at St Georges NHS Trust. The format of the course will be similar to the usual "Bristol" format. Accommodation will be available in a hotel in Wimbledon where the course dinner will be held on Thursday night.

We look forward to another great meeting with much new information to discuss.

The inferior hypogastric plexus

2009-10-21T22:09:00.008+01:00

The three great autonomic plexi are the cardiac (thorax), coeliac (abdomen) and hypogastric (pelvic) plexi. Our collective awareness has diminished since WW2 when cadaveric teaching material were stored in formalin. The great nineteenth century anatomists including Robert Lee and Henry Gray used alcohol to preserve their material . None of the 200 colleagues on the Bristol Anatomy Course had seen this material prior to the course. Diabetologists have not seen the coeliac plexus. Cardiac surgeons have not seen the cardiac plexus as they tend to avoid the posterior surface of the left atrium.

This view of the inferior hypogastric plexus (IHP) is from material embalmed in methanol. The morphological detail is dramatically improved over formalinised material where there is barely a strand of neurological material in place of the entire plexus. Injuries in childbirth and persistent straining during defaecation result in endometriosis, adenomyosis and fibroids through denervation-reinnervation. Similar principles apply to the other plexi so that many of Burkitt's diseases of Western civilisation may result from autonomic injury.

Aberrant reinnervation in the Fallopian tubes

2009-09-23T15:52:00.013+01:00

Dr John Sampson first proposed that retrograde menstruation gave rise to endometriosis in the 1920's. Contemporary gynaecology does not give a mechanism for this "reverse" flow of menstrual debris from the uterus along the Fallopian tubes.

New studies (UK, Australia, Belgium) confirm abnormal nerves in the uterus that may upset the normal pattern of menstruation. Others have shown disordered motility of the Fallopian tubes though without demonstrating abnormal nerves in the Fallopian tubes. The image shows a cross section of the Fallopian tube as it passes through the uterine muscle (intramural Fallopian tube). Nerve fibres stain brown using an antibody named anti-S100 (standard histological technique). At 2, 4, 8 and 10 o'clock there are collections of abnormal nerves around the Fallopian tube. Nerves are important in propelling material in the correct direction. These abnormal nerves will also promote retrograde menstruation and prevent normal progress of the egg from the ovary to the uterus. This is the first publication of this observation. Injuries in childbirth and during physical efforts during defecation may contribute to these observations - among other events.

International Society for Fallopian Tubes 2009

2009-09-05T09:41:00.014+01:00

The Royal London Hospital played host to a two-day meeting of the ISFT. And a very good meeting resulted. Startling access to the Fallopian tube from every conceivable angle. There were too many highlights to describe in detail. Witnessing the cone-shaped, swirl of mucus at the time of ovulation that touched down on peritoneal surfaces looking for the fimbriae of the Fallopian tube. Like a non-violent tornado or bath water looking for the plughole - safe conduct of the egg was assured . There was no random explosion from the surface of the ovary - just subtle and quiet precision captured for the moment. And no randomised controlled trial for this piece of insight - thankfully.

Then we had 4D ultrasound, fertiloscopy and salpingoscopy to confirm tubal patency and normal mucosae. Impeccable microsurgery from Dr Charles Koh, Milwaukee, and Professor Tranh, France who used 8/0 suture material in multiple planes to re-join tubes in the most compromised positions. Finally, in a tour de force, Dr Gregorii Brodski, a German colleague, described the blood supply, nerve supply and morphology of 100 Fallopian tubes - a postdoctoral thesis in 15 minutes.

Robert Lee and the cardiac plexus

2009-09-01T10:33:00.006+01:00

Robert Lee, of St Georges Hospital, Hyde Park, London, drew the pelvic plexi from women who died during pregnancy. Specimens were preserved in alcohol. He repeated the process in non-pregnant women and animals to confirm the observations. He had some difficulty persuading his colleagues including Dr T Snow Beck. After the resignation of the Marquess of Northumberland and the entire Physiological Committee of The Royal Society, Lee's findings became accepted. He then went on to draw the cardiac plexus (above) which he published in 1851.

If he were around at the moment he might be asking where all those abnormal conduction pathways originate ? what is their natural history ? and what is the impact of their "ablation" ?

The cardiac plexus

2009-08-30T11:58:00.013+01:00

Cardiologists are busy "ablating aberrant pathways" in patients with arrhythmias. Some of these abnormal pathways are clearly aberrant nerves (UCLA group).

http://www.ncbi.nlm.nih.gov/pubmed/19631911?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Superior, middle and inferior cardiac nerves converge bilaterally on the cardiac plexus on the posterior surface of the left atrium among the pulmonary veins - in "tiger country". No cardiac surgeons go there; neither do many cardiologists. http://www.bartleby.com/107/220.html

One of the original descriptions was by Robert Lee of St Georges Hospital, London in 1851. He had already found the inferior hypogastric plexus in postpartum women (where it is enlarged) then he proceeded to non-pregnant women and animals to confirm the observations. His preparations were preserved in alcohol - not formalin. The above is a plasticised specimen that shows an outline of the plexus rather than all of it.

http://ukpmc.ac.uk/articlerender.cgi?artid=517813

One common source of midline autonomic injury is persistent physical efforts during defaecation which has different effects from infancy to the elderly. Another is childbirth for the same reasons. There will be many other sources of injury. If cardiologists ablate neural pathways, will they not result in more "sprouting" of pathways ? Some more natural history must be helpful.

http://heart.bmj.com/cgi/content/extract/95/13/1108-b

Uterosacral ligaments - part 3

2009-08-18T20:05:00.011+01:00

There is an increasing awareness that obstetric events in a womans’ first labor may contribute to her subsequent gynaecological outcomes (1).

The initial evidence arises from studies in the 1950’s from St Louis, Missouri, which related chronic pelvic pain to difficulties in labor (2). More recent evidence offers the view that intrapartum injuries to autonomic nerves contributes to the development of endometriosis, adenomyosis and leiomyomas (3, 4). In a prospective study of 2240 nulliparous women over four years, there were

worse gynaecologic outcomes at 47 months follow-up for almost all intrapartum interventions including induction of labor. http://www.whonamedit.com/synd.cfm/1697.html

Uterosacral ligaments contain branches of the inferior hypogastric plexus that deliver autonomic nerves to the uterus and vagina. Difficult intrapartum episodes results in attenuation, or even avulsion, of the uterosacral ligaments with widespread reinnervation at the site of the injury presenting with chronic pelvic pain 5-10 years later (3-5). Uterosacral “defects” are not widely recognised in the clinical literature though vaginal, levator and neurologic injuries have been recorded as adverse consequences of vaginal delivery.

That gynaecologic outcomes may be a consequence of intrapartum events is an important question that needs urgent attention.

More about uterosacral ligaments

2009-08-13T15:05:00.007+01:00

Childbirth results in injuries to muscles, ligaments, blood vessels and nerves throughout your pelvis. These injuries heal over time.

Many women present with gynaecological symptoms some years after childbirth. They often have extensive investigations including pelvic imaging and diagnostic laparoscopy. New, powerful imaging techniques including 3D ultrasound and MRI demonstrate the legacies of injuries in childbirth.

As long ago as the 1930's HL Gainey, Kansas described deficits in anatomical support of the vagina in women with prolapse that he called "vaginal defects". More recently we have found levator "defects", uterosacral ligament "defects" and neurological "defects" in women with menstrual problems, pelvic pain, prolapse, incontinence - in fact, in almost every form of clinical gynaecological presentation.

The study of these injuries, will lead to improvements in womens' gynaecological care in the next few years. Notably where there have been injuries to pelvic nerves as their re-growth may cause much pain and suffering.

Uterosacral injuries, or, "defects"

2009-08-05T17:51:00.011+01:00

The consequences of vaginal delivery on the posterior axis of pelvic support along the uterosacral-rectovaginal-perineal axis, may not have been fully appreciated. At most laparoscopy lists you will see examples of avulsion, attenuation or asymmetry of uterosacral ligaments in women with chronic pelvic pain (Fig 1 & 2). The left uterosacral ligament is missing, the right is pulled out of its sheath, there is evidence of scarring - almost rupture - of the posterior aspect of the uterus, and, there are extensive varices
.

Treatment with GnRH provided temporary, though incomplete, relief. Immunohistochemistry of the uterine isthmus and uterosacral insertions showed extensive reinnervation. The pain was largely relieved after hysterectomy.

Attribution of pain is always controversial. Abnormal innervation inevitably contributes to pain - and it frequently recurs despite removal of all pelvic organs. The extent of the contribution of other injuries is less certain.

Bristol Anatomy Course No.12

2009-07-30T21:35:00.004+01:00

The next Bristol Anatomy Courses for gynaecologists will be in 2010. The primary aim of the course is to provide you with precise and up-to-date clinical anatomy to assist you with your surgical work. We deal with normal nulliparous and multiparous anatomy though the main task is to understand the anatomical consequences of normal delivery.

The anatomical injuries contribute to many gynaecological presentations . In North America these mature, anatomical injuries are known as "anatomic defects". Originally there were "fascial defects" though we now have fascial, levator, uterosacral, vascular and neurological "defects". Each has its own set of appearances and clinical consequences - over time.

It is quite a lot to get through in a two-day course, though we do use many different educational formats with some talented faculty. There is plenty of time for informal discussion with the faculty and Gynecare colleagues (http://www.gynecare.com/ ) before, and during, the course dinner.

See http://www.bristolanatomycourse.co.uk/ for details.