The topography and morphometrics of the pubic ligaments

Penile suspensory ligament: anatomy, function, and clinical perspectives of its repair

BACKGROUND

The penile suspensory ligament (PSL) plays a significant role in penile support and erection and its injury or congenital absence may result in functional impairment of erectile function.

AIM

To describe the diagnosis and surgical repair technique for PSL abnormalities and overall outcomes.

METHODS

A comprehensive review of the literature was performed to understand the anatomic relevance of the PSL and historical management of PSL defects. A contemporary method for PSL repair is described using a transverse infrapubic incision with placement of midline anchoring (non-absorbable braided) sutures between the tunica albuginea (TA) and symphysis pubis to correct penile position and instability.

OUTCOMES

Surgical success defined as degree of penile curvature and penile stability for sexual intercourse as well as patient and partner satisfaction rates were reviewed.

RESULTS

Though limited in number, available case series in the literature indicate a success rate between 85-100%, and more recent reviews fall in the 85-91% range. Patient satisfaction rates vary from 82-88%, but some series included patients with penile dysmorphic disorder and Peyronie's disease, which are known to have higher dissatisfaction rates related to the underlying etiology itself. In patients with venogenic erectile dysfunction (ED), resolution was 100% but de novo ED occurred in 3-5%; these cases were all successfully managed medically.

CLINICAL IMPLICATIONS

This review addresses the diagnosis of PSL abnormalities and demonstrates a simple but effective repair technique to significantly improve erectile stability in men with acceptable risk.

STRENGTHS AND LIMITATIONS

This is a comprehensive review of the available research on PSL abnormalities that outlines its diverse patient presentation and a systematic method to diagnosis and repair PSL defects. The patient satisfaction rates are reasonably high but given the relatively rarity of this entity, larger longitudinal multi-institutional studies are required to further elucidate risks of de novo ED, penile shortening, and functional outcomes over the long-term.

CONCLUSION

PSL repair using permanent anchoring sutures or a fascial graft between the pubic symphysis and the TA of the corpora cavernosa is a safe and efficacious way to restore an important part of the penile suspensory apparatus that helps stabilize the penis during erection for normal sexual function.

Age-related morphological changes of the pubic symphyseal surface: using three-dimensional statistical shape modeling

Computational analysis of the pubic symphyseal surface is widely used for accurate age estimation, offering quantitative precision through the detection of subtle morphological changes. However, these methods often lack insights into the underlying morphological changes across different age groups. To bridge this gap, the study utilizes statistical shape modeling (SSM), a versatile tool capable of describing diverse morphological variations within populations. This study aimed to elucidate the direction and extent of these morphological changes, identify the contributing factors, and pinpoint key variations crucial for distinguishing between age groups. Computed tomography (CT) scans of 252 subjects from the National Forensic Service of South Korea were employed, subjected to preprocessing and landmark-based alignment. Through this approach, the study visualized and validated significant age-related morphological changes and highlighted the shape variations essential for differentiating between consecutive age groups. This study holds significance in elucidating the intricate nature of age-related morphological changes in the pubic symphyseal surface. Thus, these findings can serve as valuable cornerstones for enhancing age-at-death estimation techniques in forensic anthropology.

The Complex Challenge of Urosymphyseal Fistula and Pubic Osteomyelitis in Prostate Cancer Survivors

Background and objective

Urosymphyseal fistula (UF) and pubic osteomyelitis (PO) are rare and often poorly recognized long-term complications of treatment for localized prostate cancer. Our aim was to describe UF/PO in prostate cancer survivors.

Methods

We performed a retrospective review of 26 patients treated for UF/PO after localized prostate cancer treatment at University Hospitals Leuven (1996-2021). We analyzed data for demographic characteristics, history, urethral manipulations (UMs), diagnostic and therapeutic approaches, microbiology, and treatment success.

Key findings and limitations

Before diagnosis, 80.8% of the patients had undergone RP, 88.5% received radiotherapy, and 84.6% had at least one UM. The median time from radiotherapy (RT), the last UM, and the first symptoms to diagnosis were 102 mo, 4 mo, and 43 d, respectively. Treatment included cystectomy (n = 19), bladder-sparing interventions (n = 5), and conservative treatment (n = 2). Pubic debridement was required in 21 patients. All cystectomy patients had a history of RT. Imaging-detected UF led to cystectomy in 94.1% of cases. Full conservative treatment succeeded only in non-irradiated patients. Bone cultures were positive in 95% of cases and discordant with urine cultures in 82.4%. Reinterventions and severe complications affected 56.5% of patients; all were UF/PO-free after up to four treatment attempts. Our study is limited by the small sample size, retrospective nature, and possible information and referral bias.

Conclusions and clinical implications

UF/PO can occur years after local prostate cancer treatment. Risk factors include RT and UMs. Conservative treatment rarely succeeds, particularly in irradiated patients with persistent UF. Most patients require multidisciplinary treatment involving cystectomy and pubic debridement. A perioperative bone culture to guide postoperative antibiotic treatment is crucial because of discordance with urine cultures. Postoperative complications are common, often requiring reintervention. Caution with UMs is advised after pelvic RT.

Patient summary

We looked at data for patients with a rare complication that can occur after treatment for localized prostate cancer that involves a small tunnel between the lower urinary tract and the pubic bone, and infection in the pubic bone. Diagnosis occurred years after pelvic radiotherapy and shortly after a procedure performed through the urethra, typically surgery for narrowing of the urethra. Most patients needed removal of their bladder and surgical cleaning of the pubic bone, followed by long-term antibiotics. The bacteria found in bone were often different from those found in the patient's urine, which is important in guiding antibiotic treatment after surgery.

Morphology and arterial supply of the pyramidalis muscle in an Australian female population using computed tomography angiography

INTRODUCTION

The structure and function of the human anterolateral abdominal wall have been thoroughly described. However, there has been limited anatomical study of the pyramidalis muscle and its arterial supply. The aim of this study was to analyse the patterns of arterial supply to the pyramidalis in a female population.

METHODS

A retrospective study of 32 computed tomography angiography scans of the abdominal wall of adult women was performed to assess the prevalence (bilateral or unilateral presence, or absence), morphology (medial border height, base width and thickness) of pyramidalis and patterns of arterial supply.

RESULTS

Pyramidalis prevalence was bilateral in 75% of computed tomography angiography studies (24/32), unilateral in 6.3% (2/32) and absent in 18.8% (6/32). Of the five patterns of pyramidalis arterial supply observed and described in detail, the most frequent (68%, 34/50 of cases) originated from an exclusive muscular branch of the inferior epigastric artery. Origin from the pubic branch of the inferior epigastric artery was seen in 4% (2/50). There was a single case (2%, 1/50) of artery origin from a variant obturator artery, a common trunk with the pubic branch from the inferior epigastric artery, and from the muscular branch to rectus abdominis. The artery could not be defined in 22% (11/50).

CONCLUSION

In this computed tomography angiography study of women, five patterns of Pyramidalis arterial supply were identified. In the majority of cases, the pyramidalis derived its arterial supply from an exclusive, isolated muscular branch of the inferior epigastric artery.

Cleft Sign in MRI May Represent the Disruption of Cartilage Structure within Pubic Symphysis and Pubic Plate: A Cadaver Case Report

BACKGROUND/OBJECTIVES

Long-standing groin pain is a severe issue for athletes, often associated with the cleft sign on magnetic resonance imaging (MRI) scans, yet its underlying causes are poorly understood. The purpose of this study is to histologically examine the pubic plate structure in cadavers with and without the cleft sign on MRI, shedding light on the pathology behind the cleft sign.

METHODS

Three fresh human pelvic cadavers underwent 3.0T MRI to detect the cleft sign before histological dissection of pubic plates. Pubic plate tissues were fixed in formalin, decalcified, and processed. Of the two cleft sign-negative specimens, one was cut into sagittal sections, and the other was cut into coronal sections for histology. For the cleft sign positive specimen, a sagittal section was cut. Moreover, 5 µm thick sections were cut at different axial levels for each orientation. Sections were subjected to Safranin O, Alcian blue, and Herovici's staining or hematoxylin and eosin staining.

RESULTS

MRI confirmed that one specimen had a cleft sign in the inferior region on both sides of the pubis and that two specimens had no cleft sign. Both sagittal and coronal sections showed the presence of a cartilage structure continuing from the pubic symphysis to 3 mm laterally within the pubic plate. In the specimen with a positive cleft sign, cartilage damage within the pubic symphysis and pubic plate was identified as revealed by Safranin O staining, Herovici's staining, and H&E staining.

CONCLUSIONS

This study elucidated the existence of a cartilage component extending from the pubic symphysis to the pubic plate. The cleft sign in MRI correlated with a disruption in the cartilage component in histology within this specific area.

The Role of MRI in Groin Pain Syndrome in Athletes

Groin pain syndrome (GPS) is one of the most frequent injuries in competitive sports. Stresses generated in the lower limbs by quick turns and accelerations, such as in soccer, basketball or hockey, can produce localized regions of increased forces, resulting in anatomical lesions. The differential diagnoses are numerous and comprise articular, extra-articular, muscular, tendinous and visceral clinical conditions and a correct diagnosis is crucial if treatment is to be efficient. MRI is the gold standard of diagnostic techniques, especially when an alternative pathology needs to be excluded and/or other imaging techniques such as ultrasound or radiography do not lead to a diagnosis. This paper, based on the current literature, gives a comprehensive review of the anatomy of the pubic region and of the typical MRI findings in those affected by GPS. Many clinical conditions causing GPS can be investigated by MRI within appropriate protocols. However, MRI shows limits in reliability in the investigation of inguinal and femoral hernias and therefore is not the imaging technique of choice for studying these clinical conditions.

Significant relationship between musculoaponeurotic attachment of the abdominal and thigh adductor muscles to the pubis: implications for the diagnosis of groin pain

Groin pain is prevalent in orthopedic and sports medicine, causing reduced mobility and limiting sports activity. To effectively manage groin pain, understanding the detailed anatomy of supporting muscles is crucial. This study aimed to investigate the musculoaponeurotic attachments on the pubis and the relationship among intramuscular aponeuroses of abdominal and thigh adductor musculatures. Macroscopic analyses were performed in 10 pelvic halves. The bone morphology of the pubis was assessed in two pelvic halves using microcomputed tomography. Histological investigations were conducted in two pelvic halves. The external oblique aponeurosis extended to the adductor longus aponeurosis, forming conjoined aponeurosis, which attached to a small impression distal to the pubic crest. The gracilis aponeurosis merges with the adductor brevis aponeurosis and is attached to the proximal part of the inferior pubic ramus. The rectus abdominis and pyramidalis aponeuroses were attached to the pubic crest and intermingled with the gracilis-adductor brevis aponeurosis, forming bilateral conjoined aponeurosis, which attached to a broad area covering the anteroinferior surface of the pubis. Histologically, these two areas of conjoined aponeuroses were attached to the pubis via the fibrocartilage enthesis. Microcomputed tomography revealed two distinctive bone morphologies, a small impression and an elongated osseous prominence on pubis, corresponded to the two areas of conjoined aponeuroses. This study demonstrated close relationships between the aponeurotic attachment of the external oblique and adductor longus, and between the rectus abdominis, pyramidalis, gracilis, and adductor brevis. The findings of aponeurotic complexes would aid in diagnostic and surgical approaches for athletic groin pain.

New Insights into the Musculotendinous and Ligamentous attachments at the Pubic Symphysis: a systematic review

OBJECTIVE

Collection and meta-analysis of all relevant anatomical studies related to the pubic symphysis to provide a state of the art review of its musculotendinous and ligamentous attachments from 2010 to date.

METHODS

A systematic search of published literature databases (PubMed, Web of Science and Embase) was conducted according to the PRISMA guidelines from January 2010 up until now. All papers investigating the anatomy of the musculotendinous attachments of the pubis and the pubic ligaments were eligible. Methodological quality was assessed using the Quality Appraisal for Cadaveric Studies (QUACS scale). A narrative analysis approach was adopted to synthesise the findings.

RESULTS

After screening and review of 1313 papers, a total of six studies investigating the anatomy of the pubic ligaments and tendons were included. Of the six articles included in this systematic review, five articles performed a macroscopic anatomical dissection, three articles performed a microscopic (histological) study, and one article combined microscopic examination with an MRI imaging examination. The anatomy of the pubic symphysis was examined in 76 anatomical cadavers (60 embalmed, 16 fresh frozen). In total 44 male cadavers (58%), 28 female cadavers (37%) and four cadavers whose gender was not stated were dissected.

CONCLUSION

The age-old accepted concept of the fusion of the rectus abdominis with the adductor longus via the aponeurotic plate is outdated. New anatomical concepts like the pyramidalis-anterior pubic ligament-adductor longus complex (PLAC), recto-gracilis tendon, fusion of adductor brevis with gracilis, etc. are recently introduced. The awareness of anatomy and morphology of the pubic ligaments plays a significant role in understanding the diagnosis and treatment of groin pain.

A survey of pelvic types on computed tomography images

BACKGROUND

In the medical literature several classifications of the pelvis according to its shape can be found. The most common classification distinguishes four general pelvis types: gynecoid, android, anthropoid and platypelloid. Natural childbirth may be significantly prolonged, difficult or even impossible if the pelvis shape is not in proportion to the size of the fetus. The objectives of our study were to calculate major diameters and conjugate diameters of the female bony pelvic ring and to determine the major pelvic types according to their shape. Based on the parameters obtained, we aimed to establish a relationship between some pelvic types and difficult childbirth.

METHODS

The study was prospective in design and included 54 female subjects of various ages who had been referred for computed tomography of the pelvis, as part of the diagnosis of an underlying condition. In each patient, five most important parameters in two planes were measured and the pelvic type was determined by using the brim index and a special formula for android type. All measurements were performed using the Vue PACS v 12.1.6.1005 program. The description of the pelvic inlet was used to confirm all pelvic types. Data on previous births were taken from the questionnaire filled out by the subjects during the radiological examination.

RESULTS

Gynecoid pelvic type was the most common in our sample (28 pelvises - 52%), followed by platypelloid type (11 pelvises - 20%), anthropoid type (8 pelvises - 15%) and finally android type (7 pelvises - 13%). There was a statistically significant difference in the diameter bispinous length (p<0.05) between the platypelloid and anthropoid pelvic types. Pathological degree of stenosis was present in seven pelvises (the first degree in six pelvises and the second degree in one pelvis). The frequency of cesarean section was 31.82% and this technique was most frequently used in the subjects with a gynecoid pelvic type. The duration of natural labor ranged from 4 to 18hours. There was no statistically significant difference in the duration of labor between subjects with different pelvic types.

CONCLUSIONS

Gynecoid pelvic type was present in more than half of our subjects. Although this type is considered ideal for labor, we have not established that it has a great influence on whether the labor will be performed naturally or by cesarean section, neither that it significantly affects the length of birth. The gross narrowing of the pelvic ring is present in non-gynecoid pelvic types. The data obtained will certainly be useful to the obstetrician when planning the labor and considering all the factors that may affect the course of birth.

Imaging Insights Into Abdominal Wall Function

Purpose

The successful repair of any complex ventral hernia requires a thorough understanding of the underlying anatomical defect and its functional context. We describe an improved “functional” approach to CT imaging of the abdominal wall that can facilitate this understanding and assist surgical planning.

Methods

This invited article reports the observational experience gained from the functional abdominal wall CT examinations of 88 patients who underwent complex ventral hernia repair using pre-operative Botulinum toxin A (BTA) infiltration of the lateral oblique abdominal muscles as well as a further eight patients with diastasis rectus abdominis who were examined to exclude ventral hernia.

Results

The use of a functional CT protocol which supplements resting images with additional “crunching” images (acquired with the abdominal wall muscles all strongly contracted) can significantly improve the demonstration of ventral hernia defects. Crunching acquisitions can also help differentiate true hernias from dysfunctional bulges, identify muscle denervation or atrophic changes, reveal otherwise occult hernias that may be missed on resting or Valsalva images alone, and assist the pre-operative assessment of BTA effect.

Conclusion

A more functional approach to pre-operative CT imaging of the abdominal wall can significantly improve the understanding of complex ventral hernia defects and help formulate effective surgical plans that achieve low recurrence rates and good functional outcomes.