[Anatomy of the visceral fascia of the pelvis from the didactic viewpoint]

Vaginal multipurpose prevention technologies: promising approaches for enhancing women's sexual and reproductive health

Introduction: Multipurpose prevention technologies (MPTs) have the potential to avert multiple concomitant sexual and reproductive health issues in women such as sexually transmitted infections and unintended pregnancy. MPTs incorporate one or more active pharmaceutical ingredients in a single product, which adds more convenience for users and may promote increased adherence. Various vaginal dosage forms/delivery systems have been studied for designing MPTs. However, several challenges remain that are mainly related to requirements of individual drugs or intended multiple applications.Areas covered: This review focuses on the emerging need and development of vaginal MPTs. It illustrates numerous examples that are currently in the preclinical and clinical development pipeline, highlighting the concept behind vaginal MPTs. The article also highlights the challenges associated with formulation design and development, including regulatory issues that need to be addressed.Expert opinion: Vaginal MPTs present great potential to empower women with novel, efficient, and safe products for protection against sexually transmitted infections and unintended pregnancy. However, several technological issues and regulatory gaps still need to be addressed in order to meet real-world needs.

Studies and methodologies on vaginal drug permeation

The vagina stands as an important alternative to the oral route for those systemic drugs that are poorly absorbed orally or are rapidly metabolized by the liver. Drug permeation through the vaginal tissue can be estimated by using in vitro, ex vivo and in vivo models. The latter ones, although more realistic, assume ethical and biological limitations due to animal handling. Therefore, in vitro and ex vivo models have been developed to predict drug absorption through the vagina while allowing for simultaneous toxicity and pathogenesis studies. This review focuses on available methodologies to study vaginal drug permeation discussing their advantages and drawbacks. The technical complexity, costs and the ethical issues of an available model, along with its accuracy and reproducibility will determine if it is valid and applicable. Therefore every model shall be evaluated, validated and standardized in order to allow for extrapolations and results presumption, and so improving vaginal drug research and stressing its benefits.

Terminologia Anatomica versus unofficial descriptions and nomenclature of the fasciae and ligaments of the female pelvis: a dissection-based comparative study

OBJECTIVE

The aims of this study were: (1) to define and classify those connective structures of the female pelvis that are of potential clinical interest, (2) to evaluate the adequacy of the Terminologia Anatomica (official nomenclature) and (3) to establish a correspondence between the official nomenclature and the most commonly used terms.

STUDY DESIGN

The results of 30 macroscopic and laparoscopic dissections of fresh cadavers with and without vessel injection of colored latex solutions were compared with the descriptions and definitions in the Terminologia Anatomica and the most frequently cited English and non-English literature from 1890 to 2003.

RESULTS

We identified 3 groups of fasciae, parietal pelvic fascia, visceral pelvic fascia, and extraserosal pelvic fascia, which could be divided into diverse clinically relevant anatomical structures characterized by different locations, spatial orientation, and consistency. These structures differed considerably with regard to number and nomenclature from those described in the Terminologia Anatomica and part of the literature.

CONCLUSION

Our results suggest that the official terminology applied to the connective structures of the female pelvis could be profitably revised and expanded. We offer a complete description of these structures and suggest a classification that may be useful for teaching and clinical purposes.

Morphology of the suburethral pubocervical fascia in women with stress urinary incontinence: a comparison of histologic and MRI findings

To correlate MRI with histologic findings of the suburethral pubocervical fascia in women with urodynamic stress incontinence. Thirty-one women with urodynamically proven stress urinary incontinence without relevant prolapse underwent preoperative MRI. Tissue specimens obtained from the pubocervical fascia were examined immunohistochemically (types I and III collagen, smooth muscle actin) and the results compared with the MRI findings. MRI demonstrated an intact pubocervical fascia in 61.3% of the cases and a fascial defect in 38.7%. A fascial defect demonstrated by MRI was associated with a decrease in actin (P<0.09) and an increase in collagen III (P<0.01) compared to an intact fascia. In women with stress urinary incontinence, smooth muscle actin in the pubocervical fascia is decreased, changed in structure, and replaced by type III collagen. MRI allows evaluation of the pubocervical fascia and its morphologic changes.

[Subdivision of the female pelvic connective tissue: new interpretation based on morphological and embryological studies]

As we suppose that the knowledge of the prenatal development within the pelvic floor is necessary to understand the subdivision of the pelvic connective tissue we studied transparent sections through the untouched pelvis of fetuses and newborn. We compared them with those of adults and included modern imaging techniques. Our results show, that the classical concept concerning the subdivision of the pelvic connective tissue needs to be revised.

Why consider vaginal drug administration?

OBJECTIVE

To review the anatomy and physiology of the vagina, the merits of vaginal drug administration, and the currently available vaginal drug-administration systems.

DESIGN

Review of basic and clinical research.

RESULT(S)

Although clinicians commonly use topically administered drugs in the vagina, this route for systemic drug administration is somewhat novel. Experience with a variety of products demonstrates that the vagina is a highly effective site for drug delivery, particularly in women's health. The vagina is often an ideal route for drug administration because it allows for the administration of lower doses, steady drug levels, and less frequent administration than the oral route. With vaginal drug administration, absorption is unaffected by gastrointestinal disturbances, there is no first-pass effect, and use is discreet. Knowledge of anatomy, physiology, histology, and immunology of the vagina should allow clinicians to reassure their patients concerning this mode of delivery. Greater understanding and experience by clinicians should lead to increased use and acceptance of the vagina as a route for drug administration.

CONCLUSION(S)

The safety and efficacy of vaginal administration have been well established. The vaginal route of drug delivery is acceptable and may even be a preferable route of administration for many drugs, particularly hormones, whether for contraception or postmenopausal estrogen therapy.

Total pelvic mesh repair: a ten-year experience

INTRODUCTION

This report describes our technique and experience in restoring the pelvic floor of females with pelvic organ prolapse.

METHODS

Total pelvic mesh repair uses a strip of Marlex Mesh secured between the perineal body and the sacrum. Two additional strips, attached to the first, are tunneled laterally to the pubis and support the vagina and bladder laterally. Candidates for the procedure have failed previous standard repair or manifest combined organ prolapse on physical and cystodefecography exams.

RESULTS

From January 1990 to December 1999, 236 females had total pelvic mesh repair, and 205 (87 percent) were available for follow-up. Median age was 64 (range, 32-89) years, median parity 2 (range, 1-9); 63 percent had birth-related complications. Bladder protrusion, vaginal protrusion, or both were the predominant chief complaint (54 percent), followed by anorectal protrusion (48 percent). Findings on physical examination showed degrees of prolapse of rectum (74 percent) and vagina (57 percent), perineal descent (63 percent), enterocele (47 percent), and rectocele (44 percent). Mean procedure time and length of hospital stay were 3.2 (standard deviation 0.75) hours and 6 (standard deviation 2.2) days, respectively. Reoperation rate because of complications of the total pelvic mesh repair procedure was 10 percent. Marlex erosion into rectum or vagina occurred in 5 percent of patients and constituted 46 percent of the complications requiring reoperation. Additional surgical procedures at various intervals subsequent to total pelvic mesh repair have been performed in 36 percent of patients to further improve bladder function and have been performed in 28 percent of patients to improve anorectal function. There has been no recurrence of rectal or vaginal prolapse to date. Reports of overall satisfaction for correction of primary symptoms for patients grouped into early (0.5-3 years), middle (>3-6 years) and late (>6 years) were 68 percent, 73 percent, and 74 percent respectively.

CONCLUSION

Total pelvic mesh repair is a safe and effective operation for females with pelvic organ prolapse.

The surgical anatomy of the fasciae and the fascial spaces related to the rectum

The perirectal fasciae and their vascular and neural relationships were studied based on the dissection of 46 fresh cadavers. The rectal fascia is a tubular sleeve, areolar in nature, which houses the superior rectal vessels and lymphatics. The nerves which supply fibres to the pelvic plexus run close to the rectum, contained in the urogenital and presacral fasciae. The rectum is attached to these two fasciae by the rectal stalks, which take a spiral course round the rectum, being posterolateral in the upper rectum, lateral in the mid-rectum and anterolateral in the lower rectum. During rectal resection the pelvic nn. may be preserved if the rectal dissection proceeds close to the rectal fascia. After cutting the rectal insertion of the presacral fascia, the lower rectal stalks (paraproctium) come into direct view and can be divided close to the rectal wall with no risk of damage to the pelvic plexus.

Topography and subdivision of the pelvic connective tissue in human fetuses and in the adult

We investigated epoxy resin impregnated sections through the pelves of 9 to 37-week-old fetuses, of newborn infants, and of adults to study the topography and subdivision of the pelvic connective tissue. Fetal and adult preparations show that the pelvic connective tissue can be subdivided into a presacral, a perirectal and a paravisceral compartment. Whereas the presacral and the perirectal compartment contain connective tissue, adipose tissue and supplying structures, the paravisceral compartment is mainly composed of adipose tissue. While only a very thin rectal fascia was found at the border of the perirectal compartment, no further visceral pelvic fascia can be seen in the impregnated sections. Moreover it is shown that the ligaments of the pelvic cavity are only composed of the sacrouterine ligaments and the pubovesical ligaments in the female and the puboprostatic ligaments in the male. Our data show that sectional anatomy provides new insights into the organization of the pelvic connective tissue, that may be of clinical importance.

Operative anatomy and technique of radical parametrial resection in the surgical treatment of cervical cancer

Wertheim's radical operation aimed, by removing the parametrial tissue far from the tumour, to achieve margins free of disease. The paratissues contain the lymphatic channels draining the cervix. They run to the pelvic wall and are interspersed by lymph nodes scattered throughout the parametrium. If lymphadenectomy is to be curative then the entire parametrium must be removed. To this end the resection of the cardinal ligament was pushed to its limit by dissection directly at the pelvic wall. The surgical technique is guided by the anatomy of the pelvic fascia. The gaine hypogastrique lies just beneath the peritoneum and facilitates the opening of the paravesical space. The following are discussed: the condensations of the pelvic fascia; the composition of the cardinal ligament; the division into a venous, an arterial, and a neurovegetative root; and the anatomy of the connective tissue planes. The order in which the surgical steps are carried out is important. The paraspaces are opened first. The ureter is identified, and lymphadenectomy is performed. The rectum is dissected off the vagina, and the uterosacral ligaments are identified and removed. Only then is the vesico-uterine fold opened. The bladder is dissected off the vagina, and the anterior parametrium is clamped and divided. Now the cardinal ligament is completely exposed. The bladder, rectum and ureter have been mobilized so that the parametrium can be divided sharply directly at the pelvic wall, clipping the vessels step-by-step. The paracolpium is clamped and divided according to the proposed vaginal cuff. Thus, the entire lymphatic drainage can be removed. The value of this extension of radical abdominal hysterectomy lies especially in the treatment of large, voluminous tumours.