2010 PG course surgical anatomy ±è¼±¿Á Àü³²´ë 2010-11-14.pdf

Basic urogyn anatomy slides

1. Understanding the
surgical anatomy of
female pelvis
Sun-OuckKim
From the Department of Urology, Chonnam
National University College of Medicine

2. CHONNAM NATIONAL UNIVERSITY HOSPITAL
female bony pelvis
Fig 1.The female pelvis from above: the sacrospinous ligament extends from the ischial spines to the lateral
margins of the sacrum and coccyx anterior to the sacrotuberous ligament, which extends from the ischial
tuberosity to the coccyx. The sciatic foramina are above and below the sacrospinous ligament and anterior
to the sacrotuberous ligament.

3. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Muscular support of pelvic floor
Pelvic diaphragm
Fig 2. A caudal view of the levator ani muscles in the bony pelvis.

4. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Levator ani muscles
Fig3.Thelevatoranimuscleseenfromabovelookingoverthesacralpromontory(SAC)showingthe
pubovaginalmuscle(PVM).Theurethra,vagina,andrectumhavebeentransectedjustabovethepelvicfloor.
PAMdenotespuboanalmuscle;ATLA:arcustendineuslevatorani;andICM:iliococcygealmuscle.(Theinternal
obturatormuscleshavebeenremovedtoclarifylevatormuscleorigins.)(FromKearneyetal.2004,32with
permissionofElsevierNorthHolland,NewYork,cDeLancey2003)
Urogenital hiatus

5. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Pelvic floor structures
Fig4.(Top)Inferiorthree-quarterview,seenfromtheleft,ofthepelvicfloor
structuresappearingbehindtheischiopubicrami(grey).Thatportionofthe
perinealmembrane(blue)connectingthepuboperineusmusclesintheperineal
bodyisshown.Thelateralportionsoftheperinealmembranehavebeenremoved.
(Bottom)Thepelvicbones(outlinedfromimageaboveinwhite)andperinealbody
havebeenremovedtoshowaclose-upofthearrangementoftheiliococcygeal,
pubococcygeal,andpuborectalismuscles,aswellastheurethra(umber),vagina
(pink),andrectum(brown).Individualmusclebandsareidentifiedbyanumber
inscribedneartheiroriginonthearcustendineus(white).Thepuboperineus
muscle(2)ispartofthepubococcygealmuscle.Thisfigureappearsincoloronline
(FromLienetal.,532004)

6. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Levator plate
Fig 5.Midsagittal section of the pelvis. A, Normal tone in the levator ani with acute anorectal angle and horizontal
levator plate. Note the normal vaginal axis. B, With loss of tone in the levator ani there is change in the vaginal axis,
sagging of the levator plate, and enlargement of the urogenital hiatus. Note the wider angle.

7. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Urogenital diaphragm
(triangle)
Fig 6. Muscles of the perineum. On
the subject's right side, the
membranous layer of the superficial
fascia has been removed (note the
cut edge).On the subject's left side,
the symphysis pubis, pubis, part of
the ischiopubic ramus, superficial
perineal muscles, and inferior fascia
of the urogenital diaphragm have
been removed to show the deep
perineal muscles.

8. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Urethral support system
Fig7.Lateralviewofthecomponentsoftheurethralsupportsystem.Notehowthelevatoranimusclessupportthe
rectum,vagina,andurethrovesicalneck.Alsonotehowtheendopelvicfasciabesidetheurethraattachestothelevator
animuscle;contractionofthelevatormuscleleadstoelevationoftheurethrovesicalneck.Puborectalismuscleis
removedforclarity.Drawingshowsthecontinuityofthedeepperinealmuscleswiththesphincterurethrae.

9. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Urethral and pelvic floor
muscular anatomy
Fig 8. Lateral view of urethral and pelvic floor
muscular anatomy. BC denotes bulbocavernosus;
CU, compressor urethrae; D, detrusor; LA,
levator ani; US, urethral sphincter; UVS,
urethrovaginal sphincter. Puborectalis muscle is
removed for clarity. (c DeLancey 2004).

10. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Perineal body
Fig 9.Diagram of pelvic organs. This shows the two major muscular supporting structures. The upper is the pelvic
diaphragm, and the lower is the perineal membrane with associated muscles anteriorly and the anal sphincter
posteriorly

11. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Endopelvic fascia
connective tissue supports
Fig 10. The arcus tendineus represents the insertion of the levator muscle into the obturator muscle of the lateral
pelvic side wall.

12. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Levator plate and pelvic fascia
Thomas M. Pelviperineology 2008; 27: 156-159
Fig 11. Several views of
pelvic fascia (in blue
color): this conjonctive
structure stretches
transversally and, from
front to back,from its
nearly circonferencial
insertion.

13. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Anterior urethral supports
Fig 12.Cross section of urethral supports below the bladder neck. The urethra is supported by a hammock of anterior
vaginal wall suspended to the levators (pubococcygeus muscles) and the fascial attachments (FA) to the tendinous arch of
the pelvic fascia. In essence it is a ―double hammock.‖ Illustrations of anterior vaginal wall defects
Photo of the space of Retzius. White arrows shows the arcus tendineus levator ani and the black
arrows the arcus tendineus fasciae pelvis.

14. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Anterior vaginal wall defects
Fig 13.Illustrations of anterior
vaginal wall defects. A, Normal
bladder supported by suspension to
arcus tendineus of the pelvic fascia
(ATPF). The arrowson the diagrams
show the amount of descent that
occurs with the weakness of the
supports. B, Cystocele from
weakness of central vaginal wall
supports. C, Cystocele from
weakness of lateral supports, either
separation of the ATPF from the
fascia overlying the levator ani
muscle on the right or stretching of
the fascial layer. D, Cystocele from
a combined central and lateral
defect.

15. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Middle support:
Cardinal and uterosacral ligaments
Fig 14.The cardinal and uterosacral ligaments provide
support to the cervix and indirectly the bladder base.
The retropubic, vesicovaginal, and rectovaginal spaces
are seen at the level of the cervix.

16. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Posterior supports;
Vagina and supportive structures
Fig15.Vaginaandsupportivestructuresdrawnfromdissectionof56-year-oldcadaverafterhysterectomy.Bladderhasbeen
removedabovethevesicalneck.Paracolpiumextendsalonglateralwallofvagina.B,InlevelI,paracolpiumsuspends
vaginafromlateralpelvicwalls.InlevelII,vaginaisattachedtoarcustendineusofpelvicfasciaandsuperiorfasciaoflevator
animuscles.

17. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Perineal membrane
Fig16.(A)Theperinealmembranespansthearchbetweentheischiopubicramiwitheachsideattachedtothe
otherthroughtheirconnectionintheperinealbody.(B)Notethatseparationofthefibersinthisarealeavesthe
rectumunsupportedandresultsinalowposteriorprolapse.(cDeLancey1999)

18. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Posterior prolapse
Fig18.steriorprolapseduetoseparationoftheperinealbody.
Notetheendofthehymenalringthatlieslaterallyonthesideof
thevagina,nolongerunitedwithitscompanionontheotherside.
(cDeLancey2004)
Fig17.Mid-vaginalposteriorprolapsethat
protrudesthroughtheintroitusdespiteanormally
supportedperinealbody.(cDeLancey2004)

19. Brandon et al. Am J Obstet Gynecol. 2009 May ; 200(5): 583

20. Fig 21. A, Image at level of anorectal junction shows intact puborectalis muscle (arrows) forming sling around rectum (R). Note
right puborectalis muscle is thinner than left. B, At level of rectum shows relationship between internal anal sphincter (arrowheads),
external anal sphincter (black arrows), and puborectalis muscle (white arrows). C, Rectum shows normal iliococcygeus muscles
(arrows) with upward convexity. D, At level of rectum shows urogenital diaphragm (white arrows) as most caudal layer of pelvic
floor with attachment to external anal sphincter (black arrows). Note right side of diaphragm is thinner than left. E, At level of anal
canal illustrates normal internal (arrowhead) and external (arrows) anal sphincter muscles.
Woodfield et al. AJR 2010;194:1640-1649

21. Fig 22. Pubococcygeal line
(PCL) (black line, A) extends
from inferior symphysis pubis
to last joint of coccyx (A) and
midpubic line (MPL) (long
white line, B) extends along
long axis of symphysis pubis
(B). Perpendicular
measurements from anatomic
reference points in anterior
(dashed lines), middle (arrows),
and posterior (short white lines)
compartments are also shown
with respect to PCL and MPL.
Fig 23. -Descent of bladder
base (arrow) 3.5 cm below both
pubococcygeal line (PCL)
(dashed line) and 1.5 cm below
midpubic line (MPL) (solid line)
consistent with moderate (PCL
staging) or stage 3 (MPL
staging) bladder prolapse.
-Descent of uterus with anterior
cervical lip (white arrow) 5.0 cm
below both pubococcygeal line
(PCL) (dashed line) and 1.2 cm
below midpubic line (MPL)
(solid line) consistent with
moderate (PCL staging) or
stage 3(MPL staging) uterine
prolapse.Also note bladder
prolapse (black arrow).
MPLPCL

22. Table 2. MRI Staging of Pelvic Organ Prolapse Using PubococcygealLine (PCL)
Stage Criteria *
Small prolapse 1 to < 3 cm below PCL
Moderate prolapse 3–6 cm below PCL
Large prolapse > 6 cm below PCL
Note—Moderate prolapseand large prolapseare usually symptomatic *Distance of inferior
bladder base, anterior cervical lip, and anterior anorectaljunction from PCL.
Stage Criteria*
0 > 3 cm to (TVLb–2 cm) above MPL
1 Does not meet stage 0, but > 1 cm above MPL
2 ≤ 1 cm above or below MPL
3 > 1 cm below MPL
4 Complete organ eversion
Note—Stages 2–4 are usually symptomatic. The MPL reference line and clinical pelvic organ prolapsequantification
examination use the same staging system. *Distance of inferior bladder base, anterior cervical lip, and anterior anorectal
junction from MPL. On physical examination and sagittalMR images, total vaginal length (TVL) is the greatest vertical vaginal
measurement in centimeters from the posterior vaginal fornix to the level of the introitusin patients with a cervix. In patients
without a cervix, the measurement is made from the most superior aspect of the vaginal cuff to the level of the introitus.
Table 3. MRI Staging of Pelvic Organ Prolapse Using Midpubic Line (MPL)
Singh K, et al. Am J Obstet Gynecol Gynecol 2001; 185:71–77

23. CHONNAM NATIONAL UNIVERSITY HOSPITAL
POPQ system
Fig 19. Landmarks for quantitative pelvic examination: Aa,
point A anterior; Ap, point A posterior; Ba, point B anterior;
Bp, point B posterior; C, cervix or vaginal cuff; D,
posterior fornix (if cervix is present); gh, genital hiatus; pb,
perineal body; tvl, total vaginal length.
Fig 20. Diagrammatic representation of a stage 3 anterior
vaginal wall prolapse identifying both the POPQ points.
Stage 3 Ba

24. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Stage Leading edge of points Aa, Ba, Ap, Bp Leading edge of point C and/or D
0 All 4 points (Aa, Ba, Ap, Bp) are 3 cm above the hymenalremnants (value
¼ 23) Points C and D are at a position above the hymenalremnants that
is equal to or within 2 cm of the total vaginal length (values ≥ -(tvl*-2))
1 All points are >1 cm above the hymenalremnants (value ≤-1)
2 Leading edge of the prolapseprotrudes to a point to or above 1 cm above
the hymenalremnants but no more than 1 cm beyond the hymenal
remnants (value ≥-1 to ≤+1)
3 Maximal prolapseprotrudes at least 1 cm beyond the hymenalremnants
but <2 cm the total vaginal length (value ≥+1 to +( tvl-2))
4 Maximal prolapseprotrudes to within 2 cm of the total length of the
vaginal tube (value ≥ (tvl-2))
*tvl¼ total vaginal length
Table 1. Ordinal Staging System of the POPQ
Staging of POPQ system

25. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Anatomy of the female urethra
Fig24.Midsagittalsectionshowingtheanatomyoftheolderfemaleurethra.(cDeLancey1997)

26. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Transverse histologic section
of the midurethra
Fig 25. Transverse histologic
section of the midurethra from a
21-year-oldwoman. At left,
structures are visualized using a
sigma-actin smooth muscle stain.
At right, the contralateral side is
stained with Masson‘s trichrome.
Shown are the pubovesical
muscle (PVM), the circumferential
smooth muscle (C. Sm M)
surrounding the submucosa of the
urethral lumen, and the
longitudinal smooth muscle (L.
Sm M) layer. At right, the
contralateral side is stained with
Masson‘s trichrome to show the
arcus tendineus facia pelvis
(ATFP), the striated urogenital
sphincter muscle (Str. M), the
levator ani (LA), and the anterior
vaginal wall (V).

27. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Hormonal sensitive urethra
Urethral mucosa
Transitional cell
-> Nonkeratinizing squamous cell
Submucosal tissue
Rich vascular plexus
Special arteriovenous anastomosis
Watertight closure / increased blood flow
Connective tissues
Glands-middle, lower third urethra

28. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Mechanism of continence;
Hammock hypothesis

29. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Mechanism of continence;
Integral theory
Fig 26. The nine main connective tissue structures potentially needing surgical repair

30. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Zones of damage
Fig 27. The Suspension Bridge Analogy The suspension bridge analogy illustrates how the pelvic structures are
interdependent. In a suspension bridge strength is maintained through tensioning of suspensory steel wires (arrows).
Weakening any one part of the structure may disturb the equilibrium, strength and function of the whole. Relating the
analogy to figure 1-05, form (ie shape and strength) is achieved because the vagina and bladder are suspended from
the bony pelvis by ligaments (PUL, USL, ATFP) and fascia (F). The structural dimension develops when these are
stretched by muscle forces (arrows). The causes of dysfunction: the zones of damage

31. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Anterior zone
1. External urethral ligament (EUL)
2. Suburethral vagina (hammock)
3. Pubourethral ligament (PUL)
Middle zone
4. Arcus tendineus fascia pelvis
(ATFP)
5. Pubocervical fascial defect (PCF)
(cystocoele)
6. ‗Zone of critical elasticity‘ (ZCE) -
restoration of elasticity if ‗tethered‘
by scarring
Posterior zone
7. Uterosacral ligaments (USL)
defect
8. Rectovaginal fascial defect (RVF)
9. Perineal body (PB).
Fig 28. The nine main connective tissue structures potentially needing surgical repair
Connective tissue potentially
needing surgical repair

32. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Site-specific method for pelvic
floor repair
Figur 29. Site-specific method for pelvic floor repair T= Polypropylene tapes = Pubourethral (PUL), Uterosacral (USL),
Arcus tendineus fascia pelvis (ATFP

33. CHONNAM NATIONAL UNIVERSITY HOSPITAL
Functional pelvis
Increased knowledge of the anatomy of the
pelvic floor and lower urinary tract has led to
a better understanding of the
pathophysiology of incontinence and pelvic
organ prolapse.
This led to the development of newer and
minimally invasive treatment options.