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1
Q

What is the location of the sacral plexus?

A

L4-S4 on the anterior surface of the piriformis muscle

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2
Q

Which nerves are in the presacral space?

A

-hypogastric nerves
-superior hypogastric plexus
-portions of the interior hypogastric plexus

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3
Q

What are the major branches of the sacral plexus?

A

Superior Gluteal
Inferior Gluteal
Sciatic
Posterior cutaneous nerve of thigh
Pudendal

‘Some Irish Sailor Pesters Polly’.

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4
Q

What are the boundaries of the presacral space?

A

-aortic bifurcation
-left common iliac vessels
-right ureter
-pelvic floor

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5
Q

What are the boundaries of the greater sciatic foramen?

A
  1. greater sciatic notch
  2. sacrotuberous ligament
  3. ischial spine and SSL
  4. anterior sacroiliac ligament.
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6
Q

What is the innervation of the muscles of the levator ani on the pelvic side and on the perineal side?

A

The pelvic aspect of the levator ani are innervated by a nerve that runs along the superior aspect of the muscles. The perineal innervation is from the pudendal nerve.

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7
Q

Which type of muscle fibers give the levator ani mm their baseline tone?

Which type of muscle fibers give the levator ani mm their ability to contract beyond the baseline tone?

A

type 1 slow twitch fibers

type 2 fast twitch fibers

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8
Q

Describe the boundaries of the retropubic space.

A

pubic symphysis
pubic rami
pubic bone
obturator internus mm
Bladder

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9
Q

Describe the content of the retropubic space.

A

dorsal clitoral neurovascular bundle
obturator neurovascular bundle,
venous plexus,
accessory obturator vessels, the Pectineal line (cooper’s ligament)

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10
Q

What are the components and origins of the pelvic diaphragm?

A

PR- pubic symphysis wrap around the rectum back to pubic symphysis

PC-pubic symphysis to coccyx

IC-along the arcus tendineus levator ani from the pubis to the ischial spine to insert in the midline onto the coccyx

coccygeus mm- ischial spine to the lower sacrum/coccyx overlying the SSL

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11
Q

Your SSLF is bleeding from the pararectal space.

What do you do?

A

alert the room
hemostatic agents
pressure
gain visualization
vascular clip
IR

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12
Q

Innervation of the pelvic diaphram

A

levator ani nerve
coccygeal plexus

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13
Q

the transversalis fascia of the abdominal wall is a continuation of which pelvic structure?

A

pectineal line

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14
Q

What is the arcus tendineus fascia in the pelvis and what is the importance of this structure?

A

thick white band of fascia that converges along the surface of the obturator internus muscle extending from the posterior aspect of the superior pelvic ramus to the ischial spine.

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15
Q

Which blood vessels are most likely to be injured during paravaginal repair?

A

oburator or accessory obturator

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16
Q

You’re doing your sacral dissection and there is bleeding. What do you do?

A

-Assess the area for vital structures
-hold pressure
-attempt hemostasis with simple bipolar cautery
- apply floseal (thrombin with gelatin), hold pressure for 5 minutes

-bone wax, stainless steel thumbtacks

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17
Q

You’re doing a burch and there is bleeding. What do you do?

A

pressure, floseal, bone wax

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18
Q

What are the origins of the obturator artery and vein?

A

internal iliacs

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19
Q

What is the origin of the accessory obturator artery?

A

external iliac

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20
Q

What is the blood supply of the ureter?

Which side does it enter from?

A

the ureter is supplied by the blood vessel it crosses
-ovarian, internal iliac, superior vesical, and inferior vesical arteries

medial when above the pelvic brim
lateral when below the pelvic brim

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21
Q

Which nerve is located lateral to the psoas muscle?

A

lateral femoral cutaneous nerve

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22
Q

What is the innervation of the ureter?

A

sympathetic T10 to L2

parasympathetic S2-S4

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23
Q

List the branches of the external iliac artery

A

inferior epigastric artery
deep circumflex artery
superficial circumflex artery

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24
Q

What are the branches of the posterior division of the internal iliac artery.

A

Iliolumbar
lateral sacral
superior gluteal

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25
What are the branches of the anterior division of the internal iliac artery.
obliterated umbilical superior vesical inferior vesical uterine vaginal obturator middle rectal inferior gluteal internal pudendal
26
What vessel does the middle sacral vein drain into?
left common iliac vein
27
where does the middle sacral artery arise from?
abdominal aorta
28
What the structures in level 2 support?
-arcus tendineus fasciae pelvis -superior fascia of the levator ani muscles.
29
mullerian anomalies can be associated with anomalies in which other organ systems
renal, cardiac, hearing, skeletal,
30
Bladder exstrophy results from a defect in what?
Failure of ventral wall of the urogenital sinus to increase leading to breakdown of the urogenital membrane
31
What is the incidence of bladder exstrophy
1 per 20,000 to 33,000
32
67 anatomy
33
What is the drooping lily sign?
It describes the inferolateral displacement of the opacified lower pole moiety, typically caused by an obstructed (and therefore unopacified) upper pole moiety.
34
Weigert-Meyer Rule
upper renal moiety ureter- medial and inferior; frequently ends in a ureterocele lower renal moiety ureter has orthotopic insertion lateral and superior; vesicoureteral reflux can occur
35
which vessel prevents migration of horseshoe kidneys?
inferior mesenteric artery
36
what is the etiology of an ectopic ureter?
2 ureteric buds develop from one mesonephric duct. The abnormal bud moves downward with the mesonephric duct to enter at an abnormal location.
37
UDS parameters for ISD
VLPP <60cm H2O MUCP <20 cm H2O
38
contraindications to anticholinergics besides: dry eyes, dry mouth, constipation, narrow angle glaucoma,
retention, gastroparesis, solid oral KCl replacement
39
what are the borders of the pararectal space?
cardinal ligament anteriorly, the rectum medially, the internal iliac artery laterally, and the sacrum posteriorly.
40
contraindications to botox
acute UTI, inability to perform CIC, myasthenia gravis, allergy to Botox, urinary retention not performing or willing to perform CIC. Relative contraindication is history of recurrent UTI.
41
what does PTNS stand for?
Percutaneous tibial nerve stimulation
42
What are the contraindications to neuromodulation therapy?
inadequate clinical response to a therapeutic trial, inability to operate the device, pregnancy. Relative contraindications include rapidly progressive neurologic disease, patients with established complete SCI, patients with abnormal sacral anatomy.
43
What is the proper angle for the PTNS needle?
60 degree
44
Efficacy for PTNS
55% have moderate or marked improve
45
who should not get a bladder augment for refractory OAB?
I do not recommend bladder augmentation for any patients with bowel disease, short bowel, reduced manual dexterity/inability to catheterize, and reduced cognitive function.
46
define polyuria
>40 cc/kg per 24 hrs
47
What is your differential for polyuria?
solute diuresis vs water diuresis solute- sugar, salt, mannitol (used for patients with increased intracranial pressure), urea from tissue breakdown, AKI, or exongenous urea for hyponatremia water- diabetes insipidus or polydypsia
48
Your patient does a bladder diary and you see a Urine output of >40 cc/kg per 24 hrs What is your next in evaluating this patient?
H+P UA-glucose, spec gravity BMP refer to nephro 24 hour urine study- total solute excretion, urine osmolality, sodium, potassium, chloride, creatinine, urea nitrogen, and glucose
49
define nocturnal polyuria
>33% UOP overnight if over 65 >20% in young patients or 20% ot 33% in middle age patients.
50
MUCP At what rate does the machine pull the vesical catheter?
1mm/s
51
Do you perform routine UPP?
no because there are no measurements that reliably predict surgical success or define severity of the disease
51
MUCP Define the following: 1. max urethral pressure 2. MUCP 3. functional urethral length 4. pressure transmission ratio
1. highest pressure measured 2. MUCP- the difference between maximum urethral pressure and intravesical pressure 3. functional urethral length-length where urethral pressure exceeds the intravesical pressure. 4. pressure transmission ratio- expressed as a percentile, of the change in urethral pressure (P ura ) to the change in vesical pressure (P ves ) associated with a cough.
52
Your UDS patient develops bradycardia and HTN next steps
-sit them upright to orthostatically drop BP -drain the bladder -nitropaste -consider rectal distention and tight clothing as a noxious stimuli to remove
53
complications from a burch?
Bleeding, infection-UTI, osteitis pubis, injury to surrounding structures (urethra, bladder, vasculature, neurologic), , voiding dysfunction, ureteral obstruction, fistula.
54
success for burch
1 year 85% to 90%, and at 5 years are about 70%
55
bulkamid efficacy
Cure or improvement occurs in 70% to 80% of patients, with total continence achieved in around 40%.
56
what are the ingredients of bulkamid?
2.5% Polyacrylamide hydrogel and 97.5% water,
57
at what level of retention after botox
300cc if asymptomatic 150-200cc if symptomatic
58
contraindication to botox
ALS Amyotrophic lateral sclerosis Myasthenia gravis urinary retention UTI allergy
59
What does biofeedback for FI do for the patient
rectal sensation, coordination of the EAS strength

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