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Dissection bias in subperitoneal pelvic anatomy
1504 2. Moher D, Schulz KF, Altman DG, CONSORT. The CONSORT statement: revised recommendations for improving the quality of reports of parallel group randomized trials. BMC Med Res Methodol 2001;1:2. 3. Lindsay R, Gallagher JC, Kleerkoper M, Pickar JH. Effect of lower doses of conjugated equine estrogens with and without
Letters to the Editors medroxyprogesterone acetate on bone in early postmenopausal women. JAMA 2002;287:2668-76. 4. Gallagher J, Baylink DJ, McClung M. Prevention of bone loss with tibolone in postmenopausal women: results of two randomized, double-blind, placebo-controlled, dose-finding studies. J Clin Endocrinol Metab 2001;86:4717-26.
0002-9378/$ - see front matter Ó 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.ajog.2005.10.200
Dissection bias in subperitoneal pelvic anatomy To the Editors: At the beginning of the 21st century there are still uncertainties and discrepant views about the anatomy of the subperitoneal support structures of the pelvic organs in the female. Scientific efforts to clarify this matter, as presented in the paper of Yabuki et al,1 are therefore certainly warranted. Exploring the subperitoneal female pelvic anatomy in depth is not only important for the sake of academic insight but also with respect to clinical application particularly to improve and optimize surgical treatment both for benign (genital prolapse, stress incontinence) and malignant (cervical and vaginal cancer) conditions. The study of Yabuki et al1 provides valuable information on anatomic details, especially relating to the topography of the pelvic autonomic nerve system. Importantly, the different functions of the uterovaginal support structuresdneurovascular supply on one hand and suspension/fixation on the other handdare topographically assigned. However, a major drawback of this work is the fact that the authors basically construct an anatomy of the subperitoneal female pelvis fitting to their radical hysterectomy technique through the process of dissection of either fixed or fresh cadavers of old women by creating (and naming) a variety of spaces, subspaces, structures, and substructures. This constructivistic top-down approach in pelvic anatomy is to a high degree biased by subjectivity as there are many continuous transitions between the loose areolar tissue and dense connective tissue in the subperitoneal female pelvis. Depending on the extension of the dissection, a nearly unlimited number of spaces and structures can be constructed without a correlation to the undistorted (by dissection) topographic anatomy represented in plastinated cross-sections of cadavers and to the magnetic resonance imaging (MRI) of living subjects. In order to justify the relevance of dissection artifacts such as ‘‘cranial and caudal chambers of the pararectal space,’’
0002-9378/$ - see front matter Ó 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.ajog.2005.10.202
‘‘Okabayashi’s paravaginal space,’’ ‘‘superficial and deep layer of the vesicouterine ligament,’’ etc, as basis for a specific surgical anatomy for radical hysterectomy, the authors have to prove the superiority of their surgical procedure over standard treatment. To overcome the problem of dissection bias we have suggested a developmentally based bottom-up approach to comprehend the subperitoneal female pelvis.2 This concept also facilitates the understanding of local tumor spread, and its transformation into surgical anatomy led to excellent results.3,4 Michael Ho¨ckel, PhD, MD Department of Obstetrics and Gynecology University of Leipzig Leipzig, Germany Helga Fritsch, MD Division of Clinical and Functional Anatomy Department of Anatomy, Histology and Embryology Medical University Innsbruck, Austria E-mail: [email protected]
References 1. Yabuki Y, Sasaki H, Hatakeyama N, Murakami G. Discrepancies between classic anatomy and modern gynecologic surgery on pelvic connective tissue structure: harmonization of those concepts by collaborative cadaver dissection. Am J Obstet Gynecol 2005;193:7-15. 2. Fritsch H. The connective tissue sheath of uterus and vagina in the human female fetus. Ann Anat 1992;174:261-6. 3. Ho¨ckel M, Horn L-C, Hentschel B, Ho¨ckel S, Naumann G. Total mesometrial resection: high resolution nerve-sparing radical hysterectomy based on developmentally defined surgical anatomy. Int J Gynecol Cancer 2003;13:791-803. 4. Ho¨ckel M, Horn L-C, Fritsch H. Local tumour spread in stage IBeIIB cervical carcinoma is confined to the mesenchymal compartment of uterovaginal organogenesis. Lancet Oncol 2005;6:751-6.
Letters to the Editors medroxyprogesterone acetate on bone in early postmenopausal women. JAMA 2002;287:2668-76. 4. Gallagher J, Baylink DJ, McClung M. Prevention of bone loss with tibolone in postmenopausal women: results of two randomized, double-blind, placebo-controlled, dose-finding studies. J Clin Endocrinol Metab 2001;86:4717-26.
0002-9378/$ - see front matter Ó 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.ajog.2005.10.200
Dissection bias in subperitoneal pelvic anatomy To the Editors: At the beginning of the 21st century there are still uncertainties and discrepant views about the anatomy of the subperitoneal support structures of the pelvic organs in the female. Scientific efforts to clarify this matter, as presented in the paper of Yabuki et al,1 are therefore certainly warranted. Exploring the subperitoneal female pelvic anatomy in depth is not only important for the sake of academic insight but also with respect to clinical application particularly to improve and optimize surgical treatment both for benign (genital prolapse, stress incontinence) and malignant (cervical and vaginal cancer) conditions. The study of Yabuki et al1 provides valuable information on anatomic details, especially relating to the topography of the pelvic autonomic nerve system. Importantly, the different functions of the uterovaginal support structuresdneurovascular supply on one hand and suspension/fixation on the other handdare topographically assigned. However, a major drawback of this work is the fact that the authors basically construct an anatomy of the subperitoneal female pelvis fitting to their radical hysterectomy technique through the process of dissection of either fixed or fresh cadavers of old women by creating (and naming) a variety of spaces, subspaces, structures, and substructures. This constructivistic top-down approach in pelvic anatomy is to a high degree biased by subjectivity as there are many continuous transitions between the loose areolar tissue and dense connective tissue in the subperitoneal female pelvis. Depending on the extension of the dissection, a nearly unlimited number of spaces and structures can be constructed without a correlation to the undistorted (by dissection) topographic anatomy represented in plastinated cross-sections of cadavers and to the magnetic resonance imaging (MRI) of living subjects. In order to justify the relevance of dissection artifacts such as ‘‘cranial and caudal chambers of the pararectal space,’’
0002-9378/$ - see front matter Ó 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.ajog.2005.10.202
‘‘Okabayashi’s paravaginal space,’’ ‘‘superficial and deep layer of the vesicouterine ligament,’’ etc, as basis for a specific surgical anatomy for radical hysterectomy, the authors have to prove the superiority of their surgical procedure over standard treatment. To overcome the problem of dissection bias we have suggested a developmentally based bottom-up approach to comprehend the subperitoneal female pelvis.2 This concept also facilitates the understanding of local tumor spread, and its transformation into surgical anatomy led to excellent results.3,4 Michael Ho¨ckel, PhD, MD Department of Obstetrics and Gynecology University of Leipzig Leipzig, Germany Helga Fritsch, MD Division of Clinical and Functional Anatomy Department of Anatomy, Histology and Embryology Medical University Innsbruck, Austria E-mail: [email protected]
References 1. Yabuki Y, Sasaki H, Hatakeyama N, Murakami G. Discrepancies between classic anatomy and modern gynecologic surgery on pelvic connective tissue structure: harmonization of those concepts by collaborative cadaver dissection. Am J Obstet Gynecol 2005;193:7-15. 2. Fritsch H. The connective tissue sheath of uterus and vagina in the human female fetus. Ann Anat 1992;174:261-6. 3. Ho¨ckel M, Horn L-C, Hentschel B, Ho¨ckel S, Naumann G. Total mesometrial resection: high resolution nerve-sparing radical hysterectomy based on developmentally defined surgical anatomy. Int J Gynecol Cancer 2003;13:791-803. 4. Ho¨ckel M, Horn L-C, Fritsch H. Local tumour spread in stage IBeIIB cervical carcinoma is confined to the mesenchymal compartment of uterovaginal organogenesis. Lancet Oncol 2005;6:751-6.