Article

Three Dimensional Reconstruction and Modeling of Complex Pelvic Anatomical Structures by Using Plastinated Cross Sections

Abstract and Figures

Computerized reconstruction of anatomical structures is becoming very useful for developing anatomical teaching modules and animations. The first computer-aided 3D reconstruction was achieved in 1965 by Glaser and Van der Loos. With the improvements in computer hardware and software tools, computerized modeling of anatomical structures has become very useful for visualizing complex 3D forms. Three-dimensional visualization of various microanatomic structures using special preparation and staining methods is important. Although databases exist consisting of serial sections derived from frozen cadaver material, plastination represents an alternate method for developing anatomical data useful for computerized reconstruction. Plastination is used as an excellent tool for studying different anatomical and clinical questions. The sheet plastination technique is unique because it offers the possibility to produce transparent slices series, which can easily be processed morphometrically. A female pelvis was obtained, plastinated, sectioned and subject to 3D computerized reconstruction using WinSURF modeling system (SURFdriver Software). Qualitative observations revealed that the morphological features of the model were consistent with those displayed by typical cadaveric specimens. Morphometric analysis indicated that the model did not significantly differ from a sample of cadaveric specimens. This data supports the use of plastinates for generating tissues sections useful for 3D computerized modeling.
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MATERIALE PLASTICE 52 No. 3 2015 http://www.revmaterialeplastice.ro 381
Three Dimensional Reconstruction and Modeling of Complex Pelvic
Anatomical Structures by Using Plastinated Cross Sections
MIRCEA-CONSTANTIN SORA1,2, GÜRKAN ERMAN3, LAURENTIU PIRTEA4, MARIOARA BOIA5*, PETRU MATUSZ 6, IOAN SAS4
1Medical University of Vienna, Plastination Laboratory, Microscopy & Advanced Optical Imaging, Schwarzspanierstr. 17, Vienna
1090, Austria
2Sigmund Freud University, Freudplatz 1, Messe Str, 1, 1020 Vienna, Austria
3 Medical University Vienna, General Hospital Vienna, Department of Biomedical Imaging and Image-guided Therapy, Waehringer
Guertel 18-20, 1090, Vienna, Austria
4"Victor Babes” University of Medicine and Pharmacy Timisoara, Department of Obstetrics and Gynecology, 2 Eftimie Murgu Sq.,
300041, Timisoara, Romania
5“Victor Babes” University of Medicine and Pharmacy Timisoara, Department of Neonatology, 2 Eftimie Murgu Sq., 300041,
Timisoara, Romania
6"Victor Babes” University of Medicine and Pharmacy Timisoara, Department of Anatomy, 2 Eftimie Murgu Sq., 300041, Timisoara,
Romania.
Computerized reconstruction of anatomical structures is becoming very useful for developing anatomical
teaching modules and animations. The first computer-aided 3D reconstruction was achieved in 1965 by
Glaser and Van der Loos. With the improvements in computer hardware and software tools, computerized
modeling of anatomical structures has become very useful for visualizing complex 3D forms. Three-
dimensional visualization of various microanatomic structures using special preparation and staining methods
is important. Although databases exist consisting of serial sections derived from frozen cadaver material,
plastination represents an alternate method for developing anatomical data useful for computerized
reconstruction. Plastination is used as an excellent tool for studying different anatomical and clinical questions.
The sheet plastination technique is unique because it offers the possibility to produce transparent slices
series, which can easily be processed morphometrically. A female pelvis was obtained, plastinated, sectioned
and subject to 3D computerized reconstruction using WinSURF modeling system (SURFdriver Software).
Qualitative observations revealed that the morphological features of the model were consistent with those
displayed by typical cadaveric specimens. Morphometric analysis indicated that the model did not significantly
differ from a sample of cadaveric specimens. This data supports the use of plastinates for generating tissues
sections useful for 3D computerized modeling.
Keywords: plastination, 3D reconstruction, anatomy, female pelvis, urinary bladder, uterus.
Since its development 30 years ago, plastination is the
best method for the preservation of human tissue. In recent
years, plastination has been applied as excellent method
for studying different anatomical-clinical questions. By
using the E12 technique, we obtained transparent slices
that show different structures in their initial position,
especially regarding the muscular, vascular and interstitial
tissue [1-3]. With many of the modern diagnostic
techniques, including corrosion casts [4], radiographic
imaging such as computed tomography [5-8], magnetic
resonance imaging [9], and ultrasound [10, 11], the
importance for understanding serial sectioned anatomy of
the human body cannot be overlooked. The E12 plastination
method allows accurate, precise and transparent sectional
preparations offering accurate visual clarity of gross
structures down to a submacroscopic level viewable with
the naked eye [12-15].
The main steps for the E12 plastination method are:
cold dehydration, degreasing, impregnation and finally
curing [13, 16, 17]. There are two methods for obtaining
E12 slices, namely the classical E12 method for 3mm thick
slices and the ultra-thin E12 plastination method for slices
between 0.3 - 1mm [12-14, 18-20]. Anatomical structures
of the desired region are then 3D reconstructed. Three
dimensional reconstruction computer models made from
* email marianaboia@yahoo.com; Tel.: 0740137597
scanned plastinated models may have benefits in terms of
representing real tissue and in case of 3D-IT
reconstructions. This offers the opportunity to compare the
use of identical physical and virtual models for the
development of a 3D anatomical computer models basic
system and its interactive manipulation.
The pelvic floor has a complex spatial structure, whose
knowledge is a condition for assessing pathologies in this
area [20, 21]. Women, for the most part, undergo pelvic
floor examinations for urinary incontinence or prolapse of
the internal genitalia or of the urinary bladder [20, 22, 23].
Pelvic floor dysfunction, which includes urinary and fecal
incontinence as well as pelvic organ prolapsed, is a highly
prevalent disease in women. Ten percent of all women
undergo at least one operation to treat pelvic floor
dysfunction during their lifetime [20]. Up to day, little is
known about specific pelvic floor pathomorphology and
even less about pathophysiology as it relates to pelvic floor
dysfunction. DeLancey et al. [24] used Magnetic
Resonance Imaging (MRI) to investigate levator ani muscle
damages, Lien et al. [25] constructed a computerized
model in order to determine the stretch forces that exceed
the forces which muscle tissue can usually sustain. In our
study, a three-dimensional (3D) model of the pelvis was
built based on thin slice plastination cross-sections of the
MATERIALE PLASTICE 52 No. 3 2015http://www.revmaterialeplastice.ro382
adult female pelvis and 3D reconstruction technology. In
order to investigate biomechanical the Petros and Ulmsten
theory, the key structures of the pelvic floor had to be
defined and reconstructed [26]. The key ligaments, such
as the pubourethral ligament, the cardinal ligament, the
uterosacral ligament and the pubovesical ligaments were
first detected on plastinated slices and then reconstructed.
Experimental part
The 3D model was reconstructed from a 70 year old
female cadaver specimen. The specimen was a part of
the human donation program of the Medical University of
Vienna. The female pelvis was frozen at –80°C for one
week and afterwards it was plastinated according to the
standard ultra-thin E12 slice plastination method [14].
Freeze substitution is the standard dehydration procedure
for plastination. Shrinkage is minimized when cold acetone
is used. The tissue block was submerged in cold (-25 °C)
acetone (high purity) for dehydration. Degreasing was
performed by using methylene chloride (high purity).
Impregnation was performed using the following epoxy
Biodur (Rathausstr.18, 69126 Heidelberg, Germany)
mixture: E12 (resin)/ E6 (hardener)/ E600 (accelerator)
(Sora et al., 2007). When impregnation was completed,
the tissue block was removed from the vacuum chamber.
A mold was constructed of styrofoam and lined with
polyethylene foil and the tissue block inserted. The mold
containing the impregnated specimen and resin-mix was
placed in a 65°C oven for four days to harden the resin-mix.
The tissue/resin block was cooled to room temperature
and the mold removed. A contact point diamond blade
saw, Exact 310 CP (Exact Apparatebau GmbH, Norderstedt,
Germany) was used for cutting the block. The hardened
E12 block was cut into 1.6 ± 0.26 mm. Finally, the caudal
surfaces of the plastinated slices were scanned into a
computer using an EPSON GT-10000+ Color Image
Scanner. In every scan, a ruler as a calibration marker was
included. For morphological measurements, the UTHSCSA
IMAGE TOOL v.2.0 for Windows software (The University
of Texas Health Science Center in San Antonio) was used.
The objects which had to be reconstructed were traced
manually by using a graphic table (Wacom Cintiq 24HD).
Each object was traced and numbered accordingly on every
BMP file. After that, the reconstruction was rendered,
visualized and qualitatively checked for surface
discontinuities by rotating the model. The following
features, defined as objects, were used in the
reconstruction: pelvic girdle, levator ani, obturator internus,
coccygeus, piriformis muscles, rectum, uterus, uterosacral
ligaments, cardinal ligament, ureter, urinary bladder,
pubovesical ligament, urethra, pubourethral ligament,
vagina, lumbosacral plexus, internal and external iliac
arteries, sciatic nerve, lumbar plexus, obturator nerve and
pudendal nerve.
Results and discussions
The transparency and color of the plastinated slices
were perfect and of high quality (fig. 1A, 1B, 2A, 2B).
Sectional plastination showed the structures of the pelvic
floor muscles and their relationship to adjacent structures
with a resolution down to the microscopic level (fig. 1B,
2B). This method allowed assessment of the course of
muscle fibers and ligaments.
Once scanned and loaded into WinSURF, automatic
edge detection was used to quickly collect tissue borders
or contours. These contours were visualized on the tissue
borders and showed close continuity with the edges of the
objects. The pelvis model was rendered and rotated in real
time and it resembled well with a representative cadaveric
pelvis. The quality of the reconstructed images appeared
distinct, especially the spatial positions and complicated
relationships of contiguous structures of the female pelvis.
All reconstructed structures can be displayed in groups or
as a whole and interactively rotated in 3D space. Various
features, such as transparency control, individual object
selection, animation and a variety of manipulation modes
facilitate visualization of the complex pelvic anatomy (fig.
3-5).
Quantitative measurements showed that the overall
morphology was retained. Coefficients of variation for the
six variables ranged from a low of 11.3% to 19.5%. None of
the variables recorded from the model were significantly
different from the corresponding values measured from
the cadaveric specimens at the p <0.05 level.
The pelvic floor extends between pubis and sacrum and
consists of the urogenital and the pelvic diaphragm. The
pelvic diaphragm consists of the levator ani, the coccygeus
and the sphincter ani muscles. The levator ani muscle has
three parts: pubococcygeus, iliococcygeus and
puborectalis muscles. It is perforated by the rectum [27].
The urogenital diaphragm consists of the transversus
perinei, sphincter urethrae externus, the bulbospongiosus
and the ischiocavernosus muscles [27]. The pelvic floor
Fig.1. Plastinated
transverse section of the
female pelvis below the
pubic symphysis.
A - Whole image; slice
thickness 1.6 mm.
B - Detail of a plastinated
cross section of the marked
area on figure 1A.
EoM - External obturator
muscle; IoM - Internal
obturator muscle; PpL –
Posterior pubic ligament;
PrM – Puborectalis muscle;
PuL – Pubouretral ligament;
R – Rectum; U – Urethra; V
- Vagina. [Color figure can
be viewed in the online
issue, which is available at
www.revmaterialeplastice.ro]
Fig.2. Plastinated transverse
section of the female pelvis
at the level the femoral
head. A - Whole image; slice
thickness 1.6 mm. B - Detail
of a plastinated cross
section of the marked area
on figure 2A.. C – Cervix; Cx
– Coccygis; ImU – Intramural
part of ureter;IoM - Internal
obturator muscle; PfV –
Posterior fornix of the
vagina; PvL – Pubovesical
ligament; R – Rectum; UB –
Urinary bladder; Ur – Ureter;
UsL – Uterosacral ligament.
[Color figure can be viewed
in the online issue, which is
available at
www.revmaterialeplastice.ro]
MATERIALE PLASTICE 52 No. 3 2015 http://www.revmaterialeplastice.ro 383
contains only striated muscles. Its purpose is to hold the
pelvic organs and to occlude the urethra and the rectum
[28, 29]. The pudendal nerve (S2-S4) passes through the
pudendal canal (Alcock-canal) and innervates motoric the
pelvic floor and the genitalia and the anus sensitive [27,
28]. The physiological tasks of the female pelvic floor are
to provide the correct sequences of events during miction,
defecation and giving birth. Damage in the pelvic floor can
cause malfunction of these sequences. Malfunctions are
urinary incontinence, stool incontinence, uterine
descensus, uterine prolapse, cystocele, rectocele,
douglasocele and enterocele [29].
Miction, defecation and giving birth can only run correctly
if the pelvic floor is fully functional. The integral theory leads
incontinence back to a weakness of the vaginal wall. The
inserting muscles and ligaments are responsible for the
physiological processes. Following a weakness in the
vaginal wall leads to malfunction [26]. Re-establishing the
physiological structures shall lead to a restitution [30]. The
four pairs of muscles (three parts of the levator ani and the
coccygeus muscles) contract in different directions. This
causes a tension in the vaginal wall [31]. The fascia and
ligaments support this process significantly [30].
The pelvic floor has a complex spatial structure, of which
only parts are visualized on sectional images [32-34]. It is,
however, necessary for proper assessment of pathologies
to correctly relate the visualized part to the entire structure.
A 3D model in which the positions of the imaging plane of
interest are shown improves the vividness of depiction.
With recourse to the plastinated sections it was possible
to derive additional information, such as the course of
muscle fibers or connections of the muscles with each
other for a given imaging plane. In contrast to anatomic
preparation, the structures and spatial relationships of the
tissues were not altered by plastination. Although muscular
tonicity is not present in cadaveric material, a study [34]
about the postmortem changes of the levator ani muscle
showed that there are only little changes in its architecture
after death. This study used MRT and CT of living subjects
and compared those with plastinated slices to point out
those morphologic studies done on plastinated slices of
the pelvis floor can be assign to living humans.
Thin plastinated slices of 1.6 mm are essential if 3D
reconstruction is desired [13, 20, 35, 36]. Due to the high
transparency of the slices, also fine ligaments could be
identified: pubourethral ligament, the cardinal ligament,
the uterosacral ligament and the pubovesical ligaments.
These ligaments take a key role in suspending the organs,
like urinary bladder, urethra, vagina and the uterus, in
preventing their prolapse. Although the process of
plastination extends the time and effort required to
generate images for analysis, considerable detail is
provided and the reconstructed pelvic model exhibits the
bones and surrounding soft tissue. The thin slices used in
this study offer numerous advantages over other gross
anatomical preparation methods currently utilized to
generate images for computer reconstruction. The
reconstruction of these anatomical structures is only
possible due to the transparency of plastinated slices. A
major problem that occurs with existing anatomical
databases is the low resolution for smaller anatomical
structures. Plastination provides a useful alternative for
generating anatomical databases. Plastinates are
significantly easier to cut, stain, and handle compared to
fresh frozen tissue since they are significantly more durable
owing due to the epoxy infiltrate. Although the female
pelvis reconstruction presented here did not appear to be
affected by a loss of this information (tissue loss between
slices), further testing will be required to examine this issue.
The capability of reconstructing individual and combined
images of the pelvic structures, viewing them from all
surgical angles, and allowing for accurate measurement
of their spatial relationships enables important guidance
for surgeons. The reconstructed model can also be used
for residency education, testing an unusual surgery and for
the development of new surgical approaches. The 3D
model of the female pelvis presented in this paper provides
a stereoscopic view to study the adjacent relationship and
arrangement of respective pelvis sections.
Fig.5. Inferior view of the 3D
reconstruction of the female perineum.
AcL – Anococcygeal ligament; EasM –
External anal sphincter muscle; IcM –
Ischiocavernosus muscle; PcM –
Pubococcygeus muscle; PuL –
Pubourethral ligament; PvL –
Pubovesical ligament; R – Rectum; U –
Urethra; UB – Urinary bladder; UsL –
Uterosacral ligament; Ut – Uterus; Va -
Vagina. [Color figure can be viewed in
the online issue, which is available at
www.revmaterialeplastice.ro]
Fig.3. Cranial view of the 3D
reconstruction of the female pelvis.
CL – Cardinal ligament; CM – Coccygeus
muscle; IoM - Internal obturator muscle;
PcM – Pubococcygeus muscle; PM –
Perineal membrane; PN – Pudendal nerve;
R – Rectum; UB – Urinary bladder; Ur –
Ureter; UsL – Uterosacral ligament; Ut –
Uterus. [Color figure can be viewed in the
online issue, which is available at
www.revmaterialeplastice.ro]
Fig.4. Lateral view of the 3D
reconstruction of the female pelvis.
CL – Cardinal ligament; EasM – External
anal sphincter muscle; IcM – Iliococcygeus
muscle; PcM – Pubococcygeus muscle;
PrM – Puborectalis muscle; PvL –
Pubovesical ligament; R – Rectum; U –
Urethra; UB – Urinary bladder; UsL –
Uterosacral ligament; Ut – Uterus. [Color
figure can be viewed in the online issue,
which is available at
www.revmaterialeplastice.ro]
MATERIALE PLASTICE 52 No. 3 2015http://www.revmaterialeplastice.ro384
Conclusions
The utilization of plastinated slices for generating tissues
sections is useful for 3D computerized modeling. The 3D
model of the female pelvis presented in this paper provides
a stereoscopic view to study the adjacent relationship and
arrangement of respective pelvis sections. Our model could
lead to a better understanding of the pelvic floor anatomy
and serve as a realistic model in the generation of a Finite
Elements model, which will undergo biomechanical stress
investigations.
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Manuscript received: 6.12.2014
... [12] Operations such as tumor surgeries made within the pelvic fasciae requires a detailed pelvic anatomy knowledge. [13,14] Orientation to three-dimensional and cross-sectional anatomy of the pelvis is crucial to provide a comprehensive adaptation to the pelvic region. [13,15] Examination of the cross-sectional anatomy of the pelvis with the plastination technique can be beneficial for both education and research purposes. ...
... [13,14] Orientation to three-dimensional and cross-sectional anatomy of the pelvis is crucial to provide a comprehensive adaptation to the pelvic region. [13,15] Examination of the cross-sectional anatomy of the pelvis with the plastination technique can be beneficial for both education and research purposes. [12,13,15] In this study, the pelvis of a male cadaver was sectioned into 8 mm thick coronal slices and plastinated using silicone plastination technique. ...
... [13,15] Examination of the cross-sectional anatomy of the pelvis with the plastination technique can be beneficial for both education and research purposes. [12,13,15] In this study, the pelvis of a male cadaver was sectioned into 8 mm thick coronal slices and plastinated using silicone plastination technique. The benefits of the cross-sectional plastination technique has been revealed by previous studies in terms of understanding the threedimensional anatomy. ...
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Objectives: The aim of this study was to provide long-term preservation of the pelvic coronal cross-sections using plastination technique. Thus, we intended to provide a better understanding of the three-dimensional anatomy of the pelvis for education and research purposes. Methods: The standard plastination method was combined with the section plastination technique. The coronal pelvis sections of 8mm thickness were passed through the plastination stages. At these stages, unlike the techniques in the literature, surgical aspirator was used for cleaning the surfaces of the sections and xylene was used for lightening the plastinates. Results: At the end of the plastination stages, the sections preserved the real color and texture extremely well. Sections were dry, odorless, hygienic and could be handled without special precaution. Moreover, anatomical details were very clear and understandable, so that any structure could be measured photogrammetrically. Conclusion: Examination of the pelvic anatomy with coronal sections via plastination method could be very effectively used in education and research. In this way, a technological and up-to-date innovation can be provided for the development and understanding of three-dimensional anatomy. Real examination of cross-sectional anatomy instead of virtual radiological images can provide a useful and effective tool for both students and researchers.
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Technical Report
Für Beckenbodenstörungen, die nicht mit nicht-chirurgischen Verfahren behandelt werden können, wurde die minimal-invasive Chirurgie ein häufigeres und das sicherste Reparaturverfahren. Diese neuen Behandlungen sind wirksamer als ihre traditionellen Pendants mit einer Vielzahl von Vorteilen: kleinerer oder gar kein Bauchschnitt, minimale Narben, weniger Gewebeschäden und kürzere Erholungszeit. Jedoch wurden zahlreiche Fälle von postoperativen Beschwerden bei Patienten berichtet, die sich einer Wiederherstellungschirurgie unterzogen hatten. Abgesehen von der Fähigkeit des Chirurgen, hängt der Erfolg solcher Behandlungstechniken von verschiedenen Faktoren ab, wie beispielsweise eine der Art des anatomischen Defekts angemessene Behandlung, Biokompatibilität des Netzmaterials und ausreichende Informationen über das postoperative Verhalten der Netze im Körper. In BINGO wurden einachsige und zweiachsige (biaxiale) experimentelle Protokolle zur mechanischen Charakterisierung von trockenen Netzen entwickelt. An verschiedenen, von der DynaMesh FEG Textiltechnik mbH gefertigten, Implantaten wurden Tests durchgeführt, wobei die Deformation der Netze mit einem hoch entwickelten digitalen Bildkorrelationsverfahren gemessen wurde. Das nichtlineare Spannungs-Dehnungsverhalten und die Änderung der effektiven Porosität der Implantate wurden gemessen, um die Leistung des implantierten Netzes zu charakterisieren. Verringerte effektive Porosität des Netzes bildet mehr Narbengewebe; mit Schrumpfen der Maschen verringert sich die Flexibilität des Netzes. Virtuelle (in silico) klinische Studien der chirurgischen Implantate mittels Finite-Elemente-Simulationen können niemals effektiv sein, wenn das Modell nicht nahe an der Realität ist. Daher haben wir erstmals ein 3D-Computermodell des weiblichen Beckenbodens ohne Vereinfachungen, weder bei der Anatomie noch in ihrer Biomechanik, konstruiert. Die wichtigsten Highlights des Modells sind wie folgt: • Es wurden Anstrengungen unternommen, eine anatomisch stetige Geometrie der weichen Faszien zu verstehen und zu erzeugen, die nur sehr schwer über herkömmliche medizinische Bildgebungsverfahren zu konstruieren ist. • Die endopelvine Faszie wurde als heterogenes Netzwerk von Kollagen, Elastin, Nerven und nicht-vaskulären glatten Muskelfasern mit unterschiedlicher Dichte seiner Bestandteile in kraniokaudaler Richtung betrachtet, wie durch Petros vorgeschlagen. Dies beleuchtet das Konzept der phänomenologischen Unterschiede der Harninkontinenz und Prolaps (von Blase und Harnröhre) als Folge einer lokalisierten Reduktion von Kollagen, anstatt einer kompletten Schwächung der Faszie. • Das Konzept des pubozervikalen Bandes, das die Blasenhypermobilität einschränkt, wurde ebenfalls integriert. Verschiedene Berechnungen werden mit einem Berechnungsmodell mit gesundem und beschädigtem Stützgewebe durchgeführt und Vergleiche vorgenommen, um die Pathophysiologie der Erkrankungen des weiblichen Beckenbodens zu verstehen. Das Computermodell kann verschiedene Arten von Störungen bei Frauen mit bestimmten Arten von anatomischen Defekte simulieren, wie Defekt des Harnröhrenschließmuskels, Defekt der mittleren Harnröhren, Prolaps des Scheidengewölbes, Zystozele und Rektozele. So können die Pathophysiologie der weiblichen Beckenbodenstörungen und andere Phänomene, wie vaginale Entbindung, effektiv untersucht werden.
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Abstract In this Theory paper, the complex interplay of the specific structures involved in female urinary continence are analyzed. In addition the effects of age, hormones, and iatrogenically induced scar tissue on these structures, are discussed specifically with regard to understanding the proper basis for treatment of urinary incontinence. According to the Theory stress and urge symptoms may both derive, for different reasons from the same anatomical defect, a lax vagina. This laxity may be caused by defects within the vaginal wall itself, or its supporting structures i.e. ligaments, muscles, and their connective tissue insertions. The vagina has a dual function. It mediates (transmits) the various muscle movements involved in bladder neck opening and closure through three separate closure mechanisms. It also has a structural function, and prevents urgency by supporting the hypothesized stretch receptors at the proximal urethra and bladder neck. Altered collagen/elastin in the vaginal connective tissue and/or its ligamentous supports may cause laxity. This dissipates the muscle contraction, causing stress incontinence, and/or activation of an inappropriate micturition reflex, (“bladder instability”) by stimulation of bladder base stretch receptors. The latter is manifested by symptoms of frequency, urgency, nocturia with or without urine loss.
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Zusammenfassung Die Kenntnis der funktionellen Anatomie ist eine Grundvoraussetzung für die sichere und zielorientierte rekonstruktive Therapie der Inkontinenz und der Prolapssyndrome des Beckenbodens der Frau. Anhand von anatomischen Zeichnungen wird das Zusammenspiel des muskulären und des bindegewebigen Beckenbodens mit der Auswirkung auf die Funktion der Urethra, der Blase, der Vagina, des Uterus und des Rektums verdeutlicht. Exemplarisch werden therapeutische Rationale der operativen Rekonstruktion des Beckenbodens aus der funktionellen Anatomie definiert und begründet.
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