Pelvic Sidewall Anatomy in Gynecologic Oncology—New Insights into a Potential Avascular Space

Abstract

The surgical treatment of gynecological malignancies is, except for tumors diagnosed at the earliest stages and patients’ desire for fertility preservation, not limited to only the affected organ. In cases of metastatic iliac lymph nodes, gynecological tumors or recurrences located near the pelvic sidewall, oncogynecologists should dissect tissues in that region. Moreover, surgery of deep infiltrating endometriosis, e.g., within the sacral plexus, or oncological procedures, such as a laterally extended endoplevic resection or a laterally extended parametrectomy, often require a dissection of the pelvic sidewall. Dissection should be meticulous, and detailed knowledge of anatomy is mandatory. There are many controversies among authors regarding the terminology in the pelvic sidewall. In particular, several imprecise or confusing definitions exist in regard to the region located medially to the psoas major muscle. Therefore, after discussing the anatomy of the pelvic sidewall and the commonly used terminology, we define a new term and boundaries of a potential avascular space, the medial psoas space. Contrary to the variety of earlier definitions, the proposed boundaries relate to a truly avascular space and could help surgeons to avoid complications resulting from misleading anatomical descriptions. Additionally, describing the clear boundaries of and possible anatomical variations in the medial psoas space may urge oncogynecologists to consider different approaches during surgery. The purpose of the present study is to describe the anatomy of the pelvic sidewall and the applications of the medial psoas space in gynecologic oncology.

A three-headed psoas major muscle: a case report

“…It is also important to accentuate, that together with the obturator internus muscle, PM is a part of the lateral anatomical limit of the pelvic sidewall (PSW) [11]. Surgical procedures, such as treatment of gynecological tumors, excluding tumors diagnosed at the earliest stages and patients' desire for fertility preservation, metastatic iliac lymph nodes, recurrences located near the PSW, deep infiltrating endometriosis (e.g.…”

“…Surgical procedures, such as treatment of gynecological tumors, excluding tumors diagnosed at the earliest stages and patients' desire for fertility preservation, metastatic iliac lymph nodes, recurrences located near the PSW, deep infiltrating endometriosis (e.g. within the sacral plexus), or procedures, such as a laterally extended endoplevic resection or a laterally extended parametrectomy, often require a dissection of the PSW [11]. Any kind of a variability within the PM muscle might potentially disturb the surgical treatment and lead to further complications, therefore knowledge of its variation seems important in order to consider different approaches during surgery.…”

An Update on the Role of MRI in Treatment Stratification of Patients with Cervical Cancer

“…Stage IIIB is the extension of the tumour to the pelvic sidewall. The pelvic sidewall is bordered by the obturator internus and piriformis muscles and contains the iliac vessels, pelvic ureters, and lateral lymph nodes [41]. On MRI, a tumour within 3 mm of the lateral pelvic wall is considered a sidewall invasion.…”

Liver surface depressions in the presence of diaphragmatic muscular bands on trans-illumination

“…While the cause for these surface depressions has not been definitively elucidated, several theories have been put forward, including: compression by ribs[ 5 , 6 ], pulmonary emphysema[ 7 ], congenital parenchymal weakness zones[ 8 - 10 ], hepatic trauma[ 11 ], tumour necrosis leading to desmoplasia and subsequent capsular retraction[ 10 , 11 , 12 ], regression of liver metastases after chemotherapy[ 11 , 13 ], adjacent inflammatory foci (gallbladder empyema, liver abscesses or cirrhosis) leading to parenchymal scarring and capsular retraction[ 14 ], localized iatrogenic injury after trans-arterial chemo-embolization (TACE)[ 15 ], fibrous bands and diaphragmatic scars[ 16 ]. Although none have been definitively proven as the cause for surface depressions, diaphragmatic muscular bands have gained little attention as an aetiologic factor.…”