1. 3D ANATOMICAL BASIS FOR TRANSOBTURATOR SURGERIES Prof. Paulo Palma

2. Paradigm shifts 1. Integral Theory, 1993 (Peter Petros) –Creating neoligaments using tapes –Reinforcement of pubourethral ligament –Midurethral tape placement. 2. Transobturator Approach, 2001 (Delorme) - Reinforcement of urethropelvic ligament - Less visceral and vascular complications - Less irritative voiding symptoms

3. Sacro Uterine Ligament Ligament Bladder Uterus P Tendineous Arc PubourethralLigament Sacrum Urethropelvic Ligament Vagina Anterior MedianPosterior Compartiments

4. P Tendineous Arc Sacrum Vagina PubourethralLigament Urethropelvic Ligament Sacro Uterine Ligament Ligament LIGAMENTS

5. Rest

6. Straining

7. Voiding

8. 1 2 3 4 1. Superficial Transverse Muscle of perineum 2. Isquiocavernosous muscle 3. Bulbocavernosous Muscle 4. External Anal Esfincter First muscular layer

9. 5 5.Deep Transversal Muscle of perineum Second Muscular Layer

10. 6 7 8 6. Pubovaginal 7. Puborectal 8. Ileococcigeous White Line

11. RECTOVAGINAL FASCIA

12. VESICOVAGINAL FASCIA

13. Bony Anatomy Ischial tuberosity Pubic Symphysis Ischiopubic ramus Obturator Canal

14. Muscular Anatomy Clitoris Gracilis Adductor longus Adductor magnus

15. Muscular Anatomy MuscleFunctionInnervation Adductor longusAdducts & flexes thighObturator (L2,3) Adductor brevisAdducts & flexes thighObturator (L2, 3) Adductor magnus Adducts, extends, flexes & rotates thigh Obturator (L2, 3) & Tibial (L4, 5) Gracilis Adducts thigh, flexes knee Obturator (L2, 3) Obturator internusLateral rotator of thighObturator (L5, S1) Obturator externusLateral rotator of thighObturator (L3, 4) Pectineus Flexes thigh, Adducts thigh Femoral (L2, 3)

16. Obturator Vessels Retroperitoneal View Obturator vessels Obturator nerve Obturator canal

17. Obturator Vascular Anatomy

18. Obturator - Neuroanatomy From anterior division of L2-4 Innervates all muscles of the obturator region, except pectineus Passes through obturator canal and splits to innervate the muscles that adduct the thigh and help with external rotation Small sensory area on the medial thigh

19. P Tendineous Arc Uterus Vagina Anterior aginal Wall Defects

20. P Tendineous Arc Uterus Vagina LateralDefect Anterior aginal Wall Defects

21. Lateral Defect Anterior aginal Wall Defects

22. P Tendineous Arc Uterus Vagina Central Defect Central Defect Central Defect

24. Central Defect: Treatment

25. P Tendineous Arc Uterus Vagina Anterior Vaginal Prolapse (AVP) PubourethralLigament

26. P Uterus Vagina Lateral Defect Anterior Vaginal Prolapse (AVP) Central Defect Central Defect Tendineous Arc

27. P Uterus Vagina Anterior Vaginal Prolapse (AVP)

28. Evaluation of pelvic floor reconstructive surgery using tridimentional helical CT Fig 3. Notice the well supported bladder base and the TOT arms

29. P Tendineous Arc Rectum Uterus Vagina Levator ani PosteriorDefect Posterior Vaginal Prolapse (PVP)

30. SacrospinalLigament P Tendineous Arc Rectum Uterus Vagina Levator ani Posterior Vaginal Prolapse Repair

31. Evaluation of pelvic floor reconstructive surgery using tridimentional helical CT Fig 4. Infracoccigeal sacropexy showing indirectly the “neo rectovagianl fascia”