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The boundary between the 2 is the arcuate line that starts at the superior pubic ramus and extends to the sacral promontory symptoms 32 weeks pregnant buy meclizine cheap. Paired-greater and lesser sciatic foramina medicine 6 year program meclizine 25 mg generic, obturator foramina; nonpaired-pelvic inlet and pelvic outlet. What structures are found in Alcock canal and what is another name for Alcock canal The pudendal (Alcock) canal runs approximately 4 cm above the lower ridge of ischial tuberosity and contains the pudendal artery, pudendal veins, and the pudendal nerve; all are invested in connective tissue, binding these structures to the perineal surface of the obturator internus fascia. One must be cautious during ligation and division of the dorsal venous complex, as damage to the striated sphincter can occur. What anatomic reason may account for the relatively higher incidence of axial skeletal and pelvic bone metastases in patients with metastatic prostate cancer, as opposed to lung metastases for example There are numerous interconnections between the pelvic venous plexuses and the emissary veins of the pelvic bones and vertebral venous plexuses, which may be routes of dissemination of infection or tumor from the diseased prostate. What artery has its origin off the inferior epigastric artery and can be identified medial to the femoral vein during pelvic surgery The accessory obturator artery arises from the inferior epigastric artery in 25% of patients and continues on through the obturator canal. Following a radical dissection of inguinal lymph nodes for penile carcinoma, the surgeon decided to cover the area with a rectus myocutaneous flap. The middle rectal artery anastomoses with the superior and inferior rectal arteries to supply the rectum. It also gives small branches to provide additional arterial supply to the seminal vesicles and prostate. What accessory vein drains in to the inferior surface of the external iliac vein in at least 50% of patients Care must be taken to not tear this vein at the time of pelvic lymph node dissection. True/False: Intramural longitudinal vessels run the length of the ureter in 75% of patients. In the other 25% of patients, the intramural ureteral vessels form a fine interconnecting mesh with less collateral flow and render the ureter more prone to ischemic insult. This intramural, interconnecting meshlike vascular pattern is often found in the pelvic ureter, and therefore, this portion of the ureter is less suited for ureteroureterostomy. What is one of the main reasons that the primary repair of the pelvic ureter is often prone to strictures The blood supply of the pelvic ureter is based on longitudinal collaterals that run along it, which are often severed following both the primary injury to the ureter and subsequent mobilization during its repair, thus limiting its blood supply with a high risk for ischemic strictures. In a normal adult male, at what anatomic location are the ureters closest to each other The ureters are closest and are located within 5 cm of each other as they cross the iliac vessels. What is the principal arterial supply to prostatic adenomas in benign prostatic hyperplasia and where are the origin and principal branches of the prostatic artery The inferior vesical arteries have urethral artery branches that enter the prostate posterolaterally at its junction with the bladder and these branches are the principal arterial supply to the adenomas. The short segment at the end of the inferior vesical artery after all the branches to the bladder but before the bifurcation between the capsular and urethral branches is called the prostatic artery. When an accessory pudendal artery is present and is supplementing or replacing the penile arterial supply by the common penile artery, what is its origin An accessory pudendal artery is present in approximately 4% of patients undergoing a radical retropubic prostatectomy and arises from the inferior vesical artery, superior vesical artery, and obturator artery. The internal pudendal artery in the male lies anterior to the piriformis muscle, sacral plexus of nerves, and the inferior gluteal artery. As it crosses the ischial spine, it is covered by the gluteus maximus muscle and overlapped by the sacrotuberous ligament. The pudendal nerve is medial to the artery while the nerve to the obturator internus muscle is lateral to the internal pudendal artery. The aorta gives rise to 2 common iliac arteries at the level of 4th lumbar vertebra. What artery arises posteriorly at the level of the aortic bifurcation and what does it supply It is the middle sacral artery and it supplies the sacral foramina and the rectum. The posterior trunk gives rise to 3 parietal branches: the superior gluteal, the ascending lumbar, and the lateral sacral branches. The anterior trunk gives rise to 7 branches: the superior vesical, the middle rectal, the inferior vesical, the uterine, the internal pudendal, the obturator, and the inferior gluteal branches. What are the sources of collateral blood supply to the pelvic organs in the case of bilateral ligation of the internal iliac arteries due to massive hemorrhage Aortic branches (middle sacral and lumbar arteries) and inferior mesenteric branches (inferior mesenteric artery). True/False: In a nerve-sparing cystoprostatectomy, the unilateral internal iliac artery should be ligated and divided to improve hemostasis and facilitate the nerve-sparing procedure, thereby possibly maintaining erectile function. The internal iliac artery should be preserved and the superior vesical artery should be ligated and divided proximally in order to maintain the integrity of the internal pudendal artery and to prevent vasculogenic erectile dysfunction. The superficial circumflex iliac, external pudendal, and superficial inferior epigastric vessels. At what anatomic site does the internal iliac artery branch in to its anterior and posterior trunks It can arise from the anterior trunk of the internal iliac artery, the inferior epigastric artery, or the inferior gluteal artery.

Diseases

• Adenomyosis
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• Pseudohermaphrodism anorectal anomalies
• Carney syndrome
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Sexual reproduction involves the concerted release of these two components symptoms 7 days past ovulation order meclizine 25 mg mastercard, which subsequently fuse to re-form the diploid chromosome number symptoms 9 days after ovulation meclizine 25mg with mastercard, resulting in a new, genetically unique individual, a process termed fertilization. Fertilization involves a number of key, sequential steps, these are: (1) the acquisition of sperm motility and chemotaxis; (2) capacitation and the acrosome reaction; (3) sperm-egg fusion; and (4) egg activation and the initiation of embryo development. Following the acquisition of motility, sperm begin to make their way up the female reproductive tract towards the egg, employing a process termed chemotaxis. Chemotaxis is a phenomenon by which single cells or multicellular organisms direct their movements according to certain chemicals in their environment. How human sperm are attracted towards the egg is still a matter of debate, with multiple mechanisms proposed [2]. In some non-mammalian species, peptides or proteins are known to act as chemoattractants (agents of chemotaxis), such as unsaturated fatty acids [1]. Sperm motility and chemotaxis Sperm generated in the testis are immature and immotile, and need to undergo a variety of modifications in order to obtain fertilization competency. The first step of maturation occurs within the testis, where sperm acquire proteins and cholesterols secreted from the epididymis [1]. This process includes alterations in ion concentration, membrane fluidity, membrane hyperpolarization, intracellular pH, protein phosphorylation and concentrations of reactive 98 Textbook of Clinical Embryology, ed. A soluble adenylyl cyclase is also thought to be an enzyme of fundamental importance, activated in the female tract by bicarbonate and calcium, appearing to initiate capacitation [5, 6]. Capacitation is thought to involve membraneassociated factors which prepare the sperm for egg binding and fertilization, and also contribute towards hyperactivation, a phenomenon now recorded in all mammalian species, involving significant changes in flagellum motility [7, 8]. The mammalian acrosome is a highly specialized organelle overlying the sperm nucleus. In eutherian mammals, fusion with the oolemma begins at the equatorial segment (vii). The posterior region of the sperm head and the tail are subsequently incorporated by the egg via membrane fusion, whereas the anterior region of the head, where the inner membrane is exposed, is engulfed by the egg in a phagocytic manner (viii, ix). In general, acrosomal exocytosis is thought to be required for successful fusion of the sperm with the egg. Egg ligands There are several key players within the egg that are involved in sperm-egg fusion. Intriguingly, the activity of a Zn21-dependent metalloprotease is also considered to be involved, the identity of which, or which gamete expresses it, is not known [12, 15, 16]. Following the events of gamete fusion, the egg primes itself for a major event of fertilization. Instead, the egg nucleus is arrested at the metaphase of the second meiotic division, following the exclusion of the first polar body at egg maturation. All these features must be modified to allow embryogenesis following fertilization. Sperm-egg fusion Membrane fusion requires a mechanism in which two lipid bilayers are transformed from two separate barriers in to a single lipid bilayer, in this case involving fusion between the sperm and egg membranes. This is thought to involve a variety of receptor/ligand interactions, on both the sperm and the egg. Another candidate is thought to be a testis-specific protein, Izumo, only detectable on acrosome-reacted sperm. Izumo knockout male mice are sterile, despite normal mating behaviour and ejaculation [15]. Of note is the ability of Izumo to bind identical or closely related immunoglobulin family members [14]. The egg membrane undergoes physical and chemical changes to prevent polyspermy and to protect and support the embryo. In most mammals, meiotic arrest is released to allow the cell cycle to complete, forming a haploid female pronucleus that is capable of combining with the sperm-derived male pronucleus. Active Cdc2 drives entry in to M-phase by phosphorylating substrates that lead to nuclear envelope breakdown and spindle formation [17]. The sperm nuclear envelope is then removed, and sperm-specific protamines or histones are replaced by histone variants from maternal stores [17]. The duration and initiation of these events differ between species, beginning at day 1 (2-cell stage) in the mouse. Cytoskeletal rearrangements occur, presumably to support zygotic growth and development.

Extensive parenchymal destruction involving the whole kidney associated with hypertension is also an indication for nephrectomy treatment zinc overdose buy meclizine 25 mg free shipping. What is the likelihood that she will have an improvement in her hypertension with a nephrectomy Approximately 65% of patients with significant unilateral renal involvement will have improvement in their hypertension medicine 1800s meclizine 25mg free shipping. Calcification is associated with the normal tissue response from the destructive process and subsequent mineralization of the fibrous scar tissue. Small calcifications can be observed while larger ones should be removed in a parenchyma sparing fashion if there is adequate global kidney function in the remaining parenchyma. Scarring in the bladder at the level of the ureteral orifice can cause contraction of the surrounding tissue leading to a contracted rigid golf hole type ureteral orifice. After 3 weeks of medical therapy he has no improvement in his ureteral obstruction. The addition of prednisone to his regimen would be indicated and should improve his ureteral stenosis. What are the remaining options for the treatment of his distal ureteral stricture Accusize balloon dilation/incision, psoas hitch reimplantation, Boari flap reimplantation, and ileal interposition. Hematogenous spread from a primary pulmonary source or direct inoculation from the female genital tract. He has a poorly defined fullness to the globus major of the epididymis that is directly associated with the testis. The ultrasound reveals a solid mass involving the testis and epididymis as well as a small associated loculated hydrocele. Obstructive azoospermia can occur and with more advanced disease, nodular epididymitis can lead to fistulization of sinus tracts to the skin. Most patients will require epididymal or testicular sperm aspiration followed by in vitro fertilization. How many Americans experience a bout of renal colic caused by nephrolithiasis annually Is the worldwide incidence of kidney stones increasing, decreasing, or about the same and why This is thought to be the result of more cultures adopting a Western diet as well as global warming contributing to increased dehydration. The male:female ratio is shifting, in the last few years it has been closer to 3:1, but is currently 1. Roughly 7% of women and 13% of men will develop at least one stone at some point in their lifetimes. Struvite stones are twice as likely to occur in women because of the higher incidence of urinary tract infections in females. A peak incidence for nephrolithiasis occurs from 30 to 60 years old with 35 to 45 being the peak decade. What is the current estimated yearly cost of kidney stone disease in the United States What is the risk for stone recurrence after an initial symptomatic episode of urolithiasis Obesity is a strong predictor of stone recurrence especially in first-time stone formers. Obesity causes changes in urine chemistry reflecting increased calcium, uric acid, sodium, and decreased citrate in the urine. Obesity is associated with a higher risk for both uric acid and calcium oxalate stones. Insulin resistance at the cellular level results in hyperinsulinemia, which in turn causes defects in renal production of ammonia, lowering the pH of the urine. What medications can be used to facilitate ureteral stone passage in urolithiasis The rate of stone passage increases approximately 30% with the use of -blockers, and the need for narcotics and surgical intervention decreases. In addition, calcium channel blockers such as nifedipine have been shown to cause ureteral dilatation and relaxation resulting in increased spontaneous stone passage rates. A proximal ureteral stone will have a lower chance of spontaneous stone passage (50%) than a distal ureteral stone (85%). Patients with planned interventions should be treated with antibiotics prior to the intervention. In patients presenting with a ureteral stone, with well-controlled symptoms, what are the recommendations for medical expulsion therapy The average time to stone passage is 1 week for 2 mm, 2 weeks for 2 to 4 mm, and 3 weeks for 4 mm. How long should one wait for an asymptomatic stone to pass or move before considering doing a surgical procedure For stones 10 mm approximately 95% will pass spontaneously within 4 to 6 weeks, following that time, if the stone has not passed spontaneously, one should consider intervention. After that time, the risk of possible longterm complications, such as strictures, increases.

Influence of group culture and culture volume on the formation of human blastocysts: a prospective randomized study medicine 319 pill buy meclizine 25mg cheap. The presence of a sponsoring embryo in a batch of poor quality thawed embryos significantly increases pregnancy and implantation rate the treatment 2014 buy cheap meclizine 25 mg on-line. Continuous observation of rabbit preimplantation embryos in vitro by using a culture device connected to a microscope. Chronologically, evolution began when micromanipulation techniques were used to assist fertilization in cases of male factor infertility [1]. Another methodology associated with breach of the zona pellucida is assisted hatching, which involves drilling a hole in the zona of an embryo [7]. The stages at which biopsy can be performed include first and/or second polar bodies; removed sequentially on the day of oocyte collection and on day 1 (after fertilization check) [9] or simultaneously after fertilization check, or the removal of one or two blastomeres from a day 3 cleavage stage embryo [8] or trophectoderm cells from a day 5 or 6 blastocyst [10, 11]. In this chapter all of these will be discussed individually, with the pros and cons of each being evaluated. The hole size is critical; if it is too large there is a risk of several blastomeres being dragged out along with the one being biopsied. Additionally, there have been suggestions that large holes may be detrimental to embryonic development. If the hole is too small, stresses on blastomeres undergoing biopsy may be excessive, leading to cell lysis. In the case of blastocyst biopsy, holes that are too small may inhibit hatching, leading to implantation failure or the formation of trophoblastic vesicles resulting in blighted ovum [12]. Also, further mechanical pinching off of a portion of the hatching blastocyst may increase the likelihood of monozygotic twinning [13]. The approach is simple and efficient but necessitates the correct positioning, release and rotation of the oocyte, a process that requires extensive skill and experience if it is to be performed successfully. However, a Breaching the zona pellucida Naturally, sampling of genetic material from oocytes and embryos relies on creating a hole in the zona 286 Textbook of Clinical Embryology, ed. Chapter 28: Embryo biopsy small number of groups are using this method for cleavage stage embryo biopsy as it may have the advantage of protecting the embryo until expansion. This is because it is thought that the zonal flaps close after the biopsy pipette is removed, unlike the actual holes created chemically or with a laser which remain open. Holes may allow premature hatching of the embryo and could lead to the problems highlighted earlier [12, 13]. The dimension of the hole created using acid is difficult to standardize as it depends on the amount of acid used, the resistance of the zona and the skill of the operator. Acid tyrodes Localized dissolution of the zona pellucida using a controlled, directed stream of acid tyrodes (pH 2. Problems with the irradiation spectra of some of these systems have meant they are unsuitable for clinical application [24]. The size of the hole created can be controlled depending on the type of biopsy to be performed. Drilling should start at the outer edge of the zona and, using short bursts, gradually move inwards keeping the firing position a safe distance from the adjacent blastomeres. It is important to remember that the laser actually creates a trench in the zona which extends above and below the apparent hole. In addition, the use of a laser for zona drilling means that subsequent biopsy can be performed without the need to change pipettes or move to another culture dish/droplet, as is the case when using acid tyrodes. Piezo-mediated devices these devices harness the piezo-electric effect to transmit a small crystal lattice distortion to the tip of a pipette, driving it forward in a precise and controlled manner. Some work with piezo-mediated drilling has been done in both human and animal models [31]. However, work performed in the mouse has led to concern that excessive use could be detrimental to embryo development.