Development of a novel classification system for anatomical variants of the puboprostatic ligaments with expert validation

Authors

  • Michael Kim Division of Clinical Anatomy, Department of Anatomy & Cell Biology, Western University
  • Shawna L Boyle Division of Urology, Department of Surgery, Western University
  • Alfonso Fernandez Division of Urology, Department of Surgery, Western University
  • Edward D Matsumoto Division of Urology, Department of Surgery, McMaster University
  • Kenneth T Pace Division of Urology, Department of Surgery, University of Toronto
  • Maurice Anidjar Division of Urology, Department of Surgery, McGill University
  • Gregory N Kozak Division of Urology, Department of Surgery, University of Calgary
  • Sumit Dave Division of Urology, Departments of Surgery and Pediatrics, Western University
  • Blayne K Welk Division of Urology, Department of Surgery, Western University
  • Marjorie I Johnson Division of Clinical Anatomy, Department of Anatomy & Cell Biology, Western University
  • Stephen E Pautler Divisions of Urology & Surgical Oncology, Departments of Surgery and Oncology, Western University

DOI:

https://doi.org/10.5489/cuaj.1797

Keywords:

prostate, ligaments, classification, variation, anatomy

Abstract

Introduction: We propose a novel classification system with a validation study to help clinicians identify and typify commonly seen variants of the puboprostatic ligaments (PPL).

Methods: A preliminary dissection of 6 male cadavers and a prospective dataset of over 300 robotic-assisted laparoscopic radical prostatectomies (RARP) recorded on video were used to identify 4 distinct ligament types. Then the prospectively collected database of surgical videos was used to isolate images of the PPL from RARP. Over 300 surgical videos were reviewed and classified with 1 to 5 pictures saved for reference of the type of PPL. To validate the new classification system, we selected 5 independent, blinded expert robotic surgeons to classify 100 ligaments based on morphology into a 4-type system: parallel, V-shaped, inverted V-shape, and fused. One week later, a subset of 25 photographs was sent to the same experts and classified. Statistical analyses were performed to determine both the intra-rater and inter-rater reliability of the proposed system.

Results: Inverted V-shaped ligaments were noted most frequently (29.97%), parallel and V-shaped ligaments were found at 19.19% and 11.11%, respectively and fused ligaments were noted less frequently (6.06%). There was good intra-rater agreement (κ = 0.66) and inter-rater agreement (κ = 0.67) for the classification system.

Conclusions: This classification system provided standardized descriptions of ligament variations that could be adopted universally to help clinicians categorize the variants. The system, validated by several blinded expert surgeons, demonstrated that surgeons were able to learn and correctly classify the variants. The system may be useful in helping to predict peri- and postoperative outcomes; however, this will require further study.

Downloads

Download data is not yet available.

Author Biographies

Michael Kim, Division of Clinical Anatomy, Department of Anatomy & Cell Biology, Western University

MSc

Shawna L Boyle, Division of Urology, Department of Surgery, Western University

MD

Alfonso Fernandez, Division of Urology, Department of Surgery, Western University

MD

Edward D Matsumoto, Division of Urology, Department of Surgery, McMaster University

MD MEd FRCSC Dip ABU

Kenneth T Pace, Division of Urology, Department of Surgery, University of Toronto

MD MSc FRCSC

Maurice Anidjar, Division of Urology, Department of Surgery, McGill University

MD PhD

Gregory N Kozak, Division of Urology, Department of Surgery, University of Calgary

MD FRCSC

Sumit Dave, Division of Urology, Departments of Surgery and Pediatrics, Western University

MD MCh

Blayne K Welk, Division of Urology, Department of Surgery, Western University

MSc MD FRCSC

Marjorie I Johnson, Division of Clinical Anatomy, Department of Anatomy & Cell Biology, Western University

PhD

Stephen E Pautler, Divisions of Urology & Surgical Oncology, Departments of Surgery and Oncology, Western University

BSc MD FRCSC

Downloads

Published

2014-12-15

How to Cite

Kim, M., Boyle, S. L., Fernandez, A., Matsumoto, E. D., Pace, K. T., Anidjar, M., Kozak, G. N., Dave, S., Welk, B. K., Johnson, M. I., & Pautler, S. E. (2014). Development of a novel classification system for anatomical variants of the puboprostatic ligaments with expert validation. Canadian Urological Association Journal, 8(11-12), 432–6. https://doi.org/10.5489/cuaj.1797

Issue

Section

Original Research