A model patient

Author's Accepted Manuscript A model patient: Female pelvic anatomy can be viewed in diverse 3D images with a new interactive tool Jiajia Luo, James A. Ashton-Miller, John O.L. DeLancey PII: DOI: Reference:

S0002-9378(11)01073-8 10.1016/j.ajog.2011.08.023 YMOB 8446

To appear in:

American Journal of Obstetrics and Gynecology

Please cite this article as: Luo, J., Ashton-Miller, J.A., DeLancey, J.O.L., A model patient: Female pelvic anatomy can be viewed in diverse 3D images with a new interactive tool, American Journal of Obstetrics and Gynecology, (2011), doi: 10.1016/j.ajog.2011.08.023. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

[PRINT VERSION] Images in Gynecology

[HED] A model patient

[SUBTITLE] Female pelvic anatomy can be viewed in diverse 3D images with a new interactive tool

JiajiaLuo, MS; James A. Ashton-Miller, PhD; John O.L. DeLancey, MD From the Biomechanics Research Laboratory, Department of Mechanical Engineering (MrLuo and Dr Ashton-Miller), College of Engineering, and the Department of Obstetrics and Gynecology (DrDeLancey), Medical School, University of Michigan, Ann Arbor, MI. DISCLOSURE: Dr. John OL DeLancey and Dr. James A Ashton-Miller receive research support from American Medical Systems and Kimberly Clark Corporation. Dr. DeLancey has been a consultant for Johnson and Johnson and American Medical System. Dr. Ashton-Miller has been a consultant for American Medical System. JiajiaLuo’s doctoral studies are partially funded by American Medical Systems and Kimberly Clark Corporation. Presented as a short oral presentationat the 31st Annual Scientific Meeting of the American UrogynecologicSociety, Sept 30, 2010 to Oct 2, 2010, Long Beach, CA. Case notes

We developed, in portable document format (PDF), a detailed 3-dimensional(3D) interactive anatomic model of 23 pelvic structures, including the muscles, ligaments, and fascia of the pelvic floor and the organs it supports. Bones, blood vessels, and the perineum are illustrated as well. To produce this tool, 3D volumetric models were created from serial 5-mm-thick images obtained with a 3 Tesla magnetic resonance (MR) scanner. The subject was a healthy,45-yearold, multiparous woman who was at the 50th percentile for height. MR images were then imported into 3D Slicersoftware,version 3.4.1 (Brigham and Women’s Hospital, Boston, MA).Each structure was traced using the most clearly visible axial and/or coronal plane images and lofted into a 3D virtual model based on our previous anatomic work.Models were validated against the original scans and tracings. Next, the 3D models generated by 3D Slicer were imported into Adobe 3D Reviewer 9.0 (Adobe Systems Inc., San Jose, CA), exported as a universal 3D file, and with the aid of the program’s 3D tool, inserted into Adobe Acrobat 9 Pro and saved as a PDF file. Conclusions The 3D PDF file allowsthe user to view and manipulate detailed 3D models of pelvic anatomy without any specialized visualization software. For example, the model can be rotated and magnified; structures can be hidden or rendered transparent, making it easier to understand complex anatomical relationships (Figure; an interactive model is available online at www.AJOG.org).All that is needed is the readily available—and free—Adobe Reader and cross section capability is available with Adobe Acrobat. Availability of this anatomically accurate model is critical to avoiding errors in comprehension that can arise from conceptually-based anatomic representations. [USE FIGURE 2 in file inventory—labeled “interactive 3D manipulation with labels.”] Figure.The user can manipulate the 3-dimensional model of pelvic structures. A,This is a threequarter, right anterolateral view; B, Hiding the bones reveals selected features (Ut, uterus; B, bladder; Ura, urethra; V, Vagina; R, rectum; CL, cardinal ligament; USL, uterosacral ligament; PeB, perineal body; LA, levatorani; EAS, external anal sphincter); C,Making the bladder and urethra transparent reveals the underlying structures; D,Sample sagittal cross-section of the

remaining structures; E, Sample axial cross-section. © University of Michigan Pelvic Floor Research Group (2011).

[ONLINE VERSION] Images in Gynecology

[HED] A model patient

[SUBTITLE] Female pelvic anatomy can be viewed in diverse 3D images with a new interactive tool

JiajiaLuo, MS; James A. Ashton-Miller, PhD; John O.L. DeLancey, MD From the Biomechanics Research Laboratory, Department of Mechanical Engineering (MrLuo and Dr Ashton-Miller), College of Engineering, and the Department of Obstetrics and Gynecology (DrDeLancey), Medical School, University of Michigan, Ann Arbor, MI. DISCLOSURE: Dr. John OL DeLancey and Dr. James A Ashton-Miller receive research support from American Medical Systems and Kimberly Clark Corporation. Dr. DeLancey has been a consultant for Johnson and Johnson and American Medical System. Dr. Ashton-Miller has been a consultant for American Medical System. JiajiaLuo’s doctoral studies are partially funded by American Medical Systems and Kimberly Clark Corporation. Presented as a short oral presentationat the 31st Annual Scientific Meeting of the American UrogynecologicSociety, Sept 30, 2010 to Oct 2, 2010, Long Beach, CA. Case notes

We developed, in portable document format (PDF), a detailed 3-dimensional(3D) interactive anatomic model of 23 pelvic structures, including the muscles, ligaments, and fascia of the pelvic floor and the organs it supports. Bones, blood vessels, and the perineum are illustrated as well. To produce this tool, 3D volumetric models were created from serial 5-mm-thick images obtained with a 3 Tesla magnetic resonance (MR) scanner. The subject was a healthy,45-yearold, multiparous woman who was at the 50th percentile for height. MR images were then imported into 3D Slicersoftware,version 3.4.1 (Brigham and Women’s Hospital, Boston, MA).Each structure was traced using the most clearly visible axial and/or coronal plane images and lofted into a 3D virtual model based on our previous anatomic work.1-5Models were validated against the original scans and tracings. Next, the 3D models generated by 3D Slicer were imported into Adobe 3D Reviewer 9.0 (Adobe Systems Inc., San Jose, CA), exported as a universal 3D file, and with the aid of the program’s 3D tool, inserted into Adobe Acrobat 9 Pro and saved as a PDF file. Conclusions The 3D PDF file allows the user to view and manipulate detailed 3D models of pelvic anatomy without any specialized visualization software. For example, the model can be rotated and magnified; structures can be hidden or rendered transparent, making it easier to understand complex anatomical relationships (Figure; an interactive model is available online at www.AJOG.org).All that is needed is the readily available—and free—Adobe Reader and cross section capability is available with Adobe Acrobat. Availability of this anatomically accurate model is critical to avoiding errors in comprehension that can arise from conceptually-based anatomic representations. Acknowledgments We gratefully acknowledge support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Grant R01 HD 38665, and the Office for Research on Women’s Health, Specialized Centers of Research: Sex and Gender Factors Affecting Women’s Health, Grant P50 HD044406. References

1. Hsu Y, Fenner DE, Weadock WJ, DeLancey JO. Magnetic resonance imaging and 3dimensional analysis of external anal sphincter anatomy.Obstet Gynecol 2005;106:125965. 2. Margulies RU, Hsu Y, Kearney R, Stein T, Umek WH, DeLancey JO. Appearance of the levator ani muscle subdivisions in magnetic resonance images.Obstet Gynecol 2006;107:1064-9. 3. Hsu Y, Lewicky-Gaupp C, DeLancey JO. Posterior compartment anatomy as seen in magnetic resonance imagingand 3-dimensional reconstruction from asymptomatic nulliparas.Am J Obstet Gynecol 2008;198:651.e1-7. 4. Brandon CJ, Lewicky-Gaupp, Larson KA, DeLancey JO. Anatomy of the perineal membrane as seen in magnetic resonance images of nulliparous women.Am J Obstet Gynecol 2009;200:583.e1-6. 5. Larson KA, Yousuf A, Lewicky-Gaupp C, Fenner DE, DeLancey JO. Perineal body anatomy in living women: 3-dimensional analysis using thin-slice magnetic resonance imaging.Am J Obstet Gynecol 2010;203:494.e15-21. [USE FIGURES 2(second in file inventory list) and 4 (fourth in file inventory list); 1 and 3 are the same but unlabeled—no point repeating.] [FIGURE 2 in file inventory—labeled “interactive 3D manipulation with labels.”] Figure 1.The user can manipulate the 3-dimensional (3D) model of pelvic structures. A, This is a three-quarter, right anterolateral view; B, Hiding the bones reveals selected features (Ut, uterus; B, bladder; Ura, urethra; V, Vagina; R, rectum; CL, cardinal ligament; USL, uterosacral ligament; PeB, perineal body; LA, levatorani; EAS, external anal sphincter); C,Making the bladder and urethra transparent reveals the underlying structures; D,Sample sagittal cross-section of the remaining structures; E, Sample axial cross-section. © University of Michigan Pelvic Floor Research Group (2011). [FIGURE 4 in file inventory—“interface with labels.”] Figure 2.The manipulation interface includes a model tree and toolbar. A,The model tree allows users to hide, isolate, or render transparent individual anatomic structures by right clicking on the

label.B,Using this button in the 3D toolbar at the top, it is possible to zoom in or out, rotate the model, spin it, and pan over it;C, The model tree can be toggled on and off with this button; D,Cross-sections can be cut at a given location and orientation; E,The 3D model is activated by clicking on the portable document format file.© University of Michigan Pelvic Floor Research Group (2011). [Listed in inventory file as3D_FemalePelvicFloordemo video.] Clip 1. Use of the model is illustrated. [Listed in inventory file as 3D_FemalePelvicFloor PDF] Clip 2. Here is an opportunity to try the new tool. Click on the portable document format file to begin. [TOC lines] [IM-E11-23]

Images in Gynecology

[HED] A model patient

[SUBTITLE] Researchers have developed a new interactive tool that displays the female pelvic anatomy in a range of 3-dimensional images. Users select features to achieve the “specimen” of choice.

JiajiaLuo, MS; James A. Ashton-Miller, PhD; John O.L. DeLancey, MD

Interactive 3D manipulation Click here to download high resolution image

Interactive 3D manipulation-with labels Click here to download high resolution image

Manipulation Interface Click here to download high resolution image

Manipulation Interface-with labels Click here to download high resolution image