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Li Y, Ma YB, Xiao Y, Shi GC, Zhao YM, Zhou JS, Tong C, Liu RT, Yan LK. The characteristics of the urogenital fascia in the retrorectal space based on male cadaveric dissection and its clinical application. BMC Surg 2023; 23:93. [PMID: 37069543 PMCID: PMC10111664 DOI: 10.1186/s12893-023-01993-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 04/07/2023] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND The architecture of retrorectal fasciae is complex, as determined by different anatomical concepts. The aim of this study was to examine the anatomical characteristics of the inferomedial extension of the urogenital fascia (UGF) involving the pelvis to explore its relationship with the adjacent fasciae. Furthermore, we have expounded on the clinical application of UGF. METHOD For our study, we examined 20 adult male pelvic specimens fixed in formalin, including 2 entire pelvic specimens and 18 semipelvic specimens. Our department has performed 466 laparoscopic rectal cancer procedures since January 2020. We reviewed the surgical videos involving UGF preservation and analyzed the anatomy of the UGF. RESULTS The bilateral hypogastric nerves ran between the visceral and parietal layers of the UGF. The visceral fascia migrated ventrally at the fourth sacral vertebra, which formed the rectosacral fascia together with the fascia propria of the rectum; the parietal layer continually extended to the pelvic diaphragm, terminating at the levator ani muscle. At the third to fourth sacral vertebra level, the two layers constituted the lateral ligaments. CONCLUSION The double layers of the UGF are vital structures for comprehending the posterior fascia relationship of the rectum. The upper segment between the fascia propria of the rectum and the visceral layer has no evident nerves or blood vessels and is regarded as the " holy plane" for the operation.
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Affiliation(s)
- Yi Li
- First Department of General Surgery, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, 710000, China
| | - Yan-Bing Ma
- Department of Human Anatomy, Histology and Embryology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, 710061, China
| | - Yang Xiao
- Department of Anorectal Surgery, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, 710000, China
| | - Guang-Cun Shi
- Medical School of Yan'an University, Yan'an, Shaanxi, 716000, China
| | - Ya-Min Zhao
- Department of General Surgery, Shandong Provincial Linyi Jinluo Hospital, Linyi, Shandong, 276000, China
| | - Jin-Song Zhou
- Department of Human Anatomy, Histology and Embryology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, 710061, China
| | - Cong Tong
- First Department of General Surgery, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, 710000, China
| | - Rui-Ting Liu
- First Department of General Surgery, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, 710000, China
| | - Li-Kun Yan
- First Department of General Surgery, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, 710000, China.
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Chong C, Hamza Y, Tan YW, Paul A, Garriboli M, Wright AJ, Olsburgh J, Taylor C, Sinha MD, Mishra P, Taghizadeh A. Long-term urology outcomes of anorectal malformation. J Pediatr Urol 2022; 18:150.e1-150.e6. [PMID: 35283020 DOI: 10.1016/j.jpurol.2022.01.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 12/09/2021] [Accepted: 01/31/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Urological problems are a recognised feature of anorectal malformation (ARM). Previous assumptions of favourable long-term urinary outcomes are being challenged. OBJECTIVE We hypothesised that urinary tract problems are common in ARM and frequently persist into adulthood. We retrospectively reviewed long-term renal and bladder outcomes in ARM patients. STUDY DESIGN Patients with ARM born between 1984-2005 were identified from electronic hospital databases. Their case notes were reviewed. Renal outcomes included serum creatinine and the need for renal replacement therapy. Bladder outcomes included symptom review, bladder medication, need for intermittent catheterisation, videourodynamics and whether the patient had undergone augmentation cystoplasty. RESULT (TABLE 1): The case notes of 50 patients were reviewed. The median age at last follow up was 18 years (range 12-34 years). The level of fistula was noted to be high in 17 patients, intermediate in eight, and low in 10. Four had cloaca. Congenital urological abnormalities were present in 25 (50%). An abnormal spinal cord was present in 22 (44%) patients. VACTERL association occurred in 27 (54%). Chronic kidney disease stage II or above was found in 14 (28%) patients, of whom four required a renal transplant. Abnormal bladder outcomes were found in 39 (78%) patients. Augmentation cystoplasty with Mitrofanoff had been performed in 12. Of those who had not undergone cystoplasty, 17 had urinary symptoms, including urinary incontinence in 12. Of the 39 patients with abnormal bladder outcome, 19 (49%) did not have a spinal cord abnormality. There was no significant statistical association between level of ARM and abnormal renal outcome or presence of bladder abnormality. DISCUSSION Adverse renal and bladder outcomes are common in our cohort of young people with ARM with a significantly higher incidence compared with current literature. We did not demonstrate an association between level of ARM or presence of spinal cord anomaly with persistent bladder problems. Congenital urological anomalies are more common in those who later have an abnormal renal outcome. Although this difference is statistically significant, one fifth of patients born with anatomically normal upper tracts develop reduced renal function, implying an important acquired component. CONCLUSION Bladder problems and reduced renal function affect a significant proportion of young adults with ARM. Neither adverse outcome is reliably predicted from ARM level, congenital urological anomaly or spinal cord anomaly. We advise continued long-term bladder and kidney follow-up for all patients with ARM.
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Affiliation(s)
- Clara Chong
- Department of Paediatric Urology, Evelina London Children's Hospital, Westminster Bridge Road, London, SE1 7EH, United Kingdom; Department of Paediatric Surgery, Evelina London Children's Hospital, London, United Kingdom.
| | - Yaser Hamza
- Kings College London, London, United Kingdom
| | - Yew Wei Tan
- Department of Paediatric Surgery, Evelina London Children's Hospital, London, United Kingdom
| | - Anu Paul
- Department of Paediatric Urology, Evelina London Children's Hospital, Westminster Bridge Road, London, SE1 7EH, United Kingdom
| | - Massimo Garriboli
- Department of Paediatric Urology, Evelina London Children's Hospital, Westminster Bridge Road, London, SE1 7EH, United Kingdom
| | - Anne J Wright
- Department of Paediatric Nephrourology, Evelina London Children's Hospital, London, United Kingdom
| | - Jonathon Olsburgh
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Claire Taylor
- Department of Urology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Manish D Sinha
- Kings College London, London, United Kingdom; Department of Paediatric Nephrourology, Evelina London Children's Hospital, London, United Kingdom
| | - Pankaj Mishra
- Department of Paediatric Urology, Evelina London Children's Hospital, Westminster Bridge Road, London, SE1 7EH, United Kingdom
| | - Arash Taghizadeh
- Department of Paediatric Urology, Evelina London Children's Hospital, Westminster Bridge Road, London, SE1 7EH, United Kingdom; Kings College London, London, United Kingdom
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Long-term effects of laparoscopic lateral pelvic lymph node dissection on urinary retention in rectal cancer. Surg Endosc 2021; 36:999-1007. [PMID: 33616731 DOI: 10.1007/s00464-021-08364-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 02/09/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND The addition of lateral pelvic lymph node dissection (LPLND) in rectal cancer surgery has been reported to increase the incidence of post-operative urinary retention. Here, we assessed the predictive factors and long-term outcomes of urinary retention following laparoscopic LPLND (L-LPLND) with total mesorectal excision (TME) for advanced lower rectal cancer. METHODS This retrospective single-institutional study reviewed post-operative urinary retention in 71 patients with lower rectal cancer who underwent L-LPLND with TME. Patients with preoperative urinary dysfunction or who underwent unilateral LPLND were excluded. Detailed information regarding patient clinicopathologic characteristics, post-void residual urine volume, and the presence or absence of urinary retention over time was collected from clinical and histopathologic reports and telephone surveys. Urinary retention was defined as residual urine > 100 mL and the need for further treatment. RESULTS Post-operative urinary retention was observed in 25/71 patients (35.2%). Multivariate analysis revealed that blood loss ≥ 400 mL [odds ratio (OR) 4.52; 95% confidence interval (CI) 1.24-16.43; p = 0.018] and inferior vesical artery (IVA) resection (OR 8.28; 95% CI 2.46-27.81; p < 0.001) were independently correlated with the incidence of urinary retention. Furthermore, bilateral IVA resection caused urinary retention in more patients than unilateral IVA resection (88.9% vs 47.1%, respectively; p = 0.049). Although urinary retention associated with unilateral IVA resection improved relatively quickly, urinary retention associated with bilateral IVA resection tended to persist over 1 year. CONCLUSION We identified the predictive factors of urinary retention following L-LPLND with TME, including increased blood loss (≥ 400 mL) and IVA resection. Urinary retention associated with unilateral IVA resection improved relatively quickly. L-LPLND with unilateral IVA resection is a feasible and safe procedure to improve oncological curability. However, if oncological curability is guaranteed, bilateral IVA resection should be avoided to prevent irreversible urinary retention.
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Mueller K, Karimuddin AA, Metcalf C, Woo A, Lefresne S. Management of Malignant Rectal Pain and Tenesmus: A Systematic Review. J Palliat Med 2019; 23:964-971. [PMID: 31682188 DOI: 10.1089/jpm.2019.0139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Malignant rectal pain (MRP) and tenesmus cause significant morbidity for cancer patients at all stages of disease. There is little evidence to guide management of these symptoms. Objective: The objective of this review was to summarize the existing evidence base for palliative management of MRP and tenesmus outside of standard oncologic or surgical management. Design: A systematic review of PubMed and Embase was conducted according to PRISMA guidelines using preselected search terms for publications between 1980 and January 2017. Setting/Subjects: Studies that described management for patients with tenesmoid pain from malignant tumors of the rectum, anus, or perineum were identified. Measurements: The primary outcome was response of pain to treatment. Results: The search produced 1412 titles. Twenty articles met criteria for inclusion in the review, including 11 case series and 9 case reports. A variety of treatments were found with most patients receiving interventional procedures, but overall evidence to support any particular intervention is limited and of poor quality. Conclusions: This review highlights the limited current evidence base for medical and interventional treatments for MRP and tenesmus. Further study is needed to clarify the best approach to managing these challenging symptoms.
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Affiliation(s)
- Katelyn Mueller
- 2D Palliative Care, Burnaby Hospital, Burnaby, British Columbia, Canada
| | - Ahmer A Karimuddin
- Department of Surgery, St. Paul's Hospital, Providence Health, Vancouver, British Columbia, Canada
| | - Corey Metcalf
- Department of Medical Oncology/Palliative Care, BC Cancer Agency Vancouver Centre, Vancouver, British Columbia, Canada
| | - Annie Woo
- Department of Pharmacy, and BC Cancer Agency Vancouver Centre, Vancouver, British Columbia, Canada
| | - Shilo Lefresne
- Department of Radiation Oncology, BC Cancer Agency Vancouver Centre, Vancouver, British Columbia, Canada
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Correia JAP, De-Ary-Pires B, Pires-Neto MA, De Ary-Pires R. The developmental anatomy of the human superior hypogastric plexus: A morphometrical investigation with clinical and surgical correlations. Clin Anat 2011; 23:962-70. [PMID: 20949499 DOI: 10.1002/ca.21027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The superior hypogastric plexus (SHP) is the part of the autonomic nervous system, which is responsible for the sympathetic innervation of pelvic organs and extrapelvic genitals in humans of both sexes. The SHP also functions as the anatomic pathway for the major part of visceral sensitive fibers originating from pelvic viscera. In this study, the morphology of the SHP was analyzed through anatomical dissections performed both in human adult and fetal cadavers. A computerized morphometrical investigation of the SHP was also performed and the resulting quantitative data statistically assessed. The comparison between fetal and adult SHP revealed that in the male group there was a developmental increase of six times (in height) and of about five times (in width); while in the female group, there was a developmental increase of 3.5 times both in height and width values. In addition, the distance from the superior border of the SHP to the bifurcation of the common iliac arteries presented a developmental increase of about six times in the male group, and about four times in the female group. We propose an original morphological classification with six types, based upon the anatomical arrangement of the nervous fibers in this autonomic plexus.
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Kinugasa Y, Sugihara K. Topology of the Fascial Structures in Rectal Surgery: Complete Cancer Resection and the Importance of Avoiding Autonomic Nerve Injury. SEMINARS IN COLON AND RECTAL SURGERY 2010. [DOI: 10.1053/j.scrs.2010.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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7
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Resection of rectal cancer: a historical review. Surg Today 2010; 40:501-6. [PMID: 20496130 DOI: 10.1007/s00595-009-4153-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2009] [Accepted: 07/13/2009] [Indexed: 10/19/2022]
Abstract
Local control of rectal cancer and patient survival have improved remarkably with advances in surgical techniques and adjuvant therapy. By applying advanced surgical principles, surgeons can now excise most rectal cancers completely, often preserving the anal sphincter and leaving the patient with relatively normal bowel and pelvic function. Historically, the earliest surgical approaches to rectal cancer were via the perineum. As surgical techniques and general anesthesia improved, other approaches such as a posterior approach were undertaken to improve access to the whole rectum. Consequently, abdominoperineal resection became the standard treatment until anterior resection was introduced for proximal rectal cancers. The most important surgical breakthrough in recent years has been the advent of total mesorectal excision (TME). The emphasis in rectal cancer surgery is on preservation of function, with dissection being done in appropriate anatomical planes. Thus, mobilization of the rectum has a long history, and is seen in modern procedures including TME and intersphincter resection. This article reviews the progression of the surgical management of rectal cancer with reference to historical perspectives. We discuss the major surgical considerations for mobilization of the rectum in several surgical procedures, from conventional operations to modern standardized TME.
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Camanni D, Zaccara A, Capitanucci ML, Mosiello G, Iacobelli BD, De Gennaro M. Bladder After Total Urogenital Mobilization for Congenital Adrenal Hyperplasia and Cloaca—Does it Behave the Same? J Urol 2009; 182:1892-7. [DOI: 10.1016/j.juro.2009.02.067] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2008] [Indexed: 10/20/2022]
Affiliation(s)
- Daniela Camanni
- Urodynamic Unit, Department of Nephrology and Urology and Newborn Surgery Unit (BDI), Bambino Gesù Children's Hospital, Rome, Italy
| | - Antonio Zaccara
- Urodynamic Unit, Department of Nephrology and Urology and Newborn Surgery Unit (BDI), Bambino Gesù Children's Hospital, Rome, Italy
| | - Maria Luisa Capitanucci
- Urodynamic Unit, Department of Nephrology and Urology and Newborn Surgery Unit (BDI), Bambino Gesù Children's Hospital, Rome, Italy
| | - Giovanni Mosiello
- Urodynamic Unit, Department of Nephrology and Urology and Newborn Surgery Unit (BDI), Bambino Gesù Children's Hospital, Rome, Italy
| | - Barbara D. Iacobelli
- Urodynamic Unit, Department of Nephrology and Urology and Newborn Surgery Unit (BDI), Bambino Gesù Children's Hospital, Rome, Italy
| | - Mario De Gennaro
- Urodynamic Unit, Department of Nephrology and Urology and Newborn Surgery Unit (BDI), Bambino Gesù Children's Hospital, Rome, Italy
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Intraprostatic local anesthesia with periprostatic nerve block for transrectal ultrasound guided prostate biopsy. J Urol 2009; 182:479-83; discussion 483-4. [PMID: 19524987 DOI: 10.1016/j.juro.2009.04.029] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2009] [Indexed: 11/22/2022]
Abstract
PURPOSE Prostate biopsy is an invasive procedure that may be painful and require some form of anesthesia. We compared the pain control results of periprostatic nerve block alone vs periprostatic nerve block with intraprostatic anesthesia as local anesthesia for prostate biopsy. MATERIALS AND METHODS A total of 300 patients who underwent transrectal ultrasound guided prostate biopsy were randomized into 3 groups. Group 1 of 100 patients received periprostatic nerve block and intraprostatic local anesthesia with 5 ml 2% lidocaine. Group 2 of 100 patients received periprostatic nerve block and the same amount of 0.9% NaCl by intraprostatic injection. Group 3 of 100 patients received no anesthesia. Patients were asked to use a scale of 0 to 10 to complete a visual analog scale questionnaire about pain during probe insertion, anesthesia and biopsy. RESULTS Pain control was similar during probe insertion and anesthesia in the 3 groups (p = 0.885 and 0.227, respectively). Pain during biopsy in group 1 was significantly less than in groups 2 and 3 (p <0.0001). In patients with a smaller prostate volume (48 ml or less) these differences were still significant between group 1 and 2 (p <0.0001), although not in patients with a larger prostate volume (greater than 48 ml) (p = 0.185). In patients 66 years old or younger these differences were also significant in groups 1 and 2 (p <0.0001) but not in older patients (p = 0.155). CONCLUSIONS Combining periprostatic nerve block and intraprostatic local anesthesia provided significantly better pain control than periprostatic nerve block alone. The combination may be of maximum benefit in patients with a smaller prostate volume or younger patients.
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10
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Dobrowolski S, Wojciechowski J, Dobosz M, Hać S, Sledziński Z. Prospective Evaluation of the Defecatory Functional Results in Patients Following Aorto-Aortic Reconstruction Surgery for an Abdominal Aortic Aneurysm. Surg Today 2007; 37:831-6. [PMID: 17879031 DOI: 10.1007/s00595-007-3511-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2007] [Accepted: 03/20/2007] [Indexed: 11/26/2022]
Abstract
PURPOSE Anterior rectal resections have been associated with postoperative bowel function abnormalities, a condition defined as anterior resection syndrome. Autonomic denervation could be one of the possible mechanisms underlying this complication. Damage to the preaortic tissue containing autonomic nervous plexus during abdominal aortic reconstruction surgery may affect the anorectal defecation function. METHODS The anorectal function was prospectively studied in 22 patients undergoing abdominal aortic reconstruction surgery. The patients were examined preoperatively and 6 months postoperatively by symptom-specific questionnaires. RESULTS Postoperatively, the patients showed no significant impairment of the anorectal functions in both constipation- and fecal incontinence-specific questionnaires. Self-estimation of the defecatory function was slightly lower compared with preoperative scores. CONCLUSION An injury to the intermesenteric, inferior mesenteric, and superior hypogastric plexuses does not significantly influence the defecatory functions in patients following abdominal reconstruction surgery for an abdominal aortic aneurysm.
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Affiliation(s)
- Sebastian Dobrowolski
- Department of General, Endocrine and Transplant Surgery, Municipal Hospital in Gdańsk, Medical University of Gdańsk, Debinki 7, 80-211 Gdańsk, Poland
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11
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Lee HY, Lee HJ, Byun SS, Lee SE, Hong SK, Kim SH. Effect of Intraprostatic Local Anesthesia During Transrectal Ultrasound Guided Prostate Biopsy: Comparison of 3 Methods in a Randomized, Double-Blind, Placebo Controlled Trial. J Urol 2007; 178:469-72; discussion 472. [PMID: 17561127 DOI: 10.1016/j.juro.2007.03.130] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2006] [Indexed: 11/17/2022]
Abstract
PURPOSE We evaluated the effect of intracapsular anesthesia and periprostatic nerve block during transrectal ultrasound guided prostate biopsy. MATERIALS AND METHODS In a prospective, randomized, double-blind, placebo controlled study 152 consecutive patients were randomized into 3 groups. Group 1 of 41 patients was administered intraprostatic local anesthesia into the right and left sides with a total of 2 ml 1% lidocaine and a periprostatic injection of 2 ml saline later. Group 2 of 49 patients was administered intraprostatic injection of 2 ml saline, followed by periprostatic local anesthesia with 2 ml 1% lidocaine. Group 3 of 62 patients received intraprostatic and periprostatic local anesthesia with 2 ml 1% lidocaine. Patients were asked to grade the pain level using a 10-point linear visual analog pain scale 1) when the transrectal ultrasound probe was inserted, 2) during anesthesia, 3) during biopsy and 4) 20 minutes after biopsy. One-way ANOVA and the Kruskal-Wallis test with the Tukey post hoc test were used to compare patient characteristics and pain scale responses among the 3 groups. RESULTS No major complications, including sepsis and severe rectal bleeding, were noted in any patient. There were statistically significant differences in pain scores among groups 1 to 3 during anesthesia (mean +/- SD 5.6 +/- 2.5, 6.7 +/- 2.3 and 4.9 +/- 2.1, p = 0.003) and during biopsy (4.3 +/- 2.7, 4.5 +/- 2.6 and 2.7 +/- 2.1, respectively, p = 0.032). There were no differences in pain scores among the 3 groups during probe insertion (p = 0.39). CONCLUSIONS A combination of intracapsular anesthesia and periprostatic nerve block is an effective and useful technique that is well tolerated by the patient. It decreases the level of pain and discomfort associated with the prostatic biopsy procedure.
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Affiliation(s)
- Ho Yun Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Gyeonggi-do, Korea
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Kinugasa Y, Murakami G, Suzuki D, Sugihara K. Histological identification of fascial structures posterolateral to the rectum. Br J Surg 2007; 94:620-6. [PMID: 17330242 DOI: 10.1002/bjs.5540] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND A comprehensive understanding of fascial structures around the rectum is important for surgeons. Multilaminar fascial structures have provided different interpretations of reliable surgical planes in rectal surgery. METHODS Pelvic visceral materials for histological assessment were obtained from 12 male cadavers. Large specimens covering wide areas around the mesorectum were embedded in paraffin, followed by preparation of semiserial horizontal sections and sagittal sections for histological examination. RESULTS Histological examination demonstrated a prehypogastric nerve fascia and parietal presacral fascia in the retrorectal multilaminar structure. The parietal presacral fascia seemed to divide into several lateral continuations. The prehypogastric nerve fascia appeared to join the most medial continuation of the parietal presacral fascia, which continued ventrally and communicated with Denonvilliers' fascia. Any fascial structure connecting directly between the fascia propria of the rectum and the parietal presacral fascia (that is, the rectosacral fascia) was not found in sagittal sections. CONCLUSION In the retrorectal multilaminar structure, prehypogastric nerve fascia is evident between the fascia propria of the rectum and the parietal presacral fascia. Sharp dissection in front of the prehypogastric nerve fascia according to the histological configuration of the posterolateral fasciae seems reliable.
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Affiliation(s)
- Y Kinugasa
- Department of Surgical Oncology, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
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Kinugasa Y, Murakami G, Uchimoto K, Takenaka A, Yajima T, Sugihara K. Operating behind Denonvilliers' fascia for reliable preservation of urogenital autonomic nerves in total mesorectal excision: a histologic study using cadaveric specimens, including a surgical experiment using fresh cadaveric models. Dis Colon Rectum 2006; 49:1024-32. [PMID: 16732487 DOI: 10.1007/s10350-006-0557-7] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE Little is known about which urogenital nerves are liable to be injured along surgical planes in front of or behind Denonvilliers' fascia. METHODS AND RESULTS Using semiserial histology for five fixed male pelves, we demonstrated that: 1) left/right communicating branches of bilateral pelvic plexuses run immediately in front of Denonvilliers' fascia; and 2) a lateral continuation of Denonvilliers' fascia separates the urogenital neurovascular bundle from the mesorectum. Notably, the mesorectum contains no or few extramural ganglion cells. At the level of the seminal vesicles, incision in front of Denonvilliers' fascia seems likely to injure superior parts of the pelvic plexus and the left/right communication. Moreover, at the prostate level, this incision misleads the surgical plane into the neurovascular bundle. Fresh cadaveric dissections of five unfixed male pelves confirmed that the surgical plane in front of Denonvilliers' fascia continues to a fascial space for the pelvic plexus containing ganglion cell clusters lateral and/or inferior to the seminal vesicles. CONCLUSIONS To preserve all autonomic nerves for urogenital function, optimal total mesorectal excision for rectal cancer requires dissection behind Denonvilliers' fascia.
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Affiliation(s)
- Yusuke Kinugasa
- Department of Surgical Oncology, Graduate School, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan.
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Mutaguchi K, Shinohara K, Matsubara A, Yasumoto H, Mita K, Usui T. Local anesthesia during 10 core biopsy of the prostate: comparison of 2 methods. J Urol 2005; 173:742-5. [PMID: 15711260 DOI: 10.1097/01.ju.0000152119.28959.3a] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE We investigated the effectiveness of a new method, intraprostatic administration of local anesthesia vs traditional periprostatic injection for decreasing the discomfort caused by transrectal ultrasound guided, 10 core biopsy of the prostate. MATERIALS AND METHODS We studied 71 patients who received intraprostatic anesthesia between October 2002 and March 2003, and 99 who received periprostatic anesthesia between October 2001 and September 2002 before prostate biopsy. After biopsy patients were given a questionnaire, which consisted of 5 questions about pain and 3 about morbidity, and were asked to complete it and mail it to our department. RESULTS The mean score +/- SD for the degree of pain during biopsy in the periprostatic groups was 2.6 +/- 1.1 and that in the intraprostatic group was 1.9 +/- 1.1, which was significantly different (p <0.001). Other items, including the degree of pain after biopsy, duration and location of pain, and medicine intake for pain, were not significantly different between the 2 groups. There was no significant difference in morbidity, including hematuria, hemospermia and rectal bleeding, between the 2 groups. CONCLUSIONS Intraprostatic administration of local anesthesia significantly decreases the pain associated with prostate biopsy compared with periprostatic nerve block. It is a simple, safe and rapid technique that should be considered in all patients undergoing transrectal ultrasound guided prostate biopsy.
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Affiliation(s)
- Kazuaki Mutaguchi
- Division of Frontier Medical Science, Department of Urology, Programs for Biomedical Research, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan.
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Rodrigues AO, Machado MT, Wroclawski ER. Prostate innervation and local anesthesia in prostate procedures. REVISTA DO HOSPITAL DAS CLINICAS 2002; 57:287-92. [PMID: 12612762 DOI: 10.1590/s0041-87812002000600008] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The nerve supply of the human prostate is very abundant, and knowledge of the anatomy contributes to successful administration of local anesthesia. However, the exact anatomy of extrinsic neuronal cell bodies of the autonomic and sensory innervation of the prostate is not clear, except in other animals. Branches of pelvic ganglia composed of pelvic (parasympathetic) and hypogastric (sympathetic) nerves innervate the prostate. The autonomic nervous system plays an important role in the growth, maturation, and secretory function of this gland. Prostate procedures under local anesthesia, such as transurethral prostatic resections or transrectal ultrasound-guided prostatic biopsy, are safe, simple, and effective. Local anesthesia can be feasible for many special conditions including uncomplicated prostate surgery and may be particularly useful for the high-risk group of patients for whom inhalation or spinal anesthesia is inadvisable.
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Ludwikowski B, Hayward IO, Fritsch H. Rectovaginal fascia: An important structure in pelvic visceral surgery? About its development, structure, and function. J Pediatr Surg 2002; 37:634-8. [PMID: 11912525 DOI: 10.1053/jpsu.2002.31624] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The existence, development, and function of the rectovaginal fascia has been discussed in literature. In women, a defect in the fascia leads to rectoceles and severe constipation. In pediatric textbooks for anorectal or urogenital surgery, however, it is not mentioned. Does the fascia exist in children? METHODS The pelvises of 31 female and, as controls, 31 male fetuses (age from 9 weeks of gestation to newborn) were plastinated. Sections (transversal, sagittal, and frontal) were stained with azure II/ methylenblue/ basic fuchsin and viewed at a magnification of 6.5x to 80x. In addition, the authors investigated macroscopically and microscopically the rectovaginal fascia in 1 fetal and 1 adult cadaver. RESULTS At the beginning of the fetal period the authors recognized the anlage of the rectovaginal fascia caudal from the rectouterine excavation. Later, a fascia of connective tissue develops. It is connected directly to areolar connective tissue at the dorsal wall of the vagina. Neurovascular bundles are situated ventrolaterally of the rectal wall. At the level of the anorectal flexure this fascia separates the rectum and the vagina. CONCLUSIONS Our investigations indicate that the rectovaginal fascia is completely developed in newborns, through differentiation of mesenchyme, which develops into a fascia. It protects different compartments and serves as an abutment to the rectal wall. Thus, it is important for adequate bowel emptying. For the surgeon it is a leading structure for preventing nerve damage of the autonomic nerve supply of the pelvic organs. It should be known, protected, and, if necessary, reconstructed.
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