Surgical anatomy of the pubovesical (puboprostatic) ligaments

Radical retropubic prostatectomy: control of Santorini's venous plexus

OBJECTIVE

Historical review of the procedures and maneuvers described in the literature for the control of Santorini's venous plexus.

MATERIAL AND METHOD

Review of original articles on the design of procedures and maneuvers for the control of the Santorini's venous plexus.

RESULTS

The control of Santorini's plexus is crucial to reduce blood loss and dissect the prostatic apex. The procedure was first performed by Chute in 1954 and has undergone subsequent modifications by several authors (Reiner and Walsh, Hayashi, Myers, etc.) who have published different maneuvers for its control.

CONCLUSION

There is no ideal procedure or maneuver for the control of the Santorini's plexus.

Urinary continence outcomes following vaginoplasty in patients with congenital adrenal hyperplasia

BACKGROUND

Feminizing genitoplasty techniques have diversified to encompass the spectrum of atypical genitalia in 46,XX congenital adrenal hyperplasia (CAH) patients. However, long-term outcomes evaluating postoperative continence following complex vaginoplasty remain scarce.

OBJECTIVE

The aim was to review our surgical experience and assess postoperative urinary continence outcomes in CAH patients following complex, primary vaginoplasty.

STUDY DESIGN

We retrospectively reviewed CAH patients who underwent complex, primary vaginoplasty at a single center by a single surgeon from 1996 to 2013. We collected data on clinical characteristics, surgical techniques and postoperative urinary continence outcomes. In patients who had reached toilet-training age, continence outcomes were reviewed.

RESULTS

Twenty-four patients met the inclusion criteria. The median age at the time of surgery was 8 months (interquartile range [IQR] 1 year-6 months). The median length of follow up was 6 years (IQR 10 years-3 years). These patients required complex reconstruction because of more extensive virilization: total urogenital mobilization (TUM, 10), pull-through vaginoplasty (9), partial urogenital mobilization (3), or pull-through vaginoplasty with partial urogenital mobilization (2). After surgery, 15 out of 24 (62.5%) reported age appropriate toilet-training without further complaints. Seven (29.2%) patients reported daytime incontinence or enuresis that resolved with conservative management. Two patients reported day and night incontinence requiring urethral bulking procedures following TUM.

DISCUSSION

Twenty-two (91.7%) of our patients achieved continence without further surgical intervention. Of these patients, the TUM patients had serious incontinence issues. Our study represents a review of clinically significant cases from the female CAH population. The limitations of our study include a relatively small sample size and retrospective design.

CONCLUSION

Females with CAH and urogenital virilization most often achieved age appropriate toilet-training following vaginoplasty. Daytime incontinence and enuresis resolved without operative management in the vast majority of cases. TUM carries a risk of severe incontinence and may require further procedures to achieve urinary continence.

Preliminary results for continence recovery after intrafascial extraperitoneal laparoscopic radical prostatectomy

Purpose

We present our initial experience and surgical outcomes for the most recent refinement of bilateral intrafascial nerve-sparing extraperitoneal laparoscopic radical prostatectomy (nsELRP).

Materials and Methods

Among 62 patients who underwent laparoscopic radical prostatectomy, 50 patients underwent intrafascial nsELRP by a single surgeon at Pusan National University Hospital from November 2011 to April 2012. As part of the intrafascial technique, the dissection plane is directly on the prostatic capsule to preserve most of the periprostatic fascia containing small vessels and nerves, endopelvic fascia, neurovascular bundle, and puboprostatic ligament. Postoperative continence recovery was established by daily consumption of pads. Follow-up was done at 2 weeks, 6 weeks, and 3 months after surgery.

Results

The patients' mean age was 66.5±6.2 years. The mean operation time and mean blood loss were 149.3±28.1 minutes and 155.4±168.1 ml, respectively. The mean hospitalization time and mean catheterization time were 6.3±5.1 days and 5.5±4.7 days, respectively. Two weeks after the operation, a total of 14 patients (28.0%) were pad-free but the other incontinent patient group used on average 2.3 pads per day. After 6 weeks, 35 patients (70.0%) achieved pad-free status and 7 patients (14.0%) required more than 2 pads per day. At 3 months after surgery, a total of 31 patients were available for follow-up, and 26 patients (83.9%) were pad-free.

Conclusions

Compared with conventional laparoscopic prostatectomy, the intrafascial nsELRP procedure enables the preservation of periprostatic structures that are essential to the recovery of surgical structures related to continence. As a result, early postoperative continence can be achieved.

Anatomy and histology of the lower urinary tract

The function of the lower urinary tract is basically storage of urine in the bladder and the at-will periodic evacuation of the stored urine. Urinary incontinence is one of the most common lower urinary tract disorders in adults, but especially in the elderly female. The urethra, its sphincters, and the pelvic floor are key structures in the achievement of continence, but their basic anatomy is little known and, to some extent, still incompletely understood. Because questions with respect to continence arise from human morbidity, but are often investigated in rodent animal models, we present findings in human and rodent anatomy and histology. Differences between males and females in the role that the pelvic floor plays in the maintenance of continence are described. Furthermore, we briefly describe the embryologic origin of ureters, bladder, and urethra, because the developmental origin of structures such as the vesicoureteral junction, the bladder trigone, and the penile urethra are often invoked to explain (clinical) observations. As the human pelvic floor has acquired features in evolution that are typical for a species with bipedal movement, we also compare the pelvic floor of humans with that of rodents to better understand the rodent (or any other quadruped, for that matter) as an experimental model species. The general conclusion is that the "Bauplan" is well conserved, even though its common features are sometimes difficult to discern.

Anatomical Landmarks of Radical Prostatecomy

INTRODUCTION

In the present study, we review current literature and based on our experience, we present the anatomical landmarks of open and laparoscopic/endoscopic radical prostatectomy.

METHODS

A thorough literature search was performed with the Medline database on the anatomy and the nomenclature of the structures surrounding the prostate gland. The correct handling of puboprostatic ligaments, external urethral sphincter, prostatic fascias and neurovascular bundle is necessary for avoiding malfunction of the urogenital system after radical prostatectomy.

RESULTS

When evaluating new prostatectomy techniques, we should always take into account both clinical and final oncological outcomes. The present review adds further knowledge to the existing "postprostatectomy anatomical hazard" debate. It emphasizes upon the role of the puboprostatic ligaments and the course of the external urethral sphincter for urinary continence. When performing an intrafascial nerve sparing prostatectomy most urologists tend to approach as close to the prostatic capsula as possible, even though there is no concurrence regarding the nomenclature of the surrounding fascias and the course of the actual neurovascular bundles. After completion of an intrafascial technique the specimen does not contain any periprostatic tissue and thus the detection of pT3a disease is not feasible. This especially becomes problematic if the tumour reaches the resection margin.

DISCUSSION

Nerve sparing open and laparoscopic radical prostatectomy should aim in maintaining sexual function, recuperating early continence after surgery, without hindering the final oncological outcome to the procedure. Despite the different approaches for radical prostatectomy the key for better results is the understanding of the anatomy of the bladder neck and the urethra.

Nerve Sparing Endoscopic Extraperitoneal Radical Prostatectomy– Effect of Puboprostatic Ligament Preservation on Early Continence and Positive Margins

INTRODUCTION

A technical modification of nerve sparing endoscopic extraperitoneal radical prostatectomy (nsEERPE) with preservation of the puboprostatic ligaments is presented and compared to a previous technique.

MATERIALS AND METHODS

nsEERPE was performed in 100 men with clinically localized adenocarcinoma of the prostate from March 2004 through February 2005. Patients were divided into two groups: Group A included patients in whom a standard nsEERPE was performed (n=50), and group B included patients in whom a puboprostatic ligament sparing nsEERPE was performed (n=50). The postoperative follow-up was 2 weeks and 3 months evaluating preliminary effects on early continence and positive margins.

RESULTS

The early return to continence at 2 weeks postoperatively was achieved by 6 patients (12%) in group A, and 12 patients (24%) in group B. Three months after the procedure 24 (48%) and 38 (76%) patients were continent, in groups A and B respectively. Clinical outcome (early continence) was significantly better for Group B patients, at 2 weeks (chi-square test, p=0.0019) and at 3 months (chi-square test, p=0.0347) following surgery. No cases of complete or severe incontinence (more than 5 pads/day) were observed at 3 months after surgery, in either groups. Groups A and B did not exhibit significant differences regarding their histological status. In group A, positive margins were detected in 6.5% and 26.3% of patients with pT2 and pT3, respectively. In group B, positive margins were found in 3.2% and 15.8% of patients with pT2 and pT3, respectively

CONCLUSION

We propose the use of puboprostatic ligament-sparing nsEERPE as an intriguing method to ascertain recuperation of early continence after nerve sparing procedures, without hindering the final oncological outcome.

Surgical anatomy of the puboprostatic complex with special reference to radical perineal prostatectomy

OBJECTIVE

To investigate the retropubic space and attachments of the prostate and urethra, with special reference to radical perineal prostatectomy.

MATERIALS AND METHODS

Anatomical relationships were assessed intraoperatively in 60 patients, and in five cadavers after preparing the dorsal vein complex with coloured latex. Cross-sections of the area of interest were evaluated by microscopy.

RESULTS

The puboprostatic (pubovesical) ligaments could be clearly distinguished from the median part of the puboprostatic complex continuous with the urethral suspensory mechanism. The dorsal vein complex is integrated into this fibromuscular attachment of the prostate and male urethra. During the perineal approach, dissection in this region follows the so-called avascular plane.

CONCLUSION

With this new insight into the anatomical relationships the nomenclature derived from radical retropubic prostatectomy could be mirrored. In radical perineal prostatectomy, both the urethral suspensory mechanism and the dorsal vein complex can be preserved.

The puboprostatic ligament and the male urethral suspensory mechanism: an anatomic study

OBJECTIVES

To perform a detailed anatomic study of the puboprostatic ligament and male urethral suspensory mechanism with comparisons to homologous female anatomy.

METHODS

Anatomic dissections were performed on hemipelves of normal fresh male and female cadavers.

RESULTS

The puboprostatic ligament was not a discrete "band" of fascia that simply fixes the prostate to the public symphysis, but a pyramid-shaped structure that is part of a larger urethral suspensory mechanism that attaches the membraneous urethra to the pubic bone. As in the female, the male urethral suspensory mechanism was composed of three continuous structures: the anterior pubourethral ligament (suspensory ligament of the penis and fascial reflection of the perineal membrane), the intermediate pubourethral ligament (arcuate and transverse ligaments), and the posterior pubourethral ligament (the puboprostatic ligament). The attachments of the urethral suspensory mechanism bilaterally inserted along the lateral border of the urethra to form a sling of support from the pubic arch.

CONCLUSIONS

The male and female urethral suspensory mechanism are comparable. Understanding the relationship of the male urethral suspensory mechanism to the urethra, striated urethral sphincter, and dorsal vein may help in performing the apical dissection of the prostate during radical retropubic prostatectomy and in preserving urinary continence following radical pelvic surgery.

Improving the exposure of the prostate in radical retropubic prostatectomy: longitudinal bunching of the deep venous plexus

As an adjunct to radical retropubic prostatectomy, a new technique is introduced to gather together into a midline bundle as much of the deep venous plexus as is possible practically. The technique improves the exposure of the prostate and the spatial orientation before apical dissection.

Anatomical basis of total prostatocystectomy in man

In the first part of this paper special emphasis is given to the anatomy of Denonvillier 's fascia which is derived from the prostatic capsule and covers the seminal vesicles, and to the preprostatic veins. In the second part devoted to the surgical technique of total prostatocystectomy the authors propose that the vesicoprostatic unit be freed by dissecting posterior to Denonvillier 's fascia. It is also proposed that the membranous urethra be sectioned prior to performing hemostasis of the preprostatic veins.

Radical retropubic prostatectomy

We herein present a modification of the Campbell technique for radical retropubic prostatectomy used in 75 consecutive patients undergoing surgical extirpation of the malignant gland. This technique provides for predictable and careful anatomic removal of the prostate. The postoperative complications have been minimal and urinary incontinence has been negligible.