Neuroanatomy of the ureterovesical junction: clinical implications

Single-port-plus-one robot-assisted laparoscopic Lich-Gregoir direct nipple ureteral extravesical reimplantation in pediatric primary obstructive megaureter, comparing to laparoscopic cohen

PURPOSE

To compare the effects of a single-port-plus-one robotic laparoscopic-modified Lich-Gregoir direct nipple approach and traditional laparoscopic Cohen in treating pediatric primary obstructive megaureter.

MATERIALS AND METHODS

The clinical data of 24 children with primary obstructive megaureter from January 2021 to November 2021 were analyzed retrospectively. Among them, 12 children (8 boys and 4 girls, the average age were 17.17 ± 6.31 months) treated with the laparoscopic Cohen method were defined as group C. The remaining 12 children (7 boys and 5 girls, the average age was 17.33 ± 6.99 months) underwent single-port-plus-one robotic laparoscopic-modified Lich-Gregoir direct nipple ureteral extravesical reimplantation were defined as group L. The parameters of pre-operation, intraoperative and postoperative were compared.

RESULTS

There were no differences in the patient characteristics and average follow-up time between the two groups (P > 0.05).The obstruction resolution rate was 100% in both groups. The total operation time in group L is slightly longer than that in group C(P < 0.001),but the intraperitoneal operation time of the two groups was comparable(P > 0.05). The postoperative parameters included blood loss, gross haematuria time, indwelling catheterization time and hospitalization time in group L is shorter than group C(P < 0.05). One year post-operation, decreasing in ureteral diameter and APRPD, and increasing in DRF were remarkably observed in both two groups(P < 0.05). Ureteral diameter, APRPD, and DRF were not significantly different both in pre-operation and post-operation between Group L and Group C(P > 0.05).

CONCLUSION

Single-port-plus-one robot-assisted laparoscopic-modified Lich-Gregoir direct nipple approach and traditional laparoscopic Cohen are both dependable techniques for ureteral reimplantation in the treatment of pediatric primary obstructive megaureter. Since Lich-Gregoir can preserve the physiological direction of the ureter and direct nipple reimplantation enhances the effect of anti-refluxing, this technique is favorable for being promoted and applied in robot surgery.

The LUAA Gundeti Technique for Bilateral Robotic Ureteral Reimplantation: Lessons Learned over a Decade for Optimal (Resolution, Urinary Retention, and Perioperative Complications) Trifecta Outcomes

Background

Ureteral reimplantation is the gold standard treatment for high-grade vesicoureteral reflux (VUR) in pediatric patients. Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) using the LUAA technique has emerged as a viable alternative to traditional open and laparoscopic surgical correction.

Objective

To evaluate the outcomes, reflux resolution, urinary retention, and complications associated with bilateral RALUR-EV for primary VUR using the LUAA Gundeti technique in pediatric patients.

Design setting and participants

A retrospective study was conducted at a single academic center, involving 34 consecutive pediatric patients who underwent RALUR-EV for bilateral VUR management between December 2008 and December 2022. The study included only patients who were evaluated with postoperative voiding cystourethrogram (VCUG).

Surgical procedure

The LUAA extravesical ureteral reimplantation technique was performed, involving the identification and mobilization of the ureter, creation of a peritoneal window, dissection close to the neurovascular bundle, Y dissection at the ureterovesical junction, detrusorotomy, detrusorrhaphy with advential inclusion, and apical alignment suture.

Measurements

The primary outcome was radiographic resolution of VUR on VCUG. The secondary outcomes included urinary retention and Clavien-Dindo grade III complications.

Results and limitations

The overall radiographic resolution rate was 85.2%, with success rates of 76.7%, 75%, and 96.7% across the three distinct patient cohorts. The overall Clavien-Dindo grade III complication rate was 5.8%, and transient urinary retention was 8.8%. Resolution of urinary retention occurred within 7-28 d. The study's limitations include the small sample size, single-center design, and retrospective nature.

Conclusions

The LUAA technique demonstrates sustainable outcomes for VUR resolution with a low incidence of transient urinary retention and complications. A thorough understanding of pelvic anatomy is essential for successful dissection and minimization of the risk of complications. Further studies are needed to evaluate the effectiveness of different approaches in reducing the incidence of transient urinary retention following bilateral extravesical reimplantation.

Patient summary

In this study, we examined the results of the Gundeti LUAA surgical technique for treating primary vesicoureteral reflux in children. We identified various essential modifications that increase the likelihood of achieving favorable outcomes.

Ureteral reimplantation for pediatric vesicoureteral reflux and primary obstructive megaureter: Transvesicoscopic cohen vs. Politano-Leadbetter approaches

BACKGROUND

Transvesicoscopic approaches for ureteral reimplantation (UR) are effective surgical techniques with which to resolve vesicoureteral reflux (VUR) or primary obstructive megaureter (POM) in pediatric patients. However, the effectiveness of different UR surgical methods for these two diseases is still unclear.

PURPOSE

To compare the effects of Cohen's cross-trigonal and Politano-Leadbetter techniques in children in need of UR.

METHODS

A retrospective chart review was performed for consecutive patients who underwent UR at our institution between May 2018 and November 2019, including those treated for vesicoureteral reflux (VUR) or primary obstructive megaureter (POM). Patients who underwent Cohen's technique included in Group C, and those who underwent the Politano-Leadbetter technique were included in Group P. Patient characteristics, perioperative parameters, and short-term postoperative outcomes were compared.

RESULTS

Forty-six patients who underwent unilateral UR were included in the analysis. At presentation, those in Group P (N = 22, 12 diagnosed with VUR and 10 with POM) did not differ from those in Group C (N = 24, 12 diagnosed with VUR and 12 with POM) with respect to age, sex, disease type or severity. For VUR patients, reflux was clinically resolved for all patients in both groups; however, only a 75% resolution rate was observed in Group C, with 3 patients experiencing persistent low-grade, clinically insignificant reflux, while a 100% resolution rate was found in Group P (P > 0.05). Among POM patients, the obstruction was resolved for all those in Group P and for 90% of those in Group C; this difference was also not statistically significant (P > 0.05). At the 1-year follow-up, the ureteral diameter (P < 0.05) and anterior-posterior renal pelvic diameter (APRPD) (P < 0.05) of Group P were significantly reduced, and differential renal function (DRF) (P < 0.05) was slightly improved compared with that in Group C in both VUR and POM patients.

CONCLUSIONS

Politano-Leadbetter and Cohen are both reliable techniques for UR in children with VUR or POM, and the short-term outcomes of these methods in solving reflux and obstruction are comparable. Besides traditional Cohen's technique, Politano-Leadbetter's technique maybe a potential choice for ureteral reimplantation in children.

Extravesical vs. intravesical ureteric reimplantation for primary vesicoureteral reflux: A systematic review and meta-analysis

PURPOSE

This study aims to compare the outcomes of extravesical (EVUR) and intravesical (IVUR) ureteric reimplantation for primary vesicoureteral reflux (VUR) via systematic review and meta-analysis.

METHODS

Literature review from Medline, Embase, and Cochrane since inception to March 2022 was performed. Meta-analysis was conducted on eligible randomized controlled trials (RCT) and observational cohort studies (OCS) comparing outcomes between EVUR and IVUR.

RESULTS

Twelve studies were included, comprising 577 patients (778 ureters) operated by EVUR and 395 patients (635 ureters) by IVUR. Pre-operative VUR grade, postoperative VUR persistence and hydronephrosis was not statistically significant. EVUR had shorter operative time [mean differences (MD) -22.91 min; 95% confidence interval (CI), -44.53 to -1.30, P = 0.04] and hospital stay (MD -2.09 days; 95% CI, -2.82 to -1.36, P < 0.00001) compared to IVUR. Bilateral EVUR had higher risk of postoperative acute urinary retention (ARU) (8.1%) compared to bilateral IVUR (1.7%) (OR = 4.40; 95% CI, 1.33-14.58, P = 0.02). No patient undergoing unilateral EVUR or IVUR experienced ARU.

CONCLUSION

Both EVUR and IVUR are equally effective in correcting primary VUR. Operative time and hospital stay are shorter after EVUR compared to IVUR. However, bilateral EVUR is associated with higher risk of postoperative ARU.

Armamentarium to treat primary vesicoureteral reflux in children

Primary vesicoureteral reflux often spontaneously resolves in children. However, in select patients, untreated reflux can contribute to recurrent pyelonephritis leading to irreversible renal damage. Management is therefore based on a given child's likelihood of recurrent urinary tract infections and risk of subsequent renal parenchymal injury. Therapeutic options for urinary reflux are diverse, ranging from observation with or without continuous low-dose antibiotic prophylaxis to a variety of operative interventions.

Efficacy and safety of silodosin, vardenafil versus silodosin in combination with vardenafil as a medical expulsive therapy for distal ureteric stones: a prospective randomized double-blind study

Background

Urolithiasis is considered one of the most common diseases in urological practice. Its prevalence is about 1% to 15% with 30 years old as the peak age of incidence. Medical expulsive therapy (MET) has been used as a conservative treatment for patients with ureteral stones. Nitrergic fibers have been identified to have a relaxant effect on the distal ureteral smooth musculature. The objective of our study was to evaluate the efficacy and safety of the combination of silodosin and vardenafil as a medical expulsive therapy in comparison with each drug alone.

Methods

One hundred and two male patients with uncomplicated distal ureteric stone 6–10 mm were enrolled in the study. The patients were randomly divided into 3 equal groups, and each one consists of 34 patients. Group I received silodosin 8 mg once daily, group II vardenafil 5 mg once daily and group III combination of silodosin 8 mg and vardenafil 5 mg once daily. The treatment was given for all the patients until stone expulsion or a maximum of 4 weeks. The primary endpoint was the stone expulsion rate, and the secondary endpoints were time to stone expulsion, number of hospital visits for pain, amount of analgesic required and side effects associated with MET.

Results

Our study showed that the stone expulsion rate was higher in combination = 90.0% than silodosin = 76.7% and vardenafil groups = 60.0% (P = 0.025), the time to stone expulsion was significantly shorter in combination = 11.23 ± 3.14 than silodosin = 12.50 ± 1.66 and vardenafil groups 14.67 ± 1.24 days (P < 0.01), the number of hospital visits for pain was statistically significant between the three groups (silodosin 1.35 ± 0.9, vardenafil 1.65 ± 1.09 and combination groups 1.02 ± 0.80) (P = 0.038) and lesser amount of analgesic required in combination 313.6 ± 2.85.5 than silodosin 613.44 ± 483.62 and vardenafil groups 716.97 ± 685.3 (P = 0.008). There was no significant difference among the studied groups as regards the drugs side effects except for retrograde ejaculation (silodosin and combination = 86.7% vs vardenafil groups = 0.0%) (P < 0.05) and increased erection (combination = 26.7%, vardenafil = 23.3% and silodosin groups = 0%) (P = 0.010).

Conclusion

The prescription of vardenafil in combination with silodosin is safe and more effective than silodosin or vardenafil alone as a MET.

Precise characterization of urinary tract innervation using three-dimensional reconstruction: A contemporary review

A precise understanding of the autonomic innervation of the urinary tract is crucial to successful management of urologic disease given the important role that neurophysiology plays in genitourinary pathology. Recent studies using a combination of contemporary histopathology and imaging technologies have furthered our understanding of the spatial nerve distribution in the kidneys, ureters, and bladder. The findings of these recent studies may have important clinical applications in expanding our knowledge of the etiology and treatment of disease processes affecting the urinary tract. In this narrative review, our goal is to provide an overview of the autonomic innervation of the urinary tract. Specifically, we aim to provide a three-dimensional gender-specific description of renal, ureteral and vesical innervation. We also highlight some possible opportunities for clinical and investigational application of this new knowledge.

A nonsurgical and nonpharmacological care bundle for preventing upper urinary tract damage in patients with spinal cord injury and neurogenic bladder

AIM

To establish a care bundle in spinal cord injury patients with neurogenic bladder to avoid upper urinary tract damage and to provide guidance for health care staff in use of nonsurgical and nonpharmacological adjunctive strategies to improve patients' clinical outcomes.

BACKGROUND

Prevention of upper urinary tract damage is critical in the management of spinal cord injury patients with a neurogenic bladder, but there are no authoritative guidelines or high-quality randomized controlled trials.

DESIGN

The study was conducted on the basis of Fulbrook and Mooney's seven-step method for care bundle development.

DATA SOURCES

The databases PubMed, Embase, Science Citation Index, the Cumulative Index to Nursing and Allied Health Literature, the National Guideline Clearinghouse, the Cochrane Library, China Biology Medicine, China National Knowledge Infrastructure, and China Dissertation Database were searched from the date of each database's inception to April 2017.

REVIEW METHODS

We evaluated the literature according to the Joanna Briggs Institute evidence pre-ranking and grade recommendation system (2014 version). The results were examined using a self-designed data extraction.

RESULTS

A three-element cluster including clean intermittent catheterization, bladder function training, and transcutaneous low-frequency pulsed electrical stimulation was formed.

CONCLUSION

The development of this bundle can provide a scientific basis for effective prevention of neurogenic upper urinary tract damage in clinical practice.

Local anatomy around terminal ureter related to the anterior leaf of the vesicouterine ligament in radical hysterectomy

OBJECTIVES

Radical hysterectomy is performed for invasive cervical cancer. In this surgery, separation of the anterior leaf and posterior leaves of the vesicouterine ligament (VUL) is important. We studied the local anatomy of the anterior leaf of the VUL, especially the branches of the umbilical artery from the view point of surgery and cadaver dissection.

STUDY DESIGN

We observed the cervicovesical blood vessels and the connective tissue layer continued from umbilical artery and searched for the origin of the cervicovesical blood vessels in radical hysterectomy. We also dissected a formalin-fixed female cadaver, and observed the same points.

RESULTS

After separation of the connective tissue of urinary bladder from the cervical fascia, we could discern the outline of the distal ureter near the ureterovesical junction. We separate the connective tissue of the so-called anterior leaf of the VUL enwrapping the ureter gently, and then the ureter with the connective tissue is completely rolled out laterally. We identified a cervicovesical vessel crossing over the ureter. We looked for the central side of the cervicovesical vessel and found that cervicovesical vessel was a branch of the superior vesical artery. And, during cadaver dissection, we found that the connective tissue and the branches of the superior vesical artery were similarly observed.

CONCLUSIONS

We found the precise anatomy of the connective tissue layer from umbilical artery to urinary bladder and the superior vesical artery. Our procedure based on the precise anatomy obtained in this study is reasonable anatomically as a method for separation of the vesicouterine ligament during radical hysterectomy.

Lower urinary tract dysfunction in pediatric patients after ureteroneocystostomy due to vesicoureteral reflux: Long-term follow-up

OBJECTIVE

The aim of the present study was to evaluate long-term lower urinary tract dysfunction (LUTD) in pediatric patients who underwent ureteroneocystostomy due to vesicoureteral reflux.

METHODS

The present retrospective study was performed on 61 patients. Patients were divided into 3 groups: Group 1 (n = 26), did not have LUTD; Group 2 (n = 23), had LUTD; and Group 3 (n = 12), was not toilet trained preoperatively. Patients were reassessed regarding de novo LUTD or the persistence of LUTD at least 7 years after the ureteroneocystostomy.

RESULTS

Mean patient age was 7 years (range 1-15) when ureteroneocystostomy was performed and the surgery was associated with a 92% success rate. The mean follow-up period was 10 years (range 7-12 years). Postoperative LUTD was present in 6 (23%), 12 (52%), and 1 (8.3%) patients in Groups 1, 2, and 3, respectively. The presence of LUTD before surgery and bilateral repair in the same setting were predictive risk factors for the presence of LUTD during the long-term follow-up. LUTD occurred at higher rate in Group 2 than in Groups 1 and 3 (52% vs. 23% and 8.3%, respectively; P = .015). The presence of de novo LUTD was significant in Group 1 compared with the presence of preoperative and postoperative LUTD (P = .031, Wilcoxon analysis).

CONCLUSIONS

LUTD may not resolve after a ureteroneocystostomy, and additional therapy could be necessary. Due to the probability of damage to the ureterovesical nerve and/or disturbed bladder dynamics, de novo LUTD may occur in patients with bilateral high-grade reflux without LUTD before a ureteroneocystostomy.

Extravesical Ureteral Reimplantation Following Lich-Gregoir Technique for the Correction of Vesico-Ureteral Reflux Retrospective Comparative Study Open vs. Laparoscopy

Introduction: The aim is to compare the outcome of open versus laparoscopic Lich-Gregoir technique in patients with vesicoureteral reflux. We report a retrospective multicenter comparative study between open and laparoscopic extra-vesical ureteral reimplantation (EVUR) following Lich-Gregoir (LG) technique for the correction of Vesico-Ureteral Reflux (VUR). Materials and Methods: Between January 2007 and December 2015, 96 patients with VUR (69 females and 27 males) and deterioration of the renal function, underwent EVUR following LG technique. Fifty patients (16 males and 34 females) were operated by open surgery (group A). The mean age was 4.22 years-old, (14-147 months). Laparoscopic approach (group B) was performed in 46 patients (11 males and 35 females). The mean age was 4.19 years-old (15-110 months). We compared the results in relation to degree of VUR, operative time, hospital stay, post-operative pain medications, recovery time, complications, successful rate, recurrence, and follow-up. Statistical analysis was done used Chi square test for categorical variables and the Student t-test for continuous variables. P < 0.05 was considered significant. Results: In both groups no correlation was identified between age or weight and operative time, length of stay or total analgesia used. The mean operative time for group A was 63.2 and 125.4 min for unilateral and bilateral VUR, respectively, and for the group B was 127.90 and 184.5 min, respectively. There was no conversion in the laparoscopic group. Perioperative mucosal perforation of the bladder occurred in 6 patients of group A and 4 patients of group B and was immediately repaired. One patient had to be reoperated for leakage in group B. The mean duration of Morphine, IV and PO analgesia was shorter in group B. The mean hospital stay was 5.46 days for group A and 1.54 days for Group B. The success rate was 98% in group A and 97, 8% in group B. The mean follow-up was 3.67 years for the open and 1.54 years for the laparoscopic group. Transitory voiding dysfunction occurred in bilateral EVUR in one case in each group. Conclusion: Laparoscopic or Open approach for the correction of VUR following Lich-Gregoir technique is effective in unilateral and bilateral VUR with similar results. Laparoscopic approach reduces significantly (p < 0.05 in each item) post-operative pain medication, hospital stay, and allows for a faster return to normal activity.

Tadalafil Facilitates the Distal Ureteral Stone Expulsion: A Meta-Analysis

OBJECTIVE

To assess the efficacy and safety of tadalafil in facilitating the spontaneous passage of distal ureteral stones.

METHODS

The relevant studies were identified by searching MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials up to November 2016. Randomized controlled trials evaluating effects of tadalafil for distal ureteral stones were included.

RESULTS

Six publications involving 921 patients were included. Compared with tamsulosin monotherapy, tadalafil monotherapy or combined with tamsulosin has a significantly higher stone expulsion rate (relative risk [RR], 1.16; 95% confidence interval [CI], 1.05 to 1.29; p = 0.004; RR, 1.24; 95% CI, 1.09 to 1.42; p = 0.001, respectively) and shorter time to stone expulsion (mean difference [MD], -1.33 days; 95% CI, -2.44 to -0.23; p = 0.02; MD, -1.98 days; 95% CI, -3.08 to -0.88; p = 0.0004, respectively). Statistically significant differences were noted in pain episodes and analgesic use in favor of group tadalafil alone compared to group tamsulosin alone. The analgesic use was significantly lower in the combined group than in the tamsulosin alone group. Although the occurrence of drug-related adverse events in the tadalafil alone or combined with tamsulosin was higher than that in the use of tamsulosin-alone group, the most common adverse events were mild and tolerable.

CONCLUSIONS

Our study suggested that medical expulsive therapy for the distal ureteral stones using tadalafil alone or combined with tamsulosin is safe, efficacious, and well tolerated.

Origin and nature of pelvic ureter innervation

AIMS

Innervation of the pelvic ureter traditionally comes from the pelvic plexus. This innervation is independent: adrenergic and cholinergic. The purpose of this study was to describe more precisely the origin and nature of its innervation (adrenergic, cholinergic, nitrergic, and somatic).

METHODS

Six specimens of normal human fetal pelvis (four male and two female) from 20 to 30 weeks gestation were studied. The sections of these fetuses, carried out every 5 µm without interval, were treated with Hematoxylin Eosin (HE), with Masson's trichrome (TriM), immunolabeling of smooth muscle cells with smooth anti-actin, of nerves with anti-S100 protein, anti-tyrosine hydroxylase, anti-VAChT, anti-nNOS, and with anti- peripheral myelin protein 22 (PMP 22). The slides were scanned and two-dimensional images reconstructed in 3D, and analyzed.

RESULTS

The terminal pelvic ureter travels above and inside the inferior hypogastric plexus (IHP). The nerve fibers that innervate the ureterovesical junction come mainly from the superior hypogastric plexus (SHP) which gives off the hypogastric nerves and pelvic branches of the sacral plexus that form the IHP. Most nerve fibers meet below the ureter, behind the bladder to form an ascending bundle, which innervates the pelvic ureter. Immunohistochemical analysis shows that the nerves of the pelvic ureter consist of adrenergic, cholinergic, and nitrergic fibers.

CONCLUSION

The innervation of the distal ureter depends mainly on the SHP. This innervation is adrenergic, cholinergic, and nitrergic. It innervates the pelvic ureter in an ascending manner. This anatomical information can change rectal resection and ureteral reimplantation techniques and drug treatments for pelvic ureter stones. Neurourol. Urodynam. 36:271-279, 2017. © 2015 Wiley Periodicals, Inc.

Evaluation of the efficacy of sexual intercourse in expulsion of distal ureteric stones

OBJECTIVE

To evaluate the efficacy of sexual intercourse in expulsion of distal ureteric stones.

PATIENTS AND METHODS

The study included 56 patients with distal ureteric or intramural stone. The stones size ranged from 5 to 10 mm and were detected by US, plain X-ray film, and non-enhanced CT. The patients were divided randomly into group A included 28 patients who were advised to do sexual intercourse 3-4 times/week with administration of symptomatic treatment, and group B included 28 patients receiving symptomatic treatment only (control group) and were instructed not to do sexual intercourse or masturbation during the study. Follow-up (4 weeks) was done by plain X-ray, US, and urine analysis every week and by asking the patients about stone passage, time of expulsion, number of colicky attacks, and analgesic injections.

RESULTS

Group A patients mean age was 36.5 ± 10.7 years and group B 37.3 ± 12.5 years. Stone expulsion rate, in the first 2 weeks for group A, was 82% (23/28), while in group B 53% (16/28), (P = 0.006). At the fourth week, expulsion rate for group A reached to 89%, but in group B 71.4%. The mean expulsion time was shorter in group A (11.9 ± 4.4 days) than group B (16.2 ± 6.7 days). The number of colicky attacks and analgesics for group A was less than group B.

CONCLUSIONS

Practicing sexual intercourse for 3-4 times/week for married male patients with distal ureteric stone (5-10 mm) increases the expulsion rate and decreases the frequency of renal colic and the needs for analgesic.

Selective pelvic autonomic nerve stimulation with simultaneous intraoperative monitoring of internal anal sphincter and bladder innervation

BACKGROUND

Pelvic autonomic nerve preservation avoids postoperative functional disturbances. The aim of this feasibility study was to develop a neuromonitoring system with simultaneous intraoperative verification of internal anal sphincter (IAS) activity and intravesical pressure.

METHODS

14 pigs underwent low anterior rectal resection. During intermittent bipolar electric stimulation of the inferior hypogastric plexus (IHP) and the pelvic splanchnic nerves (PSN), electromyographic signals of the IAS and manometry of the urinary bladder were observed simultaneously.

RESULTS

Stimulation of IHP and PSN as well as simultaneous intraoperative monitoring could be realized with an adapted neuromonitoring device. Neurostimulation resulted in either bladder or IAS activation or concerted activation of both. Intravesical pressure increase as well as amplitude increase of the IAS neuromonitoring signal did not differ significantly between stimulation of IHP and PSN [6.0 cm H(2)O (interquartile range [IQR] 3.5-9.0) vs. 6.0 cm H(2)O (IQR 3.0-10.0) and 12.1 μV (IQR 3.0-36.7) vs. 40.1 μV (IQR 9.0-64.3)] (p > 0.05).

CONCLUSIONS

Pelvic autonomic nerve stimulation with simultaneous intraoperative monitoring of IAS and bladder innervation is feasible. The method may enable neuromonitoring with increasing selectivity for pelvic autonomic nerve preservation.

Coexistence of adrenergic and cholinergic nerves in the inferior hypogastric plexus: anatomical and immunohistochemical study with 3D reconstruction in human male fetus

Classic anatomical methods have failed to determine the precise location, origin and nature of nerve fibres in the inferior hypogastric plexus (IHP). The purpose of this study was to identify the location and nature (adrenergic and/or cholinergic) of IHP nerve fibres and to provide a three-dimensional (3D) representation of pelvic nerves and their relationship to other anatomical structures. Serial transverse sections of the pelvic portion of two human male fetuses (16 and 17 weeks' gestation) were studied histologically and immunohistochemically, digitized and reconstructed three-dimensionally. 3D reconstruction allowed a 'computer-assisted dissection', identifying the precise location and distribution of the pelvic nerve elements. Proximal (supra-levator) and distal (infra-levator) communications between the pudendal nerve and IHP were observed. By determining the nature of the nerve fibres using immunostaining, we were able to demonstrate that the hypogastric nerves and pelvic splanchnic nerves, which are classically considered purely sympathetic and parasympathetic, respectively, contain both adrenergic and cholinergic nerve fibres. The pelvic autonomic nervous system is more complex than previously thought, as adrenergic and cholinergic fibres were found to co-exist in both 'sympathetic' and 'parasympathetic' nerves. This study is the first step to a 3D cartography of neurotransmitter distribution which could help in the selection of molecules to be used in the treatment of incontinence, erectile dysfunction and ejaculatory disorders.

Conservative surgery plus brachytherapy treatment for boys with prostate and/or bladder neck rhabdomyosarcoma: a single team experience

PURPOSE

The aim of this study is to report the results of a conservative surgery + brachytherapy treatment for boys with prostate and/or bladder-neck rhabdomyosarcoma avoiding total cystectomy or prostatectomy and external radiotherapy.

PATIENTS

From 1991 to 2007, 26 boys were operated for a residual mass after chemotherapy (1 for local relapse). All patients underwent a conservative surgical procedure, with bladder-neck and urethra preservation. Surgery was never microscopically complete. Brachytherapy was systematically performed after tumor resection, as a perioperative procedure, consisting of 2 loops encompassing the prostate and the bladder-neck area. A dose of 60 Gy was delivered with low dose rate. Bladder function was evaluated clinically and with urodynamic study for boys with abnormal continence.

RESULTS

Median age at operation was 23 months (9 months-11 years). Seventeen boys underwent a partial prostatectomy associated in 5 with a partial cystectomy. The remaining 9 patients underwent a partial cystectomy with no procedure at the level of the prostate. At a median follow-up of 4 years (10 months-14.5 years), 24 of 26 boys are alive. Only 1 patient relapsed locally out of the brachytherapy field and died. A second boy died from metastatic relapse. Only 1 patient with bladder dysfunction after treatment underwent a total cystectomy. Four patients are too young to be evaluated for bladder function (<4 years of age). Seven patients, aged 4 to 6 years, have daytime continence, 1 has diurnal dribbling. Among 11 boys older than 6 years, 9 (82%) are normally continent (3 after temporary dribbling), 2 have diurnal dribbling treated by bladder education.

CONCLUSION

Even if very long-term sequelae of brachytherapy cannot be evaluated, this conservative combined treatment may allow normal continence in nearly all patients, even after temporary diurnal incontinence and should be discussed as an alternative to external radiotherapy or radical surgery.

Reconstruction of cavernous nerves by nerve grafts to restore potency: contemporary review of technical principles and basic anatomy

PURPOSE OF REVIEW

The review discusses the efficacy of reconstructing the neurovascular bundle to regain sexual function if nerve-sparing prostatectomy is unfeasible.

RECENT FINDINGS

Eleven studies could be found describing the reconstruction of neurovascular bundles. All reconstructive procedures displayed technical inadequacies. The effectiveness of unilateral neurovascular bundle reconstruction remains statistically insignificant when compared with procedures without reconstruction. The efficacy of reconstructing both neurovascular bundles ranges between 0 and 43%. Concerning basic anatomy, the neurovascular bundle contains fibers innervating the cavernous nerves, prostate, rectum, and levator ani muscle. The terms cavernous nerve and neurovascular bundle have often been wrongly considered synonymous. The pelvic splanchnic nerves probably do not join the neurovascular bundle proximal to the bladder/prostate junction but rather at variable distances from 10 to 20 mm distal to it. Therefore, described proximal coaptation sites at the bladder/prostate junction possibly encompass only the hypogastric nerve.

SUMMARY

Modest clinical results are partly due to inadequate surgical techniques and are mainly due to the anatomical and topographical complexity of the cavernous nerves. Contemporary nerve grafting techniques probably do not allow for the regeneration of all cavernous nerves.

Wilhelm von Waldeyer-Hartz (1836-1921): An anatomist who left his mark

Wilhelm Waldeyer was anatomist, physiologist, and pathologist during the German Empire (the so-called Second Reich). His scientific career left many traces still noticeable today. Not only is he commemorated in "his" pharyngeal lymphoid ring and other eponyms, but he also coined an impressive range of successful medical terms, including "chromosome" and "neuron." Moreover, Waldeyer left truly physical traces by donating parts of his body to his own Institute of Anatomy in Berlin. His scientific production does, however, also include "pseudoscientific" works, notably his questionable research on African brains.

Bladder/Prostate Rhabdomyosarcoma: Past, Present and Future

PURPOSE

The last few decades have witnessed substantial improvement in outcomes in children with bladder/prostate rhabdomyosarcoma. We reviewed relevant historical aspects of treatment, current treatment strategies and new developments. Most importantly we identified areas of existing controversy, which will provide direction for future studies and continued improvements in therapy.

MATERIALS AND METHODS

A database (PubMed, MEDLINE, etc) search was performed from 1966 through January 2005. Approximately 500 citations were identified. Relevant citations were reviewed in detail.

RESULTS

While the reported cure rate has improved to approximately 70% to 80% and bladder preservation rates as high as 60% are reported, substantial controversy continues in certain areas. Specifically the long-term function of preserved bladders, the contribution of radiotherapy to bladder dysfunction, the timing of reconstruction and molecular markers of disease progression are among the areas that require further investigation.

CONCLUSIONS

Substantial progress has been made as a result of multi-institutional collaborative trials. Future combined studies are required to further the treatment of this childhood malignancy.

[Primary vesicoureteral reflux and extravesical ureteral reimplantation in chidren]

PURPOSE

to assess the results of the Lich-Gregoire procedure in the treatment of primary vesicoureteral reflux (VUR).

MATERIALS AND METHODS

In a 2.5-year period, 141 children with primary VUR underwent a vesicoureteral reimplantation using the Lich-Gregoire procedure in 101 patients (158 ureters) and the Cohen procedure in 48 patients (68 ureters). Patients were evaluated retrospectively in a non randomized fashion and data were recorded about: age, indications for surgery, days with the bladder catheter, length of stay, and short and long-term complications.

RESULTS

The control average time was 1.71 years (from 8 months to 3.5 years). A) Early complications. No obstruction was seen in this series. Five children (8.6 of the bilaterally simultaneously operated) showed urinary retention, but only three needed replacement of the bladder catheter and only one of them needed temporary clean intermittent catheterization. Nausea, vomiting, pain and hematuria were sporadic and limited in time. B) Late complications. The long-term results were good (95%). Seven ureters (4.4%) had persistent VUR and 3 children (6.7% of the unilateral cases) had contralateral VUR. Only 3 ureters needed a new surgical treatment (2%) for persistent ipsilateral VUR. Short and long-term complications, days with bladder catheter and length of stay in the hospital were significantly smaller in the group of patients operated with Lich-Gregoire procedure than in patients operated with the Cohen technique.

CONCLUSIONS

The Lich-Gregoire procedure is a technique associated with shorter postoperative hospitalization and less discomfort, pain and hematuria than the intravesical technique. Both techniques were effective in correcting VUR. Extravesical reimplantation can cause transitory bladder dysfunction in a small percentage of the bilateral cases.

Recent neuroanatomical studies on the neurovascular bundle of the prostate and cavernosal nerves: clinical reflections on radical prostatectomy

The neurovascular bundle of the prostate and cavernosal nerves have been used to describe the same structure ever since the publication of the first studies on the neuroanatomy of the lower urogenital tract of men, studies that were prompted by postoperative complications arising from radical prostatectomy. In urological surgery every effort is made to preserve or restore the neurovascular bundle of the prostate to avoid erectile dysfunction (ED). However, the postoperative potency rates are yet to be satisfactory despite all advancements in radical prostatectomy technique. As the technology associated with urological surgery develops and topographical studies on neuroanatomy are cultivated, new observations seriously challenge the classical teachings on the topography of the neurovascular bundle of the prostate and the cavernosal nerves. The present review revisits the classical and most recent data on the topographical anatomy of the neurovascular bundle of the prostate and cavernosal nerves and their implications on radical prostatectomy techniques.

Anatomical basis for nerve-sparing radical hysterectomy: immunohistochemical study of the pelvic autonomic nerves

BACKGROUND

Autonomic nerve damage plays a crucial role in the etiology of bladder dysfunction, sexual dysfunction, and colorectal motility disorders that occur after radical hysterectomy. We investigated the extent and nature of nerve damage in conventional and nerve-sparing radical hysterectomy.

METHODS

Macroscopical disruption of nerves was assessed through anatomical dissection after conventional and nerve-sparing surgery on five fixed and one fresh cadaver. Immunohistochemical analysis of surgical margins was performed to confirm nerve damage using a general nerve marker (S100) and a sympathetic nerve marker (anti-tyrosine hydroxylase) within sections of biopsies.

RESULTS

Macroscopical dissection showed that in the conventional procedure, transsection of the uterosacral ligaments resulted in disruption of the major part of the hypogastric nerve. After nerve-sparing surgery, only the medial branches of the hypogastric nerve appeared disrupted. Division of the cardinal ligaments in the conventional procedure identified the inferior hypogastric plexus running into the most posterior border of the surgical margin. The anterior part of the plexus was disrupted. Dissection of the nerves after the nerve-sparing procedure showed that this anterior part of the plexus was not involved in the surgical dissection line. Dissection of the vesicouterine ligament disrupted only small nerves on the medial border of the inferior hypogastric plexus in both techniques. Microscopical evaluation of the surgical margins confirmed the macroscopical findings.

CONCLUSION

Conventional radical hysterectomy results in disruption of a substantial part of the pelvic autonomic nerves. The nerve-sparing modification leads to macroscopic reduction in nerve disruption which is substantiated by microscopical evaluation of surgical margins.

NEUROANATOMY OF THE HUMAN FEMALE LOWER UROGENITAL TRACT

PURPOSE

The neuroanatomy of the female lower urogenital tract remains controversial. We defined the topographical anatomy and differential immunohistochemical characteristics of the dorsal nerve of the clitoris, the cavernous nerve and the nerves innervating the female urethral sphincter complex.

MATERIALS AND METHODS

A total of 16 normal female human pelvic specimens at 14 to 34 weeks of gestation were studied by immunohistochemical techniques. Serial sections were stained with antibodies raised against the neuronal markers S-100 and neuronal nitric oxide synthase (nNOS), vesicular acetylcholine transporter, calcitonin gene-related peptide and substance P. The serial sections were computer reconstructed into 3-dimensional images.

RESULTS

Under the pubic arch at the hilum of the clitoral bodies the branches of the cavernous nerves joined the clitoral dorsal nerve to transform its immunoreactivity to nNOS positive. The cavernous nerves originated from the vaginal nervous plexus occupying the 2 and 10 o'clock positions on the anterolateral vagina and they traveled at the 5 and 7 o'clock positions along the urethra. The urethral sphincter complex was innervated by nNOS immunoreactive and nonimmunoreactive nerve fibers arising from the vaginal nervous plexus and pudendal nerve, respectively.

CONCLUSIONS

The dorsal nerve of the clitoris receives nNOS positive branches from the cavernous nerve as a possible redundant mechanism for clitoral erectile function. The urethral sphincter complex has dual innervation, which pierces into the urethral sphincter complex at different locations. The study of the neuroanatomy of the female lower urogenital tract is germane to the strategic design of female reconstructive surgery.