David Moszkowicz

Division of Autonomic Nerves Within the Neurovascular Bundles Distally into Corpora Cavernosa and Corpus Spongiosum Components: Immunohistochemical Confirmation with Three-Dimensional Reconstruction

BACKGROUND Detailed knowledge of the distribution and distal course of periprostatic nerves is essential to improve functional outcomes (erection and continence) after radical prostatectomy (RP). OBJECTIVE To describe the location of nerve fibres within neurovascular bundles (NVBs) and around the prostate by three-dimensional (3D) computer-assisted anatomic dissection (CAAD) in human foetuses and adult cadavers. DESIGN, SETTING, AND PARTICIPANTS Serial transverse sections of the pelvic portion were performed in seven human male foetuses and four male adult cadavers. Sections were treated by histologic coloration and neuronal immunolabelling of S100 protein. 3D pelvic reconstruction was achieved with digitised serial sections and WinSurf software. MEASUREMENTS We evaluated the distribution of nerve fibres within the NVB qualitatively. The distribution of periprostatic nerves was also evaluated quantitatively in the adult specimens. RESULTS AND LIMITATIONS Periprostatic nerve fibres were dispersed around the prostate on all sides with a significant percentage of these fibres present in the anterior and anterolateral sectors. At the prostate apex and the urethral levels, the NVBs have two divisions: cavernous nerves (CNs) and corpus spongiosum nerves (CSNs). The CNs were a continuation of the anterior and anterolateral fibres around the apex of the prostate, travelling towards the corpora cavernosa. The CSNs were a continuation of the posterolateral NVBs, and they eventually reached the corpus spongiosum. The limitations of this study were the small number of specimens available and the lack of functional information. CONCLUSIONS The anterolateral position of CNs at the apex of the prostate and the autonomic innervation towards the corpus spongiosum via CSNs indicate possible ways to minimise the effect of prostate surgery on sexual function. The ideal dissection plane should probably include the preservation of the anterolateral tissues and fascias to avoid CN lesions. Anatomic knowledge gained from CAAD pertains directly to proper surgical technique and subsequent recovery of erectile function after RP.

Internal anal sphincter parasympathetic-nitrergic and sympathetic-adrenergic innervation: a 3-dimensional morphological and functional analysis.

BACKGROUND: Little detailed information is available concerning morphological and functional autonomic nerve supply to the internal anal sphincter. However, denervation of the sphincter potentially affects anal function after rectal surgery for cancer. OBJECTIVE: The aim of this study was to identify the location and type (nitrergic, adrenergic, and cholinergic) of nerve fibers in the internal anal sphincter and to provide a 3-dimensional representation of their structural relationship in the human fetus. MATERIALS AND METHODS: serial transverse sections were obtained from 14 human fetuses (7 male, 7 female, 15–31 weeks of gestation) and were studied histologically and immunohistochemically; digitized serial sections were used to construct a 3-dimensional representation of the pelvis. MAIN OUTCOMES MEASURES: The location and type of internal anal sphincter nerves were assessed qualitatively. RESULTS: Posteroinferior fibers originating from the inferior hypogastric plexus posteroinferior angle projected to the posterolateral and posterior rectal wall and internal anal sphincter, forming the inferior rectal plexus. The inferior rectal plexus contained vesicular acetylcholine transporter-positive (cholinergic), tyrosine hydroxylase-positive (adrenergic/sympathetic), and neural nitric oxide synthase-positive (nitrergic) fibers. The intrasphincteric vesicular acetylcholine transporter-positive fibers included both neural nitric oxide synthase-negative fibers and neural nitric oxide synthase-positive fibers (nitrergic-parasympathetic). LIMITATIONS: The study focused on topographic and functional anatomy, so that quantitative data were not obtained. A small number of fetal specimens were available. CONCLUSIONS: We report the precise location and distribution of the autonomic neural supply to the internal anal sphincter. This description contributes to the understanding of neurogenic postoperative sphincteric dysfunction. Three-dimensional cartography of pelvic-perineal neurotransmitters provides an anatomical and physiological basis for the selection and development of pharmacological agents to be used in the treatment of primary or postoperative continence and evacuation disorders.

Autonomic-somatic communications in the human pelvis: computer-assisted anatomic dissection in male and female fetuses

Sphincter continence and sexual function require co‐ordinated activity of autonomic and somatic neural pathways, which communicate at several levels in the human pelvis. However, classical dissection approaches are only of limited value for the determination and examination of thin nerve fibres belonging to autonomic supralevator and somatic infralevator pathways. In this study, we aimed to identify the location and nature of communications between these two pathways by combining specific neuronal immunohistochemical staining and three‐dimensional reconstruction imaging. We studied 14 normal human fetal pelvic specimens (seven male and seven female, 15–31 weeks’ gestation) by three‐dimensional computer‐assisted anatomic dissection (CAAD) with neural, nitrergic and myelin sheath markers. We determined the precise location and distribution of both the supra‐ and infralevator neural pathways, for which we provide a three‐dimensional presentation. We found that the two pathways crossed each other distally in an X‐shaped area in two spatial planes. They yielded dual innervation to five targets: the anal sphincter, levator ani muscles, urethral sphincter, corpus spongiosum and perineal muscles, and corpora cavernosa. The two pathways communicated at three levels: proximal supralevator, intermediary intralevator and distal infralevator. The dorsal penis/clitoris nerve (DN) had segmental nitrergic activity. The proximal DN was nNOS‐negative, whereas the distal DN was nNOS‐positive. Distal communication was found to involve interaction of the autonomic nitrergic cavernous nerves with somatic nitrergic branches of the DN, with nitrergic activity carried in the distal part of the nerve. In conclusion, the pelvic structures responsible for sphincter continence and sexual function receive dual innervation from the autonomic supralevator and the somatic infralevator pathways. These two pathways displayed proximal, intermediate and distal communication. The distal communication between the CN and branches of the DN extended nitrergic activity to the distal part of the cavernous bodies in fetuses of both sexes. These structures are important for erectile function, and care should therefore be taken to conserve this communication during reconstructive surgery.

Preservation of an intra-pancreatic hepatic artery during duodenopancreatectomy for melanoma metastasis

We describe the case of a hepatic artery originating from a hepato-mesenteric trunk and traveling through the head of the pancreas, found preoperatively in a 44-year-old woman presenting two metachrone intra-pancreatic metastasis of a skin melanoma. Few cases with this anatomic variation have been found in the published literature consulted and this is the first case of duodenopancreatectomy for melanoma metastasis associated with this anatomic variant. In this patient, multidetector CT image with angiography and 3-D reconstruction demonstrated that the common hepatic artery arose from the superior mesenteric artery without any other arterial supply to the liver. Pancreatoduodenectomy with arterial conservation and without reconstruction was performed. Routine preoperative computerized tomographic angiography helps to recognize the hepatic vascular anatomy and thereby prepares the surgeon to better deal with at risk vascular variants intraoperatively. During pancreatic resection, every attempt should be made to preserve the variant hepatic vessels, particularly if they irrigate the entire liver. Increased alertness of the vascular anatomy would decrease the probability of intraoperative vascular injury and consequent postoperative complications such as biliary necrosis, biliary anastomotic leaks or hemorrhage.

Preservation of Genital Innervation in Women During Total Mesorectal Excision: Which Anterior Plane?

BackgroundErectile dysfunction, principally related to injury of the autonomic nerve fibers in men, is a major cause of postoperative morbidity after anterolateral dissection during total mesorectal excision (TME) for rectal adenocarcinoma. However, the autonomic innervation of erectile bodies is less known in women, and the anterolateral plane of dissection during TME remains unclear. The existence of the rectovaginal septum (RVS) is controversial. The purpose of the present study was to identify the RVS in the human fetus and adult female by dissection, immunohistochemistry, and three-dimensional reconstruction, and to define its relationship with erectile nerve fibers so as to determine the anterolateral plane of dissection during TME, which could reduce postoperative sexual dysfunction in women.MethodMacroscopic dissection, histologic studies, and immunohistochemistry examination with 3D reconstruction were performed in six fresh female adult cadavers and six female fetuses.ResultsThe RVS was clearly definable in all adult specimens. It was composed of multiple connective tissue, with smooth muscle fibers originating from the uterus and the vagina. It is closely applied to the vagina and has a relationship with the neurovascular bundles (NVBs) that contain erectile fibers intended for the clitoris. The NVBs are situated anteriorly to the posterior extension of rectovaginal septum. This posterior extension protects the NVBs during the anterior and anterolateral dissection for removal of rectal cancer.ConclusionsTo reduce the risk of postoperative sexual dysfunction in women undergoing TME for rectal cancer, we recommend careful dissection to the anterior mesorectum to develop a plane of dissection behind the posterior extension of the RVS if oncologically reasonable.

Concepts of the rectovaginal septum: implications for function and surgery.

IntroductionIn the pelvis, the rectogenital septum (RGS) separates the urogenital compartment from the digestive compartment. In men, it corresponds to Denonvilliers’ rectoprostatic fascia or rectovesical septum (RVS). Its purpose—and, indeed, its existence—are controversial in women. The purpose of this review was to update knowledge about the RGS in women and, in particular, to clarify its relationship to pelvic nerves in order to deduce practical consequences of pelvic surgery and compare it to the RVS in men.MethodsA review of the anatomical and surgical literature was undertaken. Evidence for embryological origin, composition, and surgical importance of the RGS in women and men is suggested.ResultsThis manuscript presents evidence of the existence of the RGS in both women (rectovaginal septum, RVaS) and men (rectovesical septum, RVS). It originates from the genital structures and extends from the rectogenital pouch to the perineal body. It is composed of connective tissue associated with bundles of smooth muscle cells and has lateral expansions in close contact with neurovascular bundles originating from the inferior hypogastric plexus. During pelvic surgery for carcinoma, preservation of nerve fibers of erectile bodies is necessary if possible. The RGS is thus an important surgical landmark during urogenital sinus surgery, prolapse surgery, and proctectomy in women as well as during proctectomy and prostatectomy in men.ConclusionsThe RGS is present in women as well as in men, with great similarities between the two sexes. It represents an important surgical landmark during pelvic nerve-sparing surgery.

Dieulafoy’s lesion of the gallbladder

A 63-year-old woman presented with a history of progressive abdominal pain, nausea, and vomiting 7 days after she had undergone thoracoabdominal aneurysm repair. On presentation, her body temperature was 37.4 C and blood pressure was 132/65 mmHg. Physical examination revealed focal right upper quadrant abdominal tenderness. Laboratory tests showed a normal leukocyte count, but an elevation of liver enzymes (alanine aminotransferase, 304 UI/l; aspartate aminotransferase, 185 UI/l; conjugated bilirubinemia, 65 lM/L) and anemia (hemoglobin level, 9.6 g/dL). CT-scan of the abdomen showed a distended gallbladder filled with hyperdense hemorrhagic bile, and an 8-mm hypervascular lesion (Fig. 1). She was brought to the operating room for an emergency laparoscopy, and underwent cholecystectomy and transcystic drainage. At a follow-up visit, she was asymptomatic and the drain was removed. The diagnosis of hemobilia caused by Dieulafoy’s lesion (D’sL) of the gallbladder was confirmed by pathologic examination (normal vessel that has abnormally large diameter, protruding through a small mucosal defect which has fibrinoid necrosis at its base). It was associated with lesions of ischemic cholecystitis. We report here a case of a non-iatrogenic cause of hemobilia of gallbladder origin. This the first case of D’SL of the gallbladder and consecutive hemocholecyst reported in English language. D’sL accounts for 1–2 % of lifethreatening acute gastrointestinal bleeding, and is commonly found in the stomach [1]. Mucosal erosion is classically linked to ischemic injury that is possibly related to cardiovascular diseases which further weakens a fragile point of the GI tract wall [2]. Traditionally, an arteriography is the gold-standard in the diagnosis and the treatment of hemobilia. However, the presence of a blush on the CTscan led to immediate surgery in order to stop the bleeding and has prevented to perform a useless arteriography. Besides, the trans-cystic drainage is usually chosen to perform bile duct washing in case of hemobilia of unknown origin, as described by others [3, 4]. In the present case, it ensured to eliminate blood clotting within the common bile duct. In conclusion, the lesson learned from the experience is that a D’sL of the gallbladder should be included in the etiologic diagnosis of haemobilia. Hemocholecyst is a classical indication of immediate cholecystectomy and external biliary drainage.

Erratum to: Preservation of Genital Innervation in Women During Total Mesorectal Excision: Which Anterior Plane?

Fig. 4 Three-dimensional (3D) view of fetus intrapelvic organs with pelvic nerves. Superior infraperitoneal 3D view of a 30-week-old female fetus: intrapelvic organs with immunolabeled pelvic nerves showing the position of the inferior hypogastric plexus (IHP) on the lateral aspects of the rectum. From the IHP, efferent branches rise in distal directions: postero-inferior for the rectal wall, lateral for the levator ani muscles, and antero-inferior to form the NVBs. Some fibers from the NVBs branch medially to innervate the posterior vaginal wall. More caudally, the bundle puts out fibers in three major projections: an anterior projection for the urethral sphincter complex, an anterolateral projection (the cavernous nerve) that travels anterolaterally to the vagina to reach the corpora cavernosa, and a posterolateral projection (the spongious nerve) that continues posterolaterally to the vagina to innervate the corpus spongiosum. In inset, blue arrows show the directions of the IHP and NVB main terminal efferences. Ur urethra The online version of the original article can be found under doi:10.1007/s00268-011-1313-2.