Donald R. Cahill

Prostate Shape, External Striated Urethral Sphincter and Radical Prostatectomy: The Apical Dissection

In an anatomical study of 64 gross specimens the external striated urethral sphincter was reconfirmed to extend as a single unit from the proximal penile urethra to the bladder base. The configuration of the external striated urethral sphincter was variable and was related to the shape of the apical prostate. Two basic prostatic shapes were recognized, distinguished by the presence or absence of an anterior apical notch. Whether a notch existed depended upon the degree of lateral lobe development and the position of its anterior commissure. In radical prostatectomy knowledge of the variation in the shape of the prostatic apex can help the surgeon to achieve optimal urethral transection with maximal preservation of the external striated urethral sphincter and other tissues of the continence mechanism.

Experimental study in the dog of the non-active role of the tooth in the eruptive process

The role of the tooth in eruption was studied radiographically and histologically after experimental manipulations of the crowns of permanent mandibular premolars in dogs. Crowns were removed and dead crown shells or metal or silicone replicas were substituted into dental follicles just prior to scheduled eruption. These replacements erupted on schedule after formation of the usual eruption pathways and formation of trabecular bone from the base of the bony crypt. Removal of crowns, but without adding replacements, also exhibited these same hallmarks of eruption. We conclude that tooth eruption is a series of metabolic events in alveolar bone characterized by bone resorption and formation on opposite sides of the dental follicle and the tooth does not contribute to this process.

Anatomy of the sural nerve complex

The anatomy of the sural nerve complex in 20 cadaveric limbs was determined by dissection. The nerve usually consists of four named components: the medial sural cutaneous nerve, the lateral sural cutaneous nerve, the peroneal communicating branch, and the sural nerve. In most instances (80%), the sural nerve is formed in the distal portion of the leg by the union of the medial sural cutaneous nerve and the peroneal communicating branch. In 20% of cases, the peroneal communicating branch is absent. In such cases, the sural nerve is derived from the medial sural cutaneous nerve alone. The lateral sural cutaneous nerve is laterally situated and usually divides into medial and lateral branches. In a few cases, its medial division may contribute to the sural nerve through the peroneal communicating branch. The peroneal communicating branch can be of substantial caliber and may be useful as a source of nerve graft without complete sacrifice of the sural nerve. We describe a technique of isolation of the peroneal communicating branch for use as a nerve graft.

Infraclavicular brachial plexus block: parasagittal anatomy important to the coracoid technique.

Infraclavicular brachial plexus block is a technique well suited to prolonged continuous catheter use.We used a coracoid approach to this block to create an easily understood technique. We reviewed the magnetic resonance images of the brachial plexus from 20 male and 20 female patients. Using scout films, the parasagittal section 2 cm medial to the coracoid process was identified. Along this oblique section, we located a point approximately 2 cm caudad to the coracoid process on the skin of the anterior chest wall. From this point, we determined simulated needle direction to contact the neurovascular bundle and measured depth. At the skin entry site, the direct posterior insertion of a needle will make contact with the cords of the brachial plexus where they surround the second part of the axillary artery in all images. The mean (range) distance (depth along the needle shaft) from the skin to the anterior wall of the axillary artery was 4.24 +/- 1.49 cm (2.25-7.75 cm) in men and 4.01 +/- 1.29 cm (2.25-6.5 cm) in women. Hopefully, this study will facilitate the use of this block. Implications: We sought a consistent, palpable landmark for facilitation of the infraclavicular brachial plexus block. We used magnetic resonance images of the brachial plexus to determine the depth and needle orientation needed to contact the brachial plexus. Hopefully, this study will facilitate the use of this block. (Anesth Analg 1998;87:870-3)

Supraclavicular nerve block: Anatomic analysis of a method to prevent pneumothorax

Supraclavicular nerve blocks are technically easy to perform, but may be associated with pneumothorax. The objective of this study is to define the parasagittal anatomy important to our modified technique of supraclavicular nerve block designed to decrease the incidence of pneumothorax and to determine whether this technique is anatomically sound. Two cadaver specimens were studied. One embalmed specimen was dissected to establish the relationship of the brachial plexus to our modified needle entry site. The neck and upper thorax of an unembalmed cadaver were frozen, and parasagittal serial sections were made to establish the relationship of the brachial plexus to surface features and the chest cavity. Additionally, 12 volunteers underwent magnetic resonance (MR) imaging and anatomic measurements of their supraclavicular anatomy important to our modified block. MR imaging showed that in no instance using our modified technique was the lung contacted by the simulated needle before entering either the subclavian artery or contacting the brachial plexus. Our technique has been used in more than 110 patients without pneumothorax. The combination of our cadaver and magnetic resonance data suggests that our plumb-bob technique of supraclavicular nerve block is anatomically sound and may minimize the development of pneumothorax during supraclavicular block.

Anatomy of radical prostatectomy as defined by magnetic resonance imaging.

PURPOSE We examined and defined anatomical structures relevant to radical prostatectomy using magnetic resonance imaging. MATERIALS AND METHODS Before radical prostatectomy, 15 men underwent high-resolution magnetic resonance imaging studies of their pelvic floors (fast spin echo, T2 weighting of 3- to 4-mm. contiguous or overlapping slices) in axial, coronal, and sagittal planes. RESULTS Pubovesical ligaments, rather than the commonly reported puboprostatic ligaments, were observed attaching the bladder-prostate unit to the pubis. We suggest that the part of the urethra that extends from the apex of the prostate to the bulb of the penis, which is surrounded by the striated sphincter, should be termed the sphincteric urethra rather than the membranous urethra. Further, we found no evidence that supports the traditional concept of a urogenital diaphragm. The lower part of the striated urethral sphincter was flanked on its sides by the anterior recesses of the ischioanal fossae. The portion of the levator ani, which we have termed the puboanalis sling, flanked the apex of the prostate. The most anteromedial portion of this sling inserts into the perineal body and should be termed the puboperinealis. The terminal part of the gastrointestinal tract (the part continued beyond the levator ani) should be termed the anal canal, not the rectum, as used frequently in the urologic literature. Therefore, the initial plane of dissection in radical perineal prostatectomy passes along the anterior portion of the anal canal, not the rectum. CONCLUSION We used magnetic resonance imaging to study male pelvic floor and perineal anatomy without the artifact of dissection. This study allowed us to devise a more precise nomenclature with respect to radical prostatectomy and, in so doing, to provide a better understanding of both the retropubic and the perineal operations.

Anatomy of the ulnar nerve at the elbow: Potential relationship of acute ulnar neuropathy to gender differences

Men develop perioperative ulnar neuropathies more frequently than women. To determine the role of anatomical gender differences in the development of these neuropathies, we performed several studies of the anatomy of the ulnar nerve, cubital tunnel, and elbow region. These studies included detailed dissection of male and female embalmed and unembalmed cadavers, ultrasound measurements of the tissue layers at the elbow, and measurement of various dimensions of the coronoid process of the ulna in multiple skeletal sets. No gross anatomical differences were found between genders regarding the course of the ulnar nerve through the upper limb. However, there was a strikingly larger (2–19 times greater) fat content on the medial aspect of the elbow in women compared to men, and the tubercle of the coronoid process was approximately 1.5 times larger in men (P ≤ .002, rank sum test). Our finding suggest that the tubercle of the coronoid process is a likely area for external compression‐induced ischemia of the ulnar nerve because the nerve and its arterial supply (the posterior ulnar recurrent artery) are covered at the tubercle only by skin, subcutaneous fat, and a very thin aponeurosis of the flexor carpi ulnaris. Importantly, this tubercle is larger and the nerve and blood vessels passing by it are less protected by subcutaneous fat in men than in women. These two anatomical differences between men and women may contribute to the increased frequency of perioperative ulnar neuropathy induced by external pressure at the medial aspect of the elbow in men. Clin. Anat. 11:372–378, 1998.

PUBOPERINEALES: MUSCULAR BOUNDARIES OF THE MALE UROGENITAL HIATUS IN 3D FROM MAGNETIC RESONANCE IMAGING

PURPOSE The aims of this report are 1) to extend our previous two-dimensional magnetic resonance imaging study to create a three-dimensional image of the pelvic floor, including the puboperinealis, the most anteromedial component of the levator ani; 2) to clarify the historical controversy about this particular component of the levator ani; and 3) to present clinical implications of this muscle with respect to urinary continence and radical prostatectomy. MATERIALS AND METHODS We reused the axial magnetic resonance imaging series from 1 of 15 men in a previous series. Analyze AVWTM allowed creation of three-dimensional images. Further, a movie clip of all three-dimensional images was developed and placed at the manuscript-dedicated Web site: http://www.mayo. edu/ppmovie/pp.html. RESULTS Our three-dimensional images show how the puboperinealis portion of the levator ani flanks the urethra as it courses from the pubis to its insertion in the perineal body. CONCLUSIONS The puboperinealis corresponds to muscles previously designated as the levator prostatae, Wilsons muscle, pubourethralis, and levator urethrae, among others. The images suggest that the puboperinealis is the muscle most responsible for the quick stop phenomenon of urination in the male. Our study supports the suggestion that weakening of the puboperinealis by transection, traction injury, or denervation may affect urinary continence after radical prostatectomy.

Developmental changes in the extracellular matrix of the dental follicle during tooth eruption

Eruption of the third and fourth mandibular premolars in the dog begins at 15 weeks of age, is dependent upon the dental follicle, and is complete by 23 weeks. Our study covered the period from 12 to 20 weeks, and revealed several changes in extracellular matrix structure and organization of the follicle which correlate with specific physiological events in eruption. First, the average DNA content per follicle reached a maximum at 14 weeks. Two weeks later, follicle size had increased 1.3- to 2.4- times. Second, the collagen content of follicles increased 2.5-fold over the study period, with two-thirds of this increase over the last four weeks. Type I collagen was the major collagen at all stages of follicular development. The amount of proteoglycan rose 45% from 16 to 20 weeks of age. Third, the ultrastructure of the dental follicle prior to eruption (12 weeks) indicated a disorganized interstitial connective tissue matrix; during eruption, two size classes of fibrils were observed which clustered together in linearly aligned bundles. Fourth, gel electrophoretic analyses resolved more than twenty follicle proteins with the major species a Mr = 95k glycoprotein. Immunoblotting demonstrated only one minor component was derived from serum. Comparison of noncollagenous proteins from different aged follicles indicated that three small polypeptides (Mr = 20-25 k) were present primarily at 16 weeks, the same time at which root elongation begins. A different sequence of changes was exhibited by two other proteins of Mr = 13 and 15 k. These findings may serve as biochemical markers of stages of dental follicle development and facilitate a search for local control mechanisms.

The effect of removing the true dental follicle on premolar eruption in the dog

Eruption is a highly localized process during which the bone resorption and formation that occur on opposite sides of the tooth are dependent upon the surrounding soft tissues, the true dental follicle externally and the enamel organ internally. To examine the ability of the enamel organ to cause eruption the external layer (dental follicle) was removed just prior to and up to 4 weeks before eruption in 13 mandibular premolars in dogs and eruption followed clinically, radiographically and histologically. None of the teeth without dental follicles erupted but three teeth from which the follicle was separated then replaced did erupt. These data indicate that the enamel organ without the dental follicle cannot support tooth eruption and provide indirect evidence for the central role of the dental follicle, alone or in combination with the enamel organ, in eruption.