J. Moscovici

Contribution to the study of the tributaries and the termination of the external jugular vein

SummaryThe dissection of 100 external jugular veins in 50 cadavers was the object of this anatomic study. A certain number of notions concerning the afferent veins, the mode of termination and the valvular system of this vessel were defined. 1)Afferent veins. Along its pathway toward the deep venous system, the external jugular vein successively received: the transverse cervical vein in 88 cases (88%), usually opposite the intersection of the external jugular vein with the dorsal border of the sterno- cleidomastoid muscle; the suprascapular vein in 47 cases (47%); the anterior jugular vein in 46 cases (46%); the cervical vein or anastomosis with the latter in 13 cases (13%). 2)Mode of termination. Forty-three subjects presented a symmetric mechanism. 100 anastomoses can be classed into three types: in 60 cases (60%), the external jugular vein flowed into the jugulo-subclavian venous confluence; in 36 cases (36%), in to the subclavian vein at a distance from its junction with the internal jugular vein; in 4 cases (4%) in to the trunk of the internal jugular vein. 3)Study of the valves. There were studied in 25 subjects (50 external jugular veins). The valves were found in the ostial and paraostial position in 49 out of 50 veins.RésuméCette étude anatomique repose sur la dissection de 100 vv. jugulaires externes chez 50 cadavres. Elle a permis de préciser un certain nombre de notions concernant les veines afférentes, le mode de terminaison et le système valvulaire de ce vaisseau. 1)Veines afférentes. Le long de son trajet vers le sytème veineux profond, la v. jugulaire externe reçoit successivement: la v. cervicale transverse dans 88 cas (88 %), habituellement en regard du croisement de la v. jugulaire externe avec le bord dorsal du m. sterno-cléido-mastoïdien ; la v. supra-scapulaire dans 47 cas (47 %); la v. jugulaire antérieure dans 46 cas (46 %) ; la v. céphalique ou une anastomose avec celle-ci dans 13 cas (13 %). 2)Mode de terminaison. Quarante trois sujets présentent un dispositif symétrique. Les 100 abouchements peuvent être classés en trois types : dans 60 cas (60 %) la v. jugulaire externe se déverse dans le confluent veineux jugulo-subclavier ; dans 36 cas (36 %), dans la v. subclavière à distance de sa réunion avec la v. jugulaire interne ; dans 4 cas (4 %) dans le tronc de la v. jugulaire interne. 3)Etude des valvules. Recherchées chez 25 sujets (50 vv. jugulaires externes), les valvules ont été retrouvées dans 49 cas sur 50 en position ostiale ou paraostiale.

Microsurgical anatomy of the internal vertebral venous plexuses

Few studies have been done about the venous vascularization of the spine since neuroradiologic studies in the 1960s and 70s. The aim of this study was to clarify the topography of the internal vertebral venous plexuses in relation to the posterior longitudinal ligament and the dura. The relationships of the vv. were studied at different levels of the spine. The internal vertebral venous system of seven cadavers was injected with a blue bicomponent silicon rubber. It consisted with an anterior and a posterior venous plexus. At the cervical level, the anterior longitudinal vv. are located in a dehiscence of the periosteal layer, in the lateral part of the spinal canal. At each level, they joined the contralateral one at the midline by a retrocorporeal v. located behind the posterior longitudinal ligament. No vv. were found in the epidural space. There was a major development of the retrocorporeal v. of the axis, but it did not receive any venous drainage from the vertebral body. At the thoracic and lumbar levels, the anterior venous plexuses remain within a dehiscence of the periosteal layer, which is thinner. The retrocorporeal vv. become pre-ligamentous. We did not find any posterior venous plexuses at the cervical level, but they were evident at the thoracic level and became more voluminous and sinusoidal in the lumbar region.

Contribution to the study of the venous vasculature of the penis

The penile veins are thought to be responsible for some erectile disorders. The aim of this study was to describe the anatomy and function of these veins. The venous systems of 25 cadaveric penises were studied by various anatomic and histologic techniques. The superficial veins arising from the tegumentary layers drain into the superficial dorsal vein which in three-quarters of cases empties into the left great saphenous vein. The veins of the deep internal system, running below the deep fascia of the penis, emerge from the erectile bodies and can be divided into two systems, one anterosuperior and the other posteroinferior. The anterosuperior system comprises the veins of the glans which will form the deep dorsal vein the latter receives blood from the medial portion of the corpus spongiosum and from the free portion of the corpora cavernosum mainly via the circumflex veins. It ends in the pre-prostatic plexus. The posteroinferior system, issuing from the posterior portion of the erectile bodies, is composed of the bulbar, cavernous and crural veins which drain towards the pre-prostatic plexus and the internal pudendal veins. Anastomoses link the two networks, superficial and deep. Study of the structure of the veins of the deep system reveals the presence of muscular cushions, which we have shown to have adrenergic innervation. These findings are compared with those of the literature, which show variations which are mainly of number. The place of veins in the mechanism of erection is discussed.

Sexual function of young women with myelomeningocele.

OBJECTIVES To assess the sexual function of young women with spina bifida and myelomeningocele and to determine the factors influencing their sexual function. METHODS A postal cross-sectional study using a self-administered questionnaire was performed in 44 women, mean age 27.66 ± 5.89 years, with spina bifida and myelomeningocele. The questionnaire included the Brief Index of Sexual Functioning for Women and questions about voiding mode, urinary symptoms, socioeconomic status, education level, lifestyle, and partnership. In parallel, data were also collected from the paediatric surgery records of patients who returned the questionnaire. RESULTS The response rate was 56.8% (25/44). All domains of female sexual function (thoughts/desires, arousal, frequency of sexual activity, receptivity/initiation, pleasure/orgasm, relationship satisfaction) were altered. Urinary incontinence was likely to be the main factor responsible for altered sexual function and was associated with lower thoughts/desires, arousal, and receptivity/initiation scores. Wearing pads also constituted a limitation to achieving intimacy. CONCLUSIONS Young myelomeningocele women report poor sexual functioning. The presence of urinary incontinence is associated with lower thoughts/desire, arousal, and receptivity/initiation.

Torsion du cordon spermatique chez l’enfant : impact du mode de consultation sur le délai de prise en charge et le taux d’orchidectomie

INTRODUCTION Acute scrotal pain is a true surgical emergency as patients presenting with acute scrotal pain may suffer from spermatic cord torsion and gonadal loss. We assessed whether the type of consultation (first consultation in our center or secondary transfer from a peripheral hospital or primary care practice), distance from home to hospital, and duration of pain had an impact on the orchiectomy rate. PATIENTS AND METHODS We retrospectively reviewed the medical records of all patients under 15years of age suffering from acute scrotal pain who had surgical exploration between January 2007 and January 2010 in our center. Patient demographics, transfer status, time to consultation in our center, time to surgery, operative findings and clinical outcome were reviewed. RESULTS Of the 76 patients with acute scrotal pain in whom surgical exploration was performed, 59 had acute spermatic cord torsion, 16 had torsion of the testicular appendage, and 1 had orchitis. In patients with acute spermatic cord torsion, the median age was 13 years (range: 0.18-14.97). In patients with acute spermatic cord torsion, 32 came straight to our center (direct admission group, 54.2%), and 27 (45.8%) came after a prior consultation out of side the center (transfer group). The median journey was 19km (range: 2.5-113) in the direct admission group and 44km (range: 2.5-393) in the transfer group (P=0.0072). The median time between pain onset and consultation at our center was 4.3h (range: 0.5-48) in the direct admission group, and 11h (range: 2-48) in the transfer group (P=0.6139). The median time between admission at our center and surgery was 2.5h, with no difference between the 2 groups (P=0.8789). The orchiectomy rate was 25% in the direct admission group and 14.8% in the transfer group (P=0.5177). In children who underwent orchiectomy, the duration of pain was consistently over 6h. The duration of pain was greater in patients with orchiectomy (12h [range: 1-72]) than in patients without orchiectomy (12h [range: 6-48]; P=0.0001). CONCLUSION In this study, the orchiectomy rate depended on the duration of pain but not on transfer status. Acute scrotal pain must lead to surgical exploration as soon as possible, requiring close collaboration between peripheral hospitals, primary care physicians, and referral centers.

Vie sexuelle des jeunes adultes opérés dans l’enfance d’un hypospadias postérieur

OBJECTIVE To evaluate outcomes and long-term sexual quality of life after hypospadias surgery. Seventeen-years-old patients operated for a posterior hypospadias in childhood were included in a transversal study. PATIENTS AND METHODS Fifteen patients, among the forty children treated since 1997, accepted to participate. These young men (mean age at the first surgery was 27.9±20months) were clinically reviewed and responded to questionnaires (EUROQOL 5, IIEF15 and non-validated questionnaire). This study arises about 8.4±5years after the last visit in paediatric department. RESULTS Mean study age was 21.2±4.7years. One third of patients thought that global quality of life was distorted. Although 33% of the patients had erectile dysfunction, 80% were satisfied with their sexual quality of life. The most important complains were relative to the penile appearance. Number of procedures was not predictive of patients satisfaction about penile function and appearance. Thirty-three percents of the patients would have been satisfied to have psychological and medical support. They would be interested in having contact with patients who suffered from the same congenital abnormality. CONCLUSION These patients had functional and esthetical disturbances. This visit leads to a specific visit in 20% cases. In this study, medical follow-up does not seem to be counselling and had to be adapted. Adequate follow-up transition between paediatric and adult departments especially during adolescence seems to be necessary.

Free tubularised vesical mucosa graft for congenital stenosis of the urethra in children

BACKGROUND Reconstruction of urethral strictures in children remains a challenge to the pediatric surgeon as these are often related to different rare congenital anomalies with various clinical presentations that endanger renal function and should be repaired in young children. Multiple techniques have been described for their repair. We aimed to determine whether the use of a free tubularised bladder mucosal graft associated to a prior tubeless vesicostomy was feasible and sure, as this technique of reconstruction using tubularised grafts has not been described yet in young children. RESULTS Two newborn male patients were referred to our department. Both presented a congenital stenosis of the urethra as a part of a complex urethral malformation. Surgery involved prior tubeless vesicostomy, free bladder mucosal graft for urethral reconstruction, and vesicostomy closure for both children. Postoperative evolution was satisfying in both children and cystourethroscopy showed permeable urethra. Satisfying cosmetic and functional results have been obtained in the two cases. CONCLUSIONS The prior vesicostomy prevents kidney damage in the context of complex genital and urinary malformations. Bladder mucosas immunohistological properties are the most similar to those of the urethral tissue, and are appropriate for this type of correction, making our technique feasible and sure. LEVEL OF EVIDENCE 5.

P364 - Urétroplastie suspendue par greffon libre de muqueuse vésicale dans la prise en charge de sténoses congénitales de l’urètre bulbaire et membraneux chez l’enfant : à propos de deux cas

Nous decrivons, dans le cadre de malformations urogenitales complexes chez deux nouveau-nes de sexe masculin, la reparation uretrale par une technique dont nous n’avons pas retrouve de description prealable dans la litterature. Observations Le 1er enfant presentait, dans un contexte de malformation anorectale haute, une large fistule uretrale penienne moyenne, en amont d’un uretre balanique permeable et d’un meat apical. Il existait une stenose de l’uretre membraneux en amont de la fistule. Le second presentait une duplication de l’uretre avec un meat apical et un meat hypospade balano-preputial. Il existait une stenose a la confluence bulbaire des 2 uretres. Dans les 2 cas, la prise en charge a consiste en la realisation neonatale d’une vesicostomie incontinente, puis d’une reconstruction employant une uretroplastie suspendue par greffon libre de muqueuse vesicale, a 1 et 2 ans respectivement. Chez le 1er enfant, la fistule penienne moyenne a ete fermee a 3 ans. Resultats Les suites ont ete simples, le jet urinaire est correct, il n’y a pas de dysurie, l’aspect cosmetique de la verge est satisfaisant. Conclusion L’uretroplastie suspendue par greffon libre de muqueuse vesicale est une bonne technique de reparation de stenoses de l’uretre anterieur et posterieur chez l’enfant.

Hypospadias. Prise en charge chirurgicaleHypospadias. Surgical management

Prendre en charge un hypospadias, c’est d’abord faire un bilan précis des anomalies anatomiques, celles-ci étant liées à un défaut de développement d’intensité variable des différents tissus de la face inférieure du pénis. Par défi nition, il existe tout d’abord une anomalie de situation de l’orifi ce urétral qui s’ouvre à la face ventrale du pénis, en position variable entre le gland et le périnée. En aval du méat, l’urètre est réduit à une plaque plus ou moins large et plus ou moins longue, le gland étant étalé. Le méat est souvent sténosé, ceci étant habituellement sans conséquence. On peut défi nir deux grands groupes d’hypospadias, les formes antérieures, distales, les plus fréquentes et les formes postérieures, sévères, plus rares. Dans certains cas cependant, le méat est distal, mais tout l’urètre terminal est anormal, sans corps spongieux, très adhérent à la peau, en fait non utilisable lors de la réparation. La courbure du pénis est habituelle, le plus souvent simple courbure du gland liée à la rétraction des enveloppes superfi cielles. La courbure du corps du pénis, plus rare, est secondaire à une rétraction des enveloppes profondes plus ou moins associée à une brièveté de la plaque urétrale ou de l’urètre. Exceptionnellement, la courbure est en relation avec une déformation des corps caverneux. L’anomalie cutanée est pratiquement constante. Le fourreau est habituellement insuffi sant à la face inférieure ce qui contribue à la cassure du gland et entraîne un enfouissement du pénis dans les tissus scrotaux. Le prépuce est généralement ouvert à sa face inférieure et plus ou moins anormal à la face supérieure. Certaines formes sévères s’accompagnent d’un enlisement du pénis et d’une bifi dité scrotale. 2. La place des examens complémentaires

Artère pulmonaire gauche rétro trachéale: mise au point embryologique et anatomique à propos d’un cas

But de l’étude.— Décrire les anomalies de développement des arcs vasculaires et illustrer les différentes malformations qui en résultent par l’imagerie en coupes. Matériel et méthodes.— Travail rétrospectif à partir de sept cas pédiatriques pour lesquels l’exploration tridimensionnelle des anomalies vasculaires par scanner multi détecteurs a permis d’établir un diagnostic anatomique. Résultat.— La radiographie thoracique et le transit œso-gastro-duodénal permettent de suspecter une anomalie vasculaire compressive chez un enfant présentant une symptomatologie respiratoire persistante ou un stridor congénital. L’imagerie en coupes fait le diagnostic anatomique de la malformation, objective la compression des organes de voisinage et guide le traitement chirurgical. Après avoir rappelé l’embryogenèse des arcs vasculaires, nous nous attacherons à corréler les anomalies de développement aux aspects tomodensitométriques grâce aux reconstructions mutiplanaires et volumiques. Ainsi nous présenterons les aspects tomodensitmétriques, non seulement des principales anomalies du 4e arc, y compris les anomalies de longueur et de continuité de la crosse, mais aussi celles plus rares du 6e arc, que sont l’artère pulmonaire gauche rétro trachéale et l’aplasie d’une artère pulmonaire. Conclusion.— Grâce à sa résolution spatiale inframillimétrique, le scanner multi détecteurs tend à supplanter l’angiographie dans le bilan des malformations des gros vaisseaux. Elle permet aux radiologues et aux chirurgiens d’avoir accès, de manière non invasive, à une imagerie tridimensionnelle.