Jean-François Uhl

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.

The structure and innervation of the male urethra: histological and immunohistochemical studies with three-dimensional reconstruction.

The structure of the striated urethral sphincter, the so‐called rhabdosphincter, remains the subject of controversy. There are two main concepts regarding its structure: either it is a part of the urogenital diaphragm, or it extends from the base of the bladder up to the urogenital diaphragm and is an integral part of the urethra. It is also uncertain whether it possesses a somatic innervation or a mixed innervation (i.e. autonomic and somatic). The purpose of this study was to show the precise location of the nerves running to the urethra, and to try to determine their exact nature. Histology and immunohistochemistry were performed in the external urethral sphincter of ten male fetuses (114–342 mm crown–rump length, or between 14 and 40 weeks of gestation). A three‐dimensional (3D) reconstruction of the urethral structure and its innervation was made from serial sections. The 3D reconstruction of the same section levels with different strains allowed us to identify the precise structure of the muscle layers (smooth and striated muscle fibres) and the nature of the nerve elements (myelinated and unmyelinated), their distributions and their relationship to the urethral wall, the prostate and the seminal vesicles. Histological and immunohistochemical 3D reconstruction of the anatomical elements of the urethral sphincter helps us to understand the 3D arrangement of the sphincter muscle layers. It also provides a better understanding of the origin and nature of the nerve elements that play a role in urinary continence.

Tridimensional Computer-Assisted Anatomic Dissection of Posterolateral Prostatic Neurovascular Bundles

BACKGROUNDnDetailed knowledge of nerve distribution in the neurovascular bundle (NVB) is essential to preserve sexual function after prostatic surgery.nnnOBJECTIVEnTo identify the location as well as the type (adrenergic, cholinergic, and sensory) of nerve fibres within the NVB and to provide a three-dimensional (3D) representation of their structural relationship in the human male foetus.nnnDESIGN, SETTING, AND PARTICIPANTSnSerial transverse sections were performed every 150-200 microm in the pelvic portion of six human male foetuses (15-20 wk of gestation). Sections were treated with histologic and immunohistochemical methods (hematin-eosin-safran, Luxol Fast Blue, immunolabelling of protein S100, vesicular acetylcholine transporter, tyrosine hydroxylase, calcitonin gene-related peptide, and substance P). The 3D pelvic reconstruction was obtained from digitised serial sections using WinSurf software.nnnMEASUREMENTSnNVB nerve location and type were evaluated qualitatively.nnnRESULTS AND LIMITATIONSnThe 3D reconstruction allowed precise identification of pelvic organ innervation. Nerve fibres derived from the inferior hypogastric plexus followed two courses: posterior and lateral, providing cholinergic, adrenergic, and sensory innervation to seminal vesicles, vas deferens, prostate, and urethral sphincter. Cavernous nerve fibres did not strictly follow the NVB course; they were distributed at several levels, in a fanlike formation. The main limitations of this study were the limited number of specimens available due to legal restriction and the time-consuming nature of the manually performed stages in the method.nnnCONCLUSIONSnThe distribution of nerve fibres within the posterolateral prostatic NVB and the existence of mixed innervation in the posterior and lateral fibre courses at the level of the prostate and seminal vesicles give us an insight into how to minimise effects on sexual function during prostatic surgery. The 3D computer-assisted anatomic dissection represents an original method of applying anatomic knowledge to surgical technique to improve nerve preservation and decrease postoperative sexual complications.

Static foot disorders: a major risk factor for chronic venous disease?

Objective To study the relationship between the static foot disorders (SFDs) and chronic venous disease (CVD). Material and methods A retrospective study of 824 feet in unselected 412 patients seen by one phlebologist using a standardized record form. A complete clinical, aetiological, anatomical and pathological elements (CEAP) classification was determined. Alleged venous symptoms were recorded using a 10-point visual analogue scale and scored using a customized questionnaire. A standardized measurement of the Djian-Annonier angle was used to quantify and identify the presence of any static disorder of the foot. Results There were 156 men (37.8%) and 256 women (62.2%) who were included in this study. A majority of patients (59.3%) had a CEAP classification of C3 or greater. Static disorders of the feet were found to be very common in the study population: 137 feet were hollow feet (16.6%) and 120 flat feet (14.5%). Thus, 31% of all of the feet had some form of SFD. A significant correlation was found between the incidence of SFD and body mass index (P < 0.01), the presence of symptoms (P<0.001) and prolonged standing during the day (>5 hours, P < 0.05). The severity of the CVD, represented by the CEAP clinical classes, was also found to be very significantly related to the SFD (P < 0.001). This correlation was found to be independent of age. Conclusion Static disorders of the foot can be considered as an important risk factor that negatively affects CVD. In daily practice, it is often underestimated. This emphasizes the crucial importance of the detection of SFD during the clinical exam of all CVD patients. Correction of static disorders of the feet will improve symptoms due to the SFD, as well as those related to venous stasis. These results can easily be explained by improvement of foot pump efficacy during walking.

Prospective randomized controlled study of patient compliance in using a compression stocking: Importance of recommendations of the practitioner as a factor for better compliance

Background Patient compliance is the cornerstone of compression therapy success. However, there has been up to now no tool to assess it other than self-reporting by the patient, which is not reliable. Material and methods Forty active females classified C2S were enrolled to wear compression stockings (CS) providing a pressure of 15–20u2009mmHg at the ankle. A thermal probe was inserted in the stocking (Thermotrack®), recording the skin temperature every 20u2009min for four weeks. The patients were randomized in two groups of 20: – Group 1: Receiving minimal recommendations by their physician at the office. – Group 2: Receiving in-depth recommendations by the physician reinforced with SMS message which were repeated once a week for four weeks. The basic CEAP classification and the quality of life (QoL) were recorded before and after four weeks. Results The two groups are similar for age, symptoms and type of CS. The analysis of the thermal curves showed a significant increase (+33%) in the average wearing time daily in the group 2: 8u2009h vs. 5.6u2009h (group1) pu2009<u20090.01. The average number of days worn per week is also increased: 3.4 (group 1) vs. 4.8 (group 2), thus improving patient compliance from 48.5% to 70% as a direct result of the physician recommendations (pu2009<u20090.001). Conclusion This is the first study assessing the real compliance in CVD patients of using compression. It shows that better and repeated recommendations by the practitioner result in an increase in time the compression is used by 33%. The study also suggests that the number of days the compression stocking is worn is a good criterion of patient compliance.

Compression versus inner sole for venous patients with foot static disorders: a prospective trial comparing symptoms and quality of life

Objective To prospectively compare the improvement in quality of life and symptoms achieved when using two treatments—medical compression stockings and inner sole—in subjects with symptomatic chronic venous disease in the presence of foot static disorders. Materials and methods This prospective study included 24 patients with a symptomatic chronic venous disease associated with foot static disorders. The basic CEAP was used to classify the patients. The venous symptoms were recorded using a 10-point visual analog scale and scored using a customized questionnaire. Patient-reported quality of life data were acquired using a CIVIC questionnaire. A standardized measurement of the Djian-Annonier angle was used to quantify the foot static disorders. We compared the use of the following two treatments: medical compression stockings (18u2009mm of Hg) and inner sole. For this comparison, we used a crossover technique over 4 successive weeks. Results One male and 23 female patients were included in this study. We found significant improvement in quality of life scores when only medical compression stockings were used (pu2009<u20090.005), only inner sole were used (pu2009<u20090.01) and also when both treatments were used together (pu2009<u20090.001), compared with no treatment. This was mainly observed for the somatic component of CIVIC. The symptoms of pain, heaviness, swollen feeling, and cramps were significantly improved by the two treatments, whether given separately (pu2009<u20090.001) or together (pu2009<u20090.0001). No additive effect of the treatments was observed. Conclusion This study suggests that a number of leg symptoms occurring in varicose veins patients are not likely to have a venous origin. They are frequently related to a foot static disorder, which is responsible for postural changes. This study also strongly demonstrates the need for correction of the foot static disorder if such a disorder is present in any patient with chronic venous disease. The use of the inner sole will improve the symptoms and also the quality of life with an efficiency that is almost equal to that provided by the medical compression stockings and the combined use of both treatments is recommended.

RECONSTRUCTION TRIDIMENSIONNELLE DES PLEXUS VEINEUX VERTÉBRAUX INTERNES ET ANTÉRIEURS D'UN FŒTUS HUMAIN : ÉTUDE DE FAISABILITÉ

Resume Les plexus veineux vertebraux internes et anterieurs ont fait l’objet de nombreuses etudes du fait de leur importance clinique dans les pathologies de la colonne vertebrale et les interruptions de la veine cave inferieure. Le but de cette etude de faisabilite est de realiser une reconstruction 3D de l’espace epidural anterieur thoracique bas d’un fœtus humain de 69 mm vertex-coccyx de la Collection Rouviere de 1927. Quarante coupes (espacees de 40 μm) au niveau des dixieme et onzieme vertebres thoraciques et des disques intervertebraux sous-jacents ont servi pour la reconstruction 3D realisee par le logiciel SURFdriver. Dans une etude preliminaire, les structures de l’espace epidural sont apparues a ce stade deja en place et comparables a celles de l’âge adulte (2002) ; la reconstruction 3D a partir des coupes microscopiques a permis de mieux visualiser les plexus veineux et leurs rapports et represente donc un complement aux etudes histologiques.

Reconstruction 3D de l’appareil uro-génital à partir des coupes anatomiques de « visible human »

Objectifs Realiser une modelisation 3D de l’appareil uro-genital de l’homme a partir des coupes de Visible Human. Materiel et methodes 400 coupes du dataset de « Visible Human » de 1600 a 1900. Le logiciel SURFDRIVER est utilise pour realiser le contourage et la modelisation 3D. Resultats Les rapports anatomiques des organes du petit bassin sont etudies grâce a l’utilisation des techniques de realite virtuelle : rotation du modele 3D et modification de la transparence des organes. L’etude anatomique comprend la vessie, l’uretre, la prostate les vesicules seminales et les canaux deferents ainsi que le haut appareil. Conclusion Ce nouvel outil pedagogique et de recherche est precieux pour l’etude de l’anatomie topographique et de la morphometrie.

Reconstruction 3D de l’appareil uro-génital masculin à partir des coupes anatomiques de « Korean Visible Human »

Objectifs realiser une modelisation 3D de l’appareil uro-genial de l’homme a partir des coupes de Korean Visible Human. Materiel et methodes 440 coupes espacees de 1 mm du dataset de Korean VisHum sont utilisees. Le logiciel SURFDRIVER version 3.5 est utilise pour realiser la segmentation par contourage manuel puis la reconstruction surfacique et la modelisation 3D. Le travail a ete realise sur un PC pentium 4 2 Ghz 512 M de Ram sous windows XP. Resultats 42 structures anatomiques sont representees : reins, ureteres, vessie (paroi interne et externe), urethre, testicules, epididymes, canaux deferents, vesicules seminales, prostate, rectum, canal anal, aorte abdominale, superior mesenteric artery, arteres et veines renales, VCI, rachis lombaire, disques intervertebraux, sacrum, femurs et contour cutane. Leurs rapports anatomiques des organes du petit bassin sont etudies grâce a l’utilisation des techniques de realite virtuelle. L’interactivite et la transparence variable des differentes structures permettent une manipulation aisee du modele 3D. Conclusion ce nouvel outil pedagogique et de recherche est precieux pour l’etude de l’anatomie.

Anatomie et embryologie de la petite veine saphène : rapports nerveux et implications thérapeutiques

Objectif identifier les risques nerveux et les zones dangereuses lors des procedures therapeutiques interessant la petite veine saphene (PVS). Methodes L’Embryologie est illustree par la theorie des nerfs « angio-directeurs ». L’anatomie descriptive est basee sur la dissection de 120 cadavres frais. L’imagerie echographique est realisee par le duplex couleur chez des patients variqueux. Resultats description des rapports nerveux de la PVS : Dans la fosse poplitee elle croise lateralement le nerf tibial, ou parfois le nerf du muscle gastrocnemien medial. A la pointe du mollet, la PVS rejoint les 2 branches fibulaire et tibiale du nerf sural qu’elle longe jusqu’a la cheville. Le Duplex permet d’identifier la PVS dans le compartiment saphenien (œil egyptien), delimitee les 2 couches du fascia : une couche superficielle sous-cutanee et une couche profonde, le fascia musculaire. Conclusion le clinicien doit savoir identifier la PVS et connaitre les zones dangereuses en vue de l’abord chirurgical ou des procedures : — existence possible d’une « artere petite saphene » a la partie haute du mollet qui est dangereuse lors des injections sclerosantes ; — proximite des nerfs au niveau de la cheville, de la pointe du mollet et surtout de la fosse poplitee. Le clinicien doit etre bien au fait de tous ces pieges anatomiques pour eviter de leser les nerfs.