K. Colleselli

THE FEMALE URETHRAL SPHINCTER: A MORPHOLOGICAL AND TOPOGRAPHICAL STUDY

PURPOSE We reassess the anatomy and topography of the female urethral sphincter system and its innervation in regard to urethra sparing anterior exenteration and other surgical procedures. MATERIALS AND METHODS Anatomical and histological studies were performed on 9 fetal specimens and 4 adult cadavers. Using graphics software the anatomical structures of the true pelvis were reconstructed based on computerized tomography cross sections and digitized histological sections. On the adult cadavers anterior exenteration was performed to study the implications of the isolated urethra and its sphincter mechanism. RESULTS Strata of connective tissue were found to divide the smooth muscles of the proximal two-thirds of the female urethra into 3 layers. Computer guided 3-dimensional reconstruction of digitized histological sections showed that thin fibers of the pelvic plexus course to this part of the urethra. The majority of these fibers may be preserved by carefully dissecting the bladder neck and the proximal portion of the urethra, leaving the lateral vaginal walls intact. The striated rhabdosphincter, which is innervated by fibers of the pudendal nerve, was in the caudal third of the urethra. CONCLUSIONS A well-defined sphincteric structure or sphincter could not be anatomically recognized in the bladder neck region. The majority of rhabdosphincter fibers were found in the middle and caudal thirds of the urethra. Thus, in patients undergoing removal of the bladder neck and part of the proximal portion of the urethra continence can be maintained by the remaining urethral sphincter system, provided that innervation remains essentially intact.

Original Articles: Bladder Cancer: The Risk of Urethral Tumors in Female Bladder Cancer: Can the Urethra be Used for Orthotopic Reconstruction of the Lower Urinary Tract?

ABSTRACTWe studied the risk of synchronous or secondary urethral tumors after long-term followup in women with bladder cancer. The charts of women treated for various stages of bladder cancer between 1973 and 1992 were reviewed. Of 356 evaluable patients 268 presented initially with primary and 78 with multilocular tumor involvement. There were 498 episodes of recurrent tumors in 127 patients, and a total 1,210 tumor locations in 854 primary and recurrent episodes of bladder cancer. Mean followup for these patients was 5.5 years (range 0.05 to 33.1). Overall 7 of 356 patients (2%) had urethral tumor involvement, all at initial presentation. Statistical comparison of various defined tumor localizations in the bladder revealed that the bladder neck (p <0.000) and trigone (p <0.035) were significantly more often the region of primary tumor occurrence in the urethral tumor group. All patients with secondary urethral tumors had tumor involvement of the bladder neck at the same time. A 1% urethral tumor involve...

Rationale and Technique of Nerve Sparing Radical Cystectomy Before an Orthotopic Neobladder Procedure in Women

PURPOSE We developed refinements in the technique of cystectomy and subsequent intestine to urethra anastomosis to improve postoperative results in women undergoing anterior exenteration and creation of an orthotopic neobladder to the urethra. MATERIALS AND METHODS Anatomical dissection and microdissection studies were performed on formalin-carbol fixed adult cadavers and correlated with previous anatomical and clinical findings. The resulting surgical variations were performed in 5 carefully selected women undergoing lower urinary tract reconstruction. RESULTS Optimal postoperative results in regard to continence and voiding without compromising oncological outcome may be obtained by preserving the entire lateral vaginal walls, performing nerve sparing dissection of the bladder neck and proximal urethra, removing 1 cm. proximal urethra en bloc with the cystectomy specimen and using additional attachments of the anastomosed intestinal pouch to surrounding pelvic structures. Patients achieved day and night continence after 6 months, mean pouch volume was 580 cc (range 450 to 750) and residual volumes ranged from 0 to 150 cc. No tumor recurred after 6 to 17 months. CONCLUSIONS Refinements in the technique of radical cystectomy and orthotopic neobladder to the urethra in women may improve continence and spontaneous voiding without compromising surgical oncological outcome, and they further justify orthotopic diversion in select women with bladder cancer.

Lower Urinary Tract Reconstruction Following Cystectomy In Women Using The Kock Ileal Reservoir With Bilateral Ureteroileal Urethrostomy: Initial Clinical Experience

Since June 1990, 14 women 31 to 70 years old (mean age 57 years) have undergone lower urinary tract reconstruction by bilateral ureteroileal urethrostomy using a Kock ileal reservoir. Indications for cystectomy included transitional cell carcinoma in 9 patients, urachal adenocarcinoma in 2, cervical carcinoma in 1, mesenchymal tumor of endometrial origin in 1 and a fibrotic radiated bladder in 1. Early and late complications have been few, occurring in 2 patients and 1, respectively. Excellent continence has been achieved during the day and night in 100% of patients. Of the 14 patients 12 void volitionally per urethra without high residual volume, while 2 require intermittent catheterization. All patients are completely satisfied. Tumor recurred in the pelvis in 1 patient with an extensive mesenchymal tumor necessitating conversion to a continent cutaneous Kock reservoir. All patients are currently alive without evidence of disease. This initial experience with lower urinary tract reconstruction in women has yielded extraordinary results and we believe that the option of lower urinary tract reconstruction following cystectomy can be offered safely to selected female patients.

TRANSURETHRAL ULTRASOUND: EVALUATION OF ANATOMY AND FUNCTION OF THE RHABDOSPHINCTER OF THE MALE URETHRA

PURPOSE A combined anatomic-sonographic study was undertaken to investigate whether the anatomical arrangement and the contractions of the rhabdosphincter of the male urethra could be visualized by transurethral ultrasound. Furthermore, this new technique was compared with standard urodynamic tests. MATERIALS AND METHODS In 7 cadavers transurethral ultrasound was performed to define sono-morphological criteria of the rhabdosphincter, and the sonographic pictures were then compared to histological sections. In 48 patients the rhabdosphincter of the male urethra was investigated by transurethral ultrasound and urodynamic techniques. Of these patients 40 were completely continent after radical prostatectomy and 8 presented with urinary stress incontinence after transurethral resection of the prostate or radical prostatectomy. The decrease of the distance between the rhabdosphincter and the transducer during contraction served as quantitative parameter for the contractility of the muscle. RESULTS The anatomical arrangement and contractions of the rhabdosphincter loop could be clearly visualized on transurethral ultrasound (during contraction the rhabdosphincter retracts the urethra, pulling it towards the rectum). Ultrasound showed scars in 3 patients with postoperative urinary stress incontinence, thinning of the muscle in 3 complete atrophy of the rhabdosphincter in 2 and minimal contractions of the rhabdosphincter in 1. Urethral closure pressures were decreased and decrease in rhabdosphincter-transducer distance was statistically significantly decreased in the incontinent patients. CONCLUSIONS Our sono-morphological data and anatomical histological results strongly suggest that the rhabdosphincter constitutes the main component of the continence mechanism in post-prostatectomy patients. Unlike urethral pressure profiles, which can only reveal zones of higher intraluminal pressure between the bladder and the penile urethra, transurethral ultrasound is highly specific for measurement of the function of the rhabdosphincter.

Nerve-Preserving Bilateral Retroperitoneal Lymphadenectomy: Anatomical Study and Operative Approach

In a study of the sympathetic trunk in 18 cadavers a new anatomical approach for modified bilateral retroperitoneal lymphadenectomy was developed, which is characterized by unilateral preservation of the L3 ganglion and the fibers arising from this ganglion. Furthermore, the sympathetic trunk and its lumbar branches were dissected, including the connections between the right and left sympathetic trunks arising from the L3 and L4 ganglia. On the right side the fibers were found dorsal to the inferior vena cava from where they pass into the aortocaval zone. Caudal to the inferior mesenteric artery these fibers communicate with the left para-aortic fibers. The precise topographic inter-relationship between the L2 and L3 ganglia was studied; the lower margin of the L3 ganglion was located 1 cm. cranial to the origin of the inferior mesenteric artery. Based on these findings a modified operative technique was developed for stages B1 and B2 testicular tumors. With the help of this modification it should be possible to preserve ejaculatory function in 50% of the patients who undergo an operation for small retroperitoneal tumors. However, this modification can be justified only if the recurrence rate is not higher than that with radical bilateral lymphadenectomy.

Usefulness of the ratio free/total prostatespecific antigen in addition to total PSA levels in prostate cancer screening

OBJECTIVES Two different studies were performed. The aim of the first study was to define whether the measurement of the ratio between free and total prostate-specific antigen (f/t PSA) in serum may enhance the ability of PSA-based screening for early detection of prostate cancer in men with elevated serum PSA levels. A second study was undertaken to investigate the value of f/t PSA ratio in serum to improve the specificity of prostate cancer screening in men with serum PSA levels between 2.5 and 10.0 ng/mL. METHODS In a retrospective study of 266 men with elevated PSA levels and proven biopsy results, f/t PSA levels were measured using deep frozen serum samples. In a second study we enrolled 158 men with elevated PSA levels according to age reference ranges apparent from our current PSA screening study with additional measurement of the f/t PSA ratio. All study volunteers with a free f/t PSA ratio cutoff point of < or = 22% underwent digital rectal examination, transrectal ultrasonography, and biopsy of the prostate. Free and total PSA levels were measured with the Delfia PSA dual label f/t PSA kit (Wallac Oy Turku, Finland). RESULTS 106 of 158 men with elevated total PSA values between 2.5 and 10.0 ng/mL (group 1) have been further evaluated and 37 prostate cancers were detected. Mean percentage of free PSA was 10% in men with cancer and 22% in men with benign prostatic hyperplasia. Using a f/t PSA ratio of < or = 22% as a biopsy criterion 30% of the negative biopsies could be eliminated while still detecting 98% carcinomas. CONCLUSIONS Measurement of f/t PSA reduces the number of unnecessary biopsies in PSA screening without missing many cancers.

POSTTRAUMATIC POSTERIOR URETHRAL STRICTURE REPAIR: ANATOMY, SURGICAL APPROACH AND LONG-TERM RESULTS

PURPOSE We describe the anatomy, surgical approach and long-term results of posterior urethral stricture repair. MATERIALS AND METHODS Between 1975 and 1991, 86 patients underwent surgery for posttraumatic posterior urethral stricture. In 65 patients the urethral lesion was corrected by 1-stage reconstructive surgery via the perineal approach. In 21 patients the urethra was reconstructed with a 2-stage procedure. In an anatomical study the course of the urethra through the pelvic floor was investigated and the concomitant structures were dissected. According to the anatomy a perineal approach was used in 7 male adult cadavers. RESULTS Due to the optimized anastomotic technique urinary flow rates of more than 20 ml. per second could be achieved in 29 of all 42 patients followed. Only 6 of these patients had peak urinary flow rates of less than 15 ml. per second. No patient had any recurrent strictures at the anastomotic site that would have required surgical revision. CONCLUSIONS Our results suggest that adequate primary care and the perineal approach combined with an exact anastomosis technique are essential for successful treatment of posttraumatic strictures of the posterior urethra.

The use of neobladders in women undergoing cystectomy for transitional-cell cancer

SummaryRecent studies have provided us with new insights into the natural history of female bladder cancer as well as the behaviour of the isolated urethra after cystectomy. Based on more than 16 years of experience with orthotopic lower urinary tract reconstruction to the urethra in men, a similar approach was attempted in women with transitional-cell cancer of the bladder. Refinements in the technique of cystectomy and subsequent intestinourethral anastomosis based on anatomical, histological, and clinical studies are described that should improve postoperative results in women undergoing anterior exenteration and creation of an orthotopic neobladder to the urethra. Our findings in a series of 11 patients are presented and compared with data from other institutions. Improved postoperative continence and micturition without compromise of the oncological outcome may be a result of preservation of the entire lateral vaginal walls, nerve-sparing dissection of the bladder neck and proximal urethra, removal of 1 cm of proximal urethra en bloc with the cystectomy specimen, and a J-omentum flap or an additional attachment of the anastomosed intestinal pouch to surrounding pelvic structures. Taken together, our average of 90% daytime and 73% nighttime continence, 90% spontaneous residual-free micturition, and 100% patient satisfaction without compromise of the surgical oncological outcome seems to justify the creation of an orthotopic neobladder in selected women with bladder cancer.

Functional urinary bladder wall substitute using a free innervated latissimus dorsi muscle flap.

&NA; This study was designed to investigate the ability of the latissimus dorsi muscle in situ to evacuate a bladder reservoir and to study the functional, anatomic, and histopathologic results of partial or subtotal bladder reconstruction with an innervated free latissimus dorsi muscle in mongrel dogs. In group I (four dogs), the latissimus dorsi muscle was dissected and tailored in situ. Then the so‐formed pedicled latissimus dorsi muscle flap was wrapped around tissue expanders of varying sizes (volumes of 50, 100, and 150 cc, respectively) to form a bladder‐like reservoir. Electromyography and intraluminal pressure measurements were done at the time of surgery and 6 months thereafter using a standard electromyograph and a Dantec urodynamic unit. In group II (four dogs), the dome of the bladder wall was removed, with up to 50 percent of the mucosal layer being left intact. The resulting muscular defect was repaired with a free innervated latissimus dorsi muscle flap. The transferred latissimus dorsi muscle was shaped and wrapped around the bladder in a spiral form, with particular attention to the resting tension. The thoracodorsal vessels were anastomosed to the pelvic branches of the hypogastric vessels, and the thoracodorsal nerve was coapted to a pelvic motor nerve that was selected by use of a nerve stimulator. Cystography and urodynamic studies were performed after 3, 6, and 9 months. Electromyography was done after 9 months, before sacrifice of the animals, which was followed by regular histologic and electron microscopic examinations. Stimulation of the thoracodorsal nerve of the reconfigured latissimus dorsi muscle reservoirs in situ after 6 months yielded average intraluminal pressures of 190 cmH2O at maximum capacity and 35 cmH2O at a minimum capacity of 10 to 15 cc. Stimulation of the latissimus dorsi muscle transferred to the bladder resulted in a visible and measurable contraction of the transplanted muscle after 9 months. Urodynamic values preoperatively and postoperatively were basically unchanged. During cystography, the bladder outline was smooth during both filling and voiding. Light and electron microscopic examinations confirmed viable, reinnervated muscle. The reconfigured pedicled latissimus dorsi muscle has the ability to evacuate a bladder‐like reservoir after nerve stimulation. A detrusor function of the bladder can be induced through the contractility of a reinnervated free latissimus dorsi muscle that was wrapped around the bladder. An innervated free latissimus dorsi muscle flap does not undergo severe muscle fibrosis, contracture, and atrophy such as occur after transfer of completely or partially denervated, pedicled muscle. This means that a functional bladder reconstruction/augmentation can be achieved by microneurovascular transfer of a latissimus dorsi muscle flap. (Plast. Reconstr. Surg. 100: 402, 1997.)