S. Poisel

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.

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.

Anatomy and innervation of the rhabdosphincter of the male urethra.

The striated sphincter of the male urethra and its innervation are still a subject of controversy. Essentially, two concepts of its anatomy can be found in the literature. Some authors describe the rhabdosphincter as part of the urogenital diaphragm caudal to the prostate, others as a striated muscle which extends from the base of the bladder to the “urogenital diaphragm.”

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.

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.

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.

Anatomical approach in surgery on the membranous urethra

The short section of the urethra that passes through the urogenital diaphragm is termed the membranous urethra. It is accompanied by several vessels and nerve fibers, lesions of which may result in erectile impotence. In surgery on the membranous urethra the perineal body is of crucial importance, and precise knowledge of the course of the urethra through the pelvic floor is essential. Furthermore, the relationship between the membranous urethra and its accompanying structures is of great importance. These include the branches of the internal pudendal artery, the prostatic venous plexus, and the cavernous nerves coursing ventrally from the pelvic plexus. In surgery on the membranous urethra a median approach is used.

Modified Retroperitoneal Lymph Node Dissection for Testicular Tumour: Open and Laparoscopic Approach, Operative Technique and Results

Publisher Summary This chapter describes open and laparoscopic approach for modified retroperitoneal lymph node dissection for testicular tumor. The long-term morbidity of retroperitoneal lymphadenectomy is primarily a result of a lesion of the postganglionic sympathetic nerve fibers resulting in loss of ejaculation. In an effort to preserve these fibers, several medical centers have lately developed a number of modifications, including the nerve-sparing or the template techniques. The incidence of loss of ejaculation is directly related to the operative technique and the extent of retroperitoneal lymphadenectomy. Mapping of retroperitoneal lymph nodes is an essential precondition for modifying the boundaries of dissection to achieve a good compromise between radical surgery and the preservation of antegrade ejaculation in the maximum number of patients. In stage IIa patients, modified retroperitoneal lymph node dissection using the template technique was performed. In patients presenting with stage IIb tumors, modified retroperitoneal lymphadenectomy was performed by means of the template technique within the boundaries following induction chemotherapy. It was found that in stage IIc patients, the residual tumor was resected after induction chemotherapy.