Stéphane Droupy

Division of Autonomic Nerves Within the Neurovascular Bundles Distally into Corpora Cavernosa and Corpus Spongiosum Components: Immunohistochemical Confirmation with Three-Dimensional Reconstruction

BACKGROUND Detailed knowledge of the distribution and distal course of periprostatic nerves is essential to improve functional outcomes (erection and continence) after radical prostatectomy (RP). OBJECTIVE To describe the location of nerve fibres within neurovascular bundles (NVBs) and around the prostate by three-dimensional (3D) computer-assisted anatomic dissection (CAAD) in human foetuses and adult cadavers. DESIGN, SETTING, AND PARTICIPANTS Serial transverse sections of the pelvic portion were performed in seven human male foetuses and four male adult cadavers. Sections were treated by histologic coloration and neuronal immunolabelling of S100 protein. 3D pelvic reconstruction was achieved with digitised serial sections and WinSurf software. MEASUREMENTS We evaluated the distribution of nerve fibres within the NVB qualitatively. The distribution of periprostatic nerves was also evaluated quantitatively in the adult specimens. RESULTS AND LIMITATIONS Periprostatic nerve fibres were dispersed around the prostate on all sides with a significant percentage of these fibres present in the anterior and anterolateral sectors. At the prostate apex and the urethral levels, the NVBs have two divisions: cavernous nerves (CNs) and corpus spongiosum nerves (CSNs). The CNs were a continuation of the anterior and anterolateral fibres around the apex of the prostate, travelling towards the corpora cavernosa. The CSNs were a continuation of the posterolateral NVBs, and they eventually reached the corpus spongiosum. The limitations of this study were the small number of specimens available and the lack of functional information. CONCLUSIONS The anterolateral position of CNs at the apex of the prostate and the autonomic innervation towards the corpus spongiosum via CSNs indicate possible ways to minimise the effect of prostate surgery on sexual function. The ideal dissection plane should probably include the preservation of the anterolateral tissues and fascias to avoid CN lesions. Anatomic knowledge gained from CAAD pertains directly to proper surgical technique and subsequent recovery of erectile function after RP.

‘Burned‐out’ primary testicular cancer

To report the natural history of ‘burned‐out’ testicular tumour (a testicular tumour that has regressed spontaneously with no treatment and that generally presents at the stage of metastases).

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.

Prognostic value of prostate circulating cells detection in prostate cancer patients: a prospective study

In clinically organ-confined prostate cancer patients, bloodstream tumour cell dissemination generally occurs, and may be enhanced by surgical prostate manipulation. To evaluate cancer-cell seeding impact upon patient recurrence-free survival, 155 patients were prospectively enrolled then followed. Here, 57 patients presented blood prostate cell shedding preoperatively and intraoperatively (group I). Of the 98 preoperatively negative patients, 53 (54%) remained negative (group II) and 45 (46%) became intraoperatively positive (group III). Median biological and clinical recurrence-free time was far shorter in group I (36.2 months, P<0.0001) than in group II (69.6 months) but did not significantly differ in group II and III (69.6 months vs 65.0). Such 5-year follow-up data show that preoperative circulating prostate cells are an independent prognosis factor of recurrence. Moreover, tumour handling induces cancer-cell seeding but surgical blood dissemination does not accelerate cancer evolution.

Tridimensional Computer-Assisted Anatomic Dissection of Posterolateral Prostatic Neurovascular Bundles

BACKGROUND Detailed knowledge of nerve distribution in the neurovascular bundle (NVB) is essential to preserve sexual function after prostatic surgery. OBJECTIVE To 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. DESIGN, SETTING, AND PARTICIPANTS Serial 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. MEASUREMENTS NVB nerve location and type were evaluated qualitatively. RESULTS AND LIMITATIONS The 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. CONCLUSIONS The 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.

Effect of dutasteride on the symptoms of benign prostatic hyperplasia, and patient quality of life and discomfort, in clinical practice

To assess the improvements in symptoms, quality of life (QoL), discomfort and satisfaction in patients with symptomatic benign prostatic hyperplasia (BPH) treated with dutasteride in clinical practice.

Predictive factors of complications after robot-assisted laparoscopic partial nephrectomy: a retrospective multicentre study

To analyse the predictive factors of complications after robot‐assisted laparoscopic partial nephrectomy (RALPN).

Bilateral hydronephrosis in a patient with Erdheim-Chester disease

Erdheim-Chester disease is a rare systemic disorder, which involves the retroperitoneum and kidneys in almost a third of the cases. CASE REPORT A 68-year-old white man presented in October 1997 with persistent edema of the lower limbs associated with acute pulmonary edema. He had a history of breathlessness on exertion, which led to the diagnosis of histiocytosis X (Langerhans cell granulomatosis) in 1983, although lung biopsy failed to demonstrate X bodies. Hemoglobin was 10.2 gm./dl. (normal 12 to 16), erythrocyte sedimentation rate 100 (normal 4 to 8) and serum creatinine 130 mmol./l. (normal 50 to 100). Thoracic computerized tomography (CT) showed diffuse interstitial fibrosis, periaortic fibrosis of the descending thoracic aorta and bilateral adrenal hyperplasia. Abdominal CT and magnetic resonance imaging revealed bilateral hydronephrosis associated with right hilar lymphadenopathy (part A of figure), nonspecific adrenal hyperplasia (part B of figure) and retroperitoneal fibrosis at the level of L1 and L2 vertebrae. Excretory urography demonstrated a 3-hour delay in excretion from the left kidney, nonvisualization of the ureters and a heterogeneous appearance of the hips. Bilateral retrograde pyelography revealed bilateral lumbar ureteral stenosis extending 3 to 4 cm. below the ureteropelvic junction. A silicone double pigtail ureteral stent was inserted on both sides. Erdheim-Chester disease was confirmed on radiographs of the humerus, which showed specific signs, such as bilateral and symmetrical metaphyseal sclerosis, cortical thickening and medullary sclerosis. Endocrine tests were normal. CT guided biopsies failed to demonstrate specific histological features of Erdheim-Chester fibrosis. The patient received 1 mg./kg. prednisone daily for 6 months because of persistently elevated erythrocyte sedimentation rate and stable appearance of the fibrosis. He died of myocardial infarction in July 1998. Autopsy findings confirmed the diagnosis of Erdheim-Chester disease with specific pathological characteristics.

Surgical prevention and management of vascular complications of kidney transplantation

The main surgical changes in kidney procurement, preparation, and transplantation procedures occurred 20 years ago and were undertaken despite the inability to design randomized studies. The objective was to assess the evolution of vascular complications after kidney transplantation in a setting of surgical preventive measures in a historical series. A monocentric series of 3129 consecutive kidney transplantations performed over 3 decades was reviewed. The occurrence of arterial or venous thromboses, stenoses, and aneurysms was analyzed in relation with kidney procurement, preparation, and transplantation techniques. Vascular complications occurred in 13.5% of the recipients with a mean 3‐year decrease in kidney graft function. The transplantation of a right kidney without renal vein extension, multiple renal arteries, ex vivo vascular repairs, and end‐to‐end arterial anastomoses were the unfavorable surgical vascular factors. It was possible to manage Transplant Renal Artery Stenosis (TRAS) nonsurgically in 80% of the cases. The prevention of vascular complications begins from the time of organ procurement by skilled surgeons. The aims of organ preparation are to evaluate the vascular risk, select the organs, and to simplify the anatomical constraints of vascular implantations. The three surgical steps of kidney transplantation are determinant in postoperative vascular complications and the duration of graft function.

Evolution in the concept of erection anatomy

PurposeTo review and to summarize the literature on anatomy and physiology of erection in the past three decades, especially the work done in our institution.MethodsA search of the PubMed database was performed using keywords erection, anatomy and erectile dysfunction (ED). Relevant articles were reviewed, analyzed and summarized.ResultsPenile vascularisation and innervation vary substantially. Internal pudendal artery is the major source of penile blood supply, but a supralevator accessory pudendal artery that may originate from inferior vesical or obturator or external iliac arteries is not uncommon. Section of this artery during radical prostatectomy (RP) may adversely affect postoperative potency. Anastomoses between the supra and the infralevator arterial pathways are frequent. The cavernous nerves (CNs) contain parasympathetic and sympathetic nerve fibers and these nerves lie within leaves of the lateral endopelvic fascia. Anastomoses between the CNs and the dorsal nerve of the penis are common. Nitric oxide released from noradrenergic, noncholinergic neurotransmission of the CN and from the endothelium is the principal neurotransmitter-mediating penile erection. Interactions between pro-erectile and anti-erectile neurotransmitters are not completely defined. Finally, medial preoptic area and paraventricular nucleus are the key structures in the central control of sexual function and penile erection.ConclusionsThe surgical and functional anatomy of erection is complex. Precise knowledge of penile vascularisation and innervation facilitates treatment of ED especially after RP.