V. Delmas

Systematic biopsies accurately predict extracapsular extension of prostate cancer and persistent/recurrent detectable PSA after radical prostatectomy.

OBJECTIVESnTo determine if methodic analysis of systematic echo-guided biopsies associated with prostatic-specific antigen (PSA) and PSA density can accurately predict the actual pathologic stage of prostate cancer (Ca P).nnnMETHODSnOne hundred patients with clinically localized (T1, T2) Ca P who underwent radical prostatectomy (RP) were preoperatively staged by digital rectal examination (DRE), measurement of serum PSA (Yang Pros-check) and PSA density (PSAD), and transrectal echo-guided systematic biopsies (three in each lobe aiming to sample prostatic capsule) to evaluate T stage, Gleason grade, number of positive biopsies, and presence of cancer in the periprostatic tissues. Radical prostatectomy specimens were processed following the McNeal method. The PSA levels were measured every month for 2 years.nnnRESULTSnExtracapsular disease was detected on the specimen in 45% of the patients, persistent/recurrent detectable PSA in 47% (mean follow-up 18 months). Clinical stage T2 B, presence of Gleason grade 4, PSA > 25 ng/mL, PSAD > 0.6, number of positive biopsies > 66% of the total number of cores taken had a positive predictive value (PPV), respectively, of 72%, 66%, 80%, and 87%. Periprostatic tissue was evaluable on the core biopsies in 77% of the cases. Presence of cancer in the periprostatic fat on the core biopsies had a PPV of 94% for extracapsular disease/biological recurrence.nnnCONCLUSIONSnThe presence of extracapsular cancerous tissue on prostatic core biopsies accurately predicts extracapsular extension of Ca P. Therefore, care should be taken when performing prostate biopsies to sample the prostate capsule and surrounding tissues to obtain a more accurate staging of the disease. The second best predictor of extracapsular disease is the percentage of positive biopsies.

Classical and nerve-sparing radical hysterectomy: an evaluation of the risk of injury to the autonomous pelvic nerves

Radical hysterectomy represents the treatment of choice for FIGO stage IA2–IIA cervical cancer. It is associated with several serious complications such as urinary and anorectal dysfunction due to surgical trauma to the autonomous nervous system. In order to determine those surgical steps involving the risk of nerve injury during both classical and nerve-sparing radical hysterectomy, we investigated the relationships between pelvic fascial, vascular and nervous structures in a large series of embalmed and fresh female cadavers. We showed that the extent of potential denervation after classical radical hysterectomy is directly correlated with the radicality of the operation. The surgical steps that carry a high risk of nerve injury are the resection of the uterosacral and vesicouterine ligaments and of the paracervix. A nerve-sparing approach to radical hysterectomy for cervical cancer is feasible if specific resection limits, such as the deep uterine vein, are carefully identified and respected. However, a nerve-sparing surgical effort should be balanced with the oncological priorities of removal of disease and all its potential routes of local spread.RésuméLhystérectomie radicale est le traitement de choix pour les cancers du col utérin de stade IA2–IIA de la Fédération Internationale de Gynécologie Obstétrique (FIGO). Cette intervention comporte plusieurs séquelles graves, telles que les dysfonctions urinaires ou ano-rectales, par traumatisme chirurgical des nerfs végétatifs pelviens. Pour mettre en évidence les temps chirurgicaux impliquant un risque de lésion nerveuse lors dune hystérectomie radicale classique et avec préservation nerveuse, nous avons recherché les rapports entre le fascia pelvien, les structures vasculaires et nerveuses sur une large série de sujets anatomiques féminins embaumés et non embaumés. Nous avons montré que létendue de la dénervation potentielle après hystérectomie radicale classique était directement en rapport avec le caractère radical de lintervention. Les temps chirurgicaux à haut risque pour des lésions nerveuses sont la résection des ligaments utéro-sacraux, des ligaments vésico-utérins et du paracervix. Lhystérectomie radicale avec préservation nerveuse est possible si des limites de résection spécifiques telle que la veine utérine profonde sont soigneusement identifiées et respectées. Cependant une chirurgie de préservation nerveuse doit être mise en balance avec les priorités carcinologiques dexérèse du cancer et de toutes ses voies potentielles de dissémination locale.

Clinical interest of digestive arterial trunk anastomoses.

Arterial vascularization of the gastrointestinal tract is a three-level system composed of the coeliac trunk, and both superior and inferior mesenteric arteries. The three levels are joined together via arterial trunk anastomoses such as the so-called and well-known Riolan arcade or supramarginal arcade. The aim of this study was to review the embryology of the digestive arteries in order to understand the anatomic variations, the development of the arterial trunk anastomoses and the potential collateral circulation in the case of obstruction of one or several arterial trunks. The arch theory by Mac Kay and Tandler longitudinal arterial anastomosis account for the genesis of the arterial trunk anastomoses and the main anatomic variations. The coeliac trunk and the superior mesenteric artery are joined together via the pancreaticoduodenal arcades and the Bühler arcade. These anastomoses are divided during pancreatic resections but developed in the case of coeliac trunk stenosis. The mesenteric arteries are joined together by the Riolan, Villemin arcades and by the marginal artery of Drummond. This collateral circulation and the Riolan arcade in particular, is utilized during left colonic resection. In the case of this collateral circulation insufficiency, inferior mesenteric artery reimplantation is necessary during abdominal aortic aneurysmectomy. Arteriopathy, more and more frequent due to population ageing is responsible for frequent obliteration of one or several digestive arterial trunks with subsequent development of collateral circulation. For such reasons, a sound knowledge of digestive arterial anatomy is an absolute prerequisite for surgical practice.

Anomalies of lateralization in man : a case of total situs inversus

Total or complete visceral situs inversus is the complete inversion of position of the thoracic and abdominal viscera. The aim of this study is to report a case of complete situs inversus and to review our knowledge of the anomalies of lateralization. A case of complete sinus inversus was discovered incidentally during anatomic dissection in a female subject aged 87 years. The thoracic and abdominal organs had a position symmetric with the normal. This was associated with a common mesentery and incomplete rotation of the colon, placing the cecum under the left lobe of the liver. These alimentary anomalies were discovered in adult life during a surgical operation for small intestinal occlusion, as evidenced by the abdominal scar and peritoneal adhesions. No cardiac, pulmonary, splenic or facial sinus anomalies were encountered. The incidence of complete situs inversus is estimated as 1/8000 in the general population. It may be isolated or associated with malformations, especially cardiac or alimentary. It may be discovered in infancy because of associated anomalies but often remains asymptomatic and discovered by chance in adult life. Complete situs inversus may form part of the multiple malformational syndromes such as that of Kartagener, with recessive autosomal transmission (complete situs inversus, bronchiectasis, chronic sinusitis, male infertility), which represents 20–25% of cases of complete situs inversus. In view of the frequency of this type of anomaly, a knowledge of anomalies of lateralization is essential in clinical practice.

Vagina, abdominal skin, and aponeurosis: do they have similar biomechanical properties?

Introduction and hypothesisDespite minimal fundamental works, there is an increasing use of meshes in urogynecology. The concept is mainly based on experiences with abdominal wall surgery. We aimed to compare the biomechanical properties of vaginal tissue, abdominal aponeurosis, and skin.MethodsSamples from 11 fresh women cadavers without prolapse were collected. Uniaxial tension tests were performed and stress–strain curves were obtained.ResultsBiomechanical properties of the vagina, aponeurosis, and skin differed significantly. The aponeurosis was much more rigid and less extendible than the vagina and skin. Vaginal tissue was less rigid but more extendible than skin. There was no difference between the vagina and skin at low strains (pu2009=u20090.341), but a highly significant difference at large strains (pu2009=u20090.005).ConclusionsSkin and aponeurosis are not suited to predict vaginal tissue biomechanics. We should be cautious when transferring experiences from abdominal wall surgery to vaginal reconstructive surgery.

Effect of radiation therapy after radical prostatectomy on serum prostate-specific antigen measured by an ultrasensitive assay

OBJECTIVESnTo study prospectively the impact of adjuvant radiation therapy on the serum level of prostate-specific antigen (PSA), as measured by an ultrasensitive Yang Proscheck assay in patients with detectable serum PSA and a negative metastatic survey after radical prostatectomy for T1 or T2 prostate cancer.nnnMETHODSnSeventeen patients had a detectable serum PSA (2.40 +/- 2.1 ng/mL; range, 0.5 to 10) by the Yang polyclonal assay 2 to 71 months after radical prostatectomy for P2N0 (2 patients) or P3N0 (15 patients) prostate cancer. Metastatic workup (bone and computed tomography scan) was negative; 9 of 17 patients had a local recurrence documented by a positive biopsy of the vesicourethral anastomosis. All patients were treated by external radiotherapy, receiving 65 Gy on the prostate fossa over 5 weeks for an assumed low volume residual disease. Patients were followed up by determination of serum PSA every 3 months, using the Yang ultrasensitive assay for a mean duration of 14.4 months.nnnRESULTSnIn 17.6% of the patients (3 of 17) PSA became undetectable (less than 0.05 ng/mL) after radiotherapy. Radiotherapy had no impact on PSA in 35.3% (6 of 17). PSA decreased after radiation therapy within 6 months in 47.1% (8 of 17) and for up to 12 months in 2 patients, with a nadir of 0.28 ng/mL. All patients in this group experienced a secondary rise in PSA a mean of 10.6 months (range, 6 to 18 months) after radiotherapy.nnnCONCLUSIONSnExternal radiotherapy has a limited impact on residual disease after radical prostatectomy, as assessed by its impact on PSA.

Micturition Disturbances and Human Immunodeficiency Virus Infection

PURPOSEnHuman immunodeficiency virus (HIV) infections often lead to urological disorders, including tumors, infections and micturitional disturbances. It often is difficult to identify the origin of voiding disorders but the most frequent causes are infections (prostatitis and so forth), obstruction (cervico-prostatic or urethral) and neurological (encephalitis, myelitis, polyradiculoneuritis and so forth). We determined the etiologies, therapy and clinical outcome of micturitional disturbances in the acquired immunodeficiency syndrome.nnnMATERIALS AND METHODSnBetween February 1989 and September 1992 we studied prospectively 39 HIV positive patients with voiding symptoms, such as straining, urinary retention, frequency and urgency. Each patient underwent a thorough neurological and urological examination, along with radiological evaluation of the urogenital tract and nervous system. Urodynamic evaluation was performed to specify the etiology and type of disturbance before treatment. The patients were followed for 2 to 24 months (mean 9) and 34 (87%) had urodynamic abnormalities, including a hyperactive bladder, bladder sphincter dyssynergia and a hypoactive bladder.nnnRESULTSnThe cause of the voiding disorder was neurological in 61.5% of the cases, and the 2 most frequent disorders were cerebral toxoplasmosis and HIV encephalitis. Treatment was usually given to relieve symptoms with drugs acting on the detrusor-sphincter complex. A total of 22 patients (57%) had lasting improvement, while 17 (43%) died 2 to 24 months (mean 8) after onset of the voiding symptoms.nnnCONCLUSIONSnA micturition problem is an unfavorable event since it usually indicates a neurological cause.

Going back to dissection in a medical curriculum: the paradigm of Necker-Enfants Malades

In 1999, we first reported on various methods of teaching anatomy subsequent to visits to a variety of medical schools in the United States and Europe. We compared the number of contact hours for lectures, dissection classes and tutorials and provided different models for the teaching of anatomy. With respect to the nine French medical schools surveyed, it is clear that the French model is characterized by being lecture-orientated (time in lectures > time in tutorials > time spent on dissection). For the American model (also in the UK and some other parts of Europe), the training is often characterized by being dissection-based (time spent on dissection > time in lectures > time in tutorials; 10 medical schools surveyed). Exceptionally, in one Australian school, time in tutorials exceeds time in lectures (dissection = 0). The differences between the French and American models relate to teaching aims—where dissection predominates, the aims are not just the learning of anatomical facts but include practical skill acquisition and experiential learning. In 2001, to help us change the methods of teaching of anatomy in our medical school at CHU Necker-Enfants Malades (Paris V, France), we asked other French medical schools (and some foreign schools) to suggest ways of organizing anatomy training within certain time constraints. In this paper, we present the answers received. The responses received were of two kinds: (1) those providing a description of the anatomy teaching in their own medical school; (2) those providing a system for organizing the teaching if we, in Paris, have 120xa0hours in total to teach gross anatomy (except neuroanatomy). In the latter case, a considerable variety of different, and innovative, alternative schemes were suggested that are described in this article.

Morphometry by computerized three-dimensional reconstruction of the hypogastric plexus of a human fetus

The histological study of the plexus hypogastricus inferior (hypogastric plexus) of a human fetus does not permit the direct appreciation of its spatial configuration and its complicated relations. Developments in the field of computer science and three-dimensional (3D) reconstruction from serial histological sections have allowed a precise description of its morphometry and relations. The histological sections which were used came from the Rouvière collection of the Institute of Anatomy in Paris. A personal computer (IMAC) system of image analysis with reconstruction software was used. Serial pelvic histological sections were directly digitized from the slides. Image treatment and reconstruction were done with manual methods. The 3D reconstruction of the hypogastric plexus, the nerves, the pelvic skeleton and viscera were done. The hypogastric plexus and its topographic relations with the other organs were visualized and studied in three dimensions, and its morphometry was studied. The direct acquisition of the images from the slides allowed excellent high-quality digital images to be obtained. However, manual processing for the reconstruction was time-consuming. At first, the reconstruction of the various pelvic structures was done separately for each organ. Then the structures were visualized all together. Thus, the hypogastric plexus could be examined under various incidences with each organ. The virtual images obtained show new details of the topographic relations and improve knowledge of the precise innervation of the pelvic organs. The French version of this article is available in the form of electronic supplementary material and can be obtained by using the Springer Link server located at http://dx.doi.org/10.1007/s00276-002-0091-9.RésuméLétude du plexus hypogastricus inferior, (plexus hypogastrique) du foetus humain à partir de coupes histologiques ne permet pas une appréciation directe de sa configuration spatiale et de ses rapports complexes. Le développement doutils informatiques performants de reconstruction tridimensionnelle (3D) a permis, à partir de coupes histologiques sériées (bidimensionnelles), de préciser sa morphométrie et ses rapports grâce un outil détude interactif. Les coupes histologiques utilisées provenaient de la collection dembryons Rouvière de lInstitut dAnatomie de Paris. Le matériel informatique se composait dun micro-ordinateur et de systèmes de traitement et de reconstruction dimages. Les coupes du bassin ont été directement numérisées à partir des lames. Les images ont été traitées et reconstruites manuellement. Le plexus hypogastrique, les nerfs, le squelette et tous les organes du pelvis ont été reconstruits. La morphométrie du plexus hypogastrique ainsi que ses rapports avec les organes pelviens ont été visualisés et étudiés en trois dimensions. Lacquisition des images directement à partir des lames permet dobtenir des images numériques dexcellente qualité. Cependant, leur traitement manuel en vue de la reconstruction est long et fastidieux. La reconstruction des différentes structures anatomiques du pelvis se fait dabord séparément, organe par organe. Ensuite les structures sont visualisées en association. Le plexus hypogastrique peut ainsi être examiné sous différentes incidences avec chacun des organes. Les images virtuelles ainsi obtenues apportent des précisions nouvelles sur les rapports et améliorent la connaissance de linnervation précise des viscères pelviens.

The human lumbar anterior epidural space: morphological comparison in adult and fetal specimens.

Abstract To increase our understanding of the clinical anatomy of the epidural space, the human lumbar anterior epidural space was studied morphologically and developmentally. Histological transverse sections of human lumbar spines were taken at the level of the intervertebral disc and the vertebral body in adult specimens and in fetuses aged 13, 15, 21, 32 and 39xa0weeks (menstrual age). At 13xa0weeks, connective tissue filled the epidural space. The dura mater was attached anteriorly to the posterior longitudinal ligament (PLL). The PLL was attached to the vertebral body beside the midline, whereas it adhered to the posterior edge of intervertebral disc. The anterior internal vertebral venous plexus was located anterolaterally and anteromedially. The vertebral canal was lined with connective tissue that differentiated in a periosteum in contact with the ossification centers. At 15xa0weeks, the PLL was composed of deep and superficial layers. At 21xa0weeks, the attachment between the dura mater and PLL was ligament-like at the level of the vertebral body. At 32xa0weeks, the dura mater was adherent to the superficial layer of PLL. At 39xa0weeks, groups of adipocytes were identified, and the dura mater was attached to the PLL by some ligaments. There were many more similarities between the adult and the 39-week fetus. In conclusion, some differences in the anatomy of the epidural space exist at each fetal stage studied. The structures of the epidural space are already formed in the fetus of 13xa0weeks, but they differentiate progressively within the connective tissue. Electronic supplementary material to this paper can be obtained by using the Springer Link server located at http://dx.doi.org/10.1007/s00276-002-0041-6.Résumé Pour mieux comprendre lanatomie clinique de lespace épidural, nous avons réalisé une étude morphologique de lespace épidural lombaire antérieur humain. Des coupes histologiques transversales de la colonne lombaire de foetus humains âgés de 13, 15, 21, 32 et 39xa0semaines daménorrhée (SA) et dun adulte, ont été réalisées au niveau du disque intervertébral et du corps vertébral. A 13xa0SA, du tissu conjonctif remplit lespace épidural. La partie antérieure de la dure-mère est collée au ligament longitudinal postérieur (LLP). Le LLP est attaché au corps vertébral au niveau de sa portion médiane, mais il est adhérent au bord postérieur du disque intervertébral. Les plexus veineux vertébraux internes antérieurs sont localisés au niveau des parties antéro-latérale et antéro-médiale. Le canal vertébral est limité par du tissu conjonctif qui se différencie en périoste au contact des centres dossification. A 15xa0SA, le LLP présente une couche profonde et une couche superficielle. A 21xa0SA, au niveau du corps vertébral, laccolement entre la dure-mère et le LLP se fait par lintermédiaire dun tissu simulant de véritables ligaments. Il y a beaucoup de similarités entre le foetus de 39xa0SA et ladulte. En conclusion, les structures sont déjà en place dès 13xa0SA mais elles se différencient progressivement à lintérieur dune zone de tissu conjonctif.