Vincent Delmas

Percentage of Cancer on Biopsy Cores Accurately Predicts Extracapsular Extension and Biochemical Relapse after Radical Prostatectomy for T1–T2 Prostate Cancer

Purpose: To perform a multivariate analysis to investigate the usefulness of eight preoperative variables as predictors of final pathological stage (pT), positive surgical margins (PSM) and biological progression after radical prostatectomy (RP).Materials and Methods: In 143 patients undergoing RP for T1–T2 prostate cancer, the respective values of age, clinical stage, preoperative prostate–specific antigen (PSA), prostate–specific antigen density (PSAD), number of positive biopsies (NPB), Gleason score, length of tissue core invaded by cancer (LTI) and topography (uni/bilaterality) of positive biopsies for predicting extracapsular extension, PSM and biochemical failure (PSA≥0.05 ng/ml) were evaluated retrospectively. Univariate and multivariate analyses were applied to define the statistical significance of each variable. Actuarial survival without biological progression was calculated using the Kaplan–Meier method (log–rank test).Results: In this series, 44.8% of patients had extracapsular extension with 41.3% PSM. The mean PSA was 12.4 ng/ml. In univariate analysis, LTI (p<0.0001), NPB (p = 0.0023), PSA (p = 0.0039) and Gleason score (p = 0.0136) were the most powerful variables to predict pT stage; however, in logistic regression analysis, LTI was the most predictive feature. For prediction of PSM, some variables (LTI, NPB and PSA) were found to be of statistical value in univariate analysis, and LTI in combination with NPB and PSA in multivariate analysis. For biological progression, statistical analysis (log rank test) showed PSAD and LTI to be significant predictors.Conclusion: The pathological report regarding the biopsy contains crucial information influencing the prediction of pT stage, PSM and biological progression after RP. LTI, NPB and PSA are the most useful parameters for this purpose.

RADICAL PROSTATECTOMY FOR PROSTATE CANCER: THE PERINEAL APPROACH INCREASES THE RISK OF SURGICALLY INDUCED POSITIVE MARGINS AND CAPSULAR INCISIONS

PURPOSE We compare the incidence of positive surgical margins in patients who underwent perineal or retropubic radical prostatectomy for clinically localized (stage T1, T2) prostate cancer. MATERIALS AND METHODS In this retrospective, nonrandomized study we reexamined the specimens of 94 consecutive patients who underwent radical perineal (48) or retropubic (46) prostatectomy for clinically localized prostate cancer (stage T1, T2) and with pathological stage pT2 (intracapsular), pT3A (established extracapsular extension without positive margins) or pT3B (extracapsular extension with positive margins) without lymph node involvement (N0). We assessed the presence or absence of extracapsular cancer with or without positive margins, incisions of the prostatic capsule exposing cancer (surgically induced positive margins) or benign glandular tissue. Patients were followed for 3 to 66 months (mean 25) using an ultrasensitive prostate specific antigen assay with a lower detection limit of less than 0.05 ng./ml. RESULTS The overall incidence of positive margins in cancer tissue was 56% in the perineal and 61% in the retropubic group, and biochemical failure-free survival was 67% each. However, surgically induced positive margins in patients with organ confined disease were more frequent in the perineal than retropubic group (43 versus 29%, p < 0.05) and associated with a 37% risk of biochemical failure (prostate specific antigen greater than 0.1 ng./ml.) at mean followup. In addition, capsular incisions exposing benign tissue were more frequent in the perineal than retropubic group (90 versus 37%, p < 0.05) irrespective of pathological stage. CONCLUSIONS Although overall positive margins and biochemical failure rates are similar or identical for the perineal and retropubic approaches for organ confined prostate cancer, the perineal approach is associated with a significantly higher risk of capsular incisions and surgically induced positive margins and, thus, a higher risk of biochemical failure.

A 970 Hounsfield units (HU) threshold of kidney stone density on non-contrast computed tomography (NCCT) improves patients' selection for extracorporeal shockwave lithotripsy (ESWL): evidence from a prospective study.

Study Type – Therapy (prospective cohort)

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.

Pectoral and femoral fasciae: common aspects and regional specializations

The aim of this study was to analyse the organization of the deep fascia of the pectoral region and of the thigh. Six unembalmed cadavers (four men, two women, age range 48–93 years old) were studied by dissection and by histological (HE, van Gieson and azan-Mallory) and immunohistochemical (anti S-100) stains; morphometric studies were also performed in order to evaluate the thickness of the deep fascia in the different regions. The pectoral fascia is a thin lamina (mean thickness ± SD: 297 ± 37 μm), adherent to the pectoralis major muscle via numerous intramuscular fibrous septa that detach from its inner surface. Many muscular fibres are inserted into both sides of the septa and into the fascia. The histological study demonstrates that the pectoral fascia is formed by a single layer of undulated collagen fibres, intermixed with many elastic fibres. In the thigh, the deep fascia (fascia lata) is independent from the underlying muscle, separated by the epimysium and a layer of loose connective tissue. The fascia lata presents a mean thickness of 944 μm (±102 μm) and it is formed by bundles of collagen fibres, arranged in two to three layers. In each layer, the fibres are parallel to each other, whereas the orientation of the fibres varies from one layer to the adjacent one. The van Gieson elastic fibres stain highlights the presence of elastic fibres only in the more external layer of the fascia lata. In the thigh the epimysium is easily recognizable under the deep fascia and presents a mean thickness of 48 μm. Both the fascia lata and pectoral fascia result innerved, no specific differences in density or type of innervations is highlighted. The deep fascia of the pectoral region is morphologically and functionally different from that of the thigh: the fascia lata is a relatively autonomous structure with respect to the underlying muscular plane, while the pectoralis fascia acts as an additional insertion for the pectoralis major muscle. Different portions of the pectoralis major muscle are activated according to the glenohumeral joint movements and, consequently, selective portions of the pectoral fascia are stretched, activating specific patterns of proprioceptors. So, the pectoralis muscle has to be considered together with its fascia, and so as a myofascial unit, acting as an integrated control motor system.

Prostatic Tissual Distribution of Alfuzosin in Patients with Benign Prostatic Hyperplasia Following Repeated Oral Administration

OBJECTIVES The blood and prostatic concentrations of alfuzosin were determined in patients with benign prostatic hyperplasia (BPH). METHODS 12 patients scheduled for BPH surgery were treated with alfuzosin 5 mg twice daily prior to surgery in an open trial. Seven doses were given over a 4-day period. Blood samples were drawn before the first and the last intake (day 3). On day 4 (surgery day), a blood and prostate tissue sample were taken simultaneously 12 hours after the last drug intake. RESULTS Mean trough blood levels were 6.0+/-4.6 ng/ml and 5.8+/-3.7 ng/ml on day 3 and day 4, respectively, indicating a stable alfuzosin concentration. The mean prostate concentration on day 4 was 12.3+/-5.6 ng/g. Alfuzosin prostate and blood concentrations at 12 hours post dosing on day 4 were significantly correlated (r=0.804, p=0.0016); the prostate-blood ratio was 2.4+/-0.7. CONCLUSIONS Oral administration of alfuzosin leads to a high diffusion of the drug into the prostate of BPH patients.

The Ankle Retinacula: Morphological Evidence of the Proprioceptive Role of the Fascial System

Study Design: Research report. Objectives: To evaluate the anatomical characteristics of the ankle retinacula and their relationship with the fasciae and muscles in healthy subjects and in patients with ankle sprain outcomes. Background: The role of the retinacula in proprioception has begun to emerge, but without clear anatomical bases or descriptions of their possible damage in patients with ankle sprain outcomes. Methods: Dissection, histological and immunohistochemical analysis of 27 legs. An in vivo radiological study by MRI was also performed on 7 healthy volunteers, 17 patients with outcomes of ankle sprain, and 3 amputated legs. Results: The retinacula are thickenings of the deep fascia presenting bone or muscular connections. They are formed of 2–3 layers of parallel collagen fibre bundles, densely packaged with a little loose connective tissue, without elastic fibres but many nervous fibres and corpuscles. By MRI, the retinacula appeared as low-signal-intensity bands with a mean thickness of 1 mm. In patients with outcomes of ankle sprain, MR findings were abnormal retinacula thickness, signal intensity, and full-thickness gap. Discussion: The retinacula are not static structures for joint stabilisation, like the ligaments, but a specialisation of the fascia for local spatial proprioception of the movements of foot and ankle. Their anatomical variations and accessory bundles may be viewed as morphological evidence of the integrative role of the fascial system in peripheral control of articular motility.

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.

Diagnostic Value of Ten Systematic TRUS-Guided Prostate Biopsies

Objective: To evaluate the improvement in the rate of detection of prostate cancer using an extensive protocol involving ten transrectal biopsies. Methods: A total of 162 patients submitted to transrectal ultrasound-guided biopsy for elevated prostate-specific antigen (PSA) and/or abnormality on digital rectal examination were studied consecutively and prospectively. Five biopsies were performed in each lobe: between the three standard biopsies on each side, two additional biopsy specimens were taken in the same plane and at the same 45° angle. Results: The complication rate with the ten-biopsy protocol was 1.85%. Prostate cancer was detected in 40.1% of the patients. In the overall series, the percentage of diagnostic improvement brought about by this ten-biopsy protocol was +3.1%. The percentage improvement was greatest (+4.9%) in patients with PSA ≤10 ng/ml. Conclusion: Increasing the number of biopsy cores without altering the angle of biopsy and/or the zone sampled does not lead to a significant improvement in the detection of prostate cancer.

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.