Wolfgang Dorschner

Evolution of endoscopic extraperitoneal radical prostatectomy (EERPE)—technical improvements and development of a nerve-sparing, potency-preserving approach

During the last decade, laparoscopy has become a standard technique in the armoury of the urologist due to constant technological advances and refinements. Laparoscopic radical prostatectomy (LRPE), although technically demanding and associated with a considerable learning curve, has become the surgical procedure of choice in selected and specialized urological centers around the globe for patients with clinically localized prostate cancer. However, a major drawback of LRPE is the transperitoneal route of access to the extraperitoneal prostate. The principal disadvantages of LRPE are potential intraperitoneal complications, such as bowel injury, ileus, intraperitoneal bleeding, intraperitoneal urinary leakage, intraperitoneal adhesion formation and concomitant small bowel obstruction. Endoscopic extraperitoneal radical prostatectomy (EERPE) is a further advancement of minimal invasive surgery as it overcomes the limitations of LRPE by the strictly extraperitoneal route of access combining the advantages of minimal invasive surgery with those of an extraperitoneal procedure. Based on our growing experience with this procedure, we have introduced several technical modifications, improvements and refinements including a nerve-sparing, potency-preserving approach (nEERPE) in an effort to further improve this minimally invasive procedure.

THE DISPUTE ABOUT THE EXTERNAL SPHINCTER AND THE UROGENITAL DIAPHRAGM

PURPOSE Basic scientific facts, such as anatomical structures, are rarely subjected to critical reappraisal. Nevertheless, several clinical phenomena exist which are inconsistent with the description of the anatomy of the so-called external sphincter muscle and urogenital diaphragm. MATERIALS AND METHODS We performed a global examination of the anatomy of the entire lower urinary tract in 50 male autopsy specimens. For comparison magnetic resonance imaging of the same regions was performed on 12 healthy patients. RESULTS Direct comparison of the results of both methods revealed the exact same topography of the bladder neck. The external sphincter or musculus sphincter urethrae is an independent morphological unit separated from the surrounding pelvic floor muscles by connective tissue. CONCLUSIONS The musculus transversus perinei profundus or deep transverse perineal muscle, which is believed to constitute the major element of the urogenital diaphragm, does not exist. There is histomorphological evidence that the external sphincter consists of a striated (musculus sphincter urethrae transversostriatus) and smooth muscle (musculus sphincter urethrae glaber) component.

Alterations in connexin expression in the bladder of patients with urge symptoms

To compare the formation of gap junctions between detrusor smooth muscle cells in situ and the distribution of connexin (Cx)40, Cx43 and Cx45 expressions in bladder biopsies from a control group (with bladder tumour) and from patients with urge symptoms, as smooth muscle cells of the human detrusor muscle communicate via gap junctions and express several connexin subtypes, alterations of which may be involved in the causes of lower urinary tract symptoms.

Structure and function of the bladder neck.

Introduction.- Materials and Methods.- Musculus Detrusor Vesicae.- The Musculature of the Trigonum Vesicae.- Diaphragma Urogenitale.- Musculus Sphincter Urethrae.- Musculus Dilatator Urethrae.- Musculus Ejaculatorius.- Changes of the Muscles of the Lower Uninary Tract with Age.- Three Dimensional Model of the Anatomy of the Lower Urinary Tract.- Fundamentals of the Neuroanatomy of the Lower Urinary Tract.- Discussion (Functional Interpretation of the Anatomical Findings).- Further Studies and New Approaches.- Terminologia Anatomica of the Lower Urinary Tract.- Summary.- References.- Subject Index.

A New Theory of Micturition and Urinary Continence Based on Histomorphological Studies

Results of a histomorphological study of serial sections carried out in frontal, transversal and sagittal directions in 65 bladder necks are presented. It is shown that the trigonal system of the urinary bladder consists of two anatomical structures: first, of a muscle originating from the muscle system of both ureters and converging to form within the bladder the interureteric ridge, the musculus interuretericus and of a second structure forming the actual trigonum vesicae. It is the musculus sphincter trigonalis or musculus sphincter vesicae. This muscle elliptically embraces the internal urethral orifice and is only formed by one muscle lamella. It does not as has often been described extend in any form to the urethra or to the surroundings. The so-called Bell muscle does not exist. During the reproductive years the lower part of the sphincter trigonalis is strongly pervaded with prostate tissue. This could enable the muscle to have a double function: a continence function in accordance with a consequent distinction between the urinary bladder and the urethra as urinary and sexual tract, and during ejaculation the muscle could prevent the retrograde ejaculation and on the other hand the contraction of the muscle could lead to the release of the prostate secretion.

Smooth muscle cells from human urinary bladder express connexin 43 in vivo and in vitro

Abstract. Smooth muscle cells (SMC) of the human urinary bladder are believed to be electrically coupled. However, it has not been successfully demonstrated the nature of the underlying cell-cell communication. Here, we used Western blot technique to demonstrate the gap junction protein connexin 43 (Cx 43) in human bladder musculature and in smooth muscle cell cultures. We found expression of Cx 43 in all samples of the detrusor (Mdv, n=6) and in five of six samples of the internal sphincter (Mv). Cx 43 expression was less in cell cultures, 60% showing Cx 43 expression. Iontophoretic application of the gap junction permeable fluorescent dye lucifer yellow revealed a mean of 2.6±2.2 (mean±SD, n=8) coupled cells in cultured smooth muscle cells. Our findings support the notion that Cx 43 is constitutively expressed in human bladder SMC in vivo. Thus, the function of the bladder is likely to be influenced by the organisation of smooth muscle cells into functional syncytia.

Hernia repair during endoscopic (laparoscopic) radical prostatectomy.

We retrospectively reviewed our experience in performing endoscopic extraperitoneal radical prostatectomy (EERPE) and totally extraperitoneal (TEP) hernia repair in one procedure to evaluate its feasibility and safety. Based on our experience of 70 laparoscopic radical prostatectomies, a total of 60 patients underwent EERPE. Eight of these had 10 hernias repaired with Prolene mesh. The median total operating time for EERPE was 165 minutes. Mesh placement required an additional 15 minutes for a unilateral hernia and 25 minutes for bilateral hernias. The conversion rate and the reoperation rate were 0%. The median duration of vesical catheterization was 8.3 days. One patient required a blood transfusion. The most common minor complications, occurring in eight patients, were edema and hematoma of the penis. No wound infection occurred. The only major complication was a deep venous thrombosis in one patient. No additional complications developed in the hernioplasty group. We conclude that the extraperitoneal approach for radical prostatectomy allows concomitant inguinal hernia repair with a low morbidity rate and within an acceptable operating time.

Anatomische Grundlagen der Harnkontinenz

ZusammenfassungDie morphologischen Grundlagen der Harnkontinenz werden anhaltend kontrovers diskutiert. Die große Widersprüchlichkeit der Literatur war der Grund für eine erneute Studie zur Morphologie des unteren Harntraktes. In Form von histologischen Serienschnitten erfolgte die vollständige Aufarbeitung der gesamten Blasenhalsregion von 50 männlichen und 15 weiblichen Verstorbenen aller Altersgruppen. Dabei gelang der Nachweis eines eigenständigen M. sphincter vesicae, der als einzige Struktur elliptisch den Blasenauslass umgreift. Muskellamellen des Detrusor sind an dessen Formung nicht beteiligt.Der M. sphincter urethrae hingegen umgreift hufeisenförmig die Harnröhre und besteht bei beiden Geschlechtern aus einem quergestreiften und einem glattmuskulären Teil (M. sphincter urethrae transversostriatus et glaber). Er existiert unabhängig von der umgebenden Beckenbodenmuskulatur. Ein sog. M. transversus perinei profundus als Hauptelement eines klassischen Diaphragma urogenitale existiert nicht. Alle histomorphologischen Befunde fanden Eingang in die Konstruktion eines digitalen 3D-Modells des unteren Harntraktes.AbstractThe morphological fundamentals of urinary continence are still subject to controversy. This was the reason for a renewed examination of the sphincter musculature of the lower urinary tract. This study included 50 male and 15 female autopsy specimens. The organs of the lower urinary tract including the neighboring organs had been removed in their entirety and histologically reprocessed en bloc as a complete series of sections.We were able to demonstrate that the internal sphincter or m. sphincter vesicae is represented as a circular, distinct structure which elliptically embraces the internal urethral orifice. Lamellas of the detrusor are not involved in the formation of the internal sphincter. In females and males, the external sphincter consists of a striated and a smooth muscular part (m. sphincter urethrae transversostriatus et glaber). In transverse sections, the muscle has a horseshoe shape. It is completely separated by connective tissue from the musculature of the pelvic floor. A deep transverse perineal muscle does not exist.The histological findings were used for the construction of a digital three-dimensional model of the anatomy of the lower urinary tract. Computer animations of the model with integrated original histologies were generated and stored as a computer video on a CD-ROM attached to this journal.

Detrusor smooth muscle cells of the guinea-pig are functionally coupled via gap junctions in situ and in cell culture

Abstract. Intercellular communication between smooth muscle cells is crucial for contractile behaviour in normal and pathologically altered urinary bladder. Since the study of coupling is difficult in situ, we established cell cultures of bladder smooth muscle cells to analyse coupling mechanisms. Microinjection of Lucifer yellow demonstrated syncytia composed of only a few to several dozen cells. Electron-microscopic examination of freeze-fracture specimens and ultrathin sections revealed that the dye-coupling was based on typical gap junction formation between the cultured smooth muscle cells. Furthermore, we were able to demonstrate gap junctions within the tissue fragments from which the primary cultures were grown. By Western blotting, we found connexin-43-positive protein bands both in native tissue probes from the guinea-pig urinary bladder and in smooth muscle cell cultures. Extracellular electrical stimulation of single cells evoked calcium transients, as visualized by fura-2 ratiofluorimetry. Calcium waves propagated throughout the syncytia with a declining amplitude, showing that the calcium signal was not regenerative. Therefore, the calcium signal was probably transmitted by a diffusible factor. These findings correlated well with the dye-coupling that we found between detrusor smooth muscle cells in situ. The use of smooth muscle cell cultures therefore seems to be a feasible approach for studying coupling behaviour in vitro.

Is the Male Dog Comparable to Human? A Histological Study of the Muscle Systems of the Lower Urinary Tract

Because of their superficial anatomical resemblance, the male dog seems to be suitable for studying the physiologic and pathological alterations of the bladder neck of human males. The present study was carried out to compare and contrast the muscular anatomy of the male dog lower urinary tract with that of humans. The complete lower urinary tract, including the surrounding organs (bulb of penis, prostate, rectum and musculature of the pelvic floor) were removed from adult and newborn male dogs and histologically processed using serial section technique. Based on our own histological investigations, three‐dimensional (3D)‐models of the anatomy of the lower urinary tract were constructed to depict the corresponding structures and the differences between the species. The results of this study confirm that the lower urinary tract of the male dog bears some anatomical resemblance (musculus detrusor vesicae, prostate, prostatic and membranous urethra) to man. As with human males, the two parts of the musculus sphincter urethrae (glaber and transversostriatus) are evident in the canine bladder neck. Nevertheless, considerable differences in formation of individual muscles should be noted. In male dogs, no separate anatomic entity can be identified as vesical or internal sphincter. The individual course of the ventral and lateral longitudinal musculature and of the circularly arranged smooth musculature of the urethra is different to that of humans. Differences in the anatomy of individual muscles of the bladder neck in the male dog and man suggest that physiological interpretations of urethral functions obtained in one species cannot be attributed without qualification to the other.