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Introduction: Distal femur fractures are a group of fractures that have been a topic of debate for the past decade, were traditionally treated mainly using conservative methods. However, with advancements in surgical techniques and implants, operative intervention has now become the preferred treatment approach. There are various methods for treating distal femur fractures and the present study compares the treatment of distal femoral fracture using distal femur nailing versus the use of locking plate. Aim: To compare the functional outcomes of stabilising distal femur fractures using locking compression plating versus retrograde nailing and to evaluate the merits and drawbacks of each procedure. Materials and Methods: A cross-sectional comparative study was conducted in the Department of Orthopaedics at Calcutta National Medical College and Hospital, Kolkata, West Bengal, India, over a one-year period from (January 2021 to January 2022. Total 46 patients with distal femur fractures were included, with six lost to follow-up. Two groups were divided in which total 20 patients underwent distal femoral nailing, while 20 were treated with distal femoral locking plates. Functional outcomes were assessed using the NEER Score, aiming for perfect restoration of the articular surface, stable fixation, full knee range of motion, and good functional results. Data were entered into a Microsoft Excel spreadsheet for statistical analysis using Statistical Packages for Social Sciences (SPSS) (version 27.0; SPSS Inc., Chicago, IL, USA). Numerical variables were summarised as mean and standard deviation, while categorical variables were presented as counts and percentages. A p-value of =0.05 was considered statistically significant. Results: The study population consisted of 70% males with a mean age of approximately 55 years. Road traffic accidents were the most common mode of injury. The mean time for radiological union in the nailing group was 14.05 weeks, significantly shorter than the 16 weeks in the plating group. The mean range of knee flexion was 111° in the nailing group and 114.5° in the plating group. The average NEER score was 84.10 for the plating group and 83.30 for the nailing group. There was no statistically significant difference in functional outcomes between the two groups. Conclusion: Both retrograde intramedullary nailing and the use of locking compression plates can be considered as suitable treatment options. Early weight-bearing can be initiated with retrograde nailing. No significant difference was observed in terms of outcome, fracture healing, or NEER score. The time taken for radiological union of fractures using both techniques was comparable. Proper operative planning, execution, and adherence to a strict rehabilitation protocol play crucial roles in the overall patient outcome. [ABSTRACT FROM AUTHOR]

Background: Simple and safe fingertip reconstruction methods involve the use of local neurovascular islands flaps that can preserve functional length and sensitivity, and reconstruction with skin of the same texture. However, techniques involving flaps have numerous drawbacks and do not satisfy all the requirements for fingertip reconstruction. A particular problem is the persistence of contracture deformity due to lack of full flap advancement. We present a new technique using uni-pedicled volar rotational advancement flap with large Z-plasty, and describe the results of long-term follow-up. Methods: From October 1993 to December 2009, 112 fingers of 98 patients were covered with uni-pedicled volar rotational advancement flap with large Z-plasty after sustaining various types of injuries or finger pulp avulsion. A longitudinal incision was made along the lateral border of the digit and a large neurovascular volar flap was elevated just above the pulleys and flexor tendon sheath. To release tension, a large Z-plasty was applied at the metacarpophalangeal joint or interphalangeal joint crease. The final patient outcomes were reviewed retrospectively. Results: All fingertip injuries were treated without flap necrosis. Partial wound dehiscence was observed in two patients and average static two-point discrimination was 5.2 mm. There were no postoperative contracture deformities, joint stiffness, paresthesia, or hypersensitivity. Most patients were left with acceptable scarring and were free of postoperative pain and cold intolerance during the long-term follow-up. Conclusions: Our novel technique provides durable, completely sensate, and well-vascularized coverage of the fingertip with minimal discomfort to patients. [ABSTRACT FROM AUTHOR]

The close proximity of arteries and veins is a well-known anatomical finding documented in the extremities of all vertebrates. However, the physiological consequences of this arrangement are rarely given proper consideration nor are they covered in the textbook list of mechanisms that aid blood flow. We hypothesized that arterial pressure pulsations can significantly increase blood flow in the adjacent valve-containing vein segments. To demonstrate the existence of this mechanism, 10- to 15-cm sections of the bovine forelimb neurovascular bundle were isolated. The proximal and distal ends of the median artery and adjacent veins were cannulated, their tributaries were tied off, and the dissected bundle was then inserted into an airtight enclosure to mimic in vivo encasement by surrounding muscle. Pulsatile pressure was subsequently applied to the arterial segment while recording venous flow. At pressure settings mimicking physiological scenarios, arterial pulsations caused a highly significant increase in venous return. The amplitude of this effect was dependent on the arterial pulsation rate, stroke volume, and pressure gradient across the vein segment. [ABSTRACT FROM AUTHOR]

Case: The case of an active 16-year-old adolescent girl who presented with rib malunion and 1 year of unremitting intercostal nerve pain after sustaining multiple rib fractures is presented. She underwent successful bony and soft-tissue decompression of her eighth and ninth intercostal nerves to relieve neurogenic symptoms. Conclusion: When conservative treatment fails, chronic intercostal nerve pain due to chest wall trauma may be effectively managed with surgical bony decompression of the offending intercostal bundle(s). Anatomic knowledge of the intercostal nerve and a critical history and physical examination were critical for accurate diagnosis and surgical decompression of the patient's intercostal nerve. [ABSTRACT FROM AUTHOR]

Purpose: Anatomical reconstruction of the calcaneofibular ligament (CFL) is a common technique to treat chronic lateral ankle instability. A bone tunnel is used to fix the graft in the calcaneus. The purpose of this study is to provide some recommendations about tunnel entrance and tunnel direction based on anatomical landmarks. Methods: The study consisted of two parts. The first part assessed the lateral tunnel entrance for location and safety. The second part addressed the tunnel direction and safety upon exiting the calcaneum on the medial side. In the first part, 29 specimens were used to locate the anatomical insertion of the CFL based on the intersection of two lines related to the fibular axis and specific landmarks on the lateral malleolus. In the second part, 22 specimens were dissected to determine the position of the neurovascular structures at risk during tunnel drilling. Therefore, a method based on four imaginary squares using external anatomical landmarks was developed. Results: For the tunnel entrance on the lateral side, the mean distance to the centre of the CFL footprint was 2.8 ± 3.0 mm (0–10.4 mm). The mean distance between both observers was 4.2 ± 3.2 mm (0–10.3 mm). The mean distance to the sural nerve was 1.4 ± 2 mm (0–5.8 mm). The mean distance to the peroneal tendons was 7.3 ± 3.1 mm (1.2–12.4 mm). For the tunnel exit on the medial side, the two anterior squares always contained the neurovascular bundle. A safe zone without important neurovascular structures was found and corresponded to the two posterior squares. Conclusion: Lateral landmarks enabled to locate the CFL footprint. Precautions should be taken to protect the nearby sural nerve. A safe zone on the medial side could be determined to guide safe tunnel direction. A calcaneal tunnel should be directed to the posterior inferior medial edge of the calcaneal tuberosity. [ABSTRACT FROM AUTHOR]

Background: Total mesorectal excision (TME) has decreased the local recurrence rate and improved the overall survival of rectal cancer patients. However, urinary dysfunction remains a clinical problem after rectal cancer surgery. The aim was to assess the risk factors for postoperative urinary dysfunction.Methods: This study was a single-center, retrospective analysis of 104 patients who underwent laparoscopic rectal surgery between November 2016 and October 2017. Postoperative urinary dysfunction was defined as the need for urinary catheter re-insertion or the presence of residual urine (≥ 150 mL) postoperatively.Results: Postoperative urinary dysfunction was seen in 18 patients (17%). Multivariate analysis showed that male sex (odds ratio 3.89, p = 0.034) and anterior wall tumor location (odds ratio = 4.07, p = 0.037) were the predictors of postoperative urinary dysfunction. Compared with patients without risk factors, those with the two risk factors needed longer hospital stays (16 days vs. 30 days, p = 0.0022).Conclusion: Male sex and anterior wall tumor location were the risk factors for urinary dysfunction after laparoscopic rectal surgery. [ABSTRACT FROM AUTHOR]

Objective: To perform a descriptive microscopic study of prostatectomy specimens from 19 patients which anatomically characterizes the distributions of periprostatic nerve qualities, and to visualize these using diffusion tensor imaging (DTI). Materials and Methods: Serial whole‐mounted sections were stained for cholinergic (neuronal nitric oxide synthase), adrenergic (tyrosine hydroxylase) and sensory (calcitonin gene‐related peptide) nerves. Extracapsular stained nerves were counted by prostate surface sector, and classified by diameter. Stain‐related relative density was calculated, and distribution patterns were evaluated. To better visualize the reported neuronal structures and independently confirm our findings, nerve concordance in five male volunteers was investigated using a 3‐Tesla magnetic resonance imaging‐DTI system. Results: At the base, cholinergic nerves were distributed from the anterolateral to posterior sectors, continuing posterolaterally (mid‐section) into the posterolateral‐posterior sector toward the apex. Adrenergic nerves were distributed across the anterolateral‐posterior sectors at the base, with the course narrowing to the posterolateral‐posterior sectors at the mid‐ and apical levels. Sensory fibres were found posterolaterally posteriorly at the base, continuing posterolaterally over the mid‐ and apical levels. Although it was not possible to determine the different nerve qualities, DTI confirmed histological findings from the base to the apex. Conclusions: Different types of nerve fibres were found to vary in distribution. When linked to possible functional aspects of the different nerve types, this morphological evidence may be of importance to further protect function after radical prostatectomy (RP). To our knowledge, this is the first time that DTI has confirmed reported histological findings in nerve‐sparing RPs. DTI could be an important tool with which to correlate nerves to tumour for better preoperative planning and to incorporate imaging into treatment. [ABSTRACT FROM AUTHOR]

Purpose: With the rapidly expanding anatomical and technical knowledge surrounding nervesparing radical prostatectomy (NSRP), anatomical and operative textbooks have failed to keep pace with the literature. A surgical skill laboratory (SSL) was designed to educate urology trainees on surgical anatomy and techniques for NSRP. The objective was to assess the validity of a SSL program. Methods: A low-fidelity, anatomically accurate prostate model with its appropriate fascial coverings and location of the neurovascular bundle was created. Participants were surveyed prior to a SSL workshop for their knowledge of NSRP focusing on clinical and anatomical considerations. An interactive 2-h tutorial and workshop was then undertaken outlining the clinical and anatomical nuances for NSRP, with participants then practising an intra and inter-fascial NSRP on the model. Participants were resurveyed immediately after the workshop and at 6 months. Results: Thirty participants completed the NSRP workshop. Significant differences (p < 0.0001) in anatomical and clinical knowledge were noted after the workshop with improvements for both junior and senior trainees. The knowledge was retained at 6 months following the workshop. Conclusions: A low-fidelity bench-top model is a feasible and reproducible technique for improving the understanding of periprostatic anatomy and the different surgical approaches for NSRP. The SSL is useful and knowledge gained appears to be retained by workshop participants. SSL workshops are a valid hands-on approach to teaching surgical skills and should remain an integral part of urology training. [ABSTRACT FROM AUTHOR]

Introduction: The Prostate Imaging Reporting and Data System (PI-RADS) was mainly developed for the purposes of prostate cancer (PCa) detection. However, its widespread use suggests that it may play a role in a preoperative workup prior to endoscopic radical prostatectomy (ERP). Aim: To evaluate the prognostic value of PI-RADS in predicting extraprostatic extension (EPE) and its influence on surgical planning of ERP. Material and methods: The analysis involved data of 154 consecutive prostate cancer patients, in whom multiparametric 3.0T magnetic resonance imaging (mpMRI) was performed before ERP. Standard descriptive assessment of mpMRI images was compared with the PI-RADS system with respect to prostate cancer staging and subsequent potential surgical template adjustment. Results: PI-RADS significantly outperformed the standard way of mpMRI reporting in staging (AUC = 0.615 vs. 0.552, p = 0.036) with PI-RADS 5 established as the best threshold. After reevaluation of imaging, the initial surgical plan was modified based on mpMRI in terms of feasibility and extent of neurovascular bundle preservation during ERP on 96 (31.2%) sides, while on the remaining 212 (68.8%) sides the templates were left unchanged. Decisions based on mpMRI were not associated with increased risk of a positive surgical margin (PSM). Conclusions: The PI-RADS outperforms the standard staging method using mpMRI and may assist the decision-making process regarding the extent of resection during ERP without increasing the risk of PSM. [ABSTRACT FROM AUTHOR]

Objective: To show the feasibility, oncological and functional outcomes of neurovascular bundle (NVB) preservation during salvage robot‐assisted radical prostatectomy (RARP). Patients and Methods: In the present institutional review board‐approved retrospective analysis, between January 2008 and March 2016, 80 patients underwent salvage RARP, performed by a single surgeon (V.P), because of local recurrence after primary treatment. These patients were categorized into two groups depending on the degree of nerve‐sparing (NS) performed: a good‐NS group (≥50% of NVB preservation) and a poor‐NS group (<50% of NVB preservation). A standard transperitoneal six‐port technique, using the DaVinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA), was performed, and either an anterograde or a retrograde approach was used for NVB preservation. Validated questionnaires were used preoperatively (Sexual Health Inventory for Men [SHIM] and American Urological Association scores). Potency after salvage RARP was defined as the ability to achieve a successful erection with penetration >50% of the time, while full continence after salvage RARPwas defined as 0 pads used. The Kaplan–Meier method was used for survival and predictive estimations, and regression models were used to identify the predictors of potency, continence and biochemical failure (BCF). Results: The potency rate at 12 months was higher in the good‐NS group (25.6% vs 4.3%; P = 0.036) regardless of previous SHIM score, and good NS tended to be predictive of potency after salvage RARP (P = 0.065). The full continence rate at 12 months and BCF rate were similar in the two groups, and non‐radiation primary treatment was the only predictor of continence at 12 months after salvage RARP (P = 0.033). Conclusions: Our data support the feasibility and safety of NVB preservation for salvage RARP conducted in select patients in a high‐volume institution and the subsequent better recovery of adequate erections for intercourse. [ABSTRACT FROM AUTHOR]

Introduction: We aimed to evaluate the diagnostic performance of 3.0-T multiparametric magnetic resonance imaging (mpMRI) in preoperative staging of prostate cancer (PCa) and its influence on the extent of resection during endoscopic radical prostatectomy (ERP) among cancer risk groups.Material and Methods: The data of 154 patients with PCa in whom mpMRI was performed prior to ERP between 2011 and 2015 were included. The initial decision whether to perform neurovascular bundle (NVB) sparing surgery was based on EAU guidelines. mpMRI images were reevaluated prior to prostatectomy to modify the surgical template. Imaging was compared with pathological reports to investigate the diagnostic performance of mpMRI.Results: The surgical template was modified in 69 (44.8%) patients after reevaluation of mpMRI. More preserving NVB sparing was attempted in 17 (11.0%) men, in whom NVB would have been resected if mpMRI had not been available. More aggressive NVB resection was performed in 52 (33.8%) men, in whom innervation would have been spared if basing solely based on guidelines. Among all PCa risk groups mpMRI had an impact on the surgical template with more aggressive surgery in 63.0% and 33.3% of men in the low- and intermediate-risk group, respectively, and more preserving in 21.4% of the high-risk patients. The change in extent of resection was not correlated with a higher risk of positive surgical margins (p = 0.196).Conclusions: Preoperative mpMRI exerts a significant impact on decision making concerning the extent of resection during ERP irrespective of the PCa risk group. [ABSTRACT FROM AUTHOR]

A preoperative computed tomography scan is useful to determine neurovascular exit points from orbit to supraorbital region. Determining the structure of exiting points (absence or presence, if present, being in form of foramen or notch) is important to plan the surgical approach. The aim of the study was to provide the radiological data by multi-detector computed tomography for estimating exiting points of the neurovascular bundles of the supraorbital region whether through foramen or notch in living subjects related to side (right/left), sex and age. Computed tomography examinations of 214 (102 male and 112 female) adult patients, aged average 44.2 ± 14 years, were evaluated, retrospectively. Presence or absence, number and nature (foramen/notch) of exiting points of neurovascular bundles were noted in each side regarding sex and age groups. The distance of foramen/notch to the midline of the face was recorded. Single notch was seen on the right in 123 and in 134 on the left, single foramen was seen in 62 on the right and in 56 on the left side and double foramen was seen in 13 on the right and in 6 on the left. The absence was seen in 16 on the right and 18 on the left side. No significant difference was seen on frequency compared between the sexes and age groups. Foramen was seen in 58 sides unilaterally and in 39 sides bilaterally. Notch was unilateral in 75 sides and bilateral in 95 sides. It was shown that males had a wider distance between right side foramen and left side notch to midline. Age groups did not show a significant difference in terms of side. Absence and foramen presence made up about 30-40 % of cases. Notch was the most common form. Foramen/notch presence was statistically unaffected by the sex and age factors. In terms of surgery, preoperative assessment of orbital exit points with computed tomography is essential. [ABSTRACT FROM AUTHOR]

Muscle spindles are skeletal muscle sensory organs involved in the sensation of position and movement of the body. We have explored the capability of phase contrast computed tomography to visualise muscle spindles in murine skeletal muscle. In particular, we have validated the visualisation of nerve fibres through phase contrast computed tomography using light microscopy on stained histological sections. We further present the first three-dimensional visualisation of muscle spindles in mouse soleus skeletal muscle in conjunction with the neurovascular bundle associated with it. [ABSTRACT FROM AUTHOR]

Context In 2010, we published a review summarising the available literature on surgical anatomy of the prostate and adjacent structures involved in cancer control and the functional outcome of prostatectomy. Objective To provide an update based on new literature to help the surgeon improve oncologic and surgical outcomes of radical prostatectomy (RP). Evidence acquisition We searched the PubMed database using the keywords radical prostatectomy, anatomy, neurovascular bundle, nerve, fascia, pelvis, sphincter, urethra, urinary continence, and erectile function. Relevant articles and textbook chapters published since the last review were critically reviewed, analysed, and summarised. Moreover, we integrated aspects that were not addressed in the last review into this update. Evidence synthesis We found new evidence for several topics. Up to 40% of the cross-sectional surface area of the urethral sphincter tissue is laterally overlapped by the dorsal vascular complex and might be injured during en bloc ligation. Denonvilliers fascia is fused with the base of the prostate in a horizontal fashion dorsally/caudally of the seminal vesicles, requiring sharp detachment when preserved. During extended pelvic lymph node dissection, the erectile nerves are at risk in the presacral and internal iliac area. Dissection planes for nerve sparing can be graded according to the amount of tissue left on the prostate as a safety margin against positive surgical margins. Vascular structures can serve as landmarks. The urethral sphincter and its length after RP are influenced by the shape of the apex. Taking this shape into account allows preservation of additional sphincter length with improved postoperative continence. Conclusions This update provides additional, detailed information about the surgical anatomy of the prostate and adjacent tissues involved in RP. This anatomy remains complex and widely variable. These details facilitate surgical orientation and dissection during RP and ideally should translate into improved outcomes. Patient summary Based on recent anatomic findings regarding the prostate and its surrounding tissue, the urologist can individualise the dissection during RP according to cancer and patient characteristics to improve oncologic and functional results at the same time. [ABSTRACT FROM AUTHOR]

Introduction: In the pelvis, the rectogenital septum (RGS) separates the urogenital compartment from the digestive compartment. In men, it corresponds to Denonvilliers' rectoprostatic fascia or rectovesical septum (RVS). Its purpose-and, indeed, its existence-are controversial in women. The purpose of this review was to update knowledge about the RGS in women and, in particular, to clarify its relationship to pelvic nerves in order to deduce practical consequences of pelvic surgery and compare it to the RVS in men. Methods: A review of the anatomical and surgical literature was undertaken. Evidence for embryological origin, composition, and surgical importance of the RGS in women and men is suggested. Results: This manuscript presents evidence of the existence of the RGS in both women (rectovaginal septum, RVaS) and men (rectovesical septum, RVS). It originates from the genital structures and extends from the rectogenital pouch to the perineal body. It is composed of connective tissue associated with bundles of smooth muscle cells and has lateral expansions in close contact with neurovascular bundles originating from the inferior hypogastric plexus. During pelvic surgery for carcinoma, preservation of nerve fibers of erectile bodies is necessary if possible. The RGS is thus an important surgical landmark during urogenital sinus surgery, prolapse surgery, and proctectomy in women as well as during proctectomy and prostatectomy in men. Conclusions: The RGS is present in women as well as in men, with great similarities between the two sexes. It represents an important surgical landmark during pelvic nerve-sparing surgery. [ABSTRACT FROM AUTHOR]

Introduction: The main objective of gender reassignment surgery (GRS) in male to female (MtF) transgender people is to create a functional and aesthetic vagino-clitoral complex. Here we report on a modified preparation of the neurovascular bundle (NVB). Materials and Methods: Between May 2011 and September 2014, 96 consecutive MtF transgender patients underwent GRS at our department. Sensitivity of the neoclitoris was assessed afterwards. Results were compared with a historical cohort from our department (2004- 2010, n = 119) in which perioperative treatment was the same except for the preparation of the NVB. Results: In 92 (95.8%) and 78 (81.2%) patients information on neoclitoral sensitivity was available and in 79 (82.3%) and 69 (71.9%) sensitivity was tested semiquantatively after first and second stage procedure respectively. A semiquantitative grading system correlated significantly with intermedium-term ability to achieve orgasms (p = 0.036). The modification led to a reduction in operation time by an average of 61 min. With the modified technique, we had a higher rate of postoperative local hematoma but with no need for further intervention. Conclusions: Preparation is safe and time saving both preserving the neoclitoral sensitivity and promoting a preferably feminine aspect of the mons pubis. Semiquantitative testing of sensitivity correlates with the intermedium-term capability of achieving orgasms. [ABSTRACT FROM AUTHOR]

Purpose: Postoperative sexual and urinary dysfunction may occur after rectal cancer surgery involving the pelvis, but this problem cannot be solved. The aim of this study was to examine the nerve morphology of the neurovascular bundle in cadavers to determine possible causes of nerve damage during surgery. Methods: Twenty-two formalin-fixed cadavers were used in the study. The cadavers were donated to the Tokyo Medical University. The study comprised histological evaluation of paraffin-embedded bilateral neurovascular bundle specimens from the cadavers. Four slides of 3-cm thick were made every 1 cm in a plane perpendicular to the rectum towards the pelvic floor from the peritoneal reflection in bilateral neurovascular bundles in 22 cadavers. The number of nerves, the mean nerve area, and the mean nerve diameter were measured in each slide. Results: The results were categorized into cases with high (group H) and low (group L) positions of the pelvis 1 cm above and 2 cm below the peritoneal reflection, respectively. There was no significant difference in the number of nerves between these groups. The nerve area and nerve diameter were significantly smaller in group L, and these characteristics were more marked in males. Conclusions: Our results show that the nerves of the neurovascular bundle became smaller in the deep pelvis. This may cause these nerves to be more susceptible to injury, resulting in nerve damage in the deep pelvis that leads to postoperative dysfunction. Particularly, this type of nerve damage may be a cause of postoperative sexual dysfunction in males. [ABSTRACT FROM AUTHOR]

This study applied a simulation method to map the temperature distribution based on magnetic resonance imaging (MRI) of individual patients, and investigated the influence of different pelvic tissue types as well as the choice of thermal property parameters on the efficiency of endorectal cooling balloon (ECB). MR images of four subjects with different prostate sizes and pelvic tissue compositions, including fatty tissue and venous plexus, were analyzed. The MR images acquired using endorectal coil provided a realistic geometry of deformed prostate that resembled the anatomy in the presence of ECB. A single slice with the largest two-dimensional (2D) cross-sectional area of the prostate gland was selected for analysis. The rectal wall, prostate gland, peri-rectal fatty tissue, peri-prostatic fatty tissue, peri-prostatic venous plexus, and urinary bladder were manually segmented. Pennes’ bioheat thermal model was used to simulate the temperature distribution dynamics, by using an in-house finite element mesh based solver written in MATLAB. The results showed that prostate size and periprostatic venous plexus were two major factors affecting ECB cooling efficiency. For cases with negligible amount of venous plexus and small prostate, the average temperature in the prostate and neurovascular bundles could be cooled down to 25 °C within 30 min. For cases with abundant venous plexus and large prostate, the temperature could not reach 25 °C at the end of 3 h cooling. Large prostate made the cooling difficult to propagate through. The impact of fatty tissue on cooling effect was small. The filling of bladder with warm urine during the ECB cooling procedure did not affect the temperature in the prostate or NVB. In addition to the 2D simulation, in one case a 3D pelvic model was constructed for volumetric simulation. It was found that the 2D slice with the largest cross-sectional area of prostate had the most abundant venous plexus, and was the most difficult slice to cool, thus it may provide a conservative prediction of the cooling effect. This feasibility study demonstrated that the simulation tool could potentially be used for adjusting the setting of ECB for individual patients during hypothermic radical prostatectomy. Further studies using MR thermometry are required to validate the in silico results obtained using simulation. [ABSTRACT FROM AUTHOR]

Introduction: Indocyanine green (ICG) is a fluorescent molecule that provokes detectable photon emission. The use of ICG with near-infrared (NIR) imaging system (Akorn, Lake Forest, IL) has been described during robotic partial nephrectomy (RAPN) as an adjunctive means of identifying renal artery and parenchymal perfusion. We propose the use of the ICG with NIR fluorescence during laparoscopic robot-assisted radical prostatectomy (RARP), to identify the benchmark artery improving the preservation of neurovascular bundle and to improve the visualization of the vascularization and then the hemostasis. Methods: From April 2015 to February 2016, 62 patients underwent to RARP in our Urology Unit. In 26 consecutive patients, in the attempt to have a better visualization of neurovascular bundles, we used to inject ICG during the procedure. We evaluated the percentage of identification of neurovascular bundles using NIR fluorescence. Then, we evaluated complications related to injection of ICG and operative time differences between RARP with and without ICG injection performed by the same surgeons. Results: We identified prostatic arteries and neurovascular bundles using NIR fluorescence technology in all patients (100%). There was not any increase in the operative time compared with RARP without ICG injection performed by the same surgeons. Complications related to injection of ICG did not occurred. Conclusions: In our experience, even if on a limited number of patients, the application of ICG with NIR fluorescence during RARP is helpful to identify the benchmark artery of neurovascular bundle. [ABSTRACT FROM AUTHOR]

Background Many elderly or impotent men with prostate cancer may not receive a bundle-preserving radical prostatectomy as a result of uncertainty regarding the effect on urinary incontinence. Objective We searched for predictors of urinary incontinence 1 yr after surgery among surgical steps during radical prostatectomy. Design, setting, and participants More than 100 surgeons in 14 centers prospectively collected data on surgical steps during an open or robot-assisted laparoscopic radical prostatectomy. At 1 yr after surgery, a neutral third-party secretariat collected patient-reported information on urinary incontinence. After excluding men with preoperative urinary incontinence or postoperative irradiation, data were available for 3379 men. Intervention Surgical steps during radical prostatectomy, including dissection plane as a measure of the degree of preservation of the two neurovascular bundles. Outcome measurements and statistical analysis Urinary incontinence 1 yr after surgery was measured as patient-reported use of pads. In different categories of surgical steps, we calculated the percentage of men changing pads “about once per 24 h” or more often. Relative risks were calculated as percentage ratios between categories. Results and limitations A strong association was found between the degree of bundle preservation and urinary incontinence 1 yr after surgery. We set the highest degree of bundle preservation (bilateral intrafascial dissection) as the reference category (relative risk = 1.0). For the men in the remaining six groups, ordered according to the degree of preservation, we obtained the following relative risks (95% confidence interval [CI]): 1.07 (0.63–1.83), 1.19 (0.77–1.85), 1.56 (0.99–2.45), 1.78 (1.13–2.81), 2.27 (1.45–3.53), and 2.37 (1.52–3.69). In the latter group, no preservation of any of the bundles was performed. The pattern was similar for preoperatively impotent men and for elderly men. Limitations of this analysis include the fact that noise influences the relative risks, due to variations between surgeons in the use of undocumented surgical steps of the procedure, variations in surgical experience and in how the surgical steps are reported, as well as variations in the metrics of patient-reported use of pads. Conclusions We found that the degree of preservation of the two neurovascular bundles during radical prostatectomy predicts the rate of urinary incontinence 1 yr after the operation. According to our findings, preservation of both neurovascular bundles to avoid urinary incontinence is also meaningful for elderly and impotent men. Patient summary We studied the degree of preservation of the two neurovascular bundles during radical prostatectomy and found that the risk of incontinence decreases if the surgeon preserves two bundles instead of one, and if the surgeon preserves some part of a bundle rather than not doing so. [ABSTRACT FROM AUTHOR]

The absence of effective preventive dental programme leads to a multiplication of patients with single or multi-tooth edentations. Clinical and technical difficulties for prosthetic treatments appear in totally edentulous patients due to sharp bone atrophy. Depending on the mandibular reorganisation due to age and edentation, mandibular canal presents calibre (it diminishes) and position changes (it approaches to the alveolar mandibular ridge) modifications. Prosthetic treatments with dental implants imply a series of local and regional contraindications. In the present article, we studied a number of 32 computerised topographies (CT), on which we could establish the cranio-caudal and vestibulo-oral position of the mandibular canal. The CT also presents the relation of the mental foramen with the edentulous ridge. The relation of the mandibular canal with the alveolar ridge presents a very important aspect for establishing the treatment plan for the patient. The clinical safe-zone must be established regarding the topography of the mandibular canal, in such way that neither the osteotomy, nor dental implant placement will harm in any way the integrity of the contents of the mandibular canal. [ABSTRACT FROM AUTHOR]

The absence of effective preventive dental programme leads to a multiplication of patients with single or multi-tooth edentations. Clinical and technical difficulties for prosthetic treatments appear in totally edentulous patients due to sharp bone atrophy. Depending on the mandibular reorganisation due to age and edentation, mandibular canal presents calibre (it diminishes) and position changes (it approaches to the alveolar mandibular ridge) modifications. Prosthetic treatments with dental implants imply a series of local and regional contraindications. In the present article, we studied a number of 32 computerised topographies (CT), on which we could establish the cranio-caudal and vestibulo-oral position of the mandibular canal. The CT also presents the relation of the mental foramen with the edentulous ridge. The relation of the mandibular canal with the alveolar ridge presents a very important aspect for establishing the treatment plan for the patient. The clinical safe-zone must be established regarding the topography of the mandibular canal, in such way that neither the osteotomy, nor dental implant placement will harm in any way the integrity of the contents of the mandibular canal. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the accuracy of presurgical endorectal MRI (eMRI) for local staging before radical prostatectomy (RP) and its influence on neurovascular bundle (NVB) resection during radical prostatectomy. Patients and methods: A total of 385 patients with histologically proven prostate cancer (PCa) have been included in this retrospective study between 2004 and 2008. All patients underwent preoperative eMRI at 1.5 T before open RP. Staging results by eMRI were compared with the histopathological findings. The presence of positive surgical margins and extent of nerve-sparing procedure were evaluated. Subgroup analysis of low-risk group and intermediate to high-risk group based on D'Amico criteria was conducted. Results: In 294 (76.4%) patients, pathological stage was correctly predicted, 69 patients (17.9%) were understaged and 22 (5.7%) overstaged. Overall sensitivity, specificity, negative and positive predictive value for predicting extracapsular extension (ECE) were 41.5, 91.8, 78.0 and 69.0%, respectively. One hundred and fifty-two (48.4%) of the patients classified as stage cT2 by eMRI underwent bilateral NVB sparing, whereas 14 (19.7%) patients with reported ECE underwent bilateral NVB sparing ( P < 0.01). Overall positive surgical margin rate was 14.8%. Sensitivity of predicting ECE and positive predictive value were lower in the low-risk group than in the intermediate and high-risk group. Conclusions: eMRI is effective in predicting extracapsular extension in an intermediate to high-risk group. Preoperative eMRI in patients with low-risk criteria is not recommended as a routine assessment modality. eMRI findings did appear to influence surgical strategy as patients with imaging findings suggesting >cT2 disease were less likely to undergo NVB sparing. [ABSTRACT FROM AUTHOR]

Objective To propose a method to assess and report the amount of neurovascular tissue present in radical prostatectomy ( RP) specimens., Patients and Methods The data of 133 consecutive patients who underwent robot-assisted RP by a single surgeon ( V.R. P.) were prospectively collected., Degree of nerve sparing ( NS) was graded intraoperatively by the surgeon independently at either side as complete, partial or none., A pathologist who was 'blinded' to the surgeon's classification measured the following parameters at the posterolateral aspect of the apex, base and mid prostate at either side of the RP specimen: length, width and area of neural tissue, number of nerves per high-power field and number of total slides containing neural tissue., Measurements were correlated to the surgeon's intraoperative perception., Results All measurements correlated significantly with surgeon's intent of NS at all locations ( P = 0.001)., Among them, the cross-sectional area had the highest correlation coefficient (-0.550 at apex, -0.604 at mid prostate and -0.606 at the base)., Conclusions The cross-sectional area of nerve tissue showed the highest correlation with surgeon's intent of NS at all locations., Having a standardised method of assessing and reporting residual nerve tissue allows the surgeon to objectively evaluate the quality of nerve preservation and to compare the progress of his NS technique over time. [ABSTRACT FROM AUTHOR]

Aim: To evaluate whether nerve-sparing radical prostatectomy (NSRP) results in a residual tumor in the remaining neurovascular bundle (NVB). Materials and methods: A total of 88 patients underwent bilateral NSRP. The ipsilateral NVB was excised uni-/bilaterally on the tumor side, separately. Factors affecting NVB involvement were evaluated. Results: The mean patient age and preoperative serum prostate specific antigen (PSA) were 63.8 ± 6.2 years (49-76) and 12.9 ± 9.4 ng/mL (2.4-45.5), respectively. Digital rectal examination (DRE) suggested nodules in 34 patients (38.6%). Uni- and bilateral NVB resections were performed on 40 (45.5%) and 48 patients (54.5%), respectively, according to transrectal ultrasound-guided prostate biopsy (TRUS-Bx) pathology findings. NVB dissection was performed easily in all patients. The only factors correlated with tumor presence in the remaining NVB were a positive DRE finding (85.7% vs. 34.6%, P = 0.012), final pathology Gleason score (P = 0.016), capsular penetration/extracapsular extension (P = 0.001), and seminal vesicle invasion (P = 0.002). NVB involvement was detected in only 7 (8%) patients (6 had bilateral NVB resections), and the mean PSA was 19 ± 14.3 ng/mL in this group. The number of biopsy cores ranged between 6 and 27. In 15 patients, prostate cancer was diagnosed on repeat biopsies, and none had NVB invasion on pathology. Conclusion: NVBs seem to have been excised unnecessarily on the tumor side (81 out of 88 patients). No preoperative parameter other than DRE status was correlated with NVB involvement. Further criteria should be evaluated in performing NSRP. [ABSTRACT FROM AUTHOR]

Purpose: To study microscopic patterns of remaining peripheral nerves (PN) after nerve-sparing (NS) radical prostatectomy (RP) and possible consequences for nerve preparation. Methods: Specimens from 27 patients (7 = non-NSRP, 20 = unilateral NS) were examined. Sections were investigated for PN content by immunoassaying. 120 whole-mounted slides were divided into four sectors, and extracapsular nerves were counted; the mean posterior/anterior ratio was calculated. Calculated ratios were correlated with the respective volumes of prostatic tissue (PV). After dividing the patient cohort into two subgroups, shared by the median value of the posterior/anterior nerve ratios, the absolute PN contents on the anterior surface of the NS sides were compared. Results: Anatomical posterior nerve percentage in non-NS aspects ranged from 0.0-100.0 to 26.7-94.6% with a mean of 66.60 ± 25.4% and 68.83 ± 16.0% (>/<200 μm, respectively). Individual ratios from two nerve categories showed significant correlation ( P < 0.008). Mean posterior ratios were 83.04/79.68 and 39.21/56.00, respectively. After unilateral NS, 3.17-fold (2.25 vs. 0.71 nerves, P = 0.05) and 2.26-fold (21.54 vs. 9.53, P = 0.08) nerve fibers were resected in the anterior area in comparison with type A. After unilateral NS, the variation impact on the anterior nerve content of the NS side could be demonstrated. Conclusions: The amounts of nerves localized on the anterior prostate after RP vary interindividually. Saving only a minor part of the anterior areas may have an impact on the quantity of excised nerves adjacent to the specimen and impair postoperative functional results. Especially for those patients without a major posterolateral bundle distribution, surgeons should adapt the procedure and start nerve preservation more anteriorly to maximize the probability of satisfactory postoperative functional results. [ABSTRACT FROM AUTHOR]

The uterine myoma pseudocapsule is a neurovascular bundle surrounding fibroid, containing neuropeptides, probably involved in uterine scar healing. We studied neurotensin (NT), neuropeptide tyrosine (NPY), and protein gene product 9.5 (PGP 9.5) nerve fibres in the pseudocapsule neurovascular bundle of intramural uterine fibroids on 67 no pregnant women by intracapsular myomectomy sparing the neurovascular bundle, sampling full thickness specimens of the pseudocapsule of uterine fibroids (PUF) and normal myometrium (NM) obtained from the fundus uteri (FU) and the uterine body (UB). The samples were sent for histological and immunofluorescent analyses and compared by morphometrical quantification. The Conventional Unit (C.U.) difference of NT, NPY, and PGP 9.5 nerve fibres was statistically analyzed. Our results showed that NT, NPY, and PGP 9.5 neurofibers are almost equally present in PUF as in NM of a no pregnant uterus. As all of these neuropeptides are present in the uterine muscle and can affect muscle contractility, uterine peristalsis and muscular healing. A myomectomy respecting the pseudocapsule neurofibers should facilitate smooth muscle scarring and promote restoration of normal uterine peristalsis with a possible positive influence on fertility. [ABSTRACT FROM AUTHOR]

The uterine myoma pseudocapsule is a neurovascular bundle surrounding fibroid, containing neuropeptides, probably involved in uterine scar healing. We studied neurotensin (NT), neuropeptide tyrosine (NPY), and protein gene product 9.5 (PGP 9.5) nerve fibres in the pseudocapsule neurovascular bundle of intramural uterine fibroids on 67 no pregnant women by intracapsular myomectomy sparing the neurovascular bundle, sampling full thickness specimens of the pseudocapsule of uterine fibroids (PUF) and normal myometrium (NM) obtained from the fundus uteri (FU) and the uterine body (UB). The samples were sent for histological and immunofluorescent analyses and compared by morphometrical quantification. The Conventional Unit (C.U.) difference of NT, NPY, and PGP 9.5 nerve fibres was statistically analyzed. Our results showed that NT, NPY, and PGP 9.5 neurofibers are almost equally present in PUF as in NM of a no pregnant uterus. As all of these neuropeptides are present in the uterine muscle and can affect muscle contractility, uterine peristalsis and muscular healing. A myomectomy respecting the pseudocapsule neurofibers should facilitate smooth muscle scarring and promote restoration of normal uterine peristalsis with a possible positive influence on fertility. [ABSTRACT FROM AUTHOR]

STUDY QUESTION Can uterine scar healing after laparoscopic intracapsular myomectomy (LIM) be adequately monitored by traditional two-dimensional (2D) ultrasound (US) and Doppler velocimetry? SUMMARY ANSWER The myometrial area of the scar after LIM can be followed by 2D US and Doppler velocimetry. WHAT IS KNOWN ALREADY Apart from post-surgical adhesions, the main concern linked to laparoscopic myomectomy is the quality of healing of the myometrial incision: it has been suggested that US could be useful for assessing uterine scars after myomectomy. However, no diagnostic method has yet been widely accepted to assess the healing process. STUDY DESIGN, SIZE, DURATION A cohort prospective study (level of evidence II-2), run in University-affiliated hospitals: 149 women with symptomatic uterine fibroids (UFs) underwent LIM, between January 2007 and October 2011. During follow up 13 patients withdrew from the study. PARTICIPANTS/MATERIALS, SETTING, METHODS After LIM, all patients were followed by traditional 2D US scanning and Doppler velocimetry on Days: 0, 1, 7, 30 and 45. Authors evaluated: number, size and location of UFs, scar diameter and Doppler velocimetry and resistance index (RI) of the uterine arteries, at their ascending branch. MAIN RESULTS AND THE ROLE OF CHANCE The uterine examination showed a significant (P < 0.05) progressive reduction of uterine scar area from 78% of the previous UF location on the first day, to 19% on 30th day, and <4% on the 45th day. There was no correlation with the size of the fibroid or the relative reduction in the size of the scar, on both Days 1 and 45. There was a significant (P < 0.05) increase in the RI of the ipsilateral uterine arteries from 0.65 on the first post-operative day to 0.83 after 7 days followed by a decrease to 0.71 on the 30th and 0.61 on the 45th post-operative day. LIMITATIONS, REASONS FOR CAUTION This is a cohort investigation on a limited number of patients and it does not surgically compare LIM and ‘classic’ myomectomy in the scar US follow up. WIDER IMPLICATIONS OF THE FINDINGS LIM avoided intraoperative bleeding and excessive tissue damage, as post-operative US follow up showed, with just two intra-myometrial hematomas (1.5%). The 2D US and Doppler velocimetry, a non-invasive safe method to check the myometrium after LIM, can detect post-operative hematoma and disechogenic, heterogeneous or ill-defined scar area, all unfavorable signs for myometrial scarring. Moreover, Doppler transvaginal monitoring, evaluating the pulsatility index (PI) and RI of the uterine arteries at their ascending branch, could identify patients with altered PI and RI parameters, possible markers of impaired wound healing. STUDY FUNDING/COMPETING INTEREST(S) None. [ABSTRACT FROM AUTHOR]

In the past few decades, a number of studies have reported that accessory foramina are located on the internal aspect of the mandible, indicating their potential importance for effective and successful clinical procedures. The aim of this study is to evaluate adult, infantile, and fetal human mandibles for occurrence of accessory foramina. To our knowledge, this is the first time that an attempt has been made to examine their particular co-location using a systematic approach and perspective. A total of 397 human mandibles, including 299 adult, 18 infantile, and 80 fetal, were investigated macroscopically for the frequency, position, and diameter of accessory foramina. In 96 % of investigated adult mandibles, at least one accessory foramen was found. Foramina were located either superior or inferior to the genial tubercle, as well as lateral to the tubercle. Bearing in mind their usual location, four different types of coexistence of foramina were distinguished. Accessory foramina were also present in similar locations in infantile and fetal mandibles. Accessory mandibular foramina are constant structures of human mandible. Their frequency, size, and location vary depending on the type of the foramen. Observations on children and fetal mandibles showed no significant differences in evaluation of accessory foramina, with the exception of lower occurrence in this group of subjects. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To allow a morphological evaluation of pseudocapsule vasculature of uterine leiomyomas (ULs). Design: Preliminary prospective study. Setting: University-affiliated hospitals. Patients: Ten women with symptomatic myomas warranting laparotomic hysterectomies. Methods: Pseudocapsules of ULs were isolated from the surrounding myometrium, for a digital reconstruction of pseudocapsule vessels and analysis by three-dimensional structure applying the Allen-Cahn mathematical model. The images were converted in a matrix and an appropriate created software elaborated the images. The “nonlocal” Allen-Cahn mathematical model was applied to reduce the image noise and to regulate vessel outlines obtaining a “clean” image. Main outcome measures: The geometrical characteristics and morphology of vessel pseudocapsule network of ULs. Results: The disarray in vascular architecture was evident from the absence of vessel parallelism and variable intervascular distances. An abnormal vascular branching of pseudocapsule was indicated by the different density of vessels per space and some vascular walls without interruption indicated vessel tortuosity. There were vascular spaces, which did not communicate with other vessels (“cul-de-sac” vessels). Conclusions: Pseudocapsule vasculature showed increase of tortuosity, disarray, abnormal branching and the presence of “cul-de-sac” vessels. Three-dimensional reconstruction of leiomyoma pseudocapsule vasculature network, despite the benign nature of ULs, showed geometrical characteristics of malignant neoplasm vessels. [Copyright &y& Elsevier]

OBJECTIVE: • To characterize the immunohistochemical nature of sympathetic and parasympathetic nerves surrounding the prostate. MATERIALS AND METHODS: • Using serial sectioning, four male cadavers were investigated using a combination of haematoxylin and eosin staining and immunohistochemistry. Both the sympathetic and parasympathetic contributions to the autonomic nervous system in the periprostatic region were assessed by staining analysis, the number of nerves fibres was quantified, their position relative to the prostate recorded and their function inferred. • The fascial architecture of the neurovascular bundle (NVB) was also quantified. RESULTS: • Approximately 27.8% of all nerve fibres identified were found on the anterior half of the prostate, above the 3 to 9 o’clock level. At the base, mid, and apex of rostate, parasympathetic fibres accounted for 4%, 5% and 6.8% of the nerves located on the anterolateral aspect of the prostate, respectively. • Sympathetic nerves found above the 3 to 9 o’clock level represented ª 15% of the total number of nerves. • When staining the periprostatic fascia, the classical NVB exhibited a distinct fascial architecture with three separate compartments. CONCLUSIONS: • A tiny minority of nerves in the anterior periprostatic region are functionally significant parasympathetic nerves. • There is little anatomical evidence to support higher incisions in the lateral prostatic fascia to spare cavernous nerve fibres, although such approaches may reduce the risk of traction injury on the more posterolaterally located NVB. • The presence of distinct fascial compartments in the NVB is also confirmed. [ABSTRACT FROM AUTHOR]

Little detailed information is available concerning autonomic and somatic nerve supply to the clitoris, potentially causing difficulties for nerve preservation during pelvic and perineal surgery. To identify the location and type (nitrergic, adrenergic, cholinergic and sensory) of nerve fibers in the clitoris and to provide a three-dimensional (3D) representation of their structural relationship in the human female fetus. Serial transverse sections were obtained from five human female fetuses (18-31 weeks of gestation) and subjected to histological and immunohistochemical investigations; digitized serial sections were used to construct a 3D representation of the pelvis. Pelvic-perineal nerve location and type were evaluated qualitatively. The female neurovascular bundle (NVB) is the anteroinferior terminal portion of the inferior hypogastric plexus that runs along the postero-lateral then lateral face of the vagina and is rich in nNOS-positive fibers. The cavernous nerve (CN) is a thin ventrocaudal collateral projection of the NVB, and this projection does not strictly follow the NVB course. The CN runs along the lateral surface of the vagina and urethra and penetrates the homolateral clitoral crus. The CN provides adrenergic, cholinergic, and nitrergic innervation to the clitoris, but not sensory innervation. The spongious nerve (SN) is the terminal and main projection of the NVB and provides nitrergic innervation to the vestibular bulbs. The dorsal clitoris nerve (DCN), somatic branche of the pudendal nerve, runs along the superior surface of the clitoral crus and body and has a segmental proerectile nitrergic activity related to communicating branches with the CN. 'Computer-assisted anatomic dissection' allowed the identification of the precise location and distribution of the autonomic and somatic neural supply to female erectile bodies, providing an anatomical basis for nerve-sparing surgical techniques, and participating to the understanding of neurogenic female sexual dysfunction. [ABSTRACT FROM AUTHOR]

Background: Prostate adenocarcinoma, which may recur despite aggressive treatment, has the potential to spread to the lumbosacral plexus. This intraneural involvement is not widely known and is thought to be from direct perineural spread. We hypothesized that high-resolution imaging could provide supportive evidence for this mechanism. Methods: The clinical data and imaging studies (magnetic resonance imaging, MRI, and positron emission tomography/computed tomography, PET/CT) of patients evaluated at our institution between 2004 and 2009 for lumbosacral plexopathy due to intraneural prostate carcinoma were retrospectively reviewed. Results: Four patients presenting with painful lumbosacral plexopathy were found to have intraneural lumbosacral prostate adenocarcinoma. Two patients had involvement of the lumbosacral plexus ipsilateral to the lobe of the prostate most involved with adenocarcinoma at prostatectomy. High-resolution MRI and PET/CT studies revealed similar findings: abnormal soft tissue signal was followed from the prostate ( n = 1) or prostatic bed ( n = 3) area along the expected course of the pelvic plexus to the level of the sciatic notch, where it involved the sacral spinal nerves and sciatic nerve. Imaging findings were consistent with neoplastic infiltration, which was confirmed at biopsy in three patients. Conclusions: The potential for prostate adenocarcinoma to spread to the lumbosacral plexus has, to our knowledge, not been readily appreciated. Because the imaging findings are often subtle, we believe that intraneural lumbosacral plexus involvement may not be uncommon. This study, with the use of high-resolution MRI and PET/CT studies, supports the direct perineural spread of prostate adenocarcinoma via the pelvic plexus to the lumbosacral plexus. This mechanism could also explain cases of leptomeningeal and/or dural-based prostate metastases. [ABSTRACT FROM AUTHOR]

Abstract: 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 150–200μm 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. [Copyright &y& Elsevier]

Introduction. A promoting effect of thyroid hormones has been established on the maturation of central and peripheral nervous systems. However, effects on autonomic nerves have never been experimentally investigated. Aim. To assess the effect of a local treatment combining silicone guides and local administration of Triiodothyronine (T3) on the erectile function and the histological neuroregeneration of crushed cavernous nerves (CNs) in rats. Methods. Forty-five rats were divided into five equal groups: SHAM surgery, guide without crush, crush, crush + guide, crush + guide + T3. All surgical procedures were bilateral. CNs were crushed with microvascular bulldog clamp of 100 g/cm2. A silicone guide was placed around the nerves. The guides were filled with T3 neuroregenerative solution. Main Outcome Measures. Erectile function was assessed 10 weeks post-operatively. Intra-cavernous pressure (ICP) and mean arterial pressure (MAP) were monitored during electrical stimulation of CNs at various frequencies. The main outcome was hardness of erection defined as ΔICP/MAP. Fluorescent immunohistochemical analysis of CNs was performed to assess regeneration of nerves morphologically. Results. Electrophysiological data showed increased recovery of erectile function in the group with guide + T3 neuroregenerative solution compared with the empty guide. Immunohistochemical analysis of cavernous nerves demonstrated in morphology that regenerated axons were straighter in nerves with guide and more regular if guides had been filled with T3. Conclusion. The use of guides prevented axonal sprouting, facilitated functional neuroregeneration and enabled a local delivery of thyroid hormones. Triiodothyronine improved neuroregeneration and recovery of erectile function after a nerve-sparing–like injury in a rat model. Bessede T, Alsaid B, Ferretti L, Pierre M, Bernabé J, Giuliano F, Karam I, Benoît G, and Droupy S. Effect of a local delivery of triiodothyronine (T3) within neuroregenerative guide on recovery of erectile function in a rat-model of cavernous nerve injury. J Sex Med 2010;7:1798–1806. [ABSTRACT FROM AUTHOR]

Compartment syndrome (CS) is a common complication of crush injury but it is rare to find bilateral gluteal compartment syndrome (BGCS). Only six cases of BGCS have been reported in the literature. This syndrome has been reported after crush injury, drug overdose, surgical positioning, and vascular surgery. Apart from CS, crush injury is associated with multi-system adverse effects and these patients are at high risk for renal failure and sepsis. CS patients may present with dehydration; coagulation disorders; elevated creatine phosphokinase and myoglobin levels; hyperkalemia and hypocalcaemia, which may cause life-threatening arrhythmias and therefore need urgent and aggressive therapy. The early goal in these patients is prevention of acute renal failure with aggressive fluid therapy, alkalinization of urine, and forced diuresis. Early treatment of hyperkalemia, antibiotic therapy, immunoprophylaxis, and wound care will minimize the risk of arrhythmias and sepsis. CS must be considered when any patient is diagnosed with crush injury syndrome. CS is defined as elevation of interstitial/intracompartmental pressure, leading to microvascular and myoneural dysfunction and secondary hypoxia; it may cause functional loss or even death if not detected early and treated properly. The increase in pressure in one or all compartments of the gluteal region causes CS with devastating effects on muscle and neurovascular bundles. CS is traditionally diagnosed on the basis of five 'p's: pain, pallor, paraesthesia, pulselessness and paralysis. Diagnosis of gluteal CS is difficult as the peripheral pulses are preserved and the condition is usually only diagnosed when neurological abnormality is noticed. Diagnosis of CS can be made by direct measurement of the compartment pressure and magnetic resonance imaging or computerized tomography. Gluteal CS is managed by fasciotomy and debridement of necrosed tissue, with secondary closure of fascia. A high index of suspicion is necessary for the early diagnosis of gluteal CS, and this will reduce the disability and complications as a consequence of this syndrome. The acute-care physician, the intensivist, and the trauma surgeon must be aware of this rare syndrome, as it can result in multiorgan dysfunction and death. Here we report a case of bilateral gluteal CS that was successfully treated in our trauma intensive care unit. [ABSTRACT FROM AUTHOR]

Abstract: Context: Detailed knowledge of the anatomy of the prostate and adjacent tissues is mandatory during radical prostatectomy to ensure reliable oncologic and functional outcomes. Objective: To review critically and to summarize the available literature on surgical anatomy of the prostate and adjacent structures involved in cancer control, erectile function, and urinary continence. Evidence acquisition: A search of the PubMed database was performed using the keywords radical prostatectomy, anatomy, neurovascular bundle, fascia, pelvis, and sphincter. Relevant articles and textbook chapters were reviewed, analyzed, and summarized. Evidence synthesis: Anatomy of the prostate and the adjacent tissues varies substantially. The fascia surrounding the prostate is multilayered, sometimes either fused with the prostate capsule or clearly separated from the capsule as a reflection of interindividual variations. The neurovascular bundle (NVB) is situated between the fascial layers covering the prostate. The NVB is composed of numerous nerve fibers superimposed on a scaffold of veins, arteries, and variable amounts of adipose tissue surrounding almost the entire lateral and posterior surfaces of the prostate. The NVB is also in close, cage-like contact to the seminal vesicles. The external urethral sphincter is a complex structure in close anatomic and functional relationship to the pelvic floor, and its fragile innervation is in close association to the prostate apex. Finally, the shape and size of the prostate can significantly modify the anatomy of the NVB, the urethral sphincter, the dorsal vascular complex, and the pubovesical/puboprostatic ligaments. Conclusions: The surgical anatomy of the prostate and adjacent tissues involved in radical prostatectomy is complex. Precise knowledge of all relevant anatomic structures facilitates surgical orientation and dissection during radical prostatectomy and ideally translates into both superior rates of cancer control and improved functional outcomes postoperatively. [Copyright &y& Elsevier]

The neuroanatomical structures of the radical prostatectomy (RP) are extensively discussed for their existence, localization and function. Especially structures, e.g. the so-called neurovascular bundle (NVB) that are points of debate in numerous anatomical studies. We review the literature and present our observations in cadaveric specimens, to reconstruct neuroanatomical structures in three dimensions (3D) with the use of appropriate computer applications and produce images of operative fields. We used an internet PubMed survey ( ) to review recent publications and included back copies of historical neuroanatomical studies from our own library. Our own experimental cadaveric (specimens preserved in Thiel’s solution) studies of the autonomic nerve supply of the lower urinary tract were also reviewed. Visualization of the pelvic anatomy and neuroanatomy was done using computer-based software packages. No unified terminology for the structures of the NVBs can be presented to date. The innervation of the smooth muscular structures of the urethra and the complex morphology of urethral sphincter remain unclear. Our cadaveric studies showed that nerves are located on the lateral aspect of the prostate in addition to the NVBs described at the dorsolateral side of the prostate. The neuroanatomical investigations of the male pelvis and visualization of the structures in 3D enable the presentation of operative sites as seen intraoperatively. Moreover, dynamic depiction of the pelvic floor is also possible. [ABSTRACT FROM AUTHOR]

OBJECTIVE To analyse the distance between the ipsilateral neurovascular bundles (NVBs) and foci of prostate cancer (N-T distance) in specimens removed by radical prostatectomy (RP) and identify the predictor for N-T distance for preserving the ipsilateral NVB, as an accurate understanding of the anatomical relationship between prostate cancer foci and the NVB is necessary for establishing the indications for the appropriate use of nerve-sparing (NS) modifications of RP. PATIENTS AND METHODS The study included 245 patients with prostate cancer who had RP through the perineal or retropubic approach between June 2000 and November 2006. The analysis focused on 302 foci of prostate cancer (192 cases), which involved at least the posterolateral region of the prostate. The N-T distance was separately measured in the apex, middle and base of the prostate, and was correlated with the maximum diameter and Gleason score of the foci, and the preoperative prostate-specific antigen (PSA) level. RESULTS The mean N-T distance was 2.98, 2.95 and 3.03 mm in the apex (216 foci), middle (195 foci) and base (80 foci), respectively. In the apex, the N-T distance was related to both tumour size and preoperative PSA value ( P < 0.001 and P < 0.05, respectively). In the base, tumour size was related to the N-T distance ( P < 0.01), but the preoperative PSA level was not related to the N-T distance. In the middle, the association of tumour size with N-T distance was of borderline significance ( P = 0.07). Irrespective of tumour location, the Gleason score did not contribute to the N-T distance. CONCLUSIONS These findings show the basic information necessary when making a decision to perform NS-RP in patients with localized prostate cancer. The application of N-T distance could provide a better strategy for determining indications that warrant the use of NS RP than with the conventional tactile feedback approach. [ABSTRACT FROM AUTHOR]

Because of few anatomic reports investigating the mechanism of lateral epicondylitis (tennis elbow), we performed cadaveric and clinical studies to investigate the involvement of neurovascular bundles passing through the common extensor origin. We dissected and observed under a light microscope tissue samples of neurovascular bundles passing through the common extensor tendon from 40 upper left and right limbs from cadavers. Tissue samples were prepared by hematoxylin & eosin and Weil's myelin staining. We also investigated the records of 20 patients who had been treated for lateral epicondylitis between 1991 and 2004. From cadavers, we found 60 bundles in the common extensor tendon, each 0.5 to 1.0 mm in diameter, with more bundles in the right than left limbs. Twenty-four of these bundles passed over the vertex of the lateral epicondyle of the humerus, and most of the bundles contained only one artery each. The bundles mostly originated from the radial recurrent artery, passing through the aponeurosis of the extensor corpi radialis brevis, but in some cases originated from the radial collateral artery, passing through the aponeurosis of the triceps brachii muscle. The bundles had a membranous covering when passing through the aponeurosis and produced a hiatus. Histological analysis of resected common extensor tendon tissue, 1 cm in diameter, of patients showed hyaline degeneration and fibrosis formation infiltration. Neurovascular bundles passed through the common extensor tendon in nine cases; six cases showed pulsing bleeding. After a mean follow-up of two years (6–48 months), 16 cases showed excellent results, two showed good results and two showed reliefs. Lateral epicondylitis could be caused by damage to neurovascular bundles when they pass through the common extensor origin; one cause of pain is the neurovascular bundle being compressed when passing through the common extensor tendon, secondary to the pathologic degeneration of the origin of the common extensor tendon. [ABSTRACT FROM AUTHOR]

Objective. Because the recovery of erectile function and the avoidance of positive surgical margins are important but competing outcomes, the decision whether to preserve or resect a neurovascular bundle (NVB) during radical prostatectomy (RP) is based on information concerning mostly the presence and location of extracapsular extension (ECE). Conventional endorectal magnetic resonance imaging (e-ctMRI) and functional endorectal MRI (e-ftMRI) of the prostate provide an excellent depiction of the pelvic and prostate anatomy, and are also useful in predicting the presence of prostate cancer as well as ECE, seminal vesicle invasion (SVI) and NVB involvement. Their predictive qualities, however, have shown significant interobserver variability. The aims of this study are to report on accuracy using e-ctMRI and e-ftMRI, and to assess their value in making the decision whether to preserve or resect the NVBs during RP. Material and methods. From 2004 to 2007, 75 consecutive patients with a biopsy-proven prostate cancer and satisfactory erectile function, who were scheduled to undergo RP, were subjected to e-ctMRI and e-ftMRI before surgery. Interpretation was performed by a highly experienced radiologist blinded to patient clinical data. All patients underwent RP and a nerve-sparing (NS) procedure was considered appropriate if the tumour did not extend outside the capsule in the posterolateral region of the prostate as assessed by the images. Results. An NSRP was performed in 78.7% of patients. Based on the e-ctMRI and e-ftMRI findings, the operative strategy was changed in 44% of patients. The findings favoured NVB preservation in 67% of patients with a high clinical probability of ECE, and opposed NVB preservation in 33% of patients with a low clinical probability of ECE. Based on the final histopathological findings, the surgical plan was successfully changed in all patients. The sensitivity, specificity and accuracy rate were 92%, 100% and 100% for ECE, SVI and NVB involvement, respectively, results which are higher than all other published international standards in this matter. Conclusions. e-ctMRI and e-ftMRI comprise a sufficient modality in detecting prostate cancer, ECE, SVI and NVB involvement. This technique seems to one of the most sensitive preoperative clinical staging methods for selective patients, and extremely useful for identifying candidates for an NSRP. [ABSTRACT FROM AUTHOR]

Abstract: Background: The functional outcome of a nerve-sparing radical prostatectomy (RP) depends on the knowledge of autonomic nerve distribution in correlation to the prostate. Objective: Recent literature has focused predominantly on the anterior prostate; this study evaluates the nerve distribution on the entire prostate, using a two-dimensional approach. Design, setting, and participants: From 17 non-nerve-sparing (NS) RP specimens, 77 whole mounted serial sections were immunostained with PGP9.5 and analyzed. Intervention: Each prostate half was divided into 12 sectors (three levels: apex, mid-part, base; four courses: anterior, anterolateral, posterolateral, posterior). Measurements: The extracapsular nerves were counted and classified by size (>200μm or ≤200μm). Results and limitations: Approximately two-thirds of the nerves were located in the posterolateral while 26.3/27.0% were located in the anterior and anterolateral. In the anterolateral, along the base–apex direction, the nerves decreased whereas they increased in the posterior. In the anterior, the highest counts were found in the mid-prostate. PGP 9.5 stain helps to determine the extracapsular nerve distribution, however, it does not allow a functional allocation. Conclusions: The nerve course expands from the base in the mid-part to the anterior sector, before it narrows towards the apex in the posterior lateral and posterior sectors. Therefore, it is recommended that the surgeon focus on nerve preservation in particular at the apex, starting in the anterior at the mid section as well as the common posterolateral course. [Copyright &y& Elsevier]

Background: The description for T4a oral tongue cancer in the 8th edition AJCC staging can be improved further. In this article we attempted to identify the important radiological (MRI) findings that could possibly be included in the staging eventually.Methods: We included all oral tongue squamous cell carcinoma patients who underwent surgery at TMH between Jan 2012 to Dec 2018 and whose MRIs were available for review. The relation of the tumor to the neurovascular bundle (NVB) on MRI was classified as Type I to IV. The association of the type of NVB involvement with DFS and the presence of PNI in the final HPR was analyzed.Results: Two-hundred and fifty-nine patients satisfied the eligibility criteria. The majority of them were men (82.6%), with a median age of 49 Yrs. Sixty-nine percent of patients had either abutment (Type III) or encasement (Type IV) of the NVB. The presence of Abutment/encasement of the NVB was significantly associated with the presence of PNI in the final HPR (p < 0.001). This abutment/encasement was seen in clinically advanced T-stage tumors. However, the presence of abutment/encasement of the NVB influenced the DFS in the univariate analysis only.Conclusion: Abutment/encasement of the NVB in patients with carcinoma oral tongue is often seen in advanced-stage tumors and is significantly associated with the presence of PNI in the final HPR. Hence, the relation of the tumor with the NVB should be further assessed to understand its importance and its possible inclusion in the AJCC T-staging. [ABSTRACT FROM AUTHOR]

Abstract: Background: The exact distribution of periprostatic autonomic nerves is under debate. Objective: To study the topographical anatomy of autonomic nerves of the periprostatic tissue and the capsule of the prostate (CAP). Design, Setting, and Participants: Whole-mount sections of 30 prostates from patients having undergone non–nerve-sparing radical prostatectomy were investigated after immunohistochemical nerve staining. Sections from the base, the middle, and the apex were evaluated. All sections were divided into 12 sectors, which were combined into the following regions: ventral, ventrolateral, dorsolateral, and dorsal. Measurements: Quantification of periprostatic and capsular nerves was performed within the sectors. Computerised planimetry of the total periprostatic nerve surface area of each region was performed (Image-J software, Wayne Rasband, National Institute of Health, USA). Results and Limitations: A total of 3514, 3860, and 3902 periprostatic nerves was counted at the base, the middle, and the apex, respectively (p =0.068). The ratio of periprostatic nerves to capsular nerves was 3.6, 2.1, and 1.9 at the base, the middle, and the apex, respectively (p =0.004). Computerised planimetry revealed a significant decrease in total nerve surface area from the base over the middle towards the apex, with 241.79, 133.64, and 89.50mm2 (p =0.004). The percentage of total nerve surface area was highest dorsolaterally (84.1%, 75.1%, and 74.5% at base, middle, and apex, respectively) but variable: Up to 39.9% of nerve surface area was found ventrolaterally and up to 45.5% in the dorsal position. The study is limited by the fact that autonomic nerve distribution was only investigated from the base to the apex of the prostate. Conclusions: Periprostatic nerve distribution is variable, with a high percentage of nerves in the ventrolateral and dorsal positions. Total periprostatic nerve surface area decreases from the base towards the apex due to nerves leaving the NVB branching into the prostate. This can only be discovered by nerve planimetry, not by quantification. [Copyright &y& Elsevier]

Introduction. Erectile dysfunction remains a major functional complication of radical prostatectomy in the modern era despite surgical techniques to preserve the penile autonomic nerve supply. Aim. To develop and evaluate a neurostimulation system for cavernous nerve electrical stimulation for future use as a chronic implantation device that neurotrophically promotes erectile function recovery following radical prostatectomy. Method. After radical retropubic prostatectomy, the neurovascular bundle was stimulated using a temporarily placed electrode array of an implantable neurostimulation system (20 Hz frequency, 260 µ seconds pulse width, 5 mA–60 mA amplitude up to 10 minutes), and penile circumference increases were measured. Main Outcome Measure. Increase in penile circumference. Results. Among 12 men (mean age 60.3 years) enrolled in this study, 6 (50%) demonstrated measurable increases in penile circumference in response to cavernous nerve stimulation. Among these six men, the mean increase was 5.0 mm (range 1.6 mm to 7.0 mm). Temporary surgical placement of the device was done with relative ease, and there was no evidence of injury to the neurovascular bundle. Conclusions. A chronic implantable nerve stimulation system for cavernous nerve stimulation having possible neuromodulatory effects on the recovery of penile erections after radical prostatectomy is feasible. Burnett AL, Teloken PE, Briganti A, Whitehurst T, and Montorsi F. Intraoperative assessment of an implantable electrode array for cavernous nerve stimulation. J Sex Med 2008;5:1949–1954. [ABSTRACT FROM AUTHOR]

The treatment of prostate cancer (PCa) with nerve sparing radical prostatectomy (NSRP) has experienced a substantial improvement in recent years due to new insights in anatomy of the prostate and of the adjacent structures. Knowledge of this specific anatomy is mandatory during RP in order to avoid injuries to functional tissue. Above all, these tissues are the neurovascular bundle (NVB) and the urethral sphincter. We therefore reviewed the available literature on prostatic anatomy and summarized it in this article. A search of the PubMed database was performed using the keywords radical prostatectomy, anatomy, neurovascular bundle, fascia, pelvis and sphincter. Relevant articles were reviewed, analyzed and summarized. This article gives an insight in the anatomy of the NVB, the urethral sphincter and the fascias surrounding the prostate. The NVB might be hampered near the seminal vesicles, at the lateral surface of the prostate and in the area of the prostato-urethral junction. The urethral sphincter might be hampered during dissection of the dorsal vein complex and during dissection of the urethra at the prostatic apex. Finally, the anatomy of the fascias surrounding the prostate is complex and can inter-individually vary substantially, which adds to the technical difficulties of NSRP. With this article we provide an overview on the complex anatomy of the prostate and the adjacent tissues. Respecting and considering these anatomic principles during NSRP should result in good postoperative functional outcome, as well as in good outcome in cancer control. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: Recent literature describes indications for a more-complex course of fibres of the neurovascular bundle (NVB), despite the widely held assumption that it is gathered at the rectolateral side of the prostate. The objective of this study therefore was to determine the typical pattern of nerve distribution along the prostatic capsule. Materials and methods: Permanent sections of 31 patients, who underwent non-nerve-sparing radical prostectomy (RP) at our institution, were investigated. A total of 186 slides taken from the apex, mid-part, and base of the prostate was analyzed by microscopy. Before microscopy, slides were divided into 12 sectors and numbered clockwise starting from “1” for left ventral sides to “6” for the rectal sides (accordingly, “12”–“7” for right half). Every single nerve and ganglion in the prostatic capsule and the periprostatic tissue was counted in each sector. Results: The majority of nerves found in the sectors corresponded to the typical location of the NVB at the rectolateral sides of the prostate (4/5 or 8/9 o’clock sectors). In these two sectors, a median of 45.9–65.6% of counted nerves per half was found. However, a significant amount of nerves (21.5%–28.5%) was detected above the horizontal line. Conclusions: We conclude that 1/5–1/4 of nerves can be found along the ventral circumference of the prostatic capsule. To preserve a maximum number of nerves, we therefore recommend a modification of the surgical technique by focusing on a high incision for nerve sparing on the ventral parts of the prostate. [Copyright &y& Elsevier]

To investigate the topographical relationship of the cavernosal nerves (CNs) to seminal vesicles, prostate, rhabdosphincter and urethra during the development of the prostate, and to use the resulting morphological data to modify the surgical technique of nerve-sparing radical prostatectomy. The study included 29 male fetuses (gestational age 9–37 weeks) and eight adult specimens assessed anatomically and histologically. Using the plastination technique and anatomical dissection, the course of the CNs was investigated in all specimens. Based on these morphological results, the technique of dissecting the CNs during nerve-sparing radical retropubic prostatectomy was modified. During early fetal development the fibres of the CNs enclose the prostatic and membranous urethra dorsally and laterally. During the growth of the prostate, the CNs running along the prostate become displaced further anteriorly and spread, thus forming a concave shape (like a‘curtain’) of the neurovascular bundles (NVB). Therefore, dissection of the NVB has to start anteriorly to preserve all the nerve fibres that are spread along the surface of the lateral lobes of the prostate. From these anatomical findings we propose a modified‘curtain dissection’ to improve preservation of the CNs running in the NVB, in which the incision of the periprostatic fascia and dissection of the NVB is far more anterior than previously described. [ABSTRACT FROM AUTHOR]

To accurately define the anatomy of the neurovascular bundle (NVB) in men.The NVB was microdissected in detail bilaterally in 12 fixed human male adult cadavers. The anatomy of the NVB and its relationship to surrounding pelvic structures was ascertained in each specimen.Previous reports of the anatomy of the NVB have not mentioned its levator ani and anterior rectal component. The anatomy of the cavernosal nerves is such that accurate graft anastomosis to proximal and distal cavernosal nerve segments is extremely difficult.The current anatomical description of the cavernosal nerve and NVB is inaccurate. [ABSTRACT FROM AUTHOR]