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PubMed2004

[Identification of pelvic autonomic nerves during partial and total mesorectal excision--influence parameters and significance for neurogenic bladder].

INTRODUCTION: The objective of the present prospective study was to determine the frequency of pelvic autonomic nerve preservation (PANP) during total mesorectal excision (TME) for rectal carcinoma, and to identify a possible link between PANP and postoperative micturition disturbances. METHODS: Between March 1997 and February 2003, 229 patients with adenocarcinoma of the rectum were operated on with sphincter preservation in 178 (78%) cases. In 101 (48%) patients, the tumor did not invade the muscularis propria. To determine influence parameters on the achievement of complete PANP, a multivariate analysis was performed. The number of complete-partial-or nonidentification of the nerves (superior hypogastric plexus up to the neurovascular bundles) was documented and correlated with micturition disturbances. RESULTS: The pelvic autonomic nerves were identified completely in 169 (74%), partially in 25 (11%), and could not be demonstrated in 35 (15%) patients. Multivariate analysis showed multivisceral resection ( p<0.001), gender ( p<0.001), surgeon (<25 operations >, p<0.001), and tumor site (middle/upper third vs lower third of rectum, p= 0.011) to exert an independent influence on the achievement of complete PANP. Twenty (8.8%) patients needed a long-term urinary catheter. Preservation of the parasympathetic nerves was associated with low bladder dysfunction rates (4.1 vs 22.4%, p<0.001). CONCLUSIONS: To minimize the risk of postoperative micturition disturbances due to neurogenic bladder, pelvic autonomic nerves should be identified during TME. Neurogenic bladder after TME is a useful parameter to assess the quality of surgical treatment for rectal carcinoma.

Adult↗
PubMed1976

[Cholinergic contraction of the dog urinary bladder by electrical stimulation of the n. pelvicus and the ligamenta lateralia nerves and its affection by atropine and scopolaminebutylbromide (author's transl)].

As is well known contraction of the urinary bladder induced by electrical stimulation of the N. pelvicus-hypogastric plexus in the dog can only be diminished by atropine but not completely abolished. The result of stimulation can, however, be quantitatively abolished by the quaternary ammonium base hyoscine-n-butylbromide (scopolaminebutylbromide, Buscopan). Apart from antimuscarine-like peripheral effects, Buscopan also possesses, in contrast to atropine, antinicotine-like ganglion-blocking properties. Since Buscopan possesses only anticholinergic properties the contraction triggered off by stimulation of the nerve can be considered as being purely cholinergic. In the collateral ligaments of the urinary bladder of the dog there is another nervous system which when electrically stimulated contracts the bladder. Depending on the dosage the effect of stimulation can be diminished or abolished by atropine as well as by Buscopan. The result of stimulation can be diminished by hexamethonium and increased by eserine (physostigmine). Because of the effect of atropine-Buscopan (inhibition) and eserine (increase) this nervous system can be characterised pharmacologically as cholinergic.

Animals↗
PubMed1991

[Histologic identification of the afferent fibers of the pelvic plexus].

The inferior hypogastric (pelvic) plexus conveys two types of fibres: sympathetic fibres originating in the thoracolumbar sympathetic chain and parasympathetic fibers originating in the sacral anterior rami. By using a histofluorescent stain (glyoxalic acid) and a histochemical stain (thiocholine) in 17 fresh cadavres, we have demonstrated that the sympathetic fibres arise from sacral sympathetic ganglia. These fibres participate in the constitution of the pelvic splanchnic nerves. In this study, we confirm that the inferior roots of the pelvic plexus are not only parasympathetic, but also sympathetic.

Adrenergic Fibers↗
PubMed1996

Anterior resection syndrome is secondary to sympathetic denervation.

The mechanism of faecal incontinence following low anterior resection (LAR) has been speculative and the role of disordered neorectal dynamics difficult to quantify. Using a new methodology which quantifies rectal response to rapid and ramp inflation, in combination with anal physiology, we have evaluated 25 LAR-7 with major incontinence and 5 with minor incontinence. The three groups had comparable age, duration post surgery and anastomotic distance from the puborectalis. The resting anal canal pressure (RAP) did not related to the anastomotic distance (R2 = 0.09). With the anastomosis at and below 3 cms from the puborectalis, the rectoanal inhibitory reflex (RAIR) was a sustained drop in the mid anal canal pressure, in contrast to the normal pattern of recovery above this level. Major incontinence was characterised by a subnormal anal defence, hypersensitive neorectal dynamics and high amplitude contractile wave while minor incontinence was characterised by a hypernormal anal defence and a lesser degree of neorectal hypersensitivity. The mathematical viscoelastic rectal model, defined an increasing longitudinal smooth muscle tone and a decreasing functional collagen with increasing severity of incontinence as well as a high and low circular smooth muscle (CSM) tone with major and minor incontinence respectively. This correlated with previous in vitro studies on myenteric plexus denervation and localised damage to the inferior mesenteric plexus respectively. Based on the findings in this study, we conclude that major incontinence is secondary to neurotenesis of the inferior mesenteric ganglia and the hypogastric plexus, whereas minor incontinence represents a localised neurotenesis/neuropraxia of the inferior mesenteric plexus.

Adult↗
PubMedDate not supplied

Urinary incontinence after bilateral parasacral sciatic-nerve block: report of two cases.

OBJECTIVE: The authors describe the occurrence of urinary incontinence after bilateral parasacral sciatic-nerve blocks. CASE REPORT: Two female patients scheduled for bilateral hallux valgus corrective surgery under bilateral parasacral sciatic-nerve block developed urinary incontinence manifested by 3 episodes of enuresis in the first 5 hours after surgery. Physical examination revealed bilateral perineal and gluteal anesthesia and no bladder distention in both patients. Ten hours after block placement, both patients had recovered perineal sensibility and were able to control micturition. CONCLUSION: Given the anatomic relations between the sacral plexus and the autonomic and somatic afferent and efferent innervation of the bladder and urethra, the urinary incontinence observed in our 2 patients could be explained by loss of afferent activity by spread of the local-anesthetic solution to pelvic nerves, loss of the efferent innervation of the posterior urethral sphincter by spread of the local-anesthetic solution to the urethral branches of the hypogastric plexus, and loss of external urethral sphincter tonus by block of the pudendal nerves. Anesthesiologists should consider the possibility of occurrence of urinary incontinence when performing bilateral parasacral sciatic-nerve blocks.

Adult↗
PubMed1995

Distribution of noradrenergic neurons in the female rat pelvic plexus and involvement in the genital tract innervation.

The involvement of the pelvic plexus noradrenergic neurons in the innervation of the genital tract was studied in the female rat. Several small ganglia were observed in addition to the paracervical ganglion and immunocytochemistry for tyrosine hydroxylase was performed to examine the distribution and number of the noradrenergic neurons. 5069 +/- 1525 nerve cell bodies were counted in the paracervical ganglion and 9.0 +/- 0.8% of them were noradrenergic, displaying a clear somatotopic distribution in the ventro-medial part of the ganglion. Some accessory ganglia were located ventral to the main paracervical ganglion. 414 +/- 149 nerve cell bodies were found in the accessory ganglia, of which 20.4 +/- 3.1% were noradrenergic. Ganglia along the vesical branch of the hypogastric nerve, referred to as an hypogastric plexus, contained 233 +/- 83 neurons among which 12.7 +/- 7.2% were noradrenergic. Bilateral removal of the pelvic plexus produced degeneration of all the tyrosine hydroxylase-immunoreactive nerve fibres in the lower part of the uterus and in the cervix. In contrast, excision of the paracervical ganglia and the accessory ganglia caused no significant change in this innervation pattern. Combined retrograde tracing study and immunocytochemistry for tyrosine hydroxylase revealed a very small number of noradrenergic neurons also labelled with fluoro-Gold. Both findings suggest a limited involvement of the pelvic plexus noradrenergic neurons in the innervation of the lower genital tract.

Animals↗
PubMed1997

Visualisation of nitric oxide released by nerve stimulation.

We have visualised nitric oxide (NO) released from the electrically stimulated myenteric plexus and hypogastric nerve. NO was visualised by a reaction with luminol and hydrogen peroxide to generate photons which were counted using a microscope coupled to a photon counting camera. Electrical stimulation of the tissues induced an increase in photon counts which was frequency-dependent and prevented by inhibition of the NO synthase or by tetrodotoxin. The light emitted during nerve stimulation was not only observed at the nerve terminals but also at the axon and soma. Our results indicate that NO released from the whole nerve cell may affect target cells surrounding all parts of the nitrergic neuron. Thus, NO functions as a unique mechanism of synaptic and non-synaptic communication in the nervous system.

Animals↗
PubMed1993

Radical hysterectomy: a randomized study comparing two techniques for resection of the cardinal ligament.

To compare two different surgical techniques for the resection of the cardinal ligaments during radical operation for cervical cancer, 84 patients with locally advanced cervical cancer (FIGO stages IB-IIA > or = 4 cm, IIB-III) primarily treated with chemotherapy and then eligible for radical surgery underwent radical hysterectomy. Lateral parametria were resected by using the Meigs technique or a modified Magara technique. The procedure to be performed on the right hand side was randomly chosen, consequently the left cardinal ligament was resected with the other technique. Evaluation of the first 35 cases showed that the median size of the parametria resected with the modified Magara technique (52 mm) was significantly greater than that removed with the Meigs technique (34 mm) (P < 0.05). Therefore hemoclips were routinely adopted in the following 49 cases. In 11% of cases hemoclips could not be used due to a deep and narrow pelvis or varicosities of the hypogastric plexus, therefore clamps were necessary. Bleeding complicating parametrial dissection occurred independently of the adopted technique. Five-years DFS is 100, 80, and 52% for stage IB-IIA > 4 cm, IIB and III, respectively. The study showed that the modified Magara technique is feasible and safe and allows for a more radical resection of the parametrial tissue. Furthermore, this approach seems to improve the local control of disease.

Adenocarcinoma↗
PubMed1998

Total mesorectal excision for cancer of the rectum.

The concept of total mesorectal excision (TME) was first described by R. J. Heald in 1982 as a radical cancer operation based on the anatomy of fascial planes and fibrous spaces of the pelvis. The ampulla recti is invested by a fascia propria which is a part of the visceral pelvic fascia. The fascia propria is separated from the parietal pelvic fascia by the pelvirectal fibrous space, which is a compartment of the subperitoneal space of the pelvis. The lateral ligaments of the rectum divides the pelvirectal space into a prerectal and a retrorectal part. TME is defined as the resection of the rectum with its surrounding fatty and lymphatic tissue contained within the visceral sheet of the pelvic fascia. The dissection proceeds in the nearly avascular cleavage plane between the visceral and the parietal fascial sheets, allowing maximal protection of the hypogastric nerves and the inferior hypogastric plexus. Continuity of the prerectal and retrorectal parts of the field of dissection is established by dividing the lateral ligaments of the rectum slightly inside the point where they swing away from the parietal fascia of the pelvic side wall. By following this plane of dissection it is possible to achieve en bloc excision of the total mass of perirectal lymphatic and fatty tissue down to the pelvic floor.

Humans↗
PubMed1999

Anatomic basis of minimal anterior extraperitoneal approach to the lumbar spine.

Anterior lumbar spine approaches may be indicated for fusion in degenerative lumbar spine disorders or to fill discal and bone gaps after fracture reduction. We present an anterior extraperitoneal approach applicable to any discal and vertebral levels from T12 to S1. The anatomic study, based on 25 cadavers, highlights retroperitoneal dissection principles for easy kidney and duodenopancreatic mobilisation and direct left anterior access to the entire lumbar spine. We established a precise description of the lumbar veins and the anastomoses between the left renal vein and hemiazygos system, in order to define different topographic and anatomic factors related to safe and easily reproducible approaches for cage or graft implementation. Independent of the level and previous intraperitoneal surgery, lumbar spine access with this approach safeguards the kidney, ureter, spleen, hypogastric plexus and duodenopancreatic system. Regarding operating time, blood-loss and possibilities for freshening and grafting, this technique seems an effective counterbalance to the difficulties and complex technology of endoscopic approaches. The clinical study includes our first 42 cases in traumatic and degenerative lesions. Avoiding the neurologic or hemorrhagic risk inherent in classical posterior lumbar interbody fusion (PLIF) techniques, it can be considered as a reasonable and valid alternative. This technique could be used in the near future for mini invasive discal prosthesis insertion.

Cadaver↗
PubMed1994

Radical abdominopelvic lymphadenectomy: historic perspective and current role in the surgical management of rectal cancer.

Radical abdominopelvic lymphadenectomy for rectal cancer is based on the tenet that removal of all potentially involved lymphatic tissue will yield a lower rate of locoregional failure and improve survival. At centers with extensive experience with the procedure, the operating time is only modestly prolonged compared with conventional resection. Blood loss and postoperative hospitalization are not significantly increased. Urinary dysfunction and impotence associated with radical abdominopelvic lymphadenectomy (as high as 80 percent and 76 percent, respectively, in recent series) have been major deterrents to its more routine application. Preservation of the hypogastric plexus and even selective preservation of a unilateral S4 nerve root have been shown to reduce the occurrence of genitourinary complications. Improved five-year survival of 68 percent and local recurrence rates of 5 to 20 percent for TNM Stage III cancers have been achieved with radical abdominopelvic lymphadenectomy. These results compare favorably with recent trials of adjuvant chemoradiation after conventional resection in stage-matched patients. The rationale, evolution, and application of radical abdominopelvic lymphadenectomy to the surgical management of rectal cancer are critically examined. The potential benefits of radical abdominopelvic lymphadenectomy, which have been demonstrated in nonrandomized trials, should be evaluated in a prospective and properly randomized study to clearly establish or refute its efficacy.

Abdomen↗
PubMed1991

Preservation of urine voiding and sexual function after rectal cancer surgery.

In order to decrease the urinary and sexual morbidity which follows radical pelvic lymphadenectomy for rectal cancer, we began selective preservation of the pelvic autonomic nerves. Between 1985 and 1987, 134 patients with rectal cancer underwent a curative resection (52 abdominoperineal resections, 82 sphincter-saving resections) with extended pelvic lymphadenectomy and selective pelvic autonomic nerve preservation (PANP). PANP was classified into five degrees depending on the extent of pelvic dissection. First-degree PANP indicates complete preservation of the nerves; second-degree PANP indicates destruction of the hypogastric plexus: third-degree PANP indicates partial preservation of the pelvic autonomic plexus; fourth-degree PANP indicates bilateral or unilateral preservation of only the fourth pelvic parasympathetic nerve; and fifth-degree PANP indicates complete destruction of the pelvic autonomic nerves. Most patients with first-degree PANP were able to spontaneously void 7-10 days following the operation. However, 78 percent (28/36) of patients with fifth-degree PANP had not regained bladder sensation by the third postoperative week and were discharged with an indwelling catheter; 58 percent (21/36) had not regained bladder sensation by the 60th postoperative day. The cystometric data indicate a progressive decline in bladder sensation and function with increasingly extensive pelvic dissection. However, preservation of only the fourth parasympathetic nerve (fourth-degree PANP) resulted in partial sparing of bladder sensation and voiding function. Evaluation of sexual function in males under 60 years of age revealed that only 31 percent (12/39) recovered erectile function and only 19 percent (6/39) recovered normal ejaculatory function in the first postoperative year. Most of these patients had complete preservation of their pelvic autonomic plexus (i.e., first-degree PANP). Four patients with partial PANP have recovered erectile function. Complete PANP is the best way to prevent urinary and sexual morbidity after rectal resection. The opposing goals of maximizing the chance for cure and minimizing morbidity must be individualized and balanced in each patient. Our data demonstrate that it is now possible to perform radical pelvic lymphadenectomy in the majority of patients with advanced rectal cancer with a minimum of voiding dysfunction. Preservation of sexual function in males is more difficult and depends on complete PANP and, as such, should be restricted to the group of patients with Dukes' A and B carcinomas.

Adult↗
PubMed2000

Contribution to the surgical anatomy of the ligaments of the rectum.

PURPOSE: Many authors have discussed the presence and the importance of the lateral ligaments of the rectum. Our contribution aims at clarifying some aspects of surgical anatomy that help in the preservation of the urogenital functions and may influence the surgical practice. METHODS: From 1994 to 1998 we examined 27 fresh cadavers and five embalmed pelves. We performed all dissections with a technique similar to that used for the surgical mobilization of the rectum. RESULTS: The lateral ligaments of the rectum are trapezoid structures originating from mesorectum and are anchored to the endopelvic fascia; as lateral extensions of the mesorectum, they must be included in the surgical specimen. According to our results, three main structures can be recognized laterally to the rectum: 1) the lateral ligament, which does not contain important structures; 2) the inferior hypogastric plexus and the urogenital bundle; and 3) the lateral neurovascular pedicle of the rectum that comprises the nervi recti and the middle rectal artery, both running under the lateral ligament, although at different angles. CONCLUSION: At the point of insertion into the endopelvic fascia, the lateral ligaments run close to the urogenital bundle. Nevertheless, the dissection at its attachment is safe if the urogenital bundle is kept under visual control.

Cadaver↗
PubMed2004

The rectogenital septum: morphology, function, and clinical relevance.

PURPOSE: The rectogenital septum (known in clinical literature as Denonvilliers' fascia) forms an incomplete partition between the rectum and the urogenital organs in both men and women. It is composed of collagenous and elastic fibers and smooth muscle cells intermingled with nerve fibers emerging from the autonomic inferior hypogastric plexus. The aim of this study was to investigate the fetal development of the rectogenital septum, and the origin and innervation of the longitudinal smooth muscle cells within the septum, as well as to consider possible effects on function of operations that compromise the integrity of these structures. METHODS: Macroscopic dissections on embalmed human pelves and plastination histology of 40 fetal and newborn pelvic specimens were performed. By means of conventional and immunohistochemical staining methods using monoclonal and polyclonal antibodies for tissue analysis and neuronal labeling, the motor and sensory innervation of the longitudinal muscle bundles within the septum was defined. RESULTS: The rectogenital septum is formed by a local condensation of mesenchymal connective tissue in the early fetal period. The longitudinal muscle bundles could be traced back to the longitudinal layer of the rectal wall, and, using the septum as a guiding structure, it was possible to identify autonomic nerve fibers and ganglion cells innervating the muscle cells and crossing the midline without detectable gender differences. CONCLUSIONS: Because of a coinnervation of the rectal muscle layers and the adjacent longitudinal muscle fibers of the septum, a functional correlation between the two structures during defecation is postulated. On the basis of these findings, a safer dissection of the anterior rectal wall during rectal resection is postulated, thus limiting functional disturbance and preventing neural damage.

Adult↗
PubMed2005

Expression of mouse Coiled-coil-DIX1 (Ccd1), a positive regulator of Wnt signaling, during embryonic development.

Wnt signaling plays an important role in cell growth, differentiation, polarity formation, and neural development. We have recently identified the Coiled-coil-DIX1 (Ccd1) gene encoding a third type of a DIX domain-containing protein. Ccd1 forms homomeric and heteromeric complexes with Dishevelled and Axin, and positively regulates the Wnt/beta-catenin pathway. Here, we examined the spatiotemporal expression pattern of Ccd1 mRNA in mouse embryos from embryonic day 6.5 (E6.5) to E17.5 by in situ hybridization. Ccd1 expression was detected in the node region in gastrula embryos, in the cephalic mesenchyme and tail bud at E8.5, and in the branchial arch and forelimb bud at E9.5. In the central nervous system, Ccd1 expression began and persisted in the regions where the neurons differentiated, so that it was observed throughout the brain and spinal cord at E17.5. Ccd1 expression was also strong in the peripheral nervous system, including sensory cranial ganglia (trigeminal, facial, and vestibulocochlear ganglia), dorsal root ganglia, and autonomic ganglia (sympathetic ganglia, celiac ganglion, and hypogastric plexus). Ccd1 was detected in the sensory organs, such as the inner nuclear layer of the neural retina, saccule and cochlea of the inner ear, and nasal epithelium. Outside the nervous system, Ccd1 mRNA was observed in the cartilage, tongue, lung bud, stomach, and gonad at E12.5-E14.5, and in the tooth bud, bronchial epithelium, and kidney at E17.5. Taken together, these findings demonstrate that Ccd1 expression is observed in all the neurons in the nervous system, closely associated with neural crest-derived tissues, and largely overlapping with the regions where several Wnt genes are reported to play a role.

Animals↗
PubMed1992

A test for the identification of relevant sympathetic nerve fibers during nerve sparing retroperitoneal lymphadenectomy.

We present a new intraoperative test for the identification of sympathetic nerve fibers relevant to ejaculation during nerve sparing retroperitoneal lymphadenectomy in patients with nonseminomatous testicular tumors. Electrostimulation of specific isolated postganglionic nerve fibers resulted in intraoperative ejaculation in 9 of 11 patients. Ejaculation was without tumescence in a noneruptive manner and was reproducible in most cases upon repeated stimulation. In 6 patients ejaculation resulted after stimulation of the L3 fiber and in 1 each after stimulation of the L1, L2 and hypogastric plexus. The test seems to be particularly useful in post-chemotherapeutic dissections or otherwise extended dissections when sparing of irrelevant fibers is to be avoided.

Adrenergic Fibers↗
PubMed1991

Sympathetic inhibition of papaverine induced erection.

We studied the effect of neurostimulation of the lumbar sympathetic trunks on papaverine-induced penile erection in dogs and monkeys. The mean of 124 cm. H2O intracavernous pressure after papaverine injection was reduced under sympathetic trunk stimulation to 40.6 cm. H2O within a mean of 39 sec. In addition the flow of the internal pudendal artery was reduced indicating a decrease of the inflow to the penis. After the sympathetic stimulation was terminated, the intracavernous pressure increased again to the same level as before. This pressure recovery time was delayed after several sympathetic stimulations from 134 sec. (5 min. after papaverine injection) to at least 362 sec. (45 minutes after papaverine injection). Stimulation of the inferior hypogastric plexus had no effect on the intracavernous pressure. The neurostimulation range (3-4V; 20 Hz) was most effective in reducing the papaverine action on penile smooth muscles. The effect of sympathetic trunk stimulation seems to antagonize the relaxing action of papaverine on the cavernous smooth muscles and the cavernous arterioles. Our results imply that high sympathetic tone in some patients with psychogenic impotence may explain their poor response to intracavernous injection of papaverine.

Animals↗
PubMed1997

Neuroanatomy of the male rhabdosphincter.

OBJECTIVES: The external striated urethral sphincter (rhabdosphincter) is a tubular muscle sleeve that extends from the prostato-membranous urethra and perineal membrane to the bladder neck. The male rhabdosphincter neuroanatomy remains unclear, and a better understanding of its innervation may provide insight into potential modifications of radical pelvic surgery to improve urinary continence. METHODS: Fresh cadaveric dissections of 12 male hemipelves were undertaken to investigate the neuroanatomy of the urinary rhabdosphincter. RESULTS: Neuroanatomic courses of the nerve supply to the rhabdosphincter revealed that, in the perineum, the perineal nerve (a terminal branch of the pudendal nerve) provided branches directly to the bulbospongiosus muscle and the urinary rhabdosphincter. In the pelvis, the course of the pelvic nerve was as follows: (1) arising from the inferior hypogastric plexus, it had a weblike course beneath the muscle fascia of the levator ani muscle; (2) traveling posterolateral to the rectum, it gave many branches that perforated into the lateral rectum; and (3) at the level of the prostatic apex, still beneath the levator ani muscle fascia (superior fascia), it sent multiple direct branches to the inferolateral aspect of urinary rhabdosphincter. The pudendal nerve traversed the pelvis in the pudendal canal, and, before leaving the pelvis to enter the perineum, it gave an intrapelvic branch that courses with the pelvic nerve to innervate the rhabdosphincter. CONCLUSIONS: Our understanding of the neuroanatomy of what may be the continence nerves has been improved by fresh cadaveric dissection. The rhabdosphincter receives nerve fibers from the pelvic nerve and dual innervation from an intrapelvic branch and a perineal branch of the pudendal nerve. Better understanding of these anatomic findings may have potential surgical significance with respect to improvement in postoperative urinary continence.

Cadaver↗