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PubMed1998

Preservation of putative continence nerves during radical retropubic prostatectomy leads to more rapid return of urinary continence.

OBJECTIVES: Urinary incontinence is a significant complication of radical pelvic surgery. A better understanding of the neuroanatomy of the rhabdosphincter has led to the modification of the radical retropubic prostatectomy to optimize the recovery of postoperative urinary control. METHODS: Mock radical retropubic prostatectomy was performed on fresh cadavers to determine which surgical maneuvers could injure what may be the continence nerves. To assess the clinical significance of modifying the radical retropubic prostatectomy based on these anatomic studies, a contemporary series of 60 consecutive patients who underwent radical retropubic prostatectomy with continence nerve preservation was compared with a control group of 38 consecutive patients who had a standard anatomic radical retropubic prostatectomy. RESULTS: At the level of the prostatic apex, both the pelvic and pudendal nerves gave intrapelvic branches that bilaterally coursed to the external urinary sphincter to enter at the 5 and 7 o'clock positions. The mock radical prostatectomy revealed that the nerves to the external urinary sphincter were most prone to injury when a right angle clamp was used to develop a plane between the posterior rhabdosphincter and anterior rectum and if the urethral anastomotic sutures were placed at the 5 and 7 o'clock positions. In addition, blunt dissection of the tips of the seminal vesicles injured the inferior hypogastric plexus. Modifications to preserve the continence nerves were incorporated in the anatomic radical prostatectomy. Although overall continence rates were similar for the two groups (98.3% for continence nerve-preserving radical prostatectomy versus 92. 1% for standard prostatectomy), continence nerve preservation decreased the time to achieve continence. CONCLUSIONS: During radical retropubic prostatectomy, surgical maneuvers that avoid injury to the continence nerves resulted in the more rapid return of urinary control.

Cadaver↗

PubMed2000

Continence-preserving anatomic radical retropubic prostatectomy.

INTRODUCTION: Urinary continence, especially in regard to the time required to regain urinary control after radical prostatectomy, remains a significant complication of the procedure. TECHNICAL CONSIDERATIONS: The "no touch" or "avoidance" surgical principles that are the basis for continence-preserving radical prostatectomy primarily focus on the preservation of the following components of the external striated urethral sphincteric complex: the entire circumferential musculature of the rhabdosphincter, the fascial investments (the pubourethral ligaments anterolaterally and median fibrous raphe posteriorly), and the innervation of both the rhabdosphincter by way of the intrapelvic branch of the pudendal nerve (somatic) and the mucosal and smooth muscle components by way of the urethral branch of the inferior hypogastric plexus (autonomic). CONCLUSIONS: The clinical impact of preserving the external striated urethral sphincter, its innervation, and its fascial attachments by performing a continence-preserving anatomic retropubic prostatectomy is a shorter time to achieve urinary continence.

Humans↗

PubMedDate not supplied

Computed tomography-guided pudendal nerve block. A new diagnostic approach to long-term anoperineal pain: a report of two cases.

OBJECTIVE: To show the value of computed tomography (CT) in selectively blocking the pudendal nerve in patients with long-term anogenital pain of uncertain etiology. We report a technique to selectively block the pudendal nerve using CT guidance in 2 patients with long-term anogenital pain. CASE REPORT: In 1 patient, a competitive cyclist, the diagnosis of pudendal neuralgia was substantiated by blocking the nerve under CT. The procedure relieved the pain for approximately 24 hours. In the other patient, pudendal nerve block produced perineal analgesia but no pain relief. Superior hypogastric plexus block relieved the pain significantly for about 4 weeks on 2 separate occasions, suggesting sympathetically maintained pain. CONCLUSION: The use of CT to guide the procedure allowed precision in performing the procedure and in making a differential diagnosis.

Adult↗

PubMed2003

Laparoscopic presacral neurolysis for endometriosis-related pelvic pain.

BACKGROUND: Some patients with endometriosis are candidates for sympathectomy of the superior hypogastric plexus. The objective of this paper is to describe our technique of laparoscopic presacral neurolysis for sympathectomy and to report 1 year results of the first 15 cases. METHODS: To achieve this objective in a prospective observational study of 1 year follow-up; we performed laparoscopic presacral chemical neurolysis with phenol in 15 patients with pelvic pain and minimal-moderate endometriosis. The main outcome measures were: the impact of treatment on pelvic symptom resolution, non-opioid analgesic consumption during menses, sexual performance and observed complications and side effects during 1 year follow-up. RESULTS: We noted a significant reduction in total pelvic symptom score as compared with baseline mean (SD) of 9.04 (1.2). The mean difference [95% confidence interval (CI)] of reduction was 5.7 (4.9-6.5), 5.8 (5.0-6.6) and 5.8 (4.9-6.6) from the baseline at the 3rd, 6th and 12th postoperative month (P < 0.001). We observed a significant improvement in Sabbatberg Sexual Rating Scale as compared with baseline mean (SD) of 30.9 (4.3). The mean difference (95% CI) of increase was 33.4 (30.3-36.4), 33.2 (30.1-36.2) and 33.2 (30.1-36.3) from the baseline at the 3rd, 6th and 12th postoperative month. We observed a significant reduction in analgesic consumption during menses in terms of total naproxen sodium tablets as compared with baseline mean (SD) of 8.9 (1.1). The mean difference (95% CI) of reduction in the total number of naproxen sodium 250 mg tablets was 6.5 (5.5-7.5), 6.7 (5.7-7.7) and 6.6 (5.6-7.6) from the baseline at the 3rd, 6th and 12th postoperative month. The most common side effect was constipation. CONCLUSION: Laparoscopic presacral neurolysis is feasible and simple. More data is needed to support its efficacy and safety.

Adult↗

PubMed2004

Ipsilateral seminal emission generated by electrostimulation of the lumbar sympathetic nerve during nerve sparing laparoscopic retroperitoneal lymph node dissection for testicular cancer.

PURPOSE: To confirm nerve preservation during laparoscopic retroperitoneal lymph node dissection we perform electrostimulation of the lumbar sympathetic nerves relevant to ejaculation. In recent cases we monitored seminal emission using endoscopy of the posterior urethra to observe the response to stimulation. MATERIALS AND METHODS: Six patients with testicular tumors underwent intraoperative stimulation of the lumbar sympathetic nerves during laparoscopic retroperitoneal lymph node dissection with a unilateral modified template. A long handled pair of bipolar electrodes was inserted through a laparoscopic port, and ipsilateral and contralateral lumbar sympathetic nerves were individually electrostimulated. Ipsilateral stimulation was performed at the preserved lumbar splanchnic nerves and contralateral stimulation was performed at the union of nerve fibers derived from the lumbar splanchnic nerve just above the superior hypogastric plexus. The side of generated seminal emission was monitored simultaneously by endoscopy of the posterior urethra. RESULTS: In all patients each electrostimulation generated unilateral seminal emission. Each stimulation of a lumbar splanchnic nerve, whether ipsilateral or contralateral, caused seminal emission only from the ejaculatory orifice of the stimulated side. CONCLUSIONS: Intraoperative electrostimulation of the lumbar sympathetic nerves generated only ipsilateral seminal emission. This suggests that some efferent sympathetic signals for emission might run ipsilaterally in humans.

Adult↗

PubMed1988

The Ferrier lecture, 1986. The actions of parasympathetic and sympathetic nerves in human micturition, erection and seminal emission, and their restoration in paraplegic patients by implanted electrical stimulators.

Implants that stimulate the S2, S3 and S4 anterior roots improve micturition, defaecation and penile erection in many patients with spinal-cord injuries. The posterior rhizotomy that is commonly done at the same time usually cures their urinary incontinence, and may greatly improve bladder compliance. Implants that stimulate the hypogastric plexus allow semen to be obtained easily from some men with spinal injuries who cannot ejaculate, and may allow an implant-driven erection. A little new knowledge about the neurophysiology of the pelvic organs has come from studying the performance of these implants.

Ejaculation↗

PubMed1983

Imipramine for the treatment of sterility in patients following retroperitoneal lymph node dissection.

The major long-term morbidity following retroperitoneal lymph node dissection is sterility resulting from sacrifice of the thoracolumbar chain or the hypogastric plexus during dissection of the iliac vessels at the bifurcation. Seven males who were devoid of sperm emission and ejaculation as a result of this kind of operation for testicular cancer were treated with imipramine 25 mg t.i.d. In 2 of the patients, antegrade ejaculation appeared during treatment with this drug. We feel that this success rate of 2 out of 7 calls for further studies, as the problem of these young men was considered hopeless until recently.

Adult↗

PubMed1978

Time course of degeneration of short and long postganglionic sympathetic nerve fibres and effect of pentobarbitone and colchicine on degeneration.

1 The time-course of degeneration of sympathetic nerves was investigated by measurement of the endogenous noradrenaline content of the rat vas deferens, submandibular gland and spleen following sympathectomy.2 Extirpation of the hypogastric plexus, superior cervical ganglion and coeliac plexus under pentobarbitone anaesthesia caused 50% depletion of the noradrenaline content of the vas deferens, submandibular gland and spleen in approximately 16, 19 and 21 h, respectively.3 Under pentobarbitone anaesthesia, proximal sympathectomy (i.e., close to the end organ) produced depletion of the noradrenaline content of the submandibular gland 8 h earlier than that caused by distal sympathectomy. Under ether anaesthesia, the time difference in obtaining the same degree of depletion after the two procedures of sympathectomy was only 2 hours.4 Removal of the superior cervical ganglion under ether anaesthesia resulted in almost complete depletion of noradrenaline content of the submandibular gland in 17 h, whereas when a similar operation was performed under pentobarbitone anaesthesia, nearly 24 h were required for the same degree of depletion. Similarly, the noradrenaline content of the spleen was depleted 4 h earlier if the coeliac plexus was ablated under ether as compared to pentobarbitone anaesthesia.5 Local application of colchicine (10 mg/ml, 30 min) to postganglionic sympathetic nerve axons had no effect on the noradrenaline content of the submandibular gland up to 24 hours. However, removal of the superior ganglion following colchicine application considerably slowed the depletion of the noradrenaline content of the submandibular gland (at 17 and 20 h after ganglionectomy, 10 and 20% depletion, respectively, in the experimental gland, as compared to 70 and 80%, respectively, in the control gland).6 To explain the results, it is proposed that injury to the sympathetic nerves at the site of sectioning triggers a signal (messenger substance) which travels down to the nerve endings to produce degeneration. Thus, the length of the extrinsic nerve fibre influences the time course of degeneration by changing the rate of transport of the messenger substance, whereas pentobarbitone and colchicine alter the synthesis and/or transport of the messenger substance to modify the time-course of degeneration.

Animals↗

PubMed1980

Electrophysiological analysis of colchicine-induced supersensitivity in the rat vas deferens.

1. The supersensitivity in smooth muscle of the rat vas deferens induced by local application of colchicine to the hypogastric plexus was investigated electrophysiologically. 2. Spontaneous junction potentials could be detected in nearly all of the impaled cells, but they occurred with lesser frequency and smaller amplitude in the colchicine-treated rat vas deferens than in the control tissue. However, this clearly demonstrated that, although attenuated, neuromuscular transmission still persisted after colchicine treatment. 3. The mean resting potential of smooth muscle cells of the colchicine-treated vas deferens (58.2 +/- 0.3 mV, n - 146) was not significantly different from that of the cells of the contralateral control tissue (58.1 +/- 0.2 mV, n = 130). 4. The threshold potential for action potentials induced by either nerve stimulation or extracellular current application was more negative by approximately 10 mV in the colchicine-treated vas deferens in comparison with the control tissue. 5. Externally applied current pulses of long duration failed to produce electrotonic potentials in any smooth muscle cell of normally innervated rat vas deferens which was located more than 0.5 mm from the partition electrode. In the colchicine-treated tissue, however, electrotonic potentials in the smooth muscle cell could be detected for a distance up to 2.5 mm from the partition electrode. The space constant in the colchicine-treated tissue was determined to be 0.79 +/- 0.02 mm (n = 10). 6. It is concluded that (i) the magnitude of depolarization from resting to threshold potentials in the colchicine-treated vas deferens was significantly smaller than that in the contralateral control tissue and (ii) that the current spread in a longitudinal direction was improved following colchicine treatment.

Animals↗

PubMed1981

Physiology of mammalian prevertebral ganglia.

When assessing the physiological role of the prevertebral ganglia, the following should be considered. Ganglion cells in these ganglia receive continuous excitatory synaptic input from peripheral sensory mechanoreceptors and central preganglionic neurons. The latter may result from sensory afferents projecting from the gastrointestinal tract to spinal preganglionic neurons or as a result of endogenous oscillator activity located in the spinal cord (18) or within the ganglion (45). Peripheral and spinal reflex pathways probably do not operate as separate, independent pathways. Rather, they must be considered functionally integrated in the prevertebral ganglia. Because of continuous synaptic input, the prevertebral neuron operates at some level of "neurogenic tone" that provides capabilities for bi-directional responses. An increase in spinal or peripheral synaptic input will be matched by a proportional increase in output firing. The functional effect of spatial summation of peripheral and central input is to prime the prevertebral neuron so that adjustments in its firing frequency can be made without the lag inherent in building up a response in a quiescent system. Not all prevertebral ganglia participate in reflex activity. It may be that reflex activity between prevertebral ganglia and visceral smooth muscle depends upon the nature of the mechanical activity of the muscle. For example, the mechanical activity of smooth muscle of the vas deferens is not characterized by spontaneous, myogenic, regularly occurring contractions. Mechanical activity in this organ occurs in bursts. There is no evidence to suggest that sensory fibers project from the wall of the vas deferens to the hypogastric plexus thereby forming a peripheral reflex arc. Contraction of th smooth muscle of the vas deferens is brought about by bursts of nerve impulses through simple relay connections in the pelvic plexus. Smooth muscles supplied by this ganglion have a direct line to the central nervous system and are secured by a "fail-safe" system. In contrast, the mechanical activity of the gastrointestinal system is characterized by slow spontaneous myogenic activity. Pattern formation of motor activity is achieved by reflex activity within the enteric plexuses. Extrinsic alteration of the nature and pattern of contraction of smooth muscle of the gastrointestinal tract would be best served by prevertebral ganglia that modulate and adjust motor function by continuous integration of convergent weak synaptic input emanating from the peripheral and central nervous systems. When a prevertebral neuron is part of a peripheral reflex loop, its physiological role may be to modulate end organ activity; when it does not participate in a peripheral reflex loop, its role may be to relay CNS input and initiate end organ activity.

Animals↗

PubMed1994

Preservation of antegrade ejaculation in retroperitoneal lymphadenectomy due to residual masses after primary chemotherapy for testicular carcinoma.

We report 18 consecutive patients with testis cancer and retroperitoneal residual masses with normal tumor markers, who underwent lymphadenectomy. Aiming to preserve the antegrade ejaculation, we carried out surgical modifications which basically attempt to preserve: (1) both sympathetic lumbar trunks, (2) the superior hypogastric plexus and (3) some of the postganglionic branches. With a mean follow-up of 28.1 months (range 6-62 months), 15 (83.3%) of the 18 patients preserved ejaculation, without significant differences between ejaculation volumes before and after lymphadenectomy. At the present time, 3 of 4 possible patients have fathered children. Mass size seems to be an important predictive factor of ejaculation preservation. One patient relapsed in the retroperitoneal dissection area, representing a recurrence rate of 5.5%. The disease-free survival rate was 94.4%, and 1 patient died due to disease progression with lung recurrence. Thus preservation of ejaculation was possible in most of these patients.

Adult↗

PubMed1982

A comparative study of changes in innervation and development of supersensitivity in the rat vas deferens after various procedures.

The relationship between morphological and functional changes in adrenergic nerves and the development of supersensitivity in the rat vas deferens was comparatively investigated after surgical denervation, chemical sympathectomy by 6-hydroxydopamine, daily treatment of animals with reserpine, or local application of colchicine to the hypogastric plexus. The order of ability to produce supersensitivity, as judged by the extent of the increase in the pD2 value of norepinephrine and the maximum response to norepinephrine, was as follows: denervation = colchicine greater than 6-hydroxydopamine greater than reserpine. These procedures produced alterations in morphological characteristics of the nerve ending with severeness of degeneration in the following order: denervation greater than 6-hydroxydopamine greater than colchicine greater than reserpine. Twitch contractions induced by transmural nerve stimulation were slightly reduced after colchicine or 6-hydroxydopamine treatment, markedly reduced by reserpine, and abolished by denervation. Therefore, the development of supersensitivity in the rat vas deferens is not necessarily in proportion to the morphological or functioning changes in adrenergic nerves. The results suggest that some neurofactor, e.g. trophic factor, is involved in the control of the drug sensitivity of smooth muscle in addition to the neurotransmitter itself.

Animals↗

PubMed1975

Urge incontinence in women.

A survey has been presented of the author's personal methods to treat urge incontinence in women caused by neurogenic disturbances or by urethritis. Denervation of the bladder by unilateral or bilateral resection of the inferior hypogastric plexus is used for neurogenic disturbances with uninhibited bladder contractions or hypertonic bladders and in cases of interstitial cystitis, if a preoperative blockade with local anaesthesia has given a favourable result. Urethral diverticula are extirpated. Urethritis is treated with careful dilatation of the uretha and massage in combination with local treatment of the mucosa with 1% solution of silver nitrate. In cases with a narrow urethral orifice a meatotomy is made. Women with wide external orifice and recurrent urethritis following intercourse are operated upon. A structure similar to the frenulum of the prepuce in the male is constructed, which closes the orifice at the introduction of the penis.

Adolescent↗

PubMed2000

Laparoscopic presacral neurectomy for chronic pelvic pain.

Presacral neurectomy is an effective treatment for chronic pelvic pain and dysmenorrhea. The theory behind presacral neurectomy for pain relief is based upon the anatomy of the sensory pathways from the pelvic viscera through the inferior and superior hypogastric plexus, located in the presacral area, to the spinal columns. The excision of the presacral nerve trunk can obstruct pain sensory pathways. Unfortunately 20-25% of patients treated medically for severe, disabling pelvic pain fail to show improvement. As a result, presacral neurectomy has become an alternative management for those with chronic pelvic pain and dysmenorrhea, especially for those who have failed to respond to medical treatment. Operative endoscopy further facilitates the adaptation of the laparoscopic approach to this pelvic denervation. The efficacy of pain relief by laparoscopic presacral neurectomy in chronic pelvic pain and dysmenorrhea is documented at about 75-80%. Major complications are rare with a rate of less than 1% reported. Laparoscopic presacral neurectomy therefore offers an effective alternative treatment and should also be considered as the initial surgical intervention for chronic pelvic pain.

Chronic Disease↗

PubMed2000

[Innervation of Denonvilliers' recto-vesical fascia. Anatomical study].

OBJECTIVE: Dissection of Denonvilliers' rectovesical fascia allows easy cleavage of the prostatorectal and prostatovesical spaces. Its lateral limit in the "neurovascular pedicles" justifies its resection during radical prostatectomy. The objective of this study was to define the course and to observe the structure of nerves crossing the rectovesical fascia, as the sheaths of these nerves may be invaded by prostatic adenocarcinoma tumour cells. MATERIAL AND METHODS: After dissection of a fresh cadavre to define the relations of this fascia with the pedicles, rectovesical fascia biopsies were taken during radical prostatectomies. Transverse sections were performed and examined histologically. RESULTS: Certain nerves, derived from the neurovascular pedicle of the inferior hypogastric plexus, cross the rectovesical fascia to innervate the prostate. CONCLUSION: This confirms the importance of complete resection of the rectovesical fascia during radical prostatectomy for cancer, not only for surgical reasons, but also to ensure oncologically satisfactory surgery, i.e. with healthy resection margins.

Aged↗

PubMed2000

[Posterior rectopexy in total rectal prolapse-].

STUDY AIM: The aim of this retrospective study was to report the results of posterior Orr-Loygue rectopexy in 55 patients operated on for rectal prolapse. PATIENTS AND METHOD: From 1986 to 1997, 114 patients were operated on for rectal prolapse and 55 had an Orr-Loygue operation. There were 47 women and 8 men (mean age: 55 years). Twenty-five patients (45%) had fecal incontinence, 26 (47%) described preoperative 'constipation'. The procedure was performed under general anesthesia, through laparotomy in 51 patients, through laparoscopy in 4 patients. Resection of sigmoid colon was associated to rectopexy in four patients. RESULTS: Mortality rate was 0 and morbidity rate 12%. Mean hospital stay duration was 13.5 days. Mean follow-up was 63 months and at the end of the study, four patients (7%) had recurrence, 5/25 patients had still incontinence; 55% of the patients had unchanged postoperative bowel function, 22% described improvement (including the four patients with resection-rectopexy) but 38% (21/55) suffered from postoperative 'constipation'. The rate of 'constipation' induced or majored by rectopexy was 22% but the functional trouble described appeared often complex. CONCLUSION: Posterior Orr-Loygue rectopexy is the operation recommended for patients in good general condition, especially if fecal incontinence is associated. In the course of the procedure, preservation of pelvic nerves and hypogastric plexus, and positioning of the strips not too tight between the anterolateral rectal walls and promontory must be emphasized. Posterior Orr-Loygue rectopexy is contraindicated when general anesthesis is too risky and when bowel dysfunction and/or rectal exoneration dysfunction are present.

Adolescent↗

PubMed2001

Cadaveric dissection for the rectal surgeon.

The benefits of total mesorectal excision are due to the complete excision of the mesorectum with preservation of the pelvic autonomic nerve plexuses, the hypogastric nerves and nervi erigentes. Several important structures are incompletely seen at operation, and cadaveric dissection of an intact lower trunk and a sagittally hemisected pelvis is a valuable exercise in demonstrating them. A method for dissection is described which illustrates the key anatomical points.

Autonomic Nervous System↗

PubMed2001

Iatrogenic ejaculation disorders and their prevention.

Ejaculation is mediated by sympathetic fibers originating from the D10-L2 medullar center. These nerves rise from the lumbar ganglia of the paravertebral sympathetic trunk and travel posteriorly to the vena cava and then to the interaortocaval space, on the right side, and laterally to the aorta, on the left side. They are the principal constituents of the superior hypogastric plexus. Many surgical operations can cause an ejaculation disorder, but the most important is retroperitoneal lymphadenectomy (RL) for testis cancer, because it involves young patients and it has been the subject of important researches in order to perform lymph node dissection without ejaculation loss (unilateral lymphadenectomy and nerve sparing lymphadenectomy). Our experience concerns 41 patients who underwent RL for testis cancer from 1983 to 1998. Survival rate was 95.2% (mean follow up 64 months). RL was performed bilaterally in 14 patients. Two of them died of metastases within 2 years after the operation. Ejaculation was maintained in only 4 of the 12 surviving patients (33%). All the 17 patients (100%) underwent right monolateral RL and 7 of the 10 (70%) underwent left monolateral RL preserved ejaculation. The anatomosurgical concepts of the RL sparing the ejaculation can be adopted in other retroperitoneal surgical operations that can produce ejaculation disorders, such as wide lymphadenectomy for renal cell carcinoma or tumors of the upper urinary tract, exeresis of pre- aortic tumors, exeresis or disjunction of horseshoe kidney and aorto-iliac revascularization. Surgical therapy of benign prostatic hyperplasia (BPH) (open surgery or transurethral prostatic resection) is associated with retrograde ejaculation in nearly 100% of cases. The mechanism of the dysfunction is clear, if following the procedure the bladder neck remains opened. Loss of ejaculation is reported in variable percentage after the newer endoscopic techniques for the treatment of BPH. Transurethral needle ablation (TUNA) seems to have the lower risk of retrograde ejaculation. Retrograde ejaculation can also be related to a traumatic injury of the posterior urethra, because of the trauma itself or the therapy. Finally, the ejaculation disorder can be produced by several drugs that block, as a main or secondary effect, the alpha-adrenoreceptors or act at the central level. This side effect has to be kept in mind when these drugs are used in young or sexually active patients.

Ejaculation↗