A Combined Technology to Protect the Anatomic Integrity of Distal Urethral Sphincter Complex in Radical Prostatectomy Improves Early Urinary Continence Recovery Without Sacrifice of Oncological Outcomes

PurposeOur primary aim was to present a combined technique to protect the anatomic integrity of distal urethral sphincter complex (DUSC) during minimally invasive radical prostatectomy (RP) and discuss its impact on urinary continence (UC) recovery. The second aim was to define the learning curve of the combined technique.MethodsWe conducted a non-randomized retrospective study. There were 314 consecutive patients who received RP by the same urologist surgeon with more than 2,000 prior cases in Shanghai Ruijin Hospital between March 2017 and April 2020. Included in this study were 263 patients with clinical T1–T2 stage. We modified a combined RP (Comb-RP) technique including endopelvic fascia no-incising technique, dorsal venous complex (DVC) no-ligation technique, intrafascial dissection technique, and anterior reconstruction technique so as to preserve the anatomic integrity of DUSC. The patients were assigned to two groups: a Comb-RP group and a conventional RP (Conv-RP) group. Continence rates were assessed every 3 months after removal of the catheter. UC was defined as 0 pad per day. Peri-operative variables of the patient including operation time, estimated blood lost (EBL), positive surgical margin (PSM), and postoperative complications were also collected. Scatter-graphs of learning curves were drawn using locally weighted scatterplot smoothing (LOWESS).ResultsRP was accomplished smoothly in all 263 cases. The pad-free UC rates in Conv-RP group and Comb-RP group were 17.3 vs. 27.8% (P = 0.048) at the removal of the catheter, 35.8 vs. 50.0% (P = 0.027) at 1 month, 60.5 vs. 76.1% (P = 0.012) at 3 months, 87.7 vs. 96.5% (P = 0.022) at 6 months, and 94.7 vs. 97.7% (P = 0.343) at 12 months. Kaplan–Meier analysis showed significantly higher and faster continence recovery in the Comb-RP group (mean 4.9 vs. 2.6 months, Log Rank P = 0.001). There was no significant difference in PSM rate between the Comb-RP and Conv-RP group (31.1 vs. 31.2%, P =0.986). The learning curves of peri-operative variables, oncological and functional outcomes achieved the lowest point or plateau at the 20th–60th cases.ConclusionsThe anatomic integrity and intact pelvic floor interplay of DUSC is important for its function. Our combined technique was a safe and feasible technique for improving early UC in RP with no significantly increased PSM rate and no significant difference in long-term UC.

A simplified cervix model in response to induction balloon in pre-labour

Background: Induction of labour is poorly understood even though it is performed in 20% of births in the United States. One method of induction, the balloon dilator applied with traction to the interior os of the cervix, engages a softening process, permitting dilation and effacement to proceed until the beginning of active labour. The purpose of this work is to develop a simple model capable of reproducing the dilation and effacement effect in the presence of a balloon. Methods: The cervix, anchored by the uterus and the endopelvic fascia was modelled in pre-labour. The spring-loaded, double sliding-joint, double pin-joint mechanism model was developed with a Modelica-compatible system, MapleSoft MapleSim 6.1, with a stiff Rosenbrock solver and 1E-4 absolute and relative tolerances. Total simulation time for pre-labour was seven hours and simulations ended at 4.50 cm dilation diameter and 2.25 cm effacement. Results: Three spring configurations were tested: one pin joint, one sliding joint and combined pin-joint-sliding-joint. Feedback, based on dilation speed modulated the spring values, permitting controlled dilation. Dilation diameter speed was maintained at 0.692 cm · hr−1 over the majority of the simulation time. In the sliding-joint-only mode the maximum spring constant value was 23800 N · m−1. In pin-joint-only the maximum spring constant value was 0.41 N·m· rad−1.With a sliding-joint-pin-joint pair the maximum spring constants are 2000 N · m−1 and 0.41 N · m · rad−1, respectively. Conclusions: The model, a simplified one-quarter version of the cervix, is capable of maintaining near-constant dilation rates, similar to published clinical observations for pre-labour. Lowest spring constant values are achieved when two springs are used, but nearly identical tracking of dilation speed can be achieved with only a pin joint spring. Initial and final values for effacement and dilation also match published clinical observations. These results provide a framework for development of electro-mechanical phantoms for induction training, as well as dilator testing and development.

A simplified cervix model in response to induction balloon in pre-labour

Background: Induction of labour is poorly understood even though it is performed in 20% of births in the United States. One method of induction, the balloon dilator applied with traction to the interior os of the cervix, engages a softening process, permitting dilation and effacement to proceed until the beginning of active labour. The purpose of this work is to develop a simple model capable of reproducing the dilation and effacement effect in the presence of a balloon. Methods: The cervix, anchored by the uterus and the endopelvic fascia was modelled in pre-labour. The spring-loaded, double sliding-joint, double pin-joint mechanism model was developed with a Modelica-compatible system, MapleSoft MapleSim 6.1, with a stiff Rosenbrock solver and 1E-4 absolute and relative tolerances. Total simulation time for pre-labour was seven hours and simulations ended at 4.50 cm dilation diameter and 2.25 cm effacement. Results: Three spring configurations were tested: one pin joint, one sliding joint and combined pin-joint-sliding-joint. Feedback, based on dilation speed modulated the spring values, permitting controlled dilation. Dilation diameter speed was maintained at 0.692 cm · hr−1 over the majority of the simulation time. In the sliding-joint-only mode the maximum spring constant value was 23800 N · m−1. In pin-joint-only the maximum spring constant value was 0.41 N·m· rad−1.With a sliding-joint-pin-joint pair the maximum spring constants are 2000 N · m−1 and 0.41 N · m · rad−1, respectively. Conclusions: The model, a simplified one-quarter version of the cervix, is capable of maintaining near-constant dilation rates, similar to published clinical observations for pre-labour. Lowest spring constant values are achieved when two springs are used, but nearly identical tracking of dilation speed can be achieved with only a pin joint spring. Initial and final values for effacement and dilation also match published clinical observations. These results provide a framework for development of electro-mechanical phantoms for induction training, as well as dilator testing and development.

Relationship between the endopelvic fasciae and the inferior hypogastric plexus Activity Log

The Inferior Hypogastric Plexus (PHI) is a difficult plexus to define and dissect, hence the ease with which it can be injured both in anatomical and surgical research. Defining its relationships, with respect to the endopelvic fascia (FEP), including its formation and branches, (Baader B., et al., 2003, p. 129) would facilitate their dissection. This anatomical investigation aims to standardize different portions that require a different approach to preserve their integrity. Cadaveric material belonging to the Third Chair of Anatomy of the School of Medicine, Buenos Aires University was used. One (n=1) formolized male adult organ block and seventeen (n=17) hemipelvis were dissected: five (n=5) adult male hemipelvis formolized, nine (n=9) fetal hemipelvis formolized (7 male and 2 female), between 18 and 36 weeks of gestational age calculated by femoral length, and three (n=3) adult hemipelvis from fresh cadavers, two (n=2) female and one (n=1) male. Microdissection elements and magnifying glasses were used. We were able to distinguish three different sectors: the first, preplexual, located posterior and lateral to the FEP, where the sympathetic components (hypogastric nerves) and the parasympathetic (pelvic splanchnic nerves) have not yet converged to form the plexus. A second sector, plexual, with the plexus already fully formed, located in the thickness of the FEP. Finally, its terminal portion, already devoid of the FEP, formed by nerves that go to the perineal membrane accompanied by arterial and venous vessels. Each of these sectors requires a different approach in both anatomical and surgical dissection.

Enterocele Presenting as Anterior Rectal Prolapse: Resolution with Vaginal Repair

An enterocele is a pelvic hernia formed from the separation of endopelvic fascia, associated with the posterior or anterior vaginal fornix, and most commonly located in the posterior superior vaginal segment. Rectal prolapse is a debilitating condition in which the mucosa of the rectum protrudes circumferentially from the anus. Surgical repair is the recommended treatment for rectal prolapse, and though there are many different surgical options, there is no consensus on which approach is best. We present a case of anterior rectal prolapse due to enterocele which was treated by correction of enterocele with a vaginal approach and propose some clinical features and diagnostic techniques that may distinguish this entity from traditional rectal prolapse.

Transvaginal mesh repair of anterior enterocele following radical cystectomy and ileal conduit diversion

Complex pelvic organ prolapses may develop after radical cystectomy. We report a case of an anterior enterocele, which was repaired vaginally and using mesh placed extraperitoneally. We present the case of a 75-year-old woman who underwent a radical cystectomy and ileal conduit diversion for treatment of invasive bladder cancer. She developed a vaginal vault prolapse 4 months later. She then underwent a vaginal repair and sacrospinous fixation using no mesh. She then presented to our clinic 4 months later with a prolapse recurrence involving an anterior enterocele. She was treated successfully with a transvaginal mesh repair for reconstruction of the anterior vaginal wall, iliococcygeal suspension and colpocliesis. We argue that there is a place for the vaginal use of mesh in the surgical treatment of an anterior enterocele when a substantial loss of endopelvic fascia is encountered. The extraperitoneal technique seems to be a good option while reducing the surgical risks for the patient.