Internal Spermatic Fascia Research Articles

ANGIOEMBOLISATION OF CREMASTERIC ARTERY FOR SCROTAL HAEMATOMA FOLLOWING HERNIAL REPAIR

Cremasteric artery is a branch of inferior epigastric artery supplying the cremaster muscle and coverings of the cord. The possible consequence of injury to this artery is scrotal haematoma. We present a case of haemorrhage from unexpected cresmastric artery injury post-hernioplasty treated with angioembolisation. To the best of our knowledge, this has not been reported in literature.
 A 66-year-old gentleman with left indirect inguinal hernia underwent a left inguinal hernioplasty in our institution with no immediate complications. However he presented to the emergency department the day after the procedure with complaints of rapidly worsening painful left scrotal swelling accompanied with symptoms of intestinal obstruction. Emergency laparotomy and re-do left hernioplasty was performed, revealing a strangulated inguinoscrotal hernia. Post-operatively, there was non-resolving scrotal swelling with a drop in the haemoglobin level; from 11.9g/dl to 8.5g/dl requiring packed cell transfusion. CT angiogram revealed active contrast extravasation from the left cremasteric artery. Angiographic run confirmed the finding and the left cresmatric artery was superselectively cannulated with a 1.9Fr microcatheter and embolization done with 0.5mm microcoil. Ultrasound scan 24-hour post-procedure showed patent proximal vessel. Clinically there was a reduction of the left scrotal swelling and the haemoglobin remained stable. 
 Cremasteric artery courses laterally deep into the fascia transversalis entering the cord deep to the internal spermatic fascia to supply the cremaster muscle and coverings of the cord. This course renders the artery to be prone for injury during procedure such as hernioplasty; one of the possible consequences is scrotal haematoma. This artery is usually small in caliber and its identification is important for efficient and effective treatment.
 Angioembolisation is able to treat this injury with superior precision owing to its ability for localization and selective cannulation of the offending vessel.

Embryonic developmental process and clinical anatomy of the preperitoneal fascia and its clinical significance.

Many researchers have different views on the origin and anatomy of the preperitoneal fascia. The purpose of this study is to review studies on the anatomy related to the preperitoneal fascia and to investigate the origin, structure, and clinical significance of the preperitoneal fascia in conjunction with previous anatomical findings of the genitourinary fascia, using the embryogenesis of the genitourinary system as a guide. Publications on the preperitoneal and genitourinary fascia are reviewed, with emphasis on the anatomy of the preperitoneal fascia and its relationship to the embryonic development of the genitourinary organs. We also describe previous anatomical studies of the genitourinary fascia in the inguinal region through the fixation of formalin-fixed cadavers. Published literature on the origin, structure, and distribution of the preperitoneal fascia is sometimes inconsistent. However, studies on the urogenital fascia provide more than sufficient evidence that the formation of the preperitoneal fascia is closely related to the embryonic development of the urogenital fascia and its tegument. Combined with previous anatomical studies of the genitourinary fascia in the inguinal region of formalin-fixed cadavers showed that there is a complete fascial system. This fascial system moves from the retroperitoneum to the anterior peritoneum as the preperitoneal fascia. We can assume that the preperitoneal fascia (PPF) is continuous with the retroperitoneal renal fascia, ureter and its accessory vessels, lymphatic vessels, peritoneum of the bladder, internal spermatic fascia, and other peritoneal and pelvic urogenital organ surfaces, which means that the urogenital fascia (UGF) is a complete fascial system, which migrates into PPF in the preperitoneal space and the internal spermatic fascia in the inguinal canal.

小児陰嚢水腫・精索水腫の新手術法 : われわれの腹膜鞘状突起・内精筋膜一括閉鎖術の実際

小児陰嚢水腫・精索水腫の新手術法 : われわれの腹膜鞘状突起・内精筋膜一括閉鎖術の実際

V8-07 MICROSCOPIC SUBINGUINAL VARICOCELECTOMY WITH LIGATION OF CREMASTERIC MUSCLE FIBERS

You have accessJournal of UrologyMale Voiding/Infection/Infertility/Testis1 Apr 2014V8-07 MICROSCOPIC SUBINGUINAL VARICOCELECTOMY WITH LIGATION OF CREMASTERIC MUSCLE FIBERS Brooke Harnisch and Jay Sandlow Brooke HarnischBrooke Harnisch More articles by this author and Jay SandlowJay Sandlow More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2154AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Microscopic subinguinal varicocelectomy reduces hydrocele formation and varicocele recurrence. However, failure to ligate small veins around the testicular artery and those within the cremasteric muscle fibers can cause varicocele recurrence even in the best of hands. We demonstrate our approach to microscopic subinguinal varicocelectomy where cremasteric muscle fibers are ligated with low complication and recurrence rates. METHODS An IRB approved database was queried for all patients undergoing microscopic subinguinal varicocelectomy between March 2005 and June 2013 by a single surgeon. A 3 cm subinguinal incision was made. The cord structures were then grasped with an atraumatic Babcock clamp and brought out through the wound. Through the operating microscope at 10-20X magnification, cremasteric fibers were dissected and isolated. Internal spermatic fascia was incised. The vas deferens and associated vessels were isolated and separated from the remaining cord structures using a vessel loop. A vascular Doppler probe was used to identify the spermatic artery. Internal spermatic veins were identified and ligated. Individual lymphatic vessels were preserved whenever possible. Cremasteric fibers were then ligated and cauterized. Demographic, clinical, laboratory data, and complications were reported. RESULTS A total of 184 patients were identified. Mean age was 32.8 ±4.7. A majority of patients had grade II varicoceles and underwent a bilateral procedure. Mean sperm concentration, sperm motility and total progressive motile sperm significantly improved post-operatively (Table 1). Overall, complication rate was 1%. There were two hydroceles and one spermatic cord hematoma. Testicular atrophy and varicocele recurrence did not occur in any patients. CONCLUSIONS Microscopic subinguinal varicocelectomy with ligation of the cremasteric fibers offers an effective method in controlling cremastric veins resulting in minimal complications with no evidence of recurrence. Results: Pre and Post-Operative Semen Analysis Semen parameters Pre-operative (mean± SD) Post-operative (mean± SD) P value Sperm concentration (million/ml) 11.7 ± 13.3 18.2 ± 18.9 < 0.001 Sperm motility (%) 35.1 ± 14.6 41.5 ± 16 < 0.001 Total progressive motile sperm (million) 9.9 ± 16.1 18.5 ± 26.7 < 0.001 © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e786-e787 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Brooke Harnisch More articles by this author Jay Sandlow More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Penile Pump Placement for the Inflatable Penile Prosthesis

FIGURE 1 During penile prosthesis insertion, penile pump placement is important. Patient satisfaction can be highly influenced by a malpositioned penile pump. The layers of the scrotum are depicted. Ideally, the penile pump is placed in the midline in a space developed by incising the midline scrotal-spongiosal septum, in between the external and internal spermatic fascia, and secured with sutures. Scrotal septum Superficial inguinal ring

Subinguinal Varicocelectomy With Loupes Only, Sans Surgical Microscope

Dear Editor, I would like to comment Abdelrahman and Eassa on their important paper on the assessment of loupe-assisted subinguinal varicocelectomy in infertile men (1). Methodology was complete, including a group of patients and another of controls, of adequate sample size, defined with valid inclusion and exclusion criteria, and followed-up at 3 and 6 months with measures of seminal count/morphology and relevant hormones. As for surgical anatomy and technique, the authors correctly approached internal spermatic veins after opening the internal spermatic fascia. They correctly mention a ‘compartment of the vas’ internal to the internal spermatic fascia. Many experts, however, erroneously state that the vas sits outside the internal spermatic fascia (2). The vas indeed lies internal to the internal spermatic fascia (i.e. in the spermatic cord’s internal compartment) but is further ensheathed by a membranous layer continuing from the respective layer of the abdominopelvic extraperitoneal tissue. The internal spermatic vessels, nerves and lymphatics all within the internal compartment are similarly packed by another membranous sheath (3). The authors preserved the veins of the vas, “except when abnormally engorged veins were evident”. My preference is not to ligate these, but instead cremasteric veins plus their anastomoses with the external pudendal vein. The cremasteric veins are found between the internal and external spermatic fasciae, i.e. in the cord’s external compartment. Intact veins of the vas serve for venous flow after ligation of the internal spermatic and cremasteric veins. Gubernacular veins were not ligated; consequently the testis was not delivered. I concur: if sacrificed, testicular venous return relies only on the small deferential veins (3). With loupes only (sans surgical microscope), 0% recurrence and 0% hydrocele were achieved; admirable rates, totally comparable with those of subinguinal varicocelectomy under microscope -better than rates of others using loupes [2.9% hydrocele, 2.9% reccurence (4)]. Complication rates of subinguinal varicocelectomy without loupes— 15% hydrocele, 10% recurrence seem higher than others’ 7.3% hydrocele, 2.63% recurrence (5), which, however, merge inguinal and subinguinal procedures. In statistical analysis, the authors unfortunately disregarded their paired and time-series design, and performed multiple, pair-wise comparisons, increasing probability of type I error. Instead, analysis should start with testing for normal distribution; if so, a 2-way-ANOVA for repeated measurements would reveal an overall difference; then post-hoc analysis should follow to detect differences between duos of data. In case of non-normal distribution, Friedman test should be applied for the time-series triplets of each group, and Mann-Whitney U-tests for duos of data at each time point (6). In conclusion, the paper strongly supports loupe-assisted subinguinal varicocelectomy in infertile adults. It can be ameliorated in surgical anatomy regarding compartments of the spermatic cord, and has pitfalls in statistical analysis. Nevertheless, the paper has great virtues: excellent surgical results and justified semen and hormonal findings. What I liked most was the honest declaration ‘so it [this technique] should be used, especially in developing countries where the microsurgery equipment is not available every where”. I hope the authors obtain this equipment. I look forward to reading their next paper on microsurgical subinguinal varicocelectomy.

Microanatomy of the spermatic cords during microsurgical inguinal varicocelectomy: initial experience in Asian men

The microanatomy of the inguinal spermatic cords has never been reported in Asia. The purpose of this study was to describe the number and relationship of the veins, arteries and lymphatics in the spermatic cord and to clarify the location of the vas deferens in Asian men. Fifty-one patients receiving 79 primary microsurgical varicocelectomies performed by a single surgeon from April 2011 to July 2012 were studied. The number of internal and external spermatic veins, testicular arteries and lymphatic channels preserved during the inguinal microsurgical varicocelectomy were recorded. The relationship between the right and left vascular anatomy during bilateral varicocelectomies was evaluated. The data showed that mean numbers of 1.5±0.9 arteries, 5.6±2.2 spermatic veins and 3.6±1.9 lymphatics were identified during the repairs. The internal spermatic arteries were surrounded by a dense complex of adherent veins in 81.2% of the cases. The external spermatic vein or veins were found in 60.8% of the cases. The vas deferens may be contained within the internal spermatic fascia. The results suggest that the number of veins may be highly variable and less than those reported in the English literature, but there is some similarity in the inguinal microanatomy of the right and left spermatic cords. Further research is warranted to clarify our results.

Vasectomy occlusion technique combining thermal cautery and fascial interposition

Recent research on vasectomy shows that combining cautery and fascial interposition (FI) achieves the most effective occlusion of the vas and minimizes the risk of failure. We present a technique that combines cautery and FI and is suitable for low-resource settings. The surgical technique consists of 1) exposing the vas with the no-scalpel approach; 2) cauterizing the epithelium of lumen of the vas using a portable battery-powered cautery device; 3) performing FI by grasping internal spermatic fascia and applying a free tie with suture material on the fascia to cover the prostatic stump of the vas and separate the two ends of the cut vas; and 4) excising a small 0.5 to 1 cm of the testicular stump. To maximize vasectomy effectiveness, vasectomy providers should consider learning thermal cautery and FI to occlude vas deferens.

Angiofibrolipoma of the spermatic cord

Dear Sir, I am Dr Qing-Li Liu, from the Department of Urology of the First Hospital of Qinhuangdao in Qinhuangdao, Hebei Province, China. I write to present a case report of spermatic cord angiofibrolipoma. Angiofibrolipoma is a histological variant of lipoma, which usually presents as a solitary, subcutaneous, circumscribed lesion in the back, neck or shoulders. Here, we report a case of angiofibrolipoma of the spermatic cord. To our knowledge, such a case has not been previously reported in the literature. A 3-year-old boy presented with a right inguinal mass that had first been noticed 1 month earlier. On physical examination, the mass was located in the right spermatic cord and felt elastic, with no tenderness. The transillumination test was negative. Ultrasonography of the spermatic cord revealed a cystic-solid echo mass lesion, 2.5 cm in diameter, with minimum blood flow. Under general anaesthesia, a 3-cm inguinal oblique incision was made and the spermatic cord was isolated and occluded with a noncrushing clamp at the level of the internal ring. A tumour was found under the internal spermatic fascia; the tumour had a well-circumscribed boundary and was not adjacent to the right testicle and epididymis. The spermatic vessels and vas deferens were identified posterior to the mass. A 0.2-cm-thick pseudo-capsule surrounded the entire tumour. After the spermatic vessels and vas deferens were securely protected, the tumour was completely removed. Macroscopic examination revealed that the cut surface of the tumour was a multilocular cyst filled with blood, and there were no necrotic or cystic changes. The pathological examination revealed mature adipocytes, blood vessels and dense collagenous tissue (Figure 1), without the evidence of mitosis or cellular pleomorphism. These findings were consistent with angiofibrolipoma. At 6-month follow-up, there was no evidence of recurrence and the right testicle size was normal. Figure 1 A histological study (H&E stain) showed the three characteristic findings of angiofibrolipomas: mature adipocytes, blood vessels and dense collagenous tissue. (A): Low-power and (B): high-power views. Scale bar = 125 μm Tumours of the spermatic cord are rare. Overall, 30% of such tumours are malignant; and the rest are benign. Lipoma is the most common benign lesion; among the others are leiomyomas, dermoid cysts, epidermoid cysts and lymphangiomas 1. The conventional lipoma is a collection of mature adipocytes arising from subcutaneous tissues of the trunk, neck and proximal extremities 2. Histological variants of lipomas include fibrolipomas, angiolipomas, angiofibrolipomas, angiomyolipomas and infiltrating angiolipomas. These lesions are categorized according to their content of fat, muscle, blood vessel and connective tissue. The growths are not encapsulated but are histologically distinct from surrounding tissues. They have low-to-moderate cellularity and are not clinically aggressive 3, 4. Angiofibrolipomas are a mixture of mature adipocytes, vascular tissue and collagenous connective tissue. To our knowledge, the present case study is the first report of a spermatic cord angiofibrolipoma. The patient presented with an elastic inguinal mass on physical examination, and the diagnosis required histopathological assessment. Perhaps a preoperative incisional biopsy of the lesion could have confirmed the diagnosis before definitive resection. However, as with any lipoma, complete surgical excision and histopathological confirmation of margins are adequate for both diagnosis and treatment. During the operation, we found a fibrous pseudo-capsule, which was formed through a desmoplastic reaction 5. The pseudo-capsule was helpful in the tumour resection and in protecting the spermatic vessels and vas deferens from damage. In such cases, surgical excision, histological examination and long-term follow-up for recurrence are recommended.

Extravaginal testicular torsion: a clinical entity with unspecified surgical anatomy

To review and evaluate the anatomical definitions of perinatal extravaginal torsion (EVT) of the testis. An extensive review of the literature was made to reveal the prevalent anatomical background predisposing to EVT. Gross appearance of twisted testes obtained during surgery for 14 cases of EVT was used to test the validity of the above theories. The most commonly accepted suggestions describe an EVT within dartos muscle that includes all layers of spermatic cord or an EVT outside parietal layer of tunica vaginalis within internal spermatic fascia. However, both of them were found inadequately documented, while a large volume of controversial data has been accumulated, that raises doubts regarding the validity of such definitions. The gross appearance of twisted testes failed to confirm both an EVT including all layers of the spermatic cord and also an EVT outside tunica vaginalis as possible mechanisms of torsion. The anatomical basis of EVT remains unclear and further investigation is required.

Inhibition of tumor necrosis factor-α-induced intercellular adhesion molecule-1 expression in diabetic rats: role of insulin

The effects of insulin on intercellular adhesion molecule (ICAM)-1-mediated leukocyte adhesion and migration were investigated. Diabetic rats (alloxan, 42 mg/kg, i. v., 42 days), matching controls, and insulin (NPH, 2 IU/day for 12 days) treated diabetic rats were used. The internal spermatic fascia of the animals was used for direct vital microscopy of the microcirculation, and for quantitation of ICAM-1 expression by immunohistochemistry and reverse transcriptase-polymerase chain reaction (RT-PCR). Experiments were performed 2 h after the local injection of recombinant rat tumor necrosis factor-alpha (5 ng). Relative to controls (C), diabetic (D) rats exhibited a reduced number of adhered (D: 2.2 +/- 0.4 and C: 14.1 +/- 0.6 cells/100 microm venule length, P < 0.001) and migrated leukocytes (D: 1.1 +/- 0.3 and C: 6.3 +/- 0.6 cells/1,000 microm (2), P < 0.001) accompanied by low expression of ICAM-1 in postcapillary venules (D: 18 +/- 4 and C: 51 +/- 7 arbitrary units, P < 0.001). There were no differences in ICAM-1 mRNA levels (D: 1.01 +/- 0.05 and C: 1.18 +/- 0.09 ICAM-1/GAPDH ratio, P > 0.05). Treatment of diabetic rats with insulin restored the number of adhered (10.9 +/- 1.2 cells/100 microm venule length), and migrated leukocytes (4.0 +/- 0.3 cells/1,000 microm (2)) as well as ICAM-1 expression (45 +/- 3 arbitrary units). Levels of mRNA for ICAM-1 remained unchanged after treatment (1.15 +/- 0.04 ICAM-1/GAPDH ratio). Insulin modulates TNF-alpha-induced ICAM-1 expression on microvascular endothelium controlling, therefore, leukocyte adhesion and migration.

Resuscitation affects microcirculatory polymorphonuclear leukocyte behavior after hemorrhagic shock: role of hypertonic saline and pentoxifylline.

We have previously shown that lung injury following fluid resuscitation either with hypertonic saline (HS) or lactated Ringer's (LR) plus pentoxifylline (PTX) attenuated acute lung injury when compared with LR resuscitation. The objective of the present study is to determine whether our previous observations are accompanied by changes in polymorphonu-clear leukocyte (PMN) behavior. To study this, PMN-endothelial cell interactions, microcirculatory blood flow, lung histology, lung PMN infiltration (MPO, Myeloperoxidase), and lung intra-cellular adhesion molecule-1 (ICAM-1) expression were assessed in a controlled hemorrhagic shock model followed by LR, HS, and LR+PTX resuscitation in rodents. Rats (240-300 g) were bled to a mean arterial pressure (MAP) of 35 mm Hg for 1 hr and then randomized into three groups: HS (7.5% NaCl, 4 ml/kg); LR (3x shed blood); and LR+PTX (25 mg/kg). Additionally, total shed blood was reinfused. A sham group underwent no shock and no treatment. The internal spermatic fascia was exteriorized and the microcirculation was observed by closed-circuit TV coupled to a microscope, 2 and 6 hrs after treatment. The number of leukocytes sticking to the venular endothelium was determined 2 hrs after fluid resuscitation. Microcirculatory blood flow was measured by an optical Doppler velocimeter. Lung histology and lung MPO immunostaining were assessed at 6 hrs, and lung ICAM-1 expression was determined by immunostaining at 2 hrs following fluid resuscitation. Two hours after treatment, HS (1.4 +/- 0.4), LR+PTX (1.7 +/- 0.3), and sham (0.4 +/- 0.2) groups presented significant reductions in leukocyte adherence (cells/100 microm venule length), compared with the LR group (4.0 +/- 0.9, P < 0.05). No differences were observed 6 hrs after treatment on leukocyte adherence and microcirculatory blood flow. ICAM-1 expression was significantly higher in LR-treated animals compared with the HS, LR+PTX, and sham groups (P < 0.01). PMN infiltration and overall lung injury were significantly attenuated by HS and LR+PTX. These results support earlier studies that indicated the potential application of HS and PTX in shock therapy and the increase in PMN-endothelial cell interaction and lung injury after LR resuscitation.

Enalapril interferes with the effect of diclofenac on leucocyte-endothelium interaction in hypertensive rats.

Nonsteroidal anti-inflammatory drugs are known to attenuate the effects of some antihypertensive agents. However, the effect these drugs have on leukocyte migration when combined with antihypertensive agents has not been studied. To investigate this effect, we treated spontaneously hypertensive rats with saline, diclofenac, enalapril, or diclofenac combined with enalapril and observed leukocyte-endothelium interaction. Blood pressure was increased by diclofenac, reduced by enalapril and reduced by the combination of the two. Diclofenac did not interfere with the blood pressure-lowering effect of enalapril. Internal spermatic fascia venules were observed using intravital microscopy. Diclofenac reduced rollers, whereas enalapril, alone or combined with diclofenac, had no significant effect on rollers. All treatments reduced adherent and migrated leukocytes and expression of endothelial intercellular adhesion molecule-1. Venular shear rate, venular diameters, number of circulating leukocytes, and post-leukotriene B4 expression of l-selectin and CD11/CD18 integrin in leukocytes were unaffected by any treatment. Expression of P-selectin was reduced by diclofenac and unaffected by enalapril, even when combined with diclofenac. Our data suggest that, although diclofenac does not interfere with the enalapril anti-hypertensive effect, enalapril interferes with the effect diclofenac has on leukocyte rolling and endothelial P-selectin expression. Involvement of reduced endothelial intercellular adhesion molecule-1 expression might explain the lower numbers of adherent and migrated leukocytes. The anti-inflammatory properties of a nonsteroidal anti-inflammatory drug could therefore be attenuated in hypertensive patients receiving an angiotensin-converting enzyme inhibitor.

Probucol restores the defective leukocyte–endothelial interaction in experimental diabetes

Defective leukocyte–endothelial interactions have been observed in experimental type 1 diabetes. One of the mechanisms involved in the late complications of diabetes mellitus is the formation of free radicals species. Antioxidant treatment has been demonstrated to have beneficial effects on the complications observed in this pathology. Using intravital microscopy to visualize venules of the internal spermatic fascia, we demonstrated that the defective leukocyte–endothelial interactions in alloxan-induced diabetic rats could be corrected by probucol treatment. The defects were quantitated by the number of leukocytes rolling along the venular endothelium, sticking to the venular wall after topical application of zymosan-activated plasma (10%–0.1 ml) or leukotriene B 4 (1 μM/0.1 ml) and migrated after the application of a local irritant stimulus (carrageenan, 100 μg/0.1 ml). Leukocyte counts, erythrocyte velocity and venular shear rate, unaltered in diabetic rats, were not modified by this treatment. Reactive oxygen species formation by endothelial cells increased in diabetic preparations, and the reduced expression of adhesion molecules such as intercellular adhesion molecule-1 (ICAM-1) and P-selectin in cross-sections of the whole testis of the animals, were both restored by the antioxidant agent. Therefore, antioxidant treatment improves leukocyte–endothelial interaction in diabetic rats at least in part by restoring the expression of adhesion molecules in venules of diabetic rats.

Minalrestat and leukocyte migration in diabetes mellitus.

We recently demonstrated that aldose reductase inhibition was effective in restoring the reduced migratory capacity of leukocytes in diabetic rats. To investigate the mechanism(s) involved in the restoring effect, we used minalrestat, an aldose reductase inhibitor. In sodium pentobarbital-anesthetized (40 mg/kg, intraperitoneally) alloxan-diabetic or galactosemic male Wistar rats, the internal spermatic fascia was exteriorized, and the number of leukocytes rolling along the venular endothelium and the number of leukocytes sticking to the vascular wall after topical application of zymosan-activated plasma or leukotriene B(4) (1 ng/ml), as well as after the application of a local irritant stimulus (carrageenan, 100 microg), were determined using intravital microscopy. Data from animals that were treated with and those that were not treated with minalrestat (10 mg/kg/d by gavage) were compared. The reduced number of leukocytes rolling along the venular endothelium (by about 70%) and the number of adhered and migrated leukocytes in postcapillary venules (by 60%) were significantly restored to control values after minalrestat treatment. Total or differential leukocyte counts, venular blood flow velocity or wall shear rate were not altered by minalrestat treatment. The expression of ICAM-1 and P-selectin, cell adhesion molecules involved in the interaction of leukocyte-endothelium, reduced in diabetic rats was restored by minalrestat treatment. We conclude that an enhanced flux through the polyol pathway might be involved in the reduced expression of ICAM-1 and P-selectin contributing to the impaired leukocyte-endothelial interactions in diabetes mellitus and that aldose reductase inhibition restores the defect, restoring the reduced expression.

Assessment of efficacy of bothropic antivenom therapy on microcirculatory effects induced by Bothrops jararaca snake venom

Intravenous administration of antibothropic antivenom (BAv) neutralises the systemic effects, but does not efficiently reverse the local symptoms elicited by the Bothrops jararaca venom (BjV). The mechanisms involved in this poor protection have not been clarified. In this work, intravital microscopy studies were carried out to determine the efficacy of different schedules of BAv treatment on local effects evoked by topical application of BjV in the microcirculatory network of the internal spermatic fascia of Wistar rats. Results demonstrated that BAv administration 15 min before, simultaneously with, or 15 min after BjV application did not totally reverse the local symptoms, represented by disturbances of coagulation, development of haemorrhage lesions, vascular permeability increase and increment on leukocyte–endothelium interactions. This lack of effectiveness neither reflects an inadequate amount of specific antibodies in the antivenom against toxins responsible for local effects nor an insufficient dose of circulating BAv during the assays. Administration of fluorescein isothiocyanate (FITC) labelled-BAv showed the dynamics of distribution of the antivenom in the microcirculatory network. Images obtained from prior and simultaneously treated animals showed that the antivenom remains at luminal side of vessels before venom application, and the latency time to antivenom leakage is coincidental to that for local effects evoked by the venom. In addition, images from posterior treatment demonstrated that the intense alterations in the microcirculatory network impair antivenom distribution at the site of injection. Together, our data show that the lack of effectiveness of antivenom therapy is due to impaired and delayed venom and antivenom interaction at the site of injury.

Ascorbic acid supplementation restores defective leukocyte-endothelial interaction in alloxan-diabetic rats.

Defective leukocyte-endothelial interactions are observed in experimental diabetes and may reduce the capacity to mount an adequate inflammatory response. The present study investigated the effect of ascorbic acid, an inhibitor of free radical and glycated protein formation as well as an aldose reductase inhibitor, on leukocyte-endothelial interaction in alloxan-diabetic rats. Rats were rendered diabetic by alloxan injection (40 mg/kg; iv). After 30 days, diabetic and nondiabetic controls were supplemented for 12 days with ascorbic acid (50 or 200 mg/kg/day) or received saline by gavage. The number of rollers, stickers after zymosan-activated plasma (10%) or leukotriene B(4) (1 microM) applied topically, and migrated cells after local injection of carrageenan (100 microg) were determined in the venules of the internal spermatic fascia by intravital microscopy. Erythrocyte velocity and wall shear rate were determined as well. Reactive oxygen species formation by endothelial cells was measured in vivo by the same technique. Immunocytochemistry for ICAM-1 detection on the endothelium of the venules of the internal spermatic fascia was carried out in cross sections of the whole testis of the animals. The reduced number of rollers, stickers and migrated cells, as well as the higher production of reactive oxygen species by endothelial cells in diabetic rats was corrected by ascorbic acid supplementation. The low immunoreactivity for ICAM-1 in the venules of diabetic rats was improved by ascorbic acid supplementation. Ascorbic acid supplementation did not interfere with erythrocyte velocity or wall shear stress. Ascorbic acid administered to control rats did not alter the parameters studied above. We conclude that ascorbic acid improves leukocyte-endothelial interaction in diabetic rats at least in part by restoring the expression of ICAM-1 in the venules of diabetic rats.

Applied anatomy of the genital branch of the genitofemoral nerve in open inguinal herniorrhaphy.

To record the anatomical variations and clinical importance of the genital branch of the genitofemoral nerve in the inguinal canal. Neuropathology study. General hospital, Taiwan. 58 cadavers. 116 dissections findings of the genitofemoral nerve in the inguinal canal. Anatomical variations. All the genital branches passed through the ventral aspect of the internal ring. Almost all these branches entered the ring and continued within the spermatic cord between the fibres of the cremaster and the internal spermatic fascia. In 59% the nerve was related to the inferior fibres and in 38% it was in relation to the lateral or medial fibres. In only 3% did the genital branch run outside the spermatic cord. To avoid damage to the genital branch of the genitofemoral nerve, suturing should be done over the dorsal aspect of the internal ring. The cremaster should be incised longitudinal rather than transversely and the genital branch of the genitofemoral nerve should be identified before repair of the posterior wall.

Lipomas of the cord and round ligament.

To determine the incidence, significance, and anatomy of spermatic cord and round ligament lipomas. This was a retrospective review of 280 hernia repairs on 217 patients performed by a single surgeon (M.E.A.) from January 1996 to January 2000. The incidence of cord lipoma and relationship to inguinal hernia were evaluated. Further, when identified at the time of laparoscopic preperitoneal hernia repair, the anatomy of the lipomas was studied both at the time of surgery and again on review of videotapes. One hundred ninety-nine laparoscopic and 81 open inguinal hernia repairs were performed on 192 male patients and 25 female patients. Sixty-three lipomas of the cord were identified for an incidence of 22.5%. Overall, 18 cord lipomas were found in groins without hernias, and these were identified before surgery in 10 (2 by physical examination, 7 by groin ultrasound, and 1 by magnetic resonance imaging). The remaining nine were misidentified as a hernia before surgery. Fourteen of these patients presented with groin pain and four were asymptomatic. Forty-five lipomas were associated with hernias and were characterized as a hernia by examination in 43 instances. There were 32 (51%) cord lipomas associated with indirect hernias, 11 (17%) with direct hernias, and 1 each with pantaloon and femoral hernias. Nine lipomas were found in women, seven presenting with groin pain and six found without an associated peritoneal defect. Two patients presented with symptomatic cord lipomas after laparoscopic hernia repair. A lipoma of the cord is herniated fat that appears to originate from the retroperitoneal fat outside and posterior to the internal spermatic fascia and protrudes through the internal ring lateral to the cord. They are generally not visible by transperitoneal inspection unless manually reduced. Lipomas of the cord and round ligament occur with a significant incidence. They can cause hernia-type symptoms in the absence of a true hernia (associated with a peritoneal defect). They should be considered in the patient with groin pain and normal examination results. They can be easily overlooked at the time of laparoscopic hernia repair, and this can lead to an unsatisfactory result.

THE ANATOMICAL APPROACH TO INGUINAL ORCHIOPEXY

Achieving a scrotally positioned testis with no iatrogenic atrophy is the primary goal of the surgical treatment of cryptorchidism. The success rate is associated with preoperative testicular position and the technique used. Our success rate with inguinal orchiopexy for abdominal testis is higher than those previously published and may be due to our anatomical approach to retroperitoneal dissection. We review the relevant anatomy and discuss the surgical technique of inguinal orchiopexy. We researched and reviewed the relevant technical and anatomical literature on inguinal orchiopexy, and describe the anatomical approach to orchiopexy in detail. An understanding of the retroperitoneal fascial layers is the key to understanding surgery of the retroperitoneum. Dividing the internal spermatic fascia is required for the surgeon to separate the processus vaginalis from the vas and vessels. The average age of children undergoing cryptorchid surgery has decreased dramatically during the last 40 years. In such young patients extensive mobilization of the vas and vessels may be accomplished through a relatively small incision. We believe that our success rate with inguinal orchiopexy for abdominal testis is associated with our anatomical approach to retroperitoneal dissection.