Middle Rectal Research Articles

Imaging for Hemorrhoidal Disease: Navigating Rectal Artery Embolization from Planning to Follow-up.

Hemorrhoid disease is very common, affecting greater than one-third of adults. Conservative management and several office-based procedures are useful in the treatment of internal hemorrhoids. Patients with refractory hemorrhoid disease have traditionally been treated with surgical hemorrhoidectomy. Rectal artery embolization has emerged as an alternative to surgical hemorrhoidectomy and has been shown to be safe and effective in case series and clinical trials completed over the past decade. Embolization has significantly less postprocedure pain when compared with surgical hemorrhoidectomy with similar outcomes. Pre- and postprocedure imaging are not routinely performed. Intraprocedural imaging consists of selective catheterization of the superior rectal arteries from the inferior mesenteric artery, and the middle rectal arteries from the internal iliac artery. The inferior rectal artery is seldom embolized due to the supply of the levator ani muscle and skin. To date, intermediate and large particles and fibered and nonfibered coils have been used successfully.

Preoperative factors associated with lateral lymph node metastasis in lower rectal cancer and the evaluation of the middle rectal artery.

This study aimed to identify cases in which lateral lymph node (LLN) dissection (LLND) can be excluded by clarifying preoperative factors, including an evaluation of the middle rectal artery (MRA), associated with LLN metastasis. Fifty-five consecutive patients who underwent preoperative positron emission tomography-computed tomography (PET/CT) and total mesorectal excision with LLND for rectal cancer were included. We retrospectively investigated the preoperative clinical factors associated with pathological LLN (pLLN) metastasis. We analyzed the regions of pLLN metastasis using MRA. pLLN metastasis occurred in 13 (23.6%) patients. According to a multivariate analysis, clinical LLN (cLLN) metastasis based on short-axis size and LLN status based on PET/CT were independent preoperative factors of pLLN metastasis. The negative predictive value (NPV) was high (97.1%) in patients evaluated as negative based on PET/CT and cLLN short-axis size. MRA was detected in 24 patients (43.6%) using contrast-enhanced CT, and there was a significant relationship between pLLN metastasis and the presence of MRA. pLLN metastasis in the internal iliac region but not in the obturator region was significantly correlated with the presence of MRA. Combined cLLN metastasis based on short-axis size and PET/CT showed a higher NPV, suggesting this to be a useful method for identifying cases in which LLND can be excluded.

Arterial Embolization as a Prominent Option in the Treatment of Hemorrhoid Diseases

Hemorrhoidal disease (HD) is the most common anorectal disease, affecting millions of people worldwide. The most common clinical picture is rectal bleeding, which significantly impairs the quality of life of patients. Treatment of HD varies from diet and lifestyle changes to radical surgery, depending on the degree and severity of symptoms. Endovascular embolization of superior rectal artery (SRA), known as emborrhoid technique, has recently emerged as a promising minimally invasive approach. Because hemorrhoidal plexuses are almost entirely fed through the SRA. They are also fed less by middle rectal artery (MRA) and rarely inferior rectal artery (IRA). Due to some anastomoses and unpredictable variations, vascular structures must be examined before the procedure. So far, there have been reports of studies involving a small number of patients regarding the use of coils and particles as embolization agents. Some of these used particles and coils alone, while others used a combination of particles and/or coils. The studies demonstrated similar clinical efficacy with satisfactory results, and no significant complications such as ischemic necrosis were observed. The use of liquid embolic agents such as N-butyl-cyanoacrylate (NBCA) and ethylene vinyl alcohol copolymer (EVOH) has also recently been suggested to be effective. In conclusion, the current data support the feasibility, effectiveness, and safety of rectal artery embolization for hemorrhoidal disease. However, there is no guideline or consensus in the selection of embolic materials. More randomized controlled studies are needed. This review aims to evaluate the effectiveness and feasibility of embolization applications in hemorrhoidal diseases.

Improved method of hemostasis for the middle rectal artery

Objective. To obtain data on the comparative characteristics of traditional and improved methods of hemostasis for the middle rectal artery (MRA).Materials and methods. The material for the sectional study was 206 corpses of men (the age of the deceased was from 22 to 82 years, the average age was 57 years) and 113 corpses of women (the age of the deceased was from 32 to 93 years, the average age was 63 years). To achieve the purpose of the study, the following methods were used: vascular injection, dissection, statistical processing. 85 patients of both sexes aged from 57 to 75 years were selected to conduct the clinical part of the study at Gomel Regional Specialized Clinical Hospital. Among them, 50 people were in the comparison group and 35 people were in the main group. All patients were diagnosed with stage I or II rectal cancer. The operative technique for performing hemostasis on the MRA during anterior rectal resection in the comparison group included sequential ligation and stitching between the clamps first of the distal third of the length of this artery, and then its proximal third. In the main group, the method of hemostasis for MRA was supplemented by ligation and stitching of this vessel in the middle third of its length. Statistical data processing included parametric and nonparametric methods of comparative analysis.Results. On cadaveric material, it was found that most of the extraorgan anastomoses of the MRA both in men and women have been localized in the middle third of this artery. The results obtained during the clinical study demonstrate the superiority of the improved hemostasis method for MRA over the traditional method. The proposed method includes additional ligation and stitching of the middle third of the MRA.Conclusion. The improved hemostasis method for MRA in anterior rectal resection is highly effective, which makes it possible to recommend it as the method of choice in the surgical treatment of upper ampullary rectal cancer of stage I or II.

The implications of the anatomy of the nerves and vessels in the treatment of rectosigmoid endometriosis.

Endometriosis is a common benign gynecological disease characterized by the presence of endometrial glands and stroma outside the uterus. It can be defined as endometrioma, superficial peritoneal endometriosis or deep infiltrating endometriosis (DIE) depending on the location and the depth of infiltration of the organs. In 5%-12% of cases, DIE affects the digestive tract, frequently involving the distal part of the sigmoid colon and rectum. Surgery is generally recommended in cases of obstructive symptoms and in cases with pain that is non-responsive to medical treatment. Selection of the most optimal surgical technique for the treatment of bowel endometriosis must consider different variables, including the number of lesions, eventual multifocal lesions, as well as length, width and grade of infiltration into the bowel wall. Except for some major and widely accepted indications regarding bowel resection, established international guidelines are not clear on when to employ a more conservative approach like rectal shaving or discoid resection, and when, instead, to opt for bowel resection. Damage to the pelvic autonomic nervous system may be avoided by detection of the middle rectal artery, where its relationship with female pelvic nerve fibers allows its use as an anatomical landmark. To reduce the risk of potential vascular and nervous complications related to bowel resection, a less invasive approach such as shaving or discoid resection can be considered as potential treatment options. Additionally, the middle rectal artery can be used as a reference point in cases of upper bowel resection, where a trans mesorectal technique should be preferred to prevent devascularization and denervation of the bowel segments not affected by the disease.

Abstract No. 40 Embolization of the Superior and Middle Rectal Arteries for the Treatment of Symptomatic Hemorrhoidal Disease using the Combination of Metallic Coils and Microspheres

To investigate the feasibility and initial results of superior and median rectal artery embolization for patients with symptomatic hemorrhoidal bleeding disease. Prospective, single-center cohort that included 10 consecutive patients who underwent superior (SRA) and middle rectal arteries (MRA) embolization with microspheres (1100 μm) and metallic coils, with a follow-up period of 6 months. Embolizations planning and guidance was performed using Embo_ASSIST software with virtual injection (GE Healthcare, IL). Inclusion criteria comprised: Symptomatic hemorrhoidal disease refractory to clinical treatment, and with Goligher classification II or III. Exclusion criteria were previous surgery for hemorrhoidal disease and Goligher classification IV. Technical success was defined as successful catheterization and embolization of the hemorrhoidal arteries using the EmboASSIST software. Hemorrhoid severity (HSS) and the quality of life (QoL) scores were used to evaluate the clinical outcomes. Procedure-related adverse event was defined according to the Society of interventional Radiology in minor or major complications. Ten patients (4 men, 6 women) underwent rectal arteries embolization for hemorrhoidal bleeding disease, with a mean age of 59 (± 13) years old. Goligher classification were level II in 70% and 3 in 30% of patients. Technical success was achieved in all patients. SRA were embolized in 100% and MRA in 80% (90% unilateral and bilateral in 10%). Mean time off work after hospital discharge was 1.4 (±0.7) days. Median procedures time was 102,5 (± 38) minutes. The HSS and QoL scores improved 91% and 85% respectively, without clinical recurrence at the 6 months follow-up (table 1). One patient (10%) had a rectal ischemia that required surgical treatment. Embolization of both superior and middle rectal arteries was feasible and improved symptoms and quality of life in patients with grade II-III hemorrhoidal disease. No clinical recurrence was observed during the first 6-month follow-up.

Outcomes of Hemorrhoidal Artery Embolization from a Multidisciplinary Outpatient Interventional Center

PurposeTo evaluate the safety and efficacy of outpatient transarterial embolization for symptomatic refractory internal hemorrhoids. Materials and MethodsRetrospective analysis of 134 patients who underwent hemorrhoidal artery embolization (HAE) for symptomatic internal hemorrhoids between August 2021 and June 2022 (76 men and 58 women) was performed. The mean age was 54.9 years, with a mean Goligher hemorrhoid grade (HG) of 2.1. Branches of the superior rectal artery (SRA) or middle rectal artery supplying the corpus cavernosum recti were embolized with both spherical particles and microcoils. Standard-of-care evaluations were performed at baseline and the 1 month follow-up, which included hemorrhoid-related pain (HRP) (0–10), hemorrhoid symptoms score (HSS) (5–20), quality of life (QoL) (0–4), French bleeding score (FBS) (0–9), and HG (0–4). Clinical success was defined as improvement of symptoms without additional treatment. ResultsEmbolization of at least 1 hemorrhoidal artery was achieved in 133 (99%) of the 134 patients. The mean number of SRA branches embolized per patient was 2.9 ± 1.0. Clinical success was seen in 93% (124 of 134) of patients at the 1-month follow-up, with 10 patients requiring repeat embolization. There were significant improvements in all mean outcomes at 1 month: HSS (11–7.8; P < .01), HRP (4.1–1.3; P < .01), QoL (2.2–0.8; P < .01), FBS (4.4–2.2; P < .01), and HG (2.3–1.2; P < .05). There were no severe adverse events. ConclusionsHAE is a safe and effective outpatient treatment for refractory symptomatic internal hemorrhoids in the short term.

The Middle Rectal Artery: Revisited Anatomy and Surgical Implications of a Neglected Blood Vessel.

Although the middle rectal artery is a relevant anatomical landmark for rectal resection and lateral lymph node dissection, descriptions of this entity are highly divergent. Dissection, visualization, morphometry, and 3-dimensional reconstruction of the middle rectal artery to facilitate its management in surgery. Macroscopic dissection, histologic study, morphometric measurements, and virtual modeling. University laboratory of applied surgical anatomy. This study includes formalin-fixed hemipelvis specimens (n=37) obtained from body donors (age, 67-97 y). The main outcome measures are photo documentation of origin, trajectory, diameter, and branching pattern; immunolabeling of lymphatics; and 3-dimensional reconstruction of the middle rectal artery. The middle rectal artery was present in 71.4% of body donors (21.4% bilateral, 50% unilateral), originated from the anterior division of the internal iliac artery, and branched either from the internal pudendal artery (45.5%), the inferior gluteal artery (22.7%), the gluteal-pudendal trunk (22.7%), or a trifurcation (9.1%). One to 3 branches of varying diameters (0.5-3.5 mm) entered the mesorectum from the ventrolateral (35.7%), lateral (42.9%), or dorsolateral (21.4%) aspect. The middle rectal artery was accompanied by podoplanin-immunoreactive lymphatic vessels and gave off additional branches (81.8%) to the urogenital pelvic organs. Three-dimensional reconstruction revealed the complex course of the middle rectal artery from the pelvic sidewall through the pelvic nerve plexus and parietal pelvic fascia into the mesorectum. Findings retrieved from body donors may be prone to age- and fixation-related processes. The investigation disclosed the rather high prevalence of the middle rectal artery, its 3-dimensional topographic anatomy, and its proximity to the autonomic pelvic nerves. These features play a role in the surgical management of this blood vessel. The data provide the anatomical rationale for the lateral lymphatic spread of rectal cancer and an anatomical basis for nerve-preserving lateral lymph node dissection.

Rectosigmoidectomy with Complete Neurovascular Preservation for Deep Endometriosis

Study Objective To demonstrate the surgical steps involved in nerve-sparing and mesorectal-sparing segmental rectosigmoid resection. Design Step-by-step video demonstration of the technique. Setting Tertiary University Hospital. Patients or Participants The surgery was performed on a 34-year-old woman with complaints of progressive dysmenorrhea, dyspareunia, chronic pelvic pain, and menstrual dyschezia associated with infertility. Imaging exams showed extensive retrocervical lesions and two confluent intestinal lesions measuring 70mm and 25mm starting at approximately 13cm from the anal verge, with involvement of 40% of its circumference. Interventions Believe that the preservation of vascularization promotes adequate healing, and the preservation of the motor innervation that runs through the mesentery promotes good peristalsis. Initially correctly identifying the extent of the lesion and planning the resection. When the lesion is adhered to the rectovaginal septum or to the cervix, it must initially be isolated through the lateralization of the noble structures and centralization of the disease, keeping the hypogastric nerves, the splanchnic nerves, the inferior hypogastric plexus, and the middle rectal artery preserved. Start separating the rectum or sigmoid from its mesentery by sectioning it near to the dorsal wall, using energy forceps, dissecting up to above and below the lesion. Traction and counter-traction will show the correct space for dissection. Closer to the wall, the lower the probability of bleeding and the greater the preservation of the vascular-nervous elements. Rectosigmoidectomy performed with the section of the distal rectum, mini-laparotomy for exteriorization of the surgical piece, and placement of the circular stapler's anvil followed by stapled end-to-end colorectal anastomosis under laparoscopic view. Measurements and Main Results Surgical time of 120min, with minimal blood loss, favorable postoperative evolution, being discharged on the third day of hospitalization. Conclusion Although many centers already perform rectosigmoidectomy with complete neurovascular preservation, this technique has not yet been widely described. However, it is an effective, safe technique with greater damage control. To demonstrate the surgical steps involved in nerve-sparing and mesorectal-sparing segmental rectosigmoid resection. Step-by-step video demonstration of the technique. Tertiary University Hospital. The surgery was performed on a 34-year-old woman with complaints of progressive dysmenorrhea, dyspareunia, chronic pelvic pain, and menstrual dyschezia associated with infertility. Imaging exams showed extensive retrocervical lesions and two confluent intestinal lesions measuring 70mm and 25mm starting at approximately 13cm from the anal verge, with involvement of 40% of its circumference. Believe that the preservation of vascularization promotes adequate healing, and the preservation of the motor innervation that runs through the mesentery promotes good peristalsis. Initially correctly identifying the extent of the lesion and planning the resection. When the lesion is adhered to the rectovaginal septum or to the cervix, it must initially be isolated through the lateralization of the noble structures and centralization of the disease, keeping the hypogastric nerves, the splanchnic nerves, the inferior hypogastric plexus, and the middle rectal artery preserved. Start separating the rectum or sigmoid from its mesentery by sectioning it near to the dorsal wall, using energy forceps, dissecting up to above and below the lesion. Traction and counter-traction will show the correct space for dissection. Closer to the wall, the lower the probability of bleeding and the greater the preservation of the vascular-nervous elements. Rectosigmoidectomy performed with the section of the distal rectum, mini-laparotomy for exteriorization of the surgical piece, and placement of the circular stapler's anvil followed by stapled end-to-end colorectal anastomosis under laparoscopic view. Surgical time of 120min, with minimal blood loss, favorable postoperative evolution, being discharged on the third day of hospitalization. Although many centers already perform rectosigmoidectomy with complete neurovascular preservation, this technique has not yet been widely described. However, it is an effective, safe technique with greater damage control.

S651 Safety and Efficacy of Hemorrhoidal Artery Embolization in Patients Refractory to Conservative Management

Introduction: Endovascular hemorrhoidal artery embolization has emerged as an analogous therapy to Doppler-guided ligation. The purpose of this study was to evaluate the safety and efficacy of outpatient transarterial embolization for symptomatic refractory internal hemorrhoids. Methods: One hundred and twenty-six patients with symptomatic bleeding internal hemorrhoids refractory to prior treatment (e.g., banding, dietary/lifestyle modifications) were treated between August 2021 and May 2022 (62 men and 64 women). The average age was 58.3 +/- 15.8 years with an average Goligher's hemorrhoid grade of 2.2. Patients underwent superior and/or middle rectal artery embolization to the target arteries demonstrating abnormal vascular blush of the hemorrhoidal cushion with spherical embolic particles (500 or 600 micron) and/or microcoils (2-6 mm). Patients were discharged two hours post-procedure and were evaluated at baseline and 1-month for the following standardized outcomes: hemorrhoid related pain (HRP, 0-10), hemorrhoid symptoms score (HSS, 5-20), quality of life (QoL, 0-4), French bleeding score (FBS, 0-9), and hemorrhoid grade (0-4). Results: Femoral (121/126) or radial access (5/126) was performed and successful embolization of the superior and/or middle rectal artery was achieved in 126/126 (100%) patients. Statistically significant improvements in all outcomes were reported at follow-up (baseline vs 1 month): HRP (4.6 vs 1.7, p < 0.001), HSS (10.2 vs 7.1, p < 0.001), QoL (2.4 vs 0.7, p < 0.001), FBS (3.9 vs 1.5, p < 0.001), and hemorrhoid grade (2.0 vs 1.6, p = 0.03). One minor adverse event was reported: post-procedural peri-anal pain that required topical cream, which resolved soon after treatment. No major adverse events were reported. Conclusion: Hemorrhoidal artery embolization is a safe and effective outpatient treatment for refractory symptomatic internal hemorrhoids.

S2128 Rectal Ischemia in a Patient After EVAR and COVID-19

Introduction: Ischemic proctitis is a rare, but serious, source of GI bleeding as mortality rates approach 20-40%. Patients for which ischemia should be considered are those with previous surgery, older patients, and those with known peripheral arterial disease. Case Description/Methods: 80-year-old male with history of hyperlipidemia and hypertension presented to the hospital for shortness of breath secondary to COVID-19 pneumonia. His respiratory status continued to decline requiring mechanical ventilation and ICU admission. During his admission, he was found to have acute left lower extremity ischemia requiring stenting of his superficial femoral artery and abdominal endovascular aneurysm repair (EVAR). He was started on anticoagulation with heparin infusion. His hospital course was further complicated large volume maroon-colored stools concerning for lower GI bleed. Colonoscopy was performed at the bedside to further evaluate. In the rectum, there were circumferential ulcerations with inflammation and exudate, extending 10 cm from the anal verge. Biopsies were consistent with rectal ischemia. Unfortunately, soon after the patient developed worsening acidosis requiring CVVHD and increased requirement for pressor support. The family ultimately decided to pursue comfort care and the patient was palliatively extubated (Figure). Discussion: Rectal ischemia is rare as the rectum has blood supply from the inferior mesenteric and bilateral iliac arteries. In our patient, during EVAR graft repair, the IMA was occluded by a stent, the iliac arteries however, remained intact providing the middle rectal and pudendal artery as sources of collateral blood supply. It is hypothesized that a hypercoagulable state caused by COVID-19 infection coupled with ongoing hypotension in the setting of critical illness in our patient with significant peripheral arterial disease led to the low flow state in bilateral iliac arteries causing ischemic proctitis. Rectal ischemia must be considered early in patients because, while most cases of lower GI bleeding can be treated conservatively, rectal ischemia is an indication for prompt surgical intervention. Surgical intervention is required to remove necrotic bowel and potential sources of infection causing septic shock.Figure 1.: Circumferential rectal ischemia as seen by colonoscopy.

The Emborrhoid Technique for Treatment of Bleeding Hemorrhoids in Patients with High Surgical Risk.

The Emborrhoid is an innovative non-surgical technique for the treatment of severe hemorrhoidal bleeding. Patient selection and the impact on quality of life have not been fully investigated. This prospective observational study aims to evaluate the clinical outcomes after Emborrhoid in patients with high surgical risk. All patients with high surgical risk and anemia due to hemorrhoids were enrolled. Clinical data and previous blood transfusions were collected. The Hemorrhoidal Disease Symptom Score and Short Health Scala were completed before the procedure and during the follow-up visits at 1, 6 and 12 months. Transfusions and serum hemoglobin level variations were registered. Perioperative complications and the recurrence of bleeding were assessed. Trans-radial/femoral embolization of superior rectal artery, and/or middle rectal artery was performed with Interlock and Detachable Embolization Coils. From September 2020 to February 2022, 21 patients underwent a superselective embolization of all branches of the superior rectal artery. The transradial approach was most frequently performed compared to transfemoral access. After the procedure, no signs of ischemia were identified; three minor complications were observed. The mean follow-up was 18.5 ± 6.0 months. At the last follow-up, the mean increase of hemoglobin for patients was 1.2 ± 1.6 g/dL. Three patients needed transfusions during follow-up for recurrent hemorrhoidal bleeding. The Hemorrhoidal Disease Symptom Score and Short Health Scala decreased from 11.1 ± 4.2 to 4.7 ± 4.6 (p < 0.0001) and from 18.8 ± 4.8 to 10.2 ± 4.9 (p < 0.0001), respectively. Patients who had given up on their daily activities due to anemia have returned to their previous lifestyle. Emborrhoid seems to be a safe and effective option for the treatment of bleeding hemorrhoids in frail patients. The low complication rate and the significant reduction of post-defecation bleeding episodes are related to the improvement of the hemorrhoidal symptoms and patients’ quality of life.

Treatment of ruptured rectal artery aneurysm in a patient with neurofibromatosis

BackgroundSuperior rectal artery (SRA) aneurysms are rare. Although melena is the most common symptom, it has not been observed in cases of aneurysms located in the SRA trunk. Here, we report a case of a ruptured SRA trunk aneurysm successfully treated with coil embolization. Including our case, three of the four reported cases of SRA trunk aneurysms were related to neurofibromatosis type 1 (NF1).Case presentationA 52-year-old woman with NF1 was referred to our hospital for the investigation of an abdominal mass with back pain. She had previously undergone a blood transfusion at another hospital for anemia without melena. Computed tomography angiography revealed a ruptured SRA trunk aneurysm measuring 3 cm in diameter and surrounded by a retroperitoneal hematoma. The aneurysm was isolated by embolizing the SRA trunk distally and proximally. Distal embolization was performed retrogradely from the internal iliac artery (IIA) via the middle rectal artery (MRA)-SRA anastomosis because the antegrade approach from the inferior mesenteric artery (IMA) failed. To our knowledge, this is the first case of successful coil embolization of an IMA branch through the IIA.ConclusionSRA trunk aneurysms are rare; however, they are frequently associated with NF1. Antegrade distal embolization beyond the aneurysm is sometimes difficult to achieve. In such cases, a retrograde approach via MRA-SRA anastomosis can be the choice for isolating SRA trunk aneurysms.

Anatomical classification of middle rectal arteries regarding detailed vasculature patterns.

This study aimed to clarify the anatomy of middle rectal artery and pelvic vasculature patterns, and to provide schematic information in a manner applicable to the total mesorectal excision. Forty sides of pelvis from 20 formalin-embalmed cadavers (10 male, 10 female) were dissected, and all the pelvic vasculatures from the internal iliac artery were investigated, focusing on the middle rectal artery. Middle rectal arteries were classified into major types depending on their vascular origins. Each type was subdivided into minor types according to variability of the pelvic vasculature. A middle rectal artery was identified in 18 out of 20 cadavers, and in 25 out of 40 pelvic sides. In most cases, the middle rectal artery originated from the internal pudendal artery or inferior gluteal artery. These two arteries arose directly from the anterior trunk of the internal iliac artery or were bifurcated from the gluteal-pudendal trunk. In rare cases, these arteries arose from the posterior trunk of the internal iliac artery. The other origins of the middle rectal artery included the gluteal pudendal trunk, inferior vesical artery, internal iliac artery, obturator artery, and the prostatic artery, and the pelvic vasculatures in these cases also presented variability. The detailed anatomical findings related to the middle rectal artery and pelvic vasculatures are noteworthy for their improved clinical applicability.

Protection of nontarget structures in prostatic artery embolization.

ObjectiveTo describe the efficacy and safety of protective embolization during prostatic artery embolization, as well as to discuss its clinical relevance.Materials and MethodsThis was a retrospective, observational, single-center study including 39 patients who underwent prostatic artery embolization to treat lower urinary tract symptoms related to benign prostatic hyperplasia between June 2008 and March 2018. Follow-up evaluations, performed at 3 and 12 months after the procedure, included determination of the International Prostate Symptom Score, a quality of life score, and prostate-specific antigen levels, as well as ultrasound, magnetic resonance imaging, and uroflowmetry.ResultsProtective embolization was performed in 45 arteries: in the middle rectal artery in 19 (42.2%); in the accessory internal pudendal artery in 11 (24.4%); in an internal pudendal artery anastomosis in 10 (22.2%); in the superior vesical artery in four (8.9%); and in the obturator artery in one (2.2%). There was one case of nontarget embolization leading to a penile ulcer, which was attributed to reflux of microspheres to an unprotected artery. There were no complications related to the protected branches. All of the patients showed significant improvement in all of the outcomes studied (p < 0.05), and none reported worsening of sexual function during follow-up.ConclusionProtective embolization can reduce nontarget embolization during prostatic artery embolization without affecting the results of the procedure. In addition, no adverse events other than those expected or previously reported were observed. Therefore, protective embolization of pudendal region is safe.

Exposure of the Middle Rectal Artery and Lateral Ligament of the Rectum Following the Gate Approach during Total Mesorectal Excision.

Controversial surgical anatomical landmarks in the deep pelvis can be visualized and identified using current technologies. Performing the gate approach technique during deep lateral dissection for total mesorectal excision facilitates visualization of the pelvic neurovascular structures following simple dissection steps to preserve the pelvic autonomic nerves and avoid accidental vascular injuries. Here, we discuss laparoscopic exposure of an infrequent disposition of the middle rectal artery anterior to the lateral ligament of the rectum while performing the gate approach.

Endometriosis Affecting the Base of Appendix and the Middle Rectal Artery: A Case Report

Study Objective To demonstrate the rare case of deep endometriosis affecting the base of appendix and the middle rectal artery. Also, highlight the robotic approach assisting for a precise dissection and landmark identification. Design Case report for anatomical study and description of the procedure using video. Setting Tertiary Hospital. Patients or Participants A 38-year-old nulliparous woman presents with acyclic pelvic pain for one year, worse during sexual intercourse. She also had diarrhea during menstrual cycles and constipation the rest of the month. She underwent two failed in vitro fertilizations (IVF) and still had one frozen embryo. In the physical examination her uterus was partially fixed, and she felt pain in the posterior vaginal fornix touch. The MRI evidenced an 83.5 cc uterus, bilateral uterosacral thickening, bilateral round ligament nodules measuring 0.9 cm in the right and 1.7cm in the left. There were also an irregular fibrous tissue and adhesions on the anterior and lateral uterine aspects measuring 3.3 × 1.3 × 1.8 cm in proximity with the posterior vesical wall and right adnexa. Interventions We performed a robotic-assisted laparoscopic resection of superficial and deep lesions of endometriosis including peritoneum, uterosacral ligaments, retrocervix, round ligaments, uterus and bladder, rectum, a rare lesion in proximity with de middle rectal artery on the right and a large lesion in the base of appendix, affecting the cecum and the ileum, treated with ileocecal resection (typhlectomy) with primary ileocolic anastomosis. Measurements and Main Results Patient was discharged in the sixth postoperative day, with mild abdominal pain. The histological diagnosis confirmed endometriosis of all specimens. Conclusion We had a favorable outcome regarding the surgical approach in resecting an extensive disease with atypical lesions, including proximity to an arterial vessel and a large intestinal nodule that compromised the base of appendix. To demonstrate the rare case of deep endometriosis affecting the base of appendix and the middle rectal artery. Also, highlight the robotic approach assisting for a precise dissection and landmark identification. Case report for anatomical study and description of the procedure using video. Tertiary Hospital. A 38-year-old nulliparous woman presents with acyclic pelvic pain for one year, worse during sexual intercourse. She also had diarrhea during menstrual cycles and constipation the rest of the month. She underwent two failed in vitro fertilizations (IVF) and still had one frozen embryo. In the physical examination her uterus was partially fixed, and she felt pain in the posterior vaginal fornix touch. The MRI evidenced an 83.5 cc uterus, bilateral uterosacral thickening, bilateral round ligament nodules measuring 0.9 cm in the right and 1.7cm in the left. There were also an irregular fibrous tissue and adhesions on the anterior and lateral uterine aspects measuring 3.3 × 1.3 × 1.8 cm in proximity with the posterior vesical wall and right adnexa. We performed a robotic-assisted laparoscopic resection of superficial and deep lesions of endometriosis including peritoneum, uterosacral ligaments, retrocervix, round ligaments, uterus and bladder, rectum, a rare lesion in proximity with de middle rectal artery on the right and a large lesion in the base of appendix, affecting the cecum and the ileum, treated with ileocecal resection (typhlectomy) with primary ileocolic anastomosis. Patient was discharged in the sixth postoperative day, with mild abdominal pain. The histological diagnosis confirmed endometriosis of all specimens. We had a favorable outcome regarding the surgical approach in resecting an extensive disease with atypical lesions, including proximity to an arterial vessel and a large intestinal nodule that compromised the base of appendix.

Pelvic Neuroanatomy Learning from Fresh Frozen Cadaveric Dissections: Overview of Commonly Encountered Pelvic Nerves in Neuropelveology

<h3>Study Objective</h3> To describe commonly encountered pelvic nerves and anatomical landmarks in neuropelveologic surgery. <h3>Design</h3> A narrated video explanation of the autonomic nerves and the somatic nerves in the pelvis, their origin, sensory and motor function. <h3>Setting</h3> An anatomic theater for cadaveric dissections and an urban general hospital for in vivo laparoscopy. <h3>Patients or Participants</h3> N/A. <h3>Interventions</h3> Neuropelveology is new groundbreaking discipline in medicine established by Prof. Marc Possover. Neuropelveology is concerned with the diagnosis of injuries and dysfunctions of the pelvic nerves and with the treatment of the symptoms and diseases caused by them. Sparing the pelvic nerves during surgery requires surgical expertise and an immense understanding of pelvic neuroanatomy. In this video, we educationally reviewed with laparoscopic viewpoint pictures of the superior and inferior hypogastric plexus, hypogastric nerves, pelvic splanchnic nerves, sacral splanchnic nerves, femoral nerve, genitofemoral nerve, obturator nerve, lumbosacral trunk, sacral nerve roots (plexus), pudendal nerve (plexus), sciatic nerve, posterior cutaneous nerve of the thigh. Considering the anatomical relationships between these nerves and adjacent structures, we identified the external and iliac vessels, gluteal vessels, internal pudendal vessels, uterine artery, middle rectal artery, ureter, levator ani muscles, coccygeal muscle, piriform muscle, obturator internus muscle, sacrospinous ligament, sacrotuberous ligament, Alcock's canal, ischial rectal (anal) fossa, lesser sciatic foramen, greater sciatic notch, as well as other anatomical structures in the region of those mentioned. <h3>Measurements and Main Results</h3> Cadaveric laparoscopic dissection provided excellent visual information on essential pelvic neural pathways. <h3>Conclusion</h3> The fresh frozen cadaveric dissections are essential tool for acquiring the knowledge of pelvic anatomy, especially the nerve system. The most important nerves groups are the hypogastric plexus and the sympathetic trunk for the autonomic nerve system, and the sacral and the lumbar plexuses for the somatic nerve system. Preservation of the pelvic neural pathways is necessary to deliver the best patient outcomes while minimizing unwanted surgical complications.

Anatomical controversies involved in radical resection of rectal cancer

The concept of total mesorectal resection provides a quality control standard that can be followed for radical resection of rectal cancer, but some anatomical problems are still controversial. Compared with traditional open surgery, laparoscopic radical rectal surgery has better surgical vision, better neurological protection, better operating space. However, if the surgeon has insufficient understanding of the anatomy, collateral damage may occur, such as uncontrollable bleeding during the operation, postoperative urination and defecation dysfunction and so on. Based on the interpretation of the researches at home and abroad, combined with the clinical experience, we elucidate some associated issues, including anatomic variation of inferior mesenteric vessels, the controversy of inferior mesenteric artery ligation plane, the controversy of lymph node dissection in No. 253, the anatomical variation of middle rectal artery, and the anatomical controversy of lateral lymph node dissection in rectal cancer, in order to provide better cognitive process for the clinical front-line surgeons.

The middle rectal artery detected by contrast-enhanced magnetic resonance imaging predicts lateral lymph node metastasis in lower rectal cancer

PurposeLateral lymph node (LLN) metastasis is one of the leading causes of local recurrence in patients with lower rectal cancer. Unfortunately, no diagnostic biomarkers are currently available that can predict LLN metastasis preoperatively. Accordingly, we investigated the relationship between the middle rectal artery (MRA) identified by contrast-enhanced magnetic resonance imaging (ceMRI) and LLN metastases.MethodsData from 102 patients with lower rectal cancer who underwent surgery, and were evaluated by preoperative ceMRI, between 2008 and 2016 were reviewed retrospectively. Two expert radiologists evaluated the MRA findings. The diagnostic performance of MRA for LLN metastasis was evaluated by a multivariate analysis with conventional clinicopathological factors.ResultsThe MRA was detected in 67 patients (65.7%), including 32 (31.4%) with bilateral MRA and 35 (34.3%) with unilateral MRA. The tumor size, presence of the MRA, and clinical LLN status were significantly correlated with LLN metastasis. A multivariate analysis demonstrated that the presence of MRA (P = 0.045) and clinical LLN status (P = 0.001) were independent predictive factors for LLN metastasis. Furthermore, the sensitivity and negative predictive value of MRA for LLN metastasis were 95% and 97.1%, respectively.ConclusionWe successfully demonstrated that MRAs could be clearly detected by ceMRI, and the presence of MRA robustly predicted LLN metastasis in patients with lower rectal cancer, highlighting its clinical significance in the selection of more appropriate treatment strategies.Trial registrationTrial registration number: retrospectively registered 2126Trial registration date of registration: August 23, 2019