Prerectal Space Research Articles

Rectal Injury during Penile Inversion Vaginoplasty: An Algorithmic Approach to Prevention and Management.

Penile inversion vaginoplasty (PIV) is a common procedure for transfeminine patients, with the goal of creating a functional vaginal canal and clitoris and a natural-appearing vulva. Creation of the neovagina requires opening of the prerectal space, most commonly from a perineal approach, and the reported rates of rectal perforation during this dissection range from 3% to 5%. Adult patients who underwent PIV at the authors' institution were identified retrospectively. Demographics, operative information, and postoperative clinical outcomes were extracted from the electronic medical record. Ten of 146 patients (6.8%) experienced a rectal injury. All patients underwent an immediate repair (two-layer repair in eight patients, and three-layer repair in two), with two patients subsequently requiring temporary fecal diversion and two requiring muscle flaps (1.4% each). Literature review identified 18 relevant publications, with scarce in-depth analysis of management of initial rectal injuries. The authors' algorithmic approach to rectal injury during PIV is designed to facilitate decision-making based on preoperative preparation, consistent intraoperative monitoring, feasibility of primary repair of the rectum, and a multidisciplinary approach to longitudinal postoperative care. Therapeutic, IV.

Assessing Symmetry and Accuracy of SpaceOAR Insertion Prior to Radical Radiotherapy to the Prostate: a Single UK Centre Experience

Purpose: SpaceOAR is an absorbable hydrogel inserted into the prerectal space of men undergoing radical radiotherapy to the prostate with the intention of reducing radiation-induced rectal toxicity. The benefit of SpaceOAR insertion in reducing rectal toxicity is related to the degree of prostate–rectum separation and symmetry of spacer placement [1,2]. Assessment of SpaceOAR insertion symmetry using a standardised scoring system can facilitate positional optimisation of future SpaceOAR insertion.

Anatomical observation and clinical significance of rectosacral fascia in total mesorectal resection

Objective: To observe the anatomical architecture of rectosacral fascia and discuss the best plan for accurate peri-rectal dissection in laparoscopic/robotic total mesorectal resection (TME). Methods: A descriptive cohort study was carried out. A total of 127 patients with rectal cancer who underwent TME in the Department of Colorectal Surgery at the affiliated Union hospital of Fujian Medical University were included, patients' demographics with their pathological details and operation videos were collected for analysis. Another 20 high-definition images of post-TME surgical specimens were collected from our digital database. A total of 28 cadaveric models were examined at the Laboratory of Clinical Applied Anatomy, Fujian Medical University, to observe the anatomical details of rectosacral fascia. Results: (1) Anatomical observation showed that the pre-hypogastric fascia attaches to the proper fascia of the mesorectum in a horizontal arc posteriorly, forming the rectosacral fascia. If this fusion couldn't be identified and appropriately transected during posterior space dissection, it would be easy to destroy the proper fascia and dissect through the mesorectum resulting in residual mesorectum tissue. After the fascia transaction, the proper fascia of the mesorectum is still intact distally. The upper part of rectosacral fascia bilaterally re-separated again into the proper fascia and pre-hypogastric fascia. The pre-hypogastric fascia acts as a "fascia barrier" when dissecting the lateral space constantly from posterior to anterior. The right attachment of the rectosacral fascia was gradually transected. The pelvic plexus from the right S2-S4 was covered by the pre-hypogastric fascia which is considered the outer side layer of rectosacral fascia laterally. It was observed that the fascia continued with the anterior layer of the Denonvilliers' fascia, which has been transected during anterior space dissection. The proper fascia, which is the inner side layer of rectosacral fascia laterally, was still intact. The edge of the right rectosacral fascia attachment ran obliquely from the back and upward into the front direction. The left extension was similar to the right. (2) Cadaveric specimens: at the level of the lower edge of S4 vertebral body, the pre-hypogastric fascia fused with the proper fascia to form the rectosacral fascia. The right attachment margin of the rectosacral fascia was cut off step by step. The attachment margin of the rectosacral fascia went from the back and upward to the front downward direction. The right edge of rectosacral fascia attachment continued with the anterior layer of the Denonvilliers' fascia at the pre-rectal space and attached to the pre-hypogastric fascia laterally. The pelvic plexus sends out many tiny rectal branches on the anterolateral side, which pass through the transitional area between pre-hypogastric fascia and the anterior layer of the Denonvilliers' fascia to innervate the rectum. (3) TME specimens observation: the posterior attachment of rectosacral fascia was curved around the mesorectum with bilateral oblique attachments. The mesorectum was covered by fusion fascia below the posterior and bilateral attachment margin while it was covered only by the proper fascia above it. Conclusion: according to the morphological characteristics of rectosacral fascia, the rectosacral fascia should be dissected at the level of S4 vertebral body posterior to the rectum in an arc, shape and then enter the superior-levator space. Before dissecting the bilateral spaces, the anterior space of the rectum should be dissected first. The anterior layer of the Denonvilliers' fascia should be cut off into an inverted "U" shape, and then the lateral space should be dissected from anterior to posterior. Finally, the lateral attachment of rectosacral fascia was transected to ensure the integrity of the mesorectum without damaging the pelvic plexus branches and NVB.

Considering the ‘Multi‐layered’ theory of Denonvilliers’ fascia: how to approach for neurovascular bundle preservation on performing rectal mobilization (cadaveric study)

Denonvilliers’ fascia, an important and yet, controversial structure, was first noted by a French Surgeon, Charles-Pierre Denonvilliers after a series of anatomical dissections of the perineum in 1936 1, 2. This structure is vital for colorectal surgeons as the understanding of it would significantly improve the oncological and functional outcomes after rectal cancer surgery. In the classical description of the total mesorectal excision (TME), Professor Heald advocated that the dissection plane should be in front of the Denonvilliers’ fascia during anterior mobilisation of the low rectum 3. Professor Bokey, amongst others, suggested this layer should be left intact, unless when dealing with locally advanced, anteriorly located tumours 4. A pragmatic approach was proposed by Professor Mortensen’s group in Oxford when performing anterior mobilisation of the low rectum 5. In this issue, Ghareeb et al. 6, on reviewing their videos of low anterior resection, noted the presence of multiple fascial layers in the pre-rectal space, went on to study 18 newly fixed male and female cadavers, with a binocular loupe for a more detailed dissection. They have confirmed the multi-layered theory of Denonvilliers’ fascia, as opposed to ‘fusion’ or ‘condensation’ of embryonic connective tissues. The authors proposed their technique to initiate the anterior rectal mobilisation by making an incision a few millimetres posterior to the peritoneal reflection to minimise the injuries to the neurovascular bundles. The study also provided insight into the mysteries of the Denonvilliers’ fascia in females. This cadaveric study has added further evidence and understanding of this important anatomical structure. With the advancement of surgical equipment, including ever-improving higher resolution imaging with a magnified view; we are in a better position and equipped to provide a more precise surgical dissection.

The 'multilayer' theory of Denonvilliers' fascia: anatomical dissection of cadavers with the aim to improve neurovascular bundle preservation during rectal mobilization.

Denonvilliers' fascia is thought to be a multilayered fascial structure, based on its embryological development with the neurovascular bundle embedded within it. Recently, this theory had been proven histologically and by confocal microscopy in many published articles. However, the literature does not report on how surgeons can identify these structures. We aimed to determine the optimal surgical approach for preserving these critical structures. Eighteen cadavers (13 male/five female) were included and treated according to the ethical considerations stated in the donation consent of our institution. Dissection was performed with the assistance of binocular loupes for better anatomical detail. The compositions of the prerectal fascia and the neurovascular bundle were observed and recorded at different levels of dissection using a high-definition camera. The theoretical multilayered fascia was found in male specimens as three fascial layers originating from the perineal body, seminal vesicles and posterior bladder neck. The first layer merged posterolaterally and fused with the rectosacral fascia (Waldeyer's fascia). The neurovascular bundle in male specimens was observed piercing the second and third layers, while the first layer acted as a protective cover. Dissection of female specimens demonstrated only one layer in the prerectal space. Intiating anterior rectal mobilization by incising the peritoneum posterior to its reflection seems to be anatomically correct to preserve DVF. However, its applicability may be difficult in a narrow chanllenging pelvis. The lateral rectal ligaments and Waldeyer's fascia should be dissected from their attachments to the proper fascia of the rectum.

2171 EUS-Guided Transrectal Drainage and Stent Placement for Large Presacral Abscess Secondary to Acute Appendicitis

INTRODUCTION: A presacral abscess is one of the most difficult abscesses to be drained. It is very challenging to drain it through the transabdominal route due to overlying pelvic structures. We present a patient with sizeable presacral abscess secondary to acute appendicitis that was drained transrectal under an endoscopic-ultrasound (EUS) guidance with stent placement. CASE DESCRIPTION/METHODS: A 23-year old male presented with worsening pelvic pain, fever, and chills for four weeks. He denies any change in the bowel movement, dysuria, recent trauma, or bladder or bowel incontinence. Past medical history was unremarkable and had no surgeries. Vital signs were normal except for the temperature of 101.2 F. Abdomen was soft, non-tender, with audible bowel sound. The rectal and genital exam was normal. Labs revealed Hgb 11.2 g/dl, WBC 17.9k/mm3, platelets 545k/mm3, creatinine 0.7 mg/dl, CRP 18.8 mg/dl, negative HIV, and negative urine and blood cultures. CT scan of the abdomen and pelvis revealed large presacral abscess and possibly ruptured acute appendicitis. Magnetic resonance enterography (MRE) showed 9.6 × 2.6 × 6.1 cm presacral abscess with acute ruptured appendicitis (Figure 1). Interventional Radiologist was consulted for drainage, but abscess was not amenable to be drained percutaneously. Despite being on intravenous antibiotics, the patient continued to be spiking febrile and having persistent pelvic pain. So, rectal endoscopic ultrasound (EUS) was performed and showed 5 cm × 3.5 cm abscess in the pre-rectal space (Figure 2). Aspiration was done with the 19-gauge needle using a transrectal approach. A 7Fr x 5 cm double pigtail plastic stent and a 10Fr x 5 cm double pigtail plastic stent were placed into the abscess (Figure 3). Good drainage from the stent was visualized into the rectum. Patient’s symptoms improved. Fluid cultures remained negative, Leukocytosis resolved, and he was discharged in a stable condition. He will follow up with a repeated CT pelvis in 2 weeks to assess for resolution of abscess and interval appendectomy. DISCUSSION: The presacral abscess is a complication with difficult management in the course of acute appendicitis. It is challenging to drain with the transabdominal route because of the overlying pelvic structures. EUS-guided transrectal drainage is safer and effective in these cases. The clinician should be aware of this treatment modality and considered as the first-line option.

Feasibility of Using Hydrogel Spacers for Borderline-Resectable and Locally Advanced Pancreatic Tumors

Feasibility of Using Hydrogel Spacers for Borderline-Resectable and Locally Advanced Pancreatic Tumors

Laparoscopic surgery of total mesorectal excision based on pelvic membrane anatomy

Total mesorectal excision (TME) is the basic principle of surgery in rectal cancer which requires en bloc removal of the tumor and its regional lymph nodes. This conincides with the theory of membrane anatomy that emphasizes en bloc resection and avoids cancer leakage. The basis of membrane anatomy is the fusion of peritoneum and three key pointsare needed to understand the fusion and fusion fascia:(1) the fusion only occursin peritoneum; (2) the inside of fusion fascia cannot be separated; (3) the fusion can be diversiform. Only mastering these key points can we comprehend and apply this theory dialectically. The membrane anatomy in rectum is different from stomach or colon because of its specific location. The posterior space of rectum is filled with the loose connective tissue which is the degeneration of peritoneum fusion. In this space, the anterior lay of presacral fascia fuses with the proper fascia of rectum at the S4 level and separates the space into the retrorectal space and the supralevator space. Denonvilliers fascia is the fusion fascia in front of rectum, which forms the prerectal space and retroprostatic space, and extends to lateral pelvic wall with fusion of the parietal fascia of pelvis, covering the neurovascular bundle (NVB) together. The proper fascia of rectum surrounds the middle rectal artery, the pelvic plexus rectal branch and the adipose tissue to form the lateral rectal pedicle at 10 o'clock and 2 o'clock near the pelvic floor. At the level of levator ani hiatus, the fusion of levator ani muscle fascia and the proper fascia of rectum forms the Hiatal ligament, which fixs the anal canal and closes the levator ani hiatus.This article intends to discuss the above points from the perspective of membrane anatomy, in order to better guide surgeons to complete laparoscopic total mesorectal excision for rectal cancer.

Late Rectal Bleeding in Patients with and Without Pre-Rectal Hydrogel Spacer During Proton Beam Therapy for Prostate Cancer

Rectal toxicity is a potential late complication of radiation therapy for localized prostate cancer. A randomized trial in patients treated with IMRT supported the use of a bio-absorbable hydrogel spacer, inserted between the rectum and prostate, to reduce rectal toxicity. Proton beam therapy (PBT) improves low to moderate dose rectal dosimetry parameters and decreases integral dose compared to IMRT; however, rectal toxicity can still occur given the proximity the prostate to the anterior rectal wall. The benefit of a hydrogel rectal spacer for patients undergoing PBT has not been well studied. We examined the dosimetric impact of rectal spacer and late rectal bleeding rates in patients undergoing PBT. Patients with localized, clinical stage T1-2 prostate adenocarcinoma were treated at a single institution using conventionally fractionated PBT (typically 79.2 CGE in 44 fractions) from 2013 to 2017. Baseline clinical parameters were collected prospectively in an institutional review board-approved registry. Intraprostatic fiducial placement for daily image-guided RT. A subset of patients also had a commercially available hydrogel spacer transperineally inserted in the pre-rectal space at the time of fiducial placement. Daily immobilization with rectal balloon was used in patients who did not undergo spacer placement. Late GI toxicity (after 6 months), including rectal bleeding (RB), was graded using CTCAE v4.0. A total of 192 patients were treated with PBT without spacer and 82 were treated with spacer. Overall, 17%, 58%, and 24% of patients had low, intermediate, and high-risk disease, respectively. Most patients had radiation to the prostate and seminal vesicles only (91%), while 9% had elective nodal coverage. There were no differences between the two groups with regards to age, risk group, aspirin/anticoagulation use, and baseline GI comorbidities (IBD, hemorrhoids, fissures, hypertension). The mean PTV D95% was 79.1 CGE and 78.8 CGE in the non-spacer and spacer cohort, respectively (p=0.23). Use of hydrogel spacer significantly reduced the volume of rectal wall treated in the 50-81 Gy dose range (table). In the entire cohort, RB was associated with a history of smoking, anti-coagulation use, and hypertension. In patients with at least 6 months follow up, median follow up was 18 and 11 months in the non-spacer and spacer groups, respectively. Between the non-spacer and spacer groups, there was a reduction in the 1-year rates of any RB (13.5% vs 6.8%) and Grade 2 or worst RB (6.2% vs 2.3%), but this did not reach statistical significance (log-rank p=0.22 and p=0.50). Insertion of a hydrogel spacer in patients undergoing PBT for prostate cancer improves rectal wall dosimetry and may decrease the rate of late rectal bleeding. Further follow-up is awaited to see if this difference is statistically significant.Abstract SU_26_2253; Table 1Rectal Wall Vx (Gy)No Spacer (%)Spacer (%)P-valueV5030.021.5<0.001V6523.111.3<0.001V7020.27.4<0.001V7516.33.6<0.001V81 (cc)0.2 cc0 cc<0.001 Open table in a new tab

Denonvilliers' fascia in men: a sheet plastination and confocal microscopy study of the prerectal space and the presence of an optimal anterior plane when mobilizing the rectum for cancer.

The aim of this study was to investigate the detailed, in situ, morphology of Denonvilliers fascia (DVF) in cadavers using sheet plastination and confocal microscopy and to review and describe the optimal anterior plane for mobilisation of the distal rectum.. Six, male cadavers (age range, 46-87 years) were prepared as six sets of transverse (x2), coronal (x1) and sagittal (x3) plastinated sections which were examined under a confocal laser scanning microscope. In this study a consistent space between the anterior rectal wall and the posterior surface of the prostate and seminal vesicles above the level of the perineal body was termed the prerectal space. Within that prerectal space we identified fibres which take their origin from the external urethral sphincter (EUS), together with others from the longitudinal rectal muscle (LRM) and the connective tissue sheaths of neurovascular bundles. Neither the EUS- nor the LRM-originated fibres were continuous with the endopelvic fascia;they are interposed laterally and cranially by multiple neurovascular bundles. Further, our results suggest that the peritoneum does not descend deep within the prerectal space. This study reveals the undisturbed, in situ, structural detail of membrane-like structures in the prerectal space and confirms that the optimal plane for anterolateral mobilization of the rectum is posterior to the multilayered DVF. This article is protected by copyright. All rights reserved.

Technique of dissection in the pre-rectal space of laparoscopic total mesorectal excision

The development of laparoscopic total mesorectal excision (TME) has been promoting the better understanding of the anatomy in pre-rectal space for surgeons. If the dissection in pre-rectal space was inappropriate and entered into wrong anatomic planes, it would be easier to cause the proper fascia of rectum incomplete and damage the neurovascular bundles, and reduce the radical surgery outcome and induce urinary and sexual dysfunction, finally, affect the prognosis in patients. For surgical approach in pre-rectal space, the author proposed: Based on the related literatures, transecting the Denonvilliers′ fascia (DVF) when it′s definitely thickened after cutting the peritoneum 0.5 cm anterior to peri-toneal reflection, entering and dissecting in the space between DVF and the proper fascia of rectum, and forming a typical Three-line feature , including the cutting line of peritoneal reflection, the proximal and distal cutting lines of DVF, which can serve as the mark line and mark plane of the entrance to pre-rectal space. Not only this approach can keep the proper completeness of rectal fascia, but also it maximally reserves the DVF. Here, this article discussed the embryonic origins and anatomic characters of DVF, the structures of neurovascular bundles, dissection in the pre-rectal space, surgical approach and clinical outcomes between DVF and laparoscopic TME. Key words: Rectal neoplasms; Total mesorectal excision; Surgical procedures, opera-tive; Denonvilliers′ fascia; Laparos-copy

Plasmacytoid Carcinoma of the Bladder: A Urothelial Carcinoma Variant With a Predilection for Intraperitoneal Spread

Bladder plasmacytoid carcinoma is an invasive urothelial carcinoma subtype that is emphasized for its morphological overlap with plasma cells and metastatic carcinoma. Our experience suggests frequent intraperitoneal spread that is not typical of conventional urothelial carcinoma. We identified cases of plasmacytoid urothelial carcinoma diagnosed on radical cystectomy. Patient age, gender, American Joint Committee on Cancer (7th edition) stage, metastatic spread/recurrence sites and clinical disease status at last followup were recorded. A total of 10 male and 5 female patients 42 to 81 years old were identified. One tumor was pT2, 11 pT3 and 3 pT4. Six of 15 patients (40%) presented with lymph node metastasis and 5 (33%) had intraperitoneal metastasis at cystectomy. These initial sites of metastatic spread included the prerectal space, ovary and vagina, ovary and fallopian tube, bowel serosa, and omentum and bowel serosa in 1 case each. Three patients had subsequent metastasis involving the prerectal space, pleural fluid and small bowel serosa, and bowel serosa in 1 each. Eight patients had followup information available, including 3 who died of disease, 3 with disease and 2 with no evidence of disease. Of the patients 33% with the plasmacytoid variant of urothelial carcinoma presented with intraperitoneal disease spread and 20% had subsequent metastasis involving serosal surfaces. The possibility of noncontiguous intraperitoneal spread involving serosal surfaces should be recognized to ensure proper intraoperative staging and clinical followup for patients with plasmacytoid carcinoma.

Laparoscopic ultralow anterior rectal resection in APPEAR technique for deep rectal cancer

IndicationsThe key of modern rectal surgery has been the advent oftotal mesorectal excision (TME) [1]. Laparoscopic colorec-tal surgery is proven to be equivalent [2]. The AnteriorPerineal Plane for Ultralow Anterior Resection of theRectum (APPEAR) technique [3] allows a coloanalanastomosis by safe mobilization of the distal rectum andthe pelvic floor musculature under direct vision, especiallyfor the puborectal muscle and the external anal sphincter(EAS). As the APPEAR technique has only been combinedwith the abdominal part performed in the conventional“open” manner, we report the first case with previouslaparoscopic mobilization of the rectum with TME plusmobilization of the left colon and the splenic flexure.A 69-year-old male without further medical historypresented with a circular rectal adenocarcinoma (G2, M0),5 cm from the anal verge. Digital rectal examinationrevealed an almost circular ulceroinfiltrative lesion withrestricted mobility (Mason 3) about 5 to 6 cm from the analverge centered on the anterior rectal wall. There was noclinical evidence for sphincter involvement neither underresting pressure nor under squeeze. The endoscopicultrasound (EUS) staged the tumor as uT3 uN+. Thehigh-resolution MRI report of the pelvis concluded thatthe lesion was stranding the perirectal fat tissue but not themesorectal fascia; the anterior aspect of the circumferentialmargin was not at risk. Further there were obvious signs oflymphadenopathy (T3 N2) without pelvic wall infiltrationor inguinal lymph nodes, verifying the results of the EUS.For restaging after neoadjuvant treatment, the patientpresented without side effects in excellent condition. Thehigh-resolution MRI showed good tumor response (yT3yN0) with considerably regressive mesorectal infiltration.The tumor was mobile in the pelvis (Mason 2) and duringEUS the aboral tumor margin presented 5 cm oral of theanal verge and 2 cm oral of the puborectal muscle, showingsufficient resection margin for this tumor grading (G2). Thepatient was then referred to our department and scheduledfor laparoscopically assisted low anterior resection. Perinealapproach was considered as a valuable alternative tointersphincteric resection. The patient gave surgical consentto undergo any surgical procedure necessary to treat hisrectal cancer, preferably preserving anal continuity.MethodAfter preoperative insertion of a peridural catheter accord-ing to our standard “fast-track” scheme, the patient wasplaced under general anesthesia in the lithotomy positionand received prophylactic antibiotics on induction. Thelaparoscopic anterior resection was performed by a four-trocar approach (Fig. 1). TME was performed preservingthe autonomous nerves. In the prerectal space, the seminalvesicles were separated while the filmy Denonvillers’ fasciawas preserved. In this manner the spatium between theprostate and rectum was entered and dissected towards thepelvic floor. As the tumor was filling almost all pelvicspace, neither a linear nor an angular stapler could bepositioned below the tumor. Thus avoiding APR theAPPEAR technique was chosen as an intraoperativedecision. The mesocolon was divided and the colon

Anatomic observation of annular distribution of perirectal fascia and space around the mesorectum

To explore the regional anatomy of the rectum including the perirectal fasciae and spaces. Twenty-one cadavers (15 males and 6 females) were embalmed and their vessels were visualized by injection with color dye. From the cadavers, 30 hemipelvis and 6 three-quarter pelvis were harvested. The perirectal fasciae and spaces and the pelvic autonomic nerves were dissected and examined. Three tissue layers were dissected from the inside to the periphery including the proper rectal fascia enveloping the mesorectum, the presacral fascia, and the piriformis fascia fused with the sacral periosteum. The mesorectum comprised 2 parts with the classical posterolateral fat covered by the proper rectal fascia posteriorly and the anterior fat covered by the posterior layer of Denonvilliers fascia anteriorly. Extending anteriorly to the anterior layer of Denonvilliers fascia, the presacral fascia bisected the space between the mesorectum and the piriformis fascia into the retrorectal space and the presacral space. The retrorectal space extended cranially to the left retrocolic space, anterior to the space between the 2 layers of Denonvilliers fascia(prerectal space). From the inside to the periphery, the proper rectal fascia, the presacral fascia, and the muscular fascia are distributed in an annular pattern around the mesorectum. The presacral fascia divides the perirectal space into 2 annular parts, the central retrorectal space and the peripheral presacral space. The retrorectal space is the ideal surgical plane for total mesorectal excision.

Complete laparoscopic treatment of genital prolapse with meshes including vaginal promontofixation and anterior repair: A series of 138 patients

Study objective To evaluate feasibility and anatomic and functional results of complete laparoscopic treatment of genital prolapse with meshes. Design Retrospective monocentric study (Canadian Task Force classification II-2). Setting Centre Hospitalier Universitaire de Clermont-Ferrand, Polyclinique Hôtel Dieu, France. Patients One hundred thirty-eight consecutive patients operated from January 1, 1998, through December 31, 2003. Interventions Laparoscopic promontofixation using meshes placed anteriorly in the vesicovaginal space and posteriorly to the levator ani muscles and in the prerectal space. In the space of Retzius, the anterior compartment was treated with paravaginal repair, Burch colposuspension, or both. Measurements and main results Mean follow-up was 33.7 months, with 7 patients lost to follow-up. Mean operating time was 190 minutes without any conversion to laparotomy or major perioperative complications. In all, 98% of patients were satisfied with the operation. Anatomic recurrence rate was 11%, and functional recurrence rate was 12%, with maximum delay of 40 months. A total of 57 patients (46%) had postoperative stress urinary incontinence (grade 1 or 2 in most cases), including 9 who did not receive any perioperative treatment for stress urinary incontinence. Seven patients (5%) had vaginal erosion, and for 2 of them (1%), meshes had to be removed because of infectious complications. Conclusion Complete laparoscopic treatment of prolapse including promontofixation appears to be an efficient and viable technique. Treatment of stress urinary incontinence as a consequence of surgery should be improved. Laparoscopic placement of meshes induced few complications.

Histotopographic study of the rectourethralis muscle

Radical perineal prostatectomy, relative to retropubic prostatectomy, has become an increasingly used surgical technique for prostate cancer, following advances in laparoscopic methods for pelvic lymph node dissection. Recent protocols of risk stratification may even obviate the need for lymph node dissection. Section of the rectourethralis muscle (RUM) is necessary for access to the retroprostatic space, however, during this procedure rectal injuries may be produced. In this work, we studied the topography and morphology of the RUM, which, despite its importance in perineal surgery, has not been univocally described in the literature. After in situ formalin fixation, the pelvic viscera were removed from 16 male cadavers (age: 54-72 years) and from 4 full-term infants (gestational age: 37-38 weeks). Serial macrosections of the bladder base, prostate gland, and lower rectum cut in horizontal (6 adults and 2 infants) and sagittal (6 adults and 2 infants) planes underwent histological (hematoxylin and eosin, azan-Mallory, and Weigert's staining) and immunohistochemical (anti-smooth muscle actin and anti-sarcomeric actin) study. The remaining 4 adult specimens were cut in horizontal and sagittal planes and plastinated using the epoxy resin E12 sheet procedure. RUM was identified in 10 of 12 (83%) adult specimens and in 4 of 4 (100%) infant specimens. In both sagittal and transverse sections, it showed a triangular-shaped configuration. In all cases, at the level of its posterior portion, fibers continuing with the longitudinal muscular layer of the rectum were visible. In the majority of adult and infant cases, attachment of muscle fibers into the anterior wall of the anal canal was also observed. Anteriorly, the mean (+/-SD) distance between the RUM and the membranous urethra was 5.3 (+/-1.25) mm in adults and 1.0 (+/-0.41) mm in infants. Location of RUM in the prerectal space and the absence of urethral attachment makes the original name of this muscle, "prerectal," by Henle, more correct. In 7 of 10 (70%) adult cases and in 1 of 4 (25%) infant cases, muscle fibers were densely packed along the lateral portions of the RUM, while in its central portion connective tissue was prevalent, with sparse numbers of smooth muscle fibers. Immunohistochemical staining showed that this muscle consists almost entirely of smooth fibers. In all the infant specimens, the RUM was clearly separated from the levator ani, while in 8 of 10 (80%) adult cases, striated fibers of the levator ani and smooth fibers of the RUM intermingled. These structural associations suggest a functional cooperation between the two muscles, particularly in determining the anorectal flexure.

Modified Extrafascial Radical Retropubic Prostatectomy Technique Decreases Frequency of Positive Surgical Margins in T2 Cancers

Objectives: In an effort to decrease the frequency of postoperative positive surgical margins (+SM), a modified extrafascial radical prostatectomy technique was developed and evaluated.Methods: 402 consecutive radical prostatectomy specimens removed for clinical stage T2 cancers from 1987 to 1994 were histologically examined prospectively for tumor volume, extraprostatic extension and +SM. Surgical technique modification was introduced in 1990. We compared the histologic status and biological outcome of the prostatectomy cases in 1987–1989 (n = 166) to those treated from 1990 to 1994 (n = 236).Results: The two series were comparable in (1) clinical stage and preoperative (PSA, (2) tumor volume, grade and location, and (3) capsular penetration, seminal vesicle and lymph node status. +SM fell from 32 to 25% overall, but for 146 (36%) prostates with a tumor volume <2 cm³, +SM fell from 21 to 6% which was statistically significant. Outcome measured by biological progression showed a decrease from 33% for +SM to 13% for –SM for cases with a tumor volume <2 cm³. For cancer volumes >2 cm³, the incidence of +SM did not vary significantly. We describe the anatomic details necessary for exposure of periprostatic fascias and extrafascial dissection at (1) the prostatourethral junction which ensures wide excision of the anterior and apical aspect of the prostate, (2) the posterior and apical area (development of the prerectal space), lateral and posterior areas at the base of the prostate which ensures wide excision of the rectoprostatic fascia (Denonvilliers’s fascia) and lateral prostatic fascia.Conclusions: Differences in surgical technique probably accounted for the significant decrease in +SM for those T2 cancers with volumes ≤2 cm³ which represents 36% of the T2 cancers in our series. Recent screening with PSA (T1c cancers) increases the incidence of these cancers ≤2cm³. This modified uni– or bilateral anatomic extrafascial prostatectomy with improved +SM and biological progression rates for T2 cases should be evaluated for T1c cases.

Nerve Block in Prostate Surgery

Purpose We describe a novel technique for anesthetizing the prostate, which should be used for patients at risk undergoing prostate surgery with general, spinal or epidural anesthesia. Materials and Methods Local anesthesia to the prostatic plexus supplemented by monitored anesthesia care was performed on 40 patients with outflow obstruction secondary to an enlarged prostate. Of the patients 34 underwent transurethral resection of the prostate, 5 underwent visual laser ablation and 1 underwent transurethral electrovaporization. A 20 gauge spinal needle was inserted via a suprapubic approach toward the base and apex of the prostate, and guided by the left index finger inserted into the rectum. Lidocaine was injected into the prerectal space. Bulging of the rectal wall caused by the amount of lidocaine injected was appreciated. Insertion into the proper area was essential for a good anesthetic result. Results Adequate anesthesia levels could be obtained without major complications. All but 1 patient with poor bladder compliance were rendered free of a Foley catheter. There were no deaths. Conclusions This technique has definite advantages for patients who are at risk for prostate surgery with general or spinal anesthesia.