Superior Vesical Research Articles

Prostatic Artery Origin Variability: Five Steps to Improve Identification during Percutaneous Embolization.

Background and Objectives: The purpose of the current paper is to present our study on the variability in the prostatic artery origin, discuss the less frequent origins, and present the challenges of the prostatic artery embolization (PAE) procedure, thus aiding young interventional radiologists. Materials and Methods: We studied the origins of the prostatic artery on digital subtraction angiography (DSA) examinations from PAE procedures on 35 male pelvises (70 hemi-pelvises). Results: Our study has demonstrated that the most frequent origin of the prostatic artery (PA) is the internal pudendal artery (IPA), 37.1%, followed by the anterior gluteal trunk, 27.1%, and the superior vesical artery (SVA), 21.4%. Less frequent origins are the obturator artery (OBT), 11.4%, and the inferior gluteal artery (IGA), 2.8%. Conclusions: Compared to other studies, we notice some differences in the statistical results, but the most frequent origins remain the same. What is more important for young interventional radiologists is to be aware of all the possible origins of the PA in order to be able to offer a proper treatment to their patients. The important aspect that will ensure the success of the procedure without post-procedural complications is represented by the successful embolization of the targeted prostatic parenchyma.

Superior Vesical Fissure as an Incomplete Form of Bladder Exstrophy: A Case Report with Clinico-Pathological Correlation and a Comprehensive Literature Review.

Multiple variants of classic bladder exstrophy have been described, all of them infrequent. Superior vesical fissure is a mild variant of this pathology in which genital involvement is scarce or absent. To date, there are only isolated reports of this entity. We report a full-term female patient of Arabian descent with a clinical and radiological diagnosis of superior vesical fissure that was surgically corrected in our center with a favorable evolution. Histological study, supported by immunohistochemical techniques, showed squamous and transitional epithelium and discrete chronic inflammation. Our literature review identified 26 reports of superior vesical fissure (including ours), with high heterogeneity in terms of clinical characterization and associated malformations and with only two histological reports. The clinical evolution of the patients reported in the literature was favorable, with lower morbidity and mortality than in classical forms of bladder exstrophy.

Phosphodiesterase-5 inhibitors tadalafil and sildenafil potentiate nitrergic-nerve mediated relaxations in the bladder vasculature

Recent studies suggest that lower urinary tract dysfunction may arise due to changes in local perfusion. Phosphodiesterase-5 inhibitors can improve urinary bladder blood flow, although the local mechanisms have not been fully elucidated. The aim was to pharmacologically characterise the vascular supply to the bladder and determine the mechanisms underlying the effects of the phosphodiesterase-5 inhibitors tadalafil and sildenafil. Responses of isolated rings of porcine superior vesical arteries to electrical field stimulation (EFS) were measured in the absence and presence of inhibitors of key neurotransmitter systems. Vasodilation responses to nitric oxide (NO) donors were also recorded, and the effects of phosphodiesterase-5 inhibitors on all responses determined. EFS caused biphasic responses with an initial vasoconstriction and a slower developing vasodilation. Vasoconstriction was mediated by ATP (55%) and noradrenaline (45%) release, whilst vasodilation was reduced by L-NNA (100 μM) (80%) and propranolol (1 μM) (20%). The nitrergic component was inhibited (81%) by L-NPA, a selective inhibitor of neuronal nitric oxide synthase (nNOS). Endothelial removal did not affect vasodilation. Tadalafil and sildenafil depressed noradrenaline-evoked vasoconstriction (by 26.8% and 35.5% respectively, P < 0.01), enhanced vasodilation to EFS (by 27.8% and 51.8% respectively, p < 0.01) and enhanced responses to NO donors nitroprusside, SIN-1, and SNAP, increasing pIC50 values (P < 0.01), without affecting maximal responses. In conclusion, neuronal NOS has a predominant role in regulating vascular tone of the porcine superior vesical artery and potentiation of nNO-mediated vasodilation is the primary mechanism underlying effects of phosphodiesterase-5 inhibitors in the bladder vasculature.

Angiographic Imaging of Prostatic Artery Origin in a Greek Population and Correlation With Technical and Clinical Aspects of Prostatic Artery Embolization.

Background This study aimed, first, to angiographically investigate and analyze prostatic artery (PA) origin in a Greek male population with benign prostatic hyperplasia (BPH) treated with prostatic artery embolization (PAE) and, second, to correlate prostatic arterial anatomy with technical and clinical aspects of PAE. Methodology This was a retrospective study of BPH patients who underwent PAE in a single tertiary center in Greece from June 2019 to July 2022. For the first part of the study, PA was imaged with computed tomography angiography (CTA) before PAE and with digital subtraction angiography (DSA) during PAE in all patients. A widely accepted system for the classification of PA origin was applied. Type I, a common origin of PA and superior vesical artery (SVA) from the anterior division of internal iliac artery (IIA). Type II, PA originating from the anterior division of IIA, separate from, and inferior to SVA. Type III, the origin of PA from the obturator artery. Type IV, the origin of PA from the internal pudendal artery. Type V, rarer origins of PA. For the second part of the study, a subgroup of patients from the first part (treated with the same PAE protocol and free of vascular pathology that could have interfered with the technical success of PAE) was selected. In this subgroup, differences in PA origin were correlated with technical aspects (feasibility of catheterization of PA, fluoroscopy time (FT), dose area product (DAP)) and clinical outcomes of PAE. Results After the exclusion of four patients, 159 patients were included in the first part of the study. From a total of 355 PAs, 110 (31%) were compatible with type I, 58 (16.3%) type II, 45 (12.7%) type III, 110 (31%) type IV, and 32 (9%) type V. PA origin from an accessory internal pudendal artery was the most common among the rare origins of type V. Regarding the second part of the study (a subgroup of 101 patients selected to facilitate comparisons between the different types of PA origin), type I was associated with significantly more incidences of failed or difficult catheterization of the PA compared to all other types combined (27/64 vs. 18/138, p < 0.001). Types III, IV, and V showed a relatively low degree of technical difficulty. Patients with type I PA origin of at least one pelvic side (subgroup (I), n = 48) had significantly longer FT and DAP compared to the rest (subgroup (O), n = 53). Clinical success rates of PAE were slightly lower for the subgroup (I), although the difference was not statistically significant (75.8% vs. 83.8% at 18 months post-PAE, p = 0.137). No major complications were observed. Conclusions This is the first study of PA origin in Greece. It was demonstrated that types I and IV of PA origin were the most common and had the same prevalence. Type I showed significantly higher technical difficulty compared to the others, but had no significant impact on the clinical outcomes of PAE.

Morphometric measurements for potential dangers of anterior intra-pelvic approach in women: A cadaveric study.

This study aimed to improve the surgical anatomical knowledge of pelvic/acetabular trauma surgeons by providing detailed morphometric data on some of the most vulnerable arteries and nerves due to constant bony landmarks during anterior intra-pelvic approach fixation of acetabular fractures in women. Ten hemipelvis were dissected from 5 female cadavers. The following measurements relative to the symphysis were performed: (1) the distance of the corona mortis anastomosis and (2) the bisection of the external iliac vein with the pubic ramus. In addition, dis- tance to the pelvic brim at the level of pectineal convexity of the following structures was measured: (3) depth of obturatory neurovascu- lar bundle, (4) superior vesical artery, and (5) vaginal artery. Also, the clock position of the (6) gluteal superior and inferior vessels due to sciatic notch in the supine position. Due to antero-superior corner of sacroiliac joint (7) location of the common iliac artery bifurcation, (8) location of the bifurcation of internal iliac vessels to truncuses, (9) bifurcation of superior gluteal artery and lateral sacral artery, and (10) L5 nerve were measured. The descriptive statistics were given as medians and ranges as this is a descriptive anatomical study without comparisons. The median distance of corona mortis to symphysis pubis was 59.5 mm (range = 58-61). The external iliac vein bisected the pubic arm 68.5 mm (range=65-70) lateral to the symphysis pubis. At the level of pectineal convexity (about the middle of the pelvic brim), obturatory neurovascular bundle, superior vesical artery, and vaginal artery were 15 mm (range=13-16), 24 mm (range=23-25), and 36 mm (range=34-38) inferior to the pelvic brim, respectively. The superior gluteal vessels leave the sciatic notch at 12 o'clock position in supine position. Inferior gluteal vessels leave the sciatic notch at 31⁄2 o'clock position (given for left side). Common iliac artery bifurcation bisects the SI joint 5 mm (4-7) superior to antero-superior corner of the Sacro-iliac (SI) joint. The internal iliac artery gives its posterior trunk 18 mm (range=15-20) straightly anterior to antero-superior corner of the SI joint. Bifurcation of superior gluteal artery and lateral sacral artery was 11 mm (range = 10-12) away from the beginning of the posterior truncus. L5 root's medial margin was 9 mm (range = 7-10) medial to this landmark, where its lateral margin was on the SI joint (2 mm medial to 2 mm lateral). The majority of the bleeding complications of the major branches of the internal and external iliac arteries and neurologic palsies due to obturatory nerve and L5 nerve root damage within the operative field of the anterior intra-pelvic approach can be avoided or managed by utilizing morphometric data provided from this study. N/A.

Detection of the Vesical Arteries Using Three-dimensional Digital Subtraction Angiography Relevant to Intra-arterial Infusion Chemotherapy for Bladder Cancer Using Double-balloon Catheters.

This study aims to assess and measure the origin of the superior vesical artery and its distance from the anterior trunk of the internal iliac artery, to which the anticancer drug is infused via double-balloon-occluded arterial infusion bladder-preserving therapy for locally invasive bladder cancer. The 160 pelvic sides of 80 patients were analyzed. Double-balloon catheters were bilaterally introduced into the contralateral superior gluteal artery via the internal iliac arteries using a bilateral transfemoral approach. The proximal balloon is placed at the internal iliac artery, proximally from superior gluteal artery bifurcation, whereas the distal balloon at the origin of the superior gluteal artery to isolate the anterior trunk of the internal iliac artery discharging to the targeted vesical arteries between the balloons. The side hole between the distal and proximal balloons was adjusted at the origin of the anterior trunk of the internal iliac artery to allow clear visualization of the angiographic flow into the bladder. After the distal and proximal balloons were inflated, three-dimensional rotational digital subtraction angiography was performed by simultaneous contrast injection from one extension tube connected to bilateral catheters. The distance (X) between the origins of anterior trunk of the internal iliac artery and superior vesical artery was measured on three-dimensional digital subtraction angiography images, and the origin of the inferior vesical artery was investigated. All superior vesical artery originated from anterior trunk of the internal iliac artery. The mean x was 7.2 mm (range 1.0-22.0 mm). All inferior vesical arterys branched from anterior trunk of the internal iliac artery or its branches. Superior vesical artery commonly originates from the proximal portion of anterior trunk of the internal iliac artery close to superior gluteal artery bifurcation.

The superior vesical artery: A review of conflicting definitions and how these could affect invasive procedures.

Since the superior umbilical artery is the only functioning branch of the patent umbilical artery, some anatomical and surgical books/atlases fail to clarify that it is a branch of the umbilical artery and not a direct branch of the anterior division of the internal iliac artery and so specifically state that it is a direct branch of the internal iliac artery. This discrepancy in nomenclature can obviously affect invasive procedures and communication between physicians. Therefore, the present review is intended to highlight this issue. The term "superior vesical artery" was searched using standard search engines, for example, PubMed and Google Scholar. Several standard and specialized anatomy textbooks were also examined to ascertain how the superior vesical artery was described. Thirty-two articles were identified that used the terms "superior vesical artery" or "superior vesical arteries." After applying exclusion criteria, in 28 papers, the definition of the superior vesical artery was undetermined in eight, described as a direct branch of the internal iliac artery in 13, described as a branch of the umbilical artery in six, and defined as being equivalent to the umbilical artery in one. Of the sampled textbooks, some defined the superior vesicle artery as a branch of the umbilical artery, some as a direct branch of the internal iliac artery and some as both. Taken all together, most define the superior vesical artery as a branch of the umbilical artery. As the superior vesical artery is described as a branch of the umbilical artery in the internationally accepted terminology (Terminologia Anatomica), we recommend that this definition be used by anatomists and physicians alike so that communication is clear.

Laparoscopic radical hysterectomy and total vaginectomy for vaginal malignant melanoma with cervical metastasis

The presented case is a 63-years-old multiparous woman admitted with the complaint of postmenopausal bleeding. On gynecologic examination multifocal lesions were detected, including 1 cm on lateral vaginal wall, 4 cm on posterior vaginal wall and 0.5 cm on the left lateral part of the cervix. Histopathology examination gave a diagnosis of epithelioid malignant melanoma. Consequently, laparoscopic radical hysterectomy and total vaginectomy with bilateral pelvic and inguinofemoral lymph node dissection were planned. On both sides, pararectal and paravesical spaces were created and the ureter was identified. Then, the vesicouterine and vesicovaginal spaces were developed. Uterine artery and superior vesical artery were coagulated, cut and the lateral parametrium was prepared. The left ureter was dissected and the ureteral tunnel was unroofed up to the bladder entrance. Subsequently, the anterolateral parametrium was transected. Then, the infundibulopelvic and sacrouterine ligaments were sealed and transected. At this time, the rectovaginal space was developed. Bilateral paracolpos were transected. The endopelvic fascia with the levator muscles were sealed and cut circumferentially. Anteriorly, the pubovesicocervical fascia was transected and the bladder was mobilized up to the uretrovesical junction. Thereafter, through a vaginal approach, the cervix and vagina were inverted by grasping the cervix with a tenaculum. An incision on the posterior vaginal wall at the introitus was made and the urogenital diaphragm was dissected to connect with the pelvic cavity. The vaginal entrance was cut circumferentially and the surgical specimen was extracted. In conclusion, laparoscopy can be considered as a feasible approach for radical hysterectomy and total vaginectomy in selected patients.

Stereotactic navigation using registration based on intra-abdominal landmarks in robotic-assisted lateral pelvic lymph node dissection.

We carried out robot-assisted lateral pelvic lymph node dissection (LPLND) for rectal cancer with a stereotactic navigation system. The purpose of this study was to evaluate the accuracy and feasibility of the system. We constructed a navigation system based on the Polaris Spectra optical tracking device (Northern Digital Inc., Canada) and the open-source software 3D Slicer (version 3.8.1; http://www.slicer.org ). We used the landmark-based registration method for patient-to-image registration. Body surface landmarks and intra-abdominal landmarks were used. We evaluated the time required for registration and target registration error (TRE; the distance between corresponding points after registration) for the root of the superior gluteal artery the root of the obturator or superior vesical artery, and the obturator foramen during minimally invasive LPLND for rectal cancer. Five patients who had LPLND for rectal cancer at the University of Tokyo Hospital between September 2020 and May 2021 were enrolled. The mean time required for registration was 49s with the body surface landmarks and 88s with the intra-abdominal landmarks. The mean TRE improved markedly when the registration was performed using intra-abdominal landmarks. The mean TRE of the root of the superior gluteal artery, the root of the obturator or superior vesical artery, and the obturator foramen were 55.8mm, 53.4mm, and 55.2mm with the body surface landmarks and 11.8mm, 10.0mm, and 12.6mm with the intra-abdominal landmarks, respectively. There were no adverse events related to the registration process. When stereotactic navigation systems are used for minimally invasive LPLND, the use of intra-abdominal landmarks for registration is feasible and may allow simpler and more accurate navigation than the use of body surface landmarks.

A cadaveric study on the origins of the uterine artery

The uterine artery (UA) is a visceral branch from the anterior division of the internal iliac artery (IIA). Knowledge of the variant origins of this artery is critical during radiologic and surgical procedures of the pelvis, especially those involving the uterus, where managing blood flow is vital. Though its path and destination are well agreed upon, the origin of the UA differs notably, and has led many anatomists to create numerous descriptions for the distinctive variation. This project investigated the origin of the UA in the unique South Texas population of female cadavers donated to the UT Health San Antonio and established a fundamental and comprehensive classification system of the origin of this vessel which readily accommodates previous systems while improving its descriptive terminology. As the UA was identified, its origin was classified into three different ranks—primary, secondary, or tertiary. Primary‐ranked vessels originated directly from the internal iliac artery (IIA) and took three different formations as a separate branch, bifurcation with another vessel, or trifurcation with two other vessels. Secondary‐ranked UAs originated from primary vessels and tertiary‐ranked vessels originated from secondary vessels. 58.97% (23/39) of the UAs studied arose from the IIA as a primary‐ranked vessel, 38.5% (15/39) as a secondary rank, and 2.6% (1/39) as a tertiary rank. 21.7% (5/23) of primary‐ranked UAs took origin from IIA as a separate branch, 56.5% (13/23) as bifurcation with another vessel and 21.7% (5/23) as trifurcation with two other vessels. The UA originated as a bifurcation with the umbilical artery (UmbA) in 13/13 cases. UA origin as a trifurcation was observed in 3 different patterns: 40% (2/5) with the UmbA and the superior vesical artery (SVA); 40% (2/5) with the UmbA and vaginal artery (VA); 20% (1/5) with SVA and the internal pudendal artery (IPA). 93.3% (14/15) of secondary‐ranked UA arose from the UmbA and 6.7% (1/15) from the IPA. We observed a single tertiary ranked UA arising from the vaginal artery (VA), which took origin from the UmbA, a branch of the anterior division of the IIA. It is imperative that the prevalence of these primary‐ranked UA bifurcations and trifurcations be further established since permanent occlusion at the vessel’s origin may subsequently lead to necrosis of unintended tissues. Larger sample sizes amongst differing populations may lead to the discovery of uncommon bifurcation and trifurcation patterns, or with similar vessels in differing proportions. It would also be important to translate the evaluation criteria used in this study into 3D and 4D digital subtraction angiography or cone‐beam computed tomography software for clinical studies. Increasing awareness of the variant origins of the UA will ultimately improve patient treatment outcomes, particularly for female reproductive health.

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.

Superselective vesical artery embolisation of bleeding associated with bladder cancer

Superselective vesical artery embolization is used in the control of bleeding due to bladder cancer. However, there are few studies with a small number of patients. The current study aimed to investigate the efficacy, complications, and short-mid-term results of super-selective transarterial embolization in the treatment of persistent hematuria associated with bladder cancer. A retrospective examination was made of 13 patients with bladder cancer-related persistent hematuria who were applied with selective vesical artery embolization in the interventional radiology unit. The patients were evaluated in terms of the success of the treatment, the patients' need for additional interventional procedures, and the complications related to the procedure. Superselective superior vesical artery embolization was applied to a total of 13 patients with a mean age of 78.85±11.76 years and a median follow-up of 181 days. The time without bleeding was determined as a median of 159 days (min: 15, max:1410 days). The short-term clinical success was calculated as 84.6%. In the long-term follow-up of the patients in this study, the clinical success was determined to be 76.9% and no major complications were observed in any patient. Superselective embolization of vesical arteries is an effective and reliable treatment method for bladder cancer-related bleeding with high clinical success rates and low complication rates.

Efficiencies in Robotic Radical Trachelectomy

<h3>Study Objective</h3> To demonstrate an efficient and stepwise approach to performing a robotic radical trachelectomy. <h3>Design</h3> Video description of dissection of the retroperitoneal space and identification of key structures, the nerve sparing technique, creation of a deep and lateral bladder flap, cerclage placement and specimen removal, and reapproximation of the vagina to the uterus. Patient provided consent for the video and publication. This video with no identifying patient data was exempt from Institutional Review Boards Approval. <h3>Setting</h3> Robotic-assisted laparoscopy was performed. <h3>Patients or Participants</h3> We present a patient with early-stage cervical adenocarcinoma who was an appropriate candidate for fertility-sparing surgery. <h3>Interventions</h3> After the right retroperitoneum space is entered, key landmarks are noted. After finding the ureter, the paravesical and obturator spaces were created. The superior vesical artery, obturator nerve, and uterine artery are identified and dissected. The ureter is dissected off the flap to the level of the right uterine artery and uterosacral ligament. The rectovaginal septum is then dissected as the next natural field. The same steps are repeated on the left side. The bladder flap is created, making sure that it is both deep and lateral for easier dissection of the vesicovainal ligament and visualization during robotic surgery. The uterocervical junction is incised circumferentially. The round ligaments and uterine manipulator are left in place to aid in the placement of the cerclage, removal of the specimen, and suturing of the vagina to the uterus. <h3>Measurements and Main Results</h3> Utilizing these efficiencies resulted in a shorter operative time of 2 hours and 38 minutes (versus 5 hours and 8 minutes) in this robotic radical trachelectomy. <h3>Conclusion</h3> The efficiencies were the following: an orderly fashion in going from field to field which resulted in less movements, dissecting the bladder flap deep and lateral which aided in taking down the vesicovaginal ligament and visualization, and utilizing the uterine manipulator throughout the case.

Fluorescence vessel and ureter navigation during laparoscopic lateral lymph node dissection.

Lateral lymph node metastasis in lower rectal cancer is considered a local disease in Japan, and guidelines suggest lateral lymph node dissection (LLND). However, laparoscopic procedures are relatively difficult. The ureter and hypogastric fascia must be dissected from the vesicohypogastric fascia to preserve the autonomic nerve and ureter. Additionally, lymph node dissection around the internal iliac artery is complex because many patterns of branching from the internal iliac artery exist. We investigated the utility of fluorescence ureter and vessel navigation using a near-infrared ray fluorescent ureteral catheter (NIRFUC) and indocyanine green (ICG). Fourteen patients who underwent laparoscopic LLND using fluorescence navigation were included. Eleven patients had rectal cancer, 1 had anal cancer, and 2 exhibited recurrence of rectal cancer. Eleven patients underwent NIRFUC insertion before surgery. Fluorescence vessel navigation (FVN) was performed with intraoperative ICG injections in 14 patients, with a total of 18 sides. The outcome measures were ureter navigation visibility, detection of the branch form from the internal iliac artery with FVN, differences between the fluorescence findings and anatomy of the internal iliac artery determined after LLND, and the surgical outcome. In all 11 patients, the ureters were clearly identified as fluorescent before dissection around the ureter. FVN revealed the internal iliac, umbilical, and superior vesical arteries in all patients. The branch from the internal iliac artery according to the Adachi classification was revealed on 16 sides (89%). The time from intravenous ICG injection to fluorescence of the internal iliac artery was 38 (17-57) s. The time from intravenous injection to when the vessels were observed as fluorescent was 113 (65-661) s. No ureteral or vessel injuries occurred. Fluorescence navigation of vessels and the ureter is feasible in laparoscopic LLND and has the potential to increase safety. Examination of fluorescence navigation for laparoscopic colorectal cancer surgery Research Ethics Committee of the Kawaguchi Municipal Medical Center (Saitama, Japan) approval number: 2020-3. https://kawaguchi-mmc.org/wp-content/uploads/clinicalresearch-r02.pdf.

A preliminary study of bilateral color mapping of pig bladder vasculature demonstrates potential for acute hemi-ischemic events.

BackgroundChronic ischemia is a known risk factor for the development of lower urinary tract symptoms (LUTS) and bladder hypocontractility. Less is known, however, about the impact of acute ischemia. Classic teaching suggests that collateral circulation is robust in the bladder and, therefore, loss of a single source of blood flow should have no deleterious effect. This study aims to provide visual evidence that segmental vascular supply is critical for maintaining adequate perfusion to the bladder.MethodsEx vivo pig bladders were cannulated bilaterally in the superior vesical arteries and perfused using contrasting red and green dye. Images were collected at each step of the perfusion dyeing process and these images were analyzed using a custom program to calculate the average hue of each side. Statistical analysis was performed using Student’s t-test.ResultsThe two halves being perfused by separate arteries showed a statistically significant difference when compared (P<0.05) on both the outer wall (n=9) and in the mucosal layer (n=4). On the outside wall, the average normalized hue of the green halves was 27.5°±14.3°, while the average normalized hue of the red halves was −58.7°±3.1°. In the mucosa, the average normalized hue of the green halves was 34.5°±17.4°, while the average normalized hue of the red halves was −51.5°±3.5°.ConclusionsThis study identified a novel color mapping method to study pig bladder vascular supply. The results demonstrated a lack of collateral blood flow, highlighting the possibly of acute hemi-ischemic event. However, further research in the effect of acute ischemia on bladder function is necessary.

Angiographic prostatic arterial anatomy in a Turkish population with benign prostatic hyperplasia

Background/aim Prostatic artery embolization (PAE) is a minimally invasive effective method in the treatment of benign prostatic hyperplasia (BPH). The procedure is technically challenging, as pelvic vascular anatomy is highly prone to variations and the identification of the prostatic artery (PA) is the most time-consuming step, which can lead to increased procedure times. The aim of this study was to categorize the anatomic variations in the prostatic supply in patients with BPH treated with PAE.Materials and methods The digital subtraction angiography findings of 68 PAE procedures were reviewed retrospectively and the age, PA origin, number, and procedure of the patients were recorded. The origin of the PA was classified into 5 subtypes using the de Assis/Carnavale classification. The incidence of each anatomic type was calculated. Results In the 68 PAE procedures, 119 pelvic sides were analyzed and a total of 119 PAs were classified. The most common origin was type 1 (n = 43, 36.1%), with the PA originating from the anterior division of the internal iliac artery (IIA), from a common trunk with the superior vesical artery. This was followed by type 4 (n = 34, 28.6%), with the PA originating from the internal pudendal artery; type 3 (n = 22, 18.5%), with the PA originating from the obturator artery; and type 2 (n = 13, 10.9%), with the PA originating from the anterior division of the IIA. Conclusion Anatomic variations are common in the IIA and PA, showing racial and individual differences. Following a standard classification system to identify the origin of the PA is crucial and being aware of the most common types in each population will make PAE a faster and safer procedure.

Internal hernia beneath superior vesical artery after pelvic lymphadenectomy for cervical cancer: a case report and literature review

BackgroundThe common complications of radical hysterectomy and pelvic lymphadenectomy usually include wound infection, hemorrhage or hematomas, lymphocele, uretheral injury, ileus and incisional hernias. However, internal hernia secondary to the orifice associated with the uncovered vessels after pelvic lymphadenectomy is very rare.Case presentationWe report a case of internal hernia with intestinal perforation beneath the superior vesical artery that occurred one month after laparoscopic pelvic lymphadenectomy for cervical cancer. A partial ileum resection was performed and the right superior vesical artery was transected to prevent recurrence of the internal hernia.ConclusionsRetroperitonealization after the pelvic lymphadenectomy should be considered in patients with tortuous, elongated arteries which could be causal lesions of an internal hernia.

Clinical outcome and analysis of procedural failure during uterine artery chemoembolisation as a treatment of caesarean scar pregnancy.

IntroductionCaesarean scar pregnancy (CSP) is a relatively rare yet life-threatening condition in which the embryo is implanted in the scar after caesarean section. Recent studies have reported that uterine artery chemoembolisation (UAC) can be safe and effective method in treating CSP.AimTo present the clinical outcome of UAC with a mixture of methotrexate and gelatine sponge for the treatment of CSP and analysis of procedural failure.Material and methodsForty-one patients diagnosed with CSP were treated with selective endovascular chemoembolisation of uterine arteries. Short- and long-term results, reasons for procedural failure, and clinical outcome were analysed.ResultsPrimary procedure failed in 7 out of 41 (17%) cases. In 4 cases additional blood supply to the CSP was disclosed; 3 out of 4 from an ovarian artery and one from a superior vesical artery. In other 3 patients, reperfusion of uterine arteries was observed. All these 7 patients underwent successful secondary embolisation. The majority of the followed-up patients reported regular menses after the intervention. Four women suffered from amenorrhoea and 2 from hypomenorrhoea that continued after 90 days. Twelve patients expressed the desire for subsequent pregnancy. From this group, 5 conceived within a year of the procedure. The rest did not achieve a pregnancy.ConclusionsUAC proved to be a safe and effective method and should be considered as an option for CSP treatment, especially for women hoping to preserve their fertility. However, the presence of collateral blood supply should always be considered.

The Bermuda`s Triangle a Didactic Description of the Retroperitoneal Anatomy

Study Objective The objective of this video is to teach an ¨effective¨ technique to find and clip the uterine arteries, previous to a total laparoscopic hysterectomy (TLH). Design video article. Setting Private Hospital. Patients or Participants N/A Interventions Hysterectomy is one of the most common surgical procedures around the world; Just in the USA, around 600,000 procedures are done yearly. The total laparoscopic hysterectomy has become one of the most common used techniques. According to the actual literature, the complication rate is in the range of 5.7/1000 procedures and bleeding is one of the most stressful complication. The purpose of this video article is to describe ¨The Bermuda´s Triangle¨ a very didactic description of the retroperitoneal vascular anatomy; With this description, it will be extremely easy to find and clip the uterine arteries, before performing a total laparoscopic hysterectomy. We named The Bermuda`s Triangle, because on the Atlantic Ocean the Bermuda's triangle is one of the most enigmatic and scare places, the same happened with the retroperitoneal space With the uterine arteries occluded, we decrease the uterine blood supply by 79%. After the initial anatomic pelvic inspection, we will see the pelvic side wall, we can draw an inverted triangle, that is formed from the superior side by utero-ovaric ligament, from the inferior side by the ureter and from the external side from the IP ligament, at the middle of the triangle we are gaining access into the retroperitoneal space; it will be quite easy to identify the vascular structures, nerves and ureter. The internal iliac artery will be identified, giving a bifurcation into uterine artery and superior vesical artery. The titanium clips are placed on the uterine artery. Measurements and Main Results N/A Conclusion The uterine arteries are clipped at the base, in an extremely easy and safe style. Doing this, we are decreasing the chances of a hemorrhage.

Modified sandwich embolization technique for postpartum hemorrhage caused by uterine artery pseudoaneurysm: a case series.

Uterine artery pseudoaneurysm (UAP) is rare but can cause life-threatening postpartum hemorrhage (PPH). To evaluate a novel sandwich embolization technique as a treatment for PPH caused by UAP. This retrospective study included 10 patients with PPH caused by UAP who were treated using a modified sandwich embolization technique at the Radiology Department, Third Affiliated Hospital of Guangzhou Medical University between April 2009 and September 2018. Baseline clinical characteristics, intraoperative data (including treatment effectiveness) and postoperative data (including re-bleeding events and complications) were extracted from the medical records. Uterine arterial angiography showed cystic shadowing of the vascular wall during the arterial phase in all patients. Spraying of contrast agent into the pseudoaneurysm was observed for large UAPs, and the pseudoaneurysm disappeared in the venous phase. The pseudoaneurysm blood supply was from the uterine artery in 9 patients (90%) and the uterine, superior vesical, internal pudendal and nameless little arteries in 1 patient (10%). Bleeding symptoms were completely relieved in all patients after sandwich embolization. Eight patients experienced painful contractions in the perioperative period, but there were no other postoperative complications. During the 1-year postoperative follow-up, 9 patients (90%) had no re-bleeding symptoms/signs. One patient (10%), who had a pseudoaneurysm supplied by the uterine, superior vesical, internal pudendal and nameless little arteries, experienced re-bleeding 20days after surgery and was treated by hysterectomy. Modified sandwich embolization is an effective treatment for PPH caused by UAP.