The inferior hypogastric plexus (pelvic plexus): its importance in neural preservation techniques.

The progress in the surgery of male neurological cancers relies on the anatomico-surgical approach to the pelvic neural structures. The objective of our study was to provide a better understanding of the inferior hypogastric plexus (IHP) and its anatomical relationships in order to spare it during radical prostatectomy. Fifteen male formalin-preserved cadavers which had no sub-umbilical scar were used. In five subjects, the superior hypogastric plexus (SHP) and the pre-sacral plexus were displayed then the IHP and its sacral afferents (pelvic splanchnic nerves or erector nerves of Eckhardt) were dissected out. Serial sections of the IHP were then studied in ten subjects. This allowed its identification on certain imaging sections obtained in pelvic tumor pathology and these made up the "reference cuts". The IHP lies within a fibro-fatty plate which is flat, rectangular, sub-peritoneal, sagittal and symmetrical. It arises at the level of the intersection between the vas deferens and the terminal pelvic ureter and follows the postero-lateral aspect and circumvolutions of the seminal vesicle, with which there is a plane of surgical cleavage. The seminal vesicle is, therefore, an essential landmark for this neural structure. The plane of this cleavage may be used in pelvic cancer surgery. The safest technical means of respecting sexual function and the integrity of the IHP is to keep it at a distance. The preservation of a lateral layer of the seminal vesicle is probably a method of limiting these complications as long as this does not conflict with the oncological clearance. An irregular communicating branch was found in one of five cases between the IHP, the sacral plexus and the pudendal nerve. This communicating branch lay immediately behind the intersection between the vas deferens and the ureter in the sacral concavity. It overhangs the IHP in the seminal vesicle. Impotence remains a frequent complication after radical prostatectomy. The methods of neural preservation at the prostatic apex are known but neural preservation should also be carried out posteriorly at the lateral pole of the seminal vesicle. The possibility of posterior neural preservation may be assessed pre-operatively by study of the "reference sections". The cleavage plane between the seminal vesicle and the IHP may be used intra-operatively to spare the IHP. The cavernous nerve in particular emerges at the antero-inferior border of the IHP before running along the postero-lateral aspect of the prostate. It therefore passes in contact with the seminal vesicle and may as a result be injured during radical prostatectomy with vesiculectomy. A proximal communicating branch between the IHP and the pudendal nerve is irregular. Such communicating branches may explain a better recovery of sexual function in curative neurological cancer surgery. The essential relationship of the IHP is with the seminal vesicle. The two are in tight contact and the seminal vesicle has a true plane of surgical cleavage with IHP. The risk of injuries to the posterior erectile mechanisms can be reduced either by using the cleavage plane between the IHP and seminal vesicle or by leaving a layer of the seminal vesicle when the oncological conditions allow. During celio-surgery, the operator must be careful to retract the little bands of the seminal vesicle and divide the fibrous and vascular tracts which tighten during this maneuver. During an abdominal approach, dissection of the seminal vesicle takes place at the bottom of a real pit. The operator must carry out the division leaving a layer of the seminal vesicle in place rather than trying to extract all the seminal vesicle by placing the forceps blindly. This maneuver is naturally dependent on the oncological situation. The anatomical confirmation of a regular or irregular proximal or distal communicating branch between the IHP and the pudendal nerve is probably an explanation for the sometimes uncertain results of new techniques of neural preservation in curative cancer surgery.

[Recurrent peri-stomal varix hemorrhage after diversion using the Bricker's technique]. / Hémorragies récurrentes par des varices péri-stomiales après dérivation selon Bricker.

Peristomal varices can occur in patients with gastrointestinal or urinary diversions associated with portal hypertension. It is now no longer rare to propose radical surgery for invasive bladder tumours in patients also suffering from hepatic cirrhosis, responsible for specific subsequent complications. Less than ten cases of varicose haemorrhages have been described on ileal bladders. The authors report the case of a patient with cirrhosis (Child B) treated surgically (radical cystoprostatectomy and Bricker transileal cutaneous diversion) for invasive bladder tumour. Episodes of bleeding varices occurred two months after surgery. Repeated and abundant haemorrhage led to the placement of an intrahepatic shunt (TIPS) allowing reduction of the portal hypertension and the severity of the bleeding. When local control of the bleeding is no longer possible, reduction of the portosystemic pressure gradient is required. TIPS is an effective alternative to surgical shunts, responsible for high morbidity and mortality in these debilitated patients.

[Long-term results of interferential current stimulation in the treatment of bladder instability]. / Résultats à long-terme de la stimulation par courants interférentiels dans le traitement de l'instabilité vésicale.

OBJECTIVE: To study the late results of interferential current stimulation in the treatment of detrusor instability. MATERIAL AND METHODS: 62 patients with detrusor instability refractory to medical treatment by anticholinergic drugs were treated by interferential current stimulation. This technique combines the advantages of retraining stimulation with external application. This retrospective study was based on 62 patients (43 children, 11 men and 8 women) presenting with detrusor instability between January 1990 and December 1997. All patients were assessed clinically and by a radiological, bacteriological and urodynamic work-up prior to treatment. The mean follow-up was 5 years (range: 18 months to 10 years). RESULTS: The results of this technique were excellent, with 80.9% of cures at one year, but they tended to fade over time to 40% of cures at 5 years. However, results which deteriorate after one year can generally be maintained by performing 5 maintenance sessions every 12 or 18 months. CONCLUSION: Treatment of detrusor instability by interferential current is a reliable technique which constitutes an alternative to the other methods of retraining stimulation and can be performed in cases of instability refractory to anticholinergic drugs, before considering neuromodulation or surgery. Five to 10 maintenance sessions every 12 or 18 months ensure stable long-term results in the majority of cases.

Tendinous arch of the pelvic fascia: application to the technique of paravaginal colposuspension.

The authors give a description of the anatomy and topography of the tendinous arch of the pelvic fascia (TAPF), in order to facilitate its location during surgery. 35 TAPF in 25 female cadavers were dissected. The reproducibility of the landmarks was then verified at laparotomy. The TAPF can be easily identified and its resistance remains constant, even when the pelvic floor is hypotrophic. Its anterior extremity (d2) is at about 46 mm on a line perpendicular to the anterior edge of the pectineal ligament (35-55 mm), next to the pubovesical ligament. Its median part (dl) is perpendicular to the obturator foramen at a site located at an average of 30 mm below the obturator foramen (25-50 mm). Its posterior end is located at the ischial spine. These anterior landmarks, the only ones useful during surgery, allow its very easy location with the palmar surface of the finger. Testard and Delancey demonstrated the major role of the TAPF in stabilising the urethra submitted to strain. Richardson described a technique of paravaginal suspension for curing paravaginal fascial defect. The TAPF has never been well described, but his work allows its easy location during surgery. The suture of the vagina to the TAPF allows a more physiologic and stronger suspension of the bladder neck than other classical techniques.

[Role of systematic scrotal ultrasonography in the management of male infertility: prospective study of 609 cases]. / Intérêt de l'échographie scrotale systématique dans la prise en charge de l'homme infertile: étude prospective de 609 cas.

OBJECTIVES: To assess the benefit and diagnostic contribution of systematic scrotal ultrasound in the management of infertile men. MATERIAL AND METHODS: Between 1st January and 31st December 1997, the authors conducted a consecutive and prospective study of 609 infertile patients corresponding to 418 cases of oligoasthenoteratospermia and 191 cases of azoospermia. All patients were investigated by scrotal ultrasound. RESULTS: 133 patients (21.8%) did not present any clinical or ultrasound abnormality. 60 patients (9.9%) presented isolated clinical abnormalities and 125 patients (20.5%) presented a discordance between clinical findings and ultrasound results. 9 patients (1.5%) presented an ultrasound nodule, 6 of which were discovered incidentally. 22 patients (3.6%) in whom the clinical features were more difficult to interpret, presented unambiguous findings. CONCLUSION: Scrotal ultrasound makes a considerable contribution to more appropriate management of infertile men and diagnoses 1.5% of testicular tumours.

[A case of metastatic nephroblastoma in an adult with favorable outcome under cisplatyl, etoposide]. / Un cas de néphroblastome métastasé chez l'adulte d'évolution favorable sous cisplatyl, étoposide.

Wilm's tumor is exceptional in adulthood. Its treatment is based on radical nephrectomy, adjuvant chemotherapy and radiotherapy. The prognosis is poorer compared with children because adults present more frequently with advanced stages and chemotherapy has a moderate efficacy. The various protocols of chemotherapy and the indications of radiotherapy are not defined with precision, mainly due to the rarity of the disease. The authors report a case of adult Wilm's tumor with a favorable evolution followed 4 years in spite of an unfavorable histology, lung metastases and a relapse after a first chemotherapy.

[Epididymal leiomyosarcoma. A case report with review of the literature]. / Le léiomyosarcome de l'épididyme. A propos d'un cas avec revue de la littérature.

The authors report the 14th case of leiomyosarcoma of the epididymis in a 67-year-old man. Treatment consisted of radical left orchidectomy without adjuvant chemotherapy or radiotherapy. The patient is free of local or distant recurrence with a follow-up of 2 years. The other 13 cases reported in the literature are briefly reviewed.