Somatic and autonomic nerve density of the urethra, periurethral tissue, and anterior vaginal wall: an immunohistochemical study in adult female cadavers.

INTRODUCTION AND HYPOTHESIS: Retropubic procedures may disrupt nerves supplying the pelvic viscera; however, knowledge of pelvic neuroanatomy is limited. We sought to characterize somatic and autonomic nerve density within the urethra, periurethral tissue, and anterior vagina. METHODS: Axial sections were obtained from pelvic tissue harvested from female cadavers ≤24 h from death at three anatomical levels: the midurethra, proximal urethra, and upper trigone. Periurethral/perivesical tissue was divided into medial and lateral sections, and the anterior vagina into middle, medial, and lateral sections. Double immunofluorescent staining for beta III tubulin (ßIIIT), a global axonal marker, and myelin basic protein (MBP), a myelinated nerve marker, was performed. Threshold-based automatic image segmentation distinguished stained areas. Autonomic and somatic density were calculated as percentage of tissue stained with ßIIIT alone, and with ßIIIT and MBP respectively. Statistical comparisons were made using nonparametric Friedman tests. RESULTS: Six cadavers, aged 22-73, were examined. Overall, autonomic nerve density was highest at the midurethral level in the lateral and middle anterior vagina. Somatic density was highest in the external urethral sphincter (midurethra mean 0.15%, SD ±0.11; proximal urethra 0.19%, SD ±0.19). Comparison of annotated sections revealed significant differences in autonomic density among the lateral, medial, and middle vagina at the midurethra level (0.71%, SD ±0.48 vs 0.60%, SD ±0.48 vs 0.70%, SD ±0.63, p=0.03). Autonomic density was greater than somatic density in all sections. CONCLUSIONS: Autonomic and somatic nerves are diffusely distributed throughout the periurethral tissue and anterior vagina, with few significant differences in nerve density among sections analyzed. Minimizing tissue disruption near urethral skeletal muscle critical for urinary continence may prevent adverse postoperative urinary symptoms.

[Anatomical and histological investigation of the area anterior to the anorectum passing through the levator hiatus].

Objective: To document the anatomical structure of the area anterior to the anorectum passing through the levator hiatus between the levator ani slings bilaterally. Methods: Three male hemipelvises were examined at the Laboratory of Clinical Applied Anatomy, Fujian Medical University. (1) The anatomical assessment was performed in three ways; namely, by abdominal followed by perineal dissection, by examining serial cross-sections, and by examining median sagittal sections. (2) The series was stained with hematoxylin and eosin to enable identification of nerves, vessels, and smooth and striated muscles. Results: (1) It was found that the rectourethralis muscle is closest to the deep transverse perineal muscle where the longitudinal muscle of the rectum extends into the posteroinferior area of the membranous urethra. The communicating branches of the neurovascular bundle (NVB) were identified at the posterior edge of the rectourethralis muscle on both sides. The rectum was found to be fixed to the membranous urethra through the rectourethral muscle, contributing to the anorectal angle of the anterior rectal wall. (2) Serial cross-sections from the anal to the oral side were examined. At the level of the external anal sphincter, the longitudinal muscle of the rectum was found to extend caudally and divide into two muscle bundles on the oral side of the external anal sphincter. One of these muscle bundles angled dorsally and caudally, forming the conjoined longitudinal muscle, which was found to insert into the intersphincteric space (between the internal and external anal sphincters). The other muscle bundle angled ventrally and caudally, filling the gap between the external anal sphincter and the bulbocavernosus muscle, forming the perineal body. At the level of the superficial transverse perineal muscle, this small muscle bundle headed laterally and intertwined with the longitudinal muscle in the region of the perineal body. At the level of the rectourethralis and deep transverse perineal muscle, the external urethral sphincter was found to occupy an almost completely circular space along the membranous part of the urethra. The dorsal part of the external urethral sphincter was found to be thin at the point of attachment of the rectourethralis muscle, the ventral part of the longitudinal muscle of the rectum. We identified a venous plexus from the NVB located close to the oral and ventral side of the deep transverse perineal muscle. Many vascular branches from the NVB were found to be penetrating the longitudinal muscle and the ventral part of rectourethralis muscle at the level of the apex of the prostate. The rectourethral muscle was wrapped ventrally around the membranous urethra and apex of the prostate. The boundary between the longitudinal muscle and prostate gradually became more distinct, being located at the anterior end of the transabdominal dissection plane. (3) Histological examination showed that the dorsal part of the external urethral sphincter (striated muscle) is thin adjacent to the striated muscle fibers from the deep transverse perineal muscle and the NVB dorsally and close by. The rectourethral muscle was found to fill the space created by the internal anal sphincter, deep transverse perineal muscle, and both levator ani muscles. Many tortuous vessels and tiny nerve fibers from the NVB were identified penetrating the muscle fibers of the deep transverse perineal and rectourethral muscles. The structure of the superficial transverse perineal muscle was typical of striated muscle. These findings were reconstructed three-dimensionally. Conclusions: In intersphincteric resection or abdominoperineal resection for very low rectal cancer, the anterior dissection plane behind Denonvilliers' fascia disappears at the level of the apex of the prostate. The prostate and both NVBs should be used as landmarks during transanal dissection of the non-surgical plane. The rectourethralis muscle should be divided near the rectum side unless tumor involvement is suspected. The superficial and deep transverse perineal muscles, as well as their supplied vessels and nerve fibers from the NVB. In addition, the cutting direction should be adjusted according to the anorectal angle to minimize urethral injury.

FEATURES OF PRENATAL MORPHOGENESIS AND PECULARITIES OF THE UTRICULUS PROSTATICUS FETAL ANATOMY.

OBJECTIVE: Aim: To determine the peculiarities of the structural organization of the utriculus prostaticus (UP) in pre-fetuses and fetuses. PATIENTS AND METHODS: Materials and methods: The study of macroscopic features and microscopic peculiarities of the prostate gland and the prostatic part of the urethra was carried out on 46 sections of human pre-fetuses and fetuses aged from 9 weeks to birth (31,0-375,0 mm PCL). The work uses the method of microscopic study of serial histological and topographic-anatomical specimens of the prostate gland, as well as the method of the thin preparation of the prostate part of the urethra in fetuses of different ages and morphometry. RESULTS: Results: In 58,0-66,0 mm PCL fetuses the paramesonephric ducts are reduced, except of their connected caudal part, which is a morphological substrate for the development of the UP. At 72,0-79,0 mm PCL fetuses, cavity is replaced by cellular mass. At the 85,0-120,0 mm PCL fetuses, the UP connects with the lumen of the urethra. The cavity of the UP intensivelly proliferates with cells. In fetuses of 125,0-135,0 mm PCL is presente dense arrangement of glandular elements, which are surrounded by fibrous-muscular membrane. In fetuses of 150,0-160,0 mm PCL, in the caudal direction, the cavity of the UP gradually narrows, it forms invaginations, especially in the middle and lower parts, or is divided into separate, interconnected chambers. In fetuses of 170,0-185,0 mm PCL, UP has elongated-oval or rounded-oval shape. In the caudal direction, the UP is directed ventral to the colliculus seminalis and is located slightly anterior and superior to the ejaculatory ducts. In 8-month-old fetuses, the lumen of the UP is lined with a pseudostratified cubical epithelium, outside of which there is a tunica muscularis. Ejaculatory ducts lined with a two-layer cuboidal epithelium are placed on both sides of the UP. A 270,0 mm PCL fetus has no UP at the apex of the colliculus seminalis. In fetuses 315,0-335,0 mm PCL, the process of cavity formation spreads to new areas of glandular formations of the prostate gland and their final branches. Most of the glandular formations open into the prostatic part of the urethra directly below the UP and the distal parts of the ejaculatory ducts. Microscopic examination of frontal sections of the prostate gland of a fetus with a 360,0 mm PCL revealed a septum in the UP which divides the cavity of the UP into the right and left halves of a round-oval shape. CONCLUSION: Conclusions: The formation of utriculus prostaticus occurs from the paramesonephric ducts in the 11th week of fetal development. At the beginning of the 4th month of intrauterine development, it gradually decreases in size. From the middle of the 5th month of prenatal development, the utriculus prostaticus lengthens, and starting from the fetus of 7 months, both its length and width increase. At the end of the fetal period, the utriculus prostaticus acquires a round-oval shape, its length increases from 0,5 to 4,3 mm during prenatal ontogeny.

Anatomic relationships of the clitoral body, bulbs of the vestibule, and urethra.

BACKGROUND: Although recent studies have enhanced our understanding of the anatomy of the clitoris and its somatic innervation, less emphasis has been placed on the anatomic relationships of the clitoris to its surrounding structures. OBJECTIVE: This study aimed to further characterize the gross and histologic relationships of the clitoris, vestibular bulbs, and urethra. STUDY DESIGN: Detailed dissections were performed in 30 unembalmed female cadavers. In 23 specimens, gross dissections were performed, and relationships of the clitoris, vestibular bulbs, and urethra were annotated. Histologic evaluation was performed in 7 specimens, in which tissues were harvested within 24 hours from death. Descriptive statistics were used for data analyses. RESULTS: The clitoral body consisted of 2 components, the proximal body and the distal body. The distal body was oriented ≤90° from the proximal body, forming an outer and inner angle at the inflection point. A "septumlike" arrangement of fibroconnective and vascular tissues was noted between the inner angle of the clitoral body and the urethra. Neurovascular bundles coursed laterally along the clitoral body and the surfaces of the crura and vestibular bulbs. The vestibular bulbs approached each other over the ventral surface of the urethra, at the commissure of the vestibular bulbs. Each bulb was separated by fibrous tissue and did not merge along the midline. The vestibular bulbs approximated the clitoral body, but the erectile tissue of the vestibular bulbs was separated from the corpora cavernosa of the clitoral body by the tunica albuginea. The erectile tissue of the vestibular bulbs abutted the ventrolateral walls of the urethra but was separated from the urethral mucosa by an indiscrete layer of erectilelike tissue with dense stroma. CONCLUSION: This study provided gross and histological confirmation of the relationships of the clitoris, vestibular bulbs, and urethra. Detailed knowledge of the anatomy of the clitoris is crucial for reducing surgical complications associated with periclitoral and distal urethral procedures, which may adversely affect sexual arousal and sexual function.

Membranous urethral length on magnetic resonance imaging as a novel predictor of urinary continence after delayed anastomotic urethroplasty for pelvic fracture urethral injury.

PURPOSE: We studied the impact of membranous urethral length (MUL) on magnetic resonance imaging (MRI) on post-urethroplasty continence in male patients with pelvic fracture urethral injury (PFUI). METHODS: Of 169 male patients with PFUI who underwent delayed anastomotic urethroplasty between 2008 and 2020, 85 who underwent preoperative MRI, had no recurrent stenosis on cystoscopy, and underwent a 1-h pad test 1 year after surgery were included. MUL was defined as the distance from the distal end of the disrupted proximal urethra to the apex of the prostate, as measured using T2-weighted MRI. Urinary incontinence (UI) was defined as a 1-h pad test weight > 2.0 g. RESULTS: None of the patients had UI before a pelvic fracture. Eighty-two patients (96.5%) had a measurable MUL, and the median length was 8.1 (interquartile range [IQR], 5.2-10.8) mm. The median weight of the 1-h pad test was 1.0 (IQR, 0.0-4.0) g, and 26 (30.6%) patients had UI. An open bladder neck (odds ratio [OR], 4.6; 95% confidence interval [CI], 1.0-22.0; p = 0.04) and a short measurable membranous urethra (for every extra mm: OR, 1.2; 95% CI, 1.0-1.3; p = 0.04) were significant UI predictors on multivariate analysis. CONCLUSIONS: A long MUL is significantly positively associated with urinary continence in male patients with PFUI. This could be of potential value to reconstructive urologists when counseling patients regarding post-urethroplasty continence before urethroplasty.

Inverse correlation between urethral length and continence before and after native tissue pelvic floor reconstruction.

Urethral length was evaluated retrospectively in patients with prolapse undergoing anterior native-tissue repair. Effects of age, prolapse stage, defect pattern, urodynamic and clinical stress test findings, and tension-free vaginal tape (TVT) surgery indication were analyzed using Mann-Whitney and Wilcoxon tests and linear and logistic regression. Of 394 patients, 61% had stage II/III and 39% had stage IV prolapse; 90% of defects were central (10% were lateral). Median pre- and postoperative urethral lengths were 14 and 22 mm (p < 0.01). Preoperative urethral length was greater with lateral defects [p < 0.01, B 6.38, 95% confidence interval (CI) 4.67-8.08] and increased stress incontinence risk (p < 0.01, odds ratio 1.07, 95% CI 1.03-1.12). Postoperative urethral length depended on prolapse stage (p < 0.01, B 1.61, 95% CI 0.85-2.38) and defect type (p = 0.02, B - 1.42, 95% CI - 2.65 to - 0.2). Postoperatively, TVT surgery was indicated in 5.1% of patients (median 9 months), who had longer urethras than those without this indication (p = 0.043). Native-tissue prolapse repair including Kelly plication increased urethral length, reflecting re-urethralization, particularly with central defects. The functional impact of urethral length in the context of connective tissue aging should be examined further.

Anatomy of Cowper's gland in humans suggesting a secretion and emission mechanism facilitated by cooperation of striated and smooth muscles.

This study presents the detailed anatomy of the Cowper's gland in humans. Elucidating the mechanism of secretion and emission of the Cowper's gland requires analysis of the muscles around the Cowper's gland. We hypothesized that the Cowper's gland involves not only smooth muscle but also the striated muscles of the pelvic floor. Here, we provide comprehensive and three-dimensional anatomy of the Cowper's gland and its surrounding structures, which overcomes the current local and planar understanding. In this study, seven male corpses of body donors were used to conduct macroscopic anatomy, histology, and three-dimensional reconstruction. The Cowper's gland was surrounded laterally and posterosuperiorly by striated and smooth muscles, respectively. The striated muscle bundle was connected from the superficial transverse perineal muscle, levator ani, and external anal sphincter to the external urethral sphincter (rhabdosphincter). The smooth muscle was part of the deep transverse perineal muscle and entered between the bilateral Cowper's glands and lobules. Our findings indicate that the secretion and emission of the Cowper's gland in humans are carried out through the cooperation of striated and smooth muscles.

A novel nomogram for the delayed transperineal anastomotic urethroplasty based on relative position between the proximal urethra and the pubic ramus in pelvic fracture injury patients: a retrospective analysis.

PURPOSE: Many reconstructive urologists have observed that higher urethra injuries lead to potentially less successful repairs. This article introduces a novel prognostic factor for pelvic fracture caused urethral injury (PFUI) to predict stricture recurrence after delayed transperineal anastomotic urethroplasty (TAU) patients with PFUI based on urethra injury locations. MATERIALS AND METHODS: Patients who underwent suprapubic cystostomy tube placement and delayed TAU for PFUI by a single surgeon between 2009 and 2018 were screened. A total of 151 patients completed the follow-up. The relative location between the proximal urethra and the pubic ramus (PUE-PR), a novel stricture length classification method based on the anatomical landmark, was divided into a lower, middle, and upper group reflected by urethrogram. The nomogram was developed based on significant coefficients identified by multivariable Cox regression. RESULTS: Based on the relative position between the proximal urethra end and the pubic ramus (PUE-PR), 47 (31%), 66 (44%), and 38 (25%) patients were assigned to the lower, middle, and upper group, respectively. A total of 33 patients (22%) patients had a recurrence. The median (IQR) follow-up was 49 months (28-75). Smoking, endoscopic treatment history, and PUE-PR were identified as independent risk factors for stricture recurrence. The nomogram showed good discrimination with a C-index of 76.67%. The decision curve analysis (DCA) indicated that the model could bring more clinical net benefit when a threshold probability is larger than 8%. CONCLUSIONS: PUE-PR is a new prognostic factor for PFUI to predict stricture recurrence after TAU. A novel nomogram incorporating PUE-PR could be applied to facilitate the prediction of stricture recurrence after delayed TAU for PFUI.

Novel anatomical apical dissection utilizing puboprostatic "open-collar" technique: Impact on apical surgical margin and early continence recovery.

PURPOSE: To evaluate the impact of modifications to anatomical apical dissection including a puboprostatic open-collar technique, which visualizes the lateral aspect of the apex and dorsal vein complex (DVC) covering the rhabdosphincter while preserving the puboprostatic collar, on positive surgical margin (PSM) and continence recovery. METHODS: One-hundred-and-sixty-seven patients underwent gasless single-port retroperitoneoscopic radical prostatectomy using a three-dimensional head-mounted display system. Sequentially modified surgical techniques comprised puboprostatic open-collar technique, sutureless transection of the DVC, retrograde urethral dissection, and anterior reconstruction. The associations of these modifications with PSM and continence recovery were assessed. RESULTS: The puboprostatic open-collar technique, sutureless DVC transection, and retrograde urethral dissection were significantly associated with lower apical PSM (P = 0.003, 0.003, and 0.010, respectively). The former two also showed similar associations in 84 patients with anterior apical tumor (P = 0.021 and 0.030, respectively). Among 92 patients undergoing all of these three procedures, overall and apical PSM rates were 13.0% and 3.3%, respectively. Retrograde urethral dissection (odds ratio [OR] 2.73, P = 0.004) together with nerve sparing (OR 2.77, P = 0.003) and anterior apical tumor (OR 0.45, P = 0.017) were independently associated with immediate continence recovery. A multivariable model for 3-month continence recovery included anterior apical tumor (OR 0.28, P = 0.003) and puboprostatic open-collar technique (OR 3.42, P = 0.062). Immediate and 3-month continence recovery rates were 56.3% and 85.4%, respectively, in 103 patients undergoing both the puboprostatic open-collar technique and retrograde urethral dissection. CONCLUSION: Novel anatomical apical dissection utilizing a puboprostatic open-collar technique may favorably impact on both apical surgical margin and continence recovery.

Effect of prostatic apex shape (Lee types) and urethral sphincter length in preoperative MRI on very early continence rates after radical prostatectomy.

PURPOSE: To test the effect of anatomic variants of the prostatic apex overlapping the membranous urethra (Lee type classification), as well as median urethral sphincter length (USL) in preoperative multiparametric magnetic resonance imaging (mpMRI) on the very early continence in open (ORP) and robotic-assisted radical prostatectomy (RARP) patients. METHODS: In 128 consecutive patients (01/2018-12/2019), USL and the prostatic apex classified according to Lee types A-D in mpMRI prior to ORP or RARP were retrospectively analyzed. Uni- and multivariable logistic regression models were used to identify anatomic characteristics for very early continence rates, defined as urine loss of ≤ 1 g in the PAD-test. RESULTS: Of 128 patients with mpMRI prior to surgery, 76 (59.4%) underwent RARP vs. 52 (40.6%) ORP. In total, median USL was 15, 15 and 10 mm in the sagittal, coronal and axial dimensions. After stratification according to very early continence in the PAD-test (≤ 1 g vs. > 1 g), continent patients had significantly more frequently Lee type D (71.4 vs. 54.4%) and C (14.3 vs. 7.6%, p = 0.03). In multivariable logistic regression models, the sagittal median USL (odds ratio [OR] 1.03) and Lee type C (OR: 7.0) and D (OR: 4.9) were independent predictors for achieving very early continence in the PAD-test. CONCLUSION: Patients' individual anatomical characteristics in mpMRI prior to radical prostatectomy can be used to predict very early continence. Lee type C and D suggest being the most favorable anatomical characteristics. Moreover, longer sagittal median USL in mpMRI seems to improve very early continence rates.

Gross Anatomy of Urethra and Penis in Uncastrated and Castrated Buck of Black Bengal Goat

SUMMARY: Urethral process, sigmoid flexure, urethra at the pelvic arch and neck of urinary bladder in goats are very much prone to form obstructive urolithiasis. The present study was carried out to establish baseline work on the normal measurement of the urethral passage and different segments of penis of uncastrated and castrated Black Bengal (BB) goat which will be supportive for obstructive urolithiasis management. Different segment of penis along with urethra of 25 uncastrated and 25 castrated male Black Bengal goats were collected from different slaughter house of Chattogram City Corporation. The length and diameter of male urethra and different segment of penis in uncastrated buck were significantly higher (p<.001) than castrated buck. The length of the pelvic urethra was 5.88 ± 0.111 cm and 4.58 ± 0.15 cm in uncastrated and castrated buck respectively. The length of the neck of urinary bladder; root, body, sigmoid flexure, glans penis and urethral process of the penis in uncastrated and castrated buck were 0.688 ± 0.156 cm and 0.38 ± 0.048 cm, 5.02 ± 0.09 cm and 4.24±0.10 cm, 23.48 ± 0.37 cm and 22.74 ± 0.43 cm, 9.2 ± 0.107 cm and 8.18 ± 0.29 cm, 1.92 ± 0.032 cm and 1.44 ± 0.10 cm, 2.32 ± 0.029 cm and 1.78 ± 0.07 cm respectively. The diameter of the neck of urinary bladder, root, body, sigmoid flexure, glans penis and urethral process of the penis in uncastrated and castrated buck were 1.94 ± 0.041 cm and 1.44 ± 0.05 cm, 3.7 ± 0.049 cm and 3.3 ± 0.144 cm, 2.63 ± 0.066 cm and 1.86 ± 0.08 cm, 2.77 ± 0.90 cm and 2.18 ± 0.07 cm , 1.81 ± 0.034 cm and 1.4 ± 0.06 cm, 0.66 ± 0.014 cm and 0.56 ± 0.05 cm respectively. Finally, total lengths of penis in uncastrated and castrated buck were 30.42±0.459 cm and 28.42±0.553 cm respectively. The length and diameter of the neck of the urinary bladder, root, sigmoid flexure, urethral process of the penis are clinically more important for obstructive urolithiasis.

RESUMEN: El proceso uretral, el ángulo sigmoideo, la uretra en el arco pélvico y el cuello de la vejiga urinaria en las cabras son muy propensos a formar urolitiasis obstructiva. El presente estudio se llevó a cabo para establecer un trabajo de referencia sobre la medición normal del pasaje uretral y diferentes segmentos de pene de cabra de Bengala Negra (BB) no castrada y castrada, que serán de apoyo para el manejo de la urolitiasis obstructiva. Se recolectaron diferentes segmentos de pene junto con la uretra de 25 machos de cabras de Bengala negras sin castrar y 25 castrados de diferentes mataderos de Chattogram City Corporation. La longitud y el diámetro de la uretra y los diferentes segmentos del pene en el macho no castrado fueron significativamente más altos (p <0,001) que en el macho castrado. La longitud de la uretra pélvica fue de 5,88 ± 0,111 cm y 4,58 ± 0,15 cm en animales sin castrar y castrados, respectivamente. La longitud del cuello de la vejiga urinaria; raíz, cuerpo, flexión sigmoidea, glande del pene y proceso uretral del pene en el macho sin castrar y castrado fueron 0,688 ± 0,156 cm y 0,38 ± 0,048 cm, 5,02 ± 0,09 cm y 4,24 ± 0,10 cm, 23,48 ± 0,37 cm y 22,74 ± 0,43 cm , 9,2 ± 0,107 cm y 8,18 ± 0,29 cm, 1,92 ± 0,032 cm y 1,44 ± 0,10 cm, 2,32 ± 0,029 cm y 1,78 ± 0,07 cm, respectivamente. El diámetro del cuello de la vejiga urinaria, la raíz, el cuerpo, el ángulo sigmoide, el glande del pene y el proceso uretral del pene en el macho no castrado y castrado fueron 1,94 ± 0,041 cm y 1,44 ± 0,05 cm, 3,7 ± 0,049 cm y 3,3 ± 0,144 cm. 2,63 ± 0,066 cm y 1,86 ± 0,08 cm, 2,77 ± 0,90 cm y 2,18 ± 0,07 cm, 1,81 ± 0,034 cm y 1,4 ± 0,06 cm, 0,66 ± 0,014 cm y 0,56 ± 0,05 cm respectivamente. Finalmente, las longitudes totales de pene en machos castrados y no castrados fueron de 30,42 ± 0,459 cm y 28,42 ± 0,553 cm respectivamente. La longitud y el diámetro del cuello de la vejiga urinaria, la raíz, el ángulo sigmoideo y el proceso uretral del pene son clínicamente más importantes para la urolitiasis obstructiva.

Architecture of female urethral supporting structures based on undeformed high-resolution sectional anatomical images.

Female urinary incontinence mainly relates to damage of female urethra supporting structures, while its anatomy and function specially in which the connective tissue part are still unclear and controversial. We study it based on 4 thin-sectional, high-resolution, transverse sectional anatomical images [Chinese Visible Human (CVH) images] and 10 high-resolution MRI images from volunteers. The female urethral supporting structures and its adjacent structures were segmented and three-dimensional (3D) reconstructed with Amira software. The urethral supporting structures include muscular and connective tissue supporting structures. Muscular supporting structures are composed of levator ani muslce and striated urethral sphincter, the connective tissue supporting structures are composed of anterior vaginal wall, pubovesical muscle, pubovesical ligament, lateral vesical ligament, and tendinous arch of pelvic fascia (TAPF). The anterior vaginal wall includes tight and loose connections between urethral, bladder, and vagina. The lateral vesical ligament connects the proximal part of the urethra to the TAPF. The pubovesical muscle is crescent shaped and continues with the detrusor of the bladder superior and directly connects the TAPF laterally. The TAPF is an obvious fibrous structure that originates at the middle-posterior surface of the pubis, travels onto the parietal pelvic fascia, and inserts posteriorly onto the ischial spine. The anterior vaginal wall, the pubovesical muscle, the lateral vesical ligament, and the TAPF create the "hammock" structure and supplement DeLancey's theory. Its support to the proximal urethra and neck of bladder is crucial to maintain stability and urinary continence during increased abdominal pressure.

Histological and morphometric evaluation of the urethra and penis in male New Zealand White rabbits.

This stereudy aimed at performing a histological and morphometric evaluation of the urethra and penis of male rabbits. Seven male New Zealand White rabbits weighing 2.1-3 kg were used in the study. The whole urethra, from the urinary bladder to the external urethral orifice, was dissected from the rabbits, and the tissue was sliced into sections at an interval of 2 mm. The sections were stained with haematoxylin-eosin, Masson-Goldner trichrome stain, Van Gieson's stain and Movat-Russell modified pentachrome stain. A detailed evaluation of the morphology and morphometry was performed. The parameters assessed were the type and height of epithelium, thickness and composition of connective tissue, and thickness and structure of muscularis. The histological structure of the rabbit urethra was found to be similar to humans. However, although the rabbits were found to have the same type of penis as the humans, the internal structure of the corpora cavernosa, the relative thickness of the tunica albuginea and the rudimentary glands of the penis were found to differ in these animals. The results of the present study may be useful in the designing of implants, drug testing or surgical procedures on the physiological and pathological urethra.

Prostate Bed Delineation Guidelines for Postoperative Radiation Therapy: On Behalf Of The Francophone Group of Urological Radiation Therapy.

PURPOSE: Prostate bed (PB) irradiation is considered the standard postoperative treatment after radical prostatectomy (RP) for tumors with high-risk features or persistent prostate-specific antigen, or for salvage treatment in case of biological relapse. Four consensus guidelines have been published to standardize practices and reduce the interobserver variability in PB delineation but with discordant recommendations. To improve the reproducibility in the PB delineation, the Francophone Group of Urological Radiotherapy (Groupe Francophone de Radiothérapie Urologique [GFRU]) worked to propose a new and more reproducible consensus guideline for PB clinical target volume (CTV) definition. METHODS AND MATERIALS: A 4-step procedure was used. First, a group of 10 GFRU prostate experts evaluated the 4 existing delineation guidelines for postoperative radiation therapy (European Organization for Research and Treatment of Cancer; the Faculty of Radiation Oncology Genito-Urinary Group; the Radiation Therapy Oncology Group; and the Princess Margaret Hospital) to identify divergent issues. Second, data sets of 50 magnetic resonance imaging studies (25 after RP and 25 with an intact prostate gland) were analyzed to identify the relevant anatomic boundaries of the PB. Third, a literature review of surgical, anatomic, histologic, and imaging data was performed to identify the relevant PB boundaries. Fourth, a final consensus on PB CTV definition was reached among experts. RESULTS: Definitive limits of the PB CTV delineation were defined using easily visible landmarks on computed tomography scans (CT). The purpose was to ensure a better reproducibility of PB definition for any radiation oncologist even without experience in postoperative radiation therapy. CONCLUSIONS: New recommendations for PB delineation based on simple anatomic boundaries and available as a CT image atlas are proposed by the GFRU. Improvement in uniformity in PB CTV definition and treatment homogeneity in the context of clinical trials are expected.

Feasibility, technique and accuracy of ultrasound-guided transurethral injections into the urinary sphincter of female cadavers: proof of concept.

BACKGROUND: The injection of muscle precursor cells (MPC) into the external urinary sphincter muscle (EUS) is a promising therapeutic option for regenerative treatment of stress urinary incontinence (SUI). The objective of the present project was to conduct a pre-clinical trial to investigate the feasibility and accuracy of ultrasound (US) guided, transurethral injections into the EUS of female cadavers. METHODS: This is a prospective, anatomical, interventional and radiological cadaveric laboratory investigation. Two urologists performed transurethral US-guided injections to deliver nano-iron particles into the EUS. The intervention was performed in three unfixed, fresh female cadavers. Each cadaver received MRI before and CT as well as MRI of the pelvis after the injections. RESULTS: The precision and accumulation of nano-iron particles in the EUS was compared using a rating scale to evaluate left versus right and anterior versus posterior distribution in axial and sagittal orientation with US, MRI and CT. The accuracy of our US-guided injections into the anterior target region yielded 4 points on the rating scale. Adequate precision and accumulation of particles in the left versus right EUS were also demonstrated (3 vs. 3.33 points, respectively). Signal intensity in MRI revealed a mean ratio of 0.33 before and after injection. CT scans showed no relevant artefacts impairing the assessment. CONCLUSION: US-guided, transurethral injection into the EUS is feasible and imaging reveals a precise accumulation in the target region. Our method provides an appropriate approach to deliver MPC in the EUS muscle for a regenerative treatment of SUI in the near future.

Postoperative membranous urethral length is the single most important surgical factor predicting recovery of postoperative urinary continence.

PURPOSE: To analyze the potential surgical factors affecting postoperative urinary continence, including postoperative membranous urethral length (MUL), in an era where open radical prostatectomy (ORP) and robot-assisted radical prostatectomy (RARP) coexist. METHODS: Consecutive patients undergoing either ORP or RARP between April 2009 and June 2017 were included in this study. Pericatheter urethrography (PCU) was performed the day of catheter removal to confirm healing of the vesicourethral anastomosis and to measure PCU-MUL. Daily usage of incontinence pad was self-reported by the patient at each post-operative visit through a questionnaire. Univariate and multivariate analyses were performed to identify factors that influenced recovery of continence. RESULTS: Of the 196 patients included, 121 and 75 patients received ORP and RARP, respectively. The cumulative full continence rates (0 pad/day) at 1 year in the ORP and RARP groups were 87% and 95%, respectively. In the univariate analysis, older age, high preoperative International Prostate Symptom Score (IPSS) irritative symptom domain, ORP, poorer NVB preservation, and shorter PCU-MUL were associated with delayed recovery of full continence. In the multivariate analysis, only older age, high preoperative IPSS irritative symptom domain, and shorter PCU-MUL remained as independent factors significantly associated with delayed recovery of full continence. CONCLUSIONS: Our study highlights the importance of saving the MUL as long as possible in terms of continence recovery. This holds true for ORP even in the era of RARP and surgeons should not simply give up the prospect of early urinary continence in exchange for the patient's choice of ORP instead of RARP.

Predictors of urinary toxicity with MRI-assisted radiosurgery for low-dose-rate prostate brachytherapy.

PURPOSE: MRI-assisted radiosurgery (MARS) is a modern technique for prostate brachytherapy that provides superior soft tissue contrast. The purpose of this analysis was to evaluate treatment planning factors associated with urinary toxicity, particularly damage to the membranous urethra (MUL) and external urethral sphincter (EUS), after MARS. MATERIAL AND METHODS: We retrospectively reviewed 227 patients treated with MARS. Comparisons were made between several factors including preimplantation length of the MUL and EUS dosimetric characteristics after implantation with longitudinal changes in American Urological Association (AUA) urinary symptom score. RESULTS: Rates of grade 3 urinary incontinence and obstructive urinary symptoms were 4% and 2%. A piecewise mixed univariate model revealed that MUL and V200, V150, V125, and D5 to the EUS were all associated with increased rates of urinary toxicity over time. On univariate logistic regression, MUL >14.2 mm (odds ratio [OR] 2.03 per cm3, 95% confidence interval [CI] 1.10-3.77, p = 0.025), V125 to the EUS (OR 3.21 cm3, 95% CI 1.18-8.71, p = 0.022), and use of the I-125 isotope (OR 3.45, 95% CI 1.55-7.70, p = 0.001) were associated with subacute urinary toxicity (i.e., that occurring at 4-8 months). Optimal dose-constraint limits to the EUS were determined to be V200 < 0.04 cm3 (p = 0.002), V150 < 0.12 cm3 (p = 0.041), V125 < 0.45 cm3 (p = 0.033), D30 < 160 Gy (p = 0.004), and D5 < 218 Gy (p = 0.016). CONCLUSIONS: MARS brachytherapy provides detailed anatomic information for treatment planning, implantation, and quality assurance. Overall rates of urinary toxicity are low; however, several dosimetric variables associated with the EUS were found to correlate with urinary toxicity.

Spatial distribution of smooth muscle tissue in the female pelvic floor and surrounding the urethra and vagina.

Data regarding urethral supporting structures are insufficient for understanding the mechanism of stress urinary incontinence. Whether smooth muscle fibers contribute to urethral support and pelvic floor support structures is unclear. This study aimed to clarify the histological structures and spatial distributions of smooth muscle tissues surrounding the urethra and vagina. Using cadaveric specimens, macroscopic anatomical and histological evaluations were conducted. Six female cadavers were used for macroscopic observations. Ten female cadavers were used for histological observations. Three pelvises were cut in a plane vertical to the urethra, and the other pelvises were cut in a plane parallel to the urethra and vagina to observe tissues surrounding the urethra and vagina. The major tissue component around the proper muscle layer of the urethra was smooth muscle tissue, which mediated among the urethra, pubis, and levator ani. Smooth muscle tissues laterally extended the smooth muscle fibers, both superiorly and inferiorly toward the levator ani, with a few fibers inserted in the levator ani. Smooth muscle was found between the urethral walls and pubic bones. Smooth muscle may contribute to the mechanism of pelvic floor support.