Topographical anatomy of the penile arteries

OBJECTIVE

To determine the relationship of the penile arteries to anatomical landmarks and thus ease their identification, so avoiding injury during surgery.

MATERIALS AND METHODS

The penile arteries in 12 formalin-preserved adult male cadavers were dissected and the distances measured between the cavernosal arteries and both the endopelvic fascia and distal attachment of the crura to the ischial bones. The distance between the origins of both bulbar and cavernosal arteries, their length and the length of the cavernosal bodies and crural attachments were also measured.

RESULTS

Several anatomical variations, e.g. accessory pudendal arteries, multiple cavernosal and bulbar arteries, irrigation of cavernosal bodies by contralateral branches, anastomosis of cavernosal arteries with accessory pudendal branches, dorsal artery or bulbar artery as main branches of accessory pudendal arteries, were observed in 13 of the 24 specimens. The mean distances between the anterior attachment of the crura to the ischial rami and the site on the tunica albuginea where the cavernosal arteries penetrated the cavernosal bodies were 1.26 cm on the right and 0.69 cm on the left. The corresponding measurements between the cavernosal arteries and the endopelvic fascia were 5.68 cm (right) and 4.85 cm (left). The mean extracavernosal lengths of the right and left cavernosal arteries were 2.47 and 2.2 cm, respectively.

CONCLUSIONS

Multiple anatomical variations of the arterial penile anatomy occur frequently. Surgery at the penile hilum may easily damage the cavernosal arteries, which lie medially to the dorsal nerves and arteries of the penis, have an extracavernosal length of about 2.3 cm and perforate the tunica albuginea about 1 cm distally to the anterior attachment of the crura to the ischial ramus.

[Review of complications of urinary diversions performed during a 6-year period in the era of orthotopic neobladders]

OBJECTIVE

To compare the morbidity of different types of permanent urinary diversion.

METHODS

We reviewed the postoperative and longterm complications observed in 85 patients who underwent permanent urinary diversion from December, 1986 to January, 1993: cutaneous ureterostomy (16 pts.), transintestinal incontinent cutaneous ureterostomy (41 pts.), orthotopic neobladder (27 pts.). All patients underwent radical cystectomy for bladder carcinoma. The surgical technique utilized for the construction of the orthotopic neobladders were as follows: Camey 1 (4 cases), Camey II (6 cases), Mainz (2 cases), Hautman (6 cases), detubularized sigmoid (6 cases). We also reviewed and used for comparison 18 augmentation cystoplasties that underwent simple subtotal cystectomy. Augmentation cystoplasty was performed with the sigmoid (n = 8), ileon (n = 5) and ileocecal segment (n = 4).

RESULTS

The incidence of postoperative complications was similar for all types of urinary diversion (64.3% for cutaneous ureterostomy, 61% for transintestinal intermittent cutaneous ureterostomy, 59.3% for orthotopic neobladder), although patients with orthotopic neobladders required surgery more frequently (7.1% for cutaneous ureterostomy, 22% for transintestinal cutaneous ureterostomy, 41% for orthotopic neobladder). The incidence of postoperative complications was much lower in patients who underwent augmentation cystoplasty (complications 17.7%; none required surgery). The percentage of longterm complications was 71.4% for cutaneous ureterostomy, 74.2% for cutaneous transintestinal ureterostomy, 86.9% for orthotopic neobladders and 100% for augmentation cystoplasties. The patients who required surgery were 14.3%, 19.3%, 26% and 47%, respectively. Twelve out of 24 patients in whom metalic staples were employed for the construction of the neobladders and cystoplasties developed bladder stones; 78.3% of the patients with orthotopic neobladders showed perfect daytime continence, 65.2% night-time incontinence and 21.7% stress incontinence. The figures for augmentation cystoplasties were 94.1%, 5.9% and 5.9%; 4.3% of patients with orthotopic neobladders and 29.4% of patients with augmentation cystoplasties required self intermittent catheterization. Patients with larger neobladders showed best continence rates. Fifty-three ureters were reimplanted in the orthotopic neobladders of augmentation cystoplasties with the Le Duc technique; 17% developed ureteral stenosis and 15.1% vesicoureteral reflux.

CONCLUSION

Patients who undergo permanent urinary diversion have a far from negligible number of postoperative and long-term complications. Orthotopic intestinal neobladders have a slightly higher rate of serious complications than incontinent cutaneous diversions.

[Prognostic value of lymphatic metastasis in bladder cancer]

OBJECTIVE

The presence of lymph node metastasis in bladder cancer is considered to be a sign of poor prognosis. The present study was performed to analyze the influence of the number of positive lymph nodes on survival and the therapeutic value of lymphadenectomy in pN+patients.

METHODS

From January, 1983 to January, 1993, 160 patients aged 39 to 77 years (mean 61.8) underwent radical cystectomy and pelvic lymphadenectomy for carcinoma of the bladder. The records of 122 patients were available for review. The UICC 1978 classification system was used.

RESULTS

Cancer-specific mortality was 22.8% (16/70) for pNo patients, 44.4% (4/9) for pN1 patients and 88.9% (16/18) for pN2-4 patients. We obtained the following cancer-specific mortality by stratifying according to T category: 5.4% (2/37) for pNoT1-T3a, 42.4% (14/33) for pNoT3b-T4, 0% (0/2) for pNIT1-T3a, 57.1% (4/7) for pNIT3b-T4 and 88.9% (16/18) for pN2-4T3b-T4.

CONCLUSION

The presence of only 1 positive regional lymph node (pN1) appears to worsen patient survival, particularly when the primary tumor is T3b or worse. In these cases cancer-specific mortality after patient discharge increased from 42% for the pNo patients to 57% for the pN1 patients (p > 0.05). Radical cystectomy was highly effective and curative in 95% of T1-T3apNo-1 patients (37/39). The presence of multiple positive lymph nodes carries a very poor prognosis, with 89% of the patients dying at a mean of 12 months.

[Secondary bladder melanoma. Report of a case concomitant with urothelial tumor of the bladder]

OBJECTIVES

To report on a case of melanoma, a rare tumor type metastatic to the bladder.

METHOD/RESULTS

A case of melanoma metastatic to the bladder was incidentally discovered in a patient with urothelial cancer. The clinical features, diagnostic and therapeutic aspects are described.

CONCLUSIONS

In a patient with malignant melanoma presenting irritative micturion syndrome and/or hematuria, endoscopic bladder exploration with multiple random biopsy must be performed to rule out melanoma metastatic to the bladder metastasis.