- •Preface and Acknowledgments
- •Contents
- •Contributors
- •1: Embryology for Urologists
- •Introduction
- •Renal Development
- •Pronephros
- •Mesonephros
- •Metanephros
- •Development of the Collecting System
- •Critical Steps in Further Development
- •Anomalies of the Kidney
- •Renal Agenesis
- •Renal Aplasia
- •Renal Hypoplasia
- •Renal Ectopia
- •Renal Fusion
- •Ureteral Development
- •Anomalies of Origin
- •Anomalies of Number
- •Incomplete Ureteral Duplication
- •Complete Ureteral Duplication
- •Ureteral Ectopia
- •Embryology of Ectopia
- •Clinical Correlation
- •Location of Ectopic Ureteral Orifices – Male (in Descending Order According to Incidence)
- •Symptoms
- •Ureteroceles
- •Congenital Ureteral Obstruction
- •Pipestem Ureter
- •Megaureter-Megacystis Syndrome
- •Prune Belly Syndrome
- •Vascular Ureteral Obstructions
- •Division of the Urogenital Sinus
- •Bladder Development
- •Urachal Anomalies
- •Cloacal Duct Anomalies
- •Other Bladder Anomalies
- •Bladder Diverticula
- •Bladder Extrophy
- •Gonadal Development
- •Testicular Differentiation
- •Ovarian Differentiation
- •Gonadal Anomalies
- •Genital Duct System
- •Disorders of Testicular Function
- •Female Ductal Development
- •Prostatic Urethral Valves
- •Gonadal Duct Anomalies
- •External Genital Development
- •Male External Genital Development
- •Female External Genital Development
- •Anomalies of the External Genitalia
- •References
- •2: Gross and Laparoscopic Anatomy of the Upper Urinary Tract and Retroperitoneum
- •Overview
- •The Kidneys
- •The Renal Vasculature
- •The Renal Collecting System
- •The Ureters
- •Retroperitoneal Lymphatics
- •Retroperitoneal Nerves
- •The Adrenal Glands
- •References
- •3: Gross and Laparoscopic Anatomy of the Lower Urinary Tract and Pelvis
- •Introduction
- •Female Pelvis
- •Male Pelvis
- •Pelvic Floor
- •Urinary Bladder
- •Urethra
- •Male Urethra
- •Female Urethra
- •Sphincter Mechanisms
- •The Bladder Neck Component
- •The Urethral Wall Component
- •The External Urethral Sphincter
- •Summary
- •References
- •4: Anatomy of the Male Reproductive System
- •Testis and Scrotum
- •Spermatogenesis
- •Hormonal Regulation of Spermatogenesis
- •Genetic Regulation of Spermatogenesis
- •Epididymis and Ductus Deferens
- •Accessory Sex Glands
- •Prostate
- •Seminal Vesicles
- •Bulbourethral Glands
- •Penis
- •Erection and Ejaculation
- •References
- •5: Imaging of the Upper Tracts
- •Anatomy of the Upper Tracts and Introduction to Imaging Modalities
- •Introduction
- •Renal Upper Tract Basic Anatomy
- •Modalities Used for Imaging the Upper Tracts
- •Ultrasound
- •Radiation Issues
- •Contrast Issues
- •Renal and Upper Tract Tumors
- •Benign Renal Tumors
- •Transitional Cell Carcinoma
- •Renal Mass Biopsy
- •Renal Stone Disease
- •Ultrasound
- •Plain Radiographs and IVU
- •Renal Cystic Disease
- •Benign Renal Cysts
- •Hereditary Renal Cystic Disease
- •Complex Renal Cysts
- •Renal Trauma
- •References
- •Introduction
- •Pathophysiology
- •Susceptibility and Resistance
- •Epidemiological Breakpoints
- •Clinical Breakpoints
- •Pharmacodynamic Parameters
- •Pharmacokinetic Parameters
- •Fosfomycin
- •Nitrofurantoin
- •Pivmecillinam
- •b-Lactam-Antibiotics
- •Penicillins
- •Cephalosporins
- •Carbapenems
- •Aminoglycosides
- •Fluoroquinolones
- •Trimethoprim, Cotrimoxazole
- •Glycopeptides
- •Linezolid
- •Conclusion
- •References
- •7: An Overview of Renal Physiology
- •Introduction
- •Body Fluid Compartments
- •Regulation of Potassium Balance
- •Regulation of Acid–Base Balance
- •Diuretics
- •Suggested Reading
- •8: Ureteral Physiology and Pharmacology
- •Ureteral Anatomy
- •Modulation of Peristalsis
- •Ureteral Pharmacology
- •Conclusion
- •References
- •Introduction
- •Afferent Signaling Pathways
- •Efferent Signaling
- •Parasympathetic Nerves
- •Sympathetic Nerves
- •Vesico-Spinal-Vesical Micturition Reflex
- •Peripheral Targets
- •Afferent Signaling Mechanisms
- •Urothelium
- •Myocytes
- •Cholinergic Receptors
- •Muscarinic Receptors
- •Nicotinic Receptors
- •Adrenergic Receptors (ARs)
- •a-Adrenoceptors
- •b-Adrenoceptors
- •Transient Receptor Potential (TRP) Receptors
- •Phosphodiesterases (PDEs)
- •CNS Targets
- •Opioid Receptors
- •Serotonin (5-HT) Mechanisms
- •g-Amino Butyric Acid (GABA) Mechanisms
- •Gabapentin
- •Neurokinin and Neurokinin Receptors
- •Summary
- •References
- •10: Pharmacology of Sexual Function
- •Introduction
- •Sexual Desire/Arousal
- •Endocrinology
- •Steroids in the Male
- •Steroids in the Female
- •Neurohormones
- •Neurotransmitters
- •Dopamine
- •Serotonin
- •Pharmacological Strategies
- •CNS Drugs
- •Enzyme-inducing Antiepileptic Drugs
- •Erectile Function
- •Ejaculatory Function
- •Premature Ejaculation
- •Abnormal Ejaculation
- •Conclusions
- •References
- •Epidemiology
- •Calcium-Based Urolithiasis
- •Uric Acid Urolithiasis
- •Infectious Urolithiasis
- •Cystine-Based Urolithiasis
- •Aims
- •Who Deserves Metabolic Evaluation?
- •Metabolic Workup for Stone Producers
- •Medical History and Physical Examination
- •Stone Analysis
- •Serum Chemistry
- •Urine Evaluation
- •Urine Cultures
- •Urinalysis
- •Twenty-Four Hour Urine Collections
- •Radiologic Imaging
- •Medical Management
- •Conservative Management
- •Increased Fluid Intake
- •Citrus Juices
- •Dietary Restrictions
- •Restricted Oxalate Diet
- •Conservative Measures
- •Selective Medical Therapy
- •Absorptive Hypercalciuria
- •Thiazide
- •Orthophosphate
- •Renal Hypercalciuria
- •Primary Hyperparathyroidism
- •Hyperuricosuric Calcium Oxalate Nephrolithiasis
- •Enteric Hyperoxaluria
- •Hypocitraturic Calcium Oxalate Nephrolithiasis
- •Distal Renal Tubular Acidosis
- •Chronic Diarrheal States
- •Thiazide-Induced Hypocitraturia
- •Idiopathic Hypocitraturic Calcium Oxalate Nephrolithiasis
- •Hypomagnesiuric Calcium Nephrolithiasis
- •Gouty Diathesis
- •Cystinuria
- •Infection Lithiasis
- •Summary
- •References
- •12: Molecular Biology for Urologists
- •Introduction
- •Inherited Changes in Cancer Cells
- •VEGR and Cell Signaling
- •Targeting mTOR
- •Conclusion
- •References
- •13: Chemotherapeutic Agents for Urologic Oncology
- •Introduction
- •Bladder Cancer
- •Muscle Invasive Bladder Cancer
- •Metastatic Bladder Cancer
- •Conclusion
- •Prostate Cancer
- •Other Chemotherapeutic Drugs or Combinations for Treating HRPC
- •Conclusion
- •Renal Cell Carcinoma
- •Chemotherapy
- •Immunotherapy
- •Angiogenesis Inhibitor Drugs
- •Conclusion
- •Testicular Cancer
- •Stage I Seminoma
- •Stage I non-seminomatous Germ Cell Tumours (NSGCT)
- •Metastatic Germ Cell Tumours
- •Low-Volume Metastatic Disease (Stage II A/B)
- •Advanced Metastatic Disease
- •Salvage Chemotherapy for Relapsed or Refractory Disease
- •Conclusion
- •Penile Cancer
- •Side Effects of Chemotherapy
- •Conclusion
- •References
- •14: Tumor and Transplant Immunology
- •Antibodies
- •Cytotoxic and T-helper Cells
- •Immunosuppression
- •Induction Therapy
- •Maintenance Therapy
- •Rejection
- •Posttransplant Lymphoproliferative Disease
- •Summary
- •References
- •15: Pathophysiology of Renal Obstruction
- •Causes of Renal Obstruction
- •Effects on Prenatal Development
- •Prenatal Hydronephrosis
- •Spectrum of Renal Abnormalities
- •Renal Functional Changes
- •Renal Growth/Counterbalance
- •Vascular Changes
- •Inflammatory Mediators
- •Glomerular Development Changes
- •Mechanical Stretch of Renal Tubules
- •Unilateral Versus Bilateral
- •Limitations of Animal Models
- •Future Research
- •Issues in Patient Management
- •Diagnostic Imaging
- •Ultrasound
- •Intravenous Urography
- •Antegrade Urography and the Whitaker Test
- •Nuclear Renography
- •Computed Tomography
- •Magnetic Resonance Urography
- •Hypertension
- •Postobstructive Diuresis
- •References
- •Introduction
- •The Normal Lower Urinary Tract
- •Anatomy
- •Storage Function
- •Voiding Function
- •Neural Control
- •Symptoms
- •Flow Rate and Post-void Residual
- •Voiding Cystometry
- •Male
- •Female
- •Neurourology
- •Conclusions
- •References
- •17: Urologic Endocrinology
- •The Testis
- •Normal Androgen Metabolism
- •Epidemiological Aspects
- •Prostate
- •Brain
- •Muscle Mass and Adipose Tissue
- •Bones
- •Ematopoiesis
- •Metabolism
- •Cardiovascular System
- •Clinical Assessment
- •Biochemical Assessment
- •Treatment Modalities
- •Oral Preparations
- •Parenteral Preparations
- •Transdermal Preparations
- •Side Effects and Treatment Monitoring
- •Body Composition
- •Cognitive Decline
- •Bone Metabolism
- •The Kidneys
- •Endocrine Functions of the Kidney
- •Erythropoietin
- •Calcitriol
- •Renin
- •Paraneoplastic Syndromes
- •Hypercalcemia
- •Hypertension
- •Polycythemia
- •Other Endocrine Abnormalities
- •References
- •General Physiology
- •Prostate Innervation
- •Summary
- •References
- •Wound Healing
- •Inflammation
- •Proliferation
- •Remodeling
- •Principles of Plastic Surgery
- •Tissue Characteristics
- •Grafts
- •Flap
- •References
- •Lower Urinary Tract Symptoms
- •Storage Phase
- •Voiding Phase
- •Return to Storage Phase
- •Urodynamic Parameters
- •Urodynamic Techniques
- •Volume Voided Charts
- •Pad Testing
- •Typical Test Schedule
- •Uroflowmetry
- •Post Voiding Residual
- •Further Diagnostic Evaluation of Patients
- •Cystometry with or Without Video
- •Cystometry
- •Videocystometrography (Cystometry + Cystourethrography)
- •Cystometric Findings
- •Comment:
- •Measurements During the Storage Phase:
- •Measurements During the Voiding Phase:
- •Abnormal Function
- •Disorders of Sensation
- •Causes of Hypersensitive Bladder Sensation
- •Causes of Hyposensitive Bladder Sensation
- •Disorders of Detrusor Motor Function
- •Bladder Outflow Tract Dysfunction
- •Detrusor–Urethral Dyssynergia
- •Detrusor–Bladder Neck Dyssynergia
- •Detrusor–Sphincter Dyssynergia
- •Complex Urodynamic Investigation
- •Urethral Pressure Measurement
- •Technique
- •Neurophysiological Evaluation
- •Conclusion
- •References
- •Endoscopy
- •Cystourethroscopy
- •Ureteroscopy and Ureteropyeloscopy
- •Nephroscopy
- •Virtual Reality Simulators
- •Lasers
- •Clinical Application of Lasers
- •Condylomata Acuminata
- •Urolithiasis
- •Benign Prostatic Hyperplasia
- •Ureteral and Urethral Strictures
- •Conclusion
- •References
- •Introduction
- •The Prostatitis Syndromes
- •The Scope of the Problem
- •Category III CP/CPPS
- •The Goal of Treatment
- •Conservative Management
- •Drug Therapy
- •Antibiotics
- •Anti-inflammatories
- •Alpha blockers
- •Hormone Therapies
- •Phytotherapies
- •Analgesics, muscle relaxants and neuromodulators
- •Surgery
- •A Practical Management Plan
- •References
- •Orchitis
- •Definition and Etiology
- •Clinical Signs and Symptoms
- •Diagnostic Evaluation
- •Treatment of Infectious Orchitis
- •Epididymitis
- •Definition and Etiology
- •Clinical Signs and Symptoms
- •Diagnostic Evaluation of Epididymitis
- •Treatment of Acute Epididymitis
- •Treatment of Chronic Epididymitis
- •Treatment of Spermatic Cord Torsion
- •Fournier’s Gangrene
- •Definition and Etiology
- •Risk Factors
- •Clinical Signs and Symptoms
- •Diagnostic Evaluation
- •Treatment
- •References
- •Fungal Infections
- •Candidiasis
- •Aspergillosis
- •Cryptococcosis
- •Blastomycosis
- •Coccidioidomycosis
- •Histoplasmosis
- •Radiographic Findings
- •Treatment
- •Tuberculosis
- •Clinical Manifestations
- •Diagnosis
- •Treatment
- •Schistosomiasis
- •Clinical Manifestations
- •Diagnosis
- •Treatment
- •Filariasis
- •Clinical Manifestations
- •Diagnosis
- •Treatment
- •Onchocerciasis
- •References
- •25: Sexually Transmitted Infections
- •Introduction
- •STIs Associated with Genital Ulcers
- •Herpes Simplex Virus
- •Diagnosis
- •Treatment
- •Chancroid
- •Diagnosis
- •Treatment
- •Syphilis
- •Diagnosis
- •Treatment
- •Lymphogranuloma Venereum
- •Diagnosis
- •Treatment
- •Chlamydia
- •Diagnosis
- •Treatment
- •Gonorrhea
- •Diagnosis
- •Treatment
- •Trichomoniasis
- •Diagnosis
- •Treatment
- •Human Papilloma Virus
- •Diagnosis
- •Treatment
- •Scabies
- •Diagnosis
- •Treatment
- •References
- •26: Hematuria: Evaluation and Management
- •Introduction
- •Classification of Hematuria
- •Macroscopic Hematuria
- •Microscopic Hematuria
- •Dipstick Hematuria
- •Pseudohematuria
- •Factitious Hematuria
- •Menstruation
- •Aetiology
- •Malignancy
- •Urinary Calculi
- •Infection and Inflammation
- •Benign Prostatic Hyperplasia
- •Trauma
- •Drugs
- •Nephrological Causes
- •Assessment
- •History
- •Examination
- •Investigations
- •Dipstick Urinalysis
- •Cytology
- •Molecular Tests
- •Blood Tests
- •Flexible Cystoscopy
- •Upper Urinary Tract Evaluation
- •Renal USS
- •KUB Abdominal X-Ray
- •Intravenous Urography (IVU)
- •Computed Tomography (CT)
- •Retrograde Urogram Studies
- •Magnetic Resonance Imaging (MRI)
- •Additional Tests and Renal Biopsy
- •Intractable Hematuria
- •Loin Pain Hematuria Syndrome
- •References
- •27: Benign Prostatic Hyperplasia (BPH)
- •Historical Background
- •Pathophysiology
- •Patient Assessment
- •Treatment of BPH
- •Watchful Waiting
- •Drug Therapy
- •Interventional Therapies
- •Conclusions
- •References
- •28: Practical Guidelines for the Treatment of Erectile Dysfunction and Peyronie´s Disease
- •Erectile Dysfunction
- •Introduction
- •Diagnosis
- •Basic Evaluation
- •Cardiovascular System and Sexual Activity
- •Optional Tests
- •Treatment
- •Medical Treatment
- •Oral Agents
- •Phosphodiesterase Type 5 (PDE 5) Inhibitors
- •Nonresponders to PDE5 Inhibitors
- •Apomorphine SL
- •Yohimbine
- •Intracavernosal and Intraurethral Therapy
- •Intracavernosal Injection (ICI) Therapy
- •Intraurethral Therapy
- •Vacuum Constriction Devices
- •Surgical Therapy
- •Conclusion
- •Peyronie´s Disease (PD)
- •Introduction
- •Oral Drug Therapy
- •Intralesional Drug Therapy
- •Iontophoresis
- •Radiation Therapy
- •Surgical Therapy
- •References
- •29: Premature Ejaculation
- •Introduction
- •Epidemiology
- •Defining Premature Ejaculation
- •Voluntary Control
- •Sexual Satisfaction
- •Distress
- •Psychosexual Counseling
- •Pharmacological Treatment
- •On-Demand Treatment with Tramadol
- •Topical Anesthetics
- •Phosphodiesterase Inhibitors
- •Surgery
- •Conclusion
- •References
- •30: The Role of Interventional Management for Urinary Tract Calculi
- •Contraindications to ESWL
- •Complications of ESWL
- •PCNL Access
- •Instrumentation for PCNL
- •Nephrostomy Drains Post PCNL
- •Contraindications to PCNL
- •Complications of PCNL
- •Semirigid Ureteroscopy
- •Flexible Ureteroscopy
- •Electrohydraulic Lithotripsy (EHL)
- •Ultrasound
- •Ballistic Lithotripsy
- •Laser Lithotripsy
- •Ureteric Stents
- •Staghorn Calculi
- •Lower Pole Stones
- •Horseshoe Kidneys and Stones
- •Calyceal Diverticula Stones
- •Stones and PUJ Obstruction
- •Treatment of Ureteric Colic
- •Medical Expulsive Therapy (MET)
- •Intervention for Ureteric Stones
- •Stones in Pregnancy
- •Morbid Obesity
- •References
- •Anatomy and Function
- •Pathophysiology
- •Management
- •Optical Urethrotomy/Dilatation
- •Urethral Stents
- •Preoperative Assessment
- •Urethroplasty
- •Anastomotic Urethroplasty
- •Substitution Urethroplasty
- •Grafts Versus Flaps
- •Oral Mucosal Grafts
- •Tissue Engineering
- •Graft Position
- •Conclusion
- •References
- •32: Urinary Incontinence
- •Epidemiology and Risk Factors
- •Pathophysiology
- •Urge Incontinence
- •Conservative Treatments
- •Pharmacotherapy
- •Invasive/ Surgical Therapies
- •Stress Urinary Incontinence
- •Male SUI Therapies
- •Female SUI Therapies
- •Mixed Urinary Incontinence
- •Conclusions
- •References
- •33: Neurogenic Bladder
- •Introduction
- •Examination and Diagnostic Tests
- •History and Physical Examination
- •Imaging
- •Urodynamics (UDS)
- •Evoked Potentials
- •Classifications
- •Somatic Pathways
- •Brain Lesions
- •Cerebrovascular Accident (CVA)
- •Parkinson’s Disease (PD)
- •Multiple Sclerosis
- •Huntington’s Disease
- •Dementias
- •Normal Pressure Hydrocephalus (NPH)
- •Tumors
- •Psychiatric Disorders
- •Spinal Lesions and Pathology
- •Intervertebral Disk Prolapse
- •Spinal Cord Injury (SCI)
- •Transverse Myelitis
- •Peripheral Neuropathies
- •Metabolic Neuropathies
- •Pelvic Surgery
- •Treatment
- •Summary
- •References
- •34: Pelvic Prolapse
- •Introduction
- •Epidemiology
- •Anatomy and Pathophysiology
- •Evaluation and Diagnosis
- •Outcome Measures
- •Imaging
- •Urodynamics
- •Indications for Management
- •Biosynthetics
- •Surgical Management
- •Anterior Compartment Repair
- •Uterine/Apical Prolapse
- •Enterocele Repair
- •Conclusion
- •References
- •35: Urinary Tract Fistula
- •Introduction
- •Urogynecologic Fistula
- •Vesicovaginal Fistula
- •Etiology and Risk Factors
- •Clinical Factors
- •Evaluation and Diagnosis
- •Pelvic Examination
- •Cystoscopy
- •Imaging
- •Treatment
- •Conservative Management
- •Surgical Management
- •Urethrovaginal Fistula
- •Etiology and Presentation
- •Diagnosis and Management
- •Ureterovaginal Fistula
- •Etiology and Presentation
- •Diagnosis and Management
- •Vesicouterine Fistula
- •Etiology and Presentation
- •Diagnosis and Management
- •Uro-Enteric Fistula
- •Vesicoenteric Fistula
- •Pyeloenteric Fistula
- •Urethrorectal Fistula
- •References
- •36: Urologic Trauma
- •Introduction
- •Kidney
- •Expectant Management
- •Endovascular Therapy
- •Operative Intervention
- •Operative Management: Follow-up
- •Reno-Vascular Injuries
- •Pediatric Renal Injuries
- •Adrenal
- •Ureter
- •Diagnosis
- •Treatment
- •Delayed Diagnosis
- •Bladder and Posterior Urethra
- •Bladder Injuries: Initial Management
- •Bladder Injuries: Formal Repair
- •Anterior Urethral Trauma
- •Fractured Penis
- •Penile Amputation
- •Scrotal and Testicular Trauma
- •Imaging
- •CT-IVP (CT with Delayed Images)
- •Technique
- •Cystogram
- •Technique
- •Retrograde Urethrogram (RUG)
- •Technique
- •Retrograde Pyelogram (RPG)
- •Technique
- •One-Shot IVP
- •Technique
- •References
- •37: Bladder Cancer
- •Who Should Be Investigated?
- •Epidemiology
- •Risk Factors
- •Role of Screening
- •Signs and Symptoms
- •Imaging
- •Cystoscopy
- •Urine Tests
- •PDD-Assisted TUR
- •Pathology
- •NMIBC and Risk Groups
- •Intravesical Chemotherapy
- •Intravesical Immunotherapy
- •Immediate Cystectomy and CIS
- •Radical Cystectomy with Pelvic Lymph Node Dissection
- •sexual function-preserving techniques
- •Bladder-Preservation Treatments
- •Neoadjuvant Chemotherapy
- •Adjuvant Chemotherapy
- •Preoperative Radiotherapy
- •Follow-up After TUR in NMIBC
- •References
- •38: Prostate Cancer
- •Introduction
- •Epidemiology
- •Race
- •Geographic Variation
- •Risk Factors and Prevention
- •Family History
- •Diet and Lifestyle
- •Prevention
- •Screening and Diagnosis
- •Current Screening Recommendations
- •Biopsy
- •Pathology
- •Prognosis
- •Treatment of Prostate Cancer
- •Treatment for Localized Prostate Cancer (T1, T2)
- •Radical Prostatectomy
- •EBRT
- •IMRT
- •Brachytherapy
- •Treatment for Locally Advanced Prostate Cancer (T3, T4)
- •EBRT with ADT
- •Radical Prostatectomy
- •Androgen-Deprivation Therapy
- •Summary
- •References
- •39: The Management of Testis Cancer
- •Presentation and Diagnosis
- •Serum Tumor Markers
- •Primary Surgery
- •Testis Preserving Surgery
- •Risk Stratification
- •Surveillance Versus Primary RPLND
- •Primary RPLND
- •Adjuvant Treatment for High Risk
- •Clinical Stage 1 Seminoma
- •Risk-Stratified Adjuvant Treatment
- •Adjuvant Radiotherapy
- •Adjuvant Low Dose Chemotherapy
- •Primary Combination Chemotherapy
- •Late Toxicity
- •Salvage Strategies
- •Conclusion
- •References
- •Index
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46 |
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Practical Urology: EssEntial PrinciPlEs and PracticE |
wall of the pelvis,and a visceral layer covering the |
nomenclature. Particularly the presence of a |
|
pelvic organs. The tendinous arch represents the |
deep transverse perineal muscle is under exten- |
|
transition between the parietal and visceral part. |
sive discussion, as demonstrated below. |
|
Often the visceral layer is clinically indicated as |
The pelvic diaphragm consists of the levator |
|
the endopelvic fascia, especially with regard to |
ani muscle and the coccygeus muscle (M. ischio- |
|
radical prostatectomy and nerve-sparing proce- |
coccygeus). The levator ani muscle in turn con- |
|
dures. Whether the prostate is actually separated |
sists of the following structures, which are |
|
by its own prostatic fascia is under discussion. |
named according to their origins and insertions: |
|
The absence of the fascia in the apical region of |
the pubococcygeus muscle, iliococcygeus mus- |
|
the prostate and the formation of the so-called |
cle and puborectalis muscle. A superior and |
|
puboprostatic ligaments5 by the endopelvic fas- |
inferior fascia covers the levator ani muscle, the |
|
cia suggest that the visceral layer of the pelvic fas- |
superior layer being part of the parietal layer of |
|
cia (= endopelvic fascia) and the fascia of the |
the pelvic fascia as described above. The levator |
|
prostate correlate. The puboprostatic ligaments |
ani muscle forms an archway-shaped opening |
|
between the anterior fascia of the prostate and |
for the anus and urethra in males, and the anus, |
|
the pubic bone/symphysis pubis do not represent |
vagina and urethra in females. The innervations |
|
ligamentous structures in the proper sense. In |
for the striated muscles derive principally from |
|
fact the puboprostatic ligaments are character- |
the sacral plexus (S3 and S4); some nerve fibers |
|
ized by an aggregation of the pelvic fascia. |
reach the puborectal muscle via the pudendal |
|
Possibly muscle fibers (smooth or striated) also |
nerve located in the pudendal canal. Even |
|
contribute to the configuration of the so-called |
though the contributions of the shape topogra- |
|
puboprostatic ligaments. |
phy and the contraction of the pelvic diaphragm |
|
Similarly there is a lack of clarity regarding |
to anal continence seem to be proven, it is still |
|
Denonvilliers’ fascia. The anatomical nomencla- |
unclear to what extent these anatomical struc- |
|
ture utilizes the description rectoprostatic fascia |
tures also affect urinary continence. Recent |
|
or septum. It represents a membranous separa- |
publications have reported the muscular inde- |
|
tion between the rectum and the prostate/uri- |
pendence between the pelvic diaphragm and |
|
nary bladder.The fascia emerges from two layers |
the striated external urethral sphincter, whereas |
|
of a peritoneal cul-de-sac, ranging from the |
an association by connective tissue forming a |
|
deepest point of the rectovesical excavation to |
tendinous connection starting from the inferior |
|
the pelvic floor. There has been extensive dis- |
part of the external urethral sphincter in females |
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cussion about the possibility of surgical separa- |
could be demonstrated. Especially because of |
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tion of both layers during radical prostatectomy. |
these interactions,the authors suggest the neces- |
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Currently it is evident that microscopically the |
sity of an intact pelvic diaphragm for urinary |
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rectoprostatic fascia consists of two formerly |
continence. |
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peritoneal layers, which often cannot be divided |
Considering the urogenital diaphragm, the |
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bluntly. It is assumed that authors illustrating |
exact anatomical and histomorphological com- |
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techniques of fascia separation are referencing |
position is still undefined. Almost all anatomi- |
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the space between Denonvilliers’ fascia and the |
cal atlases report that the urogenital diaphragm |
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rectal fascia propria (a part of the visceral layer |
consists of the deep transverse perineal muscle |
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of the pelvic fascia = endopelvic fascia). |
(less developed in females) with a superior and |
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Periprostatic neural and vascular structures are |
inferior urogenital fascia. Additionally, the |
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focused on below.2,3,5-10 |
superficial transverse perineal muscle inserting |
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at the perineal body (= central tendon of the |
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perineum),the striated external urethral sphinc- |
Pelvic Floor |
ter and the surrounding connective tissue com- |
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plete the traditional view of the urogenital |
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diaphragm. Some authors report the existence |
Two fibromuscular layers are responsible for the |
of a deep transverse perineal muscle, but most |
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closure of the inferior pelvic aperture: the pelvic |
recent studies could not verify this conclusion. |
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diaphragm and the urogenital diaphragm. It has |
The urogenital diaphragm is described as layers |
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to be emphasized at this point that the term uro- |
of connective tissue embedding the external |
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genital diaphragm is not part of the anatomic |
urethral sphincter in conjunction with the |
47
gross and laParoscoPic anatomy of thE lowEr Urinary tract and PElvis
perineal body, the structures of the inferior pubic bone and the superficial transverse perineal muscle. Whether these findings about the muscular structures of the urogenital diaphragm are possibly due to age-related fatty degeneration of muscular tissue is under discussion and remains unexplained. The main vascular and neural structures – the internal pudendal artery and the pudendal nerve – are located directly below the urogenital diaphragm. The bulbourethral glands (Cowper’s glands) are located laterally to the membranous urethra at the level of the urogenital diaphragm. The urethral sphincter mechanism is described
below.2,11-17
Urinary Bladder
The urinary bladder is a muscular, distensible organ for urine collection and controlled micturition. Macroscopically the urinary bladder is divided into the apex, corpus, fundus and collum. The average filling volume ranges between 300 and 500 cm3. The mucosa is only loosely adherent to the subjacent muscular layers,except for the trigone, where a direct adhesion to the submucosal layers can be found. A fold raised between the obliquely passing ureters on both sides forming the ureteral orifices characterizes the trigone.
The urinary bladder wall is structured as followes: mucosa (transitional cells), submucosa, detrusor muscle (three layers), and surrounding adipose and connective tissue. The detrusor muscle is subdivided into an external and internal longitudinal muscle layer, as well as an interjacent circular layer. The bladder neck, including the trigone, consists of two muscular layers. A specialized circular smooth muscle could not be found. The longitudinal muscle fibers in conjunction with the extending longitudinal fibers of both ureters extend below the bladder neck and reach the muscular layers of the urethra. In male humans these structures reach the point of the seminal colliculus.
The blood supply of the urinary bladder generally derives from two main branches of each of the internal iliac arteries: the superior vesical artery and the inferior vesical artery – often named the superior and inferior vesical pedicle during surgery. The superior vesical artery descends from a common branch with the
former umbilical artery, which is part of the medial umbilical ligament. The inferior vesical artery arises from a common branch of the middle rectal artery. Prostatic branches generally derive from the inferior vesical artery. Varying distinct venous plexuses on both sides of the vesical base secure the blood drainage of the urinary bladder. These venous vessels communicate extensively with the prostatic venous plexus in male and the vaginal venous plexus in female humans.
Organs of the pelvis, in contrast to other regions, present a widespread field of lymph node drainage. The urinary bladder drains its lymph fluid through external iliac lymph nodes, internal iliac lymph nodes, lymph nodes in the obturator fossa and common iliac lymph nodes (Fig. 3.4).
A complex neural system facilitates the correct functioning of the urinary bladder as a storage and drainage system. Interactions between independent reflex pathways and arbitrary actions are necessary for a precise process. Both the autonomous and the somatic nervous system contribute to carrying out the tasks of bladder filling and emptying.
Anatomic nerve fibers reach the urinary bladder (and adjacent organs) through the inferior hypogastric plexus (= pelvic plexus). The inferior hypogastric plexus thus comprises the parasympathetic and sympathetic nerve tracts. Anatomically the inferior hypogastric plexus derives from the singular superior hypogastric plexus, which reaches the pelvis proximally and
Figure 3.4. areas of lymphadenectomy for pelvic surgery: post pubic (pp), external iliac (ei), obturator fossa (of), internal iliac (ii), common iliac (ci), aortal (ao). (reprinted from schilling et al.18 with permission from wiley-Blackwell).
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48 |
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Practical Urology: EssEntial PrinciPlEs and PracticE |
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the urinary bladder (and most probably of the |
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proximal urethra as well) run along the para- |
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sympathetic nerves. Contraction of the detrusor |
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muscle is mediated through the parasympa- |
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thetic nervous system. The pudendal nerve is |
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part of the somatic nervous system and inner- |
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vates the striated parts of the external urethral |
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sphincter. The pudendal nerve courses in the |
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pudendal canal at the bottom of the inferior |
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pubic bone after the distribution of the lum- |
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bosacral plexus. The variation of an intrapelvic |
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nerve branching off the pudendal nerve prior to |
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entering the pudendal canal and running on the |
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inside of the levator muscle has been described. |
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Stimulation results in increased contraction of |
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the external urethral sphincter and adjacent |
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segments of the levator muscle. Complex inter- |
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connections of the different sections of the cen- |
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tral nervous system, including Onuf’s nucleus |
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(located in the sacral part of the spinal cord), the |
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Figure 3.5. nerve course of the sympathetic fibers deriving |
periaqueductal gray, the pontine micturition |
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center and the frontal lobe of the cerebrum, are |
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from the superior hypogastric plexus (ci: common iliac artery, u: |
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involved in the process of filling and emptying. |
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ureter). (reprinted from schilling et al.18 with permission from |
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wiley-Blackwell). |
For example, it could be demonstrated that pel- |
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vic floor training for stress urinary incontinence |
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not only influences the competence of the |
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medial to the crossing of the distal ureter and |
sphincteric mechanisms, but the training also |
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the common iliac artery on both sides (Fig. 3.5). |
results in restructuring of supraspinal central |
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The plexus is part of the rectouterine or rec- |
nervous system components.2,3,18-22 |
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tovesical fold beside the pouch of Douglas |
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(Fig. 3.3). The plexus extends laterally to the |
Prostate, Seminal Vesicles and |
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rectum, the vagina (in females), the bladder |
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neck and the seminal vesicles (in males) in a |
Deferent Ducts |
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sagittal direction. The continuing course of |
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nerve fibers along the prostate is described in |
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the following chapter. An allocation of nerve |
The prostate is often compared to a chestnut of |
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fibers within the plexus to innervated targets |
about 20 g. With the base aligned to the urinary |
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seems to be possible. Roughly, the anterior part |
bladder and the apex proximate to the external |
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is responsible for urogenital innervations, and |
urinary sphincter, the prostate incorporates |
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the posterior part serves the rectum. |
the prostatic urethra with a length of about 3 cm. |
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The sympathetic fibers of the hypogastric |
McNeal defined the different zones of the |
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plexus originate from the superior hypogastric |
prostate based on histopathological analysis: the |
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plexus, which is fed by nerve fibers from two |
peripheral zone, the central zone, the transi- |
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superior retroperitoneal sympathetic chains |
tional zone and the anterior fibromuscular zone. |
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called the sacral splanchnic nerves. Sympathetic |
This definition has to be separated from the |
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excitation generally results in inhibition of the |
macroscopic classification into lobes. The ejacu- |
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detrusor muscle and stimulation of the smooth |
latory ducts are paired tubes formed on each |
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muscle sphincter cells, which leads to a filling of |
side by fusion of the deferent duct and the duct |
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the urinary bladder. The parasympathetic fibers |
of the seminal vesicle. The orifices of the ejacu- |
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derive from the sacral spinal cord (S2–S5) and |
latory ducts are located on the seminal collicu- |
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reach the inferior hypogastric plexus via pelvic |
lus (also called the verumontanum). Fifteen to |
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splanchnic nerves exiting from the foramina of |
thirty orifices of ducts of the prostate glands are |
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the sacral bone. Sensory afferent nerve fibers of |
located beside the seminal colliculus. |
49
gross and laParoscoPic anatomy of thE lowEr Urinary tract and PElvis
The seminal vesicles are located lateral to the |
The description of the anatomic affiliations of |
deferent ducts. Dorsally and laterally fibers from |
pelvic lymph nodes to the drainage field was |
the inferior hypogastric plexus engulf the vesi- |
originally based on lymphographic studies. |
cles. The space between Dennonvillier’s fascia |
Recent findings are the results of sentinel lymph |
dorsally and the fascia covering the posterior |
node studies.The injection of 99mTc-labeled nano- |
wall of the bladder is called the spatium urovesi- |
colloid into the prostate facilitates the identifica- |
cale (urovesical space). Branches of the inferior |
tion of sentinel lymph nodes either by surgery or |
vesical artery, the middle rectal artery and the |
by radiological imaging (Fig. 3.6). The lymph |
artery of the vas deferens usually reach the sem- |
nodes of the obturator fossa, the external iliac |
inal vesicle at its tip. |
lymph nodes, the internal and finally the com- |
The deferent duct is characterized by a dilata- |
mon iliac lymph nodes are responsible for the |
tion prior to the confluence with the duct of the |
drainage of the prostate gland (Figs. 3.4 and 3.7). |
seminal vesicle called the ampulla. The deferent |
Although oncological aspects are still the main |
duct is accompanied by one or two separate |
concern of every radical prostatectomy treating |
arteries (arteries of the vas deferens), which |
prostate cancer, quality of life aspects including |
derive from the inferior vesical artery. |
erectile function as well as continence have |
The inferior vesical and the middle rectal |
become important. The existence of the endopel- |
artery contribute to the blood supply of the |
vic fascia equipollent to the visceral layer of the |
prostate. The main vessels enter the prostate on |
pelvic fascia has been outlined above. Most |
both sides at the dorsolateral aspect close to the |
authors would agree that the neurovascular |
base of the prostate. Smaller vessels perforate the |
structures are located between the prostate sur- |
prostate capsule directly.Venous drainage moves |
face with its fibromuscular capsule and the vis- |
from the surrounding prostatic venous plexus. |
ceral layer of the pelvic fascia, which extends to |
Accessory pudendal arteries can be found in |
Denonviellers’ fascia at the dorsolateral aspect of |
about 25% of the patient population undergoing |
the prostate (Fig. 3.8). Some studies describe a |
radical prostatectomy. An accessory pudendal |
merger between these two layers. Whether ner- |
artery is defined as a vessel starting above the |
vous tissue can also be found in the fold between |
level of the levator ani running down to the penile |
the visceral and the parietal layer of the pelvic |
structures below the symphysis pubis and the |
fascia remains unclear. In 1985, Donker, Walsh |
pubic bone, respectively. Some authors subdivide |
et al. were the first to extensively describe the |
the accessory arteries into lateral (alongside the |
neurovascular bundle. The technique of nerve- |
anterolateral aspect of the prostate) and apical |
sparing radical prostatectomy and cystectomy |
(inferior and lateral to the puboprostatic liga- |
was adapted regarding these anatomical find- |
ments) accessory pudendal arteries.The extent of |
ings. Especially the course of these periprostatic |
their contribution to the erectile function of the |
nerves has resurfaced as a focus of academic |
penis is still under investigation and discussion. |
interest. The entry of the inferior hypogastric |
The puboprostatic complex includes the pubo- |
plexus into the pelvis and its location lateral to |
prostatic ligaments, the prostatic venous plexus |
the seminal vesicles, including the convergent |
and their correlation to the prostate and the |
fibers of the sacral splanchnic nerves (sympa- |
external urethral sphincter. The puboprostatic |
thetic) and pelvic splanchnic nerves (parasym- |
ligaments formed by the endopelvic fascia, first |
pathetic), has been referred to above. In contrast |
described by Young, are described above. The |
to a separate dorsolateral nerve bundle, several |
prostatic venous plexus communicates exten- |
authorsreinvestigatedtheanatomyanddescribed |
sively with the distinct venous plexus of the uri- |
different nerve dispersions. The periprostatic |
nary bladder cranially and the superficial/deep |
nerves proceed divergently especially in the mid- |
dorsal veins of the penis. The proper name |
part of the prostate; therefore, a varying amount |
(Santorini’s plexus) refers to their initial discov- |
of nerve tissue can be found also in the anterior |
ery by Giovanni Domenico Santorini in 1724. The |
and anterolateral aspect of the prostate in addi- |
venous plexus is imbedded in the fibrous struc- |
tion to the known accumulation in the dorsolat- |
ture of the so-called puboprostatic ligaments.The |
eral course (Fig. 3.9). Characteristically, nerve |
puboprostatic plexus directly covers the anterior |
fibers converge towards the apex located at the |
elevated part of the external urethral sphincter |
posterior and posterolateral side of the apex and |
(see also Chap. Sphincter Mechanisms). |
the urethra, respectively. In addition, parts of the |
50
Practical Urology: EssEntial PrinciPlEs and PracticE
Figure 3.6. radiological image of sentinel lymph nodes after injection of 99mtc-labeled nanocolloid into the prostate. Left column: ct scan images, middle column: sPEct images, right column: ct/sPEct fused images. sentinel lymph node located inside the red indicator.