Functional anatomy of pelvic floor Rocca Rossetti, Salvatore
Archivio italiano di urologia, andrologia,
2016-Mar-31, Volume:
88, Issue:
1
Journal Article
Peer reviewed
Open access
Generally, descriptions of the pelvic floor are discordant, since its complex structures and the complexity of pathological disorders of such structures; commonly the descriptions are sectorial, ...concerning muscles, fascial developments, ligaments and so on. On the contrary to understand completely nature and function of the pelvic floor it is necessary to study it in the most unitary view and in the most global aspect, considering embriology, philogenesy, anthropologic development and its multiple activities others than urological, gynaecological and intestinal ones. Recent acquirements succeeded in clarifying many aspects of pelvic floor activity, whose musculature has been investigated through electromyography, sonography, magnetic resonance, histology, histochemistry, molecular research. Utilizing recent research concerning not only urinary and gynecologic aspects but also those regarding statics and dynamics of pelvis and its floor, it is now possible to study this important body part as a unit; that means to consider it in the whole body economy to which maintaining upright position, walking and behavior or physical conduct do not share less than urinary, genital, and intestinal functions. It is today possible to consider the pelvic floor as a musclefascial unit with synergic and antagonistic activity of muscular bundles, among them more or less interlaced, with multiple functions and not only the function of pelvic cup closure.
We characterize the consequences of androgen deprivation therapy on body composition in elderly men.
Using a dual energy x-ray absorptiometry instrument, we determined the changes in bone mineral ...density, bone mineral content, fat body mass and lean body mass in 35 patients with prostate cancer without bone metastases who received luteinizing hormone releasing hormone analogue for 12 months.
At baseline conditions 46% of cases were classified as osteopenic and 14% as osteoporotic at the lumbar spine and 40% were osteopenic and 4% osteoporotic at the hip. Androgen deprivation significantly decreased bone mineral density either at the lumbar spine (mean gm./cm.
2 SD 1.00 0.194, 0.986 0.172 and 0.977 0.182 at baseline, and 6 and 12 months, respectively, p <0.002) or the hip (0.929 0.136, 0.926 0.144 and 0.923 0.138, p <0.03). A more than 2% decrease in bone mineral density was found at the lumbar spine in 19 men (54.3%) and at the hip in 15 (42.9%). Bone mineral content paralleled the bone mineral density pattern. Lean body mass decreased (mean gm. SD 50,287 6,656, 49,296 6,554 and 49,327 6,345, p <0.003), whereas fat body mass consistently increased (18,115 6,209, 20,724 6,029 and 21,604 5,923 p <0.001).
Serial bone densitometry evaluation during androgen deprivation therapy may allow the detection of patients with prostate cancer at risk for osteoporotic fractures, that is those with osteopenia or osteoporosis at baseline and fast bone loss. The change in body composition may predispose patients to accidental falls, thus increasing the risk of bone fracture.
Objective:
We describe the original surgical technique of supra-ampullar cystectomy associated with ileal neobladder, and present our results in terms of preservation of sexual potency, urinary ...continence and cancer control along twenty years of experience.
Materials and Methods:
Twenty-eight consecutive patients with bladder tumor—27 transitional cell carcinomas (TCC) and 1 leiomyosarcoma—underwent supra-ampullar cystectomy with ileal orthotopic neobladder (2 Camey I and 26 Camey II) between May 1984 and June 1999. The median age of the patients was 51.0 years (range 23–65). Preoperatively 24 patients had superficial high-risk TCC. Involvement of prostatic urethra was excluded by means of preoperative endoscopic biopsies. The bladder, part of the prostate with the prostatic urethra and regional lymph nodes were removed, while the vas deferens with deferential ampullae, seminal vesicles, ejaculatory ducts and the peripheral portion of the prostate were maintained. Median followup was 90.5 months (range 10–228).
Results:
Out of 28 patients 6 died of bladder cancer (all with metastases, 2 also with local recurrence); 4 out of the 22 patients who were free of disease at followup died of other causes. Potency was preserved in 26 patients (92.8%), reporting satisfactory sexual intercourses; 15 patients (53.5%) also maintained antegrade ejaculation allowing procreation in 3 cases. In one patient the orthotopic neobladder according to Camey I was converted into an ileal conduit because of the excessive capacity of the reservoir, high post-void residual and recurrent pyelonephritis. Of the remaining 27 patients 16 showed both daytime and nightime urinary continence (average interval between micturitions = 3
hours), 6 were continent during the day and 5 performed self-intermittent catheterization.
Conclusion:
Supra-ampullar cystectomy with detubularized ileal orthotopic neobladder allows to preserve sexual function in nearly all the cases and to maintain urinary continence in most patients, without compromising oncological outcome. The indication must be restricted to highly selected cases, without potential risk of local recurrences and concomitant prostatic carcinoma.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
This article describes both the open and laparoscopic operative techniques of supra-ampullar cystectomy (SAC).
Both open (photographs and drawings) and laparoscopic (attached DVD) SAC are explained ...step by step.
Between May 1984 and December 2005, 31 patients with bladder tumour underwent SAC with ileal orthotopic neobladder (2 Camey I, 26 Camey II, and 3 Y). Three patients underwent laparoscopy. Preoperatively, 26 patients had superficial high-risk transitional cell carcinoma (TCC). Median follow-up was 95.0 mo (range: 5-260 mo). The 10-yr cause-specific survival rate was 76.7%. Two patients had local recurrence. Potency was preserved in 28 patients (90.3%); 15 patients (48.3%) also maintained antegrade ejaculation, allowing procreation in 3 cases. In one patient the Camey I neobladder was converted into an ileal conduit (high postvoid residual, recurrent pyelonephritis). None of the remaining patients had daytime incontinence, eight had nightime urinary incontinence, and six performed intermittent self-catheterisation.
SAC with detubularised ileal orthotopic neobladder allows preservation of sexual function and maintenance of urinary continence in most patients, without compromising oncologic outcome. The key element is the very strict and careful preoperative selection of the patients.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
The QUIBUS study is the largest investigation ever performed in Italy with an extensive use of the ICS-BPH questionnaire. The internal consistency of each of its three domains was high for ICS-Male ...(Cronbach's alpha = 0.83 and 0.89 for symptoms and bother, respectively) and lower for ICS-Sex (Cronbach's alpha = 0.63 and 0.75, see a following paper of this issue) and ICS-QoL (Cronbach's alpha = 0.53), as previously reported in the validation study of this tool. Voiding symptoms were more frequently reported, with reduced urinary stream, terminal dribble and incomplete bladder emptying as the most frequently represented. The first storage symptom in the ranking by frequency was 'rush to toilet' (70% of the population), in 7th position; however, the relevant bother was among the highest reported. Items related to urinary incontinence appeared, when present, highly bothersome (87-92% of patients), even though exhibited by a minority of the population (5-34%). The mean (+/-SD) IPSS, calculated on 970 patients, was 15 (+/-7). Two major discrepancies were found in the comparison between IPSS and ICS-Male. First, terminal dribble, which is not considered in the IPSS, is often reported in the ICS-Male. Second, some storage symptoms (nocturia and day-time frequency) are less frequently reported in the ICS-Male than in the IPSS, while being, in general, highly bothersome. As regards QoL, 95% of subjects declared that they would not be completely happy to spend the rest of their life with their actual symptoms (ICS-QoL item 33) and 79% that BPH influences their life from 'a little' to 'a lot' (ICS-QoL item 30). The mean (+/-SD) IPSS-QoL single question score was 3.0 +/- 1.4 (n = 970), and the frequency distribution of scores was equivalent to the one detected by the corresponding question of ICS-QoL (item 33). SF-36, a disease-independent questionnaire about QoL, after a 1-year follow-up is expected to clarify which among the IPSS and ICS-BPH items better describe the impact of BPH on QoL.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
In a prospective trial conducted by the Gruppo Onco Urologico Piemontese, newly diagnosed prostate cancer patients with bone metastases were randomized to receive goserelin (3.6 mg subcutaneously ...every 4 weeks) or goserelin plus mitomycin at 14 mg/m2 i.v. every 6 weeks. Treatment was planned to be continued until progression. The study was interrupted because of inadequate accrual rate when 63 patients had been recruited. A long-term follow-up (median, 47 months), performed to counterbalance the limited number of patients included, revealed no difference in time to progression and overall survival between the study treatments. However, 56.5% of assessable patients allocated to the chemotherapy arm presented a > or =90% reduction of prostate-specific antigen levels compared with 36.3% in the goserelin group, and previously elevated levels normalized in 73.9% versus 45.4%. Non-progressing patients received 5-7 cycles of mitomycin C with acceptable toxicity, but the cytotoxic treatment was interrupted early in all cases within the first year due to cumulative myelotoxicity. In conclusion, the results, although inconclusive, fail to support a clear advantage in terms of cost/benefit of chemotherapy plus hormone therapy over hormone treatment alone in advanced prostate cancer with bone involvement.
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