| Objective Urinary fistulas (vesicovaginal and urethro-vaginal fistulas) was regarded as a troublesome health problem for surgeon. In different countries, the cause of this disease was not the same. It was a common complication of childbirth in developing country where obstetric care was inadequate and in the United States, the majority of urinary fistulas arised as complications of gynecologic surgery, malignant tumor and radiotherapy. According to the size and cause, urinary fistulas could be divided into two types: simple and complex. And for the latter, surgical repair was the only available way to choose. In complex cases, the simple anatomic repair of the fistulas has been proven followed by recurrence frequently because of the high tension after suture or poor healing due to diabetes, tuberculosis and radiotherapy. For these reasons, in complex cases tissue transposition was often needed to provide additional coverage. The pedicled bulbocavernous muscle flap was regarded as a suitable graft for the repair of complex urinary fitulas. The advantages included adequate vascularization, stronger flap, simple procedure and less trauma. It was the same to other flaps that the necrosis of the flap due to pedicle injure and insufficient blood perfusion was still the main cause of surgical failure. And the objective of this study was to give an exact description of the bulbocavernous muscle with its pedicles, and to provide the surgeons anatomic knowledge by detailed dissection in 15 female adult cadavers and imitation of the operation in 3 female pelvic sample.Methods 15 female fixed cadavers and 3 female pelvic samples were provided by the department of anatomy of Shandong university. According to the design of the operative procedure, the author dissected the perineal regions of these specimens, mainly observed the configuration, position, adjacent structure and blood supply of the bulbocavernous muscles. Then the length and breath of the muscles were measured and the length and draw of the pedicles were obtained at the same time. 3 female pelvic samples were severed into two parts along the median line of the pubic symphysis, clitoris and the perineal central tendon to show the longitudinal aspect of these samples. In order to simulate the operative procedure, the bulbucavernous muscle flaps were tunneled beneath the lesser lip of pudendum, transported between the vagina and urethra. Then the relationship between the muscle flap, vagina and urethra was observed. All the data obtained in this study were expressed in the form ofx±s and divided into two groups on the basis of left or right sides And a chi-squareanalysis was used to determine the significance of the results.Results1. Results of the anatomic observationThe bulbocavernous muscles were bigeminal band-shaped muscular tissue which were located in the regions of labium majus pudendi and the superficial perineal space. The upper and lower heads of the muscles attached at the clitoris and the perineal central tendon respectively. The muscles were fixed by the fibrofatty tissue around and covered the bulb of vestibule and the inferior fascia of urogenital diaphragm below. The lesser lip of pudendum and vaginal vestibule could be found in the medial aspect of the muscle and the musculus ischiocavernosus was located in the lateral aspect of the muscle. In this study, a total of 30 bulbocavernous muscles were dissected in 15 cadavers. The length of the muscles (muscular part) on left sides was 9.1±1.8cm; on the right sides it was 9.0±1.9cm. The length of the muscles was measured as 9.0±1.8cm on average. The breadth of the muscles (the middle part) was 1.5±0.2cm on the left sides and 1.5±0.4cm on the right sides. On average, the breadth was measured as 1.5±0.3cm. The bulbocavernous artery originated from the perineal artery and the pedicles of the muscles contained 1 to 2 arterial branches. In this study, a total of 42 branches was found. The pedicles contained 1 branch were found on 18 sides (60%) and on the other 12 sides (40%) two-branch pedicles were confirmed. The length of the pedicles ranged from the starting point where the bulbocavernous artery originated to the end point where the artery entered the muscle was 2.5±0.6cm on the left sides and 2.5±0.5cm on the right sides. On the average, they were measured as 2.5±0.6cm. All the pedicles entered the lower 1/2 lateral posterior aspect of the muscles and were found as end muscular branches with no arterial collateral circulation. The angle composed by the pedicles and the line from the ischiadic tuberosity to the perineal central tendon was 64±14°on the left sides and 68±15°on the right sides. On average, it was 65±13°. The vein of the bulbocavernous muscles contained 1 (85%) to 2 (15%) branches which accompanied the bulbocavernous arteries. In 5 cadavers, plexus venosus was found around and behind the bulbocavernous muscles. The data in this study were divided into two groups on the basis of left or right side and no statistical difference were found using a chi-square analysis.2. Simulation of the operative procedureSimulation of the operative procedure was performed in 3 female pelvic samples to confirm whether the flaps could be compressed after transposition. In this study, no obvious aversion or angulation of the vagina and urethra were found after transposition and the flaps could not be compressed if the vagina and urethra were separated adequately. The tunnel beneath the lesser lip of pudendum was regarded as the only position where compression might appear.Conclusion Compared with other grafts, the advantages of the pedicled bulbocavernous muscle flap for the repair of complex fistulas in female patients included more simple procedure and less trauma; stronger graft and easier mobilization; adequate perfusion and lower rate of necrosis after operation. And The knowledge of the exact anatomy of the bulbocavernous muscle and its blood supply can provide a basis prerequisite for its use as a pedicled muscle flap for the repair of female fistulas and help to enhance the achievement ratio of the surgery. Objective Bladder transitional cell carcinoma (BTCC) was regarded as a common tumor with high recurrence rate to urologist. The diagnosis and surveillance of bladder cancer mainly depend on the frequent use of cystoscopy. The metallic cystoscopy gave patients more tramau and was difficult to be accepted. Although flexible cystoscopy has made evaluation somewhat more acceptable to patients, the technique remained invasive. Among the noninvasive techniques, the most common was voiding or washing cytology. This assay, however, was not adequately sensitive, particularly with tumors that were well or moderately differentiated. Moreover it was difficult to perform and required significant experience in this area. Special interest has been generated in noninvasive objective urinary tumor markers which were helpful in the diagnosis or surveillance of bladder cancer. Unfortunately, because a single tumor marker with 100% sensitivity and negative predictive value that could replace cystoscopy, did not exist, the role of urinary tumor markers was still adjunctive to cystoscopy, substituting or eliminating the need for cytology in certain indications. BTCC had a multi-step process of genesis, progress, invasion and metastasis and each step had special characteristics. At the same time, BTCC could be divided into several types according to the different tumor behaviors. Until now, no single tumor marker had the ability to reveal all these characteristics and different types. So the choice of tumor markers as combined assay which would provide a higher sensitivity should be based on the tumor behaviors as a whole. In this study, we chose urinary CYFRA21-1 which revealed the qualitative change of intracellular content of cytokeratins during the course when normal urothelial cells develop into tumor cells, telomerase which had a high expression in the course of tumor cell proliferation and VEGF which could be regarded as a predictor of relapse and stage progression in superficial bladder cancer as combined assay to detect BTCC in 100 patients. The sensitivity of combined assay was compared with that of each single marker and urinary cytology respectively to explore the clinical value of combined assay in the detection of bladder transitional cell carcinoma.Methods. In this study, a total of 73 male and 27 female patients with a mean age of 61 years ( range 31 to 82 ) were enrolled. All patients were further proved to be with BTCC based on the pathologic findings after operation. Primary tumor of bladder was identified in 52 patients, whereas recurrent tumor was found in 48 patients. Then the patients were divided into superficial cancer group ( Tis,Ta,T1) and invasive cancer group (T2—T4), according to the stages of tumor based on the TNM classification. Among all the patients, 46 cases were with superficial and 54 cases with invasive cancer. Grade of tumor was determined from resection specimens as 39 cases of G I, 27 cases of G II and 34 cases of G III using the World Health Organization grading system. To determine the specificity, 50 control patients with hematuria but without bladder cancer were also evaluated. The mean age of this group was 53 years. Ultrasonography, excretory urography or cystoscopy were performed within this population and the diagnosis included 18 cases with genitourinary infections, 16 cases with benign prostatic hyperplasia, 14 cases with urinary calculi and 2 cases with urethral stricture. Midstream urine specimens were collected from each patients before surgery and were aliquoted for different assays. Urinary CYFRA21-1 and VEGF were detected by ELISA, telomerase detected by the telomeric repeat amplification protocol. The cytology was performed immediately at the time of specimen collection by the same investigator. The sensitivity of combined assay was compared with that of each single marker and urinary cytology respectively and a chi-square analysis was used to determine the significance of the results using Statistical Package for Social Sciences, version 11.5. Statistical significance was set at P<0.05 in all analyses.Results. In the 100 patients, the sensitivity was 74.0% for urinary CYFRA21-1, 71.0% for telomerase, 69.0% for vascular endothelial growth factor ,and 38.0% for cytology. CYFRA21-1, telomerase and vascular endothelial growth factor proved significantly more sensitive than cytology respectively (P=0.000). The sensitivity of combined assay in this study was 94.0% and it was significantly higher than that of cytology, urinary telomerase, CYFRA21-1 or vascular endothelial growth factor (P=0.000). In 50 patients with hematuria but without bladder cancer, the overall specificity of the assays was 78.0% for CYFRA21-1, 84.0% for telomerase, 88.0% for VEGF, and 92.0% for cytology.Conclusions. Urinary CYFRA21-1, telomerase and VEGF revealed the different characteristics of BTCC during the course of tumor genesis, progress, invasion and metastasis and were regarded as useful tumor markers in the detection of bladder transitional cell carcinoma. Combined assay of these three markers had a higher sensitivity than any single marker or urinary cytology and appeared to be of interest in the detection of bladder transitional cell carcinoma.
|
PDF Full Text Request