The intra-pelvic innervation : anatomical and immuno-histochemical study with three-dimensional reconstruction

Introduction : L’utilisation des méthodes anatomiques classiques rend difficile la localisationprécise des micro-fibres nerveuses et ne permet pas de déterminer leur nature ni leur fonction.La chirurgie pelvienne est associée à des séquelles urinaires et sexuelles fréquentes causéespar lésion iatrogène des nerfs pelviens. La connaissance de l’anatomie et de la physiologie del’innervation intra-pelvienne est fondamentale pour tenter de réduire le taux de troublesfonctionnels postopératoires.Objectifs : i) étudier l’anatomie topographique et la nature de fibres nerveuses intrapelvienneen utilisant la reconstruction tridimensionnelle des coupes histologiques immunomarquéesii) standardiser la technique de Dissection Anatomique Assistée par Ordinateur(DAAO) et vérifier sa faisabilité sur des sujets adultes et iii) établir grâce à cette technique deDAAO des modèles pédagogiques tridimensionnels afin d’améliorer la compréhension desdysfonctions sphinctériennes et sexuelles survenant après la chirurgie (rectale et prostatique)et d’adapter éventuellement la technique opératoire.Matériel et méthodes : Des coupes histologiques sériées de pelvis ont été réalisées chez septfoetus masculins, sept foetus féminins et six cadavres adultes masculins. Les coupes ont ététraitées par des méthodes histologiques (Hématoxyline-Eosine et trichrome de Masson) etimmuno-histochimiques pour détecter les fibres nerveuses (anti-S100), les fibres somatiques(anti-PMP22), les fibres adrénergiques (anti-TH), cholinergiques (anti-VAChT), sensitives(anti-SP/CGRP) et nitrergiques (anti-nNOS) ainsi que l’actine lisse des sphincters. Les lamesont ensuite été numérisées par un scanner de haute résolution optique et les imagesbidimensionnelles ont été reconstruites en trois dimensions grâce au logiciel WinSurf.Résultats: La reconstruction tri-dimensionnelle des coupes histologiques immuno-marquéesa permis d'identifier l’anatomie topographique et structurelle de l’innervation intra-pelvienne.Les structures nerveuses afférentes du plexus hypogastrique inférieur (PHI) : nerfssplanchniques pelviens (NSP) et nerfs hypogastriques (NH) véhiculent de façon mixte l’influxsympathique et parasympathique pelvien.Les fibres nerveuses issues de la partie distale du PHI sont responsables de la continenceurinaire et de la fonction sexuelle. Elles sont regroupées et associées au pédicule vasculairepour former la bandelette neuro-vasculaire (BNV). Trois efférences principales sont issues decette BNV : i) des fibres antérieures destinées au sphincter urétral, ii) des fibres antérolatérales,par rapport à la prostate et au vagin, constituant le nerf caverneux destiné aux corpscaverneux du pénis/clitoris et iii) des fibres nerveuses postéro-latérales, par rapport à laprostate et au vagin, formant le « nerf spongieux » destiné aux corps spongieux/bulbesvestibulaires.Les communications autonomiques-somatiques entre le PHI supra-lévatorien et le nerfpudendal infra-lévatorien existent à trois niveaux ; proximal, intermédiaire et distal. Lacommunication distale caverno-pudendale est responsable de l’activité érectile segmentaireobservée au sein du nerf dorsal du pénis/clitoris.Conclusion: La DAAO est une méthode originale de recherche anatomique qui a étéprogressivement améliorée au sein de notre unité de recherche. Cette évolution illustre le faitque l'anatomie descriptive est encore une science dynamique. Notre étude a permis dedévelopper des modèles anatomo-physiologiques d’innervation pelvienne contribuant àaméliorer du point de vue morphologique, chirurgical et pédagogique la compréhension derégions anatomiques complexes comme le petit bassin.Introduction: Classic anatomical methods have limitations in micro determination of nervefibre location. Furthermore, the precise detection of the nerve fibres nature is not possible bymeans of dissection. Pelvic surgery is associated with urinary and sexual consequence causedby iatrogenic damage of the pelvic nerves. Anatomic and physiologic knowledge of the intrapelvicinnervation is essential to reduce the rate of postoperative functional complication.Objectives: i) to study the topographic anatomy and the nature of intra-pelvic nerve fibersusing three-dimensional reconstruction of histological immuno-labeled sections ii)standardize the technique of Computer-Assisted Anatomic Dissection (CAAD) and check itsfeasibility on adult subjects iii) reconstructe three dimensional teaching models to improveunderstanding of urinary and sexual dysfunction occurring after surgery (of rectal and ofprostate) to ameliorate the operative technique.Materials and methods: serial histological sections of pelvic portion were performed inseven male foetuses, seven female foetuses and six adult male cadavers. The sections weretraited by histological methods (Hematoxylin-Eosin and Masson's trichrome) and immunohistochemicalmarker of the nerve fibers (anti-S100), the somatic fibers (anti-PMP22), theadrenergic (anti-TH), cholinergic (anti-VAChT), sensory (anti-SP/CGRP) and nitrergic (antinNOS)fibers and the actin smooth muscles. The slides were then digitized by a scanner ofhigh optical resolution and two-dimensional images were reconstructed in three dimensionsusing WinSurf software.Results: The three dimensional reconstruction of histological immuno-labelled sectionsidentified structural and topographic anatomy of intra-pelvic innervation. The afferencenerves of the inferior hypogastric plexus (IHP): pelvic splanchnic nerves (PSN) andhypogastric nerves (HN) contain both sympathetic and parasympathetic fibers.The nerve fibers from the distal part of the IHP is responsible for urinary continence andsexual function. They are grouped and associated with the vascular pedicle to form theneurovascular bundles (NVB). Efferences of this NVB are distributed in three maindirections: i) anterior fibers the urethral sphincter, ii) anterolateral fibers, compared withprostate / vagina, which constitute the cavernous nerve for the corpora cavernosa of the penis/ clitoris and iii) " spongious nerve”, which is the continuity of posterior-lateral nerve fibers,compared with prostate / vagina, for the corpus spongiosum / vestibular bulbs.Autonomic-somatic communications between supra-lavator IHP and infra-levator pudendalnerve are present at three levels; proximal, intermediate and distal communications. Cavernopudendaldistal communication provides segmental erectile activity of the dorsal nerve of thepenis / clitoris.Conclusion: The CAAD is an original method in anatomical research which has beenprogressively improved. This illustrates the fact that descriptive anatomy is still a dynamicscience. Our study has developed anatomico-physiological models of intra-pelvic innervationcontributing to a better understanding of complex anatomica

Esophageal Cancer Metastases to Unexpected Sites: A Systematic Review

The most common pattern of esophageal cancer metastases (ECM) is to the lymph nodes, lung, liver, bones, adrenal glands, and brain. On the other hand, unexpected metastasis (UM) spread to uncommon sites has increasingly reported and consequently affected the pathway of diagnosis, staging, and management. Using the PubMed database, a systematic search of the following headings “Esophageal” and “Metastasis” or “Metastases” was performed, 10049 articles were identified, and the articles were included if they demonstrated unexpected ECM. 84% of cases were men with an average age of 60.7 years. EC was located in the lower third in 65%. Two-thirds of the UM originated from the lower esophagus, and the two major histological types were adenocarcinoma 40% and squamous cell carcinoma 60%. Metastases were disseminated toward five main anatomical sites: the head and neck (42%), thoracic (17%), abdomen and pelvis (25%), extremities (9%), and multiple skin and muscle metastases (7%). The EC metastases were found to be synchronous 42% and metachronous 58%, isolated in 53.5% and multiple in 46.5%. The overall survival rate was 10.2 months. Since distant metastases are responsible for most EC-related deaths, understanding of ECM dissemination patterns needs more extensive studies. These critical data are the cornerstone of optimal cancer approach and treatment

Pancreatic Hydatid Cyst Causing Acute Pancreatitis: A Case Report and Literature Review

Hydatidosis is a public health problem in endemic countries. Hydatid cysts are located usually in the liver and the lungs. Primary pancreatic hydatid cyst is in unusual location and rarely causes acute pancreatitis. In this paper, we report a case of a 34-year-old man who admitted with recurrent acute pancreatitis. Following the preoperation investigations, the primary impression was a pancreatic pseudocyst. During surgery, a primary hydatid cyst was detected in the pancreas measuring 35 × 20 × 15 cm. The treatment consisted of evacuation and external draining of the cyst. In addition, we summarized 14 cases of primary hydatid cyst of the pancreas associated with acute pancreatitis reported in the literature

Angioembolization of Scrotal Arteriovenous Malformations: A Case Report and Literature Review

Arteriovenous malformations (AVMs) of the scrotum are rare lesions, usually diagnosed incidentally during the evaluation of scrotal masses or infertility. It could be presented with acute bleeding or acute pain. We are presenting a case of painless bilateral infiltrated scrotal mass (more advanced in the left side) developed dramatically over a year, no other symptoms existed. The diagnosis was made using duplex ultrasound (DUS), computed tomography arteriography (CTA), and digital subtraction angiography (DSA). Three sessions of angioembolization were performed and followed by surgical resection of the left side of the scrotum

Language of written medical educational materials for non-English speaking populations: an evaluation of a simplified bi-lingual approach

International audienceBACKGROUND : Debates have arisen in various non-English speaking countries over the chosen language of instruction in medical education, whether it has to be the English language or the mother tongue. English-based education supporters argue that English is the leading international language of medicine and research, and a crucial tool for Continuing Medical Education (CME), as well as for students who seek practice abroad. On the other hand, mother-tongue-based medical education supporters present it as a way to endorse communication and comprehension between medical practitioners and health care system users, to bridge the gap between practitioners and the paramedical staff, and to overcome linguistic dualism and the language thinking disparity while studying in another. This study aimed to evaluate one of the simplified bi-lingual approaches in terms of medical-educational-written texts for a non-English speaking population: Arabic speaking medical students in specific.METHODS : 1546 Arabic-speaking-medical students from different countries participated in a one-step-interactive-experimental-online test. The test assessed participants' scientific comprehension of three distinct written paragraphs: The first paragraph used conventional mother tongue (Arabic), the second combined English terminology and simplified mother tongue (hybrid), and the third used an English excerpt (English). Two multiple-choice questions (First question in Arabic, second in English) followed each paragraph. Response time was communicated for each paragraph. Participants were asked to select their favorable method. Repeated Measures ANOVA models and Paired Samples t-Test were used for statistical analysis.RESULTS : Participants scored a mean of [0.10] for the Arabic paragraph, [0.72] for the hybrid paragraph, and [0.24] for the English paragraph (P <  0.001). Results showed a significantly higher mean of points and correct answers within the fastest time for the hybrid paragraph [0.68] compared to the Arabic [0.08] and English [0.18] paragraphs (P <  0.001). Moreover, 50% of participants preferred the hybrid paragraph over the other two paragraphs.CONCLUSIONS : Taking into consideration the large number of participants and the statistically significant results, authors propose that simplified Arabic combined with English terminology may present a viable alternative method for medical-educational-written texts in Arabic-speaking population

Pelvic Myxoid Leiomyoma Mass between Vagina and Rectum

Leiomyomas are the most common pelvic tumors in women. About 20–30% of women older than 35 are affected. Rare conditions of leiomyomas have extrauterine locations. Myxoid degeneration is a rare type of leiomyoma degeneration. We report a case of solid-cystic myxoid leiomyoma in a 53-year-old woman complained of constipation, urinary hesitation, and malodorous vaginal discharge with palpable 17×12 cm mass between vagina and rectum. Regarding the inferior location of the mass, a perineal approach was used to enucleate it. This rare location has not been mentioned before. The woman was finally diagnosed by pathologists which was myxoid leiomyoma

Syrian crises effect on specialty choice and the decision to work in the country among residents of six major hospitals in Syria, Damascus.

Assessing the impact of war on medical residents' specialty choices and migration decisions is critical to ensure the sustainability of healthcare systems worldwide. This study aimed to evaluate the effect of the Syrian crisis on specialty choices, related factors, and decisions to work in Syria among residents of six major university hospitals in Damascus. A cross-sectional study was conducted using a validated questionnaire from 20/4/2022 to 20/5/2022, including all eligible residents with no missing data. The questionnaire was comprised of 68 items, and residents were divided into two groups: group 1 included residents who made their specialty choice after the end of the military war in Damascus 2018, while group 2 included residents who made their specialty choice (the point of submitting their lists and applying for residency) during the war. A total of 370 residents were included, with 38.4% females and 61.6% males. Our findings revealed that 30% of residents preferred working in Syria, while 43.5% preferred working abroad. The factor of a "safer and more stable life" was significantly higher in Group 1 than in Group 2 (3.86>3.5, p-value = 0.026). Additionally, Group 1 residents were more likely to choose radiology, pathology, laboratory, and psychiatry specialization as their specialties, while choosing surgical specializations and hematology decreased compared to Group 2 (p-value2.21, Standard deviation = 0.22, p-value = 0.033). The Syrian crisis and its economic aftermath have influenced residents' specialty choices and practice locations. Even after the war's end, the high level of migration intentions could negatively affect the quality of provided healthcare services

This questionnaire aims to collect data about factors affecting the choice of medical specialty.

This questionnaire aims to collect data about factors affecting the choice of medical specialty.</p

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Assessing the impact of war on medical residents’ specialty choices and migration decisions is critical to ensure the sustainability of healthcare systems worldwide. This study aimed to evaluate the effect of the Syrian crisis on specialty choices, related factors, and decisions to work in Syria among residents of six major university hospitals in Damascus. A cross-sectional study was conducted using a validated questionnaire from 20/4/2022 to 20/5/2022, including all eligible residents with no missing data. The questionnaire was comprised of 68 items, and residents were divided into two groups: group 1 included residents who made their specialty choice after the end of the military war in Damascus 2018, while group 2 included residents who made their specialty choice (the point of submitting their lists and applying for residency) during the war. A total of 370 residents were included, with 38.4% females and 61.6% males. Our findings revealed that 30% of residents preferred working in Syria, while 43.5% preferred working abroad. The factor of a "safer and more stable life" was significantly higher in Group 1 than in Group 2 (3.86>3.5, p-value = 0.026). Additionally, Group 1 residents were more likely to choose radiology, pathology, laboratory, and psychiatry specialization as their specialties, while choosing surgical specializations and hematology decreased compared to Group 2 (p-value2.21, Standard deviation = 0.22, p-value = 0.033). The Syrian crisis and its economic aftermath have influenced residents’ specialty choices and practice locations. Even after the war’s end, the high level of migration intentions could negatively affect the quality of provided healthcare services.</div