RESULTSFrom a surgical standpoint there was a trizonal neural architecture including the proximal neurovascular plate (PNP), the predominant NVB (PNB) and ANPs. The PNP was a mean (range) of 5 (3-10) mm lateral to the seminal vesicles, was 3 (2-7) mm thick, 7 (5-25) mm wide and 9 (4-30) mm long. It was within 6 (4-15) mm of the bladder neck, 5 (2-7) mm of the endopelvic fascia and overlapped 5 (0-7) mm of the proximal prostate. The PNB varied in shape and size from the proximal to distal end, was thickest at the base and most variable near the apex. In eight of 12 cases, there was a medial extension behind the prostate, which converged medially at the apex in four cases. ANPs were noted within the layers of levator fascia and/or lateral pelvic fascia on the anterolateral aspect in five cases and in three on the posterior aspect of the prostate. In nine cadavers, the proximal third of the prostate was covered by the PNP where these ANPs were most prominent. The ANPs formed a plexus on the posterolateral aspect of the apex in four cases. CONCLUSIONWe have created an anatomical map of neurovascular tissue relevant to robotic prostatectomy. A tri-zonal neural architecture is described which has helped in standardizing the steps of robotic prostatectomy. KEYWORDSrobotic prostatectomy, nerve sparing technique, tri-zonal neural architecture, anatomy OBJECTIVETo review the neural architecture around the prostate gland, as it is relevant for nervesparing robotic prostatectomy, including in particular the anatomy of the proximal neurovascular tissue, the neurovascular bundle (NVB), and accessory neural pathways (ANPs).

An anatomical basis was sought for the postulated roles of nitric oxide (NO) as a labile transcellular messenger in the dorsal vagal complex (NTS-X). The diaphorase activity of NO synthase was used as a marker of neurons in NTS-X that are presumed to convert L-arginine to L-citrulline and NO. Nicotinamide adenine dinucleotide phosphate diaphorase (NADPHd) staining patterns in the nucleus tractus solitarii (NTS) were spatially related to terminal sites of primary visceral afferents from 1) orosensory receptors (e.g., rostral-central nucleus); 2) soft palate, pharynx, larynx, and tracheobronchial tree (e.g., dorsal, intermediate, and interstitial nuclei); 3) esophagus (nucleus centralis); 4) stomach (nucleus gelatinosus); 5) hepatic and coeliac nerves (nucleus subpostrema); and 6) carotid body and baroreceptors (medial commissural and dorsal-lateral nuclei). Primary visceral afferents were identified as sources of NADPHd-stained fiber plexuses in the NTS-X based on three findings: 1) the presence of NADPHd in nodose ganglion cells with morphological features of first-order sensory relay neurons; 2) retrograde transport of Fluoro-Gold (FG) or cholera toxin B (CT-B) from NTS-X to NADPHd-positive nodose ganglion neurons; and 3) striking reductions of NADPHd-stained processes within primary vagal projection fields ipsilateral to unilateral nodose ganglionectomy. A central origin of NADPHd-stained processes in NTS-X was identified in the medial parvicellular subdivision of the paraventricular hypothalamic nucleus. We conclude that NO of peripheral and central origin may modulate viscerosensory signal processing in the NTS-X and autonomic reflex function.

Projections from the nucleus tractus solitarii (NTS) to the spinal cord were demonstrated in the male Sprague-Dawley rat. In retrograde transport studies, a horseradish peroxidase conjugate or a fluorescent dye, FluoroGold, were injected into midcervical or upper thoracic spinal segments. Most solitariospinal neurons were multipolar or bipolar and located between the obex and spinomedullary junction. Solitariospinal neurons were concentrated in proximity to the ventral border of the solitary tract and extended dorsally into the intermediate division and ventrolaterally into the intermediate reticular zone (IRt) of the lateral tegmental field. This subgroup predominantly projects to midcervical spinal segments. A subset of small neurons was retrogradely labeled from cervical or thoracic spinal segments in the medial commissural nucleus and contiguous with a periventricular group surrounding the central canal. In anterograde transport studies, iontophoretic deposits of Phaseolus vulgaris leucoagglutinin were centered stereotaxically on sites in NTS identified by retrograde transport data. The lectin was incorporated by neurons of the solitary complex and transported bilaterally by axons that emerged from the nucleus and entered the reticular formation. The solitario-reticular (transtegmental) pathway irradiated diagonally across the IRt and extended caudally into the cervical lateral funiculus and spinal gray. A small periventricular-spinal pathway also descended longitudinally to the neuraxis. Solitariospinal neurons project to superficial lamina of the dorsal horn, laminae VII and X and ventral horn. The projections are predominantly contralateral to phrenic and intercostal motor nuclei and ipsilateral to the intermediolateral cell column. The solitariospinal projection represents the shortest route in the central nervous system, other than the local intraspinal reflex, through which first order visceral afferents signal cardiorespiratory and alimentary motor nuclei.

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Visceral feedback circuits in lower brainstem were elucidated with retrograde tracers by mapping neurons that issue local projections to the general visceral afferent division of the nucleus tractus solitarii (NTS) and dorsomotor vagal nucleus (DMX) in adult male rats. In study 1, spinal and intramedullary afferents to the visceral-sensorimotor complex (NTS-X) were traced to contiguous populations of cell bodies arranged in cylindrical segmental organization. NTS-X afferents derive from curvilinear arrays of neurons that parallel the efferent radiations of the solitariotegmental tract. Newly discovered afferents arise from circumscribed cell groups in the dorsal reticular formation and periventricular zone. Another source was traced to a paraambigual cell column in the apex of the rostral ventrolateral reticular nucleus (n.RVL). In study 2, catecholaminergic afferents were initially defined with combined retrograde transport-immunocytochemical methods. Deposits of retrograde tracers into NTS-X transported to neurons containing tyrosine hydroxylase (TH) in the A1, C1, and C3 areas or phenylethanolamine N-methyltransferase (PNMT) in the C1 area of the n.RVL and C3 area. In study 3, it was revealed that NTS-X afferents arise, in part, as collaterals of thoracic reticulospinal neurons. Deposits of the retrograde fluorescent tracer Fluorogold into the upper thoracic cord and rhodamine-labeled microbeads into NTS-X transported to the same neurons within a subambigual locus in n.RVL and parts of nucleus raphe magnus. In study 4, dual retrograde tracer-immunocytochemical analysis demonstrated that catecholamines are synthesized by a subset of neurons in the n.RVL that issue collaterals to the NTS-X and thoracic cord. Double retrogradely labeled TH- or PNMT-immunoreactive cell bodies were restricted to the C1 area within a 450-microns column bordered rostrally by the facial nucleus and ventrally by the medullary subpial surface. We conclude that visceral reflex arcs are reciprocally organized. Targets of NTS projection are also sources of local NTS-X afferent innervation. Catecholaminergic and other local afferents from reticular formation, periventricular, and spinal gray may, via collaterals, simultaneously modulate visceral reflex excitability at the level of NTS and the outflow of autonomic and respiratory motoneurons.

An anatomical basis was sought for the postulated roles of nitric oxide (NO) as a labile transcellular messenger in the dorsal vagal complex (NTS-X). The diaphorase activity of NO synthase was used as a marker of neurons in NTS-X that are presumed to convert L-arginine to L-citrulline and NO. Nicotinamide adenine dinucleotide phosphate diaphorase (NADPHd) staining patterns in the nucleus tractus solitarii (NTS) were spatially related to terminal sites of primary visceral afferents from 1) orosensory receptors (e.g., rostral-central nucleus); 2) soft palate, pharynx, larynx, and tracheobronchial tree (e.g., dorsal, intermediate, and interstitial nuclei); 3) esophagus (nucleus centralis); 4) stomach (nucleus gelatinosus); 5) hepatic and coeliac nerves (nucleus subpostrema); and 6) carotid body and baroreceptors (medial commissural and dorsal-lateral nuclei). Primary visceral afferents were identified as sources of NADPHd-stained fiber plexuses in the NTS-X based on three findings: 1) the presence of NADPHd in nodose ganglion cells with morphological features of first-order sensory relay neurons; 2) retrograde transport of Fluoro-Gold (FG) or cholera toxin B (CT-B) from NTS-X to NADPHd-positive nodose ganglion neurons; and 3) striking reductions of NADPHd-stained processes within primary vagal projection fields ipsilateral to unilateral nodose ganglionectomy. A central origin of NADPHd-stained processes in NTS-X was identified in the medial parvicellular subdivision of the paraventricular hypothalamic nucleus. We conclude that NO of peripheral and central origin may modulate viscerosensory signal processing in the NTS-X and autonomic reflex function.

Forearm compartment syndrome is a surgical emergency that usually requires release of the superficial muscle compartments. In some clinical situations it is imperative to also explore the deep muscle compartments. There are no anatomical guides for surgical exploration of the deep compartments that would minimize collateral damage to surrounding vessels, nerves, and muscles. Surgical injury in the setting of ischemia, especially vascular injury, compounds the tissue damage that has already occurred. The authors evaluated four surgical approaches (three volar and one dorsal) to the deep forearm by performing detailed anatomical dissections on 10 embalmed and plastinated cadavers. They used a scoring system to rate the approaches for their ability to visualize the deep space without causing iatrogenic injury to superficial muscles, arteries, and nerves. In the volar forearm, an ulnar approach to the deep space is simple, causes the least iatrogenic surgical injury, and provides access to the deep volar forearm structures. The plane of dissection is between the flexor carpi ulnaris and the flexor digitorum superficialis. Dividing one or two distal segmental branches of the ulnar artery to the distal flexor digitorum superficialis exposes the pronator quadratus. Lifting the ulnar neurovascular bundle with the flexor digitorum superficialis in the middle third of the forearm exposes the flexor digitorum profundus and the flexor pollicis longus. This approach to the deep space requires no sharp dissection. In the dorsal forearm, a midline approach between the extensor digitorum communis and the extensor carpi radialis brevis is simple and safe.

The study was conducted on random sample of seventy-one dried, typical cervical vertebrae (C3–C6). The data on the age, sex, and built was not available. Using vernier calipers with 0.01 mm accuracy, the anteroposterior and transverse diameters of transverse foramina and their distance from the medial margin of the uncinate process were measured bilaterally. The mean diameter of the right/left transverse foramen varied from 2.54 mm to 7.79 mm (mean = 5.55 ± 0.87 mm) and from 2.65 mm to 7.35 mm (mean = 5.48 ± 0.77 mm), respectively. The transverse foramen was less than 3.5 mm in three vertebrae on the right and two on the left. The osteocytes observed in 21.3% of specimens and the narrow transverse foramen may place patients at risk for vertebrobasilar insufficiency or thrombus formation. The mean distance of the transverse foramen from the medial margin of uncinate process is an important landmark to avoid vertebral artery laceration and was 5.0 ± 0.87 mm (range: 3.5–7.9 mm) on the right and 5.0 ± 1.0 mm (range: 3.2–7.7 mm) on the left side. No statistically significant difference was observed between the right and left sides. The accessory transverse foramina seen in 24% of vertebrae suggest duplications or fenestrations in the vertebral artery.