Cauda equina syndrome results from an injury to the lumbosacral nerve roots below the tip of the conus medullaris, occuring in between 2 and 6% of all laminectomies performed for lumbar disc herniation. This article relates the anatomy of the nervous system of the bladder, rectum, anus and sexual organs to the signs and symptoms of cauda equina syndrome, and reviews the literature for the acute management of these patients.
Peyronies disease (PD) is estimated to affect approximately 3–9% of men worldwide and maybe associated with pain, erectile dysfunction and penile deformity including shortening. The condition has significant debilitating effects on quality of life, self-esteem and psychological wellbeing in addition to sexual function. Surgical results add further to this by patients having dissatisfaction with various aspects of outcomes. Non-surgical management may allow patients to avoid the morbidities associated with surgery and still achieve improved functional and aesthetic outcomes. Several non-surgical options are currently being employed in the treatment of PD that may reduce or stabilize both objective measures (e.g. penile length and deformity) and subjective measures (including sexual function, pain and partner satisfaction). Nonsurgical management can allow patients to avoid the morbidities associated with surgery and still achieve improved functional and aesthetic outcomes. In this article we explore the current non-surgical management options for PD including oral, mechanical therapies, intralesional and topical treatments. We also briefly discuss future treatment options in the form of stem cell therapy.
The understanding of abdominal vascular anatomy and its anatomical variations is of considerable importance in upper abdominal surgery. We present the rare finding of a common hepatic artery arising from the superior mesenteric artery and passing anterior to the pancreatic gland in a patient undergoing a pancreaticoduodenectomy. Anatomical variation of the arterial blood supply to the liver is common, with only 52-80% 1 of patients having 'normal anatomy' where the common hepatic artery (CHA) arises from the coeliac trunk, and divides into gastroduodenal artery and proper hepatic artery, which then divides into right and left hepatic arteries at the hilum of the liver. In 1955 Michels proposed a classification scheme with the 10 most common variants of arterial blood supply to the liver, based on the result of 200 cadaver livers.2 Hiatt et al simplified the scheme in 1994 to just six arterial variants (Table 1). 3 Type 9 in the Michels classification and type 5 in the Hiatt classification describe the variation with the CHA arising from the superior mesenteric artery (SMA), occurring in 1-5%. 1,2 Case HistoryA 73-year-old male patient presented with 14kg weight loss and progressive jaundice over four months. Endoscopic ultrasonography of the pancreas demonstrated a 1.6cm  2.7cm mass in the head of the pancreas and fine needle aspiration confirmed an adenocarcinoma. Preoperative computed tomography demonstrated that the tumour was touching the portal vein, for less than 180°of its circumference over a 1.5cm distance, without invasion. The SMA was clear from the tumour. However, the entire CHA was seen to arise from the SMA, passing anterior to the pancreas, posterior to the first part of the duodenum and up to the hilum of the liver (Figs 1 and 2). There was no accessory or replaced left hepatic artery from the left gastric artery. The splenic arteries arose from the aorta as a separate branch.The patient duly underwent a pylorus preserving pancreaticoduodenectomy. Intraoperative findings (Fig 3) confirmed the presence of a palpable pulse over the pancreatic head. The anatomical position of the CHA required careful dissection from the anterior surface of the pancreatic head, made complicated by the presence of an element of fibrosis. After resection, the artery was left running over the pancreas (Fig 4) and a pedicle of omentum was dissected. This was placed between the hepatic artery and pancreaticojejunostomy anastomosis in an attempt to decrease the risk of arterial complications should the patient develop a postoperative pancreatic fistula.The patient spent one day in the intensive care unit. He was discharged without further complications after seven days and reviewed at two months. Postoperative histology
Purpose of review The aim of this article is to provide an overview of the current literature specific to surgery for localized penile cancer including novel reconstructive techniques. Centralization of penile cancer services in many European countries and in particular the United Kingdom has resulted in an increased proportion of men undergoing organ-sparing surgery (OSS) rather than partial or total penectomy. In this review, we focus on reconstructive techniques following surgery for the primary penile tumour. Recent findings The widespread adoption of penile preserving techniques in Europe and North America has shown both oncological safety as well as good cosmetic and functional outcomes. Recent evidence has suggested that narrower surgical margins do not affect overall cancer-specific survival or local recurrence rates. Therefore, excellent cosmetic and functional outcomes can be achieved using techniques such as glans resurfacing using split-thickness skin grafts, dorsal or ventral V–Y skin advancement and urethral centralization after partial penectomy. For patients requiring more radical surgery such as total penectomy, phallic reconstruction is a suitable option using free flaps or pedicled flaps. Summary The use of OSS has transformed the lives of penile cancer patients who can avoid the significant clinical and psychological consequences of more radical surgical treatments. Careful case selection and preoperative counselling is advised prior to reconstructive techniques. Close postoperative clinical surveillance is necessary for early detection of local recurrence.
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