I remember that the first report of en bloc no touch, (Dr. Scoffone) was in March 2017.
If you need this, the phone number for Dr. Miller’s office is (615) 322-2880. I searched for Dr. Nicole Miller Vanderbilt urology.
I hope you have a speedy response from her.
Understanding incontinnence: how many urinary sphincters are there?
I -- How many sphincters control the unrine flow?
www.niddk.nih.gov/health-information/urologic-diseases/urinary-tract-how-it-works
Three sets of muscles work together like a dam, keeping urine in the bladder between trips to the bathroom.
(A) The first set is the muscles of the urethra itself.
(B) The area where the urethra joins the bladder is the bladder neck. The bladder neck, composed of the second set of muscles known as the "internal sphincter", helps urine stay in the bladder.
(C) The third set of muscles is the pelvic floor muscles, also referred to as the external sphincter, which surround and support the urethra.
To urinate, the brain signals the muscular bladder wall to tighten, squeezing urine out of the bladder. At the same time, the brain signals the sphincters to relax. As the sphincters relax, urine exits the bladder through the urethra.
II -- Smooth muscle bundles pass on either side of the urethra are sometimes called the "internal urethral sphincter"
en.m.wikipedia.org/wiki/Urination
Anatomy of the bladder and outlet
The interior of the bladder
Main articles: Urinary bladder and Urethra
The main organs involved in urination are the urinary bladder and the urethra. The smooth muscle of the bladder, known as the detrusor, is innervated by sympathetic nervous system fibers from the lumbar spinal cord and parasympathetic fibers from the sacral spinal cord.[4] Fibers in the pelvic nerves constitute the main afferent limb of the voiding reflex; the parasympathetic fibers to the bladder that constitute the excitatory efferent limb also travel in these nerves. "Part of the urethra is surrounded by the male or female external urethral sphincter", which is innervated by the somatic pudendal nerve originating in the cord, in an area termed Onuf's nucleus.[5]
"Smooth muscle bundles pass on either side of the urethra, and these fibers are sometimes called the internal urethral sphincter, although they do not encircle the urethra. Further along the urethra is a sphincter of skeletal muscle, the sphincter of the membranous urethra (external urethral sphincter)". The bladder's epithelium is termed transitional epithelium which contains a superficial layer of dome-like cells and multiple layers of stratified cuboidal cells underneath when evacuated. When the bladder is fully distended the superficial cells become squamous (flat) and the stratification of the cuboidal cells is reduced in order to provide lateral stretching.
III -- Smooth muscles
en.m.wikipedia.org/wiki/Smooth_muscle
Smooth muscle
Smooth muscle is an involuntary non-striated muscle. It is divided into two subgroups; the single-unit (unitary) and multiunit smooth muscle. Within single-unit cells, the whole bundle or sheet contracts as a syncytium.
Smooth muscle cells are found in the walls of hollow organs, including the stomach, intestines, urinary bladder and uterus, and in the walls of passageways, such as the arteries and veins of the circulatory system, and the tracts of the respiratory, urinary, and reproductive systems. These cells are also present in the eyes and are able to change the size of the iris and alter the shape of the lens. In the skin, smooth muscle cells cause hair to stand erect in response to cold temperature or fear.[1]
VI -- Involuntary muscles
www.ck12.org/book/CK-12-Life-Science-Concepts-For-Middle-School/section/11.9/
Summary
Muscles that are under your conscious control are called voluntary muscles, while muscles that are not under your conscious control are called involuntary muscles.
The three types of muscles in the body include skeletal muscle, smooth muscle, and cardiac muscle.
Does the heart have muscles?
When you think of muscles, you might think of biceps and the external muscles you see in a bodybuilder. However, some muscles are found deep inside your body. The heart, for example, is a very muscular organ. It has to pump blood all around your body.
Types of Muscles
The muscular system consists of all the muscles in the body. This is the body system that allows us to move. You also depend on many muscles to keep you alive. Your heart, which is mostly muscle, pumps blood around your body.
Each muscle in the body is made up of cells called muscle fibers. Muscle fibers are long, thin cells that can do something that other cells cannot do—they are able to get shorter. Shortening of muscle fibers is called contraction. Muscle fibers can contract because they are made of proteins, called actin and myosin, that form long filaments (or fibers). When muscles contract, these protein filaments slide or glide past one another, shortening the length of the cell. When your muscles relax, the length extends back to the previous position. Nearly all movement in the body is the result of muscle contraction.
You can control some muscle movements. However, certain muscle movements happen without you thinking about them. Muscles that are under your conscious control are called voluntary muscles. Muscles that are not under your conscious control are called involuntary muscles.
Muscle tissue is one of the four types of tissue found in animals. There are three different types of muscle in the body (Figure below):
Skeletal muscle is made up of voluntary muscles, usually attached to the skeleton. Skeletal muscles move the body. They can also contract involuntarily by reflexes. For example, you can choose to move your arm, but your arm would move automatically if you were to burn your finger on a stove top. This voluntary contraction begins with a thought process. A signal from your brain tells your muscles to contract or relax. Quickly contract and relax the muscles in your fingers a few times. Think about how quickly these signals must travel throughout your body to make this happen.
Smooth muscle is composed of involuntary muscles found within the walls of organs and structures such as the esophagus, stomach, intestines, and blood vessels. These muscles push materials like food or blood through organs. Unlike skeletal muscle, smooth muscle can never be under your control.
Cardiac muscle is also an involuntary muscle, found only in the heart. The cardiac muscle fibers all contract together, generating enough force to push blood throughout the body. What would happen if this muscle was under conscious or voluntary control?
Understanding how Bladder Neck Preservation(BNP) Reduces HoLEP Incontinence
I have been doing research to understand more about the BNP technique and to find out what is and where is the donut shape of fibers that Dr. Miller was talking about located. Below are the results.
Background: two members of this thread posted that they had gone to Dr. Miller (Vanderbilt, Nashville, TN) for HoLEP. During HoLEP, she incorporated a technique called Bladder Neck Preservation to reduce the chance of or eliminate incontinence. After HoLEP, these two members did not suffer incontinence. One of the two members had asked Dr. Miller for more information about this technique and whether there was any undesirable effects. Her answers were, a band of tissue was preserved and no downsides. That is all the info we have. We do not know where this band of tissue is located nor how does this technique work.
A) Is Dr. Miller's Bladder Neck Preservation Technique a New Technique?
Actually, No. BNP has been used in radical prostatectomy since the 1900. Surprisingly, in radical prostatectomy (in which the prostrate is removed due to cancer) incontinence has been a serious problem just like HoLEP. At least two ways were found and proposed to reduce Incontinence. One way was BNP and the other way was to preserve the striated and smooth muscles surrounding the urethra which was reconnected to the bladder neck after prostrate removal. Both the bladder neck's circular fibers and the smooth fibers surrounding the prostectic urethra (or part of it) are called the internal sphincters (Plse see my previous post.)
Literature of BNP dated back to the 1902. See for example (free access):
Bladder neck preservation during classic laparoscopic radical prostatectomy – point of technique and preliminary results
Piotr L. Chłosta, Tomasz Drewa, [...], and Andrzej Borówka
www.ncbi.nlm.nih.gov/pmc/articles/PMC3516968/#!po=81.5789
"The concept of bladder neck preservation was first presented during open retropubic radical prostatectomy [10, 11]. The goal of the urological surgeon performing radical prostatectomy for prostate cancer is to eliminate the cancer and minimize the side effects associated with treatment. It seems that careful dissection of the prostate from the bladder can be performed in such a manner as to preserve most of the circular fibres of the bladder neck. This so-called bladder-neck preservation technique appears to reduce the risk of an anastomotic stricture and accelerate the return of urinary continence [11]. The true urethra-to-urethra anastomosis is the goal of the technique [12]. A few years "
These "circular fibres of the bladder neck" is the donut of fibers which dr. Miller said she preserved. Note also the words "true urethra-to-urethra anastomosis". More info on these two is given below.
(B) Where Are The Bladder Neck And The Circular Fibers Located?
See figure 6 of the above paper: Cone shape of preserved bladder neck (blue and upside down) and tension-free end-to-end anastomosis.
I also found that there are many YouTube videos about radical prostatectomy. The following excellent video shows the bladder neck and the circular fibers.
youtu.be/l-fYIeBEGmY
(Go to YouTube and search for this title or add the header htt... )
Bladder Neck Sparing Robotic Radical Prostatectomy with Detailed Anatomy by Dr. Lutfi Tunc
Stop! this is a bloody video. Do not watch unless u are keen to learn about the prostate anatomy and have no problem with watching a bloody surgical operation
I can not post pictures here. So I will use time stamps on the video to show the important landmarks of the prostate.
T=26 --- shows the cone shape bladder neck and the circular fibers as the bladder neck is connected to the prostate.
T=44 to T=48 --- both show a cut away view of the circular fibers of the bladder neck .
T=1:03 --- shows the urethra that joins the prostrate and bladder neck is being cut to disconnect the two organs.
T=27:00 to T= 30:25 --- see caption and explanation, it said the internal sphincter. The video shows the cone shape bladder neck just like figure 6 of the above paper.
T=30:36 --- showing the internal sphincter.
T=30:27 to T=30:55 --- exposing then cut the urethra joining the bladder neck to the prostate.
T=33:10 to T=35:56 --- separating the bladder neck from the prostate.
T=50:05 to T=55:46 -- see caption, external sphincter. Also starts to separate the urethra from the prostrate. The urethra is pulled out from the prostrate at the apex of the prostate.
T=55:46 --- severing the urethra from the apex of the prostate and leaving behind a length of urethra equal to about the length of the prostate.
T=55:58 --- prostate is free and is being removed.
T=1:00:41 to T=1:10:29 --- connecting the urethra to the bladder neck.
T=1:10:29 --- test for leak at the joint between the urethra and the bladder neck.
Qestions I Don't Understand
I put water into a measuring cup to 100cc then transfer to a plastic cup. This give me an idea of how large is a 100cc prostate is. From the above video, I estimate that the diameter of the urethra which is probably less than 3/8 inch.
Q1) Apparently, urologists such as Dr. Miller who incorporate BNP do not cut away or damage the circular fibers forming the bladder neck which is also one of the two internal sphincters. Does this mean that all other HoLEP surgeons do cut away or damage the circular fibers at the bladder neck?
Q2) If my estimate is correct, the diameter opening at the bladder neck is less than 3/8, then how does the nucleated lateral lobes in one or two or three big pieces be pushed through this small opening at the bladder neck?
Q3) The second internal sphincter is the striated fiber smooth muscles surrounding the prostatic urethra (or part of it). Does HoLEP remove these muscles together with the adenoma?
Which zone of the prostate causes BPH and make us suffer?
Answer: the transition zone which is only a portion of the prostate. The boundary of this transition zone is the surgical capsule. HoLEP nucleation is down to the surgical capsule.
As examples, the TZV (transition zone volume) is 55% for a 46cc and 71% for a 107cc prostate (all average values ). TURP removes 90% of a 46cc prostate whereas open prostatectomy removes 97% of a 107cc prostate. For TURP, the values are average of 120 patients whereas for OP, are average values of 48 patients.
Details are given below.
I am new to and ignorant about BPH and have been confused about the various zones of the prostate and their relationship to BPH. If this issue is elementary and general knowledge, I am sorry to waste ur time. Today, I seem to have found the answer.
These are the zones of the prostate: transition zone, peripheral zone, central zone and anterior fibromuscular stroma.
Below are papers that studies that show BPH come from the transition zone.
(1) "The importance of measuring the prostatic transition zone: an anatomical and radiological study"
A.R. ZLOTTA, B. DJAVAN*, M. DAMOUN, T. ROUMEGUERE, M. PETEIN†, K. ENTEZARI, M. MARBERGER* and C.C. SCHULMAN
Departments of Urology and †Pathology, Erasme Hospital, University Clinics of Brussels, Belgium, and *Department of Urology, University Hospital of Vienna, Vienna, Austria
BJU International (1999), 84, 661–666
onlinelibrary.wiley.com/doi/pdf/10.1046/j.1464-410x.1999.00214.x
(Add header htt...Free access)
"The clinical importance of the transition zone (TZ) of the prostate has been established recently [1]. A new appreciation of prostatic anatomy, and particularly of the TZ, was introduced by McNeal’s work [2] 20 years ago on the morphology and pathology of the gland. With TRUS, a routine tool for managing prostatic diseases, McNeal’s outstanding work can be understood and appreciated; this author suggested that BPH was largely confined to the TZ and did not occur to any significant degree in the peripheral zone [2,3]. As the adenoma enlarges it compresses the peripheral zone of the prostate. The border between the TZ and the outer zone corresponds to the surgical capsule visible during surgery and may also be detectable with TRUS [4,5]. Using TRUS, the TZ can be measured, assuming, as for the whole prostate, that the TZ is an ellipsoid. Thus the estimate of the TZ indicates the amount of BPH tissue in patients with symptomatic BPH. In such patients, most urologists generally estimate (using TRUS) the size of the entire prostate before choosing a surgical technique; however, the volume which corresponds to the adenoma to be resected or enucleated is the TZ and not the whole prostate. Therefore, knowing the volume of the TZ may help in planning a surgical approach for BPH, or currently, in planning a medical or alternative minimally invasive technique [6,7]. Indeed, the choice of many of these methods has been shown to depend on the volume of the prostate, and especially of the TZ [6,7].
The TZ volume may also be used to assess the severity of BPH. Recently, Terris et al. [8] reported that in 136 men, the TRUS measurements of TZ dimensions correlated better than total prostatic volumes with the severity of BPH. Kaplan et al. [9] showed that the TZ index (the ratio of TZ volume to prostate volume) correlated significantly with the usual variables of BPH. On evaluating 61 men with symptomatic BPH, using symptoms, peak flow rate (Qmax), and pressure-flow studies, there was only a weak correlation of total prostate volume with symptoms, Qmax and detrusor pressure, but a stronger correlation between the TZ volume and Qmax. If a TZ index of 50 was used as the threshold, TZ was a highly significant discriminator of those patients with more severe abnormalities [9]."
(2) "Transition zone volume measurement – is it useful before surgery for benign prostatic hyperplasia?"
Daimantas Milonas, Aivaras Matjošaitis, Mindaugas Jievaltas
Department of Urology, Kaunas University of Medicine, Lithuania
Medicina (Kaunas) 2007; 43(10)
medicina.lsmuni.lt/med/0710/0710-05e.pdf
(Add header htt...Free access)
"Pathological and morphological studies have proven that an enlargement of the prostate, in the event of benign prostatic hyperplasia (BPH), is due to the enlarged transition zone (TZ). In such a case, there is no significant growth of peripheral and central zones because “adenoma” compresses them......
The importance of transition zone was studied and confirmed in many aspects: impact on duration, complications and effectiveness of surgical treatment; choice of medical BPH treatment modalities; more accurate detection of prostate cancer; bladder outlet obstruction and severity of symptoms; prediction of acute urinary retention (3–8) and other aspects.
There is another very interesting aspect, especially from a practical point of view, associated with the transition zone – TZV correlation with the weight of surgical specimens removed during surgery. Indications for transurethral prostatic resection (TURP) and an open operation depend mostly on prostate size. According to the prostate development theory, described by McNeal, removed tissue weight during surgery depends on the transition zone. In such circumstances, it is very important to know if the preoperative investigation of the transition zone is correct and the measured volume is the same as the removed weight of the specimen.
Results
The mean (SD, range) age of patients was 69 years (±7.56, 45–92). The mean TPV (total prostate volume) was 63.9 mL (±40.99, 16–326.7), the mean TZV (transition zone volume)$ was 39.9 mL (±34.19, 5– 275.8), and the mean surgical specimen weight (TW) was 37.5 g (±35.09, 5–280). The difference between measured TZV and resected TW was significant (39.9 vs. 37.5). Removed TW constituted 94% of TZV and 58.7% of TPV.
In 17 (10.12%) cases, TZV was equal (±1 mL) to removed TW. The value of TZV was different than TW in 151 of 168 cases,
In the TURP group (n=120), the mean TPV was 46.46 mL (±17.68, 16–90.2), the mean TZV was 25.43 mL (±13.19, 5–61.6), and the mean resected TW was 22.9 g (±13.41, 5–66). The difference between measured TZV and resected TW was significant (25.43 vs. 22.9). Resected TW constituted 90% of measured TZV and and 49.3% of TPV. (TZV/TPV=55%)
In the group of patients who underwent open surgery (n=48), the mean TPV was 107.41 mL (±49.7, 28–326.7), the mean TZV was 76.1 mL (±42.97, 13– 275.8), and the mean resected TW was 73.96 g (±44.96, 18–280). The difference between estimated TZV and enucleated TW did not reach a significant level ). Enucleated TW constituted 97.2% of TZV and 68.9% of TPV. (TZV/TPV=71%)
To see the various zones of the prostate, go to
www.health.harvard.edu/newsletter_article/Using-PSA-to-determine-prognosis
Fig 2 prostate anatomy.
My guess is that it does, at least as practiced at IU.
Have time to elaborate how IU does HoLEP to let u believe "HoLEP damage the areas outside of the transitional zone"?
At my check up in may she said, “the bladder neck and the prostate are continuous so the bladderneck comes out with the prostate tissue.” She said specifically I am only left with the external sphincter. This tells me that she went beyond the transitional zone as it is shown in the Harvard diagram. — May 25, 2018 conversation with Dr. Krambeck.
My question is as I age my muscles will weaken will this lead to incontinence again? Another issue is the statin that I take is known to weaken muscles.
For anyone considering HoLEP I would suggest Dr. Nicole Miller at Vanderbilt or Dr. CM Scoffone in Turin Italy. Dr. Miller uses a technique that preserves the bladder neck. Dr. Scoffone has developed en bloc no touch HoLEP. According to a report that DL posted 86% of the men had no sexual side effects. I don’t know what if any are the prostate size limits for this procedure. I assume they are the same as in standard HoLEP. I don’t remember anything about incontinence.
Removing the circular fibers of and at the bladder neck does not make sense to me and is greatly troubling.
If u have time to read the papers I cited above, they both said that it is the transition zone overgrowth that causes BPH. DR. MIller also said that BPH surgery removes The Transition zone tissues in a HoLEP paper about HoLEP patient selection. If u Google transition zone and BPH, u may find other papers.
While doing research on BPH, I have often come across bladder contracture (a post surgery complication) that is the bladder neck (internal sphincter) closed up causing urine retention in the bladder and a catheter has to be put in to drain the urine. But I have never come across that tissues at bladder neck has overgrown and is the source of problem for BPH.
U are Dr. K's patient, u have the right to call her to find out if she did remove the circular fibers at the bladder neck.
Also shouldn't u be forewarned before HoLEP ?
I have watched many TURP, GLL, HoLEP YouTube videos, some several times, and had never heard any surgeon said that they were resecting the circular fibers at the bladder neck.
We seem to agree that the internal sphincter (involuntary muscles) controls the stress incontinence. After HoLEP, stress incontinence recovers overtime. This suggests HoLEP does not remove the internal sphincter that is the bladder neck. If the circular fibers are removed, I don"t believe they will regrow and become fully fuctional again.
Perhaps, I am wrong because of my ignorance.
If interested, Below are pictures showing the bladder neck, internal and external sphincters. But not sure how accurate are these pictures.
www.google.com/search?rlz=1C9BKJA_enUS605US605&hl=en-US&q=bladder+sphincter+relaxation&sa=X&ved=2ahUKEwiIn-fwsK7dAhUBw1kKHYm2BLQQ1QIoBnoECAkQBw&biw=1024&bih=748#imgrc=cYi7k9QIMFMvQM:
Thanks for the information.
Did you ever get a response from Dr. Miller?