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Etienne Anne-laure - One of the best experts on this subject based on the ideXlab platform.
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CONTRIBUTION TO THE STUDY OF INTERVENTIONAL SPINE ULTRASOUND IN THE DOG: ESTABLISHMENT OF ULTRASOUND-GUIDED TECHNIQUES FOR SUBARACHNOID PUNCTURES AND ANALYSIS OF THEIR APPLICATION
Université de Liège Liège Belgique, 2016Co-Authors: Etienne Anne-laureAbstract:audience: researcher, professional, studentSUMMARY Percutaneous ultrasound guidance has become a routine procedure in veterinary medicine in domestic animals. It allows precise placement of the needle in the desired target. Punctures of the subarachnoid Space in dogs are frequently carried out in veterinary practice for diagnostic purposes. In these procedures, the placement of the needle into the subarachnoid Space (atlanto-occipital or lumbar) is commonly performed blindly by feeling the bony anatomical landmarks but this can be laborious or even impossible in some patients as reported in human medicine. The topic of this study is ultrasound guidance for the placement of the needle during puncture of the subarachnoid Space. The needle placement can be done under ultrasound guidance according to two methods. The "indirect guidance" is a method of deferred ultrasound guidance. The "direct guidance" is a real time procedure in which the operator holds the needle in one hand and the ultrasound probe in the other. It allows direct visualization of the needle (if direct guidance), the target structure, adjacent tissues (including vascular structures) and potential injectate while minimizing the risk of complications. Punctures of the subarachnoid Space are carried out by placing the needle in the cisterna magna or in the caudal lumbar subarachnoid Space (between the fifth and sixth lumbar vertebrae). The cisternal puncture is most frequently used in practice but presents greater risk of iatrogenic lesions of the brain stem. The lumbar puncture is technically more difficult and is frequently contaminated by iatrogenic blood. Cerebrospinal fluid punctures have several clinical applications. They allow to collect cerebrospinal fluid for diagnostic testing, to realize myelograms or myeloscanners by injecting contrast medium and to perform spinal anesthesia or analgesia by injecting one or more substance(s) blocking the conduction of the spinal nerves. Subarachnoid lumbar puncture is used commonly in the dog for cerebrospinal fluid collection and/or myelography. Percutaneous ultrasound anatomy of the lumbar region in the dog and a technique for ultrasound-guided lumbar puncture were described in the first study. Ultrasound images obtained ex- vivo and in-vivo were compared with anatomic sections and used to identify the landmarks for ultrasound-guided lumbar puncture. The ultrasound-guided procedure was established on cadavers and then applied in-vivo on eight dogs. The anatomic landmarks for the ultrasound-guided puncture, which should be identified using the parasagittal oblique ultrasound image, were the articular processes of the fifth and sixth lumbar vertebrae and the interarcuate Space. The spinal needle was directed under direct ultrasound-guidance toward the Triangular Space located between the contiguous articular processes of the fifth and sixth lumbar vertebrae and then advanced to enter the vertebral canal. Using these precise ultrasound anatomic landmarks, an ultrasound-guided technique for lumbar puncture is applicable to dogs. Cisternal puncture in dogs and cats is commonly carried out. Percutaneous ultrasound anatomy of the cisternal region in the dog and the cat and an indirect technique for ultrasound-guided cisternal puncture were described in the second study. Ultrasound images obtained ex-vivo and in-vivo were compared with anatomic sections and used to identify the landmarks for ultrasound-guided cisternal puncture. The ultrasound-guided procedure was established in cadavers and then applied in- vivo in seven dogs and two cats. The anatomic landmarks for the ultrasound-guided puncture were the cisterna magna, the spinal cord, the two occipital condyles on transverse images, the external occipital crest and the dorsal arch of the first cervical vertebra on longitudinal images. Using these ultrasound anatomic landmarks, an indirect ultrasound-guided technique for cisternal puncture is applicable to dogs and cats. The standard technique for placing a needle into the canine lumbar subarachnoid Space is primarily based on the palpation of anatomic landmarks and the use of probing movements of the needle. However, this technique can be challenging for novice operators. The aim of the third observational, prospective, ex vivo, feasibility study was to compare ultrasound-guided versus standard anatomic landmark approaches for novices performing needle placement into the lumbar subarachnoid Space using dog cadavers. Eight experienced operators validated the canine cadaver model as usable for training landmark and ultrasound-guided needle placement into the lumbar subarachnoid Space based on realistic anatomy and tissue consistency. With informed consent, 67 final year veterinary students were prospectively enrolled in the study. Students had no prior experience in needle placement into the lumbar subarachnoid Space nor use of ultrasound. Each student received a short theoretical training about each technique before the trial and then attempted blind landmark-guided and ultrasound-guided techniques on randomized canine cadavers. After having performed both procedures, the operators completed a self-evaluation questionnaire about their performance and self-confidence. Total success rates for students were 48% and 77% for the landmark- and ultrasound-guided technique, respectively. Ultrasound guidance significantly increased total success rate when compared to the landmark-guided technique and significantly reduced the number of attempts. With ultrasound guidance self-confidence was improved, without bringing any significant change in duration of the needle placement procedure. Findings indicated that the use of ultrasound guidance and cadavers is a feasible method for training novice operators in needle placement into the canine lumbar subarachnoid Space after short theoretical training. Ultrasound-guided techniques for needle placement in the cisterna magna and in the lumbar subarachnoid Space were described in the dog. The aim of the fourth observational, prospective, ex-vivo study was to compare the impact of ultrasound guidance for the cisternal versus lumbar needle placement using dog cadavers. With informed consent, 83 operators were prospectively enrolled in the study. They were divided in four groups depending on experience. Each operator received a short theoretical training about each technique before the trial and then attempted a cisternal and lumbar punctures with blind landmark-guided and ultrasound-guided techniques on randomized canine cadavers. The lumbar ultrasound-guidance was direct while the cisternal ultrasound-guidance was indirect. After having performed each procedure, the operators completed a self-evaluation questionnaire about their previous experience, their performance and their self-confidence. The ultrasound guidance significantly increased total success rate in both areas compared with the blind technique but more significantly in the lumbar region. The cisternal ultrasound guidance significantly improved the number of attempts, the time needed to perform the procedure and the self-confidence in inexperienced and experienced operators. The lumbar ultrasound guidance significantly increased the self-confidence in inexperienced and experienced operators and significantly decreased the number of attempts in inexperienced operators. The first cause of failure cited was different according to the location of the puncture and was related to the nature of ultrasound guidance. Findings indicated that the use of ultrasound guidance by novice and experienced operators improved different parameters according to the location of the needle placement. This study demonstrated that inexperienced operators are able to use ultrasound guidance after a short theoretical teaching session in an ex-vivo context and this supports the use of ultrasound-guidance for learning and teaching purposes. The study of the impact of ultrasound guidance for needle placement procedures described in this work could be developed and studied for other technically difficult or risky procedures on dogs. If the benefits of ultrasound guidance demonstrated ex-vivo in this work are transferable to the clinical conditions, punctures of the subarachnoid injections would be less « scary » for novice operators and become routine procedures applicable by a large numbers of veterinarians
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CONTRIBUTION TO THE STUDY OF INTERVENTIONAL SPINE ULTRASOUND IN THE DOG: ESTABLISHMENT OF ULTRASOUND-GUIDED TECHNIQUES FOR SUBARACHNOID PUNCTURES AND ANALYSIS OF THEIR APPLICATION
Université de Liège Liège Belgique, 2016Co-Authors: Etienne Anne-laureAbstract:SUMMARY Percutaneous ultrasound guidance has become a routine procedure in veterinary medicine in domestic animals. It allows precise placement of the needle in the desired target. Punctures of the subarachnoid Space in dogs are frequently carried out in veterinary practice for diagnostic purposes. In these procedures, the placement of the needle into the subarachnoid Space (atlanto-occipital or lumbar) is commonly performed blindly by feeling the bony anatomical landmarks but this can be laborious or even impossible in some patients as reported in human medicine. The topic of this study is ultrasound guidance for the placement of the needle during puncture of the subarachnoid Space. The needle placement can be done under ultrasound guidance according to two methods. The "indirect guidance" is a method of deferred ultrasound guidance. The "direct guidance" is a real time procedure in which the operator holds the needle in one hand and the ultrasound probe in the other. It allows direct visualization of the needle (if direct guidance), the target structure, adjacent tissues (including vascular structures) and potential injectate while minimizing the risk of complications. Punctures of the subarachnoid Space are carried out by placing the needle in the cisterna magna or in the caudal lumbar subarachnoid Space (between the fifth and sixth lumbar vertebrae). The cisternal puncture is most frequently used in practice but presents greater risk of iatrogenic lesions of the brain stem. The lumbar puncture is technically more difficult and is frequently contaminated by iatrogenic blood. Cerebrospinal fluid punctures have several clinical applications. They allow to collect cerebrospinal fluid for diagnostic testing, to realize myelograms or myeloscanners by injecting contrast medium and to perform spinal anesthesia or analgesia by injecting one or more substance(s) blocking the conduction of the spinal nerves. Subarachnoid lumbar puncture is used commonly in the dog for cerebrospinal fluid collection and/or myelography. Percutaneous ultrasound anatomy of the lumbar region in the dog and a technique for ultrasound-guided lumbar puncture were described in the first study. Ultrasound images obtained ex- vivo and in-vivo were compared with anatomic sections and used to identify the landmarks for ultrasound-guided lumbar puncture. The ultrasound-guided procedure was established on cadavers and then applied in-vivo on eight dogs. The anatomic landmarks for the ultrasound-guided puncture, which should be identified using the parasagittal oblique ultrasound image, were the articular processes of the fifth and sixth lumbar vertebrae and the interarcuate Space. The spinal needle was directed under direct ultrasound-guidance toward the Triangular Space located between the contiguous articular processes of the fifth and sixth lumbar vertebrae and then advanced to enter the vertebral canal. Using these precise ultrasound anatomic landmarks, an ultrasound-guided technique for lumbar puncture is applicable to dogs. Cisternal puncture in dogs and cats is commonly carried out. Percutaneous ultrasound anatomy of the cisternal region in the dog and the cat and an indirect technique for ultrasound-guided cisternal puncture were described in the second study. Ultrasound images obtained ex-vivo and in-vivo were compared with anatomic sections and used to identify the landmarks for ultrasound-guided cisternal puncture. The ultrasound-guided procedure was established in cadavers and then applied in- vivo in seven dogs and two cats. The anatomic landmarks for the ultrasound-guided puncture were the cisterna magna, the spinal cord, the two occipital condyles on transverse images, the external occipital crest and the dorsal arch of the first cervical vertebra on longitudinal images. Using these ultrasound anatomic landmarks, an indirect ultrasound-guided technique for cisternal puncture is applicable to dogs and cats. The standard technique for placing a needle into the canine lumbar subarachnoid Space is primarily based on the palpation of anatomic landmarks and the use of probing movements of the needle. However, this technique can be challenging for novice operators. The aim of the third observational, prospective, ex vivo, feasibility study was to compare ultrasound-guided versus standard anatomic landmark approaches for novices performing needle placement into the lumbar subarachnoid Space using dog cadavers. Eight experienced operators validated the canine cadaver model as usable for training landmark and ultrasound-guided needle placement into the lumbar subarachnoid Space based on realistic anatomy and tissue consistency. With informed consent, 67 final year veterinary students were prospectively enrolled in the study. Students had no prior experience in needle placement into the lumbar subarachnoid Space nor use of ultrasound. Each student received a short theoretical training about each technique before the trial and then attempted blind landmark-guided and ultrasound-guided techniques on randomized canine cadavers. After having performed both procedures, the operators completed a self-evaluation questionnaire about their performance and self-confidence. Total success rates for students were 48% and 77% for the landmark- and ultrasound-guided technique, respectively. Ultrasound guidance significantly increased total success rate when compared to the landmark-guided technique and significantly reduced the number of attempts. With ultrasound guidance self-confidence was improved, without bringing any significant change in duration of the needle placement procedure. Findings indicated that the use of ultrasound guidance and cadavers is a feasible method for training novice operators in needle placement into the canine lumbar subarachnoid Space after short theoretical training. Ultrasound-guided techniques for needle placement in the cisterna magna and in the lumbar subarachnoid Space were described in the dog. The aim of the fourth observational, prospective, ex-vivo study was to compare the impact of ultrasound guidance for the cisternal versus lumbar needle placement using dog cadavers. With informed consent, 83 operators were prospectively enrolled in the study. They were divided in four groups depending on experience. Each operator received a short theoretical training about each technique before the trial and then attempted a cisternal and lumbar punctures with blind landmark-guided and ultrasound-guided techniques on randomized canine cadavers. The lumbar ultrasound-guidance was direct while the cisternal ultrasound-guidance was indirect. After having performed each procedure, the operators completed a self-evaluation questionnaire about their previous experience, their performance and their self-confidence. The ultrasound guidance significantly increased total success rate in both areas compared with the blind technique but more significantly in the lumbar region. The cisternal ultrasound guidance significantly improved the number of attempts, the time needed to perform the procedure and the self-confidence in inexperienced and experienced operators. The lumbar ultrasound guidance significantly increased the self-confidence in inexperienced and experienced operators and significantly decreased the number of attempts in inexperienced operators. The first cause of failure cited was different according to the location of the puncture and was related to the nature of ultrasound guidance. Findings indicated that the use of ultrasound guidance by novice and experienced operators improved different parameters according to the location of the needle placement. This study demonstrated that inexperienced operators are able to use ultrasound guidance after a short theoretical teaching session in an ex-vivo context and this supports the use of ultrasound-guidance for learning and teaching purposes. The study of the impact of ultrasound guidance for needle placement procedures described in this work could be developed and studied for other technically difficult or risky procedures on dogs. If the benefits of ultrasound guidance demonstrated ex-vivo in this work are transferable to the clinical conditions, punctures of the subarachnoid injections would be less « scary » for novice operators and become routine procedures applicable by a large numbers of veterinarians
Shiv Narain Kureel - One of the best experts on this subject based on the ideXlab platform.
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a novel midline scroto perineal approach facilitating innervation preserving sphincteroplasty and radical corporal detachment for reconstruction of exstrophy epispadias
Urology, 2011Co-Authors: Shiv Narain Kureel, Archika Gupta, Santosh Kumar, Vinita Singh, D DalelaAbstract:Objective To report a novel surgical approach for single-stage repair of exstrophy-epispadias, with the specific aim of innervation, preserving sphincteroplasty corporal detachment for penile lengthening and ischio-pubic ramotomy for Linia-alba approximation. Material and Methods Twenty-five classic exstrophy with compliant bladder plate and 10 incontinent epispadias patients were selected. Preoperative magnetic resonance angiogram of urogenital diaphragm showed Triangular Space between ischio-cavernosus, bulbo-spongiosus, and transverse-perinei muscles containing sphincteric branch of perineal artery indicating the course of sphincteric nerve. Bladder plate was mobilized. Through a midline scrotal septal and transverse incision along the base of urogenital triangle, the urogenital diaphragm was exposed. Corpora were separated from the urethral plate while preserving the glanular continuity and innervation to striated urethral sphincter, using muscle stimulator and nerve integrity monitor. In the subperiosteal plane along the ischio-pubic rami, the corpora were detached. Repair included ureteric reimplantation; anatomic reconstruction of bladder, bladder neck, urethra, and striated sphincter; corporo-glanuloplasty; ischio-pubic ramotomy; and abdominal closure. Assessment included surgical problems, cosmetic satisfaction, erectile function, continence, and upper tract status at 2-year follow-up. Result There was no corporal loss. Postoperative complications included 4 perineal suture line infections, 11 peno-pubic fistula, and 1 adhesive intestinal obstruction. Erectile function was good in 33 patients. Penile length was gratifying in 25. Of 28 patients, 20 (71.4%) had dry interval of two hours. Dimercaptosuccinic acid study demonstrated upper tract scarring in 2 patients. Conclusion This approach facilitates innervation preserving sphincteroplasty and precise restoration of anatomy to near normal without operative accidents because of wide exposure gained, improving the functional and cosmetic results.
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surgical anatomy of urogenital diaphragm and course of its vessels in exstrophy epispadias
Urology, 2011Co-Authors: Shiv Narain Kureel, Archika Gupta, R K GuptaAbstract:Objectives To report the surgical anatomy of the muscles of the urogenital diaphragm and the pattern of its vessels in the classic exstrophy bladder and incontinent epispadias. Methods A total of 11 patients, 9 with unoperated classic exstrophy and 2 with incontinent epispadias, who were >5 years old at presentation, were selected for the present study. Magnetic resonance imaging of the pelvis was performed using a 3.0 T magnetic resonance imaging scanner and an 8-channel coil. Computed tomography was performed for 5 patients using a multidetector row helical computed tomography scanner. Angiograms of the vessels of the urogenital diaphragm were also obtained using magnetic resonance imaging and computed tomography. Results A central perineal body was seen in all the patients, with attachment of the bulbospongiosus anteriorly, superficial transverse perinei laterally, and anal sphincter posteriorly. At the root of corpora, the ischiocavernosus muscle was also seen. The triangle among the ischiocavernosus, bulbospongiosus, and superficial transverse perinei muscle was accentuated and contained the perineal artery, indirectly indicating the course of the perineal nerve. The dorsal penile artery was nearer to the posterior edge of the ischiopubic ramus, before coursing on the lateral aspect of the anterior segment of the corpora. The deep transverse perinei muscle and laid open external urethral sphincter were also seen in the proximal planes of the urogenital diaphragm. Conclusions First, all the muscles of the urogenital diaphragm, including the external urethral sphincter, were present in the exstrophy bladder. Second, the perineal artery and its sphincteric branches were in the Triangular Space between the ischiocavernosus, bulbospongiosus, and superficial transverse perinei muscle. Finally, the dorsal penile artery ran along the inner edge of the ischiopubic ramus before lying on lateral aspect of the corpora.
Manfred Tschabitscher - One of the best experts on this subject based on the ideXlab platform.
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Endoscopic transnasal approach to the cavernous sinus versus transcranial route: anatomic study.
Neurosurgery, 2005Co-Authors: Luigi Maria Cavallo, Paolo Cappabianca, Renato Galzio, Giorgio Iaconetta, Enrico De Divitiis, Manfred TschabitscherAbstract:OBJECTIVE The aim of the present study was to compare the anatomy of the cavernous sinus via an endoscopic transnasal route with the anatomy of the same region explored by the transcranial route. The purpose was to identify and correlate the corresponding anatomic landmarks both through the endoscopic transnasal transsphenoidal and the microscopic transcranial views. METHODS Five fresh injected heads (10 specimens) were dissected by the endoscopic transnasal and microsurgical transcranial approaches. A comparison of different microsurgical corridors of the cavernous sinus with the corresponding endoscopic transnasal ones was performed. RESULTS Through the endoscopic transnasal approach, it is possible to explore only some of the parasellar and middle cranial fossa subregions. Because of the complex multilevel architecture of the cavernous sinus, there is not always a correspondence between the surgical corridors bounded through the transcranial route and those exposed through the endoscopic transnasal approach. Nevertheless, some surgical corridors specific to the endoscopic transnasal route are evident: a C-shaped corridor is identifiable medial to the "intracavernous" internal carotid artery, whereas a wider Triangular area is delineable lateral to the internal carotid artery; inside the latter, three more surgical corridors (a superior Triangular Space, a superior quadrangular Space, and an inferior quadrangular Space) can be described. CONCLUSION Different surgical corridors can be defined during the endoscopic transnasal approach to the anteroinferior portion of the cavernous sinus, as already established for the transcranial route as well. Knowledge of these could be useful in decreasing morbidity and mortality during surgery in this region, these approaches being reserved to experienced transsphenoidal surgeons only.
Han Suk Ryu - One of the best experts on this subject based on the ideXlab platform.
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Imaging Findings of Variable Axillary Mass and Axillary Lymphadenopathy
Ultrasound in medicine & biology, 2014Co-Authors: Sung Hee Park, Yu Mi Jeong, So Hyun Cho, Hyun Kyung Jung, Soo Jin Kim, Han Suk RyuAbstract:The axilla is a Triangular Space that contains mesenchymal tissues such as fat, vessels, nerves and lymph nodes, from which various diseases can develop. This article describes axillary masses and axillary lymphadenopathies using imaging findings from techniques such as ultrasonography, mammography, computed tomography and magnetic resonance imaging. Awareness of the characteristic imaging findings of disease entities that cause axillary masses and various axillary lymphadenopathies will help in the accurate diagnosis of axillary lesions.
Archika Gupta - One of the best experts on this subject based on the ideXlab platform.
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a novel midline scroto perineal approach facilitating innervation preserving sphincteroplasty and radical corporal detachment for reconstruction of exstrophy epispadias
Urology, 2011Co-Authors: Shiv Narain Kureel, Archika Gupta, Santosh Kumar, Vinita Singh, D DalelaAbstract:Objective To report a novel surgical approach for single-stage repair of exstrophy-epispadias, with the specific aim of innervation, preserving sphincteroplasty corporal detachment for penile lengthening and ischio-pubic ramotomy for Linia-alba approximation. Material and Methods Twenty-five classic exstrophy with compliant bladder plate and 10 incontinent epispadias patients were selected. Preoperative magnetic resonance angiogram of urogenital diaphragm showed Triangular Space between ischio-cavernosus, bulbo-spongiosus, and transverse-perinei muscles containing sphincteric branch of perineal artery indicating the course of sphincteric nerve. Bladder plate was mobilized. Through a midline scrotal septal and transverse incision along the base of urogenital triangle, the urogenital diaphragm was exposed. Corpora were separated from the urethral plate while preserving the glanular continuity and innervation to striated urethral sphincter, using muscle stimulator and nerve integrity monitor. In the subperiosteal plane along the ischio-pubic rami, the corpora were detached. Repair included ureteric reimplantation; anatomic reconstruction of bladder, bladder neck, urethra, and striated sphincter; corporo-glanuloplasty; ischio-pubic ramotomy; and abdominal closure. Assessment included surgical problems, cosmetic satisfaction, erectile function, continence, and upper tract status at 2-year follow-up. Result There was no corporal loss. Postoperative complications included 4 perineal suture line infections, 11 peno-pubic fistula, and 1 adhesive intestinal obstruction. Erectile function was good in 33 patients. Penile length was gratifying in 25. Of 28 patients, 20 (71.4%) had dry interval of two hours. Dimercaptosuccinic acid study demonstrated upper tract scarring in 2 patients. Conclusion This approach facilitates innervation preserving sphincteroplasty and precise restoration of anatomy to near normal without operative accidents because of wide exposure gained, improving the functional and cosmetic results.
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surgical anatomy of urogenital diaphragm and course of its vessels in exstrophy epispadias
Urology, 2011Co-Authors: Shiv Narain Kureel, Archika Gupta, R K GuptaAbstract:Objectives To report the surgical anatomy of the muscles of the urogenital diaphragm and the pattern of its vessels in the classic exstrophy bladder and incontinent epispadias. Methods A total of 11 patients, 9 with unoperated classic exstrophy and 2 with incontinent epispadias, who were >5 years old at presentation, were selected for the present study. Magnetic resonance imaging of the pelvis was performed using a 3.0 T magnetic resonance imaging scanner and an 8-channel coil. Computed tomography was performed for 5 patients using a multidetector row helical computed tomography scanner. Angiograms of the vessels of the urogenital diaphragm were also obtained using magnetic resonance imaging and computed tomography. Results A central perineal body was seen in all the patients, with attachment of the bulbospongiosus anteriorly, superficial transverse perinei laterally, and anal sphincter posteriorly. At the root of corpora, the ischiocavernosus muscle was also seen. The triangle among the ischiocavernosus, bulbospongiosus, and superficial transverse perinei muscle was accentuated and contained the perineal artery, indirectly indicating the course of the perineal nerve. The dorsal penile artery was nearer to the posterior edge of the ischiopubic ramus, before coursing on the lateral aspect of the anterior segment of the corpora. The deep transverse perinei muscle and laid open external urethral sphincter were also seen in the proximal planes of the urogenital diaphragm. Conclusions First, all the muscles of the urogenital diaphragm, including the external urethral sphincter, were present in the exstrophy bladder. Second, the perineal artery and its sphincteric branches were in the Triangular Space between the ischiocavernosus, bulbospongiosus, and superficial transverse perinei muscle. Finally, the dorsal penile artery ran along the inner edge of the ischiopubic ramus before lying on lateral aspect of the corpora.
