模拟解剖性前盆腔脏器清除对女性控尿机制的损伤

目的探讨女性解剖性前盆腔脏器清除术对控尿机制的影响,以进一步指导相关临床工作和研究。方法对符合研究需要的成人女性尸体20具进行控尿神经的大体解剖后,模拟经耻骨后解剖性前盆腔脏器清除术,以明确可能会损伤控尿神经的操作,并提出相应的防范措施。结果女性盆丛的阴道丛和尿道从有神经分支进入尿道;其中膀胱尿道丛量较少,紧帖盆侧壁几乎与尿道上缘平行走向尿道。阴部神经的阴蒂背神经和阴部神经发出神经支配尿道,以阴部神经为主要。明确上述控尿神经,模拟手术表明紧靠盆壁的操作、尿道近端切除〉0．5cm、吻合尿道-新膀胱进针过深等都是易于损伤控尿的神经．肌肉的操作,应针对这些因素进行防范。结论手术中针对易于损伤控尿的神经、肌肉的操作因素进行防范,有助于女性控尿机制的保护。     

女性新膀胱术中保护控尿机制的解剖学基础及其应用

近年来女性控尿机制解剖学的深入研究使女性新膀胱术得以广泛开展 ,相对于男性 ,女性新膀胱术后排空障碍更为常见。手术中保留合适的尿道长度 ,保护女性控尿的神经机制及维持新膀胱尿道的正常角度可以明显改善女性新膀胱术后的控尿功能     

女性新膀胱术中保护控尿机制的解剖学基础及其应用

近年来女性控尿机制解剖学的深入研究使女性新膀胱术得以广泛开展，相对于男性，女性新膀胱术后排空障碍更为常见。手术中保留合适的尿道长度，保护女性控尿的神经机制及维持新膀胱尿道的正常角度可以明显改善女性新膀胱术后的控尿功能。     

盆腔神经丛的应用解剖

目的　探寻下尿路手术中避免损伤盆腔神经丛 (盆丛 )的解剖标志。　方法　对 2 0个盆腔器官标本作盆丛大体解剖或组织切片 ,观察盆丛与盆腔脏器的毗邻关系。　结果　盆丛位于直肠的前外侧 ,距肛门口 (9.6± 1.5 )cm ,精囊的后外侧 ,在前列腺基底部与前列腺血管形成神经血管束 ,于尿道膜部外侧和后外侧穿过尿生殖膈。　结论　精囊和神经血管束可作为下尿路术中避免损伤盆丛的解剖标志 ,了解盆丛的解剖分布 ,对减少医源性阳萎发生率有重要意义。     

男性控尿神经的解剖学研究进展

下尿路手术中对控尿神经的损伤是造成患者术后尿失禁的重要因素 ,近年来的研究表明盆丛和阴部神经盆内、盆外分支都参与控尿神经的组成 ,解剖学的发展使下尿路手术中保护控尿神经成为可能 ,特别是对前列腺尖部控尿神经和盆丛的保护对保留患者术后的控尿功能尤为重要     

女性控尿机制的研究及其在原位新膀胱术中的应用

近10多年来,随着对女性人体盆腔和尿道局部解剖学的深入研究,临床泌尿外科医师对膀胱颈、尿道、横纹括约肌、尿道支持组织及这些结构的神经支配在女性控尿中的作用有了新的认识,指导和推动了原位新膀胱术在女性患者中的应用,提高了临床效果和患者生活质量。本文就有关女性控尿机制及其在原位新膀胱术中的应用进展作一介绍。     

男性控尿神经的解剖学研究进展

下尿路手术中对控尿神经的损伤是造成患者术后尿失禁的重要因素，近年来的研究表明盆丛和阴部神经盆内、盆外分支都参与控尿神经的组成，解剖学的发展使下尿路手术中保护控尿神经成为可能，特别是对前列腺尖部控尿神经和盆丛的保护对保留患者术后的控尿功能尤为重要。     

减少耻骨后前列腺癌根治术并发症的体会

目的探讨耻骨后前列腺癌根治术手术技巧及改进,减少手术并发症。方法对16例前列腺癌患者进行耻骨后前列腺癌根治术。结果16例患者手术顺利,平均手术时间3.5h,术中平均出血量700ml,术中无直肠损伤者。术后尿瘘1例,尿道狭窄1例,无尿失禁。结论有效控制背深静脉丛,精细解剖前列腺尖部,保护尿控神经,以及良好的尿道膀胱吻合术能有效地减少手术并发症。     

经会阴修复重建男性尿道的应用解剖

目的探讨经会阴修复重建男性尿道的解剖学基础,寻求减少损伤的方法. 方法防腐成年男尸12具,经会阴逐层解剖至尿道前列腺尖部,观察层间结构和联系、尿道前列腺尖部和膜部周围结构,测量有关数据;另用新鲜男尸3具,模拟经会阴修复重建男性尿道手术操作. 结果支配阴囊、会阴及尿道球部的动、静脉及神经均是从两外侧走向中线;前尿道海绵体的腹、背侧与相邻组织间有致密纤维组织相连接.阴茎海绵体神经呈网状紧贴前列腺表面从底部走向尖部,穿过尿生殖膈,呈网格状展开,神经束网宽为(12.11±2.32) mm. 结论会阴结构复杂,手术时靠中线操作可减少损伤;在膜部尿道外侧5 mm的范围内操作,从前外侧紧贴前列腺表面分离前列腺尖部组织,可避免损伤神经束.     

男性盆腔神经丛及神经血管束的应用解剖

目的认识盆丛、神经血管束（NVB）与周围组织器官的关系。方法对10例成人男性盆腔器官标本作盆丛、NVB大体解剖,1例43岁成人新鲜盆腔脏器作连续切片,观察盆丛、NVB与周围组织器官的关系。结果盆丛位于腹膜后、直肠的侧壁,呈网络状,精囊腺的后外侧,由盆丛发出的阴茎海绵体神经在前列腺后外侧走行,这些神经与前列腺被膜血管组成NVB。NVB的密度沿前列腺下行时逐渐变稀,在膜部尿道的外侧和后外侧分布于尿道旁的横纹肌中。结论明确盆丛、NVB位置以及与盆腔器官的毗邻关系,有助于术中有效鉴别和保护盆丛和NVB,达到保留性神经的盆腔、会阴部手术的目的。     

Radical cystectomy (anterior exenteration) in the female patient

Anterior exenteration in the female patient can be performed accurately with a disciplined anatomic approach. The lymphadenectomy provides staging for the carcinoma. Excision of the uterus, a portion of the vagina, and the urethra reduces the potential for pelvic recurrence. Vaginal reconstruction and continent urinary diversion provide a better quality of life with maintenance of sexual function and urinary continence.     

女性控尿解剖机制的多层螺旋CT研究

目的 研究女性控尿解剖机制在16层螺旋CT上的表现和价值.方法 对正常控尿的20位女性的下尿路、盆底肌肉进行16层螺旋cT的横截位连续增强扫描.在层距1mm、层厚2mm、螺距1.5、床进速度4.5mm/s的条件下,注射优维显后28s～35s进行连续扫描.结果 在增强的16层螺旋CT影像上,可以区分女性尿道与阴道等尿道周围组织;与控尿有关的盆底肌肉也能够清楚显示;CT观察证实女性尿道的肌肉是独立的,与盆底其他肌肉并不相连.结论 增强的16层螺旋CT可作为观察女性尿道的影像学方法,具有一定的临床应用价值.     

Use of a urethral occlusion device for treatment of incontinence in a patient with heterotopic urinary diversion

Incontinence is a frequent complication of continent cutaneous urinary diversion that usually requires surgical intervention for correction. We report a novel nonsurgical therapy for reservoir incontinence in a woman who underwent anterior pelvic exenteration with formation of an Indiana pouch urinary diversion for treatment of adenocarcinoma of the urethra. When she subsequently developed urinary incontinence that was only partially responsive to anticholinergic therapy, stomal continence was restored by using a disposable urethral occlusion device.     

Virtual Reality of the Lower Urinary Tract in Women

Advances in computerized and imaging technology permit both students and doctors to depict the anatomy of the human pelvis more realistically than with previous methods. Further refinements outline fine pelvic structures, such as the nerve plexus, which may as a result be spared during major pelvic surgery, thus preserving the function of the bladder neck and urethra. Dynamic computerized tomography or magnetic resonance imaging, coupled with three-dimensional depiction of the lower urinary tract and its adjacent structures, enable visualization of the whole lower urinary tract and the pelvic floor musculature in both continent and incontinent women. In patients with a reconstructed lower urinary tract computer-assisted image processing shows the postoperatively altered topographical anatomy. This may be clinically useful for interpretation of unexpected findings with conventional imaging modalities, postoperative morbidity, and surgical planning of a lower abdominal reoperation. Examples of our own work regarding the innervation of female pelvic organs, dynamic depiction of the bladder and pelvic floor musculature during straining in normal and incontinent women, and the situation of female patients after undergoing an anterior pelvic exenteration with subsequent orthotopic neobladder procedure, are given. In addition, the data of these patients have been compiled for virtual reality endoscopy, which is useful for patient consent and for teaching residents, students and nurses.     

Preservation of Putative Continence Nerves during Radical Retropubic Prostatectomy Leads to More Rapid Return of Urinary Continence

Objectives. Urinary incontinence is a significant complication of radical pelvic surgery. A better understanding of the neuroanatomy of the rhabdosphincter has led to the modification of the radical retropubic prostatectomy to optimize the recovery of postoperative urinary control.Methods. Mock radical retropubic prostatectomy was performed on fresh cadavers to determine which surgical maneuvers could injure what may be the continence nerves. To assess the clinical significance of modifying the radical retropubic prostatectomy based on these anatomic studies, a contemporary series of 60 consecutive patients who underwent radical retropubic prostatectomy with continence nerve preservation was compared with a control group of 38 consecutive patients who had a standard anatomic radical retropubic prostatectomy.Results. At the level of the prostatic apex, both the pelvic and pudendal nerves gave intrapelvic branches that bilaterally coursed to the external urinary sphincter to enter at the 5 and 7 o’clock positions. The mock radical prostatectomy revealed that the nerves to the external urinary sphincter were most prone to injury when a right angle clamp was used to develop a plane between the posterior rhabdosphincter and anterior rectum and if the urethral anastomotic sutures were placed at the 5 and 7 o’clock positions. In addition, blunt dissection of the tips of the seminal vesicles injured the inferior hypogastric plexus. Modifications to preserve the continence nerves were incorporated in the anatomic radical prostatectomy. Although overall continence rates were similar for the two groups (98.3% for continence nerve-preserving radical prostatectomy versus 92.1% for standard prostatectomy), continence nerve preservation decreased the time to achieve continence.Conclusions. During radical retropubic prostatectomy, surgical maneuvers that avoid injury to the continence nerves resulted in the more rapid return of urinary control.     

An anatomical description of the male and female urethral sphincter complex

PURPOSE: We performed a detailed study of the lower urinary tract of the male and female human fetus to elucidate the anatomy of the urethral sphincter complex in both sexes and its relationship to the surrounding organs and tissues. MATERIALS AND METHODS: A total of 12 male and 14 female normal human pelvic specimens ranging from 17.5 to 38 weeks of gestation were studied by serial sections and immunohistochemical analysis. Three-dimensional reconstructions were created from serial sections to demonstrate the anatomy of the lower urogenital tract and urethral sphincter in both sexes. Specific attention was directed to the sphincteric muscle of the urethra. RESULTS: The urinary continence mechanism is formed by a combination of detrusor, trigone and urethral sphincter muscles with distinctive histological characteristics in both sexes. In males the external urethral sphincter covers the ventral surface of the prostate as a crescent shape above the verumontanum, horseshoe shape below the verumontanum and crescent shape along the proximal bulbar urethra. The levator ani muscles form an open circle around the external sphincter with a hiatus at the ventral aspect. In females the external urethral sphincter covers the ventral surface of the urethra in a horseshoe shape. Caudally the same horseshoe-shaped external sphincter increases in size to envelop the distal vagina. The levator ani muscles do not support the proximal urethra. The smooth and striated muscle components of the urethral sphincter complex are inseparable in both sexes. CONCLUSIONS: The developmental anatomy of the urethral sphincter complex is analogous in both sexes. The male and female urinary sphincter mechanism is composed of detrusor, trigone and urethral muscles, each of different muscular origins. The levator ani does not surround the ventral aspect of the urethra and may not have an active role in continence in both sexes. This new concept in the anatomy of male and female sphincter morphology may help to refine our reconstructive and ablative surgical techniques.     

What are the supportive structures of the female urethra?

AIMS: Female stress urinary incontinence is thought to result from impairment of the connective tissue "ligaments" of the urethra. Surgical repair of female incontinence mainly involves fixation of the urethra to the pubic bone or other surrounding structures. In the present anatomical-radiological study, the anatomy of the connective tissue structures around the female urethra was investigated to determine the anatomical structures that support the urethra and the rhabdosphincter. MATERIALS AND METHODS: The topography of the anterior compartment of the female pelvis was studied in serial sections and one anatomical preparation of 30 female fetuses and of six adult females. The pelves of 29 female fetuses were processed according to plastination histology technique. The pelves of the six adult specimens were processed according to sheet plastination technique. In addition, the anatomical findings were compared with MR images of 41 adult female volunteers. RESULTS: The ventro-lateral aspect of the urethra remains free of fixating ligaments throughout its pelvic course. Ventro-laterally the urethra is enclosed by the ventral parts of the levator ani, its fasciae and a ventral urethral connective tissue bridge connecting both sides. Dorsally, the urethra is intimately connected to the wall of the vagina. CONCLUSIONS: The female urethra has no direct ligamentous fixation to the pubic bone. Urethral continence after pregnancy and childbirth may be explained by a widening of the hiatus of the levator ani or the anterior vaginal wall, resulting in overstretching of the ventral urethral connective tissue bridge or the disruption of the fixation between urethra and vagina.     

Anatomy of female continence

Various muscle, connective tissue, and neurologic structures within the pelvic floor play critical roles in the maintenance of both urinary and fecal continence. Recent advances in technology, combined with greater precision during anatomic study, have expanded our understanding of the role played by the pelvic floor in maintaining continence. The goal of this article is to summarize recent research on female pelvic anatomy, with a particular emphasis on the evidence base related to urinary incontinence. The content is organized to accomplish three aims: (1) Identify, within the context of pelvic floor anatomy, the structures that comprise the urinary continence system, (2) Describe the functional dynamics of urinary continence, including factors in resting urethral pressure and pressure transmission, and (3) Present the rationale, technique, and interpretation of various methods of measuring pelvic floor function.     

Supralevator pelvic exenteration with simultaneous bowel and urinary reconstruction. Two case reports]

Two male patients underwent supralevator pelvic exenteration, preserving their normal voiding and evacuating function. Case 1 was a 19-year-old man with pineal region tumor, and a metastatic lesion in the bottom of the rectovesical pouch, possibly through the ventriculo-peritoneal shunt. Following supralevator pelvic exenteration, the construction of double pouches, a colonic J pouch and Mainz pouch to the urethra, were performed. Case 2 was a 39-year-old man with bulky retrovesical tumor. He underwent supralevator pelvic exenteration by sigmoid colo-proctostomy and U-pouch to the urethra. Both patients achieved continent except for urinary leakage at night and were able to defecate and urinate voluntarily. Urodynamic study revealed that the pressure in their urinary pouches was low.