男性盆丛神经的观察及其临床意义

目的：直肠癌扩大根治术是提高术后生存率，减少癌细胞转移的重要术式，但其术后排尿和性功能障碍并发症较多，其原因是术中损伤了盆丛神经。本文对盆丛的研究可为改进直肠癌扩大根治术，降低并发症，提高生存质量，提供解剖学资料。方法：用３０侧男性盆腔标本，通过冰醋酸松解剥离方法，对盆丛的起源、组成和分支分布进行了详细观测。结果：盆丛长径为４１．６±７．３ｍｍ，宽径２９．８±８．５ｍｍ。盆丛又继续形成直肠丛、膀胱丛和前列腺丛，三个次级丛参与管理排尿功能和性功能。结论：手术中如能对盆丛及其次级丛神经加以保护，免受或减少损伤，可防止或减少术后并发症的发生。     

盆腔内筋膜的解剖结构及神经走形：避免修复中的损伤

背景：盆腔内走行着大量支配泌尿生殖等系统脏器的神经,包括内脏神经和脊神经两种,每一种均由运动神经和感觉神经两种成分组成。其中内脏神经的核心为盆丛。1982年,Heald提出的全直肠系膜切除已经成为直肠癌诊疗的“金标准”。但术中极易损伤神经,导致术后出现尿潴留、性功能障碍等并发症。目的：综述前人的研究,以明确盆腔内筋膜的解剖结构和神经走形。方法：以“splanchnic nerves,superior hypogastric plexus,pelvic plexus,pelvic splanchnic nerve,total mesorectal excision(TME),clinical anatomy”为关键词,检索2000年1月至2015年1月PubMed数据库中关于盆腔内神经及相关脊神经的走形和成分、盆腔内神经节及相关脏器反射等研究,以盆腔内的神经为主。结果与结论：盆腔内的主要内脏神经丛为：①上腹下丛：主体位于由左、右髂总动脉和骶岬围成的髂间三角内,左髂总静脉和第5腰椎前面。②盆丛：腹下神经、盆内脏神经、骶内脏神经在直肠侧面的后下方1/3处汇合形成神经丛,也称下腹下丛,位于输尿管后下方、膀胱及精囊腺的背侧。由内脏神经丛发出的神经包含交感神经、副交感神经及感觉神经3种成分,走行分布在盆腔各脏器表面,支配其运动与感觉功能。明确的盆腔内筋膜的解剖结构和神经走形是全直肠系膜切除成功的关键,可在手术中最大程度避免神经损伤,提高患者预后及生活质量。中国组织工程研究杂志出版内容重点：组织构建;骨细胞;软骨细胞;细胞培养;成纤维细胞;血管内皮细胞;骨质疏松;组织工程     

直肠癌全直肠系膜切除术中易损伤神经的定位及应用

目的 :探讨直肠癌全系膜切除术中容易损伤的有关内脏神经丛及分支的定位。方法 :在成人男性骨盆矢状标本及男性躯干标本上解剖观测有关内脏神经丛及分支的形态及位置。结果 :上腹下丛位于腹主动脉分叉至骶骨岬下约 2cm的范围内 ;左右腹下神经的夹角约为 95 .9° ;两侧神经的投影点分别位于骶骨岬中点至左右坐骨大切迹下缘 (近坐骨棘 )内侧一横指处 ;盆丛上、下端的投影点分别位于直肠膀胱陷凹上外侧约 4.71cm和 2 .98cm的盆壁 ,盆丛内侧缘距直肠外侧约 1 .1 1cm处。结论 :手术中应根据神经的定位分离或保护各神经丛及分支 ,就能最大限度的避免损伤神经 ,防止术后性功能及排尿功能障碍。     

宫颈癌根治术后神经源性排尿障碍的解剖学因素及预防

在24侧成人女性标本上,解剖观察了盆腔脏器旁结构的内容、分层及脏器旁结构中盆丛的组成、位置、分支和分布,并对盆丛作了分区定位.观察了子宫骶韧带和子宫主韧带与盆丛的相互关系.分析探讨了宫颈癌根治术后神经源性排尿障碍的原因及术中保护部分盆丛的临床应用要点.     

盆部内脏神经血管的解剖特点及临床应用

目的:探讨经腹腔镜行全直肠系膜切除术中盆部内脏神经和血管的保护.方法:解剖32具成人躯干标本(女15、男17)和31侧成人男性骨盆矢状标本,结合腹腔镜手术,观测有关的盆腔血管神经的形态及定位.结果:(1)骶中静脉大多1支,61%偏左,骶外侧静脉53%为两支,骶前静脉丛在骶曲处密集粗大,骶椎椎前穿通静脉在第4、5骶椎前方形成静脉窦,且与骨膜结合紧密.(2)盆从位于距直肠外侧约1.1cm和距直肠膀胱陷凹上外测约4.7cm处的骨盆侧壁.左右腹下神经分别于骶骨岬上下1.0～2.0 cm的范围内分出,其夹角约95.9°.上腹下丛位于腹主动脉分叉周围至骶骨岬下2 cm之间.(3)腹腔镜下骶前间隙主要由少量的疏松结缔组织填允容易分离,解剖层面清晰.结论:手术中应找准解剖层面,根据血管神经的定位以神经为导向进行分离,可避免损伤盆部的内脏神经及骶前静脉丛.     

男性尿道膜部括约肌支配神经的应用解剖

目的:为根治性膀胱前列腺切除手术中保护尿道控尿神经提供解剖学依据。方法:对15例成年男性尸体盆腔标本进行解剖,观察支配尿道膜部括约肌神经的组成、形态及毗邻关系。结果:尿道膜部括约肌接受下腹下丛和阴部神经盆内盆外分支支配,其中盆神经起源于下腹下丛远端盆内脏神经分支,沿肛提肌表面到达尿道膜部5点和7点位;40%的标本中阴部神经存在盆内分支,此分支自阴部管内的阴部神经主干穿肛提肌进入盆内,与盆神经一起支配尿道膜部括约肌,其进入尿道膜部的位置距离前列腺尖部(5.3±1.8)mm。在53.3%的标本中阴茎背神经发出分支到达尿道膜部,此分支进入尿道膜部的位置距离前列腺尖部(4.2±1.1)mm。结论:根治性膀胱前列腺切除术中对控尿神经的保护是多方面的,术中对精囊和前列腺尖部的操作最易损伤控尿神经。     

人海绵体神经的应用解剖及临床意义

海绵体神经起源于盆神经丛的次级神经丛-前列腺丛,含有交感神经纤维和副交感神经纤维两种成分。该神经与尿道血管形成神经血管束,沿前列腺两侧向远端走形,穿尿生殖膈后,发出分支进入海绵体,或与阴茎背神经交通,最后管理阴茎勃起组织。在盆内手术如膀胱、前列腺的根治性手术和全直肠系膜切除术后因海绵体神经损伤而导致患者术后勃起功能障碍时有发生。熟悉海绵体神经及其分支的走行特点及其与周围结构的关系,能降低手术并发症。在海绵体神经损伤后的重建方面也取得了一定的成果。     

前列腺丛和阴茎海绵体丛的临床解剖学

为了配合前列腺根治术保护阴茎海绵体的神经支配减少术后性功能障碍并发症出现的需要,作者在18具成人男性盆腔标本上观察了前列腺丛和阴茎海绵体丛的形态、位置、与血管的关系,并作了定位调查,为临床应用提供解剖学依据。     

男性盆腔神经丛的外科应用解剖

目的　探讨泌尿外科术中避免损伤盆腔神经丛 (盆丛 )的解剖标志。方法　对 42具盆腔器官作盆腔解剖或组织切片 ,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 ( 9.5± 1.6)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 ,穿尿生殖膈。结论　精囊和前列腺神经血管束可作为泌尿外科术中防止损伤盆丛的一个标志。     

与子宫颈癌手术有关的盆丛解剖学基础

解剖了9例18侧女性盆腔标本,着重观察了盆丛与子宫颈癌根治术有关的子宫骶骨韧带、主韧带的关系。提出了在术中保留盆丛和减少并发症的方法,并与过去术中没有注意保护盆丛的效果作了对比.     

Extrinsic innervation of the pelvic organs in the lesser pelvis of human embryos

Realistic models to understand the developmental appearance of the pelvic nervous system in mammals are scarce. We visualized the development of the inferior hypogastric plexus and its preganglionic connections in human embryos at 4–8 weeks post-fertilization, using Amira 3D reconstruction and Cinema 4D-remodelling software. We defined the embryonic lesser pelvis as the pelvic area caudal to both umbilical arteries and containing the hindgut. Neural crest cells (NCCs) appeared dorsolateral to the median sacral artery near vertebra S1 at ~5 weeks and had extended to vertebra S5 1 day later. Once para-arterial, NCCs either formed sympathetic ganglia or continued to migrate ventrally to the pre-arterial region, where they formed large bilateral inferior hypogastric ganglionic cell clusters (IHGCs). Unlike more cranial pre-aortic plexuses, both IHGCs did not merge because the 'pelvic pouch', a temporary caudal extension of the peritoneal cavity, interposed. Although NCCs in the sacral area started to migrate later, they reached their pre-arterial position simultaneously with the NCCs in the thoracolumbar regions. Accordingly, the superior hypogastric nerve, a caudal extension of the lumbar splanchnic nerves along the superior rectal artery, contacted the IHGCs only 1 day later than the lumbar splanchnic nerves contacted the inferior mesenteric ganglion. The superior hypogastric nerve subsequently splits to become the superior hypogastric plexus. The IHGCs had two additional sources of preganglionic innervation, of which the pelvic splanchnic nerves arrived at ~6.5 weeks and the sacral splanchnic nerves only at ~8 weeks. After all preganglionic connections had formed, separate parts of the inferior hypogastric plexus formed at the bladder neck and distal hindgut.     

The innervation of the external urethral sphincter muscle

Innervation of external urethral sphincter muscle was examined in 100 human fetuses and 10 adults of both sexes. Examined nerves take place from deep perineal nerve (branch of pudendal nerve) and, probably, from pelvic splanchnic nerves (via inferior hypogastric plexus). However, this supposition needs further microscopic research. It is also concluded that pelvic splanchnic nerves and pudendal nerve arise from the same ventral branches of spinal nerves (S2-S4).     

Topography of the pelvic autonomic nervous system and its potential impact on surgical intervention in the pelvis

Bladder, bowel, and sexual dysfunction caused by iatrogenic lesions of the inferior hypogastric plexus (IHP) are well known and commonly tolerated in pelvic surgery. Because the pelvic autonomic nerves are difficult to define and dissect in surgery, and their importance often ignored, we conducted a gross anatomic study of 90 adult and four fetal hemipelves. Using various non-surgical approaches, the anatomic relations and pathways of the IHP were dissected. The IHP extended from the sacrum to the genital organs at the level of the lower sacral vertebrae. It originated from three different sources: the hypogastric nerve, the sacral splanchnic nerves from the sacral sympathetic trunk (mostly the S2 ganglion), and the pelvic splanchnic nerves, which branched primarily from the third and fourth sacral ventral rami. These fibers converge to form a uniform nerve plate medial to the vascular layer and deep to the peritoneum. The posterior portion of the IHP supplied the rectum and the anterior portion of the urogenital organs; nerve fibers traveled directly from the IHP to the anterolateral wall of the rectum and to the inferolateral and posterolateral aspects of the urogenital organs. The autonomic supply from the IHP was supplemented by nerves accompanying the ureter and the arteries. An understanding of the location of the autonomic pelvic network, including important landmarks, should help prevent iatrogenic injury through the adoption of surgical techniques that reduce or prevent postoperative autonomic dysfunction.     

Nerve contributions to the pelvic plexus and the umbilical cord

Serial sections of human embryos and fetuses reveal that the sacral nerves which contribute fibers to the pelvic plexus often have dorsal, ventral, and oblique communicating rami. The ventral rami resemble the white rami of upper thoracic nerves and some of their fibers pass close by or through the chain ganglia and into the pelvic plexus. The sizes of the ventral rami are often in inverse proportion to that of the pelvic splanchnic nerves. That is, when the pelvic splanchnic nerves are poorly developed, the ventral rami are large, and conversely, when the pelvic splanchnic nevers are well developed, these rami are small. The pelvic plexus was found to receive fibers from the sympathetic trunk and its ganglia in addition to those from the hypogastric plexus and the pelvic splanchnic nerves. Analysis of the observations made in this study together with a review of the literature in light of the present day classification of nerve fibers raises serious doubts concerning the limits set for the outflow of preganglionic nerve fibers from the spinal cord and the distribution of gray and white rami as described in recent textbooks in terms of their histological and physiological significance. Nerve fibers from the pelvic plexus can be traced along the walls of the bladder and the urachus and along the umbilical arteries into the umbilical cord. In embryos, only a few scattered nerve fibers were found distal to the umbilicus, but in fetuses at term, distinct nerve bundles were identified in the cord. These bundles sent branches to the walls of the umbilical arteries; other branches terminated as “end-nets” in Wharton's jelly. These nets appeared as fine fibers with nodular swellings at irregular intervals. Innervation of the umbilical arteries was richest within the first few inches of the cord. Beyond this region, the nerves rapidly decreased in number. “End-nets” were present as far as four inches from the umbilicus. Granular cells resembling Langerhans' cells were found in the cord. Often these cells were closely associated with fine nerve fibers.     

Origin of peptide-containing fibers in the inferior mesenteric ganglion of the guinea-pig: Immunohistochemical studies with antisera to substance P,enkephalin, vasoactive intestinal polypeptide,cholecystokinin and bombesin

After different denervation procedures the guinea-pig inferior mesenteric ganglion was analysed by immunohistochemistry using antisera to substance P, enkephalin, vasoactive intestinal polypeptide, cholecystokinin and bombesin. The results demonstrate that each of the nerve trunks connected to the ganglion carries specific peptidergic pathways. Thus, the lumbar splachnic nerves contain substance P-immunoreactive primary afferent neurons, which to a large extent traverse the ganglion, and enkephalin-immunoreactive preganglionic neurons; the colonie nerves carry vasoactive intestinal polypeptide-, cholecystokinin- and bombesin-immunoreactive fibers from the distal colon to the ganglion; the hypogastric nerves contain vasoactive intestinal polypeptide-positive fibers from the pelvic plexus; and the intermesenteric nerve contains vasoactive intestinal polypeptide, cholecystokinin, substance P and enkephalin from divergent sources. By studying accumulations of peptides in ligated lumbar splanchnic, intermesenteric, hypogastric and colonic nerves the existence of these major peptidergic pathways was confirmed and evidence was obtained for additional, not so prominent, peptidergic projections. The results are discussed in view of earlier morphological and physiological studies.     

Coexistence of adrenergic and cholinergic nerves in the inferior hypogastric plexus: anatomical and immunohistochemical study with 3D reconstruction in human male fetus

Classic anatomical methods have failed to determine the precise location, origin and nature of nerve fibres in the inferior hypogastric plexus (IHP). The purpose of this study was to identify the location and nature (adrenergic and/or cholinergic) of IHP nerve fibres and to provide a three-dimensional (3D) representation of pelvic nerves and their relationship to other anatomical structures. Serial transverse sections of the pelvic portion of two human male fetuses (16 and 17 weeks' gestation) were studied histologically and immunohistochemically, digitized and reconstructed three-dimensionally. 3D reconstruction allowed a 'computer-assisted dissection', identifying the precise location and distribution of the pelvic nerve elements. Proximal (supra-levator) and distal (infra-levator) communications between the pudendal nerve and IHP were observed. By determining the nature of the nerve fibres using immunostaining, we were able to demonstrate that the hypogastric nerves and pelvic splanchnic nerves, which are classically considered purely sympathetic and parasympathetic, respectively, contain both adrenergic and cholinergic nerve fibres. The pelvic autonomic nervous system is more complex than previously thought, as adrenergic and cholinergic fibres were found to co-exist in both 'sympathetic' and 'parasympathetic' nerves. This study is the first step to a 3D cartography of neurotransmitter distribution which could help in the selection of molecules to be used in the treatment of incontinence, erectile dysfunction and ejaculatory disorders.     

全直肠系膜切除相关盆自主神经的解剖学观察

目的：阐述全直肠系膜切除术相关盆自主神经的局部解剖学特点，探讨盆自主神经保留的部位和对策。方法：对20具男性盆腔固定标本进行解剖观察。结果：腹主动脉丛远离肠系膜下动脉起点；上腹下丛贴近骶岬表面；腹下神经部分毗邻输尿管；盆内脏神经伴行直肠中动脉外侧部；下腹下丛位于直肠系膜后外侧；其直肠侧支走行于直肠侧韧带内，直肠前支向前穿过Denonvilliers筋膜后叶；勃起神经位于Denonvilliers筋膜前叶外侧部。结论：盆自主神经保留的部位是：离断肠系膜下血管时的腹主动脉丛左干，直肠后分离时的上腹下丛和腹下神经，直肠侧面分离时的下腹下丛和盆内脏神经，直肠前分离时的勃起神经。共同原则是：在直肠后间隙中贴近直肠系膜操作；直视下操作；避免过度牵引直肠系膜。     

Topography of the pelvic autonomic nerves in human fetuses between 21-29 weeks of gestation

Summary A topographical study concerning the autonomic nerves in the pelvis of human fetuses was performed by investigating 300–600 m thick sections through fetal pelves, impregnated with the epoxy resin E 12 and cut with a diamond wire-saw. In addition the inferior hypogastric plexus of a 26-week old male fetus was dissected by lateral approach. In 21–29-week old fetuses the pelvic autonomic nerves are relatively thick. Thus the nerves stand out well against surrounding structures and their topographical relationships can exactly be determined. The inferior hypogastric plexus of 21–29-week old fetuses is situated on a curved line between the rectum and the ventrally adjacent structure. It constitutes a rectangular plate, which cannot be subdivided into individual plexuses for the different pelvic organs. The fetal plexus is heavily ganglionated. Large ganglia, forming the so-called ganglion of Frankenhaeuser, are found in the female as well as in the male fetus. In the fetal pelvis the connective tissue compartments are still clearly arranged, because adipose tissue is not yet abundant. The greater part of the inferior hypogastric plexus is situated exactly at the border between a dense visceral tissue medially and a loose parietal tissue laterally. The plexus does not share a common connective tissue cover with the pelvic blood vessels. In fetuses the inferior hypogastric plexus lies in close vicinity to serveral organs, but the pelvic floor is the only region where the nerves can hardly be separated from the surrounding structures.