Precise localization of the autonomic nerves from the pelvic plexus to the corpora cavernosa: a detailed anatomical study of the adult male pelvis

The anatomical location of the branches of the pelvic plexus that innervate the corpora cavernosa has been identified previously in stillborn male neonates and fetuses. Based upon these observations, the techniques of radical retropubic prostatectomy and cystectomy have been modified to avoid injury to the autonomic innervation of the corpora cavernosa. However, the exact anatomical relationships of these nerves to the prostate, urethra and other pelvic structures in adults are unclear, since the initial anatomical studies of the pelvic plexus were performed in stillborn neonates in whom the accompanying vessels and fascia had been removed. Because these nerves are microscopic in size and can only be identified by their association with other pelvic structures, it was believed that a more refined understanding of the anatomy was necessary. In an effort to identify precisely the relationship of the cavernous branches of the pelvic plexus to the lateral pelvic fascia and the branches of the prostatovesicular arteries and veins, the following study was performed. Shortly after death a 60-year-old man was perfused completely with Bouin's fixative solution. The entire bladder, prostate, urethra, penis, corpora cavernosa, rectum, and pelvic sidewall fascia and musculature were removed en bloc. The specimen was serially sectioned transversely at 10 mu thickness, and every tenth section was stained with hematoxylin and eosin. An anatomical reconstruction in 3 dimensions was performed and illustrated. Thus, the specific location of the nerves that innervate the corpora cavernosa and their important relationships to the urethra, prostatic capsule, Denonvilliers' fascia and pelvic floor vasculature have been identified.     

射精时泄精和膀胱颈关闭的控制机理

通过对犬胸腰段内脏神经的电刺激来验证射精时交感神经信号的传导径路。该信号在射精时，使精液从射精管道泄出并使膀胱颈关闭。在大的胸腰段内脏神经中有两组神经纤维，一组从胸段和腰１的交感神经干发出，下行到主动脉前壁上的肠系膜尾丛（相当于人类的肠系膜下神经丛和腹下丛的上部）；另一组从腰段（腰１～腰５）的交感神经干发出，延伸到主动脉前壁，但不覆盖精索动脉，称为腰部内脏神经。用电刺激第１组神经，既不引起泄精，也不引起膀胱颈关闭；而刺激第２组神经（腰部内脏神经）的每一分支，都可引起泄精和膀胱颈关闭，当腹下神经被切断后，上述两种现象就不再发生。经过一段时间后，由于腰骶交感神经干和精索神经的代偿作用可恢复泄精，但膀胱颈关闭得不到代偿。因此，切断腹下神经可导致大的逆行射精。     

Clinical indications and outcomes with nerve-sparing cystectomy in patients with bladder cancer

The autonomic sympathetic and parasympathetic nerve fibers from the pelvic plexus pass through the dorsomedial pedicle of the bladder ending as the paraprostatic neurovascular bundle or paravaginal plexus before supplying the urogenital diaphragm, sphincter, and erectile organs. Preservation of the autonomic innervation is important for sexual, lower urinary tract, and bowel function. Oncologic outcome is not compromised by a nerve-sparing cystectomy if adequate selection criteria are applied. During pelvic lymphadenectomy nerve sparing is not impaired as long as the dissection is performed on the lateral, not medial side of the ureters, where the nerves lie. Nerve-sparing radical cystectomy preserves sexual function and, in the case of orthotopic bladder substitution, better continence, and decreased catheterization rates (especially in women) are achieved. Therefore, under the proper circumstances, nerve-sparing radical cystectomy is to be strongly recommended.     

Radical prostatectomy with preservation of sexual function: anatomical and pathological considerations

The technique for radical retropubic prostatectomy has been modified to avoid injury to the branches of the pelvic plexus that innervate the corpora cavernosa. The surgical procedure is based on an understanding of the anatomical relationships between the branches of the pelvic plexus that innervate the corpora cavernosa, the capsular branches of the prostatic vessels that provide the scaffolding for these nerves, and the lateral pelvic fascia. The modifications involve two steps in the procedure: 1) the incision in the lateral pelvic fascia is placed anterior to the neurovascular bundle, which is located dorsolateral to the prostate along the pelvic sidewall; 2) the lateral pedicle is divided close to the prostate to avoid injury to the branches of the pelvic plexus that accompany the capsular vessels of the prostate. Pathologic evaluation of 16 prostatic specimens removed by this modified procedure demonstrated no compromise in the adequacy of the surgical margins. Postoperative sexual function was evaluated in 12 men who underwent the procedure 2-10 months previously. All have experienced erections and six have achieved successful vaginal penetration and orgasm. Of the six patients with sexual partners who have been followed 6 months or longer, five (83%) are fully potent. These data indicate that it is possible to cure localized prostatic cancer with surgery and maintain postoperative sexual function.     

Regulation of the bladder neck closure by lumbar splanchnic nerves at ejaculation in the dog

To clarify the role of canine thoracolumbar splanchnic nerves for bladder neck closure during ejaculation, these nerves of adult male mongrel dogs were exposed under anesthesia using ketamine hydrochloride and pentobarbital, and electrical stimulation and anatomical dissection studies were performed. Bladder neck closure by the stimulation of each sympathetic nerve was monitored with a 10 Fr silicon catheter equipped with pressure-sensitive rubber balloon placed at the bladder neck. The dissection study revealed that canine thoracolumbar splanchnic nerves consisted of two nerve groups: one branching from the sympathetic trunks at thoracic and L1 ganglia, reaching caudal mesenteric plexus (CMP) through the anterior wall of the aorta, the other branching from the sympathetic trunks at level L2–L5 ganglia, reaching CMP through the posterior side of the bilateral spermatic arteries. The former were designated intermesenteric splanchnic nerves, the latter lumbar splanchnic nerves. No bladder neck closure was observed by electrical stimulation of the distal end of severed intermesenteric splanchnic nerves or of the sympathetic trunks at the lumbopelvic level among 10 dogs examined. At least one lumbar splanchnic nerve generated the closure in all 10 dogs and generally, a few lumbar splanchnic nerves, generated the closure. The results indicate that bladder neck closure during ejaculation is generated by lumbar splanchnic nerves regardless of their branching levels from lumbar sympathetic ganglia, but not by either intermesenteric splanchnic nerves or pelvic sympathetic trunks. © 1993 Wiley-Liss, Inc.     

直肠癌根治术中保留骨盆自主神经的神经解剖学基础及临床意义

目的　探讨直肠癌根治术中保留神经的解剖学基础。　方法　解剖 6例完整尸体标本(男 4例 ,女 2例 )和 4例直肠及盆腔未受破坏的矢状半骨盆标本 ,观察骨盆神经组成及走行。　结果　显露下腹神经干 ,确定其在第 5腰椎处分为左、右下腹神经。其特点是较为粗大 ,位置固定 ,在腹主动脉分叉处易找到 ,呈网状联系 ,质地较实 ,为灰白色 ,与腹主动脉较近。分叉后左右下腹神经还有较粗大分支。骨盆内脏神经在大体标本上较难辨认 ,在矢状半骨盆标本中见到发自骶前孔 2～ 4的骨盆内脏神经 ,该神经较纤细 ,在侧韧带处呈丛状的细小纤维。　结论　保留下腹神经临床上较易完成。保留骨盆内脏神经则须细心操作 ,预保留神经的一侧在侧韧带水平的手术操作应尽量贴近直肠进行。     

The distribution of intramural nerves in urinary bladder after partial denervation in the female rat

We evaluated the degree of neuronal plasticity following a partial denervation of the rat urinary bladder. Using acetylcholinesterase staining we found that the postganglionic nerves from the pelvic ganglion reach the intact bladder as 1–4 nerve trunks on each side, slightly ventral and caudal to the ureteral orifices. Normally a few thinner nerves also reach the bladder posterolateral to the ureterovesical junction. The nerves ventral to the ureters run in the ventral longitudinal muscle layer as well-defined trunks with a pattern that does not differ much from one animal to another. The nerves reaching the bladder dorsolaterally innervate the dorsolateral aspects in a more irregular fashion. Some anastomoses are found across the midline between nerves from either side. This nerve pattern is already in place in newborn rats. After removal of the pelvic ganglion on one side in the adult rat the ipsilateral ventral nerves rapidly degenerate, whereas some dorsolateral␣nerves usually survive. Axons from the intact ventral␣nerves can be seen crossing over to the denervated side in the anastomoses. After 13 weeks the surviving ventral nerves, which normally run at some distance from the ventral midline, now run in the midline with equal amounts of ventral longitudinal muscle on either side, and with their branches evenly distributed to both sides. The same pattern is seen after 27 weeks. Unilateral ganglionectomy in 3-week-old rats leads to the same changes in nerve distribution as in the adult rat. We conclude that there is a high degree of plasticity in the bladder innervation following a partial denervation, and that this plasticity includes the distribution of its main intramural nerve trunks. Received: 2 October 1997 / Accepted: 2 January 1998     

Acetylcholinesterase-positive nerves of the rhesus monkey bronchial tree.

The rhesus monkey lung was stained both by histological methods and histochemically for specific acetylcholinesterase (AChE). AChE-containing nerves in bundles were demonstrated in connective tissue of the hilum and in association with clusters of ganglion cells. These bundles become associated with the bronchial tree as they enter the lung parenchyma, and their numbers of myelinated fibres diminish as they pass scattered ganglion cells along the bronchial system. Extrachondral and subchondral plexuses of nerves were found to be interconnected and to contribute to the perimuscular varicose nerve plexus of the bronchi and bronchioles. These nerve plexuses were found to extend as far as the respiratory bronchioles. In the bronchial submucosa there are AChE-positive nerve plexuses which arise from three sources: (1) the adventitial plexus in bronchioles, or the subchondral plexus in bronchi, (2) the perimuscular nerve plexus, and (3) AChe-containing nerves associated with the bronchial artery. The submucosal plexus appears to innervate the acinar submucosal glands in bronchi as well as continuing as central nerves in the mucosal folds. In the bronchioles the nerves in the mucosal fold are in close relationship with the mucosa.     

The autonomic nervous system,sympathetic chain and stellate ganglion

The complementary sympathetic and parasympathetic systems arise and leave the CNS at different sites.In the sympathetic system, fibres arise from the lateral columns of segments T1–L2 to join paired trunks that extend from the base of the skull to the coccyx and form 3 cervical, 11 thoracic, 4 lumbar and 4 sacral ganglia. Somatic fibres pass via 31 spinal nerves to provide vasoconstrictor fibres, secretory fibres to salivary glands, and pilomotor fibres to skin; visceral fibres pass to thoracic and abdominal viscera, the adrenal medulla, cranial and facial structures. From the thoracic sympathetic trunk, splanchnic nerves pass to end in coeliac, aortic and hypogastric plexuses. The parasympathetic system has a cranial and sacral component and has effects on viscera and vascular systems that is the opposite of the sympathetic. The cranial outflow passes in cranial nerves III, VII, IX and X to ganglia from which are supplied the ciliary muscles, lacrimal and nasal glands, and salivary glands. Via the vagi and pelvic splanchnics branches are distributed to the alimentary tract, bladder and bowel sphincters.     

Nerve fibre counts for an intercostal nerve to cauda equina nerve root anastomosis

Mean nerve root diameters of thoracal, lumbal and sacral roots have been determined and the corresponding cross section areas calculated. The myelinated axons of these roots have been counted and the axon densities calculated. The myelinated axons of 3 lower intercostal nerves have also been counted. One intercostal nerve has with about 9,000 myelinated fibres enough axons for the regeneration of the ventral (3,000) and dorsal (16,000) myelinated fibres of the sacral roots 3 and 4 together. One intercostal has enough nerve fibres to reconstruct urinary bladder and bowel function on one side. The importance of performing a nerve anastomosis which considers functional aspects has been emphasized.     

J. Edouard Samson Address: the autonomic nerve supply of bone. An experimental study of the intraosseous adrenergic nervi vasorum in the rabbit.

The anatomy of the autonomic sympathetic vasomotor nerve supply of bone was studied in rabbits by methods of histochemistry, and fluorescent and electron microscopy. Our observations show that the intraosseous vessels are richly supplied by adrenergic nerves. The large primary nerves are located on or about the surface of the vessel; the medium sized secondary nerves spiral around the long axis of vessels lying more deeply in the tunica adventitia; and the fine tertiary nerves form a rich plexus at the outer area of the tunica media. The tertiary nerves have various structures which probably contain neurotransmitter substance--that is, noradrenaline--and function as neuro-vasomuscular synapses. The sympathetic nerve supply of bone originates from the appropriate ganglion, and in the case of the tibial diaphysis it descends through the sciatic nerve and thereafter mainly through the medial popliteal nerve and enters the bone alongside the nutrient artery.     

The anatomy of the pectoral nerves and their significance in brachial plexus reconstruction

Twenty-nine brachial plexuses from 13 embalmed and 5 fresh cadavers were examined under x3.5 loupe magnification to collect systematic and topographic anatomical data regarding the lateral and medial pectoral nerves. Additionally, nerve biopsy specimens were harvested in 5 fresh cadavers to obtain histomorphometric data. In all dissections the pectoral nerves exited at the trunk level as 3 distinct nerves. The superior pectoral nerve (from the anterior division of the superior trunk) commences just distal to the suprascapular nerve and courses laterally to innervate the lateral clavicular portion of the pectoralis major muscle (PM) with 2 to 4 branches. The middle pectoral nerve (from the anterior division of the middle trunk) courses distally and enters the infraclavicular fossa with 2 constant branches. The superficial branch terminates in the medial clavicular and upper sternal parts of the PM. The deep branch always forms a plexus with the medial pectoral or inferior pectoral nerve (from the anterior division of the inferior trunk), which courses at a right angle around the the lateral thoracic artery. From this plexus several branches terminate in the Pm. The branch to the lower aspect of the PM pierces the pectoralis minor muscle in two thirds of cases, whereas it passes its inferior border to reach the lower aspects of the PM with an average length of 15 cm in one third of cases. Knowledge of the detailed anatomy of the pectoral nerves, as outlined in this study, clarifies the obscure anatomic relationship of the lateral and medial pectoral nerves and allows easy intraoperative location of the medial pectoral nerve at the exit of the lateral thoracic artery. The length of the inferior pectoral nerve, the number of motor axons, and the anatomical proximity of this nerve make it an expendable but powerful source of reinnervation to the musculocutaneous nerve in upper brachial plexus injuries.     

Innervation of the levator ani muscles: description of the nerve branches to the pubococcygeus,iliococcygeus, and puborectalis muscles

We described the innervation of the levator ani muscles (LAM) in human female cadavers. Detailed pelvic dissections of the pubococcygeus (PCM), iliococcygeus (ICM), and puborectalis muscles (PRM) were performed on 17 formaldehyde-fixed cadavers. The pudendal nerve and the sacral nerves entering the pelvis were traced thoroughly, and nerve branches innervating the LAM were documented. Histological analysis of nerve branches entering the LAM confirmed myelinated nerve tissue. LAM were innervated by the pudendal nerve branches, perineal nerve, and inferior rectal nerve (IRN) in 15 (88.2%) and 6 (35.3%) cadavers, respectively, and by the direct sacral nerves S3 and/or S4 in 12 cadavers (70.6%). A variant IRN, independent of the pudendal nerve, was found to innervate the LAM in seven (41.2%) cadavers. The PCM and the PRM were both primarily innervated by the pudendal nerve branches in 13 cadavers (76.5%) each. The ICM was primarily innervated by the direct sacral nerves S3 and/or S4 in 11 cadavers (64.7%).     

臂丛神经根性撕脱伤患者三叉神经支配区感觉改变与交感神经功能状态关系的探讨

目的：研究臂丛神经根性撕脱伤患者面部三叉神经支配区感觉变化与交感神经功能状态的关系。方法：对38例臂丛神经根性撕脱伤患者面部三叉神经支配区感觉和交感神经功能状况进行临床检查与分析。同时对臂丛神经，膈神经和融神经损伤情况进行电生理学检查，结果：38例臂丛神经根性撕脱伤患者中，19例伴有交感神经损伤，13例面部感觉减退，交感神经功能减退的19例患者中，12例伴有面部感觉减退（63.2%)；面部感觉减退的13例患者中，12例伴有交感神经功能减退（92.3%)，臂丛神经根性撕脱伤患者受伤短期内，可有患侧头面部交感神经功能和面部感觉减退，一段时期以后，患侧面部三叉神经支配区感觉可随交感神经症状的消失而逐渐恢复，结论：臂丛神经根性撕脱伤患者常伴有颈部交感神经损伤，可能患侧面部三叉神经支配区感觉减退与颈部交感神经损伤有关。     

Interconnections of the upper ventral rami of the human sacral plexus: A reappraisal for dorsal rhizotomy in neurostimulation operations

The extension of a dorsal rhizotomy in bladder stimulation patients is partly determined by connections between the ventral rami of the second, third, and fourth sacral spinal nerves. The literature is inconclusive on interconnections of these ventral rami in the human sacral plexus. The sacral plexuses of ten human cadavers were dissected in this gross anatomy study. In nine cases a branch connecting the ventral rami of the second and third sacral spinal nerves was found. Electron microscopy demonstrated the presence of thick myelinated fibers in this branch. In the male plexuses this branch formed the only link between the second sacral spinal segment and the pelvic plexus. The ventral ramus of the second sacral nerve always contributed to the pudendal nerve, whereas involvement of the ventral rami of the first and third sacral nerves differed individually and intersexually.     

Neuroanatomical approach to radical cystoprostatectomy with preservation of sexual function

The technique for radical cystoprostatectomy has been modified to avoid injury to the branches of the pelvic plexus that innervate the corpora cavernosa. Although the course of the neurovascular bundles in the region of the prostate and urethra has been well charted, the exact relationship of the cavernous nerves to the seminal vesicles and bladder has remained unclear. In an effort to delineate this anatomy more clearly, detailed anatomical dissections were performed on 9 male human cadavers. This study demonstrated that the pelvic plexus is located retroperitoneally on the lateral wall of the rectum 5 to 11 cm. from the anal verge with its midpoint related to the tip of the seminal vesicle. The cavernous branches travel in a direct route from the pelvic plexus toward the posterolateral base of the prostate, gradually coalescing from a group of fibers approximately 12 mm. wide to a more organized bundle approximately 6 mm. wide at the level of the prostate. Because the bulk of the pelvic plexus and its important branches are located lateral and posterior to the seminal vesicles, the seminal vesicles can be used as a landmark intraoperatively to avoid injury to the pelvic plexus when ligating the posterior pedicle. During the last 5 years 25 men have undergone radical cystoprostatectomy. Pathological evaluation of all specimens demonstrated negative surgical margins and no patient has had locally recurrent tumor. Of the patients undergoing cystectomy alone 83 per cent are potent. Although all patients undergoing urethrectomy were able to have erections postoperatively, only 40 per cent have erections that are sufficient for intercourse. These data indicate that to date it is possible to perform radical cystoprostatectomy with preservation of sexual function in the majority of patients without compromise to the curative aspects of the radical operation.     

AUTONOMIC NERVES CROSS THE POSTERIOR PLANE OF RECTAL DISSECTION

This investigation was an anatomical study to determine whether branches of the pre-sacral autonomic plexus cross the posterior plane of surgical dissection to supply the rectum. Initially four cadaver hemi-pelves were dissected. Twelve patients undergoing full rectal mobilization were then studied at operation. In all subjects the pre-sacral nerves were arranged as a plexus below the sacral promontory, rather than as individual left and right nerve trunks. Structures thought to be nerves were identified crossing the plane of posterior mobilization of the rectum. They were traced towards their origin and destination, photographed and representative fibres biopsied. A total of 42 such structures were biopsied (16 in cadavers, 26 in operative cases) and 40 were confirmed to be nerves. These nerves connect the pre-sacral autonomic plexus with the posterior aspect of the rectum and were found at all sacral levels. In the operative cases the level of the positive biopsies were S1-six, S2-six, S3-five. S4-four. S5-three. The posterior plane of rectal dissection is therefore crossed by autonomic nerves that innervate the rectum. The pre-sacral nerves have been found to form a plexus in all subjects.     

人体前列腺外侧神经血管束显微解剖研究

目的了解人体前列腺外侧神经血管束的具体走行和分布。方法采用手术显微镜，对成年男性尸体前列腺外侧神经血管束进行解剖观察，同时采用组织切片神经性一氧化氮合酶(nNOS)免疫组织化学染色方法，对1具成年男尸标本前列腺外侧神经血管束进行染色分析。结果盆丛发出分支与血管一起构成神经血管束，分成两支沿前列腺后外侧和前外侧走行到达尿生殖膈。前列腺后外侧、前外侧神经血管束与尿生殖膈组成三角区，三角区中央可见前列腺包膜，该区无神经血管覆盖。后外侧和前外侧神经血管束中的神经穿过尿生殖膈上筋膜后，在截石位膜部尿道外会合成一支。前列腺外侧神经血管束nNOS免疫组织化学染色，前列腺后外侧和前外侧神经血管束中均存在大量nNOS神经元细胞体和神经纤维。结论前列腺外侧存在2条神经血管束，分别为前外侧和后外侧神经血管束，包含nNOS染色阳性神经节细胞。     

从盆腔筋膜的外科解剖来理解直肠全系膜切除术的层次

目的探讨直肠系膜与盆腔筋膜和神经的关系，以明确直肠全系膜切除术合理的切除平面。方法对24具尸体的盆腔进行解剖。结果直肠周围的层次是连续的，可以分为2段3层，2段指耻骨联合至坐骨棘和坐骨棘至骶岬；3层分别为脏筋膜、膀胱腹下筋膜和壁筋膜。在膀胱腹下筋膜与脏筋膜之间存在盆丛及其膀胱、子宫神经分支，而在脏、壁筋膜之间存在腹下神经和盆内脏神经。结论直肠全系膜切除术的层次在直肠后方为脏、壁筋膜之间，而在直肠侧方实际上位于脏筋膜和膀胱腹下筋膜之间。侧后方的腹下神经、侧前方的盆丛及其分支是正确层次的标记。