腹膜外腹腔镜下根治性前列腺切除术的临床解剖学研究

目的结合腹腔镜下根治性前列腺切除术术式特点,寻找盆腔定位标志,以提供理论知识和减少术后并发症。 方法解剖7例成年男性盆腔标本,观察膀胱颈、前列腺侧方及尖部周围组织,并测量定位。 结果膀胱颈与前列腺底交界处有两条肌性纵行纤维束,横径为（4.42±1.38）mm,距离膀胱正中线（1.78±0.32）mm。膀胱前列腺间沟后外侧有一较恒定的前列腺动脉干,距沟（16.34±5.76）mm处呈"爪"形分支。盆丛位于直肠两侧,其上部内侧发出直肠丛。下部纤维在前列腺后外侧构成宽约5.40 mm的神经血管束（NVB）。NVB内含海绵体神经,于前列腺尖部5点、7点外（2.84±0.56）mm处进入。阴茎背神经在距前列腺尖部（2.78±1.04）mm处发出细小分支,进入尿道外括约肌的5点、7点。括约肌亦受NVB发出的细小纤维支配,分布于3～5点、7～9点位。 结论术中离断膀胱颈部时,可根据膀胱颈部肌性纵行纤维束位置切开。以膀胱前列腺间沟为标志,距离其25 mm以上结扎动脉。通过辨认NVB中的小血管避免损伤海绵体神经。分离前列腺尖部、离断尿道、吻合膀胱颈尿道时,勿损伤其5、7点位的神经。术中寻找上述标志,最大程度保留组织,为减少术后并发症提供了参考。     

男性盆丛解剖标志在下尿路手术中的意义

为探寻下尿路手术中避免损伤盆丛的解剖标志，对１０个盆腔器官标本作盆丛大体解剖或大切片，观察盆丛与盆腔器官的毗邻关系，结果表明，盆丛位于直肠的前外侧，精囊腺的后外侧，在前列腺基底部与前列腺外侧的血管形成神经血管束，于尿道感染部的外侧和后外仙穿过尿生殖膈，认为精囊腺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，文中还对盆丛的解剖分布及其与医源性阳萎的关系进行了讨论。     

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。     

精囊周围血管神经的临床解剖学研究

目的:研究精囊周围血管神经的精确定位,为行精囊微创手术提供解剖学依据。方法:解剖20具成年男性尸体骨盆标本,观察精囊周围血管神经的走行和分支,测量神经丛的定位数据。结果:精囊神经丛一部分随神经血管束从两侧分布至精囊,距前列腺后正中沟的最近距离为(2.85±0.18)cm;另有一部分行于Denonvillier筋膜中,分支至精囊后方,距前列腺后正中沟的最近距离分别为(0.81±0.06)cm。精囊动脉发自膀胱下动脉后分为4型:1支主干直接至精囊的为55%;1支主干至精囊与输精管壶腹之间的为15%,分2支主干的为25%,其中1支至精囊,另1支至精囊与输精管壶腹之间,其他占5%。自精囊动脉穿过前列腺神经丛后至精囊后外方的最近距离为(1.08±0.09)cm。结论:术中分离精囊时的距离,两侧2.85 cm、后方0.81 cm时可减少神经丛的损伤;在精囊后外方以及精囊与输精管壶腹间结扎血管可减少出血。     

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。     

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。     

保留生育能力的膀胱切除和回肠成形术:一项长期随访结果

保留神经的膀胱前列腺切除术维持患者勃起功能的有效率大约在 5 0 % ,对于性功能正常的年轻男性患者来说 ,这种根治性手术值得推荐。作者报道了采用改良的膀胱全切和膀胱代替术式维持患者性功能 ,保留生育能力的 13年研究经验和结果。保留生育能力的膀胱全切为标准膀胱根治手术的改良方式 ,即先游离膀胱后壁 ,再处理精囊两侧 ,保留精囊、输精管、前列腺包膜及其血管神经束。此种手术可以保证切除完整的膀胱、前列腺尿道及周围增生组织 ,并可避免损伤支配阴茎海绵体的盆腔神经束。1990年 4月至 2 0 0 2年 10月 ,共有 6 8例患者采用此种术式行…     

全直肠系膜切除术中保留男性盆腔自主神经的解剖基础

目的 探讨成年男性盆腔自主神经的筋膜层次及其解剖标记,明确全直肠系膜切除术中保留男性盆腔自主神经的解剖基础.方法 对12具男性尸体盆腔(24侧半盆腔)进行解剖.结果 盆腔自主神经走行筋膜层次为:腹下神经走行于脏筋膜后叶内,盆丛位于膀胱腹下筋膜与脏筋膜间,精囊前列腺分支位于Denonvilliers筋膜前侧方.骶骨岬、输...     

保留性神经血管束的手术

经典的前列腺癌根治术和根治性全膀既切除术后，性功能的恢复率一般只有0％～10％。1982年，Walsh等“‘研究了这一现象，并指出这两种手术高发阳萎的主要原因是术中损伤了盆丛及支配阴茎海绵体的神经。Walsh等对胎儿的性神经显微切片，特别是对支配阴茎海绵体血管神经的走行作了精细的观察，建立了详细的海绵体神经行程的三维模型。根据这一研究，他们推测术中损伤性神经的主要原因是：①在切除前列腺及其邻近的组织过程中，以及在分离前列腺的侧方或膀跳底部时损伤了盆丛；②在切断前列腺的尖部和横断膜部尿道时，损伤了神经血管束。因此…     

保留海绵体神经血管束的根治性膀胱切除术（附13例报告）

为了提高保存性功能的膀胱癌根治术的手术效果，自１９９０年５月至１９９４年８月，对１３例膀胱癌患者进行了保留海绵体神经血管束的根治性膀胱切除术。患者年龄３１～７２岁，术前性功能正常，术后随访６～５６个月，平均１９个月，１１例阴茎勃起恢复，可以性交，２例有勃起但不能达到性交。手术的关键是：（１）于精囊三角处切开膀胱直肠筋膜，在该筋膜前钝性分离至前列腺尖部，将海绵体神经血管束向外侧推开；（２）紧贴精囊和前列腺，切断精囊门的血管蒂、前列腺上蒂和下蒂。本组１３例均有勃起，２例不能达到性交可能与老年有关     

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.     

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.     

Multiple vasodilator pathways from the pelvic plexus to the penis of the rat.

The main penile or cavernous nerve is usually regarded as the most important vasodilator projection in the rat. Although other descending pathways have been described, there is little detailed information on their importance. In this present report, we provide topographic and quantitative information on lateral and ventral penile branches and examine the vasodilator fibers which join the pudendal neurovascular bundle. Seventeen Sprague-Dawley rats were used. The techniques included injection of dye in the penis to label neurons in the pelvic plexus in combination with transection of the main penile nerve (MPN). NADPH diaphorase (NADPH-d) histochemistry was used to assess the effects of transection of vasodilator pathways on innervation of the penis and for in situ staining of the pelvic plexus. Distinct clusters of penile neurons are aggregated at the origin of several nerve tracts leaving the posterior margin of the major pelvic ganglion (MPG). Multiple NADPH-d+ fiber bundles coursed over the anterior surface of the prostate to reach the penis. Branches from these tracts joined the pudendal neurovascular bundle proximal to the hilum of the penis and provided innervation to the artery throughout its course in the pudendal canal. Consistent with the presence of multiple penile pathways, transection of the MPN reduced, but did not eliminate retrograde labeling of penile neurons in the MPG and only modestly decreased NADPH-d+ fibers in the penis. This study confirms that there are multiple pathways by which vasodilator fibers reach the penis. If a similar allocation of vasodilator output is present in man, preservation of finer branches of the pelvic plexus would be important in surgical procedures on the prostate.     

前列腺癌患者根治术后尿失禁的预防

目的探讨保护尿道膜部括约肌和神经血管束及重建膀胱颈部对前列腺癌根治术后尿失禁的预防作用。方法对32例前列腺癌采用保护尿道膜部括约肌和前列腺旁神经血管束,并在重建膀胱颈部黏膜充分外翻后的后壁行折叠缝合1针的方法,进行前列腺癌根治术,观察术后尿失禁发生情况。结果经6～72个月随访,全部患者排尿通畅,无肿瘤复发,除2例发生轻度尿失禁外,其余30例在6个月内均恢复尿控能力。结论保护尿道膜部括约肌和前列腺旁神经血管束,在充分外翻膀胱黏膜的重建膀胱颈后壁折叠缝合,能减少前列腺癌根治术后尿失禁的发生。     

Imaging the cavernous nerves in the rat prostate using optical coherence tomography

INTRODUCTION: Improvements in identification, imaging, and visualization of the cavernous nerves (CNs) during radical prostatectomy, which are responsible for erectile function, may improve nerve preservation and post-operative potency. Optical coherence tomography (OCT) is capable of real-time, high-resolution, cross-sectional, in vivo tissue imaging. The rat prostate serves as an excellent model for studying the use of OCT for imaging the CNs, as the rat CN is a large, visible, and distinct bundle allowing for easy identification with OCT in addition to histologic confirmation. MATERIALS AND METHODS: Imaging was performed with the Niris OCT system and a handheld 8 Fr probe, capable of acquiring real-time images with 11-microm axial and 25-microm lateral resolution in tissue. Open surgical exposure of the prostate was performed on a total of six male rats, and OCT images of the prostate, CN, pelvic plexus ganglion, seminal vesicle, blood vessels, and periprostatic fat were acquired. CN electrical stimulation with simultaneous intracorporeal pressure measurements was performed to confirm proper identification of the CNs. The prostate and CNs were also processed for histologic analysis and further confirmation. RESULTS: Cross-sectional and longitudinal OCT images of the CNs were acquired and compared with histologic sections. The CN and ganglion could be differentiated from the surrounding prostate gland, seminal vesicle, blood vessels, bladder, and fatty tissue. CONCLUSIONS: We report preliminary results of OCT images of the rat CNs with histologic correlation and erectile stimulation measurements, thus providing interpretation of prostate structures as they appear in OCT images.