女性原位尿流改道控尿机制的基础研究及临床应用

目的探讨女性控尿解剖形态机制，并与女性原位尿流改道临床应用相结合，以进一步指导女性原位尿流改道的研究和临床推广工作。方法（1）对20具成人女性尸体进行盆丛及其分支，主要是尿道支、阴部神经及其尿道支的解剖。（2）解剖出完整的尿道及周围的肌肉等进行病理学HE染色、肌肉染色、结缔组织染色、银染等。（3）对20例正常控尿女性的下尿路、盆底的MRI矢状位、冠状位及横截位扫描，观察控尿有关的组织形态及其变化。（4）结合上述基础研究的结果，总结、分析40例女性原位尿流改道患者的控尿情况、并发症等临床问题。结果（1）盆丛分支有直肠丛、阴道丛、膀胱尿道丛，阴道丛分支到膀胱颈、尿道，在阴道、膀胱颈两侧走行，约在尿道的5、7点进入尿道；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，距膀胱尿道连接部外约0．5—0．7cm，约在10～11、1～2点处进入尿道。阴部神经尿道支主要由其终末支发出，在耻骨联合下缘正对处的11、2点位置进入尿道。（2）病理结果表明，横纹肌主要位于尿道远端2／3，与盆底肌肉并不相连，主要包饶尿道，部分肌肉在远端还同时包饶阴道。对完整下尿路的大块组织切片HE染色、肌肉染色、结缔组织染色、银染等显示：神经分布在尿道的肌肉之间，横纹肌分布于尿道中外2／3的尿道，内中1／3交界处与平滑肌混杂存在，在外1／3有横纹肌包饶阴道。（3）MRI可清楚显示与控尿有关的盆底肌肉；正常控尿女性膀胱颈子宫口位于齿尾线以上。（4）上述基础研究与40例临床应用相结合表明，女性控尿主要由横纹括约肌完成，此肌肉主要由阴部神经支配，术中注意该肌肉的保护，女性同样可以获得理想的控尿效果。结论女性控尿的主要因素是受阴部神经尿道支和盆丛分支?

The basic and clinical study of female urinary continent mechanism in female orthotopic urinary diversion

Objective To study the morphological mechanism of female urinary continence and the clinical applied effects in female orthotopic urinary diversion. Methods （1） The gross anatomy had been done on 20 female cadavers. In each cadaver, to investigate the pelvic autonomic nerve and pudendal nerve to urethra, including the composing, distributing, dominating range and the point to the urethra. We also studied the composing, morphologic and component of urinary continent muscles. （2） We collected the lower urinary specimens for histologie examination. Longitudinal and transverse sections made from the specimens were stained with hematoxylin-eosin, PTAH, modified Bielschowsky and Masson＇s trichrome. （3） MRI was applied for 20 normal continence women to investigate the urethra, the urinary continent muscles, and so on. （4） Based on the basical study, the clinical effects of orthotopic urinary diversion in 40 women were also analyzed. Results （1） The pelvic plexus sent the bundles to rectum, vagina and the urinary, bladder-urethra. The vagina sent the bundles to the urethra and going into urethra just at 5 and 7 o＇clock. The bundles to urethra went along the side of pelvis and into urethra at 10 - 11 and 1 - 2 o＇clock. The terminal branches of the pudendal nerve, some of clitoris dorsal nerve were found to run to the urethra at 11 and 2 o＇clock, just under the lower side of pubic symphysis. （2） In histology, the urinary sphincter muscles located mainly in the outside 2/3 of urrethra and didn＇t coalesce with the pelvic floor muscles.The smooth muscle distributed the whole urethra, the sphincter distributed the outsidet 2/3 urethra and wrapped the vagina in the outsight 1/3 of urethra. In the inner-middle urethra, the smooth muscle and sphincter were intermingled. （3） The urinary continence muscles were visible easily in MRI, and the bladder neck and the cervix were above the pubis-coecygeal line in normal women. （4） In clinic, the results of female orthotopic urinary diversion were