【探秘】前列腺应用解剖精粹（二）.docx

【探秘】前列腺应用解剖精粹（二）编者按在过去的几十年中，随着对前列腺解剖认识的不断加深以及手术技术的飞速发展，前列腺癌手术治疗的肿瘤控制和功能结果得到了显著改善。为帮助泌尿科医生了解根治性前列腺切除术涉及的解剖结构，并正确应用其中的命名术语，EuropeanUro1.ogy杂志发文（PMID:19931974）对前列腺及其周围结构作了详细描述。本专栏对原文作了编译，并对原文图片作了高清化和中文标注。全部内容分为3期，本文为第二期，介绍前列腺周围筋膜（前列腺后方筋膜即Denonvi1.1.iers筋膜）、前列腺筋膜与神经血管束的关系、前列腺包膜、神经血管束（NVB）.因译者水平有限，译文难免存在不准确的地方，欢迎各位同道指正.O1.Posteriorprostaticfasciaandsemina1.vesic1.esfascia（Denonvi1.1.iersfascia）（前列腺后方筋膜和精囊筋膜（狄氏筋膜）前列腺和精携的后表面被一层连续的前列腺后方筋膜（PPF）和精囊筋膜（SVF）紧密覆盖，也被称为直肠前列腺筋膜、直肠膀胱隔、前列腺精囊筋膜和众所周知的狄氏筋膜（图1,2和7）。一些作者认为pPF/SVF起源于膀胱后穹隆处胚胎腹膜的融合.另有人认为pPF/SVF实际位于两层腹膜融合后残余物的前方,两层腹膜融合后使得后方的直肠固有筋膜与前方的pPF/SVF之间形成直肠前分离平面.pPF/SVF头侧起源于腹腔尾端（直肠膀胱陷凹，图2）的前方。然后pPF/SVF向远端延伸至前列腺尖部，终止于前列腺尿道交界处，形成一个与会阴中心腱连续的终板。它由胶原纤维、弹性纤维和大量肌纤维构成，有着从易碎的半透明膜到致密的单层膜的变化。常提到的pPF/SVF的后层实际是直肠固有筋膜，它是独立于pPF/SVF的结构。pPF/SVF通常在前列腺的后表面中央与前列腺包膜融合.在前列腺的后夕网，pPF/SVF与前列腺包膜没有明显附着，在pPF/SVF与包膜之间的间隙内填充着网状组织和NVBe02Re1.ationshipbetweentheprostaticfasciasandthe于S2-4腹支的盆腔和舐内脏神经。在海绵体中，这些神经主要负责勃起时血管扩张和动脉血流增加。盆腔神经丛的密集神经网络位于膀胱与直肠之间呈矢状走行的扁平状矩形纤维-脂肪层内。泌尿生殖道的神经分支走行在膀胱和膀胱颈的外侧并向尾侧延伸。盆腔神经丛的前部发出膀胱、前列腺、精囊和输精管的神经纤维，下半部发出负责勃起功能的海绵体神经.盆腔神经丛的纤维以笼状围绕膀胱颈、前列腺近端和精囊的外侧，而在这些器官的前表面，神经纤维相对较少（图2,5,7,8）。这些神经纤维有些是微观的，在手术中无法被识别。然而在根治性前列腺切除术中，具有光学放大作用的手术技术能够更好地识别这些结构。尽管这些神经的确切作用尚不清楚，但很可能是直接支配这些器官.Coste1.1.o等指出，这些走行至尿道括约肌、被命名为"海绵体神经”的分支主要位于盆腔神经丛的后部.它们位于精囊的后外侧，靠近精囊顶端走行。在根治性前列腺切除术中轻柔地游离精囊或采用保留精度的技术可以减少损伤这些神经的风睑，以改善术后尿控和勃起。据报道，这些神经与下列解剖标志的距离为：与精现直接接触（Omm）,距膀胱颈4mm,映琥肌2mm从这开始，海绵体神经和盆腔神经丛继续向尾侧走行，距前列腺血管蒂外侧仅0-7mm.这些神经纤维往往保持微观，并伴有血管结构，这就是为什么将该复合体称为NVB.该神经束不仅包含支配阴茎海绵体的神经纤维，还包含支配前列腺和尿道括约肌的神经纤维。从前列腺基底部到尖部，NVB的血管分出终末支穿透前列腺包膜，将NVB与包膜固定.前列腺外侧的神经解剖可能会有很大变化。Mu1.1.er的最初报告描述了位于前列腺后夕Mi1.厢前外侧的神经。Wa1.sh和Donker随后描述了位于前列腺后外侧的明显的NVBe最近的研究表明，该区域的神经解剖存在差异。Takenaka等证实了如Mu1.1.er最初描述的那样，神经在前列腺的外侧和前外侧表面呈喷雾状分布，并得出结论，NVB不是一个明显的结构，而是由许多细微分散的纤维组成.1.unacek等发现,NVB在妊娠腑台期发育为明显的结构,随后在前列腺发育时分散在前列腺外表面。他们还证实了前列腺增生的进展大大增加了神经在前列22 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MyersRRMa1.eurethra1.Sphinctericanatomyandradica1.prostatectomy.Uro1.C1.inNorthAm1991;18:211-27.118 1.eeSE,ByunSS,1.eeHJ,eta1.Impactofvariationsinprostaticapexshapeonear1.yrecoveryofurinarycontinenceafterradica1.retropubicprostatectomy.Uro1.ogy2006;68:137-41.译者简介王冬医学硕士，主治医师。现就职于陕西中医药大学附属医院。陕西省中西医结合学会泌尿外科专委会、男科专委会委员。在西安交通大学第二附属医院学习泌尿外科内腔镜技术。在中山大学附属第六医院学习层面外科学相关理论及技术。在北京大学第一医院完成泌尿外科及男科专科医师培训.科普专栏作者，泌尿外科医生学习联盟通讯编委.在社交媒体撰写专业文章10余篇，总UV量超过10万人次。