LRP相关前列腺周解剖及临床应用
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摘要
迄至目前,普遍认为局限性前列腺癌的治疗仍以根治性前列腺切除术最为有效。而过去的三十年,前列腺癌根治手术的方法发生了非常大的变化,经历了开放性手术、各种入路的腹腔镜手术、以及日益兴起的机器人辅助手术。在我国,经过广大泌尿外科医师的努力,10年来,腹腔镜前列腺癌根治术总体上已积累有相当数量的病例,不少操作步骤得到了规范。推动手术进步的不仅有新医疗设备的积极应用,也依赖对前列腺周解剖结构的深入了解。正如Robert P. Myers所言：熟悉解剖的外科医生,可以给患者以更少的出血、更好的切缘、更多的功能保存。
然而,前列腺及其周围盆腔解剖结构相当复杂。首先,男性骨盆本身因个体不同而有显著差异,骨盆宽则前列腺易于到达；骨盆窄深,前列腺处的操作不易进行,特别在施行神经保留与膀胱尿道重建步骤时。其次,前列腺的神经血管复合体、以及前列腺周筋膜结构变化很大,有些解剖结构还存在不同的命名,如狄氏筋膜(Denonvilliers fascia)解剖学上定义为“介于前列腺与直肠间紧贴前列腺之后的结构(Between prostate and rectum, adherent to prostate posteriorly) ",在不同文献中就至少有直肠膀胱隔(Rectovesical septum)、前列腺直肠隔(Prostaterectal fascia)、直肠生殖器筋膜(Rectogenital fascia)等三个名称。
另外,虽说现有的LRP手术延长了患者的生存期,但从控尿功能保护、勃起功能恢复、以及尽量减少并发症的目的而言,需要明确的局部解剖、需要优化的手术操作并不少。为此,本研究拟采用固定尸体、活体腹腔镜来研究LRP手术相关解剖结构,重点研究LRP分离层面上的筋膜解剖、组织间隙、勃起相关神经走行、控尿相关解剖、以及LRP术中解剖标志和相关手术技巧。
第一章LRP相关前列腺周筋膜的应用解剖学研究
目的：阐明腹腔镜前列腺癌根治术时所经过的前列腺周围筋膜结构的组织学特征以指导前列腺癌根治术。
方法：
1、采用本科生局部解剖学课结束后遗留10%福尔马林固定、骨盆完整男性尸体24具,打开骨盆后,按前列腺前方、侧方、侧后方、后方的顺序进行解剖,重点观察耻骨前列腺韧带、前列腺筋膜、狄氏筋膜、盆筋膜等结构。
2、对4个腹腔镜膀胱癌根治性全膀胱切除术后膀胱、精囊、前列腺完整保留新鲜组织标本进行研究,重点观察膀胱后壁与精囊之间组织结构、Denonvilliers筋膜与腺体联系情况,作筋膜与其内面腺体组织学切片观察。
结果：
1、Denonvilliers筋膜可分为纤维膜性的前叶和脂性的后叶。
2、射精管以下,DF前叶致密似皮革样15例(62.5%),薄弱似膜状9例(37.5%)；筋膜前叶可自腺体表面剥离至尖部者18例(75%),无法在不损害腺体组织的情况下完整剥离筋膜者6例(25%),所有DF前叶均于膜部尿道处与直肠尿道肌紧密粘着。
3、Denonvilliers筋膜前叶在膀胱直肠陷凹(Douglas窝)之下,将此处分为易于剥离的两个层面：“精囊后隙”与“直肠前隙”
4、前列腺侧后方筋膜与前列腺包囊之间的间隙变化较大,24例尸体标本中14例(58.3%)包囊与筋膜间较为疏松,10例(41.7%)筋膜与包囊紧密联系,但仍可以在不损伤腺体的情况下剥除筋膜。
5、前列腺侧前方筋膜向前列腺腹侧(前方)移行、延续时与其内面包囊逐渐融合,很难或无法剥离。
6、耻骨前列腺韧带耻骨端平均宽6.9mm；前列腺附着处较宽,平均宽12.5mm；中间平均宽5.3mm；韧带中央厚约2mm,由坚韧的结缔组织束构成。
7、耻骨前列腺韧带不是耻骨后间隙联系耻骨骨膜与泌尿生殖系脏器的唯一结构,在坚韧的耻骨前列腺韧带上、下方均有稀疏的耻骨膀胱韧带及耻骨尿道韧带联系相关脏器。
8、在新鲜组织标本上,前列腺包囊在前列腺侧后方可被分离出。
结论：
1、前列腺周筋膜结构及其与腺体之间的间隙变化很大,循某些平面可相对轻易地分离前列腺。
2、有必要对在前列腺筋膜与盆壁筋膜这互相移行的结构之间穿行的神经、血管走行进行基于手术需要的进一步解剖学研究。
第二章LRP术后勃起功能相关神经的应用解剖学研究
目的：基于目前实际开展的LRP手术所能达到的精度,结合最大限度保存NVB及CN的理念,对相关神经的应用解剖学进行研究。
方法：
1、肉眼观察24例男尸盆腔脏器标本精囊及其以下血管神经束的走行、其内神经血管的伴行关系；贴前列腺表面分离,记录神经、血管束走行及与前列腺筋膜(Prostate fascia, PF)的关系。测量NVB距前列腺底部、中部、尖部的距禺。
2、2具完整男性骨盆标本,肉眼观察骶尾椎前神经血管组织、盆丛和前列腺外侧NVB。显微镜下解剖观察前列腺外侧NVB。
结果：
1、关于神经血管束中神经的走行,可以观察到两种情况：(1)神经与血管伴行于前列腺后外侧,逐渐变细走向前列腺尖部,这种情况在24具尸体中有16(2/3)例出现；(2)神经束于前列腺底部分成两支,一支走行情况如“(1)”所描述,一支走向前列腺腹侧,向尖部逐渐变细,但不越过耻骨前列腺韧带外侧缘,两支神经束之间无神经分布,出现出现这种情况的比例为1/3。
2、神经血管束在同一具尸体标本上走行情况相同,即一侧NVB中神经单支出现,对侧观察到也是单支；一侧NVB中神经出现两支,对侧观察到也是两支。
3、后外侧神经血管束很容易在不伤及前列腺体或包囊的前提下游离开,前外侧的神经纤维与前列腺包囊(Capsule)之间几无间隙,不易分开。
结论：
1、神经血管束中神经走行变异很大,决定了保留神经的LRP手术在部分病例中具有不明确的效果。
2、把NVB经过前列腺的部分看成有着独立神经筋膜层的结构,有助于手术中对相关分离层面的理解。
第三章LRP相关控尿功能的应用解剖学研究
目的：通过观察与LRP手术尿控相关的重要解剖学结构,再模拟相关手术入路,明确这些重要结构与尿控的关系。
方法：10%福尔马林固定男性尸体2具,重点观察与手术有关的尖部解剖,如前列腺尖、膜部尿道交汇处周围肌性及纤维性结构,尿道角度维持相关筋膜等。
结果：
1、前列腺尖部及膜部尿道交汇处覆盖一层致密的纤维组织膜,此筋膜移行自盆膈上筋膜。
2、前列腺尖约3-5mm及其以下膜部尿道周围包绕肌性结构,前方较为韧厚、后方相对薄弱,肌组织可自前列腺尖部钝性剥离开。
3、将前列腺尖部前方的筋膜结构去除,模拟LRP手术,发现要完成在前列腺尖部以下不损伤其周围肌性组织、垂直断开尿道有一定难度。
4、观察到同一具标本,前列腺尖部以下、盆膈以上尿道前后面可以暴露的长度并不相等。将前列腺向前上方上提后,膜部以上尿道更易于剪切。
结论：
我们认为LRP术中在分离前列腺及其周边组织时,以下技巧有助于术后尿控：1、尽量沿精囊腺、前列腺表面分离Denonvilliers筋膜至耻骨直肠肌表面；2、自后向前横断尿道视野相对清晰、角度自下而上,有利于保留足够长的尿道；3、向头侧牵拉前列腺紧张膜部尿道后,有助于增下其下方尿道暴露,易于横断；4、前列腺尖与尿道交汇处横纹括约肌在前列腺周围的厚薄不一,于前方及两侧方钝性分离前列腺尖可避免损伤横纹括约肌。
第四章LRP术中前列腺前方静脉丛控制的解剖学研究
目的：通过模拟LRP手术在前列腺前方经过的层面,进一步探索处理前列腺前方血管的有效方法
方法：2例男尸盆腔标本,观察耻骨前列腺韧带与耻骨骨膜及前列腺附着处情况,于其中段最狭窄处自上而下依次剪断韧带纤维,切开前列腺两侧盆壁筋膜,增加前列腺的游离度,将其压向后方,显露前列腺尖及盆膈以上尿道。模拟LRP手术对此处的处理方法,观察其效果。
结果：
1、耻骨前列腺韧带张力很大。
2、前列腺两韧带之间的“前列腺浅表静脉”,较长较粗。
3、耻骨前列腺韧带以下,完全拨开前列腺之前疏松组织后,亦无法清晰辨认前列腺前部静脉丛。
4、尿道处静脉与尿道壁组织附着程度不如前列腺部紧密,相对疏松些。但静脉浅面的筋膜结构致密、坚韧,与静脉丛难以分开。
结论：前列腺前方静脉丛解剖结构相对复杂,LRP术中通常采用的缝扎法未必可靠。
第五章LRP术中解剖标志及手术技巧
目的：对LRP相关手术录像进行基于解剖学的研究,旨在寻找手术中的解剖学标志,探索手术技巧和制定手术操作的相关指南。
方法：2010年10月至2011年3月,我科所有多孔(本组5孔,同期实施的单孔LRP手术不在此列)LRP手术完整录像16例。重点观察经腹膜外腹腔镜下前列腺癌根治术(Endoscopic Extraperitoneal Radical Prostatectomy, EERPE)的以下环节：1、腹膜外耻骨后间隙的建立；2、盆腔淋巴结清扫；3、膀胱颈切开及颈口处理；4、精囊腺、输精管的游离；5、Denonvilliers筋膜间隙的分离；6、前列腺筋膜和盆壁筋膜以及在两者之间的切开；7、耻骨前列腺韧带的处理；8、前列腺前部、盆膈以上尿道部静脉的处理；9、前列腺尖部处理及剪断尿道。重点探讨：1、如何避免损伤直肠；2、如何保存控尿相关机制；3、如何有效控制DVC,避免大量出血；4、如何保存NVB。
结果：
1、盆腔淋巴结清扫须注意旋髂动静脉。
2、膀胱颈循前外侧、前面、后面的顺序分离切开。
3、循精囊后隙下分,相对容易。
4、狄氏筋膜两叶间分离较易,贴前叶之前分离未必成功。
5、前列腺侧面经过的层面不同,其间走行的NVB保存程度不同。
6、在现有普通LRP手术条件下,要将前列腺筋膜完整自前列腺表面剥离开,几乎是不可能的；但在前列腺表面的某些区域,前列腺筋膜是可以剥离的。
7、耻骨前列腺韧带与DVC的处理可以贴前列腺前表面走行,且不必缝扎DVC。
8、先断尿道后壁比先断尿道前壁有利。
结论：
LRP手术的某些步骤有进一步改良的空间。
Radical prostatectomy (RP) is the only primary treatment modality of localized prostate cancer (PC) that has proved its effectiveness against other ways. During the last three decades, the surgical treatment of prostate cancer has changed remarkably, The 3 main ways are open radical prostatectomy, laparoscopic prostatectomy and Robotic assistant prostatectomy. In our country, with all the urologists' hard working, we have had a quite large quantitative cases, many operative procedures have been standarded. What made the surgery progress were not only the new medical instruments but also the understanding of periprostatic anatomy. As Robert P. Myers said: In general surgeons who know the anatomy protect the patient by virtue of less blood loss, better margins of resection and greater functional preservation.
The periprostatic anatomy is quite complicated. One aspect that is crucial to the understanding of the complex anatomy of the male pelvis is its significant individual variation. Some pelves are wide, making the prostate easily accessible, whereas other pelves are deep and narrow, complicating the access to the prostate particularly at the moment of performing a nerve-sparing surgery or a watertight urethrovesical reconstruction. The neurovascular structures surrounding the prostate may also vary from patient to patient, and the surgeon should be ready to understand those variations in order to tailor the surgical technique to the intraoperative findings Some anatomic structure have different names, Such as Dononvillier's fascia has at least the other 3 names:Rectovesical septum, prostaterectal fascia and rectogenital fascia.
Though many patients get a quite long life span after the LRP operation, We still have a long way to go in order to give the patients a good urinary continence and erectile function. In the following studies, the regional anatomical observation on fixed cadaver, we will primarily focus on the understanding of the periprostatic fascial anatomy and the different extents of neurovascular bundle dissection in relation to the location and distribution of the cavernous nerves. Also, we provide an overview of the configuration of the urinary sphincter and its supporting structures. Then, we will study the operation skill in LRP.
Chapter 1 Applied anatomy study on the LRP correlative periprostatic fascia
Objective:To study the periprostatic fascia relate to the LRP operation.
Methods:
1.24 fixed male cadavers with integrated pelvis were dissected and observed, The anatomical sequence was from the anterior aspect of the prostate to side, and then to rear. The observative emphasis were puboprostatic ligament, prostatic fascia, Denonvillier's fascia and pelvic fascia.
2.4 organ specimen with bladder, seminal vesicles and prostate integrated after the laparoscopic radical resection of the bladder. The tissues between posterior wall of urinary bladder and seminal vesicles, the tissues between prostate and Denonvillier's fascia were studied.
Results:
1. The Denonvilliers' fascia has two layers:the fibromembranous anterior layer and the lipoid posterior layer.
2. Below ejaculatory ducts, the anterior layer are variety:15 cases (62.5%) like the leather,9 cases(37.5%) like the membrane; The frontier layer can be stripped from the surface of the prostate in 18(75%) case, Can not be stripped without damaged the gland tissue in 6(25%) cases. All the anterior layer tightly adhere to the rectourethral muscle in membranous urethra.
3. The area below Douglas were divided into 2 loosened planes:"the gap behind seminal vesicles" and "the front gap of rectum".
4. The interspace between prostatic between prostatic capsule and lateral fascia changed comparatively large, The interface was loosening in 14 cases and tightly contacted in 10 cases, the tight ones'fascia can not be dissected without prostate damaged.
5. From lateral to anterior surface, the prostatic fascia can not be dissected from the capsule.
6. The average breadth of the puboprostatic ligament in pubis part was 6.9mm, in prostate part was 12.5mm; the middle part was 5.3mm; the center was 2mm thick. The puboprostatic ligament composed of tough connective tissue.
7. The puboprostatic ligament is not the only constitution contact pubis periosteum and urogenital system organs in the retropubic space. There are puborectal ligament upper and pubourethral ligament under the tough puboprostatic ligament.
8. In the fresh specimen, prostate capsule can be dissected on the lateral surface.
Conclusions:
1. The interspace between prostate and the periprostatic fascia is changed, Along some plane can dissect swimmingly.
2. On account of the demand of surgery, We need further anatomic study on the nerve and blood vessel between prostatic fascia and parietal pelvic fascia.
Chapter 2 Applied Anatomic study on erection functional related nerve
Objective:Based on the accuracy of the practical LRP and the idea of preserve NVB and CN utmostly, To clarify the correlated nerve anatomy.
Methods:
1.24 fixed male pelvic specimens were dissected and observed, The courser of the NVB below the Seminal Vesicles was noted, The distance between prostate and the NVB was measured.
2.2 Integrity android pelvis, The nerve and blood before Sacrococcygeal vertebrae were visual studied.
Results:
1. The nerves running in the neurovascular bundle have two states:(1) The neurovascular bundle of the prostate descends along the postero-lateral border of the prostate, taper to the apex of prostate gland. This kind of circumstance happened in 16 cases; (2) The neurovascular bundle fall into two branches at the base of prostate, one branch run as (1), the other branch run to the front of the prostate, taper to apex of prostate gland at the lateral of the puboprostatic ligament. This kind of circumstance happened in 8 cases.
2. The bilateral neurovascular bundles have the same distribution, that mean neurovascular bundles symmetric distributed.
3. The posterior-lateral neurovascular bundle can be easily dissected. The anterior-lateral nerve adhered tightly to the capsule can not be separated easily.
Conclusions:
1. The neurovascular bundles have different distribution in different cases, This may cause a indefinite nerve preservation effect in some patients.
2. Look the NVB as a independent nerve fascia layer structure, may make for the understanding of the relevantly structure.
Chapter 3 Applied Anatomic study on urinary continence following LRP
Objective: To investigate the relationship between some important urinary continence related anatomy and LRP.
Methods:2 fixed male hemi-pelvises removal of the ilium were dissected and observed.
Results:
1. The apex of the prostate and membranous urethra were covered a pyknotic fibrous tissue membrane, this fascia transferred from superior fascia of pelvic diaphragm.
2. The 3 to 5mm apex of the prostate and the below membranous urethra are surround by musculature with a thick anterior part and a weak posterior part, the musculature can be dissected easily.
3. Simulated the operation of LRP, We found it was hard to cut the urethra perpendicularly without damage the musculature of the prostate apex.
4. In a same specimen, the length of the anterior and posterior urethra above the pelvic diaphragm is not the same. Drag the prostate to anterosuperior, the urethra above pelvic diaphragm will be cut easily.
Conclusions:
We think the following technique make for urinary continence after LRP:1. Try to dissect Denonvilliers' fascia to the surface of musculus puborectalis along the surface of seminal vesicle and prostate; 2. Transect the urethra from rear to the anterior surface, Which may reserve enough urethra; 3. Drag the prostate to the headward will help to transect the urethra; 4. Sphincter around periprostate has different thickness in different part, Dissection bluntly the apex of prostate may refrain from damage the sphincter.
Chapter 4 Anatomic study of Dorsal vein complex relate to LRP
Objective: To explore the modus operandi in deal with Dorsal vein complex.
Methods:2 fixed male pelvic specimens, Observed the puboprostatic ligament adhesive situation, cut the PL from upper to below from the midpiece, cut the lateral pelvic fascia, Press the prostate to rearward. Simulate the handling way in LRP, observe the effects.
Results:
1. The puboprostatic ligament has a large tension.
2. The prostate superficial vein between the two PLs is quite long and large.
3. Below the PL, It is impossible to distinguish the DVC even after push aside all the areolar tissue.
4. The vein on anterior surface of the urethra has a loosening attach to urethra, but the fascia of DVC can not be dissected.
Conclusions:The anatomy of DVC is quite complicated, transfixion way often used in LRP may not always safe.
Chapter 5 Laparoscopic anatomic and Surgery skill study on LRP
Objective:To observe the anatomical features of the LRP endoscopically in living bodies and find proper anatomical landmarks in LRP and provide the theory guidance for the LRP.
Methods:The LRP of 16 prostate cancer were observed and analyzed. Emphasis observation the following component elements: 1. Set up extraperitoneal; 2.Pelvic cavity lymph nodes resection; 3.Resection of the neck of bladder and deal with the neck; 4. Dissociation of the seminal vesicle and Deferentia; 5. Dissociation of the Denonvilliers'fascia; 6. Dissection between fascia prostatae and parietal pelvic fascia;7. Deal with puboprostatic ligament; 8. Deal with DVC; 9. Deal with the apex of prostate and cut the urethra.
Results:
1.Pay attention to circumflex iliac vein and circumflex iliac artery.
2.Resection of the bladder neck from anterolateral to frontal to posterior.
3. It is relatively easy dissection along the gap in rear of Seminal Vesicles.
4. It is easy to dissection along the gap of the two Denonvilliers'fascia layers, It is not always succeed before the anterior layer.
5. Dissection though different plane have different NVB preservation level.
6. Only part prostate fascia can be dissected from the surface of prostate during LRP
7. We may deal with PL and DVC along the surface of prostate and need not transfixion of DVC.
8. We may dissect the posterior wall prior to anterior wall of the urethra.
Conclusions:Some steps of the LRP may have further improve.
然而,前列腺及其周围盆腔解剖结构相当复杂。首先,男性骨盆本身因个体不同而有显著差异,骨盆宽则前列腺易于到达；骨盆窄深,前列腺处的操作不易进行,特别在施行神经保留与膀胱尿道重建步骤时。其次,前列腺的神经血管复合体、以及前列腺周筋膜结构变化很大,有些解剖结构还存在不同的命名,如狄氏筋膜(Denonvilliers fascia)解剖学上定义为“介于前列腺与直肠间紧贴前列腺之后的结构(Between prostate and rectum, adherent to prostate posteriorly) ",在不同文献中就至少有直肠膀胱隔(Rectovesical septum)、前列腺直肠隔(Prostaterectal fascia)、直肠生殖器筋膜(Rectogenital fascia)等三个名称。
另外,虽说现有的LRP手术延长了患者的生存期,但从控尿功能保护、勃起功能恢复、以及尽量减少并发症的目的而言,需要明确的局部解剖、需要优化的手术操作并不少。为此,本研究拟采用固定尸体、活体腹腔镜来研究LRP手术相关解剖结构,重点研究LRP分离层面上的筋膜解剖、组织间隙、勃起相关神经走行、控尿相关解剖、以及LRP术中解剖标志和相关手术技巧。
第一章LRP相关前列腺周筋膜的应用解剖学研究
目的：阐明腹腔镜前列腺癌根治术时所经过的前列腺周围筋膜结构的组织学特征以指导前列腺癌根治术。
方法：
1、采用本科生局部解剖学课结束后遗留10%福尔马林固定、骨盆完整男性尸体24具,打开骨盆后,按前列腺前方、侧方、侧后方、后方的顺序进行解剖,重点观察耻骨前列腺韧带、前列腺筋膜、狄氏筋膜、盆筋膜等结构。
2、对4个腹腔镜膀胱癌根治性全膀胱切除术后膀胱、精囊、前列腺完整保留新鲜组织标本进行研究,重点观察膀胱后壁与精囊之间组织结构、Denonvilliers筋膜与腺体联系情况,作筋膜与其内面腺体组织学切片观察。
结果：
1、Denonvilliers筋膜可分为纤维膜性的前叶和脂性的后叶。
2、射精管以下,DF前叶致密似皮革样15例(62.5%),薄弱似膜状9例(37.5%)；筋膜前叶可自腺体表面剥离至尖部者18例(75%),无法在不损害腺体组织的情况下完整剥离筋膜者6例(25%),所有DF前叶均于膜部尿道处与直肠尿道肌紧密粘着。
3、Denonvilliers筋膜前叶在膀胱直肠陷凹(Douglas窝)之下,将此处分为易于剥离的两个层面：“精囊后隙”与“直肠前隙”
4、前列腺侧后方筋膜与前列腺包囊之间的间隙变化较大,24例尸体标本中14例(58.3%)包囊与筋膜间较为疏松,10例(41.7%)筋膜与包囊紧密联系,但仍可以在不损伤腺体的情况下剥除筋膜。
5、前列腺侧前方筋膜向前列腺腹侧(前方)移行、延续时与其内面包囊逐渐融合,很难或无法剥离。
6、耻骨前列腺韧带耻骨端平均宽6.9mm；前列腺附着处较宽,平均宽12.5mm；中间平均宽5.3mm；韧带中央厚约2mm,由坚韧的结缔组织束构成。
7、耻骨前列腺韧带不是耻骨后间隙联系耻骨骨膜与泌尿生殖系脏器的唯一结构,在坚韧的耻骨前列腺韧带上、下方均有稀疏的耻骨膀胱韧带及耻骨尿道韧带联系相关脏器。
8、在新鲜组织标本上,前列腺包囊在前列腺侧后方可被分离出。
结论：
1、前列腺周筋膜结构及其与腺体之间的间隙变化很大,循某些平面可相对轻易地分离前列腺。
2、有必要对在前列腺筋膜与盆壁筋膜这互相移行的结构之间穿行的神经、血管走行进行基于手术需要的进一步解剖学研究。
第二章LRP术后勃起功能相关神经的应用解剖学研究
目的：基于目前实际开展的LRP手术所能达到的精度,结合最大限度保存NVB及CN的理念,对相关神经的应用解剖学进行研究。
方法：
1、肉眼观察24例男尸盆腔脏器标本精囊及其以下血管神经束的走行、其内神经血管的伴行关系；贴前列腺表面分离,记录神经、血管束走行及与前列腺筋膜(Prostate fascia, PF)的关系。测量NVB距前列腺底部、中部、尖部的距禺。
2、2具完整男性骨盆标本,肉眼观察骶尾椎前神经血管组织、盆丛和前列腺外侧NVB。显微镜下解剖观察前列腺外侧NVB。
结果：
1、关于神经血管束中神经的走行,可以观察到两种情况：(1)神经与血管伴行于前列腺后外侧,逐渐变细走向前列腺尖部,这种情况在24具尸体中有16(2/3)例出现；(2)神经束于前列腺底部分成两支,一支走行情况如“(1)”所描述,一支走向前列腺腹侧,向尖部逐渐变细,但不越过耻骨前列腺韧带外侧缘,两支神经束之间无神经分布,出现出现这种情况的比例为1/3。
2、神经血管束在同一具尸体标本上走行情况相同,即一侧NVB中神经单支出现,对侧观察到也是单支；一侧NVB中神经出现两支,对侧观察到也是两支。
3、后外侧神经血管束很容易在不伤及前列腺体或包囊的前提下游离开,前外侧的神经纤维与前列腺包囊(Capsule)之间几无间隙,不易分开。
结论：
1、神经血管束中神经走行变异很大,决定了保留神经的LRP手术在部分病例中具有不明确的效果。
2、把NVB经过前列腺的部分看成有着独立神经筋膜层的结构,有助于手术中对相关分离层面的理解。
第三章LRP相关控尿功能的应用解剖学研究
目的：通过观察与LRP手术尿控相关的重要解剖学结构,再模拟相关手术入路,明确这些重要结构与尿控的关系。
方法：10%福尔马林固定男性尸体2具,重点观察与手术有关的尖部解剖,如前列腺尖、膜部尿道交汇处周围肌性及纤维性结构,尿道角度维持相关筋膜等。
结果：
1、前列腺尖部及膜部尿道交汇处覆盖一层致密的纤维组织膜,此筋膜移行自盆膈上筋膜。
2、前列腺尖约3-5mm及其以下膜部尿道周围包绕肌性结构,前方较为韧厚、后方相对薄弱,肌组织可自前列腺尖部钝性剥离开。
3、将前列腺尖部前方的筋膜结构去除,模拟LRP手术,发现要完成在前列腺尖部以下不损伤其周围肌性组织、垂直断开尿道有一定难度。
4、观察到同一具标本,前列腺尖部以下、盆膈以上尿道前后面可以暴露的长度并不相等。将前列腺向前上方上提后,膜部以上尿道更易于剪切。
结论：
我们认为LRP术中在分离前列腺及其周边组织时,以下技巧有助于术后尿控：1、尽量沿精囊腺、前列腺表面分离Denonvilliers筋膜至耻骨直肠肌表面；2、自后向前横断尿道视野相对清晰、角度自下而上,有利于保留足够长的尿道；3、向头侧牵拉前列腺紧张膜部尿道后,有助于增下其下方尿道暴露,易于横断；4、前列腺尖与尿道交汇处横纹括约肌在前列腺周围的厚薄不一,于前方及两侧方钝性分离前列腺尖可避免损伤横纹括约肌。
第四章LRP术中前列腺前方静脉丛控制的解剖学研究
目的：通过模拟LRP手术在前列腺前方经过的层面,进一步探索处理前列腺前方血管的有效方法
方法：2例男尸盆腔标本,观察耻骨前列腺韧带与耻骨骨膜及前列腺附着处情况,于其中段最狭窄处自上而下依次剪断韧带纤维,切开前列腺两侧盆壁筋膜,增加前列腺的游离度,将其压向后方,显露前列腺尖及盆膈以上尿道。模拟LRP手术对此处的处理方法,观察其效果。
结果：
1、耻骨前列腺韧带张力很大。
2、前列腺两韧带之间的“前列腺浅表静脉”,较长较粗。
3、耻骨前列腺韧带以下,完全拨开前列腺之前疏松组织后,亦无法清晰辨认前列腺前部静脉丛。
4、尿道处静脉与尿道壁组织附着程度不如前列腺部紧密,相对疏松些。但静脉浅面的筋膜结构致密、坚韧,与静脉丛难以分开。
结论：前列腺前方静脉丛解剖结构相对复杂,LRP术中通常采用的缝扎法未必可靠。
第五章LRP术中解剖标志及手术技巧
目的：对LRP相关手术录像进行基于解剖学的研究,旨在寻找手术中的解剖学标志,探索手术技巧和制定手术操作的相关指南。
方法：2010年10月至2011年3月,我科所有多孔(本组5孔,同期实施的单孔LRP手术不在此列)LRP手术完整录像16例。重点观察经腹膜外腹腔镜下前列腺癌根治术(Endoscopic Extraperitoneal Radical Prostatectomy, EERPE)的以下环节：1、腹膜外耻骨后间隙的建立；2、盆腔淋巴结清扫；3、膀胱颈切开及颈口处理；4、精囊腺、输精管的游离；5、Denonvilliers筋膜间隙的分离；6、前列腺筋膜和盆壁筋膜以及在两者之间的切开；7、耻骨前列腺韧带的处理；8、前列腺前部、盆膈以上尿道部静脉的处理；9、前列腺尖部处理及剪断尿道。重点探讨：1、如何避免损伤直肠；2、如何保存控尿相关机制；3、如何有效控制DVC,避免大量出血；4、如何保存NVB。
结果：
1、盆腔淋巴结清扫须注意旋髂动静脉。
2、膀胱颈循前外侧、前面、后面的顺序分离切开。
3、循精囊后隙下分,相对容易。
4、狄氏筋膜两叶间分离较易,贴前叶之前分离未必成功。
5、前列腺侧面经过的层面不同,其间走行的NVB保存程度不同。
6、在现有普通LRP手术条件下,要将前列腺筋膜完整自前列腺表面剥离开,几乎是不可能的；但在前列腺表面的某些区域,前列腺筋膜是可以剥离的。
7、耻骨前列腺韧带与DVC的处理可以贴前列腺前表面走行,且不必缝扎DVC。
8、先断尿道后壁比先断尿道前壁有利。
结论：
LRP手术的某些步骤有进一步改良的空间。
Radical prostatectomy (RP) is the only primary treatment modality of localized prostate cancer (PC) that has proved its effectiveness against other ways. During the last three decades, the surgical treatment of prostate cancer has changed remarkably, The 3 main ways are open radical prostatectomy, laparoscopic prostatectomy and Robotic assistant prostatectomy. In our country, with all the urologists' hard working, we have had a quite large quantitative cases, many operative procedures have been standarded. What made the surgery progress were not only the new medical instruments but also the understanding of periprostatic anatomy. As Robert P. Myers said: In general surgeons who know the anatomy protect the patient by virtue of less blood loss, better margins of resection and greater functional preservation.
The periprostatic anatomy is quite complicated. One aspect that is crucial to the understanding of the complex anatomy of the male pelvis is its significant individual variation. Some pelves are wide, making the prostate easily accessible, whereas other pelves are deep and narrow, complicating the access to the prostate particularly at the moment of performing a nerve-sparing surgery or a watertight urethrovesical reconstruction. The neurovascular structures surrounding the prostate may also vary from patient to patient, and the surgeon should be ready to understand those variations in order to tailor the surgical technique to the intraoperative findings Some anatomic structure have different names, Such as Dononvillier's fascia has at least the other 3 names:Rectovesical septum, prostaterectal fascia and rectogenital fascia.
Though many patients get a quite long life span after the LRP operation, We still have a long way to go in order to give the patients a good urinary continence and erectile function. In the following studies, the regional anatomical observation on fixed cadaver, we will primarily focus on the understanding of the periprostatic fascial anatomy and the different extents of neurovascular bundle dissection in relation to the location and distribution of the cavernous nerves. Also, we provide an overview of the configuration of the urinary sphincter and its supporting structures. Then, we will study the operation skill in LRP.
Chapter 1 Applied anatomy study on the LRP correlative periprostatic fascia
Objective:To study the periprostatic fascia relate to the LRP operation.
Methods:
1.24 fixed male cadavers with integrated pelvis were dissected and observed, The anatomical sequence was from the anterior aspect of the prostate to side, and then to rear. The observative emphasis were puboprostatic ligament, prostatic fascia, Denonvillier's fascia and pelvic fascia.
2.4 organ specimen with bladder, seminal vesicles and prostate integrated after the laparoscopic radical resection of the bladder. The tissues between posterior wall of urinary bladder and seminal vesicles, the tissues between prostate and Denonvillier's fascia were studied.
Results:
1. The Denonvilliers' fascia has two layers:the fibromembranous anterior layer and the lipoid posterior layer.
2. Below ejaculatory ducts, the anterior layer are variety:15 cases (62.5%) like the leather,9 cases(37.5%) like the membrane; The frontier layer can be stripped from the surface of the prostate in 18(75%) case, Can not be stripped without damaged the gland tissue in 6(25%) cases. All the anterior layer tightly adhere to the rectourethral muscle in membranous urethra.
3. The area below Douglas were divided into 2 loosened planes:"the gap behind seminal vesicles" and "the front gap of rectum".
4. The interspace between prostatic between prostatic capsule and lateral fascia changed comparatively large, The interface was loosening in 14 cases and tightly contacted in 10 cases, the tight ones'fascia can not be dissected without prostate damaged.
5. From lateral to anterior surface, the prostatic fascia can not be dissected from the capsule.
6. The average breadth of the puboprostatic ligament in pubis part was 6.9mm, in prostate part was 12.5mm; the middle part was 5.3mm; the center was 2mm thick. The puboprostatic ligament composed of tough connective tissue.
7. The puboprostatic ligament is not the only constitution contact pubis periosteum and urogenital system organs in the retropubic space. There are puborectal ligament upper and pubourethral ligament under the tough puboprostatic ligament.
8. In the fresh specimen, prostate capsule can be dissected on the lateral surface.
Conclusions:
1. The interspace between prostate and the periprostatic fascia is changed, Along some plane can dissect swimmingly.
2. On account of the demand of surgery, We need further anatomic study on the nerve and blood vessel between prostatic fascia and parietal pelvic fascia.
Chapter 2 Applied Anatomic study on erection functional related nerve
Objective:Based on the accuracy of the practical LRP and the idea of preserve NVB and CN utmostly, To clarify the correlated nerve anatomy.
Methods:
1.24 fixed male pelvic specimens were dissected and observed, The courser of the NVB below the Seminal Vesicles was noted, The distance between prostate and the NVB was measured.
2.2 Integrity android pelvis, The nerve and blood before Sacrococcygeal vertebrae were visual studied.
Results:
1. The nerves running in the neurovascular bundle have two states:(1) The neurovascular bundle of the prostate descends along the postero-lateral border of the prostate, taper to the apex of prostate gland. This kind of circumstance happened in 16 cases; (2) The neurovascular bundle fall into two branches at the base of prostate, one branch run as (1), the other branch run to the front of the prostate, taper to apex of prostate gland at the lateral of the puboprostatic ligament. This kind of circumstance happened in 8 cases.
2. The bilateral neurovascular bundles have the same distribution, that mean neurovascular bundles symmetric distributed.
3. The posterior-lateral neurovascular bundle can be easily dissected. The anterior-lateral nerve adhered tightly to the capsule can not be separated easily.
Conclusions:
1. The neurovascular bundles have different distribution in different cases, This may cause a indefinite nerve preservation effect in some patients.
2. Look the NVB as a independent nerve fascia layer structure, may make for the understanding of the relevantly structure.
Chapter 3 Applied Anatomic study on urinary continence following LRP
Objective: To investigate the relationship between some important urinary continence related anatomy and LRP.
Methods:2 fixed male hemi-pelvises removal of the ilium were dissected and observed.
Results:
1. The apex of the prostate and membranous urethra were covered a pyknotic fibrous tissue membrane, this fascia transferred from superior fascia of pelvic diaphragm.
2. The 3 to 5mm apex of the prostate and the below membranous urethra are surround by musculature with a thick anterior part and a weak posterior part, the musculature can be dissected easily.
3. Simulated the operation of LRP, We found it was hard to cut the urethra perpendicularly without damage the musculature of the prostate apex.
4. In a same specimen, the length of the anterior and posterior urethra above the pelvic diaphragm is not the same. Drag the prostate to anterosuperior, the urethra above pelvic diaphragm will be cut easily.
Conclusions:
We think the following technique make for urinary continence after LRP:1. Try to dissect Denonvilliers' fascia to the surface of musculus puborectalis along the surface of seminal vesicle and prostate; 2. Transect the urethra from rear to the anterior surface, Which may reserve enough urethra; 3. Drag the prostate to the headward will help to transect the urethra; 4. Sphincter around periprostate has different thickness in different part, Dissection bluntly the apex of prostate may refrain from damage the sphincter.
Chapter 4 Anatomic study of Dorsal vein complex relate to LRP
Objective: To explore the modus operandi in deal with Dorsal vein complex.
Methods:2 fixed male pelvic specimens, Observed the puboprostatic ligament adhesive situation, cut the PL from upper to below from the midpiece, cut the lateral pelvic fascia, Press the prostate to rearward. Simulate the handling way in LRP, observe the effects.
Results:
1. The puboprostatic ligament has a large tension.
2. The prostate superficial vein between the two PLs is quite long and large.
3. Below the PL, It is impossible to distinguish the DVC even after push aside all the areolar tissue.
4. The vein on anterior surface of the urethra has a loosening attach to urethra, but the fascia of DVC can not be dissected.
Conclusions:The anatomy of DVC is quite complicated, transfixion way often used in LRP may not always safe.
Chapter 5 Laparoscopic anatomic and Surgery skill study on LRP
Objective:To observe the anatomical features of the LRP endoscopically in living bodies and find proper anatomical landmarks in LRP and provide the theory guidance for the LRP.
Methods:The LRP of 16 prostate cancer were observed and analyzed. Emphasis observation the following component elements: 1. Set up extraperitoneal; 2.Pelvic cavity lymph nodes resection; 3.Resection of the neck of bladder and deal with the neck; 4. Dissociation of the seminal vesicle and Deferentia; 5. Dissociation of the Denonvilliers'fascia; 6. Dissection between fascia prostatae and parietal pelvic fascia;7. Deal with puboprostatic ligament; 8. Deal with DVC; 9. Deal with the apex of prostate and cut the urethra.
Results:
1.Pay attention to circumflex iliac vein and circumflex iliac artery.
2.Resection of the bladder neck from anterolateral to frontal to posterior.
3. It is relatively easy dissection along the gap in rear of Seminal Vesicles.
4. It is easy to dissection along the gap of the two Denonvilliers'fascia layers, It is not always succeed before the anterior layer.
5. Dissection though different plane have different NVB preservation level.
6. Only part prostate fascia can be dissected from the surface of prostate during LRP
7. We may deal with PL and DVC along the surface of prostate and need not transfixion of DVC.
8. We may dissect the posterior wall prior to anterior wall of the urethra.
Conclusions:Some steps of the LRP may have further improve.
引文
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