【作者】 方克伟；

【导师】 杨达宽； 宋波； 李泽惠； 黄云超；

【作者基本信息】 昆明医学院 ， 外科学， 2006， 博士

【摘要】 目的：通过研究明确女性控尿机制的神经来源、组成、分布以及尿道括约肌复合体的形态、分布等，并与临床研究结合，探讨女性原位尿流改道的相关临床问题，以进一步指导临床工作和研究。 方法：1，对符合研究需要的成人女性尸体20具进行控尿神经及肌肉的大体解剖：从会阴开始解剖，解剖出阴部管，游离出阴部神经，向头侧解剖其起源，向尾侧循坐骨直肠窝追踪其终末分支，注意进入尿道的部位、角度。然后行正中矢状面断开盆腔以便于解剖盆腔，从脊柱近端开始游离骶神经根（S₁-S₄），找出下腹下丛（盆丛），追踪其分支，主要是尿道支。显露控尿神经后，模拟经阴道和经耻骨后手术以明确那些可能会损伤这些神经的操作，提出相应的防范措施。2，解剖出完整的尿道及周围的肌肉、阴道等组织，进行大体观察；并对上述组织进行病理学检查，包括HE染色、肌肉染色、结缔组织染色、银染等。3，对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，同时进行CT的横截位连续扫描并进行对比。4，在CT的横截位连续扫描影像资料的基础上，手工勾画尿道的轮廓，在个人电脑上利用三维成像软件进行女性尿道三维成像的初步探索。5，结合上述基础研究的结果，对女性原位尿流改道的控尿情况、并发症、复发等临床问题进行总结、分析，以便使基础研究更好的指导临床工作。 结果：1，女性尸体解剖显示盆丛位于梨状肌下缘内侧、直肠两侧，形状不规则，由S₂-S₄神经分支、腰骶干的分支组成；其分支有直肠丛、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。阴部神经的主干在坐骨棘水平发出肛门支，主干向前内走行，依次发出阴蒂背神经、阴部神经，尿道支主要由后者发出，少数还同时由阴蒂背神经发出，走行在球海绵体肌外缘，向前、上行，恰在耻骨联合下缘正对处的11、2点位置进入尿道。此解剖结果对麻醉科、妇产科等也12有实用意义。2，紧靠盆壁的操作、尿道近端切除＞0.5cm、吻合尿道-新膀胱进针过深等都是易于损伤控尿的神经、肌肉的操作，应针对这些因素进行防范。3，病理结果表明，横纹肌主要位于尿道远端2／3，与盆底肌肉更多还原

【Abstract】 Objective: To study the morphological mechanism of urinary continence and the clinical applied effects in female orthotopic urinary diversion. To investigate the pelvic autonomic nerve and pudendal nerve to female urethra in female corpse, including their composing, distributing, dominating range, the point of its come into the urethra and their neighbors. We also study the composing, morphologic and component of urinary continent muscles and their relationship between the vagina and the pelvic floor muscles. Based on the basical study, the clinical effects of orthotopic urinary diversion in women were also investigated.Methods: 1, The gross anatomy had been done on 20 female cadavers. In each cadaver, the dissection proceeded from both perineal approach and intrapelvic approach. The perineal dissection involved isolating the pudendal nerve exiting the pudendal canal (Alcock’ Canal) and tracing the terminal branches through the ischiorectal fossa and its terminal branches to the urethra. After the perineal dissection, parasagittal section of each en bloc pelvis allowed wide exposure for the intrapelvic dissection. Beginning from the vertebral column, the individual sacral nerve roots (S1-S4) were isolated. The pelvic nerve, taking origin from the inferior hypogastric plexus, was then followed along the lateral rectum, and was traced in detail as its branches approached the urinary sphincter complex. Deep to the course of the pelvic nerve, the pudendal nerve was identified running in the pudendal canal and was finally traced in its intrapelvic course and into the schiorectal fossa. 2, With the nerve to the urinary sphincter complex (the continence nerve) exposed, mock retropubic operations were performed to identify any surgical maneuvers that might damage the nerves and muscles. 3, Checking the whole female lower urinary grossly and in pathology, we collected the representative specimens of presumptive nerve tissue for histologic examination. Longitudinal and transverse sections made from representative nerve samples were stained with hematoxylin-eosin, PTAH, Modified更多还原