【探泌】前列腺应用解剖精粹（三）

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，European Urology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，本文为第三期，介绍不同筋膜层面分离技术（筋膜内分离、筋膜间分离及筋膜外分离）、膀胱前列腺肌（VPM）、盆底肌肉系统、尿道外括约肌、前列腺尖部形状。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。

01  不同筋膜层面分离技术

      前列腺的筋膜和神经解剖对根治性前列腺切除术具有重要意义，尤其是筋膜代表了重要的手术分离层面。根据术中选择的分离层面，会有几种技术上的变化（图9）。以下描述了不同手术分离层面的解剖学含义。

1.Intrafascial dissection（筋膜内分离）

NVB的筋膜内分离是沿着前列腺包膜层面分离，分离层面在前列腺前外侧和后外侧时位于PF内侧或内部，以及pPF/SVF前方（图9和10）。尽管如此，部分pPF/SVF通常仍保留在前列腺标本的后表面，与中线的包膜融合。从6点钟位置开始顺行分离时，可能会发现一个更容易分离的层面，因为在这个水平上，pPF/SVF较厚并且可以更容易地识别为单层结构。从侧方高位进入时，由于筋膜呈多层分布，尤其是在前列腺后外侧边界处，该层面可能更难识别。筋膜内入路可对外侧PF进行全层保留，NVB位于PF外侧且被PF覆盖，因此能够完全保留NVB。在手术结束时，NVB所在的前列腺包膜后外侧和外侧表面将没有PF及部分pPF/SVF（图10）。筋膜内分离时不慎突破包膜的风险是最大的。

2.Interfascial dissection（筋膜间分离）

NVB的筋膜间分离是在PF外部或外侧分离前列腺前外侧和后外侧，同时在前列腺轴面5、7点钟位置或2、10点钟位置NVB的内侧分离。通过将完整的NVB移出前列腺，从而使前列腺后外侧仍被筋膜覆盖（图9和10）。根据解剖学差异，该技术可能更倾向于切除部分NVB，因为这种分离方法不一定能保留分散在前列腺前外侧表面的所有神经纤维。外侧PF保留在前列腺而不是附着在NVB，pPF/SVF保留在前列腺的后表面。与筋膜内分离相比，这种方法允许前列腺周围有更大的组织缓冲区，可能是肿瘤学上较安全的方法。

3.Extrafascial dissection（筋膜外分离）

筋膜外分离是在LAF外侧和pPF / SVF后方分离（图9）。在这种情况下，沿前列腺后外侧延伸的NVB被完全切除，同时LAF、PF和pPF/SVF被保留在前列腺。与筋膜内和筋膜间分离相比，这种方法使前列腺周围组织量最大。因此，它是肿瘤学上最安全的分离方法，但可能导致完全的勃起功能障碍。

02  Vesicoprostatic muscle（膀胱前列腺肌）

      在前列腺后方游离时，膀胱颈后部与精囊和输精管壶腹之间的组织有着重要作用（图2和7）。该组织层被认为含有pPF/SVF的前层。一项研究表明，该组织包含两种不同的组织类型。内层组织直接位于膀胱黏膜下，由起源于外侧纵向逼尿肌的平滑肌纤维组成。这些纤维纵向走行并插入前列腺基底部。该层被认为与腹侧逼尿肌群相对应，被称为膀胱前列腺肌。更靠后方的第二层组织与内层紧密接触，由纤维脂肪组织组成，与膀胱外膜连续。

03  Pelvic floor musculature（盆底肌肉系统）

      前盆腔最内层肌肉是肛提肌。在尿道括约肌附近，它被称为尿道提肌、前列腺提肌或耻骨尿道肌，代表了肛提肌的前内侧部分（图1，3，5）。有两份报告将该肌肉的术语定为耻骨会阴肌。报告认为耻骨会阴肌作为肛提肌增厚的部分，由两块源自耻骨的带状肌肉组成，位于前列腺尿道交界处的两侧，在尿道的背侧和肛门直肠交界处的前方附着于会阴体（图3）。相对于肛提肌的其他部分，这部分从侧面邻近的耻骨直肠肌的前方伸出。耻骨会阴肌和耻骨直肠肌的自主收缩将尿道向前、向上牵拉，导致尿道关闭和尿流终止。这些肌肉很可能负责排尿时的主动快-停机制，因此在主动维持尿控方面有着重要作用，在游离前列腺尖部和尿道时，以及吻合膀胱尿道时可能存在损伤的风险。

      通常将肛肠交界处与会阴体之间的肌肉结构称为直肠尿道肌，其位于尿道括约肌复合体的远端（＞1cm）（图2和3）。该肌肉结构与经会阴根治性前列腺切除术有关，因需要将其切开以进入前列腺尖部。然而一些研究表明，该肌肉与尿道并无接触，这意味着术语“直肠尿道肌”是不恰当的。

04  External urethral sphincter（尿道外括约肌）

      尿道外括约肌复合体主要位于前列腺尖部的远端。它与耻骨会阴肌关系密切但又相互独立，因此单独位于盆底（图2，3，5）。它受盆腔神经丛的自主神经支配，这些自主神经部分与NVB并行，部分来自阴部神经的分支。这些神经纤维在两侧从后外侧进入尿道括约肌，主要在5点钟和7点钟位置，以及3点钟和9点钟位置。前列腺尖部距最近的阴部神经分支进入尿道括约肌的位置为3-13mm。

      尿道括约肌和前列腺尖部的后方靠近直肠的前表面（图2和3）。尿道括约肌本身由两种不同类型的肌肉组成（图3）。外层肌由横纹肌纤维构成，外形为垂直的圆柱形至圆锥形，横截面呈马蹄形或Ω形。有人将这部分括约肌命名为“横纹括约肌”。但该肌纤维的走行尚不清楚，可能是水平或垂直的。这种差异可能与尿道腔相对于人体纵轴存在不同轴线，以及组织学切片方式有关。这些肌纤维主要为慢肌纤维，相对于耻骨会阴肌的快肌纤维而言，其在排尿控制方面具有被动功能。横纹括约肌插入前列腺尖部和前表面。括约肌腹侧和腹外侧的肌肉较厚，后外侧的较薄。括约肌的后半圈被背正中脊腱弓中断，背正中脊在括约肌尾侧与会阴中心腱连续，向头侧与pPF/SVF连续。一些作者认为，背正中脊和邻近组织作为括约肌收缩时的支点，使尿道向背侧和尾侧方向运动。这种收缩与耻骨会阴肌的收缩相结合，形成了闭合尿道的双吊索机制。在根治性前列腺切除术中重建这一后方支点可能会改善早期尿控恢复。但尚无确切证据。

      尿道括约肌的内层肌完全围绕着尿道，由平滑肌纤维和弹性组织构成。但有人提出该肌肉的形状类似于横纹肌的Ω形。平滑肌层可分为靠外的环形层和靠内的纵向层。靠内的纵向肌层主要位于尿道的前面和后面。但所有的肌层都相互混杂，这表明括约肌的活动是所有肌层联动的结果。

05  Apical prostate shape（前列腺尖部形状）

      前列腺尖部的形状可能会有很大变化，直接影响从尖部发出的尿道长度。尖部可能呈环状、双侧对称、单侧不对称、仅前方、仅后方与尿道括约肌重叠，或直接终止于尿道括约肌上方（图11）。Lee等指出，在所有病例中，38%的为环状重叠，25%的为前方重叠，22%的为后方重叠，15%的未重叠。在游离以及横断尖部尿道时应注意——明显的重叠使尿道括约肌长度的保留变得困难。

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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。

编辑：张桂芳

审核：王欣

终审：郭涛