男性尿道解剖(男性泌尿系统解剖)

频道：生活百科日期：2023-06-28 浏览：1242

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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，本文为第一期，介绍耻骨前列腺韧带、背血管复合体（DVC）、阴部副动脉及前列腺的筋膜包括盆内筋膜、前列腺周围筋膜（前方的前列腺周围筋膜、外侧的前列腺周围筋膜）。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。

在腹侧，来源于膀胱的外层纵向肌纤维覆盖前列腺近端并在腺体上延伸。这些肌纤维构成了逼尿肌群（图1和2）。耻骨膀胱/耻骨前列腺韧带（PV/PPLs）是源自盆内筋膜脏层的成对纤维带，它们插入耻骨后表面的远端三分之一处，位于尿道括约肌的前方（图3）。由于该韧带向下附着于前列腺腹侧，故通常被称为“耻骨前列腺韧带”。在前列腺较小或正常大小的患者中，PV/PPLs与膀胱前部的附着关系很容易被识别，但当前列腺增生向腹侧扩张时就比较难以辨认。PV/PPLs将前列腺、尿道和膀胱稳定在耻骨，被认为是尿控机制中“悬吊系统”的重要组成部分。一些作者认为，在根治性前列腺切除术中保留这些韧带可能会改善早期尿控恢复，但尚无确切证据。经会阴和腹腔镜手术有利于保留PV/PPLs，而开放耻骨后前列腺切除术比较难保留PV/PPLs。

俗称的“背静脉复合体”（dorsal vein complex）或“圣托里尼丛”（Santorini's plexus）覆盖前列腺和尿道括约肌的腹侧，其引流阴茎静脉以及尿道和盆腔侧静脉。它通常含有小动脉，这些小动脉源自膀胱下动脉。因此，背静脉复合体本质上是背血管复合体（DVC；图1-3）。在前列腺尖部的远端，括约肌筋膜将DVC与尿道括约肌分开。在前列腺尖部，DVC可被PV/PPLs分为内侧组和外侧组。然后，DVC在前列腺的腹侧向头侧延伸至膀胱，并与膀胱静脉和前列腺侧静脉有着多变的吻合。在腹侧，DVC被延伸过来的盆内筋膜脏层和逼尿肌群覆盖。在前列腺尿道交界处，前列腺与DVC之间存在一个无血管平面，形成了控制DVC的标志。当接近前列腺尿道交界处时，可能有易变的支撑纤维带（Muller's坐骨前列腺韧带，Walsh's柱）位于横纹括约肌的侧面，并被横纹括约肌的前层插入。

阴部副动脉位于盆隔上方，经过耻骨后方，最终进入阴茎。它们可能起源于髂内或髂外动脉或闭孔动脉，而不是前面提到的DVC内的小动脉。4-75%的男性存在阴部副动脉，向海绵体提供单侧或双侧的动脉血供。海绵体的血供可能仅来自这些动脉。这种情况下，前列腺切除术中必须保留这些动脉，以避免因阴茎动脉血供不足而导致的勃起功能障碍。阴部副动脉可分为两种类型（图4）。

外侧阴部副动脉沿着盆筋膜腱弓走行在膀胱、前列腺和盆侧壁之间的凹沟内（图4）。还可能从外侧进入耻骨下方。它们都在盆内筋膜的上方或下方走行。走行在盆内筋膜上方的动脉（图4a 译者注）通常是膀胱下动脉或髂内动脉的分支，走行在盆内筋膜下方的动脉通常是闭孔动脉或髂外动脉的分支（图4c和图4d 译者注）。

尖部阴部副动脉位于PV/PPLs的下方和外侧，靠近前列腺尖部的前外侧（图4）。它们的特点是穿过邻近的肛提肌，从外侧出现。然后沿切线接近前列腺尖部，并可能经常在平行进入DVC向阴茎走行之前，延伸至尖部。据推测，它们是闭孔动脉或肛提肌下阴部动脉的分支（图4b 译者注）。粗大的尖部阴部副动脉代表了变异的阴部动脉，而较小的尖部阴部副动脉通常仅向海绵体提供少量动脉血供。

①Endopelvic fascia（盆内筋膜）

盆腔器官被筋膜覆盖。根据解剖学术语，盆筋膜有壁层和脏层之分。壁层是指覆盖肛提肌内侧面的筋膜，一些作者将其称为盆内筋膜。还有作者将全部壁层和脏层盆筋膜称为盆内筋膜。在本文中，我们区分了盆内筋膜壁层和盆内筋膜脏层。盆内筋膜脏层覆盖盆腔器官，包括前列腺、膀胱和直肠，并在前列腺的腹侧上部与腺体的前纤维肌肉基质融合（图1-3）。

沿着前列腺和膀胱外侧的盆腔侧壁，盆内筋膜壁层和脏层融合在一起。作为筋膜的凝聚，这种融合通常表现为一条发白的线，被命名为盆筋膜腱弓。它从PV/PPLs延伸至坐骨棘。手术中可通过在此融合处的内侧或外侧切开盆内筋膜来进入前列腺外侧。一些作者认为，在根治性前列腺切除术中避免切开盆内筋膜——通常与筋膜内保留神经技术结合——可能会改善早期尿控恢复和术后勃起功能，但尚无确切证据。

盆内筋膜壁层包括肛提肌筋膜（图1）。紧邻盆筋膜腱弓的外侧切开盆内筋膜壁层时，会切开肛提肌筋膜（LAF），显露肛提肌纤维，使LAF附着于前列腺。在盆筋膜腱弓的内侧切开盆内筋膜脏层时，会使肛提肌被其筋膜覆盖而不显露肌纤维。结果是前列腺仅被前列腺筋膜（PF）覆盖，而不被LAF覆盖。

②Periprostatic fascias（前列腺周围筋膜）

Costello等、Takenaka等以及过去的Walsh和Partin将前列腺外表面的筋膜称为盆外侧筋膜。对紧邻前列腺的筋膜，Myers和Villers、Stolzenburg等和Tewariet等将其称为前列腺周围筋膜，Graefen等和BudaÜs等将其称为盆旁筋膜，Menon等、Secin等和Nielsen等将其称为前列腺筋膜。该筋膜并不是在前列腺外表面延伸的单层离散结构。通常它在前列腺上排列为数层，由胶原和脂肪组织构成。因此，本文出于实用目的，我们使用PPF来表示所有位于前列腺且在前列腺包膜外的筋膜。根据位置将覆盖前列腺的PPF分为三类（图1-3和5）。（即前方的前列腺周围筋膜、外侧的前列腺周围筋膜、前列腺后方筋膜，译者注）

③Anterior periprostatic fascia（前方的前列腺周围筋膜）

这一类是与前列腺前表面有关的盆内筋膜脏层，大约从10-11点钟位置至1-2点钟位置，覆盖逼尿肌群、背血管复合体，并在中线与前列腺前纤维肌肉基质融合（图1）。

④Lateral periprostatic fascia（外侧的前列腺周围筋膜）

一旦在盆筋膜腱弓的外侧打开盆内筋膜，并将肛提肌推向外侧，前列腺外表面的最外层筋膜便是肛提肌筋膜。而且多数情况下还有一内层筋膜覆盖前列腺包膜，这层筋膜通常为多层结构，被称为前列腺筋膜（PF）。这两层筋膜（LAF和PF）都构成了PPF。这些筋膜位于前列腺前外侧，从前列腺的前表面向后方或背侧延伸以围绕神经血管束（NVB），外层的LAF在NVB外侧穿过，最终成为直肠旁筋膜将直肠与肛提肌分开。内层的PF在NVB内侧穿过，覆盖下方的前列腺包膜。前列腺包膜与外侧PF之间的关系可能因人而异（图6）。Kiyoshima等发现，在所有病例中，有52%的患者的LAF（他们称其为“盆外侧筋膜”）并没有附着在前列腺“包膜”。在上述病例中，表层空间由疏松结缔组织和脂肪组织构成，被称为网状组织。此外，在这些病例中，NVB并无明显结构，而是散布在前列腺外表面。值得注意的是，作者仅使用苏木精和伊红染色，因此无法区分真包膜的平滑肌与PF的胶原纤维，而是均视为前列腺包膜。在剩下的48%的患者中，LAF与前列腺包膜融合，在两层之间并未见到网状组织。仅在前列腺的后外侧角没有上述融合，NVB在该处表现为明显的束状。

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