治疗复杂性后尿道狭窄三种手术入路的比较解剖学研究
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摘要
现在交通事故及外伤增多，尤其是战争中骨盆及尿道伤机率增大，文献报道骨盆骨折有5—10％尿道损伤，10％为后尿道损伤，其中80％并发狭窄。后尿道处于会阴较深处，治疗棘手。对于复杂性后尿道狭窄常采用经腹，经耻骨及经会阴入路手术治疗。本研究旨在评价三种手术入路的优劣。拟通过本研究达到以下目的：
1、比较经耻骨上缘、耻骨下缘、会阴三种手术入路点分别到尿道球膜部交界处、尿道前列腺尖部和膀胱颈的距离及尿道膜部纵轴和尿道前列腺部纵轴所对应的三种手术入路点的角度；
2、比较经耻骨上部分切除入路、耻骨下部分切除入路及会阴入路显示后尿道的损伤情况并进行评分；
3、探讨耻骨下部分切除入路在治疗复杂性后尿道狭窄中的应用。
材料与方法1、35具成年男性尸体标本尿道正中矢状面切开成两侧，均取右侧，分别测量并比较耻骨上缘中点(A)、耻骨下缘中点(B)及会阴部两坐骨结节上缘连线中点(C)分别到尿道球膜部连接处(D)、前列腺尖(E)及膀胱颈(F)的距离；测量耻骨上缘中点到尿道球膜部交界处的连线与其到尿道前列腺尖的连线所成角
度艺EAD(a，)，耻骨下缘中点到尿道球膜部交界处的连线与其
到尿道前列腺尖的连线所成角度艺EBD(aZ)，会阴部两坐骨结
节上缘连线中点到尿道球膜部交界处的连线与其到尿道前列
腺尖的连线所成角度乙EFD(a。);耻骨上缘中点到膀肤颈的连
线与其到尿道前列腺尖的连线所成角度艺FAE(刀，)，耻骨下
缘中点到膀肤颈的连线与其到尿道前列腺尖的连线所成角度
‘FBE(夕2)，会阴部两坐骨结节上缘连线中点到膀肤颈的连
线与其到尿道前列腺尖的连线所成角度艺FCE(刀。)。
2、21具成年男性尸体分别经耻骨上部分切除(7例)、耻
骨下部分切除(7例)、会阴(7例)三种手术入路显露后尿道，
标记可能损伤的组织器官并评分。
3、复杂性后尿道狭窄患者8例，年龄7一55岁，平均29.7
岁，均留置膀肤造屡管，均行3次以上手术，经膀肤尿道造
影及尿道逆行造影、MR等检查提示尿道狭窄段长度为4一8 em，
平均scm，6例勃起功能障碍。采用耻骨下部分切除入路阴囊
中隔皮瓣尿道成形术，耻骨下部分切除约宽约4 cm，高2一3 Cm
梯形骨块，留下耻骨联合上缘宽Icm骨桥。
结果
1、各测量点之间的距离AD=(6.5士0.5)em，BD=(2.2士0.5)
CD二(3.4士0.6)cm，其中BD 、./ml卜d
八了C nU
(6 .6士0.5)em，BE二(3.0土0.5)em，CE=(4.4士0.
其中BE m， E=m，
C AC
BF=(4.5士0.5)em，CF=(6.5士0.6)em，其中BF SNK法)。各点连线所成角度中，匕EAD(al)=(9.3土2.0)“，
艺EBD(aZ)=(1 7.4士3.8)”，艺ECD(a3)=(9.2士1.6)”，其
中al与aZ有显著性差异(只0.05)，a3与aZ有显著性差异
(只0.05)，al与a3无显著性差异(乃0.05);匕FAE(刀，)二
(22.6土2.6)“，艺FBE(刀2)=(33.6士6.4)”，乙FCE(刀3)=
(15.0士3.2)”，其中刀2)刀，)刀3(只O，05，SNK法)。
2、耻骨上部分入路显露后尿道损伤评分:15分;经耻
骨下部分入路显露后尿道损伤评分:17分;经会阴入路显露后
尿道损伤组织器官评分:13分。
3、8例中7例手术一次成功，最大尿流率成人18、20m/s，
儿童8、12m/s，随访3月一2年，
碍加重，
后留置U
6个月后逐渐恢复;1
效果良好，1人术后性功能障
人尿线变细，经尿道冷刀切开
形管2月后拔除U管，排尿通畅。无骨盆疼痛及步态
不稳。2人l年后勃起功能障碍好转。
结论
1、暴露从优到劣依次为经耻骨下部分、经会阴、经耻骨
上部分;
2、损伤从大到小依次为经耻骨下部分、经会阴、经耻骨
上部分;
3、对于复杂性后尿道狭窄，多次手术效果不佳者，经耻
骨下部分切除入路后尿道成形为一种有效的方法。
Objectives:
Nowadays, traffic accident and trauma grow in number, especially the probability of the pelvic and the urethral injury increases in war. According to the documents there is 5-10% urethral injury appeared after pelvis fracture, and 10% of the urethral injury lies in posterior urethra, about 80% urethral injury will come into urethral stricture. The posterior urethral stricture is difficult to treat because it lies in the very deep pelvic cavity. The common surgical approaches of treatment the posterior urethral stricture is via the superior part of pubis, the inferior part of pubis and perineum. This study is to evaluate the advantage and disadvantage of the three surgical approaches in treatment the posterior urethral stricture. Our objectives are:
1. To compare the distance from via the midpoint superior margin of pubis, the midpoint inferior margin of pubis and perineum to the bulbi-membranous urethra joint, the apex of the prostate and the bladder neck. To compare the angles of membranous urethra correspondence of the three operative approaches point, and the angles of the prostatic urethra correspondence of the three surgical approaches point.
2. To compare the damage scores via the superior part of pubis,
the inferior part of pubis and perineum to expose the posterior urethra.
3. to present the initial experience and results of via the inferior margin of pubis to treatment the of complex posterior urethral stricture. Materials and methods:
1.Thirty-five adult male corpses were cut from the median sagittal plane of urethra into two parts ,choose the right side, measured the distance from the bulbi-membranous urethra joint
(D) to the superior median margin of pubis (A) , to the inferior intermedial margin of pubis (B) and to the middle point of the both superior margin of ischial tuberosity in the perineum ( C ). and from the apex of prostate (E) to the same three points above. So did from the bladder neck (F) . Measured the angleEAD ( a1) formed from the line of the superior median margin of pubis ( A ) to the bulbi-membranous urethra joint (D) and to the apex of prostate
(E) , the angle EBD ( a2) formed from the line of the inferior median margin of pubis (B) to the bulbi-membranous urethra joint
(D) and the apex of prostate (E) ,the angle ECD (a3) formed from the line of he middle point of the both superior margin of ischial tuberosity in the perineum (C) to the bulbi-membranous urethra joint (D) and to the apex of prostate (E) .the angle FAE (B1 ) formed from the line of the superior median margin of pubis
(A) to the apex of prostate (E) and the bladder neck ( F) ,the angle FBE (B2) formed from the line of the inferior median margin of
pubis (B) to ) to the apex of prostate (E) and the bladder neck (F) ,the angle ZFCE (B3 ) formed from the middle point of the both superior margin of ischial tuberosity in the perineum (C ) to the apex of prostate (E) and to the bladder neck (F) .
2.Furthermore, twenty one adult male corpses were dissected with the surgical approaches via the midpoint superior part of pubis(7 cases), via the midpoint inferior part of pubis(7 cases) and via perineum (7cases)to expose the posterior urethra. The destructed constitutions and organs were marked and scored.
3. 8 patients of complex posterior urethral stricture are researched. Patients from 7 to 55 years , mean 29.7 years, checked by cystourethrography, urethral retrogradiography and MR suggested the length of urethral stricture from 4 cm to 8 cm, mean 5 cm. Six patients appeared erective dysfunction. All detained bladder stoma tube, got more than three operations, treated via the inferior part of pubis. Excisied the inferior part trapezoid pubic of broad 4 cm and high 2 to 3 cm?kept lcm high bone bridge of the superior part of pubis, and used scrotum median septum pedicled skin flap to urethroplasty.
Results:
1. AD = (6.5 + 0.5) cm, BD = (2.2 + 0.5) cm, CD =( 3.4 + 0.6) cm, and BD < CD < AD (P<0.05 , SNK means); AE=(6.6+0.5)cm, BE=(3.0+0.5)cm, CE=(4.4+0.7)cm, and BE
1、比较经耻骨上缘、耻骨下缘、会阴三种手术入路点分别到尿道球膜部交界处、尿道前列腺尖部和膀胱颈的距离及尿道膜部纵轴和尿道前列腺部纵轴所对应的三种手术入路点的角度；
2、比较经耻骨上部分切除入路、耻骨下部分切除入路及会阴入路显示后尿道的损伤情况并进行评分；
3、探讨耻骨下部分切除入路在治疗复杂性后尿道狭窄中的应用。
材料与方法1、35具成年男性尸体标本尿道正中矢状面切开成两侧，均取右侧，分别测量并比较耻骨上缘中点(A)、耻骨下缘中点(B)及会阴部两坐骨结节上缘连线中点(C)分别到尿道球膜部连接处(D)、前列腺尖(E)及膀胱颈(F)的距离；测量耻骨上缘中点到尿道球膜部交界处的连线与其到尿道前列腺尖的连线所成角
度艺EAD(a，)，耻骨下缘中点到尿道球膜部交界处的连线与其
到尿道前列腺尖的连线所成角度艺EBD(aZ)，会阴部两坐骨结
节上缘连线中点到尿道球膜部交界处的连线与其到尿道前列
腺尖的连线所成角度乙EFD(a。);耻骨上缘中点到膀肤颈的连
线与其到尿道前列腺尖的连线所成角度艺FAE(刀，)，耻骨下
缘中点到膀肤颈的连线与其到尿道前列腺尖的连线所成角度
‘FBE(夕2)，会阴部两坐骨结节上缘连线中点到膀肤颈的连
线与其到尿道前列腺尖的连线所成角度艺FCE(刀。)。
2、21具成年男性尸体分别经耻骨上部分切除(7例)、耻
骨下部分切除(7例)、会阴(7例)三种手术入路显露后尿道，
标记可能损伤的组织器官并评分。
3、复杂性后尿道狭窄患者8例，年龄7一55岁，平均29.7
岁，均留置膀肤造屡管，均行3次以上手术，经膀肤尿道造
影及尿道逆行造影、MR等检查提示尿道狭窄段长度为4一8 em，
平均scm，6例勃起功能障碍。采用耻骨下部分切除入路阴囊
中隔皮瓣尿道成形术，耻骨下部分切除约宽约4 cm，高2一3 Cm
梯形骨块，留下耻骨联合上缘宽Icm骨桥。
结果
1、各测量点之间的距离AD=(6.5士0.5)em，BD=(2.2士0.5)
CD二(3.4士0.6)cm，其中BD
八了C nU
(6 .6士0.5)em，BE二(3.0土0.5)em，CE=(4.4士0.
其中BE
C AC
BF=(4.5士0.5)em，CF=(6.5士0.6)em，其中BF
艺EBD(aZ)=(1 7.4士3.8)”，艺ECD(a3)=(9.2士1.6)”，其
中al与aZ有显著性差异(只0.05)，a3与aZ有显著性差异
(只0.05)，al与a3无显著性差异(乃0.05);匕FAE(刀，)二
(22.6土2.6)“，艺FBE(刀2)=(33.6士6.4)”，乙FCE(刀3)=
(15.0士3.2)”，其中刀2)刀，)刀3(只O，05，SNK法)。
2、耻骨上部分入路显露后尿道损伤评分:15分;经耻
骨下部分入路显露后尿道损伤评分:17分;经会阴入路显露后
尿道损伤组织器官评分:13分。
3、8例中7例手术一次成功，最大尿流率成人18、20m/s，
儿童8、12m/s，随访3月一2年，
碍加重，
后留置U
6个月后逐渐恢复;1
效果良好，1人术后性功能障
人尿线变细，经尿道冷刀切开
形管2月后拔除U管，排尿通畅。无骨盆疼痛及步态
不稳。2人l年后勃起功能障碍好转。
结论
1、暴露从优到劣依次为经耻骨下部分、经会阴、经耻骨
上部分;
2、损伤从大到小依次为经耻骨下部分、经会阴、经耻骨
上部分;
3、对于复杂性后尿道狭窄，多次手术效果不佳者，经耻
骨下部分切除入路后尿道成形为一种有效的方法。
Objectives:
Nowadays, traffic accident and trauma grow in number, especially the probability of the pelvic and the urethral injury increases in war. According to the documents there is 5-10% urethral injury appeared after pelvis fracture, and 10% of the urethral injury lies in posterior urethra, about 80% urethral injury will come into urethral stricture. The posterior urethral stricture is difficult to treat because it lies in the very deep pelvic cavity. The common surgical approaches of treatment the posterior urethral stricture is via the superior part of pubis, the inferior part of pubis and perineum. This study is to evaluate the advantage and disadvantage of the three surgical approaches in treatment the posterior urethral stricture. Our objectives are:
1. To compare the distance from via the midpoint superior margin of pubis, the midpoint inferior margin of pubis and perineum to the bulbi-membranous urethra joint, the apex of the prostate and the bladder neck. To compare the angles of membranous urethra correspondence of the three operative approaches point, and the angles of the prostatic urethra correspondence of the three surgical approaches point.
2. To compare the damage scores via the superior part of pubis,
the inferior part of pubis and perineum to expose the posterior urethra.
3. to present the initial experience and results of via the inferior margin of pubis to treatment the of complex posterior urethral stricture. Materials and methods:
1.Thirty-five adult male corpses were cut from the median sagittal plane of urethra into two parts ,choose the right side, measured the distance from the bulbi-membranous urethra joint
(D) to the superior median margin of pubis (A) , to the inferior intermedial margin of pubis (B) and to the middle point of the both superior margin of ischial tuberosity in the perineum ( C ). and from the apex of prostate (E) to the same three points above. So did from the bladder neck (F) . Measured the angleEAD ( a1) formed from the line of the superior median margin of pubis ( A ) to the bulbi-membranous urethra joint (D) and to the apex of prostate
(E) , the angle EBD ( a2) formed from the line of the inferior median margin of pubis (B) to the bulbi-membranous urethra joint
(D) and the apex of prostate (E) ,the angle ECD (a3) formed from the line of he middle point of the both superior margin of ischial tuberosity in the perineum (C) to the bulbi-membranous urethra joint (D) and to the apex of prostate (E) .the angle FAE (B1 ) formed from the line of the superior median margin of pubis
(A) to the apex of prostate (E) and the bladder neck ( F) ,the angle FBE (B2) formed from the line of the inferior median margin of
pubis (B) to ) to the apex of prostate (E) and the bladder neck (F) ,the angle ZFCE (B3 ) formed from the middle point of the both superior margin of ischial tuberosity in the perineum (C ) to the apex of prostate (E) and to the bladder neck (F) .
2.Furthermore, twenty one adult male corpses were dissected with the surgical approaches via the midpoint superior part of pubis(7 cases), via the midpoint inferior part of pubis(7 cases) and via perineum (7cases)to expose the posterior urethra. The destructed constitutions and organs were marked and scored.
3. 8 patients of complex posterior urethral stricture are researched. Patients from 7 to 55 years , mean 29.7 years, checked by cystourethrography, urethral retrogradiography and MR suggested the length of urethral stricture from 4 cm to 8 cm, mean 5 cm. Six patients appeared erective dysfunction. All detained bladder stoma tube, got more than three operations, treated via the inferior part of pubis. Excisied the inferior part trapezoid pubic of broad 4 cm and high 2 to 3 cm?kept lcm high bone bridge of the superior part of pubis, and used scrotum median septum pedicled skin flap to urethroplasty.
Results:
1. AD = (6.5 + 0.5) cm, BD = (2.2 + 0.5) cm, CD =( 3.4 + 0.6) cm, and BD < CD < AD (P<0.05 , SNK means); AE=(6.6+0.5)cm, BE=(3.0+0.5)cm, CE=(4.4+0.7)cm, and BE
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[37]何恢绪主编．尿道下裂外科学[M]．人民军医出版社，1998年，17—20．
[38]Strasser H, Bartsch G. Anatomy and innervation of the rhabdosphincter of the male urethra[J]. Semin Urol Oncol. 2000;18(1):2-8.
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J Urol, 2003, 170 (2): 464-467.
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[46] Koraitim MM. Failed posterior urethroplasty: lessons learned[J]. Urology. 2003 Oct;62(4):719-22.
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repair with an off-the-shelf collagen matrix[J]. J Urol.2003,169(1): 170-3.
[51]Aggarwal SK, Goel D, Gupta CR, et al. The use ofpedicled appendix graft for substitution of urethra in recurrent urethral stricture[J]. J Pediatr Surg. 2002, 37(2): 246-50.
[52]梅骅，苏泽轩，郑克立．泌尿外科临床解剖学[M]．山东科学技术出版社，2002，第一版，240-255．
[53]Hunter K, Moore K, Cody D, et al. Conservative management for postprostatectomy urinary incontinence. Cochrane Database Syst Rev. 2004;2:CD001843.
[54]McLennan MT, Melick CF, Cannon S. The position of the urethrovesical junction after incontinence surgery: early postoperative changes[J]. Int Urogynecol J Pelvic Floor Dysfunct. 2004,15(1):44-8.
[55]李炎唐．泌尿和男子生殖系创伤[M]．人民军医出版社出版，2003年第1版，3—8．
[56]Ozumba D, Starr AJ, Benedetti GE, et al. Male sexual function after pelvic fracture[J]. Orthopedics. 2004,27(3):313-8.
[57]郭应禄，辛钟成．勃起功能障碍外科治疗学[M]．北京医科大学出版社．2000年，第一版：1—12．
[58]Wespes E, Wildschutz T, Roumeguere T, et al. The place of surgery for vascular impotence in the third millennium[J]. J Urol. 2003,170(4 Pt 1):1284-6.
[59]Shenfeld OZ, Kiselgorf D, Gofrit ON, et al. The incidence and causes of erectile dysfunction after pelvic fractures associated with posterior urethral disruption[J]. J Urol. 2003,169(6):2173-6.
[60]张玉海，邵强．前列腺外科[M]．人民卫生出版社，2003年，274-280．
[61]邓春华，孙祥宙．外伤性勃起功能障碍．见丘少鹏，邓春华主编．男科疾病误诊误治与防范[M]．科学技术文献出版社．2002年，第一版：133—141．
[62]Anis J, Ben Amna M, Hajri M, et al. Perineo-transpubic approach to the management of posterior urethral post-traumatic rupture[J]. Ann Urol(Paris). 2002,36(5):318-21.
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