治疗复杂性后尿道狭窄3种手术入路的比较解剖学研究

Comparative anatomical study of three surgical approaches for treating complex posterior urethral stricture

目的评价经耻骨上、耻骨下、会阴3种手术入路治疗复杂性后尿道狭窄的优劣。方法解剖35具成年男性尸体标本,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)的距离及相关角度;对另20具成年男性尸体标本分别经3种手术入路显露后尿道,标记可能损伤的组织器官并评分。结果各点之间的距离AD=(6.5±0.5)cm,BD=(2.2±0.5)cm,CD=(3.4±0.6)cm,BD<CD<AD (P<0.05,SNK法);AE=(6.6±0.5)cm,BE=(3.0±0.5)cm,CE=(4.4±0.7)cm,BE<CE<AE (P<0.05,SNK法);AF=(5.7±0.6)cm,BF=(4.5±0.5)cm,CF=(6.5±0.6)cm,BF<AF<CF(P<0.05,SNK法)。各点连线所成角度中,∠EAD (α1)=(9.3±2.0)o,∠EBD (α2)=(17.4±3.8)o,∠ECD (α3)=(9.2±1.6)o,α1与α2有显著性差异(P<0.05,t=11.1),α3与α2有显著性差异(P<0.05,t=12.1),α1与α3无显著性差异(P>0.05,t=0.13);∠FAE (β1) =(22.7±2.6)o,∠FBE (β2 )=(32.9±6.4)o,∠FCE (β3)= (15.0±3.2)o,其中β2>β1>β3(P<0.05,SNK法)。经耻骨上入路损伤评分为13分,经耻骨下为20分,经会阴为15分。结论暴露从优到劣依次为经耻骨下、经耻骨上、经会阴;损伤从大到小依次为经耻骨下、经会阴、经耻骨上部分。

Objective To evaluate the advantages and disadvantages o f 3 surgical approaches via superior intermedial margin of the pubis, inferior medial margin of the pubis, and the perineum, respectively, in the treatment of posterior urethral stricture. Methods Thirty-five adult male corpses were disse cted in which the distances from the bulbo-membranous urethra conjuction (D), th e apex of prostate (E), and the bladder neck (F) to the superior medial margin o f the pubis (A), the inferior medial mar-gin of the pubis (B) and the midpoint o f linear distance between the two ischial tuberosities on the perineum (C) were respec-tively measured and compared. Another 20 adult male corpses were subjecte d to the 3 surgical approaches as described above and the urethra was exposed t o identify the tissues and organs with possible injuries resulted from the surge ry, which were e-valuated by scoring. Results The distances measured were as fol lows: 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, SN K means); AE=6.6±0.5 cm, BE=3.0±0.5 cm, CE=4.4±0.7 cm, and BE<CE<AE (P=0.05, SNK means); AF=5.7±0.6 cm, BF=4.5±0.5 cm, CF=6.5±0.6 cm, and BF<AF<CF (P=0.0 5, SNK means). The angles∠EAD (α 1 )=(9.3±2.0) o , ∠EBD (α 2 )=(17.4±3.8) o , ∠ECD (α 3 )=(9.2±1.6) o , showing marked difference between α 1 and α 2 (P<0.05, t=11.1) and between α 3 and α 2 (P<0.05, t=12.1), but not between α 1 and α 3 (P>0.05, t=0.13). The angles ∠FAE (β 1 ) =(22.7±2.6) o , ∠FBE (β 2 )=(32.9±6.4) o , ∠FCE (β 3 )=(15.0±3.2) o , and β 2 >β 1 >β 3 (P=0.05, SNK means). The score for tissue and organ injuries for the appro ach of the superior medial margin of the pubis was 13, 20 for the approach of in ferior medial margin of the pubis, and 15 for perineum approach. Conclusions In terms of operative field exposure, the best operation approach is via the infer i-or pubis, followed by superior pubis approach and perineum approach; while in view of the injuries, superior pubis approach is better than the perineum and i nferior pubis approaches. The inferior pubis approach should be the primary choi ce in the treatment of posterior urethral stricture.