【作者】 王海涛；

【导师】 霍然；

【作者基本信息】 山东大学 ， 外科学（整形）（专业学位）， 2017， 博士

【摘要】 论文纲要包皮过长(redundant prepuce)作为男性外生殖器最常见的疾病,在我国18岁以上男性发病率30%-50%,其存在阻碍阴茎的正常发育、导致包皮与阴茎头及尿路的炎症、增加性传播疾病、诱发阴茎癌等众多危害。随生活水平和保健意识的提高,行包皮过长手术治疗的患者也越来越多。传统的包皮环切术将包皮与阴茎浅筋膜、血管、淋巴管、神经等组织一并切除,手术创伤大,术后并发症多。近年来,较为先进的术式主要集中在去除包皮皮肤或表皮层的改良包皮环切术,保留了阴茎浅筋膜系统,术后效果良好。然而,作为此类手术的基础解剖研究甚少,目前尚未见有关包皮断层形态学观察的报道,鉴于此,我们从包皮环行断层解剖的角度出发,寻找各包皮断层形态学的差异与联系,尤其是各断层脉管系统、神经构筑的差异与联系,探究分层剥离包皮皮肤或表皮层的解剖可能与基础,旨在为仅切除多余的包皮皮肤或表皮层,保留包皮固有层及内外板间的筋膜、血管、淋巴管、神经的一系列改良手术方式提供理论依据,进而探讨仅切除多余的包皮皮肤或表皮层的改良包皮坏切术联合阴茎增粗术治疗包皮过长伴阴茎细小的临床应用效果。在第一章第一部分通过对50例传统包皮环切术后包皮组织标本进行包皮断层脉管系统观察,结果表明:通过包皮断层解剖证明仅切除多余的包皮表皮层手术操作的可行性;包皮表皮层缺乏血管、淋巴管,而真皮层及肉膜层含有丰富的血管、淋巴管,血管以小静脉为主、真皮层内较具皮下层内丰富,仅切除包皮表皮层、保留包皮固有层及内外板间的筋膜、血管、淋巴管的手术方式,可有效避免血肿、水肿等并发症。在本章第二部分通过对本章第一部分50例标本进行包皮断层组织形态学及神经构筑观察,结果表明:包皮表皮层缺乏神经纤维,而真皮层及肉膜层含有丰富的神经纤维,仅切除包皮表皮层、保留包皮内外板固有层间的筋膜与神经等组织的手术方式,可避免损伤神经而发生感觉异常等并发症;内板表皮较平坦,角质层薄,易受伤,且含较多作为病毒靶细胞的郎格罕氏细胞,易受到HIV、HPV等病毒及细菌的感染,为病毒及细菌进入男性生殖道的主要途径。在第二章选择我院收治的120例包皮过长伴阴茎细小者,随机将其分成研究组与对照组,每组各60例,研究组采用改良包皮环切阴茎浅筋膜后移法行阴茎增粗术,对照组实施单纯去表皮包皮环切阴茎增粗术,比较分析两组阴茎周径、直径变化差、勃起功能、术后并发症等指标,结果表明:改良包皮环切阴茎浅筋膜后移法阴茎增粗术效果显著,其能够更好地充分利用自体组织增粗阴茎,且能同时解决包皮过长的问题;术中保留较少的包皮内板对降低HIV、HPV等病毒及细菌感染率有重要意义,且能提供更多的阴茎浅筋膜组织用于阴茎增粗。第一章 包皮断层形态学观察第一部分包皮断层脉管系统观察目的探讨包皮各环行断层脉管系统的差异与联系,从脉管系统角度探究分层剥离包皮皮肤或表皮层的解剖可能与基础。方法随机选取威海市立医院烧伤整形美容外科2013年6月至2014年12月间,利用传统包皮环切术后包皮组织标本50例进行组织形态学观察。分别将标本自表皮真皮交界层行断层皮片剥离,并将其分为包皮内板表皮组、包皮外板表皮组、包皮内板真皮肉膜组、包皮外板真皮肉膜组4组。应用HE染色及SMA免疫组化染色光镜观察各组组织形态及其各断层脉管系统的差异与联系。结果包皮内板表皮较平坦、角质层较薄,外板表皮突延伸、角质层较厚;内、外板表皮均缺乏血管、淋巴管;包皮内、外板真皮经剥离后,已无表皮残留,真皮及肉膜内血管、淋巴管丰富,血管以小静脉为主、真皮层内较肉膜层内丰富;内板真皮肉膜组血管密度明显大于外板真皮肉膜组,有显著差异(P<0.05)。结论通过包皮断层解剖证明仅切除多余的包皮表皮层手术操作的可行性;包皮内、外板表皮层缺乏血管、淋巴管,而真皮层及肉膜层含有丰富的血管、淋巴管,故而仅切除多余的包皮表皮层,保留包皮固有层及内外板间的筋膜、血管、淋巴管的手术方式,可有效减少损伤血管、淋巴管而发生血肿、水肿等并发症。第二部分包皮断层神经构筑观察目的:观察包皮各环行断层组织形态及其神经构筑的差异与联系,从神经构筑角度探究分层剥离包皮皮肤或表皮层的解剖可能与基础。方法:以随机选取的威海市立医院烧伤整形美容外科2013年6月至2014年12月间、利用传统包皮环切术后的50例包皮组织标本为实验对象,采用S-100免疫组化染色及NFP免疫荧光染色等方法,对各组组织形态及其各断层神经构筑的差异与联系进行观察。结果:包皮内、外板表皮均缺乏神经纤维,但内板真皮乳头内含有较丰富的触觉小体,且内板表皮层分布较多的郎格罕氏细胞;真皮及肉膜内神经纤维丰富,但肉膜层内较真皮层内神经纤维分布密度大;内板真皮肉膜组神经纤维分布较外板真皮肉膜组明显丰富,差异有统计学意义(P<0.05)。结论:包皮内、外板表皮层缺乏神经纤维,而真皮层及肉膜层含有丰富的神经纤维,因此仅切除包皮表皮层、保留包皮内外板固有层间的筋膜与神经等组织的手术方式,可减少损伤神经而发生感觉异常等并发症;内板表皮较平坦,角质层薄,易受伤,且含较多作为病毒靶细胞的郎格罕氏细胞,易受到HIV、HPV等病毒及细菌的感染,为病毒及细菌进入男性生殖道的主要途径。第二章改良包皮环切浅筋膜后移法阴茎增粗术的疗效观察目的:探讨改良包皮环切浅筋膜后移法阴茎增粗术的临床治疗效果。方法:选择2010年6月至2015年6月我院收治的120例包皮过长伴阴茎细小者,随机将其分成研究组与对照组,每组各60例,研究组采用改良包皮环切阴茎浅筋膜后移法行阴茎增粗术,对照组实施去表皮包皮环切阴茎增粗术,比较分析两组阴茎周径、阴茎直径、阴茎勃起功能、术后并发症等指标。结果:研究组术后静息状态下阴茎周径7.61 ±0.30cm,术后勃起状态阴茎周径11.23±0.78cm,较术前明显增粗(P<0.05),且优于对照组术后静息状态下阴茎周径及术后勃起状态阴茎周径(P<0.05)。研究组术后1个月、3个月、6个月的阴茎直径变化差与对照组比较差异有统计学意义(P<0.05)。两组患者手术对其阴茎勃起功能无明显影响。随访3～12个月,两组已婚患者感觉性生活质量改善,研究组术后不良反应发生率低于对照组(P<0.05)。结论:与去表皮包皮环切阴茎增粗术比较,改良包皮环切阴茎浅筋膜后移法在解决包皮过长问题的同时,能够更好地充分利用自体组织增粗阴茎,且阴茎增粗术效果更显著;可有效减少血肿、水肿、感觉异常等并发症的发生:术中保留较少的包皮内板有利于降低HIV、HPV等病毒及细菌感染率,同时尽可能多的提供阴茎浅筋膜组织用于阴茎增粗。更多还原

【Abstract】 OUTLINERedundant prepuce,as the most common genital diseases for male,has an incidence rate of more than 30%-50%in our country among 18 years old male and above.Its existence hinders the normal development of the penis,leads to inflammation in prepuce,glans and urethra,increases the sexually transmitted diseases and even induces penile cancer and many other hazards.With the improvement of living standard and consciousness of health care,more and more patients undergo the redundant operation.Traditional circumcision cut off the foreskin and the penile superficial fascia,blood vessels,lymphatic vessels,nerves and other tissue resection,with a large surgical trauma and many postoperative complications.In recent years,more advanced surgical procedure is mainly focused on the removal of foreskin skin or skin layer of modified circumcision,retained the superficial fascia of the penis system,and the effect is good after the operation.However,as a basis for such an operation,there is few anatomical study on the morpholog of the foreskin sectional observation reports.In view of this,we dissected from the foreskin ring sectional angle.find the difference and contact of the foreskin sectional morphology,especially the differences and relations between the seetional vasculature,innervation,and to explore the anatomic basis delamination or prepuce skin epidermis and a series of modified surgical methods to retain the foreskin of lamina propria and inner and outer plate between the fascia,blood vessels.lymphatie vessels and nerves to and provide a theoretical basis,and to explore the clinical effect of it.In the first part of the first chapterm foreskin tissue specimens of 50 cases of’traditional circumcision foreskin were observed,and the results show that the sectional vasculature anatomy proved the feasibility of only foreskin prepuce operation in excess of the epidermis:epidermal layer of the prepuce is lack of blood vessels and lymphatic vessels,but dermis and layer of meat are rich in blood vessels.lymphatic tube,so surgery of only resection of the epidermis,remaining prepuce fascia,vascular and lymphatic foreskin stroma and between the inner and outer plate,can effectively avoid the complications such as hematoma,edema.In the second part of this chapter,through observation to the morphological and histological structure of nerve wrapping sectional of the 50 specimens,the results show that the foreskin epidermis and dermis are lack of nerve fibers,but layer of meat is rich in nerve fibers,so only surgery of only resection of the epidermis,the remaining prepuce operation preputial lamina between the fascia and nerve other organizations,can avoid the nerve injury and complications such as paresthesia.The inner epidermis is flat,and with thin cuticle,so it is more vulnerable,and contain more Langerhans cells as a viral target cells,susceptible to HIV,HPV and other viral and bacterial infections,and thus is the main portal for HIV,HPV and other viruses and bacteria into of the male.In the second chapter.120 cases of phimosis with small penis in our hospital were selected and randomly divided into study group and control group,with 60 cases in each group.The study group adopted improved circumcision superficial fascia retrocession for penile augmentation surgery,the control group to implement the epidermal cireumeision of penile augmentation with,comparative analysis of two groups of penile circumference,diameter of the penis,penile erectile function and postoperative complications.IThe results show that the effect of improved circumcision superficial penile fascia retrocession augmentation is more significant.It can make full use of autologous tissue thickening of the penis,and can also solve the problem of less redundant prepuce:the foreskin was kept on reducing HIV and HPV viruses and bacteria infection rate,which is of important significance.Chaper Ⅰ Sectional morphology observation of prepucePart Ⅰ.Sectional vascular system observation of prepuceObjective:To investigate the differences and relations between the circular prepuce vascular system sectional,and to explore the anatomic basis of layered peeling or prepuce skin epidermis from the vascular system perspective.Methods:Randomly selected 50 patients from the burns and plastic surgery in Weihai Municipal Hospital from June 2013 to December 2014,who had undergone the traditional circumcision and took their foreskin tissue as the specimens,which were undergone histomorphology observation.Respectively,the specimens were peeled from the epidermis and dermis layer of the skin,and then divided into 4 groups,which are group A,group B,group C and group D.HE staining and SMA immunohistochemical staining were used to observe the differences and relations between the tissue morphology and the different vascular system.Results:The foreskin epidermis is flat with thin cuticle,and the outer epidermis has sudden extension with thick cuticle:the inner and outer plate epidermis were lack of blood vessels and lymphatic vessels:after the inner and outer plate leather was stripped off,there is no inner epidermal residue,and the membrane of leather and meat in of are rich in vascular and lymphatic vessels.Rich blood vessels are mainly small veins,the dermis layer of leather is richer than that of meat;vascular density of the inner plate meat membrane group was significantly greater than the outer plate of dermal meat membrane group,and the difference was signitlcant(P<0.05).Conclusion:The foreskin sectional anatomy proved the feasibility of the operation of redundant prepuce:epidermal layer of the prepuce is lack of blood vessels and lymphatic vessels,but dermis and layer of meat are rich in blood vessels.lymphatic tube,so surgery of only resection of the epidermis.remaining prepuce fascia.vascular and lymphatic foreskin stroma and between the inner and outer plate,can effectively avoid the complications Such as hrmatoma,edema.Part Ⅱ.Sectional innervation observation of prepuceObjective:To observe the differences and relations between the sectional structure and wrapping ring innervation,and to explore the anatomic basis of layered peeling or prepuce skin epidermis from the perspective of innervation foreskin delamination.Methods:Randomly selected 50 patients from the burns and plastic surgery in Weihai Municipal Hospital from June 2013 to December 2014,who had undergone the traditional circumcision and took their foreskin tissue as the specimens,which were undergone S-100 immunohistochemically staining and NFP immunofluorescence staining method to observe the differences and relations between each structure and each sectional innervation.Results:The foreskin of the inner and outer plate are lack of epidermal nerve fibers,but the inner plate of dermal papilla contains rich corpuscles,and with the distribution of more epidermal Langerhans cells;nerve fibers in the dermis and the meat film is rich,but the nerve fiber density in layer of meat is larger than that in the layer of leather;the distribution of nerve fibers in the dermis dartos group is significantly enriched,and the difference was statistically significant(P<0.05).Conclusion:The foreskin epidermis and dermis are lack of nerve fibers,but layer of leather and meat are rich in nerve fibers,so only surgery of only resection of the epidermis.the remaining prepuce operation preputial lamina between the fascia and nerve other organizations.can avoid the nerve injury and complications such as paresthesia.The inner epidermis is flat.and with thin cuticle,so it is more vulnerable.and contains more Langerhans cells as a viral target cells,susceptible to HIV,HPV and other viral or bacterial infections,and thus is the main portal for HIV、HPV and other viruses or bacteria into the male.Chaper Ⅱ.The efficacy of modified circumcision with penile augmentationObjective:To explore the clinical therapeutic effect of penile augmentation with superficial fascia retrocession.Methods:120 cases of phimosis with small penis in our hospital were selected and randomly divided into study group and control group,with 60 cases in each group.The study group adopted improved circumcision superficial fascia retrocession for penile augmentation surgery,the control group to implement the epidermal circumcision of penile augmentation with,comparative analysis of two groups of penile circumference,diameter of the penis,penile erectile function and postoperative complications.Results:Postoperative resting penile circumference of the study group was 7.60 +0.31cm.postoperative erection penis circumference was 11.24 + 0.82cm,significantly higher than the preoperative thickening(P<0.05),and the rest is better than the control group after operation under the penile circumference and postoperative erection penile circumference(P<0.05).There was a significant dif1ference between the 1 months,3 months,6 months after surger in the study group,and the difference was statistically significant(P<0.05).The operation of the two groups had no significant effect on the erectile function of the patients.Both groups were followed from 3 up to 12 months.The quality of sex life for the two groups was significant])improved.The incidence of adverse reactions in the study group was lower than that in the control group(P<0.05).Conclusion:The results show that the effect of improved circumcision superficial pcenile fascia retrocession augmentation is more significant.It can make Full use of autologous tissue thickening of the penis,and can also solve the problem of less redundant prepuce:the foreskin was kept on reducing HIV and HPV viruses and bacteria infection rate,which is of important significance.更多还原