李钢医生的科普号

British Journal of Urology International 2011 (Impact Factor: 2.865)Introduction to biodegradable polylactic acid ureteral stent application for treatment of ureteral war injuryGang Li, Zhong-Xin Wang , Wei-Jun Fu , Bao-fa Hong , Xiao-Xiong Wang, Lei Cao , Fu-Qiang Xu , Qiang Song , Fu-Zhai Cui , Xu ZhangOrgan Transplant Center, 309th Hospital of PLA, Beijing 100091, ChinaFig. 1.A, three kinds of cartridge cases without base(the base of cartridge case is cut off).B, configuration of the firearm fragment wound generator.C, firearm fragment injury was made to ureter by shrapnel.D, histological observation of the wounded ureter tissue after firearm fragment injury.: the full-thickness of ureter was completely torn up by the firearm fragment, with hemorrage at sub-mucosa layer around the wounds and within muscular layer. There were residues at surrounding location, and a small quantity of neutrophil aggregated in minute vessels (HE×40).E, polylactic acid biodegradable ureteral stent.F, polylactic acid ureteral stent was inserted into the ureter.Fig. 2. KUB and IVP of Group B preoperation and postoperatione (white arrows pointing to the biodegradable stent).A, IVP preoperation: the image was clear, and no hydronephrosis or hydroureter was found in bilateral renal pelvis and ureter.B, IVP at 40 days postoperatively: the biodegradable stents remained in good shape and position. Slight hydronephrosis could be seen on the other side.C, KUB at 80 days postoperatively : partial degradation of the stent could be seen.D, IVP at 80 days postoperatively: no hydronephrosis on the side with stent while moderate hydronephrosis on the other side without stent. The junctures where ureters meet bladder were clear on both sides.E, KUB at 120 days postoperatively: the stent degraded almost completely with a few fragments left in the ureters.F, IVP at 120 days postoperatively: no hydronephrosis on the side with stent while severe hydronephrosis on the other side without stent.Fig. 3. renogram quantitative analysis.A, ratio of Renal Partial Concentration Index (RPCI) (unwounded side/wounded side) in group A.B, ratio of half time of kidney washout (unwounded side/wounded side) in group A.C, ratio of Renal Partial Concentration Index (RPCI) (biodegradable stent side/unstented side) in group B.D, ratio of half time of kidney washout(biodegradable stent side/unstented side) in gtoup B.ABSTRACTOBJECTIVEA new canine model with ureteral war injury was created, based on which the operability and effectiveness of biodegradable ureteral stent for clinical treatment of ureteral war injury was studied.MATERIALS AND METHODSA set of device was made and employed to generate firearm fragment wounds to unilateral ureters (on randomly-chosen sides) of 9 Beagle dogs in Group A. Later, debridement and suture were conducted for the wounded ureters. Both intravenous pyelography (IVP) and radioactive renography were performed at the three time points, namely, 40 days, 80 days, and 120 days postoperatively. Firearm fragment wounds were made to the bilateral ureters in 9 Beagle dogs of Group B. A polylactic acid stent was placed unilaterally (on randomly-chosen side) while the ureter on the other side was debrided and sutured without stenting. Both intravenous pyelography (IVP) and radioactive renography were performed at the three time points, namely, 40 days, 80 days, and 120 days postoperatively. The operability and effectiveness of the biodegradable ureteral stent were studied thereafter.RESULTS In Group A, the hydronephrosis and hydroureter occurred and got worse postoperatively on the wounded sides in all 9 Beagle dogs. The ratio of Renal Partial Concentration Index (RPCI) between bilateral kidneys (unwounded side/wounded side) kept increasing. The ratio of half time of kidney washout between bilateral kidneys (unwounded side/wounded side) kept decreasing. In Group B, neither hydronephrosis nor hydroureter could be found postoperatively in stented ureters while both hydronephrosis and hydroureter occurred in unstented ureters in all 9 Beagle dogs. The RPCI ratio between bilateral kidneys (stented side/unstented side) kept increasing while the half time of kidney washout ratio between bilateral kidneys (stented side/unstented side) kept decreasing. The differences were of statistical significance.CONCLUSIONIn Group A, the new canine model with firearm fragment wounds was tested and proved to be operable and effective. In Group B, the hydronephrosis and hydroureter were effectively prevented beforehand in ureters with biodegradable stents placement as opposed to the ureters without stent where hydronephrosis and hydroureter occurred. The renal concentration capacity was effectively protected and the half time of kidney washout was shortened.KEY WORDSureter, biodegradable, stent, wounds and injuries, firearms, model, animalINTRODUCTIONIn order to treat the ureteral war injury, ureteral stents are used for holding the ureters open and draining. Currently, the most widely adopted stent is the double-J stent[1-3]. However, placement of double-J stent requires a second procedure for removal, which is invasive and causes great patient discomfort; in addition, long-term placement of ureteral stents cause many complications, including infection, blockage by encrustation, hematuria, discomfort, and calculus[4-8]. Therefore, a biocompatible uereteral stent triggering less complications is demanded.With the development of study in biodegradable polymers applied for urinary stents[9-16], there has been a progress in the research on polylactic acid applied for ureteral stents[17-25]. Biodegradable polymers, with greater biocompatibility, can degrade in vivo; therefore, it obviates the need for a second procedure for stent removal and is much more reliable.The purpose of this research is to discuss the efficacy and feasibility of polylactic acid ureteral stents applied in the canine model for treatment of ureteral war injuries.MATERIALS AND METHODSThe device for firearm fragment woundsWe manufactured a set of device for generating firearm fragment wounds with home-made firecrackers, cartridge cases (The base of cartridge case has been cut off) and shrapnel (fig. 1-A and B). The production of the firecrackers is unified, and each firecracker contains 3 g of black powder (explosion speed 400m/s), has the same fuse (5 cm) and the same weight (12±0.2 g). Four cartridge cases (tank machine gun) of 7.62mm in calibre are connected in series to form explore section, and two cartridge cases (type-95 rifle) of 5.8 mm in caliber are connected in series to form sight section, and then the explore section and sight section are connected in series. In addition, another cartridge case (anti-materiel rifle) of 12.7mm can be added as a protective handle. Shrapnel is glued to the exit of sight section. The work principle of the decive is explained as follow. The firecracker explodes in the first segment of explosion section and generates shock waves successively through the second, third, and fourth segments of explosion section. Then the shockwaves pass through the sight section with a smaller caliber and project out the shrapnel to generate firearm fragment wounds. The blast damage area and power is under control (The maximum effective range is about 10 cm), and the said device is legal in China, a country with strict gun control laws.Polylactic acid ureteral stentThe material is provided by Department of Materials Science and Engineering of Tsinghua University in China. The stent used in this experiment is manufactured by PLLA(Poly-L-lactic acid) and PDLLA(Poly-DL-lactic acid) mixed together in mass proportion. A 25% barium sulfate addictive was applied to the material to enhance its radio-opacity. After the process of mixing, forming, cutting, winding, drying, trimming, and 60Co irradiation for sterilization, the cylindrical stent with a spiral and helical design was formed (with 50 mm in length, 0.8 mm in inner diameter, and 1.4 mm in outer diameter) (fig 1-E). With an expansion rate of 26.80±1.66%, the stent is capable of expanding at the designated location and be locked. According to the in vitro observation, it takes approximately 10 weeks for the hydrolytic degradation process of the stent in canine urine at 37 ℃, and the biodegradable stent degraded to sand-like substance finally.Experimental animals and groupingAnimal experiments were done in the Experimental Animal Center at the General Hospital of PLA in China. Eighteen Beagle dogs ranging from 9-11.5 kg were selected. Eight were male and 10 were female. The animals were randomly divided into two groups, namely Group A and Group B, with 9 dogs in each group.Operative procedures Beagle dogs were anesthetized generally by 3% Pentobarbital (25mg/kg) and trachea cannula was employed for mechanical respiration. Put at supine position, dog was cut at hypogastrium and bladder was found. After that, a mark was made where ureters meet bladder. The ureter of Beagle dog is about 15 cm in length, and the mid-ureter (7 cm away form the ureterovesical orifice) was selected as the location where injuries were to be made.The Group A was used to build up the canine model of ureteral war injury. The firearm fragment injuries were made to unilateral ureters on the randomly-chosen side (fig 1-C). Then, wounds were bundled up by wet gauze and kept for 30 minutes. After that, debridement was performed. The injury segment (1 cm) of ureter was cut off for pathological examination (fig 1-D). And two pieces of 6-0 absorbable sutures were used for end-to-end anastomosis to restore the continuity of ureters. Ureters on the opposite side remained intact.Group B was used for observing the biodegradable stent’s effect in the treatment of ureteral firearm injuries. Firearm injuries were made to ureters in the same measure as in Group A but on both sides. Successive process of debridement, cutting the wounded site, and suturing were conducted in exactly the same way as in Group A. In the meanwhile, unilateral ureters on randomly-chosen side were selected for biodegradable stent placement (fig 1-F). The stent’s mid-point was positioned exactly where ureteroureterotomy had been performed, and the stent was fixed at the site of anastomosis with 6-0 absorbable sutures. The ureters on the opposite side stayed without stent implantation.Conventional drainage and abdominal closure were performed, and both replacement of wound dressing and anti-infection treatment were provided postoperatively. Sutures were removed one week postoperatively. All surgery was done by the author himself.Assessment One week preoperatively and 40 days, 80 days, and 120 days postoperatively, all of the Beagle dogs underwent intravenous pyelography (IVP) and renogram. At 40 days, 80 days, and 120 days postoperatively, 3 Beagle dogs from Group A and 3 Beagle dogs from Group B were randomly selected and sacrificed by overdose of anesthesia after the examination.Data analysisRenogram quantitative analysis indicators were processed one-way ANOVA by software the SPSS 13.0. When P

International Journal of Urology, 2011,June (Impact fact: 1.158)Anatomical Variation of the Posterior Lumbar Tributaries of the Left Renal Vein in Retroperitoneal Laparoscopic Left Living Donor NephrectomyGang Li, Jun Dong, Jin-Shan Lu, Qiang Zu, Su-Xia Yang, Hong-Zhao Li, Xin Ma, Xu ZhangOrgan Transplant Center, 309 Hospital of PLA, Beijing, 100091, Chinafig 1Afig 1Bfig 1Cfig 1DFigure 1. (A) Type 1, The lumbar vein runs parallel to the route of the renal artery, perpendicular to the psoas major, and drains into the left renal vein dorsally. (B) Type 2, The lumbar azygos vein passes the renal artery dorsally, and imported the left renal vein dorsally. (C) Type 3, The lumbar vein runs parallel to the route of the renal artery, perpendicular to the psoas major; another lumbar azygos vein passes the renal artery dorsally; these two veins import the left renal vein dorsally and separately; In this picture, PLAV has been cut near the site of entry of it into the renal vein. (D) Type 4, The lumbar vein runs parallel to the route of the renal artery, perpendicular to the psoas major; another lumbar azygos vein passes the renal artery dorsally; these two veins confluence to form reno-hemi-azygo-lumbar trunk(AZV) and drain into left renal vein dorsally. AO, aorta; IVC, inferior vena cava; LK, left kidney; U, ureter; LA, left artery; LV, left vein; AV, adrenal vein; GV, gonadal vein; PLV, posterior lumbar vein connected with left ascending lumbar vein; PLAV, posterior lumbar azygos vein connected with hemiazygos vein; *, AZV(reno-hemi-azygo-lumbar trunk); PS, psoas major;fig 2Afig 2Bfig 2CFigure 2. (A) Type 5, There is no lumbar vein or lumbar azygos vein connecting the left renal vein and the ascending lumbar vein/hemiazygos vein. (B) Type 6, The lumbar azygos vein passes the renal artery dorsally, and imports the gonadal vein. (C) Type 7, There are 2 lumbar veins and 1 lumbar azygos vein, draining into the left renal vein dorsally and separately. Picture a and b were taken at different time point, because the 3 different lumbar/lumbar azygos vein could not be exposed at the same time in the same field of vision duiring the operation. AO, aorta; IVC, inferior vena cava; LK, left kidney; U, ureter; LA, left artery; LV, left vein; AV, adrenal vein; GV, gonadal vein; PLV, posterior lumbar vein connected with left ascending lumbar vein; PLAV, posterior lumbar azygos vein connected with hemiazygos vein; PS, psoas major;ABSTRACTOBJECTIVES: To increase awareness of the anatomical variation of the posterior lumbar tributaries of the left renal vein in retroperitoneal laparoscopic left living donor nephrectomy.METHODS: Sixty-one cases of retroperitoneal laparoscopic left living donor nephrectomy were performed from March 2008 to June 2010. The anatomical variations of the posterior lumbar tributaries of the left renal vein in these patients were noted.RESULTS: According to the variation of posterior lumbar tributaries, there are 7 types in total, including 5 main types (accounts for 95.1%, 58/61 cases), and the type of reno-hemi-azygo-lumbar trunk (AZV) (accounts for 16.4%, 10/61 cases). According to the number of posterior lumbar tributaries, no lumbar vein covers 16.4% (10/61 cases), one lumbar vein accounts for 47.5% (29/61 cases), two lumbar veins accounts for 32.8% (20/61 cases), and 3 lumbar veins share the proportion of 3.3% (2/61 cases). According the operation time during the process of managing posterior lumbar veins, it is type 4 (AZV) on which the surgeon spends the most time (P 80 ml/min. Mismatched donor-recipient pairs were 0 to 3 and Computed Tomography Angiography (CTA) or Magnetic Resonance Angiography (MRA) revealed normal morphology of the arteries in all 63 donor kidneys. The left kidney had 2 renal arteries in 6 cases, and the remaining donor kidneys had a single artery and a single vein. CT urography showed normal morphology and position of the renal pelvis and ureter in all donor kidneys.Retroperitoneal Laparoscopic TechniquesGeneral anesthesia was administered by tracheal cannulation. The patient was placed in the right lateral decubitus position with overextension. A 2-cm incision was made below the 12th rib in the posterior axillary line. The muscular layer and lumbodorsal fascia were bluntly divided, and an index finger was inserted to separate the retroperitoneal space bluntly. A balloon dissector was placed into the retroperitoneal space and 600 to 800 ml gas was infused to maintain the balloon dilation for 5 minutes. The gas was then evacuated and the balloon dissector removed. Under guidance of the index finger extending into the retroperitoneal space through the incision, a 5-mm puncture cannula was inserted below the costal margin in the anterior axillary line, and a 10-mm puncture cannula was inserted 2 cm above the superior border of the iliac crest in the mid-axillary line. Another12-mm puncture cannula was inserted at the 2-cm incision. Then the skin incision was sutured. The laparoscope was placed through the trocar in the mid-axillary line and the carbon dioxide insufflator was connected to the same trocar to achieve the pneumoretroperitoneum (pressure 14 mm Hg). Extraperitoneal fat at the surface of Gerota’s fascia was cleaned and Gerota’s fascia was incised along the peritoneal fold. The perirenal fat was dissected to reveal the surface of the kidney in proper order, first ventral surface, second dorsal surface, third lower pole and last upper pole of the kidney. Upward dissection along the anterior surface of the psoas major muscle outside Gerota’s fascia led to the renal pedicle dorsally and caudally. The adipose tissue surrounding the renal hilum was left intact as much as possible. The renal artery and vein were circumferentially mobilized from the renal hilum to the proximal ends as close as possible to their origins from the abdominal aorta and inferior vena cava. The posterior lumbar vein, spermatic vein and adrenal vein were circumferentially mobilized, ligated and cut in turn by harmonic scalpels. If the diameter of the vein was less than or equal to 3 mm, the vein was coagulated and cut at once by ultrasonic coagulating shears of harmonic scalpels. If the diameter was more than 3mm, the vein was ligated by 2 hem-o-locks and transected between them. The ureter was identified and transected with scissors near the junction of the iliac vessels after distal clamping. A transverse 6-cm skin incision was extended from the second trocar, and the subscutaneous tissue and muscles were cut. Then the incision was blocked by the surgeon’s left hand to prevent gas leakage. With the help of the surgeon’s left hand, the renal artery was controlled with two Hem-o-lock clips at the proximal end as close as possible to its origins from the abdominal aorta and subsequently rapidly transected with scissors without any clips on the kidney side. The renal vein was controlled and transected similarly. Then the kidney was taken out by the surgeon’s left hand as soon as possible, and placed immediately in an iced organ-preservation solution for renal perfusion.Data analysisThe operation time during the process of managing posterior lumbar vein was processed one-way ANOVA by software the SPSS 13.0. When P

中国男科学杂志 2009,121何学酉 1李钢 1张旭 2姜辉 2赵连明 3戴东曦 3谢毅1中国人民解放军总医院泌尿外科 （北京100853）2北京医科大学第三附属医院泌尿外科（北京 100191）3北京朝阳医院男科（北京 100020）通讯作者： 李钢，ligamg@sina.com，解放军总医院泌尿外科姜辉，jianghui55@163.com，北京医科大学第三附属医院泌尿外科戴东曦，daidxi@163.com，北京朝阳医院男科摘 要 目的 评估小剂量雄激素治疗男性少弱精子症的有效性和安全性。方法 采用多中心、随机、单盲、安慰剂对照的方法，对129例患者进行了疗程3月的临床研究。结果 治疗后，雄激素组患者的精液量、精子活力、精子活率、精子果糖、血睾酮升高，精子畸形率降低，差异有统计学意义；而安慰剂组患者的上述指标均无统计学差异。结论 小剂量雄激素补充治疗可显著提高少弱精子症患者的精液量、精子活力、精子活率、精子果糖和血睾酮，降低精子畸形率。关键词 少弱精子症 小剂量 雄激素Clinical study of a small dose of androgen for the treatment of oligo-asthenospermatism1HE Xue-you 1LI Gang 1ZHANG Xu 2JIANG Hui 2ZHAO Lian-ming 3DAI Dong-xi 3XIE Yi1Department of Urinary Surgery, The General Hospital of PLA, Beijing, 100853, China2Department of Urinary Surgery, Peking University Third Hospital, Beijing, 100191, China3Department of Urinary Surgery, Beijing Chao-Yang Hospital, Beijing, 100020, ChinaABSTRACT Purpose: To investigate the effect of a small quantity of androgen for the treatment of oligo-asthenospermatism. Methods: A total of 129 patients with oligo-asthenospermatism were enrolled in the multicentre, randomized, single-blind, placebo-controlled clinical trial with treatment by either testosterone undecanoate or placebo for 3 months. Results: There were significant increase in semen volume, motility and survival rate of sperm, fructose level of seminal plasma and testosterone level of plasma, and decrease in teratosperm rate in patients of androgen group. While there were no significant difference in patients of placebo group. Conclusion: Patients with oligo-asthenospermatism can gain significant increase in semen volume, motility and survival rate of sperm, fructose level of seminal plasma and testosterone level of plasma, and decrease in teratosperm rate after the treatment of a small dose of androgen.Key words oligo-asthenospermatism a small quantity androgen 男子不育症是临床常见的疾病，引起男性不育的原因可能有环境因素、生活方式、心理因素和生理性疾病等[1]。近年来，人类出现精子数量与质量下降，男子不育症发病率有升高趋势。据王益鑫的统计，国内男子不育症病因中，特发性少、弱精子症的比率在1986～1991年间分别为10.57%、7.70%，而在1992～1993年间则分别升至13.33%、17.42%[2]。对于特发性少、弱精子症，临床上多采用经验性治疗，其中小剂量雄激素补充治疗仍是一个有争议的研究热点。2005年10月至2007年4月，我们采用多中心、随机、单盲、安慰剂对照的方法，对129例患者进行了临床研究，现报告如下：资料与方法一、入选及排除标准 入选标准：1、婚后同居性功能正常；2、未避孕；3、女方妇科检查生育能力正常；4、精液常规检查按《WHO不育夫妇标准检查与诊断手册》[3]，符合少弱精子症的标准（精子密度< 20×106/ml，精子活力a+b< 50%）；5、抗精子抗体阴性；6、精液中果糖水平正常或低于正常值，但大于0。排除标准： 1、婚后不能长期同居；2、性功能异常，不能够将精液排入女方阴道；3、存在严重损害勃起功能的阴茎解剖结构异常；4、生殖激素5项中（FSH、LH、PRL、T、E2）任何一项异常；5、精液液化时间异常；6、精索静脉曲张；7、无精子症；8、任何身体、精神或滥用药物引起的，可能影响患者完成试验或妨碍其参加试验的健康异常；9、服用抗雄激素药、雄激素；10、访视前30d内服用任何其他研究药物（包括安慰剂）；11、对安特尔或任何研究药物过敏。二、一般临床资料本研究分三个医疗中心：解放军总医院，北京大学附属第三医院，首都医科大学朝阳医院，随机入组144例少弱精症患者，最后完成随访共129例。其中，安特尔组患者：安慰剂组患者的比例为85:44。本研究入组患者全部为中国男性，年龄最大的41岁，最小的23岁，平均34岁，不育病史最长的10年，最短的2年。三、试验方案 本研究是对各种病因所致的少弱精子症患者进行多中心、随机、单盲、安慰剂对照的前瞻性研究。患者入组后，先按照WHO精液实验室检测程序[4]行精液常规分析加特检（果糖、碱性磷酸酶）。并检查生殖激素5项（根据WHO配对药箱测定）。然后进入疗程3月的治疗期，安特尔组给予十一酸睾酮胶囊（安特尔）40mg 口服 每日2次，安慰剂组给予外观类似的淀粉胶囊 口服 每日2次。3月治疗结束时，复查精液常规分析加特检，及性腺五项。四、疗效指标 包括精液量、精子密度、精子活力、精子活率、精子畸形率、精子果糖和血睾酮。五、统计分析 本研究数据采用统计软件CHISS2004进行t检验、方差分析、t'检验、秩和检验。结果 对最终完成研究的129名患者的数据进行统计分析。安特尔组85名患者和安慰剂组44名患者，治疗前的基线值相比，精液量、精子密度、精子活力、精子活率、精子畸形率、精子果糖和血睾酮均无统计学差异，见表1。 3月治疗结束后，安慰剂组患者治疗后与治疗前相比，上述指标均无统计学差异，见表2。 3月治疗结束后，安特尔组患者治疗后与治疗前相比，精液量升高(P

Chinese Medical Journal, 2010 Oct (Impact Factor: 0.952)The modified one-cut circumcision technique by clamp (reports of 2000 cases)LI Gang, LI Qian, Fu Wei-jun, Hong Bao-fa, Luo Jin, Xu Fu-qiang, Cao Lei, Kang Yi-sheng , Dong Xin, Wang Yan, Liu Li, Zhang Xu,Organ Transplant Center,309 Hospital of PLA, Beijing, 100091, ChinaFigure 1a: Preoperative Photo. The prepuce relaxed naturally. b, c, d: 4 mosquito clamps was placed at 3, 6, 9 and 12 o’clock points where inner and outer layers meet.Figure 2 a: The prepuce was lifted by the assistant vertically with moderate tension. b: The surgeon used the index finger and middle finger of his left hand to press down so as to neutralize the tension caused by lifting the prepuce. The right hand was used to hold the large curved clamp with its radian downwards.Figure 3The foreskin was clamped with the inclined large curved clamp, with lower edge of the clamp closely next to the dorsal midline of glans, top of the clamp reached to the coronary sulcus, and the included angle was 30° between the penis and the long axis of the large curved clamp.Figure 4The figure shows the uniform and symmetrical remaining inner prepuce, and the neat cutting edge.Figure 5Final closure (a: Ventral. b: Dorsal. c: Lateral. d: 1 week after the operation)【Key words】 Circumcision, Male; Foreskin; Phimosis【Abstract】 Backgroud: Circumcision is a major urological operation which requires high surgical technique. We introduce the method of modified one-cut circumcision technique by clamp, which has many advantages such as less operating time and neat cutting edge. Methods: We reviewed 2000 cases with the modified one-cut circumcision surgery in our hospital from 2005 to 2009 and concluded our clinical experience. Results: Dorsal penile nerve block by two-point injection was applied. The modified circumcision by using clamp was performed in patients with redundant prepuce. Electronic coagulation was applied for hemostasis and 5-0 absorbable catgut was used for suture. The traditional circumcision was performed in patients with phimosis. Conclusions: Dorsal penile nerve block by two-point injection showed good clinical effect. The modified circumcision by using clamp leaded to shorter operation time and better post-operation performance. Electronic coagulation was safe and reliable. The primary goal of operation was to expose the external orifice of urethra to ensure normal voiding and ejaculation.In the western courtries, circumcision has been performed for a long time. However, because of religious and cultural differences, circumcision was rare in China before 20th century. As a result of this, penile cancer, accounting for 17 percent of all cancers, was the most common [1]. With the introduction of Western medicine in the 1920s, especially after the establishment of Urology as a separate department, circumcision was carried out gradually. The incidence of penile cancer was also reduced to 0.34/100,000, which was similar to the western developed countries[1]. Recently in China, circumcision is one of the most basic operations in urological surgery. More and more people have realized the efficacy of circumcision in preventing acquisition and transmission of sexually transmitted infections[2, 3].Two thousands patients at General Hospital of PLA received the circumcision of a new mothod, named the modified one-cut technique by clamp. We had satisfactory results. Compared with other techniques[4,5], the said technique features less operating time, uniform and symmetrical remaining inner prepuce and neat cutting edge. As long as the mosquito clamp is positioned accurately, only one cut is needed to clear the redundant prepuce. We didn’t need to trim the prepuce, which is a procedure employed by traditional circumcision technique. Skilled surgeon can finish the whole process within 15 minutes.METHODSClinical backgroundFrom February 2005 to June 2009, 2000 patient at General Hospital of PLA received the modified one-cut circumcision by clamp. The cohort aged from 9 to 71, consisting of 1,760 cases of excess foreskin and 240 cases of phimosis. The technique was efficient both for redundant prepuce and phimosis.AnesthesiaRoutine tests were performed before the operation. Dorsal penile nerve block anesthesia was performed by 1% Lidocaine Hydrochloride Injection fluid. Injection points were located at 2 and 10 o’clock of the root of the penis where dorsal nerves of penis pass through[6]. The pinhead was punctured vertically and stopped when resistance from albuginea was felt. Then 2/3 of Lidocaine dose was injected. The rest 1/3 was injected subcutaneously around the root of the penis.If pain was not relieved, more anesthesias would be added: (1) an injection was made from where Corpus spongiosum meets Bulbocavernosus and went along the surface of Bulbocavernosus muscle towards the urethral bulb. In this process, caution should be made to protect the testes and spermatic cords from damage[7]. (2) according to clinical experience, Lidocaine injection subcutaneously at raphe penis will be helpful.The modified one-cut circumcision technique by clamp The patient was in supine position, with penis in weak state after anesthesia. The prepuce relaxed naturally. Assistant used 4 mosquito clamps to clip prepuce at 3, 6, 9 and 12 o’clock points where inner and outer layers meet (Fig 1). In this way, the prepuce was lifted by the assistant vertically with moderate tension. The surgeon used the left hand to press down the prepuce so as to neutralize the tension caused by lifting. The right hand was used to hold the large curved clamp with its radian downwards (Fig 2). The foreskin was clamped by the large curved clamp at 30°with penis, keeping the lower edge of the clamp close to the dorsal midline of glans and the top of the clamp reaching to the collum glandis (Fig 3). The large curved clamp should be closed slowly, so that the glans could slip away rather than being caught up. Incision was performed exactly next to the lower edge of the large curved clamp with blade upward, so that the excess distant prepuce could be cut off without glans injury(Fig 4).The dorsal shallow vein was ligated with 5-0 silk. The surgeon could choose bipolar electrocoagulation or unipolar electrocoagulation for hemostasis (electrocoagulation energy: 20 J). As the blood vessels along the wounded edge got retracted easily, surgeon could roll up the wounded edge and conducted hemostasis. For these tiny bleeding spots along the wounded edge, we sutured them together with the skin surface for hemostasis.After hemostasis, the surgeon sutured four points respectively at the dorsal, ventral, left and right of the wounded edge with 5-0 absorbable suture. When suturing the point at the ventral side, the surgeon should try to match the frenulum preputii with raphe penis. The rest cutting edge was sutured at interrupted distance (Fig 5).The replacement of the wound dressing was performed 3 days after operation, and the average healing period was 7~10 days. Most of the patients healed well after the dressing was removed. To those who did not heal well enough, Nitrofurazone Solution bathing(4 times per day for consecutive 3 to 5 consecutive days) was used as an adjunctive therapy. Sexual activities were forbidden within one month after the operation.RESULTSThe result of the surgery on cases with excess foreskin or phimosisThe technique is easy to master. A surgeon with experience in conventional method can completely master the modified technique after 2.5 operations in average. And surgeon without any relevant experience can also be skilled after 18 operations in average. The whole process from anesthesia to wound dressing can be finished within 15 minutes by skilled surgeon. And the operating time is no more than 25 minutes for a new practitioner.Among the 2000 patients with excess forskin or phimosis, 1,975(98.75%) patients were considered as perfect heal. Hemorrhage took place in 4(0.2%) patients postoperatively, 3 patients healed after the second operation while 1 patient received the third operation due to poor healing. One (0.05%) patient was operated again because of poor healing caused by hematoma and another 1(0.05%) patient was operated again due to wound infection. Eighteen (0.9%) patients were considered as poor healing at the local wounded edge due to other reasons and the problem was solved with Nitrofurazone Solution bathing for 3 to 7 days. Skin accumulation was found in 1(0.05%) patient and he was operated again after 6 months.Only 29(1.45%) patients complained about pain after operation.DISCUSIONAdvantagesThe modified technique has many advantages, such as less operating time and neat cutting edge. As long as the mosquito clamp is positioned accurately, only one quick cut is needed to clear the excess inner and outer plate of prepuce, which obviates the need of trimming prepuce. This is also efficient for hemostasis in exposing the blood vessels before they get retracted. The whole process from anesthesia to wound dressing can be finished within 15 minutes by skilled surgeon. When the foreskin is removed, the cutting edge appears in the shape of symmetrical circular arcs with moderate inner plate left. The cosmetic effect is clear.Compared with circumcision at the root penile skin[8], the one-cut circumcision technique by clamp can be adopted in wider fields, including cutting operations in treating narrow preputial ring, recurrent balanoposthitis or prepuce hypertrophy. The one-cut technique is also used in treating suspicious ulcer or neoplasm on inner layers requiring a pathological examination.Compared with the stratified circumcision which retaining the subcutaneous fascia[9], the one-cut circumcision technique by clamp allows quick cut, quick blood vessel exposure and quick hemostasis, but less bleeding, less operation time and therefore less suffering. The stratified circumcision helps us with protecting fascia and lymphatic circulation system, reducing the edema period. But in the real practice, the circulatory system of blood and lymph is hardly protected and therefore operation time is greatly increased. As to one-cut circumcision technique by clamp, edema is efficiently avoided when we use compression bandaging technique. After the wound heal, the patients can gently knead the edema foreskin so as to improving the reconstruction of venous collateral circulation and heal edema. When weighting the advantages and disadvantages, we recommend the one-cut circumcision technique by clamp.HemostasisElectronic coagulation is safe and effective. Blood vessels within subcutaneous fascia are thin, therefore, it requires a proper and accurate approach when conducting hemostasis. When inadequate hemostasis was performed, postoperative bleeding may occur. When the author initially operated, 4 patients were found postoperative bleeding, which required a second surgery to remove the hematoma. 3 patients healed well while the remaining one suffered a third operation due to edema and poor blood supply caused by massive damage to subcutaneous tissues. Therefore, the author prefers a slight excessive hemostasis. By this method, chances of a second operation can be reduced to the minimal level, though necrosis on the wounds is found in some cases, which can be treated by Nitrofurazone Solution bathing[10].Frenulum treatmentFrenulum treatment is a core procedure in circumcision. Frenulum preputii is the median prepuce fold on the ventral surface of glans penis，which connects the deep of preputium penis to external orifice of urethral[7]. If the frenulum preputii is short, the penis may bend downwards when erection. Consequently, the frenulum preputii may break due to high pressure during sexual activities. Therefore, we deem that the frenulum preputii should be kept for 1.5～2cm, with an excessive length remaining rather than a too short leftover. So when the surgeon uses mosquito clamp to pick up the ventral foreskin at frenulum preputii, the pick-up point should be chosen a little more proximal.The blood vessels are normally crowded at frenulum preputii and easily get retracted under the wounded surface. Excessive coagulation may lead to necrosis, while inadequate hemostasis gives rise to postoperative bleeding. Therefore, horizontal suturing at distal end of the frenulum preputii can be effective for hemostasis.Frenulum preputii is not totally forbidden area for operation, if we understand thoroughly about the frenulum preputii's contribution to erection. As for those with short frenulum preputii, frenulum preputii contracture or broken frenulum preputii, horizontal incision accompanied by longitudinal suture shall be adopted[11,12], for this technique can release the force focused on frenulum preputii when erection. Even if there is no frenulum preputii, erectile function will by no means be affected.Treatment of phimosisPatients with phimosis vary within a great scale. There can be no adhesion between foreskin and penis in which the modified one-cut circumcision technique by clamp can be applied. But when there is serious adhesion extending to the external orifice of urethral, serious inflammation, vegetation or even abscess within foreskin, the traditional circumcision with scissors should be appled. The author is convinced that there are 5 basic principles in phimosis treatment: (1) The primary goal is to expose the external orifice of urethral to ensure normal voiding and ejaculation. (2) Removing the infected lesions and potential risks of infection as completely as possible. (3) Cutting and rendering suspicious tissues to pathological examination. (4) Exposing the glans as completely as possible. (5) Trying to trim the penis to a normal status and foreskin shape. Based on the abovementioned principle, the surgeon is required to integrate cosmetic techniques including Z-plasty or V-Y plasty with flexibility.In the summary, dorsal penile nerve block by two points injection shows good clinical effect. The modified circumcision by using clamp leads to shorter operation time but better post-operation performance. Electronic coagulation is safe and reliable. The most important principle of operation for patients with phimosis is to expose the external orifice of urethra.REFERENCE: 1. Wu JP. Wu Jie-ping’s Urology. Jinan: Shandong Science and Technology Press 2004: 22, 10132. Perera CL, Bridgewater FH, Thavaneswaran P, Maddern GJ. Safety and efficacy of nontherapeutic male circumcision: a systematic review. Ann Fam Med 2010; 8: 64-72. PMID: 200652813. Wang ML, Macklin EA, Tracy E, Nadel H, Catlin EA. Updated parental viewpoints on male neonatal circumcision in the United States. Clin Pediatr (Phila) 2010; 49: 130-136. PMID: 200805194. Xiao XM. Practical foreskain surgery. Beijing: People’s PLA Medical Press 1994: 38-585. He Y, Zhou XH. Balloon dilation treatment of phimosis in boys (Report of 512 cases). Chin Med J (Engl) 1991; 104: 491-493. PMID: 18740256. Xiao YH, Liu ZL, Peng SL, Wang W, Hang Y. Anatomic evidence of dorsal penile nerve block for circumcision and its clinical applications. Academic Journal of PLA Postgraduate Medical School 2007; 28: 177-178.7. Williams PL (author); Yang L, Gao YM (translators). Gray‘s Anatomy , 38th edition. Shenyang: Liaoning Education Press 1996: 1288, 18588. Chen K, Liu JC, Fu HY, Shen JY. Circumcision of the root-skin of penis for the treatment of redundant prepuce. Chinese Journal of Urology 2005; 26: 51-53.9. Zhang JY, Hu JZ, Yuan Cy, Sun CW. Experience of the improvement of circumcision. Chinese Journal of Aesthetic Medicine 2007; 16: 1218-1220.10. Weiss HA, Larke N, Halperin D. Complications of circumcision in male neonates, infants and children: a systematic review. BMC Urol 2010; 10: 2-4. PMID: 2015888311. Frank Hinman, Jr (author); Guan DZ, Mei H (translators). Atlas of Urology Surgery, 2nd edition. Beijing: People’s Health Publishing House 2005: 17412. Li G, Hong BF, Zhang X, He XY, Li SR, Luo J, et al. Experiences of operation for frenulum of prepuce (reports of 150 cases). Chinese Journal of Aesthetic Medicine 2009; 18: 433-435.

中国男科学杂志 2006,05 李钢1 何学酉1 王晓刚2 王晓雄1 洪宝发1解放军总医院泌尿外科 北京 100853【摘要】 目的 提高对男性假两性畸形的诊断水平，总结治疗经验。方法 回顾1982年至2005年间我院诊治的47名男性假两性畸形患者，其中最长随访时间23年，并结合文献对其病因、诊断、治疗进行讨论。结果 47名患者临床确诊为男性假两性畸形，其中31名患者通过实验室、影像学等检查进一步明确病因学诊断。42名患者接受了手术治疗，24名术后性别为男性，18名为女性。24名男性患者中，第1次手术后恢复良好出院6名，第1次手术后恢复欠佳出院18名；在我院接受2次及2次以上手术共17例次。18名女性患者，均第1次手术后恢复良好出院，其中12名建议婚前再次手术成形。结论 早期诊断对提高疗效果意义重大；病因诊断对治疗有一定的指导意义；治疗应着重于性别选择和性腺处理两个方面；术后性别宜首选女性。【关键词】 男性假两性畸形 诊断 手术 性别Clinical study of the diagnosis and treatment of male pseudohermaphroditism (reports of 47 cases)Li Gang 1 He Xueyou 1 Wang Xiaoxiong1 Hong Baofa1Department of Urinary Surgery, The General Hospital of PLA, Beijing, 100853, China【Abstract】 PURPOSE: To improve the accuracy of diagnosis and summarize the experience of treatment for male pseudohermaphroditism. MATERIALS AND METHODS: To review the 47 cases with the diagnosis of male pseudohermaphroditism from 1982 to 2005. The longest follow-up time was 17 years. RESULTS: Etiologic diagnosis had been made for 31 of the 47 patients with the help of laboratory examination, ultrasonic and radiological examination. 42 patients had received operations after which 24 of them went to their result as male and 18 as female. In man’s cases, only 6 of 24 patients recover completely in hospital after the first time operation. The male patients had received further operations 17 person-time in our hospital. While in female cases, all the 18 patients recovered successfully in hospital after the first operation, and 12 of them were recommended to receive plastic operation before the marriage. CONCLUSIONS: Early accurate diagnosis is very important for the medical treatment and Etiologic diagnosis is useful in this course. Emphasis should be placed on the sex choice and gonad treatment. Female is more advisable in the sex choice for the patients.【Key words】 male pseudohermaphroditism diagnosis operation sex性别的认定包括形态标准（核型、性腺、生殖管道、外阴部及第二性征）与心理标准（抚养性别、社会性别）。形态标准与心理标准之间出现矛盾，即为性心理不正常，包括易性癖和易装癖等。形态标准之间出现矛盾，即为性分化异常或两性畸形，具体可分为性染色体畸变、男性假两性畸形、女性假两性畸形和真两性畸形[1]。其中，男性假两性畸形是指染色体为46XY，性腺为睾丸，但是生殖管道和/或外生殖器男性化不全[2]，它属于性分化异常中病因和类型最复杂的一种。本文回顾了1982年至2005年间我院收治的47例男性假两性畸形病例，结合文献，对其诊断和治疗做一初步探讨。1 资料和方法本组病例分别来自我院泌尿外科、内分泌科和妇产科。患者初次至我院就诊时最小年龄2.33岁，最大28岁，平均15.54岁；已婚1名，未婚46名。父母为姑表亲结婚1例，发现亲“兄弟”为相同患者的4组。入院后31名患者通过实验室、影像学等检查进一步明确了病因学诊断，16名患者未明确病因学诊断，具体诊断情况见表1。表1 我院收治的男性假两性畸形患者病因分类诊断 例 核型 外阴表型 年龄 骨龄 青春期 青春期 苗勒管 内分泌检查 家族发病 数 变声、 乳房发 结构 情况及其 喉结、 育 他 阴腋毛低促性腺激 2 46XY 男性表型, 15-24, 较正常 无 无 无 LH、FSH、T↓,素性性腺机 阴茎、睾 平均 同龄小 GnRH兴奋试验、能减退 丸小 19.5 6-9岁 HCG兴奋T试验减弱46XY型性 4 46XY 女性表型, 17-28, 较正常 无 无 无 LH、FSH↑,T↓, 2“姐妹”腺发育不全 阴蒂小,未 平均 同龄小 E2↓,HCG兴奋 患者1组,见睾丸,2 22.8 1-6岁 T试验无 已婚1例例盲端阴道17-α羟化 3 46XY 女性幼稚型 16-17, 较正常 无 无 无 LH、FSH↑,T↓,酶缺陷 ,阴蒂略大, 平均 同龄小 E2正常或↓2例盲端阴 16.3 3-6岁道,1例可扪及腹股沟睾丸完全性雄激 1 46XY 女性表型, 22 无 无 无 LH、FSH、T正常素不敏感综 有或无腹股 范围,E2↑合征(CAIS) 沟睾丸部分性雄激 7 46XY 女性幼稚型 5-23, 较正常 有不同 2例有, 无 LH、FSH、T、E2素不敏感综 至两性畸形 平均 同龄小 程度变 2例无 正常或↑合征(PAIS) 伴尿道下裂, 14.7 1-3岁 化大阴唇或腹股沟可扪及睾丸5-α还原酶 14 46XY 两性畸形,会 8-24, 较正常 有不同 无 无 T正常或↑，T/DHT↑ 父母姑表缺乏症 阴型或阴囊 平均 同龄大 程度变 大于30倍以上 亲结婚1例性尿道下裂 14.6, 4岁到 化 ,2“姐妹”、大阴唇或腹 小4岁 3“姐妹”股沟可扪及睾丸 患者各1组备注：1、大于18岁的患者，骨龄按18岁计算。 2、未获得病因诊断的男性假两性畸形患者中，有3“兄弟”患者1组，但他们还有一个妹妹未见异常。2 结果本组47名患者中，外院接受手术后来我院再次诊治5名，初次诊治即来我院的患者42名。在我院诊治过程中，患者接受手术治疗的42名，非手术治疗2名，因其他原因未治疗出院3名。随访最长时间23年。在我院接受手术的42名患者，术前抚养性别男性8名，术前抚养性别女性34名。术前抚养性别男性的8名患者，术后全部维持男性性别（其中，1名患者16岁时在外院行双侧隐睾切除术，但心理性别为男性，24岁来我院就诊后，接受雄激素替代治疗）；术前抚养性别为女性的34名患者，术后性别改为男性16名，维持女性18名；因此，术后患者性别情况总计男性24名，女性16名，具体情况见表2、表3。术后性别男性的24名患者在第一次住院手术过程中，第1次手术后恢复良好出院7名，第1次手术后恢复欠佳出院17名（带膀胱造瘘管出院4例，尿道瘘6例，尿道狭窄2例，感染1例，外形欠佳4例）；在我院接受2次及2次以上手术共17例次（尿道瘘修补4例次，尿道狭窄扩张3例次，尿道外口切开1例次，尿道成形术5例次，阴茎畸形矫正1例次，阴茎延长术2例次，阴茎假体植入术1例次）。术后性别女性的18名患者，均第1次手术后恢复良好出院，其中12名建议婚前再次手术阴道成形。非手术治疗患者2名，诊断均为低促性腺激素性性腺机能减退，他们将终身接受补充雄激素替代治疗。未治疗自动出院3名，1名诊断为完全性雄激素不敏感综合征（CAIS）,因超声未找到睾丸，后自动出院；2名病因诊断未明确，因经济等原因自动出院。表2 患者接受治疗情况诊断 非手术治疗 手术 术前男 术后男 术后男 术前女 术后女 术后女及其他 治疗 变男 变女 变男 变女低促性腺激素性性 2 0 0 0 0 0 0 0腺机能减退46XY型性腺发育 0 4 0 0 0 4 0 4不全17-α羟化酶缺陷 0 3 0 0 0 3 0 3完全性雄激素不敏 1 0 0 0 0 0 0 0感综合征(CAIS)部分性雄激素不敏 0 7 2 2 0 5 3 2感综合征(PAIS)5-α还原酶缺乏症 0 14 1 1 0 13 7 6男性假两性畸形 2 14 5 5 0 9 6 3表3 患者接受首次手术情况 术后性别为男性的患者24名 术后性别为女性的患者18名手术类型 男性外生殖器重建及/或 隐睾 经外阴双侧 经腹双侧性腺及/ 阴蒂阴道成形术 阴蒂成形术 隐睾固定及/或阴道切除 切除 性腺切除 或内生殖器切除手术例次 23 1 12 5 4 23 讨论从表1可以看出，外阴表型两性畸形的患者，就诊时年龄包括从幼儿期至青春期前后；外阴表型为基本男性或者女性的患者，初次来我院就诊时平均年龄>18岁。因此，对于外阴表型两性畸形不典型的患者，往往青春期前不易发现；就诊时如果没有结合详细的实验室检查、影像学检查，也不容易分辨性别、确定病因学诊断，从而导致延误诊断，影响治疗效果。为了实现男性假两性畸形的早期诊断，应该着重注意以下几方面。1、病史和家族史。本组患者中，父母为姑表亲结婚1例，发现亲“兄弟”为相同患者的4组，因此家族发病史对早期诊断有提示作用。2、体格检查，尤其是外阴表型和第二性征。不同患者两性畸形的严重程度差异较大，因此对可疑的患者，要着重检查尿道开口的位置、阴囊或大阴唇或腹股沟有无可疑的性腺等，青春期后的第二性征（喉结、声音、毛发分布、乳房等）、肛门指检前列腺也可作为诊断参考依据。3、核型鉴定是诊断的关键，在此基础上才能够进一步进行病因学诊断。4、影像学检查。超声、CT甚至 MRI，作为无创的检查手段，对于探查性腺的有无、部位、大小、形态结构，及子宫、输卵管、前列腺、精囊腺、输精管等生殖管道是否存在、发育状况等有很高的敏感性，因此，对于确定诊断、术前检查、术后动态观察，都有重要的价值。张素阁等人也做过相关的研究[3-5]。5、内腔镜检查。包括尿生殖窦内腔镜、腹腔镜在内的微创手段[6]，创伤小，观察直观，还可以取活检，从而获取病理诊断的“金指标”。 6、内分泌和激素检查。查血包括FSH、LH、T、DHT、E2、T/DHT、GnRH兴奋试验、HCG兴奋T试验、ACTH兴奋试验等，查尿包括17-酮类固醇、17-羟皮质类固醇、孕三醇等，它们是实现病因诊断的重要依据。7、阴道刮片检查。因为阴道上皮对外源性和内源性的各种激素都很敏感，因此可以通过该检查反映机体的激素分泌情况。早期确诊，有利于尽早安排手术、治疗方案，确立术后性别，防止发育不全的性腺恶变以及患者心理变态。确诊男性假两性畸形后，应结合实验室、病理学等检查进一步明确病因学诊断。由于胚胎的生殖管和外阴有自发地向女性分化的能力，所以，男性表型的分化，完全是睾丸的作用。据此，在结合相关文献的基础上[1、2]，我们将男性假两性畸形分为3大类：1、睾酮的产生障碍；2、睾酮的作用障碍；3、其他。具体见表4。其中，特发性低促性腺激素性性腺机能减退能否列入男性假两性畸形，尚存争议。因为他们的核型、表型、性腺、生殖管道均为男性（性分化明确），只是由于性腺轴的高位有问题，才导致性腺机能减退、雄激素合成不足以及生殖管道等发育不全。但是，由于他们符合男性假两性畸形的诊断条件，因此，本文中暂将其列入男性假两性畸形分类中。表4 男性假两性畸形的分类诊断 定义睾 ⑴特发性低促性腺激素性性腺机能减退 由于FSH、LH分泌减少而引起的性腺机能减退,不能合成足量睾酮酮产 ⑵Leydig细胞对LH无反应 Leydig细胞发育不全或Leydig细胞上的LH/HCG受体缺陷都会导致Leydig生 细胞对LH/HCG的刺激无反应,不能合成睾酮.为常染色体隐性遗传.障碍 ⑶46XY型性腺发育不全 又称胚胎睾丸退化综合征、睾丸消失综合征,可为家族性或散发性,病因 未明,家族性可能为基因突变所致. 睾酮的合 ⑷22-23碳链裂酶缺陷 睾酮和皮质激素的前体是胆固醇，睾酮的合成需要5种酶系统参加，这5 成和代谢 ⑸3-β羟甾脱氢酶缺陷 种酶的缺陷使睾酮的合成受影响，前3种酶的缺陷还影响皮质醇和醛固酮 所需的各 ⑹17-α羟化酶缺陷 的合成。 种酶缺乏 ⑺17-20碳链裂解酶缺陷 ⑻17-β羟甾脱氢酶缺陷睾 雄激 ⑼完全性雄激素不敏感综合征 AIS指雄激素受体发生了质或量的改变,使雄激素不能发挥其男性化作用,酮 素不 (CAIS) 又称睾丸女性化症.CAIS的表型为完全女性,青春期可有或无阴毛和腋毛.作 敏感用 综合 部分性雄 ⑽Lubs综合征 PAIS在病因、核型、遗传方式、血LH、T等都与CAIS相同,但外阴有不障 征 激不敏感 ⑾Gilbert-Dreyfus综合征 同程度的男性化.过去曾报道过的各种综合征,现在认为病因都是AR基碍 (AIS) 综合征 ⑿Reifenstein综合征 因突变,属于PAIS.又称家族性不完全性男性假两性畸形Ⅰ型. (PAIS) ⒀Rosewater综合征 ⒁5-α还原酶缺乏症 睾酮通过5-α还原酶转化为双氢睾酮，后者是未分化外阴衍化成男性外阴 的主要雄激素。5-α还原酶缺乏将导致假两性畸形。又称为假阴道会阴阴 囊型尿道下裂，家族性不完全性男性假两性畸形Ⅱ型。其 ⒂苗勒管持续存在综合征 睾丸Sertoli细胞不分泌MIS或苗勒管对MIS不敏感，苗勒管不退化，分化他 成输卵管、子宫由于各医院实验室条件不同，有的患者可能难以进一步得出确切的病因学诊断，譬如，如果实验室不能够查血DHT或5-α还原酶活性，就不能够通过T/DHT>35或5-α还原酶活性低下来诊断5-α还原酶缺乏症。但是，我们认为，虽然病因学诊断很重要，但它对于确定治疗方案不是决定因素；确诊男性假两性畸形后，在遵循男性假两性畸形治疗原则的前提下，可以开展治疗。本组16名未明确病因学诊断的患者，除了2名自动出院，其他14名均接受了手术治疗。我们认为，手术的目的是使患者较健康地参加社会生活劳动和性生活。手术的关键是术后性别的选择和性腺的处理。手术的原则包括：1、早期手术。最好在新生儿期治疗[7]，使术后性别和患者的抚养性别、社会性别一致，以避免心理变态。2、术后性别的选择[8]应该根据外生殖器、生殖管道、性腺的优势、患者本人及家属意愿、手术时年龄及术前的抚养性别和社会性别等综合考虑，但医生应更重点考虑外生殖器、生殖管道的手术条件以及患者术前的社会性别，如有可能术后性别首选女性。中国人重男轻女的思想普遍存在，本组患者中术前抚养性别为男性8例，家属全部要求术后继续保留男性性别；术前抚养性别女性34例，术后性别改为男性16例。但是，从上述手术结果统计可以看出，由于使患者成为男性的手术复杂，对患者自身手术条件、医生手术水平、术后护理等要求高，手术完全愈合后出院的比例不够满意。术后出现各种并发症的几率很大；而且，往往一次手术不能够满意，甚至需要多次手术。本组1名长期随访的患者，自其12岁至30岁的18年间在我院行多次手术，包括阴茎畸形矫正术、阴道切除、皮管尿道成行形、膀胱造瘘、睾丸下降、阴囊成形、阴茎延长术、阴茎假体植入术，患者术后性生活能力差，心理负担重，经济负担也很重。因此，根据我们的随访经验，我们认为术后性别首选女性，这与国内外很多报道的观点是一致的[9-11]。但是，对于就诊时年龄较大，社会性别已为男性，且强烈要求术后维持男性性别的患者，则应充分尊重他们的意见，因为对于这些患者，既使术后不能正常性生活，但是他们的术后形态性别与其性心理和性行为倾向一致，不至于出现性心理变态，能够较健康地参与社会劳动生活，这也更符合“生理-心理-社会医学模式”；但是，对他们应该术前详细地交待手术复杂、术后可能出现并发症多、术后男性性功能差等情况，在取得充分理解和认同后再实施手术。此外，对于5-α还原酶缺乏症的患者，也有学者认为[12、13] 他们若按女性抚养，成年后常发生性别倒转，因此宜按男性抚养，青春期前行男性外生殖器矫形。3、应将和抚育性别相矛盾的性腺和生殖管道切除，尤其是异位的或发育不良的性腺，以防止恶变的可能[14、15]。有文献报道单纯性ＸＹ性腺发育不全的患者中有约30%～60%发生生殖细胞肿瘤,是性发育异常中最易发生肿瘤的病种[16]。4、术后长期补充相应的激素，以促进和维持相应的第二性征。男性假两性畸形患者的治疗，不仅包括手术，还涉及了心理、社会等多方面因素，是一个长期的问题。关于他们术后的生活质量如何？是否能够正常的参与社会工作？是否有满意的性生活？是否结婚及婚姻是否幸福？等等，我们还将继续随访、观察和统计，希望能够得出更加全面的治疗和关怀方案。参考文献1. 吴阶平主编. 吴阶平泌尿外科学. 山东: 山东科学技术出版社, 2004: 476-4772. 周瑞锦, 刘中华, 玄绪军主编. 泌尿生殖系统遗传病与先天畸形. 郑州: 郑州大学出版社, 2002: 357-3583. 张素阁, 刘兰芬, 李新民, 等. 性别畸形的超声诊断分析. 上海医学影像杂志1998; 7(3): 115-1174. 苏雅娟, 李丽荣, 刘晓菡. 超声诊断男性假两性畸形1例. 中华超声影像学杂志 2000; 9(2): 915. 许茜, 李彩英, 时高峰, 等. CT诊断2例男性假两性畸形. 中国医学影像学杂志 2002; 10(1): 686. 何勉, 黄建昭, 王宁宁. 3例46XY男性假两性畸形的腹腔镜检查. 中国内镜杂志 1999; 5(6): 69-717. Pappis C, Constantinides C, Chiotis D, et al. Persistent Mullerian duct structures in cryptorchid male infants: surgical dilemmas. J Pediatr Surg 1979; 14(2): 128-318. 洪伟平, 许达开, 苏劲. 男性假两性畸形的诊断和治疗（附21例临床分析）. 中华泌尿外科杂志 2003; 23(11): 772-7739. 崔毓桂, 张桂元. 5-α还原酶缺乏症的初步实验研究. 南京医科大学学报1996; 16(5): 437-44110.李汉忠, 黄金国, 王惠君. CYP17(17α-羟化酶)缺陷型的诊断和治疗. 生殖医学杂志 2000; 9(4): 207-21111.马卫海, 刘轶民, 刘春雷, 等. 男性假两性畸形——睾丸完全女性化综合征. 中国厂矿医学 1999; 3: 229-23012. 毓桂. 类固醇5α-还原酶与5α-还原酶缺乏症（综述）. 国外医学内分泌分册 1995; 15(1):4-713.Wilson JD, et al. Steroid 5α-reductaseⅡ deficiency. EndocrineReviews 1993; 14(5): 577-58014.周红荣, 胡象莲. 男性假两性畸形与性腺肿瘤的关系. 上海医学. 1994, 17(4): 23715.Deligeoroglou E, Fotaki P, Kokkalis D. Description of 8 cases with gonadal dysgenesis syndrome type 46XY[J]. Akush Ginekol(sofiia) 2001; 42(2): 9-1216.陈镘如, 李福平, 徐克惠. 两性畸形40例的临床分析. 四川医学 2004; 25(11): 1177-1179

患者： 我母亲61岁。四五年前检查到左侧肾有一个2厘米左右的一个囊肿，现在检查发现长大了。长到4.8厘米了。病人心脏不好，心脏膈部瘤在两个心室中间，做过尿常规正常，验血肾功也正常 应该采取什么样的治疗方法好了。她这种身体情况能做手术吗，如果能做要采用那种方式手术呢。解放军第309医院泌尿外科李钢：理论上来说，您母亲这么大的肾囊肿，应该具有手术指征。现在的治疗方案都是微创化，即后腹腔镜手术完成肾囊肿去顶减压。但是结合你母亲的身体条件，也可以选择定期复查，观察对比囊肿的大小变化，如果迅速增大，则可以优先考虑手术。如果变化缓慢，也可以暂不处理。

患者： 腰疼去医院做彩超结果，双肾形态大小正常，边界清楚，结构尚清不扩张。右肾上极皮质内显示约6*5mm强回声，边界清，内回声欠均匀，呈网络状样改变。双肾内均示强回声光团，后伴声影，左侧大约4*4mm右侧约6*5mm 无治疗 这份检查报告能看出来错构瘤是良性还是恶性，严重吗？结石吃中药有效果吗？解放军第309医院泌尿外科李钢：错构瘤的成分是血管脂肪和平滑肌，是良性肿瘤，在超声上表现为强回声。但是，超声的准确性有限，只是一种筛查手段，如果想进一步明确诊断，做到心里有数，建议行双肾核磁平扫+增强检查。

患者： 前列患腺增生，7/4.9/4.9 未做任何治疗 可以做汽化电切术吗？谢谢解放军第309医院泌尿外科李钢：前列腺增生的患者，不是仅仅前列腺大就应该手术，而是有手术适应征，包括：1）尿潴留（至少有一次在拔除导管后不能排尿）；2）反复发作的血尿；3）由于前列腺增生引起的肾输尿管积水；4）合并膀胱结石；5）反复发作的尿路感染；6）巨大膀胱憩室。7）有其长期排尿困难引起的巨大疝气、痔疮等。如果您有上述手术适应症，可以考虑手术治疗。

患者： 2010年11月发现双肾下垂约2个椎体 主要症状有失眠 尿后不适伴有点尿频 全身乏力 恶心 中药吃过一段时间 没有效果 手术治疗成功率多少 有什么后遗症解放军第309医院泌尿外科李钢：首先，要明确肾下垂的手术指征：即肾下垂的症状明显影响工作生活，且有并发肾积水、肾盂炎、肾结石等情况者，可作肾脏悬吊固定术。对于双侧肾下垂患者，可先将严重侧肾脏悬吊，待2～3个月后再观察对侧肾脏以决定是否手术。目前腹腔镜微创技术已经成为泌尿外科的主流技术，我院采用后腹腔镜肾脏悬吊术，这种方法微创、安全、有效。

Archives of Surgery, 2012, Feb (Impact Fact: 4.5)Inter-transversalis-fascia Approach in Urological Laparoscopic OperationsGang Lia,b,1, Yeyong Qiana,1, Hongwei Baia, Zhigang Songc, Weijun Fub, Baofa Hongb, Jinfeng Jiaa, Bingyi Shia,*, Xu Zhangb,*aOrgan Transplant Center, 309 Hospital of PLA, Beijing, 100091, ChinabDepartment of Urology, 301 Hospital of PLA, Beijing, 100853, China cDepartment of Pathology, 301 Hospital of PLA, Beijing, 100853, ChinaFig. 1- Clinical anatomy of the transversalis fascia (TF)(A) cross plane below the 12th rib, (B) cross plane of the anterior superior iliac spine, (C) cross plane above the deep ring, (D) cross plane of the superior border of pubic symphysis, (E) sagittal plane from the linea alba.1= peritoneum (blue); 2= fascial space between the deep layer of TF and peritoneum; 3= deep layer of TF (red); 4= fascial space between the two layers of TF; 5= superficial layer of TF (green); 6= fascial space between superficial layer of TF and the transversus abdominis; 7= transversus abdominis; 8= obliquus internus abdominis muscle; 9= obliquus externus abdominis muscle; 10= linea alba; 11= inferior epigastric artery; 12= posterior rectus sheath; 13= rectus abdominis muscle; 14= anterior rectus sheath; 15= abdominal cavity; 16= colon; 17= Gerota’s (perirenal) fascia; 18= perinephric fat; 19= left kidney; 20= fascia lumbodorsalis; 21= latissimus dorsi muscle; 22= quadratus lumborum muscle; 23= psoas major muscle; 24= iliacus; 25= left common iliac artery; 26= left external iliac vein; 27= left gonadal artery; 28= iliopsoas muscle; 29= sartorius muscle; 30= rectum; 31= obturator internus muscle; 32= levator ani muscle; 33= coccyx; 34= right seminal vesicle; 35= prostate; 36= bladder; 37= obturator vein; 38= pubis; 39= obturator externus muscle; 40= median umbilical ligament; 41= medial umbilical ligament; 42= umbilicus; 43= Retzius space; 44= Bogros space; 45= retroperitoneal fat; 46= vas deferens; 47= superfiscial branch of deep dosal vein of penis; 48= pubic symphysis;Fig. 2 – Balloon dilation in the inter-transversalis-fascia space(A) the balloon dissector is inserted into the inter-transversalis-fascia space from the incision below the 12th rib in the posterior axillary line, (B) the balloon dissector is inserted into the inter-transversalis-fascia space from the incision at the base of the umbilicus, (C) the two layers of transversalis fascia (TF) are separated in the peritoneum.1= peritoneum (blue); 2= fascial space between the deep layer of TF and peritoneum; 3= deep layer of TF (red); 4= fascial space between the two layers of TF; 5= superficial layer of TF (green); 6= fascial space between superficial layer of TF and the transversus abdominis; 7= transversus abdominis; 8= linea alba; 9= balloon dissector.Fig. 3- Inter-transversalis-fascia approach during the retroperitoneal laparoscopic left nephrectomy(A) posteriorly, the two layers of transversalis fascia (TF) fuse in the outer edge of the quadratus lumborum muscle, (B) superiorly, the two layers of TF fuse and blend with the fascial covering of the inferior surface of the diaphragm, (C) posteriorly, the binding site of the two layers of TF keeps moving inferiorly and interiorly, from the quadratus lumborum to the psoas major, (D) anteriorly, the two layers of TF fuse in the anterior axillary line and superficially cover the peritoneum in the anterior abdominal wall; deeper to the deep layer of TF, it is the perirenal fascia near the quadratus lumborum and the peritoneum near the anterior axillary line. (E) incising the deep layer of TF near the peritoneal fold and dissecting between the deep layer of TF and the underlying perirenal fascia, we could then reach the peritoneum, (F) incising the perirenal fascia, we could see the deep perirenal fat.1= superficial layer of TF (covering the interior surface of transversus abdominis); 2= superficial layer of TF (covering the anterior surface of quadratus lumborum muscle ); 3= superficial layer of TF(covering the anterior surface of psoas major muscle);4= superficial layer of TF(covering the inferior surface of the diaphragm); 5= deep layer of TF (superficially covering the perirenal fascia); 6= deep layer of TF (superficially covering the peritoneum); 7= deep layer of TF (superficially covering the peritoneum fold line); 8= binding line of the two layers of TF; 9= white reticular fibers between the two layers of TF; 10= fat between the two layers of TF; 11=peritoneum; 12= perirenal fascia; 13= perinephric fat;Fig. 4- Inter-transversalis-fascia approach during the extraperitoneal laparoscopic radical prostatectomy(A) the space between the two layers of transversalis fascia (TF) in the region of anterior inferior abdominal wall, (B) the space between the two layers of TF in the left anterior inferior abdominal wall, (C) the inferior epigastric vessel runs between the two layers of TF, (D) the space between the two layers of TF in the left inguinal region, (E) cutting off the superficially branch of deep dorsal vein of penis (SBDDV) embedded in the fat in the Retzius space, (F) cutting off the SBDDV and cleaning up the fat in the Retzius space, then we can see the deep layer of TF which superficially covering the prostate.1= superficial layer of TF (covering the interior surface of rectus abdominis muscle); 2= superficial layer of TF (covering the interior surface of transversus abdominis); 3= superficial layer of TF (covering the interior surface of pubis ); 4= deep layer of TF (superficially covering the peritoneum); 5= deep layer of TF (superficially covering the left external iliac vessel); 6= deep layer of TF (superficially covering the bladder); 7= deep layer of TF (superficially covering the prostate); 8= white reticular fibers between the two layers of TF; 9= fat between the two layers of TF; 10= left inferior epigastric vessel (running through the space between the two layers); 11= left pubic vein; 12= SBDDV; 13= Retzius space; 14= Bogros space.Fig. 5- Inter-transversalis-fascia approach during the transperitoneal laparoscopic partial cystectomy(A) after establishment of pneumoperitoneum, we can see the posterior aspect of median unbilical ligament and bladder, (B) the peritoneum and urachus are incised and transversalis fascia (TF) is exposed, (C) the TF is incised and the rectus abdominis is exposed, (D) the two layers of TF are identified, (E) the space between the two layers of TF was bluntly separated, (F) we can reach the Retzius space between the two layers of TF.1= peritoneum (covering the interior surface of the median umbilical ligament); 2= peritoneum (covering the interior surface of the bladder ); 3= peritoneum; 4= fat between the peritoneum and deep layer of TF; 5= deep layer of TF; 6= superficial layer of TF; 7= white reticular fibers between the two layers of TF; 8= fat between the two layers of TF; 9= rectus abdominis muscle; 10= white reticular fibers between the rectus abdominis muscle and the superficial layer of TF; 11= pubis;Fig. 6- Histological examination of the transversalis fascia (TF): picture A (H&E × 12.5) displays an enlarged view of location A in picture B.1= peritoneum; 2= fascial space between the deep layer of TF and peritoneum; 3= deep layer of TF; 4= fascial space between the two layers of TF; 5= superficial layer of TF; 6= fascial space between the transversus abdominis and superficial layer of TF; 7= transversus abdominis; AbstractObjective: To study the clinical anatomy of transversalis fascia (TF) and explore the inter-transversalis-fascia approach in urological laparoscopic operations (ULO).Design: Prospective study.Setting: Academic hospital.Other participants: From January 2009 to April 2011 in 309 Hospital of PLA and 301 Hospital of PLA, 1217 cases of urological laparoscopic or open operations were collected and analyzed, 10 cases of laparoscopic hernia repairs were analyzed, as well as 3 fresh autopsy were included.Main outcome Measures: The anatomy of TF were studied and the inter-trasversalis-fasica approach were explored in ULO. Further, they were proved in the open operations and fresh autopsies. Photographs were taken from the inter-transversalis-fascia approach in ULO, micrograph was taken for microscopic structure of TF, and color atlas of TF anatomy (cross and sagittal sections) were draw.Results: The TF is a general plane of connective tissue lying between the inner surface of transversus abdominis and the extraperitoneal fat, which can be divided into two layers: superficial layer and deep layer, with an amorphous fibroareolar space between them. The inter-transversalis-fascia approach in ULO is the approach between the two layers of TF.Conclusions: The concept of “inter-transversalis fascia approach” is put forward for the first time. Surgeons can get a clean, clear and bloodless operating space in ULO through the inter-transversalis-fascia approach.1. IntroductionIn urological retroperitoneal laparoscopic operations (RLO) or extraperitoneal laparoscopic operations (ELO), surgeons need to dilate the potential fascial space to a real large space for further operation. Therefore, it is very important to identify the retroperitoneal or extraperitoneal fascia and fascial spaces. If the balloon dissector is placed in the exact fascial space, a clean and clear space without hemorrhage can be achieved after balloon dilation, which will undoubtedly benefit further operation. Otherwise, the normal fascial layers will be destroyed by the process of dilation and the fascial space will be filled with blood and fiber in mess, which will embarrass the next manipulation.According to Gray’s Anatomy, the transversalis fascia (TF) is a thin layer of connective tissue lying between the inner surface of transversus abdominis and the extraperitoneal fat[1]. It is one of the most important anatomy marker during the establishment of operating space for RLO and ELO.In this research, we studied the clinical anatomy of TF and explored the inter-transversalis-fascia approach for urological laparoscopic operations (ULO).2. Patients and methods2.1 EnrollmentFrom January 2009 to April 2011 in 309 Hospital of PLA and 301 Hospital of PLA, 1217 cases of urological laparoscopic or open operations were analyzed, 10 cases of laparoscopic hernia repair were analyzed, as well as 3 fresh autopsy were included (Table 1).2.2 Surgical technique2.2.1 Inter-transversalis-fascia approach during retroperitoneal laparoscopic left nephrectomy (RLLN)The patient is placed in the right lateral decubitus position with overextension. A 2-cm incision is made below the 12th rib in the posterior axillary line. The muscular layer, lumbodorsal fascia and superficial layer of TF are bluntly divided. Then, the forefinger is inserted to separate the space between the two layers of TF bluntly. A balloon dissector is placed into the inter-transversali-fascia space and 600 ml gas is infused to maintain the balloon dilation (Fig.2A). The gas is then evacuated and the balloon dissector is removed. Under guidance of the forefinger extending into the space through the incision, a 10-mm puncture cannula is inserted 2 cm above the superior border of the iliac crest in the mid-axillary line. The laparoscope is placed through the trocar and the carbon dioxide insufflator is connected with a pressure of 14 mm Hg. Other trocars are then inserted under laparoscopic view.2.2.2 Inter-transversalis-fascia approach during extraperitoneal laparoscopic radical prostatectomy (ELRP)The patient is placed in a trendelenburg. A 1.5-cm incision is made at the base of the umbilicus, the anterior rectus sheath is incised transversely and the rectus abdominis were pulled aside bluntly. With blunt forefinger dissection along the surface of the posterior rectus sheath, the superficial layer of TF is torn and then the space between the two layers of TF is reached by forefinger. A balloon dilator is inserted into the inter-transversalis-fascia space and 1200 ml gas is inflated to develop the space (Fig.2B). The gas is then evacuated and the balloon dissector was removed. A 10-mm puncture cannula was inserted at the umbilicus incision. The laparoscope is placed through the trocar and the carbon dioxide insufflator is connected with pressure of 14 mmHg. Other trocars are then inserted under laparoscopic view.2.2.3 Inter-transversalis-fascia approach during transperitoneal laparoscopic partial cystectomy (TLPC)Pneumoperitoneum is established using an open trocar placement with a Hasson technique. The laparoscope is placed through the trocar and the insufflation pressure is maintained at 14 mm Hg. The other trocars are then placed under laparoscopic view. Then, we divide the urachus high above the bladder using a hook electrocautery device, identify the two layers of TF, and separate the inter-transversalis-fascia space for further operation (Fig.2C).2.2.4 Taking a sample for histological examinationA piece of tissue was cut from the abdominal wall in left middle axillary line below the 12th rib (thickness from the peritoneum to transversus abdominis) during fresh autopsy.2.3 OutcomesPhotographs of the inter-transversalis-fascia approach in ULO were taken (Fig 3-5). Color atlas of TF anatomy (cross and sagittal sections) were drawn (Fig 1). And microscopic structure of TF was observed by microscope (Fig 6).3. Results3.1 Color atlas of TF anatomy (Fig.1)The TF is a general plane of connective tissue lying between the inner surface of transversus abdominis and the extraperitoneal fat, and it can be divided into two layers: superficial layer and deep layer. The superficial layer of TF closely covers the internal surface of the transversus abdominis and aponeurosis, so dissection between them is relative difficult. There is an amorphous fibroareolar space which is filled with fat and loose fibrous tissue between the superficial layer and deep layer of TF. The fiber of matrix in the space becomes thick and dense in the region of myopectineal orifice, and the fatty tissue becomes abundant in the retroperitoneal region. There is also a loose amorphous fibroareolar space between the deep layer of TF and peritoneum, which is filled with fat and loose fibrous tissue and contains the medial umbilical ligament, median umbilical ligament, and the bladder in the central aspect of the lower anterior abdominal wall.Superiorly, the two layers of TF fuse and blend with the fasciae covering the inferior surface of the diaphragm. Anteriorly, the superficial layer of TF forms a continuous sheet covering the inner surface of transversus abdominis and posterior rectus sheath (or rectus abdominis), and the deep layer of TF covering the outer surface of peritoneum. Posteriorly, the two layers join together and forms a continuous sheet anterior to the lumbar fascia, but the binding site of these two layers keeps moving. For example, these two layers join together in the outer edge of the quadratus lumborum on renal hilum plane, and in the outer edge of psoas major on the 3rd lumbar vertebra plane. Inferiorly the TF is continuous with the pelvic fascia which can also be divided into two layers. The superficial layer covers the inner surface of inguinal region, iliacus, psoas major and external iliac vessles, and form the opening of the deep inguinal ring. The deep layer covers the former half part of bladder and prostate, and forms a conical shealth around the vas deferens and spermatic vessel in male (or the round ligament of the uterus in female) as the internal spermatic fascia.3.2 Inter-transversalis-fascia approach in ULOThe inter-transversalis-fascia approach is the approach between the two layers of TF. Photographs of the inter-transversalis-fascia approach were taken in RLLN (Fig.2), ELRP (Fig.3) and TLPC (Fig.4). We can see the superficial layer and deep layer of TF, the fat and white reticular fibers between the two layers. The retroperitoneal space, extroperitoneal space, Retzius space and Bogros space are parts of the space between the two layer of TF. The inferior epigastric vessels penetrate the superior layer of the transversalis fascia as it originates from the external iliac vessels and run in the matrix between the two layers (Fig.3C), then it penetrate the superficial layer of TF at the level of linea arcuatea and run into the rectus sheath (Fig.1B-D). Moreover, the superficially branch of deep dorsal vein of penis (SBDDV) in the Retzius space also penetrates the superior layer of the transversalis fascia and drain into deep dosal vein of penis (Fig.1B, 3E).3.3 Histological examination of TFSeven layers of structure from transversus abdominis to peritoneum can be observed under the microscope in left middle axillary line below the 12th rib (Fig.5). The histological examination further proves the two-layers-structure of TF.4. DiscussionIn the traditional open surgery, surgeons do not pay enough attention to the TF and fascial spaces, which are usually cut open as a single fascial plane. In the ULO, surgeons need to find the correct potential fascial space and dilate it to a real large space for further operation. Therefore, it is very important for surgeons to grasp the anatomy of TF and fascial spaces. In this study, we put forward the concept of “inter-transversalis fascia approach” for the first time, which will help surgeons to get a clean and clear operating space without hemorrhage during the ULO.There has been much confusion about the exact definition, anatomy, composition and significance of the TF and fascial spaces.Cooper originally described the structure of TF in 1804 as a thin layer of fascia extending upward from the superficial femoral arch (inguinal ligament) and covering the internal surface of abdominal muscle aponeurosis[2], then he defined it as TF in 1844[3]. Some other scholars had different views on the definition of the TF. Skandalakis illustrated it as “the entire connective tissue sheet lining the musculature of the abdominal cavity” [4]. His description was also accepted by Lampe[5]. Braus defined the TF as all the tissue between the transversus abdominis and the peritoneum[6]. Condon represented: “TF covers the internal surface of the transverses abdominis muscle and aponeurosis, separating them from the underlying preperitoneal fat and peritoneum” [7]. Neil stated in Gray’s anatomy: “It is part of the general layer of fascia between the peritoneum and the abdominal wall.”[1].Cooper originally described the TF as a bilaminar structure[2,3]. Mackay, Morton, Read RC also agreed with the bilaminar structure of the TF[8-10]. MacKay described that the inferior epigastric vessels originated from the external iliac vessels and penetrated the posterior layer of the TF[8]. Morton characterized the TF as sometimes being bilaminar with the epigastric vessels lying between[9]. Read demonstrated two laminae of TF inserting into Cooper’s ligament, with the inferior epigastric vasculature between[10]. However, some scholars, such as McVay[11] and Condon[12], believed that the TF as a single-layer structure. Moreover, Anson[13] and Arregui[14] have named the posterior layer of TF as the preperitoneal fascia.The TF in the anterior inferior abdominal wall and groin region were mainly involved in these previous studies, which were related with the hernia and abdominal wall surgery. However, the TF in the retroperitoneal region has not been mentioned in these studies.Urologist Qiu has studied the clinical anatomy of fasciae and fascia spaces in the retroperitoneal cavity by analyzing retroperitoneal laparoscopic operations, CT/MRI scan of patients and fresh autopsy[15]. He found that the lateral conal fascia covered the superficial surface of the posterior layer of perirenal fascia, and the TF covered the inner surface of transvesalis abdominis. Posteriorly, the lateral conal fascia and the TF fused at the lateral edge of quadratus lumborum. Anteriorly, the two layers fused in the anterior axillary line. In addition, lateral conal fascia and TF encircled the pararenal fat, the cavity formed by these two fascias was called pararenal space. However, his study was localized to the retroperitoneal cavity, which did not extend to the anterior abdominal wall.By summarizing these former scholars’ research outputs, combining the knowledge of urology and hernia and abdominal surgery, and breaking the limit of different disciplines, we explored the layers, range and structure of TF in its entirety, and established the theory of inter-transversalis-fascia approach of ULO for the first time.With laparoscopic exploration, structures are magnified, and the various fascial planes are more clearly defined with blood flow. In the open operations, the operating field is limited, but in this way, the anatomy of the fasciae and fascial spaces in local can been further confirmed. By the approach of fresh cadavers, the fasciae are pale, easily disrupted and difficult to distinguish without the advantage of blood flow, but the operating field is unlimited. Therefore, we can get a more comprehensive picture of the TF and fascial spaces by combining these three methods.Our study supports the opinions that the TF is a general plane of connective tissue lying between the inner surface of transversus abdominis and the extraperitoneal fat. Moreover, it composes a complex three-dimensional structure with two layers of fascias and an amorphous fibroareolar space filled with fat and loose fibrous tissue between them. The RLLN, ELRP, TLPC and total extraperitoneal repair of hernia are actually accomplished by the inter-transversalis-fascia approach.In fact, the retroperitoneal space, extroperitoneal space, Retzius space and Bogros space are different parts of the space between the two layers of TF. The fat between two layers of TF in the retroperitoneal region has been recognized as retroperitoneal fat or paranephric fat[15]. Moreover, the deep layer of TF has been named as the preperitoneal fascia[13,14] or the lateral conal fascia[15]. The inferior epigastric vessels and SBDDV travel between these two layers. The matrix in the space between the two layers of TF is asymmetrical. For example, near the level of the umbilicus lateral to the umbilical folds, the two layers of TF are intimately fused and the intervening fatty tissue is sparse. The fibrous tissue between the two layers of TF becomes thick and dense in the region of myopectineal orifice, which can stand against the abdominal pressure and prevent hernia. The intervening fatty tissue becomes abundant in the retroperitoneal region, which can protect the kidneys and ureters from external bumping.5. ConclusionsThe TF composes a complex three-dimensional structure. It can be divided into two layers: superficial layer and deep layer, with an amorphous fibroareolar space between them. The inter-transversalis-fascia approach in ULO is the approach between the two layers of TF. Surgeons can get a clean, clear and bloodless operating space in ULO by the inter-transversalis-fascia approach.ACKNOWLEDGEMENTDr Bing Ma, Department of general surgery, 301 Hospital of PLA, provided technical assistance.References1. Neil RB. Anterior abdominal wall. In: Susan S, editor-in-Chief. Gray’s Anatomy, ed. 39. New York: Churchill Livingstone; 2004. Section. 7. chapt. 67.2. Cooper A. Of the anatomy of the parts concerned with inguinal hernia. In: The Anatomy and Surgical Treatment of Inguinal and Congenital Hernia. London: Longman and Co; 1804. p. 4-6.3. Cooper A. Of the anatomy of the parts concerned with inguinal hernia. In: The Anatomy and Surgical Treatment of Inguinal and Congenital Hernia. Philadelphia: Lea and Blanchard; 1844. P. 26-27.4. Skandalakis JE, Gray SW, Skandalakis LJ, Colborn GL, Pemberton LB. Surgical anatomy of the inguinal area. World J Surg. 1989; 13: 490-498.5. Spangen L. Shutter mechanisms in the inguinal canal. In: Arregui ME, Nagan RF, editors. Inguinal hernia repair: advances or controversies? Oxford: Radcliffe Medical Press; 1994. p. 55-60.6. Braus H. Anatomie des Menschen, Band.Ⅰ. Berlin: Julius Springer; 1921.7. Condon RE. Surgical anatomy of the transversus abdominis and trasversalis fasciae. Ann Surg. 1971; 173: 1-5.8. Mackay JY. The relations of the aponeurosis of the transversalis and internal oblique muscles to the deep epigastric artery and to the inguinal canal. In: Cleland J, editor. Memoirs and Memoranda in Anatomy, Vol. 1. London: Williams and Norgate; 1889. p. 143-146.9. Morton T. The surgical anatomy of inguinal herniae, the testis and its coverings. London: Taylor and Walton; 1841.10. Read RC. Cooper's posterior lamina of transversalis fascia. Surg Gynecol Obstet. 1992; 174: 426-434.11. McVay C, Anson BJ. Composition of the rectus sheath. J Anat Rec. 1940; 77: 213-225.12. Condon RE. The anatomy of the inguinal region and its relationship to groin hernia. In: Nyhus LM, Condon RE, editors. Hernia, ed. 4. Philadelphia: JB Lippincott; 1995. p. 16-72.13. Anson BJ, Morgan EH, McVay CB. Surgical natomy of the inguinal region based upon a study of 500 body-halves. Surg Gynecol Obstet. 1960; 3: 707-725.14. Arregui ME. Surgical anatomy of the preperitoneal fasciae and posterior transversalis fasciae in the inguinal region. Hernia. 1997; 1: 101-110.15. Qiu J, Chen X, Yuan X, et al. Clinical anatomy of fasciae and fascial spaces in retroperitoneal cavity. Chin J Clin Anat. 2009; 27(3): 251-255.Table 1 Operations involved in this studyViariable No. of operationsUrologic operationsRetroperitoneal laparoscopic adrenalectomy 233Retroperitoneal laparoscopic (partial) nephrectomy 588Retroperitoneal laparoscopic nephroureterectomy 74Retroperitoneal laparoscopic pelvilithotomy/ ureterolithotomy 15Retroperitoneal laparoscopic nephropyeloplasty 34Retroperitoneal laparoscopic unroofing of cyst of kidney 80Extraperitoneal laparoscopic radical prostatectomy 76Laparoscopic radical/partial cystectomy 32Excision of carcinoma of urachus 1Lumbar nephrectomy 13Laparonephrectomy 24Kidney transplantation 35Radical/partial cystectomy 5Suprapubic prostatectomy 7Total 1217Laparoscopic hernia repairsTransabdominal preperitoneal repair of hernia，TAPP 8Total extraperitoneal repair of hernia，TEP 2Total 10