Ninković M, Stenzl A, Hess M, Feichtinger H, Schwabegger A, Colleselli K, Bartsch G, Anderl H
Department of Plastic Surgery, University of Innsbruck, Austria.
Plast Reconstr Surg. 1997 Aug;100(2):402-11; discussion 412-4. doi: 10.1097/00006534-199708000-00020.
This study was designed to investigate the ability of the latissimus dorsi muscle in situ to evacuate a bladder reservoir and to study the functional, anatomic, and histopathologic results of partial or subtotal bladder reconstruction with an innervated free latissimus dorsi muscle in mongrel dogs. In group I (four dogs), the latissimus dorsi muscle was dissected and tailored in situ. Then the so-formed pedicled latissimus dorsi muscle flap was wrapped around tissue expanders of varying sizes (volumes of 50, 100, and 150 cc, respectively) to form a bladder-like reservoir. Electromyography and intraluminal pressure measurements were done at the time of surgery and 6 months thereafter using a standard electromyograph and a Dantec urodynamic unit. In group II (four dogs), the dome of the bladder wall was removed, with up to 50 percent of the mucosal layer being left intact. The resulting muscular defect was repaired with a free innervated latissimus dorsi muscle flap. The transferred latissimus dorsi muscle was shaped and wrapped around the bladder in a spiral form, with particular attention to the resting tension. The thoracodorsal vessels were anastomosed to the pelvic branches of the hypogastric vessels, and the thoracodorsal nerve was coapted to a pelvic motor nerve that was selected by use of a nerve stimulator. Cystography and urodynamic studies were performed after 3, 6, and 9 months. Electromyography was done after 9 months, before sacrifice of the animals, which was followed by regular histologic and electron microscopic examinations. Stimulation of the thoracodorsal nerve of the reconfigured latissimus dorsi muscle reservoirs in situ after 6 months yielded average intraluminal pressures of 190 cmH2O at maximum capacity and 35 cmH2O at a minimum capacity of 10 to 15 cc. Stimulation of the latissimus dorsi muscle transferred to the bladder resulted in a visible and measurable contraction of the transplanted muscle after 9 months. Urodynamic values preoperatively and postoperatively were basically unchanged. During cystography, the bladder outline was smooth during both filling and voiding. Light and electron microscopic examinations confirmed viable, reinnervated muscle. The reconfigured pedicled latissimus dorsi muscle has the ability to evacuate a bladder-like reservoir after nerve stimulation. A detrusor function of the bladder can be induced through the contractility of a reinnervated free latissimus dorsi muscle that was wrapped around the bladder. An innervated free latissimus dorsi muscle flap does not undergo severe muscle fibrosis, contracture, and atrophy such as occur after transfer of completely or partially denervated, pedicled muscle. This means that a functional bladder reconstruction/augmentation can be achieved by microneurovascular transfer of a latissimus dorsi muscle flap.
本研究旨在调查背阔肌在原位排空膀胱储尿囊的能力，并研究在杂种犬中使用带神经支配的游离背阔肌进行部分或次全膀胱重建后的功能、解剖和组织病理学结果。在第一组（四只犬）中，解剖并在原位修整背阔肌。然后将形成的带蒂背阔肌皮瓣包裹在不同大小（分别为50、100和150 cc体积）的组织扩张器周围，以形成膀胱样储尿囊。在手术时及术后6个月，使用标准肌电图仪和丹泰克尿动力学装置进行肌电图和腔内压力测量。在第二组（四只犬）中，切除膀胱壁顶部，保留高达50%的黏膜层。用游离的带神经支配的背阔肌皮瓣修复由此产生的肌肉缺损。转移的背阔肌被塑形并以螺旋形式包裹在膀胱周围，特别注意静息张力。胸背血管与腹下血管的盆腔分支进行吻合，胸背神经与通过神经刺激器选择的盆腔运动神经进行接合。在3、6和9个月后进行膀胱造影和尿动力学研究。在9个月后、处死动物前进行肌电图检查，随后进行常规组织学和电子显微镜检查。6个月后刺激原位重新构建的背阔肌储尿囊的胸背神经，在最大容量时平均腔内压力为190 cmH2O，在最小容量10至15 cc时为35 cmH2O。刺激转移到膀胱的背阔肌，9个月后移植肌肉出现可见且可测量的收缩。术前和术后尿动力学值基本未变。在膀胱造影期间，充盈和排尿时膀胱轮廓均光滑。光镜和电镜检查证实肌肉存活且重新获得神经支配。重新构建的带蒂背阔肌在神经刺激后有能力排空膀胱样储尿囊。通过包裹在膀胱周围的重新获得神经支配的游离背阔肌的收缩性，可以诱导膀胱逼尿肌功能。带神经支配的游离背阔肌皮瓣不会像完全或部分去神经支配的带蒂肌肉转移后那样发生严重的肌肉纤维化、挛缩和萎缩。这意味着通过背阔肌皮瓣的显微神经血管转移可以实现功能性膀胱重建/扩大。
