王亞非
(臨沂市中醫醫院泌尿外科,山東臨沂276002)
顯微手術治療精索靜脈曲張的臨床研究
王亞非
(臨沂市中醫醫院泌尿外科,山東臨沂276002)
目的評價精索靜脈曲張顯微結扎術治療男性精索靜脈曲張伴不育患者的療效與安全性。方法對89例精索靜脈曲張伴不育患者行精索靜脈顯微結扎術。結果術后隨訪1~2年,精索靜脈曲張全部消失,無復發,睪丸鞘膜積液和睪丸萎縮,77.53%(69/89例)精液精液質量顯著提高,44.94%(40/89例)女方受孕。結論顯微結扎術具有患者術后精液改善率高,術后自然孕率高,術后復發率和鞘膜積液發生率低的特點。
精索靜脈曲張/治療;顯微結扎術/外科手術
精索靜脈曲張與男性不育的密切關系[1-2],大約30%不育男性患有精索靜脈曲張。外科治療的理想術式應該達到保存和恢復滿意的睪丸功能,消除靜脈曲張,最低的復發率以及較低的費用[3]。近年來,我們采用外環下精索靜脈顯微解剖結扎術治療不育性精索靜脈曲張89例,取得良好效果?,F報道如下。
1.1一般資料精索靜脈曲張伴不育患者89例,年齡平均26歲;其中單側病變67例,雙側病變22例;Ⅱ度43側,Ⅲ度46側。
1.2手術方法腹股溝外環下作一長約3 cm切口。切開各層分離提取精索,將睪丸提出切口外,結扎擴張的提睪肌靜脈。在10倍手術放大鏡下結扎所有精索外靜脈。若睪丸引帶處有擴張的靜脈,應結扎,還納睪丸,提取精索,切開提睪肌及精索內外筋膜,分離精索內靜脈,予以結扎、切斷。保留輸精管營養血管,輸精管周圍擴張靜脈的直徑若>1mm,應予結扎。最后僅剩下睪丸動脈、淋巴管、輸精管及伴行營養血管,以及直徑<1mm的細小靜脈。
隨訪1~2年,均未見復發、睪丸鞘膜積液和睪丸萎縮。術后77.53%(69/89)例精液精子數量明顯增多,正常形態精子增多,異常形態精子減少,精子活動力顯著提高。44.94%(40/89)女方受孕。
精索靜脈曲張引發不育的機制存在不同觀點,但目前達成的共識是精索靜脈曲張可以引發精液理化和功能檢測異常、睪丸體積減小、睪丸間質內Leydig細胞功能減退。精索靜脈曲張引起的男性不育和陰囊脹痛不適可通過手術治療緩解癥狀和改善生育功能。其最佳手術方法仍具爭議。傳統的經腹股溝、腹膜后途徑精索靜脈高位結扎術及應用腹腔鏡行精索內靜脈結扎術不能有效分離出睪丸動脈及精索淋巴管加以保護,甚至將睪丸動脈及淋巴管一并結扎及漏扎靜脈分枝。這使得術后睪丸萎縮、鞘膜積液等并發癥及精索靜脈曲張復發率增加。另外,其效果也受到質疑[4-5]。傳統術式復發率高的原因,是由于精索靜脈側支的存在。Robert等[6]行精索血管造影證實精索靜脈存在許多側支,復發的原因除漏扎這些側支靜脈外,尚有7%原因是由于陰囊存在側支靜脈。近年來,顯微外科手術以其創傷小、并發癥少、術后復發率低、可明顯改善精液質量及提高妊娠率等優勢,被認為是治療精索靜脈曲張的“金標準”。本組患者術后復發率及嚴重并發癥如睪丸萎縮發生率均未見發生,與報道相符[7]。通過本組患者治療體會,我們認為采用顯微外科手術行精索內靜脈結扎術與傳統開放手術相比有以下優點:①降低了復發率,精索靜脈顯微解剖結扎術術后精索靜脈曲張復發率僅為2%以內,而非顯微外科手術卻高達9%~16%[8]。②有效保護了淋巴管。睪丸鞘膜積液發生率幾乎為零[9]。傳統術式鞘膜積液發生率為3%~39%[10]。③準確的鑒別和保護睪丸動脈及其分支(直徑細至0.5~1.5mm)、提睪肌動脈及其分支,術后睪丸萎縮、無精子癥發生率降低[11]。
總體而言,顯微手術在對精液分析參數的改善、術后復發等方面明顯優于腹膜后高位結扎術和腹腔鏡手術,且創傷小、術后恢復快、醫療資源占有較少,易于被患者接受,值得臨床推廣。
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A Clinical Study of M icrosu rgical Varicocelectom y for M ale In fertility
W ang Yafei
(The Chinese TraditionalMedicine Hospital in LinyiCity,Linyi276002,Shandong)
Ob jectiveTo evaluate theeffectivenessand safety ofmicrosurgical varicocelectomy formale infertility.M ethodsWe usem icrosurgical varicocelectomy to treat 89 patientsw ith varicocele.Resu ltsA fter 1_2 years,all patients did not have the complications such as recurrence,testis atrophy and hydrocele.The 69 patients’sperm concentration and motility were significantly improved.40 infertile patients’s w ifes were pregnant.ConclusionThe evidence shows thatm icrosurgicalvaricocelectomy ishigher sperm im provement rate,highernaturalpregnancy rate and lower incidenceof recurrenceand hydrocele.
Varicocele/therpy;M icrosugical/surgicaloperation
R697.24
:A
:1008-4118(2013)03-0035-02
10.3969/j.issn.1008-4118.2013.03.16
2013-07-19