符紅霞 梁培育 周治彥
【摘要】目的:探討外環(huán)下顯微外科精索靜脈結(jié)扎術(shù)對精索靜脈曲張患者精液質(zhì)量的影響,并觀察和分析其安全性。方法:選擇本院2012年10月至2014年3月精索靜脈曲張患者104例,根據(jù)手術(shù)方法分為對照組51例和觀察組53例,對照組患者采用腹腔鏡下精索靜脈結(jié)扎術(shù),觀察組患者采用外環(huán)下顯微外科精索靜脈結(jié)扎術(shù)。記錄兩組患者手術(shù)時間、出血量、術(shù)后住院天數(shù),檢測治療前后精液質(zhì)量及畸形率,觀察術(shù)后并發(fā)癥及復(fù)發(fā)狀況。結(jié)果:觀察組出血量和住院時間分別為(24.58±4.93)mL和(5.13±1.24)d,均低于對照組,差異有統(tǒng)計學(xué)意義(P<0.05);觀察組患者治療后精子數(shù)量、精子活力和精子活動率分別為(43.76±7.22)×106/mL、(48.66±5.93)%和(55.28±7.50)%,均高于對照組治療后(34.53±5.28)×106/mL、(37.83±6.36)%和(52.15±7.12)%,差異具有統(tǒng)計學(xué)意義(P<0.05)。觀察組患者治療后精子畸形率為(12.42±3.86)%,低于對照組治療后(16.21±5.08)%,差異具有統(tǒng)計學(xué)意義(P<0.05)。觀察組患者不良反應(yīng)及復(fù)發(fā)總計4例(7.55%),低于對照組10例(19.61%),差異具有統(tǒng)計學(xué)意義(P<0.05)。結(jié)論:外環(huán)下顯微鏡精索靜脈結(jié)扎術(shù)創(chuàng)傷小、恢復(fù)較快,能夠顯著提高患者精子數(shù)量和質(zhì)量,術(shù)中可有效保護(hù)睪丸動脈及淋巴管,減少術(shù)后并發(fā)癥及復(fù)發(fā)率。
【關(guān)鍵詞】顯微外科;精索靜脈結(jié)扎術(shù);精索靜脈曲張;精液質(zhì)量
Impact on semen quality of varicocele patients with spermatic vein ligation under the outer ring microsurgeryFU Hongxia, LIANG Peiyu, ZHOU Zhiyan. Department of Urology,The Hospital Affiliated to Hainan Medical University, Haikou 570102, Hainan, China
【Abstract】Objectives: To explore the impact on semen quality of varicocele patients with spermatic vein ligation under the outer ring microsurgery, and to observe and analyze its security. Methods: 104 varicocele patients were selected in the hospital from October in 2012 to March in 2014 and according to the operation method, were divided into the control group (51 cases) and the observation group (53 cases). The control group was treated by laparoscopic ligation of spermatic vein, while the observation group was treated by microsurgery under the outer ring ligation of spermatic vein. The operation time, blood loss, postoperative hospitalization time of two groups was recorded; the semen quality and malformation rate before and after the treatment was detected; the postoperative complications and recurrence was observed. Results: The blood loss and hospitalization time of the observation group respectively were (24.58±4.93) ml and (5.13±1.24) d, lower than the control group, with statistically significant difference (P<0.05). The sperm amount, sperm motility and sperm activity respectively of the observation group after treatment were (43.76±7.22)×106/ml, (48.66±5.93) % and (55.28±7.50) %, higher than the control group (34.53±5.28)×106/ml, (37.83±6.36) % and (52.15±7.12) %, with statistically significant difference (P<0.05). The sperm malformation rate of the observation group after treatment was (12.42±3.86) %, lower than the control group (16.21±5.08) %, with statistically significant difference (P<0.05). The total adverse reaction and recurrence in the observation group were 4 cases and 7.55%, lower than the control group (10 cases, 19.61%), with statistically significant difference (P<0.05). Conclusions: For outer ring ligation of spermatic vein under the microscope, it causes little injury and pain with rapid recovery, which can also significantly improve the sperm count and quality. During the operation it can effectively protect the testicular artery and lymphatic vessels, while reduce the postoperative complications and the recurrence rate.
【Key words】Microsurgery; Spermatic vein ligation; Varicocele; Semen quality
【中圖分類號】R697+.24【文獻(xiàn)標(biāo)志碼】A
精索靜脈曲張是精索靜脈因多種原因回流受阻、不暢,精索蔓狀靜脈叢擴(kuò)張、迂曲、伸長,在陰囊里形成蚯蚓形狀的團(tuán)塊,易引起患者睪丸的功能進(jìn)行性衰退。主要表現(xiàn)為疼痛、陰囊墜脹不適、精液異常、男性不育等。臨床治療以精索靜脈結(jié)扎手術(shù)為主,以有效阻止血液的返流[1,2]。近年來,顯微鏡外科精索靜脈結(jié)扎術(shù)逐漸得到廣泛應(yīng)用,已成為治療VC的主要術(shù)式。本研究旨在探討外環(huán)下顯微外科精索靜脈結(jié)扎術(shù)對精索靜脈曲張患者精液質(zhì)量的影響,并觀察和分析其安全性。
1資料與方法
1.1一般資料
隨機(jī)選擇本院2012年10月至2014年3月精索靜脈曲張患者104例,納入病例:均進(jìn)行陰囊彩超顯示精索靜脈曲張并伴反流、Valsalva 實(shí)驗(yàn)陽性。排除病例:繼發(fā)性精索靜脈曲張患者。入選患者年齡24~49歲,平均(31.75±7.80)歲,根據(jù)手術(shù)方法分為對照組51例和觀察組53例,對照組患者采用腹腔鏡下精索靜脈結(jié)扎術(shù);觀察組患者采用外環(huán)下顯微外科精索靜脈結(jié)扎術(shù)。兩組患者年齡、病變部位、程度和病程比較,差異無統(tǒng)計學(xué)意義(P>0.05),具有可比性。見表1。
1.2方法和指標(biāo)
1.2.1治療方法觀察組患者采用外環(huán)下顯微外科精索靜脈結(jié)扎術(shù),在股溝外環(huán)下陰囊外上方作長約2~3cm 的斜形切口,逐層切開,露出精索、提起后牽出,將睪丸提出切口外,切斷結(jié)扎擴(kuò)張的睪丸引帶靜脈,顯微鏡下分離精索內(nèi)外靜脈、提睪肌靜脈,雙重結(jié)扎后切斷,術(shù)中保護(hù)睪丸動脈、淋巴管及相關(guān)神經(jīng)。還納精索,逐層關(guān)閉切口。如為雙側(cè)病變,采取同樣的術(shù)式進(jìn)行處理。對照組患者采用腹腔鏡(Olympus 腹腔鏡系統(tǒng))下精索靜脈結(jié)扎術(shù),距離內(nèi)環(huán)口2~3cm處精索血管外側(cè),切開后腹膜,游離整束精索血管,分離精索內(nèi)動、靜脈,雙重絲線結(jié)扎精索靜脈并離斷[3,4]。本研究經(jīng)醫(yī)院倫理委員會批準(zhǔn),患者及家屬的同意簽署知情同意書。
1.2.2主要指標(biāo)記錄兩組患者手術(shù)時間、出血量、術(shù)后住院天數(shù),術(shù)后并發(fā)癥及6個月后復(fù)發(fā)狀況,檢測手術(shù)前后精液質(zhì)量,包括精子密度、精子活力、巴氏染色計數(shù)精子畸形率。
1.3統(tǒng)計學(xué)處理
用SPSS11.0統(tǒng)計軟件。計量資料采用均數(shù)±標(biāo)準(zhǔn)差(±s)表示,采用t檢驗(yàn),計數(shù)資料比較用χ2檢驗(yàn),P<0.05時差異有統(tǒng)計學(xué)意義。2結(jié)果
2.1兩組患者手術(shù)狀況結(jié)果比較
觀察組出血量和住院時間分別為(24.58±4.93)mL和(5.13±1.24)d,均低于對照組,差異有統(tǒng)計學(xué)意義(P<0.05),兩組手術(shù)時間比較,差異無統(tǒng)計學(xué)意義(P>0.05)。見表2。
2.2兩組患者治療前后精液質(zhì)量結(jié)果比較
觀察組患者治療后精子數(shù)量、精子活力和精子活動率分別為(43.76±7.22)×106/mL、(48.66±5.93)%和(55.28±7.50)%,均高于對照組治療后,兩組治療后均高于治療前,差異具有統(tǒng)計學(xué)意義(P<0.05)。觀察組患者治療后精子畸形率為(12.42±3.86)%,低于對照組治療后,兩組治療后均低于治療前,差異具有統(tǒng)計學(xué)意義(P<0.05)。見表3。
2.3兩組患者不良反應(yīng)及復(fù)發(fā)情況比較
觀察組患者不良反應(yīng)及復(fù)發(fā)總計4例(7.55%),低于對照組,差異具有統(tǒng)計學(xué)意義(P<0.05)。見表4。
3討論
精索靜脈曲張是臨床常見的一種男性疾病,也是引起不育的常見原因之一,多發(fā)生于青壯年。隨著顯微外科技術(shù)的發(fā)展,外環(huán)下顯微外科精索靜脈結(jié)扎術(shù)逐漸在臨床上應(yīng)用,逐漸成為較為理想的治療方式[5-7]。
本次研究結(jié)果顯示,觀察組出血量和住院時間均低于對照組,差異有統(tǒng)計學(xué)意義(P<0.05),提示外環(huán)下顯微外科精索靜脈結(jié)扎術(shù)創(chuàng)傷小、恢復(fù)較快。外環(huán)下顯微外科精索靜脈結(jié)扎術(shù)麻醉簡單、術(shù)中損傷小,有利于患者的康復(fù)。研究結(jié)果顯示,觀察組患者治療后精子數(shù)量、精子活力和精子活動率均高于對照組,觀察組患者治療后精子畸形率低于對照組,差異具有統(tǒng)計學(xué)意義(P<0.05)。提示外環(huán)下顯微外科精索靜脈結(jié)扎術(shù)可顯著提高患者精子數(shù)量和質(zhì)量。精索內(nèi)靜脈、精索動脈和輸精管分化成細(xì)小分支包繞睪丸動脈,參與構(gòu)成精索,精索靜脈血流淤滯能夠影響睪丸的生精功能。顯微鏡手術(shù)的要點(diǎn)為結(jié)扎所有的精索靜脈、提睪肌,可以有效阻止靜脈反流,使患者的睪丸生長及功能獲得恢復(fù),精子產(chǎn)生過程趨于正常,精子數(shù)量和質(zhì)量得以改善[8-10]。睪丸動脈對精液質(zhì)量的改善起著重要的作用,顯微鏡下能夠準(zhǔn)確辨認(rèn)睪丸動脈,有利于睪丸生精功能的恢復(fù)及精液質(zhì)量及精子活力的提高[11-13]。
本次研究結(jié)果顯示,觀察組患者不良反應(yīng)及復(fù)發(fā)率低于對照組,差異具有統(tǒng)計學(xué)意義(P<0.05)。提示外環(huán)下顯微鏡精索靜脈結(jié)扎術(shù)可減少術(shù)后并發(fā)癥及復(fù)發(fā)率。腹腔鏡術(shù)手術(shù)時間較短,但對精索內(nèi)靜脈進(jìn)行結(jié)扎難以對可能存在曲張情況的輸精管和提睪肌靜脈進(jìn)行處理,易導(dǎo)致術(shù)后復(fù)發(fā)。在顯微鏡下能夠準(zhǔn)確辨認(rèn)睪丸動脈、精索淋巴管,細(xì)致操作可充分保留精索淋巴管及睪丸動脈,能夠有效降低術(shù)后因動脈損傷引起的睪丸萎縮,因結(jié)扎淋巴管引起陰囊水腫的風(fēng)險,對精索靜脈徹底結(jié)扎及顯微鏡下還可發(fā)現(xiàn)細(xì)小靜脈分支并結(jié)扎以避免持續(xù)靜脈曲張[14]。外環(huán)下顯微鏡精索靜脈結(jié)扎術(shù)需要一定的熟練程度,尤其是顯微鏡下的操作技巧。本研究尚需進(jìn)一步觀察患者生育狀況。
綜上所述,外環(huán)下顯微鏡精索靜脈結(jié)扎術(shù)創(chuàng)傷小、恢復(fù)較快,能夠顯著提高患者精子數(shù)量和質(zhì)量,術(shù)中可有效保護(hù)睪丸動脈及淋巴管,減少術(shù)后并發(fā)癥及復(fù)發(fā)率。
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