摘要
目的探讨腹腔镜精索静脉高位结扎术中保留睾丸动脉的手术技巧和临床疗效。方法回顾性分析2015年1月至2020年6月中山大学附属第三医院收治的97例精索静脉曲张患者的临床资料,均由同一术者行腹腔镜精索静脉高位结扎术。其中,初期(2015年1月至2016年12月)行精索静脉高位集束结扎术35例为对照组,后期(2017年1月至2020年6月)行保留睾丸动脉的精索静脉高位结扎术62例为观察组。观察组年龄(21.9±6.7)岁;病变共74侧,位于左侧47例,右侧3例,双侧12例;精索静脉曲张分度Ⅰ度22侧,Ⅱ度28侧,Ⅲ度24侧;临床表现为阴囊不适、疼痛及阴囊静脉团块等症状35侧(47.3%);不育24例(38.7%);精子密度(23.7±5.9)×10^(6)/ml;精子活动度(a级+b级)(33.9±4.1)%。对照组年龄(23.7±4.6)岁;病变共42侧,位于左侧26例,右侧2例,双侧7例;精索静脉曲张分度Ⅰ度10侧,Ⅱ度17侧,Ⅲ度15侧;临床表现为阴囊不适、疼痛及阴囊静脉团块等症状19侧(45.2%);不育14例(40.0%);精子密度(22.3±6.2)×10^(6)/ml;精子活动度(a级+b级)(32.6±4.8)%。两组术前资料比较差异均无统计学意义(P>0.05)。观察组按照游离精索、分离睾丸动脉、结扎精索静脉的程序化步骤进行手术,术中通过分离钳和电钩的配合分离睾丸动脉,以分离钳夹住精索筋膜起固定作用,持电钩(不需通电)钝性分离精索内血管和淋巴管。比较两组的手术时间、并发症、复发率、阴囊症状改善率、精液质量改善率,不育患者2年内配偶自然妊娠率等情况。结果观察组与对照组相比,手术时间长[(35.8±7.7)min与(16.5±5.5)min,P<0.001],术后急性附睾炎发生率低[1.4%(1侧)与11.9%(5侧),P<0.05],睾丸萎缩发生率低[0与7.1%(3侧),P<0.05],阴囊症状改善率高[77.1%(27侧)与47.4%(9侧),P<0.05],精液质量改善率高[72.6%(45例)与51.4%(18例),P<0.05],不育患者2年内配偶自然妊娠率高[70.8%(17例)与50.0%(7例),P<0.05],差异均有统计学意义。两组术后鞘膜积液和阴囊水肿发生率[9.5%(7侧)与9.5%(4侧),P>0.05]、精索静脉曲张复发率[8.1%(6侧)与7.1%(3侧),P>0.05]差异均无统计学意义。结论腹腔镜精索静脉高位结扎术中使用分离钳和电钩配合有助于分离睾丸动脉;保留睾丸动脉的精索静脉高位结扎术的疗效和并发症情况优于精索静脉高位集束结扎术。
Objective To discuss the surgical techniques and evaluate the clinical effects of laparoscopic varicocelectomy with testicular artery preservation.Methods In this retrospective study,we collected clinical data of 97 patients with varicocele who underwent laparoscopic varicocelectomy from January 2015 to June 2020.All operations were performed by the same experienced urologist.Conventional laparoscopic varicocelectomy without testicular artery preservation was performed in earlier 35 patients(January 2015 to December 2016),which were taken as control group.The latter 62 patients(January 2017 to June 2020)underwent laparoscopic varicocelectomy with testicular artery preservation were taken as observational group.In observational group,average age was(21.9±6.7)years,there were 47 cases on the left side,3 cases on the right side and 12 cases bilaterally,totaling 74 sides.There were 22 sides of varicose veinsⅠ,28 sides of varicose veinsⅡand 24 sides of varicose veinsⅢ.Clinical manifestations such as scrotal discomfort,pain and scrotal vein masses were observed on 35 sides(47.3%),infertility was observed in 24 cases(38.7%).Average sperm density was(23.7±5.9)×10^(6)/ml,average sperm motility(grade a+b)was(33.9±4.1)%.In control group,average age was(23.7±4.6)years,there were 26 cases on the left side,2 cases on the right side,7 cases bilaterally,totaling 42 sides.There were 10 sides of varicose veinsⅠ,17 sides of varicose veinsⅡ,15 sides of varicose veinsⅢ.Clinical manifestations of scrotal discomfort,pain and scrotal vein masses were observed on 19 sides(45.2%),infertility was observed in 14 cases(40.0%).Average sperm density was(22.3±6.2)×10^(6)/ml,average sperm motility(grade a+b)was(32.6±4.8)%.There was no significant statistical difference in preoperative clinical data between two groups(P>0.05).The observational group followed the procedural steps of freeing the spermatic cord,isolating the testicular artery,and ligating the spermatic vein.The testicular artery was separated by the separating forceps and the electric hook,with the separating forceps holding the spermatic cord fascia in place and the electric hook(without electricity)bluntly separating the blood vessels and lymphatic vessels in the spermatic cord.The operative time,complications,recurrence rate,improvement rate of scrotal symptoms and semen quality,spontaneous pregnancy rate of spouses within 2 years in infertile patients were compared between the two groups.Results The mean operative time in observational group was longer than control group[(35.8±7.7)min vs.(16.5±5.5)min,P<0.001].Occurrence of postoperative acute epididymitis was lower in observational group compared to control group[1.4%(1 side)vs.11.9%(5 sides),P<0.05].No testicular atrophy(0 side)occurred in observational group,however,this complication could be found in 7.1%(3 sides)of control group(P<0.05).Improvement rate of scrotal symptoms and semen quality was higher in observational group than that in control group after operations[77.1%(27 sides)vs.47.4%(9 sides),P<0.05;and 72.6%(45 cases)vs.51.4%(18 cases),P<0.05].The rates of spousal natural pregnancy within 2 years in infertile patients was higher in observational group than that in control group[70.8%(17 cases)vs.50.0%(7 cases),P<0.05].The rates of hydrocele and scrotal edema were similar in two groups[9.5%(7 sides)vs.9.5(4 sides)%,P>0.05],and the recurrence rate of varicocele was similar[8.1%(6 sides)vs.7.1%(3 sides),P>0.05),without statistically significant difference.Conclusions Using separating forcep and electronic hook can help to separate the testicular artery when performing laparoscopic varicocelectomy.In this operation,to preserve the testicular artery can get better effects an less complications.
作者
吴杰英
李腾成
黄展森
黄群雄
狄金明
Wu Jieying;Li Tengcheng;Huang Zhansen;Huang Qunxiong;Di Jinming(Department of Urology,the Third Affiliated Hospital of SUN Yat-sen University,Guangzhou 510630,China;Department of Infertility and Sexual Medicine,the Third Affiliated Hospital of SUN Yat-sen University,Guangzhou 510630,China)
出处
《中华泌尿外科杂志》
CAS
CSCD
北大核心
2021年第4期294-299,共6页
Chinese Journal of Urology
基金
广东省自然科学基金(2018A030313261)
广东省医学科学技术研究基金(A2018079)。
