精索静脉曲张的治疗方法探讨

目的探讨腹腔镜、经腹股沟管和经腹膜后3种方法高位结扎精索静脉治疗精索静脉曲张的临床应用价值。方法回顾近6年精索静脉曲张患者130例，均为单侧首次治疗，其中腹腔镜手术19例（I组），经腹股沟管手术61例（Ⅱ组），经腹膜后手术50例（Ⅲ组）。结果Ⅰ组手术3个操作通道皮肤切口共长约3cm，Ⅱ组和Ⅲ组手术切口约3-5cm。3种手术平均手术时间分别为35、40、28min，平均住院费用分别为6500元、2280元、2160元，术后阴囊肿胀发生率分别为10．5％（2／19）、16．4％（10／61）、0％（0／50），睾丸萎缩发生率分别为0％（0／19）、4．9％（3／61）、0％（0／50）。腹腔镜手术术后阴囊皮下气肿发生率21．1％（4／19），脐部感染发生率5．5％（1／19）。术后随访1年治愈率分别为94．7％（18／19）、78．7％（48／61）、96％（48／50）。Ⅰ组手术住院费用、Ⅲ组术后阴囊肿胀发生率、Ⅱ组术后1年治愈率与其他两组比较差异有统计学意义（P〈0．05）。3种方法手术时间、术后睾丸萎缩发生率比较差异无统计学意义（P〉0．05）。结论经腹膜后高位结扎精索静脉是单侧精索静脉曲张的首选治疗方法。     

三种精索静脉高位结扎术治疗儿童精索静脉曲张的疗效分析

目的探讨经腹腔、腹膜后、腹股沟三种不同精索静脉结扎手术对儿童精索静脉曲张疗效的影响。 方法回顾性分析2009年至2017年单中心收治的97例行精索静脉高位结扎手术患儿（0～14岁）的临床资料,并对其随访。根据精索静脉结扎的手术方式分为A组（腹腔镜下精索静脉高位结扎术,30例）、B组（腹膜后高选择性精索静脉高位结扎术,38例）、C组（腹股沟高选择性精索静脉高位结扎术,29例）,比较三组患儿手术时间、出血量、术后住院天数、阴囊水肿、睾丸鞘膜积液、复发、睾丸萎缩、阴囊不适改善情况的差别。 结果A组平均手术时间（63±4）min长于B组（36±2）min,（P<0.001）和C组（45±4）min,（P=0.002）。A组术后平均住院时间（2.40±0.18） d高于B组（1.04±0.18）d,（P<0.001）和C组（1.28±0.22）d,（P<0.001）。三组患者术后均未出现睾丸萎缩。A组阴囊水肿发生率高于C组（χ²=6.15,P=0.015）,A组鞘膜积液发生率高于B组（χ²=4.76,P=0.034）和C组（χ²=7.67,P=0.006）。三组复发率、阴囊不适改善率比较差异均无统计学意义。 结论腹股沟精索高选择性静脉结扎术操作简单、创伤小、恢复快、并发症发生率低。腹腔镜下精索静脉结扎术需注意保护淋巴管,以减少阴囊水肿和鞘膜积液的发生。     

三种不同术式治疗精索静脉曲张的疗效对比分析

目的比较分析三种不同手术方式治疗精索静脉曲张（VC）的疗效。方法选择1 000例初发的单侧VC患者分别采用开放经腹膜后精索内静脉高位结扎术（腹膜后组,n=360）、经腹股沟超选择性精索内静脉结扎术（腹股沟组,n=324）及经腹腔镜精索内静脉高位结扎术（腹腔镜组,n=316）治疗,分析各组手术操作要点,并对各组手术并发症进行比较。结果三种术式术后附睾炎、阴囊水肿、睾丸鞘膜积液发生例数分别为腹膜后组22例、15例和28例;腹股沟组54例、40例和57例;腹腔镜组32例、23例和32例。腹膜后组和腹腔镜组术后附睾炎、阴囊水肿、睾丸鞘膜积液及腹股沟区疼痛的发生率明显低于腹股沟组（P〈0.05）。结论开放经腹膜后精索内静脉高位结扎术及经腹腔镜精索内静脉高位结扎术具有术后恢复快、并发症较少的优点。由于腹腔镜手术费用明显较高,对术者操作有更高的要求,麻醉要求更高,所以经腹膜后精索内静脉高位结扎术治疗VC具有独特的优势,值得推广。     

不同手术方式治疗精索静脉曲张的疗效比较

目的 比较高选择性精索静脉高位结扎术、经腹股沟管入路精索静脉结扎术和腹腔镜下改良Palomo术3种方法治疗精索静脉曲张的效果. 方法回顾性分析Ⅱ度以上原发性精索静脉曲张患者1075例,685例获随访.根据手术方式分3组:A组为高选择性精索静脉高位结扎术组,369例;B组为经腹股沟管人路精索静脉结扎术组.218例;C组为腹腔镜下改良Palomo术组,98例.对比观察3组术后阴囊水肿,睾丸、局部皮肤疼痛、麻木,睾丸萎缩,复发等远、近期并发症及精液改善和生育情况. 结果 A、B、C 3组复发率分别为3.3%(12/369)、7.3%(16/218)、5.1%(5/98),A、B组间比较差异有统计学意义(P<0.05);术后3个月睾丸萎缩发生率分别为0.5%(2/369)、17.9%(39/218)、9.2%(9/98),3组间比较差异有统计学意义(P<0.05);术后阴囊水肿发生率分别为1.4%(5/369)、17.4%(38/218)、16.3%(16/98),A组与B、C组间比较差异有统计学意义(P<0.05).A组≤30岁患者术后3～6个月精液质量提高率和术后1～2年配偶自然怀孕率高于其他2组≤30岁患者(P30岁者(P<0.05). 结论 高选择性精索静脉高位结扎术简单且术后阴囊水肿和睾丸萎缩发生率低,术后精液质量提高率和术后1～2年内配偶自然怀孕率高,值得临床推广.     

经腹股沟和经腹股沟下途径显微镜精索静脉结扎术的疗效对比

目的比较经腹股沟和经腹股沟下途径显微镜精索静脉结扎术治疗精索静脉曲张的安全性和疗效。方法回顾性分析我院2016年1月至2019年6月显微镜精索静脉结扎术治疗精索静脉曲张145例资料,经腹股沟途径53例,经腹股沟下途径92例。比较两组手术时间、结扎精索静脉数量、阴囊疼痛缓解率、精子质量改善情况及并发症(睾丸鞘膜积液、睾丸萎缩、复发)。结果经腹股沟途径手术比经腹股沟下途径手术时间短[(34.2±5.0)min vs(37.8±8.4)min,t=–3.245,P=0.001],且结扎精索内静脉数量少[(6.1±1.3)根vs(8.3±1.5)根,t=–9.171,P<0.001]。两组术后精子质量改善情况、阴囊疼痛缓解率及并发症发生率差异无统计学意义。结论显微镜下经腹股沟和经腹股沟下途径精索静脉结扎术治疗精索静脉曲张均疗效确切而且安全。经腹股沟途径需结扎的精索内静脉少,手术时间短。     

经腹腔入路腹腔镜高选择性精索静脉结扎术的疗效观察

目的探讨经腹腔入路腹腔镜高选择性精索静脉结扎术的临床疗效。 方法回顾性分析2012年12月至2018年12月,兰州大学第一医院收治的352例行腹腔镜高选择性精索静脉结扎术治疗的精索静脉曲张患者的临床资料,比较患者术后6个月与术前的症状、精液质量改善情况,统计术后1年时配偶怀孕率、复发率及并发症发生率等。 结果术后成功随访患者341例,失访11例。术前因阴囊坠胀疼痛症状就诊者87例,术后症状消失者55例（63.21%）,缓解29例（33.33%）,无改善3例（3.44%）。因婚后不育就诊者254例,其中少弱精症者225例,术后6个月平均精液质量较术前显著改善（P<0.05）;其中无精子症29例,术后6个月8例（27.58%）精液中出现精子,但与术前比较差异无统计学意义（P>0.05）。术后1年配偶怀孕91例（35.82%）,复发12例（3.51%）,并发鞘膜积液5例（1.46%）,阴囊水肿2例（0.58%）,附睾炎0例,睾丸萎缩0例。 结论经腹腔入路腹腔镜高选择性精索静脉结扎术治疗精索静脉曲张临床疗效确切。     

腹股沟下途径显微技术精索静脉结扎术与腹腔镜精索内静脉高位结扎术的疗效比较

目的 观察比较两种手术方式治疗精索静脉曲张(VC)的临床疗效.方法 将2010年1月至2011年6月就诊的60例VC患者随机均分为两组:A组予以腹股沟下途径显微技术精索静脉结扎术,B组予以腹腔镜单纯精索内静脉高位结扎术.分析两组术后近、远期并发症、复发率及术后精液改善情况等指标,比较两组临床疗效.结果 两种手术方式术后精液质量均较术前明显提高(P＜0.05),但组间比较差异无统计学意义(P＞0.05);两组术后精索水肿、睾丸鞘膜积液等近期并发症差异无统计学意义(P＞0.05);均未出现睾丸萎缩等远期并发症;但A组复发率低于B组,差异有统计学意义(P＜0.05).结论 两种手术方式治疗VC均有明显临床疗效,但腹股沟下途径显微技术精索静脉结扎术式因其术后复发率更少,且具有操作简便、治愈率高等优点,可作为手术治疗VC的首选.     

经皮小切口腹膜外超选择性精索静脉结扎和腹腔镜手术治疗精索静脉曲张的临床随机对照研究

目的：比较经皮小切口腹膜外超选择性精索静脉结扎和腹腔镜下精索静脉高位结扎术治疗精索静脉曲张的效果。方法：将884例精索静脉曲张患者分成两组,A组为经皮小切口腹膜外超选择性精索静脉结扎组,810例;B组为腹腔镜下精索静脉高位结扎组,74例;比较两组的手术时间、术后住院天数、住院费用、症状缓解率、并发症发生率和精液质量改善率等。结果：两组平均手术时间、术后住院天数相似,差异无统计学意义（P〉0．05）;A组住院费用比B组少,差异有统计学意义（P〈0．05）;A组复发率及睾丸鞘膜积液、阴囊水肿和附睾肿痛等术后并发症发生率低于B组,差异有统计学意义（P〈0．05）;两组术后6个月精液质量改善率相似,差异无统计学意义（P〉0．05）。结论：经皮小切口腹膜外超选择性精索静脉结扎术属于微创手术,较腹腔镜下精索静脉高位结扎术具有复发率低、并发症少、住院费用低、疗效好和易推广等优点。     

腹腔镜保留睾丸动脉精索静脉高位结扎术对睾丸生精功能的影响

目的 探讨腹腔镜下精索内静脉高位结扎同时保留睾丸动脉治疗精索静脉曲张的应用价值.方法 选取156例精索静脉曲张患者,随机分成A、B两组:A组采用腹腔镜下保留睾丸动脉精索静脉高位结扎术,B组采用传统的Palomo术式.比较两组手术前后精液质量参数变化、术后并发症的发生率.结果 A组的手术时间为(32.24士8.35)min,明显短于B组(36.45士9.14)min (P＜0.05),术后阴囊水肿(2.67％)、附睾炎(4％)、睾丸萎缩率(2.67％)明显低于B组(P＜0.05),住院时间、术后复发率比较无统计学意义(P＞0.05);术后精子计数[(43.00±4.3)×106]、精子活率[(65.00±4.55)％]明显高于B组[(37.20士5.45)×106]、[(53.34±6.73)％](P＜0.05),精子密度、精子活力分级比较差异无显著性(P＞0.05).结论 保留睾丸动脉腹腔镜精索内静脉高位结扎术能够明显提高术后精液参数质量,降低阴囊水肿、附睾炎、睾丸萎缩的发生率.     

精索血管解剖在经腹股沟下途径显微镜精索静脉结扎术的临床应用

目的 探讨经腹股沟下显微镜精索静脉结扎术治疗精索静脉曲张的手术技巧及其疗效分析.方法 总结本院自2014年10月至2016年4月应用经腹股沟下途径显微镜下精索静脉结扎术治疗精索静脉曲张64例患者的临床资料.对术中结扎静脉数量、睾丸动脉数量、手术时间、术后并发症发生率、术后复发率、术后精液质量改善情况进行总结分析.结果 单侧手术时间54~80 min,平均62.16 min.术中均有效保留1~2支睾丸动脉.术中发现精索内静脉数量:(8.67±1.27)条;动脉数量(1.18±0.46)条;术后并发症发生率:阴囊水肿3.12%(2/64);术后精液质量改善率87.10%(27/31),临床症状缓解率82.98%(39/47).结论 经腹股沟下途径显微镜精索静脉结扎术手术并发症少,复发率低,有效保留睾丸动脉,有效改善精液治疗,提高致孕率.掌握精索血管的解剖对手术具有很大帮助.     

显微外科精索静脉曲张切除术治疗男性不育

精索静脉曲张(VAC)是导致男性不育的常见原因。手术是治疗VAC的主要方法。传统手术方法包括Palo-mo手术、经腹股沟精索内静脉高位结扎术及腹腔镜手术术后睾丸鞘膜积液、睾丸动脉损伤等并发症的发生率及VAC复发率较高。近年来国际上兴起的显微外科精索静脉曲张切除术(MV)可有效的保护精索淋巴管及睾丸动脉,彻底结扎除输精管静脉外的所有精索静脉,使并发症及复发率大为降低。MV可显著改善VAC不育患者的精液质量,提高妊娠率;对严重少弱精子症或非梗阻性无精子症的患者的精液质量也有改善作用,目前已成为治疗VAC的"金标准"。     

Lymphatic sparing laparoscopic varicocelectomy: a microsurgical repair

PURPOSE: The division of lymphatic vessels during pediatric varicocelectomy is complicated by hydrocele formation, testicular hypertrophy due to intratesticular edema and decline in testicular function. To prevent these complications, we introduced a microsurgical lymphatic sparing dissection into laparoscopic varicocelectomy. MATERIALS AND METHODS: We retrospectively compared outcomes in 104 boys who underwent microsurgical laparoscopic repair for grade II to III varicocele between April 1999 and December 2002 to a group of 67 boys operated on using conventional laparoscopy without lymphatic preservation between January 1997 and March 1999. Using 10x to 20x optical magnification, the lymphatic vessels were identified as colorless tubular structures that were easily separated and preserved. RESULTS: After a mean followup of 17 months there was no significant difference in varicocele recurrence between the 2 groups (6.7% vs 8.9%, p = 0.56). Hydrocele formation and testicular hypertrophy occurred significantly less frequently after microsurgical repair (1.9% and 2.9%, respectively, vs 17.9% and 20.1% in the conventional group, p = 0.0003). No major complications were encountered. CONCLUSIONS: Preservation of lymphatics in laparoscopic varicocelectomy is technically feasible, and decreases hydrocele formation and the development of testicular hypertrophy. This microsurgical modification is a safe and efficacious alternative for urologists skilled in reconstructive laparoscopy.     

精索静脉曲张显微手术及腹腔镜手术疗效对比

目的对比评价显微技术精索静脉结扎术和腹腔镜精索静脉高位结扎术治疗精索静脉曲张引起不育症患者的临床疗效。方法分析65例应用显微技术精索静脉结扎术和64例应用腹腔镜精索静脉高位结扎术的不育症患者。结果两组患者手术均正常完成,未发生术后并发症。显微手术组双侧精索静脉曲张的手术时间长于腹腔镜手术时间,两者差别具有统计学意义(P0.05)。129例患者均得到术后3个月复诊:84例精子活力改善(提高20%以上),其中显微手术组45例(45/65),腹腔镜手术组39例(39/63)(P0.05)。107例患者术后6个月复诊结果:21例精子活力改善(与上次复查结果对比提高20%以上),其中显微手术组17例(17/52),腹腔镜手术组6例(6/55)(P0.05)。术后12个月与6月数据接近。结论显微技术精索静脉结扎术在术后疗效方面优于腹腔镜手术。     

Treatment of palpable varicocele in infertile men: a meta-analysis to define the best technique

To date, there have been no randomized, controlled, prospective clinical studies that compare various techniques to describe the best method for the treatment of varicocele in infertile men. This meta-analysis aims to address the best treatment modality for palpable varicocele in infertile men. A MEDLINE search was performed for articles published between January 1980 and April 2008, and we analyzed 36 studies reporting postoperative spontaneous pregnancy rates and/or complication rates after varicocele repair using various techniques in infertile men with palpable unilateral or bilateral varicocele. Spontaneous pregnancy rates and postoperative complications such as hydrocele formation, recurrence, or persistence were compared among the techniques. In addition, interventional failure with radiologic embolization and reported complications with the laparoscopic approach were reviewed. Overall spontaneous pregnancy rates were 37.69% in the Palomo technique series, 41.97% in the microsurgical varicocelectomy techniques, 30.07% in the laparoscopic varicocelectomy techniques, 33.2% in the radiologic embolization, and 36% in the macroscopic inguinal (Ivanissevich) varicocelectomy series, revealing significant differences among the techniques (P = .001). Overall recurrence rates were 14.97% in the Palomo technique series, 1.05% in the microsurgical varicocelectomy techniques, 4.3% in the laparoscopic varicocelectomy techniques, 12.7% in the radiologic embolization, and 2.63% in the macroscopic inguinal (Ivanissevich) or subinguinal varicocelectomy series, revealing significant difference among the techniques (P = .001). Overall hydrocele formation rates were 8.24% in the Palomo technique series, 0.44% in the microsurgical varicocelectomy techniques, 2.84% in the laparoscopic varicocelectomy, and 7.3% in the macroscopic inguinal (Ivanissevich) or subinguinal varicocelectomy series, revealing significant difference among the techniques (P = .001). We conclude that the microsurgical varicocelectomy technique has higher spontaneous pregnancy rates and lower postoperative recurrence and hydrocele formation than conventional varicocelectomy techniques in infertile men. However, prospective, randomized, and comparative studies with large number of patients are needed to compare the efficacy of microsurgical varicocelectomy with that of other treatment modalities in infertile men with varicocele.     

Surgical treatment of varicocele with inguinal microligation technique. 6-year experience

BACKGROUND: Varicocele is found approximately in 15% of the male population and is considered a major cause of infertility. Varicocele management include surgical (traditional or laparoscopic) or conservative techniques (sclerotherapy). The authors present their experience on microsurgical inguinal varicocelectomy. This technique has been adopted since 1992 to decrease the incidence of recidives of high spermatic vein ligation; it also permitted to use local or loco-regional anesthesia, reducing time of hospitalization and realizing a minimally invasive approach. METHODS: From 1992 to 1997, 433 microsurgical inguinal varicocelectomy with artery and lymphatic sparing have been performed at the Militar Hospital of Milan in 409 young men with idiopathic varicocele. All patients were discharged 24 hours after operation. Only those who lived particularly far from the hospital remained for 48 hours. RESULTS: Clinical controls were performed I, III, VI months after operation. At the third control (VI month), a new semen analysis was performed, and 65% of patients had an improvement of seminal characteristics. In 394 patients, a complete resolution of varicocele was observed; 4 patients had a recurrence of the pathology and 11 had a recidive. Seventy-three patients who presented a concomitant homolateral inguinal hernia were treated at the same time. CONCLUSIONS: The conclusion is drawn that microsurgical ligation of spermatic veins represents a good surgical option in the treatment of varicocele. It is a quite simple technique that guarantees a low risk of recidives, permits using local or loco-regional anesthesia and can be performed in day-surgery with good results, few complications and good short and long term results.     

不同手术方式治疗精索静脉曲张的回顾性分析(附658例报告)

目的比较不同手术方法治疗精索静脉曲张(varicocele,VC)的效果及优缺点。方法收集我院2010年1月至2014年1月我院收治的VC患者658病例资料。按照手术方式不同,分为腹股沟结扎组194例,腹膜后高位结扎组167例,腹腔镜组148例,显微镜组149例。对其手术时间、术后住院时间、术后并发症、复发情况、妻子怀孕率等临床资料进行回顾性分析。结果显微手术组比腹股沟组、腹膜后组、腹腔镜组手术时间长,但显微镜组患者术后住院时间明显缩短明显优于腹股沟组和腹膜后组(P0.05)。术后3个月复诊,失访69例,并发症发生率在腹股沟组、腹膜后组、腹腔镜组、显微外科组分别为47.9%、59.9%、41.2%和13.4%,显微镜组最低(P0.016 7)。显微镜组妻子怀孕率达68.6%,为4组最高(P0.016 7)。结论显微镜下精索静脉结扎术是治疗VC的最佳方法,值得推荐。显微镜组无复发,其他三组复发率分别为14.5%、16.4%、5.7%,差异有统计学意义(P0.016 7)。结论显微手术在术后复发及并发症等方面明显优于腹股沟手术、腹膜后高位结扎术和腹腔镜手术;显微手术创伤小、术后恢复快,是治疗VC安全有效的方式。     

Open non‐microsurgical,laparoscopic or open microsurgical varicocelectomy for male infertility: a meta‐analysis of randomized controlled trials

Study Type – Therapy (systematic review) Level of Evidence 1a What's known on the subject? and What does the study add? There are several surgical techniques for the treatment of varicocele in infertile men, including open non‐microsurgical, laparoscopic and microsurgical varicocelectomy. It is currently unclear, however, which is the most beneficial method for patients. The present meta‐analysis found that microsurgical varicocelectomy is the most effective and least morbid method among the three varicocelectomy techniques for treating varicocele in infertile men.

OBJECTIVE

• ? To compare various techniques of open non‐microsurgical, laparoscopic or microsurgical varicocelectomy procedures to describe the best method for treating varicocele in infertile men.

PATIENTS AND METHODS

• ? We searched PubMed, Embase, the Cochrane Library, the Institute for Scientific Information (ISI) – Science Citation Index and the Chinese Biomedicine Literature Database up to June 2011. Only randomized controlled trials (RCTs) were included in the present study.
• ? The outcome measures assessed were pregnancy rate (primary), the incidence of recurrent varicocele, time to return to work, the incidence of postoperative hydrocele and operation duration (secondary).
• ? Two authors independently assessed the study quality and extracted data. All data were analysed using Review Manager (version 5.0).

RESULTS

• ? The present study included four randomized controlled trials comprising 1,015 patients in total.
• ? At the follow‐up endpoints, patients who had undergone microsurgery showed a significant advantage over those who had undergone open varicocelectomy in terms of pregnancy rate (odds ratio [OR]= 1.63, 95% confidence interval [CI]: 1.19–2.23].
• ? There was no significant difference between laparoscopic and open varicocelectomy (OR = 1.11, 95% CI: 0.65–1.88) or between microsurgery and laparoscopic varicocelectomy (OR = 1.37, 95% CI: 0.84–2.24).
• ? The incidences of recurrent varicocele and postoperative hydrocele were significantly lower after microsurgery than after laparoscopic or open varicocelectomy.
• ? The time to return to work after microsurgery and laparoscopic varicocelectomy was significantly shorter than that after open varicocelectomy.
• ? The operation duration of microsurgical varicocelectomy was longer than that of laparoscopic or open varicocelectomy.

CONCLUSIONS

• ? Current evidence indicates that microsurgical varicocelectomy is the most effective and least morbid method among the three varicocelectomy techniques for treating varicocele in infertile men.
• ? More high‐quality, multicentre, long‐term RCTs are required to verify the findings.

     

改良外环下显微镜精索静脉结扎术的临床疗效观察

目的 探讨分析改良外环下显微镜精索静脉结扎术对精索静脉曲张的临床疗效.方法 回顾性分析本院2012年8月至2014年6月收治的精索静脉曲张患者112例,按照不同的手术方式分成腹股沟结扎组28例,腹腔镜组28例,腹股沟外环下显微镜组28例,改良外环下显微镜组(外环口纵向切开约1 cm)28例.对比分析各组的手术效果及术后并发症.结果 四组手术均顺利完成.应用显微镜的两组间手术时间无统计学差异(P＞0.05),但比腹股沟结扎组、腹腔镜组手术时间长(P＜0.05).显微镜两组间住院时间无统计学差异(P＞0.05),比腹股沟结扎组、腹腔镜组住院时间明显缩短(P＜0.05).根据术后疼痛(VAS)评分,显微镜的两组术后疼痛较轻(P＜0.05),且这两组组间比较无统计学差异.腹股沟外环下显微镜组与改良外环下显微镜组保留精索动脉数比较统计学有显著差异(P =0.001),改良外环下显微镜组遇到的动脉数更少.四组间术后并发症,显微镜两组较低(P＜0.05),而这两组组间比较无统计学差异(P＞0.05).四组的复发率分别为28.6％、10.7％、0％、0％(P＜0.05),显微镜的两组均无复发.术后四组的精液密度、精液活力都较术前得到改善,其中显微镜的两组改善更明显,这两组组间比较无统计学差异(P＞0.05).1年后自然怀孕率,四组间差异无统计学意义(P＞0.05).结论 显微镜治疗精索静脉曲张疗效好,并发症少,术后疼痛轻及住院时间短.同时改良外环下显微镜精索静脉结扎术更易于操作,是一种安全有效的手术方式.     

Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique.

Conventional techniques of varicocele repair are associated with substantial risks of hydrocele formation, ligation of the testicular artery, and varicocele recurrence. We describe a microsurgical technique of varicocelectomy that significantly lowers the incidence of these complications. The testicle is delivered through a 2 to 3 cm. inguinal incision, and all external spermatic and gubernacular veins are ligated. The testis is returned to the scrotum and the spermatic cord is dissected under the operating microscope. The testicular artery and lymphatics are identified and preserved. All internal spermatic veins are doubly ligated with small hemoclips or 4-zero silk and divided. The vas deferens and its vessels are preserved. Initially, we performed 33 conventional inguinal varicocelectomies in 24 men without delivery of the testis or use of a microscope. Postoperatively, 3 unilateral hydroceles (9%) and 3 unilateral recurrences (9%) were detected. For the next 12 cases 2.5x loupes were used resulting in no hydroceles but another recurrence (8%). We then performed 640 varicocelectomies in 429 men using the microsurgical technique with delivery of the testis. Among 382 men available for followup examination from 6 months to 7 years postoperatively no hydroceles and no cases of testicular atrophy were found. A total of 4 unilateral recurrent varicoceles (0.6%) was identified. The differences between the techniques in the incidence of hydrocele formation and varicocele recurrence are highly significant (p < 0.001). No wound infections occurred in any men. Four scrotal hematomas (0.6%), 1 of which required surgical drainage, occurred in the group with microsurgical ligation and delivery of the testis compared to none with the conventional technique. Preoperative and postoperative semen analyses (mean 3.57 analyses per patient) were obtained on 271 men. The changes in sperm count x 10(6) cc (36.9 to 46.8, p < 0.001), per cent motility (39.6 to 45.7%, p < 0.001) and per cent normal forms (48.4 to 52.10%, p < 0.001) were highly significant. The pregnancy rate was 152 of 357 couples (43%) followed for a minimum of 6 months postoperatively. Delivery of the testis through a small inguinal incision provides direct visual access to all possible avenues of testicular venous drainage. The operating microscope allows identification of the testicular artery, lymphatics and small venous channels. This minimally invasive, outpatient technique results in a significant decrease in the incidence of hydrocele formation, testicular artery injury and varicocele recurrence.