经直肠超声实时引导在精囊镜手术中的应用研究

目的探讨经直肠超声实时引导在射精管梗阻性无精子症或少弱精子症患者精囊镜手术中的应用价值。方法回顾性分析2011年9月至2015年12月北京大学第三医院经直肠超声实时引导行精囊镜手术治疗的25例射精管梗阻性无精子症或少弱精子症患者的临床资料。患者年龄(29.4±4.5)岁;精液量0.4(0~2.8)ml,精液pH值6.5(5~7.5),精子总数0(0~580)百万个,精子密度0(0~90.7)百万个/ml,精子活率0(0~24.1%),结合MRI、经直肠超声检查等初步诊断为梗阻性无精子症或少弱精子症。其中13例为前期常规精囊镜手术失败患者(无法找到通道进入射精管和精囊)。均行经直肠超声实时引导下精囊镜射精管梗阻疏通术,分析手术成功率、并发症及随访结果。手术成功的定义为精囊镜疏通射精管后顺利进入精囊。结果25例中21例(84%)精囊镜成功进入精囊腺,手术时间75(31,148)min,术后所有患者均无严重并发症。4例(16%)手术失败患者中,1例术中探查考虑为先天发育不良,2例双侧均未见明确射精管开口,1例术中诊断为Müllerian管囊肿,未见明确精阜小凹及双侧射精管开口。21例精囊镜手术成功者术后3~6个月复查,精液量2.0(0~5.2)ml,精子总数28(0~832)百万个,精子密度5.6(0~110.3)百万个/ml,精子活率5.4%(0~63.6%),与术前精液量0.4(0~2.8)ml]、精子总数0(0~342)百万个]、精子密度0(0~90.7)百万个/ml]、精子活率0(0~24.1%)]比较,差异均有统计学意义(P<0.05)。在17例电话随访5~9年的患者中,3例配偶自然妊娠受孕;9例精液质量改善但患者配偶未自然受孕,行体外受精-胚胎移植技术受孕。结论术中经直肠超声引导可以增加精囊镜手术的成功率和安全性,对常规精囊镜手术困难的射精管梗阻性无精子症或少弱精子症效果良好。

Use of real-time transrectal ultrasound guidance in seminal vesiculoscopy

Objective To explore the application of real-time transrectal ultrasound(TRUS)during seminal vesiculoscopy in infertile men with azoospermia or oligoasthenospermia.Methods We retrospectively analyzed the clinical data of 25 cases of azoospermia or oligoasthenospermia due to ejaculate ducts obstruction who were treated with real-time transrectal ultrasound-guided seminal vesiculoscopy between September 2011 and December 2015.Patients’age was(29.4±4.5)years.All patients accepted semen analysis,serum sex hormone,MRI,TRUS and then diagnosed as obstructive azoospermia,and 13 cases had intractable obstructive azoospermia or oligoasthenospermia after the failure of simple seminal vesiculoscopy(the path to the ejaculatory duct and seminal vesicle couldn’t be found).All patients were treated with seminal vesiculoscopy under real-time guidance with TRUS.We assessed the success rate of surgery,surgical time and complications.Results The scope was successfully inserted into the seminal vesicle in 21 of the 25 cases(success rate,84%).The median operative time was 75(31,148)min.None of the patients developed severe complications.Among 4 failure cases(4/25,16%),1 was due to abnormal congenital development.In 2 cases,a clear outlet of the dual ejaculatory duct could not be found after it was inserted into the prostatic utricle.One case was considered as a Müllerian tubular cyst,and the seminal vesicle scope was used to assess the cystic side wall.The 21 patients were followed up for 3 to 6 months,semen volume 2.0(0-5.2)ml,total sperm 28(0-832)×10⁶/ejaculate,sperm density 5.6(0-110.3)×10⁶/ml,mobility rate of sperm 5.4%(0-63.6%),and the differences were significant as compared to that before the surgerysemen volume 0.4(0-2.8)ml,total sperm 0(0-342)×10⁶/ejaculate,sperm density 0(0-90.7)×10⁶/ml,mobility rate of sperm 0(0-24.1%),all P<0.05].Among the 17 patients who underwent follow-up of 5 to 9 years,3 patients was conceived naturally and 9 patients’postoperative sperm quality has improved and pregnancy in vitro fertilization by extracting sperm from semen.Conclusions Intraoperative real-time transrectal ultrasound guidance can improved the success rate of seminal vesiculoscopy and promoted operative safety.