腹横纹切口保留睾丸引带阴囊皮下睾丸固定术治疗隐睾症的 …

为了研究治疗先天性隐睾症的最佳术式，以提高隐睾症的治疗水平，采用腹横纹切口保留睾丸引带阴囊皮下睾丸固定术（研究组）治疗隐睾症９６例１１０枚，获得随访者９４例１０８枚，同时采用患侧下腹斜切口肉膜囊睾丸固定术（对照组）治疗隐睾症５０例６２枚。结果研究组睾丸大小及硬度优９４枚，占８７．０％，良９枚，占８．３％，差５枚，占４．６％；睾丸位置优９３枚，占８６．１％，良９枚，占８．３％，差６枚，占５．６％；无     

先天性隐睾症术式改良及疗效评价

目的：对先天性隐睾症的术式改良及疗效进行评价。方法：研究组采用腹横纹切品保留睾丸引带阴囊皮下睾丸固定术１１０例,得到随访１０８侧隐睾。对照组采用内膜囊丸固定术并得到随访６２侧。结果：研究组睾丸大小及硬度优９４侧,良９侧,差５侧;睾丸位置优９５侧,良９侧,差６侧;无睾丸萎缩及回缩,切口Ⅰ期愈合率１００％,瘢痕不明显。对照组睾丸大小及硬度优４１侧,良７例,差１４侧,睾丸位置优４３侧,良８侧,差１１侧;     

先天性隐睾症术式改良及疗效分析

目的 研究先天性隐睾症术式改良的临床疗效.方法 选取本院在2009年3月～2014年3月间收治的42例先天性隐睾症患者的临床资料,随机将患者平分为两组,每组各21例病例.对照组行肉膜囊睾丸固定术治疗,观察组采用腹横纹切口保留睾丸引带阴囊皮下睾丸固定术治疗,比较两组患者术后的治疗优良率.结果 观察组有13例患者治疗情况为优,7例患者恢复良好,总优良率为95.2％;对照组有7例患者治疗情况为优,8例患者恢复良好,总优良率为71.4％.观察组治疗优良率明显优于对照组,对比差异显著,具有统计学意义(P＜0.05).结论 采用腹横纹切口保留睾丸引带阴囊皮下睾丸固定术有利于减少对患者身体的损伤,切口瘢痕较小,同时不会增加并发症的发生,具备较高的安全性与可靠性,有利于促进患者疾病的好转,值得临床推广应用.     

儿童睾丸扭转103例诊治分析

目的提高儿童睾丸扭转的诊治水平。方法回顾分析1993年1月-2008年1月总计103例14岁以下睾丸扭转患儿的诊治临床资料。砖果年龄1．5d～14岁（平均4．8岁）。睾丸扭转部位：左侧64例,右侧34例,双侧5例。9例（8．74％）患儿（扭转〈6h）行手法复位成功;手术探查94例（91．26％）,保留睾丸行睾丸固定术25例（21例扭转〈6h,3例扭转12～24h,1例扭转〉24h）。睾丸坏死切除69例。右侧睾丸扭转而左侧精索明显长者19例行对侧睾丸固定术。52例（50．49％）患儿病理报告为睾丸附睾缺血性坏死。38例（36．89％）患儿随访1～6年,未发现再发睾丸扭转,5例患侧睾丸萎缩。结论儿童睾丸扭转的早诊断、及时手术治疗是睾丸成活的关键。     

计算机导航在脊柱外科手术应用实验和临床研究

目的探讨计算机导航技术在脊柱外科中的应用价值。方法自2002年12月将红外线主动诱导计算机导航系统应用于脊柱外科，进行了相关的实验和临床研究。实验研究采用40具成人颈椎标本，分别采用盲法、透视法、透视导航法、CT三维导航法和Iso—C术中三维导航法进行下颈椎椎弓根螺钉植入。术后通过大体解剖观察评价植钉的准确性。同时对163例采用不同导航方式（包括透视导航、CT三维导航和Iso—C术中三维导航）辅助下脊柱外科手术进行回顾性分析，通过术后影像学检查判断内固定术的植钉准确性。结果实验研究共植入螺钉398枚。盲法组平均手术时间27min；优29枚（36.3％），良21枚（26.3％），差30枚（37．5％）。透视法组平均手术时间112min；优35枚（44．9％），良29枚（37.2％），差14枚（17．9％）。透视导航法组平均手术时间69min；优34枚（42．5％），良36枚（45．0％），差10枚（12．5％）。CT三维导航法组平均手术时间98min；优70枚（87．5％），良10枚（12．5％），无差的螺钉。Iso—C术中三维导航法组平均手术时间91min；优72枚（90％），良8枚（10％），无差的螺钉。临床病例中，透视导航组共272枚螺钉，优243枚（89．3％），良29枚（10．7％）。CT导航组共571枚螺钉，优485枚（84．9％），良82枚（14．4％），差4枚（0．7％，均发生于早期颈椎手术病例）。Iso—C术中三维导航组共142枚螺钉，优136枚（95．8％），良6枚（4．2％，5枚为颈椎，1枚为腰椎）。结论正确应用计算机导航系统能显著提高脊柱外科手术的安全性。三种导航方法各有优缺点，Iso—C术中三维导航技术具有良好的应用前景并有可能逐渐替代其他两种导航技术。     

腹股沟可触及睾丸的隐睾的微创治疗

目的探讨腹股沟可触及睾丸的隐睾的微创治疗方法。方法2007年8月～2008年3月对60例腹股沟区可触及睾丸的隐睾,根据睾丸位置高低,采取经阴囊或腹腔镜辅助下睾丸固定手术。结果经阴囊睾丸固定术24例,睾丸位于外环口与阴囊上极之间,23例固定于阴囊底,1例固定于阴囊上极。经阴囊转腹腔镜睾丸固定术2例,均为右侧,睾丸位于外环口与阴囊上极之间,经隐囊手术睾丸下降位置不满意,转为腹腔镜手术将睾丸固定于阴囊底。经腹腔镜睾丸固定术34例,其中睾丸位于腹股沟内16例（41.1%）,位于近外环口处18例（52.9%）,合并腹股沟斜疝8例（23.5%）,均在腹腔镜下行内环口结扎,术后睾丸固定于阴囊底部。60例B超随访3～6个月,平均4.3月,无睾丸萎缩及回缩,无腹股沟斜疝的发生。结论可触及睾丸的腹股沟隐睾如果能推到阴囊上极,则可选择经阴囊切口的睾丸固定术;如果不能将睾丸推到阴囊上极或经阴囊切口不能将睾丸固定到阴囊底时,可选择腹腔镜手术。2种手术方法睾丸固定位置满意,可作为临床医师的参考手术方式之一。     

腹腔镜下腹腔内高位隐睾下降固定术的疗效观察

目的：探讨腹腔镜下腹腔内高位隐睾下降固定术的疗效。方法：应用腹腔镜技术进行诊断并行隐睾下降固定术治疗不可触及的高位腹腔内型隐睾患儿21例（24侧）,年龄2～12岁,平均4岁。结果：21例患儿均得到明确诊断。14例（17侧）行一期睾丸下降固定术,3例行Fowler Stephens一期睾丸下降固定术,3例睾丸缺如,1例行睾丸萎缩切除术。随访6～30个月,平均16个月,下降固定的睾丸位置良好,睾丸均无萎缩和回缩。结论：采用腹腔镜技术可以准确诊断高位不可触及的腹腔内型隐睾,并可同时行睾丸下降固定术,安全、有效、微创,值得推广。     

腹腔镜诊治未触及睾丸的隐睾42例

目的 探讨腹腔镜在未触及睾丸的隐睾患儿中的诊断及治疗作用。方法 对42例未触及睾丸的隐睾患儿腹腔镜检查，根据睾丸的位置及发育情况，分别行睾丸一期固定术，分期Fowler-Stephens手术或切除术，结果 腹腔内睾丸28例（28/42，66.7%），其中4例行分期Fowler-Stephens手术，1例行分期睾丸固定术，余23例行一期睾丸固定术，睾丸发育不良4例（4/42，9.5%）,经腹腔沟区探查行切除术；睾丸缺如7例（7/42，16.7%）；腹股沟管内睾丸3例（3/42，7.1%），行常规睾丸固定术。术后随访6-60个月，平均38个月，患侧睾丸位置和发育基本正常。结论 腹腔镜能够准确诊断未触及睾丸的隐睾，并可做相应的治疗。     

改良Weaver法治疗陈旧性重度肩锁关节脱位

目的 观察改良Weaver法治疗陈旧性重度肩锁关节脱位的临床疗效。方法 用1枚克氏针由肩峰通过肩锁关节穿入锁骨外端固定肩锁关节，喙肩韧带的肩峰端切断，旋转移位重建喙锁韧带。结果 23例术后随访1－5年，按优，良，差标准评定疗效，优19例（82．6％），良3例（13．0％），差1例（4．3％），优良率95．6％，结论 该方法操作简单，创伤小，远期疗效好，可满意恢复肩关节功能。     

表皮生长因子和表皮生长因子受体在隐睾症男童表达的改变及其临床意义

目的:探讨表皮生长因子(EGF)及表皮生长因子受体(EGFR)在隐睾症男童的表达改变及其临床意义。方法：用放射性免疫法测定血清EGF，免疫组化法测定EGFR表达。结果(1)5—9岁及10—14岁隐睾症男童血清EGF水平显著低于正常男童(P＜0．01)，(2)腹腔隐睾症患者的血清EGF水平比腹股沟管内及腹股沟管外隐睾症患者显著为低，(3)睾丸固定术后6个月血清EGF水平显著增高(P＜0．05)，(4)2—4岁患者间质细胞中EGFR的表达显著低于5岁以上的患者(P＜0．05)，(5)腹腔隐睾症及腹股沟管内隐睾症患者的EGFR阳性表达显著低于腹股沟外隐睾症患者(P＜0．01)。结论：EGF及EGFR的表达可能和年龄及睾丸位置有关。睾丸固定术可改善隐睾症男童的EGF及EGFR的表达。     

SURGICAL MANAGEMENT OF THE NONPALPABLE TESTIS: THE CHILDREN'S HOSPITAL OF PHILADELPHIA EXPERIENCE

Purpose

The management of the nonpalpable testis permits an individualized operative approach. We analyze the results of surgical management of a large series of patients with a nonpalpable testis.

Materials and Methods

Between January 1986 and June 1994 we treated 1,866 boys with undescended testes. There were 447 testes (24%) that were not palpable at presentation. Intraoperative data on these patients were collected for age at presentation, bilateral testes position, testicular size, associated inguinal anomalies (vas, epididymis and processus vaginalis) and surgical approach. For intra-abdominal testes postoperative results of 2 surgical techniques, the Fowler-Stephens procedure and Koop orchiopexy (retroperitoneal mobilization of spermatic vessels and vas) were compared in 76 patients with at least 18 months of followup.

Results

Average patient age at presentation was 34 months with 63% presenting before age 48 months. Of the impalpable testes 58% were on the left side, 35% were on the right side and 7% were bilateral. At operation 181 testes (41%) were atrophic or absent, 91 (20%) were intraabdominal with 14 (3.1%) bilateral, 136 (30%) were in the inguinal canal and 39 (9%) were in other locations, including 22 at the pubic tubercle, 2 in the upper scrotum, 13 in the superficial inguinal pouch and 2 in the perineum. Of the intra-abdominal group associated extratesticular malformations were identified in 36 cases (39%). Attachment of the vas deferens to the testis was abnormal in 23 of 64 cases (36%), including 10 that were completely detached and 13 with head or tail attachment only.Of the 91 evaluable cases in the intra-abdominal group 38 (42%) had been treated with the Fowler-Stephens repair (5 in 2 stages), 33 (36%) with inguinal orchiopexy and intraperitoneal dissection without dividing the spermatic vessels, 5 with 2-stage procedures and vessel preservation and 14 (15%) with orchiectomy. One testis was left in situ. The inguinal approach with intraperitoneal extension was successful in defining the testis location or blind-ending vas and vessels in 100% of the cases. A single operation to perform orchiopexy was successful in 92% of the cases. Overall, results were considered excellent or acceptable in 32 of 33 cases (97%) after Koop orchiopexy and 28 of 38 (74%) after the Fowler-Stephens orchiopexy.

Conclusions

Nonpalpable testes accounted for 24% of the patients presenting with undescended testes. At surgical exploration 39% of impalpable testes were distal to the external inguinal ring, 41% were atrophic or absent and 20% were intra-abdominal. All cases were treated through a standard inguinal incision. These data provide evidence that the inguinal approach to orchiopexy with transperitoneal mobilization of the vas and vessels without transection is highly successful for the intra-abdominal cryptorchid testis and, to date, is the preferred technique for the management of the intra-abdominal undescended testis.     

腹腔镜下手术治疗腹股沟型隐睾

目的 探讨腹腔镜下睾丸固定术治疗腹股沟型隐睾的可行性及微创优势. 方法 腹股沟型隐睾患儿90例.年龄8个月～6岁,平均17个月.左侧24例、右侧53例、双侧13例,共103个睾丸.腹腔镜下离断鞘状突或疝囊,松解腹膜后精索,将睾丸拉入腹腔,离断引带;将睾丸拉入阴囊固定. 结果 90例103个睾丸手术均顺利,无中转开放手术者.平均手术时间(32.7±5.2)min.103个睾丸患侧鞘状突未闭93侧(90.3%);77例单侧隐睾对侧鞘状突未闭12例(15.6%).术中发生皮下气肿3例(3.3%),拔出套管后,经切口排出气体,气肿消失.术后随访6～12个月,103个睾丸均在阴囊内,无萎缩及睾丸回缩. 结论 腹腔镜下腹股沟型隐睾固定手术安全、有效,弥补了开放术式破坏腹股沟管解剖完整性、腹膜后高位松解困难等缺陷.     

Prescrotal Orchiopexy: An Alternative Surgical Approach for the Palpable Undescended Testis

PurposeInguinal exploration has been a standard approach for the management of palpable undescended testis. We performed prescrotal orchiopexy in patients with palpable undescended testes at our institution and we report our results.Materials and MethodsWe reviewed the charts of patients with palpable undescended testes treated with prescrotal orchiopexy from 1999 to 2002. All children were referred to a university children’s hospital and 1 of 2 surgeons performed the procedures. Examination using anesthesia was performed prior to any incision. If the testis was palpable and could be drawn close to the scrotum, prescrotal orchiopexy was performed. Retractile testes were excluded.ResultsDuring this period 291 patients underwent orchiopexy. Prescrotal orchiopexy was performed in 78 patients. Followup was 1 to 36 months (median 6). The overall success rate was 98.8% and the overall complication rate was 4.7%. At 7 months postoperatively 1 patient had a palpable retractile testicle. One patient had wound hematoma and another patient had wound cellulitis. At 31 months of followup 1 patient was considered to have a 25% decrease in testis size. All patients were without clinical evidence of hernia or hydrocele.ConclusionsPrescrotal orchiopexy is a successful procedure in select patients with a low complication rate. It has the advantage of a single, perfectly cosmetic incision. This approach should be considered an option when performing orchiopexy in a patient with a palpable, mobile undescended testis.     

Laparoscopy for impalpable testis: classification-based management

BACKGROUND: The undescended testis represents one of the most common disorders of childhood. The authors evaluated the safety and efficacy of laparoscopy for the abdominal testis and present a classification of the laparoscopic diagnostic findings to facilitate decision making. METHODS: Between 2000 and 2005, 95 patients (22 bilateral and 73 unilateral testes, for a total of 117 impalpable testes) with a mean age of 5 years underwent laparoscopy. The testis was managed according to a special classification of the diagnostic findings. Testicular position, size, and viability according to technetium-99m ((99m)Tc) were assessed during the follow-up evaluation. RESULTS: The laparoscopic findings were classified into six types: type 0 (no testis or vanished testis proximal to the internal ring; 9 patients [7.5%]); type 1 (atrophic intracanalicular testis; 6 patients [5.4%], for whom no further intervention was administered); type 2 (testis at the internal ring with looping vas; 15 patients [14.5%], for whom laparoscopic orchiopexy was performed); type 3 (testis at the internal ring without looping of the vas; 29 patients [24.7%], for whom laparoscopic orchiopexy also was performed; type 4 (high abdominal testes; 49 patients [41.9%], with Staged Fowler-Stephens orchiopexy performed for 47 testes and laparoscopic orchidectomy for 2 testes; and type 5 (persistence of Müllerian duct structures [PMDS] or other abnormalities; 7 testes [6%]). After a mean follow-up period of 3 years, the laparoscopic orchiopexy testes were of good size and viable, but four testes (8.7%) were at the neck of the scrotum. The laparoscopically staged Fowler-Stephens orchiopexy group showed atrophy in two testes (4.3%), and all were in the bottom of the scrotum. CONCLUSIONS: Classification of the laparoscopic findings facilitates decision making. Laparoscopic orchiopexy is a natural extension of diagnostic laparoscopy for the intraabdominal testis at the internal ring or that seen peeping from it. Laparoscopically staged Fowler-Stephens orchiopexy is the procedure of choice for the high intraabdominal testis not amenable to the one-stage procedure.     

Single scrotal incision orchiopexy for palpable undescended testis

OBJECTIVE: To prospectively evaluate the Bianchi single scrotal incision technique for orchiopexy in boys with palpable undescended testis. METHODS: A total of 35 orchiopexies were performed in 28 patients. The patent processus vaginalis was dissected and cut high without ligation, while in Bianchi's original procedure, the patent processus vaginalis is dissected up to the external inguinal canal, ligated high and divided. Testicular size and position were assessed at 2 and 6 weeks and 6 months. RESULTS: The single incision technique was successful in all cases. All testes were satisfactorily positioned in the scrotum. All testes showed good anatomical and cosmetic results at 6-month follow-up. CONCLUSION: Single scrotal incision orchiopexy without ligation of the patent processus vaginalis has proved to be simple, safe and effective in selected cases compared with the standard two-incision approach in the treatment of palpable undescended testis.     

Results of orchiopexy for the undescended testis

The undescended testis is one of the most common congenital abnormalities of the genitourinary system. Outcomes of orchiopexy include (1) having a viable, palpable testis in the scrotum, (2) fertility, as measured by paternity rates or semen analysis in adulthood and (3) risk of testicular cancer. Multiple operative techniques have been described and are associated with various success rates. In the past decade, success of orchiopexy for inguinal testes has been >95%. For abdominal testes, success for orchiopexy has been >85–90% in most series with single stage orchiopexy or two stage Fowler–Stephens orchiopexy, both with open surgical or laparoscopic technique. However, having a palpable testis in the scrotum does not assure fertility, as there are iatrogenic factors that may adversely affect the outcome. In adult men with a history of unilateral orchiopexy, fertility is nearly normal, but is significantly reduced following bilateral orchiopexy. The risk of testicular carcinoma is increased by a factor of 3.7 to 7.5 times. Tumor type is most commonly seminoma if the testis is undescended, whereas tumors that occur following orchiopexy are much more likely to be nonseminomatous.     

Laparoscopic versus open orchiopexy in the management of abdominal testis: A descriptive study

AIMS: Treatment of patients with abdominal non-palpable testis (NPT) is still controversial among pediatric urologists. This is a prospective randomized comparative study between open and laparoscopic orchiopexy for management of abdominal testis. The aim of this study was to evaluate the success rate and morbidity of both approaches. METHODS: Eighty-two patients with a mean age of 5.3 years were evaluated by laparoscopy for 87 NPT. Patients with viable abdominal testes were randomly treated with either open or laparoscopic orchiopexy procedures. RESULTS: On laparoscopy, 75 viable abdominal testes were found. According to location: 41 (47.1%) testes were high abdominal, 27 (31%) testes were low abdominal and 7 (8%) testes were peeping from the internal ring. Laparoscopic first stage Fowler-Stephens orchiopexy was done initially for those with high abdominal testes. For further management, all patients were divided randomly into open (36 cases) and laparoscopic (39 cases) groups where primary (with spermatic vessel preservation) or second stage Fowler-Stephens orchiopexy was done. Statistical analysis was done using Student's t-test. Laparoscopic procedures showed significant less morbidity than the open counterparts. Follow up ranged from 9 to 31 months and included evaluation of testicular site and size. All testes were located satisfactorily inside the scrotum. Five cases of testicular atrophy were encountered (three and two testes with open and laparoscopic second stage Fowler-Stephens orchiopexy respectively) after 1 year follow up. CONCLUSION: Results of open versus laparoscopic orchiopexy procedures (primary or staged) are fairly comparable. However, laparoscopy provides significantly less morbidity.     

经脐单一切口腹腔镜联合2mm trocar治疗腹腔型隐睾

目的探讨经脐单一切口腹腔镜联合2 mm trocar治疗腹腔型隐睾的应用价值。方法 2009年11月～2011年1月,采用经脐单一切口腹腔镜联合2 mm trocar治疗11例腹腔型隐睾。脐下缘1.5 cm弧形切口,置入自制多通道trocar,置入5 mm腹腔镜和操作器械1把,脐与耻骨联合连线中点处直接穿刺置入2 mm trocar,置入2 mm腹腔镜抓钳,进行手术。结果 10例11侧成功将隐睾下降固定于阴囊;1例1侧行隐睾切除术。手术时间30～70 min,平均45 min。无手术并发症发生。10例随访3～14个月,平均8.8月,未发现下降的睾丸萎缩。结论经脐单一切口腹腔镜联合2 mm trocar治疗操作不复杂的腹腔型隐睾可行。     

The ascending testis and the testis undescended since birth share the same histopathology

PURPOSE: The etiology of the ascending testis is controversial. We propose that ascending testis, defined as a testis previously thought to be descended and later noted to be out of the scrotum, is due to mild hypogonadotropic hypogonadism affecting both testes. The diagnosis of these low types of true undescended testes is difficult to make clinically in children since they are frequently confused with retractile testes. In this study we compared testicular biopsies in a group of boys with ascending testes with those in boys who had an undescended testis since birth (primary undescended testis). MATERIALS AND METHODS: Between 1985 and 1995, 91 patients with ascending testes underwent orchiopexy and bilateral testis biopsy. The total germ cell count, processus vaginalis status, age at surgery and whether followup was done by a pediatrician or pediatric urologist were compared in patients with ascending and unilateral primary undescended testes. RESULTS: The total germ cell count was similar in the undescended and the contralateral descended testis in patients with ascending and primary undescended testes. The processus vaginalis was more likely to be closed in ascending testes (57% versus 36%, p = 0.0001). Age at surgery and the total germ cell count were similar in patients followed by pediatricians and pediatric urologists. CONCLUSIONS: The ascending testis has the same germ cell count as the primary undescended testis. Yearly followup by the primary care physician is recommended for patients with retractile testes.