经直肠超声引导下精囊穿刺灌注治疗顽固性血精长期疗效观察

目的:评价经直肠超声(TRUS)引导下经会阴精囊穿刺灌注抗生素治疗顽固性血精的长期疗效。方法:入选12名患者,年龄(36.4±10.8)岁,病程(13.9±6.4)个月。取得前列腺按摩液(EPS)并进行细菌培养。在TRUS引导下经会阴穿刺抽吸影像异常侧精囊液(SVF)进行细菌培养。根据EPS细菌培养和药敏试验结果选择抗生素,细菌培养阴性者选择广谱抗生素,在TRUS引导下穿刺精囊进行灌洗和冲洗。1个月后复查时如血精未消失,则再次穿刺灌药。以后每3个月随访1次。结果:TRUS发现精囊和/或射精管异常影像者9例,包括精囊和/或射精管扩张7例;精囊壁增厚3例;精囊壁钙化或精囊结石3例;副中肾管囊肿1例。7例SVF培养阳性,其中耐甲氧西林金黄色葡萄球菌4例,耐甲氧西林凝固酶阴性葡萄球菌、大肠埃希菌、奇异变形杆菌各1例。随访10例,随访时间(31.4±5.7)个月,中位时间31.5个月。治疗后从未复发3例,曾经复发7例;末次随访时2例仍有持续发作,8例未发作。结论:TRUS引导下精囊穿刺灌注抗生素治疗顽固性血精有一定疗效。     

经直肠超声引导下精囊穿刺在精囊疾病中的诊断价值

目的探讨经直肠超声(TRUS)引导下精囊穿刺对精囊疾病的诊断价值。方法28例因血精和排尿困难进行超声检查患者，平均年龄38岁，平均病程15．8个月。对超声发现精囊扩张、囊肿的患者在TRUS引导下经会阴穿刺抽吸精囊液(SVF)或囊肿液，进行细菌培养、药敏实验和细胞学检查，注射造影剂摄片。1个月后随访或重复穿刺。对含有实性成分的病变则穿刺活检进行病理学检查。结果经TRUS诊断精囊和(或)射精管异常扩张20例，精囊囊肿5例，精囊癌3例。伴精囊壁增厚6例、钙化2例，结石1例。陈旧血性液体均从扩张侧精囊内或囊肿内吸出，其中包括精囊扩张17例，共19侧，射精管扩张3例均为单侧，精囊囊肿5例有2例合并出血。细菌培养阳性17例．其中耐药菌10例，穿刺后一过性轻度血尿7例，3d内消失。随访26例，时间6～36个月。重复穿刺者19例，21侧，均为精囊炎及射精管扩张患者的抗生素灌注治疗，1次穿刺未复发6例．2次穿刺未复发3例，10例患者经3次穿刺仍未治愈。结论TRUS可直接观察精囊细微结构改变，获得纯粹的精囊液、囊肿液或进行组织活检，进一步通过细菌学、细胞学、组织病理学及造影检查对明确精囊疾病的性质具有可靠的诊断价值。对顽固性血精的治疗也有一定帮助。     

慢性精囊炎的介入治疗

目的 :探讨超声引导下经会阴精囊穿刺置管滴注抗生素在治疗慢性精囊炎中的价值。　方法 :4 2例血精症病人 ,均行直肠超声检查 ,其中 2例行超声引导下经会阴穿刺活检 ,5例行尿道镜检查 ,余 35例炎症性血精症采用超声引导下经会阴精囊穿刺滴注抗生素治疗。　结果 :35例炎症性血精症 (其中 17例合并前列腺炎 ) ,采用超声引导下经会阴精囊穿刺滴注抗生素治疗后 32例血精消失 (91.4 3% )。　结论 :超声引导下经会阴精囊穿刺和经导管滴注抗生素是一种诊断和治疗慢性精囊炎有效的方法。     

超声引导下精囊穿刺置管治疗顽固性血精

目的:探讨经直肠超声引导下经会阴精囊穿刺置管连续滴注抗生素在治疗顽固性血精的价值。方法:25例临床诊断为顽固性血精的患者,在经直肠超声实时引导下行经会阴精囊穿刺置管术,在取得精囊液后留置导管,经导管连续滴注抗生素一周。结果:25例患者均一次穿刺置管成功,其中23例完成一周治疗,2例由于导管滑脱而提早拔管。治疗后随访6个月~2年,23例血精消失(92.0%),2例复发,其中1例为提早拔管者。结论:超声引导下经会阴精囊穿刺置管滴注抗生素是一种治疗顽固性血精安全而有效的方法。     

42例血精症病因的诊断与治疗

目的：探讨血精症病因的诊断与治疗。方法：对42例血精症患者中4l例进行超声引导下经会阴精囊穿刺造影，精囊液常规检查和细菌培养及其他检查；1例作直肠指检、CT与超声检查。针对血精症的病因采用多种方法进行治疗。结果：42例血精症的病因分别为前列腺癌、精囊癌和后尿道炎症各l例，精阜开口处息肉4例，精囊炎35例，其中17例并发前列腺炎。2例肿瘤源性血精症采用根治性前列腺和精囊切除术后治愈，35例炎性血精症采用超声引导下经会阴精囊穿刺滴注抗生素治疗后32例血精消失(91．4％)，4例精阜开口处息肉和l例后尿道炎症经相应治疗后痊愈。结论：血精症主要是下尿路生殖道的炎症，尤其是前列腺和精囊炎引起，超声引导下经会阴精囊穿刺和经导管滴注抗生素是一种诊断和治疗慢性精囊炎有效的方法。     

原发性精囊癌1例报道并文献复习

目的 探讨原发性精囊癌的诊治方法.方法 分析收治的原发性精囊癌1例,结合文献进行复习.结果 经CT、MRI及经直肠超声(transrectal ultrasound,TRUS)引导下穿刺活检确诊为精囊腺癌,行左侧精囊肿物切除、右侧精囊切除、膀胱与前列腺部分切除及左输尿管膀胱再吻合术,术后恢复良好.现已随访23个月,未见复发转移.结论 原发性精囊癌临床罕见,术前诊断较为困难,TRUS引导下穿刺活检可明确诊断,应根据患者个体情况选择不同的根治性切除术.术后定期随访,注意是否复发转移.     

经直肠超声引导穿刺活检诊断早期前列腺癌漏诊原因的分析

目的:分析经直肠超声(TRUS)引导下穿刺活检诊断前列腺癌的漏诊原因,减少漏诊率,提高诊断率。方法:80例疑似前列腺癌的良性前列腺增生(BPH)患者行TRUS引导下穿刺活检,结果均为阴性,均行前列腺电切术(TURP),术后标本行病理检查。结果:25例术后病理报告为前列腺癌,漏诊率31.25%(25/80)。其中10例行经会阴前列腺癌根治术、8例行手术去势、7例行药物去势。结论:TRUS引导穿刺活检诊断前列腺癌存在一定的漏诊,多次或多点穿刺活检可以减少漏诊率。     

徒手TRUS引导下经会阴前列腺活检的临床应用探讨

目的:探讨徒手"12+X"法TRUS引导下经会阴前列腺活检术诊断前列腺癌的临床应用价值。方法:2014年12月~2015年12月,对74例可疑前列腺癌患者行经直肠B超引导下18G自动穿刺活检针行双侧外周带12点法系统穿刺,其中直肠指诊(DRE)触及结节24例,超声提示异常回声14例,前列腺核磁提示异常信号30例;前列腺特异性抗原(PSA)<4ng/ml者14例,PSA 4~10ng/ml 25例,PSA>10ng/ml者35例。同时对每个可疑病灶进行1~2针靶向穿刺。回顾性分析穿刺的阳性率和并发症。结果:成功对74例患者进行徒手"12+X"法TRUS引导下经会阴前列腺活检术。年龄43~81岁,中位年龄72岁;PSA 1.9~500ng/ml,中位PSA17.8ng/ml。经病理诊断,前列腺癌23例,阳性率31.1%,穿刺阴性病例中3例TURP术后病理诊断结果为前列腺癌;2例首次穿刺阴性,6个月后重复穿刺时发现前列腺癌。低危前列腺癌(Gleason≤6分)、中危前列腺癌(Gleason=7分)和高危前列腺癌(Gleason≥8分)分别为13.1%、30.4%和56.5%。其余51例为良性前列腺增生或合并前列腺炎症。术后短暂和轻度的肉眼血尿6例(8.1%),均在1~3d后缓解,5例(6.8%)轻度发热,2例(2.7%)会阴部轻度不适。无脓毒症、急性尿潴留等严重并发症的发生。结论:徒手"12+X"法TRUS引导下经会阴前列腺活检安全可行,阳性率稳定,值得在临床上进一步推广。     

经会阴前列腺包膜下穿刺治疗慢性前列腺炎

目的 :探讨经会阴前列腺包膜下穿刺注射药物治疗慢性前列腺炎的效果。　方法 :对 4 0例难治性慢性前列腺炎患者的前列腺液进行细菌培养和药敏试验 ,选择一种敏感抗生素 ,加入地塞米松和利多卡因的混合液中行经会阴前列腺包膜下注射 ,隔 7d注射 1次 ,4次为 1个疗程 ,治疗后 1个月评价其疗效并随访 6个月。　结果 :4 0例慢性前列腺炎患者中治愈 2 1例 (5 2 .5 % ) ,有效 16例 (40 % ) ,无效 3例 (7.5 % ) ,总有效率达 92 .5 %。 2 8例获 6个月随访 ,无 1例复发。　结论 :经会阴前列腺包膜下穿刺注射药物治疗慢性前列腺炎是一种安全有效、治愈率较高的治疗方法。     

腹腔镜手术切除精囊囊肿

精囊囊肿是一种罕见疾病,人群中发病率低于0．005％。有症状的精囊囊肿常需手术治疗,治疗方法有经直肠穿刺抽吸、经尿道内镜去顶减压或穿刺抽吸、经腹或经会阴囊肿切除。随着腹腔镜技术成熟,腹腔镜逐渐应用到精囊囊肿手术,目前国外文献仅有11例经腹腔镜行精囊囊肿切除的报告,国内未见正式报告。新近,我们成功行经腹腔镜精囊切除术1例。报告如下。     

Hematospermia: An investigation of the bleeding site and underlying lesions

Background : The site of hemorrhage and causative lesions in patients with hematospermia were evaluated using the puncture technique for seminal vesicles and/or müllerian duct cysts under ultrasound guidance.
Methods : Twenty-one patients aged 26–75 years (mean, 49.8 years) underwent transperineal needle aspiration of the seminal vesicles and/or müllerian duct cysts guided by transrectal ultrasonography (TRUS).
Results : Dark reddish seminal vesicle fluid was aspirated and the site of bleeding was considered to be the seminal vesicles in 11 patients (52%) (group A). In group A, abnormalities of the seminal vesicles were noted in nine patients (82%). These consisted of dilated seminal vesicles in seven (bilateral in four, unilateral in three), a seminal vesicle cyst in one and seminal vesicle amyloidosis in one. A müllerian duct cyst was confirmed to be the bleeding site in two patients (10%; group B). The bleeding site was estimated to be organs rather than the seminal vesicles in four patients (group C), in all of whom ectopic prostatic tissue was observed in the prostatic urethra. In groups B and C, seminal vesicle abnormalities were not detected by TRUS. In the remaining four patients (group D), failure to aspirate seminal vesicle fluid means that it is unclear whether hemorrhage was from the seminal vesicle or from another source. In group D, ectopic prostatic tissue was demonstrated in the prostatic urethra of three patients and unilateral seminal vesicle dilation was detected by TRUS in one patient.
Conclusion : Puncture of the seminal vesicles and/or müllerian duct cysts under ultrasonic guidance as well as cystourethroscopy is a useful and minimally invasive examination for determination of the bleeding site responsible for hematospermia.     

经尿道精囊镜技术诊治血精的临床研究

目的 探讨经尿道精囊镜技术对顽固性血精的诊断和临床应用价值.方法 筛检2010年6月至2011年7月,对16例顽固性血精患者,年龄22~47岁,平均35.5±5.3岁;病程3~48个月,平均6.6±3.6个月,采用了经尿道精囊镜诊断和治疗.结果 手术全部成功,时间25~45 min,平均30.2±8.4 min,平均随访期为8.3个月(6～12个月),术后随访至今,仅1例精囊炎性出血患者术后3个月血精复发,治疗后半年内没有血精症状出现,视为治愈,本组治愈率为93.75%.结论 经尿道精囊镜检操作简单,创伤小,可作为顽固性血精的有效诊治方法.     

Ejaculatory duct obstruction

Ejaculatory duct obstruction presents with infertility, pain, or hematospermia. Partial or functional forms of ejaculatory duct obstruction can be difficult to diagnose. Transrectal ultrasound has replaced formal vasography as the first-line diagnostic test but is not specific. Adjunctive procedures such as seminal vesicle aspiration, seminal vesiculography, and chromotubation further delineate the diagnosis. Using an evidence-based approach, this article reviews how best to approach the diagnosis and treatment of ejaculatory duct obstruction.     

精囊镜血精诊治29例并文献复习

目的 探讨经尿道精囊镜检诊治顽固性血精的安全性及可行性.方法 回顾性分析本院自2008年9月至2013年8月开展经尿道精囊镜检诊治的29例顽固性血精患者的临床资料,结合文献复习顽固性血精的治疗方法.患者年龄26 ～ 55岁,平均42岁,血精病程6～48个月,平均12个月,药物和物理治疗无效.结果 29例精囊镜检均成功,手术时间分别为20～ 75 min,平均35min.精囊镜检示慢性炎症11例,结石5例,息肉3例,射精管梗阻扩张3例,未发现明显病变7例.无尿道和精囊损伤等并发症.术后随访,其中17例患者血精症状消失,1例术后9个月再发血精,呈间歇性发作,持续随访中.结果表明29例顽固性血精患者采用精囊镜检治疗,近期疗效显著,远期治疗有效率为55.2％.结论 经尿道精囊镜检操作简单,创伤小,可作为顽固性血精的有效诊治方法之一.     

Imaging diagnosis, transurethral endoscopic observation, and management of 43 cases of persistent and refractory hematospermia

The goal of this study was to explore minimally invasive transurethral imaging and surgery for the treatment of severe, persistent hematospermia in cases that were refractory to conservative treatments. The study included 43 patients (aged 22-77 years; average, 44.6 years) with long-lasting, severe hematospermia, accompanied by discomfort or pain in the lumbosacral or perineal region, dysuria, frequent micturition, decreased semen volume, and/or azoospermia. Patient symptoms had persisted for 1 to 10 years (average, 5.3 years). Computed tomography or magnetic resonance imaging of each patient was evaluated, and transurethral surgery was performed. The causes of hematospermia were identified in all 43 patients, and their ejaculatory duct obstruction or seminal vesiculitis was successfully treated. No serious intraoperative or postoperative complications occurred. Pathologic analyses revealed that all of the resected or biopsied seminal vesicle tissues had chronic nonspecific inflammation in the seminal vesicle wall, and no tumors were identified. Preoperative symptomology of hematospermia disappeared in all patients followed up for 2 to 30 months (average, 16 months). A single patient experienced recurrence at 11 months and had a second minimally invasive surgery that was curative. A total of 95.3% (41 of 43) of the patients experienced normal orgasmic intensity after surgery. Magnetic resonance imaging is a valuable and accurate diagnostic method for the identification of causative factors underlying hematospermia. Transurethral dilation of ejaculatory ducts, incision of the verumontanum or the distal end of the ejaculatory ducts, and incision or resection of the relevant cysts represent simple, safe, and reliable approaches for the management of refractory cases of hematospermia that do not respond to conservative treatments.     

Seminal vesicle sperm aspiration in the diagnosis of ejaculatory duct obstruction

OBJECTIVE: To determine the effectiveness of seminal vesicle aspiration in the diagnosis and treatment of patients with ejaculatory duct obstruction. PATIENTS, SUBJECTS AND METHODS: Between March 1998 and February 1999, 10 infertile men with ejaculatory duct obstruction (EDO, mean age 32.7 years, range 25-47) and 10 fertile volunteers (mean age 33.2 years, range 25-42) underwent transrectal ultrasonography (TRUS) and TRUS-guided seminal vesicle aspiration. The volume of and presence of motile sperm in the aspirate was compared with the TRUS findings for both groups. RESULTS: From TRUS of the patients with EDO, the mean (sd, range) transverse diameter of the right and left seminal vesicles were 1.97 (0.54, 0.8-2.6) cm and 1.93 (0.53, 0.9-2.6) cm; the corresponding values in the control group were 1.03 (0.15, 0.8-1.3) cm and 1.0 (0. 12, 0.8-1.4) cm, respectively (P<0.001). In all, 20 aspirate samples were obtained from the patients with EDO by bilateral seminal vesicle aspiration and only one (10%) had no sperm within the aspirate fluid. Of these 10 patients, two had immotile sperm and the remaining seven (14 samples) had a mean motile sperm count of 0.63 (0.45, 0.1-1.0)x106 /mL, whereas seven of eight men assessed in the control group had no motile sperm (one patient had immotile sperm within the aspirate fluid); this difference was significant (P<0.01). CONCLUSIONS: The aspiration of significant numbers of motile sperm from the seminal vesicles suggests the presence of distal obstructions of the ejaculatory duct and enables infertile couples to be candidates for assisted reproduction. However, there is a need for further research to determine the use of this technique in the diagnosis of partial EDO.     

A clinical entity of cystic dilatation of the utricle associated with hemospermia

PURPOSE: We investigated the mechanism of hemospermia in patients with a midline cyst (MLC) of the prostate, focusing on cystic dilatation of the utricle (CDU) as a possible causative lesion. MATERIALS AND METHODS: Of 138 patients with hemospermia 30 (22%) had an MLC, of whom 19 underwent transperineal needle aspiration of the MLC and bilateral seminal vesicles to determine the site of bleeding. Following MLC aspiration a mixture of dye and contrast medium was injected. The verumontanum was observed endoscopically and pelvic x-ray was done. RESULTS: Seminal vesicle fluid on 1 or 2 sides was hemorrhagic in 13 of the 19 patients (aspiration failed in 6) and fluid from the MLC was nonhemorrhagic in 5 of the 19 (aspiration failed in 7). The MLC communicated with the urethra (CDU) in 15 patients (79%) and with 1 or 2 ejaculatory ducts in 11 (58%). In 5 of 11 patients with communication with the ejaculatory duct hemospermia persisted for more than 1 year. Four of these patients were cured by transurethral unroofing of the CDU. CONCLUSIONS: CDU is a significant underlying lesion for hemospermia. Communication with the ejaculatory ducts was frequent in patients with chronic hemospermia and transurethral unroofing was effective for eliminating hemospermia.     

A case of prostatic cancer with a low PSA level accompanied with cystic formation requiring differentiation from adenocarcinoma of the seminal vesicle

A 70-year-old man with the complaint of macrohematuria and hematospermia was admitted to our hospital for further examination of a cystic formation of the right seminal vesicle, 3.6 cm in diameter, detected by magnetic resonance imaging(MRI). Cystoscopy revealed no remarkable change, but urine cytology was class III. The serum concentration of prostate specific antigen (PSA) was within the normal range of 1.83 ng/ml. Transperineal needle biopsy of the prostate and cystic tumor of the seminal vesicle revealed adenocarcinoma of the prostate and seminal vesicle, but immunostaining for PSA was negative, so we diagnosed the case as primary adenocarcinoma of the seminal vesicle. Bloody fluid of the cyst was obtained by transperineal aspiration, but no cancer cells were detected by cytological examination. Total prostatectomy was performed, and pathological findings was infiltration of prostate cancer into the seminal vesicle (pT3b) because immunostaining of the PSA was positive.     

经尿道精囊镜技术在精囊疾病诊断治疗中的临床应用(附52例报告)

目的:探讨经尿道精囊镜技术在精囊疾病诊治中的临床应用价值。方法:回顾性分析我院泌尿外科2009年10月~2013年2月采用经尿道精囊镜治疗顽固性血精52例患者的临床资料,并结合文献复习临床常见的精囊疾病的病因和诊治方法。本组患者均由药物及物理疗法治疗3个月无效。术前完善常规检查后,进行精囊灌洗,射精管扩张、钬激光碎石以及精囊囊肿去顶等治疗,术后定期随访。结果:本组52例均进镜成功,镜检示血精36例,精囊慢性炎症27例,精囊囊肿18例,精囊结石17例,射精管梗阻16例,精囊脓肿合并附睾结核1例,精囊淀粉样变3例,精囊肉芽肿1例。术后随访3~12个月,2例术后出现急性附睾炎,给予抗感染治疗后治愈,未出现尿失禁、急性前列腺炎和直肠损伤等并发症。结论:经尿道精囊镜技术在对精囊疾病进行检查的同时也可以治疗精囊疾病,是诊断治疗精囊疾病的一种安全、有效、微创的新技术,值得临床推广。