经外环口以下途径显微镜下精索静脉结扎术治疗精索静脉曲张术后复发的疗效分析

目的分析精索静脉曲张(VC)术后复发的病因,探讨经外环口以下途径显微镜下精索静脉结扎术(MV)治疗复发VC的疗效。方法回顾性分析2015年4月至2019年4月青岛大学附属医院收治的16例VC术后复发患者的病例资料。中位年龄27(18~36)岁。5例既往曾行精索内静脉高位结扎术,11例曾行腹腔镜精索静脉结扎术;16例于术后1~3年复诊时诊断为VC复发。复诊病因包括婚后未育10例、阴囊疼痛12例,其中婚后未育合并阴囊疼痛者6例。本组16例复发后,术前评估VC临床分级Ⅲ级13例(左侧8例,双侧5例),Ⅱ级3例(均为左侧)。疼痛视觉模拟评分(VAS)中位值为2.5(0~4)分。彩色多普勒血流显像(CDFI)分度:Ⅲ度12例(左侧7例,双侧5例),Ⅱ度4例(均为左侧)。12例临床分级和CDFI分度均为Ⅲ级(度)者的左肾血管CDFI检查提示合并胡桃夹现象(NCP)。术前血清睾酮(16.2±4.9)nmol/ml,精子浓度(11.8±3.9)×10⁶/ml,前向运动精子比例(PR)(24.4±4.2)%。本组16例均行经外环口以下途径的MV手术。全麻,患者取平卧位。术中取腹股沟管外环口以下斜切口,分离显露精索,其下方插入纱布条并垫高。使用手术显微镜放大术野4~6倍,彻底结扎并切断扩张迂曲的精索外和精索内静脉所有分支,注意保护精索内动脉和淋巴管。术中11例仅行左侧MV手术,5例行双侧MV手术,所有患者术中均探及明显扩张迂曲的精索外及精索内静脉,通过MV手术可以清晰解剖并充分保护精索内动脉及淋巴管。术中每例平均结扎左侧精索外静脉(2.1±0.6)支、精索内静脉(10.1±1.1)支,解剖出左侧精索内动脉(1.3±0.5)支、淋巴管(3.0±1.0)支,结扎右侧精索外静脉(1.4±0.5)支、精索内静脉(6.6±0.5)支,解剖出右侧精索内动脉(1.4±0.5)支、淋巴管(2.6±0.5)支。记录患者术后6个月的VAS、阴囊触诊情况、CDFI、精液分析、血清睾酮等指标,并与术前比较。结果本组16例21侧MV手术均顺利完成。术后6个月复查,所有患者查体阴囊无明显迂曲血管团,Valsalva试验呈阴性。VAS中位值为0(0~2)分,较术前显著降低(Z=-2.994,P<0.05)。精子浓度(16.2±4.6)×10⁶/ml,PR(34.5±4.1)%,均较术前明显改善(P<0.05);血清睾酮水平(16.6±4.4)nmol/ml,较术前无显著变化(P>0.05)。复查CDFI提示精索内静脉无明显反流。16例术后随访期内均未发生睾丸萎缩、鞘膜积液等并发症。术后随访1~3年,10例因婚后未育就诊者中5例术后随访期内完成生育。结论VC术后复发与静脉漏扎有关,特别是对于Ⅲ级VC或合并NCP的VC患者,采用内环口以上的传统高位结扎术或腹腔镜手术极可能漏扎较细的精索内静脉和外环口以下水平的精索外静脉。经外环口以下途径的MV手术,通过彻底结扎精索内和精索外静脉,同时保护精索内动脉和淋巴管,不仅可有效避免VC术后复发及并发症,而且可以缓解阴囊坠痛症状和改善精液质量。

Analysis of the cause of varicocele recurrence and the application of sub-inguinal microsurgical varicocelectomy in recurrent varicocele

Objective To analyze the cause of varicocele(VC)recurrence and investigate the efficacy of sub-inguinal microsurgical varicocelectomy(MV)for recurrent VC.Methods All of 16 inpatients diagnosed as recurrent VC,in the Department of Andrology of the Affiliated Hospital of Qingdao University from 2015 April to 2019 April,were performed sub-inguinal MV.The age of the inpatients was 18-36 years old,median 27 years old.5 cases were originally performed retroperitoneal high ligation of spermatic vein and other 11 cases were originally performed laparoscopic varicocelectomy.During the review one to three years after the previous operation,all of 16 patients were diagnosed as VC recurrence.The complains of these patients during the review included male subfertility(10 cases)and scrotal pain(12 cases),in which 6 cases’complains were male subfertility with scrotal pain.After admission,13 patients were classified as GradeⅢ(left in 8 cases,bilateral in 5 cases)and 3 patients as GradeⅡ(all left).The median of their visual analogue scale(VAS)was 2.5.Color doppler flow imaging(CDFI)grading showed:GradeⅢin 12 cases(left in 7 cases,bilateral in 5 cases),GradeⅡin 4 cases(all left).Particularly,12 of them were Graded asⅢsimultaneously accompanying with Nut-cracker Phenomenon(NCP).Preoperative tests showed that the average serum testosterone was(16.2±4.9)nmol/ml,the average sperm concentration was(11.8±3.9)×10⁶/ml and the progressive motility rate(PR)was(24.4±4.2)%.All of the patients were performed sub-inguinal MV using general anesthesia and supine position.The spermatic cords were clearly exposed and padded up by inserting gauze strips under them.During the operation,the field was magnified 4-6 times with the microscope.Then all of the dilated external and internal spermatic veins were ligated,at the same time the internal spermatic artery and lymph vessels were well preserved.During these operations,11 patients underwent left-side MV,while other 5 did bilateral MVs.During these MVs,we found twisted and dilated external and internal spermatic veins in all cases and well preserved the internal spermatic arteries and lymph vessels.The number of ligated left and right external spermatic veins were(2.1±0.6)and(1.4±0.5)respectively and the number of ligated left and right internal spermatic veins were(10.1±1.1)and(6.6±0.5)respectively.We also found out(1.3±0.5)internal spermatic arteries and(3.0±1.0)lymph-vessels on left side.On right side,there were(1.4±0.5)internal spermatic arteries and(2.6±0.5)lymph-vessels respectively.At last,we summarily analyzed the pre-operative and post-operative VAS,serum testosterone,CDFI and semen analysis data.Results All of the 16 sub-inguinal MVs were successfully performed.All patients were reviewed comprehensively 6 months after MV.The reviewed results showed that the post-operative VAS was significantly reduced(Z=-2.994,P<0.05),palpable scrotal vessels disappeared and Valsalva tests were negative.No obvious reflux of internal spermatic veins were detected by CDFI.Interestingly,the sperm concentration and motility were both significantly improved 6 months after MV(P<0.05),while there was not remarkable increase of the serum testosterone after MV(P>0.05).During the follow up,no testicular atrophy,hydrocele and other complications were found.Up to submission,five of the ten patients who presented for male subfertility have impregnated their wives.Conclusions The most possible cause of VC recurrence could be the omission of the external and internal spermatic veins,particularly in the gradeⅢVC patients or VC accompanied with NCP.The sub-inguinal MV,which can discover more twisted spermatic veins and at the same time preserve the spermatic artery and lymph-vessels,shows better clinical efficacy than other procedures.