摘要目的 评估和比较传统腹膜后开放手术、腹腔镜手术、显微镜手术治疗精索静脉曲张的临床疗效。方法 回顾性分析2014年1月—2017年8月收治的227例左侧精索静脉曲张患者临床资料。其中行腹膜后开放手术（Palomo术式）106例,腹腔镜手术48例,显微镜手术73例。比较三组手术时间、住院天数、手术并发症、复发率以及治疗前、后精液质量变化。结果 三组患者年龄、精索静脉曲张临床分级构成等基本资料比较,其差异无统计学意义（P>0.05）;三组中,显微镜组较其他两组手术时间更长[（25.6±10.3）min vs. （28.5±6.9）min vs. （81.4±23.5）min,P<0.05）];但其术后复发率更低（13.2% vs 16.7% vs 1.4%,P<0.05）;三组住院时间、术后睾丸萎缩、阴囊水肿、附睾肿胀发生率比较,差异无统计学意义（P>0.05）;术后6个月三组患者精子密度、总活动率、前向运动精子百分率均较术前明显提高,差异有统计学意义（P<0.05）;其中显微镜组较其他两组改善程度更为显著,差异有统计学意义（P<0.05）。结论 显微镜手术治疗精索静脉曲张,在术后复发率以及精液质量改善方面优于Palomo手术和腹腔镜手术,手术创伤小,应是临床治疗精索静脉曲张的首选方案。
Abstract：Objective： To explore the efficacy and safety of Palomo varicocelectomy, laparoscopic varicocelectomy, and microscopic varicocelectomy in the treatment of varicocele. Methods： The clinical data of 227 patients with left side varicoceles were retrospectively analyzed. Patients were divided into three groups according to the operative methods: 106 treated by Palomo varicocelectomy (group A), 48 by laparoscopic varicocelectomy (group B) and 73 by microscopic varicocelectomy (group C). The operation time, hospital stay, incidence of complications and semen quality pre- and post-operation were compared. Results： There was no significant difference among three groups in the patient’s age and clinical grade of varicocele (P>0.05). The operation time in group C was significantly longer than in groups A and B [(25.6±10.3) min vs. (28.5±6.9) min vs. (81.4±23.5) min, P<0.05], but the postoperative recurrence rate in group C was lowest (13.2% vs. 16.7% vs. 1.4%, P<0.05). There was no significant difference among three groups in hospital stay, incidence of testicular atrophy, scrotal edema and epididymis swell (all P>0.05). Sperm concentration, total motility and progressive motility in three groups were all improved after operation, more significantly in group C than groups A and B (all P<0.05). Conclusion： Microscopic varicocelectomy was associated with more significant improvements of sperm quality and lower recurrence rate than Palomo varicocelectomy and laparoscopic varicocelectomy, and became the first choice for treatment of varicocele clinically.
[1] 那彦群,叶章群,孙颖浩,等.中国泌尿外科疾病诊断治疗指南.北京:人民卫生出版社,2014:597. [2] NETO FT, BACH PV, NAJARI BB, et al.Spermatogenesis in humans and its affecting factors. Semin Cell Dev Biol, 2016,59: 10-26. [3] 中华医学会男科分会.中国男科疾病诊断治疗指南与专家共识.北京:人民卫生出版社,2016:41. [4] 武小强,杨宇,吴芃,等.精索血管的显微组织解剖及临床应用.中华男科学杂志,2012,18(6):518-521. [5] GUPTA C, CHINCHOLE A, SHAH R, et al.Microscopic varicocelectomy as a treatment option for patients with severe oligospermia. Investig Clin Urol, 2018,59(3):182-186. [6] 李茂林,章静,王治国,等.显微外科治疗青年男性精索静脉曲张的疗效分析.微创泌尿外科杂志,2017,6(4):248-251. [7] GOLDSTEIN M, TANRIKUT C.Microsurgical management of male infertility. Nat Clin Pract Urol, 2006,3(7):381-391. [8] JOHNSON D, SANDLOW J.Treatment of varicoceles: techniques and outcomes. Fertil Steril, 2017,108(3):378-384. [9] 李虎,文艳玲,董超雄,等.精索静脉曲张4种手术方式临床疗效比较.中华男科学杂志,2016,22(4):311-314. [10] 陈国强,蒋冬非,陈晨,等.精索内动静脉同时结扎治疗精索静脉曲张的临床研究.中华男科学杂志,2010,16(2):154-157. [11] ENATSU N, YAMAGUCHI K, CHIBA K, et al.Clinical outcome of microsurgical varicocelectomy in infertile men with severe oligozoospermia. Urology, 2014,83(5):1071-1074. [12] CAYAN S, SHAVAKHABOV S, KADIOĞLU A. Treatment of palpable varicocele in infertile men: a meta-analysis to define the best technique. J Androl, 2009,30(1):33-40. [13] 唐松喜,周辉良,丁一郎.腹股沟外环下切口显微精索静脉结扎术睾丸动脉系统的保护.临床泌尿外科杂志,2016,31(4):311-313. [14] BRYNIARSKI P, TABOROWSKI P, RAJWA P, et al.The comparison of laparoscopic and microsurgical varicocoelectomy in infertile men with varicocoele on paternity rate 12 months after surgery:a prospective randomized controlled trial. Andrology, 2017,5(3):445-450. [15] 黄健,江专新,覃云凌,等.显微精索静脉结扎术治疗精索静脉曲张的疗效评价(附48例报告) 中华男科学杂志,2015,21(8):757-759. [16] 彭靖,龙海,袁亦铭,等.显微镜下和腹腔镜下精索静脉结扎术的疗效比较.北京大学学报(医学版),2014,46(4):541-543. [17] ÇAYAN S, ŞAHIN S, AKBAY E.Paternity rates and time to conception in adolescents with varicocele undergoing microsurgical varicocele repair vs observation only:A single institution experience with 408 Patients. J Urol, 2017,198(1):195-201.
