显微镜下小切口经腹股沟管内环和外环精索静脉结扎术治疗男性不育症的比较

Comparison of microscopically small incision ligation of spermatic vein through inner ring vs. outer ring of inguinal canal in the treatment of male infertility

目的:对比显微镜下小切口经腹股沟管内环和外环入路精索静脉结扎术治疗男性不育症的临床效果。方法:回顾性分析2013年1月-2019年12月,开封市中心医院和许昌市中心医院泌尿外科住院并接受手术的单侧原发性中-重度精索静脉曲张合并男性不育症患者212例,根据手术入路不同分为显微镜下小切口经腹股沟管内环入路(内环组)107例和外环入路(外环组)105例。记录两组的切口长度、手术时间、精索静脉结扎数目、术中出血量、副损伤发生率,以及术后视觉模拟疼痛评分、医疗费用、精索静脉曲张复发率、并发症、术后6个月的精液化验结果以及配偶1年内的自然受孕率等。结果:相比外环组,内环组手术时间短[(49.63±10.69)min vs.(82.80±10.33)min],术中结扎的精索静脉数目少[(4.54±0.78)支vs.(10.30±1.32)支],出血量多[(6.26±1.18)mL vs.(3.04±0.94)mL],均差异有统计学意义(P<0.05)。两组术后相比术前精子浓度[(45.77±3.16)×10^(6)/mL vs.(20.60±2.73)×10^(6)/mL;(46.50±2.91)×10^(6)/mL vs.(19.73±2.25)×106/mL]和a+b级精子百分比[(50.38±2.04)%vs.(35.24±3.65)%;(49.30±1.63)%vs.(35.53±2.30)%]均有改善,差异有统计学意义(P<0.05)。内环组术中有5例腹膜破裂,予以修补,未发生肠管和腹壁下动静脉损伤;外环组术后3例发生阴囊皮肤水肿,2周内消退。两组无切口感染、附睾炎或鞘膜积液等并发症发生。内、外环组患者配偶的1年自然受孕率分别为35.51%(38/107)和40.00%(42/105),差异无统计学意义(χ^(2)=0.454,P=0.52)。结论:显微镜下小切口经腹股沟管内环入路和外环入路精索静脉结扎术治疗男性VC不育症均安全有效,经内环切口术式的操作时间较短,并发症稍多。

Objective:To investigate the clinical effect of spermatic vein ligation through inner ring vs.outer ring of inguinal canal under microscope in the treatment of male infertility.Methods:A total of 212 patients with unilateral primary moderate to severe varicocele complicated with male infertility who were hospitalized and operated in the Department of Urology of Kaifeng Central Hospital and Department of Urology of Xuchang Central Hospital from January 2013 to December 2019 were analyzed retrospectively.According to different operation methods,the patients were divided into inner ring group(107 cases receiving small incision through inguinal canal inner ring approach)and outer ring group(105 cases given outer ring approach).The incision length,operation time,number of spermatic vein ligation,intraoperative bleeding,side injury,postoperative visual analog pain score(VAS),length of hospital stay,medical expenses,varicocele recurrence rate and complications,semen test results at 6 th month after operation and natural pregnancy rate of spouse within 1 year were recorded.Results:The inner ring group had shorter operation time[(49.63±10.69)min vs.(82.80±10.33)min],less number of spermatic veins ligation[(4.54±0.78)vs.(10.30±1.32)]and more intraoperative bleeding[(6.26±1.18)mL vs.(3.04±0.94)mL]than in the outer ring group,and the difference was statistically significant(P<0.05).The postoperative sperm concentration[(45.77±3.16)×10^(6)/mL vs.(20.60±2.73)×10^(6)/mL;(46.50±2.91)×106/mL vs.(19.73±2.25)×10^(6)/mL]and the percentage of Grade a+b sperm[(50.38±2.04)%vs.(35.24±3.65)%;(49.30±1.63)%vs.(35.53±2.30)%]in the two groups were improved respectively as compared with those preoperation,and the difference was statistically significant(P<0.05).In the inner ring group,peritoneal rupture in 5 cases was repaired,and there were no intestinal and subabdominal arteriovenous injuries.In the outer ring group,there were 3 cases of scrotal skin edema,which subsided within 2 weeks.No complications such as incision infection,epididymitis or hydrocele occurred in the two groups.The 1-year natural conception rate of the spouses was 35.51%(38/107)and 40.0%(42/105)in inner ring group and outer ring group,respectively,and the difference was not statistically significant(χ^(2)=0.454,P=0.52).Conclusions:Microsurgical ligation of spermatic vein through inner-ring or outer-ring of inguinal canal is effective and safe for the treatment of male infertility with varicocele.The operation time is shorter in inner ring group and the complications are slightly more.