影响显微镜下输精管附睾吻合术后结果的因素分析

Factors affecting the results of microsurgical vasoepididymostomy

目的:分析影响显微镜下输精管附睾吻合术后复通率的可能术中因素。方法:2009年1月至2010年7月北京大学第一医院男科中心共对73例梗阻性无精子症患者行显微镜下输精管附睾吻合术,患者平均年龄31(23～48)岁,平均梗阻时间50.9(2～180)月。术后根据患者的术中情况分别对吻合数量、吻合部位和附睾液3个因素进行分析,其中双侧吻合53例,单侧吻合20例;头部吻合19例,体部吻合46例,尾部吻合8例;附睾液中找到活动精子伴附睾液持续流出55例,不动精子伴附睾液量少18例。术后3个月开始复查精液常规,精子密度>1×104个/mL证实为精道复通。结果:20例患者失访,有53例患者成功随访,患者平均随访13.8(4～22)个月,其中38例患者术后精液中出现精子,总体复通率为71.7%(38/53)。精子密度为(1～48)×106个/mL,活力0%～65%(a+b级)。双侧和单侧吻合的复通率分别为80.5%和41.7%;头部、体部和尾部吻合的复通率分别为38.5%、78.8%和100%;附睾液中活动精子和不动精子的复通率分别为83.7%和40%。17例患者配偶自然怀孕,自然怀孕率33.3%(17/53)。结论:除了显微吻合技术外,双侧吻合、体尾部吻合和流动的附睾液中找到活动精子均可以明显提高复通率。

Objective： To evaluate the intraoperative factors affecting the patency of microsurgical vasoepididymostomy.Methods： From January 2009 to July 2010,73 men with obstructive azoospermia had undergone longitudinal intussusception vasoepididymostomy（LIVE）.The mean age（range） was 31 years（23 to 48） for the patients and their mean infertility was 50.9 months（2 to 180）.All the patients were included in three groups by the clinical variables in surgery： anastomosis number,anastomosis sites,epididymal fluid analysis.Bilateral and lateral anastomosis was in 50 and 23 cases,respectively.The anastomosis on caput,corpus and caudal was in 19,46,and 8 cases respectively.Motile sperm in the epididymal fuild continuing flowage could be found in 55 patients.By contrast,immotile sperm could be found in 18 patients.Semen analysis was done at the end of 3 months,and patency was arbitrarily defined as10 000 sperm/mL in ejaculate in at least one semen analysis after surgery.Results： Of all the patients,53 were followed up.Sperm was present in the ejaculate in 38 patients postoperatively.The overall patency rate was 71.7%（38/53）.Patency rates of bilateral surgery and of lateral surgery achieved 80.7% and 27.6%;of caput anastomosis 38.5%,of corpus anastomosis 78.8%,of caudal anastomosis 100%,of motile sperm with epididymal fluid continuing flowage 83.7% and of immotile sperm 40%,respectively.In the study,17 patients（33.3%,17/53） reported spontaneous pregnancy.Conclusion： Except for microsurgical technology,bilateral anastomosis,corpus or caudal anastomosis,and motile sperm with epididymal fluid continuing flowage may improve patency rate postoperatively.