腹腔镜下有选择性的精索静脉高位结扎术治疗精索静脉曲张疗效的Meta分析

The efficacy of laparoscopic selective ligation of spermatic vein for the treatment of varicocele ： a meta - analysis

目的系统评价腹腔镜下有选择性的精索静脉高位结扎术（包括腹腔镜单纯精索内静脉高位结扎术、腹腔镜单纯保留精索动脉的精索静脉结扎术、腹腔镜单纯保留淋巴管的精索静脉结扎术）与腹腔镜精索血管集束状结扎术治疗精索静脉曲张的疗效。方法计算机检索Cochrane Central Register of Con-trolled Trials（CENTRAL）、PubMed、EMbase、中国知网（CNKI）、维普数据库（VIP）、万方数据库（WangfangDate），查找所有纳入腹腔镜下有选择性的精索静脉高位结扎术治疗精索静脉曲张的随机对照试验（RCT），文献检索起始时间均为建库到2012年12月。同时手检纳入文献的参考文献。按纳入排除标准由两人独立进行RCT的筛选、资料提取和质量评价后，采用RevMan5．1软件进行Meta分析，并采用GRADE系统进行证据质量评价。结果共纳入13个随机对照试验，包括1061例精索静脉曲张患者。Meta分析结果显示：①腹腔镜下有选择性的精索静脉高位结扎术与腹腔镜精索血管集束状高位结扎术相比，术后继发鞘膜积液的发生率低[RR=0．07，95％CI（0．03，0．19）]、术后睾丸萎缩率低[RR=0．09，95％CI（0．03，0．27）]、精液质量改善率高[RR=1．29，95％CI（1．08，1．55）]、术后自然孕率高[RR=1．53，95％CI（1．03，2．29）]，而手术时间长[SMD=1．83，95％CI（0．37，3．28）]、复发率较高[RR=3．73，95％CI（1．92，7．23）]。②腹腔镜单纯精索内静脉结扎术（保留精索动脉和淋巴管的精索静脉结扎术）与腹腔镜精索血管集束状结扎术相比，术后继发鞘膜积液的发生率低[RR=0．04，95％CI（0．01，0，21）]、术后睾丸萎缩率低[RR=0．08，95％CI（0．02，0．30）]、精液质量改善率高[RR=1．37，95％CI（1．12，1．68）]、术后自然孕率高[RR=1．76，95％CI（1．00，3．07）]，而手术时间长[SMD=3．16，95％CI（2．15，4．16）]、复发率较高RR=3．85，95％CI（1．62，9．17）]。③腹腔镜保留精索动脉的精索静脉结扎术与腹腔镜精索血管集束状结扎术相比，术后睾丸萎缩发生率低[RR=0．12，95％CI（0．02，0．86），P=0．04]和术后复发率较高[RR：5．68，95％cI（1．50，21．53），P=0．01]，而术后鞘膜积液发生率和精液质量改善率差异无统计学意义（P〉0．05）。④腹腔镜保留淋巴管的精索静脉结扎术和腹腔镜精索血管集束状结扎术相比，鞘膜积液发生率低[RR=0．10，95％CI（0．02，0．52），P=0．007]和手术时间长[SMD=0．52，95％CI（0．17，0．87，P=0．004]，而术后复发率和自然孕率差异无统计学意义（P〉0．05）。结论与腹腔镜精索血管集束状高位结扎术相比，腹腔镜下有选择性的精索静脉高位结扎术（尤其是同时腹腔镜单纯精索内静脉高位结扎术）具有术后精液质量改善率、术后自然孕率高，术后睾丸萎缩发生率和鞘膜积液发生率低的特点；但手术时间长及复发率较高。远期疗效有待于高质量大样本长期随访的RCT进一步验证。

Objectives To evaluate clinical efficacy of laparoscopic selective ligation of spermatic vein,including laparoscopic high ligation of internal spermatic vein, laparoscopic varix ligation with internal spermatic artery preservation and laparoscopic varix ligation with lymphatic vessels, and laparoscopic cluster ligation of spermatic vessels for the treatment of varicocele. Methods Such database as cochrane central register of controlled trials （ CEN- TRAL） ,PubMed, EMbase, CNK1, V1Pand Wangfang were searched from their establishment to December 2012 for collecting the randomized controlled trials （RCT） about laparoscopic selective ligation of spermatic vein and laparoscopic cluster ligation of spermatic vessels for the treatment of varicocele, and the references of those RCTs were also searched by hand. After study selection, assessment and data extraction conducted by two reviewers independently, meta - analyses were performed by using the RevMan 5.1 soft ware. The level of evidence was assessed by using the GRADE system. Results 13 studies involving 1061 patients were included. The results of meta - analyses showed that ： ①compared with the control group, laparoscopic selective ligation of spermatic vein had lower incidence of postoperative secondary hydrocele[ RR = 0.07,95% CI （ 0.03,0.19 ） ], postoperative testicular atrophy [ RR = 0.09, 95% CI （0.03,0.27） ], and higher rate of semen quality improvement [ RR = 1.29, 95% CI （ 1.08,1.55 ） ] and spontaneous pregnancy[ RR = 1.53,95 % CI （ 1.03,2.29 ） ], but longer operation time [ SMD = 1.83,95 % CI （0. 37,3.28） ] ,higher recurrence rate[ RR =3.73, 95% CI（1.92,7.23） ]. ②compared with the control group,laparescopic high ligation of internal spermatic vein had lower incidence of postoperative secondary hydrocele [ RR = 0. 04,95% CI （0.01,0.21） ], postoperative testicular atrophy[ RR = 0.08,95% CI （0.02,0.3） ], and higher rate of semen quality improvement[ RR = 1.37,95% CI （1.12,1.68） ] and spontaneous pregnancy[ （ RR = i. 76,95% CI（1.00,3.07） ] ,but longer operation time[ SMD =3.16,95% CI（2.15,4.16） ] ,higher recurrence rate[ （ RR = 3.85,95% CI（1.62,9.17） ]. ③compared with the control group,laparoscopic varix ligation with internal spermatic artery preservation had lower incidence of postoperative testicular atrophy[ （ RR = O. 12,95 % CI （ 0.02,0.86, P = 0. 04） ] and higher recurrence rate[ （RR = 5.68,95% CI（1.50,21.53） ], P =0.01）. But there were no significant in postoperative secondary hydrocele incidence and semen quality improvement rate（ P 〉 0.05 ）. ④compared with the control group, laparoscopic varix ligation with lymphatic vessels had lower incidence of postoperative secondary hydrocele[ RR =0.10,95% CI（0.02,0.52, P =0. 007 ） ] and longer operation time[ （ SMD = 0.52,95% CI（0. 17,0.87, P =0.004）]. But there were no significant in recurrence rate and spontaneous pregnancy rate（ P 〉0. 05 ）. Conclusions The current evidence shows：compared with the laparoscopic cluster ligation of spermatic ves- sels, laparoscopic selective ligation of spermatic vein, especially artery - lymphatics sparing laparescopic varicocelectomy, had lower incidence of postoperative secondary hydrocele and postoperative testicular atrophy, and higher rate of semen quality improvement and spontaneous pregnancy, but longer operation time and higher recurrence rate. The long - term efficacy remains high - quality and large - sample studies are required.