腹腔镜手术治疗不可触及型隐睾的临床研究:附151例报告

Laparoscopic treatment for impalpable undescended testis in children:A report of 151 cases

目的:探讨腹腔镜手术处理不可触及型隐睾的诊治策略。方法:收集2013年1月至2023年12月在浙江大学医学院附属金华医院小儿外科诊断不可触及型隐睾行腹腔镜探查的151例患儿的临床资料。其中单侧140例,双侧11例,年龄6.5~52个月,平均(13.2±2.5)个月,大多数以阴囊空虚为首发临床表现,检查合并斜疝5例、鞘膜积液6例。记录B型超声结果并分析患儿入院时年龄、首发临床表现、手术时间、术中睾丸大小和位置、术中出血量、术后并发症(切口感染、血肿、切口疝等)等资料。结果:151例患儿均行腹腔镜探查术,术中发现精索及输精管盲端4例;腹腔内高位隐睾共7例(包括双侧1例):腹腔镜下一期睾丸固定术3例,腹腔镜下一期Fowler-stephens睾丸固定术1例,腹腔镜下分期Fowler-stephens睾丸固定术3例(双侧1例);腹腔内低位隐睾共98例(双侧10例):腹腔镜下一期睾丸固定术89例(双侧10例),经腹股沟管途径睾丸固定术9例;术中发现精索及输精管通过内环口共42例:经腹股沟管探查明确睾丸退化综合征40例,予切除盲端;睾丸发育不良2例,行一期睾丸固定术。术后随访1~128个月,平均(65.5±12.4)个月,术后并发症主要有睾丸回缩3例(腹腔内低位隐睾3例),睾丸萎缩2例(腹腔内低位隐睾1例,腹腔内高位隐睾1例),无切口感染、阴囊血肿、切口疝等其他并发症。术后1、3、6个月患侧睾丸体积与健侧睾丸相比差异无统计学意义(P>0.05)。结论:腹腔镜探查术是治疗不可触及型隐睾的首选治疗方式。对于腹腔内低位隐睾或部分腹腔内高位隐睾可选择腹腔镜下一期睾丸固定术,而多数腹腔内高位隐睾建议采用分期腹腔镜下Fowler-stephens睾丸固定术,提高术后患儿睾丸存活率。对于睾丸退化综合征可不做常规的腹股沟探查进行精索盲端切除,减少手术创伤。

Objective:To evaluative the strategy of laparoscopic diagnosis and treatment for impalpable undescended testis.Methods:From January 2013 to December 2023,151 cases with undescended testis were enrolled and retrospectively analyzed in the department of pediatric surgery of Jinhua hospital affiliated to Zhejiang University School of Medicine.Of 151 cases with undescended testis initially presenting with scrotal empty,140 cases were on unilateral side and 11 cases on bilateral side,with the mean age of(13.2±5.5)months.The findings of preoperative physical examination showed 5 cases of inguinal hernia and 6 case of hydrocele.The age on admission,initial clinical symptoms,surgical time,volume and location of the testis,volume of intra-operative bleeding,and postoperative complications(wound infection,hematoma,and incisional hernia and so on)were recorded and analyzed by B-type ultrasound.Results:Laparoscopic exploration was performed on the 151 cases to find the end of vas deferens and spermatic vessel in 4 cases;7 cases with high intra-abdominal testes(including 1 bilateral)were diagnosed,one-stage laparoscopic orchiopexy was performed in 3 cases,one-stage laparoscopic Fowler-stephens orchiopexy in one case,and secondary laparoscopic Fowler-stephens orchiopexy in 3 cases(including 1 bilateral);98 cases with low intra-abdominal testes(including 10 bilateral)were diagnosed,and one-stage laparoscopic orchiopexy was performed in 89 cases(including 10 bilateral),trans-inguinal canal orchiopexy was performed in 9 cases.During the operation,vas deferens and spermatic vessel via internal ring was found in 42 cases,of which 40 cases with vanishing testis syndrome and 2 cases with testicular dysplasia were respectively confirmed by trans-inguinal canal laparotomy.The mean time of postoperative follow-up was(65.5±12.4)months.Apart from testicular retraction in 3 cases with low intra-abdominal testes,and testicular atrophy in 2 cases(1 case with low intra-abdominal testis and 1 case with high intra-abdominal testis),none of other complications were found.Compared with the volume of healthy testis,the volume of affected testis was not statistically different at month 1,3 and 6 respectively on follow-up.Conclusion:Laparoscopy is the first-choice therapy in the management of impalpable undescended testis.One-stage laparoscopic orchiopexy is suitable for low intra-abdominal testis and part of high intra-abdominal testis.However,secondary laparoscopic Fowler-stephens orchiopexy is recommended for most high intra-abdominal testis.In order to reduce operative trauma,surgical removal of vanishing testis remnants in an inguinal or scrotal position may not be indicated.