Clinical analysis of laparoscopic high ligation of spermatic vein with accurate separation of internal spermatic vein in the treatment of varicocele
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摘要: 目的 比较分析精准分离精索内静脉的腹腔镜精索静脉高位结扎术与普通腹腔镜精索静脉高位结扎术(集中束状结扎)的疗效，并评估应用价值和临床优势。方法 回顾性分析2018年1月—2020年7月郑州大学第一附属医院收治的225例精索静脉曲张患者的临床资料，根据手术方式的不同分为精准分离精索内静脉的腹腔镜精索静脉高位结扎术组108例(A组)和普通腹腔镜精索静脉高位结扎术组117例(B组)。比较两组基本资料、术中术后并发症、手术时间、出血量、住院时间、术后6~12个月的精液质量、阴囊缓解率、配偶怀孕率、睾丸大小及复发率等。结果 两组患者的年龄、BMI、病因、曲张程度等一般资料比较差异均无统计学意义(P＞0.05)；A、B组患者术中出血量[(5.50±0.50) mL vs.(5.43±0.50) mL]及住院时间[(5.32±0.47) d vs.(5.26±0.44) d]比较差异无统计学意义(P＞0.05)；但A组手术时间长于B组[(30.56±4.33) min vs.(22.27±3.66) min]，差异有显著统计学意义(P＜0.01)；A组术后阴囊水肿或睾丸鞘膜积液发生率、急性附睾炎发生率及复发率均低于B组(0 vs.5.1%、0 vs.6.0%、0.9% vs.7.7%，P＜0.05)，虽然A组睾丸萎缩发生率低于B组(0 vs.1.7%)，但差异无统计学意义(P＞0.05)；两组术后的a级精子活力、a+b级精子活力、形态正常比例精子、双侧睾丸大小均得到提高(P＜0.05)，但A组术后的a级精子活力、a+b级精子活力、形态正常比例精子优于B组(P＜0.05)。A组术后1年的阴囊缓解率和怀孕率均优于B组，差异有统计学意义(P＜0.05)。结论 精准分离精索内静脉的腹腔镜精索静脉高位结扎术相对于普通腹腔镜精索静脉高位结扎术疗效佳、术后并发症少、复发率低，且阴囊缓解率和怀孕率较高，是一种安全、有效的手术方式。Abstract: Objective To compare and analyze the curative effect between laparoscopic high ligation of spermatic vein with accurate separation of internal spermatic vein and ordinary laparoscopic high ligation of spermatic vein (concentrated bundle ligation), and to evaluate its application value and clinical advantages.Methods The clinical data of 225 patients with varicocele treated in our hospital from January 2018 to July 2020 were analyzed retrospectively, including 108 cases of laparoscopic high ligation of spermatic vein with accurate separation of internal spermatic vein (group A) and 117 cases of ordinary laparoscopic high ligation of varicocele (group B). We compared the basic data between the two groups, including intraoperative and postoperative complications, operation time, blood loss, hospital stay, semen quality, scrotal remission rate, spouse pregnancy rate, testicular size and recurrence rate 6 to 12 months after operation.Results There was no significant difference in age, BMI, etiology or varicose degree between the two groups (P> 0.05), and there was no significant difference in intraoperative blood loss [(5.50±0.50) mL vs. (5.43±0.50) mL] or hospital stay [(5.32±0.47) d vs. (5.26±0.44) d] between group A and group B (P> 0.05). However, the duration of operation in group A [(30.56±4.33) min vs. (22.27±3.66) min] was longer than that in group B (P< 0.01). The incidence rate of postoperative scrotal edema or testicular hydrocele, acute epididymitis, and recurrence rate were lower in group A than in group B (0 vs.5.1%, 0 vs.6.0%, 0.9% vs. 7.7%,P< 0.05). Although the number of testicular atrophy in group A was smaller than that in group B (0 vs. 1.7%), there was no statistical significance (P> 0.05). The quality of grade a sperm, quality of a+b sperm, normal proportion sperm and size of bilateral testis were improved in both groups before and after surgery (P< 0.05), but the effect of quality a sperm, quality of a+b sperm and normal proportion sperm were better in group A than in group B (P< 0.05). The scrotum remission rate and pregnancy rate in group A were better than group B in 1 year after operation, and the difference was statistically significant (P< 0.05).Conclusion Generally speaking, compared with ordinary laparoscopic high ligation of spermatic vein, laparoscopic high ligation of spermatic vein with accurate separation of internal spermatic vein has better curative effect, less postoperative complications, lower recurrence rate, higher scrotal remission rate and pregnancy rate, so it is a safe and effective operation.
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Key words:
- varicocele /
- accurate separation /
- laparoscopic /
- high ligation of spermatic vein
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表 1 两组患者基本资料比较
例(%)，X±S 项目 A组(n=108) B组(n=117) χ2/t P值 年龄/岁 25.51± 2.90 26.09± 3.81 -1.269 0.206 BMI/(kg·m-2) 24.03± 2.76 24.34± 1.47 -1.071 0.285 单双侧 0.005 0.941 单侧 17(15.7) 18(15.4) 双侧 91(84.3) 99(84.6) VC程度 1.956 0.162 Ⅰ级 2(1.9) 2(1.7) Ⅱ级 83(76.9) 99(84.6) Ⅲ级 23(21.3) 16(13.7) 病因 0.455 0.500 疼痛 33(30.6) 31(26.5) 不育 75(69.4) 86(73.5) 
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表 2 两组术中、术后指标比较
例(%)，X±S 指标 A组(n=108) B组(n=117) χ2/t P值 手术时长/min 30.56±4.33 22.27±3.66 15.530 ＜0.001 术中出血量/mL 5.50±0.50 5.43±0.50 1.090 0.277 住院时间/d 5.32±0.47 5.26±0.44 1.117 0.265 阴囊水肿或睾丸鞘膜积液 0 6(5.1) - 0.0301) 睾丸萎缩 0 2(1.7) - 0.4991) 急性附睾炎 0 7(6.0) - 0.0151) 复发 1(0.9) 9(7.7) 4.566 0.0332) 注：1)连续性修正χ2检验；2)Fisher精确检验。
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表 3 两组术前、术后精液质量及睾丸大小比较
X±S 指标 A组(n=108) B组(n=117) 统计值 P值 术前 a级精子活力/% 15.19±6.57 15.96±5.56 -0.943 0.347 a+b级精子活力/% 35.17±10.08 34.93±9.14 0.184 0.854 形态正常比例精子/% 4.71±3.43 4.50±2.88 0.496 0.620 左侧睾丸大小/mL 9.75±1.73 10.02±1.69 -1.176 0.241 右侧睾丸大小/mL 9.96±1.45 9.99±1.42 -0.1221) 0.9031) 术后 a级精子活力/% 25.63±7.14 22.35±8.26 3.178 0.002 a+b级精子活力/% 51.59±12.73 44.59±13.91 3.927 ＜0.001 形态正常比例精子/% 10.16±5.77 8.31±5.18 2.535 0.012 左侧睾丸大小/mL 10.59±1.56 10.60±1.51 -0.058 0.953 右侧睾丸大小/mL 10.63±1.49 10.76±1.51 -0.6061) 0.5451) 注：1)右侧睾丸大小：A组91例，B组99例。门诊随访的过程中，部分患者为左侧的精索静脉曲张的彩超报告缺少右侧睾丸大小，故除去了左侧精索静脉曲张睾丸大小的比较。
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表 4 两组术前、术后精液质量及睾丸大小比较
A组组内比较 统计值 P值 B组组内比较 统计值 P值 a级精子活力/% -14.964 ＜0.001 a级精子活力/% -6.613 ＜0.001 a+b级精子活力/% -13.904 ＜0.001 a+b级精子活力/% -6.281 ＜0.001 形态正常比例精子/% -9.221 ＜0.001 形态正常比例精子/% -6.888 ＜0.001 左侧睾丸大小/mL -7.273 ＜0.001 左侧睾丸大小/mL -5.168 ＜0.001 右侧睾丸大小/mL -5.427 ＜0.001 右侧睾丸大小/mL -6.489 ＜0.001
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