【作者】 曾京华；

【导师】 胡卫列；

【作者基本信息】 南方医科大学 ， 外科学， 2013， 博士

【摘要】 研究背景精索静脉曲张(varicocele, VC)是精索静脉回流受阻或瓣膜功能失去作用导致反流引起血液瘀滞,从而使蔓状静脉丛迂曲扩张。由于部队高强度的训练,长期站立,精索静脉曲张成为部队官兵高发疾病。精索静脉曲张可引起阴囊胀痛,训练时加重,并影响睾丸的生精功能,导致男性不育,危害官兵的心理健康,影响了部队的战斗力。手术治疗精索静脉曲张可以有效阻止静脉反流,缓解症状,打破局部血液瘀积对睾丸的危害,使大多数患者的睾丸精子功能得到改善。以往我院治疗精索静脉曲张的主要手段是后腹膜高位结扎(改良palomo)术,近年随着我院编制的调整、联勤,收治了大量陆军精索静脉曲张患者,在对术后患者的随访及复诊中发现,陆军患者术后阴囊慢性疼痛及鞘膜积液的发生率明显高于海军及地方患者,特别是阴囊慢性疼痛,患者反复就诊,不能进行正常的训练,这临床出现的新问题,引起了我们的重视,希望通过改进术式来解决这些问题。目前,尚无对此类高体能训练患者术式选择、术后并发症等有较深入研究的报道。精索静脉曲张是引起不育的重要原因,手术治疗是有效的方法,手术方式的选择还存在争议,且尚未明确不同术式在改善生育力方面的差异,因此,我们希望通过对比不同术式对改善患者睾丸生精功能影响,为精索静脉曲张引起的不育患者提供更佳的手术方式。官兵的心理健康日益受部队的重视,目前对精索静脉曲张患者心理的调查研究仍较少,因此,我们就精索静脉曲张患者心理状况进行SDS和SAS调查研究,为心理干预提供理论依据。第一章显微镜下高选择精索静脉结扎术与改良palomo术治疗陆军青壮年精索静脉曲张患者术后并发症的比较目的应用显微镜下保留精索动脉、淋巴的精索静脉高位结扎术与改良palomo术治疗陆军青壮年精索静脉曲张患者,并对两种术式的术后并发症进行比较。方法选择原发性精索静脉曲张陆军青壮年患者260例,根据手术方式随机分2组：A组为显微镜下经腹股沟途径高选择性保留精索内动脉、淋巴管的精索静脉高位结扎术组,130例；B组为改良palomo术(精索内血管、淋巴集束结扎),130例。比较两组术后鞘膜积液、阴囊疼痛、睾丸萎缩、复发等并发症情况。结果经过1年随访,A、B组术后出现鞘膜积液发生率为3.1%(4/130)、14.6%(19/130),组间比较差异有统计学意义(P=0.001)；A、B术后阴囊疼痛缓解率分别为90.7%(118/130)、67.7%(88/130),组间比较差异有统计学意义(P=0.000)；术后睾丸萎缩发生率分别为0%(0/130)、1.5%(2/130),组间比较差异有统计学意义(P=0.005)；术后复发的发生率分别为5.3%(7/130)、3.8%(5/130),A、B组间比较差异无统计学意义(P=0.545)。结论原发性精索静脉曲张陆军患者,选择在显微镜下保留精索内动脉、淋巴管的精索静脉高位结扎术,术后鞘膜积液、阴囊疼痛、睾丸萎缩的发生率明显降低,而术后复发的机会并未增加。第二章比较两种手术方式治疗重度精索静脉曲张对睾丸生精功能的影响目的应用显微镜下高选择精索静脉结扎术与改良palomo术,治疗重度精索静脉曲张陆军患者,就两种术式对改善患者精液参数、性激素水平的疗效进行比较。方法选择原发性重度(Ⅲ0)精索静脉曲张陆军青壮年患者50例,根据手术方式随机分2组：A组是显微镜下经腹股沟途径保留精索内动脉、淋巴管的高选择性精索静脉结扎术,25例；B组为改良palomo术(腹膜后高位精索内血管、淋巴集束结扎),25例；比较两组术前和术后3个月、6个月精液参数(精子密度、精子总数和精子活力)、性激素水平(血清卵泡刺激素、黄体生成素、睾酮)、抑制素B的变化。结果经过3个月、6个月随访,A、B组术后精子密度、精子总数、精子活力和血清睾酮、抑制素B水平均提高,血清FSH、LH水平下降,手术前后差异均有统计学意义(P=0.000)；术后6个月A组精子活力、抑制素B提高度大于B组,差异具有统计学意义(p=0.000,p=0.001)；术后6个月A组FSH、LH降低程度大于B组,差异具有统计学意义(P=0.03,p=0.000)；术后A组精子密度、精子总数、血清T提高程度与B组无明显差异,差异无统计学意义。结论两种术式治疗精索静脉曲张,均能改善患者的精液质量,而显微外科手术对患者精子活力、抑制素B提高程度和FSH、LH的降低大于改良Pamolo手术。第三章Ⅲ0精索静脉曲张患者心理状况SDS、SAS的调查分析目的调查精索静脉曲张患者抑郁和焦虑心理状况,探讨患者心理状况和精液参数之间的关系。方法选择原发性Ⅲ度精索静脉曲张陆军青壮年患者100例,采用抑郁自评量表(SDS)和焦虑自评量表(SAS)进行测试,评价患者心理状况和精液参数、临床症状、知情状况等之间的关系。结果精索静脉曲张患者SAS、SDS评分高于军内常模,差异有统计学意义(P=0.000)；知情和不知情之间SDS、SAS比较,知情组SDS、SAS标准分低于不知情组,差异具有统计学意义(P=0.011,P=0.013)；阴囊轻度疼痛组和中度以上疼痛组之间SDS、SAS比较,轻度疼痛SDS、SAS标准分低于中度疼痛组,差异具有统计学意义(P=0.002,P=0.001)；精子活力正常组和精子活力异常组SDS、SAS比较,正常组SDS、SAS标准分低于异常组,差异有统计学意义(P=0.004,P=0.006)；精子活动率正常组和异常组之间SAS、SDS标准分统计学无差异性,精子密度正常组和异常组SAS、SDS评分差异无统计学意义。结论重度精索静脉曲张患者普遍存在焦虑和抑郁问题,焦虑和抑郁可能影响到患者睾丸的生精功能。更多还原

【Abstract】 BackgroundVaricoceles are dilated and tortuous testicular veins of the pampiniform plexus of the spermatic cord. As the high strength training, varicocele became a high incidence of disease in the soldiers. Varicocele can cause scrotal pain, and scrotal pain will aggravated with the training. Varicocele also can affect the testicular spermatogenesis, leading to male infertility; harm the mental health, the disease will influence the battle effectiveness of the army. The operation to treat varicocele can effectively prevent venous reflux, avoid the local blood stasis damage to testis, and make the most of patients with testicular sperm functional improvement. The main means of our hospital in the treatment of varicocele is retroperitoneal high ligation operation (Palomo). With adjustment of the establishment in our hospital, we treated a large munber of army patient with varicocele in recent years. Found by follow-up of patients with postoperative, army of postoperative patients with chronic pain and hydrocele of the scrotum was significantly higher than that in the Navy and local patients. Especially patients with chronic scrotum pain always repeated treatment, which can not be normal training. At present, there is no such in-depth research reports about selection of operation, postoperative complications in high fitness training patients.We were attracted by the new clinical problem, and hope to solve these problems by improving operation. Varicocele is an important cause of infertility, and operation is an effective method for treatment of infertility caused by varicocele. But now selection of operative mode is controversial, and is not yet clear of the differences in improving fertility, however, the investigation in varicocele patients psychological still less at present.The soldiers mental health is influenced by forces attention, therefore, we hope to provide better operation mode for patients with varicocele. We will use SDS and SAS to investigate the psychological status of patients with varicocele, and provide a theoretical basis for the psychological intervention.Part IPostoperative complications of microscopic versus Renovated Palomo varicocelectomy for primary varicocele in army personnelObjectiveTo comparison of the postoperative complications of microscopic or renovated palomo varicoceletomy in army patients with primary Varicoceles of GradeⅢ.MethodsA total of260army personnel with varicocele were randomized to receive microscopic varicocelectomy (group A, n=130) and renovated Palomo varicocelectomy (group B, n=130). The postoperative recurrence and complications (soermatic and testicular hydrocele, testicular pain and testicular atrophy) were compared between the two groups.ResultsAfter1year of follow-up, the recurrence rates in groups A and B were statistically comparable (5.3%vs3.8%, P=0.545). The incidences of testicular atrophy and soermatic and testicular hydrocele were significantly lower in group A than in group B (0.7%vs3.1%, P=0.005;3.1%vs14.6%, P=0.001), and the rate of testicular pain relief was significantly higher in group A (90.7%vs67.7%, P=0.000). ConclusionMicroscopic varicocelectomy can be a good choice in the treatment of varicocele in army personnel.Part IIComparison of the therapeutic effects of microscopic or Renovated Palomo varicocelectomy on Testicular Function in Patients with Varicoceles of GradeⅢObjectiveTo comparison of the therapeutic effects of microscopic or Renovated Palomo varicocelectomy on Testicular Function in Patients with Varicoceles of GradeⅢ, including the change of semen Parameter and serum reproductive hormones levels before and after varicocelectomy.MethodsAll50army patients with grade Ⅲ varicocele were randomly divided into two groups, group A(n=25)was treated with microscopic varicocelectomy, group B (n=25) was treated with Renovated Palomo varicocelectomy. The therapeutic effects of the two operative methods were compared, such as serum level of follicle stimulating hormone(FSH), Luteinizing hormone(LH), testosterone(T), inhibin B(INHB), sperm density, the amount of sperm and the proportion of sperm in grade(a+b).ResultsAfter3months and6months of follow-up, Sperm density, the amount of sperm, the proportion of sperm in grade(a+b), serum testosterone(T) and serum level of inhibin B were all significantly increased after operation in two groups compared with that before operation (p=0.000). Serum hormone (FSH) and Luteinizing hormone (LH) were significantly decreased after operation in two groups compared with that before operation (p=0.000). The degree of sperm motility and serum level of inhibin B increase were significantly higher in A group than that in B group (p=0.000, p=0.001). The degree of LH and FSH decrease were significantly higher in A group than that in B group (p=0.000, p=0.001). There were no significant differences in the degree of Sperm density increase, the degree of the amount of sperm increase and the degree of testosterone (T) increase between A group and B group.ConclusionBoth of the two operative options can improved spermatogenesis in patients with varicocele of Ⅲ grade, while patients may be get more benefit from treatment by Microsurgical varicocelectomy.Part ⅢSurvey Of psychological status of patients with varicocele of grade Ⅲ using SDS and SASObjectiveTo survey Of psychological status of patients with varicocele of grade Ⅲ using SDS and SAS, Explore the relationship between psychological status of patients and spermatogenesis.MethodsSelf-rating depression scale(SDS) and self-rating anxiety scale(SAS) were used to test on100army patients with varicocele of grade Ⅲ, to evaluate the relationship between psychological conditions and semen parameters, clinical symptoms, informed position.ResultsScore of SDS and SAS of patients with varicocele were obviously higher than that of norms in chinese army men. Standard score of SDS and SAS were obviously affected by clinical symptoms, informed position. Score of SDS and SAS in sperm motility abnormal group was significantly higher than that in the normal group (p<0.05). There was no significant difference in score of SDS and SAS between sperm density abnormal group and normal group (p>0.05).ConclusionDepression and anxiety were generally found in patients with varicocele of grade Ⅲ. Patients who without knowledge, severe clinical symptoms have more psychological disorders of depression and anxiety. Anxiety and depression may affect the function of testicular spermatogenic.更多还原