精囊镜辅助血流调整治疗射精管梗阻
Summary
本方案介绍了精囊内镜联合钬激光治疗射精管囊肿引起的射精管梗阻的临床应用。
Abstract
经尿道射精管切除术 （TURED） 是治疗射精管囊肿引起的射精管阻塞 （EDO） 的主要手术方法。通常需要术中切除verumontanum以暴露射精管。然而，保留verumontanum结构可以更好地模拟正常的生理解剖结构。维持藜膜可能会增加术后远端射精管瘢痕形成的风险，导致复发性梗阻或精液量减少。因此，我们尝试了一种保留verumontanum的新技术，与TURED相比，它相对更容易，更安全。以下是程序步骤：1.通过尿道外口将6F精囊镜引入verumontanum附近，定位患侧射精管的开口，并将导丝引入囊肿。这一成功的步骤保留了verumontanum，最大限度地保留了远端射精管中的抗反流机制。2.钬激光将患侧射精管开口扩大至5mm，降低术后射精管开口闭合的可能性，简化手术过程。3.在囊肿内创建一个窗口以进入对侧精囊，然后使用钬激光将开口燃烧并扩张至5毫米，将对侧射精管重定向到囊腔。这种修改保留了健康侧射精管的开口，并为精液提供了新的流出通道，降低了术后精液量减少的风险。患者术后无并发症，住院时间较短，精液量有所改善。因此，这种手术方法简单而有效。
Introduction
射精管梗阻是男性生殖系统的一种罕见疾病，据报道发病率为 1%-5%1,2。射精管囊肿是射精管阻塞的主要原因。典型EDO患者的精液检查显示四个显着特征：1.精液量小于2 mL，梗阻严重程度与精液量减少直接相关;2.少精子症，双侧完全梗阻导致无精子症;3.精液pH值降低;4. 精浆果糖水平降低，有时甚至降至 0 mM/L3.EDO引起的男性不育症可以通过手术治疗，保守治疗效果较差4。过去，主要方法是经尿道切除射精管。尽管这种方法具有减少创伤和减少术中并发症等好处，但手术切除藰膜会破坏远端射精管的正常生理结构。这反过来又增加了术后并发症的风险，如尿流、附睾炎、逆行射精和尿失禁5。同时，手术过程中的热量产生可能导致射精管、精囊甚至直肠的损伤，电切口的热效应可能会引起新的梗阻6。
verumontanum 是男性生殖系统中至关重要的解剖元件，确保射精过程中精液的精确和有序排出，同时也有助于防止逆行流动。目前尚不清楚TURED的缺点是否可以通过保留痈来改善。一些研究试图利用激光辅助内窥镜治疗 EDO，同时保留 verumontanum 2,7,8,9。尽管手术方法各不相同，但术后精液恢复非常成功，并发症极少。这表明保留附睾头可能是有益的。然而，他们使用的方法相对复杂，不会干预健康的射精管，这可能会增加复发的风险。因此，我们提出了一种简单有效的手术方法。
在这项研究中，精囊镜通过导线器引导进入患侧的射精管囊肿。然后，使用钬激光扩大患侧射精管开口，以确保其具有足够大的流出通道。
Protocol
Representative Results
Discussion
TURED是治疗射精管囊肿引起的射精管阻塞的主要手术方法，其主要手术方式是用电切口切除囊肿后，以释放压力并渣滓精管11。研究对象在访问期间被问及他们的病史，并且都有正常的性活动频率（每周 1-2 次），没有性功能障碍或血精症。术前精液检查显示，均有精子，但精子数量少于正常值，精液量减少。结合患者的睾丸体积、精浆果糖和影像学检查，足以支持精膜远端不完?…
Offenlegungen
The authors have nothing to disclose.
Acknowledgements
作者要感谢KMMU第二附属医院提供与这项工作相关的病例和医疗记录。这项研究没有资金支持。
Materials
| Camera system | Karl Storz, Germany | TC200EN | Endoscopic camera system |
| Fr18 Cathete | Zhanjiang City Shida Industrial Co., Ltd. | 2660476 | Drainage of urine |
| Fr6/7.5 vesiculoscope | Richard Wolf, germany | 8702.534 | Operative procedure |
| iodophor | Shanghai Likang Disinfectant Hi-Tech Co., Ltd. | 31005102 | Skin disinfection |
| Nitinol Guidewire 0.035" | C. R Bard, Inc. Covington, GA | 150NFS35 | Guide |
| Propofol | Sichuan Kelun Pharmaceutical Research Institute Co., Ltd. | H20203571 | Induction and maintenance of anesthesia |
| Remifentanil | Yichang Humanwell Pharmaceuticals CO,Ltd. | H20030200 | Maintenance of anesthesia |
| Rocuronium bromide | Zhejiang Huahai Pharmaceuticals CO,Ltd. | H20183264 | Induction and maintenance of anesthesia |
| Sevoflurane | Jiangsu Hengrui Pharmaceuticals Co., Ltd. | H20070172 | Maintenance of anesthesia |
| Slimline EZ 200 | LUMENIS, USA | 0642-393-01 | Dissect capsule wall |
| Sodium Chloride Physiological Solution | Hua Ren MEDICAL TECHNOLOGY CO. Ltd. | H20034093 | Flushing fluid |
| Sufentanil | Yichang Humanwell Pharmaceuticals CO,Ltd. | H20054171 | Induction and maintenance of anesthesia |
| Syringe 50 mL | Double Pigeon Group Co. Ltd. | 20163141179 | Inject 0.9% sodium chloride solution into the vesiculoscope |
| VersaPulse PowerSuite 100W Laser System | LUMENIS, Germany | PS.INT.100W | Provide energy |
Referenzen
- Avellino, G. J., Lipshultz, L. I., Sigman, M., Hwang, K. Transurethral resection of the ejaculatory ducts: etiology of obstruction and surgical treatment options. Fertil Steril. 111 (3), 427-443 (2019).
- Modgil, V., Rai, S., Ralph, D. J., Muneer, A. An update on the diagnosis and management of ejaculatory duct obstruction. Nat Rev Urol. 13 (1), 13-20 (2016).
- Paick, J., Kim, S. H., Kim, S. W. Ejaculatory duct obstruction in infertile men. BJU Int. 85 (6), 720-724 (2000).
- Wang, H., et al. Transurethral seminal vesiculoscopy using a 6F vesiculoscope for ejaculatory duct obstruction: initial experience. J Androl. 33 (4), 637-643 (2012).
- Galloway, M., Woods, R., Nicholson, S., Foggin, J., Elliott, L. An audit of waiting times in a haematology clinic before and after the introduction of point-of-care testing. Clin Lab Haematol. 21 (3), 201-205 (1999).
- WD, Z., et al. Clinical effect analysis of two surgical methods for the treatment of ejaculatory duct obstruction. Chinese J Androl. 4, 43-45 (2013).
- Halpern, E. J., Hirsch, I. H. Sonographically guided transurethral laser incision of a Müllerian duct cyst for treatment of ejaculatory duct obstruction. AJR. Am J Roentgenol. 175 (3), 777-778 (2000).
- Oh, T. H., Seo, I. Y. Endoscopic treatment for persistent hematospermia: a novel technique using a holmium laser. Scand J Surg. 105 (3), 174-177 (2016).
- Lee, J. Y., Diaz, R. R., Choi, Y. D., Cho, K. S. Hybrid method of transurethral resection of ejaculatory ducts using holmium: yttriumaluminium garnet laser on complete ejaculatory duct obstruction. Yonsei Med J. 54 (4), 1062-1065 (2013).
- Guo, Y., et al. Role of MRI in assessment of ejaculatory duct obstruction. J Xray Sci Technol. 21 (1), 141-146 (2013).
- Heshmat, S., Lo, K. C. Evaluation and treatment of ejaculatory duct obstruction in infertile men. Can J Urol. 13 (Suppl 1), 18-21 (2006).
- Tu, X. A., et al. Transurethral bipolar plasma kinetic resection of ejaculatory duct for treatment of ejaculatory duct obstruction. J Xray Sci Technol. 21 (2), 293-302 (2013).
- El-Assmy, A., El-Tholoth, H., Abouelkheir, R. T., Abou-El-Ghar, M. E. Transurethral resection of ejaculatory duct in infertile men: outcome and predictors of success. Int Urol Nephrol. 44 (6), 1623-1630 (2012).
- Faydaci, G., et al. Effectiveness of doxazosin on erectile dysfunction in patients with lower urinary tract symptoms. Int Urol Nephrol. 43 (3), 619-624 (2011).
- McQuaid, J. W., Tanrikut, C. Ejaculatory duct obstruction: current diagnosis and treatment. Curr Urol Rep. 14 (4), 291-297 (2013).
- Liu, Z. Y., et al. Transurethral seminal vesiculoscopy in the diagnosis and treatment of persistent or recurrent hemospermia: a single-institution experience. Asian J Androl. 11 (5), 566-570 (2009).
- Guo, S., et al. The application of pediatric ureteroscope for seminal vesiculoscopy. Minim Invasive Surg. 2015, 946147 (2015).
- Xu, B., et al. Novel methods for the diagnosis and treatment of ejaculatory duct obstruction. BJU Int. 108 (2), 263-266 (2011).
- Enikeev, D., Shariat, S. F., Taratkin, M., Glybochko, P. The changing role of lasers in urologic surgery. Curr Opin Urol. 30 (1), 24-29 (2020).
