血管保留性显微外科纵向套叠血管表皮造口术治疗附睾梗阻性无精子症
Summary
本方案描述了一种保留血管的纵向肠套叠血管表皮造口术，使用现成的单针缝合线在中国，这是一种安全有效的手术，可以改善患者的通畅性和自然妊娠率。
Abstract
附睾是梗阻性无精子症 （OA） 中梗阻的常见部位。自2000年以来，血管顶端骨造口术已成为治疗附睾OA的重要方法。经典的显微镜血管顶端切开术有两个挑战。首先，用双针缝合线进行输精管和附睾的吻合术。然而，中国缺乏高质量和具有成本效益的双针缝合线，这导致吻合术的难度增加和成功率低。其次，输精管的分离不会保留输精管系统，尽管输精管输精管在输精管、附睾和睾丸的血液供应中起着重要作用。这会影响吻合口区域和附睾的血液供应。
因此，该团队进行了创新的改进来解决这些问题。质量好、性价比高的单针缝合线，在中国等国家容易购买，用于显微外科纵向肠套叠血管表脑造口术。这样可以优化手术程序，缩短手术时间，同时保证吻合的成功率。创新性地提出了保留输精管血管的手术方法，因为附睾OA的病因在中国主要是炎症性的。使用显微外科镊子分离和保护脉管系统，最大限度地保护输精管和附睾的血液供应。术后随访通畅率达到81.7%，表明手术治疗效果较好。
Introduction
不孕夫妇的人数每年都在增加。OA发生在20%-40%的育龄男性无精子症病例中1。附睾梗阻约占OA病例的30%，是最常见的梗阻部位之一。然而，这一比例在中国可能更高2，3。OA的治疗因梗阻部位而异。OA 的常见病因包括输精管切除术、泌尿生殖道感染、泌尿生殖系统结核、医源性损伤和特发性梗阻。在中国，OA的病因多为泌尿生殖道感染或附睾炎引起的附睾梗阻，而输精管切除术是西方国家最常见的病因2，3。这两种类型的梗阻需要略有不同的手术方法。
显微外科血管表雄腺造口术（MVE）自2000年以来已成为治疗附睾OA的重要方法4。MVE是男性显微外科手术中最具挑战性的手术，包括显微外科端到端单肾小管吻合术、端到端吻合口术、三角测量、肾小管内陷术和肾小管肠套叠技术5.纵向肠套叠血管表切开术（LIVE）更有利，因为附睾小管6，7，8的开口更宽。基于本案在中国的特点，提出了一种基于改进的单臂缝合MVE技术，改进的、保留船舶的、改良的单臂缝合LIVE技术。该技术不仅可以在不易获得双针缝合的区域进行血管表皮环切术（VE），还可以保留输精管的脉管系统并维持正常的生理结构。
Protocol
该研究获得中山大学第一附属医院的批准。诊断标准、手术适应证和禁忌证均符合《男科诊疗指南》和《中国男科学会》和《欧洲泌尿外科学会性健康和生殖健康指南》的专家共识。如果女性伴侣患有影响生育能力的疾病，则患者将被排除在本研究之外。 1. 操作仪器 确保 材料表中提到的灭菌器械和其他设备的可用性。 <p class="jove_title…
Representative Results
一项研究纳入了92名在中国广州中山大学附属医院被诊断患有继发于附睾梗阻的无精子症的男性，他们在2017年1月至2018年12月期间接受了手术。92名男性的平均年龄为30.77±5.38岁（范围：20-47岁）（表1）。所有男性均接受了双侧容器保留，改进，单臂技术进行LIVE，平均手术时间为223.59±31.73 min。未发现术后并发症或严重不良事件。建立了定期随访计划，在术后6周进行第一次精液分析，?…
Discussion
泌尿生殖道感染和附睾炎是附睾OA的常见原因。VE已成为治疗附睾OA的重要方法，自2000年以来已在临床上应用4。输精管和附睾的吻合术是用双针缝合线进行的，在经典的MVE6，8，9中不保留输精管的血管。由于双针缝合线价格昂贵且不易获得，且我国大多数患者的病因与西方国家不同，因此提出了血管保存技术?…
Disclosures
The authors have nothing to disclose.
Acknowledgements
本研究由中山大学附属第一医院东科临床研究培训项目（编号：2019002、编号：2019008）和国家卫生健康委员会中华人民共和国男性生殖与遗传学重点实验室（编号：KF202001）资助。
Materials
| 0.9% sodium chloride solution | Guangdong Otsuka Pharmaceutical Co. LTD | 21M1204 | Dilute antibiotics, irrigate. |
| 1 mL syringe | Kindly Medical, Shanghai | K20210826 | inject diluted methylene blue or 0.9% sodium chloride solution |
| 1% iodophor | Guangzhou Qingfeng Disinfection Products Co., LTD | Q/QFXD2 | Disinfect the surgical area. |
| 10-0 polypropylene sutures | Ethicon, LLC | REBBES | Used when anastomosing. |
| 3-0 polyglactin 910 sutures | Ethicon, LLC | RGMCLH | Suture skin incisions at the end of surgery. |
| 5-0 polyglactin 910 sutures | Ethicon, LLC | RBMMPQ | Suture skin incisions at the end of surgery. |
| 8-0 polypropylene sutures | Ethicon, LLC | RDBBLS | Used when anastomosing. |
| 9-0 polypropylene sutures | Ethicon, LLC | RABDTE | Used when anastomosing. |
| F16 urinary catheter | Well Lead Medical, Guangzhou | 20190612 | Drainage of urine due to long operation time. |
| micro haemostatic forceps | Shanghai Surgical Instrument Factory | W40350 | Used in surgical procedures |
| micro scissors | Cheng-He,NingBo | HC-A008 | Used in surgical procedures |
| micro tweezers | Cheng-He,NingBo | HC-A002 | Used in surgical procedures |
| microneedle holder | Cheng-He,NingBo | HC-GN006 | Used in surgical procedures |
| ophthalmic scissors | Shanghai Surgical Instrument Factory | Y00040 | Used in surgical procedures |
| polyglactin 910 sutures | Ethicon, LLC | RBMMPQ | Suture skin incisions at the end of surgery. |
| silk braided non-absorbable suture | Ethicon, LLC | SB84G | ligate the broken end of the vas deferens |
| skin marker | Medplus Inc. | 21120206 | Mark surgical incisions and suture sites. |
| surgical microscope Carl Zeiss S88 | Carl Zeiss | Carl Zeiss S88 | Enlarge your field of vision during surgery. |
| vas-fixation clamp | Shanghai Surgical Instrument Factory | JCZ220 | Used in surgical procedures |
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Tags
Vessel-sparingMicrosurgicalLongitudinal IntussusceptionVasoepididymostomyEpididymal Obstructive AzoospermiaSingle Needle SuturesVas Deferens VesselsMicrosurgical TrainingFoley CatheterVas-fixation ClampVascular SlingMicro Hemostatic ForcepsMethylene BlueSodium ChlorideTunica VaginalisOphthalmic ScissorsSilk Braided Suture
Cite This Article
Zhou, M., Zhuang, J., Liao, W., Long, S., Tu, X. Vessel-Sparing Microsurgical Longitudinal Intussusception Vasoepididymostomy to Treat Epididymal Obstructive Azoospermia. J. Vis. Exp. (183), e63774, doi:10.3791/63774 (2022).