隐睾术后患者远期生育功能随访研究

发布时间：2018-05-12 02:33

本文选题：隐睾 + 睾丸松解固定术　；参考：《山东大学》2012年博士论文

【摘要】：研究背景和目的：隐睾是小儿外科最常见的泌尿生殖系畸形之一,被认为是引起睾丸癌变和男性不育的主要危险因素。药物治疗曾作为手术的辅助治疗,但因其疗效存在争议,所以手术治疗是目前主要的治疗方式。手术虽然不能降低睾丸癌的发生率,但利于早期发现,而在生育力方面,尽管目前大多数隐睾患者早期接受了睾丸松解固定术,但成年后仍有部分不育,特别是双侧隐睾患者,术后的不育率高达67%。手术到底能否提高生育力?早在18世纪解剖学家John Hunter曾假设隐睾睾丸的结构及功能异常是因为睾丸本身发育的异常而不是继发于睾丸位置的异常,遗憾的是这个至关重要的问题到现在仍无明确答案,因此也就不难理解手术到底能否提高生育力的问题被争论了几十年,至今却仍无定论。所以,多年来对于隐睾患者生育力的研究未曾间断,研究方法也多种多样,但由于种种原因的限制,生育力却始终难于量化。目前已有的多数研究仅限于一种指标的分析,而多位学者建议,为综合评价隐睾患者术后的远期生育力,应同时分析多项指标,从不同角度全面评价患者的生育功能,以求更深入地认识隐睾。所以本研究即通过同时分析隐睾患者术后远期的生育率、生育时间、精液检查、体格检查、睾丸体积及性功能,综合评价单双侧隐睾患者术后的生育能力,并初步探讨影响生育力的因素,为临床提供参考。方法：选择1981.10-1997.11之间因隐睾在山东省立医院接受睾丸松解固定术的患者342例,单侧237例,双侧105例,查阅其住院临床资料,通过信件、电话、及面访等形式联系患者来医院,进行体格检查、超声检查,并完成生育情况调查表及简明男性性功能调查问卷,未婚者需行精液检查。将隐睾患者分单侧组和双侧组,按结婚与否分为已婚组和未婚组。按睾丸位置分为腹腔内／内环口、腹股沟管、外环口组,对所得数据进行统计学分析。结果：共有50例患者完成随访,其中1例因静脉曲张被排除,最终共49例(14.3%)符合纳入标准的患者获得完整资料,其中单侧隐睾患者33例,已婚者14例,未婚者19例,多睾症1例(患侧为双睾丸,将发育差的睾丸切除,发育相对好者降至阴囊固定)。双侧隐睾患者16例,已婚、未婚者各8例。所有受访者手术时年龄为1.6岁-11岁,平均5.5岁,随访时年龄为19岁-36岁,平均26.9岁。 1、已婚者生育率和生育时间已婚者中13例(92.9%)单侧隐睾患者顺利生育,平均生育时间为3个月,3例(37.5%)双侧隐睾患者顺利生育,平均生育时间为6.3个月。已婚单侧隐睾患者生育率远大于双侧,且差异有统计学意义(P=O.011)。已婚者中3例(单侧隐睾1例,双侧隐睾2例)不育者经药物治疗后生育,1例治疗后精液检查正常,随访时正准备怀孕,2例正接受药物治疗。 2、未婚者精液检查未婚者中,16例(84.2%)单侧隐睾患者精液正常,双侧仅2例(25%)正常,单侧隐睾患者精液正常率大于双侧,差异有统计学意义(P=0.006)。而在双侧隐睾精液异常者中有4例患者(66.7%)的睾丸(一侧或双侧)位于腹腔内。 3、睾丸超声所有受访者中均未发现睾丸癌变患者,单侧隐睾患侧睾丸体积为10.78±2.00ml,小于健侧(15.81±3.64m1),且差异有统计学意义(t=t=7.626,P0.01),双侧隐睾睾丸体积为9.75±3.75m1,单侧隐睾腹腔内睾丸体积为7.49±1.02ml,双侧腹腔内睾丸体积为5.62±1.92ml,均小于相应得此腹股沟管组和外环口组。部分隐睾患者的患侧睾丸回声不均,血流少,易变形,单侧隐睾患者健患侧超声表现无明显差异(大小、回声、饱满度)的有4例(12.1%),其余患者则在睾丸实质回声、血流信号、质地软硬等方面表现不同。单侧隐睾已婚者中4人(28.6%)、未婚者中有10人(52.6%)超声诊断为附睾囊肿；而已婚者中有5人(35.7%)、未婚者中8人(42.1%)发现睾丸微石症,其中的已婚者均已生育。因双侧隐睾患者例数少,未就睾丸微石症和附睾囊肿的发生情况做统计。 4、性功能在已婚患者中,单双侧隐睾患者的性功能满意度调查得分均大于1分,即均满意。但单侧已婚隐睾患者BSFI得分平均为32.93±3.05,而双侧为27.88±4.94,单侧大于双侧,且差异有统计学意义(P=0.014)。单侧隐睾患者中5例(35.7%)、双侧已婚者中有6例(75%)性功能异常,部分患者同时存在性欲、勃起或射精功能中的两或三项异常,且这些双侧隐睾性功能异常者亦合并精液异常。未婚者中,单侧隐睾患者术后BSFI得分平均为4.42±1.22,双侧为3.43±0.95,两组比较无显著性差异(P=0.065)。单侧隐睾性欲障碍者有5例(26.3%),而双侧亦有5例(62.5%)。 5、查体单侧隐睾患者第二性征无明显异常,有4例睾丸位于阴囊上极,5例患侧隐睾触诊较健侧软,1例未触及睾丸(术后睾丸萎缩)。而双侧隐睾中4例少弱精或无精症患者第二性征发育欠佳,表现为喉结发育差,阴毛少,阴茎小,睾丸小、声音似女性；触诊睾丸较软。结论： 1、单侧隐睾患者的生育率大于双侧,单侧隐睾无论术前睾丸位置如何及手术年龄大小,生育率仍接近正常人群。而双侧隐睾患者尽管早期接受了手术,但生育率仍显著低于单侧及正常人群,且已婚生育者生育时间较单侧长,即生育较单侧困难。部分不育者通过药物治疗后可生育。 2、未婚单侧隐睾患者精液正常率接近正常人群,而双侧隐睾术后精液质量正常者则远少于单侧；双侧腹腔内型隐睾患者精液更易异常。未婚患者精液检查异常者暂观察,待结婚后再考虑是否需要治疗。 3、单侧隐睾的睾丸体积小于健侧睾丸,在单双侧隐睾中腹腔内隐睾睾丸体积均小于腹股沟及外环口组,而腹股沟管组小于外环口组,因此,术前睾丸位置越高,成年后睾丸体积越小,特别是腹腔内型隐睾受影响更明显。多数单侧隐睾患者睾丸超声显示实质回声不均、血流信号少、质地软、易变形等,因此,虽然早期进行了手术,但术后隐睾睾丸发育仍较健侧差。 4、部分双侧隐睾患者第二性征发育异常,特别是少弱精及无精症患者,表现为无喉结,阴毛少,阴茎短小,无胡须,声音异常等。虽然部分单侧隐睾患者患侧阴囊发育较健侧差,睾丸较健侧小,触诊质较软,但第二性征无明显异常。 5、虽然所有受访者的性功能总体满意度调查均为满意或非常满意,但部分已婚患者在性欲、勃起功能及射精功能上存在一方面或多方面的异常,特别是双侧隐睾患者；单侧隐睾已婚者性功能总体评分大于双侧,而在未婚者中,单双侧隐睾患者性欲评分无显著差别。
[Abstract]:Background and purpose of the study :

This study has been used as adjuvant therapy for cryptorchidism , but it is difficult to quantify the fertility of cryptorchidism .

Method :

A total of 342 patients were selected from 1981 . 10 - 1997.11 by cryptorchidism in Shandong Provincial Hospital . There were 237 cases , 105 cases with bilateral side , 105 cases in hospital , physical examination and ultrasonic examination .

Results :

A total of 50 patients were followed up , of which 1 case was excluded due to varsity . A total of 49 ( 14.3 % ) patients who met the inclusion criteria received complete information , including 33 patients with unilateral cryptorchidism , 14 in the married , 19 in the unmarried , and 1 in the cryptorchidism . Among the 16 patients with bilateral cryptorchidism , 8 were married and unmarried . All the respondents were aged from 1.6 to 11 years with an average age of 5.5 years . The age at follow - up ranged from 19 to 36 years , with an average age of 26 . 9 years .

1 . There were 13 cases ( 92.9 % ) of the married people with one - sided cryptorchidism ( 92.9 % ) . The average birth time was 3 months , 3 cases ( 37.5 % ) had smooth birth , and the average birth time was 6.3 months . 3 cases ( 1 case with unilateral cryptorchidism and 2 cases of bilateral cryptorchidism ) were given birth after drug treatment .

2 . Among the unmarried subjects , 16 ( 84.2 % ) patients with unilateral cryptorchidism were normal , only 2 cases ( 25 % ) in bilateral cryptorchidism were normal , and the normal rate of semen of unilateral cryptorchidism was more than that of bilateral ones ( P = 0.006 ) , while 4 patients ( 66.7 % ) in bilateral cryptorchidism were located in the abdominal cavity .

There were 4 cases ( 28.6 % ) in one - sided cryptorchidism and 10 ( 52.6 % ) in the unmarried .
Among the married people , 5 ( 34.7 % ) and 8 ( 42.1 % ) of the unmarried were found to have testicular microlithiasis , among which the married people were given birth . Because of the number of patients with bilateral cryptorchidism , there was no statistic on the occurrence of testicular microlithiasis and Epidermis cyst .

Among the patients with unilateral cryptorchidism , the average score of BSFI was 32.93 卤 3.05 and 27.88 卤 4.94 on both sides , and there was no significant difference between the two groups ( P = 0.065 ) .

5 . There was no obvious abnormality in the second sign of cryptorchidism in the cryptorchidism , 4 of which were located on the upper pole of scrotum , 5 cases with the side cryptorchidism were better than the healthy side and 1 case did not reach the testis ( the testis atrophy after operation ) .
Soft touch of the testis .

Conclusion :

1 . The fertility rate of patients with unilateral cryptorchidism is greater than that of bilateral and unilateral cryptorchidism .

2 . The normal rate of semen was close to the normal group in unmarried unilateral cryptorchidism , while the semen quality of bilateral cryptorchidism was much less than that of unilateral cryptorchidism .
The semen of the patients with bilateral abdominal cavity type cryptorchidism is more abnormal . The semen examination of unmarried patients is temporarily observed , and whether treatment is needed after the marriage is to be considered .

3 . Testicular volume of unilateral cryptorchidism is less than that of healthy testis , and the volume of cryptorchidism in the cryptorchidism is smaller than that in outer ring group .

4 . The second sign of bilateral cryptorchidism is abnormal , especially in patients with oligoasthenospermia and oligospermia , which is characterized by no laryngeal junction , less pubic hair , short penis , no beard , abnormal sound , etc .

5 . Although the overall satisfaction survey of sexual function of all respondents was satisfactory or very satisfactory , some married patients had one or more abnormalities in sexual desire , erectile function and ejaculation function , especially in patients with bilateral cryptorchidism ;
The overall score of sexual function of unilateral cryptorchidism was greater than that of bilateral , while in the unmarried , there was no significant difference in sexual desire score between single and bilateral cryptorchidism .

【学位授予单位】：山东大学
【学位级别】：博士
【学位授予年份】：2012
【分类号】：R726.9

【参考文献】