超声成像技术在无精子症患者病因诊治中的应用价值
发布时间：2018-09-05 15:43
【摘要】：目的：①探讨经阴囊及经直肠超声诊断无精子症病因的价值。②应用实时超声弹性成像技术评估梗阻性无精子症(OA)与非梗阻性无精子症(NOA)附睾硬度的差异,初步探讨实时超声弹性成像技术在无精子症病因诊断及鉴别诊断的临床应用价值。③应用经阴囊及经直肠超声为临床筛选输精管与附睾管吻合术适应症提供可靠的影像学依据。 方法：研究对象为2013年5月-2014年4月间就诊于我院男性科及生殖科的不育症患者,不育时间在2年-7年,均经临床诊断为无精子症,共77例,年龄22岁-45岁,平均(34.4士4.5)岁。使用仪器为Hitachi preirus彩色多普勒超声诊断仪,具有实时超声弹性成像功能及弹性应变率比值与弥散定量分析软件。经阴囊常规超声检查及实时超声弹性成像检查使用探头型号均为L-74M,频率为5MHz-13MHz;经直肠腔内常规超声检查探头型号为V-53W,频率为4MHz-8MHz。(1)经阴囊常规超声检查时分别多切面观察双侧睾丸、附睾、精索静脉、近端输精管的二维灰阶图像及彩色血流超声图,测量睾丸大小并计算睾丸体积(mL),判断睾丸是否缩小；测量附睾各部分厚径并判断附睾管是否扩张；判断精索静脉是否曲张并进行分级；测量输精管内径并判断是否扩张。(2)经直肠常规超声检查时分别多面扫查前列腺、两侧精囊、射精管及输精管壶腹部,观察其形态、内部回声情况,并测量前列腺及精囊大小；观察射精管是否扩张并测量其长径及内径；测量输精管壶腹部最大内径。(3)附睾超声弹性成像及定量分析方法：分别对附睾头部及尾部进行超声弹性成像检查,由弥散定量分析软件自动测算硬度指数SI值,重复测量5次记录并取平均值。(4)输精管附睾吻合术(VE)适应症超声筛查方法即有以下阳性发现者认为具有手术适应症：①睾丸体积≥15ml。②附睾管扩张,呈“网格样”改变,内径3mm。③睾丸网扩张,呈“网格样”改变。④输精管扩张,内径1mm。⑤精囊、射精管、前列腺未见明显异常。⑥附睾无先天异常。其中①、⑤和⑥项为必须标准。所有患者均与睾丸活检及手术结果对照。统计方法：收集所有数据后采用SPSS17.0统计软件进行数据分析处理,使用卡方及Fisher检验对OA与NOA共同病因检出病变能力进行评估；弹性成像SI值采用均数±标准差(x±S)表示；OA与NOA两组间SI值的比较先进行Dunnett T3两两比较,再采用单因素方差分析及独立样本T检验；分别选取OA与NOA的附睾头SI值及附睾尾SI值绘制受试者工作特征曲线(ROC曲线),以ROC曲线下面积(Az)来判断SI指标对诊断无精子症的准确性。 结果：(1)超声提示精道梗阻者37例(归为OA组),占总数的48.0%(37/77)；无精道梗阻者21例(归为NOA组),占总数的27.3%(21/77),超声检出OA组病因高于NOA组病因,且差异有统计学意义。(2)无精子症OA组病因包括慢性附睾炎伴附睾管扩张、输精管结扎术后伴附睾管扩张、射精管囊肿及射精管狭窄；NOA组包括睾丸发育不良、隐睾、精索静脉曲张及单侧睾丸发育不良并精索静脉曲张；两组患者共同病因包括附睾管扩张、附睾囊肿及精索静脉曲张,其中附睾管扩张及精索静脉曲张在OA组中出现的频率高于NOA组,附睾囊肿在NOA组出现频率高于OA组,差异均有统计学意义；(3)附睾弹性成像结果显示：OA组附睾头SI值略高于NOA组附睾头SI值,二者差异无统计学意义(P0.05)；OA组附睾尾SI值高于NOA组附睾尾SI值,二者差异有统计学意义(P0.05)。OA组与NOA组附睾头SI=2.46为诊断阈值时,其敏感性为95.9%,特异性为16.7%,二者的差异无统计学意义(P=0.968)；OA组与NOA组附睾尾SI=2.57为诊断阈值时,其敏感性为95.9%,特异性为25%,二者的差异无统计学意义(P=0.069)。OA组及NOA组附睾头部及附睾尾部SI值的ROC曲线下面积(Az)分别为0.502、0.594,说明诊断准确性较低,即SI值用于诊断无精子症可靠性低。(4).超声筛查VE手术适应症的准确率为92.85%,占7.14(1/28)。 结论：(1)应用经阴囊超声及经直肠超声检查技术可对无精子症病因做出诊断或方向性提示,对临床诊断及治疗方法提供有价值的影像学依据。(2)经阴囊及经直肠超声检查技术对非梗阻性无精子症患者病因诊断的准确率高于梗阻性无精子症患者,但其病变检出率低于梗阻性无精子症；在鉴别诊断梗阻性与非梗阻性无精子症共同病因检出能力的差异作用较弱。(3)超声实时组织弹性成像弥散定量分析技术对梗阻性无精子症及非梗阻性无精子症附睾尾的硬度改变有一定诊断价值；(4)硬度指数SI值对梗阻性无精子症及非梗阻性无精子症附睾硬度的鉴别诊断准确性低,其价值有待研究；(5)经阴囊及经直肠超声检查技术在梗阻性无精子症患者输精管附睾吻合术前筛选手术适应症有较高价值。
[Abstract]:Objective: To investigate the value of transscrotal and transrectal ultrasonography in the diagnosis of azoospermia. 2. To evaluate the difference of epididymal stiffness between obstructive azoospermia (OA) and non-obstructive azoospermia (NOA) by real-time ultrasound elastography, and to explore the clinical response of real-time ultrasound elastography in the etiological diagnosis and differential diagnosis of azoospermia. Value. 3. Transscrotal and transrectal ultrasonography provide reliable imaging basis for screening the indications of vas deferens and epididymis anastomosis.
METHODS: Seventy-seven infertile men (22-45 years old, average age 34.4 Shi 4.5 years) with two to seven years of clinical diagnosis of azoospermia were selected from May 2013 to April 2014. The instrument was Hitachi preirus color Doppler ultrasound diagnostic instrument with real-time ultrasonic elasticity. The probe type was L-74M and the frequency was 5 MHz-13 MHz for routine ultrasound examination of scrotum and real-time ultrasound elastography. The probe type was V-53W and the frequency was 4 MHz-8 MHz for routine ultrasound examination of scrotum. The size of testis was measured and testicular volume (mL) was calculated to determine whether the testis was reduced; the thickness of each part of epididymis was measured and whether the epididymal duct was dilated; the varicocele was judged and graded; the diameter of vas deferens was measured. (2) The prostate, bilateral seminal vesicles, ejaculatory ducts and ampulla of vas deferens were scanned by transrectal ultrasonography to observe their morphology, internal echo, and the size of prostate and seminal vesicles, to observe whether the ejaculatory ducts were dilated and to measure their length and internal diameter, and to measure the maximum internal diameter of vas deferens ampulla. (3) Appendix. Ultrasonic elastography and quantitative analysis of the epididymis: the head and tail of the epididymis were examined by ultrasonic elastography, the SI value of the hardness index was calculated automatically by the diffusion quantitative analysis software, and the SI value was measured five times repeatedly and the average value was obtained. (4) Vasoepididymostomy (VE) indications for ultrasound screening method that there are the following positive findings considered to have. Indications: 1. Testicular volume (> 15ml). 2. The epididymal duct was dilated in a "mesh" shape with an inner diameter of 3mm. 3. The testicular reticulum was dilated in a "mesh" shape. 4. The vas deferens was dilated with an inner diameter of 1mm. _seminal vesicle, ejaculatory duct and prostate were not abnormal. _There were no congenital abnormalities in the epididymis. Testicular biopsy and operation results were compared. Statistical methods: All data were collected and analyzed by SPSS17.0 statistical software. Chi-square test and Fisher test were used to evaluate the ability of detecting lesions of common cause of OA and NOA; SI value of elastography was expressed by mean (+S); SI value between OA and NOA was first compared. Dunnett T3 was compared by one-way ANOVA and independent sample T test, and the SI values of the epididymal head and tail of OA and NOA were selected to draw the ROC curve, and the area under the ROC curve (Az) was used to judge the accuracy of SI index in the diagnosis of azoospermia.
Results: (1) Ultrasound showed that 37 cases of semen obstruction (OA group), accounting for 48.0% (37/77); 21 cases of azoospermia obstruction (NOA group), accounting for 27.3% (21/77). The etiology of OA group was higher than that of NOA group, and the difference was statistically significant. (2) The etiology of azoospermia OA group included chronic epididymitis with epididymal duct dilatation, vasectomy ligation. The NOA group included testicular dysplasia, cryptorchidism, varicocele and unilateral testicular dysplasia with varicocele; the common causes of the two groups included dilatation of the epididymal duct, epididymal cyst and varicocele, including dilatation of the epididymal duct and varicocele in the OA group. The frequency of occurrence of epididymal cyst in NOA group was higher than that in NOA group, and the frequency of occurrence of epididymal cyst in NOA group was higher than that in OA group, the difference was statistically significant. (3) The results of epididymal elastography showed that the SI value of the head of epididymis in OA group was slightly higher than that of the head of epididymis in NOA group, and the difference was statistically significant (P 0.05). The sensitivity and specificity were 95.9% and 16.7% respectively in OA group and NOA group when SI = 2.46 was the diagnostic threshold (P = 0.968), and 95.9% and 25% respectively in OA group and NOA group when SI = 2.57 was the diagnostic threshold (P = 0.069). The area under the ROC curve (Az) of SI value of head and tail of epididymis was 0.502 and 0.594 respectively, indicating that the diagnostic accuracy was low, that is, the SI value was used to diagnose azoospermia with low reliability. (4) The accuracy rate of ultrasound screening for VE operation indication was 92.85%, accounting for 7.14 (1/28).
Conclusion: (1) Transscrotal ultrasonography and transrectal ultrasonography can provide valuable imaging evidence for the diagnosis and treatment of azoospermia. (2) Transscrotal ultrasonography and transrectal ultrasonography are more accurate in the etiological diagnosis of non-obstructive azoospermia than obstructive azoospermia. The detection rate of lesions in patients with obstructive azoospermia was lower than that in patients with obstructive azoospermia, and the difference in the detection ability of common etiology between obstructive and non-obstructive azoospermia was weak. (3) Ultrasound real-time tissue elastography diffusion quantitative analysis technique has the effect on the changes of epididymal tail stiffness in obstructive azoospermia and non-obstructive azoospermia. It has certain diagnostic value; (4) SI value of stiffness index is low in the differential diagnosis of obstructive azoospermia and non-obstructive azoospermia epididymal stiffness, and its value needs to be studied; (5) Transscrotal and transrectal ultrasonography in obstructive azoospermia patients before vasoepididymal anastomosis screening surgical indications has higher value.
【学位授予单位】：昆明医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R698;R445.1
本文编号：2224718
[Abstract]:Objective: To investigate the value of transscrotal and transrectal ultrasonography in the diagnosis of azoospermia. 2. To evaluate the difference of epididymal stiffness between obstructive azoospermia (OA) and non-obstructive azoospermia (NOA) by real-time ultrasound elastography, and to explore the clinical response of real-time ultrasound elastography in the etiological diagnosis and differential diagnosis of azoospermia. Value. 3. Transscrotal and transrectal ultrasonography provide reliable imaging basis for screening the indications of vas deferens and epididymis anastomosis.
METHODS: Seventy-seven infertile men (22-45 years old, average age 34.4 Shi 4.5 years) with two to seven years of clinical diagnosis of azoospermia were selected from May 2013 to April 2014. The instrument was Hitachi preirus color Doppler ultrasound diagnostic instrument with real-time ultrasonic elasticity. The probe type was L-74M and the frequency was 5 MHz-13 MHz for routine ultrasound examination of scrotum and real-time ultrasound elastography. The probe type was V-53W and the frequency was 4 MHz-8 MHz for routine ultrasound examination of scrotum. The size of testis was measured and testicular volume (mL) was calculated to determine whether the testis was reduced; the thickness of each part of epididymis was measured and whether the epididymal duct was dilated; the varicocele was judged and graded; the diameter of vas deferens was measured. (2) The prostate, bilateral seminal vesicles, ejaculatory ducts and ampulla of vas deferens were scanned by transrectal ultrasonography to observe their morphology, internal echo, and the size of prostate and seminal vesicles, to observe whether the ejaculatory ducts were dilated and to measure their length and internal diameter, and to measure the maximum internal diameter of vas deferens ampulla. (3) Appendix. Ultrasonic elastography and quantitative analysis of the epididymis: the head and tail of the epididymis were examined by ultrasonic elastography, the SI value of the hardness index was calculated automatically by the diffusion quantitative analysis software, and the SI value was measured five times repeatedly and the average value was obtained. (4) Vasoepididymostomy (VE) indications for ultrasound screening method that there are the following positive findings considered to have. Indications: 1. Testicular volume (> 15ml). 2. The epididymal duct was dilated in a "mesh" shape with an inner diameter of 3mm. 3. The testicular reticulum was dilated in a "mesh" shape. 4. The vas deferens was dilated with an inner diameter of 1mm. _seminal vesicle, ejaculatory duct and prostate were not abnormal. _There were no congenital abnormalities in the epididymis. Testicular biopsy and operation results were compared. Statistical methods: All data were collected and analyzed by SPSS17.0 statistical software. Chi-square test and Fisher test were used to evaluate the ability of detecting lesions of common cause of OA and NOA; SI value of elastography was expressed by mean (+S); SI value between OA and NOA was first compared. Dunnett T3 was compared by one-way ANOVA and independent sample T test, and the SI values of the epididymal head and tail of OA and NOA were selected to draw the ROC curve, and the area under the ROC curve (Az) was used to judge the accuracy of SI index in the diagnosis of azoospermia.
Results: (1) Ultrasound showed that 37 cases of semen obstruction (OA group), accounting for 48.0% (37/77); 21 cases of azoospermia obstruction (NOA group), accounting for 27.3% (21/77). The etiology of OA group was higher than that of NOA group, and the difference was statistically significant. (2) The etiology of azoospermia OA group included chronic epididymitis with epididymal duct dilatation, vasectomy ligation. The NOA group included testicular dysplasia, cryptorchidism, varicocele and unilateral testicular dysplasia with varicocele; the common causes of the two groups included dilatation of the epididymal duct, epididymal cyst and varicocele, including dilatation of the epididymal duct and varicocele in the OA group. The frequency of occurrence of epididymal cyst in NOA group was higher than that in NOA group, and the frequency of occurrence of epididymal cyst in NOA group was higher than that in OA group, the difference was statistically significant. (3) The results of epididymal elastography showed that the SI value of the head of epididymis in OA group was slightly higher than that of the head of epididymis in NOA group, and the difference was statistically significant (P 0.05). The sensitivity and specificity were 95.9% and 16.7% respectively in OA group and NOA group when SI = 2.46 was the diagnostic threshold (P = 0.968), and 95.9% and 25% respectively in OA group and NOA group when SI = 2.57 was the diagnostic threshold (P = 0.069). The area under the ROC curve (Az) of SI value of head and tail of epididymis was 0.502 and 0.594 respectively, indicating that the diagnostic accuracy was low, that is, the SI value was used to diagnose azoospermia with low reliability. (4) The accuracy rate of ultrasound screening for VE operation indication was 92.85%, accounting for 7.14 (1/28).
Conclusion: (1) Transscrotal ultrasonography and transrectal ultrasonography can provide valuable imaging evidence for the diagnosis and treatment of azoospermia. (2) Transscrotal ultrasonography and transrectal ultrasonography are more accurate in the etiological diagnosis of non-obstructive azoospermia than obstructive azoospermia. The detection rate of lesions in patients with obstructive azoospermia was lower than that in patients with obstructive azoospermia, and the difference in the detection ability of common etiology between obstructive and non-obstructive azoospermia was weak. (3) Ultrasound real-time tissue elastography diffusion quantitative analysis technique has the effect on the changes of epididymal tail stiffness in obstructive azoospermia and non-obstructive azoospermia. It has certain diagnostic value; (4) SI value of stiffness index is low in the differential diagnosis of obstructive azoospermia and non-obstructive azoospermia epididymal stiffness, and its value needs to be studied; (5) Transscrotal and transrectal ultrasonography in obstructive azoospermia patients before vasoepididymal anastomosis screening surgical indications has higher value.
【学位授予单位】：昆明医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R698;R445.1
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