287例顽固性血精的病因学分析及精道内镜技术诊治研究

发布时间：2018-06-17 06:19

本文选题：血精 + 射精管梗阻　；参考：《第三军医大学》2017年硕士论文

【摘要】：背景精液中混有血液谓之血精,占到泌尿生殖系统症状的1%。由于绝大多数患者的血精症状表现为良性、自限性状态,因此,一般仅需予以心理安慰、等待观察或药物保守治疗。但是部分患者的血精症状呈反复发作,迁延不愈,成为顽固性血精,这给其造成巨大的心理负担和顾虑。部分顽固性血精患者,甚至伴有其他相关症状。有文献显示年龄40岁以上的顽固性血精患者,其血精可能是某种潜在恶性病变的首发症状。为此,对顽固性血精患者有必要进行深入的检查和治疗。近年来兴起的精道内镜技术在顽固性血精的诊治方面已经显示出其独特的优势,从根本上改善了顽固性血精及射精管梗阻(EDO)患者的治疗效果。但该技术作为一种新型手术方式,临床应用尚不广泛,其应用的适应证和禁忌证,临床操作技巧和长期疗效等尚处于不断探索阶段。因此,对顽固性血精患者进行深入的影像学研究并利用精道内镜技术进行病因诊断和针对性治疗具有重要的理论意义和临床应用价值。目的:应用MRI检查对顽固性血精及伴发的EDO进行影像学特征和病因学分析,并通过精道内镜技术对顽固性血精进行病因诊断和相应治疗,分析引起顽固性血精的确切病因,探讨精道内镜技术的操作技巧和中远期疗效。材料和方法:回顾性分析自2009年1月至2016年12月期间就诊于我院泌尿外科的顽固性血精患者临床资料。患者入院后进行各类实验室检查,经直肠B超(TRUS),盆腔MRI检查及前列腺活检等初步筛查,根据结果排除由于泌尿生殖系肿瘤,长期口服抗凝剂,严重肝功能损害所导致的血精患者,选择血精病史超过6个月,且均经规范保守性药物治疗1个月以上无效,并进行了盆腔MRI检查和精道内镜技术治疗的患者共计287例,纳入本项研究。本研究对血精患者的盆腔MRI检查结果进行分析,研究和探讨顽固性血精的MRI影像学特征和引起血精的精道远端区域常见病变;结合术中精道内镜下所见,分析顽固性血精的临床特征,总结精道内镜技术应用的技巧及相关注意事项,并随访观察精道内镜技术治疗顽固性血精的中远期疗效和并发症。结果:一、顽固性血精患者MRI影像学特征改变:287例患者中,85.7%(246/287)的患者存在精囊内信号强度异常,精囊囊性扩张或增大,精道远端区域出现囊性占位等特征性改变。62.7%(180/287)的患者表现为精囊内信号强度异常改变,其中27.2%(78/287)的患者其单侧或双侧精囊在T1WI相上呈中至高信号,而在T2WI相上呈低信号,提示精囊内为新鲜出血,35.5%(102/287)的患者单侧或双侧精囊在T1WI、T2WI相上均呈现为中至高强度信号,提示精囊内为陈旧性出血;35.9%(103/287)的患者表现为精道远端区域存在多种囊性占位性改变,其中24.7%(71/287)为前列腺小囊囊肿(Prostatic utricular cyst),大小(0.6×0.7)cm~(2.3×2.5)cm,6.3%(18/287)为苗勒管囊肿(Müllerian duct cyst),大小(3.4×4.0)cm~(8.8×11.5)cm,1.7%(5/287)为射精管囊肿(Ejaculatory duct cyst),3.1%(9/287)为精囊囊肿(Seminal vesicle cyst);在精道远端区域存在囊肿的35.9%(103/287)患者中,21.3%(61/287)伴有精囊或囊肿内出血,其中15例为新鲜出血,46例为陈旧性出血;30.7%(88/287)的患者表现为精囊显著扩张或增大,腺体宽度≥1.7cm,腺管直径5mm,该类患者的精囊宽度平均为(2.15±0.36)cm。14.3%(41/287)的患者其MRI检查显示精道远端区域均未见明显信号强度和形态结构改变,与正常的MRI影像学特征无明显差异。二、顽固性血精的精道内镜诊治情况:287例患者中,268例患者进行了精道内镜观察和治疗,9例患者因存在射精管开口发育异常或双侧精囊腺原发性或继发性萎缩等未能成功进镜。10例患者显示存在后尿道异常曲张血管或海绵状血管瘤样改变,进行了血管瘤电切及电灼处理。其中71.6%(192/268)的患者采用经前列腺小囊内开窗进镜,10.4%(28/268)的患者采用前列腺小囊内病理性开口进镜,16.8%(45/268)的患者采用了射精管远端切开进镜,1.1%(3/268)的患者采用了射精管自然开口逆行进镜。其中最常用的进镜方式为经前列腺小囊内开窗进镜。针对不同患者的情况采取的治疗性操作有精道扩张,囊肿去顶状电切、囊壁烧灼,钬激光碎石取石,套石篮取石,精囊冲洗等。手术操作时间20~70min,平均36min,失血量0~20ml,平均8ml,未见明显术中并发症发生。患者住院3~6天,平均4.5天。三、顽固性血精患者术后疗效随访:253例患者成功随访,34例患者失访,随访时间5~72个月。获得随访的253例患者术后均未发生附睾炎、直肠损伤、逆行性射精、尿失禁等严重并发症。所有成功进行内镜治疗的患者,其顽固性血精症状均在术后2~6周内消失,92.5%(234/253)的患者随访期内未再出现复发。仅7.5%(19/253)的患者于术后血精消失5~20个月后复发,其中9例患者再次接受精道内镜处理,随访1~3个月后症状消失。10例年龄40岁以上患者性高潮快感强度有不同程度减弱。16例进行射精管远端切开术后患者自述术后精液量较术前增多且变得稀薄。术前因血精伴婚后不育的19例患者术后精液质量明显改善,术后1~6月复查精液常规示精液量1.5~4.5ml,精子浓度21.5~63.0×106/ml,A+B级精子比例为27.4~66.7%,其中36.8%(7/19)的患者配偶于术后9~24个月自然怀孕。结论:精道远端区域炎症和感染、各类囊性占位以及偶伴的精囊或前列腺小囊内结石形成所导致的精道完全性或不完全性梗阻是引起顽固性血精的最主要病因。精道内镜技术既可对精道远端区域常见疾病进行病因学诊断,又可在明确病因的基础上行针对性治疗。对于保守治疗无效的顽固性血精及EDO患者,应用精道内镜技术进行诊治,安全性好,疗效理想,值得临床上推广应用。
[Abstract]:The 1%. of the background semen, which is mixed with blood spermatozoa, accounts for the symptoms of the genitourinary system, because the symptoms of most of the patients are benign and self limiting. Therefore, they usually need psychological comfort, waiting for observation or conservative treatment. However, the symptoms of blood spermatozoa in some patients are recurring, deferred and become stubborn blood. Sperm, which causes great psychological burden and concern. Some intractable hemosperm patients, even associated with other related symptoms. The literature shows that the blood sperm may be the first symptom of a potential malignant lesion in patients aged over 40 years of age. Therefore, it is necessary to examine and treat intractable hemosperm patients. The advanced endoscopic endoscopy technology has shown its unique advantages in the diagnosis and treatment of intractable hemosinosemin, which has fundamentally improved the treatment effect of intractable hemosinosemin and ejaculatory tube obstruction (EDO). However, as a new mode of operation, the clinical application is not widely used, the application of indications and taboos, clinical operation techniques Therefore, it is of great theoretical significance and clinical value to carry out in-depth imaging studies on intractable hemosinoses and the use of sperm endoscopy for etiological diagnosis and targeted treatment. Objective: to apply MRI to the imaging features of stubborn hemosinosin and the associated EDO. The etiology of intractable hemosinosinosus was diagnosed and treated by endoscopy, and the exact cause of intractable hemosinosinosus was analyzed. The operative techniques and the median efficacy of endoscopy were discussed. Materials and methods were reviewed and analyzed from January 2009 to December 2016 in the Department of Urology in our hospital. Clinical data of patients with solid hemosperm. After admission to the hospital, a variety of laboratory tests were carried out. The patients were screened by TRUS, pelvic MRI, and prostate biopsy. The patients were selected for more than 6 months of history of hemosperm by removing the results of the urogenital tumors, long-term oral anticoagulants and severe liver dysfunction. A total of 287 patients with pelvic MRI and fine canal endoscopic therapy were included in this study. The results of pelvic MRI examination in patients with hemosinoses were analyzed, the MRI imaging features of intractable hemosinoses and common diseases in the distal part of the seminal tract causing hemosinoses were studied. The clinical features of intractable hemosinoses were analyzed, the clinical features of intractable hemosinoses were analyzed, the techniques for the application of endoscopes and related notices were summarized, and the median follow-up and complications were followed up and observed in the treatment of intractable hemosinosinoses. Results: first, the MRI imaging features of intractable hemosinoses were changed: 287 cases, 85.7% Patients (246/287) had abnormal signal intensity within the seminal vesicle, cystic dilatation or enlargement of seminal vesicle, and cystic occupancy in the distal area of the seminal vesicle. The patients with characteristic changes in.62.7% (180/287) showed abnormal signal intensity changes in the seminal vesicle, of which 27.2% (78/287) had a middle or high signal in the T1WI phase of the single or bilateral seminal vesicles, while in the T2WI phase. The low signal showed that the seminal vesicle was fresh bleeding. The unilateral or bilateral seminal vesicles in 35.5% (102/287) patients were both in T1WI and T2WI, suggesting that the seminal vesicle was old bleeding. 35.9% (103/287) showed multiple cystic space occupying changes in the distal area of the seminal tract, of which 24.7% (71/287) was the prostatic sac. Cysts (Prostatic utricular cyst), size (0.6 x 0.7) cm~ (2.3 * 2.5) cm, 6.3% (18/287) of the lerylic duct cyst (M u llerian duct cyst), size (3.4 x 4) cm~ (8.8 x 11.5) cm, 1.7% of spermatic cyst (1.7%), and 3.1% cyst in the distal area of the seminal tract 287) of the patients, 21.3% (61/287) was accompanied by seminal vesicles or cysts, of which 15 were fresh bleeding and 46 were old bleeding; 30.7% (88/287) showed significant dilation or enlargement of the seminal vesicle, the width of the gland was more than 1.7cm, the diameter of the gland was 5mm, and the average of the seminal vesicles of these patients was (2.15 + 0.36) cm.14.3% (41/287) in the patients whose MRI examination showed sperm. No significant signal intensity and morphological changes were found in the distal part of the canal, and there was no significant difference between the normal MRI imaging features. Two, the diagnosis and treatment of intractable seminal sperm endoscopy: of the 287 patients, 268 patients underwent sperm endoscopic observation and treatment, 9 patients had abnormal opening of the emination tube or primary or bilateral seminal vesicles. .10 patients with secondary atrophy showed abnormal posterior urethral varicose veins or cavernous angiomatous changes, and electrocautery and cauterization of hemangiomas were performed. 71.6% (192/268) of the patients were treated with a prostatic pouch open window, and 10.4% (28/268) with a pathological open endoscope in the prostatic capsule, 16.8 The patients (45/268) used the distal incision of the ejaculatory canal, and 1.1% (3/268) patients used the ejaculatory tube natural open retrograde approach. The most commonly used way of entering the mirror was to open the window through the prostatic capsule. The therapeutic operation for different patients included the dilation of the fine canal, the cyst removal, the burning of the wall and the holmium laser. Stone extraction, stone basket taking stone, seminal vesicle irrigation, operation time 20~70min, average 36min, blood loss 0~20ml, average 8ml, no obvious intraoperative complications. Patients hospitalized 3~6 days, average 4.5 days. Three, intractable hemosperm patients follow up after operation: 253 patients were followed up successfully, 34 patients were lost and followed up for 5~72 months. 2 53 patients did not have epididymitis, rectal injury, retrograde ejaculation, and urinary incontinence. All patients who succeeded in endoscopic treatment disappeared in 2~6 weeks after the operation, and 92.5% (234/253) of the patients had no recurrence during the follow-up period. Only 7.5% (19/253) of the patients disappeared after the operation for 5~20 months. After 1~3 months, the symptoms disappeared in 9 cases, and the symptoms disappeared after 1~3 months. The orgasm intensity intensity of the patients over 40 years old decreased to a different degree. The amount of seminal fluid in the patients after the distal ejaculation of the ejaculatory tube was more than before the operation and thinner. 19 patients with hemosinoses with Postmarital infertility. The quality of semen was improved significantly after the operation. 1~6 month after the operation, the volume of semen was 1.5~4.5ml, the sperm concentration was 21.5~63.0 x 106/ml, the proportion of A+B grade sperm was 27.4~66.7%, of which 36.8% (7/19) patients were naturally pregnant after 9~24 months after operation. Conclusion: inflammation and infection of the distal part of the spermatozoa, all kinds of cystic space and the companion seminal vesicle or front row Complete or incomplete obstruction of the fine duct caused by the formation of the calculi in the glandular capsule is the most important cause of intractable hemosposinosus. The endoscopic technique of the fine tract can not only diagnose the common diseases in the distal area of the seminal tract, but also make the targeted treatment on the basis of the clear cause. For the ineffective treatment of the conservative treatment, the intractable hemospsema and EDO patients are not effective. Precise endoscopic surgery is a safe and effective method. It is worthy of clinical application.
【学位授予单位】：第三军医大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R699.8

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