本文選題：隱睪 + 睪丸松解固定術(shù)�。� 參考：《山東大學(xué)》2012年博士論文

【摘要】：研究背景和目的： 隱睪是小兒外科最常見(jiàn)的泌尿生殖系畸形之一,被認(rèn)為是引起睪丸癌變和男性不育的主要危險(xiǎn)因素。藥物治療曾作為手術(shù)的輔助治療,但因其療效存在爭(zhēng)議,所以手術(shù)治療是目前主要的治療方式。手術(shù)雖然不能降低睪丸癌的發(fā)生率,但利于早期發(fā)現(xiàn),而在生育力方面,盡管目前大多數(shù)隱睪患者早期接受了睪丸松解固定術(shù),但成年后仍有部分不育,特別是雙側(cè)隱睪患者,術(shù)后的不育率高達(dá)67%。手術(shù)到底能否提高生育力?早在18世紀(jì)解剖學(xué)家John Hunter曾假設(shè)隱睪睪丸的結(jié)構(gòu)及功能異常是因?yàn)椴G丸本身發(fā)育的異常而不是繼發(fā)于睪丸位置的異常,遺憾的是這個(gè)至關(guān)重要的問(wèn)題到現(xiàn)在仍無(wú)明確答案,因此也就不難理解手術(shù)到底能否提高生育力的問(wèn)題被爭(zhēng)論了幾十年,至今卻仍無(wú)定論。所以,多年來(lái)對(duì)于隱睪患者生育力的研究未曾間斷,研究方法也多種多樣,但由于種種原因的限制,生育力卻始終難于量化。目前已有的多數(shù)研究?jī)H限于一種指標(biāo)的分析,而多位學(xué)者建議,為綜合評(píng)價(jià)隱睪患者術(shù)后的遠(yuǎn)期生育力,應(yīng)同時(shí)分析多項(xiàng)指標(biāo),從不同角度全面評(píng)價(jià)患者的生育功能,以求更深入地認(rèn)識(shí)隱睪。所以本研究即通過(guò)同時(shí)分析隱睪患者術(shù)后遠(yuǎn)期的生育率、生育時(shí)間、精液檢查、體格檢查、睪丸體積及性功能,綜合評(píng)價(jià)單雙側(cè)隱睪患者術(shù)后的生育能力,并初步探討影響生育力的因素,為臨床提供參考。 方法： 選擇1981.10-1997.11之間因隱睪在山東省立醫(yī)院接受睪丸松解固定術(shù)的患者342例,單側(cè)237例,雙側(cè)105例,查閱其住院臨床資料,通過(guò)信件、電話(huà)、及面訪等形式聯(lián)系患者來(lái)醫(yī)院,進(jìn)行體格檢查、超聲檢查,并完成生育情況調(diào)查表及簡(jiǎn)明男性性功能調(diào)查問(wèn)卷,未婚者需行精液檢查。將隱睪患者分單側(cè)組和雙側(cè)組,按結(jié)婚與否分為已婚組和未婚組。按睪丸位置分為腹腔內(nèi)／內(nèi)環(huán)口、腹股溝管、外環(huán)口組,對(duì)所得數(shù)據(jù)進(jìn)行統(tǒng)計(jì)學(xué)分析。 結(jié)果： 共有50例患者完成隨訪,其中1例因靜脈曲張被排除,最終共49例(14.3%)符合納入標(biāo)準(zhǔn)的患者獲得完整資料,其中單側(cè)隱睪患者33例,已婚者14例,未婚者19例,多睪癥1例(患側(cè)為雙睪丸,將發(fā)育差的睪丸切除,發(fā)育相對(duì)好者降至陰囊固定)。雙側(cè)隱睪患者16例,已婚、未婚者各8例。所有受訪者手術(shù)時(shí)年齡為1.6歲-11歲,平均5.5歲,隨訪時(shí)年齡為19歲-36歲,平均26.9歲。 1、已婚者生育率和生育時(shí)間已婚者中13例(92.9%)單側(cè)隱睪患者順利生育,平均生育時(shí)間為3個(gè)月,3例(37.5%)雙側(cè)隱睪患者順利生育,平均生育時(shí)間為6.3個(gè)月。已婚單側(cè)隱睪患者生育率遠(yuǎn)大于雙側(cè),且差異有統(tǒng)計(jì)學(xué)意義(P=O.011)。已婚者中3例(單側(cè)隱睪1例,雙側(cè)隱睪2例)不育者經(jīng)藥物治療后生育,1例治療后精液檢查正常,隨訪時(shí)正準(zhǔn)備懷孕,2例正接受藥物治療。 2、未婚者精液檢查未婚者中,16例(84.2%)單側(cè)隱睪患者精液正常,雙側(cè)僅2例(25%)正常,單側(cè)隱睪患者精液正常率大于雙側(cè),差異有統(tǒng)計(jì)學(xué)意義(P=0.006)。而在雙側(cè)隱睪精液異常者中有4例患者(66.7%)的睪丸(一側(cè)或雙側(cè))位于腹腔內(nèi)。 3、睪丸超聲所有受訪者中均未發(fā)現(xiàn)睪丸癌變患者,單側(cè)隱睪患側(cè)睪丸體積為10.78±2.00ml,小于健側(cè)(15.81±3.64m1),且差異有統(tǒng)計(jì)學(xué)意義(t=t=7.626,P0.01),雙側(cè)隱睪睪丸體積為9.75±3.75m1,單側(cè)隱睪腹腔內(nèi)睪丸體積為7.49±1.02ml,雙側(cè)腹腔內(nèi)睪丸體積為5.62±1.92ml,均小于相應(yīng)得此腹股溝管組和外環(huán)口組。部分隱睪患者的患側(cè)睪丸回聲不均,血流少,易變形,單側(cè)隱睪患者健患側(cè)超聲表現(xiàn)無(wú)明顯差異(大小、回聲、飽滿(mǎn)度)的有4例(12.1%),其余患者則在睪丸實(shí)質(zhì)回聲、血流信號(hào)、質(zhì)地軟硬等方面表現(xiàn)不同。單側(cè)隱睪已婚者中4人(28.6%)、未婚者中有10人(52.6%)超聲診斷為附睪囊腫；而已婚者中有5人(35.7%)、未婚者中8人(42.1%)發(fā)現(xiàn)睪丸微石癥,其中的已婚者均已生育。因雙側(cè)隱睪患者例數(shù)少,未就睪丸微石癥和附睪囊腫的發(fā)生情況做統(tǒng)計(jì)。 4、性功能在已婚患者中,單雙側(cè)隱睪患者的性功能滿(mǎn)意度調(diào)查得分均大于1分,即均滿(mǎn)意。但單側(cè)已婚隱睪患者BSFI得分平均為32.93±3.05,而雙側(cè)為27.88±4.94,單側(cè)大于雙側(cè),且差異有統(tǒng)計(jì)學(xué)意義(P=0.014)。單側(cè)隱睪患者中5例(35.7%)、雙側(cè)已婚者中有6例(75%)性功能異常,部分患者同時(shí)存在性欲、勃起或射精功能中的兩或三項(xiàng)異常,且這些雙側(cè)隱睪性功能異常者亦合并精液異常。未婚者中,單側(cè)隱睪患者術(shù)后BSFI得分平均為4.42±1.22,雙側(cè)為3.43±0.95,兩組比較無(wú)顯著性差異(P=0.065)。單側(cè)隱睪性欲障礙者有5例(26.3%),而雙側(cè)亦有5例(62.5%)。 5、查體單側(cè)隱睪患者第二性征無(wú)明顯異常,有4例睪丸位于陰囊上極,5例患側(cè)隱睪觸診較健側(cè)軟,1例未觸及睪丸(術(shù)后睪丸萎縮)。而雙側(cè)隱睪中4例少弱精或無(wú)精癥患者第二性征發(fā)育欠佳,表現(xiàn)為喉結(jié)發(fā)育差,陰毛少,陰莖小,睪丸小、聲音似女性；觸診睪丸較軟。 結(jié)論： 1、單側(cè)隱睪患者的生育率大于雙側(cè),單側(cè)隱睪無(wú)論術(shù)前睪丸位置如何及手術(shù)年齡大小,生育率仍接近正常人群。而雙側(cè)隱睪患者盡管早期接受了手術(shù),但生育率仍顯著低于單側(cè)及正常人群,且已婚生育者生育時(shí)間較單側(cè)長(zhǎng),即生育較單側(cè)困難。部分不育者通過(guò)藥物治療后可生育。 2、未婚單側(cè)隱睪患者精液正常率接近正常人群,而雙側(cè)隱睪術(shù)后精液質(zhì)量正常者則遠(yuǎn)少于單側(cè)；雙側(cè)腹腔內(nèi)型隱睪患者精液更易異常。未婚患者精液檢查異常者暫觀察,待結(jié)婚后再考慮是否需要治療。 3、單側(cè)隱睪的睪丸體積小于健側(cè)睪丸,在單雙側(cè)隱睪中腹腔內(nèi)隱睪睪丸體積均小于腹股溝及外環(huán)口組,而腹股溝管組小于外環(huán)口組,因此,術(shù)前睪丸位置越高,成年后睪丸體積越小,特別是腹腔內(nèi)型隱睪受影響更明顯。多數(shù)單側(cè)隱睪患者睪丸超聲顯示實(shí)質(zhì)回聲不均、血流信號(hào)少、質(zhì)地軟、易變形等,因此,雖然早期進(jìn)行了手術(shù),但術(shù)后隱睪睪丸發(fā)育仍較健側(cè)差。 4、部分雙側(cè)隱睪患者第二性征發(fā)育異常,特別是少弱精及無(wú)精癥患者,表現(xiàn)為無(wú)喉結(jié),陰毛少,陰莖短小,無(wú)胡須,聲音異常等。雖然部分單側(cè)隱睪患者患側(cè)陰囊發(fā)育較健側(cè)差,睪丸較健側(cè)小,觸診質(zhì)較軟,但第二性征無(wú)明顯異常。 5、雖然所有受訪者的性功能總體滿(mǎn)意度調(diào)查均為滿(mǎn)意或非常滿(mǎn)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異常,特別是雙側(cè)隱睪患者；單側(cè)隱睪已婚者性功能總體評(píng)分大于雙側(cè),而在未婚者中,單雙側(cè)隱睪患者性欲評(píng)分無(wú)顯著差別。
[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 鹵 3.05 and 27.88 鹵 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 .

【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2012
【分類(lèi)號(hào)】：R726.9

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