本文選題：血精 + 射精管梗阻�。� 參考：《第三軍醫(yī)大學(xué)》2017年碩士論文

【摘要】：背景精液中混有血液謂之血精,占到泌尿生殖系統(tǒng)癥狀的1%。由于絕大多數(shù)患者的血精癥狀表現(xiàn)為良性、自限性狀態(tài),因此,一般僅需予以心理安慰、等待觀察或藥物保守治療。但是部分患者的血精癥狀呈反復(fù)發(fā)作,遷延不愈,成為頑固性血精,這給其造成巨大的心理負(fù)擔(dān)和顧慮。部分頑固性血精患者,甚至伴有其他相關(guān)癥狀。有文獻(xiàn)顯示年齡40歲以上的頑固性血精患者,其血精可能是某種潛在惡性病變的首發(fā)癥狀。為此,對頑固性血精患者有必要進(jìn)行深入的檢查和治療。近年來興起的精道內(nèi)鏡技術(shù)在頑固性血精的診治方面已經(jīng)顯示出其獨(dú)特的優(yōu)勢,從根本上改善了頑固性血精及射精管梗阻(EDO)患者的治療效果。但該技術(shù)作為一種新型手術(shù)方式,臨床應(yīng)用尚不廣泛,其應(yīng)用的適應(yīng)證和禁忌證,臨床操作技巧和長期療效等尚處于不斷探索階段。因此,對頑固性血精患者進(jìn)行深入的影像學(xué)研究并利用精道內(nèi)鏡技術(shù)進(jìn)行病因診斷和針對性治療具有重要的理論意義和臨床應(yīng)用價值。目的:應(yīng)用MRI檢查對頑固性血精及伴發(fā)的EDO進(jìn)行影像學(xué)特征和病因?qū)W分析,并通過精道內(nèi)鏡技術(shù)對頑固性血精進(jìn)行病因診斷和相應(yīng)治療,分析引起頑固性血精的確切病因,探討精道內(nèi)鏡技術(shù)的操作技巧和中遠(yuǎn)期療效。材料和方法:回顧性分析自2009年1月至2016年12月期間就診于我院泌尿外科的頑固性血精患者臨床資料�；颊呷朐汉筮M(jìn)行各類實(shí)驗(yàn)室檢查,經(jīng)直腸B超(TRUS),盆腔MRI檢查及前列腺活檢等初步篩查,根據(jù)結(jié)果排除由于泌尿生殖系腫瘤,長期口服抗凝劑,嚴(yán)重肝功能損害所導(dǎo)致的血精患者,選擇血精病史超過6個月,且均經(jīng)規(guī)范保守性藥物治療1個月以上無效,并進(jìn)行了盆腔MRI檢查和精道內(nèi)鏡技術(shù)治療的患者共計(jì)287例,納入本項(xiàng)研究。本研究對血精患者的盆腔MRI檢查結(jié)果進(jìn)行分析,研究和探討頑固性血精的MRI影像學(xué)特征和引起血精的精道遠(yuǎn)端區(qū)域常見病變;結(jié)合術(shù)中精道內(nèi)鏡下所見,分析頑固性血精的臨床特征,總結(jié)精道內(nèi)鏡技術(shù)應(yīng)用的技巧及相關(guān)注意事項(xiàng),并隨訪觀察精道內(nèi)鏡技術(shù)治療頑固性血精的中遠(yuǎn)期療效和并發(fā)癥。結(jié)果:一、頑固性血精患者M(jìn)RI影像學(xué)特征改變:287例患者中,85.7%(246/287)的患者存在精囊內(nèi)信號強(qiáng)度異常,精囊囊性擴(kuò)張或增大,精道遠(yuǎn)端區(qū)域出現(xiàn)囊性占位等特征性改變。62.7%(180/287)的患者表現(xiàn)為精囊內(nèi)信號強(qiáng)度異常改變,其中27.2%(78/287)的患者其單側(cè)或雙側(cè)精囊在T1WI相上呈中至高信號,而在T2WI相上呈低信號,提示精囊內(nèi)為新鮮出血,35.5%(102/287)的患者單側(cè)或雙側(cè)精囊在T1WI、T2WI相上均呈現(xiàn)為中至高強(qiáng)度信號,提示精囊內(nèi)為陳舊性出血;35.9%(103/287)的患者表現(xiàn)為精道遠(yuǎn)端區(qū)域存在多種囊性占位性改變,其中24.7%(71/287)為前列腺小囊囊腫(Prostatic utricular cyst),大小(0.6×0.7)cm~(2.3×2.5)cm,6.3%(18/287)為苗勒管囊腫(Müllerian duct cyst),大小(3.4×4.0)cm~(8.8×11.5)cm,1.7%(5/287)為射精管囊腫(Ejaculatory duct cyst),3.1%(9/287)為精囊囊腫(Seminal vesicle cyst);在精道遠(yuǎn)端區(qū)域存在囊腫的35.9%(103/287)患者中,21.3%(61/287)伴有精囊或囊腫內(nèi)出血,其中15例為新鮮出血,46例為陳舊性出血;30.7%(88/287)的患者表現(xiàn)為精囊顯著擴(kuò)張或增大,腺體寬度≥1.7cm,腺管直徑5mm,該類患者的精囊寬度平均為(2.15±0.36)cm。14.3%(41/287)的患者其MRI檢查顯示精道遠(yuǎn)端區(qū)域均未見明顯信號強(qiáng)度和形態(tài)結(jié)構(gòu)改變,與正常的MRI影像學(xué)特征無明顯差異。二、頑固性血精的精道內(nèi)鏡診治情況:287例患者中,268例患者進(jìn)行了精道內(nèi)鏡觀察和治療,9例患者因存在射精管開口發(fā)育異�；螂p側(cè)精囊腺原發(fā)性或繼發(fā)性萎縮等未能成功進(jìn)鏡。10例患者顯示存在后尿道異常曲張血管或海綿狀血管瘤樣改變,進(jìn)行了血管瘤電切及電灼處理。其中71.6%(192/268)的患者采用經(jīng)前列腺小囊內(nèi)開窗進(jìn)鏡,10.4%(28/268)的患者采用前列腺小囊內(nèi)病理性開口進(jìn)鏡,16.8%(45/268)的患者采用了射精管遠(yuǎn)端切開進(jìn)鏡,1.1%(3/268)的患者采用了射精管自然開口逆行進(jìn)鏡。其中最常用的進(jìn)鏡方式為經(jīng)前列腺小囊內(nèi)開窗進(jìn)鏡。針對不同患者的情況采取的治療性操作有精道擴(kuò)張,囊腫去頂狀電切、囊壁燒灼,鈥激光碎石取石,套石籃取石,精囊沖洗等。手術(shù)操作時間20~70min,平均36min,失血量0~20ml,平均8ml,未見明顯術(shù)中并發(fā)癥發(fā)生。患者住院3~6天,平均4.5天。三、頑固性血精患者術(shù)后療效隨訪:253例患者成功隨訪,34例患者失訪,隨訪時間5~72個月。獲得隨訪的253例患者術(shù)后均未發(fā)生附睪炎、直腸損傷、逆行性射精、尿失禁等嚴(yán)重并發(fā)癥。所有成功進(jìn)行內(nèi)鏡治療的患者,其頑固性血精癥狀均在術(shù)后2~6周內(nèi)消失,92.5%(234/253)的患者隨訪期內(nèi)未再出現(xiàn)復(fù)發(fā)。僅7.5%(19/253)的患者于術(shù)后血精消失5~20個月后復(fù)發(fā),其中9例患者再次接受精道內(nèi)鏡處理,隨訪1~3個月后癥狀消失。10例年齡40歲以上患者性高潮快感強(qiáng)度有不同程度減弱。16例進(jìn)行射精管遠(yuǎn)端切開術(shù)后患者自述術(shù)后精液量較術(shù)前增多且變得稀薄。術(shù)前因血精伴婚后不育的19例患者術(shù)后精液質(zhì)量明顯改善,術(shù)后1~6月復(fù)查精液常規(guī)示精液量1.5~4.5ml,精子濃度21.5~63.0×106/ml,A+B級精子比例為27.4~66.7%,其中36.8%(7/19)的患者配偶于術(shù)后9~24個月自然懷孕。結(jié)論:精道遠(yuǎn)端區(qū)域炎癥和感染、各類囊性占位以及偶伴的精囊或前列腺小囊內(nèi)結(jié)石形成所導(dǎo)致的精道完全性或不完全性梗阻是引起頑固性血精的最主要病因。精道內(nèi)鏡技術(shù)既可對精道遠(yuǎn)端區(qū)域常見疾病進(jìn)行病因?qū)W診斷,又可在明確病因的基礎(chǔ)上行針對性治療。對于保守治療無效的頑固性血精及EDO患者,應(yīng)用精道內(nèi)鏡技術(shù)進(jìn)行診治,安全性好,療效理想,值得臨床上推廣應(yīng)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.
【學(xué)位授予單位】：第三軍醫(yī)大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R699.8

【參考文獻(xiàn)】

相關(guān)期刊論文 前9條

1 廖良功;李彥鋒;朱通;張勇;羅勇;李波軍;李珂;劉旭東;江軍;靳風(fēng)爍;;精道內(nèi)鏡技術(shù)診治頑固性血精216例臨床分析[J];臨床泌尿外科雜志;2017年01期

2 唐松喜;周輝良;丁一郎;;經(jīng)尿道精囊鏡技術(shù)治療頑固性血精與射精管梗阻性無精癥、少弱精癥的臨床效果[J];中華醫(yī)學(xué)雜志;2016年36期

3 廖良功;李彥鋒;;精道遠(yuǎn)端區(qū)域常見病變及精囊鏡診治技術(shù)的應(yīng)用[J];中華醫(yī)學(xué)雜志;2016年36期

4 王明松;周庭友;張勇;羅勇;李珂;黃灶明;劉旭東;孫中義;江軍;吳剛;李彥鋒;;精道遠(yuǎn)端區(qū)域應(yīng)用解剖及MRI影像特征研究[J];第三軍醫(yī)大學(xué)學(xué)報(bào);2015年23期

5 靳風(fēng)爍;李彥鋒;;血精及射精管梗阻的精囊鏡診治技術(shù)[J];臨床泌尿外科雜志;2015年01期

6 崔志強(qiáng);王永傳;都靖;周海軍;于志勇;高恩江;盧洪凱;;經(jīng)尿道精囊鏡聯(lián)合非那雄胺治療頑固性血精的療效觀察[J];中華男科學(xué)雜志;2014年06期

7 陸敏華;賀情情;張浩;肖恒軍;劉小彭;高新;張炎;;經(jīng)直腸超聲在精囊炎病程判定及治療策略選擇中的應(yīng)用[J];中華腔鏡泌尿外科雜志(電子版);2013年06期

8 李波軍;李珂;張超;張軍;張勇;周波;孫中義;靳風(fēng)爍;張克勤;李彥鋒;;頑固性血精患者M(jìn)RI影像特征研究[J];第三軍醫(yī)大學(xué)學(xué)報(bào);2013年17期

9 王韌;陳亞青;周永昌;黃慕民;張心如;;超聲引導(dǎo)下精囊穿刺置管治療頑固性血精[J];臨床泌尿外科雜志;2007年11期

，

本文編號：2030041