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隐睾研究最新进展Recent developments in cryptorchidism research转载2008-05-23

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  • 作者:cfl
  • 更新日期:2019-07-04 13:41
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【概述】【 Overview】 源于肾体内侧的性腺始基,妊娠6~7周时睾丸开始形成,4个月时逐渐成熟并随着苗勒氏管,自后腹膜延盆向下降,进入阴囊。隐睾症是睾丸在发育过程中未能按正常情况从腰部腹膜后下降到达阴囊底部,中途停滞在腹腔内、腹股沟区、阴囊入口或

   【概述】【 Overview】

  源于肾体内侧的性腺始基,妊娠6~7周时睾丸开始形成,4个月时逐渐成熟并随着苗勒氏管,自后腹膜延盆向下降,进入阴囊。隐睾症是睾丸在发育过程中未能按正常情况从腰部腹膜后下降到达阴囊底部,中途停滞在腹腔内、腹股沟区、阴囊入口或其他部位。

  The gonadal origin originating from the inside of the kidney, the testicle begins to form at 6 to 7 weeks of pregnancy, matures gradually at 4 months, and with the Miaoleshi tube, descends from the posterior peritoneum to the scrotum. Cryptorchidism is the failure of the testis to descend from the peritoneum of the waist to the bottom of the scrotum during normal development, and to stagnate in the abdominal cavity, the peritoneal groove, the scrotum entrance, or other parts.

  隐睾症不同程度的影响睾丸的发育和生精,可导致少精,弱精甚至无精。Y染色体上有睾丸形成的基因。内分泌、遗传及机械因素可影响睾丸的正常下降。The different degrees of cryptorchidism affect the development and spermatogenesis of the testis, which can lead to less spermatorrhea, weak spermatorrhea, and even no spermatorrhea. There is a gene for testicular formation on the Y chromosome. Endocrine, genetic and mechanical factors can affect the normal decline of testis.

  【诊断】

  【 Diagnosis】

  如果隐睾位于腹股沟管内及腹内高位或者睾丸缺如,临床检查常常摸不到睾丸。临床体检摸不到的隐睾约占全部隐睾的20%。对于这些病人常常先作HCG刺激试验,即注射HCG1500IU,隔日1次,共3次,注射前后检查血清中睾丸酮水平,如果注射后血清睾丸酮水平升高,表示有功能性睾丸组织存在,如果注射后血清睾丸酮水平不变,常表示没有功能性睾丸组织存在。

  If the cryptorchidism is located in the inguinal tube and high in the abdomen or the testis are absent, the testicle is often not touched in clinical examinations. The cryptorchidism that can not be touched by clinical examination accounts for about 20 of all cryptorchidism. For these patients, HCG stimulus tests are often performed first, IE, HCG1500 IU is injected once every other day, for a total of 3 times. The level of testosterone in the serum is checked before and after injection. If the level of testosterone in the serum increases after injection, functional testicular tissue is present. If the level of testosterone in the serum remains unchanged after injection, it is often indicated that there is no functional testicular tissue.

  对于临床摸不到的隐睾,B型超声波检查是目前最常用的方法,这种检查无损伤且可以同时检查病人有无肾积水、畸形、结石等泌尿系统病变,对于腹股沟管内的隐睾有相当高的诊断率,但对于腹内隐睾的诊断率还不够高。选择性精索内静脉造影是一个曾经广泛采用的方法,可从造影剂注入后的精索内静脉末端形态来诊断隐睾的位置或者睾丸缺如,但常常由于静脉瓣影响了精索内静脉显影,而且对2岁以下的儿童操作很困难。电子计算机断层扫描(CTScan)和核磁共振(MRI)近年来也用于腹内隐睾的定位诊断,均有相当高的准确性,Wolverson报告20例病人作CT检查,准确率达96%;Fritzche报告12例病人共15个隐睾经MRI证实14个隐睾,1例高位误诊。这二种检查的缺点是在年幼的儿童检查比较困难而且费用很高。

  For clinically inaccessible cryptorchidism, type B ultrasound is the most commonly used method at present. This type of examination is non-invasive and can simultaneously examine patients for urinary system lesions such as hydronephrosis, malformations, and stones. There is a fairly high diagnostic rate of cryptorchidism in the inguinal tube. However, the diagnosis rate of cryptorchidism is not high enough. Selective spermatography is a method that has been widely used to diagnose the position of the cryptorchidism or the absence of the testis from the end morphology of the spermatic vein after injection of contrast agents, but it is often affected by the venous valve. Internal vein development, It is also difficult to operate children under the age of 2. Computerized tomography(CTScan) and magnetic resonance(MRI) have also been used for positioning diagnosis of abdominal cryptorchidism in recent years. Both have a high degree of accuracy. Wolverson reported 20 patients for CT examination with an accuracy rate of 96. Fritzche reported a total of 15 cryptorchidism in 12 patients confirmed 14 cryptorchidism by MRI, and 1 was misdiagnosed at a high level. The disadvantage of these two types of examination is that it is difficult and expensive to check in young children.

  腹腔镜近年来已广泛的用于腹内隐睾的诊断和治疗。腹腔镜应用范围广泛,可用于各种年龄的病人及1岁以下儿童,操作方法简单而且时间短,诊断率可达88%至100%,可以确定隐睾的位置或者睾丸缺如。在腹腔镜检查中常可先在腹膜后沿睾丸血管解剖位置找睾丸血管,沿精索血管可找到位于腹内或者腹股沟内环处睾丸,如果沿血管见到血管盲端可以确定是睾丸缺如,如果盲端有结节应切除并送病理检查。Diamond总结在腹腔镜检查临床摸不到的隐睾有三种结果:①在腹股沟内环以上看到精索血管和输精管盲端,缺乏睾丸;②正常精索进入腹股沟管内环;③腹内睾丸。后者均需作手术探查。如果检查中只看到输精管进入腹股沟管而没有看到精索血管也应作剖腹探查。检查中如果观察到高位腹内隐睾及很长的输精管,可作分期睾丸固定术第一期手术,即分离、钳夹并切断精索血管,留待以后作第二期睾丸固定术。如果术中发现睾丸发育不正常宜于作分期睾丸固定术,应经腹腔镜作睾丸切除术。

  Laparoscopy has been widely used in the diagnosis and treatment of abdominal cryptorchidism in recent years. Laparoscopic applications are widely available for patients of all ages and children under 1 year of age. The operation method is simple and the time is short. The diagnostic rate can reach 88 to 100 <UNK>, and the location of the cryptorchidism or the lack of testicles can be determined. In the laparoscopic examination, Changke first looked for testicular blood vessels along the posterior peritoneum along the testicular vascular anatomical position, and along the spermatoidal vessels, the testis can be found in the abdominal or inguinal inner ring. If the vascular blind end is seen along the blood vessels, it can be determined that the testis are absent. If there are nodules at the blind end, they should be removed and sent for pathological examination. Diamond concluded that there are three results of cryptorchidism that can not be touched clinically by laparoscopic examination: 1 See spermatocele and spermatocele blind ends above the groin inner ring, lack of testicles; 2 Normal spermatic cord enters the inner ring of the groin tube; The testicles in the abdomen. The latter requires surgical exploration. If you see only the vasculature entering the groin tube and not the vasculature, you should also explore the Caesarean section. If the upper abdominal cryptorchidism and a long vasectomy are observed during the examination, the first phase of testicular fixation can be performed in stages, that is, separating, clamping and cutting the spermatocele vessels, leaving for the second period of testicular fixation. If abnormal testicular development is found during surgery, it is appropriate to perform staging testicular fixation. Laparoscopic testicectomy should be performed.

  【治疗措施】[treatment measures]

  隐睾的治疗是使处于不正常位置的睾丸至正常位置。隐睾的治疗主要是基于以下几个主要理由:①由于隐睾处于不正常的位置损害了睾丸的正常生精能力,睾丸下降后可以增加生精;②由于隐睾的恶性变发生率较高,应将睾丸置入阴囊以便早期发现病变;③解除儿童及家长的心理压力因素。隐睾的治疗时间是2岁以内,治疗的主要方法有激素治疗和睾丸固定术。

  The treatment of cryptorchidism is to put the testicles in an abnormal position to normal position. The treatment of the cryptorchidism is mainly based on the following main reasons: 1. Since the abnormal position of the cryptorchidism impairs the normal spermatogenic ability of the testis, the testis can be increased after dropping; Because of the higher incidence of malignant changes in the cryptorchidism, the testicles should be placed in the scrotum for early detection of lesions; 3 relieves the psychological pressure factors of children and parents. The treatment time of cryptorchidism is less than 2 years old. The main methods of treatment are hormone therapy and testicular fixation.

  激素治疗是指使用促性激素或者促性激素释放激素来调整下丘脑——垂体——睾丸内分泌轴而促使隐睾下降。HCG(促性腺激素,Human Chorionic Gonadotropin)治疗,HCG的治疗方法是指使用3000IU至40000IU注射量,在数天至数周时间内注射,目前常用的是:1至6岁使用HCG250IU,每周2次共5周;1至6岁使用500IU,每周2次共5周;6岁以后使用100IU,每周2次共5周的治疗方案。隐睾的下降率对双侧隐睾在30%~50%左右,而对单侧隐睾在15%~30%左右。下丘脑促性腺激素释放激素(GnRH,Gonadotropin Releasing Hormone)或者LHRH,(Luteinizing Hormone Releasing Hormone)是近年来应用较多的治疗激素,常采用鼻腔喷雾吸入法,每次每侧鼻腔为200μg,每日3次共四周,成功率在10%~60%的范围内。Rajfer认为成功率差别很大是由于有些作者将可回缩的隐睾计算在内,这种隐睾激素治疗的成功率很高。

  Hormone therapy refers to the use of sex stimulating hormone or sex promoting hormone release hormone to adjust the hypothalamus-pituitary-testicular endocrine axis and promote the decline of the cryptorchidism. HCG(Human Chorionic Gonadotropin) treatment, HCG's treatment method refers to the use of 3000 IU to 40,000 IU injections, injected in a few days to several weeks, currently commonly used is: 1 to 6 years old Use HCG250 IU twice a week for 5 weeks; Use 500 IU from 1 to 6 years old, 2 times a week for 5 weeks; After the age of 6, 100 IUs are used for a total of 5 weeks of treatment twice a week. The rate of decline of the cryptorchidism is about 30 to 50 in the bilateral cryptorchidism, and about 15 to 30 in the unilateral cryptorchidism. The hypothalamus gonadotropin hormone release hormone(GnRH) or LHRH(LHRH) is a treatment hormone used in recent years. The nasal spray inhalation method is often used. Each time it is 200 μg per side, 3 times per day, 4 weeks, 4 weeks The success rate is within the range of 10 to 60 <UNK>. Rajfer believes that the great difference in success rate is due to the fact that some authors count retractable cryptorchidism, and the success rate of this cryptorchioid hormone treatment is high.

  睾丸固定术是隐睾的主要治疗疗法,在手术治疗的同时还可以治疗合并的腹股沟疝,手术治疗的原则是采用适当的下腹部切口,手术中充分游离精索,修补疝囊及固定睾丸于阴囊中,标准的睾丸固定是作腹股沟斜切口,修补疝囊并游离睾丸及精索,再将睾丸置入阴囊中并固定,术中注意固定睾丸后精索无张力,保证睾丸血运。

  Testicular fixation is the main treatment of cryptorchidism. It can also be used to treat combined inguinal hernia. The principle of surgical treatment is to use appropriate lower abdominal incision, free spermatotomy during surgery, repair of hernia sac and fixation of testis. In the scrotum, The standard testicular fixation is to make a groin oblique incision, repair the hernia sac and free the testicle and spermatorrhea, and then place the testicle in the scrotum and fix it. During the operation, pay attention to fixing the testicle without tension and ensuring the blood flow of the testicle.

  部分腹内高位隐睾病人输精管较长且弯曲在腹股沟管中,可作切断精索血管、下移睾丸的手术(Fowler-Stephen手术),亦可作分期手术,即第一期切断精索血管,第二期移下睾丸。

  Some patients with high epiglottis have long vasculature and are bent in the groin tube. They can be used to cut the spermatocele and move the testis(Fowler-Stephen surgery). They can also perform staged surgery, that is, the first phase. Cut the spermatocele and remove the testis in the second phase.

  少数病人则因高位腹内隐睾需作睾丸自体移植手术,即切断精索血管,将精索内动脉和静脉与腹壁下深动脉和静脉吻合及置睾丸于阴囊中,这种手术方法需要显微外科技术。

  A small number of patients require autologous testicular transplantation due to high abdominal cryptorchidism, that is, cutting off spermatocele vessels, anastomosis of spermatic arteries and veins with subabdominal deep arteries and veins, and placing testis in the scrotum. Need microsurgical techniques.

  单侧和双侧隐睾经手术治疗后,特别是早期手术治疗后均有助于改进精原细胞的发育,增加精原细胞的数量及青春期后的生精。Lipshulty在一组单侧隐睾病人手术治疗随访中报告,青春期前手术者在青春期后62%有生育能力,未手术者仅有46%的生育能力。

  After unilateral and bilateral cryptorchidism surgery, especially after early surgery, it will help to improve the development of spermatocytes, increase the number of spermatocytes and post-puberty spermatogenesis. Lipshulty reported during the follow-up of surgical treatment of a group of patients with unilateral cryptorchidism that pre-adolescent surgeons had fertility after puberty, and non-surgical patients had only 46 fertility.

  手术治疗时间与青春期后生育也有密切关系。Ludwing报道一组病人,1~2岁之间手术者成年以后87.7%,有正常生育能力,3~4岁之间手术者57.1%有正常生育能力。

  Surgical treatment time is also closely related to post-adolescent fertility. Ludwing reported that a group of patients, between the ages of 1 and 2, had 87.7 after adulthood and had normal fertility. Between the ages of 3 and 4, the surgeon had normal fertility.

  【病因学】[Etiology]

  在胚胎发育过程中睾丸的正常下降过程受到内分泌激素和物理机械因素的影响。睾丸下降分为二个阶段,第一阶段包括胚胎期分化、睾丸形成及从泌尿生殖嵴移到腹股沟,第二阶段即睾丸从腹股沟移至阴囊中,第二阶段主要是由激素控制。影响睾丸下降的物理机械因素有:①睾丸系带有提睾肌的牵引作用。②腹内压力推压睾丸理降至阴囊中。③正常的附睾发育也是睾丸下降的因素。内分泌因素主要是指影响睾丸下降的分泌轴即下丘脑——垂体——睾丸轴异常而产生隐睾,此外睾丸支持细胞所分泌的苗勒氏管抑制物(MIS)及男性激素睾丸酮、双氢睾丸酮也影响睾丸下降,在Kallmann综合征的病人缺乏下丘脑促性腺激素释放激素GnRH(Gonadotropin Releasing Hormone)常发生隐睾。Gendel发出隐睾病人的LH(Luteinizing Hormone)血清水平低于正常人。Walsh等症实有5d-脱氢酶缺乏的病人睾丸酮不能有效地转化为双氢睾丸酮,也足以影响睾丸下降而产生隐睾。总之睾丸下降是一个非常复杂的胚胎发育过程,受到内分泌、遗传及物理机械因素的影响,这些综合因素的异常均可以引起隐睾的发生。

  The normal descending process of testicle during embryonic development is influenced by endocrine hormones and physical mechanical factors. The testicular decline is divided into two stages. The first stage includes embryonic differentiation, testicular formation and movement from the urogenital crest to the groin. The second stage is the movement of the testicle from the groin to the scrotum. The second stage is mainly controlled by hormones. The physical and mechanical factors that affect testicular decline are: 1. The testicular system has the pull effect of lifting the testosterone muscle. 2 Intraabdominal pressure pushes the testosterone down to the scrotum. Normal epididymis development is also a factor in testicular decline. Endocrine factors mainly refer to the abnormal hypothalamus-pituitary-testicular axis that affects the decline of the testis, and the production of cryptorchidism. In addition, the Miaoleshi inhibition(MIS) and the male hormone testosterone secreted by testicular support cells and dihydrotestosterone also affect testicular decline. Patients with Kallmann syndrome lack the hypothalamus gonadotropin releasing hormone GnRH(Gonadotropin Relaxing Horbone) and often have cryptorchidism. The serum level of LH(Luteining Horizon) in Gendel's cryptorchidism patients was lower than that of normal humans. Walsh et al. have patients with 5d-dehydrogenase deficiency whose testosterone can not be effectively converted to dihydrotestosterone, and is also sufficient to affect testicular decline and produce cryptorchidism. In short, testicular decline is a very complex embryonic development process. It is affected by endocrine, genetic, and physical mechanical factors. The abnormalities of these combined factors can cause the occurrence of cryptorchidism.

  【病理改变】[Pathological changes]

  隐睾的异常位置停留时间较长,所居位置越高,睾丸的损害越大,在1.5~2岁以后睾丸的组织学改变主要有曲细精管变小,生精少,小管周围组织增强(Cooper,Mengel)。间质细胞增加或减少而支持细胞增加。Hadyiselimovic等在对隐睾作了电子显微镜研究之后发现隐睾病人的睾丸变化包括:①细胞内线粒体破坏;②细胞浆和内质网中缺乏核糖体;③精细胞和支持细胞中胶原纤维增加。而且如果是单侧隐睾,对侧正常下降至阴囊的睾丸可能也有病理性改变。

  The abnormal position of the cryptorchidism is longer, and the higher the location, the greater the damage to the testis. After 1.5 to 2 years of age, the histological changes of the testis mainly include smaller fine spermatozies, less spermatorrhea, and enhanced tissue around the tubules(Cooper, Mendel). Interstitial cells increase or decrease while supporting cell growth. Hadyiselimovic et al. found that testicular changes in patients with cryptorchidism after electron microscopy studies included: 1. intracellular mitochondrial destruction; 2 There is a lack of ribosomes in cytoplasm and endoplasmic Reticulum; There is an increase in collagen in spermatocytes and support cells. And if it is a unilateral cryptorchidism, there may also be pathological changes in the testis that normally descend to the scrotum on the opposite side.

  【流行病学】【 Epidemiology】

  隐睾的发病率是0.7%~0.8%(Cour Palais Scorer)。发病率与胎儿的发育有直接的关系,在不成熟的胚儿发生率可达30%左右,在成熟足月胎儿出生时是3.4%,而至1岁时是0.7%~0.8%。

  The incidence of cryptorchidism is 0.7 <UNK> -0.8 <UNK>(Cour Palais Scorer). The incidence rate is directly related to the development of the fetus. The incidence rate of immature embryos can reach about 30 <UNK>, 3.4 <UNK> at the birth of a mature fullmoon fetus, and 0.7 <UNK> -0.8 <UNK> at the age of 1.

  【临床表现】【 Clinical performance】

  隐睾的分类:Classification of cryptorchidism:

  隐睾的分类方法从发病原因、隐睾的位置和隐睾的性质有没的分类方法。The classification method of cryptorchidism has a classification method from the cause of morbidity, the location of cryptorchidism, and the nature of cryptorchichidism.

  King根据隐睾发生的原因作如下分类:King classifies the causes of cryptorchidism as follows:

  (1)末端器官发育不良,睾丸小于正常并有少量生殖细胞,常伴有异常管道结构。(1) The terminal organ is stunted, the testicle is smaller than normal and has a small number of germ cells, often accompanied by abnormal duct structure.

  (2)异位睾丸,睾丸下降通过腹股沟管但是降入阴囊以外的位置。(2) Heterotopic testis, which descend through the groin tube but fall outside the scrotum.

  (3)异常促性腺激素刺激,包括内分泌异常综合征可产生隐睾。(3) Abnormal gonadotropin stimulation, including endocrine abnormal syndrome, can produce cryptorchidism.

  (4)机械因素(如腹股沟管闭锁)。(4) Mechanical factors(such as inguinal tube locking).

  (5)腹内压力异常(如Prune Belly综合征),睾丸不下降。(5) Abnormal abdominal pressure(such as Prune Bell syndrome), the testicles do not drop.

  Hinman及Hopp也提出其他的分类方法。Hinman and Hopp also proposed other classification methods.

  一般认为,如下的分类方法在临床上更为实用:It is generally believed that the following classification methods are more clinically practical:

  (1)可回缩的睾丸。

  (1) Retractable testicles.

  (2)真性隐睾:(2) True cryptorchidism:

  ①腹内高位隐睾;1 High cryptorchidism in the abdomen;

  ②腹股沟隐睾;2 groin cryptorchidism;

  ③阴囊高位隐睾;3 scrotum high cryptorchidism;

  ④滑动性隐睾。4 Sliding cryptorchidism.

  (3)异位睾丸。(3) Ectopic testis.

  (4)无睾畸形(单侧、双侧无睾畸形)。(4) No testosterone deformity(unilateral, bilateral non-testosterone deformity).

  可回缩的睾丸是指睾丸提睾肌过于活动,睾丸可回缩至阴囊以上位置,但夜间休息及检查中用手可将睾丸置于阴囊中,这种病人在青春期以后睾丸位置、大小正常,生育力同正常人。异位睾丸指睾丸位于阴囊以外耻骨上方、大腿股部、会阴部、阴茎概根部及横位异位,应作手术纠正。无睾畸形多由妊娠期间子宫内精索扭转产生。

  The retractable testicle means that the testicular muscles are too active, and the testicle can be retracted to a position above the scrotum, but the testicle can be placed in the scrotum by the hand during night rest and examination. This patient has normal testicle position and size after puberty. Fertility is normal. Exotopic testosterone refers to the testis located above the pubic bone outside the scrotum, the thigh, the perineum, the base of the penis, and the lateral ectopic, and should be surgically corrected. The absence of testosterone deformities is mostly caused by the torsion of the uterine spermatic cord during pregnancy.

  隐睾伴有的异常:Abnormal with cryptorchidism:

  隐睾可以是一个单发的疾病,也可以伴有其他的泌尿生殖系统异常及伴有其他的内分泌疾病和遗传疾病。The cryptorchidism can be a single disease, or it can be accompanied by other abnormalities in the genitourinary system and other endocrine diseases and genetic diseases.

  Felton报告658例隐睾病人,2.5%伴有较大的泌尿系统异常,主要有单侧重复肾,肾异位,肾萎缩,肾积水,马蹄肾,输尿管重复畸形及肾盂、输尿管连接处狭窄。隐睾病人也可伴有尿道下裂和先天性后尿道瓣膜。

  Felton reported 658 cases of cryptorchidism, 2.5 cases with large urinary system abnormalities, mainly unilateral repeated kidney, renal ectopic, renal atrophy, hydronephrosis, horseshoe kidney, ureteral recurrent deformity, and renal pelvis, ureteral joint stenosis. Patients with cryptorchidism can also be accompanied by hypospadias and congenital posterior urethral valves.

  隐睾常伴有输精管和附睾畸形(Marshall)。Windholtz描叙了四种睾丸和附睾的异常:①先天性睾畸形伴有附睾和输精管下降;②隐睾伴有下降的附睾和输精管;睾丸和附睾分离;③输精管、睾丸及附睾均在阴囊中,呈分离状;④睾丸与附睾相连,但管道分离。Scorer指出附睾可能变长,部分或者完全闭锁,也可能完全与睾丸分离。在妊娠期间使用乙烯雌酚(DES)的妇女在妊娠时可以产生隐睾和附睾缺如。隐睾和输精管缺如还常发生于囊性纤维化的病人。

  The cryptorchidism is often accompanied by vasectomy and Marshall. Windholtz described four types of abnormal testis and epididymis: 1 Congenital testosterone with epididymis and vasectomy; The cryptorchidism is accompanied by descending epididymis and vasculature; Separation of testis and epididymis; 3 vasectomy, testis and epididymis are all in the scrotum, showing a separation; 4 The testicles are connected to the epididymis, but the pipes are separated. Scorer pointed out that the epididymis may become longer, partially or completely locked, and may also be completely separated from the testis. Women who use ethylene estrogen(DES) during pregnancy can develop cryptorchidism and epididymis during pregnancy. Cryptorchidism and vasectomy are also common in patients with cystic fibrosis.

  常染色体和性染色体的异常均可引起隐睾的发生。常见的伴有隐睾发生的遗传内分泌综合征有:Abnormalities of autosomes and sex chromosomes can cause the occurrence of cryptorchidism. The common genetic endocrine syndrome with cryptorchidism is:

  (1)Kallmann综合征:是X一链隐性遗传疾病,促性腺激素分泌激素低下,性功能低下,常伴有隐睾。

  (1) Kallmann syndrome: It is an X-chain recessive genetic disease with low gonadotropin secretion hormone and low sexual function, often accompanied by cryptorchidism.

  (2)Klinefelter综合征(小睾丸综合征):病人表现无睾症体型,男性乳腺发育,隐睾且睾丸小而质地硬,睾丸曲精管透明样变和纤维化,不能生精。

  (2) Efelter's syndrome(small testicular syndrome): The patient shows no testosterone, male breast development, small and hard testis, transparent changes and fibrosis of testicular spermatorrhea, and no sperm production.

  (3)Noonan综合征(男性Turner氏综合征):病人常有面部异常,心血管异常,泌尿系统异常和隐睾(70%)。

  (3) Noonan syndrome(male Turner's syndrome): Patients often have facial abnormalities, cardiovascular abnormalities, urinary system abnormalities, and cryptorchidism(70 <UNK>).

  (4)其他还有Prader-Willi综合征、Down综合征、Aarkog综合征等其他遗传、内分泌综合征常常伴有隐睾的发生。

  (4) Other genetic and endocrine syndromes such as Prader-Williams syndrome, Down syndrome, Aarkogs syndrome, etc. are often accompanied by cryptorchidism.

  真性和假性二性畸形的病人往往有复杂的遗传和内分泌异常,如病人伴有隐睾,须先做详细的遗传和内分泌学检查,再作进一步治疗。

  Patients with true and pseudo dimorphism often have complex genetic and endocrine abnormalities. If the patient is accompanied by a cryptorchidism, detailed genetic and endocrine examinations must be performed before further treatment.

  【并发症】[Complications]

  隐睾的并发症:Complications of cryptorchidism:

  隐睾与不孕症。隐睾由于组织病理学的改变,没有正常的生精功能,隐睾的位置越高,在阴囊以上的位置时间越长,睾丸曲细精管的损害越大。Mengel经用普通显微镜和电子显微镜观察,隐睾病人睾丸在2岁以前就有曲细精管和间质细胞的病理学改变及明显的生精损害。Hecker检查正常成人及单侧隐睾病人经睾丸固定术以后的精子浓度,前者明显高于后者,表明单侧隐睾病人有双侧隐睾损害。双侧隐睾病人未经治疗,不孕症可达100%,如早期治疗生生育力可达40%。而单侧隐睾早期治疗后生育力可达60%。病人在2岁以前进行治疗有助于改进精原细胞的发育,增加精原细胞数量及以后的生精。单侧和双侧隐睾病人尽管早期治疗,成年以后生精能力仍低于正常。

  Cryptorchidism and infertility. Due to changes in Histopathology, the cryptorchidism has no normal spermatogenic function. The higher the position of the cryptorchidism, the longer the position above the scrotum, and the greater the damage to the testicular fine spermatorrhea. Mengel observed with ordinary microscopes and electron microscopes, the testis of cryptorchidism patients had pathological changes in the fine spermatogonia and stromal cells and obvious spermatogenic damage before the age of 2. Hecker examined the sperm concentration of normal adults and patients with unilateral cryptorchidism after testicular fixation. The former was significantly higher than the latter, indicating that patients with unilateral cryptorchidism had bilateral cryptorchidism. Patients with bilateral cryptorchidism are not treated, and infertility can reach 100 <UNK>, such as early treatment of reproductive fertility up to 40 <UNK>. After the early treatment of the unilateral cryptorchidism, the fertility can reach 60 <UNK>. Treatment of patients before the age of 2 can help improve the development of spermatocytes, increase the number of spermatocytes and subsequent spermatozoa. In patients with unilateral and bilateral cryptorchidism, the spermatogenic ability in adult patients is still lower than normal despite early treatment.

  隐睾与睾丸扭转,由于隐睾病人睾丸与系带之间常有发育异常,故易发生睾丸扭转。进入青春期后由于睾丸体积增大发生机会更多。Rigter报告64%的成人隐睾扭转是由于睾丸发生恶性变,以至睾丸重量及睾丸重力轴改变而发生。治疗原则是睾丸固定术或者需要时做睾丸切除术。

  The testicular torsion is easy to occur because of abnormal development between the testicle and the tether in patients with cryptorchidism. After entering puberty, there is a greater chance of occurrence due to increased testicular volume. Rigter reported that 64 adult cryptorchidism torsion occurred due to malignant changes in the testis, as well as changes in the weight of the testis and the gravitational axis of the testis. The principle of treatment is testicular fixation or testicectomy when needed.

  隐睾与恶性变:Cryptorchidism and Malignant Change:

  隐睾病人在青春期后有很高的恶性变发生率。隐睾发生恶性变的发生率是正常人的25至48倍(Whiter及Welvar)大约10%的睾丸肿瘤发生于隐睾。由于隐睾的组织学异常,所以早期手术并不能防止隐睾发生恶性变,而单侧隐睾的病人,对侧已降至阴囊正常位置的睾丸组织学亦有异常,所以亦有较高的恶性变发生率。Johnson在单侧隐睾恶性变的病人中发现有五分之一的恶性变发生在非隐睾一侧睾丸中,而双侧隐睾的病人,如果一侧发生恶性变,另侧睾丸有15%的机会也发生恶性变。

  Patients with cryptorchidism have a high rate of malignant changes after puberty. The incidence of malignant changes in the cryptorchidism is 25 to 48 times that of normal people(White and Welvar). About 10 testicular tumors occur in the cryptorchidism. Due to histological abnormalities in the cryptorchidism, early surgery did not prevent malignant changes in the cryptorchidism, and patients with unilateral cryptorchidism also had abnormalities in the testicular histology of the opposite side that had fallen to the normal position of the scrotum, so there was also a high rate of malignant changes. rate. Johnson found that one-fifth of the malignant changes in patients with unilateral cryptorchidism occurred in the testis on the side of the non-cryptorchidism, while patients with bilateral cryptorchidism had a malignant change on one side and 15 on the other side of the testis. The chance of malignant change.

  隐睾的位置与恶性变有明显的关系,腹内隐睾恶性变发生率四倍于腹股沟隐睾,而双侧腹内隐睾,如一侧发生恶性变,另一侧睾丸有30%的机会亦发生恶性变。

  The position of the cryptorchidism has a clear relationship with malignant changes. The incidence of malignant changes in the abdominal cryptorchidism is four times that of the inguinal cryptorchidism, while the bilateral abdominal cryptorchidism, such as malignant changes on one side, has 30 opportunities on the other side of the testicle. Malignant change.

  Skakkebaek在隐睾病人活检中发现原位癌引起了对隐睾恶性变的新认识,其发生率在30%。

  Skakkebaek found in the biopsy of patients with cryptorchidism that in situ cancer caused a new understanding of malignant changes in cryptorchidism, with a incidence of 30 degrees.

  总之,为了观察隐睾的变化及早期发现恶性变,应早期施行睾丸固定术,特别是腹内隐睾应早期移入阴囊,如不能移入阴囊中应做睾丸切除术。隐睾发生恶性变后,多为精原细胞瘤,应及时做睾丸根治性切除术及后腹膜区放射治疗。

  In short, in order to observe the changes of the cryptorchidism and the early detection of malignant changes, testicular fixation should be performed early, especially in the abdominal cryptorchidism should be moved into the scrotum early, such as testicular resection that can not be moved into the scrotum. After the malignant change of cryptorchidism, it is mostly spermatoblastoma, and it should be done in time for testicular radical resection and posterior peritoneal radiotherapy.

  睾丸固定术(睾丸牵引术)Testicular fixation(testicular traction)

  手术方法 :手术常规采用腹股沟韧带上方斜切口。若手术前已明确是高位隐睾,可选择下腹正中切口或腹直肌切口。并发腹股沟斜疝者将疝囊分离后高位结扎。切断睾丸引带,充分游离精索,使其长度能达到阴囊底部无张力为好。用4号丝线“8”字缝合睾丸底部(不打结),以备牵引。用手指沿切口下方在腹壁深筋膜的深面向阴囊分离直达阴囊最低处,并在阴囊壁上作一切口,在阴囊皮肤与肉膜之间分离出一间隙形成一肉膜外的囊袋。切开肉膜后将已充分游离的睾丸利用睾丸牵引线经此间隙及阴囊切口拉出于切口之外,用丝线间断缝合肉膜的切口至仅容精索自由通过,将睾丸置入阴囊内肉膜外之囊袋中,并将睾丸白膜与肉膜间断缝合,睾丸白膜牵引线自阴囊切口旁用缝针引出,然后缝合阴囊切口。睾丸即位于阴囊内。阴囊内可置橡皮条引流,24h后拔出。睾丸牵引线与橡皮条连接(橡皮条可用乳胶手套手臂圈代替),并用宽胶布固定于大腿内侧,保持适当张力,2周后抽出牵引线。

  Method of operation: The upper oblique incision of the inguinal ligament is used in routine operation. If it is clearly a high cryptorchidism before surgery, you can choose the lower abdominal middle incision or rectus abdominis incision. High ligation of hernia sac after separation in patients with inguinal hernia. Cut off the testicle lead, fully free spermatorrhea, so that its length can reach the bottom of the scrotum without Zhangliwei. Sew the bottom of the testicle(not knotted) with the "8" word of the 4th wire to prepare for traction. Use your fingers to separate the lower part of the scrotum along the deep side of the abdominal wall fascia below the incision to the lowest part of the scrotum, and make all the mouth on the scrotum wall to separate a gap between the scrotum skin and the flesh membrane to form an outer capsule. bag. After cutting the flesh membrane, the fully free testicle is pulled out of the incision using testicular traction lines through this gap and scrotum incision. The incision of the flesh membrane is sutured with filaments until only the spermatorrhea is allowed to pass freely, and the testicle is placed in the scrotum. In the capsule outside the flesh membrane, The testicular white membrane and the flesh membrane were sutured intermittently. The testicular white membrane traction line was drawn by a suture needle next to the scrotum incision and then the scrotum incision was sutured. The testicles are located in the scrotum. The scrotum can be placed in a rubber strip and pulled out after 24h. The testicular traction line is connected to the rubber strip(the rubber strap can be replaced by a latex glove arm ring) and is fixed to the inside of the thigh with a wide tape to maintain proper tension. After 2 weeks, the traction line is drawn.

  睾丸固定应强调,充分松解精索、不损伤精索血管、保护好睾丸血供,在无张力的条件下固定睾丸,只有这样才能避免术后睾丸萎缩。我们在常规睾丸固定的基础上,用4号丝线“8”字缝合睾丸底部白膜牵引固定于大腿内侧,保持适当张力,根据张力情况及时调整,2周后再抽出牵引线,增强了睾丸固定的效果,有效防止了睾丸回缩,有利于精索进一步延长,尤其适用于精索相对较短的患者,与利用阴囊切口固定于大腿内侧手术相比,手术创伤小,术后恢复快,避免了第2次手术,减轻了经济负担。

  The testicular fixation should be emphasized, fully loosen the spermatic cord, do not damage the spermatic vessels, protect the testicular blood supply, and fix the testicle under no tension conditions. Only in this way can the testicular atrophy be avoided after surgery. On the basis of conventional testicular fixation, we use the 4th wire "8" word to suture the white film traction at the bottom of the testicle and fix it to the inside of the thigh, maintain appropriate tension, adjust it in time according to the tension situation, and pull out the traction line after 2 weeks to enhance the testicle. Fixed effect, Effective prevention of testicular retraction, conducive to the further extension of spermatic cord, especially for patients with relatively short spermatic cord, compared with the use of scrotal incision fixed to the inner thigh surgery, the surgery trauma is small, postoperative recovery is rapid, and the second operation is avoided. Reduce the economic burden.

  腹腔镜联合小切口肉膜囊睾丸固定术加精索固定术治疗高位隐睾

  Laparoscopy combined with small incision granulocyte testicular fixation plus spermatotomy for the treatment of high cryptorchidism

  是最先进的技术,出血少,恢复快,固定牢靠。

  Is the most advanced technology, less bleeding, quick recovery, secure.

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