Y H p c T P . H 5 C h i M i n h * P h u B a n T a p 1 9 -^ S o 5 =^ 2015 j ^ g ^ i - ^ ^ ^ Y h p c
DANH GIA KET QUA DIEU TRI TINH HOAN AN KHONG SO THAY BANG PHAU THUAT NOI SOI 6 BUNG
Nguyen Thi Mai Thuy*, Trhi Dinh Phugng*
T O M T A T
^ Muc tieu: Ddnh gid vai tro cua ph&u thuqt ngi soi ti-ong chm dodn vd di'eu tii tinh hoa}t ffn khong sb thay d tre cnt.
Phucmg phdp nghien cm: Nghien ahi hoi deu 118 trubng hop dn linh hodn khong sb thay duqc pltdu thuqt ngi soi tqi benh vien Nhi Trung iTcmg tie thdng 1/2011 deh 12/2014. Kit qud phdu thuqt duvc ddnh gid toi thiiu sau 6 thdng bang tham khdm ldm sdng ud sieu dm ddnh gid vi ti-i vd kich thudc cua tinh hodn.
^ Ket qud: 98 benh nhan duqc phau thuat (118 tinli hodn ah khong sb tliay). 41/118 (34,7%) benli nhdn duqc phdu thudt ben phdi, 37/118 (31.4%) benh nhdn ben trdi, 20 benh nhan dmc phdu thuqt an tinh hodn 2 ben diiein 40/118 (33,9%). Co 115/118 (97,5%,) trudng hgp tinh liodn an duqc ldm sieu dm ti-udc mo. 50/115 (43,5%) sieu am CO thay tinh hodn ti-ong obung. 13/118 (11%) trubng hop teo tinh hodn. 51/118 (43,2%,) tmong liap liq tinh hodn nqi soi 21/118 (17,8%) hq tinh hoan dubng bat 33/118 (28%)tnrbng hap lam Stepliais-Towler. Ddnh gid toi thiol sau mo'6 thdng duqc 88/118 (74,6%) ti-ubng hqp hq tinh hodn. Co 4/72 (5,6%) titmig liap teo tinh hodn. 63/72 {87,5%o) tnamg hap sb thay tinh hodn dbiu liay biu cao.
Ket ludn: Phdu thuqt ngi soi obung la mot phuong phdp an todn vd hieu qud trong cha'n dodn vd dieu h^
tinli hodn dn khong sb thdy a tre em. Sieu dm kltong phdi Id mdt phuang tiat chdn dodn c6 do ddc hieu kliong cao trong benh ly ndy.
Tii khoa: An tinh hodn. mo'ngi soi, md'ndi soi hq tinh hodn A B S T R A C T
OUTCOME OF LAPAROSCOPIC ORCHIDOPEXY FOR NON-PALPABIE TESTIS N g u y e n Thi Mai Thuy, Tran Dinh P h u o n g
* Y H o c TP. H o Chi M m h * S u p p l e m e n t of Vol. 19 - No 5 - 2015:209 - 212
Objective: To demonstrate that laparoscopic intervention should be considered as initial surgical approach in the management ofthe non-palpable testis
Methods: We retrospedively revieioed 98 medical records of patients zoho underwent laparoscopic exploration for ihe non-palpable testis between 1/2011 and 12/2014. Intra-opa-ative data of 118 non-pdpable testis were collected Operative success zvas defined at less 6 months after surgery by clinical examination and ultrasound.
Results: 98 patiaits (118 non-palpable testis units) underwent laparoscopic exploration. 41/118 (34 7%J patients were operated in tlie right side, 37/118 (31 4%) patients wei-e operated in the left side. 20 patients were operated for bilateral non-palpable testis. Ultrasound was done for 115/118 (97.5%) non-palpable testis units b^orc operation Testis loas found hy ultrasound in 50/115 (43 5%). Laparoscopic orchidapexy was performed in 51/118 (43.2%,) non palpable testis units. Laparoscopic Stephens-Fozvler procedure was performed in 33/118 (28%o) non-palpable testis units. Orchidapexy by inguinal indsion zoas done in 21/118 (17.8%). Testicular atrophy occurred in 13/118 (11%). Follow-up 6 months after surgery zvas available for 88/118 (74,6%o) ncsi-
*Bf nh vien Nhi Trung Uong
Tac gid lien lac: Ths Bs. Nguyen Thi Mai Thuy, DT :0913379595, Email: nguyen [email protected]
Chuyen De Ngoai Nhi 2Q9
Nghien cuu Y hpc Y Hpc TP. Ho Chi M i n h • Phu Ban Tap 19 * So 5 * 2015
palpable testis units: 63/72 (87.5%) testis units in tlte so-otiim, 4/72 (5,6%) atrophic testis zoas idetttified.
Conclusion: Our finding support the use of an initial laparoscopic approach in tlte management of the non- palpable testis. We also recommended that ultrasound is iwt a good investigation to predid the testiadar absence fijr non-palpable testis.
Key word: Non-palpable testis, laparoscopic, orchidapexy.
D A T V A N D E
Tinh hoan chua xuraig biu la mot benh ly thuong gap 6 tre em. Khoang 3% tre trai sinh du thang CO tinh hoan chua xuong biu. Ty le nay co the toi 30% o tre sinh non thang. Tuy nhien, da phan tinh hoan se tu di chuyen xuong biu trong nam (teu tien. Lua tuoi can thiep ph^u thuat hien nay thuong la sau 1 tuoi. Tuy hiem g^p di t^t phoi hpp trong benh ly nay nhung can rat than trpng idii tre kem theo cac di tat sinh due.
Tinh hoan ah khong so thay trong ong ben tiu CO the CO tinh hoan nam trong o bung hoac tinh hoan teo. Cac nghien cuu da chiing minh rang cac tham do hinh anh nhu sieu am, chup MRI, chup cat lop co dp dac hieu rat (hap trong chah doan tinh hoan ah khong so thay. Phlu thult npi soi la mpt phuong phap chah doan co dp dac hi?u cao de tim vj tri tinh hoan trong 6 bung va can thiet de chah doan kh3ng dinh co teo tinh hoan.
Nhlm khao sat hieu qua va tinh kha thi cua phau thuat npi soi dieu tri an tinh hoan khong so thay 6 tre em, chiing toi da tien hanh nghien cuu hoi cuu cac benh nhi dupc phau thuat npi soi dieu tri an tinh hoan khong sa thay tai benh n e n Nhi Trung Uong tir thang 1/2011 den thang 12/2014.
Muc tieu nghien d m
Danh gia vai tro cua phau thuat noi soi trong chah doan va dieu tri tinh hoan ah khong so thay 6 tre em.
DOIlUONG-PHl/ONGPHAPNGHIENaJlJ Chung toi nghien cuu hoi cuu cac ho sa tinh hoan Sl khong so thay dupc phau thuat tai b?nh vien Nhi Trung Uong tu thang 1^011 den thang 12/2014. Thu th|p cac thong so truoc mo ve tuoi, gioi, ben tinh hoan an, sieu am truoc mo tim tinh
hoan. Vi tri ciia tinh hoan trong mo va each thiic mo (npi soi, mo duong ben, lam phau thuat Steven-Fowler) dupc ghi chep lai.Vai cac benh nhan ha duoc tinh hoan xuong biu dupc danh gia ket qua sau phlu thuat it nhat 6 thang bling tham kham lam sang va sieu am do kidi thuoc tinh hoan.
K E T Q U A
Trong fhoi gjan ng^en a i u chiing toi co 98 benh nhan (118 tinh hoan) an tinh hoan khong so thay dupc phau thuat npi soi 6 bung. 41/118 (34,7%) benh nhan dupc phlu thuat ben phai, 37/118 {31,4%) benh nhan dupc phlu thuat ben trai, 20 benh niian dupc phau thuat an tinh hoan 2 ben chiem 40/118 (33,9%). Tuoi trung binh la 5 tuoi (thap nliat la 1 tuoi, cao nhat la 16 tuoi).
Co 115A18 (97,5%) trucmg hop tinh hoan ah duoc lam sieu am truoc mo, chi co 50A15 (43,5%) sieu am tra loi thay tinh hoan trong 6 bung. 41/50 (82%) trucmg hpp sieu am tra lpi tinh hoan sat 16 ben sau. 105/118 (89%) co Ihay tinh hoan trong mo. 13 truong hpp tinh hoan khong fhay trong bung, 16 ben sau da dong kin, nhin thay bo mach tinh di ra ngoai ong ben. 8/13 bTjong hop dupc mo ben thi tat ca 8 favong hpp thay tinh hoan da teo. Ca 13 (11%) truong hpp (Jeu dupc chan doan la teo tinh hoan.
21/118 (17,8%) truong hpp trong mo thay lo ben sau ma, con ong phiic tinh mac rpng, tinh hoan nam sat 16 ben sau. Cac truang hpp nay dupc hg tinh hoan duong ben. 51/118 (43,2%) tiuong hpp ha tinh hoan noi soi. Khong borong hpp nao tan khau 1^ 16 ben sau. 33/118 (28%) tniong hpp bo mgch tinh ngin nen Iam phlu thuat Stephens-Fowler. Khong co bi&i chung trong va sau mo.
Co 88/118 (74,6%) Irucmg hop lirf, hoan
Chuyen D e Ngoai N h i
Y Hpc TP. Ho Chi Minh * P h u Ban Tap 19 * So 5 * 2015 Nghien cuu Y hpc dupc kham lgi sau mo', 30/118 (25,4%) truong
hpp chiing toi bi mat lien lac. Trong so benh nhan dupc kham lai co 72 truong hpp tinh hoan da hg xuong biu h-ong mo, thay 63/72 (87,5%) tinh hoan nam 6 biu hay biu cao, 5/72 (6,9%) tinh hoan con nim cao trong ong ben, 4/72 (5,6%) teo tinh hoan sau mo. Kich thuoc tinh hoan dupc hg tuong duong ben doi dien.
Trong 33 truong hpp dupc lam Stephens- Fpwler, chiing t6i kham lai dupc 21 trudng hpp da phlu thuat thi II, co 2/21 (9,5%) truong hop bi teo tinh hoan sau mo, co 1 trudng hop trong mo chi ha tinh hoan xuong 16 ben nong do thiing tinh qua cang khi kham lai thi tinh hoan nay nam a 1/3 giiia ong ben.
BAN LU4N Chan doan
Trong benh ly tinh hoan an khong sd thay co the tinh hoan nam trong 6 byng hoac teo tinh hoan. Ty le gap teo tinh hoan dao dpng khoang 20% trong tinh hoan &i khong sd thay tuy theo nghien aiu ('-^J. De khang dinh co tinh hoan trong bung khdng va vj tri cua tinh hoan trong bung thi cac phucmg tien chan doan hinh anh nhu sigu am, chup MRI cd dp dac hieu khong cao P'. Trong nghien ciiu ciia chiing tdi thi chi co 50/115 (43,5%) trudng hpp sieu am thay co tmh hoan nhung trong mo chiing tdi thay 105/118 (89%) trudng hpp cd thay tinh hoan tiong bung.
Chiing toi nhgn thay khi tinh hoan nim sat 16 b?n siu thi thudng de nhin thay tren sieu am hon la khi nam trong ho chau. Da phan 41/50 (82%) trudng hpp nhin tha'y tinh hoan tren sieu am thi khi phau thugt chiing tdi thay tinh hoan d sat Id ben sau, ong phiic tinh mac cdn rpng.
Vl kh6ng CO phuang tien chah doan cd dp dac hi^u cao de tra ldi cau hoi co tinh hoan hay kh6ng nen npi soi 6 bung dupc coi la mot phuong tien chah doan hiiu hieu nhat. Chiing t6i cho rang npi soi vua co y nghia chah doan, vua cd y nghTa dieu tri Dgc biet khi co kem theo nhiing di tat oia bp phan sinh due thi viec phat hien nhiing ton thuong nam trong benh canh roi
loan phat tiien gidi tinh (DSD) la het siic c ^ thiet cho ke hoach dieu tri.
Chiing tdi nhgn thay khi lo ben dong km, nhin thay bo mach tinh da di ra ngoai bung thi viec md ben la khong can thiet. Cd 13 benh nhan chiing toi khdng thay tinh hoan tiong bung, 16 ben sau da ddng, bd mach tinh di ra ngoai ong ben. 8/13 benh niian cua chiing toi cd mo ben kiem tra ttii tat ca cac trudng hpp nay tinh hoan deu teo nhd.
Kha nang ha tinh hoan
Trong nghien ciiu, chiing tdi nhan thay khi tinh hoan nam d sat 16 ben sau va dng phiic tinh mgc cdn rpng thi cd the hg tinh hoan bSng dudng ben de dang. Viec ddng igi ong phiic mgc la can thiet khi 16 ben sau cdn rpng.
Khi thay ong ben ddng hoac ong phiic tinh mac cdn nhung nhd thi nen phau tich ha tinh hoan npi soi. Nhung trudng hpp nay bo mach tinh thudng ngan hon va viec su dung npi soi de phau tich lam dai thung tinh la het siic can thiet.
Chiing t6i thudng uu tien dung keo de phau b'ch phiic mac doc theo bd mgch tinh va ttiung tinh.
Dot dten phai chii y tranh xa bd mach tinh va dng dan tinh. Chiing toi thudng khong cat day chang biu tinh hoan.
Khi bd mach tinh ngan thi phau thugt that mach tinh (phau thuat Stephens-Fowler) nen dupc lua chpn. Klu lua chpn phau thugt nay, chiing tdi khdng phlu b'ch bo mgch tmh va thimg tinh ma chi kep clip bd mach tinh d each tinh hoan khoang l-2an. Sau khi kep mach thi ngudn mau nudi tinh hoan se den tir mach mau di theo dng dan tmh va day chang biiu tinh hoan. Viec phau h'ch tinh hoan tiong phlu thugt thit mach tinh thi 1 se lam tang nguy co teo tinh hoan d thi 2.
Viec dong Io ben sau
Trong cac benh nhan kham lai sau mo an tinh hoan chiing tdi thay khdng cd trudng hpp nao cd thoat vi ben hoac nuoc mang tinh hoan.
Qua do chiing toi nhan thay viec ddng dng ben la khdng can thiet tiong npi soi. Cd le dieu
Chuyen De Ngoai Nhi 211
Nghien airu Y hpc Y Hpc TP. Hb Chi M i n h * P h u Ban T a p 19 * So 5 * 2015 nay dupc giai thich la do nhiing trudng hop
cdn dng phiic tinh mac rpng, chiing toi md dudng ben \ a bao gid ciing that ong. Nhiing trudng hpp npi soi thi thudng dng da ddng hoac cdn ong rat nhd.
Ket qua
Trong nghien ciiu ciia chiing tdi cd 88/118 (74,6%) trudng hop tinh hoan dupc kham lai; cd 72/88 trudng hpp tinh hoan da ha xuong biu hrong md; thay 4/72 (5,6%) frudng hpp teo tinh hoan; 63/72 (87,5%) tiirdng hpp sd tiiay tinh hoan d biu. 5/72 (6,9%) tinh hoan cdn nam cao trong dng ben. Kich thudc tinh hoan dupc ha tuong ducmg ben doi dien.
Trong 33 benh nhan duoc Iam phau thuat Stephens-Fowler, chiing tdi da kham Iai dupc 21 trudng hpp dupc mo thi hai, cd 2/21 (9,5%) trudng hpp tinh hoan bi teo, cd 1 trudng hpp trong md chi ha tinh hoan xuong Id ben ndng do thung bnh qua cang khi kham lgi lhi tinh hoan nay nim d 1/3 giiia dng ben. Cdn Iai 18/21 tinh hoan nim tgi biu, kich thuoc tinh hoan tucmg duong ben ddi dien.
Theo mpt sd nghien cuu tren the gidi thi ty 1?
phau thuat npi soi thanh cdng tiong benh ly tinh hoan an dao ddng tCf 90%-100%. Vdi phlu thuat Stephens-Fowler la 66,7%-100%. Tuy nhien mpt sd tac gia khac Iai cho rang ty le teo tinh hoan khi ha tinh hoan bang npi soi va phau thugt Stephens -Fowler la tucmg duong "•^.
Chiing tdi nhan thay rang khi bd mach tinh ngan, thi viec co ha tinh hoan xudng biu lam tang nguy co teo hnh hoan. Hogc neu dua dupc tinh hoan ra ngoai 6 bung thi kha nang phau thuat lan 2 de ha tinh hoan xuong biu
cung rat khd khan. Cd le phlu thuat Stephens- Fowler la phlu thugt nen lua chon cho nhung trudng hpp nay.
KETLUAN
Phlu thuat npi soi 6 byng la mpt phuang phap an toan va hieu qua trong chah doan va dieu tii hnh hoan an khdng sd thay d tee em.
Sieu am khdng phai la mdt phuong tifn chah doan cd dp dgc hieu khdng cao. Phlu thuat Stephens-Fowler nen duoc lua chpn neu thiing tinh qua ngan.
TAI LIEU THAM KHAO
1 Ala^iiatram S, Nathaniel C Cudcow P, et al (2014) Testicular outcome following laparoscopic second stage Fowler- Stephens oichidopexy. J Pediatr Urol.,10(l) pp,186-92 -, Alzahem A (2013) Laparoscopy-asasted orchiopexy veisus
laparoscopic two-stage Fowler- Stephens orchiopexy for nonpalpable testes: Comparative study. Urol Ajinp(2)pp-lll>4.
3 Casanova N C Johnson EK. Bowen DK, et al (2013). Two-Step Fowlei-Stq^hens orchiopexy for uitra-abdommal testes: a 28- year a n ^ e uistituticm experience. J Urol. 190(4)-pp. 1371-6.
4. Castillo-Ortiz J, Muniz-Colon L, Escudero K, et al (2014).
Laparoscopy in the surgical management of the ncm-palpable testis. Front Pediatr. (2).28; pp.1-4
5 D | n g Quang TaSn, Nguyin Thanh N h u (2010). Phau thujt ngi SCH dieu tri tinh hoan an khong sir thay Ngo?! khoa (60):
pp235-239
6 Mehendale VG, Shenoy SN, Shah RS, et al (2013) laparoscopic management of impalpable undescended testes 20 years' expenence J Miium Access Surg. 9(4) p p 149-53.
7 Safwat AS, Hammouda HM. Kurkar AA, et al (2013).
CXitcome of Wlateral laparoscopic Fowler-Stephens oichidopexy for bilateral intis-abdonunal testes. Can J Urol-20(5)-pp,6951-5.
Ngdy nhan bdi bdo: 24/08/2015.
Ngdy phan bien nhan xet bdi bdo 25/08/2015.
Ngdy bdi bdo dwac dang: 01/10/2015
Chuyen De Ngoai Nhi
