Y HOC Vl|T NAM THANG 6 • SO 2/2014
NGHIEN CITU DAC DIEM LAM SANG, CAN LAM SANG BENH TINH H O A N KHONG XUONG B ! U 6" NGITOI LON
T6MTAT
M^c dich: Nghien cthj mpt sd dac diem lam sang va din lam sang tinh hoan l^ong xuong biu ngi/di idn.
DSi tu'ang v i phu'dng phap nghien c i h i : Gom nhOha b§nii nhan tit 18 tuoi trd len, di/dc ciian doan v^ piiau thu?t THKXB tai khoa Piiau Thuat Tiet Nieu cua benh vien Vi§t Oufc tij' thang 1 nSm 2011 den het thang 7 2013. Cac thong tin thu thap gom: tuoi phat hi^n benh, tuoi di kham ^ n dau, tuoi mo, kham lam sdng, vi tn tinh hoan,... xet nghiem can lam sang bao g3m si^u Sm, tinh dich do, xet nghiem n5i tiet to,...
Kfit qud nghlSn cihi: Co 144 benh nhan trang do gom 97 b?nh nhan THKXB mpt ben va 47 benh nhan THKXB hai ben vdi 191 tinh hoan du'dc nghien aftj.
Tuoi bung binh cua benh nhan; 26,6 ± 5,7 tuoi. Tuoi b^nh nhan ldn nhat du'dc phlu thuat; 46 tuoi. Tinh hoan khong xuong biu c^ng d cao thi kha nSng teo tinh hoin c^ng ldn, su" khac biet cd y nghTa thong ke vdi (p<0,05). Ty 1^ teo tinh hoan nSng chiem 82,2%
(157 tinh htran) nhieu hdn ty I? teo viJfa va nhe 17,8%
{17 tinh hodn), si/ khac biet cd y nghTa thong ke vdi (p<0,05). Nong dp testosterone cua benh nhSn THKXB hai bgn \i 13,0325 ± 6,3385 (nmol/l) thap hdn nong d$ testosterone cua benh nhSn THKXB mOt bgn la 16,4221 ± 7,45756 (nniol/l), su' khac biet cd y nghTa thdng ki vdi {p = 0,016 < 0,05). The h'cli tinh dich va m§t dp tinh trung d benh nhan THKXB hai ben thap hdn d b§nh nhSn THKXB mpt ben, su" khac bi?t cd y nghTa thSng ke vdi (p < 0,05). K i t lujin: Tinh hoan khong xuong blu tuy khdng khd de chan doan nhuhg v3n con mpt ty 1^ cao den kham va dieu trj mupn. Cac d$c diem 13m sdng va can lim sang cho thiy tinh hoan khdng xuong blu d ngifdi Idn cd tien lu^ng xau, anh hudng tdl su'c kho^ sinh sSn cua ngu'di benh.
SUMMARY
CUNZCAL AND PARACLINICAL SYMPTOMS OF ADULT CRYPTORCHIDISM OPERATED
AT VIET DUC HOSPITAL Purpose: Evaluation of clinical and paradlnlcal symptoms of adult cryptorchidism operated at Viet Due hospital. Patients and methods: Adult patients from 18 years old were diagnosed as cryptorchidism and operated at Urology department of Viet Due hospital during the period from January 2011 to July 2013.
OInical and para-clinical signs were analyzed. Results:
We studied 144 patients induding 97 patients with unilateral undecended testis and 47 patients with bilateral undecended testes. Thus, a total of 191 testes
* Khoa pr n& ni^ - Bgnh vi^n Vlgt Due Phin bi4n khoa hgc: PGS.TS Nguyin Kjr
Nguyen Quang*
were studied. The mean [range] age was 26.6 ± 5,7 [18-46] years. The higher the testis, the more atrophic testis was (p < 0.05). The rate of severely atrophic testes v/as 82.2% (157 testes). The serum testosterone level In patients with bilateral cryptorchidism was 13.0 ± 6.3 nmol/l, less than that m patients with unilateral cryptorchidism (16.4 ± 7.4 nmol/l) (p<0.05). The semen volume and sperm concentration in patients with bilateral undescended testes were less than those in patients with unilateral undescended testis (p<0.05). Conclusion: Despite of undifflcult diagnosis, cryptorchidism is still treated too late. Patient's clinical and para-dlnlcal signs reveal a poor prognosis, especially reproductive possibility.
I. OAT VAN OE
Tinh hoan khong xuong biu la tinh hoan dCrng lai bat thu'cfng tren du'dng di chuyen xuong biu thdi ky phoi thai, khac vdi tinh hoan lac cho la ttnh hoan nam ngoai du'dng di chuyen binh thudncj cua no.
Tren the gidi cung nhu' d Viet Nam da c6 nhieu nghien ciTu ve dieu trj tinh hoan khong xuong biu. Tren thu'c te, benh nhan THKXB chiem mot ty le cao den kham va dieu trj d cac benh vien cung nhu" d benh vien Viet Ou'c, tronp dd so lu'dng benh nhan phau thuat tren 18 tuoi cdn kha cao, nhu" vay se dan den ket qua lau dai khong tot. Chinh vi ly do do chung toi thyc hien de tai nay vdi muc tieu: Nghien cuii m^t sd
die (ffent iim sing vi can iim sing tinh hoin khdng xud'ng biu d ngu'di ldn.
II. o d l T U p N G VA PHUd^JG P H A P NGHIEN COU Gom nhihig benh nhan tu" 18 tuoi t r d len, dude chan doan va phau thuat THKXB tai khoa Phau Thuat Tiet Nieu cua benh vien Viet Ou'c tCr thang 1 nam 2 0 1 l ' d e n het thang 7 nam 2013.
Cac thong tin thu thap gom: tuoi phat hien benh, tuoi di kham lan dau^ tuoi mo, kham lam sang, vj tri tinh hoan,... Chan doan can lam sang bao gom sieu am, tinh dich do, xet nghiem npi tiet to (LH, FSH, testosterone,...)
Tren sieu am, do kich thu'dc = cao x rong x dai tinh ra the ti'ch bang cong thirc cua Lambert:
The tfch (ml) = 0,71 x (rpng x dai x cao) /LOGO.
So sanh vdi ben lanh hay so sanh vdi kfch thu'dc ngu'di cung lu'a tuoi neu THKXB hai ben d u ^ tren cd sd tmh chl so teo tinh hoan (Theo cong thu'c tfnh cua Niedzielski J).
Y HOC Vlfrr NAM T H A N B 6 - SO 2/2014
100 = chi so teo tinh hoan The tich tinh hoan ianh - the fa'ch tinh hoan benh
The tich Hnh hoan ianh
l»liJc dp teo tinh hoan (so sanh vdi Isen ianh) theo Aubert (1982):
- Teo nhe: VTHKXB > 2/3 VTH ianh
- Teo visa: 1/2 VTH ianh < VTHKXB ^ 2/3 VTH ianh - Teo nang: VTHKXB ^ 1/2 VTH ianh
IN. Kft-QUA NGHIEN Ciru . ,-, u- u u- Tong cong co 144 benh nhan, trong do gom 97 benh nhan THKXB mot ben va 47 benh nhan THKXB hai ben (co 24 benh nhan mo 2 ian nen co 168 ho sO nghien cifu). Tong so co 191 tmh hoan du'dc nghien cisu.
3.1. Nhdm tuSi benh nhan phlu thuat
Trang 144 b?nh nhan du'dc nghien ciJu, sS lu'dng benh nhan phan bo theo cac nhom tuoi duac the hiin qua bieu do 1 du'di day:
Bleu 031. Phan bo benh nhan theo nhom tuoi
Tyle o/o
• Tuoi trung binh cua benh nhan: 26,6 ± 5,7 - Tuoi benh nhan idn nliat du'dc phau thuat; 46 tuoi.
3.2. Cic d| t$t phoi hdp
So lu'dng v j t^ ie cac dj tat nieu - sinh due di i<em trong cac benh nhan nghien cuU du'dc the hien d bang 3.1 nhU sau:
Bing 1: Cac di tat phSi hdp D| tat phcii hop Lo dai lech thap Thoat vi ben Di tat khac Khonq kem di tat
Tong
So lifdng 2 18
5 119 144
Ty le'/o 1,39%
12,5%
3,47%
82,64%
100%
Tmng sS144 binh nhin nghiin cdu cd 2 binh nhin (1,39%) co kem dl tit lo dii thap, 18 binh nhSn (12,5%) CO thoit vl ben cilng bin vi 5 (3,47%) binh nhin co kem di tit khic (cong dudng vat, nang mio dnh hoin...)
3,3. L]^ do v i o vi|n
L^ do b?nh nhan di kham va dieu trj du'dc trinh bay theo bleu do 2.
Y HOC V l f r NAM THANG 6 - SO 2/2014
Bieu do 2. Ly do vao vien
•" Kliong ihay luili boa Dau vung btfii bii Ly do kliac
Benh nhin vio vi^ chu y&J H w khong thiy dnh hoan d Ijiu: 99 BIV (68,75%), ^ do vao vien dii&n ty le ftrt»j? doi nh§u la vo sinh: 27 BN (18,75%), con Ial la nhdng ly do tmc: dau vung tjen blu, roi ban ahrig diMig, khong a? ham mu^ tinh due, Ididng mgc long vung So phan sinh due, khong gidng ban ajiiggk^....
3.4. PhSn loai tinh hodn
Co 191 Tinh hoan khong xuong biu du'dc phau thuat, phan loai theo tieu chuan THKXB sd thay va THKXB khong sd thay cho ket qua 66 (34,55%) tinh hoan sd thay du'dc, cdn lai 135 (65,45%) tinh hoan khong sd thay ma chi biet du'dc qua cac phu'dng tien chan doan hinh anh.
3.5. Phan bo theo ben THKXB Trong 144 benh nhan nghien CUXJ C6: 50
(34,72%) benh nhan Tinh hoan khong xuong biu ben phai, 47 (32,64%) benh nhan Tinh hoan khong xuong biu ben trai va 47 (32,64%) benh nhan Tinh hoan khong xuong biu hai ben.
3.6. Lien quan vj tri THKXB vd the tich tinh hodn
Lien quan cua mu'c dp teo tinh hoan vdi vj tri Tinh hoan khong xuong biu du'dc the hien qua bang 2.
Bing 2. Uen quan y[ tri THKXB va mu'c do teo tinh hoan
THKXB d cao THKXB d thap
Tong
Teo nh^ vd vuTa
^
(3,6%)
^ 0 "
(37%)
Teo nang
106 (96,4%)51 (63%)
Tong 110 (100%)
81 (100%)
T 4 \ 157 \ 19l~
_ . (l^'S"/?) _ I (82,2%) I _(>Q0%) _ . Jinfi hoan khong xudng tnu cang d cao thi kha nana teo tinh hoan cang ldn, sd khac bletai y nghla thdng ke vdl(p<0,05), Ty le teo tinh hoan ning chiem 822% (157 tinh hoan) nhieu hdn'ty le teo vu&
vi nhg 17,8% (17 tinh hoan), sdkhac biet co y nghia thong ke vdl(p<0,05).
Bing3:y\ tn THKXB tru'dc phau thuat VI tri THKXB
u lo ben nonq u tronq dnq ben O io ben sau Tronq d bunq
Tonq
So lu'dnq 14 67 51 59 191
Ty le % 7,33 % 35,08 % 26,7 % 30,89 % 100%
3.7. Ket qui x i t nghidm n$l tiet tS
C6117 benh nhan du'dc lam xet nghiem testosterone, ket qua xet nghiem testosterone du'dc trinh bay ttong bang 4.
Bing 4. D^nh qia noi tiet to testosterone Hdtbgn
Gii tii trung binh Sdl^ch Gia trj ldn nhat Gii tr| nho nhSt JAAtil
7,4575634,7 T S ~
Hal ben l.'W.I.. . . " ' ° ? " I 6,33850 I 28 I 1 .
NSng dp testosterone cda binh nhin THKXB hai ben la :^ ,^ 50=13,0325 ± 6,3385 (nmol/l) thap
him niSng d$ testosterone cua binh nhin THKXB mot bin ii'X,, ± SD = 16,4221 ± 7,45756 (nmol/l),
sd khic blit coy nghia diongke vdi (p = 0.016 < 0,05).
Y HQC VlgT NAM THAHG 6 - 8 0 2/2014
3.8. Ket qua xet nghiem tinh dich tfo . , ,„
Co 84 benh nhan di/dc lam xet nghiem tinh djch do trong so 144 benh nhan nghien cuU, ket qua xet nghiem tinh dich nhi/ trojig bang 5,6.
Bing 5. I<et qua the tich tinh dich va so ben TtiKXB Ben THKXB
Tong
The tich tinh djch "
Binh thu'dng
37 (68,8%)9 (29%)
46 (54,8%)
Thap
16 (31,2%)22 (71%)
38
Tong
53 (100%)31 (100%)
aoq%) 84
"• ben.
The dch Unh dich dbenh nhan THKXB hai ben diap hdn dbenh nhan THKXB mpt y nghia thong'ki vdi(p<0,05).
sd khic biit cn Bing 6. Lien quan
Ben THKXB Mpt ben HaibSn
Tong
qiiJa so ben THK XB va mi t do tinh trunq Mat do tinh trCing Binh thu'dnq
26 49,1%
0 0%
26 31%
Thap 15 28,3%
0 0%
15 17,9%
Khonq cd tinh trung 12 22,6%
31 100%
43 51,1%
Tong 53 100%
31 100%
84 100%
IV. BAN LU^N
TTnh hoan khong xuong biu la mdt trong nhutig bat thu'dng ve sir phat then cd quan sinh due thudng gap nhat d nam gidi vdi tan suat 2 - 5% tre nam ra ddi.
NSm 1956, Scorer phat hien 2700 tre sd sinh cd 180 tre tinh hoan khong xuSng blu ty le 4%.
1960 Ward va Hunter R. neu Ien ty le tinh hoan khong xuong biu la 2,3%. Theo cac tac gia nay:
trong vong 1 nam ke tir sau khi sinh tinh hoan cd kha nSng tU xuong biu. Grunner 1^. Grapin C, 1992 cho biet tinh hoan khong xuong biu d con trai 2 • 12 tuoi la 0,8 - 0,9%. Nam 1979, Kleinteich lan nu^ neu ty le tinh hoan khong xuong biu d tre sd sinh la 3,4 - 5,8%, sau 1 nam ty le nay giam cdn 1,82% cho den tuoi day thi.
Nam 1990, Thai Lan Thu' cho biet tre em Viet Nam khi de du diang thu'dng gap ty le tinh hoan khdng xuong biu la 2%, nhutig d tre de khong du thang ty le gap kha cao 15%; khi tudi vj thanh nien ty le tinh hoan khong xuong biu chl con 0,28%.
Trong nghien c\l\s cua chiing toi; Op tuoi trung binh ciia nhom phau thuat la cao 26,6 ± 5,7 tudi. Tudi cao nhat du'dc phau thuat la 46 tudi. Co 22,2% benh nhan phau thuat lis 30 tudi trd Ien, m^c du da biet tinh hoan klidng is vi trf binh thudng nhutig benh nhan van di kham va dieu trj mupn tham chi ia chl den khi lay vd khdng thay co con mdi di kham IJy le di kham vi
vd sinh: 27 bn -18,75%) dieu nay gay kho khSn cho viec phau thuat va tien lu'dng dieu trj sau phau thuat dat ket qua thap.
Cd 23 bdnh nhan mdi phat hien benh, con !;i 121 benh nhan da phat hien benli tiT nhd nhutig chl di kham va dieu trj khi khdng sd thay tinh hoan d biu (99 benh nhan) hoac khi lay vd khdnj cd con (27 benh nhan) va mdt phan la vi 1^ do khac (dau vung ben blu, khdng cd ham muon tinh due, khdng mpc ldng sinh due, khdng giong ban ddng trang lira...). Oieu dd ndi len si/ nhSn thii'c ve benh cung nliu' tuyen truyen, y te cdng ddng ciia chung ta cdn kem.
Tinh hoan khdng xudng blu cd the phdl hop vdi nhieu hdi chii'ng dj dang: thieu mau Fanconi;
hdi chirng Prader - Willi - Labhart; hdi chiJng Cornelia de Lange; hpi chii'ng Noonan hoac Turner nam tfnh; hdi chimg Potter; hdi chiltig Russell- Silver; hdi chutig Smith - Lemli - Opitz, Benh nhan bj tinh hoan khdng xudng biu con cb the bj kem theo cong du'dng vat, lo dai ledi thap, ... Trong nghien cCi'u ciia chiing tdi, cd 18 benh nhan (12,5%) cd thoat vj ben ciing ben,,?
benh nhan (1,39%) co kem dj'tat lo dai thSp,5 benh nhan (3,47%) kem dj tat khac (nang niifc thimg tinh, cong nhd du'dng vat...).
Trong nghien ciru ciia chung tdi cd 6f
(34,55%) tinh hoan sd thay va 135 (65,45%)
tinh hoan khdng sd thay, ty le nay cung tiTOng
ddng vdi mdt sd nghien culj khac nhu' OJa:
Y HQC VlgT NAM T H A H G 6 - SO 2^014
Hoang Tien Viet (2007), cac ty le tu'dng ijtig la 35,4%- 64,6%.
Vj t r i THKXB la dieu quan tam ciia gia dinh va phau thuat vien, vi co lien quan tc^ viec dieu tri kha nSng ha tinh hoan xuong biu. Tinh hoan cang d cao trong o bung cang phu'c tap ve su*
phat trien cua tinh hoan va phau thuat ha tinh hoan xuong biu khd khan, chi'nh tinh hoan kem phat trien nen ket qua cung kho danh gia du'dc.
Theo J.Auberi: tinh hoan khong xuong tiiu d cac vj tri d lo ben nong 55,7%, d ong ben 34,73%, d trong d bung 8,42%. Kleinteich neu ty 1? tinh hoan d Io ben nong 7 2 % , d ong ben 2 0 % , d trong 6 bunp 8%. Thai Lan Thu' (Viet Du'c, 1990) Chan doan vj t r i tinh hoan khi tham kham d lo ben nonq 18,3%, trong ong ben 44,2%, trong bao thoat v\ ben 31,2%, khong sd thay 8,4%. Trong nghiSn CU\J cua chiing toi, ty le THKXB d cac vt trf du'dc phan bd nhU bang 3'.
Theo dd, tinh hoan d lo ben nong chiem ty le it (7,33%), cdn lai chu yeu la tinh hoan d tren cao trong bung:
Cac tac gia cho rSng tinh hoan khonq xuong blu phai/trai khong khac nhau nhieu, khoang; 45 - 55% ben phai/ 35-45% ben trai, mac du cd tac gia cho rSng xu hu'dng tinh hoan phai chay xudng biu sdm hdn so vdi tinh hoan trai. Luciano A.F. va cpng sy* (2014) nghiSn ciili tren phoi thai ngu'di cho thSy tinh hoan ben ph^i cd xu hu'dng xuong blu sdm hdn so vdi ben trai. Kleinteich duci ra ty l | c6 kh^c b§n phai 7 0 % ben trai 30%.
T h i i Lan Thu" neu len ty le tinh hoan khong xuong biu ben phai 43%, ben trai 37%.
Tinh hOcin hai ben khong xuong biu nhan dutfc si/ quan t i m cua nhieu tac gia. Kleinteich 1979 clio rSng c6 6in 1/3 la hai ben, J.Auvert 38,71%, Thai Lan Thu" 18%, Hoang Tien Viet (2007) la 17,5%, Bui VSn Hda (1998) la 23%. Trong nghien CU\J cua Chung toi thi ty I? THKXB ben trai (32,6%), ben phSl (34,8%), hai ben (32,6%). Cung chi'nh vl ty le Tinh ho^n khong xudng biu hai ben trong nhdm nghien ciru cua chung toi cao nen tien ludng dSu trj sau mo la k^m.
The b'ch tinh hoan la mot thong so dac biet
; cho ph^p udc ludng so luidng va kha nSng hoat d$ng cua c i c dng sinh tinh. Nd giup cho bac sT dm hieu ngwen nhan vo sinh do tinh hoan hay do tac
• dudng dan tinh. Khi cac ong sinh tinh Wiong phat trien, the ti'ch Unh hoan qiam ro r^t [21].
' Qua nghlSn cutj cua chung toi, tinh hoan khong xudng biu cang d cao ^ i ty le va mu'c dQ teo tinh hodn d i n g Idn, su* khac biet cd y nghTa I tiidng ke v ^ (p<0,05). Tuy nhien, nhin chung . trong nhdm b^nh nhan nghien cuXi ciia chung toi
ty le teo tinh hoan nang la cao vdi 157 benh nhan (82,2%), cd le la do tudi phau thuat mupn.
Trong 144 benh nhan nghien ciru thi co 84 benh nhan du'dc iam tinh djch do, chiing toi thay cd SLT khac biet ve mat dp tinh triing d benh nhan tinh hoan khdng xuong biu mpt ben va d benh nhan tinh hoan khong xuong biu hai ben co y nghTa thong ke vdi (p < 0,05; F=0,747 gan 1), cd 31 (100%) benh nhan THKXB hai ben du'dc lam xet nghiem tinh djch do thi ^ t ca d i u khong CO tinh trung, cdn d 53 benh nhan Tinh hoan khong xudng biu mpt ben cd 12 (22,64%) benh nhan khong cd tinh triing. Cac chi so khac nhu* npi tiet to testosterone va the ttch tinh djch cung cho thay kem hdn d benh nhan b| tinh hoan khdng xuong biu 2 ben. Dieu nay cho ttiay tien lu'dng re van de sinh san cho nhOtig benh nhan bj tinh hoan khong xudng biu d ca hai b§n la rat xau,
V. K ^ L U A N
Tinh hoan khdng xuong biu tuy khdng khd de chan doan nhutig van cdn mpt ty le cao den kham va dieu tri mupn. Cac dac diem lam sang va can lam sang cho thay tinh hoan khdng xudng biu d ngu'di Idn cd tien lu'dng xau, anh hu'dng tdl su'c khoe sinh san cua ngu'di bdnh.
TAI LI|U THAM KHAO
1 . Luciano A.F. and Francisco J.B.S.: Testicular migration chronology: do tiie right and tiie left testes migrate at the same time? Analysis of 164 iiuman fetuses. BJU Int 2014; 113: 650-653 2. Nguyen Quang (2012): "Qua trinh sinii tinh",
Benh hpc nam khoa cd ban, NXB Y hpc, tr 31-37.
3. Niedzielski J (2003), "The usefulness testicular atrophy Index in the assessment undescended testicle", Preliminary report, Rocziniki Akademii Medyan? Bialymstoky, p 112 - 1 1 4 . 4. Douglas A. Husmann (2002): "Cryptorchidism",
Clinical pediatric urology, p 1125 - 1248.
5. Nguyen Thanh Liem (2002), "Tinh hoan khong xuong biu", Phau thuat tiet meu tre em, NXB Y hpc, tr 2 1 3 - 2 3 1 .
6. Israel Franco (2002), "Evaluation and management of impalpable testis", Oinical pediatic urology, p 1 1 5 5 - 1 1 7 0 .
/ . Steven G. DocimcMD (2000), "The undescended testide. Diagnosis and managemenr, American Family Physician, p 2037-2044.
8. H i a i Lan Thtf, Hoang Van Hiin^ i^^^^' "^^^
xet bu'dc dau ve b'nh chat lam sang, dieu tri vd giai phau benh ly ciia Tinh hoan khong xudng biu trong mu'di nim 1981-1990, Ngoai khoa thu'c hanh y diTtfc hoc Viet Nam, XXIII, tr 27-32.
