TAP CHi NGHIEN CUU Y HQC ^ -
DAC OIEM HiNH ANH SIEU AM TRIPPLEX VA KET QUA DIEU TRI CAN THIEP NUT MACH TRONG GIAN TTNH MACH TINH
Nguydn Duy H u n g \ Trdn Cong H o a n \ Tnnh Van Tuin' 'Bgnh vign Huv nghj Viet Diic. ^Trw&ng Dgt hoc YHd N6i Gian tinh mach tmh la benh Ihu&ng gdp & nam gi&i khde mgnh, gay ndn tmh trgng hidm mugn co con, Iham chl vd sinh neu khdng duoc chan doan va didu In Cho t&i nay. vigc chan doan bgnh chu yeu dga vio cdc tiigu chimg Idm sang va sidu am Doppler mdu Mgc lieu cua dd tdi nhdm md ta dac diem hinh anh sieu am Tiipplex vd ddnh gid kel qud dieu Ig can thigp nut mach trong gian tmh mgch Imh Ket qua cho thaytu thang 11/2010 den Ihdng 06/2011. 21 b$nh nhan gian tinh mgch tmh dwgc chi dinh can thigp nol mach kin hmh dnh sieu dm cua tinh mgch Imh co duong kinh l&n nhat tru&c khi lam nghiem phdp Valsalva dao ding tu 2 - 2.5mm. sau kht Idm nghidm phdp dao ddng tw3.4 - 5mm. tuung img vdi gidn do II Id 28,57%, dplllla 71,43% Ty 1$ can thigp niit m^ch thanh cong cao. dat 92,4 - 96% Th&i gian ndm vign vd hdi phgc sau d ^ tn ngan. trung binh 1.1 ±0,3 ngay Bien chwng trong qud tnnh can thigp Id rach thdnh mach (4,76%) vaira hda chat gay xo (9.52%) Theo dot sau didu tn 3 Ihdng thay the lich tinh hoan gidm nhieu nhat id 1,6cm'so vol tru&c khi dieu tn, du&ng kinh llnh m^ch tinh giam trung binh -1.32 ± 0.08mm. toe dg dong chaygm trung binh -0.39 ± 0,21mm sau khi Idm nghidm phdp Valsalva v&i p < 0,05
Tu khda. gian tTnh mach tmh, sieu am Doppler mau
I. DAT VAN DE
Gidn ITnh maeh tmh la mdt benh thudng gap a nam gidi, chidm khoang 8 - 23 % nam gidi khde manh va khoang 40% trudng hop benh nhdn ddn kham vi hidm mudn Viee ehan dodn xae dmh hien nay ehii ydu dua vdo tneu chirng Idm sang va sieu dm Doppler mau [1]
Didu tn gian ITnh mach tinh cd nhieu phuang phap nhu phdu thudt thdt ITnh maeh tmh qua ndi soi 6 bung, mo m d hodc dien quang can thiep nut mach Tuy nhien. cac phuang phap nay vdn cd ty Id tai phdt va bidn chirng nhu trdn dich mdng hnh hoan, teo hnh hoan, ton thuang mach Vdi s u hen bd eiia dien quang can thidp, phuang phap didu tn gidn tinh mach tmh bdng can thiep nut maeh ngay cang duoc dp dung rdng rai vd d u o c coi
Oia chi lien h0 Tnnh van Tuan. bp mon Ngoai, truOng Dai hoc YHa NOI
Email tLian_thuy@yahoo com Ngaynhan 26/03/2013 Ngay duoc chdp thuan: 2Q/G/2013
nhu mdt p h u o n g phap it xam hai nhung rat hieu qua vi ly Id thanh cdng cao, !•/ le tai phat va bidn ehirng thdp [2]
Tai Viet Nam chdn doan va didu tn gian ITnh mach linh bang phuo'ng phdp dien quang can Ihiep dd dan d u a e dp dung a cdc benh vien Idn nhu benh vidn Viet Dire va benh vier Bach Mai Mdc du vay, cac ddc diem hinh anh eua gidn ITnh maeh hnh tren sieu am Doppler mau eung n h u ket qua didu In cua phu'ang phap dien quang can Ihiep vdn chu-a dug'C nghidn ciru ddy du vd ed he thong Vi vayd^
tdl d u a c tldn hdnh vdi muc hdu Md ta dSc diem hinh anh sieu am Tnpplex vd danh gia j kdt qua dieu In can thiep ndi mach trong gian j
tTnh maeh tmh j
11. D 6 | TU'P'NG VA PHU'ONG PHAP |
1. Ddi tu'O'ng ' Benh nhan gian tTnh mach tmh ddn kham
vd didu In tai benh vien Viet Dire vd bdnhvi6n Bach Mai lii' thang 11 ndm 2010 ddn thang 06 nam 2011
Tr.Mr.YN fl-? n\ - 2013
• TAP CHi NGHIEN CLPU Y HOC Tieu chudn lua chon'
- Bdnh nhdn nam, khdng phan biet lira luoi - Gidn tTnh maeh tmh phat hidn 6uac tren Idm sang
- Chan doan xac dinh gian ITnh mach tinh tren sieu dm Doppler mau
- Chi dmh didu tn bdng phuong phap can Ihidp ndi mach
Tieu chuan loai tru,
- Nghi ngd gidn tTnh maeh hnh trdn Idm sang nhung khdng ed ddu hieu gian trdn sidu am Tnpplex
- Khdng d u o c didu tn bdng phuang phdp can thiep ndi mach
- Benh nhan khdng tdi kham, khdng theo
doi duoc trong thdi gian t6i thieu 3 thang 2. Phu'O'ng phap: md ta tien eiru Ky thudt thue hien
Nghidn ciru thuc hidn tren mdy sieu am Logig P5 ciia hang GE (My), cd sieu dm Doppler mau, ddu dd cong loi 3,5 MHz va ddu dd phdng 7MHz
Cdc chl lieu nghien eii'u - Tuoi, tneu ehii'ng Idm sdng
- Ddnh gia mire do vd phdn dd gidn tTnh mach tmh tren lam sang theo phan do ciia Td chirc Y te Thd gidi [3)
- Ddnh gia mirc do vd phdn dd gidn tTnh mach tmh trdn sieu Doppler theo phdn dd eua Cornud [4] (bang 1)
Bang 1. Phan do gian tinh mach t i n h tren lam sang va sieu am Doppler mau Gian t m h mach tinh
tren lam sang [3]
Gian t i n h mach tTnh tren sieu am Doppler mau [4]
S d thdy bill tTnh mach gian khi lam Ddng trao nguac tdn tai dudi 1 giay vd nghiem phap Valsalva duac coi nhu ddng trao nguac smh ly S d lhay biii tTnh mach gian khi nghi
ngoi nhung khdng nhin thdy
Ddng trao nguac tdn tai dudi 2 gidy, giam ddn trong khi lam nghiem phap Valsalva va bidn mdt trudc khi ket thiic nghiem phdp Bill tTnh maeh gidn ed thd s d va nhin ° ° " 9 ^'^° " ^ ^ ' ^ ^ ^^"^ f^' ^^^^ ^ gidy, ed hinh thdy khi nghi ngai eao nguyen trong suot thai gian lam
nghiem phap Valsalva
. - Danh gia kdt qua ciia thu thuat VH hidu '., qua dieu tn
^ Trong vd ngay sau khi lam thii thudt phdn loai giai phdu ITnh maeh tmh, sd luang Coil si> dung, sd nhanh bdn cdn niil, kdt qua didu tri: tdc hoan loan hoae khdng hoan loan,
^ bidn chirng trdi Coil, ton thuang Ihanh mach, huydt khdi ITnh mach
+ Sau Ihdi gian 3 thdng dua tren cac kdt
•'•qua sidu dm, xet nghiem hnh dich dd, ndi tidt
;IH6 nam ddng thdi Iheo doi cac bien chirng jS'mudn nhu tran dieh mang tmh hoan, teo tmh,.
3. Dao diHC nghien cii'u
Nghien cii'u thue hidn true liep trdn benh nhdn nen cac thdng tin ndng vd benh tdl trong hd sa benh an duae gdn ma sd dd dam bao tinh chinh xac, hodn todn d u o c bao mdt vd ehi d u a c sir dung cho mue dieh nghien ciru i l l . K E T Q U A
Tir 11/2010 ddn 06/2011, su' dung sieu dm Doppler mau, chung tdi da chdn dodn gidn ITnh maeh tmh cho 21 trudng hap vdi do tudi trung binh 23,7 ± 5,07 (dao ddng 12 - 34 tudi).
''JCNCYH83(3)-2013
TAP CHi NGHIEN CU'U Y HQC • trong dd thudng gdp nhat lii' 21 - 28 luoi Tneu Chung lam sang gdp nhieu nhdt Id dau tu'c viing biu 14/21 (66,7%), l u s d lhay biii gidn ITnh mach 7/21 (33,3%), cham con 4/21 (19,1%), tdng bdi liet m6 hdi viing blu 4/21 (19,1%) vd tdl phdt sau di4u t n c a n thidp
Bang 2. Dac didm hlnh anh cua gian tTnh mach t i n h tren sieu a m Doppler mau mach 3/21 (14,3%)
Chi dmh sidu dm Doppler mau de chan dodn bdnh ly gidn tTnh mach hnh, Hinh anh bill gidn lhay doi trdn sieu am trudc va sau khi Idm nghidm phdp Valsalva d u o c ghi nhan {bang 2)
Tho'i diem lam sieu am Doppler mau
Du'O'ng kinh biii tTnh
mach (mm) (n = 21)
Tru'dc khi lam nghiem phdp Valsalva
< 1,5 1,5-2 2 - 2 , 5
>2,5 3-3,5 3,5-4
2 6 9 4 4 13
9,52 28,57 42,86 19,06 19,05 61,9 Sau khi lam nghiem phap
Valsalva
19,05
Oanh gia mirc dd gian tTnh mach tmh tren Idm sang dua vdo s a hodc quan sat thay bin gian tTnh mach theo tieu chudn cua T 6 chuc Y Id Thd gioi [3] vd ddng mau trao nguae theo Ihdi gian trudc va sau khi lam nghiem phap valsava trdn sidu dm Doppler mau theo tieu chuan ciia Cornud [4], kdt qua Irong bang 3
Bang 3. phan do gian tTnh mach t i n h tren lam s a n g va sieu am Phan
1 III Tong so
do Lam sang
0 7 (33,3%) 14 (66,7%) 21 (100%)
Siei u a m Doppler mau 0 6 (28,57%) 15(71,43%) 21 (100%)
Chi dinh can thiep mach de didu tn biii gidn tTnh mach bdng vdl lieu coils kim loai hoac dung dich keo smh hoc de gay xa tdc mach Kdl qua Idl ca 21 benh nhan ddu duoc nut tdc hodn todn ITnh mach tmh gidn, Bidn chirng trong qud trinh can thiep gdm ton thuang thanh maeh 1/21 (4,76%) va trdl hda chdt nut maeh 2/21 (9,52%)
Thdi gian ndm vien trung binh Id 1,1 ± 0,3 ngay {dao dong tii* 1 - 2 ngay)
Theo ddi sau 3 thang thdy dudng kinh trung binh eiia tTnh maeh tmh sau lam nghiem phdp Valsalva giam trung binh Id -1,32 ± 0,08mm (dao ddng ttr -1,5 - 0,5mm), toe do ddng chay gram sau khi lam nghidm phap IS
TCNCYH 83 (3) 2013
- TAP CHI NGHIEN CU'U Y HOC - 0,39 ± 0,21mm (dao ddng lii' -0,6 - 0,8mm),
The lich tmh hoan khdng cd s u thay doi trudc va sau didu In vdi p < 0,05, Cd 2 Irudng hap (9,52%) vdn edn ddng trao nguac dd II sau didu In va 3 trudng hap (14,28%) cd trdn djch mang tinh hodn Khdng cd ly Id ldi phdi trong loan bd nghien cuu
IV. BAN LUAN
Vd luoi: trong 21 benh nhan duo'c nghien CLTU, tuoi trung binh Id 23,7 ± 5,07 (dao ddng tir 12 • 31 tuoi nhung nhdm tuoi hay gdp nhdt Id tir 21 - 28 chidm ty Id 61,9% (13/21 benh nhan) Ty Id ndy phu hop vdi edc nghien cii'U cua Meachman va Kursh vdi 22% nam gidi khoe manh cd gian ITnh maeh tmh, trong dd 68% Id nam gidi tre tuoi (5, 6] Nguyen nhan gian ITnh mach tmh hay gap d lira luoi nay Id do su phat tnen nhanh ve kich thude cua tTnh mach tmh va edc hoat ddng the luc manh, dae biet d nhu'ng ngudi choi the thao
Lam sang: dau tire viing biu Id tneu ehirng phd bien nhdt khidn benh nhdn ddn khdm (66,7%) Co thd sd thdy biii tTnh mach gian di kem vdl dau lire vung biu ben Ddi vdi nhCrng trudng hop den khdm vi ehdm eon va biii gian
•' tTnh maeh tai phat sau didu tn can thiep maeh thi ty le benh lan luat Id 1 9 , 1 % va 14,3%
Theo Kocvara, ty Id gian ITnh maeh tmh trong
^ cac benh nhan cham con la 40% edn theo Yavelz, ty le lai phdt gidn ITnh mach tmh sau can thiep maeh Id 37% [7, 8] S u chenh lech '' tuang ddi Idn giu'a kdt qua nghidn eiru eua Chung ldi vdi cac tae gia tren co the la do each lua chon benh nhan nghien ciru
Bdi vdl hinh anh cua gian ITnh maeli tmh
!£• tren sidu am Doppler mdu (hinh 1), chimg tdi 3' thdy dudng kinh Idn nhdt cua biii tTnh maeh '• tmh VLjng biu trudc khi Idm nghiem phap
Valsalva hay gap la tii' 2 - 2,5mm (42,86%), sau khi lam nghiem phap thudng gian tu' 3,4 - 5mm (61,9%) D d nhay cua sieu am trong ehan dodn ITnh maeh tmh da duoc khdng dmh qua nhieu nghien cii'u. Theo Petros, ty Id gidn tTnh maeh tinh tren Idm sang la 7 1 % vd trdn sidu dm 93 % [9] Theo Hoekstra thdy chi khi tTnh mach tmh gidn tii' 3 - 3,5 mm thi mdi ed the s d thay tren lam sang [10]
D 6 I vdl chi dmh didu tri niit maeh ty Id gdp ddng trdo nguac mirc dd III tren sieu dm Id 15 benh nhdn (71,43%), phii hop vdi Idm sdng khi ma cac benh nhdn gidn ITnh mach do III eung hay gap nhdt (66,7%) Viec danh gia ddng trao nguae tTnh maeh giup Idm tang dd nhay. dd dae hieu cua sieu am trong chdn dodn gidn llnh maeh tmh Nghien eiru eua Cornud [4] tren 403 benh nhan duac sieu am, chup ITnh mach trude niit maeh eho thdy ddng trao nguac dd III ludn cho kdt qua duong tinh tren chup tTnh mach Ddi vdi ddng trao nguoc do II thi ty le nay chiem tdi 80% Tac gia cho rdng vdi nhung benh nhdn khdng cd tneu chung lam sang thi ddng trao nguac mirc dd III mdi cdn didu In (hinh 2)
Hinh 1. Gian tTnh mach t i n h trai sau khi lam nghiem phap Valsalva
TCNCYH 83 (3) - 2013
TAP CHi NGHIEN CU'U Y HOC •
Hinh 2. Ddng trao ngu'crc do I Vdl nhu'ng truang hop cd c&i dmh dieu In
nut gian tTnh mach tmh dd III Iren Idm sdng (66 7%) thi c d 7 bdnh nhdn gian do II trdn sidu dm Doppler mau (33,3%), khdng cd trudng hap ndo gian dd I Nghidn ciru ciia Chiou [11]
tren 127 truang hap gian tTnh maeh hnh eho thdy cd 59 bdnh nhan gian dd III (46,5%), 57 benh nhan gian dd II (44,9%) vd 11 benh nhan gian do I (8,7%) vdi dd nhdy trdn sieu dm Doppler ldn luat la 100% vdi gian dd 11 va III vd 32% vol gidn dd I Vide phdn Ion eae truang hop duac niit ITnh mach tmh ddu gian d mire do III phii hap vdi cac tneu ehung Idm sang khi ma dau va tu s d thdy eae biii tTnh mach gian d vung biu la ede tneu ehii'ng chinh khidn benh nhdn den khdm benh
Kdt qua dieu In eho thdy 100% bdnh nhan gay tdc duae hoan loan tTnh mach tmh bdng phuang phdp can thiep niit mach Ty Id thanh cdng ciia phuang phap dat toi 92,4 - 96%, tuang duong vdi ket qua cua edc tae gia nudc ngoai [4, 8] Bidn chirng trong qua trinh can thiep la rach thanh mach (4,76%) vd trdi hda chat gdy xa (9,52%) tuang d u o n g vdi nghien cii'u ciia Cornud la tii' 5 - 1 1 % [4]
Thdi gian ndm vien trong nghien ciru trung binh la 1,1 ± 0,3 ngdy, luong d u o n g nghien ciru eua cdc tac gia nude ngodi [4, 6, 8] Thai
gian ndm vien ngdn vd n g u d i benh hoi phue nhanh sau can thiep la mdt uu diem Idn so voi ede phuang phdp didu tn khac vi thd ngu'di ta thudng chon p h u a n g phap can thiep nut mach han Id chon p h u o n g phdp didu tn bSng phdu thudt
Theo ddi sau 3 thang dieu In ehiing tdi th^y hdu nhu thd tieh tmh hoan hai ben khong bi anh h u d n g , khdng co bidn chirng teo tmh hodn The tich tmh hoan giam nhidu nhat sai didu In la 1,6 em^ (giam d u o i 20% so vdi the tieh truo'c khi didu In) Theo Cornud, khac voi cac phuang phdp didu tn phdu thuat, bien ehung teo tmh hodn rat il gdp trong qua trinh can thiep nut mach do khdng lam tdn thu'O'ng he bach huydt [4]
Sau dieu tn can thiep mach, dudng kinh trung binh va Ide do ddng ehay eiia tTnh mach tmh khi lam nghiem phap Valsalv'a giam di ro ret (p < 0,05) Nhidu nghien ciru cung cho thdy, tdc dd ddng chay vd dudng kinh tinh mach tmh sau can thiep giam vd gia In binh thudng [ 1 . 2 , 7],
Nghidn eiru cua ehung ldi ed 2 trudng hap (9,52%) vdn cdn ddng trdo nguac dd II sau didu In, Theo mdt sd tae gia [7, 10, 11], trong trudng hap ddng trao n g u a c ldn tai sau die"
tn xuat phdt tu' ITnh maeh tmh ngoai thi can
92 TCNCYH R:^n) 201^
• TAP CHl NGHIEN CUU Y HOC phdi hap ddnh gia ca d u d n g kinh tTnh mgch
dd Iheo ddi tdi phdt sau didu trj Cornud cho ring, nhidu trudng hop ddng trdo nguac do III (70%) sau didu tn cd the chuyen sang dd II (20%) Ddi vdi dd 11, ddng trao nguae chi het trong 50% s6 trudng hap [4]
V. KET LUAN
Sidu dm Doppler mdu de chi dmh niit gidn tTnh maeh tmh khi dudng kinh Idn nhat eua biii ITnh maeh tmh viing biu trude khi lam nghiem phdp Valsalva tir 2 - 2,5mm (42,86%), sau khi lam nghiem phdp tir 3,4- 5mm (61,9%)
Didu tn bdng can thiep niit gian ITnh mach tmh cho ty Id thanh cdng dat tdi 92,4 - 96%
Bidn chirng trong qua trinh can Ihiep didu tn Id rach thanh mach (4,76%) vd trdi hda chdt gay xa (9,52%) Thdi gian ndm vien va hoi phue sau didu tn ngan, trung binh Id 1,1 ± 0,3 ngay Theo ddi sau didu tn 3 thang the lich Imh hoan giam khdng dang kd so vai trudc khi didu tn (< 20%), dudng kinh trung binh va tdc do ddng chay ciia tTnh mach tmh khi lam nghidm phdp Valsalva ddu giam di rd ret (p < 0,05)
Lcrl cam e n
Nhdm nghien eiru xm ehan thdnh cam an khoa Chan dodn Hinh anh, benh vien Viet Dire va benh vidn Bach Mai da giup d d trong qud trinh nghidn eiru vd thue hien de tai
TAI LIEU THAM KHAO 1 Kocvara R et al. (2005). Lymphatic sparing laparoscopic varicocelectomy a mi- crosurgical repair J Urol. 173(5), 1751 - 1 7 5 4 2. Lord DJ, Burrows PE (2003). Pediatric vancoeele embolization, Tech Vase Inlerv Ra- diol 6(4), 1 6 9 - 1 7 5
3. WHO (2000). WHO Manual for the Stan
dardized Investigation, Diagnosis and Man- agement of the Inferhle Male' Cambridge, Cambridge University Press.
*.. Cornud et al (1992). Traitement non chirurgical des varieoedle par embolisation des veines spermatiques et interet du Doppler couleur dans le bilan pre el posl- embolisalion • Contraception, ferlilitd, sexualild, 20(11), 1 0 4 8 - 1053
5. Meacham RB et al (1994). The incidence of varicoceles in the general population when evaluated by physical examination, gray scale sonography and color Doppler sonography J Urol, 151(6), 1535-1538
6. Kursh ED (1987). What is the incidence of vancoeele m a fertile population^, Fertil StenI 48(3), 5 1 0 - 5 1 1
7. Kocvara R et al (2005). Lymphatic spar- ing laparoscopic varicocelectomy a microsur- gical repair J Urol, 173(5), 1751 - 1754
8. Yavetz H et al (1992). Efficacy of varico- cele embolization versus ligation of the left internal spermatic vein for improvement of sperm quality, International Journal of An dro I- ogy 15(4), 3 3 8 - 3 4 4
9. Petros JA et al (1991). Correlation of testicular color Doppler ultrasonography, physical examination and venography in the detection of left varicoceles in men with infertility J Urol, 145 (4), 785 - 788
10. Hoekstra, T o d d , Michael AW (1995).
The Correlation of Internal Spermatic Vein Palpability With Ultrasonographic Diameter and Reversal of Venous Flow, The Journal of Urology 153(1), 8 2 - 8 4
11. Chiou RK et al (1997). Color Doppler ultrasound cntena to diagnose varicoceles correlahon of a new scoring system w/ith physical examination Urology, 50(6), 953 - 956
' TCNCYH 83 (3)-2013
TAP CHi NGHIEN C U U Y HQC •
Summary
IMAGE CHARACTERISTICS OF TRIPPLEX ULTRASOUND AND RE- SULTS OF INTRAVASCULAR INTERVENTION IN VARICOCELE
Vancoeele disease is common in healthy male which cause difhculty lo have children, even infertility if the condition was not diagnosed and treated Today the diagnosis is mainly based on clinical symptoms and Tnpplex ultrasound The purpose of this study is lo describe the character- istics of Tnpplex ultrasound and to assess the result of vascular button intervention in varicocele Results 21 patients were diagnosed with varicocele by Tnpplex ultrasound and undenAfent intravascular intervention when the intravenous ultrasound images were largest in diameter ranged from 2 to 2 5 mm before doing the Valsalva test and from 3 4 to 5 mm after doing the Valsalva test, corresponding to grade II at 28 57% and grade III at 71 4 3 % The rate of vascular intervention was highly successful, reaching 92 4 - 96% The duration of the hospitalization and recovenng time after treatment averaged 1 1 ± 0 3 days The side effect of vascular rupture was 4 76% dunng surgery and dnfhng chemicals which cause cirrhosis (9 52%) After 3 months of treatment the semen volume was r reduced lo at most 1 6 e m ' compared to before treatment, the vein diameter was reduced to an average of -1 32 ± 0 08 mm, and the flow rate was decreased on the average to - 0 39 ± 0 21 mm after doing the Valsalva test with p < 0 05
Keywords: varicocele, Tripplex ultrasound
TCNCYH 83 (3) ' 201-
