ft4 A i . « TT^Hl Y HOC VIET NAM THANG 11-50 2/2010
VO TINH KHONG BE TAG KEM GIAN TINH MACH TINH: HIEU QUA
CUA VI PHAU COT TINH M A C H TINH GIAN HAI BEN NGA BEN - Biu Nguyen Thanh Nhu*, Nguyen H6 Vinh Phudc
•rtifjff •r'l'i.i l-^ijiJT lisya S i U ' V •''
TOM TAT
Md dau: Vd tinh khong be tac cd the do gian tmh mach tinh gay ra. Muc tieu: Khao sat hieu qua ciia phUdng phap vi phau cot tinh mach tinh gian hai ben nga ben-biu tren benh nhan vo tinh khong be tac co gian tmh mach tinh.
Ddi tUdng va phUdng phap nghien cii'u:
Nghien ciru lam sang tien ciTu md ta. Vi phau thuat cot tinh mach tinh gian hai ben nga ben-biu va sinh thiet tinh hoan dUdc thUc hien tren cac benh nhan dieu tri vo tinh khdng be tac cd kem gian tinh mach tinh, tai khoa Nam Hgc, benh vien Binh Dan, tir thang 01/2008 den 12/2008.
Ket qua: 41 benh nhan. Trong 1 nam theo doi, ti le cd tinh triing di dgng hau phau la 21,95% (9 trudng hdp). 1 trUdng hdp hien dang mang thai va 4 trUdng hdp da cd con (9,75%).
Ket luan: Vi phau cot tinh mach tinh gian hai ben nga ben-biu la mgt lUa chgn cho nhiing benh nhan vd tinh khong be tac cd kem gian tTnh mach tinh.
Tu' khoa: gian tinh mach tinh, vl phau thuat cot tinh mach tinh gian hai ben nga ben-biu, vo tinh khong be tac,
ABSTRACT
Non-obstructive azoospermia associated with varicocele: efTicacy of bilateral scroto-
inguinal microscopic varicocelectomy Background: Nonobstructive azoospermia can be caused by varicocele. Objective:
Evaluating efficacy of bilateral scroto-inguinal microscopic varicocelectomy in non-obstructive azoopermic men with varicocele.
*• BV Binh Ddn TP HCM
Methods: A prosspective clinical descriptive study. Bilateral scroto-inguinal microscopic varicocelectomy and testicular biopsy were performed on non-obstructive azoospemia patients with varicocele admitted from January 2008 to December 2008 at Department of Andrology, Binh Dan hospital.
Results: 41 patients. After 1 year, 21.95%
(9 cases) of those had motile sperm. 1 patient's wife has been pregnant and 4 patients had live births (9.75%).
Conclusion: Bilateral scroto-inguinal microscopic varicocelectomy is a solution for non obstructive azoospermic men with varicocele.
Key-words: microscopic varicocelectomy, non-obstructive azoospermia, varicocele.
I. MdOAU
Vd tinh dugc dinh nghia la khdng cd tinh trimg trong tinh dich khi xuat tinh, chilm khoang 1% nam gidi va len den 15% d nam gidi hiem mudn . Ti le benh nhan vd tinh khdng be tac (VTKBT) cd kem gian tinh mach tinh (GTMT) chilm tir 5-10% ^'\ Phau thuat cdt tmh mach tinh giup cai thien tinh dich dd trong 60-80% benh nhan vd sinh cd GTMT ^'^. Ngay ca trudng hgp vd tinh, phau thuat cdt tinh mach tinh cung giiip cd lai tinh triing trong tinh dich ^. Cac tac gia thuc hien nghien ciiu nay nham muc tieu khao sat hieu qua ciia phuong phap vi phau cdt tinh mach tinh gian hai ben nga ben-biu tren benh nhan VTKBT cd GTMT.
I & j • ; : f i ?
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HOI NGHj KHOA HOC LAN THlf IV • HOI TIET NIEU - THAN HOC VIET NAM
II. OOI TUONG VA PHUONG PHAP NGHIEN COU Day la nghien ciiu lam sang tien ciiu md ta. Doi tugng khao sat nhiing benh nhan dieu tri VTKBT kem GTMT, tai khoa Nam Hgc, benh vien Bmh Dan, tir thang 01/2008 din 12/2008.
Tinh dich dd trudc md dugc thuc hien tdi thieu 2 \hn, each nhau tdi thieu 1 thang.
Vi phau thuat cdt tinh mach tinh gian hai ben nga ben-biu ^ va sinh thiet tinh hoan dugc thuc hien tren cac benh nhan. Cac bien chiing nhu: tu mau biu, teo tinh hoan, tran dich tinh mac hoac GTMT tai phat dugc ghi nhan. Benh nhan dugc thuc hien tinh dich dd sau phau thuat mdi ba thang. Mdi benh nhan cd tdi thieu 2 lan thir tinh dich dd hau phau.
Ghi nhan tinh trang cd thai va/hoac cd con tu nhien hoac nhd hd trg sinh san.
III. KET QUA
Trong thdi gian 1 nam, tir thang 1/2008 den 12/2008, nghien ciiu khao sat 41 benh
nhan VTKBT, 100% cd GTMT hai ben. Tudi trung binh ciia benh nhan la 31,59 ± 4,37 (23-41 tudi). Tinh dich dd trudc md: cd vai tinh triing bit ddng trong 6 trudng hgp (14,6%) va sau khi quay ly tam khdng tim thay tinh triing trong 35 trudng hgp (85,4%).
Ket qua sinh thiet tinh hoan cd 6 trudng hgp giam sinh tinh (14,6%)), 10 trudng hgp ngimg sinh tinh nira chimg (24,4%)), 23 trudng hgp hoi chimg toan te bao Sertoli (56,l%o) va 2 trudng hgp thoai hda hyalin (4,9%)).
100%) benh nhan dugc theo ddi hau phau bang dien thoai va tham kham true tilp, ghi nhan ve thai ky va cd con. Thdi gian theo doi trung binh la 17,32 ± 2,29 (14 - 23 thang). 9 trudng hgp (21,95%)) cd tinh triing (TT) di ddng hau phau. 5 trudng hgp cd thai va co con (9,75%)), trong dd cd 3 trudng hgp da co con tu nhien va 1 trudng hgp cd con nhd thu tinh trong dng nghiem (TTTON) (bang 1).
Ten
NVT LVC NCD VTH HSC NVQ NAT NTH NDA
Bdng 1: Ket qua nhung trudn Sinh thiet hai tinh hoan
Sinh tinh nira chu'ng Sinh tinh nira chu'ng Hdi chirng toan te bao Sertoli
Giam sinh tinh Giam sinh tinh Giam sinh tinh Hdi chu'ng toan te bao Sertoli
Sinh tinh nira chu'ng Sinh tinh nira chu'ng
g h g p cd t i n h t n i n g va/hoac Thdi gian co
TT 3 thang 3 thang 9 thang 3 thang 6 thang 12 thang 3 thang 3 thang 3 thang
Mat do
(xloVml)
14 8 17
4 1 37 1 1 4
cd con hau Di dong
(Vo) 8 6 5 4 6 35
4 1 1
phau.
Co con/thai
TU nhien TU nhien TU nhien TTTON TTTON ChUa CO ChUa CO ChUa CO ChUa CO
Khdng cd cac bien chiing nhu tu mau biu, tai phat.
IV. BANLUAN ' 1, 1. Hieu qua trong cai thien tinh djch
do va CO thai/co con
Theo Matthews va nhieu tac gia khac, ti le cd tinh triing di ddng trong tinh dich sau phau thuat cdt tinh mach tinh gian thay ddi tir
teo tinh hoan, tran dich tinh mac hoac GTMT
21% len din 55% 1.3,4,5,7,9
(bang 2). Ti le co thai tu nhien ciia cac tac gia nay la 5,3-9,1%
(bang 2). Nhu vay, vd tinh khdng phai la vo vgng. Phlu thuat cdt tinh mach tinh cd the mang lai kha nang cd con cho cac cap vg chdng VTKBT. Ti le thanh cdng nghien ciiu
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Y HOC VIET NAM THANG 11 - SO 2/2010
ciia chiing tdi la 22%), thudc miic thip so vdi cac nghien eim khac, cd le do sd benh nhan ciia chiing tdi thudc nhdm "xku" (hdi chiing toan te bao Sertoli va thoai hda hyalin) cd ti le cao (bang 3). Ti le benh nhan cd hdi chiing toan te bao Sertoli trong nghien ciiu ciia chiing tdi la 56%) (23/41) so vdi nghien eim ciia Matthews ^ la 30% (3/10), cua Kim '* la 8,8% (3/34), cua Kadioglu^ la 20,8% (5/24),
cua Esteves ' la 35,3% (6/17) va ciia Lee ^ la 52,6% (10/19).
Ti le cd thai tu nhien trong nghien ciiu ciia chiing tdi la 7,3%) ciing tuong tu nhu cac nghien eim tren (bang 2).
Ti le sinh tre sdng khde manh trong nghien ciiu nay la 9,75%o (4 trudng hgp). Cac nghien ciiu khac khdng thay neu rd ti le nay.
Bdng 2 Tac gia Matthews (1998)^
Kim (1999)"
KadioqIu (2001)^
Pasqualotto (2003)^
Esteves (2005)^
Lee (2007)5 Chunq tdi (2010)
: Ket qua phau thuat cdt t i n n
22 28 24 15 17 19 41
Ky thuat mo VP dudi ben
VPben VPben VP dudi ben VP dudi ben
VPben VPben
o/o
2 ben 77 71 70,8
80 65 21 100
1 mach tinh Thdi gian
theo doi 10 thang 15 thang 13 thang
KR 19 thang
7 thang 17 thang
gian tren ben Sd BN CO TT sau mo
12 (55%)_
12 (43%)
^ 5 (20,8%) 7 (46,6%) 8 (47%) 7 (36,4%)
9 (22%)
1 nhan vd tinh.
So BN CO thai TU nhien
2(9,1%) 0 0 1 (6,7%)
KR 1 (5,3%) 3 (7,3%)
TTTON 3 2 Co KR Co KR 2
BN: benh nhan, KR: khdng rd, VP: vi phau.
2. Phau thuat gian tinh mach tinh mot ben hay hai ben ?
Trong vd tinh, GTMT da anh hudng tren ca hai tinh hoan, do vay phau thuat ca hai ben la hoan toan hgp ly. De chan doan GTMT chiing tdi dua tren kham lam sang va phau thuat tham sat biu ^, cac tac gia khac '•^•''•^''' dua tren kham lam sang nen ti le chan doan va phau thuat GTMT hai ben cua cac tac gia nay thap ban cua chimg tdi (21-80%) so vdi 100%). Dang tiee la cac tac gia nay, Matthews ^ Kim "*, Kadioglu \ Pasqualotto ^ va Lee ^ diu khdng cho biet ti le rieng biet cd tinh trung lai trong tinh dich cua cac trudng hgp md GTMT hai ben va cua cac trudng hgp phau thuat mdt ben, de cd thi biet dugc phau thuat GTMT hai ben cd thanh cdng cao ban la phlu thuat GTMT mdt ben hay khdng.
Nlu duac so sanh, cd le phlu thuat GTMT
hai ben cd ti le thanh cdng cao hon phau thuat GTMT mdt ben, vi, trong mdt nghien cuu so sanh su khac biet ciia ti le cd thai tu nhien ciia phau thuat GTMT hai ben va mdt ben (ddi vdi cac trudng hgp hiem mudn do thilu nhugc tinh kem GTMT), Libman^ ghi nhan ti le cd thai tu nhien ddi vdi nhimg trudng hgp cdt tinh mach tinh gian hai ben la 49%, cao hon so vdi nhdm benh nhan cdt tinh mach tinh gian mdt ben la 36%o.
3. Lien quan giCra ket qua sinh thiet tinh hoan va kha nang co tinh triing trong tinh dich sau phau thuat
Sinh thiet tinh hoan la mdt veu td quan trgng de tien lugng hau phau ' . Ngoai trir bao cao ciia Pasqualotto ^, cac bao cao khac (ke ca nghien eim cua chiing tdi) deu ghi nhan cac trudng hgp giam sinh tinh hay ngimg sinh tinh nira chimg cd tien lugng tdt
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HOI NGHI KHOA HOC LAN THlf IV • HOI TIET NIEU - THAN HOC VIET NAM
ban la hdi chimg toan te bao Sertoli (bang 3).
Ti le cd TT lai trong tinh dich ddi vdi cac trudng hgp giam sinh tinh la 40-100%, ngimg smh tinh nua chimg la 21-100%) va hdi chiing
toan tl bao Sertoli la 0-10%. Chiing tdi chua ghi nhan trudng hgp thoai hda hyalin nao co TT trong tinh dich hau phau.
Bdng 3: Lien quan giiia ket qua sinh thiet tinh hoan va Tac gia
Matthews '' Kim (1999)"
Kadioglu (2001)^
Pasqualotto (2003)^
Esteves (2005)^
Lee (2007) ^ Chiing tdi (2010)
Giam sinh tinh n
4 18
5 4 6 3 ' 6
CoTT 4 (100%)
10 (56%) 2 (40%)
0 5 (83%) 2 (67%) 3 (50%)
d le cd TT trong tinh dich hau phaa Ngiing sinh tinh
nu'a chijrng n
3 13 14 6 5 ' 6
10
C6TT 3 (100%)
5 (39%) 3 (21%) 3 (50%) 3 (60%) 4 (67%) 4 (40%)
Hoi chu'ng toan te bao Sertoli n
3 3 5 5 6 10 23
C6TT 0 0 0 4 (80%)
0 1 (10%) 2 (8,7%)
V. KET LUAN
Vd tinh khdng be tac khdng phai la vd vgng, ngay ca khi ket qua sinh thiet tinh hoan la hdi chiing toan te bao Sertoli. Vi phau cdt tinh mach tinh gian hai ben nga ben-biu mang lai kha nang cd tinh trung di ddng trong tinh dich va cd con sinh hgc tu nhien hay kem hd trg sinh san cho nhirng benh nhan VTKBT cd kem GTMT.
TAI LIEU THAM KHAO
1. Esteves SC, Glina S (2005). Recovery of spermatogenesis after microsurgical suBinguinal varicocele repair in azoospermic men is related to testicular histology. Int BrazJ Urol; 31(6):541-548.
2. Goldstein M. Surgical management of male infertility and other scrotal disorder. In Campbell - Walsh's Urology 2007, W.B Saunders, 1532-1587.
3. Kadioglu A, Tefekli A, Cayan S (2001).
Microsurgical inguinal varicocele repair in azoospermic men. Urology; 57:328-333.
4. Kim ED, Leibman BB, Grinblat DM (1999). Varicocele repair improves semen parameters in azoospermic men with spermatogenic failure. J Urol; 162:737-740.
5. Lee JS, Park HJ, Seo JT (2007). What is the indication of varicocelectomy in men with nonobstructive azoospermia?. Urol;
69:352-355.
6. Libman J, Jarvi K, Lo K (2006). Beneficial effect of microsurgical varicocelectomy is superior for men with bilateral versus unilateral repair. J Urol; 176:2602-2605.
7. Matthews GJ, Matthews ED, Goldstein M (1998). Induction of spermatogenesis and achievement of pregnancy after microsurgical varicocelectimy in men with azoospermia and severe oligoasthenospermia.
Fertil Steril; 70:71-75.
8. Nguyen Thanh Nhir, Tran Chung Thiiy, Mai Ba Tien Dung (2010). Vi phlu thuat cot tinh mach tinh gian hai ben nga ben-biu: hi?u qua dieu trj trong hiem mugn nam. Tap Chi Y Hgc Thuc Hanh; 14 (2):43-47.
9. Pasqualotto FF, Lucon AM, Hallak J, Goes PM, Saldanha LB, Arap S (2003).
Induction of spermatogenesis in azoospermic men after varicocele repair. Human Reproduction; 18 (1): 108-112.
10. Weedin JW, Khera IVl, Lipshultz Ll (2010).
Varicocele repair in patients with nonobstructive azoospermia: a meta-analysis.
JUrol; 183(6):2309-2315.
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