RU2756019C1 - Minimally invasive method for surgical treatment of varicocele - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely to urology and andrology. Direct access to the pampiniform plexus is performed under local anesthesia. The testicular vein and the collaterals thereof - the pampiniform plexus - are ligated and transected in a single block at the site closest to the testicle, without using optical magnification.EFFECT: method provides a possibility of resecting the testicular vein with the maximum amount of venous collaterals without inflicting injury on the artery and the deferent duct, performing operative support without using optical magnification, method provides a possibility of using local anesthesia followed by rapid rehabilitation of the patient.1 cl, 1 ex

Description

The alleged invention relates to medicine, namely to urology, and can be used for the surgical treatment of patients with varicocele.

Varicocele to this day remains an interesting and ambiguously interpreted urological disease, one of the most common diseases among men, the frequency of occurrence of which, according to various authors, varies from 2.3% to 30% (Artyukhin A.A. Fundamentals of vascular andrology. M .: Academy, 2008. 222 pp., Clinical guidelines. Urology. Ed. By NA Lopatkin. - M. "Eotar-Media", 2007.). Varicocele is a proven cause of male infertility, the frequency of which is directly proportional to the clinical stage of the disease (Majzoub A, Elbardisi H, Arafa M, Agarwal A, Al Said S, Al Rumaihi K. Does the number of veins ligated during varicococele surgery influence post-operative semen and hormone results? Andrology. 2016 Jun 17.doi: 10.1111 / andr.12226). At present, the increased interest of clinicians is caused by the violation of the functional consistency of the testicles associated with changes in the scrotum with varicocele, as well as the extreme social significance of the pathology, tk. more than 40% of infertile marriages are caused by male infertility, and in 40-80% of cases, varicocele is the cause of reduced fertility. The most common varicocele occurs at the age of 15-30, as well as among athletes and manual workers. Athletes, especially professional ones, are at risk, since prolonged tension of the muscles of the abdominal wall, accompanied by an increase in intra-abdominal pressure and difficulty in the outflow of blood into the inferior vena cava, is one of the mechanical factors in the development of varicocele. There is no specific prophylaxis and conservative treatment for varicocele. Treatment of varicocele is only surgical. There are about 120 types of surgical interventions for varicocele known in the world, but most of them are only of historical importance due to the high incidence of relapses.

The most commonly used selective suprainguinal (laparoscopic clipping of the testicular vein), subinguinal and endovascular (phlebosclerosis) surgical methods for treating varicocele, which is associated with their safety and efficacy. Currently, there is no consensus in favor of this or that methodology, which determines the relevance of further research.

As an analogue, the method of microsurgical ligation of the spermatic cord veins from the subinguinal approach according to J.L. Marmar (JL Marmar, T. J. DeBcncditis, D. Praiss. The management of varicoceles by microdissection of the spermatic cord at the external inguinal ring // Fertil Sterii. - 1985. - Vol. 43. - P. 2279-2288. )

Disadvantages:

1. The need to use microsurgical techniques.

2. The need for anesthesia.

3. Long duration of surgery.

The closest analogue is microsurgical ligation of the spermatic cord veins according to Goldstein. (Goldstein M .: Complications and results of varicocelec-lomy, in Goldstein M (Ed): Surgery of Male Infertility. Philadelphia, WB Saunders, 1995, chapter 22). The method is carried out as follows: Under spinal anesthesia, a skin incision is made 2 cm below the external inguinal ring. The spermatic cord stands out from the surrounding tissues, is taken on the holder. Further, the testicle is dislocated into the operating wound. Revision, coagulation of collaterals of veins of the external testicular vein is performed. The testicle returns to the scrotum and then microdissection of the elements of the spermatic cord is performed using microsurgical techniques. The veins of the spermatic cord are ligated and resected. Hemostasis. Restoration of the integrity of the seminal fascia, wound closure.

Disadvantages:

1. The need to use microsurgical techniques.

2. The need for anesthesia.

3. Duration of surgery.

4. Operational trauma (dislocation of the testicle into the wound).

Tasks:

1. to develop a minimally invasive method of treating varicocele, providing high efficiency.

2. to develop a method for the treatment of varicocele, providing a decrease in the overall incidence of postoperative complications, the length of hospital stay, the duration of postoperative rehabilitation and the frequency of disease relapses in the postoperative period.

3. Develop an easy-to-follow treatment for varicocele.

To solve the set tasks, an approach was chosen that provides high efficiency - subinguinal ligation of the testicular vein with collaterals as close as possible to the testicle (since ileospermic reflux is the cause of recurrence in 10.7%). The most convenient place is in the projection of the plexus plexus, where venous anastomoses are formed. This access allows the use of local infiltration anesthesia. The anatomy of the location of the elements of the spermatic cord allows you to displace the vas deferens and the accompanying vessels back, thereby preventing injury to the latter. The venous system in this projection is represented by a plexus plexus and is well visualized without the use of microscopic techniques. In most cases, the testicular artery runs posteriorly, allowing the plexus to be ligated and traversed in a single block. When the artery is located in the thickness of the plexus, atraumatic dissection of veins and their separate ligation are possible. The method is comparable to the results of analogs, but it is minimally invasive and easy to use and to train a surgeon.

In relation to the closest analogue, the claimed method has the following technical result. The use of the proposed method for the treatment of varicocele allows to resect the testicular vein with the maximum number of venous collaterals in a single block as close as possible to the testicle without trauma to the artery and vas deferens, to perform an operation without using optical magnification, this method allows the use of local anesthesia followed by rapid rehabilitation of the patient.

The method is carried out as follows.

Under local infiltration anesthesia (sol. Lidocaini 1%), a vertical incision of the skin of the scrotum is made 3-4 cm below the external inguinal ring. The spermatic cord is secreted layer by layer from the surrounding tissues. The fascia of the spermatic cord is dissected longitudinally. The testicular artery, lymphatic vessels, the vas deferens with accompanying artery and vein move backward. The remaining veins of the plexus plexus are ligated in a single block with suture material 4 / 0-5 / 0 and intersected, the small branches are coagulated. Control of hemostasis. Layer-by-layer wound closure with interrupted sutures. Aseptic sticker. Suspension on the scrotum.

The inventive method for the treatment of varicocele has been clinically tested.

763 patients with grade I-III varicocele underwent subinguinal ligation of the testicular vein using the method accepted in the clinic. All patients were discharged on the 2nd day after surgery without complications. When observing patients for 12-60 months (after surgical treatment) on the basis of clinical, laboratory and instrumental studies (spermogram, ultrasound control) data for testicular hypotrophy, hydrocele was not detected, patients showed an improvement in spermatogenesis / or no progression of pathospermia during the observation.

Clinical example: Patient I., 28 years old, with a diagnosis of left varicocele II degree, confirmed by ultrasound examination. Was admitted to the clinic with complaints of pulling pain in the scrotum, mainly on the left side after moderate physical exertion. On examination: The condition is satisfactory. Body mass index: 24. The degree of muscle development is satisfactory. Ultrasound of the kidneys, bladder: ultrasound signs of organic pathology of the urinary system were not revealed. USDG signs of impaired renal vascular architectonics were not revealed. Ultrasound of the scrotum: ultrasound signs of grade II varicocele (confirmed by a positive Valsalva test, venous reflux and an increase in the diameter of the veins of more than 1.5 mm with Doppler examination of the spermatic cord vessels). Cyst of the right testicle. Spermogram: oligoasthenoteratozoospermia. Diagnosed with grade II varicocele. Cyst of the right testicle.

The patient underwent subinguinal ligation of the testicular vein on the left. Features of the operation: The operation was performed under local anesthesia sol. Lidocaini 1% - 20 ml. Surgical access 3-4 cm below the outer ring of the inguinal canal, 2 cm incision. Testicular artery, lymphatic vessels, vas deferens with accompanying artery and vein are pushed back. The veins of the plexus plexus are ligated with suture material 4 / 0-5 / 0, crossed, coagulation of small branches. Control of hemostasis. Layer-by-layer wound closure with 5/0 interrupted sutures. Aseptic sticker. Suspension on the scrotum. The operation time was 38 minutes. There were no intraoperative and postoperative complications. The patient was discharged 1 day after surgery. Restriction of physical activity, sports activities in the patient was 7 days. 3, 6, 12, 24 months after the operation: according to the ultrasound data for hypotrophy, hydrocele, relapse of varicocele was not revealed.

Claims (1)

A method of surgical treatment of varicocele, characterized in that under local anesthesia, direct access is made to the plexus plexus, where the testicular vein and its collaterals - plexus plexus are ligated and crossed in a single block in the place closest to the testicle, without using optical magnification.