显微镜下精索去神经术治疗难治性睾丸痛的临床观察与分析
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摘要
目的:显微镜下精索去神经术是一种用于治疗难治性睾丸痛的治疗方式。有研究证实,精索相关神经纤维脱髓鞘是慢性睾丸痛(CO)的可能原因。方法:回顾性分析2014年8月～2018年2月我院28例行显微镜下精索去神经术患者的临床资料。入选标准为慢性睾丸疼痛持续3个月以上,保守治疗失败,神经和泌尿系统检查无阳性发现,且局部麻醉精索后疼痛暂时缓解,最终行显微镜下精索去神经手术。采用主观视觉模拟评分法(VAS)评估术前和术后疼痛,并使用客观标准化和验证的疼痛影响问卷-6(PIQ-6)分数。结果:成功随访28例患者,随访1年25例(89.3%)VAS提示疼痛显著减轻,其中15例(53.6%)疼痛完全缓解;3例(10.7%)无显著疼痛改变。PIQ-6评分显示,随访3个月19例(67.9%)患者有效疼痛缓解;术后6个月22例(78.6%)患者有效疼痛缓解,术后1年、2年均为23例(82.1%)患者有效疼痛缓解。结论:显微镜下精索去神经手术治疗是一种有效地治疗难治性CO的微创方法。
Objective: Microsurgical denervation of the spermatic cord is a treatment option for chronic orchialgia refractory to conservative treatment. A recent study showed specific nerve fibers as the possible cause of chronic orchialgia. Our goal was to present the outcomes of ligation of these nerves using a technique of targeted microsurgical denervation of the spermatic cord. Method: We retrospectively reviewed 28 cases who underwent targeted microsurgical denervation of the spermatic cord from August 2014 to February 2018. Selection criteria were chronic testicular pain more than 3 months in duration, failed conservative treatments, negative neurological and urological workup, and temporary resolution of pain with a local anesthetic spermatic cord block. Targeted microsurgical denervation of the spermatic cord was performed. Pain was assessed preoperatively and postoperatively using a subjective visual analog scale and objectively with the standardized and validated Pain Impact Questionnaire-6(PIQ-6) score. Result: Follow-up data were available on 28 cases. During a median follow-up period of 12(range, 10-29) months, 25 cases(89.3%) showed a significant reduction in pain and 3(10.7%) had no change in pain by subjective visual analog scale scoring. Of cases with a significant reduction in pain 15(53.6%) had complete resolution and 19(67.9%) had a 50% or greater reduction. Objective PIQ-6 analysis showed a significant reduction in pain in 78.6% of patients 6 months postoperatively, in 82.1% at 1 year, in 82.1% at 2 years. Conclusion: Targeted microsurgical denervation of the spermatic cord is an effective, minimally invasive approach with potential long-term durability in patients with refractory chronic orchialgia.
Objective: Microsurgical denervation of the spermatic cord is a treatment option for chronic orchialgia refractory to conservative treatment. A recent study showed specific nerve fibers as the possible cause of chronic orchialgia. Our goal was to present the outcomes of ligation of these nerves using a technique of targeted microsurgical denervation of the spermatic cord. Method: We retrospectively reviewed 28 cases who underwent targeted microsurgical denervation of the spermatic cord from August 2014 to February 2018. Selection criteria were chronic testicular pain more than 3 months in duration, failed conservative treatments, negative neurological and urological workup, and temporary resolution of pain with a local anesthetic spermatic cord block. Targeted microsurgical denervation of the spermatic cord was performed. Pain was assessed preoperatively and postoperatively using a subjective visual analog scale and objectively with the standardized and validated Pain Impact Questionnaire-6(PIQ-6) score. Result: Follow-up data were available on 28 cases. During a median follow-up period of 12(range, 10-29) months, 25 cases(89.3%) showed a significant reduction in pain and 3(10.7%) had no change in pain by subjective visual analog scale scoring. Of cases with a significant reduction in pain 15(53.6%) had complete resolution and 19(67.9%) had a 50% or greater reduction. Objective PIQ-6 analysis showed a significant reduction in pain in 78.6% of patients 6 months postoperatively, in 82.1% at 1 year, in 82.1% at 2 years. Conclusion: Targeted microsurgical denervation of the spermatic cord is an effective, minimally invasive approach with potential long-term durability in patients with refractory chronic orchialgia.
引文
1 Levine L.Chronic orchialgia:evaluation and discussion of treatment options[J].Ther Adv Urol,2010,2(5-06):209-214.
2 Nangia A K,Myles J L,Thomas AJ JR.Vasectomy reversal for the post-vasectomy pain syndrome:a clinical and histological evaluation[J].J Urol,2000,164(6):1939-1942.
3 Massaron S,Bona S,Fumagalli U,et al.Analysis of post-surgical pain after inguinal hernia repair:aprospective study of 1,440operations[J].Hernia,2007,11(6):517-525.
4 Calixte N,Brahmbhatt J,Parekattil S.Chronic Testicular and Groin Pain:Pathway to Relief[J].Curr Urol Rep,2017,18(10):83-83.
5 Chaudhari R,Sharma S,Khant S,et al.Microsurgical Denervation of Spermatic Cord for Chronic Idiopathic Orchialgia:Long-Term Results from an Institutional Experience[J].World J Mens Health,2019,37(1):78-84.
6许远兵,甘星.日间手术模式在显微镜辅助精索静脉曲张结扎术中的应用[J].临床泌尿外科杂志,2019,34(4):297-300.
7 Calixte N,Brahmbhatt J,Parekattil S.Genital pain:algorithm for management[J].Transl Androl Urol,2017,6(2):252-257.
8 Starke N R,Costabile R A.Medical management of chronic orchialgia[J].Transl Androl Urol,2017,6(Suppl 1):S48-S50.
9 Sinha V,Ramasamy R.Post-vasectomy pain syndrome:diagnosis,management and treatment options[J].Transl Androl Urol,2017,6(Suppl 1):S44-S47.
10 Tatem A,Kovac J R.Chronic scrotal pain and microsurgical spermatic cord denervation:tricks of the trade[J].Transl Androl Urol,2017,6(Suppl 1):S30-S36.
11 Marconi M,Palma C,Troncoso P,et al.Microsurgical Spermatic Cord Denervation as a Treatment for Chronic Scrotal Content Pain:A Multicenter Open Label Trial[J].J Urol,2015,194(5):1323-1327.
12 Calixte N,Tojuola B,Kartal I,et al.Parekattil.Targeted Robotic Assisted Microsurgical Denervation of the Spermatic Cord for the Treatment of Chronic Orchialgia or Groin Pain:A Single Center,Large Series Review[J].J Urol,2018,199(4):1015-1022.
13 Parekattil S J,Gudeloglu A,Brahmbhatt J V,et al.Trifecta nerve complex:potential anatomical basis for microsurgical denervation of the spermatic cord for chronic orchialgia[J].J Urol,2013,190(1):265-270.
14 Tu X A,Gao Y,Zhang Y D,et al.Microsurgical denervation of the spermatic cord for treatment of idiopathic chronic orchialgia[J].Chin Med J(Engl),2012,125(15):2784-2786.
15 Sigalos J T,Pastuszak A W.Chronic orchialgia:epidemiology,diagnosis and evaluation[J].Transl Androl Urol,2017,6(Suppl 1):S37-S43.
16 Oka S,Shiraishi K,Matsuyama H.Microsurgical Anatomy of the Spermatic Cord and Spermatic Fascia:Distribution of Lymphatics,and Sensory and Autonomic Nerves[J].J Urol,2016,195(6):1841-1847.
2 Nangia A K,Myles J L,Thomas AJ JR.Vasectomy reversal for the post-vasectomy pain syndrome:a clinical and histological evaluation[J].J Urol,2000,164(6):1939-1942.
3 Massaron S,Bona S,Fumagalli U,et al.Analysis of post-surgical pain after inguinal hernia repair:aprospective study of 1,440operations[J].Hernia,2007,11(6):517-525.
4 Calixte N,Brahmbhatt J,Parekattil S.Chronic Testicular and Groin Pain:Pathway to Relief[J].Curr Urol Rep,2017,18(10):83-83.
5 Chaudhari R,Sharma S,Khant S,et al.Microsurgical Denervation of Spermatic Cord for Chronic Idiopathic Orchialgia:Long-Term Results from an Institutional Experience[J].World J Mens Health,2019,37(1):78-84.
6许远兵,甘星.日间手术模式在显微镜辅助精索静脉曲张结扎术中的应用[J].临床泌尿外科杂志,2019,34(4):297-300.
7 Calixte N,Brahmbhatt J,Parekattil S.Genital pain:algorithm for management[J].Transl Androl Urol,2017,6(2):252-257.
8 Starke N R,Costabile R A.Medical management of chronic orchialgia[J].Transl Androl Urol,2017,6(Suppl 1):S48-S50.
9 Sinha V,Ramasamy R.Post-vasectomy pain syndrome:diagnosis,management and treatment options[J].Transl Androl Urol,2017,6(Suppl 1):S44-S47.
10 Tatem A,Kovac J R.Chronic scrotal pain and microsurgical spermatic cord denervation:tricks of the trade[J].Transl Androl Urol,2017,6(Suppl 1):S30-S36.
11 Marconi M,Palma C,Troncoso P,et al.Microsurgical Spermatic Cord Denervation as a Treatment for Chronic Scrotal Content Pain:A Multicenter Open Label Trial[J].J Urol,2015,194(5):1323-1327.
12 Calixte N,Tojuola B,Kartal I,et al.Parekattil.Targeted Robotic Assisted Microsurgical Denervation of the Spermatic Cord for the Treatment of Chronic Orchialgia or Groin Pain:A Single Center,Large Series Review[J].J Urol,2018,199(4):1015-1022.
13 Parekattil S J,Gudeloglu A,Brahmbhatt J V,et al.Trifecta nerve complex:potential anatomical basis for microsurgical denervation of the spermatic cord for chronic orchialgia[J].J Urol,2013,190(1):265-270.
14 Tu X A,Gao Y,Zhang Y D,et al.Microsurgical denervation of the spermatic cord for treatment of idiopathic chronic orchialgia[J].Chin Med J(Engl),2012,125(15):2784-2786.
15 Sigalos J T,Pastuszak A W.Chronic orchialgia:epidemiology,diagnosis and evaluation[J].Transl Androl Urol,2017,6(Suppl 1):S37-S43.
16 Oka S,Shiraishi K,Matsuyama H.Microsurgical Anatomy of the Spermatic Cord and Spermatic Fascia:Distribution of Lymphatics,and Sensory and Autonomic Nerves[J].J Urol,2016,195(6):1841-1847.