1、冷刀在血精治疗中的应用,LOGO,,TRANSURETHRAL INCISION FOR HEMATOSPERMIA CAUSED BY EJACULATORY DUCT OBSTRUCTION经尿道切开治疗射精管梗阻引起的血精H. FUSE, R. NISHIO, K. MURAKAMI, and A. OKUMURADepartment of Urology, Faculty of Medicine, Toyama Medical and Pharmaceutical University. Toyama. JapanArchives of Androhgy, 49:43338, 2003
2、,,A 51-year-old male consulted our University Hospital with a chief complaint of hematospermia. Hematospermia had been recognized 4 months earlier and treated with coagulants at a local clinic, but the disorder was not improved. The patient had 2 children一位51岁男性血精患者，病史4月余，局部使用促凝药，症状未改善。有2个孩子。,,Macro
3、scopic appearance of the semen was slightly red and 5- 10 red blood cells in the semen were detected per high-power field (x400).精液高倍镜下5-10个红细胞，肉眼红色。血常规、肝肾功能、细胞学检查、睾酮、LH、FSH、PSA均正常,,Transurethral ultrasonography demonstrated a cystic lesion surrounded by hyperechoic lesion at the middle level of the
4、 prostate (Figure 1),,vasography showed distal dilationof the ejaculatory duct (Figure 2).,,Magnetic resonance imaging (MRl) showed a high signal intensity lesion in the middle of the prostate at T1- and T2-weighed MR image (Figure 3).,,RESULTS,Under spinal anesthesia, urethrocystoscopy was performe
5、d and an enlarged vermontanum with orifice at the center was observed. A 3-Fr ureteral catheter was inserted into the orifice of the cystic lesion and the cyst wall was incised with a cold knife (OES Urethrotome, Olympus, Tokyo, Japan) guided by the catheter until the cyst was opened.腰麻下，膀胱镜3F输尿管导管插
6、入囊肿并用冷刀在导管引导下切开囊肿。,,During the procedure, a careful incision was made to avoid injuring the rectum 在这过程中要仔细操作避免损伤直肠。Following the incision of the cyst, bloody fluid spurted from the cyst. Inside of the cyst, 2 orifices were observed, which were considered to be ejaculatory ducts.从切口可见血性液体喷出，囊内可见2个孔，
7、考虑为射精管开口,,One month after surgery, hematospermia resolved completely and there has not been any recurrence for 7 months.术后1个月，血精完全消失，随访7个月未复发。,,DISCUSSION,the standard procedure for the treatment of ejaculatory duct obstruction with or without midline cyst involves transurethral resection or incisio
8、n of the ejaculatory ducts射精管梗阻伴或不伴囊肿的标准治疗方法是经尿道切除或切开射精管Potential complications associated with transurethral procedure of the disorder are rectal insult, urethral external sphincter injury, retrograde ejaculation, or urine reflux through the ejaculatory ducts潜在并发症包括直肠损伤、尿道外括约肌损伤、逆行射精、尿液逆流通过射精管。,,It
9、 is concluded that hematospermia induced by ejaculatory duct obstruction, especially when otherwise incurable, could be successfully treated with transurethral approach可以推断，射精管梗阻引起的血精，特别是其他方法无法治愈的，可以通过经尿道方法成功解决。,,顽固性血精症的微创诊治技术及其技巧李彦锋，粱培和等重庆医学2010年11月第39卷第22期（论著）,,研究的治疗方法,用经尿道途径，通过切开精阜，显露射精管，根据射精管扩张与
10、否，并结合经肛门精囊按摩，辨别射精管走行方向及其开口，冷刀切开射精管及其囊肿，应用输尿管镜沿射精管或囊腔路径，显露双侧精囊开口，从而对精囊进行观察，冲洗，电灼或开口切开术，恢复精道的通畅性。,,资料,入选21例患者，常规行经直肠超声(trans-rectal ultrasonography，TRUS)筛选性检查，特征性改变包括：前列腺内中线区域或偏向一侧的囊性结构或液性暗区；偶伴团块状增强回声，后伴声影，提示结石或钙化形成；精囊增大并呈囊性扩张；精囊区域的囊性或液性暗区。64排螺旋CT检查显示：前列腺中线区域或偏向一侧的射精管走形区域低密度影或囊性结构；偶伴单发或多发性钙化影；双侧或单侧精囊腺
11、明显增大，横径超过15cm；精囊区域显著增大的囊性结构。,,方法,电切镜观察精阜，多见精阜较正常显著隆起、增大，中央可见细小的射精管开口。采用自行改进的电切环，主要是将前端约5 mm宽度的电切环修整为约23 mm的电切环，并根据需要调整其弯曲的角度，以利精确切割组织。减少局部创伤。,,小心切开精阜，使隆起的精阜处变平或轻微凹陷，此时通常可显露双侧射精管开口，射精管如无扩张，一般难于辨认其开口，此时助手食指伸入肛门内，对双侧精囊区域进行挤压按摩，即可观察到射精管内流出乳白色略带胶冻状液体或暗红色、咖啡色血性液体，从而可分辨射精管开口及是否单侧或两侧精囊或射精管存在血精。,,选择流出暗红色、咖啡色
12、液体一侧，必要时应用导丝引导取冷刀小心向12：00方向挑开。即可见显著囊性扩大的射精管或囊肿并有血性液体溢出，换输尿管镜观察，部分患者可见射精管内黄褐色结石堆积，射精管囊肿远端侧后方一般可见菲薄半透明膜状物覆盖的精囊开口或裂隙状精囊开口，血精严重者可见从精囊开口处溢出明显血性液体。,,部分患者囊肿位于中线区域，与射精管及精阜无交通，切开囊肿其内未见血性液体，而是清亮无色液体。且囊肿各壁完整。未见与精囊的交通，此时。通过肛门挤压按摩精囊。囊肿壁外侧可见沿射精管溢出的血性精液，证实该类囊肿为Mullerian囊肿。导致射精管梗阻，引起血精。遂同上法切开扩大射精管并进行精囊的冲洗和观察。,,结果,1
13、5例可见精阜较正常显著隆起、增大，6例精阜未见明显改变；明确存在偏离中线的射精管囊肿(Wolffian囊肿)者7例，其中左侧6例，右侧1例。位于精阜深部中线区域的Mullerian囊肿或前列腺囊肿9例，其中，4例与双侧精囊及射精管无交通，提示符合Mullerian囊肿。5例于内壁的侧后方可见明显卵圆形裂隙状精囊开口，或被菲薄半透明膜状物覆盖的精囊开口。提示符合前列腺囊肿,,讨论,术中注意事项和技巧主要是：(1)精阜的显著隆起一般意味着该区域存在明显梗阻，故可直接应用电刀切除隆起的精阜；(2)如切除精阜后。深面不能直接显露囊肿，或难以分辨射精管，需结合肛门内精囊按摩，使血性液体从射精管溢出，从而
14、或插入导丝进行引导，或直接沿之小心向深部电切或冷刀挑开；(3)根据术中所见囊肿是否偏离中线，是否与精囊相沟通可鉴别囊肿的类型，并据情况行单纯切开、电灼或电切除处理；(4)对于较为深在的囊肿，需反复通过肛门指检的辅助确认电切的深度，避免损伤直肠；(5)如果是射精管囊肿，通过该囊肿通常仅能观察到一侧的精囊情况。需注意结合双侧精囊按摩，确认对侧精囊及射精管的通畅性，必要时可同时行对侧射精管切开；(6)对于存在与精囊无沟通的Mullerian囊肿处理后，需继续观察和探查双侧射精管的通畅性；(7)可应用输尿管镜对双侧射精管及精囊进行全面观察；(8)如有精囊囊肿，可行囊肿切开、电灼和电切除等处理。,,阅读体会,冷刀适用于前列腺小囊囊肿（射精管囊肿、苗勒氏管囊肿）引起的血精患者囊肿较大或表浅 电切与冷刀均可目前国内外文献报道较多应用电刀切开，应用冷刀切开较少，通过“冷刀 ，血精 or射精管”等关键词相互联合搜索万方数据库及pubmed仅找到2篇文章。且发表时间较早。,,,谢谢,
