Surgical treatment of azoospermia caused by iatrogenic injury to bilateral vas deferens

: 目的: 探讨医源性双侧输精管损伤致无精子症的治疗经验。方法: 回顾性分析因医源性双侧输精管损伤致无精子症11例患者的临床资料，患者年龄20~33岁，术前诊断为无精子症；既往均有盆腔手术病史，其中7例儿时曾行双侧腹股沟斜疝修补术，4例曾行双侧隐睾下降固定术。 结果:　术中均行双侧腹股沟区探查，6例患者术中可见双侧输精管腹股沟管内段闭锁,切除闭锁段后，行显微镜下双侧输精管端端吻合术。5例可于内环口处或内环口附近见输精管被离断残端，远端输精管无法寻及，联合腹腔镜探查腹腔后，再行输精管端端吻合术，其中2例因单侧输精管腹腔段缺损较长，无法吻合，行单侧吻合。术后随访3个月至1年，7例患者精液常规查见精子，精子浓度为(0.4~35)×10⁶/ml，精子活力为15%~46%；4例未见精子。结论: 有盆腔手术史的无精子症患者，应特别注意医源性输精管损伤的可能，无张力的输精管吻合至关重要，必要时可通过改变解剖路径，缩短输精管行程来重建输精管。. METHODS: We retrospectively analyzed 11 cases of azoospermia caused by iatrogenic injury to bilateral vas deferens. The patients were aged 20－33 years, all diagnosed with azoospermia preoperatively and none with a history of pelvic operation. Seven of them had received bilateral inguinal hernia repair and the other 4 undergone bilateral orchidopexy in the childhood. RESULTS: Intraoperative exploration of the bilateral inguinal region was performed in all the patients. Bilateral vas deference atresia was found in the inguinal canal in 6 cases, which was treated by microscopic vasovasostomy following removal of the atresic segment. Vas deferens residual was observed in or near the deep inguinal ring in the other 5 cases, with the distal vas deferens inaccessible, which was treated by bilateral vasovasostomy in 3 cases and unilateral vasovasostomy in 2 (for longer defect segment than could be anastomosed) following combined laparoscopic exploration of the abdominal cavity. The patients were followed up for 3－12 months postoperatively, during which sperm were detected in 7 cases, with sperm concentration ranging from 0.4×10⁶/ml to 35×10⁶/ml and grade a+b sperm from 15% to 46%. CONCLUSIONS: For the diagnosis of azoospermia, especially in patients with no history of pelvic operation, special attention should be paid to iatrogenic injury to the vas deferens. For the treatment of the disease, non-tension vasovasostomy is essential and, when necessary, the vas deferens can be reconstructed by changing its anatomical path and shortening its length.