显微镜下睾丸取精术治疗非梗阻性无精子症的手术结局及其预测指标分析  

Outcome and predictors of microsurgical testicular sperm extraction for non-obstructive azoospermia

作　　者：杨超[1] 田汝辉[2] 姚晨成 李宪辰 黄煜华[1] 陈慧兴[1] 李朋[1] 智二磊[1] 赵亮宇 汪小波 洪艳[1] 邓存忠 李铮[1] YANG Chao;TIAN Ruhui;YAO Chencheng;LI Xianchen;HUANG Yuhua;CHEN Huixing;LI Peng;ZHI Erlei;ZHAO Liangyu;WANG Xiaobo;HONG Yan;DENG Cunzhong;LI Zheng(Department of Andrology,Urologic Medical Center,Shanghai General Hospital,Shanghai Jiao Tong University School of Medicine,Shanghai 200080,China;不详)

机构地区：[1]上海交通大学附属第一人民医院泌尿外科临床医学中心男科,上海200080 [2]上海交通大学泌尿外科研究所

出　　处：《上海医学》2021年第7期501-505,共5页Shanghai Medical Journal

基　　金：国家重点专项研发计划(2017YFC1002003);中国科学院战略性先导科技专项(A类)(XDA16020701);国家自然科学基金(81701428,81871215);上海市第一人民医院临床研究创新团队建设项目(2020科165)。

摘　　要：目的探讨显微镜下睾丸取精术(m-TESE)在非梗阻性无精子症(NOA)治疗中的应用,并分析影响手术结局的因素和预测指标。方法回顾性收集2017年6月—2020年1月在上海交通大学附属第一人民医院就诊的677例NOA患者资料,统计患者手术结局,分析患者无精子症相关病因分类、年龄、性激素[卵泡刺激素(FSH)、黄体生成素(LH)、睾酮(T)、雌二醇(E_(2))、泌乳素(PRL)、抗苗勒管激素(AMH)和抑制素B]水平与手术结局的关系。结果纳入患者的FSH和LH分别为(27.5±15.7)和(14.3±9.1)U/L,均显著高于正常值上限。NOA患者病因分类依次为,特发性NOA 454例(67.1%),克氏综合征73例(10.8%),精索静脉曲张63例(9.3%),隐睾或有隐睾手术史45例(6.7%),Y染色体AZFc缺失19例(2.8%),睾丸炎16例(2.4%),辐射或放射治疗、化学治疗史7例(1.0%)。成功获取179例(26.4%)患者的精子;其中,睾丸炎患者取精成功率最高,为13/16;辐射或化学治疗、放射治疗史患者最低,为1/7。根据手术结局,将特发性NOA患者分为成功组和失败组。成功组患者的FSH和LH水平均显著高于失败组,而AMH水平显著低于失败组(P值均<0.05)。logistic回归分析结果表明,AMH、FSH和LH均对手术结局有一定的预测价值,其中AMH的拟合优度最佳(χ^(2)=31.477,P=0.0001)。绘制ROC曲线,AMH的AUC为0.713,FSH和LH分别为0.576和0.552。1例(0.1%)患者术后出现切口感染。结论m-TESE是治疗NOA的有效方法,患者病因是影响手术结局的重要因素。对于特发性NOA患者,AMH对手术结局的预测能力最高。Objective To explore the application of microsurgical testicular sperm extraction(m-TESE)in patients with non-obstructive azoospermia(NOA)and the predictors of the outcome.Methods A total of 677 NOA patients who underwent m-TESE procedures from June 2017 to January 2020 in our hospital were collected in this retrospective cohort study.The relationship between pathogeny,age,sex hormone levels(follicle stimulating hormone[FSH],luteinizing hormone[LH],testosterone[T],estradiol[E_(2)],prolactin[PRL],anti-Mullerian hormone[AMH]and statin B)and surgical outcome was analyzed.Results The levels of FSH and LH in the included patients were(27.5±15.7)and(14.3±9.1)U/L respectively,which were significantly higher than the upper limit of normal value.The etiological classification of NOA patients was as follows:idiopathic NOA in 454 cases(67.1%),Klinefelter syndrome in 73 cases(10.8%),varicocele in 63 cases(9.3%),operation history of cryptorchidism or cryptorchidism in 45 cases(6.7%),Y-chromosome AZFc deletion in 19 cases(2.8%),orchitis in 16 cases(2.4%),radiation,radiotherapy or chemotherapy history in 7 cases(1.0%).The sperm was successfully obtained from 179 patients(179/677,26.4%).The patients with orchitis had the highest success rate of sperm collection(13/16),while the patients with radiation,chemotherapy or radiotherapy history had the lowest success rate(1/7).In idiopathic NOA patients,successful cases had higher levels of FSH and LH and lower AMH level than losers(all P<0.05).AMH,FSH and LH had certain predictive value for surgical outcome,and AMH had the best goodness of fit(χ^(2)=31.477,P=0.0001).ROC curve showed that AMH displayed the highest AUC value(0.713)compared to FSH(0.576)and LH(0.552).Wound infection occurred in one patient(0.1%).Conclusion m-TESE is an effective procedure for the treatment of NOA.The etiology is closely associated with the successful rate of m-TESE.For patients with idiopathic NOA,AMH shows the best reliability to predict the outcome of m-TESE.

关 键 词：无精子症 取精术 显微手术 抗苗勒管激素 不育 男性 

分 类 号：R699.8[医药卫生—泌尿科学]