目的 总结胡桃夹综合征(nutcracker syndrome, NCS)合并中重度左侧精索静脉曲张(varicocele,VC)的临床特点及手术方法。方法 回顾性分析2012-07至2019-07民航总医院收治NCS伴有左侧VC患者8例。年龄15～54岁,平均25岁;平均体重指数18.3。临床表现为阴囊坠胀、疼痛,查体为中重度的左侧VC,精液分析示少精症或弱精症,尿常规示红细胞(+～+++)、蛋白(+～++)。彩超及腹部血管强化CT示腹主动脉与肠系膜上动脉夹角缩小压迫左肾静脉,平均夹角23.4°,左肾静脉的肾门处与受压处直径比较高,平均为5.1。所有患者均行左精索-髂外静脉分流术联合左精索静脉高位结扎术,术中于腹膜后将左侧精索静脉离断,近端与左髂外静脉端侧吻合,远端结扎。结果 手术均获成功,无切口感染、血栓形成等并发症。随访6个月,患者阴囊症状消失,尿潜血和尿蛋白转阴,阴囊彩超未探及精索静脉反流,术后的左肾静脉肾门处与受压处直径比、精子活力a+b级比率较术前有明显好转,差异有统计学意义(P<0.001),术后精子密度与术前相比无统计学差异。结论 NCS是临床少见疾病,常合并VC、血尿、蛋白尿,左精索-髂外静脉分流联合精索静脉高位结扎术治疗NCS合并VC是安全、有效的。
Abstract
Objective To summarize the clinical features of and surgical approaches to nutcracker syndrome (NCS) with moderate and severe left varicocele (VC). Methods The clinical data on 8 patients of NCS with left VC admitted to our hospital between July 2012 and July 2019 was retrospectively analyzed. The age of these patients ranged from 15 to 54 (mean 25 years old). The average body mass index was 18.3. The clinical manifestations were scrotal swelling and pain. Physical examination showed moderate to severe left VC while semen analysis pointed to oligospermia or asthenospermia. Routine urine tests showed microscopic haematuria (+-+++) and proteinuria (+-++). Ultrasonography and enhanced abdominal CT showed compression of the left renal vein due to the narrowing of the angle between the abdominal aorta and superior mesenteric artery, with an average angle of 23.4°. Left renalvein hilar diameter to aortomesenteric diameter ratio was high,with an average of 5.1. All patients received left spermatic-external iliac vein bypass combined with high ligation of left VC. During the surgery, the left spermatic vein was cut off retroperitoneally, the proximal end was anastomosed with the left external iliac vein end-to-side, and the distal end was ligated. Results All the operations were successful without such complications as incision infection or thrombosis. After 6 months of follow-up, it was found that scrotal symptoms and regurgitation of the spermatic vein had disappeared, so had haematuria and proteinuria. The postoperative ratio of the left renal vein hilar diameter to the aortomesenteric diameter ratio and the sperm motility a+b ratio were significantly improved (P<0.001), but sperm density did not change significantly (P=0.05). Conclusions NCS is a rare disease, which is often associated with VC, hematuria and proteinuria. Left spermatic-external iliac vein bypass combined with ligation of the spermatic vein is a safe and effective treatment of NCS with VC.
关键词
胡桃夹综合征 /
精索静脉曲张 /
静脉吻合 /
髂外静脉分流术
Key words
nutcracker syndrome /
varicocele /
venous anastomosis /
external iliac venous bypass
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参考文献
[1] Maloni K C, Calligaro K D, Lipshutz W, et al. Nutcracker syndrome as an unusual cause of postprandial pain [J]. Vasc Endovascular Surg, 2020, 54(3): 283-285.
[2] Dunphy L, Penna M, Tam E, et al. Left renal vein entrapment syndrome: nutcracker syndrome![J]. BMJ Case Rep, 2019, 12(9). doi:10.1136/bcr-2019-230877.
[3] Ananthan K, Onida S, Davies A H. Nutcracker syndrome: an update on current diagnostic criteria and management guidelines[J]. Eur J Vasc Endovasc Surg, 2017, 53(6):886-894.
[4] Orczyk K, Wysiadecki G, Majos A, et al. What each clinical anatomist has to know about left renal vein entrapment syndrome (nutcracker syndrome): a review of the most important findings[J]. Biomed Res Int, 2017, 2017: 1746570.
[5] Orczyk K, Labetowicz P, Lodziński S, et al. The nutcracker syndrome. Morphology and clinical aspects of the important vascular variations: a systematic study of 112 cases[J]. Int Angiol, 2016, 35(1): 71-77.
[6] Berthelot J M, Douane F, Maugars Y, et al. Nutcracker syndrome: a rare cause of left flank pain that can also manifest as unexplained pelvic pain[J]. Joint Bone Spine, 2017, 84(5): 557-562.
[7] De Macedo G L, Dos Santos M A, Sarris A B, et al. Diagnosis and treatment of the Nutcracker syndrome: a review of the last 10 years[J]. J Vasc Bras, 2018, 17(3): 220-228.
[8] Kurklinsky A K, Rooke T W. Nutcracker phenomenon and nutcracker syndrome [J]. Mayo Clin Proc, 2010, 85(6): 552-559.
[9] Kim K W, Cho J Y, Kim S H, et al. Diagnostic value of computed tomographic findings of nutcracker syndrome: correlation with renal venography and renocaval pressure gradients[J]. Eur J Radiol, 2011, 80(3):648-654.
[10] Said S M, Gloviczki P, Kalra M, et al. Renal nutcracker syndrome: surgical options[J]. Semin Vasc Surg, 2013, 26(1):35-42.
[11] Alaygut D, Bayram M, Soylu A, et al. Clinical course of children with nutcracker syndrome[J]. Urology, 2013, 82(3): 686-690.
[12] Avgerinos E D, Saadeddin Z, Humar R, et al. Outcomes of left renal vein stenting in patients with nutcracker syndrome[J]. J Vasc Surg Venous Lymphat Disord, 2019, 7(6):853-859.
[13] Velasquez C A, Saeyeldin A, Zafar M A, et al. A systematic review on management of nutcracker syndrome[J]. J Vasc Surg Venous Lymphat Disord, 2018, 6(2):271-278.
[14] 王声政, 张雪培, 陶 金, 等. 后腹腔镜下左肾静脉外支架术治疗胡桃夹综合征的疗效分析 [J]. 中华泌尿外科杂志,2017, 38(3): 174-177.
[15] Gilmore B F, Benrashid E, Geersen D, et al. Gonadal vein transposition is a safe and effective treatment of nutcracker syndrome[J]. J Vasc Surg Venous Lymphat Disord, 2020, 8. doi:10.1016/ j.jvsv.2020.09.002.
[16] Miler R, Shang E K, Park W M. Gonadal vein transposition in nutcracker syndrome[J]. Ann Vasc Surg, 2018, 46:205.e13-205.e16.
[17] Gong X Y, Zheng W, Du H, et al. Treatment of nutcracker syndrome with spermatic vein ligation and iliac vein anastomosis: case report of three cases[J]. Asian Pac J Trop Med, 2012, 5(11): 923-924.
[18] 陈国晓,张祥生,朱晓博,等 .显微镜下分流术治疗精索静脉曲张合并“胡桃夹”综合征的临床研究[J].中华男科学杂志, 2017, 23(9): 798-803.
[19] Xu D F, Gao Y, Chen J, et al. Laparoscopic inferior mesenteric-gonadal vein bypass for the treatment of nutcracker syndrome[J]. J Vasc Surg, 2013, 57(5): 1429-1431.
[20] Li H, Zhang M C, Jiang Y, et al. Microsurgical spermatic-inferior epigastric vein anastomosis for treating nutcracker syndrome-associated varicocele in infertile men: a preliminary experience [J]. Urology, 2014, 83(1): 94-99.
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