淺論大鼠一側(cè)睪丸扭轉(zhuǎn)后切除對另側(cè)睪丸組織的保護作用

1、淺論大鼠一側(cè)睪丸扭轉(zhuǎn)后切除對另側(cè)睪丸組織的保護作用                  作者：王浩，秦樂，黃淵，陳肖鳴【摘要】  目的 ：探討大鼠一側(cè)睪丸扭轉(zhuǎn)后行切除術(shù)對另側(cè)睪丸組織的保護作用。方法：將63只青春期前SD大鼠隨機分為假手術(shù)組、扭轉(zhuǎn)復位組和扭轉(zhuǎn)切除組，每組21只。假手術(shù)組將左側(cè)陰囊打開分離暴露睪丸后，不予扭轉(zhuǎn)，即將睪丸再固定于陰囊壁上，并縫合陰囊。扭轉(zhuǎn)復位組和扭轉(zhuǎn)切除組則依Turner法建立左側(cè)睪丸扭轉(zhuǎn)模型，均先扭轉(zhuǎn)4 h，

2、其后前者行復位固定術(shù)，后者行切除術(shù)。三組分別于復位后4 h、24 h、1周各處死大鼠7只，取右側(cè)睪丸行丙二醛（MDA）、白介素-6（IL-6）檢測及病理評估，左側(cè)睪丸僅行病理評估。結(jié)果 ：各組左側(cè)睪丸病理評分值均達到最差分數(shù)，病理切片結(jié)果示存在絕大部分壞死或完全性壞死。與扭轉(zhuǎn)切除組比較，扭轉(zhuǎn)復位組對側(cè)睪丸的MDA、IL-6值、病理評分等均有不同程度升高，且1周時生精細胞層數(shù)結(jié)合精細小管直徑所示的預(yù)后情況亦較差；而各指標在扭轉(zhuǎn)切除組與假手術(shù)組的相比中未示明顯差異。結(jié)論 ：單側(cè)睪丸扭轉(zhuǎn)復位后對側(cè)睪丸早期即可出現(xiàn)繼發(fā)性損傷。在明確扭轉(zhuǎn)側(cè)睪丸出現(xiàn)壞死后，不復位直接行切除術(shù)可以保護對側(cè)睪丸。 【關(guān)鍵詞】

3、  一側(cè)睪丸扭轉(zhuǎn) 對側(cè)睪丸損傷 睪丸切除術(shù) 保護Abstract:  Objective: To explore the protective effects of orchiectomy on contralateral testis of SD rats with unilateral testicular torsion through the biochemical and histological indexes. Methods ：Sixty-three prepubertal Sprague-Dawley rats were randomly divided

4、into 3 groups， with 21 rats in each group. The sham operation group underwent a sham operation of the left testis under general anaesthesia. The torsion/detorsion group and the torsion/orchiectomy group underwent a similar operation but the left testis was rotated 720 °clockwisely for 4 h， main

5、tained by fixing the testes to the scrotum，then detorsion was performed in the torsion/detorsion group，while orchiectomy was performed in the torsion/orchiectomy group. Both testes of seven rats from each group were sacrificed at 4 hour，24 hour and 1 week intervals after surgery. Then，the biochemica

6、l parameters such as malondialdehyde (MDA) and interleukin-6 (IL-6) were evaluated ；histology index and seminiferous tubule diameter were assessed on right testes，while the left were only assessed by histology index. Results:Compared with The torsion/orchiectomy group，the biochemical parameters and

7、histological grades in the torsion/detorsion group increased in different degrees， and the prognosis status demonstrated by the number of spermatogenic cell associated with the decreased mean diameter of the seminiferous tubule， there are a worse prognoses in the torsion/detorsion group. However，the

8、re were no significant differences of every indexes between the sham operation group and the torsion/orchiectomy group. Its also known that all the left testes get the most vicious histological grade，and pathological sections showed completely necrosis or severe bulk necrosis. Conclusion:These resul

9、ts suggest that the injury of contralateral testes may occur in early time after unilateral testicular torsion/detorsion， and whenever，the testis necrosis definitely，performed orchiectomy after unilateral testicular torsion without detorsion can do protective effects on contralateral testis.Key word

10、s:  unilateral testicular torsion ；contralateral testis injury ；orchiectomy；protection睪丸扭轉(zhuǎn)是小兒外科臨床常見的急癥，處理得當與否將影響治療效果。研究表明，睪丸扭轉(zhuǎn)可導致精索內(nèi)營養(yǎng)血管箝閉，除致使同側(cè)睪丸急性缺血損傷外1，還可能致對側(cè)睪丸不同程度的受損。本研究擬通過動物實驗觀察單側(cè)睪丸扭轉(zhuǎn)復位后切除與否對側(cè)睪丸的影響。1  材料和方法1.1  動物分組  據(jù)Skoglund統(tǒng)計，該病發(fā)生集中于青春前期，平均年齡為14.9歲，故選取相應(yīng)時段的2830 d的健康雄性SD大

11、鼠63只，體重150200 g，隨機分為假手術(shù)組、扭轉(zhuǎn)復位組和扭轉(zhuǎn)切除組，每組21只。1.2  動物模型建立  所有大鼠均在術(shù)前以25%烏拉坦行腹腔注射全麻。假手術(shù)組將左側(cè)陰囊打開，分離暴露左側(cè)睪丸后即予固定縫合。扭轉(zhuǎn)復位組和扭轉(zhuǎn)切除組先依Turner法建立左側(cè)睪丸扭轉(zhuǎn)模型：左下腹小切口，游離左側(cè)睪丸，切斷睪丸引帶，分離周圍組織至附睪頭，睪丸順時針扭轉(zhuǎn)720 °，固定扭轉(zhuǎn)側(cè)睪丸防止自然復位，維持4 h后原切口打開，扭轉(zhuǎn)復位組復位扭轉(zhuǎn)睪丸并固定后關(guān)閉切口；扭轉(zhuǎn)切除組不予復位，直接切除扭轉(zhuǎn)的睪丸及附睪，結(jié)扎精索末端后縫合切口。1.3  標本制備 

12、各組大鼠分別于術(shù)后4 h、24 h、1周時以快速脫頸法處死7只，采集未扭轉(zhuǎn)側(cè)睪丸標本，將所有睪丸標本沿中軸切開分為兩部分，一部分睪丸用于制備組織勻漿，另一部分睪丸迅速置于10%的中性福爾馬林中待制作石蠟切片常規(guī)HE染色。扭轉(zhuǎn)側(cè)睪丸HE染色標本制作方法同未扭轉(zhuǎn)側(cè)。1.4  檢測方法1.5  統(tǒng)計學處理方法  多組比較用單因素方差分析，組間兩兩比較方差齊性用LSD檢驗，方差不齊性用Dunnett T3檢驗。         2  結(jié)果相對于假手術(shù)組與扭轉(zhuǎn)切除組，扭轉(zhuǎn)復位組的對側(cè)睪

13、丸MDA、IL-6值、病理評分（見表1、圖1）等均在術(shù)后4 h起有明顯升高（P0.05），而假手術(shù)組與扭轉(zhuǎn)切除組的同類指標比較差異無顯著性。另外，扭轉(zhuǎn)側(cè)睪丸損傷較重，損傷后4 h即可見組織內(nèi)大片凝固性壞死及細胞脫落，病理評分均達4分，后期組織結(jié)構(gòu)紊亂，細胞形態(tài)消失，故1周時無法行生精上皮層計數(shù)及MSTD測量（見圖2）。3  討論當前關(guān)于單側(cè)睪丸扭轉(zhuǎn)復位后是否可致對側(cè)睪丸損傷尚存爭議。部分學者認為早期對側(cè)睪丸無損害；多數(shù)學者則認為對側(cè)睪丸早期即可出現(xiàn)病理性改變7-9。本實驗中，扭轉(zhuǎn)復位組與假手術(shù)組對比，MDA作為細胞膜脂質(zhì)受氧自由基攻擊后的產(chǎn)物，可以間接反映體內(nèi)自由基的生成量，自4 h

14、起升高，提示睪丸組織內(nèi)自由基過量，存在過氧化損傷；IL-6是大鼠體內(nèi)主要的炎癥反應(yīng)遞質(zhì)之一，本身有趨化作用，其在局部的濃度和組織受損情況密切相關(guān)，自4 h起開始升高，提示睪丸組織內(nèi)炎癥遞質(zhì)聚集，間接證明存在損傷；而病理評分亦在4 h時升高，提示存在光鏡下可見的生殖細胞損傷；1周時生精上皮層計數(shù)與MSTD明顯降低，提示生精功能預(yù)后不良。結(jié)合上述，我們認為單側(cè)睪丸扭轉(zhuǎn)復位后可致對側(cè)睪丸早期出現(xiàn)損傷。另外，假手術(shù)組與扭轉(zhuǎn)切除組對側(cè)睪丸在各指標的比較中差異均未見顯著性，提示扭轉(zhuǎn)切除組中大鼠的對側(cè)睪丸無明顯受損。相比于前述扭轉(zhuǎn)復位組中大鼠睪丸的損傷情況，我們認為在一側(cè)睪丸扭轉(zhuǎn)后出現(xiàn)嚴重壞死的情況下，不予

15、復位而行睪丸切除對另側(cè)睪丸組織有顯著的保護作用。在我們此前的系列研究中已經(jīng)證實：對側(cè)睪丸的損傷主要來自單側(cè)睪丸扭轉(zhuǎn)復位后缺血再灌注損傷過程中過量生成的氧自由基和NO，其中NO的損傷作用更是占了主導地位。單側(cè)睪丸扭轉(zhuǎn)后不予復位而行切除避免了缺血再灌注損傷的發(fā)生，也就阻斷了過量的氧自由基和NO的生成途徑，進而保護了對側(cè)睪丸。當前臨床處理單側(cè)睪丸扭轉(zhuǎn)病例，發(fā)現(xiàn)扭轉(zhuǎn)側(cè)睪丸未完全壞死，一般需予復位保留；但是，即便對側(cè)睪丸出現(xiàn)完全性壞死，也往往由于各種原因（如：家屬要求、僥幸心理等）予以復位保留，但就本實驗結(jié)果來看，這類做法并不可取。【參考文獻】  1 姜濤,張仁科,宋希雙,等.睪丸扭轉(zhuǎn)處理與探

16、討J.中華男科學,2004,10(37),185-187.林濤,李旭良.單側(cè)睪丸扭轉(zhuǎn)后對另側(cè)睪丸影響的研究進展J.臨床小兒外科雜志,2003,2(6):442-443.李鐵強,朱朝陽,姜鴻胥,等.睪丸扭轉(zhuǎn)(附18例報告)J.中華泌尿外科雜志,2002,23(10): 631-632.Turner TT, Bang HJ,Lysiak JL.The molecular pathology ofexperimental testicular torsion suggests adjunct therapy tosurgical repairJ.J Urol, 2004,172(6):2574-25

17、78.Cosentino MJ, Nishida M, Rabinowitz R, et al. Histopathol-ogy of prepubertal rat testes subjected to various durationsof spermatic cord torsionsJ. Androl,1986,7(1):23-31.Aydin S, Ugras S, Odabas O, et al. Experimental testiculartorsion and its effects on the contralateral testicleJ.IntUrol Nephrol,1997,29(6):661-665.Savas C,Ozguner IF, Ozguner M,et al.The effects of unilat-eral testic