Alom Manaf, Ziegelmann Matthew, Savage Josh, Miest Tanner, Köhler Tobias S, Trost Landon
Department of Urology, Mayo Clinic, Rochester, MN, USA.
Transl Androl Urol. 2017 Aug;6(4):761-772. doi: 10.21037/tau.2017.07.34.
From 2014-2016, our clinical practice progressively incorporated several male infertility and andrology procedures performed under local anesthesia, including circumcision, hydrocelectomy, malleable penile prostheses, orchiectomy, penile plication, spermatocelectomy, testicular prostheses, varicocelectomy, vasectomy reversal (VR), and testicular and microepididymal sperm aspiration (TESE/MESA). Given the observed outcomes and potential financial and logistical benefits of this approach for surgeons and patients, we sought to describe our initial experience.
A retrospective analysis was performed of all andrologic office-based (local anesthesia only) and select OR (general or monitored anesthesia care) procedures performed from 2014-2016. Financial and outcomes analyses were performed for infertility cases due to the homogeneity of payment modalities and number of cases available. Demographic, clinicopathologic, and procedural costs (direct and indirect) were reviewed and compared.
A total of 32 VRs, 24 hydrocelectomies, 24 TESEs, 10 circumcisions, 9 MESA/TESEs, 4 spermatocelectomies, 3 orchiectomies (1 inguinal), 2 microTESEs, 2 testicular prostheses, 1 malleable penile prosthesis, 1 penile plication, and 1 varicocelectomy. Compared to the OR, male infertility procedures performed in the clinic with local anesthesia were performed for a fraction of the cost: MESA/TESE (78% reduction), TESE (89% reduction), and VR (62% reduction). All office-based procedures were completed successfully without significant modifications to technique. Outcomes were similar between the office and OR including operative time (VR: 181 190 min, P=0.34), rate of vasoepididymostomy (VE) (23% 32%, P=0.56), total sperm counts (72.2 50.9 million, P=0.56), and successful sperm retrieval (MESA/TESE 100% 100%, P=1.00; TESE 80% 100%, P=0.36). To our knowledge, the current study also represents the first report of office-based VE under local anesthesia alone. For hydrocelectomy procedures, recurrence (4%) and hematoma (4%) rates were low (mean 4.2 months follow-up), although this likely relates to modifications with technique and not the anesthesia or operative setting. Overall, when given the choice, 86% of patients chose an office-based approach over the OR.
Office-based andrology procedures using local anesthesia may be successfully performed without compromising surgical technique or outcomes. This approach significantly reduces costs for patients and the overall healthcare system and has become our treatment modality of choice.
2014年至2016年期间，我们的临床实践逐步纳入了多项在局部麻醉下进行的男性不育和男科手术，包括包皮环切术、鞘膜积液切除术、可弯曲阴茎假体植入术、睾丸切除术、阴茎折叠术、精液囊肿切除术、睾丸假体植入术、精索静脉曲张切除术、输精管复通术（VR）以及睾丸和显微附睾精子抽吸术（TESE/MESA）。鉴于观察到的结果以及这种方法对外科医生和患者潜在的经济和后勤效益，我们试图描述我们的初步经验。
对2014年至2016年期间在男科门诊（仅局部麻醉）以及部分手术室（全身麻醉或监护麻醉）进行的所有手术进行回顾性分析。由于支付方式的同质性和可用病例数量，对不育病例进行了财务和结果分析。对人口统计学、临床病理和手术成本（直接和间接）进行了审查和比较。
共进行了32例输精管复通术、24例鞘膜积液切除术、24例睾丸精子抽吸术、10例包皮环切术、9例显微附睾/睾丸精子抽吸术、4例精液囊肿切除术、3例睾丸切除术（1例腹股沟）、2例显微睾丸精子抽吸术、2例睾丸假体植入术、1例可弯曲阴茎假体植入术、1例阴茎折叠术和1例精索静脉曲张切除术。与手术室相比，在门诊局部麻醉下进行的男性不育手术成本仅为其一小部分：显微附睾/睾丸精子抽吸术（降低78%）、睾丸精子抽吸术（降低89%）和输精管复通术（降低62%）。所有门诊手术均成功完成，技术无需重大修改。门诊和手术室的结果相似，包括手术时间（输精管复通术：181±190分钟，P = 0.34）、输精管附睾吻合术（VE）发生率（23%±32%，P = 0.56）、总精子计数（72.2±5090万，P = 0.56）以及成功获取精子的情况（显微附睾/睾丸精子抽吸术100%±100%，P = 1.00；睾丸精子抽吸术80%±100%，P = 0.36）。据我们所知，本研究也是仅在局部麻醉下门诊进行输精管附睾吻合术的首例报告。对于鞘膜积液切除术，复发率（4%）和血肿发生率（4%）较低（平均随访4.2个月），不过这可能与技术改进有关，而非麻醉或手术环境。总体而言，在有选择的情况下，86%的患者选择门诊手术方式而非手术室手术。
使用局部麻醉的门诊男科手术可以成功进行，而不会影响手术技术或结果。这种方法显著降低了患者和整个医疗系统的成本，已成为我们的首选治疗方式。
