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±q¸Ñ­å¦ì¸m¨Ó¬Ý¡A±q¹«Áѳ¡¡]inguinal¡^©Î§C¦ì¹«Áѳ¡¡]sub-inguinal¡^À³¸Ó¬O³Ì¦X¾Aªº¤â³N³¡¦ì¡A¥D­n¬Oâé¤YÀR¯ß¦^¬y¨t²Î¦pinternal spermatic veins, cremasteric and vasal veins¦b¦¹³B¥i»´©ö±´¬d±o¨ì¡C¦ý¦¹³B¦åºÞ¤×¨ä¬O§C¦ì¹«Áѳ¡¡]subinguinal¡^¦åºÞ¤ÀªK¦h¥B½ÆÂø¡A­n¦¨¥\¦a§¹¦¨ÀR¯ßºI°£¦P®É«O¯d°Ê¯ß¡B²O¤ÚºÞ¤Î¯«¸g«D±`§xÃø¡A¦Ó³y¦¨¶Ç²Î¦×²´¹«Áѳ¡ºë¯ÁÀR¯ß¦±±iºI°£³N¡]conventional inguinal ligation¡^ªº°ª¥¢±Ñ²v¤Î°ª³±Ån¿n¤ô²v¡C§Q¥ÎÅã·L¤â³N¥i¤j¤j§ïµ½³o­Ó¯ÊÂI¡AMarmar©MKimµ¥¤H³ø§i§Q¥ÎÅã·L¤â³N¡A¬I¦æ§C¦ì¹«ÁѺë¯ÁÀR¯ß¦±±iºI°£³N¡]microscopic sub-inguinal¡@varicocelectomy¡^¡A¦b466¨Ò¯f¤H¤¤´_µo²v¤£¨ì¢°%(16)¡AGoldsteinµ¥¤H¬I¦æÅã·L¹«ÁѺë¯ÁÀR¯ß¦±±iºI°£³N¡]microscopic inguinal vaicocelectomy¡^¡A´_µo²v¥u¦³0.6%¡A³±Ån¿n¤ôµo¥Í²v¤£¨ì1%(6)¡A¦]¦¹¥Ø«eÅã·L¹«ÁѩΧC¦ì¹«ÁѺë¯ÁÀR¯ß¦±±iºI°£³Nº¥¦¨«Ü¦h±M®aªº³Ì¨Î¿ï¾Ü¡C¥»°|¤j¬ù¤E¤Q¦~¥N´N¶}©l§QÅã·L¤â³N¦bºë¯ÁÀR¯ß¦±ªºªvÀø¡A¥D­n¬O¸g¥Ñ§C¦ì¹«Áѳ¡¡]sub-inguinal approach¡^¶i¦æ¤â³N¡A¦ý¦¹³B¦åºÞ¤ÀªK¦h¡A«D±oÅã·LÃè¡]6-25X¡^À°¦£¤£¥i¡A¤£¹L«á¨Óµo²{¸g¥Ñ°ª¦ì¹«Áѳ¡¡]±µªñ¤º¹«ÁÑÀô¡^¤â³N¡A¦¹³B¦åºÞ¤ÀªK¤Ö(17)¡A§Q¥Î¤j¬ù3-4Xªºloupe´N¥i»´©ö°µ¦nÀR¯ßªº­éÂ÷¤Îµ²²Ï¡A¦P®É¤S¥i°µ¦n°Ê¯ß¡B²O¤Úªº«O¯d¡A¬Ù®É¤S¬Ù¿ú¡A§Ú­Ì§Q¥Î³o­Ó¤èªk´X¦~¨Ó¦b254­Ó¯f¤H¤¤¡A´_µo²v¬ù3%¦Ó³±Ån¿n¤ôµo¥Í²v«h¬°1.4%(8)¡C

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1. Pryor JL, Howads SS (1987): Varicocele. Urol Clin North Am 14:499-513.
2. Gorelick J and Goldstein M. Loss of fertility in men with varicocele. Fertil Steril 59:613-616,1993
3. Jonson W. 120 infertile men. Br J Urol 47:230. 1975
4. Greenberg SH, Lipshultz LI, and Wein AJ. Experience with 425 subfertile male patients.J Urol 19:507, 1978
5. Dubin L, and Amelar RD. Etiologic factors in 1294 consecutive cases of male infertility. Fertil Steril 22:469, 1971
6. Goldstein M, Gilbert BR, et al. Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique. J Urol 148: 1808-1811, 1992
7. Cayan S, Kadioglu TC, et al. Comparison of results and complications of high ligation surgery and microsurgical high inguinal varicocelectomy in the treatment of varicocele. Urology 55: 751-754, 2000
8. Hsieh ML, Huang ST, Chen Y, Huang HC, WangTH, Chu HS, and Chang PL High Inguinal Loupe-assisted Varicocelectomy for Subfertile Men with Varicococeles: Technical Feasibility, Clinical Outcomes and Complications. Arch. Androl. 52:179-183,2006
9. Marmar JL, Corson ST, Batzer FR, Gocial BG. Insemination data on men with varicoele. Fertil Steril 57: 1084-1090, 1992
10. Daitch JA, Bedaiwy MA et al. Varicocelectomy improves intrauterine insemination success rates in men with varicocelectomy. J Urol 165: 1510-1513, 2001
11. Sayfan J, Adam YG, Soffer Y. A new entity in varicocele subfertility: the ¡§cremasteric reflux¡¨. Ferti. Steril 1980; 33: 88-90.
12. Polomo T. Radical cures of varicocele by to new technique: preliminary report. J Urol 61:604, 1949.
13. Rothman CM, Newmark H III, Karson RA. The recurrent varicocele ¡V a poorly recognized problem. Fertil Steril 1981; 35: 552-6
14. Murray RR Jr, Mitchell SE, Kadir S et al. Comparison of recurrent varicocele anatomy following surgery and percutaneous balloon occlusion. J Urol 1986; 135: 286 -9.
15. Hirsch IR, Abdel-Meguid TA, Gomella LG. Postsurgical outcomes assessment following varicocele ligation: laparoscopic versus subinguinal approach. Urology 1998; 51:810-5
16. Marmar JL, Kim Y. Subinguinal microscopic varicocelectomy: a technical critique and statistical analsis of semen and pregnancy data. J Urol 1994: 152: 1127-32.
17. Hopps CV, Lemer ML, Schlegel PN, Goldstein M. Intraoperative varicocele anatomy: a microscopic study of the inguinal versus subinguinal approach. J Urol 2003; 170:2366
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