#16
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Óâàæàåìûé ä-ð Æèâîâ,
Hargreave T.B.: Varicocele: overview and commentary on the results of the World Health Organization varicocele trial. In Waites G.M.H., Frick J. and Baker G.W.H. (eds). "Current Advances in Andrology", Proceedings of the VIth International Congress of Andrology. Salzburg, Monduzzi Editore, Bologna, 31-44. Lenzi A., Gandini L., Bagolan P., Nahum A., Dondero F.: Sperm parameters after early left varicocele treatment. Fertil. Steril., 69: 347-349, 1998. Nieschlag E., Hertle L., Fischedick A., Behre H.M.: Treatment of Varicocele: Counselling as Effective as Occlusion of the Vena Spermatica. Annual Meeting of the Pacific Coast Fertility Society, held April 26-30, 1995 in Coronado, California. Nieschlag E., Behre H.M., Meschede D., Kamischke A.: Disoders and the testicular level. In Nieschlag E. and Behre H.M. (Eds), Andrology: Male Reproductive Health and Dysfunction. Springer, Heidelberg, pp. 133-159, 1997. Nieschlag E., Hertle L., Fischedick A., Abshagen K., Behre H.M.: Update on treatment of varicocele: counselling as effective as occlusion of the vena spermatica. Hum. Reprod., 13: 2147-2150, 1998. À ìîå ëè÷íîå ìíåíèå î âëèÿíèè âàðèêîöåëå íà àòðîôèþ ÿè÷êà è ò.ä. Âû ìîæåòå óçíàòü èç ìîåé êíèãè. Ïîâåðüòå, âîïðîñû âàðèêîöåëå ñëèøêîì ñëîæíû è ñåðüåçíû, ÷òîáû èõ ìîæíî áûëî ðåøèòü ïóòåì ýëåêòðîííîé äèñêóññèè.  êíèãå ðàññìîòðåíû ñàìûå ïðîòèâîïîëîæíûå è ïðîòèâîðå÷èâûå ìíåíèÿ ó÷åíûõ èç ñàìûõ ðàçíûõ ñòðàí, â ò.÷. è âåäóùèõ àìåðèêàíñêèõ èññëåäîâàòåëåé. Ðàáîòû M.Goldstein'a íàì êîíå÷íî èçâåñòíû, à åãî îïåðàòèâíûé ìåòîä ëå÷åíèÿ âàðèêîöåëå ñ âûâîðà÷èâàíèåì ÿè÷êà âðÿä ëè ïîëó÷èò ðàñïðîñòðàíåíèå. Ñ óâàæåíèåì Àëåêñàíäð Ïåðøóêîâ |
#17
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Óâàæàåìûé À.Ïåðøóêîâ, ñïàñèáî çà ñîäåðæàòåëüíóþ ìîíîãðàôèþ. Ñ÷èòàþ, äàííàÿ òåìà î÷åíü äèñêóòàáåëüíà. Ä-ð Æèâîâ ñòîðîííèê àìåðèêàíñêîãî ïîäõîäà ê ëå÷åíèþ âàðèêîöåëå, íî ãäå èñòèíà? Åñòü î÷åíü ìíîãî ñïîðíûõ ìîìåíòîâ. È ïîêà â Ðîññèè íå áóäóò ñîçäàíû ñòàíäàðòû , äî òåõ ïîð áóäóò ñóùåñòâîâàòü ðàçëè÷íûå òî÷êè çðåíèÿ è ðàçëè÷íûå ïîäõîäû ê äàííîé ïðîáëåìå. Ìîæåò ñòîèò îáñóäèòü íà Ïëåíóìå Ïðàâëåíèÿ Ðîññèéñêîãî îáùåñòâà óðîëîãîâ?
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#18
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Óâàæàåìûé ä-ð Àëåêñàíäð (íå çíàþ ê ñîæàëåíèþ Âàøåãî îò÷åñòâà) Ïåðøóêîâ. Ñïàñèáî çà ïðèâåäåííûå ññûëêè.
Èòàê, ðàáîòà Lenzi A. et al.á 1998 Àâòîðû ïèøóò ñëåäóþùåå: 1. The mean values of sperm parameters in the patient study group were similar to those of the healthy controls except that the sperm concentration was significantly lower. Ýòî ïåðåâîäèòñÿ íà ðóññêèé ÿçûê òàê: "Ñðåäíèå çíà÷åíèÿ ïàðàìåòðîâ ñïåðìîãðàììû èññëåäóåìîé ãðóïïû ïàöèåíòîâ íå îòëè÷àëèñü îò êîíòðîëüíîé ãðóïïû çäîðîâûõ, çà èñêëþ÷åíèåì òîãî, ÷òî (ó ïàöèåíòîâ) êîíöåíòðàöèÿ ñïåðìàòîçîèäîâ áûëà çíà÷èòåëüíî íèæå". 2. However, sperm motility and morphology mean values in the patient study group were significantly higher than those of the unoperated patients. Ïåðåâîä: "Òåì íå ìåíåå ñðåäíèå ïîêàçàòåëè ïîäâèæíîñòè è ìîðôîëîãèè ñïåðìàòîçîèäîâ ó ïàöèåíòîâ èññëåäóåìîé ãðóïïû áûëè çíà÷èòåëüíî âûøå, ÷åì ó íåîïåðèðîâàííûõ ïàöèåíòîâ". 3. CONCLUSION(S): This study indicates that surgery in adolescence can be useful, possibly because the testis is developing at that age. Large-scale, double-blind controlled trials on early treatment of left varicocele are needed to identify possible markers of disease severity. Ïåðåâîä: "Âûâîäû: Äàííîå èññëåäîâàíèå ïîêàçûâàåò, ÷òî îïåðàöèè ó ïîäðîñòêîâ ìîãóò áûòü ïîëåçíûìè, âîçìîæíî ïîòîìó, ÷òî ÿè÷êî ðàçâèâàåòñÿ â ýòîì âîçðàñòå. Áîëåå îáøèðíûå, äâîéíûå ñëåïûå êîíòðîëèðóåìûå èññëåäîâàíèÿ ëåâîñòîðîííåãî âàðèêîöåëå íåîáõîäèìû äëÿ òîãî, ÷òîáû èäåíòèôèöèðîâàòü âîçìîæíûå ìàðêåðû òÿæåñòè çàáîëåâàíèÿ". Âîò ññûëêà íà [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]. Èòàê, óâàæàåìûé Àëåêñàíäð (îïÿòü æå èçâèíèòå çà íåçíàíèå Âàøåãî îò÷åñòâà, ä-ðà A. Lenzi ñ ñîàâò., âî âñÿêîì ñëó÷àå ñóäÿ ïî öèòèðîâàííîé Âàì æå ñòàòüå, Âû ìîæåòå ñìåëî èñêëþ÷àòü èç ñâîèõ åäèíîìûøëåííèêîâ. Îíè îòñòàèâàþò äèàìåòðàëüíî ïðîòèâîïîëîæíóþ òî÷êó çðåíèÿ î òîì, ÷òî âàðèêîöåëå óìåíüøàåò ïîêàçàòåëè ôåðòèëüíîñòè è ÷òî äàííîå çàáîëåâàíèå ñëåäóåò îïåðèðîâàòü â ïîäðîñòêîâîì âîçðàñòå. Âèäèìî Âû íåòî÷íî ïåðåâåëè ñòàòüþ, ëèáî ÷åãî òî íå ïîíÿëè. Òåïåðü ïî ñëåäóþùåìó àâòîðó. Íó âî ïåðâûõ who is Dr. Eberhard Nieschlag? À îí åñòü ðåïðîäóêòèâíûé ýíäîêðèíîëîã, êîòîðûé çàèíòåðåñîâàí â òîì, ÷òîáû áîëüíûå ìóæñêîé èíôåðòèëüíîñòüþ íå îïåðèðîâàëèñü, à ïîëó÷àëè íåêîå êîíñåðâàòèâíîå ëå÷åíèå èëè øëè íà IVF/ICSI. Êñòàòè, ä-ð Ïðåøóêîâ, Âàøå çàìå÷àíèå ïî ïîâîäó "âûâîðà÷èâàíèÿ ÿè÷êà" êàê ïðåïÿäñòâèÿ ê ðàñïðîñòðàíåíèþ îïåðàöèè M. Goldstein (ìû ñäåëàëè óæå áîëåå 100 ìèêðîõèðóðãè÷åñêèõ âàðèêîöåëýêòîìèé ïî ýòîìó àâòîðó) ãîâîðèò î òîì, ÷òî Âû âåðîÿòíî íå ñîâñåì õîðîøî ñåáå ïðåäñòàâëÿåòå ýòó îïåðàöèþ, ñêîðåå âñåãî íå âèäåëè êàê îíà äåëàåòñÿ è ÷åì âîîáùå îòëè÷àåòñÿ îò âûñîêèõ ëèãèðîâàíèé ÿè÷êîâîé âåíû ïî Èâàíèññåâè÷ó/Ïàëîìî. Åñëè ÿ îøèáàþñü ïîæàëóéñòà âñå æå ñîîáùèòå â ÷åì Âû âèäèòå îòëè÷èå îïåðàöèè M. Goldstein îò îïåðàöèé Ïàëîìî/Èâàíèññåâè÷à? Êàê ñïåöèàëèñòó ïî ëå÷åíèþ âàðèêîöåëå ýòà ðàçíèöà äîëæíà áûòü Âàì õîðîøî èçâåñòíà. Ðàâíî êàê è òî, çà÷åì ïðè îïåðàöèè M. Goldstein "âûâîðà÷èâàåòñÿ" ÿè÷êî (ýòî, êñòàòè, îòíþäü íå ÿâëÿåòñÿ îïðåäåëÿþùåé îñîáåííîñòüþ äàííîé îïåðàöèè). Èç åäèíñòâåííîé öèòèðîâàííîé Âàìè îïóáëèêîâàííîé â ðåôåðèðóåìîì æóðíàëå ðàáîòå ä-ðà Eberhard Nieschlag ñëåäóåò, ÷òî â êà÷åñòâå ëå÷åíèÿ âàðèêîöåëå èñïîëüçîâàëèñü îïåðàöèè âûñîêîãî ëèãèðîâàíèÿ èëè ýìáîëèçàöèè ÿè÷êîâîé âåíû. Ýòè îïåðàöèè êàê ðàç ïàòîãåíåòè÷åñêè ìàëî îáîñíîâàíû, ò.ê. îíè áëîêèðóþò âñåãî îäèí èç 5 âîçìîæíûõ êîëëåêòîðîâ ïàòîëîãè÷åñêîãî âåíîçíîãî îòòîîêà èç ÿè÷êà ïðè âàðèêîöåëå. Âî-âòîðûõ èñïîëüçîâàëñÿ âñåãî ëèøü 12 ìåñÿ÷íûé ñðîê íàáëþäåíèÿ ïîñëå îïåðàöèè, ÷òî ìîãëî áûòü íåäîñòàòî÷íûì. Â-òðåòüèõ â ðàáîòå àíàëèçèðîâàëàñü ÷àñòîòà íàñòóïëåíèÿ áåðåìåííîñòåé â ñåìåéíûõ ïàðàõ, ãäå èíôåðòèëüíîñòü áûëà ïî ïðè÷èíå ìóæñêîãî ôàêòîðà (?), à èìåâøàÿ ìåñòî ìóæñêàÿ èíôåðòèëüíîñòü áûëà ñâÿçàíà ñ âàðèêîöåëå (?). Çäåñü âîçíèêàåò âîïðîñ - à òîëüêî ëè âàðèêîöåëå áûëî ïðè÷èíîé èíôåðòèëüíîñòè â îáñëåäîâàííûõ ïàðàõ? Â-÷åòâåðòûõ íåïîíÿòíî ïî÷åìó íå ñðàâíèâàëèñü ïàðàìåòðû ñïåðìîãðàììû ó ïðîîïåðèðîâàííûõ è íåïðîîïåðèðîâàííûõ? Åñëè ïîñëå îïåðàöèè ïîêàçàòåëè ñïåðìîãðàììû óëó÷øèëèñü. òî âîçìîæíî áåðåìåííîñòü íå íàñòóïàëà ïî äðóãèì ïðè÷èíàì? Â-ïÿòûõ äàæå ïî äàííûì àâòîðà ðàáîòû, ÷àñòîòà áåðåìåííîñòåé â ãðóïïå ïðîîïåðèðîâàííûõ áûëà íà 4% âûøå (ñòàòèñòè÷åñêè íå çíà÷èìî). Âîçìîæíî ïðè óâåëè÷åíèè ÷èñëà íàáëþäåíèé - ðàçíèöà öâåëè÷èòñÿ è ñòàíåò ñòàòèñòè÷åñêè çíà÷èìîé? Èòàê [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] îòíþäü íå áåçïðå÷àí ïî äèçàéíó è ñêîðåå âûçûâàåò âîïðîñû, ÷åì äàåò ÿñíûå îòâåòû. Èòàê, â ñóõîì îñòàòêå ä-ð Àëåêñàíäð Ïåðøóêîâ + ä-ð Eberhard Nieschlag ñ îäíîé ñòîðîíû, ïðîòèâ îñòàëüíîãî óðîëîãè÷åñêîãî ìèðà ñ äðóãîé. Êñòàòè, äëÿ scorpio, ñòàíäàðòû ëå÷åíèÿ âàðèêîöåëå Åâðîïåéñêîé Óðîëîãè÷åñêîé Àññîöèàöèè ìàëî ÷åì îòëè÷àþòñÿ îò òàêîâûõ Àìåðèêàíñêîé Óðîëîãè÷åñêîé Àññîöèàöèè. Òåïåðü ñòàòüè â çàùèòó àêòèâíîãî õèðóðãè÷åñêîãî ëå÷åíèÿ âàðèêîöåëå è, â ÷àñòíîñòè òîãî, ÷òî âàðèêîöåëå ÿâëÿåòñÿ ïðè÷èíîé àòðîôèè ÿè÷êà (Âû, ä-ð Ïåðøóêîâ, íà ñâîåì ñàéòå öèòèðóåòå Á.Í. Õîëüöîâà îò 1927 ã., êîòîðûé ãîâîðèò î òîì, ÷òî àòðîôèÿ ÿè÷êà â ðåçóëüòàòå âàðèêîöåëå áûâàåò ðåäêî. Âû ñàìè íå ïîíèìàåòå àáñóðäíîñòü äàííîé öèòàòû?): [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] È ýòî òîëüêî çà ïîñëåäíèé ïÿòîê ëåò è òî íå âñå. ×òî Âû îòâåòèòå íà ýòî, óâàæàåìûé ä-ð Ïåðøóêîâ. |
#19
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[Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ], ñ êîòîðûì ÿ íå ìîãó íå ñîãëàñèòñÿ. Îí ïðîòèâ îïåðàöèé áëîêèðóþùèõ êðîâòîê òîëüêî ïî ÿè÷êîé âåíå è çà äàëüíåéøåå ïðîäîëæåíèå èññëåäîâàíèé ïî âûÿñíåíèþ ðåàëüíîé íåîáõîäèìîñòè âàðèêîöåëýêòîìèè. Òàêèì îáðàçîì, ä-ð Ïåðøóêîâ, ä-ð Eberhard Nieschlag ÿâëÿåòñÿ àøèì åäèíîìûøëåííèêîì ëèøü îò÷àñòè. Íå ÿâëÿÿñü õèðóðãîì-óðîëîãîì, îí âñå æå íå ñòîëü êàòåãîðè÷åí â òîì, ÷òî õèðóðãè÷åñêîå ëå÷åíèå âàðèêîöåëå íàäîáíî íàïðî÷ü îòìåíèòü.
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#20
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Óâàæàåìûé ä-ð Æèâîâ,
A.Kamischke and E.Nieschlag: In our opinion, for the time being there are no convincing reasons indicating that interventive treatment is superior to councelling combined with optimization of female reproductive functions in terms of pregnancy. Therefore intervention by surgical or angiographic occlusion of the spermatic vein cannot be recommended to date. This conclusion is in agreement with the recommendations arising from the 35th Royal College of Obstetricians and Gynaecologists Study Group which concluded that: “There is insufficient evidence to recommend occlusion of the left internal spermatic vein in subfertile or oligozoospermic men with varicocele” and that “Occlusion of the left internal spermatic vein in young men with a varicocele should be performed only in the context of an appropriately designed, large prospective study” (RCOG Study Group, 1998). See - A.Kamischke and E.Nieschlag: Varicocele treatment in the light evidence-based andrology. Hum. reprod., Vol.7, N1, pp.65-69, 2001. See – RCOG Study Group. Recommendation arising from the 35th RCOG Study Group: evidence based fertility treatment. In Tempelton, A., Cooke, I. and O’Brian, P.M.S.(eds). Evidence based fertility treatment, RCOG Press, London, pp. 397-403, 1998. Îïåðàöèÿ ïðè âàðèêîöåëå äîëæíà íîñèòü íå êîñìåòè÷åñêèé ýôôåêò - à èìåííî îòñóòñòâèå ðàñøèðåíèÿ âåí ñïëåòåíèÿ è ðåöèäèâà, ýòî òî, ÷åì ãîðäèòñÿ Ì.Ãîëäñòåéí, à ïðèâîäèòü ê íîðìàëèçàöèè ñïåðìàòîãåíåçà. Êîíöåíòðàöèÿ æå ÿâëÿåòñÿ îäíèì èç íàèãëàâíåéøèõ ïàðàìåòðîâ è Âû êàê óðîëîã-àíäðîëîã äîëæíû ïîíèìàòü ýòî. ×òî êàñàåòñÿ ìåòîäèê îïåðàöèé - îíè äåòàëüíî îïèñàíû â ìîåé êíèãå. Ìíîãèõ èç íèõ Âû íàâåðíÿêà íå çíàåòå. Îïåðàöèþ Èâàíèññåâè÷à, î êîòîðîé Âû óïîìèíàåòå, Âû è ñàìè-òî íèêîãäà íå äåëàëè, òàê êàê ýòó îïåðàöèþ ïðåäëîæèë íå Îñêàð Èâàíèññåâè÷, à Ðîáá, êîòîðûé áûë äðóãîì Òóëëî÷à, êîòîðûé ñ÷èòàåòñÿ îñíîâîïîëîæíèêîì áåçîòëàãàòåëüíîé îïåðàöèè - âàðèêîöåëåêòîìèè, è ðàáîòó êîòîðîãî Âû íå ÷èòàëè, òàê æå êàê åå íå ÷èòàëè 99,9% ñîâðåìåííûõ âðà÷åé. Òàê ÷òî äåëàÿ "îïåðàöèþ Èâàíèññåâè÷à" Âû íà ñàìîì äåëå äåëàåòå îïåðàöèþ Ðîááà. À ýôôåêòèâíîñòü îïåðàöèè îïðåäåëÿåòñÿ íå íàëè÷èåì âàðèêîöåëå, à âîçìîæíîñòüþ èìåòü äåòåé, î ÷åì è íàñòàèâàåò Íèåøëàã. À èñêóññòâî õèðóðãà ñîñòîèò íå â òîì, ñêîëüêî ëþäåé îí ïðîîïåðèðîâàë, à â òîì êàê ïîìî÷ü ïàöèåíòó áåç îïåðàöèè. Õî÷ó Âàì ïîñîâåòîâàòü âñå æå ïðî÷èòàòü êíèãó «Âàðèêîöåëå è íåêîòîðûå ïðîáëåìû ìóæñêîãî áåñïëîäèÿ». Ñ óâàæåíèåì Àëåêñàíäð Ïåðøóêîâ |
#21
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Óâàæàåìûé ä-ð Ïåðøóêîâ,
ß íå ñîâñåì ïîíÿë Âàøó îöåíêó "ãîðäîñòè" ä-ðà Ìàðêà Ãîëäñòåéíà. Äà, îí ãîðäèòñÿ íèçêîé ÷àñòîòîé îñëîæíåíèé è ðåöèäèâîâ ñóáèíãâèíàëüíîé ìèêðîõèðóðãè÷åñêîé âàðèêîöåëýêòîìèè èëè ÑÌ (ðå÷ü íå èäåò î âûñîêèõ ëèãèðîâàíèÿõ ÿè÷êîâîé âåíû èëè åå ýìáîëèçàöèè, êîòîðûå òîëüêî è êðèòèêóåò ä-ð Nieschlag, à Ì. Ãîëäñòåéí èìè íå ãîðäèòñÿ). È ïðàâèëüíî äåëàåò. Âåäü îïåðàöèÿ ÑÌ óñòðàíÿåò àíîìàëüíûé òåìïåðàòóðíûé ðåæèì ÿè÷êà, ÷òî ïðåïÿäñòâóåò åãî äàëüíåéøåé àòðîôèè è óõóëäøåíèþ ñïåðìàòîãåíåçà (Âû òàê è íå îòâåòèëè íà âîïðîñ, ñ÷èòàåòå ëè Âû àòðîôèþ ÿèêà îäíèì èç ñëåäñòâèé âàðèêîöåëå?). Îí òàêæå ãîðäèòñÿ è "íîðìàëèçàöèåé ñïåðìàòîãåíåçà", è âûñîêîé ÷àñòîòîé áåðåìåííîñòåé ïîñëå îïåðàöèè (î ÷åì âåñü ñûð-áîð). Äàéòå âñå æå ñåáå òðóä ïðî÷åñòü ýòó [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] è äðóãèå öèòèðîâàííûå ìíîþ ðàíåå. Åñòåñòâåííî, êàê ïðàâèëüíî ãîâîðèò Âàø òîâàðèù èç Ãåðìàíèè, òðåáóþòñÿ äàëüíåéøèå áîëåå îáøèðíûå èññëåäîâàíèÿ ñ ëó÷øèì äèçàéíîì è ñ áîëåå âûñîêîé äîñòîâåðíãñòüþ. Íî ñóùåñòâóþùèå äàííûå òàêæå íåëüçÿ èãíîðèðîâàòü. Ðàâíî êàê è ìíåíèÿ êîíñåíñóñîâ Àìåðèêàíñêîé è Åâðîïåéñêîé óðîëîãè÷åñêèõ Àññîöèàöèè. Öèòàòà:
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Óâàæàåìûé ä-ð Æèâîâ,
1. Andrea Lenzi et al.(1998) Âû, äîêòîð Æèâîâ, òàê îêàçûâàåòñÿ è íå ïðî÷èòàëè ðàáîòó ïîëíîñòüþ. Âû îãðàíè÷èëèñü àáñòðàêòîì èç Ìåäëàéíà, ïîýòîìó òàê îáðàäîâàëèñü, ÷òî ñòàëè îáâèíÿòü ìåíÿ â íåçíàíèè àíãëèéñêîãî ÿçûêà. Åñëè áû Âû ÷èòàëè ëèòåðàòóðó íå íàñêîêîì è íå àáñòðàêòàìè, òî Âû áû ïîíèìàëè ðàçíèöó ìåæäó àáñòðàêòîì ñòàòüè â Èíòåðíåòå è íàñòîÿùåé ñòàòüåé â íàó÷íîì æóðíàëå. Èòàê, â ÷åì ñóòü ðàáîòû Lenzi (1998): 3 ãðóïïû èññëåäóåìûõ (ïî 19 ìóæ÷èí) îäíîãî âîçðàñòà (18-21 ëåò): 1 – çäîðîâûå, 2 – îïåðèðîâàííûå ïî ïîâîäó âàðèêîöåëå â âîçðàñòå 11-16 ëåò, 3 – ïàöèåíòû ñ âàðèêîöåëå íåîïåðèðîâàííûå. Âñåì ñäåëàíû àíàëèçû ýÿêóëÿòà (SD – ñòàíäàðòíîå îòêëîíåíèå; ÊÏ- êîíöåíòðàöèÿ ñïåðìàòîçîèäîâ ìëí/ìë; À - ïîäâèæíîñòü êàòåãîðèè À(%); ÏÔ -ïàòîëîãè÷åñêèå ôîðìû (%). 1 ãðóïïà: ÊÏ = 83 (SD= 31); À= 51 (SD=7); ÏÔ = 40 (4). 2 ãðóïïà: ÊÏ = 59 (SD=28); À=48 (SD=12); ÏÔ= 42(SD=8). 3 ãðóïïà: ÊÏ = 46 (SD 12); A=38 (SD=9); ÏÔ=52 (SD=8). Ïî êîíöåíòðàöèè ðàçëè÷èÿ 2 è 3 ãðóïï ñòàòèñòè÷åñêè íåäîñòîâåðíû, íî êîíöåíòðàöèÿ âî 2 ãðóïïå ñòàòèñòè÷åñêè äîñòîâåðíî íèæå, ÷åì ó çäîðîâûõ ëèö. Î ÷åì ýòî íàì ãîâîðèò? À ýòî ãîâîðèò òîëüêî î òîì, ÷òî âàðèêîöåëåêòîìèÿ íå ïðèíåñëà æåëàåìîãî óñïåõà, ò.å. õîòü îïåðèðóé, õîòü íå îïåðèðóé, à ðåçóëüòàò îäèíàêîâ. À äàëüøå, åñëè Âû çíàåòå ìåäèöèíñêóþ ñòàòèñòèêó, íà÷èíàþòñÿ åùå áîëåå èíòåðåñíûå âåùè. Ñòàíäàðòíîå îòêëîíåíèå. Èç 2 â îáå ñòîðîíû. Ò.å. êîíöåíòðàöèÿ ñïåðìàòîçîèäîâ ó ïàöèåíòîâ ïîñëå îïåðàöèè áûëà â ïðåäåëàõ 3(!) äî 115 ìëí/ìë. Ýòî ãîâîðèò î òîì, ÷òî êàê ìèíèìóì ó 1 ïàöèåíòà êîíöåíòðàöèÿ ñïåìàòîçîèäîâ áûëà êðàéíå íèçêà – 3 ìëí, ò.å. ó áîëüíîãî áûëà òÿæåëàÿ îëèãîçîîñïåðìèÿ, ÷òî êàê èçâåñòíî ÿâëÿåòñÿ ïðè÷èíîé áåñïëîäèÿ. Âû â àáñòðàêòå ýòî âèäåëè? Ó ïàöèåíòîâ ñ âàðèêîöåëå áåç îïåðàöèè ñèòóàöèÿ ëó÷øå: 46 (SD 12), ò.å. – ïðåäåëû îò 22 äî 70 ìëí/ìë. À íèæíÿÿ ãðàíèöà íîðìû ñîãëàñíî ðåêîìåíäàöèÿì ÂÎÇ – 20 ìëí. Òåïåðü ïîãîâîðèì î ïîäâèæíîñòè è è ïàòîëîãè÷åñêèõ ôîðìàõ. Ïîêàçàòåëè â îáåèõ ãðóïïàõ ñòàòèñòè÷åñêè ðàçëè÷àþòñÿ. Íó è ÷òî? Âåäü â îáåèõ ãðóïïàõ îíè íàõîäÿòñÿ â ïðåäåëàõ íîðìû! Òàì íîðìà, è òàì – íîðìà. Íîðìà – îíà è â Àôðèêå íîðìà. (Äëÿ ëþáîçíàòåëüíûõ – íîðìû ÂÎÇ(1997) – Ïîäâèæíîñòü êàòåãîðèè À â íîðìå äîëæíà áûòü áîëüøå 25%, à íàëè÷èå ïàòîëîãè÷åñêèõ ôîðì íå áîëåå 70%.). Òåïåðü ïî ïîâîäó ãèïîòðîôèè ÿè÷êà, èëè êàê Âû åùå åå íàçûâàåòå – àòðîôèÿ. Òàê âîò, íè ó îäíîãî ïàöèåíòà áåç îïåðàöèè (ãðóïïà 3) íå áûëî òåñòèêóëÿðíîé ãèïîòðîôèè (ñì. ñòð 349, 4-ÿ ñòðîêà ñâåðõó âî 2-é êîëîíêå). Òàê ÷òî íå÷åãî ïóãàòü ëþäåé, äîêòîð Æèâîâ! Lenzi ñ ñîàâò. ãîâîðÿò, ÷òî âîçìîæíî âàðèêîöåëå ÿâëÿåòñÿ îòÿãîùàþùèì, à íå âåäóùèì ôàêòîðîì ïîâðåæäåíèÿ ñïåìàòîãåíåçà, íî â íàñòîÿùåå âðåìÿ åùå íåò ìàðêåðîâ, êîòîðûå ìîãóò ýòî îïðåäåëèòü. Âû æå, äîêòîð Æèâîâ, âìåñòî òîãî, ÷òîáû ïðî÷èòàòü ñòàòüþ, ññûëàåòåñü íà àáñòðàêò!? 2. «Èç åäèíñòâåííîé öèòèðîâàííîé Âàìè îïóáëèêîâàííîé â ðåôåðèðóåìîì æóðíàëå ðàáîòå ä-ðà Eberhard Nieschlag» Äîêòîð Æèâîâ, ÷èòàéòå íîðìàëüíûå æóðíàëû, à íå ðåôåðàòû! 3. «Ýòè îïåðàöèè êàê ðàç ïàòîãåíåòè÷åñêè ìàëî îáîñíîâàíû, ò.ê. îíè áëîêèðóþò âñåãî îäèí èç 5 âîçìîæíûõ êîëëåêòîðîâ ïàòîëîãè÷åñêîãî âåíîçíîãî îòòîîêà èç ÿè÷êà ïðè âàðèêîöåëå» Âû õîòü ñàìè ïîíèìàåòå, ÷òî ãîâîðèòå? 4. «Âî-âòîðûõ èñïîëüçîâàëñÿ âñåãî ëèøü 12 ìåñÿ÷íûé ñðîê íàáëþäåíèÿ ïîñëå îïåðàöèè,» Ãîëäñòåéí ïðåêðàñíî íàáëþäàåò ïàöèåíòîâ íà÷èíàÿ óæå ñ 6 ìåñÿöåâ ïîñëå îïåðàöèè. Âû æå, äîêòîð Æèâîâ, äîëæíû çíàòü ïîëîæåíèÿ ÂÎÇ î ôåðòèëüíîñòè. (Goldstein M., Gilbert B.R., Dicker A.P., Dwosh J., Gnecco C.: Microsurgical inguinal varicocelectomy with delivery of the testis: an artery and lymphatic sparing technique. J.Urol., 148: 1808-1811, 1992). 5. Ïî äðóãèì âîïðîñàì îòíîñèòåëüíî òðóäîâ Íèåøëàãà îáðàùàéòåñü ëó÷øå íåïîñðåäñòâåííî ê àâòîðàì, à íå êî ìíå, è íå íàäî óñòðàèâàòü öèðê. 6. Çðÿ Âû òàê î Áîðèñå Õîëüöîâå. Âî ïåðâûõ îí áûë âåëèêîëåïíûé ó÷åíûé, è ïî åãî ìåòîäó äî ñèõ ïîð îïåðèðóþò áîëüíûõ. Âî âòîðûõ, ýòî ïðîñòî íåêðàñèâî ñ Âàøåé ñòîðîíû. 7. Ïðîñìîòðåë ÿ òî, ÷òî Âû íàñîáèðàëè â Ñåòè «çà ïîñëåäíèé ïÿòîê ëåò». Íó íå õîòèòå Âû ÷èòàòü íîðìàëüíóþ ëèòåðàòóðó, êîðìèòåñü àáñòðàêòàìè. Ó÷èëè Âàñ àíãëèéñîìó ÿçûêó ïî-âèäèìîìó õîðîøèå ó÷èòåëÿ, íî Âû îêàçàëèñü ïëîõèì ó÷åíèêîì. Ëåíü Âàì ïîëíîñòüþ ðàáîòó ïðî÷èòàòü. 8. Ïî ïîâîäó àòðîôèè ÿè÷êà. Âû, äîêòîð Æèâîâ, äîëæíû ïîíèìàòü ðàçíèöó ìåæäó àòðîôèåé, ãèïîïëàçèåé è ãèïîòðîôèåé ÿè÷êà. Àòðîôèÿ ÿè÷êà èëè àçîîñïåðìèÿ íàèáîëåå òÿæêèå îñëîæíåíèÿ âàðèêîöåëåêòîìèè, î êîòîðûõ, îäíàêî, ðåäêî ñîîáùàåòñÿ, ïîýòîìó èñòèííàÿ èõ ÷àñòîòà íåèçâåñòíà (Goldstein M.et al. 1992). Òàêèå îñëîæíåíèÿ íå òîëüêî ñíèæàþò ýôôåêòèâíîñòü îïåðàòèâíîãî ëå÷åíèÿ, íî è ñòàâèò ïîä âîïðîñ ïðèìåíåíèå åãî âîîáùå. Àòðîôèÿ ÿè÷êà ïîñëå îïåðàöèè âîçíèêàåò äîñòàòî÷íî ðåäêî 2:1000 (Goldstein M., 1995). Òåì íå ìåíåå, äàæå îäèí ñëó÷àé òåñòèêóëÿðíîé àòðîôèè ñðåäè 1000 îïåðàöèé high ligation ìîæåò áûòü äðàìàòè÷åñêèì îñëîæíåíèåì äëÿ ìîëîäîãî ïàöèåíòà (Flati G. et al. 1994). Ïîñëå äâóñòîðîííåé âàðèêîöåëåêòîìèè ìîæåò âîçíèêàòü àçîîñïåðìèÿ èëè òÿæåëàÿ îëèãîçîîñïåðìèÿ (Silber S., 1979). Ýòî, íåñîìíåííî, ñòàâèò âîïðîñ î ïðàâîìåðíîñòè è ïðèìåíèìîñòè îïåðàöèé òèïà high ligation â äåòñêîì âîçðàñòå. 9. «Ïðàâèëüíî! ß íèêîãäà íå çàáèâàþ ñåáå ãîëîâó èíôîðìàöèåé, êîòîðàÿ èìååò ëèøü èñòðîè÷åñêè-àêàäåìè÷åñêîå çíà÷åíèå.» ß áû Âàì, äîêòîð Æèâîâ, âñå æå ïîñîâåòîâàë ÷èòàòü ëèòåðàòóðó, è èñòîðè÷åñêóþ è àêàäåìè÷åñêóþ. Âî ïåðâûõ çíàëè áû ïîáîëüøå, ïîãðàìîòíåå áû ñòàëè, à âî âòîðûõ âåëè áû ñåáÿ áîëåå êóëüòóðíî. 10. «ÄËß ÝÒÎÃÎ ÌÛ ×ÈÒÀÅÌ ÍÀÈÁÎËÅÅ ÄÎÑÒÎÂÐÅÍÓÞ È ÑÎÂÐÅÌÅÍÍÓÞ ËÈÒÅÐÀÒÓÐÓ.» Ïîçâîëüòå çàñîìíåâàòüñÿ! Ïî÷åìó æå òàêàÿ àãðåññèÿ îò Âàñ, äîêòîð Æèâîâ? Ïî÷åìó Âû òàê ÿðîñòíî çàùèùàåòå íåîáõîäèìîñòü îïåðàòèâíîãî ëå÷åíèÿ? Íå ïîòîìó ëè, ÷òî â Âàøåé êëèíèêå òàêàÿ îïåðàöèÿ ñòîèò 920$ è Âû, ïðîîïåðèðîâàâ 100 ÷åëîâåê, âîøëè âî âêóñ? Òàêèì îáðàçîì, äîêòîð Æèâîâ, Âû îòíîñèòåñü ê òåì âðà÷àì, äëÿ êîòîðûõ ïàöèåíò ñ âàðèêîöåëå= æèâûå äåíüãè (èëè ready money). Ñîâåòóþ Âàì âïðåäü ÷èòàòü ñòàòüè ïîëíîñòüþ, à íå ïîëüçîâàòüñÿ àáñòðàêòàìè èç Èíòåðíåòà, âûäåðãèâàÿ èç êîíòåêñòà óäîáíûå Âàì ôàêòû.  ñëåäóþùèé ðàç ìîæåòå îáðàùàòüñÿ êî ìíå êîãäà íàïèøåòå êíèãó î ïîëüçå îïåðàöèè âàðèêîöåëå, ãäå ïðèâåäåòå ñîáñòâåííûå äàííûå, ÑÎÁÑÒÂÅÍÍÛÅ, À ÍÅ ×ÓÆÈÅ. Íà ýòîì äèñêóññèþ ñ Âàìè ñ÷èòàþ çàêîí÷åííîé. Ñ óâàæåíèåì Àëåêñàíäð Ïåðøóêîâ |
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Óâàæàåìûé Àëåêñàíäð Èâàíîâè÷!
Î÷åíü æàëü, åñëè Âû íå áóäåòå áîëüøå ïðèíèìàòü ó÷àñòèå íà ýòîì ôîðóìå è íè òîëüêî ïî âîïðîñàì, ñâÿçàííûì ñ âàðèêîöåëå. Íàäåþñü, ÷òî ìîäåðàòîð ôîðóìà, íåñìîòðÿ íà âñþ îñòðîòó âàøåé äèñêóññèè, ïðèäåðæèâàåòñÿ òîãî æå ìíåíèÿ. Ñ óâàæåíèåì! P.S. Ñëó÷àéíî îáíàðóæèë, ÷òî íåîäíîçíà÷íîñòü îïåðàöèîííûõ âìåøàòåëüñòâ ïðè âàðèêîöåëå îáñóæäàëàñü åù¸ íà ïåðâîì ñúåçäå Ðîññèéñêèõ óðîëîãîâ (â 1926 ã.!) ([Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]) Êàê äàëåêî, çà ïðîøåäøåå âðåìÿ, ïðîäâèíóëàñü â ýòîì âîïðîñå óðîëîãè÷åñêàÿ íàóêà? |
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Walsh: Campbell's Urology, 8th ed., 2002
"Varicocele is an extremely common entity, present in 15% of the male population. Varicoceles are found in approximately 35% of men with primary infertility but 75% to 81% of men with secondary infertility. Mounting evidence clearly demonstrates that varicocele causes progressive duration-dependent injury to the testis. Larger varicoceles appear to cause more damage than small varicoceles, and, conversely, repair of large varicoceles results in greater improvement of semen quality. Varicocelectomy can halt the progressive duration-dependent decline in semen quality found in men with varicoceles. The earlier the age at which varicocele is repaired, the more likely is recovery of spermatogenic function. Variococelectomy can also improve Leydig cell function, resulting in increased testosterone levels (Su et al, 1995)."
"Varicocelectomy results in significant improvement in semen analysis in 60% to 80% of men. Reported pregnancy rates after varicocelectomy vary from 20% to 60%. A randomized controlled trial of surgery versus no surgery in infertile men with varicoceles revealed a pregnancy rate of 44% at 1 year in the surgery group versus 10% in the control group (Madgar et al, 1995). In our series of 1500 microsurgical operations, 43% of couples were pregnant at 1 year (Goldstein et al, 1992) and 69% at 2 years when couples with female factors were excluded. Microsurgical varicocelectomy results in return of sperm to the ejaculate in 50% of azoospermic men with palpable varicoceles (Matthews et al, 1998; Kim et al, 1999). The results of varicocelectomy are also related to the size of the varicocele. Repair of large varicoceles results in a significantly greater improvement in semen quality than that achieved with repair of small varicoceles (Steckel et al, 1993; Jarow et al, 1996). In addition, large varicoceles are associated with greater preoperative impairment in semen quality than small varicoceles and, consequently, overall pregnancy rates are similar regardless of varicocele size. In men with large left and small right varicoceles, bilateral repair results in significantly greater improvement in semen parameters than only left repairs (Sherr and Goldstein, 1999). Some evidence suggests that the younger the patient is at the time of varicocele repair, the greater the improvement after repair, and the more likely the testis is to recover from varicocele-induced injury (Kass et al, 1987). Varicocele recurrence, testicular artery ligation, or postvaricocelectomy hydrocele formation is often associated with poor postoperative results. In infertile men with low serum testosterone levels, microsurgical varicocelectomy alone results in substantial improvement in serum testosterone levels (Su et al, 1995)." |
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Óâàæàåìûé Àëåêñàíäð Èâàíîâè÷!
ß, êàê è íåèçâåñòíî ñ êàêîé öåëüþ ïîÿâèâøèéñÿ çäåñü ñïåöèàëèñò ïî îçîíó è ìîé âå÷íûé îïïîíåíò Â.ß. Çàéöåâ ñîæàëåþ î Âàøåì èñ÷åçíîâåíèè. Íà ìîé âçãëÿä ýòî ëèøíèé ðàç ïîäòâåðæäàåò Âàøó íåñïîñîáíîñòü ñïîêîéíî è êîíñòðóêòèâíî âîñïðèíèìàòü êðèòèêó â ñâîé àäðåñ. Ýòî ìîæåò âûçûâàòü òîëüêî ñîæàëåíèå è æåëàíèå ðåêîìåíäîâàòü Âàì îïÿòü æå íå áûòü ñòîëü 100% óâåðåííûì â ñâîåé ïðàâîòå. Äàæå åñëè Âû íàïèñàëè ìîíîãðàôèþ ïî îáñóæäàåìîìó âîïðîñó. Ê ñëîâó ñêàçàòü íè îäíà ìîíîãðàôèÿ íå ÿâëÿåòñÿ Áèáëèåé. Êñòàòè, "óðîëîãè÷åñêóþ áèáëèþ" äëÿ âñåõ íàøèõ ÷èòàþùèõ êîëëåã â ìèðå, ïðîöèòèðîâàë êîëëåãà Alon. Ïî ìîåìó ñåãîäíÿøíÿÿ ïîçèöèÿ, îñíîâàííàÿ íà äàííûõ ÏÎÄÀÂËßÞÙÅÃÎ ÁÎËÜØÈÍÑÒÂÀ ÍÀÈÁÎËÅÅ ÐÅËÅÂÀÍÒÍÛÕ ÈÑÑËÅÄÎÂÀÍÈÉ, èçëîæåíà äîñòàòî÷íî ÿñíî. îòñàåòñÿ òîëüêî ñäåëàòü ïðàâèëüíûé ïåðåâîä. Äà, ê ñîæàëåíèþ ïîëíûå òåêñòû áîëüøèíñòâà ñòàòåé íå äîñòóïíû on-line è ìû â èíòåðíåò-äèñêóññèÿõ ìîæåì ïðèâîäèòü èíòåðåñóþùèå íàñ ïóáëèêàöèè òîëüêî â âèäå àáñòðàêòîâ. ß íå ïîíèìàþ ïî÷åìó Àëåêñàíäð Èâàíîâè÷ èç òîãî, ÷òî ÿ öèòèðóþ àáñòðàêòû çàêëþ÷èë, ÷òî ÿ ÷èòàþ òîëüêî èõ. Äëÿ Âàñ, Àëåêñàíäð Èâàíîâè÷ äîëîæó, ÷òî äëÿ ñâîåé ñîáñòâåííîé áèáëèîòåêè ÿ âûïèñûâàþ: Journal of Urology, European Urology è Contemporary Urology, ÷èòàþ âñå íàèáîëåå ìåíÿ èíòåðåñóþùåå åñòåñòâåííî â âèäå ñàìûõ ÷òî íè íà åñòü ïîëíûõ òåêñòîâ.  ìîåé áèáëèîòåêå óðîëîãè÷åñêîé ëèòåðàòóðû èìåþòñÿ âñå ñàìûå ïîñëåäíèå ìîíîãðàôèè àìåðèêàíñêèõ è åâðîïåéñêèõ àâòîðîâ ïî òåìàì, êîòîðûìè ÿ è ìîè êîëëåãè çàíèìàåìñÿ â áîëüøåé ñòåïåíè. Åñòü Ñampbell's Urology êîíå÷íî è ìíîãî ÷òî åùå. Òàê ÷òî Âû äèñêóòèðóåòå îòíþäü íå ñ íîâè÷êîì â ïðîáëåìå âàðèêîöåëå. Andrea Lenzi et al.(1998) Ñóäÿ îïÿòü æå ïî àáñòðàêòó 1-ÿ ãðóïïà âñå æå áûëè ïðîîïåðèðîâàííûå áîëüíûå, âòîðàÿ çäîðîâûå, òðåòüñÿ íåîïåðèðîâàííûå áîëüíûå. Íî ýòî íå ñòîëü ñóùåñòâåííî. Ãëàâíîå âñå æå âûâîä, êîòîðûé ñäåëàëè àâòîðû: "Äàííîå èññëåäîâàíèå ïîêàçûâàåò, ÷òî îïåðàöèè ó ïîäðîñòêîâ ìîãóò áûòü ïîëåçíûìè, âîçìîæíî ïîòîìó, ÷òî ÿè÷êî ïðîäîëæàåò ðàçâèâàòüñÿ â ýòîì âîçðàñòå. Áîëåå îáøèðíûå, äâîéíûå ñëåïûå êîíòðîëèðóåìûå èññëåäîâàíèÿ ëåâîñòîðîííåãî âàðèêîöåëå íåîáõîäèìû äëÿ òîãî, ÷òîáû èäåíòèôèöèðîâàòü âîçìîæíûå ìàðêåðû òÿæåñòè çàáîëåâàíèÿ". Ïðîñòèòå, ýòîò âûâîä ìîæíî òðàêòîâàòü êàê òî èíà÷å ÷åì òî, ÷òî àâòîðû âî âñÿêîì ñëó÷àå íå ñ÷èòàþò âàðèêîöåëýêòîìèè áåñïîëåçíûìè, êàê ýòî ïðåäëàãàåòå Âû? Èëè Âû çàïðåùàåòå ìíå âåðèòü ñîáñòâåííûì ãëàçàì? Òåì íå ìåíåå ïîñòàðàþñü äîáûòü ýòó ñòàòüþ â ïîëíîì âèäå. Öèòàòà:
Mounting evidence clearly demonstrates that varicocele causes progressive duration-dependent injury to the testis. Larger varicoceles appear to cause more damage than small varicoceles, and, conversely, repair of large varicoceles results in greater improvement of semen quality. Varicocelectomy can halt the progressive duration-dependent decline in semen quality found in men with varicoceles. The earlier the age at which varicocele is repaired, the more likely is recovery of spermatogenic function. Variococelectomy can also improve Leydig cell function, resulting in increased testosterone levels (Su et al, 1995)." Èëè ÿ äîëæåí èãíîðèðîâàòü ýòî? Öèòàòà:
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Ñ íàèëó÷øèìè ïîæåëàíèÿìè. |
#26
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Öèòàòà:
Òîëüêî ïîòîìó, ÷òî áóäåò æàëü, åñëè ôîðóì ïîêèíåò åù¸ îäèí äóìàþùèé, àíàëèçèðóþùèé âðà÷, ñî ñâîèìè ïðåäñòàâëåíèÿìè, îïûòîì. Âíå çàâèñèìîñòè, ïðàâ îí èëè íåò â âàøåé äèñêóññèè. (ß îá ýòîì, åñòåñòâåííî, ñóäèòü íå ìîãó). Ðàçðåøèòå åù¸ ðàç íàïîìíèòü, ÷òî ìû íàõîäèìñÿ â Äèñêóññèîííîì êëóáå. È èìåííî îáñóæäåíèÿ, ñïîðû, ñîìíåíèÿ, à íå ïðîñòîå öèòèðîâàíèå ñèþìèíóòíûõ ñòàíäàðòîâ, ìîãóò ñïîñîáñòâîâàòü áîëåå ãëóáîêîìó ïðîíèêíîâåíèþ â ñóùåñòâî âîïðîñà. Îñîáåííî, åñëè äèñêóññèè âåäóòñÿ êîððåêòíî, áåç ïåðåõîäà íà ëè÷íîñòè. Ñ óâàæåíèåì! |
#27
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Öèòàòà:
Êàê ìîæíî ïðîíèêíóòü ãëóáæå â ñóòü âîïðîñà, åñëè íå âçÿòü â òîëê î ÷åì èäåò ðå÷ü? |
#28
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Óâàæàåìûé Åâãåíèé Åâãåíüåâè÷!
Âî-ïåðâûõ, Âû íåîðèãèíàëüíû. Ñîåäèíÿòü îáðûâêè äâóõ íåçàâèñèìûõ ôðàç è äåëàòü èç íèõ âûâîäû àêòèâíî èñïîëüçóþò, ê ïðèìåðó, ïîëèòòåõíîëîãè, â áîðüáå ñ ñîïåðíèêàìè ñâîèõ êàíäèäàòîâ. Êàê îïðåäåëÿþò òàêèå òåõíîëîãèè Âàì íàâåðíÿêà èçâåñòíî. Âî-âòîðûõ, òî ÷òî ÿ íå ìîãó áûòü ýêñïåðòîì â òåìå, ñ êîòîðîé íå áûë ñâÿçàí ïî ðàáîòå, íå îçíà÷àåò, ÷òî «íå ìîãó âçÿòü â òîëê î ÷åì èäåò ðå÷ü». |
#29
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Óâàæàåìûé Âëàäèìèð ßêîâëåâè÷,
×òî äëÿ Âàñ ÿâëÿåòñÿ êðèòåðèåì "äóìàþùåãî âðà÷à"? ß ïî÷òè óâåðåí, ÷òî ëþáîé êòî áû îí íè áûë, åñëè âûñêàçûâàåòñÿ ïðîòèâ íåíàâèñòíûõ Âàì ñòàíäàðòîâ ìåäèöèíñêîé ïîìîùè - óæå ïðè÷èñëÿåòñÿ Âàìè ê äóìàþùèì òîëüêî íà îñíîâàíèè òîãî, ÷òî êàê áû "íåñòàíäàðòíî ìûñëèò". Íó à åñëè ýòîò íåêòî åùå ïðîÿâèò èíòåðåñ ê îçîíó, Âû ãîòîâû åìó ïðîñòèòü äàæå îòïåòîå øàðëàòàíñòâî, êàê ýòî áûëî íå ðàç íà ôîðóìå. Õîòåëîñü áû, ÷òîáû Âû ïðîÿâëÿëè îáúåêòèâíîñòü. Ëàäíî, ÷òî Âû íå ñïåöèàëèñò â îáñóæäàåìîé òåìå. Íî ñàìè áû ïîñìîòðåëè öèòèðîâàííûå ìíîþ èñòî÷íèêè, ñðàâíèëè áû ñ òåì, ÷òî ïðèâåë ìîé îïïîíåò (ïîëòîðû ïóáëèêàöèè íàïîëîâèíó íå â òåìó) è îöåíèëè áû êòî èç íàñ áëèæå ê èñòèíå íå êðèòåðèþ "êòî ïðîòèâ ñòàíäàðòîâ" èëè "êòî àëüòåðíàòèâíåå". È ñòàíäàðòû è ó÷åáíèê Campbell's Urology ïèøóòñÿ íà îñíîâàíèè áåñïðèñòðàñòíîãî àíàëèçà ýêñïåðòàìè èìåþùåéñÿ íà ñåãîäíÿøíèé äåíü ðåëåâàíòíîé ëèòåðàòóðû. Ñåãîäíÿ â óðîëîãèè ìíîãèå ðàíåå "íåîñïðîèìûå" îïåðàöèè ïîïàëè â ðàçðÿä íåíóæíûõ. Ýòî è íåôðîïåêñèÿ, è ïèåëîëèòîòîìèÿ è óðåòåðîëèòîòîìèÿ è íåêîòîðûå äðóãèå. Ñ âàðèêîöåëýêòîìèÿìè íà ñåãîäíÿøíèé äåíü ýòî íå ïðîèñõîäèò. Ïîêà ìû íå èìååì äîñòàòî÷íî ôàêòîâ äëÿ ïðèçíàíèÿ èõ íåíóæíîñòè. À ä-ð Ïåðøóêîâ, ïî÷óâñòâîâàâ ñåáÿ ãîñïîäîì îò âàðèêîöåëå, óæå âñå è çà âñåõ ðåøèë. Ýòî ìíå è íå ïîíðàâèëîñü ãëàâíûì îáðàçîì â åãî ïîçèöèè. ñ óâàæåíèåì. |
#30
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Öèòàòà:
À êàê áû Âû îòíåñëèñü ê âðà÷àì, êîòîðûå ïîñìåëè áû ðàññóæäàòü ( â ÄÊ!) î öåëåñîîáðàçíîñòè ýòèõ îïåðàöèé, êîãäà îíè ñ÷èòàëèñü íåîñïîðèìûìè? Åù¸ ðàç, ÿ íå ìîãó âûñêàçûâàòüñÿ ïî âàðèêîöåëýêòîìèè, íî îáðàòèë Âàøå âíèìàíèå, ÷òî åù¸ 1929 ã. òàêîé àâòîðèòåòíûé óðîëîã, êàê Ôðîíøòåéí, êàê è öåëûé ðÿä äðóãèõ ñïåöèàëèñòîâ ñ÷èòàëè, ÷òî ïîêàçàíèÿ ê îïåðàòèâíîìó âìåøàòåëüñòâó ïðè âàðèêîöåëå äîëæíû áûòü îãðàíè÷åíû. Íå ìîãëè áû Âû ñîîáùèòü, âåçäå ëè ïðèäåðæèâàþòñÿ ýòîé ðåêîìåíäàöèè â íàñòîÿùåå âðåìÿ? Ïî ïîâîäó ä-ðà Ïåðøóêîâà îñòàþñü ïðè ñâîåì ìíåíèè: áóäåò æàëü åñëè îí áîëüøå íå áóäåò ïðèíèìàòü ó÷àñòèå íà ýòîì ôîðóìå. (Ñ îçîíîòåðàïèåé, íàñêîëüêî ìíå èçâåñòíî, Àëåêñàíäð Èâàíîâè÷, íèêàê íå ñâÿçàí). Ñ óâàæåíèåì. P.S. Öèòàòà:
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