11. mamakacis nebayoflobiTi qirurgiuli kontracepcia (vazeqtomia)

11. mamakacis nebayoflobiTi qirurgiulikontracepcia (vazeqtomia)Sesavalimamakacis sterilizacia – vazeqtomia nebayoflobiTi qirurgiuli proceduraa,romelic mamakacis nayofierebis samudamo daTrgunvis mizniT tardeba. igigulisxmobs Teslsavali gzis blokirebas spermis gamavlobis asacileblad.vazeqtomia warmoadgens mamakacis kontracepciis farTod gavrcelebul, sakmaodmartiv, advilad Sesasrulebel, iaf da saimedo meTods. operacia ar cvlismamakacis garegnobas, xmas, Zalas, eakulatis moculobas an sqesobriv qcevas.sikvdilianoba aseptikis wesebis dacvisa da qirurgis maRali kvalifikaciisSemTxvevaSi sakmaod iSviaTad gvxvdeba (daaxloebiT 1 sikvdilis SemTxveva 300 000warmoebul operaciaze). (1,3, 13 xarisxi A)meTodebi:tradiciuli vazeqtomiauskalpelo vazeqtomiatradiciuli vazeqtomiisgan gansxvavebiT e.wuskalpelo meTodis gamoyenebisas Teslsavalisadinaris gamosayofad saTesle parkis zeda da Suamesamedis sazRvarze, [sur.1] saTesle parkis kanisada kunTovani Sris skalpeliT gakveTis nacvladmimarTaven punqcias. aseTi midgoma mkveTradamcirebs vazeqtomiis garTulebebis, gansakuTrebiThematomis, ganviTarebis albaTobas. uskalpelo,usisxlo vazeqtomia pirvelad 1974 wels SesruldaCineTSi (6, xarisxi A).sur.1Mmoqmedebis meqanizmiTeslsavali gzebis gamavlobis darRveva, obturacia xelovnurad, qirurgiuligziT, rac gamoricxavs spermatozoidebis moxvedras eakulatSi (obturaciuliazoospermia), Sesabamisad kvercxujredis ganayofierebas da orsulobas.efeqturobavazeqtomia kontracepciis erT-erTi yvelaze saimedo, efeqturi, permanentulimeTodia.204

pacientebi, romelTaTvisac vazeqtomia Sesaferisi meTodia• reproduqciuli asakis mamakacebi (Cveulebriv 50 wlis asakamde);• mamakacebi, visac surT mudmivi maRalefeqturi kontraceptiuli meTodi;• mamakacebi, romelTa meuRleebis janmrTelobas orsulobis SemTxvevaSiSeiZleba seriozuli riski Seeqmnas;• mamakacebi, romelTac esmiT da nebayoflobiT Tanxmdebian proceduraze;• mamakacebi / wyvilebi, romlebic darwmunebulni arian, rom aRar surT meti BbavSvis gaCena.upiratesobebi• maRali efeqturoba (0.1 - 0.15 orsuloba yovel as qalSi weliwadSi);• mudmivi efeqti;• xels ar uSlis sqesobriv cxovrebas;• kargia im wyvilebisTvis, roca orsuloba an kvercxsavali milebis gadakvanZvaQ qalis janmrTelobas seriozul risks Seuqmnida;• martivi qirurgiuli Careva adgilobrivi anesTeziis qveS;• grZelvadiani gverdiTi efeqtebis ararseboba;• ar axdens gavlenas sqesobriv funqciaze (saTesleebis mier hormonebisproduqciaze);naklovanebebi• unda CaiTvalos mudmiv (Seuqcevad) saSualebad;• SesaZloa, pacientma momavalSi inanos;• dagvianebuli efeqti (saWiroa 3 Tvemde dro an 20-mde eakulacia);• mcire operaciuli riski da gverdiTi efeqtebi, gansakuTrebiT zogadinarkozis gamoyenebis SemTxvevaSi;• xanmokle diskomforti / tkivili proceduris Semdeg;• saWiroa qirurgis saTanado momzadeba;• ar icavs sqesobrivi gziT gadamdebi daavadebebisgan;(1, 2, 4 xarisxi A, 8, xarisxi B)CaatareT pacientisa da SesaZleblobis farglebSi partnioris konsultacia.ecadeT, SeafasoT operaciis Semdgomi sinanulis SesaZlebloba.yvelaze gavrcelebuli sinanulis faqtorebia:• 30 wlamde asaki;• bavSvebis ar yola;• aramyari urTierToba;• zewola partnioris mxridan vazeqtomiis Casatareblad;• partnioris arainformirebuloba vazeqtomiis Sesaxeb;• pacientma axlaxan gadaitana piradi krizisi;• pacienti fiqrobs rom seqsualuri problemebi gadawydeba sterilizaciiT;• dainteresebulia spermis SenaxviT da aRdgeniTi operaciiT(7, xarisxi A, 9, 12, xarisxi B);205

Sesabamis moqmedebas moiTxovs Semdegi pirovnuli aspeqtebi:problema Mmoqmedeba safuZvelimomavalSiSvilebisgaCenis survilididi interesiSeqcevadobisSesaxebar eTanxmeba anxels ar awersinformirebulTanxmobaszewola sxvapirovnebisagandepresiaojaxuriproblemebipacientiucoloa an aryavs SvilebidaazusteT pacientismotivaciada saWiroebis SemTxvevaSidaexmareT sxva meTodisSerCevaSidaazusteT pacientismotivacia da saWiroebisSemTxvevaSi daexmareT sxvameTodis SerCevaSigansazRvreT, xom ar arisgaugebroba meTodis irgvliv(mag. Wori, miTi). amSemTxvevaSi saWiroadamatebiTi konsultacia. Tupacients mainc ar sursxelis mowera, daexmareTsxva meTodis SerCevaSi.daazusteT pacientismotivacia da saWiroebisSemTxvevaSi daexmareT sxvameTodis SerCevaSidaazusteT pacientismotivacia da saWiroebisSemTxvevaSi daexmareT sxvameTodis SerCevaSidaazusteT pacientismotivacia da saWiroebisSemTxvevaSi daexmareT sxvameTodis SerCevaSidaazusteT pacientismotivacia da saWiroebisSemTxvevaSi daexmareT sxvameTodis SerCevaSivazeqtomia mudmivi meTodia.momavalSi Svilebis gaCenis msurvelwyvilebs daexmareT sxva meTodisSerCevaSi.vazeqtomia mudmivi meTodia.wyvilebs, romlebsac SeiZlebamomavalSi Svilebis gaCenaainteresebdeT, daexmareT sxvameTodis SerCevaSi.pacientebs xSirad arasworad esmiTes procedura, konsultaciisSemdegac ki.qirurgiuli Carevis, gansakuTrebiTki nebayoflobiTi sterilizaciisCatarebamde aucilebeliainformirebuli Tanxmoba.nebayoflobiT sterilizaciasTandakavSirebuli sinanuli ufroZlieria, roca gadawyvetilebismiReba zewolis qveS xdeba.vazeqtomia mudmivi meTodia. Tusaxezea emociuri arastabiluroba,gadawyvetilebis miReba undagadavaddes.ramdenadac vazeqtomia mudmivimeTodia, proceduris Catarebisgadawyvetileba umjobesia miRebuliqnas, roca partniorebiSexmatkbilebulni arian.vazeqtomia mudmivi meTodia.sinanulis albaToba ufro maRalia,roca saxezea romelime aRniSnulisituacia.• diagramis gamoyenebiT daaTvaliereT sxeulis is nawilebiromelTanac Sexeba geqnebaT operaciis dros da ganixileTproceduris moqmedeba seqsualur funqciaze;• xazgasmiT aRniSneT, rom es procedura operaciaa da misi efeqti undaCaiTvalos mudmivad e.i. Tu operacia warmatebiT Caivlis, pacientiveRar SeZlebs gaxdes mama;206

• auxseniT SesaZlo umniSvnelo garTulebebi:hematoma;inficireba;spermogranuloma;epididimiti.• auxseniT sxva garTulebebisa da warumatebeli operaciis(warumateblobis koeficienti pirvel wels - 0.15%; da 0,04%-mogvianebiT) SesaZlo riski;• ganixileT kontracepciis sxva meTodebi;• auxseniT kondomis gamoyenebis aucilebloba misi da partniorisdasacavad sqesobrivi gziT gadamdebi infeqciisagan;• auxseniT sxva meTodebis gamoyenebis aucilebloba sanam sperma argaiwmindeba spermatozoidebisagan, ganusazRvreT operaciis Semdegspermis gamokvlevis dro;• ganixileT fasi da gadaxdis gzebi;• upasuxeT pacientis yvela kiTxvas;• TxoveT pacients waikiTxos da xeli moaweros informirebulTanxmobas;• gaacaniT da miawodeT pacients operaciis wina da Semdgomiinstruqciebi. (1, 3, 13 xarisxi A).sterilizaciaze nebayoflobiTi informirebuli Tanxmobis formame, qvemorexelismomweri ------------------------------------- gTxovT, CamitaroT( gvari, saxeli )qirurgiuli sterilizacia meTodiT -------------------------------------------------(uCveneT procedura)mogmarTavT am TxovniT sakuTari surviliT, yovelgvari Zaldatanebis anvinmes zegavlenis gareSe. vacnobiereb, rom1. me da Cem partniors SegviZlia gamoviyenoT arsebuli droebiTikontracepciis meTodebi.2. procedura, romelic Camitardeba, warmoadgens qirurgiul operaciasda me detalurad amixsnes misi yvela detali.3. qirurgiuli operacia garda dadebiTi Sedegebisa, Seicavs garkveulrisks. ris Sesaxebac var informirebuli4. Tu procedura Catarda warmatebiT, me aRar SemeZleba myavdes Svilebi.5. procedura iTvleba Seuqcevadad.6. me SemiZlia operaciis warmoebamde nebismier momentSi Sevcvalogadawyvetileba---------------------------------------------------------------- ------------------------------------(pacientis xelmowera)(TariRi)----------------------------------------------------------------- -----------------------------------(mkurnali eqimis xelmowera)(TariRi)im SemTxvevaSi Tu pacientma ar icis kiTxva da/an wera, maSin pacientis ndobiTaRWurvilma imave sqesis pirma, romelic metyvelebs imave enaze romelzecpacienti, xeli unda moaweros Semdeg gancxadebas:me, qvemorexelismomweri, vadastureb------------------------------------------------------------------- -----------------------------------(xelmowera)(TariRi)207

winasaoperacio instruqcia1. operaciis win Tqven savsebiT darwmunebuli unda iyoT Tqvenigadawyvetilebis sisworeSi, kontracepciis qirurgiuli meTodis arCevanSi,romelic Seuqcevad saSualebad iTvleba. Tqven SegiZliaT, SecvaloTTqveni gadawyvetileba nebismier dros vazeqtomiis warmoebamde.2. miiReT abazana an Sxapi operaciis wina Rames da vazeqtomiis dRes.gansakuTrebuli yuradReba miaqcieT sasqeso parkis, asos, Sorisis daukana tanis sisufTaves.3. moiyvaneT Tanmxlebi, romelic dagexmarebaT sasurvel adgilas (saxli...)misvlaSi.operaciis Semdgomi instruqcia1. operaciis Semdeg moerideT fexiT xangrZliv siaruls an velosipediTgadaadgilebas da a.S. saTesle parkisa da naoperacieb midamoze xaxunisada zewolis Tavidan asacileblad;2. sasurvelia, woliTi reJimi operaciis dRes;3. moerideT fizikur daZabvas operaciidan pirveli 48 sT ganmavlobaSi;4. aucileblobis SemTxvevaSi SeSupebis, sisxldenis, tkivilis andiskomfortis asacileblad SeiZleba, gamoyenebul iqnas civi kompresinaoperacieb midamoSi; an miiReT tkivilgamayuCebeli saSualeba 4-6 saaTisintervaliT (dasaxeleba an doza daazusteT eqimTan);5. pirveli ori dRis manZilze rekomendirebulia suspenzoriumis anmoWerili TeTreulis xmareba;6. nu miiRebT abazanas an Sxaps operaciidan pirvel or dRes;7. nu moixsniT naxvevs 3 dRe;8. moerideT Zlier fizikur samuSaos (simZimeebis awevas da a.S.) pirvelikviris ganmavlobaSi;9. Cveulebriv operaciidan 2-3 dRis Semdeg SegiZliaT aRadginoT sqesobrivikontaqti (Tu okluziis mizniT gamoyenebul iqna koagulacia Tavi SeikaveTerTi kviris manZilze);10. orsulobis Tavidan asacileblad gamoiyeneT kondomi an kontracepciissxva meTodi, sanam eakulatSi spermatozoidebis ararseboba ardadasturdeba spermis orjeradi gamokvleviT; gaxsovdeT: vazeqtomias araaqvs swrafi efeqti. sadinarebis gaTavisuflebas spermatozoidebisaganCveulebriv 12 kvira an 20 eakulacia sWirdeba;11. Tu vazeqtomia Catarda tradiciuli meTodiT, nakeri ixsneba meSvide dRes;12. operaciis Semdeg SeiZleba gqondeT tkivilis an garkveuli diskomfortisSegrZneba, an mciredi SeSupeba, kanis feris Secvla (silurje) saTesleparkis midamoSi. es yovelive iTvleba normalur movlenad da ar undaSegaSfoToT. dauyovnebliv mimarTeT eqims Tu: maRali temperaturagagrZelda ramdenime dRes, SeamCnieT sisxliani an Cirqiani gamonadeniWrilobidan, gaZlierda tkivili an saTesle parkis mkveTri SeSupeba;partniors ar mouvida menstruacia da zemoaRniSnuli pirobebis dacvismiuxedavad fiqrobs, rom orsuladaa.operaciis Catarebamde grovdeba detaluri anamnezi: am dros gansakuTrebulimniSvneloba eniWeba anamnezSi sisxldenebs, alergiul reaqcias (kerZod,analgetikur saSualebebze), gul-sisxlZarRvTa sistemis daavadebebs, Sardsasqesosistemis infeqciebs, Saqrian diabets, anemias da sqesobrivi gziT gadamdebdaavadebebs.208

obieqturi gamokvleva moicavs pacientis zogadi mdgomareobis gamokvlevas,arteriuli wnevisa da pulsis gansazRvras, Sorisis midamos kanisa da kanqveSaqsovilis mdgomareobas, saTesle parkis adgilobrivi anTebiTi procesi,varikocele, kriptorqizmi da a.S.laboratoriuli gamokvlevebi tardeba mxolod gansakuTrebul SemTxvevebSi.zogierTi specialisti gvirCevs hemoglobinisa da sisxlis Sededebis gansazRvras.umravles SemTxvevaSi, pacientis gamokiTxva da obieqturi gamokvleva sruliadsakmarisia operaciis sawarmoeblad. (1, 7, 10 xarisxi A)qirurgiuli teqnika: misi arCevani mTlianad qirurgzea damokidebuligamomdinare misi kvalifikaciisa da teqnikuri SesaZleblobebidan.pirobebivazeqtomia SeiZleba Catardes, rogorc ambulatoriulad, ise stacionarispirobebSi.mdgomareobebi, romelic sifrTxiles moiTxovsmdgomareoba gafrTxileba safuZveliadgilobrivi infeqciebi:a) saTesle parkis kanisb) mwvave sggig) balano-postitid) epididimiti an orqiti;mwvave sistemuri infeqcia(mag. gripi) angastroenteritigul-sisxlZarRvTa sistemisdaavadebebi,Sededebis darRveva,endokrinuli daavadebebi(mag. diabeti)*anamnezSi saTesle parkistravma*didi zomis varikocele*didi zomis hidrocele*filariazi; elefantiazi*saTesle parkSidaaradiagnostirebuliwarmonaqmni*kriptorqizmi – (calmxrivian ormxrivi, dadasturebulinayofiereba)*sazardulis TiaqarigadadeT procedurainfeqciis morCenamdegadadeT procedurainfeqciis morCenamdeprocedurasasurvelia CatardesstacionalurpirobebSi.operaciamde undagakontroldesmniSvnelovanisamecidinoproblemebi.am mdgomareobebisSemTxvevaSiprocedura undaCatardes stacionarispirobebSi gamocdiliqirurgis mier.am mdgomareobebmaSeiZleba gazardon iseTigarTulebebis riski,rogoricaapostoperaciuli infeqciapostoperaciuligarTulebebis,gansakuTrebiT infeqciismaRali riskipacientebs mniSvnelovanisamedicino problemebiTSeiZleba dasWirdeTspecialuri qirurgiulimarTva da monitoringi.samedicino problemebmaseiZleba gaarTulonoperacia da gazardoninfeqciis riskiam mdgomareobebmaSeiZleba gaarTulonoperacia da gazardoninfeqciis riski.209

temperatura saoperacioSi minimum 20-25C unda iyos, rasac gadamwyvetimniSvneloba aqvs kremasteris da saTesle parkis xorciani garsisrelaqsaciisaTvis, rac mniSvnelovnad aadvilebs:_ manipulacias Teslsaval gzebze;_ Teslsavali sadinaris fiqsacias saTesle parkis Sexorcebis midamoSida gvexmareba_ relaqsirebuli saTesle bagirakidan Teslsavali sadinaris izolirebaSi;_ saoperacio drois SemcirebaSi;_ garTulebebis ganviTarebis riskis SemcirebaSi.instrumentebi da masalebi uskalpelo vazeqtomiisaTvisinstrumentebibeWdiseburi damWeripreparirebadi damWeri sur. 2swori makratelimasalaantiseptiuri xsnari saoperacio velis dasamuSavebladspiritisteriluri xelTaTmanebisteriluri qirurgiuli zewrebi10 CC Sprici 1,5 diuimis, 25 an 27- kalibris nemsiT1% an 2% lidokainis xsnari epinefrinis (adrenalinis) gareSemasalebi Teslsavali gzebis okluziisaTvis qirurgis Sexedulebisamebr(magaliTad, koagulaciis aparati, qromis steriluri xsnari, ketguti,aragawovadi abreSumi ligirebisaTvis)steriluri marla, leikoplastiri, suspenzoriumi; (1, 5, 6, xarisxi A)winasaoperacio momzadebakonsultireba da informirebuli Tanxmobavazeqtomiis operaciis warmoebamde pacientma unda miiRos Sesabamisiinformacia-konsultacia, da mogceT informirebuli Tanxmoba. procedurisdawyebamde kidev erTxel darwmundiT, rom pacients ar surs meti bavSvis yolada rom surs SeudgeT operacias sterilizaciis mizniT.winasaoperacio anamnezi da gamokvlevawinasaoperacio anamnezi da gamokvleva SeiZleba Catardes operaciis dRes anramdenime dRiT adre. saWiroa momzaddes pacientis samkurnalo baraTi. zogadiwinasaoperacio gamokvleva moicavs saoperacio midamos daTvalierebas dagaTvaliswinebuli procedurebisa da testebis Catarebas. laboratoriuli210

gamokvlevebis Catareba Cveulebriv ar aris saWiro, magram Tu Tqven eWviSegeparaT raime gadaxraze gagzavneT laboratoriul gamokvlevaze anspecialistTan damatebiTi konsultaciisaTvis. adgilobrivi kanis infeqciebisda sasqeso gzebis infeqciuri daavadebebis mkurnaloba unda moxdesoperaciamde.SesaZlo winaaRmdegCvenebis droebiTi an SedarebiTi mizezebia:- mkveTrad gamoxatuli wyalmanki;- saTesle parkis spilovaneba;- adgilobrivi paTologiuri mdgomareobebi (mag, sazardulisTiaqari, Sexorcebebi, warmonaqmnebi saTesle parkze);- mZime xarisxis anemia;- darRvevebi sisxlis SededebaSi.bevri zemoaRniSnuli eqvemdebareba mkurnalobas, ris Semdeg tardeba vazeqtomia.maRali riskis DSemTxvevaSi saWiroa pacientTan erTad SeafasoT procedurisdadebiTi da uaryofiTi aspeqtebi.pacientis momzadeba operaciisaTvispremedikacia trankvilizatorebiT _ operaciis win miRebuli transkvilizatorixels uwyobs saTesle parkis kunTovani qsovilis relaqsacias, rac kanis sisqismaqsimalurad Semcirebis SesaZleblobas iZleva.winasaoperacio instruqciis mixedviT momzadebuli pacienti wevs moxerxebuladzurgze mcire baliSiT TavqveS.sasqeso asos fiqsaciaoperaciis gasaadvileblad aucilebelia sasqeso asos fiqsacia saoperaciomidamos gareT. daafiqsireT aso “12 saaTis” mdgomareobaSi, ise rom kargadxedavdeT Sexorcebis xazs. albaT, upiratesoba unda mivaniWoT rezinisbandaJisagan gakeTebul maryuJs, romelic asos Tavze ecmeba. [ix. ilustr. c]saoperacio velis momzadebasanam daiwyebdeT saoperacio velis momzadebas guldasmiT daaTvaliereTsaTesle parki, palpaciiT gansazRvreT saTesle parkis sisqe da Teslsavalisadinaris diametri. saTesle parki, sasqeso aso, muclis qveda nawili dabarZayebis zemo mesamedi daamuSaveT Tbili antiseptikuri xsnariT. upiratesobaeniWeba providon iodins an qlorgeqsidinis gamTbar xsnars. moerideT spirtianixsnaris gamoyenebas gansakuTrebiT mgrZnobiare zonebSi.xelebis damuSavebauskalpelo vazeqtomia mcire qirurgiuli operaciaa, romelic moiTxovsgarkveuli antiseptikuri procedurebis Catarebas infeqciisprofilaqtikisaTvis.anesTezia211

adgilobrivi anesTeziis saimedo meTodi mniSvnelovan rols TamaSobsvazeqtomiis umtkivneulod CatarebaSi. misi meSveobiT SesaZlebelia TavidanaviciloT mravajeradi ineqciis Sedegad testikuluri sisxlZarRvebis dazianebada hematomis ganviTareba rasac adgili aqvs anesTeziis tradiciuli meTodisgamoyenebis dros. doqtor li Sankiangis anesTeziis meTodi akmayofilebs ammoTxovnebs da aqvs garkveuli upiratesoba. meTodi gulisxmobs sadinaris zedakanis gautkivarebas [e] da saanesTezio xsnaris saoperacio midamodan moSorebiT,Teslsavali sadinaris gaswvriv, sazardulis rgolis mimarTulebiT Seyvanas [f].amdenad, erTi ineqciiT SesaZlebelia orive Teslsavali sadinaris nervisblokireba rac mniSvnelovnad amcirebs sisxldenis saSiSroebas. anesTeziisTvisgamoiyeneba lidokaini epinefrinis gareSe, vinaidan ukanaskneli sisxlZarRvebisSeviwroebis gamo naklebad SesamCnevs xdis sisxldenas operaciis dros. aqve undaaRiniSnos ukanasknel wlebSi danergili unemso anesTeziis meTodi, instrumentida gamoyenebis meTodi ixileT gamoyenebul literaturaSi.operaciis Catarebisas gamoiyeneba doqtor li Sankiangis mier mowodebuli oriZiriTadi instrumenti: gareTa beWdiseburi [a] da preparirebadi damWeri [b];saTesle parkis zeda da Sua mesamedis sazRvarze Sesabamisi midamos adgilobrivigautkivarebis Semdeg beWdiseburi damWeri edeba Teslsaval sadinars, kanisgaxsnis gareSe. meore instrumenti, preparirebadi damWeri maxvili boloTi,gamoiyeneba kanisa da Teslsavali sadinaris kedlis punqciisa da mcireganakveTis Sesasruleblad Teslgamomtan sadinarze, orive mxares. Tumca,sasurvelia gamoviyenoT uskalpelo vazeqtomiis monopunqciuri meTodi, rodesacpunqcia saTesle parkis Sua xazze tardeba.sadinaris gamoyofa-izolirebis Semdeg tardeba misi okluzia erT–erTi qvemoTaRwerili meTodiT. Teslsavali sadinari ligirdeba da umravles SemTxvevaSi,ikveTeba; izolirebisa da gadakveTis Semdeg sadinaris orive bolo 1sm siRrmezefulgirdeba orive mimarTulebiT sanaTurSi nemsiseburi eleqtrodis anTermokauteris CadgmiT. Tumca zogierTi qirurgi sadinaris izolirebis Semdegkmayofildeba absorbirebadi an araabsorbirebadi masaliT ligirebiTgadakveTis gareSe. igive sruldeba meore mxaresac. unda aRiniSnos, rom spermagrovdeba gadakveTili sadinarebis boloebSi (anTebiTi granulomisganviTarebiT) ufro xSirad ligaciis dros, vidre vazeqtomiis sxvameTodebisas, rac gvevlineba “kontraceptiuli warumateblobis” SemTxvevebisxSir mizezad. meti saimedobisaTvis rekomendirebulia Teslgamomtani sadinarismcire segmentis amokveTa [q] (Tumca, es ar iTvleba aucileblad). zogierTiavtoris mier SemoTavazebulia gadakveTili boloebis fasciiT daxurvismeTodic.bolo dros, specialistTa garkveuli jgufis mier mowodebulia vazeqtomiismodifikacia, romelic gulisxmobs sadinaris gadakveTas gadakvanZvis gareSe (e.w.vazeqtomia Teslsavali gzebis Ria boloebiT) da misi abdominaluri boloebis1.5 sm –ze kauterizacias an Termokoagulacias, aseve fasciis gamoyenebasgadakveTili vas deferense boloebis dasafarad. modifikacia saSualebas gvaZlevsSevamciroT SegubebiTi epididimitis ganviTarebis albaToba. mniSvnelovaniaaRiniSnos isic, rom rekonstruqciuli operaciis Catarebis aucileblobisas esgacilebiT ioli amocanaa, vidre sadinaris orive bolos fulgirebis Semdeg.Wrilobis dasaxurad ixmareba mxolod steriluri naxvevi [s]. gansxvavebiTtradiciuli vazeqtomiisagan, sadac ganakveTi ZiriTadad ikereba.212

operaciis mimdinareobis msvleloba ix. ilustr.a b c de f hgi j k lm n o pq r spacienti klinikidan ewereba operaciis Catarebidan 15-30 wuTis Semdeg. (1, 10, 11,xarisxi A)vazeqtomiis Semdgomi garTulebebitradiciuli vazeqtomiis Semdgomi garTulebebia: epididimiti, saTesle parkisabscesi, warumateblad Catarebuli vazeqtomia,spermogaranuloma, celuliti dahematoma (11, xarisxi A, 12, xarisxi B).213

Wrilobisinfeqciavazeqtomiis Semdeg ganviTarebuli problemis marTvaproblema Sefaseba marTvadaazusteT infeqciisan abscesis arsebobaTu saxezea kanis infeqcia,umkurnaleT antibiotikebiT. Tusaxezea abscesi, moaxdineT drenirebada umkurnaleT Cvenebis mixedviT.hematoma(kanqveSa)granulomaZlieri SeSupebatkiviliganakveTis areSigansazRvreTinfeqciis an abscesisarsebobagamoricxeT SesaZloinfeqcia an hematoma.SeamowmeT saTesleparkis SeSupeba.gamoricxeT SesaZloinfeqcia an hematoma.gamoricxeT infeqcia,granuloma anepididimiti.daadeT Tbili, sveli kompresebi dadaakvirdiT saTesle parks.; esgaivlis droTa ganmavlobaSi.daakvirdiT; es iSviaTia (< 0.4%),Cveulebriv TviTgamosworebadia daspontanurad gaivlis.Tu didi da mtkivneulia, SeiZlebasaWiro iyos qirurgiuli marTva.daakvirdiT; es Cveulebrivspontanurad gaivlis 1-dan 3 kviraSi.saWiroebis SemTxvevaSi gamoiyeneTsaTesle parkis damWeri.Tu ar aris infeqcia, umkurnaleTsimptomurad saTesle parkis damWeriTda saWiroebis mixedviTtkivilgamayuCeblebiT. tkiviliCveulebriv spontanurad gaivlis.vazeqtomiis Semdeg raime sistemuri daavadeba da misi gavlena Sardsasqesoorganoebis simsivneebis an aTerosklerozis ganviTarebaze dadasturebuli araris.rodis iwyeba vazeqtomiis efeqti• vazeqtomiis Sedegad myari kontracepciuli efeqti dgeba 3 Tvis Semdeg;• aRniSnul periodSi mamakacs undaPpqondes aqtiuri sqesobrivi cxovreba,mxolod im pirobiT, rom man da misma partniorma saWiroa gamoiyenonkontracepciis damatebiTi meTodi;• vazeqtomiidan 3 Tvis gasvlis Semdeg mizanSewonilia spermis orjeradigamokvleva (Tu es SesaZlebelia), rom dadasturdes meTodiskontracepciuli efeqti.warumateblobis mizezi SeiZleba iyos:1. Teslsavali gzebis rekanalizacia;2. arasworad Catarebuli operacia (sxva struqturis okluzia);3. Tandayolili anomalia – vas deference dublikacia, rac SeumCneveli darCaoperaciis dros; (4, 5, xarisxi A, )214

mamakacis sterilizaciis Seqcevadobavazeqtomia unda ganixilebodes, rogorc kontracepciis permanentuli,Seuqcevadi meTodi, miuxedavad guldasmiT Catarebuli konsultaciisa, mravalipacienti iTxovs nayofierebis aRdgenas, rasac xSirad adgili aqvs gayris,bavSvis sikvdilis an bavSvis yolis survilisas. gansakuTrebuli yuradRebaunda mieqces Semdeg garemoebebs:• fertilobis aRdgena sakmaod rTuli qirurgiuli operaciaa, romeliciTxovs qirurgis specialur momzadebas;• fertilobis aRdgena zogierT SemTxvevaSi SeuZlebelia da mizezad Tavadsterilizaciis meTodi gvevlineba;• sterilizaciis Seqcevadoba ar aris garantirebuli Tundac saTanadoCvenebisa da qirurgis maRali kvalifikaciis SemTxvevaSi;• fertilobis aRdgenis qirurgiuli meTodi sakmaod ZviradRirebuliagarda amisa, arsebobs anesTeziasa da Tavad operaciasTan dakavSirebuligarTulebebis albaToba iseve, rogorc sxva qirurgiuli Carevis dros (2, 3, 13,xarisxi A);amdenad, miuxedavad fertilobis aRdgenis SesaZleblobisa, nebayoflobiTiqirurgiuli sterilizacia unda CaiTvalos kontracepciis Seuqcevad meTodad.vazeqtomiis Semdeg fertilobis aRdgenis mikroqirurgiuli operaciisefeqturoba Seadgens 16-79% (saSualod 50%) eakulatSi spermatozoidebisaRmoCenis sixSire Seadgens 81-98%, rac ar iTvleba operaciis efeqturobismaCveneblad, vinaidan sasurvel gamosavlad gvevlineba orsulobis dadgoma.operaciis Sedegebi metwilad damokidebilia sxvadasxva mizezze, kerZod: ravadaa gasuli vazeqtomiis Semdeg, pacientisa da misi meuRlis asaki, warmoebulivazeqtomiis meTodi, antispermuli antisxeulebis arseboba da misi done; raxasiaTisaa aRdgeniTi operacia (vazovazostomia an vazoepididimostomia),rogori rekonstruqcia iqna nawarmoebi calmxrivi Tu ormxrivi.operaciis efeqturoba damokidebulia agreTve rekonstruqciis teqnikazec(mikro an makroqirurgiuli, erT an orsarTuliani nakeri, qirurgi gamocdilebada momzadebis done, sxva paTologiis varikocele da a.S. arseboba.Beiker-is mier Catarebuli multicentruli kvleva efuZneboda 9 wlisganmavlobaSi 5 sxvadasxva dawesebulebaSi nawarmoebi 1469 mamakacis vazeqtomiismikroqirurgiuli rekonstruqciis Sedegebs. dadginda, rom vazeqtomiidan 3 wlisganmavlobaSi Catarebuli rekonstruqciis Semdeg Tanafardoba gamavlobasa daorsulobas Soris Sesabamisad 97% da 76% iyo. 3-8 wlamde periodSi nawarmoebirekonstruqciis Semdeg 88% da 53%, 9-14 wlis Semdeg 79 da44%, xolo 15 wlis dameti drois Semdeg igi 71% da 30% Seadgenda. vazeqtomiis Semdeg praqtikuladyovelTvis antispermantisxeulebis arseboba dgindeba. eakulatis raodenobaucvlelia.orsulobis dadgomis albaToba, rogorc wesi, ormxrivi rekonstruqciisas ufromaRalia. Tu intraoperaciulad miRebul siTxeSi romelime mxarezespermatozoidebi ver iqna nanaxi, unda vifiqroT saTeslis danamatis meoradobturaciaze. aseT SemTxvevaSi mikroqirurgiuli vazoepididimoanastomozisSesruleba aucilebelia. mikroqirurgiul operaciamde axdenen danamatidanspermis aspiracias, damuSavebas da krioprezervacias, warumatebeli operaciis215

SemTxvevaSi ICSI-is sawarmoeblad. axali da kriokonservirebuli spermiTmiRweuli Sedegebi praqtikulad identuria (1, 4, xarisxi A).vazeqtomiis Semdgomi rekonstruqciis, spermis mopovebisa da ICSI –s Sedarebaam mizniT ori specialuri kvleva iqna Catarebuli. aRmoCnda, rom vazeqtomiisSemdgom mikroqirurgiuli wesiT Catarebuli rekonstruqciis SemdegmSobiarobam 47%, xolo spermis mopovebisa da ICSI erTi ciklis Semdeg 33%Seadgina.mikroqirurgiuli rekonstruqcia zemoxsenebul meTodTan mimarTebaSi SedarebiTiafi proceduraa. MESA / TESA-s da ICSI procedurebi unda daigegmos mxolodqirurgiuli rekonstruqciis uSedegobis an SeuZleblobis dros (1, 4, 6,xarisxi A).gamoyenebuli literatura1. evropis urologTa asociaciis saxelmZRvanelo rekomendacibi (gaidlainebi)urologiur daavadebebze, II gamocema, saqarTvelos urologTa asociacia,Tbilisi, 2002. (xarisxi A)2. Свод практических рекомендаций по применению средств контрацепции. UNFPA;ВОЗ. Издание второе, 2005. (xarisxi A)3. Медицинские критерии приемлимости для использования методов контрацепции,UNFPA;ВОЗ , третье издание, 2004 (xarisxi A)4. Cook L., Pun A., Vliet H., Gallo M., Lopez L., Scalpel versus no-scalpel incision for vasectomy ,Cochrane Database of Systematic Reviews 2006 (xarisxi A)5. Hatcher RA, Guest F. Stevart F et al. Contraceptive Technoloty 1988-1989 14 th RevisedEdition. New York: Irvington Publishers, 1988. (xarisxi A)6. Huber D, et al. (Association for Voluntary Sterilization) Trip report, The People`s Republic obChina. June 19-30, 1985. (xarisxi A)7. Labrecque M., Dufresne C., Barone M and St-HilaireK., Vasectomy surgical techniques: asystematic review, BMC Medicine 2004, 2:21 (xarisxi A)8. Li S, Goldstein M, Zhu J,Huber D: The no-scalpel vasectomy. J Urol 1991; 145:341-344.(xarisxi B)9. No-Needle, no-Scalpel Vasektomy J. Urol. 145, 2005, (xarisxi B)10. No scalpel Vasectomy: An illustrated Guide for Surgeons,3 rd .New York: Engender Health2003 (xarisxi A)11. Parekattil SJ, Kuang W, Kolettis PN, Pasqualotto FF, Teloken P, Teloken C, Nangia AK,Daitch JA, Niederberger C, Thomas AJ Jr. Multi-institutional validation of vasectomy reversalpredictor. J Urol. 2006 Jan;175(1):247-9. (xarisxi A)12. Wortman J. Vasectomy-what are the problems. Popul Rep 1985; D(2):25-39. (xarisxi B)13. International Planned Parenthood Federation, Medical and Service Delivery Guidelines for Sexual andReproductive Healthcare Services, Third Edition, 2004. Available online: www.ippf.org (xarisxiA)216

avtorTa jgufisaqarTvelos reproduqtologTa asociacia⇒ a. xomasuriZe _ profesori, medicinis mecnierebaTa doqtori;i.Jordanias sax. adamianis reproduqciuli janmrTelobis s/kinstitutis direqtori;⇒ S.NniSnianiZe;⇒ g. cqitiSvili.eqspertebi:⇒ d. oTxmezuri _ i. Jordanias sax. adamianis reproduqciis s/kinstitutis mecnier TanamSromeli, medicinis doqtori;⇒ g. cercvaZe _ medicinis doqtori. i.Jordanias sax. adamianisreproduqciis s/k instituti. Sobadobis regulaciisganyofilebis ufrosi;⇒ saojaxo medicinis profesionalTa kavSiri _ i. qarosaniZe.217

protokolimamakacis nebayoflobiTi qirurgiuli kontracepcia(vazeqtomia)(andrologebis, reproduqtologebis da urologebisaTvis)pacientebi, romelTaTvisac vazeqtomia Sesaferisi meTodia:• reproduqciuli asakis mamakacebi (Cveulebriv 50 wlis asakamde);• mamakacebi, visac surT mudmivi maRalefeqturi kontraceptiuli meTodi;• mamakacebi, romelTa meuRleebis janmrTelobas orsulobis SemTxvevaSiSeiZleba seriozuli riski Seeqmnas;• mamakacebi, romelTac esmiT da nebayoflobiT Tanxmdebian proceduraze;• mamakacebi / wyvilebi, romlebic darwmunebulni arian, rom aRar surT metibavSvis gaCena;qirurgiuli teqnika: misi arCevani mTlianad qirurgzea damokidebuligamomdinare misi kvalifikaciisa da teqnikuri SesaZleblobebidan.pirobebivazeqtomia SeiZleba Catardes, rogorc ambulatoriulad, ise stacionarispirobebSi.mdgomareobebi, romelic sifrTxiles moiTxovsmdgomareoba gafrTxileba safuZveliadgilobrivi infeqciebi:a) saTesle parkis kanisb) mwvave sggig) balano-postitid) epididimiti an orqiti;mwvave sistemuri infeqcia(mag. gripi) angastroenteritigul-sisxlZarRvTa sistemisdaavadebebi,Sededebis darRveva,endokrinuli daavadebebi(mag. diabeti)gadadeT procedurainfeqciis morCenamdegadadeT procedurainfeqciis morCenamdeprocedurasasurvelia CatardesstacionalurpirobebSi.operaciamde undagakontroldesmniSvnelovanisamecidinoproblemebi.am mdgomareobebmaSeiZleba gazardon iseTigarTulebebis riski,rogoricaapostoperaciuli infeqciapostoperaciuligarTulebebis,gansakuTrebiT infeqciismaRali riskipacientebs mniSvnelovanisamedicino problemebiTSeiZleba dasWirdeTspecialuri qirurgiulimarTva da monitoringi.samedicino problemebmaseiZleba gaarTulonoperacia da gazardoninfeqciis riski218

*anamnezSi saTesle parkistravma*didi zomis varikocele*didi zomis hidrocele*filariazi; elefantiazi*saTesle parkSidaaradiagnostirebuliwarmonaqmni*kriptorqizmi – (calmxrivian ormxrivi, dadasturebulinayofiereba)*sazardulis Tiaqariam mdgomareobebisSemTxvevaSiprocedura undaCatardes stacionarispirobebSi gamocdiliqirurgis mier.am mdgomareobebmaSeiZleba gaarTulonoperacia da gazardoninfeqciis riski.vazeqtomiis Semdgomi garTulebebitradiciuli vazeqtomiis Semdgomi garTulebebia: epididimiti, saTesle parkisabscesi, warumateblad Catarebuli vazeqtomia, spermogaranuloma, celuliti dahematoma.Wrilobisinfeqciavazeqtomiis Semdeg ganviTarebuli problemis marTvaproblema Sefaseba marTvadaazusteT infeqciisan abscesis arsebobaTu saxezea kanis infeqcia,umkurnaleT antibiotikebiT. Tusaxezea abscesi, moaxdineT drenirebada umkurnaleT Cvenebis mixedviT.hematoma(kanqveSa)granulomaZlieri SeSupebatkiviliganakveTis areSigansazRvreTinfeqciis an abscesisarsebobagamoricxeT SesaZloinfeqcia an hematoma.SeamowmeT saTesleparkis SeSupeba.gamoricxeT SesaZloinfeqcia an hematoma.gamoricxeT infeqcia,granuloma anepididimiti.daadeT Tbili, sveli kompresebi dadaakvirdiT saTesle parks.; esgaivlis droTa ganmavlobaSi.daakvirdiT; es iSviaTia (< 0.4%),Cveulebriv TviTgamosworebadia daspontanurad gaivlis.Tu didi da mtkivneulia, SeiZlebasaWiro iyos qirurgiuli marTva.daakvirdiT; es Cveulebrivspontanurad gaivlis 1-dan 3 kviraSi.saWiroebis SemTxvevaSi gamoiyeneTsaTesle parkis damWeri.Tu ar aris infeqcia, umkurnaleTsimptomurad saTesle parkis damWeriTda saWiroebis mixedviTtkivilgamayuCeblebiT. tkiviliCveulebriv spontanurad gaivlis.219