A complete dissection of the whole testicular parenchyma is required in most patients with nonobstructive azoospermia to obtain enough good quality testicular spermatozoa for ICSI.

BACKGROUND: Due to the heterogeneous distribution of seminiferous tubules (STs) in patients with nonobstructive azoospermia (NOA), retrieving enough good quality spermatozoa for ICSI may require a complete testicular dissection. According to the only available study in this field, spermatozoa may be found in the testis surface in 34.2% of patients, while a deeper testicular dissection is able to provide spermatozoa for ICSI in 28% of those without spermatozoa in the testis surface. OBJECTIVES: To determine the probability of finding enough spermatozoa for ICSI at the initial wide incision of the testis in a cohort of men with NOA undergoing microdissection testicular spermatozoa extraction (mTESE). MATERIALS AND METHODS: We evaluated 276 patients, aged 37 (20-62) years, who underwent unilateral (86, 31.15%) or bilateral (190, 68.8%) mTESE from January 2018 through December 2021. During mTESE, the entire surface of the testicular parenchyma was explored first in search for dilated STs: if no/ not enough spermatozoa were retrieved, the deeper portion of the parenchyma was explored. RESULTS: Spermatozoa were retrieved in 137 patients (49.6%). Histopathology demonstrated Sertoli-cell only syndrome in 65.6% of operated testes, while maturation arrest was found in 19.5%, hypospermatogenesis (HS) in 12.7%, and hyalinosis in 2%. Spermatozoa were obtained from the testis surface in 46 of 276 patients (16.6%), and after a complete dissection in 91 subjects (32.9%). On multivariate logistic regression, only the histopathological subcategory HS was predictive of the chance of retrieving spermatozoa from the surface of the testis (OR 3.24, 95% CI 1.37-7.69, p = 0.007). DISCUSSION: Most patients with NOA, particularly those with unfavorable histopathological patterns, require a complete dissection of the testicular parenchyma to obtain enough good quality for ICSI. CONCLUSIONS: By enabling the complete exploration of the testicular parenchyma, mTESE is to be preferred to cTESE to retrieve spermatozoa in patients with NOA.

Surgical treatment of varicocele by a subinguinal approach combined with antegrade intraoperative sclerotherapy of venous vessels.

OBJECTIVE: To evaluate the efficacy, in terms of recurrences, complications and operative duration, of a new technique for treating varicocele. PATIENTS AND METHODS: Between September 1999 and December 2002 we evaluated 307 men aged 17-51 years with varicocele. In all of the men the clinical diagnosis was confirmed by ultrasonography. The men were treated by a variant of the microsurgical technique described in 1994. A 2-3 cm distal subinguinal incision was made at the level of the superficial inguinal ring and the spermatic cord was exposed. The largest vein in the spermatic cord fat was cannulated. A 7-9 cm segment of the spermatic cord was clamped for 8-10 min; at the start of the ischaemia time, 1.5-3 mL of 3% atoxysclerol was injected into the cannulated vein. After sclerotherapy, the vein was ligated at the injection site, and the blood flow to the cord was restored. RESULTS: The mean operative duration was 25 min. Follow-up at 3 and 6 months after surgery, with objective examination and scrotal ultrasonography, revealed one case of clinical recurrence/persistence. The most common complication was penile lymphangitis (nine men) that regressed spontaneously; three men had temporary orchialgia. There were no cases of secondary hydrocele or testicular atrophy. CONCLUSIONS: The modified technique appears to be relatively easy and safe, and to of low cost. Given the promising results in terms of complications and persistence, the treatment appears to be a suitable first-line approach for the surgical treatment of varicocele.

Testicular-sparing microsurgery for suspected testicular masses.

OBJECTIVE: To describe a microsurgical technique for removing suspected testicular masses with sparing of the testicular parenchyma, and to describe case studies. PATIENTS AND METHODS: Six men were referred with testicular lesions (3-6 mm) detected on ultrasonography (US); in one, the lesion was palpable. US showed hypoechoic lesions and in two cases were mixed hypoechoic and anechoic. In these men, the testicular lesion was identified by US before surgery, giving three-dimensional coordinates to facilitate intraoperative recognition. A traditional inguinal incision was used and the funiculus clamped subinguinally without opening the canal. The testicle was isolated after sectioning the gubernaculum testis. In a separate operative field, an equatorial incision of the albuginea was made in a plane orthogonal to the major axis of the testicle, sparing the subtunical vasa. The parenchymal lobuli were dislodged and the seminiferous tubules dissociated, the nodule identified and completely removed, together with approximately 1 mm of surrounding healthy tissue. This technique can also be used for microsurgical testicular sperm extraction (MicroTESE), to retrieve sperm in infertile men. RESULTS: In two infertile men MicroTESE was also performed. Histology revealed one case each of seminoma, Leydig-cell tumour, Leydig cell hyperplasia, atrophy, normality in the incidental forms, and complicated cysts of the albuginea. In the follow-up for infertility reasons, no scarring was observable on the tunica albuginea in the men who had conservative therapy. One year later the patient with seminoma was free of disease. CONCLUSIONS: The increasingly frequent detection of benign testicular lesions, particularly in infertile men, calls for a surgical approach that must be as conservative as possible for the testicular parenchyma. We think that microsurgery should be the first-line technique in small suspected testicular lesions in infertile men.

Detection of testicular ultrasonographic lesions in severe male infertility.

PURPOSE: We retrospectively assessed the number and histology of testicular lesions diagnosed clinically and by ultrasonography in a population of infertile men. MATERIALS AND METHODS: From October 2000 to January 2003, 560 infertile men underwent physical examination, hormonal assessment (follicle-stimulating hormone, luteinizing hormone, testosterone) and scrotal ultrasonography. Eight men were diagnosed with focal testicular ultrasonographic lesions. In 4 cases there was a palpable lesion and in the other 4 cases the lesion was not palpable, diagnosed by ultrasonography (1 was cryptorchid). Only cases of lesions with clear-cut ultrasonographic edges and no history of recent genital infections were considered for explorative surgery through the groin. Microcalcifications were reported if present. The testicle was only preserved when frozen section examination revealed a benign lesion and the margins were negative. RESULTS: Gynecomastia was not present in any patient. No microcalcifications were observed. Follicle-stimulating hormone was high in all patients (range 19.8 to 66.0 mUI/ml, mean 34.4). Luteinizing hormone levels were variable (range 1.32 to 28 mUI/ml, mean 12.3). Testosterone was normal in all cases (range 2.82 to 6.25 ng/ml, mean 4.2). Ultrasonographic features of the lesions were hypoechoic area (6 patients) and mixed hyper-hypoechoic area (2 patients). Histological outcomes of Leydig cell tumor (in 3 patients), focal Leydig cell hyperplasia (1 patient), fibrosis (1 patient), diffuse Leydig cell hyperplasia (1 patient), classic seminoma (1 patient) and embryonal carcinoma (in 1 patient) were observed. CONCLUSIONS: Of 560 infertile patients 8 (1.4%) showed focal testicular lesions, 2 (0.4%) were diagnosed with germ cell tumors and 3 (0.5%) with interstitial cell neoplasms. The malignant tumors were both palpable and in 2 of 3 cases Leydig cell tumors were diagnosed only with ultrasonography.

Premature ejaculation. 1. Definition and etiology.

There is no general agreement on the definition of premature ejaculation, therefore scientific studies often reach discordant results depending on whether they assess the increase in ejaculatory latency or the couple's sexual satisfaction. Etiological theories can be divided into psycho-sexual (anxiety-related, behavioral) and biological (pelvic floor alteration, hypersensitivity of the glans penis, accelerated conduction and cortical amplification of the genital stimuli), both sharing the neurobiological assumption of serotonergic mediation. Premature ejaculation can be iatrogenic (amphetamine, cocaine, dopaminergic drugs) or secondary to urological diseases (prostatovesiculitis, frenulum breve) or to neurological diseases (multiple sclerosis, peripheral neuropathies, medullary expansion processes).

High incidence of benign testicular neoplasms diagnosed by ultrasound.

PURPOSE: We evaluated the clinical and histological significance of incidental ultrasonographic focal testicular lesions and assessed whether a conservative surgical approach may put the patient at higher oncological risk due to insufficient surgical eradication. MATERIALS AND METHODS: From October 2000 to May 2002 all patients with infertility, scrotal swelling, scrotal pain, varicocele, scrotal trauma or erectile dysfunction underwent scrotal ultrasonography. A total of 1,320 patients were investigated. Focal testicular lesions were found in 27 patients (2%), palpable nodules were present in 17 (63%) and nonpalpable incidental lesions were diagnosed in 10. Nodule diameter was 3 to 24 mm. All patients underwent explorative surgery via inguinotomy and preventive clamping of the spermatic cord. The nodules were completely removed with biopsy of the resection margins. Nonpalpable lesions were removed under ultrasonographic guidance. The testicle was only preserved when frozen section revealed a benign lesion and margins were negative. RESULTS: Of the 17 cases of palpable lesions (diameter 3 to 24 mm) conservative surgery was performed in 8 (47%). Definitive histological diagnosis showed Leydig cell tumor in 2 (25%), and large cell calcifying Sertoli's cell tumor, adenomatoid tumor, pseudofibrotic tumor of the tunica albuginea, epidermoid cyst, tubular fibrosis and non-Hodgkin's lymphoma in each 1 (12.5%). The remaining 9 patients (53%) underwent orchidectomy. Definitive histological examination revealed pure seminoma in 4 patients (44%), embryonal carcinoma in 4 (44%) and diffuse Leydig cell hyperplasia in 1 (12%). Seven of the 10 pts (70%) with nonpalpable nodules (diameter 4 to 16 mm) underwent conservative surgery. Histological study revealed focal Leydig cell hyperplasia in 1 case (10%), fibrosis in 3 (30%), infarction in 2 (20%) and mesothelial hyperplasia in 1 (10%). Orchiectomy was performed in the remaining 3 pts. Histology showed diffuse Leydig cell tumor in 2 pts (20%) and adenomatoid tumor with abscessed areas in 1 (10%). Neither atrophy nor local relapse was observed in pts who underwent conservative treatment during followup (mean: 1 month, range 19 to 9). CONCLUSIONS: The incidental diagnosis of testicular ultrasound alterations is increasing and 80% show a benign histology. In these cases a conservative surgical approach is the best option and it does not expose the patient to the risk of relapse.