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Biomedical subjects

Marc Goldstein

Publications and source records attributed to Marc Goldstein.

At least 37 records · Page 2Linked to original sources
PubMed2004

Superior outcomes of microsurgical vasectomy reversal in men with the same female partners.

OBJECTIVE: To evaluate the outcomes of vasectomy reversals in men with the same female partners. DESIGN: Retrospective analysis with comparison with a historical cohort. SETTING: University hospital. PATIENT(S): Among 1,048 patients who underwent microsurgical vasectomy reversal from 1986 to 2002, 27 men (2.6%) were identified who had the same partners as before their vasectomy. INTERVENTION(S): Microsurgical vasovasostomy or vasoepididymostomy. MAIN OUTCOME MEASURE(S): Semen parameters, clinical pregnancy, and live birth rates. RESULT(S): The mean age of the men was 38.5 years, and 37.2 years for their female partners. The reasons for vasectomy reversal were death of a child in 33% of cases and desire for more children in 66% of cases. The overall patency rate was 100% at 1 month postoperatively, with an average sperm concentration of 30 million/mL and 24% motility. Among patients with follow-up beyond 1 year, the natural pregnancy rate was 86%, which was achieved at 8.3 months postoperatively, with a live birth rate of 82%. The live birth rate in couples with the death of a child was 100%. CONCLUSION(S): The outcomes of vasectomy reversal in men with the same female partners are better than for men with new partners. Possible reasons for these superior results are previous proven fecundity as a couple, shorter time interval since vasectomy, and emotional dedication.

Adult↗
PubMed2004

Microsurgical treatment of persistent or recurrent varicocele.

OBJECTIVE: To examine the effectiveness of subinguinal microsurgical varicocelectomy in the treatment of persistent or recurrent varicocele. DESIGN: Retrospective chart review. SETTING: Urban, tertiary care, academic teaching hospital. PATIENT(S): Fifty-four men who presented for treatment of persistent or recurrent varicocele. INTERVENTION(S): A single surgeon using an artery and lymphatic sparing subinguinal microsurgical technique with delivery of the testis repaired all varicocele. MAIN OUTCOME MEASURE(S): Preoperative to postoperative changes in semen parameters (volume of ejaculate, sperm concentration, percent motility, percent morphologically normal sperm, total motile sperm concentration), serum hormone levels, and testicular volume. Pregnancy rates and surgical complications were documented. RESULT(S): Postoperative mean serum T and mean testicular volume increased significantly from prevaricocelectomy levels. Median sperm concentration, percent motility, and total motile sperm per ejaculate improved significantly following recurrent varicocelectomy. Among patients with follow-up over 24 weeks (65%, 35 out of 54), the overall pregnancy rate was 40% (14 out of 35), including 23% (8 out of 35) of pregnancies achieved through natural intercourse, 9% (3 out of 35) with IVF/intracytoplasmic sperm injection, and 9% (3 out of 35) with IUI. Complications such as hydrocele, hematoma, wound infection, and testicular atrophy were not observed during the follow-up period. CONCLUSION(S): Treatment of persistent or recurrent varicocele using an artery and lymphatic sparing subinguinal microsurgical technique with delivery of the testis improves semen parameters, serum T levels, and testicular volume from preoperative levels without a significant risk of postoperative complications.

Female↗
PubMed2004

Sperm cryopreservation and in vitro fertilization/intracytoplasmic sperm injection in men with congenital bilateral absence of the vas deferens: a success story.

In this study we evaluate the use of cryopreservation of sperm obtained at the time of surgical exploration in men with congenital bilateral absence of the vas deferens. We assess the impact of cryopreservation on pregnancy rates after IVF/intracytoplasmic sperm injection. Intraoperative cryopreservation of sperm at the time of microsurgical epididymal sperm aspiration in men with congenital bilateral absence of the vas deferens resulted in a 100% live delivery rate per couple, providing the highest pregnancy rates of any infertility treatment.

Adult↗
PubMed2004

Intraoperative characterization of arterial vasculature in spermatic cord.

OBJECTIVES: To characterize the arterial microanatomy within the spermatic cord. METHODS: Between June 2002 and March 2003, 72 men underwent 120 microsurgical subinguinal varicocelectomies for the treatment of varicocele. A micro-ruler was used to measure the diameter of each artery in the spermatic cord at the external inguinal ring. RESULTS: A single testicular artery was identified in 83 (69%), two testicular arteries in 32 (27%), and three arteries in 4 (3%) of 120 cases. The testicular artery diameter ranged from 0.2 to 1.9 mm (mean 1.0). A single vasal artery was identified in 117 (98%) of 120 cases, with the vasal artery diameter ranging between 0.2 and 1.8 mm (mean 0.6). A single cremasteric artery was identified in 66 (55%), two arteries in 37 (31%), and three arteries in 5 (4%) of 120 cases. The cremasteric artery diameter ranged from 0.1 to 1.5 mm (mean 0.5). The diameter of the testicular artery was equal to or greater than the sum of the vasal and cremasteric artery diameters in 69 (57.5%) of 120 spermatic cords. CONCLUSIONS: The testicular artery was consistently the largest caliber arterial vessel, with a diameter equal to or greater than the sum of the vasal and cremasteric arteries in more than 50% of the spermatic cords. This suggests that although the vasal and cremasteric arteries combined contribute significantly to the testicular blood supply, the testicular artery provides most of the blood flow to the human testes. Preservation of the testicular arteries is recommended for optimal testicular blood flow.

Adolescent↗
PubMed2004

The impact of obstructive interval and sperm granuloma on outcome of vasectomy reversal.

PURPOSE: We studied the impact of the interval from vasectomy to reversal and presence of sperm granuloma on outcomes of reversal. MATERIALS AND METHODS: A total of 213 microsurgical vasectomy reversals performed by a single surgeon were stratified according to obstructive intervals of less than 5 years, 5 to 10 years, 10 to 15 years and greater than 15 years. The effects of obstructive interval on patency and pregnancy rates were assessed using multivariate logistical regression. The impact of sperm granuloma on patency and pregnancy was assessed using the chi-square test. RESULTS: Patency did not change with increasing obstructive intervals as can be seen with 91% patency at less than 5 years, 88% at 5 to 10 years, 91% at 10 to 15 and 89% at greater than 15 years. There was no difference in pregnancy rates (89%, 82% or 86%) at obstructive intervals of 0 to 5, 5 to 10 or 10 to 15 years, respectively. Pregnancy rates were significantly lower (44%, p <0.05) with obstructive intervals greater than 15 years. Men with at least unilateral sperm granuloma had patency of 95% vs 78% without granulomas, a trend which did not quite reach statistical significance (p = 0.07). There was no difference in pregnancy rates with or without granulomas. CONCLUSIONS: Vasectomy reversal patency rates are high regardless of time since vasectomy. Pregnancy rates are lower more than 15 years after vasectomy. Sperm granuloma had a favorable impact on patency. Our data indicate that for obstructive intervals less than 15 years vasectomy reversal yields much higher pregnancy rates than in vitro fertilization and intracytoplasmic sperm injection, and that even for intervals greater than 15 years reversal outcomes equal or exceed those of in vitro fertilization and intracytoplasmic sperm injection.

Female↗
PubMed2004

Robotic microsurgical vasovasostomy and vasoepididymostomy: a prospective randomized study in a rat model.

PURPOSE: Microsurgical vasovasostomy and vasoepididymostomy remain technically challenging procedures. Refinements in technique have continually improved patency and pregnancy rates for the 2 procedures in experienced hands. Advances in surgical robotics produced the Da Vinci robot (Intuitive Surgical, Inc., Sunnyvale, California) with motion reduction and no tremor, features that may improve outcomes in microsurgery. We report a randomized prospective study of vasoepididymostomy and vasovasostomy using the Da Vinci robot in rats. MATERIALS AND METHODS: A total of 24 adult male Wistar rats underwent vasectomy through a midline abdominal incision. Two weeks later the animals were randomized to microsurgical multilayer vasovasostomy, longitudinal vasoepididymostomy or robotic vasovasostomy and vasoepididymostomy groups. Outcomes measured included surgical time, complications, patency and sperm granuloma formation at 9 weeks. RESULTS: Animals were sacrificed 9 weeks after microsurgery. There were no significant differences in complications among the groups. Robotic vasovasostomy was significantly faster than the conventional microsurgical technique (68.5 vs 102.5 minutes, p = 0.002). The robotic and microsurgical vasoepididymostomy groups did not differ significantly in time. Patency rates were 100% for the robotic vasovasostomy and vasoepididymostomy groups, and 90% in the microsurgical vasovasostomy and vasoepididymostomy groups. These differences were not significant. Sperm granulomas were found in 70% of microsurgical vasovasostomy anastomoses and 27% of robotic vasovasostomy anastomoses (p = 0.001). No significant difference in the sperm granuloma rate was found between the robotic or microsurgical vasoepididymostomy groups (42% and 50%, respectively, p = 0.37). CONCLUSIONS: To our knowledge we report the first randomized prospective study using the Da Vinci robot for microsurgery. We believe that the improved stability and motion reduction during microsurgical suturing with the robot helped achieve excellent patency rates for vasovasostomy and vasoepididymostomy. The robot may also allow experienced microsurgeons to perform microsurgical procedures in patients at remote locations where no experienced microsurgeons are available.

Animals↗
PubMed2004

Intravasal "toothpaste" in men with obstructive azoospermia is derived from vasal epithelium, not sperm.

PURPOSE: Men undergoing vasectomy reversal many years after vasectomy are at increased risk for secondary epididymal obstruction. When this occurs the intravasal fluid is often a thick, white, toothpaste-like material devoid of sperm. In this study we characterize the vasal fluid found in men with a newly described entity, segmental dysplasia of the vas deferens, in which at least 2 distinct sites of vasal obstruction are present. We determine the significance of this fluid in men with obstructive azoospermia. MATERIALS AND METHODS: Three men who underwent scrotal exploration for obstructive azoospermia due to segmental dysplasia of the vas deferens were evaluated. Each underwent scrotal exploration including bilateral vasotomy and testicular biopsy. Intravasal fluid was collected, evaluated microscopically and sent for cytopathological evaluation. RESULTS: All men had isolated segments of the vas 2 to 5 cm in length that were not connected to the epididymis or ejaculatory ducts. We have named this condition segmental dysplasia of the vas deferens. Vasotomy was performed between aplastic segments, revealing thick, white, toothpaste-like material identical to that seen in men with secondary epididymal obstruction undergoing vasectomy reversal. Cytopathological evaluation of this fluid revealed proteinaceous concretions and rare clusters of degenerated columnar epithelial cells, but no sperm or sperm products. CONCLUSIONS: Thick, white, toothpaste-like material is produced between 2 obstructed segments as seen in men with segmental dysplasia of the vas deferens and with secondary epididymal obstruction. Our findings in men with segmental dysplasia of the vas deferens indicate that vasal "toothpaste" must be derived from vasal epithelium, not sperm.

Body Fluids↗
PubMed2004

Toward a sutureless vasovasostomy: use of biomaterials and surgical sealants in a rodent vasovasostomy model.

PURPOSE: With 500,000 to 800,000 vasectomies performed annually and a reversal rate of 3% to 8% vasectomy reversal has become a commonly performed procedure. Two-layer microsurgical vasovasostomy remains the gold standard for surgical reconstruction of the vas. However, this procedure is technically demanding and time-consuming. We determined the ability of biomaterials and surgical sealants to decrease the number of sutures used, enhance anastomosis watertightness and decrease operative time. MATERIALS AND METHODS: Adult male Wistar rats underwent vasectomy 2 weeks prior to vasovasostomy. Standard 2-layer microsurgical repair was performed in control animals. Experimental groups underwent 3-suture mucosal approximation and then completion of the anastomosis with a biomaterial membrane and/or synthetic sealant. The rats were sacrificed 9 weeks after vasovasostomy. Anastomotic patency was assessed functionally by the presence of motile sperm in the vas distal to the testes and anastomosis, and mechanically by methylene blue vasogram. The presence and size of sperm granulomas were also recorded. RESULTS: Microsurgical vasovasostomy required significantly less time when biomaterial (42.7 minutes) or sealant (40 minutes) was used compared to the standard sutured group (102.5 minutes, each p < 0.001). There was no difference in patency between the standard sutured and biomaterial groups (90% vs 92%). Patency was significantly lower in the sealant groups, that is 70% in the suture, biomaterial and sealant group, and 75% in the suture and sealant group. The biomaterial group had only 1 sperm granuloma in 12 procedures, which was significantly better than the 7 in the control group (p <0.001). CONCLUSIONS: Using a biomaterial wrap during vasovasostomy resulted in significantly decreased operative time and fewer sperm granulomas than in the control group. Sealants were not effective. Biomaterial wrap may support vasovasostomy and by decreasing leakage improve the outcome.

Animals↗
PubMed2004

The presence of vasal vessels in men with congenital bilateral absence of the vas deferens.

PURPOSE: We characterized spermatic cord microanatomy in men with congenital bilateral absence of the vas deferens (CBAVD) presenting for varicocelectomy. We discuss the implications of these findings for varicocele repair. MATERIALS AND METHODS: Between 1997 and 2003, 8 men with CBAVD underwent a total of 11 microsurgical subinguinal varicocelectomies at microsurgical epididymal sperm aspiration and cryopreservation. All 8 men had palpable grades II to III varicoceles and in 6 varicoceles were repaired due to painful symptomatology, while 2 had testicular hypotrophy with an abnormal hormonal profile. Three men had bilateral varicoceles repaired, while 5 underwent unilateral varicocelectomy. All patients provided a thorough history and underwent physical examination, hormonal evaluation, semen analysis, genetic testing and renal ultrasonography. RESULTS: Intraoperative microsurgical dissection confirmed dilated internal and external spermatic veins, and absence of the vas deferens in all 11 spermatic cords. Characteristic tortuous vasal vessels of normal caliber were clearly identified in all 11 (100%) of these spermatic cords between the internal and external spermatic fasciae in the location where the vas deferens is usually found. CONCLUSIONS: Despite the absence of the vas deferens normal sized, orthotopically located vasal vessels were present in 100% of the spermatic cords examined. Furthermore, the caliber of the vasal veins was sufficient to provide adequate venous return from the testis following ligation of the internal and external spermatic veins. In patients with CBAVD presenting for varicocele repair standard microsurgical varicocelectomy with ligation of all internal and external spermatic veins can be performed without the risk of testicular congestion secondary to inadequate venous drainage.

Humans↗
PubMed2004

Multidisciplinary predialysis care and morbidity and mortality of patients on dialysis.

BACKGROUND: Multidisciplinary predialysis care results in fewer hospitalizations and more patients starting hemodialysis therapy with vascular access. Rigorous comparisons of the effect of different types of predialysis care on outcomes after the initiation of dialysis therapy are in their infancy. We hypothesized that outcomes after the initiation of dialysis therapy would be superior in patients receiving multidisciplinary predialysis care than in those receiving conventional care. METHODS: All incident dialysis patients at our center who had received at least 3 months of specialist predialysis care were categorized according to whether they had attended the multidisciplinary Progressive Renal Disease Clinic (PRDC). Patients with a failed transplant, acute renal failure, or previous renal replacement therapy were excluded. We compared these groups at initiation and during 3 years of dialysis therapy. RESULTS: At the start of dialysis therapy, patient demographics and residual renal function were similar. PRDC patients were more likely to have a functioning access and be administered angiotensin-converting enzyme inhibitors, iron supplements, and bicarbonate therapy and had greater serum albumin and serum calcium levels. PRDC patients had fewer hospitalizations at 1 year (7.0 versus 69.7 d/patient/y; P < 0.01) and during the study duration (10.8 versus 57.4 d/patient/y; P < 0.05). There were fewer deaths in the PRDC group at 1 year (2% versus 23%; P < 0.01) and during the study duration (21% versus 42%; P < 0.05). A history of cardiovascular disease, older age, and non-PRDC predialysis care independently predicted death on dialysis therapy. CONCLUSION: Multidisciplinary predialysis care is associated with superior clinical outcomes after the start of dialysis therapy.

Adult↗
PubMed2004

[Microsurgical approaches to the treatment of obstructive azoospermia].

In the past 5 to 10 years, very few fields in modern medicine have changed so dramatically as reproductive medicine, especially for the treatment of male infertility. Advances have been made in intracytoplasmic sperm injection (ICSI), refined microsurgical reconstructive techniques (vasovasostomy and vasoepididymostomy), and microsurgical techniques of surgical sperm retrieval from the epididymis and testis. All men with epididymal obstruction (obstructive azoospermia) now have the opportunity to father their own biological children. In this article, the authors reviewed the most updated microsurgical vasovasostomy, vasoepididymostomy techniques and surgical indications as well as the key factors for successful microsurgical treatment. They also predicted the future directions and discussed the advantages of microsurgical techniques, emphasized the significant roles of microsurgical training for urological doctors to treat male infertility.

Epididymis↗
PubMed2003

Relationship between semen cultures, leukospermia, and semen analysis in men undergoing fertility evaluation.

OBJECTIVE: To determine the correlation between semen cultures, semen Gram stains, leukospermia, and semen analysis parameters in asymptomatic men undergoing fertility evaluation. DESIGN: Prospective clinical study. SETTINGS: Infertility clinic at a university teaching hospital. PATIENT(S): Two hundred ninety-nine asymptomatic men undergoing fertility evaluation. INTERVENTION(S): After an antibacterial skin preparation, all men gave semen specimens for culture, Gram stains, semen analysis, and assessment for leukospermia. MAIN OUTCOME MEASURE(S): A comparison of the presence or absence of bacteriospermia, the specific bacterial isolate, the quantity of bacteriospermia, the presence or absence of leukospermia, and semen analysis parameters. RESULT(S): The presence or absence of bacteriospermia or leukospermia did not correlate with each other. Leukospermia did not correlate with semen parameters. Staphylococcus species was the most common isolate (25.4% of all patients) and did not correlate with semen parameters or leukospermia. Streptococcus viridans (15.4% of all patients) and Enterococcus faecalis (7.4% of all patients) were the next most common isolates and were associated with statistically significantly poorer semen quality. CONCLUSION(S): Leukospermia is a poor marker for either bacteriospermia or impaired semen quality. Staphylococcus species are commonly isolated but appear to be innocuous. Streptococcus viridans and Enterococcus faecalis are associated with poorer semen quality and may warrant treatment.

Adult↗
PubMed2003

Resolution of massive uremic tumoral calcinosis with daily nocturnal home hemodialysis.

BACKGROUND: Derangements in bone mineral metabolism are an invariable consequence of end-stage renal disease (ESRD). Extraosseous tumoral calcification is a relatively uncommon complication that can be associated with substantial morbidity. METHODS: The authors report a case of an ESRD patient who had severe tumoral calcification of his shoulder, hands, and feet despite daily conventional hemodialysis. Conversion to daily nocturnal hemodialysis (DNHD) led to a dramatic resolution of his calcific deposits within only 9 months of initiating this form of renal replacement therapy. RESULTS: After initiating DNHD, the patient's serum phosphate level, which had been exceedingly difficult to control, normalized within the first week. Despite maintaining a high dialysate calcium (Ca) bath up to 4.2 mEq/L (2.1 mmol/L; to maintain calcium balance and suppress parathyroid hormone [PTH]), there was ongoing dissolution of the calcific deposits. This occurred with relatively preserved bone mineral density. The Ca x phosphorus (PO4) product decreased from 85 mg2/dL2 (6.80 mmol2/L2) and remained less than 55 mg2/dL2 (4.4 mmol2/L2) throughout the patient's course on DNHD. PTH levels fell precipitously early on but then rose again several months after starting DNHD. This PTH rebound as well as the possible mechanisms underlying the dissolution of this patient's extraosseous calcifications are explored further. CONCLUSION: Extraosseous tumoral calcification associated with ESRD is an uncommon but potentially serious complication in this patient population. DNHD, by offering superior phosphate clearance, can facilitate the dissolution of these calcific deposits over a relatively short period. This effect can be seen despite using high calcium concentration dialysate to maintain calcium balance and mitigate hyperparathyroidism.

Absorptiometry, Photon↗
PubMed2003

Microsurgical vasoepididymostomy: a prospective randomized study of 3 intussusception techniques in rats.

PURPOSE: Vasoepididymostomy is a technically challenging but cost-effective treatment for obstructive azoospermia. We evaluated the outcomes of 3 intussusception vasoepididymostomy techniques, namely 3 suture triangulation, 2 suture transverse and a new 2 suture longitudinal technique. MATERIALS AND METHODS: Male Wistar rats were randomized into 4 experimental and 1 control groups. After 3 weeks of vasal obstruction bilateral vasoepididymostomy was performed. In group I, 3 sutures were placed in triangular fashion. In group II, 2 sutures were placed perpendicular to the tubule. In group III, 2 sutures were placed longitudinal to the tubule. The tubules were then opened in the direction of the needles and anastomosed to the vasa. After 5 months patency was evaluated in blinded fashion. RESULTS: The functional patency rate (presence of motile sperm in the vas) was 64%, 64% and 93% in groups I to III, respectively (p <0.001). As evaluated by methylene blue retrograde vasography toward the epididymis, the mechanical patency rate was similar for the 3 techniques, that is 86%, 86% and 93% in groups I to III, respectively. The sperm granuloma rate was significantly lower in group III (36%, 21% and 0% in groups I to III, respectively, p <0.001). CONCLUSIONS: Transverse 2 suture vasoepididymostomy has a patency rate similar to that of the 3 suture technique. Our new 2 suture longitudinal technique, which allows a larger opening in the epididymal tubule for anastomosis, is superior to the 2 and 3 suture techniques with respect to the patency and sperm granuloma rates.

Anastomosis, Surgical↗
PubMed2003

Cryopreservation of sperm: indications, methods and results.

PURPOSE: We review the history of the cryopreservation of human sperm. The current methods of cryopreservation and indications are highlighted, and the success rates of the various uses of cryopreserved sperm are reviewed. Potential adverse sequelae of human cryopreservation are also discussed. MATERIALS AND METHODS: Indications for cryopreservation include several applications, namely homologous and donor insemination, cryopreservation prior to surgical infertility treatment, intraoperative cryopreservation, postoperative cryopreservation, cryopreservation prior to treatment for malignancies and nonmalignant diseases, as well as premortem and postmortem cryopreservation. RESULTS: With the use of intracytoplasmic sperm injection, open microsurgical epididymal sperm aspiration and testicular sperm extraction with cryopreserved sperm in men with obstructive azoospermia yields pregnancy rates similar to those using fresh sperm. Intraoperative cryopreservation is recommended for complex reconstructive cases with lower patency rates, including vasoepididymostomy and vasoepididymostomy to the efferent ductule. In addition, sperm banking is strongly recommended for all patients with malignant disease who may wish to have children, since a small but significant percent of these men later use their banked semen. Although there is concern about the transfer of genetically damaged sperm after cryopreservation, no proven increase in genetic or phenotypic abnormalities in offspring has been identified. CONCLUSIONS: Sperm cryopreservation has revolutionized the field of assisted reproduction. Cryopreserving sperm avoids the need for additional surgery in couples undergoing repeated in vitro fertilization/intracytoplasmic sperm injection cycles. Moreover, it provides hope for men undergoing chemotherapy, radiation or radical surgery who once had no chance for future fertility.

Cryopreservation↗
PubMed2003

Intraoperative varicocele anatomy: a microscopic study of the inguinal versus subinguinal approach.

PURPOSE: The groin approach to varicocelectomy is performed by an inguinal (aponeurosis of external oblique opened) or subinguinal (external oblique aponeurosis intact) technique. We describe the number and relationship of internal and external spermatic arteries, veins and lymphatics within the subinguinal portion of the spermatic cord in infertile men undergoing microscopic varicocelectomy and compare these findings to the microanatomy observed with the inguinal approach. MATERIALS AND METHODS: A total of 48 consecutive patients underwent 84 microsurgical subinguinal varicocelectomies during which the detailed intraoperative microanatomy of the spermatic cord and gubernacula was recorded. These observations were compared with a previously reported group of 83 consecutive patients that underwent 115 inguinal varicocelectomies. Subinguinal microscopic findings were also evaluated relative to clinical varicocele grade. RESULTS: The spermatic cord in the subinguinal dissection was characterized by a smaller number of large (greater than 5 mm) internal spermatic veins and a greater number of small (less than 2 mm) internal spermatic veins than the cord in the inguinal dissection (mean 0.4 vs 1.9 large veins and mean 7.9 vs 4.7 small veins, respectively). The subinguinal dissection was also characterized by a significantly greater percentage of external spermatic veins greater than 2 mm than that observed during inguinal dissection (93% vs 74%, respectively, p <0.05). Multiple spermatic arteries were identified in 75% of subinguinal dissections and in only 31% of inguinal dissections (p <0.03). Internal spermatic arteries were surrounded by a dense complex of adherent veins in 95% of cases using the subinguinal approach, whereas this finding was true in only 30% of cases with the inguinal approach (p <0.001). The clinical grade of a varicocele was significantly associated with the number of internal spermatic veins greater than 2 mm found intraoperatively (p <0.001) but not with the maximum internal spermatic vein diameter. CONCLUSIONS: Although the subinguinal approach to microsurgical varicocelectomy obviates the need to open the aponeurosis of the external oblique, it is associated with a greater number of internal spermatic veins and arteries compared with the inguinal approach. The primary branch point for the testicular artery occurs most commonly during its course through the inguinal canal. Internal spermatic arteries at the subinguinal level are more than 3 times as likely to be surrounded by a dense network of adherent veins than when they are identified at the inguinal level. Taken together, these data suggest that microscopic dissection is more difficult with a subinguinal incision.

Adolescent↗
PubMed2002

Ultrasound guided needle localization and microsurgical exploration for incidental nonpalpable testicular tumors.

PURPOSE: We describe a technique by which incidental, nonpalpable intratesticular tumors are excised using intraoperative ultrasonography and the operating microscope. MATERIALS AND METHODS: Men with impalpable intratesticular tumors incidentally detected by ultrasonography underwent intraoperative ultrasound guided needle localization and microsurgical exploration of the mass. The testis was delivered through an inguinal incision and placed on ice to minimize warm ischemia. Two rubber shod vascular clamps were placed across the spermatic cord. The tumor was identified by ultrasound and localized with a 30 gauge needle, which was placed adjacent to the tumor. An operating microscope providing 6x to 25x magnification was used to excise the lesion with a 2 to 5 mm. margin. Tissue diagnosis was obtained by frozen section. Multiple random biopsies of the remaining parenchyma were done to confirm absent malignancy. RESULTS: Ultrasound showed incidental, nonpalpable testis tumors in 4 of the 65 men who underwent infertility evaluation and were entered into the microsurgical testis biopsy database between January 1995 and December 2001. All lesions were hypoechoic. Frozen section analysis of the lesions revealed 2 Leydig cell tumors, 1 mass with an inconclusive pathological diagnosis and 1 inflammatory mass. On permanent section the latter 2 lesions were seminoma. The seminomas were 1.6 and 0.9 cm. in the greatest diameter, and the Leydig cell tumors were 0.35 and 0.2 cm., respectively. Random biopsies were positive for seminoma and intratubular germ cell neoplasia in both testes with seminoma. These 2 patients subsequently opted to undergo radical orchiectomy. No residual tumor was detected in either radical orchiectomy specimen. CONCLUSIONS: Intraoperative ultrasound guided needle localization with microsurgical exploration is a safe and effective approach to even small impalpable testicular masses. This technique provides the opportunity to identify and remove benign and malignant lesions, and preserve the testis when the lesion is benign. In cases of a solitary testis or bilateral synchronous lesions the technique allows a potentially testis sparing operation for small malignancies.

Biopsy↗