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Observations made upon dogs and humans with apparent infarction of the testis secondary to torsion of the spermatic cord suggest that the treatment of choice for questionably viable testis is detorsion of the cord, replacement of the testis in its hemiscrotum, and fixation of the opposite testis. This form of therapy may be applicable to all "torsed testes" regardless of viability.
Previous studies of the rat have shown that testosterone concentrations within the interstitial and seminiferous tubularfluids of the testes are significantly higher than normal serum levels, and further, that although intratesticular testosterone concentration can be substantially reduced without an effect on spermatogenesis, the concentration that is minimally required to maintain spermatogenesis is also substantially higher than serum levels. The purpose of the present study was to adapt a minimally invasive technique to sample human intratesticular fluid to enable parallel observations in man. To this end, aspiration methods were first developed for the rat testis and then adapted to the human. The testosterone concentration in fluid obtained by unilateral aspiration of rat testes was approximately 50 ng/mL, similar to the known concentration in seminiferous tubular fluid. These aspiration methods were then adapted to obtain intratesticular fluid from human testes. Studies of 12 fertile human subjects demonstrated that percutaneous testicular aspiration could be performed safely and successfully using a 19-gauge needle. Nine additional human subjects had bilateral testicular aspiration and simultaneous measurement of peripheral blood testosterone levels. Testicular aspirations yielded 8 to 117 microL of fluid from each testicle. The mean concentration of testosterone in aspirates obtained from the 21 patients was 609 +/- 50 ng/mL. Dihydrotestosterone and 3alpha-androstanediol concentrations were quite low, below the limits of detection of our assay. The SHBG/ABP concentration in the aspirates was 8.5 +/- 1.1 nM. These results define testosterone as the major androgenic steroid in the human testis, as in the rat testis, and indicate that the testosterone concentration within the human testis is approximately 200-fold greater than that of SHBG/ABP, and more than 100-fold greater than the concentration of testosterone found in normal human serum.
OBJECTIVE: To analyze the utility of laparoscopic evaluation in the diagnosis of the nonpalpable testis versus conventional imaging techniques based on our experience with 51 cases and data reported in the literature. METHODS/RESULTS: Testicular tumors were found in both intra-abdominal testes in one patient, as well as 7 cases of evanescent testis and 39 testicular rests in the inguinal canal. Four other intra-abdominal testes showed no changes. CONCLUSIONS: The possibility of an existing intra-abdominal testis and its possible progression to malignancy warrant exploration of the nonpalpable testis by laparoscopy, a very simple and effective procedure.
A 37-year-old man was admitted with a painful mass in his left inguinal region. He had an undescended testis on the left side. Six months earlier, he had noted that his left inguinal testis was larger, and he had suddenly developed pain in the left inguinal region. The levels of AFP, hCG beta and LDH were normal. We diagnosed a left undescended testicular tumor and torsion of the left testis. Left inguinal high orchiectomy showed a torsion of the left testis and histopathological examination of the specimen revealed seminoma.
Cystic dysplasia of the testis (CDT) is a rare, benign and congenital lesion causing scrotal mass in pediatric population that can mimic testicular cancer. This lesion consists of cystic dilation of the rete testis and it is frequently associated with renal or genitourinary tract anomalies as renal agenesis and multicystic dysplasia of the kidney. This frequent presentation suggests that testicular cystic dysplasia is associated with a defect of the metamesonephric system in particular with a defect in the connection between the efferent ducts derived from the mesonephros and the rete testis tubules derived from the gonadoblastoma. The role of ultrasound is of primary importance for clinical diagnosis and follow-up of untreated forms. The sonographic appearance of CDT consists of multiple cysts in the mediastinum testis. The cysts range in size from microscopic to several millimetres and may involve the whole testicular parenchyma or have a focal aspect. If the cysts are tiny, the ultrasound must be able to distinguish between CDT and testicular microlithiasis, a potential premalignant condition. Today it is possible thanks to high frequency 7.5 to 10 mHz probes. In the past orchiectomy has been considered as the treatment of the choice for CDT. Today, non operative management of CDT represents an effective alternative option in these patients and the primary benefit of this approach is the preservation of endocrine function and spermiogenic activity. However, the natural history of untreated CDT and its effect on normal testicular tissue are still unknown, therefore long-term follow-up is recommended.
A 24-year-old man was admitted to our hospital with the complaint of a painless mass in the left testis. Gynecomastia was not present. The serum levels of alpha fetoprotein and human chorionic gonadotropin-beta were not elevated. Ultrasound sonography showed a hypoechoic lesion in the left testis. There was no evidence of retroperitoneal lymph node enlargement or distant metastasis on computerized tomography. With a diagnosis of left testicular tumor, left high orchiectomy was done. The tumor measured 10 x 11 mm in size within the testis and was histologically diagnosed as benign Sertoli cell tumor. Immunohistochemcal analysis revealed negative findings with the tumor markers inhibin, CAM 5.2, pancytokeratin, EMA, and PLAP. No adjuvant therapy was performed. Twenty-six cases of Sertoli cell tumor of the testis in the Japanese literature are reviewed.
A case of fibrous pseudotumor originating from the tunica vaginalis testis is reported. A 42-year-old man was referred to our hospital with the complaint of painless nodules along his right epididymis. There was no evidence of specific history. Ultrasonography showed an isoechoic small mass attached to the right testis. Inflammatory granulomas of the right epididymis were suspected, and an operation was carried out. The operative appearance indicated tumors of various sizes originating from the tunica vaginalis testis. Tumors were resected with the tunica vaginalis testis. Pathological diagnosis of the tumor was a fibrous pseudotumor. We reviewed and discussed 33 cases of intrascrotal fibrous pseudotumor, including our case, in the Japanese literature.
The authors report 16 cases of torsion of the testis and 3 cases with twisting of the testicular appendix. Fifteen children with torsion of the testis and one child with twisting of the testicular appendix were operated upon. Late results were followed up in 14 cases within the terms from 6 months to 7 years. Atrophy of the testis was not observed in children, operated upon in earlier terms of the affection, irrespective of the degree of the torsion. In late patients' admission to the hospital even small size torsions resulted in testicular atrophy in 4 cases. To improve the results of treatment in children with torsion of the testis early operative interventions are greatly advocated.
AIM: The expression of the cytokines IL-2, IL-6, IL-10, IFN-g and TNF-a and the adhesion proteins CD99 and CD106 was studied in the human testis at the protein level. METHODS: The expression of the cytokines and the adhesion proteins was assessed using immunohistochemistry and immunoblotting. RESULTS: None of the cytokines studied was present in the human testis, but CD99 and CD106 (VCAM-1) strongly were expressed in all the testes investigated. CD99 was present in the interstitial tissue of the human testis as well as in the Sertoli cells. The identity of the CD99+ interstitial cells is unclear. CD106 (VCAM-1) was present in Leydig cells as well as the basal parts of the Sertoli cells in the seminiferous tubules. In immunoblotting, CD99 was demonstrated at molecular ratios of 46-57 (kD). This is a novel isoform of the molecule. CONCLUSION: The human testis produces both CD99 and CD106 and as CD106 mediates cell binding to lymphocytes, it is possible that the human Leydig cells adhere to lymphocytes like the rodent Leydig cells.
Carcinoid tumor of the testis is exceedingly rare. Most carcinoid tumors occur in the appendix or ileocecal region (85%), while others are found in the lung, liver, and genitourinary tract (15%). A primary carcinoid testis tumor may originate from argentaffin or Kulchitsky's cells, which are located in the Lieberkuhn crypt. Preoperative ultrasound may show a solid, hypoechoic, well-defined margin mass combined with calcification or a cyst. Differential diagnosis of the ultrasound appearance is testicular tumor (teratoma/embryonal cell carcinoma), epidermoid tumor, tuberculous epididymo-orchitis, and the result of trauma. Radical orchiectomy remains the main treatment for a carcinoid testis tumor. Grossly, surgical removal of the tumor presents with a solid mass, tan to white in color. Immunohistochemical study shows that tumor cells are diffusely reactive to antibodies to keratins AE1 and AE3, chromogranin-A, neuron-specific enolase (NSE), and synaptophysin. A pure primary testicular carcinoid tumor has been treated as a benign lesion, while metastatic carcinoid tumor has a poor prognosis regardless of the primary site. To rule out the possibility of metastasis resulting from an extra-testicular primary carcinoid, careful and thorough postoperative whole body surveys are important. Chest X-ray, chest computed tomogram (CT), abdominal and pelvic CT, and octreotide scintigraphy are indicated. We herein describe a case of primary carcinoid tumor of the testis and review the literature.
Testicular maldescent is known to be associated with later development of malignancy. The maldescended testis is prone to other complications--in particular, torsion. We report an unusual coincidence of both malignancy and torsion of an intra-abdominal testis which closely simulated a ruptured appendix abscess. This case demonstrates that an intra-abdominal testis can develop acute life-threatening complications which should be considered in any patient with acute abdominal symptoms who has an 'absent' testis.
The diagnostic accuracy of laparoscopy for impalpable testis is well recognized. However, in some cases, laparoscopic findings may be misleading, and a viable gonad may be missed with significant medico-legal implications. From January 1993 to December 2000, 202 patients with 219 impalpable testes were evaluated. In 95 cases, the gonad was immediately visualized, and in 5, the presence of a testis was documented by inserting the scope into the processus vaginalis. In the 119 remaining cases, no gonad was seen while entering the abdomen with the laparoscope. All patients with documented vas and vessels exiting the inguinal ring were surgically explored. Ten testes were found, 8 ectopic, with significant changes in shape and position, and 2 were canalicular. In the absence of hormone stimulation, no testes were found while exploring patients with cord structures coursing a closed inguinal ring and with contralateral hypertrophy. In 1 patient with absent vas and vessels, the testis was found at the lower renal pole while removing a dysplastic kidney. Despite technical refinements and an increase in clinical practice, a small percentage of viable testes may be missed with laparoscopic findings consistent with absent/vanished inguinal testis. Therefore, inguinal exploration is mandatory in all these cases.
The testis is descended through the processus vaginalis via propulsive force generated by the muscles derived from the gubernaculum. After propelling the testis, the smooth muscle should undergo programmed cell death for obliteration of the processus vaginalis. Achievement of programmed cell death mandates a transient decrease in sympathetic, but an increase in parasympathetic, tonuses. Since the sympathetic tonus is androgen-dependent, the decrease in androgen levels during the third trimester appears to be responsible for the process. Alterations in timing, intensity or duration of the decrease in sympathetic tonus under the control of the central nervous system give rise to hernia, hydrocele or abnormal testis localizations. The persistence of decrease causes undescended, retracted, or ascended testis. Absence or inadequacy of the decrease in sympathetic tonus results in rescue of more smooth muscle, thus inhibiting the obliteration. Inadequacy in the intensity or duration rescues less smooth muscle and gives rise to a hydrocele. Persistence of signals towards inducing programmed cell death contributes to decrease in fertility, and provides a basis for epididymo-vasal anomalies. The reduction in the central regulatory mechanism that involves catecholaminergic activity explains the blunting of luteinizing hormone (LH) response to gonadotropin-releasing hormone (GnRH). The explained mechanism precisely defines the role of all factors, and links all of the associations related to the process of descent.
Undescended testis or cryptorchidism remains a common condition. It affects 1% of individuals! and is treated by pediatric surgeons, urologists, and general surgeons depending on the age of the patient, spe- cialist services, and expertise available. Laparoscopy has been used for the localization of impalpable testis for more than 15years. However, minimal access surgery has now made its impact in this field of surgery in terms of surgical intervention. It is used not only for the localization of undescended testis but also to per- form Iaparosco'pic orchidectomy/ and both stages of the Foweler-Stevens orchiopexyY Minimal access surgery is also used for the ligation of the testicular vein for var-icocele.' The clinical anatomy of the unde- scended testis and varicocele is interrelated and therefore is dealt with in the same chapter, although there is no association between the two clinical conditions.
A case of a giant epidermoid cyst of the testis is presented. A 65-year-old man was incidentally pointed out to have left scrotal painless swelling. Physical examination revealed an over hen-egg sized enlargement of the left scrotal contents. Ultrasonography revealed a 7.5 X 5.5 X 4.0 cm solid tumor with heterogeneous echogenicity. No other abnormal findings were observed including tumor markers. Since preoperative examination did not rule out malignancy, we performed left high orchiectomy. Pathological diagnosis was a epidermoid cyst of the testis with a small portion of atrophic testis. Although the preoperative diagnosis of testicular epidermoid cyst is possible, it may be considerably difficult when a giant epidermoid cyst is occupying the testis.
OBJECTIVE: To explore the effects of testis murine cytomegalovirus (MCMV) infection on mature sperm acrosome reaction and spermatic function of membrane in mice. METHODS: BALB/c mice without MCMV infection were randomly devided into two groups: an experimental group (48 mice) and a control group (30 mice). The mice in the control group were treated by inoculation DMEM without MCMV into testis, while those in the experimental one were directly inoculated with MCMV into testis. Mice in two groups were sacrificed separately at 1, 2, 4, 6, 9, 14 d post inoculation (D1, 2, 4, 6, 9, 14 PI), and the MCMV M83 mRNA gene was detected inside the testes by in situ hybridization (ISH) with one episode MCMV late-mRNA probe labeled with digoxin, meanwhile acrosome reaction and the function of membrane of mature sperms in the epididymis tails was measured. RESULTS: The positive signal of ISH of MCMV was mainly founded in the two kinds of testicular cells (spermatogenic cells and Leydig cells) in the experimental group. Compared with that of the control group, the sperm acrosome reaction in the experimental group was decreased significantly by the rate from (71 +/- 6)%, (70 +/- 7)% to (58 +/- 9)%, (56 +/- 9)% (P < 0.05) separately on D2 PI and D4 PI. And the sperm membrane hypo-osmotic swelling was decreased significantly by the rate from (60 +/- 7)%, (50 +/- 4)% to (48 +/- 9)%, (38 +/- 8)% (P < 0.05) separately also on D2 PI and D4 PI. CONCLUSION: The model of CMV infection in murine testis was established. The sperm acrosome reaction and function of membrane in mice might be descented significantly by MCMV infection in the early period, which shows that MCMV infection might influent the sperm's function.
OBJECTIVE: To investigate the changes of nuclear factor-kappa gene binding (NF-kappaB) expression in and apoptosis of spermatogenic epithelial cells in the restored testis after torsion and analyze the relationship between them. METHODS: Sixteen male SD rats underwent torsion of the left testis clockwise at an angle of 720 degrees for 2 hours and then the testis was restored to the original position and fixed. Then the 16 rats were randomly divided into 2 equal group: Group I in which salicylazosulfapyridium (SASP) suspension was infused intra-gastrically 5 h after operation and then once a day for 4 times, and Group II in which normal saline (NS) was infused in the same manner. Eight rats (Group III) underwent sham operation and then infused with NS in the same manner as that of Group II. Three days after operation the rats were killed and the samples of the testes at the torsion side were taken out and the seminiferous tubules were isolated. Western blotting was used to detect the NF-kappaB expression in the cytoplasm and nucleus of spermatogenic epithelial cells. Immunohistochemistry was used to detect the in situ expression of NF-kappaB. The apoptosis of the spermatogenic epithelial cells was examined by TUNEL method. RESULTS: Western blotting showed that the NF-kappaB expression in the cytoplasm of spermatogenic epithelial cells of Group II was 9.4 +/- 2.68, somewhat lower, but not significantly, than those of Group I and III (12 +/- 2.2 and 11.1 +/- 3 respectively, both P > 0.05). The NF-kappaB expression in the nucleus of spermatogenic epithelial cells of Group II was 21.1 +/- 3.6, significantly higher than those of Group I and III (8.4 +/- 3.1 and 6.0 +/- 2.3 respectively, both P < 0.05). However, there were no significant differences in the NF-kappaB expression in the cytoplasm and nucleus of spermatogenic epithelial cells between Groups I and III. The NF-kappaB activity coefficient of spermatogenic epithelial cells of Group II was 2.32 +/- 0.4, significantly higher than those of Groups I and III (0.68 +/- 0.3 and 0.52 +/- 0.1 respectively, both P < 0.01). However, there was no significant difference in the NF-kappaB activity coefficient of spermatogenic epithelial cells between Groups I and III (P > 0.05). The NF-kappaB positive cell rate of Group II was 66.1% +/- 3.8%, significantly higher than those of Groups I and III (15.6% +/- 2.6% and 10.8% +/- 2.7%, both P < 0.01). The apoptotic cell rate of Group II was 37.2% +/- 3.3%, significantly higher than those of Groups I and III (7.7% +/- 2.0% and 5.9% +/- 1.7%, both P < 0.01). CONCLUSION: After the torsion of testis, NF-kappaB was activated and released from the nucleus into the cytoplasm, thus initiating the apoptosis of spermatogenic epithelial cells.
Because prepubertal testis tumors are rare, their management has historically been based on experience with the more common adult testis tumors. However, recent studies highlighting the natural history of these tumors and their response to therapy have resulted in a modern management algorithm that optimizes testicular preservation and minimizes the morbidity of adjuvant therapies. Many prepubertal testis tumors are benign and can be managed with testis-sparing tumor excision. Localized malignant tumors (yolk sac tumors) may be managed with excision alone. Recurrent tumors and metastatic disease can almost always be treated successfully with platinum-based chemotherapy.