COMPARISON OF IN-OFFICE PERCUTANEOUS TESTIS BIOPSY WITH OPEN TESTICULAR BIOPSY. Thomas G. Harrington and Bruce R. Gilbert, Stony Brook, N.Y. (Presentation by Dr. Harrington)
Concern regarding in-office percutaneous testis biopsy (PTB) has centered on the potential for undetected testicular injury due to the blinded nature of the procedure. With scrotal ultrasound and an antisperm antibody assay, we evaluated a group of men undergoing an in-office PTB and a cohort of men having an open testis biopsy (OTB).
30 consecutive infertile men with either azoospermia or severely impaired semen quality in which ductal obstruction was suspected chose to undergo either a PTB (14 patients) or OTB (16 patients). All patients had at least two preoperative semen analyses. Direct and/or Indirect assays of IgG and IgA antisperm antibodies (ASA) were measured both pre and postoperatively (MAR test). Two biopsy specimens were obtained from each testis; one which was placed in Bouin's solution for formal sectioning and another which was placed on a slide and examined immediately under phase contrast microscopy for the presence or absence of mature spermatozoa. Scrotal ultrasound and ASA measurements were performed preoperatively (pre), in the immediate postoperative period (immpo) and at one month (1mpo),3 months (3mpo) and 6 months (6mpo).
3 of 14 (21%) PTB patients demonstrated sonographic evidence of intratesticular hematoma (IH) characterized by the development of a hypoechoic region within the testicular parenchyma. All three IH resolved by 3 months postoperatively. In contrast, 10 of 16 (63%) OTB patients demonstrated IH or a new area of increased echogenicity at 1mpo (intraparenchymal scar; IS). All IS persisted out to 6 months postoperatively No PTB or OTB patients developed ASA in either serum (azoospermic patients) or on sperm postoperatively. The procedure was limited to a unilateral biopsy in 2 of 3 PTB patients due to dizziness and/or diaphoresis. All OTB patients had general anesthesia and perioperative analgesia. 11 of 16 (69%) of the OTB patients required narcotic analgesia for two days or more postop. Local anesthesia was used for the PTB. No PTB patients required narcotic analgesia and all returned to routine activities in 24 hours. No postoperative infections or extra testicular hematomas were noted in either group. Pathology was diagnostic in all specimens. In 2/14 PTC specimens, less than 10 cross sections of seminiferous tubules were obtained.
PTB is well tolerated by the patient with fewer ultrasound detected complications then OTB and is of equal diagnostic value to OTB. PTC should be considered a preferred alternative to open testis biopsy in the evaluation of azoospermia or in the patient presenting with severely impaired semen quality in which complete or partial obstruction is suspected.
The scrotum is first prepped with a 5% povidone-iodine solution and draped sterilely. METHODS (Figure 2)
2% Lidocaine is infiltrated subcutaneously at the sites of biopsy and around the vas deferens bilaterally.
METHODS (Figure 3)
Epididymal injury is avoided by grasping the epididymis with the non-dominant hand. Vascular injury is avoided by obtaining tissue from the medial or lateral aspect of the upper pole, areas least likely to contain a major arterial branch. METHODS
43 consecutive infertile men, in whom ductal obstruction was suspected, chose to undergo either PTB (23) or an OTB (20). All patients had at least two preoperative semen analyses.
2% Lidocaine was injected subcutaneously along the median raphe (for the left testis) and skin overlying the lateral aspect of the right testis as well as around the vas deferens bilaterally.
An 18 ga. (15 cm length) Microvasive Biopsy needle with a 17mm specimen notch, was use to obtain two biopsy specimens from each testis. One of these biopsy specimens was touched to a slide ("touch prep") and examined immediately for the presence or absence of mature spermatozoa. The cores were then rolled onto a 1/2 cm sheet of sterile specimen paper and placed immediately into Bouin's solution in preparation for formal sectioning.
Scrotal ultrasound and anti-sperm antibody measurements (sperm-MAR) were performed preoperatively (pre), in the immediate post-operative period (immpo) and at the one month (1mpo), 3 months (3mpo) and 6 months (6mpo) following the procedure. RESULTS
Three of 23 (13%) patients who underwent PTB demonstrated sonographic evidence of intratesticular hematoma (IH). This was characterized by the development of a hypoechoic region within the testicular parenchyma. All three IH resolved by three months post-operatively. One additional patient presented with unilateral epididymitis (2 weeks after the procedure) that was effectively treated with a PO antibiotic. In contrast, 10 of 20 (50%) patients who underwent OTB demonstrated IH or a new area of increased echogenicity at 1mpo, consistent with intraparenchymal scar (IS). All IS persisted out to six months post-operatively.
All OTB patients underwent general anesthesia and required perioperative analgesia. Local anesthesia was used for the PTB. 14 of 20 (70%) of the OTB patients required narcotic analgesia for two days or more post-op. No PTB patients required narcotic analgesia and all returned to routine activities within 24 hours. The procedure was limited to a unilateral biopsy in 2 of 3 PTB patients due to dizziness and/or diaphoresis.
No PTB or OTB patients developed ASA in either serum (for azoospermic patients) or on sperm post operatively.
Pathology was diagnostic in all specimens. RESULTS
# patients IH IS analgesia ASA
IH = intraparenchymal hematoma
IS = intraparenchymal scar
ASA = antisperm antibody
PTB should be considered an alternative to OTB in the evaluation of the subfertile male in whom ductal obstruction is suspected for several reasons:
(1) PTB is safe. Its use resulted in a lower incidence of sonographically detected injuries, that were transient in nature when compared with OTB. In addition, the use of general anesthesia, with its attended risks, was avoided. Neither PTB or OTB resulted in formation of ASA up to six months post-op.
(2) PTB is cost effective. It is easily performed in an office setting with minimal instrumentation. It does not require the use of an operative suite or general anesthesia.
(3) PTB is efficacious. Although fewer tubules were obtained with PTB then with OTB, the tubular architecture was well preserved and the specimen was diagnostic in all cases.