Needle biopsy of testes: a safe outpatient procedure

Histological Comparison of Testicular Needle Biopsy and En Bloc Samples in Abattoir Calves

the aim of this study was to test whether a single testicular needle biopsy could provide histological results comparable to en bloc resection histology and whether one biopsy was sufficient to reflect the histology of an entire pair of testicles. Two methods of sample collection were tested on 32 bull calves aged five to eight months to compare histological parameters of needle biopsy with those of en bloc resection samples. One testicular needle biopsy of the right and three en bloc samples of both testicles were collected and compared for the number of tubular cross sections, tubules with elongated spermatids (ES), outer/inner diameter of tubules, thickness of tubular wall, and number of Sertoli cells (SC). Additionally, animal data were considered. No significant differences were found between the left and right testis or among the individual locations of en bloc samples. However, histologically significant differences (Bonferroni-adjusted significance level: p < 0.05/6 = 0.0083) were found between the needle biopsy and en bloc resection regarding the tubular cross sections per visual field (p < 0.05), the outer (p = 0.01) and inner diameter and the thickness of the tubular wall (both p < 0.01). In the SOX9 immunohistochemical staining, no significant differences (p > 0.05) could be observed for SC numbers between needle biopsy and en bloc samples. In conclusion, results of testicular needle biopsy do not have the same validity as the en bloc resection histology. Furthermore, one biopsy is insufficient to reflect the histology of the entire testicular pair.

Percutaneous biopsy of the testicle: a mini review with a proposal flow chart for non-obstructive azoospermia

A general consensus on the role of testicular biopsy in non-obstructive azoospermia (NOA) is needed. This paper reviews and updates technical aspects and clinical performance of the percutaneous testicular biopsy techniques, in particular large-needle aspiration biopsy (LNAB), and proposes a flow chart for the management of NOA. The English literature and original data were reviewed or analyzed. Large-needle biopsy (LNB) includes large-needle cutting biopsy (LNCB) and large-needle aspiration biopsy (LNAB). LNCB usually requires scrotal incision for the insertion of relatively large needles. Fine-needle aspiration biopsy (FNAB) does not require surgical equipment or expertise, employs the smallest needles (23- to 20-gauge), and permits sperm cytologic detection. LNAB also does not require surgical equipment or expertise, employs needles of size from 20- to 18-gauge, is safe, and can be used for testicular histology and sperm recovery. An operative flow chart is proposed for the management of NOA in which FNAB, LNAB and open surgical biopsy are used for the optimal management of NOA.

Large needle percutaneous aspiration biopsy of the testicle in men with nonobstructive azoospermia: technical performance

The aim of this study was to relate retrospectively in 215 percutaneous large needle aspiration biopsy (LNAB) of the testicles the number of seminiferous tubules (ST) per testicular biopsy, from differently sized testicles, to the size of the needle used in order to obtain information useful for selecting the needle size according to the testicular size. Clinical, ultrasonographic and pathologic data of 134 patients with nonobstructive azoospermia examined with LNAB were retrospectively analyzed. One hundred and sixty-three testicles with volume>or=10 ml, 39<10 ml and>or=6 ml, 13<6 ml underwent 215 LNABs. In the larger testicle group the prevalence of adequate biopsies (ST>/=20) varied from 83% to 50% with a statistically significant difference among the needle groups (P=0.028) and being 83% in the biopsies with the 18 gauge (g.) needle. The mean number of ST obtained with the 18 g. needle was significantly higher than that obtained with the other needles (P=0.000). In the medium volume testicle group the adequate biopsy incidence varied from 20% to 83.3% with statistical significance among the various needle groups (P=0.042) being 83.3% in the biopsies with the 22 g. needle. In the smaller testicle group the mean number of ST obtained with the 22 g. needle was significantly higher than with the 20 g. needle (71 versus 25, P=0.011). In the patients with nonobstructive azoospermia, the 18 g. needle seemed to offer the best performance in the larger testicles, while in the medium and lower sized testicles the smaller 22 g. needle gave results comparable to or slightly better than the other larger needles.

Fine-needle and large-needle percutaneous aspiration biopsy of testicles in men with nonobstructive azoospermia: Safety and diagnostic performance

OBJECTIVE

To assess by ultrasonography the safety of the association fine-needle aspiration (FNA) plus a new percutaneous large-needle aspiration biopsy technique (LNAB), and to compare the results obtained with the two techniques in the same testicle and with FNA in the two testicles of the same patient.

DESIGN

Retrospective analysis of clinical, ultrasonographic, and pathologic data.

SETTING

Clinical and academic research environment.

PATIENT(S)

Three hundred and eighty-seven testicles of 233 patients (ages 19 to 57 years) with nonobstructive azoospermia were consecutively examined with FNA (154) or FNA + LNAB (233); 54 patients (89 testicles) examined with FNA + LNAB underwent a second ultrasonography up to 63 days after.

INTERVENTION(S)

Ultrasonography, FNA, LNAB.

MAIN OUTCOME MEASURE(S)

Hypoechoic area at ultrasonography; cytologic picture at FNA or LNAB of only Sertoli cells (category 1), spermatogenetic cells different from elongated spermatids or spermatozoa (category 2), and elongated spermatids and/or spermatozoa (category 3).

RESULT(S)

Among the 54 patients monitored by ultrasonography 48 (88.9%) showed no difference and 6 (11.1%) showed an hypoechoic area < or =1 cm in the second image. Category 1 occurred at FNA or LNAB in a very similar number of testicles (36% vs. 36.9%). Categories 2 and 3 were more frequent at LNAB (29.9% vs. 9.8%) and at FNA (54.2% vs. 33.2%), respectively. One hundred and sixty-six patients had both testicles examined by FNA; 147 pair of testicles were concordant for the presence or the absence of spermatozoa or elongated spermatids. In the remaining 19 patients (11.4%), these spermatogenetic cells were shown only in the specimen from one of the two testicles. These 19 patients accounted for 20.0% of 93 patients with spermatogenetic cells in at least one of the two testicles.

CONCLUSION(S)

The combination of FNA and LNAB did not produce clinically or subclinically relevant complications. No important differences in the identification of category 1 with FNA or LNAB were found. Fine-needle aspiration was more adequate in identifying category 3, which was particularly relevant in 20% of the men who had these cells in at least one of the two testicles.

Fine-needle aspiration cytology of the testis: can it be a single diagnostic modality in azoospermia?

PURPOSE

The aim of this study was to determine whether fine-needle aspiration cytology (FNAC) of testis alone is sufficient to diagnose testicular function and whether follicle-stimulating hormone (FSH) estimation can be safely eliminated from the evaluation protocol of the azoospermic subject.

MATERIALS AND METHODS

We studied 46 adult azoospermic males who were infertile for more than 2 years following marriage. Hormonal profile was done in all. Later all 46 patients were subjected to bilateral FNAC of the testes. The cytological findings were correlated with histological findings.

RESULTS

We found 95.65% agreement between FNAC and testicular biopsy. Though serum FSH estimation was done in all patients in this series, in none of the cases did it affect overall management.

CONCLUSION

FNAC is a quick, safe and minimally invasive modality. Following a well-performed semen analysis in an azoospermic subject, it appears that FNAC may be the only investigation needed. It provides a reliable diagnosis in patients with either obstructive or non-obstructive azoospermia. Routine estimation of FSH can be omitted from the investigative protocol in these patients.

Percutaneous cutting needle biopsies for histopathological assessment and sperm retrieval in men with azoospermia

BACKGROUND

Twenty-three men (45 testes) with azoospermia underwent percutaneous testicular biopsy under local anaesthesia.

METHODS

In all but one of the 45 testes two biopsies were taken close to each other, one with a 16 gauge (n = 44) and another with a 14 gauge (n = 45) cutting needle, both with a 19 mm notch. Three quarters of the tissue was used for histopathological assessment and one quarter for direct microscopy.

RESULTS

The histopathological findings were similar between the two needles. The observations with direct microscopy corresponded with the histopathological assessments concerning the presence of mature spermatids in 41 of 45 (91%) biopsies using the 14 gauge and in 40 of 44 (91%) biopsies using the 16 gauge needle. There were no post-operative complications except for minimal pain and minor local swelling.

CONCLUSIONS

Percutaneous material retrieved using 16 gauge and 14 gauge needles is sufficient for histopathological assessment, and the two needles are equally reliable for testicular sperm retrieval. However, needle biopsy with one puncture may not be representative of the entire testis.

Testicular sperm extraction by Trucut needle and milking of seminiferous tubules: a technique with high yield and patient acceptability

OBJECTIVE

To assess the sperm yield and patient acceptability of Trucut needle testicular biopsy followed by seminiferous tubule milking.

DESIGN

Prospective case analysis.

SETTING

The Regional Fertility Center, Royal Maternity Hospital, Belfast, Northern Ireland, United Kingdom.

PATIENT(S)

Forty-one males with obstructive azoospermia (normal testicular volume and FSH and LH levels).

INTERVENTION(S)

Trucut needle testicular biopsies under local anesthetic with milking of the seminiferous tubules.

MAIN OUTCOME MEASURE(S)

Quantitation of sperm retrieved per biopsy core and patient follow-up by questionnaire.

RESULT(S)

A mean of 105,634 sperm (range, 5,000-427,800) were retrieved, and the mean biopsy weight was 9.17 mg. Twenty-six subjects found the biopsy painless and 15 were pain-free after biopsy.

CONCLUSION(S)

The Trucut needle can be used in combination with seminiferous tubule milking to obtain large numbers of sperm in men with obstructive azoospermia.

A percutaneous large-needle aspiration biopsy technique for histologic examination of the testis in infertile patients

OBJECTIVE

To describe a relatively new percutaneous large-needle aspiration biopsy technique for histologic examination of the testis in infertile patients.

DESIGN

Retrospective analysis of clinical and pathologic data.

SETTING

Clinical and academic research environment.

PATIENT(S)

Sixty-six infertile patients who underwent testicular biopsy.

INTERVENTION(S)

Local anesthesia was induced through spermatic cord block with lidocaine, and a relatively large needle (usually 18- or 20-gauge) was introduced percutaneously into the testicle without a scrotal incision.

MAIN OUTCOME MEASURE(S)

The number of seminiferous tubules per histologic section of each testicular biopsy sample.

RESULT(S)

A mean of 74 seminiferous tubules were obtained in the histologic sections of each biopsy sample. This number varied according to the size of the needle used; it was 24.7 when a 21-gauge needle was used, 56.2 when a 20-gauge needle was used, and 103 when an 18-gauge needle was used. The biopsies were performed in the office. No significant hematomas occurred, no antibiotic prophylaxis was prescribed, and no postbiopsy medical or pharmacologic interventions were required.

CONCLUSION(S)

Tissue specimens as large as those obtained with open surgical biopsy can be obtained from the testicles of infertile patients with the use of a percutaneous technique that is easier, less costly, and safer than any previously reported.

Yield and efficacy of biopty gun testis needle biopsy

OBJECTIVES

To assess whether a preliminary skin incision enhances diagnostic yield of percutaneous testis biopsy and to further evaluate the clinical efficacy of this procedure.

METHODS

A total of 45 men (67 testes) underwent testicular biopsy with two passes of a Biopty gun spring-loaded needle. Twenty-seven biopsies were performed without a preliminary skin incision (group 1), and 40 were performed after a small scrotal incision (group 2). In 56 testes, needle biopsy histopathologic diagnosis was compared with that of open biopsy or orchiectomy specimens from the same patient. Needle and surgical specimens were fixed in Bouin's solution and sent separately for independent, blinded, histologic interpretation.

RESULTS

Complications of the procedure were negligible. In all 67 needle biopsies, specimen quality was adequate for histopathologic interpretation. The mean number of seminiferous tubules obtained from needle biopsy was 28% higher among patients having a preliminary skin incision (25.9) compared with those without (18.7, P = 0.023). Correlation between needle and open histopathologic diagnosis was excellent (55 of 56, 98%).

CONCLUSIONS

A preliminary skin incision made before needle biopsy increases the diagnostic yield of percutaneous testis biopsy. Percutaneous testis biopsy using the Biopty gun needle provides equal diagnostic information when compared with open testis biopsy or orchiectomy specimens. The concomitant reduction in morbidity and cost make this an attractive diagnostic procedure.

Testicular needle biopsy: is it a safe and adequate method?

We aimed to investigate if testicular needle biopsy is adequate and safe for the examination of testis. Needle biopsies were performed on 21 testes of 5 patients with advanced prostate cancer and 11 patients with cryptorchidism before orchiectomy. Biopsies were done with the prostatic tru-cut needle. After needle biopsy, the tract and puncture sites were explored and an incisional biopsy was performed on each testis. Both needle specimens and open biopsy specimens were fixed in Bouin's solution and sent for histologic examination. There were small haematomas in two testes and moderate haemorrhage between tunica vaginalis layers in another. The tissues obtained by needle biopsy were sufficient except for two specimens and diagnostic accuracy was perfect. Nevertheless, measurement of the seminiferous tubules of the lamina propria could not be achieved in many cases.

Percutaneous testis biopsy: an alternative to open testicular biopsy in the evaluation of the subfertile man

PURPOSE

We evaluated the safety and efficacy of percutaneous testis biopsy by comparing the ultrasound appearance and histological status of testicular parenchyma obtained to those noted after open testis biopsy.

MATERIALS AND METHODS

A total of 51 consecutive infertile men with azoospermia or severely impaired semen quality, in whom ductal obstruction was suspected, underwent percutaneous (31) or open (20) testis biopsy, with 58 and 34 procedures performed, respectively. Scrotal ultrasound was performed preoperatively, and at 2 weeks and 1, 3 and 6 months after biopsy. In addition, immunoglobulins G and A antisperm antibody assays were obtained preoperatively and postoperatively. Two biopsy specimens were obtained from each testis for formal histological evaluation. A touch preparation was also performed and examined immediately for mature spermatozoa using phase contrast microscopy.

RESULTS

All biopsies yielded adequate tissue for diagnosis and morphometric analysis. Of 58 percutaneous biopsies 4 (7%) demonstrated sonographic evidence of intratesticular bleeding, characterized by a hypoechoic region within the testicular parenchyma, which resolved by 6 months postoperatively. In contrast, 10 of 34 open biopsies (29%) showed evidence of intratesticular bleeding or a new area of increased echogenicity at 1 month after the procedure (intraparenchymatous scar). All intraparenchymatous scars persisted to 6 months postoperatively. No patient undergoing percutaneous or open testis biopsy had antisperm antibodies in the seminal fluid or serum (azoospermia cases) or on sperm postoperatively. Of the 32 and 20 patients undergoing percutaneous and open testis biopsy 3 (9%) and 14 (70%), respectively, required narcotic analgesia. All patients returned to routine activities within 24 hours after percutaneous testis biopsy. No postoperative infections or extratesticular hematomas were noted. Pathological study was diagnostic in all specimens.

CONCLUSIONS

Percutaneous testis biopsy is well tolerated by the patient, with fewer apparent complications than and diagnostic value equal to open testis biopsy. Percutaneous testis biopsy should be considered an alternative to open biopsy.

Biopty gun testis needle biopsy: a preliminary clinical experience

OBJECTIVE

To assess the reliability, safety and patient satisfaction of transcutaneous Biopty (Bard Urological, Covington, GA, USA) gun testis biopsies.

PATIENTS AND METHODS

Nineteen young men who were referred for evaluation of azoospermia were included in the study. The procedure was performed in an outpatient setting, under local anaesthesia and without sedation. Two passes of the Biopty gun spring-loaded needle were performed unilaterally in each patient.

RESULTS

An average of 38.9 seminiferous tubules were evaluable per patient. The procedure was extremely well-tolerated by all patients and most felt that the procedure was no more distressing than simple phlebotomy.

CONCLUSION

Transcutaneous testis needle biopsy performed with the Biopty gun is safe, rapid and cost-effective. This technique may represent a viable alternative to the open method of testis biopsy.

A comparison of open versus needle biopsy (Tru-cut R) of the testis

Testicular biopsy is an important investigation in the management of an infertile patient with azoospermia. The study is aimed at defining the role of needle biopsy (Tru-cut R) of the testes as an alternative to conventional open testicular biopsy in a prospective controlled trial of 45 consecutive patients. Our study shows that needle biospy of the testis is safe and effective, making it a reliable alternative to open biopsy of the testes.

Comparison of flow cytometry to routine testicular biopsy in male infertility

We compared DNA flow cytometry to morphologic evaluation of routine testicular biopsies as methods of monitoring spermatogenesis. The study group consisted of 14 azoospermic men and 5 others who underwent testicular surgery unassociated with fertility problems. The findings for both studies were divided into three groups: normal, moderately abnormal, and markedly abnormal. Correlations between the findings from routine biopsy and flow cytometry were good. Of 9 patients having normal testicular morphology, 7 had normal ploidy classes by DNA flow cytometry while 2 had moderately abnormal histograms. Of 5 cases with moderately abnormal morphology, 1 had normal, 1 had moderately abnormal, and 3 had markedly abnormal ploidy distributions. In 5 cases described as Sertoli cell only, all DNA histograms were markedly abnormal, consisting almost exclusively of diploid cells. DNA flow cytometry of testicular biopsies and aspirates has been demonstrated to be a rapid, reproducible, and objective approach in evaluating the infertile male and is a promising method to investigate spermatogenesis in an outpatient clinic in lieu of formal testis biopsy.

Epididymal microsurgery: current techniques and new horizons

Surgical treatment for obstructive azoospermia was introduced about 30 years ago with the development of Bayle's vasoepididymal fistula technique (Bayle: Enc Med Chir 41:435, 1966). More recently this has been replaced by single tubule end-to-end microvasoepididymal bypass procedures with improved success rates. We describe the use of animal models in the development and application of a modified end-to-end microanastomosis technique in which the vas deferens is attached to a single surface convolution of the ductus epididymidis. In comparison with other microvasoepididymostomy (micro-VE) procedures, this technique results in less postoperative scarring and allows for easier access to the epididymis in those patients requiring subsequent epididymal surgery. With this procedure 60% of patients produced spermatozoa after operation, and 10% of 102 patients have so far achieved pregnancies. For patients, such as those with congenital absence of the vasa deferentia, whose infertility cannot be corrected by microvasoepididymal surgery, we describe a microaspiration procedure that can be used to collect spermatozoa from the epididymis for use in in vitro fertilization (IVF). This procedure has a low success rate at present, with an 18% fertilization and 3% pregnancy rate per cycle. Improvements in treatment procedures for aspirated sperm samples, such as the use of motility stimulators and in vitro maturation by coculture with epididymal tubule segments before IVF, may enhance the success for this technique. Microinjection of sperm collected by epididymal microaspiration into oocytes may be an alternative method of treatment for these patients in the future. Two procedures (microepididymoepididymostomy and the vas bridge bypass) that are currently being modelled in the rabbit may provide new directions for epididymal microsurgery and for examining epididymal function. Although the two methods are technically more difficult than standard micro-VE procedures, preliminary studies are encouraging and suggest a future role for these techniques in treating obstructive azoospermia. Such techniques make use of the epididymis distal to the obstruction site and may be particularly important in improving the success of surgery for obstructive azoospermic patients with high-level obstructions in whom sperm quality following micro-VE surgery is often poor.