Testicular microlithiasis: Is there an agreed protocol?

Onco-TESE (Testicular Sperm Extraction): Insights from a Tertiary Center and Comprehensive Literature Analysis

Background and Objectives: The peak of incidence of testicular cancer (TC) occurs among individuals in their reproductive age, emphasizing the importance of fertility preservation as an integral aspect of disease management. Sperm cryopreservation performed before orchiectomy is ineffective in azoospermic men, necessitating alternative approaches such as microdissection testicular sperm extraction (mTESE) at the time of orchiectomy (onco-mTESE) to obtain viable sperm. This study presents the findings from our institution's experience with onco-mTESE and critically discusses our results in light of the existing body of literature. Materials and Methods: This is a tertiary center retrospective analysis of onco-mTESE procedures performed at a single center between December 2011 and July 2022. The included patients were post-puberal men with testicular tumors requiring orchiectomy, along with concomitant severe oligozoospermia or azoospermia. Bilateral mTESE was performed in all cases. Surgical outcomes, sperm retrieval rates, the usage of preserved viable sperm, assistive reproductive techniques' results, and post-operative serum testosterone were recorded. Results: A total of nine patients were included, with a median age of 34 (IQR 29-36) years. All patients had germ cell tumors (GCTs), with seminomatous and non-seminomatous GCTs accounting for 44.4% (n = 4) and 55.6% (n = 5) of patients, respectively. Sperm retrieval occurred in three (33%) patients: one patient in the ipsilateral testis, one in the contralateral testis, and one in both testes. No complications were reported during the procedure, and no post-operative hypogonadism was observed. Among the three patients with successful sperm retrieval, an intracytoplasmic sperm injection (ICSI) was performed in two patients, resulting in two pregnancies, leading to one healthy live birth and one miscarriage. Conclusions: In the context of TC, it is essential to conduct a thorough evaluation of testicular function, including a semen analysis and cryopreservation. Onco-mTESE has proven its safety in preserving fertility in azoospermic cases while ensuring the efficacy of oncological treatment.

Pearls and Pitfalls of Pediatric Scrotal Imaging

Ultrasonography (US) is the primary imaging modality for the evaluation of pediatric scrotal disease. The ability to obtain exceptional anatomical detail and testicular perfusion information without ionizing radiation makes it the essential tool for evaluating scrotal pain and palpable masses. Challenges arise in both the performance and interpretation of scrotal US in the child. Optimizing imaging parameters and recognizing key differentiating US features help minimize misinterpretations that can lead to poor patient outcomes. Key pearls and pitfalls in pediatric scrotal ultrasound methods and diagnoses are reviewed. Knowledge of what is normal for the various ages of childhood from neonate through adolescence is necessary for accurate US analysis. Imaging evaluation of key causes of the acute painful scrotum including testicular appendage torsion, epididymitis, and testicular torsion are discussed. Sonographic features for the diagnosis of benign and malignant scrotal masses, microlithiasis, and cryptorchidism are reviewed.

Disorders in the function of Sertoli cells and arrest in the differentiation of gonocytes in patients with cryptochidism and microlithiasis

PURPOSE

This study aimed to correlate the presence of microlithiasis (ML) in cryptorchidism (CO) patients with the functionality of Sertoli cells and the arrest of gonocyte differentiation.

METHODS

Testicular biopsies were obtained from 21 inguinal CO pediatric patients and were classified in two groups as follows: patients with ML and those without ML. In both groups, the number of Sertoli cells/seminiferous cords and their functionality were determined, considering the concentrations of inhibin B. In addition, the area and the histological alterations of seminiferous epithelium were evaluated. The arrest of gonocyte differentiation was determined by immunoreactivity to SALL4, AP2ɣ, PLAP and POU5F1.

RESULTS

We found a statistical correlation between the presence of ML with the alterations in the functionality of Sertoli cells without reflecting in the differentiation of the gonocytes.

CONCLUSION

The study of this population suggests that the association between CO and ML shows a malfunction of the Sertoli cells without necessarily causing arrest in the differentiation of gonocytes in these patients.

Genes associated with testicular germ cell tumors and testicular dysgenesis in patients with testicular microlithiasis

Testicular microlithiasis (TM) is one of the symptoms of testicular dysgenesis syndrome (TDS). TM is particularly interesting as an informative marker of testicular germ cell tumors (TGCTs). KIT ligand gene (KITLG), BCL2 antagonist/killer 1 (BAK1), and sprouty RTK signaling antagonist 4 (SPRY4) genes are associated with a high risk of TGCTs, whereas bone morphogenetic protein 7 gene (BMP7), transforming growth factor beta receptor 3 gene (TGFBR3), and homeobox D cluster genes (HOXD) are related to TDS. Using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis, we investigated allele and genotype frequencies for KITLG (rs995030, rs1508595), SPRY4 (rs4624820, rs6897876), BAK1 (rs210138), BMP7 (rs388286), TGFBR3 (rs12082710), and HOXD (rs17198432) in 142 TGCT patients, 137 TM patients, and 153 fertile men (control group). We found significant differences in the KITLG GG_rs995030 genotype in TM (P = 0.01) and TGCT patients (P = 0.0005) compared with the control. We also revealed strong associations between KITLG_rs1508595 and TM (G allele, P = 0.003; GG genotype, P = 0.01) and between KITLG_rs1508595 and TGCTs (G allele, P = 0.0001; GG genotype, P = 0.0007). Moreover, there was a significant difference in BMP7_rs388286 between the TGCT group and the control (T allele, P = 0.00004; TT genotype, P = 0.00006) and between the TM group and the control (T allele, P = 0.04). HOXD also demonstrated a strong association with TGCTs (rs17198432 A allele, P = 0.0001; AA genotype, P = 0.001). Furthermore, significant differences were found between the TGCT group and the control in the BAK1_rs210138 G allele (P = 0.03) and the GG genotype (P = 0.01). KITLG and BMP7 genes, associated with the development of TGCTs, may also be related to TM. In summary, the KITLG GG_rs995030, GG_rs1508595, BMP7 TT_rs388286, HOXD AA_rs17198432, and BAK1 GG_rs210138 genotypes were associated with a high risk of TGCT development.

Testicular Microlithiasis: Case Report and Current Knowledge

Sonographic evaluation is the gold standard in diagnosing of testicular microlithiasis, the nature of which has raised controversy in opinions regarding its premalignant or benign tendency. Testicular microlithiasis is often an incidental finding on sonographic examination with indications for other disease processes, and it may or may not require additional follow-up. This pathology has raised equal interest among domestic and foreign researchers, and studies have been performed on both adult and pediatric populations, yet there is no standard recommendation for follow-up care of testicular microlithiasis. Isolated testicular microlithiasis and that with additional risk factors may require different approaches to testing and care. In this publication, a case study is reviewed and two approaches to follow-up care of testicular microlithiasis based on the associated risk factors or a lack of thereof are discussed.

Testicular microlithiasis: what urologists should know. A review of the current literature

Introduction

Testicular microlithiasis is a finding incidental to the ultrasound examination of the scrotum. This article presents some new data regarding the etiopathology of testicular microliths. As there is a growing body of literature available, which associates testicular microlithiasis with a testicular germ cell tumor or male infertility, our review focuses on these relations (based on a new meta-analysis and retrospective follow-up programs). The purpose of this review is to summarize the knowledge about testicular microlithiasis and discuss the latest recommendations.

Material and methods

A comprehensive literature review was performed using Science Direct and Scopus with MeSH terms and keywords 'testicular microlithiasis', testicular tumor', male infertility'.

Results

The clinical consequences of testicular microlithiasis depend on the co-occurrence of specific risk factors. The presence of testicular microlithiasis alone in the absence of risk factors is not an indication for further investigation.

Conclusions

A link between testicular microlithiasis and testicular cancer as well as male infertility has been analyzed. Follow-up is only recommended where risk factors of testicular cancer other than testicular microlithiasis are present.

Sertoli cell tumour in a pet rabbit (Oryctolagus cuniculus): histological and immunohistochemical characterization

The present study describes a case of a spontaneous, unilateral Sertoli cell tumour (SCT) in a 6-year-old pet rabbit. The rabbit was presented with a palpable, unilateral, subcutaneous left inguinal mass, consistent with the suspected clinical diagnosis of neoplasia developing within the retained testis in the inguinal canal. The intrascrotal contralateral testis was palpable, but reduced in volume. The rabbit underwent orchiectomy and both the testes were collected, formalin-fixed, and submitted for histopathological examination. Microscopically, the enlarged testis was effaced by an intratubular SCT in which numerous intratubular microliths were evident. The contralateral testis was severely atrophied. Immunohistochemical stains showed neoplastic Sertoli cells that were diffusely positive for vimentin and anti-Müllerian-Hormone and multifocally positive for cytokeratins and desmin. Eighteen months after the surgery, the rabbit showed no clinical signs of disease. This is the first report of a spontaneously occurring rabbit SCT histologically described and immunohistochemically investigated.

Prevalence and risk factors of testicular microlithiasis in patients with hypospadias: a retrospective study

BACKGROUND

It has been described that the incidence of testicular microlithiasis is high in several congenital disorders which may be associated with testicular impairment and infertility. Several reports have shown that a prepubertal or pubertal hormonal abnormality in the pituitary-gonadal axis was identified in some patients with hypospadias that is one of the most common disorders of sex development. However, exact prevalence or risk factors of testicular microlithiasis in patients with hypospadias have not reported so far. In the present study, to clarify the prevalence and risk factors of testicular microlithiasis in patients with hypospadias, a retrospective chart review was performed.

METHODS

Children with hypospadias who underwent testicular ultrasonography between January 2010 and April 2016 were enrolled in the present study. Severity of hypospadias was divided into mild and severe. The prevalence and risk factors of testicular microlithiasis or classic testicular microlithiasis were examined.

RESULTS

Of 121 children, mild and severe hypospadias were identified in 66 and 55, respectively. Sixteen children had undescended testis. Median age at ultrasonography evaluation was 1.7 years old. Testicular microlithiasis and classic testicular microlithiasis were documented in 17 children (14.0%) and 8 (6.6%), respectively. Logistic regression analysis revealed that presence of undescended testis was only a significant factor for testicular microlithiasis and classic testicular microlithiasis. The prevalence of testicular microlithiasis or classic testicular microlithiasis was significantly higher in children with undescended testis compared to those without undescended testis (testicular microlithiasis; 43.8% versus 9.5% (p = 0.002), classic testicular microlithiasis; 37.5% versus 1.9% (p < 0.001).

CONCLUSIONS

The current study demonstrated that the presence of undescended testis was only a significant risk factor for testicular microlithiasis or classic testicular microlithiasis in patients with hypospadias. As co-existing undescended testis has been reported as a risk factor for testicular dysfunction among patients with hypospadias, the current findings suggest that testicular microlithiasis in children with hypospadias may be associated with impaired testicular function. Conversely, patients with isolated HS seem to have lower risks for testicular impairment. Further investigation with longer follow-up will be needed to clarify these findings.

There is a mass in the scrotum-what does it mean?: Evaluation of the scrotal mass

Similar to the experience of finding a lump upon physical examination of the breast, the detection of an intrascrotal mass is often a frightening experience for both the patient and his physician. Ultrasound is a nearly ideal modality for evaluation of the scrotum. This manuscript will review the sonographic assessment of the common pathologic and normal conditions that may present as a mass within the scrotum, including discussion of intratesticular and extratesticular etiologies.