Conventional multiple or microdissection testicular sperm extraction: a comparative study

BACKGROUND

Testicular sperm extraction (TESE) with ICSI is becoming the first-line treatment for non-obstructive azoospermia (NOA). Recently, the sperm retrieval rate (SRR) by microdissection TESE was reported to be higher than by conventional TESE. However, a comprehensive comparison between multiple and microdissection TESE patients including histological findings has not been reported.

METHODS

Patients with NOA who underwent microdissection TESE (n = 56) or multiple TESE (n = 37) were compared. Pre-operative characteristics were similar between groups. In addition, microscopic findings during microdissection TESE also were investigated.

RESULTS

Operative time was significantly longer for microdissection TESE than for multiple TESE. Histological examination suggested that spermatogenesis was relatively more impaired in the microdissection TESE group than in the multiple TESE group. Despite this, SRR by microdissection TESE (42.9%) appeared higher than by conventional TESE (35.1%) although this observation failed to reach statistical significance. Seventeen of 26 patients (65.4%) with heterogeneous tubule were successful for sperm retrieval. No severe operative complications occurred in any patient in either group, and no patient required post-operative hormone replacement to treat hypogonadism.

CONCLUSIONS

Microsurgical technique is safe and may improve SRR for TESE in a variety of patients with NOA, especially patients with heterogeneous testicular tubules.

Testosterone suppresses spermatogenesis in juvenile spermatogonial depletion (jsd ) mice

Male juvenile spermatogonial depletion (jsd/jsd) mice are sterile because of a failure of spermatogonial differentiation. We have previously reported the recovery of spermatogonial differentiation by suppressing the levels of gonadotropins and testosterone with Nal-Glu, a GnRH antagonist. To determine whether suppression of testosterone or the gonadotropins was responsible for spermatogenic recovery, we examined the effect of supplementation of LH or FSH along with Nal-Glu treatment. Systemic administration of flutamide, an androgen receptor antagonist, was also examined. LH supplementation elevated both serum and intratesticular testosterone levels and suppressed the recovery of spermatogonial differentiation in a dose-dependent manner. Supplementation with FSH did not affect either testosterone levels or spermatogonial differentiation. Furthermore, the mice treated with flutamide showed some recovery of spermatogonial differentiation. The overall findings revealed that testosterone action mediated by androgen receptors suppressed the spermatogonial differentiation in jsd/jsd mice and suggested that spermatogonial differentiation in the jsd mutant is highly sensitive to testosterone suppression.

Defect in germ cells, not in supporting cells, is the cause of male infertility in the jsd mutant mouse: proliferation of spermatogonial stem cells without differentiation

C57BL/6 (B6)-jsd/jsd male mice are sterile because of lack of spermatogenesis. To find the cause of the deficient spermatogenesis, we have examined whether the mutation phenotype is the result of a defect in germ cells or in supporting cells using germ cell transplantation. In the seminiferous tubules of B6-jsd/jsd mutant mice, donor germ cells derived from the wild type GFP transgenic mouse (B6-+/+GFP) were able to undergo complete spermatogenesis, indicating that the juvenile spermatogonial depletion (jsd/jsd) mouse possesses normal supporting cell functions. In contrast, undifferentiated spermatogonia derived from B6-jsd/jsd mice were unable to differentiate in the seminiferous tubules of W/W v mice, even if the mutant germ cells successfully settled in the tubules. These results demonstrate that the deficiency in spermatogenesis of B6-jsd/jsd mice can be ascribed to a defect in spermatogonia but not in their supporting cell environment. Furthermore, the defect in B6-jsd/jsd spermatogonia is not in their ability to proliferate, but in their differentiation and may result from their hypersensitivity to high concentrations of androgen in the testis.

Histology of the fetal prune belly syndrome with reference to the efficacy of prenatal decompression

BACKGROUND

Deficient abdominal musculature, complex abnormalities of urinary tracts and bilateral abdominal cryptorchidism represent the basic characteristics of prune belly syndrome (PBS). Although prenatal diagnosis of PBS is rarely made, because of the wide variety of ultrasonographic images, reported cases have gradually increased. Once a fetus suspected of having PBS is found, it is sometimes difficult for the pediatric urologists to decide how to treat them. The histology of the kidney and urinary tracts in fetuses with PBS was reviewed in order to give suggestions on the management of prenatal cases.

METHODS

Autopsy records of nine fetuses (5 males, 2 females and 2 undetermined) with characteristically distended and deficient abdominal wall were reviewed. Gestational age (GA) at detection ranged from 12 to 25 weeks and at delivery from 13 to 32 weeks.

RESULTS

Renal histology in two fetuses showed earlier than normal disappearance of cortical nephrogenic zone replaced by cortical cysts and dysplastic structures. The nephrogenic zone was retained in five fetuses which were younger than GA 20 weeks. While the number of glomeruli along the medullary ray was normal for the age in three fetuses younger than GA 20 weeks, it was decreased in all others. Bladder histology was variable showing both increased musculature and defective or dysplastic muscles. There was a tendency for connective tissues in the bladder wall to increase in proportion to GA, The ureter revealed scarcity of muscle bundles among dense connective tissue. The urethra was atretic in eight fetuses.

CONCLUSION

The clinical implication from the renal histology is that decompression of the urinary tract should be done before GA 20 weeks. However, the early fetal treatment appears to have no effect on the urodynamics in this disorder with deficient musculature.

[Congenital hydronephrosis detected by prenatal ultrasonography: the effect of pyeloplasty on renal function]

PURPOSE

Prenatal detection of congenital hydronephrosis has raised new questions with regard to the need of management and the indications for operation. Moreover, there is considerable controversy whether or not pyeloplasty improves long-term renal function. We evaluated the operative results of this entity under the setting of well defined indications for surgery.

MATERIALS AND METHODS

The indications for pyeloplasty included Society for Fetal Urology-grade (SFU-grade) 3 and grade 4 hydronephrosis on ultrasonogram together with obstructive pattern on modified "Well Tempered" diuretic renogram. We analysed the postoperative changes of ultrasonographic findings, differential renal function, and renogram patterns in 28 children with unilateral hydronephrosis detected prenatally.

RESULTS

Of the patients, 27 had grade-4 hydronephrosis on preoperative ultrasonogram. Pyeloplasty was effective in decreasing the grade of dilatation in all kidneys except one. Of the involved renal units, 14 (50%) had reduced differential renal function less than 45% on the preoperative renogram. Differential renal function increased significantly by absolute value of 5% or greater in 8 kidneys (29%), but decreases in 5 kidneys (18%). In the remaining 15 kidneys (54%) there was no significant differences between pre- and post-operative differential renal function. Postoperative diuretic renogram changed to non-obstructive pattern in 26 kidneys (93%). Another 2 kidneys showed hypofunctioning pattern.

CONCLUSIONS

The results suggest that, although pyeloplasty decreases ultrasonographic dilatation of hydronephrosis and improves excretory pattern of diuretic renogram, significant increase of differential renal function is expected in only one third of the involved kidneys.

Stimulation of spermatogonial differentiation in juvenile spermatogonial depletion (jsd) mutant mice by gonadotropin-releasing hormone antagonist treatment

Male juvenile spermatogonial depletion (jsd) mutant mice are sterile because of spermatogenic failure and so may provide a model for genetically caused human male infertility. To test the effects of testosterone suppression therapy on spermatogenesis in jsd/jsd mice, we treated them with Nal-Glu, a GnRH antagonist. Treatment with Nal-Glu at 2500 microg/kg/day was started at 5.5 or 8 weeks of age and continued for 4 or 8 weeks. Differentiation of spermatogonia was evaluated by the percentage of tubules containing two or more spermatocytes (% of differentiating tubules). Nal-Glu treatment caused a marked decrease in the weights of the testes and seminal vesicles and intratesticular testosterone concentrations. However, in contrast to a value of 1.3% in untreated jsd/jsd mice, the mean % of differentiating tubules was 59.9% and 25.1% in treatment groups started at 5.5 and 8 weeks of age, respectively. We propose that spermatogonial differentiation in jsd/jsd mutant mice is sensitive to the high intratesticular levels of testosterone and can only proceed when testosterone production is suppressed.

[Perinatal and perianesthetic management of the sacrococcygeal teratoma in a neonate]

We report perinatal and perianesthetic management of a female infant with sacrococcygeal teratoma who underwent fetal bladder puncture and postnatal tumor resection. At 33 weeks' gestation, fetal ultrasonography revealed an intrapelvic mass, oligohydramnios and the dilatation of the bladder. At 34 weeks' gestation, bladder puncture was performed in utero to relieve urinary obstruction by the mass. And it served to reserve the renal function but caused remarkable ascites at birth due to urine leakage to the peritoneum through the puncture site. After the delivery by cesarean section, the patient underwent the tumor extirpation at 2 days of life. The operation and anesthesia proceeded uneventfully. In previous reports, several mortalities due to exsanguinating hemorrhage during surgery have been reported. In addition, sacrococcygeal teratoma is occasionally accompanied by coagulopathy and high output cardiac failure caused by arteriovenous fistulae. Therefore it is important for good patient outcomes to evaluate preoperatively the risks mentioned above.

Follow-up of children after fetal treatment for obstructive uropathy

BACKGROUND

Improvement in the ability to evaluate fetuses with obstructive uropathy, combined with technologic advances, has allowed successful fetal treatment of these conditions in Japan. We analyzed the prenatal and postnatal clinical courses of patients who underwent shunt placement in utero.

METHODS

We treated 6 patients who underwent fetal intervention and were transferred to us for urologic management. Gestational age at detection of abnormalities ranged from 11 weeks to 31 weeks, and fetal intervention was done between 16 weeks and 32 weeks. Excluding 1 infant who was delivered 6 days after the intervention, the mean period between shunt placement and delivery was 17 weeks.

RESULTS

Urologic pathology included prune belly syndrome with urethral hypoplasia in 3 patients, cloacal anomaly in 1, posterior urethral valves in 1, and pelviureteric junction stenosis of a solitary kidney in 1. Four patients required ventilation support in the neonatal period, and 2 of them suffered frequent infections during follow-up. Five patients who underwent vesico-amniotic shunt placement continue to require clean intermittent catheterizations via vesicostomy because of hypoactive detrusors and hypoplastic urethras. After urologic treatment, serum creatinine in 5 patients reached a minimum of less than 0.4 mg/dL at some time during the first year of life. Another patient with a minimum creatinine level of 1.0 mg/dL has moderate renal insufficiency.

CONCLUSION

From our series, it appears that early (before 20 weeks of gestation) shunt placement in severe lower urinary tract obstruction may benefit renal and pulmonary function. However, its efficacy in regard to bladder function remains questionable: shunt placement does not permit regular storage and evacuation, which may be essential for functional bladder development.

[Preoperative localization of enlarged parathyroid glands by 99mTc-MIBI scintigraphy]

BACKGROUND

Recent studies have shown that 99mTc-methoxy-isobutyl-isonitrile (99mTc-MIBI), a new agent for myocardial perfusion imaging, can be successfully applied to parathyroid imaging. We evaluated the efficacy of 99mTc-MIBI scintigraphy for preoperative localization of enlarged parathyroid glands in patients with hyperparathyroidism.

PATIENTS AND METHODS

From June 1994 to September 1996, 24 patients with biochemical confirmation of hyperparathyroidism were studied with 99mTc-MIBI scintigraphy prior to operation. Eleven patients had primary hyperparathyroidism (PHPT) and 13 had secondary hyperparathyroidism (SHPT) associated with chronic renal failure, including one patient with recurrent disease after subtotal parathyroidectomy. A positive 99mTc-MIBI scan for an enlarged gland was defined as an area of persistent focal uptake on the delayed image acquired at 150 min after intravenous injection of 600 MBq of 99mTc-MIBI.

RESULTS

Of 11 patients with PHPT, 10, were found to have solitary parathyroid adenomas at surgery and one patient had primary hyperplasia. 99mTc-MIBI scintigraphy accurately detected 9 of 10 adenomas and 2 of 3 hyperplastic glands with no false positive results. Both of the two glands that were not detected by 99mTc-MIBI weighed 200 mg. The mean weight of the 11 glands that were visualized was 1264 mg (range 300 approximately 4300 mg). The sensitivity and predictive value positive for PHPT were 84.6% and 100%, respectively. In 13 patients with SHPT, all of 49 parathyroid glands were identified during surgery, with 43 hyperplastic glands and 6 normal-size glands. Of 43 hyperplastic glands, 28 were detected by 99mTc-MIBI and there was significant difference between the mean weight of these 28 glands (999 mg, range 290 approximately 2630 mg) and that of the 15 nonimaged hyperplastic glands (283 mg, range 90 approximately 540 mg). None of the six normal glands were imaged with 99mTc-MIBI. One patient had a false positive scan caused by a thyroid nodule. The sensitivity and predictive value positive for SHPT were 65.1% and 96.6%, respectively.

CONCLUSION

99mTc-MIBI scintigraphy is an excellent imaging method for localization of enlarged parathyroid glands in patients with hyperparathyroidism, especially with PHPT. However, it has the difficulty to demonstrate enlarged glands smaller than 300 mg in weight.

[Tumor enucleation for intrapelvic schwannoma: a report of two cases]

A 65-year-old man and a 35-year-old woman were diagnosed with intrapelvic tumors originating from the sacral nerves by computed tomographic (CT) scan, magnetic resonance imaging (MRI) and angiography. These tumors were tightly adhered to the iliac arteries and veins and could not be resected completely. Since the cryostat sections revealed benign schwannomas histopathologically, we enucleated the tumors without the pseudocapsules. All of the 57 intrapelvic schwannomas previously reported in Japan were resected with pseudocapsules. Both of our patients showed improvement of subjective symptoms, but should be followed up and examined for the presence of regrowth of tumors.

[Retroperitoneal mucinous cystadenocarcinoma associated with horseshoe kidney: a case report]

We report a case of retroperitoneal mucinous cystadenocarcinoma in a patient with a horseshoe kidney. A 61-year-old woman was admitted to our hospital for examination and therapy of an abdominal mass. Various examinations revealed, a retroperitoneal tumor and a horseshoe kidney. Open surgery was performed. Pathological findings revealed mucinous cystadenocarcinoma. We review and discuss 17 cases of retroperitoneal mucinous cystadenocarcinoma, which have been reported in Japan.

[Urinary tract abnormalities associated with anorectal malformations]

Anorectal malformation (ARM) is often associated with urological problems such as congenital urogenital anomalies, recto-urinary fistula, neurogenic bladder due to vertebral anomalies and operative complications. We analyzed 57 cases of ARM and discussed about the management of associated urogenital anomalies during neonatal and infantile period. The incidence of urogenital anomalies was 85.7% in high type, 65.5% in intermediate type and 38.1% in low type. Among these urinary tract anomalies, VUR was most common and was documented in 38.6% of ARM patients. Renal dysplasia, PUJ stenosis, megaureter and urethral stenosis was also common in these patients. Renal dysfunction was documented in 5 cases (2 in high type, 2 in intermediate and 1 in low type), mainly due to VUR and renal aplasia. These results show the need for evaluation of urinary tract during the neonatal and early infantile period even in low type ARM. The management of urinary tract anomalies associated with ARM is firmly related with the management of ARM itself, and we must be closely in co-operation with pediatric surgeons.

[Histological study of fetal hydronephrosis. Development background of prenatal treatment]

It is still unclear whether prenatal decompression of the dilated urinary tracts can preserve renal development and function. Following the previous report on the relationship between the nephrogenesis and the gestational weeks in normal fetuses, we studied the hydronephrotic kidneys to find the histological background of the fetal treatment. Of the fetuses autopsied in the Department of Pathology of our Institute from 1982 to 1992, 32 kidneys from 21 fetuses associated with dilatation of the upper urinary tracts irrespective of the presence of urethral obstruction on macroscopic inspections were reviewed. The underlying disorders causing hydronephrosis included urethral obstruction in 7, vesico-intestinal fissure in 3, hydrometrocolpos in 2 and double ureter in 1. The etiology of the hydronephrosis was not clarified in another 8. The position and configuration of the ureteral orifices were not described in the autopsy reports. Microscopic examination was done to define the radial glomerular count (RGC), presence or absence of the nephrogenic zone, cortical cysts and dysplastic elements, changes of the collecting tubules and interstitium. Of the kidneys 19 had cortical cysts of various sizes. In some kidneys, the normal cortex was mixed with pathological segments where there were subcapsular small cysts and tubular dilatation. Nephrogenic zone, which was observed in specimens of 33-weeks fetus with moderate hydronephrosis, was already missing by 28 weeks in severe hydronephrosis. Collecting tubules were dilated in 12 kidneys with mild to moderate hydronephrosis. Tubular atrophy and increase in the interstitium were seen in 12 kidneys, eleven of which were of the fetus over 30 weeks.(ABSTRACT TRUNCATED AT 250 WORDS)

[Histological study of the fetal kidneys. Development of the nephrons according to gestational weeks]

Despite recent advance of prenatal ultrasonography leading to an increase in the detection of various fetal urological abnormalities, a lot a unresolved problems exist surrounding their diagnosis and management. It is unclear whether an antenatal intervention helps to preserve the renal function, because little has been known about the nephrogenesis of the human fetal kidney associated with congenital obstruction. To find the normal development of the kidney, we studied the fetal kidneys in relation to the gestational weeks. Of all fetuses autopsied in the Department of Pathology of our Institute from 1982 to 1992, 87 kidneys from 60 fetuses which showed no abnormalities of the urinary tracts on macroscopic inspections were reviewed. Microscopic examination was done to define the radial glomerular count (RGC) and glomerular size according to gestational weeks. Nephrogenic zone was observed in all kidneys before 34 weeks of gestation, and disappeared in all kidneys after 37 weeks. The RGC increased steadily with gestational weeks, and gradually reached a plateau of around 12 counts at about 36 weeks. The RGC was not influenced by the intrauterine fetal growth. The glomeruli were arranged in the uniform fashion on the medullary ray with the smallest in the most superficial cortex and the largest in the juxtamedullary zone. The superficial glomeruli remained at the surprisingly same size up to birth. Juxtamedullary glomeruli showed no significant differences before birth, either. Based on the present studies to know the normal standard of renal development, pathological changes are possible to define. It was thought that an understanding of the morphological characteristics of fetal kidneys would give clues to elucidate pathogenesis of abnormal kidneys.

[Indications for urinary drainage in neonates detected in utero]

The routine use of maternal ultrasonography has led to increasing discovery of fetal abnormalities of the urinary tract. It is well known that some of the fetal hydronephrosis improves spontaneously, and that there is non-obstructed type of hydronephrosis. However, some of the infants require the management in the neonatal periods because of the mass effect from the dilated urinary tract, urinary tract infection, or deterioration of the renal function. Herein we report on 103 cases with urinary tract abnormalities detected by the prenatal ultrasonography, and analysed the renal function in the early neonatal periods to determine the necessity of the emergency urinary drainage. 1. Renal function of the normal neonates (control) Seventy four infants without abnormalities of the urinary tract were studied on serum creatinine (SCr) and fractional excretion of sodium (FENa) during the first four weeks of life. The SCr of infants at birth to one day postnatally was almost the same with maternal SCr. In infants with a gestational age of 33-40 weeks it fell steadily and reached the value around 0.6 mg/dl at 1 week after birth. The fall of SCr was significantly slow in infants with a GA of 28-32 weeks. Similarly, the FENa was significantly higher in infants with a GA of 28-32 weeks than in infants with a GA of more than 33 weeks. Glomerulo-tubular balance was maintained as early as 1 week postnatally in the latter group. 2. Infants treated in the neonatal periods Urological management was done on 26 infants (23%) during the neonatal periods.(ABSTRACT TRUNCATED AT 250 WORDS)

[Management of multicystic dysplastic kidney detected in perinatal periods]

We analyzed 17 cases of multicystic dysplastic kidney (MCDK) to document the natural history of MCDK and its management. One patient was nephrectomied for respiratory failure associated with MCDK. Follow-up studies of 14 kidneys revealed that 5 kidneys (36%) did not change in size, 7 kidneys (50%) decreased in size. Two kidneys (14%) increased in size during the follow up periods and were nephrectomized. Hypertension and malignancy was not observed in our cases. Evaluations for the contralateral kidney and urinary tract system were performed in 15 patients and 5 (33%) revealed abnormalities--two patients with VUR, 1 with PUJ stenosis, 1 with ureteral stricture and 1 with ectopic ureterocele. In our hospital, the management for MCDK is conservative in most cases. Nephrectomy is indicated when there are complications resulting from the size of MCDK, or when the kidney continues to increase in size after the second year of life.