Surgical Approaches (McIntyre)

McIntyre

The patient is a 30 year old White male , who is a consultation from Thomas J. Lee MD for evaluation of infertility. The patient has been married for 4 years to a 32 year old female, Jess. Her doctor is Dr Lau. The patient has been trying unsuccessfully for a pregnancy for one year. She has not had children in the past. She has regular cycles. She has not yet had an HSG. She is not on meds for fertility. He has fathered no other children. He has not had testicular trauma. He has not been diagnosed with a varicocele in the past. He denies a history of undescended testicles, chemical exposures, radiation, post pubertal mumps, and chemotherapy. He has had no previous semen analysis. He has not had a hormone profile checked.

The couple has tried timed intercourse. They have intercourse intermittently around the time of ovulation. They do not use lubricants.

Testes : normal testes, vas deferens normal, Bilateral Grade I varicocele

Varicocele

Progressive motility low

Post varicocelectomy: increased semen parameters 

Incidence of varicocele in general population

20%

Incidence of varicocele in infertility space

40%

Most common surgically correctable cause for a male infertility

Varicocele

Different grades of varicocele 

Grade 1 only palpable with Valsalva 

Grade 2 palpable without Valsalva but gets bigger with

Grade 3 seen through skin

Layers of scrotum and spermatic cord

Skin, dartos, external spermatic fascia, cremaster, internal spermatic fascia, tunica vaginalis

To fix hydrocele, you have to remove the

tunica vaginalis

Contents of inguinal canal

Testicular artery, genital branch of genitofemoral nerve, and vas deferens

(also testicular vein and lymphatics)

Stay cephalad of the inguinal ligament because of ? 

femoral artery and vein is close under 

Theories of causes of varicoceles

Refluxing renal metabolites

Hormonal dysfunction

Hypoxia and ROS

Hyperthermia

Indications for varicocelectomy

Impaired semen quality

Testicular pain

Prevention of testicular atrophy in adolescents or if atrophy is present in adults

Techniques for varicocelectomy

Laparoscopic

Retroperitoneal

Inguinal
Subinguinal

Endovascular embolization

Postoperative care for varicocelectomy and post op follow up 

Avoid strenous activity for 4 weeks 

Standard wound care 

Semen analysis around 12 weeks 

Varicocelectomy improves _____ parameters which may improve changes of natural conception or help efforts of assisted reproduction

semen

form of surgical sterilization by which the vas deferens is divided or damaged to the point it will no longer transport sperm

Vasectomy 

Vasovasostomy

Vasectomy reversal

Vasoepididymostomy

bypass epididymal obstruction

Presence of epididymal obstruction requires a

Vasoepididymostomy

Greatest predictor of epidymal obstruction is time since 

Vasectomy 

less than 3 years 97% will have successful vasovasostomy 

greater than 3 years see specialist

Sperm can be preserved during vasectomy reversal for use in

IVF

Clear fluid with mostly normal motile sperm

Grade 1

Clear fluid with mostly normal non-motile sperm

Grade 2

Cloudier fluid with mostly sperm heads 

Grade 3

cloudier with only sperm heads

Grade 4

paste like with no sperm

Grade 5

(epididymal obstruction)

Fluid grade 1-3 has good outcomes using

Vasovasostomy

Grade 4 and 5 patients would benefit from 

Vasoepididymostomy 

Cutting tunica vaginalis exposes

epididymis

Post operative care for vasoepididymostomy

Scrotal support

Abstinence from intercourse

Restricted to light duty activities

first semen analysis at 6 weeks and regular intervals after

May takes months for sperm to return

_______ only ciliated portion of male reproductive tract 

Efferent ducts 

The patient is a 26 year old Caucasian/White male, who is a consultation from Dr. K for evaluation of infertility and azoospermia The patient has been married for 6 years to a 25 year old female, Dot. Her doctor is Dr. K . The patient has been trying unsuccessfully for a pregnancy for several years. She has not had children in the past. She has regular cycles. She has had a HSG which was normal. She is not on meds for fertility.

He has fathered no other children. He has not had testicular trauma. He has not been diagnosed with a varicocele in the past. Mr. Smithson denies a history of undescended testicles, chemical exposures, radiation, post pubertal mumps, and chemotherapy. He has had previous semen analysis. The results of the semen analysis were 0.3 Azoo x2.

The couple has tried timed intercourse. They have intercourse intermittently around the time of ovulation. They do not use lubricants.

Scrotum : I can not palpate either vas adequately to be convinced that they are present

Look at volume and pH 

CF 

Seminal vesicles are also atretic in

CF

Bulbourethral glands <_%

Prostate ___-___%

Seminal vesicles ___-____%

Vas deferens/epididymis ___-___%

5

20-30

60-70

6-10

1.5 cc LLN and 7-8 ULN

For volume of ejaculate 

Patients with CBAVD have _______ azoospermia

obstructive

Sperm retrieval in OA

percutaneous approach (need 8-10 good sperm) of epididymis

Biopsy gun from testicle

FNA of testicle

The patient is a 36 year old African American/Black male, who is a consultation from Thomas Meyrs for evaluation of infertility. The patient has been married for 6 years. To a 34 year old female, Sally. Her doctor is Dr Ringler. The patient has been trying unsuccessfully for a pregnancy for one year. She has not had children in the past. She has regular cycles. She has had a HSG which was normal. She is not on meds for fertility. He has fathered no other children. He has not had testicular trauma. He has not been diagnosed with a varicocele in the past. Mr. Mathers denies a history of chemical exposures, radiation, and post pubertal mumps. He has had no previous semen analysis. He has not had a hormone profile checked.

The couple has tried timed intercourse. They have intercourse intermittently around the time of ovulation. They do not use Lubricants

He does have a history of Lupus and has received cytoxan for some time in the past. Currently he is on prednisone for treatment.

Testosterone 504 ng/ml (above 350 good)

LH 14 (1.5-9.3)

FSH 40 (1.6-8)

Azoospermia

Cytoxan- chemotherapy wiped out primordial germ cells

Testicular failure/ primary hypogonadism (no inhibin) 

Men of reproductive age should not have an FSH over

7.5

Treatment for non-obstructive azoospermia

Micro Testicular sperm extraction and in vitro fertilization

Micro Tese (look for more opaque tubules)

Pt is a 25 yr old male present after pulling groin 2 weeks ago playing kickball.

Noted a knot come up and thinks it is getting bigger

Never had this before was not red or tender, is getting in the way when sitting

What type of cancer does he have?

LD 953 (80-210)

Beta HCG 11.1 (less than 1)

AFP 1.1 (less than 15)

Choriocarcinoma

Work Up of Testicular Mass

•History and Physical Exam

•Labs*

–bHCG

–LDH

–AFP

•Radical Orchiectomy

•Ct Scan

______ incision makes it radical orchectomy instead of simple

Inguinal

bulk tumor marker, how much is there

Lactate dehydrogenase

Check after to removal to see if there is anything left. After 4 half life’s

AFP 7 days longest so check 4 weeks after removal.

In pure seminoma only ___ will be elevated

LDH

What is the most common GCT ?

Mixed

Most common pure tumor is?

Seminoma

Yolk sac tumor

AFP

Choriocarcinoma

βHCG

Seminoma with mets to retroperitoneum

Chemo/ radiation

NSGCT with mets to retroperitoneum

Surgery/ Chemo

Right sided landing zone nodes

Paracaval

Interaortocaval

Preaortic

Left sided landing zone nodes 

Interaortocaval 

Preaortic 

Paraortic 

Sympathetic

Ejaculation

Preganglionic neurons innervate the epididymis, vas deferens, seminal vesicles, prostate, and penis

Intermediolateral nucleus at the T12-L2 level

Preganglionic fibers travel through the sympathetic chain

Exit through lumbar splanchnic nerves

Synapses in the inferior mesenteric ganglion

Pass through hypogastric plexus

Parasympathetic 

Erection

Preganglionic neurons innervate the corpora cavernosa

IML at the S2-S4 level.

Exit through pelvic nerves

Pass through the hypogastric plexus

Internal pudendal artery ends in the ____

penis as dorsal nerve of the penis

Nerve that causes ______ runs on top of the prostate

erection

NO stimulates smooth muscle guanylate cyclase, upregulating synthesis of ____

cGMP

____ hydrolyzes cGMP to 5'-GMP

PDE5

ED can be treated by inhibiting ____

PDE5

Main physical causes of ED

Vascular

Diabetes

Medication

(heart disease, smoking, long term HTN)

Pelvic surgery, radiation, trauma (prosectomy)

Sildenafil was first approved from

primary pulmonary HTN

Half life of ____ is longer can take it daily 5 mg (get aroused for it) or on demand

cialis

Self-injections for ED

If you are failing oral medication including dual therapy but do not want to do the vacuum device

Daily Cialis + on demand Viagra or Levitra for dual therapy

Injection main ingredient is alprostadil which is a

PGE1 agonist