Human Reproduction, Vol. 16, No. 10, 2154-2159,
October 2001
© 2001 European Society of Human Reproduction and Embryology
Percutaneous cutting needle biopsies for histopathological assessment and sperm retrieval in men with azoospermia
1 Department of Obstetrics and Gynaecology, Huddinge University Hospital, Andrology Centre, Department of Woman and Child Health, 2 Karolinska Hospital, Stockholm and 3 Department of Anatomy and Histology, Swedish University of Agricultural Sciences, Uppsala, Sweden
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Abstract |
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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.
Key words: azoospermia/histopathological diagnosis/percutaneous needle biopsy/spermatogenesis
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Introduction |
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TopAbstractIntroductionMaterials and methodsResultsDiscussionReferences |
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Open testis biopsy is recognized as being the standard procedure for obtaining testicular tissue for assessment of spermatogenesis. Recently, percutaneous needle biopsy has also been used for histopathological assessment (Cohen and Warner, 1987
; Rajfer and Binder, 1989), and for testicular extraction of spermatozoa for intracytoplasmic sperm injection (ICSI) (Bourne et al., 1995; Hovatta et al., 1995). Two different types of percutaneous needles have been used, cutting needles and aspiration needles. The cutting type was used in a study by Kessaris et al. (1995) where the biopsy was performed with an ASAP 18 core biopsy system (18 gauge with 17 mm notch). They found a 95% correlation between percutaneous and open biopsy regarding the histopathological diagnosis. Studies comparing percutaneous aspiration needles with open testicular biopsy for histopathological assessment gave less correlation (Mallidis and Baker, 1994; Rosenlund et al., 1998). The aim of this study was to compare the biopsies taken with two cutting needles, 14 gauge and 16 gauge, and to see if they can be used for histopathological assessment of spermatogenesis and for presence of mature spermatids. |
Materials and methods |
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TopAbstractIntroductionMaterials and methodsResultsDiscussionReferences |
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Twentythree men, aged 27–45 years, underwent percutaneous testicular biopsy as part of an infertility investigation. Both testes in all but one man were investigated, hence a total of 45 testes. Twentyone men had non-obstructive azoospermia and two showed clinical signs of obstructive azoospermia. The testicular volumes, determined by orchidometry, ranged from 2–25 ml. Two men had karyotype 47,XXY and the other 21 had normal karyotype, 46,XY.
All biopsies were performed under local anaesthesia with a pre-operative injection of 0.5 mg alfentanilum (Rapifen®; Janssen-Cilag, Birkerod, Denmark) and 2.5 mg midazolam (Dormicum®; Roche, Basel, Switzerland). The scrotal area was washed with 0.5% chlorhexidine solution followed by physiological saline and then draped. Seven millilitres of prilocaine hydrochloride (Citanest®10 mg/ml, Astra; Södertälje, Sweden) was injected around the vas deferens as described by Li et al. (1992), using a 22 gauge, 5 cm needle (Microlance 3®, 22G 0.7x50 mm; Becton Dickinson, Dublin, Ireland). Additionally, 1 ml prilocaine hydrochloride was injected into the scrotal skin. The testis was grasped between the thumb and forefinger of the non-dominant hand and rotated ventrally to prevent epididymal injury. The needle was inserted into the cranial pole towards the centre of the testicle. Two biopsies were taken close to each other, first with a 14 gauge (n = 45) and then with a 16 gauge (n = 44) needle (Bard MAGNUM Biopsy Instrument, C.R.Bard Inc., Covington, GA, USA), both with a 19 mm notch. Three quarters of the testicular material was fixed and plastic-embedded for histopathological assessment, and one quarter reserved for direct microscopy. Evaluation of testicular biopsy specimens was as described by Rosenlund et al. (Rosenlund et al., 1998).
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Results |
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The amount of tissue retrieved was sufficient for histopathological assessment in nearly all biopsies. In biopsies where tubules could be identified, the median numbers of tubular sections were 35 and 20 with the 14 gauge and 16 gauge needles respectively. An overview of the results is presented in Table I
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The results of the histopathological assessments were identical in 35 testes irrespective of the needle size used, 14 gauge or 16 gauge. In nine testes (patients 6, 8, 11, 12, 13 and 16) the major findings were identical but some discrepancies were noted between the results using the two needles (as occurred in patient 13, Figure 1b
), and also the single 16 gauge needle, as occurred in patient 11, left testis, Figure 1c and 1d.
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Presence of mature spermatids/testicular spermatozoa— direct microscopy versus histopathological assessment
Direct microscopic observations corresponded well with the histopathological assessment concerning the presence of mature spermatids/testicular spermatozoa in 41 of 45 (91%) of the 14 gauge biopsies and in 40 of 44 (91%) 16 gauge biopsies. Discrepancies were found in patients 6, 7, 11 and 12 where direct microscopy showed testicular spermatozoa, but the histopathological assessment showed a disruption of spermatogenesis at various stages, with round spermatids being the most advanced germ cells observed.
Presence of testicular spermatozoa in direct microscopy—14 gauge versus 16 gauge biopsies
Presence or absence of testicular spermatozoa was assessed in direct microscopy with full agreement between the two needle size biopsies in 42 of 44 (95%) paired biopsies. Discrepancy was found between direct microscopy in two patients (patient 7 and 8) where spermatozoa were found only in the 16 gauge and 14 gauge biopsies respectively.
Presence of mature spermatids in testicular sections—14 gauge versus 16 gauge biopsies
Full agreement concerning presence or absence of mature spermatids between 14 gauge and 16 gauge biopsies was found in 40 of 44 (91%) paired biopsies. Discrepancies were found in four testes (patients 6, 8 and 11) where mature spermatids were only found in two testes with the 14 gauge needle and in two other testes with the 16 gauge needle.
In the 89 performed biopsies small cut arteries were seen in nine cases and extravasal red blood cells were observed in five cases (Figure 1a
). The latter were all seen in the second (16 gauge) biopsy.
Follicle stimulating hormone (FSH) concentration in serum of the 23 men ranged between 2 and 68 IU/l. The two highest FSH values, 68 and 42 IU/l, were from men with severely impaired spermatogenesis. However, the third highest value (36 IU/l, patient 6) was from a man with karyotype 47,XXY, who revealed focal spermatogenesis (one out of 30 tubules assessed, Figure 1e).
All operations were performed on an outpatient basis under local anaesthesia and were well tolerated by the patients, who were all discharged from the clinic within 3 h. There were no post-operative complications except for minor pain and minor subcutaneous swelling.
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Discussion |
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TopAbstractIntroductionMaterials and methodsResultsDiscussionReferences |
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In a previous study investigating men with non-obstructive azoospermia (Rosenlund et al., 1998
), we found that testicular material obtained by percutaneous biopsies using 21 gauge and 19 gauge aspirating needles was not sufficient for histopathological assessment of spermatogenesis in most cases compared to biopsies obtained by open surgery. Mallidis and Baker (1994), using a 20 gauge aspiration needle, reported 56% full agreement in the histological diagnosis comparing open biopsy and tissue aspiration (47 testes) (Mallidis and Baker, 1994).
In this present study, using 16 gauge and 14 gauge cutting needles, all specimens retrieved by a single biopsy were sufficient for histopathological assessment of spermatogenesis, even though the number of tubular cross-sections was lower using the thinner 16 gauge needle. The efficiency of a cutting needle biopsy for testicular histopathological evaluation has also been demonstrated by Kessaris et al. (1995), who found a 95% correlation between percutaneous and open biopsy regarding the histopathological diagnosis (Kessaris et al., 1995). However, the diagnosis in their study was more heterogeneous than in our study, which mainly consisted of men with non-obstructive azoospermia.
In the present study, one biopsy was taken using each sized needle. The extent to which the material from one needle biopsy is representative of the real testicular status could be disputed. Silber et al. (1997) claimed that the distribution of spermatogenesis in the testicles of azoospermic men is homogeneous (Silber et al., 1997). They suggested that a single biopsy is sufficient to diagnose the presence of spermatozoa based on the assumption that multi-focal distribution of spermatogenesis throughout the entire testes is present in non-obstructive azoospermia. Other authors (Tournaye et al., 1996; Ezeh et al., 1998; Hauser et al., 1998; Amer et al., 1999) have recommended multiple biopsies to enhance diagnostic accuracy. In our study, the findings in the two biopsies taken from each testis were generally the same, but in eight out of the 44 (18%) paired observations from the same testis there were slight discrepancies. These observations show that spermatogenesis is not always homogeneously distributed throughout the testicular parenchyma. Thus, only one puncture with a cutting needle is not representative of the entire testis in some azoospermic men. However, it has been postulated that multiple testicular biopsies with multiple incisions in the tunica albuginea may result in interrupting a sufficient proportion of testicular arteries to cause permanent testicular injury (Schlegel and Su, 1997) and post-sampling fibrosis (Tournaye et al., 1997). In addition, excision of multiple testicular biopsy samples can result in long time impairment of testosterone production (Manning et al., 1998).
It has been suggested that open biopsy is safer than needle biopsy as the arteries can be identified during open testicular biopsy (Schlegel and Su, 1997). Being a blind procedure, there has been a fear that percutaneous needle biopsy may cause vascular injury. In our study we found signs of microscopic bleeding (extravasal red blood cells or cut arteries) in 14 of the total 89 (16%) biopsies. However, there were no clinical complications except for minimal pain and minor subcutaneous swelling. We did not carry out any post-operative ultrasound screening. Intratesticular bleeding was reported in the 30 min following the biopsy, observed sonographically as a hypoechoic region in the testicular parenchyma (Harrington et al., 1996). This was observed in only 7% (four of 58) of the percutaneous biopsies performed with an 18 gauge Microvasive biopsy needle with a notch of 17 mm (two biopsy specimens from each testicle). In contrast, the proportion of open testis biopsies resulting in signs of testicular bleeding was 29% (10 out of 34). It appears that a needle biopsy using a cutting needle could reduce the risk of post-operative intratesticular haematoma compared with open biopsy. It is also likely that the needle diameter and the number of needle biopsies affect post-operative bleeding.
It has been suggested the use of an operation microscope to examine the surface of the testis for subtunical vessels before making biopsy incisions (Schlegel and Su, 1997). However, this technique does not exclude the risk that tiny arteries may accidentally be cut during this form of open surgery (Tuuri et al., 1999).
To conclude, percutaneous testicular needle biopsy using 16 gauge and 14 gauge cutting needles to investigate men with non-obstructive azoospermia is a simple and relatively cost-effective procedure. It can be carried out under local anaesthesia on an outpatient basis. The material retrieved by this method is sufficient for histopathological assessment of spermatogenesis. Needle biopsies can also be used for cryopreservation (Tuuri et al., 1999). The two needles seem to be equally reliable for testicular biopsy for histopathological evaluation and for testicular sperm retrieval.
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Notes |
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4 To whom correspondence should be addressed. E-mail: bjorn.rosenlund{at}obgyn.hs.sll.se
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References |
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Submitted on March 7, 2001; accepted on June 5, 2001.
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