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The case of the month

January 2006 case

A 31 yo Egyptian patient was referred to a Urologist for the management of a right testicular tumour discovered at ultrasound scrotal examination performed to explore an azoospermia causing primary infertility.
The patient weighted 90kg, his height was 1,71m, and he was a smoker (10 cigarettes/day).
The clinical examination showed two normal testis, vas deferents, and prostate.
Sperm analysis (performed twice) showed a normal volume ejaculate with no spermatozoa and many white cells.
Ejaculate biochemical analysis showed, on 3 different ejaculates, normal fructose (seminal vesicle), subnormal acid phosphatase, low citrate and zinc (Prostate), normal carnitine and alpha,1-4 glucosidase.
The patient is 46XY with no Y chromosome microdeletions.

Sperm cultures, Chlamydiae Trachomatis PCR in urine and serodiagnosis of hepatitis, HIV and Syphilis were normal.
Hormonal assessment:
Testosterone: 7.5ng/ml (normal: 3.5-8.5), Inhibin B: 45 pg/ml (normal: 80-270), FSH: 10 UI/L (normal: 3-7), LH: 6.9 UI/L (normal:3-8).

Scrotal Ultrasound showed a normal left testis of 11.2ml. The right testis of 13 ml presented a nodular ovoid lesion of 12/6mm, striated, located at the upper pole of the testis, hypervascularized on color Doppler and not well limited. No microlithiasis, no varicocele, normal epididymis.

Question 1:
What is your diagnosis concerning the origin of the infertility?

• Secretory azoospermia from unknown origin?
• Excretory azoospermia by ejaculatory ducts obstruction?
• Secretory azoospermia due to the testicular tumor?
• Excretory azoospermia due to chronic prostatitis?

Correct answer: A
The low level of B Inhibin, high level of FSH, normal rates of epididymal and seminal vesicle biochemical markers argue strongly for a secretory, non obstructive azoospermia. The probability that the azoospermia could be due to the testicular tumor is low as the B Inhibin is low and only an oligo, asthenospermia or teratospermia might be expected in case of unilateral testicular tumor.

Question 2:
What do you propose to the patient?

• Serum bHCG and a-fetoprotein and radical orchiectomy?
• Serum bHCG and a-fetoprotein and tumor excision plus frozen sections?
• Serum bHCG and a-fetoprotein and percutaneous biopsy?
• Serum bHCG and a-fetoprotein and US watchful waiting if serum markers normal?

Correct answer: B
Considering the high incidence of benign lesions found in ultrasound examination and the value of frozen sections in the management of nonpalpable incidental testicular tumor, testicular sparing surgery appears as a reasonable option in that patient. [1, 2]

References

Carmignani L, Gadda F, Gazzano G, Nerva F, Mancini M, Ferruti M, Bulfamante G, Bosari S, Coggi G, Rocco F, Colpi GM. High incidence of benign testicular neoplasms diagnosed by ultrasound. J Urol 2003, 170:1783-1786.

Leroy X, Rigot J-M, Aubert S, Ballereau C, Gosselin B. Value of frozen section examination for the management of nonpalpable incidental testicular tumors. Eur Urol 2003, 44:458-460.