V11-09: Using microscope for onco-testicular sperm extraction for bilateral testis tumors
Testis cancer presents a unique problem in male fertility preservation. As many as 50-70% of patients diagnosed with testis cancer are subfertile at the time of diagnosis and up to 15% are azoospermic. Many patients will also require adjuvant radiotherapy or chemotherapy further complicating future fertility potential. In this video, we aim to provide a step-by-step guide to the performance of microsurgical onco-testicular sperm extraction (onco-TESE) in the setting of radical orchiectomy for testis cancer in an azoospermic patient.
A 34-year-old man with bilateral testis masses underwent right orchiectomy at another institution for pT3 pure seminoma, and was subsequently found to be azoospermic when attempting cryopreservation of ejaculated sperm. Metastatic evaluation and tumor markers were negative, and he was subsequently referred for contralateral orchiectomy and fertility preservation. The patient had a preoperative scrotal ultrasound demonstrating multifocal left testis masses up to 1.3 cm in size clustered in the upper pole of the testis and a normal-appearing lower pole. The patient gave signed, informed consent for surgery and production of video abstract. At the time of left orchiectomy, simultaneous microsurgical onco-TESE was performed on a separate sterile field with an operating microscope. Guided by preoperative ultrasound, a targeted lower pole bivalving incision was used. Dilated tubules were identified, extracted, and processed for cryopreservation. Areas of scarred and flat tubules, or nodular tumor, were avoided in micro-dissection.
This patient had successful retrieval and cryopreservation of abundant testicular sperm following targeted ex-vivo testicular micro-dissection. Final pathology again was pure seminoma from the left testis, and three vials of approximately 63,000 sperm per vial were cryopreserved.
This video provides a step-by-step guide to microsurgical onco-TESE coordinated with radical orchiectomy for testis cancer as a means of fertility preservation in an azoospermic patient. Microsurgical onco-TESE should be offered to azoospermic patients when undergoing orchiectomy for testis cancer. Use of preoperative imaging and the surgical microscope guide surgical dissection and optimize sperm recovery.