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Microsurgical Sperm Retrieval under Local Anesthesia Part 2
Silber: For nonobstructive azoospermia,microsurgery of the testes is required because Silber: For nonobstructive azoospermia,microsurgery of the testes is required because the epididymis will contain no sperm. Okay, here, I'm going to inject the anestheticand this is going to sting, all right? It's going to sting. And now I'm going to injectsome more into your cords and it's going to sting. Could be for 10 seconds after Iinject this. After the testicle is anesthetized, the antiscrotalskin must also be anesthetized because of nerve fibers that don't come in directlyvia the cord. This allows a small incision to be made over the scrotum to expose thetestes. Okay, so is that hurting at all?.
Patient: No. Patient: No. Silber: This is patent with maturationarrest, who had undergone a previous extensive scrotal operation causing a lot of adhesions,a great deal of scar tissue, so that this would appear to be one of the more difficulttesticle procedures that we would have seen. Furthermore, with maturation arrest, in contradictionto Sertoli cells only or Klinefelters or cryptorchidism, it is very difficult to determine under themicroscope where in the seminal tubules the sperm may be located, because the tubulesare filled with spermatogenic elements even though there a very few and very rare elongatedsperm to be found.
In this type of case, an open procedure, whichas you can see is painless, allows us to retrieve In this type of case, an open procedure, whichas you can see is painless, allows us to retrieve enough tissue to actually search for thoseelongated sperm within this maturation arrest tissue. Without doing any damage to the testicleitself and without damaging the blood supply to the precious seminids for the tubules thatare left. We find this much more safe than multiple needle biopsy, therefore. Is this hurting you? laughs Patient: No. Silber: Okay.
Patient: I'll take the skirt. Patient: I'll take the skirt. Woman 1: Yeah, I was going to say, do youwant baked potato or fries with that? Patient: Whatever there is. Actually, do youhave mashed? Silber: We then divide the testiculartissue into three segments. One portion for histology, one portion for enzyme digestion,and one portion for mechanical dissociation. It should be noted that with Sertoli cellonly, under the microscope we can usually find which specific tubules actually havethe sperm and avoid the removal of two much tissue. With maturation arrest, you have toremove more tissue and be very, very cautious.
And careful that any of the remaining tissueis not damaged. and careful that any of the remaining tissueis not damaged. Now we have to dissect the tubules under themicroscope once they're removed fully in order to see if we can find those rare, maturesperm that are located within the tubules. Woman 2: inaudible, 03:1503:18 Patient: So, they're going to stitch upjust the testicle? Woman 2: Right, just the testicle. Patient: Oh, so the skin is not â€”inaudible,03:23 Woman 2: The skin is not â€” right.
Silber: Can you see one? Silber: Can you see one? Woman 3: Right there. Silber: That'd be amazing. Woman 3: Look. Can you see it? Silber: Yeah! I do. Woman 3: Oh my god. Silber: She found a sperm. In summary, we want to demonstrate that microsurgicalsperm retrieval can be performed painlessly.
Under local anesthesia, just as painlesslyas needle aspiration, but has the advantage under local anesthesia, just as painlesslyas needle aspiration, but has the advantage that we can retrieve many more sperm fromjust the right area of the epididymis. We have the opportunity for microsurgical reconstruction,which will give an 80 to 95 percent chance of sperm in the ejaculate. And, furthermore,we can avoid testicular damage. Okay, so it that hurting at all? Patient: No, a lot less than I'd expect. Silber: So, we'll just wash them off. Patient: I was trying to take a nap.