Fine needle aspiration cytology of epididymal nodules and its corroboration with ultrasonographic-histological findings.

BACKGROUND: Fine needle aspiration cytology (FNAC) assisted with scrotal ultrasonography is the best preoperative diagnostic modality for palpable epididymal nodules. It also aids in their successive remedial approach as well as serves semi-therapeutically in cystic lesions. The objectives of this study are to recognize the spectrum of pathological conditions giving rise to epididymal nodules, then to compare them with corresponding ultrasound images, and to evaluate the histological features wherever practicable. METHODS: Total 62 patients underwent FNAC as well as sonographic evaluation for their epididymal nodules. Histopathology was performed in only 20 cases. RESULTS: Epididymitis either caused by tuberculosis (30.6%), or in its acute (11.3%) and chronic (8.1%) forms remained the commonest cytological diagnosis. Neoplastic lesions included mostly adenomatoid tumors (8.1%), and another case of seminomatous spread from ipsilateral testicular primary. Nineteen of the excised masses corroborated with their respective cytodiagnoses. The discrepant lesion was actually a papillary cystadenoma, which was cytologically misinterpreted as adenomatoid tumor. CONCLUSIONS: FNAC becomes the first-hand investigative measure for epididymal nodules, by virtue of its early, easy and highly accurate diagnostic implications. It segregates the patients into proper therapeutic protocol and thereby estranges those who really need operative management. When deployed together with ultrasound, the diagnostic accuracy of FNAC improves further.

Torsion of huge epididymal cyst in a 16-year-old boy: case report and review of the literature.

Epididymal cysts (ECs) are relatively common in adults, rare in children. Normally their treatment is conservative. They may be situated anywhere in the organ, frequently in the region of the head. Torsion of these cysts is extremely rare in both children and adults, causing acute scrotal swelling. The diagnosis is intraoperative. A 16-year-old boy was referred to our Divisional Clinic by the treating physician for scrotal swelling appeared 4 months earlier. Absence of a history of minor scrotal trauma. Ultrasonography showed a 40×50 mm fluid-filled right para-testicular mass. We performed surgery finding a large black cyst connected to the head of the epididymis with 720°-degrees rotation. Histology revealed an acquired EC. The particularity of our case is due to the absence of symptoms in association with a big EC twisted of 720° degrees. This is the only case reported in literature. All patients with EC torsion reported presented symptoms related to acute scrotum.

Intraparenchymal Epididymal Cyst (IEC) 4 cm in Diameter in a 15-Year Old Male Patient; a Case Report and Review of the Literature.

Intraparenchymal epididymal cysts (IECs) are benign cystic formations of the epididymis of unknown pathogenesis, which typically appear in adolescence or adulthood. In patients older than 14 years old their prevalence is doubled. After systematic and thorough research of the current literature, we did not find another case report of intraparenchymal epididymal cyst with similar dimensions. The male patient, 15 years old, visited our outpatient department complaining of pain in the right hemiscrotum. Diagnosis of IEC was confirmed after the conduction of ultrasound examination. Patient underwent surgical exploration of the right hemiscrotum. Resection of the IEC followed. Postoperative course was uneventful, with recession of the symptoms. In our opinion, IECs should be surgically removed, either when they are symptomatic or when they are asymptomatic, but of a diameter greater than 1 cm and without regression tendency.

Treatment of bilateral varicocele and other scrotal comorbidities using a single scrotal access: our experience on 34 patients.

INTRODUCTION: Varicocele is the main cause of infertility in male and the most correctable cause of it too. In this study, we present our experience on 34 patients affected by bilateral varicocele and other scrotal comorbidities treated underwent surgery with a scrotal access. MATERIALS AND METHODS: 34 patients were enrolled with clinical palpable and infraclinical (ultrasonic doppler scanning) bilateral varicocele and other comorbidities like right hydrocele, left hydrocele, bilateral hydrocele, and epididymal cyst. They all underwent scrotal bilateral varicocelectomy under local anesthesia. RESULTS AND DISCUSSION: At 6 months, no other complications were reported. No case of testicular atrophy was observed. None had recurrence of varicocele. All scrotal comorbidities were treated as well. CONCLUSION: Scrotal access with local anesthesia is a safe and useful technique to treat patients with bilateral varicocele and other scrotal comorbidities.

Routine pathology evaluation of hydrocele and spermatocele specimens is associated with significant costs and no identifiable benefit.

PURPOSE: Hydrocelectomy and spermatocelectomy are routine scrotal surgeries. A significant number of the surgical specimens are sent for pathology analysis. However, to our knowledge no study has been done to examine outcomes and necessity, which results in significant potentially unnecessary costs to the patient and the health care system. We evaluated outcomes and surgical pathology analysis of hydroceles and spermatoceles. MATERIALS AND METHODS: We performed a retrospective, single institution chart review of all patients who underwent initial surgery for hydrocele or spermatocele between January 2000 and August 2013. We determined the number of cases in which a surgical specimen was sent for pathology examination. The cost for each specimen was estimated at the department of pathology. RESULTS: A total of 264 routine scrotal cases were performed during the 14-year period. Surgical specimens were sent for pathology analysis in 102 hydrocelectomy cases (51%) and in 57 spermatocelectomy cases (90%). No pathology specimen showed any indication of malignancy. The estimated direct total cost of pathology analysis was $49,449 in this cohort. CONCLUSIONS: No malignancy was detected in 159 hydrocele and spermatocele specimens during the 14 study years, suggesting that the pathology analysis is of little clinical benefit. Forgoing surgical pathology analysis of these specimens would result in significant cost savings to the patient and the health care system.

Florid mesothelial hyperplasia of the tunica vaginalis mimicking malignant mesothelioma: a clinicopathologic study of 12 cases.

The tunica vaginalis is an embryologically derived mesothelium-lined outpouching of the peritoneal cavity, which may develop neoplastic mesothelial proliferations similar to, although much less commonly than, pleural or peritoneal surfaces. We herein report our experience with 12 cases of florid paratesticular mesothelial hyperplasia, highlighting the spectrum of morphologic changes seen and the utility of fluorescence in situ hybridization analysis of homozygous deletion of 9p21 as an adjunct diagnostic tool. All cases were referred because of concern regarding the nature of the mesothelial proliferation. The median age of patients at presentation was 44.5 years (range, 16 to 71 y). Ten of 12 patients clinically presented with hydroceles (2 of which were complicated by infection or hemorrhage), 1 with "paraepididymal cyst" and 1 patient with an epididymal cyst. In contrast to the normal tunica consisting of a thin fibrous wall lined by a monolayer of flattened bland mesothelium and no significant inflammation, all of our cases were characterized by background changes of fibroblastic organization and stromal chronic inflammation. In all cases, the mesothelial proliferation within the fibrous and inflamed stroma was sparse and consisted of linear arrays of widely spaced horizontally orientated simple nonbranching elongated tubules and small solid nests and cords that were well spaced apart. There was an abrupt linear demarcation of tubules at the deep aspect of the fibrous tissue, with no evidence of definite invasion into the submesothelial tissue. Fluorescence in situ hybridization for 9p21 was negative in all 5 cases in which tissue was available for analysis. Nine patients with extended follow-up were alive (median 8 y; range, 1 to 13 y). In summary, the proliferative changes seen in reactive mesothelial hyperplasia associated with hydroceles may be florid and mimic malignant mesothelioma. In particular, the entrapment of isolated mesothelial clusters within deep fibrous tissue may be the cause of significant diagnostic difficulty. There are, however, morphologic clues such as linear arraying of widely spaced architecturally simple cell clusters that may aid in the correct identification of the benignity of these proliferations.

Sclerotherapy of hydroceles and spermatoceles with alcohol: results and effects on the semen analysis.

PURPOSE: To evaluate the success rates of sclerotherapy of the tunica vaginalis with alcohol for the treatment of hydroceles and/or spermatoceles, as well as, evaluation of pain, formation of hematomas, infection and its effects in spermatogenesis. MATERIALS AND METHODS: A total of 69 patients, with offsprings and diagnosis of hydrocele and/or spermatocele, were treated during the period from April 2003 to June 2007. Semen analysis was obtained from patients who were able to provide us with samples. The sclerotherapy with alcohol at 99.5% was undertaken as outpatient procedure. RESULTS: The average volume drained pre-sclerotherapy was 279.82 mL (27 to 1145). The median follow-up was 43 months (9 to 80). A total of 114 procedures were performed on 84 units, with an average of 1.35 procedures/unit and an overall success rate of 97.62%. Of the 69 patients, 7 (10.14%) reported minor pain immediately after the procedure, 3 (4.35%) moderate pain and 2 (2.89%) intense pain. Post-Sclerotherapy spermograms revealed reduction of the parameters regarding: concentration, motility and morphology up to 6 months post procedure, with return to normal parameters 12th months after procedure. CONCLUSIONS: Sclerotherapy of hydroceles and spermatoceles with 99.5% alcohol is an efficient procedure that can be performed without difficulties, cost-effectiveness, with few side effects and which may be performed in patients who wish fertility.

Sclerotherapy of hydroceles and spermatoceles with alcohol: results and effects on the semen analysis

PURPOSE: To evaluate the success rates of sclerotherapy of the tunica vaginalis with alcohol for the treatment of hydroceles and/or spermatoceles, as well as, evaluation of pain, formation of hematomas, infection and its effects in spermatogenesis . MATERIALS AND METHODS: A total of 69 patients, with offsprings and diagnosis of hydrocele and/or spermatocele, were treated during the period from April 2003 to June 2007. Semen analysis was obtained from patients who were able to provide us with samples. The sclerotherapy with alcohol at 99.5 percent was undertaken as outpatient procedure. RESULTS: The average volume drained pre-sclerotherapy was 279.82 mL (27 to 1145). The median follow-up was 43 months (9 to 80). A total of 114 procedures were performed on 84 units, with an average of 1.35 procedures / unit and an overall success rate of 97.62 percent. Of the 69 patients, 7 (10.14 percent) reported minor pain immediately after the procedure, 3 (4.35 percent) moderate pain and 2 (2.89 percent) intense pain. Post-Sclerotherapy spermograms revealed reduction of the parameters regarding: concentration, motility and morphology up to 6 months post procedure , with return to normal parameters 12th months after procedure. CONCLUSIONS: Sclerotherapy of hydroceles and spermatoceles with 99.5 percent alcohol is an efficient procedure that can be perormed without difficulties, cost-effectiveness, with few side effects and which may be performed in patients who wish fertility.

Imaging of non-neoplastic intratesticular masses.

The use of high-frequency ultrasound is increasing for the treatment of cystic, vascular, and solid non-neoplastic intratesticular masses. Cystic lesions examined include simple testicular cysts, tunica albuginea cysts, epidermoid cysts, tubular ectasia of rete testis, and intratesticular abscesses. Vascular lesions examined include intratesticular varicocele and intratesticular arteriovenous malformations. Solid lesions examined include fibrous pseudotumor of the testis, focal or segmental testicular infarct, fibrosis of the testis, testicular hematoma, congenital testicular adrenal rests, tuberculoma, and sarcoidosis. Gray-scale and color-flow Doppler sonography facilitate the visualization of the benign characteristics of the lesions. Magnetic resonance imaging can also help as a problem-solving modality in some cases.

Cystic dysplasia of the epididymis: a disorder of mesonephric differentiation associated with renal maldevelopment.

The occurrence of congenital epididymal malformations with a cystic component has not been fully characterized. Most epididymal cysts occur later in life and are likely acquired. In addition, congenital malformations of the male excretory system are extremely uncommon in fetuses and neonates, and epididymal dysplastic changes have not been reported in these cases. In this study, we report 20 cases (including 19 fetal/neonatal autopsies and one surgical specimen from an older child) showing the same spectrum of histological findings in the epididymis, characterized by cystic ductal dilation with dysplastic ducts of variable diameters and irregular shapes, with ill-defined walls. Efferent ductules also showed dysplastic features. In addition, 18 cases had either renal and/or urinary tract anomalies, including renal dysplasia (eight), pelvicaliceal dilation (eight), renal agenesis (four) and hypoplasia (one), ureteral agenesis (two) and hypoplasia (one), urethra and bladder agenesis (two), prostate agenesis (two), and autosomal recessive polycystic renal disease (two). Our observations led to the recognition of a peculiar, not previously described congenital lesion of the epididymis, and we propose the term cystic dysplasia of the epididymis for this anomaly. Similar to what is observed in other male genital system anomalies (including malformations of the rete testis, vas deferens, and seminal vesicles), most lesions occurred in association with renal and/or urinary tract malformations, suggesting a spectrum of congenital malformations. The shared embryological origin of these structures may explain their simultaneous occurrence, possibly related to disrupted mesonephric duct development.

[Epididymal cyst in von Hippel-Lindau syndrome: clinicopathologic analysis of 3 cases].

OBJECTIVE: To investigate the clinicopathologic features of epididymal cyst in von Hippel-Lindau (VHL) syndrome. METHODS: We reviewed the clinical data of 3 epididymal cyst patients treated by surgery, and detected the expressions of HIF-1alpha, VEGF, alpha-SMA and CD34 in the epididymal tissue samples by the immunohistochemistry SP method. RESULTS: All the 3 patients underwent surgical removal of the epididymal cyst. Immunohistochemistry of the epididymal tissues showed HIF-1alpha, VEGF, alpha-SMA and CD34 to be positive. All the 3 cases were confirmed to be VHL syndrome, 1 right after surgery, and the other 2 within 8 years postoperatively. CONCLUSION: Epididymal cyst is a usual benign disease, which may occur independently of or be complicated by VHL syndrome. If immunohistochemistry of epididymal tissues shows HIF-1alpha, VEGF, alpha-SMA and CD34 to be positive, VHL syndrome should be considered, and further clinical examinations and post-operation follow-up are necessitated.

A rare case of large epididymal cyst in androgen insensitivity syndrome removed laparoscopically.

Androgen insensitivity syndrome is a disorder of sexual differentiation with 46XY karyotype. The gonad is at risk (33% by 50 years of age) for development of malignant tumors. Hence, gonadectomy is warranted. We present a case of a 22-year-old woman diagnosed with androgen insensitivity syndrome during investigation of primary amenorrhea. Ultrasonography showed intraabdominally-located gonads, with a large, nontender cyst of 9.2 x 5.6 x 5.4 cm size, with limited mobility, to the right of the midline. There was also a partial septum, with a wall thickness of 1 to 2 mm and containing clear fluid. Because of suspicion of malignancy, complete surgery including laparoscopic peritoneal cytologic study, gonadectomy, lymphadenectomy, and omentectomy were performed. Histopathologic study showed testis with an epididymal cyst. Formation of epididymal cyst is rare in these cases. The patient did well in the postoperative period. She was put on hormone replacement therapy and is doing well.