Campbell-Walsh Urology, 11th Edition

PART VI

Male Genitalia

41

Surgery of the Scrotum and Seminal Vesicles

Frank A. Celigoj; Raymond A. Costabile

Questions

  1. Which of the following vessels has the least direct contribution to the arterial supply of the vas deferens?
  2. Deferential artery
  3. Internal spermatic artery
  4. Superior vesicle artery
  5. Inferior epigastric artery
  6. Inferior epididymal artery
  7. The best reason for using the no-scalpel vasectomy technique is:
  8. it has a higher sterilization rate than standard vasectomy with incision.
  9. patients are rendered sterile in less time.
  10. it is easier to learn than the standard technique.
  11. it results in a lower rate of complications, including hematoma and infection.
  12. it results in a higher rate of reversibility.
  13. The no-scalpel technique for vasectomy reduces the rate of:
  14. hematoma.
  15. vasectomy failures.
  16. recanalization.
  17. injury to testicular artery.
  18. chronic orchialgia.
  19. Vasectomy failure rate when both the abdominal and testicular ends of the divided vas deferens are occluded with hemoclips is:
  20. less than 1%.
  21. 5% to 10%.
  22. 10% to 20%.
  23. 20% to 30%.
  24. 50% to 60%.
  25. The technical aspect shown to decrease vasectomy failure rates the most is:
  26. no-scalpel technique.
  27. conventional technique.
  28. fascial interposition of dartos fascia between the divided ends of the vas deferens.
  29. occluding both ends of the divided vas deferens with hemoclips.
  30. occluding both ends of the divided vas deferens thermally with the use of intraluminal cautery.
  31. The technical aspect when performing vasectomy to make vasectomy reversal easier in the future is:
  32. no-scalpel technique.
  33. not excising a long segment of vas deferens.
  34. dividing the vas deferens as close to the epididymis as possible.
  35. occluding both ends of the divided vas deferens with hemoclips.
  36. occluding both ends of the divided vas deferens thermally with the use of intraluminal cautery.
  37. Vasectomy has been established as associated with:
  38. prostate cancer.
  39. dementia.
  40. cardiovascular disease.
  41. atherosclerosis.
  42. a 10% incidence of chronic scrotal pain.
  43. What is the estimated percentage of men who develop antisperm antibodies after vasectomy?
  44. 0% to 20%
  45. 20% to 40%
  46. 40% to 60%
  47. 60% to 80%
  48. > 80%
  49. Which of the following is an indication for repeat vasectomy?
  50. Painless sperm granuloma
  51. Motile sperm found in semen analysis 3 months after vasectomy
  52. Nonmotile sperm found in semen analysis 3 months after vasectomy
  53. Persistent testicular pain 3 months after vasectomy
  54. All of the above
  55. Pressure-induced injury following vasectomy occurs in:
  56. the testis.
  57. the ejaculatory duct.
  58. the epididymis.
  59. the vas deferens.
  60. the seminal vesicles.
  61. In the management of chronic orchialgia, which of the following statements is TRUE?
  62. Imaging studies are not indicated.
  63. Varicocele is not a significant contributor of chronic scrotal pain.
  64. Orchiectomy usually relieves the pain.
  65. Denervation of the cord may offer relief in selected cases.
  66. Diagnostic epididymal puncture should be performed to rule out chronic bacterial epididymitis.
  67. Which of the following statements is TRUE regarding hydrocelectomy?
  68. Hematoma is the least frequent complication.
  69. The Jaboulay bottleneck operation is associated with a high recurrence rate.
  70. The Lord plication is an ideal operation for long-standing postinfectious hydroceles.
  71. Sclerotherapy is often the treatment of choice for young men of reproductive age.
  72. The Jaboulay bottleneck operation is associated with a low recurrence rate.
  73. A nontransilluminating, nontender mass is noted in the epididymis on physical examination and confirmed to be solid by sonography. What is the most likely diagnosis?
  74. Epididymal cyst
  75. Adenomatoid tumor
  76. Spermatocele
  77. Testicular tumor
  78. Hydrocele
  79. Men who were treated with epididymectomy for chronic epididymitis responded the most favorably if:
  80. there was a palpable epididymal abnormality.
  81. there was no palpable abnormality, but there were sonographic changes of the epididymis.
  82. there were no palpable abnormalities and no sonographic changes of the epididymis.
  83. they had improvement of pain with spermatic cord block.
  84. none of the above applied.
  85. Which of the following statements is TRUE regarding retractile testes in adults?
  86. As in children, surgical repair is never indicated.
  87. A dartos pouch orchidopexy is the treatment of choice.
  88. Simple three-stitch orchiopexy of the tunica albuginea to the dartos, as for torsion prophylaxis, is effective in preventing retraction.
  89. Bilateral orchiopexy is necessary for a unilateral retractile testis.
  90. Coexisting varicocele is common.
  91. The most appropriate approach to a long-standing, thick-walled, loculated hydrocele is:
  92. excision of the hydrocele sac.
  93. the Jaboulay bottleneck technique.
  94. the Lord plication technique.
  95. the inguinal approach.
  96. sclerotherapy.
  97. In men with chronic orchitis without an identifiable bacterial pathogen, antibiotics:
  98. decrease the length of symptoms.
  99. improve the severity of symptoms.
  100. decrease the length of time to full activity.
  101. are steadily being prescribed more frequently empirically.
  102. none of the above apply.
  103. When a clinically palpable varicocele is encountered in a patient with orchialgia, varicocelectomy will resolve the pain:
  104. 10% of the time.
  105. 25% of the time.
  106. 50% of the time.
  107. 75% of the time.
  108. 90% of the time.
  109. What is the embryologic origin of the seminal vesicles?
  110. Müllerian duct
  111. Ectodermal ridge
  112. Distal mesonephric duct
  113. Swelling of the distal paramesonephric duct
  114. Neural crest cells
  115. What percentage of the ejaculate volume is made up of seminal vesicle secretions?
  116. 5% to 10%
  117. 20% to 30%
  118. 60% to 80%
  119. 90%
  120. The seminal vesicle does not contribute to the seminal plasma volume.
  121. What artery is the major blood supply to the seminal vesicle?
  122. Hypogastric
  123. Vesiculodeferential artery
  124. Inferior vesicle
  125. Internal iliac
  126. Deep dorsal penile
  127. Decreased T1 signal intensity on MRI, along with increased T2 intensity of seminal vesicles, is indicative of which process?
  128. Inflammation of the seminal vesicles
  129. Hemorrhage within the seminal vesicles
  130. Seminal vesicle tumors
  131. Seminal vesicle cysts
  132. Normal seminal vesicles
  133. Agenesis of the seminal vesicle is associated with significant ipsilateral renal anomalies. What is the embryologic reason for this?
  134. A genetic defect links seminal vesicle agenesis to renal agenesis.
  135. A mutation occurs in the cystic fibrosis transmembrane regulator gene.
  136. There was an insult to the mesonephric duct at approximately 12 weeks' gestation.
  137. There was an embryologic insult to the mesonephric duct earlier than 7 weeks' gestation.
  138. There is no association between agenesis of the seminal vesicle and ipsilateral renal anomalies.
  139. What disorder is frequently associated with bilateral agenesis of the seminal vesicles?
  140. Cystic fibrosis
  141. Kartagener syndrome
  142. Young syndrome
  143. Kallmann syndrome
  144. Klinefelter syndrome
  145. What causes the majority of seminal vesicle cysts?
  146. Ejaculatory duct stone
  147. Obstruction of the ejaculatory duct
  148. Inflammation
  149. Renal agenesis
  150. Trisomy 21
  151. What is the most common type of malignant neoplasm found in seminal vesicles?
  152. Primary adenocarcinoma
  153. Sarcoma
  154. Cystosarcoma phyllodes
  155. Metastatic tumors
  156. Amyloidosis
  157. What is the best initial test for a suspected seminal vesicle abnormality?
  158. Computed tomography (CT)
  159. Transrectal ultrasonography
  160. Magnetic resonance imaging (MRI)
  161. Fine-needle biopsy
  162. Vasography
  163. What is the best method to differentiate a benign from malignant seminal vesicle mass?
  164. Biopsy of the lesion
  165. Contrast medium-enhanced CT
  166. Gadolinium-enhanced MRI
  167. Transrectal ultrasonography
  168. Rectal examination
  169. What is the best surgical approach to a congenital lesion of the seminal vesicle?
  170. The perineal route because this has the quickest recovery.
  171. The transcoccygeal route because these are usually large lesions.
  172. The laparoscopic route so that the ipsilateral kidney can be dealt with concomitantly and recovery may be shorter.
  173. The paravesical route because this has a lower incidence of postoperative erectile dysfunction.
  174. The transvesical route because rectal injury is much less likely.
  175. What is the best indication for the transcoccygeal approach to the seminal vesicle?
  176. Need for exploration of the ipsilateral kidney
  177. Patient with previous suprapubic and/or perineal surgery
  178. Patient wishing to maintain potency
  179. Patient with bilateral large seminal vesicle lesions
  180. Patient with metastatic tumor to the seminal vesicle
  181. In a patient with a seminal vesicle abscess, the treatment of choice is:
  182. laparoscopic unroofing.
  183. transvesical excision of the seminal vesicle.
  184. aspiration and antibiotic instillation.
  185. endoscopic unroofing by deep transurethral resection.
  186. retropubic approach to unroof the abscess.

Answers

  1. c. Superior vesicle artery.The superior vesicle artery does not supply the vas deferens, whereas all of the other arteries listed may have a branch to the vas deferens.
  2. d. It results in a lower rate of complications, including hematoma and infection.This method eliminates the scalpel incision, results in fewer hematomas and infections, and leaves a much smaller wound than conventional methods of accessing the vas deferens for vasectomy.
  3. a. Hematoma.The no-scalpel technique significantly decreases the rate of hematomas, infections, and pain during the procedure.
  4. a. Less than 1%.Vasectomy failure rate when both the abdominal and testicular ends of the divided vas deferens are occluded with hemoclips is less than 1%.
  5. c. Fascial interposition of dartos fascia between the divided ends of the vas deferens. Interposition of dartos fascia between the divided ends of the vas deferens is a technique for occlusion that has been reported to reduce the recanalization rate to nearly zero.
  6. b. Not excising a long segment of vas deferens.The technical aspects when performing vasectomy to make vasectomy reversal easier in the future include not excising a long segment of vas deferens, dividing the vas deferens approximately 3 cm cephalad to the cauda of the epididymis in the straight portion of the vas deferens, and transecting the vas deferens, followed by low-voltage cautery occlusion and then by fascial interposition.
  7. e. A 10% incidence of chronic scrotal pain. Vasectomy does not have an established association with prostate cancer, dementia, cardiovascular disease, or atherosclerosis, although it has been associated with a 10% incidence of chronic scrotal pain.
  8. d. 60% to 80%. Vasectomy disrupts the blood-testis barrier, resulting in detectable levels of serum antisperm antibodies in 60% to 80% of men.
  9. b. Motile sperm found in semen analysis 3 months after vasectomy.If any motile sperm are found in the ejaculate 3 months after vasectomy, consideration should be given to repeating the procedure.
  10. c. The epididymis.The brunt of pressure-induced damage after vasectomy falls on the epididymis and efferent ductules.
  11. d. Denervation of the cord may offer relief in selected cases.Microsurgical total denervation of the spermatic cord is a procedure used with reported success in several small series.
  12. e. The Jaboulay bottleneck operation is associated with a low recurrence rate. The Jaboulay bottleneck operation, in which the sac edges are sewn together behind the cord, reduces the chance of recurrence caused by reapposition of the edges of the hydrocele sac.
  13. b. Adenomatoid tumor.Most nontransilluminable solid epididymal masses are benign adenomatoid tumors.
  14. a. There was a palpable epididymal abnormality.A retrospective review of men who underwent epididymectomy for chronic epididymitis showed that outcomes were best when the patient had a palpable epididymal abnormality on physical examination. Men in this study without a palpable abnormality, but with sonographic changes, had slightly worse outcomes, and those with neither a palpable abnormality nor a demonstrable ultrasonographic abnormality did not improve with epididymectomy.
  15. b. A dartos pouch orchidopexy is the treatment of choice.Creation of a dartos pouch will keep the testis well down into the scrotum and permanently prevent retraction.
  16. a. Excision of the hydrocele sac.Excising the hydrocele is recommended for long-standing, thick-walled, loculated hydroceles.
  17. d. Are steadily being prescribed more frequently empirically.Despite evidence that up to 75% of patients with epididymitis/orchitis do not have an identifiable bacterial urinary tract infection concomitantly with their clinical epididymitis, antibiotics are routinely given. Empirical antibiotic administration in the absence of positive urine cultures has been steadily increasing, from 75% to 95% between the years of 1965 and 2005 and is not indicated.
  18. c. 50% of the time.When a clinically palpable varicocele is encountered in a patient with orchialgia, varicocelectomy will resolve the pain 50% of the time.
  19. c. Distal mesonephric duct.The seminal vesicle develops as a dorsolateral bulbous swelling of the distal mesonephric duct at approximately 12 fetal weeks.
  20. c. 60% to 80%.The secretions from the seminal vesicle contribute 60% to 80% of the ejaculate volume.
  21. b. Vesiculodeferential artery.The blood supply to the seminal vesicle is from the vesiculodeferential artery, a branch of the superior vesical artery.
  22. a. Inflammation of the seminal vesicles.Seminal vesiculitis shows decreased signal intensity on the T1-weighted image, whereas the T2-weighted image intensity is higher than that of both fat and the normal seminal vesicle.
  23. d. There was an embryologic insult to the mesonephric duct earlier than at 7 weeks' gestation.Unilateral agenesis of the seminal vesicles has an incidence of 0.6% to 1% and may be associated with unilateral absence of the vas deferens, as well as ipsilateral renal anomalies.
  24. a. Cystic fibrosis. Of men with bilateral absence of the vas deferens or seminal vesicles, 70% to 80% carry the genetic mutation associated with cystic fibrosis.Conversely, 80% to 95% of men with cystic fibrosis have bilateral absence of the vas deferens or seminal vesicles.
  25. b. Obstruction of the ejaculatory duct.Cysts of the seminal vesicles may be either congenital or acquired and are thought to be due to obstruction of the ejaculatory duct.
  26. d. Metastatic tumors. Very few primary tumors of the seminal vesicles have been reported. It is more common for carcinoma of the bladder, prostate, or rectum, or lymphoma to secondarily involve the seminal vesicles.
  27. b. Transrectal ultrasonography.Transrectal ultrasonography is the preferred initial test for seminal vesicle abnormality, because of its low invasiveness, ease of performance, and ability to perform concomitant transrectal biopsies.
  28. a. Biopsy of the lesion.Transrectal ultrasonography and biopsy of the seminal vesicle mass is accurate and easily accomplished.
  29. c. The laparoscopic route so that the ipsilateral kidney can be dealt with concomitantly and recovery may be shorter.Although data are limited for laparoscopic excision of benign seminal vesicle disease alone, this approach appears to afford superb visualization with minimal postoperative morbidity and shorter hospitalization, compared with the open surgical alternatives.
  30. b. Patient with previous suprapubic and/or perineal surgery.In individuals for whom the perineal or supine position may be difficult to maintain, or for those who have had multiple suprapubic or perineal surgeries, the transcoccygeal approach may be useful.
  31. d. Endoscopic unroofing by deep transurethral resection.If the abscess is in the portion of the seminal vesicle adjacent to the prostate, a deep transurethral resection into the prostatic substance, just distal to the bladder neck at the 5-o'clock or 7-o'clock position, may be effective in relieving the problem. However, a CT-guided aspiration and drain placement is becoming the preferred least-traumatic option.

Chapter review

  1. Because scrotal cases are considered clean rather than sterile, prophylactic antibiotics are recommended preoperatively. Hair removal should occur immediately before the procedure.
  2. Fournier gangrene is a necrotizing fasciitis that involves the skin and subcutaneous tissue and is confined by the dartos fascia on the penis, Colles fascia in the perineum, and Scarpa fascia in the abdomen. Proper resuscitation requires broad-spectrum antibiotics, including a third-generation cephalosporin, an aminoglycoside, and metronidazole. These patients require fluid resuscitation and, when hemodynamically stable, debridement. Daily debridement in the operating room until all nonviable tissue is removed should be subsequently performed.
  3. Ninety-seven percent of patients undergoing open-ended vasectomy develop sperm granulomas.
  4. Division of the vas deferens during vasectomy should occur at least 3 cm from the epididymitis. There is no vasectomy technique that is 100% effective; more than 80% of the patients achieve azoospermia at 3 months following vasectomy.
  5. When the testis is removed for orchialgia, pain relief is better achieved if the orchiectomy is performed through an inguinal incision rather than a transscrotal incision.
  6. There is no level 1 evidence that orchiectomy is effective for the treatment of chronic orchialgia.
  7. Any surgical manipulation of the epididymis results in azoospermia on that side.
  8. Leaving a scrotal drain after scrotal procedures does not lessen the complication rate or the development of postoperative hematomas.
  9. When repairing large hydroceles, the epididymis and spermatic vessels may be splayed by the hydrocele, and care must be taken to identify them to avoid injury.
  10. Microsurgical denervation of the spermatic cord has been used for the treatment of orchialgia with reported success rates as high as two thirds achieving pain relief. It should only be considered if a cord block is successful.
  11. Seminal vesicle cysts are associated with ipsilateral renal agenesis or dysplasia in two thirds of patients and have been associated with polycystic kidney disease.
  12. Mycobacterium tuberculosisand Schistosoma haematobium may infect the seminal vesicles.
  13. Vasectomy has not been established to be associated with prostate cancer, dementia, cardiovascular disease, or atherosclerosis, although it has been associated with a 10% incidence of chronic scrotal pain.
  14. Vasectomy disrupts the blood-testis barrier, resulting in detectable levels of serum antisperm antibodies in 60% to 80% of men.
  15. The Jaboulay bottleneck operation, in which the sac edges are sewn together behind the cord, reduces the chance of recurrence caused by reapposition of the edges of the hydrocele sac.
  16. Of men with bilateral absence of the vas deferens or seminal vesicles, 70% to 80% are carriers of the genetic mutation associated with cystic fibrosis. Conversely, 80% to 95% of men with cystic fibrosis have bilateral absence of the vas deferens or seminal vesicles.
  17. Very few primary tumors of the seminal vesicles have been reported. It is more common for carcinoma of the bladder, prostate, or rectum or lymphoma to secondarily involve the seminal vesicles.