Chapter 12. Male Reproductive System-2

8/14/2019 Chapter 12. Male Reproductive System-2

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Surgery of the MaleSurgery of the Male

Reproductive SystemReproductive System

December, 2007December, 2007


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ContentsContents

1.1. AnatomyAnatomy

2.2. Congenital disordersCongenital disorders

3.3. Acquired conditionsAcquired conditions

4.4. Orchiectomy (castration)Orchiectomy (castration)


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1. Anatomy1. Anatomy

Tests, scrotumTests, scrotum

Epididymis, ductus deferensEpididymis, ductus deferens

Spermatic cordSpermatic cord Prostate glandProstate gland

PenisPenis Root, body, glansRoot, body, glans


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2.Congenital disorders2.Congenital disorders

A. CryptochidismA. Cryptochidism

B. Persistent frenulum


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A. CryptorchidismA. Cryptorchidism

PathophysiologyPathophysiology A hereditary conditionA hereditary conditionThe affected testicle may be found nearThe affected testicle may be found near

the scrotum, within the inguinal canal,the scrotum, within the inguinal canal,or within the abdomenor within the abdomen

The higher temperature of atypicalThe higher temperature of atypicalenvironment results inenvironment results in Degeneration of the germinal epitheliumDegeneration of the germinal epithelium

and loss of spermatogenesisand loss of spermatogenesis Endocrine function is minimally affectedEndocrine function is minimally affected


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DiagnosisDiagnosis PalpationPalpation

A definitive diagnosis cannot be madeA definitive diagnosis cannot be madebefore 6 months of agebefore 6 months of age

TreatmentTreatment

Surgical replacementSurgical replacement An increased risk of spermatic cord torsionAn increased risk of spermatic cord torsionand testicular neoplasiaand testicular neoplasia

Surgical removalSurgical removal

Extra-abdominal testesExtra-abdominal testes Abdominal testesAbdominal testes Ventral median incisionVentral median incision Parapreputial abdominal incisionParapreputial abdominal incision


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Nodular, neoplastic cryptorchid testiclewith testichular torsion


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A persistent frenulum isdeviating the glans penisventrally

B. Persistent frenulum


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3. Acquired conditions3. Acquired conditions

A. Prostatic diseaseA. Prostatic disease

B. Testicular tumorsB. Testicular tumors

C. Penile injuryC. Penile injury


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A. Prostatic diseaseA. Prostatic disease

It isIt is most common in older intactmost common in older intact

male dogsmale dogs, but is rare in cats., but is rare in cats.

PathophysiologyPathophysiology

1.1. Benign prostatic hyperplasiaBenign prostatic hyperplasia

2.2. Suppurative prostatitisSuppurative prostatitis

3.3. Prostates cystsProstates cysts

4.4. Prostatic neoplasiaProstatic neoplasia


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PathophysiologyPathophysiology

1.1. Benign prostatic hyperplasiaBenign prostatic hyperplasia1.1. It is a change due toIt is a change due to agingaging that is seen in male dogsthat is seen in male dogs

under the influence of either testosterone orunder the influence of either testosterone or

estrogen.estrogen.

2.2. Prolonged exposure toProlonged exposure to testosteronetestosterone causescauses glandularglandular

hyperplasiahyperplasia

3.3. Exposure toExposure to estrogenestrogen causescauses squamous metaplasiasquamous metaplasia

2.2. Suppurative prostatitisSuppurative prostatitis

1.1. It occurs when bacteria colonize the prostate gland,It occurs when bacteria colonize the prostate gland,

usually via an ascending urinary tract infectionusually via an ascending urinary tract infection..2.2. If left untreated, microabscesses develop andIf left untreated, microabscesses develop and

coalesce, resulting in prostatic abscess.coalesce, resulting in prostatic abscess.


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3.3.

Prostates cystsProstates cysts

1.1. They result from either ductal occlusionThey result from either ductal occlusionsecondary to squamous metaplasia, or fromsecondary to squamous metaplasia, or fromincreased secretion by glandular tissue.increased secretion by glandular tissue.

2.2. Paraprostatic cysts arise from the uterusParaprostatic cysts arise from the uterus

masculinus, a remnant of the mullerian ductmasculinus, a remnant of the mullerian ductadjacent to the prostate gland.adjacent to the prostate gland.

4.4. Prostatic neoplasiaProstatic neoplasia1.1. It may be primary or secondary to urinaryIt may be primary or secondary to urinary

bladder or urethral cancer.bladder or urethral cancer.2.2. Transitional cell carcinoma andTransitional cell carcinoma and

adenocarcinoma are most common.adenocarcinoma are most common.


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Clinical presentationClinical presentationThey are usuallyThey are usually the result of pressurethe result of pressureon adjacent structures and may includeon adjacent structures and may include Problems with defectionProblems with defection

Constipation, tenesmus, dyscheziaConstipation, tenesmus, dyschezia Urinary tract signsUrinary tract signs

Hematuria, bleeding between urination, urineHematuria, bleeding between urination, urineretention, urinary incontinenceretention, urinary incontinence

Locomotion problemsLocomotion problems Rear limb stiffness, lameness, or weaknessRear limb stiffness, lameness, or weakness

Systemic signs of illness, especially if theSystemic signs of illness, especially if theunderlying cause is infectious or neoplasiaunderlying cause is infectious or neoplasia Depression, weight loss, anorexia, feverDepression, weight loss, anorexia, fever


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DiagnosisDiagnosis Physical examinationPhysical examination

Imaging studiesImaging studies

Laboratory studiesLaboratory studies


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DiagnosisDiagnosis

1.1. Physical examinationPhysical examination

1.1. Digital rectal examDigital rectal exam provides information on prostateprovides information on prostatesize, symmetry, texture, and mobilitysize, symmetry, texture, and mobility

2.2. Symmetric prostatomegalySymmetric prostatomegaly is associated withis associated with

benign hyperplasia and prostatitisbenign hyperplasia and prostatitis

3.3. Asymmetric enlargementAsymmetric enlargement is more often found withis more often found with

cysts, abscesses, and neoplasiacysts, abscesses, and neoplasia

2.2. Imaging studiesImaging studies

1.1. Abdominal radiographs and ultrasoundAbdominal radiographs and ultrasound may revealmay reveal

cystic areas within the gland as well as lumbarcystic areas within the gland as well as lumbar

lymphadenopathylymphadenopathy2.2. If neoplasia is suspected, pelvic and thoracicIf neoplasia is suspected, pelvic and thoracic

radiographs are recommended to screen forradiographs are recommended to screen for bone orbone or

pulmonary metastasespulmonary metastases


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3.3. Laboratory studiesLaboratory studies

1.1. Cytologic diagnosisCytologic diagnosis

1.1. It may be obtained from urine sediment,It may be obtained from urine sediment,

ejaculation and prostatic fluid analysis, prostaticejaculation and prostatic fluid analysis, prostatic

wash, or prostatic needle aspirate.wash, or prostatic needle aspirate.

2.2. Caution should be used with cysts or abscessesCaution should be used with cysts or abscessesto avoid laceration of the gland andto avoid laceration of the gland and

contamination of the abdominal cavity.contamination of the abdominal cavity.

2.2. Histologic diagnosisHistologic diagnosis

1.1. It may be obtained either by ultrasound-guidedIt may be obtained either by ultrasound-guided

percutaneous biopsy or at the time of surgerypercutaneous biopsy or at the time of surgery


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Treatment optionsTreatment options1.1. AntibioticsAntibiotics

1.1. They are used to treatThey are used to treat bacterial prostatitisbacterial prostatitis

2.2. The drug selected must be able toThe drug selected must be able to reachreach therapeutictherapeuticconcentrations within the prostateconcentrations within the prostate

2.2. CastrationCastration1.1. It is recommended for hyperplasia and suppurativeIt is recommended for hyperplasia and suppurative

prostatitis toprostatitis to shrink the gland and decreaseshrink the gland and decrease

glandular secretionglandular secretion2.2. Estrogen therapyEstrogen therapy has a similar effect, but carriershas a similar effect, but carriersthe risk of bone marrow suppression and squamousthe risk of bone marrow suppression and squamousmetaplasia of the prostatemetaplasia of the prostate

3.3. Marsupialization of the prostate glandMarsupialization of the prostate gland1.1. A fistula is created between the fluid sac and theA fistula is created between the fluid sac and the

abdominal wall for drainageabdominal wall for drainage2.2. The stoma heals by granulation over several weeksThe stoma heals by granulation over several weeks

3.3. The primary complication is premature healing,The primary complication is premature healing,which causes recurrence of the cyst or abscesswhich causes recurrence of the cyst or abscess

4.4. Concurrent castration is recommendedConcurrent castration is recommended


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4.4. Subtotal (intracapsular) prostatectomySubtotal (intracapsular) prostatectomy

1.1. It is indicated for multiple cysts and microabscessesIt is indicated for multiple cysts and microabscesses

2.2. It is also a palliative therapy for prostatic neoplasiaIt is also a palliative therapy for prostatic neoplasia

3.3. It spares the essential nerves and blood supply toIt spares the essential nerves and blood supply to

the urinary bladder and urethral sphincter, locatedthe urinary bladder and urethral sphincter, located

along the dorsal surface of the bladder neck andalong the dorsal surface of the bladder neck and

prostateprostate

4.4. Complete prostatectomyComplete prostatectomy1.1. It usually results inIt usually results in urinary incontinenceurinary incontinence..

2.2. Urine leakage and urethral stenosisUrine leakage and urethral stenosis are alsoare also

common complications.common complications.

3.3. These problems, coupled with theThese problems, coupled with the poor long-termpoor long-term

prognosis for prostatic neoplasiaprognosis for prostatic neoplasia, limit the, limit theusefulness of this procedureusefulness of this procedure


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Omentalization of a prostatic abscess


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Prostatic abscesses and cysts may betreated using multiple Penrose drains


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Intraoperative appearance of a large

prostatic cyst with squamousmetaplasia

Nodular cryptorchidtesticle, Sertoli cell

tumor


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The cyst within the left lobe of the prostatedue to benign hypertrophy

: the urethra in the center


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This large periprostatic cyst originated fromthe dorsolateral aspect of the prostate glandand caused urethral obstruction and ruptureof the urinary bladder


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Omentalization of a periprostatic cyst


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To marsupialize a prostatic cyst or abscess


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Total prostatectomy


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Subtotal prostatectomy


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Subtotal (intracapsular)Subtotal (intracapsular)

prostatectomyprostatectomy Approximately 80% of the diseasedApproximately 80% of the diseased

parenchyma is removed with electrocautery,parenchyma is removed with electrocautery,

leaving a dorsal strip of urethra as a bridge forleaving a dorsal strip of urethra as a bridge for

epithelial regeneration. The prostatic capsule,epithelial regeneration. The prostatic capsule,

with a thin rim of the parenchyma, is thenwith a thin rim of the parenchyma, is then

sutured to prevent urine leakage.sutured to prevent urine leakage.

Postoperatively, a urinary catheter isPostoperatively, a urinary catheter is

maintained for 5 days to maintain bladdermaintained for 5 days to maintain bladder

decompression and minimize stress on thedecompression and minimize stress on the

suture line.suture line.


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B. Testicular tumorsB. Testicular tumors

They areThey are common in older dogscommon in older dogs butbut

rare in catsrare in cats

Multiple occurrence is commonMultiple occurrence is common, with, with

50% of affected dogs having50% of affected dogs having bilateralbilateral

involvement.involvement.


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ClassificationClassification SeminomaSeminoma

It is the most common neoplasia cause ofIt is the most common neoplasia cause ofscrotal enlargementscrotal enlargement

Sertoli cell tumorsSertoli cell tumorsThey are the most common tumor in retainedThey are the most common tumor in retained

(cryptorchid) testicles.(cryptorchid) testicles.They have the potential to metastasize and toThey have the potential to metastasize and to

produceproduce estrogenestrogen, causing feminization and, causing feminization and

bone marrow toxicitybone marrow toxicity

Interstitial cell tumorsInterstitial cell tumorsThey are usually small and asymptomatic,They are usually small and asymptomatic,

causing neither scrotal enlargement norcausing neither scrotal enlargement nor

feminizationfeminization


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Clinical presentationClinical presentation Scrotal swelling or asymmetry is detected byScrotal swelling or asymmetry is detected by

palpation of the testiclespalpation of the testicles Signs of feminization, seen with Sertoli cellSigns of feminization, seen with Sertoli cell

tumors, include alopecia, hyperpigmentation,tumors, include alopecia, hyperpigmentation,

pendulous prepuce, penile atrophy, andpendulous prepuce, penile atrophy, and

gynecomastiagynecomastia

DiagnosisDiagnosis Hematologic work-up may reveal signs ofHematologic work-up may reveal signs of

estrogen toxicity (thrombocytopenia,estrogen toxicity (thrombocytopenia,

granulocytopenia, anemia)granulocytopenia, anemia) Metastastic disease may occur in up to 15% ofMetastastic disease may occur in up to 15% of

dogs with Sertoli cell tumors, primarily bydogs with Sertoli cell tumors, primarily by

lymphatic spreadlymphatic spread


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TreatmentTreatment Castration with removal of the adjacentCastration with removal of the adjacent

spermatic cord is the treatment ofspermatic cord is the treatment of

choicechoice Prophylactic antibiotics, platelet richProphylactic antibiotics, platelet rich

plasma, and anabolic steroids may beplasma, and anabolic steroids may be

needed in cases of bone marrowneeded in cases of bone marrow

suppressionsuppression


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C. Penile injuryC. Penile injury

Because of its exposed location, theBecause of its exposed location, the

penis is vulnerable to injury from bitepenis is vulnerable to injury from bite

wounds, strangulation, blunt andwounds, strangulation, blunt and

penetrating trauma, and breedingpenetrating trauma, and breedinginjury.injury.


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Clinical presentationClinical presentation

HemorrhageHemorrhage

is the most common clinical sign andis the most common clinical sign and

may be intermittent or profuse.may be intermittent or profuse.

Dysuria and hematuriaDysuria and hematuria may be seen with rupture ofmay be seen with rupture of

the penile urethra or fracture of the os penis.the penile urethra or fracture of the os penis.

Hair or foreign material wrapped around the base ofHair or foreign material wrapped around the base of

the penis will result in athe penis will result in a strangulated appearance,strangulated appearance,with tissue edema and pain and necrosiswith tissue edema and pain and necrosis..

DiagnosisDiagnosis It is based primarily onIt is based primarily on clinical examinationclinical examination..

Survey and contrast radiography help define theSurvey and contrast radiography help define theextent of any urethral damage.extent of any urethral damage.


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Penile trauma, inflammation, and edema secondary to paraphimosis


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TreatmentTreatment Mild lacerations and bite woundsMild lacerations and bite wounds

They are allowed to heal by granulation.They are allowed to heal by granulation. Deep wounds with persistent hemorrhage require sutureDeep wounds with persistent hemorrhage require suture

repair of the tunica albuginea and penile mucosa.repair of the tunica albuginea and penile mucosa. Fractures of the os penisFractures of the os penis

They are treated conservatively with urinaryThey are treated conservatively with urinarycatheterization and rest.catheterization and rest.

Rarely, open reduction and fixation is required forRarely, open reduction and fixation is required forunstable fractures.unstable fractures.

Incomplete urethral disruptionIncomplete urethral disruption It responds well to urinary catheteriazation and rest.It responds well to urinary catheteriazation and rest. Complete urethral transection requires anastomosis andComplete urethral transection requires anastomosis and

postoperative catheterization for 2-3 weeks.postoperative catheterization for 2-3 weeks.

Severe traumaSevere trauma Extensive infection or necrosis may require partial penileExtensive infection or necrosis may require partial penile

amputation or amputation with scrotal or perinealamputation or amputation with scrotal or perinealurethrostomyurethrostomy


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Penile neoplasia, trauma, or congenital anomaliesmay be treatedby subtotal penile amputation andscrotal urethrostomy


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Differential diagnosesDifferential diagnoses PhimosisPhimosis

Inability of the penis to protrude from theInability of the penis to protrude from the

prepuce or sheathprepuce or sheath

ParaphimosisParaphimosis Inability to retract the penis into the prepuceInability to retract the penis into the prepuce PriapismPriapism

Persistent erectionPersistent erection Penile tumorsPenile tumors

Transmissible venereal tumorTransmissible venereal tumor


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Mild paraphimosis


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Lengthen the prepuce


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Phallopexy


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Preputial reconstruction to narrow the orifice


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To enlarge the preputial orifice


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S i l i i lS i l i i l


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B.B. Surgical principlesSurgical principles

A.A. DogsDogs

a)a) Single prescrotal incisionSingle prescrotal incision

b)b) The ligation technique depends onThe ligation technique depends on

a)a) the surgeons preferencethe surgeons preference

b)b) the size of the patientthe size of the patient

c)c) Closed castration (BW


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Open canine castration

S i l i i lS i l i i l


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B.B. Surgical principlesSurgical principles

A.A. CatsCats

A.A. Bilateral scrotal incisionBilateral scrotal incisionB.B. Spermatic cords areSpermatic cords are

A.A. ligated with absorbable suturesligated with absorbable sutures

B.B. tied in a figure-eight knottied in a figure-eight knot


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Feline castration


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An overhand technique for feline castration


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Vasectomy


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Nodular, neoplastic cryptorchid testicle

with testichular torsion


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Partial penile amputation

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Chapter 12. Male Reproductive System-2

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