1 University Departments of Obstetrics and Gynaecology, Jessop Hospital For Women, Leavygreave Road, Sheffield S3 7RE and 2 Department of Molecular Biology and Biotechnology, University of Sheffield, Sheffield S10 2TN, UK
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Abstract |
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Key words: analgesia/azoospermia/gonadal failure/outpatient/testicular biopsy
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Introduction |
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Testicular biopsy for sperm extraction performed without the use of general anaesthesia may reduce the cost of ICSI of the oocytes and may pose fewer risks to patients. We conducted a prospective study to evaluate the safety and cost-effectiveness of an outpatient testicular biopsy programme carried out under i.v. sedation and local anaesthetics for TESE in men with non-obstructive azoospermia.
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Materials and methods |
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Analgesia for testicular biopsy
Patients were premedicated with 10 mg of temazepam orally 1 h before the onset of the operation. General anaesthesia was induced with propofol (12 mg/kg) and fentanyl (12 µg/kg), and intermittent positive ventilation was maintained with a mixture of 60% nitrous oxide and 40% oxygen with 0.11.5% isoflurane through a laryngeal mask airway.
Outpatient analgesia was achieved with lignocaine spray, spermatic cord block and scrotal infiltration with local anaesthetic and i.v. midazolam sedation. Briefly, an i.v. line was inserted using a size 21-gauge butterfly needle. A bolus dose of midazolam (Hypnoval; Roche Products Ltd, Welwyn Garden City, UK; diluted 10 mg in 10 ml of normal saline) was given i.v., depending on body weight and need of the patient (0.01 mg/kg). An initial dose of 2 mg was given, and if necessary additional boluses of 1 mg were injected (i.e. dosing intermittently) with a limit of the total dose set at 5 mg, to achieve level 1 sedation of the modified Ramsay score (Ramsay et al., 1974; O'Sullivan and Park, 1990
). Each dose was given slowly over 6090 s. Except for the first two patients in the outpatient group, 2 mg of midazolam was required to achieve this degree of sedation. Thereafter, each patient received 20 mg of topical lignocaine hydrochloride (two sprays of lignocaine hydrochloride, 10% spray; Astra Ltd, Kings Langley, UK). In total, 10 mg was applied over the skin of the spermatic cord through which bupivacaine would be injected into the spermatic cord, and another 10 mg over the anterior scrotal skin where the incision was to be made. After 2 min, spermatic cord block was accomplished by the assistant holding the spermatic cord gently between the forefinger and thumb, both at the inguinoscrotal junction and just above the scrotum, in order to immobilize the spermatic cord. Plain 0.5% bupivacaine hydrochloride solution (910 ml of 5 mg/ml solution; Astra Ltd) was slowly injected around the spermatic cord using a 21-gauge needle attached to a 10-ml syringe. Before the injection, the plunger of the needle was aspirated to avoid inadvertent intravascular injection of local anaesthetic. The injection was given slowly over 2 min while watching and talking to the patient. To ensure good anaesthesia, three passes were made through the spermatic cord at three different angles, with 3 ml being given each time, without withdrawing the needle completely through the skin.
After 5 min, the skin of the scrotum was kept taut over the anterior surface of the testicle with the non-dominant hand while the skin and subcutaneous tissues at the site of the incision were infiltrated with 1 ml (20 mg) of 2% lignocaine hydrochloride (100 mg/5 ml; Astra Ltd) in 1 in 200 000 adrenaline solution using a 25-gauge needle after a negative aspiration test in order to achieve scrotal anaesthesia. Testicular biopsy proceeded 2 min later.
Resuscitative facilities were always available in the operating room and checked before surgery. The personnel were trained in cardiopulmonary resuscitation. Anaesthetist cover was only used when we started the outpatient analgesia programme, during which the first set of two patients who required >2 mg of midazolam underwent their testicular biopsy. The same gynaecologist administered the analgesia and sedation in all the patients.
Testicular biopsy
The hair in the operating area had been removed by the patient the night before surgery. The operating area was washed with Hibitane solution, and draped with sterile towels that also entirely covered the patient's legs. The scrotum and testes were delivered through a hole in the centre of the drape. With the dominant hand, a 1- to 2-cm transverse incision was made with a size 11 blade on the centre of the anterior portion of the testis, through the point of entry of the needle used for scrotal infiltration with local anaesthetic, and through the skin and dartos muscle to the tunica vaginalis. The tunica vaginalis was lifted with two pairs of artery forceps, with the help of an assistant, and opened with a pair of iris scissors, releasing clear-coloured fluid to visualize the anterior surface of the tunica albuginea and testicle. A stay suture of 4/0 Vicryl Rapide suture (Ethicon Ltd, Edinburgh, UK) was placed in the tunica albuginea, tied loosely, and clipped in order to stabilize the testis within the operating field and to ensure that the tunica albuginea was sharply incised. A transverse incision was made through the tunica albuginea to expose the seminiferous tubules which protruded through the incision. Gentle pressure on the testis extruded more seminiferous tubules. The extruded piece of testicular tissue measuring between 0.5x1.0x0.5 cm and 1.0x1.5x1.5 cm, was excised with a wet, sharp pair of curved iris scissors without touching the specimen, for histopathological analysis. A similar amount of tissue was removed for sperm extraction and genetic studies. The tunica albuginea and tunica vaginalis were closed in layers with interrupted 3/0 Vicryl stitches, avoiding the testicular parenchyma to minimize postoperative discomfort. The skin was closed with a continuous subcuticular 4/0 Vicryl stitch. The same procedure was repeated on the opposite testis. Satisfactory haemostasis was secured before wound closure. The scrotum was cleaned with Hibitane solution and a dry scrotal dressing applied. All biopsies were performed by the same surgeon. The biopsy specimen for histopathological analysis was picked up with a pair of non-toothed artery forceps and placed in a labelled plastic pot containing 25 ml of Bouin's fixative immediately after removal from the testis.
Intraoperative monitoring
Throughout the operation, the patients in the outpatient group were monitored using a non-invasive electronic monitor, Accurator 3 (Datascope Corp. Ltd, Huntingdon, Cambs., UK) at 15-min intervals to check the blood pressure, pulse and respiration rates, and continuously with pulse oximetry (Ohmeda, Biox 3740; Louisville, USA) to check oxygen saturation. The pulse oximeter probe was attached to the index or middle finger. Sedation scores were assessed on a scale of 0 to 3 (0 = awake, 1 = dozing intermittently, 2 = mostly sleeping, 3 = difficult to wake) using the modified Ramsay score (Ramsay et al., 1974). Patients were familiarized with the visual analogue scale (VAS) and categorical verbal score (CVS) scale before surgery. Pain scores were assessed using both a 4-point CVS (0 = no pain, mild pain, moderate pain, severe pain) and VAS (0 mm = no pain, 100 mm = worst pain imaginable) at the time of incision and discharge, at 15-min intervals during the operation, and at any other time that pain was felt. Communication was maintained with the patients throughout the operation and they were questioned or observed for subjective symptoms of local anaesthetic overdose such as tinnitus, light headedness, perioral numbness and seizures or collapse. The patients who received general anaesthesia were monitored with continuous tidal volume, pulse oximetry, electrocardiography, non-invasive arterial pressure and end-tidal carbon dioxide concentration measurements.
Recovery
Assessment of the level of sedation and postoperative pain was made with the CVS scale as described above in both groups of patients. Nausea and vomiting were recorded. Monitoring of heart and respiratory rates, blood pressure and oxygen saturation continued as performed intraoperatively. Postoperative analgesia comprised diclofenac sodium suppository after the operation (50 mg immediately after the operation and another 50 mg at night following discharge from hospital). Subsequently, i.m. morphine tartrate, 1020 mg, 4-hourly up to three doses as required for moderate to severe pain, and two tablets of Co-codamol (one tablet = 500 mg paracetamol and 8 mg codeine phosphate) 8-hourly up to a maximum dose of eight tablets in 24 h for mild and moderate pain. Nausea was treated with i.m. prochlorperazine maleate, 12.5 mg. The recovery time was taken as time between the onset of eye opening after the general anaesthesia (for the general anaesthesia group) or the end of the operation (for outpatient group) to the time when the patients met the discharge criteria.
Discharge
Patients were discharged when they had stable vital signs, could tolerate oral fluids, had minimal nausea, could walk with minimal assistance, and no bleeding was observed from the testicular wound. No antibiotics or pressure scrotal dressing were applied. At the time of discharge, patients were asked to complete later a questionnaire regarding postoperative testicular swelling, infection, pain, use of analgesics, and the time following the operation that they resumed daily activities and coitus.
Follow-up assessment
Patients were contacted by telephone the following day to assess their progress, and seen one week after the procedure to examine the biopsy site, assess their satisfaction and review the postoperative questionnaire. At this time testicular volumes were estimated and the biopsy sites examined.
Satisfaction scores were assessed by first informing each patient about our experience of testicular biopsy under outpatient analgesia or general analgesia before asking them to choose their analgesic option should a repeat testicular biopsy become necessary.
Testicular sperm extraction
A piece of biopsy tissue was minced into fine pieces (<1 mm3) with a pair of sterile glass microscope slides for approximately 25 min and transferred in phosphate-buffered saline to a conical centrifuge tube (Falcon type, 100 mm; Fahrenheight Laboratory Supplies, Rotherham, UK), vortexed for 5 min and centrifuged for 5 min at 500 g. The pellet was resuspended for 5 min in 2 ml of erythrocyte-lysing buffer (155 mM NH4Cl, 10 mM KHCO3, 2 mM EDTA, pH 7.2) and allowed to stand for 5 min. After centrifugation at 500 g for 5 min, the pellet was resuspended in Earle's balanced salt solution (EBSS) (Gibco BRL, Life Technologies, Paisley, UK) and transferred to a Petri dish containing 3 ml of EBSS. The medium was overlayered with 1 ml of paraffin oil. The preparations were examined under an inverted microscope (Olympus UK Ltd, London) equipped with Hoffman modulation contrast photomicroscopy at magnifications of x200 and x400 for the presence of testicular spermatozoa immediately, and then incubated at 37°C in an atmosphere of 5% CO2, 5% O2, 90% N2 for up to 72 h. The testicular cultures were examined subjectively each day for the presence of motile testicular spermatozoa.
Histopathology
Pieces of testicular biopsy were fixed immediately in Bouin's solution. Semi-thin paraffin wax sections (4 µm) were stained with haematoxylin and eosin, and examined by light microscopy at x400 magnification using standard techniques.
Costing
Procedural and staff costs were obtained from the Finance Department of the Royal Hallamshire Hospital, Sheffield, UK. Treatments in the UK are not covered necessarily by insurance. Many patients in the UK are treated under the National Health Service (NHS). There was a difference in purchasing contracts between the units where outpatient analgesia and general anaesthesia were performed. Direct evaluation of the actual costs of the procedures would have been inappropriate as the same materials could have different cost. NHS charges for the procedures were therefore used for cost estimates in order to ensure equitable distribution of costs between the two groups of patients. NHS private fees were used for surgeon, assistant surgeon and anaesthetist fees, as well as for consultation. The overhead costs were taken as 40% of the treatment cost in both groups because of difficulties in obtaining the exact cost. Because the main interest was to highlight the difference in direct cost between the two groups of patients, the late postoperative morbidity, analgesic requirement and time taken to resume normal activity (which were similar in both groups of patients) were therefore not considered in cost estimation. Although each patient had his karyotype performed, at least two semen analyses, and plasma FSH, LH and testosterone concentrations measured, the costs of these investigations were also not considered because they were not related directly to testicular biopsy. The term theatre used below (e.g. Table IV) includes consumables, operating theatre assistant and recovery costs and capital equipment per case.
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Statistics
Values were presented as medians unless otherwise stated. Median values between the groups were compared with MannWhitney U-test and categorical variables with 2 or Fisher's exact test as appropriate. Results for the comparison between groups are presented as two-sided P-values with 95% confidence intervals (CI), and P <0.05 was judged as statistically significant.
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Results |
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None of the patients had a history of allergy to local anaesthetic which would have made them unsuitable for outpatient analgesia. The groups were comparable in age, body mass index, ASA status, duration of surgery, testicular volume and the incision size (Table I). Both groups showed haemodynamic stability throughout both the operating and recovery periods, with little or no alteration of the heart and respiratory rates, blood pressure and oxygen saturation. Much fibrous tissue was found in the tunica vaginalis of patients with testicular atrophy, making surgery more difficult, though elevating the tunica vaginalis with a pair of artery forceps before cutting through it made access to the tunica albuginea easier. Nevertheless, there was no significant correlation between testicular size and the duration of surgery (r = 0.054, F = 0.107; P = 0.75). Bleeding was not a problem and was encountered in the tunica vaginalis. Haemostasis was easily achieved by either tying off the bleeding points with sutures or controlling them with diathermy. Slipping of the incision site on the testis out of the operating field occurred in two patients each of the general anaesthesia and outpatient analgesia groups. This resulted in severe pain (CVS, 4; VAS, 8) and the need to increase the dose of midazolam from 2 to 5 mg in the outpatient group, as well as an increase in operating time to 45 min and the size of the incision from 1 to 2.5 cm in order to identify the incision site on the tunica albuginea in both groups. The problem was remedied by placing a stay suture in the tunica albuginea. Symptoms of local anaesthetic overdose were not observed in any of the patients.
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Nausea and vomiting
None of the patients suffered nausea and vomiting, although two in the general anaesthesia group received i.m. ondansetron (50 mg) prophylactically.
Recovery time
Late recovery criteria (discharge criteria) were fulfilled approximately 2 h earlier in the outpatient group than in those who had testicular biopsy under general anaesthesia; the difference was statistically significant (P <0.0001; Table II).
Postoperative morbidity
Late operative morbidity is shown in Table III. All the patients felt bruised at the site of the biopsy, but this symptom diminished remarkably after three days, and none of the patients required analgesia. None of the patients suffered scrotal wound infection or haematoma. Neither prophylactic antibiotics nor scrotal support was used. A telephone call three days postoperatively revealed no problems. In all cases the wound was well healed by 710 days when they were reviewed. Coitus was resumed within 10 days of the operation in all patients. There was no change in testicular size after the operation, as measured with the orchidometer. The two groups did not differ in their median postoperative pain scores after discharge, testicular swelling, requirement for antibiotics, the need for analgesics, infection, haematoma formation, and onset of resumption of coitus or work.
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Cost of care
The costs of testicular biopsy for TESE are detailed in Table IV. The overall cost for testicular biopsy was £236.12 as an outpatient procedure, compared with £577.23 when performed under general anaesthesia. Thus, there was an approximately 3-fold saving in cost when using the outpatient approach. The factors which accounted for the difference in costs between the two procedures were the cost of haemoglobin estimation, which was performed before general anaesthesia, the professional fees for hiring the anaesthetist and operating theatre assistant, the cost of admission to the ambulatory unit, the higher overhead costs of the operating areas and consumables, and the fact that more nursing and portering staff were required after surgery in the general anaesthetic group.
Patient satisfaction
Among those who had general anaesthesia, 17 (90%) would prefer outpatient testicular biopsy for a repeat testicular biopsy should that become necessary, provided there is minimal or no pain. Their reasons included avoiding the risks of general anaesthesia, no fasting required, no sore throat afterwards, and being aware of what was happening. Two patients in the general anaesthesia group who chose general anaesthesia for their repeat testicular biopsy did so because of fear of pain. Only three patients (14%) who had outpatient testicular biopsy would want general anaesthesia should a repeat biopsy become necessary. Two of these were the first set on whom we operated during our learning curve, when we used 57 ml of bupivacaine solution rather than the 910 ml which later became our routine dose for spermatic cord block on each side. The third patient had severe testicular atrophy from Klinefelter's syndrome, was nervous, and should have received more sedation than the 2 mg midazolam administered. Of the four patients with Klinefelter's syndrome in this programme, two received general analgesia and two outpatient analgesia. Thus, more patients were in favour of outpatient testicular biopsy (Fisher's exact test: 16.69; P <0.0001; Table V).
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Discussion |
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We have modified the technique of outpatient analgesia by using i.v. midazolam to allay anxiety and produce anterograde amnesia for the procedure, and using lignocaine spray before spermatic cord block and scrotal infiltration in order to prevent pain at the site of injection. For the spermatic cord block, we employed a simpler technique of gently holding the spermatic cord just above the scrotum and at the inguinoscrotal region, and injecting the cord in between with local anaesthetic rather than locating the pubic tubercle and making measurements before injecting around the spermatic cord. This block is effective because the autonomic nerve, the superior spermatic nerve (T10), which innervates the testis and tunica albuginea, and the ilioinguinal and genitofemoral nerves which receive sensory input from the tunica vaginalis and anterior scrotal wall, are in close proximity to the cord not only in the region of the pubic tubercle but also throughout its course (Fuchs, 1982; Bannister and Dyson, 1995
; Figure 1
). Local infiltration of the scrotum further blocks the innervation from the ilioinguinal and genitofemoral nerves as well as the genital branches of the pudendal nerve and posterior cutaneous nerve of the thigh which innervate the posterior scrotal wall (Bannister and Dyson, 1995
). There was haemodynamic stability in all the patients and there was satisfactory pain control in almost all cases, making this approach a safe and an effective method for testicular biopsy in azoospermic men with gonadal failure.
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As the cost of health care services comes under closer scrutiny, we compared the cost of outpatient testicular biopsy with that under general anaesthesia. Such an economic evaluation is useful for decision making in resource allocation and patient counselling. The approximately 3-fold decrease in the cost of outpatient testicular biopsy compared with the same procedure under general anaesthesia is a further demonstration of the advantage of outpatient analgesia over general anaesthesia tortesticular biopsy. Much of the difference in direct costs of testicular biopsy derive from the use of a greater number of nursing staff, use of anaesthetic assistant and anaesthetist, as well as higher overhead costs and the cost of consumables in the group who received general anaesthesia.
Three of the patients in the outpatient analgesia group would want general analgesia for a possible repeat testicular biopsy. Two of these were the first patients on whom we operated during our learning curve of outpatient analgesia, and they experienced more pain, received more sedation, and had a larger incision than subsequent patients. The analgesia became very effective as we gained more experience and increased the dose of bupivacaine used for the spermatic cord block. The third patient had severe testicular atrophy which could make testicular biopsy relatively more difficult because of more fibrous tissue and smaller testicular volume. With more experience, however, this difficulty was overcomeas reflected by the lack of correlation between testicular volume and operative time in this study. Nevertheless, the approval rate of 88% for outpatient analgesia with i.v. sedation and local anaesthetics is significantly higher than 13% for general anaesthesia obtained in this study, and compares with the 97% satisfaction rate reported previously following spermatic cord block for intrascrotal surgery (Wakefield and Elewa, 1994). However, comparison was not made with the group who received general anaesthesia in that study.
Although none of our patients had testicular atrophy, it has been speculated that this may follow spermatic cord block (Craft and Tsirigotis, 1995). This followed a report of testicular atrophy in an animal model following blind needle puncture of the testis and epididymis under spermatic cord block (Goldstein et al., 1983
). On the other hand, Schlegel and Su (1997) have demonstrated with ultrasound and Doppler studies of the testis that testicular atrophy following testicular biopsy is due to devascularization of the subtunical end arteries supplying the testicular segments during testicular biopsy. Such injuries can also occur even with a single open or needle testicular biopsy (Harrington et al., 1996
). Studies using testes obtained during autopsy confirmed these findings (Jarow, 1991
). Although the main blood supply to the testis is from the testicular vessels, which arise from the aorta, some contribution comes from the long artery of the vas which is a branch of the internal vesical artery from the internal iliac artery (Trainer, 1992
). It is therefore unlikely that injury to the testicular artery during spermatic cord block will necessarily lead to devascularization of the testis. Given the sample size of our study, the low incidence of testicular atrophy in the reported animal study, and the fact that we did not study vascular flow through the testicular artery with Doppler postoperatively, it is difficult to reach any conclusion regarding the relationship between spermatic cord block and testicular atrophy. Overdose of local anaesthetics, especially bupivacaine, can produce toxic cardiovascular and neurological symptoms, but none of our patients showed any symptoms of local anaesthetic toxicity. This may be because the amounts of lignocaine and bupivacaine administered were far below the toxic dose (Scott, 1989
; Wildsmith, 1990
; Palve et al., 1995
) and because a negative aspiration test was carried out in all cases before injecting the local anaesthetic in order to avoid inadvertent intravascular injection. Vigorous pulling of the cord should be avoided during its mobilization in order to avoid the suprapubic pain which also occurred in our first two patients during the operation and recovery periods. That this pain resolved with an increase in the amount of bupivacaine administered suggests that the suprapubic pain is a referred pain due to pulling or inadequate block of the superior spermatic nerve. The key to the effectiveness of local anaesthetic in controlling the pain appears to be giving an adequate dose of local anaesthetic, waiting for the onset of its action before making the testicular incision, and maintaining communication with the patient. Lignocaine ensures immediate onset of the action necessary to make the skin incision and its action lasts for 4560 min. Bupivacaine provides 34 h of effective analgesia required for surgery and recovery (Cassady, 1987
). The addition of adrenaline solution causing local vasoconstriction ensures a relatively avascular operating field and delays the absorption of lignocaine. The fear that the addition of adrenaline may lead to tissue ischaemia and sloughing, as is the case with local anaesthetic block for penile surgery, or postoperative haematoma as unsecured vessels may bleed as the adrenaline effect wears off (Cassady, 1987
), did not materialize. This may be because the scrotum is highly vascular and because of good haemostasis achieved during surgery. Patients must be monitored through the procedure and during the recovery period because of the potential cardiorespiratory complications of benzodiazepines which can occur with higher doses. In our patients, the addition of midazolam led to no clinically untoward effects on oxygen saturation and vital signs, and therefore was safe. The sedation produced did not delay the patients' discharge from hospital, and this may be a reflection of a small amount of midazolam used. For sedation as preoperative premedication, midazolam 0.070.10 mg/kg is the dosage range recommended (Vinik et al., 1982
). However, most of our patients required only 2 mg of midazolam, irrespective of their body weight. In spite of the absence of complications attributable to midazolam, resuscitative equipment and oxygen must be kept in the operating theatre and staff should be trained in cardiopulmonary resuscitation as the need may occasionally arise to increase the dose of local anaesthetics and i.v. sedation. Although diazepam produces anterograde amnesia, anxiolysis and sedation, it may cause delayed recovery attributable to its long elimination half-life of 2137 h and to pharmacologically active metabolites; it can also cause a high incidence of pain and thrombophlebitis at the site of i.v. injection (Report of the working party on guidelines for sedation by non-anaesthetists, 1993
). In contrast, midazolam has the advantage of a faster onset of action, a shorter elimination half-life of about 90 min, and no active metabolite in addition to being an effective amnesic, sedative and anxiolytic agent (Report of the working party on guidelines for sedation by non-anaesthetists, 1993
). Because of amnesia, patients should not sign documents and should avoid driving or operating machinery within 24 h following surgery. A synthetic absorbable suture which rapidly falls out from the testis in 710 days postoperatively was used so that the removal of testicular sutures was not required, rapid absorption of skin sutures occurred, and the wounds healed with minimal tissue reaction.
Ideally, this should have been a randomized study, but our local circumstances made this impossible. However, the fact that the operation was performed by the same gynaecologist using the same technique and similar operating time, as well as the fact that the patients were selected consecutively and monitored with a similar protocol, minimized bias in this study. The fact that the surgeon may be more competent and experienced by the time of outpatient procedures were performed may be another source of bias. Ideally, actual costs rather than charge estimates of costs should have been used. However, the use of charge estimates of costs in our setting ensures equitable distribution of costs between the groups of patients and reduces the probability of bias in cost estimation.
Although we have used bilateral testicular biopsies, our sperm retrieval rate of 70% compares with that of 62% reported by Schlegel et al. (1997), who almost exclusively used a single testicular incision, and values of 5076% reported from other studies that used up to 20 multiple small incisions (Tournaye et al., 1996, 1997
). This finding suggests that the quantity of tissue used for TESE may be as important as the site of biopsy, and supports the hypothesis that spermatogenesis in these men may be distributed uniformly (Silber et al., 1997
), rather than focally (Tournaye et al., 1996
).
We conclude that the analgesic technique of i.v. midazolam sedation and local anaesthetic with lignocaine spray, spermatic cord block with bupivacaine and scrotal infiltration with lignocaine provide a cost-effective analgesia for TESE in men with non-obstructive azoospermia. This method is also associated with shorter recovery time and better patient satisfaction. However, a need may arise occasionally to increase the dose of local anaesthetics and i.v. sedation such that resuscitative equipment should always be available in the operating room and the personnel involved should be trained in cardiopulmonary resuscitation. The haemodynamic stability and lack of adverse reactions to local anaesthetics or midazolam sedation observed among all patients in this study supports the safety of the technique, but further studies with Doppler and larger numbers of patients will be required to explore any long-term relationship between the spermatic cord block and testicular atrophy.
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Acknowledgments |
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Notes |
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References |
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Submitted on January 2, 1998; accepted on October 20, 1998.