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Showing posts with label Reproductive. Show all posts
Showing posts with label Reproductive. Show all posts

Monday, November 30, 2020

AZOOSPERMIA II: EXCURRENT DUCT OBSTRUCTION

AZOOSPERMIA II: EXCURRENT DUCT OBSTRUCTION

AZOOSPERMIA II: EXCURRENT DUCT OBSTRUCTION

Excurrent ductal obstruction results in azoospermia from blockage of the ductal system after sperm exit the testicle. The posttesticular reproductive tract includes the epididymis, vas deferens, seminal vesicles, and associated ejaculatory apparatus (see Plate 3-3). Ductal obstruction can be due to congenital or acquired causes. In cases of idiopathic obstruction, 65% of blockages will be found in the epididymis, 30% in the vas deferens, and 5% at the level of the ejaculatory duct. Rarely, intratesticular obstruction of testis efferent ductules (see Plate 3-3) may occur.

AZOOSPERMIA I: SPERM PRODUCTION PROBLEMS—GENETICS

AZOOSPERMIA I: SPERM PRODUCTION PROBLEMS—GENETICS

AZOOSPERMIA I: SPERM PRODUCTION PROBLEMS—GENETICS

It is thought that a significant proportion of male infertility is due to underlying genetic causes. Currently, genetic testing for male infertility is based mainly on abnormalities of sperm concentration. However, it is clear that the epididymis plays a large role in the development of sperm motility and that 200 to 300 genes control sperm motility. Thus, as our knowledge of genomics develops, genetic testing for abnormal motility will also become routine in the future.

SEMEN ANALYSIS AND SPERM MORPHOLOGY

SEMEN ANALYSIS AND SPERM MORPHOLOGY

SEMEN ANALYSIS AND SPERM MORPHOLOGY

Although not a true measure of fertility, the semen analysis, if abnormal, suggests that the probability of achieving fertility is lower than normal. For a male infertility evaluation, two semen analyses, performed with 2 to 3 days of sexual abstinence, are sought due to the large biologic variability in semen quality. Lubricants should be avoided and the specimen kept at body temperature during transport.

ANATOMY OF A SPERM

ANATOMY OF A SPERM

ANATOMY OF A SPERM

The mature spermatozoon is an elaborate, specialized cell produced in massive quantity, up to 1200 per second. Spermatogenesis begins when Type B spermatogonia divide mitotically to produce diploid primary spermatocytes (2n), which then duplicate their DNA during interphase. After a meiotic division, each daughter cell contains one partner of the homologous chromosome pair, and they are called secondary spermatocytes (2n). These cells rapidly enter a second meiotic division in which the chromatids then separate at the centromere to yield haploid early-round spermatids (n). Thus, theoretically, each primary spermatocyte yields four spermatids, although fewer actually result, as the complexity of meiosis is associated with germ cell loss.

ANOMALIES OF THE SPERMATIC CORD

ANOMALIES OF THE SPERMATIC CORD

ANOMALIES OF THE SPERMATIC CORD

Tumors of the paratesticular tissues and spermatic cord are rare and can occur in all age groups. More often, paratesticular tissues are involved by extension from primary germ cell testis tumors. Benign tumors are observed in two of three cases and are usually mesodermal in origin and include adenomatoid tumors, lipomas, fibromas, occasionally myomas from the cremasteric muscle, hemangiomas, neurofibromas, and lymphangiomas. Adenomatoid tumors are the most common benign tumors, accounting for 30% of all paratesticular tumors. They present as solid, asymptomatic masses found on routine examination and are located in the epididymis, testis tunic, or, rarely, the spermatic cord. On sectioning, they appear uniformly white, yellow, or tan and exhibit a fibrous consistency. Histologically, epithelial cells with vacuoles and uniformly sized, round nuclei are observed. Occasionally, adenomatoid tumors are misclassified as mesotheliomas. Dermoid cysts, the term given to cysts lined by squamous epithelium, are also rare causes of scrotal masses. Mesotheliomas of the testis adnexa usually present as firm, painless scrotal masses in association with an enlarging hydrocele (see Plate 3-9) in older individuals. Grossly, they are poorly demarcated lesions with firm, shaggy, and friable areas throughout. Microscopic examination reveals complex papillary structures and dense fibroconnective tissue containing scattered calcifications.

SEMINAL VESICLE SURGICAL APPROACHES

SEMINAL VESICLE SURGICAL APPROACHES

SEMINAL VESICLE SURGICAL APPROACHES

The seminal vesicle is a uniquely male organ, derived from the mesonephric duct (see Plate 1-2) beginning at 13 fetal weeks. The normal adult seminal vesicle is 5 to 8 cm in length and 1.5 cm in width and has a volume of 10 mL. The blood supply is derived from the deferential artery or, occasionally, from branches of the inferior vesical artery. The seminal vesicles receive innervation from adrenergic fibers via the hypogastric nerve.

BREAST IMAGING

BREAST IMAGING

BREAST IMAGING

In current medical practice, breast imaging is dominated by two modalities, mammography and ultrasonography, for screening and evaluation of suspicious breast lesions. Magnetic resonance imaging (MRI) has demonstrated promise as an adjunct to traditional imaging for selected situations. Other modalities such as thermal imaging (thermography), molecular breast imaging (scintimammography), three-dimensional mammography (tomosynthesis), electrical impedance imaging (T-scan), and transillumination are either experimental or have not proven to be effective.

MONDOR DISEASE

MONDOR DISEASE

MONDOR DISEASE

Mondor disease, or superficial angiitis, is a superficial thrombophlebitis of the breast, named after Henri Mondor (1885-1962), a French surgeon who first described the disease in 1939. This is a very uncommon clinical entity that may occur during the late reproductive or early menopausal years. The predominant age for patients with Mondor disease is between 30 and 60 years. This should not be confused with Paget-Schroetter disease, which refers to deep vein thrombosis of an upper extremity vein, including the axillary or subclavian vein often following vigorous activity (though it can also occur spontaneously).

GALACTORRHEA

GALACTORRHEA

GALACTORRHEA

Galactorrhea is the spontaneous bilateral discharge of milky fluid from the nipples. (Many women, especially those who have given birth, can express small amounts of milky fluid from one or both nipples, and this is not considered abnormal.) Galactorrhea is uncommon but reports vary from 1% to 30%, depending on the population studied. Although not inherently dangerous, galactorrhea can be the harbinger of significant underlying physiologic disruptions and, as such, deserves careful evaluation.

PAINFUL ENGORGEMENT, PUERPERAL MASTITIS

PAINFUL ENGORGEMENT, PUERPERAL MASTITIS

PAINFUL ENGORGEMENT, PUERPERAL MASTITIS

Painful engorgement of the breast is caused by vascular and lymphatic stasis. It usually occurs on the third or fourth day postpartum, before the onset of lactation. It also occurs when lactation, once established, is interrupted. The breasts are heavy, painful, warm, firm and tender to palpation, with prominent axillary prolongations (axillary tail of Spence, part of the mammary gland that extends along the inferolateral edge of the pectoralis major toward the axilla). Fever rarely exceeds 1 or 2 degrees (°F) over normal. The overlying skin may be edematous and the nipple may be so flattened that the baby cannot grasp it. Pumping or manually expressing some breast milk can help reduce engorgement, allowing the baby to properly latch and nurse. The degree of engorgement usually lessens with each child; first-time mothers often have more engorgement than women who are nursing their second or subsequent children. In cases where lactation is being discontinued, the breasts should be firmly bound and ice packs and analgesics used as needed for pain relief.

GYNECOMASTIA

GYNECOMASTIA

GYNECOMASTIA

Some degree of mammary hypertrophy is normally found in the male breast during adolescence. In two-thirds of all boys between the ages of 14 and 17 years, a button-shaped plaque of mammary tissue is palpated beneath the nipple. This is known as the puberty node. Although gynecomastia is usually bilateral, it can be unilateral. Normally, this involutes before the age of 21. Rarely, this adolescent growth of tissue may be two or three times its normal size and may be persistent. Sometimes it has been found so discrete and firm that the observers classified the enlargement as a benign fibroadenoma. Fat deposition without glandular proliferation is termed pseudogynecomastia.

POLYTHELIA, POLYMASTIA, HYPERTROPHY

POLYTHELIA, POLYMASTIA, HYPERTROPHY

POLYTHELIA, POLYMASTIA, HYPERTROPHY

Congenital anomalies of the breast, such as agenesis or amastia, aplasia, or the absence of nipple and/or areola, are extremely rare. (Athelia or amastia is sometimes associated with Poland syndrome, consisting of absent chest wall muscles, absence of ribs 2 to 5, and deformi- ties of hands or vertebrae.) An increase in the number of mammae or of nipples only is encountered somewhat more frequently. Both these conditions find ready explanation in the embryologic development of the breast. During the 6th to the 12th week of fetal life, the mammary glands first develop as solid down growths of the epidermis that extend into the mesenchyme from the axilla to the inguinal regions the milk lines. Later, these ridges disappear, except in the pectoral area where the normal breast develops.

Sunday, November 1, 2020

THE BREAST: FUNCTIONAL CHANGES AND LACTATION

THE BREAST: FUNCTIONAL CHANGES AND LACTATION

THE BREAST: FUNCTIONAL CHANGES AND LACTATION

The maturational changes in hormones from the anterior pituitary gland and ovary are major factors in the development and functioning of the mammary gland. Follicle-stimulating and luteinizing hormones are indispensable for the production of ovarian estrogen and progesterone, which, in turn, control mammary gland development. These are necessary but not sufficient to prepare the breast for lactation.

THE BREAST: POSITION AND STRUCTURE

THE BREAST: POSITION AND STRUCTURE

THE BREAST: POSITION AND STRUCTURE

The breast is shown in its partially dissected state in the upper part of the plate and below in sagittal section. The size of the breast is variable, but in most instances it extends from the second through the sixth rib, and from the sternum to the anterior axillary line, with an axillary tail in the outer and upper portions, which can be palpated along the outer border of the pectoralis major muscle. The mammary tissue lies directly over the pectoralis major muscle and is separated from the outer fascia of this muscle by a layer of adipose tissue, which is continuous with the fatty stroma of the gland itself.

THE BREAST: DEVELOPMENTAL STAGES

THE BREAST: DEVELOPMENTAL STAGES

THE BREAST: DEVELOPMENTAL STAGES

In a human new born at birth, in the female as well as in the male, the mammary glands have developed sufficiently so that they appear as distinct hemispheroidal elevations, palpable as movable soft masses. This is especially prominent in postterm infants. Histologically, a number of branching channels with layers of lining cells and plugs of basal cells at their ends, the future milk ducts and glandular lobules, respectively, can easily be recognized. In a great number of infants an everted nipple is observed, and in about 10% a greatly enlarged gland can be palpated, a condition that received the unfortunate name of mastitis neonatorum, though no signs of inflammation exist. These early glandular structures may produce a milk like secretion, the “witch’s milk,” starting 2 or 3 days after birth. All these neonatal phenomena in the breast are the result of the very intensive, maternal estrogen driven developmental processes in the last stages of intrauterine life. The changes subside within the first 2 to 3 weeks of life. It is during this period that the breast undergoes marked involutional changes leading to the quiescent stage, which is characteristic of infancy and childhood. During these periods, the male and the female glands consist of a few branching rudimentary ducts lined by flattened epithelium, surrounded by collagenous connective tissue.

THE BREAST: LYMPHATIC DRAINAGE

THE BREAST: LYMPHATIC DRAINAGE

THE BREAST: LYMPHATIC DRAINAGE

The lymphatic distribution of the breast is complex. The mammary gland has a very rich network of lymph vessels, which is separated into two planes, the superficial or subareolar plexus of lymphatics and the deep or fascial plexus. Both originate in the interlobular spaces and in the walls of the lactiferous ducts. The lymph nodes that drain the breast are not linked in a straight line; instead, they are staggered, variable, and fixed within fat pads. This arrangement complicates lymph node removal during breast cancer surgery.

THE BREAST: BLOOD SUPPLY

THE BREAST: BLOOD SUPPLY

THE BREAST: BLOOD SUPPLY

The sources of the abundant vascular supply of the mammary gland are the descending thoracic aorta, from which the posterior intercostal arteries branch off; the subclavian artery, from which the internal mammary artery arises; and the axillary artery, serving the mammary gland through the lateral thoracic and sometimes through another branch, the external mammary artery. Additional blood may be supplied by branches from the thoracodorsal artery and the thoracoacromial artery, which is a short trunk that arises from the forepart of the axillary artery, its origin being generally overlapped by the upper edge of the pectoralis minor. The intercostal branches of the internal mammary artery, the thoracic portion of which lies behind the cartilage of the six upper ribs just outside the parietal layer of the pleura, supply the medial aspect of the gland. The lateral cutaneous branches of the third, fourth, and fifth aortic intercostal arteries enter the gland laterally. The lateral cutaneous branches of the intercostal arteries penetrate the muscles of the side of the chest and then divide into anterior and posterior rami, of which only the anterior rami reach the mammary gland. The branches from the lateral thoracic artery, which descends along the lower border of the minor pectoral muscle, approach the gland from behind in the region of the upper outer quadrant. One of these branches (in women more developed than the other branches) is the external mammary artery, which turns around the edge of the pectoralis major muscle, where it could be seen in the picture if the breast were lifted up. An extensive network of anastomoses exists between the lateral thoracic artery and those vessels deriving from the internal mammary artery; the latter also anastomoses with the intercostal arteries, so that two or even three of the main sources supply many parts of the gland. The ramifications of all three main arteries form a circular plexus around the areola, which ensures the blood supply of the nipple and areola. The breast skin depends on the subdermal plexus for its blood supply. This plexus is in communication with underlying deeper vessels supplying the breast parenchyma, where a second plexus from the same main vessels is formed in the deeper regions of the gland.

BENIGN PROSTATE SURGERY IV TRANSURETHRAL

BENIGN PROSTATE SURGERY IV TRANSURETHRAL

BENIGN PROSTATE SURGERY IV TRANSURETHRAL

Transurethral resection of the prostate (TURP) is currently the most popular approach for the surgical treatment of benign prostatic hyperplasia (BPH). It has the advantage of being an endoscopic procedure that avoids an abdominal or perineal incision and is associated with earlier ambulation and faster convalescence than the “open” approaches. It is appropriate for the treatment of small to moderate size (75 g) prostatic enlargement and is technically more sophisticated than the open surgical procedures. With benign prostatic enlargement, the objective is complete removal of the adenomatous tissue to the surgical (false) capsule, but in cases of urethral obstruction due to advanced prostatic cancer, a “channel” TURP is performed to reestablish urethral patency.

BENIGN PROSTATE SURGERY III PERINEAL

BENIGN PROSTATE SURGERY III PERINEAL

BENIGN PROSTATE SURGERY III PERINEAL

The perineal prostatectomy is an uncommon approach for the surgical treatment of benign prostatic hyperplasia (BPH) but has several advantages over other “open” approaches. The operation is excellent for the removal of very large glands and permits complete removal of all adenomatous tissue. Anatomically, the perineal region varies less dramatically with body habitus than does the lower abdominal region, reducing operative times. Patients with prior renal transplantation or mesh inguinal hernia repairs in which the retropubic space may be scarred or obliterated are particularly well suited for this approach. Drainage of fluid after the procedure is “dependent” in that infected urine or exudate drains away from the operative area and is not retained within a cavity. Also, bleeding can be controlled under direct vision. Finally, morbidity and convalescence are low and minimal, respectively, with the perineal approach.

MALIGNANT PROSTATE SURGERY I LAPAROSCOPIC AND ROBOTIC

MALIGNANT PROSTATE SURGERY I LAPAROSCOPIC AND ROBOTIC

MALIGNANT PROSTATE SURGERY I LAPAROSCOPIC AND ROBOTIC

In an effort to decrease the morbidity associated with radical prostatectomy surgery, minimally invasive, laparoscopic approaches to prostate removal have become popular over the last 10 to 15 years. This is possible because of advances in task-specific surgical instruments, digital video equipment, and computers and robotic technology. Robotic laparoscopic prostatectomy, introduced in 2002, incorporates “wristed technology” in robotic arms that enable movement with the facility of a human wrist. This advance promises to reduce the longer operative times and learning curve associated with laparoscopic prostatectomy. Long-term cure rates with laparoscopic procedures are now being reported and appear similar to those of retropubic and perineal approaches.

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