Lanjutan resume lecture male genital disorder (slide 23-46)

Varicocele &ART

Varicocele dengan alat reproduksi berbantu.

Ppt : After microligation: Spermatogenesis was achieved in 7 (of 15) patients, (-) sperm retrieval, Semen samples should
be cryopreserved, ICSI is still needed

Varicocele Repair in Patients With Nonobstructive

Azoospermia: A Meta-Analysis

Kalau ada pasien varicocele dengan azoospermia tetap harus dioperasi sebelum bayi tabung.

Ppt : Result of this meta analysis is some men with NOA can benefit from varicocele repair, Resulting the motile of
sperm, and spontaneous pregnancy, Histopathology as the only statistically significant factor of predictor success,
Overall this meta analysis demonstrate that varicocele repair can performed safely and effectively in men with NOA

Management

Kapan pasien varicocele harus dioperasi? Apakah varicocele semua harus dioperasi? Tidak semua varicocele harus
dioperasi krn hanya mengganggu sekitar 40% kesuburan, 60% ga ada gangguan. Kecuali kalau volume berkurang dan
sudah 1 tahun tetap tidak punya anak baru dioperasi. Kalau ada gangguan semen dan gangguan lain bermakna baru
dioperasi. Ada banyak pro dan kontra mengenai 60% ga ada masalah kenapa harus dioperasi dan kalau tidak dioperasi
masak nunggu spermanya sampai hancur baru dioperasi? Jadi pada anak, kl ada testis yg mengecil kontralateral di atas
20% atau mengecil bilateral kanan kiri atau grade 2 dna grade 3, nyeri usia 14/15 th sudah bisa dioperasi maka dioperasi.

Ppt : AUA Male Infertility Committee: Indications for surgical correction

- Relief of significant testicular discomfort or pain not responsive to routine sympt tx

- testicular atrophy (vol diff >20% or > 2cc)
- possible contribution to male infertility
- resulting in atrophy and impairment of seminal parameters and leydig cells
- abnormal semen parameters function
- varicocele is palpable

Management in Adolescents

- No strict criteria necessitate surgical intervention

- Each case handled individually
- general guidelines used by some pediatric urologist include the presence of one or more: decreased ipsilateral
testicular size (20%), Bilateral varicoceles, Gr 2 or gr 3, Symptomatic painful varicocele, Abnormal semen analysis
(if needed)

Surgical Management

Technique : Open surgery, Microscopic surgery : gold standar, Laparoscopy, Embolization / schlerotherapy

3 most common surgical approaches : inguinal, Retroperitoneal, subinguinal

Kalau misalkan ada varicocele lalu kita operasi, kapan cek sperma nya? Jawabannya 3-4 bulan. Butuh waktu 72
hari.

Varicocelectomy
Varicocele akan membaik setelah operasi dan kemungkinan hamil/pregnancy rate 40-50%. Tapi perlu diingat bahwa
dengan operasi varicocele tidak ada jaminan bahwa dia bisa punya anak.

2. Azoospermia

Ketika 2 kali melakukan pemeriksaan dan spermanya tetap 0 itu disebut azoospermia.

Ppt : the absence of spermatozoa in the ejaculate after assessment of centrifugated semen on at least 2 occasions

- 1% of the male population

Walaupun dikatakan Cuma 1% tp kenyataannya pasti banyak sekali krn makanan yg kita makan juga sudah
tercemar plastic, insektisida, pestisida.
- 10-15% of men who seek fertility evaluation
- Klasifikasi ada 2 yaitu : Obstructive Azoospermia (OA) dan Non Obstructive Azoospermia (NOA)
Pertanyaannya varicocele itu termasuk yang obstruktif atau non obstruktif? Jawabannya adalah non obstruktif,
tidak ada obstruktif sama sekali.
- The key components of evaluation: sexual and medical history, Ext genital PE, Hormonal measurements
Sperm Retrieval for OA

- Percutaneous epididymal sperm aspiration (PESA), TOC

- microsurgical epididymal sperm aspiration (MESA)
- Goal Sperm retrieval : Best sperm quality, Minimize damage, Simplest method, Enough samples to
cryopreservation
- Successful rate was of 62-85 % from total cases. Faliure rate 20%  MESA/TESE-mTESE

PESA

ADVANTAGE : Minimal discomfort for the patient, Minimal fibrosis, Lesser complication compare to open surgery, (-)
microsurgical instruments, Simple technique with low cost.

DISADVANTAGE : Blind procedure, Sometime mixed with blood, Fibrosis?!

TERAPI

Pembedahan

- Vasovasostomi, : org udh vasektomi terus disambung lagi namanya vasovasostomi

- Vasoepdidimiostomi : vas deferens nya rusak jadinya ga cukup panjang maka disambung dgn epididymis
- TURED : trans uretra restriksi of ejaculatory duct
- Sperm retrieval : PESA, MESA, TESA, TESE/ mTESE --- ICSI (intra cytoplasmic sperm injection, hanya
membutuhkan 1 sel sperma yg bagus intinya tidak perlu ekor kita masukkan ke dalam)

Vasovasostomi : Mikroskop, Single-layer anastomosis dan two-layer anastomosis, vasovasostomi  watertight, ASA,
Tension-free
TURED

- Sistoskopi  resektoskope kecil dan loop elektrokauter  verumontanum direseksi di midline

- Reseksi mulai dari apeks prostat berdekatan dengan sfingter uretra eksterna dan rektum
- Pasien pria infertil 65-70% menunjukkan perbaikan kualitas semen secara signifikan setelah TURED dan 20-30%
pasangannya menjadi hamil

3. ICSI

- intra cytoplasmic sperm injection, hanya membutuhkan 1 sel sperma yg bagus intinya tidak perlu ekor kita masukkan
ke dalam oosit

- low sperm count is involved

- Started in 1992 for severe OAT & Azoospermia

- Sperms retrieval from testis/epididymal

- Wife ovarian stimuli & oocyte retrieval