Histopathological pattern of testicular diseases in western Saudi Arabia

Discussion

Testicular biopsy has been conventionally used as an important procedure in the diagnosis and management of infertility. Radiologically guided testicular biopsy is a less invasive method of obtaining specimen for histological diagnosis;19 however, open biopsies or orchidectomies have also been performed, frequently in difficult cases, inflammatory conditions and testicular tumors, accounting for substantial workload on the histopathologist. Recently, robotic assisted surgery has also been introduced in andrological surgical practices.20 Excisional surgery of the testis is also therapeutically indicated for benign conditions of the testis such as infarctions of testicular torsion, testicular atrophy in cryptorchidism, or in chronic epididymo orchitis irresponsive to traditional treatments.5

During the study period, we reported 108 cases of primary infertility; the mean age of patients who underwent testicular biopsies for male infertility was 28 ±7.9 years (range 13-50). A study on testicular biopsies from Zaria, Nigeria in their 472 cases, reported a mean age of 31 years,21 whereas a group from Lagos Nigeria reported a mean age of 30 years.22 A group of Pakistani scientists in their study on evaluation of azoospermia and testicular biopsies reported a mean age of 28 years.23 From within the KSA, a study from the city of Jeddah reported a mean age of 24.5 years.24 Most of the studies cited in the discussion appear to observe a mean age above 30 years including this present study, suggesting a possibility that the female partners have to go through detailed investigations before the male partner is submitted to the invasive procedure of testicular biopsies. However, in one study from Jeddah, KSA that observed a younger mean age of less than 25 years, this difference as well as many other observed differences in their study as compared with other studies have not been well understood.24 On the basis of age range, we also noted testicular biopsy for infertility, carried out at a very young age of 13; most likely due to typographic error or other errors of recording, beyond our control.

In the present study, we found hypospermatogenesis to be the most common pattern of histology accounting for 22.7% cases. Ahmed and Bello from Zaria, Nigeria in their 472 cases, also found hypospermatogenesis to be the most frequent histology accounting for 35.2% of their cases.21 Whereas a scientists from Lagos, Nigeria, found a testicular atrophy in 30 (58.8%) as the most common diagnosis.22 In the same year, Parikh et al from India reported Sertoli cell only syndrome (SCOS) to be the most common abnormal histopathological finding accounting for 18.75% of their cases.25 Similar was the observation by a group from Pakistan, who observed SCOS in 30.2% of their cases.23 There is only one recent study on the histological patterns of testicular biopsies from KSA, in which Abdulla and Bondagji from Jeddah, also found hypospermatogenesis to be most frequent, accounting for 29% of their cases.24 Although different observations have been reported from recent studies from a number of geographical regions, hypospermatogenesis appears to be the most common diagnosis reported by most of them and our observations are in concordance with other studies including the study from KSA.

In our experience, hemorrhagic infarction from testicular torsion accounted for about a quarter of all cases (46 out of 199 cases). Although these figure appear to be high, our study is only a hospital-based pathology data and is obviously biased by the local practices of the urology surgeons. However, this condition is quite rare and figures of as low as 1.1 per 100,000 have been reported recently from Korea.26 The cause or the precipitating factor of torsion is usually not detectable, in majority of cases; however, in rare instances trauma has been reported to be the underlying factor.27

We also found complete hemorrhagic infarction in all our patients of torsion of testis. Recently from Central KSA, a case of torsion of testis in an elderly 63 year old patient, was found to have a seminoma as the underlying cause.28 Torsion of testis is predominantly a disease of young age, with highest incidence reported in adolescent age group.26 The mean age of our torsion was 32.1±8.1 years (range 15-91 years). Case reports of testicular torsion in extremes of ages have been reported in the medical literature at the age of 67 years age from UK.29 One of our patient was 91 year old, but we do not have any clinical history, investigations or follow-up to present and publish it as a case report in the medical literature. Cryptorchidism considered as the most common anomaly of genitourinary tract accounting for 3% cases in full term boys.30 In our experience too, cryptorchidism accounted for about 10% of total cases (22 out of 199 cases). This is a condition of newborns and infants, and a delay in surgery can lead to infertility and high risk of testicular cancers. At most centres, the target for surgery is within one year.31 In the present study, patients of cryptorchidism had a mean age of 19±4.7 years (range 15-39 years). The possible explanation of this gross difference in the age at presentation and performance of surgery can be explained by lack of education and possible problems with access to treatment. Interestingly, none of the cases revealed any premalignant or malignant lesion on histological examination of the orchidectomy specimens. These aspects of our observation need to be followed up in well-designed prospective clinicopathological studies.

In our experience, there were 12 cases of malignant primary testicular tumors, accounting for only about 6% of our testicular histopathology workload. Although these figures are quite low, nonetheless are in conformation with world literature, which report its rarity especially in Asian populations;6 as well as from the KSA.7,8 Scientists from London, analyzing the global incidence of testicular cancer have reported its incidence rate to be highest in New Zealand and lowest in India.32 Researcher from Denmark found testicular cancer to be a rare disease, with approximately 300 cases per year in their whole country, although it was the most common cancer in men aged 20 to 40 years.33 Similarly, Assi et al6 from Lebanon report a mean age of 32 years in their testicular tumor patients. The finding of these studies are also endorsed locally by the Saudi Cancer registry (published in September 2017) which reported testicular cancer as a rare tumor, with only 98 new testicular cancers reported in 2014.34 The age of our patients with testicular tumors ranged from 16 to 70 years with a mean age of 38.2±9.5 years. Although the number of testicular cancer patients are low; our observation are in conformation with figures reported from the global, regional, and national studies.

The limitations of the study were the possible errors of data recording (such as age), which were not within our control, as it was a retrospective study. Moreover, due to very low number of testicular malignancies, in-depth discussion on malignancies and any meaningful epidemiological conclusion could not be made.

In conclusion, our observation of testicular histopathology pattern appears to be similar to the reported world literature as well as from the KSA. Minor differences in age range appear to be due to limitations of retrospective study such as improper recording of data or possibly lack of education in the rural population, leading to late presentation to the hospitals.