SURGICAL ANATOMY : TESTIS

Ovoid , 4 to 5 cm long, 3 cm wide, and 2.5 cm deep ; volume of 30 mL.

They are enclosed in a tough capsule comprising

Tunica vaginalis Tunica albuginea Tunica vasculosa

Tunica vaginalis of peritoneum envelops the whole testis except its posterior border and its superior pole.
Tunica albuginea Dense, irregular connective-tissue capsule Posteriorly, forms a median septum, the mediastinum testis, from which more delicate connective tissue divides the parenchyma in to 200 to 300 compartments containing seminiferous tubules.

Figure 1. Drawing shows the normal intrascrotal anatomy.

Deurdulian C et al. Radiographics 2007;27:357-369

2007 by Radiological Society of North America

Figure 2a. Normal anatomy.

Deurdulian C et al. Radiographics 2007;27:357-369

2007 by Radiological Society of North America

These coiled tubules anastomose in the mediastinum of testis to form the rete testis, from which 6 to 12 ductuli efferentia pass to the head of the epididymis. Two free surfaces Medial and Lateral Two borders Anterior and Posterior.

The posterior border

Superior portion is related to the head of the epididymis,

Inferior portion related to the body and tail of the epididymis. The right testicle, in most cases, is at a higher level than the left. Occasionally, the right testicle is lower in total situs inversus

Head of the epididymis is firmly fixed to the upper pole of the testis Body and the tail are less firmly fixed to the posterior border of the testis. At the upper one-third of the posterior border, the testicular artery bifurcates into testicular and epididymal branches During epididymectomy,

The surgeon should start from the lower pole and proceed upward about 2.5 cm. From there, the surgeon will find the bifurcation, and should ligate only the epididymal branch. This will avoid injury to the testicular branch of the artery and testicular atrophy.

EPIDIDYMAL BRANCHES

EPIDIDYMAL ANOMALIES May not be in its normal position It may be elongated or dissociated from the testis There may be a very small tunica vaginalis, or it may be wider than usual, forming a mesorchium Occasionally, the epididymis is descended and the testis is retained

Such separation of testis and epididymis usually results in blindly ending vasa efferentia dilated to form spermatoceles.

EPIDIDYMAL ANOMALIES

spermatic cord
A matrix of connective tissue continuous preperitoneal connective tissue. proximally with the

Concentrically invested by three layers of tissue Contains the Ductus deferens (vas), three arteries, three veins, the pampiniform plexus, and two nerves. ( ilioinguinal .N lies just lateral to the major layers of the cord)

The elements of the spermatic cord relate to each other as follows. Anterior : Posterior: Pampiniform plexus Ductus deferens Remnant of processes vaginalis or hernial sac

Three layers of fascia External spermatic fascia continuation of the fascia of the external oblique muscle. Cremasteric fascia primarily continuous with the musculature and fascia of the internal oblique and, in some cases the transversus abdominis muscle as well. Internal spermatic fascia continuation of the Transversalis fascia.

Vascular Supply
Arteries
The internal spermatic, or testicular, artery Arises from the aorta. Chief source of blood to the testis. The artery of the ductus deferens (deferential artery) emerges from the inferior vesicular artery. The external spermatic, or cremasteric, artery springs from the inferior epigastric artery.

ARTERIAL SUPPLY

1. 2. 3. 4. 5.

TESTICULAR DIFFERENTIAL CREMASTERIC ANT. SCROTAL POST. SCROTAL

Arteries CONTD

In its course to the testis, the testicular artery branches into an internal artery and an inferior testicular artery and into a capital artery to the head of the epididymis ( Fig. 2-44 ).
The level of this branching varies ; inguinal canal in 31% to 88% of cases ( Caution when performing an inguinal varicocelectomy ) Arterial anastomosis at the head of the epididymis, Between the testicular and the capital arteries at the tail Between the testicular and the epididymal, the cremasteric, and the vasal arteries (see Fig. 2-44 ). The testicular arteries enter the mediastinum and ramify in the tunica vasculosa principally in the anterior, medial, and lateral portions of the lower pole and the anterior segment of the upper pole ( Fig. 2-45 ).

INTERNAL ARTERIAL DISTRIBUTION

Testicular biopsy Medial or lateral surface of the upper pole, where the risk of vascular injury is minimal Collateral circulation for testis Anastomoses between the testicular and deferential vessels (fig. 25-7). Anastomoses between the testicular and the cremasteric arteries Anastomoses between the testicular and scrotal vessels.

According to Neuhof and Mencher, collateral circulation is sufficient to prevent gangrene upon division of the cord in 98% of their patients.

VEINS

Veins that

drain the testis, epididymis, and spermatic cord connect with Deep and a Superficial venous network.

Deep network

more common pathway and has three components: The Pampiniform Venous Plexus
formed in the spermatic cord by 10 to 12 veins that segregate into anterior and posterior groups (Fig. 25-9). Each group is drained by three or four veins that join to form two veins proximal to the internal inguinal ring. These veins run in the extraperitoneal space on either side of testicular artery. Vein on the right opens in to the inferior vena cava Vein on the left enters the left renal vein. the

The cremasteric venous network

flows into the inferior epigastric veins. The deferential vein drains into the pelvic plexus.

Superficial venous network The scrotal veins external pudendal veins internal saphenous vein

superficial perineal veins

internal pudendal vein.

Within this system, the cremasteric vein joins the venous plexus of the spermatic cord and the inferior epigastric vein.

varicocele Veins of the pampiniform plexus are elongated and dilated. Adolescents and young adults, with most occurring on the left side.

Right testicular vein joins the low-pressure IVC whereas the left vein joins the left renal vein, in which the venous pressure is higher Rarely, malignant disease of the left kidney extends along the renal vein and blocks the exit of the testicular vein. A rapidly developing left-sided varicocele lead one to examine the left kidney. should therefore always

In adolescent boys with varicocele,

some element of testicular growth arrest may be found

Varicocelectomy

Ligation of the dilated veins. Current indications for correction in teenage boys are Large varicocele (particularly if symptomatic)

Discrepancy in testicular size exceeding 10-20%. Surgical correction has been shown to restore testicular volume in a high percentage of cases.

However, Grasso et al. found that left spermatic vein ligation for low-grade varicocele in patients more than 30 years old did not improve sperm quality or rate of paternity when compared with an untreated control group
Persistence of varicosities is the most frequent complication. ( Results from failure to ligate all the varicosed veins)

Lymphatics Superficial and a deep plexus of lymph vessels

spermatic cord
Lateral and pre aortic lymph nodes. Nodal infiltration in metastasis: Right testicle: Node or nodes located at the vicinity of the angle between the renal vein and the IVC Precaval nodes at the aortic bifurcation Left testicle: Para aortic Pre aortic nodes nodes (inferior mesenteric nodes)

From either testicle, metastasis occasionally reaches into the pelvis and to the external iliac nodes.

Innervation AUTONOMOUS Comprises sympathetic and general visceral sensory fibers

Associated with the collateral ganglia and plexuses of the aorta in the region of the superior mesenteric and renal arteries.

These fibers course along with the testicular arteries to the testes

The spinal cord levels : T5 to T12 (but chiefly from T10 and T11).

Genital branch of the genitofemoral nerve (L1, L2)

Enters the inguinal canal through the internal inguinal ring.

Serves the cremasteric muscle.

ilioinguinal nerve (L1)

Emerges between the external and internal oblique muscles near the anterior superior iliac spine.

Enters the canal and subsequently exits from the external inguinal ring.
Supplies the skin of the penile root upper part of the scrotum upper medial thigh.

Histology

-- Testis

From outside to inside.

Tunica vaginalis
Two serous layers (parietal and visceral) which represent the outpocketing of the peritoneum.

Tunica albuginea
Dense connective tissue enveloping the testicular parenchyma; its fibrous septa form approximately pyramid-shaped lobules. The bases of the pyramids are related to the tunica albuginea; The apices are related to the posterior aspect of the tunica albuginea forming the mediastinum testis.

Each pyramidal lobule contains 2-4 convoluted seminiferous tubules which are responsible for the genesis of spermatozoa

Each testis contains approximately 500 seminiferous tubules, with a combined length of approximately 250 m.

Posteriorly , these convoluted tubules become straight and anastomose to form the rete testis from which 10-12 efferent ducts are formed.

The efferent ducts pierce the head of the epididymis.

tunica albuginea and pass into the

The interstitial tissue

Lies between the tubules. Contains the Leydig cells which synthesize other steroid hormones. testosterone and

The Sertoli cells lining the lumen of the seminiferous tubules are epithelial cells and have some metabolic effect on the germinal cells.

HISTOLOGY Epididymis Epididymis is a long (4-6 m) and very tortuous tube.

It is lined by pseudostratified columnar epithelium, which rests on a basement membrane with smooth muscle fibers. These fibers serve to propel the sperm to the ductus deferens. HISTOLOGY -- Spermatic cord The histology of the spermatic cord is that of the anatomic entities it contains

Orchiectomy Every effort should be made to save the testicle except in testicular necrosis due to spermatic torsion or malignancy. Approaches: Through the scrotum in benign disease Through an inguinal incision if malignancy is suspected The scrotal approach should be done through a incision since the blood vessels run transversely. In testicular malignacy, Retroperitoneal lymphadenectomy may be necessary as well as high ligation and removal of the spermatic cord. Occasionally hemiscrotectomy must be done if there is a fixation of the testicle to the skin. transverse scrotal

NOTE: - The testicular arteries branch off the abdominal aorta near the kidneys. The right testicular vein drains directly into the inferior vena cava, while the left testicular vein drains into the left renal vein and then into the inferior vena cava. Note how the vessels cross over the ureters and enter and exit the inguinal canal with the spermatic cord via the deep and superficial inguinal rings, respectively. - The arterial supply of the pelvis is supplied by the common iliac arteries, which are the end branches of the abdominal aorta. The common iliac arteries branch into the external iliac arteries (which continue as femoral arteries) and the internal iliac arteries. - The posterior division of the internal iliac artery gives off the iliolumbar, lateral sacral, and superior gluteal arteries. - The anterior division gives off the umbilical artery, which further branches off as the superior vesical artery and the medial umbilical ligament (obliterated umbilical artery. The anterior division also gives off the obturator, middle rectal, inferior gluteal, inferior vesical, and internal pudendal arteries.

- Review the contents of the inguinal canal and spermatic cord. Remember the descent of the testes during development, and the various fascial and muscular layers of the scrotum. This process is detailed below. - Note the testicular artery and vein and the genital branch of the genitofemoral nerve entering the spermatic cord at the deep inguinal ring. The ilioinguinal nerve sends branches to the scrotum (or labia in females) through the inguinal canal, but is not part of the spermatic cord. - The ductus deferens travels up the spermatic cord in the inguinal canal, exits from the deep inguinal ring and turns towards the prostate gland located below the bladder.

- The testis is covered by a dense collagenous coat called the tunica albuginea. Septa extend into the testis to separate the lobules. In mature testis, there is a prominent vascular layer immediately beneath the tunica albuginea. - Most of the testis is occupied by highly coiled seminiferous tubules, as seen in most of the bottom panel. The blue arrows point to Leydig cells that secrete testosterone. We will look at these structures more closely in the next slide. - The abundant seminiferous tubules all lead into the mediastinum of the testis, separated from the rest of the testis by the tunica albuginea as well. The mediastinum includes the rete testis, which lead to the efferent ducts and then the epididymis at the posterior aspect of the testis. The epididymis can be divided into three parts the head, the body, and the tail. - The ductus deferens is continuous with the tail of the epididymis. As mentioned before, it passes through the superficial inguinal ring in the spermatic cord, through the inguinal canal, exits the deep inguinal ring, and joins the duct of the seminal vesicle to form the ejactulatory duct.

- The seminiferous tubules are composed of spermatogonia located at the base of the epithelium with large round nuclei. - Spermatogonia give rise to primary spermatocytes, with larger nuclei midwsay up in the epithelium. The nuclei are round with distinct bundles of dense chromosomes. These cells are in extended prophase of the first meiotic division. - The primary spermatocytes further develop into spermatids located higher up in the epithelium toward the lumen. The round nuclei become smaller, denser, and change shape into the heads of mature sperm, or spermatozoa. - Also found within the seminiferous tubules are Sertoli cells, which are large, relatively pale and irregularly shaped. We can see a prominent nucleolus within the Sertoli cell nucleus. These cells primarily support and nourish the germ cells in the testis with long, apical cytoplasmic folds. They contain testosterone and FSH receptors.

- Within the loose connective tissue of the testis, among seminiferous tubules, we can see Leydig cells. They are indicated by the arrow in the bottom panel. These cells secrete the male steroid hormone, testosterone. There may be small capillaries found among the clusters of Leydig cells.

- Fully formed spermatozoa leave the seminiferous tubules by straight tubules and enter interconnected channels called rete testis within the mediastinum (bottom left). These flattened channels are lined with low cuboidal epithelium. As mentioned before, the mediastinum contains the dense connective tissue of the tunica albuginea.

- The rete testis lead into the efferent ductules (bottom right) that lead into the head of the epididymis. Efferent ductules have unusual serrated or scalloped epithelial lining. This is due to alternating tall and short cells. Note the cells have cilia, which beat to help move mature sperm to the epididymis.

- Note the efferent ductules located right next to the epididymis. They empty their contents into the head of the epididymis, located outside the testis. - Note the difference between the epithelia of the efferent ductules and the epididymis. The long and convoluted epididymis is lined by pseudostratified columnar epithelium (bottom right) with stereocilia. - Sperm is stored in the tail of the epididymis in preparation for ejaculation. - From there, the sperm enters the ductus deferens.