Combined Trifocal and Microsurgical Testicular Sperm Extraction Is the Best Technique for Testicular Sperm Retrieval in "Low-Chance" Nonobstructive Azoospermia

Background: There is no consensus for the best testicular sperm extraction (TESE) technique in patients with "low-chance" nonobstructive azoospermia (NOA). Objective: To determine sperm retrieval rates in an intraindividual comparison using three locations of the testicle with and without the assistance of a microscope (microsurgical TESE [M-TESE]). Design, setting, and participants: A series of 65 patients with low-chance NOA presenting with low testicular volume (<8 ml) and high serum follicle-stimulating hormone (FSH) (>12.4 IU/l) underwent trifocal-TESE plus M-TESE bilaterally (four biopsies per testis). Intervention: Sperm retrieval was performed as trifocal-TESE (upper, middle, and lower testicular pole) with and without the assistance of a microscope in the middle incision. Outcome measurements and statistical analysis: The number of evaluated tubules, the mean spermatogenetic scores, and the sperm retrieval rates were evaluated to determine retrieval locations and the use of the microscope. The Friedman and Cochrane Q tests were applied to determine statistical differences. Receiver operating characteristic curves were used for the analysis of serum FSH and testicular volume as preoperative prognostic factors. Results and limitations: The sperm retrieval success of 66.2% using the combined technique, meaning the percentage of patients with at least one tubule containing elongated spermatids, was the highest in the combination of trifocal-and M-TESE (p < 0.01), indicating this technique as optimal for patients with low-chance NOA. M-TESE and trifocal-TESE alone were not significantly better. The mean spermatogenetic score giving the number of tubules with elongated spermatids in relation to all tubules was significantly higher in M-TESE versus conventional TESE (p < 0.01), indicating the superior quality of the tissue harvested using the microscope. These results are limited by the definition of "success" using "one" spermatid/tubule. Preoperatively, high serum FSH and low testicular volumes did not exclude successful sperm retrieval. Conclusions: The combination of trifocal-and M-TESE is the best technique to reach high sperm retrieval rates in patients with low-chance NOA. (C) 2012 European Association of Urology. Published by Elsevier B. V. All rights reserved.