Aim： To evaluate the immunohistopathological changes in the contralateral testis of rats after an experimental spermatic cord torsion. Methods： Male Sprague-Dawley rats of 45-50 days old were subjected to a 720°...Aim： To evaluate the immunohistopathological changes in the contralateral testis of rats after an experimental spermatic cord torsion. Methods： Male Sprague-Dawley rats of 45-50 days old were subjected to a 720° unilateral spermatic cord torsion for 10, 30 and 80 days （experimental group, E）, respectively or sham operation （control group, C）. Histopathology of the contralateral testis as well as germ cell apoptosis were studied using the Terminal Deoxynucleotidyl Transferase Biotin-dUTP Nick End Labeling （TUNEL） technique. The number of testicular lymphocytes, mast cells and macrophages, and the expression of tumor necrosis factor-α （TNF-α） and its receptor （TNFR1） in testicular cells of the contralateral testis were quantified by histochemistry and immunohistochemistry. TNF-α concentration in testicular fluid was determined by ELISA. Results： In the contralateral testis of rats from the E group, the maximal degree of damage of the germinal epithelium was seen 30 days after torsion. At this time we observed in the E group vs. the C group increases： （i） the number of testicular T-lymphocytes; （ii） the number of testicular mast cells and macrophages; （iii） the percentage of macrophages expressing TNF-α; （iv） TNF-α concentration in testicular fluid; （v） the number of apoptotic germ cells; and （vi） the number of TNFR1^＋ germ cells. Conclusion： Experimental spermatic cord torsion induces, in the contralateral testis, a focal damage of seminiferous tubules characterized by apoptosis and sloughing of germ cells. Results suggest humoral and cellular immune mediated testicular cell damage in which macrophages and mast cells seem to be involved in the induction of germ cell apoptosis through the TNF-α/TNFR1 system and in the modulation of the inflammatory process.展开更多
We retrospectively reviewed data for 286 patients with varicocele who underwent microsurgical subinguinal varicocelectomy from March 2015 to May 2017 in Shanghai General Hospital(Shanghai,China).In this surgical appro...We retrospectively reviewed data for 286 patients with varicocele who underwent microsurgical subinguinal varicocelectomy from March 2015 to May 2017 in Shanghai General Hospital(Shanghai,China).In this surgical approach,the testis was delivered,and the gubernacular and external cremasteric veins were stripped.In addition,the spermatic cord was delivered downward with continuous double traction away from the external ring.The remaining procedure was similar to the conventional approach.We followed patients for at least 3 months and evaluated postoperative semen parameters,pain symptoms,and complications.We excluded data for 32 men due to inadequate follow-up(<3 months).Of the remaining 254 patients,73 had oligoasthenospermia,121 had nonobstructive azoospermia,and 60 had symptomatic varicoceles.Total progressive sperm counts increased in the oligoasthenospermic patients from a median preoperative value of 9.15×10^6 ml^?1 to 25.33×10^6 ml^?1(n=34),and 35.6%(26/73)initially oligoasthenospermic men contributed to unassisted pregnancies.Sperm returned to the ejaculate in 12.4%(15/121)azoospermia patients.In patients with scrotal pain(n=60),43(71.7%)reported complete resolution of pain,16(26.7%)reported partial resolution,and 1(1.7%)reported no change.No patients experienced varicocele recurrence.This doubletraction strategy avoids opening the external oblique aponeurosis,and results in less damage and faster recovery.In addition,the stripping strategy eliminates potential damage to the testis caused by the varicose veins.Our results showed that microsurgical subinguinal varicocelectomy using spermatic cord double traction in conjunction with testicular delivery for vein stripping is a safe and effective approach for varicocele repair.展开更多
Three patients with nutcracker syndrome(NCS) were enrolled in the study.Their clinical symptoms mainly included proteinuria and serious varicocele.Color Doppler ultrasound and computed tomography showed that the patie...Three patients with nutcracker syndrome(NCS) were enrolled in the study.Their clinical symptoms mainly included proteinuria and serious varicocele.Color Doppler ultrasound and computed tomography showed that the patients had constricted abdominal aortas,reduced superior mesenteric artery angles,and thinned left renal veins.Patients then underwent left spermatic vein ligation and iliac vein anastomosis.They were checked tliree months after their operation,and results showed that their sperms were improved and their proteinuria disappeared. The color Doppler ultrasound showed new cycle pathways.NCS clinical manifestations are complicated,and need combination diagnosis of symptoms and auxiliary examination to detennine surgical indications.Ligation of spermatic vein and vein anastomosis can be used to treat NCS.展开更多
The microanatomy of the inguinal spermatic cords has never been reported in Asia. The purpose of this study was to describe the number and relationship of the veins, arteries and lymphatics in the spermatic cord and t...The microanatomy of the inguinal spermatic cords has never been reported in Asia. The purpose of this study was to describe the number and relationship of the veins, arteries and lymphatics in the spermatic cord and to clarify the location of the vas deferens in Asian men. Fifty-one patients receiving 79 primary microsurgical varicocelectomies performed by a single surgeon from April 2011 to July 2012 were studied. The number of internal and external spermatic veins, testicular arteries and lymphatic channels preserved during the inguinal microsurgical varicocelectomy were recorded. The relationship between the right and left vascular anatomy during bilateral varicocelectomies was evaluated. The data showed that mean numbers of 1.5±0.9 arteries, 5.6±2.2 spermatic veins and 3.6±1.9 lymphatics were identified during the repairs. The internal spermatic arteries were surrounded by a dense complex of adherent veins in 81.2% of the cases. The external spermatic vein or veins were found in 60.8% of the cases. The vas deferens may be contained within the internal spermatic fascia. The results suggest that the number of veins may be highly variable and less than those reported in the English literature, but there is some similarity in the inguinal microanatomy of the right and left spermatic cords, Further research is warranted to clarify our results.展开更多
Spermatic cord leiomyosarcomas (LMSs) are rare tumors which may cause significant morbidity and mortality if inadequately diagnosed or treated. We report a case of a paratesticular LMS in a 60-year-old man who present...Spermatic cord leiomyosarcomas (LMSs) are rare tumors which may cause significant morbidity and mortality if inadequately diagnosed or treated. We report a case of a paratesticular LMS in a 60-year-old man who presented with a right scrotal mass. The patient was evaluated by scrotal ultrasound and computed tomography of the abdomen and pelvis (including scans of the scrotum), which revealed a large extratesticular mass. The lesion proved to be malignant and the patient underwent radical orchiectomy with high cord ligation. To improve the assignment of this lesion, we further analyze the imaging features of LMS and corre-late them with pathologic findings.展开更多
The aim of this study was to validate the effectiveness of targeted microsurgical spermatic cord denervation (MSCD) of the trifecta nerve complex in comparison to traditional full MSCD with complete skeletonization of...The aim of this study was to validate the effectiveness of targeted microsurgical spermatic cord denervation (MSCD) of the trifecta nerve complex in comparison to traditional full MSCD with complete skeletonization of the spermatic cord in men with chronic orchialgia. Retrospective chart review was performed by a single fellowship-trained microsurge on between 2011 and 2016. Patie nts had follow-ups at 6 weeks, 6 mon ths, and 1 year postoperatively. Thirty-nine men with chronic orchialgia un derwe nt full MSCD between 2011 and 2013. In July 2013, after the publication of an anatomic study with identification of Wallerian degeneration of the trifecta nerve complex in men with chronic orchialgia, the technique was changed to targeted MSCD. From July 2013 to March 2016, 43 men underwent targeted MSCD. When comparing the full MSCD group to the targeted MSCD group, there was no significant difference in resolution of pain (66.7% vs 69.8%, P = 0.88), no difference in partial relief of pain (17.9% vs 23.3%, P =0.55), and no difference in failure to respond rates (15.4% vs 7.0%, P= 0.22) between the two groups. There was no differenee in mean change of visual analog pain scale scores between the two groups (P= 0.27). Targeted MSCD had a shorter operative time (53 min vs 21 min, P = 0.0001). Targeted MSCD offers patients comparable outcomes to traditional full MSCD, with a shorter operative time, a less technically challenging surgery, and potentially less risk to cord structures which should be preserved.展开更多
Acute scrotal pain(AsP)requiring surgical exploration is common in the pediatric population,but little has been reported on this subject with regard to the adult population.The aim of this study was to investigate the...Acute scrotal pain(AsP)requiring surgical exploration is common in the pediatric population,but little has been reported on this subject with regard to the adult population.The aim of this study was to investigate the demographic and clinical characteristics and outcomes of scrotal explorations performed on adult patients.Patients over 21 years of age who underwent surgical exploration for ASP with suspected testicular torsion(TT)at 14 French hospitals between January 2005 and December 2019 were included in this study.The main outcome measures were demographic characteristics,pathology found during scrotal exploration,and perioperative outcomes.Logistic regression was used to perform univariate and multivariate analyses to identify predictors of TT.Data for 1329 men were analyzed.The median age was 30(interquartile range[IQR]:25-35;range:21-89)years.Regarding the clinical examination,867(65.2%)patients presented with an elevation of the testicle,613(46.1%)patients with scrotal edema or erythema,and 211(15.9%)patients with nausea or vomiting.Operative findings identified TT in only 684(51.5%)patients,epididymo-orchitis in 112(8.4%)patients,a tumor in 16(1.2%)patients,and no causes in 475(35.7%)patients.Orchiectomy for nonviable testes was required in 101(7.6%)patients.In multivariate analysis,an elevation of the testicle,erythema/swelling,and the presence of nausea/vomiting were found to be associated with the occurrence of TT.Testicular torsion is not exclusive to children and adolescents,so must be considered in males of any age with acute scrotal findings.However,one-third of scrotal explorations in adults did not lead to a diagnosis.展开更多
BACKGROUND Tumors of the spermatic cord are rare,and approximately 25%are malignant neoplasms.Metastatic spermatic cord tumors are even rarer.Several studies have revealed that the most frequent primary tumors metasta...BACKGROUND Tumors of the spermatic cord are rare,and approximately 25%are malignant neoplasms.Metastatic spermatic cord tumors are even rarer.Several studies have revealed that the most frequent primary tumors metastasizing to the spermatic cord and peritesticular tissues are neoplasms of the stomach and prostate.Furthermore,metastasis to the spermatic cord or epididymis may occur via retrograde lymphatic and hematic routes.We present the case of a man with gastric cancer that metastasized to the spermatic cord and epididymis,with concomitant ipsilateral hydronephrosis after surgical resection and chemotherapy for his primary tumor.CASE SUMMARY A 71-year-old man underwent total gastrectomy for pT4aN2 poorly differentiated gastric adenocarcinoma in December 2016.Two months after surgery,he received adjuvant chemotherapy with TS-1 from February 2017 to February 2018.Surveillance computed tomography(CT)was performed in June 2018,which did not reveal any sign of tumor recurrence.In November 2019,he presented with left lower quadrant abdominal pain and a palpable left inguinal-scrotal mass.CT revealed left mild hydronephrosis and a left scrotal mass measuring 4.0 cm×1.7 cm.Tumor biomarkers,including alpha-fetoprotein(AFP),lactate dehydrogenase(LDH),beta-human chorionic gonadotropin(βHCG),carcinoembryonic antigen(CEA),and carbohydrate antigen 19-9(CA19-9)were all normal.Renal and testicular echography showed left hydronephrosis and a left peritesticular soft tissue lesion with blood flow.Diagnostic ureteroscopy showed left lower ureter narrowing without an intraluminal lesion.A biopsy was obtained for the indurated spermatic cord and epididymis,which showed poorly differentiated adenocarcinoma.Immunohistochemical staining demonstrated that the tumor was diffusely and strongly positive for homeobox protein CDX2.The features were consistent with metastatic adenocarcinoma of a primary gastric tumor.CONCLUSION In patients with a history of primary cancer,an inguinal mass of unknown cause with accompanying ipsilateral hydronephrosis may be a sign of distant metastasis from a primary tumor,especially of gastrointestinal origin.展开更多
BACKGROUND Pleomorphic rhabdomyosarcoma(RMS)of the spermatic cord is a group of rare neoplasms,and a secondary hydrocele testis occasionally occurs.The misdiagnosis of paratesticular mass may lead to a therapeutic del...BACKGROUND Pleomorphic rhabdomyosarcoma(RMS)of the spermatic cord is a group of rare neoplasms,and a secondary hydrocele testis occasionally occurs.The misdiagnosis of paratesticular mass may lead to a therapeutic delay.CASE SUMMARY A 79-year-old man presented to our clinic complaining of a 1-mo history of painless scrotal swelling.Physical examination revealed approximately a 15 cm×10 cm×5 cm inguinal mass with limited mobility.Contrast-enhanced magnetic resonance imaging showed a hydrocele testis,several enlarged inguinal lymph nodes,and a heterogeneously enhanced lesion with a relatively well-defined margin in the left inguinal region.Due to the imaging findings,he was diagnosed with pleomorphic RMS and received a wide resection of the mass,an inguinal incision with a high section of the left spermatic cord,and a left radical orchiectomy.He experienced local relapse 1 mo postoperatively and received radiotherapy and anlotinib hydrochloride-based immunotherapy as adjuvant therapy.The patient died 3 mo after the surgery.CONCLUSION The optimal interventions for advanced-stage pleomorphic RMS patients should be investigated by more preclinical studies and clinical trials.Physicians need to be aware of the occurrence of pleomorphic RMS in unusual locations,especially when accompanied by a hydrocele testis.展开更多
Few cases of Liposarcoma of the spermatic cord have been reported in the literature. This rare tumor represents 7% of malignant tumors of the spermatic cord. We report a case of an unusual liposarcoma of the spermatic...Few cases of Liposarcoma of the spermatic cord have been reported in the literature. This rare tumor represents 7% of malignant tumors of the spermatic cord. We report a case of an unusual liposarcoma of the spermatic cord, with respect to its sclerosing variant, occurring in a healthy looking 42 years old man. A wide local excision of the tumor was performed. Adjuvant radiotherapy may sometimes be effective on local recurrence. Even though this tumor evolves slowly, a prolonged follow up is required because of the risk of late recurrence.展开更多
BACKGROUND Sperm granuloma is a rare disease in clinical andrology and its incidence is still unclear worldwide.According to the existing literature,sperm granuloma often occurs unilaterally.Clinical and ultrasound fe...BACKGROUND Sperm granuloma is a rare disease in clinical andrology and its incidence is still unclear worldwide.According to the existing literature,sperm granuloma often occurs unilaterally.Clinical and ultrasound features are similar to epididymal tuberculosis,chronic epididymitis and other diseases.Sperm granuloma is usually diagnosed based on postoperative histopathological and immunohistochemical examination.CASE SUMMARY A 46-year-old man was admitted to the hospital due to the presence of a left scrotal mass for 3 mo and aggravation of pain for 1 wk.The lesions at both sites were surgically resected.Postoperative pathological examination showed that the left spermatic cord mass and the right epididymal mass were consistent with sperm granuloma.The sperm granulomas then recurred 3 mo after surgery.There is little change in the local mass so far.CONCLUSION The case report is helpful for our understanding of this disease.In clinical diagnosis,it should be distinguished from epididymal tuberculosis,chronic epididymitis and other diseases.Color Doppler ultrasound can be used as a preferred examination method but postoperative pathological examination is still needed for diagnosis.展开更多
Background: To evaluate aetiology of acute scrotum after surgical exploration suspicious for spermatic cord torsion, to compare surgical with clinical findings and to support the clinician distinguishing spermatic cor...Background: To evaluate aetiology of acute scrotum after surgical exploration suspicious for spermatic cord torsion, to compare surgical with clinical findings and to support the clinician distinguishing spermatic cord torsion from other diseases mimicking this emergency requiring surgical exploration. Methods: All men with the diagnosis of an acute scrotum who underwent emergency scrotal exploration between January 1995 and October 2009 were retrospectively evaluated. Results: 230 patients were analyzed. Torsion of the spermatic cord (53%) was the most common cause followed by torsion of the testis appendages (25%). Patients with spermatic cord torsion were significantly older (15.5 y) and haunted hospital faster than others (p Conclusions: Our data demonstrate that spermatic cord torsion is more common in adolescent. Short pain duration and high intrascrotal position of the testicle are associated with higher probability of spermatic cord torsion. Duplex sonography plays an important role in the diagnostic workup but history and physical examination are the crucial parameters. In nebulous clinical cases emergency surgical exploration has to be recommended.展开更多
Aberrant adrenocortical tissue in spermatic cord is rare in adult population. We report an unusual case of a 52-year-old male patient with an aberrant adrenocortical tissue which is incidentally resected within lipoma...Aberrant adrenocortical tissue in spermatic cord is rare in adult population. We report an unusual case of a 52-year-old male patient with an aberrant adrenocortical tissue which is incidentally resected within lipoma of spermatic cord and identified on microscopic examination. Although he was diagnosed with right inguinal hernia, there was no significant hernia orifice intraoperatively. When the 2nd operation by anterior open approach was undergone, there was a fat-like tissue adhered to the spermatic cord. It was removed and the histopathological finding first revealed aberrant adrenocortical tissue in the resected lipoma of spermatic cord (Figure 1). This abnormal tissue is usually found incidentally during inguinal operation. In general, most of the aberrant adrenal tissue becomes atrophic by adult life. Moreover, it is not clinically significant and also not associated with endocrine abnormalities.展开更多
Introduction: The purpose of this work is to evaluate the epidemiological, clinical and therapeutic aspects of spermatic cord in our context. Patients and Methods: This is a retrospective study over a period of 4 year...Introduction: The purpose of this work is to evaluate the epidemiological, clinical and therapeutic aspects of spermatic cord in our context. Patients and Methods: This is a retrospective study over a period of 4 years from January 1, 2014 to June 30, 2018. Results: We collected 55 cases divided into 26 cases, 44.27% for the Thies Regional Hospital, 21% or 38.18% for the Mbour EPS and 8 cases representing 14.55% for the Saint Jean de Dieu Hospital. We found an average age of 20.03 years with extremes of 4 years and 56 years. In 28 patients or 50% of cases, we found no particular pathological history, while in 4 patients or 7.14%, we found a notion of recurrent ipsilateral testicular pain. We recorded 67.27% (n = 37) of the cases received for testicular pain;15 patients or 27.27% presented a large painful pouch. Two patients (3.64%) were received for inguinal swelling and 1 patient (1.82%) presented testicular atrophy. The average consultation time is 16.9 hours with extremes of 2 hours and 96 hours. The torsion was in 59.61% of cases (n = 32) located on the right versus 40.38% (n = 22) on the left. There was no bilateral form. The pick-up time was 3 hours with extremes of 1 h to 24 h. All patients benefited from an exploratory scrotomy. We found a total of 22 patients or 40% of cases with ischemic testis, 8 cases or 14.55% of patients with necrotic testis and 2 cases or 3.64% where the testis was normal. Orchidopexy was performed in 46 patients or 83.63% and orchiectomy in 9 patients. Conclusion: Care is urgent. There is a need for better awareness of the population and the medical staff for the early diagnosis.展开更多
Primary liposarcoma of the spermatic cord is rare, and preoperative diagnosis is difficult. We report a rare case of well-differentiated liposarcoma in 65-year-old man. The patient’s chief complaint was painless enla...Primary liposarcoma of the spermatic cord is rare, and preoperative diagnosis is difficult. We report a rare case of well-differentiated liposarcoma in 65-year-old man. The patient’s chief complaint was painless enlargement of a mass in the right inguinal area that had persisted for about two months. The main component of the mass was wrapped around the spermatic cord and several components were around the testis. Ultrasonography of the main component showed mixed echogenicity. CT showed an ovoid fat-containing nodule and several other fat-density masses surrounding the testis. The mass was surgically removed, along with the right testis and spermatic cord. A pathological examination showed a well-differentiated liposarcoma of the right spermatic cord and testis.展开更多
Introduction: Torsion of the spermatic cord is an emergency whose delay in treatment conditions the functional prognosis of the testicle. The aim of this study was to analyze the management of spermatic cord torsion i...Introduction: Torsion of the spermatic cord is an emergency whose delay in treatment conditions the functional prognosis of the testicle. The aim of this study was to analyze the management of spermatic cord torsion in the Urology Andrology Department of the Ignace Deen National Hospital in Conakry. Material and methods: This was a ten-year retrospective descriptive study from January 1, 2012 to December 31, 2021. It involved all patients admitted for torsion of the spermatic cord, confirmed at surgical exploration. Results: We identified 21 cases of torsion of the spermatic cord. The mean age of the patients was 17.9 ± 4.4 years. The average consultation time was 19.2 ± 21.4 hours with extremes of [2 h and 98 h]. Only 6 patients (28.6%) consulted before the sixth hour. All patients presented with scrotal swelling. At scrototomy, all torsions were intravaginal with two turns of spiral in 13 cases and three turns in 8 cases. Orchiectomy followed by contralateral orchidopexy was performed in 6 cases. In the other cases, bilateral orchidopexy was performed after detorsion. The average hospital stay was 4.5 days. We recorded 4 cases of testicular atrophy after orchidopexy. Conclusion: Spermatic cord torsion is an infrequent emergency in our department. The delay in consultation remains the main predictive factor of testicular necrosis. Emergency exploratory scrotomy should be the rule.展开更多
Background: A high level of sperm chromatin decondensation results in loss of DNA quality and it is associated with poor embryonic prognosis in Assisted Reproductive Technology (ART). This had lead to introduction of ...Background: A high level of sperm chromatin decondensation results in loss of DNA quality and it is associated with poor embryonic prognosis in Assisted Reproductive Technology (ART). This had lead to introduction of sperm DNA compaction testing in assessment of clinical male infertility. Toluidine blue assay is one of most commonly used tests to measure chromatin decondensation in research studies and also in clinical routine use. So the objective of our study was to assess the level of sperm chromatin decondensation by toluidine blue assay in men dealing with couple infertility. Methods: The sperm samples of 96 patients referred for infertility, over a 4-month period from September 2020 to January 2021, were stained with toluidine blue and observed under an optical microscope. These were evaluated according to the World Health Organization. Results: The 25 - 34 age group was the most represented among infertile men. There was a non-significant correlation between age and the level of spermatic chromatin condensation (r = 0.0348). Spermatic parameters had averages above standards norms, apart from that of low vitality. Spermatic chromatin decondenization affected 96% of infertile patients. Asthenozoospermia was the most common abnormality. Among standard parameters of spermogram, only the concentration of spermatozoa in the semen was weakly correlated (r = 0.18) with sperm chromatin decondensation. Conclusion: The level of sperm chromatin condensation is, on the one hand, a parameter independent of the age of the subject; on the other hand, allows to evaluate male infertility, like the classic parameters of the spermogram and spermocytogram. However, in view of the high probability of changes in the nuclear quality of sperm intrinsic to the analysis process and sperm concentration, an improvement of the toluidine blue test using the swim-up technique and associated with image processing software is possible.展开更多
Introduction: Twisting of the spermatic cord is part of urological emergencies. It can occur at any age with a predilection for children and adolescents. There is no literature on spermatic cord torsion in octogenaria...Introduction: Twisting of the spermatic cord is part of urological emergencies. It can occur at any age with a predilection for children and adolescents. There is no literature on spermatic cord torsion in octogenarians, probably due to its rarity. The majority of recent studies show spermatic cord torsion in patients under 55 years of age. This is why we present a case of spermatic cord torsion in an 80 years old subject. Case Presentation: We present a case of torsion of the spermatic cord in an 80-year-old subject. The diagnosis was made on anamnestic and clinical grounds. The patient presented with scrotal pain, unilateral, of sudden onset, violent intensity without urinary signs with an ascended testicle. The urine dipstick was unremarkable. Management was done surgically and as an emergency. The postoperative course was satisfactory. Conclusion: Spermatic cord torsion in octogenarians is exceptional and should be suspected in the first instance in the presence of any sudden onset, severe testicular pain without urinary signs with an ascended testicle and a negative urine dipstick.展开更多
Aim:To assess the relation of reactive oxygen species(ROS)and antioxidants in the internal spermatic vein blood compared to the peripheral venous blood.Methods:Sixty-eight infertile oligoasthenozoospemic patients asso...Aim:To assess the relation of reactive oxygen species(ROS)and antioxidants in the internal spermatic vein blood compared to the peripheral venous blood.Methods:Sixty-eight infertile oligoasthenozoospemic patients associated with varicocele were investigated.During inguinal varicocelectomy,blood samples of internal sper- matic as well as median cubital veins were withdrawn.Three ROS factors(malondialdehyde[MDA],hydrogen peroxide H_2O_2,nitric oxide[NO])and four antioxidants(superoxide dismutase[SOD],catalase[Cat],glutathione peroxidase[GPx] and vitamin C)were estimated in these blood samples.Results:Mean levels of tested ROS factors were significantly higher in the internal spermatic venous blood compared to those in the peripheral one (mean±SD)(MDA 18.7±1.4 nmol/mL vs.15.4±1.4 nmol/mL,H_2O_2 43.6±8.0 μmol/mL vs.30.8±8.1 μmol/mL,NO 2.3±0.5 nmol/L vs.1.6±0.4 nmol/L,P<0.01).Mean levels of tested antioxidants were significantly lower in the internal spermatic venous blood compared to those in the peripheral one(superoxide dismutase 1690.7±130.0 U/mL vs.1818.5±143.0 U/mL,catalase 38.9±6.1 mol/L vs.47.9±10.2 mol/L,GPx 20.4±8.1 U/mL vs.23.0±8.4 U/mL,vita- min C 0.3±0.1 vs.0.4±0.1 mg/dL,P<0.05).Conclusion:Internal spermatic venous blood of infertile male cases associated with varicocele demonstrated elevated levels of ROS and decreased levels of antioxidants compared to peripheral venous circulation.(Asian J Androl 2006 Jul;8:451-454)展开更多
Objective:The diagnosis and treatment of this disease were discussed based on the relevant literature and the clinical data of spermatic fibrous histiocytoma in our hospital.Methods:The clinical data of 1 case of sper...Objective:The diagnosis and treatment of this disease were discussed based on the relevant literature and the clinical data of spermatic fibrous histiocytoma in our hospital.Methods:The clinical data of 1 case of spermatic cord fibrous histiocytoma admitted to urology department were retrospectively analyzed,combined with relevant literature review and discussion.Results:After surgical radical treatment,the pathological result was fibrous histiocytoma.Conclusion:Spermatic cord fibrous histiocytoma is a rare tumor of genitourinary system.The diagnosis is mainly based on pathological results.Surgery is the first choice for treatment.Adjuvant radiotherapy and chemotherapy are not effective and the prognosis is poor.Regular postoperative review is required.展开更多
文摘Aim： To evaluate the immunohistopathological changes in the contralateral testis of rats after an experimental spermatic cord torsion. Methods： Male Sprague-Dawley rats of 45-50 days old were subjected to a 720° unilateral spermatic cord torsion for 10, 30 and 80 days （experimental group, E）, respectively or sham operation （control group, C）. Histopathology of the contralateral testis as well as germ cell apoptosis were studied using the Terminal Deoxynucleotidyl Transferase Biotin-dUTP Nick End Labeling （TUNEL） technique. The number of testicular lymphocytes, mast cells and macrophages, and the expression of tumor necrosis factor-α （TNF-α） and its receptor （TNFR1） in testicular cells of the contralateral testis were quantified by histochemistry and immunohistochemistry. TNF-α concentration in testicular fluid was determined by ELISA. Results： In the contralateral testis of rats from the E group, the maximal degree of damage of the germinal epithelium was seen 30 days after torsion. At this time we observed in the E group vs. the C group increases： （i） the number of testicular T-lymphocytes; （ii） the number of testicular mast cells and macrophages; （iii） the percentage of macrophages expressing TNF-α; （iv） TNF-α concentration in testicular fluid; （v） the number of apoptotic germ cells; and （vi） the number of TNFR1^＋ germ cells. Conclusion： Experimental spermatic cord torsion induces, in the contralateral testis, a focal damage of seminiferous tubules characterized by apoptosis and sloughing of germ cells. Results suggest humoral and cellular immune mediated testicular cell damage in which macrophages and mast cells seem to be involved in the induction of germ cell apoptosis through the TNF-α/TNFR1 system and in the modulation of the inflammatory process.
基金This work was supported by grants from the National Key Research and Development Program(No.2017YFC1002003)Clinical Research Innovation Plan of Shanghai General Hospital(No.KD007-ly01)+2 种基金National Science Foundation for Young Scientists of China(No.81701428)National Nature Science Foundation of China(No.31230048)Doctoral Innovation Fund Projects from Shanghai Jiao Tong University School of Medicine(No.BXJ201838).
文摘We retrospectively reviewed data for 286 patients with varicocele who underwent microsurgical subinguinal varicocelectomy from March 2015 to May 2017 in Shanghai General Hospital(Shanghai,China).In this surgical approach,the testis was delivered,and the gubernacular and external cremasteric veins were stripped.In addition,the spermatic cord was delivered downward with continuous double traction away from the external ring.The remaining procedure was similar to the conventional approach.We followed patients for at least 3 months and evaluated postoperative semen parameters,pain symptoms,and complications.We excluded data for 32 men due to inadequate follow-up(<3 months).Of the remaining 254 patients,73 had oligoasthenospermia,121 had nonobstructive azoospermia,and 60 had symptomatic varicoceles.Total progressive sperm counts increased in the oligoasthenospermic patients from a median preoperative value of 9.15×10^6 ml^?1 to 25.33×10^6 ml^?1(n=34),and 35.6%(26/73)initially oligoasthenospermic men contributed to unassisted pregnancies.Sperm returned to the ejaculate in 12.4%(15/121)azoospermia patients.In patients with scrotal pain(n=60),43(71.7%)reported complete resolution of pain,16(26.7%)reported partial resolution,and 1(1.7%)reported no change.No patients experienced varicocele recurrence.This doubletraction strategy avoids opening the external oblique aponeurosis,and results in less damage and faster recovery.In addition,the stripping strategy eliminates potential damage to the testis caused by the varicose veins.Our results showed that microsurgical subinguinal varicocelectomy using spermatic cord double traction in conjunction with testicular delivery for vein stripping is a safe and effective approach for varicocele repair.
文摘Three patients with nutcracker syndrome(NCS) were enrolled in the study.Their clinical symptoms mainly included proteinuria and serious varicocele.Color Doppler ultrasound and computed tomography showed that the patients had constricted abdominal aortas,reduced superior mesenteric artery angles,and thinned left renal veins.Patients then underwent left spermatic vein ligation and iliac vein anastomosis.They were checked tliree months after their operation,and results showed that their sperms were improved and their proteinuria disappeared. The color Doppler ultrasound showed new cycle pathways.NCS clinical manifestations are complicated,and need combination diagnosis of symptoms and auxiliary examination to detennine surgical indications.Ligation of spermatic vein and vein anastomosis can be used to treat NCS.
文摘The microanatomy of the inguinal spermatic cords has never been reported in Asia. The purpose of this study was to describe the number and relationship of the veins, arteries and lymphatics in the spermatic cord and to clarify the location of the vas deferens in Asian men. Fifty-one patients receiving 79 primary microsurgical varicocelectomies performed by a single surgeon from April 2011 to July 2012 were studied. The number of internal and external spermatic veins, testicular arteries and lymphatic channels preserved during the inguinal microsurgical varicocelectomy were recorded. The relationship between the right and left vascular anatomy during bilateral varicocelectomies was evaluated. The data showed that mean numbers of 1.5±0.9 arteries, 5.6±2.2 spermatic veins and 3.6±1.9 lymphatics were identified during the repairs. The internal spermatic arteries were surrounded by a dense complex of adherent veins in 81.2% of the cases. The external spermatic vein or veins were found in 60.8% of the cases. The vas deferens may be contained within the internal spermatic fascia. The results suggest that the number of veins may be highly variable and less than those reported in the English literature, but there is some similarity in the inguinal microanatomy of the right and left spermatic cords, Further research is warranted to clarify our results.
文摘Spermatic cord leiomyosarcomas (LMSs) are rare tumors which may cause significant morbidity and mortality if inadequately diagnosed or treated. We report a case of a paratesticular LMS in a 60-year-old man who presented with a right scrotal mass. The patient was evaluated by scrotal ultrasound and computed tomography of the abdomen and pelvis (including scans of the scrotum), which revealed a large extratesticular mass. The lesion proved to be malignant and the patient underwent radical orchiectomy with high cord ligation. To improve the assignment of this lesion, we further analyze the imaging features of LMS and corre-late them with pathologic findings.
文摘The aim of this study was to validate the effectiveness of targeted microsurgical spermatic cord denervation (MSCD) of the trifecta nerve complex in comparison to traditional full MSCD with complete skeletonization of the spermatic cord in men with chronic orchialgia. Retrospective chart review was performed by a single fellowship-trained microsurge on between 2011 and 2016. Patie nts had follow-ups at 6 weeks, 6 mon ths, and 1 year postoperatively. Thirty-nine men with chronic orchialgia un derwe nt full MSCD between 2011 and 2013. In July 2013, after the publication of an anatomic study with identification of Wallerian degeneration of the trifecta nerve complex in men with chronic orchialgia, the technique was changed to targeted MSCD. From July 2013 to March 2016, 43 men underwent targeted MSCD. When comparing the full MSCD group to the targeted MSCD group, there was no significant difference in resolution of pain (66.7% vs 69.8%, P = 0.88), no difference in partial relief of pain (17.9% vs 23.3%, P =0.55), and no difference in failure to respond rates (15.4% vs 7.0%, P= 0.22) between the two groups. There was no differenee in mean change of visual analog pain scale scores between the two groups (P= 0.27). Targeted MSCD had a shorter operative time (53 min vs 21 min, P = 0.0001). Targeted MSCD offers patients comparable outcomes to traditional full MSCD, with a shorter operative time, a less technically challenging surgery, and potentially less risk to cord structures which should be preserved.
文摘Acute scrotal pain(AsP)requiring surgical exploration is common in the pediatric population,but little has been reported on this subject with regard to the adult population.The aim of this study was to investigate the demographic and clinical characteristics and outcomes of scrotal explorations performed on adult patients.Patients over 21 years of age who underwent surgical exploration for ASP with suspected testicular torsion(TT)at 14 French hospitals between January 2005 and December 2019 were included in this study.The main outcome measures were demographic characteristics,pathology found during scrotal exploration,and perioperative outcomes.Logistic regression was used to perform univariate and multivariate analyses to identify predictors of TT.Data for 1329 men were analyzed.The median age was 30(interquartile range[IQR]:25-35;range:21-89)years.Regarding the clinical examination,867(65.2%)patients presented with an elevation of the testicle,613(46.1%)patients with scrotal edema or erythema,and 211(15.9%)patients with nausea or vomiting.Operative findings identified TT in only 684(51.5%)patients,epididymo-orchitis in 112(8.4%)patients,a tumor in 16(1.2%)patients,and no causes in 475(35.7%)patients.Orchiectomy for nonviable testes was required in 101(7.6%)patients.In multivariate analysis,an elevation of the testicle,erythema/swelling,and the presence of nausea/vomiting were found to be associated with the occurrence of TT.Testicular torsion is not exclusive to children and adolescents,so must be considered in males of any age with acute scrotal findings.However,one-third of scrotal explorations in adults did not lead to a diagnosis.
文摘BACKGROUND Tumors of the spermatic cord are rare,and approximately 25%are malignant neoplasms.Metastatic spermatic cord tumors are even rarer.Several studies have revealed that the most frequent primary tumors metastasizing to the spermatic cord and peritesticular tissues are neoplasms of the stomach and prostate.Furthermore,metastasis to the spermatic cord or epididymis may occur via retrograde lymphatic and hematic routes.We present the case of a man with gastric cancer that metastasized to the spermatic cord and epididymis,with concomitant ipsilateral hydronephrosis after surgical resection and chemotherapy for his primary tumor.CASE SUMMARY A 71-year-old man underwent total gastrectomy for pT4aN2 poorly differentiated gastric adenocarcinoma in December 2016.Two months after surgery,he received adjuvant chemotherapy with TS-1 from February 2017 to February 2018.Surveillance computed tomography(CT)was performed in June 2018,which did not reveal any sign of tumor recurrence.In November 2019,he presented with left lower quadrant abdominal pain and a palpable left inguinal-scrotal mass.CT revealed left mild hydronephrosis and a left scrotal mass measuring 4.0 cm×1.7 cm.Tumor biomarkers,including alpha-fetoprotein(AFP),lactate dehydrogenase(LDH),beta-human chorionic gonadotropin(βHCG),carcinoembryonic antigen(CEA),and carbohydrate antigen 19-9(CA19-9)were all normal.Renal and testicular echography showed left hydronephrosis and a left peritesticular soft tissue lesion with blood flow.Diagnostic ureteroscopy showed left lower ureter narrowing without an intraluminal lesion.A biopsy was obtained for the indurated spermatic cord and epididymis,which showed poorly differentiated adenocarcinoma.Immunohistochemical staining demonstrated that the tumor was diffusely and strongly positive for homeobox protein CDX2.The features were consistent with metastatic adenocarcinoma of a primary gastric tumor.CONCLUSION In patients with a history of primary cancer,an inguinal mass of unknown cause with accompanying ipsilateral hydronephrosis may be a sign of distant metastasis from a primary tumor,especially of gastrointestinal origin.
文摘BACKGROUND Pleomorphic rhabdomyosarcoma(RMS)of the spermatic cord is a group of rare neoplasms,and a secondary hydrocele testis occasionally occurs.The misdiagnosis of paratesticular mass may lead to a therapeutic delay.CASE SUMMARY A 79-year-old man presented to our clinic complaining of a 1-mo history of painless scrotal swelling.Physical examination revealed approximately a 15 cm×10 cm×5 cm inguinal mass with limited mobility.Contrast-enhanced magnetic resonance imaging showed a hydrocele testis,several enlarged inguinal lymph nodes,and a heterogeneously enhanced lesion with a relatively well-defined margin in the left inguinal region.Due to the imaging findings,he was diagnosed with pleomorphic RMS and received a wide resection of the mass,an inguinal incision with a high section of the left spermatic cord,and a left radical orchiectomy.He experienced local relapse 1 mo postoperatively and received radiotherapy and anlotinib hydrochloride-based immunotherapy as adjuvant therapy.The patient died 3 mo after the surgery.CONCLUSION The optimal interventions for advanced-stage pleomorphic RMS patients should be investigated by more preclinical studies and clinical trials.Physicians need to be aware of the occurrence of pleomorphic RMS in unusual locations,especially when accompanied by a hydrocele testis.
文摘Few cases of Liposarcoma of the spermatic cord have been reported in the literature. This rare tumor represents 7% of malignant tumors of the spermatic cord. We report a case of an unusual liposarcoma of the spermatic cord, with respect to its sclerosing variant, occurring in a healthy looking 42 years old man. A wide local excision of the tumor was performed. Adjuvant radiotherapy may sometimes be effective on local recurrence. Even though this tumor evolves slowly, a prolonged follow up is required because of the risk of late recurrence.
文摘BACKGROUND Sperm granuloma is a rare disease in clinical andrology and its incidence is still unclear worldwide.According to the existing literature,sperm granuloma often occurs unilaterally.Clinical and ultrasound features are similar to epididymal tuberculosis,chronic epididymitis and other diseases.Sperm granuloma is usually diagnosed based on postoperative histopathological and immunohistochemical examination.CASE SUMMARY A 46-year-old man was admitted to the hospital due to the presence of a left scrotal mass for 3 mo and aggravation of pain for 1 wk.The lesions at both sites were surgically resected.Postoperative pathological examination showed that the left spermatic cord mass and the right epididymal mass were consistent with sperm granuloma.The sperm granulomas then recurred 3 mo after surgery.There is little change in the local mass so far.CONCLUSION The case report is helpful for our understanding of this disease.In clinical diagnosis,it should be distinguished from epididymal tuberculosis,chronic epididymitis and other diseases.Color Doppler ultrasound can be used as a preferred examination method but postoperative pathological examination is still needed for diagnosis.
文摘Background: To evaluate aetiology of acute scrotum after surgical exploration suspicious for spermatic cord torsion, to compare surgical with clinical findings and to support the clinician distinguishing spermatic cord torsion from other diseases mimicking this emergency requiring surgical exploration. Methods: All men with the diagnosis of an acute scrotum who underwent emergency scrotal exploration between January 1995 and October 2009 were retrospectively evaluated. Results: 230 patients were analyzed. Torsion of the spermatic cord (53%) was the most common cause followed by torsion of the testis appendages (25%). Patients with spermatic cord torsion were significantly older (15.5 y) and haunted hospital faster than others (p Conclusions: Our data demonstrate that spermatic cord torsion is more common in adolescent. Short pain duration and high intrascrotal position of the testicle are associated with higher probability of spermatic cord torsion. Duplex sonography plays an important role in the diagnostic workup but history and physical examination are the crucial parameters. In nebulous clinical cases emergency surgical exploration has to be recommended.
文摘Aberrant adrenocortical tissue in spermatic cord is rare in adult population. We report an unusual case of a 52-year-old male patient with an aberrant adrenocortical tissue which is incidentally resected within lipoma of spermatic cord and identified on microscopic examination. Although he was diagnosed with right inguinal hernia, there was no significant hernia orifice intraoperatively. When the 2nd operation by anterior open approach was undergone, there was a fat-like tissue adhered to the spermatic cord. It was removed and the histopathological finding first revealed aberrant adrenocortical tissue in the resected lipoma of spermatic cord (Figure 1). This abnormal tissue is usually found incidentally during inguinal operation. In general, most of the aberrant adrenal tissue becomes atrophic by adult life. Moreover, it is not clinically significant and also not associated with endocrine abnormalities.
文摘Introduction: The purpose of this work is to evaluate the epidemiological, clinical and therapeutic aspects of spermatic cord in our context. Patients and Methods: This is a retrospective study over a period of 4 years from January 1, 2014 to June 30, 2018. Results: We collected 55 cases divided into 26 cases, 44.27% for the Thies Regional Hospital, 21% or 38.18% for the Mbour EPS and 8 cases representing 14.55% for the Saint Jean de Dieu Hospital. We found an average age of 20.03 years with extremes of 4 years and 56 years. In 28 patients or 50% of cases, we found no particular pathological history, while in 4 patients or 7.14%, we found a notion of recurrent ipsilateral testicular pain. We recorded 67.27% (n = 37) of the cases received for testicular pain;15 patients or 27.27% presented a large painful pouch. Two patients (3.64%) were received for inguinal swelling and 1 patient (1.82%) presented testicular atrophy. The average consultation time is 16.9 hours with extremes of 2 hours and 96 hours. The torsion was in 59.61% of cases (n = 32) located on the right versus 40.38% (n = 22) on the left. There was no bilateral form. The pick-up time was 3 hours with extremes of 1 h to 24 h. All patients benefited from an exploratory scrotomy. We found a total of 22 patients or 40% of cases with ischemic testis, 8 cases or 14.55% of patients with necrotic testis and 2 cases or 3.64% where the testis was normal. Orchidopexy was performed in 46 patients or 83.63% and orchiectomy in 9 patients. Conclusion: Care is urgent. There is a need for better awareness of the population and the medical staff for the early diagnosis.
文摘Primary liposarcoma of the spermatic cord is rare, and preoperative diagnosis is difficult. We report a rare case of well-differentiated liposarcoma in 65-year-old man. The patient’s chief complaint was painless enlargement of a mass in the right inguinal area that had persisted for about two months. The main component of the mass was wrapped around the spermatic cord and several components were around the testis. Ultrasonography of the main component showed mixed echogenicity. CT showed an ovoid fat-containing nodule and several other fat-density masses surrounding the testis. The mass was surgically removed, along with the right testis and spermatic cord. A pathological examination showed a well-differentiated liposarcoma of the right spermatic cord and testis.
文摘Introduction: Torsion of the spermatic cord is an emergency whose delay in treatment conditions the functional prognosis of the testicle. The aim of this study was to analyze the management of spermatic cord torsion in the Urology Andrology Department of the Ignace Deen National Hospital in Conakry. Material and methods: This was a ten-year retrospective descriptive study from January 1, 2012 to December 31, 2021. It involved all patients admitted for torsion of the spermatic cord, confirmed at surgical exploration. Results: We identified 21 cases of torsion of the spermatic cord. The mean age of the patients was 17.9 ± 4.4 years. The average consultation time was 19.2 ± 21.4 hours with extremes of [2 h and 98 h]. Only 6 patients (28.6%) consulted before the sixth hour. All patients presented with scrotal swelling. At scrototomy, all torsions were intravaginal with two turns of spiral in 13 cases and three turns in 8 cases. Orchiectomy followed by contralateral orchidopexy was performed in 6 cases. In the other cases, bilateral orchidopexy was performed after detorsion. The average hospital stay was 4.5 days. We recorded 4 cases of testicular atrophy after orchidopexy. Conclusion: Spermatic cord torsion is an infrequent emergency in our department. The delay in consultation remains the main predictive factor of testicular necrosis. Emergency exploratory scrotomy should be the rule.
文摘Background: A high level of sperm chromatin decondensation results in loss of DNA quality and it is associated with poor embryonic prognosis in Assisted Reproductive Technology (ART). This had lead to introduction of sperm DNA compaction testing in assessment of clinical male infertility. Toluidine blue assay is one of most commonly used tests to measure chromatin decondensation in research studies and also in clinical routine use. So the objective of our study was to assess the level of sperm chromatin decondensation by toluidine blue assay in men dealing with couple infertility. Methods: The sperm samples of 96 patients referred for infertility, over a 4-month period from September 2020 to January 2021, were stained with toluidine blue and observed under an optical microscope. These were evaluated according to the World Health Organization. Results: The 25 - 34 age group was the most represented among infertile men. There was a non-significant correlation between age and the level of spermatic chromatin condensation (r = 0.0348). Spermatic parameters had averages above standards norms, apart from that of low vitality. Spermatic chromatin decondenization affected 96% of infertile patients. Asthenozoospermia was the most common abnormality. Among standard parameters of spermogram, only the concentration of spermatozoa in the semen was weakly correlated (r = 0.18) with sperm chromatin decondensation. Conclusion: The level of sperm chromatin condensation is, on the one hand, a parameter independent of the age of the subject; on the other hand, allows to evaluate male infertility, like the classic parameters of the spermogram and spermocytogram. However, in view of the high probability of changes in the nuclear quality of sperm intrinsic to the analysis process and sperm concentration, an improvement of the toluidine blue test using the swim-up technique and associated with image processing software is possible.
文摘Introduction: Twisting of the spermatic cord is part of urological emergencies. It can occur at any age with a predilection for children and adolescents. There is no literature on spermatic cord torsion in octogenarians, probably due to its rarity. The majority of recent studies show spermatic cord torsion in patients under 55 years of age. This is why we present a case of spermatic cord torsion in an 80 years old subject. Case Presentation: We present a case of torsion of the spermatic cord in an 80-year-old subject. The diagnosis was made on anamnestic and clinical grounds. The patient presented with scrotal pain, unilateral, of sudden onset, violent intensity without urinary signs with an ascended testicle. The urine dipstick was unremarkable. Management was done surgically and as an emergency. The postoperative course was satisfactory. Conclusion: Spermatic cord torsion in octogenarians is exceptional and should be suspected in the first instance in the presence of any sudden onset, severe testicular pain without urinary signs with an ascended testicle and a negative urine dipstick.
文摘Aim:To assess the relation of reactive oxygen species(ROS)and antioxidants in the internal spermatic vein blood compared to the peripheral venous blood.Methods:Sixty-eight infertile oligoasthenozoospemic patients associated with varicocele were investigated.During inguinal varicocelectomy,blood samples of internal sper- matic as well as median cubital veins were withdrawn.Three ROS factors(malondialdehyde[MDA],hydrogen peroxide H_2O_2,nitric oxide[NO])and four antioxidants(superoxide dismutase[SOD],catalase[Cat],glutathione peroxidase[GPx] and vitamin C)were estimated in these blood samples.Results:Mean levels of tested ROS factors were significantly higher in the internal spermatic venous blood compared to those in the peripheral one (mean±SD)(MDA 18.7±1.4 nmol/mL vs.15.4±1.4 nmol/mL,H_2O_2 43.6±8.0 μmol/mL vs.30.8±8.1 μmol/mL,NO 2.3±0.5 nmol/L vs.1.6±0.4 nmol/L,P<0.01).Mean levels of tested antioxidants were significantly lower in the internal spermatic venous blood compared to those in the peripheral one(superoxide dismutase 1690.7±130.0 U/mL vs.1818.5±143.0 U/mL,catalase 38.9±6.1 mol/L vs.47.9±10.2 mol/L,GPx 20.4±8.1 U/mL vs.23.0±8.4 U/mL,vita- min C 0.3±0.1 vs.0.4±0.1 mg/dL,P<0.05).Conclusion:Internal spermatic venous blood of infertile male cases associated with varicocele demonstrated elevated levels of ROS and decreased levels of antioxidants compared to peripheral venous circulation.(Asian J Androl 2006 Jul;8:451-454)
文摘Objective:The diagnosis and treatment of this disease were discussed based on the relevant literature and the clinical data of spermatic fibrous histiocytoma in our hospital.Methods:The clinical data of 1 case of spermatic cord fibrous histiocytoma admitted to urology department were retrospectively analyzed,combined with relevant literature review and discussion.Results:After surgical radical treatment,the pathological result was fibrous histiocytoma.Conclusion:Spermatic cord fibrous histiocytoma is a rare tumor of genitourinary system.The diagnosis is mainly based on pathological results.Surgery is the first choice for treatment.Adjuvant radiotherapy and chemotherapy are not effective and the prognosis is poor.Regular postoperative review is required.
