Enlarged Leydig cells could also be observed in the interstitial tissue. They contained many vacuoles and electron-dense mitochondria. Some of them showed a disrupted cell membrane (Fig. 23).
Group III showed many layers of spermatogenic cells similar to that of the control. The primary spermatocytes showed dispersed heterochromatin within the nucleus. The cytoplasm showed a prominent Golgi apparatus and many mitochondria. The early spermatids showed peripherally situated mitochondria, chromatoid bodies, and acrosomal vesicles (Fig. 24). In some tubules, the early spermatids showed a moderately electron-dense cytoplasm with many vacuoles and an apparent decrease in the number of mitochondria. Cytoplasmic bridges could be detected between the cells (Fig. 25). Sertoli cells appeared more or less similar to those of the control group (Fig. 26).
In group II (torsion detorsion group), the SNTs showed a significant decrease in the mean surface area of the SNTs and the mean spermatogenic height as compared with those of the control group (P < 0.05). However, group III (orchiectomy group) showed a nonsignificant change as compared with the control group I (Table 1).
Acute scrotum is a clinical syndrome mainly caused by torsion of the spermatic cord that constitutes a surgical emergency affecting newborns, children, and adolescents. This syndrome often leads to infertility because the ipsilateral (torted) and contralateral (not torted) testis are affected, an outcome that makes surgical intervention mandatory .
The present study observed many structural alterations in the contralateral testis 2 h following unilateral testicular torsion detorsion (UTD). In this study, sloughing and exfoliation of the germ cells in the lumina of the tubules were observed. In addition, large vacuoles were detected in between the spermatogenic epithelium. Similarly, many reports have shown that UTD results in contralateral testicular damage. This damage included an uneven distribution of the SNTs, interstitial edema, markedly reduced numbers of spermatogenic cells up to the absence of germ cells, and replacement of tubules by hyaline material in addition to apoptosis and sloughing of germ cells [6,8,13–17].
The exfoliation of the germ cells could be because of a primary effect on the cell-to-cell junctions between Sertoli and germ cells . Moreover, the spaces and vacuoles detected in between the spermatogenic epithelium might be because of the exfoliation and the sloughing of germ cells .
The mechanism of contralateral testicular damage after UTD remains controversial. Multiple factors contribute toward the injury of the contralateral testis after UTD. The main pathophysiology of testicular torsion detorsion is I/R injury of the testis .
Accordingly, different authors have suggested a role of blood supply in the contralateral testicular affection, although the results have been contradictory. Many authors have reported that UTT causes a decrease in the contralateral testicular blood flow and hypoxia, which may lead to contralateral degeneration of germ cells and testicular damage [8,15]. However, other authors have reported increased, rather than reduced, blood perfusion after UTD in the contralateral testis [19,20]. The present results were in agreement with those of the increased blood perfusion studies as detected by the congested blood vessels.
The testis is controlled by the visceral sympathetic nerves , and testicular parenchyma shows very rich innervation, distributed mainly to the blood vessels . The visceral sympathetic nerves can be activated after UTT and may cause an increase in the blood perfusion in the contralateral testis .
The SNTs are avascular and yet very metabolically active. The SNTs depend on the transport of oxygen and nutrients from the interstitial vasculature and require a regular blood flow to maintain normal spermatogenesis. Therefore, they are susceptible to alterations in blood flow. Moreover, PO2 is dependent on blood flow and disturbances in blood flow may easily alter the amount of oxygen available for critical metabolic processes in spermatogenesis .
Reperfusion time appears to be a determinant of contralateral testicular damage because of the consequent oxidative insult that accompanies the increase in ROS following I/R . Furthermore, Akcora et al., in their experimental study, concluded that gradual detorsion in two steps decreased the degree of testicular reperfusion injury in rats. This was detected by significant decreased superoxide dismutase and glutathione peroxidase activities in the sudden detorsion group as compared with the gradual detorsion group as well as preservation of the structure of the testis .
Testicular torsion caused loss of spermatogenesis and a significant increase in germ cell apoptosis arising from a significant increase in the proapoptotic molecules and intratesticular ROS concomitant with reperfusion . When ROS production exceeds the capacity of the defense mechanisms, cell damage occurs as mammalian testes are highly sensitive to oxidative free radical damage [5,26].
Moreover, upon reperfusion of the tissue, oxygen becomes available, resulting in the generation of a huge amount of free radicals that react with the lipids present in the cell membrane and mitochondrial membrane, leading to the disruption of the integrity of the cell and damage to the cell membrane. Sperm are highly sensitive to oxidative stress and particularly to lipid peroxidation because of their high content of polyunsaturated fatty acids in the plasma membrane [27,28].
Oxidative stress arises with the recruitment of neutrophils, which secrete inflammatory cytokines such as tumor necrosis factor-α, interleukin-1β, and interleukin-8. The invading neutrophils may also secrete factors that induce Sertoli cells to secrete FasL . Fas receptors are present on the germ cell membrane. FasL binding initiates the intracellular ‘death domain’ pathway, which leads to DNA degradation, thus causing germ cell death .
By electron microscopic examination, the present results showed that the primary spermatocytes and the spermatids were principally affected. The abnormalities included cytoplasmic vacuoles, a decrease in mitochondria, and irregular nuclei. Similar results have been obtained in previous studies . It has been reported that spermatogonia, capillary endothelium, connective tissue, and peritubular fibroblasts are rarely involved. Trauma to the blood–testis barrier initiated by testicular torsion induces the release of apoptotic-activating factors (cytokines), which subsequently cause extensive apoptosis in the germinal epithelium of the contralateral testis .
In the present work, many multinucleated giant cells were observed inside the tubules. A similar observation has been made in a previous study . Other authors have reported testicular multinucleated giant cells as a degenerative syndrome resulting from the inability of tetraploid primary spermatocytes to complete meiotic division; thus, maturation arrested at the spermatid stage of development . Giant cells may also be formed as a result of the fusion of spermatids because of alterations in the intercellular bridges . Moreover, it has been suggested that multinucleated giant cells could be aggregates of degenerated spermatocytes and spermatids that were often sloughed into the lumen of the SNTs .
Other studies have reported that histopathologic testicular damage and humoral and cellular immune responses occur simultaneously in the contralateral testis after UTD. They suggested the involvement of an immunologic mechanism in the induction of the lesion in the contralateral testis . Other theories proposed included autoimmunity and the release of acrosomal enzyme .
The results of the present study showed that interstitial spaces were wide and hypercellular with congested blood vessels. There was an apparent increase in the number of Leydig cells along with other mononuclear cellular infiltration. These results were in agreement with those of a previous study . The authors found clusters of Leydig cells surrounded by many cells such as plasma cells and macrophages and increased fibroblasts in the interstitium.
The vacuolation and the apparent increase in the number of interstitial cells that was observed in the present work might be attributed to increased activity of Leydig cells. It has been reported that Leydig cells normally release their hormones into the interstitium, from which it diffuses to the tubules to exert their local effect on spermatogenesis and into blood and lymphatic vessels to exert their systemic effect. The SNTs feed back to inhibit Leydig cells. Therefore, any local damage to SNTs appears to reduce this inhibitory effect and induces hypertrophy and increased activity of Leydig cells .
In addition, I/R injury resembles an inflammatory response, resulting in the activation of endothelial cells and subsequent leukocyte margination, followed by diapedesis to the interstitium of the testis, increasing the number of cells in the interstitium .
In the present study, the epididymis following UTD showed that contralateral epididymal tubules were full of exudates, necrotic material, degenerated cells, and absent sperm. The tubules were surrounded by wide connective tissue spaces containing inflammatory cells, exudates, necrotic material, and congested blood vessels. The structural changes in the epididymis could be a consequence of the changes detected in the SNTs. As the lumena of the SNTs were filled with necrotic material, exudates with absence of sperms, it is also expected that the epididymal tubule show the same content.
In the present work, in the contralateral testis after testicular torsion and orchiectomy, the spermatogenic cells lining most of the SNTs were organized and rested on their surrounding basement membranes. The lumina of the tubules contained late spermatids with their long tails.
These results were in agreement with the results of a previous study. The authors reported that the structural changes in the contralateral testis in the torsion/detorsion group were significantly more (58.6%) than those of the torsion/orchiectomy group (48.0%) .
Moreover, many authors have suggested that orchiectomy had a prophylactic value and maintained fertility more than detorsion after testicular torsion in the contralateral testis [11,37].
An explanation for this could be that after the detorsion procedure, reperfusion not only increased blood flow but also increased the presence of oxygen free radicals, which caused cellular damage through lipid peroxidation . It has been reported that the tissue superoxide dismutase level decreased more in animals that underwent detorsion procedures than in orchiectomized animals .
In contrast, in a recent clinical study, it was concluded that detorsion with orchiopexy yields better testicular function than orchiectomy in the short term. This was detected by the high levels of testosterone and serum inhibin B levels .
Moreover, Romeo et al. carried out a prospective study evaluating patients 5 years following testicular torsion. They reported that hormonal testicular function could be compromised after testicular torsion, although the type of surgery (orchiectomy or detorsion) did not seem to alter the effect of this I/R injury .
There is a possibility of an immunologic mechanism that damages the contralateral testis. Testicular torsion results in exposure of the antigenic stimulation, thus increasing the immunologic mechanisms. Therefore, removal of the torted testis would tend to protect against the development of contralateral testicular damage. Furthermore, the return of blood flow to a testis that was already damaged (detorsion) might increase the stimulation of a presumed immune-mediated attack on the contralateral testis .
The present results showed that orchiectomy following testicular torsion better preserved the structure of the contralateral testis and epididymis as compared with detorsion. Taking into consideration the current methodology (study plan), it cannot be generalized that orchiectomy is the favorable choice. Many factors may have played a role in the outcome of the study: the duration of the experiment (1 week), the duration of torsion (2 h), the degree of torsion (720°), the species (rat), and the sudden detorsion. Therefore, further studies are required to analyze each of these factors to obtain a more specific and detailed protocol as to when to choose orchiectomy and when to choose detorsion.
Conflicts of interest
There is no conflict of interest to declare.
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Keywords:© 2012 The Egyptian Journal of Histology
contralateral testis; detorsion; orchiectomy; testicular torsion.