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Objective. To explore the effect of scrotal reconstruction following avulsion on spermatogenesis.
Methods. Three patients were followed-up after having their scrotums reconstructed. Two scrotums were reconstructed by skin flap. Another patient's testicles were buried in thigh pockets. The follow-up continued from 3 months to 4 years after operation, and we examined the sperm quality, sexual function, sexual hormone, and testis biopsy.
Results. The follow-up data showed that the spermatogenesis was not altered in the early stage (up to three months), but was substantially abnormal in the late stage (after two years).
Conclusions. Using the thick skin flaps, or burying the testicle for scrotum reconstruction are not recommended for patients who wish to remain fertile.
The incidence of scrotal trauma in civilian life compared to other body areas is relatively low but since the development of industrialisation in our country, avulsions of the skin of the penis and scrotum have become more prevalent each year. The skin loss is often extensive and skin cover for the testes and penis has been provided in several ways: by means of reimplantation of testes in the thigh, split thickness skin grafts and flaps. However, the data on spermatogenesis have been rarely reported after reconstruction of cover for the testes. In this study, three patients were followed-up whose sperm quality, sexual action, hormone level, and testis biopsy were examined.
1. Materials and methods
1.1 Case 1
A 19-year-old man, the skin of the penis and whole scrotum were avulsed by a rotating mechanical shaft. He presented 3 h after injury with exposed testes and penis. The skin of the penis was avulsed incompletely, with a pedicle of attachment at the coronal sulcus. The blood supply was maintained in his testis and penis (Fig. 1) . After debriding the wound thoroughly, the scrotum was reconstructed with an iliogroin skin flap and the avulsed skin of the penis was replaced. A free split thickness skin graft was used on the dorsum of the penis.
A 42-year-old man, the scrotum was bitten by a pig and the majority of the skin was lost. After debriding the wound thoroughly, the right testicle was bare and the remaining skin of the scrotum could not cover the wound. An iliogroin skin flap was created to repair the defect of scrotum.
1.3 Case 3
A 31-year-old man, the scrotum was avulsed by the rotating wheel of a train. The victim's left lower limb and left testicle were excised because of serious damage. The right testicle was buried in the right thigh and the remaining wound was covered with free split thickness skin graft.
2. Result of follow-up
2.1 Case 1
Three months after the operation, the patient was followed-up (Fig. 2) . The penis could become erect and the sperm quality examination showed a normal result for volume of sperm at 2.5 ml, the liquefaction time 20 min, the sperm count 90×109/l and the rate of activity 85%. At 30 months post-reconstruction, the patient was examined again. The reconstructed scrotum had become soft and thin (Fig. 3) . The patient could achieve satisfactory sexual intercourse. The sperm examination showed the capacity of sperm 3 ml, the liquefaction time 35 min, the count of sperm 0.8×109/l and the rate of activity 0%. After a week, the sperm quality was tested again and the result was confirmed. There were normal sexual hormones in 30 months containing TTE 24.1 nmol/l, FSH 7.0 mIU/ml, LH 3.5 mIU/ml. The anti-sperm antibody was negative. Testis biopsy showed that there were rare spermatogenic cells except for supporting cells in the convoluted semi-niferous tubule. The limiting membrane became incrassate and there was no obvious fibrous tissue hyperplasia and inflammatory cells infiltration in the tubes and interstitium (Fig. 4) . The electron microscope showed that there were no mature sperm. The number of myofibroblasts and fibro-tissues increased outside the tubule (Fig. 5) .
Fig. 4(Case 1) Testis biopsy: there are rarely spermatogenic cells except for supporting cells in the convoluted seminiferous tubules. The limiting membrane became incrassate and there were not obvious fibrous tissue hyperplasia and inflammatory cells infiltration in the tubes and interstitium. HE×200.
Fig. 5(Case 1) There was a integrity configuration in the transverse surface of convoluted seminiferous tubule and most cells were supporting cells in the tubule. The layers of myocyteoid and fibroblast increased out of the tubule.
Post-operation, the patient was followed-up for 48 months (Fig. 6) . Because one testicle was not damaged, the sperm examination showed the volume of sperm 2.5 ml, the liquefaction time 20 min, the count of sperm 82×109/l and the rate of activity 65%. The sexual hormone showed TTE 16.4 nmol/l, FSH 7.8 mIU/ml, LH 3.1 mIU/ml. There was an abnormal result of testis biopsy in right testicle. The spermatogenic cells decreased and the mature sperms were discovered by chance in the convoluted seminiferous tubule. The limiting membrane became incrassate and there were not obvious fibrous tissue hyperplasia and inflammatory cells infiltration in the tubes and interstitium (Fig. 7) .
Fig. 7(Case 2) Testis biopsy in right testicle: the spermatogenic cells decreased and the mature sperms were discovered by chance in the convoluted seminiferous tubules. The limiting membrane became incrassate and there were not obvious fibrous tissue hyperplasia and inflammatory cells infiltration in the tubes and interstitium. HE×200.
Post-operation 31 months, the patient was followed-up (Fig. 8) . The sperm examination showed the capacity of sperm 2.5 ml, the liquefaction time 40 min, the count of sperm 0–2/l and the rate of activity 0%. The sexual hormone showed TTE 10.2 nmol/l, FSH 18.8 mIU/ml, LH 5.9 mIU/ml, E2<73.4, PRL338 mIU/ml. The anti-sperm antibody was negative. Testis biopsy showed that the spermatogenic cells decreased and the mature sperms were rare in the convoluted seminiferous tubule. The basement membrane became incrassate and there were fibrous tissue hyperplasia in the interstitium. (Fig. 9) .
Fig. 8(Case 3) Thirty-one months the right testicle buried.
Fig. 9(Case 3) Testis biopsy showed that the spermatogenic cells decreased and the mature sperms were rare in the convoluted seminiferous tubules. The basement membrane became incrassate and there were fibrous tissue hyperplasia in the interstitium HE×200.
Although not life threatening, avulsion injuries of the scrotum can have serious psychological and physiological consequences. Numerous techniques have been described for the reconstruction of the scrotum. It is clear that when scrotal remnants are sufficient, their elasticity often allows for primary coverage of the wound.
However, this technique does not work well in patients in whom the testis is devoid of tunica vaginalis. Moreover, fixation of the graft is quite difficult in infected or delayed cases. In the past, when the scrotum was avulsed completely, the testis often was buried in the thigh. But this techniques had certain disadvantages for the patients: (1) psychologically, they are not satisfied because of absence of the scrotum; (2) there is constant pain at the implanted site as a result of mechanical trauma; and (3) very frequently, these testis undergo atrophic changes.
Since the main function of the scrotum is that of a local thermoregulator for the testis, the temperature of the testis in the reconstructed location must be maintained as close as possible to the temperature within the normal scrotum. Moore and Quick have demonstrated that temperatures 2–8 °C lower than the abdominal temperature are necessary for normal spermatogenesis. Moore confined the testis of guinea pigs in the abdominal cavity and Fukui exposed the scrotum of rabbits to abnormally high temperatures. Each of the findings demonstrated regression and disorganisation of spermatogenesis and the germinal epithelium. David measured the temperatures of the abdominal cavity, scrotum, superficial thigh, and deep thigh in 15 patients and discovered essentially the same temperature in the deep thigh as intra-abdominal. The temperature of the superficial thigh closely paralleled that of the scrotum. These findings indicated that if the testis was to be buried in the thigh it would have to be placed just beneath the skin, for the temperature beneath the subcutaneous fat would lead to regression and disorganisation of spermatogenesis.
have been described to reconstruct scrotum. Because of the testis being covered by thick fat or even muscle, the temperatures of such reconstructed scrotums are likely to be higher than that of the normal scrotums. The spermatogenesis of testis may be altered in these scrotums, which are reconstructed by thick flaps. Other authors have postulated that the temperature of the scrotum reconstructed by flap can interfere with spermatogenesis,
but few follow-up data such as the sperm examination, sexual hormone and testis biopsy are reported in these patients. The follow-up results of three patients are reported in this article. The results suggest that the spermatogenesis of testis are not interfered in the early stage (in three months), but there are abnormal results of the sperm quality examination and testis biopsy at two years. However, the sexual action and sexual hormone are not interfered in the late stage. A very interesting phenomena was discovered in our follow-up, namely that the flap or the skin covering the testis becomes soft and thin (Fig. 3, Fig. 6, Fig. 10) . This phenomena is also discovered in the patient who's scrotum was repaired by split thickness grafts.
Our follow-up results show that the scrotum reconstructed by flaps and the method of burying testis in deep thigh will interfere with spermatogenesis. But the time course for this interference is quite slow, the spermatogenesis is likely to be unaltered in the early stage after scrotal reconstruction, but it is substantially altered at two years. The patients' sexual activity is not an appropriate index to evaluate spermatogenesis. In addition, thick flaps are not recommended to reconstructed scrotum. The thin flap
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