Case and literature review on TERT

The case report article titled“Tubular ectasia of rete testis with obstructive azoospermia and infertility: A case report and literature review”, was published on December 11, 2024.

Tubular ectasia of rete testis (TERT) is a benign yet elusive condition, marked by the dilation of the rete testis. It stems from a variety of causes, including post-infectious inflammation, trauma, prior surgeries in the inguinal or scrotal area, mechanical compression of ducts, and congenital malformations. Despite its significance, TERT is seldom reported in medical literature, especially in relation to infertility.

This paper showcases a 33-year-old male patient who visited the male infertility clinic with a 5-year history of primary infertility. His overall health was good, with no history of scrotal issues, genital infections, or traumas. Physical examination showed normal-sized testes, but the epididymides were enlarged with multiple cysts. Semen analysis consistently indicated azoospermia, while serum hormone levels and tumor markers were normal. Genetic testing also revealed a normal male karyotype and no Y-chromosome microdeletions.

Scrotal ultrasound was a key diagnostic step. It showed extensive cystic changes in the rete testis area, more pronounced on the right side and extending into the epididymis. Transrectal ultrasonography further detected obstructive changes in the ejaculatory ducts, causing cystic dilation of the seminal vesicles and vas deferens. A testicular needle biopsy was carried out, and it demonstrated normal spermatogenesis, leading to a diagnosis of obstructive azoospermia.

During surgery, the epididymis had multiple cystic dilations, and vasography showed that the vasa deferentia were patent without distal blockage. However, sperm were not found in the epididymal aspirates. In contrast, testicular aspiration retrieved sperm, which were cryopreserved for potential intracytoplasmic sperm injection (ICSI).

TERT has a low prevalence, affecting about 1.64% of the general population and 1.2% of men being evaluated for infertility. It is often incidentally discovered during testicular ultrasonography. Some patients might experience scrotal pain, but this could be due to associated conditions like epididymal cysts. TERT is frequently linked with epididymal pathologies. When diagnosing TERT, it's crucial to differentiate it from both benign and malignant conditions. The diagnosis usually combines clinical factors, such as age and symptoms, with characteristic ultrasound findings.

The connection between TERT and male infertility remains unclear. Some studies suggest that TERT might contribute to abnormal semen analysis results. However, it's hard to determine its exact impact because patients often have other factors that could affect fertility. In this case, the patient didn't have common infertility-related risk factors like undescended testes or varicoceles, making TERT a potential main cause of his infertility.

For managing TERT, a conservative approach is usually recommended for asymptomatic patients with no signs of malignancy. But for those with chronic testicular pain, surgical options like spermatic cord block or microsurgical denervation might be considered. In severe cases, orchiectomy could be an option.

In conclusion, TERT is a rare condition with an uncertain impact on male fertility. More research is needed to fully understand its role in infertility and to improve diagnostic and treatment methods. This case report provides valuable insights into TERT-associated infertility, highlighting the importance of a thorough approach in diagnosing and managing such cases.

DOI: 10.1002/uro2.102