CPT® Code 54500

1. Indications

Biopsy of the testis is performed for several specific indications, primarily related to the evaluation of testicular health and function. The following conditions may warrant this procedure:

• Evaluation of Testicular Masses - When a mass is detected in the testis, a biopsy may be necessary to determine its nature, whether benign or malignant.
• Azoospermia - In cases where there is an absence of living sperm in a semen sample, a testicular biopsy can help ascertain whether sperm are present in the testicular tissue.

2. Procedure

The procedure for a needle biopsy of the testis involves several critical steps to ensure accuracy and patient safety. The following outlines the procedural steps:

• Step 1: Preparation - The area of the skin over the planned puncture site is thoroughly cleansed with an antiseptic solution to reduce the risk of infection. This step is crucial for maintaining a sterile environment during the procedure.
• Step 2: Anesthesia - A local anesthetic is administered to the patient as needed. This is done to minimize discomfort during the biopsy, allowing for a more tolerable experience.
• Step 3: Needle Insertion - A large bore needle is then carefully inserted into the testis. The physician must ensure proper technique to obtain an adequate tissue sample while avoiding damage to surrounding structures.
• Step 4: Tissue Sample Collection - Once the needle is in place, a tissue sample is extracted from the testis. This sample is critical for subsequent laboratory analysis.
• Step 5: Sample Handling - The obtained tissue sample is placed in Bouin's fluid if the biopsy is performed to evaluate azoospermia. This preservation method is essential for maintaining the integrity of the sample during transport to the infertility laboratory for histological evaluation.

3. Post-Procedure

After the needle biopsy of the testis, patients may experience some discomfort or swelling at the puncture site. It is important for healthcare providers to monitor the site for any signs of infection or complications. Patients are typically advised to avoid strenuous activities for a short period following the procedure to facilitate healing. The tissue sample will be sent to a laboratory for histological evaluation, and results will be communicated to the patient in a timely manner to guide further management based on the findings.