P–095 Outcomes and predictive factors of successful salvage microdissection testicular sperm extraction (mTESE) after failed TESE in men with non-obstructive azoospermia: results from a multicenter study

Study question

We assessed the outcome and predictors of successful salvage microdissection testicular sperm extraction (mTESE) in non-obstructive azoospermia (NOA) men previously submitted to unfruitful classic (cTESE).

Summary answer

The sperm retrieval rate at salvage mTESE was almost 50%. Hypospermatogenesis and low FSH values were associated with positive outcomes at salvage mTESE

What is known already

In men with NOA testicular sperm can be retrieved using cTESE in approximately 50% of cases. mTESE has been proposed as a salvage treatment option for men with a previously failed TESE, but data are scarce.

Study design, size, duration

Multicenter, cross-sectional study. Complete data from 61 NOA men who underwent mTESE after a failed cTESE between 01/2014 and 10/2020, at 6 tertiary referral centers in Italy were analysed.

Participants/materials, setting, methods

All men underwent testicular ultrasound, hormonal and genetic blood testing. Histopathological diagnosis from TESE was collected in every man. Semen analyses were based on the 2010 WHO reference criteria. mTESE was performed according to the technique of Schlegel et al. (1999). Descriptive statistics and logistic regression models were used to investigate potential predictors of positive sperm retrieval (SR+) after salvage mTESE.

Main results and the role of chance

Overall, median (IQR) age and testicular volume were 35 (31–38) years and 10 (6–15) ml, respectively. Baseline serum FSH and total testosterone levels were 17.1 (8.6–30.4) mUI/mL and 4.7 (3.5–6.4) ng/mL, respectively. Sertoli-cell-only (SCO) syndrome, maturation arrest (MA) and hypospermatogenesis were found in 24 (39.3%), 21 (34.4%) and 16 (26.2%) men after cTESE, respectively. Spermatozoa were retrieved in 30 (49.2%) men at salvage mTESE. Patients with a diagnosis of hypospermatogenesis had a higher rate of SR + [12/16 (75%)] than those with MA [12/21 (57.1%)] and SCOS [6/24 (25%)] after salvage mTESE (p < 0.01), which was bilateral in 36 (59%) cases. FSH was higher [16.5 (8–22) vs. 8.9 (5–13) mUI/mL, p < 0.01] in SR- patients compared to SR+. No difference in clinical characteristics was found between patients with SR+ and SR- at salvage mTESE. There were no significant complications after mTESE. Multivariable logistic regression analysis showed that hypospermatogenesis (OR 9.7; p < 0.01) and low FSH levels (OR 0.9, p < 0.001) were independent predictors of SR+ after salvage mTESE, after accounting for age.

Limitations, reasons for caution

Despite we analysed one of the largest series of salvage mTESE, the samples size is too small to draw general conclusions. Because of the multicenter nature of the study we cannot rely on standardization of surgical techniques for TESE.

Wider implications of the findings: This is one of the larger studies on salvage mTESE. The selection of patients for salvage mTESE is of critical importance.

Trial registration number

na

High prevalence of testicular cancer in azoospermic men without spermatogenesis

BACKGROUND

An increased risk of testicular cancer in men with infertility and poor semen quality has been reported. Our aim was to investigate the prevalence of testicular nodules and cancer in azoospermic subjects with different spermatogenetic patterns.

METHODS

A total of 1443 consecutive infertile men were investigated, out of which 145 (10.0%) were found to be azoospermic. By using clinical examination and testicular ultrasound, 11 out of the 145 patients showed testicular nodules (2.8-26 mm). To obtain spermatozoa for assisted reproduction, 97 subjects required testicular sperm extraction (TESE) and biopsy, including the 11 patients with nodules. They were divided into two groups according to biopsy results: Group A (n = 38) with complete Sertoli cell-only syndrome (SCOS) and Group B (n = 59) with varying spermatogenetic patterns. Ten nodules were found in Group A and one in Group B.

RESULTS

In azoospermic men, the overall prevalence of nodules was 7.5%. In complete SCOS, the prevalence of nodules and cancer was 10/38 (26.3%) and 4/38 (10.5%), respectively. Amongst the cancers, one embryonal carcinoma, one seminoma and two in-situ carcinomas were found.

CONCLUSION

The prevalence of testicular nodules and cancer in azoospermic men with complete SCOS is very high. In these subjects, the role of clinical evaluation, ultrasound and biopsy should be emphasized.

Restoration of Posterior Aspect of Rhabdosphincter Shortens Continence Time After Radical Retropubic Prostatectomy

PURPOSE

Prolonged postoperative incontinence is a major drawback of RRP. Age, scars in the rhabdosphincter, nonnerve sparing surgery and postoperative sphincter insufficiency can cause temporary or definitive urinary incontinence. We believe that sphincter deficiency is the main cause of early incontinence. Urinary leakage results from the shortening of anatomical and functional sphincter length due to caudal retraction of the urethral sphincteric complex and disruption of the median posterior fibrous raphe. We describe a modification of the Walsh RRP that overcomes caudal retraction, reconstructs the posterior fibrous raphe and decreases time to continence. The primary study end point was early continence rate assessment. Long-term continence (1 year) and erectile function assessment were secondary end points.

MATERIALS AND METHODS

To avoid caudal retraction of the urethrosphincteric complex, before completing the vesicourethral anastomosis the posterior semicircumference of the sphincter is joined to the residuum of Denonvilliers' fascia and fixed to the posterior bladder wall 1 to 2 cm cranial and dorsal to the new bladder neck. Vesicourethral anastomosis is subsequently performed with care taken not to involve the neurovascular bundles. A total of 161 patients with clinically confined disease underwent modified RRP (group 1). They were compared with a historical series of 50 patients who underwent standard RRP (group 2). Early continence was defined as no pad use but patients using 1 diaper were also considered continent. Continence, assessed prospectively as the number of pads daily, was evaluated 3, 30 and 90 days, and 1 year after catheter removal. The continence state was assessed by a multivariate logistic model. Erectile function was evaluated using the International Index of Erectile Function questionnaire preoperatively and after 18 months in patients younger than 65 years who underwent nerve sparing surgery.

RESULTS

In group 1, 116 (72%), 127 (78.8%) and 139 patients (86.3%) were continent 3, 30 and 90 days after catheter removal compared with 7 (14%), 15 (30%) and 23 (46%), respectively, in group 2. One-year continence rates were 96% and 90%, respectively. Erectile function was similar in groups 1 and 2 (46% and 42%, respectively). Multivariate analysis showed that continence was significantly influenced by operation type, stage and patient age.

CONCLUSIONS

Careful reconstruction of the posterior aspect of the rhabdosphincter markedly shortens time to continence.

The Long-Term Hormone Levels and Sexual Function of Monorchid Patients

The purpose of this study was to evaluate monorchid patients’ long-term hormone levels and sexual function.

Materials and Methods

Between September and December 2005, 20 patients were reassessed, having undergone orchiectomy for testicular tumors at the Policlinico and at the National Tumor Institute in Milan between 1986 and 1996. Four patients had seminoma, three of them underwent radiotherapy; 15 patients with embryonal carcinoma subsequently underwent retroperitoneal lymphadenectomy, and one of them underwent chemotherapy; one patient had a Leydig cell tumour. The patients’ case histories were analysed; they underwent urological examination, endocrine test, scrotal ultrasound, and blood samples were taken for testosterone, FSH, LH, prolactin, E2, total cholesterol, triglyceride, beta-HCG, alpha-FP and LDH assays. Body mass index was calculated. Patients were also asked to fill in the IIEF questionnaire.

Results

Patients’ mean age was 30.7 years at the time of orchiectomy, and 44.7 at the time of endocrine/sexology follow up. Case histories showed that 2 patients suffered from arterial hypertension, for which they were receiving treatment, 2 patients were obese, none of the patients suffered from endocrine disorders. Upon ultrasound evaluation, the remaining testicle mean volume was 22.04 mL. All patients presented testosterone levels at the lower limits of the normal range (mean value 3.3 ng/ml). In 5 patients values were below the lower limit, indicating marked hypogonadism. Only one patient suffered from moderate erectile dysfunction.

Conclusions

Twenty-five per cent of patients showed low testosterone levels. In view of the long life expectancy of patients suffering from testicular tumors, it is fundamental to consider the long-term problems that a mutilation such as orchiectomy can involve. Patients undergoing orchidectomy in general should be considered to be at higher risk of andropause.

[Physiology of the urethral sphincteric vesico-prostatic complex]

We propose a review of the literature about innervation and physiology of the urethral sphincteric complex. Parasympathetic innervation of the pelvic viscera comes from ventral branches of the sacral nerves (S2-S4). The orthosympathetic component derives from superior hypogastric plexus and runs down the hypogastric nerves to form the right and left pelvic plexus together with the parasympathetic component. The pelvic plexus is situated inferolaterally with respect to the rectum and runs on the surface of the levator ani muscle down to the prostatic apex. The pelvic plexus gives innervation to the rectum, the bladder, the prostate and the urethral sphincteric complex. The pelvic muscular floor is innervated by the somatic component (pudendal nerve) derived from the sacral branches (S2-S4). Bladder neck and smooth muscle urethral sphincter innervation is given mostly by the orthosympathetic component. The rhabdosphincter innervation comes from the pudendal nerve and from the pelvic plexus; its role in the continence mechanism is probably to give steady tonic urethral compression. Levator ani muscle takes part in the sphincteric complex with its anteromedial pubococcygeal portion. It plays its role strengthening the sphincteric tone during increase of the abdominal pressure or during active quick stop cessation of the urinary stream.

[Anatomy of the urethral sphincteric vesico-prostatic complex]

As 27 different names have been proposed for the components of the urethral sphincter, it is difficult to build a clear anatomical model of it. Starting from a review of the literature and from some personal observations of surgical anatomy, our aim is to draw a vision as much organic as possible of the anatomy of the urethral sphincter. The components of the urethral sphincter are: the bladder neck (preprostatic sphincter), the smooth muscle urethral sphincter, the rhabdosphincter and levator ani muscle. Recently the rhabdosphincter has been proposed as a vertical structure that extends from the pelvic cavity (bladder base) to the perineal cavity. It can be round-shaped or omega-shaped. The anterior insertions are along the anterolateral aspect of the prostate (superiorly) and on the perineal fascia (inferiorly). The posterior insertions are on the Denonvilliers fascia and posterior aspect of the prostatic apex (superiorly) and on the central perineal tendon (inferiorly). The rhabdosphincter has strong means of fixations: anteriorly it is fixed to the pubis by the pubo-urethral ligaments, posteriorly it is supported by the medial fibrous raphe of the perineum. The anteromedial fibres of levator ani muscle are involved in the continence mechanism by their strong relation with the rhabdosphincter and the prostate.

[Personal research: reconstruction of the urethral striated sphincter]

OBJECTIVE

Incontinence is one of the drawbacks of radical prostatectomy. The causes of post-operative incontinence are sphincter deficiency (SD) and bladder dysfunction (BD). SD seems to be the main cause of incontinence and long time to continence. We present a surgical modification of the anatomical radical retropubic prostatectomy consisting in the reconstruction of the posterior aspect of the striated urethral sphincter in order to obtain a quick recovery of continence postoperatively.

MATERIALS AND METHODS

Caudal retraction of the urethro-sphincteric complex after apical dissection of the prostate often occurs. Furthermore posterior fibrous raphe interruption can cause shortening of anatomical and functional urethral length and affect continence. In order to avoid caudal retraction of the sphincteric complex, after completing vesico-urethral anastomosis, the posterior emicircumference of the striated sphincter is fixed to the posterior aspect of the bladder one centimeter cranially and posteriorly to the urethro-vesical anastomosis. The rabdosphincter is sutured separately from the urethro-vesical suturing. This technical modification makes it possible to obtain an anatomical length of the urethra of about a centimeter more than with the standard technique, replacing it in a more anatomical position. Furthermore, this technique provides the new posterior platform for the urethro-sphincteric complex. Twenty-four patients with clinical organ confined disease and age range 54-74 years (mean 64 years) underwent Walsh's anatomical radical retropubic prostatectomy with reconstruction of the rabdosphincter (group A). Catheter was removed 7 to 11 days postoperatively. Early continence was assessed objectively with the number of pads per day as follows: 0-1 mini pad = continent; 1-2 pads per day = mild incontinence; 2 or more pads per day = severe incontinence. Continence was evaluated at 3 days and one month after catheter removal. Group A compared to 21 patients (group B) who underwent standard anatomical RPP (historical control group).

RESULTS

In group A 16/24 patients (66.7%) and 19/24 patients (79.2%) were continent respectively at three days after removal of the catheter and after one month; mild incontinence (1-2 pads/day) was present in 6/24 patients (25%) and 3/24 (12.5%) respectively, 2/24 patients (8.3%) suffered from severe incontinence after 3 days and one month. In group B 7/21 patients (33%) were continent at hospital discharge, 11/21 (52%) after one month.

CONCLUSIONS

Careful reconstruction of the posterior aspects of the rabdosphincter shortens time to continence after RRP.

Long-term results of intrarenal surgery for branched calculi: is such surgery still valid?

OBJECTIVE

To evaluate whether intrarenal surgery for branched calculi remains valid in the light of current new techniques, e.g. percutaneous nephrolithotomy and extracorporeal shockwave lithotripsy.

PATIENTS AND METHODS

Between January 1978 and October 1984, 44 patients (24 male and 20 female, mean age 42.5 years, range 14-66) underwent complex surgery for large stones, requiring opening of the renal pelvis and a transparenchymal approach to the calices; 47 renal units were operated in 49 procedures. The evaluation before surgery included creatinine and blood nitrogen levels, blood pressure measurement, urine culture, abdominal plain X-ray (44 patients), intravenous urography (42) and isotopic renography with renal scintigraphy (five). Renal lithiasis was categorized and all patients underwent extended pyelolithotomy with a transparenchymal approach, achieved by partial nephrectomy (six patients), radial paravascular nephrotomy (10), posterior lower nephrolithotomy (29), resection of the posterior segment (two), and posterior segmentotomy and reconstruction (2); 16 operations were performed under ischaemia. In October 1996, the patients were clinically evaluated by serum creatinine levels (42), urine cultures (42), abdominal plain X-ray (42), IVU (34), isotopic renography (eight), renal ultrasonography (eight) and blood pressure measurement (44). The mean follow-up was 14.8 years.

RESULTS

The major postoperative complications were; residual stones (six patients), fistula with ureteric stenosis (one, with a permanent nephrostomy), toxic temporary hepatic failure (one), femoral arterial embolism (one, resolved using a Fogarty catheter) and recurrent large stones (two, operated 1 and 5 years later). From 1984 to 1996, 19 patients had recurrent stones and two underwent dialysis. In October 1996, the renal function of 47 renal units was stable or normal in 36 (77%), reduced in seven (15%) and lost in four (8%); 24 patients were hypertensive (12 preoperatively), nine have urinary tract infection, three are positive for hepatitis B or C virus, and lithiasis has recurred in 15 renal units.

CONCLUSIONS

Intrarenal surgery, conducted using modern anatomical guidelines, was an effective treatment for renal branched stones. The long-term results are satisfactory after appropriate correction of the urinary tract, with the consequent prevention of stasis and chronic infection. The definitive comparison between surgical and combined endoscopic/extracorporeal methods will only become clear when there is a comparable follow-up. Currently, surgery remains preferable in patients with giant calculi, a small pelvis and prevalent calyceal development.

Original Digital Technique to Isolate Santorini'S Plexus and Membranous Urethra during Radical Retropubic Prostatectomy and Radical Cystectomy

The authors give the results obtained with their digital technique for isolating Santorini's plexus during radical retropubic cystectomy or radical prostatectomy. Objectives: to reduce bleeding during surgery; to respect anatomic structures; greater safety during resection of the urethra; to respect the neurovascular erectile bundles; to assess post-operative erection. This technique was used in 46 operations (32 cystectomies and 14 radical prostatectomies) between January 1997 and February 1998. Blood loss from the plexus was 150 ml max. Operating time was reduced by about 15 minutes. Although the number of cases is still small, this digital isolation technique can be considered safe, almost bloodless and should preserve erection in a higher percentage of patients compared to the “classic” nerve-sparing technique.