FSH levels and testicular volumes are associated with the severity of testicular histopathology in men with non-obstructive azoospermia

Purpose

The purpose of this study is to assess a potential association between FSH levels and testicular volumes with the severity of testicular histopathology on testicular biopsy in men with non-obstructive azoospermia (NOA) undergoing microdissection testicular sperm extraction (microTESE).

Methods

A retrospective chart review was performed from the electronic health records of men who underwent microTESE with NOA.

Results

Eighty-six men with NOA underwent microTESE with concomitant testicular biopsy for permanent section to assess the testicular cellular architecture. The histopathological patterns were categorized by severity indicating the odds of sperm retrieval into 2 categories. The unfavorable category included Sertoli cell only pattern and early maturation arrest (n = 50) and the favorable category included late maturation arrest and hypospermatogenesis patterns (n = 36). In the men with unfavorable histopathologic patterns, the mean FSH level was 22.9 ± 16.6 IU/L, and the mean testicular volume was 10.4 ± 6.0 cc. This was in comparison to men with favorable histopathologic patterns revealing a mean FSH level of FSH 13.3 ± 12.0 with a mean testicular volume of 13.3 ± 5.9 cc. There was a statistically significant higher FSH level in men with unfavorable histopathology than favorable (p = 0.004) as well as a significant smaller mean testicular volume in men with unfavorable histopathology (p = 0.029).

Conclusions

Higher serum FSH levels and smaller testicular volumes are associated with more severe testicular histopathological patterns in men with NOA.

The impact of ipsilateral testicular atrophy on semen quality and sperm DNA fragmentation response to varicocele repair

Varicoceles adversely impact semen quality and sperm DNA fragmentation, which typically improve with surgical repair. Some men with varicoceles have ipsilateral testicular atrophy due to damage from the varicocele. This study assessed semen quality and the sperm DNA fragmentation index (DFI) response to varicocele repair in men with ipsilateral testicular atrophy (TA) versus men with no testicular atrophy (NTA). Semen parameter values and DFI in both groups were compared preoperatively and postoperatively. The Mann–Whitney U test and the Wilcoxon signed-rank test were used where appropriate. There were 20 men in the TA group and 121 men in the NTA group with no difference in age, varicocele grade, or preoperative semen parameter values between the two groups. The NTA group had a higher preoperative DFI than the TA group. Both groups showed improvement in semen quality postoperatively, only the TA group showed a significant improvement in DFI, whereas the NTA group showed significant improvements in several parameter values and DFI. The change from preoperative to postoperative parameter values when comparing the two groups revealed a difference in total sperm motile count and DFI, with a larger mean improvement in the NTA group than in the TA group. Both TA and NTA groups showed improved semen quality and DFI after varicocele repair, but the NTA group had more improvement than the TA group. However, only total motile count (TMC) and DFI had a significantly greater mean change in preoperative to postoperative response in the NTA group than in the TA group.

A comprehensive assessment of predictors of fertility outcomes in men with non-obstructive azoospermia undergoing microdissection testicular sperm extraction

BACKGROUND

Microdissection testicular sperm extraction (microTESE) in men with non-obstructive azoospermia (NOA) is the procedure that results in the highest number of sperm cells retrieved for in vitro fertilization (IVF). This study presents a novel assessment of predictors of sperm retrieval as well as downstream embryology and pregnancy outcomes in cases of men with NOA undergoing microTESE.

METHODS

A retrospective chart review of 72 men who underwent microTESE for predictors of fertility outcomes including sperm retrieved at microTESE, embryology progression to embryo transfer (ET), clinical pregnancy, live birth, and surplus sperm retrieved for additional IVF/intracytoplasmic injection cycles beyond one initial cycle. Statistical models for each of these outcomes were fitted, with a p-value of < 0.05 considered significant for the parameters estimated in each model.

RESULTS

Seventy-two men underwent microTESE, and 51/72 (70.8%) had sperm retrieved. Of those, 29/43 (67.4%) reached ET. Of the couples who underwent ET, 21/29 (72.4%) achieved pregnancy and 18/29 (62.1%) resulted in live birth. Of the men with sperm retrieved, 38/51 (74.5%) had surplus sperm cryopreserved beyond the initial IVF cycle. Age, testicular volume, FSH, and testicular histopathology were assessed as predictors for sperm retrieved at microTESE, progression to ET, pregnancy, live birth, and surplus sperm. There were no preoperative predictors of sperm retrieval, clinical pregnancy, or live birth. Age predicted reaching ET, with older men having increased odds. FSH level had a negative relationship with surplus sperm retrieved. Men with hypospermatogenesis histology had higher rates of sperm retrieval, clinical pregnancy, live birth, and having surplus sperm.

CONCLUSIONS

Men who underwent microTESE with a hypospermatogenesis histopathology had better outcomes, including higher rates of sperm retrieval, clinical pregnancy, live birth, and having surplus sperm retrieved. Increasing male partner age increased the odds of reaching ET. No other clinical factors were predictive for the outcomes considered.

Prednisone after vasectomy reversal may improve semen parameters: one institution's experience

INTRODUCTION

Patients with suboptimal semen parameters following vasectomy reversal represent a diagnostic and therapeutic challenge. This may be caused by either partial or complete anastomotic obstruction. Despite the relatively common clinical use of corticosteroids in this patient population, data remain sparse. Thus, we set out to evaluate the safety and efficacy of prednisone after vasectomy reversal.

MATERIALS AND METHODS

A chart review was performed from January 1, 2008 to September 30, 2018 to identify men in which prednisone was used for suspected anastomotic obstruction after vasectomy reversal. Obstruction was based on sub-optimal or decreasing semen parameters and physical exam findings. A course consisted of 2 weeks of 20 mg PO daily followed by 2 weeks of 10 mg PO daily.

RESULTS

A total of 89 patients were identified in which prednisone was used postoperatively. Total motile sperm counts were found to increase in the overall cohort by 10.5 million (p < 0.0002) after a course of prednisone. On sub-group analysis, men who had a bilateral vasovasostomy (VV) or VV/vasoepididymostomy experienced an increase in total motile sperm counts by 13.4 million (p < 0.0012) and 6.2 million (p < 0.014), respectively. Patients who were patent at the time of prednisone treatment were more likely to see an improvement in total motile sperm counts (76.9% versus 33.3%, p < 0.003).

CONCLUSIONS

Prednisone seems to be safe and potentially efficacious in men with suspected anastomotic obstruction following vasectomy reversals. Further studies are needed to more conclusively determine the treatment's effectiveness in this patient cohort.

Extended indications for varicocelectomy

The relationship between varicoceles and subfertility is well-established, but recent evidence suggests that varicoceles may cause global testicular dysfunction. This has led to exploration into expanding the indications for varicocelectomy. This review examines the literature regarding varix ligation as a treatment for non-obstructive azoospermia, elevated DNA fragmentation, and hypogonadism.

Preoperative ureteral stenting prior to ureteroscopy for management of urolithiasis does not impact the postoperative return for unplanned care

Introduction:

Return for unplanned postoperative care is an important quality metric in the United States. Most of our postoperative return visits occur after ureteroscopy. Routine preoperative ureteral stenting is not recommended by the American Urological Association due to its impact on the quality of life, despite its proposed operative advantages. We evaluated the association between preoperative ureteral stenting and the resulting perioperative outcomes in the context of quality measures such as return to the emergency department (ED) and readmission rates.

Materials and Methods:

After the Institutional Review Board approval, a retrospective review of patients undergoing ureteroscopy from February 2014 to present was conducted. Patient's demographics and perioperative outcomes were compared based on the presence or absence of a ureteral stent before ureteroscopy. Details and rates of nurse calls, returns to the ED, and readmissions within 90 days were also compared.

Results:

A total of 421 instances of ureteroscopy, 278 prestented ureteroscopy (psURS), and 143 direct ureteroscopy (dURS) were included for analysis. Preoperative demographics were similar. The psURS cohort was more likely to undergo flexible ureteroscopy, utilized an access sheath more often (P < 0.0001), and had less ureteral dilation (P < 0.0001). Prestenting did not influence operative time (P = 0.8534) or stone-free rates (P = 0.2241). dURS patients were more likely to call the nurse; however, psURS versus dURS yielded no difference in return to the ED or readmission within 90 days.

Conclusions:

In this study, preoperative stenting offered few operative advantages and did not meaningfully influence returns to the ED and readmissions within 90 days after ureteroscopy.

A Comparison of Clinical Outcomes of Operating Room Versus Office-based Ureteral Stenting With the Novel Use of Nitrous Oxide Sedation

OBJECTIVES

To examine the safety and effectiveness of placing ureteral stents in an office-based setting vs in the operating room (OR).

METHODS

A retrospective chart review was performed to examine outcomes, specifically complication rate, unanticipated hospitalizations, and stent failures, when patients received JJ stents in the clinic procedure suite, using local analgesia and/or nitrous oxide gas analgesia, compared to patients who had ureteral stents placed in the OR, typically with general anesthesia. Additionally, multivariable analysis was performed to determine predictors of complications.

RESULTS

Around 565 procedures were performed in the clinic and 179 were performed in the OR. The complication rate for the clinic group was 4.1%, compared to 7.8% in the OR group. Unplanned admissions to the hospital occurred after 3.0% of clinic procedures and 9.5% of OR procedures. Stent placements failed in 1.1% of clinic procedures and 0.56% of OR procedures. Clinic procedure time was 10 minutes vs 12 minutes in the OR (P <0.01). Clinic vs OR setting was not predictive of complications (P = 0.99). We did not identify factors that impacted complication rate in ureteral stent placement in the clinic vs OR setting. Notably, the procedure time for a clinic stent placement was significantly shorter than the OR stent placement.

CONCLUSIONS

This study demonstrates excellent outcomes with a novel approach to a standard procedure, with shorter procedure time and no difference in complication rates.

Vasectomy reversal utilizing fibrin glue

Over 500,000 men in America have a vasectomy annually; 2% to 6% of these individuals later elect to have a vasectomy reversal. Vasovasostomies are typically performed using a single- or double-layer closure, with no demonstrated difference between the two in terms of success rates. In 2005, Ho et al described a microscopic technique in which three full-thickness sutures are used and the anastomosis is reinforced with fibrin glue. At our institution, a similar technique has been used for >10 years. To describe our experience, a retrospective chart review was undertaken. Patient demographic information and operative characteristics were analyzed. In each case, fibrin glue was circumferentially applied to reinforce the anastomosis. The overall patency rate was 88.4%, and rates comparing individuals who had their vasectomy reversal within 10 years of vasectomy reached statistical significance with an odds ratio of 2.91 (P = 0.048). Median operative time was 94 minutes. Other demographic variables analyzed did not have a correlation with patency. In conclusion, our technique provides acceptable patency rates, especially with obstructive intervals of 10 years or less, while likely resulting in cost savings given the decreased operating room time and suture used.

Acquired Buried Penis in Adults: A Review of Surgical Management

INTRODUCTION

Acquired buried penis (ABP) is a urologic condition that has significant morbidity and negative effect on quality of life, including but not limited to sexual function, hygiene, micturition, and self-image. This disease process is characterized by a wide degree of variability and severity that requires a patient-specific approach and significant flexibility on the surgeon's behalf.

AIM

To review and present the current evaluation and surgical management of this rare and complex patient population.

METHODS

A structured review of the English language literature from 1970 to June 2018 was performed using the PubMed and MEDLINE medical databases. Queried terms included "buried penis," "concealed penis," "hidden penis," "adult buried penis," "cicatricial penis," "trapped penis," "inconspicuous penis," "scrotoplasty and obesity," "penile release," "penile skin graft," "penile reconstruction," and "pubic lift." Papers were individually reviewed for their utility and applicability to the management of adult ABP. Manuscripts focusing on pediatric patients were excluded.

MAIN OUTCOME MEASURE

Current surgical management options for adult ABP are heterogenous but focus on preserving shaft length while improving cosmesis and voiding function.

RESULTS

Surgical versatility remains critical for successful outcomes. However, recent advances in surgical techniques for correction of adult ABP focus on the use of skin grafting to cover the shaft, along with lipectomy and/or scrotoplasty to further aid penile exposure. Collaboration with multiple surgical services is often required to achieve optimal outcomes.

CONCLUSION

ABP is a complex urologic condition with equally complex surgical treatment options. Care must be taken when planning a surgical intervention, and support from plastic or general surgery may be required. However, with careful selection, surgical correction frequently leads to significant improvement in function and quality of life. Smith-Harrison LI, Piotrowski J, Machen GL, et al. Acquired Buried Penis in Adults: A Review of Surgical Management. Sex Med Rev 2020;8:150-157.

Feasibility and clinical outcomes of ureteral stenting in the office procedural suite

INTRODUCTION

Stent placement is a common procedure for addressing obstructive uropathy. However, lack of operating room (OR) availability can substantially delay this procedure. In this study, we sought to assess the feasibility, safety, and efficacy of this procedure in a clinical setting using nitrous oxide (N2O) and local anesthesia.

MATERIALS AND METHODS

Patients included in this study included those who were determined to need management of urinary obstruction with a JJ ("double J") stent and had their procedure performed in the clinic procedure suite with N2O anesthesia.

RESULTS

We present a case series of 565 patients undergoing ureteral stent placements in a clinic operative suite with N2O. In this cohort, complications occurred after 4.1% of procedures and unplanned admissions to the hospital occurred after 2.5% of procedures. Stent placements failed in 1.0% of procedures. Failures occurred due to pain in 2/565 patients. No anesthetic complications were encountered.

CONCLUSION

We report the feasibility and clinical outcomes of ureteral stent placements for ureteral obstruction in a clinic setting with the use of local anesthetic or N2O anesthesia, with excellent results. A majority of patients tolerated the procedure well and only 2 of 565 had their procedures stopped due to discomfort. To our knowledge, this is the first report of the use of N2O anesthetic for conscious sedation for the placement of ureteral stents.

Analysis of urban vs. rural vasectomy demographics: a multi-institutional, retrospective comparison

Background

Each year in the US, approximately 500,000 men choose to undergo a vasectomy for permanent sterilization. Despite being a very common procedure, studies reporting demographic data and characteristics that motivate men to choose a vasectomy are somewhat limited. With this analysis, the primary objective was to determine if a difference existed between the ages and number of children among men choosing to have a vasectomy at urology practices in urban (Austin, TX = City A, population 947,890) and rural (Temple, TX = City B, population 76,277) settings. A secondary objective was to establish if there was a trend in these variables over time.

Methods

After IRB approval was obtained from each institution, a retrospective chart review was undertaken to identify men who had undergone a vasectomy at each facility from 2011-2017. Demographic data was recorded. Statistical analysis was done using student's t-test and linear regression.

Results

The mean age at time of vasectomy in City A was 37.41 years versus 36.18 in City B (P<0.001). Men in City A underwent vasectomy after a mean of 1.96 children as opposed to a mean of 2.60 children in City B (P<0.001). There was no statistically significant trend in average age or number of children over time.

Conclusions

Men in an urban setting underwent vasectomy at an older age and with fewer children when compared to a rural practice environment. While studies evaluating demographics of men undergoing vasectomy have previously been performed, our results are unique in terms of a direct comparison between different population concentrations.

Ibuprofen does not have an adverse impact on semen parameters

PURPOSE

A recent study suggested that ibuprofen may alter testicular physiology in a state of compensated hypogonadism, but only evaluated spermatogenic cells in a laboratory ex-vivo model with no significant effect, and found no significant change in follicle stimulating hormone (FSH) in men treated with ibuprofen. The study did not evaluate the impact of ibuprofen use on clinical semen parameters, which has not been assessed to date. The purpose of this study was to evaluate the impact of ibuprofen on semen parameters.

METHODS

In a retrospective chart review from October 2012 to February 2018, 64 men had semen analyses revealing leukocytospermia and were treated with a 3-week course of ibuprofen 600 mg every 8 hours (1800 mg per day) and had a repeat semen analyses 3 weeks later.

RESULTS

Of the 64 men diagnosed with leukocytospermia, 51 returned for post-treatment semen analyses. Parameters included semen volume, sperm concentration, motility, TMC, and forward progression. Morphology was excluded as it could not be standardized between assessments with strict Kruger criteria versus WHO fourth edition criteria depending on the lab in which it was performed. The mean age of these men was 35 (SD 4.6). There was no difference in mean abstinence intervals prior to semen analyses for the pre-treatment and post-treatment data. There was no significant difference in pre-treatment and post-treatment semen volumes, sperm concentrations, motility, TMC, or forward progression.

CONCLUSIONS

Among men with leukocytospermia, the treatment with a 3-week course of ibuprofen at 1800 mg per day did not demonstrate a significant adverse impact on semen volume, sperm concentration, motility, TMC, or forward progressive motility when compared to pre-treatment semen analyses parameters.

Comparison of utilization of pressurized automated versus manual hand irrigation during ureteroscopy in the absence of ureteral access sheath

This study compared patient outcomes following irrigation applied using an automated pressure system (AP) to hand irrigation utilizing a syringe (HI) during ureteroscopy. Retrospective chart review was performed to evaluate ureteroscopy procedures without a ureteral access sheath. Procedures in which irrigation was applied by AP were compared to those with HI. Statistical analyses included chi-squared tests and Student's t tests. The AP group contained 206 procedures and the HI group, 25. The AP and HI groups were 54.9% and 36% male, respectively. Mean ages were 53.7 ± 18.9 years in the AP group and 44.0 ± 18.5 years in the HI group. Complication rates were 11.2% in the AP and 8.3% in the HI group (P > 0.99). One stone retrieval failure and one stone recurrence occurred in the HI group; one patient had residual stone in the AP group. No urinary tract infections occurred in the HI group; in the AP group, urinary tract infections occurred in 1.9% of cases. The postoperative pain incidence was equivalent (P = 0.498). The AP group had one subcapsular hematoma; no calyceal ruptures occurred in either group. In conclusion, irrigation applied by an automated setup appears safe, with similar outcomes to irrigation applied with a handheld syringe.

The use of a string with a stent for self-removal following ureteroscopy: A safe practice to remain

Abstract objectives

To examine the safety and effectiveness of the use of a stent with a string attached after ureteroscopy (URS) for self-removal of the stent by the patient.

Patients and methods

After Institutional Review Board approval, a retrospective chart review was performed concerning patients who underwent URS and received an indwelling stent with or without a string attached to the stent (94 vs 349, respectively). Amongst the string group patients received a single- or a double-arm-stringed stent (31 vs 63, respectively). Statistical analyses included chi-squared and Student’s t-tests.

Results

The string group consisted of 94 procedures, in which 59.6% of the patients were male with a mean (SD) age of 50.0 (16.5) years. In the no-string group, 51.3% of the 349 procedures were performed in males and the mean (SD) age was 54.9 (18.1) years. Complication rates were 12.8% in the string group and 14.0% in the no-string group (P = 0.867). In the string group, 17.0% of the patients returned to the Emergency Department, whilst 15.8% of the no-string patients returned (P = 0.753). The complication rate in the single- and double-arm groups were 12.9% and 12.7%, respectively (P > 0.910). Self-removal of stents was successful in 94.7% of patients (89/94).

Conclusions

The use of a stent with a string after URS appears safe and effective. Few patients had difficulty removing their stents and complication rates were similar in the groups with and without a string attached to their stents. Single- and double-arm-stringed stents have similar complication rates.

Time trends for bacterial species and resistance patterns in semen in patients undergoing evaluation for male infertility

Semen from asymptomatic men who are being evaluated as male partners in interfile couples have been reported to contain a variety of bacteria. Longitudinal studies of the variation of these bacteria over time and their resistance patterns have not been commonly reported. At our institution, residues from semen samples are routinely evaluated for bacteria, including antibiotic sensitivity profiles. We set out to profile the changes in semen bacteria and antibiotic resistance at our institution over time. A total of 72 semen isolates were examined for type of bacteria and sensitivity to a panel of antibiotics. The results were divided into two separate 5-year intervals (the first beginning in 2006, the second in 2011) and compared. The majority of bacteria were skin flora, with Streptococcus and Staphylococcus being the most prevalent. The resistance data for these two pathogens showed minimal statistically significant difference between the two time periods, although the Staphylococcus species did show a trend toward increasing resistance, suggesting that antibiotics currently used in sperm cell preparations may need to be varied.

Phosphodiesterase type 5 inhibitors usage and prostate cancer: a match-paired analysis

Background

To treat erectile dysfunction (ED), phosphodiesterase type 5 inhibitors (PDE5i) are commonly used. However, to date, only a few studies exist evaluate a possible effect on the incidence of prostate cancer. One such study completed by the authors’ institution suggested men who use PDE5i for ED may have a lower incidence of prostate cancer. This study was meant to address some of the shortcomings of the former study and further characterize the link between prostate cancer and PDE5i use.

Methods

A retrospective, match-paired analysis was undertaken: 5,717 patients were identified between 2000 and 2011; a 1:2 match pair analysis ultimately identified 394 cases with cancer and 788 controls without cancer. Pairs were matched based on age, ethnicity, and PSA value.

Results

No correlation existed between PDE5i use and prostate cancer [OR 1.02, 95% confidence interval (CI): 0.78–1.35, P=0.8842] or diabetes mellitus and prostate cancer (OR 1.12, 95% CI: 0.84–1.48, P=0.4499). A statistically significant correlation was demonstrated with PSA and prostate cancer (OR 1.48, 95% CI: 1.38–1.58, P<0.0001).

Conclusions

The data suggest that there is essentially no association with PDE5i use and prostate cancer.

Robotic repair of vesicovaginal fistulas using fibrin sealant

INTRODUCTION

Although infrequent, when encountered vesicovaginal fistulas (VVF) are a difficult condition for both patients and physicians alike. After the first robotic repair was described in 2005, this has been an increasingly common treatment modality. At our institution between 2009 and 2014, eleven of these patients were evaluated and treated with robotic repair. However, fibrin sealant was used in place of the traditional tissue flap. Included are six patients who had previously undergone operative repair.

MATERIALS AND METHODS

After IRB approval was obtained, a retrospective study was undertaken to identify patients with VVF. Inclusion criteria were operative repair utilizing a da Vinci robotic system; there were no exclusion criteria. A total of eleven patients were identified, and in each case, a robot assisted laparoscopic approach was utilized and Tisseel fibrin sealant was used in lieu of tissue interposition.

RESULTS

All patients underwent successful repair of their VVF without evidence of recurrence at a mean follow up of 15.6 months.

CONCLUSIONS

Robotic vesicovaginal fistula repair with fibrin sealant seems to be a safe and viable alternative to the traditional repair utilizing a tissue flap.