A novel on-a-chip system with a 3D-bioinspired gut mucus suitable to investigate bacterial endotoxins dynamics

The possible pathogenic impact of pro-inflammatory molecules produced by the gut microbiota is one of the hypotheses considered at the basis of the biomolecular dialogue governing the microbiota-gut-brain axis. Among these molecules, lipopolysaccharides (LPS) produced by Gram-negative gut microbiota strains may have a potential key role due to their toxic effects in both the gut and the brain. In this work, we engineered a new dynamic fluidic system, the MINERVA device (MI-device), with the potential to advance the current knowledge of the biological mechanisms regulating the microbiota-gut molecular crosstalk. The MI-device supported the growth of bacteria that are part of the intestinal microbiota under dynamic conditions within a 3D moving mucus model, with features comparable to the physiological conditions (storage modulus of 80 ± 19 Pa, network mesh size of 41 ± 3 nm), without affecting their viability (∼ 109 bacteria/mL). The integration of a fluidically optimized and user-friendly design with a bioinspired microenvironment enabled the sterile extraction and quantification of the LPS produced within the mucus by bacteria (from 423 ± 34 ng/mL to 1785 ± 91 ng/mL). Compatibility with commercially available Transwell-like inserts allows the user to precisely control the transport phenomena that occur between the two chambers by selecting the pore density of the insert membrane without changing the design of the system. The MI-device is able to provide the flow of sterile medium enriched with LPS directly produced by bacteria, opening up the possibility of studying the effects of bacteria-derived molecules on cells in depth, as well as the assessment and characterization of their effects in a physiological or pathological scenario.

Surgical and minimally invasive treatment of ischaemic and non-ischaemic priapism: a systematic review by the EAU Sexual and Reproductive Health Guidelines panel

Surgical treatments for ischemic priapism (IP) include shunts or penile implants. Non-ischemic priapism (NIP) is usually the result of penile/perineal trauma causing an arterial fistula and embolisation may be required. We conducted a systematic review on behalf of the EAU Sexual and Reproductive health Guidelines panel to analyse the available evidence on efficacy and safety of surgical modalities for IP and NIP. Outcomes were priapism resolution, sexual function and adverse events following surgery. Overall, 63 studies (n = 923) met inclusion criteria up to September 2021. For IP (n = 702), surgery comprised distal (n = 274), proximal shunts (n = 209) and penile prostheses (n = 194). Resolution occurred in 18.7-100% for distal, 5.7-100% for proximal shunts and 100% for penile prostheses. Potency rate was 20-100% for distal, 11.1-77.2% for proximal shunts, and 26.3-100% for penile prostheses, respectively. Patient satisfaction was 60-100% following penile prostheses implantation. Complications were 0-42.5% for shunts and 0-13.6% for IPP. For NIP (n = 221), embolisation success was 85.7-100% and potency 80-100%. The majority of studies were retrospective cohort studies. Risk of bias was high. Overall, surgical shunts have acceptable success rates in IP. Proximal/venous shunts should be abandoned due to morbidity/ED rates. In IP > 48 h, best outcomes are seen with penile prostheses implantation. Embolisation is the mainstay technique for NIP with high resolution rates and adequate erectile function.

Radical Nephroureterectomy Tetrafecta: A Proposal Reporting Surgical Strategy Quality at Surgery

Background

Standardized methods for reporting surgical quality have been described for all the major urological procedures apart from radical nephroureterectomy (RNU).

Objective

To propose a tetrafecta criterion for assessing the quality of RNU based on a consensus panel within the Young Association of Urology (YAU) Urothelial Group, and to test the impact of this tetrafecta in a multicenter, large contemporary cohort of patients treated with RNU for upper tract urothelial carcinoma (UTUC).

Design, setting, and participants

This was a retrospective analysis of 1765 patients with UTUC treated between 2000 and 2021.

Outcome measurements and statistical analysis

We interviewed the YAU Urothelial Group to propose and score a list of items to be included in the “RNU-fecta.” A ranking was generated for the criteria with the highest sum score. These criteria were applied to a large multicenter cohort of patients. Kaplan-Meier curves were built to evaluate differences in overall survival (OS) rates between groups, and a multivariable logistic regression model was used to find the predictors of achieving the RNU tetrafecta.

Results and limitations

The criteria with the highest score included three surgical items such as negative soft tissue surgical margins, bladder cuff excision, lymph node dissection according to guideline recommendations, and one oncological item defined by the absence of any recurrence in ≤12 mo. These items formed the RNU tetrafecta. Within a median follow-up of 30 mo, 52.6% of patients achieved the RNU tetrafecta. The 5-yr OS rates were significantly higher for patients achieving tetrafecta than for their counterparts (76% vs 51%). Younger age, lower body mass index, and robotic approach were found to be independent predictors of tetrafecta achievement. Conversely, a higher Eastern Cooperative Oncology Group score, higher clinical stage, and bladder cancer history were inversely associated with tetrafecta.

Conclusions

Herein, we present a “tetrafecta” composite endpoint that may serve as a potential tool to assess the overall quality of the RNU procedure. Pending external validation, this tool could allow a comparison between surgical series and may be useful for assessing the learning curve of the procedure as well as for evaluating the impact of new technologies in the field.

Patient summary

In this study, a tetrafecta criterion was developed for assessing the surgical quality of radical nephroureterectomy in patients with upper tract urothelial carcinoma. Patients who achieved tetrafecta had higher 5-yr overall survival rates than those who did not.

P-438 Fertility outcomes in male cancer recipients of hematopoietic cell transplantation who stored their semen for fertility preservation

Study question

What are the prevalence estimates of post-hematopoietic cell transplantation (HCT) natural conceptions or after ART using stored semen?

Summary answer

Natural live birth rate following HCT can be estimated at 9% (95%CI:4-22%) but can be increased to 58% (95%CI:43-72%) with the use of frozen semen.

What is known already

With the improvements and expanding indications of HCT, the number of adult male cancer survivors who received HCT is increasing. These men face the risk of treatment-induced infertility and are generally recommended to store their semen prior to embark in HCT. However, information on long term usage and on effectiveness of frozen sperm samples in this specific population is not well defined.

Study design, size, duration

All male cancer recipients of autologous or allogeneic transplantation who cryopreserved semen between 1987 and 2016 in the biobank of the Assisted Reproductive Technology Unit of the Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico in Milan were considered. Information was obtained from patients’ charts or through active investigation. The main studied topics included results from semen analyses, attempt to parenthood, use of stored spermatozoa and both natural and Assisted Reproductive Technique (ART) mediated conceptions.

Participants/materials, setting, methods

The study is restricted to men who met the following eligibility criteria: i) semen cryopreserved for fertility preservation between 1987 and 2016; ii) post-banking follow-up documenting HCT iii) survival of at least 5 years from HCT.

Main results and the role of chance

One-hundred and two HCT survivors were selected. The median [IQR] age at sperm banking was 29 [23-34]. About half of subjects had autologous HCT (n = 50), the remaining 52 received allogenic HCT. Lymphomas were the most frequent indications. The median spermatozoa concentration at the time storage was 39 [7-85] millions/ml. Fifty-four (53%) men performed a post-treatment sperm analysis and azoospermia was documented in 45 of them (83%, 95%CI: 71-91%). The remaining nine showed viable spermatozoa, of whom six had severe oligospermia (concentration <1 million/mL). The other three had semen concentration >5 Millions/ml, compatible with a natural conception. Overall, based on semen analyses, one could infer the necessity to use ART in 51 out of 54 subjects, corresponding to 94% (95%CI: 85-98%). Forty-three of the 102 included men (42%) sought childbearing. Four had a natural live birth (9%, 95%CI: 4-22%). Thirty-three used their cryopreserved sperm samples, corresponding to 32% (95%CI: 24-42%) of the whole cohort. Twenty-one of these 33 men had at least one live birth (64%, 95%CI: 47-78%). Finally, six men seeking pregnancy and who did not conceive have not used their frozen semen. Overall, 25 out of 43 men interested in fatherhood had a live birth (58%, 95%CI: 43-72%).

Limitations, reasons for caution

Limitation of our study is missing detailed information on status of illness and comorbidities (in particular the frequency of Graft-versus host disease) and lack precise information on the myeloablative regimen used. Furthermore, our sample size is not very large and therefore the 95%CI of the reported proportions are wide.

Wider implications of the findings

Autologous or allogeneic HCT induces infertility in a very high percentage of patients. These findings support the need to prioritize sperm preservation before HCT also in cancer patients who are not candidate for HCT at first instance but who may need this treatment for failure of first line treatments.

Trial registration number

not applicable

P–089 Paternal age affects the performance of EAU guidelines for genetic testing in infertile men: implications for candidate selection

Study question

We aimed at challenge EAU Guidelines for genetic testing performance in infertile men according to normal vs. advanced paternal age (APA).

Summary answer

EAU Guidelines perform better in karyotype analysis (KA) and Y-chromosome microdeletions (YCM) investigation in men above 35 years of age.

What is known already

EAU Guidelines for genetic testing in infertile men recommend specific threshold for candidate selection for both KA (<10 million spermatozoa/ml) and YCM (<5 million spermatozoa/ml). However, paternal age is not taken into account for candidate selection in this setting.

Study design, size, duration

Data from 2188 infertile men (according to WHO definition) consecutively evaluated at a single academic centre were analysed.

Participants/materials, setting, methods

Demographic, clinical and laboratory data were analysed. Semen analyses were based on 2010 WHO criteria. Advanced age was defined as above 35. All men underwent KA and YCM testing. EAU Guidelines were validated in our cohort and according to APA. Specificity, sensitivity, and AUC were estimated for all scenarios. A Wald-type test compared AUC according to APA for KA and YCM. Decision curve analysis (DCA) estimated the benefit of using EAU Guidelines according to APA.

Main results and the role of chance

Median (IQR) paternal age was 37 (34–41) years. Advanced paternal age was found in 1306 (60%) of included men. Prevalence of KA and YCM was 4% (48 men) and 1% (13 men), respectively. EAU Guidelines sensitivity, specificity and AUC in the overall population were 85%, 47% and 66% for KA, whereas they were 100%, 57% and 80% for YCM. When stratifying according to APA, EAU Guidelines performed better in men over 35 both in terms of KA and YCM detection. Specifically, AUC for KA detection in men with APA was 70% vs. 63% in younger men (p = 0.04). AUC for YCM detection in men with APA was 82% vs. 79% in younger men (p = 0.03). DCA confirmed higher net benefit in using EAU Guidelines in old vs. young men for the detection of both KA and YCM.

Limitations, reasons for caution

It is a retrospective analysis at a single, tertiary-referral academic centre, thus raising the possibility of selection biases.

Wider implications of the findings: EAU Guidelines for genetic testing in infertile men perform differentially according to APA. KA and YCM are better detected in older men, likely due to a wider pool of confounding etiological factors in young men. These results suggest the implementation of more accurate predictive models in younger men.

Trial registration number

Not applicable

O-151 Detailed characterization of infertile men with idiopathic versus unexplained infertility: a single-center experience

Study question

We aimed to investigate the rate of and the clinical characteristics of men with idiopathic versus unexplained infertility from a cohort of white-European men.

Summary answer

Approximately 20% and 5% of men evaluated for primary couple’s infertility depicted characteristics suggestive for idiopathic and unexplained infertility, respectively.

What is known already

Male factor infertility (MFI) can be associated with clinical, hormonal and genetic diseases, but MFI is idiopathic in almost 30% of cases.

Study design, size, duration

Data from 3098 infertile men (according to WHO definition) consecutively evaluated between 2003-2020 at a single academic centre were analysed and compared with those of 103 fertile controls. Health-significant comorbidities were scored with the Charlson Comorbidity Index (CCI). Idiopathic infertility was defined for pathological semen analysis but normal physical examination and endocrine, genetic and biochemical laboratory testing. Unexplained infertility is defined as infertility of unknown origin with normal sperm parameters.

Participants/materials, setting, methods

Testicular volume (TV) was assessed with a Prader’s orchidometer. Serum hormones and sperm DNA fragmentation index (SDF) were measured in every patient. Vitamin D3 (VitD) deficiency was considered for vitD levels <20 ng/mL. Semen analyses were based on the 2010 WHO reference criteria. Health-significant comorbidities were scored with the Charlson Comorbidity Index (CCI).

Main results and the role of chance

Overall, 570 (18.5%) and 154 (5.0%) patients depicted criteria suggestive for either idiopathic or unexplained primary infertility, respectively. Groups were similar in terms of age, BMI, CCI, recreational habits, circulating serum hormones and SDF. Testicular volume was lower in men with idiopathic vs. unexplained infertility [median (IQR) 20 (15-25) vs. 20 (17-25); p < 0.001]; more idiopathic than unexplained infertile men depicted TV < 15ml (23.4% vs. 12%; p < 0.01). Similarly, vitD levels were lower [22 (17-28) vs. 27 (21-42) ng/mL; p < 0.001] in idiopathic vs. unexplained infertile men, with a higher rate of pathologic VitD levels in the same group (42.1% vs. 10%; p = 0.04). When compared to fertile controls, groups were similar in terms of age, BMI, CCI and serum hormones values. TV was larger in fertile controls than idiopathic and unexplained infertile men (all p < 0.01). At multivariable logistic regression analysis only vitD deficiency (OR 8.1, p = 0.03) was found to be associated with idiopathic infertility after accounting for age, BMI, testosterone values and TV. 

Limitations, reasons for caution

The small number of fertile controls may raise the possibility of biases.

Wider implications of the findings

Idiopathic and unexplained infertility were identified in approximately 20% and 5% of men evaluated, respectively. Idiopathic infertile men showed lower TV and lower vitD values compared to men with unexplained infertility. Future studies are needed to develop a more tailored management to these difficult MFI cases.

Trial registration number

.

P–108 Which infertile men with normal semen analysis deserve a second semen analysis in the real-life setting?

Study question

Guidelines suggest that one semen analysis is sufficient during the diagnostic work-up of an infertile man in the case of normality as for WHO criteria.

Summary answer

We investigated the rate and the clinical features of men with abnormal sperm parameters at a second test, after a normal first semen analysis.

What is known already

A second test is recommended when the first semen analysis depicted abnormal sperm parameters.

Study design, size, duration

Complete demographic, clinical and laboratory data from 1358 consecutive primary infertile men (infertility as for WHO definition) were analysed. Health-significant comorbidities were scored with the Charlson Comorbidity Index (CCI). Serum hormones were measured in every patient. Patients underwent two consecutive semen analyses at the same laboratory, which followed 2010 WHO reference criteria.

Participants/materials, setting, methods

Descriptive statistics and logistic regression models tested the association between clinical variables and semen parameters. Receiver operative characteristic (ROC) curves were used to assess the relationship between clinical variables and to create a composite risk score for pathological sperm parameters at a second test.

Main results and the role of chance

At first analysis, 212 (15.6%) infertile men had normal semen parameters. Of 212, 87 (41.0%) had a second normal semen analysis, while 80 (37.7%), 35 (16.5%) and 10 (4.7%) men showed 1, 2 and 3 pathological sperm parameters at second test. Men with a pathological second semen analysis had higher CCI scores (p < 0.001), smaller testicular volume (p < 0.001) and higher FSH values (p < 0.01) than those with normal second samples. Overall, despite being within normal ranges, sperm concentration was lower [34 (23–57) vs. 62 (35–94); p < 0.01] in men with an abnormal second sample compared to those with confirmed normality. At multivariable logistic regression analysis, smaller testicular volume (OR 0.9, p = 0.03), FSH (OR 1.2, p < 0.01), and lower sperm concentration (OR 0.9, p < 0.01) were associated with pathological second semen analyses, after accounting for age and CCI. ROC curves showed that testicular volume <15 ml, FSH values >6 mUI/ml and sperm concentration <40 mil/ml had good predictive ability for pathologic second sperm parameters (all AUC >0.8). Considering 1-point for each of the previous variables, the chances of a pathological second analysis increased from 38.8% to 74.6%, 77.3% and 100% among patients with risk scores of 0, 1, 2 and 3, respectively (p < 0.001).

Limitations, reasons for caution

It is a retrospective analysis at a single, tertiary-referral academic centre, thus raising the possibility of selection biases. In spite of this, all patients have been consistently analysed over time with a rigorous follow-up, thus limiting potential heterogeneity in terms of data reporting.

Wider implications of the findings: Approximately 60% of infertile men with a normal semen analysis depicted a pathological second test. Smaller testicles, higher FSH, lower sperm concentrations were independently associated with a pathologic second test. These features could be useful to identify those infertile men with a normal semen analysis who deserve a second test.

Trial registration number

Not applicable

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

P–094 Kidney function impairment in primary infertile men

Study question

We investigated the prevalence of kidney function impairment in a homogeneous cohort of white-European primary infertile men.

Summary answer

Mild kidney function impairment characteristics were found in 9% of asymptomatic and unaware patients presenting for primary infertility investigation.

What is known already

Infertile men have shown a worse overall health status compared to the fertile counterpart. We investigated the prevalence of kidney function impairment in a homogeneous cohort of white-European primary infertile men.

Study design, size, duration

In this corss-sectional study, complete clinical and laboratories data from a cohort of 557 consecutive men aged >18 years, presenting for primary infertility investigation were analyzed.

Participants/materials, setting, methods

Comorbidities (as scored with the Charlson Comorbidity Index (CCI)) were collected in each patient. Primary outcome was the presence of functional impairment of the kidney (defined as an estimated glomerular filtration rates <90 ml/min/1.73m², according to the Kidney Outcomes Quality Initiative). The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) function was used for eGFR calculation. Logistic regression analyses tested the association between kidney function impairment and clinical and semen features.

Main results and the role of chance

Of 557, 51 (9.3%) patients depicted at least a mild loss of kidney function (eGFR<90 ml/min /1.73m²). Median [interquartile (IQR)] age was 38 (35–42) years for normal kidney function group vs. 41 (36–46.5) years for those with impaired renal function (p < 0.001). Those with impaired renal function had also a higher BMI [26.1 (24.4–27.8) vs. 24.9 (23.2–26.8); p = 0.002] and higher numbers of comorbidities [CCI≥ 1 in 11 (21.5%) vs. 40 (7.9%) patients (p < 0.001)]. Of note, they had more frequently history of hypertension [10 (19.6%) vs. 31 (6.1%), p = 0.001]. Groups did not differ in terms of hormonal and semen features. At logistic regression analysis, older age and CCI≥1 were associated with a higher risk of impaired eGFR (OR 1.06; 95%CI 1.01–1.11; p = 0.016 and OR 2.41; 95%CI 1.06–5.15; p = 0.028, respectively)(table). No association was found between sperm parameters and eGFR impairment (all p > 0.05), after accounting for age, CCI, BMI, FSH, testicular volume, and varicocele.

Limitations, reasons for caution

Mild kidney function impairment characteristics were found in 9% of asymptomatic and unaware patients presenting for primary infertility investigation. Age and the rate of comorbidities are associated with reduced eGFR. Wider implications of the findings: This novel finding confirms growing data on a significant association of male infertility with a poorer overall male health status.

Trial registration number

Not applicable