Global Practice Patterns and Variations in the Medical and Surgical Management of Non-Obstructive Azoospermia: Results of a World-Wide Survey, Guidelines and Expert Recommendations

PURPOSE

Non-obstructive azoospermia (NOA) is a common, but complex problem, with multiple therapeutic options and a lack of clear guidelines. Hence, there is considerable controversy and marked variation in the management of NOA. This survey evaluates contemporary global practices related to medical and surgical management for patients with NOA.

MATERIALS AND METHODS

A 56-question online survey covering various aspects of the evaluation and management of NOA was sent to specialists around the globe. This paper analyzes the results of the second half of the survey dealing with the management of NOA. Results have been compared to current guidelines, and expert recommendations have been provided using a Delphi process.

RESULTS

Participants from 49 countries submitted 336 valid responses. Hormonal therapy for 3 to 6 months was suggested before surgical sperm retrieval (SSR) by 29.6% and 23.6% of participants for normogonadotropic hypogonadism and hypergonadotropic hypogonadism respectively. The SSR rate was reported as 50.0% by 26.0% to 50.0% of participants. Interestingly, 46.0% reported successful SSR in <10% of men with Klinefelter syndrome and 41.3% routinely recommended preimplantation genetic testing. Varicocele repair prior to SSR is recommended by 57.7%. Half of the respondents (57.4%) reported using ultrasound to identify the most vascularized areas in the testis for SSR. One-third proceed directly to microdissection testicular sperm extraction (mTESE) in every case of NOA while others use a staged approach. After a failed conventional TESE, 23.8% wait for 3 months, while 33.1% wait for 6 months before proceeding to mTESE. The cut-off of follicle-stimulating hormone for positive SSR was reported to be 12-19 IU/mL by 22.5% of participants and 20-40 IU/mL by 27.8%, while 31.8% reported no upper limit.

CONCLUSIONS

This is the largest survey to date on the real-world medical and surgical management of NOA by reproductive experts. It demonstrates a diverse practice pattern and highlights the need for evidence-based international consensus guidelines.

Global Practice Patterns in the Evaluation of Non-Obstructive Azoospermia: Results of a World-Wide Survey and Expert Recommendations

PURPOSE

Non-obstructive azoospermia (NOA) represents the persistent absence of sperm in ejaculate without obstruction, stemming from diverse disease processes. This survey explores global practices in NOA diagnosis, comparing them with guidelines and offering expert recommendations.

MATERIALS AND METHODS

A 56-item questionnaire survey on NOA diagnosis and management was conducted globally from July to September 2022. This paper focuses on part 1, evaluating NOA diagnosis. Data from 367 participants across 49 countries were analyzed descriptively, with a Delphi process used for expert recommendations.

RESULTS

Of 336 eligible responses, most participants were experienced attending physicians (70.93%). To diagnose azoospermia definitively, 81.7% requested two semen samples. Commonly ordered hormone tests included serum follicle-stimulating hormone (FSH) (97.0%), total testosterone (92.9%), and luteinizing hormone (86.9%). Genetic testing was requested by 66.6%, with karyotype analysis (86.2%) and Y chromosome microdeletions (88.3%) prevalent. Diagnostic testicular biopsy, distinguishing obstructive azoospermia (OA) from NOA, was not performed by 45.1%, while 34.6% did it selectively. Differentiation relied on physical examination (76.1%), serum hormone profiles (69.6%), and semen tests (68.1%). Expectations of finding sperm surgically were higher in men with normal FSH, larger testes, and a history of sperm in ejaculate.

CONCLUSIONS

This expert survey, encompassing 367 participants from 49 countries, unveils congruence with recommended guidelines in NOA diagnosis. However, noteworthy disparities in practices suggest a need for evidence-based, international consensus guidelines to standardize NOA evaluation, addressing existing gaps in professional recommendations.

Effect of bulbospongiosus muscle injection with botulinum-A toxin for treatment of lifelong premature ejaculation; a randomized controlled trial

This study aimed at assessing a new line of treatment for lifelong premature ejaculation which is botulinum-A toxin injection into the bulbospongiosus muscle. Sixty patients with lifelong premature ejaculation were independently randomized into 2 groups; group I, 100 U botulinum-A toxin at 10 U/ml saline was injected with ultrasound guidance into the bulbospongiosus muscle and group II which was injected with similar volume of saline. The primary outcome was to compare both groups for changes in the Premature Ejaculation Profile (PEP), Intravaginal Ejaculatory Latency Time (IELT) and partner's satisfaction at 1, 3 and 6 months after intervention. The second outcome was to compare the adverse events in both groups. Fifty-seven patients completed the study. In group I, the mean PEP increased significantly at 1- (P = 0.02) and 3- months (P = 0.04) with insignificant increase at 6-month (P = 0.6) of follow-up. Also, no significant changes had been noted in IELT or partner's satisfaction scores throughout the study duration (P > 0.05). In group II, no significant changes had been noted in the PEP, IELT and partner's satisfaction scores throughout the study duration (P > 0.05). There were insignificant differences in the changes in the mean PEP (P = 0.7, 0.6 and 0.4), IELT (P = 0.6,0.6 and 0.5) and partner's satisfaction scores (P = 0.5,0.7 and 0.3) in comparison to the baseline values at 1-, 3- and 6- months, respectively between both groups. Adverse events were observed in only 3 patients (5.3%). In group I, mild erectile dysfunction and post micturition dribbling were reported in one patient each. Where in group II, one patient reported bleeding per urethra (P = 0.5). To conclude, injection of botulinum-A toxin into bulbospongiosus seems to be safe but failed to prove clinical efficacy for treatment of lifelong premature ejaculation when compared to placebo.

Progress on microstructure features and creep properties of prospective Tin-Silver-Zinc alloy using a magnetic field

In the current work, applying a rotating magnetic field (RMF) is an innovative approach to improve the microstructure features and creep resistance of Sn-2.0Ag-2.0Zn (SAZ) alloy. The results revealed that RMF does not change intermetallic compounds (IMCs) constituents furthermore SAZ alloy with applying a magnetic field (SAZ-B) exhibited microstructure refinement and homogeneous distribution of IMCs. Moreover, SAZ-B displayed more creep resistance (∼366%) and greater creep rupture time (∼56.4%) than those of SAZ alloy. These results have great implications in improving the alloy’s performance for industrial applications.

Indirect genetic effects on the relationships between production and feeding behaviour traits in growing Duroc pigs

Performance and feeding behaviour traits in growing pigs could be affected by social interaction effects when animals are raised in group. So, properly knowing the genetic correlations between direct and social interaction effects among performance and feeding behaviour traits could improve the accuracy of the genetic evaluations. Our aim was to explore the role of feeding behaviour traits (FBT) and indirect genetic effects (IGEs) in the genetic evaluations of growing pigs. Thus, genetic parameters were estimated for production traits (PT): average daily gain, average daily feed consumption, feed conversion ratio and backfat thickness; as well as for FBT: average daily feeding rate, average daily feeding frequency, average daily occupation time and average daily time between consecutive visits. Traits were recorded in 1144 Duroc pigs during the fattening period. Two bivariate models were fitted: classic animal model and an animal model fitting IGE. Estimations were done following Bayesian procedures. Heritability estimates obtained with classic animal model for all studied traits were medium-high. The additional heritable variation captured by IGE supposed that the ratios of total genetic variance to phenotypic variance (T2) were higher than the heritability estimates obtained with the classic model, except for occupation time trait, when a lower value (0.20 ± 0.19) was estimated. This is due to a high and negative correlation between IGE and direct genetic effects (DGEs) of this particular trait (-0.78 ± 0.27). Results from classic animal model do not evidence a clear role of FBT to improve the accuracy of breeding value predictions for PT; only average daily feeding rate seems to show a positive correlation (around 0.50 to 0.60) with average daily gain, average daily feed consumption and backfat thickness. However, when IGE model was fitted, the number of estimates of genetic correlations between FBT and PT showing a relevant magnitude increased, generally for the correlations between IGE of FBT and DGE of PT; or particularly for the correlations between IGE of average daily feeding frequency, and the IGE of all the PT, except average daily gain. Thus, in evaluations using the animal model with IGE fitted, the inclusion of FBT could aid the improvement of the accuracy of breeding value predictions for PT. This is a consequence of the improved genetic relationships between traits that can be fitted when considering such models.

Association of interleukin-6 gene promoter polymorphism with acne vulgaris and its severity

BACKGROUND

Acne vulgaris (AV) is an inflammatory disorder with a possible genetic background. Different cytokines and mediators are involved in its pathogenesis.

AIM

Our aim was to investigate the interleukin (IL)-6 572 polymorphism in patients with AV and its relation to patient sex and acne severity.

METHODS

In total, 30 patients with acne and 20 healthy controls (HCs) were enrolled. The Global Acne Grading System was used to assess acne severity. The IL-6 572 gene promoter polymorphism was assessed using the PCR-restriction fragment length polymorphism method.

RESULTS

There was a significantly higher association of IL-6 572 variants genotypes in patients with acne (93%) compared with the HC group (45%) (P < 0.001), with a higher incidence of the IL-6 572 CC polymorphism in patients with acne. A significant difference (P < 0.001) between C and G alleles in patients vs. HCs was detected. There were no significant associations between the IL-6 572 variant genotypes and either patient sex or AV severity.

CONCLUSION

IL-6 gene promoter polymorphism might have a role in AV susceptibility but it is not related to AV severity.

Genetic analysis of meat quality traits in maternal lines of rabbit and their diallel cross

Young rabbits, the dams of which came from a full diallel cross among four maternal lines (A, V, H and LP) and the sires from a single paternal line (R), that produce sixteen genetic groups, was carried out to evaluate the genetic groups and to estimate the crossbreeding genetic parameters of meat quality. The meat quality traits were recorded by NIRS from a sample of 285 longissimus lumborum muscles. Crossbreeding parameters were estimated according to Dickerson model. No differences in protein were found. The line A had significant differences with V line for intramuscular fat, and fatty acids groups. Significant differences for these traits appeared between the crossbred AH and VV (in favor of AH). As conclusion, the significant contrasts between genetic types for chemical composition of the meat are mainly consequence of direct-maternal genetic effects, having grandmaternal and maternal heterosis effects a less relevant role.

Goserelin acetate before transurethral resection of moderately enlarged benign prostatic hyperplasia: Prospective randomised-controlled clinical trial

Objective

To evaluate the impact of a luteinising hormone-releasing hormone (LHRH) agonist, goserelin acetate (GA), on surgical blood loss during transurethral resection of the prostate (TURP), as well as its histopathological effect on prostatic microvessel density (MVD).

Patients and methods

Patients who underwent TURP due to benign prostatic enlargement (60–100 mL) were randomly subdivided into two equal groups according to whether they received preoperative GA administration (3.6 mg; group A) or not (group B). Evaluation parameters were operative time, weight of resected prostatic tissue, perioperative haematocrit (HCT) changes, estimation of intraoperative blood loss, and suburethral and stromal prostatic MVD. Effects of GA on prostate weight and any possible side-effects were also monitored.

Results

In all, 35 and 33 patients were included in groups A and B, respectively. Operative time and HCT values’ changes were significantly less in group A (P < 0.05). Also, operative blood loss (both total and adjusted per weight of resected tissue) was lower in group A, at a mean (SD) of 178.13 (77.71) mL and 3.74 (1.52) mL/g vs 371.75 (91.09) mL and 8.59 (2.42) mL/g (P < 0.001). The median MVD in both suburethral [8 vs 11 vessels/high-power field (HPF)] and stromal tissues (9 vs 17 vessels/HPF) were significantly lower in group A (P < 0.001). Side-effects were minimal.

Conclusion

A single dose of GA, a LHRH agonist, before TURP is safe and effective in reducing surgical blood loss. It significantly reduced MVD in both suburethral and stromal nodular prostatic tissues without regional discrepancy.

Genetic analysis of slaughter and carcass quality traits in crossbred rabbits coming from a diallel cross of four maternal lines

<p>An experiment was carried out to estimate the genetic group effects and the crossbreeding genetic parameters of slaughter and carcass traits using data on the rabbits that were progeny of does coming from a full diallel cross between 4 maternal lines (A, V, H and LP) mated to bucks of the paternal line R. The rabbits of the 16 genetic groups, corresponding to the type of does of the diallel cross, were distributed in 4 Spanish farms and 1 genetic group (V line) was present in all farms in order to connect records among them and to be used as reference group. Crossbreeding parameters were estimated according to Dickerson’s model. 1896 rabbits were measured for slaughter traits and 950 for carcass traits. The A and LP lines had the lowest values for dressing percentage (–1.71 and –1.98 compared with H line and –1.49 and –1.75 with the V line, respectively). The A line was the heaviest for commercial carcass weight. No relevant differences were observed between the crossbred groups for all traits. Regarding the reciprocal effects, there were significant differences in favour of A line as sire line in the crossbred AV. Regarding the combination of direct and maternal effects, the A line showed significantly higher values for cold carcass weight (133 g., 71 g. and 142 g. compared to the H, LP and V lines). For the same parameter the H line showed significantly higher averages on dressing percentages than A and LP lines, 1.44 and 2.13%, respectively. Line A also showed, in general, better direct- maternal effects than the V line. Grand-maternal effects were less important than direct-maternal ones. The estimates of maternal heterosis were, in general, negative, which could be a consequence of the positive heterosis for litter size. However, despite this relationship between growth and litter traits, it has not been common to find negative maternal heterosis in growth traits. A diminution of dressing percentage was detected in some crossbreds (AL and LV) and care must be taken if these types are used.</p>

Genetic analysis of growth traits in the progeny of rabbit does from a diallel cross

An experiment was carried out to estimate the genetic group effects and the crossbreeding genetic parameters of growth traits [body weight (BW), average daily gain (ADG), feed intake (FI) and feed conversion ratio (FCR)] in rabbits during fattening between 28 and 63 d. The rabbits were the progeny of does coming from a full diallel cross between 4 maternal lines (A, V, H and LP) mated to bucks of the paternal line R. On thousand fifty five  rabbits were controlled and the traits were recorded weekly, with the cage as the experimental unit for FI and FCR (283 cages). The genetic group (V line) was present in all farms in order to connect records among them and to be used as reference group. Crossbreeding parameters were estimated according to the Dickerson model. Regarding dam effects between pure lines for BW at weaning, A line was the heaviest and showed significant differences with LP and V lines (61 and 30 g, respectively). Upon completion of the fattening period, the differences in favour of A line for BW at weaning were compensated. Throughout the fattening period, no significant differences were observed between the lines as dam lines. At the end of the fattening period, no significant differences were observed between the crossbred groups. Regarding the reciprocal effects, the most relevant results were the significances for FCR in favour of H as sire line. For all traits, the confidence intervals at 95% of all contrast and effects were large. The estimates of maternal heterosis were, in general, negative, which could be a consequence of the positive heterosis for litter size. The AH cross showed significant maternal heterosis for BW at 43 d (–53 g), ADG between 28 and 42 d (–3.5 g/d), FI between 28 and 63 d (–7 g/d) and FCR between 42 and 63 d (–0.15). The combination of direct and maternal effects of the V line was the worst for all growth traits, showing significant differences with the LP line for most of them, for instance 0.13 worse FCR between 28 and 63 d. Grand-maternal effects were less important than direct-maternal.

Effective population size and inbreeding depression on litter size in rabbits. A case study

The purpose of this study is to use demographic and litter size data on four Spanish maternal lines of rabbits (A, V, H and LP), as a case study, in order to: (i) estimate the effective population size of the lines, as a measure of the rate of increase of inbreeding, and (ii) study whether the inbreeding effect on litter size traits depends on the pattern of its accumulation over time. The lines are being selected for litter size at weaning and are kept closed at the same selection nucleus under the same selection and management programme. The study considered 47,794 l and a pedigree of 14,622 animals. Some practices in mating and selection management allow an increase of the inbreeding coefficient lower than 0.01 per generation in these lines of around 25 males and 125 females. Their effective population size (Ne) was around 57.3, showing that the effect of selection, increasing the inbreeding, was counterbalanced by the management practices, intended to reduce the rate of inbreeding increase. The inbreeding of each individual was broken down into three components: old, intermediate and new inbreeding. The coefficients of regression of the old, intermediate and new inbreeding on total born (TB), number born alive (NBA) and number weaned (NW) per litter showed a decreasing trend from positive to negative values. Regression coefficients significantly different from zero were those for the old inbreeding on TB (6.79 ± 2.37) and NBA (5.92 ± 2.37). The contrast between the coefficients of regression between the old and new inbreeding were significant for the three litter size traits: 7.57 ± 1.72 for TB; 6.66 ± 1.73 for NBA and 5.13 ± 1.67 for NW. These results have been interpreted as the combined action of purging unfavourable genes and artificial selection favoured by the inbreeding throughout the generations of selection.

Role of posterior tibial nerve stimulation in the treatment of refractory monosymptomatic nocturnal enuresis: a pilot study

PURPOSE

We evaluated the early clinical and urodynamic results of posterior tibial nerve stimulation in patients with refractory monosymptomatic nocturnal enuresis.

MATERIALS AND METHODS

We randomly assigned 28 patients with refractory monosymptomatic nocturnal enuresis to 2 equal groups. Group 1 received a weekly session of posterior tibial nerve stimulation for 12 weeks and group 2 was the placebo group. Evaluation was performed in each group at baseline and after posterior tibial nerve stimulation to compare clinical and urodynamic findings. Another clinical assessment was done 3 months after the first followup.

RESULTS

The 2 groups were comparable in baseline clinical and urodynamic data. Overall, 13 patients (46.4%) had detrusor overactivity and 14 (50%) had decreased bladder capacity. After treatment 11 group 1 patients (78.6%) had a partial or full response to posterior tibial nerve stimulation but only 2 (14.3%) in group 2 had a partial response (p = 0.002). Also, the average number of wet nights in group 1 was significantly lower than at baseline (p = 0.002). All urodynamic parameters significantly improved in group 1. In contrast, the number of wet nights and urodynamic parameters did not change significantly in group 2. At 3-month followup the number of patients with a partial or full response in group 1 had decreased from 11 (78.6%) to 6 (42.9%). No change was evident in group 2.

CONCLUSIONS

Posterior tibial nerve stimulation can be a viable treatment option in some patients with refractory monosymptomatic nocturnal enuresis. However, deterioration in some responders with time suggests the need for maintenance protocols.

Impact of a Double-Pigtail Stent on Ureteral Peristalsis in the Porcine Model: Initial Studies Using a Novel Implantable Magnetic Sensor

BACKGROUND AND PURPOSE

The effect of stents on ureteral peristalsis in vivo is not entirely clear. We sought to develop a minimally invasive method for its study.

MATERIALS AND METHODS

In female domestic pigs, electrical potentials from the ureter were measured by bipolar steel-wire electromyography electrodes delivered laparoscopically. Mechanical movement was measured by giant magneto resistive sensors mounted on custom-made aluminum strips. After baseline values were obtained, the animals were randomized to receive silicone or polyurethane stents, and ureteral peristalsis was measured for 8 hours acutely and for 4 hours 1 week later.

RESULTS

Implantation of the devices took an average of 30 minutes. A consistent correlation was found between laparoscopically observed peristaltic waves and the peristalsis detected by the two measuring devices. The devices themselves did not affect peristalsis. Stent insertion increased peristaltic activity initially but later reduced or stopped it. There was no difference in the effects of the two types of stents.

CONCLUSIONS

The new technique permits close monitoring of ureteral peristalsis in vivo. Smaller stents appear to have less immediate effect than larger ones, but all type of stents tested eventually caused aperistalsis.

Evaluation of serum neopterin, high-sensitivity C-reactive protein and thiobarbituric acid reactive substances in Egyptian patients with acute coronary syndromes

The present study evaluated serum neopterin, high-sensitivity C-reactive protein (hs-CRP) and thiobarbituric acid reactive substances (TBARS) in Egyptian patients with acute coronary artery disease. Thirty-six patients with unstable angina aged (mean +/- SD) 61.3+/-9.4 years, 29 patients with myocardial infarction aged 58.2+/-8.7 years and 24 sex- and age-matched control subjects were included in the study. Neopterin levels were significantly higher in patients with myocardial infarction and those with unstable angina than in the healthy control group (P<0.001). The serum level of neopterin in the control group (median [range]) was 3.25 nmol/L (1.25 nmol/L to 5.4 nmol/L), whereas in patients with unstable angina and those with myocardial infarction, neopterin levels were 10.4 nmol/L (3.5 nmol/L to 15.2 nmol/L) and 12.6 nmol/L (3.25 nmol/L to 17.8 nmol/L), respectively. Levels of hs-CRP and TBARS were also significantly higher in patients with unstable angina and those with myocardial infarction than in the healthy control group (P<0.01). The medians (ranges) of hs-CRP were 4.8 mg/L (2.5 mg/L to 9.9 mg/L), 12.0 mg/L (4.6 mg/L to 31.0 mg/L) and 12.3 mg/L (7.5 mg/L to 32.1 mg/L) in the control group, patients with unstable angina and those with myocardial infarction, respectively. The means +/- SD of TBARS in the control group, patients with unstable angina and those with myocardial infarction were 0.64+/-0.17 mumol/L, 1.17+/-0.31 mumol/L and 1.17+/-0.49 mumol/L, respectively. TBARS positively correlated with hs-CRP and neopterin levels. Furthermore, when both patients and controls were classified according to their smoking status, significantly higher levels of neopterin and TBARS were found in the smokers of each subgroup than in the nonsmokers.In conclusion, the present study found a higher level of neopterin, hs-CRP and TBARS in patients with coronary artery disease. Serum neopterin and hs-CRP positively correlated with the level of TBARS. The authors suggest that triggering factors (eg, smoking, high cholesterol, elevated body mass index or raised blood pressure) may lead to increased oxidative stress, which induces an inflammatory insult leading to higher levels of inflammatory markers such as neopterin and hs-CRP.

Laparoscopic cyst decortication in autosomal dominant polycystic kidney disease: impact on pain, hypertension, and renal function

BACKGROUND AND PURPOSE

In patients with autosomal dominant polycystic kidney disease (ADPKD), laparoscopic cyst decortication (LCD) has been proposed as a means to relieve chronic cyst-related pain. We present our 7-year experience with LCD for ADPKD with regard to pain relief, hypertension, and renal function.

PATIENTS AND METHODS

Between August 1994 and February 2001, 29 ADPKD patients with chronic pain (N=29), hypertension (N=21), and renal insufficiency (N=10) underwent 35 LCD procedures. Every detectable cyst within 2 mm of the renal surface was treated. Pain relief was assessed using a pain analog scale; relative pain relief (RPR) equaled (preoperative pain score) - (postoperative pain score)/(preoperative pain score). Hypertension was evaluated using the antihypertensive therapeutic index (ATI): [(dose of blood pressure medication 1/max dose 1) + (dose med 2/max dose 2) + etc.] x 10. Renal function was assessed using the Cockcroft and Gault formula for creatinine clearance.

RESULTS

The mean operating room time was 4.9 hours (range 2.6-6.6 hours) with no conversions to open surgery. An average of 220 cysts (range 4-692) were treated per patient. The mean follow-up was 32.3 months (range 6-72 months). The RPR was 58%, 47%, and 63% at 12, 24, and 36 months, respectively. At 12, 24, and 36 months, 73%, 52%, and 81% of patients, respectively, noted >50% improvement in their pain compared with the preoperative situation. Five patients became normotensive, and patients improved their ATI by an average of 49% (range 11%-93%). However, six patients had worsening hypertension, with an ATI increase averaging 53% (range 11%-122%), and one patient who was not hypertensive preoperatively has since developed hypertension. The creatinine clearance changed +4%, +7%, and -2% at 12, 24, and 36 months, respectively. Only one patient had a >20% increase in creatinine clearance. The only patients with a >20% decrease in creatinine clearance were those who had a creatinine clearance <30 mg/dL preoperatively (average decrease 34% [range 20%-51%]).

CONCLUSIONS

For ADPKD patients with debilitating pain, extensive LCD can provide durable relief. In the majority of patients with pain and hypertension, a marked improvement in blood pressure also occurs. Cyst decortication was not associated with worsening renal function; indeed, renal function remained largely unchanged over the 3-year follow-up period.

Combined percutaneous and retrograde approach to staghorn calculi with application of the ureteral access sheath to facilitate percutaneous nephrolithotomy

PURPOSE

We describe our technique and clinical experience with application of the ureteral access sheath for single access ablation of staghorn and partial staghorn calculi.

MATERIALS AND METHODS

We retrospectively reviewed our experience with 9 patients who underwent percutaneous nephrolithotomy for staghorn (6) or partial staghorn (3) renal calculi using a combined antegrade and retrograde approach. Patient data, operative parameters, efficacy of stone ablation and convalescence parameters were reviewed.

RESULTS

Mean operative time for the primary procedure was 3.1 hours with a mean estimated blood loss of 290 ml. Postoperatively, the mean analgesic requirement was 33.2 mg. MSO(4) equivalents. Hospital stay was 3.2 days. There were no major and 4 minor (44%) complications. No patient required transfusion. Complete stone clearance was achieved in 7 of the 9 cases (78%) using a single percutaneous nephrostomy tract.

CONCLUSIONS

Our preliminary clinical experience using the ureteral access sheath during percutaneous nephrolithotomy for simultaneous antegrade and retrograde stone treatment has been favorable. A large renal stone burden can be successfully managed with a single percutaneous access and limited blood loss.

Comparison of intrarenal pressure and irrigant flow during percutaneous nephroscopy with an indwelling ureteral catheter, ureteral occlusion balloon, and ureteral access sheath

OBJECTIVES

To determine the differential effects on renal pressures and irrigation flow associated with the application of different ureteral catheters during percutaneous nephrolithotomy.

METHODS

Using ex vivo fresh cadaveric tissue, we established a percutaneous nephrolithotomy model. After obtaining lower pole percutaneous access, we recorded the pressure and irrigant flow measurements. Measurements were made with an empty ureter, 6F ureteral catheter, occlusion balloon catheter, and ureteral access sheaths (10/12F and 12/14F). Three 1-minute trials for each condition were recorded in each of four kidneys.

RESULTS

Ureteral catheterization with both the 10/12F and the 12/14F ureteral access sheaths resulted in significantly decreased intrarenal pressures in the pressure range tested compared with an empty ureter, a ureteral catheter, or an occlusion balloon application. Total irrigant flow for the 12/14F ureteral access sheath was significantly higher than for the empty ureter, ureteral catheter, or occlusion balloon in the entire pressure range evaluated.

CONCLUSIONS

In this in vitro cadaveric model, application of the ureteral access sheath during percutaneous nephrolithotomy resulted in decreased intrarenal pressures and increased irrigant flow.

Spontaneous and GnRH-provoked gonadotropin secretion and testosterone response to human chorionic gonadotropin in adolescent boys with thalassaemia major and delayed puberty

To elucidate whether the cause of sexual maturation arrest in thalassaemia is of gonadal or pituitary etiology, 10 males with thalassaemia and delayed puberty and 10 with constitutional delay of growth and pubertal maturation (CSS) were extensively studied. Their spontaneous nocturnal gonadotropin secretion and gonadotropin response to intravenous 100 micrograms gonadotropin-releasing hormone (GnRH) were evaluated. Circulating testosterone concentration and clinical response were evaluated after 3 days, 4 weeks and 6 months of intramuscular administration of human chorionic gonadotropin (HCG) (2500 U/m2/dose). Thalassaemic boys had significantly lower circulating concentrations of testosterone compared to those with constitutional delay of growth and sexual maturation (CSS) at the same pubertal stage. Short- and long-term testosterone response to administrations of HCG was markedly decreased in thalassaemic boys. After 6 months of HCG administration 50 per cent (5/10) of the boys did not show significant testicular enlargement or genital changes. Despite the low circulating concentrations of testosterone, none of the patients had high basal or exaggerated gonadotropin response to gonadotropin releasing hormone (GnRH) stimulation. Luteinizing hormone (LH) peak responses to GnRH were significantly lower as compared to controls. Follicle-stimulating hormone (FSH) peak responses to GnRH did not differ among the two study groups. The mean nocturnal LH and FSH secretion was significantly decreased in all thalassaemic boys as compared to boys with CSS at the same pubertal stage (testicular volume). These data proved that hypogonadotropic hypogonadism is the main cause of delayed/failed puberty in adolescents with thalassaemia major. MRI studies revealed complete empty sella (n = 5), marked diminution of the pituitary size (n = 5), thinning of the pituitary stalk (n = 3) with its posterior displacement (n = 2), and evidence of iron deposition in the pituitary gland and midbrain (n = 8) in thalassaemic patients, denoting a high incidence of structural abnormalities (atrophy) of the pituitary gland. Moreover, in many of the thalassaemic boys, the defective testosterone response to long-term (6 months) HCG therapy denoted significant testicular atrophy and/or failure secondary to siderosis. It appears that testosterone replacement might be superior to HCG therapy in these patients. This therapy should be introduced at the proper time in these hypogonadal patients to induce their sexual development and to support their linear growth spurt and bone mineral accretion.

[The role of beta-ray therapy in the treatment of choroidal and ciliary body melanomas]

100 cases of uveal melanomas, were treated with 106RU 106RH beta-brachytherapy, between June 1983 and September 1987. 82 eyes having a follow-up superior or equal to 12 months, were analysed. 13 of these 82 eyes have been enucleated. 4 patients have died. 3 have at this time, hepatic dissemination. The first 43 patients were analysed at the 18th month after irradiation. The majority of tumors with initial thickness inferior to 5 mm had a regression superior to 50%, at the 18th month. The majority of tumors with initial thickness superior to 5 mm, had a regression inferior to 50%, at the same time. Functional results have also been noticed in this series of 43 eyes, and were satisfactory.

[Evaluation of 100 melanomas of the choroid and ciliary body treated by application of ruthenium (RU 106 Rh 106)]

100 cases of uveal melanomas, were treated with 106 RU 106 RH beta-brachytherapy, between June 1983 and September 1987. 82 eyes having a follow-up superior or equal to 6 months, were analysed. 13 of these 82 eyes have been enucleated. 2 patients, have died, 2 have at this time, hepatic dissemination. The first 43 patients were analysed at the 18th month after irradiation. The majority of tumors with initial thickness inferior to 5 mm had a regression superior to 50%, at the 18th month. The majority of tumors with initial thickness superior to 5 mm, had a regression inferior to 50%, at the same time. Functional results have also been noticed in this series of 43 eyes, and were satisfactory.

A short note on praziquantel in human fascioliasis

Ten patients suffering from fascioliasis were treated with praziquantel. In two patients, egg counts dropped to zero following treatment, but there was no significant reduction in egg counts in the other eight.

Some functional properties of oilseed proteins

Oilseeds have potential food uses because of their high protein content. Besides, these proteins when added to a type of foods, supply desirable functional properties, such as whipping capacity and viscosity, emulsification and water and oil holding capacities. Rapeseed and soybean protein isolates were found to possess whipping capacity followed by those of sunflower, peanut, sesame, cottonseed and safflower. The addition of sugar improved the whipping properties of oilseed proteins. The whipping capacity of oilseed proteins decreased due to heating at 100 degrees C for time of 15 to 60 min. Soybean protein had the highest emulsifying capacity compared with the other oilseed proteins. The heated oilseed proteins had emulsification properties similar to or better than the control. Glandless cottonseed protein had high water and oil holding capacities. The water holding capacity of oilseed proteins decreased gradually as the duration of heating at 100 degrees C was increased. On the other hand the heated oilseed proteins had oil holding capacities similar to or better than unheated proteins.

A focus of human fascioliasis in the Nile Delta, Egypt

This study was carried out in Abis II village. A representative sample of the population was examined for parasitic infections. Of these 40 cases were positive for Fasciola ova and the diagnosis was confirmed. The prevalence of fascioliasis was 7.3 per cent. The egg size was determined in both human and animal samples. Although the ova measurements corresponded in many instances to Fasciola hepatica, yet the identification of the Fasciola spp. needs further investigations.

Synthesis of some phthalazine derivatives chemically related to hydralazine

The potent antihypertensive properties of hydralazine and dihydralazine prompted the synthesis of sixteen new phthalazine derivatives with thiosemicarbazide or beta-propionamide residues to investigate their possible antihypertensive activity.