P-121 Azoospermia: are there neonatal differences regarding the source of sperm for ICSI?

Study question

In couples with azoospermia undergoing intracytoplasmic sperm injection (ICSI), are neonatal outcomes different depending on sperm origin (epididymal-PESA, testicular-TESA or donor sperm)?

Summary answer

Newborns from PESA or TESA had similar neonatal outcomes. Comparing to donor cases, PESA/TESA cycles didn’t present increased levels of malformation or stillbirth.

What is known already

Since the introduction of ICSI and the demonstration that the spermatozoa derived either from the epididymis or the testis were capable of normal fertilization and pregnancy, it was possible for azoospermic men to father their own children. However, it raised concerns that the quality of spermatozoa in terms of DNA damage or maturation when collected from non-ejaculated semen could differ from that collected from ejaculated and whether sperm of different origins will affect the neonatal outcome and safety of ICSI.

Study design, size, duration

Retrospective cohort study performed at a reproductive medicine center, using data from 359 deliveries from 945 cycles of ICSI of couples with infertility due to azoospermia, performed between 1995 and 2021. Data were collected from electronic records.

Participants/materials, setting, methods

A total of 359 deliveries were divided in 3 groups, according to the sperm source: PESA (n = 138), TESA (n = 139) and DONOR (n = 82). A total of 402 newborns were evaluated: PESA (n = 162); TESA (n = 156); DONOR (n = 84). Neonatal outcomes and congenital malformations were analyzed for singletons, twins and triplets separately. Statistical analysis: Anova, chi-square and Fischer test, considering p < 0.05.

Main results and the role of chance

Comparing the 3 groups (PESA, TESA, and donor sperm), the following results were found: The mean birth weight (BW), length and Apgar score > 7 for singletons and twins did not differ between groups; neither did prematurity or extreme prematurity. According to birth percentile, there was a lower rate of small for gestational age (SGA) newborn in the epididymal group (PESA, 1.5% vs. TESA, 8.5% vs. sperm donor, 5.5%, p = 0.004). Also, in 158 twin births, the number of newborns with low birth weight (<2500g) was significantly smaller in the epididymal group (PESA, 32.9% vs. TESA, 62.5%; donor sperm, 73.1%, p = 0.001). There were three stillbirths in triplets (PESA group). We also found six cases of neonatal mortality (one in singleton pregnancy in TESA group, 3 in twins (two in PESA group and one donor sperm group), and two in triplets (one in TESA and one in PESA groups). The total number of congenital malformations was 8 (2.48%) (PESA n = 1, 0.62%; TESA, n = 2, 1.28%, and donor sperm, n = 5, 5.95%, p = 0.02).

Limitations, reasons for caution

The possibility of incomplete medical records is an important limitation to be considered in retrospective studies. Larger studies are important to better assess the risk of malformation in this population.

Wider implications of the findings

In this study, there were no differences on neonatal outcomes regarding the source of sperm used for ICSI, with PESA, TESA and donor groups, as well as congenital malformation. It showed equally safe options with testis, epididymal or ejaculated sperm for azoospermia treatments.

Trial registration number

not applicable

P–110 Does the Body Mass Index affect sperm quality?

Study question

Does the body mass index (BMI) have an impact on semen analysis results?

Summary answer

The increase in BMI has a negative impact on sperm motility.

What is known already

Obesity is an increasingly prevalent health condition worldwide and can affect male fertility in various ways. It is known that obesity can cause testicular inflammation, higher testicular temperature, hypogonadism, sperm DNA fragmentation, and erectile dysfunction. However, there are still conflicting data regarding the correlation between BMI and semen parameters in the seminal analysis.

Study design, size, duration

Observational, cross-sectional, retrospective study using data from 1147 patients seen at a private infertility clinic between 2010 and 2020. The data were collected from electronic records in a prospective database.

Participants/materials, setting, methods

Patients were divided according to BMI (healthy weight, overweight, obesity classes I, II, III), and their seminal profiles were compared, according to 2010’s World Health Organization’s parameters. Cancer, cryptorchidism, viral orchitis, altered karyotype, Y chromosome microdeletions, vasectomy reversion, and testosterone use were excluding factors. Student t-tests and multiple linear regression were used for statistical analysis. The results were adjusted for age, alcohol, tobacco, and drug use, medication intake, physical activity, comorbidities, and scrotum heat factors.

Main results and the role of chance

From a total of 1384 patients, 219 were excluded. The BMI varied between 18,9 and 50,8 kg/m². From the 1147 patients, 297 had BMI 18.5–24.9 kg/m² (healthy weight, group 1), 611 had BMI 25–29.9 kg/m² (overweight, group 2), 179 had BMI 30–34.5 kg/m² (obese, group 3), 60 had BMI ≥ 35 kg/m² (extremely obese, group 4). The mean age for groups 1 through 4 was 37.6, 38.5, 38.2, and 36.5 years old. The comparison of the groups’ seminal parameters shows a significant decrease in progressive and total motility in patients with BMI ≥ 35 kg/m².The progressive motility was 43.8% in group 1, 44.1% in group 2, 42.4% in group 3, and 35.2% in group 4 (p = 0.07) and the total motility was 54.4%, 54.1%, 53.6%, and 45.9%, respectively (p = 0.012). The complementary analysis determined BMI 29 kg/m² as the cutoff for negative impact on progressive motility (p = 0.044) and 31 kg/m² on total motility (p = 0.036). The results were still significant after age, use of cannabis, and hypertension adjustments – the other possible interfering factors were not significant.

Limitations, reasons for caution

Besides the fact that this was a retrospective study, it also has a smaller sample size of patients with extreme obesity. This is probably related to the fact that the patients seeking reproductive treatment in a private clinic have a greater purchasing power and lower prevalence of obesity.

Wider implications of the findings: In this study, sperm quality is negatively affected by BMI, with impairment since 29 kg/m² for progressive and 31 kg/m² for total motility. Our data support the potential deleterious role of obesity on semen parameters, reinforcing the importance of weight control in infertility prevention.

Trial registration number

Not applicable

P–107 Does hematological cancer have the same impact on sperm quality as testicular cancer?

Study question

Does hematological cancer have the same impact on sperm quality as testicular cancer before chemo or radiotherapy? Summary answer: Hematological cancer has no impact on sperm quality before treatment.

What is known already

The deleterious effects of chemo and radiotherapy on testicular function are well known. Furthermore, testicular cancer causes a negative impact on sperm quality, even before treatment, probably due to local action. Hematological cancer, particularly Hodgkin lymphoma, seems to produce inflammatory alterations in the testis. However, it is not clear if hematological cancer can compromise spermatogenesis, as does testicular cancer.

Study design, size, duration

Observational, cross-sectional, retrospective study using data from 360 patients seen at a private infertility clinic between 1992 and 2019 for sperm cryopreservation before treatment. The data were collected from electronic records in a prospective database.

Participants/materials, setting, methods

Seminal samples from patients that cryopreserved semen due to hematological or testicular cancer were compared. Sperm analyses were performed according to the 2010’s World Health Organization (WHO)’s parameters. Seminal volume, total sperm number, sperm concentration, total and progressive motility, and vitality were analysed. In the hematological group, leukemia and lymphoma, and Hodgkin and non-Hodgkin lymphoma were compared. Student t-tests and Chi-Square were used, considering p < 0.05 statistically significant.

Main results and the role of chance

This study included 295 patients with testicular cancer (TEST) and 100 with hematological cancer (HEMAT). Patients that had already started chemo or radiotherapy (4 HEMAT and 12 TEST) were excluded, and 4 HEMAT and 15 TEST were azoospermic or cryptozoospermic (41.7% vs. 53,0%, p = 0,792 ). The other parameters were analysed in 92 HEMAT and 268 TEST. The mean age of the HEMAT group was 28.2 years and 27.9 for the TEST group (p = 0,858). The TEST group had higher rates of oligozoospermia (50.7% vs 31.5%, p = 0.001) and of severe oligozoospermia (29.5% vs 15.2%, p = 0.006) than the HEMAT group. Furthermore, 69.6% HEMAT had normal concentration, compared to 45.9% TEST (p < 0.001). The mean concentration of the HEMAT group was 35 mi/mL, normal according to the WHO’s standards, and the TEST group was 12 mi/mL, below the WHO’s normal standards (p < 0.001). No difference was found when comparing leukemia and lymphoma, or Hodgkin and non-Hodgkin lymphoma.

Limitations, reasons for caution

Besides the fact that this study is retrospective, it also has a small sample size. Furthermore, no analyses regarding sperm morphology were made.

Wider implications of the findings: In this study, testicular cancer had a negative impact on spermatogenesis and sperm quality, whereas hematological cancer did not. However, counseling regarding fertility preservation using sperm banking prior to chemo or radiotherapy should be reinforced in all young cancer patients.

Trial registration number

Not applicable

Human sperm cryopreservation prior cancer treatment: Follow up of 480 males for 23 years

e24061

Background: Cancer treatment represents a potential risk for spermatogenesis and may compromise male fertility. Semen freezing has become a routine process for male patients prior to cancer treatment to preserve their fertility. We sought to provide information regarding what happens to the cryopreserved material and the fertility in cancer treated patients. Using a cohort from a 23-year cryopreservation program. Methods: Patients whom cryopreserved sperm to preserve fertility due to diagnosis of cancer between 1995 and 2018 in a single private center of reproductive medicine in south of Brazil were selected. A retrospective analysis of medical records was performed and clinico-pathological characteristics were collected using standard templates. Results: A total of 480 patients were evaluated for sperm cryopreservation before cancer treatment. Testis cancer was the most prevalent (59.3%), followed by hematologic malignancies (21.4%) and prostate cancer (5.4%). The age at cryopreservation varied from 14 to 72 y/o. Among them, 61.3% were up to 30 years old, and 10.8% more than 40 y/o. 8 patients decided to not cryopreserve The mean time between the freezing and the beginning of cancer treatment was 5.5 days. Eleven patients presented azoospermia; 3 of them froze testicular tissue. A shorter time between cancer diagnosis and sperm banking was observed for hematologic malignancies ( p=0.044). Out of the 472 patients, 46.8% still keep the sperm cryopreserved, 34.3% decided to discard it, 1.9% transferred it to another clinic, 8,5% abandon the specimen and 8,5% died without using it. The main reason for discard the sample was pregnancy and/or normal sperm count after treatment. The mean age of discarding was 35.7±10.3 years old. The period of maintenance cryopreservation was 5 years (min 1 month, max 23 years). The mean time of freezing before abandoning was 7.5±4.4 years Eighty-two patients achieved pregnancy. Spontaneous pregnancies occurred in 53 cases, and 47 underwent assisted reproduction with the cryopreserved sample, with 61,7% of pregnancy (n=29).15.3% of those that have children still keep the sperm cryopreserved; 11.4% gave up on having children. Out of the 133, 66.9% authorized the use of their specimen post-mortem. Conclusions: Only one third of the patients have maintained fertility after cancer treatment and 35% of pregnancies after cancer treatment were possible due to sperm preservation. Considering the high pregnancy rate with assisted reproduction techniques in patients that lost testicular functionsemen cryopreservation is warranted.

Usefulness of prostate-specific antigen (PSA) rise as a marker of prostate cancer in men treated with dutasteride: lessons from the REDUCE study

OBJECTIVES

To determine if dutasteride-treated men can be monitored safely and adequately for prostate cancer based on data from the Reduction by Dutasteride in Prostate Cancer Events (REDUCE) study. To analyse whether the use of treatment-specific criteria for repeat biopsy maintains the usefulness of prostate-specific antigen (PSA) level for detecting high grade cancers.

PATIENTS AND METHODS

The REDUCE study was a randomized, double-blind, placebo-controlled investigation of whether dutasteride (0.5 mg/day) reduced the risk of biopsy-detectable prostate cancer in men with a previous negative biopsy. The usefulness of PSA was evaluated using biopsy thresholds defined by National Comprehensive Cancer Network guidelines in the placebo group and any rise in PSA from nadir (the lowest PSA level achieved while in the study) in the dutasteride group. The number of cancers detected on biopsy in the absence of increased/suspicious PSA level as well as sensitivity, specificity, positive predictive value and negative predictive value for high grade prostate cancer detection were analysed by treatment group. Prostate cancer pathological characteristics were compared between men who did and did not meet biopsy thresholds.

RESULTS

Of 8231 men randomized, 3305 (dutasteride) and 3424 (placebo) underwent at least one prostate biopsy during the study and were included in the analysis. If only men meeting biopsy thresholds underwent biopsy, 25% (47/191) of Gleason 7 and 24% (7/29) of Gleason 8-10 cancers would have been missed in the dutasteride group, and 37% (78/209) of Gleason 7 and 22% (4/18) Gleason 8-10 cancers would have been missed in the placebo group. In both groups, the incidence of Gleason 7 and Gleason 8-10 cancers generally increased with greater rises in PSA. Sensitivity of PSA kinetics was higher and specificity was lower for the detection of Gleason 7-10 cancers in men treated with dutasteride vs placebo. Men with Gleason 7 and Gleason 8-10 cancer meeting biopsy thresholds had greater numbers of positive cores, percent core involvement, and biopsy cancer volume vs men not meeting thresholds.

CONCLUSION

Using treatment-specific biopsy thresholds, the present study shows that the ability of PSA kinetics to detect high grade prostate cancer is maintained with dutasteride compared with placebo in men with a previous negative biopsy. The sensitivity of PSA kinetics with dutasteride was similar to (Gleason 8-10) or higher than (Gleason 7-10) the placebo group; however, biopsy decisions based on a single increased PSA measurement from nadir in the dutasteride group resulted in a lower specificity compared with using a comparable biopsy threshold in the placebo group, indicating the importance of confirmation of PSA measurements.

Antibiotics and observation have a similar impact on asymptomatic patients with a raised PSA

OBJECTIVES

• To compare the influence of a 4-week course of empirical antimicrobial therapy or observation on the prostate-specific antigen (PSA) levels of asymptomatic patients with a raised baseline PSA. • To identify whether a decrease in PSA can predict the risk of prostate cancer (PCa) detection on prostate biopsy.

PATIENTS AND METHODS

• Patients were referred to our ambulatory centre because of a raised PSA level (>2.5 ng/mL) with a normal digital rectal examination. A 12-core prostate biopsy was indicated in these patients and they were offered antibiotic treatment with levofloxacin 500 mg daily for 30 days. • Patients who did not agree to use antibiotics but who still showed interest in participating underwent simple observation, serving as controls. • Total and free PSA levels at baseline and after 45 days were measured. Variation in PSA level was calculated. • All patients underwent a 12-core prostate biopsy 6 weeks after the initial visit.

RESULTS

• In all, 245 men were enrolled, but 43 were lost due to follow-up. A total of 145 patients who used antibiotics and 57 controls were included in the analysis. • The median baseline PSA levels were 7.6 and 7.7 ng/mL in the antibiotic and control groups, respectively, with median follow-up levels of 6.8 and 7.0 ng/mL. The follow-up PSA level was significantly lower than the initial PSA level (P = 0.009). • Mean absolute and percentage variation in PSA level were similar in both groups (P = 0.828 and 0.128, respectively). • The overall PCa detection rate was 15.8%, and did not differ among the groups (P = 0.203). Regarding the percentage variation in PSA level, patients diagnosed with PCa tended to have their PSA level increased (22.4 vs -5.3%; P = 0.001). Indeed, a decrease of 20% in PSA was not predictive of a negative prostate biopsy (P = 0.41). • The area under the receiver operating characteristic curve for percentage PSA variation as a predictor of PCa was 0.660.

CONCLUSIONS

• PSA levels tend to fall when repeated after 45 days, regardless of antibiotic use. • Despite being associated with the chance of PCa, no percentage PSA variation threshold value exhibits satisfactory discriminatory properties.

[Transumbilical single-incision laparoscopic ureterolithotomy]

INTRODUCTION

laparoendoscopic single-site surgery (LESS) using transumbilical access and conventional laparoscopic instruments is a very attractive alternative to perform ureterolithotomy for ureteral stone with failed endourological management.

MATERIAL AND METHOD

a 29-year-old woman presented with chronic right lumbar pain and a 1.2 cm impacted calculus localized at transition of abdominal to pelvic ureter. Semi-rigid ureteroscopy had failed to fragment the stone and shockwave lithotripsy was not available. Double-J ureteral catheter had been inserted preoperatively. We performed a transumbilical single-incision laparoscopic ureterolithotomy. Three conventional trocars were inserted in a single semi-circular umbilical incision. Right colon was detached and the ureter was identified. Calculus was extracted and the ureteral incision was closed with intracorporal sutures.

RESULTS

ureterolithotomy was successfully completed, with all the operative steps performed transumbically. Operative time was 180 minutes. No single-port device or articulating and bent instruments were utilized. Estimated blood loss was less than 50 mL. No intraoperative, access-related and postoperative complications took place. The duration of hospitalization was 24 hours and scarless appearance was observed on postoperative day 15.

CONCLUSION

transumbilical single-incision laparoscopic ureterolithotomy is feasible and safe. This approach offers an inherent cosmetic advantage and few postoperative discomfort. Additional experience and continued investigation are warranted.

Standards for clinical trials in male sexual dysfunctions

INTRODUCTION

Clinical trials in male sexual dysfunction (MSD) are expanding. Consequently, there is a need for consensus standards in this area.

AIM

To develop an evidence-based, state-of-the-art consensus report on standards for clinical trials in MSD.

METHODS

A literature review was performed examining clinical trials in erectile dysfunction (ED), premature ejaculation (PE), delayed/absent ejaculation, libido disorders/loss of desire, hypogonadism, and Peyronie's disease, focusing on publications published in the last 20 years. This manuscript represents the opinions of eight experts from seven countries developed in a consensus process. This document was presented for peer review and debate in a public forum and revisions were made based on recommendations of chairpersons to the International Consultation on Sexual Medicine.

MAIN OUTCOME MEASURE

Expert opinion was based on the grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate.

RESULTS

According to experience and recent publications in dealing with clinical trials in sexual dysfunction, recommendations have been made for conducting trials in patients with ED, PE, delayed ejaculation, libido disorders, hypogonadism, and Peyronie's disease.

CONCLUSIONS

It is important that future clinical trials are conducted using standards upon which investigators can rely when reading manuscripts or conducting new trials in this field.

Effect of dutasteride on the risk of prostate cancer

BACKGROUND

We conducted a study to determine whether dutasteride reduces the risk of incident prostate cancer, as detected on biopsy, among men who are at increased risk for the disease.

METHODS

In this 4-year, multicenter, randomized, double-blind, placebo-controlled, parallel-group study, we compared dutasteride, at a dose of 0.5 mg daily, with placebo. Men were eligible for inclusion in the study if they were 50 to 75 years of age, had a prostate-specific antigen (PSA) level of 2.5 to 10.0 ng per milliliter, and had had one negative prostate biopsy (6 to 12 cores) within 6 months before enrollment. Subjects underwent a 10-core transrectal ultrasound-guided biopsy at 2 and 4 years.

RESULTS

Among 6729 men who underwent a biopsy or prostate surgery, cancer was detected in 659 of the 3305 men in the dutasteride group, as compared with 858 of the 3424 men in the placebo group, representing a relative risk reduction with dutasteride of 22.8% (95% confidence interval, 15.2 to 29.8) over the 4-year study period (P<0.001). Overall, in years 1 through 4, among the 6706 men who underwent a needle biopsy, there were 220 tumors with a Gleason score of 7 to 10 among 3299 men in the dutasteride group and 233 among 3407 men in the placebo group (P=0.81). During years 3 and 4, there were 12 tumors with a Gleason score of 8 to 10 in the dutasteride group, as compared with only 1 in the placebo group (P=0.003). Dutasteride therapy, as compared with placebo, resulted in a reduction in the rate of acute urinary retention (1.6% vs. 6.7%, a 77.3% relative reduction). The incidence of adverse events was similar to that in studies of dutasteride therapy for benign prostatic hyperplasia, except that in our study, as compared with previous studies, the relative incidence of the composite category of cardiac failure was higher in the dutasteride group than in the placebo group (0.7% [30 men] vs. 0.4% [16 men], P=0.03).

CONCLUSIONS

Over the course of the 4-year study period, dutasteride reduced the risk of incident prostate cancer detected on biopsy and improved the outcomes related to benign prostatic hyperplasia. (ClinicalTrials.gov number, NCT00056407.)

Health and quality of life in urology: issues in general urology and urological oncology

OBJECTIVES

Frequently, the term "quality of life" has been used to justify personal and professional decisions in all fields of medicine. Nowadays, quality of life studies are based on development and validation of sensitive measures of patient outcomes, incorporating functional status and perceived health status. Thus, quality of life has become an outcome as important as survival and effectiveness.

METHODS

A systematic review using Pubmed and Medline was performed, searching for papers concerning health related quality of life and urology. The most relevant articles where questionnaires and interviews were described and validated were listed.

RESULTS

Based on psychometric properties, a search between 1970 and 2007 identified a total of 25 recommendable articles with generic inventories and specific modules that have been developed, validated and used in clinical practice or research. Historical aspects, quality of life concepts, validation of questionnaires and structured interviews, and most used instruments in generic health-related quality of life, general urology and urological oncology have been discussed.

CONCLUSIONS

A brief review of historic background of health related quality of life and urology was performed.

Worldwide comparison of prostate needle biopsy quality in the reduction by dutasteride of prostate cancer events (REDUCE) study: Improvement with investigator training

e16029

Background: The accuracy of prostate cancer detection by biopsy is influenced by the number and length of needle biopsy cores. We compared these two biopsy quality factors among study sites worldwide for the pre-study entry biopsies (6–12 cores) and study-mandated biopsies (10 cores) at year 2 of the REDUCE study. Methods: Prostate biopsy quality indicators were evaluated retrospectively. Data were compared from entry and year 2 biopsies for subjects enrolled in the study in 6 geographic regions (see table ). Investigator training was provided for REDUCE study protocol-required standardization prior to year 2 biopsies. Training included emphasis on quality of the biopsies. Results: Data were collected from 4638 entry and 6275 year 2 subjects, respectively. At entry, the aggregate length of biopsies, number of cores per subject, and core length differed significantly among regions (p < 0.0001). Aggregate length was longest in biopsies obtained in Australia and the highest core number was observed in South America. At year 2, each region collected a mean of 10 cores per subject (per protocol), and the aggregate length and mean core length were greater than the entry biopsies (for each analyzed parameter, p < 0.0001); variance among sites was reduced for all quality measures. Conclusions: There were significant differences in biopsy quality (number of cores and length of tissue obtained) around the world at entry. Following the REDUCE study protocol-required standardization and investigator training, biopsies obtained at year 2 showed an increase in the mean aggregate length, mean core number, and mean core length compared with the entry biopsies. Our data suggests that variance in biopsy quality may be reduced by investigator training, thereby optimizing quality and cancer detection. [Table: see text]

[Table: see text]

Overactive bladder: prevalence and implications in Brazil

OBJECTIVES

To assess overactive bladder (OAB) prevalence, associated factors and implications in a young population.

METHODS

An independent population-based study was carried out. A self-applicative questionnaire covering urinary symptoms, coping strategies, quality of life and treatment seeking behavior was developed.

RESULTS

A total of 848 subjects between 15 and 55 years completed the questionnaire. The overall prevalence of OAB was 18.9%. Women were significantly more affected than men (p = 0.001). All age groups were equally affected (p = 0.152). Subjects with OAB reported significant impairment on household chores (p = 0.009), physical activities (p = 0.016), sleep (p < 0.001), work (p < 0.001), social life (p < 0.001) and sexual life (p < 0.001). In addition, OAB individuals present higher prevalence of depression (p = 0.036), anxiety (p < 0.001), shame (p < 0.001) and tiredness (p < 0.001) OAB was independently associated to sexual life impairment (OR = 3.36, 95% CI=1.20-9.39). Only 27.5% of OAB subjects sought for medical counseling.

CONCLUSIONS

OAB is a highly prevalent condition, even in such a young population. It affects both genders, yet it is more frequently observed in women. OAB is an important health condition, with serious impact on quality of life and sexual function. A large percentual of individuals remain unrecognized, under treated and consequently suffer for long periods of time.

Multi-Institutional Validation of Vasectomy Reversal Predictor

PURPOSE

Some urologists who perform vasectomy reversals are not experienced with performing VE. A model to preoperatively identify patients who may require referral to an experienced VE surgeon was created (). We tested the model at multiple institutions.

MATERIALS AND METHODS

The model had previously been designed in 483 patients who underwent vasectomy reversal at 1 institution (100% sensitive and 59% specific for predicting the need for VE). It was based on time since vasectomy and patient age. We tested it prospectively in 33 patients and retrospectively in a total of 312 at 6 other institutions. The predictive accuracy of the model was compared to using a simple duration from vasectomy cutoff alone, as is used in clinical practice.

RESULTS

The model had 84% sensitivity and 58% specificity for detecting the need for VE in a total of 345 patients at 7 institutions. If using only a duration from vasectomy cutoff of 10 years to predict the need for VE, sensitivity was only 69%. At a cutoff of 4 years sensitivity was 99% but specificity was only 23%. Thus, the model performed better than any specific duration cutoff alone.

CONCLUSIONS

The predictive model provides 84% sensitivity for detecting patients who may require VE during vasectomy reversal across 7 institutions (58% specificity). The model more accurately predicts the need for VE than using a specific duration from vasectomy cutoff alone.

LOW SERUM TESTOSTERONE LEVELS ARE ASSOCIATED WITH POSITIVE SURGICAL MARGINS IN RADICAL RETROPUBIC PROSTATECTOMY: HYPOGONADISM REPRESENTS BAD PROGNOSIS IN PROSTATE CANCER

PURPOSE

It has been reported that more aggressive prostate cancer (PC) can be associated with low serum testosterone levels. The relationship between serum androgens and PC is still not completely understood. In this study we examined the association of prognostic factors in men who underwent radical retropubic (RRP) prostatectomy with low or normal total testosterone.

MATERIALS AND METHODS

We retrospectively evaluated 64 consecutive patients with localized PC treated with RRP between July 2002 and November 2003. PC was diagnosed by transrectal ultrasonography guided biopsy performed for either a suspicious digital rectal examination or serum prostate specific antigen greater than 4.0 ng/ml. Gleason score was determined in prostatic biopsies. Pathological TNM staging (1997), capsular perforation, seminal vesicle involvement and surgical margin status were determined in all surgical specimens. The threshold for serum total testosterone was 270 ng/dl. In all analyses p <0.05 was considered statistically significant.

RESULTS

There were no statistically significant differences among prostate specific antigen, Gleason score (biopsy or specimen), pathological stage, capsular perforation and seminal vesicle involvement. However, patients with low total testosterone had increased positive surgical margins (p = 0.026).

CONCLUSIONS

Patients with low total testosterone more frequently present with positive surgical margins in RRP specimens. The true association between low testosterone and poor clinical outcome in the long term needs validation in large prospective studies.

Diabetes mellitus is associated with subnormal serum levels of free testosterone in men

OBJECTIVE

To evaluate the relationship between diabetes mellitus (DM) and serum levels of free (FT) and total (TT) testosterone.

PATIENTS AND METHODS

A cross-sectional study was carried out including 746 men, of whom 116 (15.6%) were diabetics. Both groups, diabetic and nondiabetic, were paired according to age. Body mass index (BMI) and waist-to-hip ratio (WHR) were calculated, and a stratification analysis correlating DM and elevated BMI (>25 kg/m(2)) and WHR (>1) with the presence of subnormal FT and TT levels was performed.

RESULTS

FT and TT serum levels were subnormal in 46% and 34% of diabetics, respectively, and in 24% and 23% of nondiabetics. Subnormal FT levels were strongly correlated with DM (odds ratio (OR) 2.7; 95% confidence interval (CI) 1.8-4.1) but not with elevated BMI (OR 1.4; 95% CI 1.0-2.0). Subnormal TT levels were more strongly associated with elevated BMI and WHR (OR 2.6; 95% CI 1.7-3.9 and 2.0; 1.4-2.9) than with DM (1.7; 1.1-2.6 and 2.0; 1.3-3.2).

CONCLUSION

These data strongly suggest that DM is associated with subnormal FT levels, and that TT levels are influenced more by obesity and central adiposity.

Intracavernosal etilefrine self-injection therapy for recurrent priapism: One decade of follow-up

Recurrent idiopathic priapism is a rare condition that, if not properly treated, may lead to impaired quality of life and erectile dysfunction. Treatment can be achieved by prevention of priapism episodes with systemic therapy or by early intervention with intracavernosal self-injection of sympathomimetic agents. We describe a case of a young patient with recurrent idiopathic priapism who has used etilefrine self-injection for the past 10 years with good efficacy and libido and erectile function preservation. This report suggests that this approach may be safely indicated in selected cases, particularly when sexual function preservation is a major concern.

Glycosylated haemoglobin levels and the severity of erectile function in diabetic men

OBJECTIVE

To evaluate the association between the levels of glycosylated haemoglobin (HbA1c) and the severity of erectile dysfunction (ED) in men with diabetes mellitus (DM).

PATIENTS AND METHODS

This cross-sectional study included sexually active men with a diagnosis of DM attending a urological medical centre from January 2000 to December 2001. The 115 men with ED (95%) completed the International Index of Erectile Function questionnaire, and fasting serum glucose and HbA1c serum levels were measured. The relationship between the severity of ED and serum HbA1c levels was assessed.

RESULTS

Of men with HbA1c levels of < 8%, half had mild, and 18% and 32% had moderate and severe ED, respectively (P = 0.038); of men with HbA1c levels of > or = 8%, 25%, 29%, and 46% had mild, moderate and severe ED, respectively (P = 0.008). In addition, men with HbA1c levels of > or = 11% had a statistically higher prevalence of severe ED (P = 0.002). There was no difference in severity of ED in the HbA1c subgroups when the duration of DM was < or = 5 years (P = 0.87), but most men with HbA1c levels of > or = 8% and a history of DM of 6-10 or > 10 years had severe ED (P < 0.03).

CONCLUSION

This study suggests that the severity of ED is associated with increasing HbA1c levels in diabetic men.

Successful birth after injection of frozen human oocytes with frozen epididymal spermatozoa

A couple (female 31, male 42 years old) with infertility due to obstructive azoospermy returned to the clinic in order to attempt pregnancy using their frozen oocytes and epididymal sperm cells, which had been cryopreserved at the time of a previous IVF attempt. Two days before the scheduled transfer, eight oocytes were thawed; 5/8 (63%) oocytes survived and 4/5 (80%) oocytes fertilized after intracytoplasmic sperm injection (ICSI) with the previously frozen epididymal spermatozoa. All four fertilized ova cleaved (100%). On day 2 after thawing, four embryos were transferred; three with two cells (grade II) and one with three cells (grade III). Hormonal support for the established pregnancy was maintained with oestradiol and progesterone orally until 12 weeks of gestation, and the patient was delivered by Caesarean section at 40 weeks of gestation; the baby boy weighed 3025 g, and measured 51 cm, with Apgar of 10 in the 1st and 5th min. The cryopreservation and warming protocol used for this study yielded very favourable results, comparing well with reports in the literature. This case report demonstrates that it is possible to obtain high rates of oocyte survival following thawing and high rates of fertilization after ICSI, with viable development of the resulting embryos.

Urethral catheter removal 7 or 14 days after radical retropubic prostatectomy: clinical implications and complications in a randomized study

PURPOSE

To evaluate the hypothesis that a 7-day period of indwelling catheter after radical retropubic prostatectomy is effective and safe without the need of performing cystography.

METHODS

In the period from January of 2000 to July of 2002, 73 patients underwent radical retropubic prostatectomy, and these patients were prospectively randomized in 2 groups: Group 1-37 patients who had the urethral catheter removed 7 days after the procedure, and Group 2-36 patients who had the catheter removed 14 days after the surgery. The 2 groups were similar, the surgeons and the technique were the same, and no cystography was performed to evaluate the presence of leaks.

RESULTS

Two patients in Group 1 had bleeding and clot retention after having the catheter taken out in the seventh postoperative day and were managed by putting the catheter back in for 7 more days. Two patients in Group 2 developed bladder neck stricture and were treated by bladder neck incision with success. The continence rate was the same, with 2 cases of incontinence in each group. About 2 pads a day were used by the patients with incontinence. The average follow-up was 17.5 months (12-36 months). No urinary fistula, urinoma, or pelvic abscesses developed after catheter removal. Two patients were excluded from the analysis of this series: 1 died with a pulmonary embolus in the third postoperative day, and 1 developed a urinary suprapubic fistula before catheter withdrawal, which was maintained for 16 days.

CONCLUSION

Withdrawal of the urethral catheter 7 days after radical retropubic prostatectomy, without performing cystography, has a low rate of short-term complications that are equivalent to withdrawal 14 days after the surgery.

Prevalence of Peyronie's disease in men over 50-y-old from Southern Brazil

The pathogenesis of Peyronie's disease still remains an enigma and few epidemiological studies are available. The purpose of this study was to determine the prevalence of Peyronie's disease in males older than 50 y. From 26 to 30 July 1998, 1071 men attended the 'Prostate Cancer Awareness Week of Santa Casa Hospital, Porto Alegre, Brazil'. In the prostate exam they also consented to be screened for Peyronie's disease. They underwent the 5-item International Index of Erectile Function (IIEF-5) questionnaire for evaluation of the erectile condition. The presence of a well-defined plaque in the penis was the diagnostic criterion for Peyronie's disease. The men were examined by five senior residents, under supervision by the staff Urologist. Men younger than 50 y as well as patients under intracavernous injection therapy for erectile dysfunction were excluded from the study. Chi2 test was used for statistical analysis. Nine hundred and fifty-four (89.1%) out of the 1071 men with a mean age of 62 y (ranging from 52 to 77) were included in the study. Peyronie's disease plaques were found in 35 men (3.67%). Eight hundred and forty-five (88.6%) were Caucasians. There was no significant statistical difference regarding age (P > 0.05). The presence of erectile dysfunction in the men with Peyronie's disease and without this condition, was 68.6% and 53.5%, respectively (P > 0.05). From this data we can conclude that the prevalence of Peyronie's disease is higher than in formerly reported studies. Further observations should be carried out in different communities and in other groups of patients in order to confirm our results.

Protective effect of allopurinol in the renal ischemia--reperfusion in uninephrectomized rats

The effect of allopurinol (an inhibitor of xanthine oxidase) on oxidative stress, renal dysfunction, and histologic alterations was evaluated during the renal ischemia--reperfusion in uninephrectomized rats. Renal malondialdehyde and serum creatinine levels significantly increased after renal ischemia--reperfusion. However, the pretreatment with allopurinol demonstrated a protector effect in these parameters. Renal ischemia--reperfusion provoked a significant renal damage in the operated group. Tubular atrophy and interstitial fibrosis were attenuated by allopurinol when given prior to the surgery. In our study, allopurinol had a strong tendency to exert a beneficial effect during renal ischemia--reperfusion in uninephrectomized rats.

Penile straightening with crural graft of the corpus cavernosum

PURPOSE

We present a surgical alternative to penile straightening in Peyronie's disease that avoids penile shortening by using tissue from the crural segment of the corpora cavernosa as a graft.

MATERIALS AND METHODS

We treated 7 patients with stable Peyronie's disease and satisfactory penile rigidity but significant curvature that precluded intercourse with this technique. An incision is made in the fibrous area and after stretching the gap is covered with a graft removed from the crural segment of the corpora cavernosa.

RESULTS

In 6 of the 7 men straightening was satisfactory but in 1 it was not complete. No patient reported worse penile rigidity postoperatively. Donor site healing was uneventful.

CONCLUSIONS

Use of tissue from the corpus cavernosum to correct penile curvature is effective. However, our results are preliminary, and long-term effectiveness and safety must be confirmed in a larger number of cases.

Tamoxifen versus placebo in the treatment of Peyronie's disease

PURPOSE

We evaluated the effects of oral tamoxifen and placebo in patients with Peyronie's disease.

MATERIALS AND METHODS

We selected 25 patients with Peyronie's disease who did not have calcified plaque for treatment in the andrology outpatient clinic. A medical history was obtained, and physical examination, penile x-ray, penile ultrasound and pharmacologically induced erection with prostaglandin E1 were performed. Patients were randomly divided into group 1--those who received 20 mg. tamoxifen twice daily for 3 months and group 2--those who received placebo for the same period. The same evaluations were done 4 months later and results were compared. Qualitative (chi-square test) and quantitative (Student's t test) results were analyzed using the Yates correction factor with p <0.05 considered significant.

RESULTS

Pain subsided in 66.6 and 75% of the patients treated with tamoxifen and placebo, respectively (p >0.05). In groups 1 and 2 a reduction in the penile deformity was noticed by 46.1 and 41.7% of the patients (p >0.05), and a decrease in plaque size was noticed by 30.7 and 25%, respectively. On the other hand, objective measurements did not reveal any difference in plaque area or curvature angle.

CONCLUSIONS

This study did not show significant improvement in pain, curvature or plaque size in patients with Peyronie's disease who were treated with tamoxifen compared with those treated with placebo.

Effects of long-term cocaine exposure on spermatogenesis and fertility in peripubertal male rats

PURPOSE

This study was conducted to investigate the effects of long-term administration of cocaine on spermatogenesis and fertility in adult male rats.

MATERIALS AND METHODS

Thirty-day-old male Sprague-Dawley rats were given cocaine hydrochloride (15 mg./kg. body weight, corresponding to an average single dose for a heavy cocaine user) either daily or twice weekly (weekend group, cocaine given on Saturday and Sunday) and mated with pregnancy-proven female rats after 100 and 150 days of exposure to the drug. Pregnancy rates and litter birth weights were evaluated. Serum testosterone, follicle stimulating hormone and luteinizing hormone levels were measured in all adult rats. Morphologic analysis of the testis entailed the evaluation of quantitative and qualitative histologic parameters to assess the effect of cocaine on various stages of spermatogenesis.

RESULTS

After 100 days of treatment, the rats receiving daily cocaine had a pregnancy rate of only 33% versus 86% for the controls (p < 0.05). In rats exposed to cocaine for 150 days the pregnancy rate was 50% compared with 100% for controls (p < 0.05). The birth weights of offspring from the group receiving daily cocaine was 10% less than that of controls (p < 0.05). The weight of the testis and epididymis was not affected by cocaine exposure. Morphometric analysis showed significant differences between the cocaine-treated groups (both the daily cocaine and twice weekly cocaine groups) and their respective controls. The mean diameter of seminiferous tubules in the daily and twice weekly cocaine groups was reduced when compared with their respective controls. These differences between treated groups and their controls were statistically significant (p < 0.05). Similarly the thickness of the germinal epithelium was less in the cocaine-treated groups than in the controls (p < 0.05). Degenerating cells were more numerous in both daily and twice weekly cocaine groups than the controls. Furthermore, the number of step VII spermatids was reduced in both daily and twice weekly cocaine groups, a difference that was statistically significant (p < 0.05).

CONCLUSION

Our findings demonstrate that chronic administration of cocaine to peripubertal male rats has a profound effect on their testicular function. Even with twice weekly administration there was a significant adverse effect on spermatogenesis although this was not manifested by diminished fertility in this group. These findings confirm that chronic administration of cocaine to male rats can have a deleterious effect on spermatogenesis and fertility.

Congenital abnormality of corpora cavernosa and erectile dysfunction: a case report

We report on a young man who had absence of the septum and muscle in the corpora cavernosa. He had no tumescence or erection with either the nocturnal penile tumescence test or intracorporeal injection of a combination of vasoactive drugs. No other urological or extra-urological congenital defects were found. A malleable penile prosthesis was implanted.

Prosthetic penile infection: "rescue procedure" with rifamycin

Penile prosthetic implantation is a successful procedure for the management of male erectile impotence. However, infection remains the most serious complication requiring removal of the device. Later reinsertion can be difficult due to fibrosis and a shortened penis. We present 3 cases of penile infection with Staphylococcus epidermidis in which a new penile prosthesis was placed after 72 hours of continuous irrigation of the corpora cavernosa with rifamycin. The procedure requires judicious selection of patients and a stable clinical status.