Comparison of sperm retrieval rate between superficial and deep dissection during microscopic testicular sperm extraction

Objective

The purpose of the study was to compare the outcome of microscopic testicular sperm extraction (micro-TESE) between superficial and deep dissection on the same testicle in terms of sperm retrieval rate (SRR).

Patients and Methods

In a retrospective study from June 2019 to October 2021, 44 patients with nonobstructive azoospermia who underwent micro-TESE with positive results (mature sperm identified) were included. Eight patients were excluded from the study due to deficient documentation on superficial and deep dissection. A total of 36 patients were included; 60 testicles were examined for superficial and deep biopsies. Testicular histopathology was performed in all patients, and a hormonal evaluation was obtained before the micro-TESE attempt.

Results

Thirty-six patients and 60 testicles were included in the study. Of them, 47 (78.3%) testicles had positive results. Superficial TESE was positive in 38 (63.3%) testicles, and deep TESE was successful in 45 (75.0%) testicles. An improvement of 13.9% in the SRR was observed, following deep dissection. However, there was no statistically significant difference (P = 0.166). Rates of positive sperm retrieval (from any side) did not differ significantly based on patients' age, microdissection testicular sperm extraction sides, and hormonal concentrations; these differences were not apparent after superficial or deep TESE.

Conclusion

The presented findings suggest that although successful SRRs of deep TESE were higher than that of its superficial counterpart, there was no significant statistical difference. A larger body of evidence is needed to provide a higher grade of recommendation.

Consensus and Diversity in the Management of Varicocele for Male Infertility: Results of a Global Practice Survey and Comparison with Guidelines and Recommendations

PURPOSE

Varicocele is a common problem among infertile men. Varicocele repair (VR) is frequently performed to improve semen parameters and the chances of pregnancy. However, there is a lack of consensus about the diagnosis, indications for VR and its outcomes. The aim of this study was to explore global practice patterns on the management of varicocele in the context of male infertility.

MATERIALS AND METHODS

Sixty practicing urologists/andrologists from 23 countries contributed 382 multiple-choice-questions pertaining to varicocele management. These were condensed into an online questionnaire that was forwarded to clinicians involved in male infertility management through direct invitation. The results were analyzed for disagreement and agreement in practice patterns and, compared with the latest guidelines of international professional societies (American Urological Association [AUA], American Society for Reproductive Medicine [ASRM], and European Association of Urology [EAU]), and with evidence emerging from recent systematic reviews and meta-analyses. Additionally, an expert opinion on each topic was provided based on the consensus of 16 experts in the field.

RESULTS

The questionnaire was answered by 574 clinicians from 59 countries. The majority of respondents were urologists/uro-andrologists. A wide diversity of opinion was seen in every aspect of varicocele diagnosis, indications for repair, choice of technique, management of sub-clinical varicocele and the role of VR in azoospermia. A significant proportion of the responses were at odds with the recommendations of AUA, ASRM, and EAU. A large number of clinical situations were identified where no guidelines are available.

CONCLUSIONS

This study is the largest global survey performed to date on the clinical management of varicocele for male infertility. It demonstrates: 1) a wide disagreement in the approach to varicocele management, 2) large gaps in the clinical practice guidelines from professional societies, and 3) the need for further studies on several aspects of varicocele management in infertile men.

Micro-dissection testicular sperm extraction in Klinefelter's syndrome patients, King Faisal Specialist Hospital and Research Center, Riyadh experience

Background:

In Klinefelter's syndrome patients with azoospermia, microscopic testicular sperm extraction (m-TESE) can be proposed as a therapeutic option.

Aim of Study:

The aim of this study is to assess the sperm retrieval rate in patients with Klinefelter syndrome in King Faisal Specialist Hospital, Riyadh.

Methodology:

Retrospective, Chart review of 32 patients with Klinefelter syndrome who underwent m-TESE were reviewed and analyzed. All patients had two sets of semen analysis after 3 − 5 days abstinence of ejaculation with further study of semen by in vitro fertilization (IVF) wash. The hormonal analysis was studied. Ultrasonography of testes was assessed preoperatively. Testicular tubules were sent to the IVF laboratory and were studied under the microscope looking for sperms. Some testicular tissues were sent for the histopathology diagnosis

Results:

Patients’ mean age was 34.9 ± 6.0 years. Mean hormonal levels of E2, FSH, LH, prolactin, and testosterone were 96.0 ± 22.0 pmol/L, 29.8 ± 5.4 IU/L, 19.0 ± 2.9 IU/L, 15.4 ± 3.6 ug/L, and 10.0 ± 1.9 nmol/L, respectively. There were two mosaic Klinefelter syndrome patients (6.25%), whereas 30 patients had a nonmosaic form (93.75%). The overall sperm retrieval rate was 37.5%. All patients had small bilateral testes. Sperm retrieval was successful in three patients with hypospermatogenesis, one patient with maturation arrest, and 8 patients with Sertoli-cell-only pattern. Four patients with complete hyalinization of testicular tissues had complete failure to retrieve sperms. The pregnancy rate after intra-cytoplasmic sperm injection was 50%.

Conclusions:

The sperm retrieval rate in Klinefelter syndrome patients with m-TESE is in accordance with most of those reported in the literature. Regarding histopathology, hypo-spermatogenesis showed a favorable outcome. The pregnancy rate with intra-cytoplasmic sperm injection was 50%.

The yield of microscopic varicocelectomy in men with severe oligospermia

Introduction:

Varicocele is detected in 35%–50% of men with primary infertility and up to 81% with secondary infertility. Various studies have shown that varicocele is related to testicular hypotrophy and impaired spermatogenesis. The effect of varicocelectomy in mild-to-moderate male factor infertility has been well reported. However, only a few studies addressed the impact of varicocelectomy in severe oligospermia.

Methods:

We included 45 patients with severe oligospermia (<5 million/mL) who underwent microsurgical varicocelectomy between May 2014 and November 2017. Results of semen analysis taken at 6 months after varicocelectomy were compared and patients were divided into responders and nonresponders. Chi-square was used to compare the preoperative and postoperative sperm count, motility, and volume.

Results:

After 6 months only one patient was found to be a responder with a pre- to post-operative motility of 45%–74% and a sperm concentration of 1 million/mL to 28.1 million/mL. There was a significant improvement in the mean sperm concentration after varicocelectomy which improved from 1.31 million/mL to 5.32 million/mL. However, a significant decrease in sperm motility was noted which decreased from 35.62% to 28.64% postoperatively. Postoperative semen volume increased from 2.56 mL to 3.19 mL, but this difference was not found to be statistically significant (P > 0.05). Four patients (8.9%) were found to have azoospermia after a 6-month follow-up. In these four patients who turned azoospermic had count <50,000 sperm/mL, two of them had a history of cryptospermia before varicocelectomy. Ejaculate sperm returned in two of these four patients in long-term follow-up (>6 months).

Conclusion:

The magnitude of improvement after microsurgical varicocelectomy for severely oligospermic patients is less profound than reported in mild male factor infertility.

Primary infertility secondary to a hidden posterior urethral valve representing a diagnostic challenge in the fifth decade

Posterior urethral valves (PUVs) are frequently recognized during the perinatal period. Delayed diagnosis is reported usually within the first decade of life with diverse clinical presentations. In the current case report, we describe a 45 years old man patient who presented with aspermia and primary infertility for 8 years in whom his diagnostic workup revealed radiological imaging suggestive of PUVs. This phenomenon was confirmed by cystourethroscopy that showed obstructive valve. Endoscopic ablation resulted in significant improvement of his seminal parameter with successful conception.

Serum testosterone levels and other determinants of sperm retrieval in microdissection testicular sperm extraction

Background

Microdissection testicular sperm extraction (microTESE) has become the standard of care for sperm retrieval in non-obstructive azoospermia (NOA) patients. Understanding the significant determinants of microTESE outcomes may result in improvements in sperm retrieval rates and provide better-informed clinical decisions.

Methods

This is a clinical retrospective study conducted through chart review of 421 NOA patients who underwent microTESE between August 2009 and July 2015 in a tertiary-care referral hospital. Clinical, biochemical and histopathological characteristics were collected. Normal serum testosterone level was defined as testosterone >9.9 nmol/L. Multiple logistic regression was used to identify determinants of microTESE in the studied population. A P<0.05 was considered significant.

Results

Sperms were successfully retrieved in 39.4% of cases. The average testosterone level was 11.51±7.40 and 11.67±6.42 in patients with successful and unsuccessful microTESE, respectively (P=0.820). No significant association was found between serum testosterone level and sperm motility and amount. Of all variables, histological subtype remained to be the most significant determinant of microTESE outcomes in the examined population, with hypospermatogenesis having over a 3-fold higher odd of successful microTESE than sertoli-cell only.

Conclusions

Serum testosterone level appears to have no significant association with microTESE outcomes in NOA. The underlying histological pattern is a significant determinant of the procedure’s success.

Co-administration of intravesical bacillus Calmette-Guérin and interferon α-2B as first line in treating superficial transitional cell carcinoma of the urinary bladder

OBJECTIVE

• To evaluate the efficacy and toxicity of the combination of bacillus Calmette-Guérin (BCG) and interferon α-2B (IFNα-2B) in treating superficial bladder cancer (SBC). The mentioned combination has shown synergism in pre-clinical studies.

PATIENTS AND METHODS

• The present study is a single-arm, open-label, single-institution prospective trial. Patients with Ta, T1 or in situ carcinoma and no previous intravesical therapy were included between July 2002 and June 2009. • Patients were treated with weekly intravesical instillation of 27 mg of BCG mixed with 10 million units (MU) of IFNα-2B for six consecutive weeks followed by 3-weekly booster instillations at 3 months if there was no recurrence. • The primary endpoint was disease recurrence. Secondary endpoints were disease progression and toxicity. • Patients were followed-up with cystoscopy and urine cytology every 3 months.

RESULTS

• In all, 50 patients were included. • At a median follow-up of 55.8 months, 31 (62%) patients were recurrence-free. • Progression to muscle invasion occurred in two (4%) and metastasis occurred in two (4%) patients. • Treatment was well tolerated, with grade III dysuria and frequency occurring in 18 and 14% of patients, respectively, and with 74% of patients being able to complete the maintenance dosage.

CONCLUSION

• The combination of BCG and IFNα-2B in the patient population with SBC has similar efficacy and toxicity to BCG monotherapy.

Steroid therapy for idiopathic retroperitoneal fibrosis: dose and duration

PURPOSE

Idiopathic retroperitoneal fibrosis is an uncommon disease of unknown etiology that may involve the ureters and other retroperitoneal structures. Surgical ureterolysis as well as medical treatment with steroids have been used to treat these patients. However, there is no agreement as to the dose and duration of steroid. We adopted a regimen of long-term steroid use in this prospective study.

MATERIALS AND METHODS

We treated 12 patients with idiopathic retroperitoneal fibrosis with a regimen of steroids during a 10-year period. Tissue diagnosis was established by biopsy of all lesions and ureteral obstruction was managed with insertion of a nephrostomy tube or a ureteral stent. The initial dose of prednisolone was 60 mg. on alternate days for 2 months and was tapered during the following 2 months to a daily dose of 5 mg. The total duration of prednisolone use was 2 years.

RESULTS

Of the 12 patients 11 who completed this treatment regimen have been followed for a duration of 26 to 132 months (median 63.1) after discontinuation of treatment. Good response in the form of relief of symptoms and regression of the mass occurred in 9 cases and there were 2 failures. In 1 case the retroperitoneal mass did not regress and surgical ureterolysis was required. In the 2nd case symptoms recurred after discontinuation of steroid and a further small dose of steroids was required. Function deteriorated in 1 of 19 functioning renal units. No steroid related serious side effects developed.

CONCLUSIONS

This regimen of steroid may be used as the primary mode of treatment for the majority of patients with idiopathic retroperitoneal fibrosis with minimal complications. Patients with idiopathic retroperitoneal fibrosis should be followed periodically for the rest of their lives.

The impact of internal spermatic artery ligation during laparoscopic varicocelectomy on recurrence rate and short post operative outcome

OBJECTIVE

To prospectively compare the recurrence rate and short postoperative outcome after randomized laparoscopic varix ligation with internal spermatic artery (ISA) preservation versus laparoscopic varix ligation with ISA ligation.

MATERIAL AND METHODS

Twenty-five patients with 35 varicocele who required varix ligation for infertility in 13 patients, scrotal pain in 15 patients and scrotal swelling in 2 patients who underwent one of two procedures: laparoscopic varix ligation with ISA prservation (Group A) or laparoscopic varix ligation with ISA ligation (Group B) were postoperatively evaluated for short post operative outcome and underwent percutaneous spermatic venograms to detect recurrence. Fisher's Exact Test was used for statistical analysis.

RESULTS

Recurrence through parallel collaterals was noted in 39% and 5.9% in Group A and Group B respectively as demonstrated on percutaneous spermatic venous venography (PSV) (statistically significant p = 0.0408). Preoperative pain completely resolved in all patients in Group B and persisted in 45% in Group A. However, this was not statistically significant (p = 0.088). No testicular atrophy or hydrocele formation was noted in either group.

CONCLUSIONS

Laparoscopic varix ligation with ISA ligation has lower recurrence rate than laparoscopic varix ligation without ISA ligation and may provide better varicocele related pain control with no increase in hydrocele or testicular atrophy rate. We recommend ISA ligation routinely during laparoscopic varix ligation.

Prostatic carcinoma: a nutritional disease? Conflicting data from the Kingdom of Saudi Arabia

PURPOSE

The incidence of prostate cancer in Saudi Arabia has been reported to be low at 1.4 to 2.1/100,000 person-years. We prospectively evaluated the true incidence of this disease and its association with dietary factors.

MATERIALS AND METHODS

From 1994 to 1997 inclusive Saudi men older than 50 years treated at our institution for various presenting symptoms and diseases were randomly selected from various departments. They were examined prospectively with digital rectal examination, and total and free prostate specific antigen measurement. Transrectal ultrasound and prostatic biopsy were performed when either test was abnormal. Nutrition questionnaires and detailed interviews with a nutritionist were completed to assess the type of diet, and amount of saturated and polyunsaturated fat consumption of patients with prostatic carcinoma and controls.

RESULTS

For the 2,270 Saudi men screened we noted an incidence of 3.1/100,000 person-years. Our nutritional survey revealed that recent fat consumption was greater than 120 gm. per person daily, of which about 40% was from meat and dairy products. Saturated fat comprised about 50% of the total fat intake. There was no difference in the amount of fat in the diet of men with and without prostatic carcinoma.

CONCLUSIONS

The incidence of prostatic carcinoma in the Kingdom of Saudi Arabia is low despite a high saturated fat diet in recent years. This finding contradicts most western clinical studies, which indicate a positive association of a high fat diet with prostatic carcinoma.

Prospective phase II trial of alternating intravesical Bacillus Calmette-Guérin (BCG) and interferon alpha IIB in the treatment and prevention of superficial transitional cell carcinoma of the urinary bladder: preliminary results

BACKGROUND AND OBJECTIVE

Evaluate the efficacy and toxicity of alternating intravesical instillation of Bacillus Calmette-Guerin(BCG) and Interferon alpha2-b (IFN) in the treatment and prevention of recurrence of superficial transitional cell carcinoma (TCC) of the urinary bladder.

METHODS

Patients with Ta, T1 tumors and carcinoma in situ, either recurrent (TaG1, T1G1) or primary/recurrent TaG2 TaG3, T1G2, T1G3 and Tis (T: Tumor stage, G: grade) are eligible. All patients received intravesical BCG 81 mg on Weeks 1, 3, 5 and 7 and IFN 100 million units on Weeks 2, 4, 6 and 8. Cystoscopy performed 4 weeks after completion of therapy, and every 3 months thereafter.

RESULTS

There was a total of 37 patients. Thirteen had TaG2, 13 T1G2, 1 T1G1, 4 TaG1, 1 TaG3, 3 T1G3 and 7 Tis (5 concurrent with other above tumors). Index lesion cleared in 7/10 patients. With a median follow-up of 26.2 month, 22 patients (59%) failed above therapy. Median time to treatment failure was 7 months. Seven, 6 and 9 patients recurred at a higher, lower and same stage or grade respectively. No grade 3 or 4 toxicity was encountered.

CONCLUSIONS

Alternating intravesical BCG and IFN is effective and well tolerated therapy for superficial TCC of urinary bladder.

Incidence and pattern of varicocele recurrence after laparoscopic ligation of the internal spermatic vein with preservation of the testicular artery

OBJECTIVES

To determine the incidence and pattern of recurrence of varicocele after laparoscopic internal spermatic vein ligation with testicular artery preservation.

METHODS

In a prospective study, 16 patients who underwent 20 laparoscopic varix ligation were evaluated postoperatively for recurrence by clinical physical examination and percutaneous spermatic venography.

RESULTS

No significant complications were encountered with the surgical or radiological procedure. Clinical recurrence was detected by physical examination in 20% of cases, while percutaneous spermatic venography detected recurrence in 45% of cases. The sensitivity and specificity of clinical physical examination for detecting varicocele recurrence was 33% and 90.9%, respectively with an accuracy rate of 65%. Recurrences were through parallel collaterals or medial transverse collaterals in 88.8% and 11.2%, respectively. Parallel collaterals joined the spermatic vein in mid or high retroperitoneum in seven patients while it joined the renal vein in one patient. There were no low retroperitoneal parallel collaterals.

CONCLUSIONS

Laparoscopic ligation of internal spermatic vein with preservation of testicular artery is a procedure that is associated with low morbidity and quick recovery. It is able to achieve its surgical objective in only 55% of cases, however. Such information should be taken into consideration during patient counselling when selecting the operative technique of choice for varicocele ligation.

Double-blind randomized crossover study comparing intracorporeal prostaglandin E1 with combination of prostaglandin E1 and lidocaine in the treatment of organic impotence

OBJECTIVES

To study the efficacy of lidocaine 1% in relieving pain associated with intracorporeal prostaglandin E1 and to assess its effect on the pharmacological erection.

METHODS

Twenty-two patients who had previously experienced pain with intracorporeal prostaglandin E1 injections were submitted to a double-blind randomized crossover study to evaluate comparatively the effects of intracorporeal prostaglandin E1 alone and in combination with lidocaine. The signed rank test was used for statistical analysis of the results.

RESULTS

With prostaglandin E1 monotherapy (20 micrograms) 86.3% of patients experienced pain and 27.2% had an adequate erection. With combination therapy (prostaglandin E1 20 micrograms plus lidocaine 1% 1 cc) 45.4% of patients experienced pain and 57.8% of patients had improvement of pain compared with prostaglandin E1 monotherapy. The adequate erectile response rate with combination therapy was 63.6%; in addition, 31.8% of patients noted enhancement in the duration of erection. The signed rank test was significant for the pain response (P < 0.01) and for the degree of erection (P < 0.01). The signed rank test was not, however, significant for the increase in duration of erection after combination therapy. No significant side effects were noted after either injection.

CONCLUSIONS

Lidocaine 1% can be safely and usefully combined with intracorporeal prostaglandin E1 in the treatment of erectile dysfunction with alleviation of pain and enhancement of erectile effect.

Spermatic cord torsion in adults

A five year retrospective review of 15 cases of spermatic cord torsion in male patients 18-years or older was performed. Eighty percent of patients were correctly diagnosed at time of initial presentation while 20% of patients were misdiagnosed as epididymitis. Fifty three percent of cases has history of similar previous attacks. The average delay prior to presentation was 7 hours. Absence of fever was the rule occurring in all patients. Leucocytosis and significant pyuria were commonly encountered occurring in 33% and 27% of patients respectively. Our orchidectomy rate was 20%. Our data suggest that while, in adult patients presenting with scrotal pain, the absence of pyuria make the diagnosis of epididymitis unlikely as a cause of the condition, the presence of significant pyuria even if associated with leucocytosis does not exclude spermatic cord torsion and further studies with Doppler examination and Radionuclide Scans are necessary to establish the diagnosis.

The clinicopathological features of bladder carcinoma among Saudis in Riyadh Central Hospital

In a retrospective study, the records of 54 Saudi patients constituting 35.2% of the total number of patients with bladder carcinoma presenting to Riyadh Central Hospital over a seven year period (1985G to 1992G) were reviewed. Eighty-one percent of the patients were habitants of the Central Province of Saudi Arabia. Their mean age was 60 +/- 14.8 years. Male to female ratio was 5:1; gross hematuria was the main presenting symptom, occurring in 90% of patients. Twenty-four patients presented six months or more after the onset of symptoms. Upper tract deterioration was noted in 50% of cases at the time of initial presentation. A total of 76.9% of bladder tumors were transitional cell carcinoma, 19.2% were squamous cell carcinoma and 3.8% were poorly differentiated. Only 29% were superficial tumors while 71% were at least muscle-invading at presentation. The majority of tumors were of high grade. This study shows that high grade muscle-invading transitional cell carcinoma is the most frequent histological pattern of bladder tumor in Riyadh Central Hospital. Delay in patient presentation associated with a tendency for invasion of bladder tumor in this region resulted in a high percentage of incurable disease.

Fournier's gangrene of the scrotum following anorectal disorders

Five cases of Fournier's gangrene of the scrotum following anorectal disorders were encountered in a period of 2 years. Perirectal abscess was the most common associated underlying condition occurring in three patients. E. coli was the predominant organism cultured in all cases. A chronic debilitating condition was encountered in 3 patients. The mortality rate was 20%, but serious life threatening complications occurred in 4 of our patients. Error in diagnosis and delay in initiating medical treatment were the main causes of the high mortality rate associated with the disease. We advocate thorough rectal examination including proctoscopy in all cases of Fournier's gangrene, especially when no obvious source is apparent.

Incidence of bacteremia and bacteriuria in patients with non-infection-related urinary stones undergoing extracorporeal shock wave lithotripsy

In a prospective pilot study, 26 patients with non-infection-related renal or ureteric stones and sterile urine were examined for evidence of bacteriuria and bacteremia following extracorporeal shock wave lithotripsy (SWL). Blood samples were obtained for aerobic and anaerobic bacterial culture at the end of, and 1 hour after, the SWL procedure. Urine cultures were performed 24 hours before and after treatment. Bacteremia was recorded in 7.7% of the patients immediately after SWL but in no patient at 1 hour after treatment. None of the patients manifested significant bacteriuria or post-SWL fever. These findings support the contention that, provided the urine is sterile and a negative history of urosepsis is available, antibiotic prophylaxis is unnecessary in patients with non-infected renal stones submitted to SWL treatment.

Double-blind, cross-over study comparing prostaglandin E1 and papaverine in patients with vasculogenic impotence

Intracorporeal injection of vasoactive agents is the treatment of choice for many patients with organic impotence. However, some patients with vasculogenic impotence respond poorly to injections of papaverine or papaverine/phentolamine. This study was conducted to determine if patients with vasculogenic impotence who failed to respond to papaverine might respond to prostaglandin E1 and thus be salvaged from possible prosthetic surgery. A total of 54 patients with vasculogenic impotence were administered intracorporeal prostaglandin E1 (20 micrograms) and intracorporeal papaverine (60 mg) randomized in a double-blind fashion and crossed over one week later. Forty-six percent of patients receiving prostaglandin E1 produced a satisfactory erection compared with 14 percent of patients with a similar response to papaverine. The difference between these results was highly significantly by the McNemar test. The number of side effects were similar for both drugs. Prostaglandin E1 might be considered the intracorporeal agent of choice for patients with significant vasculogenic impotence.

[Alteration of systemic hemodynamics in dogs with adrenal hypertension]

Arterial hypertension was reproduced in 20 dogs by suturing the adrenal glands with ligature. Arterial pressure showed a significant fall in 2 weeks; cardiac output diminished, and the general peripheral resistance displayed a sharp elevation. The phasic syndrome of hypodynamia, a reduction of the contractility index, of the volumetric rate of cardiac output, of the cardiac index, and of the rate of increase of the intraventricular pressure pointed to reduction of the myocardial contractility. Three months after the suturing there was an even greater elevation of arterial pressure, and hemodynamic shifts were analogous to the two-week hypertension period.