Orchidopexy for Ascending Testicles in Adulthood After Remote Hernia Repair: A Report of Two Cases.

Testicular ascent to the inguinal region after hernia repair has been previously reported as a rare complication of this surgery in pediatric patients. This article presents two cases of adult patients with ascending testicles after inguinal hernia repair that was performed in childhood. Both men underwent orchidopexy through a combined inguinal and scrotal approach, the latter for the creation of a sub-dartos pouch. In both cases, this intervention was completed successfully without complication and resulted in a satisfactory post-operative position of the testicles in the scrotal sac. This surgical approach appears to be a safe management option for adult men with ascending testicles after inguinal hernia repair.

Combined robotic and subinguinal microsurgical vasovasostomy for vasal obstruction after inguinal hernia repair.

Obstruction of the vas deferens may occur after inguinal hernia repair with mesh and lead to infertility. In cases where natural conception is desired and after obtaining test results that suggest the presence of spermatogenesis, surgical reconstruction can be attempted but may be difficult. Several approaches have been reported, including the laparoscopic mobilisation of the pelvic vas deferens, as well as mobilisation and passage of the scrotal vas deferens intra-abdominally for robot-assisted vasovasostomy. We describe a novel approach that used the surgical robot and a no-touch technique to mobilise the pelvic vas deferens and deliver it to the subinguinal region for subinguinal microsurgical vasovasostomy. This approach appeared to be feasible and safe, allows for simultaneous bilateral repair if needed, and was associated with rapid postoperative convalescence.

The additive impact of the distal ureteral diameter ratio in predicting early breakthrough urinary tract infections in children with vesicoureteral reflux.

INTRODUCTION: Many factors influence patient and provider decisions to surgically correct vesicoureteral reflux (VUR), including risk of breakthrough febrile urinary tract infections and likelihood of spontaneous resolution. Ureteral diameter ratio has been shown in several studies to be more predictive than reflux grade with regard to breakthrough urinary tract infection (UTI). We developed and investigated the accuracy of a computational model for predicating febrile breakthrough urinary tract infection within 13 months of starting prophylactic antibiotics in children with VUR. OBJECTIVE: The aim of this study was to validate a model for evaluating the impact of distal ureteral diameter ratio (UDR) in predicting early breakthrough urinary tract infections in children with VUR. STUDY DESIGN: Following a retrospective review, we recorded patient demographics, presenting symptoms, VUR grade, laterality, VUR during filling or voiding, initial bladder volume at the onset of VUR, ureteral duplication, voiding dysfunction, distal ureteral diameter ratio, and number of UTIs prior to VUR diagnosis. NeUROn++, a set of C++ programs, was used to model each data set using logistic regression and neural networks with different architectures. RESULTS: After exclusions, 136 children (93 girls and 43 boys) diagnosed with primary VUR had detailed VCUG and UDR data available. Fourteen children (10.3%) experienced breakthrough febrile UTI events within 13 months of VUR diagnosis. There was a significant association with UDR and breakthrough UTI (p = 0.008). Various computational prediction models for the outcome of breakthrough UTI were developed and evaluated. The computational model that fit best was a model using all variables with an ROC of 0.802. DISCUSSION AND CONCLUSIONS: Clinicians and parents often opt for intervention based on likelihood of spontaneous resolution of VUR as well as clinical course, thereby placing an emphasis on the ability to predict likelihood of breakthrough UTI infections. Our statistical analysis and prediction models further confirm UDR as an important variable predictive of breakthrough UTIs within the first 13 months of beginning prophylactic antibiotics. Furthermore, we developed a neural network model incorporating UDR and grade with an ability to yield the greatest accuracy of any breakthrough UTI predictive calculator to date at 80%.

Superficial Penile Vein Thrombophlebitis After Microsurgical Varicocelectomy: Case Series.

Varicocele is a common condition, estimated to be present in 15% of the general male population. It consists of abnormal dilation and tortuosity of the internal spermatic veins within the pampiniform plexus of the spermatic cord. In adults, varicocele repair may be considered in cases of scrotal pain, or of infertility associated with impaired sperm parameters. Microsurgical varicocelectomy is currently a common method for varicocele repair. Superficial penile vein thrombophlebitis has been previously reported to occur after microsurgical varicocelectomy but has not been well recognized as a possible complication of this surgery. We present three cases of superficial penile vein thrombophlebitis after microsurgical varicocelectomy. Diagnosis on this condition was based on physical examination, mainly a palpable cord-like structure along the involved vein, without overlying redness. Signs and symptoms of superficial penile vein thrombophlebitis resolved after a 4-8-week course of aspirin at the dose of 325 mg daily. Awareness of this possible post-operative complication and its possible management could be helpful to the clinicians involved in the care of patients with varicoceles.

Association between the lengths of excised obstructed vas deferens segments at the time of vasovasostomy and surgical outcomes.

OBJECTIVE: This study aimed to determine whether the length of the excised obstructed vas deferens at vasovasostomy (VV) performed for fertility is associated with semen parameters and/or pregnancy outcomes postoperatively. MATERIAL AND METHODS: The patients who underwent a VV at our institution from September 2004 to December 2018 were contacted via questionnaire and a chart review was performed. Linear and logistic regression models were used to determine the associations between the length of the obstructed vas deferens removed and postoperative outcomes including sperm concentration, motility, and successful pregnancy after reversal. RESULTS: A total of 83/170 questionnaires were returned. After exclusions, a total of 35 patients were included for analysis. The mean age of the patients at the time of surgery was 40.1 years and the mean time since vasectomy 9.3 years. The mean length of the obstructed vas deferens removed during VV was 2.25 cm. The longer the vas deferens segments removed, the more significant was the increase in sperm motility at 3 and 9 months postoperatively (p=0.011 and 0.008, respectively), but decreased sperm motility at 6 months (p=0.029). In 75.9% of the patients, sperm was present postoperatively, 23.2% achieved pregnancy through natural conception, and 55.8% achieved pregnancy using assisted reproductive techniques. There was no significant relationship between the length of the vas deferens removed and sperm concentration or pregnancy achieved after surgery. CONCLUSION: In this cohort, the length of the excised obstructed vas deferens at VV was associated with improved sperm motility at 3 and 9 months postoperatively but not with pregnancy outcomes.

Paratesticular colon cancer metastasis in an area of remote trauma.

A 53-year-old man with a history of colon adenocarcinoma and remote scrotal trauma resulting in a palpable nodule. Gradual increase in the size of this lesion over the year prior to his presentation to our clinic prompted scrotal ultrasound that demonstrated a 1.1 cm solid lesion, which appeared to arise from the right epididymal tail. Subsequent positron emission tomography (PET) scan showed intense focal uptake at the base of the right testicle, suspicious for epididymitis versus underlying neoplasm. Scrotal exploration through an inguinal approach revealed a paratesticular mass. Frozen section from an excisional biopsy was positive for adenocarcinoma. Radical orchiectomy was completed. Final pathology returned as metastatic adenocarcinoma involving soft tissue; testis and spermatic cord were without diagnostic abnormalities and surgical margins were not involved. Subsequent analysis was consistent with colorectal origin. The patient recovered well from surgery and is continuing treatment of metastatic colon cancer per the medical oncology team.

Computer model predicting breakthrough febrile urinary tract infection in children with primary vesicoureteral reflux.

INTRODUCTION AND OBJECTIVE: Factors influencing the decision to surgically correct vesicoureteral reflux (VUR) include risk of breakthrough febrile urinary tract infection (fUTI) or renal scarring, and decreased likelihood of spontaneous resolution. Improved identification of children at risk for recurrent fUTI may impact management decisions, and allow for more individualized VUR management. We have developed and investigated the accuracy of a multivariable computational model to predict probability of breakthrough fUTI in children with primary VUR. STUDY DESIGN: Children with primary VUR and detailed clinical and voiding cystourethrogram (VCUG) data were identified. Patient demographics, VCUG findings including grade, laterality, and bladder volume at onset of VUR, UTI history, presence of bladder-bowel dysfunction (BBD), and breakthrough fUTI were assessed. The VCUG dataset was randomized into a training set of 288 with a separate representational cross-validation set of 96. Various model types and architectures were investigated using neUROn++, a set of C++ programs. RESULTS: Two hundred fifty-five children (208 girls, 47 boys) diagnosed with primary VUR at a mean age of 3.1 years (±2.6) met all inclusion criteria. A total 384 VCUGs were analyzed. Median follow-up was 24 months (interquartile range 12-52 months). Sixty-eight children (26.7%) experienced 90 breakthrough fUTI events. Dilating VUR, reflux occurring at low bladder volumes, BBD, and history of multiple infections/fUTI were associated with breakthrough fUTI (Table). A 2-hidden node neural network model had the best fit with a receiver operating characteristic curve area of 0.755 for predicting breakthrough fUTI. DISCUSSION: The risk of recurrent febrile infections, renal parenchymal scarring, and likelihood of spontaneous resolution, as well as parental preference all influence management of primary VUR. The genesis of UTI is multifactorial, making precise prediction of an individual child's risk of breakthrough fUTI challenging. Demonstrated risk factors for UTI include age, gender, VUR grade, reflux at low bladder volume, BBD, and UTI history. We developed a prognostic calculator using a multivariable model with 76% accuracy that can be deployed for availability on the Internet, allowing input variables to be entered to calculate the odds of an individual child developing a breakthrough fUTI. CONCLUSIONS: A computational model using multiple variables including bladder volume at onset of VUR provides individualized prediction of children at risk for breakthrough fUTI. A web-based prognostic calculator based on this model will provide a useful tool for assessing personalized risk of breakthrough fUTI in children with primary VUR.

Male contraception: history and development.

Although the twentieth century has seen great strides in the development of female contraception, not a single new agent has been introduced as an approved method for common use for male contraception. Condoms (considered uncomfortable by some) and vasectomy (a permanent invasive procedure) are the only options provided to men, leaving an undue burden on women to bear contraceptive responsibility. Significant developments have, however, been made with regard to hormonal and nonhormonal contraception, and minor, reversible, procedural contraception. This article reviews the currently available, soon to be available, and theoretically possible methods of male contraception.

Effect of combined locally delivered growth factors and systemic sildenafil citrate on microrecanalization in biodegradable conduit for vas deferens reconstruction.

OBJECTIVE: To investigate the effect of the combination of locally delivered growth factors and oral sildenafil citrate on cross-conduit microrecanalization. METHODS: A total of 42 rats were divided into 7 groups. Of the 42 rats, 6 underwent bilateral vasectomy and bilateral end-to-end vasovasostomy and 12 underwent bilateral vasectomy. Of the latter 12, 6 received sildenafil citrate orally (10 mg/kg/d) for 24 weeks and 6 received placebo. A total of 24 rats underwent bilateral vasectomy and bilateral reconstruction with implantation of a 5-mm biodegradable conduit that bridged the 2 vasal ends. Of the 24 rats with conduits, 12 also had 250 pg of transforming growth factor-ß and 12.5 pg of platelet-derived growth factor-ß sustained release nanoparticles placed in immediate proximity to the conduit. The remaining 12 rats with conduits (6 without growth factors and 6 with growth factors) also received sildenafil citrate orally (10 mg/kg/d) for 24 weeks; the others received placebo. The reconstructed segments were harvested for histologic examination at 24 weeks. RESULTS: Five of 6 primary vasovasostomy and no vasectomy-only rats sired litters. Significantly more microcanals per conduit were observed in rats receiving sildenafil citrate: without growth factors, 3.9 vs. 0 canals/conduit (P < 0.001); with growth factors, 5.5 vs. 0.25 canals/conduit (P < 0.001). The rats receiving sildenafil citrate with growth factors showed a trend toward more microcanals per conduit than the rats receiving sildenafil citrate without growth factors (5.5 vs 3.9; P = .10). Rats receiving growth factors but no sildenafil citrate did not produce more canals than the rats receiving neither growth factor nor sildenafil citrate (0.25 vs 0; P = NS). CONCLUSION: Orally administered sildenafil citrate enhances formation of microcanalization after postvasectomy reconstruction using a biodegradable conduit in a rat model. Locally delivered growth factors appear to increase the number of microcanals.

Current options for preservation of fertility in the male.

Modern cancer therapies have greatly improved survival rates in men of reproductive age and younger; however, surgery, chemotherapy, and irradiation may lead to male infertility. Men with cancer should be counseled about fertility preservation before initiating therapy, when possible. Currently, options for male fertility preservation include cryopreservation of semen or testicular tissue. However, prepubertal boys pose a special problem in this area.

Micro-recanalization in a biodegradable graft for reconstruction of the vas deferens is enhanced by sildenafil citrate.

This study investigated the effect of sildenafil citrate on micro-recanalization and neovascularization, which were previously demonstrated in a rat model using biodegradable grafts (BGs) for vas deferens reconstruction. A total of 24 male rats underwent bilateral vasectomy with removal of a 0.5-cm vasal segment and were randomly assigned to four groups. Groups 1 and 2 underwent immediate vasovasostomy. Groups 3 and 4 underwent interposition of a 0.5-cm BG in the vasal gap. Groups 1 and 3 were given 5 mg kg(-1) day(-1) oral sildenafil. Other groups were given placebo. Rats were housed with females 12 weeks postoperatively. Reconstructed vasal segments were harvested 16 weeks postoperatively and analyzed histologically. Fluid from the distal vasal stump was analyzed for motile sperm. Urine samples obtained 16 weeks postoperatively were analyzed for cGMP levels. cGMP levels in rats treated with sildenafil were significantly higher than in control rats. No pregnancies were sired by grafted groups. In all, 5/6 rats in group 1 and 3/6 rats in group 2 sired litters. No motile sperm were noted in the vasal fluid of the grafted groups. Motile sperm were noted in all rats in group 1 and in 5/6 rats in group 2. In addition, 29 and 4 microcanals were detected in the sildenafil and placebo groups, respectively (P = 0.023). No microcanal exceeded 3 mm in length. An average of 12 and 28 blood vessels per graft were noted in the placebo and sildenafil groups, respectively (P < 0.0001). In conclusion, sildenafil enhances micro-recanalization and neovascularization in BG used for vas deferens reconstruction, but does not increase the microcanal length after 16 weeks.

Unusual scrotal pathology: an overview.

The diverse embryological origins of the contents of the scrotum create an environment that fosters a wide variety of unusual pathologies. Most scrotal pathologies are discovered by the patient and are initially evaluated by a thorough physical examination and scrotal ultrasonography. Scrotal lesions can be broadly grouped by the anatomical location in which they develop; the clinician must consider a wide differential diagnosis based on this location. Solid testicular masses are considered germ cell tumors until proven otherwise, but numerous other possible pathologies exist, including ectopic tissue, metastasis, and other neoplastic growths. Rete testis lesions are classified as developmental, benign or malignant. Cystic lesions of the epididymis are most commonly benign, but malignant neoplasms can also be present. The paratesticular region has the broadest differential diagnosis, as it contains numerous distinct structures and is a common location for ectopic tissue and metastatic disease; a narrower range of lesions develop in the scrotal wall because of its simpler anatomy. Treatment options range from conservative observation to wide surgical excision and should be considered carefully; the aim of therapy is to remove malignant or potentially malignant tissue while minimizing effects on fertility and function.

Risks and complications of vasectomy.

Vasectomy is a safe and effective procedure for permanent contraception. Vasectomy is 30 times less likely to fail and 20 times less likely to have postoperative complications than its gynecologic counterpart. Complications from vasectomy are rare and minor in nature. Immediate risks include infection, hematoma, and pain. Complications seldom lead to hospitalization or aggressive medical management. Technique is surgeon dependent; however, certain techniques, such as fascial interposition, seem to decrease rates of vasectomy failure. Despite myriad vasectomy techniques, failure rates are less than those seen with tubal ligation. Available data suggest that vasectomized men do not seem at increased risk for immune-complex diseases.

Validation of a prognostic calculator for prediction of early vesicoureteral reflux resolution in children.

PURPOSE: Treatment of vesicoureteral reflux with observation or surgery is based on a number of clinical variables. We developed a prognostic calculator to predict spontaneous resolution using a computational model. External validation of the computational model is crucial for wide application in clinical practice. MATERIALS AND METHODS: We reviewed the records of 82 Japanese children with primary vesicoureteral reflux with resolution status known at 2 years after diagnosis. Clinical data were input into the online prognostic calculator. Prognostic accuracy, positive predictive value and negative predictive value were calculated by comparing the predicted and actual clinical results. Clinical parameters were compared to determine the characteristics of cases in which the computational model failed to predict the reflux outcome. RESULTS: The 2-year resolution rate was 49% (40 of 82 patients). Of the cases 42 (51%) were predicted to resolve and 40 (49%) not to resolve by the prognostic calculator. Overall accuracy of the prognostic calculator was 80.5%, with the prediction accurate in 66 patients and inaccurate in 16. Sensitivity for spontaneous resolution was 82.5% and specificity was 78.6%. Positive predictive value was 78.6% and negative predictive value was 82.5%. The ROC for this calculator was 0.793. Mean age in the 16 cases that were inaccurately predicted (4.96 years) was significantly higher than in the 66 that were accurately predicted (3.00, p <0.05). CONCLUSIONS: The prognostic calculator was 80.5% accurate at predicting reflux resolution and was more accurate in younger children. This calculator can be widely applied for many patients with reflux.

Early microrecanalization of vas deferens following biodegradable graft implantation in bilaterally vasectomized rats.

We evaluated a biodegradable graft for reconstruction of rat vasa deferentia with long obstructed or missing segments. A total of 47 Sprague-Dawley rats underwent bilateral vasectomy and were divided into groups according to length of the vas deferens affected (0.5, 1, 1.5 cm). After 8 weeks, poly-(D,L-lactide) (PDLA) grafts were used to reconnect the vas deferens. Grafts and adjoining vasa deferentia were excised 8 and 12 weeks later and evaluated microscopically. At 8 weeks, microscopic changes included a robust inflammatory response around the grafts. All grafts were still intact but in the early stages of degradation. No microtubules, indicative of vas deferens recanalization, were identified. One specimen showed evidence of healing and neovascularization at the interface zone between the vas deferens and the graft. At 12 weeks, grafts were further degraded but still present. Microscopic evaluation showed decreased inflammation. Seven specimens showed neovascularization at the interface zone; two of these showed distinct epithelialized vas deferens microcanals at the graft edges. One specimen showed a microcanal spanning the entire 0.5-cm graft. A time period of 8 weeks is not ample enough for vas deferens regeneration in the setting of a biodegradable PDLA graft; however, early evidence of re-growth was seen at 12 weeks. A longer healing time should permit further biodegradation of the graft, as well as re-growth and possible eventual reconnection of the vas deferens, allowing passage of sperm. These findings suggest a potential role for biodegradable grafts in the reconstruction of vas deferens with long obstructed segments.

The use of immunofluorescence in microdissection testicular sperm extraction.

Microdissection testicular sperm extraction (TESE) has been used in the treatment of male infertility in cases of nonobstructive azoospermia (NOA). In some NOA cases, there is significant difficulty identifying sperm within the testes, and we propose that an immunofluorescence technique may assist in locating sperm foci for use in in vitro fertilization and intracytoplasmic sperm injection. The purpose of this study was to evaluate the feasibility of this novel technique. Thirteen fertile and 8 sterile mice were anesthetized, and a lower abdominal incision was performed to deliver the testes. Then a small incision was made into the tunica albuginea near the vascular pedicle to expose the seminiferous tubules. A microinjector fitted with a micropipette was used to inject fluorescein isothiocyanate-conjugated mouse anti-human acrosomal IgM antibody (HS-14) into adjacent injection sites along the exposed seminiferous tubules. Following antibody injection, the testes were examined under a Bio-Rad Multiphoton microscope to locate sperm through visualization of fluorescence. Sperm were identified in 22 of 26 testes from fertile mice either by morphologic appearance or by their motility, which was obvious under direct visualization. There was strong binding of the antibody to both the sperm head and tail. In contrast, no sperm were visualized in the sterile mice group. Use of an immunofluorescence technique during microdissection TESE for detection of sperm is a novel and feasible concept. Further studies of this technique are planned.

Adding renal scan data improves the accuracy of a computational model to predict vesicoureteral reflux resolution.

PURPOSE: We previously developed a computational model to predict vesicoureteral reflux resolution 1 and 2 years after diagnosis. Previous studies suggest that an abnormal renal scan may be a predictor of the failure of vesicoureteral reflux to resolve. We investigated whether the addition of renal scan data would improve the accuracy of our computational model. MATERIALS AND METHODS: Medical records and renal scans were reviewed on 161 children, including 127 girls and 34 boys, with primary reflux between 1988 and 2004. In addition to the 9 input variables from our prior model, we added renal scan data on decreased relative renal function (40% or less in the refluxing kidney) and renal scars. Resolution outcome was evaluated 1 and 2 years after diagnosis. Data sets were prepared for 1 and 2-year outcomes, and randomized into a modeling set of 111 and a cross-validation set of 50. The model was constructed using neUROn++. RESULTS: A logistic regression model had the best fit with an ROC area of 0.945 for predicting reflux resolution in the 2-year model. This was improved compared to our previous model without renal scan data. A prognostic calculator using this model can be deployed for availability on the Internet, allowing input variables to be entered and calculating the odds of resolution. CONCLUSIONS: This computational model uses multiple variables, including renal scan data, to improve individualized prediction of early reflux resolution with almost 95% accuracy. The prognostic calculator is a useful tool for predicting individualized vesicoureteral reflux resolution.

Involvement of growth factors in the process of post-vasectomy micro-recanalization.

PURPOSE: We investigated the role of growth factors in the process of post-vasectomy micro-recanalization using real-time polymerase chain reaction, enzyme-linked immunosorbent assay and histopathological analyses of the vasectomy sites and controls at different time points in a rat model. MATERIALS AND METHODS: Unilateral vasectomies were performed in 18 rats with sham surgery on the contralateral side. Vasectomy sites and vas segments of similar length from the sham operated sides were taken for analysis at 2, 8 and 12 weeks. Real-time polymerase chain reaction was used to test the expression of mRNA of 7 common growth factors and select growth factor receptors. Enzyme-linked immunosorbent assay was performed for growth factors with strong positive polymerase chain reaction findings. Histopathological examination was performed by a staff pathologist (BRD) to detect micro-recanalization, defined as tubules visible on hematoxylin and eosin staining with an epithelial lining of cuboidal or columnar cells. RESULTS: Micro-canals were found in 2 of 18 rat specimens. Real-time polymerase chain reaction of all specimens demonstrated a 12-fold increase in platelet-derived growth factor-beta, a 6-fold increase in platelet-derived growth factor-beta receptor, an 11-fold increase in platelet-derived growth factor-alpha, a 7-fold increase in platelet-derived growth factor-alpha receptor and a 9-fold increase in transforming growth factor-beta compared to the sham operated side. All increases were sustained and statistically significant (p <0.05). Enzyme-linked immunosorbent assay revealed statistically significantly increased expression of platelet-derived growth factor-beta protein. CONCLUSIONS: The demonstrated micro-recanalization and sustained growth factor up-regulation at vasectomy sites suggest a possible mechanism for post-vasectomy ejaculate sperm identification. There is a need for further research on the potential role of select growth factors in reconstruction of the male reproductive tract.

Therapeutic testis biopsy for sperm retrieval.

PURPOSE OF REVIEW: The introduction of IVF and intracytoplasmic sperm injection revolutionized the treatment of male infertility by requiring a minimal number of sperm to achieve pregnancy. We describe the various methods for testicular sperm retrieval in different types of azoospermia. RECENT FINDINGS: Different techniques for surgical sperm retrieval are available, including testicular sperm aspiration, single, multisite and microdissection testicular sperm extraction, as well as percutaneous and microsurgical epididymal sperm aspiration. While these methods have similar retrieval outcomes in obstructive azoospermia, testicular sperm extraction procedures appear to be more beneficial in cases of nonobstructive azoospermia. A reliable algorithm for predicting the outcome of microdissection testicular sperm extraction using clinical parameters is still lacking, and may be difficult to develop, given the fact that this method is designed to detect and sample even minute areas of focal spermatogenesis. SUMMARY: A variety of surgical sperm retrieval procedures can be performed for the purpose of subsequent or simultaneous IVF/intracytoplasmic sperm injection. The decision regarding the type of procedure should be based on the type of azoospermia, specific clinical circumstances, as well as on the surgeon's preference and experience.