Sperm morphology: Evaluating its clinical relevance in contemporary fertility practice.

Background: The World Health Organization (WHO) recommends reporting sperm morphology in a standard semen analysis. However, the clinical utility and prognostic value of morphology is often debated. Methods: We reviewed and summarized studies that assessed both the benefits and limitations of sperm morphology in the context of natural fertility, assisted reproductive technologies, and recurrent pregnancy loss. We additionally describe possible environmental and anatomical etiologies of teratozoospermia. Results: Sperm morphology evaluation has continuously evolved since the release of the first WHO manual in 1980. Initially, several large studies reported significant inverse associations between fertility outcomes and teratozoospermia. Most recent studies, however, fail to show an association between sperm morphology and natural or assisted fertility outcomes. Conclusion: Sperm morphology analysis may have limited diagnostic and prognostic value. Providers should be aware of these limitations when counseling or managing infertile patients.

Obstructing ureteral calculus causing massive hydronephrosis in a renal allograft.

Nephrolithiasis is a rare complication of renal transplantation. Patients with an obstructing calculus in a renal allograft often lack the usual renal colic symptoms, and therefore present with atypical symptoms. Treatment of obstructing calculi is imperative to prevent renal allograft failure and other complications. We report the case of a 46-year-old man who presented 28 years after renal transplant with renal failure and massive hydronephrosis secondary to an obstructing calculus.

Endoscopic diagnosis of renal pseudoaneurysm following ureteroscopy.

Renal pseudoaneurysm following ureteroscopy is a rare cause of hematuria usually diagnosed and treated with angiography and embolization. Here we present a case of a small pseudoaneurysm causing intermittent flank pain and gross hematuria associated with clot retention initially diagnosed during ureteroscopy and subsequently treated with a combined endourologic and endovascular approach.

Enthalpic signature of methonium desolvation revealed in a synthetic host-guest system based on cucurbit[7]uril.

Methonium (N(+)Me3) is an organic cation widely distributed in biological systems. As an organic cation, the binding of methonium to protein receptors requires the removal of a positive charge from water. The appearance of methonium in biological transmitters and receptors seems at odds with the large unfavorable desolvation free energy reported for tetramethylammonium (TMA(+)), a frequently utilized surrogate of methonium. Here, we report an experimental system that facilitates incremental internalization of methonium within the molecular cavity of cucurbit[7]uril (CB[7]). Using a combination of experimental and computational studies, we show that the transfer of methonium from bulk water (partially solvated methonium state) to the CB[7] cavity (mostly desolvated methonium state) is accompanied by a remarkably small desolvation enthalpy of just 0.5 ± 0.3 kcal·mol(-1), a value significantly less endothermic than those values suggested from gas-phase model studies. Our results are in accord with neutron scattering measurements that suggest methonium produces only a minimal perturbation in the bulk water structure, which highlights the limitations of gas-phase models. More surprisingly, the incremental withdrawal of the methonium surface from water produces a nonmonotonic response in desolvation enthalpy. A partially desolvated state exists, in which a portion of the methonium group remains exposed to solvent. This structure incurs an increased enthalpic penalty of ~3 kcal·mol(-1) compared to other solvation states. We attribute this observation to the pre-encapsulation dewetting of the methonium surface. Together, our results offer a rationale for the wide distribution of methonium in a biological context and suggest limitations to computational estimates of binding affinities based on simple parametrization of solvent-accessible surface area.

Accuracy of Radiology Reports for Obstructing Ureteral Stone Size in the Emergency Department.

OBJECTIVE: To evaluate the number of dimensions of obstructing ureteral stones in the emergency department (ED) described in present-day radiology computed tomography reports and assess for measurement discrepancies between radiologist and urologist review. METHODS: We conducted a single-center retrospective study of patients who presented to the ED with unilateral, solitary, obstructing ureteral stones from March 2018 to March 2021. Stone size in each reported dimension recorded by the radiologist was extracted from the chart and then compared to size independently measured by one of our urologists for all 3 stone dimensions. Our primary outcome was the number of stone dimensions included in the radiology report. RESULTS: In total, 181 patients were included for analysis. 82.3% of radiology reports described the stone in one dimension, 15% in two dimensions, and 2.7% in three dimensions. There was a significant difference in median maximal stone size between radiologist and urologist measurement (5.5 vs 6.5 mm, respectively, P < .001). One hundred fourteen stones (62%) had the maximal measurement recorded in the craniocaudal (CC) dimension by urologist review. Only 26% of radiology reports had the CC measurement included in the radiology report. CONCLUSION: Ureteral stone size in a present-day ED cohort is still frequently measured in only 1 or 2 dimensions. In many cases, this is associated with an absence of a reported CC measurement. Inadequate characterization of stone size may affect acute management. This study hopes to encourage reporting of all three dimensions of obstructing ureteral stones in the ED setting for improvements in patient management.

Large Variations in the Prices of Urologic Procedures at Academic Medical Centers 1 Year After Implementation of the Price Transparency Final Rule.

Importance: Patients with urologic diseases often experience financial toxicity, defined as high levels of financial burden and concern, after receiving care. The Price Transparency Final Rule, which requires hospitals to disclose both the commercial and cash prices for at least 300 services, was implemented to facilitate price shopping, decrease price dispersion, and lower health care costs. Objective: To evaluate compliance with the Price Transparency Final Rule and to quantify variations in the price of urologic procedures among academic hospitals and by insurance class. Design, Setting, and Participants: This was a cross-sectional study that determined the prices of 5 common urologic procedures among academic medical centers and by insurance class. Prices were obtained from the Turquoise Health Database on March 24, 2022. Academic hospitals were identified from the Association of American Medical Colleges website. The 5 most common urologic procedures were cystourethroscopy, prostate biopsy, laparoscopic radical prostatectomy, transurethral resection of the prostate, and ureteroscopy with laser lithotripsy. Using the corresponding Current Procedural Terminology codes, the Turquoise Health Database was queried to identify the cash price, Medicare price, Medicaid price, and commercial insurance price for these procedures. Exposures: The Price Transparency Final Rule, which went into effect January 1, 2021. Main Outcomes and Measures: Variability in procedure price among academic medical centers and by insurance class (Medicare, Medicaid, commercial, and cash price). Results: Of 153 hospitals, only 20 (13%) listed a commercial price for all 5 procedures. The commercial price was reported most often for cystourethroscopy (86 hospitals [56%]) and least often for laparoscopic radical prostatectomy (45 hospitals [29%]). The cash price was lower than the Medicare, Medicaid, and commercial price at 24 hospitals (16%). Prices varied substantially across hospitals for all 5 procedures. There were significant variations in the prices of cystoscopy (χ23 = 85.9; P = .001), prostate biopsy (χ23 = 64.6; P = .001), prostatectomy (χ23 = 24.4; P = .001), transurethral resection of the prostate (χ23 = 51.3; P = .001), and ureteroscopy with laser lithotripsy (χ23 = 63.0; P = .001) by insurance type. Conclusions and Relevance: These findings suggest that, more than 1 year after the implementation of the Price Transparency Final Rule, there are still large variations in the prices of urologic procedures among academic hospitals and by insurance class. Currently, in certain situations, health care costs could be reduced if patients paid out of pocket. The Centers for Medicare & Medicaid Services may improve price transparency by better enforcing penalties for noncompliance, increasing penalties, and ensuring that hospitals report prices in a way that is easy for patients to access and understand.

Urinary Metabolic Disturbances During Topiramate Use and their Reversibility Following Drug Cessation.

OBJECTIVE: To understand the metabolic disturbances of stone formers currently taking topiramate and to examine the reversibility of these disturbances with cessation of the medication. MATERIALS AND METHODS: All progress notes written by 5 endourologists from a single academic center were retrospectively reviewed from January 2010 to July 2020 containing the words "topiramate" or "topamax." Inclusion criteria were age >18 and presence of either a 24-hour urine sample or stone analysis while on topiramate. In addition, a subgroup of 18 patients with 24-hour urine samples before and after stopping topiramate were identified. RESULTS: A total of 93 patients were identified and included for final analysis. Twenty-four hour urine samples were available in 67 patients and showed mean citrate excretion of 331 ± 322 mg/d, mean pH of 6.6 ± 0.5, and mean calcium phosphate supersaturation of 1.9 ± 1.1. In the subgroup analysis urinary citrate excretion increased from 225 mg/d to 614 mg/d (P <.01) and pH decreased from 6.59 ± 0.54 to 6.33 ± 0.47 (P = .06) after stopping topiramate. In addition, 114 stone events occurred in 73 distinct patients, with 50% of stones either pure or majority (≥50%) calcium phosphate by composition. CONCLUSION: Hypocitraturia and elevated pH is seen during topiramate use with resultant higher rate of calcium phosphate stone formation compared to the general population. Stopping topiramate leads to significant increase in citrate excretion and normalization of pH. These metabolic disturbances appear to be reversible with medication cessation.

Genetic testing for men with infertility: techniques and indications.

Genetic testing is an integral component in the workup of male infertility as genetic conditions may be responsible for up to 15% of all cases. Currently, three genetic tests are commonly performed and recommended by major urologic associations: karyotype analysis (KA), Y-chromosome microdeletion testing, and CFTR mutation testing. Despite widespread adoption of these tests, an etiology for infertility remains elusive in up to 80% of cases. Recent work has identified intriguing new targets for genetic testing which may soon see clinical relevance. This review will discuss the indications and techniques for currently offered genetic tests and briefly explore ongoing research directions within this field.

Testosterone therapy: where do the latest guidelines agree and differ?

PURPOSE OF REVIEW: The incidence of testosterone deficiency and number of men on testosterone therapy (TTh) has increased significantly over the past 3 decades. This rise has been accompanied by controversies surrounding the indications and possible adverse effects of therapy. To better inform prescribing habits among providers, many major medical associations have devised guidelines regarding the diagnosis and management of testosterone deficiency. While these guidelines agree in many areas, there are some key differences that should be identified. This review will explore the similarities, differences, and rationale for these guidelines. RECENT FINDINGS: Over the past 7 years, much attention has been devoted to the implications of TTh on cardiac health. All reviewed guidelines include dedicated sections discussing these implications and the society's position on prescribing testosterone considering recent findings, however, differ on specific contraindications to TTh and when to initiate therapy after a cardiovascular event. In addition, the American College of Physicians released its first guideline earlier this year which may impact prescribing habits among primary care physicians. SUMMARY: The differences between testosterone deficiency guidelines may indicate gaps in our knowledge of testosterone deficiency and focuses of future research efforts. Prescribers should be aware of these differences and discuss all treatment options with their patients.

Progress in translational reproductive science: testicular tissue transplantation and in vitro spermatogenesis.

Since the birth of the first child conceived via in vitro fertilization 40 years ago, fertility treatments and assisted reproductive technology have allowed many couples to reach their reproductive goals. As of yet, no fertility options are available for men who cannot produce functional sperm, but many experimental therapies have demonstrated promising results in animal models. Both autologous (stem cell transplantation, de novo morphogenesis, and testicular tissue grafting) and outside-the-body (xenografting and in vitro spermatogenesis) approaches exist for restoring sperm production in infertile animals with varying degrees of success. Once safety profiles are established and an ideal patient population is chosen, some of these techniques may be ready for human experimentation in the near future, with likely clinical implementation within the next decade.