The effect of hypogonadism and testosterone-enhancing therapy on alkaline phosphatase and bone mineral density.

OBJECTIVE: To evaluate the relationship of testosterone-enhancing therapy on alkaline phosphatase (AP) in relation to bone mineral density (BMD) in hypogonadal men. PATIENTS AND METHODS: Retrospective review of 140 men with testosterone levels of <350 ng/dL undergoing testosterone-enhancing therapy and followed for 2 years. Follicle-stimulating hormone, luteinising hormone, free testosterone, total testosterone, sex hormone binding globulin, calcium, AP, vitamin D, parathyroid hormone, and dual-energy X-ray absorptiometry (DEXA) scans were analysed. A subgroup of 36 men with one DEXA scan before and one DEXA 2 years after initiating treatment was performed. RESULTS: Analysis of the relationship between testosterone and AP at initiation of therapy using stiff linear splines suggested that bone turnover occurs at total testosterone levels of <250 ng/dL. In men with testosterone levels of <250 ng/dL, there was a negative correlation between testosterone and AP (R(2) = -0.347, P < 0.001), and no correlation when testosterone levels were between 250 and 350 ng/dL. In the subgroup analysis, the mean (sd) testosterone level was 264 (103) ng/dL initially and 701 (245), 539 (292), and 338 (189) ng/dL at 6, 12, and 24 months, respectively. AP decreased from a mean (sd) of 87 (38) U/L to 57 (12) U/L (P = 0.015), 60 (17) U/L (P < 0.001), and 55 (10) U/L (P = 0.03) at 6, 12, and 24 months, respectively. The BMD increased by a mean (sd) of 20 (39)% (P = 0.003) on DEXA. CONCLUSION: In hypogonadal men, the decrease in AP is associated with an increase in BMD on DEXA testing. This result suggests the use of AP as a marker of response to therapy.

Severe testicular atrophy does not affect the success of microdissection testicular sperm extraction.

PURPOSE: Men with azoospermia and severe testicular atrophy may be counseled to avoid sperm retrieval due to perceived limited success. We evaluated the outcomes of microdissection testicular sperm extraction in men with severe testicular atrophy (volume 2 ml or less). MATERIALS AND METHODS: We reviewed the records of 1,127 men with nonobstructive azoospermia who underwent microdissection testicular sperm extraction followed by intracytoplasmic sperm injection. They were classified into 3 groups based on average testicular volume, including 2 ml or less, greater than 2 to less than 10 and 10 or greater. Sperm retrieval, clinical pregnancy and live birth rates were calculated. Clinical features evaluated included age, follicle-stimulating hormone level, cryptorchidism history, Klinefelter syndrome, varicocele and testicular histology on diagnostic biopsy. RESULTS: Testicular sperm were successfully retrieved in 56% of the men. The sperm retrieval rate in those with a testicular volume of 2 ml or less, greater than 2 to less than 10 and 10 or greater was 55%, 56% and 55%, respectively. Clinical pregnancy and live birth rates were similar in men in the 3 groups who underwent sperm retrieval (55.2%, 50.0% and 47.0%, and 47.2%, 43.0% and 42.2%, respectively). Of the 106 men with an average testis volume of 2 ml or less those from whom sperm were retrieved were younger (31.1 vs 35.2 years) and more likely to have a history of Klinefelter syndrome (82.2% vs 55.6%) than men in whom sperm were not found (p <0.05). Men in this group had a higher prevalence of Klinefelter syndrome than men with a testis volume of greater than 2 ml (72.6% vs 5.3%, p <0.0001). Men younger than 30 years with Klinefelter syndrome had a higher sperm retrieval rate than men older than 30 years without Klinefelter syndrome (81.8% vs 33%, p <0.01). There was no cutoff point for age beyond which sperm could not be retrieved in men with small testes. On multivariable analysis younger age was the only preoperative factor associated with successful sperm retrieval in men with small testes (2 ml or less). CONCLUSIONS: Testicular volume does not affect the sperm retrieval rate at our center for microdissection testicular sperm extraction. Of men with the smallest volume testes those who were younger with Klinefelter syndrome had the highest sperm retrieval rate. Severe testicular atrophy should not be a contraindication to microdissection testicular sperm extraction.

Robot-Assisted Excision of Congenital Mega-Seminal Vesicle Associated with Zinner's Syndrome.

Background: Abnormalities of mesonephric ducts are rare congenital conditions, which can present with vague symptoms in otherwise healthy men. Zinner's syndrome is the association of an enlarged seminal vesicle cyst with ipsilateral renal agenesis, which can be symptomatic and require operative interventions. Case: We present the case of an otherwise healthy 24-year-old man who presented with a symptomatic 15 cm seminal vesicle cyst, which was completely excised using a robot-assisted approach. Conclusion: Use of robotic surgery for excision of large seminal vesicle cysts is a safe and effective operative procedure.