The association between elevated serum oestradiol levels and clinically significant erectile dysfunction in men presenting for andrological evaluation.

The goal of this study was to investigate the association between serum oestradiol levels and clinically significant erectile dysfunction in a cohort of men presenting for andrological evaluation. Retrospective review was conducted of patients that presented to a urologist with practice in andrology over an 18-month period. Patients completed the Male Sexual Health Questionnaire and had serum total testosterone and oestradiol measurements prior to 10:30 a.m. via immunoassay. t Tests, chi-square tests and multivariate logistic regression were used to compare clinical characteristics between those with adequate erectile function (erection scale score > 2) vs. clinically significant erectile dysfunction (erection scale score ≤ 2). Among 256 patients, average age was 49 years (SD 15), average serum oestradiol was 22.3 pg/ml (SD 10.6), and average serum total testosterone was 465.9 pg/ml (SD 206.3). On multivariate logistic regression, serum oestradiol was associated with clinically significant erectile dysfunction (OR 1.52 per SD increase, 95% CI 1.11-2.09, p = 0.009) when controlling for serum total testosterone, age, body mass index and smoking status. These results warrant future studies on the utility of measuring serum oestradiol in patients with erectile dysfunction and the use of aromatase inhibitors in patients with erectile dysfunction and elevated serum oestradiol.

A Systematic Review of Randomized Controlled Trials Comparing Buccal Mucosal Graft Harvest Site Non-Closure versus Closure in Patients Undergoing Urethral Reconstruction.

PURPOSE: To assess the effects of buccal mucosal graft site non-closure versus closure on postoperative oral morbidity for male undergoing augmentation urethroplasty for urethral stricture. MATERIALS AND METHODS: We included randomized controlled trials. Inclusion criteria were male over the age of 18 with urethral stricture disease requiring reconstruction with buccal mucosal graft harvest. Primary outcomes of the review were postoperative oral pain, need for secondary oral procedures and cosmetic defects. RESULTS: We included 5 studies with 346 randomized patients with urethral strictures, of whom 260 completed the trials. In terms of primary outcomes, non-closure graft site may reduce oral pain on postoperative day #1 (standard mean difference [SMD] 0.24 lower; 95% confidence interval [CI] 0.61 lower to 0.12 higher; low certainty evidence [CoE]) but we are uncertain how this impacts pain on postoperative days 3 to 6 (SMD 0.35; 95% CI 0.12 to 0.81 higher; very low CoE). We are also very uncertain as to how it affects the need for secondary oral procedures (risk ratio [RR] 0.22; 95% CI 0.01 to 4.28; very low CoE). Non-closure may increase the risk of cosmetic defects (RR 2.40; 95% CI 0.93 to 6.22; low CoE). CONCLUSIONS: This review describes the trade-off for buccal mucosal graft site non-closure versus closure for various patient-important outcomes; decision-making will likely hinge on the relative value individual patients and surgeons place on them. The supporting evidence was rated as low and very low, thereby signaling substantial underlying uncertainty and the need for better trials.

Transrectal Ureteroscopic Stone Management in a Patient with Ureterosigmoidostomy.

Background: Published case reports on the management of ureteral stones in patients with prior ureterosigmoidostomy have described the challenges of direct retrograde access to the ureter using standard endourologic instruments. In light of these challenges, reported effective techniques have involved either (1) direct retrograde access utilizing sigmoid endoscopy with air insufflation or (2) percutaneous antegrade access. We report the first experience of effective retrograde ureteroscopy utilizing traditional endourologic instruments in a patient without percutaneous access. Case Presentation: The patient is a 70-year-old man born with bladder exstrophy who underwent end colostomy and ureterosigmoidostomy as a child. He presented with a symptomatic 6 mm stone at the right ureterosigmoid junction. A trial of spontaneous passage failed because of persistent pain. Treatment options were limited by the patient's recent history of coronary stent placement, requiring uninterrupted antiplatelet therapy with clopidogrel. As such, we attempted retrograde ureteroscopy through a transrectal approach. Anticipating some difficulty in the identification of the ureteral orifices, we administered methylene blue at the time of induction. After placing the patient in lithotomy position, we advanced a flexible cystoscope to the rectosigmoid junction where we identified a ureteral orifice. Guidewire access was obtained and we confirmed right-sided laterality with fluoroscopic imaging. A semirigid ureteroscope was passed to the ureterosigmoid junction where the stone was encountered and retrieved intact using a basket. A 6 × 26 Double-J stent was placed with a string to facilitate removal 5 days later. The postoperative course was unremarkable. Conclusion: Despite the previously reported challenges of the approach, retrograde ureteroscopy without percutaneous access represents a viable treatment option for ureteral stones in patients with ureterosigmoidostomy.

A Multi-Institutional Study of Struvite Stones: Patterns of Infection and Colonization.

OBJECTIVE: To examine urine and stone bacteriology of struvite stone formers in a large cohort of patients undergoing percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: A total of 1191 patients, with stone and urine cultures, treated with PCNL for renal calculi were included in the study. Statistical differences were assessed using Mann-Whitney U and T-tests. RESULTS: Stone cultures were positive in 72% of patients with struvite stones. Urea-splitting organisms accounted for only half of the positive stone cultures. Enterococcus (9/50, 18%), Proteus (9/50, 18%), and Escherichia coli (6/50, 12%) were the most commonly identified organisms. Notably, two-thirds of struvite formers with negative stone culture had at least one positive culture for a urea-splitting organism on urine culture going back 1 year from the time of surgery. A majority (67%) of struvite stone cultures were found to be resistant to first- and second-generation cephalosporins. CONCLUSIONS: The bacteriology of struvite stones has shifted away from traditional urea-splitting organisms and antibiotic coverage must be expanded to include organisms such as Enterococcus that do not respond to cephalosporins. Causative organisms may be found by going back in time to identify the initial organism that could have induced struvite stone formation to inform preventative therapy.

Age, Body Mass Index, and Frequency of Sexual Activity are Independent Predictors of Testosterone Deficiency in Men With Erectile Dysfunction.

OBJECTIVES: To identify clinical predictors of testosterone deficiency (TD) in men with erectile dysfunction (ED), thereby identifying subgroups that are most likely to benefit from targeted testosterone screening. METHODS: Retrospective review was conducted on 498 men evaluated for ED between January 2013 and July 2014. Testing for TD by early morning serum measurement was offered to all eligible men. Patients with history of prostate cancer or testosterone replacement were excluded. Univariable linear regression was conducted to analyze 19 clinical variables for associations with serum total testosterone (TT), calculated free testosterone (cFT), and TD (T <300 ng/dL or cFT <6.5 ng/dL). Variables significant on univariable analysis were included in multiple regression models. RESULTS: A total of 225 men met inclusion criteria. Lower TT levels were associated with greater body mass index (BMI), less frequent sexual activity, and absence of clinical depression on multiple regression analysis. TT decreased by 49.5 ng/dL for each 5-point increase in BMI. BMI and age were the only independent predictors of cFT levels on multivariable analysis. Overall, 62 subjects (27.6%) met criteria for TD. Older age, greater BMI, and less frequent sexual activity were the only independent predictors of TD on multiple regression. We observed a 2.2-fold increase in the odds of TD for every 5-point increase in BMI, and a 1.8-fold increase for every 10 year increase in age. CONCLUSIONS: Men with ED and elevated BMI, advanced age, or infrequent sexual activity appear to be at high risk of TD, and such patients represent excellent potential candidates for targeted testosterone screening.