The vasal fluid proteomic profile and microscopic sperm presence at time of vasectomy reversal.

BACKGROUND: The microscopic characteristics of vasal fluid at time of vasectomy reversal (VR) guide operative decision making and predict fertility outcomes. The proteomic profile of this vasal fluid has not been described or correlated with the microscopic fluid appearance. To characterize the vasal fluid proteome at time of VR and evaluate the variation of the vasal fluid proteome with respect to microscopic presence of sperm. METHODS: A prospective cohort study was conducted enrolling twenty-five men undergoing VR for infertility and/or pain at a University-affiliated hospital. Vasal fluid samples obtained at time of VR were grouped based on presence of sperm on light microscopy at time of VR. Proteomic profiles were generated using liquid chromatography/ tandem mass spectrometry, and MS/MS protein spectral counts compared between individuals and treatment groups, controlling for less than 5% protein false discovery rate (FDR). Proteins were matched with the human swissprot database using the Comet search engine, and categorized by Gene Ontology (GO) terms. RESULTS: There was large variability between the 46 vasal fluid samples collected, with 1,692 unique proteins detected. The three most abundant proteins were Lactotransferrin, Cysteine-rich secretory protein 1, A-kinase anchor protein 4. There was no correlation between the proteome and microscopic sperm presence. Prevalent GO terms included viral process, signal transduction, innate immune response, protein folding and spermatogenesis. CONCLUSIONS: We describe the proteome and the most common proteins in vasal fluid at time of VR. Numerable sperm, testis and epididymis specific proteins were present even in the absence of sperm on microscopy. Further evaluation is needed to determine if a protein biomarker may better guide operative decision making and predict VR fertility outcomes.

The safety and efficacy of transurethral microwave therapy in high-risk catheter-dependent men.

OBJECTIVE: Previous studies have demonstrated the efficacy of transurethral microwave therapy (TUMT) in the management of high-risk catheter-dependent men, although few have assessed safety in high-risk patients, including those continuing anticoagulation therapy during treatment. Our goal was to assess the safety and effectiveness of TUMT in a population of high-risk catheter-dependent men. MATERIAL AND METHODS: A retrospective analysis of patients who underwent TUMT at a single Veterans Affairs facility for the treatment of benign prostatic hyperplasia was completed. The primary outcome was 30-day postprocedural complications by Clavien-Dindo grade, including bleeding events. The secondary outcome was success in catheter removal. RESULTS: We performed TUMT in 157 men, 105 of whom had urinary retention-requiring an indwelling urethral catheter or clean intermittent catheterization. Overall, 86% of patients underwent TUMT while on anticoagulant therapy and 25% were treated while taking warfarin. The median age of the patients was 76.9 years (95% CI 74.9-78.8) median ASA-score was 3, and median follow-up was 26 months (range 1-65). Only two men experienced hematuria requiring treatment postoperatively and no transfusions were required. Only two patients (1.9%) required readmission within 30 days after treatment. There were 24 (22.9%) Clavien-Dindo grade I-II complications without grade III or higher complications. Urinary retention resolved in 63.7% of men after treatment. CONCLUSION: Our results suggest that TUMT is a safe and reasonably effective treatment for high-risk catheter-dependent men. Furthermore, the low incidence of adverse bleeding events suggests that TUMT is a safe treatment modality for men requiring uninterrupted anticoagulation.

Unilateral segmental dysplasia of the vas deferens.

A healthy 35-year-old male presented for vasectomy after fathering two children. Due to difficulty palpating the left vas, the patient was taken to the operating room for scrotal exploration and vasectomy. The left vas was absent; however, a 1.2 cm pearly nodule was identified in the scrotum along its suspected course. This nodule was excised, found to contain thick white pasty fluid, and confirmed vas deferens by pathology. The patient was found to have normal kidneys on renal ultrasound and was indeed a carrier for cystic fibrosis gene mutations. We herein discuss management and implications of vasal anomalies.

24 Hour urine metabolic differences between solitary and multiple stone formers: Results of the Collaboration on Urolithiasis in Pediatrics (CUP) working group.

INTRODUCTION: Specific factors associated with the risk of developing pediatric urinary stone disease remain unclear, especially those that may be associated with recurrent stone disease. OBJECTIVE: We compared the results of 24-h urine collections in children with a solitary stone episode to those with multiple stone episodes to determine if there is a difference that may be associated with multiple stone formation in children. STUDY DESIGN: A multi-institutional retrospective analysis was completed to assess 24-h urinary metabolic profiles in children with urolithiasis aged 2-18 years old. Differences in mean urine collections between the two groups were assessed using chi-square tests to test the associations among gender, stone type, and multiple stone status, as well as multivariate analyses using general linear models. RESULTS: We analyzed 142 solitary stone patients and 136 multiple stone patients from four centers were included. Multiple stone patients were older than solitary stone patients (mean 13.4 ± 3.6 years vs. 12 ± 3.9 years, p = 0.002). Females were more likely to have multiple stones (58% vs. 39%, p = 0.002). BMI was not associated with multiple stones (p = 0.8467). Multiple stone formers had lower urine volumes, although this did not reach statistical significance when compared with solitary stone formation (20.4 mL/kg/day ± 11.5 vs. 22.9 ± 13.0, p = 0.0880). Higher values for super-saturation of calcium oxalate were associated with multiple stone disease in univariate (p = 0.0485) and multivariate analysis (p = 0.0469) (Figure). Centers located in the Southeast of the United States saw a higher proportion of children with multiple stones (Tennessee 62.7%, Virginia 44.4%, Oregon 31.6%, Michigan 27.3%, p < 0.0001). DISCUSSION: In a large multi-institutional retrospective analysis we found that multiple stone disease was associated with higher super-saturations of calcium oxalate. Many urinary parameters changed with patient age, highlighting that the values should be interpreted with respect to patient age. The inability to comment on follow-up because of the nature of our dataset is a limitation of this study. CONCLUSION: Multiple stone disease in children is associated with higher super-saturation calcium oxalate, while lower urinary volume may also be associated with multiple stones; however, further study is required. Early metabolic evaluation may help risk stratify children likely to form multiple stones.

Advances in understanding and treating premature ejaculation.

Over the past several years, many advances have been made in our understanding of the epidemiology, pathophysiology, and management of premature ejaculation. Newly developed definitions of premature ejaculation are now available, and our perception of the classification, prevalence, aetiological factors, and treatment options for premature ejaculation have evolved. Despite ongoing research, there remains much to be learned about all aspects of this common sexual disorder, in particular effective clinical diagnosis and treatment options.

Erectile Function Outcomes after Robot-Assisted Radical Prostatectomy: Is It Superior to Open Retropubic or Laparoscopic Approach?

INTRODUCTION: Erectile dysfunction (ED) is one of the most commonly affected domains of health-related quality of life after prostate cancer therapy. Functional outcomes after radical prostatectomy (RP) have continued to improve through refinement of surgical techniques and development of several procedural modifications. In this context, it has been hypothesized that robotic technologies should simplify the preservation of the neurovascular bundle, thus possibly providing improved functional outcomes. AIM: To compare the prevalence of post-RP ED and identify whether recently developed robotic technologies are able to improve erectile function (EF) recovery after RP. METHODS: Literature Review. MAIN OUTCOME MEASURE: To evaluate whether post-therapy ED rates after robotic surgery have shown improvement when compared with the other forms of nerve-sparing RP. RESULTS: Previously published series have shown EF recovery rates after robot-assisted RP (RARP) ranging between 40% and 90% of patients at 12 months, postoperatively. Some claim that the RARP procedure can also significantly shorten recovery time in return of EF when compared with open RP. On the other hand, some authors have reported that patients undergoing minimally invasive RP have experienced even more ED on comparison. CONCLUSIONS: Although it has been widely promoted by the industry and hospitals, at the moment there are not enough evidence-based data to answer the question, "Does RARP surgery provide better EF outcomes?." Because of the current market trends and patient preferences, the perfect randomized study will probably never be performed, and thus the question of which procedure's results are superior will most likely remain unanswered. Isgoren AE, Saitz TR, and Serefoglu EC. Erectile function outcomes after robot-assisted radical prostatectomy: Is it superior to open retropubic or laparoscopic approach? Sex Med Rev 2014;2:10-23.

Side Effects of 5-Alpha Reductase Inhibitors: A Comprehensive Review.

INTRODUCTION: 5α-reductase inhibitors (5ARI) include finasteride and dutasteride, and are commonly prescribed in the treatment of benign prostatic hyperplasia and androgenic alopecia. 5ARIs are associated with several known adverse effects (AEs), with varying reported prevalence rates. AIM: The aim was to review and summarize findings from published literature detailing AEs associated with 5ARI use. A secondary aim was to review potential mechanisms of action, which may account for these observed and reported AEs. METHODS: A PubMed search was conducted on articles published from 1992 to 2012, which reported AEs with 5ARIs. Priority was given to randomized, placebo-controlled trials. Studies investigating potential mechanisms of action for 5ARIs were included for review. MAIN OUTCOME MEASURES: AE data reported from available trials were summarized and reviewed. RESULTS: Reported AEs with 5ARIs include sexual dysfunction, infertility, mood disorders, gynecomastia, high-grade prostate cancer, breast cancer, and cardiovascular morbidity/risk factors, although their true association, prevalence, causality, and clinical significance remain unclear. A pooled summary of all randomized, placebo-controlled trials evaluating 5ARIs (N = 62,827) revealed slightly increased rates over placebo for decreased libido (1.5%), erectile dysfunction (ED) (1.6%), ejaculatory dysfunction (EjD) (3.4%), and gynecomastia (1.3%). The limited data available on the impact of 5ARIs on mood disorders demonstrate statistically significant (although clinically minimal) differences in rates of depression and/or anxiety. Similarly, there are limited reports of reversible, diminished fertility among susceptible individuals. Post-marketing surveillance reports have questioned the actual prevalence of AEs associated with 5ARI use and suggest the possibility of persistent symptoms after drug discontinuation. Well-designed studies evaluating these reports are needed. CONCLUSIONS: 5ARIs are associated with slightly increased rates of decreased libido, ED, EjD, gynecomastia, depression, and/or anxiety. Further studies directed at identifying prevalence rates and persistence of symptoms beyond drug discontinuation are required to assess causality. Trost L, Saitz TR, and Hellstrom WJG. Side effects of 5-alpha reductase inhibitors: A comprehensive review. Sex Med Rev 2013;1:24-41.

Induction of cold ischemia in patients with solitary kidney using retrograde intrarenal cooling: 2-year functional outcomes.

PURPOSE: Renal hypothermia is commonly utilized during nephron sparing surgery to minimize ischemic tissue damage. We propose a method to induce renal hypothermia using continuous retrograde irrigation of iced saline via dual-lumen ureteral catheter. We will report results in an ex vivo porcine model followed by clinical outcomes in a series of patients with solitary kidney undergoing robotic-assisted laparoscopic partial nephrectomy (RALPN). MATERIALS AND METHODS: First, we performed temperature measurements during retrograde renal cooling in a porcine model before investigating the technique in humans. In porcine experiments, renal cortical temperature measurements (n = 270) were recorded during retrograde infusion of ice-cold saline via a 10-Fr dual-lumen ureteral catheter placed in ureter. Subsequently, a series of patients (n = 10) undergoing RALPN with a solitary kidney had concomitant intra-operative retrograde renal cooling. A 10-Fr dual-lumen ureteral catheter was placed at initiation of anesthesia and cold saline initiated prior to renal artery clamping. RESULTS: Porcine cortical temperature reached the target temperature (≤20 °C) within an average of 203 s of retrograde irrigation. In the clinical series, patients' mean preoperative creatinine was 1.16 mg/dL (GFR = 60). At a median follow-up of 10 months (range 1-27 months), postoperative creatinine was 1.50 mg/dL (GFR = 41.28). Average clamp time was 19.4 min. All patients had negative surgical margins. CONCLUSIONS: Retrograde irrigation is a technically feasible method to induce cold ischemia, which may provide an additional protective effect of renal function in patients who have a solitary kidney undergoing surgery via a minimally invasive approach.

Premature ejaculation: do we have effective therapy?

INTRODUCTION: Premature ejaculation (PE) is the most common sexual dysfunction, with the majority of PE patients remaining undiagnosed and undertreated. Despite its prevalence, there is a current paucity of data regarding available treatment options and mechanisms. The objective of the current investigation is to review and summarize pertinent literature on therapeutic options for the treatment of PE, including behavioral/psychologic, oral pharmacotherapy, and surgery. METHODS: A pubmed search was conducted on articles reporting data on available treatment options for PE. Articles describing potential mechanisms of action were additionally included for review. Preference was given towards randomized, controlled trials, when available. RESULTS: PE remains an underdiagnosed and undertreated disease process, with limited data available regarding potential underlying mechanisms and long-term outcomes of treatment options. Psychological/behavioral therapies, including the stop-start, squeeze, and pelvic floor rehabilitation techniques have demonstrated improvements in short-term series, with decreased efficacy with additional follow-up. Topical therapies, which are commonly utilized result in prolonged intravaginal ejaculatory latency time (IELT) at the expense of potential penile/vaginal Hypothesia. Oral therapies similarly demonstrate improved IELTs with variable side effect profiles and include selective serotonin reuptake inhibitors (daily or on demand), phosphodiesterase-5 inhibitors, alpha-1 adrenergic antagonists, and tramadol. Alternative therapies such as acupuncture have shown benefits in limited studies. Surgery is not commonly performed and is not recommended by available guidelines. CONCLUSIONS: PE is a common condition, with limited data available regarding its underlying pathophysiology and treatment. Available therapies include topical, oral, behavioral/psychologic modification, or a combination thereof. Additional research is required to assess the optimal treatment strategies and algorithms as well as to better define the mechanisms for PE and its management.

New insights on premature ejaculation: a review of definition, classification, prevalence and treatment.

There are ongoing debates about the definition, classification and prevalence of premature ejaculation (PE). The first evidence-based definition of PE was limited to heterosexual men with lifelong PE who engage in vaginal intercourse. Unfortunately, many patients with the complaint of PE do not meet these criteria. However, these men can be diagnosed as one of the PE subtypes, namely acquired PE, natural variable PE or premature-like ejaculatory dysfunction. Nevertheless, the validity of these subtypes has not yet been supported by evidence. The absence of a universally accepted PE definition and lack of standards for data acquisition have resulted in prevalence studies that have reported conflicting rates. The very high prevalence of 20%-30% is probably due to the vague terminology used in the definitions at the time when such surveys were conducted. Although many men may complain of PE when questioned for a population-based prevalence study, only a few of them will actively seek treatment for their complaint, even though most of these patients would define symptoms congruent with PE. The complaints of acquired PE patients may be more severe, whereas complaints of patients experiencing premature-like ejaculatory dysfunction seem to be least severe among men with various forms of PE. Although numerous treatment modalities have been proposed for management of PE, only antidepressants and topical anaesthetic creams have currently been proven to be effective. However, as none of the treatment modalities have been approved by the regulatory agencies, further studies must be carried to develop a beneficial treatment strategy for PE.