Assessment of Effectiveness and Safety of Aspiration-Assisted Nephrostomic Access Sheaths in PCNL and Intrarenal Pressures Evaluation: A Systematic Review of the Literature.

Background: Different suction-assisted nephrostomic sheaths have been developed for percutaneous nephrolithotomy (PCNL). Objectives: (1) To examine PCNL techniques performed with different aspiration-assisted sheaths (Clear Petra® sheath, Superperc, SuperminiPCNL, and a miniPCNL patented sheath), with specific regard to effectiveness and safety outcomes in adult and paediatric patients; (2) to extrapolate intrarenal pressure (IRP) data during these procedures. Methods: A systematic literature search was performed in accordance with PRISMA guidelines. Relevant articles up to 8 February 2024 were included. Results: Twenty-five studies were selected, thirteen retrospective and twelve prospective. The use of four different aspirating sheaths for miniPCNL was reported: Clear Petra® sheath, Superperc, SuperminiPCNL, and a miniPCNL patented sheath. Stone free rates (SFRs) across techniques ranged from 71.3% to 100%, and complication rates from 1.5% to 38.9%. Infectious complication rates varied from 0 to 27.8% and bleeding complication rates from 0 to 8.9%. Most complications were low grade ones. The trend among studies comparing aspiration- and non-aspiration-assisted miniPCNL was towards equivalent or better SFRs and lower overall infectious and bleeding complication rates in suction techniques. Operation time was consistently lower in suction procedures, with a mean shortening of the procedural time of 19 min. Seven studies reported IRP values during suction miniPCNL. Two studies reported satisfactory SFRs and adequate safety profiles in paediatric patient cohorts. Conclusions: MiniPCNL with aspirating sheaths appears to be safe and effective in both adult and paediatric patients. A trend towards a reduction of overall infectious and bleeding complications with respect to non-suction procedures is evident, with comparable or better SFRs and consistently shorter operative times. The IRP profile seems to be safe with the aid of aspirating sheaths. However, high quality evidence on this topic is still lacking.

Infertile men with semen parameters above WHO reference limits at first assessment may deserve a second semen analysis: Challenging the guidelines in the real-life scenario.

OBJECTIVES: To investigate which infertile men with semen parameters above WHO reference limits at first semen analysis deserve a second semen test. MATERIALS AND METHODS: Data from 1358 consecutive infertile men were analysed. Patients underwent two consecutive semen analyses at the same laboratory. Descriptive statistics and logistic regression models tested the association between clinical variables and semen parameters. A new predicting model was identified through logistic regression analysis exploring potential predictors of semen parameters below WHO reference limits after a previously normal one. Diagnostic accuracy of the new model was compared with AUA/ASRM and EAU guidelines. Decision curve analyses (DCA) tested their clinical benefit. RESULTS: Of 1358, 212 (15.6%) infertile men had semen parameters above WHO reference limits at first analysis. Of 212, 87 (41.0%) had a second semen analysis with results above WHO reference limits. Men with sperm parameters below reference limits at second analysis had higher FSH values, but lower testicular volume (TV) (all p<0.01) compared to men with a second semen analysis above WHO limits. At multivariable logistic regression analysis, lower TV (OR 0.9, p = 0.03), higher FSH (OR 1.2, p<0.01), and lower total sperm count (OR 0.9, p<0.01) were associated with second semen analyses below WHO limits. DCA showed the superior net benefit of using the new model, compared to both AUA/ASRM and EAU guidelines to identify those men with a second semen sample below WHO limits after a previously normal one. CONCLUSIONS: Approximately 60% of infertile men with a first semen analysis above WHO limits have a second analysis with results below limits. The newly identified risk model might be useful to select infertile men with initial semen results above WHO limits who deserve a second semen analysis.

Medications mostly associated with priapism events: assessment of the 2015-2020 Food and Drug Administration (FDA) pharmacovigilance database entries.

A range of drugs have a direct role in triggering ischaemic priapism. We aimed at identifying: a) which medications are associated with most priapism-reports; and, b) within these medications, comparing their potential to elicit priapism through a disproportionality analysis. The FDA Adverse Event Reporting System (FAERS) database was queried to identify those drugs associated the most with priapism reports over the last 5 years. Only those drugs being associated with a minimum of 30 priapism reports were considered. The Proportional Reporting Ratios (PRRs), and their 95% confidence intervals were computed. Out of the whole 2015-2020 database, 1233 priapism reports were identified, 933 of which (75.7%) were associated with 11 medications with a minimum of 30 priapism-reports each. Trazodone, olanzapine and tadalafil showed levels of disproportionate reporting, with a PRR of 9.04 (CI95%: 7.73-10.58), 1.55 (CI95%: 1.27-1.89), and 1.42 (CI95%: 1.10-1.43), respectively. Most (57.5%) of the reports associated with the phosphodiesterase type 5 inhibitors (PDE5Is) were related with concomitant priapism-eliciting drugs taken at the same time and/or inappropriate intake/excessive dosage. Patients taking trazodone and/or antipsychotics need to be aware of the priapism-risk; awareness among prescribers would help in reducing priapism-related detrimental sequelae; PDE5I-intake is not responsible for priapism by itself, when appropriate medical supervision is provided.

Varicocoele embolization with sclerosing agents leads to lower radiation exposure and procedural costs than coils: Data from a real-life before and after study.

OBJECTIVES: To investigate clinical outcomes, radiation exposure and procedural costs associated with percutaneous varicocoele embolization using coils and sclerosing agents (SAs) in a cohort of young-adult men. MATERIALS AND METHODS: Data from consecutive men treated with percutaneous varicocoele embolization using coils and SA between 2017 and 2021 were analyzed. The allocation was based on a change of policy occurred in June 2020 with the substitution of coils with SA (before and after study). Semen analysis values were based on 2010 WHO reference criteria. Anatomic variants of gonadal veins were categorized according to Jargiello et al. Intraoperative radiation dose and procedural costs were collected for each patient. Descriptive statistics and linear regression models were used to describe the association between clinical parameters with procedural costs and radiation exposure. RESULTS: One hundred sixteen men were included, of whom 76 (65.5%) received coils, and 40 (34.5%) received SA. Baseline characteristics of the two study groups did not differ. A type 3 Jargiello anatomic variation of left gonadal vein was found in 45.7% of cases. Radiation dose was lower in the SA group as compared to the coils one (13.2 [7-43] vs. 19.8 [12-57] Gy/cm2 ; p < 0.001). Similarly, procedural costs were lower for the SA group (169.6 [169-199] € vs. 642.5 [561-775] €; p < 0.001). At follow-up, pain and sperm variables significantly improved in both groups (p < 0.01), without differences among the embolic materials. Linear regression model revealed that coils use was associated with higher radiation exposure (beta 8.8, p = 0.02) than SA after accounting for anatomic variation of gonadal vein, body mass index, and vascular access. CONCLUSIONS: SA and coils for varicocoele embolization are equally safe and effective. The use of SA was associated with lower radiation exposure and procedural costs than coils. These results should be considered in terms of public health cost and patient's safety.

Cost analysis between mini-percutaneous nephrolithotomy with and without vacuum-assisted access sheath.

PURPOSE: To perform a cost analysis between vacuum-assisted percutaneous nephrolithotomy (vmPCNL) and minimally invasive PCNL (MIP) and explore potential predictors of costs associated with the procedures. METHODS: We analyzed data from 225 patients who underwent vmPCNL or MIP at a single tertiary referral academic center between January 2016 and December 2020. We collected patients' demographics, peri-and postoperative data and detailed expense records. After propensity score matching, 108 (66.7%) vmPCNL and 54 (33.3%) MIP procedures were analyzed. Descriptive statistics assessed differences in clinical and operative parameters. Univariable and multivariable linear regression models tested the association between clinical variables and costs. RESULTS: Operative time (OT) was shorter for vmPCNL, and the use of additional instruments to complete litholapaxy was more frequent in MIP (all p ≤ 0.01). Length of stay (LOS) was longer for MIP patients (p = 0.03) and the stone-free (SF) rate was higher after vmPCNL (p = 0.04). The overall instrumentation cost was higher for vmPCNL (p < 0.001), but total procedural costs were equivalent (p = 0.9). However, the overall cost for the hospitalization was higher for MIP than vmPCNL (p = 0.01). Univariable linear regression revealed that patient's comorbidities, OT, any postoperative complication and LOS were associated with hospitalization costs (all p < 0.001). Multivariable linear regression analysis revealed that LOS and OT were associated with hospitalization costs (all p < 0.001), after accounting for vmPCNL procedure, patients' comorbidities, and complications. CONCLUSION: vmPCNL may represent a valid option due to clinical and economic benefits. Shorter OT, the lower need for disposable equipment and the lower complication rate reduced procedural and hospitalization costs.

Extensive Assessment of Underlying Etiological Factors in Primary Infertile Men Reduces the Proportion of Men With Idiopathic Infertility.

Objective: Up to 40% of infertile men remain without a recognized cause (i.e., idiopathic infertility). We aimed to identify, categorize, and report the supposed causes of male infertility in a cohort of white-European men presenting for primary couple's infertility, by using a thorough and extensive baseline diagnostic work-up. Material and Methods: Cross-sectional study of 1,174 primary infertile men who underwent a thorough diagnostic work-up including: detailed medical history, physical examination, hormonal assessment, genetic testing, semen analyses; semen and urine cultures; testis color Duplex US. Men without any identified causal factor were considered as idiopathic. Six different etiological categories were established, and their prevalence was estimated. Logistic regression models estimated the risk of missing causal identification. Results: A possible causal factor was identified in 928 (81%) men. Hypogonadism was the most frequent identified cause (37%), followed by varicocele (27%). Genetic abnormalities were found in 5% of patients. A causal factor was more easily identifiable for the more severe infertility cases, and azoospermic men were those less likely to be defined as idiopathic (OR and 95% CIs: 0.09; 0.04-0.20). Relative proportion of identified causes remained constant during the 10-year study period (p>0.43). Conclusions: Due to a more comprehensive and extensive diagnostic work-up, at least one underlying cause of male infertility factor in 4 out of 5 infertile men can be identified. Men with a less severe phenotype remain a clinical challenge in terms of establishing a possible etiologic factor. Further studies are needed to assess which subset of infertile men deserves a more extensive work-up.

Incidence and predictors of readmission within 30 days of transurethral resection of the prostate: a single center European experience.

Hospital readmission rates have been analyzed due to their contribution to increasing medical costs. Little is known about readmission rates after urological procedures. We aimed to assess the incidence and predictors of 30-day readmission after discharge in patients treated with transurethral resection of the prostate (TURP). Data from 160 consecutive patients who underwent TURP from January 2015 to December 2016 were analysed. Intra hospitalization characteristics included length of stay (LOS), catheterization time (CT) and complications. Comorbidities were scored with the Charlson Comorbidity Index (CCI). Mean (SD) age was 70.1 (8.1) yrs and mean prostate volume was 80 (20.1) ml. Mean LOS and CT were 4.9 (2.5) days and 3.3 (1.6) days, respectively. The overall 30-day readmission rate was 14.4%, but only 7 (4.4%) patients required hospitalization. The most frequent reasons for readmission were haematuria (6.8%), fever/urinary tract infections (4.3%) and acute urinary retention (3.1%). Multivariable logistic regression analysis revealed age, CCI and CT to be independent predictors of readmission. However, when analysed according to age at the time of surgery, a beneficial effect from longer CT was observed only for patients older than 75 years. These parameters should be taken in account at the time of discharge after TURP.

Male infertility as a proxy of the overall male health status.

INTRODUCTION: Male infertility (MI) has been widely associated with different comorbid conditions. The aim of this review is to summarize the available evidences investigating the link between MI cancer, chronic non-malignant conditions and overall health. EVIDENCE ACQUISITION: A literature search has been conducted using the MEDLINE/PubMed and Scopus databases for English-language original and review articles and selecting publications from January 2007 to June 2017, although highly regarded older publications were also considered. The following key words and MeSH terms were combined: "male infertility," "semen analysis," "health," "comorbidities," "cancer," "metabolic syndrome," "diabetes," "hypertension," "cardiovascular diseases," and "mortality." EVIDENCE SYNTHESIS: Several studies supported a higher risk of testis cancer for patients with MI; conversely, controversial findings have been reported on the association between prostate cancer and MI. Beside urogenital malignancies, melanoma, bladder, thyroid and hematological malignancies have been also more frequently reported among infertile men. Large cohort studies supported a significant association between diabetes mellitus, metabolic disorders and MI. Similarly, the risk of developing cardiovascular diseases appears to be higher among infertile men. Of note, a significant association between semen alterations and the overall burden of comorbidities, as well as the overall mortality, has been reported. A common genetic background appears as the main pathophysiological link between infertility and other comorbidities. CONCLUSIONS: Male infertility is a proxy of the overall male health status. Physicians should comprehensively assess men presenting for couple infertility and properly followed-up these patients given their higher risk of developing cancer.

Metabolic syndrome in White-European men presenting for secondary couple's infertility: an investigation of the clinical and reproductive burden.

We aimed to determine the impact of metabolic syndrome (MetS) on reproductive function in men with secondary infertility, a condition that has received relatively little attention from researchers. Complete demographic, clinical, and laboratory data from 167 consecutive secondary infertile men were analyzed. Health-significant comorbidities were scored with the Charlson Comorbidity Index (CCI; categorised 0 vs 1 vs 2 or higher). NCEP-ATP III criteria were used to define MetS. Semen analysis values were assessed based on the 2010 World Health Organization (WHO) reference criteria. Descriptive statistics and logistic regression models tested the association between semen parameters and clinical characteristics and MetS. MetS was found in 20 (12%) of 167 men. Patients with MetS were older (P < 0.001) and had a greater BMI (P < 0.001) compared with those without MetS. MetS patients had lower levels of total testosterone (P = 0.001), sex hormone-binding globulin, inhibin B, and anti-Mόllerian hormone (all P ≤ 0.03), and they were hypogonadal at a higher prevalence (P = 0.01) than patients without MetS. Moreover, MetS patients presented lower values of semen volume, sperm concentration, and sperm normal morphology (all P ≤ 0.03). At multivariate logistic regression analysis, no parameters predicted sperm concentration, normal sperm morphology, and total progressive motility. Our data show that almost 1 of 8 White-European men presenting for secondary couple's infertility is diagnosed with MetS. MetS was found to be associated with a higher prevalence of hypogonadism, decreased semen volume, decreased sperm concentration, and normal morphology in a specific cohort of White-European men.