Distribution and Positive Predictive Value of Follicle Stimulating Hormone Levels Among Nonazoospermic Men.

PURPOSE: Our goal was to characterize the distribution of follicle stimulating hormone (FSH) in fertile and subfertile nonazoospermic men, and to determine the ability of various FSH thresholds to predict fertility status. MATERIALS AND METHODS: We performed a retrospective cohort study of 1389 nonazoospermic men who presented for fertility evaluation. Men with at least 2 semen analyses and 1 FSH level were included. Men were dichotomized into fertile and subfertile groups based on total motile sperm count. FSH was evaluated within a multivariable model, and positive predictive values (PPVs) for subfertility were used to assess the clinical utility of various FSH thresholds. RESULTS: One thousand fifteen (80%) men were classified as fertile and 274 (20%) as subfertile. Age, presence of varicocele, and testosterone levels were not statistically different between the groups. Median FSH was 4.0 vs 6.0 (P < .001) among fertile vs subfertile men. Multiple FSH thresholds ranging from 2.9 to 9.3 performed similarly in predicting fertility status (PPV 0.49-0.59). Only FSH thresholds above the 95th percentile (12.1) had PPVs greater than 0.7. The highest PPV (0.84) was seen at an FSH of 20.8 (99th percentile). CONCLUSIONS: While there were significant differences in FSH levels among fertile and subfertile nonazoospermic men, multiple FSH cutoffs between 2.2 and 9.3 performed poorly for prediction of fertility status as determined by total motile sperm count. It was not until the 95th percentile FSH value that a clinically useful level of predictability for subfertility was reached, indicating that FSH should not be used as a standalone test of fertility status. Nonetheless, FSH testing remains clinically useful and may be most informative in the setting of extreme values or discordant FSH and semen analysis results.

Variations in Low Intensity Shockwave Treatment Protocols for Erectile Dysfunction: A Review of the Literature and Guide to Offering Treatment.

Low-intensity shockwave therapy (LiSWT) for erectile dysfunction (ED) continues to gain popularity in both clinical practice and the academic literature. The majority of trials and meta-analysis studies have shown LiSWT to be low risk with a trend toward positive improvements in International Index of Erectile Function (IIEF) scores. However, there is still debate over the clinical utility of LiSWT and there is no agreed upon optimal treatment protocol. In this review article we summarize published meta-analysis studies of LiSWT for ED, and review the treatment protocols from randomized sham-control trials published in the last 10 years. We found the most common device settings were an energy of 0.09 mJ/mm² and a frequency of 5 Hz. Shock number and location varied, but the most common protocol was 1,500 shocks per session, with 900 shocks to the penis (shaft, base, or hilum) and 600 shocks to the proximal corpora/crura. Protocols ranged from 4 to 12 treatment sessions. We also describe our institutional experience with LiSWT, including patient counseling and treatment protocol.

Assessing the Prevalence of Low Testosterone and Elevated Follicle Stimulating Hormone Among Men Presenting for Fertility Evaluation Without Oligospermia.

OBJECTIVE: To compare the prevalence of abnormal hormone parameters among men with and without oligospermia to determine the value of universal hormonal screening during initial fertility evaluation. MATERIALS AND METHODS: We retrospectively evaluated men who underwent semen analysis and hormonal evaluation (morning testosterone [T] and follicle-stimulating hormone [FSH]) between January 2002 and May 2021. Sperm concentration was dichotomized at 15 million/mL according to World Health Organization (WHO) criteria. We compared median and interquartile range (IQR) T and FSH levels according to sperm concentration using Kruskal-Wallis test. Differences in prevalence of low testosterone (<300 ng/dL) and abnormal FSH (>7.6mIU/mL) were determined using chi-square test. RESULTS: 1164 men had a morning serum T. There was no difference in median T among men with normal vs abnormal sperm concentration (316 ng/dL, IQR 250-399 vs 316 ng/dL, IQR 253-419; P = .52). FSH was measured in 1261 men. Median FSH was higher among men with sperm concentration <15 million/mL (6.0IU/mL, IQR 3.9-10.7 vs 3.8IU/mL, IQR 2.7-5.7; P < .001). Among men with ≥15 million/mL concentration, 44.1% were found to have low T (P = .874) and 10.8% had an FSH ≥7.6 mIU/mL (P < .001). Among men with ≥15 million/mL sperm concentration who underwent both T and FSH evaluation, 43.6% had at least 1 hormonal abnormality. CONCLUSION: Almost half of men with normal sperm concentration had low T. As low T may have long-term implications for both fertility and overall health, providers should consider universal T screening in men presenting for fertility evaluation.

Ring Flap Metoidioplasty.

OBJECTIVE: To describe our technique for performing ring flap metoidioplasty in transgender men. METHODS: In a ring flap metoidioplasty, the urethra is created from bilateral anteriorly based labia minora and vestibular flaps. This technique is combined with Ghent scrotoplasty, vaginectomy (distal mucosal excision and proximal mucosal fulguration followed by cavity closure) and perineal masculinization. Suprapubic tube is placed for urinary diversion. To avoid disrupting the anteriorly based urethral pedicles, we do not perform monsplasty, division of the suspensory ligament, or resection of the labial folds adjacent to the penis at the time of ring flap metoidioplasty. Typically, resection of labial folds adjacent to the penis and testicular prosthesis insertion are performed 4-6 months after metoidioplasty. RESULTS: From November 2017 to June 2021, 52 patients underwent metoidioplasty with urethroplasty and concomitant vaginectomy by two surgeons (BF, MC). Median age was 30 years, and median follow-up was 22 months. Urethrocutaneous fistula developed in 7 (13%) patients, 1 of whom had spontaneous closure of the fistula. Urethral stricture occurred in 4 (8%) patients. Fistula repair and/or urethroplasty was required in 8 (15%) patients. Non urethral complications included bacteremia (1 patient) and venous thromboembolism (1 patient). CONCLUSION: Ring flap metoidioplasty allows select patients to obtain masculine appearing genitals and the ability to void standing.

Orchidopexy and Split-thickness Skin Graft for Scrotal Defects After Necrotizing Fasciitis.

OBJECTIVE: To demonstrate a technique for performing orchidopexy and split-thickness skin graft for patients with deficient scrotal skin after debridement for Fournier's gangrene. This is an alternative strategy to healing by secondary intention, flaps, or testicular thigh pouches. METHODS: Orchidopexy was performed after initial debridement using interrupted Vicryl sutures to bring the testicles and inferior penis together. During this procedure, the testicles and spermatic cord were mobilized, and redundant spermatic cord was coiled under the abdominal wall. Once patients were medically stable with no additional planned debridement, a split-thickness skin graft at a depth of 18/1000 inch and meshed 2:1 was applied to the scrotum. The graft was covered with a bolster dressing that was sutured to the scrotum for 5 to 7 days. An inpatient stay was not required after skin graft and bolster placement. Patients were evaluated for cosmetic appearance, pain, and need for revision. RESULTS: From 2017-2021, 10 patients underwent orchiopexy and split-thickness skin graft to the scrotum. Etiology of Fournier's gangrene included diabetes (5), urethral stricture (2), alcohol abuse (2), unknown (1). Median age was 56 years and median BMI was 30 kg/m2. Median length of stay after orchidopexy and skin graft were 18 and 9 days respectively. At a median follow-up of 8 months, there were no issues with chronic pain, discomfort, or need for further intervention. CONCLUSION: Orchidopexy and split-thickness skin graft to scrotum is a feasible method of scrotal reconstruction that leads to acceptable clinical and cosmetic results, and does not result in prolonged inpatient hospitalization. Future research should focus on long term sexual function and quality of life outcomes.

Surgically Extracted Epididymal Sperm from Men with Obstructive Azoospermia Results in Similar In Vitro Fertilization/Intracytoplasmic Sperm Injection Outcomes Compared with Normal Ejaculated Sperm.

PURPOSE: Controversy exists around the use of epididymal sperm for in vitro fertilization and intracytoplasmic sperm injection for couples with obstructive azoospermia, and the ability to reliably predict fertility outcomes with surgically extracted epididymal sperm remains limited. To provide additional clinical context, we sought to compare in vitro fertilization/intracytoplasmic sperm injection outcomes of epididymal sperm from couples with obstructive azoospermia to outcomes of couples using normal, ejaculated sperm. MATERIALS AND METHODS: We performed a case-control analysis of 40 couples who underwent office based epididymal sperm retrieval for obstructive azoospermia followed by in vitro fertilization/intracytoplasmic sperm injection compared with a control group of 38 female, age matched couples with no evidence of female factor infertility who underwent in vitro fertilization/intracytoplasmic sperm injection with normal, ejaculated sperm. Primary outcome was live birth on the initial embryo transfer. RESULTS: Epididymal samples yielded a median total motile sperm count of 9.1 million, compared to 81 million for ejaculated sperm. On the primary embryo transfer fertilization rate (71% vs 77%, p=0.2), blastulation rate (48% vs 59%, p=0.09), clinical pregnancy rate (70% vs 58%, p=0.4), and live birth rate (58% vs 47%, p=0.4) did not differ between epididymal and ejaculated sperm groups. CONCLUSIONS: For couples with a male partner with obstructive azoospermia epididymal sperm in vitro fertilization/intracytoplasmic sperm injection outcomes compare similarly with age matched controls undergoing in vitro fertilization/intracytoplasmic sperm injection using normal, ejaculated sperm. These results may help reproductive surgeons provide reassurance about the use of obstructed epididymal sperm as well as help guide discussions about anticipated outcomes of in vitro fertilization/intracytoplasmic sperm injection.

Challenging Ethical Scenarios in the Surgical Treatment of Erectile Dysfunction: A Survey of High-Volume Penile Prosthesis Surgeons.

OBJECTIVE: To investigate how surgeons approach ethically challenging scenarios that arise in penile prosthesis surgery and identify patient-related factors that impact their approach. METHODS: A survey was distributed to the Society for Urologic Prosthetic Surgeons membership consisting of 6 ethically challenging scenarios: an HIV+ patient, a patient with cognitive disability, a registered sex offender, a nonverbal patient, a litigious patient, and an uncontrolled diabetic patient whose insurance will lapse soon. Additional clinical information was provided to assess how the likelihood to offer surgery might change. The primary outcome was the likelihood of offering surgery in each scenario. RESULTS: The response rate was 15.6% (n = 29). When compared to the baseline patient, respondents had a lower likelihood of offering surgery in all scenarios except the HIV+ patient, with the lowest likelihood of offering surgery to a sex offender (P < .01). Within each scenario, factors associated with an increased odds of offering surgery included knowledge that a patient with Down Syndrome is high functioning (odds ratio [OR] 5.0, confidence interval [CI]: 1.4-17.8), that a prior sex offender is currently married (OR 16.5, CI:3.5-99.8), that a litigious patient sued a surgeon for a retained sponge (OR 6.3, CI:1.7-24.3), and that a nonverbal patient had expressed prior interest in penile prosthesis surgery (OR 4.5, CI: 1.3-16.2). CONCLUSION: Ethical principles, including respect for autonomy, nonmaleficence, beneficence, and justice, are appropriately applied by urological prosthetic surgeons when ethical challenges arise. While the likelihood of offering penile prosthesis surgery is decreased with most ethical dilemmas, specific clinical factors often augment decision-making.

Is the relative value of surgeon effort equal across surgical specialties?

BACKGROUND: Although relative value units are used to measure physician productivity, research has demonstrated incongruencies between relative value units and actual surgeon work effort. We sought to determine whether this variation extends across surgical specialties. METHODS: A retrospective review of surgical cases was conducted using the 2017 American College of Surgeons National Surgical Quality Improvement Program database. For each case, we identified the primary Current Procedural Terminology, surgical specialty, total relative value units, and 5 alternative measures of work effort. We then examined the correlation between a Current Procedural Terminology's mean total relative value unit and work effort. Finally, we constructed a multivariable linear regression model to evaluate the association between surgical specialty and the expected mean total relative value unit adjusting for work effort and patient characteristics. RESULTS: A total of 876,515 cases met the inclusion criteria. Overall, median operative time correlated well with mean total relative value unit (R = 0.85), though it was lowest for cardiac surgery (R = 0.51) and highest for otolaryngology (R = 0.97). Neurosurgery had the greatest increase in mean total relative value unit per hour of operative time (12.9/h). Mean total relative value unit correlated modestly with length of stay (R = 0.58) and serious adverse events (R = 0.61) and weakly with readmission (R = 0.42) and mortality (R = 0.29). When holding these metrics constant, the multivariable model showed mean total relative value units differed according to surgical specialty alone. Compared with general surgery, neurosurgery and cardiac surgery earned 3.41 to 3.61 additional mean total relative value units (P < .05), while orthopedics, otolaryngology, thoracic, urology, and vascular surgery received fewer mean total relative value units (-1.84 to -4.43, P < .05). CONCLUSION: Surgeon productivity is increasingly measured using relative value units. While mean total relative value units correlate well with operative time, they may not reflect other aspects of work effort. Differences in mean total relative value units by surgical specialty demonstrate potential inequities in the determination of physician productivity.

Sperm Extraction in Obstructive Azoospermia: What's Next?

For men with obstructive azoospermia, several surgical sperm retrieval techniques can facilitate conception with assisted reproductive technology. The evolution of both percutaneous and open approaches to sperm retrieval has been affected by technological innovations, including the surgical microscope, in vitro fertilization, and intracytoplasmic sperm injection. Further modifications to these procedures are designed to minimize patient morbidity and increase the quality and quantity of sperm samples. Innovative technologies promise to further ameliorate outcomes by selecting the highest quality sperm. Although various approaches to surgical sperm retrieval are now well established, several advancements in sperm selection and optimization are being developed.

Correlation of Relative Value Units With Surgical Complexity and Physician Workload in Urology.

OBJECTIVE: To define the relationship between urology relative value units (RVUs) and measures of surgical complexity and physician workload. Secondary objectives include: (1) identifying procedures with outlying RVU values for their measures of surgical complexity and workload; and (2) calculating projected RVU values for these procedures. METHODS: We obtained surgical case data for 71 urology current procedural terminology (CPT) codes from the 2017 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Pearson correlation coefficients were calculated to measure the association between mean total work RVU and operative time, length of hospital stay, serious adverse events, readmissions, and mortality. We developed a multivariable regression model to predict mean total work RVU from these measures. Studentized residuals were used to identify outlying CPT codes for both bivariable and multivariable regression models, and empirically derived RVU values from complexity and work effort metrics were estimated. RESULTS: We analyzed 71 urology CPT codes encompassing 55,068 cases. RVUs correlated well with median length of hospital stay (R = 0.81), median operative time (R = 0.92), serious adverse events (R = 0.83), and readmissions (R = 0.74). RVUs were poorly correlated with mortality (R = 0.34). Outlying procedures identified using the multivariable model were retroperitoneal lymph node dissection (projected +21.09 RVUs), laparoscopic ureteroneocystotomy (projected -12.34 RVUs), and cystectomy with bilateral pelvic lymphadenectomy (projected +9.37 RVUs). CONCLUSION: Urology work RVUs correlate more with operative time than other measures of surgical complexity and physician workload. There exist several significant outlying procedures for various work measures. Incorporating objective work data may improve RVU assignments in the future.

The modern testicular prosthesis: patient selection and counseling, surgical technique, and outcomes.

The testicular prosthesis can be an afterthought for providers when performing an orchiectomy for testicular cancer, torsion, atrophic testis, or trauma. However, data suggest that patients find the offer of a testicular prosthesis and counseling regarding placement to be extremely important from both a pragmatic and a psychosocial perspective. Only two-thirds of men undergoing orchiectomy are offered an implant at the time of orchiectomy and of those offered about one-third move forward with prosthesis placement. The relatively low acceptance rate is in stark contrast with high patient satisfaction and low complication rates for those who undergo the procedure. The most common postoperative patient concerns are minor and involve implant positioning, size, and weight. Herein, we provide an up-to-date review of modern preoperative evaluation, patient selection, expectation management, surgical technique, and expected outcomes for testicular prostheses.

Twitter Mentions and Academic Citations in the Urologic Literature.

OBJECTIVE: To quantify the relationship between the number of Twitter mentions and the number of academic citations a urologic publication receives. MATERIALS AND METHODS: Two hundred and thirteen papers from 7 prominent urologic journals were examined 37 months after publication. Articles were evaluated with 2 citation based "bibliometrics" (Scopus, Google Scholar) and Twitter mentions were tracked using the Altmetric Bookmarklet. The number of article citations and Twitter mentions were compared using one-way Analysis of variance (ANOVA) and bivariate fit analysis. RESULTS: Seventy-three percent of articles had at least 1 Twitter mention. Forty-two percent of Twitter mentions occurred within the first week of the online publication date. Articles mentioned on Twitter had 2.0-fold more Scopus citations (P <.01), and 2.3-fold more Google Scholar citations (P <. 01) compared to articles with no Twitter mentions. Female urologic articles had the greatest number of Twitter mentions (5.7 mentions/article) while pediatric urology had the fewest mean number of Twitter mentions (0.8 mentions/article). A total of 8.9% of papers were tweeted by their authors. Author tweeted articles were associated with a 12.3 (2.0-fold) and 15.5 (1.8-fold) mean citation increase for Scopus and Google Scholar (P <. 01 and P = . 01) compared to articles not shared by their authors on Twitter. CONCLUSION: The majority of urologic publications are being shared on Twitter. The number of citations a urologic publication receives up to 3 years after release is positively associated with the number of mentions it has on Twitter. Twitter activity may be an early indicator of ultimate academic impact of an academic urologic paper.

Postural dependence of passive tension in the supraspinatus following rotator cuff repair: a simulation analysis.

BACKGROUND: Despite surgical advances, repair of rotator cuff tears is associated with 20-70% incidence of recurrent tearing. The tension required to repair the torn tendon influences surgical outcomes and may be dependent on the gap length from torn tendon that must be spanned by the repair. Detailed understanding of forces throughout the range of motion (ROM) may allow surgeons to make evidence-based recommendations for post-operative care. METHODS: We used a computational shoulder model to assess passive tension and total moment-generating capacity in supraspinatus for repairs of gaps up to 3 cm throughout the shoulder (ROM). FINDINGS: In 60° abduction, increased gap length from 0.5 cm to 3 cm caused increases in passive force from 3N to 58 N, consistent with those seen during clinical repair. For reduced abduction, passive forces increased substantially. For a 0.5 cm gap, tension throughout the ROM (elevation, plane of elevation, and rotation) is within reasonable limits, but larger gaps are associated with tensions that markedly exceed reported pull-out strength of sutures and anchors. Peak moment for a large 3 cm gap length was 5.09 Nm, a 53% reduction in moment-generating capacity compared to uninjured supraspinatus. INTERPRETATION: We conclude that shoulder posture is an important determinant of passive forces during rotator cuff repair surgery. Choosing postures that reduce forces intraoperatively to permit repair of larger gaps may lead to failure postoperatively when the shoulder is mobilized. For larger defects, loss of strength in supraspinatus may be substantial following repair even if retear is prevented.