Delayed Treatment With Low-intensity Extracorporeal Shock Wave Therapy in an Irreversible Rat Model of Stress Urinary Incontinence.

OBJECTIVE: To determine the outcomes and mechanisms of delayed low-intensity extracorporeal shock wave therapy (Li-ESWT) in a rat model of irreversible stress urinary incontinence (SUI). MATERIALS AND METHODS: Twenty-four female Sprague-Dawley rats were randomly assigned into 3 groups: sham control, vaginal balloon dilation + ß-aminopropionitrile (BAPN; SUI group), and vaginal balloon dilation + BAPN + treatment with Li-ESWT (SUI-Li-ESWT group). An irreversible SUI model was developed by inhibiting the urethral structural recovery with BAPN daily for 5 weeks. Thereafter, in the SUI-Li-ESWT group, Li-ESWT was administered twice per week for 2 weeks. After a 1-week washout, all 24 rats were evaluated with functional and histologic studies at 17 weeks of age. Endogenous progenitor cells were detected via the EdU-labeling method. RESULTS: Functional analysis with leak point pressure testing showed that the SUI-Li-ESWT group had significantly higher leak point pressures compared with untreated rats. Increased urethral and vaginal smooth and striated muscle content and increased thickness of the vaginal wall were noted in the SUI-Li-ESWT group. The SUI group had significantly decreased neuronal nitric oxide /tyrosine hydroxylase positive nerves ratio in the smooth muscle layers of the urethra, while the SUI-Li-ESWT group had neuronal nitric oxide/tyrosine hydroxylase+ nerves ratio similar to that of the control group. The continuality of urothelial cell lining was also improved in the SUI-Li-ESWT group. In addition, there were significantly increased EdU-positive cells in the SUI-Li-ESWT group. CONCLUSION: Li-ESWT appears to increase smooth muscle content in the urethra and the vagina, increase the thickness of urethral wall, improve striated muscle content and neuromuscular junctions, restore the integrity of the urothelium, and increase the number of EdU-retaining progenitor cells in the urethral wall.

Treatment of stress urinary incontinence with low-intensity extracorporeal shock wave therapy in a vaginal balloon dilation induced rat model.

BACKGROUND: To investigate the outcomes and mechanisms of low-intensity extracorporeal shock wave therapy (Li-ESWT) on stress urinary incontinence (SUI) in a vaginal balloon dilation (VBD) rat model. METHODS: Thirty Sprague-Dawley rats were randomly grouped into normal controls, VBD only, and VBD with Li-ESWT. Li-ESWT was administered twice per week for 3 weeks. Afterward, all 30 rats were assessed with functional and histological studies. To explore the acute effect of Li-ESWT, another 25 rats, given intraperitoneal 5-ethynyl-2-deoxyuridine (EdU) at birth, were treated with Li-ESWT followed by assessment of vascular endothelial growth factor (VEGF) expression and endogenous progenitor cells distribution at 24 hours or 1 week after the last Li-ESWT therapy. Additionally, rat myoblast L6 cells were used for myotube formation assay in vitro. RESULTS: Functional analysis with leak-point pressure (LPP) testing showed that rats treated with Li-ESWT following VBD had significantly higher LPP relative to those receiving VBD only (44.8±3.2 versus 27.0±2.9 cmH2O, P<0.01). Histological examinations showed increased urethral sphincter regeneration in Li-ESWT group. The rats treated with Li-ESWT also had increased vascularity, which was confirmed by immunohistochemistry of rat endothelial cell antigen, while reverse-transcriptase polymerase chain reaction (RT-PCR) showed VEGF expression was significantly enhanced. Additionally, there were significantly increased EdU+ cells in Li-ESWT treated rats at 24 hours. In vitro, Li-ESWT promoted myotube formation from L6 cells. CONCLUSIONS: Li-ESWT ameliorated SUI by promoting angiogenesis, progenitor cell recruitment, and urethral sphincter regeneration in a rat model induced by VBD. Li-ESWT represents a potential novel non-invasive therapy for SUI.

Tunica albuginea allograft: a new model of LaPeyronie's disease with penile curvature and subtunical ossification.

The pathophysiology of LaPeyronie's disease (PD) is considered to be multifactorial, involving genetic predisposition, trauma, inflammation and altered wound healing. However, these factors have not yet been validated using animal models. In this study, we have presented a new model obtained by tunica albuginea allograft. A total of 40, 16-week-old male rats were used. Of these, 8 rats served as controls and underwent a 10 × 2-mm-wide tunical excision with subsequent autografting, whereas the remaining 32 underwent the same excision with grafting of the defect with another rat's tunica. Morphological and functional testing was performed at 1, 3, 7 and 12 weeks after grafting. Intracavernous pressure, the degree of penile curvature and elastic fiber length were evaluated for comparison between the allograft and control groups. The tissues were obtained for histological examination. The penile curvature was significantly greater in the allografted rats as compared with the control rats. The erectile function was maintained in all rats, except in those assessed at 12 weeks. The elastin fiber length was decreased in the allografted tunica as compared to control. SMAD2 expression was detected in the inner part of the allograft, and both collagen-II- and osteocalcin-positive cells were also noted. Tunica albuginea (TA) allograft in rats is an excellent model of PD. The persistence of curvature beyond 12 weeks and the presence of ossification in the inner layer of the TA were similar to those observed in men with PD. Validation studies using this animal model would aid understanding of the PD pathophysiology for effective therapeutic interventions.

Out-of-pocket fertility patient expense: data from a multicenter prospective infertility cohort.

PURPOSE: The high costs of fertility care may deter couples from seeking care. Urologists often are asked about the costs of these treatments. To our knowledge previous studies have not addressed the direct out-of-pocket costs to couples. We characterized these expenses in patients seeking fertility care. MATERIALS AND METHODS: Couples were prospectively recruited from 8 community and academic reproductive endocrinology clinics. Each participating couple completed face-to-face or telephone interviews and cost diaries at study enrollment, and 4, 10 and 18 months of care. We determined overall out-of-pocket costs, in addition to relationships between out-of-pocket costs and treatment type, clinical outcomes and socioeconomic characteristics on multivariate linear regression analysis. RESULTS: A total of 332 couples completed cost diaries and had data available on treatment and outcomes. Average age was 36.8 and 35.6 years in men and women, respectively. Of this cohort 19% received noncycle based therapy, 4% used ovulation induction medication only, 22% underwent intrauterine insemination and 55% underwent in vitro fertilization. The median overall out-of-pocket expense was $5,338 (IQR 1,197-19,840). Couples using medication only had the lowest median out-of-pocket expenses at $912 while those using in vitro fertilization had the highest at $19,234. After multivariate adjustment the out-of-pocket expense was not significantly associated with successful pregnancy. On multivariate analysis couples treated with in vitro fertilization spent an average of $15,435 more than those treated with intrauterine insemination. Couples spent about $6,955 for each additional in vitro fertilization cycle. CONCLUSIONS: These data provide real-world estimates of out-of-pocket costs, which can be used to help couples plan for expenses that they may incur with treatment.

Penile prosthesis implantation in Chinese patients with severe erectile dysfunction: 10-year experience.

We retrospectively evaluated the clinical outcome of penile prosthesis implantation (PPI) in Chinese patients with severe erectile dysfunction (SED). From July 2000 to December 2011, 224 patients (mean age: 35.9±11.8 years, range: 20-75 years) with SED underwent PPI by experienced surgeon according to standard PPI procedure at our centre. A malleable prosthesis (AMS 650) was implanted in 45 cases (20.1%), and a three-piece inflatable prosthesis (AMS 700 CXM or AMS 700 CXR) was implanted in 179 cases (79.9%). Surgical outcomes, including postoperative complications, clinical efficacy and couple satisfaction, were evaluated over than 6 months postoperatively using medical record abstraction, IIEF-5, quality of life (QoL) scores, and the patient/partner sexual satisfaction score proposed by Bhojwani et al. Of the 224 patients eligible for the study, 201 subjects (89.7%) completed follow-up. All of patients could perform sexual intercourse post PPI with the mean postoperative IIEF-5 and QoL scores were 20.02±2.32 and 5.28±0.76, respectively, which were significantly improved compared with the preoperative scores (6.29±1.5 and 2.13±0.84, P<0.01). Of the 201 men, mechanical malfunction occurred in four cases (2.0%) and three cases were re-implanted new device, and two cases (1.0%) developed a mild curvature of the penis. Scrotal erosion with infection occurred in one case with diabetes mellitus (0.5%) and required complete removal of the implanted AMS 700 CXM. Satisfactory sexual intercourse at least twice per month was reported by 178 men (88.6%), and overall satisfaction with the PPI surgery was reported by 89.0% of men and 82.5% of partners. Patient satisfaction in the three-piece inflatable prosthesis group was higher than in the malleable prosthesis group (P<0.05). Satisfaction, however, between the types of prostheses, did not differ in the partner survey. PPI is a safe and effective treatment option for Chinese patients with SED and experienced surgeon perform PPI according to standard PPI procedure could reduce the postoperative complications of PPI and could improve patient satisfaction ratio and QoL.

Time costs of fertility care: the hidden hardship of building a family.

OBJECTIVE: To determine the time that infertile couples spend seeking and utilizing fertility care. DESIGN: Prospective cohort. SETTING: Eight community and academic infertility practices. PATIENT(S): A total of 319 couples presenting for a fertility evaluation. INTERVENTION(S): Face-to-face and telephone interviews and questionnaires. MAIN OUTCOME MEASURE(S): Participants recorded diaries of time spent on provider visits, travel, telephone, and miscellaneous activities. Participants also recorded time off from work due to the physical and mental stress related to fertility care. Linear regression was used to assess relationship between fertility characteristics and time spent pursuing care. RESULT(S): Diaries were completed by 319 subjects. Over an 18-month time period, the average time spent on fertility care was 125 hours, equating to 15.6 days, assuming an 8-hour workday. For couples utilizing cycle-based treatments (CBT), overall time spent pursuing care averaged 142 hours, versus 58 hours for couples using other therapies, with the majority of time spent on provider visits (73 hours). After multivariable adjustment for clinical and sociodemographic characteristics, possessing a college degree and intensity of fertility treatment were independently associated with increased time spent pursuing fertility care. Furthermore, couples that spent the most time on care were significantly more likely to experience fertility-related stress. CONCLUSION(S): Over the course of 18 months of observation, couples pursuing fertility treatment dedicated large amounts of time to attaining their family-building goals. This burden on couples adds to the already significant financial and emotional burdens of fertility treatment and provides new insight into the difficulties that these couples face.

National incidence and outcomes of postoperative urinary retention in the Surgical Care Improvement Project.

BACKGROUND: The national incidence of postoperative urinary retention (POUR), its risk factors, and associated outcomes are not well understood. METHODS: We identified patients undergoing one of the Surgical Care Improvement Project surgeries using the National Inpatient Sample. By using International Classification of Diseases, 9th revision, Clinical Modification codes (ICD-9-CM), we identified POUR and the outcomes urinary tract infection, noninfectious catheter-related complications, length of stay, and posthospitalization care. Multivariable analysis identified predictors of POUR and its associated outcomes. RESULTS: A total of 415,409 patients, representing 2,077,045 nationally, underwent one of the Surgical Care Improvement Project procedures with 43,030 (2.1%) developing POUR. Age, sex, type of surgery, and medical comorbidities were predictive of POUR with a .71 area under the curve. Patients with POUR had greater odds of having urinary tract infections (odds ratio [OR], 2.3; 95% confidence interval [CI], 2.2-2.5), suffering catheter-related complications (OR, 5.2; 95% CI, 3.8-7.0), and needing additional posthospitalization care (OR, 1.3; 95% CI, 1.25-1.4), and they had a greater length of stay (.24 extra days). CONCLUSIONS: Patients at risk for POUR can be identified, and they may benefit from interventions to prevent POUR.

Relative renal function does not improve after relieving chronic renal obstruction.

UNLABELLED: Study Type - Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Technetium-99m MAG3 renography can be used to quantify relative renal function (RRF). Deterioration of renal function occurs with chronic obstruction. Small studies have previously shown that RRF is not improved in adult patients after pyeloplasty. Some studies have suggested that patients with higher preoperative RRF are more likely to improve. To our knowledge, these data represent the largest review of cases related to this subject. This study verifies past studies' assertions that RRF does not improve after relief of chronic renal obstruction. Using multivariable analysis, we identify lower age and lower preoperative RRF as predictors of >7% improvement in RRF. These data suggest that the aim of relieving obstruction should be to maintain RRF and alleviate symptoms, but not to seek improvement in overall renal function. OBJECTIVE: To determine the change in relative renal function (RRF) after relief of chronic obstruction in adults. PATIENTS AND METHODS: We retrospectively identified 85 adult patients who underwent scintigraphic diuretic renography before and after an intervention to relieve chronic unilateral renal obstruction. Patients were stratified into groups of low (<20%), medium (20-40%) and high (>40%) preoperative RRF in the obstructed kidney. Each group was assessed for change in RRF after relief of obstruction. We performed multivariable logistic regression analysis to determine whether age and pre-procedural RRF predicted a >7% improvement in RRF, controlling for medical comorbidities and type of obstruction. RESULTS: The mean (sd) patient age was 43.6 (16.8) years and 66% of patients were female. The mean (sd) pre- and postoperative RRF values were not significantly different (37.6 [12.3] % vs 38.4 [13.6] %; P = 0.31). Patients stratified by low, medium and high preoperative function showed no significant change in postoperative RRF (P = 0.53, 0.39 and 0.77, respectively). In multivariable logistic regression analysis, younger age (odds ratio [OR] 0.90, 95% confidence interval [CI] 0.83-0.98) and lower preoperative RRF (OR 0.90, 95% CI 0.83-0.97) predicted improvement in RRF of >7%, after adjustment. CONCLUSIONS: RRF does not significantly increase after relief of chronic obstruction. The goals of relieving chronic renal obstruction should be to maintain renal function and relieve symptoms, but not to regain renal function.

Safer urethral catheters: how study of catheter balloon pressure and force can guide design.

OBJECTIVES: To better define urethral catheter balloon pressures and extraction forces during traumatic placement and removal of urethral catheters. To help guide design for safer urethral catheters. MATERIALS AND METHODS: Measurements of balloon pressure were made upon filling within the urethra vs the bladder. Extraction forces were measured upon removal of a catheter with a filled balloon from the bladder. Models for the bladder and urethra included an ex vivo model (funnel, 'bladder', attached to a 30 F tube, 'urethra') and fresh human male cadavers. The mean (SEM) balloon pressures and extraction forces were calculated. RESULTS: In the ex vivo model, the mean (SEM) pressures upon filling the balloon with 10 mL were on average three-times higher within the ex vivo'urethra' (177 [6] kPa) vs 'bladder' (59 [2] kPa) across multiple catheter types. In the human cadaver, the mean balloon pressure was 1.9-times higher within the urethra (139 [11] kPa) vs bladder (68 [4] kPa). Balloon pressure increased non-linearly during intraurethral filling of both models, resulting in either balloon rupture (silicone catheters) or 'ballooning' of the neck of the balloon filling port (latex catheters). Removal of a filled balloon per the ex vivo model 'urethra' and cadaveric urethra, similarly required increasing force with greater balloon fill volumes (e.g. 9.34 [0.44] N for 5 mL vs 41.37 [8.01] N for 10 mL balloon volume). CONCLUSIONS: Iatrogenic complications from improper urethral catheter use is common. Catheter balloon pressures and manual extraction forces associated with urethral injury are significantly greater than those found with normal use. The differences in pressure and force may be incorporated into a safer urethral catheter design, which may significantly reduce iatrogenic urethral injury associated with catheterization.

Impact of urethral ultrasonography on decision-making in anterior urethroplasty.

OBJECTIVE: To assess the impact of urethral ultrasonography on decision-making in complex anterior urethral reconstructions. PATIENTS AND METHODS: This was an institutional review board approved retrospective review of 500 patients receiving anterior urethroplasty from 1985 to 2007. In all, 232 patients met the inclusion criteria of documented preoperative clinical assessment, retrograde urethrogram (RUG), urethral ultrasonogram, and measured operative stricture length and dimensions. At the time of surgery, intraoperative urethral ultrasonography was performed. A preoperative planned reconstructive approach was compared with the reconstructive procedure performed to determine how often urethral ultrasonography impacted operative decision-making. RESULTS: Of the 232 patients in our review, 115 (50%), 88 (38%) and 16 (7%) received respectively anastomotic, buccal mucosa graft and fasciocutaneous flap urethroplasties. Intraoperative ultrasonography changed surgical approach in 44 patients (19%), and was integral in deciding between two equally possible approaches in an additional 61 patients (26%). In patients whose approach was changed from anastomotic urethroplasty to an onlay urethroplasty, mean RUG length was 2.0 cm while mean ultrasound length was significantly longer at 3.4 cm (P= 0.02). When the surgical approach was changed from an onlay urethroplasty to an anastomotic urethroplasty, mean RUG length was 2.7 cm compared with a significantly shorter intraoperative ultrasonography length of 1.9 cm (P < 0.005). CONCLUSIONS: Ultrasonography of the anterior urethra directly influenced our reconstructive operative approach in 45% of patients. It is a simple, reliable procedure that adds valuable clinical insight and objective radiographic data to help select the optimal anterior urethral reconstructive approach.

National incidence and impact of noninfectious urethral catheter related complications on the Surgical Care Improvement Project.

PURPOSE: We defined the incidence and health outcomes related impact of noninfectious urethral catheter related complications for the 7 surgical procedures monitored by the Joint Commission as part of the Surgical Care Improvement Project. MATERIALS AND METHODS: We performed a cross-sectional analysis of the 2007 National Inpatient Sample (a 20% stratified sampling of nonfederal United States hospitals) using ICD-9-CM procedure and diagnostic codes to identify the incidence of catheter related complications for coronary artery bypass graft, and noncoronary artery bypass graft cardiac surgery, hysterectomy, colon, hip, knee and major vascular surgery. Univariate and multivariate analysis (with a significance level of less than 0.05) was performed to determine if these complications were associated with length of stay, urinary tract infections and/or deaths. RESULTS: A total of 1,420 cases of catheter related complications were identified nationally. The incidence of catheter related complications varied by surgical procedure (average 1 in 528 men and 1 in 5,217 women for all procedures). Univariate analysis revealed that in the presence of catheter related complications, mean length of stay (6 of 7 procedures, range 1.5 to 3.0 days, p <0.05) and urinary tract infection (5 of 7 procedures, absolute range 6.9% to 11.8%, p <0.05) were statistically increased for most procedures. Multivariate analysis demonstrated a significant association between catheter related complications, and increased length of stay (range 1.5 to 3.5 days, p <0.05) and urinary tract infection (OR 2.4-6.8, p <0.05) for 5 and 6 of 7 procedure types, respectively, but not mortality rate (0 of 7 procedures). CONCLUSIONS: Catheter related complications are reported rarely, but are associated with increased length of stay and urinary tract infection rates for patients in the Surgical Care Improvement Project.

Selective arterial embolization of angiomyolipoma leading to pulmonary hypertension.

OBJECTIVES: To report two cases of secondary pulmonary hypertension resulting from microsphere extravasation following selective arterial embolization of renal angiomyolipoma, its diagnosis, and management. METHODS: We reviewed the cases of two patients at the University of California, San Francisco, treated with selective arterial embolization for management of their angiomyolipoma (AML) using Tris-Acryl Gelatin Microspheres. RESULTS: Both patients were women, ages 51 and 77. Indications for treatment were the following: Patient 1 was treated for a large asymptomatic AML. Patient 2 was treated for a symptomatic, bleeding AML. Both patients developed progressive hypoxia following selective arterial embolization using Tris-Acryl Gelatin Microspheres. Each patient underwent a subsequent work up including a CT chest, echocardiogram, and chest x-ray. Both demonstrated significant pulmonary hypertension following their procedure and were discharged with supplemental oxygen. CONCLUSIONS: Selective arterial embolization of AML with microsphere extravasation into the pulmonary vasculature can lead to pulmonary hypertension and hypoxemia.

Squamous cell carcinoma at the site of a Prince Albert's piercing.

INTRODUCTION: Medical practitioners should be aware of genital piercing and its potential complications. General piercings are associate with complications common to all piercings as well as some unique to urethral piercings. Specifically, the association between carcinoma and genital piercing is not well recognized. AIM: The present study is a report of two cases describing squamous cell carcinoma associated with genital piercing. METHODS: Case reports of two men admitted to an academic medical center. RESULTS: A 60-year-old man with a history of HIV and hepatitis C as well as a Prince Albert piercing presented for treatment of a urethrocutaneous fistula. A biopsy of indurated granulation tissue surrounding the fistula revealed invasive, moderately-differentiated squamous cell carcinoma. A 56-year-old man with a history of HIV, hepatitis C, and a Prince Albert piercing presented following a single episode of gross hematuria. He also reported splitting of his urinary stream. On physical examination, areas of necrosis were noted on the glans penis; biopsy revealed invasive, poorly-differentiated squamous cell carcinoma. CONCLUSIONS: The present study is the first to suggest a possible association between squamous cell carcinoma of the penis/urethra and genital piercing. Patients with genital piercings, especially those with concurrent risk factors such as HIV and HCV, should be counselled about this rare complication.

Differences in the clinical characteristics of primarily and secondarily infertile men with varicocele.

OBJECTIVE: To compare the clinical characteristics of primarily and secondarily infertile men with varicocele. DESIGN: Cross-sectional analysis. SETTING: Male infertility clinic, tertiary health care center. PATIENT(S): Two hundred ninety-five infertile men with palpable varicoceles. INTERVENTION(S): Clinical evaluation including patient reproductive history (including assessment of primary or secondary infertility), physical examination, hormonal assessment and at least two semen analyses. MAIN OUTCOME MEASURE(S): Differences in the characteristics of men with primary vs. secondary infertility. RESULT(S): Two hundred five subjects were identified with primary infertility and 90 with secondary infertility. Secondarily infertile men were older (39.6 years vs. 35.0 years), with older partners (35.4 years vs. 33.2 years), but had higher sperm densities (51.3 vs. 36.0 million/mL) and a greater percentage of morphologically normal sperm (30.6% vs. 24.1%). A lower proportion of secondarily infertile men had total motile sperm count (TMC) <20 million compared with primarily infertile men (31.1% vs. 46.5%). Groups did not differ regarding infertility duration, tobacco or alcohol use, varicocele grade or laterality, testis volumes, or hormonal parameters. In multivariate modeling, secondary infertility (vs. primary) was an independent predictor of TMC >20 million (odds ratio 1.9). CONCLUSION(S): Men with secondary infertility are older and have older partners than primarily infertile men, yet they have significantly better sperm concentrations. Infertility in this group may be influenced by maternal reproductive potential.

Health related quality of life in patients treated with multimodal therapy for prostate cancer.

PURPOSE: Patients with prostate cancer and high risk disease characteristics may benefit from multimodal therapy. However, the effects of multimodal therapy on health related quality of life have not been comprehensively described. We further characterized health related quality of life in patients treated with multimodal therapy. MATERIALS AND METHODS: Patient data were obtained from the CaPSURE database, a national disease registry of men with prostate cancer. Included patients received active primary therapy (ie surgery or various forms of radiation) for prostate cancer with or without adjuvant or neoadjuvant therapy, and had complete clinical data, including health related quality of life assessments at baseline and through 2 years after treatment. The association between health related quality of life outcomes and different primary therapies with and without adjuvant or neoadjuvant therapy over time was analyzed using a repeated measures mixed model for each primary therapy. RESULTS: A total of 2,204 men met the study criteria. As primary therapy 1,427 patients received radical prostatectomy, 267 received external beam radiation therapy and 510 received brachytherapy. When androgen deprivation therapy was included with radical prostatectomy, brachytherapy or external beam radiation therapy, there was a transient loss of sexual function that improved within 9 months postoperatively. When external beam radiation therapy was given with brachytherapy there was continuous worsening of urinary function and bother through 21 months. CONCLUSIONS: Multimodal therapy may lead to declines in health related quality of life especially in the domains of urinary function, urinary bother and sexual function. These effects must be considered and patients must be counseled appropriately before initiation of multimodal therapy.

Bilateral but not unilateral testicular hypotrophy predicts for severe impairment of semen quality in men with varicocele undergoing infertility evaluation.

OBJECTIVES: Varicocele is a common cause of infertility, and varicocele-associated testicular hypotrophy has been described as a potential cause of decreased semen quality. We investigated the relationship between testicular hypotrophy and poor semen quality in infertile men with varicoceles. We hypothesized that bilateral hypotrophy is required before the semen quality is severely impaired. METHODS: We retrospectively identified consecutive patients with palpable varicoceles undergoing an infertility evaluation at a single academic center. Each patient was evaluated by the same clinician with history and physical examination. Testicular hypotrophy was defined as a size discrepancy of greater than 3 mL or an absolute size of less than 14 mL. Multivariate logistic regression analysis was used to determine the clinical predictors of total motile sperm count (TMC) of less than 20 million. RESULTS: A total of 245 men with complete data were identified, and 103 men with a TMC of less than 20 million sperm (mean age 36.2 +/- 6.6 years) were compared with 142 men with normal TMCs (mean age 37.1 +/- 6.5 years). On multivariate analysis, men with bilateral hypotrophy were nearly nine times more likely to have a TMC of less than 20 million sperm than were men without hypotrophy (odds ratio 8.8, 95% confidence interval 2.4 to 32.1), and six times more likely than those with unilateral hypotrophy (odds ratio 6.0, 95% confidence interval 1.4 to 26.3). Unilateral hypotrophy alone did not predict for a low TMC. CONCLUSIONS: Among men with varicoceles undergoing infertility evaluation, those with bilateral hypotrophy are at the greatest risk of impaired semen quality.

Motor cortex stimulation: mild transient benefit in a primate model of Parkinson disease.

OBJECT: The authors sought to examine the therapeutic efficacy of motor cortex stimulation (MCS) in 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-treated macaques and to characterize therapeutic differences with varying modes, frequencies, and durations of stimulation. METHODS: Motor cortex stimulation was delivered at currents below motor threshold and at frequencies between 5 and 150 Hz through epidural electrodes over the primary motor cortex. The animals were studied during and without MCS using video analysis, activity logging, and food retrieval tasks. Animals were examined using two different stimulation protocols. The first protocol consisted of 1 hour of MCS therapy daily. The second protocol exposed the animal to continuous MCS for more than 24 hours with at least 2 weeks between MCS treatments. CONCLUSIONS: Daily MCS yielded no consistent change in symptoms, but MCS at 2-week intervals resulted in significant increases in activity. Effects of biweekly MCS disappeared, however, within 24 hours of the onset of continuous MCS. In this study, MCS only temporarily reduced the severity of MPTP-induced parkinsonism.