A novel nomogram for prediction of spermatogenic improvement following empiric medical therapy for moderate-severe oligospermia.

INTRODUCTION: To identify pre-treatment clinical variables and hormonal responses predictive of successful spermatogenic response to empiric medical therapy (EMT), then to create a nomogram to guide clinical therapy. MATERIALS AND METHODS: All men who had been treated at our institution with EMT for moderate-severe oligospermia (≤ 10 million sperm/mL) from 2003 to 2014 were included in our study. Men with hypogonadotropic hypogonadism, azoospermia, or those who had varicocelectomy or had received fertility altering medications within 6 months of initiating EMT were excluded, as well as those who did not obtain a follow up semen analysis. Pre-treatment clinical variables, hormonal responses, and spermatogenic responses were assessed. Success was defined by improvements in baseline sperm concentrations as follows: (1) cryptospermia to ≥ 0.3 million/mL, (2) > 100% increase in sperm concentration for men with baseline concentration < 1 million/mL, or (3) a 30% increase in sperm concentration for men with a baseline concentration between 1-10 million/mL. We performed univariate analysis to evaluate for predictors of success. The Wilcoxon rank sum test was used for continuous variables and the Fisher's exact test was used for categorical variables. Multivariable logistic regression was then used to build a nomogram. RESULTS: We identified 107 men who were treated with EMT for oligospermia (≤ 10 million sperm/mL) who met our inclusion criteria. Forty-five men (42%) exhibited a poor spermatogenic response to EMT and 62 men (58%) exhibited a good response. Univariate analysis did not identify significant differences in any variable between the two groups. Multivariate analysis did identify predictive combinations which allowed the development of a nomogram with a high concordance index (0.78) for predicting spermatogenic response to EMT. CONCLUSIONS: While none of the individual pre-treatment clinical variables or hormonal responses were predictive of success following EMT, analysis of multiple factors in concert yielded a clinically useful nomogram with a high concordance index.

Outcomes of Prostate Biopsy in Men with Hypogonadism Prior or During Testosterone Replacement Therapy

Introduction: The relationship between Testosterone Replacement Therapy (TRT) and prostate cancer remains controversial. Most TRT studies show no change in prostate specific antigen (PSA) but some men do have PSA rise or develop an abnormal digital rectal exam (aDRE). Our objective was to examine the biopsy results of men with symptomatic hypogonadism before or during therapy. Materials and Methods: Data was extracted from our medical record on men with hypogonadism who had a prostate biopsy within the past 4 years done by 3 Urologists with guideline driven practice patterns. Results: 96 men were identified. Mean age at biopsy was 63 (range 40–85) and median PSA was 3.78ng/dL (0.5–662). Of the 61 men not on TRT, median PSA was 4.34 (0.5 to 662) and mean total testosterone 254 (191–341). There were 29 (47.5%) prostate cancers found (6 Gleason score 6, 13 Gleason score 7, 10 Gleason score 8 or 9). Of the 35 men on TRT, median PSA was 3.27 (0.5 to 13.7). The %PSA increase ranged from 2 to 251% (mean 93.5%). Mean total testosterone was 383 (146–792). Of the 14 men treated < 2 years, none had cancer. Of the 21 men treated 2 or more years 5 had cancer (2 Gleason score 6, 3 Gleason score 7). Conclusions: Men with hypogonadism and a clinical indication for biopsy often have prostate cancer, many high grade. No men with an initial PSA rise on TRT had cancer. Men on long term TRT should be monitored with PSA and DRE per guidelines.

Rare case of monozygotic twins diagnosed with klinefelter syndrome during evaluation for infertility.

Although neither Klinefelter syndrome nor monozygotic twins are particularly rare (1/667 male births and 3-4/1000 live births, respectively), the occurrence of both in the same pregnancy (ie, identical twins with Klinefelter syndrome) is exceedingly rare and has only been reported three times previously in the literature. This report describes the fourth ever reported case of monozygotic twins with Klinefelter syndrome (who presented to our male fertility clinic with failure to conceive) and sheds interesting light on the reproductive concordance observed with this rare clinical entity. To our knowledge, this is the first reported case of monozygotic twins with Klinefelter syndrome that describes the infertility workup and outcomes of microsurgical testicular sperm extraction.

Outcomes of Prostate Biopsy in Men with Hypogonadism Prior or During Testosterone Replacement Therapy.

INTRODUCTION: The relationship between Testosterone Replacement Therapy (TRT) and prostate cancer remains controversial. Most TRT studies show no change in prostate specific antigen (PSA) but some men do have PSA rise or develop an abnormal digital rectal exam (aDRE). Our objective was to examine the biopsy results of men with symptomatic hypogonadism before or during therapy. MATERIALS AND METHODS: Data was extracted from our medical record on men with hypogonadism who had a prostate biopsy within the past 4 years done by 3 Urologists with guideline driven practice patterns. RESULTS: 96 men were identified. Mean age at biopsy was 63 (range 40-85) and median PSA was 3.78ng/dL (0.5-662). Of the 61 men not on TRT, median PSA was 4.34 (0.5 to 662) and mean total testosterone 254 (191-341). There were 29 (47.5%) prostate cancers found (6 Gleason score 6, 13 Gleason score 7, 10 Gleason score 8 or 9). Of the 35 men on TRT, median PSA was 3.27 (0.5 to 13.7). The %PSA increase ranged from 2 to 251% (mean 93.5%). Mean total testosterone was 383 (146-792). Of the 14 men treated < 2 years, none had cancer. Of the 21 men treated 2 or more years 5 had cancer (2 Gleason score 6, 3 Gleason score 7). CONCLUSIONS: Men with hypogonadism and a clinical indication for biopsy often have prostate cancer, many high grade. No men with an initial PSA rise on TRT had cancer. Men on long term TRT should be monitored with PSA and DRE per guidelines.

Is there a rationale for penile rehabilitation following radical prostatectomy?

Erectile function recovery after radical prostatectomy (RP) is an increasingly prominent quality-of-life outcome following surgery. Following RP many men, despite the advent of cavernous nerve-sparing surgical technique, have moderately or significantly impaired erectile function (EF). The term penile rehabilitation (PR) is used to define interventions that maintain the health of erectile tissue in the context of nervous, vascular, and structural tissue injury. The goal of PR is to regain, as closely re-approximate, preoperative erectile function. PR is based on an increasing volume of preclinical and clinical data, but conclusive evidence of efficacy has not been established, and therefore the concept of PR remains controversial. The optimal PR regimen has not been established, but all strategies rely on one or more erectile dysfunction treatments to be administered on a regular basis regardless of actual use for sexual activity. This review highlights recent studies and evidence related to PR.

Testicular sclerosing sertoli cell tumor: a case report and review of the literature.

Sertoli cell tumors are very rare testicular tumors, representing 0.4% to 1.5% of all testicular malignancies. They are subclassified as classic, large-cell calcifying, and sclerosing Sertoli cell tumors (SSCT) based on distinct clinical features. Only 42 cases of SSCTs have been reported in the literature. We present a case of a 23-year-old man diagnosed with SSCT.

Functional sperm testing and the role of proteomics in the evaluation of male infertility.

The limitations of conventional semen analysis testing in the diagnosis and management of male factor infertility have been well documented. A number of more sophisticated assays including measurements of sperm deoxyribonucleic acid (DNA) fragmentation rates, seminal oxidative stress, and antioxidant capacity have been increasingly used in the evaluation of male infertility. Moreover, in the past few years, tremendous advancements in the burgeoning field of sperm proteomics promise to revolutionize the andrologist's diagnostic armamentarium, as will be discussed in this review.

Robotic intra-abdominal vasectomy reversal: A new approach to a difficult problem.

The management of obstructive azoospermia resulting from intra-abdominal vasal obstruction poses a formidable surgical challenge. A number of surgical methods have been described to address this problem, including both open and laparoscopic approaches to mobilize and sometimes even re-route the abdominal vas deferens prior to performing a re-anastamosis. We present the first report, to our knowledge, of robotic intra-abdominal vasectomy reversal used to repair obstructive azoospermia resulting from prior laparoscopic vasectomy. In doing so, we summarize the techniques described previously in the literature and build upon this body of surgical experience by combining robotic-assisted laparoscopic mobilization of the vas with robotic vasovasostomy. We believe this novel approach for repairing intra-abdominal vasal defects minimizes morbidity, while at the same time obviating the need for the operating microscope, and thus represents a practical alternative to existing techniques.

Use of a preoperative checklist reduces risk of penile prosthesis infection.

PURPOSE: Infection of a penile prosthesis is a devastating complication that necessitates the removal of all device components. Many aspects of preoperative and intraoperative infection prophylaxis practices have been examined but the specific relevant factors remain unknown. We determined whether use of a mandatory checklist of perioperative practices believed to reduce the risk of prosthesis infection would impact patient safety. MATERIALS AND METHODS: We retrospectively reviewed men with erectile dysfunction who underwent penile prosthesis insertion. Only patients who had not previously undergone penile prosthesis surgery were included in the study. After an outbreak of infections, a mandatory checklist comprised of best infection prophylaxis practices was developed and was required for all subsequent implant surgeries. Patient cohorts were divided into 3 groups of baseline period, outbreak period and intervention period. Statistical analysis was performed using the chi-square test, Fisher's exact test and ANOVA. RESULTS: During the baseline period 2 of 68 (2.9%) inflatable penile prosthesis devices became infected. During the outbreak period 6 of 11 (54.5%) devices became infected, representing an incidence risk ratio 18.55 times that of the baseline period. After the implementation of the preoperative checklist the incidence risk ratio decreased to 0.0 in the intervention period with 0 of 52 devices (0%) becoming infected. CONCLUSIONS: After an outbreak of an unusually high number of penile prosthesis infections, implementation of a required checklist brought the rate down to zero. Although the specific factors that led to the infection outbreak and subsequent cessation of infections are unknown, we have shown that use of a checklist was associated with a dramatic impact on patient safety.

Lifestyle, environment, and male reproductive health.

A large number of environmental and lifestyle factors may negatively affect spermatogenesis and male fertility. This article enumerates the current state of knowledge regarding those that have been identified, and extrapolates the predicted magnitude of these effects over the next 20 years based on current societal trends. However, it is likely that additional factors have yet to be recognized. Additional research is needed to further define and clarify environmental factors that affect male fertility in order to mitigate their effects.

Aggressive angiomyxoma of the scrotum.

INTRODUCTION: Aggressive angiomyxoma (AAM) is a rare, benign mass with propensity for local invasion and recurrence after resection. Infrequently, this tumor can be found arising from the scrotum or cord structures in males. AIM/METHODS: A case report is presented followed by a review of relevant literature addressing the diagnosis, imaging, management and follow-up for aggressive angiomyxoma of the scrotum. RESULTS: Imaging can assist in further characterization of masses noted on physical exam. Scrotal sonography is typically the primary imaging modality utilized and magnetic resonance imaging is able to provide further anatomic detail. Treatment mainstay is surgical resection with necessary long term surveillance.

Penile ossification: A traumatic event or evolutionary throwback? Case report and review of the literature.

Penile ossification is very rare, with only a handful of histologically confirmed reported cases. The most common condition leading to penile ossification is Peyronie's disease. Other conditions, such as gout, end-stage renal disease, diabetes mellitus, hyperparathyroidism and local trauma, have also been associated with penile ossification. We report a unique case of near-complete penile ossification of the corporal bodies with histologic confirmation on pathologic review. Our report summarizes the literature regarding this rare entity.

A rare case of metastatic lung cancer to the bladder.

Cancer metastasis to the bladder from non-contiguous sites is very rare. Lung metastasis to the bladder is even more uncommon, with an extensive literature search identifying only four documented cases in the past 20 years. Of these four cases, only one was from lung adenocarcinoma. In this report, we present the case of a 66-year-old male with known lung adenocarcinoma found to have the incidental finding of a bladder mass upon computed tomography imaging. Histochemical staining of samples from the bladder confirmed metastatic dissemination from the primary lung malignancy.

Rare case of paratesticular solitary fibrous tumour (lipomatous hemangiopericytoma).

A 26-year-old male presented with an asymptomatic 6-cm left paratesticular mass. Ultrasound and magnetic resonance imaging confirmed this mass as extratesticular, likely a tumour arising from the left spermatic cord. The mass demonstrated marked avid enhancement on post-contrast images, suggestive of a spermatic cord sarcoma. A left inguinal exploration was performed and gross examination of the mass revealed a well-circumscribed tumour with a discrete capsule separating it from the ipsilateral spermatic cord. The mass was resected without performing an orchiectomy and histology demonstrated a solitary fibrous tumour (lipomatous hemangiopericytoma), with minimal proliferative activity and negative margins. The occurrence of a paratesticular solitary fibrous tumour is exceedingly rare, with only a handful of case reports. We review the literature regarding this rare entity and discuss its diagnosis and management.

Management of ejaculatory disorders in infertile men.

Ejaculatory dysfunction is a highly prevalent clinical condition that may be classified along a continuum that ranges from premature ejaculation (PE), through retarded or delayed ejaculation (DE), to complete anejaculation (AE). Retrograde ejaculation (RE) represents a distinct entity in which ejaculate is expelled either partially or completely into the bladder. While DE and PE are significant sources of sexual dissatisfaction among men and their partners, patients with these disorders retain normal fertility in most cases. Conversely, men with AE and RE are unable to deliver sperm into the female genital tract and are therefore rendered subfertile. Therefore, in reviewing ejaculatory disorders as they relate to fertility, this paper will primarily focus on the diagnosis and management of AE and RE. Physiology, diagnostic strategies, pharmacological treatments, and procedural interventions relevant to AE and RE are discussed.

Carcinosarcoma of the bladder: case report and review of the literature.

Primary osteosarcomas of the bladder account for about 0.04% of bladder neoplasms. Most of the patients in the literature expired within 6 months and, in almost all of the cases in the literature, radical cystectomy with postoperative chemotherapy was the treatment choice. A 79-year-old gentleman presented with gross hematuria. Cystoscopy demonstrated a 2- to 3-cm tumour along the lateral wall of the bladder. The tumour was resected incompletely via initial transurethral resection of bladder tumour (TURBT), and a second TURBT was subsequently performed to fully resect the residual mass. Surgical pathology from these 2 resections revealed osteosarcoma with invasion into the muscularis propria. A cystoprostatectomy was performed and final pathologic specimen revealed high-grade CIS without evidence of residual osteosarcoma. Postoperatively, the patient did not receive chemotherapy or radiation and currently remains disease-free 2 years post-radical cystectomy. Only 33 well-documented cases of primary osteosarcoma of the bladder have been reported to date. However, there are only 3 cases in which TURBT resulted in complete resection.

Other work has highlighted the limitations of using histopathology to predict success after varicocelectomy.

The morbidity associated with performing testicular biopsy on all men before varicocele repair appears to outweigh the benefit of any prognostic information obtained.

Chronic viral hepatitis and hepatocellular carcinoma.

BACKGROUND: Hepatocellular carcinoma (HCC) is the third leading cause of death from malignancy worldwide, and its increasing incidence parallels rising global rates of hepatitis B (HBV) and hepatitis C (HCV). METHODS: This retrospective review was undertaken to identify differences in the epidemiology and tumor characteristics of 255 patients with HCC due to chronic HBV (n = 105) or HCV (n = 150). RESULTS: Hepatitis B patients were predominantly Asian (84%), whereas HCV patients were predominantly Caucasian (72%; p < 0.0001). Hepatitis B patients exhibited stronger family histories of liver disease (54%) and HCC (33%), whereas HCV risk factors included blood transfusion (56%), intravenous drug abuse (31%), and alcohol consumption (44%; p < 0.0001 for all comparisons). Pretreatment laboratory values showed lower albumin and platelet levels but higher bilirubin and AST levels in HCV versus HBV patients (p < 0.0001 to 0.01). As cirrhosis was present in nearly all HCV patients, but only in 79% of HBV patients, HCV patients had more stigmata of portal hypertension, including ascites (65%), varices (86%), splenomegaly (77%), and encephalopathy (41%; p < 0.0002 for all comparisons). Although tumors in HBV patients were larger (7.3 cm versus 5.1 cm; p = 0.0001) and more frequently bilobar, the tumor grade, number of tumors, and metastases were similar for both groups. Hepatitis C patients received less treatment, including chemoembolization and surgical resection. The 5-year survival was higher in HBV patients compared to HCV patients (56% versus 36%, p = 0.046). CONCLUSIONS: Patients with HBV- and HCV-related HCC have different epidemiologic, clinical, and survival characteristics. More HCV patients presented with advanced cirrhosis, received less aggressive treatment, and experienced lower 5-year survival.