Advanced sperm testing.

PURPOSE OF REVIEW: The sensitivity of semen analysis for detection of infertility remains low. Many factors not measured in traditional semen analysis may contribute to male factor infertility. DNA fragmentation, oxidative stress, and sperm aneuploidy are three factors that may contribute further information to the evaluation when semen analysis is inconclusive. RECENT FINDINGS: DNA fragmentation measures the destruction of and failure to repair damage to DNA. Increased DNA fragmentation has been used as a marker for oxidative stress as well as toxic exposure. The oxidative stress adduct measures DNA aberrations, which sperm cannot repair and has been used to support use of antioxidants. Lastly, the aneuploid sperm frequency is a quantitative measure of deviation from the normal chromosomal complement. Although elevated sperm aneuploid frequency has been associated with recurrent pregnancy loss and implantation failures, barriers remain to its routine use. SUMMARY: We identified these three adjunctive tests, which have the potential to alter either management or counseling of patients with regards to male factor infertility. Elevated DNA fragmentation or significant sperm aneuploidy may suggest the need for further investigation or further preimplantation genetic testing prior to IVF. The oxidative stress adduct may lend further explanation and improved counseling of the infertile patient.

Cryptozoospermia Associated With Genital Tucking Behavior in a Transwoman.

Transwomen may elect to pursue fertility preservation prior beginning hormonal treatment or proceeding with gender-affirming surgery. To date, there has been little research specifically investigating factors influencing fertility and preservation thereof among transwomen. Here, we review the case of a transwoman who engaged in genital tucking behavior presenting with severe oligospermia, and we review the literature regarding transgender fertility preservation and the role of the heat stress hypothesis with regards to this common behavior.

Advanced paternal age does not affect embryo aneuploidy following blastocyst biopsy in egg donor cycles.

PURPOSE: To study the impact of advanced paternal age on embryo aneuploidy. METHODS: This is a multicenter international retrospective case series of couples undergoing assisted reproduction via in vitro fertilization using donor eggs to control for maternal factors and preimplantation genetic testing for aneuploidy via next-generation sequencing at Igenomix reproductive testing centers. The main outcome measure was the prevalence of embryo aneuploidy in egg donor cycles. Semen analysis data was retrieved for a small subset of the male patients. RESULTS: Data from 1202 IVF/ICSI egg donor cycles using ejaculated sperm (total 6934 embryos) evaluated using PGT-A between January 2016 and April 2018 in a global population across all Igenomix centers were included. No significant association was identified between advancing paternal age and the prevalence of embryo aneuploidy overall and when analyzing for each chromosome. There was also no significant association between advancing paternal age and specific aneuploid conditions (monosomy, trisomy, partial deletion/duplication) for all chromosomes in the genome. CONCLUSIONS: This is the largest study of its kind in an international patient population to evaluate the impact of advancing paternal age on embryo aneuploidy. We conclude there is no specific effect of paternal age on the prevalence of embryo aneuploidy in the context of embryo biopsies from egg donor cycles.

Infection Prevention Considerations for Complex Penile Prosthesis Recipients.

PURPOSE OF REVIEW: The purpose of this review is to critically analyze and summarize recent studies in the area of penile prosthesis surgery outcomes with a focus on infection prevention in high-risk patients. RECENT FINDINGS: Reduction of surgical time in complex prosthesis surgery may reduce infection risk. Concomitant implant surgery is not associated with increased infection risk. Certain immunocompromised patients may be more likely to have penile implant infections, but these may not include patients with well-controlled HIV, well-controlled diabetes, or transplant recipients. Substance abuse is correlated with increased risk of infection after penile implant surgery. Careful patient selection and preoperative optimization can reduce infection risk in spinal cord injury patients. In the last 5 years, there have been several important studies investigating the risk of penile prosthesis infection in complex patients, clarifying which patient categories are at increased risk and how that risk can be mitigated.

Transurethral ablation of a prostatic utricle cyst with the use of a holmium laser.

OBJECTIVE: To demonstrate a safe and effective approach to the treatment of obstructing midline prostate utricle cyst with the use of a holmium laser. DESIGN: Video presentation. SETTING: University hospital. PATIENT(S): A 33-year-old man presented with chronic pelvic pain, pain with ejaculation, and infertility. Semen analysis demonstrated oligoasthenospermia with poor viability and computerized tomographic scan identified the presence of a midline 2-3-cm prostatic cyst with dilated seminal vesicles bilaterally. Transrectal ultrasound in the office confirmed the diagnosis of midline obstructing prostatic utricle cyst and estimated the distance from the urethra. INTERVENTION(S): Transurethral ablation of a midline prostate utricle cyst with the use of a holmium laser. MAIN OUTCOME MEASURE(S): Intraoperative technique highlighting the main steps for a transurethral ablation of a midline prostate utricle cyst with the use of a holmium laser. RESULT(S): This video highlights the technique for transurethral ablation of a midline prostate utricle cyst with the use of a holmium laser to unroof the cyst. Retrograde vesiculography was performed to confirm patency of the ejaculatory ducts. Outpatient surgery was tolerated well and the patient was discharged. After surgery at 4 weeks, his symptoms had abated and semen analysis revealed normozoospermia. CONCLUSION(S): We demonstrate safe and effective transurethral ablation of a midline prostate utricle cyst with the use of a holmium laser. Preoperative transrectal ultrasound or cross-sectional imaging can be useful for operative planning. When the orifices of the ejaculatory ducts can be identified, vesiculography can be performed to confirm patency of the ducts and seminal vesicles after relief of the obstructing cyst.

Infection Prevention Strategies Prior to Penile Implant Surgery.

CONTEXT: Over the last 4 decades, penile implant surgery has advanced significantly. Penile implant infection prevention continues to be an active area of research due to the significant patient morbidity associated with infection. OBJECTIVE: To summarize current approaches and supporting data for infection prevention. EVIDENCE SYNTHESIS: Common approaches to infection prevention include careful patient selection and preoperative evaluation, broad-spectrum antimicrobial prophylaxis, and modifications to surgical technique that minimize skin contact and postoperative hematoma formation. CONCLUSION: Many of these measures have proven efficacious, but our knowledge regarding the pathophysiology of penile prosthesis infection continues to evolve and demands continued efforts towards infection prevention.

Multicenter Investigation of the Micro-Organisms Involved in Penile Prosthesis Infection: An Analysis of the Efficacy of the AUA and EAU Guidelines for Penile Prosthesis Prophylaxis.

INTRODUCTION: Penile prosthesis infections remain challenging despite advancements in surgical technique, device improvements, and adoption of antibiotic prophylaxis guidelines. AIM: To investigate penile prosthesis infection microbiology to consider which changes in practice could decrease infection rates, to evaluate current antibiotic prophylaxis guidelines, and to develop a proposed algorithm for penile prosthesis infections. METHODS: This retrospective institutional review board-exempt multi-institutional study from 25 centers reviewed intraoperative cultures obtained at explantation or Mulcahy salvage of infected three-piece inflatable penile prostheses (IPPs). Antibiotic usage was recorded at implantation, admission for infection, and explantation or salvage surgery. Cultures were obtained from purulent material in the implant space and from the biofilm on the device. MAIN OUTCOME MEASURES: Intraoperative culture data from infected IPPs. RESULTS: Two hundred twenty-seven intraoperative cultures (2002-2016) were obtained at salvage or explantation. No culture growth occurred in 33% of cases and gram-positive and gram-negative organisms were found in 73% and 39% of positive cultures, respectively. Candida species (11.1%), anaerobes (10.5%) and methicillin-resistant Staphylococcus aureus (9.2%) constituted nearly one third of 153 positive cultures. Multi-organism infections occurred in 25% of positive cultures. Antibiotic regimens at initial implantation were generally consistent with American Urological Association (AUA) and European Association of Urology (EAU) guidelines. However, the micro-organisms identified in this study were covered by these guidelines in only 62% to 86% of cases. Antibiotic selection at admissions for infection and salvage or explantation varied widely compared with those at IPP implantation. CONCLUSION: This study documents a high incidence of anaerobic, Candida, and methicillin-resistant S aureus infections. In addition, approximately one third of infected penile prosthesis cases had negative cultures. Micro-organisms identified in this study were not covered by the AUA and EAU antibiotic guidelines in at least 14% to 38% of cases. These findings suggest broadening antibiotic prophylaxis guidelines and creating a management algorithm for IPP infections might lower infection rates and improve salvage success. Gross MS, Phillips EA, Carrasquillo RJ, et al. Multicenter Investigation of the Micro-Organisms Involved in Penile Prosthesis Infection: An Analysis of the Efficacy of the AUA and EAU Guidelines for Penile Prosthesis Prophylaxis. J Sex Med 2017;14:455-463.

5-Alpha-reductase inhibitors in diseases of the prostate.

PURPOSE OF REVIEW: To summarize the history of the use of 5-alpha-reductase inhibitors in the treatment of urologic diseases and discuss the current practices and indications for therapy. RECENT FINDINGS: 5-Alpha-reductase inhibitors (5-ARIs) are indicated in the treatment of benign prostatic hyperplasia (BPH) with obstructive urinary symptoms to reduce symptoms, reduce the risk of acute urinary retention, and reduce the risk of needing surgical management for this condition. These drugs have also been employed in the treatment of recurrent and refractory hematuria of prostatic origin because of their effect on the androgen-mediated angiogenic pathways in the prostate. Data support the use of 5-ARIs for this indication, though this is off-label use. There is no role for the use of 5-ARIs in primary prostate cancer chemoprevention and they may increase the risk of developing high-grade prostate cancer. Current investigations are underway to determine the efficacy of 5-ARIs in the secondary treatment of localized prostate cancer as adjunctive therapy, which may decrease the likelihood of prostate cancer progression and increase the likelihood that patients will remain on active surveillance. SUMMARY: 5-ARIs have significantly impacted the medical treatment of urologic disease, in particular BPH, and prostatic hematuria. Their use in the secondary treatment of prostate cancer is currently under investigation.