Testosterone deficiency in men with end stage renal disease and kidney transplantation: a narrative review.

Testosterone deficiency is a prevalent condition that frequently affects individuals with end-stage renal disease (ESRD) and those who have undergone renal transplantation. While the etiology of this condition is complex, its implications in this population are far-reaching, impacting various domains such as endocrine profile, sexual and erectile function, bone mineral density (BMD), anemia, and graft survival following renal transplantation. Herein, we review the most recent literature exploring the pathophysiology of testosterone deficiency in ESRD and renal transplant patients, examining its diverse effects on this demographic, and assessing the advantages of testosterone replacement therapy (TRT). Existing evidence suggests that TRT is a safe intervention in ESRD and renal transplant patients, demonstrating improvements across multiple domains. Despite valuable insights from numerous studies, a critical need persists for larger, high-quality prospective studies to comprehensively grasp the nuances of TRT, especially in this vulnerable population. Proactive screening and treatment of testosterone deficiency may prove beneficial, emphasizing the urgency for further research in this area.

Impact of pre- and peri-operative risk factors on length of stay and hospital readmission following minimally-invasive partial nephrectomy.

Objective: We conducted an analysis of the American College of Surgeons National Surgical Quality Improvement Program database for minimally-invasive partial nephrectomy cases reported with the goal to identify pre- and peri-operative variables associated with length of stay (LOS) greater than 3 days and readmission within 30 days. Methods: Records from 2008 to 2018 for "laparoscopy, surgical; partial nephrectomy" for prolonged LOS and readmission cohorts were compiled. Univariate analysis with Chi-square, t-tests, and multivariable logistic regression analysis with odds ratios (ORs), p-values, and 95% confidence intervals assessed statistical associations. Results: Totally, 20 306 records for LOS greater than 3 days and 15 854 for readmission within 30 days were available. Univariate and multivariable analysis exhibited similar results. For LOS greater than 3 days, undergoing non-elective surgery (OR=5.247), transfusion of greater than four units within 72 h prior to surgery (OR=5.072), pre-operative renal failure or dialysis (OR=2.941), and poor pre-operative functional status (OR=2.540) exhibited the strongest statistically significant associations. For hospital readmission within 30 days, loss in body weight greater than 10% in 6 months prior to surgery (OR=2.227) and bleeding disorders (OR=2.081) exhibited strongest statistically significant associations. Conclusion: Multiple pre- and peri-operative risk factors are independently associated with prolonged LOS and hospital readmission within 30 days of surgery using the American College of Surgeons National Surgical Quality Improvement Program data. Recognizing the risks factors that can potentially be improved prior to minimally-invasive partial nephrectomy is crucial to informing patient selection, optimization strategies, and patient education.

A phase 2 randomized, placebo-controlled crossover trial to evaluate safety and efficacy of platelet-rich plasma injections for Peyronie's disease: clinical trial update.

Peyronie's Disease (PD) is characterized by fibrotic plaques in the penile tunica albuginea, causing curvature and painful erections. Current treatments have limited established efficacy. Platelet-Rich Plasma (PRP), known for modulating inflammation, offers a potential alternative. This randomized, placebo-controlled, crossover study at the University of Miami assesses PRP's safety and efficacy for PD. Forty-one PD patients were randomized into PRP-placebo (Group A) and placebo-PRP (Group B) sequences, receiving two injections of each treatment over three months, with a crossover to receive two injections of alternate treatment over the next three months. Assessments include pain scale, goniometry, questionnaires, and curvature evaluations. Preliminary analysis of 28 patients shows that PRP is safe. There were no adverse events, including penile complications, during follow-up. Pain scores during treatments showed no significant difference between PRP and placebo (p = 0.52). Over six months, the PRP-Placebo group's median PDQ score decreased from 1.9 (IQR: 1.7-2.9) to 1.4 (IQR: 0.7-2.1). This change was not statistically significant (p = 0.098). In contrast, the Placebo-PRP group showed a significant reduction from 1.8 (IQR: 1.4-2.6) to 1.2 (IQR: 1.0-2.0) (p = 0.020). No significant changes in IIEF scores were observed. Both groups initially had a median penile curvature of 40 degrees. At 3 months, the PRP-Placebo group's curvature decreased to 38 degrees (IQR: 35-47.5), while the Placebo-PRP group decreased to 35 degrees (IQR: 30-60). At 6 months, the PRP-Placebo group showed a significant reduction to 25 degrees (IQR: 20-40, p = 0.047), while the Placebo-PRP group's reduction to 32.5 degrees (IQR: 20-50) was not significant (p = 0.490). These early results indicate a delayed PRP effect, prompting further investigation into its long-term impacts. Although limited by sample size, this study suggests PRP injections as a safe treatment for PD, with ongoing research aiming to clarify its therapeutic value.

Isolation and In Vitro Propagation of Human Spermatogonial Stem Cells (SSCs).

Preservation of human spermatogonial stem cells (SSCs) may be suitable for young male patients at risk of male infertility due to various causes, such as gonadotoxic treatment or genetic diseases. With optimal cryopreservation, cell viability can be retained to reestablish spermatogenesis in the future through autologous transplantation or in vitro differentiation of SSCs. This protocol outlines techniques to optimize the SSCs isolation and in vitro culture. With particular emphasis on the microscopic characteristics encountered, this protocol outlines a broader approach to processing tissues with varying morphologies among patients.

Research trends in testosterone deficiency and management: A bibliometric analysis approach to quality improvement in urology resident education.

INTRODUCTION: Previous work has demonstrated a deficiency in urology resident education when it comes to andrology and male infertility. We analyzed the top 100 most frequently cited and influential articles published on testosterone deficiency and its associated therapy, allowing trainees and clinicians to review and understand the characteristics of impactful literature for self-directed learning purposes. METHODS: The ISI Web of Knowledge database was used to find articles on testosterone deficiency, hypogonadism, and replacement therapies. Relevant, peer-reviewed, English articles were included. Article details, including title, citation count, publication year, and more, were gathered. Articles were classified based on content (e.g. clinical outcomes, anatomy, and trends) using defined criteria. RESULTS: The top 300 most cited were reviewed with 100 included. The most cited article had 774 citations, averaging 234 in the top 100. Publication years had peaks in 2003-2004 and 2006-2007. The US led in publications (56), followed by England (16), Germany (14), and Italy (13). Common affiliations included US Department of Veteran Affairs, Veterans Health Administration, RIC Research Education Clinical Center, and University of California System. Articles were categorized as LOE 2 (47), LOE 1 (22), and LOE 5 (21). Articles focused on clinical outcomes (71.7%), anatomy/biomechanics/physiology (14.1%), clinical guidelines (8.1%), and screening (4%). The "Journal of Clinical Endocrinology & Metabolism" published 26 of the top 100 cited articles. CONCLUSIONS: This analysis highlights influential articles regarding testosterone deficiency and management. The discussed articles have significant clinical and therapeutic implications for the practicing urologist which may bolster deficits in current resident education.

Persistent need for ongoing medical or surgical therapy despite UroLift: Data from an academic center.

INTRODUCTION: The prostatic urethral lift (PUL) is a popular surgical option for benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS). Prior 5-year data from the multicenter L.I.F.T. trial suggested durability and a surgical retreatment rate of 13.6% at five years. We assessed the proportion of patients who had ongoing medical or surgical BPH management following PUL. METHODS: With institutional review board approval, cases of PUL performed from 2015-2020 at our academic institution were retrospectively reviewed for management of BPH following PUL. RESULTS: A total of 209 men were identified, with followup available for 198 (95%). Mean age was 68.9 years and mean followup was 18.5 months. Mean prostate size was 43 g. Patients were discharged from recovery in 97% of cases, with 29% discharged with indwelling or intermittent catheterization. The rate of 30-day complications was 18%, with 89% graded Clavien I-II. Postoperatively, mean improvements in International Prostate Symptom Score (IPSS) and quality of life subscore (QoL) were 5.3 and 1.1 points, respectively. Unplanned emergency room or clinic visits within 30 days of the procedure occurred in 14% and 17% of men, respectively, with 4% requiring hospital readmission. In followup, α-blockers and/or 5α-reductase inhibitors were continued or initiated postoperatively for 44% of men; 20% of men required repeat surgical intervention at a mean of 19.2 months (1.4-56.4), consisting of repeat PUL (30%), transurethral resection of prostate (28%), or thulium laser enucleation (18%). Overall, 53% of men needed medication and/or repeat surgery for BPH following PUL, and this was independent of age, race, prostate volume, intravesical prostate protrusion, baseline IPSS and QOL, stricture, number of implants used, or a history of urinary retention (p>0.05). CONCLUSIONS: Most men undergoing PUL require ongoing medical and/or surgical management for BPH. Patients should be counseled as to the likelihood of failure as a unimodal therapy long-term.

Age-dependent effect on contralateral testicular compensation after testicular loss.

OBJECTIVE: To study compensatory changes in testicular growth and the hormonal axis after unilateral orchiectomy in a neonatal, prepubertal, and pubertal/adult murine model. This is the first study to use a neonatal mouse survival surgery model. DESIGN: A laboratory-based study examining a control, neonatal, prepubertal, and pubertal/adult mouse model. SETTING: University-based basic science research laboratory. ANIMALS: Control, neonatal (2-4 days of life), prepubertal (12-21 days of life), and pubertal/adult (42-44 days of life) C57BL/6 mouse models. INTERVENTION: Unilateral orchiectomy in the neonatal, prepubertal, and pubertal/adult mouse models at their respective ages. MAIN OUTCOME MEASURES: Body and testis weight and testicular length in the long axis were measured in a blinded fashion. In a similar way, testosterone, luteinizing hormone (LH), and follicle-stimulating hormone were assessed. RESULTS: Testes from neonatal and prepubertal mice weighed more (110.5, 12.2 and 103.0, 7.2 mg, respectively) than the control mice (91, 11.9 mg). There was no difference between the postpubertal group and the control group. The degree of compensatory hypertrophy was greater in the neonatal group but not in the prepubertal group when compared with the postpubertal group. Differences in follicle-stimulating hormone and testosterone were not statistically significant between the experimental and control arms. LH was significantly elevated in all experimental groups compared with the control. CONCLUSIONS: This is the first study to assess testicular compensatory hypertrophy using a neonatal mouse survival surgery model. Testicular hypertrophy occurs when unilateral loss occurs before puberty, but not in adulthood in mice. Earlier testis loss may contribute to a greater degree of growth. Functionally, the unilateral testis can maintain eugonadal testosterone levels, but higher levels of LH are required after hemicastration to sustain eugonadal testosterone levels.

A Case Report on "Pearling": Removal of Infected Objects During Circumcision.

The insertion of foreign bodies underneath the skin of the penis is commonly referred to as "pearling." Although rare, there are case reports that describe acute complications such as infection and damage to surrounding penile neurovascular structures; however, there is a paucity of data describing long-term complications and surgical management of such cases. A 43-year-old male presented with a penile abscess secondary to "pearling" five years after insertion. His abscess was drained and selected foreign objects were subsequently removed during a simultaneous circumcision procedure. This report describes a case in which surgical removal of penile foreign bodies was performed during a circumcision without the need for additional incisions. The case is unique in that it details a complication five years after initial insertion with microbiological data to guide adequate treatment.

Factors Associated With Restarting Androgenic Anabolic Steroids After Cessation in Men With Infertility: A Retrospective Analysis.

Introduction The use of androgenic anabolic steroids (AAS) negatively affects male fertility by disrupting hormone release and reducing testosterone levels. Despite this, many men using steroids are unaware of fertility-related consequences. We aimed to determine the factors associated with AAS resumption during fertility treatment, specifically focusing on the duration, age, and dosage of AAS use prior to treatment. Our study, the first of its kind, investigated risk factors for resuming AAS following fertility assessment. Methods We conducted a retrospective review of adult men diagnosed with infertility due to chronic AAS use between 2012 and 2022 at the University of Miami. The study included men with azoospermia or severe oligospermia who were instructed to stop using AAS. Excluded were those who underwent orchiectomy for benign or malignant conditions. We collected data on demographic characteristics, AAS route details, fertility treatments, and AAS resumption. We hypothesized that risk factors for restarting AAS would include duration of AAS use, type of AAS, pre-treatment testosterone levels, and increased age. Results We identified 94 men with infertility caused by AAS use. Among them, 31 (33.0%) resumed AAS therapy within eight months after cessation. The median age of men who restarted AAS was 40 years. Those who resumed AAS had used it for a longer duration prior to fertility assessment compared to those who did not (60 months vs. 17 months, respectively). However, we found no statistically significant differences in age, duration of AAS use, AAS administration details, or serum testosterone levels at the time of initial assessment. Conclusion In conclusion, most men seeking fertility assessment due to AAS abuse did not resume testosterone therapy. However, those who did restart AAS had a longer history of AAS use. Future high-quality prospective studies are needed to better understand the risk factors associated with resuming AAS in male infertility caused by anabolic steroids.

ChatGPT Performance on the American Urological Association Self-assessment Study Program and the Potential Influence of Artificial Intelligence in Urologic Training.

OBJECTIVE: To assess chat generative pre-trained transformer's (ChatGPT) performance on the American Urological Association Self-Assessment Study Program (AUA SASP) and stratify performance by question stem complexity. METHODS: Questions from the 2021-2022 AUA SASP program were administered to ChatGPT version 3 (ChatGPT-3). Questions were administered to the model utilizing a standardized prompt. The answer choice selected by ChatGPT was then used to answer the question stem in the AUA SASP program. ChatGPT was then prompted to assign a question stem order (first, second, third) to each question. The percentage of correctly answered questions was determined for each order level. All responses provided by ChatGPT were qualitatively assessed for appropriate rationale. RESULTS: A total of 268 questions were administered to ChatGPT. ChatGPT performed better on 2021 compared to the 2022 AUA SASP question set, answering 42.3% versus 30.0% of questions correctly (P < .05). Hundred percent of answer explanations provided appropriate, relevant rationale regardless of whether the answer was correct. Further stratification included assessment by question order level. ChatGPT performed progressively better on the 2021 question set with decreasing order levels, with first-order questions reaching 53.8% (n = 14). However, differences in proportions did not reach statistical significance (P > .05). CONCLUSION: ChatGPT answered many high-level questions correctly and provided a reasonable rationale for each answer choice. While ChatGPT was unable to answer numerous first-order questions, future language processing model learning may lead to the optimization of its fund of knowledge. This may lead to the utilization of artificial intelligence like ChatGPT as an educational tool for urology trainees and professors.

Efficacy and safety outcomes of a compounded testosterone pellet versus a branded testosterone pellet in men with testosterone deficiency: a single-center, open-label, randomized trial.

Background: Testosterone deficiency (TD) is a prevalent condition, especially in men ≥45 years old, and testosterone therapy (TTh) can improve the quality of life in these patients. Aim: To evaluate the safety profile of compounded subcutaneous testosterone pellets and to compare the efficacy between compounded and market brand testosterone pellets for TTh: E100 (Empower Pharmacy) and Testopel (Food and Drug Administration approved), respectively. Methods: This was a prospective, phase 3, randomized, noninferiority clinical trial. We enrolled 75 men diagnosed with TD and randomized them 1:1 to a market brand group and a compounded pellet group. The patients were implanted with their respective testosterone pellets: Testopel (10 pellets of 75 mg) and E100 (8 pellets of 100 mg). Outcomes: We evaluated adverse events after implantation and followed men at 2, 4, and 6 months for morning laboratory levels (prior to 10 am): serum testosterone, estradiol, hematocrit, and prostate-specific antigen. Results: After randomization, 33 participants were enrolled in the Testopel arm and 42 in the E100 arm. Serum testosterone levels were similar between the groups at 2, 4, and 6 months, with most men (82%) dropping to <300 ng/dL by the end of the trial. Adverse events were also similar, such as elevations in prostate-specific antigen, estradiol, and hematocrit. Most dropouts were related to persistent TD symptoms and serum testosterone <300 ng/dL, with similar rates between the groups in the study. Clinical Implications: Men treated with Testopel and E100 pellets had comparable serum testosterone levels and similar adverse event rates, providing an effective choice of long-term TTh among men with TD. Strengths and Limitations: Strengths include the prospective, randomized, single-blinded study design and adequate follow-up. Limitations include the lack of external validity and the single-institution cohort. Conclusion: E100 compounded testosterone pellets are a noninferior option of TTh as compared with Testopel for men presenting with TD.

Investigating the Impact of Kratom (Mitragyna speciosa) Use Upon Male Sexual Health.

Purpose: Kratom (Mitragyna speciosa) exhibits µ-receptor agonism and is used as an opioid substitute. While opioids are known to inhibit sexual behavior, less is known regarding kratom. We conducted a pilot study to assess the subjective impact of kratom upon male sexual health including erectile and ejaculatory function. Patients and Methods: Twitter and Reddit (r/Kratom) were accessed to disseminate our survey featuring validated instruments (the International Index of Erectile Function, IIEF, and the premature ejaculation diagnostic tool, PEDT). Sexual health prior to and after 4 weeks of kratom use was assessed. Results: Most males surveyed (n = 165) were 18-40 years old (84.9%), with 95.8% of respondents using it at least weekly and 82.4% using kratom for ≥1 year. Reasons for use included treating pain (39.4%), and mental health conditions (63.6%). Kratom was associated with a positive (37.7%) and negative (20.5%) impact on sexual health. Kratom subjectively increased time to ejaculation in 104 (66.6%) patients, perceived as positive by 62 (59.6%). Seventy-eight patients answered questions about premature ejaculation. The median (with interquartile range, IQR, following;) pre-kratom and kratom use scores were 13.0; 8.0 and 6.5; 5.0, respectively (p < 0.001). Ejaculation before 5 minutes improved after kratom (51.3% vs 12.8%) (p < 0.0001). Following kratom use, patients reported lack of frustration with ejaculation prior to desire (21.8% vs 61.5%) (p < 0.001). The erectile function domain of the IIEF was statistically significantly different however - clinically similar pre-kratom use (29.0; 5.75) versus 27.0; 6.75 during kratom use (p = 0.037). Conclusion: Clinicians treating male sexual health should be aware of kratom and its potential effect on ejaculatory and erectile function.

Examining potential mechanisms of testicular fibrosis in Klinefelter Syndrome: A review of current understanding.

BACKGROUND: Men with Klinefelter Syndrome develop some degree of seminiferous tubule degeneration, hyalinization, and fibrosis by adulthood. However, the pathophysiology surrounding testicular fibrosis in Klinefelter Syndrome patients remains incompletely understood. OBJECTIVES: To perform a systematic review of literature studying the mechanisms of fibrosis initiation or propagation in Klinefelter Syndrome testes. MATERIALS/METHODS: PubMed was searched systematically for articles specific to Klinefelter Syndrome and the process of fibrosis. Articles that did not contain original data or specifically addressed the target material were excluded. Additional references were extracted when pertinent from the reference lists of included studies. RESULTS: Primary search yielded 139 articles for abstract review, which was narrowed to 16 for full-text review. Following full-text review, eight contained original data and met topic criteria, with one paper added from reference review for a total of nine papers. DISCUSSION: The date range for included papers was 1992-2022. The proposed mechanisms of fibrosis mainly were centered around the impact of altered Sertoli cells on germ cells, the hormonal impact on Leydig cells, the inflammation mediated by mast cells, or the fibrous extracellular matrix deposition by peritubular myoid cells. Additionally, discussions of the role of the altered microvasculature and the specific proteins involved in the blood-testis barrier or the seminiferous tubule architecture are reviewed. Recent papers have incorporated advanced sequencing and offer future directions for targeted gene expression analysis. Still, much of the published data consists solely of immunohistological assessment by age range, creating difficulties in extrapolating causality. CONCLUSION: The specific initiating factors of fibrosis of the seminiferous tubules and the propagation mechanisms unique to Klinefelter Syndrome remain incompletely understood with a relative paucity of data. Nonetheless, academic interest is increasing in this field as it may further elucidate the pathophysiology behind Klinefelter syndrome.

A Comparative Analysis of Ergonomic Risk Utilizing the 4K-3D Exoscope Versus Standard Operating Microscope for Male Fertility Microsurgery.

OBJECTIVE: To stratify ergonomic risk in a urologic microsurgeon using the 4K-3D exoscope versus the operating microscope (OM) with wearable technology. METHODS: The surgeon was calibrated with wearable sensor inertial measurement units (IMUs) on the head and upper arms. Each inertial measurement units contained an accelerometer, magnetometer, and gyroscope to measure surgeon joint angle change during microscopic procedures for male fertility. The validated modified rapid upper limb assessment was used to determine the proportion of time spent in ranges of risk. Categories 1-4 were assigned for the head and upper extremities (4= highest ergonomic risk). Chi-squared analysis was used to analyze differences in proportions. RESULTS: A total of 500 and 479 minutes from 4K-3D exoscope and OM guided surgeries were analyzed. The 4K-3D exoscope significantly favored upper arm category 1 positioning compared to the OM (56.2% vs 37.7%; P < .0001). The OM exposed the surgeon to higher category 3 positioning (14.6% vs 1.6%; P <.0001). More time was spent with the neck "extended" using the 4K-3D exoscope (51.8% vs 19.5%; P < .0001) with 67% of neck extension between 0-10° (category 1). Overall, more time was spent with the neck in risk group 1-2 with the OM (P < .0001). CONCLUSION: The 4K-3D exoscope offers favorable ergonomic positioning for the upper extremities which may reduce work stress-related injury. More operative time was spent with the neck in mild extension with 4K-3D exoscope utilization. However, the OM favored longer operative times in low-risk neck ergonomic positions.

Fertility Preservation in Adolescents with Klinefelter Syndrome is Experimental but May Increase Therapeutic Options for Biological Paternity.

While approximately half of adult Klinefelter syndrome (KS) patients have retrievable sperm on micro testicular sperm extraction, success is limited by testicular hyalinization beginning at puberty. Recent surgical and laboratory advances lend themselves to experimental fertility preservation in appropriately selected adolescent KS patients.

Understanding the dopaminergic pathway relative to men's sexual dysfunction in patients with Parkinson's disease: a narrative review with implications for future research.

Parkinson's disease (PD) is often most recognized for motor symptoms but associated non-motor symptoms such as sexual dysfunction can significantly impact quality of life. This condition involves a hormonal disruption and has a predilection for male patients, yet there are no formal guidelines for screening or management of sexual health pathology in these patients. While prior publications have addressed the presence of sexual dysfunction (SD) among men with PD, there has been a paucity of work examining the hypothalamic-pituitary-gonadal (HPG) axis and the interplay between dopamine, prolactin (PRL), and testosterone. This review provides an overview of data extracted from the existing peer-reviewed literature regarding hormonal and sexual health changes in men with PD and the impact of dopaminergic and/or androgen replacement therapy. Furthermore, while some research suggests that PD patients are at higher risk for prolactin elevation and testosterone deficiency, heterogeneity of the data limits extrapolation. Additionally, data related to pharmacologic optimization of the HPG axis in this patient population is similarly limited. Prospective studies are needed to better characterize the hormonal pathophysiology of PD as it relates to sexual dysfunction such that men at risk can be effectively identified so as to offer interventions that may improve quality of life.

In vitro propagation of XXY human Klinefelter spermatogonial stem cells: A step towards new fertility opportunities.

Klinefelter Syndrome (KS) is characterized by a masculine phenotype, supernumerary sex chromosomes (47, XXY), and impaired fertility due to loss of spermatogonial stem cells (SSCs). Early testicular cryopreservation could be an option for future fertility treatments in these patients, including SSCs transplantation or in vitro spermatogenesis. It is critically essential to adapt current in vitro SSCs propagation systems as a fertility option for KS patients. KS human testicular samples (13,15- and 17-year-old non-mosaic KS boys) were donated by patients enrolled in an experimental testicular tissue banking program. Testicular cells were isolated from cryopreserved tissue and propagated in long-term culture for 110 days. Cell-specific gene expression confirmed the presence of all four main cell types found in testes: Spermatogonia, Sertoli, Leydig, and Peritubular cells. A population of ZBTB16+ undifferentiated spermatogonia was identified throughout the culture using digital PCR. Flow cytometric analysis also detected an HLA-/CD9+/CD49f+ population, indicating maintenance of a stem cell subpopulation among the spermatogonial cells. FISH staining for chromosomes X and Y showed most cells containing an XXY karyotype with a smaller number containing either XY or XX. Both XY and XX populations were able to be enriched by magnetic sorting for CD9 as a spermatogonia marker. Molecular karyotyping demonstrated genomic stability of the cultured cells, over time. Finally, single-cell RNAseq analysis confirmed transcription of ID4, TCN2, and NANOS 3 within a population of putative SSCs population. This is the first study showing successful isolation and long-term in vitro propagation of human KS testicular cells. These findings could inform the development of therapeutic fertility options for KS patients, either through in vitro spermatogenesis or transplantation of SSC, in vivo.

Morphometric and immunohistochemical analysis as a method to identify undifferentiated spermatogonial cells in adult subjects with Klinefelter syndrome: a cohort study.

OBJECTIVE: To study the prevalence of spermatogonia in adult subjects with Klinefelter syndrome (KS) using MAGE-A4 and UCHL1 (PGP9.5) immunohistochemistry as markers for undifferentiated spermatogonial cells. We aimed to compare this method to the gold standard of hematoxylin and eosin (H & E) staining with histologic analysis in the largest reported cohort of adult subjects with KS. DESIGN: A retrospective cohort study. SETTING: Infertility Clinic and Institute for Regenerative Medicine. PATIENT(S): This study consisted of 79 adult subjects with KS and 12 adult control subjects. INTERVENTION(S): The subjects with KS (n = 79) underwent bilateral testicular biopsy in an initial effort to recover spermatozoa for in vitro fertilization and intracytoplasmic sperm injection. The institutional review board approved the use of a portion of the archived diagnostic pathology paraffin blocks for the study. The samples were superimposed onto microscopic slides and labeled with the PGP9.5 and MAGE-A4 antibodies. Subjects (n = 12) who had previously consented to be organ donors via the National Disease Research Interchange were selected as controls. Dedicated genitourinary pathologists examined the H & E-, PGP9.5-, and MAGE-A4-stained tissue for presence of undifferentiated spermatogonia and spermatozoa with the use of a virtual microscopy software. MAIN OUTCOME MEASURE(S): The primary outcome was the presence of MAGE-A4-positive or UCHL1-positive tubules that indicate undifferentiated spermatogonia. Supportive outcomes include assessing the biopsy specimen for the following: total surface area; total seminiferous tubule surface area; total interstitium surface area; the total number of seminiferous tubules; and MAGE-A4- negative or UCHL1-negative tubules. Additionally, clinical information, such as age, karyotype, height, weight, mean testicle size, and hormonal panel (luteinizing hormone, follicle-stimulating hormone, and testosterone), was obtained and used in a single and multivariable analysis with linear regression to determine predictive factors for the number of UCHL1-positive tubules. RESULT(S): The mean age of the subjects in the KS group was 32.9 ± 0.7 years (range, 16-48). UCHL1 (PGP9.5) and MAGE-A4 staining showed that 74.7% (n = 59) and 40.5% (n = 32) of the subjects with KS, respectively, were positive for undifferentiated spermatogonia compared with 100% (n = 12) of the control subjects who were positive for both the markers. Hematoxylin and eosin with microscopic analysis showed that only 10.1% (n = 8) of the subjects were positive for spermatogonia. The mean number of positive tubules per subject with KS was 11.8 ± 1.8 for UCHL1 and 3.7 ± 1.0 for MAGE-A4. Secondary analysis showed 7 (8.9%) adult subjects with KS as positive for spermatozoa on biopsy. The population having negative testicular sperm extraction results (n = 72) showed a spermatogonia-positive rate of 1.4%, (n = 1), 72.2% (n = 52), and 34.7% (n = 25) using H & E, UCHL1, and MAGE-A4, respectively. Further analysis showed that 54 (75.0%) subjects were either positive for UCHL1 or MAGE-A4. Twenty (27.8%) subjects were positive for both UCHL1 and MAGE-A4. Multivariate analysis with linear regression showed no significant correlation between clinical variables and the number of UCHL1-positive tubules found on biopsy specimens. CONCLUSION(S): We report a cohort of adult subjects with KS undergoing analysis for the presence of undifferentiated spermatogonia. UCHL1 and MAGE-A4 immunostaining appear to be an effective way of identifying undifferentiated spermatogonia in testicular biopsy specimens of subjects with KS. Despite observing deterioration in the testicular architecture, many patients remain positive for undifferentiated spermatogonia, which could be harvested and potentially used for infertility therapy in a patient with KS who is azoospermic and has negative testicular sperm extraction results.