Significant medical pathology discovered during a male infertility evaluation.

PURPOSE: Because a pregnancy can be achieved without a male infertility evaluation, some have questioned its usefulness. However, by bypassing a urological evaluation the man might not learn the cause of infertility and not be offered specific corrective therapy. In addition, men with subfertility may have a serious underlying medical or genetic problem that could also be overlooked. We determine the incidence of significant medical pathology discovered during a male infertility evaluation at 2 academic infertility practices. MATERIALS AND METHODS: All men examined for either primary or secondary infertility were included in our study, while men seen for vasectomy reversal were not. All patients underwent evaluation, consisting of a complete history, physical examination, semen analysis, hormone testing, urinalysis and genetic testing when appropriate. RESULTS: Significant medical pathology was discovered in 33 of 536 (6%) patients. A total of 27 patients had genetic abnormalities, including cystic fibrosis mutations in 24 and karyotypic abnormalities in 3. Of the remaining 6 patients 1 had testis cancer, 1 prostate cancer, 3 diabetes mellitus and 1 hypothyroidism. CONCLUSIONS: Significant medical pathology can be detected by a male infertility evaluation. In addition to identifying the cause of infertility, the evaluation may uncover conditions that threaten the health of the male partner or any potential offspring.

Repeat vasectomy reversal after initial failure: overall results and predictors for success.

PURPOSE: We review the treatment outcomes for microsurgical reconstruction following failed vasectomy reversal and identify predictors for success. MATERIALS AND METHODS: We performed a retrospective review of our experience with microsurgical reconstruction in 41 men who underwent 1 or more prior unsuccessful vasectomy reversal procedures. Of these patients 20 underwent bilateral (16) or unilateral (4) vasoepididymostomy, 11 underwent bilateral (7) or unilateral (4) vasovasostomy and 10 underwent unilateral vasoepididymostomy with contralateral vasovasostomy. Postoperative followup consisted of serial semen analyses and telephone interviews. RESULTS: Patency and pregnancy followup data were available in 33 and 31 patients, respectively. Five couples had ongoing uncorrected female factor infertility problems and were not included in pregnancy rate calculations. Mean obstructive interval was 10.6 years. Overall patency and pregnancy rates were 79 and 31%, respectively. Mean total motile sperm count for patients demonstrating patency at followup was 38.0 million. History of conception with the current partner was predictive of future conception with 4 of 5 nonremarried couples (80%) initiating a pregnancy versus 3 of 18 remarried couples (17%) (p = 0.006). Other factors, including smoking history and obstructive interval, did not correlate with postoperative success. Reconstruction with vasovasostomy on at least 1 side trended toward improved patency (p = 0.17) and pregnancy rates (p = 0.15), although they did not assume statistical significance. CONCLUSIONS: Microsurgical reconstruction following failed vasectomy reversal is associated with high patency and moderate pregnancy rates at short-term followup. In our series previous conception with the current partner was predictive of future conception after reconstruction. Urologists performing repeat vasectomy reversal must be familiar with microsurgical techniques, since almost three-quarters of patients will require at least unilateral vasoepididymostomy.

PIP: This paper reviews treatment outcomes for microsurgical reconstruction following failed vasectomy reversal. Additionally, the report also examines a variety of factors, including smoking history, time since vasectomy, prior conception with current partner, as well as type of repair, in an attempt to identify predictors of successful surgical outcome. A total of 41 men, who underwent one or more prior unsuccessful vasectomy reversal procedure, participated in the study. Of these patients, 20 underwent bilateral (16) or unilateral (4) vasoepididymostomy; 11 underwent bilateral (7) or unilateral (4) vasovasostomy; and 10 underwent unilateral vasoepididymostomy with contralateral vasovasostomy. Patency and pregnancy follow-up data were available in 33 and 31 patients, respectively. Due to the ongoing severe female factor fertility problems, 5 couples were not included from pregnancy rate calculations. The total patency and pregnancy rates were 79% and 31%, respectively. Mean total motile sperm count for patients demonstrating patency at follow-up was 38 million. The history of conception with the current partner was predictive of future conception with 4 or 5 nonremarried couples (80%) initiating pregnancy versus 3 of 18 remarried couples (17%) (p = 0.006). Reconstruction with vasovasostomy on at least one side trended toward improved patency (p = 0.17) and pregnancy rates (p = 0.15) although they did not assume statistical significance. The study concludes that microsurgical reconstruction following failed vasectomy reversal is associated with high patency and moderate pregnancy rates at short-term follow-up.

Adult pseudosarcoma of the bladder.

Pseudosarcomatous tumor of the urinary bladder is an unusual benign proliferative lesion that poses a diagnostic dilemma for both the urologist and pathologist. Its clinical and histologic features mimic a malignant neoplasm, although simple excision is curative. Although similar lesions have been reported in multiple extravesicle locations, most commonly the lung, bladder lesions have only recently been reported. We describe 2 cases of pseudosarcomatous bladder tumors presenting in patients with no known risk factors. We review clinical, histologic, and management issues in these patients. By recognizing the existence of this lesion, possible extensive and inappropriate surgery may be avoided.

Intermittent azoospermia associated with epididymal sarcoidosis.

OBJECTIVE: To report an unusual case of intermittent azoospermia associated with epididymal sarcoidosis. DESIGN: Retrospective case analysis. SETTING: Wilford Hall Medical Center. PATIENT(S): A 36-year-old male with secondary infertility and epididymal sarcoidosis. INTERVENTION(S): None. MAIN OUTCOME MEASURES(S): An analysis of sperm count in relation to steroid courses. RESULTS(S): Epididymalgia, and to a lesser extent, sperm counts were noted to fluctuate temporally around steroid courses given for pulmonary flares of sarcoidosis. Epididymal sarcoidosis can be associated with intermittent azoospermia. Presumably, epididymal granulomas undergo exacerbations and remissions and cause intermittent ductal obstruction. CONCLUSIONS(S): Because of the unpredictable effect of sarcoidosis on the male genital tract, all patients interested in paternity should obtain a semen analysis at the time of disease diagnosis. If oligospermia is noted or if there is clinical evidence of epididymal involvement, the patient should be offered sperm banking for possible future assisted reproductive techniques.

The effect of parenteral testosterone replacement on prostate specific antigen in hypogonadal men with erectile dysfunction.

PURPOSE: Parenteral testosterone supplementation is a common treatment for erectile dysfunction in hypogonadal men. Despite its frequent use, the effect of testosterone on prostate specific antigen (PSA) in these patients has not been documented previously. In this study we determined the effect of parenteral testosterone replacement on PSA and PSA velocity in a group of men being treated for erectile dysfunction. MATERIALS AND METHODS: A retrospective analysis of 48 patients (mean age 65.9) was performed and 2 study groups were identified. Group 1 consisted of 27 patients with a serum PSA level before and after initiating testosterone replacement therapy, and group 2 consisted of 27 men with a minimum of 3 PSA measurements (intervals of 6 months or greater) while on testosterone replacement. Each man had erectile dysfunction, a normal digital rectal examination and a low or low-normal total serum testosterone level before initiating therapy. Testosterone replacement was discontinued if no subjective improvement in erectile function was obtained, or if prostate adenocarcinoma was suggested by digital rectal examination or PSA. RESULTS: The mean increase in PSA after initiating testosterone replacement was 0.29 ng./ml. representing a mean change of 37% from baseline (mean interval 12.8 months). The mean PSA velocity was 0.05 ng./ml. per year. Pretreatment testosterone level, age and testosterone dose did not independently alter the PSA during testosterone replacement. Eleven men required prostate biopsies during treatment. Biopsies were indicated for abnormal digital rectal examination in 10 men and an elevated PSA in 1. All biopsies were benign. CONCLUSIONS: Parenteral testosterone replacement in hypogonadal men with normal pretreatment digital rectal examination and serum PSA levels does not alter PSA or PSA velocity beyond established nontreatment norms. Thus, any significant increase in PSA or PSA velocity should not be attributed to testosterone replacement therapy and should be evaluated.

Long-segment ureteral replacement with expanded polytetrafluoroethylene grafts.

OBJECTIVES: Traumatic loss of significant lengths of ureter all too often results in nephrectomy when vascularized pedicles of bowel or bladder fail or are not available for substitution. Historically, alloplastic replacement of ureters has failed due to obstruction, bioincompatibility, or graft migration. This study was undertaken to test the performance of ringed expanded polytetrafluoroethylene (PTFE) tube grafts as ureteral replacements in a canine model. METHODS: Eight female dogs underwent partial ureteral replacement with ringed PTFE tube grafts. An involuting anastomosis was used to anchor the graft to the bladder. The dogs were followed with intravenous urograms and Whitaker infusion pressure tests for up to 12 months. RESULTS: Six of 8 animals (75%) had preservation of excellent renal function with normal intravenous urograms and low Whitaker infusion pressures. One animal had mild hydronephrosis with an elevated infusion pressure. One animal died of spontaneous renal rupture secondary to obstruction at the ureteral-graft anastomosis. All other grafts were patent by histologic examination without encrustation or infection. CONCLUSIONS: Although not suggested as first-line therapy after ureteral loss, expanded PTFE may have a use as a prosthetic ureteral replacement in situations where conventional surgical therapies are unsuccessful. This material appears to be biocompatible, and the technique of bladder anastomosis described here prevented migration of the prosthesis.

Dressing for surgical wounds of the penis.

We describe a simple tubular elastic gauze dressing for surgical wounds of the penis. The amount of pressure placed on the penis is consistent and reproducible. The material is elastic enough to avoid vascular occlusion and is easily applied with a plastic tube. The dressing stays in place, can be used with stents or catheters, and is easily removed by the patients at home.

Diagnostic tunica vaginoscopy in a rodent model of testicular torsion.

OBJECTIVES: To evaluate the effectiveness of percutaneous endoscopy of the tunica vaginalis for identifying testicular torsion in a rodent model. METHODS: One testis was randomly selected in 10 Wistar rats weighing 500 to 600 g. Following 2 hours of 720 degree torsion, bilateral percutaneous endoscopy of the tunica vaginalis was performed by a blinded investigator utilizing a 70 degree cystoscope lens through a single midline 3 to 4 mm scrotal cutdown incision. RESULTS: Using this technique, the blinded investigator was able to identify the torsed testis rapidly in every case, which was distinguished by its cyanotic color and by the size and color of the testicular surface vessels. CONCLUSIONS: Tunica vaginoscopy is a simple, accurate, rapidly performed, minimally invasive, diagnostic technique in this experimental model of testicular torsion.

Transcatheter embolization of large idiopathic renal arteriovenous fistula.

Renal arteriovenous fistulas are unusual lesions with a variety of clinical manifestations. Congenital and acquired forms have been treated successfully with transcatheter embolization for 2 decades. In the case of large aneurysmal lesions the risk of inadvertent pulmonary embolism has traditionally precluded this approach and necessitated open surgery. However, with refinements in angiographic equipment and technique, such an approach is now feasible and desirable.

Managing the Foley catheter.

Urethral catheterization of the bladder is a commonly performed but potentially hazardous procedure. With proper patient preparation and catheter selection, difficult catheterizations can be accomplished without injuring the patient. Complications of catheterization include infection, injury to the urethra or bladder, and catheter malfunction. Physician supervision of catheter care is essential. Most of all, prompt replacement of the urethral catheter with an alternative method of bladder drainage, such as spontaneous voiding, external condom catheterization, clean intermittent catheterization or, possibly, suprapubic catheterization, is the best way to prevent the complications of urethral catheterization.