Guía clínica de la Asociación Europea de Urología sobre la vasectomía / European Association of Urology Guidelines on Vasectomy

Contexto: La Asociación Europea de Urología presenta su guía clínica para la vasectomía. La vasectomía es muy eficaz, pero pueden surgir problemas que están relacionados con la falta de información preoperatoria del paciente, el procedimiento quirúrgico y el seguimiento postoperatorio. Objetivo: Esta guía clínica tiene por objeto proporcionar información y recomendaciones para los médicos que realizan vasectomías y promover el suministro de información adecuada al paciente antes de la operación para evitar expectativas poco realistas y procedimientos legales. Adquisición de la evidencia: Se llevó a cabo una revisión exhaustiva de la literatura mediante Medline, Embase y la Base de Datos Cochrane de Revisiones Sistemáticas de 1980 a 2010. La atención se centró en los ensayos controlados aleatorizados (ECA) y los metaanálisis de los ECA (nivel 1 de evidencia) y en los estudios bien diseñados sin aleatorización (nivel 2 y 3 de evidencia). Un total de 113 registros únicos fueron identificados para su consideración. Se excluyeron las publicaciones que no estaban en lengua inglesa, así como los estudios publicados como resúmenes solamente o informes de las reuniones. Síntesis de la evidencia: La guía clínica debate las indicaciones y contraindicaciones de la vasectomía, la información y el asesoramiento preoperatorio del paciente, las técnicas quirúrgicas, los cuidados postoperatorios y el posterior análisis del semen y las complicaciones y consecuencias finales. Conclusiones: La vasectomía tiene la intención de ser un método anticonceptivo permanente; No hay contraindicaciones absolutas para la misma. Las contraindicaciones relativas pueden ser la ausencia de hijos, edad < 30 años, una enfermedad grave, ninguna relación actual y dolor en el escroto. El asesoramiento preoperatorio debe incluir métodos alternativos de anticoncepción, tasas de complicación y fracaso y la necesidad de análisis del semen postoperatorio. Se debe obtener consentimiento informado antes de la operación. Aunque el uso de cauterio de la mucosa y la interposición fascial han demostrado reducir el fracaso temprano en comparación con la ligadura simple y resección de un segmento de vaso pequeño, no hay datos sólidos que muestren que una técnica de vasectomía en particular es superior en cuanto a prevención de la recanalización tardía y espontánea del embarazo después de la vasectomía. Tras el análisis del semen se puede dar el alta en caso de azoospermia documentada y en el caso de espermatozoides inmóviles en la eyaculación por lo menos 3 meses después del procedimiento (AU)

Context: The European Association of Urology presents its guidelines for vasectomy. Vasectomy is highly effective, but problems can arise that are related to insufficient preoperative patient information, the surgical procedure, and postoperative follow-up. Objective: These guidelines aim to provide information and recommendations for physicians who perform vasectomies and to promote the provision of adequate information to the patient before the operation to prevent unrealistic expectations and legal procedures. Evidence acquisition: An extensive review of the literature was carried out using Medline, Embase, and the Cochrane Database of Systematic Reviews from 1980 to 2010. The focus was on randomised controlled trials (RCTs) and meta-analyses of RCTs (level 1 evidence) and onwell-designed studies without randomisation (level 2 and 3 evidence). A total of 113 unique records were identified for consideration. Non-English language publications were excluded as well as studies published as abstracts only or reports from meetings. Evidence synthesis: The guidelines discuss indications and contraindications for vasectomy, preoperative patient information and counselling, surgical techniques, postoperative care and subsequent semen analysis, and complications and late consequences. Conclusions: Vasectomy is intended to be a permanent form of contraception. There are no absolute contraindications for vasectomy. Relative contraindications may be the absence of children, age < 30 yr, severe illness, no current relationship, and scrotal pain. Preoperative counselling should include alternative methods of contraception, complication and failure rates, and the need for postoperative semen analysis. Informed consent should be obtained before the operation. Although the use of mucosal cautery and fascial interposition have been shown to reduce early failure compared to simple ligation and excision of a small vas segment, no robust data show that a particular vasectomy technique is superior in terms of prevention of late recanalisation and spontaneous pregnancy after vasectomy. After semen analysis, clearance can be given in case of documented azoospermia and in case of rare non motile spermatozoa in the ejaculate at least 3 mo after the procedure (AU)

[European Association of Urology guidelines on vasectomy]. / Guía clínica de la Asociación Europea de Urología sobre la vasectomía.

CONTEXT: The European Association of Urology presents its guidelines for vasectomy. Vasectomy is highly effective, but problems can arise that are related to insufficient preoperative patient information, the surgical procedure, and postoperative follow-up. OBJECTIVE: These guidelines aim to provide information and recommendations for physicians who perform vasectomies and to promote the provision of adequate information to the patient before the operation to prevent unrealistic expectations and legal procedures. EVIDENCE ACQUISITION: An extensive review of the literature was carried out using Medline, Embase, and the Cochrane Database of Systematic Reviews from 1980 to 2010. The focus was on randomised controlled trials (RCTs) and meta-analyses of RCTs (level 1 evidence) and on well-designed studies without randomisation (level 2 and 3 evidence). A total of 113 unique records were identified for consideration. Non-English language publications were excluded as well as studies published as abstracts only or reports from meetings. EVIDENCE SYNTHESIS: The guidelines discuss indications and contraindications for vasectomy, preoperative patient information and counselling, surgical techniques, postoperative care and subsequent semen analysis, and complications and late consequences. CONCLUSIONS: Vasectomy is intended to be a permanent form of contraception. There are no absolute contraindications for vasectomy. Relative contraindications may be the absence of children, age <30 yr, severe illness, no current relationship, and scrotal pain. Preoperative counselling should include alternative methods of contraception, complication and failure rates, and the need for postoperative semen analysis. Informed consent should be obtained before the operation. Although the use of mucosal cautery and fascial interposition have been shown to reduce early failure compared to simple ligation and excision of a small vas segment, no robust data show that a particular vasectomy technique is superior in terms of prevention of late recanalisation and spontaneous pregnancy after vasectomy. After semen analysis, clearance can be given in case of documented azoospermia and in case of rare nonmotile spermatozoa in the ejaculate at least 3 mo after the procedure.

Haematospermia: diagnosis and treatment.

Men perceive a bloody ejaculate as an alarming physical symptom and often seek the help of urologists for explanation and treatment. After a complete urological step-by-step examination including imaging studies and flexible cystoscopy, malignancy or another significant disease can be ruled out in the majority of cases. However, many of these cases of haematospermia may still remain idiopathic and thus unsatisfactory for both the patient and his physician. The following paper reviews the aetiology, the diagnostic work-up escalation and the treatment options of haematospermia.

Cryopreservation technique: comparison of Test yolk buffer versus SpermCryo and vapour versus computerised freezing.

Semen cryopreservation offers the possibility to maintain fertility over a long time period e.g. for male cancer patients. Although its use expands worldwide, there is no established method that can be referred to as an entrenched standard for routine laboratory use. Cryodamage is still a general phenomenon and the success of cryopreservation is affected on one side by the cryoprotective agent and on the other side by the technique of freezing. In this methodological study, we compared the newly offered SpermCryo (SC) with the standard used cryoprotectant Test yolk buffer (TYB). We could show that TYB is superior to SC. In addition, we compared the two mainly used techniques for cryopreservation: computerised slow-stage freezing versus nitrogen vapour fast freezing. Regarding the sperm post-thaw motility and viability, no significant difference was found between these two methods. In conclusion, TYB can be recommended as a cryomedium of first choice and the appropriate freezing technique can be selected according to the local facilities of the institution.

Acrosome reaction in Chlamydia-positive and negative patients.

Chlamydia trachomatis infections might have a detrimental effect on various sperm functions. Data concerning the effect of C. trachomatis on the capacitation activity of sperms are lacking. The study was undertaken to evaluate whether chlamydial infection influences acromsome reaction (AR). Three groups of men were investigated for ARs -Chlamydia negative (n = 46) and positive (n = 30) patients, and healthy men (n = 53) undergoing vasectomy. The fluorescence technique for the evaluation of AR was applied. The normal range for the induction of AR was assumed DeltaAR > 12.5% for this technique. Seminal plasma was examined for IgA antibodies against C. trachomatis. There was a significant difference in AR between healthy volunteers, Chlamydia-negative and Chlamydia-positive patients. DeltaARs were 15.8 +/- 1.6% in healthy volunteers versus 12.15 +/- 2.4% in Chlamydia-negative and 9.08 +/- 1.8% in Chlamydia-postive patients, respectively (P < 0.05). Significant elevated titres of C. trachomatis-specific IgA in seminal plasma showed a negative correlation with the AR of spermatozoa. AR seems to be a valuable marker, especially in couples with idiopathic infertility.

One 10-core prostate biopsy is superior to two sets of sextant prostate biopsies.

OBJECTIVES: To compare the efficiency of different transrectal ultrasonography (TRUS)-guided prostate biopsy techniques for detecting prostate cancer. MATERIALS AND METHODS: In all, 81 prostates from radical prostatectomy were used and two consecutive sets of sextant biopsies and one 10-core biopsy taken in each specimen. The 10-core biopsy consisted of a sextant biopsy and four cores from the far lateral areas of the prostate. To simulate a transrectal biopsy procedure, all biopsies were taken under TRUS guidance. RESULTS: In the first set of sextant biopsies 44 prostate cancers (54%) were detected and in the second set 51 (63%). Combining both sets of sextant biopsies 57 (70%) of the carcinomas were detected. One set of 10-core biopsies detected 66 (82%) of all prostate cancers. Overall, with the 10-core biopsies 16% more prostate tumours were diagnosed than with two consecutive sets of sextant biopsies. To find the same number of prostate cancers as with the 10-core technique, 14% of patients undergoing sextant biopsy would require a second set and 11% at least a third set of biopsies. CONCLUSIONS: The 10-core prostate biopsy technique is superior to the commonly used sextant technique and could spare patients unnecessary repeated biopsy. Even after including a second set of sextant biopsies, the total detection rate with these 12 biopsies was inferior to the 10-core technique.

Association of DHEA-S and estradiol serum levels to symptoms of aging men.

OBJECTIVES: A number of interactions between age-related changes in serum levels of dehydroepiandrostendione sulfate (DHEA-S) and estradiol and symptoms of aging men have been proposed, yet data regarding this issue are scant. We therefore set up a prospective study to analyze these associations. METHODS: In a prospective, cross-sectional study, men aged 45-85 years were recruited. All men completed a questionnaire containing 38 items covering a number of aspects of the aging male. Questionnaires were compiled by using items from previously published and validated questionnaires. Several socioeconomic parameters were also determined. In parallel, serum levels of testosterone, free testosterone, luteinizing hormone (LH), follicle stimulating hormone (FSH), DHEA-S, estradiol, sex hormone binding globulin and prostate-specific antigen (PSA) were quantified by commercially available immunoassays. RESULTS: A total of 375 men with a mean age of 59.9 +/- 9.2 years (mean +/- standard deviation) were analyzed. Average DHEA-S and estradiol levels of 135.8 +/- 90.9 micrograms/dl and 29.7 +/- 14.6 pg/ml, respectively, were recorded. DHEA-S serum levels were negatively correlated to patient age, sexual function score, total score and PSA. Estradiol serum levels were positively correlated to testosterone and free testosterone. None of the other scores or questions revealed a correlation with DHEA-S or estradiol serum levels. CONCLUSION: This prospective study elucidates only small interactions between partial androgen deficiency of the aging male (PADAM)-related symptoms and serum levels of DHEA-S and estradiol. Nevertheless, the data suggest an impact of DHEA-S on sexual function.

Prostate cancer detection with two sets of ten-core compared with two sets of sextant biopsies.

OBJECTIVES: To compare the cancer detection of two consecutive sets of prostate biopsies using either the sextant or the 10-core technique. METHODS: Ninety-one specimens after radical prostatectomy were used and consecutive sets of biopsies were performed ex vivo on each prostate after the operation. The sextant biopsies were taken paramedian and midlobular, three per side. For the 10-core biopsies, two cores per side from the lateral areas of the prostate were added. We developed a realistic simulation of a transrectal sonographic biopsy procedure. RESULTS: In the first set of sextant biopsies, 55 prostate cancers (60.4%) were found; in the second set, 13 additional tumors were detected. Two consecutive sets of sextant biopsies thus found 68 tumors (74.7%). Using one 10-core biopsy led to cancer detection in 71 of the prostates (78%). A second 10-core biopsy revealed 11 additional tumors, for a cumulative cancer detection rate of 90.1%. We found that 9 (9.9%) of all the cancers were not diagnosed by two consecutive sets of this extended biopsy protocol. Eight of these cancers (88.9%) were clinically significant as determined by a tumor volume larger than 0.5 cm(3). CONCLUSIONS: Although the 10-core protocol is far superior to the commonly used sextant protocol, a significant number of prostate cancers can still be found on a second similar set of prostate biopsies. Even after two consecutive sets of 10-core biopsies, approximately 10% of the prostate tumors remained undetected. Most of them were clinically significant.

Effective long-term androgen suppression in men with prostate cancer using a hydrogel implant with the GnRH agonist histrelin.

OBJECTIVES: To evaluate the effectiveness of a hydrogel implant containing the gonadotropin-releasing hormone (GnRH) agonist histrelin in suppressing testosterone production in men with prostate cancer and to determine the effective dose (one, two, or four implants). METHODS: Forty-two men with prostate cancer and indications for androgen ablation were treated with one, two, or four implants. In two of the clinics, comprising 27 subjects, the treatment period was 12 months, with replacement with the same number of implants at 12-month intervals. In a third clinic, which treated 15 subjects, the implants were left in place for up to 30 months. The total experience was 605 treatment months. RESULTS: The histrelin levels were detected in serum proportional to the number of implants placed. The response, however, was similar among all three dose levels, with testosterone and luteinizing hormone essentially completely suppressed. Serum testosterone levels decreased from 21.9 +/- 17.6 nmol/L to 0.93 +/- 1.57 nmol/L within 1 month and were maintained at 0.55 +/- 0.24 nmol/L at 6 months and 0.60 +/- 0.28 nmol/L after 12 months of treatment. Of the 38 assessable patients, 35 (92%) had castrate levels of testosterone within 4 weeks of the initial implant placement. All patients followed for up for 12 months after placement of the initial set of implants maintained suppression of testosterone production while the implant was in place. CONCLUSIONS: The histrelin hydrogel implant provided adequate and reliable delivery of the potent GnRH agonist histrelin during at least 1 year using a single implant in men with prostate cancer. No apparent advantages were found in using more than one implant, and the question of the possible effectiveness of even lower doses remains open. This treatment modality appears to be both safe and effective.

Clinical outcome of microsurgical subinguinal varicocelectomy in infertile men.

The present study assesses the clinical outcome of microsurgical subinguinal varicocelectomy in infertile men, especially with regard to sperm count, motility and fertility. Between June 1990 and October 1998, 272 patients had subinguinal microsurgical varicocelectomy operations for clinical varicoceles, and their long-term results were assessed. In nearly all the patients there was a significant improvement in sperm count and sperm motility after 3 and 6 months. Very few complications arose from this procedure. We concluded that microsurgical subinguinal varicocelectomy is an effective treatment for clinical varicoceles in infertile men. The significant improvement in the quality of spermatozoa, the low complication rates and the remarkably high pregnancy rates make this a valuable alternative to in vitro reproduction techniques.

[Physiology and pathophysiology of erectile dysfunction]. / Physiologie und Pathophysiologie der erektilen Dysfunktion.

Erectile dysfunction is an entity associated with age but is not necessarily a consequence of aging. During erection the penis acts as a capacitor--accumulating blood under pressure. Erectile function is, therefore, dependent on the integration and regulation of functional interplay between psychologic, neurologic, endocrine and vasoactive factors. Any imbalance in the integration of these factors will result in erectile dysfunction. Trabecular smooth muscle is an important structure, which contributes to control of detumescence and erection. The smooth muscle tone is mediated by many hormones and vasoactive factors (e.g. norepinephrine, acetylcholine, NO, VIP, prostaglandins etc.) but its functioning is also dependent on a sufficient oxygenation to prevent the fibrosis of this important structure. This oxygenated state is achieved during erections. So we can conclude: Erections are good for erections.

[A pill for the man? Current status of fertility control in the man]. / Pille für den Mann? Aktueller Stand der Fertilitätskontrolle beim Mann.

Taking all facts into consideration from animal experiments and clinical studies with regard to the development of a male contraceptive you must be aware that the 'pill for men' will hardly be available in this century. Because of the increasing interest of the industry and the effort of the WHO and other similar institutions, like the Population Council of New York, to develop a male pill the stagnation of the past 20 years could be overcome, and it may be possible to have an adequate method in 2005. In all probability this will be a combination of hormones either from a gestagen plus testosterone preparation or a potent LHRH agonist and/or antagonist, also in combination with a long-acting testosterone preparation, with testosterone levels within the normal range. Nowadays it cannot be said which role gossypol will finally play. There are studies going on with gossypol with some promising results.

Decrease in the level and mRNA expression of LH-RH and EGF receptors after treatment with LH-RH antagonist cetrorelix in DU-145 prostate tumor xenografts in nude mice.

Using radioligand binding, RT-PCR, and Southern blot analyses, we evaluated whether agonist [D-Trp6]LH-RH and antagonist Cetrorelix could affect the levels of receptors for LH-RH and EGF and expression of mRNA for these receptors in DU-145 human androgen-independent prostate cancers xenografted into nude mice. Radioligand binding studies showed the presence of specific high affinity receptors for LH-RH and EGF in DU-145 prostate tumors. Cetrorelix, but not [D-Trp6]LH-RH significantly inhibited tumor growth. The concentration of LH-RH receptors was reduced by 22% (p<0. 05) and 67% (p<0.01) after 4 weeks of treatment with [D-Trp6]LH-RH and Cetrorelix respectively. The concentration of EGF receptors fell by 48% (p<0.05) in the [D-Trp6]LH-RH group, whereas Cetrorelix led to a 66% reduction (p<0.01). The expression of LH-RH and EGF receptor mRNA was investigated by RT-PCR analysis followed by Southern blotting. Densitometric analysis of the developed bands showed that the antagonist Cetrorelix decreased the expression of LH-RH receptor mRNA by 55% (p<0.01) compared to control group while the 20% reduction after treatment with the LH-RH agonist was non-significant. Treatment with [D-Trp6]LH-RH and Cetrorelix also reduced the expression of EGF receptor mRNA by 35% and 68% respectively (both, p<0.01) compared to control group. In conclusion, these data demonstrate that growth inhibition of DU-145 prostate tumors induced by prolonged administration of LH-RH antagonist Cetrorelix is accompanied by a marked decrease in the concentration of LH-RH and EGF receptors as well as in their mRNA levels.

Inhibition of the growth of Caki-I human renal adenocarcinoma in vivo by luteinizing hormone-releasing hormone antagonist Cetrorelix, somatostatin analog RC-160, and bombesin antagonist RC-3940-II.

BACKGROUND: Metastatic or recurrent renal cell carcinoma (RCC) is a therapeutic challenge because it is resistant to chemotherapy and external radiotherapy. No uniformly effective therapeutic agents are available for the management of patients with RCC. Hormones and growth factors may play a role in promoting the transformation and/or proliferation of kidney neoplasms. METHODS: Luteinizing hormone-releasing hormone (LH-RH) antagonist Cetrorelix (SB-75), somatostatin analog RC-160, and bombesin antagonist RC-3940-II were tested for their effects on the growth of the Caki-I renal adenocarcinoma cell line xenografted into nude mice. RESULTS: After 4 weeks of treatment, tumor volume was significantly (P < 0.01) decreased in animals receiving RC-160, to 167.5 +/- 34.2 mm3, compared with the control group (485.7 +/- 77.2 mm3). LH-RH antagonist SB-75 and bombesin antagonist RC-3940-II also significantly reduced the volume of Caki-I tumors, to 159.9 +/- 18.1 and 234.7 +/- 81.8 mm3, respectively. Somatostatin analog RC-160 decreased serum levels for growth hormone (GH) and insulin-like growth factor-I compared with controls. Treatment with RC-160, Cetrorelix, and RC-3940-II significantly reduced the number of high-affinity receptors for epidermal growth factor on Caki-I tumors. CONCLUSIONS: LH-RH antagonist Cetrorelix, somatostatin analog RC-160, and bombesin antagonist RC-3940-II effectively inhibit the growth of human Caki-I renal adenocarcinomas in nude mice. These peptide analogs should be considered for the therapy of patients with metastatic or recurrent RCC.

Luteinizing hormone-releasing hormone antagonist Cetrorelix (SB-75) and bombesin antagonist RC-3940-II inhibit the growth of androgen-independent PC-3 prostate cancer in nude mice.

BACKGROUND: Hormones like bombesin (BN)/gastrin-releasing peptide (GRP) and luteinizing hormone-releasing hormone (LH-RH) and growth factors such as epidermal growth factor (EGF) might be involved in the relapse of prostate cancer under androgen ablation therapy. Interference with receptors for BN/GRP, LH-RH, or EGF might provide a therapeutic approach to inhibit tumor growth of androgen-independent prostate cancer. METHODS: LH-RH antagonist Cetrorelix (SB-75) and the BN/GRP antagonist RC-3940-II were tested for their effects on the growth of the androgen-independent PC-3 human prostate cancer cell line xenografted into nude mice. Tumor growth, serum hormone levels, and receptor concentrations for BN/GRP and EGF were measured. RESULTS: When the treatment was started, tumor volume in all groups was 70-80 mm3. After 4 weeks, tumor volume in the control animals injected with saline was 871 +/- 233 mm3 and that of animals treated with Cetrorelix only 197 +/- 61 mm3. The BN/GRP antagonist RC-3940-II also significantly reduced PC-3 tumor volume in nude mice to 122 +/- 20 mm3. The combination of Cetrorelix and RC-3940-II produced no additional inhibition. High-affinity receptors for EGF were detected in the tumor membranes and their number was significantly decreased after administration of Cetrorelix or RC-3940-II. CONCLUSIONS: These findings demonstrate that LH-RH antagonists and BN/GRP antagonists inhibit the growth of the androgen-independent prostate cancer cell line PC-3 in vivo. Both analogs may exert a direct inhibitory effect on tumor growth through a down-regulation of EGF receptors.

Transurethral needle ablation of the prostate for the treatment of benign prostatic hyperplasia: a collaborative multicentre study.

OBJECTIVE: To assess the efficacy and safety of transurethral needle ablation of the prostate (TUNA) for patients with symptomatic benign prostatic hyperplasia (BPH) in a multicentre trial. PATIENTS AND METHODS: Seventy-six patients were recruited from five centres; all were treated with the TUNA system consisting of a powered radiofrequency generator and a TUNA catheter. The patients were evaluated prospectively using the international prostate symptom score (IPSS), uroflowmetry, quality-of-life score, and other variables, and followed for a mean of 12 months after treatment. RESULTS: Sixty-eight patients were available for follow-up: TUNA produced significant improvements in the IPSS (median 22 before, to 7.5 after treatment). urinary flow rate (mean 8.7 before, to 11.6 mL/s after treatment) and quality-of-life score (median 5 before, to 2 after treatment) at 12 months. CONCLUSIONS: If these early promising results are maintained. In the medium to long term, TUNA therapy will be a useful low-morbidity alternative for patients with symptomatic BPH.