Use of Anabolic-Androgenic Steroids and Male Fertility: A Systematic Review and Meta-analysis.

Background: Anabolic-androgenic steroids (AASs) are often used by men for bodybuilding and to improve sports performance. The use is not limited to professional competitive athletes, but many amateur men. Objective: The objective of this study was to assess and systematically review the effects of AAS on male fertility parameters, spermiogram, testosterone, follicle-stimulating hormone (FSH) and luteinising hormone (LH) and to review reversibility and other morbidity impacting fertility. Methods: Eligibility criteria - We included studies mentioning data about adult males using supraphysiologic doses of AAS for sports performance or appearance enhancement, with comparison data from general population or matched controls if available reporting fertility parameters and sexual performance. Information sources - A systematic literature search was performed using PubMed, MEDLINE, EMBASE, Google Scholar and World of Science. Controlled clinical trials randomised or nonrandomised (if available), case series with or without matched controls, case reports, cross-sectional surveys, reports on follow-up of subjects caught in doping test and their fertility parameters when reported. Risk of bias/quality assessment - The quality assessment of the included studies was performed using the Newcastle-Ottawa Scale. Results: Included studies - Thirty-two studies were included. There were 12 cohort studies, 5 case-control studies, 9 cross-sectional surveys and 6 case reports. The study population comprised 9371 individuals, of which 2671 were AAS users. Synthesis of results - AAS users had reduced levels of FSH and LH than the naïve population. These levels remained low for 3-6 months after stopping AAS. One year after stopping AAS, the users and naïve population had insignificant differences in FSH and LH values. The total testosterone (TT) levels were comparable in users and naïve populations at baseline, 3 months and 6 months after stopping, but at 1 year, TT values were lower in AAS users. Sperm concentration in AAS users and naïve population was similar, but sperm motility was lower in AAS users. The testicular size was lower in AAS users. The erectile function improved with AAS use, but on withdrawal, there was decreased libido and erectile dysfunction. Most AAS users need additional medications to mitigate detrimental effects on fertility. Description of the effect - AAS use negatively impacted the gonadotrophin levels and had lower sperm motility and testicular size. Strength - Comprehensive review of 32 publications, study population of 9371 individuals, of which 2671 were AAS users, meta-analysis of reproductive hormones, semen parameters and testis size. Limitations: The limitations are small sample size of most of the studies, polypharmacy, lack of information on dosing and high heterogeneity. Interpretation: AAS use is detrimental for sperm motility and has a partially reversible negative impact on male fertility. Users must be cautioned about its negative impact on libido and erectile function.Registration: PROSPERO Registration No. CRD42023411294.

Bilateral Single-System Ectopic Ureter: When Can We Avoid Bladder Neck Reconstruction?

Bilateral single-system ectopic ureter (BSSEU) is often associated with underdeveloped incompetent bladder neck; hence, to achieve continence, bladder neck reconstruction (BNR) is usually advocated with ureteric reimplantation. Presented here is a 14-year-old girl with BSSEU who achieved continence without BNR. An attempt is made to look at factors that could identify patients in whom BNR could be avoided.

Evaluating factors associated with the risk of hydrothorax following standard supracostal percutaneous nephrolithotomy.

Objective: To report our experience with supracostal percutaneous nephrolithotomy (SC-PNL) and evaluate factors which could predict the risk of hydrothorax following SC-PNL. Methods: We reviewed 347 patients who underwent SC-PNL from January 2011 to December 2019. Patients were assessed for demographic characteristics, indication for the supracostal access, level of supracostal access, anatomy of the kidney (normal or malrotated), site of the puncture in relation to the mid-scapular line (medial or lateral), and whether another subcostal tract for stone clearance was required or not. Patients were assessed for the incidence of hydrothorax and requirement of intercostal drain depending on the level of percutaneous access. In addition, a multivariable logistic regression analysis model was developed to identify factors which could predict the occurrence of hydrothorax following SC-PNL. Results: Of the 347 patients with SC-PNL, 248 (71.5%) underwent a supra-12th rib approach, while the rest needed a supra-11th (n=85; 24.5%) or a supra-10th (n=14; 4.0%) rib tract. Overall, 17 (4.9%) patients developed a hydrothorax, while an intercostal-drain was required in seven of these 17 patients for 48 h. None of the patients with a supra-12th rib puncture required an intercostal-drain. More than a third of the patients with a supra-10th puncture developed a hydrothorax (35.7%) and all of them required an intercostal drain. Factors such as anteriorly malrotated kidney (odds ratio [OR]=2.722; 95% confidence interval [CI]=1.042-5.617, p=0.03), puncture medial to the mid-scapular line (OR=1.669; CI=0.542-1.578, p=0.03), and an access higher than the supra-12th level (OR=5.265; CI=1.292-9.342, p<0.001) proved to be independent predictors of hydrothorax following a SC-PCNL on multivariable analysis. Conclusion: Incidence of clinically significant hydrothorax requiring an intercostal-drain after SC-PNL is very low. Knowledge of the predicting factors will help to anticipate the risk of hydrothorax in a particular patient and take necessary peri-operative measures.

Clinical Andrologists: Do We Really Need Them in the Era of ART?

Infertility is on a rise, and so is the availability of assisted reproductive technique (ART) centres. The sole aim of these centers is to help these unfortunate couples achieve pregnancy. Hence, the concentration of the treatment is on the female partner, while the male is relegated to just being a source for sperm. In the era of intracytoplasmic sperm injection, when pregnancy is possible even with a single mature sperm, evaluation and management of male factor infertility (MFI) is often neglected. MFI and poor semen parameters are markers of male health. He could be suffering from erectile or ejaculatory issues or with correctable obstructive azoospermia. A simple timely varicocele correction may help resolve the issue. It is important to understand that MFI is not a disease but may be a symptom of major underlying clinical condition like testicular or brain tumors. Infertility treatment could be the only occasion when a male seeks health-care evaluation. India has a large pool of qualified urologists trained in andrological care. In contrast, gynecologists may not be trained in the management of male patients, hence there is an important place for andrological services to be an integral part of ART centers. Andrologists would offer minimal andrological evaluation and condition-specific treatment. This could avoid or reduce the need for invasive and expensive ART. Andrologists could also choose the most appropriate mode of sperm retrieval. Undoubtedly, availability of andrological services would improve the overall quality of care, reduce the costs and complications, and would also be medicolegally safe.

Sexual dysfunction in Indian men undergoing Double J ureteral stenting following ureteroscopy-A prospective analysis.

This prospective study was aimed to evaluate the impact of an indwelling ureteral double-J stent on the sexual health of Indian men undergoing ureteroscopy. The first phase of the study included 30 men who were not counselled prior to stenting about possible sexual dysfunction, while in the next phase, 60 men were counselled about this. These 60 patients were assessed by a 6-point questionnaire: five questions from the International Index of Erectile Function-5 (IIEF-5) and an additional 6th question to assess pain during erection/ejaculation. Patients answered the questionnaire prior to ureteroscopy, at the time of stent removal and then 4 weeks after stent removal. A higher proportion of men in the second phase attempted sexual activity (68.3% vs. 26.7%; p < .001). Significant changes were noted in the total IIEF-5 score (mean 23.16 before vs. 15.65 after, p < .001) and individual IIEF-5 components: erection confidence (4.59 vs. 2.76, p = .017), maintenance ability (4.67 vs. 2.43, p = .006) and intercourse satisfaction (4.61 vs. 2.31, p < .001) and also the 'pain' question (2.83 post-stenting vs. 0.37 pre-stenting, p < .001). Most patients had a recovery of scores at 4 weeks after stent removal. Thus, ureteral DJ stenting leads to significant but temporary sexual dysfunction and patients need to be counselled regarding this.

Safety, feasibility, and quality of holmium laser en-bloc resection of nonmuscle invasive bladder tumors - A single-center experience.

INTRODUCTION: Conventional transurethral resection of bladder tumor (cTURBT), despite its piecemeal resection and associated limitations, remains the most widely practiced technique of TURBT. Resecting the tumor in a single piece would avoid most of the drawbacks of cTURBT. Our objective was to assess the feasibility, safety, and quality of Holmium (Ho) laser en-bloc resection (ERBT) for nonmuscle-invasive bladder cancer (NMIBC). MATERIALS AND METHODS: We retrospectively studied 67 patients who underwent Ho laser EBRT for primary NMIBC. Data were collected regarding tumor size, number and location, intraoperative complications, and postoperative course. Patients were grouped as first 20, next 20 (21-40), and last 27 cases to assess how the quality of resection improved with increasing experience. RESULTS: The mean tumor size was 28.7 ± 7.9 mm, with 34.3% of the patients having a tumor larger than 3 cm. While 43 patients (64.17%) had a single tumor, the rest had multiple tumors, ranging from 2 to 9 in number. The mean total duration of resection was 38.7 ± 11.6 min. No case required conversion to cTURBT. No patient experienced obturator reflex or bladder perforation. Detrusor muscle was present in 85.07% of the resections. With increasing experience, requirement for bladder irrigation and the incidence of postoperative clot evacuation decreased (P < 0.0001 and P = 0.31, respectively), and the detrusor-positive rate in the specimen increased (P = 0.24). The mean duration of catheterization was 1.76 ± 0.54 days. CONCLUSION: Ho laser ERBT is safe and feasible for complete resection of NMIBCs with no risk of obturator-nerve reflex and a high rate of detrusor-positive specimens.

A global knowledge, attitudes and practices survey on anatomical endoscopic enucleation of prostate for benign prostatic hyperplasia among urologists.

There is an increasing use of the procedure, anatomical endoscopic enucleation of the prostate, as an alternative to conventional transurethral resection of prostate for surgical treatment of benign prostatic hyperplasia. However, barriers to adoption of this procedure remain and no prior studies explored this important aspect till date. The aim of this study is to identify the predictors and barriers of surgeon-related practices in this area. The study findings may also provide valuable insight into current practice trends worldwide. To achieve the objectives, we conducted an online, cross-sectional, questionnaire-based study between 1st September 2019 and 5th October 2019 to investigate the knowledge, attitudes and practices among urologists worldwide. Our findings showed that the main barriers for adoption of the procedure were lack of mentorship, a steep learning curve, and unavailability of morcellator, bipolar or laser energy sources. Fear of urinary incontinence, bleeding and bladder injury were not major hindrance to adoption of this technique. The results also demonstrated that there will be continued increase in utility of the procedure in the future.

Entrapped Endopyelotomy Stent After Endoureterotomy for Midsegment Ureteral Stricture: The Lessons Learned.

Background: The type of the stent to be used after endoureterotomy is a matter of discussion and debate. Endopyelotomy stent is commonly used after endoureterotomy for the management of upper and the lower ureteral strictures. For the strictures in the middle segment of the ureter (lower part of upper ureter, midureter, and upper part of lower ureter), the bulbous portion of the endopyelotomy stent may not adequately cover the endoureterotomy site leading to early recurrence. Case Presentation: Presented here is a young man who underwent endoureterotomy for a postureteroscopy stricture at the L4-L5 vertebral level. The endopyelotomy stent that was placed after endoureterotomy upmigrated, and the bulbous portion of the endopyelotomy stent got stuck above the recurrent stricture site. This difficult clinical situation needed a percutaneous access for stent removal. Conclusion: We propose that tandem stents have an advantage over endopyelotomy stent postendoureterotomy for stricture in the middle portion of the ureter as it provides a good splint for healing without any risk of stent migration and complications.