Medicolegal aspects of testicular torsion.

OBJECTIVES: Testicular torsion is an active area of medical malpractice litigation because of the diagnostic uncertainty, delays in diagnosis and treatment, diagnostic errors, and resultant testicular loss. We reviewed this topic to determine the nature of patient claims and their clinical and legal outcomes. METHODS: All closed case files of a large medical malpractice insurance company based in New Jersey involving testicular torsion from the years 1979 to 1997 were retrospectively reviewed. The following data were collected: patient demographics, timing of presentation, initial complaints, diagnosis given, consultations obtained, radiographic studies, treatment provided, outcomes, and indemnity payments. RESULTS: Thirty-nine cases consisting of 58 individual claims were reviewed. Indemnity payments were made in 26 cases (67%), of which 25 (96%) were settlements, and 13 cases (33%) ended in favor of the physicians. Five cases went to trial, with only one verdict in favor of the plaintiff. The median indemnity payment was $45,000. Urologists were named most frequently (48%), and a misdiagnosis of epididymitis (61%) was most commonly cited. The mean patient age was 24.3 years. Atypical initial complaints were common (46%). Late presentation (greater than 8 hours) did not affect the medicolegal outcome. The major liabilities for paid claims were an error in diagnosis (74%), a delay in or lack of referral (48%), lack of radiologic examination (19%), failure to explore (13%), error in surgical technique or judgment (13%), and falsified records (10%). CONCLUSIONS: Testicular torsion litigation most often focuses on the urologist. Claims are more common in older patients and those with atypical complaints. Settlement is the most common outcome, with a fairly standard indemnity payment rewarded. The initial treating physician must have a high index of suspicion for the diagnosis and refer promptly. In lieu of a definitive radiologic study, or when the diagnosis is in question, the urologist should strongly consider exploration and should perform contralateral exploration when torsion is found.

Ultrasound and infertility: diagnostic and therapeutic uses.

Ultrasound has become essential in the diagnosis and management of the infertile male. Scrotal ultrasonography provides a detailed examination of the testes and assesses the presence or absence of varicoceles and can identify other abnormalities of the scrotal contents and the spermatic cord. Transrectal ultrasonography can "visualize" the excurrent ejaculatory ductal system, including the ejaculatory ducts, seminal vesicles, and vas deferens. The expansion of these ultrasonographic techniques has provided the urologist with non- or minimally invasive techniques with which to evaluate the infertile male. These advancements consequently have led to innovative surgical and radiologic treatments.

The relationship between critical evaluation of sperm morphology and the TYB-optimized zona free hamster oocyte sperm penetration assay.

The objective of this study was to analyse the relationship between the percentage of spermatozoa in semen with normal morphology, assessed using the Tygerberg criteria, and sperm fertilizing ability assessed using the TYB-optimized zona free hamster oocyte sperm penetration assay (TYB-optimized SPA), to evaluate the predictive value of strict morphology on outcome of the SPA. In a retrospective study, 56 samples were analysed. In addition to routine semen parameters, the percentage of spermatozoa with normal morphology (A forms) and the average number of penetrations per oocyte (Sperm Capacitation Index) was evaluated in all cases. Using a multiple linear regression analysis with all semen parameters, sperm morphology was the best predictor (p = 0.001) of the SPA score. The agreement between the percentage of A forms and the Sperm Capacitation Index beyond chance (kappa coefficient) was 0.5842. Twenty-two specimens had abnormal SPA scores, with 21 exhibiting abnormal sperm morphology (Sensitivity = 96%). The remaining 34 samples had normal Sperm Capacitation Index values; of these, 23 had normal sperm morphology in semen (Specificity = 68%). The positive predictive value was 96%, and the negative predictive value was 66%. All semen samples from control donors had normal semen parameters and Sperm Capacitation Index values. In conclusion, the percentage of spermatozoa with normal morphology assessed using Tygerberg criteria (> 14% A forms) are predictive of the results in the TYB-optimized SPA. However, sperm morphology appears to be a better predictor when it is normal than when it is abnormal.

Papanicolaou and Kruger assessment of sperm morphology: thresholds and agreement.

The current World Health Organization guidelines (1992) suggest that the presence of > or = 30% normal sperm forms (i.e. PAP criteria) is consistent with normal semen quality. Critical evaluation of sperm morphology (CE; Kruger classification) has shown an excellent correlation with human in vitro fertilization. Utilizing Kruger criteria, > 14% normal sperm forms has been proposed as indicative of normal semen quality. We have performed a retrospective analysis on 261 individuals to assess the agreement between PAP and Kruger criteria for normal sperm morphology (NSM). When the threshold for NSM by PAP was set at 30%, a significant agreement was found between the percentage normal forms of both criteria (Kappa coefficient = 0.37; p < 0.001). Sixty-seven (92%) of the 73 men found to have abnormal sperm morphology by PAP had abnormal semen by Kruger classification. When the threshold for NSM by PAP was established at 50%, the Kappa coefficient was 0.48 (p < 0.001). Sixty of the 72 samples (83%) classified as normal by PAP staining were normal by Kruger criteria. Interestingly, when NSM by PAP was between 30 and 50%, the specimen was just as likely to have normal or abnormal sperm morphology by Kruger (40 vs. 60%, respectively). These results strongly suggest that a high or low percentage of NSM by PAP is in agreement with the Kruger classification. The excellent agreement of Kruger and WHO criteria at the extremes (< 30% and > 50%) may obviate the need for Kruger assessment. However, when WHO morphology is between 30 and 50%, the addition of Kruger evaluation may provide meaningful information to help better diagnose a patient and plan his treatment.

Response of routine semen analysis and critical assessment of sperm morphology by Kruger classification to therapeutic varicocelectomy.

PURPOSE: We studied the effect of varicocelectomy on Kruger morphology and semen parameters. MATERIALS AND METHODS: A total of 33 subfertile men diagnosed with varicoceles was evaluated 3 months before, and 3 to 4 and 6 to 8 months after varicocelectomy. Evaluation involved routine semen analysis and sperm morphology using Kruger classification. RESULTS: Significant improvement in sperm concentration and count was found after varicocelectomy (sperm count preoperatively 117.1 +/- 29, 3 to 4 months postoperatively 162.5 +/- 41 and 6 to 8 months postoperatively 139.8 +/- 25 million sperm, p = 0.0095). Using Kruger classification, evaluation of sperm morphology revealed overall significant increase in percentage of normal A forms at 3 to 4 and 6 to 8 months after surgery (from 9.8 +/- 5.8% A forms, 13.6 +/- 7.7% A forms, and 14.5 +/- 7.5% A forms, respectively, p = 0.0002, normal greater than 14%). Twelve of the 26 patients (46%) with abnormal sperm morphology preoperatively and greater than 4% A forms reached normal levels 3 months postoperatively. Six months after surgery only 6 patients maintained normal values and 3 of the initial 14 nonresponders became normal (9 of 26, 36%). Three patients with severe teratozoospermia (less than 4% A forms) showed improvement in sperm morphology. Four patients with normal sperm morphology preoperatively were not affected by varicocelectomy. CONCLUSIONS: Surgical correction of varicocele was associated with significant improvement in sperm morphology evaluated using Kruger classification. Concentration and count improved after varicocelectomy. Changes were observed as early as 3 months after surgery.

Resident training survey in infertility.

PURPOSE: We characterize infertility training in urology residency programs. MATERIALS AND METHODS: A pilot survey was sent to randomly selected urological training programs. The modified final survey was sent to 126 approved urological residencies in North America. RESULTS: Of the 126 surveys 110 (87%) were returned. Among the programs 38% expressed interest in recruiting a faculty member with expertise in infertility, 32% indicated an inadequate number of patients available to train residents and 56% indicated that their residents were least competent in the treatment of infertile patients compared to the other urological subspecialty disciplines. CONCLUSIONS: This survey confirms the underemphasis of infertility in urological training programs and the need to enhance this training.

Development of a new alloplastic spermatocele demonstrating successful sperm retrieval in an animal model.

OBJECTIVE: To create an alloplastic spermatocele capable of repeated sperm aspiration. The alloplastic spermatocele has long been a theoretical solution to infertility for those patients with congenital absence of the vas deferens or irreversible obstruction of the male reproductive ductal system. Recent studies have suggested that sperm from efferent ducts are capable of fertilization. Clinical use of alloplastic spermatoceles for collection of epididymal sperm has resulted in unacceptably low pregnancy rates. Improvement in spermatocele function may occur if a microsurgical anastomosis is performed to the epididymis. DESIGN: A newly designed alloplastic spermatocele was implanted in 17 mature male rabbits. The faceplate of the device had a 0.7-mm orifice, allowing direct precise microsurgical anastomosis to a specific loop of the epididymal tubule. RESULTS: Sperm retrieval was possible in 16/17 (94%) animals. Repeated successful aspirations (total of 73) were performed in all but one animal. The total number of sperm collected per spermatocele averaged 115 x 10(6) (range 0 to 734 x 10(6)). The sperm motility varied widely between animals and specimens, with a maximum average of 21.6% motile sperm/aspirate per animal. All spermatoceles eventually occluded (mean time of occlusion 14 days; range 3 to 30 days). The prostheses with the attached epididymides were examined histologically. CONCLUSIONS: This prototype alloplastic spermatocele allows repeated high density sperm retrieval over a short period of time. Low sperm motility may be less problematic clinically as new techniques of IVF become available.

Fate of the upper urinary tract in multiple sclerosis.

Urologic problems are a major source of morbidity for patients with multiple sclerosis (MS). Fifty-four to 78% of patients experience bladder symptoms which are due to spinal lesions interrupting neural pathways that control micturition. MS patients could have upper or lower motor neuron lesion type bladders. Both obstructive and irritative symptoms may be present. Although lower urinary tract dysfunction has been well described in MS, few studies have investigated the fate of the upper urinary tract. Thirty-two patients with MS were referred for urodynamic evaluation. Twenty-six of the 32 patients had upper urinary tract studies performed. Only 1 of the 26 patients had evidence of upper urinary tract deterioration. It is our impression that upper tract deterioration occurs infrequently in these patients. We discuss clinical clues that may predict deterioration.

Urine contamination of seminal fluid after transurethral resection of the ejaculatory ducts.

Transurethral resection of ejaculatory duct obstruction has assumed a significant role in the treatment of infertile men. The potential impact of disruption of the ejaculatory duct apparatus after transurethral resection has not been studied. The seminal plasma of patients was evaluated after transurethral resection of the ejaculatory ducts by determining creatinine levels as a measure of urine contamination of semen. Analysis of semen parameters was retrospectively performed on preoperative and postoperative samples in 8 subfertile men diagnosed with ejaculatory duct obstruction treated by transurethral resection. These were not 8 consecutive patients but rather individuals from a larger series who had seminal plasma frozen preoperatively and postoperatively. A significant increase in seminal plasma creatinine levels postoperatively was detected in 7 of 8 patients evaluated. In patients who were requested to produce 2 specimens within 1 hour high levels of creatinine were found in both ejaculates, although creatinine levels were lower in the second ejaculate. The patient who postoperatively had low levels of creatinine in seminal plasma demonstrated an improvement in sperm concentration and morphology, and his wife became pregnant. Transurethral resection of the ejaculatory ducts results in marked improvement in some semen parameters. However, the impact of urine contamination in semen after transurethral resection of the ejaculatory ducts must be assessed in the management of patients who present with ejaculatory duct obstruction.

Cystic fibrosis and congenital agenesis of the vas deferens, antisperm antibodies and CF-genotype.

Antisperm antibodies are formed as a result of vasal and epididymal obstruction. Fourteen males of different ages (pre-, peri- and post-pubertal) with bilateral congenital vasal agenesis and epididymal obstruction secondary to cystic fibrosis (CF), and seven men with congenital bilateral aplasia of the vas deferens (CBAVD) were evaluated with regard to both the presence and levels of serum antisperm antibodies, and the CF-genotype. While IgA and IgG were not detected among pre- and peri-pubertal CF patients, 4 out of 10 (40%) exhibited IgM binding to sperm tail-tip. Post-pubertal CF patients showed high antisperm antibody (ASA) levels in 3 of the 4 males (75%) evaluated for the three isotypes assayed. ASA were found in 5 of 7 CBAVD patients (71%); IgG (n = 3) and IgM (n = 4) were found to be the predominant isotypes bound to sperm tail-tip. CF-genotype analysis revealed two pre-pubertal patients with the DeltaF508/DeltaF508 CF-genotype and a positive ASA response, thus suggesting an earlier or more severe blockage. In addition, the two CBAVD patients found to have a ?/? CF-genotype on the initial screening did not have ASA. The altered antigenicity of sperm associated with initiation of spermatogenesis appears to modify the antisperm antibody isotypes. Further studies on a larger number of patients may allow for a better understanding of the ASA response, as well as a better understanding of a possible phenotype/genotype association between the CF-genotype and the immunologic response.

Treatment outcome after varicocelectomy. A critical analysis.

After extensively reviewing the literature that addresses the efficacy of varicocelectomy, it is apparent that the extent data are flawed because of inappropriate study design and reporting. These difficulties are compounded by an inadequate understanding of the pathophysiology of the varicocele and the complexities intrinsic to the study of reproduction. Varicocelectomy does, indeed, appear to have a beneficial effect on sperm density. This effect seems more pronounced when initial semen densities are greater than 10 million/mL. Conversely, a "ceiling effect" or less of a response may occur when preoperative sperm densities are greater than 40 million/mL. Although anecdotal reports suggest that varicocelectomy may be of benefit even to the azoospermic individual, we do not ascribe to this approach. Motility and morphology may improve significantly after varicocelectomy when an associated rise in density has occurred. Isolated improvements in either of these parameters have also been observed. Simultaneous improvements in density and morphology, however, have not been reported unless a concurrent significant improvement in semen density occurs. In spite of the occasional study which indicates that varicocelectomy does not improve fertility, the preponderance of the literature does in fact support a favorable effect. After carefully analyzing the design and outcome of the studies reviewed, it is clear that a definitive statement concerning the efficacy of varicocelectomy cannot be made. This therapeutic dilemma can be resolved only by a well-designed prospective, randomized, controlled study that examines the impact of varicocelectomy on seminal parameters, sperm function tests, and the pregnancy rates in couples evaluated by stringent protocols. Patients should be stratified according to seminal parameters and age. We conclude as we began: Varicocelectomy remains an important treatment of male factor infertility.

Lead exposure in vivo alters the fertility potential of sperm in vitro.

Lead is a male reproductive toxicant. We previously reported that in vivo lead exposure results in a suppression of the hypothalamic-pituitary-testicular axis in male rats. This study was designed to assess if lead exposure in vivo alters (1) the ability of sperm to fertilize ova in vitro, (2) the morphology of the spermatozoa, and (3) the relationship of cell types in the testes as evaluated by DNA flow cytometry. Male Sprague-Dawley rats were given access to either lead-free (0.0%) or 0.3% lead acetate-containing water for 14, 30, or 60 days starting at 100 days of age. On the day of termination, sperm harvested from the caudae epididymis were incubated with eggs harvested from superovulated non-lead-treated females and were scored for stages of penetration. Sperm were also studied by electron microscopy. The testes of animals treated for 60 days were processed for DNA flow cytometry. The overall distribution of the stages of fertilization was significantly different between control and lead-treated animals. The lead-treated groups fertilized significantly fewer eggs than did sperm from the control group. Increased duration of exposure to lead acetate did not result in a more significant percentage of eggs not fertilized. No ultrastructural changes were noted in the spermatozoa of animals treated with lead compared to control animals. There were no differences in the histogram patterns of testicular cells collected from lead-treated animals and control animals. We conclude that lead alters sperm function by altering the hormonal control of spermatogenesis rather than by direct toxic action on spermatozoa.

Varicoceles: effect on testicular volume in prepubertal and pubertal males.

A total of 63 prepubertal and 17 pubertal males were examined to determine both testicular volumes and to correlate testicular volumes with the presence or absence of a varicocele. In the prepubertal group neither the left nor the right testicle predominated in size. In the pubertal group, the left testicle with an associated varicocele was smaller than the right.

Analysis of factors contributing to success in a program of micromanipulation-assisted fertilization.

OBJECTIVE: To determine factors important to clinical success in micromanipulation-assisted in vitro fertilization (IVF). DESIGN: Procedures invoked in two separate series of micromanipulation-assisted IVF cycles, one unsuccessful (series I) and the other successful (series II), were compared in an effort to identify changes that led to clinical success. SETTING: University-based IVF clinic. PATIENTS: In both IVF series involving micromanipulation, patients consisted of infertile couples who fit any of five categories of male-factor related infertility. The female patients underwent controlled hyperstimulation for oocyte retrieval and the oocytes were inseminated normally or were subjected either to partial zona dissection or subzonal sperm insertion to assist fertilization. Results in all groups were compared between the two patient series. RESULTS: In the successful series II, a noticeable improvement in fertilization rate and embryo quality was observed compared with series I. A significant increase in the percentage of patients reaching embryo transfer, the pregnancy rate per transfer, and the pregnancy rate per retrieval were noted in series II; a 25% ongoing pregnancy rate per retrieval was observed overall in this successful group, with "ongoing" defined as manifestation of at least a fetal sac on ultrasound with no detectable problems. Patients with a mixed transfer of embryos derived from manipulated and normally inseminated oocytes had a 75% rate of pregnancy per transfer in series II. Differences between the two series could not be attributed to patient selection or biases in selection of oocytes relegated to micromanipulation. However, oocyte handling, micromanipulation, and culture protocols differed significantly between the two series in that temperature and pH of oocytes was better controlled, and micromanipulation time was minimized in series II. CONCLUSION: Success in micromanipulation depends on maintenance of the oocyte in a stable and supportive environment throughout the micromanipulation procedure. It is also important to minimize trauma to the eggs by performing micromanipulation rapidly and with minimal distortion of the egg. Patients with a poor fertilization rate in standard IVF may experience a substantial increase in the likelihood of pregnancy when micromanipulation-assisted fertilization is performed on some eggs.

Treatment of congenital penile curvature with penile torsion: a new twist.

Congenital penile curvature secondary to asymmetry of corpora cavernosal length is an uncommon cause of penile deformity. Although the deformity generally is not severe enough to preclude sexual intercourse it can be a source of great concern to the patient and may cause him to avoid all sexual contact. The Nesbit procedure is a simple, effective surgical technique to correct lateral or ventral curvature. Rarely penile deviation is accompanied by penile torsion. This unique problem requires a novel surgical approach to create a straight, nontwisted erection. We report 2 cases of congenital lateral penile curvature with accompanying penile torsion and describe a simple modification of the Nesbit procedure for surgical correction.

The cofactor effect: varicocele and infertility.

The varicocele may be a cofactor that, when potentiated by other cofactors (i.e., gonadotoxins), causes male infertility. This hypothesis could explain the unpredictable effects of the varicocele on fertility. Male rats with experimental varicoceles, sham surgery, or no surgery were treated for 30 days with the known gonadotoxins cyclophosphamide or nicotine. Spermatogenesis was assessed by flow cytometry. Cyclophosphamide alone caused gonadotoxicity, and its effect was accentuated by sham or varicocele surgery. Nicotine and the presence of a varicocele were more gonadotoxic than either the varicocele or nicotine by itself. This data would lend support to the cofactor hypothesis of the pathophysiology of the varicocele.