Sperm banking before gonadotoxic treatment: is it worth the effort?

We aimed to compare the sperm quality in different cancer types and benign diseases before gonadotoxic treatment, and assess the usage rate of cryopreserved sperm for assisted reproductive treatment (ART). This retrospective study was conducted at two university clinics between January 2008 and July 2018. A total of 545 patients suffering from cancer or benign diseases were included in the study. The pretreatment sperm analyses were based on the World Health Organization (WHO) guidelines. Patients with testicular malignancy (TM) showed a significantly lower sperm count (median [interquartile range]: 18.7 × 106 [5.3 × 106-43.0 × 106] ml-1; P = 0.03) as well as total sperm count (42.4 × 106 [13.3 × 106-108.5 × 106] per ejaculate; P = 0.007) compared to other malignant and benign diseases. In addition, patients with nonseminomatous TM showed the lowest sperm count (14.3 × 106 [6.0 × 106-29.9 × 106] ml-1, vs seminomas: 16.5 × 106 [4.6 × 106-20.3 × 106] ml-1; P = 0.001). With reference to the WHO 2010 guidelines, approximately 48.0% of the patients with TM and 23.0% with hematological malignancies (HM) had oligozoospermia. During the observation period, only 29 patients (5.3%) used their frozen sperms for 48 ART cycles, resulting in 15 clinical pregnancies and 10 live births. The sperm quality varies with the type of underlying disease, with TM and HM patients showing the lowest sperm counts. Due to the observed low usage rate of cryopreserved sperm, further patient interviews and sperm analyses should be included in the routine oncologic protocols to avoid unnecessary storage expenses. However, sperm banking is worth the effort as it provides hope for men who cannot reproduce naturally after gonadotoxic treatment.

Are urologists in trouble with SARS-CoV-2? Reflections and recommendations for specific interventions.

OBJECTIVE: To assess the risk of viral infection during urological surgeries due to the possible hazards in tissue, blood, urine and aerosolised particles generated during surgery, and thus to understand the risks and make recommendations for clinical practice. PATIENTS AND METHODS: We reviewed the available literature on urological and other surgical procedures in patients with virus infections, such as human papillomavirus, human immunodeficiency virus and hepatitis B, and current publications on coronavirus disease 2019 (COVID-19). RESULTS: Several possible pathways for viral transmission appear in the literature. Recently, groups have detected severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in the urine and faeces, even after negative pharyngeal swabs. In addition, viral RNA can be detected in the blood and several tissues. During surgery, viral particles are released, aerosol-borne and present a certain risk of transmission and infection. However, there is currently no evidence on the exact risk of infection from the agents mentioned above. It remains unclear whether or not viral particles in the urine, blood or faeces are infectious. CONCLUSIONS: Whether SARS-CoV-2 can be transmitted by aerosols remains controversial. Irrespective of this, standard surgical masks offer inadequate protection from SARS-CoV-2. Full personal protective equipment, including at least filtering facepiece-2 masks and safety goggles should be used. Aerosolised particles might remain for a long time in the operating theatre and contaminate other surfaces, e.g. floors or computer input devices. Therefore, scrupulous hygiene and disinfection of surfaces must be carried out. To prevent aerosolisation during laparoscopic interventions, the pneumoperitoneum should be evacuated with suction devices. The use of virus-proof high-efficiency particulate air filters is recommended. Local separation of anaesthesia/intubation and the operating theatre can reduce the danger of viral transmission. Lumbar anaesthesia should be considered especially in endourology. Based on current knowledge, COVID-19 is not a contraindication for acute urological surgery. However, if possible, as European guideline committees recommend, non-emergency urological interventions should be postponed until negative SARS-CoV-2 tests become available.

Ultrasound of the prostate.

Ultrasound is a widely used imaging modality for evaluation of the prostate. The main topic of diagnostic imaging is an improvement of prostate cancer diagnosis. The current available systematic prostate biopsy is performed only under ultrasound guidance, but new imaging techniques allow prostate cancer visualization and therefore improved detection. Evolving methods such as contrast-enhanced colour Doppler imaging, contrast-specific ultrasound techniques and elastography may dramatically change the role of ultrasound for prostate cancer diagnosis. The purpose of this review is to provide an overview of ultrasound and its different techniques for imaging of the prostate and to discuss current trends and future directions.

Contrast-enhanced colour Doppler-targeted prostate biopsy: correlation of a subjective blood-flow rating scale with the histopathological outcome of the biopsy.

OBJECTIVE: To correlate a subjective blood-flow rating scale from contrast-enhanced colour Doppler (CECD) transrectal ultrasonography-targeted prostate biopsy with the histopathological outcome of the biopsy. PATIENTS AND METHODS: In all, 760 men with a serum total prostate-specific antigen (PSA) level of ≥ 1.25 ng/mL and a free-to-total PSA ratio of < 18% were included. CECD-targeted biopsies with five cores were taken only in hypervascular areas of the peripheral zone using a second-generation ultrasonography contrast agent, followed by a 10-core systematic biopsy. Prostate blood flow was scored using a subjective 5-point scale in which 1 indicated 'benign', 2 'probably benign', 3 'indeterminate', 4 'probably malignant' and 5 'malignant'. RESULTS: Overall 37% (283 of 760) patients had prostate cancer in the biopsy. All 100 patients with a score of 5 had cancer; 153 had a score of 4, of whom 130 (85%) had cancer and 23 had benign histology (15%); 131 had a score of 3, of whom 34 (26%) had cancer and 97 (74%) had benign histology; 284 had a score of 2, of whom 17 (6%) had cancer and 267 (94%) had benign histology; 92 had a score of 1, of whom two (2%) had cancer and 90 (98%) had benign tissue. Statistical evaluation showed that the subjective blood-flow rating scale correlated strongly and significantly (r = 0.75, P < 0.01) with the histopathological outcome of the biopsy. CONCLUSION: The present study shows that a subjective CECD blood-flow rating scale is a reliable tool to predict the pathological outcome of biopsy cores.

Contrast-enhanced colour Doppler-targeted vs a 10-core systematic repeat biopsy strategy in patients with previous high-grade prostatic intraepithelial neoplasia.

OBJECTIVE: To compare the results of contrast-enhanced colour Doppler (CECD)-targeted prostate biopsy with a systematic 10-core grey-scale biopsy scheme in patients initially diagnosed with high-grade prostatic intraepithelial neoplasia (HGPIN), as although HGPIN is thought to be a precursor to invasive adenocarcinoma, its diagnosis is no longer considered an indication for repeat prostate biopsy and patients should be followed by prostate-specific antigen levels and a digital rectal examination. PATIENTS AND METHODS: In all, 104 patients (aged 45-78 years) diagnosed with HGPIN on initial prostate needle biopsy were referred for a repeat biopsy within 6 months. Two independent examiners evaluated each patient; one used CECD-targeted biopsy (up to five cores) into hypervascular regions in the peripheral zone only, and subsequently the second took a systematic 10-core grey-scale biopsy. Cancer detection rates of both techniques were compared. RESULTS: Overall, 26 of the 104 men (25%) had prostate cancer in the repeated biopsy. Using the CECD technique cancer was detected in 21% (22 of 104). The positive re-biopsy rate using the systematic technique was 9.6% (10 of 104; P < 0.001). The total incidence of HGPIN with no evidence of tumour on re-biopsy was 8.7% (nine of 104). The Gleason score in all 22 cancers detected with the CECD technique varied between 6 and 8. The systematic technique detected cancers with Gleason scores of 6 or 7. There were no adverse events or complications. CONCLUSION: CECD increased the detection rate of prostate cancer, and using fewer biopsy cores than the systematic biopsy technique in patients previously diagnosed with HGPIN.

Allen key completely in male urethra: a case report.

INTRODUCTION: Various cases of self-inflicted foreign bodies in the male urethra have been reported. Most of them are associated with autoerotic stimulation, psychiatric disorders or intoxication. CASE PRESENTATION: We report the first case of a patient who put an Allen key completely in his urethra. The patient presented with dysuria, haematuria and penile pain. CONCLUSION: A self-inflicted urethral foreign body is a rare situation. Endoscopic removal is the recommended first-line treatment and if unsuccessful, open procedures may be necessary.

Penile strangulation in a patient with Parkinson's disease: a case report.

INTRODUCTION: Aberrant sexual behaviour such as hypersexuality or exhibitionism has been reported in patients with Parkinson's disease and its therapy. CASE PRESENTATION: We report a case of a 67-year-old man with a 10-year history of Parkinson's disease, currently under therapy with L-dopa and bromocriptine, who presented with his wedding ring constricting the base of his penis. The ring could be removed with a ring cutter without complications. CONCLUSION: The present literature concerning sexual dysfunction in Parkinson's disease and dopaminergic therapy is discussed. Doctors who treat these patients should be aware of the problem of hypersexuality associated with dopaminergic therapy.

Contrast-enhanced ultrasonography using cadence-contrast pulse sequencing technology for targeted biopsy of the prostate.

OBJECTIVE: To evaluate contrast-enhanced ultrasonography (US) using cadence-contrast pulse sequencing (CPS) technology, compared with systematic biopsy for detecting prostate cancer, as grey-scale US has low sensitivity and specificity for detecting prostate cancer. PATIENTS AND METHODS: In all, 44 men with suspicious prostate-specific antigen (PSA) levels and CPS findings were assessed; all had CPS-targeted and systematic biopsy. Transrectal CPS images were taken with a low mechanical index (0.14). A microbubble contrast agent (SonoVue, Bracco International BV, Amsterdam, the Netherlands) was administered as a bolus, with a maximum dose of 4.8 mL. CPS was used to assess prostatic vascularity. Areas with a rapid and increased contrast enhancement within the peripheral zone were defined as suspicious for prostate cancer. Up to five CPS targeted biopsies were taken and subsequently a 10-core systematic biopsy was taken. Cancer detection rates for the two techniques were compared. RESULTS: Overall, cancer was detected in 35 of 44 patients (80%), with a mean PSA level of 3.8 ng/mL. Lesions suspicious on CPS showed cancer in 35 of 44 patients (80%) and systematic biopsy detected cancer in 15 of 44 patients (34%). CPS-targeted cores were positive in 105 of 220 cores (47.7%) and in 41 of 440 systematic biopsy cores (9.3%) (P < 0.001). Lesions suspicious on CPS were false-positive in nine of 44 patients (20%). The mean Gleason score for systematic biopsy was 6.7 and for CPS-targeted biopsy 6.8 (P > 0.05). The sensitivity of CPS for detecting cancer was 100% (confidence interval, 95%). However, limitations in the series included that only CPS-positive cases were investigated, and CPS-targeted biopsy should be evaluated in a more extended biopsy scheme. CONCLUSIONS: Contrast-enhanced US using CPS enables excellent visualization of the microvasculature associated with prostate cancer, and can improve the detection of prostate cancer compared with systematic biopsy.

Anatomical approach for surgery of the male posterior urethra.

OBJECTIVE: To investigate, in a morphological study, the anatomy of the male rhabdosphincter and the relation between the membranous urethra, the rhabdosphincter and the neurovascular bundles (NVBs) to provide the anatomical basis for surgical approach of the posterior urethra as successful outcomes in urethral reconstructive surgery still remain a challenging issue. MATERIALS AND METHODS: In all, 11 complete pelves and four tissue blocks of prostate, rectum, membranous urethra and the rhabdosphincter were studied. Besides anatomical preparations, the posterior urethra and their relationship were studied by means of serial histological sections. RESULTS: In the histological cross-sections, the rhabdosphincter forms an omega-shaped loop around the anterior and lateral aspects of the membranous urethra. Ventrally and laterally, it is separated from the membranous urethra by a delicate sheath of connective tissue. Through a midline approach displacing the nerves and vessels laterally, injuries to the NVBs can be avoided. With meticulous dissection of the delicate ventral connective tissue sheath between the ventral wall of the membranous urethra and the rhabdosphincter, the two structures can be separated without damage to either of them. This anatomical approach can be used for dissection of the anterior urethral wall in urethral surgery. CONCLUSIONS: Based on precise anatomical knowledge, the ventral wall of the posterior urethra can be dissected and exposed without injuring the rhabdosphincter and the NVBs. This approach provides the basis for sparing of the rhabdosphincter and for successful outcomes in urethral surgery for the treatment of bulbo-membranous urethral strictures.

Female sexual dysfunction: a new urogynaecological research field.

OBJECTIVE: To critically review published data on the urogynaecological aspects of female sexual dysfunction (FSD), as FSD is a developing multidisciplinary issue associated with several biological, medical and psychological factors. METHODS: The reported prevalence of FSD is 19-50% and women with lower urinary tract symptoms or urinary incontinence (UI) not only complain of a deteriorating of quality of life but also of sexual life with an incidence as high as 26-47%. Furthermore, urogynaecological surgery represents an important but underestimated cause of FSD. Different databases (Pub Medical, Medline, serial titles, the Cochrane library and the NLM gateway database) were searched for the keywords 'sexuality; sexual function; urinary incontinence; pelvic organ prolapse; questionnaire; symptom severity; epidemiology; quality of life; instruments; sexual health; vagina; vaginal surgery; pelvic surgery'. RESULTS: There is a lack of a standardized instrument for assessing FSD. Recent studies investigate the impact of UI on sexual function, but the pathophysiology has not been elucidated. Vaginal or pelvic surgery does not affect overall sexual satisfaction. CONCLUSIONS: Our investigation highlights the need for studies to assess the anatomical, physiological and sensory mechanisms related to FSD. Specific questionnaire are needed to quantify the problem. In the definition, symptoms assessment and preoperative counselling is important, to make a distinction between overall sexual function and individual parameters, such as psychosocial context. Only in this way, will it be possible to identify new therapeutic targets. A definition of success in urogyneacological terms should include aspects of quality of life and quality of sexual life. Immediate research in this field is needed.

Real-time virtual ultrasonographic radiofrequency ablation of renal cell carcinoma.

OBJECTIVE: To evaluate the usefulness of real-time virtual ultrasonography (RVS) as a new navigational tool for percutaneous radiofrequency ablation (RFA) of solid renal cell carcinoma (RCC). PATIENTS AND METHODS: Ten patients with 13 RCCs were treated with percutaneous RFA using RVS, which displays ultrasonograms and corresponding multiplanar reconstruction images of computed tomography in parallel. RESULTS: RVS allowed excellent anatomical visualization and precise navigation of RFA for RCC. All patients were treated successfully in one session with percutaneous RVS RFA. There were no significant complications, and none of the patients had a local tumour recurrence during the follow-up. CONCLUSION: RVS for RFA of solid RCC is a new and promising alternative imaging method.

Comparison of the precision of transurethral endoscopic versus ultrasound-guided application of injectables.

OBJECTIVE: To compare the precision of transurethral endoscopic- vs ultrasound (US)-guided injections, as transurethral application of various injectables under endoscopic view are widely used to treat urinary incontinence. MATERIAL AND METHODS: Bovine collagen was injected into the lower urinary tract in 20 dead female pigs. In each pig five depots of collagen were injected and there were five pigs in each group. In group I collagen was injected into the urethral wall under endoscopic control. In group II collagen depots were injected periurethrally under endosocopic guidance. In group III collagen was injected into the urethral wall under US control. In group IV collagen depots were injected periurethrally under US guidance. A transurethral US probe (6 F, 15 MHz) and injection device were used for transurethral US-guided injections. In all pigs the urethra and the periurethral tissue were removed after injection and investigated using anatomical preparations and histological sections. RESULTS: In group I only two collagen depots were actually located in the urethral wall in two pigs (two of 25 depots, 8%). In group II five depots in two pigs were located in the urethral wall (five of 25 depots, 20%). The periurethral collagen depots were found to spread out in the loose connective and fat tissue around the urethra. In group III all US-guided injections of collagen were situated in the urethral wall and in group IV they were all located periurethrally. CONCLUSIONS: The present study shows that endoscopic application of injectables is an inaccurate technique, while US-guided injections are precise. US-guided injection enables excellent control of the therapeutic procedure.

Comparison of contrast-enhanced color Doppler imaging (CDI), computed tomography (CT), and magnetic resonance imaging (MRI) for the detection of crossing vessels in patients with ureteropelvic junction obstruction (UPJO).

OBJECTIVE: To assess the use of contrast-enhanced color Doppler imaging (CDI), computed tomography (CT), and magnetic resonance imaging (MRI) for the detection of crossing vessels at the ureteropelvic junction (UPJ) in patients with ureteropelvic junction obstruction (UPJO). MATERIALS AND METHODS: Forty-eight patients aged 18-69 yr (mean age, 52) who had been diagnosed with an UPJO on intravenous pyelography and diuretic renography were included. Contrast-enhanced CDI was performed by using both color Doppler frequency and color Doppler amplitude ("Power") modes. Spiral CT was performed by using a three-phase CT (arterial, venous, and excretory phases) allowing for CT angiography. MRI technique included dual-phase magnetic resonance angiography (arterial, venous) for the assessment of respective arteries and veins. The type (ie, arterial or venous) and position of the vessel relative to the UPJ (ie, anterior or posterior) were assessed. The CDI, CT, and MRI findings were correlated with the surgical findings at laparoscopic pyeloplasty. RESULTS: Forty-four of 48 patients (92%) demonstrated crossing vessels at subsequent laparoscopy. Altogether a total of 60 vessels were detected. Contrast-enhanced CDI and MRI correctly detected all crossing vessels (accuracy, 100%), whereas CT missed four posterior crossing veins (accuracy, 93%). CONCLUSION: Contrast-enhanced CDI is recommended as first-line imaging modality for the detection of crossing vessels in patients with UPJO.

Ultrasound of prostate cancer: recent advances.

Prostate cancer is the most common cancer in men. In the future, a significant further increase in the incidence of prostate cancer is expected. Therefore, improvement of prostate cancer diagnosis is a main topic of diagnostic imaging. The systematic prostate biopsy ("ten-core biopsy") is now the "gold standard" of prostate cancer diagnosis but may miss prostate cancer. Contrast-enhanced colour Doppler ultrasound (US) and elastography are evolving methods that may dramatically change the role of US for prostate cancer diagnosis. Contrast-enhanced colour Doppler US allows for investigations of the prostate blood flow and consequently for prostate cancer visualization and therefore for targeted biopsies. Comparisons between systematic and contrast-enhanced targeted biopsies have shown that the targeted approach detects more cancers and cancers with higher Gleason scores with a reduced number of biopsy cores. Furthermore, elastography, a new US technique for the assessment of tissue elasticity has been demonstrated to be useful for the detection of prostate cancer, and may further improve prostate cancer staging. Therefore, contrast-enhanced colour Doppler US and elastography may have the potential to improve prostate cancer detection, grading and staging. However, further clinical trials will be needed to determine the promise of these new US advances.

Multimodal evaluation of renal perfusional changes due to extracorporeal shock wave lithotripsy.

OBJECTIVES: To examine the effect of extracorporeal shock wave lithotripsy (ESWL) on renal perfusion before and after treatment, by assessing renal resistive index (RI) using colour Doppler ultrasonography (CDUS), magnetic resonance perfusion imaging (MRPI), radionuclide renography and big-endothelin-1 values (Big-ET-1). PATIENTS AND METHODS: In 69 normotensive patients the RI was measured before, 1, 3, 6 and 24 h after ESWL using CDUS. The RI values, measured in interlobar/arcuate arteries, were correlated with the findings on MRPI, done before and within 24 h after ESWL. In addition, renal plasma flow (RPF, assessed on radionuclide renography) and Big-ET-1 levels (a potent vasoconstrictor peptide), served as a control for evaluating renal perfusion. The patients were stratified in three age groups, i.e. or=60 years, with 23 patients in each group. RESULTS: The mean (sd) RI increased significantly in the treated kidneys, from 0.64 (0.05) before to 0.72 (0.08) after ESWL (P = 0.001). Only in patients aged >or=60 years did the RI continue to increase over the 24 h. MRPI showed a decrease of renal blood flow (RBF) in all age groups, but most significantly in those aged >or=60 years. The radionuclide renography and big-ET-1 levels changed significantly only in the oldest group. The best correlation was between RI and RBF changes detected by MRPI. CONCLUSIONS: ESWL obviously causes disturbances of renal perfusion, particularly in elderly patients (>or=60 years). Measurement of RI with Doppler techniques might provide useful information for the clinical diagnosis of renal damage.

Acute pyelonephritis: comparison of diagnosis with computed tomography and contrast-enhanced ultrasonography.

OBJECTIVE: To assess the value of contrast-enhanced ultrasonography (US) with the contrast pulse-sequence (CPS) technique for detecting renal parenchymal changes in acute pyelonephritis (APN), compared with contrast-enhanced computed tomography (CT) as the reference standard. PATIENTS AND METHODS: We examined 100 patients (82 women, 18 men; mean age 30.2 years, range 18-67); children (those aged <18 years) were excluded from the study. All patients had clinical symptoms suggestive of APN. For the US a Sequoia 512 (Acuson, Mountain View, CA, USA) unit including Cadence CPS technology, with a 6C2 probe, was used. A bolus of a 2.4-mL US contrast agent SonoVue (Bracco, Milan, Italy) was injected. For CT a multislice 16-row unit was used (Sensation 16, Siemens, Erlangen, Germany), at a table speed of 2.5 mm/s and a slice thickness of 3 mm; 100 mL of intravenous iodinated contrast agent (flow 3 mL/s) was injected. RESULTS: On contrast CT, 84 patients (84%) had renal parenchymal changes suggestive of APN; on contrast US, 82 of the 84 (98%) showed renal parenchymal changes, and APN was correctly diagnosed. Seventy-six patients (90%) had unilateral and eight (10%) had bilateral APN, and in two (2%) with APN the diagnosis could not be confirmed by US/CPS (false-negative). No false-positive findings were detected on US/CPS, which had a sensitivity of 98%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 89%. CONCLUSION: CPS/US is accurate for detecting parenchymal changes in APN; it is very sensitive and specific, and allows small renal parenchymal changes to be detected with no radiation exposure.

alpha-Blockers improve chronic ischaemia of the lower urinary tract in patients with lower urinary tract symptoms.

OBJECTIVE: To investigate whether a mechanism of action of alpha-blockers on lower urinary tract symptoms (LUTS) involves improved perfusion of the LUT. PATIENTS, SUBJECTS AND METHODS: The accuracy of perfusion measurements using transrectal colour Doppler ultrasound (TRCDUS) and colour pixel density (CPD) was initially confirmed in a porcine model. Following this confirmation, measurements were taken from four healthy male volunteers and 19 patients with LUTS. The urinary bladder was filled slowly (50 mL/min) with 0.2 m KCl, which resembles the osmolarity of concentrated urine, and evaluated by cystometry. In parallel, TRCDUS and measurement of the CPD of the LUT were performed. The patients with LUTS were then treated with daily alpha-blocker (0.4 mg tamsulosin) for 5 weeks and urodynamic variables as well as perfusion were evaluated again. RESULTS: In the healthy men, perfusion of the LUT increased considerably (157%) during filling of the bladder to a mean (sd) maximum cystometric capacity (C(max)) of 481 (28.9) mL. All the patients with LUTS had a reduced mean C(max) during filling with KCl at 322.4 (58.5) mL. The mean CPD in the urinary bladder and the prostate were only increased by 58.4% during filling with KCl. After alpha-blocker therapy the mean C(max) during filling with KCl rose to 382.5 (42.9) mL; furthermore, perfusion of the LUT measured by CPD was significantly increased (132.8%). CONCLUSIONS: The present data strongly suggest that LUTS are associated with chronic ischaemia of the prostate and urinary bladder. alpha-blockers increase perfusion in the LUT and C(max). These results might explain the therapeutic effects of alpha-blockers on LUTS.

Myoblast and fibroblast therapy for post-prostatectomy urinary incontinence: 1-year followup of 63 patients.

PURPOSE: We assessed the efficacy and safety of the application of autologous fibroblasts and myoblasts for treatment in post-prostatectomy urinary incontinence after a minimal followup of 1 year. MATERIALS AND METHODS: Sixty-three patients with stress urinary incontinence after radical prostatectomy were treated with transurethral ultrasound guided injections of autologous fibroblasts and myoblasts obtained from skeletal muscle biopsies. All subjects were evaluated preoperatively and 12 months postoperatively in terms of incontinence and Quality of Life Instrument scores, urodynamic parameters, and morphology and function of the urethra and rhabdosphincter. RESULTS: Of the 63 patients 41 were continent 12 months after implantation of cells, 17 showed improvement and 5 did not show any improvement. Incontinence and Quality of Life Instrument scores as well as thickness and contractility of the rhabdosphincter were significantly improved postoperatively. CONCLUSIONS: The use of myoblast and fibroblast therapy represents a minimally invasive, safe and effective treatment for post-prostatectomy incontinence after a followup of 1 year.