Microsurgical inguinal varicocele repair in azoospermic men.

OBJECTIVES: To evaluate the efficacy of microsurgical inguinal varicocele repair in nonobstructive azoospermic men with palpable varicocele and to determine predictive parameters of outcome. METHODS: After standard diagnostic evaluation, 24 pellet (-) completely azoospermic men and 14 pellet (+) virtually azoospermic men underwent microsurgical inguinal varicocele repair. Testicular core biopsy was also performed perioperatively in all patients. The outcome was assessed in terms of improvement in semen parameters and spontaneous pregnancy. RESULTS: After a mean follow-up of 13.4 +/- 4.7 months, motile sperm in the ejaculate could be identified in 5 (21%) of the completely azoospermic patients, and these patients were rescued from invasive sperm extraction techniques when referred to intracytoplasmic sperm injection. Testicular histopathology of these patients with postoperative improvement revealed maturation arrest at spermatid stage (n = 3), Sertoli-cell-only (SCO) pattern with focal spermatogenesis (n = 1), and hypospermatogenesis (n = 1). None of the patients with pure SCO pattern or maturation arrest at spermatocyte stage had improvement after varicocele repair. However, improvement in semen parameters was observed in 12 (85.7%) patients with virtual azoospermia, 4 (28.6%) achieved a total motile sperm count greater than 5 million, and spontaneous pregnancy occurred with 3 (21.4%) of them. CONCLUSIONS: Microsurgical inguinal varicocele repair offers completely azoospermic men the chance to provide motile sperm via ejaculate in 21%. Moreover, 28.6% of virtually azoospermic men are rescued from ICSI procedures as an initial treatment modality. Results of varicocele repair in azoospermic men also reveal that a certain threshold of spermatogenesis, requiring the presence of at least spermatids, is necessary for effective varicocele repair.

Comparison of results and complications of high ligation surgery and microsurgical high inguinal varicocelectomy in the treatment of varicocele.

OBJECTIVES: To prospectively compare sperm parameters, pregnancy and recurrence rates, and complications after randomized high ligation surgery versus microsurgical high inguinal varicocelectomy (MHIV). METHODS: Varicocele was diagnosed by physical examination and color Doppler ultrasound in 468 patients who underwent one of two procedures: high ligation surgery (n = 232) or MHIV (n = 236). The high ligation surgery was left unilateral in 142 and bilateral in 90. The MHIV was left unilateral in 128 and bilateral in 108. The patients were postoperatively evaluated by spermiograms and physical examination. The pregnancy rate was monitored for 2 years. RESULTS: One year after surgery, 34.05% in the high ligation group and 46.61% in the MHIV group had a more than 50% increase in their total motile sperm count (P = 0.000). The increase in sperm count was not statistically different between the two groups (P = 0.1), but the difference in the increase in sperm motility in the MHIV group was statistically significant (P = 0.000). Pregnancy rates at the end of 2 years reached 33.57% in the high ligation group and 42.85% in the MHIV group, not a statistically significant difference (P = 0.0571). The postoperative recurrence as detected by physical examination was markedly different between the two techniques. The recurrence rate was 15.51% in the high ligation group and 2.11% in the MHIV group (P = 0.000). Also, the incidence of postoperative hydrocele was significantly different between the two groups (9.09% in the high ligation group and 0.69% in the MHIV group; P = 0.000). CONCLUSIONS: MHIV has lower recurrence and hydrocele rates, a higher increase in sperm motility, and results in higher pregnancy rates. Therefore, it should be the preferred technique for varicocelectomy.

The effect of microsurgical varicocelectomy on serum follicle stimulating hormone, testosterone and free testosterone levels in infertile men with varicocele.

OBJECTIVES: To analyse the effects of varicocelectomy on serum follicle-stimulating hormone (FSH), testosterone and free testosterone levels, and to investigate the interrelationships between seminal and hormonal variables. PATIENTS AND METHODS: The records were retrospectively evaluated for 78 infertile patients who underwent microsurgical inguinal varicocelectomy, with documented serum FSH, testosterone, free testosterone levels, sperm concentration and sperm motility before and after surgery. Left and bilateral varicoceles were detected in 40 and 38 patients, respectively. In addition, serum hormonal values of 10 fertile men in whom physical examinations and Doppler ultrasonography revealed no evidence of varicocele were recorded and used as a control group. RESULTS: The mean (sd) serum FSH levels of all patients decreased from 15.21 (3.34) before surgery to 10.82 (2.93) mIU/mL afterward (P=0.01), and serum testosterone levels increased from 5.63 (1.40) to 8.37 (2.2) ng/mL (P=0.01), whereas free testosterone levels increased from 23.13 (3.19) to 32.83 (4.37) pg/mL (P<0.001). In contrast to the significant difference in sperm motility before and after surgery of all patients (P<0.01), the difference in sperm count was insignificant (P>0.05). Thirty-six patients with high serum FSH levels before surgery had significantly lower levels afterward (P=0.001). In this group, the sperm concentration and motility also increased, from 17.66 (4.35) to 20.76 (4.37) million/mL (P=0.05) and from 30.9 (4.4)% to 37.5 (4.34)%, respectively (P=0.01). In the remaining 42 patients who had normal preoperative serum FSH levels, there was a slight decrease after surgery (P=0.02). Their sperm concentration increased slightly (P=0. 04), and motility also increased (P=0.001). Sixty patients had a significantly higher testosterone level after surgery; in this group the sperm concentration and motility increased (P=0.01). CONCLUSION: Varicocelectomy promotes Sertoli and Leydig cell function. The significant increase in serum free testosterone level results in a significant improvement in sperm concentration and motility.

Evaluation and therapeutic approaches of voiding and erectile dysfunction in neurological Behçet's syndrome.

PURPOSE: Behçet's syndrome is a progressive inflammatory disease which involves multiple systems. It is characterized by 3 main symptoms of iridocyclitis, and oral and genital ulcerations. Nervous system involvement is seen rarely in this clinical entity and is known as neurological Behçet's syndrome. Inflammation usually occurs in the brain stem, cerebellum and medulla spinalis. Voiding and erectile dysfunction can be due to progressive inflammatory reactions in the nervous and vascular systems. We prospectively evaluated the dysfunctional bladder and penis, and therapeutic options were evaluated prospectively. MATERIALS AND METHODS: A total of 24 consecutive patients diagnosed with neurological Behçet's syndrome after neurological evaluation were enrolled in this study. Neurological involvement and localization of the nervous system were proved on evaluation. Voiding and erectile dysfunction was evaluated regardless of the presence of related symptoms, and the results were compared with those of controls. Patients with voiding dysfunction on urodynamic study were treated and reevaluated symptomatically after 3 and urodynamically after 6 months. RESULTS: The rate of erectile dysfunction in neurological Behçet's syndrome was 63%. Mixed type vasculogenic impotence, arterial insufficiency, veno-occlusive dysfunction and neurogenic impotence were identified in 7, 2, 2 and 1 patient, respectively. Detrusor instability was demonstrated in 12 patients with urgency incontinence, including 3 with detrusor-sphincter dyssynergia. Brain stem localization was determined in these patients on neurogenic evaluation. Significant improvement was observed with anticholinergic treatment and clean intermittent catheterization in 3 patients with detrusor-sphincter dyssynergia. Hypersensitive and hypocompliant detrusor was noted in patients with neurological Behçet's syndrome who had normal voiding habits. CONCLUSIONS: Incontinence or irritable bladder symptoms should not be considered innocuous clinical findings in neurological Behçet's syndrome. Lower urinary tract function should be evaluated in all patients with this neurological syndrome. The incidence of erectile dysfunction is approximately 65% and the therapeutic approach should be determined according to lower urinary tract function.

Surgical treatment of Peyronie's disease with incision and venous patch technique.

Peyronie's patients are candidates for surgical treatment when the acute phase has resolved. The choice of surgical treatment modality, either reconstructive procedure or implantation of penile prosthesis, largely depends on the type and degree of the deformity and the penile vascular status of the patient. We present the results of ou1Effects of inhibitors and rmTNF-alpha on FMLP-induced O2 production by mouse leukocytesr experience with incision and venous patch technique in Peyronie's disease. Incision and venous patch technique was performed in 20 patients with a mean duration of the disease of 26.1 +/- 19.8 months. Complete straightening was achieved in 15 (75%) patients after a mean followup of 13.2 +/- 9.4 (3-27) months. Postoperative residual curvature (< 20 degrees) was observed in 4 (20%) patients. Bulging at the graft site was noted in 1 (5%) patient. Potency was preserved in all patients except one. Incision and venous patch technique, with its satisfactory results, should be considered in Peyronie's patients having an adequate penile vascular system during chronic stable phase of the disease.

Treatment of idiopathic and postvaricocelectomy oligozoospermia with oral tamoxifen citrate.

OBJECTIVE: To identify a subgroup of men who may benefit from tamoxifen citrate (a widely prescribed drug for male infertility) among those with normogonadotrophic and hypergonadotrophic oligozoospermia, either idiopathic or after varicocelectomy. PATIENTS AND METHODS: The study included infertile men with oligozoospermia, 136 referred to our outpatient clinic and 84 infertile after varicocelectomy. All patients received tamoxifen citrate (10 mg twice daily); semen analysis and hormone tests were repeated at the end of 3 and 6 months of treatment, the values being compared with those before treatment. RESULTS: The levels of follicle-stimulating hormone, luteinizing hormone and testosterone increased in all groups receiving tamoxifen citrate. Normogonadotrophic patients had a significant increase in sperm count and concentration, while the slight increase detected in the hypergonadotrophic group was statistically insignificant. CONCLUSION: In patients with normogonadotrophic oligozoospermia, tamoxifen citrate may be offered as a practical and economic alternative before using any assisted reproduction techniques. However, double-blind placebo-controlled trials are needed to confirm the findings of this preliminary study.

Does the positive intracavernous papaverine test always indicate a normal penile vascular system?

OBJECTIVE: A positive intracavernous papaverine test has been presumed to determine normal erectile hemodynamics. Recently, positive erectile responses to intracorporeal injection tests were reported in patients with penile arterial insufficiency. METHODS: This hypothesis was assessed by obtaining hemodynamic data using color Doppler ultrasonography in 417 patients with erectile dysfunction aged between 20 and 73 years (mean 43.06 +/- 13.66). A normal penile vascular system was found in 95 patients (22.79%), veno-occlusive dysfunction in 76 (18.22%), arteriogenic erectile dysfunction (ED) in 113 (27.10%) and mixed-type ED in 133 (31.89%). RESULTS: A positive erection response was achieved in 176 patients with combined intracavernosal injection of 60 mg papaverine and self-manual genital stimulation (CIS) test, while a negative response was observed in the remaining 241 (57.79%). Color Doppler ultrasonography combined with pharmacological erection has proved a normal penile vascular system in 94 (53.41%) and penile arterial insufficiency in 82 (46.59%) patients of those who gave a positive response to the CIS test. Also, a positive CIS test response was observed in all patients with unilateral arterial insufficiency (n = 31) and in 51 patients (62.19%) out of 82 with bilateral arterial insufficiency. CONCLUSION: A positive intracavernous papaverine test indicates veno-occlusive dysfunction competence but does not necessarily signify a normal penile arterial system. The CIS test should be combined with color Doppler ultrasonography in order to determine the vascular component of ED, since the differentiation is not possible between slight penile arterial insufficiency and psychogenic or neurogenic impotence with the CIS test.

Primary gonadotropin releasing hormone and adjunctive human chorionic gonadotropin treatment in cryptorchidism: a clinical trial.

OBJECTIVES: The effect of intranasal gonadotropin-releasing hormone (GnRH) and intramuscular human chorionic gonadotropin (hCG) in the treatment of cryptorchidism was investigated in 48 prepubertal boys. METHODS: Forty-eight prepubertal boys with 70 undescended testes were enrolled into a prospective study between November 1989 and November 1991. GnRH was applied as nasal spray at a dose of 1.2 mg/day for 4 weeks. The patients with partial descent were subsequently treated with 1500 IU hCG weekly for 3 weeks. RESULTS: Complete descent was observed in 53% (37 of 70) of testes; 58% (15 of 26) in unilateral and 50% (22 of 44) in bilateral undescended testes. One abdominally located testicle did not respond to therapy. Of 37 testes located in the inguinal canal, seven (19%) descended. On the other hand, descensus rates were 100% for the testes located at the external inguinal ring and at a high scrotal level. Six primarily descended testes (16%) showed relapse during the follow-up. Surgery was performed in 12 patients (14 testes), revealing associated hernia in nine testes and epididymal anomalies in four. CONCLUSIONS: We believe that the GnRH and hCG combination is an effective therapy for undescended testes located at and beyond the external inguinal ring and should be the first treatment choice because of its noninvasiveness. Both unilateral and bilateral undescended testes responded with similar success rate to hormonal therapy. Surgery should be considered for proximal cryptorchidism.

The correlation of end-diastolic flow velocity and cavernosometry results in the diagnosis of venous leakage.

OBJECTIVES: Cavernosometry is a conventional and reliable method used in the diagnosis of caverno-venous incompetence. Recently, cavernosal artery end-diastolic blood flow velocity more than 5 cm/sec during the rigid phase and after 10 minutes with duplex ultrasonography has been considered as veno-occlusive dysfunction. METHODS: Fifteen patients with erectile dysfunction aged 20 to 56 years (mean age 35.8) were evaluated by dynamic infusion cavernosometry and duplex ultrasonography which measured end-diastolic blood flow velocity during the rigid phase of erection and after 10 minutes. RESULTS: Dynamic cavernosometry was considered the gold standard during this comparative study. The sensitivity of duplex ultrasonography was found to be 100%, its specificity was 71.42%, positive predictive value 80% and its negative predictive value was 100% in the detection of caverno-venous incompetence.

Posttraumatic high-flow priapism treated by N-butyl-cyanoacrylate embolization.

A patient with high-flow priapism was treated by transcatheter embolization of a posttraumatic left cavernosal arteriovenous fistula using N-butyl-cyanoacrylate (NBCA), resulting in complete detumescence. Erectile function has been preserved during a 3-month follow-up. Only two patients with NBCA embolization for high-flow priapism have been reported previously.

Evaluation of penile arteries in papaverine-induced erection with color Doppler ultrasonography.

OBJECTIVE: Color Doppler ultrasonography is a useful method in the evaluation of small vessels and vascular anatomy and in demonstrating dynamic changes of blood flow. The detrimental effects of different risk factors of erectile dysfunction such as diabetes mellitus, hypertension, hypercholesterolemia on the penile arterial system were investigated. METHOD: 180 patients with erectile dysfunction underwent functional evaluation of the arterial system by combined intracavernous injection of 60 mg papaverine and stimulation test and color Doppler ultrasonography. RESULTS: There were 64 patients (35.55%) whose vascular findings were normal. A total of 36 patients (20.00%) had arterial insufficiency and 42 patients (23.33%) had mixed-arteriogenic-venogenic impotence. Combination of hypertension and hypercholesterolemia was found to be more detrimental to the penile arterial system than hypertension alone, the presence of hypertension and diabetes mellitus together, diabetes alone and hypercholesterolemia. CONCLUSION: Color Doppler ultrasonography depends on variables such as equipment, operation and software version in the functional evaluation of the penile arterial system. The combination of hypertension and hypercholesterolemia was found to be more detrimental to the penile arterial system. Further studies based on larger patient populations are required in order to determine the effects of erectile dysfunction contributing disease on the penile arterial system.

Evaluation of penile arterial system with color Doppler ultrasonography in nondiabetic and diabetic males.

The parameters of the functional evaluation of the penile arterial system in sexually active males are based on a minimal number of volunteers and impotent patients of neurogenic origin who are expected to have a normal vascular system. In order to investigate these parameters in 23 sexually active diabetic and nondiabetic males, penile arterial systems were evaluated by color Doppler ultrasonography. Parameters obtained from the cavernous arteries were arterial diameter (pre- and postpapaverine), diameter increase rate and systolic peak blood flow velocity. Systolic peak blood flow velocities in papaverine-induced erection were 36.75 (+/- 9.99) and 37.50 (+/- 13.18) cm/s for right and left cavernosal arteries, respectively, in nondiabetic 16 men. The mean cavernosal artery diameter changes were 89.23 and 77.93% for right and left cavernosal arteries. Systolic peak blood flow velocities were 24.57 (+/- 7.44) and 25.42 (+/- 9.45) cm/s and diameter increase rates were 78.57 and 37.50% for right and left cavernosal arteries in diabetic sexually active men. Sexually active diabetics have a significantly lower cavernosal artery peak blood flow velocity and diameter increase rate than nondiabetics (p < 0.01). Thus a subclinic dysfunction of erection might be introduced in diabetic males. In conclusion, each investigator should determine his own standards on sexually active subjects and on those with different etiologies such as diabetics mellitus, hypertension and hypercholesterolemia, contributing to erectile dysfunction.

Treatment of penile incarceration in an impotent patient.

We report a case of penile incarceration in a 53-year-old impotent man. The base of the penis was encircled by a metal ring in order to achieve better erection. There was marked oedema of the entire penis distal to the constricting ring. The metal ring was removed successfully by cutting it with a steel saw.

Combined intracavernous injection of papaverine and stimulation (CIS) test.

The inhibitory effect of the overactivity of the sympathetic nervous system that results from outpatient clinical conditions leads to poor erectile response to intracavernous injection of papaverine. The effects of self manual genital stimulation for improvement of erectile quality in insufficient papaverine response were investigated in 171 impotent men. Twenty-nine (63.04%) of 46 patients who had a normal vascular system showed partial response to papaverine. Following self manual genital stimulation, full erection was achieved in all of them. Better erections were achieved in 28 of 42 patients with arterial disease. In patients subclassified as having slight, moderate, and severe arterial disease, improved erections were noted in 100%, 71.42%, and 64.28%, respectively. In the mixed vascular (arterial+venous) disease group (n = 46), the combined intracavernous injection of papaverine and stimulation (CIS) test led to a better erection in only 41.30%, whereas in the pure venogenic group (n = 37), this percentage was 66.66%. The inhibitory effect of the overactivity of the sympathetic nervous system is significantly reduced by the CIS test.

Cryptorchidism: is orchidopexy always preventive treatment for infertility?

Cryptorchidism is one of the testicular factors recognized as preventable disease processes. Although the effect of bilateral cryptorchidism on fertility is well documented, more studies are required in order to determine the bilateral functional and histologic effects of unilateral cryptorchidism. This clinical retrospective study analyses the effects of cryptorchidism on fertility and histopathologic changes in dystopic and eutopic testes. Among 1400 patients consulted in our infertility clinic between the years of 1989 and 1993, 47 patients (3.3%) had cryptorchidism (29 unilateral/18 bilateral). Among these patients 26 had a history of orchidopexy (mean age at the time of operation: 13.11 +/- 5.24 years). Semen analyses (3x) were available in 43 and hormone profile in 27 out of 47. The incidence of abnormal semen parameters in unilateral and bilateral group was 89.6% and 100%, respectively. Testicular biopsies were obtained from 17 patients (10 with unilateral and 7 with bilateral disease). The biopsy findings in 75% of eutopic testes in unilateral group were similar to that of dystopic testis. The high incidence and significant histologic changes in eutopic testis supports the hypothesis that the disease might be bilateral in nature. The question whether the progression of the disease can be stopped by early orchidopexy still remains unanswered until long term follow-up studies are completed.

The effects of diabetes on penile somato-afferent system.

The direct evaluation of the autonomic nervous system to detect the neurogenic component of erectile dysfunction in men is not possible. Biothesiometry, a vibration perception test, is a simple method for the assessment of the penile somato-afferent system. A nomogram for the evaluation of somato-afferent system has been developed utilizing the biothesiometer in healthy men. This nomogram was used to compare the biothesiometric values of potent and impotent diabetic patients. According to our data, the radix penis is selectively damaged by diabetes mellitus in the first stage of the disease, whereas the glans penis is damaged later on when the disease reaches the stage of impotence.

Rationale of urodynamic assessment in adult enuresis.

Between October 1988 and November 1990, 39 adult patients (average age 18.5 years) with enuresis underwent urodynamic evaluation. Filling cystometry was performed transurethrally using normal saline in the supine position. Abnormal cystometric findings were observed in 11 patients (28.2%), unstable bladder being the most common pathology (n = 7). Abnormal cystometric findings did not correlate with sex, age and diurnal symptoms of the patients. The only difference between pathologic and normal cystometry groups was the functional bladder capacity which is found to be reduced significantly in the former group. Cystometry does not contribute to the diagnosis of enuresis but helps to enlighten its physiopathology.

Penile fracture: emergency surgery for preservation of penile functions.

Traumatic rupture of the corpus cavernosum is a rare injury and occurs following a blunt trauma on erected penis. We herewith present 16 cases which underwent a uniform emergency operation. With this strategy we observed no complications, and all penile functions including erection were preserved.

Role of inhibitor deficiency in urolithiasis. I. Rationale of urinary magnesium, citrate, pyrophosphate and glycosaminoglycan determinations.

Between October 1988 and March 1990, 173 urinary stone patients (average age 38.3 years) were evaluated metabolically, especially with regard to urinary magnesium, pyrophosphate (Ppi) citrate and glycosaminoglycans (GAG). 25 healthy subjects served as controls. Inhibitory deficiency was found to be the most frequent causal factor in our series, with an incidence of 48.7% in first-time stone formers and 51.08% in recurrent urolithiasis (p less than 0.1). Deficient citrate levels were present in 46.56%, hypomagnesiuria in 24.4%, hypopyrophosphaturia in 10.7% and deficient GAG in 2.7% of the patients. Deficient urinary Ppi was seen in only 2.7% of the stone formers as the only metabolic defect, while deficient GAG was never the only causal factor. All 4 inhibitors showed no correlation with age, sex, activity of stone disease, stone weight and burden. There were no statistically significant differences with controls. We think that routine metabolic evaluation must be performed both in recurrent patients and first-time stone formers and must include urinary citrate and Mg determinations in every case. Urinary Ppi should be determined in selected cases and GAG determinations are irrational.

Role of inhibitor deficiency in urolithiasis. II. Deficiency grade-adjusted and intermittent augmentation therapy for magnesium and citrate deficiency.

63 patients with hypocitraturia (44.9% of the total) and 33 patients with hypomagnesiuria (24.8% of the total) received oral magnesium hydroxide and/or Na/K citrate in addition to other therapeutic agents if indicated and a common-sense diet. Hypocitraturic patients were categorized into 3 groups and received 27-81 mEq/day oral citrate according to the deficiency grade. Hypomagnesiuric patients also formed two groups according to the deficiency grade and received 500 and 1,000 mg/day magnesium hydroxide, respectively. Replacement was intermittant and was controlled every 3 months until reaching normal values. We evaluated 28 of 63 hypocitraturic and 15 of 33 hypomagnesiuric patients who had inhibitory deficiency as the sole causal factor of their urolithiasis. After a follow-up of 13.5 +/- 10.2 months, no patient in either group developed a new stone. Citrate and magnesium were increased significantly in the respective groups; calcium and oxalate excretion was lowered, and urine pH and volume increased significantly. A deficiency grade-adjusted and intermittant replacement therapy with Mg and citrate is very effective, has less side effects and ensures good patients compliance.