Comparative outcomes among inlay grafted incised plate, onlay preputial flap and tubularized incised plate urethroplasty for the repair of distal penile hypospadias with a narrow urethral plate.

PURPOSE: We conducted this study, comparing the outcomes among Transverse Onlay Island Flap, inlay grafted incised plate and our previous records of tubularized incised plate urethroplasty (TIPU) in patients with narrow urethral plates, aiming to determine which method of repair provides a good outcome. METHODS: This hybrid study included two datasets. The first from a prospective randomized study evaluating outcomes of two treatment modalities; Inlay graft and only flap for distal hypospadias with shallow urethral plate with 80 patients (40 patients in each group) included, the second based on our previous records of TIPU in 40 patients with distal primary hypospadias with narrow urethral plate. RESULTS: The success rate in inlay graft urethroplasty group (n = 40) was 87.5%; glandular dehiscence occurred in one case (2.5%), fistulas occurred in 2 cases (5%), and narrow meatus occurred in two cases (5%). Success rate in onlay flap urethroplasty group (n = 40) was 82.5%; glandular dehiscence occurred in two cases (5%), fistulas occurred in two cases (5%), and narrow meatus occurred in three cases (7.5%). TIPU group (n = 40) had success rate of 62.5%; glandular dehiscence occurred in eight cases (20%), fistulas occurred in five cases (12.5%), and narrow meatus occurred in seven cases (17.5%), with five cases exhibiting both narrow meatus with fistula. CONCLUSION: Inlay graft and onlay flap urethroplasty for repair of distal penile hypospadias with narrow urethral plate had higher success rate and fewer complications than traditional TIPU. Moreover, operative time was shorter in TIPU.

Post malleable Penile Prosthesis Satisfaction in elderly patients: Serial assessments.

Post penile implant sexual satisfaction in elderly patients is a multifactorial issue. In the present study, we investigated the possible implication of age on satisfaction after malleable penile implant surgery in elderly patients. We compared post-operative sexual satisfaction in the elderly with that of a younger age group (reference group). Patients were classified into three groups according to their ages (group I <45, group II between 45 and 65, and group III older than 65 years old). Modified Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaire was used at 3, 6 and 12 months after implant surgery. EDITS scores showed statistically significant high satisfaction rates in all age groups. EDITS scores were higher in the early post-operative period in younger groups compared to elderly patients. However, the difference between groups was insignificant at 12 months post-operatively (p value = .06). Our results show that elderly patients have a high post-operative satisfaction rate close to that of younger age groups, and they are suitable candidates for penile implant surgery with good and realistic post-operative sexual satisfaction expectations.

A new one-layer epididymovasostomy technique.

OBJECTIVES: To describe and evaluate the outcomes of a new epididymovasostomy technique. PATIENTS AND METHODS: Nine patients with obstructive azoospermia were treated at the Minia University Hospital using a new microsurgical bilateral epididymovasostomy technique. The technique involved the opening of a small window in the tunica of the epididymis, making an opening in the underneath epididymal tubule and keeping it open by fixing the edges of the epididymal opening to the edge of the epididymal tunica with four 10/0 nylon sutures. The abdominal cut end of the vas deferens was then anastomosed to the epididymal opening by suturing the epididymal tubule, fixed to its tunica in one layer, to the full thickness vas deferens. The main outcome measure was finding sperm in the ejaculate. RESULTS: Sperm was found in the ejaculate in six out of nine patients after our new, one-layer, epididymovasostomy technique. Mean ± sd operating time was 176 ± 23 min. CONCLUSIONS: This new, one-layer, epididymovasostomy technique provides a simple alternative method of epididymovasostomy, with reasonable outcomes. More cases and follow-up are needed to make meaningful comparisons with conventional epididymovasostomy.

Modified penile disassembly technique for boys with epispadias and those undergoing complete primary repair of exstrophy: long-term outcomes.

OBJECTIVES: To describe our experience performing the modified penile disassembly technique for boys with epispadias and for those undergoing complete primary repair of exstrophy. METHODS: Between January 2004 and July 2009, 34 boys underwent the modified penile disassembly technique at our institution. The first group included 15 boys with bladder exstrophy who underwent complete primary repair of exstrophy. The second group comprised 11 boys with penopupic epispadias after previous closure of bladder exstrophy. The third group included 8 boys with isolated complete epispadias. RESULTS: The age range was 3 months to 8 years (median, 9 months). The follow-up time ranged from 36 months to 8 years (mean, 63 months). A conical-shaped glans with the absence of any ischemic changes occurred in 94% of patients. A mild degree of penile dorsal tilt occurred in 11.7% of patients, urethrocutanous fistula in 17.6% and meatal stenosis 5.8%. In cases of complete primary repair of exstrophy, hydronephrosis occurred in 66.6% of patients. Vesicoureteral reflux appeared in 60% of patients; despite suppressive antibiotic therapy, 33.3% are awaiting reimplantation. Continence with volitional voiding with dry intervals of ≥3 h was achieved in 40% of patients. CONCLUSIONS: The modified penile disassembly technique can be used in epispadias and complete primary repair of exstrophy with excellent cosmetic results. Preservation of the distal urethral plate along with both hemiglans avoids shortening and prevents occurrence of hypospadias. Complete primary repair of exstrophy is a feasible technique with positive effects on continence with preservation of kidney function.

Optimization of spermatogenesis-regulating hormones in patients with non-obstructive azoospermia and its impact on sperm retrieval: a multicentre study.

UNLABELLED: Study Type - Therapy (outcomes) Level of Evidence 2a What's known on the subject? and What does the study add? Clomiphene citrate, hCG and human menopausal gonadotropin (hMG) are widely used in treatment of oligospermia, because they increase FSH and testosterone which are essential for spermatogenesis. Finding a sperm in non-obstructive azoospermia for intracytoplasmic sperm injection is a challenge and much effort is required to reach the optimum method of sperm retrieval. The study shows that a new protocol of clomiphene citrate, hCG and hMG in the treatment of non-obstructive azoospermia achieves an increase in the levels of FSH, LH and total testosterone to the target levels that we set. Our target level of FSH was 1.5 times its initial level and for serum testosterone it was 600-800 ng/dL. Using our described medical treatment protocol in cases of non-obstructive azoospermia, sperm may be found in patients' ejaculate (~11%) and if they remain azoospermic they will have a greater likelihood of sperms being obtained in testicular sperm extraction. OBJECTIVE: To evaluate the effect of optimizing serum level of follicle-stimulating hormone (FSH), luteinizing hormone (LH) and testosterone on sperm retrieval for intracytoplasmic sperm injection. PATIENTS AND METHODS: A total of 612 patients with non-obstructive azoospermia were evaluated with routine history, physical examination and hormonal assessment. Of these, 116 patients underwent microsurgical (micro)-testicular sperm extraction (TESE) without any medical treatment and formed the control group and the remaining 496 patients were administered clomiphene citrate in a titrated dose. Patients were classified into four groups according to their response to clomiphene citrate. Group 1: patients with an obvious increase in FSH and total testosterone (n = 372). Group 2: patients showing an increase in FSH with no or little increase in LH and total testosterone (n = 62). For these patients we continued with clomiphene citrate and added human chorionic gonadotrophin (hCG). Group 3: patients with no increase in the levels of the three hormones (n = 46). Group 4: included patients with continuously decreasing serum testosterone levels in response to the increasing dose of clomiphene citrate (n = 16). Accordingly, patients in groups 3 and 4 discontinued clomiphene citrate and started hCG and human menopausal gonadotropin (hMG). Semen analyses were performed periodically and, in patients who remained azoospermic, micro-TESE was performed. RESULTS: Sperm were noted in 54 patients (10.9%) in semen analysis after treatment in all groups (with no significant difference) at a mean (sd) concentration of 2.3 (4.1) million/mL. For the 442 patients who remained azoospermic after treatment, successful sperm retrieval was significantly higher (57%) compared with the control group (33.6%). CONCLUSION: For patients with non-obstructive azoospermia, clomiphene citrate, hCG and hMG administration, leading to an increased level of FSH and total testosterone, results in an increased rate of sperm in the ejaculate and increased likelihood of successful micro-TESE.

Protocol for developing a core outcome set for male infertility research: an international consensus development study.

STUDY QUESTION: We aim to develop, disseminate and implement a minimum data set, known as a core outcome set, for future male infertility research. WHAT IS KNOWN ALREADY: Research into male infertility can be challenging to design, conduct and report. Evidence from randomized trials can be difficult to interpret and of limited ability to inform clinical practice for numerous reasons. These may include complex issues, such as variation in outcome measures and outcome reporting bias, as well as failure to consider the perspectives of men and their partners with lived experience of fertility problems. Previously, the Core Outcome Measure for Infertility Trials (COMMIT) initiative, an international consortium of researchers, healthcare professionals and people with fertility problems, has developed a core outcome set for general infertility research. Now, a bespoke core outcome set for male infertility is required to address the unique challenges pertinent to male infertility research. STUDY DESIGN SIZE DURATION: Stakeholders, including healthcare professionals, allied healthcare professionals, scientists, researchers and people with fertility problems, will be invited to participate. Formal consensus science methods will be used, including the modified Delphi method, modified Nominal Group Technique and the National Institutes of Health's consensus development conference. PARTICIPANTS/MATERIALS SETTING METHODS: An international steering group, including the relevant stakeholders outlined above, has been established to guide the development of this core outcome set. Possible core outcomes will be identified by undertaking a systematic review of randomized controlled trials evaluating potential treatments for male factor infertility. These outcomes will be entered into a modified Delphi method. Repeated reflection and re-scoring should promote convergence towards consensus outcomes, which will be prioritized during a consensus development meeting to identify a final core outcome set. We will establish standardized definitions and recommend high-quality measurement instruments for individual core outcomes. STUDY FUNDING/COMPETING INTERESTS: This work has been supported by the Urology Foundation small project award, 2021. C.L.R.B. is the recipient of a BMGF grant and received consultancy fees from Exscentia and Exceed sperm testing, paid to the University of Dundee and speaking fees or honoraria paid personally by Ferring, Copper Surgical and RBMO. S.B. received royalties from Cambridge University Press, Speaker honoraria for Obstetrical and Gynaecological Society of Singapore, Merk SMART Masterclass and Merk FERRING Forum, paid to the University of Aberdeen. Payment for leadership roles within NHS Grampian, previously paid to self, now paid to University of Aberdeen. An Honorarium is received as Editor in Chief of Human Reproduction Open. M.L.E. is an advisor to the companies Hannah and Ro. B.W.M. received an investigator grant from the NHMRC, No: GNT1176437 is a paid consultant for ObsEva and has received research funding from Ferring and Merck. R.R.H. received royalties from Elsevier for a book, consultancy fees from Glyciome, and presentation fees from GryNumber Health and Aytu Bioscience. Aytu Bioscience also funded MiOXYS systems and sensors. Attendance at Fertility 2020 and Roadshow South Africa by Ralf Henkel was funded by LogixX Pharma Ltd. R.R.H. is also Editor in Chief of Andrologia and has been an employee of LogixX Pharma Ltd. since 2020. M.S.K. is an associate editor with Human Reproduction Open. K.Mc.E. received an honoraria for lectures from Bayer and Pharmasure in 2019 and payment for an ESHRE grant review in 2019. His attendance at ESHRE 2019 and AUA 2019 was sponsored by Pharmasure and Bayer, respectively. The remaining authors declare no competing interests. TRIAL REGISTRATION NUMBER: Core Outcome Measures in Effectiveness Trials (COMET) initiative registration No: 1586. Available at www.comet-initiative.org/Studies/Details/1586. TRIAL REGISTRATION DATE: N/A. DATE OF FIRST PATIENT'S ENROLMENT: N/A.

Long-term outcome of non-stented tubularized incised plate urethroplasty for distal hypospadias repair: a complication analysis.

INTRODUCTION: Although it is apparently simpler to perform unstented tubularized incised plate (TIP) repair for distal hypospadias repair, consensus on feasibility of the use of unstented repair is still a matter of debate. Evidence reporting that unstented repair outcome is comparable to stented repair, especially in the long-term, is still weak due to reporting outcome inconsistencies, different study designs, inclusion of more than one technique, and inherent variability in meatal locations. Thus, we need a continuous and evolving assessment of the outcome of unstented repair to compile adequate evidence on the advantage of unstented TIP repair in distal hypospadias entity. The aim of this article was to review our long-term results with tubularized incised plate urethroplasty for distal hypospadias repair without a postoperative stent to determine its outcome which might justify its use. MATERIAL AND METHODS: After a review of 154 patients with distal penile hypospadias, who underwent repair in Minia Urology & Nephrology University Hospital in the period between June 2015 and February 2018, we excluded cases who underwent MAGPI repair, redo cases and patients who failed to complete follow-up. We chose 72 patients who had only 1st time TIP repair and whom we could contact. A total of 44 out of 72 cases with stented repair were assigned to Group A, while 28 cases with unstented repair were assigned to Group B. Success was assessed based on Hypospadias Objective Penile Evaluation (HOPE) score by three separate senior pediatric urology consultants, independent of the surgeon and in the absence of high post-void residual urine (PVR). Average rate was calculated to be compared between both study groups. RESULTS: There was no statistically significant difference regarding preoperative meatal location and age at repair and short-term complications. In the long-term; there was no statistically significant difference between the occurrence of urethrocutanous fistula (UCF, 4 vs 2 cases in Group A & B, respectively) and complete disruption (2 cases in each group) with need for redo repair. Results of total mean of HOPE score calculated showed no statistically significant differences between study groups and also failed to showed statistical significance on individual domains of HOPE score. CONCLUSIONS: Unstented TIP repair showed a similar outcome to stented TIP repair of distal hypospadias especially in the long-term despite a more troublesome early postoperative period.

Clomiphene administration for cases of nonobstructive azoospermia: a multicenter study.

Clomiphene citrate is a well-established agent that has been empirically used in cases of idiopathic oligospermia. Clomiphene increases endogenous gonadotropin-releasing hormone secretion from the hypothalamus and gonadotropin hormone secretion directly from the pituitary and, thus, increases intratesticular testosterone concentration. Using intracytoplasmic sperm injection (ICSI), very few sperm may be required for fertilization. The objective of this study was to determine if the application of clomiphene citrate in males with nonobstructive azoospermia might produce sufficient sperm for ICSI, either by resulting in sperm identified in the ejaculate or by potentially improving outcomes of surgical testicular sperm extraction. Forty-two patients with nonobstructive azoospermia (age range, 25-39 years) from 3 international centers were evaluated with routine history, physical examination, and hormonal assessment. Initial testicular biopsy demonstrated maturation arrest in 42.9% and hypospermatogenesis in 57.1% of patients. Clomiphene citrate was administered, with the dose titrated to achieve serum testosterone levels between 600 ng/dL and 800 ng/dL, and semen analyses were performed at periodic intervals. In patients remaining azoospermic on semen analysis, surgical testicular biopsy and sperm extraction were performed. After clomiphene citrate therapy, 64.3% of the patients demonstrated sperm in their semen analyses ranging from 1 to 16 million sperm/mL, with a mean sperm density of 3.8 million/mL. Sufficient sperm for ICSI was retrieved by testicular sperm extraction in all patients, even though 35.7% remained azoospermic. Additionally, clomiphene citrate administration resulted in a statistically significant increase in testis biopsy patterns associated with greater likelihood of sperm obtained by surgical extraction (P < .05). We conclude that clomiphene citrate administration may result in sperm in the ejaculate of patients with nonobstructive azoospermia or the simplification of testis sperm retrieval. Surgeons may consider a course of clomiphene citrate administration prior to surgical sperm retrieval in patients with nonobstructive azoospermia.

The role of plain radiography in predicting renal stone fragmentation by shockwave lithotripsy in the era of noncontrast multidetector computed tomography.

PURPOSE: The objective of this study is to determine if plain radiography has a role in prediction of stone fragmentation by shockwave lithotripsy (SWL). PATIENTS AND METHODS: Our study included 106 patients undergoing SWL for renal stones. Based on plain radiography criteria, stones were classified according to density, homogeneity, and outline. We compared the success of SWL in fragmentation of stones with a density equal to or less than bone, nonhomogeneous stones, and stones with irregular outline to its success in stones with a density more than bone, homogeneous stones, and stones with smooth outline. RESULTS: In plain radiography, stone density equal to or less than bone, nonhomogeneous stones, and stones with irregular outline showed successful SWL fragmentation in 88.8%, 91.2%, and 90.6%, respectively. Stones with a density more than bone, homogeneous stones, and stones with smooth outline showed successful SWL fragmentation in 52.9%, 52.6%, and 57.1%, respectively. CT attenuation value was significantly less in stones successfully fragmented by SWL compared with nonfragmented stone (649±169 and 1465±256, respectively). In homogeneous stones with smooth outline having a density more than bone, we found a significantly lower CT attenuation in patients with successful stone fragmentation by SWL compared with those with failed stone fragmentation (690.9±171 and 1462±212, respectively). CONCLUSION: In relatively large solitary renal pelvic stones, plain radiography can predict the success of stone fragmentation by SWL. Nonhomogeneous stones with irregular outline and a density equal to or less than bone are expected to be successfully fragmented by SWL. Noncontrast CT is only needed, to predict success of SWL, in cases of homogeneous stones with smooth outline and density more than bone.

Evaluation of diagnostic testis biopsy and the repetition of testicular sperm extraction surgeries in infertility patients.

OBJECTIVE: To evaluate the use of a diagnostic testis biopsy and a repetition of testicular sperm extraction (TESE) surgeries in azoospermic patients and its impact on the outcome of TESE. DESIGN: Retrospective, case-control study. SETTING: University IVF center and hospital. PATIENT(S): A total of 552 azoospermic patients undergoing TESE for intracytoplasmic injection. INTERVENTION(S): At the time of the TESE, a piece of testicular tissue was prepared for histopathologic evaluation. MAIN OUTCOME MEASURE(S): Sperm retrieval rate. RESULT(S): Testicular sperm retrieval was successful in 100% of patients with obstructive azoospermia, 95.6% of patients with hypospermatogenesis, 47.9% of patients with maturation arrest, and 28.6% of patients with Sertoli cell-only syndrome in cases with no previous testicular surgery; in 100%, 91.4%, 32%, and 13.3%, respectively, in cases with a history of one testicular surgery; and in 100%, 10%, 0, and 0, respectively, in cases with a history of two testicular surgeries. CONCLUSION(S): Testicular sperm retrieval may be successful for some patients in each histopathologic category of azoospermia, with variable degrees of success for different histopathologic categories. The repetition of testicular surgeries decreases the chance of finding sperm in subsequent testicular sperm retrieval procedures.

The role of color Doppler ultrasound in prediction of the outcome of microsurgical subinguinal varicocelectomy.

PURPOSE: Overdiagnosis and undertreatment of varicocele may be responsible for the poor outcome of varicocelectomy. In this study we used color Doppler ultrasound for accurate diagnosis and grading of varicocele, and for predicting the outcome of microsurgical subinguinal varicocelectomy. MATERIALS AND METHODS: A total of 104 patients undergoing microsurgical subinguinal varicocelectomy for treatment of infertility were included in this study. Patients were evaluated with routine history, physical examination, semen analysis, hormonal assessment and scrotal ultrasound, and Doppler. After varicocelectomy improvement index in sperm concentration was calculated by dividing the difference between the postoperative and preoperative sperm concentration by the preoperative sperm concentration. Improvement index greater than 0.5 is considered a good outcome. Statistical analysis was done to study the correlation between microsurgical varicocelectomy outcome and testicular vein diameter at the inferior pole of the testis, and the degree of reflux measured by color Doppler ultrasound. RESULTS: Improvement index in sperm concentration, motility and morphology more than 0.5 was achieved in 58.8%, 27.3% and 17.6% of cases, respectively. We found that patients with a testicular vein diameter at the inferior pole of the testis of more than 2.5 mm have a significantly higher improvement index in sperm concentration, motility and morphology than patients with a testicular vein diameter less than 2.5 mm (p = 0.006, 0.016 and 0.041, respectively). We also found that patients with clear reflux detected by color Doppler ultrasound at the inferior pole of the testis have a significantly higher improvement index in sperm concentration, motility and morphology than patients with reflux detected only in the supratesticular venous channels (p = 0.013, 0.015 and 0.045, respectively). CONCLUSIONS: Color Doppler ultrasound is a useful tool for accurate diagnosis and grading of varicocele, and for predicting the outcome of varicocelectomy. We recommend varicocelectomy in cases of testicular vein diameter greater than 2.5 mm and in cases of reflux detected at the veins at the lower pole of the testis.

Stenting versus non-stenting after non-complicated ureteroscopic manipulation of stones in bilharzial ureters.

BACKGROUND: Stents were used routinely after ureteroscopy to prevent postoperative ureteral obstruction. However, because of the recognized complications of stents, non-stenting is the new trend after uncomplicated ureteroscopy. The wall of the bilharzial ureter is characteristically thick and may be calcified. The aim of this study is to see if the non-stenting trend could be applied to ureteroscopic manipulation of stones in bilharzial ureters. PATIENTS AND METHODS: In this prospective study, 56 patients, with evidence of bilharzial lesions in the urinary tract, undergoing ureteroscopy for distal ureteral stones were included. After successful uncomplicated stone fragmentation and extraction, patients were randomized into two groups. Group A includes 28 patients in whom double J 6-Fr polyurethane stents were placed for 3 weeks. Group B includes 28 non-stented patients. Postoperative fever, loin pain, lower urinary tract symptoms and change in the degree of hydronephrosis were reported. RESULTS: There was no significant difference in the mean age of patients and stone size in both groups. The mean operative time was 43 +/- 14 min in group A and 38 +/- 11 in group B. There was no significant difference in the mean loin pain score, in the first postoperative 48 h, in both groups (4.4 +/- 0.8 in group A and 4.9 +/- 0.5 in group B). Patients in group A had, significantly, more flank pain with voiding (P < 0.01), voiding pain (P = 0.04), frequency (P = 0.01) and urgency (P = 0.04). Radiologic follow-up was available for 24 patients in group A and 23 patients in group B at the 3-month visit. Hydronephrosis had improved in all patients, in both groups, with no evidence of ureteral stricture. CONCLUSION: Routine placement of stents after uncomplicated ureteroscopy for distal ureteral stones is unnecessary in bilharzial ureters. Moreover, it might be unadvisable because lower urinary tract symptoms and voiding loin pain are more in patients with ureteral stents and hydronephrosis is equally improved in stented and non-stented patients.