The impact of COVID-19 on the male genital tract: a qualitative literature review of sexual transmission and fertility implications.

The angiotensin-converting enzyme 2 receptor (ACE2) appears to be widely expressed in cells in the testes, predominantly in spermatogonia, Sertoli cells, and Leydig cells, and its co-expression with transmembrane protease serine 2 (TMPRSS2) is essential for the entry of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). For this reason, the male reproductive system could be considered a potential target for SARS-CoV-2, as well as a possible reservoir of infection. However, to date, there is very little evidence about the presence of SARS-CoV-2 in semen and testicular samples. The aim of this paper was to review the current evidence regarding the impact of SARS-CoV-2 on male fertility and sexual health, with a particular focus on reproductive hormones, the presence of the virus in seminal fluid and testis, and its impact on fertility parameters. We found very limited evidence reporting the presence of SARS-CoV-2 in semen and testicular samples, and the impact of SARS-CoV-2 on reproductive hormones and fertility parameters is unclear. The quality of the examined studies was poor due to the small sample size and several selection biases, precluding definitive conclusions. Hence, future well-designed prospective studies are needed to assess the real impact of SARS-CoV-2 on male reproductive function.

Comparison of Intralesional Hyaluronic Acid vs. Verapamil for the Treatment of Acute Phase Peyronie's Disease: A Prospective, Open-Label Non-Randomized Clinical Study.

PURPOSE: To compare the efficacy and safety of intralesional hyaluronic acid (HA) as compared with verapamil injection in patients with Peyronie's disease (PD). MATERIALS AND METHODS: Between January 2015 and December 2018, men in PD acute phase were prospectively recruited. This open-label, prospective study included 2 different protocols. Group A: 8-week cycle of weekly intraplaque injections with HA; Group B: 8-week cycle of weekly intraplaque injections with verapamil. Penile curvature, plaque size, International Index of Erectile Function (IIEF)-15 score and visual analogue scale (VAS) were assessed at baseline and after 3 months. RESULTS: Two-hundred forty-four patients were enrolled. Of these, 125 received intralesional HA (Group A), 119 received intralesional verapamil (Group B). At enrollment, median age was 56.0 years (interquartile range [IQR]=47.0-63.0 years), median curvature 35.0° (IQR=25.0°-45.0°), median IIEF-15 score 19.0 (IQR=16.0-23.0), median VAS 4.0 (IQR=4.0-5.0). Median difference for IIEF-15 was 1.0 (95% confidence interval [CI]=1.12-1.94) in Group A and 0.0 (95% CI=-0.04-0.14) in Group B (p<0.05) and median difference for VAS score was -4.0 (95% CI=-4.11--3.65) in Group A and -1.0 (95% CI=-0.50-2.01) in Group B (p<0.05). Plaque size decreased by -1.50 mm (IQR=1.60-2.10 mm) in Group A and -1.20 in Group B (p=0.10), while penile curvature decreased by -9.50° (IQR=4.50°-13.00°) in group A and -4.50 (IQR=2.50-7.50) in Group B (p<0.01). CONCLUSIONS: Intralesional HA injections could represent a reliable treatment option for the conservative management of patients with acute phase of PD.

En-Bloc Holmium Laser Enucleation of the Prostate with Early Apical Release: Are We Ready for a New Paradigm?

Background: Holmium laser enucleation of the prostate (HoLEP) is considered a safe and effective treatment in case of bladder outlet obstruction (BOO). Despite technical execution has evolved over time, from the standard three-lobes to the more recent en-bloc approaches, data comparing these two techniques are missing. The aim of the present study was to describe our en-bloc HoLEP with early apical release technique and compare peri- and postoperative results with the classical three-lobe approach in a single referral center. Materials and Methods: We prospectively analyzed all consecutive cases between 2017 and 2019 divided according to the type of approach. Patients were preoperatively studied through instrumental assessment and clinical evaluation, using validated questionnaires and then postoperatively at specific time frames. Linear regression analysis was performed to evaluate possible predictor of continuous variables. All the procedures were carried out by one single expert surgeon. Results: Overall, 168 patients were included, of which 81 were treated with classical three-lobes and 87 with en-bloc with early apical release technique. The two cohorts were comparable related to preoperative features and postoperative complication rate. Mean enucleation time (ET), lasing time, amount of energy delivered, and overall operative time were significantly lower in en-bloc procedures (p < 0.05). Stepwise multivariable linear regression showed that en-bloc strategy can significantly predict shorter ET and lower energy delivered. Stress incontinence rate at 1-month follow-up was found to be significantly reduced in the en-bloc group, compared with the counterpart. Conclusions: Both techniques are effective and safe treatment options for BOO, since peri- and postoperative surgical and functional outcomes were favorable. En-bloc strategy may significantly decrease ET and the amount of energy delivered leading to a reduced early stress incontinence rate compared with the standard approach.

Intra-peritoneal versus retropubic implantation of three-piece inflatable penile prosthesis: Patient-reported outcomes and complications.

INTRODUCTION: The role of reservoir position was investigated in this series of patients treated with three-pieces penile prosthesis implantation (PPI). The outcomes and the patients' reported quality of life after insertion of the balloon in the retropubic space, or the Retzius's space (SOR), were compared with the outcomes of patients who received an intraperitoneal implantation (IP). The study aimed to analyze how the anatomy of the SOR influenced the long-term results of PPI, especially in patients who have been previously exposed to pelvic surgery or radiotherapy. The SOR has usually been identified as ideal for concealing and protecting the reservoir; nevertheless, an increasing rate of patients that ask for a PPI do not conserve the typical favorable characteristic of the SOR. In these cases, the tissue alteration can cause a higher rate of undesired events and can impair the satisfaction from device use. In the recent literature, few articles focus on the topic of reservoir position and very poor information is available about the results of the IP insertion. MATERIALS: Our cohort of patients was retrospectively inspected; the two different subgroups, according to the reservoir position (SOR or IP) were evaluated considering the pre-operative condition, the post-operative complication, the development of undesired events or uncomfortable sensations during the follow-up. The quality of life after PPI was observed as well, with a questionnaire specifically developed for patients treated with PPI. The surgical technique adopted for the intraperitoneal implantation was described. RESULTS: The results of penile prosthesis functionality and patients' and partners' reported quality of life (QoL) showed similar results between the two groups but greater satisfaction in the relational domain of the questionnaires adopted was described in the IP subgroup. CONCLUSION: According to our observations, the IP reservoir insertion guarantees good functionality and lower rates of undesired events after PPI.

Blood plasma miR-20a-5p expression as a potential non-invasive diagnostic biomarker of male infertility: A pilot study.

BACKGROUND: Recently, alterations in miRNAs expression profile in semen have been linked to damaged spermatogenesis, suggesting miRNAs could be used as potential infertility biomarkers. In previous animal studies, miR-20a-5p was found to be down-expressed in low motile spermatozoa, implying its potential target of genes associated with cell apoptosis. OBJECTIVE: To investigate miR-20a-5p expression in blood plasma of patients suffering from non-obstructive azoospermia (NOA), compared to normozoospermic controls. MATERIALS AND METHODS: Between January 2018 and December 2019, from 52 infertile couples eligible for the study, 24 couples were finally enrolled in this monocentric observational prospective pilot study. Patients were included into two groups: Group 1 comprised men with NOA (n = 14) and Group 2 fertile men partners of women with female tubal factor infertility (n = 10). All NOA patients underwent testicular sperm extraction. The expression of circulating miR-20a-5p in plasma samples was assessed by RT-qPCR. A relative quantification strategy was adopted using the 2-ΔCq method to calculate the target miR-20a-5p expression with respect to miR-16-5p as endogenous control. RESULTS: Median blood plasma miR-20a-5p was significantly higher in patients affected by NOA (0.16 2-ΔCt , range: 0.05-0.79 2-ΔCt ) than in fertile controls (0.06 2-ΔCt , range: 0.04-0.10 2-ΔCt ), P < .001. MiR-20a-5p was positively correlated with follicle-stimulating hormone (FSH) (rrho  = -0.490, P = .015) and luteinizing hormone (LH) (rrho  = -0.462, P = .023), and negatively correlated with serum total testosterone (TT) (rrho  = -0.534, P = .007) and right and left testicular size (rrho  = -0.473, P = .020 and rrho  = -0.471, P = .020, respectively). Successful sperm retrieval (SR) rate was 50.0%. Median value of miR-20a-5p did not differ significantly among patients with successful SR and those with negative SR. Testicular histological examination showed: hypospermatogenesis in 6/14 (42.8%), maturation arrest in 4/14 (28.6%), sertoli cell-only syndrome in 4/14 (28.6%). No significant differences in miR-20a-5p were found between histopathological patterns (P > .05). CONCLUSIONS: MiR-20a-5p could represent a novel non-invasive diagnostic biomarker of male infertility.

Transvaginal mesh surgery for pelvic organ prolapse does not affect sexual function at long term follow up.

OBJECTIVE: Pelvic Organ Prolapse (POP) may impair sexual health. Though sexual dysfunction in women with POP is associated with reduced sexual arousal and dyspareunia, sexual outcomes have not been fully investigated. Transvaginal mesh repair (TVMR) is a POP therapeutic option, but is debated as a possible cause of worsening in sexual function. Aim of this study is to evaluate pre- and post-operative sexual outcomes in women undergone to TVMR. STUDY DESIGN: Data coming from sexually active women submitted to TVMR for POP with commercial mesh kits (device whose production has been suspended) were prospectively collected from 2012 to 2016 in a tertiary referral center. POP was measured according to the POP-Q classification. Patients' characteristics, operative and post-operative data were collected. Follow-up was carried out at month 1, 6, 12 and then yearly. Sexual function was measured through FSFI (Female Sexual Function Index) questionnaire. Minimum follow up was 12 months. FSFI score was assessed in these women before and after TVMR. A sub-analysis according to mesh kit used was made. RESULTS: From 2012 to 2016, 155 women underwent TVMR active for stage III or higher POP and 56 (36.6%) were sexually active, while 52 (92.9%) had adequate follow-up. Median age was 62 years (IQR 56-66), median BMI was 24,7 kg/m2 (IQR 22,3-28,9) and median parity was 2 (IQR 1-2). All patients presented anterior compartment POP and 14 (269%) had previous POP surgery. Urodynamic SUI was present in 13 (250%) patients. Commercial mesh kits used were Prolift© in 19 patients (36.5%) and Elevate© in 33 (63.5%). Median follow up was 42 months (IQR 22-59). Globally, FSFI was unaltered from TVMR at 12 months and at last follow up (p = 0.856). In detail, even if dyspareunia was reported in 1 patient, pain sub score was stable at long term follow up after TVMR (p = 0.124). Globally, there were 8 (15.4%) perioperative complications, none exceeding Clavien 2. At late follow up here was 1 (1.9%) mesh vaginal erosion occurred and there were 4 (7.7%) de novo stress urinary incontinence. Preoperative characteristics, surgical complications and outcomes were similar between mesh kits (p > 0.05). CONCLUSION: In our experience, global sexual function doesn't seem to be affected by TVMR when performed by expert surgeons. Despite being a confounding factor, lost at follow up rate was low, thus affecting only in a mild way surgical outcomes. Also ageing might be a confounding factor during follow up to establish real mesh impact on sexual function. Dyspareunia was a rare complication in patients during follow-up and pain was not a major complaint.

Testicular Fine-Needle Aspiration for Sperm Retrieval in Azoospermia: A Small Step toward the Technical Standardization.

PURPOSE: The aim was to describe our preliminary experience performing testicular fine-needle aspiration (TEFNA) with a larger needle in infertile patients with obstructive azoospermia, and to provide a systematic literature review of the different testicular sperm aspiration techniques, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations. MATERIALS AND METHODS: We prospectively collected data between March 2017 and June 2018. All men underwent bilateral TEFNA under analgo-sedation, using a larger disposable 18-gauge butterfly needle with 60 mL Luer-Lock syringe attached to it. RESULTS: Thirty consecutive patients were enrolled. Median operative time was 16 minutes (interquartile range [IQR]: 12-30 minutes). No intraoperative complications occurred. Two/thirty patients (6.7%) reported postoperative adverse events: 1 patient had prolonged orchialgia, 1 patient presented scrotal hematoma. Successful sperm retrieval was found in 28/30 cases (93.3%). Median sperm concentration was 0.05 ×106/mL (IQR: 0.001-0.1 ×106/mL). Median total sperm motility was 10% (IQR: 0%-15%). In 20/30 men (66.7%) sperm retrieved was used for fresh intracytoplasmic sperm injection cycle, in 8/30 (26.7%) sperm cryopreservation was necessary, because on the day of sperm retrieval the female resulted not responder to ovarian stimulation. In this cases mean number of 3 (IQR: 1-4) bio system straws was cryopreserved. CONCLUSIONS: TEFNA with 18-gauge needle proved to be a feasible, safe and effective treatment, even if future prospective studies will be addressed to clarify what type of azoospermia benefits from this procedure, and if a larger needle permits to improve Assisted Reproductive Technologies (ART) outcomes.

Intravesical application of platelet-rich plasma in patients with persistent haemorrhagic cystitis after hematopoietic stem cell transplantation: a single-centre preliminary experience.

PURPOSE: Haemorrhagic cystitis (HC) after allogeneic transplantation (HSCT) is a condition characterized by diffuse inflammation and bleeding from the bladder mucosa. Treatment of HC is not standardized and clinical Guidelines are elusive. The aim of this study was to evaluate the safety and efficacy of intravesical treatment with platelet-rich plasma (PRP) in patients with HC after allogenic HSCT. METHODS: Data from ten consecutive patients with BK virus-induced HC between 2013 and 2017 were collected. HC was classified into four grades. Inclusion criteria were (a) grade 3 or 4 BKV-induced HC after allogenic HSCT; (b) HC refractory to conservative therapy. All patients underwent transurethral cystoscopy and PRP treatment under general anaesthesia. RESULTS: Mean patients' age was 33.6 years. Four patients (40%) presented a grade 3 BKV-induced HC and six patients (60%) a grade 4. No intraoperative complications occurred. Postoperative complications were recorded in six patients: three patients required blood transfusion while three patients endovenous antibiotic therapy. Median time to catheter removal was 6 days (IQR 2-10). Median length of hospitalization was 35 days (IQR 6-73). At 30 days after surgery, a three-way catheter was repositioned in one patient for grade 4 haematuria, six patients had a complete response, and three a partial response. CONCLUSIONS: Our preliminary experience suggests that intravesical administration of PRP should be considered as a feasible and safe option for the treatment of BK-induced HC after HSCT. Future studies are needed to assess its potential value in other forms of haemorrhagic cystitis.