Whole-exome sequencing in patients with maturation arrest: a potential additional diagnostic tool for prevention of recurrent negative testicular sperm extraction outcomes.

STUDY QUESTION: Could whole-exome sequencing (WES) be useful in clinical practice for men with maturation arrest (MA) after a first testicular sperm extraction (TESE)? SUMMARY ANSWER: WES in combination with TESE yields substantial additional information and may potentially be added as a test to predict a negative outcome of a recurrent TESE in patients with MA. WHAT IS KNOWN ALREADY: At present, the only definitive contraindications for TESE in men with non-obstructive azoospermia (NOA) are a 46,XX karyotype and microdeletions in the azoospermia factor a (AZFa) and/or AZFb regions. After a first negative TESE with MA, no test currently exists to predict a negative outcome of a recurrent TESE. STUDY DESIGN, SIZE, DURATION: In a cohort study, we retrospectively included 26 patients with idiopathic NOA caused by complete MA diagnosed after a first TESE. PARTICIPANTS/MATERIALS, SETTING, METHODS: Twenty-six men with MA at the spermatocyte stage in all seminiferous tubules, according to a histopathological analysis performed independently by two expert histologists, and a normal karyotype (i.e. no AZF gene microdeletions on the Y chromosome) were included. Single-nucleotide polymorphism comparative genomic hybridization array and WES were carried out. The results were validated with Sanger sequencing. For all the variants thought to influence spermatogenesis, we used immunohistochemical techniques to analyse the level of the altered protein. MAIN RESULTS AND THE ROLE OF CHANCE: Deleterious homozygous variants were identified in all seven consanguineous patients and in three of the 19 non-consanguineous patients. Compound heterozygous variants were identified in another 5 of the 19 non-consanguineous patients. No recurrent variants were identified. We found new variants in genes known to be involved in azoospermia or MA [including testis expressed 11 (TEX11), meiotic double-stranded break formation protein 1 (MEI1), proteasome 26s subunit, ATPase 3 interacting protein (PSMC3IP), synaptonemal complex central element protein 1 (SYCE1) and Fanconi anaemia complementation group M (FANCM) and variants in genes not previously linked to human MA (including CCCTC-binding factor like (CTCFL), Mov10 like RISC complex RNA helicase 1 (MOV10L1), chromosome 11 open reading frame 80 (C11ORF80) and exonuclease 1 (EXO1)]. LARGE SCALE DATA: Data available on request. LIMITATIONS, REASONS FOR CAUTION: More data are required before WES screening can be used to avoid recurrent TESE, although screening should be recommended for men with a consanguineous family background. WES is still a complex technology and can generate incidental findings. WIDER IMPLICATIONS OF THE FINDINGS: Our results confirmed the genetic aetiology of MA in most patients: the proportion of individuals with at least one pathologic variant was 50% in the overall study population and 100% in the consanguineous patients. With the exception of MEI1 (compound heterozygous variants of which were identified in two cases), each variant corresponded to a specific gene-confirming the high degree of genetic heterogeneity in men with MA. Our results suggest that WES screening could help to avoid recurrent, futile TESE in men with MA in general and in consanguineous individuals in particular, but these results need to be confirmed in future studies before clinical implementation. STUDY FUNDING/COMPETING INTEREST(S): The study was funded by the Fondation Maladies Rares (Paris, France), Merck (Kenilworth, NJ, USA), IRSF (Montigny le Bretonneux, France) and Agence de la Biomédecine (Saint Denis, France). There are no competing interests. TRIAL REGISTRATION NUMBER: N/A.

[Urethroplasties for male urethral strictures: Success rates and predictive factors]. / Urétroplasties pour sténoses de l'urètre masculin : taux de succès et facteurs prédictifs.

INTRODUCTION: Urethroplasty has reported success rates ranging from 60 to 98%. Predictive factors for recurrence are rarely studied, postoperative urinary drainage modalities are not investigated. The primary objective was to evaluate the success rate of urethroplasty in our center. Secondary objectives were to identify recurrence predictive factors. METHODS: A single-center retrospective cohort including men treated with urethroplasty for stricture between 2007-2017, followed up for a minimum of 12 months. Recurrence was defined as the necessity of a new procedure (endo-urethral or surgical). Data from penile urethra (SUP) and bulbo-membranous urethra (SUBM) stenosis were analyzed separately. Recurrence-free survival (success) was analyzed according to the Kaplan-Meier model. The characteristics of the patients, the stenosis, the surgical technique, the modalities of postoperative urinary drainage were analyzed in subgroups for the bulbo-membranous urethra looking for a correlation with recurrence. RESULTS: A total of 103 patients included: 25 with SUP, 78 with SUBM. The overall success rate was 69%, CI95% [60-79] with a mean follow-up of 62.85 months. The success was 68%, CI95%[46-82] for SUP, 69.23%, CI95% [58-78] for SUBM. Recurrences occurred during the first 12 months. Only postoperative suprapubic urinary drainage was a predictive factor (HR=0.947, CI95% [0.905-0.992]). A period longer than 14 days reduced recurrence by 37%. CONCLUSION: Urethroplasty had a success rate of 69%, comparable to published series. Suprapubic urinary drainage improved the surgery outcomes. LEVEL OF PROOF: 2, Grade B.

[Congenital penile curvature: Guidelines from the Andrology and Sexual Medicine Committee of the French Association of Urology (CAMS-AFU)]. / Courbures congénitales du pénis : recommandations du Comité d'andrologie et de médecine sexuelle de l'Association française d'urologie.

INTRODUCTION: Guidelines regarding congenital penile curvature (CPC) are lacking, and this pathology has not been the subject of French recommendations to date. The Andrology and Sexual Medicine Committee (CAMS) of the French Association of Urology (AFU) propose a series of clinical practice recommendations (CPR) by answering five clinical questions concerning the diagnosis and treatment of this pathology. MATERIALS AND METHODS: After a bibliographic research between 2000 and 2021, followed by a critical reading according to the CRP method. These recommendations were written to answer five questions: (1) What are the different types of CPC? (2) What are the reasons for consultation? (3) What are the assessment methods for CPCs and their consequences? (4) What are the indications for CPCs treatment? (5) What are the corrective modalities for the treatment of CPC? RESULTS: There are two main phenotypes: CPC type 4 (the most common) and chordee without hypospadias. The diagnosis of CPC is clinical and established through enquiry and clinical examination associated with photos of the erect penis. Support can be offered if the curvature is responsible for a disability and/or sexual dissatisfaction linked to a deformation making penetration difficult and/or in the event of significant psychological impact. Only surgical treatments have demonstrated their effectiveness. For type 4 CPCs, corporoplasty (excisional, incisional, or incisionless techniques) is the gold standard. CONCLUSION: These recommendations provide support for the management of patients consulting with CPC.

[Which management for anterior urethral stricture in male? 2021 guidelines from the uro-genital reconstruction urologist group (GURU) under the aegis of CAMS-AFU (Committee of Andrology and Sexual Medicine of the French Association of Urology)]. / Quelle prise en charge pour les sténoses de l'urètre antérieur chez l'homme ? Recommandations 2021 du Groupe d'urologue de reconstruction uro-génitale (GURU) sous l'égide du CAMS-AFU (Comité d'andrologie et de médecine sexuelle de l'association française d'urologie).

OBJECTIVE: The purpose of this first french guideline is to provide a clinical framework for the diagnosis, treatment and follow-up of anterior urethral strictures. The statements are established by the subgroup working on uro-genital reconstruction surgery (GURU) from the CAMS-AFU (Andrology and Sexual Medicine Committee from the French Association of Urology). MATERIAL AND METHODS: These guidelines are adapted from the Male Urethral Stricture : American Urological Association Guideline 2016, updated by an additional bibliography from January 2016 to December 2019. Twenty-seven main scenarios seen in clinical practice are identified: from diagnosis, to treatment and follow-up. In addition, this guidelines are powered by anatomical diagrams, treatment algorithms, summaries and follow-up tables. RESULTS: Anterior urethral strictures are a common condition (0,1 à 1,4 %) in men. The diagnosis is based on a trifecta including an examination with patient reported questionnaires, urethroscopy and retrograde urethrography with voiding cystourethrography. Short meatal stenosis can be treated by dilation or meatotomy, otherwise a urethroplasty can be performed. First line treatment of penile strictures is urethroplasty. Short bulbar strictures (<2cm) may benefit from endourethral treatment (direct visual internal urethrotomy or dilation). In case of recurrence or when the stenosis measures more than 2 cm, a urethroplasty will be proposed. Repeated endourethral treatment management are no longer recommended except in case of palliative option. Urethroplasty is usually done with oral mucosa graft as the primary option, in one or two stages approach depending on the extent of the stenosis and the quality of the tissues. Excision and primary anastomosis or non-transecting techniques are discussed for bulbar urethra strictures. Follow-up by clinical monitoring with urethroscopy, or retrograde urethrography with voiding cystourethrography, is performed at least the first year and then on demand according to symptoms. CONCLUSION: Anterior urethral strictures need an open surgical approach and should be treated by urethroplasty in most cases. This statement requires a major paradigm shift in practices. Training urologist through reconstructive surgery is the next challenge in order to meet the demand.

[Recommendations of the Committee of Andrology and Sexual Medicine of the AFU concerning the management of andrological and sexual medicine pathologies during the COVID-19 crisis]. / Recommandations du Comité d'andrologie et de médecine sexuelle de l'AFU concernant la prise en charge andrologique et en médecine sexuelle en contexte et en sortie de crise sanitaire liée au COVID-19.

OBJECTIVE: To assist urologists in the management of andrological and sexual medicine pathologies during the COVID-19 crisis. MATERIAL AND METHOD: Use of the formalized consensus method. RESULTS: The medical and surgical management of patients in andrology and sexual medicine must be adapted. Consultations should, as far as possible, be carried out by tele-consultation. For operative procedures, the delay between the operative decision and the date of (re)scheduling of the procedure will depend on: (1) the level of criticality of the clinical situation; (2) the type of intervention; (3) the functional and psychological repercussions, including quality of life while waiting for the procedure; (4) the notion of losing the chance of having an optimal outcome; (5) the risk of potential complications from delaying a procedure for too long; and (6) taking into account the patient's risk factors for severe forms of COVID-19. The protection of urologists from COVID-19 should be considered. Each urologist must make the best decision for the patient, taking into account the acceptable time frame and quality of life impact before surgical management, the COVID risk parameters, the technical and anesthetic feasibility and the structural possibility of the health care institution to ensure a specific dedicated pathway during the COVID-19 health crisis. CONCLUSION: The management of andrological and sexual medicine pathologies must be adapted to the COVID-19 crisis context. Some patients may require surgery, including in emergency. These recommendations are transitional and will end with the COVID-19 crisis.

[Recommendations of the Committee of Andrology and Sexual Medicine of the AFU concerning the management of Varicocele]. / Recommandations du Comité d'Andrologie et de Médecine Sexuelle de l'AFU concernant la prise en charge de la Varicocèle.

The diagnosis of varicocele is clinical, carried out in supine and standing position and in Valsalva maneuver. Only clinical varicoceles have to be treated. A scrotal ultrasound with Doppler is generally performed as part of the infertile man's evaluation or in case of examination difficulties. The main indication for varicocele treatment is the adult man with clinical varicocele and abnormalities of sperm parameters, in a context of infertility of couple, with a partner having a satisfactory ovarian reserve and no cause of female infertility or a curable infertility cause. The decision to treat varicocele must therefore be taken after evaluation of the two partners of the couple. Adults with symptomatic varicocele and those with spermogram abnormalities may also be offered a cure for their varicocele even in the absence of a paternity plan, as well as adolescents with reduced testicular growth, an ipsilateral decrease testicular volume, or a size gradient between the 2 testes. The cure of varicocele can be carried out by surgery or by percutaneous embolization. Microsurgery (inguinal or subinguinal) offers lower rates of recurrence and complications than high surgical approaches (laparoscopic or not) and surgeries without magnification. It is therefore the reference surgical technique. Percutaneous retrograde embolization is a minimally invasive alternative to microsurgery offering satisfactory outcomes with rare and often benign complications. The cure for varicocele results in an improvement in sperm parameters and recent data seem to confirm that it increases the natural pregnancy rate. These results appear after a delay of 3 to 9 months (at least 1 to 2 cycles of spermatogenesis). When the sperm involvement was severe (azoospermia, severe oligospermia), the improvement of the spermogram allow (1) to avoid surgery testicular sperm extraction or (2) perform intrauterine insemination rather than ICSI.

[French Urological Association (AFU) guidelines for Peyronie's disease assessment and treatment]. / Recommandations pour l'évaluation et la prise en charge de la maladie de Lapeyronie : rapport du comité d'andrologie et de médecine sexuelle de l'AFU.

INTRODUCTION: Peyronie's disease is a common cause for consultation in urology. Many controversies surround its treatment. No French Guidelines have been published so far. The Committee of Andrology and Sexual Medicine of the French Association of Urology therefore offers a series of evidence-based recommendations. MATERIALS AND METHODS: These recommendations are made according to the ADAPTE method, based on European (EAU, ESSM), American (AUA, ISSM) and Canadian (CAU) recommendations, integrating French specificities due to the availability of treatments, and an update of the recent bibliography. RESULTS: The assessment of the disease is clinical. Patients with functional impairment or significant psychological repercussions may be offered treatment. The benefits and drawbacks of each treatment should be explained to the patient. Regarding non-surgical treatments, no available treatment has market authorization in France. Vitamin E is not recommended. Analgesic (oral or low-intensity shock waves) or proerectile treatments may be offered as needed, as well as traction therapy. Due to the unavailability of collagenase injections, verapamil injections may be offered. Surgical treatments are to be considered in the stabilized phase of the disease, and consist of performing a plication, an incision-graft or the placement of a penile implant according to the patient's wishes, the curvature and the penis size, as well as erectile function. Combination treatments can be offered. CONCLUSION: The management of Peyronie's disease is complex, and the levels of evidence for treatments are generally low. The success of treatment will depend on the quality of the initial assessment, the patient's information and understanding of the expected effects, and the practitioner's experience.

Quality of life associated with orthotopic neobladder and ileal conduit in women: A multicentric cross-sectional study.

PURPOSE: To compare quality of life and functional outcomes associated with orthotopic neobladder (ONB) and ileal conduit (IC) after anterior pelvic exenteration for bladder cancer in women, through a multicentric cross-sectional study. METHODS: All women who have undergone an anterior pelvic exenteration associated with ONB or IC for a bladder cancer between January 2004 and December 2014 within the three participating university hospital centers and that were still alive in February 2016 were included. Three distinct auto-administered questionnaires were submitted to the patients: the EORTC QLQ-C30, the EORTC QLQ-BLmi30 and the SF-12. Comparison of response to these questionnaires between women with ONB and those with IC were studied with Mann-Whitney U tests, with a statistically significant P-value set at<0.05. The primary endpoint was the "global health status" sub-score extracted from the EORTC QLQ-C30 questionnaire. The secondary endpoints were the functional sub-scores and symptoms sub-scores obtained with the EORTC QLQ-C30 questionnaire as well as the sub-scores obtained with the EORTC QLQ-BLmi30 and the SF-12 questionnaires. RESULTS: Forty women were included in the study (17 ONB, 23 IC). The primary endpoint was comparable between the ONB and IC women (83.3 vs. 66.7 P=0.22). Similarly, no significant statistical difference could be pointed between the ONB and IC women in terms of secondary endpoints. CONCLUSION: The present study did not report any significance difference in terms of quality of life and functional outcomes between women with ONB and those with IC after pelvic exenteration for bladder cancer. LEVEL OF EVIDENCE: 3.

Prospective multicentre observational study assessing the tolerance and perception of patients using the Liquick Base catheter with an Ergothan tip.

INTRODUCTION: Intermittent self-catheterisation has revolutionised the management of neurogenic bladder-sphincter dysfunctions. The Liquick Base catheter is characterised by a streamlined Ergothan tip. The purpose of this study is to assess the tolerance and perception of patients using this catheter. MATERIALS AND METHODS: A French prospective multicentre observational study was conducted on patients with neurogenic bladder-sphincter dysfunctions. Upon inclusion in the study, the doctor completed a questionnaire on the patient's pathology. After 3 and 6 months, the doctor checked for neurogenic developments or observations and looked for any complications relating to intermittent self-catheterisation. The patient completed a questionnaire to assess his or her perception of using the catheter. RESULTS: Out of 42 patients included in the study, two were excluded. Out of the 40 assessed patients (30 males, 10 females) with an average age of 50.1±14.9 years, there were no reported cases of false passage. Bleeding occurred at least once in 10 patients (25%) in the first three months and in three out of 20 patients (15%) between 3 and 6 months. Two (5%) patients sought medical attention in the first three months for complications related to the catheter and 4 patients sought medical attention (10%) between 3 and 6 months. After 3 months 90% of patients were still using the catheter and after 6 months 90% of patients were still using the catheter. CONCLUSION: The Liquick Base catheter is well tolerated. Patient perception is positive for all parameters being examined, leading to the continued use of the catheter in 90% of cases. LEVEL OF EVIDENCE: 2.

[Biotherapies for erectile dysfunction and Peyronie's disease: Where are we now?] / Biothérapies pour les troubles de l'érection et la maladie de la Peyronie : ou en est-on ?

INTRODUCTION: Clinical trials of cell therapy for erectile dysfunction (ED) and Peyronie's disease (PD) were recently conducted after preclinical studies. AIMS: The aims of this study are to give an update on biotherapy for ED and PD and to describe the regulatory framework for these therapies. MATERIALS AND METHODS: A literature review was performed through PubMed and Clinical.trials.gov addressing cell therapy for ED and PD and using following keywords "erectile dysfunction", "Peyronie's disease", "stem cell", and "platelet-rich plasma". RESULTS: Preclinical studies in rodent models have shown the potential benefit of cell therapy for ED after radical prostatectomy or caused by metabolic diseases, and PD. The tissues used to obtain the therapeutic product were bone marrow, adipose tissue and blood (PRP, platelet-rich plasma). Mechanism of action was shown to be temporary and mainly paracrine. Four clinical trials were published concerning ED after radical prostatectomy and in diabetic patients and one for PD. Eleven clinical trials including three randomized trials are currently going on. Preclinical and preliminary clinical results suggested the possibility to improve spontaneous erectile function and response to pharmaceutical treatment in initially non-responder patients. This effect is mediated by an improvement of penile vascularization. A reduction of penile curvature without side effect was noted after injections into the plaque of PD patients. Most of these therapeutic strategies using autologous cells were considered as "Advanced Therapy Medicinal Products" with strict regulatory frameworks imposing heavy constraints, in particular in case of "substantial" modification of the cells. The regulatory framework remains unclear and more permissive for PRP and cell therapy processes with extemporaneous preparation/injection and no "substantial" modifications. CONCLUSIONS: First results on cell therapy for ED and PD are promising. The regulatory framework can significantly change according to cell preparations and origins leading to various constraints. This regulatory framework is crucial to consider for the choice of the procedure.

[Learning curve for inflatable penile prosthesis]. / Courbe d'apprentissage d'implantation de prothèse pénienne.

INTRODUCTION: Inflatable penile prosthesis surgery is relatively rare in France, and around ten surgeons perform most of this surgery. The objective of this study was to define the learning curve concerning this surgery. METHODS: This study is a retrospective monocentric cohort of first time implantation of inflatable penile prosthesis between 2008 and 2016 in a university hospital. 68 consecutive patients underwent this procedure performed by a single surgeon. These patients were dispatched into two groups: a group of the first 20 patients and a group of the 48 last patients. For each patient, multiple parameters were measured including: duration of surgery, per operative complications, post operative morbidity according to Clavien classification, length of stay, and functional satisfaction. Parameters were compared using Fisher or Wilcoxon tests. RESULTS: Patients were on average 58.2 year old and average operating time was 87.7minutes. The average complication rate was 16.2%. Five patients from the first group and 3 patients from the second group presented a grade 3 post operative complication according to Clavien classification. The complications included 5 infections, one erosion, one irreductible paraphimosis and a prosthesis dysfunction. This difference was statistically significative (P=0.043). The average duration of hospitalization was significantly shorter in the second group (P=0.004). There was no significative difference concerning the satisfaction using the EDITS score (P=0.52) or a Likert scale (P=0.72). CONCLUSION: In this monocentric and retrospective study, the learning curve for first time implantation of inflatable penile prosthesis is acquired after 20 surgeries. Specific training could lower this number, but needs further evaluation. LEVEL OF EVIDENCE: 3.

[Adjustable continence therapy balloons in women: Evolution of efficacy within the 24 months following implantation]. / Ballons ACT chez la femme : évolution de l'efficacité au cours des 24 mois suivant l'implantation.

PURPOSE: To analyze the functional outcomes over time of ACT balloon in women with stress urinary incontinence (SUI) secondary to intrinsic sphincter deficiency (ISD). METHOD: All patients with SUI secondary to ISD who underwent bilateral ACT balloon implantation between September 2008 and November 2015 and regularly monitored for a period of at least 24 months were eligible. The results were studied at 6, 12 and 24 months. Efficacy was defined as: Success - maximum 1 safety pad per day and visual analogue scale (VAS) rating≥9/10. Improvement - decrease in the number of pads used per day and VAS≥5/10. Failure - increase or stability of the number of pads used per day and/or VAS<5/10. Failure was considered as primary when it occurred without any success or improvement. It was considered as secondary when it occurred after an initial period of success or improvement. RESULTS: 18 patients were monitored during 24 months. The success rate was respectively 17 %, 33 % and 33 % at 6, 12 and 24 months of follow-up. The improvement rate was respectively 61 %, 39 % and 17 % at 6, 12 and 24 months of follow-up. The primary failure rate was 22 %. The secondary failure rate was 6 % at 12 months and 33 % at 24 months of follow-up. CONCLUSION: ACT balloon efficacy tends to decrease with time requiring a long-term follow-up of implanted patients. LEVEL OF EVIDENCE: 4.

[Penile prosthesis implantation: Indications and outcomes]. / Indications et résultats des implants péniens.

OBJECTIVE: Our aim was to present the indications and the outcomes of penile prosthesis implantation. METHODS: A literature review was performed through PubMed using the following keywords: penile implantation ; penile prosthesis; erectile dysfunction. RESULTS: Evolution of penile prosthesis devices led to get a fiable and effective treatment for men with erectile dysfunction who do not respond to less invasive therapy. Penile implant can also be useful in the treatment of Peyronie's disease, priapism and transgender surgery. Precise information related to this surgery, especially complications, permits to obtain high satisfaction scores. CONCLUSION: Penile implant is a reliable and safe solution for the management of erectile dysfunction resulting to high couple satisfaction ratings.

[Testicular nodules of infertile men and contrast enhanced ultrasonography: preliminary study]. / Nodules testiculaires de l'homme infertile et échographie de contraste: étude préliminaire.

INTRODUCTION: The incidence of testicular nodules discovered during infertility evaluation is increasing. These nodules are suspicious of malignancy. There is no paraclinical examination which allows histological orientation to these nodules. The recommendations propose priority treatment by total orchidectomy. PATIENTS AND METHODS: Through a retrospective cohort study of infertile patients, our goal is to study the enhancement of testicular nodules after injection of ultrasound contrast. The secondary objective is to determine whether CEUS may argue in favor of conservative treatment. From june 2010 to march 2013, 24 patients had underwent ultrasound contrast study of abnormal testicular parenchyma detected prior to infertility evaluation carried ultrasound. The characteristics of ultrasound enhancement were correlated with the pathological findings of surgical patients and proposed treatments (surgery or surveillance). RESULTS: Fifteen patients were followed up, 9 were operated (7 partial orchidectomies, 2 total orchidectomies). Histological analysis found four Leydig cell tumors, 2 Sertoli cell tumors and 3 seminomas. No adverse changes were noted during the follow-up. This study showed a typical semiology of early, intense and homogeneous enhancement with a phenomenon of wash in 100% of Leydig cell tumors. All Leydig cell tumors have been treated by partial orchidectomy. Seminomas have intense enhancement in 100% of cases. There was a phenomenon of wash in 2 out of 3 cases. When a wash in was described, it was always described as heterogeneous. All seminomas were finally treated by total orchidectomy. The sensitivity and positive predictive value of ultrasound intense enhancement for the diagnosis of testicular cancer was 89% (Se) and 80% (PPV). CONCLUSION: There is a semiology of ultrasound enhancement of testicular nodules with features that can guide in favor of a malignant tumor, seminoma or Leydig cell tumor. If a prospective study was undertaken, these arrangements could guide us to treatments promoting preservation of the testicular parenchyma.

[Azoospermia and a history of inguinal hernia repair in adult]. / Azoospermie et antécédent de cure de hernie inguinale chez l'adulte.

BACKGROUND: Inguinal hernia repair is one of the most performed surgeries in the world. It is recognized that any surgery of the pelvic floor may represent a risk factor of male infertility. METHOD: Retrospective study of patients with azoospermia and a history of adult inguinal hernia repair surgery and referred to our center between January 1990 and January 2011 for infertility. RESULTS: Among 69 azoospermia patients with history of adult inguinal hernia repair surgery, 60 patients underwent surgical extraction of sperm that was successful in 75% (45/60). Positive extraction rate decreases in the subgroup of patients with risk factors for infertility (61.4%) as well as in the group with bilateral inguinal hernia (67.9%). There was no statistically significant difference in the positive rate of sperm retrieval according to surgical technique or according to the use of polypropylene mesh (P>0.05). CONCLUSION: The obstruction of the vas deferens due to an inguinal hernia repair was a potential iatrogenic cause of male infertility that was rare and underestimated. The influence of using a polypropylene mesh was not clearly demonstrated. The management of these patients is based on prevention in order to identify patients with risk factors of infertility in order to propose a presurgery cryopreservation of sperm. LEVEL OF EVIDENCE: 5.

[Clinical and paraclinical features of Klinefelter syndrome consulting for male infertility]. / Aspects cliniques et paracliniques des syndromes de Klinefelter consultant pour infertilité masculine.

PURPOSE: To attract urologists' attention on screening of Klinefelter syndrome consulting for infertility, describing its usual phenotype, in order to propose a possible reproductive technique, to prevent and to treat associated comorbidities and to manage the frequent discovery of ultrasonographic testicular lesions. PATIENTS AND METHODS: Retrospective analysis over 10 years of clinical and paraclinical features of the patients who consulted for infertility and had a 47,XX7 regular or mosaic karyotype. RESULTS: One hundred and forty-nine patients, 31.7 year-old on average [20.7-42.7], all had a severe bilateral testicular hypotrophy, subsequently confirmed by ultrasonography (mean total testicular volume: 3.7 mL [-0.20-7.64]). One hundred and twenty-two (81.9%) had normal secondary sexual characteristics, only 4 of them (2.7%) already knew their diagnosis. Their mean total testosterone levels were low (3.12 ng/mL [0.39-5.86]) but remain normal. A total of 34.2% of patients had subclinical testicular nodules discovered by ultrasonography. Excision was performed in 12 cases, confirming Leydig cell tumors. CONCLUSION: Klinefelter syndrome diagnosis can be made during a first consultation with a bilateral testicular hypotrophy as "pathognomonic" point of call in an often poor clinical observation. It is completed by an azoospermia or severe oligozoospermia. If they want to, this allows to quickly guide patients to suitable medical reproductive technique but, especially, to prevent and quickly treat comorbidities associated to this diagnosis, and also to reassure patients about the frequent discovery of subclinical testicular lesions.

[Andrological description of a population of azoospermic men with agenesis of the vas deferens]. / Description andrologique d'une population azoosperme avec une agénésie des canaux déférents consultant pour infertilité.

CONTEXT: In the 1990's, congenital agenesis of the vas deferens was identified as a minor form of cystic fibrosis in relation to the frequency of mutations of the CFTR gene associated. It is responsible for masculine infertility by obstructive azoospermia; which is not accessible to a surgical treatment. However, surgical sperm retrieval and injection de spermatozoïde en intracytopasmique (ICSI) allow fatherhood for these patients. PATIENTS AND METHODS: A retrospective analysis of 104 consecutive patients from 1996 to 2006. A comprehensive clinical, spermiologic, hormonal, imaging and genetic workup was carried on. The data from the surgical extractions and the attempts of ICSI were collected. RESULTS: Seventy-five percent of the patients had a mutation of the CFTR gene; ultrasound imaging revealed a renal or a seminal vesicle abnormality in 20% and 84.5% of the patients, respectively. The association of a semen volume less than 2 mL with a pH less than 7.2, a fructose less than 2 and mean sudoral chlore greater than 60 mmol/L enabled an immediate identification of 30% of patients carrier of the mutation and without renal abnormality. The sperm extraction rate was 98%. CONCLUSION: A search for the CFTR gene mutations and an ultrasound imaging of the genito-urinary system are essential to the workup of these patients. The association of a semen volume less than 2 mL, a semen pH less than 7.2 and a fructose less than 2 must point towards a minor form of cystic fibrosis and prompt the workup of genetic abnormalities and sudoral chlore testing. The results of the sperm extraction combined to the technical advances of IVF/ICSI allow excellent pregnancy rates of 66% for the companions of these patients.

[Should we recommend an erectile rehabilitation after radical prostatectomy? Systematic review of the literature by the Sexual Medicine Committee of the French Urology Association]. / Doit on proposer une rééducation érectile après prostatectomie radicale ? revue de la littérature du CAMS de l'AFU.

INTRODUCTION: Radical prostatectomy has evolved considerably during the last 20 years, with one hand, a thorough knowledge of the anatomy of the prostate, and secondly, the introduction of new conservation techniques of neurovascular bundles. Despite this progress, the rate of post-prostatectomy erectile dysfunction varies between 30 and 90% depending on the series and this element impacts the quality of life after radical prostatectomy. The objective of this work was to conduct a review of the literature in order to evaluate the various protocols of post-radical prostatectomy erectile rehabilitation. PATIENTS AND METHODS: A systematic review of the literature from the basic PubMed search was performed using the following keywords. Therapy erectile dysfunction, radical prostatectomy, penile rehabilitation, phosphodiesterase 5 inhibitor, intracavernous injection. RESULTS: The critical analysis of selected studies highlights the lack of standard protocol that established erectile rehabilitation early after radical prostatectomy. These studies have shown that early treatment, injections or intracavernous PDE5 inhibitors improved recovery of erections as recommended by the French Association of Urology. CONCLUSION: Management of disorders of post-radical prostatectomy sexuality is essential, it must be organized in a well-established protocol combining pharmacological and therapeutic education assistances delivered by practitioners or nurses. It would need to develop in a clinical trial a standard protocol.

[Ejaculatory disorders except premature ejaculation, orgasmic disorders]. / Troubles de l'éjaculation à l'exception de l'éjaculation prématurée, troubles de l'orgasme.

INTRODUCTION: Disorders of ejaculation and orgasm apart from premature ejaculation are pretty uncommon. METHODS: Medical literature was reviewed and combined with expert opinion of the authors. RESULTS: The semiology of these disorders is essential: aspermia, hypospermia, retrograde ejaculation, delayed or absent ejaculation with or without orgasm. Whether this is a lifelong or acquired condition, it is essential to assess the side-effects of medications i.e. psychotropic drugs, including antidepressant, neuroleptics, tramadol, alphablockers: tamsulosin and silodosin must always be surveyed. CONCLUSION: The management is often difficult, especially with a parenthood perspective. The management of lifelong disorders must rely on psychosexual therapies.

[Drugs for sexual medicine]. / Les médicaments de la médecine sexuelle.

AIM: To describe drugs used in sexual medicine. METHOD: Pubmed search for efficacy, mode of action and side effects for each molecule. Additional data were searched from the French regulatory agencies web sites (HAS and ANSM). RESULTS: 5PDIs and intracavernous injection of alprostadil are first- and second-line therapies of erectile dysfunction. Dapoxetine is the first specific and approved treatment of premature ejaculation. Androgene supplementation improves sexual desire among patient with hypogonadism as much as initial serum testosterone levels are low. Female sexual dysfunctions pharmacology is to date less developed, although candidate drugs reach phase III clinical studies. CONCLUSION: Pharmacology is one but not the only therapeutic avenue in sexual medicine. Despite real breakthrough such as 5PDIs for erectile dysfunction, incomplete knowledge and understanding of physiology, pathophysiology and pharmacology of human sexual function reduces its development particularly for women.