Orchidopexy for Ascending Testicles in Adulthood After Remote Hernia Repair: A Report of Two Cases.

Testicular ascent to the inguinal region after hernia repair has been previously reported as a rare complication of this surgery in pediatric patients. This article presents two cases of adult patients with ascending testicles after inguinal hernia repair that was performed in childhood. Both men underwent orchidopexy through a combined inguinal and scrotal approach, the latter for the creation of a sub-dartos pouch. In both cases, this intervention was completed successfully without complication and resulted in a satisfactory post-operative position of the testicles in the scrotal sac. This surgical approach appears to be a safe management option for adult men with ascending testicles after inguinal hernia repair.

Combined robotic and subinguinal microsurgical vasovasostomy for vasal obstruction after inguinal hernia repair.

Obstruction of the vas deferens may occur after inguinal hernia repair with mesh and lead to infertility. In cases where natural conception is desired and after obtaining test results that suggest the presence of spermatogenesis, surgical reconstruction can be attempted but may be difficult. Several approaches have been reported, including the laparoscopic mobilisation of the pelvic vas deferens, as well as mobilisation and passage of the scrotal vas deferens intra-abdominally for robot-assisted vasovasostomy. We describe a novel approach that used the surgical robot and a no-touch technique to mobilise the pelvic vas deferens and deliver it to the subinguinal region for subinguinal microsurgical vasovasostomy. This approach appeared to be feasible and safe, allows for simultaneous bilateral repair if needed, and was associated with rapid postoperative convalescence.

Superficial Penile Vein Thrombophlebitis After Microsurgical Varicocelectomy: Case Series.

Varicocele is a common condition, estimated to be present in 15% of the general male population. It consists of abnormal dilation and tortuosity of the internal spermatic veins within the pampiniform plexus of the spermatic cord. In adults, varicocele repair may be considered in cases of scrotal pain, or of infertility associated with impaired sperm parameters. Microsurgical varicocelectomy is currently a common method for varicocele repair. Superficial penile vein thrombophlebitis has been previously reported to occur after microsurgical varicocelectomy but has not been well recognized as a possible complication of this surgery. We present three cases of superficial penile vein thrombophlebitis after microsurgical varicocelectomy. Diagnosis on this condition was based on physical examination, mainly a palpable cord-like structure along the involved vein, without overlying redness. Signs and symptoms of superficial penile vein thrombophlebitis resolved after a 4-8-week course of aspirin at the dose of 325 mg daily. Awareness of this possible post-operative complication and its possible management could be helpful to the clinicians involved in the care of patients with varicoceles.

Association between the lengths of excised obstructed vas deferens segments at the time of vasovasostomy and surgical outcomes.

OBJECTIVE: This study aimed to determine whether the length of the excised obstructed vas deferens at vasovasostomy (VV) performed for fertility is associated with semen parameters and/or pregnancy outcomes postoperatively. MATERIAL AND METHODS: The patients who underwent a VV at our institution from September 2004 to December 2018 were contacted via questionnaire and a chart review was performed. Linear and logistic regression models were used to determine the associations between the length of the obstructed vas deferens removed and postoperative outcomes including sperm concentration, motility, and successful pregnancy after reversal. RESULTS: A total of 83/170 questionnaires were returned. After exclusions, a total of 35 patients were included for analysis. The mean age of the patients at the time of surgery was 40.1 years and the mean time since vasectomy 9.3 years. The mean length of the obstructed vas deferens removed during VV was 2.25 cm. The longer the vas deferens segments removed, the more significant was the increase in sperm motility at 3 and 9 months postoperatively (p=0.011 and 0.008, respectively), but decreased sperm motility at 6 months (p=0.029). In 75.9% of the patients, sperm was present postoperatively, 23.2% achieved pregnancy through natural conception, and 55.8% achieved pregnancy using assisted reproductive techniques. There was no significant relationship between the length of the vas deferens removed and sperm concentration or pregnancy achieved after surgery. CONCLUSION: In this cohort, the length of the excised obstructed vas deferens at VV was associated with improved sperm motility at 3 and 9 months postoperatively but not with pregnancy outcomes.

The additive impact of the distal ureteral diameter ratio in predicting early breakthrough urinary tract infections in children with vesicoureteral reflux.

INTRODUCTION: Many factors influence patient and provider decisions to surgically correct vesicoureteral reflux (VUR), including risk of breakthrough febrile urinary tract infections and likelihood of spontaneous resolution. Ureteral diameter ratio has been shown in several studies to be more predictive than reflux grade with regard to breakthrough urinary tract infection (UTI). We developed and investigated the accuracy of a computational model for predicating febrile breakthrough urinary tract infection within 13 months of starting prophylactic antibiotics in children with VUR. OBJECTIVE: The aim of this study was to validate a model for evaluating the impact of distal ureteral diameter ratio (UDR) in predicting early breakthrough urinary tract infections in children with VUR. STUDY DESIGN: Following a retrospective review, we recorded patient demographics, presenting symptoms, VUR grade, laterality, VUR during filling or voiding, initial bladder volume at the onset of VUR, ureteral duplication, voiding dysfunction, distal ureteral diameter ratio, and number of UTIs prior to VUR diagnosis. NeUROn++, a set of C++ programs, was used to model each data set using logistic regression and neural networks with different architectures. RESULTS: After exclusions, 136 children (93 girls and 43 boys) diagnosed with primary VUR had detailed VCUG and UDR data available. Fourteen children (10.3%) experienced breakthrough febrile UTI events within 13 months of VUR diagnosis. There was a significant association with UDR and breakthrough UTI (p = 0.008). Various computational prediction models for the outcome of breakthrough UTI were developed and evaluated. The computational model that fit best was a model using all variables with an ROC of 0.802. DISCUSSION AND CONCLUSIONS: Clinicians and parents often opt for intervention based on likelihood of spontaneous resolution of VUR as well as clinical course, thereby placing an emphasis on the ability to predict likelihood of breakthrough UTI infections. Our statistical analysis and prediction models further confirm UDR as an important variable predictive of breakthrough UTIs within the first 13 months of beginning prophylactic antibiotics. Furthermore, we developed a neural network model incorporating UDR and grade with an ability to yield the greatest accuracy of any breakthrough UTI predictive calculator to date at 80%.

Paratesticular colon cancer metastasis in an area of remote trauma.

A 53-year-old man with a history of colon adenocarcinoma and remote scrotal trauma resulting in a palpable nodule. Gradual increase in the size of this lesion over the year prior to his presentation to our clinic prompted scrotal ultrasound that demonstrated a 1.1 cm solid lesion, which appeared to arise from the right epididymal tail. Subsequent positron emission tomography (PET) scan showed intense focal uptake at the base of the right testicle, suspicious for epididymitis versus underlying neoplasm. Scrotal exploration through an inguinal approach revealed a paratesticular mass. Frozen section from an excisional biopsy was positive for adenocarcinoma. Radical orchiectomy was completed. Final pathology returned as metastatic adenocarcinoma involving soft tissue; testis and spermatic cord were without diagnostic abnormalities and surgical margins were not involved. Subsequent analysis was consistent with colorectal origin. The patient recovered well from surgery and is continuing treatment of metastatic colon cancer per the medical oncology team.

Validation of a prognostic calculator for prediction of early vesicoureteral reflux resolution in children.

PURPOSE: Treatment of vesicoureteral reflux with observation or surgery is based on a number of clinical variables. We developed a prognostic calculator to predict spontaneous resolution using a computational model. External validation of the computational model is crucial for wide application in clinical practice. MATERIALS AND METHODS: We reviewed the records of 82 Japanese children with primary vesicoureteral reflux with resolution status known at 2 years after diagnosis. Clinical data were input into the online prognostic calculator. Prognostic accuracy, positive predictive value and negative predictive value were calculated by comparing the predicted and actual clinical results. Clinical parameters were compared to determine the characteristics of cases in which the computational model failed to predict the reflux outcome. RESULTS: The 2-year resolution rate was 49% (40 of 82 patients). Of the cases 42 (51%) were predicted to resolve and 40 (49%) not to resolve by the prognostic calculator. Overall accuracy of the prognostic calculator was 80.5%, with the prediction accurate in 66 patients and inaccurate in 16. Sensitivity for spontaneous resolution was 82.5% and specificity was 78.6%. Positive predictive value was 78.6% and negative predictive value was 82.5%. The ROC for this calculator was 0.793. Mean age in the 16 cases that were inaccurately predicted (4.96 years) was significantly higher than in the 66 that were accurately predicted (3.00, p <0.05). CONCLUSIONS: The prognostic calculator was 80.5% accurate at predicting reflux resolution and was more accurate in younger children. This calculator can be widely applied for many patients with reflux.

Early microrecanalization of vas deferens following biodegradable graft implantation in bilaterally vasectomized rats.

We evaluated a biodegradable graft for reconstruction of rat vasa deferentia with long obstructed or missing segments. A total of 47 Sprague-Dawley rats underwent bilateral vasectomy and were divided into groups according to length of the vas deferens affected (0.5, 1, 1.5 cm). After 8 weeks, poly-(D,L-lactide) (PDLA) grafts were used to reconnect the vas deferens. Grafts and adjoining vasa deferentia were excised 8 and 12 weeks later and evaluated microscopically. At 8 weeks, microscopic changes included a robust inflammatory response around the grafts. All grafts were still intact but in the early stages of degradation. No microtubules, indicative of vas deferens recanalization, were identified. One specimen showed evidence of healing and neovascularization at the interface zone between the vas deferens and the graft. At 12 weeks, grafts were further degraded but still present. Microscopic evaluation showed decreased inflammation. Seven specimens showed neovascularization at the interface zone; two of these showed distinct epithelialized vas deferens microcanals at the graft edges. One specimen showed a microcanal spanning the entire 0.5-cm graft. A time period of 8 weeks is not ample enough for vas deferens regeneration in the setting of a biodegradable PDLA graft; however, early evidence of re-growth was seen at 12 weeks. A longer healing time should permit further biodegradation of the graft, as well as re-growth and possible eventual reconnection of the vas deferens, allowing passage of sperm. These findings suggest a potential role for biodegradable grafts in the reconstruction of vas deferens with long obstructed segments.

Involvement of growth factors in the process of post-vasectomy micro-recanalization.

PURPOSE: We investigated the role of growth factors in the process of post-vasectomy micro-recanalization using real-time polymerase chain reaction, enzyme-linked immunosorbent assay and histopathological analyses of the vasectomy sites and controls at different time points in a rat model. MATERIALS AND METHODS: Unilateral vasectomies were performed in 18 rats with sham surgery on the contralateral side. Vasectomy sites and vas segments of similar length from the sham operated sides were taken for analysis at 2, 8 and 12 weeks. Real-time polymerase chain reaction was used to test the expression of mRNA of 7 common growth factors and select growth factor receptors. Enzyme-linked immunosorbent assay was performed for growth factors with strong positive polymerase chain reaction findings. Histopathological examination was performed by a staff pathologist (BRD) to detect micro-recanalization, defined as tubules visible on hematoxylin and eosin staining with an epithelial lining of cuboidal or columnar cells. RESULTS: Micro-canals were found in 2 of 18 rat specimens. Real-time polymerase chain reaction of all specimens demonstrated a 12-fold increase in platelet-derived growth factor-beta, a 6-fold increase in platelet-derived growth factor-beta receptor, an 11-fold increase in platelet-derived growth factor-alpha, a 7-fold increase in platelet-derived growth factor-alpha receptor and a 9-fold increase in transforming growth factor-beta compared to the sham operated side. All increases were sustained and statistically significant (p <0.05). Enzyme-linked immunosorbent assay revealed statistically significantly increased expression of platelet-derived growth factor-beta protein. CONCLUSIONS: The demonstrated micro-recanalization and sustained growth factor up-regulation at vasectomy sites suggest a possible mechanism for post-vasectomy ejaculate sperm identification. There is a need for further research on the potential role of select growth factors in reconstruction of the male reproductive tract.

Adding renal scan data improves the accuracy of a computational model to predict vesicoureteral reflux resolution.

PURPOSE: We previously developed a computational model to predict vesicoureteral reflux resolution 1 and 2 years after diagnosis. Previous studies suggest that an abnormal renal scan may be a predictor of the failure of vesicoureteral reflux to resolve. We investigated whether the addition of renal scan data would improve the accuracy of our computational model. MATERIALS AND METHODS: Medical records and renal scans were reviewed on 161 children, including 127 girls and 34 boys, with primary reflux between 1988 and 2004. In addition to the 9 input variables from our prior model, we added renal scan data on decreased relative renal function (40% or less in the refluxing kidney) and renal scars. Resolution outcome was evaluated 1 and 2 years after diagnosis. Data sets were prepared for 1 and 2-year outcomes, and randomized into a modeling set of 111 and a cross-validation set of 50. The model was constructed using neUROn++. RESULTS: A logistic regression model had the best fit with an ROC area of 0.945 for predicting reflux resolution in the 2-year model. This was improved compared to our previous model without renal scan data. A prognostic calculator using this model can be deployed for availability on the Internet, allowing input variables to be entered and calculating the odds of resolution. CONCLUSIONS: This computational model uses multiple variables, including renal scan data, to improve individualized prediction of early reflux resolution with almost 95% accuracy. The prognostic calculator is a useful tool for predicting individualized vesicoureteral reflux resolution.

Analysis of outcomes of cryopreserved surgically retrieved sperm for IVF/ICSI.

We evaluated our experience to date with in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) after either cryopreserved sperm or sperm produced on the date of IVF/ICSI was used. We performed a retrospective statistical analysis of data derived from 188 women undergoing IVF/ICSI cycles using surgically retrieved sperm. A total of 318 IVF/ICSI treatment cycles with 3280 ova were performed using testicular sperm extraction (TESE, 304 cycles) or microsurgical epididymal sperm aspiration (MESA, 14 cycles). Sperm obtained at time of IVF/ICSI (fresh) or thawed cryopreserved sperm samples were used in 38 and 280 of the ICSI cycles, respectively. For IVF/ICSI cycles using both TESE and MESA sperm, the fertilization rate was 59.9% for cryopreserved sperm, and 53.6% when fresh sperm was used (chi2 P-alpha < .02, Cramer's 0.04). The fertilization rate for the TESE group alone was 60.0% for cryopreserved sperm and 55.1% for fresh sperm (chi2P-alpha = .075). Cohen effect size was computed at 0.03; yielding for P-beta = .8, 6597 ova would be required to demonstrate similarity between fresh and cryopreserved sperm in the TESE group. To demonstrate superiority of cryopreserved sperm in this group at a P-alpha significance level of .05, 7524 ova would be necessary. The pregnancy rate for the TESE group was 27.3% for cryopreserved sperm and 27% for fresh sperm. Further analysis of the pregnancy data in this group, using the methods described, yielded a chi2 P-alpha and power of 0.971 (effect size calculated at 0.002). While our fertilization rates for cryopreserved sperm are greater in analyses of surgically derived sperm, based on the 7 years required to obtain data on 3280 ova, full numerical resolution of the issue of whether cryopreserved sperm is superior or similar will not be available until approximately 2010. However, we believe these results, along with the similarity shown in pregnancy rates achieved with both types of sperm, clearly indicate that cryopreserved sperm is not inferior to fresh sperm.

Nonfunctional supernumerary testis in a 26-year-old man with orchalgia.

Polyorchidism is a rare phenomenon, with 47 histologically confirmed cases and 77 total reported cases. In most patients, it is an incidental finding or an asymptomatic scrotal mass. More than half of histologically confirmed supernumerary testes have been reported to have the potential for sperm production. We report a case of a man with symptomatic left scrotal pain who was found to have a nonfunctional supernumerary testis in his left hemiscrotum.

Computer model predicting breakthrough febrile urinary tract infection in children with primary vesicoureteral reflux.

INTRODUCTION AND OBJECTIVE: Factors influencing the decision to surgically correct vesicoureteral reflux (VUR) include risk of breakthrough febrile urinary tract infection (fUTI) or renal scarring, and decreased likelihood of spontaneous resolution. Improved identification of children at risk for recurrent fUTI may impact management decisions, and allow for more individualized VUR management. We have developed and investigated the accuracy of a multivariable computational model to predict probability of breakthrough fUTI in children with primary VUR. STUDY DESIGN: Children with primary VUR and detailed clinical and voiding cystourethrogram (VCUG) data were identified. Patient demographics, VCUG findings including grade, laterality, and bladder volume at onset of VUR, UTI history, presence of bladder-bowel dysfunction (BBD), and breakthrough fUTI were assessed. The VCUG dataset was randomized into a training set of 288 with a separate representational cross-validation set of 96. Various model types and architectures were investigated using neUROn++, a set of C++ programs. RESULTS: Two hundred fifty-five children (208 girls, 47 boys) diagnosed with primary VUR at a mean age of 3.1 years (±2.6) met all inclusion criteria. A total 384 VCUGs were analyzed. Median follow-up was 24 months (interquartile range 12-52 months). Sixty-eight children (26.7%) experienced 90 breakthrough fUTI events. Dilating VUR, reflux occurring at low bladder volumes, BBD, and history of multiple infections/fUTI were associated with breakthrough fUTI (Table). A 2-hidden node neural network model had the best fit with a receiver operating characteristic curve area of 0.755 for predicting breakthrough fUTI. DISCUSSION: The risk of recurrent febrile infections, renal parenchymal scarring, and likelihood of spontaneous resolution, as well as parental preference all influence management of primary VUR. The genesis of UTI is multifactorial, making precise prediction of an individual child's risk of breakthrough fUTI challenging. Demonstrated risk factors for UTI include age, gender, VUR grade, reflux at low bladder volume, BBD, and UTI history. We developed a prognostic calculator using a multivariable model with 76% accuracy that can be deployed for availability on the Internet, allowing input variables to be entered to calculate the odds of an individual child developing a breakthrough fUTI. CONCLUSIONS: A computational model using multiple variables including bladder volume at onset of VUR provides individualized prediction of children at risk for breakthrough fUTI. A web-based prognostic calculator based on this model will provide a useful tool for assessing personalized risk of breakthrough fUTI in children with primary VUR.

Erectile dysfunction in smokers: a penile dynamic and vascular study.

In this study, we aimed to determine the hemodynamic mechanisms through which cigarette smoking, as an independent risk factor, induces erectile dysfunction (ED). We performed a standard ED evaluation that included history; a physical exam; and serum glucose, testosterone, and prolactin levels. We then excluded ED patients with abnormal androgen profiles and patients with ED risk factors other than smoking. A total of 109 ED patients entered the study, including 71 current smokers and 38 nonsmokers. All patients then underwent extensive evaluation, including nocturnal penile tumescence and rigidity (NPTR) monitoring with Rigiscan, followed by pharmacopenile duplex ultrasonography (PPDU) and redosing pharmacocavernosometry (RPC). Results of the above tests were compared in the smoker and nonsmoker groups. We also performed receiver operating characteristic (ROC) curve analysis to determine which diagnostic parameter is most affected by cigarette smoking. The 4 most significant variates served as input features for a logistic regression model, designed to predict smoking. The average age for smokers and nonsmokers was 44.3 and 51.2 years, respectively (P = .02). Eighty-six percent of smokers had abnormal NPTR testing compared with 55% of nonsmokers (P = .02). The average peak systolic velocity (PSV) was 26.8 and 31.2 cm/s for smokers and nonsmokers, respectively, and this difference was not found to be statistically significant (P = .19) in this study. On performing RPC, an abnormal maintenance flow (MF) of >5 mL/min was detected in 89% of smokers and in 47% of nonsmokers, and the difference was significant (P < .01). With the use of smoking as the outcome, the ROC area of different diagnostic parameters was as follows: 0.79 for penile base rigidity, 0.58 for PSV, and 0.77 for MF. A logistic regression model that used the 4 most significant variates as input features yielded a ROC of 0.857. The results of NPTR testing in our smoker and nonsmoker groups indicated that ED in smokers is mainly of organic etiology. On the basis of the PPDU findings and the higher incidence of abnormal MF in the smoker group and its relatively high ROC value, we concluded that dysfunction of penile veno-occlusive mechanisms plays a substantial role in the development of ED in smokers.

Bladder tumor antigen stat test in non-urothelial malignant urologic conditions.

BACKGROUND: The bladder tumor antigen stat is a simple and fast one-step immunochromatographic assay for the detection of bladder tumor-associated antigen in urine. OBJECTIVES: To evaluate the BTA stat in non-bladder cancer patients in order to identify the categories contributing to its low specificity. METHODS: A single voided urine sample was collected from 45 patients treated in the urology clinic for conditions not related to bladder cancer. Each urine sample was examined by the BTA stat test and cytology. RESULTS: The overall specificity of the BTA stat test was 44%, which was significantly lower than that of urine cytology, 90%. The false positive rates for the BTA stat test varied among the different clinical categories, being highest in cases of urinary tract calculi (90%), and benign prostatic hypertrophy (73%). Exclusion of these categories from data analysis improved BTA stat specificity to 66%. CONCLUSIONS: Clinical categories contributing to low BTA stat specificity can be identified, and their exclusion improves the specificity of this test.

Male contraception: history and development.

Although the twentieth century has seen great strides in the development of female contraception, not a single new agent has been introduced as an approved method for common use for male contraception. Condoms (considered uncomfortable by some) and vasectomy (a permanent invasive procedure) are the only options provided to men, leaving an undue burden on women to bear contraceptive responsibility. Significant developments have, however, been made with regard to hormonal and nonhormonal contraception, and minor, reversible, procedural contraception. This article reviews the currently available, soon to be available, and theoretically possible methods of male contraception.

Effect of combined locally delivered growth factors and systemic sildenafil citrate on microrecanalization in biodegradable conduit for vas deferens reconstruction.

OBJECTIVE: To investigate the effect of the combination of locally delivered growth factors and oral sildenafil citrate on cross-conduit microrecanalization. METHODS: A total of 42 rats were divided into 7 groups. Of the 42 rats, 6 underwent bilateral vasectomy and bilateral end-to-end vasovasostomy and 12 underwent bilateral vasectomy. Of the latter 12, 6 received sildenafil citrate orally (10 mg/kg/d) for 24 weeks and 6 received placebo. A total of 24 rats underwent bilateral vasectomy and bilateral reconstruction with implantation of a 5-mm biodegradable conduit that bridged the 2 vasal ends. Of the 24 rats with conduits, 12 also had 250 pg of transforming growth factor-ß and 12.5 pg of platelet-derived growth factor-ß sustained release nanoparticles placed in immediate proximity to the conduit. The remaining 12 rats with conduits (6 without growth factors and 6 with growth factors) also received sildenafil citrate orally (10 mg/kg/d) for 24 weeks; the others received placebo. The reconstructed segments were harvested for histologic examination at 24 weeks. RESULTS: Five of 6 primary vasovasostomy and no vasectomy-only rats sired litters. Significantly more microcanals per conduit were observed in rats receiving sildenafil citrate: without growth factors, 3.9 vs. 0 canals/conduit (P < 0.001); with growth factors, 5.5 vs. 0.25 canals/conduit (P < 0.001). The rats receiving sildenafil citrate with growth factors showed a trend toward more microcanals per conduit than the rats receiving sildenafil citrate without growth factors (5.5 vs 3.9; P = .10). Rats receiving growth factors but no sildenafil citrate did not produce more canals than the rats receiving neither growth factor nor sildenafil citrate (0.25 vs 0; P = NS). CONCLUSION: Orally administered sildenafil citrate enhances formation of microcanalization after postvasectomy reconstruction using a biodegradable conduit in a rat model. Locally delivered growth factors appear to increase the number of microcanals.

Current options for preservation of fertility in the male.

Modern cancer therapies have greatly improved survival rates in men of reproductive age and younger; however, surgery, chemotherapy, and irradiation may lead to male infertility. Men with cancer should be counseled about fertility preservation before initiating therapy, when possible. Currently, options for male fertility preservation include cryopreservation of semen or testicular tissue. However, prepubertal boys pose a special problem in this area.