The Role of Varicocele in Male Factor Subfertility.

PURPOSE OF REVIEW: Varicocele may play a significant role in a subset of patients presenting with male factor infertility. Despite its relatively high prevalence amongst subfertile men, there has been controversy over the effectiveness of surgical treatments, patient selection, and when to administer treatment, particularly in the era of assisted reproductive technology. RECENT FINDINGS: In line with earlier finding, recent evidence strongly suggests that varicocelectomy improves pregnancy rates and semen parameters. The currently available literature still does not clearly elucidate the answer to this question, due to flaws in retrospective study design. Patients undergoing subinguinal microsurgical varicocelectomy appear to have the highest pregnancy rates, and lowest complication rates, compared to other surgical approaches. Current research has given us a better understanding of the relationship between varicocele and infertility. Amongst men presenting with semen analysis abnormalities and varicoceles, including those patients presenting with non-obstructive azoospermia or couples with a significant male factor component failing previous attempts at in vitro fertilization, varicocelectomy may improve take home baby rates. More robust, prospective, controlled studies are needed to further clarify the population of subfertile men with varicocele most likely to benefit from varicocelectomy.

Fertility concerns in men with genitourinary malignancies: Treatment dilemmas, fertility options, and medicolegal considerations.

BACKGROUND: With increasing genitourinary cancer survivorship in patients of reproductive age, fertility preservation has become a greater focus in the management of these patients. MATERIALS AND METHODS: We performed a review of articles pertaining to male infertility, fertility preservation, and genitourinary cancers. The aim was to review causes of infertility in patients with cancer, current options for fertility preservation, research that may expand preservation options, and ethical as well as medicolegal considerations. RESULTS: There are multiple causes of infertility in male patients with cancer, including the malignancy itself, and the treatments required to achieve a potential cure. Surgery can affect the normal pathways for erection, emission, and ejaculation. Chemotherapy can have a profound negative effect on spermatogenesis by causing chromosomal aberrations, maturation arrest, mutagenesis, and impaired spermatozoa motility. Radiation can cause cellular apoptosis with resultant reduction in spermatogonial stem cells. There are numerous methods to secure fertility before cancer treatment with the aid of cryopreservation ranging from simple patient-provided semen samples to complex sperm retrieval techniques. Research in the field of spermatogenic stem cells may lead to improved treatment options such as autotransplant of stem cells for repopulation of the testes after cancer treatment. CONCLUSIONS: Early discussion of possible fertility effects in patients undergoing genitourinary cancer treatment is critical in this era of increasing survivorship. Although current cancer treatments can cause infertility, there are well-established options for fertility preservation and current research will likely lead to improved treatment options.

Adjuvant Maneuvers for Residual Curvature Correction During Penile Prosthesis Implantation in Men with Peyronie's Disease.

INTRODUCTION: The surgical treatment of comorbid erectile dysfunction and Peyronie's disease has long included the implantation of an inflatable penile prosthesis as well as a number of adjuvant maneuvers to address residual curvature after prosthesis placement. AIM: To review the various surgical options for addressing curvature after prosthesis placement, with specific attention paid to an original article by Wilson et al. reporting on modeling over a penile prosthesis for the management of Peyronie's disease. METHODS: A literature review was performed analyzing articles reporting the management of penile curvature in patients undergoing implantation of an inflatable penile prosthesis. MAIN OUTCOME MEASURES: Reported improvement in Peyronie's deformity as well as the complication rate associated with the various surgical techniques described. RESULTS: Modeling is a well-established treatment modality among patients with Peyronie's disease undergoing penile prosthesis implantation. A variety of other adjuvant maneuvers to address residual curvature when modeling alone is insufficient has been presented in the literature. CONCLUSIONS: Over 20 years of experience with modeling over a penile prosthesis have proven the efficacy and safety of this treatment option, providing the surgeon a simple initial step for the management of residual curvature after penile implantation which allows for the use of additional adjuvant maneuvers in those with significant deformities.

Microdissection testicular sperm extraction in men with Sertoli cell-only testicular histology.

OBJECTIVE: To study the outcomes of microdissection testicular sperm extraction (microTESE) among men with pure Sertoli cell-only histology on diagnostic testicular biopsy. DESIGN: Retrospective cohort study. SETTING: Tertiary referral center. PATIENT(S): Six hundred forty patients with pure Sertoli cell-only histology on testicular biopsy who underwent microTESE by a single surgeon. INTERVENTION(S): MicroTESE. MAIN OUTCOME MEASURE(S): Sperm retrieval rates. RESULT(S): Overall, 44.5% of patients with Sertoli cell only had sperm retrieved with microTESE. No difference was noted in sperm retrieval rates based on testis volume (≥15 mL vs. <15 mL, 35.3% vs. 46.1%, respectively). Patients with ≥15 mL testicular volume and FSH 10-15 mU/mL had the worst prognosis, with a sperm retrieval rate of 6.7%. CONCLUSION(S): Patients with previous testicular biopsy demonstrating Sertoli cell-only histology can be counseled that they have a reasonable likelihood of sperm retrieval with the contemporary delivery of microTESE. Given this finding, the utility of testicular biopsy before microTESE is further questioned.

Outcomes of operative sperm retrieval strategies for fertility preservation among males scheduled to undergo cancer treatment.

OBJECTIVE: To describe the outcomes of electroejaculation (EEJ) and testicular sperm extraction (TESE) performed for fertility preservation among male patients who are unable to ejaculate or have nonobstructive azoospermia/severe oligospermia before definitive cancer therapy. DESIGN: Retrospective cohort study. SETTING: Tertiary cancer referral center. PATIENT(S): Forty-nine patients seeking fertility preservation before definitive cancer therapy, with anejaculation, religious or cultural objections to masturbation, azoospermia, or severe oligospermia requiring either EEJ or TESE. INTERVENTION(S): EEJ and TESE. MAIN OUTCOME MEASURE(S): Sperm retrieval rates. RESULT(S): Fifty-nine percent of patients overall and 60% of adolescents/young adults had sperm retrieved for cryopreservation. EEJ was successful in retrieving sperm in 60% of adolescents. Of all adolescents and young adults undergoing TESE, 33% had sperm retrieved for cryopreservation. No complications were reported. Chemotherapy was commenced without delay in all patients requiring it, frequently on the same day as the sperm retrieval. CONCLUSION(S): EEJ and TESE can be safely and successfully used for fertility preservation before cancer therapy among boys and young adult men who are unable to provide a semen specimen or have nonobstructive azoospermia, and they should be considered in all men meeting this patient profile.

Azoospermia due to spermatogenic failure.

This article summarizes the current literature regarding azoospermia caused by spermatogenic failure. The causes and genetic contributions to spermatogenic failure are reviewed. Medical therapies including use of hormonal manipulation, whether guided by a specific abnormality or empiric, to induce spermatogenesis are discussed. The role of surgical therapy, including a discussion of varicocelectomy in men with spermatogenic failure, as well as an in-depth review of surgical sperm retrieval with testicular sperm extraction and microdissection testicular sperm extraction, is provided. Finally, future directions of treatment for men with spermatogenic failure are discussed, namely, stem cell and gene therapy.

Deformity stabilization and improvement in men with untreated Peyronie's disease.

OBJECTIVE: To define predictors of the deformity stabilisation and improvement in men with untreated Peyronie's disease (PD). PATIENTS AND METHODS: The study population consisted of patients with PD-associated uniplanar curvature, who opted for no treatment and were followed for at least 12 months. All patients had deformity assessment (DA) performed on initial presentation and at follow-up. Stabilisation of PD was defined as no change between DAs (±10°), while improvement and progression were defined as ≥10° change. Patients were subdivided into different groups based on time to presentation: ≤6 months (A), 7-12 months (B), and 13-18 months (C). Multivariable analysis was used to define predictors of stabilisation and improvement. RESULTS: In all, 176 men met the inclusion criteria. The mean age was 54 years, with a mean (sd) PD duration of 9 (12) months and mean curvature of 42 (27)°. In all, 67% of the entire population had no change in deformity over time, 12% improved with a mean (sd) change of 27 (14)°, and 21% worsened with a mean (sd) change of 22 (11)°. On multivariate analysis, predictors of stabilisation included: time to presentation of >6 months (odds ratio [OR] 2.4, P < 0.01), per decade increase in age (OR 1.5, P < 0.05), and age (r = 0.32, P < 0.05). Predictors of improvement included: time to presentation of ≤6 months (OR 4.1, P < 0.001), and per decade decrease in age (OR 2.1, P < 0.01). CONCLUSIONS: In men with uniplanar curvature, PD stabilisation and improvement rates change with time-to-presentation and patient age. These data may aid in counselling patients with PD.

Prospective analysis of penile length changes after radical prostatectomy.

OBJECTIVES: To assess the impact of radical prostatectomy (RP) on penile dimensions. To assess the impact of phosphodiesterase-5 inhibitor (PDE5i) use on penile length changes. PATIENTS AND METHODS: Men undergoing RP were enrolled in this prospective study before surgery. Demographic, clinical and PDE5i frequency-of-use data were collected. Erectile function was measured using the erectile function domain (EFD) of the International Index of Erectile Function. A single evaluator measured stretched flaccid penile length (SFPL) before RP, and at 2 and 6 months after RP. Repeated measures analysis was used to test differences in SFPL between timepoints. Pearson correlation was used for univariate analyses and multiple regression was used for multivariable analysis. RESULTS: A total of 118 patients were evaluated at baseline, with 76 and 63 patients evaluated at 2 and 6 months, respectively. At 2 months, there was a 2.4-mm mean decrease in SFPL, while at 6 months there was no significant difference. At 6 months, those subjects who took a daily PDE5i had no SFPL loss (n = 36, 1±6.7 mm gain, P = 0.37 compared with baseline), while those subjects who did not consistently take a PDE5i had SFPL loss (n = 27, 4.4±6.6 mm loss, P < 0.002 compared with baseline). In multivariable analysis, PDE5i use at 6 months and 6-month EFD score without on-demand PDE5i were significant predictors of 6-month SFPL loss, suggesting that an increase in these variables leads to SFPL preservation. CONCLUSIONS: In this rigorously conducted prospective study of SFPL changes after RP, there was evidence of SFPL loss at 2 months, but not at 6 months after RP. PDE5i use moderated SFPL loss, with patients who regularly used PDE5i having no loss in SFPL.

Factors predicting publication of sexual medicine abstracts presented at the annual meeting of the American Urological Association.

INTRODUCTION: At sexual medicine meetings throughout the world, hundreds of scientific abstracts are presented each year. To our knowledge, no previous studies have looked at the rate of publication of these studies in a peer-reviewed journal. AIM: To define the fate of abstracts presented at sexual medicine sessions at the annual meeting of the American Urological Association (AUA) and to describe the factors predicting ultimate publication in scientific journals. METHODS: All abstracts presented at the 2006 and 2007 AUA annual meeting were surveyed to find sexual medicine abstracts. Publication status as of October 2009 was assessed using the Medline database. Abstract parameters were recorded including number of authors, country of origin, clinical or basic research, and area of sexual research. Predictors of publication were analyzed using a multivariable model. MAIN OUTCOME MEASURE: Publication status of all sexual medicine abstracts presented at the 2006 and 2007 AUA annual meetings. RESULTS: A total of 208 sexual medicine abstracts were presented in 2006 and 2007. Fifty-one percent of these were published by October 2009. On univariate analysis, the predictors of publication in a peer-reviewed journal included the number of authors (r=0.22, P<0.01), studies pertaining to erectile dysfunction (RR 1.3, CI 1-1.8, P=0.05), and studies originating from academic centers (RR 2.7, CI 1.7-4.3, P<0.01). On multivariate analysis, the predictors of publication included the number of authors (OR 1.3, CI 1-1.4, P<0.01) and having a study originate from an academic center (OR 5.9, CI 2.8-12.7, P<0.01). CONCLUSIONS: Fifty-one percent of the sexual medicine abstracts presented at the 2006 and 2007 annual AUA meetings have been published within 2 to 3 years of the date of presentation. Studies originating from academic centers were six times more likely to be published in a peer-reviewed journal.

Medical implications of erectile dysfunction.

Erectile dysfunction (ED) is a common condition in aging men, with a prevalence of 52% in men aged 40 to 70 years. It is frequently associated with several comorbid conditions, including cardiovascular disease, lower urinary tract symptoms, and testosterone deficiency. These conditions often have major consequences on the quality of life of patients and require adequate evaluation by the primary care practitioner. Complaints of ED, therefore, serve as a marker for these conditions and give the practitioner an opportunity to prevent the consequences of a delay in treatment. In this article, the evidence behind these associations is described.