Atypical testicular pain.

Testicular tuberculosis (TB) is rare, and, because of this, the lack of pathognomonic clinical features and its tendency to mimic other commoner conditions, the diagnosis is frequently delayed or may be missed. In this case, the initial clinical presentation was typical for bacterial epididymo-orchitis in a 38-year-old man. When the patient failed to improve with standard treatment including broadening of antibiotics, the diagnosis was re-considered because some unusual signs suggested testicular malignancy or lymphoma. Further, history-taking and subsequent cross-sectional imaging with CT/MRI identified co-existent pulmonary nodularity, thoracic and abdominal lymphadenopathy and bony changes that, together, raised the suspicion of TB. Mycobacterium tuberculosis was confirmed on DNA-based testing of the hydrocele fluid, although standard acid-fast bacilli culture was negative. This case prompted a review of the literature to explore the optimal steps in the investigation and diagnosis of this rare disease.

Testis sparing surgery for small testicular masses and frozen section assessment.

INTRODUCTION: We present our experience with patients who had suspected testicular masses, managed by a frozen section assessment and testicular sparing surgery. MATERIAL AND METHODS: We performed a retrospective review of all patients over the last 5 years, who underwent a frozen section assessment and testicular sparing surgery for small testicular lesions. The frozen section assessment was compared with the final histology. RESULTS: Twelve patients were identified. The mean age of patients was 40 years (22-58 years). The mean lesion size was 9.8 mm (3-18 mm). Presentations varied: a testicular lump was palpable in 7 patients and 3 patients were referred due to infertility with a subsequent ultrasound, which showed incidental testicular lesions. Two patients presented with testicular pain. Tumour marker levels were within the normal limits in all patients.The frozen section assessment correctly determined 10 out of 12 (83%) lesions, showing 1 (8%) lymphoma, 2 (17%) seminomas, 3 (25%) fibrosis, 3 (25%) low-grade Leydig cell tumours and 1 (8%) adenomatous tumour. The frozen section reported a benign epidermal cyst in 1 case, whilst the final histology showed a pre-pubertal type teratoma, a rare and low risk tumour. One patient (8%) had an indeterminate lesion, which proved to be a benign adenomatous tumour on final histology. All malignant cases were correctly identified.There was no malignancy in 9 out of 12 (75%) patients therefore they had testicular sparing surgery. Three patients had orchidectomy, two due to a seminoma and one due to an indeterminate lesion. One patient developed a postoperative haematoma requiring antibiotics but there were no other complications. CONCLUSIONS: Our findings demonstrate that partial orchidectomy with a frozen section assessment is useful in small testicular masses and testicular sparing surgery can be considered in order to prevent a radical orchidectomy in selected patients.

Salvage micro-dissection testicular sperm extraction; outcome in men with non-obstructive azoospermia with previous failed sperm retrievals.

OBJECTIVE: To assess the outcome of micro-dissection testicular exploration sperm extraction (m-TESE) as a salvage treatment in men with non-obstructive azoospermia (NOA) in whom no sperm was previously found on single/multiple TESE or testicular sperm aspiration (TESA). PATIENTS AND METHODS: In all, 58 men with NOA underwent m-TESE. All the patients had previously undergone either single/multiple TESE or TESA with no sperm found. All the patients underwent an m-TESE using a standard technique. Serum follicle-stimulating hormone (FSH), testosterone and histopathological diagnosis were examined as predictive factors for sperm recovery. All patients underwent preoperative genetic screening. One patient was found to have an azoospermic factor c (AZFc) micro-deletion and five were diagnosed with Kleinfelter's syndrome. RESULTS: The mean (range) patient age was 39.0 (26-57) years. Spermatozoa were successfully retrieved in 27 men by m-TESE (46.5%). The mean (range) FSH level was 19.4 (1.6-58.5) IU/L. There was no correlation in age (mean age retrieved 38.1 years, not retrieved 39.7 years, P = 0.38), FSH levels (mean FSH retrieved 21.4 IU/L, not retrieved 17.7 IU/L, P = 0.3) and the ability to find sperm by m-TESE. However, there was a significant difference in testosterone levels and sperm retrieval (mean testosterone retrieved 14.99 nmol/L, not retrieved 11.39 nmol/L, P < 0.05). Patients with a diagnosis of Sertoli-cell-only (SCO) syndrome [14/35 (40%)] and maturation arrest [four of 11 (36%)] had lower sperm retrieval rates than those in the hypospermatogenesis group [nine of 12 (75.0%)] (P < 0.05). There were no significant complications after m-TESE. CONCLUSIONS: In men with NOA who have undergone previous attempts at sperm retrieval with negative results, a salvage m-TESE offers a significant chance of finding sperm even in SCO syndrome. There does seem to be a correlation between preoperative testosterone levels and the ability to successfully find sperm.

In the era of micro-dissection sperm retrieval (m-TESE) is an isolated testicular biopsy necessary in the management of men with non-obstructive azoospermia?

OBJECTIVES: To assess the outcome of sperm retrieval using micro-dissection-TESE (m-TESE) and simultaneous diagnostic biopsy in NOA to determine if the final definitive histology correlated with the outcome of sperm retrieval by m-TESE in men with NOA. To determine if there was a correlation between FSH levels and positive sperm retrieval rates and assessed the success rate of m-TESE as either a primary or a salvage procedure after previous negative sperm retrieval. The EAU guidelines (2010) recommend that in men with non obstructive azoospermia 'a testicular biopsy is the best procedure to define the histological diagnosis and the possibility of finding sperm'. However, these guidelines do not identify which patients should have a diagnostic biopsy and if this biopsy should be performed as an isolated procedure or synchronously with sperm retrieval. It is also suggested that there is a correlation between the histological diagnosis and possibility of finding sperm on testis biopsy. PATIENTS AND METHODS: 100 men with NOA underwent a m-TESE sperm retrieval between 2005 and 2010 at a single centre. All patients underwent hormonal analysis (serum FSH, Testosterone and LH levels) and genetic analyses after full counselling including; Y-deletion, CF-gene analysis and karyotype. Thirty five men had previously undergone unsuccessful TESA/TESE or diagnostic biopsy at other centres. All patients underwent synchronous sperm retrieval and biopsy of the testis, which was sent for histopathological examination on the day of an ICSI cycle or as an isolated procedure. RESULTS: Mean age of patients was 37.25 (range 29-56 years). The mean serum FSH levels in the Sertoli cell only, maturation arrest and hypospermatogenesis groups were 21.3 IU/L (2.8-75), 16.18 (1.6-67) and 14.17 IU/L (0.8-42.3) respectively. SR rates in the respective groups were 42.85%, 26.6% and 75.86% (P= 0.023). There were no post-operative complications. In the 35 men who had previously undergone unsuccessful procedures elsewhere, the SR rates were 57.1%. The overall sperm retrieval rate was 50%. There was no correlation between SR and FSH levels (P= 0.28). CONCLUSION: M-TESE should be considered the gold standard for retrieval of testicular sperm in NOA, even in cases where there has been previously unsuccessful attempts. FSH levels and histology cannot be used to predict the success of sperm retrieval. An isolated diagnostic testicular biopsy is not recommended in men with NOA, as a significant proportion of men undergoing m-TESE will have successful a sperm retrieval irrespective of previous histology or previous unsuccessful surgery.

Analysis of the outcome of intracytoplasmic sperm injection using fresh or frozen sperm.

OBJECTIVES: • To compare the outcome of first-attempt intracytoplasmic sperm injection (ICSI) ICSI--embryo transfer (ET) cycles using frozen-thawed testicular sperm (FTTS), fresh testicular sperm (FTS), frozen-thawed epididymal sperm (FTES) and fresh epididymal sperm (FES) so as to determine which of these has the most successful ICSI outcome with respect to fertilization rate (FR), pregnancy rate (PR) and birth rate. • To assess the outcomes according to the underlying aetiology of azoospermia. PATIENTS AND METHODS: • The records of 493 patients undergoing first-attempt ICSI between 1993 and 2008 were reviewed retrospectively. FTS was used in 112 cycles, FTTS in 43 cycles, FES in 279 cycles, and FTES in 59 cycles. • Within each group, the aetiology of the azoospermia was recorded according to history, clinical examination and histological analysis (n = 316). • The FR, clinical PR and delivery rate were calculated for each group with respect to the type of sperm retrieval used. RESULTS: • Analysis of the data showed no significant differences between any of the four groups in the FR, PR or delivery rate (P > 0.05). • There were no significant differences seen between fresh sperm (FTS and FES) and frozen sperm (FTTS and FTES) or between epididymal sperm (FES and FTES) and testicular sperm (FTS and FTTS) in any of the outcomes measured (P > 0.05). However, subset analysis showed a statistically higher FR and PR for FTTS over fresh sperm. • When comparing aetiologies, there was no significant difference in the FR, clinical PR and delivery rate between obstructive azoospermia (OA) and non-obstructive azoospermia (NOA) groups. However, sub-set analysis showed a higher PR and birth rate for FTTS over fresh sperm in both OA and NOA groups. CONCLUSIONS: • The results of the present study suggest that using frozen sperm in ICSI cycles is a reliable and favourable method with the same outcome as fresh sperm. • Testicular and epididymal sperm have similar ICSI outcomes for both fresh and frozen samples. However, results suggest a tendency for higher PRs and birth rates for frozen than for fresh testicular sperm in both OA and NOA aetiologies. • The aetiology of azoospermia does not significantly affect the outcome of first-attempt ICSI. The higher rates in the frozen groups suggest that these patients have had better quality semen when they were initially harvested and frozen.

Glans resurfacing for the treatment of carcinoma in situ of the penis: surgical technique and outcomes.

BACKGROUND: The management of carcinoma in situ (CIS) of the penis is controversial, with relatively high local recurrence rates after minimally invasive therapies. OBJECTIVE: Report the surgical technique and outcome of partial glans resurfacing (PGR) and total glans resurfacing (TGR) as primary treatment modalities for CIS of the glans penis. DESIGN, SETTING, AND PARTICIPANTS: Between 2001 to 2010, 25 patients with biopsy-proven CIS underwent TGR (n=10) or PGR (n=15), defined as <50% of the glans requiring resurfacing. All patients were surveyed clinically every 3 mo for 2 yr and every 6 mo thereafter. SURGICAL PROCEDURE: Excision of the glans epithelium and subepithelium of either the entire glans or the locally affected area, with a macroscopic clear margin. The penis was then reconstructed using a split skin graft. MEASUREMENTS: Positive surgical margin (PSM) rates and rates of recurrence and progression were collated. Complications, cosmesis, and patient satisfaction were evaluated. RESULTS AND LIMITATIONS: Mean follow-up was 29 mo (range: 2-120 mo). There were no postoperative complications, and 24 of 25 patients (96%) had complete graft take with excellent cosmesis. Overall, 12 of 25 patients (48%) had PSMs. Only 7 of 25 (28%) required further surgery, 2 of 25 (8%) for extensive CIS at the margin and 5 of 25 (20%) for unexpected invasive disease. Additional surgery consisted of further resurfacing in 4 of 25 cases (16%) or glansectomy in 3 of 25 cases (12%). Those undergoing further surgery had no further compromise to their oncologic outcome. The overall local recurrence rate was 4%. There were no cases of progression. CONCLUSIONS: Glans resurfacing is a safe and effective primary treatment for CIS. The procedure maintains a functional penis without compromising oncologic control, while ensuring that definitive histopathlogy is obtained. Glans resurfacing has a low risk of recurrence and progression. Patients need to be warned that approximately 28% will require further surgery for PSM or understaging of their primary disease, although the need for further surgery does not compromise oncologic control.

Cutaneous myiasis of Cordylobia anthropophaga.

We report on a case of glans penis cutaneous myiasis with Cordylobia anthropophaga acquired from Somalia. The mode of transmission and preventative measures are discussed.

Electromotive drug administration with mitomycin C for intravesical treatment of non-muscle invasive transitional cell carcinoma.

This article reviews the use and application of electromotive drug administration for the intravesical treatment of bladder cancer. Strong evidence supports the use of passive intravesical chemotherapy in the management of non-muscle invasive bladder cancer. More recently, two published randomised trials have shown therapeutic advantage with protocols that use electromotive drug administration to enhance urothelial penetration of intravesical mitomycin C. The results suggest that the passive intravesical administration of chemotherapeutic drugs may be suboptimal. Further studies are required to demonstrate the feasibility and advantage of electromotive intravesical mitomycin C in the wider uro-oncological community.

Plaque incision and fascia lata grafting in the surgical management of Peyronie's disease.

OBJECTIVE: To assess the outcome of using modified human fascia lata (Tutoplast, Mentor Corp, Santa Barbara, CA, USA) in the surgical management of Peyronie's disease (PD), as the penile deformity associated with PD can be corrected by plaque incision and saphenous vein grafting (Lue procedure). PATIENTS AND METHODS: In all, 14 patients (mean age 51 years, range 34-59) with PD had their penile deformity corrected by plaque incision and Tutoplast grafting. Three patients had a previous unsuccessful Nesbit operation. The mean (range) penile deformity before surgery was 67.2 (20-90) degrees and the mean follow-up was 31 (17-37) months. RESULTS: Using set criteria, 13 patients were satisfied (excellent or satisfactory) with the results of surgery. The penis was completely straight in 11 of 14 patients. One patient developed de novo erectile dysfunction after surgery. In 10 patients there was no penile shortening, whereas four reported penile shortening of >1 cm. CONCLUSION: Fascia lata Tutoplast grafts provide a reliable and well tolerated biomaterial for penile reconstruction in PD. The outcome of using Tutoplast is similar to that from saphenous vein but without the morbidity associated with the donor site. However, there remains a significant risk of penile shortening and development of erectile dysfunction.

The results of plaque incision and venous grafting (Lue procedure) to correct the penile deformity of Peyronie's disease.

OBJECTIVE: To assess plaque incision and venous grafting (the Lue procedure) to correct the deformity associated with Peyronie's disease and to maintain penile length, evaluating the results over an 8-year period. PATIENTS AND METHODS: The penile deformity of 113 patients (mean age 45 years, range 17-71) with Peyronie's disease was corrected by plaque incision and saphenous vein grafting. All patients had stable Peyronie's disease and had a mean (range) penile deformity of 64.5 (20-180) degrees; the mean follow-up was 12 months. RESULTS: The result was excellent or satisfactory in 105 patients (93%), and the penis completely straightened in 97 (86%). Erectile dysfunction after surgery developed in 10 of 68 potent patients (15%) although they had arterial risk factors of diabetes, hypertension or cardiac disease that may also have contributed. There was penile shortening of > 1 cm in 29 men (25%) but this only prevented intercourse in two. Of the 51 patients with > or = 5 years of follow-up, the penis remained completely straight in 80% but the incidence of erectile dysfunction increased to 22.5% and penile shortening of > 1 cm to 35%. CONCLUSION: The Lue procedure is an effective long-term option in the surgical management of Peyronie's disease, but penile shortening after surgery remains a risk, and patients with vascular risk factors must be warned of the possibility of later erectile dysfunction.

Plaque incision and grafting as a salvage after a failed Nesbit procedure for Peyronie's disease.

OBJECTIVE: To analyse the outcome of plaque incision and grafting in patients who have a residual penile deformity after a Nesbit procedure for Peyronie's disease, as a further Nesbit procedure may present difficulties in dissection at the previous operative site, and may result in further penile shortening. PATIENTS AND METHODS: Over a 5-year period, 15 patients (mean age 58 years, range 34-66) presented with a residual penile deformity after a Nesbit procedure. All the patients had painless and stable Peyronie's disease. All patients had the Peyronie's plaque incised and grafted with either saphenous vein (12) or modified human fascia lata (three). The outcome was assessed using criteria which recorded the degree of penile shortening, quality of erections and penile angulation. RESULTS: Before surgery the mean (range) angle of deformity was 56 (40-90) degrees ; at a mean follow-up of 10 (3-16) months 11 patients had a straight penis, three a residual angle of 10-30 degrees and one had no change in angle. Two patients reported penile shortening and one a new onset of erectile dysfunction. Overall, 14 patients reported either an excellent or satisfactory result. CONCLUSIONS: These results indicate that plaque incision and grafting is an effective salvage operation to correct a residual penile deformity after a failed Nesbit procedure in patients with Peyronie's disease.

BAY41-2272, a novel nitric oxide independent soluble guanylate cyclase activator, relaxes human and rabbit corpus cavernosum in vitro.

PURPOSE: In cavernous smooth muscle nitric oxide (NO) activates soluble guanylate cyclase, which catalyzes the synthesis of cyclic guanosine 3',5'-monophosphate, leading to smooth muscle relaxation, increased blood flow and penile erection. The pyrazolopyridine derivative BAY41-2272 (5-cyclopropyl-2-[1-(2-fluoro-benzyl)-1H-pyrazolo[3,4-b]pyridine-3-yl]pyrimidin-4ylamine) was identified and found to stimulate soluble guanylate cyclase in a NO independent manner. We investigated the effect of BAY41-2272 on human and rabbit corpus cavernosum. MATERIALS AND METHODS: We investigated the effect of BAY41-2272 on the tone and nitrergic relaxation responses of human and rabbit cavernous strips in the absence and presence of the soluble guanylate cyclase inhibitor ODQ (1H-[1,2,4]oxadiazolo[4-3a]quinoxalin-1-one) or the NO synthase inhibitor L-NAME (N-nitro-L-arginine-methyl ester HCl). The potency of BAY41-2272 was compared to that of another soluble guanylate cyclase activator YC-1, and the NO releasing compound spermine NONOate (N-2-aminoethyl-N-2-hydroxy-2-nitrosohydroazino-1,2-ethylenediamine). RESULTS: BAY41-2272 resulted in concentration dependent relaxation of human and rabbit cavernosum (mean EC50 +/- SEM 489.1 +/- 22.5 and 406.3 +/- 21.5 nM., respectively). The compound was 32 times more potent than YC-1 and twice as potent as spermine-NONOate. ODQ decreased the potency of BAY41-2272, such that in the presence of 30 microM. ODQ the EC50 of BAY41-2272 induced relaxation was 1,407.3 +/- 158.0 and 1,902.7 +/- 11.0 nM. in human and rabbit tissues, respectively. L-NAME also inhibited relaxations elicited by BAY41-2272 in rabbit tissue. In the presence of 500 microM. L-NAME the EC50 of BAY41-2272 induced responses was 836.7 +/- 46.7 nM. BAY41-2272 at subthreshold concentrations of 30 to 50 nM. potentiated nitrergic responses. Moreover, the inhibition of nitrergic responses by L-NAME was reversed by 0.3 to 3 microM. BAY41-2272. CONCLUSIONS: We report that a nonNO based soluble guanylate cyclase activator relaxes human and rabbit corpus cavernosum, and potentiates nitrergic responses.

Current concepts in the pharmacotherapy of benign prostatic hyperplasia.

Benign prostatic hyperplasia is a major men's health issue, with approximately 80% of all men developing this condition within their lifetime. A variety of oral treatments is available, including alpha-adrenoceptor antagonists (alpha-blockers), 5alpha reductase inhibitors, aromatase inhibitors and phytotherapy. A large number of alpha-blockers can be administered, but no single agent has demonstrated a clear superiority over the other drugs. 5alpha Reductase inhibitors have demonstrated similar efficacy in larger volume prostates but most evidence suggests that there is no benefit in combining them with alpha-blockers. The use of phytotherapy is not entirely novel but requires further long-term evaluation before it can be endorsed for clinical use in benign prostatic hyperplasia.

A Rho-kinase inhibitor, soluble guanylate cyclase activator and nitric oxide-releasing PDE5 inhibitor: novel approaches to erectile dysfunction.

Approximately 50% of men aged over 40 suffer from male erectile dysfunction. Treatment options have widened since the launch of the phosphodiesterase type 5 (PDE5) inhibitor, sildenafil citrate (Viagra trade mark ). However, a certain portion of the patient population, such as diabetics, do not gain significant benefit from PDE5 inhibitors, possibly due to a lack of endogenous nitric oxide. Therefore, new treatment modalities based on the absence of endogenous nitric oxide have been developed. Among them are Rho-kinase inhibitors, soluble guanylate cyclase activators and nitric oxide-releasing PDE5 inhibitors. The available data concerning these compounds will be summarised and their therapeutic potential for male erectile dysfunction will be discussed.