Quantitative Proton Spectroscopy of the Testes at 3 T: Toward a Noninvasive Biomarker of Spermatogenesis.

OBJECTIVES: The aim of this study was to compare testicular metabolite concentrations between fertile control subjects and infertile men. MATERIALS AND METHODS: Single voxel proton magnetic resonance spectroscopy (H-MRS) was performed in the testes with and without water suppression at 3 T in 9 fertile control subjects and 9 infertile patients (8 with azoospermia and 1 with oligospermia). In controls only, the T1 and T2 values of water and metabolites were also measured. Absolute metabolite concentrations were calculated using the unsuppressed water signal as a reference and correcting for the relative T1 and T2 weighting of the water and metabolite signals. RESULTS: Testicular T1 values of water, total choline, and total creatine were 2028 ± 125 milliseconds, 1164 ± 105 milliseconds, and 1421 ± 314 milliseconds, respectively (mean ± standard deviation). T2 values were 154 ± 11 milliseconds, 342 ± 53 milliseconds, and 285 ± 167 milliseconds, respectively. Total choline concentration was lower in patients (mean, 1.5 mmol/L; range, 0.9-2.1 mmol/L) than controls (mean, 4.4 mmol/L; range, 3.2-5.7 mmol/L; P = 4 × 10). Total creatine concentration was likewise reduced in patients (mean, 1.1 mmol/L; range, undetectable -2.7 mmol/L) compared with controls (mean, 3.6 mmol/L; range, 2.5-4.7 mmol/L; P = 1.6 × 10). The myo-inositol signal normalized to the water reference was also lower in patients than controls (P = 4 × 10). CONCLUSIONS: Testicular metabolite concentrations, measured by proton spectroscopy at 3 T, may be valuable as noninvasive biomarkers of spermatogenesis.

Burden of Disease for Urethral Stricture Managed by Repeat Endoscopic Treatment vs Single Endoscopic Treatment or Urethroplasty in the Veterans Affairs Population.

INTRODUCTION: Male urethral stricture disease is a challenging urological condition that affects nearly a third of men 65 years old or older. Management options include dilation and urethrotomy as well as urethroplasty, an open approach with increased morbidity and durability. Presently optimal management remains debated. In this study we focus on emergent procedures required by male patients in the Veterans Health Administration after stricture treatment as an indicator of clinically significant complications, comparing treatment approaches. METHODS: We performed an institutional review board approved, retrospective, cohort study of male veterans with urethral stricture from 2005 to 2014. Our independent variable was immediate or delayed urethroplasty or continued endoscopic treatments. Our dependent variable was a stricture related procedure performed in the emergent or urgent care setting. We used a binary logistic regression model to model the likelihood of an adverse outcome as predicted by treatment type. RESULTS: In our cohort of 9,632 patients 1.8% underwent immediate urethroplasty and 3% underwent delayed urethroplasty. Of the operated men 5.3% had an adverse outcome (5% following delayed urethroplasty or continued endoscopic treatments and 1% after immediate urethroplasty, p = 0.04). On multivariate analysis repeat endoscopy and delayed urethroplasty trended toward worsening odds of adverse outcomes (p = 0.07 and p = 0.08, respectively). CONCLUSIONS: In the Veterans Health Administration system men who undergo repeated scheduled endoscopic treatments for urethral stricture may be at increased risk for emergent procedures, even if they eventually progress to urethroplasty, compared to men who undergo urethroplasty immediately after a failed endoscopic intervention.

Fasciocutaneous flap reinforcement of ventral onlay buccal mucosa grafts enables neophallus revision urethroplasty.

BACKGROUND: Urethral strictures or fistulas are common complications after phalloplasty. Neourethral defects pose a difficult reconstructive challenge using standard techniques as there is generally insufficient ventral tissue to support a graft urethroplasty. We report our experience with local fasciocutaneous flaps for support of ventrally-placed buccal mucosal grafts (BMGs) in phalloplasty. METHODS: A retrospective review of patients who underwent phalloplasty and subsequently required revision urethroplasty using BMGs between 2011 and 2015 was completed. Techniques, complications, additional procedures, and outcomes were examined. RESULTS: A total of three patients previously underwent phalloplasty with sensate radial forearm free flaps (RFFFs): two female-to-male (FTM) gender reassignment, and one oncologic penectomy. Mean age at revision urethroplasty was 41 years (range 31-47). Indications for surgery were: one meatal stenosis, four urethral strictures (mean length 3.6 ± 2.9 cm), and two urethrocutaneous fistulas. The urethral anastomosis at the base of the neophallus was the predominant location for complications: 3/4 strictures, and 2/2 fistulas. Medial thigh (2) or scrotal (1) fasciocutaneous flaps were used to support the BMG for urethroplasty. One stricture recurrence at 3 years required single-stage ventral BMG urethroplasty supported by a gracilis musculocutaneous flap. All patients were able to void from standing at mean follow up of 8.7 months (range 6-13). A total of two patients (66%) subsequently had successful placement of a penile prosthesis. CONCLUSIONS: Our early results indicate that local or regional fasciocutaneous flaps enable ventral placement of BMGs for revision urethroplasty after phalloplasty.

Outpatient Ultrasound Urethrogram for Assessment of Anterior Urethral Stricture: Early Experience.

OBJECTIVE: To describe the technique of ultrasound urethrogram (USUG) for the diagnosis of anterior urethral stricture performed in an ambulatory setting without any adjunctive imaging. MATERIALS AND METHODS: Between September 2013 and September 2015, 35 consecutive adult men (>18 years old) presenting for anterior urethral reconstruction underwent outpatient USUG prior to definitive management. No alternative imaging test was performed. Lengths of the strictures as determined by outpatient USUG and via direct intraoperative measurements were compared by a paired t test. RESULTS: Strictures were in the bulbar urethra in 24 men and in the penile urethra in 11 men. The differences between the outpatient USUG length measurements (mean = 1.86 cm) and the intraoperative stricture length measurements (mean = 2.02 cm) were not significantly different (P = .10). Additionally, the correlation coefficient between these length measurements was 0.84 (P < .001). CONCLUSION: Preoperative USUG performed in the ambulatory setting for the diagnosis and characterization of anterior urethral strictures is safe and feasible. This outpatient imaging modality offers an alternative to retrograde urethrogram.

Serum testosterone levels and mortality in men with CKD stages 3-4.

BACKGROUND: Hypogonadism in men (total testosterone <350 ng/dL) is associated with higher risk of cardiovascular disease and mortality in men on dialysis therapy. We evaluated the association of hypogonadism with all-cause mortality in men with non-dialysis-dependent chronic kidney disease (CKD). STUDY DESIGN: Retrospective, cohort study. SETTING & PARTICIPANTS: 2,419 men with CKD stages 3-4 (estimated glomerular filtration rate, 15-59 mL/min/1.73 m2) who had total testosterone measured for cause between January 1, 2005, and October 31, 2011, at a tertiary-care center in Cleveland, OH. PREDICTORS: Total testosterone measured using an immunoassay measurement in 3 forms: (1) categorized as low or testosterone replacement therapy versus normal, (2) continuous log testosterone, and (3) quintiles (100-226, 227-305, 306-392, 393-511, and 512-3,153 ng/dL). OUTCOMES: Factors associated with low total testosterone level and the association between low total testosterone level and all-cause mortality were evaluated using logistic regression, Cox proportional hazard models, and Kaplan-Meier survival curves. RESULTS: Hypogonadism was found in 1,288 of 2,419 (53%) men. In a multivariable logistic regression analysis, African American ethnicity and higher estimated glomerular filtration rate were associated with lower odds of having hypogonadism. Diabetes and higher body mass index were associated with higher odds of having hypogonadism. 357 of 2,419 (15%) patients died during a median follow-up of 2.3 years. In the multivariate Cox model, testosterone level <350 ng/dL or testosterone replacement therapy was not associated with mortality. In a multivariable model also adjusted for testosterone supplementation, higher log testosterone was associated with significantly lower mortality (HR per 1 log unit, 0.70; 95% CI, 0.55-0.89). When compared to the highest quintile, the second lowest quintile of testosterone was associated with higher mortality (HR, 1.53; 95% CI, 1.09-2.16). LIMITATIONS: Single-center study, timing of testosterone testing, lack of adjustment for proteinuria, and sampling bias. CONCLUSIONS: Low total testosterone level may be associated with higher mortality in men with CKD stages 3-4, but more studies are needed.

The economic burden of genetic tests for the infertile male: a pilot algorithm to improve test predictive value.

PURPOSE: We developed a model to optimize genetic testing in infertile men with nonobstructive azoospermia and severe oligospermia. We also assessed the optimal cutoff value of the predicted probability of advising genetic testing and evaluated the direct cost saving of using the model. MATERIALS AND METHODS: We retrospectively reviewed the records of infertile men who underwent Y microdeletion and karyotype testing at our fertility center from 2006 to 2012. Semen parameters, testicular volume, testosterone, luteinizing hormone, follicular stimulating hormone and varicocele were assessed as potential predictors of genetic disorders. We fitted logistic regression to all predictors and selected a nomogram based on the concordance index and calibration. We calculated the cost saving of using the model. RESULTS: Of 325 patients 278 fulfilled study inclusion criteria, including 27 with an abnormal karyotype, 11 with a Y microdeletion and 1 with each condition. We developed a nomogram using sperm concentration and motility, testicular volume and serum testosterone level. The nomogram concordance index was 0.738. The optimal cutoff value was 13.8% with 0.788 sensitivity, 0.590 specificity, 0.245 positive predictive value and 0.943 negative predictive value. Testing men above the 13.8% cutoff resulted in a direct 45% cost saving. However, 15.4% of genetic anomalies were missed, including 2 Y microdeletions. CONCLUSIONS: Using common clinical and laboratory parameters our nomogram detects 84.6% of genetic anomalies. Nomogram use resulted in a 45% direct cost saving but carries the risk of missing pertinent genetic abnormalities.

Office-based sperm retrieval for treatment of infertility.

This article describes sperm retrieval procedures that may be performed in an office setting. Indications for sperm retrieval, preprocedural preparation, and anesthetic considerations are discussed. Vasal sperm aspiration, percutaneous epididymal sperm aspiration, microsurgical epididymal sperm aspiration, testicular sperm aspiration, conventional, and microdissection testicular sperm extraction are reviewed. Success and complication rates as well as factors that may influence success (histopathology, cancerous cause, Klinefelter syndrome, Y microdeletions, varicocele, and hormone administration) are reviewed.

Multidisciplinary management of patients with localized bladder cancer.

Multidisciplinary approach to muscle-invasive bladder cancer is imperative to achieve optimal long-term cancer control. Radical cystectomy, pelvic lymph node dissection, and urinary diversion have been the mainstay of therapy for decades. Laparoscopic and robotic-assisted surgical techniques are becoming increasingly prevalent, and have shown short-term benefits in terms of blood loss, less pain, and smaller incisions. Neoadjuvant chemotherapy plus surgery results in absolute survival advantage and this approach is encouraged in appropriate patients. A similar survival advantage with the use of adjuvant chemotherapy has yet to be convincingly demonstrated. Bladder-preservation protocols involving a visibly complete transurethral resection followed by chemoradiation may be a feasible option for select patients.

Impact of ischemia and procurement conditions on gene expression in renal cell carcinoma.

PURPOSE: Previous studies have shown that ischemia alters gene expression in normal and malignant tissues. There are no studies that evaluated effects of ischemia in renal tumors. This study examines the impact of ischemia and tissue procurement conditions on RNA integrity and gene expression in renal cell carcinoma. EXPERIMENTAL DESIGN: Ten renal tumors were resected without renal hilar clamping from 10 patients with renal clear cell carcinoma. Immediately after tumor resection, a piece of tumor was snap frozen. Remaining tumor samples were stored at 4°C, 22°C, and 37°C and frozen at 5, 30, 60, 120, and 240 minutes. Histopathologic evaluation was conducted on all tissue samples, and only those with greater than 80% tumor were selected for further analysis. RNA integrity was confirmed by electropherograms and quantitated using RNA integrity number index. Altered gene expression was assessed by paired, two-sample t test between the zero time point and aliquots from various conditions obtained from the same tumor. RESULTS: One hundred and forty microarrays were conducted. Some RNA degradation was observed 240 minutes after resection at 37°C. The expression of more than 4,000 genes was significantly altered by ischemia times or storage conditions. The greatest gene expression changes were observed with longer ischemia time and warmer tissue procurement conditions. CONCLUSION: RNA from kidney cancer remains intact for up to 4 hours post surgical resection regardless of storage conditions. Despite excellent RNA preservation, time after resection and procurement conditions significantly influence gene expression profiles. Meticulous attention to preacquisition variables is of paramount importance for accurate tumor profiling.

Prevalence of circulating tumor cells in localized prostate cancer.

BACKGROUND: Circulating tumor cells (CTC) predict overall survival in patients with metastatic prostate cancer. The objective of this study is to measure CTC before radical prostatectomy in intermediate- and high-risk prostate cancer patients. MATERIALS AND METHODS: The study accrued 12 patients and 10 provided adequate peripheral blood sample. Blood was drawn preoperatively and assayed for CTC using the CellSearch system. Patients were categorized as CTC positive (≥ 1 CTC) or CTC negative (no CTC). RESULTS: Median age was 64.5 years (range 49-77 years), median prostate specific antigen was 7.4 ng/ml (range 5.7-25.7 ng/ml). Seven patients had intermediate-risk and 3 patients had high-risk prostate cancer. One patient was found to be CTC positive. CONCLUSIONS: Our pilot study shows that CTC are rare in patients with clinically localized disease despite intermediate- to high-risk features. CTC may not be the optimal marker to predict prognosis or detect residual disease after radical prostatectomy.

Management of poor-prognosis testicular germ cell tumors.

Currently, the outcome of patients with intermediate-and poor-risk germ cell tumors at diagnosis is optimized by the use of risk-appropriate chemotherapy and post-chemotherapy surgical resection of residual masses. Currently, there is no role for high-dose chemotherapy in the first-line setting. Patients who progress on first-line chemotherapy or who relapse after an initial complete response also have a poor prognosis. In the setting of early relapse, the standard approach at most centers is conventional-dose, ifosfamide-based regimens and post-chemotherapy resection of residual masses. The treatment of patients with late relapse is complete surgical resection whenever feasible. Salvage chemotherapy for late relapse may be used prior to surgery in patients where a complete resection is not feasible. A complete surgical resection of all residual sites of disease after chemotherapy is critical for the prevention of relapse and the long-term survival of patients with advanced germ cell tumors.

Repeat partial nephrectomy on the solitary kidney: surgical, functional and oncological outcomes.

PURPOSE: We examined outcomes in patients with recurrent or de novo renal lesions treated with repeat partial nephrectomy on a solitary kidney. MATERIALS AND METHODS: We reviewed the records of patients who underwent nephron sparing surgery at the National Cancer Institute from 1989 to 2008. Patients were included in analysis if they underwent repeat partial nephrectomy on a solitary kidney. Perioperative, functional and oncological outcomes were assessed. Functional outcomes were evaluated using the Modification of Diet in Renal Disease equation for the estimated glomerular filtration rate. Oncological efficacy was examined by the need for subsequent repeat renal surgery and the development of metastatic disease. RESULTS: A total of 25 patients were included in the analysis. A median of 4 tumors were resected. Median estimated blood loss was 2,400 ml and median operative time was 8.5 hours. Perioperative complications occurred in 52% of patients, including 1 death and the loss of 3 renal units. There was a decrease in the estimated glomerular filtration rate at followup visit 1 within 3 months after surgery but at 1-year followup the difference was not significant (p <0.01 and 0.12, respectively). Surgical intervention was recommended in 8 patients (38%) for recurrent or de novo tumors at a median of 36 months. The average metastasis-free survival rate in the cohort was 95% at 57 months (median 50, range 3 to 196). CONCLUSIONS: Repeat partial nephrectomy in patients with solitary kidney is a high risk alternative. The complication rate is high and there is a modest decrease in renal function but most patients remain free of dialysis with acceptable oncological outcomes at intermediate followup.

Prostate cancer: value of multiparametric MR imaging at 3 T for detection--histopathologic correlation.

PURPOSE: To determine utility of multiparametric imaging performed at 3 T for detection of prostate cancer by using T2-weighted magnetic resonance (MR) imaging, MR spectroscopy, and dynamic contrast material-enhanced MR imaging, with whole-mount pathologic findings as reference standard. MATERIALS AND METHODS: This prospectively designed, HIPAA-compliant, single-institution study was approved by the local institutional review board. Seventy consecutive patients (mean age, 60.4 years; mean prostate-specific antigen level, 5.47 ng/mL [5.47 microg/L]; range, 1-19.9 ng/mL [1-19.9 microg/L]) were included; informed consent was obtained from each patient. All patients had biopsy-proved prostate cancer, with a median Gleason score of 7 (range, 6-9). Images were obtained by using a combination of six-channel cardiac and endorectal coils. MR imaging and pathologic findings were evaluated independently and blinded and then correlated with histopathologic findings by using side-by-side comparison. Analyses were conducted with a raw stringent approach and an alternative neighboring method, which accounted for surgical deformation, shrinkage, and nonuniform slicing factors in pathologic specimens. Generalized estimating equations (GEEs) were used to estimate the predictive value of region-specific, pathologically determined cancer for all three modalities. This approach accounts for the correlation among multiple regions in the same individual. RESULTS: For T2-weighted MR imaging, sensitivity and specificity values obtained with stringent approach were 0.42 (95% confidence interval [CI]: 0.36, 0.47) and 0.83 (95% CI: 0.81, 0.86), and for the alternative neighboring approach, sensitivity and specificity values were 0.73 (95% CI: 0.67, 0.78) and 0.89 (95% CI: 0.85, 0.93), respectively. The combined diagnostic accuracy of T2-weighted MR imaging, dynamic contrast-enhanced MR imaging, and MR spectroscopy for peripheral zone tumors was examined by calculating their predictive value with different combinations of techniques; T2-weighted MR imaging, dynamic contrast-enhanced MR imaging, and MR spectroscopy provided significant independent and additive predictive value when GEEs were used (P < .001, P = .02, P = .002, respectively). CONCLUSION: Multiparametric MR imaging (T2-weighted MR imaging, MR spectroscopy, dynamic contrast-enhanced MR imaging) of the prostate at 3 T enables tumor detection, with reasonable sensitivity and specificity values.

Intravesical immunotherapy of superficial bladder cancer with chitosan/interleukin-12.

Intravesical BCG has been used successfully to treat superficial bladder cancer for three decades. However, 20% to 30% of patients will fail initial BCG therapy and 30% to 50% of patients will develop recurrent tumors within 5 years. Alternative or complementary strategies for the management of superficial bladder cancer are needed. Interleukin-12 (IL-12) is a potent T(H)1 cytokine with robust antitumor activity and the ability to potentiate immunologic memory. Unfortunately, intravesical IL-12 did not show antitumor efficacy in a recent clinical study of patients with recurrent superficial bladder cancer. We hypothesized that coformulation of IL-12 with chitosan, a biocompatible, mucoadhesive polysaccharide, could improve intravesical IL-12 delivery and provide an effective and durable alternative for the treatment of superficial bladder cancer. In antitumor studies, 88% to 100% of mice bearing orthotopic bladder tumors were cured after four intravesical treatments with chitosan/IL-12. In contrast, only 38% to 60% of mice treated with IL-12 alone and 0% treated with BCG were cured. Antitumor responses following chitosan/IL-12 treatments were durable and provided complete protection from intravesical tumor rechallenge. Urinary cytokine analysis showed that chitosan/IL-12 induced multiple T(H)1 cytokines at levels significantly higher than either IL-12 alone or BCG. Immunohistochemistry revealed moderate to intense tumor infiltration by T cells and macrophages following chitosan/IL-12 treatments. Bladder submucosa from cured mice contained residual populations of immune cells that returned to baseline levels after several months. Intravesical chitosan/IL-12 is a well-tolerated, effective immunotherapy that deserves further consideration for testing in humans for the management of superficial bladder cancer.

Negative functional effects of natriuretic peptides are attenuated in hypertrophic cardiac myocytes by reduced particulate guanylyl cyclase activity.

We tested the hypothesis that the negative functional effects of natriuretic peptides would be blunted in thyroxine (T4)-induced hypertrophic cardiac myocytes. We also studied the causes of these changes. Ventricular myocytes were obtained from control (n=8) and T4 (0.5 mg/kg/16 days) treated rabbit hearts (n=7). Cell shortening parameters were studied with a video edge detector. We also determined particulate (pGC) and soluble (sGC) guanylyl cyclase activity and cyclic GMP levels. Myocyte function was examined at baseline and after brain natriuretic peptide (BNP 10(-7,-6) M) or C-type natriuretic peptide (CNP 10(-7,-6) M) or zaprinast (cyclic GMP phosphodiesterase inhibitor 10(-6)M) followed by BNP or CNP. Baseline function was similar in control and T4 myocytes. BNP (5.7 +/- 0.2 to 4.3 +/- 0.1%) and CNP (5.7 +/- 0.4 to 4.2 +/- 0.2%) significantly reduced percent shortening in control myocytes. These reductions were not observed with T4 (BNP, 5.7 +/- 0.6 to 5.6 +/- 0.6; CNP, 5.6 +/- 0.4 to 5.5 +/- 0.5). BNP and CNP responded similarly after zaprinast. Baseline cyclic GMP was similar in control and T4, but BNP only increased cyclic GMP in controls. The activity of pGC was similar at baseline in control and T4, but the stimulated activity was significantly lower in T4 myocytes. Both basal and stimulated sGC activity were similar in control and hypertrophic myocytes. These results demonstrated that the ability of natriuretic peptides to reduce ventricular myocyte function was blunted in T4 hypertrophic myocytes. This blunted response was related to the reduced ability of natriuretic peptides to increase cyclic GMP levels due to a reduced stimulated particulate guanylyl cyclase activity.