[Evaluation of obstructive interval, presence of sperm granulomas and patient age as predictors of spermatogenesis in a cohort of men undergoing vasectomy reversal]. / Evaluation von Vasektomieintervall, Spermagranulom und Patientenalter als Prädiktoren der spermatogenetischen Aktivität vasektomierter Männer.

INTRODUCTION: For more than 50 years vasectomy reversal is a routinely performed procedure in the field of urology. However, there is no scientific agreement about morphological changes of the testes caused by vasectomy. The existing evidence for reduced fertility rates following vasectomy reversal demands a clear statement regarding potential histological changes and impaired spermatogenesis following vasectomy. Thus far there is little knowledge about potential histological changes of the testis caused by vasectomy. MATERIAL AND METHODS: 330 consecutive patients who underwent vasectomy reversal had bilateral testicular biopsies which were evaluated utilising semi-thin sections. The number of mature spermatids per seminiferous tubule was considered the variable of interest as it represents an objective and reproducible parameter of spermatogenesis. The number of mature spermatids per tubule was correlated with patient age, obstructive interval and the presence or absence of sperm granulomas via the chi-square test. RESULTS: Overall, 570 sections of 285 patients were eligible for evaluation. The mean patient age was 41.2 years (range 27-63 years, SD +/- 6.5 years) with a mean obstructive interval of 105.9 months (range 12-328, SD +/- 66.1). 56 patients (19.6 %) had a sperm granuloma on the right and 22 (11.6 %) on the left ductus deferens. There was no statistically significant correlation between the presence of a sperm granuloma with the number of mature spermatids per tubule (p = 0.717). Furthermore, there was neither an association of obstructive interval (p = 0.144) nor patient age (p = 0.168) with spermatogenesis. CONCLUSION: Regular spermatogenetic activity in all examined samples with development of mature spermatids was shown. Furthermore, for the first time we were able to demonstrate in a large cohort of patients that neither patient age nor obstructive interval nor sperm granuloma have a significant impact on spermatogenesis.

Impact of obstructive interval and sperm granuloma on patency and pregnancy after vasectomy reversal.

The objective of this study was to determine the effect of the obstructive interval and the presence of a sperm granuloma on vas patency and pregnancy rate following vasectomy reversal. We identified 334 patients with complete follow-up who met the inclusion criteria. There were significant associations between the obstructive interval and procedure performed as well as with patient age. Patients with longer obstructive intervals were more often older (p < 0.001) and more likely to have a vaseoepididymostomy performed (p < 0.001). There was no association between the presence of a sperm granuloma or the length of the obstructive interval with post-operative vas patency and pregnancy rates. The only independent predictor of post-operative fertility was age of the female partner (p = 0.015). Our data clearly demonstrates that when state of the art surgical techniques are used, neither the presence of a sperm granuloma nor the obstructive interval serve as prognosticators of post-operative vas patency and pregnancy rates. However, when counselling patients and their female partners, it is of utmost importance to stress that the age of the female partner is an independent predictor of successful vasectomy reversal.

[Diagnosis of erectile dysfunction--what is still needed today?]. / Diagnostik der erektilen Dysfunktion - was ist heute noch notwendig?

Diagnostic procedures for erectile dysfunction (ED) are still mandatory because ED can be the presenting symptom for a variety of diseases such as diabetes mellitus, coronary artery disease, atherosclerosis, hypertension and hyperlipidemia. Invasive testing for ED has decreased due to the high responder rate for oral PDE-5 inhibitors.

Vasectomy.

Vasectomy is regarded as the safest method now available for male fertility control. Almost 100 million men worldwide have relied on vasectomy for family planning. This review discusses all currently relevant operative techniques, including no-scalpel vasectomy, complications, possible long-term effects on the testis and epididymis, and diseases for which associations with vasectomy have been suggested, such as arteriosclerosis, autoimmune diseases and cancer of the prostate and testis. Other topics of discussion include the timing of post-operative semen analysis, patient noncompliance concerning post-operative controls, persistent cryptozoospermia and transient reappearance of spermatozoa after vasectomy, vasectomy failure and legal aspects.

Clinical findings in congenital absence of the vasa deferentia.

In a clinical study, 105 patients with congenital bilateral absence of the vas deferens (CBAVD) and 18 with congenital unilateral absence of the vas deferens (CUAVD) were investigated. CUAVD was observed on the left side in 66%. Renal agenesis was more frequent in CUAVD (73.7%) than in CBAVD (11.8%). The leading signs of CBAVD are low pH level (average 6.5) and low volume of the ejaculate (average 0.95 ml). Testicular biopsies of 52 patients revealed normal spermatogenesis or hypospermatogenesis (33% in CBAVD; 45% in CUAVD). Genetic probing and counselling concerning cystic fibrosis are necessary if extracorporal micro-fertilization is considered. The absence of the vas deferens was often overlooked by the first investigator, the average time until correct diagnosis being 4.3 years. As artificial reproduction technology becomes more common, detection of vasal agenesis will certainly be made earlier and more frequently in the future. In order to assure compatibility of subsequent prospective studies about CBAVD and CUAVD, the following investigations are considered to be necessary: (i) semen analysis (pH, volume); (ii) renal ultrasonography or excretory urogram (screening for renal agenesis); (iii) genetic cystic fibrosis screening.

Invasive diagnosis and therapy--are they still reasonable in the age of sildenafil?

Diagnosis of erectile dysfunction is important because sildenafil may not be the proper therapy for patients with underlying major diseases such as coronary sclerosis, arteriosclerosis of the stroke vessels, depression, etc., where erectile dysfunction is just a symptom of the disease.

Sexual dysfunction in Peyronie's disease: an analysis of 222 patients without previous local plaque therapy.

PURPOSE: We obtained an objective evaluation of erectile function in patients with Peyronie's disease. MATERIALS AND METHODS: Sexual dysfunction was analyzed in 222 patients with Peyronie's disease without previous local plaque therapy using a standardized protocol. RESULTS: Of the 222 patients 70 (31.5%) complained of not being able to perform intercourse. In 4 men (1.8%) standardized diagnostic procedure demonstrated only a severe angulation making coitus impossible, and in 3 men (1.4%) intercourse became unsatisfactory due to pain. Seven men (3.1%) reported distal penile flaccidity, including 4 in whom dynamic pharmacocavernosometry and pharmacocavernosography revealed veno-occlusive dysfunction. Of 56 men who complained of a complete loss of erection 51 did not respond to intracavernous pharmacological injection with prostaglandin E1, and 27 (48.2%) had abnormal arterial blood flow as shown by duplex sonography of the cavernous arteries, 47 (83.9%) had evidence of veno-occlusive dysfunction based on cavernosometric criteria and 33 (58.9%) also had cavernosographic evidence of the condition. Plaque associated venous drainage was evident in 15 of the 56 impotent patients (26.8%), equivalent to 45.5% of all cases with abnormal cavernosographic findings. CONCLUSIONS: Sexual dysfunction was evaluable in 31.5% of patients, and the main cause of impotence and loss of erection was veno-occlusive dysfunction.

Analysis of intra-operative aspirates taken during microsurgical refertilization in obstructive azoospermia--preliminary results. The BMFT Study Group for Microsurgery, Giessen.

The reasons for the discrepancy between 'patency' and 'pregnancy' in the outcome of microsurgical refertilization are partially unknown. The quality of the intra-operative aspirate and of the spermatozoa at the level of the anastomosis are discussed worldwide as important factors influencing the success of fertilization in the case of post-operative patency. In 152 men undergoing microsurgical refertilization (vasovasostomy, tubulovasostomy, microsurgical epididymal sperm aspiration, transurethral resection of the ejaculatory duct), 281 aspirates were classified intra-operatively according to Silber, and post-operatively using the Shorr staining technique. In 62 aspirates a computer-aided sperm analysis (CASA) was performed. The percentage of intact spermatozoa decreased from 94.9% at the caput to 9.4% at the cauda epididymidis. The post-operative classification demonstrated an acceptable correlation (0.71) to all grades of intraoperative classification. There was a good correspondence in Silber 4 and 5 but worse in Silber 1 and 2. In CASA, the percentage of motile spermatozoa was not different between epididymal and post-epididymal aspirates. Furthermore, velocity parameters did not differ significantly, but there was a significantly higher straightness of post-epididymal spermatozoa in comparison to epididymal spermatozoa.

MESA and TESE: experiences of the German section of urological microsurgery.

The introduction of microsurgical epididymal sperm aspiration (MESA) and testicular sperm extraction (TESE) followed by intracytoplasmic sperm injection (ICSI) has enlarged the therapeutic options for irreparable azoospermia. After standardization of the indications and surgical procedure, the German section for urological microsurgery combined the data of all groups performing assisted reproduction. The indication for MESA or TESE is given in cases of congenital aplasia of the vas deferens, irreparable obstruction of the reproductive tract, failure after refertilization, in combination with tubulovasostomy for subsequent cryopreservation and for conservatively untreatable ejaculatory disturbances. Until October 1995, 87 couples were treated by MESA and conventional IVF; the embryo transfer rate (ET) was 4.6%, the pregnancy rate 1.1%. One child (1.1%) was born. 179 couples were treated by MESA and ICSI, the ET was 68.2%, the pregnancy rate 18.4%, and 11 children (6.1%) were born. TESE in combination with ICSI was performed in 65 cases, the ET was 84.6%, the pregnancy rate 23.1% and 6 children (9.2%) were born. Modern technological developments in reproductive medicine and increasing experience in andrological surgery have stabilized the position of interdisciplinary therapeutic concepts for the treatment of infertile couples.

Limits and special features of vasoepididymostomy (VE).

Thanks to the development of microsurgical techniques, it is now possible to treat epididymis-dependent obstructive azoospermia successfully. With the help of various methods of assisted microfertilization (ICSI), surgical andrology is in a position to overcome all barriers, given the presence of spermatogenesis. Concerning the operational technique itself, there are limits in the anatomical, pathological, technical and manual field.

Microsurgical aspects of the treatment of azoospermia. The BMFT Study Group for Microsurgery.

Technical advances in microsurgery have produced a calculable success rate for reconstructive surgery in cases of obstructive azoospermia. Nevertheless, in standardized vasovasostomy and tubulovasostomy, the different outcomes for patency and pregnancy indicate that further comprehensive clinical and basic scientific studies are required to improve the results of surgery. The aspiration of epididymal and testicular spermatozoa in combination with intra-cytoplasmic sperm injection (ICSI) is one example of a fruitful integration of microsurgery into new areas of reproductive medicine. Where there is ejaculatory duct obstruction, the continuity with the posterior urethra can be restored by a transurethral operation.

A study in patients with erectile dysfunction comparing different formulations of prostaglandin E1. Alprostadil Study Group.

PURPOSE: Prostaglandin E1 sterile powder and sterile solution are 2 new formulations of exogenous prostaglandin E1 that are more convenient for auto-injection therapy for erectile dysfunction than the presently used pediatric sterile solution. Therefore, the pharmacodynamic profiles of intracavernous prostaglandin E1 sterile powder and nonalcohol sterile solution were compared with the pediatric sterile solution in men with erectile dysfunction who were known to be stable responders to intracavernous prostaglandin E1. MATERIALS AND METHODS: Based on the dose used at home, patients were randomized to 1 of 5 dose groups: 0 microgram. (placebo), 2.5 micrograms., 5 micrograms., 10 micrograms. or 20 micrograms. Each patient received a single injection of the same dose of each of the 3 formulations. The primary pharmacodynamic end points were clinical evaluation of erectile response, RigiScan real-time evaluation of erectile response and patient evaluation of erectile response. RESULTS: No significant differences were identified among the formulations for any of these end points, either by comparison among all active doses or by comparison at each prostaglandin E1 dose level. There was also little or no intra-patient variation in dose response and the inter-dose variation in response between patients was not significant. Pharmacodynamic end points were well intercorrelated, although assessment of erectile response by the patients tended to be more positive than that by RigiScan or clinical evaluation. There were no major side effects. Penile pain on injection and/or during erection occurred in 9 to 17% of the patients according to the formulations. However, penile pain was also reported by 11% of the placebo-treated patients. CONCLUSIONS;: The 3 formulations of prostaglandin E1 showed equivalence and were safe for the treatment of erectile dysfunction with respect to side effects.

Pregnancy caused by sperm from vasa efferentia.

Pregnancies induced by sperm from the vasa efferentia are extremely rare. We report on a 37-year-old male with obstructive azoospermia. An anastomosis between the vas and the rete testis region was carried out by microsurgery on the left side. A healthy male baby was born in March 1993. Paternity was proved by DNA fingerprinting.

Concentrations of vasoactive intestinal polypeptide in corpus cavernosum and peripheral venous blood during prostaglandin E1-induced erection.

Vasoactive intestinal polypeptide (VIP) has been suggested to play a role as a nonadrenergic, noncholinergic neurotransmitter or neuromodulator involved in the process of erection. Until now, data about fluctuating concentrations of VIP in corpus cavernosum (CC) blood have been controversial. The present study describes a modified radioimmunoassay method that was developed in our laboratory for the determination of VIP in plasma. Examination of 12 patients suffering from impotentia coeundi (6 men with psychogenic impotence, 2 with induratio penis plastica, and 4 with impotence of vascular origin) showed that the concentrations of VIP in corpus cavernosum blood during pharmacologically induced erection did not increase in organically healthy men or in men with impotentia coeundi of vascular origin. The VIP concentrations in peripheral venous blood and those in CC blood were similar.

Venous surgery in veno-occlusive dysfunction: long-time results after deep dorsal vein resection.

Follow-up of patients 1 year after deep dorsal vein resection gives evidence of an approximate 50-60% success rate. A careful selection of only this small percentage of patients, in whom abnormal drainage through the penile dorsum is obvious, is mandatory. Men with an arterial cofactor have to be excluded or to be subsequently treated by intracavernosal autoinjection of vasoactive substances. Late results from our study demonstrate a further loss of sufficient erection, also in men considered as persistent success by us, in the subjective view of the patient and/or his sexual partner.

[Pharmacocavernosometry and pharmacocavernosography in erectile dysfunction]. / Pharmakokavernosometrie und Pharmakokavernosographie bei erektiler Dysfunktion.

In about 30% of patients with erectile dysfunction (ED), insufficiency of the corpus cavernosum, or a so-called venous outflow disturbance, pharmacocavernosometry (PCM) and pharmacocavernosography (PCG) are at present the most physiological modes of investigation for the use of vasoactive substances. The investigation technique is described and the results of 364 studies are reported. Using PCM, it is possible to quantify venous outflow disturbances and PCG permits them to be localized. In 111 patients, both PCM and PCG were performed, using a new cavernosography pump (AP300, Fresenius). Much lower flow values were found for maintenance flow than had previously been assumed (normal value: less than 15 ml; suspect: 15-30 ml; pathological: greater than 30 ml/min). Pressure drop time was the new measurement used, i.e., the time required for an intracorporal pressure drop from 150 to 50 mmHg. A value of greater than 1 min was established to be the normal value. In cases of pronounced insufficiency of the corpus cavernosum, the pressure drop time amounts to only a few seconds. Evaluation of 200 PCGs showed that an isolated pathological outflow via the deep dorsal vein of the penis could be demonstrated in only 10%, whereas in 72% the deep veins of the penis were involved. These results show that the operative indications for so-called venous outflow disturbances are considerably restricted.

[Pharmaco-cavernosonography and cavernosometry with a new roller pump (AP 300 C)]. / Pharmakokavernosographie und Kavernosometrie mit einer neuen Rollenpumpe (AP 300 C).

The paper gives a report on the first roller pump (AP 300 C) to be serially produced and approved by the Technical Control Board (Technischer Uberwachungsverein, TUV) for cavernosometry and pharmacocavernosography, and on preliminary experience with its use.

[3 years' experience with intracavernous auto-injection therapy]. / Drei Jahre Erfahrungen mit der Schwellkörperautoinjektionstherapie.

In the last 5 years, self-injection of vasoactive drugs into the spongy body of the penis as a treatment for erectile dysfunction has become considerably more widespread. The effects and side-effects of the most frequently used vasoactive substances (papaverine, combinations of papaverine and phentolamine, and prostaglandin E1) are critically evaluated, with particular reference to persistent erection and fibrotic changes in the spongy body of the penis. Over 500 outpatients with ED were examined according to a standard program. Over 90 patients practiced self-injection for an average of 17.6 months (7320 recorded injections). Prostaglandin E1 was used for the initial injection in 200 patients. Persistent erection requiring treatment was reported by only 1 patient. In 45 cases the patients used prostaglandin E1 throughout the treatment. This is currently the vasoactive substance involving least risk in use for the diagnosis and treatment of erectile dysfunction.

[Leakage correction by resection of the deep dorsal penis vein. Assessment of results after 4 years of venous potency surgery]. / "Leakage"-Korrektur durch Resektion der Vena dorsalis penis profunda. Bestandsaufnahme nach 4 Jahren venöser Potenzchirurgie.

Resection of the deep dorsal vein is accepted as a short-term working procedure to reestablish erection in patients suffering from venous leakage. After 4 years with a standardized diagnostic and surgical program for pathologic venous drainage, we are now able to describe the outcome of vein resection in 51 men, whom we have treated 1-4 years before follow-up examination. After a median follow-up of 20 months, long-lasting full erection can be reported in 28 men. Of the remaining 23 men, reestablished erectile function decreased within 1 year in 8, while the operation failed in 15. Whereas the site of pathologic venous drainage and preoperative maintenance flow rates do not influence surgical outcome, a moderate arterial cofactor has become obvious in a large proportion of the unsuccessfully treated cases. In 14 of these men, papaverine testing has now become positive, so that penile self-injection of the drug makes adequate sexual intercourse possible. All patients with a postoperative negative papaverine reaction again have all the signs of a persistent pathological venous drainage; only in 2 of these cases has an ectopic vein been successfully resected.

[Open multicenter study of the differential diagnosis of erectile dysfunction with a papaverine-phentolamine combination (BY023)]. / Offene Multizenterstudie zur Differentialdiagnostik der erektilen Dysfunktion mit einer Papaverin-Phentolamin-Kombination (BY023).

We report the results of an open multicenter clinical trial with 115 patients. The results of a pharmacological test using intracavernously applied mixture of papaverine and phentolamine were compared with the results of a multidisciplinary evaluation of erectile dysfunction. Sensitivity and specificity of our test were determined. The injection of our drug solution caused an increase in tumescence and/or rigidity in all patients. The evaluation of the dose dependent erectile response makes it possible to distinguish between the three main pathogenetic principles: non-vascular, arterial and venous etiology of erectile dysfunction. The pharmacological test requires one to four intracavernous injections of 0.5-3.0 ml of the drug solution (7.5-45 mg papaverine hydrochloride, 0.25-1.5 mg phentolamine mesylate).