Testosterone therapy at the time of vasectomy reversal: Impact on intraoperative decision-making and interpretation of postoperative outcomes.

INTRODUCTION: During vasectomy reversal (VR), accurate intraoperative microscopic assessment of the vasal fluid for sperm presence and quality is essential in determining the indication for a vasovasostomy (VV) or vasoepididymostomy (VE). The use of testosterone therapy (TT), known to supress spermatogenesis, can potentially interfere with this determination. This initiative evaluated the impact of TT on vasal and epididymal fluid sperm characteristics and intraoperative decision-making among men on TT at the time of VR. METHODS: Of 2622 consecutive VRs performed from 2007-2023, patients actively using TT at the time of VR were identified. Details as to the type, dose, and duration of TT were documented. All patients were counselled regarding the impact of TT on spermatogenesis and encouraged to discontinue TT if possible. During VR, vasal and epididymal fluid (as indicated) was sampled and each aspirate underwent microscopic evaluation for sperm presence and quality, and categorized as: motile sperm/intact-non-motile sperm/sperm parts/no sperm. Rates of sperm presence/absence in the vasal/epididymal fluid, frequency of VV/VE, postoperative patency (presence of motile sperm), and semen parameters were compared among patients on TT vs. clinically matched patients not using TT at the time of VR. RESULTS: Among the 2622 VRs reviewed, 54 men (2%) reported using TT at the time of their VR. Despite its impact on spermatogenesis, intraoperative microscopic analysis of the reproductive fluid (vasal or epididymal) identified the presence of sperm in 95% (51/54) of patients. Testis biopsy confirmed sperm production among three patients with absence of sperm within the vasal or epididymal fluid. Rates of VV or VE did not significantly differ among men using TT at the time of VR compared to nonusers. Postoperative patency rates (TT: 78 % vs. no TT: 93%) and mean total motile sperm counts (TMC) were lower among patients using TT at the time of VR (7.9 vs. 28.3, p=0.02). CONCLUSIONS: Use of TT at the time of VR does not appear to impact rates of intraoperative microscopic identification of sperm within the reproductive fluid or the indication for VV/VE. Postoperative patency rates and total motile sperm counts may be lowered by use of TT. Moreover, the determination to the etiology azoospermia postoperatively (production vs. obstruction) may be clouded by the use of TT during VR.

Idiopathic secondary azoospermia occurrence in men with oligospermia over time.

PURPOSE: To investigate the occurrence of idiopathic secondary azoospermia (ISA) in men with oligospermia over time and identify risk factors for ISA in this population. METHODS: This was a retrospective cohort study conducted in a university-affiliated male infertility clinic. A total of 1056 oligospermic men (concentration < 15 million/ml (M/ml) and no azoospermia) with at least two SA done between 2000 and 2019 were included. The primary outcome was the occurrence of ISA by oligospermia severity. RESULTS: In the entire cohort, 31 patients (2.9%) eventually became azoospermic with time. The ≤ 1 M/ml extremely severe oligospermia (ESO) group (283 patients) had significantly higher rates of ISA in each time period compared to the 1-5 M/ml severe oligospermia (SO) (310 patients) and 5-15 M/ml mild oligospermia (MO) (463 patients) groups (p < 0.05 for all comparisons), with rates of 21.1% in the ESO, 4.8% in the SO, and 0% in the MO group (p = 0.02) after 3-5 years, reaching 32% after 5 years in the ESO group compared to no cases in the other two groups (p = 0.006). Parameters shown to predict ISA were initial concentration < 1 M/ml (OR 22.12, p < 0.001) and time interval of > 3 and 5 years (OR 4.83 and 6.84, p = 0.009 and < 0.001, respectively), whereas testosterone levels were negatively associated with ISA (OR 0.88, p = 0.03). CONCLUSIONS: Men with ≤ 1 M/ml, especially those with low testosterone levels, have a dramatically increased chance of becoming azoospermic with time. Therefore, sperm banking should be recommended in these cases. Men with a sperm concentration above 1 M/ml have low chances of becoming azoospermic, even after 3 or more years.

Intra-individual changes in sperm parameters and total motile count with time among infertile men.

BACKGROUND: Paternal age association with sperm parameters has been previously studied, demonstrating a decrease in semen volume, sperm motility, and sperm morphology, but not in sperm concentration. However, scarce data exists on the individual intra-personal changes in semen parameters with time. STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To evaluate the changes in semen parameters and total motile count of infertile men over time. MATERIALS AND METHODS: In this retrospective cohort study, infertile men without known risk factors for sperm quality deterioration and at least two semen analyses done > 3 months apart, between 2005 and 2021, were evaluated. Allocation to groups was according to time between first and last semen analyses - 3-12 months, 1-3 years, 3-5 years, and > 5 years. Basic characteristics and first and last semen analyses were compared. The primary outcome was the change in sperm parameters and the secondary outcome was the occurrence of a total motile count < 5 million in men with an initial total motile count > 10 million. RESULTS: A total of 2018 men were included in the study. The median age at first semen analyses was 36.2 (interquartile range: 32.8-40.1) years and the median time between semen analyses was 323 days (range 90-5810 days). The overall trend demonstrated an increase in concentration in the 3-12 months and the 1-3 years groups, whereas volume, motility, and morphology remained similar in these time groups. Semen analyses done more than 5 years apart showed decreased volume (p < 0.05), motility (p < 0.05) morphology (p < 0.05), and steady sperm concentration. Significant declines in TMCs were found over time (p < 0.001), with 18% and 22% of infertile men with an initial total motile count > 10 million dropping to < 5 million after 3 and 5 years, respectively. The factors independently predictive of total motile count < 5 M in the last semen analyses in men with an initial total motile count of > 10 M in a multivariate logistic regression model were baseline volume (odds ratio 0.80, p = 0.03), baseline total motile count (odds ratio 0.98, p = 0.01) and time between semen analyses - 3-5 years (odds ratio 3.79, p < 0.001) and > 5 years (odds ratio 3.49, p = 0.04) DISCUSSION: Our study demonstrates, at the individual level, that while improvement in sperm concentration is observed in the first year and between 1 and 3 years, possibly due to fertility treatments, fertility-related counseling, and lifestyle changes, semen parameters decline with time over 3 years in individuals. Of significance, close to 22% of men with an initial total motile count > 10 million (a range where spontaneous pregnancy is attainable) declined to < 5 million (a range usually indicating a need for in-vitro fertilization/intracytoplasmic sperm injection) over 5 years. This data could contribute to individualized family planning for infertile men regarding the mode and timing of conception and the need for sperm banking, in order to minimize the need for future fertility treatments.

Temporal Trends in Semen Quality, Hormone Levels, and Substance Use Among Infertile Men in Pre- and Post-Cannabis Legalization Eras in Canada.

Background: The Cannabis Act (Bill C-45) was enacted in 2018, to legalize and regulate the use, production, and sale of nonmedical cannabis in Canada. While public health and safety implications of cannabis legalization have yet to be elucidated, the wide availability of cannabis necessitates health care providers to be knowledgeable about therapeutic potential and side effects of use. This study aimed to examine the temporal trends over two decades and the impact of the Cannabis Act in Canada, implemented in October 2018, on substance use, semen parameters, and testosterone levels of infertile men. Methods: We conducted a retrospective cohort study from a prospectively maintained database of a single infertility clinic. Demographic, fertility, and substance use history were correlated with semen and hormone assessments. Temporal trends in cannabis use and semen quality between 2001 and 2021 were investigated and compared between pre-cannabis legalization eras (PRCL) and post-cannabis legalization eras (POCL). Results: Our cohort included 11,630 patients (9411 PRCL and 2230 POCL). Cannabis use increased by 8.4% per year (p<0.001), while alcohol and tobacco consumption declined (0.8% and 1.5% per year, p<0.05 and p=0.004, respectively). Similar trends were noticed in the POCL, with higher rates of cannabis use (22.4% vs. 12.9%, p<0.001) and decreased tobacco and alcohol intake (15.2% vs. 17.7%, p=0.005 and 50.5% vs. 55.2%, p<0.001, respectively) compared to the PRCL group. Semen concentration was lower in the POCL group (24.8±44.8 vs. 28.7±48.3 million/mL, p=0.03). Testosterone did not differ between the cohorts. Comparison between cannabis users (n=1715) and nonusers (n=9924) demonstrated a slight increase in sperm motility (25.9%±15.3% vs. 23.9%±15.0%, p=0.002) and decreased sperm concentration among users (27.6±53.5 vs. 23.9±15.0 million/mL, p=0.03). Conclusion: A nearly 10% rise in cannabis use in the POCL era was observed among men being investigated for infertility. Our data suggest cannabis use may be associated with an increase in testosterone, slightly improved sperm motility, and decreased sperm concentration.

Improved sperm DNA fragmentation levels in infertile men following very short abstinence of 3-4 hours.

Background: Limited data exists on possible approaches to improve sperm DNA fragmentation index (DFI) when no identifiable cause is found. The effect of short abstinence on sperm parameters has been extensively studied, but rarely reported on the effect on DFI in infertile men. In this study, we aimed to determine whether a second ejaculate provided after very short abstinence demonstrates lower DFI rates in infertile men. Methods: This prospective cohort study was conducted at Mount Sinai Hospital, Toronto, Canada, a tertiary university affiliated hospital. All men having DFI testing in addition to the standard semen analysis were identified via a prospectively collected database. Infertile men were instructed to provide two semen samples 3-4 hours apart (the first sample was given after 2-5 days of abstinence) to test the effect on DFI levels. Data analysis was performed for the comparison of the change in sperm parameters and DFI between samples and between men with DFI above and under 30%. Results: A total of 52 men provided double ejaculates 3-4 hours apart. In the entire group, DFI decreased from 38.9%±21.4% to 35.1%±21.6% in the second sample (P<0.001). Semen volume was lower on the second sample (2.3±1.4 vs. 1.5±0.9 mL, P<0.001), while the remaining parameters did not change. Forty out of 52 patients (76.9%) had improved DFI (average of 6.0±4.0 percentage points). Change in DFI varied with 22/52 (42.3%) and 7/52 (13.5%) of patients found to have decreases in DFI >5% and >10% in the second ejaculate, respectively. For men with DFI of 30-40%, 64% (7/11) of DFIs reduced to the under 30% range. First DFI value was the only parameter associated with DFI decrease to under 30% in multivariate models [odds ratio (OR), 0.62; 95% confidence interval (CI): 0.39-0.98; P=0.04]. Conclusions: This study identified significant improvements in DFI in infertile men providing a second sample after 3-4 hours. Controlled trials are needed to determine if reproductive outcomes are improved using a second ejaculate for infertile men with high initial sperm DFI values.

Survey of the quality and origins of websites on penile low-intensity shockwave therapy in Canada.

INTRODUCTION: The aim of this study was to establish the quality of patient-facing websites advertising low-intensity shockwave therapy (LISWT) for erectile dysfunction (ED) and Peyronie's disease (PD) patients in Canada. METHODS: Canadian websites offering LIWST for ED or PD were identified using online web searches. The characteristics of these websites were reviewed, along with examining the presence of HONCode certification, assigning a brief DISCERN score (a tool designed to evaluate health information online) and readability scores. We also examined the LIWST technology advertised, as well as benefits of LIWST cited by the websites. RESULTS: Twenty-five unique websites linked to 46 clinics were identified and reviewed. Twenty-four percent of websites were run by a urologist. Other specialties offering LISWT included general practitioners, anesthesiologists, naturopaths, nurse practitioners, physiotherapists, and registered massage therapists. Twenty-four percent of the websites advertised the use of a focused shockwave generator. Forty percent of the websites had peer-reviewed references. The average brief DISCERN score was 14 (standard deviation 3.4). There was no association between the physician-or non-physician-led websites and the use of peer-reviewed references, readability scores, the number of clinic locations, or higher brief discern scores. CONCLUSIONS: LISWT is readily advertised online for ED and PD patients in Canada; however, only a minority use a focused shockwave generator. There is a wide diversity of practitioners offering LISWT. Websites offering LISWT are generally of poor quality and do not provide adequate information for patients to make educated treatment decisions.

Intra-individual changes in sperm DNA fragmentation levels over short and long time periods.

PURPOSE: We aimed to examine the longitudinal, intra-personal changes in DNA fragmentation index (DFI) over time. METHODS: Men who performed at least two DFI measurements (using sperm chromatin structure assay (SCSA) between 2003 and 2019 were included in this study and allocated to groups by time between DFI tests: < 1 year, 1-3 years, 3-5 years, and > 5 years. An analysis of DFI change over time according to age groups was additionally performed. Regression models were developed to predict changes in DFI with time. RESULTS: Overall, 225 patients had two or more DFI measurements done at least a month apart (mean of 586.7± 710.0 days). The < 1 year (n = 124) and 1-3 years (n = 68) groups demonstrated decreased DFI levels, while an increase in DFI was shown in 3-5 years (n = 21) and more than 5 years (n = 12) groups - 7.1 ± 14.9%, - 4.5 ± 13.4%, + 3.2 ± 8.4%, and + 10.8 ± 18.0%, respectively, p < 0.001). This trend was similarly shown in age subgroups of under 40 years and 40-50 years at baseline DFI. Linear regression models showed that the factors predictive of DFI increase are baseline DFI and > 3 years between DFI tests. CONCLUSION: This study shows that DFI, in men being investigated for infertility, initially decreases in the first 3 years of follow-up, and then increases over time with the highest increase occurring after 5 years interval (an average increase of 10.8%). Testing infertile men's DFI levels at first evaluation may contribute to personalized consult regarding future reproductive outcomes.

How far will they go? Distance and driving times that north American men travel to see a reproductive urologist.

Male factor infertility affects about 50% of infertile couples. However, male factor infertility is largely under-evaluated due to multiple reasons. This study is to determine the time men travel for fertility evaluation, and factors associated with driving longer. Data from the Andrology Research Consortium were analysed. Driving distance and time were calculated by comparing "patient postal code" with "clinic postal code", then stratified into quartiles. Patients with the longest driving times (> 75th percentile [Q4]) were compared with those having shorter driving times. Logistic regression analysis was used to identify factors associated with longer driving times. Sixteen clinics and 3029 men were included. The median driving distance was 18.1 miles, median driving time was 32 min, and Q4 driving time was 49 min. Factors correlated with having Q4 driving time were age > 30 years, native Indian and Caucasian race, body mass index (BMI) > 30 kg/m2 , history of miscarriage, children with previous partner, self-referral, prior vasectomy, and prior marijuana use. On logistic regression, males aged < 30 years were more likely to be in Q4 for driving time versus older males. Blacks and Asians were less likely to travel further than Caucasians. Overweight/obese men, those having children with previous partner, and with prior vasectomy were more likely to be in Q4 travelling time. Factors correlated with longer driving times include younger age, native Indian and Caucasian race, higher BMI, children with prior partner, and prior vasectomy. These may reflect groups that drive long distances for reproductive care. The study provides an opportunity to better access these groups and minimise their barriers to fertility care.

Predictors of success after bilateral epididymovasostomy performed during vasectomy reversal: A multi-institutional analysis.

INTRODUCTION: Vasectomy reversal (VR) represents an excellent option for paternity in men who desire to expand their family following vasectomy. Traditional VR via vasovasostomy has a success rate upwards of 90% but when sperm or sperm parts are not present in vasal fluid, epididymovasostomy (EV) must be performed instead. Our objective was to determine which factors influence success after bilateral EV. METHODS: A prospectively maintained database with data from the U.S. and Canada was used to identify men who underwent bilateral EV at time of VR. Success was defined as motile sperm in any postoperative semen analyses. Multivariable logistic regression was used to identify predictors of success. RESULTS: A total of 200 men had at least one postoperative semen analysis, and 171 men were included in the analysis. Average age was 44.7 years, with average followup of seven months. Median time elapsed between vasectomy and EV was 15 years (interquartile range [IQR] 10-18). Overall success rate was 50%. Despite the study being adequately powered, factors such as years since vasectomy (odds ratio [OR] 1.01, confidence interval [CI] 0.95-1.06), age (OR 0.96, CI 0.91-1.01), intraoperative presence of motile sperm (OR 0.81, CI 0.41-1.62), and epidydimal fluid characteristics did not predict success. CONCLUSIONS: Bilateral EV at time of VR is successful in 50% of cases in a multi-institutional, North American cohort. Microsurgeons can be reassured that neither time elapsed nor epididymal fluid characteristics negatively impact success rates as long as sperm or sperm parts are present. Surgeons performing VR should be comfortable and prepared to perform EV if indicated.

One size does not fit all: variations by ethnicity in demographic characteristics of men seeking fertility treatment across North America.

OBJECTIVE: To compare racial differences in male fertility history and treatment. DESIGN: Retrospective review of prospectively collected data. SETTING: North American reproductive urology centers. PATIENT(S): Males undergoing urologist fertility evaluation. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Demographic and reproductive Andrology Research Consortium data. RESULT(S): The racial breakdown of 6,462 men was: 51% White, 20% Asian/Indo-Canadian/Indo-American, 6% Black, 1% Indian/Native, <1% Native Hawaiian/Other Pacific Islander, and 21% "Other". White males sought evaluation sooner (3.5 ± 4.7 vs. 3.8 ± 4.2 years), had older partners (33.3 ± 4.9 vs. 32.9 ± 5.2 years), and more had undergone vasectomy (8.4% vs. 2.9%) vs. all other races. Black males were older (38.0 ± 8.1 vs. 36.5 ± 7.4 years), sought fertility evaluation later (4.8 ± 5.1 vs. 3.6 ± 4.4 years), fewer had undergone vasectomy (3.3% vs. 5.9%), and fewer had partners who underwent intrauterine insemination (8.2% vs. 12.6%) compared with all other races. Asian/Indo-Canadian/Indo-American patients were younger (36.1 ± 7.2 vs. 36.7 ± 7.6 years), fewer had undergone vasectomy (1.2% vs. 6.9%), and more had partners who underwent intrauterine insemination (14.2% vs. 11.9%). Indian/Native males sought evaluation later (5.1 ± 6.8 vs. 3.6 ± 4.4 years) and more had undergone vasectomy (13.4% vs. 5.7%). CONCLUSION(S): Racial differences exist for males undergoing fertility evaluation by a reproductive urologist. Better understanding of these differences in history in conjunction with societal and biologic factors can guide personalized care, as well as help to better understand and address disparities in access to fertility evaluation and treatment.

The impact of cannabis use on male sexual function: A 10-year, single-center experience.

INTRODUCTION: Despite increasing consumption rates in much of the world, the impact of cannabis use on various components of male sexual function remains poorly established. The purpose of this study was to further evaluate the relationship between cannabis use and reproductive and sexual function using a large patient cohort from a single academic andrology clinic. METHODS: This is a historical cohort study from a single academic center andrology clinic. Patients from 2008-2017 were included. Intake questionnaires provided baseline demographic information, as well as data regarding substance use and various sexual function parameters. Subjects were categorized as cannabis users or non-users. Cannabis users and non-users were compared using descriptive statistics and Chi-squared tests, and regression analyses were performed to test for association. RESULTS: A total of 7809 males were included in the study; 993 (12.7%) were cannabis users and 6816 (87.3%) were non-users. Cannabis users had a higher mean Sexual Health Inventory for Men (SHIM) score (21.9±4.4 vs. 21.2±4.8, p<0.001) and mean serum total testosterone (13.4±12.0 nmol/L vs. 12.6±11.8 nmol/L, p=0.04) than non-users, although they also had a higher rate of positive Androgen Deficiency in the Aging Male (ADAM) scores (52% vs. 46%, p<0.001). Cannabis users also reported higher sexual frequency compared to non-users (8.8 events/month vs. 7.8 events/month, p<0.05). On multivariate analysis, cannabis use was not associated with SHIM score or serum testosterone concentration. Cannabis use was associated with positive ADAM scores. CONCLUSIONS: Cannabis use was not associated with clinically significant deleterious effects on male sexual parameters in this cohort.

Microscopic evaluation of the vasal fluid for sperm at the time of vasectomy reversal: Do we really need to check?

INTRODUCTION: During vasectomy reversal, intraoperative microscopic evaluation of the vasal fluid for sperm presence/quality can inform of the possibility of epididymal obstruction and need for a vasoepididymostomy (VE). In an effort to validate the utility of microscopic vasal fluid evaluation, the current initiative correlates gross vasal fluid characteristics with sperm presence and quality in a large series of VRs. METHODS: A total of 1267 vasectomy reversals yielded a total of 2522 vasal-units (right/left sides) for analysis. During vasectomy reversal, vasal fluid was sampled from the testicular-end vas and the fluid was characterized (thick-paste/opaque/translucent/clear). Each aspirate underwent microscopic evaluation for sperm quality and was categorized as: motile sperm/intact-non-motile sperm/sperm parts/no sperm. The predictive utility of the gross vasal fluid characteristics with respect to microscopic sperm presence and quality was analyzed. RESULTS: Among the 2522 vasal units analyzed, the side-to-side (left-right) concordance of vasal fluid quality and microscopic vasal sperm quality was 72% and 52%, respectively. When thick-pasty fluid was observed, no sperm were seen in the samples in 53% of cases, and if present, only non-motile sperm were observed. Even in the setting of more favorable vasal fluid characteristics (clear, translucent, and opaque fluid), no sperm were seen in 6-11% of cases, suggesting the possibility of epididymal obstruction and the need for VE. CONCLUSIONS: Intraoperative microscopic evaluation of the vasal fluid for sperm is a necessary practice during vasectomy reversal to optimize surgical outcomes. Reliance on gross vasal fluid characteristics in isolation may lead to unrecognized epididymal obstruction, and the need for a VE, in approximately 11% of cases.

Can video games enhance surgical skills acquisition for medical students? A systematic review.

OBJECTIVE: To systematically assess literature examining the impact of being a gamer or participating in video-game-based training on surgical skills acquisition amongst medical students. BACKGROUND: Video games and surgical procedures share similar skills such as visuospatial abilities and hand-eye coordination; therefore, video games can be a valuable tool for surgical training amongst medical students. However, comprehensive, up-to-date systematic reviews are necessary to confirm. METHODS: A systematic literature search of PubMed, MEDLINE, and EMBASE was performed in April 2020 with no limits set on the date of publication. Observational and randomized controlled studies were included. Quality and bias were assessed using the Newcastle-Ottawa Scale for nonrandomized studies and the Grading of Recommendations Assessment, Development and Evaluation system for randomized studies. RESULTS: A total of 575 participants from 16 studies were included. The most common surgical skills tested were laparoscopy (n = 283, from 8 studies) and robotic surgery (n = 199, from 5 studies). A history of gaming and video-game-based training were associated with improved metrics in robotic surgery and laparoscopy, respectively. Neither was beneficial in arthroscopy or bronchoscopy. Studies using the Wii U and Underground reported significant improvement in overall laparoscopic performance. CONCLUSION: Video games demonstrate potential as adjunctive training in surgical skill education, with a history of gaming and video-game-based training being beneficial in robotic surgery and laparoscopy, respectively. Methodological heterogeneity amongst included studies limit the ability to make conclusive decisions; thus, future studies with long-term follow-up, larger sample sizes, outcomes stratified by video-game characteristics, and up-to-date technology are necessary.

Availability of platelet-rich plasma for treatment of erectile dysfunction and associated costs and efficacy: A review of current publications and Canadian data.

INTRODUCTION: Platelet-rich plasma (PRP) is an increasingly used unconventional treatment option for erectile dysfunction (ED). The validity of PRP as a potential treatment for ED has been proposed in limited human trials. Furthermore, the costs associated with PRP for ED treatment are not readily promoted to patients. The goal of this review was to determine the efficacy and costs of PRP based on currently available literature and Canadian data. METHODS: A comprehensive literature review of available PRP studies and current published data pertaining to cost, availability, and provider clinics globally was conducted using the PubMed database. Physicians offering genital PRP in Canada were identified using internet searches and PRP provider directories. Physician qualifications, clinic locations, and cost information were obtained from provider websites and telephone calls to identified clinics. RESULTS: Availability of PRP injections offered for treating ED is increasing globally. There are currently no peer-reviewed publications to substantiate anecdotal evidence pertaining to the efficacy of PRP as a viable treatment option for ED patients. Our results indicate 19 providers for PRP injections in Canada, costing on average $1777 CAD per injection. No providers were affiliated with academic institutions and providers varied in their area of clinical speciality and training. CONCLUSIONS: To our knowledge, there is currently no research underway investigating the clinical efficacy of PRP for ED treatment despite its broad availability and significant cost. Patients should be informed of the lack of substantiated efficacy and safety data, as the reliability of PRP treatments requires further evaluation.

Non-conventional therapies for Peyronie's disease: what is the evidence for efficacy?

BACKGROUND: In recent years, there has been a surge in non-conventional therapies for Peyronie's disease (PD). With increasing interest in these novel therapies, we conducted a narrative review to explore the efficacy and safety of these treatments to provide clarity for patients and providers. METHODS: A literature search was conducted to find studies describing non-conventional treatments of PD. These treatments were defined as those within the standard of care, including intralesional therapies and surgical options. RESULTS: A total of 14 studies were found. Non-conventional therapies included platelet-rich plasma (PRP), hyaluronic acid (HA), combination therapy of PRP and HA, extracorporeal shockwave therapy (ESWT), stem cell therapy (SCT), mycophenolate mofetil (MMF), and H-100. Most studies were limited to animal models and reported modest improvements in angulation and erectile function. Complication rates and cost of each treatment were infrequently reported. CONCLUSIONS: There is limited evidence supporting non-conventional therapies for PD. As such, they are currently not recommended in clinical guidelines.

A Simple Guide for Simple Orchiectomy in Transition-Related Surgeries.

BACKGROUND: To date, there is no literature on orchiectomy as a stand-alone procedure in the transgender surgical context. AIM: To propose a simple guide to aid health-care professionals caring for transgender and gender nonconforming individuals seeking bilateral simple orchiectomy. METHODS: We use expert opinion to provide a novel guide for simple orchiectomy in the transition-related context for health-care professionals caring for transgender and gender nonconforming individuals. A review of relevant literature was also performed focusing on simple orchiectomy and vaginoplasty surgeries for transgender and gender nonconforming individuals. MAIN OUTCOME MEASURE: We describe the indications, surgical approach, preoperative and postoperative assessment, and the risks and benefits of bilateral simple orchiectomy in the context of gender surgery. RESULTS: This article is the first, to our knowledge, to describe a structured guide to bilateral simple orchiectomy in the context of gender surgery for health-care professionals caring for transgender and gender nonconforming individuals. CLINICAL IMPLICATIONS: Bilateral scrotal orchiectomy is a simple surgical procedure that has a defined role in the surgical management of many transgender individuals. STRENGTHS AND LIMITATIONS: This article provides an approach to simple orchiectomy in the context of gender surgery for health-care professionals. Only guidelines written in English were included. The quality of the included guidelines was not evaluated, but this was beyond the scope of this review. CONCLUSION: We present a novel guide for health-care professionals caring for transgender and gender nonconforming individuals seeking bilateral simple orchiectomy in the context of gender surgery. Francis C, Grober E, Potter E, et al. A Simple Guide for Simple Orchiectomy in Transition-Related Surgeries. Sex Med Rev 2020;8:492-496.

Initial clinical experience with simple orchiectomy procedures in the context of transition-related surgeries.

Background : One of the more common procedures conducted through the transition-related surgeries (TRSs) program is simple orchiectomy. Due to the relative novelty of TRS in Canada, national perioperative guidelines for simple orchiectomy in the context of TRS are yet to be developed. Furthermore, there is a void in the literature describing the indications and outcomes of simple orchiectomy among transgender individuals. Aims : This study is the first descriptive case series in Canada highlighting our experience with simple orchiectomy in the context of TRS. Methods : This study retrospectively assessed data from electronic patient medical records of 16 patients who had simple orchiectomy procedures at Women's College Hospital in Toronto, Canada from August 2018 to April 2019. Data were collected using a standardized data collection form which includes patient baseline demographic data, and objective and subjective clinical outcomes. Results : Mean age at surgery was 32.6 ± 10.4 years and mean time to surgery following the initial approval of referral was 9.9 ± 8.5 weeks. A majority of referrals (n = 13, 81.3%) were from urban areas with specialized TRS services. The average time on hormones was 3.1 ± 1.9 years. In terms of post-surgical complications at the 30-day day follow-up visit, there was a single post-operative sperm granuloma reported. There were no other complications identified post-surgery in our patient case series. Discussion : In Ontario, the growing recognition of the benefits of TRS has led to the development of a publicly funded pathway to TRS surgery. This study is the first assessment of simple orchiectomy performed for TRS in Canada, and it has shown that the procedure is safe and reproducible. Due to its benefits, coordinating safe and efficient access of care for this procedure should be an important action item for health systems. This study is limited by its low sample size.