Does Testicular Sperm Improve Intracytoplasmic Sperm Injection Outcomes for Nonazoospermic Infertile Men with Elevated Sperm DNA Fragmentation? A Systematic Review and Meta-analysis.

CONTEXT: For nonazoospermic infertile men with elevated sperm DNA fragmentation (SDF), it is unclear whether the use of testicular sperm for intracytoplasmic sperm injection (ICSI) may offer advantages over ejaculated sperm. OBJECTIVE: To determine whether ICSI outcomes (fertilisation rate, pregnancy rate, miscarriage rate, and live birth rate) are better with testicular sperm than with ejaculated sperm for men with elevated SDF. EVIDENCE ACQUISITION: We searched the Cochrane Central, EMBASE, MEDLINE, Web of Science, and Scopus databases (1946-2023) in February 2023 for relevant human comparative studies according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. EVIDENCE SYNTHESIS: Out of 2032 records, nine studies (more than 536 participants, mean age range 33-40.5 yr for males and 30.1-37.9 yr for females) were included in the systematic review and meta-analysis. Pooled estimates demonstrated that the pregnancy rate was significantly higher with testicular than with ejaculated sperm according to a sperm chromatin structure assay (SCSA)/sperm chromatin integrity test (SCIT) (odds ratio [OR] 2.51; p = 0.001) and terminal deoxynucleotidyl transferase dUTP nick-end labelling (TUNEL) assays (OR 3.65; p = 0.005). The live birth rate was significantly higher according to SCSA/SCIT (OR 2.59; p = 0.005). There were no significant differences in the fertilisation rate or miscarriage rate. CONCLUSIONS: Although significant improvements in pregnancy and live birth rates were observed with testicular sperm, the strength of findings is limited by availability and quality of evidence, both of which undermine recommendations for clinical practice. Standardised randomised controlled trials are needed to definitively determine whether the use of testicular sperm improves ISCI outcomes for men with high SDF. Until such evidence exists, ICSI after testicular sperm extraction or aspiration should not be routinely performed. PATIENT SUMMARY: Our review showed that for infertile men with a high level of DNA damage in their sperm, use of sperm extracted from the testicles may give better results than ejaculated sperm for a particular IVF (in vitro fertilisation) technique. However, there is a lack of high-quality data.

Are sex disparities in COVID-19 a predictable outcome of failing men's health provision?

The COVID-19 pandemic, caused by the SARS-CoV-2 coronavirus, has taken a catastrophic toll on society, health-care systems and the economy. Notably, COVID-19 has been shown to be associated with a higher mortality rate in men than in women. This disparity is likely to be a consequence of a failure to invest in men's health, as it has also been established that men have a lower life expectancy and poorer outcomes from non-communicable diseases than women. A variety of biological, social and economic factors have contributed to the sex disparities in mortality from COVID-19. A streamlined men's health programme - with the urologist as the gatekeeper of men's health - is needed to help prevent future tragedies of this nature.

Single-Center Experience with Three Metallic Ureteral Stents (Allium® URS, Memokath™-051, and Resonance®) for Chronic Ureteral Obstruction.

Purpose: Patients with chronic ureteral obstruction (CUO) are traditionally managed with polymer stents/nephrostomy. However, these are prone to failure and require regular exchange. This study evaluates the efficacy of Allium® URS, Memokath™-051, and Resonance® metallic ureteral stents in managing patients with CUO. Methods: Following institutional approval (Imperial College Healthcare NHS Trust, UK, Registration Number SPS_045), operating theater records were reviewed to identify patients with CUO managed with Allium® URS, Memokath™-051, or Resonance® metallic ureteral stents (September 2015/July 2020). Baseline patient variables (age, gender, underlying etiology, and American Society of Anesthesiologists score) and stricture characteristics (length, level, and continuity) were extracted. Intraoperative and postoperative clinical and radiologic assessments at 6 weeks, 3 months, and then every 6 months, as well as any emergency attendances, were reviewed. The primary outcome was duration of functional stent survival. Secondary outcomes included intraoperative placement success and, as an estimate of renal function, mean serum creatinine over time. Results: One hundred twenty-nine stent insertion episodes (SIEs) (Allium® URS: 23; Memokath™-051: 48; Resonance®: 58) occurred in 76 patients (Allium® URS: 16; Memokath™-051: 31; Resonance®: 29). Kaplan-Meier estimates demonstrated that Resonance® provided superior functional stent survival. Overall median actual functional stent follow-up was 11.4 months for Allium® URS, 5.5 months for Memokath™-051, and 11.7 months for Resonance®. 47.8% of Allium® URS (11/23), 64.6% of Memokath™-051 (31/48), and 19% of Resonance® SIEs (11/58) failed. No Resonance® SIEs for benign indication ended in failure. Intraoperative placement success was high (Allium® URS: 95.7%; Memokath™-051 and Resonance®: both 100%). In the first year following SIE, creatinine ranged from +21.3% to +46.7% for Allium® URS, -7.8% to +8.9% for Memokath™-051, and -9.4% to +27.3% for Resonance®. Conclusions: Allium® URS, Memokath™-051, and Resonance® metallic ureteral stents are all viable management options of CUO. In this cohort, Resonance® provided superior functional stent survival. Prospective large-scale comparisons with long-term follow-up are needed to help inform stent choice dependent on individual patient and stricture characteristics.

Anal squamous cell carcinoma in a high HIV prevalence population.

Anal Squamous Cell Carcinoma (ASCC) is a rare cancer that has a rapidly increasing incidence in areas with highly developed economies. ASCC is strongly associated with HIV and there appears to be increasing numbers of younger male persons living with HIV (PLWH) diagnosed with ASCC. This is a retrospective cohort study of HIV positive and HIV negative patients diagnosed with primary ASCC between January 2000 and January 2020 in a demographic group with high prevalence rates of HIV. One Hundred and seventy six patients were included, and clinical data was retrieved from multiple, prospective databases. A clinical subgroup was identified in this cohort of younger HIV positive males who were more likely to have had a prior diagnosis of Anal Intraepithelial Neoplasia (AIN). Gender and HIV status had no effect on staging or disease-free survival. PLWH were more likely to develop a recurrence (p < 0.000) but had a longer time to recurrence than HIV negative patients, however this was not statistically significant (46.1 months vs. 17.5 months; p = 0.077). Patients known to have a previous diagnosis of AIN were more likely to have earlier staging and local tumour excision. Five-year Disease-Free Survival was associated with tumour size and the absence of nodal or metastatic disease (p < 0.000).

A Comparison of Prostate Cancer Detection between Visual Estimation (Cognitive Registration) and Image Fusion (Software Registration) Targeted Transperineal Prostate Biopsy.

PURPOSE: We compared clinically significant prostate cancer detection by visual estimation and image fusion targeted transperineal prostate biopsy. MATERIALS AND METHODS: This multicenter study included patients with multiparametric magnetic resonance imaging lesions undergoing visual estimation or image fusion targeted transperineal biopsy (April 2017-March 2020). Propensity score matching was performed using demographics (age and ethnicity), clinical features (prostate specific antigen, prostate volume, prostate specific antigen density and digital rectal examination), multiparametric magnetic resonance imaging variables (number of lesions, PI-RADS® score, index lesion diameter, whether the lesion was diffuse and radiological T stage) and biopsy factors (number of cores, operator experience and anesthetic type). Matched groups were compared overall and by operator grade, PI-RADS score, lesion multiplicity, prostate volume and anesthetic type using targeted-only and targeted plus systematic histology. Multiple clinically significant prostate cancer thresholds were evaluated (primary: Gleason ≥3+4). RESULTS: A total of 1,071 patients with a median age of 67.3 years (IQR 61.3-72.4), median prostate specific antigen of 7.5 ng/ml (IQR 5.3-11.2) and 1,430 total lesions underwent targeted-only biopsies (visual estimation: 372 patients, 494 lesions; image fusion: 699 patients, 936 lesions). A total of 770 patients with a median age of 67.4 years (IQR 61-72.1), median prostate specific antigen of 7.1 ng/ml (IQR 5.2-10.6) and 919 total lesions underwent targeted plus systematic biopsies (visual estimation: 271 patients, 322 lesions; image fusion: 499 patients, 597 lesions). Matched comparisons demonstrated no overall difference in clinically significant prostate cancer detection between visual estimation and image fusion (primary: targeted-only 54% vs 57.4%, p=0.302; targeted plus systematic 51.2% vs 58.2%, p=0.123). Senior urologists had significantly higher detection rates using image fusion (primary: targeted-only 45.4% vs 63.7%, p=0.001; targeted plus systematic 39.4% vs 64.5%, p <0.001). CONCLUSIONS: We found no overall difference in clinically significant prostate cancer detection, although image fusion may be superior in experienced hands.

Value of systematic sampling in an mp-MRI targeted prostate biopsy strategy.

The clinical utility of systematic prostate biopsy in addition to multi-parametric magnetic resonance imagining (mp-MRI) targeted biopsy pathways remains unclear. Despite radiological advancements in mp-MRI and utilisation of international standardised reporting systems (i.e., PI-RADS, LIKERT), undetected clinically significant prostate cancer (csPCa) on imaging persists. This has prevented the widespread adoption of an exclusively targeted biopsy approach. The current evidence on csPCa cancer detection rates in mp-MRI targeted alone and combined with a non-targeted systematic sampling is presented. Arguments for and against routine limited systematic sampling as an adjunct to an mp-MRI targeted biopsy are discussed. Our review will report the clinical utility of a combined sampling strategy on csPCa detection rate. The available evidence suggests that we are yet to reach a stage where non-targeted systematic prostate biopsy can be routinely omitted in mp-MRI targeted prostate biopsy pathways. Research should focus on improving the accuracy of mp-MRI, prostate biopsy techniques, and in identifying those men that will most benefit from a combined prostate biopsy. Such strategies may help future urologists reduce the burden of non-targeted cores in modern mp-MRI prostate biopsy pathways.

A systematic review of salvage focal therapies for localised non-metastatic radiorecurrent prostate cancer.

Although radiotherapy to the prostate for cancer is effective, recurrence occurs in 10-15% within 5 years. Traditional salvage treatments for men with radiorecurrent prostate cancer comprise of watchful waiting (WW) with or without androgen deprivation therapy (ADT) or radical prostatectomy (RP). Neither strategy provides ideal therapeutic ratios. Salvage focal ablation is an emerging option. We performed a systematic review of the Medline and Embase databases for studies reporting outcomes of focal salvage brachytherapy (sBT), cryotherapy (sCT) or high-intensity focused ultrasound (sHIFU) for radiorecurrent prostate cancer (conception to April 2019). Results were screened for inclusion against predetermined eligibility criteria. Certain data were extracted, including rates of biochemical disease-free survival (BDFS), metastasis, conversion to second-line therapies and adverse events. Of a total 134 articles returned from the search, 15 studies (14 case series and 1 comparative study) reported outcomes after focal sBT [5], sCT [7] and sHIFU [3]. Cohort size varied depending on intervention, with eligible studies of sBT being small case series. Median follow-up ranged from 10 to 56 months. Although pre-salvage demographics were similar [median age range, 61-75 years; prostate-specific antigen (PSA) range, 2.8-5.5 ng/mL], there was heterogeneity in patient selection, individual treatment protocols and outcome reporting. At 3 years, BDFS ranged from 61% to 71.4% after sBT, 48.1-72.4% after sCT and 48% after sHIFU. Only studies of sCT reported 5-year BDFS, which ranged from 46.5% to 54.4%. Rates of metastasis were low after all salvage modalities, as were conversion to second-line therapies (although this was poorly reported). Grade 3 adverse events were rare. This systematic review indicates that salvage focal ablation of radiorecurrent prostate cancer provides acceptable oncological outcomes and is well tolerated. Unfortunately, there is heterogeneity in the study design of existing evidence. Level 1 research comparing salvage focal therapies to existing whole-gland strategies is needed to further establish the role of these promising treatments.

Likert vs PI-RADS v2: a comparison of two radiological scoring systems for detection of clinically significant prostate cancer.

OBJECTIVE: To compare the clinical validity and utility of Likert assessment and the Prostate Imaging Reporting and Data System (PI-RADS) v2 in the detection of clinically significant and insignificant prostate cancer. PATIENTS AND METHODS: A total of 489 pre-biopsy multiparametric magnetic resonance imaging (mpMRI) scans in consecutive patients were subject to prospective paired reporting using both Likert and PI-RADS v2 by expert uro-radiologists. Patients were offered biopsy for any Likert or PI-RADS score ≥4 or a score of 3 with PSA density ≥0.12 ng/mL/mL. Utility was evaluated in terms of proportion biopsied, and proportion of clinically significant and insignificant cancer detected (both overall and on a 'per score' basis). In those patients biopsied, the overall accuracy of each system was assessed by calculating total and partial area under the receiver-operating characteristic (ROC) curves. The primary threshold of significance was Gleason ≥3 + 4. Secondary thresholds of Gleason ≥4 + 3, Ahmed/UCL1 (Gleason ≥4 + 3 or maximum cancer core length [CCL] ≥6 or total CCL≥6) and Ahmed/UCL2 (Gleason ≥3 + 4 or maximum CCL ≥4 or total CCL ≥6) were also used. RESULTS: The median (interquartile range [IQR]) age was 66 (60-72) years and the median (IQR) prostate-specific antigen level was 7 (5-10) ng/mL. A similar proportion of men met the biopsy threshold and underwent biopsy in both groups (83.8% [Likert] vs 84.8% [PI-RADS v2]; P = 0.704). The Likert system predicted more clinically significant cancers than PI-RADS across all disease thresholds. Rates of insignificant cancers were comparable in each group. ROC analysis of biopsied patients showed that, although both scoring systems performed well as predictors of significant cancer, Likert scoring was superior to PI-RADS v2, exhibiting higher total and partial areas under the ROC curve. CONCLUSIONS: Both scoring systems demonstrated good diagnostic performance, with similar rates of decision to biopsy. Overall, Likert was superior by all definitions of clinically significant prostate cancer. It has the advantages of being flexible, intuitive and allowing inclusion of clinical data. However, its use should only be considered once radiologists have developed sufficient experience in reporting prostate mpMRI.

Metallic Ureteric Stents in Malignant Ureteric Obstruction: A Systematic Review.

The effectiveness of metallic stents in the management of malignant ureteric obstruction is unclear. This systematic review evaluates the use of 4 commercially available metallic stents (Resonance, Memokath 051, Uventa, and Allium URS). Twenty-one studies met eligibility criteria. Overall success rates ranged from 88% for the Allium stent to 65% for Memokath 051. Resonance demonstrated the lowest migration rate (1%). Uventa had the lowest obstruction rate (6%). Metallic ureteric stents offer a viable alternative in the management of malignant ureteric obstruction. Further high quality studies are required to assess cost effectiveness and refine specific indications based on etiology and level of the ureteric obstruction.