Transseptal crossed vasovasostomy.

We examined 11 patients with acquired obstructive azoospermia resulting from irreparable obstruction of 1 vas deferens and severe damage to the contralateral testis. All of the patients underwent transseptal crossed vasovasostomy with no morbidity. Of 8 patients evaluated with postoperative semen analyses 4 (50 per cent) demonstrated total sperm counts of 29 to 205 million and 2 pregnancies (25 per cent) have been reported, with followup ranging from 5 months to 2 years. The etiologies of the vasal obstruction included previous inguinal surgery in 7 patients, vasectomy in 1, ejaculatory duct obstruction in 1, ectopic ureter in 1 and vasal agenesis in 1. Factors leading to loss of the contralateral testis were torsion in 5 patients, mumps orchitis in 2, varicocele in 1, pediatric inguinal herniorrhaphy in 1, epididymal blow out in 1 and unknown in 1. A representative case involving a unilateral ectopic ureter emptying into the seminal vesicle and subsequent contralateral testicular torsion is presented. The results indicate that a transseptal crossed vasovasostomy should be done in patients satisfying the criteria presented.

Studies of the human testis. XVIII. Simultaneous measurement of nine intratesticular steroids: evidence for reduced mitochondrial function in testis of elderly men.

To determine the basis for the decline in testosterone production by the aged testis, intratesticular unconjugated steroids, including testosterone, pregnenolone (3 beta-hydroxy-5-pregnen-20-one), 17 alpha-hydroxypregnenolone (3 beta,17 alpha-dihydroxy-5-pregnen-20-one), dehydroepiandrosterone (3 beta-hydroxy-5-androsten-17-one), androstenediol (5-androstene-3 beta,17 beta-diol), progesterone, 17 alpha-hydroxyprogesterone, androstenedione (4-androstene-3,17-dione), and 17 beta-estradiol, were measured by simultaneous RIAs in 32 previously untreated elderly men (aged 61-85 yr) undergoing orchiectomy as therapy for prostatic carcinoma and 20 young men (aged 25-35 yr) with oligospermia and varicocele. In vitro steroidogenesis using labeled pregnenolone as substrate was also investigated. Serum and intratesticular testosterone levels were lower (P less than 0.05) in aged patients [3.3 +/- 1.9 ng/ml and 0.86 +/- 0.53 microgram/g tissue (mean +/- SD)] than in young men (6.4 +/- 1.9 ng/ml and 1.7 +/- 1.1 microgram/g tissue), while circulating LH levels were higher (P less than 0.05) in elderly men (151 +/- 105 ng/ml) than in the young men (79 +/- 33 ng/ml), indicating that a primary pathological process affects the senescent testis, producing a decline in testosterone production. Study of bioconversion of [3H]pregnenolone to delta 4 steroids, 17 alpha-hydroxysteroids, and C19 steroids as well as analysis of the relative amounts of intratesticular steroids, as determined by RIA, revealed no apparent differences in the process of microsomal steroidogenesis in elderly compared to that in young men. The sum of the nine measured intratesticular steroid concentrations per g tissue wt was significantly lower (P less than 0.05) in aged patients (1.94 +/- 0.93 microgram/g tissue), than in young patients (3.68 +/- 1.90 micrograms/g tissue). The sum of the nine intratesticular steroids measured was positively correlated (P less than 0.01) with circulating LH levels in both patient groups, and the slope of this regression line was 14-fold greater for young men than for elderly men. Since the total concentration of the nine measured steroids reflects the pregnenolone supplied by the mitochondria within Leydig cells, it appears that the decline in Leydig cell function in aged men is attributable to a reduced supply of mitochondrial steroid precursors rather than to an impairment in microsomal steroidogenesis.

Studies of the human testis. XVI. Evaluation of multiple indexes of testicular function in relation to advanced age, idiopathic oligospermia, or varicocele.

Testicular function was evaluated by morphologic and biochemical methods in 11 infertile men with idiopathic oligospermia, 12 men with varicocele, and 14 elderly men. The results indicate the presence of two separate subgroups with idiopathic oligospermia with distinct endocrine and morphologic parameters and suggest the involvement of different pathogenetic factors for testicular disorders among these four groups. Biochemical indexes provide further confirmation of the validity of the Leydig cell cluster index (number of Leydig cell clusters per tubular section) as a useful evaluation guide. The results support the importance of combined studies of circulating hormones and testicular histologic features in providing insight into spermatogenic disorders. Recognition of etiologic diversity is an essential basis for further efforts to delineate and apply current or new hormonal techniques for therapy.

Studies of the human testis. XVII. Gonadotropin regulation of intratesticular testosterone and estradiol in infertile men.

Serum levels of LH and FSH and the intratesticular concentrations of testosterone (T) and estradiol (E) were measured in biopsy tissue from 40 infertile men, aged 21-36 yr, of whom 21 were oligospermic men with varicocele and 19 were men with idiopathic oligospermia. Intratesticular T and E concentrations were negatively correlated (P less than 0.001) with testicular volumes, as measured with a calibrated orchidometer, suggesting that differences in measured intratesticular steroid levels in part reflect altered relative Leydig cell density as seminiferous tubular volume changes. To gather information about the regulation of intratesticular T and E by gonadotropins, we calculated an index of intratesticular steroid content by multiplying steroid concentration by testicular volume and compared these values with circulating LH and FSH levels. Highly significant positive correlations were found between both serum LH and FSH and intratesticular E content and between LH and FSH and intratesticular T content. Multivariant stepwise regression analysis revealed that while serum FSH is a strong predictor of intratesticular E (r = 0.72; P less than 0.001), serum LH is not (partial r = 0.00 when controlling for the influence of FSH). Instead, the apparent relationship between Serum LH and intratesticular E results from the highly positive correlation between serum LH and FSH in the patients studied (r = 0.71; P less than 0.001). Similarly, circulating LH levels are independently related to intratesticular T content (r = 0.67; P less than 0.001), whereas the relationship between FSH and T is indirect (partial r = 0.06 when controlling for the influence of LH). We believe that these associations suggest that the major regulator of intratesticular T content is LH and that FSH may be the important gonadotropin regulating intratesticular E.

The management of urinary fistulas and strictures with percutaneous ureteral stent catheters.

A method is described for percutaneous anterograde introduction of a ureteral stent catheter. The experience and treatment of 5 patients are reported: 2 ureterovaginal fistulas, 2 ureterocutaneous fistulas and 1 ureteral stricture. The capability of the technique to place a stent catheter in the presence of an almost complete separation of the ureter or through ureteral segments deformed by extensive cicatricial changes is emphasized. The method is advocated as a most effective alternative to supravesical drainage in patients with ureteral fistulas and impaired healing potential of ureters devitalized by surgical stripping and/or radiation therapy.

Ureteral obstruction caused by malacoplakia of the bladder over the ureteral orifice.

We have described a case of malacoplakia presenting with uremia in a young, previously healthy black man. Malacoplakia was found in the bladder over both ureteral orifices, causing obstruction. The patient was treated with antibiotics, a percutaneous nephrostomy tube, and finally with transurethral resection of the malacoplakia over the ureteral orifices. The patient's renal function improved dramatically and he is presently asymptomatic.

Surgical treatment of urethral stricture.

We reviewed 59 cases of urethral stricture diseases treated at Charity Hospital of Louisiana in New Orleans from 1965 to 1975 to determine whether surgery was a feasible alternative to repeated urethral dilatations. Five different surgical procedures were done: internal urethrotomy, Johanson-Leadbetter, patch-graft, Turner-Warwich, and dismembered technics. Results of internal urethrotomy were poor, but the other procedures had an overall success of 72 percent.

Epidermal cyst of median raphe.

Cysts of the penis are rare and references to them in standard textbooks are sketchy. A case report of a congenital epidermal cyst of the median raphe of the penis is presented; therapy involved excision of the mass. Review of the literature is given.