Open epididymal sperm aspiration (OESA): minimally invasive surgical technique for sperm retrieval.

OBJECTIVES: Male infertility caused by irreparable obstructive azoospermia is widely treated with MESA (Microsurgical Epididymal Sperm Aspiration) or TESE (Testicular Sperm Extraction) or PESA (Percutaneous Epididymal Sperm Aspiration) followed by an Intracytoplasmatic Spermatozoa Injection (ICSI). For each procedures are claimed advantages and disadvantages. Aim of this work is to describe our technique (OESA) for sperm retrieval reporting the results. METHODS: From 1998 to 2003 153 sperm retrieval procedures in azoospermic patients were performed. The technique consists in a small (1 cm.) surgical incision of scrotal wall under local or spinal anaesthesia. After inspecting the intrascrotal component to record the status of the epididymis and of the testicle, epididymal sperm aspiration was performed in the most appropriate site with 18 gauge needle. The aspirated spermatozoa were used immediately after aspiration not being permitted in our Institute cryopreservation. When no sperms were found TESE was performed. RESULTS: In 78 cases aspiration from epididymis was successful (OESA). In the other patients (75) TESE was performed. Higher count of spermatozoa were retrieved in all cases of OESA. Pregnancy rate was 26.6% for OESA and 6.4% for TESE. No complications occurred. CONCLUSIONS: This technique is very simple and easy allowing to obtain the advantages of microsurgical techniques (mainly choice of the most appropriate site of aspiration and immediate haemostasis if needed) with minimal invasivity (avoiding epididymal surgical incision). Moreover if OESA does not allow sperm extraction is possible to perform immediately TESE.

Open epididymal sperm aspiration (OESA): minimally invasiva surgical techique for sperm retrieval

OBJETIVO: La infertilidad masculina causada por azoospermia obstructiva irreparable se trata ampliamente con aspiración epididimaria microquirúrgica (MESA- microsurgical Epiddymal sperm Aspiration) o percutánea (PESA- Percutaneous Epididymal Sperm Aspiration), o con extracción testicular (TESE- Testicular Sperm Extraction) seguida por ICSI (Intracytoplasmatic spermatozoa injection). Cada uno de los procedimientos tiene ventajas e inconvenientes. El objetivo del presente artículo es describir nuestra técnica para la obtención de espermatozoides (OESA- Open Epididymal Sperm Aspiration) y comunicar nuestros resultados. MÉTODOS: Entre 1998 y 2003 se realizaron 153 procedimientos para la obtención de espermatozoides. La técnica consiste en una pequeña incisión escrotal (1 cm) bajo anestesia local o espinal. Después de inspeccionar el contenido escrotal para evaluar el estado del epidídimo y del testículo se procede a la aspiración epididimaria en el sitio más apropiado con una aguja del 18 gauge. Los espermatozoides aspirados se utilizan inmediatamente después de la aspiración porque nuestra institución no permite la criopreservación. Cuando no se encuentran espermatozoides se procede a TESE. RESULTADOS: La aspiración epididimaria fue satisfactoria en 78 casos. En los otros pacientes (75) se realizó TESE. En los casos de OESA se obtuvo un número mayor de espermatozoides. La tasa de embarazos fue del 26,6% con OESA y 6,4 % con TESE. No hubo complicaciones. CONCLUSIONES: Esta técnica es muy simple y fácil de realizar, permitiendo conseguir las ventajas de las técnicas microquirúrgicas (principalmente la elección del sitio más apropiado para la aspiración y hemostasia inmediata cuando es necesario) con mínima invasión (evitando la incisión quirúrgica del epidídimo). Además, si la OESA no obtiene espermatozoides es posible realizar inmediatamente TESE

OBJECTIVES: Male infertility caused by irreparable obstructive azoospermia is widely treated with MESA (Microsurgical Epididymal Sperm Aspiration) or TESE (Testicular Sperm Extraction) or PESA (Percutaneous Epididymal Sperm Aspiration) followed by an Intracytoplasmatic Spermatozoa Injection (ICSI). For each procedures are claimed advantages and disadvantages. Aim of this work is to describe our technique (OESA) for sperm retrieval reporting the results. METHODS: From 1998 to 2003 153 sperm retrieval procedures in azoospermic patients were performed. The technique consists in a small (1 cm.) surgical incision of scrotal wall under local or spinal anaesthesia. After inspecting the intrascrotal component to record the status of the epididymis and of the testicle, epididymal sperm aspiration was performed in the most appropriate site with 18 gauge needle. The aspirated spermatozoa were used immediately after aspiration not being permitted in our Institute cryopreservation. When no sperms were found TESE was performed. RESULTS: In 78 cases aspiration from epididymis was successful (OESA). In the other patients (75) TESE was performed. Higher count of spermatozoa were retrieved in all cases of OESA. Pregnancy rate was 26,6% for OESA and 6,4% for TESE. No complications occurred. CONCLUSIONS: This technique is very simple and easy allowing to obtain the advantages of microsurgical techniques (mainly choice of the most appropriate site of aspiration and immediate haemostasis if needed) with minimal invasivity (avoiding epididymal surgical incision). Moreover if OESA does not allow sperm extraction is possible to perform immediately TESE

Neoadiuvant treatment with intravesical interleukin-2 for recurrent superficial transitional bladder carcinoma Ta-T1/G1-2.

The aim of this study was to evaluate the direct action of IL-2 on recurrent superficial transitional bladder carcinoma and the effect on recurrence rate. 27 patients were submitted to neoadjuvant treatment by intra-vesical instillation of recombinant IL-2 and to transurethral resection. We did not observe any effect on neoplasms but the recurrence rate was less than the expected one. It is possible that treatment of bladder carcinoma with intra-vesical instillation of IL-2 may promote immuno-prophilaxis.

Low-grade left varicocele in patients over 30 years old:the effect of spermatic vein ligation on fertility.

OBJECTIVES: To evaluate the effect of spermatic vein ligation in patients over 30 years old and with low-grade left varicocele, and thus help to establish whether such patients might benefit from surgery. PATIENTS AND METHODS: A randomized study was conducted on 68 infertile patients (30-38 years old) with evidence of sperm abnormalities and who had low-grade varicocele (grade I according to Hirsch), comparing left spermatic vein ligation with no treatment. The outcome was assessed by standard sperm analysis and eventual paternity. RESULTS: There was no improvement in sperm quality in either of the groups one year after surgery, and no significant difference in paternity. CONCLUSIONS: Left spermatic vein ligation for low-grade varicocele in patients more than 30 years old cannot be recommended.

Conservative surgery in small renal tumors: our experience.

OBJECTIVE: We evaluated the effectiveness and safety of the nephron-sparing surgery in the treatment of low stage, easily accessible renal cell carcinoma versus radical nephrectomy, the "gold standard" therapy according to data in the literature. METHODS: From 1988 to 1996, 36 patients (11 women and 25 men; mean age 59.6 years) with a small (< or = 5 cm) solitary renal cell carcinoma and a normal contralateral kidney were submitted to tumor enucleation through a transperitoneal approach. Hot ischemia was performed in 14 cases for an average of 16 minutes. In order to control the extent of surgical resection, in all cases frozen step sections of surgical margins were submitted to histopathological examination. The mean follow-up was 40 months. RESULTS: Complete local resection of the renal cell carcinoma was performed in all patients, with preservation to the furthest extent of the parenchyma not affected by the disease. Renal function remained normal in all cases. Bleeding was easily controlled without clamping the renal artery in 22 cases, while hot renal ischemia was necessary in the remaining 14 cases (mean ischemia time 16 minutes). Average blood loss was 450 cc. Frozen sections of the surgical margins were negative in all cases. Only one case of local recurrence was observed one year after the nephron-sparing operation, which was treated by radical nephrectomy. All patients are alive and cancer-free today. CONCLUSIONS: Elective tumor enucleation for low stage and easily accessible renal cell carcinoma can be performed safely and with a low risk of local recurrence. Definition of the appropriate pre-operative diagnostic approach, maximum tumor size, surgical mini-invasive approach and a longer follow-up are required before this procedure can be widely recommended.

Bilateral varicocele: impact of right spermatic vein ligation on fertility.

The most frequent cause of male infertility is left varicocele. The surgical or laparoscopic approach for spermatic vein ligation is considered the best method of treatment. The approach to a clinically significant left varicocele associated with a right varicocele (frequently of a smaller size) is not univocal. We analyzed the seminal responses obtained in 65 patients with bilateral varicocele (grades 2 to 3 on the left side and grade 1 on the right side) assigned randomly to undergo unilateral or bilateral ligation. There were no significant differences between the 2 groups with regard to seminal recovery.

Comparative effects of alfuzosin versus Serenoa repens in the treatment of symptomatic benign prostatic hyperplasia.

OBJECTIVES: Sixty-three patients suffering from benign prostatic hyperplasia (BPH) entered a double-blind, comparative, parallel-groups study lasting 3 weeks, carried out to compare the efficacy and safety of alfuzosin 2.5 mg tid (n = 32) vs serenoa repens 160 mg bid (n = 31) in BPH. METHODS: Efficacy was assessed both on clinical symptoms (Boyarsky's scale, visual analogue scale, clinical global impression), urinary flow rates (uroflowmetry) and residual urinary volume (transabdominal ultrasound). Events and reported signs were recorded throughout the entire study. RESULTS: Statistically significant and clinically relevant differences were found between the two treatments in favour of alfuzosin for Boyarsky's total score (decrease from 9.6 +/- 3.0 to 5.9 +/- 3.0, 38.8% for alfuzosin and from 9.3 +/- 2.5 to 6.8 +/- 2.8, 26.9% for serenoa repens) and obstructive score (decrease from 4.9 +/- 2.1 to 3.0 +/- 1.9, 37.8% for alfuzosin; from 4.4 +/- 1.7 to 3.4 +/- 1.8, 23.1% for Serenoa repens; p = 0.01 for both). Clinically relevant differences were found between the two treatments for visual analogue scale and overall clinical impression at the end of the study. Furthermore, the increase in quality of micturition was better with alfuzosin. The proportion of responders (increase on day 21 in peak flow rate of at least 25% relative to the baseline values) was in favour of alfuzosin (71.8% and 48.4% for alfuzosin and Serenoa repens, respectively; p = 0.057). Both treatments were well tolerated. No patient treated with alfuzosin complained of any adverse event at any time during the study. One patient in the Serenoa group complained of mild pruritus which cleared spontaneously. Systolic, diastolic blood pressure and heart rate did not show any clinically relevant change during treatment with alfuzosin. CONCLUSIONS: The findings confirm the efficacy and safety of alfuzosin in symptomatic BPH and indicate the superiority of alfuzosin over Serenoa repens in the treatment of urinary signs and symptoms of BPH.

[Reevaluation of impotence following TURP]. / Rivalutazione dell'impotenza erigendi insorgente dopo TURP.

Impotence following transurethral prostatectomy is one of the main complications that still has a controversial origin. Many authors, reporting their experience, have demonstrated that this complication is due both to psychological problems and to organic causes. We review retrospectively 68 patients submitted to TURP. All patients (53 to 65 years old) were asked about their sexual efficiency before and after TURP, 6-12 months after surgery. Those who complained of erectile failure have been studied using this diagnostic protocol: plasmatic dosage of FSH, LH, Testosterone and Prolactin; penile Doppler ultrasound, polysomnographic recording of nocturnal tumescence test (NPT Test); angiography of the pudenda arteries has been performed in only one patient with pathological penile Doppler ultrasound (IPP < 0.7). The examinations demonstrated an organic impotence not secondary to vascular damage in 10 patients following surgery (incidence 15.6%). Our high incidence of this complication is, according to us, significant even if it should be considered in excess since in our study we used anamnestic criteria alone in the evaluation of sexual efficiency before surgery. In 1984 T. Lue demonstrated, through accurate histological preparations, that cavernous nerves run contiguously to the prostatic capsule at 5 and 7 hours in correspondence of the glandular apex. He suggested that impotence following TURP is due to iatrogenic lesions of these nervous structures during endoscopic resection. Similarly, we have conducted an anatomopathological study on prostate specimens taken from autopsies. We demonstrated the presence of nervous structure contiguously to the prostatic capsule in correspondence with the glandular apex. Thus, impotence following TURP probably occurs after an iatrogenic heat lesion of the periprostatic plexus caused by resection.(ABSTRACT TRUNCATED AT 250 WORDS)

[Experience with the determination of LDH-X in seminal plasma as diagnostic and prognostic factor in varicocele]. / Experiencias sobre la dosificación de la LDH-X en el plasma seminal como factor diagnóstico y pronóstico en el varicocele.

We studied the biochemical and functional properties of semen to evidence markers of diseases concerning fertility. We examined LDH especially isoenzyme LDHx in semen of patients with varicocele, diagnosed by clinical evaluation and doppler velocimetry. The existence of this enzyme is closely associated with active spermatogenesis. In conditions of testicular disease as in varicocele, a major diffusion of LDHx into the seminal plasma may occur as a reaction of the seminiferous epithelium. We evaluated 50 patients (10 normospermic patients, 20 affected by varicocele, 9 azoospermic patients, 11 oligo-astenospermic patients). We observed that the LDHx concentration in seminal plasma is proportional to the severity of the clinical damage. The follow up after spermatic vein ligation of the patients affected by varicocele demonstrated that these patients improved to the normal clinical parameters, associated to a decrease of the concentration of LDHx values.

Deep dorsal vein arterialization in vasculogenic impotence: our experience.

We describe our experience of surgical therapy for vasculogenic impotence, using a technique of arterialization of the deep dorsal vein. This technique was chosen because vascular anastomosis can easily be performed, and because of the possibility of inducing haemodynamic mechanisms which favour the maintenance of rigidity, using venous arterialization. The operation was performed on 22 selected subjects with positive results. 12 patients (55%) reported erections which enabled them to have satisfactory sexual relations one year after follow-up. From the data reported we can conclude that penile revascularization, using the technique of arterialization of the deep dorsal vein, in well selected cases of vasculogenic impotence, should be considered a valid alternative to a penile prosthesis implant.

Postpubertal cryptorchidism: review and evaluation of the fertility.

We assessed the fertility of 91 patients affected by unilateral cryptorchidism who were subjected to postpubertal orchidopexy in the last 15 years. All cases were clinically examined, evaluated by semen analysis and Doppler ultrasound of the spermatic artery. Twenty-two patients underwent testicular biopsy. The results indicate that orchidopexy is not the best treatment for postpubertal cryptorchid patients. After orchidopexy, 83.5% of patients were azoospermic or oligospermic, with or without asthenospermia.

[Evaluation of the activity of the bladder detrusor muscle and analysis of bladder function in subjects with diabetes mellitus under insulin treatment]. / Valutazione dell'attività del muscolo detrusore della vescica ed analisi della funzione vescicale in soggetti affetti da diabete mellito in trattamento insulinico.

The present report concerns investigations of detrusor muscle adrenergic innervations in patients affected by bladder neuropathy secondary to diabetes without obstructive disturbances. Detrusor contractile activity evoked by NE is markedly reduced which can probably be attributed to receptor deficit. Urodynamic evaluation demonstrated a prevalence of sensory peripheral neuropathy than a motor conduction abnormality. In vitro study demonstrated that motor conduction abnormality of detrusor contractile activity is present early without bladder disturbances. Therefore early urodynamic measurements are necessary to evaluate bladder dysfunction and neuropathy in diabetic patients.

Plasma sex hormone binding globulin in patients with prostatic carcinoma.

The concentrations of sex hormone binding globulin (SHBG) were measured in the plasma of 56 men, who were 47 to 85 years of age, by time-resolved immunofluorometric assay with a monoclonal antibody. Twenty-five of the men had untreated carcinoma of the prostate and 17 had untreated prostatic hyperplasia. There were 14 healthy control subjects. SHBG levels were significantly higher in patients with prostatic carcinoma (37.6 +/- 8.4 nmol/l) than in those with prostatic hyperplasia (24.5 +/- 5.2 nmol/l; P less than 0.05) or control subjects (14.9 +/- 2.8 nmol/l; P less than 0.01). It is not known why SHBG levels are higher in patients with carcinoma or hyperplasia of the prostate. The contradictory results obtained in other studies may be due to heterogeneity of the binding globulin causing its values to vary in the different assays used.

[Arterialization of the deep dorsal vein in selected cases of vasculogenic impotence]. / Arterializzazione della vena dorsale profonda in casi selezionati di impotenza vasculogenica.

We report our study of surgical treatment of vasculogenic impotence using the technique of arterialization of the deep dorsal vein. The results of the operation performed in 13 selected cases are good although the follow-up is still short. The reasons why we consider this technique preferable to the others available for penile revascularization are discussed.

Morphodynamic and biochemical assessment of seminal plasma in patients who underwent local prostatic hyperthermia.

Fourteen young and sexually active patients with chronic abacterial prostatitis who failed to respond to conventional medical therapy underwent four 60 minute sessions of local prostatic hyperthermia. Calculated prostatic temperature was 42 +/- 0.5 degrees C. Analysis of seminal plasma was performed pre- and postoperatively and included: number, motility, and morphology of spermatozoa; zinc, citric acid, D-fructose, and free testosterone content. Preoperative semen analysis was normal in five patients and abnormal in nine. Morphodynamic and biochemical patterns of seminal plasma were not significantly altered by thermotherapy. Local prostatic hyperthermia can be safely used in patients with chronic abacterial prostatis not responding to conventional medical therapy and desiring to preserve their reproductive potential.