Surgical procedures for male infertility: an update.

PURPOSE OF REVIEW: The aim of this review is to provide an overview of surgical treatment options for male infertility including varicocelectomy, treatment of ejaculatory duct obstruction, vasovasostomy, and sperm extraction, and to review recent advances in techniques and technologies that may improve operative outcomes. RECENT FINDINGS: Microscopic subinguinal varicocelectomy has been shown to have the highest success rates with lowest rates of complications, and may be facilitated by the use of Doppler, indocyanine green angiography, and the 4K3D operating video microscope. The standard treatment for ejaculatory duct obstruction by transurethral resection of the ejaculatory ducts has changed little over time, but vesiculoscopy may allow for temporary dilation of an obstruction to allow for natural conception, while also offering diagnostic capabilities. Use of the robotic platform has gained popularity for vasectomy reversals but controversy remains regarding the cost-effectiveness of this option. Recently, a reinforcing suture technique has been described for vasovasostomy to minimize anastomotic breakdown and reversal failure. Finally, gray-scale and color-enhanced ultrasound may improve ability to predict successful sperm retrieval during extraction procedures. SUMMARY: Though the fundamentals of surgical treatment options for male infertility have changed little with time, technological advancements have contributed to improved surgical outcomes over recent years.

Vasectomy reversal for post-vasectomy pain syndrome.

Post-vasectomy pain syndrome (PVPS) is a rare, but devastating outcome following vasectomy. Given the widespread utilization of vasectomy for permanent contraception, with more than 500,000 procedures performed annually in the United States, it can be a significant challenge for both patients and providers. Vasectomy reversal is a surgical option for men who fail conservative or medical management. Despite improvements in technique, vasectomy carries some inherent risks making pre-procedure counseling regarding the risks of PVPS paramount. Chronic post-operative pain, or PVPS, occurs in 1-2% of men undergoing the procedure. This review will examine the utility of vasectomy reversal as a means of addressing PVPS.

The devil is in the details: an analysis of the subtleties between phosphodiesterase inhibitors for erectile dysfunction.

Erectile dysfunction (ED) is a common sexual disorder with numerous etiologies involving multiple organ systems that leads to significant distress and decreased quality of life for the affected men. Fortunately, there are several modalities and interventions for treating ED. Oral medications, intra-urethral compounds, intracorporeal injections, vacuum-assist devices and surgically implanted prostheses are all part of the treatment algorithm. One of the first-lines and certainly the most widely used options for treating ED is the family of oral phosphodiesterase type 5 inhibitors (PDE5I). The introduction of these medications in the late 1990s revolutionized the field of sexual medicine. Currently there are no guidelines and minimal literature to help providers choose among drugs in this class. This review will address differences in efficacy and side effects between various members of the oral selective phosphodiesterase-5 inhibitor class of drugs.

Persistent Müllerian duct structures presenting as hematuria in an adult: Case report of robotic surgical removal and review of the literature.

Persistent Müllerian duct syndrome is a rare genetic disorder characterized by a male with retained Müllerian structures. Remnant excision must be considered due to the possibility of malignant degeneration. We review a case of delayed diagnosis in a 25-year-old man presenting with hematuria. Preoperative counseling must emphasize the risk of malignancy versus the risks to fertility. The da Vinci robot offers a novel, safe approach for excision of the relevant Müllerian structures. Dissection should be limited to structures superior to the cavernosal neurovascular bundles to preserve the continence and erectile function. A semen analysis is recommended preoperatively to determine effects on fertility.

Current applications of in utero intervention for lower urinary tract obstruction.

PURPOSE: Since the early 1980s with the inception of fetal intervention for obstructive uropathy, there have been creative attempts to improve both perinatal and long-term outcomes. Despite advances in technology and an improved understanding of lower urinary tract obstruction (LUTO) in the fetus, the results for these therapeutic interventions remain guarded and the long-term renal morbidity among survivors remains problematic. RECENT FINDINGS: Fetal LUTO represents a range of disorders but the most common of these is posterior urethral valves (PUVs). Selection criteria for candidates of possible intervention have improved with our understanding of fetal renal physiology. Serial urinalysis has marginally improved our ability to predict those that may ultimately respond to treatment [1,2], but the potential in the development of biomarkers for renal development or maldevelopment holds greater promise [3]. Advancements in fetal surgery may result in less fetal and maternal morbidity, but limited long-term improvement in outcomes highlights the controversial nature of the various interventions [4-10]. We must counsel families that fetal surgery offers hope but we cannot allow them to hold unrealistic expectations for cure. SUMMARY: In appropriately selected fetuses, intervention may improve perinatal survival but not without risk to mother and fetus. Long-term renal outcomes remain problematic amongst survivors. In the case of PUV, postnatal primary valve ablation remains the cornerstone of treatment for nephron preservation; however, our ability to mimic these results in the prenatal population remains poor [11]. Disease severity has likely predetermined those that will survive through the perinatal period with or without intervention. Nonetheless, our drive to assess and manage fetal obstructive uropathy perseveres so that we may ultimately relieve obstruction and preserve renal and lung function. We must maintain optimism that continued advances will ultimately improve outcomes, but also be realistic with our current expectations. This paper reviews the status of current in utero interventions and outcomes.

Robotic-assisted partial nephrectomy in duplicated collecting systems in the pediatric population: techniques and outcomes.

OBJECTIVE: We present our experience with pediatric robotic-assisted laparoscopic partial nephrectomy of a nonfunctioning moiety in a duplicated system (RALPN), comparing techniques and outcomes with those previously reported in the literature. To our knowledge, this is the largest series of this surgical procedure to date. PATIENTS AND METHODS: We retrospectively reviewed all pediatric patients at our institution that had undergone RALPN from 2006 to 2012. RESULTS: Twenty-one patients underwent RALPN between 2006 and 2012. Mean patient age was 4.1 years. Mean operative time was 301 min. Mean estimated blood loss was 36 ml. Mean length of stay was 38 h. The majority of cases were performed with three laparoscopic ports. At initial follow-up ultrasound 6/21 (29%) demonstrated a fluid collection. The majority of these collections occurred in cases where the resection defect was not closed intraoperatively (42% of cases vs. 11% of cases). All fluid collections were asymptomatic and managed conservatively. CONCLUSION: RALPN is associated with low complication rates. The robotic system allows for the use of only two small robotic working ports in most cases. Postoperative fluid collections may be prevented by formal closure of the polar defect, but fluid collections that do occur can be followed conservatively.

The effect of polyethylene glycol-superoxide dismutase administration on histological damage following spermatic cord torsion.

Oxygen free radicals generated during the ischemic/reperfusion period have been suggested as a possible cause for tissue damage in different organs. In this study we address the question of whether administration of polyethylene glycol-superoxide dismutase, an oxygen free radical scavenger, can alleviate histological damage associated with testicular torsion. The study included 67 Sprague-Dawley rats. In 60 rats the left testicle was rotated 720 degrees clockwise through a scrotal incision. Torsion duration was 3 hours. Five minutes before and 5 minutes after detorsion the testicle color was evaluated and scored. The remaining 7 rats underwent a sham operation. After randomization 8,000 units per kg. polyethylene glycol-superoxide dismutase were injected intraperitoneally in the treated group 1 hour before detorsion. After 14 days histological evaluation was performed on both testicles of 58 rats (2 rats died before the evaluation). No statistically significant difference was demonstrated between the treatment (28 rats) and the control groups (30 rats). Testicular color after detorsion correlated with the histological damage.