When is a varicocele repair indicated: the dilemma of hypogonadism and erectile dysfunction?

In the past, the indications for varicocelectomy are primarily for infertility with abnormal semen parameters, testicular hypotrophy/atrophy in adolescents, and/or pain. The surgical treatment of varicocele for hypogonadism is controversial and debated. Recently, multiple reports in the literature have suggested that varicocele is associated with hypogonadism and varicocele repair can increase testosterone levels. Men with hypogonadal symptoms should have at least two serum testosterone levels. Microsurgical varicocelectomy may be beneficial for men with clinically palpable varicoceles with documented hypogonadism. In this review, we summarize the most recent literature linking varicocele to hypogonadism and sexual dysfunction and the impact of repair on serum testosterone levels. We performed a search of the published English literature. The key words used were “varicocele and hypogonadism” and “varicocele surgery and testosterone.” We included published studies after 1998. We, also, evaluated the effect of surgery on the changes in the serum testosterone level regardless of the indication for the varicocele repair.     

Difficult thyroidectomies

The “difficult thyroidectomies” (DT) are motivated by several factors that, alone or in association with each other, make surgery more laborious and increase the related risks. Topographical, technical and anatomical criteria have been used by us to classify DT with a view to illustrating specific problems and suggesting appropriate strategies. According to topographical criteria we considered mediastinal goiter and resurgery; according to technical criteria we considered the presence of auto-immune thyroiditis and locally advanced malignancies; on the basis of anatomical criteria, we considered the presence of “non recurrent” laryngeal nerve and of a pre-operatory vocal cord palsy.     

Surgical management of chordoma: A systematic review

Context: Chordomas are rare primary tumors of bone characterized by local aggressiveness and poor prognosis. The surgical exeresis plays a critical role for their management.Objective: The aim was to provide an overview of the surgical management of chordomas of the mobile spine and sacrum, describing the most common surgical approaches, the role of surgical margins, the difficulties of en block resection, the outcomes of surgery, the recurrence rate and the use of associated therapies.Methods: We performed a systematic search using the keywords “chordoma” in combination with “surgery”, “spine”, “sacrum” and “radiotherapy”.Results: Fifty-eight studies, describing 1359 patients with diagnosis of chordoma were retrieved. 17 studies were performed on subjects with cervical chordomas and 49 focused on patients with sacrococcygeal chordomas. The remaining studies included patients with chordomas in cranial region and/or mobile spine and/or sacroccygeal region. The recurrence rate ranged from 25% to 60% for cervical chordomas, and from 18% to 89% for sacrococcygeal chordomas.Conclusion: Despite the remarkable advances in the local management of chordoma performed in the last decades, the current results of surgery alone are still unsatisfactory. The radical en bloc excision of tumour is technically demanding, particularly in the cervical spine. Although radical surgery must still be considered the gold standard for the management of chordomas, a multidisciplinary approach is required to improve the local control of the disease in patients who undergo both radical and non-radical surgery. Adjuvant radiation therapy increases the continuous disease-free survival and the local recurrence-free survival.Level of evidence: Systematic review; level III.     

“Acute postoperative open abdominal wall”: Nosological concept and treatment implications

The so-called “burst abdomen” has been described for many years and is a well-known clinical condition, whereas the concept of the “open abdomen” is relatively new. In clinical practice, both nosological entities are characterized by a complex spectrum of symptoms apparently disconnected, which in many cases poses a great challenge for surgical repair. In order to assess the management of these disorders in a more comprehensive and integral fashion, the concept of “acute postoperative open abdominal wall” (acute POAW) is presented, which in turn can be divided into “intentional” or planned acute POAW and “unintentional” or unplanned POAW. The understanding of the acute POAW as a single clinical process not only allows a better optimization of the therapeutic approach in the surgical repair of abdominal wall-related disorders, but also the stratification and collection of data in different patient subsets, favoring a better knowledge of the wide spectrum of conditions involved in the surgical reconstruction of the abdominal wall.     

Foreword: varicocele – unraveling the enigma

It was more than 40 years ago, as a first-year Urology resident, that I performed my first varicocele ligation (a Palomo procedure1) under the watchful eye and able hands of my staff physician. I dutifully read all I could the night before the procedure and became familiar with the names of Barfield, Macomber and Sanders, Tulloch, MacLeod, Ivanissevich, Palomo, Amelar and Dubin and others who had written about varicoceles being associated with abnormal semen parameters and a potentially surgically correctable cause of male infertility. During and after our uneventful surgical procedure, I was grilled as to the anatomy and known pathophysiology of a varicocele. I felt well-versed from my reading and proudly regurgitated all I had learned about the anatomy of the left testicular vein and pampiniform plexus, incompetent or absent valves in the vein, increased testicular temperature, sluggish flow of blood from the left testis and possible toxins from the opposing left adrenal gland vein entering the dilated, incompetent testicular vein – any or all of which could contribute to disturb spermatogenesis and cause infertility. It all seemed simple enough! I pretty much thought we knew all we needed to know about this so-called “bag of worms.”Fast-forward to the present and it becomes obvious how little we actually did know with respect to our understanding the concept of a varicocele and how it may or more commonly, may not affect spermatogenesis and fertility potential. This venous “enigma,”2 as it was so aptly termed by Dr. Turner,2 has fueled many hot debates at national and international scientific meetings among specialists in Urology, Gynecology, and Andrology. Most urologic surgeons appear to accept the fact that a varicocele is a commonly identified, potentially correctable cause for primary and secondary infertility. They also recognize that it is not a “fix” for everyone on whom they operate nor do most men with a varicocele need to have it corrected. Indeed, many men are found to have a varicocele on routine examination and may never have a fertility problem and are often unaware of the venous abnormality being present until this incidental finding is pointed out to them during the examination.If one queries the word “varicocele” in PubMed, almost 5000 scientific articles would appear, from the more recent month''s publications to an early paper dating back to 1846.3 A brief perusal of the more recent papers, particularly over the last couple of decades, leads one to appreciate how much our knowledge regarding varicoceles and their effect on the fertility and gonadal function has increased. Yet there still are many unknowns surrounding this anatomic venous anomaly.This special edition of the Asian Journal of Andrology takes us one step further in understanding the enigma of the varicocele and current controversies surrounding the indications or contraindications for ablative therapy. Drs. Agarwal and Esteves are to be heartedly congratulated on their ability to gather so many recognized, international authorities in male reproduction who share with us recent advances in understanding the pathophysiology of varicoceles and its variable affect on fertility and androgen function. In addition, world renowned surgeons and interventionalists discuss the indications, techniques and controversies regarding surgery for this venous anomaly for both adolescents and adult males.The availability and reported success of advanced assisted reproductive methods (In Vitro Fertilization with Intracytoplasmic Sperm Injection - IVF-ICSI), has dramatically altered the playing field for couples that find it difficult to conceive by natural means. Success in this area has led some reproductive endocrinologists to suggest that given a few live normal appearing sperm is all they need for intracytoplasmic sperm injection and, therefore, it does not matter if there is a varicocele or not in the male partner with suboptimal sperm quality. Disregarding the excessive costs, which are not inconsequential, and potential risks borne by the female partner undergoing ovarian stimulation and IVF, the need for repeated cycles and the inherent risks related to the greater incidence for multiple gestations, it would seem a grave disservice to a couple not to offer the option of a potentially curative solution to their infertility if the male partner has a varicocele and associated suboptimal semen quality.4,5It is obvious that since I performed my first varicocele ligation and tried to impress the staff surgeon with my thorough knowledge of varicocele anatomy and pathophysiology, there have been dramatic and meaningful advances in our understanding of the effects of varicoceles on the gonadal function of some men. We had, then, never heard the terms: reactive oxygen species and oxidative stress, DNA fragmentation, or heat-shock proteins. We never thought or had the means of looking for “subclinical varicoceles.” The conceptualization and realization of sophisticated assisted reproductive methods such as IFV/ICSI for impaired male factors were then pure speculation and fiction.The outstanding authors who have contributed to this special edition offer us a state-of-the-art view of the pathophysiology and treatment options for men with varicoceles. I would venture to predict that the next generation of researchers and surgeons will consider many of these current concepts as being as naοve and simplistic as those of the past. I do hope that the next generation of “experts” remembers the words of the 12^th century theologian, John of Salisbury:“We are like dwarfs sitting on the shoulders of giants. We see more, and things that are more distant, than they did, not because our sight is superior or because we are taller than they, but because they raise us up, and by their great stature add to ours”.     

Proteomic profile of seminal plasma in adolescents and adults with treated and untreated varicocele

Varicocele, the most important treatable cause of male infertility, is present in 15% of adult males, 35% of men with primary infertility, and 80% of men with secondary infertility. On the other hand, 80% of these men will not present infertility. Therefore, there is a need to differentiate a varicocele that is exerting a deleterious effect that is treatable from a “silent” varicocele. Despite the growing evidence of the cellular effects of varicocele, its underlying molecular mechanisms are still eluding. Proteomics has become a promising area to determine the reproductive biology of semen as well as to improve diagnosis of male infertility. This review aims to discuss the state-of-art in seminal plasma proteomics in patients with varicocele to discuss the challenges in undertaking these studies, as well as the future outlook derived from the growing body of evidence on the seminal proteome.     

Recent biological trends in management of fracture non-union

Bone regeneration is a complex, well-orchestrated physiological process of bone formation, which can be seen during normal fracture healing, and is involved in continuous remodelling throughout adult life. Currently, there is a plethora of different strategies to augment the impaired or “insufficient” bone-regeneration process, including the “gold standard” autologous bone graft, free fibula vascularised graft, allograft implantation, and use of growth factors, osteoconductive scaffolds, osteoprogenitor cells and distraction osteogenesis. Improved “local” strategies in terms of tissue engineering and gene therapy, or even “systemic” enhancement of bone repair, are under intense investigation, in an effort to overcome the limitations of the current methods, to produce bone-graft substitutes with biomechanical properties that are as identical to normal bone as possible, to accelerate the overall regeneration process, or even to address systemic conditions, such as skeletal disorders and osteoporosis. An improved understanding of the molecular and cellular events that occur during bone repair and remodeling has led to the development of biologic agents that can augment the biological microenvironment and enhance bone repair. Orthobiologics, including stem cells, osteoinductive growth factors, osteoconductive matrices, and anabolic agents, are available clinically for accelerating fracture repair and treatment of compromised bone repair situations like delayed unions and nonunions. A lack of standardized outcome measures for comparison of biologic agents in clinical fracture repair trials, frequent off-label use, and a limited understanding of the biological activity of these agents at the bone repair site have limited their efficacy in clinical applications.     

Spontaneous Rupture of the Esophagus

Spontaneous rupture of the esophagus remains a medical and surgical challenge. Its diagnosis is often missed or delayed resulting in increased morbidity and mortality, and controversy exists as to the mode of therapy for the cases seen later than 12 hours after rupture. During the last seven years, nine patients were treated at Grady Memorial Hospital. Four patients, “early group,” were operated upon within 12 hours from the onset of their symptoms and five, “late group,” were operated upon between 20-76 hours (average 41) after rupture. All four patients in the “early group” had primary repair of the rupture and two had, in addition, fundoplication. From the two patients with primary repair alone, one developed postoperative leakage at the esophageal suture line, which closed spontaneously; whereas, in the two patients with fundoplication, no leakage occurred. Three of the four patients recovered and one died from renal failure, gastrointestinal bleeding, and gastric perforation. In the “late group” one patient had T-tube drainage of the esophagus and died. Two had primary repair alone with one death and the other two had primary repair with fundoplication 20 and 76 hours postrupture and both recovered. The two deaths in the “late group” were due to leakage at the site of the rupture. This study suggests that even in patients diagnosed late as having rupture of the esophagus, primary repair can be implemented with reasonable success. Good mediastinal, pleural and gastric drainage, high levels of appropriate antibiotics, and provision of good nourishment are of paramount importance for the successful management of these desperately ill patients.     

Impact of osteoporosis in dental implants: A systematic review

AIM: To assess the failure and bone-to-implant contact rate of dental implants placed on osteoporotic subjects.METHODS: Extensive examination strategies were created to classify studies for this systematic review. MEDLINE (via PubMed) and EMBASE database were examined for studies in English up to and including May 2014. The examination presented a combination of the MeSH words described as follow: “osteoporosis” or “osteopenia” or “estrogen deficiency” AND “implant” or “dental implant” or “osseointegration”. Assessment of clinical and/or histological peri-implant conditions in osteoporosis subjects treated with titanium dental implants. The examination included a combination of the MeSH terms described as follow: “osteoporosis” or “osteopenia” or “estrogen deficiency” AND “implant” or “dental implant” or “osseointegration”.RESULTS: Of 943 potentially eligible articles, 12 were included in the study. A total of 133 subjects with osteoporosis, 73 subjects diagnosed with osteopenia and 708 healthy subjects were assessed in this systematic review. In these subjects were installed 367, 205, 2981 dental implants in osteoporotic, osteopenic and healthy subjects, respectively. The failure rate of dental implant was 10.9% in osteoporotic subjects, 8.29% in osteopenic and 11.43% in healthy ones. Bone-to-implant contact obtained from retrieved implants ranged between 49.96% to 47.84%, for osteoporosis and non-osteoporotic subjects.CONCLUSION: Osteoporotic subjects presented higher rates of implant loss, however, there is a lower evidence to strengthen or refute the hypothesis that osteoporosis may have detrimental effects on bone healing. Consequently, final conclusions regarding the effect of osteoporosis in dental implant therapy cannot be made at this time. There are no randomized clinical trial accessible for evaluation and the retrospective nature of the evaluated studies shall be taken in account when interpreting this study.     

Studies of Articular Cartilage Repair from 2009 to 2018: A Bibliometric Analysis of Articles

ObjectiveTo perform a bibliometric analysis of research on articular cartilage repair published in Chinese and English over the past decade. Fundamental and clinical research topics of high interest were further comparatively analyzed.MethodsRelevant studies published from 1 January 2009 to 31 December 2018 (10 years) were retrieved from the Wanfang database (Chinese articles) and six databases, including MEDLINE, WOS, INSPEC, SCIELO, KJD, and RSCI on the website “Web of Science” (English articles), using key words: “articular cartilage” AND “injury” AND “repair”. The articles were categorized according to research focuses for a comparative analysis between those published in Chinese vs English, and further grouped according to publication date (before and after 2014). A comparative analysis was performed on research focus to characterize the variation in research trends between two 5‐year time spans. Moreover, articles were classified as basic and clinical research studies.ResultsOverall, 5762 articles were retrieved, including 2748 in domestic Chinese journals and 3014 in international English journals. A total of 4937 articles focused on the top 10 research topics, with the top 3 being stem cells (32.1%), tissue‐engineered scaffold (22.8%), and molecular mechanisms (16.4%). Differences between the numbers of Chinese and English papers were observed for 3 topics: chondrocyte implantation (104 vs 316), osteochondral allograft (27 vs 86), and microfracture (127 vs 293). The following topics gained more research interest in the second 5‐year time span compared with the first: microfracture, osteochondral allograft, osteochondral autograft, stem cells, and tissue‐engineered scaffold. Articles with a focus on three‐dimensional‐printing technology have shown the fastest increase in publication numbers. Among 5613 research articles, basic research studies accounted for the majority (4429), with clinical studies described in only 1184 articles. The top 7 research topics of clinical studies were: chondrocyte implantation (28.7%), stem cells (21.9%), microfracture (19.2%), tissue scaffold (10.6%), osteochondral autograft (10.5%), osteochondral allograft (6.3%), and periosteal transplantation (2.8%).ConclusionStudies focused on stem cells and tissue‐engineered scaffolds led the field of damaged articular cartilage repair. International researchers studied allograft‐related implantation approaches more often than Chinese researchers. Traditional surgical techniques, such as microfracture and osteochondral transplantation, gained high research interest over the past decade.     

Surgical interventions for anterior shoulder instability in rugby players: A systematic review

AIM: To systematically evaluate the evidence-based literature on surgical treatment interventions for elite rugby players with anterior shoulder instability.METHODS: We conducted a systematic review according to the PRISMA guidelines. A literature search was performed in PubMed, EMBASE and Google Scholar using the following search terms: “rugby” and “shoulder” in combination with “instability” or “dislocation”. All articles published from inception of the included data sources to January 1^st 2014 that evaluated surgical treatment of elite rugby players with anterior shoulder instability were examined.RESULTS: Only five studies were found that met the eligibility criteria. A total of 379 shoulders in 376 elite rugby union and league players were included. All the studies were retrospective cohort or case series studies. The mean Coleman Methodological Score for the 5 studies was 47.4 (poor). Owing to heterogeneity amongst the studies, quantitative synthesis was not possible, however a detailed qualitative synthesis is reported. The overall recurrence rate of instability after surgery was 8.7%, and the mean return to competitive play, where reported, was 13 mo.CONCLUSION: Arthroscopic stabilization has been performed successfully in acute anterior instability and there is a preference for open Latarjet-type procedures when instability is associated with osseous defects.     

Global Surgery Fellowships—An Investigation of Opportunities,Outcomes, and Applicants

Following the Lancet Commission on Global Surgery in 2015, the Global Surgery Fellowships have risen in popularity, advertised as formalized opportunities for surgical trainees who have an interest in international surgical care. There is currently no up-to-date review of all fellowships available and an urgently needed overview of these opportunities is presented, including critical appraisal of their accessibility, funding, and outcomes. Detailed searches were conducted on the web engine Google, using the term “global surgery fellowship” and iterations. From the 547 resulting links, after applying exclusion criteria, 69 relevant fellowships were included in analysis. The majority of fellowships based in the United States (55%) and arranged by non-governmental organizations (NGOs) or universities (>70%). Also, 60% of fellowships had a duration of 1 year or longer. Only a quarter of the fellowships was open solely to trainees from low- or middle-income countries (LMIC), with over 80% of these being full funded. But 40% of the fellowships were advertised as open to trainees from any country, though only one-third of these provided full funding. Key themes across the fellowships’ outcomes included “Professional Development,” “Research,” and “LMIC Quality Improvement.” Almost all of the fellowships (95%) stated international travel opportunities. Twelve of the fellowships offered higher degrees, with the most common being a Masters of Public Health. The global distribution of fellowships and reduced funding opportunities for trainees from LMIC limit accessibility of the Global Surgery Fellowships. It is, however, still promising that most of key themes and high rates of international work are in line with The Lancet Commission’s recommendations. This overview of the Global Surgery Fellowships highlights the need for collaboration between institutions and has illustrated points for consideration when introducing new and the value of established fellowships.     

Antegrade scrotal sclerotherapy of internal spermatic veins for varicocele treatment: technique,complications, and results

Varicocele repair is mainly indicated in young adult patients with clinical palpable varicocele and abnormal semen parameters. Varicocele treatment is associated with a significant improvement in sperm concentration, motility, morphology, and pregnancy rate. Antegrade scrotal sclerotherapy (ASS) represented one of the main alternatives to the traditional inguinal or suprainguinal surgical ligation. This article reviews the use of ASS for varicocele treatment. We provide a brief overview of the history of the procedure and present our methods used in ASS. In addition, we review complication and success of ASS, including our own retrospective data of treating 674 patients over the last 17 years. Herein, we analyzed step by step the ASS technique and described our results with an original modified technique with a long follow-up. Between December 1997 and December 2014, we performed 674 ASS. Mean operative time was 14 min (range 9 to 50 min). No significant intraoperative complications were reported. Within 90 days from the procedure, postoperative complications were recorded in overall 49 (7.2%) patients. No major complications were recorded. A persistent/recurrent varicocele was detected in 40 (5.9%) cases. In 32/40 (80%) cases, patients showed preoperative grade III varicoceles. In patients with a low sperm number before surgery, sperm count improved from 13 × 10⁶ to 21 × 10⁶ ml⁻¹ (P < 0.001). The median value of the percentage of progressive motile forms at 1 h improved from 25% to 45% (P < 0.001). Percentage of normal forms increased from 17% before surgery to 35% 1 year after the procedure (P < 0.001). In the subgroup of the 168 infertile patients, 52 (31%) fathered offspring at a 12-month-minimum follow-up. Therefore, ASS is an effective minimal invasive treatment for varicocele with low recurrence/persistence rate.     

Safety and Sourcing of Topical Cannabinoids: Many Questions,Few Answers

BackgroundTopical cannabinoid products are increasingly being recommended and used for a variety of dermatologic conditions. Despite this, safety and efficacy data of topical preparations are lacking, and the differences between topical and oral formulations are not well characterized.ObjectiveWe reviewed the literature to gather published data on topical cannabinoid products and the differences between topical and oral formulations.MethodsThe PubMed/MEDLINE literature database was searched using the terms “cannabinoids,” “cannabidiol,” “CBD,” “topical cannabidiol,” “transdermal cannabidiol,” “hemp” and “skin.” Results were manually screened to identify published data on topical formulations of cannabinoids or cannabidiol use, adverse effects, sourcing, and solubility.ResultsTopical formulations of cannabinoids might be more nuanced than oral formulations, due not only to dosing differences, but also to potential differences in transcutaneous absorption. Safety and efficacy might need to be evaluated on a product-by-product basis until universal standards for topical preparations are better established. CONCLUSION: Topical cannabinoid products might be an important addition to the dermatologic armamentarium, with the potential to dose cannabinoids directly to the skin while minimizing systemic exposure. However, before this can be done reliably, important formulation parameters must be established and verified.     

The “Shirt Pocket” Technique—An Alternative for Augmentation-Mastopexy

Augmentation-mastopexy is a frequent procedure with high rates of early recurrence of breast ptosis, mainly after subglandular approach. The dual-plane techniques, based on the cranial dissection of the pectoralis, is the most used, but this plane does not cover the inferior pole of the breast. Then, the possibility of a downward dissection of the muscle seems to be more reasonable to retain the implant and improve postoperative results. This study aimed to review the anatomy of the pectoralis in cadavers and the use of its downward dissection to create a pocket for breast implant as a “shirt pocket.” This maneuver was associated with a superior-based dermoglandular flap to overprotect the inferior pole. No complications were related in the postoperative period. The anatomic review showed that the “shirt pocket” is a safe option if done carefully. The technique demonstrated to be feasible and seemed to be effective, being another alternative to prevent early recurrence of breast ptosis in these procedures.     

Effect of varicocelectomy on testis volume and semen parameters in adolescents: a meta-analysis

Varicocele repair in adolescent remains controversial. Our aim is to identify and combine clinical trials results published thus far to ascertain the efficacy of varicocelectomy in improving testis volume and semen parameters compared with nontreatment control. A literature search was performed using Medline, Embase and Web of Science, which included results obtained from meta-analysis, randomized and nonrandomized controlled studies. The study population was adolescents with clinically palpable varicocele with or without the testicular asymmetry or abnormal semen parameters. Cases were allocated to treatment and observation groups, and testis volume or semen parameters were adopted as outcome measures. As a result, seven randomized controlled trials (RCTs) and nonrandomized controlled trials studying bilateral testis volume or semen parameters in both treatment and observation groups were identified. Using a random effect model, mean difference of testis volume between the treatment group and the observation group was 2.9 ml (95% confidence interval [CI]: 0.6, 5.2; P< 0.05) for the varicocele side and 1.5 ml (95% CI: 0.3, 2.7; P< 0.05) for the healthy side. The random effect model analysis demonstrated that the mean difference of semen concentration, total semen motility, and normal morphology between the two groups was 13.7 × 10⁶ ml⁻¹ (95% CI: −1.4, 28.8; P = 0.075), 2.5% (95% CI: −3.6, 8.6; P= 0.424), and 2.9% (95% CI: −3.0, 8.7; P= 0.336) respectively. In conclusion, although varicocelectomy significantly improved bilateral testis volume in adolescents with varicocele compared with observation cases, semen parameters did not have any statistically significant difference between two groups. Well-planned, properly conducted RCTs are needed in order to confirm the above-mentioned conclusion further and to explore whether varicocele repair in adolescents could improve subsequently spontaneous pregnancy rates.