A novel cost-effective approach to post-vasectomy semen analysis

Study Type – Diagnostic (cost minimisation analysis)
Level of Evidence 3b

OBJECTIVE

• ? To examine compliance, clearance rates and cost‐effectiveness of a novel approach to managing men following vasectomy based on the testing of sperm viability.

PATIENTS AND METHODS

• ? Between January 2003 and March 2005, 832 men undergoing vasectomy were followed prospectively for a minimum of 12 months.
• ? Post‐vasectomy semen analysis (PVSA) was carried out at 16 weeks with repeat at 20 weeks only if sperm were detected on initial PVSA i.e. a single clear PVSA on simple microscopy was deemed sufficient for declaring vasectomy successful.
• ? In men with persistent non‐motile sperm (PNMS) in the second specimen, comprehensive analysis of number and viability of sperm using a fluorescent probe was carried out on a fresh semen specimen taken in accordance with British Andrology Society (BAS) guidelines.

RESULTS

• ? Overall compliance with the PVSA protocol was 81.3% (95% CI 78.5 to 83.8). No sperm were seen in 540 (78.8%) and 70 (10.3%) at the initial and 2^nd PVSA respectively.
• ? Persistent spermatozoa at 20 weeks were present in 66 (9.8%, 7.8 to 12.2) cases with 58 (8.6%, 6.7 to 11.0) having PNMS and 8 (1.2%, 0.6 to 2.3) having motile sperm.
• ? Fluorescent viability testing in 53 of the 58 with PNMS showed viable sperm in 2 (3.8%, 1.0 to 12.8). The failure rate of vasectomy defined by PVSA (8 with motile sperm on 2^nd PVSA and 2 with viable non‐motile sperm on fluorescent testing) was 1.2% (0.7 to 2.2).
• ? Average cost per vasectomy of PVSA using this protocol was £10.77 (US$ 16.67) compared with a minimum likely average cost using BAS guidelines of £18.10 (US$ 28).

CONCLUSION

• ? Demonstrating absence of sperm on simple light microscopy in a single specimen of semen at 16 or 20 weeks post‐vasectomy and reserving comprehensive testing of sperm viability for only the higher risk group with PNMS improves compliance and represents a cost‐effective strategy for declaring surgical success. This reduces the costs of PVSA by least 40% compared with adherence with BAS guidelines without compromising success in determining outcome after vasectomy.

     

Association between obesity and alteration of sperm DNA integrity and mitochondrial activity

Study Type – Prognosis (cohort) Level of Evidence 3a What's known on the subject? and What does the study add? The relationship between high levels of BMI and changes in altered standard semen analysis parameters are described in the literature. However, the functional characteristics of the sperm are essential to complete the evaluation of male infertility. Thus, this study provides important information about the functionality of the sperm of men with different levels of BMI.

OBJECTIVE

• ? To assess the effect of obesity on semen analysis, sperm mitochondrial activity and DNA fragmentation.

MATERIALS AND METHODS

• ? A transversal study of 305 male patients, presenting for clinical evaluation, was carried out. The patients were divided into three groups according to body mass index (BMI) as follows: eutrophic (BMI < 25 kg/m², n= 82), overweight (BMI ≥ 25 kg/m² and <30, n= 187) and obese (BMI ≥ 30 kg/m², n= 36).
• ? The variables analysed were semen analysis, rate of sperm DNA fragmentation and sperm mitochondrial activity.
• ? Groups were compared using one‐way analysis of variance followed by a least significant difference post‐hoc test. A P‐value of <0.05 was considered to indicate statistical significance.

RESULTS

• ? No differences were observed in age, ejaculatory abstinence, ejaculate volume, sperm vitality, morphology or round cell and neutrophil count among the groups.
• ? The eutrophic group had a higher percentage of sperm with progressive motility (P= 0.001). Mitochondrial activity was lower in the obese group (P= 0.037) when compared to the eutrophic, and the percentage of sperm with DNA damage was higher in the obese group (P= 0.004) than the other two groups.

CONCLUSION

• ? Increased BMI values are associated with decreased mitochondrial activity and progressive motility and increased DNA fragmentation.

     

UK practice regarding reversal of vasectomy 2001-2010: relevance to best contemporary patient management

Study Type – Practice trends (survey) Level of Evidence 2c What's known on the subject? and What does the study add? Approximately 6% of men who have had a vasectomy subsequently decide to have it reversed. For such men there are various options available, including vasal reconstruction, surgical sperm retrieval with assisted reproductive techniques, use of donated sperm or adoption. The decision‐making process with regard to the most appropriate management is challenging and the urologist requires both an intimate knowledge of the advantages and disadvantages of each of the available options and the opportunity to counsel a couple appropriately. The study confirms that patient management after previous vasectomy is a complex process, demanding detailed knowledge about the availability and outcomes of alternatives to vasectomy reversal. It recommends that couples should not be seen by urologists with diverse interests but by those with appropriate knowledge of all of the factors influencing outcome and the available management options and their costs. Urologists should also have appropriate facilities to offer intra‐operative demonstration of and, potentially, storage of sperm.

OBJECTIVES

• ? To review the management of men presenting for reversal of vasectomy amongst consultant members of the British Association of Urological Surgeons (BAUS) between 2001 and 2010.
• ? To make recommendations for contemporary practice.

SUBJECTS AND METHODS

• ? Three consecutive questionnaire‐based surveys were undertaken by BAUS consultant members in 2001, 2005 and 2010.
• ? Standard questionnaires were sent on each occasion asking urologists about their counselling of couples regarding options in achieving a conception, expectation of outcome from reconstructive surgery and the techniques of vaso‐vasostomy used.
• ? In 2005 additional information was obtained about the availability of fertility treatments and sub‐specialization of the urologist and in 2010 about the eligibility criteria for in‐vitro fertilization (IVF) treatment and synchronous sperm retrieval.

RESULTS

• ? Overall there was a 47% response rate with >80% of respondents still performing vaso‐vasostomy.
• ? More than 75% of respondents were doing <15 procedures a year and <50% of respondents counselled couples about other management options.
• ? Only 41% gave their personalized outcomes from vaso‐vasostomy, whilst >80% were using some form of magnification intra‐operatively.
• ? Members of the BAUS section of andrology were more likely to discuss options for becoming a parent and criteria for IVF treatment, to present their individualized outcomes from vaso‐vasotomy and to carry out >15 procedures a year than urologists with no andrological affiliation.

CONCLUSIONS

• ? Patient management after previous vasectomy is a complex process necessitating detailed knowledge concerning the availability and outcomes of alternatives to vaso‐vasostomy.
• ? Couples should not be seen by urologists with diverse interests but by those with appropriate knowledge of all of the factors influencing outcome.
• ? Vaso‐vasostomy should no longer be seen as a procedure within the remit of any adequately trained urologist but as one option to be considered by a sub‐specialist with access to appropriate micro‐surgical training and assisted reproductive technologies.

     

Side effects of intradetrusor botulinum toxin injections on ejaculation and fertility in men with spinal cord injury: preliminary findings

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? The beneficial effect of intradetrusor botulinum toxin (BT) injections on hyperactive bladders in individuals with spinal cord injury is known from the literature, but its potential effect on ejaculation and fertility through diffusion is not. As BT injection paralyses the bladder muscle, it may also paralyse the muscular envelopes of the adjacent reproductive organs and lead to potential negative side effects, which have not been studied yet. This study provides preliminary data on the potential negative side effects of BT injections on semen volume and retrograde ejaculation, as well as some potential beneficial effects on semen quality.

OBJECTIVE

• ? To investigate the effect of botulinum neurotoxin A on ejaculation potential and fertility. Intradetrusor injection of botulinum neurotoxin A is most commonly used nowadays to treat overactive bladder in patients with spinal cord injury (SCI).

PATIENTS AND METHODS

• ? Retrospective analyses were carried out of 11 patients with complete lesions from C5 to T6 who had received botulinum (BT) injections for their overactive bladder and who had undergone ejaculation tests before and after BT treatment.

RESULTS

• ? BT treatment was found effective in improving bladder function in up to 85% of the cases.
• ? While no patients maintained natural ejaculation following their SCI, BT treatment was found to increase the incidence of retrograde ejaculation (vibrostimulation) in 46% of cases and to diminish semen volume in 77% of cases, from an average of 1.8 mL to 1 mL.
• ? Semen quality was slightly improved following BT treatment, sperm mobility increased in 67% of cases, sperm vitality in 50% and semen culture improved in 43%.

CONCLUSIONS

• ? BT treatment has beneficial and detrimental effects on ejaculation function. The detrimental effects involve retrograde ejaculation and reduced semen volume, which are explained by the spread of toxin to the bladder neck, reducing its tonus, and to the smooth muscle sexual accessory organs, reducing the strength of their contraction.
• ? The beneficial effects are explained by the reduced contamination of the semen by urinary infection, which may improve spermatogenesis and subsequent semen quality.
• ? The results are discussed in terms of their clinical implications and advice to patients.

     

Outcomes of the management of post-chemotherapy retroperitoneal lymph node dissection-associated anejaculation

Study Type – Outcomes (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Modern surgical techniques have allowed preservation of fertility in most patients after post‐chemotherapy retroperitoneal lymph node dissection (PC‐RPLND), but some patients still have infertility after surgery. We reviewed our experience treating infertility in 26 men after PC‐RPLND. Using a structured clinical pathway we obtained sperm in 81% of men for use in assisted reproduction.

OBJECTIVE

• ? To evaluate the effectiveness of a clinical pathway on sperm retrieval outcomes in patients presenting with infertility after post‐chemotherapy (PC) retroperitoneal lymph node dissection (RPLND).

PATIENTS AND METHODS

• ? We carried out a retrospective review of patients with advanced testicular cancer, presenting with infertility after PC‐RPLND in a large reproductive urology practice.
• ? We implemented a clinical pathway where pseudoephedrine was first administered. If this medication failed, electroejaculation (EEJ) and/or testicular sperm extraction (TESE) was carried out.
• ? The primary outcome was retrieval of sperm for use in assisted reproduction.

RESULTS

• ? Four men had retrograde ejaculation, of whom two converted to antegrade ejaculation with medical therapy.
• ? In all, 22 patients had failure of emission (FOE) and, of these, no patient converted to antegrade ejaculation with medication.
• ? In patients with FOE, sperm was found in 15/20 of those experiencing a successful EEJ.
• ? Seven patients underwent TESE for azoospermia on EEJ or no ejaculate on EEJ, three of whom had sperm found on TESE.
• ? Sperm was found for assisted reproduction in 81% (21/26) patients.

CONCLUSIONS

• ? There appears to be no role for the use of pseudoephedrine therapy in patients with FOE after PC‐RPLND.
• ? The use of a structured clinical pathway may optimize patient care.

     

Incidence and clinical significance of arterial injury in varicocele repair

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

• ? This study was performed to histologically determine the rate of arterial injury in varicocele ligation surgery and to determine the clinical significance of these arterial injuries.

MATERIALS AND METHODS

• ? 41 men who underwent varicocele ligation surgery, and had segments of each ligated vessel examined histologically.
• ? The patients were followed prospectively to determine the effect of arterial injury on surgical results and clinical complications.

RESULTS

• ? Arterial ligation was identified in 6 of 41 patients (12%), and in 7 of 132 specimens (5%), which is higher than previous reports.
• ? Arterial injury was not associated with testicular atrophy and there was no apparent effect of arterial injury on surgical outcome.

CONCLUSION

• ? The rate of arterial injury during varicocele repair is higher than previously reported, but the clinical significance of these injuries appears to be limited.

     

Redefining abnormal follicle-stimulating hormone in the male infertility population

Study Type – Diagnostic (validating cohort) Level of Evidence 2a What's known on the subject? and What does the study add? FSH is a hormone released by the anterior pituitary gland via stimulation from gonadotrophin‐releasing hormone and potentially other factors. FSH reflects the status of spermatogenesis (i.e. the ability to produce sperm) as a result of the feedback between the testis and hypothalamus/pituitary glands. An elevated FSH level is indicative of abnormal spermatogenesis and may indicate primary testicular failure. The range for ‘normal’ FSH varies somewhat between institutions but has been defined by the Strong Memorial Hospital (Rochester, NY, USA) clinical laboratory as 1.4–18.1 IU/L based on the ADVIA Centaur (Siemens Medical Solutions, Tarrytown, NY, USA) FSH assay. The findings obtained in the present study could be helpful for predicting male factor infertility in patients with a borderline high FSH level (≈4.5 IU/L) and a low testosterone level compared to someone with a borderline high FSH level and a normal testosterone level. Although the ‘normal’ range for FSH is qualified as a value in the range 1.4–18.1 IU/L, the present study shows that an FSH level >4.5 IU/L was associated with abnormal semen analysis in terms of morphology and sperm concentration in the present patient population. Therefore, these findings suggest that FSH values lower than those currently considered normal may be associated with abnormal semen analysis, and that the ‘normal’ range for FSH used in clinical settings may need to be reconsidered.

OBJECTIVE

• ? To examine the correlation between follicle‐stimulating hormone (FSH) and testosterone/FSH levels with semen analysis parameters to evaluate whether the range for judging normal FSH levels should be reconsidered.

PATIENTS AND METHODS

• ? The present study included 610 male infertility patients from a single urology infertility clinic between 2004 and 2008.
• ? Patients (n = 153) were excluded for obstructive azoospermia, hypogonadotrophic hypogonadism, steroid use or failure to complete testing.
• ? Abnormal semen analysis values were based on the WHO 1999 criteria.
• ? We performed t‐tests, anova , chi‐squared tests and logistic regression to statistically examine the association between the FSH (or testosterone/FSH ratio) level and semen parameters.

RESULTS

• ? The FSH level showed statistically significant associations, as well as evidence of a dose response, with abnormal sperm concentration and morphology but not with semen volume.
• ? In men with FSH levels >7.5 IU/L, the risk of abnormal semen quality was five‐ to thirteen‐fold higher than that of men with FSH levels <2.8 IU/L depending on the specific semen parameter.
• ? Similarly, semen parameters were had a greater probability of being abnormal with decreasing testosterone/FSH ratios.

CONCLUSION

• ? A significantly increased risk of abnormal semen analyses among men with FSH levels >4.5 IU/L and decreasing testosterone/FSH ratios suggests that redefining normal FSH in infertile men would be valuable.

     

Vasectomy reversal with ultrasonography‐guided spermatic cord block

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Vasectomy reversal is often performed in general or neuraxial anaesthesia. Even though the site of vasectomy reversal is easily amenable to regional/local anaesthesia, spermatic cord blocks are rarely applied because of their risk of vascular damage within the spermatic cord. Recently, we described the technique of ultrasonography (US)‐guided spermatic cord block for scrotal surgery, which, thanks to the US guidance, at the same time avoids the risk of vascular damage of blindly performed injections and the risks of general and neuraxial anaesthesia. Vasectomy reversal can easily be done in regional anaesthesia with the newly described technique of US‐guided spermatic cord block without the risks of vascular damage by a blindly performed injection and the risks of standard general and neuraxial anaesthesia. In addition, this technique grants long‐lasting postoperative pain relief and patients recover more quickly. Microsurgical conditions are excellent and patient satisfaction is high. Thanks to these advantages, more patients undergoing vasectomy reversal might avoid general or neuraxial anaesthesia.

OBJECTIVE

• ? To assess the success rate, microsurgical conditions, postoperative recovery, complications and patient satisfaction of ultrasonography (US)‐guided spermatic cord block in patients undergoing microscopic vasectomy reversal and to compare them to a control group with general or neuraxial anaesthesia.

PATIENTS AND METHODS

• ? The present study comprised a prospective series of 10 consecutive patients undergoing US‐guided spermatic cord block for microscopic vasectomy reversal.
• ? The cohort was compared with 10 patients in a historical control group with general or neuraxial anaesthesia.

RESULTS

• ? Nineteen of 20 (95%) blocks were successful, defined as no pain >3 on the Visual Analogue Scale (VAS), no additional analgesics and/or no conversion to general anaesthesia. Median pain was 0 on the VAS (range 0–5). Additional analgesics were requested in one (5%) block, and there was no conversion to general anaesthesia.
• ? Microsurgical conditions were excellent.
• ? In the spermatic cord block vs general/neuraxial anaesthesia groups, median times (range) between surgery and first postoperative analgesics, alimentation, mobilization and hospital discharge were 12 (2–14) vs 3 (1–6), 1 (0.25–3) vs 4 (3–6), 2 (1–3) vs 6 (3–10), and 4 (3–11) vs 8.5 (6–22) h, respectively.
• ? No complications were reported after the spermatic cord block.
• ? Patient satisfaction was excellent.

CONCLUSIONS

• ? US‐guided spermatic cord block for microscopic vasectomy reversal is highly successful and provides long‐lasting perioperative analgesia.
• ? Times to alimentation, mobilization and hospital discharge are shorter under US‐guided spermatic cord block than under general/neuraxial anaesthesia.
• ? Additional anaesthetic pain management might, however, be required unexpectedly with US‐guided spermatic cord block.

     

Management of severe blunt renal trauma in adult patients: a 10-year retrospective review from an emergency hospital

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Immediate surgery for major renal trauma has led to a high rate of nephrectomy in comparison with an expectant management. We reviewed our case material on the management of severe blunt renal trauma in adults with emphasis on conservative management. Only shattered kidneys and pedicle avulsion required immediate surgery.

OBJECTIVE

• ? To review retrospectively the management of major blunt renal truma in adult patients admitted to our level I trauma centre.

PATIENTS AND METHODS

• ? Among 1460 blunt abdominal trauma cases collected from January 2001 to December 2010, 221 (15%) affected the kidneys.
• ? All patients, except seven who needed immediate laparotomy, underwent a computed tomography scan to stage the injuries.
• ? Renal injuries were graded according to the American Association for the Surgery of Trauma Grading System; grade 4 and 5 injuries were subclassified based on vascular or parenchymal injury.

RESULTS

• ? Only 45/221 patients (20%) suffered major blunt renal trauma (21 grade 3, 18 grade 4 and six grade 5); 43% of the patients had associated lesions and 77% had gross haematuria.
• ? Nephrectomy rates were 9% for grade 3, 22% for grade 4 and 83% for grade 5 with an exploration rate of 26% for major renal trauma.

CONCLUSIONS

• ? Conservative management of grade 3–5 blunt renal trauma in haemodynamically stable patients yields more favourable results with high renal salvage rate.
• ? Grade 5 injuries still result in a nephrectomy rate of more than 80%.
• ? The absence of data on long‐term outcomes and a potential inclusion bias due to the retrospective nature of the data represent major limitations of this review.

     

Application of resonance metallic stents for ureteral obstruction

Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE

• ? To determine the effectiveness of the Resonance ureteral stent and clarify the risk factors that lead to stent failure. In the present study, we review our clinical experiences using Resonance stent in treating malignant and benign ureteral obstruction.

PATIENTS AND METHODS

• ? Nineteen patients with extrinsic malignant ureteral obstruction (n= 15) and benign stricture (n= 4) were retrospectively evaluated.
• ? All patients had received Resonance stent insertion through antegrade or cystoscopic retrograde approaches. The pre‐insertion and follow‐up interventions included image studies and biochemical tests. The insertion success rate, obstruction patency rate and complications were reviewed.
• ? For categorical variables, the chi‐square test and Fisher’s exact test were carried out to determine associations between variables.

RESULTS

• ? The technical success rate of stent insertion was 84.6%. The mean follow‐up was 5 months (range 1–10.5 months).
• ? Five stents failed to alleviate the obstruction, and the patency rate was 77.3% (17/22).
• ? Patients who had had previous radiation therapy had a lower ureter patency rate in comparison with non‐radiation patients (50% vs 92.3% respectively, P= 0.039).
• ? The 6‐ and 9‐month patency rates were 81.0% with 11 stents and 27.0% with 3 stents, respectively.

CONCLUSIONS

• ? The results of the present study demonstrated that malignant or benign ureteral obstruction could be treated safely and sufficiently with the Resonance metallic stent.
• ? Careful patient selection is critical to achieve successful results.
• ? For malignant ureteral obstruction, previous radiation therapy is a risk factor for stent failure.

     

Open non‐microsurgical,laparoscopic or open microsurgical varicocelectomy for male infertility: a meta‐analysis of randomized controlled trials

Study Type – Therapy (systematic review) Level of Evidence 1a What's known on the subject? and What does the study add? There are several surgical techniques for the treatment of varicocele in infertile men, including open non‐microsurgical, laparoscopic and microsurgical varicocelectomy. It is currently unclear, however, which is the most beneficial method for patients. The present meta‐analysis found that microsurgical varicocelectomy is the most effective and least morbid method among the three varicocelectomy techniques for treating varicocele in infertile men.

OBJECTIVE

• ? To compare various techniques of open non‐microsurgical, laparoscopic or microsurgical varicocelectomy procedures to describe the best method for treating varicocele in infertile men.

PATIENTS AND METHODS

• ? We searched PubMed, Embase, the Cochrane Library, the Institute for Scientific Information (ISI) – Science Citation Index and the Chinese Biomedicine Literature Database up to June 2011. Only randomized controlled trials (RCTs) were included in the present study.
• ? The outcome measures assessed were pregnancy rate (primary), the incidence of recurrent varicocele, time to return to work, the incidence of postoperative hydrocele and operation duration (secondary).
• ? Two authors independently assessed the study quality and extracted data. All data were analysed using Review Manager (version 5.0).

RESULTS

• ? The present study included four randomized controlled trials comprising 1,015 patients in total.
• ? At the follow‐up endpoints, patients who had undergone microsurgery showed a significant advantage over those who had undergone open varicocelectomy in terms of pregnancy rate (odds ratio [OR]= 1.63, 95% confidence interval [CI]: 1.19–2.23].
• ? There was no significant difference between laparoscopic and open varicocelectomy (OR = 1.11, 95% CI: 0.65–1.88) or between microsurgery and laparoscopic varicocelectomy (OR = 1.37, 95% CI: 0.84–2.24).
• ? The incidences of recurrent varicocele and postoperative hydrocele were significantly lower after microsurgery than after laparoscopic or open varicocelectomy.
• ? The time to return to work after microsurgery and laparoscopic varicocelectomy was significantly shorter than that after open varicocelectomy.
• ? The operation duration of microsurgical varicocelectomy was longer than that of laparoscopic or open varicocelectomy.

CONCLUSIONS

• ? Current evidence indicates that microsurgical varicocelectomy is the most effective and least morbid method among the three varicocelectomy techniques for treating varicocele in infertile men.
• ? More high‐quality, multicentre, long‐term RCTs are required to verify the findings.

     

Single-stage reconstruction of complex anterior urethral strictures using overlapping dorsal and ventral buccal mucosal grafts

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? This technique has been reported to have an excellent success rate in the bulbar urethra, although no data exists for its use in the penile urethra. This is the first study to report successful use of the technique in the reconstruction of penile urethral strictures.

OBJECTIVE

• ? To review our initial experience with single‐stage overlapping dorsal and ventral buccal mucosa graft (BMG) urethroplasty for the reconstruction of complex anterior urethral strictures.

PATIENTS AND METHODS

• ? Among 696 urethroplasties performed at two tertiary urethroplasty centres from October 2007 to September 2010, single‐stage urethral reconstruction using urethral plate incision and/or excision and overlapping dorsal and ventral BMGs was used in 36 men (5%) with complex urethral strictures (mean length 4.5 cm).
• ? Demographic and perioperative data was tabulated and outcomes were analysed.

RESULTS

• ? Stricture location was bulbar (61%), penile (19%), or both bulbar and penile (20%).
• ? Dorsal grafts, applied only within the most severely strictured segment, measured a mean 42% of the opposing ventral graft length.
• ? At a mean follow‐up of 15.7 months, 32 of the 36 cases were successful (89%).
• ? Repeat urethroplasty was performed in all four recurrences, three of which were successful at a mean follow‐up of 16 months.

CONCLUSION

• ? Single‐stage reconstruction of focally obliterative long urethral strictures using overlapping dorsal and ventral BMGs is safe and effective.

     

Is joint hypermobility associated with vesico‐ureteral reflux? An assessment of 50 patients

Study Type – Aetiology (individual cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Recent studies have already shown associations between generalized joint hypermobility (GJH) and voiding and defecation dysfunction and/or slow transit constipation. Changes in extracellular matrix composition in vesico‐ureteric junction of vesico‐ureteral reflux (VUR) patients were also observed previously. This study is the first to assess joint mobility as a parameter for connective tissue composition in vesico‐ureteral reflux. We convincingly demonstrate that VUR patients have significantly more hypermobile joints compared to controls and this provides a new angle to the intriguing subjects of development of VUR and susceptibility to VUR.

OBJECTIVE

• ? To assess whether there is an increased prevalence of joint hypermobility in patients with vesico‐ureteric reflux (VUR).

MATERIALS AND METHODS

• ? We studied 50 patients with primary VUR and matched controls drawn from a reference population.
• ? Joint mobility was assessed using the Bulbena hypermobility score.

RESULTS

• ? We identified significantly more patients with VUR with generalized joint hypermobility than controls (24% vs 6.7%, P= 0.007).

CONCLUSION

• ? Our findings confirm our clinical observation of an increased rate of joint hypermobility in patients with VUR. We speculate that an altered composition of the connective tissue may contribute to the severity of the (pre‐existing) VUR phenotype.

     

Photoselective vaporization of the prostate using the 120-W lithium triborate laser in enlarged prostates (>120 cc)

Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE

• ? To evaluate experience with high power LBO laser for large prostates

PATIENTS AND METHODS

• ? Prospective database of 288 men treated with PVP from November 2006–2009
• ? 33 men identified to have transrectal ultrasound measured prostate size >120 cc
• ? All but 9 men not in urinary retention or on anticoagulant medications
• ? Average ASA Score 2.25 (range 1–4) with 11 having an ASA Score of 3 or more

RESULTS

• ? Mean operating time and laser time 109 and 86 minutes respectively
• ? IPSS, QoL and Qmax changes from baseline to 3 months for those not in retention were 24 to 8.6, 5.0 to 1.8 and 7.5 mL/s to 19.6 mL/s respectively
• ? Post void residual in these men fell from a mean of 235 mL to 88 mL
• ? Average fall in PSA was 38% for 22 men with paired PSA data
• ? Post operative urinary retention in 4 men resolved. 2 late onset clot urinary retention

CONCLUSION

• ? Early results demonstrate PVP to be safe and efficacious on early follow up in a high risk group of patients with significantly enlarged prostates, anticoagulation and urinary retention

     

In the era of micro‐dissection sperm retrieval (m‐TESE) is an isolated testicular biopsy necessary in the management of men with non‐obstructive azoospermia?

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? There are a number of ways to retrieve sperm from the testis however there is no universal consensus as to which is the best approach. Furthermore, there is controversy as to whether a diagnostic biopsy has a role in management of non‐obstructive azoospermia (NOA). This study gives support to the growing consensus that micro‐dissection TESE (m‐TESE) is the optimum approach to retrieve sperm in patients with NOA even when previous attempts have failed. Moreover, it strongly suggests that histology is unreliable in determining success rates with m‐TESE and therefore isolated diagnostic biopsies should not be performed.

OBJECTIVES

• ? To assess the outcome of sperm retrieval using micro‐dissection‐TESE (m‐TESE) and simultaneous diagnostic biopsy in NOA to determine if the final definitive histology correlated with the outcome of sperm retrieval by m‐TESE in men with NOA.
• ? To determine if there was a correlation between FSH levels and positive sperm retrieval rates and assessed the success rate of m‐TESE as either a primary or a salvage procedure after previous negative sperm retrieval.
• ? The EAU guidelines (2010) recommend that in men with non obstructive azoospermia ‘a testicular biopsy is the best procedure to define the histological diagnosis and the possibility of finding sperm’. However, these guidelines do not identify which patients should have a diagnostic biopsy and if this biopsy should be performed as an isolated procedure or synchronously with sperm retrieval. It is also suggested that there is a correlation between the histological diagnosis and possibility of finding sperm on testis biopsy.

PATIENTS AND METHODS

• ? 100 men with NOA underwent a m‐TESE sperm retrieval between 2005 and 2010 at a single centre.
• ? All patients underwent hormonal analysis (serum FSH, Testosterone and LH levels) and genetic analyses after full counselling including; Y‐deletion, CF‐gene analysis and karyotype.
• ? Thirty five men had previously undergone unsuccessful TESA/TESE or diagnostic biopsy at other centres. All patients underwent synchronous sperm retrieval and biopsy of the testis, which was sent for histopathological examination on the day of an ICSI cycle or as an isolated procedure.

RESULTS

• ? Mean age of patients was 37.25 (range 29–56 years). The mean serum FSH levels in the Sertoli cell only, maturation arrest and hypospermatogenesis groups were 21.3 IU/L (2.8–75), 16.18 (1.6–67) and 14.17 IU/L (0.8–42.3) respectively. SR rates in the respective groups were 42.85%, 26.6% and 75.86% (P= 0.023). There were no post‐operative complications.
• ? In the 35 men who had previously undergone unsuccessful procedures elsewhere, the SR rates were 57.1%. The overall sperm retrieval rate was 50%. There was no correlation between SR and FSH levels (P= 0.28).

CONCLUSION

• ? M‐TESE should be considered the gold standard for retrieval of testicular sperm in NOA, even in cases where there has been previously unsuccessful attempts. FSH levels and histology cannot be used to predict the success of sperm retrieval. An isolated diagnostic testicular biopsy is not recommended in men with NOA, as a significant proportion of men undergoing m‐TESE will have successful a sperm retrieval irrespective of previous histology or previous unsuccessful surgery.

     

Survival of patients with small cell carcinoma of the prostate during 1973-2003: a population-based study

Study Type – Therapy (inception cohort) Level of Evidence 2a What's known on the subject? and What does the study add? Small cell carcinoma of the prostate is a lethal disease. Survival data is currently based on case reports and single institution case series which give limited information on its prognostic factors. In this large population‐based study, we provide more robust estimates of survival and have defined the prognostic factors.

OBJECTIVE

• ? To describe the survival of patients with primary small cell carcinoma (SCC) of the prostate and assess prognostic factors based on a large population sample.

PATIENTS AND METHODS

• ? A total of 241 cases of SCC of the prostate were reported to the Surveillance, Epidemiology, and End Results (SEER) registries from 1973 to 2003 of which 191 cases were included in our study.
• ? We used the Kaplan–Meier method for estimating survival, and Cox proportional hazard regression modelling to evaluate prognostic variables.

RESULTS

• ? The overall age‐adjusted incidence rate was 0.278 per 1 000 000 (95% confidence interval, 0.239–0.323).
• ? In all, 60.5% presented as metastatic disease compared with 39.5% who presented as local/regional disease (P= 0.012).
• ? The 12, 24, 36, 48 and 60 months observed survival rates were 47.9%, 27.5%, 19%, 17% and 14.3% respectively.
• ? On univariate analyses, age <60, concomitant low‐grade prostatic adenocarcinoma, absence of metastasis, prostatectomy and radiation therapy were favourable prognostic factors.
• ? In multivariate regression modelling, age, pathology and stage were strong predictors of survival.

CONCLUSIONS

• ? Using the SEER database, we present the largest study describing the epidemiology of primary SCC of the prostate.
• ? We found age, concomitant low‐grade prostatic adenocarcinoma, and stage of the disease to be the strongest predictors of survival for patients with prostatic SCC.
• ? Future studies evaluating a broader range of clinical and molecular markers are needed to refine the prognostic model of this relatively rare disease.

     

Endoscopic management of vesicoureteral reflux in adult women

Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE

• ? To describe our endoscopic management of adult women with vesicoureteral reflux (VUR) and associated outcomes.

PATIENTS AND METHODS

• ? We retrospectively identified 19 adult women who presented for the endoscopic treatment of VUR from November 2001 to January 2008.
• ? Each patient was diagnosed with VUR by voiding cystourethrogram or nuclear cystourethrogram after an episode of pyelonephritis or recurrent urinary tract infections with renal scarring on ultrasound.
• ? A dimercaptosuccinic acid renal scan was performed prior to treatment. All patients underwent endoscopic treatment with dextranomer/hyaluronic acid copolymer (Deflux®). Patients with bilateral VUR received bilateral injections during the same procedure.
• ? Follow‐up imaging was obtained and success was strictly defined as no degree of VUR. Patients with residual VUR received repeat endoscopic treatment.

RESULTS

• ? Nineteen patients with a mean age of 22 years old (range 18–33 years old) underwent endoscopic treatment for VUR. A total of 79% (15/19) had pre‐existing risk factors for VUR, including prior open anti‐reflux surgery (26%), family history of VUR (26%) and childhood diagnosis of VUR (26%).
• ? Imaging revealed that 47% (9/19) had renal scarring and 26% (5/19) had bilateral VUR. The success rate was 79% (19/24) after one treatment, 92% (22/24) after 5 patients received a second treatment, and 96% (23/24) after 2 patients received a third treatment. There were no perioperative complications.

CONCLUSION

• ? Endoscopic management of VUR is both safe and effective in adult women.

     

Incidence and outcomes of ductal carcinoma of the prostate in the USA: analysis of data from the Surveillance, Epidemiology, and End Results program

Study Type – Prognosis (individual cohort) Level of Evidence 2b What's known on the subject? and What does the study add? Ductal prostate cancer is a rare histological variant of prostate cancer. The incidence, natural history and outcomes of patients with ductal have not been described. We demonstrate that ductal prostate cancers often present with advanced stage and a high percentage of men die from their disease.

OBJECTIVE

• ? To use the national Surveillance, Epidemiology, and End Results (SEER) cancer registry to describe the natural history, national incidence and treatment patterns for ductal prostate cancer (PCa) over the last 20 years, as the available literature on ductal PCa is limited to small case series because of few patient numbers.

PATIENTS AND METHODS

• ? From the SEER registry, 693 men with ductal PCa were identified from 1970.
• ? The demographics, clinical features and cause of death data were collected from men with ductal and acinar histological types.

RESULTS

• ? The incidence of ductal PCa has increased over each decade, but the overall percentage of ductal relative to acinar PCa has remained stable.
• ? Men with ductal PCa were more likely to present with advanced disease (30% T3 with ductal PCa, compared with 7% with acinar PCa).
• ? Men with ductal PCa underwent similar rates of radical surgery, lower rates of radiotherapy but a higher frequency of outlet (transurethral resection) procedures.
• ? Men with ductal PCa had a significantly greater rate of death from PCa (12% vs 4%) than men with acinar PCa.
• ? Comparing PCa‐specific mortality, men with ductal PCa had similar rates of death to men with Gleason 4 + 4 grade acinar PCa.

CONCLUSIONS

• ? Despite a stable incidence, ductal PCa remains an aggressive PCa usually presenting with advanced clinical stage and resulting in a high rate of PCa‐specific mortality similar to Gleason 4 + 4 acinar PCa.
• ? Patients would probably benefit from combined modalities including radical surgery, radiotherapy and palliative outlet procedures.

     

Focal cryotherapy for localized prostate cancer: a report from the national Cryo On-Line Database (COLD) Registry

Study Type – Therapy (data synthesis) Level of Evidence 2b What's known on the subject? and What does the study add? The efficacy of prostate cancer screening using PSA testing is still being debated, with conflicting results in randomized trials. The study shows that, even using the hypothesis most favourable to prostate cancer screening with PSA, the net number of years of life does not favour screening.

OBJECTIVE

• ? To evaluate the impact of the implementation a prostate‐specific antigen (PSA) screening programme using the European Randomized Study of Screening for Prostate Cancer (ERSPC) results and taking into account the impact of prostate biopsy and over‐treatment on mortality.

MATERIALS AND METHODS

• ? We used a model based on the number of years of life gained and lost owing to screening, using data reported in the ERSPC.
• ? We conducted a critical evaluation of the ERSPC results and of the Swedish arm of the study.

RESULTS

• ? Accounting for biopsy‐specific mortality and for over‐treatment, the balance of number of years of life was negative in the ERSPC study, with an estimated loss of 3.6 years of life per avoided death.
• ? The number of years of life becomes positive (real gain) only when fewer than 666 screened individuals are required to avoid one death.
• ? We found that in the Swedish arm of the ERSPC there was a biopsy rate of 40% compared with 27% in the ERSPC overall. The over‐treatment rate was also greater with 4.1% compared with 3.4% overall.
• ? For the last 20 years, there has been a marked difference in prostate cancer‐specific mortality between Sweden and the rest of Europe: in 2005, for the age group 65–74 the rate was 140 per 100 000 person years in Sweden and ～80 per 100 000 for the rest of Europe.

CONCLUSION

• ? Overall, PSA testing in Europe is associated with a loss in years of life and should thus not be recommended.

     

Organ‐preserving surgery for penile cancer: description of techniques and surgical outcomes

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Organ‐preserving surgeries for penile cancer have been described to reduce the morbidity associated with traditional operations. Patients derive better functional outcomes from penile‐preserving surgery, although local recurrence rates can be higher. Excellent results can be obtained at large‐volume centres. With close follow‐up, local recurrences can be identified and treated promptly (often with further local excision).

OBJECTIVE

• ? To describe the outcomes of organ‐preserving surgery for penile cancer at a UK tertiary referral centre.

PATIENTS AND METHODS

• ? Patients at Sunderland Hospital (UK) between 2001 and 2008 who had squamous cell tumours limited to the glans penis underwent penile‐preserving surgery including total glansectomy and glanuloplasty, partial glansectomy, glans relining and distal penectomy with glans reconstruction.
• ? Recurrence rates, cosmetic and functional outcomes were recorded.

RESULTS

• ? In all, 65 patients were identified with a median follow‐up of 40 months. Local recurrence was present in four patients (6%) despite 72% having intermediate or poorly differentiated tumours and 30% with T2 disease.
• ? Complications included partial graft loss (1.5%), graft contractures (4.5%) and meatal stenosis (7.5%).
• ? In all, 5% were deemed to have poor cosmetic outcome and 85% described good erections at 1 year after surgery.

CONCLUSION

• ? Penile‐preserving surgery can achieve good penile cancer control with minimal morbidity and reduced psychosexual side‐effects.