Aaron M. Bernie

Comparison of microdissection testicular sperm extraction, conventional testicular sperm extraction, and testicular sperm aspiration for nonobstructive azoospermia: a systematic review and meta-analysis

OBJECTIVE To investigate the relative differences in outcomes among microdissection testicular sperm extraction (micro-TESE), conventional testicular sperm extraction (cTESE), and testicular sperm aspiration (TESA) in men with nonobstructive azoospermia. DESIGN Systematic review and meta-analysis. SETTING Outpatient academic and private urology clinics. PATIENTS(S) Men with nonobstructive azoospermia. INTERVENTION(S) Micro-TESE, cTESE, or TESA. MAIN OUTCOME MEASURE(S) Sperm retrieval (SR). RESULT(S) Fifteen studies with a total of 1,890 patients were identified. The weighted average age of the patients was 34.4 years, the follicular stimulating hormone level was 20.5 mIU/mL, the T was 373 ng/dL, and the testicular volume was 13.5 mL. In a direct comparison, performance of micro-TESE was 1.5 times more likely (95% confidence interval 1.4-1.6) to result in successful SR as compared with cTESE. Similarly, in a direct comparison, performance of cTESE was 2.0 times more likely (95% confidence interval 1.8-2.2) to result in successful SR as compared with TESA. Because of inconsistent reporting, evaluation of other procedural characteristics and pregnancy outcomes was not possible. CONCLUSION(S) Sperm retrieval was higher for micro-TESE compared with cTESE and for cTESE compared with TESA. Standardization of reported outcomes as well as combining all available SR data would help to further elucidate the SRs of these procedures.

Outcomes of microdissection testicular sperm extraction in men with nonobstructive azoospermia due to maturation arrest.

OBJECTIVE To evaluate sperm retrieval in men with nonobstructive azoospermia and maturation arrest (MA) undergoing microdissection testicular sperm extraction (micro-TESE). DESIGN Retrospective chart review. SETTING Tertiary referral center. PATIENT(S) Men with nonobstructive azoospermia and MA who underwent micro-TESE. INTERVENTION(S) Microdissection TESE. MAIN OUTCOME MEASURE(S) Sperm retrieval rate (SRR). RESULT(S) A total of 211 patients (13%) had a histologic finding of MA at the most advanced level. The overall SRR was 52%. A total of 146 patients were classified as having early MA (arrest at the primary spermatocyte stage), and 65 as having late MA (early spermatid stage). The SRR in men with early, vs. late, MA was 40% vs. 78%. Of the 211 men with MA, 51 had diffuse MA (100% of tubules showed MA). The SRR was significantly lower in men with diffuse vs. focal MA (35% vs. 57%). On multivariable analysis, late MA and higher follicle-stimulating hormone levels were positively associated with successful sperm retrieval. CONCLUSION(S) Sperm were successfully identified in up to one half of the men with MA after micro-TESE. Among men with MA, late MA seems to be the best predictor of successful sperm retrieval with micro-TESE.

Vasectomy reversal in humans

Vasectomy is the most common urological procedure in the United States with 18% of men having a vasectomy before age 45. A significant proportion of vasectomized men ultimately request vasectomy reversal, usually due to divorce and/or remarriage. Vasectomy reversal is a commonly practiced but technically demanding microsurgical procedure that restores patency of the male excurrent ductal system in 80–99.5% of cases and enables unassisted pregnancy in 40–80% of couples. The discrepancy between the anastomotic patency rates and clinical pregnancy rates following vasectomy reversal suggests that some of the biological consequences of vasectomy may not be entirely reversible in all men. Herein we review what is known about the biological sequelae of vasectomy and vasectomy reversal in humans, and provide a succinct overview of the evaluation and surgical management of men desiring vasectomy reversal.

Microsurgical epididymal sperm aspiration: indications, techniques and outcomes.

Microsurgical epididymal sperm aspiration (MESA) refers to retrieval of sperm-containing fluid from optimal areas of the epididymis that are selected and sampled using high-power optical magnification provided by an operating microscope. Retrieved sperm are subsequently used for intracytoplasmic sperm injection (ICSI) to induce fertilization and pregnancy. MESA is considered by many experts to be the gold standard technique for sperm retrieval in men with obstructive azoospermia given its high yield of quality sperm, excellent reported fertilization and pregnancy rates, and low risk of complications. However, MESA must be performed in an operating room, requires microsurgical skills and is only useful for reproduction using ICSI. Herein we present an overview of the evaluation of candidate patients for MESA, the technical performance of the procedure and the outcomes that have been reported.

Changes in pathologic outcomes and operative trends with robot-assisted laparoscopic radical prostatectomy.

Introduction: We hypothesized that there is a reverse stage migration, or a shift toward operating on higher-risk prostate cancer, in patients undergoing robot-assisted laparoscopic prostatectomy (RALP). We therefore evaluated the stage of disease at the time of surgery for patients with prostate cancer at a large tertiary academic medical center. Materials and Methods: After institutional review board approval, we reviewed all patients that had undergone robotic prostatectomy. These patients were separated into three categories: An early era of 2005-2008, intermediate era of 2009-2010, and a current era of 2011-2012. Results: A total of 3451 patients underwent robotic prostatectomy from 2005 to 2012. The proportion men with clinical T1 tumors declined from 88.3% in the early era to 72.2% in the current era (P < 0.0001). Men with preoperative biopsy Gleason 6 disease decreased from the early to the current era (P < 0.0001), while men with preoperative biopsy Gleason ≥ 8 showed the opposite trend, increasing from the early to the current era (P = 0.0002). From the early to the current era, the proportion of patients with National Comprehensive Cancer Network (NCCN) low risk prostate cancer decreased, while those with NCCN intermediate and high-risk disease increased. The proportion of pathologic T3 disease increased from 15.5% in the early to 30.6% in the current era (P < 0.0001). On the other hand, the proportion of pathologic T2/+ SMS (surgical margin status) decreased from 6.6% in the early era to 3.1% in the current era (P = 0.0002). Conclusions: We have demonstrated a reverse stage migration in men undergoing robotic prostatectomy. Despite the increasing proportion of men with extra-capsular disease undergoing RALP, the surgical margin status has remained similar. This could reflect both the changing dynamics of the population opting for surgery as well as the learning curve of the surgeons.

Reduction en masse in a 7-year-old boy: an interesting case

Reduction en masse is a complication of inguinal hernia reduction in which a hernia is reduced back into the peritoneal cavity, but a loop of bowel remains trapped inside the hernia sac after reduction. Reduction en masse can be difficult to diagnose because of generalized and nonspecific symptoms. We describe a 7-year-old boy with an atypical presentation of reduction en masse after hernia reduction. The patient was a previously healthy child who presented with a mildly painful right inguinal mass of 1 day duration. An incarcerated hernia was noted, and after reduction, the pain dissipated for a short period, only to return with pain in the right lower quadrant and generalized peritoneal irritation. At surgical exploration, a reduction en masse was definitively diagnosed, and the incarcerated bowel was released from the hernia sac.

Lymph Node Dissection in Prostate Cancer Surgery

Lymph node dissection performed during radical prostatectomy is the gold standard for determining lymph node invasion (LNI) in patients with prostate cancer. The role of pelvic lymph node dissection in patients with low-, intermediate-, and high-risk prostate cancer has been evaluated in depth to determine the need for lymph node removal, as well as the extent of how aggressively lymph nodes should be dissected in these patients. While imaging has not played a significant role in determining LNI in prostate cancer in the past, recent advances in PET/CT, MRI, and sentinel lymph node dissection have provided another modality to identify lymph node metastases with increasing success. Many studies have been done to evaluate the preoperative variables that can be used to predict the likelihood of lymph node invasion and determine nomograms for when pelvic lymph node dissection (PLND) should be performed and whether that dissection should be limited or extended. Despite these studies, no one predictive model has been established as the gold standard, and multiple models are used in clinical practice today. The role of PLND and its effect on outcomes in prostate cancer patients has also been studied. It has been suggested that removal of lymph nodes in some cases of prostate cancer may improve clinical outcomes, decrease biochemical recurrence, and increase long-term survival rates. The introduction of minimally invasive surgery, particularly the use robotic-assisted radical prostatectomy (RARP), has raised further questions about when PLND should be performed. The comparison of outcomes of PLND in RARP versus open prostatectomy has generated new questions about what the standard for PLND should entail.