Aaron Spitz

ORTHOTOPIC URINARY DIVERSION WITH PRESERVATION OF ERECTILE AND EJACULATORY FUNCTION IN MEN REQUIRING RADICAL CYSTECTOMY FOR NONUROTHELIAL MALIGNANCY: A NEW TECHNIQUE

PURPOSE Nerve sparing techniques to preserve sexual function in men undergoing cystoprostatectomy have been well documented. The patient who desires to remain fertile with ejaculatory function poses an additional challenge. We describe a new technique for radical cystectomy and orthotopic diversion with preservation of the vasa deferentia, seminal vesicles, posterior prostate and neurovascular bundles. MATERIALS AND METHODS Four men with a median age of 26 years presented with bladder pathology necessitating cystectomy, including signet ring carcinoma of the bladder dome, leiomyosarcoma of the anterior bladder wall, leiomyosarcoma of the lateral bladder wall, and extensive polypoid cystitis glandularis of the trigone and posterior wall refractory to conservative and transurethral management. All patients wished to maintain fertility and ejaculatory function. We detail the surgical technique of extirpation of the bladder and anterior proximal prostate en bloc with preservation of the vasa deferentia, seminal vesicles, posterior prostate and neurovascular bundles as well as construction of an orthotopic reservoir. RESULTS Followup ranges from 4 months to 5 years. All patients remain completely continent and void to completion without difficulty. Erectile function is normal in all cases. Of 3 patients who ejaculate antegrade 1 has fathered a child. The remaining patient ejaculates retrograde. There has been no tumor recurrence. CONCLUSIONS The technique of cystectomy with preservation of the vasa deferentia, seminal vesicles, posterior prostate and neurovascular bundles is an excellent option in men with nonurothelial malignancy or another pathological condition that necessitates cystectomy, and in whom preservation of fertility and potency is desirable. All of our patients are fully potent and achieve ejaculation. Even the patient with retrograde ejaculation remains fertile. In terms of practicality semen retrieval from urine is much simpler than epididymal sperm aspiration and in vitro fertilization.

Bilateral emphysematous pyelonephritis: A case report and review of the literature

Emphysematous pyelonephritis is a rare, rapidly progressive, life-threatening infection of the renal parenchyma. It most commonly is unilateral, is found almost exclusively in diabetics, is associated with gas-forming coliform bacteria, and is characterized by the presence of gas within the renal parenchyma. Early aggressive therapy (combined medical and surgical) is the hallmark of successful treatment. A high index of suspicion coupled with radiographic imaging is essential to make a timely diagnosis and guide therapeutic intervention. Bilateral emphysematous pyelonephritis is an even more rare phenomena, with only 14 reported cases in the English literature and is associated with a high patient mortality. We herein present an additional case and review the literature as it pertains to bilateral emphysematous pyelonephritis. Appropriate care requires aggressive combined medical and surgical therapy in an attempt to preserve renal function without increased mortality.

VENA CAVAL RESECTION FOR BULKY METASTATIC GERM CELL TUMORS: AN 18-YEAR EXPERIENCE

PURPOSE The operative management and followup of vena caval resection for bulky metastatic germ cell tumors have been previously described in 3 series. In 1989 Ahlering and Skinner described their experience with 12 patients. We now update this experience with the most recent followup on 19 patients. MATERIALS AND METHODS From April 1978 to May 1995, 19 men underwent retroperitoneal lymph node dissection for stage B3 (N3) or C (N3, M+) germ cell tumor after induction chemotherapy. In all cases the inferior vena cava was resected because of extensive thrombosis or direct involvement of the vessel wall by a tumor. The inferior vena cava was resected from just below the renal veins to beyond the level of disease involvement. Complete resection of retroperitoneal disease was accomplished in all patients. Morbidity and mortality were examined. RESULTS The mean hospital stay was 10 days (range 7 to 13) for uncomplicated recoveries (9 patients) versus 19 days (range 6 to 32) for complicated recoveries (10 patients). Followup ranged from 1 month to 16 years. Complications included prolonged ileus, small bowel obstruction, fascial dehiscence and pneumonia with pleural effusion. Chronic edema persisted in 3 of 11 patients with followup of greater than 6 months. Of the 6 patients who died of disease recurrence 4 did not have normalization of tumor markers before surgery, and all 4 had persistence of cancer in the resected specimen. Seven patients are without disease at followup of 24 months to 16 years. All survivors had normalized tumor markers before surgery. Only 1 patient (5%) had retroperitoneal recurrence. CONCLUSIONS En bloc vena caval resection for tumor involvement or extensive thrombosis can be associated with short and long-term morbidity, is feasible, and may contribute to a prolonged tumor-free interval and a chance for cure.

Autotransplantation as an Effective Therapy for the Loin Pain-Hematuria Syndrome: Case Reports and a Review of the Literature

PURPOSE The loin pain-hematuria syndrome is a well recognized but poorly understood clinical condition in which patients have progressive loin pain accompanied by hematuria but they maintain stable renal function. We present 2 cases effectively treated with renal autotransplantation, as well as a review of the literature, and a coherent algorithm for the diagnosis and treatment of this condition. MATERIALS AND METHODS The medical literature concerning the loin pain-hematuria syndrome was reviewed. In 1994 we performed renal autotransplantation on 2 patients with the loin pain-hematuria syndrome at our institution. RESULTS Extensive urological evaluation revealed no obvious underlying abnormalities in patients with the loin pain-hematuria syndrome. Theories for the pathogenesis of this condition range from thrombotic phenomena to autoimmune processes. Treatment efforts have been directed primarily towards pain management. Narcotic dependence becomes progressive as the pain becomes debilitating. In extreme cases nephrectomy is performed despite normal renal function. Several invasive methods of nerve block and enervation provide only temporary relief. Renal autotransplantation provided lasting cessation of loin pain in both of our patients with followup of 1.5 and 2.5 years, and this intervention has been shown to provide the most durable pain relief in other series. CONCLUSIONS Renal autotransplantation provides the most durable, nonnarcotic, nephron sparing relief for patients with the loin pain-hematuria syndrome. Further investigation is necessary to elucidate the pathophysiology of this debilitating condition.

CONTEMPORARY APPROACH TO THE MALE INFERTILITY EVALUATION

Evaluation of infertile couples has revealed that male factor infertility contributes to the problem in up to 50% of cases. Evaluation of the male infertility patient may include endocrine studies, sophisticated semen testing, and select radiographic studies. Reversible and life-threatening causes of male infertility should be identified before proceeding directly to assisted reproductive technology. For cases with irreversible causes, a proper evaluation can identify patients who may be treated with the breakthrough method of intracytoplasmic sperm injection. Many men who were previously thought to be infertile may now initiate their own biologic pregnancies. This article emphasizes the essentials of the contemporary approach to evaluating the male factor in an infertile couple.

PD13-04 RESULTS OF A NORTH AMERICAN SURVEY ON THE CHARACTERISTICS OF MEN BEING ASSESSED IN MALE INFERTILITY CLINICS: THE ANDROLOGY RESEARCH CONSORTIUM

INTRODUCTION AND OBJECTIVES: The influence of parental demographics on fertility and birth outcomes is a topic of great interest to both epidemiologists and the lay public. Given logistics and certainty of exposures, data on all births in the US is often reported at the maternal level. While paternal characteristics are also known to influence birth outcomes, generational trends of paternal characteristics of child births within the United States have been poorly characterized. We sought to summarize the demographics of fathers in the US over the past 4 decades as well as describe the patterns of missing paternal data on birth certificates. METHODS: We evaluated 158,621,397 U.S. births spanning from 1973 to 2015 using data from the National Vital Statistics System of the Centers for Disease Control. Paternal, maternal and infant characteristics were analyzed and paternal ages of all births and first births were presented over time along with the mean difference in age between parents. Characteristics of births with known and unknown paternity were also compared. RESULTS: There has been a significant increase in mean paternal age among whites, blacks and asians over the past 40 years. In 1973, the mean paternal age for all births was 27.6, and 24.6 for first births, rising to 31.4 and 29.1, respectively, in 2015. Paternal age increased for all races combined and each race individually. However, interracial differences in mean age were apparent with asians > whites > blacks. The mean age difference between parents was similar over the past 40 years. In 1973, the mean parental age difference was 2.8 years’2.7 years for whites, 3.2 years for blacks and 4.2 years for asians. In 2015, the mean overall difference was 2.5 years with the difference between asian fathers and their partners decreasing the most to 3.2 years. Of all the recorded births in 1973, 91.3% had knowledge of paternal identity. This fell to 85.5% of fathers identified in 1991 and resides at 88.4% in 2015. Over the past decade, mothers younger than 20 years had the lowest proportion of reported paternal identity at 67.7% with black mothers under 20 at 50.4%. Overall, births without paternal identity were more likely associated with young, black mothers who reported less weight gain during pregnancy, and lower birth weight children. CONCLUSIONS: Overall, paternal age is rising in the US in parallel with maternal age, a trend encompassing all races. The proportion of missing paternal data is also increasing in recent years. Given the association between paternal factors and birth characteristics, further understanding of these trends is necessary.