C.B. Dhabuwala

Clinical versus subclinical varicocele: improvement in fertility after varicocelectomy

OBJECTIVE To assess the fertility after varicocelectomy in men with subclinical varicocele. DESIGN We define subclinical varicocele as the varicocele detected by Doppler examination of the scrotum, in which no varicocele was found on clinical examination. Varicocelectomy was performed on subclinical varicocele, and fertility was assessed. SETTING We reviewed the records of 54 men who underwent unilateral varicocelectomy at the Department of Urology, Wayne State University, between 1986 and 1987. PATIENTS Records of 54 men were analyzed. Thirty-eight (70%) of the varicocele were diagnosed clinically (confirmed by Doppler examination) in group 1. In 16 (30%) men, the varicocele was diagnosed by Doppler examination only, with no varicocele detectable clinically, subclinical varicocele (group 2). RESULTS Spermiograms improved in 76% of the patients in group 1 and in 81% of the patients in group 2. Fertility was assessed after 2 years of varicocelectomy. Eighteen (47%) of 38 patients in group 1 and 8 (50%) of 16 men in group 2 managed to impregnate their partners. Statistical analysis by chi 2 shows similar improvement in fertility potential between the two groups (P = 0.86). Multivariate repeated measure analysis showed significant improvement in sperm density (P = 0.0006) and sperm morphology (P = 0.0016) after varicocelectomy. CONCLUSIONS These data suggest that varicocelectomy, in infertile men with subclinical varicocele, leads to fertility in 50% of the patient population as compared with 47% in clinical varicocele group. We suggest that the use of sophisticated, noninvasive techniques such as Doppler may have a place in the management of male infertility to detect subclinical varicocele.

Effects of Long-Term Cocaine Exposure on Spermatogenesis and Fertility in Peripubertal Male Rats

PURPOSE This study was conducted to investigate the effects of long-term administration of cocaine on spermatogenesis and fertility in adult male rats. MATERIALS AND METHODS Thirty-day-old male Sprague-Dawley rats were given cocaine hydrochloride (15 mg./kg. body weight, corresponding to an average single dose for a heavy cocaine user) either daily or twice weekly (weekend group, cocaine given on Saturday and Sunday) and mated with pregnancy-proven female rats after 100 and 150 days of exposure to the drug. Pregnancy rates and litter birth weights were evaluated. Serum testosterone, follicle stimulating hormone and luteinizing hormone levels were measured in all adult rats. Morphologic analysis of the testis entailed the evaluation of quantitative and qualitative histologic parameters to assess the effect of cocaine on various stages of spermatogenesis. RESULTS After 100 days of treatment, the rats receiving daily cocaine had a pregnancy rate of only 33% versus 86% for the controls (p < 0.05). In rats exposed to cocaine for 150 days the pregnancy rate was 50% compared with 100% for controls (p < 0.05). The birth weights of offspring from the group receiving daily cocaine was 10% less than that of controls (p < 0.05). The weight of the testis and epididymis was not affected by cocaine exposure. Morphometric analysis showed significant differences between the cocaine-treated groups (both the daily cocaine and twice weekly cocaine groups) and their respective controls. The mean diameter of seminiferous tubules in the daily and twice weekly cocaine groups was reduced when compared with their respective controls. These differences between treated groups and their controls were statistically significant (p < 0.05). Similarly the thickness of the germinal epithelium was less in the cocaine-treated groups than in the controls (p < 0.05). Degenerating cells were more numerous in both daily and twice weekly cocaine groups than the controls. Furthermore, the number of step VII spermatids was reduced in both daily and twice weekly cocaine groups, a difference that was statistically significant (p < 0.05). CONCLUSION Our findings demonstrate that chronic administration of cocaine to peripubertal male rats has a profound effect on their testicular function. Even with twice weekly administration there was a significant adverse effect on spermatogenesis although this was not manifested by diminished fertility in this group. These findings confirm that chronic administration of cocaine to male rats can have a deleterious effect on spermatogenesis and fertility.

Long-Term Mechanical Reliability of Multicomponent Inflatable Penile Prosthesis: Comparison of Device Survival

OBJECTIVES To determine the mechanical reliability of multicomponent inflatable penile prosthesis, comparing five different types of devices, as well as the two-piece versus three-piece as a group. METHODS We followed 83 patients with two-piece and 283 patients with three-piece inflatable penile prostheses for a mean time of 66 months. At a cutoff of 63 months, mechanical complication rates were reviewed and statistically analyzed. RESULTS Thirty-one device-related complications occurred, and all were secondary to fluid leakage. The Mentor Alpha-1 prosthesis was significantly better than the Mentor Mark-II in terms of mechanical reliability (P = 0.01). A trend was noted toward the AMS 700 Ultrex inflatable penile prosthesis having fewer mechanical complications than the Mentor Mark-II (P = 0.06). In addition, a trend toward all three-piece prostheses being more mechanically reliable than the two-piece was noted (P = 0.08). The Mentor Alpha-1 device had a higher cumulative proportional survival (0.957) than all other devices (0.842 for AMS 700 Ultrex, 0.839 for AMS 700 CX, 0.783 for Mentor GFS, and 0.750 for Mentor Mark-II). CONCLUSIONS As a group, a trend was noted toward the three-piece prosthesis having better mechanical reliability than the two-piece prosthesis. Comparisons between the individual types of prostheses showed thatthe Mentor Alpha-1 device was significantly more mechanically reliable than the Mentor Mark-II device, and a trend was noted toward the AMS 700 Ultrex device having fewer mechanical complications than the Mentor Mark-II. The Mentor Alpha-1 prosthesis had the highest cumulative proportional survival.

EFFECT OF SURGICALLY INDUCED VARICOCELE ON TESTICULAR BLOOD FLOW AND SERTOLI CELL FUNCTION

Abstract Objectives. To evaluate the effect of varicocele on testicular blood flow and expression by Sertoli cells of transferrin and androgen-binding protein (ABP), to determine whether varicoceles impair Sertoli cell function. Methods. Experimental varicocele was established in male Sprague-Dawley rats by partial ligation of the left renal vein. The control group received a sham operation. At 30 minutes after surgery, rats underwent a xenon-133 washout study, and at 30 days after surgery, transferrin, ABP, and testicular blood flow were evaluated. Expression of transferrin and ABP were evaluated using immunohistochemical techniques. Testicular blood flow was measured using xenon-133 clearance techniques. Statistical analyses were done with an independent t test. Results. The testicular blood flow was 16.7 ± 1.25 mL/100 g/min in varicocele-bearing rats and 21.01 ± 0.46 mL/100 g/min in sham-operated rats 30 minutes after surgery. Testicular blood flow remained decreased at 30 days in varicocele-bearing rats (15.12 ± 1.08 mL/100 g/min) and remained stable in the control group (19.45 ± 0.55 mL/100 g/min). The expression of transferrin and ABP was significantly reduced in varicocele-bearing rats compared with the control group. Conclusions. Our study suggests that a decrease in testicular blood flow may lead to impaired Sertoli cell function in varicocele-bearing rats.

OUTCOME ANALYSIS OF PENILE IMPLANT SURGERY AFTER EXTERNAL BEAM RADIATION FOR PROSTATE CANCER

PURPOSE We evaluated the success and possible complication rates of penile implant surgery in patients who underwent external beam radiation therapy for prostate cancer. MATERIALS AND METHODS We reviewed the charts of 43 patients who underwent penile implant surgery after radiation therapy for prostate cancer. The type, dose and volume of radiation were assessed. The types of surgical approach and prosthesis as well as complications were recorded. A total of 34 patients was alive and traceable, and 9 were untraceable (7 dead and 2 missing). The 34 traceable patients were interviewed personally or by telephone to evaluate the function of and satisfaction with the penile implant. Followup of the 9 untraceable patients was assessed through a chart review. RESULTS A total of 35 patients (81%) received definitive radiation therapy to the prostate and seminal vesicles, and 8 (19%) underwent radical retropubic prostatectomy followed by radiation therapy to the prostatic bed. Mean age at implant surgery was 67 years (range 36 to 83). In the 43 men 46 procedures were done and mean followup was 40 months. None of the patients in this series had infection or erosion. Of the men 24 (71%) use the prosthesis at least once weekly or more for sexual intercourse, 6 (17%) use it twice monthly, 4 (12%) are not sexually active despite a functioning implant, 2 are not sexually active because of a lack of sexual partners, and 2 are not satisfied with the implant and would not recommend this device. Discomfort from the penile implant was reported by 2 patients, although they currently use the implant for intercourse at least twice weekly. CONCLUSIONS Penile prosthesis surgery can be safely and effectively performed after radiation therapy with minimal intraoperative and postoperative complications, and an excellent patient satisfaction rate.

Impotence Following Delayed Repair of Prostatomembranous Urethral Disruption

A group of 26 patients with pelvic fracture and disruption of the prostatomembranous urethra were evaluated for impotence. Impotence was defined as inability to achieve an erection firm enough for vaginal penetration. Of the patients 25 were potent before the injury, whereas 1 was only 7 years old at injury. Seven patients admitted to being potent after the injury but before the final urethral anastomosis. Four patients became potent after urethroplasty. The definitive operation to the urethra was done approximately 6 months after the injury. Only 11 of the 26 patients (46%) reported erections adequate for vaginal penetration. No patient who had adequate erections before urethroplasty became impotent postoperatively. We believe that the impotence was caused by damage to the neurovascular supply to the penis at injury.

COCAINE INDUCED APOPTOSIS IN RAT TESTES

PURPOSE Exposure of rats to chronic cocaine results in disruption of spermatogenesis including reduction of germ cells. However, the cellular mechanism responsible for the testicular damage in testes is still unknown. We have studied the role of apoptosis in cocaine induced testicular damage. MATERIALS AND METHODS Thirty-day-old male Sprague-Dawley rats were given cocaine hydrochloride (15 mg./kg. body weight) subcutaneously daily for 90 days. Control animals received equal volumes of normal saline daily for 90 days. Testes were removed at 15, 30, 60, and 90 days of cocaine administration. In situ detection of germ cells with DNA strand breaks in paraffin-embedded testicular section (5 microm.) was achieved by the terminal deoxynucleotidyl transferase (TdT)-mediated dUTP in situ nick end-labeling (TUNEL) method. DNA fragmentation was also determined by gel electrophoresis. RESULTS Apoptotic cells were found in the spermatocytes and spermatogonia of germinal epithelium. Less than 7% of seminiferous tubule cross sections showed a high level of apoptosis (> or =3 apoptotic cells per tubule) in control animals compared with experimental group where 25% of the tubules showed a high level of apoptosis (p<0.05). The number of apoptotic cells was significantly increased by 15 days, peaked at 30 days and persisted up to 90 days of cocaine exposure when compared with controls (p<0.05). DNA isolated from the cocaine treated testes displayed a clear ladder pattern whereas the DNA from controls did not. CONCLUSIONS The experimental results presented here suggest that cocaine exposure leads to significant apoptosis in rat testes and the mechanism of cocaine induced testicular injury may be related to the induction of apoptosis.

High flow malignant priapism with isolated metastasis to the corpora cavernosa

Malignant priapism is a rare disease with only 88 reported cases. We present a case of a patient with priapism secondary to isolated metastasis to corpora cavernosa from bladder tumor. Metastasis to penis usually represents evidence of a more widespread disease in 80% to 90% of the patients. Rarely, as in this case, the metastasis is solitary.

Assessment of psychosexual adjustment after insertion of inflatable penile prosthesis

OBJECTIVES To evaluate the psychosexual benefit obtained from multicomponent penile implant surgery in patients with erectile dysfunction. METHODS A psychosexual questionnaire was given to 35 patients undergoing penile prosthesis implantation before surgery and at 3 months, 6 months, and 1 year after surgery. The questionnaire consisted of 13 questions scored on a scale from 1 through 5. Results of the questionnaire were statistically analyzed for differences among the preoperative, 3-month postoperative, 6-month postoperative, and 1-year postoperative period. RESULTS The general linear model evaluation showed a significant difference for each overall combination of the following pairs: preoperative versus 3 months postoperative (P=0.0005) and 3 months postoperative versus 6 months postoperative (P=0.002). There was no overall difference between psychosexual total score at 6 months after surgery and 1 year after prosthesis implantation (P=0.85). The patients perceived improvement in their erectile ability and libido. Concern about obtaining and maintaining an erection during intercourse was significantly alleviated. There was an increase in the frequency of sexual activity and an improvement in satisfaction with sex life. A decrease in feelings of sadness, depression, anxiety, anger, frustration, and embarrassment related to sexual activity was also noted. CONCLUSIONS The current study demonstrates significant improvement in the psychosexual well being of multicomponent penile implant recipients, with attainment of a high level of patient satisfaction up to 1 year after surgery.

Priapism Associated with Sickle Cell Hemoglobinopathy in Children: Long-Term Effects on Potency

PURPOSE Children with sickle cell priapism have traditionally been treated conservatively with surgery done as a last resort. Only sparse subjective data are available on the long-term assessment of potency in these patients. MATERIALS AND METHODS We retrospectively reviewed the charts of all pediatric patients with sickle cell priapism who presented to Childrens Hospital of Michigan between 1972 and 1992, and subsequently assessed erectile capabilities subjectively by questionnaire and objectively by RigiScan. RESULTS Of the 15 patients interviewed 5 had undergone shunt procedures. The return of potency tended to vary inversely with patient age at onset and duration of priapism. CONCLUSIONS Shunts performed within 48 hours, especially in postpubertal children, seemed more likely to preserve potency.