Charles Welliver

Serum levels of enclomiphene and zuclomiphene in men with hypogonadism on long‐term clomiphene citrate treatment

To determine the relative concentrations of enclomiphene (ENC) and zuclomiphene (ZUC) isomers in men with hypogonadism on long‐term clomiphene citrate (CC) therapy, and to determine whether patient age, body mass index (BMI) or duration of therapy were predictive of relative concentrations of ENC and ZUC.

Introducing the Twitter Impact Factor: An Objective Measure of Urology's Academic Impact on Twitter

BACKGROUNDnSocial media use in academia and urology is rising. Specifically, individual journals now have Twitter accounts (Twitter Inc, San Francisco, CA, USA) and regularly tweet academic content.nnnOBJECTIVEnTo present and evaluate the Twitter impact factor (TIF), a novel means of measuring a journals academic influence in the realm of social media.nnnDESIGN, SETTING, AND PARTICIPANTSnJournal Citation Reports (JCR; Thomson Reuters, New York, NY, USA) for 2014 was queried for urologic academic journals. English-language journals with active Twitter accounts since 2013 were included. The total number of followers, tweets, and retweets over a 2-yr period were collected.nnnOUTCOME MEASURES AND STATISTICAL ANALYSISnEach journals TIF was calculated based on the number of retweets per original relevant tweet. Comparisons between the TIF and the journal impact factor (JIF) as well as the Klout score were made using the Pearson correlation.nnnRESULTS AND LIMITATIONSnOf 33 journals listed in the JCR for 2014, 7 (21%) had a Twitter presence as of 2013. The number of JCR-listed journals with a Twitter handle increased by 29% in 2014. There was an increase in the mean number of relevant tweets per journal during the study period and a 130% increase in the number of retweets over 1 yr. European Urology (1.80) and BJU International (1.46) had the highest TIFs. The journals with the highest number of Twitter followers were European Urology (5807) and the Journal of Urology (4402). The journals with the highest numbers of relevant tweets were European Urology (1159) and BJU International (1090). There was a positive but statistically insignificant association between the TIF and the JIF (r=0.64, p=0.12). There was a strongly positive linear correlation between the TIF and the Klout score (r=0.84, p=0.0086).nnnCONCLUSIONSnWith the increasing use of social media by individuals and academic journals, the TIF can be a useful tool to measure the academic reach and impact of a journal on Twitter.nnnPATIENT SUMMARYnSocial media is an increasing part of the way in which practitioners and academicians communicate. The TIF can be used to analyze the impact of journal Twitter feeds and their social media content.

Placebo Medication and Sham Surgery Responses in Benign Prostatic Hyperplasia Treatments: Implications for Clinical Trials

Placebo medications and sham surgeries have long been thought to be inert treatments. These groups served as a threshold to which an active treatment should be compared in a randomized trial to determine the true efficacy of the active treatment. However, surprising changes in subjective symptom scores and objective measures of voiding have been demonstrated in numerous placebo medication or sham surgery arms of trials. The exact mechanisms by which these inactive treatments augment patient outcomes are not clearly defined and multiple theories have been proposed to explain the often pronounced response. It appears that urologic outcomes are particularly prone to these effects and the astute physician should keep these responses in mind when interpreting any trial on a new therapy.

The Utility of Sex Hormone-Binding Globulin in Hypogonadism and Infertile Males

Purpose: We sought to determine the role of sex hormone‐binding globulin in patients with male infertility. Materials and Methods: We retrospectively reviewed the records of 168 males seen at a fertility clinic from 2012 to 2014 to investigate the accuracy of total testosterone in the biochemical diagnosis of hypogonadism using calculated bioavailable testosterone as the reference value. We used multivariable analysis to assess sex hormone‐binding globulin as an independent predictor of infertility. Results: Computations using calculated bioavailable testosterone as a standard in the measurement of definitive biochemical hypogonadism (less than 156 ng/dl) revealed 81% sensitivity, 83% specificity, 81% positive predictive value and 82% negative predictive value for diagnosing hypogonadism with total testosterone alone. Of the 90 men with total testosterone greater than 300 ng/dl, 20% had low bioavailable testosterone less than 156 ng/dl, 52% had borderline low bioavailable testosterone less than 210 ng/dl and only 48% could be considered biochemically eugonadal according to calculated bioavailable testosterone. Of the 80 patients with total testosterone less than 300 ng/dl, 19% had free testosterone levels greater than 6.5 ng/dl and, thus, could be considered to be eugonadal. By a magnitude similar to that of follicle‐stimulating hormone, sex hormone‐binding globulin independently predicted decreased sperm concentration (p = 0.0027) and motility (p = 0.0447). After excluding men with azoospermia, only sex hormone‐binding globulin levels differed significantly in classically hypogonadal men (group 1—total testosterone less than 300 ng/dl) and those missed but hypogonadal (group 2—calculated bioavailable testosterone less than 210 ng/dl) (p = 0.0001). At a more stringent cutoff of calculated bioavailable testosterone less than 156 ng/dl, sperm motility was significantly different for groups 1 and 2 (p = 0.014). Conclusions: Adding sex hormone‐binding globulin to total testosterone serum testing facilitates more accurate diagnosis with free testosterone and calculated bioavailable testosterone, and clinical implications of decreased semen parameters to a magnitude similar to that of follicle‐stimulating hormone. This warrants further study of the role of sex hormone‐binding globulin in male infertility.

Interinstitutional variability in testicular volumes and varicocele presence by ultrasound: surprising discrepancies and implications for clinical decision making.

OBJECTIVEnTo determine the variability of testicular ultrasound (US) volumes and the clinical implications.nnnMETHODSnA retrospective review identified 73 patients (62 adult and 11 adolescents) who had testicular US scans performed at both our institution (Urological Institute at Northeastern New York) and at an outside facility (outside hospital study). Testicular volume (TV) was measured using the Lambert formula: length × width × height × 0.71. TV difference (TVD) was calculated as percentage difference = 100 × (right TV - left TV)/left TV and serves as the intrapatient TVD. Patients with clinically palpable varicoceles were correlated to detection on US. Bland-Altman plots were generated to compare the limits of agreement for interinstitutional TVs. Interinstitutional agreement was measured using the Kappa (κ) coefficient.nnnRESULTSnAlthough the mean values for TVs were similar between institutions (19.1 vs 19.0 cm(3)), there was a wide range in the limits of agreement with a large standard deviation of difference (8.52 cm(3)). Interinstitutional agreement was poor regarding patients with a ≥ 20% TVD (κ = 0.09) and was even worse in patients with both varicoceles and ≥ 20% TVD (κ = 0.05). US agreement for verification of clinically detected varicoceles was good (κ = 0.67). If the variability found in this study was applied to identically sized testicles, an erroneous 20% TVD would be found in 38% of studies.nnnCONCLUSIONnInterinstitutional or inter-ultrasonographer assessment of TV varies significantly. Clinicians should cautiously interpret the US-determined TV when making surgical decisions. Images, and not just reports, should be reviewed by clinicians.

Manufacturers' data show increasing implanted cylinder sizes and measured corporal lengths in inflatable penile implants.

IntroductionWe sought to determine whether measured corporal length (MCL) or implanted device size (IDS) has changed.MethodsData were obtained from the two major penile implant companies from the years of 2005–2010 and analyzed. While we requested similar data, companies supplied information at their discretion with MCL provided by American Medical Systems and IDS provided by Coloplast. Intra-patient corporal discrepancies, disease state effects, rear tip extenders (RTEs) use and place of implantation were also provided in some part by companies.ResultsMCL and IDS increased during the study period. Despite the general trend of MCL/IDS, clinically significant (0.5xa0cm or greater) decreases in MCLs were noted in patients with Peyronie’s disease (PD) or a history of radical pelvic surgery (excludes prostatectomy). In only 2.7xa0% of cases was there an intra-patient discrepancy in cylinder size (>1xa0cm). IDS was longer in the USA (US, 19.4xa0cm) compared to outside the US (OUS, 17.7xa0cm, pxa0<xa00.0001). Cylinders were implanted without RTEs in 48.3xa0% of US cases and 73.7xa0% of OUS cases (pxa0<xa00.0001). In Coloplast devices there was an overall statistically significant change in the use of 16xa0cm (less utilized) and 20 and 22xa0cm (more utilized) cylinder lengths during the study period in US implants.ConclusionMCL and IDS increased during the study period. Men with a history of PD or radical pelvic surgery are at highest risk to have shorter MCL and to possibly receive shorter implants. Intra-patient IDS inconsistency is rare and should prompt investigation.

Sexual Side Effects of Medical and Surgical Benign Prostatic Hyperplasia Treatments

Treatments for lower urinary tract symptoms due to benign prostatic hyperplasia can be evaluated by multiple metrics. A balance within the confines of patient expectations is key to determining the ideal treatment. A troubling adverse event for some patients is sexual dysfunction. Because the cohort of men who seek treatment of sexual dysfunction and lower urinary tract symptoms is essentially identical, these disease processes frequently overlap. This article considers potential pathophysiologic causes of dysfunction with treatment and attempts to critically review the available data to assess the true incidence of sexual adverse events with treatment.

Age-Related Testosterone Decline: Whom Do We Treat and Why?

Late-onset hypogonadism (LOH) is characterized by hypogonadal symptoms, together with low serum testosterone values, in men of advancing age. For a variety of reasons, LOH has become popular in both the lay press and the scientific community. While the overall prevalence of LOH is relatively low, the potential sequelae of untreated LOH can be considerable for affected men. The diagnosis of LOH can be challenging, as symptoms are generally nonspecific and overlap with a variety of medical and psychological problems.Testosterone therapy (TTh) for affected men has become increasingly controversial after several recent observational studies observed an increased cardiovascular risk associated with TTh. However, prior studies have observed little or no cardiovascular risk associated with TTh, and recent studies also support a low cardiovascular risk in men on TTh. In this review, we discuss the LOH patient and controversy surrounding this condition and outline potential risks and benefits of treatment.