Darius A. Paduch

REPAIR VERSUS OBSERVATION IN ADOLESCENT VARICOCELE: A PROSPECTIVE STUDY

PURPOSE We designed a randomized prospective study of male adolescents with moderate and severe varicoceles to determine whether prophylactic varicocele repair is beneficial. MATERIALS AND METHODS We evaluated 2,100 boys (10 to 20 years old) for genitourinary abnormalities. From this population 2 groups of adolescents 15 to 19 years old with grade 2 or 3 varicoceles were created, including 88 who underwent varicocele repair and 36 controls. Testicular volume and pampiniform vein diameter were measured, and Doppler ultrasound was performed. RESULTS After 12 months volume of the involved left testis increased to almost normal in treated boys (mean atrophy index 12.7% at surgery and 3% 12 months later). In controls the corresponding atrophy indexes were 10 and 9%, respectively. The relative increase in left testicular volume was 26% in the surgery group and 11% in controls. In the surgery group mean pampiniform vein diameter decreased from 2.8 preoperatively to 2 mm. postoperatively but there was no change in controls. CONCLUSIONS Varicocele repair in adolescents with moderate and severe varicocele reversed testicular growth arrest and resulted in catch-up growth within 12 month of surgery.

The Functional and Structural Consequences of Cavernous Nerve Injury are Ameliorated by Sildenafil Citrate

INTRODUCTION Radical prostatectomy (RP) is associated with erectile dysfunction (ED). A single, placebo-controlled, human study has assessed the effects of regular sildenafil use after RP and demonstrated an increased chance of preservation of preoperative erectile function. Aim. This study was undertaken to define the effects of such a regimen in an animal model. METHODS Using the cavernous nerve (CN) crush injury model, animals were divided into a number of groups: no CN injury (sham), bilateral CN injury exposed to either no sildenafil (control) or sildenafil at two doses (10 and 20 mg/kg) subcutaneously daily for three different durations (3, 10, 28 days). MAIN OUTCOME MEASURES At these time points, CN electrical stimulation was used to assess erectile function by mean intracavernosal pressure (ICP)/mean arterial pressure (MAP) ratio. For the structural analyses, whole rat penes were harvested. Staining for Massons trichrome was utilized to calculate the smooth muscle-collagen ratio. Immunohistochemical antibody staining was performed for endothelial (CD31 and eNOS) and neural (GAP43, NGF, and nNOS) factors and immunoblotting was performed to analyze the AKT/eNOS pathway. Terminal deoxynucleotidyl transferase biotin-dUTP nick end labeling (TUNEL) assay was used for the assessment of apoptotic indices and the CN architecture was evaluated by transmission electron microscopy (TEM). RESULTS Erectile function was improved with sildenafil in a time- and dose-dependent fashion with maximization of erectile function recovery occurring with daily 20 mg/kg at the 28-day time point. Sildenafil use resulted in smooth muscle-collagen ratio protection and CD31 and eNOS expression preservation. Sildenafil reduced apoptotic indices significantly compared with control. Animals exposed to sildenafil had increased phosphorylation of akt and eNOS. Tem demonstrated distinct differences in architecture between control and sildenafil groups toward an increased amount of myelinized nerve fibers. CONCLUSIONS Sildenafil use in the CN crush injury model preserves erectile function that appears to be mediated predominantly through preservation of smooth muscle content and endothelial function as well as through reduction in apoptosis.

Adverse effect of paroxetine on sperm

OBJECTIVE To assess the effects of a selective serotonin reuptake inhibitor on semen parameters. DESIGN Prospective study. SETTING Academic medical center. PATIENT(S) Thirty-five healthy male volunteers, 18-65 years old. INTERVENTION(S) Paroxetine administration for 5 weeks. MAIN OUTCOME MEASURE(S) Serum hormone levels, semen analyses, percent sperm DNA fragmentation, and questionnaire assessment of sexual function assessed before, during, and 1 month after drug administration. RESULT(S) Mean sperm DNA fragmentation was significantly higher for men while on paroxetine (30.3%) versus baseline (13.8%). Before paroxetine, 9.7% of patients had a terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) score>or=30% compared with 50% at week 4 of treatment. The odds ratio (OR) of having abnormal DNA fragmentation while taking paroxetine was 9.33 (95% confidence interval, 2.3-37.9]. Multivariate logistic regression correcting for age and body mass index confirmed this correlation (OR, 11.12). Up to 35% of men noted significant changes in erectile function and up to 47% of men reported ejaculatory difficulties on medication. Recovery to near-normal sexual function was noted after stopping treatment. Standard semen parameters were not significantly altered during paroxetine treatment. CONCLUSION(S) In men with normal semen parameters, paroxetine induced abnormal sperm DNA fragmentation in a significant proportion of subjects, without a measurable effect on semen parameters. The fertility potential of a substantial number of men on paroxetine may be adversely affected by these changes in sperm DNA integrity.

A decade of experience emphasizes that testing for Y microdeletions is essential in American men with azoospermia and severe oligozoospermia

OBJECTIVE To evaluate the benefit of Y microdeletion testing. DESIGN Retrospective analysis. SETTING University-based male fertility clinic and genetics laboratory. PATIENT(S) A total of 1,591 men with sperm concentrations less than 5 million sperm/mL. INTERVENTION(S) Semen analysis, Y microdeletion testing, microdissection testicular sperm extraction (TESE). MAIN OUTCOME MEASURE(S) Sperm concentration, incidence and nature of Y microdeletions, microdissection TESE outcome. RESULT(S) We identified 149 microdeletions (9.4%). 10.4% of azoospermic men and 10.1% of men with sperm concentrations >0-1 million sperm/mL harbored microdeletions. Two-thirds of microdeletions in azoospermic men were AZFa, AZFb, AZFb+c, or complete Yq deletions. Virtually all microdeletions in oligozoospermic patients were AZFc deletions. Seven hundred eighteen patients underwent microdissection TESE, including 41 with microdeletions. Microdissection TESE failed in all patients with AZFa, AZFb, AZFb+c, and complete Yq deletions. Sperm were retrieved in 15/21 AZFc deleted patients (71.4%). The presence of an AZFc deletion was associated with increased likelihood of sperm retrieval when compared with the 48.8% retrieval rate in 385 idiopathically azoospermic men who consecutively underwent microdissection TESE at our institution during the study period. Clinical pregnancy was achieved in 10/15 azoospermic AZFc deleted patients for whom sperm were successfully retrieved. CONCLUSION(S) Of azoospermic and severely oligozoospermic American men, 10% harbor Y microdeletions that alter prognosis for surgical sperm retrieval and are vertically transmissible. Y microdeletion testing is essential for genetic and preoperative counseling in these patients.

NEW CONCEPTS IN KLINEFELTER SYNDROME

Purpose of review Klinefelter syndrome, 47,XXY and its variants, is the most common chromosomal aberration among men, with estimated frequency of 1: 500 among newborns. Men with Klinefelter syndrome present with sequels of hormonal and spermatogenic testicular failure like infertility, low testosterone, erectile dysfunction, and low bone mineral density. This review is aimed to provide the practicing urologist with an important source of clinically relevant information about Klinefelter syndrome. Recent findings Sperm can be found in over 50% of men with Klinefelter syndrome, thus men with Klinefelter syndrome are not sterile. Recent evidence suggests that children with Klinefelter syndrome are born with spermatogonia and lose large numbers of germ cells during puberty. Early diagnosis and treatment can improve the quality of life and the overall health of men with Klinefelter syndrome. Summary Growing interest in Klinefelter syndrome among translational scientists and clinicians will result in better understanding of the pathophysiology of testicular failure. In some states, screening programs for Klinefelter syndrome are already in place, which will increase the number of patients with Klinefelter syndrome seen by practicing urologists in the near future. Diagnosis and management of patients with Klinefelter syndrome is within the scope and training of urologists. Development of randomized clinical trials comparing different forms of interventions in men and children with Klinefelter syndrome will allow us to standardize the care of these patients.

Reproduction in men with Klinefelter syndrome: the past, the present, and the future.

Klinefelter syndrome (KS) is the most common chromosomal aberration in men. There are approximately 250,000 men with KS in the United States, and the prevalence of KS in male reproductive practices is 3 to 4%; however, most men are never diagnosed. KS has an effect on normal development, growth, social interactions, bone structure, and sexual and reproductive function, thus a multidisciplinary approach to men with KS is important in providing state of the art care to children and men with KS. Over the last 10 years, with advancements in artificial reproductive techniques and the successful delivery of healthy children from men with KS, the involvement of reproductive endocrinologists and urologists in the care of patients with KS is becoming commonplace. The new areas of intense research investigate optimal methods of hormonal manipulations, preservation of fertility in adolescents, and development of universal early screening programs for KS. This review provides the latest update in our understanding of the pathophysiology, natural history, and evolving paradigms of therapy in adolescents and men with KS.

Novel mutations in testis-specific ubiquitin protease 26 gene may cause male infertility and hypogonadism

Patients (n = 188) with non-obstructive azoospermia (NOA), and 17 fertile controls were screened for sequence changes in the ubiquitin specific protease (USP) 26 gene. Semen analysis, hormonal evaluation, and testicular biopsies were performed. DNA was extracted from whole blood. Denaturing high-performance liquid chromatography was used to screen for single nucleotide polymorphisms. Amino acid sequences were determined in samples with mutations. Twenty out of 188 (10.6%) infertile men had amino acid changes in USP26. No changes were found in fertile controls. 1090C-->T substitution and (363insACA; 494T-->C; 1423C-->T) change were found in 3.3 and 1.9% of patients respectively. Serum testosterone concentrations and testicular volume were lower in the mutation positive group compared with the non-mutation group (272 versus 366 ng/dl; P = 0.01) (volume: 7.88 versus 10 ml, P = 0.03). Six out of 28 (21%) patients with Sertoli cell-only syndrome, and two out of 18 (11%) patients with maturation arrest had mutations in the USP26 gene. There were no live deliveries in couples with the USP26+ mutation, and three live deliveries in the group without mutations. The USP26 gene may be of importance in male reproduction. Mutations in this gene may be associated with male infertility, and may negatively affect testicular function.

Successful testicular sperm retrieval in adolescents with Klinefelter syndrome treated with at least 1 year of topical testosterone and aromatase inhibitor.

OBJECTIVE To evaluate surgical sperm retrieval rates in adolescents with Klinefelter syndrome and testosterone replacement therapy (TRT). DESIGN Case series. SETTING Academic medical center. PATIENT(S) Ten patients with Klinefelter syndrome, aged 14-22 years, treated with testosterone replacement and aromatase inhibitor therapy for a period of 1-5 years before surgical sperm retrieval. INTERVENTION(S) Microsurgical testis sperm extraction with cryopreservation of harvested tissue. MAIN OUTCOME MEASURE(S) Presence of spermatozoa within testis tissue. RESULT(S) Successful sperm retrieval in 7/10 patients (70%). CONCLUSION(S) Use of topical TRT did not appear to suppress spermatogenesis in adolescents with KS. It is uncertain whether sperm retrieval rates would be higher or lower without testosterone replacement in these young males. Sperm cryopreservation should be discussed in all KS adolescents who are either receiving or considering initiating TRT.

The Laboratory Diagnosis of Testosterone Deficiency

The evaluation and treatment of hypogonadal men has become an important part of urologic practice. Fatigue, loss of libido, and erectile dysfunction are commonly reported, but nonspecific symptoms and laboratory verification of low testosterone (T) are an important part of evaluation in addition to a detailed history and physical examination. Significant intraindividual fluctuations in serum T levels, biologic variation of T action on end organs, the wide range of T levels in human serum samples, and technical limitations of currently available assays have led to poor reliability of T measurements in the clinical laboratory setting. There is no universally accepted threshold of T concentration that distinguishes eugonadal from hypogonadal men; thus, laboratory results have to be interpreted in the appropriate clinical setting. This review focuses on clinical, biological, and technological challenges that affect serum T measurements to educate clinicians regarding technological advances and limitations of the currently available laboratory methods to diagnose hypogonadism. A collaborative effort led by the American Urological Association between practicing clinicians, patient advocacy groups, government regulatory agencies, industry, and professional societies is underway to provide optimized assay platforms and evidence-based normal assay ranges to guide clinical decision making. Until such standardization is commonplace in clinical laboratories, the decision to treat should be based on the presence of signs and symptoms in addition to serum T measurements. Rigid interpretation of T ranges should not dictate clinical decision making or define coverage of treatment by third party payers.

The Effect of Hyperbaric Oxygen Therapy on Erectile Function Recovery in a Rat Cavernous Nerve Injury Model

INTRODUCTION Cavernosal oxygenation appears to be important for preservation of erectile tissue health. Hyperbaric oxygen therapy (HBOT) has been shown to improve tissue oxygenation and has neuromodulatory effects. AIM This study was designed to define the effects of HBOT on erectile function (EF) and cavernosal tissue in the rat cavernous nerve (CN) injury model. METHODS Four groups of Sprague-Dawley rats were studied: rats with bilateral CN crush, HBOT treated (Crush+/HBOT+); bilateral CN-crush/no HBOT (C+/H-); no crush/no HBOT (C-/H-); and no crush/HBOT (C-/H+). HBOT was delivered daily for 90 minutes at three atmospheres for 10 days commencing the day of CN crush. MAIN OUTCOME MEASURES Ten days after CN injury, the animals underwent CN stimulation measuring the maximal intracavernosal pressure/mean arterial pressure (ICP/MAP) ratios. Corporal tissue was harvested pre-sacrifice, and immunohistochemically stained for nerve growth factor (NGF), endothelial nitric oxide synthase (eNOS), and cluster of differentiation molecule (CD31). Histologic analysis was performed for Massons trichrome to assess the smooth muscle-collagen ratio. Terminal deoxynucleotidyl transferase Biotin-dUTP Nick End Labeling assay was used to define apoptotic indices (AIs). RESULTS The C+/H- group had significantly lower ICP/MAP ratios compared with C-/H- rats, (31% vs. 70%, P < 0.001). C+/H+ rats had significantly higher ICP/MAP ratio recovery compared with the C+/H- group (55% vs. 31%, P = 0.005). NGF and eNOS staining densities were higher in C+/H+ rats compared with C+/H- rats (P < 0.05 and P < 0.001, respectively). No difference was seen in CD31 expression. Staining density for MT displayed a trend toward higher smooth muscle preservation after HBOT. AIs were significantly increased by HBOT (P < 0.05). CONCLUSION HBOT following a CN injury improved EF preservation in this model, supporting the cavernosal oxygenation concept as protective mechanism for EF. The effects appear to be mediated via preservation of neurotrophic and endothelial factor expression.