David Shin

Herniorrhaphy with polypropylene mesh causing inguinal vasal obstruction: a preventable cause of obstructive azoospermia.

Objective:To report a multiinstitutional experience of men presenting with infertility secondary to inguinal hernia repair using polypropylene mesh. Summary Background Data:An estimated 80% of inguinal hernia operations involve placement of a knitted polypropylene mesh to form a “tension-free” herniorrhaphy. The prosthetic mesh induces a chronic foreign-body fibroblastic response creating scar tissue that imparts strength to the floor and leads to fewer recurrences. However, little is known about the long-term effects of the polypropylene mesh on the vas deferens, especially with regard to fertility. Methods:Eight institutions in the United States reported a total of 14 cases of azoospermia secondary to inguinal vasal obstruction related to previous polypropylene mesh herniorrhaphy. Patient characteristics and operative findings were forwarded to 1 center for tabulation of data. Results:Mean patient age was 35.5 years with an average duration of infertility of 1.8 years. Mean number of years between urologic evaluation and herniorrhaphy was 6.3 years. Types of inguinal hernia repair previously performed were: open (10), laparoscopic (2), or both (2). Nine patients had bilateral obstruction and 5 patients had unilateral obstruction with contralateral testicular atrophy or epididymal obstruction. Surgical exploration revealed a dense fibroblastic response encompassing the polypropylene mesh with either trapped or obliterated vas in all patients. Surgical reconstruction was performed in 8 of 14 men (57%). Conclusion:Reconstruction to restore fertility can be difficult secondary to fibrotic reaction. Before undergoing polypropylene mesh herniorrhaphy, men, especially of young reproductive age or with a solitary testicle, need to be carefully advised of potential obstruction and compromise to future fertility.

Pulmonary tractotomy as an abbreviated thoracotomy technique

BACKGROUND Operative abbreviated thoracotomy techniques in thoracic trauma include emergency center thoracotomy, ligation of major arterial branches, packing the thoracic cavity for diffuse bleeding, towel clip or Bogota bag closure of the chest, and pulmonary tractotomy. Pulmonary tractotomy with selective vascular ligation was originally described for deep through-and-through lung injuries that did not involve hilar vessels or airways. Pulmonary tractotomy has evolved into use as an abbreviated thoracotomy technique in patients with severe thoracic or multivisceral trauma. As with any operative technique in high-risk patients, specific procedure-related complications may occur and are analyzed herein. The objective of this manuscript is to review the indications, techniques, and results for pulmonary tractotomy in trauma patients requiring abbreviated thoracotomy. METHODS Medical records were retrospectively reviewed for 30 of 32 consecutive tractotomy patients treated at Ben Taub General Hospital, during a 3-year period. By using a model for logistic regression analysis, the characteristics of each patient and their clinical course were tested for impact on mortality. RESULTS Seventy percent of patients had at least one intraoperative parameter indicative of acidosis (pH < 7.2), coagulopathy (prothrombin time > 13.8 or partial thromboplastin time > 38.0 seconds), or hypothermia (core temperature < 34 degrees C), and 50% of patients manifested two of these three parameters. The mortality rate among the 30 patients was 17%. Three of the five patients who died were noted to be acidotic, coagulopathic, and hypothermic. Twelve of 25 patients who survived more than 1 day had at least one thoracic complication. There were no late deaths. There was one failed tractotomy and one missed injury. A second thoracotomy was not required for control of a lung injury in any patient. Logistic regression analysis showed that intraoperative blood loss was the only predictive factor for mortality. CONCLUSION Pulmonary tractotomy is a simple and effective technique in injured patients who require an abbreviated thoracotomy and has an acceptable mortality and complication rate. This follow-up report notes that as definitive therapy, tractotomy continues to allow for direct control of bleeding and air leak and obviates the need for formal resection.

MP56-10 NATIONAL TRENDS IN UTILIZATION OF PENILE PROSTHESIS SURGERY IN THE TREATMENT OF PEYRONIE′S DISEASE

next elevated if necessary which often resulted in significant dorsal curve improvement. Plaque incision(s)/partial excisions were performed at the point(s) of maximum deflection. Upon re-inflation the new enlarged defect was covered with a tachosil graft. The tachosil was then molded to the penis and covered with previously preserved dartos layer. A catheter and compressive dressing are left overnight. The device was left inflated for 4 weeks following the procedure. RESULTS: Twelve patients underwent IPP with tachosil graft. Average age of patients was 56. The average pre-operative curvature was 75 degrees (45-120) on doppler. Curvature was multiplanar dorsolaterally (left) in 11/13 patients. Average time was 145 minutes with < 100 ml of blood loss. Mean follow up time is 10 months. One patient developed an infection which necessitated device removal. There have been no signs of device aneurysm to date. Curvature correction was < 30 degrees in 12/13 patients with one patient having residual 40 degree lateral curvature with max inflation. Several patients have lateral deflection with the device uninflated. Two patients had Xiaflex injections prior to their procedure which did not appreciably influence the difficulty of the case. CONCLUSIONS: Our intermediate results continue to reveal that Tachosil offers a feasible, fast and safe alternative to grafting with IPP that does not require the graft to be sewn in place.

PD07-09 EFFECT OF ANASTROZOLE ON PROSTATE SPECIFIC ANTIGEN VALUES IN HYPOGONADAL, SUBFERTILE MEN

INTRODUCTION AND OBJECTIVES: Anastrozole, an aromatase inhibitor, is used in the empiric treatment of subfertile males to increase endogenous testosterone levels, elevate testosterone-toestradiol ratios and improve semen parameters. However, controversy exists in regard to the effect on prostate specific antigen (PSA) levels by pharmacological agents which increase testosterone levels. In addition, the effects of anastrozole on the prostate and PSA are unknown. Therefore, we sought to study the effect of the increased endogenous testosterone levels seen with anastrozole, on serum PSA levels in subfertile men. METHODS: Patients presenting with infertility and diagnosed with hypogonadism were treated with anastrozole for a minimum of three months. Serum follicle stimulating hormone (FSH), luteinizing hormone (LH), total testosterone (T), estradiol (E), testosterone-toestradiol ratio (T/E), bioavailable testosterone (BT) and PSA levels were recorded at baseline and measured at 3 months and at 5 months during therapy when available. Paired t-test was used to compare baseline and post-treatment laboratory parameters. RESULTS: A total of 50 male patients were included in the study, mean age 35.9 1.0 (SEM). Mean baseline testosterone was 270.2 11.7 ng/dl, mean T/E ratio was 10.5 0.9 and mean baseline PSA was 0.69 0.07 ng/ml. LH, T/E ratios, total testosterone and bioavailable testosterone levels increased significantly on anastrozole therapy. Slight but insignificant increase in PSA values was observed at 3 months of anastrozole treatment (0.78 0.07, p1⁄40.35). For 33 men, follow up laboratory evaluation was obtained at 5 months of anastrozole therapy and no significant change in PSA levels was observed (0.80 0.89, p 1⁄4 0.47). No patient had a signi?cant increase in PSA velocity or change in digital rectal examination requiring prostate biopsy. CONCLUSIONS: The increase in testosterone levels and improved T/E ratios observed with the use of anastrozole in the treatment of hypogonadal, subfertile males does not result in significant increases in PSA levels at 5 months of therapy. Although there does not appear to be any short term adverse effects, further study of the long-term effects of anastrozole on serum PSA is warranted. Source of Funding: none