Donald S. Crain

Youth varicocele and varicocele treatment: a meta-analysis of semen outcomes

OBJECTIVE To study youth who have a varicocele or are undergoing varicocele treatment, in relation to changes in semen, as measured by semen analysis (SA). DESIGN Meta-analysis of studies identified via a search of PubMed, Medline, and the Cochrane Library covering the last 40 years. SETTING Not applicable. PATIENT(S) Youth from studies that assessed the presence and/or treatment of varicocele with SA. INTERVENTION(S) Selected studies were analyzed in two separate meta-analyses: one for the effect of varicocele on semen, as measured by SA (hypothesis #1), the other for the effect of treatment on semen, as measured by SA (hypothesis #2). MAIN OUTCOME MEASURE(S) A random-effects model was used to calculate weighted mean difference (WMD) of semen outcomes. Heterogeneity was calculated. Bias was assessed with funnel plots and Eggers test. RESULT(S) The initial literature search returned 1,180 potentially relevant articles. For hypothesis #1, 10 studies with a total of 357 varicocele and 427 control subjects were included. Sperm density, motility, and morphology were significantly decreased when associated with a varicocele, with a WMD of -24.0×10(6)/mL (95% confidence interval [CI; -39.5 to -8.6]), -7.5% (95% CI [-12.3% to -2.7%]), and -1.7% (95% CI [-2.4% to -1.1%]), respectively. Another 10 studies with 379 treated and 270 untreated subjects were analyzed for hypothesis #2. Sperm density and motility were significantly improved following treatment, with a WMD of 14.6×10(6)/mL (95% CI [7.1-22.1]) and 6.6% (95% CI [2.1%-11.2%]), respectively. CONCLUSION(S) The presence of varicocele in youth appears to negatively affect sperm density, motility, and morphology. Treatment appears to result in moderate improvement of sperm density and mild improvement in sperm motility.

Lower Prevalence of Varicoceles in Obese Patients Found on Routine Scrotal Ultrasound

PURPOSE Research shows that obese patients have a lower incidence of varicoceles. Increased adipose tissue, which makes physical examination difficult, was hypothesized to be the cause. We evaluated the varicocele incidence on routine scrotal ultrasound to see whether difficult physical examination was causative. MATERIALS AND METHODS We reviewed all scrotal ultrasounds from the last 2 years for men 18 to 40 years old who had a recorded body mass index. Physical examination findings and the indication for ultrasound were included. We used standard criteria for ultrasound detected varicoceles. National Institutes of Health criteria was used to classify patients as normal-body mass index less than 25 kg/m(2), overweight-25 to 30 or obese-greater than 30. RESULTS Of the 1,079 patients 330 (30.6%) had an ultrasound detected varicocele. Mean ± SD body mass index in those with vs without a varicocele was 26.7 ± 3.8 vs 26.0 ± 3.7 kg/m(2) (p = 0.04). On physical examination 171 patients (16.0%) had a varicocele. Mean body mass index in those with vs without a varicocele on physical examination was 26.6 ± 3.7 vs 26.4 ± 3.9 kg/m(2) (p = 0.09). We calculated varicocele frequency by body mass index for ultrasound detected varicoceles only. Of 374 normal weight patients 129 (34.5%) had a varicocele while in the overweight and obese groups 163 of 535 (30.6%) and 43 of 170 (25.6%), respectively, had a varicocele. The difference between normal and obese patients was statistically significant (p = 0.04). CONCLUSIONS Obese patients have a lower prevalence of varicoceles detected by ultrasound. The lower prevalence is independent of physical examination and more likely due to another factor.

Etiology of Azoospermia in a Military Population

PURPOSE Male infertility is commonly seen at urology clinics and 10% to 20% of infertile males are found to be azoospermic. Azoospermia is classically categorized as nonobstructive or obstructive. This classification tailors the evaluation, diagnosis and proper treatment. We performed a retrospective study to provide an updated etiology of azoospermia in patients in the United States in a universal health care model. MATERIALS AND METHODS We retrospectively reviewed the records of men with azoospermia who presented to our institution between 2004 and 2012. Laboratory data were analyzed, included semen analysis, follicle-stimulating hormone, luteinizing hormone, testosterone, semen fructose and genetic studies. Patients underwent scrotal exploration as indicated for testis biopsy and sperm extraction. RESULTS We reviewed 139 outpatient records. Nonobstructive azoospermia was diagnosed in 99 men (71%), including 33 (34%) identified with Sertoli-cell only syndrome. Other etiologies included an idiopathic cause in 25 cases (26%), Klinefelter syndrome in 9 (9%), maturation arrest in 9 (9%), Y chromosome microdeletion in 5 (5%), cryptorchidism in 4 (4%), trauma in 4 (4%), exogenous testosterone supplementation in 4 (4%) and other genetic disorders in 6 (6%). Obstructive azoospermia was identified in 40 men (29%), of whom 16 (40%) had congenital bilateral absence of the vas deferens. Other etiologies included an idiopathic cause in 11 cases (28%), an iatrogenic condition due to a surgical cause in 5 (13%), ejaculatory duct obstruction in 3 (8%), trauma in 1 (3%), retrograde ejaculation in 1 (3%), vas deferens occlusion in 2 (5%) and unilateral absence of the vas deferens in 1 (3%). CONCLUSIONS This study delineates the etiology of azoospermia in men with universal access to care.

Operating characteristics of follicle-stimulating hormone in azoospermic men

OBJECTIVE To validate factors predictive of nonobstructive azoospermia (NOA) and to determine the operating characteristics of FSH for predicting NOA. DESIGN Retrospective cohort study. SETTING Tertiary care military treatment facility. PATIENT(S) One hundred forty azoospermic males undergoing infertility evaluation. INTERVENTION(S) Standard evaluation included history and physical, hormonal workup, and genetic evaluation. Diagnostic testicular biopsy was offered to characterize patients as obstructive azoospermia (OA) or NOA. MAIN OUTCOME MEASURE(S) Semen volume, semen fructose, FSH, T, E₂, PRL, testicular atrophy. RESULT(S) Seventy-eight of 140 azoospermic patients underwent a biopsy. The ability to predict NOA based on logistic regression was statistically significant for FSH and testicular atrophy. On multivariate analysis, only FSH remained predictive of NOA. The area under the FSH receiver operating characteristic curve was 0.847, which is significant. The cut point of FSH with the highest likelihood ratio of predicting NOA on biopsy was ≥12.3 mIU/mL. CONCLUSION(S) FSH remains the best predictor of NOA. With full knowledge of the operating characteristics of FSH in this population, a patient can be properly educated and treatment can be individualized, based on the specific risk associated with that subjects measured FSH.

Demographics of Men Receiving Vasectomies in the US Military 2000–2009

Background: We hypothesize that there is a higher incidence of vasectomy within the military at a younger age based on this equal access health care system. Materials and Methods: A review of the CHAMPS military database was conducted for men receiving vasectomies from 2000 to 2009. Age at vasectomy, number of children, race, religion, and marital status were recorded and incidence was computed. Results: Total of 82,945 vasectomies was performed. The overall incidence to have a vasectomy was approximately 7.10 per 1000 men. The highest rate of occurrence was 14.4 per 1000 men in men 30–34 years old. Whites had a higher rate than blacks at 10.03 per 1000 men compared to 6.27 per 1000 men. Protestants had the highest rate at 8.44 per 1000 men, and Jewish people had the lowest at 1.86 per 1000 men. Married men had a rate of 12.3 per 1000 men, whereas single men were 1.03 per 1000 men. Conclusions: The incidence to have a vasectomy in the military was 7.10 per 1000 men, with an age adjusted rate at 8.66 per 1000 men. This information may assist primary care providers in discussing vasectomies as a permanent form of contraception.

PD69-12 SURVEY OF SEXUAL FUNCTION AND PORNOGRAPHY

INTRODUCTION AND OBJECTIVES: In evaluating a male with sexual dysfunction, psychosexual factors should be considered. One potential but not well examined psychosexual factor is the impact of pornography use on sexual function. Given the large proportion of young men in the military and the potential detrimental effects of sexual dysfunction on quality of life, we sought to determine if there exists a correlation between degree of pornography use and sexual dysfunction. METHODS: After local institutional review board approval, patients aged 20-40 years presenting to a urology clinic were offered an anonymous survey consisting of self-reported medical history, demographic questions, validated questionnaires (including the International Index of Erectile Function [IIEF-15]), and novel questions addressing sexual function, pornography use, craving behavior, and obsessive behavior. For an interim analysis of those surveyed between February and August 2016, descriptive data were compiled and evidence for correlation between domains of the IIEF-15 and various aspects of pornography use was examined using linear regression tests. RESULTS: Surveys were completed by 312 respondents. The sample was generally healthy: 12% indicated a comorbidity other than tobacco use, 19.2% indicated tobacco use. The mean age was 31 years (sd1⁄45.9). Common demographics included white race (64.4%), non-Hispanic ethnicity (74.6%), active duty (96.8%), enlisted (77.3%), and married (68.8%). The mean scores of the IIEF-15 domains were: 26.2 (sd1⁄46.0) for erectile function, 8.6 (sd1⁄42.1) for orgasmic function, 8.1 (sd1⁄42.0) for sexual desire,10.7 (sd1⁄43.4) for intercoursesatisfaction,and7.9 (sd1⁄42.3) foroverall satisfaction. When asked how they best satisfied sexual desires, 96.6% indicated intercourse (with or without pornography) versus 3.4% who indicatedmasturbation topornography.Weekly pornographyusevaried: 25.9% indicated less than weekly, 24.6% indicated 1-2 times, 21.3% indicated 3-5 times, 5.0% indicated 6-10 times, and 4.3% indicated greater than 11 times. The typical media for viewing pornography were internet on a computer (72.3%)or asmart phone (62.3%). Therewere statistically lower scores in all IIEF-15 domains amongst respondents reporting a preference for masturbating to pornography rather than intercourse (p <0.05). However, there were no significant correlations between frequency or duration of pornography use and IIEF-15 domain scores (p> 0.05). CONCLUSIONS: There appears to be a relationship between pornography use and sexual dysfunction in men who report a preference for masturbation to pornography rather than sexual intercourse.

Supine Robotic-Assisted Retroperitoneal Lymph Node Dissection for Testicular Cancer

Background and Objectives: Robotic-assisted laparoscopic retroperitoneal lymph node dissection (RPLND) using a lower abdominal approach for testicular cancer is an advanced and relatively new surgical technique. Herein we describe technical modifications, review benefits, and report our initial series. Methods: A retrospective review of 16 patients from Jan 1, 2010 to Dec 31, 2012 who underwent robotic RPLND for nonseminomatous germ cell tumors was performed. Patients were positioned in 15° of Trendelenburg and tilted 15° to the right. An infraumbilical midline camera port, 3 robotic ports, and 2 assistant ports were placed in a lower abdominal configuration. Patient demographic and perioperative outcomes were assessed. Results: Twelve patients underwent staging, prospective nerve-sparing RPLNDs, and 4 underwent postchemotherapy RPLNDs. Mean age was 26.4 years with a mean body mass index of 27.4 kg/m. The cohort had a mean operative time of 357 minutes, mean estimated blood loss of 205 mL, mean hospital stay of 3.6 days, and mean postoperative morphine equivalent use of 47.1 mg. There were no conversions to open RPLND in this cohort. An average of 26.2 lymph nodes were sampled. Conclusions: Inferior approach for robotic RPLND enables a thorough dissection of the retroperitoneum, without repositioning, to meet oncologic goals. Further study to evaluate long-term outcomes is warranted.

A Retrospective Review of Factors Associated with Vasovasostomies in United States Military Members

Background: Men seeking a vasectomy should receive counseling prior to the procedure that includes discussion of later seeking a reversal. We sought to determine demographic factors that may predispose patients to possibly later seek a vasectomy reversal. Methods: All U.S. Military electronic health records were searched between 2000 and 2009 for either a vasectomy or vasovasostomy procedure code. Aggregate demographic information was collected and statistical analysis performed. Result: A total of 82,945 patients had a vasectomy of which 4,485 had a vasovasostomy resulting in a vasovasostomy-to-vasectomy rate of 5.04%. The average age at vasovasostomy was 34.9±5.0, with an average interval of 4.1±2.2 years. Men undergoing a vasectomy at a younger age were more likely to have a vasovasostomy. Various religions did have statistically significant differences. Within ethnic groups, only Native Americans [OR=1.39 (95% CI 1.198-1.614)] and Asians [OR=0.501 (95% CI 0.364-0.690)] had statistically significant differences when compared to Caucasians. Men with more children at the time of vasectomy were more likely to have a vasovasostomy. Conclusion: Younger men, Native Americans, and men with more children at vasectomy were more likely to undergo a vasovasostomy. The reason for these differences is unknown, but this information may assist during pre-vasectomy counseling.

Bilateral Testicular Infarction and Orchiectomy as a Complication of Polyarteritis Nodosa

We report an unusual case of a 28-year-old male with constitutional symptoms and bilateral testicular pain. After diagnosis of cytomegalovirus hepatitis, his constitutional symptoms and testicular pain worsened despite treatment for epididymoorchitis. Ultrasound was concerning for infarction. Exploration in the operating room revealed bilateral testicular infarction requiring bilateral orchiectomy with subsequent androgen hormone replacement. Pathologic diagnosis was polyarteritis nodosa (PAN). PAN is a rare systemic vasculitis that affects multiple organs. There are no previous reports of PAN-induced vasculitis leading to bilateral testicular infarction and bilateral orchiectomy.