Edward Karpman

Pretreatment Semen Parameters in Men With Cancer

PURPOSE Whether the presence or specific type of cancer significantly affects semen quality is controversial. We evaluated the semen parameters and associated malignancies of men with cancer who cryopreserved sperm at our institution before undergoing therapy. MATERIALS AND METHODS We reviewed the database from our cryopreservation laboratory during a 5-year period. Office charts of 409 of 1,409 patients were available for review. Age at banking, semen volume, sperm density, percent motile sperm and type of cancer were recorded. Semen parameters were compared to values for fertile and subfertile men established by the National Cooperative Reproductive Medicine Network as well as from a large local pre-vasectomy cohort to consider geographic variations. RESULTS A total of 717 semen samples from 409 men included 45% with testicular cancer, 10% with Hodgkins lymphoma, 7% with nonHodgkins lymphoma, 6% with sarcoma, 6% with prostate cancer, 5% with leukemia, 3% with gastrointestinal cancer and 2% with central nervous system tumors. Of these men 16% had unspecified or other rare malignancies. Mean patient age was 29.9 years (range 11.9 to 87.7), mean semen volume was 2.8 ml (range 0.1 to 15.0), mean sperm density was 47.4 x 10(6)/ml (range 0.1 to 320) and mean sperm motility was 50.0% (range 1% to 90%). For men with testicular cancer sperm density and motility were in the intermediate range. Parameters for men with all other malignancies were in the fertile range for density and intermediate range for motility. CONCLUSIONS Men with most types of cancer have pretreatment semen parameters in the fertile range for density and in the intermediate range for motility. However, men with testicular cancer statistically have lower semen quality compared to those with other malignancies. These findings further highlight the importance of pretreatment fertility preservation in this patient population before undergoing gonadotoxic treatments.

The Who, How and What of Real-World Penile Implantation in 2015: The PROPPER Registry Baseline Data

PURPOSE To date, the published data on patients treated with penile implantation generally consist of small series of single surgeon, retrospective experiences rather than prospective or large, multicenter evaluations. This study establishes a baseline of data collection from the PROPPER (Prospective Registry of Outcomes with Penile Prosthesis for Erectile Restoration). The PROPPER is the first large, prospective, multicenter, multinational, monitored, and internal review board approved study of real-world outcomes for patients with penile implants. MATERIALS AND METHODS Data from the PROPPER study were examined to determine patient baseline characteristics and primary and secondary etiologies before treatment of erectile dysfunction. Data include type and size of implant received, surgical steps/techniques used during implantation, and duration of hospital stay. RESULTS Through April 2, 2015 a total of 1,019 patients were enrolled in the study at 11 sites, with radical prostatectomy being the predominant etiology in 285 (28%). Of those 285 patients treated with radical prostatectomy 280 (98.2%) received an AMS 700™. Of these patients 65.0% (182 of 280) had placement of the reservoir in the traditional retropubic space vs 31.8% (89 of 280) in a submuscular location. Of those patients not treated with radical prostatectomy receiving an AMS 700, fewer underwent reservoir placement in the submuscular location (17.7%, 124 of 702, vs 80.9%, 568 of 702; p <0.001). Of those patients receiving an AMS 700, those treated with radical prostatectomy and those with diabetes had more outpatient admissions (less than 24 hours, 56.8% and 52.1%, respectively) compared to those with cardiovascular disease and Peyronies disease (42.0% and 35.6%, respectively, p <0.001). CONCLUSIONS This first-of-its-kind, large, prospective, multicenter study reveals most penile implant cases in North America receive an inflatable penile prosthesis and that radical prostatectomy is the most common primary etiology of penile implant surgery. Moreover, patients treated with radical prostatectomy were more likely to have the reservoir placed in a submuscular location, have a longer operating room time and be admitted to the hospital overnight compared with other patient groups.

Reservoir Alternate Surgical Implantation Technique: Preliminary Outcomes of Initial PROPPER Study of Low Profile or Spherical Reservoir Implantation in Submuscular Location or Traditional Prevesical Space

PURPOSE Alternative reservoir site placement has become an accepted technique for patients who require an inflatable penile prosthesis. To our knowledge there has been no prospective evaluation of this technique, which is currently off label. We performed a prospective, multicenter, multinational, internal review board approved study to evaluate the effectiveness and safety of alternative reservoir site placement. MATERIALS AND METHODS PROPPER initiated in June 2011, is a database containing patient outcomes of inflatable penile prosthesis implantation. Patients with AMS® penile prostheses continue to be enrolled at 13 North American sites. We examined PROPPER study data to determine surgical implantation use patterns for the AMS 700™ series. We evaluated reservoir implantation site and complications by implantation site. RESULTS A total of 759 patients had been implanted with an AMS 700 series implant by the time of evaluation. Mean patient followup was 17.8 months (range 0 to 36). There was no reported case of revision surgery for a palpable reservoir and no report of vascular or hollow viscous injury associated with alternative reservoir site placement. Two cases of reservoir herniation in the alternative reservoir site placement group and 2 in the space of Retzius group were treated with reservoir reimplantation. Patients with 1-year assessment available were satisfied or very satisfied with the device and reported a frequency of use of more than once per month. CONCLUSIONS Alternative reservoir placement in the submuscular location is an option in patients who undergo inflatable penile prosthesis surgery. Implant surgeons should consider alternative reservoir site placement a safe, effective alternative to reservoir placement in the space of Retzius.

IVF and ICSI in Male Infertility: Update on Outcomes, Risks, and Costs

Assisted reproductive technology with intracytoplasmic sperm injection (ICSI) is becoming an international panacea for couples struggling with infertility. The increasing popularity of these techniques and the data generated has given us a better understanding of the efficacy, consequences and costs of these procedures. There still remain many unanswered questions and controversies surrounding the use of IVF and ICSI. Increased experience, better refinement of these techniques and clearer indications for IVF and ICSI will inevitably minimize the risks associated with this procedure.

Adjuvant Maneuvers for Residual Curvature Correction During Penile Prosthesis Implantation in Men with Peyronie's Disease

INTRODUCTION The surgical treatment of comorbid erectile dysfunction and Peyronies disease has long included the implantation of an inflatable penile prosthesis as well as a number of adjuvant maneuvers to address residual curvature after prosthesis placement. AIM To review the various surgical options for addressing curvature after prosthesis placement, with specific attention paid to an original article by Wilson et al. reporting on modeling over a penile prosthesis for the management of Peyronies disease. METHODS A literature review was performed analyzing articles reporting the management of penile curvature in patients undergoing implantation of an inflatable penile prosthesis. MAIN OUTCOME MEASURES Reported improvement in Peyronies deformity as well as the complication rate associated with the various surgical techniques described. RESULTS Modeling is a well-established treatment modality among patients with Peyronies disease undergoing penile prosthesis implantation. A variety of other adjuvant maneuvers to address residual curvature when modeling alone is insufficient has been presented in the literature. CONCLUSIONS Over 20 years of experience with modeling over a penile prosthesis have proven the efficacy and safety of this treatment option, providing the surgeon a simple initial step for the management of residual curvature after penile implantation which allows for the use of additional adjuvant maneuvers in those with significant deformities.

Capsular Contraction with S‐Shaped Deformity of Nonlength‐Expanding Inflatable Penile Prosthesis Cylinders: Management and Prevention Strategies

Introduction Capsular contraction (CC) occurring with inflatable penile prosthesis (IPP) reservoirs has been reported by urologists as a cause of autoinflation. The concept of CC occurring around IPP cylinders has not been studied. Aims Herein we report a case of CC occurring with nonlength-expanding IPP cylinders, resulting in an S-shaped deformity. Main Outcome Measures We sought to report a novel cause of S-shaped deformity in patients after IPP surgery. Methods We reviewed a recent clinical case and conducted a literature review on capsular scar formation in prosthetic surgery. We also conducted a literature review of the inflammatory cascade related with prosthetic surgery. Results Capsular contracture of nonlength-expanding cylinders resulting in S-shaped deformity has not been previously reported. The role of certain inflammatory markers seems to play a common role of capsular contracture in the penis and other prosthetic implantation sites. Conclusions Capsular contractures around the cylinders of an IPP can cause deformity, even in patients who have appropriately sized, nonlength-expanding cylinders. A better understanding is needed regarding the mechanical properties of the tunica albuginea and the inflammatory cascade associated with penile implant surgery. This case represents an argument for early and aggressive postoperative inflation of the IPP. Future studies should evaluate the role of inflammation modulators as adjuvant therapy after IPP surgery. Karpman E and Henry G. Capsular contraction with S-shaped deformity of nonlength-expanding inflatable penile prosthesis cylinders: Management and prevention strategies. Sex Med 2013;1:95–98.

Management of Distal & Proximal Penile Prosthesis Crossover

The Surgical Techniques Section is sponsored in part by Coloplast.

Infertility in the Male: Techniques of sperm retrieval

This chapter focuses on the genetic basis of male infertility. The male specific Y (MSY) is a chromosomal material that bridges the two polar pseudoautosomal regions and is unique in the human genome. A karyotype and Y-chromosomal microdeletion assay should be obtained as complementary tests in all non-obstructive azoospermia (NOA) and severely oligospermic men prior to intracytoplasmic sperm injection (ICSI) and the use of testicular sperm. Prognosis and planning are optimized with any informative result. Steroidogenic acute regulatory (StAR) protein is the rate-limiting step for androgen biosynthesis in particular and all steroids in general. The hypothalamic-pituitary-gonadal (HPG) axis controls human sexual maturation and spermatogenesis. The hypothalamus secretes gonadotropin- releasing hormone (GnRH) which regulates the production of Folliclestimulating hormone (FSH) and luteinizing hormone (LH) by the pituitary gonadotropes. Kallmann syndrome results from the failure of the GnRH-releasing neurons to migrate to the olfactory lobe during development.

Is microsurgical intussusception vasoepididymostomy a suitable option for men with obstructive azoospermia

Is microsurgical intussusception vasoepididymostomy a suitable option for men with obstructive azoospermia?

Inflatable penile prosthesis implant length with baseline characteristic correlations: Preliminary analysis of the PROPPER study

Background “Prospective Registry of Outcomes with Penile Prosthesis for Erectile Restoration” (PROPPER) is a large, multi-institutional, prospective clinical study to collect, analyze, and report real-world outcomes for men implanted with penile prosthetic devices. We prospectively correlated co-morbid conditions and demographic data with implanted penile prosthesis size to enable clinicians to better predict implanted penis size following penile implantation. We present many new data points for the first time in the literature and postulate that radical prostatectomy (RP) is negatively correlated with penile corporal length. Methods Patient demographics, medical history, baseline characteristics and surgical details were compiled prospectively. Pearson correlation coefficient was generated for the correlation between demographic, etiology of ED, duration of ED, co-morbid conditions, pre-operative penile length (flaccid and stretched) and length of implanted penile prosthesis. Multivariate analysis was performed to define predictors of implanted prosthesis length. Results From June 2011 to June 2017, 1,135 men underwent primary implantation of penile prosthesis at a total of 11 study sites. Malleable (Spectra), 2-piece Ambicor, and 3-piece AMS 700 CX/LGX were included in the analysis. The most common patient comorbidities were CV disease (26.1%), DM (11.1%), and PD (12.4%). Primary etiology of ED: RP (27.4%), DM (20.3%), CVD (18.0%), PD (10.3%), and Priapism (1.4%), others (22.6%). Mean duration of ED is 6.2¡À4.1 years. Implant length was weakly negatively correlated with White/Caucasian (r=−0.18; P<0.01), history of RP (r=−0.13; P<0.01), PD as comorbidity (r=−0.16; P<0.01), venous leak (r=−0.08; P<0.01), and presence of stress incontinence (r=−0.13; P<0.01). Analyses showed weak positive correlations with Black/AA (r=0.32; P<0.01), CV disease as primary ED etiology (r=0.08; P<0.01) and pre-operative stretched penile length (r=0.18; P<0.01). There is a moderate correlation with pre-operative flaccid penile length (r=0.30; P<0.01). Conclusions Implanted penile prosthesis length is negatively correlated with some ethnic groups, prostatectomy, and incontinence. Positive correlates include CV disease, preoperative stretched penile length, and flaccid penile length.