F. Van Der Aa

Outcome of microdissection TESE compared with conventional TESE in non-obstructive azoospermia: a systematic review.

Retrieval of spermatozoa is unfortunately still only successful in a subset of patients suffering from non‐obstructive azoospermia (NOA) by conventional testicular sperm extraction (TESE). Microdissection TESE may have some theoretical benefits over conventional TESE, but uncertainty exists about its superiority. The objective of this systematic review was therefore to compare the efficacy and safety of microTESE with conventional TESE in men with NOA. The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis statement. Literature was searched for studies comparing outcome of conventional TESE with microdissection TESE. Primary outcome was sperm retrieval rate (SRR). Secondary outcomes were clinical predictors of sperm retrieval as well as complication rate. Of 62 articles, a total of seven studies were included in the final analysis. Overall SRR was significantly higher in the microTESE group in comparison with conventional TESE in five of these studies. Overall sperm retrieval ranged from 16.7 to 45% in the conventional TESE vs. 42.9 to 63% in the microTESE group. A sub‐analysis of the SRR according to testicular histology was available in four of the selected articles. MicroTESE in men with Sertoli cell only syndrome and hypospermatogenesis carried a small but significant more favourable outcome according to, respectively, two and one of the studies. Correlation of serum follicle stimulating hormone and testicular volume with positive outcome was variable. Fewer complications were observed on ultrasound examination after microTESE procedure. Clinical randomized studies comparing microTESE with conventional TESE in NOA are still lacking to date. Pseudo‐randomized prospective data, however, show more favourable sperm retrieval in NOA for microTESE, especially in histological patterns of patchy spermatogenesis such as Sertoli cell only syndrome. However, in patients with uniform histological patterns such as maturation arrest outcome of microTESE seems less favourable.

Is low-grade prostatic intraepithelial neoplasia a risk factor for cancer?

Introduction: High-grade prostatic intraepithelial neoplasia (HGPIN) is generally accepted to be a precursor lesion of prostate cancer. The likely outcome of isolated low-grade PIN (LGPIN) lesions in prostate biopsies remains unclear. A follow-up study of 106 patients with LGPIN- and HGPIN lesions was performed.Materials and methods: In a 2-y period, 207 men were diagnosed with isolated PIN on standard systematic sextant biopsy of the prostate. In total, 104 patients had LGPIN and 103 had HGPIN. No patients had ever received androgen deprivation therapy, chemotherapy or radiation therapy. In all, 106 patients who underwent repeat second or third sextant biopsies were analysed in the study; 30% of these patients received a selenium–vitamin E supplement for at least 6 months.Results: In total, 43 had LGPIN and 63 HGPIN on the first biopsy. The mean age was 63.5 y (range 46–77) in the LGPIN group and 64.9 y in the HGPIN group. The mean total PSA was 6.96 ng/ml (range 0.59–34.13) in the LGPIN group and 8.44 ng/ml (range 0.59–35.3) in the HGPIN group. In the LGPIN group, 30% of the patients had cancer in at least one of the repeat biopsy cores. In the HGPIN group, 27% had cancer in at least one of the repeat biopsy cores. The mean total PSA of patients who had cancer in repeat biopsies with LGPIN was 7.84 ng/ml (range 2.92–34.13). The mean total PSA of the patients who had cancer in repeat biopsy in the HGPIN was 6.73 ng/ml (range 0.56–25). There was no significant difference in PSA and pathological stage between those patients who did and those who did not receive selenium–vitamin E supplements.Conclusions: These data are intriguing since the risk of finding prostate carcinoma on repeat sextant biopsy in the LGPIN group is 30%. This is higher than commonly reported. The importance of recognising and re-biopsying HGPIN was confirmed. If chemoprevention could be shown to be effective, it might be beneficial not only in HGPIN but also in LGPIN. The possible activity of chemopreventive agents and their combination with iso-flavonoids needs further investigation.

Potency after unilateral nerve sparing surgery: a report on functional and oncological results of unilateral nerve sparing surgery

The objective of the study was to evaluate unilateral nerve sparing prostate surgery. Patient files of men who underwent unilateral nerve sparing radical prostatectomy were analyzed retrospectively after a minimum follow-up period of 18 months. Of 46 patients who received unilateral nerve sparing surgery, 14 (30.4%) regained full potency after surgery. In 92.9% of these patients, recovery occurred within a period of 18 months. Age is the single most important factor in the recuperation of potency after unilateral nerve sparing surgery. Most of the patients (84.8%) reported the ability to achieve orgasm. Of eight patients with positive section margins, two had positive section margins at the spared side only. Unilateral nerve sparing surgery remains a feasible treatment option for prostate cancer.

Conservative bladder management in advanced multiple sclerosis

Anticholinergics and intermittent catheterization are the cornerstones of bladder management in early multiple sclerosis (MS). In advanced MS however, bladder management is based more on tradition than on evidence. Nurses seem to deal with catheter problems and chronic incontinence. Despite the abundant use of indwelling catheters, there is a lack for guidelines on catheter-induced problems. The psychosexual and social impact of bladder problems in advanced MS is often neglected. The international multidisciplinary special interest group on sexual, urological and bowel dysfunction in MS (SUBDIMS) as a special interest group of the Rehabilitation in Multiple Sclerosis (RIMS) was confronted with a high variability in practice and a lack of guidelines. A literature review was prepared during three multidisciplinary expert meetings. This review will be the basis of further initiatives to improve the urological treatment of patients with advanced MS.

The role of bladder neck suspension in the era of mid-urethral sling surgery

IntroductionMid-urethral slings are currently considered to be the gold standard for the surgical treatment of stress urinary incontinence, replacing bladder neck suspension techniques which previously occupied this position. In recent years, however, there have been concerns with regard to the use of synthetic material in vaginal surgery.MethodsWe performed a review of the literature to discuss the role of bladder neck suspension techniques in the current clinical setting.ConclusionsBladder neck suspension techniques consist of vaginal techniques, needle suspension techniques and retropubic techniques. The latter two techniques have been proven to offer durable outcomes for stress urinary incontinence. As compared to autologous slings, the long-term success rates may be considered inferior, but so is the rate of complication, resulting in higher patient satisfaction. Bladder neck suspension techniques may have a role in treating recurrent and/or persisting stress urinary incontinence after (failed) sling surgery and remain of particular interest in patients with stress urinary incontinence when performing concomitant surgery, for example for prolapse.

Current State of the Art in Non-Invasive Urodynamics

Lower urinary tract symptoms (LUTS) are highly prevalent and bothersome. The pressure flow or voiding part of urodynamics gives information regarding detrusor contractility and whether bladder outlet obstruction (BOO) is present. However, urodynamics are invasive and can be associated with infection and take time to perform. Moreover it is not clear whether urodynamics are beneficial in assessing LUTS routinely or whether they are able to predict outcomes following surgery for obstruction. As a result several non-invasive techniques and investigations have been developed to try to aid in the work up and management of patients with LUTS / BPE. A PubMed search was performed to review the literature on non-invasive urodynamic tests for voiding dysfunction. Techniques include transition zone index, intravesical prostatic protrusion, prostate circle area ratio, prostatic urethral angle, resistive index, bladder wall and detrusor wall thickness, ultrasound estimated bladder weight, near infrared spectroscopy, condom catheter and penile cuff compression techniques and are summarized in this review.

Long-term functional results after unilateral mid-urethral sling transection for voiding dysfunction

OBJECTIVE To investigate the long-term outcomes of unilateral mid-urethral sling transection to treat voiding dysfunction after synthetic mid-urethral sling placement for stress urinary incontinence. STUDY DESIGN Twenty-three patients who underwent an unilateral sling transection were analyzed retrospectively. Patient records were analyzed for subjective outcome, and pre- and postoperative flow patterns were used as objective outcome parameters. RESULTS At the first postoperative follow-up, 77.3% of the patients remained dry. After a mean follow-up of 42 months, 73.9% of patients were continent. The flow pattern after lateral sling transection was significantly better than pre-operatively, with higher maximum flow rate (24.2ml/s, p=0.001), higher mean flow rate (10.4ml/s, p=0.001), higher voided volume (308.5ml, p=0.002) and lower residual volume (28.7ml, p=0.003). At final postoperative follow-up, eight patients (34.8%) reported urgency and six patients (26.1%) were incontinent; four of these patients (17.4%) mainly had urge incontinence. CONCLUSIONS Unilateral mid-urethral sling transection is a safe, effective technique to treat voiding symptoms with good preservation of continence. The technique repairs the obstructive flow effectively. Urgency and urge incontinence after mid-urethral sling placement are difficult to treat with transection alone.

Neurogenic bowel management for the adult spinal cord injury patient

BackgroundBowel function can be markedly changed after a spinal cord injury (SCI). These changes, and the care associated with managing the changes, can greatly impact a persons quality of life over a lifetime.PurposeThe purpose of the SIU-ICUD workgroup was to identify, assess, and summarize evidence and expert opinion-based themes and recommendations regarding bowel function and management in SCI populations.MethodsAs part of the SIU-ICUD joint consultation of Urologic Management of the Spinal Cord Injury, a workgroup was formed and comprehensive literature search of English language manuscripts regarding bowel physiology and management plans for the SCI patient. Articles were compiled, and recommendations in the chapter are based on group discussion and follow the Oxford Centre for Evidence-based Medicine system for levels of evidence (LOEs) and grades of recommendation (GORs).ResultsNeurogenic bowel symptoms are highly prevalent in the SCI population. Patients with injuries above the conus medullaris have increased bowel motility and poor anorectal sphincter relaxation. Patients with injuries below the conus are more likely to have an areflexic colon and low sphincter tone. Conservative management strategies include diet modification and anorectal stimulation. There are few evidence-based pharmacologic interventions, which improve fecal transit time. Intestinal ostomy can be an effective treatment for reducing hours spent per week on bowel management and colostomy may be easier to manage than ileostomy due to solid vs liquid stool.ConclusionsBy understanding physiology and treatment options, patients and care teams can work together to achieve goals and maximize quality of life after injury.

Fertility and sexuality in the spinal cord injury patient

BackgroundAfter a spinal cord injury, patients have different perceptions of sexuality, sexual function, and potential for fertility. These changes can greatly impact quality of life over a lifetime.PurposeThe purpose of this workgroup was to identify common evidence based or expert opinion themes and recommendations regarding treatment of sexuality, sexual function and fertility in the spinal cord injury population.MethodsAs part of the SIU-ICUD joint consultation of Urologic Management of the Spinal Cord Injury (SCI), a workgroup and comprehensive literature search of English language manuscripts regarding fertility and sexuality in the spinal cord injury patient were formed. Articles were compiled, and recommendations in the chapter are based on group discussion and follow the Oxford Centre for Evidence-based Medicine system for levels of evidence (LOEs) and grades of recommendation (GORs).ResultsGenital arousal, ejaculation, and orgasm are significantly impacted after spinal cord injury in both male and female SCI patients. This may have a more significant impact on potential for fertility in male spinal cord injury patients, particularly regarding ability of generate erection, semen quantity and quality. Female patients should be consulted that pregnancy is still possible after injury and a woman should expect resumption of normal reproductive function. As a result, sexual health teaching should be continued in women despite injury. Pregnancy in a SCI may cause complications such as autonomic dysreflexia, so this group should be carefully followed during pregnancy.ConclusionsBy understanding physiologic changes after injury, patients and care teams can work together to achieve goals and maximize sexual quality of life after the injury.

Three month clinical results with a rechargeable sacral neuromodulation system for the treatment of overactive bladder

The primary aim of the RELAX‐OAB study is to confirm the safety and efficacy of the Axonics r‐SNM System, a miniaturized, rechargeable SNM system.