Harris M. Nagler

RESPONSE OF ROUTINE SEMEN ANALYSIS AND CRITICAL ASSESSMENT OF SPERM MORPHOLOGY BY KRUGER CLASSIFICATION TO THERAPEUTIC VARICOCELECTOMY

PURPOSE We studied the effect of varicocelectomy on Kruger morphology and semen parameters. MATERIALS AND METHODS A total of 33 subfertile men diagnosed with varicoceles was evaluated 3 months before, and 3 to 4 and 6 to 8 months after varicocelectomy. Evaluation involved routine semen analysis and sperm morphology using Kruger classification. RESULTS Significant improvement in sperm concentration and count was found after varicocelectomy (sperm count preoperatively 117.1 +/- 29, 3 to 4 months postoperatively 162.5 +/- 41 and 6 to 8 months postoperatively 139.8 +/- 25 million sperm, p = 0.0095). Using Kruger classification, evaluation of sperm morphology revealed overall significant increase in percentage of normal A forms at 3 to 4 and 6 to 8 months after surgery (from 9.8 +/- 5.8% A forms, 13.6 +/- 7.7% A forms, and 14.5 +/- 7.5% A forms, respectively, p = 0.0002, normal greater than 14%). Twelve of the 26 patients (46%) with abnormal sperm morphology preoperatively and greater than 4% A forms reached normal levels 3 months postoperatively. Six months after surgery only 6 patients maintained normal values and 3 of the initial 14 nonresponders became normal (9 of 26, 36%). Three patients with severe teratozoospermia (less than 4% A forms) showed improvement in sperm morphology. Four patients with normal sperm morphology preoperatively were not affected by varicocelectomy. CONCLUSIONS Surgical correction of varicocele was associated with significant improvement in sperm morphology evaluated using Kruger classification. Concentration and count improved after varicocelectomy. Changes were observed as early as 3 months after surgery.

Medicolegal aspects of testicular torsion.

OBJECTIVES Testicular torsion is an active area of medical malpractice litigation because of the diagnostic uncertainty, delays in diagnosis and treatment, diagnostic errors, and resultant testicular loss. We reviewed this topic to determine the nature of patient claims and their clinical and legal outcomes. METHODS All closed case files of a large medical malpractice insurance company based in New Jersey involving testicular torsion from the years 1979 to 1997 were retrospectively reviewed. The following data were collected: patient demographics, timing of presentation, initial complaints, diagnosis given, consultations obtained, radiographic studies, treatment provided, outcomes, and indemnity payments. RESULTS Thirty-nine cases consisting of 58 individual claims were reviewed. Indemnity payments were made in 26 cases (67%), of which 25 (96%) were settlements, and 13 cases (33%) ended in favor of the physicians. Five cases went to trial, with only one verdict in favor of the plaintiff. The median indemnity payment was

Lifestyle, environment, and male reproductive health.

45,000. Urologists were named most frequently (48%), and a misdiagnosis of epididymitis (61%) was most commonly cited. The mean patient age was 24.3 years. Atypical initial complaints were common (46%). Late presentation (greater than 8 hours) did not affect the medicolegal outcome. The major liabilities for paid claims were an error in diagnosis (74%), a delay in or lack of referral (48%), lack of radiologic examination (19%), failure to explore (13%), error in surgical technique or judgment (13%), and falsified records (10%). CONCLUSIONS Testicular torsion litigation most often focuses on the urologist. Claims are more common in older patients and those with atypical complaints. Settlement is the most common outcome, with a fairly standard indemnity payment rewarded. The initial treating physician must have a high index of suspicion for the diagnosis and refer promptly. In lieu of a definitive radiologic study, or when the diagnosis is in question, the urologist should strongly consider exploration and should perform contralateral exploration when torsion is found.

Urine contamination of seminal fluid after transurethral resection of the ejaculatory ducts

A large number of environmental and lifestyle factors may negatively affect spermatogenesis and male fertility. This article enumerates the current state of knowledge regarding those that have been identified, and extrapolates the predicted magnitude of these effects over the next 20 years based on current societal trends. However, it is likely that additional factors have yet to be recognized. Additional research is needed to further define and clarify environmental factors that affect male fertility in order to mitigate their effects.

Results in the United States with Sperm Micro-Aspiration Retrieval Techniques and Assisted Reproductive Technologies

Transurethral resection of ejaculatory duct obstruction has assumed a significant role in the treatment of infertile men. The potential impact of disruption of the ejaculatory duct apparatus after transurethral resection has not been studied. The seminal plasma of patients was evaluated after transurethral resection of the ejaculatory ducts by determining creatinine levels as a measure of urine contamination of semen. Analysis of semen parameters was retrospectively performed on preoperative and postoperative samples in 8 subfertile men diagnosed with ejaculatory duct obstruction treated by transurethral resection. These were not 8 consecutive patients but rather individuals from a larger series who had seminal plasma frozen preoperatively and postoperatively. A significant increase in seminal plasma creatinine levels postoperatively was detected in 7 of 8 patients evaluated. In patients who were requested to produce 2 specimens within 1 hour high levels of creatinine were found in both ejaculates, although creatinine levels were lower in the second ejaculate. The patient who postoperatively had low levels of creatinine in seminal plasma demonstrated an improvement in sperm concentration and morphology, and his wife became pregnant. Transurethral resection of the ejaculatory ducts results in marked improvement in some semen parameters. However, the impact of urine contamination in semen after transurethral resection of the ejaculatory ducts must be assessed in the management of patients who present with ejaculatory duct obstruction.

Outcomes of Varicocelectomy Treatment: An Updated Critical Analysis

AbstractImproved methods of urological microsurgery and of various assisted reproductive technologies have resulted in the ability to achieve pregnancies with sperm aspirated microsurgically from men with bilateral congenital absence of the vasa deferentia or with ductal obstructions that cannot be surgically reconstructed. A survey was conducted of the results of such procedures performed in the United States during approximately 2 years. Female partner ovarian stimulation was initiated in 219 instances at 22 centers. Of the 219 procedures 23 (11%) were terminated without attempting any form of gamete fertilization or insemination of the wife for various reasons (no sperm or too few sperm retrieved, poor to absent sperm motility or poor quality eggs). The etiology of azoospermia in the 219 procedures was congenital absence of the vasa deferentia in 115 cases (52%), other congenital conditions in 15 (7%), failed vasectomy reversal in 37 (17%), infection in 4 (2%), other conditions (mainly ejaculatory dysf...

Factors predicting successful microsurgical vasectomy reversal.

This article provides an updated analysis of the varicocele literature published since 1994. The present authors have followed the format of the previous review and have included a summary of the results from the 1994 article at the end of each section.

Treatment of Congenital Penile Curvature with Penile Torsion: A New Twist

A man who desires restoration of fertility after vasectomy has two main treatment options for having his genetic child: vasectomy reversal or sperm extraction with subsequent in vitro fertilization with intracytoplasmic sperm injection. Microsurgical reconstructive techniques and their widespread availability have made vasectomy reversal a realistic option for many couples; however, vasectomy reversal outcomes are varied because there are many factors that alter the chance of success. Some of these factors become known preoperatively, whereas others can only be ascertained at the time of surgery. Intraoperatively, the urologist must identify factors and understand how they will affect the decision to proceed. This article systematically reviews each of these phases of decision-making and management.

Transseptal Crossed Vasovasostomy

Congenital penile curvature secondary to asymmetry of corpora cavernosal length is an uncommon cause of penile deformity. Although the deformity generally is not severe enough to preclude sexual intercourse it can be a source of great concern to the patient and may cause him to avoid all sexual contact. The Nesbit procedure is a simple, effective surgical technique to correct lateral or ventral curvature. Rarely penile deviation is accompanied by penile torsion. This unique problem requires a novel surgical approach to create a straight, nontwisted erection. We report 2 cases of congenital lateral penile curvature with accompanying penile torsion and describe a simple modification of the Nesbit procedure for surgical correction.

THE NATURAL HISTORY OF PARTIAL EJACULATORY DUCT OBSTRUCTION

We examined 11 patients with acquired obstructive azoospermia resulting from irreparable obstruction of 1 vas deferens and severe damage to the contralateral testis. All of the patients underwent transseptal crossed vasovasostomy with no morbidity. Of 8 patients evaluated with postoperative semen analyses 4 (50 per cent) demonstrated total sperm counts of 29 to 205 million and 2 pregnancies (25 per cent) have been reported, with followup ranging from 5 months to 2 years. The etiologies of the vasal obstruction included previous inguinal surgery in 7 patients, vasectomy in 1, ejaculatory duct obstruction in 1, ectopic ureter in 1 and vasal agenesis in 1. Factors leading to loss of the contralateral testis were torsion in 5 patients, mumps orchitis in 2, varicocele in 1, pediatric inguinal herniorrhaphy in 1, epididymal blow out in 1 and unknown in 1. A representative case involving a unilateral ectopic ureter emptying into the seminal vesicle and subsequent contralateral testicular torsion is presented. The results indicate that a transseptal crossed vasovasostomy should be done in patients satisfying the criteria presented.