Irvin H. Hirsch

Postsurgical outcomes assessment following varicocele ligation : Laparoscopic versus subinguinal approach

OBJECTIVES To prospectively compare and objectively assess the postsurgical outcome parameters of both laparoscopic and open subinguinal techniques for varicocele ligation in infertile men. METHODS A total of 41 evaluable patients with a history of infertility, abnormal semen analysis, and clinically diagnosed varicoceles underwent surgical ligation either by the insufflative intraperitoneal laparoscopic (n = 15), gasless laparoscopic (n = 7), or the open subinguinal (n = 19) approach. Most procedures (39 of 41) were performed in the outpatient setting, and patients were followed postoperatively for a minimum of 6 months. Postsurgical outcome was assessed by physical examination and review of a patient questionnaire quantifying the graded pain severity, analgesic requirements, and number of days to return to work. RESULTS The average operative time was 82.3 +/- 26.5 minutes for insufflative intraperitoneal laparoscopic varicocelectomy, 170 +/- 55 minutes for gasless laparoscopic varicocelectomy, and 35.6 +/- 13.5 minutes for the open subinguinal approach. The analgesic requirement was 13.7 +/- 9.9 tablets for the insufflative laparoscopic group, 22.5 +/- 11 tablets for the gasless laparoscopic group, and 10.9 +/- 10.3 tablets for the open subinguinal group. The average number of days to return to work was 4.9 +/- 2.7 for the insufflative group, 6.6 +/- 2.6 for the gasless group, and 5.1 +/- 3.7 for the open subinguinal group. CONCLUSIONS These results show no superiority of laparoscopic techniques over the standard open subinguinal technique with respect to hospital stay, analgesic requirements, or return to work. Laparoscopic techniques require excessive operative time, may have attendant complications, and require general anesthesia, limitations that preclude their routine application in varicocele ligation. However, the laparoscopic approach may have a role in the setting of other concurrently performed laparoscopic procedures.

Quantitative Testicular Biopsy in Spinal Cord Injured Men: Comparison to Fertile Controls

Spermatogenic abnormalities have been reported in the majority of spinal cord injured men on routine testicular biopsy. However, given the interim advances in their urological and rehabilitative care, a quantitative assessment of the germinal epithelium after spinal cord injury and comparison of these parameters to normal controls are warranted. Incisional testicular biopsy was performed in 14 spinal cord injured men. Quantitative micrometric techniques were applied to assess spermatogenesis and the results were compared to a normative data base of testicular biopsies previously obtained from a group of 15 fertile volunteers. From a minimum of 10 randomly selected round seminiferous tubules per subject the mean number of Sertoli cells, mature spermatids, tubular diameter and tubular wall thickness were determined in both groups and statistically analyzed. In the spinal cord injury group the mean number of spermatids per tubule was significantly lower and the mean number of Sertoli cells per tubule was significantly higher than in fertile controls (p less than 0.05). Moreover, the mean Sertoli cell-to-spermatid ratio per seminiferous tubule was significantly higher in the spinal cord injury group and discriminated between spinal cord injured men and controls, with a sensitivity of 93% and specificity of 100% (p less than 0.0001). Half of the spinal cord injury group showed a mean tubular spermatid density of less than 10. Compared to the fertile population, spinal cord injured men show significant differences in quantitative parameters of the germinal epithelium that may contribute to the reproductive dysfunction.

TESTIS BIOPSY FINDINGS IN THE SPINAL CORD INJURED PATIENT

PURPOSE Azoospermia after electroejaculation in spinal cord injured men may be due to testicular failure or obstruction. These men can initiate pregnancy with assisted reproductive techniques, such as intracytoplasmic sperm injection, but only if sperm are present in the testis biopsy. We analyzed the histopathology of testis biopsies from spinal cord injured men and assessed whether patient factors were predictive of testis biopsy pathology. MATERIALS AND METHODS A total of 50 paraplegic men undergoing testis biopsy were divided into 2 groups based on normal or abnormal testis histopathology. Patient age, post-injury years, level of lesion, hormonal status and semen analysis results were compared. RESULTS Spermatogenesis was normal in 28 of the 50 patients. Hypospermatogenesis was exhibited in 15, maturation arrest at the spermatid stage in 6 and maturation arrest at the spermatocyte stage in 1 of the 22 abnormal cases. Nevertheless, mature sperm were identified in 43 of 50 biopsies (normal spermatogenesis and hypospermatogenesis). Men with normal spermatogenesis had better forward progression of sperm and a higher testosterone-to-luteinizing hormone ratio. Otherwise, there was no statistically significant correlation between study variables and testis biopsy results. No factors were predictive of testis biopsy histopathology. CONCLUSIONS The documentation of mature sperm in 43 of 50 biopsies from spinal cord injured patients suggests that a high rate of sperm retrieval is possible using testicular sperm extraction if sperm cannot be retrieved from the ejaculate. With intracytoplasmic sperm injection techniques the majority of spinal cord injured men retain fertility potential, even if azoospermic following electroejaculation.

Antisperm antibodies in seminal plasma of spinal cord-injured men.

Central to the problem of reproductive rehabilitation of spinal cord-injured men treated by assisted ejaculatory techniques is the consistent observation of deficient semen quality. Most studies have reported asthenospermia despite the presence of normal sperm concentration in most men undergoing these procedures. To date little attention has been given to the incidence and relevance of sperm autoimmunity in this group. In 9 anejaculatory spinal cord-injured men, electroejaculation was performed. Antegrade ejaculates were obtained in 7 men and analyzed. Mean sperm antegrade concentration was 74.4 +/- 113 x 10(6)/mL with a mean motile sperm concentration of 28.6 +/- 54.0 x 10(6)/mL. Enzyme-linked immunosorbent assay (ELISA)-determined antisperm antibody response was positive in the seminal plasma of 5 of 7 patients. Because of the disproportionately high incidence of an immunologic factor in men with neurogenic infertility, sperm autoimmunity should be considered among the important causes underlying their seminal dysfunction.

Endourological reconstruction of posterior urethral disruption

While conventional methods of urethroplasty for posterior urethral disruption usually are successful technically, they may be associated with complications and often require the expertise of a specialist. Therefore, the option of an endourological approach to the treatment of the obliterated posterior urethra would be highly desirable if a comparable surgical outcome could be achieved. We describe a closed controlled method of posterior urethral reconstruction following traumatic avulsion of the posterior urethra. Urethral continuity was re-established by endoscopic identification of the true prostatic outlet, its fixation with an angiography wire and a Goodwin sound, retrograde visual urethrotomy through the fibrotic segment and balloon dilation of the entire posterior channel. Postoperative anatomical and functional results were excellent, and were achieved with much less risk and cost to the patient than those of a perineal or transpubic urethroplasty.

Are sperm motion parameters influenced by varicocele ligation

OBJECTIVE To document objectively, improvements in sperm motion parameters in subfertile men after varicocele ligation with the use of computer-aided sperm analysis. DESIGN Retrospective chart review. SETTING An academic clinical environment. PATIENT(S) Thirty-four men with varicocele as the primary cause of infertility who underwent a physical examination, hormonal profile, and Doppler ultrasound evaluation. INTERVENTION(S) Computer-aided sperm analysis was performed before and after either subinguinal or laparoscopic varicocele ligation. MAIN OUTCOME MEASURE(S) Patients were followed up for 3-18 months after operation, and average computer-aided sperm analysis values were obtained before and after operation. Computer-aided sperm analysis values were analyzed by paired Students t-test, with special reference to motility and sperm motion parameters. RESULT(S) After varicocele ligation, patients demonstrated increases in mean sperm density and in the overall distribution of sperm with rapid velocity, although the increases were not statistically significant. Mean measures of straightness, linearity, and track speed also were increased after operation, but only progressive sperm velocity was increased to a statistically significant level. CONCLUSION(S) Because progressive velocity has been a primary computer-aided sperm analysis parameter predictive of male fertility and the success of assisted reproductive techniques, we conclude that varicocele ligation results in improvements in semen parameters, especially the key parameter of progressive sperm velocity.

Urinary dysfunction in lyme disease

Lyme disease, which is caused by the spirochete Borrelia burgdorferi, is associated with a variety of neurological sequelae. We describe 7 patients with neuro-borreliosis who also had lower urinary tract dysfunction. Urodynamic evaluation revealed detrusor hyperreflexia in 5 patients and detrusor areflexia in 2. Detrusor external sphincter dyssynergia was not noted on electromyography in any patient. We observed that the urinary tract may be involved in 2 respects in the course of Lyme disease: 1) voiding dysfunction may be part of neuro-borreliosis and 2) the spirochete may directly invade the urinary tract. In 1 patient bladder infection by the Lyme spirochete was documented on biopsy. Neurological and urological symptoms in all patients were slow to resolve and convalescence was protracted. Relapses of active Lyme disease and residual neurological deficits were common. Urologists practicing in areas endemic for Lyme disease need to be aware of B. burgdorferi infection in the differential diagnosis of neurogenic bladder dysfunction. Conservative bladder management including clean intermittent catheterization guided by urodynamic evaluation is recommended.

Epidemiology of current treatment for sexual dysfunction in spinal cord injured men in the USA model spinal cord injury centers.

This study is a prospective multicenter cooperative survey of the evaluation and treatment of erectile dysfunction in men with spinal cord injury (SCI). Uniform database questionnaires were completed prospectively by patients seeking therapy for erectile dysfunction. Eighty-five SCI men aged 17-68 years (mean age = 26 +/- 17) were enrolled. Mean duration of traumatic SCI was 3 +/- 3.2 years (Range = 0.3-18 years). The level of injury was cervical in 20 patients, thoracic in 31, lumbar in 29 and sacral in five. Patients were fully evaluated and then counseled as to their therapeutic options. Twenty-eight chose to use a vacuum erection device (VED), 26 preferred pharmacological penile injection and five used both intracorporeal therapy and VED. The remainder were managed with marriage and sexual counseling in 10 patients, three underwent penile prosthesis placement and two used topical pharmacotherapy. Four patients used other forms of treatment and in nine no therapy was recommended. Of the patients that used pharmacologic injection only, 74 percent used papaverine as a single agent, 20 percent used papaverine with phentolamine, five percent used prostaglandin E (PGE1) alone and one percent used a mixture. Patients using injection therapy report sexual intercourse a mean of 3 +/- 3.4 times per month as compared with 5 +/- 3.2 times per month in those using VED. Five intracorporeal injection patients developed priapism while two patients using the VED developed subcutaneous bleeding and one developed penile ischemia. We conclude that although a spectrum of erectile dysfunction treatment is present among SCI centers, VED and pharmacological penile injection are by far the two most popular methods of treatment and papaverine is the most common drug. The incidence of complications is small in the model centers.

Validation of flow cytometry analysis in the objective assessment of spermatogenesis: comparison to the quantitative testicular biopsy.

Objective determination of spermatogenesis has been accomplished by quantitative testicular biopsy, which, although laborious, has served as the standard for spermatogenic assessment. Aspiration deoxyribonucleic acid (DNA) flow cytometry of the testis, however, has simplified this determination, and has correlated with indirect hormonal parameters of spermatogenesis and qualitative observations of the seminiferous epithelium. Nevertheless, this important modality has yet to be validated against quantitative micrometry of the testis. To determine this correlation we submitted 29 incisional testicular biopsies for simultaneous quantitative analysis and DNA flow cytometry. Micrometric parameters included the mean tubular wall thickness, and the mean tubular concentration of late spermatids and Sertoli cells. The percentage of haploid, diploid and tetraploid cells was determined for each patient. For the entire patient population a statistically significant correlation was observed between the percentage of haploid cells and the tubular concentration of late spermatids (r = 0.784, p < 0.0005) as well as the mean tubular spermatid-to-Sertoli cell ratio (r = 0.824, p < 0.0005). A similar correlation was noted for various etiological subsets of patients: spinal cord injury (r = 0.809, p < 0.002), genital tract obstruction (r = 0.705, p < 0.02) and miscellaneous diagnoses (r = 0.828, p < 0.02). For the group with testicular failure quantitative micrometry and flow cytometry demonstrated severe impairment in all patients although a statistically significant correlation could not be shown because of the small range of values. DNA flow cytometry analysis correlates strongly with the current standard of quantitative spermatogenic assessment and, therefore, it may be validated as a simplified and highly objective method of determining spermatogenesis.

Erectile dysfunction in systemic sclerosis

Systemic sclerosis (SSc, scleroderma), a connective tissue disorder involving multiple organ systems, can be a causal factor in erectile dysfunction. We present a case report and a review of the literature. Awareness of this association can hasten the detection of this disorder and influence management choices.