James A. Kashanian

Influence of increasing body mass index on semen and reproductive hormonal parameters in a multi-institutional cohort of subfertile men.

OBJECTIVEnTo determine whether obesity affects serum and seminal measures of male reproductive potential among a multi-institutional cohort.nnnDESIGNnRetrospective multi-institutional cohort study.nnnSETTINGnInfertility clinics.nnnPATIENT(S)nAll men referred for male infertility evaluation from 2002 to 2014 (n = 4,440).nnnINTERVENTION(S)nNone.nnnMAIN OUTCOME MEASURE(S)nCollected reproductive parameters included hormonal (gonadotropins, T, E2, PRL) and semen analysis (ejaculate volume, sperm concentration, motility, normal morphology) data. Body mass index (BMI) was calculated for all patients with comparisons to reproductive parameters using univariate and multiparametric models.nnnRESULT(S)nBased on World Health Organization definitions, 30.9% of the cohort was normal weight (BMI 18.5-24.9), 45.1% overweight (25-29.9), and 23.3% obese (>30). Neither FSH nor LH demonstrated significant correlations with BMI on multivariate analysis. Total T (r = -0.27) and the T:E2 ratio (r = -0.29) inversely varied with BMI, whereas E2 (r = 0.13) had a direct correlation. On univariate analyses, BMI had weak but significant negative correlations with ejaculate volume (r = -0.04), sperm concentration (r = -0.08), motility (r = -0.07), and morphology (r = -0.04). All parameters remained significant on multivariate modeling with the exception of sperm motility. Rates of azoospermia and oligospermia were also more prevalent among obese (12.7% and 31.7%, respectively) compared with normal weight men (9.8% and 24.5%).nnnCONCLUSION(S)nIn one of the largest cohorts of male fertility and obesity, serum hormone and semen parameters demonstrated mild but significant relationships with BMI, possibly contributing to subfertility in this population.

Pediatric Oncology Providers' Attitudes and Practice Patterns Regarding Fertility Preservation in Adolescent Male Cancer Patients.

Background:The aim of this study was to evaluate pediatric oncology providers’ attitudes toward fertility preservation (FP), their use of educational materials, their approach to FP discussion, and their FP knowledge specifically pertaining to adolescent males. Methods:A 40-item online survey was distributed to physicians, advanced practice nurses (APN), and nurses within pediatric oncology. Results:About 78.7% of physicians, 81.4% of APN, and 51.9% of nurses reported high levels of comfort in discussing FP options with adolescent males (P<0.05). Fifty-one percent of physicians and 54.2% of APN reported using educational materials, compared with 38.9% of nurses (P<0.05). Regarding knowledge of FP technologies, 48.7% of physicians, 52.5% of APN, and 81.1% of nurses reported being unfamiliar with intracytoplasmic sperm injection (P<0.05). An overwhelming majority (92.9%) of respondents reported having no formal training in discussing FP. Finally, 84.8% of respondents believed formal training on this issue would be useful to them. Conclusions:This study illustrates an unmet need in the education of pediatric oncology providers, as knowledge gaps and discomfort are common themes reported by health care professionals within the context of adolescent male FP care. In addition, this study reveals a high level of receptiveness to FP training by these same providers.

Scrotal Ultrasound for Pain: Low Frequency of Absolute Surgical Indications

OBJECTIVEnTo examine the results of scrotal ultrasounds (US) conducted for scrotal or testicular pain and review the pathologic findings of orchiectomies done for lesions that were suspicious for malignancy on US.nnnMATERIALS AND METHODSnWe retrospectively reviewed the indications and findings of all scrotal US completed at our institution from 2002 to 2014. If a patient underwent an orchiectomy for an intratesticular lesion that was concerning for malignancy on US, the pathology report was also reviewed.nnnRESULTSnThere were 18,593 scrotal US performed, with 7,668 (41.2%) conducted for scrotal pain. Of the US performed for pain, 80.4% revealed benign or normal findings, and only 2.2% demonstrated a finding that is an absolute indication for surgery (intratesticular lesion suspicious for malignancy 0.8%, abscess 0.7%, torsion 0.6%, infiltrative process such as lymphoma 0.1%). For those patients undergoing an orchiectomy, 75% had malignancy on pathologic analysis.nnnCONCLUSIONnThe majority of the 7668 US performed to evaluate scrotal or testicular pain reveal normal or benign findings. A low percentage demonstrates a finding that necessitates urgent or emergent surgery.

The men's health center: Disparities in gender specific health services among the top 50 "best hospitals" in America

Objective Gender-specific integrated health services have long existed in the arena of womens health care, but mens health centers (MHCs) have only recently emerged as a novel practice model. Here, we seek to evaluate the prevalence and format of MHCs found in the leading academic medical centers in the United States. Methods The US News & World Reports Top 50 Ranked Hospitals for Urology was used as our cohort. Data were gathered on the presence of MHCs and types of providers and conditions treated. An equivalent search was performed for womens health centers (WHCs). Results Sixteen of 50 (32%) promoted some type of MHC, compared to 49 of 50 (98%) offering a WHC. Eight of the top 15 ranked institutions (53%) had an MHC compared to eight of 35 (23%) remaining programs. Six of 16 MHCs incorporated providers from a variety of medical disciplines, including urologists, internists, endocrinologists, cardiologists, and psychologists, while another six of 16 MHCs were staffed solely by urologists. Eight of 16 provided services for exclusively urologic issues, four of 16 offered additional services in treatment of other medical conditions, and four of 16 did not specify. Conclusion A considerable disparity exists between the prevalence of gender-specific health services, with WHCs being much more numerous than MHCs. All but one leading institution had WHCs compared to less than one-third having MHCs. Our findings also highlight the heterogeneous nature of mens health programs, as they exhibit great variability in program type and focus, yet are all being marketed under the “Mens Health” banner.

A contemporary analysis of dual inflatable penile prosthesis and artificial urinary sphincters outcomes

Purpose: Inflatable penile prostheses and artificial urinary sphincters are used to treat men with erectile dysfunction and stress urinary incontinence, respectively. After prostate cancer treatment men often experience erectile dysfunction and stress urinary incontinence. Dual prosthetic implantation can improve the quality of life of these men. We evaluated reoperation outcomes in men who underwent dual implantation compared to each device implanted individually. Materials and Methods: We queried the SPARCS (New York State Department of Health Statewide Planning and Research Cooperative) database for men who underwent inflatable penile prosthesis and/or artificial urinary sphincter insertion between 2000 and 2014. The primary outcomes were the inflatable penile prosthesis and artificial urinary sphincter reoperation rates (revision, replacement or removal). Multivariable regression analysis was performed to assess the association of dual implantation with reoperation. Adjusted time to event analysis was also performed. Results: Median followup in the inflatable penile prosthesis cohort was 66 months (IQR 25–118) and in the artificial urinary sphincter cohort it was 69 months (IQR 27–121). Compared with men who received a penile prosthesis alone those with a penile prosthesis and an artificial urinary sphincter had a higher likelihood of undergoing inflatable penile prosthesis reoperation at 1 year (OR 2.08, 95% CI 1.32–3.27, p <0.01) and 3 years (OR 2.60, 95% CI 1.69–3.99, p <0.01). Compared with an artificial urinary sphincter alone patients with an inflatable penile prosthesis and an artificial urinary sphincter did not have a higher likelihood of undergoing artificial urinary sphincter reoperation at 1 year (p = 0.76) or 3 years (p = 0.73). Conclusions: Combined inflatable penile prosthesis and artificial urinary sphincter insertion portends a higher likelihood of inflatable penile prosthesis reoperation at 1 and 3 years. However, artificial urinary sphincter outcomes remain comparable. These findings should be used to better counsel patients about the risk of reoperation when undergoing dual implantation.

Fertility Preservation in the Male Adolescent Patient

Over 15,000 children develop cancer in the United States (US) each year (Ward et al., CA Cancer J Clin 64(2):83–103, 2014), with a 5-year survival rate for childhood cancer being roughly 80% (Robison and Hudson, Nat Rev Cancer 14(1):61–70, 2014). This extrapolates to over 385,000 childhood cancer survivors living in the United States (Phillips et al., Cancer Epidemiol Biomark Prev 24(4):653–663, 2015). With a growing number of childhood cancer survivors, oncologic counseling has seen a shift in focus from concentrating solely on short- and long-term survival benefits of treatment regimens to survivorship and long-term effects of treatments. With this shifting paradigm, short- and long-term gonadotoxic effects of cancer treatment have become a major concern for clinicians treating and patients diagnosed with malignancies. Because of this, fertility preservation (FP) among adolescent and young adult (AYA) cancer patients has become a significant area of interest and research.

Trends in Penile Prosthetics: Influence of Patient Demographics, Surgeon Volume, and Hospital Volume on Type of Penile Prosthesis Inserted in New York State

INTRODUCTIONnPenile prostheses (PPs) are a discrete, well-tolerated treatment option for men with medical refractory erectile dysfunction. Despite the increasing prevalence of erectile dysfunction, multiple series evaluating inpatient data have found a decrease in the frequency of PP surgery during the past decade.nnnAIMSnTo investigate trends in PP surgery and factors affecting the choice of different PPs in New York State.nnnMETHODSnThis study used the New York State Department of Health Statewide Planning and Research Cooperative (SPARCS) data cohort that includes longitudinal information on hospital discharges, ambulatory surgery, emergency department visits, and outpatient services. Patients older than 18 years who underwent inflatable or non-inflatable PP insertion from 2000 to 2014 were included in the study.nnnOUTCOMESnInfluence of patient demographics, surgeon volume, and hospital volume on type of PP inserted.nnnRESULTSnSince 2000, 14,114 patients received PP surgery in New York State; 12,352 PPs (88%) were inflatable and 1,762 (12%) were non-inflatable, with facility-level variation from 0% to 100%. There was an increasing trend in the number of annual procedures performed, with rates of non-inflatable PP insertion decreasing annually (P < .01). More procedures were performed in the ambulatory setting over time (P < .01). Important predictors of device choice were insurance type, year of insertion, hospital and surgeon volume, and the presence of comorbidities.nnnCLINICAL IMPLICATIONSnMajor influences in choice of PP inserted include racial and socioeconomic factors and surgeon and hospital surgical volume.nnnSTRENGTHS AND LIMITATIONSnUse of the SPARCS database, which captures inpatient and outpatient services, allows for more accurate insight into trends in contrast to inpatient sampling alone. However, SPARCS is limited to patients within New York State and the results might not be generalizable to men in other states. Also, patient preference was not accounted for in these analyses, which can play a role in PP selection.nnnCONCLUSIONSnDuring the past 14 years, there has been an increasing trend in inflatable PP surgery for the management of erectile dysfunction. Most procedures are performed in the ambulatory setting and not previously captured by prior studies using inpatient data. Kashanian JA, Golan R, Sun T, etxa0al. Trends in Penile Prosthetics: Influence of Patient Demographics, Surgeon Volume, and Hospital Volume on Type of Penile Prosthesis Inserted in New York State. J Sex Med 2018;15:245-250.

Assessing Testicular Reserve in the Male Oncology Patient

Fertility preservation is of utmost importance to males diagnosed with malignancies, but this care does not only occur in the pretreatment setting. Longitudinal follow-up is needed to determine the duration and extent of spermatogenesis impairment in men. When assessing testicular reserve in a male cancer survivor, clinicians should keep in mind that the minimum initial evaluation of the patient should include a full medical history, physical examination, and measurement of serum testosterone and FSH levels. Additionally, semen analysis is currently the gold standard for assessing fertility status in the male. This test is readily available at most tertiary care centers and can be performed at any age after puberty.

Facing a cancer diagnosis: empowering parents to speak with adolescents about sperm banking

Both pediatric oncologists and reproductive urologists share a joint responsibility to educate, treat, and advocate for male adolescent and young adult (AYA) cancer patients who require gonadotoxic therapy. The importance of fertility preservation coincides with the ever-growing number of pediatric cancer survivors, because most children now survive their malignancy into adulthood and ultimately desire family building. Unfortunately, the risk of infertility in this population is remarkably high. Green et al. reviewed the Childhood Cancer Survival Study cohort, ultimately including 6,224 men in their final analysis (1). Compared with healthy siblings, pediatric cancer survivors were roughly one-half as likely to have fathered children (hazard ratio 0.56, 95% confidence interval [CI] 0.49 to 0.63). The reproductive consequences were greatest with the use of alkylating agents and when radiation involved the testis. Fortunately, the solution for fertility preservation is often straightforward for boys who have entered puberty: preemptive sperm banking before any exposure of a reproductive insult. For parents and male AYA patients facing a new cancer diagnosis, the process of sperm banking for future fertility can be overwhelming. In addition, the providers meeting with these patients may not feel comfortable with broaching the subject or are not prepared to practically facilitate referral (2). These conditions have resulted in poor rates of sperm banking for adolescent cancer patients, which have been reported to be as low as 17.8% by one large retrospective series (3). The low rate of utilization represents failure of counseling on the part of the treatment teams despite clear guidelines from organizations including the American Society of Clinical Oncology, the American Society for Reproductive Medicine, the National Comprehensive Cancer Network, and the Association of Pediatric Hematology/Oncology Nurses (2, 3). Several groups have attempted to identify the barriers related to fertility preservation in pediatric oncology. To better understand these impediments, one must first appreciate the unique perspectives of providers, parents, and the patients themselves. Fuchs et al. petitioned the attitudes and practices of 326 oncology providers, which included physicians, nurses, and advanced practice nurses (2). Within their cohort, 92% of respondents reported no history of formal training in fertility preservation. Consequently, only 48% of providers were familiar with intracytoplasmic sperm injection, a basic fertility intervention available to these patients and a marker of overall understanding. Although 93% of responding physicians reported routinely discussing fertility preservation with their adolescent patients, only 78% reported feeling comfortable with the topic. It is intuitive to suspect that sperm banking outcomes

Gonadotropin Interpretation in a 25-Year-Old Man.

Apreviously healthy 25-year-oldman presented to the urology clinic with concerns of low energyandan interest in testosteronereplacementtherapy.Hereportednosymptomsof low libido,erectiledysfunction,orejaculatorydysfunction.Hismedicalhistorywassignificantonly forattention-deficit/hyperactivitydisorder forwhichhewasprescribeddextroamphetamine/ amphetamine. Although hewas not currently trying to conceive, hewas interested in future fertility.Onphysicalexamination,hewas178cmtallandweighed82kg(bodymass index,25.8), waswelldeveloped,hadnovisual fielddefects,andhadnogynecomastia.Hehadbilateraldescended atrophic testes that were each 4mL in volume (reference volume, 20mL). His epididymides and spermatic cord structureswere present and normal bilaterally. Given the patient’s clinical presentation and examination findings, blood tests and a semenanalysiswereperformed.Results fromthe laboratory testingare shown in theTable.