Joe Nohra

Gonadal impact of target of rapamycin inhibitors (sirolimus and everolimus) in male patients: an overview

The immunosuppressive agents target of rapamycin inhibitors (TOR‐I) (sirolimus, and everolimus) have been widely used in kidney transplantation for >10 years. Up to 40% of men receiving a kidney transplant are younger than 50, and fertility as well as erectile function are major concerns. In this review, we provide a synopsis of past studies focusing on gonadal function in men treated with TOR‐I, mainly sirolimus, to establish what impact they have on male gonads, and which pathophysiological pathways are involved. A PubMed search for the years 1990–2006 selected articles that focused on the gonadal impact of TOR‐I. Primary outcome measures were testosterone, follicle‐stimulating hormone (FSH), and luteinizing hormone (LH) levels. Secondary outcome measures were sexual function, fertility status and sperm parameters. Treatment with TOR‐I results in a decrease in testosterone level, and an opposite increase in LH. Moreover, spermatogenesis seems to be disrupted by TOR‐I and FSH levels are increased. Sirolimus and everolimus inhibit the activity of mammalian targets of rapamycin, a serine/threonine kinase involved in numerous cell‐growth processes. Molecular mechanisms of action of TOR‐I on the testis involve inhibition of a stem cell factor/c‐kit‐dependant process in spermatogonia. Preliminary results appear to show that TOR‐I treatment has deleterious actions on the testis and impairs gonadal function after renal transplantation, but the impact of these effects are unknown.

Ejaculatory function after permanent 125I prostate brachytherapy for localized prostate cancer.

PURPOSE Ejaculatory function is an underreported aspect of male sexuality in men treated for prostate cancer. We conducted the first detailed analysis of ejaculatory function in patients treated with permanent (125)I prostate brachytherapy for localized prostate cancer. PATIENTS AND METHODS Of 270 sexually active men with localized prostate cancer treated with permanent (125)I prostate brachytherapy, 241 (89%), with a mean age of 65 years (range, 43-80), responded to a mailed questionnaire derived from the Male Sexual Health Questionnaire regarding ejaculatory function. Five aspects of ejaculatory function were examined: frequency, volume, dry ejaculation, pleasure, and pain. RESULTS Of the 241 sexually active men, 81.3% had conserved ejaculatory function after prostate brachytherapy; however, the number of patients with rare/absent ejaculatory function was double the pretreatment number (p < .0001). The latter finding was correlated with age (p < .001) and the preimplant International Index of Erectile Function score (p < .001). However, 84.9% of patients with maintained ejaculatory function after implantation reported a reduced volume of ejaculate compared with 26.9% before (p < .001), with dry ejaculation accounting for 18.7% of these cases. After treatment, 30.3% of the patients experienced painful ejaculation compared with 12.9% before (p = .0001), and this was associated with a greater number of implanted needles (p = .021) and the existence of painful ejaculation before implantation (p < .0001). After implantation, 10% of patients who continued to be sexually active experienced no orgasm compared with only 1% before treatment. in addition, more patients experienced late/difficult or weak orgasms (p = .001). CONCLUSION Most men treated with brachytherapy have conserved ejaculatory function after prostate brachytherapy. However, most of these men experience a reduction in volume and a deterioration in orgasm.

Polyorchidism: Presentation of 2 Cases, Review of the Literature and a New Management Strategy

Objectives: To present 2 cases with polyorchidism, to review the literature about polyorchidism, and to propose a rational therapeutic algorithm. Methods: In our institution, we encountered 2 patients with polyorchidism: The 1st patient had bilateral double testis with testicular torsion, and the 2nd patient presented with an indolent scrotal mass. We also performed a literature search (PubMed) for other reports of polyorchidism. Results: Polyorchidism is a rare congenital anomaly that is not well known by most urologists. So far, as illustrated by our 2 cases, the management of polyorchidism is rarely conservative, and usually the supernumerary testis is removed without any evidence supporting this attitude. Rare cases are complicated by torsion (case 1), cryptorchidism, or testicular neoplasm. In case of torsion, the conservative approach depends on the viability of the twisted testis. In case of cryptorchidism, notably in children or young adults, conservative management should be proposed, if technically feasible. In case of signs of malignancy, orchiectomy must be performed. Conclusions: Conservative treatment is advised in all uncomplicated cases. Complicated cases need a careful management, but several situations can be managed conservatively. Based on the literature, we propose a simple, rational therapeutic algorithm.

Vasectomie et chirurgies contraceptives déférentielles : aspects légaux et techniques

Resume Objectifs Analyser les innovations techniques, leurs resultats et l’evolution de la legislation en France concernant la chirurgie du deferent a visee sterilisante ou contraceptive. Materiel et Methodes Une recherche bibliographique a ete realisee en utilisant les mots cles : malelcontraception/vas deferens. Parmi les 332 articles obtenus de la recherche PUBMED, nous avons selectionnes 54 articles pour leur qualite methodologique et l’importance de leurs resultats. Resultats La vasectomie reste la seule technique chirurgicale deferentielle validee. Bien que les techniques microchirurgicales reconstructrices aient permis d’ameliorer le taux de repermeabilisation, la vasectomie doit etre consideree comme une methode de sterilisation (definitive). Les autres techniques chirurgicales du deferent a visee contraceptives (reversibles) n’ont pas donne les garanties necessaires a leur utilisation en dehors de protocoles. Cependant, les resultats encourageants de certaines d’entre elles pourraient favoriser leur developpement a moyen terme. D’un point de vue legal, depuis la reforme relative aux chirurgies sterilisantes contenue dans l’article L2123- 1 du code de la Sante Publique, la realisation de la vasectomie est autorisee dans un cadre reglementaire. Conclusion L’assouplissement de la legislation et les avancees techniques dans le domaine des chirurgies deferentielles a visee contraceptives pourraient contribuer a moyen terme au developpement de la contraception masculine deferentielle en France. La diffusion de ces techniques passe par l’information du grand public et la sensibilisation de la communaute urologique.

Chirurgie du phéochromocytome par laparoscopie rétropéritonéale : analyse de la morbidité et de l’instabilité hémodynamique

Resume But Etudier la morbidite et les parametres hemodynamiques sur une serie consecutive de surrenalectomies realisees pour pheochromocytome par voie de laparoscopie retroperitoneale. Materiel et Methodes Vingt troix pheochromocytomes chez 20 patients ont ete traites par laparoscopie retroperitoneale en chirurgie reglee, et constituent notre population d’etude. Les parametres etudies ont ete : en peroperatoire : duree operatoire, pertes sanguines, pression arterielle, frequence cardiaque, et en postoperatoire : les complications infectieuses, hemorragiques et thromboemboliques. Resultats La duree operatoire moyenne a ete de 156 minutes (105-224). Les pertes sanguines moyennes ont ete de 58 mL (0-300). En peroperatoire, 15% des patients ont presente un pic de PAS > 220 mm Hg et 70% un pic de PAS > 200 mm Hg. A l’oppose, 20% des patients ont presente un nadir de PAS Conclusion La chirurgie laparoscopique pour pheochromocytome expose a une instabilite hemodynamique. En consequence, il demeure preferable de realiser la chirurgie du pheochromocytome dans des centres d’expertise (chirurgicale, anesthesique et endocrinologique).

Fertilité avant et après traitement des patients présentant une tumeur à cellule de Leydig

Resume But Determiner la fertilite a long terme des patients traites pour une tumeur a cellule de Leydig du testicule. Materiel et methodes Sur 506 tumeurs du testicule recensees en Midi Pyrenees entre 1980 et 1998,17 etaient des tumeurs a cellules de Leydig (3,3%) et constituent la population d’etude. Tous les patients avaient un dossier andrologique. L’information concernant la fertilite avant et apres orchidectomie a ete obtenue par questionnaire courrier valide. Tous les patients ont repondu au questionnaire. Resultats La duree du suivi etait de 84 mois (36-173). L’âge moyen au moment du diagnostic etait de 32 ans (24- 51). Le symptome amenant au diagnostic etait une gynecomastie dans 9 cas (53%), une augmentation de la taille du testicule dans 4 cas (24%), une douleur scrotale dans 2 cas (12%) et une infertilite masculine dans 2 cas (12%). Avant le debut de leur maladie, 13/17 (76.5%) patients avaient essaye d’avoir un enfant. Six (46.2%) y etaient parvenus. Apres traitement de leur tumeur a cellules de Leydig, 10/17 (58.8%) avaient essaye d’avoir un enfant, 7 (70%) ont reussi. Conclusion La population des hommes atteints de tumeur a cellules de Leydig du testicule est une population hypofertiie avant traitement de la tumeur. L’ablation de la tumeur ameliore cette situation mais 3 patients sur 10 restent infertiles, ce qui conduit a recommander des mesures de conservation de sperme dans cette population.

Synchronous Epidermoid Cyst and Mature Teratoma of the Testis: An Unusual Association

We describe here the first case of a synchronous epidermoid cyst and mature teratoma of the testis occurring in a young man presenting a with bilateral testicular tumor. After a clinical, biological and ultrasound evaluation, testis-sparing surgery was performed on the left testis and a total orchiectomy on the right side in accordance with oncological principles. Histopathological examination revealed a simple epidermoid cyst on the left side and a mature teratoma on the right side, following Price’s criteria. No metastasis was detected, and the patient was closely followed. The patient remains disease-free and has normal postoperative testosterone levels 3 years after the surgery.

Lethal posttraumatic rupture of a pheochromocytoma: Lesson from a postmortem diagnosis

Pheochromocytoma is challenging to diagnose, and a life-threatening situation may occur if pheochromocytoma is incorrectly diagnosed and treated. We report the first case of a lethal posttraumatic rupture of an undiagnosed pheochromocytoma in a 46-year-old man who presented with peripheral vasoconstriction and signs of peritoneal irritation after being kicked by a horse. Computed tomography, arteriography, and two exploratory laparotomies were performed. The patient died of multiorgan failure 8 h after the trauma. The diagnosis of ruptured pheochromocytoma of the left adrenal gland was made during the postmortem examination. Pheochromocytoma should be considered in cases of blunt abdominal trauma associated with unstable blood pressure, peripheral vasoconstriction and adrenal hematoma.

OPEN PARTIAL NEPHRECTOMY WITH SELECTIVE RENAL PARENCHYMAL CONTROL: A NEW RELIABLE CLAMP

We describe our experience of open partial nephrectomy with a parenchymal clamp, the Reni-Clamp, in 30 patients from January 2002 to May 2005. The mean operative and clamping time was 150 and 27 minutes, respectively, and the blood loss was 150 mL. The Reni-Clamp enabled us to perform partial nephrectomy safely in all cases of polar or external edge renal tumor.