John C. Kefer

ROLE OF ANTIOXIDANTS IN THE TREATMENT OF MALE INFERTILITY

Male infertility continues to be a clinical challenge of increasing significance. While male factors such as decreased semen quality are responsible for 25% of all infertility issues, the etiology of suboptimal semen quality is poorly understood. Many physiological, environmental, and genetic factors have been implicated, including oxidative stress. Oxidative stress is induced by reactive oxygen species (ROS), or free radicals, and although ROS are required for critical aspects of sperm function, excessive levels of ROS can negatively impact sperm quality. The origin of ROS generation, and the etiologies of increased ROS in men with suboptimal sperm quality have only recently been elucidated, offering multiple targets for potential therapy. Here, we present a critical review of the literature describing the role of oxidative stress on decreased sperm function, as well as the role of antioxidants in the treatment of male factor infertility.

Safety and Efficacy of Flexible Ureterorenoscopy and Holmium:YAG Lithotripsy for Intrarenal Stones in Anticoagulated Cases

PURPOSE We compared perioperative outcomes in patients undergoing ureterorenoscopy and Ho:YAG lithotripsy for renal calculi with or without anticoagulation. MATERIALS AND METHODS We reviewed the records of all patients undergoing flexible ureterorenoscopy and Ho:YAG lithotripsy for renal calculi at 2 institutions from 2001 to 2007. We identified 37 patients on anticoagulation with Coumadin, clopidogrel or aspirin in whom anticoagulation therapy was not discontinued before surgery. Data on the anticoagulation group were retrospectively compared to those on a contemporary matched cohort of 37 controls without anticoagulation who underwent a similar operative procedure. The 2 groups were compared with regard to the stone-free rate, and intraoperative and postoperative complications with specific reference to bleeding and thromboembolism. RESULTS The 2 groups were matched for stone size, stone location, number of stones, bilateral procedures and concomitant ureteral stones. Anticoagulation group patients were older (58.2 vs 50.4 years, p = 0.0209) and had a greater American Society of Anesthesiologists score (2.8 vs 1.9, p <0.0001) compared to the control group. No procedure had to be terminated in the anticoagulation group due to poor visibility from bleeding. The median postoperative hemoglobin decrease was greater in the anticoagulation group than in the control group (0.6 vs 0.2 gm/dl, p <0.0001). The stone-free rate (81.1% vs 78.4%, p = 0.7725), intraoperative complications (0% vs 3%, p = 0.3140), postoperative complications (11% vs 5%, p = 0.3943) and hemorrhagic or thromboembolic adverse events were comparable in the 2 groups. CONCLUSIONS When necessary, ureterorenoscopy and Ho:YAG lithotripsy can be performed safely and efficaciously for renal calculi in patients on anticoagulation therapy without the need for perioperative manipulation.

Robotic abdominal sacrocolpopexy/sacrouteropexy repair of advanced female pelvic organ prolaspe (POP): utilizing POP‐quantification‐based staging and outcomes

Associate Editor

Safety and Efficacy of Percutaneous Nephrostolithotomy in Patients on Anticoagulant Therapy

PURPOSE We assessed the safety and efficacy of percutaneous nephrostolithotomy in patients requiring long-term anticoagulant therapy. MATERIALS AND METHODS We reviewed the records of 792 patients undergoing percutaneous nephrostolithotomy at our institution from 2000 to 2007, and identified 27 on anticoagulation therapy (warfarin, clopidogrel or cilostazol) who underwent surgery after perioperative reversal and reinitiation of anticoagulation. Warfarin was withheld 5 days preoperatively with enoxaparin bridging and resumed 5 days postoperatively. Clopidogrel and cilostazol were stopped 10 days preoperatively and resumed 5 days postoperatively. We subsequently analyzed changes in preoperative and postoperative hemoglobin, serum creatinine and clotting parameters, as well as intraoperative and postoperative bleeding or thromboembolic complications. RESULTS Overall the stone-free rate with percutaneous nephrostolithotomy monotherapy was 93% (25 of 27 patients). A second look procedure was required in 5 patients and a third procedure was required in 1. Mean hemoglobin decrease was 1.5 gm/dl (range 0 to 4.1) and mean change in serum creatinine was 0.03 mg/dl (range 0 to 0.4). Two patients (7%) had significant bleeding and 1 (4%) had a thromboembolic complication. All complications were successfully managed conservatively or in a minimally invasive manner. All patients were stone-free at 1-month followup. CONCLUSIONS With careful perioperative regulation of anticoagulation therapy and clotting parameters, percutaneous nephrostolithotomy can be performed safely and efficiently in properly selected patients requiring long-term anticoagulation.

Current status of prostate-sparing cystectomy

Radical cystoprostatectomy includes en bloc excision of the prostate due to a high incidence of occult prostatic malignancy in patients with bladder cancer. Radical cystectomy has a considerable incidence of functional morbidity, and concerns regarding morbidity can delay initiation of cystectomy by the patient or physician, thereby affecting long-term prognosis. Some investigators have advocated prostate-sparing cystectomy to improve postoperative continence and potency rates, and enhance patient acceptance of timely cystectomy. While these prostate-sparing series describe excellent postoperative functional results, concerns are raised regarding the oncologic efficacy of this procedure. Prostate-sparing cystectomy is arguably one of the most controversial topics in the field of urology today.

Outcomes of Partial Nephrectomy in Patients on Chronic Oral Anticoagulant Therapy

PURPOSE We report our experience with patients requiring long-term anticoagulation therapy who underwent open or laparoscopic partial nephrectomy for renal tumors at our institution. We compared outcomes with those in a control group undergoing partial nephrectomy with no anticoagulation requirements. MATERIALS AND METHODS We retrospectively reviewed the records of 1,031 patients who underwent laparoscopic or open partial nephrectomy from 2000 to 2005. Since 2000, 31 open and 16 laparoscopic partial nephrectomies were performed in patients on chronic warfarin, clopidogrel or cilostazol. Anticoagulation was appropriately discontinued perioperatively. The 47 anticoagulated cases were compared with 47 nonanticoagulated controls that were carefully matched for surgical approach, partial nephrectomy defect size, tumor size and location, procedure year and warm ischemia time. Investigators were blinded to all clinical outcomes throughout the matching process. Bleeding and thrombotic outcomes were then analyzed. RESULTS The 2 groups were well matched for resection bed size, tumor size, tumor location (central vs peripheral), solitary kidney, operative time and warm ischemia time (each p >or=0.3). Controls had significantly higher intraoperative blood loss (300 vs 200, p <0.05) and a greater postoperative decrease in hemoglobin (3.5 vs 2.4 mg/dl, p <0.001). However, transfusion rates were similar in the 2 groups (each 15%). Five patients on anticoagulation had thrombotic events postoperatively vs none in the control group. CONCLUSIONS Patients on anticoagulation are at higher perioperative risk but with careful perioperative management of anticoagulation therapy partial nephrectomy can be performed in a safe and efficacious manner. To our knowledge this is the largest study of outcomes in this complex patient population.

Pubo-Urethral Ligament Injury Causes Long-Term Stress Urinary Incontinence in Female Rats: An Animal Model of the Integral Theory

PURPOSE We examined the long-term effects of pubo-urethral ligament deficiency as a potential model of stress urinary incontinence compared to an established model of stress urinary incontinence. MATERIALS AND METHODS A total of 21 female Sprague-Dawley rats were randomly assigned to 1 of 3 groups, including pubo-urethral ligament transection, sham pubo-urethral ligament transection and bilateral pudendal nerve transection. Leak point pressure was measured 28 days later via an implanted suprapubic catheter. After leak point pressure measurement all animals were sacrificed. The pubic arch and pelvic organs were harvested for histological examination. The Wilcoxon rank sum test was used to evaluate differences in leak point pressure among the experimental groups. RESULTS At 28 days after pubo-urethral ligament transection mean +/- SD leak point pressure was significantly decreased when comparing pubo-urethral ligament transection and pudendal nerve transection to sham treatment (15.75 +/- 6.46 and 15.10 +/- 4.98 cm H(2)O, respectively, vs 42.56 +/- 11.58, p <0.001). No difference was noted when comparing pubo-urethral ligament transection to pudendal nerve transection (p = 0.76), indicating the long-term durability of pubo-urethral ligament transection on inducing stress urinary incontinence in the female rat. Histological examination of en bloc suprapubic areas demonstrated an absent pubo-urethral ligament in the pubo-urethral ligament transection group, and an intact pubo-urethral ligament in the sham treated and pudendal nerve transection groups. CONCLUSIONS Our results show that pubo-urethral ligament deficiency in the female rat induces long-term stress urinary incontinence that is comparable to that in the established stress urinary incontinence model via pudendal nerve transection. Our novel rat model could be used to investigate mechanisms of stress urinary incontinence in females, including the role of urethral hypermobility and potential therapeutic interventions for stress urinary incontinence.

Prostate-sparing cystectomy: has Pandora’s box been opened?

En bloc removal of the prostate has traditionally been an integral component of radical cystectomy for men with bladder cancer owing to a high incidence of occult prostatic malignancy. However, the risk of functional morbidity following this procedure is considerable and can delay patient acceptance of cystectomy, which can adversely affect the long-term prognosis. Recently, some investigators have advocated prostate-sparing cystectomy (PSCx) to improve postoperative continence and potency rates, and this may also improve timely patient acceptance of cystectomy. Several of these PSCx series describe excellent functional results postoperatively and PSCx may also facilitate a laparoscopic approach, offering further dividends. However, valid concerns regarding the oncologic efficacy of this procedure still predominate and protocols for patient selection, technique and postoperative surveillance are not well defined. The concept of PSCx is arguably one of the most controversial topics in the field of bladder cancer today.