Kevin Ostrowski

Infertility with Testicular Cancer.

Testicular germ cell cancer is one of the most curable cancers. Most patients are treated during their reproductive years, making infertility a significant quality of life issue after successful treatment. This focused review evaluates the factors that contribute to infertility and specific fertility risks with the various testicular cancer treatments. Timing of patient discussions and current fertility treatments are reviewed.

Higher Outcomes of Vasectomy Reversal in Men with the Same Female Partner as Before Vasectomy

PURPOSE We reviewed fertility outcomes of vasectomy reversal at a high surgical volume center in men with the same female partner as before vasectomy. MATERIALS AND METHODS We retrospectively studied a prospective database. All vasectomy reversals were performed by a single surgeon (EFF). Patients who underwent microsurgical vasectomy reversal and had the same female partner as before vasectomy were identified from 1978 to 2011. Pregnancy and live birth rates, procedure type (bilateral vasovasostomy, bilateral vasoepididymostomy, unilateral vasovasostomy or unilateral vasoepididymostomy), patency rate, time from reversal and spouse age were evaluated. RESULTS We reviewed the records of 3,135 consecutive microsurgical vasectomy reversals. Of these patients 524 (17%) who underwent vasectomy reversal had the same female partner as before vasectomy. Complete information was available on 258 patients (49%), who had a 94% vas patency rate. The clinical pregnancy rate was 83% by natural means compared to 60% in our general vasectomy reversal population (p <0.0001). On logistic regression analysis controlling for female partner and patient ages, years from vasectomy and vasectomy reversal with the same female partner the OR was 2 (p <0.007). Average time from vasectomy was 5.7 years. Average patient and female partner age at reversal was 38.9 and 33.2 years, respectively. CONCLUSIONS Outcomes of clinical pregnancy and live birth rates are higher in men who undergo microsurgical vasectomy reversal with the same female partner. These outcomes may be related to a shorter interval from vasectomy, previous fertility and couple motivation.

Impact on Pregnancy of Gross and Microscopic Vasal Fluid during Vasectomy Reversal.

PURPOSE We compared fertility outcomes with gross and microscopic fluid findings at vasectomy reversal at a high volume vasectomy reversal center. MATERIALS AND METHODS A retrospective study of a prospective database was performed. All vasectomy reversals were performed by a single surgeon (EFF) between 1978 and 2011. The clinical pregnancy rate was self-reported or determined via patient mailers. Patient and operative findings were determined through database review. We classified vasal fluid as opalescent, creamy, pasty or clear. Intraoperative light microscopy was used to determine if sperm or sperm parts were present and if they were motile. Multivariate analysis was performed evaluating patient age, partner age, years after vasectomy, type of surgery, and gross and microscopic fluid analysis. RESULTS A total of 2,947 microsurgical vasectomy reversals were reviewed after we excluded reversals performed for post-vasectomy pain. We determined the pregnancy status of 902 (31%) cases. On univariate analysis with respect to pregnancy the presence of motile sperm at vasovasostomy neared statistical significance (p=0.075) and there was no difference between bilateral vs unilateral motile sperm. Gross fluid appearance was not statistically significant but we found the order of pregnancy success to be opalescent, creamy, clear then pasty fluid. On multivariate analysis only female partner age and sperm heads only or no sperm seen on light microscopy had statistical significance (p <0.05). CONCLUSIONS The presence of motile sperm at vasectomy reversal approaches statistical significance on univariate analysis as a factor that affects clinical pregnancy rates. On multivariate analysis female partner age and microscopic findings of sperm heads only or no sperm are inversely related to pregnancy rates. These data will help counsel couples after vasectomy reversal and reinforce the importance of female partner age.

Evaluation of Vasectomy Trends in the United States

OBJECTIVE To use the Truven Health MarketScan database to better approximate the annual rate of vasectomies performed in the US population, to determine changes over time, regional differences, providers performing this, and to know if there is any monthly variation in vasectomy rates. MATERIALS AND METHODS Claims data were evaluated from 2007 to 2015 to determine the annual prevalence of vasectomy by patient age and region in the United States. The cohort included men aged 18-64 years with at least 1 claim in any given year in Truven Health MarketScan. Provider type and place of service were evaluated in 2014 and 2015. Monthly evaluation of vasectomy prevalence compared with total claims was performed. RESULTS The prevalence of vasectomies decreased from 2007 to 2015, across all age groups and in all locations of the country (P <.001). Using these data and the most recent US census data, an estimated 527,476 vasectomies were performed in the United States in 2015. The North Central and West regions (0.64% and 0.60%, respectively) had the highest annual prevalence of vasectomies. The month of March and the end of the year had the highest proportion of vasectomies performed. In both 2014 and 2015, a urologist in the office setting performed 82% of vasectomies. CONCLUSION An estimated 527,476 vasectomies were performed in the United States in 2015. From 2007 to 2015 there was a decrease in the proportion of vasectomies performed in all age groups and in all locations of the country. The end of the year and the month of March are when the most vasectomies are performed.

A review of the epidemiology and treatment of Peyronie's disease.

Introduction Peyronie’s disease (PD) has significant effect on patients and their partners. We provide a current review of the epidemiology as well as the nonsurgical and surgical treatment of PD. Materials and methods Review of literature pertaining to PD with focus on epidemiology and treatment options. Conclusion PD is common and likely underreported. The availability of new and highly effective treatment options will catalyze patient awareness and subsequently the prevalence of disease.

Bone Saw for Calcified Peyronie's Disease Plaques

OBJECTIVES To determine the incidence of calcified Peyronies disease plaque that cannot be cut with a blade in a 100-case series and to describe the use of a soft tissue-protecting bone saw for plaque incision. METHODS Chart reviews were done of all surgically treated Peyronies disease patients at our center between October 1996 and December 2012. 100 cases were included. We evaluated our novel technique of tissue-protecting bone saw surgical use. RESULTS 100 consecutive patients underwent surgery for Peyronies disease, and 6 required transverse bone saw plaque incision due to the severity of calcification that could not be cut with a blade. Four of those 6 underwent grafting procedures with porcine submucosal intestinal substance (SIS) and 2 underwent placement of inflatable penile prosthesis (IPP) after plaque incision. There were no surgical complications. Both IPP patients had functioning prosthesis 4 and 7.3 years after surgery. One SIS-graft patient required re-operation for more proximal curvature 11 months later and ultimately required multiple plaque incisions and an IPP. CONCLUSION Densely calcified plaques occurred in 6% of a surgical series of Peyronies disease patients. The vibrating bone saw is a novel technique to incise calcified plaques before grafting or IPP placement.

MP60-04 VASAL PROTEIN PROFILE AND MICROSCOPIC SPERM PRESENCE AT TIME OF VASECTOMY REVERSAL

RESULTS: Four weeks after subcutaneous autograft of LSCs in combination with Sertoli and myoid cells in castrate mice, the cells in graft expressed 3B-HSD, SOX-9 and A-SMA. Serum testosterone in castrated mice that received autograft was significantly higher compared to mice that did not receive autograft (22.4þ/-1.9 VS 11.9þ/0.8 Ng/DL, p<0.05). Importantly, mice that received LSC autograft maintained production of LH and FSH with levels higher than mice that received testosterone pellet implant (LH 3.09þ/-1.47 VS 0.01þ/-0.01 ng/ml) (FSH 102.6þ/-28.1 VS 51.7þ/-7.4ng/ml) respectively. Furthermore, T levels consistently increased at 15, 30 and 60 days following subcutaneous autograft (12.01þ/-0.87ng/DL (neg CTL) vs 15.1þ/1.50ng/DL (15 days Autograft) vs 22.26þ/-1.33ng/DL (30 days Autograft) vs 37.3þ/-9.6ng/DL (60 days Autograft)), demonstrating differentiating LSC within the autograft. In addition, we found that levels of 3BHSD were induced upon SAG (DHH inducer) treatment in-vitro conditions. Immunostaining autografts (4 weeks), containing LSCs treated with SAG before subcutaneous implantation, showed higher levels of SOX9, and ASMA. Importantly, T levels were significantly higher (p<0.05) in mice received SAG treated autografts vs negative controls (23.95þ/4.11 Ng/DL vs 11.91þ/-0.80 Ng/DL). Collectively these results establish that Hedgehog signalling induces survival of adjacent testicular cells and regulates graft function. CONCLUSIONS: Our results demonstrate that subcutaneous autograft of LSC in combination with Sertoli cells and myoid cells can increase serum testosterone without inhibiting circulating LH and FSH in castrate mice. Extratesticular LSC appear to be regulated by Hedgehog signalling. Leydig stem cell autograft can a novel therapeutic approach to increase serum testosterone while simultaneously preserving hypothalamic-pituitary-gonadal axis. Factors involved in hedgehog signalling can be utilized to enhance graft efficacy.

Acute Ischemic Priapism Management: An Educational and Simulation Curriculum

Introduction Ischemic priapism is a urologic emergency managed by both urologic and nonurologic providers in the community. Given ischemic priapisms rare occurrence and the time-sensitive nature of treatment, effective provider education on management of this entity is imperative. We sought to develop a low-cost effective simulation model and curriculum to enhance trainee education. Methods A comprehensive didactic curriculum based on national urologic guidelines was developed, along with a low-cost, easily reproducible priapism simulator using hot dogs and Red Vines candy. The simulators cost

MP56-20 COMPARISON OF CLINICIAN AND PATIENT MEASUREMENTS USING A MOBILE PHONE APPLICATION TO ASSESS PENILE ANGULATION

1.25 each, and assembly took 10 minutes. All materials were reviewed by three urology faculty members. The curriculum was piloted with two andrology fellowship–trained urology faculty among eight urology residents (PGY2-PGY4/U1-U2) and one medical student. Participants provided feedback regarding the overall course as well as the face and content validity of the simulator. Results Cognitive test scores significantly improved on average by 15.0% (p = .002), and confidence improved from baseline somewhat or very much among 88.9% of participants after completion of the curriculum. The task trainer was rated easy to use (average score: 4.78 out of 5), and 77.8% of participants though it was somewhat or very useful for training (average score: 4.00 out of 5). Additionally, 77.8% recommended its incorporation into resident training (average score: 4.00 out of 5). Discussion This simulation curriculum is effective, inexpensive, and easily reproducible, making it ideal for groups with limited resources. Expanding access to simulation-based curricula on priapism management may improve education of both urologic and nonurologic trainees.

MP51-11 UTILIZATION OF A SURGICAL VIDEO CURRICULUM TO AUGMENT RESIDENT LEARNING

METHODS: Penile tissues from 12 Scx-GFP mice with ages 4 week, 5 week, 6 week, and 1.2 years, were dissected and processed following routine histology protocols. 6mm thick sections were stained with H&E, Massons’ trichrome (TRI), Verhoeff’s elastin (ELA), and DAPI. All sections were imaged using bright field or fluorescence microscopy techniques. Cell orientations along collagen fibers with age were analyzed using Image J Fiji. RESULTS: Figure: With age, CCG illustrated well-oriented struts at an angle of 32 to the baculum. Additionally, scleraxis and elastin expressions, and smooth muscle content increased within the struts, specifically in the 6 week-old mice. The expression of scleraxis indicated that the CCG contains mechanoactive collagenous and elastin-ridden struts that support biomechanical function of the baculum. Within the CCG of the mouse, there was more sinusoidal space in the younger age groups (4-6 weeks), and this space decreased with age, and elastin expression increased significantly (see 1 year). Compared to the CCG (A,C,E,G), the CCP (B,D,F,H) illustrated significantly lower expressions of scleraxis, elastin, and smooth muscle. CONCLUSIONS: The collagen-producing fibroblasts within the CCG and CCP express scleraxis, indicative of local mechanoactive areas. Based upon orientation of cells expressing scleraxis, the biomechanical function of the CCP is to push the glans of the penis like a piston, while the CCG stiffens the penis during erection and pulls the glans of the penis back into the prepuce post-erection. The CCG is similar to the HCC with regard to compositional ratio of collagen to muscle, elastin localization, and biomechanical function and as such is a good model to study human penile physiology.