Matthew S. Christman

Analysis of Ureteral Stent Compression Force and its Role in Malignant Obstruction

PURPOSE Extrinsic ureteral obstruction can be a challenging entity for the urologist since half of the ureteral stents placed for malignant obstruction fail. We evaluated the resistance to radial compression of various stents. MATERIALS AND METHODS Silhouette(R) 4.6Fr, 6Fr and 8Fr, Sof-Curl Tecoflex 6Fr, Resonance 6Fr, Polaris Ultra 6Fr and 7Fr, and Percuflex 6Fr and 8Fr stents were tested. The force needed to compress the stent to 50% of its original external diameter was measured at 3 locations along the stent length, including proximal, middle and distal. Statistical analysis was performed. RESULTS Statistically greater force was required to compress the Resonance and Silhouette stents compared to all others tested. These results were maintained at all 3 locations along the stent. Only the Polaris 6Fr stent differed in resistance to compression along the stent length. CONCLUSIONS The significantly higher forces required to compress the Resonance and Silhouette stents may translate into improved success in patients with malignant ureteral obstruction.

Testis cancer: a 20-year epidemiological review of the experience at a regional military medical facility.

PURPOSE Testis cancer is the most common solid malignancy in the young adult population and the incidence in this population is increasing. We present a 20-year epidemiological review of testis cancers treated at our institution. MATERIALS AND METHODS The records of testis cancer cases diagnosed between January 1988 and June 2007 were reviewed. Patient demographics, cancer histology and stage, adjuvant therapy, temporal trends and survival data are presented. Our experience was compared to trends published in the SEER (Surveillance, Epidemiology and End Results) database and the National Cancer Database. RESULTS A total of 338 testis cancers (330 germ cell tumors) were diagnosed during the study period. Median patient age at diagnosis was 26.6 years vs 34 in the SEER database. We observed a temporal increase in stage I tumors (57% to 75%) and a decrease in the proportion of seminomas (52% to 43%) during the study period. In terms of adjuvant therapy for stage I seminoma the use of radiotherapy decreased (91% to 75%), while the use of chemotherapy increased (1.5% to 7.5%). For stage I nonseminomatous germ cell tumors the use of adjuvant chemotherapy increased (12% to 20%), while the use of staging retroperitoneal lymph node dissection decreased (88% to 63%). Five-year cancer specific survival was 97.7%. CONCLUSIONS We are seeing an increase in localized disease at diagnosis, an increase in surveillance for stage I disease and 5-year survival in excess of 95%, similar to data in SEER and the National Cancer Database. However, unlike in SEER and the National Cancer Database, our patients are younger, we are seeing less seminoma and we are performing significantly more staging retroperitoneal lymph node dissection.

Youth varicocele and varicocele treatment: a meta-analysis of semen outcomes

OBJECTIVE To study youth who have a varicocele or are undergoing varicocele treatment, in relation to changes in semen, as measured by semen analysis (SA). DESIGN Meta-analysis of studies identified via a search of PubMed, Medline, and the Cochrane Library covering the last 40 years. SETTING Not applicable. PATIENT(S) Youth from studies that assessed the presence and/or treatment of varicocele with SA. INTERVENTION(S) Selected studies were analyzed in two separate meta-analyses: one for the effect of varicocele on semen, as measured by SA (hypothesis #1), the other for the effect of treatment on semen, as measured by SA (hypothesis #2). MAIN OUTCOME MEASURE(S) A random-effects model was used to calculate weighted mean difference (WMD) of semen outcomes. Heterogeneity was calculated. Bias was assessed with funnel plots and Eggers test. RESULT(S) The initial literature search returned 1,180 potentially relevant articles. For hypothesis #1, 10 studies with a total of 357 varicocele and 427 control subjects were included. Sperm density, motility, and morphology were significantly decreased when associated with a varicocele, with a WMD of -24.0×10(6)/mL (95% confidence interval [CI; -39.5 to -8.6]), -7.5% (95% CI [-12.3% to -2.7%]), and -1.7% (95% CI [-2.4% to -1.1%]), respectively. Another 10 studies with 379 treated and 270 untreated subjects were analyzed for hypothesis #2. Sperm density and motility were significantly improved following treatment, with a WMD of 14.6×10(6)/mL (95% CI [7.1-22.1]) and 6.6% (95% CI [2.1%-11.2%]), respectively. CONCLUSION(S) The presence of varicocele in youth appears to negatively affect sperm density, motility, and morphology. Treatment appears to result in moderate improvement of sperm density and mild improvement in sperm motility.

Is Internet Pornography Causing Sexual Dysfunctions? A Review with Clinical Reports

Traditional factors that once explained men’s sexual difficulties appear insufficient to account for the sharp rise in erectile dysfunction, delayed ejaculation, decreased sexual satisfaction, and diminished libido during partnered sex in men under 40. This review (1) considers data from multiple domains, e.g., clinical, biological (addiction/urology), psychological (sexual conditioning), sociological; and (2) presents a series of clinical reports, all with the aim of proposing a possible direction for future research of this phenomenon. Alterations to the brains motivational system are explored as a possible etiology underlying pornography-related sexual dysfunctions. This review also considers evidence that Internet pornography’s unique properties (limitless novelty, potential for easy escalation to more extreme material, video format, etc.) may be potent enough to condition sexual arousal to aspects of Internet pornography use that do not readily transition to real-life partners, such that sex with desired partners may not register as meeting expectations and arousal declines. Clinical reports suggest that terminating Internet pornography use is sometimes sufficient to reverse negative effects, underscoring the need for extensive investigation using methodologies that have subjects remove the variable of Internet pornography use. In the interim, a simple diagnostic protocol for assessing patients with porn-induced sexual dysfunction is put forth.

Morbidity and Efficacy of Ureteroscopic Stone Treatment in Patients with Neurogenic Bladder

PURPOSE There is a lack of information on the safety and efficacy of ureteroscopy in the neurogenic bladder population. We hypothesized that ureteroscopy in patients with neurogenic bladder would be associated with an increased risk of complications and a lower stone clearance rate than in patients without neurological impairment. MATERIALS AND METHODS We reviewed a local registry of patients with ICD-9 codes for urolithiasis between 2004 and 2012. The study cohort was assembled from all eligible patients with neurogenic bladder and a randomly selected control group that had undergone ureteroscopy. Statistical analysis of demographic variables and surgical outcomes was performed. Complications were classified according to the Clavien system. Clearance was defined by computerized tomography, renal/bladder ultrasound or direct ureterorenoscopy. RESULTS Ureteroscopy was performed a total of 173 times in 127 controls and a total of 45 times in 20 patients with neurogenic bladder. There was no difference between presenting episodes by gender (p = 1.0), race (p = 0.654) or body mass index (p = 0.519). Bacteriuria was associated with the stone episode in 16.4% of controls and 67% of neurogenic bladder cases (p <0.001). Median operative time was significantly longer in those with neurogenic bladder (80.5 minutes, IQR 50-110.5 vs 52, IQR 33-78, p = 0.0003). The proportion of complications was significantly different (p = 0.013). Stones cleared in 86.6% of controls compared to 63% of neurogenic bladder cases (p = 0.004). CONCLUSIONS Patients with neurogenic bladder have increased morbidity after ureteroscopy for upper tract calculi compared to neurologically unaffected controls. Infection has a role in this morbidity. The clearance rate is lower but the stone burden is more significant in those with neurogenic bladder.

Robot-Assisted Bladder Diverticulectomy in the Pediatric Population

BACKGROUND AND PURPOSE Surgical intervention is warranted for symptomatic congenital bladder diverticula (CBD) in children. We hypothesized that a robot-assisted approach to bladder diverticulectomy could be performed with safety and with good efficacy. Descriptions of our approach and results with robot-assisted laparoscopic bladder diverticulectomy (RALBD) are presented. PATIENTS AND METHODS We retrospectively reviewed a prospective database with Institutional Review Board approval. Eligible patients were those who underwent excision of a bladder diverticulum via a robotic approach. Data were collected on presenting symptoms, and intraoperative and postoperative courses. Voiding cystourethrography (VCUG) was performed at 3-month follow-up. Renal and bladder ultrasonography was performed at 3- and 12-month follow-up. RESULTS Fourteen patients were identified. Of the 14 patients, 6 also had a history of diurnal enuresis. Mean patient age was 7.9 years (range 4-13 years). The operation was performed via a transperitoneal approach with robot assistance. The mean operative time (including cystoscopy) was 132.7 minutes (range 113-192 min). The average length of stay was 24.4 hours (range 18-31 hours). There were no intraoperative or postoperative complications in this group. Each patient was followed for at least 1 year. All patients had a normal results of VCUG on follow-up without evidence of a diverticulum. Within 3 months, diurnal enuresis resolved in 6/6 patients. CONCLUSIONS RALBD appears to be a safe and effective modality for treatment of patients with CBD. It can serve as an alternative to the open surgical approach.

Obstructive complications of lichen sclerosus

OBJECTIVE Young males with lichen sclerosus (LS) commonly present with phimosis; complete urinary obstruction has also been described in this population, but is much rarer. We present the case report of a boy with acute renal failure secondary to urethral obstruction caused by LS, with a review of the literature regarding the occurrence of complete urinary obstruction and renal failure associated with this disease process. MATERIALS AND METHODS A comprehensive review of the literature was conducted using MEDLINE and EMBASE to characterize the association of lichen sclerosus with significant obstructive complications of the urinary tract. RESULTS The true incidence of LS is unknown. Reported rates have ranged from 10% to 95% of boys presenting with phimosis. Our review identified 14 cases of complicated urinary obstruction (seven in children) and two cases of renal failure secondary to lichen sclerosus (both in boys). CONCLUSIONS Distinctive features make this inflammatory process identifiable to the astute physician, such that new onset of phimosis in a school-age boy should raise clinical suspicion of the diagnosis. Successful outcomes, with medical and/or surgical therapy, are commonplace in this cohort. If undiagnosed, however, progression of LS can lead to significant morbidity in the form of renal failure.

Reproducibility and Reliability of Semen Analysis in Youths at Risk for Infertility

PURPOSE There are few normative data on semen analyses in youths at risk for but not presenting with infertility. Standard practice among infertility specialists includes evaluation of 2 separate semen samples, given the degree of within subject variability. We hypothesized that males transitioning from pediatric to adult care who are at risk for infertility would similarly have this variability. MATERIALS AND METHODS We retrospectively reviewed patients with a history of cryptorchidism or varicocele who submitted 2 semen samples for evaluation of fertility potential. The within subject coefficient of variation and intraclass correlation coefficient were calculated for each semen parameter to evaluate reproducibility and reliability, respectively. RESULTS A total of 79 subjects were studied. Mean ± SD age was 18.8 ± 1.2 years (range 17.8 to 24.7). The within subject coefficient of variation was high for each semen parameter, ranging from 36% for volume and motility to 82% for total motile count. Intraclass correlation coefficient for a single semen analysis ranged from 0.55 for motility to 0.88 for total count. Intraclass correlation coefficient for total motile count was 0.78 (95% CI 0.67-0.85), consistent with substantial reliability. CONCLUSIONS Although we observed within patient variability of individual semen analysis parameters, overall there was substantial agreement between consecutive semen analyses in this population at risk for infertility, particularly regarding total motile count, which is the most important determinant of fertility from a semen analysis. Therefore, it is possible to appropriately classify some young men based on the result of a single measurement as they transition from pediatric to adult care.

Comparison of testicular volume differential calculations in adolescents with varicoceles.

PURPOSE We aimed to develop a conversion formula between different calculations for testicular volume asymmetry. MATERIALS AND METHODS Male adolescents with varicoceles who underwent scrotal ultrasound were studied. Two formulas were analyzed: (1) testicular volume differential, TVDiff = (RTV - LTV)/(TTV), and (2) atrophy index, AI = (RTV - LTV)/(RTV). RTV, LTV, and TTV represent the right, left, and total testicular volume. Through transformations and regression a conversion formula between the calculations was derived. RESULTS Based on 248 ultrasounds, a clear relationship between the two formulas was demonstrated: AI = ln[(1.97 × TVDiff) + 1], (p < 0.0001). CONCLUSIONS Differential testicular volumes can easily be converted from one formula to another with near-perfect accuracy. The formulas are essentially identical and interchangeable.

Abdominoscrotal hydrocele: A systematic review

BACKGROUND Abdominoscrotal hydrocele (ASH) is an uncommon condition characterized by a fluid-filled mass with inguinoscrotal and abdominal components. Controversy exists regarding the best management. We conducted a systematic review of the literature with special interest in presentation, management and outcomes. METHODS A search was conducted of the MEDLINE/PubMed, Embase, Ovid, Web of Science and Scopus databases. Two authors independently extracted data and assessed the risk of bias in each study. RESULTS We found 18 case series that met selection criteria, describing 116 patients with 146 hydroceles. Unilateral ASH was found in 59% of cases with almost even distribution between left and right-sided hydroceles. Ipsilateral undescended testicle, testicular dysmorphism, and contralateral pathology (inguinal hernia) often accompanied ASH. Management was always surgical. The most common approaches were inguinal (67.2%), combined laparoscopic + inguinal (11.2%), and scrotal (10.3%). Complications were poorly reported, but were generally minor. There were a decreased number of complications with the scrotal approach because of avoidance of a difficult inguinal dissection. CONCLUSIONS ASH is a rare entity treated most commonly via an inguinal approach. However, consideration should be given to combining with an extraperitoneal or laparoscopic approach given coexisting pathology, or to the scrotal approach for reducing morbidity.