S. Morselli

Testicular sperm extraction after laparoscopic orchiectomy for bilateral postpubertal intra-abdominal cryptorchidism: What chance of sperm retrieval?

Infertility occurs in up to 54% of men with bilateral undescended testes. Orchiectomy is considered the best therapeutic approach, especially when cryptorchidism is diagnosed in adulthood, due to a high risk of malignancy. A 33‐year‐old man was referred with a clinical presentation of empty scrotum and an ultrasonography and magnetic resonance imaging evaluation of intra‐abdominal bilateral cryptorchidism. Follicle‐stimulating hormone was 23.20 IU/L, luteinising hormone was 14.10 IU/L, total testosterone was 12.1 nmol/L, and 17‐beta‐oestradiol was 0.16 nmol/L. Semen analysis showed absolute azoospermia. Tumour marker levels were in the normal range. Testicular volume was 4.0 ml for right testis and 4.6 ml for left testis. The patient underwent a laparoscopy bilateral orchiectomy and subsequently a testicular sperm extraction (TESE), in the purpose to finding mature spermatozoa. The biological examination revealed the presence of immature sperm cells, not efficient for a cryopreservation. The histologic analyses show a pattern of Sertoli cell‐only syndrome and maturation arrest. TESE might be a good option for patients with absolute azoospermia and cryptorchidism, especially if bilateral. The procedure, performed after orchiectomy, is safe and does not have any impact on patients health, although it is important to clarify the very low potential of sperm recovery.

Relevance of testicular histopathology on prediction of sperm retrieval rates in case of non-obstructive and obstructive azoospermia

Introduction: The aim of our research was to establish the relevance of testicular histopathology on sperm retrieval after testicular sperm extraction in patients with non-obstructive azoospermia and in patients with obstructive azoospermia, who already underwent a previous failure testicular fine needle aspiration. Methods: We evaluated a total of 82 azoospermic men, underwent testicular sperm extraction, referring to the Assisted Reproductive Technology Centre of the University of Florence, Italy between January 2008 and March 2017. A general and genital physical examination, scrotal and trans-rectal ultrasound, semen analysis, hormone measurements, including follicle-stimulating hormone, luteinizing hormone and total testosterone, were collected. Results: Successful sperm retrieval was obtained in 36 men of total (43.9%). Successful sperm retrieval was 29.5% in non-obstructive azoospermia patients, while men with obstructive azoospermia, who, underwent a previous failure testicular fine needle aspiration, had sperm retrieval in 86% of cases. Mean luteinizing hormone was 6.55 IU/L, total testosterone 4.70 ng/mL, right testicular volume 13.7 mL and left testicular volume 13.6 mL. Mean Follicle-stimulating hormone was 13.45 IU/L in patients with negative sperm retrieval and 8.18 IU/L in men with successful sperm retrieval. According to histology, 20.7% had normal spermatogenesis, 35.3% hypospermatogenesis, 35.3% maturation arrest and 8.5% Sertoli cell-only syndrome. Successful sperm retrieval was 88.2% in patients with normal spermatogenesis, 24.1% in the maturation arrest group and 48.27% in patients with hypospermatogenesis, while negative sperm retrieval was reported in Sertoli cell-only syndrome patients. Seven cases with maturation arrest showed a successful sperm retrieval. Conclusion: Testicular histopathology after testicular sperm extraction offers important information on prediction of sperm retrieval and can guide the surgeon in choosing the more suitable therapeutic practice.

Topical alprostadil (Vitaros©) in the treatment of erectile dysfunction after non-nerve-sparing robot-assisted radical prostatectomy:

Objective: The aim of the study is the evaluation of the efficacy and safety of the treatment with topical alprostadil (Vitaros©) in post-robot assisted radical prostatectomy (RARP) rehabilitation therapy of patients with erectile dysfunction (ED). Methods: Seventy-four patients were enrolled and underwent non-nerve-sparing RARP. Inclusion criteria: age <75, preoperatively International Index of Erectile Function (IIEF-5) >16, erection hardness score (EHS) ⩾2, weekly sexual intercourse ⩾1, affirmative answers to Sexual Encounter Profile Question (SEP-Q) 2 and SEP-Q3, Charlson Comorbidity Index (CCI) ⩽5, Eastern Cooperative Oncology Group (ECOG) performance status ⩽1, no moderate/severe cardiovascular disease. Results: Vitaros was administered ⩾2 twice a week. At month 6, the IIEF-5 decreased from 20.5 preoperative to 18.1 post-treatment. EHS score decreased from a mean of 3.3 to a mean of 3.0. The quality of life score decreased from an average of 5.1 to 2.3. Weekly sexual intercourse decreased from an average of 2.1 to 1.7. Six patients dropped out; 89.7% patients showed a positive SEP-Q2 and 77.8% a positive SEP-Q3. All patients responded positively to Global Assessment Questions (GAQ)-1 and 97% to GAQ-2. Of all 68 analyzed patients, 13 (17.6%) switched to intracavernous injection therapy. Conclusions: In conclusion, Vitaros may become a viable alternative to common injective therapies in well-selected patients after RARP.

Effectiveness of highly purified urofollitropin treatment in patients with idiopathic azoospermia before testicular sperm extraction

Introduction: Recent evidences demonstrated that male factor alone is responsible for about 30% cases of infertility. Human follicle-stimulating hormone (hFSH) has been introduced to increase sperm concentration, spermatogonial population, or both natural or assisted pregnancy rates (PRs) in oligozoospermic subjects with normal concentrations of gonadotropins. Methods: Fifty infertile men affected by idiopathic azoospermia were enrolled in this study, after undergoing medical history, physical and clinical examination, baseline semen parameters and hormonal plasma concentrations. Inclusion criteria were infertility for at least 2 years, idiopathic azoospermia, FSH <12 mIU/ml. Twenty-five patients were allocated to treatment with hFSH three times/week per 3 months (Fostimon), and 25 patients underwent just testicular sperm extraction (TESE) without medical treatment. All patients underwent, after 3 months, assisted reproduction techniques (ARTs) with TESE. The primary outcome was represented by the differences in the sperm retrieval rate (SRR) between groups, while the secondary outcomes were the differences in PR and fertilization rate (FR). Results: We observed a PR of 15% (3/25) and 28% (7/25) in control and treated group, respectively. SRR after medical treatment and ART was 24% (6/25), while in the control group was 12.5% (2/25). The sperm in the ejaculate of five patients (20%) after medical treatment exhibited a mean concentration of 0.9 million/ml and a mean motility of 12%. The FR was significantly greater in the treatment group with respect to the control group, 30% and 20%, respectively. Conclusions: FSH treatment showed greater efficacy rather than control by increasing the rate of PR and FR in azoospermic patients who underwent TESE.

Surgical outcome of 100 consecutive robot‐assisted pyeloplasty cases with no drainage placement for ureteropelvic junction obstruction

1 Takada N, Abe T, Shinohara N et al. Peri-operative morbidity and mortality related to radical cystectomy: a multi-institutional retrospective study in Japan. BJU Int. 2012; 110: E756–64. 2 Aziz A, May M, Burger M et al. Prediction of 90-day mortality after radical cystectomy for bladder cancer in a prospective European multicenter cohort. Eur. Urol. 2014; 66: 156–63. 3 Isbarn H, Jeldres C, Zini L et al. A population based assessment of perioperative mortality after cystectomy for bladder cancer. J. Urol. 2009; 182: 70–7. 4 Morgan TM, Keegan KA, Barocas DA et al. Predicting the probability of 90day survival of elderly patients with bladder cancer treated with radical cystectomy. J. Urol. 2011; 186: 829–34. 5 D’Elia C, Comploj E, Cerruto MA et al. 90-day mortality after radical cystectomy for bladder cancer: prognostic factors in a multicenter case series. Urol. Int. 2017; 98: 255–61. 6 Goossens-Laan CA, Gooiker GA, van Gijn W et al. A systematic review and meta-analysis of the relationship between hospital/surgeon volume and outcome for radical cystectomy: an update for the ongoing debate. Eur. Urol. 2011; 59: 775–83. 7 Sugihara T, Yasunaga H, Horiguchi H et al. Performance comparisons in major uro-oncological surgeries between the USA and Japan. Int. J. Urol. 2014; 21: 1145–50.

Tumour detection and staging through multimodal fibre-probe spectroscopy

Urothelial carcinoma (UC) is the most common type of bladder cancer. The gold standard for detecting UC is white-light cystoscopy, which is followed by tissue biopsy and pathological examination. However, such process is invasive, timeconsuming and prone to sampling errors. In this framework, optical spectroscopy techniques provide fast, label-free and non-invasive alternatives to standard histopathology. Thus, the aim of this study is to discriminate normal bladder tissues from urothelial tumours, and to identify the different stages of the disease, by means of combined auto-fluorescence, diffuse reflectance and Raman spectroscopy. In fact, these techniques were implemented in a compact and transportable setup based on two optical fibre probes: one coupled to fluorescence and reflectance excitation sources, while the other one to the 785 nm laser. Raman, fluorescence and reflected light signals were collected though the same probe used for excitation and sent to a spectrograph. We used this experimental setup for studying fresh biopsies of urothelial tumour and healthy bladder collected from 32 patients undergoing Transurethral Resection of Bladder Tumours (TURBT). Scoring methods based on ratiometric approach and Principal Component Analysis (PCA) allowed not only to discriminate healthy biopsies from tumour ones, but also to recognize three tumour stages.

Sexual health, adherence to Mediterranean diet, body weight, physical activity and mental state: factors correlated to each other

Introduction Mediterranean diet has shown a protective role against cardiovascular disease, diabetes, cancer onset, microvascular damage and dementia in many trials. Our purpose is the assessment of a correlation between physical activity, Mediterranean diet, body mass index (BMI), depression and erection disorder (ED). Methods After having signed disclaimer to the study participation, we administered the IIEF 15 questionnaire (International Index of Erectil Function), the Hamilton questionnaire for major depression, the Med-Diet Questionnaire, the Ipaq Questionnaire (International Index of Physical Activity) to 245 patients and calculated the BMI. Only 141 were eligible. We excluded patients with a history of smoking, with obesity from the second grade to rise, anorexia, hyperlipidemia, Induratio Penis Plastica, diabetes, cardiovascular and neurological disease, hypogonadism, prostatitis, diabetes, hypertension, psychiatric diseases and the history of radical prostatectomy and finally age >72 and <50 years or who were taking cholesterol-lowering medication. Patients were divided into two groups: 65 patients without ED and 76 patients with ED. Results We found a statistically difference in BMI between the groups. Adherence to Med-Diet showed a significant difference between the two groups at Student t-test and the Chi-square test. The Ipaq test and Hamilton test did not show statistical differences between the two groups neither for Student t-test nor for Chi-square test, but high levels seem to be protective factors. Conclusions Body weight and a healthy diet are protective factors against the ED, more than a sufficient physical activity. Depression has shown only a worsening tendency of the erection.

Healing of spongiosus-cutaneous fistula with Hyperbaric Oxygen Therapy (HBOT): a case report

INTRODUCTION We present a case of a spongiosus-cutaneous fistula in a 39-year-old man with recurrent episodes of cutaneous abscess in dorsal middle third penis (5 × 3 cm) treated with Hyperbaric Oxygen Therapy (HBOT). CASE REPORT After emptying nodular abscess, the patient was noncompliant for further surgery. Therefore, it was suggested the association between HBOT and antibiotic therapy. HBOT is carried out in a hyperbaric room, where the internal pressure is increased (compression phase) by entering compressed air up to 283.71 kPa in about 10 minutes. Every HBOT cycle lasted 24 days in which the patient had been taking Amoxicillin/Clavulanic Acid 875 mg/125 mg 3 tabs/day and Sulfamethoxazole/Trimethoprim 160 mg/800 mg 2 tabs/day for 2 weeks. At the end of the treatment, a penile magnetic resonance imaging and an ultrasonography were executed and they evidenced a complete remission of the lesion. In the subsequent 22 months, there was no recurrence. CONCLUSIONS Our results suggest that HBOT is an effective treatment for chronic wounds, including a spongiosus-cutaneous fistula of unknown cause, when used in combination with conventional standard therapy or further interventions. At present time, the gold standard remains surgery; nevertheless, our experience with HBOT may stimulate its use in clinical trials.