Stanton C. Honig

Herniorrhaphy with polypropylene mesh causing inguinal vasal obstruction: a preventable cause of obstructive azoospermia.

Objective:To report a multiinstitutional experience of men presenting with infertility secondary to inguinal hernia repair using polypropylene mesh. Summary Background Data:An estimated 80% of inguinal hernia operations involve placement of a knitted polypropylene mesh to form a “tension-free” herniorrhaphy. The prosthetic mesh induces a chronic foreign-body fibroblastic response creating scar tissue that imparts strength to the floor and leads to fewer recurrences. However, little is known about the long-term effects of the polypropylene mesh on the vas deferens, especially with regard to fertility. Methods:Eight institutions in the United States reported a total of 14 cases of azoospermia secondary to inguinal vasal obstruction related to previous polypropylene mesh herniorrhaphy. Patient characteristics and operative findings were forwarded to 1 center for tabulation of data. Results:Mean patient age was 35.5 years with an average duration of infertility of 1.8 years. Mean number of years between urologic evaluation and herniorrhaphy was 6.3 years. Types of inguinal hernia repair previously performed were: open (10), laparoscopic (2), or both (2). Nine patients had bilateral obstruction and 5 patients had unilateral obstruction with contralateral testicular atrophy or epididymal obstruction. Surgical exploration revealed a dense fibroblastic response encompassing the polypropylene mesh with either trapped or obliterated vas in all patients. Surgical reconstruction was performed in 8 of 14 men (57%). Conclusion:Reconstruction to restore fertility can be difficult secondary to fibrotic reaction. Before undergoing polypropylene mesh herniorrhaphy, men, especially of young reproductive age or with a solitary testicle, need to be carefully advised of potential obstruction and compromise to future fertility.

Single-Blind, Multicenter, Placebo Controlled, Parallel Study to Assess the Safety and Efficacy of Intralesional Interferon α-2b for Minimally Invasive Treatment for Peyronie’s Disease

PURPOSE We investigated the efficacy and safety of intralesional interferon alpha-2b for the treatment of Peyronies disease. MATERIALS AND METHODS A total of 117 consecutive patients with a mean age of 55.1 years who had Peyronies disease were enrolled in a single-blind, multicenter, placebo controlled, parallel study to determine the efficacy and safety of intralesional interferon alpha-2b therapy (Schering, Kenilworth, New Jersey), including 62 who received placebo and 55 who received interferon alpha-2b. Saline (10 ml) in controls and interferon alpha-2b (5 x 10(6) U) were administered biweekly for 12 weeks. Each patient was evaluated for penile curvature, plaque size and density, penile pain, erectile function and penile hemodynamics before and after study completion. Improvement in these parameters was statistically compared between the groups. RESULTS A total of 53 patients in the control arm and 50 in the interferon alpha-2b arm completed the study. Improvement in penile curvature, plaque size and density, and pain resolution was significantly greater in patients treated with interferon alpha-2b vs placebo. The increase in mean International Index of Erectile Function scores was not significantly different between the groups. Penile blood flow improvement was observed in interferon alpha-2b treated patients but not in those who received placebo. The decrease in the number of penile vascular pathologies was significantly higher in interferon alpha-2b cases. Side effects, mostly flu-like symptoms, which were frequently noted in patients on interferon alpha-2b, were mild to moderate in degree and of short duration. CONCLUSIONS This single-blind, multicenter, placebo controlled, parallel study demonstrates that intralesional interferon alpha-2b at a dose of 5 x 10(6) units biweekly for 12 weeks is effective and safe as minimally invasive therapy for Peyronies disease.

Microarray gene analysis and expression profiles of Dupuytren's contracture.

Dupuytren’s disease, although not altogether uncommon, has eluded scientists who have sought to explain the cause of this palmar fibroproliferative disorder. It can lead to severe limitations of hand function if left untreated. This study is the first broad genetic survey using microarray technology to find gene products that are overexpressed or underexpressed in diseased tissues. The authors found 23 genes with levels that differ consistently from control levels. Nine were selected for further verification using reverse transcription-polymerase chain reaction. These genes hold potential promise in explaining some of the demographic trends seen with disease, such as correlation with alcoholism and the striking predisposition for the male gender.

Non-Hodgkin's lymphoma can mimic renal adenocarcinoma with inferior vena caval involvement

Genitourinary involvement in both Hodgkins and non-Hodgkins lymphomas is common and can be confused with other benign and malignant urologic conditions. While lymphoma commonly produces vascular and ureteral encasement, intraluminal vascular involvement is rare. Indeed, there are no previous reports of renal lymphoma with tumor thrombus extending into both the renal vein and inferior vena cava. We describe the first reported case of lymphoma mimicking a Stage IIIA renal adenocarcinoma with tumor thrombus in the renal vein and the inferior vena cava. Renal lymphoma should be considered in the differential diagnosis even when tumor thrombus is present in the renal vein or vena cava.

Adrenal Hemangioma: An Unusual Adrenal Mass Delineated with Magnetic Resonance Imaging

Adrenal hemangioma should be included in the differential diagnosis of any large calcified adrenal mass. We report to our knowledge the eighth surgically removed lesion and describe its appearance on magnetic resonance imaging. This imaging includes features seen in hemangiomas elsewhere, in particular a heterogeneous mass with enhancing peripheral high intensity foci on T1 images.

The expression and distribution of deoxyribonucleic acid repair and apoptosis markers in testicular germ cells of infertile varicocele patients resembles that of old fertile men

OBJECTIVE To explore the expression and distribution of DNA damage repair and apoptosis marker proteins in human testicular germ cells of infertile varicocele patients; and to compare the expression and distribution with that of young and old fertile men. DESIGN Retrospective case-control study. SETTING Academic institutions. PATIENT(S) Testicular specimens were obtained from 8 infertile varicocele patients aged 20-30 years and from 16 fertile volunteers aged 20-82 years. INTERVENTION(S) Testicular germ cell DNA repair markers were assessed using immunohistochemical staining for the cell proliferation marker (proliferating cell nuclear antigen), DNA repair markers [poly(ADP-ribose) polymerase-1 (PARP-1), poly(ADP-ribose), X-ray repair cross-complementing 1, and apurinic/apyrimidinic endonuclease 1], and apoptosis markers (caspase 9, active caspase 3, and cleaved PARP-1). MAIN OUTCOME MEASURE(S) The prevalence and cellular localization of the above markers in testicular tissues of varicocele patients and fertile men of varying ages. RESULT(S) Statistically significant differences in DNA damage repair-associated proteins and apoptosis markers were observed in infertile men with varicocele compared with fertile young men. Old fertile men showed similar expression of the same markers when compared with infertile varicocele patients. CONCLUSION(S) The study demonstrates that there is an increase in human testicular germ cell DNA repair and apoptosis in infertile varicocele patients and that their profile resembles that of premature aging.

Reassessment of male-factor infertility, including the varicocele, sperm penetration assay, semen analysis, and in vitro fertilization

Evaluation of the male factor in infertility is becoming increasingly important as new diagnostic techniques and therapeutic options become available. Varicoceles are among the most common treatable cause of male infertility. Varicoceles are present in 10% to 20% of all males but are found in as many as 30% to 40% of men who present to an infertility clinic. Of men who have treatment for varicoceles, 50% to 75% will show some improvement in semen quality, and 30% to 40% will initiate a pregnancy. We review some controversial issues related to the diagnosis and treatment of varicoceles. In vitro fertilization, originally developed for the female with irreversible tubal damage, is now being evaluated as a possible therapy for severe male-factor infertility that has failed to respond to routine surgical or medical treatment. In vitro fertilization for the oligospermic male, however, is further complicated by the fact that men with poor sperm production frequently have poorly functioning sperm as well. Consequently, we discuss the value of the sperm penetration assay, with and without enhancement techniques to prospectively evaluate couples entering in vitro fertilization programs. We also discuss the role of strict criteria for determination of sperm morphology and quantitation of leukocytospermia in the evaluation of the infertile male. Finally, evaluation of the predictive value of “failure to fertilize‘’ at in vitro fertilization for future in vitro fertilization success is discussed.

Analysis of the clinical safety of intralesional injection of collagenase Clostridium histolyticum (CCH) for adults with Peyronie's disease (PD)

To examine the safety of intralesional injection of collagenase Clostridium histolyticum (CCH) for the treatment of Peyronies disease (PD), using a pooled safety analysis of patients who received at least one dose of CCH in any of six clinical studies.

Trends in Testosterone Replacement Therapy Use from 2003 to 2013 among Reproductive-Age Men in the United States

Purpose: Although testosterone replacement therapy use in the United States has increased dramatically in the last decade, to our knowledge trends in testosterone replacement therapy use among reproductive‐age men have not been investigated. We assessed changes in testosterone replacement therapy use and practice patterns among 18 to 45‐year‐old American men from 2003 to 2013 and compared them to older men. Materials and Methods: This is a retrospective, cross‐sectional analysis of men 18 to 45 and 56 to 64 years old who were enrolled in the Truven Health MarketScan® Commercial Claims Databases throughout each given calendar year from 2003 to 2013, including 5,094,868 men in 2013. Trends in the yearly rates of testosterone replacement therapy use were calculated using Poisson regression. Among testosterone replacement therapy users, the Cochran‐Armitage test was used to assess temporal trends in age, formulation type, semen analysis and serum testosterone level testing during the 12 months preceding the documented use of testosterone replacement therapy. Results: Between 2003 and 2013, there was a fourfold increase in the rate of testosterone use among 18 to 45‐year‐old men from 29.2/10,000 person‐years to 118.1/10,000 person‐years (p <0.0001). Among testosterone replacement therapy users, topical gel formulations were initially most used. Injection use then doubled between 2009 and 2012 (23.5% and 46.2%, respectively) and surpassed topical gel use in 2013. In men 56 to 64 years old there was a statistically significant threefold increase in testosterone replacement therapy use (p <0.0001), which was significantly smaller than the fourfold increase in younger men (p <0.0001). Conclusions: In 2003 to 2013, testosterone replacement therapy use increased fourfold in men 18 to 45 years old compared to threefold in older men. This younger age group should be a focus for future studies due to effects on fertility and unknown long‐term sequelae.

Intralesional collagenase in the treatment of Peyronie’s disease

The objective of intralesional pharmacotherapy in the treatment of Peyronie’s disease is to deliver large doses of pharmacologic agents that can have a local effect on wound remodeling, with minimal side effects. Guidelines for the treatment of peyronie’s disease published in the Journal of Sexual Medicine and the European Association of Urology offer no grade A evidence of efficacy with multiple agents such as steroids, verapamil and interferon. Intralesional collagenase is the first drug to be approved by the United States Food and Drug Administration for the treatment of Peyronie’s disease. This is based on grade A evidence. The purpose of this update is to review the literature and current data on intralesional collagenase in the treatment of Peyronie’s disease.