Thomas A. Masterson

Men With Severe Oligospermia Appear to Benefit From Varicocele Repair: A Cost-effectiveness Analysis of Assisted Reproductive Technology

OBJECTIVE To evaluate the outcomes of men who underwent varicocelectomy for total motile sperm count (TMSC) <2 million and to perform a cost-effectiveness analysis of intrauterine insemination (IUI) and in vitro fertilization with intracyctoplasmic sperm injection after varicocelectomy. METHODS We prospectively collected data of men with TMSC <2 million who underwent microsurgical subinguinal varicocelectomy. Men with azoospermia were excluded. Serum testosterone, luteinizing hormone, and follicle-stimulating hormone were measured preoperatively. Postoperative semen analysis was collected first at 3 months and then every 3 months thereafter. Cost-effectiveness for assisted reproductive technologies was calculated using reported costs. RESULTS A total of 17 men underwent varicocele repair for TMSC <2 million. The mean sperm concentration, motility, and TMSC was 1.1 ± 1.4 million/mL, 15.5% ± 12.8%, and 0.44 ± 0.54 million prior to varicocelectomy, respectively. After varicocelectomy, 14 of 17 men had improvements in TMSC. The mean change in sperm concentration, motility, and TMSC was 4.3 ± 4.7 million/mL, 12% ± 17.2%, and 6.0 ± 8.5 million, respectively. The mean postoperative sperm concentration, motility, and TMSC was 5.4 ± 5.4 million/mL, 27.5% ± 25.1%, and 6.5 ± 8.5 million, respectively. A total of 10 of 17 men had TMSC greater than 2 million. Of the 10 men, 1 man achieved spontaneous pregnancy and 7 men underwent a cycle of IUI; 2 of the 7 (28.6%) men achieved successful pregnancy with IUI (cost per pregnancy:

Medical pre-operative considerations for patients undergoing penile implantation

35,924). CONCLUSION Varicocelectomy increases TMSC in severely oligospermic patients, thus providing previously ineligible couples an opportunity to elect for IUI, a less invasive and less expensive alternative to in vitro fertilization with intracyctoplasmic sperm injection.

Mathematical and Ex Vivo Thermal Modeling for Renal Tumor Radiofrequency Ablation with Pyeloperfusion

Penile prosthesis surgery has become the standard treatment for patients with erectile dysfunction refractory to medical management. Refinements in the both the surgical technique and device manufacturing have made this a safe and reliable treatment with excellent patient satisfaction. In this review, we will overview the basic medical and pre-operative considerations for patients undergoing penile prosthesis implantation. We intend to provide a simple and practical checklist for the implanter to reference when considering implantation of a penile prosthesis.

MP43-05 S-NITROSOGLUTATHIONE REDUCTASE (GSNOR) DEFICIENCY IS A NOVEL MODEL OF SECONDARY HYPOGONADISM

BACKGROUND AND PURPOSE Radiofrequency ablation (RFA) is an effective technique for the treatment of patients with small renal tumors, although it is often limited to tumors at least 2 cm from the renal pelvis or ureter. Retrograde pyeloperfusion (PPF) of the pelvis with cold saline during RFA may protect the pelvis and ureter. We designed a mathematical and ex vivo model of RFA to investigate the effects of PPF. METHODS Our theoretical model uses heat transfer principles simplifying the RFA probe to a heat-emitting cylinder within a material. In the ex vivo model, an RFA probe was placed 18 mm from the pelvis in porcine kidneys and with temperature probes on either side of the RFA probe. Control trials with no PPF were compared with either cold saline (2°C), warm saline (38°C), or antifreeze (-20°C) pumped into the renal calix at a rate of 60 mL/min. Ablated volumes were measured and confirmed histologically. RESULTS The average steady state temperatures at each probe were highest with no PPF, followed by warm saline, cold saline, then antifreeze. Compared with no PPF, temperatures were significantly (P<0.05) colder with warm saline (-8.4°C), cold saline (-18°C), and significantly colder at the calix (warm -14°C, cold -27°C). While RFA output a constant voltage, significantly lower resistances in warm (171Ω) and cold (124Ω) PPF vs no PPF (363Ω) translated to significantly greater power outputs in warm (40 W) and cold (42 W) vs no PPF (14 W). The ablated volumes were significantly higher in warm saline (2.3 cm(3)) vs cold saline (0.84 cm(3)) and no PPF (1.1 cm(3)). Mathematical modeling produced a predictive temperature curve with R2=0.44. CONCLUSION PPF lowers temperatures throughout the entire kidney during RFA, most notably near the collecting system and is dependent on the temperature of the liquid used. In addition, PPF may cause less charring of the tissue around the probe resulting in lower resistance and higher power outputs.

Penile duplex: clinical indications and application

TUNEL, and immunohistochemical analysis for cleaved caspase-3 (apoptosis indicator), -8, -9, SHH and its receptor Patched. RESULTS: Cleaved caspase-3 was present in normal pelvic plexus and increased in a time dependent manner in all nerves of the pelvic plexus when the CN was crushed. Caspase 3 cleaved was identified primarily in glial cells, rather than neurons. Caspase 9 increased in glial cells of all nerves of the pelvic plexus, while very little caspase 8 was observed. SHH was abundant in neurons and glia of the CN, PN, HYG and ANC, while PTCH1 was identified only in neurons. CONCLUSIONS: Interruption of CN innervation, as occurs in the majority of prostatectomy patients, results in induction of apoptosis in other regions of the pelvic plexus, thus affecting continence. Apoptosis occurred primarily through the intrinsic pathway in response to CN injury. Identification of HYG and PN contribution to SUI, and involvement of the SHH pathway, identifies novel treatment avenues for intervention.

Natesto Effects on Reproductive Hormones and Semen Parameters: Results from an Ongoing Single-center, Investigator-initiated Phase IV Clinical Trial

Butany et al. [1] report the results of a 30-question electronic survey distributed to members of the International Society for Sexual Medicine (ISSM). The survey assessed the variability in the current Penile Duplex Ultrasonography (PDU) practice patterns, technique and interpretations. Although the response rate was only 9.5%, the cohort consisted of 190 respondents of which 126 (66%) had been practicing for greater than 10 years. The authors report significant heterogeneity in the practice patterns of PDU. Penile ultrasonography is a non-invasive imaging modality that evaluates macroscopic penile anatomy including assessment of penile vascular flow thus providing information pertaining to functional status of an erection [2]. The American Institute of Ultrasound in Medicine (AIUM) in conjunction with the American Urological Association (AUA) published the AIUM Practice Parameter for the Performance of an Ultrasound Examination in the Practice of Urology in 2011 [3]. The indications for penile ultrasound in urological practice ranged from evaluation of priapism, dorsal vein thrombosis, and penile tumors. In 2015, the AUA published their guidelines on Peyronie’s Disease (PD), which states an in-office intracavernosal injection (ICI) test with or without PDU should be performed prior to invasive intervention (expert opinion) [4]. Most recently, the AUA published their 2018 guidelines on ED and described that PDU may provide information differentiating primary psychogenic versus organic etiology of ED, identification of men with severe veno-occlusive dysfunction resulting in ED who are unlikely to respond to medical therapy and identify men who may be candidates for penile revascularization procedures [5]. The use of PDU to evaluate erection dysfunction (ED) was first described by Lue et al. in 1985 [6]. PDU is often combined with ICI of vasoactive substances to test penile circulation under maximal pharmacological stimulation. Various single agent drugs and combinations have been described to elicit the erection with Butany et al. finding 10 pharmacologic mixtures reported. The agent most commonly used was 10 mcg of Prostaglandin E1 [1]. PDU provides peak systolic velocity (PSV) and end -diastolic velocity (EDV) to diagnose arterial insufficiency as well as veno-occlusive dysfunction. Several different values have been reported in the literature but as published by the AUA ED Guidelines generally a PSV of less than 30 cm/s is considered evidence of arterial insufficiently whereas a EDV > 5 cm/s is consistent with veno-occlusive dysfunction. Resistance index can be calculated (PSV-EDV/PSV) and is considered another measure of veno-occlusive dysfunction. A Resistance Index of >0.80 may be indicative of normal veno-occlusive function [4]. The European Association of Urology Guidelines on ED, Premature Ejaculation, Penile Curvature, and Priapism utilizes similar values to the AUA except for the EDV which they consider >3 cm/s to diagnose veno-occlusive dysfunction [7] the survey by Butany et al. [1] found varied response regarding the values required to diagnose these conditions. PDU is also utilized in the assessment of PD. PDU allows the ability to characterize plaques and visualize calcification. The initial trials evaluating Collagenase Clostridium Histiolyticum (IMPRESS 1 & 2) excluded patients with calcified plaques as they may not likely respond to intralesional injections. Therefore patients with calcified plaques may benefit from surgical intervention [8]. As discussed previously, the AUA recommends ICI with or without PDU prior to invasive intervention for PD [4]. ICI with PDU detects arterial insufficiency as well as measurement of penile curvature for patients with PD. ICI with PDU can be quite useful in cases with more extensive curvature and those with a history of ED. For patients with PD and ED, PDU will allow accurate assessment of penile vasculature if excision and grafting is the most appropriate surgical approach, as the patient is likely to be better served * Ranjith Ramasamy ramasamy@miami.edu

Time to improvement in semen parameters after microsurgical varicocelectomy in men with severe oligospermia

Promising initial data from our perspective clinical trial demonstrates that Natesto can not only increase serum testosterone but also maintain follicle-stimulating hormone, luteinizing hormone, and importantly, semen parameters.

Comprehensive pelvic floor physical therapy program for men with idiopathic chronic pelvic pain syndrome: a prospective study

INTRODUCTION We aimed to determine the time and predictive factors of semen quality improvement in men with severe oligospermia after microsurgical varicocelectomy. METHODS Men with total motile sperm count (TMSC) <5 million on two semen analyses were identified from May 2015 to August 2017. Postoperative semen analysis was collected at 3-6 months and >6 months. We evaluated preoperative factors for successful semen quality upgrading based on assisted reproductive technology (ART) eligibility: in vitro fertilization [IVF] (<5 million), intrauterine insemination (IUI) (5-9 million), and natural pregnancy (>9 million). We compared men with TMSC <5 million to those with TMSC 5-9 million. Data are reported as means and standard error of the mean (SEM). Pregnancy data was collected by phone interview at >6 months postoperatively RESULTS: A total of 33 men were included. TMSC improved from 1.5±0.2 to 7.3±1.8 million at 3-6 months (p<0.05) and 12.2±3.6 million at >6 months (p<0.05). There was no statistical difference in TMSC between 3-6 months and >6 months. Sixteen (48.5%) men upgraded semen quality into the range of natural pregnancy. Preoperative TMSC from 2-5 million was predictive of upgrading semen quality. Twenty-four couples were contacted by phone; 20 were attempting pregnancy in the postoperative period and five (25%) of them had achieved natural pregnancy. CONCLUSIONS Men with TMSC <5 million can expect the largest improvement in TMSC from 3-6 months postoperatively with minimal improvement thereafter. Preoperative TMSC >2 million was most predictive of semen quality upgrading.

S-Nitrosoglutathione Reductase (GSNOR) Deficiency Results in Secondary Hypogonadism

Background Male chronic pelvic pain syndrome (CPPS) is a heterogeneous constellation of symptoms that causes significant impairment and is often challenging to treat. In this prospective study, we evaluated men with CPPS who underwent comprehensive pelvic floor physical therapy (PFPT) program. We used the previously validated Genitourinary Pain Index (GUPI) to measure outcomes. Methods We included 14 men who underwent physical therapy for idiopathic CPPS from October 2015 to October 2016. Men with clearly identifiable causes of pelvic pain, such as previous surgery, chronic infection, trauma, prostatitis and epididymitis were excluded. Treatment included: (I) manual therapy (internal and external) of pelvic floor and abdominal musculature to facilitate relaxation of muscles; (II) therapeutic exercises to promote range of motion, improve mobility/flexibility and strengthen weak muscles; (III) biofeedback to facilitate strengthening and relaxation of pelvic floor musculature; (IV) neuromodulation for pelvic floor muscle relaxation and pain relief. GUPI questionnaires were collected at initial evaluation and after the 10th visit. Higher scores reflect worse symptoms. Previous validation of the GUPI calculated a reduction of 7 points to robustly predict being a treatment responder (sensitivity 100%, specificity 76%) and a change in 4 points to predict modest response. Data are presented as medians (ranges). Results A total of 10 patients completed 10 visits, and the remaining four patients completed between 5 and 9 visits. The median National Institute of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) score at initial evaluation was 30.8 [16–39] and decreased to 22.2 [7–37] at the tenth visit. Five of the 10 patients (50%) in the study had a reduction of greater than 7 points indicating a robust treatment response, and two (20%) had a change of greater than 4 indicating moderate response. Three patients (30%) did not have any meaningful change in NIH-CPSI and the remaining four are in the process of completing 10 sessions. Duration of therapy appears to predict treatment response. Longer duration has better response. Conclusions Male CPPS is difficult to treat and often requires a multimodal approach. Based on the results of our pilot study, pelvic floor rehabilitation may be an effective treatment option for select patients. A larger study with a control group is needed to validate the routine use of pelvic floor rehabilitation in men with CPPS and predict characteristics of men who would respond to therapy.