Faculty Bibliography

This monograph, written by the pioneers of IVF and reproductive medicine, celebrates the history, achievements, and medical advancements made over the last 40 years in this rapidly growing field.

This multicenter retrospective chart review study performed on 162 cryptorchid patients and on 34 subjects with retractile testes suggests that cryptorchidism and retractile testes can alter spermatogenesis, with more serious damage observed in bilateral cryptorchidism. This spermatogenetic impairment is probably related to the lack of an appropriate or timely surgical correction.

OBJECTIVE:To report a multiinstitutional experience of men presenting with infertility secondary to inguinal hernia repair using polypropylene mesh. SUMMARY BACKGROUND DATA/BACKGROUND: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/CONCLUSIONS: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.

Penile fracture is an uncommon, but well-described, entity that requires emergent treatment. The classic, "text-book" history, a blow to the erect penis accompanied by a "snap," pain, and immediate detumescence, is not universally present. We report 2 cases of "false" penile fracture, a condition that closely mimics "true" penile fracture. Perhaps the most distinguishing symptoms are the absence of the "snap" and gradual detumescence, both of which suggest false fracture but are not specific. It is our intention to bring this condition to the attention of general urologists who may see it in clinical practice and to guide them in its management.

Our objective was to determine whether or not male reproductive microsurgery is adaptable to current robotic technology. We devised a model vas deferens system using rat vasa deferentia and completed vasal anastomosis with full-thickness and mucosal robotically placed, Sharpoint 10-0 bicurve nylon sutures. Experienced and inexperienced microsurgeons performed separate anastomoses. Both groups of microsurgeons completed anastomoses with accuracy and enhanced comfort. The robotic graspers had the dexterity to delicately handle the 10-0 sutures and needles. We conclude that through our model vas deferens system, we demonstrated the feasibility of applying robotic technology to male reproductive microsurgery. This pilot study reveals some advantages of the robot and suggests future use of this system in a new urological application domain.

Prostatitis and infertility are common disorders in men and many researchers have investigated a possible link between the two disorders. After almost 3 decades of research the answer to this question remains unknown, although ample evidence exists to support a relationship between male infertility and prostatitis. This paper discusses this evidence and then derives a rational treatment approach to the man with infertility and prostatitis.

PURPOSE/OBJECTIVE:We describe a simple and time efficient technique for repairing a diaphragmatic injury occurring during right hand assisted laparoscopic radical nephrectomy. MATERIALS AND METHODS/METHODS:A dual layer polypropylene and polyglactin mesh was created extracorporeally by sewing a 2 x 2 piece of polypropylene mesh to a 2 x 2 piece of polyglactin mesh with 4, 4-zero interrupted polyglactin sutures. This dual layer was then positioned manually over the diaphragmatic rent and secured with a laparoscopic stapling device. A 16Fr chest tube was placed at the conclusion of the procedure. RESULTS:Overall operative time was 3.5 hours with an estimated blood loss of 100 cc. Repair of the diaphragmatic injury extended operative time by 25 minutes. Extubation was done at the conclusion of the case and the chest tube was removed within 36 hours of the procedure. The patient was discharged home on postoperative day 3. At 14 months of followup the patient remained disease-free on radiography and without pulmonary or gastrointestinal sequelae. CONCLUSIONS:We describe a simple and time efficient technique for repairing diaphragmatic injury occurring during right hand assisted laparoscopy. This technique takes advantage of the manual and tactile sensation provided by the hand assistance device, provides a tension-free repair and avoids laparoscopic suturing.

To determine whether or not obstructive interval (OI) negatively affects patency rates in epididymovasostomy (EV) as a sole procedure alone, we reviewed medical records from obstructive azoospermia (OA) patients who underwent unilateral or bilateral epididymovasostomy. For the purpose of analysis, patients were placed into short OI (15 years or less) or long OI (more than 15 years) categories. Patency rate for the short OI group was 58%, compared to 15% for the long OI group (P<0.01). In conclusion, we observed that patency rates worsened with obstructive interval greater than 15 years. Epididymovasostomy is a challenging procedure that may not be successful, and, thus, patients should be counseled that obstructive interval might affect surgical outcomes. We routinely perform testicular sperm extraction (TESE) with sperm cryopreservation in this patient population due to the high likelihood that it will ultimately be required for assisted reproductive technology (ART).

PURPOSE/OBJECTIVE:In addition to its usefulness as a therapeutic modality, intracavernous injection may also be done in a diagnostic capacity. While a good response to an intracavernous injection test rules out venous leakage, a failed erectile response to the test in the office setting may not be completely representative of the patient erectile state. We determined by quantitative analysis the likely significance of failure to respond to intracavernous injection testing. MATERIALS AND METHODS/METHODS:Patients evaluated with the standard erectile dysfunction assessment at our andrology clinic between 1996 and 1999 were included in analysis. All 122 patients who did not meet study exclusion criteria underwent a test dose of intracavernous injection with papaverine, phentolamine and prostaglandin E1. Regardless of the response or lack of response to the test the men then underwent nocturnal penile tumescence testing, penile blood flow study and re-dose pharmacocavernosography. Results of these adjunctive tests were compared to the outcome of a papaverine, phentolamine and prostaglandin E1 intracavernous injection test by quantitative analysis. RESULTS:A total of 87 patients failed to respond to the test dose. Average age of the nonresponders versus responders was 46.8 versus 33.8 years. The duration of erectile dysfunction in nonresponders versus responders was 31.0 versus 13.7 months. Poor intracavernous injection responders required an average of 1.9-fold greater induction flow and 6-fold greater maintenance flow than good responders. Receiver operator characteristics (ROC) curve analysis revealed that the best predictors of the intracavernous injection test response were erectile dysfunction duration (ROC 0.99), patient age (ROC 0.87), maintenance flow (ROC 0.86), pressure loss (ROC 0.83) and resistive index (ROC 0.82). The ROC area for peak systolic velocity was 0.69. CONCLUSIONS:Our results indicate that age and erectile dysfunction duration alone are the most important variables affecting the results of an intracavernous injection test. However, in patients older than 40 years with a greater than 2-year history of erectile dysfunction failure to respond to intracavernous injection testing is most closely associated with venous insufficiency, as evidenced by the high ROC values for variables indicative of venous insufficiency, namely maintenance flow, pressure loss and the resistive index. Therefore, nonresponse to an office intracavernous injection test in an older patient with erectile dysfunction of long duration is most likely due to venous leakage. If only 1 confirmatory test is possible, cavernosometry provides the most information.

PURPOSE/OBJECTIVE:We evaluate the traditional role of isolated testicular biopsy as a diagnostic tool, as opposed to the value as a therapeutic procedure for azoospermic men. MATERIALS AND METHODS/METHODS:The medical records of azoospermic patients who were evaluated, and treated between 1995 and 2000 were retrospectively analyzed for history, physical examination findings, endocrine profiles, testicular histology and sperm retrieval rates. Based on these parameters, cases were placed into diagnostic categories that included obstructive or nonobstructive azoospermia. Diagnostic parameters used to distinguish obstructive from nonobstructive azoospermia were subjected to statistical analysis with the t-test, analysis of variance and receiver operating characteristics curve. RESULTS:A total of 153 azoospermic men were included in our analysis. Of men with obstructive azoospermia 96% had follicle-stimulating hormone (FSH) 7.6 mIU/ml. or less, or testicular long axis greater than 4.6 cm. Conversely, 89% of men with nonobstructive azoospermia had FSH greater than 7.6 mIU/ml., or testicular long axis 4.6 cm. or less. Receiver operating characteristics analysis revealed that FSH, testicular long axis, and luteinizing hormone were the best individual diagnostic predictors, with areas 0.87, 0.83 and 0.79, respectively. CONCLUSIONS:In the vast majority of patients obstructive azoospermia may be distinguished clinically from nonobstructive azoospermia with a thorough analysis of diagnostic parameters. Based on this result, we believe that the isolated diagnostic testicular biopsy is rarely if ever indicated. Men with FSH 7.6 mIU/ml. or greater, or testicular long axis 4.6 cm. or less may be considered to have nonobstructive azoospermia and counseled accordingly. These men are best treated with therapeutic testicular biopsy and sperm extraction, with processing and cryopreservation for usage in in vitro fertilization and intracytoplasmic sperm injection if they accept advanced reproductive treatment. Diagnostic biopsy is of no other value in this group. Men with FSH 7.6 mIU/ml. or less, or testicular long axis greater than 4.6 cm. may elect to undergo reconstructive surgery with or without testicular biopsy and sperm extraction, or testicular biopsy and sperm extraction alone depending on their reproductive goals.