Faculty Bibliography

OBJECTIVE:To assess changes in the practice patterns of urologists performing male infertility procedures (vasal reconstruction, sperm retrieval, varicocelectomy) from 2004 to 2015 in the United States. DESIGN/METHODS:Examination of self-reported procedural volumes from urologists undergoing certification and recertification using case log data provided by the American Board of Urology. The study period was stratified into early (2004-2007) and recent (2012-2015) time periods. SETTING/METHODS:Not applicable. PATIENT(S)/METHODS:None. INTERVENTION(S)/METHODS:None. MAIN OUTCOMES MEASURE(S)/METHODS:Temporal variations in male infertility practice patterns among different urologic subspecialties between the early and recent time periods. RESULT(S)/RESULTS:The overall proportion of total male infertility procedures performed by andrologists significantly increased between the early and recent groups (23% to 26%). This growth was driven by a significant increase in the proportion of varicocele repairs being performed by andrologists between the early and recent periods (19% to 25%). Most notably, an assessment of total number of male infertility procedures performed by newly certifying urologists showed that there was a significant increase in the overall proportion of all male infertility procedures being performed by recently trained andrologists (24% to 35%). This significant increase was seen individually among all three types of male infertility procedures. CONCLUSION(S)/CONCLUSIONS:With the increased trend in urologists obtaining fellowship training, male infertility surgical volume is beginning to shift from general urologists to subspecialized andrologists.

OBJECTIVE:To evaluate whether varicocelectomy improves both serum testosterone and sexual function, as assessed by the Male Sexual Health Questionnaire (MSHQ). METHODS:A retrospective chart review of patients who have undergone varicocelectomy and had both pre- and postoperative MSHQ was performed. The MSHQ is a clinically validated questionnaire that assesses erectile function, ejaculatory function, and sexual satisfaction, with higher scores indicating better function. Clinical parameters pre and postvaricocelectomy were compared with paired t test. RESULTS:Thirty-four patients met study criteria. Seventeen patients (50%) presented for infertility, and the remaining 13 had symptomatic varicocele associated with hypogonadism. Average postsurgical follow-up was 20.6 ± 12.5 months. The majority of men in the study had bilateral varicoceles and left grade III varicoceles. Significant improvements in the total MSHQ score (3.9 ± 8.7, P = .027), the MSHQ erectile function (1.2 ± 2.3, P = .007), and the MSHQ ejaculatory function (1.4 ± 3.1, P = .018) domains were seen. Fifteen (44%) men saw improvement in their erectile function and 18 (53%) saw improvement in ejaculatory function. The improvement in serum testosterone was also significant (136.0 ± 201.3 ng/dL, P = .007). CONCLUSION/CONCLUSIONS:Microsurgical repair of varicocele not only improves testosterone, but also improves patient-reported erectile and ejaculatory functions. Patients can confidently be counseled that varicocelectomy has the potential to improve sexual function along with serum testosterone.

PURPOSE: Inguinal herniorrhaphy is the most common general surgical procedure. It is associated with frequent complications such as recurrence (1.9% with mesh), post-operative hematoma (4.5%), reduced sensation (0 - 42.8%), chronic post-operative pain (5.1%), vasal injury (0.1 - 0.53%) and infection (3 - 6%)1-5. Drawing on our experience utilizing the operating microscope for varicocelectomy, vasectomy reversal and repair of iatrogenic vasal obstruction from hernia repair, we employed it for inguinal hernia repair. This paper describes the rationale, technique and outcomes of microsurgically assisted inguinal hernia repair. MATERIALS AND METHODS: 291 microsurgically assisted inguinal hernia repairs were performed on 253 men by the same urologist (MG). Simultaneous microsurgical varicocelectomy or other testicular procedures were performed in 83% of cases. All were open repairs through an inguinal incision with the vas deferens, ilioinguinal nerve, genital branch of the genitofemoral nerve and spermatic vasculature identified and preserved. Median follow up was 8.6 months, and outcomes were assessed through examination, pain reporting and pathology reports. RESULTS: Chronic postoperative pain, sensory loss, infection, hematoma, vasal injury and recurrence were assessed. The incidence of hematoma was 0.85%. No hernia recurrences, chronic postoperative pain, sensory loss, infection or vasal injury was reported. CONCLUSIONS: Using an operating microscope, complications of inguinal hernia repair such as vasal obstruction, testicular atrophy, recurrence, infection, hematoma, chronic postoperative pain and loss of sensation are minimized. Microsurgically assisted hernia repair is a promising technique, especially when employed by a urologist performing simultaneous microsurgical varicocelectomy or procedures involving spermatic cord structures or testis.

PURPOSE OF REVIEW: To describe the connection between metabolic syndrome and male sexual dysfunction. RECENT FINDINGS: Concurrent with the obesity epidemic, metabolic syndrome in the United States is reaching crisis levels. A myriad of comorbidities are rising as well, affecting cost and quality of life. Sexual dysfunction is one of these comorbidities, with an extremely high prevalence, which will only increase as the population ages.In light of this ubiquity, recent research has explored the mechanisms of decreased libido, hypogonadism and erectile dysfunction through the lens of metabolic syndrome and its individual components. Strong associations are seen between male sexual dysfunction and central obesity, poor glycemic control, hyperlipidemia, as well as hypertension. SUMMARY: The constellation of risk factors that make up metabolic syndrome are linked to male sexual dysfunction and are largely modifiable. Therefore, effective interventions targeting the underlying pathophysiology have the potential to greatly impact and improve patient sexual function and, ultimately, quality of life.

Spermatogenesis is an extraordinary complex process. The differentiation of spermatogonia into spermatozoa requires the participation of several cell types, hormones, paracrine factors, genes and epigenetic regulators. Recent researches in animals and humans have furthered our understanding of the male gamete differentiation, and led to clinical tools for the better management of male infertility. There is still much to be learned about this intricate process. In this review, the critical steps of human spermatogenesis are discussed together with its main affecting factors.

Testosterone supplementation therapy (TST) has become increasingly popular since the turn of the century. Most prescriptions in the U.S. are written by primary care providers, endocrinologists, or urologists. The FDA has requests pharmaceutical companies provide more long term data on efficacy and safety of testosterone products. Results from these studies will help define the appropriate population for TST going forward. It is hoped that these data combined with physician and public education will minimize inappropriate prescribing and allow those likely to benefit from TST to receive it.

OBJECTIVE: To evaluate the association of body mass index (BMI) and spermatic vein diameters (SVDs) in men treated for varicocele. SUBJECTS AND METHODS: One hundred fourteen men who underwent scrotal color duplex ultrasounds prior to microsurgical varicocelectomy were classified as normal (BMI = 18.5-24.9), overweight (25-29.9), or obese (>/=30). SVDs were measured with and without Valsalva, standing and supine. SVD, pre- and postoperative semen analyses (SA) were compared. RESULTS: Forty-six (40.4%) men had normal BMI, 54 (47.3%) were overweight, and 14 (12.3%) were obese. Higher BMI was associated with smaller left testis volume and larger left SVD when supine (with and without Valsalva). The association was absent when standing. Men with higher BMI had smaller differences between their left SVD Valsalva diameters when standing vs supine. There were no differences among BMI classes for right SVD measurements, preoperative SA, and postoperative SA improvement. CONCLUSION: Increased BMI is associated with larger left SVD while supine, suggesting that increased abdominal pressure while recumbent may contribute to varicocele pathology in this population. Interestingly, as in the general population, a majority of the men were overweight.