Inability to obtain sperm for fresh IVF cycles: analysis and incidence of outcomes using a database from the United States
Background/UNASSIGNED:Azoospermia is present in 10% of men presenting with infertility and surgical sperm retrieval rates for men with azoospermia due to spermatogenic dysfunction remain low. We investigated the incidence of failed fresh IVF cycles due to inability to obtain sperm and describe predictors for subsequent IVF. Methods/UNASSIGNED:A national IVF database was used to identify fresh IVF cycles in which there was failure to obtain sperm. Patient linkage was utilized to determine outcomes of subsequent IVF. Results/UNASSIGNED:Â =â€‰0.01) and male infertility (OR 0.14, pâ€‰=â€‰0.01) were associated with having no subsequent cycles. Partner sperm was used in 213 (80%) second cycles and sperm retrieval method was largely conserved (181/213, 85%). Embryos were transferred in 186 (70%) second cycles. Failed embryo transfers were due to repeat inability to obtain sperm in 5 (6%) cycles. Conclusions/UNASSIGNED:Failure to obtain sperm during fresh IVF is rare, but most affected couples will not pursue further cycles of IVF after their initial failed attempt.
Scrotal Ultrasound for Pain: Low Frequency of Absolute Surgical Indications
OBJECTIVE:To examine the results of scrotal ultrasounds (US) conducted for scrotal or testicular pain and review the pathologic findings of orchiectomies done for lesions that were suspicious for malignancy on US. MATERIALS AND METHODS/METHODS:We retrospectively reviewed the indications and findings of all scrotal US completed at our institution from 2002 to 2014. If a patient underwent an orchiectomy for an intratesticular lesion that was concerning for malignancy on US, the pathology report was also reviewed. RESULTS:There were 18,593 scrotal US performed, with 7,668 (41.2%) conducted for scrotal pain. Of the US performed for pain, 80.4% revealed benign or normal findings, and only 2.2% demonstrated a finding that is an absolute indication for surgery (intratesticular lesion suspicious for malignancy 0.8%, abscess 0.7%, torsion 0.6%, infiltrative process such as lymphoma 0.1%). For those patients undergoing an orchiectomy, 75% had malignancy on pathologic analysis. CONCLUSION/CONCLUSIONS:The majority of the 7668 US performed to evaluate scrotal or testicular pain reveal normal or benign findings. A low percentage demonstrates a finding that necessitates urgent or emergent surgery.
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Epidemiology of Traumatic Adrenal Injuries Requiring Surgery
OBJECTIVE:To analyze adrenal injuries using the National Trauma Data Bank. Adrenal trauma is rare and current literature is lacking in data from large case series. METHODS:A retrospective analysis of the National Trauma Data Bank from the years 2007-2011 was performed. Patient demographics, Injury Severity Score (ISS), mechanism of injury, type of trauma, associated injuries, and development of shock were assessed. Multivariable models were used to determine association with outcomes, such as characterization of injury, need for adrenalectomy, intensive care unit admission, and death. RESULTS:Of the 1,766,606 trauma cases recorded, 7791 involved 1 or both adrenal glands (0.44%). Common associated injuries were to the ribs (50.9%), thorax (50.0%), and liver (41.6%). Eighty adrenal injuries required surgery (80/7791, 1.0%), none of which were isolated adrenal injuries (0/120, Pâ€‰=â€‰.63). Higher ISS (Pâ€‰=â€‰.009), Black race (Pâ€‰=â€‰.031), penetrating injury (Pâ€‰<â€‰.001), and splenic (Pâ€‰<â€‰.001) and intestinal injuries (Pâ€‰=â€‰.018) were associated with need for adrenalectomy. No isolated adrenal injuries were associated with death (12% vs 0%, Pâ€‰<â€‰.0001). Older age (Pâ€‰<â€‰.001), higher ISS (Pâ€‰<â€‰.001), chronic kidney disease (Pâ€‰=â€‰.009), penetrating injuries (Pâ€‰<â€‰.001), and injuries to the aorta/vena cava (Pâ€‰=â€‰.008), peripheral vasculature (Pâ€‰<â€‰.0001), thorax (Pâ€‰=â€‰.029), brain/spinal cord (Pâ€‰<â€‰.001), and abdominal polytrauma (Pâ€‰=â€‰.005) were associated with mortality. CONCLUSIONS:Adrenal injuries are rare, comprising 0.44% of recorded traumatic injuries. Isolated adrenal injuries were not fatal and did not require surgery, and thus should be managed conservatively. Detection of adrenal injury in polytrauma patients is key, particularly penetrating trauma and concurrent splenic and/or intestinal injuries, as these patients are more likely to require adrenalectomy.
Prostate MRI: a national survey of Urologist's attitudes and perceptions
INTRODUCTION/BACKGROUND:The use of multi-parametric (MP) MRI to diagnose prostate cancer has been the subject of intense research, with many studies showing positive results. The purpose of our study is to better understand the accessibility, role, and perceived accuracy of MP-MRI in practice by surveying practicing urologists. MATERIALS AND METHODS/METHODS:Surveys were sent to 7,400 practicing American Urological Association member physicians with a current email address. The survey asked demographic information and addressed access, accuracy, cost, and role of prostate MRI in clinical practice. RESULTS:Our survey elicited 276 responses. Respondents felt that limited access and prohibitive cost of MP-MRI limits its use, 72% and 59% respectively. Academic urologists ordered more MP-MRI studies per year than those in private practice (43.3% vs. 21.1%; p<0.001). Urologists who performed more than 30 prostatectomies a year were more likely to feel that an MP-MRI would change their surgical approach (37.5% vs. 19.6%, p-value=0.002). Only 25% of respondents agreed or strongly agreed that MP-MRI should be used in active surveillance. For patients with negative biopsies and elevated PSA, 39% reported MP-MRI to be very useful. CONCLUSIONS:Our study found that MP-MRI use is most prominent among practitioners who are oncology fellowship-trained, practice at academic centers, and perform more than 30 prostatectomies per year. Limited access and prohibitive cost of MP-MRI may limit its utility in practice. Additionally, study participants perceive a lack of accuracy of MP-MRI, which is contrary to the recent literature.
A Comparative Analysis of International Knee Documentation Committee Scores for Common Pediatric and Adolescent Knee Injuries
BACKGROUND:Several different etiologies cause knee pain in the pediatric and adolescent population, including anterior knee/patellofemoral pain, patellar instability, anterior cruciate ligament (ACL) tears, meniscal tears, osteochondritis dissecans (OCD) lesions, and discoid meniscus. The purpose of the current study was to determine the relative morbidity of different causes of knee pain in children and adolescents using the International Knee Documentation Committee (IKDC) score. METHODS:We performed a retrospective review of prospectively collected data of a cohort of pediatric and adolescent patients with knee pain who presented to a single surgeon. Each patient completed an IKDC questionnaire at the time of diagnosis and patients were grouped by diagnosis for analysis. Statistical analysis was performed to compare the IKDC scores of the 7 diagnostic groups, and a P-value <0.05 was considered significant. RESULTS:The IKDC mean score for all 242 patients was 50.3Â±18.3. The mean IKDC score for patients with isolated meniscal tears was 41.2Â±16.0, combined ACL and meniscal injuries was 50.2Â±13.9, and isolated ACL tears was 48.1Â±14.1. The mean IKDC score for patients with symptomatic discoid meniscus was 46.3Â±13.2, anterior knee pain/patellofemoral pain was 49.0Â±17.4, patellar instability was 49.2Â±22.1, and OCD lesions was 62.2Â±19.5. CONCLUSIONS:The IKDC scores of most of the diagnostic groups were similar to the overall average score, with the notable exception of patients with OCD lesions exhibiting statistically significant less morbidity reflected by a higher IKDC score. Although symptoms in each individual clinical presentation may vary, knowledge of the relative morbidity of these diagnostic groups is valuable in counseling patients and their families regarding these common pediatric and adolescent sources of knee pain. LEVEL OF EVIDENCE/METHODS:Level IV.
Botulinum Toxin Type A Injections for the Treatment of Continent Catheterizable Ileal-colic Urinary Diversion Muscularis Overactivity [Case Report]
INTRODUCTION/BACKGROUND:Continent catheterizable diversions can exhibit long-term complications such as high pressures and involuntary unit contractions within the urinary reservoir, rendering them similar to neurogenic bladders. Given the similarity of these issues to neurogenic detrusor overactivity, the use of Botox injections is a logical treatment option to explore. TECHNICAL CONSIDERATIONS/METHODS:A patient with a contracted Indiana pouch continent catheterizable diversion was treated with intra-pouch Botox injections after failing maximal doses of oral anticholinergic medications. This patient underwent four consecutive percutaneous Botox pouch injections every 11-12 months under general anesthesia. Flexible cystoscope via the catch stoma was attempted first on the first two surgeries, but the scope could not reach the majority of the pouch. Thus, percutaneous access was obtained under fluoroscopic guidance, and the injections were performed through a suprapubic tube access sheath. Two hundred to four hundred units of Botox (stained with methylene blue) were visually injected in 20-40 separate injection sites. Of note, the initial dose used was 200 units and was increased to 300 units then 400 units on subsequent treatments to improve results and durability. After each round of Botox injections, the patient noted resolution of her symptoms. Postinjection urodynamic studies showed normal filling with no evidence of muscularis overactivity, even at high volumes of 600 cc. CONCLUSION/CONCLUSIONS:Botox injections may be an excellent long-term treatment option for contracted continent catheterizable diversions, or at least used as a temporizing measure before surgical augmentation. Further studies are needed to verify the durability, complications, and long-term outcomes of this procedure.
Gracilis muscle interposition flap repair of urinary fistulae: pelvic radiation is associated with persistent urinary incontinence and decreased quality of life
PURPOSE/OBJECTIVE:The primary goal of urinary fistulae repair is to improve continence and quality of life. Irradiated patients are predisposed to development of bladder outlet dysfunction (BOD), defined as bladder neck contracture or stress urinary incontinence. Here, we review our experience with gracilis flap repairs for rectourinary fistulae (RUF) and urinary cutaneous fistulae (UCF) in patients who underwent pelvic radiation. METHODS:Twenty-seven patients underwent repair of a RUF/UCF with gracilis flap between 2003 and 2013. Patients were assessed for postoperative fistula closure and BOD, and quality of life was assessed with the Expanded Prostate Index Composite (EPIC) questionnaire administered via telephone at the time of final follow-up. RESULTS:Mean age was 60Â years (50-73) with median follow-up of 28.7Â months (1.0-128). Flap failure was noted in 5/20 radiated patients versus 3/7 non-radiated patients (pÂ =Â 0.63). Of the 8 flap failures, 7 underwent secondary repair: repeat gracilis flap (2), coloanal pull-through (2), rectal advancement flap (1), sliding flap (1), and omental flap (1). Median time to revision was 7.2Â months (3.5-24.9). In irradiated patients, 18/20 (90Â %) developed BOD compared with 1/7 (14Â %) who were not radiated (pÂ =Â 0.0006). Radiation was associated with worse scores on the urinary incontinence domain of the EPIC questionnaire compared with non-radiated patients (pÂ =Â 0.0458). CONCLUSIONS:Urinary fistula repairs in radiated patients should be undertaken with caution. Even if the fistula is successfully repaired, patients may still have bladder outlet dysfunction and decreased quality of life. Consequently, patients should be counseled about all possible procedures, including permanent urinary diversion as primary therapy.
Anterior Urethral Stricture Disease Negatively Impacts the Quality of Life of Family Members
Purpose. To quantify the quality of life (QoL) distress experienced by immediate family members of patients with urethral stricture via a questionnaire given prior to definitive urethroplasty. The emotional, social, and physical effects of urethral stricture disease on the QoL of family members have not been previously described. Materials and Methods. A questionnaire was administered prospectively to an immediate family member of 51 patients undergoing anterior urethroplasty by a single surgeon (SBB). The survey was comprised of twelve questions that addressed the emotional, social, and physical consequences experienced as a result of their loved one. Results. Of the 51 surveyed family members, most were female (92.2%), lived in the same household (86.3%), and slept in the same room as the patient (70.6%). Respondents experienced sleep disturbances (56.9%) and diminished social lives (43.1%). 82.4% felt stressed by the patient's surgical treatment, and 83.9% (26/31) felt that their intimacy was negatively impacted. Conclusions. Urethral stricture disease has a significant impact on the family members of those affected. These effects may last decades and include sleep disturbance, decreased social interactions, emotional stress, and impaired sexual intimacy. Treatment of urethral stricture disease should attempt to mitigate the impact of the disease on family members as well as the patient.
Artificial Urinary Sphincters for Treatment of Urinary Incontinence in Elderly Males
INTRODUCTION/BACKGROUND:We sought to examine the role of advanced age (defined as >70 years), impaired cognitive function, and decreased manual dexterity in the rates of re-operation (revision or replacement) of artificial urinary sphincters (AUS). METHODS:From 1988 to 2012, 213 men underwent virgin AUS placements. Failure was defined as a revision performed for stress incontinence and replacement/exploration performed for urethral erosion/infection or mechanical failure. Kaplan-Meier curves were constructed to compare failure rates with age and Cox proportional hazard models were used to test associations. RESULTS:Advanced age was not associated with overall failure (p = 0.48), erosion/infection failure (p = 0.65), recurrent/persistent incontinence failure (p = 0.08), or mechanical failure (p = 0.36). Controlling for age, patients with cognitive dysfunction or decreased manual dexterity showed a higher rate of overall failure (p = 0.01). CONCLUSIONS:AUS placement is an excellent option to treat stress urinary incontinence in elderly men with intact cognition and good manual dexterity. AUS placement should be performed with caution in patients with impaired cognitive function or decreased manual dexterity, and additional effort should be made to identify these conditions both before and after surgery.