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- Cost-effectiveness analysis reveals microsurgical varicocele repair is superior to percutaneous embolization in the treatment of male infertility. [Journal Article]
- Can Urol Assoc J 2014 Sep; 8(9-10):E619-25.
Varicoceles are a common cause of male infertility; repair can be accomplished using either surgical or radiological means. We compare the cost-effectiveness of the gold standard, the microsurgical varicocele repair (MV), to the options of a nonmicrosurgical approach (NMV) and percutaneous embolization (PE) to manage varicocele-associated infertility.A Markov decision-analysis model was developed to estimate costs and pregnancy rates. Within the model, recurrences following MV and NMV were re-treated with PE and recurrences following PE were treated with repeat PE, MV or NMV. Pregnancy and recurrence rates were based on the literature, while costs were obtained from institutional and government supplied data. Univariate and probabilistic sensitivity-analyses were performed to determine the effects of the various parameters on model outcomes.Primary treatment with MV was the most cost-effective strategy at $5402 CAD (Canadian)/pregnancy. Primary treatment with NMV was the least costly approach, but it also yielded the fewest pregnancies. Primary treatment with PE was the least cost-effective strategy costing about $7300 CAD/pregnancy. Probabilistic sensitivity analysis reinforced MV as the most cost-effective strategy at a willingness-to-pay threshold of >$4100 CAD/pregnancy.MV yielded the most pregnancies at acceptable levels of incremental costs. As such, it is the preferred primary treatment strategy for varicocele-associated infertility. Treatment with PE was the least cost-effective approach and, as such, is best used only in cases of surgical failure.
- Time-domain analysis of scrotal thermoregulatory impairment in varicocele. [Journal Article]
- Front Physiol 2014.:342.
Varicocele is a common male disease defined as the pathological dilatation of the pampiniform plexus and scrotal veins with venous blood reflux. Varicocele usually impairs the scrotal thermoregulation via a hemodynamic alteration, thus inducing an increase in cutaneous temperature. The investigation of altered scrotal thermoregulation by means of thermal infrared imaging has been proved to be useful in the study of the functional thermal impairment. In this study, we use the Control System Theory to analyze the time-domain dynamics of the scrotal thermoregulation in response to a mild cold challenge. Four standard time-domain dynamic parameters of a prototype second order control system (Delay Time, Rise Time, closed poles locations, steady state error) and the static basal temperatures were directly estimated from thermal recovery curves. Thermal infrared imaging data from 31 healthy controls (HCS) and 95 varicocele patients were processed. True-positive predictions, by comparison with standard echo color Doppler findings, higher than 87% were achieved into the proper classification of the disease stage. The proposed approach could help to understand at which specific level the presence of the disease impacts the scrotal thermoregulation, which is also involved into normal spermatogenesis process.
- Inguinal and subinguinal micro-varicocelectomy, the optimal surgical management of varicocele: a meta-analysis. [JOURNAL ARTICLE]
- Asian J Androl 2014 Sep 9.
Conventional meta-analyses have shown inconsistent results for the efficacy of various treatments of varicoceles. Therefore, we performed a multiple-treatment meta-analysis to assess the effectiveness and safety of 10 methods of varicocelectomy and embolization/sclerotherapy. We systematically reviewed 35 randomized controlled trials and observational studies, from 1966 to August 5, 2013, which compared any of the following treatments for varococeles: laparoscopic, retroperitoneal, open inguinal and subinguinal varicocelectomy, microsurgical subinguinal and inguinal varicocelectomy, percutaneous venous embolization, Tauber antegrade sclerotherapy, retrograde sclerotherapy and expectant therapy (no treatment). Inguinal and subinguinal microsurgery, open inguinal, laparoscopic varicocelectomy showed a signiﬁcant advantage over expectant therapy in terms of pregnancy rates (odds ratio (OR): 3.48, 2.68, 2.92 and 2.90, respectively). Compared with retroperitoneal open surgery, inguinal microsurgery showed an improvement of sperm density (mean difference (MD): 10.60, 95% confidence interval (CI): 1.92-19.60) and sperm motility (MD: 9.09, 95% CI: 4.88-13.30). Subinguinal and inguinal microsurgery outperformed retroperitoneal open surgery in terms of recurrence (OR: 0.05, 0.06 respectively). Tauber antegrade sclerotherapy and subinguinal microsurgery were associated with the lowest risk of hydrocele formation. The odds of overall complication, compared with retroperitoneal open varicocelectomy, were lowest for inguinal microsurgery (OR = 0.07, 95% CI: 0.02-0.19), followed by subinguinal microsurgery (OR = 0.09, 95% CI: 0.02-0.19). Inguinal and subinguinal micro-varicocelectomy had the highest pregnancy rates, signiﬁcant increases in sperm parameters, with low odds of complication. These results warrant additional properly conducted randomized controlled clinical studies with larger sample sizes.
- Magnification-assisted subinguinal varicocelectomy with testicular delivery in children: a preliminary report. [Journal Article]
- World J Mens Health 2014 Aug; 32(2):93-8.
To evaluate the effectiveness of magnification-assisted subinguinal varicocelectomy (MASV) with testicular delivery in children with severe varicocele.We retrospectively analyzed the clinical data of 23 children 15 years or younger (mean age, 12.3±1.8 years) who underwent MASV with testicular delivery and ligation of all collateral veins except arteries and deferential veins between January 2010 and January 2014. All patients had grade 3 varicocele on the left side. Varicocelectomy was decided upon due to scrotal hypotrophy (n=14, 60.9%), the existence of mass (n=6, 26.1%, including 1 recurrent case), and discomfort (n=3, 13.0%). The preservation of internal spermatic artery (ISA) was successful in 8 patients (34.8%). The mean follow-up time was 10.8±6.6 months.The surgical success rate of varicocelectomy was 100%. The overall symptom resolution rate was 91.3%. The scrotal mass and discomfort disappeared, but testicular catch-up growth did not occur in 2 among 14 patients with scrotal hypotrophy. The left testis volume increased from 6.5±4.3 mL to 10.6±7.5 mL (p=0.003). There were no significant inter-group differences in terms of the surgical success rate, symptom resolution, and catch-up growth between the ISA preservation group and the ligation group. None of the subjects demonstrated testicular atrophy or hydrocele after surgery.MASV with testicular delivery is an effective and safe method for children with severe varicocele.
- Effect of varicocelectomy on sperm functional characteristics and DNA methylation. [JOURNAL ARTICLE]
- Andrologia 2014 Sep 19.
In individuals with varicocele, DNA is damaged due to high level of oxidative stress, and varicocelectomy can overcome this effect. Damaged DNA is less liable to DNA methylation, and antioxidant therapy appears to have the potential to reduce sperm oxidative stress and DNA damage and thereby maintain DNA methylation, while effect of varicocelectomy on DNA methylation patterns has remained unclear. In the light of these considerations, we aimed to examine the effect of varicocelectomy on sperm DNA methylation and functional characteristics. Fifty-two men with left-sided varicocele (grade II &III) were included. Sperm parameters, DNA fragmentation, protamine deficiency, oxidative stress and global DNA methylation were evaluated before and 3 months after surgery. Our data show that sperm concentration, percentages of spermatozoon with abnormal morphology, DNA fragmentation, protamine deficiency and oxidative stress significantly improved after surgery. Percentage of sperm motility, global DNA methylation and intensity of DNA methylation also improved after surgery, although the differences were not significant when compared with before surgery. Categorisation of individuals to subgroups revealed that improvement of DNA methylation appears to take place in oligozoospermic individuals, which are more severely affected by state of varicocele. However, this is a preliminary study, and further studies are required to solidify this conclusion.
- The role of the antisperm antibodies in male infertility assessment after microsurgical varicocelectomy. [JOURNAL ARTICLE]
- Andrology 2014 Sep 15.
Antisperm antibodies (ASA) are a cause of male infertility. ASA are often found in varicocele patients. The study objective was to assess the ASA role in fertility recovery after varicocelectomy. The longitudinal study involved 99 patients with varicocele. Patients were examined according to the WHO recommendations; ASA level was measured using the direct method of Sperm MAR test: 66 patients were ASA-negative, 33 had MAR-IgG ≥ 10%. All patients underwent microsurgical varicocelectomy. Student's t-test, Wilcoxon test, Chi-squared test and signed rank test were used for data analysis. The retrospective analysis of all operated patients data showed that the patients without spermiogram improvement after varicocelectomy had higher ASA levels. 3 months after the surgery, the initially ASA-negative varicocele patients demonstrated 2.5 times increase in number of progressive motile spermatozoa in the ejaculate (p < 0.001), accompanied by 6% decrease in abnormal sperm count (p < 0.05); the spermiogram parameters improved in 77% of cases (p < 0.01). After the surgery, ASA developed in 16% of cases (Max - MAR-IgG = 12%). The patients who were initially ASA-positive demonstrated ASA decrease only in half of the cases (16 of 33; p > 0.05). The main outcome in this group was a favourable response to the surgery (ASA level decrease) vs. no reduction in autoimmune process. The improvement in the ASA-positive group was demonstrated in the patients with higher varicocele grade (median - 2 vs. 1; p < 0.05) and lower ASA level (MAR-IgG = 48% vs. 92%; p < 0.01). The pregnancy rate within a year after surgery was 2.8 times more frequent in couples with ASA-negative men: 39% (25 of 65) in the ASA-negative group compared to 14% (4 of 28) in the ASA-positive group (p < 0.05). Thus, antisperm immune response decreases the varicocelectomy efficacy for reproductive function recovery: the higher percentage of ASA and lower grade of varicocele are associated with an unfavourable prognosis.
- A simple sperm nuclear vacuole assay with propidium iodide. [JOURNAL ARTICLE]
- Andrologia 2014 Sep 13.
Our aim was to develop a new simple sperm nuclear vacuole assay (SNVA) with propidium iodide (PI) to determine the status of nuclear vacuole (NV) of individual spermatozoa. After PI staining, sperm nuclei were classified into the 14 categories according to both nuclear morphology and the status of NV. The incidence was 57.8% (range 28-84%) in fertile controls (n = 40), and 85.1% (range 67-99%) in men with varicocele (n = 40). In the fertile group, normal nuclear-shaped spermatozoa without NV or with one small NV located in the ante-nuclear region were significantly more in comparison with the varicocele group. In the varicocele group, abnormal nuclear-shaped spermatozoa with one large NV and with multiple NVs located in the ante-nuclear region were most frequent findings. Besides, spermatozoa with NVs in both ante- and post-nuclear regions in the varicocele group were significantly more than those in the fertile group. In both fertile and varicocele groups, normal or abnormal nuclear-shaped spermatozoa with one or more vacuoles only located in the post-nuclear region occurred sparingly. The SNVA provides a useful additional approach to identify the status of NV in human spermatozoa for diagnostic purposes. A good sperm sample would have more spermatozoa without NV or with one small NV located in the ante-nuclear region.
- Surgical and endovascular interventions for nutcracker syndrome. [REVIEW]
- Semin Vasc Surg 2013 Dec; 26(4):170-177.
Nutcracker syndrome is a rare condition of left renal vein entrapment manifesting with hematuria, flank pain, and, occasionally, pelvic congestion in females or varicocele in males. Diagnosis requires a high index of suspicion upon careful history delineation. The gold standard for definite confirmation remains venography with renocaval pressure gradient. Treatment is mainly guided by the severity of symptoms. For the majority of centers, it appears that surgery remains the first-line therapy, however, endovascular alternatives are rapidly evolving into the field with favorable outcomes. This article reviews current concepts on nutcracker syndrome with particular focus on contemporary surgical and endovascular techniques and their outcomes.
- [Surgery of male infertility: an update.] [JOURNAL ARTICLE]
- Urologia 2014 Sep 12; 0(0):0.
Surgery for male infertility includes three main areas: varicocele surgery, recanalization of seminal tract, sperm retrieval.Varicocele treatment in infertily is still controversial. Recent scientific evidence appears to demonstrate that in selected cases varicocele treatment is beneficial in improving semen parameters and pregnancy rate. The key for the success of treatment seems to be a correct indication. It is our opinion that varicocele should be treated in presence of abnormal semen parameters, when clinically significant, and in adolescents with atrophy of the affected testis. So far, no specific technique, either surgical, microsurgical or sclerotherapic, can be considered the gold standard. Good results in our hands have been obtained with the microsurgical lymphatic sparing high ligation of internal spermatic vein.Innovations in surgery for seminal tract obstructions include the new tubular invagination techniques for epididimovasostomy, which showed excellent results with a simplified and time-saving microsurgical approach. In distal obstructions, a new transperineal ultrasound-guided approach has been proposed for the diagnostic work-up and treatment. Advantages of this technique and of the TURED must be balanced with those of immediate sperm retrieval for ART.In sperm retrieval, microTESE represents the most important surgical evolution in non-obstructive azoospermia. We have recently proposed a new stepwise approach starting with a minimal equatorial incision for conventional testicular biopsy which is extended to perform microTESE only when no sperm is retrieved. In this way microTESE is offered only to patients who really need it. Another field of innovation is sperm retrieval for ICSI in patients with Klinefelter Syndrome.
- [The varicocele: the proper therapy for the proper patient.] [JOURNAL ARTICLE]
- Urologia 2014 Sep 9; 81(3):165-168.
Varicocele is present in 15% to 20% of the general population, but in approximately 35% to 40% of males presenting for an evaluation of their infertility. Indeed it is well known that varicocele can cause testicular damage and infertility. No evidence indicates a varicocele treatment in infertile men who have normal semen analysis or in men with subclinical varicocele. In this situation, varicocelectomy cannot be recommended. Varicocele repair may be effective in men with subnormal semen analysis, a clinical varicocele and otherwise unexplained infertility, but we need further randomized studies to confirm that this subgroup of infertile couples will benefit from treatment. There is no doubt about the standard indications of varicocelectomy, but recent literature seems to go towards new indications of varicocele repair. The aim of this review is to give a look at the literature to analyze the proper indications to varicocelectomy for the proper patient.