500 penile prostheses implanted by a surgeon in Italy in the last 30 years

OBJECTIVES: The aim of our study was to report our experience with patients affected by Erectile Dysfunction (ED) and undergoing penile prosthetic implantation (PPI) in a single center by a single surgeon. MATERIAL AND METHODS: We retrospectively evaluated the clinical outcome of 500 patients (mean age: 51.5 years, range: 20-86 years) affected by ED and referred to our private andrological center from January 1984 to December 2013 who underwent penile prosthesis implantation, including the reported level of patient satisfaction. RESULTS: 182 silicone, 180 malleable, 18 monocomponent hydraulic and 120 multicomponents hydraulic prostheses were implanted by the same experienced surgeon. All patients were hospitalized for the procedure. All patients were evaluated immediately, 1 month (496 patients) and, for the great majority, every year after implantation. One hundred twenty five patients were lost to follow-up. Twenty two patients underwent revision surgery for complications in the postoperative period. The most serious postoperative complications were mechanical problems (45 patients, 9.0%) and infection (15 patients, 3%). Forty two (8.4%) prostheses were explanted. Overall, 80% (400/500) of patients were able to have sexual intercourse and were fully satisfied with the results. CONCLUSIONS: In our experience prosthetic surgery should be considered a good solution for men affected by ED and not responsive to other therapeutic solutions. Prosthetic surgery can be performed not only in large public hospitals but also in smaller private facilities

The woman and the penile prosthetic implant. Primary or secondary role? Personal experiences on 355 implanted patients.

In a group of 355 pts submitted to Penile Prosthesis Implant (PPI) we recorded data on their relationships with the woman (wife, partner, girlfriend, lover); the aspects of their sexual life; if they were married, divorced or widowed; if they had a lover; if they frequented brothels; if they were satisfied of their actual couple's life; after operation we recorded data concerning if they had some difficulties utilizing the PPI and their level of satisfaction. After operation most pts (93%) confirmed their satisfaction. Relational aspects: Unmarried pts: 6 pts (21-30 years old) who weren't able to penetrate their girlfriends managed to have regular sex with PPI and could marry. 42/46 unmarried pts after PPI decided to marry. In the group of married pts 3 pts weren't able to penetrate their wives; after PPI they managed to have regular intercourses and pregnancies. 15 widowers and 23 divorced pts decided to have a PPI for possible sexual encounters or stable relationships. 96/271 (28,2%) married pts declared a stable extramarital relation that could represent the main reason for having a PPI. The results of PPI are commonly accepted. Until now PPI may re-establish penile rigidity and maintenance. In our opinion the simple act of penetrate and ejaculate in vagina, without considering the importance of personal, relational, emotional factors often well linked to the specific woman, cannot be considered the ideal target of PPI

Smoke, alcohol and drug addiction and male fertility

In recent decades, the decline in human fertility has become increasingly more worrying: while therapeutic interventions might help, they are vexing for the couple and often burdened with high failure rates and costs. Prevention is the most successful approach to fertility disorders in males and females alike. We performed a literature review on three of the most common unhealthy habits - tobacco, alcohol and drug addiction - and their reported effects on male fertility. Tobacco smoking is remarkably common in most first-world countries; despite a progressive decline in the US, recent reports suggest a prevalence of more than 30% in subjects of reproductive age - a disturbing perspective, given the well-known ill-effects on reproductive and sexual function as well as general health. Alcohol consumption is often considered socially acceptable, but its negative effects on gonadal function have been consistently reported in the last 30 years. Several studies have reported a variety of negative effects on male fertility following drug abuse - a worrying phenomenon, as illicit drug consumption is on the rise, most notably in younger subjects. While evidence in these regards is still far from solid, mostly as a result of several confounding factors, it is safe to assume that cessation of tobacco smoking, alcohol consumption and recreational drug addiction might represent the best course of action for any couple trying to achieve pregnancy

A prospective study on contrast-enhanced magnetic resonance imaging of testicular lesions: distinctive features of Leydig cell tumours

OBJECTIVES: Up to 20 % of incidentally found testicular lesions are benign Leydig cell tumours (LCTs). This study evaluates the role of contrast-enhanced magnetic resonance imaging (MRI) in the identification of LCTs in a large prospective cohort study. MATERIALS AND METHODS: We enrolled 44 consecutive patients with at least one solid non-palpable testicular lesion who underwent scrotal MRI. Margins of the lesions, signal intensity and pattern of wash-in and wash-out were analysed by two radiologists. The frequency distribution of malignant and benign MRI features in the different groups was compared by using the chi-squared or Fisher's exact test. Sensitivity, specificity, positive and negative predictive value, and diagnostic accuracy were calculated. RESULTS: The sensitivity of scrotal MRI to diagnose LCTs was 89.47 % with 95.65 % specificity; sensitivity for malignant lesions was 95.65 % with 80.95 % specificity. A markedly hypointense signal on T2-WI, rapid and marked wash-in followed by a prolonged washout were distinctive features significantly associated with LCTs. Malignant lesions were significantly associated with blurred margins, weak hypointense signal on T2-WI ,and weak and progressive wash-in. The overall diagnostic accuracy was 93 %. CONCLUSIONS: LCTs have distinctive contrast-enhanced MRI features that allow the differential diagnosis of incidental testicular lesions. KEY POINTS: • MRI is able to characterize testicular lesions suggesting a specific diagnosis. • Rapid and marked wash-in is a common feature of Leydig cell tumours. • Markedly hypointense T2-WI signal is significantly correlated with benign lesions. • Blurred margins and weak hypointense T2-WI signal are correlated with malignant tumours. • Weak and progressive wash-in features are present in 85 % of seminomatous lesions

Clinical presentation, management and follow-up of 83 patients with Leydig cell tumors of the testis: a prospective case-cohort study

LCTs are more frequent than generally believed, are associated with male infertility, cryptorchidism and gynecomastia, and should be treated conservatively (in compliant patients) with active surveillance, which appears to be a safe alternative to surgical enucleation. WHAT IS KNOWN ALREADY Increasing referrals for testicular imaging have led to an increase in findings of LCTs. The features and natural history of these tumors remain largely unknown, as the available studies are small and heterogeneous. LCTs were previously treated aggressively and follow-up data are lacking. STUDY DESIGN, SIZE, DURATION A case-cohort study of consecutive patients diagnosed with LCTs over a 10-year period was prospectively enrolled from 2009 to 2018 and compared to matched cohorts of patients with seminomas or no testicular lesions screened in the same timeframe. PARTICIPANTS/MATERIALS, SETTING, METHODS Of the 9949 inpatients and outpatients referred for scrotal ultrasound, a total of 83 men with LCTs were included. Enrolled subjects underwent medical history and clinical examination and were asked to undergo routine blood tests, hormone investigations (FSH, LH, total testosterone, estradiol, inhibin B, sex hormone-binding globulin (SHBG), prolactin), and semen analysis. Patients who consented also underwent contrast-enhanced ultrasound, elastography, gadolinium-enhanced scrotal magnetic resonance imaging, and hCG stimulation test (5000 IU i.m.) with serum total testosterone and estradiol measured at 0, 24, 48, and 72 hours. MAIN RESULTS AND THE ROLE OF CHANCE In total, 83 patients diagnosed with LCTs were compared against 90 patients diagnosed with seminoma and 2683 patients without testicular lesions (NoL). LCTs were diagnosed by enucleation (48.2%), orchiectomy (13.3%), or clinical surveillance (38.5%). Testicular volume, sperm concentration, and morphology were lower (P = 0.001, P = 0.001, and P < 0.001, respectively) in patients with LCTs than in the NoL group. FSH, LH, and SHBG were higher and the testosterone/LH ratio was lower in LCTs than in the NoL group (P < 0.001). The LCT group showed higher SHBG (P = 0.018), lower sperm concentration (P = 0.029), and lower motility (P = 0.049) than the seminoma group. Risk factors for LCTs were cryptorchidism (χ2 = 28.27, P < 0.001), gynecomastia (χ2 = 54.22, P < 0.001), and low testicular volume (χ2 = 11.13, P = 0.001). Five cases were recurrences or bilateral lesions; none developed metastases during follow-up (median, 66 months). LIMITATIONS, REASONS FOR CAUTION This study has some limitations. First, hCG and second-line diagnostic investigations were not available for all tumor patients. Second, ours is a referral center for infertility, thus a selection bias may have altered the baseline features of the LCT population. However, given that the comparison cohorts were also from the same center and had been managed with a similar protocol, we do not expect a significant effect. WIDER IMPLICATIONS OF THE FINDINGS LCTs are strongly associated with male infertility, cryptorchidism, and gynecomastia, supporting the hypothesis that testicular dysgenesis syndrome plays a role in their development. Patients with LCTs are at a greater risk of endocrine and spermatogenesis abnormalities even when the tumor is resected, and thus require long-term follow-up and prompt efforts to preserve fertility after diagnosis. LCTs have a good oncological prognosis when recognized early, as tissue-sparing enucleation is curative and should replace orchiectomy. Conservative surgery and, in compliant patients, active surveillance through clinical and radiological follow-up are safe options, but require monitoring of testicular failure and recurrence

Diagnostic value of qualitative and strain ratio elastography in the differential diagnosis of non-palpable testicular lesions

The purpose of this study was to evaluate prospectively the accuracy of qualitative and strain ratio elastography (SE) in the differential diagnosis of non-palpable testicular lesions. The local review board approved the protocol and all patients gave their consent. One hundred and six patients with non-palpable testicular lesions were consecutively enrolled. Baseline ultrasonography (US) and SE were correlated with clinical and histological features and ROC curves developed for diagnostic accuracy. The non-palpable lesions were all ≤1.5 cm; 37/106 (34.9%) were malignant, 38 (35.9%) were benign, and 31 (29.2%) were non-neoplastic. Independent risk factors for malignancy were as follows: size (OR 17.788; p = 0.002), microlithiasis (OR 17.673, p < 0.001), intralesional vascularization (OR 9.207, p = 0.006), and hypoechogenicity (OR, 11.509, p = 0.036). Baseline US had 89.2% sensitivity (95% CI 74.6-97.0) and 85.5% specificity (95% CI 75.0-92.8) in identifying malignancies, and 94.6% sensitivity (95% CI 86.9-98.5) and 87.1% specificity (95% CI 70.2-96.4) in discriminating neoplasms from non-neoplastic lesions. An elasticity score (ES) of 3 out of 3 (ES3, maximum hardness) was recorded in 30/37 (81.1%) malignant lesions (p < 0.001). An intermediate score of 2 (ES2) was recorded in 19/38 (36.8%) benign neoplastic lesions and in 22/31 (71%) non-neoplastic lesions (p = 0.005 and p = 0.001 vs. malignancies). None of the non-neoplastic lesions scored ES3. Logistic regression analysis revealed a significant association between ES3 and malignancy (χ2 = 42.212, p < 0.001). ES1 and ES2 were predictors of benignity (p < 0.01). Overall, SE was 81.8% sensitive (95% CI 64.8-92.0) and 79.1% specific (95% CI 68.3-88.4) in identifying malignancies, and 58.6% sensitive (95% CI 46.7-69.9) and 100% specific (95% CI 88.8-100) in discriminating non-neoplastic lesions. Strain ratio measurement did not improve the accuracy of qualitative elastography. Strain ratio measurement offers no improvement over elastographic qualitative assessment of testicular lesions; testicular SE may support conventional US in identifying non-neoplastic lesions when findings are controversial, but its added value in clinical practice remains to be proven

Testicular dysfunction in 47, XXY boys: when it all begins. A semi-longitudinal study

Objective: Klinefelter syndrome is the most common chromosomal disorder in males, and the most common cause of hypergonadotropic hypogonadism. We describe the natural history of testicular dysfunction in patients with Klinefelter syndrome through the integration of clinical, hormonal and quantitative ultrasound data in a life-course perspective. Design: Prospective semi-longitudinal study. Methods: We included 155 subjects with 47, XXY karyotype (age range: 7 months - 55 years) naïve to testosterone replacement therapy. Subjects were divided according to pubertal stage and age group (transition age and adults). Serial clinical, hormonal and testicular ultrasound assessments were performed. Results: Testicular development progresses until Tanner stage 4, with subsequent regression, whereas Sertoli and germ cell impairment is not hormonally detected before Tanner stages 3-4, as reflected by normal inhibin B values until stage 4 and the fall in the inhibin B/FSH ratio thereafter. The Testosterone/LH ratio peaks during Tanner stages 2-3 and declines from Tanner stage 4 onward, preceding the development of overt hypogonadism. US echotexture progressively worsens until transition age, reflecting ongoing gonadal compromise, whereas quantitative US echotexture measures and the presence of both hypoechoic lesions and microlithiasis independently and significantly predict a lower circulating testosterone level. Conclusions: The findings from this large prospective study contribute to our understanding of the natural history of testicular dysfunction in Klinefelter syndrome, underlining the importance of quantitative testicular US in infancy and childhood, as well as during pubertal development and transition age, for the optimal care of Klinefelter syndrome patients

Testicular adrenal rest tumours: fisiopatologia, diagnosi e trattamento

I testicular adrenal rest tumors (TARTs) costituiscono una causa comune di disfunzione gonadica e infertilità in pazienti affetti da iperplasia surrenalica congenita (Congenital Adrenal Hyperplasia, CAH), con una prevalenza che varia dal 14 all’86%. Dal punto di vista biochimico, istologico e molecolare, i TARTs mostrano caratteristiche tipiche delle cellule surrenaliche e per questo si è ipotizzato che derivino da una proliferazione di cellule della corteccia surrenalica in sede testicolare. Studi recenti riconducono però l’origine dei TARTs a una popolazione di cellule staminali pluripotenti adrenal-like, derivanti dalla cresta urogenitale, già presenti in sede gonadica durante l’embriogenesi, che vanno incontro a differenziazione surrenalica e ad aumentata proliferazione se sottoposti a elevati livelli di ormone adrenocorticotropo (ACTH). La loro crescita può determinare un’alterazione della funzione gonadica per compressione diretta sui tubuli seminiferi e per l’influenza sull’ambiente ormonale intratesticolare per via paracrina, risultando spesso in un quadro di azoospermia di tipo ostruttivo. La diagnosi di TARTs si avvale principalmente dell’eco Color-Doppler testicolare, ma richiede una puntuale diagnosi differenziale con lesioni morfologicamente simili, quali i tumori germinali e i tumori a cellule del Leydig, in quanto la gestione terapeutica è differente. La terapia classica si basa sull’impiego di glucocorticoidi ad alte dosi, che in alcuni casi possono condurre a una regressione delle dimensioni della massa. La gestione della CAH nei soggetti che presentano TARTs richiede un approccio personalizzato con screening ecografico da adottare già a partire dall’infanzia e si avvale altresì di counseling andrologico in merito alla possibilità di preservare la fertilità tramite crioconservazione

Medical treatment to improve sperm quality

Approximately 30% of cases of couple infertility are due to a malefactor. Several conditions can interfere with spermatogenesis and reduce sperm quality and production. Treatable conditions, such as hypogonadism, varicocele, infections and obstructions, should be diagnosed and corrected, but many aspects of male factor infertility remain unclear. Various agents have been used in the attempt to increase the fertility potential of subjects with idiopathic oligoteratoasthenozoospermia. The rationale of medical treatment to improve sperm quality in these subjects has been questioned by the introduction of assisted reproductive technologies. However, there is now growing awareness of the importance of good quality spermatozoa for embryonic development and higher birth rates. Confounding factors in assessing the efficacy of male infertility treatments have erroneously inflated the superiority of assisted reproductive technologies over conventional approaches. A systematic review is given of relevant randomized controlled trials and effects on semen parameters. The analysis reveals that although results are heterogeneous, gonadotrophins, anti-oestrogens, carnitine and trace elements may be beneficial in improving sperm quality, although their effect on pregnancy rate remains controversial. The most common drug regimens are compared and an estimate of the results expected from these treatments provided