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Objective: To compare racial differences in male fertility history and treatment., Design: Retrospective review of prospectively collected data., Setting: North American reproductive urology centers., Patient(s): Males undergoing urologist fertility evaluation., Intervention(s): None., Main Outcome Measure(s): Demographic and reproductive Andrology Research Consortium data., Result(s): The racial breakdown of 6,462 men was: 51% White, 20% Asian/Indo-Canadian/Indo-American, 6% Black, 1% Indian/Native, <1% Native Hawaiian/Other Pacific Islander, and 21% "Other". White males sought evaluation sooner (3.5 ± 4.7 vs. 3.8 ± 4.2 years), had older partners (33.3 ± 4.9 vs. 32.9 ± 5.2 years), and more had undergone vasectomy (8.4% vs. 2.9%) vs. all other races. Black males were older (38.0 ± 8.1 vs. 36.5 ± 7.4 years), sought fertility evaluation later (4.8 ± 5.1 vs. 3.6 ± 4.4 years), fewer had undergone vasectomy (3.3% vs. 5.9%), and fewer had partners who underwent intrauterine insemination (8.2% vs. 12.6%) compared with all other races. Asian/Indo-Canadian/Indo-American patients were younger (36.1 ± 7.2 vs. 36.7 ± 7.6 years), fewer had undergone vasectomy (1.2% vs. 6.9%), and more had partners who underwent intrauterine insemination (14.2% vs. 11.9%). Indian/Native males sought evaluation later (5.1 ± 6.8 vs. 3.6 ± 4.4 years) and more had undergone vasectomy (13.4% vs. 5.7%)., Conclusion(s): Racial differences exist for males undergoing fertility evaluation by a reproductive urologist. Better understanding of these differences in history in conjunction with societal and biologic factors can guide personalized care, as well as help to better understand and address disparities in access to fertility evaluation and treatment., (Copyright © 2021 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The microscopic characteristics of vasal fluid at time of vasectomy reversal (VR) guide operative decision making and predict fertility outcomes. The proteomic profile of this vasal fluid has not been described or correlated with the microscopic fluid appearance. To characterize the vasal fluid proteome at time of VR and evaluate the variation of the vasal fluid proteome with respect to microscopic presence of sperm., Methods: A prospective cohort study was conducted enrolling twenty-five men undergoing VR for infertility and/or pain at a University-affiliated hospital. Vasal fluid samples obtained at time of VR were grouped based on presence of sperm on light microscopy at time of VR. Proteomic profiles were generated using liquid chromatography/ tandem mass spectrometry, and MS/MS protein spectral counts compared between individuals and treatment groups, controlling for less than 5% protein false discovery rate (FDR). Proteins were matched with the human swissprot database using the Comet search engine, and categorized by Gene Ontology (GO) terms., Results: There was large variability between the 46 vasal fluid samples collected, with 1,692 unique proteins detected. The three most abundant proteins were Lactotransferrin, Cysteine-rich secretory protein 1, A-kinase anchor protein 4. There was no correlation between the proteome and microscopic sperm presence. Prevalent GO terms included viral process, signal transduction, innate immune response, protein folding and spermatogenesis., Conclusions: We describe the proteome and the most common proteins in vasal fluid at time of VR. Numerable sperm, testis and epididymis specific proteins were present even in the absence of sperm on microscopy. Further evaluation is needed to determine if a protein biomarker may better guide operative decision making and predict VR fertility outcomes., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/tau-20-703). The authors have no conflicts of interest to declare., (2020 Translational Andrology and Urology. All rights reserved.)

Objective: To characterize the referral patterns and characteristics of men presenting for infertility evaluation using data obtained from the Andrology Research Consortium., Design: Standardized male infertility questionnaire., Setting: Male infertility centers., Patient(s): Men presenting for fertility evaluation., Intervention(s): Not applicable., Main Outcome Measure(s): Demographic, infertility history, and referral data., Result(s): The questionnaires were completed by 4,287 men, with a mean male age of 40 years ± 7.4 years and female partners age of 37 years ± 4.9 years. Most were Caucasian (54%) with other races being less commonly represented (Asian 18.6%, and African American 5.5%). The majority (59.7%) were referred by a reproductive gynecologist, 19.4% were referred by their primary care physician, 4.2% were self-referred, and 621 (14.5%) were referred by "other." Before the male infertility investigation, 12.1% of couples had undergone intrauterine insemination, and 4.9% of couples had undergone in vitro fertilization (up to six cycles). Among the male participants, 0.9% reported using finasteride (5α-reductase inhibitor) at a dose used for androgenic alopecia, and 1.6% reported exogenous testosterone use., Conclusion(s): This broad North American patient survey shows that reproductive gynecologists are the de facto gateway for most male infertility referrals, with most men being assessed in the male infertility service being referred by reproductive endocrinologists. Some of the couples with apparent male factor infertility are treated with assisted reproductive technologies before a male factor investigation. The survey also identified potentially reversible causes for the male infertility including lifestyle factors such as testosterone and 5α-reductase inhibitor use., (Copyright © 2019 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To use the Truven Health MarketScan database to better approximate the annual rate of vasectomies performed in the US population, to determine changes over time, regional differences, providers performing this, and to know if there is any monthly variation in vasectomy rates., Materials and Methods: Claims data were evaluated from 2007 to 2015 to determine the annual prevalence of vasectomy by patient age and region in the United States. The cohort included men aged 18-64 years with at least 1 claim in any given year in Truven Health MarketScan. Provider type and place of service were evaluated in 2014 and 2015. Monthly evaluation of vasectomy prevalence compared with total claims was performed., Results: The prevalence of vasectomies decreased from 2007 to 2015, across all age groups and in all locations of the country (P <.001). Using these data and the most recent US census data, an estimated 527,476 vasectomies were performed in the United States in 2015. The North Central and West regions (0.64% and 0.60%, respectively) had the highest annual prevalence of vasectomies. The month of March and the end of the year had the highest proportion of vasectomies performed. In both 2014 and 2015, a urologist in the office setting performed 82% of vasectomies., Conclusion: An estimated 527,476 vasectomies were performed in the United States in 2015. From 2007 to 2015 there was a decrease in the proportion of vasectomies performed in all age groups and in all locations of the country. The end of the year and the month of March are when the most vasectomies are performed., (Published by Elsevier Inc.)

Objective: To provide pregnancy and live birth rates from a contemporary series of vasectomy reversals in men with female partners aged ≥35 years and to correlate the results with IVF., Setting: Tertiary academic referral center., Design: Retrospective comparative study of prospectively collected database., Patient(s): Two hundred forty-six men who underwent vasectomy reversal for fertility with female partner aged ≥35 years., Intervention(s): Vasovasostomy or vasoepididymostomy., Main Outcome Measure(s): Correlation of pregnancy and live birth rate of this cohort by age groups with most recently published pregnancy and live birth rate per IVF cycle., Result(s): One hundred thirty-six men who underwent vasectomy reversal between 2006 and 2014 met our inclusion criteria. Overall pregnancy and live birth rates were 35% and 30%, respectively. Subgroup analysis by female age groups (35-37, 38-40, >40 years) demonstrated pregnancy and live birth rates comparable to those per IVF cycle by age groups according to a recently published (2015) national report., Conclusion(s): Vasectomy reversal should be strongly considered in men with a partner aged ≤40 years. Additionally, vasectomy reversal can be considered in carefully selected patients even with a partner aged >40 years., (Copyright © 2018 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: To determine the factors used to make the decision between vasovasostomy (VV) and vasoepididymostomy (VE) by leaders performing microsurgical vasectomy reversal using a questionnaire., Materials and Methods: An online questionnaire was sent to all members of the Society for the Study of Male Reproduction (SSMR), a male reproduction subspecialty society of the AUA, using the SurveyMonkey platform., Results: Sixty-seven surgeons responded to the questionnaire (27% of SSMR members). Of which 72% of members performed less than 50 vasectomy reversals per year. Also, 71% of members stated that less than 20% of their vasectomy reversals are vasoepididymostomies. When evaluating epididymal fluid at the time of reversal, 87% would perform a VE for pasty fluid, 66% with creamy fluid without sperm heads and 55% with no or scant fluid. With respect to banking sperm, 36% take sperm or testicular tissue at the time of VE while 37% sometimes take sperm mostly depending on the couple's preference. The Berger end-to-side with intussusception VE technique is used by the majority of members (78%). The presence of intact sperm or sperm parts determined the location in the epididymis for anastomosis for 55% and 19% of members respectively. Postoperative semen testing after a VE is evaluated first between 6 weeks to 3 months for 64%. The procedure is considered a failure between 6 to 12 months for 34% and 12 to 18 months for another 48% if no sperm is seen on semen analysis., Conclusions: Most members perform a VE with pasty fluid or creamy fluid without sperm heads. Three out of four members are using the Berger end-to-side intussusception technique to perform their VE. More studies are needed to determine the optimal circumstances to perform a VE as there is significant variation in responses even among members of the SSMR.

The absence of sperm in the ejaculate after vasectomy reversal is commonly caused by failure to recognize and subsequently bypass epididymal or proximal vasal obstruction at the time of vasectomy reversal. If intra-operative proximal obstruction is suspected, vasoepididymostomy (VE) is recommended rather than vasovasostomy (VV). We sought to calculate the associated risk of needing VE, rather than VV with time from original vasectomy (obstructive interval) using a large cohort of vasectomy reversal patients. We reviewed the electronic and paper vasectomy reversal database by a single surgeon from 1978 through 2012. We performed univariate analysis to identify variables that predicted the need for VE rather than VV, and then combined only significant univariates into our multi-variable analysis. 2697 total men underwent vasectomy reversal, and 239 were repeat procedures. Of the 5296 individual testes operated on, 1029 were VE. Significant variables that predicted the need for VE on univariate analysis included: age, obstructive time interval, vasectomy reversal after previous VV (repeat vasectomy reversal), and year the procedure was performed. On multi-variable analysis significant risk factors for VE were age above 50 (OR 1.36), repeat vasectomy reversal (OR 5.78), and greater obstructive time interval (OR 1.56). For every 3 years since original vasectomy, the risk of needing VE increases by 56%. There is a linear relationship between obstructive interval and need for VE. Men undergoing repeat vasectomy reversal have five times greater risk of requiring VE and men greater than 50 years of age are also at higher risk. Using these pre-operative predictors is helpful in identifying patients who will benefit from referral to an experienced surgeon who can perform VE., (© 2015 American Society of Andrology and European Academy of Andrology.)

Objective: To review our institution's experience and success with vasectomy reversal to treat postvasectomy pain syndrome (PVPS) over the last 20 years., Materials and Methods: A single surgeon (E.F.F.) performed all the vasectomy reversals. We identified 123 procedures done for PVPS treatment and were able to contact 76 patients. We sent surveys or conducted phone interviews inquiring about satisfaction, levels of pain preoperatively and postoperatively, and the need for additional procedures for pain. Thirty-one patients completed phone or written surveys. In addition, we compared the location of vasectomy among patients presenting for pain to that of fertile patients., Results: Thirty-one men had vasectomy reversal for postvasectomy pain, with median age of 38 years (range, 31-55 years), of which 26 underwent vasovasostomy (VV). Seven patients required epididymovasostomy (EV) on at least 1 side based on intraoperative findings. Eighty-two percent of patients reported improvement in their pain at 3.2 months (±3.4 months) after vasectomy reversal. Thirty-four percent patients had complete resolution of all pain. Mean pain score before procedure was 6.4 (±2.4), decreasing to a median of 2.7 (±2.7) afterward. There was a 59% improvement in pain scores (P <.001). Two patients required additional procedures for continued pain, one orchiectomy and one epididymectomy. Four patients required an additional reversal procedure, one a repeat VV at 1 year and 3 an EV at 1, 5, and 9 years, respectively. Follow-up ranged from 1 to 19 years, with a mean follow-up of 8.4 years. We found no relationship between vasectomy location and pain., Conclusion: Vasectomy reversal, through the use of both VV and EV, can provide long-term relief from PVPS., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: We compared fertility outcomes with gross and microscopic fluid findings at vasectomy reversal at a high volume vasectomy reversal center., Materials and Methods: A retrospective study of a prospective database was performed. All vasectomy reversals were performed by a single surgeon (EFF) between 1978 and 2011. The clinical pregnancy rate was self-reported or determined via patient mailers. Patient and operative findings were determined through database review. We classified vasal fluid as opalescent, creamy, pasty or clear. Intraoperative light microscopy was used to determine if sperm or sperm parts were present and if they were motile. Multivariate analysis was performed evaluating patient age, partner age, years after vasectomy, type of surgery, and gross and microscopic fluid analysis., Results: A total of 2,947 microsurgical vasectomy reversals were reviewed after we excluded reversals performed for post-vasectomy pain. We determined the pregnancy status of 902 (31%) cases. On univariate analysis with respect to pregnancy the presence of motile sperm at vasovasostomy neared statistical significance (p=0.075) and there was no difference between bilateral vs unilateral motile sperm. Gross fluid appearance was not statistically significant but we found the order of pregnancy success to be opalescent, creamy, clear then pasty fluid. On multivariate analysis only female partner age and sperm heads only or no sperm seen on light microscopy had statistical significance (p <0.05)., Conclusions: The presence of motile sperm at vasectomy reversal approaches statistical significance on univariate analysis as a factor that affects clinical pregnancy rates. On multivariate analysis female partner age and microscopic findings of sperm heads only or no sperm are inversely related to pregnancy rates. These data will help counsel couples after vasectomy reversal and reinforce the importance of female partner age., (Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We reviewed fertility outcomes of vasectomy reversal at a high surgical volume center in men with the same female partner as before vasectomy., Materials and Methods: We retrospectively studied a prospective database. All vasectomy reversals were performed by a single surgeon (EFF). Patients who underwent microsurgical vasectomy reversal and had the same female partner as before vasectomy were identified from 1978 to 2011. Pregnancy and live birth rates, procedure type (bilateral vasovasostomy, bilateral vasoepididymostomy, unilateral vasovasostomy or unilateral vasoepididymostomy), patency rate, time from reversal and spouse age were evaluated., Results: We reviewed the records of 3,135 consecutive microsurgical vasectomy reversals. Of these patients 524 (17%) who underwent vasectomy reversal had the same female partner as before vasectomy. Complete information was available on 258 patients (49%), who had a 94% vas patency rate. The clinical pregnancy rate was 83% by natural means compared to 60% in our general vasectomy reversal population (p <0.0001). On logistic regression analysis controlling for female partner and patient ages, years from vasectomy and vasectomy reversal with the same female partner the OR was 2 (p <0.007). Average time from vasectomy was 5.7 years. Average patient and female partner age at reversal was 38.9 and 33.2 years, respectively., Conclusions: Outcomes of clinical pregnancy and live birth rates are higher in men who undergo microsurgical vasectomy reversal with the same female partner. These outcomes may be related to a shorter interval from vasectomy, previous fertility and couple motivation., (Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: It was theorized that the use of permanent contraceptive methods may vary with economic conditions. We evaluated the relationship between vasectomy/vasectomy reversal frequencies at several large referral centers and national economic indicators during 2 recessions spanning 2001 to 2011., Materials and Methods: We performed an institutional review board approved, retrospective chart review to identify the number of vasectomies/vasectomy reversals per month at several large referral centers from January 2001 to July 2011. The rates of these procedures were pooled, correlated with national economic data and analyzed in a multivariate linear regression model., Results: A total of 4,599 vasectomies and 1,549 vasectomy reversals were performed at our institutions during the study period. The number of vasectomies per month positively correlated with the unemployment rate (r=0.556, p<0.001) and personal income per capita (r=0.276, p=0.002). The number of reversals per month negatively correlated with the unemployment rate (r=-0.399, p<0.001) and personal income per capita (r=-0.305, p<0.001). Neither vasectomy nor vasectomy reversal frequency significantly correlated with the inflation rate or the S&P 500®. Regression models confirmed that the unemployment rate explained more of the variance in vasectomy/vasectomy reversal frequencies than other indicators., Conclusions: We noted a correlation between the number of vasectomies/vasectomy reversals performed at our institutions and national economic indicators. The strongest association was with the unemployment rate. This points to the importance of financial pressure on family planning decisions., (Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

The evaluation and treatment of hypogonadal men has become an important part of urologic practice. Fatigue, loss of libido, and erectile dysfunction are commonly reported, but nonspecific symptoms and laboratory verification of low testosterone (T) are an important part of evaluation in addition to a detailed history and physical examination. Significant intraindividual fluctuations in serum T levels, biologic variation of T action on end organs, the wide range of T levels in human serum samples, and technical limitations of currently available assays have led to poor reliability of T measurements in the clinical laboratory setting. There is no universally accepted threshold of T concentration that distinguishes eugonadal from hypogonadal men; thus, laboratory results have to be interpreted in the appropriate clinical setting. This review focuses on clinical, biological, and technological challenges that affect serum T measurements to educate clinicians regarding technological advances and limitations of the currently available laboratory methods to diagnose hypogonadism. A collaborative effort led by the American Urological Association between practicing clinicians, patient advocacy groups, government regulatory agencies, industry, and professional societies is underway to provide optimized assay platforms and evidence-based normal assay ranges to guide clinical decision making. Until such standardization is commonplace in clinical laboratories, the decision to treat should be based on the presence of signs and symptoms in addition to serum T measurements. Rigid interpretation of T ranges should not dictate clinical decision making or define coverage of treatment by third party payers., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Introduction. Complications following renal transplantation include ureteral obstruction, urinary leak and fistula, urinary retention, urolithiasis, and vesicoureteral reflux. These complications have traditionally been managed with open surgical correction, but minimally invasive techniques are being utilized frequently. Materials and Methods. A literature review was performed on the use of endourologic techniques for the management of urologic transplant complications. Results. Ureterovesical anastomotic stricture is the most common long-term urologic complication following renal transplantation. Direct vision endoureterotomy is successful in up to 79% of cases. Urinary leak is the most frequent renal transplant complication early in the postoperative period. Up to 62% of patients have been successfully treated with maximal decompression (nephrostomy tube, ureteral stent, and Foley catheter). Excellent outcomes have been reported following transurethral resection of the prostate shortly after transplantation for patients with urinary retention. Vesicoureteral reflux after renal transplant is common. Deflux injection has been shown to resolve reflux in up to 90% of patients with low-grade disease in the absence of high pressure voiding. Donor-gifted and de novo transplant calculi may be managed with shock wave, ureteroscopic, or percutaneous lithotripsy. Conclusions. Recent advances in equipment and technique have allowed many transplant patients with complications to be effectively managed endoscopically.

Objective: To report a multiinstitutional experience of men presenting with infertility secondary to inguinal hernia repair using polypropylene mesh., Summary Background Data: 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: 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.

Objective: To document a contemporary series of vasectomy reversals performed in men 15 years or more after vasectomy and to correlate the results with spousal age and results of ICSI for obstructive azoospermia., Setting: University referral center for male infertility., Design: Retrospective analysis of a single surgeon's experience compared with reported ICSI results., Participant(s): One hundred seventy-three men who had vasectomy reversal 15 years or more after vasectomy., Intervention(s): Reversal of vasectomy by vasovasostomy or epididymovasostomy., Main Outcome Measure(s): Correlation of pregnancy results after vasectomy reversal with spousal age and published ICSI results., Result(s): Pregnancy rates for the intervals of 15-19 years, 20-25 years, and >25 years after vasectomy were 49%, 39%, and 25%, respectively. For spousal age <30 years, 30--35 years, 36-40 years, and >40 years, pregnancy rates were 64%, 49%, 32%, and 28%, respectively. The overall pregnancy rate was 43%, which is similar to the pregnancy rate of 40% for ICSI in obstructive azoospermia. Sixty-two percent of the men required a unilateral or bilateral epididymovasostomy., Conclusion(s): Spousal age is an important predictive factor after vasectomy reversal among men who have reversal 15 years or more after vasectomy. Pregnancy rates after vasectomy reversal compare favorably with those obtained with ICSI.

Purpose: We report our experience with unenhanced computerized axial tomography (CT) after percutaneous ultrasonic lithotripsy in patients thought to be at high risk for retained calculi., Materials and Methods: CT was obtained in 121 patients (124 kidneys) within 12 to 36 hours of percutaneous ultrasonic lithotripsy for staghorn or large nonstaghorn renal calculi. Cases were grouped according to the CT findings as no retained calculi, insignificant retained calculi (fragments 1 to 3 mm.), retained calculi amenable to shock wave lithotripsy and retained fragments requiring second look percutaneous ultrasonic lithotripsy or flexible nephroscopy., Results: No calculi were seen in 73 kidneys (59%) and retained calculi were identified in 51 (41%). Shock wave lithotripsy was used to treat 8 patients and another percutaneous ultrasonic lithotripsy or flexible nephroscopy was performed in 23 to remove retained stones. Insignificant calculi were noted in the remaining 21 patients., Conclusions: We believe that postoperative unenhanced CT is superior to plain renal tomography and is the best method to determine if a patient is stone-free after percutaneous ultrasonic lithotripsy. It helps to locate precisely those stones requiring a second percutaneous ultrasonic lithotripsy or nephroscopic extraction. An unenhanced renal CT devoid of calculi obviates routine postoperative second look flexible nephroscopy. We encourage others to consider this technique to define more accurately kidney stone status after percutaneous ultrasonic lithotripsy for large staghorn calculi or in any patient at high risk for retained calculi after percutaneous ultrasonic lithotripsy.

Objectives: In most endourology programs an interventional radiologist is employed to acquire renal access for percutaneous renal surgery. Over the last 13 years the senior endourologist at Oregon Health Sciences University has acquired access without employing a radiologist. We report our experience with urologist-acquired renal access for percutaneous renal surgery in 522 cases., Methods: We reviewed the records of all patients at our hospital who underwent percutaneous renal surgery between August 1983 and December 1996 with renal access being obtained in the operating room by a urologist., Results: Four hundred fifty-six patients underwent 522 procedures. Indications for percutaneous renal surgery were renal and proximal ureteral calculi (n = 516), retained ureteral stent (n = 3), and intrarenal collecting system tumor (n = 3). We were successful in gaining access to 513 of 522 kidneys (98.3%). Access was obtained via a subcostal approach in 344 procedures, over the 12th rib in 152 procedures, over the 11th rib in 15 procedures, and transabdominally in 2 procedures. Sixty-five patients (12.7%) required a second or multiple sites to facilitate complete removal of calculi. Our overall complication rate was 15.3%. Blood transfusion was required in 5.4% of the cases, ileus developed in 1.9%, pneumothorax in 1.1%, intraoperative hydrothorax in 1.1%, postoperative pleural effusion requiring aspiration in 0.9%, and septic shock in 0.9%. Our overall success rate for stone removal was 94.5%., Conclusions: In our experience, the urologist is able to safely and effectively obtain percutaneous access to the collecting system for percutaneous renal surgery as a one-stage procedure without the aid of interventional radiologists.

An uncommon complication of ileal conduit urinary diversion is bleeding varices at the stoma site. Variceal formation is a complication of portal hypertension, which is most commonly due to intrinsic liver disease. Problematic recurrent bleeding is usually managed locally or by portosystemic shunt. We report a case of recurrent, massive ileal conduit variceal hemorrhage in a patient without a significantly elevated portosystemic gradient. Therefore, this patient was not a candidate for a shunt procedure. Using a transjugular transhepatic approach to the portal vein, the varices were embolized to stasis without any complications. The patient has subsequently experienced no further bleeding episodes.

Purpose: The post-vasectomy pain syndrome is a rare but troublesome complication of vasectomy. We report our experience with 32 patients who underwent vasectomy reversal for relief of the post-vasectomy pain syndrome., Materials and Methods: The records of 32 patients undergoing vasovasostomy or epididymovasostomy for the post-vasectomy pain syndrome were evaluated for characteristics of symptoms, previous therapy, interval from vasectomy, success of surgery and duration of relief., Results: Of 32 men who underwent vasectomy reversal for the post-vasectomy pain syndrome between 1980 and 1994, 24 had relief of symptoms after the initial procedure. Of 8 men with recurrent pain 6 underwent a second reversal procedure, and 3 of them subsequently had relief of symptoms. Overall, 27 of 32 men had resolution of pain., Conclusions: In our experience vasectomy reversal has a high rate of success for relief of the post-vasectomy pain syndrome. It does not preclude other forms of surgical therapy and it should be considered in the treatment of the post-vasectomy pain syndrome.

The Northgate SD-3 is a bathless, portable shock wave lithotriptor made in the United States. It uses ultrasound localization and spark-gap, electrode-generated shock waves to fragment calculi in the upper urinary tract. Since October 1987, 312 treatments have been performed on 281 patients (286 kidneys) with stone burdens less than 2 cm. during clinical trials at 6 investigational sites in the United States. A fragmentation rate of 94% was achieved. Of the treatments 78% were judged successful (stone-free or fragments of less than 5 mm. remaining in an asymptomatic patient) and a 3-month stone-free rate of 58% was noted. The retreatment rate was 9% and the ancillary procedure rate was 5%. The complications (hematuria, ecchymosis, pain, obstruction) were mild and not unlike those seen in patients undergoing lithotripsy with other devices.

Thirteen patients with Stage Tis, Ta, or T1 transitional cell carcinoma (TCC) of the bladder treated by transurethral resections and intravesical chemotherapy developed TCC of the prostate. Among the 13 cases, cytology specimens were obtained from 10 at the time prostatic disease was diagnosed; 9 demonstrated TCC. One was treated successfully by transurethral resection of a Ta lesion involving the prostatic urethra only. One of 2 patients declining radical surgery is alive with residual disease at twenty-four months, and the other died of progressive disease at nineteen months. Of the 10 patients who underwent radical cystoprostatectomy, 7 are alive with no evidence of disease eight to forty-two months postoperatively, with 2 of these 7 having received 4 courses of systemic methotrexate, vincristine, Adriamycin, and cisplatinum (MVAC) for metastatic disease. Two of the 10 died of metastatic disease six and thirteen months postoperatively, and one frail patient died of surgical complications. When treating patients with intravesical chemotherapy for superficial TCC, biopsy of the prostate should be done during follow-up examinations, especially in the presence of cytologic or palpable prostatic abnormalities.

During a 9-year period 1,469 men who underwent microsurgical vasectomy reversal procedures were studied at 5 institutions. Of 1,247 men who had first-time procedures sperm were present in the semen in 865 of 1,012 men (86%) who had postoperative semen analyses, and pregnancy occurred in 421 of 810 couples (52%) for whom information regarding conception was available. Rates of patency (return of sperm to the semen) and pregnancy varied depending on the interval from the vasectomy until its reversal. If the interval had been less than 3 years patency was 97% and pregnancy 76%, 3 to 8 years 88% and 53%, 9 to 14 years 79% and 44% and 15 years or more 71% and 30%. The patency and pregnancy rates were no better after 2-layer microsurgical vasovasostomy than after modified 1-layer microsurgical procedures and they were statistically the same for all patients regardless of the surgeon. When sperm were absent from the intraoperative vas fluid bilaterally and the patient underwent bilateral vasovasostomy rather than vasoepididymostomy, patency occurred in 50 of 83 patients (60%) and pregnancy in 20 of 65 couples (31%). Neither presence nor absence of a sperm granuloma at the vasectomy site nor type of anesthesia affected results. Repeat microsurgical reversal procedures were less successful. A total of 222 repeat operations produced patency in 150 of 199 patients (75%) who had semen analyses and pregnancy was reported in 52 of 120 couples (43%).

The supracostal approach to renal access for ultrasonic lithotripsy continues to be used with good results at The Oregon Health Sciences University when indicated, because it provides better access to much of the kidney collecting system and proximal ureter. The complication rate is acceptably low if the precautions outlined above are followed. Access above the 11th rib is discouraged unless there is no other choice.

A new introducer needle that prevents tracking facilitates rapid and predictable entry into the chosen posterior calix with minimal use of fluoroscopy for lithotripsy or renal drainage. This device should make it possible for urologists and radiologists to acquire rapidly the skill to access the kidney in virtually all patients.

Ice-cold intracellular electrolyte flushing followed by cold storage and economy air shipment is the cheapest method to share kidneys for transplantation. This study from 1 center compares 62 primary cadaver kidney grafts imported from other centers to 128 that were retrieved locally. Cold ischemia time was 36.4 plus or minus 8.6 hours (mean plus or minus standard deviation) in the imported group and 24.2 plus or minus 8.8 hours in the locally retrieved group. The significant increase in first week dialysis (71 versus 42 per cent) and 1-month serum creatinine nadirs (2.63 plus or minus 2.73 versus 1.78 plus or minus 1.04 mg./dl.) was explained by longer cold ischemia times in the imported kidney grafts. There were no significant differences between the 2 groups with respect to actuarial kidney graft survivals and serum creatinine levels at 1, 2 and 3 years. Intracellular electrolyte flushing followed by simple cold storage and air transportation provides kidney graft survivals and long-term kidney graft function at minimal expense when the kidneys are retrieved from beating-heart cadavers and have undergone minimal warm ischemia.

During the last 25 years 100 patients have been subjected to transureteroureterostomy. In 2 cases postoperative death was attributable to other pathologic processes. We treated 94 donor units successfully in this manner. An additional 2 units, normal for several years after transureteroureterostomy, had periureteral fibrosis and stricture owing to the inferior mesenteric artery syndrome and required another definitive surgical procedure. Ninety-seven recipient kidneys remained normal after the procedure.

Community urologists and general surgeons were recruited into a cadaver kidney program in 1976. This study from 1 center compares 41 primary cadaver kidney grafts retrieved by community hospital retrieval teams to 60 primary cadaver kidney grafts retrieved by a center-based transplant team. Of the kidneys 100 were preserved with Collins' C2 flushing followed by simple cold storage and 1 was preserved with pulsatile machine perfusion. Cold storage time ranged from 9 to 44.5 hours in the community hospital kidney group and from 11 to 44 hours in the university hospital group. There was no significant difference between the 2 kidney retrieval teams with respect to 1) incidence of acute tubular necrosis, 2) 1-month serum creatinine nadir of surviving grafts, 3) 1 and 2-year serum creatinine levels and 4) actuarial graft survivals up to 5 years. Community hospital retrieval teams can provide kidneys as satisfactory for transplantation as a center-based transplant team and are a valuable resource for cadaver kidney transplant programs.

The association of daily oral cyclophosphamide with the development of transitional cell carcinoma or squamous cell carcinoma of the bladder had been documented. We report the first 2 cases of transitional cell carcinoma of the renal pelvis and an additional 4 cases of transitional cell carcinoma of the bladder following cyclophosphamide ingestion. Patients who have been taking daily oral cyclophosphamide for a prolonged period should have excretory urography, cystoscopy and bladder mucosal biopsies performed as part of a cancer surveillance protocol.

Transarterial renal embolization has been used in the management of renal cancer. We report on 9 patients who underwent selective and superselective renal arterial embolization for nonmalignant renal lesions. Embolization was done in 5 patients for hemorrhage owing to renal angiomas, renal artery, pseudoaneurysm, percutaneous renal biopsy and adult polycystic kidney disease, and in 2 patients with end stage renal disease because of massive proteinuria. Another chronic renal failure patient with severe hypertension was treated successfully with bilateral renal embolization. A postoperative renal arteriovenous fistula was treated successfully by catheter vaso-occlusion. Renal embolization may be a suitable alternative to surgery in poor operative risk patients and for technically difficult benign lesions. Renal infection is a contraindication to embolization.

Prolonged cold storage following intracellular electrolyte flushing increases the probability of significant acute tubular necrosis after cadaver kidney transplantation. The renal function of primary cadaver kidney grafts was compared in 68 recipients who required dialysis and 92 who did not require dialysis during the first week after transplantation. All kidneys were retrieved from beating-heart cadaver donors by our center, flushed with ice-cold intracellular electrolyte solution and cold-stored until transplantation at our hospital. Recipients requiring dialysis during the first week after transplantation received kidneys with a significantly longer cold storage time (27.4 plus or minus 10.2 versus 23.2 plus or minus 7.6 hours) and had significantly higher 1-month serum creatinine nadirs (2.1 plus or minus 1.3 versus 1.5 plus or minus 0.6 mg./dl.). Actuarial kidney graft survivals and serum creatinine levels 1 to 5 years after grafting were not significantly different. Acute tubular necrosis following primary cadaver kidney transplantation does not adversely affect long-term function of kidney grafts flushed with intracellular electrolyte solution and cold-stored until transplantation.

Being called to the operating room to repair a surgically damaged ureter is an opportunity and challenge that requires on-the-spot decisions based on our training and experience and can result in restoring urinary tract continuity and avoiding secondary operations. A variety of functional reparative techniques are available; however, after consideration of each case in the context in which it arises, the best solution can usually be selected.

Vasitis nodosa is an infrequently recognized, benign disorder that may be confused with malignancy of the vas deferens. A review of 30 patients with vasal masses removed during vasovasostomy revealed 20 men with vasitis nodosa. Of the patients 15 had vasal masses on physical examination, 1 of which was painful. Of the 20 patients with vasitis nodosa 14 had associated granulomatous inflammation. Vasitis nodosa is notably more common than has been reported previously and has been associated with spontaneous recanalization of the vas deferens following vasectomy.

Transplant centers are reluctant to use kidneys stored cold for more than 48 hours. During a 6-year interval we transplanted 32 kidneys preserved by intracellular electrolyte flushing that were stored cold for 48.2 to 61.4 hours. Of the recipients 91 per cent required dialysis within 1 week after transplantation. The mean serum creatinine nadir within 1 month was 3.0 mg. per dl. and graft survival at 1 month was 81 per cent. Short-term kidney graft function was not influenced significantly by the addition of magnesium sulfate to the flush solutions or by cyclosporin immunosuppression. The 1 and 2-year actuarial kidney graft survival rates were 72 and 58 per cent, respectively. The 1 and 2-year mean serum creatinine levels were 1.9 and 1.6 mg. per dl., respectively. Kidneys can be transplanted successfully after 48 hours of simple cold storage following flushing with an ice-cold intracellular electrolyte solution.

We report a case of recurrent adenocarcinoma of the bladder treated by intra-arterial infusion of 5-fluorouracil (5-FU). The use of this agent in the treatment of adenocarcinoma of the bladder is reviewed.

Sixty-nine patients underwent percutaneous nephrostolithotomy or ultrasonic lithotripsy through a nephrostomy tract placed over the 12th rib. All procedures were accomplished as a single stage in a standard operating room with patients under general anesthesia. With the exception of a single failed access the targeted calculus was removed in all instances. There were no episodes of postoperative pneumothorax or hydrothorax. One patient suffered delayed postoperative pneumonia and another patient had a delayed pleural effusion. The supracostal approach for percutaneous nephrostolithotomy is an important and safe modification of the traditional percutaneous approach to the kidney for an endourological procedure.

Transplantation of cadaver kidneys after flushing with an ice-cold intracellular electrolyte solution is inhibited by arbitrary time limits on cold ischemia. During the 25-month interval ending March 22, 1982 we transplanted 7 kidneys preserved by this method and cold-stored for 48.2 to 61.4 hours. Of the recipients 86 per cent required dialysis within 1 week after transplantation, the mean serum creatinine nadir within 1 month was 2.1 mg./dl. and the graft survival at 1 month was 71 per cent. The 1-year actuarial cadaver graft survival was 69.2 plus or minus 18.1 per cent. Kidneys preserved by this simple method can be transplanted successfully after 48 hours of simple cold storage.

Between 1974 and 1980, 48 lymph node dissections were done for nonseminomatous tumors. Of 23 patients with pathologic stage A disease 1 (4 per cent) suffered recurrence but is free of disease after chemotherapy and pulmonary resection. All 23 patients (100 per cent) are free of disease. Adjuvant chemotherapy with high dose vinblastine and constant infusion of bleomycin was given in 25 patients with stage stage B disease and none had maintenance chemotherapy. Of these 25 patients 2 (8 per cent) had evidence of recurrent disease after adjuvant chemotherapy and both are free of disease after further chemotherapy, which included cis-platinum. One patient died after a second primary embryonal carcinoma developed in the remaining testis 3 years after the initial tumor. Twenty-four of the 25 patients with stage B tumor (96 per cent) are free of disease 15 months to greater than 7 years after therapy.

A multifactorial analysis of 100 consecutive first cadaver kidney transplants was done to document the current status of this treatment for end stage renal disease and to determine the influence of the following variables on kidney losses owing to rejection: splenectomy, pre-transplant transfusions, transfusion at the transplantation, recipient sex, pre-transplant nephrectomy, donor and recipient A, B or O blood group, human leukocyte A and B antigen mismatches, kidney preservation method, donor treatment with methylprednisolone and cyclophosphamide, recipient treatment with antilymphocyte serum or antilymphoblast globulin and a low dose of steroid treatment for rejection. Pre-transplant splenectomy for leukopenia, 5 or more pre-transplant blood transfusions and pre-transplant transfusions without development of circulating cytotoxic antibodies significantly reduced kidney losses owing to rejection (p less than 0.05)., A low dose of steroid treatment for rejection resulted in a trend towards improved patient survival without sacrificing kidney graft survival. Clinical studies demonstrating decreases in kidney graft rejection should be controlled for pre-transplant blood transfusions and, possibly, for pre-transplant splenectomy for hypersplenism.

During a 25-month period, beginning in May 1977, 19 patients had Rosen incontinence devices implanted. During the 9 to 34 months of followup 26 additional operations were required for urethral compression balloon leakage, urethral compression balloon aneurysm, tubing kinks, reservoir malfunction and urethral erosion. Currently, 7 devices are in place, 6 of which are functioning and 3 of which have aneurysms of the urethral compression balloon. The 6-month failure rate of the first device was 44 per cent. During the 247 months that the devices were in place the patients were dry for 89 months, and required pad protection for 118 months and condom or an external urethral clamp for 40 months.

In inbred dogs with neonatally induced coarctation hypertension, prior serial studies during the first year after aortic banding showed extracellular volume excess with normal plasma renin activity (PRA). The present studies test the hypothesis that slowly evolving aortic constriction in this model will yield intrarenal angiotensin II excess, peripherally undetectable, with continuous slightly positive sodium balance, and thus that chronic blockade of angiotensin II formation will prevent generation of hypertension. Accordingly, we used MK421 (enalapril, 3 mg/kg twice daily), a long-acting angiotensin converting enzyme inhibitor, or placebo, administered orally, from the time of banding through 4 months after banding in sex-matched littermates randomly assigned to one of four groups: coarcted/MK421; control/MK421; coarcted/placebo; control/placebo. Results indicate that MK421 caused identical lowering of absolute forelimb systolic blood pressure in coarcted and control pups but failed to modify evolution of a significant (p less than 0.005) systolic blood pressure difference in coarcted versus control dogs. Thus, neither temporal course nor final magnitude of relative hypertension was altered by MK421. Efficacy of MK421 was documented by 83% inhibition of the pressor response to angiotensin I at nadir of drug effect and by sustained increases in angiotensin I and renin concentration throughout the period of study. Coarcted and control pups responded similarly to MK421 for all measured variables. Glomerular filtration rate and extracellular volume (measured by [14C]inulin disappearance) did not differ among groups. Thus, chronic administration of MK421 failed to prevent hypertension and did not impair maintenance of normal renal function in the evolving phase of neonatally induced coarctation hypertension. We conclude that, although angiotensin II may participate in the untreated model, it does not appear essential to generation of hypertension. We propose that the renal pressure-natriuresis mechanism regulates distal pressure, that stenosis-related resistance independently determines the proximal-distal difference, and that chronic converting enzyme inhibition lowers the set point of the former without influencing stenosis evolution, thus secondarily lowering proximal pressure by an equal degree.

Right renal vein extension by transverse closure of the transected inferior vena cava solves the problem of the short right renal vein in cadaver kidney transplantation.

Daunorubicin analogues in which the natural amino sugar, daunosamine, is replaced by neutral 2,6-dideoxy-hexopyranosyl residues have been prepared in high yields. Glycosidation of 3,4-di-O-acetyl-2,6-dideoxy-alpha-L-lyxo-hexopyranosyl chloride (13) with daunomycinone under Koenigs-Knorr conditions yielded exclusively the protected alpha-anomeric product 4, which was converted into the free glycoside 5. In contrast, the 1-chloro-D-ribo isomer 19, bearing p-nitrobenzoyl groups for hydroxyl-group protection, furnished a 5:3 mixture of the alpha (6) and beta (7) glycosides. Separation and individual deprotection afforded the target compounds 8 (from 6) and 9 (from 7). Whereas all of the D-ribo analogues (6--9) are inactive as antitumor agents in vivo against P388 lymphocytic leukemia in mice, the protected L-lyxo glycoside 4 (T/C 186) and also the free glycoside 5 (T/C 183) are highly effective in this test system; 5 is also active (T/C 146) in vivo against murine B16 melanocarcinoma.