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Introduction and objective: Erectile function is an important goal for many patients post-phalloplasty. Our objective is to demonstrate a technique for placement of a single-cylinder inflatable penile prosthesis (IPP) in patients with a neophallus. Surgical procedure: IPP placement is performed 1-2 years post-phalloplasty for optimal return of sensation and vascularization. The patient voids preoperatively. Since the bladder is emptied immediately before surgery, we opt not to place a catheter in the potentially tortuous urethra and place the reservoir as early as possible to avoid significant bladder filling, which decreases the risk of bladder injury. Cefazolin and Gentamicin are administered preoperatively and a low concentration Chlorhexidine Gluconate solution is used for irrigation. An infrapubic incision is made and dissection is carried down to the pubic symphysis. The reservoir is placed in the midline prevesical space. Sharp dissection is used to develop a space in the dorsal midline of the neophallus opposite the neourethra, which is palpable without a catheter, prior to sequential distal dilation. After measuring proximally and distally, the appropriately sized device is selected and modified with a shortened, blunted tip and proximal synthetic graft. Previously placed 3–0 FiberWire anchoring sutures on the pubic bone are secured to the proximal aspect of the device. The device is then inflated to facilitate placement into the dilated space distally before tying down the sutures. Pump placement proceeds contralateral to the vascular pedicle in the most dependent aspect of the neoscrotum. Once the tubing is connected, device cycling is performed to ensure proper placement and functioning. Results: Patients are discharged the same day with the device 60% inflated. Sexual activity may occur as early as 8 weeks postoperatively. Complications are seen in up to 40% of patients. Conclusion: Continued improvements in devices and techniques are necessary to decrease complications and improve surgical outcomes as more patients pursue IPP placement post-phalloplasty.

Purpose: Varicocele is a common problem among infertile men. Varicocele repair (VR) is frequently performed to improve semen parameters and the chances of pregnancy. However, there is a lack of consensus about the diagnosis, indications for VR and its outcomes. The aim of this study was to explore global practice patterns on the management of varicocele in the context of male infertility. Materials and Methods: Sixty practicing urologists/andrologists from 23 countries contributed 382 multiple-choice-questions pertaining to varicocele management. These were condensed into an online questionnaire that was forwarded to clinicians involved in male infertility management through direct invitation. The results were analyzed for disagreement and agreement in practice patterns and, compared with the latest guidelines of international professional societies (American Urological Association [AUA], American Society for Reproductive Medicine [ASRM], and European Association of Urology [EAU]), and with evidence emerging from recent systematic reviews and meta-analyses. Additionally, an expert opinion on each topic was provided based on the consensus of 16 experts in the field. Results: The questionnaire was answered by 574 clinicians from 59 countries. The majority of respondents were urologists/ uro-andrologists. A wide diversity of opinion was seen in every aspect of varicocele diagnosis, indications for repair, choice of technique, management of sub-clinical varicocele and the role of VR in azoospermia. A significant proportion of the responses were at odds with the recommendations of AUA, ASRM, and EAU. A large number of clinical situations were identified where no guidelines are available. Conclusions: This study is the largest global survey performed to date on the clinical management of varicocele for male infertility. It demonstrates: 1) a wide disagreement in the approach to varicocele management, 2) large gaps in the clinical practice guidelines from professional societies, and 3) the need for further studies on several aspects of varicocele management in infertile men.

Summary: Single-cell RNA sequencing has revealed extensive molecular diversity in gene programs governing mammalian spermatogenesis but fails to delineate their dynamics in the native context of seminiferous tubules, the spatially confined functional units of spermatogenesis. Here, we use Slide-seq, a spatial transcriptomics technology, to generate an atlas that captures the spatial gene expression patterns at near-single-cell resolution in the mouse and human testis. Using Slide-seq data, we devise a computational framework that accurately localizes testicular cell types in individual seminiferous tubules. Unbiased analysis systematically identifies spatially patterned genes and gene programs. Combining Slide-seq with targeted in situ RNA sequencing, we demonstrate significant differences in the cellular compositions of spermatogonial microenvironment between mouse and human testes. Finally, a comparison of the spatial atlas generated from the wild-type and diabetic mouse testis reveals a disruption in the spatial cellular organization of seminiferous tubules as a potential mechanism of diabetes-induced male infertility.