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Unexplained male infertility is a diagnosis reserved for men in whom routine semen analyses results are within normal values and physical as well as endocrine abnormalities were ruled out. In addition to erectile problems and coital factors, immunologic causes and sperm dysfunction may contribute to such condition. New etiologies of unexplained male infertility include low level leukocytospermia and mitochondrial DNA polymerase gene polymorphism. Contemporary andrology may reveal cellular and sub-cellular sperm dysfunctions which may explain subfertility in such cases, thus aiding the clinician to direct the further work-up, diagnosis and counseling of the infertile male. The objective of this article is to highlight the concept of unexplained male infertility and focuses on the diagnosis and treatment of this condition in the era of modern andrology and assisted reproductive techniques. Extensive literature review was performed using the search engines: Pubmed, Science-direct, Ovid and Scopus.

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OBJECTIVE: To perform a cost-effectiveness analysis of medical treatment of benign prostatic hyperplasia (BPH) under Brazilian public health system perspective (Unified Health System - "Sistema Único de Saúde (SUS)"). MATERIAL AND METHODS: A revision of the literature of the medical treatment of BPH using alpha-blockers, 5-alpha-reductase inhibitors and combinations was carried out. A panel of specialists defined the use of public health resources during episodes of acute urinary retention (AUR), the treatment and the evolution of these patients in public hospitals. A model of economic analysis(Markov) predicted the number of episodes of AUR and surgeries (open prostatectomy and transurethral resection of the prostate) related to BPH according to stages of evolution of the disease. Brazilian currency was converted to American dollars according to the theory of Purchasing Power Parity (PPP 2010: US$ 1 = R$ 1.70). RESULTS: The use of finasteride reduced 59.6% of AUR episodes and 57.9% the need of surgery compared to placebo, in a period of six years and taking into account a treatment discontinuity rate of 34%. The mean cost of treatment was R$ 764.11 (US$449.78) and R$ 579.57 (US$ 340.92) per patient in the finasteride and placebo groups, respectively. The incremental cost-effectiveness ratio (ICERs) was R$ 4.130 (US$ 2.429) per episode of AUR avoided and R$ 2.735 (US$ 1.609) per episode of surgery avoided. The comparison of finasteride + doxazosine to placebo showed a reduction of 75.7% of AUR episodes and 66.8% of surgeries in a 4 year time horizon, with a ICERs of R$ 21.191 (US$ 12.918) per AUR episodes avoided and R$ 11.980 (US$ 7.047) per surgery avoided. In the sensitivity analysis the adhesion rate to treatment and the cost of finasteride were the main variables that influenced the results. CONCLUSIONS: These findings suggest that the treatment of BPH with finasteride is cost-effective compared to placebo in the Brazilian public health system perspective.

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PURPOSE: To determine whether transurethral surgery under platelet inhibition is a feasible procedure. Before transurethral resection of prostate (TURP) or bladder tumours (TURB), the administration of platelet-inhibiting medication is often interrupted due to possible bleeding complications. We studied the performance of TURP and TURB under the current recommendations of the American College of Chest Physicians (ACCP) on perioperative platelet inhibition. MATERIALS AND METHODS: Patients assigned for transurethral intervention were preoperatively divided into the following risk groups: low, medium and high cardio- or cerebrovascular risk. In patients with a low-risk profile, acetylsalicylic acid (ASA) was discontinued. Patients of the medium risk group continued taking 100 mg of ASA. Patients of the high-risk group receiving dual platelet inhibition (ASA + clopidogrel) were not treated operatively. In total 346 patients from the low and medium risk groups underwent transurethral intervention. RESULTS: Forty-two out of 198 TURP were performed under 100 mg of ASA. Without ASA, a significantly shorter length of stay and earlier removal of the transurethral catheter was documented. In the parameters postoperative haemorrhage and operative revision, no significant differences were observed. Thirty-two out of 148 TURB were performed under 100 mg of ASA. Regarding the length of stay, time until catheter removal, postoperative haemorrhage and operative revision, no significant differences were found under ASA. Only significantly longer continuous irrigation was documented under ASA. CONCLUSION: In the case of a verified indication for use of platelet inhibitors, it is possible to avoid discontinuation and the consequent increased risk of thromboembolic incidents in transurethral surgery is admissible.

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OBJECTIVE: To investigate the relationships between 2nd to 4th digit ratio (digit ratio) and prostate cancer detection rate and biopsy findings, including Gleason score. MATERIALS AND METHODS: In 770 consecutive men aged 40 years or older that presented with lower urinary tract symptoms (LUTS), right hand 2nd and 4th digit lengths were measured prior to PSA determinations, DRE and transrectal ultrasonography (TRUS). Among these, 166 men with a prostate specific antigen (PSA) level ≥ 3 ng/mL or abnormal digit rectal examination (DRE) prospectively underwent prostate biopsies. The relationship between digit ratio and prostate cancer detection rate and biopsy findings was investigated. RESULTS: The study subjects were allocated to two groups by digit ratio (group A: digit ratio < 0.95; n = 420; group B: digit ratio ≥ 0.95; n = 350). Despite similar biopsy rates (22.4% vs. 20.6%, p = 0.544), group A had higher cancer detection rate (46.8% (44/94) vs. 23.6% (17/72), p = 0.002; OR = 2.847, 95% CI = 1.445-5.610). When we analyzed 408 positive biopsy cores (group A: digit ratio < 0.95, n = 282; group B: digit ratio ≥ 0.95, n = 126), group A had higher percentage of core cancer volume (46.7% vs. 37.1%, p = 0.005) and more biopsy cores with high Gleason score (sum of Gleason score ≥ 9: 18/282 (6.4%) vs. 1/126 (0.8%), p = 0.010; primary Gleason score = 5: 12/282 (4.3%) vs. 0/126 (0.0%), p = 0.021). CONCLUSIONS: A lower digit ratio is related to an increased detection rate of prostate cancer, a high percentage of core cancer volume and a high Gleason score.

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INTRODUCTION: The objective of our study is to present the first Brazilian cryoablation experience in the treatment of low and intermediate risk localized prostate cancer using 3rd generation cryoablation and real-time biplanar transrectal ultrasonography. MATERIALS AND METHODS: Ten Brazilian patients underwent primary cryoablation for localized prostate cancer between October 2010 and June 2011. All patients consented for whole gland primary cryotherapy. The procedures were performed by 3rd generation cryoablation with the Cryocare System® (Endocare, Irvine, California). Preoperative data collection included patient demographics along with prostate gland size, Gleason score, serum prostate specific antigen, and erectile function status. Operative and post-operative assessment involved estimated blood loss, operative time, complications, serum PSA level, erectile function status, urinary incontinence, biochemical disease free survival (BDFS), and follow-up time. RESULTS: All patients in the study successfully underwent whole gland cryoablation. The mean of: age, prostate size, PSA level, and Gleason score, was 66.2 years old; 40.7g; 7.8ng/mL; and 6 respectively. All patients were classified as low or moderate D'Amico risk (5 low and 5 moderate). Erectile dysfunction was present in 50% of patients. The estimated blood loss was minimal, operative time was 46.1 minutes. All patients that developed erectile dysfunction post-treatment responded to oral or intracavernosal medications with early penile rehabilitation. All patients maintained urinary continence by the end of a 10 months evaluation period and none had biochemical relapse within the mean follow-up of 13 months (7-15 months). CONCLUSION: Our initial experience shows that cryoablation is a minimally invasive option for the treatment of localized prostate cancer. Short term data seems to be promising but longer follow-up is necessary to verify oncological and functional results.

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PURPOSE: The purpose of this study was to evaluate the accuracy of multidetector computed tomography (MDCT) in the preoperative staging of renal cell carcinoma (RCC). MATERIALS AND METHODS: We retrospectively reviewed the clinical and pathological records of 312 patients with RCC who underwent staging MDCT before surgery. Radiographic findings were compared to the findings at surgery and pathological examination. All staging used 2009 updated TNM classification. RESULTS: The difference in tumor size between radiographic and pathological findings was 0.21cm. In T1a group, the difference was 0.33cm. Agreement between MDCT and histopathological findings was moderate for T staging (Kappa = 0.469), fair for N staging (Kappa = 0.322), and excellent for M staging (Kappa = 0.932). The sensitivity and specificity of MDCT in detecting perinephric fat invasion were 32.26% and 85.87%, in detecting tumor thrombosis were 84% and 100%, in detecting adrenal gland invasion were 60% and 95.79%, in detecting lymph node involvement were 50% and 96.36%, in detecting distant metastasis were 100% and 99.67%, respectively. In regard to stage grouping, 237 of 314 patients were correctly staged by MDCT, with an overall accuracy of 75.48%. CONCLUSIONS: MDCT with a dynamic contrast protocol is able to delineate RCC with high accuracy. However, a great portion of tumors were overstaged by MDCT because of overestimation of tumor size and poor visualization of infiltration of the perinephric fat. In addition, nodal metastatic lesion evaluation relies on node size only and remains a difficult task.

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INTRODUCTION: While some studies show that patients submitted to radical nephrectomy have a higher risk of developing chronic kidney disease (CKD), some studies report that carefully selected living kidney donors do not present a higher risk for CKD. Here, we aim to study predictive factors of CKD after radical nephrectomy. MATERIALS AND METHODS: Between January 2006 to January 2010, 107 patients submitted to radical nephrectomy for cortical renal tumors at our institution were enrolled in this study. Demographic data were recorded, modified Charlson-Romano Index was calculated, and creatinine clearance was estimated using abbreviated Modification of Diet in Renal Disease (MDRD) study equation. Pathological characteristics, surgical access and surgical complications were also reviewed. The end-point of the current study was new onset estimated glomerular filtration rate (eGFR) less than 60 and less than 45 mL/minute/1.73 m². RESULTS: Age, preoperative eGFR, Charlson-Romano Index and hypertension were predictive factors of renal function loss, when the end-point considered was eGFR lower than 60 mL/minute/1.73 m². Age and preoperative eGFR were predictive factors of renal function loss, when the end-point considered was eGFR lower than 45 mL/minute/1.73 m². Moreover, each year older increased 1.1 times the risk of eGFR lower than 60 and 45 mL/minute/1.73 m². After multivariate logistic regression, only age remained as an independent predictive factor of eGFR loss. CONCLUSION: Age is an independent predictive factor of GFR loss for patients submitted to radical nephrectomy for cortical renal tumors.

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PURPOSE: To assess the feasibility and performance of radical cystectomy with urinary diversion using exclusively regional anesthesia (i.e. combined spinal thoracic epidural anesthesia, CSTEA). MATERIALS AND METHODS: In 2011 radical cystectomy with extended pelvic and iliac lymphadenectomy was performed on 14 patients using urinary diversion without applying general anesthesia. Under maintained spontaneous breathing, the patients were awake and responsive during the entire procedure. Postoperatively, pain management took three days with the remaining epidural catheter before oral analgesics were administered. Mobilization and diet restoration were carried out according to the fast-track concept. Outcome measurements included operative time, blood loss, beginning of oral nutrition, beginning of mobilization, postoperative pain levels using numerical and visual analog scales (NAS/VAS), length of hospital stay. RESULTS: All surgical procedures were performed without any complications. The absence of general anesthesia did not result in any relevant disadvantages. The postoperative progress was normal in all patients. Particularly, cardiopulmonary complications and enteroparesis did not occur. The provided palliative care proved sufficient (NAS max. 3-4). Discharge followed 10 to 22 days after surgery. At the time of discharge, the patients described the procedure to be relatively positive. CONCLUSIONS: Our data show that CSTEA is an effective technique for radical cystectomy, whereby spontaneous breathing and reduced interference with the cardiopulmonary system potentially lower the perioperative risks especially for high-risk patients. We recommend practice of CSTEA for radical cystectomy to further evaluate and monitor the safety, efficacy, outcomes, and complications of CSTEA.

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PURPOSE: To compare urodynamic characteristics in patients with idiopathic detrusor overactivity (IDO) with those of an age matched cohort with diabetes mellitus (DM) and detrusor overactivity (DO). Secondly, to determine whether urodynamic features could help distinguish these two groups of patients. MATERIALS AND METHODS: Urodynamic data was collected on 58 female patients; 29 with IDO and 29 with DM and detrusor overactivity. Eight urodynamic parameters were selected for analysis: amplitude of the first overactive contraction (AOFC), the volume at the first contraction, cystometric capacity, maximal detrusor pressure, maximal flow rate, voiding pressure at maximal flow, voided volume and postvoid residual (PVR) urine volume. Finally, sensitivity analysis for distinguishing urodynamic parameters between studied groups was performed. RESULTS: AOFC, volume at AOFC and maximal detrusor pressure were statistically greater in diabetic patients, compared with the non-diabetic group of women (16.00 cm H2O versus 9.00 cm H2O, 309.00 mL versus 167.00 mL and 76.48 cm H2O versus 55.41 cm H2O respectively). A specificity of 72.41% and positive predictive value of 71.43% were achieved for AOFC with cutoff value of 12 cm H2O. These parameters were further improved with cutoff value of 258 mL for volume at AOFC and were 75.86% and 73.08% respectively. CONCLUSIONS: Certain urodynamic parameters in diabetic female patients with DO are shown to be significantly different than those in women with IDO. Further prospective study should provide additional information about the pathogenesis and progression of DO in diabetic patients as well as the validity of diabetic screening in patients with IDO.

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AIMS: To assess pelvic floor muscle (PFM) strength in women with stress urinary incontinence (SUI) and urge urinary incontinence (UUI). MATERIALS AND METHODS: 51 women were prospectively divided into two groups, according to the symptoms as SUI (G1 = 22) or UUI (G2 = 29). Demographic data, such as number of pads/ 24 hours, number of micturations/ 24 hours and nocturia, delay time of urgent void (i.e., the time period for which an urgent void could be voluntarily postponed), number of parity and vaginal deliveries were obtained using a clinical questionnaire. Objective urine loss was evaluated by 60-min. Pad Test, subjective urine stream interruption test (UST) and visual survey of perineal contraction. Objective evaluations of PFM were performed in all patients (vaginal manometry). RESULTS: Median of age, mean number of pads / 24 hours, nocturia and warning time were significantly higher in UUI comparing to SUI group. During UST, 45.45% in G1 and 3.44%, in G2, were able to interrupt the urine stream (p < 0.001). The 60-min. Pad Test was significantly higher in G2 compared to G1 women (2.7 ± 2.4 vs 1.5 ± 1.9 respectively, p = 0.049). Objective evaluation of PFM strength was significantly higher in the SUI than in the UUI patients. No statistical difference was observed regarding other studied parameters. CONCLUSION: Pelvic floor muscle weakness was significantly higher in women with UUI when compared to SUI.

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PURPOSE: To analyze the influence of urethral mobility and Valsalva leak point pressure on postoperative outcomes of transobturator sling (TOT) for female stress urinary incontinence. MATERIALS AND METHODS: A prospective cohort was conducted including 66 patients submitted to TOT from March 2006 to May 2009. Urethral hypermobility was defined as mobility ≥ 30º on Q-tip test, and Valsalva leak point pressure (VLPP) was classified as greater than 60 cmH2O or 60 and less on preoperative urodynamics. These parameters were compared through well defined postoperative objective and subjective success criteria. Intensity of urinary leakage and quality of life was analysed by ICIQ-SF. Statistical analysis was accomplished and the results rendered significant if p < 0.05. RESULTS: Mean follow up was 10 months (3 to 28). Mean age was 55 years (33 to 80), 70% were white and 30% African descendent, mean body mass index was 27 (21 to 38), average vaginal and abdominal deliveries were 2.8 and 0.5 respectively. A quarter had prior stress incontinence surgery. Patients with urethral hypermobility had higher objective success rates (98% versus 81.25%, p = 0.04). The subjective success rate was also greater in the hypermobility group (84% versus 62.5%), but statistical significance was not reached (p = 0.07). VLPP had no influence on either objective or subjective postoperative success rates (p = 0.17 and 0.34, respectively). In the subgroup analysis, those with low mobility and high VLPP had worse objective success rates in comparison to the group with hypermobility and low VLPP (p = 0.04) and also in relation to the remaining of the studied population. Other possible prognostic factors (previous surgery, mixed incontinence, gestational status) had no influence on success rates. CONCLUSIONS: High urethral mobility, regardless of the sphincteric status indicated by VLPP, is a favorable prognostic factor for tension-free transobturator tape procedure. No relationship was demonstrated between postoperative success rates and VLPP.

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PURPOSE: To study the morphologic alterations in the proximal and distal urethral edges from patients submitted to end-to-end bulbar urethroplasty. MATERIALS AND METHODS: We analyzed 12 patients submitted to anastomotic urethroplasty to treat bulbar strictures less than 2.0 cm in length. After excision of the fibrotic segment to a 28Fr urethral caliber, we obtained biopsies from the spongious tissue of the free edges (proximal: PROX and distal: DIST). Controls included normal bulbar urethras obtained from autopsies of 10 age matched individuals. The samples were histologically processed for smooth muscle cells (SMC), elastic system fibers and collagen. Stereological analysis was performed to determine the volumetric density (Vv) of each element. Also, a biochemical analysis was performed to quantify the total collagen content. RESULTS: Vv of SMC was reduced in PROX (31.48 ± 7.01 p < 0.05) and similar in DIST when compared to controls (55.65 ± 9.60%) with no statistical difference. Elastic fibers were increased in PROX (25.70 ± 3.21%; p < 0.05) and were similar to controls in DIST (15.87 ± 4.26%). Total collagen concentration in PROX (46.39 ± 8.20 μg/mg), and DIST (47.96 ± 9.42 μg/mg) did not differ from controls (48.85 ± 6.91 μg/mg). Type III collagen was similarly present in all samples. CONCLUSIONS: After excision of the stenotic segment to a caliber of 28Fr, the exposed and macroscopically normal urethral edges may present altered amounts of elastic fibers and SMC, but are free from fibrotic tissue. When excising the peri-stenotic tissue, the surgeon should be more careful in the proximal end, which is the most altered.

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PURPOSE: Recurrent priapism is prevalent in children. Different medications have been used to avoid new episodes, however, there is no consensus regarding the best option. The use of finasteride to treat priapism in adults has already been tested. The aim of the present study was to test the hypothesis that a low dose of finasteride would be effective in preventing recurrent priapism in children. MATERIALS AND METHODS: Since 2007, five children and adolescents with recurrent episodes of priapism have been treated with finasteride in our department, and the medical records of these patients were reviewed for this study. In four cases, the dose used was 1 mg a day, while the remaining patient used 1 mg twice a day. RESULTS: Prior to initiating finasteride treatment, one patient reported having had 6 episodes of acute priapism, while the remaining patients had more than 10 episodes. One of the patients reported having stuttering priapism almost daily. With a mean follow-up of 20 months, four patients had no episodes and only one patient complained of sporadic and shorter duration episodes. CONCLUSIONS: These initial results suggest that a low daily dose of finasteride appears to represent an effective and safe form of treatment for recurrent priapism in children and adolescents with SCD. However, in order to confirm these initial findings, studies with a large population and a control group are essential.

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PURPOSE: The aim of this study was to evaluate the relaxation in vitro of cavernous smooth muscle induced by a new NO donor of the complex nitrosil-ruthenium, named trans-[Ru(NH3)4(caffeine)(NO)]C13 (Rut-Caf) and sodium nitroprusside (SNP). MATERIALS AND METHODS: The tissues, immersed in isolated bath systems, were pre-contracted with phenilephrine (PE) (1 µM) and then concentration-response curves (10-12 - 10-4 M) were obtained. To clarify the mechanism of action involved, it was added to the baths ODQ (10 µM, 30 µM), oxyhemoglobin (10 µM), L-cysteine (100 µM), hydroxicobalamine (100 µM), glibenclamide, iberotoxin and apamine. Tissue samples were frozen in liquid nitrogen to measure the amount of cGMP and cAMP produced. RESULTS: The substances provoked significant relaxation of the cavernous smooth muscle. Both Rut-Caf and SNP determined dose-dependent relaxation with similar potency (pEC50) and maximum effect (Emax). The substances showed activity through activation of the soluble guanylyl cyclase (sGC), because the relaxations were inhibited by ODQ. Oxyhemoglobin significantly diminished the relaxation effect of the substances. L-cysteine failed to modify the relaxations caused by the agents. Hydroxicobalamine significantly diminished the relaxation effect of Rut-Caf. Glibenclamide significantly increased the efficacy of Rut-Caf (pEC50 4.09 x 7.09). There were no alterations of potency or maximum effect of the substances with the addition of the other ion channel blockers. Rut-Caf induced production of significant amounts of cGMP and cAMP during the relaxation process. CONCLUSIONS: In conclusion, Rut-Caf causes relaxation of smooth muscle of corpus cavernosum by means of activation of sGC with intracellular production of cGMP and cAMP; and also by release of NO in the intracellular environment. Rut-Caf releases the NO free radical and it does not act directly on the potassium ion channels.

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MAIN FINDINGS: A 22-year-old woman with complete androgen insensitivity syndrome (CAIS) presenting with primary amenorrhea and normal female external genitalia was referred for laparoscopic gonadectomy. She had been diagnosed several years earlier but was reluctant to undergo surgery. CASE HYPOTHESIS: Diagnosis of this X-linked recessive inherited syndrome characterizes by disturbance of virilization in males with an AR mutation, XY karyotipe, female genitalia and severely undescended testis with risk of malignization. The optimal time to orchidectomy is not settled; neither the real risk of malignancy in these patients. Early surgery impacts development of a complete female phenotype, with enlargement of the breasts. Based on modern diagnostic imaging using DCE-MRI and surgical technology with single port laparoscopic access we hypothesize that the optimum time for gonadectomy is not at the time of diagnosis, but once feminization has completed. PROMISING FUTURE IMPLICATIONS: An umbilical laparoendoscopic single-site access for bilateral gonadectomy appears to be the first choice approach as leaves no visible incision and diminishes the psychological impact of surgery in a patient with CAIS absolutely reassured as female. KeyPort, a single port access with duo-rotate instruments developed by Richard Wolf facilitates this surgery and allows excellent cosmetic results.

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Inferior Vena Cava (IVC) filters are mechanical devices implanted to provide prophylaxis against pulmonary emboli in patients for whom standard anticoagulation is either inadequate or contraindicated. A 67-year-old female with a 10-year-old indwelling IVC filter underwent robotic assisted laparoscopic partial nephrectomy for a right upper pole renal mass. Renal hilum dissection was complicated by adhesions secondary to eroded IVC filter struts. IVC filter erosion is a well-described phoenomena in both the radiologic and surgical literature. As many as 25% of filters are noted to be radiographically eroded; however, the incidence of clinically significant erosion is much less. Given the placement of endovascularly delivered IVC filters in close proximity to many urologic operative fields, it is important for urologists to be aware of the potential of eroded devices when pursuing para-caval dissections.

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INTRODUCTION: Urethral duplication is a rare congenital anomaly affecting mainly boys. Generally, the duplication develops on the sagittal plane; the accessory urethra may run dorsally or ventrally to the orthotopic one. We present a patient with urethral duplication in which the orthotopic urethra was patent in the penile segment but atresic in the bulbar and prostatic segment. The patient had urinary flow from the rectum and the ectopic urethra could be well identified by anal examination. MATERIALS AND METHODS: Age at surgery was 13 months. The procedure consisted of an ASTRA (anterior sagittal trans-ano-rectal) approach for dividing the urethra and rectum and was successful to move the urethra up to the perineal area. The rectum was reconstructed and the patient placed into a lithotomy position. A urethral catheter inserted in the penile urethra oriented us were the atresic urethra in bulbar area started. The scrotum was opened in the middle and the distance between the two urethral stumps proximal and distal defined the extension of no urethral tissue that consisted of 5 cm. We opened the right scrotal space and a tunica vaginalis flap was obtained and attached to the bulbar tissue for a two-stage urethroplasty strategy. RESULTS: Patient had a nice healing and the tunica vaginalis was nicely incorporated to the adjacent tissue, having the two urethral stumps well delineated. CONCLUSIONS: ASTRA approach in combination with a two-stage urethroplasty with tunica vaginalis dorsal flap proved to be an excellent combination for a rare case of urethral Y duplication having the main urethra into the rectum.