Male Infertility

CASE SCENARIO Male Infertility Craig S. Niederberger, MD,* Randall B. Meacham, MD† *Department of Urology, University of Illinois at Chicago, Chicago, IL; †University of Colorado School of Medicine, Denver, CO [Rev Urol. 2003;5(3):200–203] © 2003 MedReviews, LLC CASE REPORT 32-year-old man presents for evaluation following 2 years of unsuccessfully attempting to father a pregnancy. He has a completely negative medical and surgical history, is taking no medications, does not smoke, and consumes alcohol in moderation (averages 1 drink per week). Semen analyses, performed on 2 occasions, revealed ejaculate volumes of 1.4 mL and 1.7 mL, sperm concentrations of 4.5 million and 5.2 million sperm per mL, and motility of 46% and 43%. Serum hormone evaluation revealed a serum testosterone level (drawn at 8:30 AM) of 235 ng/dL (normal, 300-1000 ng/dL). Repeat morning serum testosterone was 217 ng/dL. Serum luteinizing hormone, follicle-stimulating hormone, and prolactin levels were all within the normal range. A Physical examination revealed the testes to be descended bilaterally with moderately decreased size and consistency. There were no varicoceles present, and the vasa deferentia and epididymis glands were unremarkable to palpation. The prostate was normal to palpation, and the remainder of the physical examination was normal. Assessment of a spun urine sediment collected immediately following ejaculation revealed only occasional sperm. Transrectal sonographic imaging of the prostate and surrounding structures revealed no evidence of ejaculatory duct obstruction or other abnormality. The patient’s partner is a 29-year-old woman with no known fertility concerns. She reports regular menses, and her past medical history is negative for any surgical or medical conditions that might affect her fertility status. MANAGEMENT OPTIONS An appropriate next step in the management of this patient would be (select one): ❑ 1. Unilateral testis biopsy with subsequent therapy based on the histologic findings ❑ 2. Bilateral testis biopsy with subsequent therapy based on the findings in the most normal testis ❑ 3. Referral to a reproductive medicine specialist for discussion of assisted reproductive technologies, such as intrauterine insemination or in vitro fertilization ❑ 4. Initiation of testosterone supplementation sufficient to achieve a serum level of at least 300 ng/dL with repeat semen analysis performed in 3 weeks ❑ 5. Initiation of testosterone supplementation as described above with assessment of semen analysis performed in 4 months ❑ 6. Initiation of clomiphene citrate therapy at a dosage of 25 mg/d, with dosage adjustment to achieve a testosterone level of at least 300 ng/dL with repeat semen analysis performed in 4 months ❑ 7. Performance of color Doppler ultrasonography to assess the patient for the presence of subclinical varicocele 200 VOL. 5 NO. 3 2003 REVIEWS IN UROLOGY Case Scenario Discussion of Last Issue’s Case Scenario IN THE LAST ISSUE, DR DEAN G. ASSIMOS Twelve months prior to referral, a 20-year-old man had intermittent right flank pain associated with nausea and emesis. A right ureteropelvic junction (UPJ) obstruction was diagnosed. The patient was treated with a cutting balloon incision of the UPJ and did well for 6 months, at which time his symptoms recurred. While symptomatic, he was evaluated with diuretic nuclear renography, which demonstrated functional obstruction of the right kidney but otherwise symmetric function (Figure 1). Computed tomography angiography showed moderate right hydronephrosis and an accessory crossing artery at the right UPJ. The ureter distal to this point appeared normal on postcontrast abdominal radiography. Serum creatinine, electrolytes, and urinalysis results were normal. After being informed of his treatment options, the THE AND COLLEAGUES PRESENTED THIS CASE REPORT: patient elected to undergo open surgical pyeloplasty. An 11th rib flank incision was made, and the renal pelvis and proximal ureter were exposed. Approximately 5 cm to 6 cm of the proximal ureter, starting just below the renal pelvis, was densely adherent to the inferior vena cava. The renal pelvis was moderately dilated and mostly intrarenal. The accessory renal artery was identified, isolated, and preserved. The ureter was transected and suture ligated just below the UPJ with 3-0 absorbable suture. The ureter distal to this point was dissected free from the inferior vena cava, and a 2-cm segment of poorly vascularized ureter was resected. The remaining ureter could not be brought up to the level of the renal pelvis for tension-free dismembered pyeloplasty, despite renal mobilization. FOLLOWING MANAGEMENT OPTIONS WERE OFFERED: ❑ 1. Renal autotransplantation ❑ 2. Flap pyeloplasty ❑ 3. Partial lower-pole nephrectomy with ❑ 4. Ileal ureter substitution ❑ 5. Nephrectomy ureterocalicostomy AUTHORS’ DISCUSSION Patients with UPJ obstruction can be treated in many ways, including antegrade and retrograde endopyelotomy, open and laparoscopic pyeloplasty, and cutting balloon incision. Our patient underwent retrograde cutting balloon incision, which has a reported success rate of 73% to 98%.1–4 The overall reported complication rates from a cutting balloon incision range from 13% to 34%.1–4 Cohen and associates3 studied 15 patients who underwent this procedure and reported a 27% failure rate, with 13% of subjects developing ureteral strictures greater than 2 cm in length. There are many options for managing secondary UPJ obstruction, including repeat endourologic intervention and open surgical or laparoscopic management. Ng and colleagues5 recently reported that, in the setting of failed primary endourologic intervention for UPJ obstruction, there is a 37.5% success rate for a secondary endourologic approach, compared with a 94.1% success rate with an open surgical salvage procedure. In this clinical scenario, each of the options listed has advantages and disadvantages. We believe that ureterocalicostomy is the best therapeutic option. In cases in which the renal pelvis is inaccessible because of either an intrarenal location or intense peripelvic scarring, ureterocalicostomy is a reliable salvage procedure since it also provides for dependent drainage and compensates for lack of adequate ureteral length. In addition, it allows reconstruction without use of a bowel segment or complex vascular surgery. Success rates for ureterocalicostomy have been reported to range from 71% to 90%.6–8 Open dismembered pyeloplasty is the ideal treatment option for a secondary UPJ obstruction. However, in this case, pyeloplasty would not have been possible because of the amount of scarring, the stricture length, and the intrarenal pelvis. Flap pyeloplasty can be performed with high success rates in the setting of a large or extrarenal pelvis since the redundant tissue can be reconstructed to VOL. 5 NO. 3 2003 REVIEWS IN UROLOGY 201 Case Scenario continued A B Figure 1. Recurrent right ureteropelvic junction (UPJ) obstruction. (A) Intravenous pyelography performed when the patient was asymptomatic, demonstrating right proximal ureteral narrowing. (B) Diuretic renography performed 2 months later, while the patient was symptomatic, demonstrating high-grade right renal obstruction. (C and D) Computed tomography angiogram with 3-dimensional reconstruction, demonstrating right UPJ obstruction with crossing lower-pole accessory vessel. C provide additional length and allow anastomosis to the ureter when an extensive defect is present.9,10 The advantages of flap pyeloplasty include the avoidance of partial nephrectomy, bowel utilization, and vascular reconstruction. It also may permit a dependent, tension-free anastomosis, without renal mobilization. Ileal ureter substitution has been used in the setting of secondary UPJ obstruction and is an ideal form of reconstruction when there is coexistent extensive proximal ureteral stricture. This procedure should be avoided in patients with known functional or anatomic small bowel disease.11,12 Contemporary success rates for ileal interposition range from 83% to 100%. Although an ileal ureter could have been created to manage our patient, it may 202 VOL. 5 NO. 3 2003 REVIEWS IN UROLOGY D have several disadvantages that are not associated with ureterocalicostomy, including the need to use a bowel segment and the potential for bowel-related complications. Furthermore, the use of ileum potentially increases the risk of long-term metabolic sequelae and stone activity. Renal autotransplantation has been reported to have excellent long-term results for patients who require ureteral replacement. Bodie and colleagues13 reported an 87% success rate in a series of 23 patients in whom this procedure was performed. Although renal autotransplantation is a feasible option, it requires that the surgeon have vascular surgical expertise. Nephrectomy should be avoided when the affected renal unit has adequate renal function. It may be the procedure of Case Scenario of the renal capsule into the anastomosis, whereas others have not found this maneuver to improve results.8,14 Perinephric fat can be used to surround the anastomosis. The retroperitoneum is drained. The internalized stent is removed 4 to 6 weeks postoperatively. If the defect is too long for a tension-free anastomosis, interposition of a short, tapered segment of ileum is indicated. The ileum should be tapered on its antimesenteric border and an end-to-end calicoileoureterostomy performed. Ureterocalicostomy is a rarely performed reconstructive procedure. However, it should be considered when the renal pelvic and proximal ureteral tissue will not allow for pyeloplasty to be performed. References 1. Figure 2. Ureterocalicostomy: lower-pole partial nephrectomy with ureteral anastomosis to lower-pole calyx. 2. 3. choice, however, when ipsilateral renal function is marginal, provided the contralateral renal unit is working well. There are several steps involved in the performance of ureterocalicostomy (Figure 2). The kidney is initially mobilized, and the hilar vessels and proximal ureter are exposed. The ureter is transected at the point of obstruction and ligated proximally with absorbable suture. A lower-pole partial nephrectomy is performed to expose the renal collecting system. Standard techniques for partial nephrectomy are employed, except the capsule surrounding the resected parenchyma is preserved. Manual compression of the kidney or temporary occlusion of the renal artery and vein may be used to limit hemorrhage. The ureter is spatulated laterally for a distance that approximates the longest dimension of the exposed calyx. The ureter is anastomosed to the calyx using running or interrupted 4-0 or 5-0 absorbable sutures. An internalized ureteral stent is placed prior to completing the anastomosis. Some surgeons advocate the incorporation 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Schwartz BF, Stoller ML. Complications of retrograde balloon cautery endopyelotomy. J Urol. 1999;162:1594–1598. Faerber GJ, Richardson TD, Farah N, Ohl DA. Retrograde treatment of ureteropelvic junction obstruction using the ureteral cutting balloon catheter. J Urol. 1997;157:454–458. Cohen TD, Gross MB, Preminger GM. Long-term follow-up of Acucise incision of ureteropelvic junction obstruction and ureteral strictures. Urology. 1996;47:317–323. Preminger GM, Clayman RV, Nakada SY, et al. A multicenter clinical trial investigating the use of a fluoroscopically controlled cutting balloon catheter for the management of ureteral and ureteropelvic junction obstruction. J Urol. 1997;157:1625–1629. Ng CS, Yost AJ, Streem SB. Management of failed primary intervention for ureteropelvic junction obstruction: 12-year, single-center experience. Urology. 2003;61:291–296. Ross JH, Streem SB, Novick AC, et al. Ureterocalicostomy for reconstruction of complicated pelviureteric junction obstruction. Br J Urol. 1990;65:322–325. Selli C, Rizzo M, Moroni F, et al. Ureterocalicostomy in the treatment of pyeloplasty failures. Urol Int. 1992;48:274–277. Mesrobian HG, Kelalis PP. Ureterocalicostomy: indications and results in 21 patients. J Urol. 1989;142:1285–1287. Tynes WV, Warden SS, Devine CJ. Advancing V-flap dismembered pyeloplasty. Urology. 1981;18:235–237. Diamond DA, Nguyen HT. Dismembered V-flap pyeloplasty. J Urol. 2001;166:233–235. Verduyckt FJ, Heesakkers JP, Debruyne FM. Long-term results of ileum interposition for ureteral obstruction. Eur Urol. 2002;42:181–187. Matlaga BR, Shah O, Assimos DG. Ileal ureter substitution: a contemporary experience. Urology. In press. Bodie B, Novick AC, Rose M, Straffon RA. Long-term results with renal autotransplantation for ureteral replacement. J Urol. 1986;136:1187–1189. Hinman F. Calicoureterostomy. In: Hinman F, ed. Atlas of Urologic Surgery. 2nd ed. Philadelphia: WB Saunders Company; 1998:840–841. VOL. 5 NO. 3 2003 REVIEWS IN UROLOGY 203