Amr Abdel Raheem

INTRODUCTION: Botulinum toxin type A (BoNT-A) has been used to treat several striated and smooth muscle disorders. During the past year, human and animal studies conducted in Egypt and Canada by two different groups of investigators have suggested a possible role for the intracavernosal injection of BoNT-A in the treatment of erectile dysfunction (ED).

AIM: To discuss BoNT-A and its current medical uses, the rationale for its new potential use in the treatment of ED, and the available evidence and concerns.

METHODS: A literature search was conducted. This review was based on the available studies presented at the European Society for Sexual Medicine, Sexual Medicine Society of North America, and International Society for Sexual Medicine meetings in 2016 by the two groups.

MAIN OUTCOME MEASURES: Sinusoidal diameter; penile color Doppler study; Erection Hardness Score; Sexual Health Inventory for Men questionnaire; and Sexual Encounter Profile questions 2 and 3.

RESULTS: Two human studies conducted by the authors and two animal studies (one from the authors' group and one from Canada) were reviewed. These seemed to suggest generally favorable outcomes with the use of BoNT-A in the treatment of ED.

CONCLUSION: BoNT-A could be a potential therapy for ED. In addition to the findings of the three pilot studies, larger multicenter trials need to be conducted to further explore the true therapeutic efficacy and clinical safety of BoNT-A in the treatment of ED. Ghanem H, Raheem AA, AbdelRahman IFS, et al. Botulinum Neurotoxin and Its Potential Role in the Treatment of Erectile Dysfunction. Sex Med Rev 2018;6:135-142.

A 59-year-old man with a 6-year history of erectile dysfunction presented to the andrology outpatient clinic. Multimodality assessment with ultrasound, MRI venography and fluoroscopic venography demonstrated an aberrant emissary vein arising from the corporal bodies causing venogenic erectile dysfunction. Selective coil embolisation of the collateral vein resulted in an almost immediate and sustained improvement in his erections.

INTRODUCTION: Peyronie's disease (PD) affects up to 9% of the male population. PD causes scarring of the tunica albuginea of the penis which leads to penile deformity making sexual intercourse difficult or impossible. PD also causes significant psychological, emotional and relationship difficulties for both patient and partner. Up until the licencing of Collagenase clostridium histolyticum (CCH) (Xiapex®, Xiaflex®), surgical correction of the penile deformity was the mainstay of treatment. Many conservative treatment options had been previously tried, however, the safety and efficacy of these options has not been demonstrated in large well-designed clinical trials. Intra-lesional CCH is now the gold standard option for the non-surgical management of PD. It is the first and only treatment approved by the Food and Drug Administration and the European Medicines Agency for PD. In this review article, we will discuss the pharmacology, clinical efficacy, safety and future of CCH intralesional injection.

EVIDENCE ACQUISITION: MEDLINE and PubMed search (from 1946). The search terms ("Collagenase Clostridium Histolyticum" OR "Xiapex" OR "Xiaflex") AND "Peyronie's disease" were used.

EVIDENCE SYNTHESIS: The safety and efficacy of intra-lesional CCH in the management of PD has been demonstrated in 2 large-scale multicenter, randomized, double-blind placebo-controlled clinical trials; the investigation for Maximal Peyronie's Reduction Efficacy and Safety Studies I and II (IMPRESS I and IMPRESS II). A new study published by our group suggests a new modified shortened protocol that will reduce the cost and duration of treatment without compromising the safety or efficacy of treatment.

CONCLUSIONS: CCH is the gold standard non-surgical option in the management of PD. The safety and efficacy of CCH has been demonstrated in large well-designed clinical trials. The new modified protocol, developed by our group, reduces the cost and inconvenience to patients whilst maintaining the efficacy. This will allow more men to benefit and will reduce the number of men undergoing surgical correction for their PD.

Many patients complain of shortened length following penile prosthesis implantation. Dorsal phalloplasty (DP) can accompany prosthesis placement to mitigate this complaint by resulting in more visible penis outside the plane of the patient's body. DP is done through the same incision. A nonabsorbable suture approximates the under surface of the skin where the penis meets the pubis to the periosteum of the pubic bone. This adjunctive procedure results in more visible proximal penile shaft. We compared penile visible length (pubic skin surface to tip) in patients who had the adjunctive procedure with prosthesis insertion to patients who had only the penile prosthesis. Totally, 66 patients had DP and 60 did not. All patients were operated through a penoscrotal incision. The tacking suture of # 5 nonabsorbable braided polyester was passed through the pubic periosteum then into the subcutaneous tissue and dermis of the under surface of the pubic skin. The suture was tied after prosthesis insertion. Efficacy of DP was evaluated by measured gain in erect visible length in the DP group, maintenance of that length gain until final follow up at 3 years, as well as by the difference in subjective evaluation criteria between both groups. The DP group had a 23% increase in visible length compared to pretacking (p < 0.0001) that was durable to 36 months. Subjectively, 80% of patients in the prosthesis alone group reported a shorter penis in contrast to 6.1% in the DP group. The DP group reported 28.4% higher satisfaction with length, compared to the control group (p < 0.0001). In conclusion, DP accompanying prosthesis insertion improved visible length, minimized the impression of shortening, and enhanced satisfaction with length.

We report on the 1st case of ischemic priapism secondary to poorly controlled homocystinuria. Homocystinuria is a rare, autosomal recessive, inherited disorder of metabolism that is caused by a deficiency of cystathionine synthase, leading to marked hyperhomocysteinemia. Arterial and/or venous thromboemboli are a major cause of mortality and morbidity in patients with homocystinuria. Untreated patients have a 50% chance of having a vascular event by 30 years of age. Increased homocysteine levels have been reported to upregulate prothrombotic factors and downregulate antithrombotic factors; in particular, increased homocystinuria has been found to downregulate nitric oxide (NO). Mice that are deficient in NO synthase in the cavernosal smooth muscles have a higher incidence of priapism. Decrease in NO synthase causes downregulation of cyclic guanosine monophosphate, phosphodiesterase type 5A, and Rho A/Rho-kinase. Because persistently increased homocysteine also downregulates NO, a similar mechanism could be proposed for priapism secondary to homocystinuria. In patients presenting with priapism, specific features of homocystinuria should be sought; in selected patients, screening with plasma total homocysteine might be appropriate. Ischemic priapism secondary to homocystinuria appears to respond well to the standard treatment options of aspiration, intracavernosal injection with phenylephrine, and, if required, a shunting procedure. Johnson M, Murphy E, Raheem A, Ralph D. Poorly Controlled Homocystinuria: A Rare Cause of Ischemic Priapism? Sex Med 2018;6:171-173.

INTRODUCTION: Peyronie's disease (PD) is a common condition that results in penile deformity, which makes sexual intercourse difficult or impossible, and causes psychological, emotional, and relationship difficulties for the man affected and his partner. Collagenase Clostridium histolyticum (CCH; Xiapex, Xiaflex) is the first licensed non-surgical treatment option for PD. The safety and efficacy have been demonstrated in two large phase III randomized controlled trials (IMPRESS I and IMPRESS II).

AIM: To review the safety and efficacy of CCH and to introduce a new shortened modified protocol for CCH that was developed by the authors to decrease the cost and duration of treatment.

METHODS: A review of the medical literature on CCH for inclusion in this review was obtained by searching the PubMed (from 1946) and Medline (from 1946) medical databases and from the screening of relevant bibliographies. The search terms Xiapex, Xiaflex, collagenase Clostridial histolyticum, and Peyronie's disease were used. Clinical trials in men with PD and scientific articles relating to pharmacologic data were included in the review. When possible, large, randomized, and well-designed trials were selected.

MAIN OUTCOME MEASURES: Changes in the angle of penile curvature and in the Peyronie's Disease Questionnaire domains.

RESULTS: The clinical trials demonstrate the safety and efficacy of CCH in the treatment of PD. The new modified protocol developed by the authors is as safe and effective as the protocol used in the clinical trials.

CONCLUSION: CCH is the first licensed non-surgical treatment for PD. Its safety and efficacy have been demonstrated in large well-designed clinical trials. The new shortened modified protocol decreases the cost and duration of the treatment without compromising the safety and efficacy of the drug. This alteration will allow more patients to benefit from CCH. Abdel Raheem A, Johnson M, Abdel-Raheem T, et al. Collagenase Clostridium histolyticum in the Treatment of Peyronie's Disease-A Review of the Literature and a New Modified Protocol. Sex Med Rev 2017;5:529-535.

BACKGROUND: Collagenase Clostridium histolyticum (CCH) is indicated for the treatment of penile curvature in adult men with Peyronie's disease (PD) with palpable plaque and curvature deformity of at least 30° at the start of therapy.

AIM: To evaluate the efficacy and safety of CCH plus vacuum-pump therapy with and without penile modeling for the management of PD.

METHODS: Adult men with PD and penile curvature of at least 30° were randomly assigned to receive CCH 0.58 mg plus vacuum therapy alone (n = 15) or with penile plaque modeling (n = 15). Patients received no more than four treatment cycles (cycle = ∼6-week duration), each consisting of two intralesional injections of CCH administered 24 to 72 hours apart. Vacuum therapy was applied twice daily from 14 days after the second injection of each cycle until the following cycle. Modeling was performed 24 to 72 hours after the second injection of each cycle.

OUTCOMES: The primary end point was change in penile curvature from baseline to week 36; additional end points included changes in Peyronie's Disease Questionnaire (PDQ) domain scores, composite response (≥20% decrease in penile curvature and decrease in PDQ bother score ≥ 1 point), and global response (small but important, moderate, or much improvement in the Global Assessment of PD).

RESULTS: At week 36, improvement in penile curvature from baseline was similar in the two groups (mean change from baseline = -23.7° [SD = 10.9] for CCH + vacuum + modeling and -23.3° [SD = 7.2] for CCH + vacuum; between-group difference = -0.3°, 95% CI = -7.3 to 6.6). Improvements in most PDQ domains, including bother, were observed from baseline to week 36 in the two groups. Most patients were composite (66.7% and 84.6% with CCH + vacuum + modeling and CCH + vacuum, respectively) and global (86.7% and 92.3%, respectively) responders. The most common adverse events were penile contusion, penile swelling, and penile pain.

CLINICAL IMPLICATIONS: Vacuum-pump therapy administered alone or in combination with modeling after CCH treatment could improve PD symptoms.

STRENGTHS AND LIMITATIONS: This was a pilot study with a small sample and limited follow-up duration.

CONCLUSION: CCH and vacuum-pump therapy (alone or combined with modeling) could be an appropriate consideration for men with PD and warrants further investigation. Ralph DJ, Abdel Raheem A, Liu G. Treatment of Peyronie's Disease With Collagenase Clostridium histolyticum and Vacuum Therapy: A Randomized, Open-Label Pilot Study. J Sex Med 2017;14:1430-1437.

OBJECTIVE: To review the current literature on early penile prosthesis implantation in patients with refractory ischemic priapism (IP).

ACQUISITION OF EVIDENCE: A systematic search for the terms "penile prosthesis", "priapism", "impotence", "fibrosis", "downsized prosthesis cylinders", and "patient satisfaction" has been carried out in PubMed, EMBASE, Cochrane, SCOPUS and Science Citation Index databases.

SYNTHESIS OF EVIDENCE: Cavernosal tissue damage in IP is time related. Conservative measures and aspiration with or without intracorporeal instillation of α-adrenergic agonists are usually successful in the early stages. Shunt surgery in patients remains debatable, as the lack of response to aspiration and instillation of α-adrenergic agonists indicates that irreversible changes in the cavernosal smooth muscle are likely to have already occurred. Immediate penile prosthesis implantation in patients with refractory IP settles the priapic episode, maintains the long term rigidity necessary to engage in penetrative sexual intercourse and prevents the otherwise inevitable penile shortening. Although complication rates after penile prosthesis implantation in acute priapism are higher than in virgin cases, they are still lower than after implantation in patients with severe corporal fibrosis due to chronic priapism. Regardless of the complication rates, penile prosthesis implantation in refractory IP should be preferred as it allows the preservation of penile length, which is one of the main factors influencing postoperative patient's satisfaction following surgery.

OBJECTIVE: The aim of this study was to report surgical and functional outcomes in patients who underwent immediate penile fracture repair following location of the tunical tear with ultrasonography.

METHODS: Patients' clinical notes from September 2005 to October 2015 were reviewed. The inclusion criteria were the documented presence of an albugineal laceration at the preoperative ultrasonography and during surgical exploration. In total, 76 patients were enrolled in the study. The aetiology, presentation, imaging results, intraoperative findings, functional outcomes and complications of surgical repair were retrospectively extrapolated from the clinical notes. Patients were questioned about their erectile and urinary function 12 months after the traumatic event. Validated questionnaires were administered to enquire about sexual and urinary function. Finally, the accuracy of the ultrasound in detecting the site of the tunical defect was evaluated.

RESULTS: The mean age was 39.5 years (range 21-72 years) and the median follow-up was 13 weeks. The aetiology of the fracture was sexual intercourse in 70 patients, the taqaandan manoeuvre in three and trauma while sleeping in three. The intraoperative findings showed a ventral and transverse tear in 93.5% of cases. Urethral injuries were evident in one-quarter of the patients. Ultrasonographic findings were confirmed intraoperatively in all patients. Worsening of the quality of erections was reported by 5% of patients, and 5.2% reported a penile curvature postoperatively.

CONCLUSION: Penile fracture is a rare urological emergency and requires early surgical exploration and repair. Ultrasonography is a cheap and readily available investigation that allows confirmation of the diagnosis, and identification of the location of the tear and the associated urethral injury.

OBJECTIVE: To assess the prevalence of obstructive sleep apnoea (OSA) in men presenting with erectile dysfunction (ED) at a single centre.

PATIENTS AND METHODS: All men attending a specialised andrology outpatient department with a new diagnosis of ED were included in this prospective study. All patients completed three questionnaires: the International Index of Erectile Function (IIEF) and two sleep questionnaires [the Obstructive Sleep Apnoea Screening questionnaire and the Insomnia Severity Index (ISI)]. Their ED management was subsequently undertaken in accordance with local and European guidelines. An OSA diagnosis was made based on a score of ≥3 on the Obstructive Sleep Apnoea Screening questionnaire and those patients were referred for specialist management.

RESULTS: Between February and September 2016, 129 patients with ED completed the study questionnaires. In all, 71 patients (55%) had a score of ≥3 on the Obstructive Sleep Apnoea Screening questionnaire, indicating a need for specialist sleep referral. Men who scored ≥3 on the Obstructive Sleep Apnoea Screening questionnaire were significantly older (61.4 vs 46.5 years; P < 0.001) and had a significantly higher body mass index (29.4 vs 26.7 kg/m ; P < 0.001) when compared to the control group (OSA score of <3). The sleep apnoea group (OSA score of ≥3) had significantly worse IIEF-ED scores (6.2 vs 9.1; P = 0.018) and ISI scores (7.9 vs 5.5; P = 0.061).

CONCLUSION: Men presenting to the andrology clinic with ED are at significant risk of having undiagnosed sleep disorders. This has serious adverse health consequences, as well as being associated with potential dangers at work and travel. The patient compliance was high with 78% completing all three questionnaires. It is feasible to screen this population for sleep disturbance and this should be part of the ED assessment.

OBJECTIVES: To evaluate the efficacy and safety of collagenase clostridium histolyticum (CCH; Xiapex , Xiaflex ) in the treatment of Peyronie's disease (PD) using a new modified treatment protocol that aims at reducing the number of injections needed and reducing patient visits, thus reducing the duration and cost of treatment.

PATIENTS AND METHODS: A prospective study of 53 patients with PD who had treatment with CCH at a single centre using a new modified protocol. The angle of curvature assessment after an intracavernosal injection of prostaglandin E1, the International Index of Erectile Function (IIEF) and Peyronie's Disease Questionnaire (PDQ) were completed at baseline and at week 12 (4 weeks after the last injection). The Global Assessment of Peyronie's disease (GAPD) questionnaire was completed at week 12. Under a penile block of 10 mL plain lignocaine 1%, a total of three intralesional injections of CCH (0.9 mg) were given at 4-weekly intervals using a new modified injection technique. In between injections patients used a combination of home modelling, stretching and a vacuum device on a daily basis to mechanically stretch the plaque. Investigator modelling was not performed.

RESULTS: The mean (range) penile curvature at baseline was 54 (30-90)°. Of the 53 patients in the study, 51 patients (96.2%) had an improvement in the angel of curvature by a mean (range) of 17.36 (0-40)° or 31.4 (0-57)% from baseline after three CCH injections. The final mean (range) curvature was 36.9 (12-75)° (P < 0.001). There was an improvement in each of the IIEF questionnaire domains, all three PDQ domains and the GAPD. CCH was well tolerated by all patients with only mild and transient local adverse events.

CONCLUSION: The new shortened protocol using CCH treatment is safe, effective, and cost efficient. The results of using only three CCH injections according to this modified protocol are comparable to those of the clinical trials that used eight CCH injections.

INTRODUCTION: Although genital injuries in civilian centers are rare, the scenario is completely different in the battlefield. If the penile distal stump is not adequate for primary reimplantation or it cannot be found, then delayed penile reconstruction needs to be considered.

AIM: To report a single-center experience with total phallic reconstruction using radial artery based forearm free flap (RAFFF) after penile traumatic loss.

METHODS: We retrospectively reviewed the clinical records of 10 patients who underwent total phallic reconstruction with the use of the RAFFF from September 2001 through August 2015 after traumatic amputation of the penis.

MAIN OUTCOME MEASURES: Patients' baseline features, surgical outcomes, complications, and satisfaction are reported.

RESULTS: The average age at the time of penile reconstruction was 36 years (range = 27-52 years). The causes of penile loss were self-amputation owing to an acute schizophrenic episode (n = 2), road traffic accident (n = 3), blast injury (n = 3), donkey bite (n = 1), and Fournier gangrene (n = 1). The average time from the trauma to reconstruction with the RAFFF was 7 years (range = 2-15 years). The urethral stump was adequate for primary anastomosis, with phallic neourethra construction in six patients. The remaining patients had complete avulsion of the penis and were voiding though a perineal urethrostomy. In consequence, they required a two-stage urethroplasty. An acute arterial thrombosis of the microsurgical anastomosis occurred in two patients and was managed successfully with immediate exploration. A neourethra stricture and fistula occurred in one patient, which needed revision. All patients who underwent complete urethral reconstruction could void and ejaculate from the tip of the phallus. After a median follow-up of 51 months (range = 1-114 months), all patients were satisfied with the size, cosmetic appearance, and sensation of the phallus. Six patients underwent inflatable penile prosthesis implantation and could engage in penetrative sex. However, revision surgery was needed in three patients (infection, n = 2; mechanical failure, n = 1).

CONCLUSION: Despite the high incidence of postoperative complications and the possible need for multiple operations, in expert hands and in large-volume centers, penile reconstruction with the RAFFF after traumatic loss of the penis yields excellent results and allows patients to regain sexual and urinary functions.

OBJECTIVE: Early insertion of a penile prosthesis in prolonged ischaemic priapism is easier to perform than late prosthesis placement, and preserves the penile length. The aim of this study was to assess whether a delayed exchange to an inflatable implant allows upsizing of the cylinders in patients who have undergone early insertion for refractory ischaemic priapism.

MATERIALS AND METHODS: Over a 30 month period, 10 patients with ischaemic priapism underwent an early insertion of a malleable penile prosthesis. The mean age was 41.3 years and the mean duration of priapism was 188 h. Following a median period of 130.5 days, all of these patients underwent exchange of the malleable to an inflatable prosthesis.

RESULTS: At the time of penile implant exchange, a median upsize in the length of the cylinders of 1 cm in either one or both corporal bodies (range 0-3 cm) was recorded. Five patients had deliberate downsizing at the initial operation owing to a previous shunt. The mean score on the five-item International Index of Erectile Function (IIEF-5) before insertion of the malleable prosthesis was 24 (range 20-25). Three months after the initial insertion of a malleable penile implant the satisfaction rate according to the IIEF-5 score was 80%. Three months after the exchange, the patient satisfaction rate increased to 90%.

CONCLUSION: Insertion of a malleable penile prosthesis is an acceptable option for patients with refractory ischaemic priapism. Although some patients deliberately have a shorter implant inserted initially owing to a previous distal shunt procedure, following a period of resolution the cylinders can be upsized at a later operation.

OBJECTIVE: To compare the long-term results of early and delayed insertion of a penile prosthesis (PP) in men with refractory ischaemic priapism (IP).

PATIENTS AND METHODS: Early insertion of a PP was carried out in 68 men with IP within a median of 7 days from the onset of priapism, while 27 had delayed insertion after a median of 5 months. The results for sexual ability, satisfaction and subjective penile shortening were assessed by questioning at follow-up visits.

RESULTS: In the early group, a malleable and an inflatable PP were implanted in 64 and four patients, respectively. After a median follow-up of 17 months, six patients needed revision surgery due to infection and curvature. Patient's satisfaction rate and ability to have sexual intercourse was 96%. In the delayed group, a malleable PP was inserted in 12 patients and an inflatable in the remaining 15. In all, 80% of the patients required a second corporotomy and downsized cylinders due to dense fibrosis. After a median follow-up of 21 months,seven patients required revision surgery due to infection,erosion and mechanical failure. In all, 25 patients were able to engage in sexual intercourse but the satisfaction rate was only 60% mainly due to significant penile shortening.

CONCLUSIONS: Early PP implantation should be the preferred option inpatients with IP, as the procedure is technically easier, has less complication rates and allows greater preservation of penile length.

PURPOSE: The current management of ischemic priapism that is refractory to conventional medical therapy is a form of shunt procedure that diverts blood away from the corpus cavernosum. We assessed the outcome of the T-shunt and intracavernous tunneling for the management of ischemic priapism.

MATERIALS AND METHODS: During a 36-month period 45 patients presented with prolonged ischemic priapism. Patients were divided into subgroups according to the duration of priapism. All patients had an unsuccessful primary treatment, and underwent a T-shunt and intracavernous tunneling with cavernous muscle biopsies. All patients completed an IIEF-5 (International Index of Erectile Function-5) questionnaire preoperatively and 6 months postoperatively.

RESULTS: Resolution of the priapism using a T-shunt and snake maneuver occurred in all patients with a priapism duration of less than 24 hours and in only 30% of those with priapism lasting more than 48 hours. After a 6-month median followup the IIEF-5 score was significantly reduced from a mean of 24 (range 23 to 25) preoperatively to 7.7 (range 5 to 24), which was related to the duration of the priapism (p <0.0005). All patients with priapism for more than 48 hours had necrotic cavernous smooth muscle on biopsy and had severe erectile dysfunction requiring the insertion of a penile prosthesis. Those patients with moderate and mild erectile dysfunction were treated with phosphodiesterase type 5 inhibitors.

CONCLUSIONS: The success of the T-shunt with snake tunneling is dependent on the duration of priapism. When it is less than 24 hours the results are favorable, although erectile dysfunction is still present in 50% of patients. In those with a priapism duration greater than 48 hours the technique usually fails to resolve the priapism and all patients end up with erectile dysfunction due to smooth muscle necrosis.

We describe and review the most recent techniques of male genital reconstruction, identifying relevant material with an unstructured PubMed-based search of previous reports, using the keywords 'reconstruction', 'glans', 'shaft', 'lymphoedema', 'skin graft', 'scrotoplasty', 'urethroplasty', and 'penile prosthesis'. This search produced 22 reports that were analysed in this review. Split-thickness skin grafts are ideal for glans reconstruction, while full-thickness skin grafts should be used to cover defects on the shaft penis, as they tend to heal with less contracture. The radial artery-based free-flap phalloplasty is the technique of total phallic reconstruction associated with the highest satisfaction rates. Further research is required to identify an ideal reconstructive technique that would guarantee superior cosmetic and functional results, minimising donor site morbidity.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: The management of patients with non-obstructive azoospermia (NOA) involves testicular sperm extraction (TESE or microdissection TESE) combined with intracytoplasmic sperm injection (ICSI). Sperm retrieval is successful in up to 50% of men with NOA; however, there is no single clinical finding or investigation that can accurately predict a positive outcome. Several studies have concluded that testicular biopsy is the best predictor of a successful TESE. The present study shows that the strongest predictor of the success of TESE is when tubules with mature spermatozoa (Johnsen score ≥8) are found in the histopathology specimen, irrespective of the overall state of spermatogenesis. The findings suggest that a lower limit threshold value of 2% of tubules with spermatogenesis in the histopathology specimen will result in a positive sperm retrieval. However, it is not practical to perform a diagnostic biopsy before TESE because this would mean that patients undergo two surgeries, which adds to the cost and increases the complications. The diagnostic biopsy is best coupled with an initial TESE before starting the ICSI cycle. Based on the findings of the histopathology specimen, patients may be then offered a repeat TESE if more sperm is needed on the day of ovum pick-up and ICSI. Also, if the initial TESE was negative, the biopsy result will help in the decision to offer a repeat TESE. This regimen is more cost-effective because the ICSI cycle will be started only if adequate sperm is retrieved.

OBJECTIVE: To assess whether testicular histopathology can predict the outcome of testicular sperm extraction (TESE) in men with non-obstructive azoospermia (NOA) and therefore the role of preoperative diagnostic testis biopsy.

PATIENTS AND METHODS: The study comprised a retrospective analysis of 388 patients with azoospermia who were referred from 2005 to 2010. Information collected included a clinical history and an examination including age and testicular size, serum follicle-stimulating hormone, two semen analyses and testicular histology collected at the time of surgical sperm retrieval (TESE or microdissection TESE).

RESULTS: In total, 388 patients with a mean (range) age of 37 (18-66) years were included in the present study. Based on the history, clinical and laboratory findings, 112 patients had obstructive azoospermia and 276 patients had NOA. All patients in the obstructed group had a positive sperm retrieval. The sperm retrieval rate for the NOA group was 50%. An analysis of the results showed that the best predictor of a positive sperm retrieval was when tubules with mature spermatozoa were seen at biopsy, irrespective of the overall state of spermatogenesis (P < 0.001).

CONCLUSIONS: The presence of tubules with spermatazoa on biospy is the best predictor of a positive surgical sperm retrieval in patients with NOA. The diagnostic biopsy is best coupled with an initial TESE before starting the intracytoplasmic sperm injection (ICSI) cycle. Based on the findings of the histopathology specimen, patients may be offered a repeat TESE if more sperm is needed on the day of ovum pick-up and ICSI, or a redo TESE if the initial TESE was negative.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: The management of patients with non-obstructive azoospermia (NOA) and some cases of obstructive azoospermia involves testicular sperm extraction (TESE or micro-dissection TESE) combined with intracytoplasmic sperm injection (ICSI). Several studies have investigated the effect of the male age, the cause of azoospermia, testicular histopathology, the type of sperm used, and the use of pentoxyphilline, on the ICSI cycle outcome in men with azoospermia. The present study showed that none of these factors influenced the ICSI outcome in men with azoospermia, thus once sperm is found in an azoospermic male, no other male factor seems to influence the ICSI outcome. To our knowledge this is the first study to comment on the outcome of ICSI in men with NOA based on testicular histopathology.

OBJECTIVES: To access the effect of: male age, the cause of azoospermia (obstructive azoospermia vs non-obstructive azoospermia [NOA]), testicular histopathology, the type of sperm used (fresh vs frozen-thawed), and the use of pentoxyphilline on the intracytoplasmic sperm injection (ICSI) cycle outcome in men with azoospermia. To our knowledge this is the first study to comment on the outcome of ICSI in men with NOA based on testicular histopathology.

PATIENTS AND METHODS: A retrospective analysis of 137 testicular sperm extraction-ICSI cycles performed between 2001-2010, involving 103 men with azoospermia, with 26 couples having repeat cycles.

RESULTS: Analysis of the results did not show any statistically significant differences in the fertilization, embryo cleavage, clinical pregnancy, live birth and miscarriage rates in relation to the male age, cuase of azoospermia, testicular histopathology, type of sperm used and the use of pentoxyphilline.

CONCLUSION: Once sperm is found in a man with azoospermia, no other male factor seems to influence the ICSI outcome.