Global Practice Patterns and Variations in the Medical and Surgical Management of Non-Obstructive Azoospermia: Results of a World-Wide Survey, Guidelines and Expert Recommendations

PURPOSE

Non-obstructive azoospermia (NOA) is a common, but complex problem, with multiple therapeutic options and a lack of clear guidelines. Hence, there is considerable controversy and marked variation in the management of NOA. This survey evaluates contemporary global practices related to medical and surgical management for patients with NOA.

MATERIALS AND METHODS

A 56-question online survey covering various aspects of the evaluation and management of NOA was sent to specialists around the globe. This paper analyzes the results of the second half of the survey dealing with the management of NOA. Results have been compared to current guidelines, and expert recommendations have been provided using a Delphi process.

RESULTS

Participants from 49 countries submitted 336 valid responses. Hormonal therapy for 3 to 6 months was suggested before surgical sperm retrieval (SSR) by 29.6% and 23.6% of participants for normogonadotropic hypogonadism and hypergonadotropic hypogonadism respectively. The SSR rate was reported as 50.0% by 26.0% to 50.0% of participants. Interestingly, 46.0% reported successful SSR in <10% of men with Klinefelter syndrome and 41.3% routinely recommended preimplantation genetic testing. Varicocele repair prior to SSR is recommended by 57.7%. Half of the respondents (57.4%) reported using ultrasound to identify the most vascularized areas in the testis for SSR. One-third proceed directly to microdissection testicular sperm extraction (mTESE) in every case of NOA while others use a staged approach. After a failed conventional TESE, 23.8% wait for 3 months, while 33.1% wait for 6 months before proceeding to mTESE. The cut-off of follicle-stimulating hormone for positive SSR was reported to be 12-19 IU/mL by 22.5% of participants and 20-40 IU/mL by 27.8%, while 31.8% reported no upper limit.

CONCLUSIONS

This is the largest survey to date on the real-world medical and surgical management of NOA by reproductive experts. It demonstrates a diverse practice pattern and highlights the need for evidence-based international consensus guidelines.

Global Practice Patterns in the Evaluation of Non-Obstructive Azoospermia: Results of a World-Wide Survey and Expert Recommendations

PURPOSE

Non-obstructive azoospermia (NOA) represents the persistent absence of sperm in ejaculate without obstruction, stemming from diverse disease processes. This survey explores global practices in NOA diagnosis, comparing them with guidelines and offering expert recommendations.

MATERIALS AND METHODS

A 56-item questionnaire survey on NOA diagnosis and management was conducted globally from July to September 2022. This paper focuses on part 1, evaluating NOA diagnosis. Data from 367 participants across 49 countries were analyzed descriptively, with a Delphi process used for expert recommendations.

RESULTS

Of 336 eligible responses, most participants were experienced attending physicians (70.93%). To diagnose azoospermia definitively, 81.7% requested two semen samples. Commonly ordered hormone tests included serum follicle-stimulating hormone (FSH) (97.0%), total testosterone (92.9%), and luteinizing hormone (86.9%). Genetic testing was requested by 66.6%, with karyotype analysis (86.2%) and Y chromosome microdeletions (88.3%) prevalent. Diagnostic testicular biopsy, distinguishing obstructive azoospermia (OA) from NOA, was not performed by 45.1%, while 34.6% did it selectively. Differentiation relied on physical examination (76.1%), serum hormone profiles (69.6%), and semen tests (68.1%). Expectations of finding sperm surgically were higher in men with normal FSH, larger testes, and a history of sperm in ejaculate.

CONCLUSIONS

This expert survey, encompassing 367 participants from 49 countries, unveils congruence with recommended guidelines in NOA diagnosis. However, noteworthy disparities in practices suggest a need for evidence-based, international consensus guidelines to standardize NOA evaluation, addressing existing gaps in professional recommendations.

A Prospective Study on the Efficacy of Cognitive Targeted Transrectal Ultrasound Prostate Biopsy in Diagnosing Clinically Significant Prostate Cancer

Purpose

We present our study, done to identify the diagnostic yield of cognitive targeted biopsy using mpMRI data, to diagnose clinically significant prostate cancers, in a cohort of biopsy and treatment naive men.

Materials and Methods

This is a prospective, single institutional study, done from September 2018 to March 2020 in 75 biopsy naive men. The patients with 3, 4 and 5 PIRADS scores underwent mpMRI cognitive target biopsy (mpMRI CTB) followed by standard biopsy (SB) in the same setting by two different urologists. Diagnostic yield of biopsy cores, complications, and stage migration of Gleason’s grades was analyzed.

Results

Out of 75 patients, 34.6% had abnormal digital rectal examination (DRE), and the median serum PSA was 10.6 (4.5–20) ng/mL. Total MRI suspicious lesions were 163. Out of 1263 SB cores, 371 cores were positive for cancer (29.35%), and out of 326 mpMRI CTB cores, 120 were positive for cancer (36.8%) (P<0.0001). Histopathological examination (HPE) revealed 88%, 92%, and 100% clinically significant cancers in PIRADS 3, 4 and 5 lesions. SB and mpMRI CTB in combination have better cancer detection yield than either of the modality when used alone (P-<0.0001). Clavien-Dindo grade 1 and grade 4a complication were seen in 47 (62.6%) and three (4%) patients.

Conclusion

In biopsy-naive men with suspected prostate cancer and equivocal DRE, the addition of pre-biopsy mpMRI detects greater numbers of people with clinically significant prostate cancer when compared with SB alone. Combining SB with mpMRI CTB has a superior diagnosing ability when compared with either of the biopsy modalities when used alone.

In situ Management of Large Upper Ureteric Calculus by Mini-Percutaneous Nephrolithotomy in the Era of Retrograde Intrarenal Surgery

Purpose

The aim of the study is to demonstrate the ease and success of in situ management of large upper ureteric stones with mini percutaneous nephrolithotomy (PCNL).

Methods

This was a prospective observational study conducted in the Department of Urology between January 2018 and June 2019. All patients underwent standard prone mini PCNL with 15Fr amplatz with 80 cases of fluoroscopic and 12 cases of ultrasound guided access. In three cases of tortuous ureters, wire was passed via retrograde catheter and retrieved via amplatz to straighten the ureter. Calculi fragmented with laser.

Results

A total of 77 patients were included in this study, 62 unilateral and 15 bilateral cases (92 renal units). The mean age was 45.4±13.7 years (range 17–71), male to female ratio was 61:16, the disease laterality (left: right) was 28:34. The mean stone size was 17.6±1.4 mm. Mean operative time was 22.4±1.5 min. 88% patients were discharged as day care. Complication rate was 6.5%, three patients had transient fever and two patients had distal migration of small fragments and they were extracted at the time of DJ stent removal by rigid ureteroscopy (100%).

Conclusion

We conclude that it is easy and effective to deal with large upper ureteric calculus when it is in a fixed position. In situ management of large upper ureteric calculus by mini-PCNL can be done safely and effectively as it is a fast procedure, prevents unnecessary manoeuvres, less complication rates and has good stone clearance rates.

Preparative thin-layer chromatographic separation followed by identification of antifungal compound in Cassia laevigata by RP-HPLC and GC-MS

BACKGROUND

Several species of the genus Cassia are known for their antioxidant, antimicrobial and antidiabetic activities, but some of the lesser-known Cassia species, e.g. C. renigera, C. biflora and C. laevigata have not been studied for their biological activities.

RESULTS

Methanol extract of C. laevigata was fractionated by preparative thin-layer chromatography. The resulting six different fractions were tested against Fusarium oxysporum and Aspergillus niger for their antifungal activity. Due to higher antifungal activity of fraction 1 of C. laevigata, this was further analyzed by reversed-phase high-performance liquid chromatography (RP-HPLC), resulting in distinct separation of one compound at a retention time of 7.2 min with an absorbance of 252 nm. Further, this compound was analyzed by gas chromatography-mass spectrometry (GC-MS) for its putative structural identification. Mass spectra of this compound resembled the spectra of anthraquinone 1-carboxylic acid by NIST library search. The genomic-level expression of chalcone synthase, a key enzyme involved in the biosynthesis of polyketides, was increased in C. laevigata when compared to other Cassia species.

CONCLUSIONS

This study provides an insight into the higher antifungal activity of C. laevigata, including the identification of anthraquinone 1-carboxylic acid, which may be responsible for the antifungal activity.