The 14th Annual International Symposium of Operative Andrology was organized by John Pryor (UK). The meeting took place in London, UK from March 9-11, 1995. Various sessions concerned either normal and abnormal erectile function or the diagnosis and treatment of male reproductive disorders.

Dr. M.A.W. Miller (UK) discussed biochemical activity in the corpus cavernosum of control and streptozocin treated diabetic rats. After rats had untreated diabetes mellitus for two months, the conversion of tritiated cyclic AMP to tritiated adenosine was measured in penile tissue. The levels of both adenosine and of nitric oxide were higher in the penile tissue of untreated diabetic rats than in controls, which was contrary to the expected findings. Further studies are planned. K. Bolayir (Turkey) reported the use of triple therapy (papaverine, phentolamine and prostaglandin E1) and the use of verapamil for intracavernosal self-injection therapy. The results with verapamil were about the same as were obtained with triple drug therapy except verapamil resulted in less frequent penile scar formation and less frequent priapism; verapamil also was cheaper than triple drug therapy.

Dr. A.G. Bhojwani (UK) reported on the use of prostaglandin E1 in male erectile dysfunction. The majority of patients required a 20 microgram dose. It was concluded that the drug is safe and effective for a wide variety of etiologies of erectile dysfunction. D. Ralph (UK) studied 118 patients with newly diagnosed Peyronie´s disease. Sixty-seven patients complained of impaired erections. His studies indicated that softening of the distal portion of the penis during erection in patients with Peyronie´s disease may be a result of cavernosal artery disease rather than a result of the Peyronie´s fibrotic process itself.

Dr. M. Ahmed and F. Osman (Saudi Arabia) evaluated erectile dysfunction with Doppler ultrasound studies.

M.C. Tritto and associates (France) reported experience with penile reconstruction using a forearm flap that was transferred microsurgically. The procedure included simultaneous construction of a neourethra. J. Barrett (UK) reported psychiatric studies of 49 patients who had undergone female to male transsexual surgery by J. Pryor (UK). Half of the patients did not have a previous history of psychiatric difficulty except for gender dysphoria. After the transsexual surgical procedures had been completed, over half of the patients were able to have sexual relations with a female. An unexpected finding was that the use of both alcohol and cigarettes increased after all surgical procedures had been completed. Additionally, it was surprising that a psychiatric sex role inventory revealed that fewer patients thought of themselves as being males postoperatively than preoperatively!

Dr. R. Schoysman (Belgium), who was the honored guest of the meeting, presented a brilliant review of epididymal surgery. He pointed out that the localized area of obstruction near the caudal end of the epididymis that results from gonorrhea now is seen infrequently as a cause of epididymal obstruction. Instead, obstruction resulting from previous episodes of chlamydial epididymitis is being encountered. Chlamydial infection results in diffuse scarring of the epididymis and thus is difficult to treat surgically. Professor Schoysman reviewed his extensive 25-year experience with vasoepididymostomy. His series included various methods of performing the anastomosis. He expressed his present preference for the microsurgical end-to-side type of anastomosis. M. Bedford (USA) discussed epididymal anatomy and physiology as they apply to the surgeon. He indicated that sperm storage and transit times are shorter in the human epididymis than occur in most animals. Also, the capacitation time of human sperm is shorter than the capacitation time observed in most animals. He mentioned studies suggesting that the cells that line the lumen of the vas deferens may have particular functions to influence sperm development other than having a purely conduit type of function. A. Hirsh (UK) reported his observations of epididymal anatomy in specimens at the Glasgow Hunterian Anatomical Collection. The specimens have been preserved for hundreds of years since John Hunter injected the vasa deferentia of the specimens with mercury to fill the entire epididymal tubule and the rete testis. The details of the anatomy of the rete were described. It was reported that 10 human specimens contained a range of 7 to 12 efferent ducts.

Dr. G. Haidl (Germany) reported that phosphatidylcholine plays a significant role in human epididymal sperm maturation. Phosphatidylcholine was observed to increase the motility of sperm in the caput epididymis. It was observed that sperm incorporate phosphatidylcholine during epididymal transit and that sperm motility thus is increased as spermatozoa progress through the epididymis. P. Temple-Smith (Australia) reported experiences with vasovasostomy using free transferred grafts of the vas in both rats and rabbits. Additional studies were performed using free vas grafts to bridge epididymal obstructions. Reasonable patency and fertility rates attested to the success of the various procedures in these experimental animals.

Dr. P.N. Schlegel (USA) reported on the incidence of various urogenital anomalies in men with congenital absence of vas deferens (CAV). Renal agenesis was seen in 11% of men with bilateral CAV and in 29% of men with unilateral CAV. The influence of various cystic fibrosis gene mutations relating to the various anomalies was examined. J. Pryor and W. Hendry (UK) attempted to classify Wolffian duct abnormalities in infertile men. They concluded that such a wide variety of abnormalities of the Wolffian duct system exist that no simple, brief classification is possible.

Dr. W. Hendry (UK) reported on his experience with the treatment of unilateral testicular obstruction. Reconstructive procedures were performed when possible. Some patients were treated with prednisolone because of the presence of antisperm antibodies and other patients underwent removal of the obstructed testicle. G. Papp et al (Hungary) reported their experience with implantation of alloplastic spermatoceles. They performed unilateral implantation of a Wagenkecht-Schirren type of prosthesis in 16 patients. Two pregnancies occurred with the use of intrauterine insemination performed with sperm aspirated postoperatively from the spermatoceles. Sperm were not retrieved from any of the spermatoceles longer than 4 months postoperatively. A.M. Belker, R.J. Sherins and L. Dennison-Lagos (USA) reported using the Diff Quick stain for simple and rapid staining of testicular biopsy touch imprints. The fixation and staining time require a total of less than 5 minutes, which allows the surgeon to make an immediate intraoperative decision about whether or not ductal obstruction is present at the time of the testicular biopsy. S. Tellaloglu et al (Turkey) reported comparisons of testicular biopsy touch imprints with permanent testicular biopsy results. They felt that the presence of 6-8 or more spermatozoa per high power field suggested that ductal obstruction was present if the patient had been observed to be azoospermic preoperatively.

Dr. R. Schoysman (Belgium) reported his observation of pregnancy rates after 12 years of follow-up in the wives of men with various degrees of oligospermia. While pregnancy occurred in the wives of 9 of 104 men who had sperm concentrations ranging from 0.1 to 1 million/ml, pregnancy rates were progressively higher in the wives of men with incrementally higher sperm concentrations. Of 510 men who had sperm concentrations between 15 and 20 million/ml, 418 achieved a conception over the 12-year duration of the study. G. Bahadur (UK) reported a study of the semen quality of men before and after chemotherapy and/or radiotherapy for testicular cancer and for Hodgkin´s disease. The average sperm concentration before initiation of therapy was 76 million/ml, while the average concentration at 19 months after completion of therapy was 20 million/ml. C. Bettocchi (UK) reported on clinical aspects of the Sertoli Cell Only Syndrome. He pointed out that the original syndrome described by del Castillo et al included azoospermia, small testes and elevated serum levels of follicle stimulating hormone. Six of 42 of Bettocchi´s patients who had a histologic diagnosis bilaterally of Sertoli Cell Only Syndrome actually had severe oligospermia rather than azoospermia! S. Micic et al (Yugoslavia) reported that patients who underwent subing-uinal varicocelectomy had significantly less days off from work than patients who underwent inguinal or low retroperitonealvaricocelectomy and that the rates of improve-ment of semen analysis results were the same in both groups. R. Pencov et al (Bulgaria) reported their experience with microsurgical anastomotic procedures to treat varicoceles.

Dr. J. Tritto et al (France) studied serum hormone patterns in men with impotence. They concluded that most aged impotent men had low levels of serum free testosterone and of serum dihydrotestosterone. N.P. Singh et al (UK) reported their experiences with vacuum constrictor devices for the treatment of male impotence. Seventy percent of 116 patients chose this type of treatment. The help of a representative of the manufacturer to explain the use of the device to the patient improved the rate of patient acceptance. A.G. Bhojwani et al (UK) reported on the results of sexual satisfaction surveys of men who had had penile prostheses and of their wives. A variety of prostheses were used. Approximately 80% of patients were happy with the device that had been implanted. R.W. Lewis (USA) reviewed the long-term results of modern three piece inflatable penile prostheses. A large amount of data was presented. Contraindications to the implantation of penile prostheses include (1) severe medical diseases, (2) severe corporal fibrosis such as may occur in patients who have sickle cell disease and (3) balanoposthitis. Postoperative infection rates were found to be the same after implantation of inflatable prostheses as occurred after implantation of noninflatable prostheses. P.A. Scheplev (Russia) reported experience with treatment of an amputated penis in 7 patients. Some patients underwent acute reimplantation, while others underwent phallic reconstruction using forearm flaps based upon the radial artery.

The final morning of the meeting was concerned with both assisted reproductive technologies and sperm aspiration procedures. J. Pryor (UK) reported experience with both subzonal insertion (SUZI) and intracytoplasmic sperm injection (ICSI) in patients who had male factor infertility and in patients who had previously failed in vitro fertilization procedures. Much better rates of fertilization, transfer and pregnancy occurred with ICSI than with SUZI. P.N. Schlegel (USA) reported his groupÕs observation of the influence of cystic fibrosis gene mutations on the results of epididymal sperm aspiration and in vitro fertilization. Rates of fertilization and of pregnancy were not significantly different if cystic fibrosis gene mutations were present than if such mutations were absent. These findings were contrary to the findings of a previous report by another group. J. Tritto (France) reported the results of microsurgical epididymal sperm aspiration and the use of testicular sperm for in vitro fertilization with ICSI in a small group of six patients. A.M. Belker (USA) reported further experience with the microsurgical aspiration of sperm from the vas deferens of men with neurogenic ejaculatory dysfunction following failure to achieve a pregnancy with the use of sperm obtained by electroejaculation. He emphasized that the percentage and quality of motility of sperm obtained by vas aspiration was significantly better than the percentage and quality of motility of sperm obtained by electroejaculation. Various possible reasons, including abnormal storage of sperm in the seminal vesicles of men with ejaculatory dysfunction and the known presence of a sperm motility inhibitor in the seminal vesicles, were mentioned.

The meeting concluded with a panel discussion of the results and expectations with sperm aspiration procedures. Panelists included A.M. Belker and P.N. Schlegel (USA), I. Craft, A. Hirsh and J. Pryor (UK), R. Schoysman (Belgium) and P. Temple-Smith (Australia). The moderator was M. Bedford (USA). Methods of obtaining sperm by means of needle aspiration of either the epididymis or testicle were reported. R. Schoysman reported that over 20 pregnancies with in vitro fertilization/ICSI had occurred in his program with the use of testicular sperm. P.N. Schlegel questioned whether or not the increased contamination of sperm with red blood cells at the time of needle aspiration procedures compared to the amount of contamination that occurs with microsurgical aspiration procedures might result in reduced rates of fertilization and pregnancy when needle aspiration is performed. All panelists agreed that it will be necessary to observe offspring of these procedures for a possible increased rate of significant congenital anomalies before recommending the use of such procedures without reservation.

Arnold M. Belker, USA



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