Biomedical subjects
Publications and source records attributed to Harris M Nagler.
Radiopharmaceutic tracers are used commonly to diagnose and monitor benign and malignant conditions of the genitourinary system. Most often, these tracers assess renal function and obstruction in "normal" and transplanted renal units. More recently, especially with the advent of positron emission tomography (PET)/CT, the role of nuclear pharmaceutics in the staging and monitoring of malignancies has expanded.
The stimulatory role of testosterone in the production and release of prostate-specific antigen (PSA) has been well characterized. Testosterone production by the testes is dependent on a functional hypothalamic-pituitary-gonadal axis. High prolactin levels have been shown to disrupt this axis, resulting in decreases in gonadotropins and testosterone levels. We report a patient with prostate cancer and elevated PSA levels followed with "watchful waiting" for several years who experienced a precipitous decrease in PSA level over a 3 month period. The patient was found to have an asymptomatic prolactin-secreting pituitary macroadenoma.
OBJECTIVE: Iatrogenic injury to the vas deferens is a well-documented complication of inguinal hernia repair. Recently obstruction related to the use of polypropylene mesh for hernia repair has been reported. We describe a case using laparoscopy to mobilize the retroperitoneal vas and deliver it to the healthy vas proximal to the vas trapped in the cicatrix induced by mesh thus allowing a tension-free microsurgical repair. DESIGN: Case report. SETTING: Outpatient male infertility practice. PATIENT(S): Obstructed azoospermic men with polypropylene mesh. INTERVENTION(S): Laparoscopic retrieval of retroperitoneal vas segment for primary microsurgical anastomosis. MAIN OUTCOME MEASURE(S): Patency of vas and presence of sperm. RESULT(S): A tension-free, patent anastomosis was performed. CONCLUSION(S): Polypropylene mesh-induced fibrosis of the vas deferens can result in obstructive azospermia. Laparoscopy can be used to permit a microsurgical bypass of the obstructed segment.
OBJECTIVES: To determine whether use of the digital rectal examination (DRE) results in decreased participation in prostate cancer (PCa) screening, which, in turn, would result in lower detection. Population-based PCa screening includes prostate-specific antigen (PSA) measurement with or without a DRE. PSA and DRE screening provide greater sensitivity than PSA alone; however, the increased participation rate resulting from PSA-alone screening may result in a greater detection rate. METHODS: We performed a survey of 13,580 healthy men undergoing PSA-only population-based screening. In addition to the basic demographic information, the survey asked whether the participant would still be willing to participate in the screening if it included a DRE. We modeled the willingness to participate to assess the effect of PSA screening versus PSA and DRE screening on the basis of previously published data and our results. RESULTS: The results of our study indicated that only 78% of men would participate in screening that included both DRE and PSA. Thus, 7800 men of a theoretical population of 10,000 would participate in a screening that included both DRE and PSA. The positive screen rate (PSA > or = 4.0 ng/mL and/or abnormal DRE) would then have been 2013, with 472 PCa cases and 1540 negative biopsies. In the PSA-alone arm, all 10,000 men would have agreed to participate, and the positive screen rate (PSA > or = 4.0 ng/mL) would have been 1480, with 499 PCa cases and 980 negative biopsies. The PSA-alone arm would thus have detected 27 more cancers and performed 560 fewer negative biopsies. CONCLUSIONS: The results of our study have demonstrated that DRE is a significant barrier to participation in PCa screening. PSA plus DRE-based programs result in fewer cases of PCa detected, with a significant increase in negative biopsies. We, therefore, suggest that future mass screening efforts include only PSA determination and omit the DRE.
OBJECTIVE: To report a multiinstitutional experience of men presenting with infertility secondary to inguinal hernia repair using polypropylene mesh. SUMMARY BACKGROUND DATA: An estimated 80% of inguinal hernia operations involve placement of a knitted polypropylene mesh to form a "tension-free" herniorrhaphy. The prosthetic mesh induces a chronic foreign-body fibroblastic response creating scar tissue that imparts strength to the floor and leads to fewer recurrences. However, little is known about the long-term effects of the polypropylene mesh on the vas deferens, especially with regard to fertility. METHODS: Eight institutions in the United States reported a total of 14 cases of azoospermia secondary to inguinal vasal obstruction related to previous polypropylene mesh herniorrhaphy. Patient characteristics and operative findings were forwarded to 1 center for tabulation of data. RESULTS: Mean patient age was 35.5 years with an average duration of infertility of 1.8 years. Mean number of years between urologic evaluation and herniorrhaphy was 6.3 years. Types of inguinal hernia repair previously performed were: open (10), laparoscopic (2), or both (2). Nine patients had bilateral obstruction and 5 patients had unilateral obstruction with contralateral testicular atrophy or epididymal obstruction. Surgical exploration revealed a dense fibroblastic response encompassing the polypropylene mesh with either trapped or obliterated vas in all patients. Surgical reconstruction was performed in 8 of 14 men (57%). CONCLUSION: Reconstruction to restore fertility can be difficult secondary to fibrotic reaction. Before undergoing polypropylene mesh herniorrhaphy, men, especially of young reproductive age or with a solitary testicle, need to be carefully advised of potential obstruction and compromise to future fertility.
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PURPOSE: We determine whether practice patterns of pediatricians contribute to delays in diagnosing and treating adolescents with varicoceles. MATERIALS AND METHODS: A survey consisting of 11 multiple-choice questions was mailed to 5,000 pediatricians selected by zip code in New York State. Zip codes were chosen to reflect urban, suburban and rural counties. RESULTS: A total of 544 of the 5000 (10.9%) surveys were returned, and 92 (16.9%) pediatricians acknowledged that they did not routinely perform physical examinations of the genitalia of adolescent males patients. Of 497 pediatricians who routinely or occasionally examine the genitalia 54 (10.9%) did not examine for the presence of varicoceles. When pediatricians were asked how they assess for the presence of varicoceles, 13 of 521 (2.5%) only used visual inspection, 50 (9.6%) only examined patients in the supine position and 379 (72.7%) of these pediatricians never used Valsalva maneuvers. Of 517 respondents 442 (85.5%) referred patients with varicoceles to a urologist for followup and 72 (13.9%) did no further evaluation. When asked to indicate what they thought was the greatest concern regarding the pediatric varicocele, 327 of 497 (65.0%) pediatricians indicated deterioration of future infertility, 120 (30.0%) indicated testicular growth retardation, 105 (24.2%) indicated pain and 18 (4.3%) indicated cosmesis. CONCLUSIONS: A significant percentage of pediatricians do not routinely perform physical examinations for varicoceles or appropriately examine for varicoceles, despite the majority being aware of the potential significance of varicoceles. This study demonstrates the need for increased educational efforts among pediatricians regarding the need for physical examination of the genitalia, the techniques for appropriate physical examination, and the need for appropriate referral and followup of adolescents with varicoceles.
PURPOSE: We evaluated the risk of epididymal injury in patients undergoing hydrocelectomy and spermatocelectomy, and determined risk factors that may increase the chance of epididymal injury. To our knowledge the incidences of epididymal injury during hydrocelectomy and spermatocelectomy have not previously been reported. MATERIALS AND METHODS: The pathology reports of all patients undergoing hydrocelectomy and spermatocelectomy at a single institution from 1990 to 2003 were retrospectively reviewed to determine if a portion of the epididymis was present in the pathology specimen. Patients with epididymis present then underwent a chart review to determine possible risk factors for epididymal injury. RESULTS: A total of 338 adults underwent unilateral or bilateral hydrocelectomy from 1990 to 2003. Another 111 patients underwent spermatocelectomy during this period. In 19 patients (5.62%) epididymal injuries were documented during hydrocelectomy and in 19 (17.12%) epididymal injuries were documented during spermatocelectomy. No specific risk factors could be identified. CONCLUSIONS: The risk of epididymal injury during hydrocelectomy and spermatocelectomy is significant. Patients must be informed of this risk since epididymal injury may lead to infertility. To our knowledge this is the first published report documenting the incidence and risk of epididymal injury during hydrocelectomy or spermatocelectomy.
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OBJECTIVE: To assess the ability of Kruger morphology to predict the outcome of the sperm penetration assay (SPA). DESIGN: A retrospective review using univariate and multivariate analysis, t tests, and logistic regression was performed to examine the correlation between Kruger morphology and the optimized zona-free hamster egg sperm penetration assay (O-HESPA). SETTING: University hospital. PATIENT(S): One hundred fifteen private-practice patients who underwent semen analysis, including Kruger morphology and O-HESPA, as part of an infertility evaluation between 1997-2000 were retrospectively reviewed. INTERVENTION(S): Retrospective analysis of the sperm penetration assay. MAIN OUTCOME MEASURE(S): Univariate and multivariate analysis, Student's t test, and logistic regression were performed to analyze Kruger morphology, count, and viability and their relationship to SCI result. RESULT(S): Univariate analysis demonstrated a statistically significant correlation between SCI and sperm count, viability, and Kruger morphology. Multivariate analysis demonstrated statistically significant correlations between SCI and count and viability. There was no correlation between Kruger morphology and SCI. Logistic regression was performed on the SCI results, using count, Kruger morphology, and viability. Sperm count was found to be the only variable that was statistically significant with respect to SCI results. CONCLUSION: This study demonstrated that Kruger morphology assessment cannot be used to predict the results of SCI or replace it in the management of the infertile couple.
OBJECTIVE: To determine if there is correlation between the size of radical prostatectomy specimens and perioperative complications including intraoperative blood loss. METHODS: One hundred twenty consecutive retropubic radical prostatectomy cases were retrospectively reviewed. Perioperative complications, intraoperative blood loss, pathologic stage, and size of the prostatectomy specimen were recorded. Logistic regression was used to determine whether variables such as age, PSA, and prostate weight are significant predictors of perioperative complications and intraoperative blood loss. RESULTS: The final analysis included a total of 117 cases. Significant complications were seen in 10 patients (8.5%). The median weight of the prostatectomy specimen in the group with major complications was 44.5 g (range 24-219) which was significantly higher than the median weight of 39.9 g (range 13-124) for the group without any complications (p = 0.034). The size of the prostate gland predicted the likelihood of a perioperative complication better than chance. A prostate size greater than 37 g was 10 times more likely to encounter major complications. Our analysis also indicated a statistically significant positive correlation between the weight of the prostatectomy specimen and intraoperative blood loss (p = 0.046). CONCLUSIONS: Prostate size correlates with a higher risk of major perioperative complications and higher intraoperative blood loss.
Bladder wall lipoma is a rare finding that includes mature, well-encapsulated fatty tissue within the submucosa of the bladder wall. We present a case of a submucosal bladder wall lipoma that was discovered incidentally during a workup for microhematuria. This lesion was seen during cystoscopy and removed using cold cup biopsy forceps. This lipoma should be differentiated from pelvic lipomatosis in that it was confined to the submucosa of the bladder wall and did not cause compression of the pelvic viscera or its structures.
Microsurgical techniques have made vasectomy reversal a realistic option for the restoration of fertility in a man who has previously undergone vasectomy. Factors that can affect the success of these procedures may become known preoperatively and intraoperatively; this article reviews each of those factors.
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