9. Surgical treatment of urinary stones; Male infertility

Question 1

Surgical treatment of urinary stones

Answer 1

Ureteroscope with a net

Intracorperal Laser Lithotripsy
- for smaller stones, via a ureteroscope

Percutaneous nephrolithotomy
- for large stones. 1cm skin incision in patients back and a nephroscope is inserted into the kidney. A probe is inserted through the nephroscope
to break up the stone.

Endoscopic surgery - for infections/struvite stones, staghorn stones.

Open surgery - midline incision under umbilicus, rare.

Question 2

Male infertility definition and causes

Answer 2

Inability to achieve pregnancy after one year of trying.

LH –> stimulates leydig cells to produce testosterone
FSH –> stimulates Sertoli cells of the seminiferous tubules to stimulate sprem production.

Causes:
• Idiopathic (60-70%)

• Testicular trauma: Very common
• Hypogonadotropic hypogonadism: No FSH. Indicates hypothalamic or pituitary abnormality, with no testicular stimulation.
• Aging: Decreased levels of testosterone and increased levels of estradiol. Number of Sertoli cells and Leydig cells decrease with age.

• Physical abnormalities:
o Cryptorchidism
o Varicocele
o Absent vas deferens (often seen in cystic fibrosis)

• Azoospermia: No sperm in ejaculate. Caused by primary testicular failure, or obstruction of ejaculatory duct.
• Sertoli-cell-only syndrome: Germinal cell aplasia. Normal levels of LH and testosterone, but FSH is elevated.
• Genetic causes: Abnormal sex chromosomes causing infertility.

• Infections: Prostatitis, epididymitis, vesiculitis can cause scarring of epididymis or seminal vesicle, blocking the flow of sperm or semen.
Prostatitis can cause high levels of WBC in semen, which causes an acidic environment, which is not favorable for sperm survival.
Viral orchitis caused by mumps is a common cause of testicular failure.

• Others:
o Steroid use: Suppress LH release
o Extreme stress, smoking, drug abuse
o Radiation and chemotherapy

Question 3

Male infertility diagnosis.

Answer 3

Check testicular size and consistency, as well as the presence of vas deferens, swelling or tenderness of epididymis.

Perform a digital rectal examination.

Semen analysis:
• Normal ejaculate volume: 2-5ml with pH of 7-8.

• Normal sperm concentration: > 20 million sperm/ml
(< 5 million = oligospermia)

• Swimming ability: More than 60% of sperm should have normal movement
• Morphology: More than 60% of sperm should have normal (< 30% = teratospermia)
• Check that there is no significant sperm agglutination or hyperviscosity
• Check that there is no significant pyospermia (< 1 million WBCs/ml)

Imaging:
• Do US to evaluate the anatomy
• Transrectal ultrasound to exclude ejaculatory duct obstruction
• Vasogram to evaluate the ductal system

Question 4

Medical treatment for male infertility

Answer 4

Medical therapy:
• hCG, GnRH and FSH. Given in hypogonadotropic hyogonadism.

• Antiestrogens (tamoxifen-testosterone) binds estrogen receptors in the hypothalamus and pituitary gland where they prevent negative feedback exerted by estrogen.
• Androgens: Used hypogonadism, hypogonadotropic hypogonadism and delayed puberty.
• Bromcryptine: Dopamine blocker that can be used in patients suffering from hyperprolactinemia.
• Systemic corticosteroids: Given to patients with anti-sperm antibodies.
• Magnesium supplements and vitamin E may benefit some patients

Question 5

Surgical treatment for male infertility

Answer 5

Surgical therapy:
• Varicocele ligation/varicocelectomy

• Microsurgical reconstruction for post-inflammatory occlusions (vasoepididymostomy)
• Testicular sperm extraction: Biopsy done to see what treatment will be most efficient
• Microsurgical epididymal sperm aspiration: When reconstruction is not possible
• Transurethral resection of ejaculatory duct