113 COMPARISON OF TESE OPERATIONS IN NON-OBSTRUCTIVE AZOOSPERMIC PATIENTS

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Comparison of TESE operations in non-obstructive azoospermic patients Turunc T.1, Gul U.1, Kuzgunbay B.1, Dirim A.2, Peskircioglu L.2, Ozkardeş H.2 Baskent University, Dept. of Urology, Adana, Turkey, 2Baskent University, Dept. of Urology, Ankara, Turkey 1

Introduction & Objectives: Comparison of conventional TESE and microdissection TESE operations was aimed. Material & Methods: Between September 2003 and June 2008, 278 patients who underwent TESE with non-obstructive asospermia were included into the study. Microdissection TESE was performed in 63 patients whose testis volumes were significantly atrophic (5 cc and less). The remaining 215 patients underwent conventional TESE procedure at the same session by 5 mm incisions in the upper and lower poles and the middle of the testicle. Multiple biopsies were taken if the initial sperm amount was not enough. Microdissection TESE was performed by enlarging the middle incision vertically in patients in whom conventional technique failed to retrieve sperms. Results: Mean age of the patients was 35.2 (range, 22-65) years. Mean infertility period was 8.04 (range, 1-35) years. Sperm was detected in 70 (32.5%) patients in conventional TESE. The sperm detected patients number increased to 110 (51.1%) by the same session microdissection TESE. The increase was statistically significant (p<0.001).



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Diagnostic outcome of 125 TEsticular Sperm Extractions procedures in non-obstructive azoospermia D’Hauwers K.W.M.1, Woldringh G.2, Kremer J.2, Mulders P.1, Ramos L.2 1 University Medical Center St Radboud, Dept. of Urology, Nijmegen, The Netherlands, 2University Medical Center St Radboud, Dept. of Gynaecology, Nijmegen, The Netherlands

Introduction & Objectives: In the Netherlands, ICSI (IntraCytoplasmatic Sperma Injection) with surgically retrieved sperm was forbidden because of concern for the children conceived with non-ejaculated sperm. Since June 2007, 2 centres are allowed to use testicular sperm for reproductive purposes. We describe the procedure and results of the first 125 Testicular Sperm Extractions (TESE’s) performed in UMC St Radboud. We evaluated whether clinical parameters (FSH, Inhibin B and testicular volume) could predict testicular histology in non-obstructive azoospermia (NOA). Material & Methods: Inclusion criteria are NOA (testicular volume between 6-15 cc, FSH > 10 E/l), oligoasthenoteratospermia without motile sperms and failed PESA. Men could choose to have the procedure done under general or local anesthesia. The side to biopt was chosen depending on size and consistence. Through a scrotal incision, the tunica albuginea was opened and a piece of ± 4mm3 testicular tissue was removed. On the testis and tunica albuginea, only bipolar cauterization was used. From all biopsies, a 5 ul aliquot of the cell suspension was fixed on a glass slide and stained with Giemsa for the histology evaluation. Three categories were differentiated from these biopsies: sperm retrieval (SRR+), maturation arrest (MA) and sertoli cell only (SCO). Results: Results: Spermatozoa was found in 60 out of 125 biopsies (Sperm recovery rate, SRR 48%). Mean (± SD) (range) SRR+ MA SCO p-value Total Group NOA

FSH U/l

Inhibin B ng/l

15.88 (± 12.19) (0.20 – 60.00) 22.54 (± 16.41) (5.20 – 77.90) 26.09 (± 9.4) (9.90 – 46) 0.002 19.92 (± 13.29) (0.20 – 77.90)

68.84 (± 63.26) (10 - 279) 41.29 (± 19.87) (10 – 77) 26.61 (± 33.42) (10 – 135) 0.014 50.04 (± 49.83) (10 – 279)

Testosteron nmol/l 16.46 (± 8.35) (2.30 – 45.00) 14.64 (± 6.83) (6.70 – 35) 16.15 (± 9.19) (7.16 – 44.4) 0.693 15.77 (± 8.13) (2.30 – 45)

LH U/l 8.41 (± 10.81) (0.20 – 74.00) 7.31 (± 3.75) (2.90 – 15.40) 10.5 (± 4.32) (3.9 – 19.7) 0.397 8.62 (± 8.20) (0.20 – 74)

Testis Volume cc 16.47 (± 5.11) (6 – 25) 14.45 (± 4.79) (5 – 25) 11.88 (± 4.32) (6 -20) 0.001 14.83 (± 5.23) (5 – 25)

Conclusions: Microdissection TESE procedure significantly increase the possibility of sperm detection according to conventional TESE in the patients with azoospermia

Conclusions: The outcome of TESE is difficult to predict, as all clinical parameters by their own fail to discriminate between SRR+, MA and SCO. However, the combination of parameters may indicate differences between categories. Discrimination between SRR+ and SCO can be done based on FSH, Inhibin B and testicular volume. Maturation arrest in contrast, shows similar clinical values as for SRR+. This can be explained by the fact that some degree of spermatogenesis is present in the testicular tubules, which is responsible for the hormonal balance (feedback) and partially filled tubules. This findings are of importance for the counseling of azoospermic men for the chance of finding sperm in the testis. Consequently, the diagnostic testicular biopsy remains as the only tool available to see if there is sperm in NOA for fertility treatment or not.

P8 UPPER AND LOWER URINARY TRACT CARCINOMA Wednesday, 18 March, 12.45-14.15, Room C6



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Potential therapeutic role of lymph node dissection in treatment of upper urinary tract cancer: Immunohistochemical analysis of negative lymph nodes and prognostic factors of lymph node recurrence Abe T.1, Shinohara N.1, Sazawa A.1, Maruyama S.1, Harabayashi T.1, Kubota K.2, Matsuno Y.2, Shibata T.3, Toyada Y.3, Shinno Y.3, Minami K.3, Sakashita S.3, Kumagai A.3, Takada N.3, Togashi M.3, Sano H.3, Mori T.3, Nonomura K.1 1 Hokkaido University School of Medicine, Dept. of Urology, Sapporo, Japan, 2Hokkaido University School of Medicine, Dept. of Surgical Pathology, Sapporo, Japan, 3Hokkaido Urothelial Cancer Research Group, Sapporo, Japan

Introduction & Objectives: We previously reported a significant difference in survival between pN0 and pNx patients with upper urinary tract (UUT) cancer (BJU Int 102:576, 2008). The present study examined the incidence of micrometastases in lymph node dissection specimens and prognostic factors of lymph node recurrence to clarify a potential therapeutic role of lymph node dissection. Material & Methods: [Study 1] Forty-three patients treated by nephroureterectomy at Hokkaido University Hospital between 1990 and 2007 were selected. All had staging lymph node dissection and all lymph nodes were negative on standard haematoxylin and eosin staining. Each block was stained for anti-cytokeratin antibody (clone: AE1/AE3). [Study 2] A retrospective multi-institutional study evaluated 397 patients undergoing predominantly nephroureterectomy for UUT cancer between 1990 and 2005. Exclusion criteria in the present study were patients with (1) neoadjuvant chemotherapy, (2) past history of invasive bladder cancer, (3) distant metastasis or (4) incomplete follow-up data. Finally, a total of 293 patients with a median follow-up of 52 months were included. The endpoint of analysis was regional lymph node recurrence. Recurrences of distant sites without lymph node recurrence were analyzed as censored data at that time. Multivariate analyses were performed using a Cox proportional hazard model. The characteristics entered in analysis were gender, age, histology, tumor grade, tumor stage and pathological node status. Results: [Study 1] Immunohistochemistry identified micrometastases in 6 (14%) of 43 patients. Of the six patients, one patient died of disease 35 months after surgery while the remaining five patients were alive at 12-119 months after surgery. [Study 2] Of 293 patients, 34 had lymph node recurrence. Multivariate analysis demonstrated that tumor grade, tumor stage and pathological node status were significant predictors of lymph node recurrence. For node status, patients with pNx [HR 4.669, 95%CI 1.851 to 11.776, p= 0.0011] and pN(+) [HR 3.774, 95%CI 1.146 to 12.433, p= 0.029] were more likely to have lymph node recurrence than those with pN0. Conclusions: Micrometastasis was detected in 14% of the patients previously diagnosed as pN0 by standard method and patients with pNx were more likely to have lymph node recurrence than those with pN0. These results indicate that lymph node dissection in conjunction with nephroureterectomy have potential therapeutic effect by eliminating micrometastasis.

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Predictors of false positives in photodynamic diagnosis of transitional cell carcinoma of the bladder Draga R.O.P.1, Grimbergen M.C.M.2, Kok E.T.1, Jonges G.N.3, Bosch J.L.H.R.1 1 University Medical Center, Dept. of Urology, Utrecht, The Netherlands, 2University Medical Center, Dept. of Clinical Physics, Utrecht, The Netherlands, 3University Medical Center, Dept. of Pathology, Utrecht, The Netherlands

Introduction & Objectives: Photodynamic diagnosis (PDD) is a technique that enhances the detection of tumours during cystoscopy using a photosensitizer which accumulates primarily in cancerous cells and will fluoresce when illuminated by violet-blue light. The specificity is approximately 50%. The aim of the study is to identify the main predictors of false positives in multivariate analysis. The second objective is to determine the optimal waiting period after transurethral resection of bladder tumours (TURBT) and intravesical therapy (IVT) to minimize the number of false positives in PDD. Material & Methods: Data of 366 procedures and 200 patients were collected. Patients were instilled with 5-aminolevulinic acid (5-ALA) intravesically and 1253 biopsies were taken from tumours and suspicious lesions. Age, gender, recent TURBT, previous IVT, urinary tract infections (UTIs) and tumour classification were examined for association with the false-positive rates in fluorescence cystoscopy. Results: The sensitivity and specificity of white light endoscopy (WLE) and PDD are 71% and 76%, 96% and 43%, respectively. Significant univariate associations are found between false positives and female gender (p=0.007, OR=2.01), IVT instillations (p=0.02, OR=1.85), Bacille Calmette-Guérin instillations (BCG; p=0.03, OR=2.16) and TURBT in the past 90 days (p=0.01, OR=2.23). In multivariate analysis female gender (p=0.001, OR=2.68) and TURBT within 90 days before PDD (p=0.01, OR=2.27) are the only significant independent predictors of false positives. In a second multivariate model the dichotomous variable ‘>1 BCG instillation in the past 90 days’ is the only predictor for false-positive findings in PDD (p=0.002, OR=4.67). Tangential illumination of the bladder wall does not seem to result in additional false positives. The false-positive rate decreases during the first 12 weeks after the latest TURBT and the latest BCG instillation. Conclusions: Female gender, previous TURBT and recent BCG instillations are important predictors of false positives in PDD. The false-positive rate decreases during the first 12 weeks after the latest TURBT and the latest BCG instillation. We recommend to perform a fluorescence guided TURBT 9-12 weeks after an incomplete first resection of low or intermediate risk non-muscle invasive tumors and 9-12 weeks after the latest BCG instillation.

Eur Urol Suppl 2009;8(4):149