Issues in managing male fertility and complications following radical cystectomy were examined in two lectures at the 17th Central European Meeting (CEM17) held Plzen, Czech Republic, with speakers focusing on surgical expertise, proper patient evaluation and strict follow-up regimens as among the recommended actions.
Professors Maurizio Brausi (IT)and Jens Sonksen (DK) gave the European School of Urology (ESU) and EAU lectures, respectively, during the second plenary session of CEM17. CEM17 was held within the auspices of the 63rd Annual Meeting of the Czech Urological Society (CUS) led by organisers Profs. Marko Babjuk and Milan Hora.
“Radical cystectomy is the best treatment option for patients with muscle invasive bladder cancer (MIBC) and recurrent or refractory NMIBC but it remains a morbid procedure with a mortality rate up to 3.9% and a variable complication rate,” said Brausi. Current literature indicates that the reported complication rates following open radical cystectomy (RC) range from 24% to 64%.
Brausi gave an overview of the various types of complications including the most commonly encountered, intra-operative complications, trombo-embolic complications, urinary infections, post-operative complications (surgical) and long-term problems. Among intra-op complications are bleeding, obturator nerve injury and bowel lesions. For the latter (bowel lesions) he recommend immediate repair, with large holes requiring resections.
In trombo-embolic problems, Brausi said the rates of deep venous thrombosis (DVT) and pulmonary embolus are up by 5%. “Prevention includes low molecular weight heparin and early mobilization which are important to reduce DVT and pulmonary embolus down to 1 to 2%,” he noted.
Meanwhile, he also said that among the long-term complications following RC are UTI, severe incontinence, urinary retention and peri-stomal hernia. Having described the various complications, Brausi took up the benefits of minimally invasive techniques which he said include small incisions, cosmetic gains, less pain or functional impairment and fewer wound-related problems.
He also discussed risk and predictive factors, the incidence of tumor seeding in laparoscopic and robot-assisted surgery, recurrence pattern issues and offered some tips and tricks in open radical cystectomy.
“I recommend surgeons to perform a simple operation and pay the maximum attention to blood loss by using clips. And use the most simple diversion you are used to,” Brausi said.
Fertility procedures in men
In the EAU Lecture, Sonksen discussed the various procedures available in treating male infertility and their corresponding indications, such as varicocelectomy, vaso-vasostomy, vaso-epididymostomy and Transurethral Resection of the Ejaculatory Ducts or TURED. He said varicocelectomy is performed in cases of poor semen quality, while the other procedures are indicated for obstructive azoospermia.
“Couples without any other reasons of documented infertility than clinical varicocele in combination with impaired semen quality should be offered fertility treatment,” said Sonksen in his take-home message.
He added that for vaso-vasostomy, this procedure is indicated for men who had vasectomy for less than eight years previous and has a gynaecologically healthy partner not older than 35 years old. Regarding TURED, he noted significant gains or improvements were seen in semen parameters and ejaculation patterns.