Have You Read?
By: Craig Niederberger, MD, FACS | Posted on: 01 Apr 2022
Yan J, Qin Y, Zhao H et al: Live birth with or without preimplantation genetic testing for aneuploidy. N Engl J Med 2021; 385: 2047–2058.
Special thanks to Drs. Joshua Calvert and Jim Hotaling at the University of Utah.
Preimplantation genetic testing for aneuploidy (PGT-A) is used in in vitro fertilization (IVF) clinics across the world: in fact, according to a 2018 Centers for Disease Control report, it was used in 37.7% of all IVF cycles in the U.S. that resulted in an embryo transfer. Theoretically, by checking blastocysts for aneuploidy before implantation, couples can reduce the rates–and associated heartache–of implantation failure or pregnancy loss.
With this background and armed with the belief that cumulative birth rate per given oocyte retrieval cycle is the most patient-centric outcome, researchers in China randomized a population of subfertile couples into 2 groups. In each IVF cycle, a single frozen embryo transfer was performed with a euploid blastocyst in the PGT-A cohort and a blastocyst chosen based on morphologic criteria in the conventional cohort. If live birth was not achieved after the first embryo transfer, subsequent embryo transfers were performed for up to 3 cycles. The researchers observed that PGT-A did not improve cumulative live birth rates compared to conventional IVF methods (77.2% vs 81.8%). Additionally, time to live birth and the number of embryos transferred to result in a birth were similar in both the genetic testing and conventional groups (1.2 vs 1.3 embryos).
From a urology perspective, 3 points are worth highlighting. First, as the “sperm wranglers,” we are shielded from the increased cost of next gen sequencing and other tests that accumulate quickly for each IVF cycle. Second, the result of the increasing use of assisted reproductive technology is that men are solely undergoing sperm retrieval rather than being evaluated as an integral component of the infertile couple. Thus, we have a strong ethical and financial obligation to maximize the male partner’s fertility and potentially shielding couples from increased costs of more aggressive assisted reproductive technology treatments. Lastly, these findings support the importance of the cumulative live-birth rate as the primary end point in reproductive clinical trials.
Nayan M, Hamilton RJ, Juurlink DN et al: Circumcision and risk of HIV among males from Ontario, Canada. J Urol 2022; 207: 424–430.
Special thanks to Drs. Andrew Lai and Omer Acar at the University of Illinois at Chicago.
Several randomized controlled trials in Africa investigated the association between circumcision and HIV infection, and pooled analysis demonstrated that circumcision had a significant impact on reducing the risk of acquiring HIV by 56%. Given the differences in patterns of spread and overall prevalence of the infection, recommending circumcision as a public health intervention to lower the risk of HIV transmission in Western countries remains an open question. In addition, studies conducted in Western populations focused on men who have sex with men and lacked sufficient power to draw generalizable conclusions.
To investigate the effect of circumcision on HIV infection in a Western population, these authors reviewed physician claim databases covering a 26-year period in Ontario, Canada. More than half a million men were included to this population-based matched cohort study, making it the largest to date. The study population was divided into circumcised males and age-matched uncircumcised counterparts. Neither the primary nor the additional sensitivity analyses demonstrated a significant difference in the risk of HIV infection between the groups.
While this study was large, it had limitations. It did not account for sexual orientation, variations in sex practices or other behaviors that could enable individualized risk assessment. Yet studies that did assess those subpopulations were criticized for small sample sizes and misclassification of exposure and outcome. As a result, circumcision may still be beneficial in reducing the risk of acquiring HIV in particular subgroups. Nevertheless, the results of this study imply caution in regarding circumcision in Western populations.
Chen A, Caron A, Jackson NJ et al: Defining properly collected urine: thresholds to improve the accuracy of urinalysis for microscopic hematuria evaluation in women. J Urol 2022; 207: 385–391.
Special thanks to Drs. Rabun Jones and Omer Acar at the University of Illinois at Chicago.
Microscopic hematuria is a highly common reason for referral to the urologist. Yet while women more often have microscopic hematuria, urological malignancies occur less frequently than in men. Menstruation and the presence of vaginal flora increase the likelihood of a contaminated sample, and current guidelines do not expressly address urinalysis specimen quality.
These investigators obtained catheterized samples and repeat midstream clean-catch voided samples from 46 women referred for microscopic hematuria and compared the quality of the referral specimen to that collected in the urology clinic. No patient in the cohort was ultimately diagnosed with urothelial cancer.
The authors observed significantly lower squamous epithelial cells, red blood cells, and white blood cells on both voided and catheterized specimens when compared to referral samples. The highest number of squamous epithelial cells with catheterized specimens was 2 per high powered field, which was used as a threshold to designate a properly collected urine sample. When that threshold was applied to the referral urinalyses, the positive predictive value was increased from 46.1% to 68.8% for true microscopic hematuria.
This prospective cohort study emphasizes the critical nature of the proper collection of urine to screen for microscopic hematuria. Over 50% of referral screening tests do not meet the AUA/Society of Urodynamics, Female Pelvic Medicine & Urogenital Reconstruction guidelines for microscopic hematuria. These improvements in specimen quality provided by midstream clean-catch samples obtained in the urology clinic may be the result of something as attainable as better patient education regarding technique. When evaluating a voided urine specimen for microscopic hematuria, the threshold of 2 squamous epithelial cells per high powered field can be used to determine the need for a repeat collection with catheterization prior to performing any potentially unnecessary diagnostic test, especially in low-risk female patients.