One major challenge in male factor infertility is nonobstructive azoospermia (NOA), which is characterized by spermatozoa-deficient semen without physical duct blockage. This review offers a thorough overview of the histopathology of the testes in NOA cases, clarifying its complex etiology and emphasizing the possible value of histopathology inspection for both diagnosis and treatment. Variable histopathological findings have been linked to NOA, such as tubular hyalinization, Sertoli cell-only syndrome, hypospermatogenesis, and germ cell arrest. Understanding the pathophysiology and forecasting the effectiveness of treatment are further enhanced by both morphometric and ultrastructural analyses. The potential significance of testicular biopsy in forecasting reproductive outcomes is assessed, especially concerning assisted reproductive technologies like intracytoplasmic sperm injection (ICSI). Besides, testicular microlithiasis, serum hormone profiles, and testicular size are investigated concerning NOA histopathology. It is concluded that understanding the histopathological patterns in NOA is crucial for its accurate diagnosis and appropriate management. Further research is still warranted to improve understanding of the complex pathophysiology underlying NOA.

Compounds isolated from Epimedium include the total flavonoids of Epimedium , icariin, and its metabolites (icaritin, icariside I, and icariside II), which have similar molecular structures. Modern pharmacological research and clinical practice have proved that Epimedium and its active components have a wide range of pharmacological effects, especially in improving sexual function, hormone regulation, anti-osteoporosis, immune function regulation, anti-oxidation, and anti-tumor activity. To date, we still need a comprehensive source of knowledge about the pharmacological effects of Epimedium and its bioactive compounds on the male reproductive system. However, their actions in other tissues have been reviewed in recent years. This review critically focuses on the Epimedium , its bioactive compounds, and the biochemical and molecular mechanisms that modulate vital pathways associated with the male reproductive system. Such intrinsic knowledge will significantly further studies on the Epimedium and its bioactive compounds that protect the male reproductive system and provide some guidances for clinical treatment of related male reproductive disorders.

Prostate cancer (PCa) is a significant health concern globally, necessitating effective treatment options. Typical treatment methods for early stage, particularly localized PCa, encompass radical procedures, such as radical prostatectomy (RP) and radiotherapy (RT), and nonradical focal therapy (FT). FT is a focused approach mainly used for treating small lesions limited to a specific zone of the prostate. Its objective is to achieve cancer control when minimizing damage to benign tissue. High-intensity focused ultrasound (HIFU) is one of the most used modalities in FT for the management of PCa. The progress in HIFU technology showcases continuous advancements, offering clinicians a variety of strategies to cater to diverse patient requirements. The advancements include the development of transrectal and transurethral HIFU machines that offer enhanced treatment distances, magnetic resonance imaging (MRI) fusion capabilities, real-time monitoring, and precise ablation. These improvements contribute to increased treatment effectiveness and better outcomes for patients. This narrative review aims to summarize the use of HIFU technology and its evolution, offering diverse options to clinicians, and explores the safety, effectiveness, and quality of different HIFU strategies, such as whole-gland ablation, hemigland ablation, and focal ablation. We conclude that nonwhole-gland HIFU offers similar cancer control with better short-term functional outcomes and fewer complications compared to whole-gland ablation. Combining HIFU with transurethral resection of the prostate (TURP) improves urinary function and reduces catheterization time. Focal ablation and hemigland ablation show promise in achieving cancer control when preserving continence and potency.

Laser enucleation of the prostate is a proven and effective size-independent method for the surgical management of symptomatic benign prostatic hyperplasia (BPH) and is considered as the “gold standard” by many clinicians. Two major hurdles that stand in the way of this becoming a universally used procedure for BPH are the steep learning curve associated with mastering the procedure and possibility of perioperative transient incontinence. Many advances in teaching methodologies have helped tackle the difficulty in learning it and increased the number of urologists utilizing the procedure. As for the second hurdle, transient incontinence rates postlaser enucleation of the prostate have improved with the advent of newer techniques of enucleation. Castellani et al.1 assesses the incidence of stress, urge, and mixed urinary incontinence following laser enucleation of the prostate by comparing en-bloc and non-en-bloc techniques in a multicenter series of 5068 men with BPH. There are several variations of laser enucleation of the prostate including the classic 3-lobe, modified 2-lobe, and en-bloc enucleation techniques. The enucleation techniques differ in the incisions of the urethral mucosa down to the surgical capsule and the direction of dissection.2 The classic 3-lobe technique was first described by Gilling et al.3 and involves separate enucleation of the median and lateral lobes. This technique is possibly the easiest to learn and offers improved endoscopic visibility as each lobe is enucleated. The modified 2-lobe technique involves enucleating a single lateral lobe and then enucleating the remaining lateral lobe with the median lobe. The en-bloc technique involves complete detachment of all 3 prostatic lobes and simultaneous enucleation of all 3 lobes in a distal-to-proximal approach.4 There are theories that en-bloc enucleation may lead to improved postoperative continence outcomes, and literature has described differing outcomes between the various techniques. Enikeev et al.5 described in a retrospective study of 1115 patients who underwent en-bloc versus 2-lobe holmium laser enucleation of the prostate (HoLEP) that there was no difference in enucleation time or 6-month functional outcomes. Morcellation was more efficient in the 2-lobe approach by about 30%. Others found en-bloc enucleation to be more time efficient than other techniques by up to 30%.6 There has been limited assessment of continence outcomes between the techniques. We commend the authors for completing the largest study assessing the urinary continence outcomes between en-bloc and non-en-bloc enucleation techniques. Non-en-bloc enucleation demonstrated higher rates of stress urinary incontinence within 1 month of surgery (40.1% vs 23.4%) compared to en-bloc technique. At >3 months postoperations, among the patients with incontinence, stress urinary incontinence rate was higher in the non-en-bloc group than that in the en-bloc group. Prostate volume (odds ratio [OR]: 2.178), surgical time (OR: 1.010), and no early apical release technique (OR: 2.915) were factors associated with higher odds of long-lasting incontinence. We congratulate the authors on this multi-institution, high-volume, and well-written paper revealing the association of en-bloc enucleation with lower rates of incontinence. However, we would like to highlight some possible confounding factors that may be influencing the outcomes. First, while the multicenter nature of the study is a strength, the study cannot control variations between surgeons. Surgeons at various institutions are more likely to perform a single technique, and the surgeon’s experience and skill-level may make a bigger impact on the early continence than the technique itself. Second, the improved continence outcomes of en-bloc may be largely attributed to the early apical release. While 63.9% of en-bloc enucleations had early apical release, only 29.8% of non-en-bloc enucleations had early apical release. Finally, as the authors highlighted, there was no standardization or tracking of postoperative management and Kegels protocol which can greatly influence continence outcomes. This study demonstrates the importance of early apical release in improved continence. Further studies controlling for confounding factors (apical release, surgeon skill/experience, and postoperative management) will be needed to determine the impact of enucleation technique on continence outcomes. In the end, we believe that the choice of technique should be mostly dependent on the surgeon’s comfort and experience level. Early apical release should be completed in every case when possible and it likely has the biggest impact on early continence. Surgeons should always counsel and educate their patients regarding the possibility of postoperative urinary incontinence and strategies for achieving earlier continence. COMPETING INTERESTS All authors declare no competing interests.

Oxidative stress is one of the main mechanisms responsible for male infertility. Various conditions such as varicocele, obesity, advanced age, and lifestyle can lead to an increase in reactive oxygen species, causing an oxidative imbalance in the reproductive environment. Spermatozoa are sensitive to reactive oxygen species and require energy to carry out their main function of fertilizing the egg. Excessive reactive oxygen species can affect sperm metabolism, leading to immobility, impaired acrosome reaction, and cell death, thereby impairing reproductive success. This double-blind randomized study evaluated the effect of supplementation with L-carnitine, acetyl-L-carnitine, vitamins, and other nutrients on semen quality in 104 infertile patients with or without varicocele, while also investigating the impact of factors such as obesity and advanced age on treatment. Sperm concentration significantly increased in the supplemented group compared to the placebo group ( P = 0.0186). Total sperm count also significantly increased in the supplemented group ( P = 0.0117), as did sperm motility ( P = 0.0120). The treatment had a positive effect on patients up to 35 years of age in terms of sperm concentration ( P = 0.0352), while a body mass index (BMI) above 25 kg m -2 had a negative effect on sperm concentration ( P = 0.0110). Results were not showing a net benefit in stratifying patients in accordance with their BMI since sperm quality increase was not affected by this parameter. In conclusion, antioxidant supplementation may be beneficial for infertile patients and has a more positive effect on younger patients with a normal weight.

This study aimed to report the outcomes of active surveillance (AS) in the management of low-risk prostate cancer (PCa). It recruited 87 men who were prospectively followed up according to the Prostate Cancer Research International Active Surveillance (PRIAS) protocol with local adaptation at SH Ho Urology Centre, Prince of Wales Hospital, Hong Kong, China. We investigated the predictors of disease progression and found that baseline prostate-specific antigen density (PSAD) and the presence of the highest Prostate Imaging-Reporting and Data System (PI-RADS) score 5 lesion on magnetic resonance imaging (MRI) are significantly correlated with disease progression. Moreover, men with PSAD >0.2 ng ml -2 or PI-RADS 4 or 5 lesions had significantly worse upgrading-free survival compared to those with PSAD ≤0.2 ng ml -2 and PI-RADS 2 or 3 lesions. The study concludes that AS is a safe and effective management strategy for selected patients to defer radical treatment and that most disease progression can be detected after the first repeated biopsy. The combination of PSAD >0.2 ng ml -2 and PI-RADS 4 or 5 lesions may serve as a useful predictor of early disease progression and provide a guide to optimize follow-up protocols for men in different risk groups.

This study was performed to investigate the learning curve of transurethral enucleation with bipolar energy (TUEB) for benign prostatic hyperplasia. The study involved 494 consecutive patients who underwent TUEB for benign prostatic hyperplasia from August 2018 to March 2022 by one surgeon (SJJ, Seoul National University Bundang Hospital, Seongnam, Korea). The patients were followed up at 1 week, 1 month, 3 months, and 6 months postoperatively. To evaluate the learning curve of TUEB, perioperative parameters including the enucleation ratio (enucleated tissue weight/transitional zone volume), TUEB efficiency (enucleated tissue weight/operation time), and enucleation efficiency (enucleated tissue weight/enucleation time) were analyzed. Functional outcomes and postoperative complications were also assessed, including the International Prostate Symptom Score (IPSS), IPSS quality-of-life (QoL) score, and uroflowmetry outcomes. The patients' median age was 72 (interquartile range [IQR]: 66-78) years, and the estimated prostate volume and transitional zone volume were 63.0 (IQR: 46.0-90.6) ml and 37.1 (IQR: 24.0-60.0) ml, respectively. The enucleation ratio, TUEB efficiency, and enucleation efficiency were 0.60 (IQR: 0.46-0.54) g ml -1 , 0.33 (IQR: 0.22-0.46) g min -1 , and 0.50 (IQR: 0.35-0.72) g min -1 , respectively, plateauing after 70 cases. The functional outcomes, including total IPSS, IPSS QoL score, and uroflowmetry outcomes, significantly improved at 6 months after TUEB (all P < 0.05), but without significant differences over the learning curve. Sixty-five (13.2%) patients developed complications after TUEB, 21.5% of whom experienced major complications (Clavien-Dindo grade ≥3). The rate of major complications declined as the number of TUEB cases increased ( P = 0.013). Our results suggest that the efficiency of TUEB stabilized within 70 procedures.

In this study, we aimed to assess the effect of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on semen parameters. The study comprised 110 sperm volunteers who self-reported SARS-CoV-2 infection from the Human Sperm Bank of the Center for Reproductive Medicine, Shandong University (Jinan, China). The volunteers had normal sperm concentration before infection. Each volunteer provided semen samples before and after infection. We selected 90 days after infection as the cutoff point. Semen parameters within 90 days after infection of 109 volunteers (group A) were compared with semen parameters before infection. Moreover, semen parameters on or after 90 days after infection of 36 volunteers (group B) were compared with semen parameters before infection. Furthermore, based on whether the volunteers had completed the three-dose SARS-CoV-2 vaccination booster, volunteers in group A and B were further divided into two subgroups separately. Semen parameters were compared before and after infection in each subgroup. Our results showed that in this cohort population, the semen quality in volunteers with normal sperm concentrations before infection decreased after SARS-CoV-2 infection within 90 days, while the semen quality returned to preinfection levels after 90 days. The completion of a three-dose SARS-CoV-2 vaccination booster may exert a protective effect on semen quality after infection.

Sperm head morphology is crucial for male factor infertility diagnosis and assessment of male reproductive potential. Several criteria are available to analyze sperm head morphology, but they are limited by poor methodology comparability and population applicability. This study aimed to explore comprehensive and new normal morphometric reference values for spermatozoa heads in fertile Asian males. An automated sperm morphology analysis system captured 23 152 stained spermatozoa from confirmed fertile males. Of these samples, 1856 sperm head images were annotated by three experienced laboratory technicians as “normal”. We employed 14 novel morphometric features to describe sperm head size (head length, head width, length/width ratio, and girth), shape (ellipse intersection over union, girth intersection over union, short-axis symmetry, and long-axis symmetry), area (head, acrosome, postacrosomal areas, and acrosome area ratio), and degrees of acrosome and nuclear uniformity. This straight-forward method for the morphometric analysis of sperm by accurate visual measurements is clinically applicable. The measured parameters present valuable information to establish morphometric reference intervals for normal sperm heads in fertile Asian males. The presented detailed measurement data will be valuable for interlaboratory comparisons and technician training. In vitro fertilization and andrology laboratory technicians can use these parameters to perform objective morphology evaluation when assessing male fertilization potential.

Genetic risk factors have been shown to contribute to the development of sexual dysfunction. However, the role of methylenetetrahydrofolate reductase (MTHFR) gene variants in the risk of erectile dysfunction (ED) remains unclear. In this study, we recruited 1254 participants who underwent ED assessed by the International Index of Erectile Function-5. The MTHFR c.677C>T variant was also measured by fluorescence polymerase chain reaction (PCR). No significant difference in the genotypic frequency of the MTHFR C677T polymorphism (CC, CT, and TT) was observed between men from the ED and non-ED groups. In addition, on binary logistic regression analysis, both crude and adjusted models showed that the risk of ED was not significantly associated with the C677T polymorphism. Interestingly, a significantly higher frequency of the 677TT polymorphism was found in severe and moderate ED (P = 0.02). The positive correlation between the MTHFR 677TT polymorphism and severe ED was confirmed by logistic regression analysis, even after adjusting for potential confounders (odds ratio [OR] = 2.46, 95% confidence interval [CI]: 1.15–5.50, P = 0.02). These findings suggest a positive correlation between the MTHFR 677TT polymorphism and the risk of severe ED. Identification of MTHFR gene polymorphisms may provide complementary information for ED patients during routine clinical diagnosis.