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The Princeton Consensus (Expert Panel) Conference is a multispecialty collaborative symposium dedicated to optimizing sexual function and preserving cardiovascular (CV) health. The Fourth Princeton Consensus Conference was convened on March 10-11, 2023 at the Huntington Medical Research Institutes in Pasadena, CA. Princeton panels I-III addressed the clinical management of men with erectile dysfunction (ED) who also had cardiovascular disease (CVD). Thirteen years since Princeton III, Princeton IV builds upon previous foundations in several key areas. Mounting evidence supports the need for providers to treat men with ED as being at risk for cardiac events until proven otherwise. Algorithms for the diagnosis and treatment of ED are updated with new recommendations for coronary artery calcium scoring for advanced CV risk stratification. Optimization of oral phosphodiesterase-5 inhibitors in the treatment of men with ED and CVD is thoroughly explored, including recent evidence regarding potential cardioprotective effects of these drugs.

UROLOGISTS APPROACH the management of male infertility by first trying to identify disease that may be corrected. The treatment of conditions such as varicocele, secondary hypogonadism, and obstruction may result [...]

Deep pelvic midline (Müllerian duct) cysts may cause obstruction of the ejaculatory duct. Two previously fertile patients with adult-onset azoospermia and one patient with severe oligozoospermia were each found to have a Müllerian duct cyst. Semen characteristics included low volume and pH, and absent semen coagulation, odor, and fructose. Vasography showed a retroprostatic and/or retrovesical cyst that communicated with the ipsilateral ejaculatory duct, reflux from the cyst into the contralateral ejaculatory duct, and absent communication of the cyst with the urethra. Transurethral incision of the cyst was successful in one patient and unsuccessful in another. Pregnancy was established by the successfully treated patient. Müllerian duct cyst may cause obstructive azoospermia or oligozoospermia, which may be progressive in adult life, and which is compatible with previous fertility.

Almost every scrotal operation may be done with local anesthesia. Occasionally general anesthesia may be elected, but the basic orientation to scrotal surgery should be with local anesthesia as long as the operation can be completed within 3 hours. The only scrotal operation for which I routinely elect general anesthesia is bilateral vasoepididymostomy because this is the only scrotal procedure that takes over 3 hours. Very rarely a scrotal hernia or a huge hydrocele obscures the cord, preventing administration of local anesthesia. Aside from these rare exceptions, I perform all scrotal surgery with local anesthesia.

This initial report from the Vasovasostomy Study Group concerns intraoperative data obtained during vasovasostomy from 639 vasa in 334 patients. These data are related to the obstructive interval (time from vasectomy to vasovasostomy) and to the presence or absence of histologically proved sperm granuloma at the old transected testicular end of the vas (vasectomy site). Rates of sperm absence from vas fluid at the testicular end increased with longer obstructive intervals and with absence of a sperm granuloma. If sperm were present in fluid at the testicular end of the vas, the quality was poorer when the obstructive interval lengthened and when sperm granuloma was absent. Vas luminal diameters at the testicular end were smaller when a sperm granuloma was present. These observations support the theory that a sperm granuloma at the vasectomy site may have a beneficial, pressure-releasing effect that could be favorable prognostically for fertility after vasovasostomy.

Improved methods of urological microsurgery and of various assisted reproductive technologies have resulted in the ability to achieve pregnancies with sperm aspirated microsurgically from men with bilateral congenital absence of the vasa deferentia or with ductal obstructions that cannot be surgically reconstructed. A survey was conducted of the results of such procedures performed in the United States during approximately 2 years. Female partner ovarian stimulation was initiated in 219 instances at 22 centers. Of the 219 procedures 23 (11%) were terminated without attempting any form of gamete fertilization or insemination of the wife for various reasons (no sperm or too few sperm retrieved, poor to absent sperm motility or poor quality eggs). The etiology of azoospermia in the 219 procedures was congenital absence of the vasa deferentia in 115 cases (52%), other congenital conditions in 15 (7%), failed vasectomy reversal in 37 (17%), infection in 4 (2%), other conditions (mainly ejaculatory dysfunctions that did not respond to electroejaculation and complex ductal obstructions) in 26 (12%) and not specified in 22 (10%). When only patient sperm was used pregnancy was achieved in 12 of 115 wives (10%) of those men who had congenital absence of the vasa deferentia and in 0 to 14% of the wives of men whose azoospermia was caused by other conditions. Of the 219 menstrual cycles in which ovarian stimulation was initiated pregnancy occurred in 24 (11%) with patient sperm and in 9 (4%) with donor sperm. Of these 33 pregnancies a full-term, live delivery occurred in 17 (52%), while 8 (24%) were ongoing at the time of reporting, 2 (6%) miscarried, 3 (9%) were chemical pregnancies, 1 (3%) resulted in a stillborn child and the outcome was unknown in 2 (6%). This new therapy offers only a modest chance of pregnancy. However, it affords men with azoospermia the opportunity to achieve paternity with their own sperm when other therapies are not available or applicable.

A patient who was impotent following pelvic trauma was evaluated by penile arteriography. The study revealed bilateral disruption of the internal pudendal artery at the level of the urogenital diaphragm. It is concluded that impotence in this case is vasculogenic, although it is not possible to eliminate conclusively the possibility of neurogenic factors. Evaluation of more patients with this new technique of penile arteriography is necessary to establish the frequency of vasculogenic impotence in pelvic trauma.