Purpose of review To synthesize contemporary, high-quality evidence on optimizing microdissection testicular sperm extraction (micro-TESE) outcomes for men with nonobstructive azoospermia (NOA). This review transitions the focus from plateaued baseline retrieval rates to a precision-based, surgeon-centric clinical pathway encompassing comprehensive preoperative, intraoperative, and laboratory domains. Recent findings Preoperative risk stratification is evolving beyond isolated clinical markers. Emerging multivariable nomograms and investigational liquid biopsies, such as seminal extracellular vesicle RNAs, offer refined predictive capabilities. Current evidence strongly supports selective varicocele repair prior to micro-TESE to significantly improve sperm retrieval and clinical pregnancy odds in specific cohorts. Conversely, hormonal optimization demands a targeted, phenotype-directed approach, emphasizing aromatase inhibitors for patients with a low testosterone-to-estradiol ratio, while the routine empirical use of clomiphene citrate remains contentious. Intraoperatively, advanced mapping modalities, including contrast-enhanced ultrasound and robotic-assisted platforms, provide high-resolution navigation. However, the systematic identification of dilated seminiferous tubules under high optical magnification, coupled with real-time embryological feedback, remains the definitive cornerstone of surgical success. Furthermore, the adjunctive use of artificial intelligence in embryological processing demonstrates significant potential in accelerating rare sperm detection. Summary Surpassing the current ceiling of micro-TESE success requires a highly individualized, multidisciplinary strategy. This encompasses rigorous genetic and endocrine profiling, phenotype-specific preoperative optimization, and meticulous, tissue-sparing microsurgical techniques. As noninvasive biomarkers and artificial intelligence transition into clinical maturity, their integration will further refine patient selection and intraoperative decision-making, ultimately elevating the standard of care for this severe cohort of male infertility.
PURPOSE OF REVIEW:Despite the effective use of phosphodiesterase type-5 inhibitors, a considerable number of patients fail initial attempts to manage erectile dysfunction with these medications. We reviewed the literature describing recent advances and future directions, and propose new regimens to manage nonresponders. RECENT FINDINGS:Patient education, psychological interventions, lifestyle changes and treatment of comorbidities are associated with improved erectile function. The administration of testosterone replacement combined with phosphodiesterase type-5 inhibitors promotes beneficial effects on erectile function in hypogonadal men. Combination of two different phosphodiesterase type-5 inhibitors at the same time is a promising approach, especially in individuals with more severe forms of erectile dysfunction, without increasing the incidence of adverse events. Although intracavernosal injection and penile prosthesis implantation are traditional and established therapeutic options to restore erectile function in refractory cases. Recent advances in medicine have expanded the therapeutic panorama, with emerging regenerative approaches, showing promising potential to restore erectile function. SUMMARY:The choice of the best strategies should be individualized according to the preferences of the patient and his sexual partner based on the advantages and disadvantages of the various options. Therefore, shared decision-making with the patient is strongly encouraged.
PURPOSE OF REVIEW:Circumcision remains one of the most commonly performed urological procedures worldwide. This narrative review discusses contemporary methods of circumcision, with emphasis on patient selection, conventional surgery, device-assisted circumcision, ShangRing, stapler devices, laser and energy-assisted techniques, wound closure, and special situations such as severe pathological phimosis and lichen sclerosus. RECENT FINDINGS:Recent literature has focused on adult phimosis management, modified conventional techniques, disposable circumcision devices, stapler devices, ShangRing, Alisklamp, Unicirc, Plastibell outcomes, laser circumcision, thermocautery, ultrasonic dissection scalpel and tissue adhesive closure. Devices generally offer shorter operative time, consistent excision and favourable cosmetic outcomes in selected patients. However, bleeding, oedema, retained rings or staples, ring-related discomfort, wound gaping and difficulty in severe pathological phimosis remain important considerations. SUMMARY:Conventional circumcision remains the most versatile reference technique against which newer methods are judged. Laser, ShangRing, stapler devices, tissue adhesive closure and other device-assisted techniques are useful adjuncts when matched appropriately to patient profile, foreskin pathology, surgeon experience and healthcare resources.
PURPOSE OF REVIEW:Cryptozoospermia, spermatozoa detectable only after centrifugation of the ejaculate, sits at the severe end of spermatogenic failure and is frequently misclassified as azoospermia. We review recent evidence on its accurate diagnosis and on optimizing the male to recover usable ejaculated sperm before defaulting to surgical retrieval. RECENT FINDINGS:Extended semen analysis reclassifies roughly one in five apparently azoospermic men as cryptozoospermic, and these men are genetically and prognostically distinct, with AZFc microdeletions strongly enriched. Hormonal therapy (selective estrogen receptor modulators, aromatase inhibitors, gonadotropins) helps a minority: eligibility is limited and benefit concentrates in normogonadotropic men, while men with azoospermia rarely respond. Microsurgical varicocelectomy improved semen parameters in about half of cryptozoospermic men with palpable varicoceles, frequently obviating surgical sperm retrieval. SUMMARY:Accurate diagnosis must precede management. In selected men, hormonal or surgical optimization can convert cryptozoospermia into an ejaculate adequate for assisted reproduction and spare an invasive retrieval, but the evidence remains largely observational and patient selection is paramount.
PURPOSE OF REVIEW:Severe male factor infertility is increasingly managed with surgical sperm retrieval, yet current noninvasive predictors cannot reliably distinguish men with retrievable focal spermatogenesis from those with global spermatogenic failure. This review evaluates epigenomic approaches, with emphasis on seminal plasma cell-free DNA methylation, for prediction of sperm retrieval in nonobstructive azoospermia. RECENT FINDINGS:Recent literature reinforces a persistent clinical limitation: conventional markers and multivariable models can inform risk, but they do not reliably distinguish focal spermatogenesis from global failure before surgery. At the same time, DNA methylation-based tissue-of-origin analysis and seminal plasma cell-free DNA (cfDNA) studies have created a new opportunity to measure sperm-associated molecular signal directly from the reproductive tract. Preliminary multisite clinical data suggest that sperm-derived cfDNA is best understood as a conditional biomarker whose meaning depends on endocrine and etiologic context. SUMMARY:Epigenomic liquid biopsy analysis of cfDNA in seminal plasma may add a biologically direct, noninvasive layer to NOA counseling. The key insight is not simply that sperm-derived cfDNA can be measured, but that its interpretation changes with FSH, genetics, histology and the differential diagnosis of azoospermia. Prospective validation is needed to determine whether this approach improves treatment counseling and surgical planning.
