Secondary ejaculatory duct obstruction: management by secondary transurethral resection of ejaculatory duct

Distal ejaculatory duct obstruction (EDO) is a relatively rare but surgically treatable cause of male infertility. Transrectal ultrasonography (TRUS) has been commonly used in infertility evaluation in recent years. These pathologies are more common than expected and treated with transurethral resection of ejaculatory duct (TURED). Although TURED is the recommended routine procedure for all cases of EDO, it has complications, such as iatrogenic obstruction, in 4% of the cases. Herein, we evaluated a patient who had developed EDO secondary to TURED.     

Aktuelle Aspekte der Refertilisierungsoperationen

Obstruction of the seminal ducts is the cause of infertility in about 5% of patients. It can be congenital or arise as the result of secondary changes. The reconstruction of the duct undertaken depends on the site of the obstruction. The introduction of microsurgical techniques has revolutionized the treatment of male infertility.A tubulovasostomy is carried out if the obstruction lies in the region of the epididymis. Such an anastomosis requires, owing to the minute anatomical relationships involved, a microsurgical procedure. For an obstruction of the vas deferens a vasovasostomy is required. Many investigations have shown that microsurgical techniques are also necessary for this procedure if a satisfactory success rate is to be achieved. The double-layer technique is the standard method for vasovasostomy. Transurethral resection of the ejaculatory ducts (TURED) is required for the very rare obstruction in this region, and men with an obstruction here cannot be regarded as forming a homogeneous group.Before advising an infertile couple it is necessary to investigate the individual conditions and possibilities. Because of the high success rate obtainable today by surgical reconstruction of the seminal ducts, this must constitute the first type of treatment to be considered, before any of the procedures of reproductive medicine are undertaken.     

Transurethral resection of cystic and non-cystic ejaculatory duct obstructions

Ejaculatory duct obstructions are diagnosed in ≈ 5% of azoospermic men and can be treated by transurethral resection (TURED) or incision of the ducts. Eight patients with azoospermia and ejaculatory duct obstructions were treated by TURED after clinical examination, semen analysis, biochemical analysis of seminal plasma, endocrine analysis, transrectal ultrasonography and testicular biopsy. In 3/3 cases of cystic and in 3/5 cases of non-cystic obstruction, TURED of the stenosis was possible. During a follow-up of 12 months there was an increase in semen volume and sperm count in 3/3 and 3/5 patients, respectively. No pregnancy was achieved during the period up to 12 months. Clinical symptoms such as haemospermia and pain disappeared in all cases. In our cases and another 98 cases of ejaculatory duct obstructions documented in the literature, men of semen quality improved in 38–60% with a pregnancy rate of men 22–31% after TURED. We conclude that there is a correlation between the aetiology of ejaculatory duct obstructions and success rate of TURED.     

经尿道射精管口电切术治疗射精管梗阻性无精子症

目的 探讨经尿道射精管口电切术（TURED）治疗射精管梗阻性无精子症的可行性和疗效。方法 对我院2003年6月—2004年12月收治的20例射精管梗阻性无精子症患者,采用精液常规分析、精浆果糖测定和经直肠前列腺精囊超声检查（TRUS）进行诊断,20例患者的精液量0．4～1．6ml,pH值6．0～7．2,精液中均未检出精子,精浆果糖为0～2．6μmoL／1次射精,其中16例的精浆果糖为0。TRUS显示前列腺中线囊肿11例,偏心性囊肿2例,双侧精囊及射精管扩张5例,一侧精囊及射精管扩张2例。所有者均使用TURED治疗,术后随访其疗效。结果 20例均完成手术,手术时间15～50min,术中出血约10～30m1,术后保留导尿管1～7d。术后随访超过3个月的15例患者中,10例（67％）术后精液质量改善,其中3例（20％）患者的配偶妊娠;随访不足3个月另尚未行精液检查。结论 TURED方法简单、安全、有效,是治疗射精管梗阻的有效手段。     

前列腺热疗后医源性射精管梗阻的诊断与治疗(附3例报告)

目的:探讨前列腺热疗后医源性射精管梗阻的诊断及治疗特点。方法:回顾分析3例前列腺热疗后射精管梗阻患者的临床资料。结果:3例患者皆因前列腺炎行经尿道前列腺热疗而导致后尿道狭窄、变形,继发射精管梗阻。经精液分析、经直肠B超检查后确诊。行经尿道射精管电切开术(TURED)后患者梗阻解除,精液恢复正常。结论:经尿道微波热疗、射频和电极导融治疗等方法在用于前列腺炎治疗时应严格掌握适应证,使用不慎可导致继发医源性射精管梗阻。经尿道射精管切开术是其首选治疗方法。     

Transurethral resection of ejaculatory duct in infertile men: outcome and predictors of success

Objectives

To evaluate the outcome of transurethral resection of the ejaculatory duct (TURED) in the treatment for ejaculatory duct obstruction (EDO) and define predictors of success.

Materials and methods

We retrospectively evaluated 23 infertile men between 2006 and 20011, who were diagnosed as having EDO. Inclusion criteria were azoospermia or oligozoospermia, low ejaculate volume, low ejaculate PH, little or no fructose in seminal plasma with normal serum levels of gonadotropins and testosterone and evidence of obstruction on transrectal ultrasonography (TRUS) or magnetic resonance images (MRI). Seventeen patients were diagnosed as complete EDO, and the remaining 6 were considered as having partial EDO. All patients were treated by TURED.

Results

Midline cysts were diagnosed in seven cases, and the remaining 16 patients had postinflammatory obstruction of ejaculatory ducts (ED). Overall, a significant improvement of semen quality was achieved after surgery. All patients with partial EDO showed improvements in semen parameters after TURED compared to 23.5?% (4/17) in those with complete EDO. Improvement in sperm count was 71.5?% and 31?% for patients with midline cysts and patients with non-cystic causes of EDO, respectively. Six (26?%) patients developed complications including epididymo-orchitis in 2, watery ejaculate in 3 and conversion to azoospermia in 1. Spontaneous pregnancies were achieved in 3 (13?%) cases: 2 (33.3?%) men with partial and 1 (5.9?%) with complete obstruction.

Conclusion

Partial EDO, whatever the etiology, has an excellent outcome after TURED. Complete EDO due to cysts appears to respond better than postinflammatory obstruction to TURED.     

Transurethral resection of ejaculatory ducts in the treatment of complete ejaculatory duct obstruction

Objectives To evaluate the value of transurethral resection of the ejaculatory duct (TURED) in the treatment of complete ejaculatory duct obstruction (EDO) as a treatable cause of male factor infertility. Materials and methods We retrospectively evaluated 12 azoospermic infertile men who were diagnosed as having complete EDO. The mean age of the patients was 32 years (range 24–40). Inclusion criteria were EDO in patients with azoospermia, normal serum levels of gonadotropins and testosterone and evidence of obstruction on transrectal ultrasonographic (TRUS) images. The definitive diagnosis was based on the absence of an efflux of methylene blue injected through the seminal vesicles during cystoscopy. All patients were treated by TURED. Results Before TURED, all patients were azoospermic and had been considered as candidates for in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI). Following the operation, sperms were seen in the ejaculates of 11/12 patients. After a mean follow-up period of 12 (range 4–36) months, five (41.6%) pregnancies were noted (three spontaneous, one with intrauterine insemination and one with IVF/ICSI). Conclusion Transurethral resection was found to be a safe and somewhat effective approach for the treatment of EDO. After TURED, a significant improvement was achieved in semen parameters, and spontaneous pregnancy resulted in three cases. In addition, TURED can reduce the need for expensive procedures such as IVF/ICSI as this modality allows IVF/ICSI to be performed with ejaculated instead of surgically retrieved sperm.     

TRANSURETHRAL RESECTION OF PARTIALLY OBSTRUCTED EJACULATORY DUCTS: SEMINAL PARAMETERS AND PREGNANCY OUTCOMES ACCORDING TO THE ETIOLOGY OF OBSTRUCTION

Purpose

We determine how transurethral resection of the ejaculatory ducts performed for infertility affects seminal parameters and pregnancy outcomes in patients with partial ejaculatory duct obstruction due to a congenital or acquired etiological factor.

Materials and Methods

Based on history and physical examination, hormonal profiles, semen analyses, transrectal ultrasonography and vasography findings partial ejaculatory duct obstruction was diagnosed in 14 men a mean of 30 years old who presented for infertility evaluation. Patients were grouped according to congenital or acquired cause of obstruction. Transurethral resection of the ejaculatory ducts was performed using the standard resectoscope loop technique. Clinical outcome was assessed by postoperative analyses of seminal parameters and pregnancy reports.

Results

Transurethral resection of the ejaculatory ducts significantly improved semen quality (ejaculate volume and percentage of sperm motility) in all patients in the congenital group, while all but 1 (83%) had an improved sperm count. Pregnancy was achieved via sexual intercourse by 66% of the patients an average of 5.7 months postoperatively. Of the acquired etiological factor group 37.5% had improved semen quality after transurethral resection of ejaculatory duct and 12.5% achieved pregnancy via sexual intercourse. Postoperative complications occurred at a similar rate in each group (33%). However, complications in the congenital etiology group were minor, while 25% of the men in the acquired group had significant impairment of seminal parameters after transurethral resection of the ejaculatory ducts.

Conclusions

Semen quality improvement and pregnancy outcome after transurethral resection of the ejaculatory ducts for partial ejaculatory duct obstruction differ significantly according to the main etiological cause of obstruction. An equivocal diagnosis of partial obstruction and technical problems during transurethral resection of the ejaculatory ducts may contribute to failure. However, in some cases the reason for failure remains unclear.     

Novel methods for the diagnosis and treatment of ejaculatory duct obstruction

Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVES

? To investigate a new method of vas deferens radiography for ejaculatory duct obstruction (EDO). ? To evaluate the effect of a procedure involving dilation of the ejaculatory duct by F9 seminal vesicoscopy.

PATIENTS AND METHODS

? Twenty‐two patients with EDO were diagnosed using semen analysis, semen fructose measurement, transrectal ultrasonography (TRUS) and vas deferens radiography. ? Of these, 18 patients were successfully treated by dilation of ejaculatory duct using F9 seminal vesicoscopy and four patients, whose treatment was unsuccessful, were treated by transurethral resection of the ejaculatory ducts (TURED). ? All patients were followed up for at least 3 months after treatment.

RESULTS

? Semen analyses in all 22 patients showed oligoasthenozoospermia or azoospermia, low semen volume (0–1.9 mL), low pH level (5.6–7.0) and absent or low semen fructose. TRUS and radiography showed pure dilated seminal vesicles on both sides in three patients, partial dilated seminal vesicles in one patient, dilation of both the ejaculatory duct and seminal vesicles in ten patients, dilated seminal vesicles and a prostatic cyst in four patients, and dilated ejaculatory duct or cystic lesions without dilated seminal vesicles in the remaining four patients. ? At >3‐month follow‐up after dilation or TURED, the semen characteristics of 18 patients were improved and sperm were present in the semen in 13 cases. Normal semen analyses were found in 7 patients and 6 patients had conceived. ? Voiding urethral radiography showed that no patients who had undergone dilation by seminal vesicoscopy had urine reflux into the ejaculatory duct. Only one patient showed urine reflux into the seminal vesicle after TURED. ? All patients felt that their symptoms had improved after treatment.

CONCLUSIONS

? The approach to vas deferens radiography using vas deferens aspiration has proved to be an effective and safe method for EDO diagnosis. ? The procedure involving the dilation of the ejaculatory duct using F9 seminal vesicoscopy is equally effective but has fewer postoperative complications than TURED.     

Ejaculatory Duct Obstruction after Transurethral Resection of the Prostate

Transurethral resection of the prostate is currently the most commonly employed surgical procedure for benign prostatic hyperplasia. Although several complications after the procedure have been well documented, ejaculatory duct obstruction is a rare complication. We describe this unusual complication in a 77-year-old male who presented with severe pain and a feeling of fullness in the lower abdomen and with dry ejaculate on three occasions after undergoing post-transurethral resection of the prostate. The patient’s post-ejaculatory urinalysis demonstrated no sperm. Transrectal ultrasonography also showed no dilatation of the bilateral seminal vesicles or ejaculatory ducts. However, ejaculatory duct obstruction was finally diagnosed on vasovesiculography. The patient was successfully treated with transurethral resection of the ejaculatory duct and remained asymptomatic 6 months postoperatively. Although transrectal ultrasonography is currently widely used to evaluate ejaculatory duct obstruction, we suggest that vasovesiculo-graphy is still a feasible and useful tool that provides detailed anatomic information for the advanced confirmation of ejaculatory duct obstruction in patients with a high suspicion of ejaculatory duct obstruction who have normal transrectal ultrasonography findings.     

评价经直肠彩色多普勒超声在男性不育症精囊和射精管病变诊断中的价值

目的探讨经直肠超声在男性不育症患者精囊和射精管病变诊断中的价值.方法应用经直肠彩色多普勒超声技术对50例男性不育症患者进行精囊和射精管检查.结果男性不育症患者经直肠超声表现呈现多样性特点,其中包括精囊先天性缺如和发育不良、慢性精囊炎如精囊肿大或精囊壁增厚伴钙化,射精管梗阻性病变如射精管扩张以及射精管囊肿,射精管壁钙化等.部分病例未发现明显精囊和射精管病变.结论经直肠彩色多普勒超声可用于射精管梗阻性病变和精囊先天性改变的诊断.对于精囊炎症性表现具有一定诊断意义,它是男性不育症患者精囊和射精管病变诊断的理想手段.     

Seminal Vesicle Urinary Reflux as a Complication of Transurethral Resection of Ejaculatory Ducts

Transurethral resection of ejaculatory ducts has become an effective surgical treatment for male infertility caused by ejaculatory duct obstruction. We report on a patient treated successfully by transurethral resection of the ejaculatory ducts for a large midline cyst who postoperatively complained of terminal urinary dribbling lasting several minutes. On video urodynamic study reflux into and delayed drainage from the right seminal vesicle were found.     

Transurethral resection of the ejaculatory ducts for treating ejaculatory symptoms

OBJECTIVES: To report our experience with transurethral resection of the ejaculatory ducts (TURED) in infertile men with symptomatic ejaculatory duct obstruction (EDO). PATIENTS AND METHODS: Before surgery, all patients complained of a decrease in the volume of their ejaculate, 14 of 15 had a non-projectile ejaculation, nine had a genitourinary infection necessitating antibiotic treatment, and five had pain with orgasm. The mean ejaculate volume and total motile sperm count was 1.1 mL and 8.1 million sperm per ejaculate. After surgery, at a mean follow-up of 2 months, 10 men reported having projectile ejaculation, and eight reported a marked improvement in their sensation of orgasm. Overall, 14 men reported a subjective improvement in their ejaculation. The average postoperative ejaculate volume was 2.3 mL and the total motile sperm count was 38.1 million per ejaculate. CONCLUSIONS: Men with symptomatic EDO who underwent TURED showed improvements in their ejaculation, sensation of orgasm, semen analysis values and fertility.     

Transurethral seminal vesiculoscopy using a 6F vesiculoscope for ejaculatory duct obstruction: initial experience

Ejaculatory duct obstruction (EDO) is a surgically correctable condition that occurs in some infertile men. The standard therapy is transurethral resection of ejaculatory ducts (TURED). However, TURED has been associated with a high risk of complications, including the impairment of semen parameters and retrograde ejaculation. In our clinical practice, vesiculoscopy has demonstrated potential as a minimally invasive alternative technique for the diagnosis and treatment of EDO. Very few studies have examined transurethral seminal vesiculoscopy (TRU-SVS) in recent years, and no study has examined 6F vesiculoscopes. Therefore, we performed a retrospective study of TRU-SVS using a 6F vesiculoscope and its effect on the diagnosis and treatment of EDO. A total of 21 patients who underwent this procedure were included in the study. The mean patient age was 28.8 years (range, 23-36 years). The procedure was completed successfully in all patients within a mean time of 31.5 minutes and a mean hospital stay of 1.17 days. All patients had EDO. Calculi were found in the ejaculatory ducts or in the seminal vesicles of 5 patients. Sperm was detected in 11 patients 1-3 months postsurgery and in another 8 patients 3-12 months postsurgery. No sperm was detected in the remaining 2 patients by 12 months postsurgery. Epididymitis, retrograde ejaculation, urinary incontinence, and rectal injury were not observed. These data indicate that TRU-SVS using a 6F vesiculoscope affords direct access to the seminal vesicle and offers the advantages of fewer complications and more optimal sperm recovery as well as direct, dynamic video imaging.     

Normal Human Ejaculatory Duct Anatomy: A Study of Cadaveric and Surgical Specimens

Purpose

We examined the anatomy of the ejaculatory ducts in normal men and correlated findings with theories of ejaculatory duct obstruction.

Materials and Methods

Gross and microscopic anatomical studies were performed on cadaveric and operative specimens derived from radical prostatectomy.

Results

Histologically, the ejaculatory ducts are a continuation of the seminal vesicles. However, the thick muscle wall of the seminal vesicle is not present within the ejaculatory duct. Normal ejaculatory duct luminal and wall dimensions are remarkably uniform among men. A luminal diameter of greater than 2.3 mm. defines a dilated system statistically.

Conclusions

The largely collagenous ejaculatory ducts may serve as simple semen conduits instead of muscular tubes with spasmodic, sphincteric or peristaltic properties. The anatomical findings presented suggest several possible mechanisms for the prevention of urinary reflux into the ejaculatory ducts.     

Diagnosis and treatment of ejaculatory duct obstruction in male infertility

OBJECTIVE: To discuss the diagnosis and treatment of ejaculatory duct obstruction in male infertility. PATIENTS AND METHODS: Twenty-four males were treated for ejaculatory duct obstruction between 1994 and 1998 in our clinic. Patients' age varied between 20 and 40 (mean=29). Ejaculatory duct obstruction was considered in patients with low to normal ejaculate volume, azoospermia or oligospermia, decreased motility, normal serum gonadotropin and testosterone levels, absent or low fructose in the ejaculate and evidence of obstruction on transrectal ultrasonography. The definitive diagnosis was made by the absence of efflux of methylene blue injected through the vas during cytoscopy. All the patients were subjected to transurethral resection of ejaculatory ducts and spermograms before and 3 months after resection were compared. RESULTS: Before transurethral resection mean sperm count was 1.66x10(6)/ml compared to 25.4x10(6)/ml postoperatively. The difference was statistically significant (p=0.001). After the operation, 58.3% of the cases had improvement in sperm motility, and 62.5% had increased ejaculate volume. No significant complications occurred, and in only 1 (4.17%) patient, there was persistent hematuria. After a mean follow-up period of 9 (6-18) months, 6 (25%) pregnancies were noted. CONCLUSION: Although transurethral resection is an effective method for the treatment of ejaculatory duct obstruction, the pregnancy rate is low, which could be related to the hazardous effects of urinary reflux into ejaculatory ducts or functional abnormalities of seminal vesicles.     

射精管梗阻的诊断与治疗：附5例报告

报告射精管梗阻引起的不育症５例，其主要表现为无精子或少精子症、精子活力降低以及射精量减少，其中２例有反复性泌尿系感染病史。５例均行经尿道射精管切开术，术后精液量均增多，３例精液质量恢复。并结合文献对其病因、诊断及治疗效果进行讨论，认为射精管梗阻引起的不育症应引起临床重视，经直肠Ｂ超检查是诊断射精管梗阻的有效手段，射精管切开术能有效地改善精液质量。     

Ejaculatory duct obstruction

Ejaculatory duct obstruction presents with infertility, pain, or hematospermia. Partial or functional forms of ejaculatory duct obstruction can be difficult to diagnose. Transrectal ultrasound has replaced formal vasography as the first-line diagnostic test but is not specific. Adjunctive procedures such as seminal vesicle aspiration, seminal vesiculography, and chromotubation further delineate the diagnosis. Using an evidence-based approach, this article reviews how best to approach the diagnosis and treatment of ejaculatory duct obstruction.     

Inflammatory-associated obstructions of the male reproductive tract

A history of urogenital inflammation occurs in 5-12% of men attending infertility clinics. Usually, infection has a detrimental effect on sperm quality by reducing concentration and motility, and possibly affecting the number of morphological normal spermatozoa. In addition, infection may be the source of auto-antibodies against spermatozoa, found in about 8% of the infertile male population. In contrast to the situation in women, there is no clear evidence that male accessory gland infections can result in epididymal blockage or vassal obstruction, with the exception of genital tuberculosis. Although Chlamydia trachomatis is a well-documented source of chronic prostatitis, the infection does not seem to cause obstruction of the reproductive tract, as it does in women. If male urogenital infection causes obstruction it is most likely located at the level of the ejaculatory ducts. Chronic prostatitis has been proved to cause scarring of the prostatic and ejaculatory ducts, resulting in low seminal volume with low fructose and alpha-glucosidase. Many of these men present with severe oligozoospermia or azoospermia, normal size testis and normal gonadotrophins. We performed an excisional testicular biopsy in all men presenting with <1 million spermatozoa per millilitre and found that 39 of 78 (50%) had a normal spermatogenesis. A history of male accessory genital infection was found in 12% of the men and 10% had abnormalities found on transrectal ultrasound of the prostate (like oedema, dilatation of the seminal vesicles and ejaculatory ducts) intraprostatic calcifications and dilatation of the periprostatic venous plexus. Ejaculatory duct obstruction is a common cause of male infertility and infections are present in at least 22-50% of these men. Transurethral resection of the ejaculatory ducts may result in a significant improvement of the sperm quality and in spontaneous pregnancies in up to 25% of the couples. In case of failure sperm aspiration from the epididymis and intracytoplasmic sperm injection is the treatment of choice.     

射精管梗阻的诊断与治疗(英文)

射精管梗阻是一种罕见现象 ,但却是男性不育的重要原因。本文对怀疑射精管阻塞病人的不同诊断、评估和治疗方法作了描述 ,包括一些新的很少侵入性的诊断和治疗射精管梗阻技术