Treatment of Ejaculatory Duct Obstruction by Seminal Vesiculoscopy Assisted Flow Modification

Summary

This protocol introduces the clinical application of seminal vesicle endoscopy combined with holmium laser in the treatment of ejaculatory duct obstruction caused by ejaculatory duct cyst.

Abstract

Transurethral resection of ejaculatory duct (TURED) is a primary surgical approach to treat ejaculatory duct obstruction (EDO) caused by the ejaculatory duct cyst. Intraoperative excision of the verumontanum is usually required to expose the ejaculatory ducts. However, preserving the verumontanum structure allows for a better simulation of normal physiological anatomy. Maintaining the verumontanum may increase the risk of postoperative distal ejaculatory duct scarring, leading to recurrent obstruction or reduced semen volume. Therefore, we attempted a novel technique that preserves the verumontanum, which is relatively easier and safer compared to TURED. The following were the procedural steps: 1. A 6F seminal vesiculoscope was introduced through the external urethral orifice to the vicinity of the verumontanum, locating the opening of the affected-side ejaculatory duct and introducing a guidewire into the cyst. This successful step preserved the verumontanum, maximizing the retention of the anti-reflux mechanism in the distal ejaculatory duct. 2. The holmium laser enlarged the affected-side ejaculatory duct opening to 5 mm, decreasing the likelihood of postoperative closure of the ejaculatory duct opening and simplifying the procedure. 3. A window was created within the cyst to access the contralateral seminal vesicle, and then a holmium laser was used to burn and dilate the opening to 5 mm, redirecting the contralateral ejaculatory duct into the cystic cavity. This modification preserved the opening of the healthy-side ejaculatory duct and provided a new outflow passage for semen, reducing the risk of decreased semen volume postoperatively. The patients experienced no complications postoperatively, had shorter hospital stays, and showed improvement in semen volume. Hence, this surgical approach is simple yet effective.

Introduction

Ejaculatory duct obstruction is a rare disease of the male reproductive system, with a reported incidence of 1%-5%^1,2. Ejaculatory duct cysts represent the predominant cause of ejaculatory duct obstruction. Semen examination in typical EDO patients reveals four distinctive characteristics: 1. Semen volume less than 2 mL, with a direct correlation between obstruction severity and decreased volume; 2. Oligospermia, with bilateral complete obstruction resulting in azoospermia; 3. Decreased pH value of semen; 4. Reduced levels of seminal plasma fructose, sometimes even dropping to 0 mM/L³. Male infertility caused by EDO can be treated with surgery and is less effective with conservative treatment⁴. In the past, the main method was transurethral resection of the ejaculatory duct. Although this approach boasts benefits like reduced trauma and fewer intraoperative complications, the surgical removal of the verumontanum disrupts the normal physiological structure of the distal ejaculatory duct. This, in turn, increases the postoperative risk of complications such as urinary reflux, epididymitis, retrograde ejaculation, and urinary incontinence⁵. At the same time, heat production during the operation may lead to the injury of the ejaculatory duct, seminal vesicle, and even rectum, and the thermal effect of the electric incision may cause new obstruction⁶.

The verumontanum stands as a crucial anatomical element within the male reproductive system, ensuring the precise and regulated discharge of semen during ejaculation while also helping to prevent retrograde flow. Whether the disadvantages of TURED can be ameliorated by preserving the seminal caruncle is unclear. Several studies have attempted to utilize laser-assisted endoscopy for the treatment of EDO while preserving verumontanum^2,7,8,9. Although the surgical approaches varied, post-operative semen recovery was notably successful with minimal complications. This indicates that preserving the epididymal head may be beneficial. However, the method they used is relatively complex and does not intervene in the healthy ejaculatory duct, which may increase the risk of recurrence. Therefore, we present a simple and effective surgical method.

In this study, the seminal vesiculoscope was guided into the ejaculatory duct cyst on the affected side by a wire guide. Then, the holmium laser was used to enlarge the ejaculatory duct opening on the affected side to ensure that it had a sufficiently large outflow channel.

Protocol

The surgical method described in this paper has been approved by the Ethics Committee of the Second Affiliated Hospital of Kunming Medical University, and the use of patient surgical videos has been authorized. Informed consent was obtained from the patients, and patient data was used for presentation.

1. Instruments for operation

1. Ensure that the display camera system and holmium laser are working properly.

2. Preparation for operation

1. Use the following inclusion criteria to select participants for this study.
   1. All patients who had been diagnosed with azoospermia or oligospermia and had consented to surgery.
   2. Semen volume less than 1.5 mL, pH<7.2. Seminal plasma fructose ≤13 µM/single ejaculation.
   3. Magnetic resonance imaging (MRI) revealed cysts in the ejaculatory duct area and enlarged bilateral seminal vesicle glands (Figure 1).
      NOTE: It is difficult to identify prostate cysts and ejaculatory duct cysts through imaging accurately. We usually confirm the diagnosis through surgery when seminal vesicle dilatation has a width greater than 17 mm¹⁰.
   4. Sex hormone levels are within the normal range. The testicular volume was more than 15 mL (individual testicular volume).
      NOTE: The purpose of testicular volume >15 mL is to rule out azoospermia caused by some testicular factors. Testicular volume was measured using ultrasound report data and Lambert's formula: L x W x H x 0.71.
   5. There were no diseases that affected the safety of surgery, such as poorly controlled hypertension and hyperglycemia, respiratory diseases, etc.
2. Use the following exclusion criteria to exclude participants from this study.
   1. Patients with urethral stricture, acute urinary tract infection, severe coagulopathy, or other contraindications to anesthesia.
   2. The testicular volume was less than 12 mL.
3. Administer intravenous antibiotics 30 min before surgery to prevent infection. Typically, use 1.5 g cefuroxime sodium with 100 mL of 0.9% sodium chloride solution.

3. Operational procedure

1. Position the patient in lithotomy for anesthesia induction using sufentanil (0.3 µg/kg), propofol (2 mg/kg), and rocuronium bromide (0.8 mg/kg). Perform tracheal intubation once drugs take effect, connecting to the anesthesia machine for mechanical ventilation.
2. Maintain with propofol (2 mg/kg/h), remifentanil (0.15 µg/kg/min), and 2% sevoflurane to achieve a BIS value of 40-60. Inject rocuronium bromide intermittently for inotropic relaxation. Disinfect the lower abdomen and perineal area 3x with iodophor.
3. Connect the seminal vesiculoscope to the display system. Insert the endoscope through the external urethral opening and carefully advance it toward the posterior urethra. The urethral mucosa appears smooth and reddish, confirming the accurate positioning of the urethra within the visual field and extending towards the posterior urethra.
4. If successful, check that the raised structure of the urethra, known as the colliculus seminalis, is visible.On either side of the colliculus seminalis, check for two small openings of the ejaculatory ducts (Figure 2A).
5. Guide a wire (Bard) through the affected side's ejaculatory duct opening, entering the ejaculatory duct cyst. Observe a significant area filled with cloudy fluid during the procedure (Figure 2B).
6. Flush the cyst with saline until achieving clear vision, examining for abnormal openings in the seminal canal. Enter the ipsilateral seminal vesicle through the abnormal ejaculatory duct cyst opening, revealing multiple honeycombed ductal lumens (Figure 2C).
7. Using a 40 W holmium laser, expand the diameter of the ejaculatory tube to approximately 5 mm, facilitating improved circulation of the flush fluid and providing a clearer view (Figure 2D).
8. Cut the ejaculatory duct opening along the direction of urine flow, which may be conducive to preserving the anti-urine reflux mechanism.
9. Identify and explore the symmetrical position of the abnormal ejaculatory duct opening on the affected side.
10. Enter the seminal vesicle of the healthy side for further exploration.Gently insert it into the seminal vesicle at the lower left and right of the cysts. It is important to note that the exact location may vary (Figure 2E).
11. Use the holmium laser to precisely incise and widen the contralateral artificial opening, allowing smooth passage for the endoscope. This marks the pivotal endpoint of the operation, where sperm in the vas deferens on both sides is effectively released through the opening of the ejaculatory duct on the affected side (Figure 2F).
12. Indwell a Fr18 catheter and rinse continuously with physiological sodium chloride to prevent blood clots from blocking the catheter.

4. Postoperative care

1. On the 1^st day post-surgery, continuously irrigate the bladder for 6 h and supplement with glucose and electrolytes as needed.
2. Remove the catheter on the 2^nd day post-surgery. Ensure that the patient experiences no evident pain after surgery; instead, they are able to endure the primary discomfort from the catheter, which is manageable without medication. Do not administer antibiotics postoperatively to patients without pre-existing infections. Keep the hospital stay for 2 days.
3. Instruct the patients to increase water intake, urinate frequently, and ejaculate as soon as possible after discharge, aiming for 1-2 times per week. Additionally, closely observe the semen volume.

5. Follow up

1. Perform semen analysis in the 3^rd month after surgery to ensure that the gag time requirement was met, and follow up after 3 months mainly through telephone interviews.
2. Perform semen samples using the automatic sperm motility testing instrument and the automatic seminal plasma biochemical instrument. Compare the semen analysis results obtained before the surgery with those at the 3^rd month post-surgery.

6. Statistical analysis

1. Analyze the results using GraphPad software and expressed as mean ± SD. Normality tests were performed using Shapiro-Wilk tests.If the preoperative and postoperative differences are normally distributed, analyze using the paired t-test; otherwise, use non-parametric tests (Mann-Whitney). Analyze differences between preoperative and postoperative data by paired t-test. Statistical differences were regarded as significant when P <0.05.

Results

A total of 5 patients were enrolled in this study, ranging in age from 27 to 34 years (median 31 years), with a disease course of 6 to 15 months (mean 9 months). Follow-up was 12 to 48 months (mean 24.8 months). All patients successfully completed the operation. The average operation time was 26 min and the average hospital stay was 2 days. All 5 cases had unilateral EDO and contralateral seminal vesicle dilatation. The demographic information, incorporating preoperative and postoperative data, pertaining to the patients...

Discussion

TURED is a primary surgical approach to treat ejaculatory duct obstruction caused by the ejaculatory duct cyst, and its main operation mode is to reveal the ejaculatory duct opening after the excision of cysts with an electric incision to relieve the pressure and dreg the seminal canal¹¹. The study subjects were asked about their medical history during the visit, and all had normal sexual activity frequency (1-2 times per week) and no sexual dysfunction or hematospermia. The preoperative semen exa...

Materials

Name	Company	Catalog Number	Comments
Camera system	Karl Storz, Germany	TC200EN	Endoscopic camera system
Fr18 Cathete	Zhanjiang City Shida Industrial Co., Ltd.	2660476	Drainage of urine
Fr6/7.5 vesiculoscope	Richard Wolf, germany	8702.534	Operative procedure
iodophor	Shanghai Likang Disinfectant Hi-Tech Co., Ltd.	31005102	Skin disinfection
Nitinol Guidewire 0.035"	C. R Bard, Inc. Covington, GA	150NFS35	Guide
Propofol	Sichuan Kelun Pharmaceutical Research Institute Co., Ltd.	H20203571	Induction and maintenance of anesthesia
Remifentanil	Yichang Humanwell Pharmaceuticals CO,Ltd.	H20030200	Maintenance of anesthesia
Rocuronium bromide	Zhejiang Huahai  Pharmaceuticals CO,Ltd.	H20183264	Induction and maintenance of anesthesia
Sevoflurane	Jiangsu Hengrui Pharmaceuticals Co., Ltd.	H20070172	Maintenance of anesthesia
Slimline EZ 200	LUMENIS, USA	0642-393-01	Dissect capsule wall
Sodium Chloride Physiological Solution	Hua Ren MEDICAL TECHNOLOGY CO. Ltd.	H20034093	Flushing fluid
Sufentanil	Yichang Humanwell Pharmaceuticals CO,Ltd.	H20054171	Induction and maintenance of anesthesia
Syringe 50 mL	Double Pigeon Group Co. Ltd.	20163141179	Inject 0.9% sodium chloride solution into the vesiculoscope
VersaPulse PowerSuite 100W Laser System	LUMENIS, Germany	PS.INT.100W	Provide energy