Morphological variations of the human ejaculatory ducts in relation to the prostatic urethra

Ejaculations and Benign Prostatic Hyperplasia: An Impossible Compromise? A Comprehensive Review

Background: Benign prostatic hyperplasia (BPH) is commonly responsible for lower urinary tract symptoms (LUTS) in men aged 50 or over. Sexual dysfunctions, such as ejaculatory disorders (EjD), go along with LUTS but are frequently overlooked in the initial evaluation. This review aimed to detail BPH-related EjD, as well as their modifications by medical, surgical, and interventional treatments. Methods: We conducted a narrative review looking for publications between 1990 and 2020, regarding physiopathology, epidemiology, evaluation, and therapeutic management (medical, surgical, and interventional) of BPH-related EjD. Results: Sixty-five articles were included in our final analysis. Forty-six percent of men presenting with LUTS reported EjD. If the prevalence increases with age and LUTS severity, the functional impairment is not correlated with age. Several self-questionnaires evaluated the sexual function, but only four approaches are specific to EjD. Medical therapies were exposed to anejaculation, rather than retrograde ejaculation (RE) (4–30% (alpha-blockers), 4–18% (5-alpha-reductase inhibitors)). Regarding surgical therapies, trans-urethral resection of the prostate (TURP) and incision of the prostate (TUIP) are associated with 50–70% and 21–35% of RE. The RE rate is important after open simple prostatectomy but can be reduced with robotic approaches and urethral sparing techniques (19%). Anatomic endoscopic enucleation of the prostate (AEEP) with or without a laser source is associated with an 11–36% RE rate, according to supramontanal preservation. Recent surgical techniques (Rezum©, Aquablation©, or Urolift©) were developed to preserve antegrade ejaculation with promising short-term results. Regardless of the surgical approach, anatomic studies suggest that the preservation of peri-montanal tissue (7.5 mm laterally; 10 mm proximally) is primordial to avoid post-operative RE. Finally, prostate artery embolization (PAE) limits the RE rate but exposes it to a 12 months 10% re-intervention rate. Conclusion: EjD concerns almost half of the patients presenting BPH-related LUTS. Initial evaluation of EjD impairment is primordial before medical or surgical therapy. Peri-montanal tissue preservation represents a key point for antegrade ejaculation preservation, regardless of the surgical option.

Evaluation of a novel technique of bladder neck and supramontanal sparing ejaculatory preserving transurethral prostatectomy

PURPOSE

Transurethral resection of the prostate (TURP) can achieve highly satisfying symptomatic and functional outcomes but the loss of antegrade ejaculation represents a major reason for the avoidance of surgical treatment to preserve normal ejaculation and paternity. We present a novel technique to duplicate both bladder neck sparing and supramontanal sparing with resection of apical tissues to improve voiding and antegrade ejaculation.

METHODS

A prospective study done from June 2018 to June 2020 on 60 consecutive male patients with normal sexual activity diagnosed with benign prostatic enlargement. These patients were randomized into two groups; 30 patients in each group. Group 1 underwent bladder neck and supramontanal sparing ejaculatory preserving transurethral bipolar resection of prostate (ep-TUBRP) and Group 2 underwent classic transurethral bipolar resection of prostate (c-TUBRP). All patients were evaluated pre- and postoperatively (after 3 months) using IPSS, Qmax and by IIEF-5.

RESULTS

In both groups, there were significant improvements 3 months postoperative in Qmax [7.97 mL/s to 18.47 mL/s (group A) and 7.8 to 20.7 mL/s (group B)] and in micturition symptoms according to reductions in IPSS score [24 to 7.5 (group A) and 25 to 8.5 (group B)]. IIEF-5 score improved significantly from a mean of 12.9 to 18.6 (group A) and from 11.6 to 16.4 (group B). Antegrade ejaculation reported in 80% of patients in group A and 27% in group B which was significant (p < 0.001). Postoperative period did not reveal acute urinary retention, stress urinary incontinence, or serious adverse events.

CONCLUSIONS

On short-term results, bladder neck and supramontanal ejaculation preserving transurethral bipolar resection of the prostate is superior to classic TURP in preservation of forward ejaculation with comparable efficacy in micturition parameters.

Three-dimensional measurement and analysis of benign prostatic hyperplasia

Background

The volume and thickness of intravesical prostatic protrusion and other characteristics of benign prostatic hyperplasia have not been investigated. We determine the effects of age and prostate volume on anatomical features of benign prostatic hyperplasia using three-dimensional measurement in this study.

Methods

This retrospective study included a total of 98 patients with benign prostatic hyperplasia. Three-dimensional models of prostate, central gland, peripheral zone, intravesical prostatic protrusion, prostatic urethra and bladder were reconstructed according to pelvic T2-weighted magnetic resonance imaging of these patients. The models were used to measure the intravesical prostatic protrusion volume, intravesical prostatic protrusion thickness, intravesical prostatic protrusion index, intravesical prostatic protrusion, prostate volume, peripheral zone volume, peripheral zone thickness, peripheral zone index, prostatic urethra thickness, the angle and distance of distal prostatic urethra with regard to coronal plane and sagittal plane and so on.

Results

Intravesical prostatic protrusion volume, intravesical prostatic protrusion thickness and peripheral zone volume of prostate volume >80 mL group were significantly higher than these in prostate volume <80 mL group (P<0.001, 0.01, 0.01, respectively). These parameters significantly increased with age (P<0.001, 0.01, 0.05, respectively). Peripheral zone index was significantly lower of prostate volume >80 mL group than these in prostate volume <80 mL group (P<0.05). Peripheral zone index significantly decreased with age (P<0.01). Intravesical prostatic protrusion index had no significant difference in all age groups. Peripheral zone thickness and prostatic urethra thickness had no significant difference in all groups. The distance and angle of distal prostatic urethra prostatic urethra with regard to coronal plane were significantly higher than these with regard to sagittal plane (both P<0.001).

Conclusions

The rearward slope of the prostatic urethra is greater than the left or right offset during the process of benign prostatic hyperplasia. Three-dimensional measurement provides good supports for further clinical and scientific research.

Anatomic study of verumontanum during endoscopic surgeries in patients with benign prostatic hyperplasia

INTRODUCTION AND OBJECTIVE

To evaluate changes in verumontanum anatomy in patients with benign prostatic hyperplasia (BPH) who used 5-alpha reductase inhibitors (5-ARIs) and to propose an anatomical classification of the verumontanum.

MATERIALS AND METHODS

We studied 86 patients with BPH and 7 patients without the disease (age under 40 years-old who underwent kidney or ureteral lithotripsy). Of the patients with BPH, 34 (mean age=67.26) had 5-ARIs use and 52 (mean age=62.69) did not use the drug. During surgeries, photographs of the seminal colliculus were taken and later, with the aid of software (Image J), the length (longitudinal diameter) and width (transverse diameter) of the verumontanum were measured in all patients. During the procedure, we evaluated the different types of verumontanum. For statistical analysis, the R-Project software was used.

RESULTS

In the group of patients with BPH who were taking medication (group 1), the mean measures of length and width of the verumontanum were 4.69mm and 2.94mm respectively. In the group of patients with BPH who did not use the drug (group 2), the mean diameters were 4.54mm and 3.20mm respectively. In the control group (group 3), the average length and width were 5.63mm and 4.11mm respectively. There was an increase in longitudinal and transverse measurements of the control group with an increase in body mass index (BMI) (p=0.0001 and p=0.035 respectively). In addition, there was a reduction in transverse diameter in the group of BPH using 5-ARI with increased prostate volume (p=0.010). We found five different verumontanum types: "volcano" (51.61%), "lighthouse" (24.73%), "whale tail" (12.90%), "hood" (5.38%) and "castle door" (5.38%), which we propose as an anatomical classification.

CONCLUSION

Veromontanum has smaller measurements in patients with BPH regardless of treatment. In the control group, there was an increase in verumontanum diameters with an increase in BMI. The volcano type of verumontanum was the most frequent regardless of groups and BMI.

Morphology of ejaculatory ducts: A systematic review

The morphology of human ejaculatory ducts has not been well established. The objective of this study was to describe macroscopic and microscopic anatomy of ejaculatory ducts. We conducted a systematic review using MEDLINE, Scopus, PubMed, and Cochrane databases. Search terms were: "ejaculatory ducts," "seminal colliculus," "prostatic utricle," "anatomy," "histology," "radiology," and "embryology." We only included studies assessing adult (>18 years) humans published before November 1, 2019. We excluded studies describing pathological ducts and case reports. Independent authors extracted data using predefined criteria. Fourteen studies were included in the qualitative synthesis. Usually, the ejaculatory ducts entered the prostate by piercing the central part of its base. Most studies identified an anteromedial curve of the ducts at the outset within the prostate, their subsequent course being a straight path towards the seminal colliculus, their terminal parts diverging immediately before joining the prostatic urethra. However, the morphology of the terminal part of the ducts was inconsistent. The mean length of the ducts ranged from 1.4 to 2.2 cm. In conclusion, the luminal diameter gradually decreased as the ducts traveled towards the seminal colliculus. Ejaculatory ducts angulate anteromedially at their onset within the prostate and travel straight towards the seminal colliculus. Their terminal parts diverge immediately before joining the prostatic urethra. However, the reported dimensions of the ducts differ among studies.

Anatomical study of the seminal vesicle system for transurethral seminal vesiculoscopy

Because of a general lack of knowledge regarding the precise anatomy of the seminal vesicle system, efforts to use transurethral seminal vesiculoscopy (TSV) are currently constrained. We investigated 26 normal adult male specimens. Contrast medium was injected into the seminal vesicle system in 18 specimens and the openings of the ejaculatory ducts were examined with an operating microscope. India ink was injected into the urethra in four specimens to investigate the function of the ejaculatory duct valve. Another four specimens were examined histologically to identify the anatomical relationships of the seminal vesicle system. We found that the openings of the ejaculatory ducts were covered by the ejaculatory duct valve, which could be classified into two types and acted as a one-way valve. The apex of the seminal colliculus together with the right and left openings of the ejaculatory ducts formed a shape resembling an isosceles triangle. This could be used to locate the openings of the ejaculatory ducts during TSV. The ejaculatory ducts can be classified into two types according to their course. During surgery, efforts must be made to protect the ejaculatory duct valve. During inspection or surgery, the second segment and the angles of the ejaculatory ducts, particularly in Type I_b and Type II cases, require particular attention. Clin. Anat. 32:244-252, 2019. © 2018 Wiley Periodicals, Inc.