Transrectal ultrasonography-guided echo-enhanced seminal vesiculography in combination with transurethral resection of the ejaculatory ducts

Azoospermia Due to Functional and Partial Ejaculatory Duct Obstruction: A Rare Case Report and Literature Review

Ejaculatory duct obstruction (EDO) is a rare but treatable cause of male infertility. This case report describes a 28-year-old male with obstructive azoospermia. The patient came to our hospital after a fertility check-up revealed azoospermia. A subsequent semen analysis confirmed azoospermia. Transrectal ultrasonography (TRUS) and magnetic resonance imaging (MRI) revealed bilaterally enlarged seminal vesicles and thickened, calcified ejaculatory duct walls. The patient underwent transurethral seminal vesiculoscopy and transurethral resection of the ejaculatory ducts (TURED) for presumed partial EDO. Despite two transurethral seminal vesiculoscopy and TURED procedures, postoperative semen analysis still showed azoospermia. TRUS indicated non-contractile seminal vesicles and an unobstructed ejaculatory duct. The patient ultimately underwent percutaneous epididymal sperm aspiration for assisted reproductive technology and his spouse got pregnant. We identified a case of azoospermia caused by a rare combination of partial and functional ejaculatory duct obstruction. There are currently no reports of similar cases. This case report aims to provide valuable insights for diagnosing and treating EDO.

Real-time transrectal ultrasound-guided seminal vesiculoscopy for the treatment of patients with persistent hematospermia: A single-center, prospective, observational study

This study aimed to describe endoscopic anatomy of the seminal tract and summarize our experience of transutricular seminal vesiculoscopy (TSV) guided by real-time transrectal ultrasonography (TRUS) in managing persistent hematospermia. A total of 281 consecutive patients with persistent hematospermia who underwent TSV with or without real-time TRUS were enrolled in this single-center, prospective, observational study. The median follow-up period was 36.5 (range: 8.0–97.5) months. TSV was successfully performed in 272 (96.8%) patients. The approach of a 4.5/6 F rigid vesiculoscope entering the seminal tract was categorized into four types on the basis of endoscopic presentation of the ejaculatory duct orifice and verumontanum. Seven (2.6%), 74 (27.2%), 64 (23.5%), and 127 (46.7%) patients had Types I (through the ejaculatory duct in the urethra), II (through the ejaculatory duct in the prostatic utricle), III (transutricular fenestration through a thin membrane), and IV (real-time transrectal ultrasound-guided transutricular fenestration) approach, respectively. In patients who successfully underwent surgery, bleeding occurred in the seminal vesicle in 249 (91.5%) patients. Seminal vesiculitis, calculus in the prostatic utricle, calculus in the ejaculatory duct, calculus in the seminal vesicle, prostatic utricle cysts, and seminal vesicle cysts were observed in 213 (78.3%), 96 (35.3%), 22 (8.1%), 81 (29.8%), 25 (9.2%), and 11 (4.0%) patients, respectively. Hematospermia was alleviated or disappeared in 244 (89.7%) patients 12 months after surgery. Fifteen patients had recurrent hematospermia, and the median time to recurrence was 7.5 (range: 2.0–18.5) months. TSV guided by TRUS may contribute to successful postoperative outcomes in managing persistent hematospermia.

A systematic review of transurethral resection of ejaculatory ducts for the management of ejaculatory duct obstruction

OBJECTIVE

Ejaculatory duct obstruction (EDO) is an uncommon but potentially treatable cause of male factor infertility. However, there are limited data on transurethral resection of the ejaculatory ducts (TURED) as a treatment option. A systematic review was therefore conducted to assess its efficacy and identify patient subgroups that benefit from the procedure.

MATERIAL AND METHODS

A database search of PubMed, Embase, and Scopus (up to January 2019) and the World Health Organization trial registry was performed to identify all studies assessing infertile men with EDO undergoing TURED. The primary outcome measures included semen parameters and natural pregnancies. The secondary outcomes included complications, symptomatic improvement, and a change from in vitro fertilization to intrauterine insemination.

RESULTS

Of 3,277 articles screened, 29 studies with 634 patients were included in the study. Although outcomes varied considerably among studies, a general increase in all semen parameters postoperatively was observed. Semen volume (n=23 studies) improved in a median of 83.0% of patients (interquartile range [IQR]: 37.5). Sperm motility and concentration (n=10 and n=21 studies) improved in a median of 63.0% (IQR: 15.0) and 62.5% (IQR: 16.5) of patients, respectively. The natural pregnancy rate across the studies was a median of 25.0% (IQR: 15.7). Improvements in both the outcomes were greater in patients with congenital etiologies and partial EDO. Differences in surgical technique did not appear to affect outcomes.

CONCLUSION

TURED is associated with improvements in semen parameters and offers a chance of restoring fertility in previously subfertile men. Although results are promising, the current evidence remains limited owing to predominantly retrospective studies with small sample sizes.

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.

Comparison of transrectal ultrasonography and transrectal ultrasonography-guided seminal vesicle aspiration in the diagnosis of the ejaculatory duct obstruction

OBJECTIVE

To compare transrectal ultrasonography (TRUS) and TRUS-guided seminal vesicle aspiration in the diagnosis of ejaculatory duct obstruction (EDO).

DESIGN

A retrospective case-controlled study comparing the findings of TRUS and TRUS-guided seminal vesicle (SV) aspiration.

SETTING

Clinics of Urology and Radiology.

PATIENT(S)

Seventy patients with suspected EDO (complete in 10, partial in 60 patients) on clinical evaluation.

INTERVENTION(S)

Each SV was punctured transrectally using a 20-gauge Chiba needle within 2 hours after ejaculation.

MAIN OUTCOME MEASURE(S)

In SV aspirates, greater than three sperm per high-power microscopic field was considered a positive result for EDO.

RESULT(S)

Fifty-five (78.6%) patients had evidence of EDO on diagnostic TRUS. However, obstruction on TRUS was confirmed in 49.1% (27 of 55) of the patients with SV aspiration. Higher sperm positivity rates were achieved in patients with SV dilation (11 of 13, 84.6%) and prostatic midline/ED cyst (12 of 16, 75.0%). Stepwise logistic regression analysis revealed that the incidence of SV dilation was significantly higher, whereas that of chronic inflammatory findings in the prostate was significantly lower in the positive SV aspirate group.

CONCLUSION(S)

TRUS alone is not a reliable tool for the diagnosis of EDO. For this reason, SV aspiration should be used as an adjunctive technique in patients with SV dilation or a prostatic midline/ED cyst to confirm the diagnosis before surgery.

Percutaneous vesiculodeferentography in the diagnosis of male infertility: A review of our results and the data reported in the literature

Vesiculodeferentography was used in the past to evaluate suspected cases of obstruction of the seminal ducts. Over the years, numerous attempts have been made to improve the technique used to perform this examination and to render it less invasive. Its use is currently indicated in selected cases, where it is combined with functional studies like seminal tract washout and followed by immediate interventions to correct the alterations revealed. Vesiculodeferentography includes collection of the contents of the seminal vesicles, which can later be used in vitro assisted fertilization procedures.

Clinical and radiological evaluation of ejaculatory duct obstruction

Ejaculatory duct obstruction (EDO) is a rare but surgically correctable cause of male infertility. With the advent and increased use of transrectal ultrasonography and magnetic resonance imaging, abnormalities of the ejaculatory duct (ED) related to infertility have been diagnosed more frequently. Recently, with the increased awareness of functional obstruction of ED, reports have been focusing on the diagnosis of partial or functional EDO. We present 2 review of the ED pathologies, imaging modalities and treatment options.