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 verumontanum2,7,8,9. 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.
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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
- Ensure that the display camera system and holmium laser are working properly.
2. Preparation for operation
- Use the following inclusion criteria to select participants for this study.
- All patients who had been diagnosed with azoospermia or oligospermia and had consented to surgery.
- Semen volume less than 1.5 mL, pH<7.2. Seminal plasma fructose ≤13 µM/single ejaculation.
- 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. - 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. - There were no diseases that affected the safety of surgery, such as poorly controlled hypertension and hyperglycemia, respiratory diseases, etc.
- Use the following exclusion criteria to exclude participants from this study.
- Patients with urethral stricture, acute urinary tract infection, severe coagulopathy, or other contraindications to anesthesia.
- The testicular volume was less than 12 mL.
- 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
- 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.
- 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.
- 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.
- 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).
- 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).
- 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).
- 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).
- Cut the ejaculatory duct opening along the direction of urine flow, which may be conducive to preserving the anti-urine reflux mechanism.
- Identify and explore the symmetrical position of the abnormal ejaculatory duct opening on the affected side.
- 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).
- 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).
- Indwell a Fr18 catheter and rinse continuously with physiological sodium chloride to prevent blood clots from blocking the catheter.
4. Postoperative care
- On the 1st day post-surgery, continuously irrigate the bladder for 6 h and supplement with glucose and electrolytes as needed.
- Remove the catheter on the 2nd 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.
- 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
- Perform semen analysis in the 3rd month after surgery to ensure that the gag time requirement was met, and follow up after 3 months mainly through telephone interviews.
- 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 3rd month post-surgery.
6. Statistical analysis
- 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.
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Representative 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 is displayed in Table 1. A representative image of the ejaculatory duct 1 month after the operation of the seminal vesiculoscopy has been provided in Supplementary Figure 1.
In our study, we observed ejaculatory duct obstruction in 5 patients due to unilateral ejaculatory duct cysts, where sperm was detected in the cyst fluid during surgery. All patients underwent postoperative follow-up with semen analysis conducted at the 3rd month after surgery. The results of semen analysis, encompassing ejaculate volume, ejaculate pH, sperm count, and seminal plasma fructose, were compared to preoperative data. As indicated in Table 2, postoperative semen-related indicators exhibited significant improvement, and these differences were statistically significant (P<0.05, determined using the paired t-test).
Figure 1: MRI scan of the ejaculatory cyst. The white arrow indicates the cyst of the ejaculatory duct. (A) T2-weighted axial cross-section image of ejaculatory duct cyst. (B) T1-weighted axial cross-section image of ejaculatory duct cyst. (C)T2-weighted axial longitudinal section image of the ejaculatory duct cyst. Please click here to view a larger version of this figure.
Figure 2: Screenshots of key surgical steps. (A) Find the verumontanum and the ejaculatory duct opening on affected side. (B)A wire guide punctures the ejaculatory duct opening. (C) Enter the cyst and find the affected seminal canal. (D) Holmium laser incision enlarges ejaculatory tube opening. (E) Manually create a window to redirect the ejaculatory duct flow of the healthy side into the cyst cavity. (F) Holmium laser incision enlarges the artificial opening on the healthy side. Please click here to view a larger version of this figure.
| Items | |
| Mean age, year | 30.4 (27-34) |
| Disease duration, months | 9 (3-15) |
| Follow up time, months | 24.8 (12-48) |
| Operation time, min | 26 (15-40) |
| Catheterization time, day | 1 |
| Hospital stay, day | 2 |
Table 1: Demographic data (including preoperative and postoperative data).
| Items | Before operation | After operation | P value |
| Volume (mL) | 0.76 ± 0.24 | 3.22 ± 0.84 | 0.004 |
| pH | 6.7 ± 0.27 | 7.38 ± 0.13 | 0.005 |
| Sperm concentration (x106/mL) | 7.16 ± 1.87 | 57.66 ± 31.53 | 0.025 |
| Seminal plasma fructose (μmol/single ejaculation) | 6.18 ± 4.10 | 29.55 ± 12.04 | 0.01 |
Table 2: Semen analysis data.
Supplementary Figure 1: A month after the operation of the seminal vesiculoscopy examination review. (A) The open ejaculatory duct on the affected side. (B) Lateral ductus openings within the ejaculatory cyst. Please click here to download this File.
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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 examination showed that all had sperm, but the number of sperm was less than normal, and the semen volume decreased. Combined with the patient's testicular volume, seminal fructose, and imaging examination, it was sufficient to support the diagnosis of incomplete obstruction of the distal end of the seminal tract. In the surgical process, it was customary to perform seminal vesiculectomy to expose the ejaculatory duct adequately. Literature reported that the improvement rate of semen parameters with this operation is from 44.5%-90.5%, and the postoperative conception rate of spouses is 13%-31%12,13,14. The incidence of complications reported in the literature was about 13%-26%15, and the main complications include urinary reflux, epididymitis, retrograde ejaculation, cystospasm, urinary incontinence, urethrorectal fistula, and postoperative bleeding. The operation completely destroyed the anti-urine reflux mechanism at the distal end of the seminal canal and made the seminal canal completely connected with the urethra, increasing the risk of urine flowing to the seminal vesicle cavity. The authors believe that the occurrence of the above complications is not conducive to the preservation of fertility in patients.
In recent years, with the innovation of endoscopy equipment and the progress of technology, it is possible to use endoscopy for in-depth diagnosis and treatment of seminal diseases. More and more scholars have applied 4.5Fr-9Fr ureteroscopy as an endoscopy of seminal tract for the diagnosis and treatment of intractable haemospermia, EDO, seminal vesiculitis, and other distal seminal tract disorders and found that the symptoms of haemospermia and perineal pain can be significantly relieved after the operation4,16,17,18. Besides, semen parameters can be improved to varying degrees, and postoperative complications such as epididymitis, retrograde ejaculation, urinary incontinence, and rectal injury rarely occur. Compared with the TURED operation, it has obvious advantages, and it is considered that the precision endoscopy technique is a safer and more effective new method for the diagnosis and treatment of EDO, seminal vesicle stones, and intractable hematospermia diseases4,16,17,18. Notably, the holmium laser has a very shallow penetration depth (0.4 mm)19, which is an interesting property that may reduce the risk of serious complications (such as rectal injury) caused by TURED. For patients with ejaculatory duct cysts combined with EDO and fertility needs, in addition to relieving obstruction and compression, the protection of fertility is particularly important.
Preserving the verumontanum structure allows for a better simulation of normal physiological anatomy. However, maintaining the verumontanum may increase the risk of postoperative distal ejaculatory duct scarring, leading to recurrent obstruction or reduced semen volume.
We employed seminal vesiculoscope and the holmium laser without excising the seminal vesicles, reaching the interior of the ejaculatory duct cyst. A total of five patients with ejaculatory duct cysts complicated with EDO were treated with endoscopy-assisted distal duct flow alteration, and good results were obtained in this study. This streamlined surgical approach improves safety and minimizes postoperative complications. The following are our procedural steps: first, a 6Fr 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 procedure preserved the verumontanum, effectively maintaining the anti-reflux mechanism in the distal ejaculatory duct. As a result, it significantly lowered the risk of postoperative complications such as epididymitis, orchitis, and retrograde ejaculation. Furthermore, the holmium laser enlarged the opening of the affected-side ejaculatory duct to about 5 mm along the urethral direction, resulting in a clearer surgical field and better control of cutting depth. With no need to worry about rectal calculations, this approach significantly lowered the possibility of postoperative closure of the ejaculatory duct opening. It streamlined surgical steps, enhancing operational safety and efficiency. Ultimately, 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 added a new outflow passage for semen, reducing the risk of decreased semen volume postoperatively.
No obvious complications were found in any patients after surgery, while statistically significant improvements were found in semen volume, sperm concentration, and semen fructose levels before and after surgery (P<0.05). Hence, we confirm the safety and effectiveness of this procedure, which not only preserves the verumontanum but also eliminates the obstruction and compression caused by the cyst. Most importantly, it improves the patient's abnormal semen parameters.
At present, this technique has only tried to treat the ejaculatory duct obstruction caused by ejaculatory duct cyst. It also provides a valuable reference for issues related to ejaculatory duct obstruction resulting from stones, cysts in the prostate, Mullerian duct cysts, prostate cysts, and inflammation. Nevertheless, due to its small sample size and lack of a control group, this study's findings have limitations that restrict their generalizability beyond its specific context. It is crucial for future research in this area to address these limitations by employing more participants and including appropriate controls in order to obtain more reliable results that can be applied across different situations.
In short, a seminal vesiculoscope combined with a holmium laser is an excellent alternative for the treatment of persistent oligospermia or anspermia in patients with EDO caused by the ejaculatory duct cyst.
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Disclosures
The authors declare that they have no competing interests.
Acknowledgments
The authors would like to thank the second affiliated hospital of KMMU for providing cases and medical records related to this work. There is no funding support for this study.
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 |
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