Efficacy of various surgical approaches in treating hematospermia using transurethral seminal vesiculoscopy.

PURPOSE: To explore the efficacy of different approaches of seminal vesiculoscopy surgery and the predictive factors of good treatment outcome. MATERIALS AND METHODS: A retrospective analysis of 68 patients who underwent seminal vesiculoscopy for hematospermia in our hospital from January 2015 to January 2021. According to different surgical approaches, they were divided into three groups: natural ejaculatory ducts (method A, 45 cases), assisted transurethral resection/incision of ejaculatory ducts (method B, 14 cases), fenestration in prostatic utricle (method C, 9 cases). We analyzed the recurrence rate of the three surgical approaches and the predictive factors of treatment efficacy. RESULTS: The total recurrence rate after the seminal vesiculoscopy for hematospermia in this group was 32.35%. The postoperative recurrence rates of the three methods were 24.44% for method A, 50.00% for method B and 44.44% for method C, and there was no significant difference among the three methods (P > 0.05). The data of five predictors of 45 cases in method A group were included in the Univariate Logistic analysis, the results suggest that whether complicated with seminal tract stones/cysts was an effective predictor (OR 0.250, P = 0.022), which was still an effective predictor in the Multivariate Logistic analysis model (OR 0.244, P = 0.010). CONCLUSIONS: The Transurethral seminal vesiculoscopy technique demonstrates a low postoperative recurrence rate in treating hematospermia. Among the various approaches, the intraoperative use of natural orifices through the ejaculatory duct exhibits the lowest recurrence rate. Additionally, seminal tract stones/cysts effectively predict favorable postoperative outcomes.

[Seminal vesiculoscopy-assisted thulium laser ablation for the treatment of ejaculatory duct obstruction: An analysis of clinical outcomes].

OBJECTIVE: To evaluate the clinical outcomes of seminal vesiculoscopy-assisted thulium laser ablation (SVS-TLA) in the treatment of oligoasthenozoospermia or azoospermia induced by ejaculatory duct obstruction (EDO). METHODS: We retrospectively analyzed the clinical data on 42 cases of EDO-induced oligoasthenozoospermia or azoospermia in our Clinic of Andrology from April 2018 to January 2020, all definitely diagnosed and treated by SVS-TLA. We followed up the patients regularly after operation, obtained their routine semen parameters at 3, 6 and 9 months postoperatively, examined them by t-test and compared them with the baseline. RESULTS: Operations were successfully completed in all the 42 cases, with an average surgery time of 52.7 minutes. Compared with the routine semen parameters collected 2 weeks before surgery, the semen volume, sperm concentration and total sperm motility of the patients were all significantly improved at 3, 6 and 9 months postoperatively (P < 0.01). Sperm were found in 40 cases at 3 months and in the other 2 cases at 6 and 9 months after surgery. Postoperative complications were observed in 7 cases, including epididymitis, perineal or testicular pain, and hematuria, which all disappeared after corresponding symptomatic treatment. No such serious complications as retrograde ejaculation, rectal injury, urethral stricture or urinary incontinence occurred in any of the cases after operation. CONCLUSION: SVS-TLA is a safe and effective option for the treatment of EDO, which can significantly improve the semen quality of the patient without causing serious postoperative complications.

Establishment of an animal model of ejaculatory duct obstruction.

This study aimed to establish animal models with different degrees of ejaculatory duct obstruction. Forty-eight male rats aged 14-15 weeks were randomly divided into three groups (n = 16): control, complete ejaculatory duct obstruction (tied around the lower seminal vesicle gland and ductus deferens with a 2-0 silk ligature), and partial ejaculatory duct obstruction (padded with a wire guide). Mortality, complications, seminal vesicle morphology and histopathology were compared in the three groups at 4 and 8 weeks postoperatively. In the complete ejaculatory duct obstruction group, seminal vesicle weight decreased gradually with increased obstruction time compared with those of the control group (p < 0.05); moreover, stone-like material was occasionally observed. In the partial ejaculatory duct obstruction group, there was an increase followed by a decrease in seminal vesicle weight in the postoperative period compared with that of the control group (p < 0.05). Histopathological lesions of seminal vesicles were observed in the complete and partial ejaculatory duct obstruction groups (8 weeks postoperatively). We successfully established animal models of complete and partial ejaculatory duct obstruction, which provide an easy-to-use tool for studying seminal vesicle changes after ejaculatory duct obstruction.

[Ectopic opening of the ejaculatory duct into the urethra: A case report and literature review].

OBJECTIVE: To explore the diagnosis and treatment of ectopic seminal duct opening into the urethra. METHODS: We reviewed the literature and retrospectively analyzed the clinical data on a case of sex development abnormality. The patient was a 16-year-old gender female seeking medical improvement of female signs, admitted to hospital with "clitoris hypertrophy, no menstruation and chromosome karyotype 46XY", treated by bilateral orchiectomy, and simultaneously examined by seminal vesiculography and cystoscopy. RESULTS: Seminal vesiculography showed the ectopic opening of the right ejaculatory duct into the urethra accompanied by dysplasia of the seminal vesicle. Cystoscopy exhibited a fissrure-like opening in the right wall of the urethra but no verumontanum. Postoperative pathology revealed bilateral undeveloped testes and epididymides. CONCLUSION: Ectopic opening of the seminal duct into the urethra is extremely rare and often complicated by many malformations, for the diagnosis of which the most reliable options are seminal vesiculography and retrograde radiography through the ectopic orifice under the cystoscope. The treatment of the disease should follow the principles of timeliness, individualization and consideration of associated malformations.

Surgical procedures for male infertility: an update.

PURPOSE OF REVIEW: The aim of this review is to provide an overview of surgical treatment options for male infertility including varicocelectomy, treatment of ejaculatory duct obstruction, vasovasostomy, and sperm extraction, and to review recent advances in techniques and technologies that may improve operative outcomes. RECENT FINDINGS: Microscopic subinguinal varicocelectomy has been shown to have the highest success rates with lowest rates of complications, and may be facilitated by the use of Doppler, indocyanine green angiography, and the 4K3D operating video microscope. The standard treatment for ejaculatory duct obstruction by transurethral resection of the ejaculatory ducts has changed little over time, but vesiculoscopy may allow for temporary dilation of an obstruction to allow for natural conception, while also offering diagnostic capabilities. Use of the robotic platform has gained popularity for vasectomy reversals but controversy remains regarding the cost-effectiveness of this option. Recently, a reinforcing suture technique has been described for vasovasostomy to minimize anastomotic breakdown and reversal failure. Finally, gray-scale and color-enhanced ultrasound may improve ability to predict successful sperm retrieval during extraction procedures. SUMMARY: Though the fundamentals of surgical treatment options for male infertility have changed little with time, technological advancements have contributed to improved surgical outcomes over recent years.

[Real-time transrectal ultrasound-guided seminal vesiculoscopy for the treatment of azoospermia secondary to ejaculatory duct obstruction].

OBJECTIVE: To evaluate the effect of real-time transrectal ultrasound-guided seminal vesiculoscopy (TRUS-SVS) in the treatment of azoospermia secondary to ejaculatory duct obstruction. METHODS: This retrospective study included 40 cases of azoospermia secondary to bilateral ejaculatory ducts obstruction treated by TRUS-SVS from June 2016 to June 2018 after failure to enter the vesiculoscope through the ejaculatory duct or prostatic utricle. We analyzed the success rate of surgery, operation time, postoperative complications, treatment results, and application value of TRUS-SVS. RESULTS: Real-time TRUS-SVS was successfully performed in 36 (90.0%) of the cases, 33 through bilateral and the other 3 through unilateral seminal vesicle, with a mean operation time of (32.8 ± 16.6) min. Thirty-seven of the cases were followed up for 6－15 (mean 9.3) months, of which sperm were found in 31 at 1－3 months and in 25 at 3－12 months, and pregnancies achieved in 9 cases within 12 months after surgery. No serious complications as retrograde ejaculation, urinary incontinence and rectal injury were observed postoperatively, except 2 cases of epididymitis and 2 cases of hematuria, which were all cured. CONCLUSIONS: For the patients who failed in seminal vesiculoscopy through the ejaculatory duct or prostatic utricle, real-time TRUS-SVS is a recommended procedure with the advantages of a high success rate, less damage to the prostate and rectum, and benefit to the improvement of semen quality.

The management and composition of symptomatic seminal vesicle calculi: aetiological analysis and current research.

OBJECTIVE: To report our experience in the diagnosis, minimally invasive treatment, and composition of seminal vesicle calculi (SVC). PATIENTS AND METHODS: In the present study, we evaluated 20 patients who were admitted to our hospital from January 2013 to January 2018. All the patients were diagnosed with intractable haematospermia and SVC. The diagnosis was further confirmed by seminal vesiculoscopy. SVC were removed by basket extraction; with larger SVC fragmented by holmium laser before extraction. Scanning electron microscopy, X-ray diffraction, and infrared spectroscopy were used to determine the SVC composition. RESULTS: All operations were completed successfully without surgical complications. SVC were mostly composed of hydroxyapatite and protein, suggesting that they were produced by infections. CONCLUSIONS: Seminal vesiculoscopy is a simple, minimally invasive technique that can be used for diagnostic confirmation and treatment of seminal vesiculitis with SVC. This study improves our understanding of SVC and provides a theoretical basis for the prevention of postoperative recurrence of SVC.

Transurethral resection of ejaculatory duct combined with seminal vesiculoscopy for management of persistent or recurrent hemospermia in men with ejaculatory duct obstruction.

BACKGROUND: Persistent or recurrent haemospermia often occurs in individuals with ejaculatory duct obstruction (EDO). This study aimed to evaluate the efficacy and safety of transurethral resection of the ejaculatory duct (TURED) combined with seminal vesiculoscopy in treating persistent or recurrent haemospermia in men with EDO. METHODS: From June 2014 to March 2018, 103 consecutive patients with EDO who underwent TURED combined with seminal vesiculoscopy for persistent or recurrent haemospermia at the Department of Urology of West China Hospital were enrolled into this retrospective study. The patients were evaluated mainly by detailed history-taking and performing semen analysis, transrectal ultrasonography, and magnetic resonance imaging. RESULTS: Among the 103 patients, 79 (76.70%) had cysts of the lower male genitourinary tract; 63 (61.17%) had blood clots; and 32 (31.07%) had calculi in the seminal vesicle and/or prostatic utricle. The duration of postoperative follow-up was 12 months, and the symptoms of haemospermia disappeared in 96 (93.20%) patients. There was no significant difference in the semen PH and sperm count before and after surgery; however, the ejaculate volume and sperm motility significantly improved postoperatively. Except for two cases of acute urinary retention and one case of watery ejaculate after surgery, no severe postoperative complications, including epididymitis, urethral stricture, urinary incontinence, retrograde ejaculation, or rectal injury, were observed. CONCLUSION: TURED combined with seminal vesiculoscopy is a suitable method for the diagnosis and treatment of persistent or recurrent haemospermia in men with EDO.

[Ectopic seminal tract opening in enlarged prostatic utricle: A report of 22 cases].

OBJECTIVE: To explore the diagnosis, classification and treatment of ectopic seminal tract opening in enlarged prostatic utricle (EPU). METHODS: We retrospectively analyzed the clinical data on 22 cases of ectopic seminal tract opening in EPU confirmed by spermography, EPU open cannula angiography or intraoperative puncture of the vas deferens and treated by transurethral incision of EPU, cold-knife incision or electric incision of EPU, full drainage of the anteriorwal, and open or laparoscopic surgery from October 1985 to October 2017. RESULTS: Five of the patients were diagnosed with ectopic opening of the vas deferens and the other 17 with ectopic opening of the ejaculatory duct in EPU. During the 3－48 months of postoperative follow-up, symptoms disappeared in all the cases, semen quality was improved in those with infertility, and 2 of the infertile patients achieved pregnancy via ICSI. CONCLUSIONS: Ectopic seminal tract opening in EPU is rare clinically. Spermography is a reliable method for the diagnosis of the disease, and its treatment should be aimed at restoring the smooth flow of semen based on proper classification and typing of the disease.

Transurethral seminal vesiculoscopy acts as a therapeutic investigation for intractable hemospermia: Step-by-step illustrations and single-surgeon experience.

OBJECTIVE: To describe the methodology of transurethral seminal vesiculoscopy and the anatomy of the seminal tract, and to report a single-surgeon experience with this procedure. METHODS: A total of 38 consecutive patients with intractable macroscopic hemospermia were enrolled from January 2010 to July 2016. A 6/7.5-Fr semirigid ureteroscope was used to enter the seminal tract by one of these two approaches: through either a trans-ejaculatory duct opening or a trans-utricle fenestration. Patient characteristics and their preoperative and postoperative measurements were analyzed retrospectively. RESULTS: The success rate of transurethral seminal vesiculoscopy was 92.1%, whereas the approaching method in most patients was the trans-utricle fenestration (88.89%). A total of 34 (94.4%) transurethral seminal vesiculoscopy inspections ended with complete remission, even though nearly half of them (47.2%) only disclosed negative perioperative findings. The median period to complete remission was 4 weeks (interquartile range 4-6 weeks) after the procedure. Four patients had recurrent hemospermia, and the median time to recurrence was 21.5 (range 13-48.5) months. CONCLUSIONS: Transurethral seminal vesiculoscopy is a valuable diagnostic tool for intractable hemospermia, and also plays a therapeutic role by blocking the vicious cycle of stasis, calculi and seminal vesiculitis. More familiarity of the anatomy and enough practice would make the learning curve less steep.

[Diagnosis and treatment of ejaculatory duct cyst: A report of 2 cases and review of the literature].

OBJECTIVE: To investigate the diagnosis and treatment of ejaculatory duct cyst. METHODS: This study included 2 male patients present at the hospital for hemospermia and abnormal sensation in the perineal region in July and August 2014. Both underwent transrectal ultrasonography, routine semen examination, CT, MRI, cystoscopy, and vesiculography before transurethral fenestration of the cysts and pathological examination of the cyst wall specimens. Analyses were made on the clinical presentations, imaging features, pathological characteristics, differential diagnosis and treatment of ejaculatory duct cyst and relevant literature was reviewed. RESULTS: The cyst wall was mainly composed of smooth muscle, the inner wall lined with pseudostratified ciliated columnar epithelia, and with positive expressions of CD10 and Muc6 proteins on immunohistochemical staining, which indicated renal iatrogenic ejaculatory duct cyst. The patients were followed up for 18 and 20 months, respectively. All symptoms disappeared and no recurrence occurred after surgery. Routine semen examination for the two patients showed the semen volumes to be 3.5 and 3.1 ml, sperm concentrations 35 and 32 ×106/ml, grade a sperm 32.0 and 26.0%, grade b sperm 18.0 and 31.0%, and semen liquidation time 30 and 34 minutes, respectively. CONCLUSIONS: Pelvic cystic masses can be detected by transrectal ultrasonography, CT and MRI, but definite diagnosis relies on vesiculography, pathological examination and immunohistochemical staining. Transurethral fenestration is safe and effective for the treatment of ejaculation duct cyst.

[Diagnosis and treatment of ejaculatory duct obstruction: Current status and advances].

Ejaculatory duct obstruction (EDO) is one of the obstructive factors for 1－5% of all cases of male infertility and it is, however, surgically correctable. Congenital developmental abnormality is a most common cause of EDO. The clinical manifestations of EDO are varied, typically with the decline of four semen parameters. Transrectal ultrasonography is an important imaging method for the diagnosis of EDO and guidance in its surgery. MRI provides high-resolution images of the reproductive system as evidence. Transurethral resection of the ejaculatory duct (TURED) is a classical operation, the application of transurethral seminal vesiculoscopy has become a new trend of minimally invasive surgery in the treatment of EDO, and the latest flexible vesiculovasoscopy (FVV) or vasoscopy techniques may further improve the diagnosis and treatment of EDO.

[Ejaculatory duct dilation combined with seminal vesicle clysis for refractory hematospermia: A report of 32 cases].

OBJECTIVE: To evaluate the effect of ejaculatory duct dilation combined with seminal vesicle clysis in the treatment of refractory hematospermia. METHODS: Using ureteroscopy, we treated 32 patients with refractory hematospermia by transurethral dilation of the ejaculatory duct combined with clysis of the seminal vesicle with diluent gentamicin. RESULTS: The operation was successfully accomplished in 31 cases, with the mean operation time of 32 (26－47) minutes. The patients were followed up for 6－39 (mean 23.6) months. No complications, such as urinary incontinence and retrograde ejaculation, were found after operation. Hematospermia completely disappeared in 27 cases, was relieved in 1, and recurred in 3 after 3 months postoperatively. Those with erectile dysfunction or mental anxiety symptoms showed significantly decreased scores of IIEF-Erectile Function (IIEF-EF) and Self-Rating Anxiety Scale (SAS). CONCLUSIONS: Ejaculatory duct dilation combined with seminal vesicle clysis under the ureteroscope, with its the advantages of high effectiveness and safety, minimal invasiveness, few complications, and easy operation, deserves general clinical application in the treatment of refractory hematospermia.

[Minimally invasive surgery for ejaculatory duct obstruction in infertile men].

Ejaculatory duct obstruction(EDO) accounts for 1- 5% of the causes of male infertility and can be corrected by various surgical methods,among which transurethral resection of the ejaculatory ducts(TURED) is considered as the gold standard for its treatment and has been well established in clinical practice. Transutricular seminal vesiculoscopy has been gaining more and more attention for its cost-effectiveness and few complications in the treatment of EDO. The clinical evidence for treating EDO by balloon dilatation and seminal vesicle lavage is limited and its application value needs to be further investigated. This paper presents an overview on the treatment of EDO in infertile men by minimally invasive surgery.

[Qilin Pills for obstructive azoospermia after ejaculatory duct reconstruction].

OBJECTIVE: To observe the clinical effect of Qilin Pills in the treatment of severe oligozoospermia after microsurgical ejaculatory duct reconstruction for obstructive azoospermia. METHODS: We retrospectively analyzed 75 cases of obstructive azoospermia treated by ejaculatory duct reconstruction followed by administration of Qilin Pills. The patients were divided into a Qilin group (n=42) and a control group (n=33) postoperatively, treated with Qilin Pills and placebo, respectively. After 3 months of medication, we compared the sperm quality between the two groups of patients. RESULTS: After 3 months' treatment, all the patients experienced remarkable improvement in sperm quality (P<0.05). Compared with the controls, the patients in the Qilin group showed dramatic increases in sperm concentration, from (0.57±0.25) and (0.60±0.18) ×106/ml before medication to (2.83±0.59) and (1.72 ±0.52) ×106/ml after medication, significantly higher in the Qilin than in the control group (P<0.05). The percentage of grade a sperm was increased from (5.52±5.97) and (5.30±6.26)% to (11.56±9.96) and (10.27±6.52)%, that of grade a+b sperm from (9.68±8.63) and (8.64±10.10)% to (23.42 ±14.10) and (20.81±14.70)%, and that of morphologically normal sperm from (2.00±1.27) and (2.31±0.94)% to (3.54±2.47) and (3.47±1.33)%, respectively. No statistically significant differences were observed in sperm motility and normal sperm morphology between the two groups after treatment (P>0.05). The total effectiveness rate was higher in the Qilin group than in the controls (88.1% vs 72.7%), but with no significant difference between the two groups (P>0.05). CONCLUSIONS: Qilin Pills are fairly effective in improving the quantity of sperm in obstructive azoospermia patients after ejaculatory duct reconstruction.

[Transurethral electrotomy combined with seminal vesiculoscopy ejaculatory duct dilatation in treating patients with Müllerian duct cyst].

OBJECTIVE: To evaluate the feasibility and efficacy of transurethral electrotomy combined with seminal vesiculoscopy ejaculatory duct dilatation in treating patients with Müllerian duct cyst. 
 METHODS: We retrospectively analyzed 12 infertile men due to Müllerian duct cyst between 2009 and 2012. They were diagnosed by semen analysis (including quantity of semen, pH and fructose), digital rectal examination, transrectal ultrasonography, magnetic resonance images and aspiration biopsy when necessary. All patients were treated by transurethral electrotomy combined with seminal vesiculoscopy ejaculatory duct dilatation and were followed up for 12 months. 
 RESULTS: A significant improvement of semen quality was achieved after surgery and the sperms could be seen. The patients' semen was analyzed for 3 times in 12 months and the results were normal. Semen volume and pure berries of the patients were increased after the operation compared with those before the operation (P<0.05). Spontaneous pregnancies were achieved in 3 patients 9-12 months after surgery. Four patients' seminal vesicle became smaller obviously.
 CONCLUSION: Transurethral electrotomy combined with seminal vesiculoscopy ejaculatory duct dilatation is effective and safe for the treatment of Müllerian duct cyst accompanied with ejaculatory duct obstruction.

Ejaculatory duct obstruction: current diagnosis and treatment.

Ejaculatory duct obstruction is an infrequent cause of obstructive azoospermia, occurring in up to 5 % of such patients. However, it is potentially correctable and warrants consideration in the differential diagnosis of the patient presenting for infertility evaluation. This review provides an overview of ejaculatory duct obstruction: its various etiologies, presentation, and associated clinical assessment. It includes a description of diagnostic imaging and interventional studies available to the practicing urologist and concludes with a discussion of current endoscopic management.