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Transurethral resection of the ejaculatory ducts: etiology of obstruction and surgical treatment options

2019; Elsevier BV; Volume: 111; Issue: 3 Linguagem: Inglês

10.1016/j.fertnstert.2019.01.001

1556-5653

Gabriella Avellino, Larry I. Lipshultz, Mark Sigman, Kathleen Hwang,

Sperm and Testicular Function

Ejaculatory duct obstruction is an uncommon but surgically correctable cause of male infertility. With the advent and increased use of high-resolution transrectal ultrasonography, anomalies of the ejaculatory ducts related to infertility have been well documented. Although there are no pathognomonic findings associated with ejaculatory duct obstruction, the diagnosis should be suspected in an infertile male with oligospermia or azoospermia with low ejaculate volume, normal secondary sex characteristics, testes, and hormonal profile, and dilated seminal vesicles, midline cyst, or calcifications on transrectal ultrasound (TRUS). Although additional larger prospective and comparative studies are needed, it appears that TRUS with aspiration is the most effective method for diagnosis. While intrusive, it is less invasive than vasography. The most robust and published evidence for treatment involves transurethral resection of ejaculatory duct (TURED). More recent experience with antegrade endoscopic approaches are promising and may also be considered. An alternative to surgeries for reversal of obstruction is sperm retrieval for in vitro fertilization/intracytoplasmic sperm injection. A thorough discussion of all alternatives, including risks and benefits, should be held with couples facing this uncommon condition to allow them to make informed decisions regarding management. Ejaculatory duct obstruction is an uncommon but surgically correctable cause of male infertility. With the advent and increased use of high-resolution transrectal ultrasonography, anomalies of the ejaculatory ducts related to infertility have been well documented. Although there are no pathognomonic findings associated with ejaculatory duct obstruction, the diagnosis should be suspected in an infertile male with oligospermia or azoospermia with low ejaculate volume, normal secondary sex characteristics, testes, and hormonal profile, and dilated seminal vesicles, midline cyst, or calcifications on transrectal ultrasound (TRUS). Although additional larger prospective and comparative studies are needed, it appears that TRUS with aspiration is the most effective method for diagnosis. While intrusive, it is less invasive than vasography. The most robust and published evidence for treatment involves transurethral resection of ejaculatory duct (TURED). More recent experience with antegrade endoscopic approaches are promising and may also be considered. An alternative to surgeries for reversal of obstruction is sperm retrieval for in vitro fertilization/intracytoplasmic sperm injection. A thorough discussion of all alternatives, including risks and benefits, should be held with couples facing this uncommon condition to allow them to make informed decisions regarding management. Discuss: You can discuss this article with its authors and other readers at https://www.fertstertdialog.com/users/16110-fertility-and-sterility/posts/42580-27518 Discuss: You can discuss this article with its authors and other readers at https://www.fertstertdialog.com/users/16110-fertility-and-sterility/posts/42580-27518 A couple may be evaluated for infertility if they are unable to conceive after 12 months of unprotected intercourse. In ∼15% of these couples, the male partner has azoospermia, due to obstructive azoospermia in 40%, indicating that spermatogenesis is preserved but the sperm is unable to reach the ejaculate. Ejaculatory duct obstruction (EDO), a specific type of obstructive azoospermia, is present in 1%–5% of infertile men (1Modgil V. Rai S. Ralph D.J. Muneer A. An update on the diagnosis and management of ejaculatory duct obstruction.Nat Rev Urol. 2016; 13: 13-20Crossref PubMed Scopus (31) Google Scholar, 2Aggour A. Mostafa H. Maged W. Endoscopic management of ejaculatory duct obstruction.Int Urol Nephrol. 1998; 30: 481-485Crossref PubMed Scopus (8) Google Scholar). Classic bilateral complete EDO is characterized by low volume, low pH, and azoospermia without fructose in the ejaculate in the setting of normal hormonal values. In cases of incomplete or partial obstruction, the patient may have low-normal volume and low-normal pH oligoasthenospermia. Typically, spermatogenesis is preserved unless there exists simultaneous hypothalamic-pituitary-gonadal axis pathology (Table 1). In addition to infertility, other symptoms may include hematospermia andor pelvic or perineal pain exacerbated by ejaculation. Farley and Barnes are credited with the first documentation of defining stenosis of the ejaculatory duct (ED) and management with transurethral resection in 1973 (3Farley S. Barnes R. Stenosis of ejaculatory ducts treated by endoscopic resection.J Urol. 1973; 109: 664-666Crossref PubMed Scopus (71) Google Scholar). In the absence of anatomic obstruction, there may be functional obstruction indicating abnormal emptying of the ejaculatory apparatus without a physical obstruction (4Font M. Pastuszak A. Case J. Lipshultz L. An infertile male with dilated seminal vesicles due to functional obstruction.Asian J Androl. 2017; 19: 256-257Google Scholar).Table 1Characteristics of categories of ejaculatory duct obstruction.ParameterComplete obstructionIncomplete/partial obstructionFunctional obstructionsVolume of ejaculateLowLow-normalLowSperm countAbsentLow-normalAbsent–lowSperm motilityAbsentLowAbsent–lowFructose in ejaculateAbsentAbsent–lowAbsent–lowEjaculate pHLowLow–normalLow–normalHormonal evaluationNormalNormalNormalSeminal vesicle sizeNormal–enlargedNormal–enlargedNormal–enlargedTestis sizeNormalNormalNormal Open table in a new tab Table 2Brief description of reference studies, detailing study type, patient populations, diagnostic methods, intervention, and outcomes.ReferenceStudy designNo. of patientsPresenting diagnosisMethod of diagnosisaMost studies included initial workup of semen analysis, physical exam, hormone parameters, ± urine analysis for retrograde ejaculation, and ± testis biopsy. Additional unique diagnostic tools are listed.InterventionOutcome reportedSemen analysis (SA)PregnancySymptom assessmentComplications54retrospective5azoo± scrotal exploration± epididymo-vasostomy with interval TURED in 4 menSA3 men with postop SA: 1 at 12 mo several mil. sperm/mL, 5% motility, 1 azoo, 1 initial increase in vol. but returned to 0.5 mL at 6 monone reportedn/anot reported45retrospective21EDOTRUS20 transurethral seminal vesiculoscopy (TRU-SVS), 1 TURED (failed TRU-SVS)SA, pregnancy19/21 (90%) improved sperm count; by 3 mo postop average sperm count 6.6 mil. (preop 0.019 mil.)4/21 (19%) spontaneous pregnancyby 3 mo postop: resolution of 3/3 painful ejaculation, 5/7 hematoserpmia, and 7/7 perineal/testicular pain7 men with postop painful ejaculation or discomfort that resolved by 3 mo postop8retrospective87subfertile men: azoo (n = 67), severe oligo (n = 17), oligo (n = 1), normal sperm concentration (n = 2) in low-vol. ejac. with acidic pH and little or no fructose grouped by etiologyscrotal exploration and vasography43 men underwent TURED ± TUIED, ± epididymovasostomySA and pregnancy18/31 (58%) “patent” after surgeryspontaneous pregnancy by etiology: müllerian duct cyst 5/12 (41%), post-infectious causes 1/6 (16.6%)n/anot reported47case report1pelvic pain/hematospermiaTRUS, SV aspiration, and vesiculographyantegrade access/retrograde balloonsymptom assessmentn/an/aresolution of symptomsnone49case report1secondary infertilityTRUS, MRIattempted antegrade trans-rectal US guided ED balloon dilationunable to complete treatmentn/an/an/anone38case report1hematospermiaTRUS, MRI, vasographycold knife incision of cystresolution of hematospermian/an/aresolution of hematospermia up to 7 mo postopnone46retrospective22infertility (complete EDO in 6, partial EDO in 16)TRUS, vasographydilation of ED by seminal vesiculoscopy, 4 pts required TURED to see EDOSA, voiding cystourethrography, symptom assessment18/22 (81%) had improved SP; 13/22 (59%) had sperm present; 7/22 (31%) had normal SP6 pregnancy3/3 (100%) pain/hematospermia resolved1 with SV reflux after TURED37retrospective26subfertile men with azoo or severe oligovasographyendoscopic incision with urethrotome, ± redo incision, ± TUREDvisualization of methylene blue, SA10 persistent azoo or severe oligo ( 11 mil. sperm/mL8 spontaneous pregnancy (31%)2 unsuccessful resectionnone52case report1complete EDO (azoo)TRUS, MRI, seminal vesiculography, midline prostatic cyst aspirationlaser incision to unroof cyst then TUREDSA2 mo follow-up: vol. 3 mL, 15.2 mil. sperm/mLn/an/anone50retrospective11infertility specifically with MPCTRUStransrectal ultrasonically-guided cyst aspirationSA, pregnancy1 mo postop: sig. reduction in MPC vol., improvement of semen vol. (10/11). total sperm count (11/11), and sperm motility/morphology; 3 mo postop: sig. increase in MPC vol., decrease in semen vol., sperm concentration, and total sperm count compared with 1 mo but still sig. improvement from baseline4/11 (36%) spontaneous pregnancy, 1 ICSI pregnancyn/anone48case report1pelvic painMRI, TRUS, SV aspirationtransrectal US–guided seminal vesiculography and wire access for canalization of ED; retrograde ED balloon dilation for EDOsymptom assessmentn/an/aresolution of painnone44retrospective72hematospermian/atransurethral seminal vesiculoscopy completed in 67/72symptom assessmentn/an/adefinite diagnosis in 67/72 (93.1%), hematospermia resolved in 70/72 (97.2%)none51case report1infertility, oligovasography, TRUSTRUS guided laser incision of cystvisualized release of seminal fluidimproved ejac. vol.not reportedn/anot reported40prospective analysis25men with EDO, 2/2 calculi, or ED disorders (excluded infertility)TRUS, TRUS SV aspiration, fluoroscopy-monitored seminal vesiculographytransurethral incision of ED with intraoperative TRUS and fluoroscopy and chromotubationsymptom assessment, SA at 1 moSA not reportedn/a96% symptom relief at 3 mo3 with epididymitis31retrospective23infertility (17 complete, 6 partial)TRUS ± MRITUREDsemen parametersstatistically sig. improvement in ejac. vol, sperm count, and motility in all pts treated; by subgroup, incomplete EDO (and not complete EDO) pts had statistically sig. increase in sperm count and motility13% (3/23) spontaneousn/a26% (2 epididymo-orchitis, 1 partial EDO with azoo, 3 watery ejaculate)26case report1infertility, azooMRI, cystoscopyTUREDvisualized release of seminal fluidn/an/an/anot reported24case report1infertility with partial EDOTRUSTUREDSA, pregnancyimproved vol. from 1.7 to 2.2 mL, sperm count from 12 mil. to 131 mil. sperm/mL, and motility from 23% to 34% within 1 y of surgerypregnancy with IUIn/apostoperative incontinence20case reports2partial EDOTRUS, intraoperative vasotomy with methylene blue in 1TUREDSA, pregnancynormalization of SA for 2 pts2 pregnancy (100%)n/anone27retrospective38partial/complete EDO for infertilityTRUS ± MRITUREDSAsig. improvement in mean ejac. vol., sperm concentration. and % motility; improvement in sperm variables observed in 59% (13/22) of pts with complete EDO and in 94% of pathologies (15/16) with partial EDO5 pregnancy (13%), 15 (40%) became candidates for IUIn/a5 (13%): AUR, UTI, epididymitis, oligo to azoo29retrospective24infertility (primary and secondary) azoo and oligointraoperative vasography ± TRUSTUREDSA, pregnancy12 (50%) improvement in sperm density and/or motility; 8 (33%) improved ejac. vol. only; 6 without improved SP7 (27%)n/a2 hematuria requiring catheterization22retrospective8infertility with complete azoo divided into cystic and noncystic causesTRUSTUREDSA, pregnancy, symptom assessment and postop TRUScystic: 3/3 (100%) increase in semen vol., pH, and sperm count; noncystic: 3/5 (60%) increase in semen vol., pH, and sperm count0% pregnancy reportedall symptoms resolved; no persistent dilated SV or ED evident after “successful” TURED by TRUS in 6/8 mennone21case reports21 primary, 1 secondary infertilitycase 1: TRUS, MRI; case 2: TRUS, intraoperative vasographyTUREDSA, pregnancy(6 mo postop) case 1: 1 mL, 10 mil. sperm/mL, 22% forward motility; case 2: 4 mL, 46 mil. sperm/mL, 40% forward motility1 (50%) spontaneous pregnancy by 12 mo, 1 pregnancy with IVFn/a1 (50%) case with increase in creatinine in seminal plasma suggesting reflux of urine32retrospective42infertility (38 azoo, 4 oligo)TRUS ± vasography, MRITUREDSA, pregnancy38/42 (90.5%) had increased semen vol. (avg. 3.68 mL); 23/38 (60.5%) with azoo had sperm postop; 4/4 oligo had increase in sperm counts (no numbers or avg. reported), 16/42 (38.1%) had normal semen parameters postopBy mean follow-up of 18 mo, 13/42 (31%) spontaneous pregnancyn/a2/42 (4.7%): 1 case of epididymitis and 1 case of watery ejaculate28retrospective46primary (80%) and secondary infertility, including azoo and oligoTRUSTUREDSA, pregnancyin total, 30/46 (65%) had improved semen quality (>50% increase in total motile sperm count); 13/22 (60%) of low-vol. azoo had increase in TMC, 3/22 (13%) of low-vol. azoo had increase in ejac. vol., 6/22 (27%) of low-vol. azoo had no change20% initiated a pregnancy avg. 6.1 mo after surgeryn/a10/46 (22%): watery high-vol. ejac. in 5; 1 GH requiring catheter, 1 UTI, 1 epididymitis, 1 post-void dribbling, 1 premature ejaculation; 1/24 (4%) of pts with sperm in ejac. preop became azoo postop24retrospective5azoo or severe oligo ( 1 y, including 6 with infertilityTRUS ± MRI or CTTURED and vesiculoscopy, ± incision and dilation of proximal ED, ± incision of cyst, bx of SVSV biopsy − all inflammation; SA if presented with infertility; symptom assessmentSA at 1 and 3 mo postop: sperm densities 16.7 mil. and 43.9 6 mil./mL, motility rates 35.3% and 64.5%, 3 men initially azoo became normospermic2/6 (33%) men had children within a year42 hematospermia resolved; 1 man underwent repeated surgery and resolvednone2retrospective11azooTRUS, intraoperative vasographyTURED confirmed by intraoperative vasography for 11/11successful vasography in 10/117/11 (63%) patency rate by SA2/11 (18%)n/a3/10 (30%): 2 epididymitis, 1 AUR11prospective25clinical symptoms ± infertility: 18 infertile (72%), 2 painful ejac. (8%), 2 hematospermia and azoo (8%), 2 pain (8%), and 1 hematospermia (4%)TRUS, vesiculography, seminal vesicle aspiration and duct chromotubationTURED in 12 pts (including 8 for infertility)comparative analysis of diagnostic tools, SA6/8 (75%) men with infertility had improved semen quality: mean ejac. vol. from 0.89 to 3.4 mL, mean total number of ejaculated sperm from 3.5 mil. to 124 mil.2/8 (25%) spontaneous pregnancy2/2 (100%) had resolution of pain, 2 hematospermia resolved4/25 (16%; 3 after TURED): 1 epididymitis, 2 limited hematuria requiring urologic reevaluation, 1 with limited19prospective9suspected EDO (complete, partial, or functional) for infertility or symptomsTRUS, SV aspiration and chromotubation, manometryTURED in 6/9symptom assessment and SA4/5 with preop SA had increase in ejac. vol. and/or 100% increase in TMC (range 4–60 mil. sperm)not examined2/3 improved1 epididymitis30retrospective15symptomatic EDO in infertilityTRUSTURED with prostatic massageSA and symptom assessment after 2 moincrease in mean ejac. vol. to 2.3 mL and total motile sperm count to 38.1 mil.4/15 (26.6%)subjective improvement in 14/15 (93.3%)none39case report1prior fertility with reduced ejac vol., painTRUSTURED with prostatic massageSA and symptom assessmentvol. from 0.8 mL to 2.1 mL, sperm count of from 75.2 mil. to 27 mil. sperm/mL, morphology from 12% to 11%, and progressive motility from 52% to 50%n/asymptoms resolvednew “fluid” eja.c with findings of elevated creatinine in the ejac. consistent with urinary reflux35retrospective14partial EDO grouped into acquired vs. congenital etiologyTRUS, intraoperative vasographyTURED with prostatic massageSA, pregnancycongenital: 6/6 (100%) improved vol. and motility, 5/6 (83%) improved sperm count; acquired: 3/8 (37.5%) improved sperm quality, 2/8 (25%) with worse SPcongenital: 4/6 (66.6%) spontaneous pregnancy, 1/6 (16.6%) by stimulated cycle/IUI; acquired: 1/8 (12.5%) spontaneous pregnancyacquired: 1 spontaneous pregnancywatery high-vol. ejac., UTI, development of azoo34retrospective12infertility with complete EDO (all azoo)TRUSTURED with TRUS-guided chromotubationSA, pregnancy, symptom assessmentat 3 mo postop: 12/12 (100%) normal ejac. vol., 11/12 (92%) had sperm present, 5/12 (41.6%) had >20 mil. sperm/mL with >30% motile sperm, 3/12 (25%) 5–15 mil. sperm/mL, 3/12 (25%) had 20 mil.), 1 (8.3%) by IUI, 1/12 (8.3%) vy IVF3/3 pain ejaculation resolved, 2/2 (100%) hematospermia resolved, 2/2 (100%) perineal/testicular pain resolvednot reported22retrospective85 with infertility, ± hematospermia, testicular/ejaculatory painvasography, ± TRUS, ± MRITURED, ± vasoepididymostomySA, pregnancy, symptom assessment5/6 (83%) men with semen vol. <1 mL and 1.5 cm or ED diameter >2.3 mm. The diagnosis is more likely if observed with a cyst or duct calcification (10Schroeder-Printzen I. Ludwig M. Köhn F. Weidner W. Surgical therapy in infertile men with ejaculatory duct obstruction: technique and outcome of a standardized surgical approach.Hum Reprod. 2000; 15: 1364-1368Crossref PubMed Scopus (55) Google Scholar). However, the specificity of positive findings is not great as not all men with dilated SVs have EDO and not all men with EDO have dilated SVs. A prospective study comparing TRUS with duct chromotubation, SV aspiration, and seminal vesiculography in men suspected of EDO, though including complete and likely partial obstruction, found that only 50% of men needed surgery based on TRUS findings. Of patients considered to have EDO according to TRUS, the authors diagnosed EDO in 48%, 36%, and 52% with the use of SV aspiration, chromotubation, and vesiculography. TRUS alone is a limited screening tool for EDO (11Purohit R.S. Wu D.S. Shinohara K. Turek P.J. A prospective comparison of 3 diagnostic methods to evaluate ejaculatory duct obstruction.J Urol. 2004; 171: 232-235Crossref PubMed Scopus (71) Google Scholar). Although its minimally invasive, TRUS is limited as a static anatomic study and by the skills of the operator. Guo et al. investigated the utility of MRI, either plain or with enhancement, in 18 patients with suspected complete and incomplete EDO. They recommended diagnosis of EDO if the diameter of the ED is >2 mm. The wall of the ejaculate duct may be thick and enhancing. The authors did not discuss the management or outcomes of their patients (12Guo Y. Liu G. Yang D. Sun X. Wang H. Deng C. Role of MRI in assessment of ejaculatory duct obstruction.J Xray Sci Technol. 2013; 21: 141-146Google Scholar).