Urologists illustrate key steps in management of duct obstruction

In the era of assisted reproduction, sperm retrieval with in vitro fertilization (IVF) appears to be the most straightforward approach to management of men with ejaculatory duct disorders who wish to conceive. Due to costs and some religious prohibitions associated with IVF, some couples may not wish to proceed to IVF. Typically, insurance companies will cover transurethral procedures for ejaculatory duct anomalies. Therefore, it is important for urologists to keep transurethral resection of the ejaculatory ducts (TURED) within their armamentarium. These three videos illustrate the key steps of TURED. This procedure, which is performed rarely, even by reproductive urologists, can enable some patients to get pregnant naturally or with intrauterine insemination where they would otherwise need IVF. The techniques illustrated here allow an optimal outcome with minimal morbidity. Specifically, they highlight the role of using methylene blue to allow precise identification of the ducts and transrectal ultrasound to visualize the relevant structures.

-Ranjith Ramasamy, MD, and James M. Hotaling, MD, MS, Section Editor

Commentary on the videos is provided by Ranjith Ramasamy, MD, director of male reproductive medicine and surgery and assistant professor of urology at the University of Miami, and 'Y'tube Section Editor James M. Hotaling, MD, MS, assistant professor of surgery (urology) at the Center for Reconstructive Urology and Men's Health, University of Utah, Salt Lake City.

Continue to the next page to watch the videos.

Transurethral resection of ejaculatory ducts: a step-by-step guide - Ranjith Ramasamy, MD, and colleagues

This video provides a step-by-step guide for transurethral resection of the ejaculatory ducts (TURED). An important step in TURED is utilizing transrectal ultrasonography-guided seminal vesicle puncture for instillation of methylene blue to allow more precise identification of ejaculatory ducts. Vesiculography under low pressure can be performed at the end of the procedure to assess for patency of ejaculatory ducts.

Dr. Hotaling: Here Dr. Ramasamy and colleagues illustrate a technique that allows both proper visualization of the ducts and confirmation of patency. These techniques ensure an adequate resection to improve potency. They also illustrate the importance of selecting the proper patients for this procedure.

Transurethral resection of the ejaculatory ducts - Sharad R. Shah, MS, MCh

This video illustrates a case of ejaculatory duct obstruction (EDO) due to congenital midline cyst. It shows the technique of utricular cannulation and Incision and utricular scopy to treat the obstruction and the postoperative result. The video also briefly discusses cystic and fibrous EDO and criteria to operate.

Dr. Ramasamy: The prostatic utricle is a small indentation in the prostatic urethra on the verumontanum, laterally flanked by openings of the ejaculatory ducts. Prostatic utricle cysts arise from the level of the verumontanum and are always in the midline. Prostatic utricle cysts can cause ejaculatory duct obstruction resulting in infertility. Dr. Shah demonstrates incision of the prostatic utricle cyst using a Collins knife. The video also demonstrates the anatomy of ejaculatory duct openings within the prostatic utricle cyst. Incising such a cyst can help a man with low ejaculate volume and azoospermia to achieve normal ejaculate volume with sperm in ejaculate.

Dr. Hotaling: Here Dr. Shah illustrates the diagnosis and treatment of a prostatic utricle cyst with endoscopic resection. This technique can be used to safely resect this and ensure patency.

Surgical management of ejaculatory duct obstruction due to prostatic utricular cyst - Phil V. Bach, MD, and Marc Goldstein, MD, DSc

Obstructive azoospermia accounts for approximately 40% of azoospermia cases and can be caused by a blockage anywhere along the male reproductive tract. Five percent of OA cases are secondary to ejaculatory duct obstruction (EDO), which may be caused by a variety of congenital or acquired etiologies. The mainstay of management for ejaculatory duct obstruction is transurethral resection of the ejaculatory ducts. We present the case and surgical management of a man with primary infertility secondary to EDO caused by a prostatic utricular cyst.

Dr. Ramasamy: When transrectal aspiration of the seminal vesicle fluid after ejaculation identifies sperm on wet prep /microscopy, EDO can be diagnosed. Sperm should typically not be present within the seminal vesicle unless there is a distal obstruction. Drs. Bach, Goldstein, and colleagues demonstrate the utility of vasogram in confirming the diagnosis of EDO. A vasogram should be performed only in the setting where microsurgical reconstruction is possible and when anatomy of the vas/seminal vesicles is poorly defined. A resection loop can be used to resect the verumontanum to expose the underlying ejaculatory ducts or prostatic utricle.

Dr. Hotaling: Here Dr. Li and colleagues illustrate the diagnostic workup of men with obstructive azoospermia in the setting of EDO. They also summarize the literature in the field. The technique for a vasogram is also illustrated, which can be a useful part of this procedure.

Dr. Hotaling is assistant professor of surgery (urology) at the Center for Reconstructive Urology and Men's Health, University of Utah, Salt Lake City.

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