Saturday, March 27, 2010

Seminal Vesiculoscopy with Ejaculatory Duct Obstruction

A 39 year old gentleman came with low volume ejaculate with oligospermia(documented on several semen analyseserum total tests) The semen volume was characteristically around 0.25-0.30 ml.His post-ejaculatory urine analysis for sperms was negative.His libido and orgasm was normal. He was evaluated with Hormone Profile(LH,FSH and Testosterone),Trans-Rectal Ultrasound for the seminal vesicles which showed grossly distended seminal vesicles and the ejaculatory duct. His seminal vesicular anatomy was further investigated with the MRI test which showed distended seminal vesicles. There was no midline or otherwise prostatic cysts. He was given option of Seminal vesiculoscopy. The surgery was performed under spinal anaesthesia.The verumontanum on cystourethroscopic examination was prominent. The bladder neck and the bladder were normal. With 6 Fr Ureteroscope the transutricular access was performed and bilateral seminal vesicles were fenestrated. The intra-operatively there was a lot of seminal clogged material pouring out from the seminal vesicles. The procedure was concluded with 14 Fr Foleys catheter kept in situ. The procedure was uneventful. Trans-utricular seminal vesiculoscopy has emerged as important diagnostic and therapeutic tool in seminal vesicle pathology. With conventional endoscopic instruments it is possible to do trans-utricular seminal vesiculoscopy. In our view this approach is better than routine trans-urethral resection of ejaculatory ducts as adequacy of deroofing is better in seminal vesiculoscopy and seminal vesicular toileting can be done at the same time. The deroofing in seminal vesiculoscopy is under direct vision and in controlled manner. In Trans Urethral Resection of Ejaculatory ducts the resection often is blind and adequacy is confirmed by methylene blue gushing out. The liberal TURED may sometime involve the risk of Bladder neck injury and even rectal injury in the hands of inexperienced resectionist. It is always stressed that the TURED should be performed by an experienced resectionist. But the seminal vesiculoscopy the possibility of such occurrences are remote. We feel the learning curve of this procedure is less and can be undertaken even in undilated seminal vesicles. This case was second in our Institute(Probably Third in India- as per personal communication with various urologists).This case was highlighted because in this there was no midline prostatic cyst so the technical question that would come in any urologists mind about the feasibility of the procedure in undilated utricle/seminal vesicles.This case shows the feasibility in cases where the utricle is not enlarged or there is no midline cyst.In a similar way the seminal vesiculoscopy can be carried out in undilated seminal vesicles.

1 comment:

  1. Thanks for sharing the information about the Seminal Vesiculoscopy with Ejaculatory Duct Obstruction.
    cure ed,male dysfunction treatment,Infertility Treatment