(182) Transurethral Laser Incision of Ejaculatory Duct for Complete Ejaculatory Duct Obstruction

Abstract

Abstract Introduction It is estimated that approximately 5% of men presenting with infertility suffer from ejaculatory duct obstruction (EDO). Patients suspected to have EDO typically have a palpable vas deferens and normal testicular exam. On semen analysis, low volume and acidic pH should increase suspicion, and transrectal ultrasound is most commonly the first diagnostic modality utilized to confirm the diagnosis when suspecting EDO. Objective The objective of this surgical video is to describe the use of holmium laser for the management of ejaculatory duct obstruction (EDO) in the setting of obstructive azoospermia. Methods This was a 35 year old male with no significant past medical history who presented with obstructive azoospermia. His partner was a 32 year old female with no significant past medical history, with regular menstrual cycles, and a normal female reproductive evaluation. Semen analysis was significant for low volume (0.5 mL) azoospermia with an acidic pH (6.8). Abdominal and pelvic computerized tomography (CT) scan from 2017 when the patient presented for appendicitis noted an incidental finding of a 9.9 cm prostatic cyst. Thus, a transrectal ultrasound (TRUS) guided aspiration was performed in the ambulatory clinic which demonstrated a large prostatic cyst, with non-motile sperm in the aspirate. The patient was consented for Cystoscopy with transurethral laser incision of ejaculatory ducts. A 22 French (F) cystoscope was used, first for pan-cystourethroscopy, and then to cannulate the right ejaculatory duct with 5F pollack catheter and guide wire. Guide wire and catheter positioning within the cyst was confirmed with fluoroscopy. A 24F resectoscope with a laser bridge working element and 550 micron holmium laser fiber at settings of 1 Joule of energy and 10 hertz frequency to incise the right ejaculatory duct, circumferentially around the wire. The ejaculatory duct was incised and cyst was drained until the ejaculatory duct and thus prostatic cyst could be cannulated and examined with the cystoscope. On examination of the cyst, no vasal openings were identified. Left seminal vesiculography was attempted but unsuccessful due to significant contrast extravasation into the urethra. Results The case went well and was uncomplicated. There were no immediate or delayed complications or adverse effects reported by the patient. Post-operative instructions included rest for 1 week, followed by ejaculation every other day for 3 months. Semen analysis and transrectal ultrasound will be performed at 3 months post-operative. Conclusions Transurethral laser incision of ejaculatory duct is a safe surgical intervention for management of complete ejaculatory duct obstruction, and is demonstrated successfully in this step-by-step surgical video. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Boston Scientific.