HOLMIUM LASER LITHOTRIPSY FOR EJACULATORY DUCT CALCULI

Abstract

A 12-year-old boy with a history of myelomeningocele pre- sented with the inability to self-catheterize. The urethral catheter passed to a point of resistance and drained approx- imately 40 ml. of urine. Further catheter manipulation failed to drain the bladder completely. The patient had begun to use the Credemaneuver to empty the bladder. Retrograde ure- thrography with an antegrade voiding study revealed a nor- mal urethra with reflux into the ejaculatory ducts. Imaging with contrast medium confirmed that calcific densities on preliminary images were within the ejaculatory ducts. The patient underwent cystoscopy. The posterior urethra was dilated with patulous ejaculatory duct orifices and an elevated bladder neck. Closer inspection within the left ejac- ulatory duct using a 17Fr cystoscope revealed a large cavity filled with calculi and a false passage. The patient and family were counseled about the risk of infertility due to ejaculatory duct obstruction as the result of calculous treatment but they elected to proceed with therapy. Laser lithotripsy was performed using a 320 mm. holmium laser fiber through the 17Fr cystoscope. The left ejaculatory duct was entered and several large calculi were fragmented and retrieved using a helical stone basket. Analysis demon- strated a calcium phosphate stone composition. Cystoscopy 3 weeks later showed a small stone fragment, which was removed. The enlarged ejaculatory duct cavity was fulgurated using a 3Fr Bugbee electrode and a Foley catheter remained indwelling for 1 week. Repeat cystoscopy due to continued difficult catheter passage revealed a small left ejaculatory duct orifice with no calculi, false passage or stricture. Currently catheterization is successful using a 16Fr catheter. DISCUSSION