Treatment Of Ejaculatory Duct Obstruction Research Articles

Treatment of Ejaculatory Duct Obstruction by Seminal Vesiculoscopy Assisted Flow Modification.

Transurethral resection of ejaculatory duct (TURED) is a primary surgical approach to treat ejaculatory duct obstruction (EDO) caused by the ejaculatory duct cyst. Intraoperative excision of the verumontanum is usually required to expose the ejaculatory ducts. However, preserving the verumontanum structure allows for a better simulation of normal physiological anatomy. Maintaining the verumontanum may increase the risk of postoperative distal ejaculatory duct scarring, leading to recurrent obstruction or reduced semen volume. Therefore, we attempted a novel technique that preserves the verumontanum, which is relatively easier and safer compared to TURED. The following were the procedural steps: 1. A 6F seminal vesiculoscope was introduced through the external urethral orifice to the vicinity of the verumontanum, locating the opening of the affected-side ejaculatory duct and introducing a guidewire into the cyst. This successful step preserved the verumontanum, maximizing the retention of the anti-reflux mechanism in the distal ejaculatory duct. 2. The holmium laser enlarged the affected-side ejaculatory duct opening to 5 mm, decreasing the likelihood of postoperative closure of the ejaculatory duct opening and simplifying the procedure. 3. A window was created within the cyst to access the contralateral seminal vesicle, and then a holmium laser was used to burn and dilate the opening to 5 mm, redirecting the contralateral ejaculatory duct into the cystic cavity. This modification preserved the opening of the healthy-side ejaculatory duct and provided a new outflow passage for semen, reducing the risk of decreased semen volume postoperatively. The patients experienced no complications postoperatively, had shorter hospital stays, and showed improvement in semen volume. Hence, this surgical approach is simple yet effective.

Efficacy analysis of 26 cases of ejaculatory duct obstruction treated by prostatic utricle neck endoscopy.

To evaluate the safety and efficacy of transvesical incision in the treatment of ejaculatory duct obstruction. The clinical data of 26 male infertile patients with ejaculatory duct obstruction were retrospectively analysed at the First Affiliated Hospital of Zhengzhou University from June 2020 to August 2021. All patients were treated with seminal vesicle neck incision for ejaculatory duct obstruction. The general clinical characteristics, intraoperative conditions and postoperative effects on the patients were recorded, and the therapeutic effect was evaluated. The ejaculatory duct was found through fenestration, and the seminal vesicle gland was smoothly entered in 25 patients (96.2%). Among them, 22 cases underwent bilateral endoscopy and three underwent unilateral endoscopy. Sperm appeared in 23 cases (88.5%) 3 months after surgery. The sperm concentration and motility postoperatively at 6 months were higher than that at 3 months postoperatively. No postoperative complications, such as epididymitis or retrograde ejaculation, occurred. Searching for the ejaculatory duct via the neck of the prostatic utricle, assisted by a low-energy holmium laser, is a new method for the treatment of ejaculatory duct obstruction. Microscopic vision is clear using this approach and the postoperative complications are few, which has high value for clinical application.

Surgical procedures for male infertility: an update.

The aim of this review is to provide an overview of surgical treatment options for male infertility including varicocelectomy, treatment of ejaculatory duct obstruction, vasovasostomy, and sperm extraction, and to review recent advances in techniques and technologies that may improve operative outcomes. Microscopic subinguinal varicocelectomy has been shown to have the highest success rates with lowest rates of complications, and may be facilitated by the use of Doppler, indocyanine green angiography, and the 4K3D operating video microscope. The standard treatment for ejaculatory duct obstruction by transurethral resection of the ejaculatory ducts has changed little over time, but vesiculoscopy may allow for temporary dilation of an obstruction to allow for natural conception, while also offering diagnostic capabilities. Use of the robotic platform has gained popularity for vasectomy reversals but controversy remains regarding the cost-effectiveness of this option. Recently, a reinforcing suture technique has been described for vasovasostomy to minimize anastomotic breakdown and reversal failure. Finally, gray-scale and color-enhanced ultrasound may improve ability to predict successful sperm retrieval during extraction procedures. Though the fundamentals of surgical treatment options for male infertility have changed little with time, technological advancements have contributed to improved surgical outcomes over recent years.

Application of ultrasound-guided seminal vesicle radiography combining CT three-dimensional reconstruction technique in transurethral seminal vesiculoscopy.

For the treatment of ejaculatory duct obstruction, transurethral seminal vesiculoscopy (TSV) is the most common method, but the success rate is much lower than studies that have reported. So we developed a new ultrasound-guided seminal vesicle radiography (UGSVR) combining CT three-dimensional reconstruction (CT-TR) technique to improve the success rate of TSV. Between June 2018 and November 2019, 32 patients were enrolled and randomly assigned to two groups: experimental group (UGSvR combining CT-TR) and control group (standard evaluation). Baseline information, including age, smoking history and body mass index (BMI), was compared preoperatively. Surgical parameters included success rates (SR), surgical time (ST), catheter days (CD), length of hospital stays (HS) and complications were compared between groups. There were no statistically significant differences in baseline data between the two groups (all p>.05). There were no significant differences in the CD, HS and complications between the two groups (all p>.05), but the differences in ST and SR were statistically significant (p<.05). In conclusion, this new technique of UGSvR combining CT-TR was achieving a satisfactory increase in the success rate of TSV, while not increasing the incidence of complications, compared to normal evaluation before TSV operation.

AB034. Advances in the diagnosis and treatment of ejaculatory duct obstructive diseases

Ejaculatory duct obstruction (EDO) is a cause of sperm dysfunction caused by obstructive factors in relation to vas deferens and epididymal obstruction. It is also one of the few male infertilities that can be cured by surgery, accounting for 1% to 5% of all male infertility causes. The causes of EDO can be divided into congenital and acquired factors. Congenital factors include loss of development, stenosis, Wolffian tube, Müllerian tube dysplasia, etc. Acquired factors include surgery, trauma, infection or inflammation, stones, tumors, etc. Congenital dysplasia is the most common cause of EDO when compared with acquired factors. EDO can be divided into one-sided EDO and bilateral EDO according to the anatomy of obstruction. According to the degree of obstruction, it can be divided into two types. Complete obstruction and incomplete obstruction. The clinical manifestations of complete obstruction are typical “four low” semen characteristics, that is, the amount of semen is small, there is no sperm, the pH of the seminal plasma is low, and the refined berry sugar is zero. Incomplete obstruction may have a variety of manifestations such as oligospermia, blood, pelvic pain. EDO has many clinical manifestations. Typically, typical semen exhibits a “four lows” feature. Transrectal ultrasound is an important imaging and surgical treatment for EDO screening. Magnetic resonance imaging provides high-resolution images of the reproductive system. Transurethral resection of the urethra (TURED) is a classic procedure for the treatment of EDO. The application of transurethral seminal vesiculoscopy has become a new trend of minimally invasive surgery in the treatment of EDO, and the latest flexible vesiculovasoscopy (FVV) or vasoscopy techniques may further improve the diagnosis and treatment of EDO.

AB088. The application of vesiculoscopy in the patients of hematospermia and ejaculatory duct obstruction (216 cases report)

ObjectiveTo evaluate the clinical effects of the vesiculoscopy and related endoscopic technique on the treatment of ejaculatory duct obstruction (EDO) and severe, persistent hematospermia in cases that were refractory to conservative treatments by retrospectively analyzing the clinical data of the patients treated in our hospital.MethodsClinical data from 216 patients with persistent and refractory hematospermia or EDO in our hospital since Jan. 2009 to May. 2015 was retrospectively analyzed. Data collected included history, symptoms, as well as ultrasound and MRI of the morphological features of the bilateral seminal vesicles (SV) and ejaculatory duct (ED) areas. Seminal vesiculoscopy and /or transurethral resection of the ejaculatory duct (TURED) or other related procedure were performed according to individual situation. The effects of endoscopic treatment on the refractory haematospermia and EDO were followed up.ResultsThe age range of the patients was 21–80 years (mean, 43.2 years). The history of hematospermia lasted for 6 to 120 months (mean, 35.2 months). The operations include: (I) seminal vesiculoscopy + seminal vesicle irrigation; (II) transurethral resection of the cysts in ED area and fulguration of the cyst wall; (III) lithotripsy and/or removing stones of seminal duct; (IV) fulguration of the abnormal blood vessels at posterior urethra; (V) TURED. The operation time ranged from 20 to 65 min (mean, 33 min). The seminal vesiculoscopy and related procedure were successfully performed in 211 patients, and were failed to perform in 5 patients because of the atrophy or abnormal anatomy of the seminal vesicles. 27.3% (59/216) of the patients had cysts in the ED area and 12.5% (27/216) had stone or calcification in the SV, ED or utricular cyst. 204 patients were followed up for 3–72 months (mean, 35 months). The hematospermia of all the patients were disappeared within 2–6 weeks and 94.6% (193/204) of the patients did not appear the haematospermia anymore. 5.4% (11/204) of the patients present a recurrence after 5~20 months, 6 of them performed the second time seminal vesiculoscopy and were recovered later, 5 of them were recovered by the conservative treatment (oral drug administration). No intra- or post-operative obvious complications were observed. 3.9% (8/204) of the patients who more than 40 years old complained that the orgasmic intensity was slightly decreased after operation, but 96.1% (196/204) of the patients did not complain any change of the orgasms. The volume of semen, and the concentration and activity of sperm in 18 in fertile patients were significantly improved, and 38.9% (7/18) of the patients made their spouse pregnant naturally 6–24 months later after operation.ConclusionsThe ejaculatory duct obstruction, stone in the seminal duct and/ or the cysts in the ED area may be the predominant factors for the appearance of hematospermia The transurethral seminal vesiculoscopy technique and related procedure represent a kind of simple, reliable, safe and effective approaches for the management of refractory hematospermia and EDO.

Editorial Comment

Editorial Comment

Transurethral bipolar plasma kinetic resection of ejaculatory duct for treatment of ejaculatory duct obstruction

To evaluate the efficacy of transurethral bipolar plasma kinetic resection of ejaculatory duct for ejaculatory duct obstruction. The clinical information of 42 cases of ejaculatory duct obstruction was analyzed between July 2008 and June 2012. The diagnostic criteria included semen analysis, fructose and neutral α-glucosidase measurement in seminal plasma, transrectal ultrasonography, magnetic resonance imaging and vasography necessarily. Endoscopic procedure with bipolar plasma kinetic resection of ejaculatory duct was performed in all patients. Among these cases followed up 6 ≈ 24 months after operation, 38 patients (90.5%) had improved semen parameters, 23 azoospermic patients (60.5%) had sperm in the semen and 13 patients' wife (31%) achieved pregnancies in 42 cases of bipolar plasma kinetic resection of ejaculatory duct. Postoperative complications ensued as epididymitis in 1 case, watery ejaculate in 1, but no serious complication was observed. Bipolar plasma kinetic resection of ejaculatory duct appears to represent a promising endoscopic treatment alternative for ejaculatory duct obstruction patients, with high efficacy, less complications, quicker recovery and satisfactory follow-up parameters.

Transurethral resection of ejaculatory duct in infertile men: outcome and predictors of success

To evaluate the outcome of transurethral resection of the ejaculatory duct (TURED) in the treatment for ejaculatory duct obstruction (EDO) and define predictors of success. We retrospectively evaluated 23 infertile men between 2006 and 20011, who were diagnosed as having EDO. Inclusion criteria were azoospermia or oligozoospermia, low ejaculate volume, low ejaculate PH, little or no fructose in seminal plasma with normal serum levels of gonadotropins and testosterone and evidence of obstruction on transrectal ultrasonography (TRUS) or magnetic resonance images (MRI). Seventeen patients were diagnosed as complete EDO, and the remaining 6 were considered as having partial EDO. All patients were treated by TURED. Midline cysts were diagnosed in seven cases, and the remaining 16 patients had postinflammatory obstruction of ejaculatory ducts (ED). Overall, a significant improvement of semen quality was achieved after surgery. All patients with partial EDO showed improvements in semen parameters after TURED compared to 23.5% (4/17) in those with complete EDO. Improvement in sperm count was 71.5% and 31% for patients with midline cysts and patients with non-cystic causes of EDO, respectively. Six (26%) patients developed complications including epididymo-orchitis in 2, watery ejaculate in 3 and conversion to azoospermia in 1. Spontaneous pregnancies were achieved in 3 (13%) cases: 2 (33.3%) men with partial and 1 (5.9%) with complete obstruction. Partial EDO, whatever the etiology, has an excellent outcome after TURED. Complete EDO due to cysts appears to respond better than postinflammatory obstruction to TURED.

Transurethral Seminal Vesiculoscopy Using a 6F Vesiculoscope for Ejaculatory Duct Obstruction: Initial Experience

Ejaculatory duct obstruction (EDO) is a surgically correctable condition that occurs in some infertile men. The standard therapy is transurethral resection of ejaculatory ducts (TURED). However, TURED has been associated with a high risk of complications, including the impairment of semen parameters and retrograde ejaculation. In our clinical practice, vesiculoscopy has demonstrated potential as a minimally invasive alternative technique for the diagnosis and treatment of EDO. Very few studies have examined transurethral seminal vesiculoscopy (TRU-SVS) in recent years, and no study has examined 6F vesiculoscopes. Therefore, we performed a retrospective study of TRU-SVS using a 6F vesiculoscope and its effect on the diagnosis and treatment of EDO. A total of 21 patients who underwent this procedure were included in the study. The mean patient age was 28.8 years (range, 23-36 years). The procedure was completed successfully in all patients within a mean time of 31.5 minutes and a mean hospital stay of 1.17 days. All patients had EDO. Calculi were found in the ejaculatory ducts or in the seminal vesicles of 5 patients. Sperm was detected in 11 patients 1-3 months postsurgery and in another 8 patients 3-12 months postsurgery. No sperm was detected in the remaining 2 patients by 12 months postsurgery. Epididymitis, retrograde ejaculation, urinary incontinence, and rectal injury were not observed. These data indicate that TRU-SVS using a 6F vesiculoscope affords direct access to the seminal vesicle and offers the advantages of fewer complications and more optimal sperm recovery as well as direct, dynamic video imaging.

Less invasive causal treatment of ejaculatory duct obstruction by balloon dilation: a case report, literature review and suggestion of a CT- or MRI-guided intervention.

Uni- or bilateral ejaculatory duct obstruction (EDO) is a rare but correctable cause of infertility, chronic pelvic pain and postejaculatory pain. EDO is a congenital or acquired condition, it is the underlying cause of infertility in approximately 5% of infertile men. If acquired, the etiology often remains unresolved, but prostatitis or urethritis with post-inflammatory adhesion of the duct walls seems to be a common underlying pathomechanism.Although a certain constellation of physicochemical semen parameters may lead to correct diagnosis, EDO often resembles a diagnosis by exclusion. Imaging of acquired EDO remains a challenge and the established surgical therapy, transurethral resection of the ejaculatory ducts (TURED), leads to a low rate of natural conception and a high rate of complications such as reflux of urine and epididymitis. We present a case of a male with suspected EDO who underwent a combined approach to both, semi-invasive diagnosis and therapy by transrectal puncture of the seminal vesicles and antegrade balloon-dilation of the ejaculatory ducts. Possibilities and pitfalls of this procedure are described and the literature is reviewed.Furthermore, we suggest a CT- or MRI-guided, percutaneous intervention for treatment of ejaculatory duct obstruction by balloon dilation and demonstrate initial steps of this procedure with a body donor. We call this new procedure PTED (percutaneous transgluteal ejaculatory ductoplasty).

Novel methods for the diagnosis and treatment of ejaculatory duct obstruction

• To investigate a new method of vas deferens radiography for ejaculatory duct obstruction (EDO). • To evaluate the effect of a procedure involving dilation of the ejaculatory duct by F9 seminal vesicoscopy. • Twenty-two patients with EDO were diagnosed using semen analysis, semen fructose measurement, transrectal ultrasonography (TRUS) and vas deferens radiography. • Of these, 18 patients were successfully treated by dilation of ejaculatory duct using F9 seminal vesicoscopy and four patients, whose treatment was unsuccessful, were treated by transurethral resection of the ejaculatory ducts (TURED). • All patients were followed up for at least 3 months after treatment. • Semen analyses in all 22 patients showed oligoasthenozoospermia or azoospermia, low semen volume (0-1.9 mL), low pH level (5.6-7.0) and absent or low semen fructose. TRUS and radiography showed pure dilated seminal vesicles on both sides in three patients, partial dilated seminal vesicles in one patient, dilation of both the ejaculatory duct and seminal vesicles in ten patients, dilated seminal vesicles and a prostatic cyst in four patients, and dilated ejaculatory duct or cystic lesions without dilated seminal vesicles in the remaining four patients. • At >3-month follow-up after dilation or TURED, the semen characteristics of 18 patients were improved and sperm were present in the semen in 13 cases. Normal semen analyses were found in 7 patients and 6 patients had conceived. • Voiding urethral radiography showed that no patients who had undergone dilation by seminal vesicoscopy had urine reflux into the ejaculatory duct. Only one patient showed urine reflux into the seminal vesicle after TURED. • All patients felt that their symptoms had improved after treatment. • The approach to vas deferens radiography using vas deferens aspiration has proved to be an effective and safe method for EDO diagnosis. • The procedure involving the dilation of the ejaculatory duct using F9 seminal vesicoscopy is equally effective but has fewer postoperative complications than TURED.

Application of diagnosis and treatment for infertility patients with ejaculatory duct obstruction by transrectal ultrasound

Objective To evaluate the value of diagnosis and treatment in male infertility patients with ejaculatory duct obstruction (EDO) using transrectal ultrasonography (TRUS). Methods Forty-six male infertile patients with EDO were enrolled in this study. The results of TRUS were analyzed retrospectively. Furthermore,the fluid of cysts were measured in the laboratory. Results The 46 patients were all diagnosed in clinic,23 patients were ejaculatory duct cysts, 11 patients were Miillerian duct cysts, and 12 patients were dilations of the ejaculatory duct. Dilations of the ejaculatory duct were induced by bacterial infection in 8 patients, by tubercular in 3 patients, and by ejaculatory duct stone in 1 patients. Conclusions TRUS is a desirable method for the diagnosis and treatment of EDO. Key words: Endosonography; Infertility,male; Ejaculatory duct obstruction

TREATMENT OF EJACULATORY DUCT OBSTRUCTION: A NEW ALGORITHM

TREATMENT OF EJACULATORY DUCT OBSTRUCTION: A NEW ALGORITHM

1579: Can the Number or Type of Findings Improve the Diagnostic Accuracy of Transrectal Ultrasound in the Treatment of Ejaculatory Duct Obstruction?

You have accessJournal of UrologyDiscussed Poster, Tuesday, May 11, 2004, 1:00 - 5:00 pm1 Apr 20041579: Can the Number or Type of Findings Improve the Diagnostic Accuracy of Transrectal Ultrasound in the Treatment of Ejaculatory Duct Obstruction? Rajveer S. Purohit, Katsuto Shinohara, Paul J. Turek, and San Francisco Rajveer S. PurohitRajveer S. Purohit More articles by this author , Katsuto ShinoharaKatsuto Shinohara More articles by this author , Paul J. TurekPaul J. Turek More articles by this author , and San FranciscoSan Francisco More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(18)38787-1AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "1579: Can the Number or Type of Findings Improve the Diagnostic Accuracy of Transrectal Ultrasound in the Treatment of Ejaculatory Duct Obstruction?." The Journal of Urology, 171(4S), p. 417 © 2016 by American Urological AssociationFiguresReferencesRelatedDetails Volume 171Issue 4SApril 2004Page: 417 Advertisement Copyright & Permissions© 2016 by American Urological AssociationMetricsAuthor Information Rajveer S. Purohit More articles by this author Katsuto Shinohara More articles by this author Paul J. Turek More articles by this author San Francisco More articles by this author Expand All Advertisement PDF DownloadLoading ...

Diagnosis and Treatment of Male Infertility

As a result of the technological advance provided by intracytoplasmic sperm injection (ICSI) in 1992, the evaluation and treatment of the infertile male has changed significantly. Many men who were previously thought to be irreversibly infertile have the potential to initiate their own biologic pregnancy. However, not all men having impaired semen parameter are ideal candidates for ICSI for numerous reasons including a lack of addressing the underlying problem causing the male infertility, unknown genetic consequences, and cost-effectiveness issues. In this era of ICSI, the fundamental approach to the male with suspected subfertility is unchanged and is based on a history, physical examination, and focused laboratory testing. The urologist should approach the patient with an intent to identify remediable causes of subfertility given the specific clinical situation. For instance, should a gentleman have his varicocele repaired or vasectomy reversed, or should he proceed directly with ICSI? If no factors can be improved in a timely manner, then ICSI should be considered using the available sperm. Examples of recent advances include the diagnosis and treatment of ejaculatory duct obstruction, indications and techniques for performing test is biopsy, and technique for sperm harvesting. In addition, potential genetic causes of male subfertility should be diagnosed and discussed with the patient. Cystic fibrosis gene mutation, karyotype abnormalities, and Y-chromosome microdeletions all have recently been identified as causative for male infertility in otherwise phenotypically normal men. With recently evolved diagnostic and therapeutic techniques now available for the infertile couple, even the most severe male factor problems in patients previously considered irreversibly infertile are now potentially treatable. The physician should be aware of the availability and limitations of these new and exciting reproductive technologies because they will allow him to provide timely and more effective therapy for the infertile couple. An understanding of these advances by all physicians is important as we progress into the 21st century.

Does response to treatment of ejaculatory duct obstruction in infertile men vary with pathology?

Objective: To describe the pathology-specific response to transurethral resection of ejaculatory ducts (TURED) in patients with complete or partial ejaculatory duct obstruction and to evaluate the role of TURED in light of powerful assisted reproductive technologies. Design: Retrospective clinical study. Setting: University hospital. Patient(s): Thirty-eight infertile men with obstruction of the ejaculatory ducts. Intervention(s): Diagnosis by transrectal ultrasonography or magnetic resonance imaging, and treatment with TURED. Main Outcome Measure(s): Changes in semen variables, pregnancy outcomes, and complication rates were analyzed before and after surgery. Result(s): Improvement in semen variables was significantly better in patients with partial obstruction (94%) of ducts than in those with complete obstruction (59%) ( P=.04). Cystic obstruction, especially midline and eccentric cysts, responded best to TURED. Before surgery, all patients were candidates for IVF/ICSI; after surgery, 32% of azoospermic men and 81% of oligospermic men conceived spontaneously or were referred for IUI instead of IVF/ICSI. Conclusion(s): Ejaculatory duct obstruction due to cysts appears to respond best to TURED. In addition, TURED may decrease the need for IVF/ICSI as primary treatment in many cases. Finally, TURED may allow IVF/ICSI to be performed with ejaculated rather than surgically retrieved sperm.

Diagnosis and Treatment of Ejaculatory Duct Obstruction in Male Infertility

Objective: To discuss the diagnosis and treatment of ejaculatory duct obstruction in male infertility. Patients and Methods: Twenty–four males were treated for ejaculatory duct obstruction between 1994 and 1998 in our clinic. Patients’ age varied between 20 and 40 (mean=29). Ejaculatory duct obstruction was considered in patients with low to normal ejaculate volume, azoospermia or oligospermia, decreased motility, normal serum gonadotropin and testosterone levels, absent or low fructose in the ejaculate and evidence of obstruction on transrectal ultrasonography. The definitive diagnosis was made by the absence of efflux of methylene blue injected through the vas during cytoscopy. All the patients were subjected to transurethral resection of ejaculatory ducts and spermograms before and 3 months after resection were compared. Results: Before transurethral resection mean sperm count was 1.66×10⁶/ml compared to 25.4×10⁶/ml postoperatively. The difference was statistically significant (p=0.001). After the operation, 58.3% of the cases had improvement in sperm motility, and 62.5% had increased ejaculate volume. No significant complications occurred, and in only 1 (4.17%) patient, there was persistent hematuria. After a mean follow–up period of 9 (6–18) months, 6 (25%) pregnancies were noted. Conclusion: Although transurethral resection is an effective method for the treatment of ejaculatory duct obstruction, the pregnancy rate is low, which could be related to the hazardous effects of urinary reflux into ejaculatory ducts or functional abnormalities of seminal vesicles.

Surgical therapy in infertile men with ejaculatory duct obstruction: technique and outcome of a standardized surgical approach.

In severe oligozoospermia or azoospermia, low ejaculate volume, low ejaculate pH and little or no fructose in seminal plasma suggest an obstruction of the seminal pathways at the level of the prostate gland, when vasal aplasia and ejaculatory disorders are excluded. We report on our standardized surgical approach in 16 consecutive patients with this condition after clinical evaluation, semen analysis, endocrine assessment, testicular biopsy and transrectal ultrasonography. Pre-operatively, sperm analysis demonstrated typical low-volume ejaculates with azoospermia in 12 and severe oligozoospermia in four cases. Ultrasonography demonstrated seven central (Müllerian) and five lateral cystic lesions. Four cases with central obstruction revealed no ultrasonographic pathology. After intra-operative vasopuncture and vasography for definite localization of the level of obstruction, transurethral incision and/or resection of ejaculatory ducts (TURED) was performed. Patency was proven in 15 out of 16 cases by 'intra-operative chromotubation'. In nine out of 12 patients, spermatozoa could be harvested intra-operatively from the vas. During the follow-up of 12 months, post-operative ejaculates showed persistent patency in six out of seven Müllerian cysts with concomitant improvement of sperm quality. Only three of the other nine cases remained patent with the worst results in lateral cystic lesions. Only two of the patients with Müllerian cysts have fathered a child so far. The data provide evidence for the effectiveness of surgical treatment of ejaculatory duct obstruction, especially in the case of central cystic lesions. The combination of surgery, cryostoring of spermatozoa retrieved intra-operatively and the possible storage of ejaculated spermatozoa post-operatively creates the possibility of subsequently using reproductive techniques if pregnancy is not achieved.

Ejaculatory duct obstruction: diagnosis and treatment with transrectal sonography.

Ejaculatory duct obstruction is thought to be a relatively uncommon but readily treatable cause of male infertility. Obstruction is frequently caused by cysts originating from or impinging on the ejaculatory ducts. The use of transrectal sonography has facilitated identification of patients with ejaculatory duct obstruction and has led to the realization that this abnormality is more common than was previously recognized. Transrectal sonography now plays a critical role in both the diagnosis and the treatment of this condition. The purpose of this pictorial essay is to illustrate the use of transrectal sonography in the diagnosis and treatment of ejaculatory duct obstruction.