Transurethral Resection of Ejaculatory Duct Obstruction: Monopolar, Bipolar or Holmium Laser?
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1 Transurethral Resection of Ejaculatory Duct Obstruction: Monopolar, Bipolar or Holmium Laser? Selahittin Çayan, MD, FECSM Professor of Urology University of Mersin School of Medicine, Department of Urology, Mersin, Turkey
2 Ejaculatory Duct Obstruction Incidence: 1-5% 1942 R. Gutierrez 1973 S. Farley and R. Barnes Importance of EDO in men: Painful ejaculation, decreased force Hematospermia Perineal and testicular pain Infertility Low ejaculate volume Azoospermia Oligospermia/idiopathic infertility
3 Classification of Ejaculatory Duct Obstruction (EDO) Anatomy (Smooth muscle, columnar epithelium) Proximal (Lenght: mm, Diameter: 1,7+0,3 mm) Middle part (Lenght: 5-8 mm, Diameter: 0,6+0,1 mm) Distal (Lenght: 2-5 mm, Diameter: 0,3+0,1 mm) Congenital Cysts (Midline/lateral) Determinations predicts success for treatment Atresia& stenosis Acquired (Secondary obstruction) Stone, calcification Infection, inflammation
4 Classification of midline cysts causing obstruction Mullerian cyst Normal duct Utricle cyst Ejaculatory duct cyst
5 Algorithm for Diagnosis and Treatment of EDO Obstructive infertility (Palpable vas deferens, testicular volume >15 ml) Ejaculate volume Normal Low FSH (Partial EDO) Retragrade ejaculation Negative Positive Pozitive TRUS Negative Bladder irrigation /ART Complete Partial MRI Aspiration, chromotubation, vesiculography, SV EF, manometry TUR ED Proximal obst?, exploration? McQuaid JW, Tanrıkut Ç, Curr Urol Rep 2013, AUA Guidelines2010, EAU Guidelines 2015
6 Diagnostic Methods Transrectal ultrasound (TRUS) Non-invazive, cheap, easy procedure Findings for obstruction Dilated SV (A-P> 1,5 cm) Dilated vazal ampulla (>6mm) Dilated ejaculatory duct (>2mm) Stone/calcification TRUS is not gold standard for diagnosis of EDO EAU Guidelines on Male Inferility, 2012, Lotti F, Hum Reprod, 20014, Engin G, Diagn Interv Radiol 2012; 18:
7 Chromotubation
8 Diagnostic Methods MRI Advantages: - Multiplan imaging - High resolution - Non-invazive Dysadvantages: - Expensive - Not easy procedure Vasodynamics SV Scintigraphy Complicated cases? Engin G, Kadıoğlu A, Orhan İ Acta Radiol 2000; 41: Orhan İ et al, Urology, 2008
9 Surgical Treatment of Ejaculatory Duct Obstruction Transurethral resection of Ejaculatory Duct (TUR-ED) Monopolar Bipolar Laser incision (Neodyium, holmium) Alternative treatment methods to TUR-ED Transutricular seminal vesiculoscopy TRUS guided re-canalization and balloon dilation Laparoscopic excision (External prostatic ED cyst)
10 Case presentation 39 years old man, primary infertility Testicular pain, painful ejaculation Physical examination: Normal (No varicocele) Testis volume: 18 ml / 18 ml normal consistency Semen analysis: Ejaculate volume: 0.4 ml, Azoospermia (pellet -) Hormonal evaluation: FSH and total testosterone: N Transrectal ultrasound: Midline cyst (1,1 cm)
11 TUR-ED Transurethral midline resection of verumontanum Resection should not be extended to proximally or distally Depth of the resection should be well defined Eflux of the duct should be seen Avoid from cauterization Urethral catheterization for hours
12 Cyst wall after TUR-ED
13 Primary TUR-ED
14 Secondary TUR-ED
15 Results of TUR-ED Improvement in hematospermia Relief in symptoms (50-95%) Improvement in sperm parameters Partial obstruction: 94% Complet obstruction: 59% Complications: 0-20% Hematuria, infection (Epididymoorchitis) Retrograde ejaculation, reflux, fistula, ED, stenosis Positive effect of TURED on ART To obviate the need for ART (20-40%) To downstage the level of ART From IUI to spontaneous pregnancy (13%) From IVF/ICSI to IUI (50%) Kadıoğlu A, Fertil Steril 2001; 76: McQuaid JW, Tanrıkut Ç, Curr Urol rep 2013 ;14:
16 Bipolar Technology Different systems Different techniques Vapor, chip removal, enucleation Same: Work with saline
17 Why Bipolar Technology?: Theory Increased visibility Avoiding complications of monopolar TURED Functioning in normal saline instead of in conventional nonconductive irrigation fluid, dilutional hyponatremia risk should be eliminated Haemostatic capacity reported to be superior in ex vivo studies: Deeper coagulation Simultaneous cut and seal effect Early catheter removal Shorter hospitalization
18 Laser techniques Holmium laser incision Wavelength 2140 nm, Solid-state laser Absorbed by water, normal saline as irrigating fluid 532 nm (Greenlight) vaporisation Diode laser vaporisation Thulium : yttrium aluminium garnet Laser (Tm:YAG)
19 Why Laser Technology? Increased visibility Avoiding complications of monopolar TURED Functioning in normal saline instead of in conventional nonconductive irrigation fluid Beter hemostasis Can be performed under anti-coagulants Early catheter removal Shorter hospitalization Disadvantages: Needs experience and endoscopic skills Most common post-operative complication - dysuria
20 Transurethral incision of the Ejaculatory Duct with Holmium laser 11 patients Azoospermia and low ejaculate volume Midline cyst Unroofing of midline prostate cyst (Laser) No severe complication Hematospermia (1 case) Jiang et al, Asian J Androl, 2014
21 32 year old man Azoospermia and low ejaculate volume Midline cyst Unroofing of midline prostate cyst (Laser) Complet resection of the cyst wall (mono-polar)
22 Surgical Treatment of Ejaculatory Duct Obstruction Transurethral resection of Ejaculatory Duct (TUR-ED) Monopolar Bipolar Laser (Neodyium, holmium) Alternative treatment methods to TUR-ED Transutricular seminal vesiculoscopy TRUS guided re-canalization and balloon dilation Laparoscopic excision (External prostatic ED cyst)
23 Transutricular seminal vesiculoscopy UROLOGY 73: , 2009.
24 TRUS guided balloon dilation J Vasc Interv Radiol 2006;17: 169
25 Laparoscopic excision of extraprostatic ejaculatory duct cyst Three cases Laparoscopic excision of extraprostatic ED cyst Improvement in semen parameters: 2/3 Wang et al, Journal Compilation, 2007
26 Conclusions Transurethral resection of ejaculatory duct is a well accepted treatment of ejaculatory duct pathologies. It is safe, easy to perform and effective treatment modality. Embryological remnants are effective to predict prognosis. All methods are highly effective to improve symptoms and to correct obstruction. Laser incision/un-roofing may decrease complication rates.
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