Introduction: Ejaculatory duct obstruction is rare and diagnosed in 1-5% of infertile men. Etiology of the obstruction could be congenital or acquired disorders such as seminal vesicle calculi, post inflammatory scar formation at the prostate level, and trauma or previous transurethral surgery. Main presenting complaints include infertility, ejaculatory and testicular pain, perineal discomfort and hematospermia. Rarely, it can present with low back pain, urinary obstruction, dysuria and difficulty in defecation. The diagnosis should be suspected in the presence of low volume azoospermia, fructose negative with normal hormonal profile and genetic screening. The diagnostic modality of choice is radiological in the form of either transrectal ultrasound or pelvic magnetic resonance imaging. Herein, we describe the surgical management of patients with obstruction of the ejaculatory ducts through a case presentation with operative technique.
Methods: A brief narrated surgical video discusses the background and etiology of obstruction of the ejaculatory describing a classical presentation of patients with obstruction of the ejaculatory ducts. Initial evaluation included hormonal profile, genetic studies, semen analysis finding, and imaging. Furthermore, we herein demonstrated a step-by-step operative technique on how to perform transurethral resection, determining the appropriate resection depth and adjuvant intraoperative imaging and maneuvers such as vasograms with Methylene blue to ensure adequate patency and successful opening of the ejaculatory ducts. A written consent was obtained from the patient prior to proceeding according to hospital policy.
Results: The patient was taken for transurethral resection of the ejaculatory ducts. The procedure consisted of bilateral vasograms with 24F butterfly needle to ensure the patency of the vas deferens followed by methylene blue injection into the vas deferens which aided in determining the depth of the resection. Transurethral resection of the cyst with 7F pediatric monopolar resectoscope was performed just above the verumontanum. Once the cyst was unroofed, methylene blue and thick dense seminal fluid with crusted flakes was visualized signifying an adequate resection and successful opening of the ejaculatory ducts. Meticulous care was taken not to resect deeply to avoid deeper tissue damage and adequate hemostasis ensured. 16F Foley catheter was placed for three days post operatively. One week post operative semen analysis showed a rare motile spermatozoa.
Conclusions: Transurehtral resection of the ejaculatory ducts is the mainstay of treatment in men with ejaculatory duct obstruction.