Hybrid Method of Transurethral Resection of Ejaculatory Ducts Using Holmium:Yttriumaluminium Garnet Laser on Complete Ejaculatory Duct Obstruction
A 32-year old, single man presented with azoospermia and low semen volume which was noted one and half a year ago. He had no other known medical problems. Semen analysis revealed that the total volume was 0.5 mL and had no identifiable spermatozoa. Bilateral vas deferens were palpable on physical examination. TRUS revealed a midline prostatic cyst of approximately 1.5 cm in diameter with dilated seminal vesicles (). Pelvic MRI revealed a 2 cm sized prostatic utricular cyst and mild dilatation of the seminal vesicle (). Seminal vesiculography was performed to evaluate ejaculatory duct obstruction because of the prostatic ultracular cyst (). Under seminal vesiculography, the seminal vesicles and midline cyst were found to be filled with contrast media (). Fluid which was aspirated from the midline cyst contained some spermatozoa on examination under light microscopy. Preoperative cystoscopy revealed a narrowing of the prostatic urethra near the verumontanum due to a midline prostatic cyst (). Therefore, a diagnosis of a EDO was made and TUREJD was planned.\nUnder spinal anesthesia, the patient was placed in the lithotomy position. A 10 mL diluted indigo-carmine solution was injected through a midline cyst guided TRUS. Using a 24 Fr resectoscope (Karl Storz, Tuttlingen, Germany) with a laser bridge and a Ho:YAG laser with a 550 µm laser fiber (Lumenis, Yokneam, Israel), unroofing of the midline prostate cyst was performed. During the unroofing process, the power was set at 2 J and 10 Hz. After the process, the diluted indigo-carmine solution was extravasated to the surrounding area. When sufficient space at the prostatic urethra was secured following incision with the Ho:YAG laser, a monopolar TUR was performed (). Using TUR, the cystic wall was completely resected and a guidewire was inserted through the ejaculatory duct. The ejaculatory ducts and their wall were visualized using a 6.5 Fr semi-rigid ureteroscope (Richard Wolf GmbH, Knittlingen, Germany) and appeared to be normal ().\nThe patient was discharged the following day after the Foley catheter was removed. After a month, the patient did not have any lower urinary tract symptoms. A month later, postoperative semen analysis showed normal findings with a 3 mL volume. Concentration of spermatozoa was 15.2×106/mL.