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Antegrade ejaculatory duct recanalization and dilation
CASE
ANTEGRADE JONATHAN
REPORT
EJACULATORY DUCT RECANAL .IZAT ‘ION AND DILATION P JAROW, M.D., AND RONALD J. ZAGORIA, M.D.
ABSTRACT-Ejaculatory duct obstruction is a rare but correctable cause of male infertility. Standard therapy is transurethral resection of the ejaculatory ducts, which is frequently complicated by seminal vesicle urinary reflux and is contraindicated when the obstruction is located outside the prostate gland. Herein, we report a minimally invasive technique that successfully dilated the ejaculatory duct without-complications in a patient with unilateral, complete ejaculatory duct obstruction located outside the prostate. UROLOGY@ 46: 743-746, 1995.
jaculatory duct obstruction is a relatively uncommon disorder. Patients with ejaculatory duct obstruction may present with infertility, hematospermia, pelvic pain, or be asymptomatic.1-4 The diagnosis of ejaculatory duct obstruction is suspected in symptomatic patients with abnormal transrectal ultrasonographic findings5-9 and confirmed by either vasography3,10 or seminal vesiculography.ll The standard method of management of patients with symptomatic ejaculatory duct obstruction is transurethral resection of the ejaculatory duct (TURED). 5*12-14However, there are many potential complications associated with TURED, including injury to the internal or external urinary sphincter, rectal injury, and reflux of urine into the male genital tract.t5,16 Herein, we describe a minimally invasive technique for balloon dilation of the ejaculatory duct, which could be used as an alternative to TURED in the management of patients with ejaculatory duct obstruction. The obstructed ejaculatory duct was recanalized in an antegrade fashion using modified angiographic techniques via a transrectal puncture of the seminal vesicle performed under transrectal ultrasonographic guidance. After recanalizing the ejaculatory duct orifice, the ejaculatory duct was retrograde balloon dilated following urethroscopic positioning of the balloon just inside the ostium of the ejaculatory duct. This is the first report of this minimally invasive technique for the canalization and balloon dilation of the ejaculatory duct.
E
From the Departments of Urology and Radiology, Bowman Gray School of Medicine, Wake Forest University, WinstonSalem, North Carolina Reprint requests: Jonathan P. Jarow, M.D., Department of Urology, Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, NC 27157 Submitted: April 7, 1995, accepted (with revisions): May 16, 1995 UFCOLOGYa 46 (51, 1995
CASE REPORT A 35year-old man was referred for evaluation of a 3-year history of low back pain and hematospermia despite treatment with antibiotics. His prior evaluation included a normal intravenous urogram, normal abdominaVpelvic computed tomography scan, and normal urethroscopy. Physical examination revealed normal external genitalia and a normal rectal examination. Semen analysis revealed normal sperm count and motility but reduced ejaculate volume. Transrectal ultrasonography revealed a markedly dilated left seminal vesicle, hyperechoic ejaculatory duct, and a normal right seminal vesicle (Fig. 1). Seminal vesicle aspiration and seminal vesiculography were performed under transrectal ultrasonographic guidance. l1 The aspirate obtained from the left seminal vesicle revealed 3 mL of chocolate brown material with sperm too numerous to count on microscopic examination. The aspirate obtained from the right seminal vesicle was negative for sperm. Seminal vesiculography revealed complete obstruction of the left ejaculatory duct (Fig. 2) at a site outside the prostate gland. The right ejaculatory duct was patent. The patient received a preoperative enema and quinolone antibiotic preparation and underwent balloon dilation of the ejaculatory duct under general anesthesia. Access to the left seminal vesicle was obtained by transrectal puncture using a 17gauge needle under transrectal ultrasonographic guidance. A small volume of contrast material was injected into the left seminal vesicle to confirm satisfactory needle placement within the lumen of the persistently dilated seminal vesicle. An angiographic guide wire was advanced through the needle into the seminal vesicle, and the needle was withdrawn. A 5F angiographic catheter was then advanced through the needle guide, over the guide wire, and into the seminal vesicle. Using standard catheter and guide wire techniques, the catheter 743
FIGURE 1. Sagittal tran.WeCtal ultrasonographic image of the left seminal vesicle [white arrowhead) and ejaculatory duct (black arrow) demonstrating dilation of the seminal vesicle and hyperechogenicity of the ejaculatory duct.
FIGURE 2. directed left the seminal obstruction the prostate
Percutaneous transrectal ultrasonographic seminal vesiculography reveals dilation of vesicle and ampullary vas deferens with of the ejaculatory duct (arrow) outside of gland.
and guide wire tip were manipulated until the catheter was directed toward the ejaculatory duct. A 0.035inch heavy-duty straight guide wire was used to advance the catheter through the occluded ejaculatory duct. The guide wire passed through 744
FIGURE 3. Radiographic image of the balloon dilation catheter inflated within the left ejaculatory duct and simultaneous cystoscopic imaging of catheter placement.
the ejaculatory duct into the urethra, where it was then retrieved with a urethroscope. The guide wire was seen to exit the recanalized ejaculatory duct in its normal position on the verumontanum. The urethroscope and guide wire tip were then withdrawn through the urethra. The angiographic guide wire ends were now simultaneously accessible both transurethrally and transrectally. A 4-mm diameter angiographic balloon dilation catheter was then advanced in a retrograde direction through the urethra over the guide wire. Simultaneous observation through the urethroscope and fluoroscopy confirmed proper positioning of the balloon catheter just inside the urethral orifice of the ejaculatory duct. The balloon was then maximally inflated two times to assure adequate dilation of the ejaculatory duct (Fig. 3). The balloon dilation catheter was then removed, and the angiographic catheter was reinserted transrectally into the left seminal vesicle. A repeat seminal vesiculogram was performed after removal of the guide wire by injecting saline through the catheter and observing the ejaculatory duct orifice under direct vision with the urethroscope. This resulted in demonstrable antegrade flow of fluid exiting the left ejaculatory duct. For further confirmation, the left ejaculatory duct was now easily catheterized using a straight 5F catheter and guide wire in a retrograde direction from the urethroscope. The transrectal ultrasound probe and the urethroscope were then removed and a urethral catheter was placed. The patient noted full resolution of the pelvic pain postoperatively COMMENT Ejaculatory duct obstruction is a relatively new and infrequent diagnosis. The traditional method UROLOGY’
46 61, 19%
of diagnosis was vasography, which is an invasive study and not often performed without specific indications.’ Transrectal ultrasonography is a noninvasive alternative to vasography and provides excellent imaging of the seminal vesicles, ampullary vas deferens, and prostate.7 The availability of a noninvasive diagnostic modality has led to more frequent testing of symptomatic patients, which has resulted in a higher detection rate of ejaculatory duct abnormalities. Complete bilateral ejaculatory duct obstruction results in azoospermia and patients with this disorder usually present with infertility. Diagnostic criteria include low ejaculate volume azoospermia, dilated seminal vesicles on transrectal ultrasonography, and presence of numerous sperm within seminal vesicle aspirate. l1 Partial ejaculatory duct obstruction is more difficult to diagnose, since semen analysis and transrectal ultrasonographic findings are often nonspecific.5Jj,8 Findings suggestive of the diagnosis of partial ejaculatory duct obstruction include low ejaculate volume, reduced sperm count and motility, and sonographic images demonstrating dilated seminal vesicles or ejaculatory ducts. Abnormalities of the ejaculatory ducts and seminal vesicles may also cause hematospermia and pain.1,2,4 Transrectal ultrasonographic findings include evidence of ejaculatory duct obstruction and cystic lesions within the prostate, such as mullerian duct cysts.1,7 The potential etiologies of ejaculatory duct obstruction include infection, traumatic injury (iatrogenie), prostate cysts, and idiopathic. Regardless of the etiology of ejaculatory duct obstruction, the treatment is the same. The traditional treatment of ejaculatory duct obstruction is TURED. This is a relatively rare lesion, and reports of the management of ejaculatory duct obstruction are limited to case reports like this one and a few small series.3,5,9,12,14 There are several potentially serious complications associated with TURED, including damage to the urinary sphincters resulting in urinary incontinence or retrograde ejaculation. In addition, resection of the ejaculatory ducts may extend too far posteriorly and injure the rectum with potential fistula formation. Fortunately, these complications rarely occur, and transurethral resection has been reported to be a very successful treatment modality for patients with ejaculatory duct obstruction. However, resection of the ejaculatory duct urethral orifice destroys the normal flap valve mechanism, which prevents reflux of urine into the male genital system. Therefore, urine contamination of the semen is a frequent complication of TURED.15;16 The urine reduces a patient’s fertility potential and may pose a risk for future infection, such as epididymitis. uRoLoGYa
46 (5), 1995
Balloon dilation is an alternative treatment modality to surgical resection of the ejaculatory ducts. Attempts at transurethral catheterization of the ejaculatory ducts have been thwarted by difficulty in locating the urethral orifice of the ejaculatory duct. This is especially difficult in a patient with ejaculatory duct obstruction and distortion of normal anatomy We have previously been able to catheterize the ejaculatory duct transurethrally after partial resection of the ejaculatory ducts and then perform balloon dilation. However, it frequently appeared that the “partial” resection removed the site of obstruction, and this method does not preserve the normal ejaculatory duct orifice anatomy. The antegrade approach through the seminal vesicles has the advantage of preserving ejaculatory duct orifice anatomy while being technically easier to perform. Patients with complete obstruction have significant dilation of the seminal vesicles, which makes manipulation of the catheters within the seminal vesicle easier. In contrast, the catheter passes through the ejaculatory duct more easily in patients who have partial ejaculatory duct obstruction despite the limited area in which to manipulate the catheter in the smaller seminal vesicles. This technique of antegrade recanalization of the ejaculatory ducts combined with retrograde balloon dilation under direct vision preserves normal ejaculatory duct anatomy while avoiding the other more serious potential complications associated with TURED. The patient described in this report experienced symptomatic relief without complication, and a follow-up semen analysis did not reveal any urine contamination of the semen. Further study is needed to determine the long-term success of this new technique. REFERENCES 1. Littrup PJ, Lee F, McLeary RD, Wu D, Lee A, and Kumasaka GH: Transrectal US of the seminal vesicles and ejaculatory ducts: clinical correlation. Radiology 168: 625-628, 1988. 2. Papp G, and Molnar J: Causes and differential diagnosis of hematospermia. Andrologia 13: 474-478, 1981. 3. Pryor JP, and Hendry WF: Ejaculatory duct obstruction in subfertile males: analysis of 87 patients. Fertil Steril 56: 72%730,1991. 4. Worischeck JH, and Parra RO: Chronic hematospermia: assessment by transrectal ultrasound. Urology 43: 515-520, 1994. 5. Meacham RB, Hellerstein DK, and Lipshultz LI: Evaluation and treatment of ejaculatory duct obstruction in the infertile male. Fertil Steril 59: 393-397, 1993. 6. Jarow JP: Transrectal ultrasonography of infertile men. Fertil Steril 60: 1035-1039, 1993. 7. Kuligowska E, Baker CE, and Oates RD: Male infertility: role of transrectal US in diagnosis and management. Radiology 185: 353-360, 1992. 8. Hellerstein DK, Meacham RB, and Lipshultz LI: Transrectal ultrasound and partial ejaculatory duct obstruction in male infertility. Urology 39: 449-452, 1992. 745
9. Belker AM, and Steinbock GS: Transrectal prostate ultrasonography as a diagnostic and therapeutic aid for ejaculatory duct obstruction. J Urol 144: 356-358, 1990. 10. Ford K, Carson CC 3d, Dunnick NR, Osborne D, and Paulson DF: The role of seminal vesiculography in the evaluation of male infertility. Fertil Steril 37: 552-556, 1982. 11. Jarow JP: Seminal vesicle aspiration in the management of patients with ejaculatory duct obstruction. J Urol 152: 899-901, 1994. 12. Silber SJ: Ejaculatory duct obstruction. J Urol 124: 294-297, 1980.
746
13. Vicente J, de1 Portillo L, and Pomerol MM: Endoscopic surgery in distal obstruction of the ejaculatory ducts. Eur Uro19: 338-340, 1983. 14. Carson CC: Transurethral resection for ejaculatory duct stenosis and oligospermia. Fertil Steril41: 482-484, 1984. 15. Vazquez-Levin MH, Dressler KP, and Nagler HM: Urine contamination of seminal fluid after transurethral resection of the ejaculatory ducts. J Urol 152: 2049-2052, 1994. 16. Goluboff ET, Kaplan SA, and Fisch H: Seminal vesicle urinary reflux as a complication of transurethral resection of ejaculatory ducts. J Urol 153: 1234-1235, 1995.
uROLcGY@ 46 (51, 1995
ANTEGRADE JONATHAN
REPORT
EJACULATORY DUCT RECANAL .IZAT ‘ION AND DILATION P JAROW, M.D., AND RONALD J. ZAGORIA, M.D.
ABSTRACT-Ejaculatory duct obstruction is a rare but correctable cause of male infertility. Standard therapy is transurethral resection of the ejaculatory ducts, which is frequently complicated by seminal vesicle urinary reflux and is contraindicated when the obstruction is located outside the prostate gland. Herein, we report a minimally invasive technique that successfully dilated the ejaculatory duct without-complications in a patient with unilateral, complete ejaculatory duct obstruction located outside the prostate. UROLOGY@ 46: 743-746, 1995.
jaculatory duct obstruction is a relatively uncommon disorder. Patients with ejaculatory duct obstruction may present with infertility, hematospermia, pelvic pain, or be asymptomatic.1-4 The diagnosis of ejaculatory duct obstruction is suspected in symptomatic patients with abnormal transrectal ultrasonographic findings5-9 and confirmed by either vasography3,10 or seminal vesiculography.ll The standard method of management of patients with symptomatic ejaculatory duct obstruction is transurethral resection of the ejaculatory duct (TURED). 5*12-14However, there are many potential complications associated with TURED, including injury to the internal or external urinary sphincter, rectal injury, and reflux of urine into the male genital tract.t5,16 Herein, we describe a minimally invasive technique for balloon dilation of the ejaculatory duct, which could be used as an alternative to TURED in the management of patients with ejaculatory duct obstruction. The obstructed ejaculatory duct was recanalized in an antegrade fashion using modified angiographic techniques via a transrectal puncture of the seminal vesicle performed under transrectal ultrasonographic guidance. After recanalizing the ejaculatory duct orifice, the ejaculatory duct was retrograde balloon dilated following urethroscopic positioning of the balloon just inside the ostium of the ejaculatory duct. This is the first report of this minimally invasive technique for the canalization and balloon dilation of the ejaculatory duct.
E
From the Departments of Urology and Radiology, Bowman Gray School of Medicine, Wake Forest University, WinstonSalem, North Carolina Reprint requests: Jonathan P. Jarow, M.D., Department of Urology, Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, NC 27157 Submitted: April 7, 1995, accepted (with revisions): May 16, 1995 UFCOLOGYa 46 (51, 1995
CASE REPORT A 35year-old man was referred for evaluation of a 3-year history of low back pain and hematospermia despite treatment with antibiotics. His prior evaluation included a normal intravenous urogram, normal abdominaVpelvic computed tomography scan, and normal urethroscopy. Physical examination revealed normal external genitalia and a normal rectal examination. Semen analysis revealed normal sperm count and motility but reduced ejaculate volume. Transrectal ultrasonography revealed a markedly dilated left seminal vesicle, hyperechoic ejaculatory duct, and a normal right seminal vesicle (Fig. 1). Seminal vesicle aspiration and seminal vesiculography were performed under transrectal ultrasonographic guidance. l1 The aspirate obtained from the left seminal vesicle revealed 3 mL of chocolate brown material with sperm too numerous to count on microscopic examination. The aspirate obtained from the right seminal vesicle was negative for sperm. Seminal vesiculography revealed complete obstruction of the left ejaculatory duct (Fig. 2) at a site outside the prostate gland. The right ejaculatory duct was patent. The patient received a preoperative enema and quinolone antibiotic preparation and underwent balloon dilation of the ejaculatory duct under general anesthesia. Access to the left seminal vesicle was obtained by transrectal puncture using a 17gauge needle under transrectal ultrasonographic guidance. A small volume of contrast material was injected into the left seminal vesicle to confirm satisfactory needle placement within the lumen of the persistently dilated seminal vesicle. An angiographic guide wire was advanced through the needle into the seminal vesicle, and the needle was withdrawn. A 5F angiographic catheter was then advanced through the needle guide, over the guide wire, and into the seminal vesicle. Using standard catheter and guide wire techniques, the catheter 743
FIGURE 1. Sagittal tran.WeCtal ultrasonographic image of the left seminal vesicle [white arrowhead) and ejaculatory duct (black arrow) demonstrating dilation of the seminal vesicle and hyperechogenicity of the ejaculatory duct.
FIGURE 2. directed left the seminal obstruction the prostate
Percutaneous transrectal ultrasonographic seminal vesiculography reveals dilation of vesicle and ampullary vas deferens with of the ejaculatory duct (arrow) outside of gland.
and guide wire tip were manipulated until the catheter was directed toward the ejaculatory duct. A 0.035inch heavy-duty straight guide wire was used to advance the catheter through the occluded ejaculatory duct. The guide wire passed through 744
FIGURE 3. Radiographic image of the balloon dilation catheter inflated within the left ejaculatory duct and simultaneous cystoscopic imaging of catheter placement.
the ejaculatory duct into the urethra, where it was then retrieved with a urethroscope. The guide wire was seen to exit the recanalized ejaculatory duct in its normal position on the verumontanum. The urethroscope and guide wire tip were then withdrawn through the urethra. The angiographic guide wire ends were now simultaneously accessible both transurethrally and transrectally. A 4-mm diameter angiographic balloon dilation catheter was then advanced in a retrograde direction through the urethra over the guide wire. Simultaneous observation through the urethroscope and fluoroscopy confirmed proper positioning of the balloon catheter just inside the urethral orifice of the ejaculatory duct. The balloon was then maximally inflated two times to assure adequate dilation of the ejaculatory duct (Fig. 3). The balloon dilation catheter was then removed, and the angiographic catheter was reinserted transrectally into the left seminal vesicle. A repeat seminal vesiculogram was performed after removal of the guide wire by injecting saline through the catheter and observing the ejaculatory duct orifice under direct vision with the urethroscope. This resulted in demonstrable antegrade flow of fluid exiting the left ejaculatory duct. For further confirmation, the left ejaculatory duct was now easily catheterized using a straight 5F catheter and guide wire in a retrograde direction from the urethroscope. The transrectal ultrasound probe and the urethroscope were then removed and a urethral catheter was placed. The patient noted full resolution of the pelvic pain postoperatively COMMENT Ejaculatory duct obstruction is a relatively new and infrequent diagnosis. The traditional method UROLOGY’
46 61, 19%
of diagnosis was vasography, which is an invasive study and not often performed without specific indications.’ Transrectal ultrasonography is a noninvasive alternative to vasography and provides excellent imaging of the seminal vesicles, ampullary vas deferens, and prostate.7 The availability of a noninvasive diagnostic modality has led to more frequent testing of symptomatic patients, which has resulted in a higher detection rate of ejaculatory duct abnormalities. Complete bilateral ejaculatory duct obstruction results in azoospermia and patients with this disorder usually present with infertility. Diagnostic criteria include low ejaculate volume azoospermia, dilated seminal vesicles on transrectal ultrasonography, and presence of numerous sperm within seminal vesicle aspirate. l1 Partial ejaculatory duct obstruction is more difficult to diagnose, since semen analysis and transrectal ultrasonographic findings are often nonspecific.5Jj,8 Findings suggestive of the diagnosis of partial ejaculatory duct obstruction include low ejaculate volume, reduced sperm count and motility, and sonographic images demonstrating dilated seminal vesicles or ejaculatory ducts. Abnormalities of the ejaculatory ducts and seminal vesicles may also cause hematospermia and pain.1,2,4 Transrectal ultrasonographic findings include evidence of ejaculatory duct obstruction and cystic lesions within the prostate, such as mullerian duct cysts.1,7 The potential etiologies of ejaculatory duct obstruction include infection, traumatic injury (iatrogenie), prostate cysts, and idiopathic. Regardless of the etiology of ejaculatory duct obstruction, the treatment is the same. The traditional treatment of ejaculatory duct obstruction is TURED. This is a relatively rare lesion, and reports of the management of ejaculatory duct obstruction are limited to case reports like this one and a few small series.3,5,9,12,14 There are several potentially serious complications associated with TURED, including damage to the urinary sphincters resulting in urinary incontinence or retrograde ejaculation. In addition, resection of the ejaculatory ducts may extend too far posteriorly and injure the rectum with potential fistula formation. Fortunately, these complications rarely occur, and transurethral resection has been reported to be a very successful treatment modality for patients with ejaculatory duct obstruction. However, resection of the ejaculatory duct urethral orifice destroys the normal flap valve mechanism, which prevents reflux of urine into the male genital system. Therefore, urine contamination of the semen is a frequent complication of TURED.15;16 The urine reduces a patient’s fertility potential and may pose a risk for future infection, such as epididymitis. uRoLoGYa
46 (5), 1995
Balloon dilation is an alternative treatment modality to surgical resection of the ejaculatory ducts. Attempts at transurethral catheterization of the ejaculatory ducts have been thwarted by difficulty in locating the urethral orifice of the ejaculatory duct. This is especially difficult in a patient with ejaculatory duct obstruction and distortion of normal anatomy We have previously been able to catheterize the ejaculatory duct transurethrally after partial resection of the ejaculatory ducts and then perform balloon dilation. However, it frequently appeared that the “partial” resection removed the site of obstruction, and this method does not preserve the normal ejaculatory duct orifice anatomy. The antegrade approach through the seminal vesicles has the advantage of preserving ejaculatory duct orifice anatomy while being technically easier to perform. Patients with complete obstruction have significant dilation of the seminal vesicles, which makes manipulation of the catheters within the seminal vesicle easier. In contrast, the catheter passes through the ejaculatory duct more easily in patients who have partial ejaculatory duct obstruction despite the limited area in which to manipulate the catheter in the smaller seminal vesicles. This technique of antegrade recanalization of the ejaculatory ducts combined with retrograde balloon dilation under direct vision preserves normal ejaculatory duct anatomy while avoiding the other more serious potential complications associated with TURED. The patient described in this report experienced symptomatic relief without complication, and a follow-up semen analysis did not reveal any urine contamination of the semen. Further study is needed to determine the long-term success of this new technique. REFERENCES 1. Littrup PJ, Lee F, McLeary RD, Wu D, Lee A, and Kumasaka GH: Transrectal US of the seminal vesicles and ejaculatory ducts: clinical correlation. Radiology 168: 625-628, 1988. 2. Papp G, and Molnar J: Causes and differential diagnosis of hematospermia. Andrologia 13: 474-478, 1981. 3. Pryor JP, and Hendry WF: Ejaculatory duct obstruction in subfertile males: analysis of 87 patients. Fertil Steril 56: 72%730,1991. 4. Worischeck JH, and Parra RO: Chronic hematospermia: assessment by transrectal ultrasound. Urology 43: 515-520, 1994. 5. Meacham RB, Hellerstein DK, and Lipshultz LI: Evaluation and treatment of ejaculatory duct obstruction in the infertile male. Fertil Steril 59: 393-397, 1993. 6. Jarow JP: Transrectal ultrasonography of infertile men. Fertil Steril 60: 1035-1039, 1993. 7. Kuligowska E, Baker CE, and Oates RD: Male infertility: role of transrectal US in diagnosis and management. Radiology 185: 353-360, 1992. 8. Hellerstein DK, Meacham RB, and Lipshultz LI: Transrectal ultrasound and partial ejaculatory duct obstruction in male infertility. Urology 39: 449-452, 1992. 745
9. Belker AM, and Steinbock GS: Transrectal prostate ultrasonography as a diagnostic and therapeutic aid for ejaculatory duct obstruction. J Urol 144: 356-358, 1990. 10. Ford K, Carson CC 3d, Dunnick NR, Osborne D, and Paulson DF: The role of seminal vesiculography in the evaluation of male infertility. Fertil Steril 37: 552-556, 1982. 11. Jarow JP: Seminal vesicle aspiration in the management of patients with ejaculatory duct obstruction. J Urol 152: 899-901, 1994. 12. Silber SJ: Ejaculatory duct obstruction. J Urol 124: 294-297, 1980.
746
13. Vicente J, de1 Portillo L, and Pomerol MM: Endoscopic surgery in distal obstruction of the ejaculatory ducts. Eur Uro19: 338-340, 1983. 14. Carson CC: Transurethral resection for ejaculatory duct stenosis and oligospermia. Fertil Steril41: 482-484, 1984. 15. Vazquez-Levin MH, Dressler KP, and Nagler HM: Urine contamination of seminal fluid after transurethral resection of the ejaculatory ducts. J Urol 152: 2049-2052, 1994. 16. Goluboff ET, Kaplan SA, and Fisch H: Seminal vesicle urinary reflux as a complication of transurethral resection of ejaculatory ducts. J Urol 153: 1234-1235, 1995.
uROLcGY@ 46 (51, 1995