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Modified resectoscope loop for transurethral resection of the ejaculatory duct
SURGEON'S WORKSHOP
MODIFIED RESECTOSCOPE LOOP FOR TRANSURETHRAL RESECTION OF THE EJACULATORY DUCT EDMUND SABANEGH, JR., M.D. ANTHONY THOMAS, JR., M.D. From the Department of Urology, Cleveland Clinic Foundation, Cleveland, Ohio
ABSTRACT--We report the design of a modified resectoscope loop for transurethral resection of the ejaculatory ducts. The loop is a modification of a standard 24 F resectoscope loop. Cutting dimensions are 2.5 mm in width and 3 mm in depth for the modified loop versus 6 mm in width and 5 mm in depth for the conventional loop. This modification allows precise resection of obstructed ejaculatory ducts with minimal trauma to the prostatic fossa, reducing the potential for troublesome bleeding.
Transurethrai"resection has become popular for the treatment of partial and complete obstruction of the ejaculatory ducts since first described by Farley and Barnes i more than 20 years ago. The endoscopic technique involves resection of the floor of the prostate, immediately lateral to or including the verumontanum, to open the ejaculator/ducts. 2-4 Despite advances in endoscopic instrumentation, most urologists use the standard resection loop as was originally described for the procedure. This loop was designed for resection of a bulk of tissue, such as for hypertrophic prostate tissue or bladder tumors. It is not well suited for the more precise and delicate resection required to open the ejaculatory ducts, In addition, the width of the loop allows inad;eertent lateral lobe resection, which can contribute to troublesome postoperative bleedingJ We report the design of a modified resection loop that has proven both efficient and safe for transurethral resection of the obstructed ejaculator/ ducts.
depth for the modified loop versus 6 m m in width and 5 m m in depth for the conventional loop. Our technique for treatment of ejaculator/duct obstruction is as follows. With the patient in a dorsal lithotomy position, a vasogram is performed by isolating a portion of the straight vas and cannulating it with a 30 gauge lymphangiogram needle. A mixture of injectable saline and radiographic contrast (1:1 ratio) with a small amount of indigo carmine is injected into the vas. The diagnosis of ejaculator/duct obstruction is confirmed and the modified resectoscope loop is used to resect a strip •of tissue on the floor of the prostate, just proximal to and including a portion of the verumontanum
TECHNIQUE The loop is a modification of the standard 24 F resectoscope loop (Karl Storz Company, Germany). The design minimizes lateral lobe resection while allowing a precise depth and width of tissue to be taken from the floor of the prostate (Fig. 1).- Its measured depth prevents resecting too deeply. Cutting dimensions are 2.5 m m in width and 3 m m in Configuration of the standard (left) versus the modified (right) 24 F resectoscope loop.
FIGURE 1.
Subrnitted: June 28, 1994, accepted:July 28, 1994
UROLOGY ~ / DECEMBER1994 / VOLUME44, NUMBER6
909
t
5rnm
FIGURE 2.
Resection technique of standard (upper) versus modified (lower) loop.
(Fig. 2). Resection of the entire v e r u m o n t a n u m is not necessary, as it destroys a helpful l a n d m a r k for any subsequent endoscopic procedures, should they be necessary. Only cutting current is utilized to minimize the potential for scarring of the opened ducts, w h i c h m a y o c c u r after excessive use of cautery. Generally; one or two cuts on each side are sufficient to open the ducts and allow free efflux of the indigo carmine mixture to be seen. An 18 F Foley catheter is left in place after the procedure and removed the following morning. COMMENT The modified resection loop is uniquely suited for transurethral resection of the ejaculatory duct. The more narrow lateral excursion of the loop allows for precise resection with minimal trauma to the prostatic fossa, reducing the potential for troublesome bleeding. Using this modified technique, we are
91 0
able to relieve ejaculatory duct obstruction w i t h o u t significant morbidity. Anthony Thomas, Jr., M.D. Department of Urology, A 100 The Cleveland Clinic Foundation 9500 Euclid Avenue: Cleveland, Ohio 44195
REFERENCES 1. Farley S, and Barnes R: Stenosis of ejaculatory ducts: treated by endoscopic resection. J Urol 109: 664-666, 1973. 2. Weintraub ME De Mouy E, and Hellstrom WJ: Newer modalities in the diagnosis and treatment of ejaculatory duct obstruction. J Urol 150:1150-1154, 1993. 3. Vicente J, de1 Portillo L, and Pomerol M: Endoscopic surgery in distal obstruction of the ejaculatory ducts. Eur Urol 9: 338-340, 1983. 4. Meacham RB, Hellerstein DK, and Lipshultz LI: Evalu' ation and treatment of ejaculatory duct obstruction in the infertile male. Fertil Steril 59: 393-397, 1993.
UROLOGY~ / DECeMBeR1994 I VOLUM~44, NUkIBER6
MODIFIED RESECTOSCOPE LOOP FOR TRANSURETHRAL RESECTION OF THE EJACULATORY DUCT EDMUND SABANEGH, JR., M.D. ANTHONY THOMAS, JR., M.D. From the Department of Urology, Cleveland Clinic Foundation, Cleveland, Ohio
ABSTRACT--We report the design of a modified resectoscope loop for transurethral resection of the ejaculatory ducts. The loop is a modification of a standard 24 F resectoscope loop. Cutting dimensions are 2.5 mm in width and 3 mm in depth for the modified loop versus 6 mm in width and 5 mm in depth for the conventional loop. This modification allows precise resection of obstructed ejaculatory ducts with minimal trauma to the prostatic fossa, reducing the potential for troublesome bleeding.
Transurethrai"resection has become popular for the treatment of partial and complete obstruction of the ejaculatory ducts since first described by Farley and Barnes i more than 20 years ago. The endoscopic technique involves resection of the floor of the prostate, immediately lateral to or including the verumontanum, to open the ejaculator/ducts. 2-4 Despite advances in endoscopic instrumentation, most urologists use the standard resection loop as was originally described for the procedure. This loop was designed for resection of a bulk of tissue, such as for hypertrophic prostate tissue or bladder tumors. It is not well suited for the more precise and delicate resection required to open the ejaculatory ducts, In addition, the width of the loop allows inad;eertent lateral lobe resection, which can contribute to troublesome postoperative bleedingJ We report the design of a modified resection loop that has proven both efficient and safe for transurethral resection of the obstructed ejaculator/ ducts.
depth for the modified loop versus 6 m m in width and 5 m m in depth for the conventional loop. Our technique for treatment of ejaculator/duct obstruction is as follows. With the patient in a dorsal lithotomy position, a vasogram is performed by isolating a portion of the straight vas and cannulating it with a 30 gauge lymphangiogram needle. A mixture of injectable saline and radiographic contrast (1:1 ratio) with a small amount of indigo carmine is injected into the vas. The diagnosis of ejaculator/duct obstruction is confirmed and the modified resectoscope loop is used to resect a strip •of tissue on the floor of the prostate, just proximal to and including a portion of the verumontanum
TECHNIQUE The loop is a modification of the standard 24 F resectoscope loop (Karl Storz Company, Germany). The design minimizes lateral lobe resection while allowing a precise depth and width of tissue to be taken from the floor of the prostate (Fig. 1).- Its measured depth prevents resecting too deeply. Cutting dimensions are 2.5 m m in width and 3 m m in Configuration of the standard (left) versus the modified (right) 24 F resectoscope loop.
FIGURE 1.
Subrnitted: June 28, 1994, accepted:July 28, 1994
UROLOGY ~ / DECEMBER1994 / VOLUME44, NUMBER6
909
t
5rnm
FIGURE 2.
Resection technique of standard (upper) versus modified (lower) loop.
(Fig. 2). Resection of the entire v e r u m o n t a n u m is not necessary, as it destroys a helpful l a n d m a r k for any subsequent endoscopic procedures, should they be necessary. Only cutting current is utilized to minimize the potential for scarring of the opened ducts, w h i c h m a y o c c u r after excessive use of cautery. Generally; one or two cuts on each side are sufficient to open the ducts and allow free efflux of the indigo carmine mixture to be seen. An 18 F Foley catheter is left in place after the procedure and removed the following morning. COMMENT The modified resection loop is uniquely suited for transurethral resection of the ejaculatory duct. The more narrow lateral excursion of the loop allows for precise resection with minimal trauma to the prostatic fossa, reducing the potential for troublesome bleeding. Using this modified technique, we are
91 0
able to relieve ejaculatory duct obstruction w i t h o u t significant morbidity. Anthony Thomas, Jr., M.D. Department of Urology, A 100 The Cleveland Clinic Foundation 9500 Euclid Avenue: Cleveland, Ohio 44195
REFERENCES 1. Farley S, and Barnes R: Stenosis of ejaculatory ducts: treated by endoscopic resection. J Urol 109: 664-666, 1973. 2. Weintraub ME De Mouy E, and Hellstrom WJ: Newer modalities in the diagnosis and treatment of ejaculatory duct obstruction. J Urol 150:1150-1154, 1993. 3. Vicente J, de1 Portillo L, and Pomerol M: Endoscopic surgery in distal obstruction of the ejaculatory ducts. Eur Urol 9: 338-340, 1983. 4. Meacham RB, Hellerstein DK, and Lipshultz LI: Evalu' ation and treatment of ejaculatory duct obstruction in the infertile male. Fertil Steril 59: 393-397, 1993.
UROLOGY~ / DECeMBeR1994 I VOLUM~44, NUkIBER6