- Email: [email protected]
V3-11 SURGICAL MANAGEMENT OF EJACULATORY DUCT OBSTRUCTION DUE TO PROSTATIC UTRICULAR CYST
e470
THE JOURNAL OF UROLOGYâ
Vol. 195, No. 4S, Supplement, Saturday, May 7, 2016
V3-11
V3-12
SURGICAL MANAGEMENT OF EJACULATORY DUCT OBSTRUCTION DUE TO PROSTATIC UTRICULAR CYST
REAL-TIME MRI ASSESSMENT OF AGE-RELATED VOIDING FUNCTION AND URETHRAL FORM
Phil Bach*, Filipe Tenorio Lira Neto, New York, NY; Ryan Chuang, Los Angeles, CA; Bobby Najari, Richard Lee, Philip Li, Marc Goldstein, New York, NY
Toshiyuki Iwahata*, Shigehiro Soh, Keisuke Suzuki, Tomohiro Kobayashi, Shin Takeshi, Yoshitomo Kobori, Hiroshi Okada, Koshigaya, Japan
INTRODUCTION AND OBJECTIVES: Azoospermia is present in 10-15% of infertile men and can be divided into two broad categories: obstructive azoospermia (OA) and non-obstructive azoospermia. OA accounts for approximately 40% of azoospermia cases and can be caused by a blockage anywhere along the male reproductive tract. 5% of OA cases are secondary to ejaculatory duct obstruction, which may be caused by a variety of congenital or acquired etiologies. The mainstay of management for ejaculatory duct obstruction is transurethral resection of the ejaculatory ducts (TURED). We present the case and surgical management of a man with primary infertility secondary to ejaculatory duct obstruction caused by a prostatic utricular cyst. METHODS: A 38 year old man with primary infertility presented with low semen volume, severe oligospermia and highly elevated sperm DNA fragmentation. He had an unremarkable physical exam, normal hormone levels, and a midline utricular cyst on both transrectal ultrasound and MRI, suggestive of ejaculatory duct obstruction. In the operating room, we successfully retrieved abundant highly motile sperm from both testes and vasa deferens. Next, to assess patency, we injected indigo carmine into the right vasotomy site and noted the dye coming out of the left vasotomy site, suggesting that both vasa deferens emptied into a common, obstructed cavity. A vasogram with water soluble contrast subsequently revealed bilaterally patent vasa deferens emptying into an obstructing midline utricular cyst. A TURED was carefully performed using a 24-Fr resectoscope while indigo carmine was instilled into both vasa deferens. Once inside the cyst, both ejaculatory ducts were visualized and a number of small stones were flushed out. A Foley catheter was placed for 24 hours and the patient instructed to ejaculate frequently to maintain patency of the freshly resected cyst. RESULTS: Following the resection, indigo carmine could be seen flowing freely from a widely patent outflow tract. The patient tolerated the procedure well and was discharged home without complications. The sperm retrieved from the testes and vasa deferens had significantly lower DNA fragmentation than the ejaculated sperm and is currently being used for in vitro fertilization. Results from a follow-up semen analysis are pending. CONCLUSIONS: While uncommon, ejaculatory duct obstruction due to midline utricular cyst is highly amenable to surgical management with TURED. Source of Funding: This project was supported by The Frederick J. and Theresa Dow Wallace Fund of the New York Community Trust. This project was also supported by grant number T32HS00066 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.
INTRODUCTION AND OBJECTIVES: Boys and elder males often present with lower urinary tract symptoms (LUTS). LUTS is usually caused by neurological disorders or smooth muscle dysfunction but can result from abnormal urethral anatomy. In males, voiding may be altered by the morphological characteristics of the urethra, and boys and elder men with LUTS sometimes have imaging findings showing urethral obstruction and high-pressure bladder. The present study used real-time magnetic resonance imaging (rtMRI) to investigate the morphological characteristics and dynamic motion of the bladder and urethra. Using intergenerational imaging data, we evaluated the relationship between voiding function and urethral anatomy throughout life in males. METHODS: This study enrolled 15 males: 4 school-aged boys and 4 pubescent males with nocturnal enuresis or daytime incontinence, 3 healthy young men (control), and 4 elder men. All patients underwent rtMRI during micturition while in a lateral position on an MRI table. Dynamic images were used to measure and evaluate urethral anatomy, length of the prostatic urethra, and the angles of the urethra and posterior bladder base. RESULTS: Prepubescent males with LUTS had kinking and defects of the urethra; the young men (control) had no kinking. At puberty, the urethra was straight or exhibited mild kinking. There was less movement of the bladder neck and urethra in the elder men than in the younger men (Fig. 1). Movement of the lower urinary tract was inversely associated with age. CONCLUSIONS: In children with an undeveloped prostate, the structure of the urethra is more fragile than in adults. This is likely a characteristic of urethral morphology in children. During development of secondary sex characteristics, urethral maturation in the prostate increases urethral resistance, and kinking of the posterior urethra may resolve spontaneously. Limitations in bladder neck and urethra movement in males appear to be strongly associated with age and voiding function.
Source of Funding: None
THE JOURNAL OF UROLOGYâ
Vol. 195, No. 4S, Supplement, Saturday, May 7, 2016
V3-11
V3-12
SURGICAL MANAGEMENT OF EJACULATORY DUCT OBSTRUCTION DUE TO PROSTATIC UTRICULAR CYST
REAL-TIME MRI ASSESSMENT OF AGE-RELATED VOIDING FUNCTION AND URETHRAL FORM
Phil Bach*, Filipe Tenorio Lira Neto, New York, NY; Ryan Chuang, Los Angeles, CA; Bobby Najari, Richard Lee, Philip Li, Marc Goldstein, New York, NY
Toshiyuki Iwahata*, Shigehiro Soh, Keisuke Suzuki, Tomohiro Kobayashi, Shin Takeshi, Yoshitomo Kobori, Hiroshi Okada, Koshigaya, Japan
INTRODUCTION AND OBJECTIVES: Azoospermia is present in 10-15% of infertile men and can be divided into two broad categories: obstructive azoospermia (OA) and non-obstructive azoospermia. OA accounts for approximately 40% of azoospermia cases and can be caused by a blockage anywhere along the male reproductive tract. 5% of OA cases are secondary to ejaculatory duct obstruction, which may be caused by a variety of congenital or acquired etiologies. The mainstay of management for ejaculatory duct obstruction is transurethral resection of the ejaculatory ducts (TURED). We present the case and surgical management of a man with primary infertility secondary to ejaculatory duct obstruction caused by a prostatic utricular cyst. METHODS: A 38 year old man with primary infertility presented with low semen volume, severe oligospermia and highly elevated sperm DNA fragmentation. He had an unremarkable physical exam, normal hormone levels, and a midline utricular cyst on both transrectal ultrasound and MRI, suggestive of ejaculatory duct obstruction. In the operating room, we successfully retrieved abundant highly motile sperm from both testes and vasa deferens. Next, to assess patency, we injected indigo carmine into the right vasotomy site and noted the dye coming out of the left vasotomy site, suggesting that both vasa deferens emptied into a common, obstructed cavity. A vasogram with water soluble contrast subsequently revealed bilaterally patent vasa deferens emptying into an obstructing midline utricular cyst. A TURED was carefully performed using a 24-Fr resectoscope while indigo carmine was instilled into both vasa deferens. Once inside the cyst, both ejaculatory ducts were visualized and a number of small stones were flushed out. A Foley catheter was placed for 24 hours and the patient instructed to ejaculate frequently to maintain patency of the freshly resected cyst. RESULTS: Following the resection, indigo carmine could be seen flowing freely from a widely patent outflow tract. The patient tolerated the procedure well and was discharged home without complications. The sperm retrieved from the testes and vasa deferens had significantly lower DNA fragmentation than the ejaculated sperm and is currently being used for in vitro fertilization. Results from a follow-up semen analysis are pending. CONCLUSIONS: While uncommon, ejaculatory duct obstruction due to midline utricular cyst is highly amenable to surgical management with TURED. Source of Funding: This project was supported by The Frederick J. and Theresa Dow Wallace Fund of the New York Community Trust. This project was also supported by grant number T32HS00066 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.
INTRODUCTION AND OBJECTIVES: Boys and elder males often present with lower urinary tract symptoms (LUTS). LUTS is usually caused by neurological disorders or smooth muscle dysfunction but can result from abnormal urethral anatomy. In males, voiding may be altered by the morphological characteristics of the urethra, and boys and elder men with LUTS sometimes have imaging findings showing urethral obstruction and high-pressure bladder. The present study used real-time magnetic resonance imaging (rtMRI) to investigate the morphological characteristics and dynamic motion of the bladder and urethra. Using intergenerational imaging data, we evaluated the relationship between voiding function and urethral anatomy throughout life in males. METHODS: This study enrolled 15 males: 4 school-aged boys and 4 pubescent males with nocturnal enuresis or daytime incontinence, 3 healthy young men (control), and 4 elder men. All patients underwent rtMRI during micturition while in a lateral position on an MRI table. Dynamic images were used to measure and evaluate urethral anatomy, length of the prostatic urethra, and the angles of the urethra and posterior bladder base. RESULTS: Prepubescent males with LUTS had kinking and defects of the urethra; the young men (control) had no kinking. At puberty, the urethra was straight or exhibited mild kinking. There was less movement of the bladder neck and urethra in the elder men than in the younger men (Fig. 1). Movement of the lower urinary tract was inversely associated with age. CONCLUSIONS: In children with an undeveloped prostate, the structure of the urethra is more fragile than in adults. This is likely a characteristic of urethral morphology in children. During development of secondary sex characteristics, urethral maturation in the prostate increases urethral resistance, and kinking of the posterior urethra may resolve spontaneously. Limitations in bladder neck and urethra movement in males appear to be strongly associated with age and voiding function.
Source of Funding: None