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Transurethral seminal vesiculoscopy for recurrent hemospermia



Disorders of the seminal tract, such as recurrent hemospermia, seminal vesiculitis, and stones, may lead to dysfunction of the reproductive system and cause great psychological burden. However, the traditional management for these diseases is obscure and often invasive. Transrectal ultrasound examination[1] and magnetic resonance imaging (MRI)[2] are not accurate since the majority of patients do not present obvious imaging changes at an early stage and neither of them would provide information of the possible cause of hemospermia. Other methods of examination, such as vasovesiculography, are invasive and may have negative side effects.To get more news about Seminal vesiculitis cause hemospermia, you can visit our official website.

With advances in endoscopic technology, Yang et al.[4] introduced in vivo transurethral seminal vesiculoscopy (TSV) in 2002. Since then, urologists and andrologists have explored the application of TSV as a diagnostic[5] and treatment tool for seminal tract stones,[6] recurrent hemospermia,[5] and ejaculatory duct obstructions.[7] However, the safety of this procedure is yet to be validated because the anatomic and histological structure of the ejaculatory duct is poorly understood. In addition, detailed procedures for this surgery have not been clearly illustrated, particularly with regard to gaining access to the ejaculatory duct. More details of this procedure remain unexplored (e.g., the relative location of the ejaculatory duct orifice and the verumontanum, the safety of establishing the surgical path, and the appropriate surgical instruments).

Here, we summarize our experience from 419 TSV cases by illustrating detailed surgical techniques, treatment outcomes, and intraoperative findings, with a discussion on the safety and rationale of this procedure, key steps for this surgery, and the relative location of the ejaculatory duct orifice and verumontanum.
TSV was performed in 419 patients with an initial diagnosis of persistent hemospermia at Shanghai Changhai Hospital (Shanghai, China). This study was approved by the institutional review board of Shanghai Changhai Hospital. Informed consents were obtained from all patients before administering the treatment.

The indications for each disease have been described previously.[5] Briefly, all patients with hemospermia were treated with oral antibiotics for a minimum of 4 weeks before the surgery. All patients were psychologically influenced by persistent or recurrent hemospermia and had a strong wish for surgical intervention. Important preoperative counseling included the duration of hemospermia, the color of hemospermia, pain with ejaculation, hematuria, reproductive history, and PSA level. We also focused on identifying that the blood was in the sperm rather than from the urine or from the bleeding of the urethra. Routine urogenital clinical examinations were performed in all cases, including digital rectal examination (DRE), to rule out the possibility of advanced prostate cancer. Routine urine and blood tests were performed. None of these patients were with concurrent hematuria or bladder cancer (ruled out during the operation by examination of the bladder). PSA test was done for all patients. If the PSA level is higher than 4 ng ml−1, another PSA test was prescribed for the patients and a prostate biopsy is considered. No prostate cancer patient was detected. All patients received at least one kind of imaging examination, including transrectal ultrasound, pelvic computed tomography, and MRI, before and after the surgery. We performed these examinations to have better information about the anatomy and lesions of the seminal vesicle or the ejaculatory duct, such as the dilation of the ejaculatory duct, stones and blood clot in the seminal tract, and to rule out the possibility of prostate cancer and malignancy of the seminal vesicle. Among these examinations, MRI is the most informative one and previous studies have illustrated imaging findings of seminal tract disorders.
All procedures were performed with the patients in a lithotomy position with laryngeal mask general anesthesia or spinal anesthesia. The endoscopic procedure was performed through the normal anatomic path of the distal seminal tracts with a 7-F rigid vesiculoscope in the initial 154 cases, and a 5-F or 6-F rigid vesiculoscope in later cases [Supplementary Figure 1 [Additional file 1]]. The TSV procedure is illustrated in [Figure 1]. First, the vesiculoscope was inserted into the urethra and a careful search for the ejaculatory duct orifice was performed on the outside wall of the verumontanum. Second, the vesiculoscope was inserted to access the ejaculatory duct. There are two ways to enter the ejaculatory duct depending on the endoscopic presentation [Figure 2]. In some patients, the orifice of the ejaculatory duct was observed from the urethra, and then the vesiculoscope was inserted directly into the ejaculatory duct (Type A), whereas in other patients, when the ejaculatory duct orifice could not be identified on the surface of the verumontanum (Types B, C, and D), a surgical path was established. In Type B patients, the ejaculatory duct and the verumontanum were only separated by a thin layer of white membrane-like tissue, and a “Zebra guidewire” (Straight Tip, black/white PTFE-coated Jacket guidewire, ST-32150, Urovision, Oberbayern, Germany) could be used to establish the surgical path from the verumontanum to the ejaculatory duct. However, in Type C patients, the membrane-like tissue was not identifiable at the first sight; tentative punctures using the guidewire on the suspected spot on the inner wall of the verumontanum were applied. The course of the ejaculatory duct is just beneath the inner wall of verumontanum, approximately 45° from the central line on the sagittal plane. However, the surgical path could not be established in some cases, leading to the failure of the procedure (Type D). Third, the vesiculoscope was inserted into the seminal vesicle. Close observation and treatments were performed according to endoscopic findings. A typical manifestation of the seminal vesicle was honeycomb-like tissues, and the surgeon needed to go through every small cavity in the seminal vesicles. In cases of stenosis of the ejaculatory duct orifice, holmium (Ho:YAG) or thulium fiber laser was applied to expand the surgical path. Typically, blood mixed with seminal plasma fluid could be identified in hemospermia patients. Continuous saline irrigation with a 50-ml syringe was applied to clear out the seminal plasma fluid, blood, and small calculi. Grasping forceps were applied for larger calculi. In cases with hemorrhagic spots, a low-power holmium fiber laser was applied for hemostasis. The catheter was placed after surgery and removed on the 2nd day.

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