Final roentgenograms were performed to check for epididymal blowouts. A urethral catheter was left in place for 24 h. Patients were discharged the next day.
During injection, the catheter had a tendency to be pulled back and out of the ejaculatory duct orifice. It was important to manually maintain the catheter steady in place. Occasionally, the contrast would proceed into the seminal vesicle rather than into the vas deferens. In such a case, the catheter was withdrawn for a short distance and reinserted, with a finger in the rectum gently compressing the seminal vesicle (now full of contrast medium and palpable) against the prostate.
Transurethral retrograde vasography was performed and showed full patency of the vas deferens in two cases and inguinal obstruction in one.
The procedure was difficult in one case requiring a meticulous search for the orifices and this prolonged operative time. It was, however, straightforward in the other two cases with an average operative time of 30 min.
Final roentgenograms showed neither epididymal blowouts nor extravasation. For all patients, the postoperative period was uneventful.
No complications issued from the procedure, apart from hematuria in one patient. The condition was controlled by pulling on the urethral catheter for an additional 24 h.
Animal studies showed that vasography has a measurable adverse effect on vasal flow rates and therefore on fertility. This applies to both the direct puncture method and the partial thickness vasostomy, although the former compromises patency to a lesser extent. Pressure-flow studies of the vas deferens showed partial or complete stricture formation, despite the absence of significant histological changes. This effect (structure formation) was of a progressive nature .
There is less concern about stricture formation after vasography in a patient undergoing vasovasostomy or epididymovasostomy, as the manipulated site is often used for the anastomosis. In contrast, a patient with obstruction at the inguinal vas deferens or ejaculatory duct may suffer significantly if stricture occurs at the vasography site .
Stricture formation with subsequent obstruction as a result of vasography is possibly due to ischemia of the involved segment or due to an inflammatory reaction in response to extravasation of sperm and/or contrast medium .
Moreover, vasography is performed in an antegrade direction where the puncture point is in the scrotal portion of the vas deferens and the contrast medium is injected upward toward the ejaculatory ducts. This gives no information about patency of the caudal seminal track, the lower vas deferens, and the epididymis, possibly leading to missing a common site of obstruction . This, in addition to the possibility of iatrogenic obstruction at the puncture site, is the downside inherent in vasography.
In contrast, transurethral retrograde vasography overcomes the problem of iatrogenic obstruction, notorious in classic vasography, by injecting the contrast medium through the ejaculatory duct orifice (a natural orifice) rather than through the wall of the vas deferens, sparing the vas deferens from unnecessary puncture or incision.
In addition, transurethral retrograde vasography evaluates patency of the whole seminal track down to the epididymis. Retrograde injection enables epididymography, in contrast to the alternatives that miss the lowermost parts of the seminal track .
Exposure and cannulation of the ejaculatory duct orifice may require resection of a chip of the overlying tissue in some cases. In patient candidates for trans-urethral resection of the ejaculatory ducts (TURED), this poses no problem. Otherwise, in non-TURED candidates requiring resection, it is yet to be known whether this resection, if needed, will compromise fertility in any way, bearing in mind that resection increases the caliber of the ejaculatory duct orifice, thereby potentially increasing patency. However, it should be mentioned that minor complications, including sporadic cases of epididymitis because of urine reflux, have rarely been associated with TURED . As stated earlier, none of our cases suffered epididymitis or orchitis. This is consistent with most available reports on TURED.
Retrograde injection and epididymography did not result in epididymal blowouts because of the adoption of passive spontaneous flow after the initial bolus injection, the adoption of visual monitoring by fluoroscopy that allowed stopping injection once the tail of the epididymis was reached, and because of the antegrade regurge of the contrast medium around the catheter and into the bladder, allowing decompression of the injection system. Absence of blowouts was confirmed by the final roentgenograms that showed no extravasation.
The virtue of transurethral retrograde vasography over traditional methods for testing patency of the vas deferens becomes apparent in the case scenarios of unsuspected ejaculatory duct obstruction, inguinal obstruction, and obstruction of the vasa efferentia (pre-epididymal obstruction), where the vas deferens suffers the consequences of puncturing or incision that complicate obstruction further, leaving behind a stricture after resolution of the identified site of obstruction. This can be avoided by transurethral retrograde vasography.
The transurethral approach to the seminal track, and the initial trial of balloon dilatation reported upon in this study, paves the way for future scalpel-free intervention, whereby a stricture can be dilated and stented, and fibrinolytic agents injected to resolve obstruction of the vas deferens.
Transurethral retrograde vasography tests the patency of the whole length of the seminal track from the ejaculatory duct orifice down to the epididymis, without jeopardizing the vas deferens and without the risk of stricture formation, inherent to classic vasography, especially in patient candidates for transurethral resection of the ejaculatory ducts. Although we believe that the procedure can be of benefit for non-TURED candidates as well, this cannot be confirmed by this case series. The transurethral retrograde approach to the seminal track opens the door for scalpel-free dilatation and stenting of obstruction along the vas deferens.
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balloon dilatation; transurethral; urethroscope; vas deferens; vasography