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Transurethral retrograde vasography

Shaeer, Osamaa; Shaeer, Kamala; El-Assemy, Ahmadb

doi: 10.1097/01.XHA.0000397086.31318.d3
Original articles
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Purpose Vasography entails canulation of the vas deferens, possibly leading to stricture formation. It does not provide information about the lowermost part of the vas deferens and the epididymis, being performed in an antegrade direction. ‘Transurethral retrograde vasography’ is an alternative to classic vasography, designed to test the whole seminal track down to the epididymis in a retrograde fashion, without puncturing or opening the vas deferens. This is the first report of the technique.

Patients and methods Transurethral retrograde vasography was performed in three infertile male patients with obstructive azoospermia after obtaining a written informed consent.

Interventions A ureteric catheter was introduced into the orifice of the ejaculatory duct. Contrast medium was injected into the vas deferens and monitored by fluoroscopy down to the epididymis or to the site of obstruction. The technique for surgical correction was determined accordingly and carried out in the same setting.

Results Patency of the seminal track was successfully evaluated in all patients, without jeopardizing the vas deferens and without complications.

Conclusion Transurethral retrograde vasography tests the patency of the whole length of the seminal track from the ejaculatory duct orifice down to the epididymis, without the risk of stricture formation in the vas deferens, a risk inherent to classic vasography, especially in patients who are candidates for transurethral resection of the ejaculatory ducts. It also opens the door for scalpel-free dilatation and stenting of vas deferens strictures.

aDepartment of Andrology, Faculty of Medicine, Cairo University, Cairo

bUrology and Nephrology Center, Mansoura University, Egypt

Correspondence to Osama Shaeer, 21 Gaber Ibn Hayan Street, Dokki, Giza, Egypt Tel: +202-33359047/+202-33374360; fax: +202-37605181; e-mail: Dr.osama@alrijal.com

Received December 22, 2010

Accepted February 13, 2011

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Introduction

One of the cornerstones of successful restoration of patency in cases of obstructive azoospermia is identifying the site or sites of obstruction and selecting the surgical approach accordingly, whether epididymovasostomy, vasovasostomy [1], transurethral resection of the ejaculatory ducts [2], laparoscopic pelviscrotal vasovasostomy [3], or a combination of the above.

Locating the point of obstruction can be difficult and misleading. It can be based on clinical data, chemical markers such as fructose and α-glucosidase, transrectal ultrasonography, seminal vesiculography, seminal vesicle aspiration, or vasography.

Vasography is the single investigation that directly tests most of the length of the seminal track for patency, pinpointing and documenting the site of obstruction. However, it entails canulation of the vas deferens to inject the contrast material. The site of canulation commonly suffers stricture formation, ending in iatrogenic obstruction. It is recommended that vasography is performed exclusively intraoperatively during reconstruction of the seminal track [4]. Nevertheless, it still retains the hazard of stricture formation, whether performed by the puncture method or by formal vasostomy [5,6], unless epididymovasostomy or vasovasostomy is performed at the same point [6].

This study is a description of ‘transurethral retrograde vasography’, whereby contrast medium is injected through the ejaculatory duct orifice along the vas deferens in a retrograde direction down to the epididymis, to evaluate patency of the whole length of the seminal track without jeopardizing the vas deferens, eliminating the risks of scarring and iatrogenic obstruction inherent to vasography. This is the first report of the technique.

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Patients and methods

Transurethral retrograde vasography was performed in three male patients with obstructive azoospermia, as confirmed by testicular biopsy. All three cases had sonographic and biochemical evidence of ejaculatory duct obstruction. Transurethral retrograde vasography was performed in conjunction with transurethral resection of the ejaculatory ducts to exclude concomitant obstruction elsewhere along the seminal track. The choice of further surgical intervention for correction of obstruction was made accordingly.

All patients provided a written informed consent explaining the experimental nature of the procedure and its possible complications, before surgery.

The procedure was performed under general anesthesia. Patients were placed in a lithotomic position. Preliminary urethroscopy and cystoscopy were performed.

Resection of one slice of the veromontanum showed the orifices of the ejaculatory ducts in one patient. Exposing the ejaculatory ducts required further resection in the other two cases (Fig. 1).

Figure 1

Figure 1

Once a pinpoint orifice appeared, it was not necessary to resect further, as the narrow orifice yielded to gentle probing by the blunt tip of the ureteric catheter. The bladder was emptied.

A ureteric catheter (size 4 French: 1.3-mm thick) was introduced through the side port. The catheter was guided into the openings of the ejaculatory ducts one at a time; a guide wire was inserted upon which the catheter was advanced for an average distance of 4 cm (Fig. 2).

Figure 2

Figure 2

A syringe was hooked up to the operator's end of the catheter by an adapter. Sperm medium was injected through the ureteric catheter into the seminal track, aspirated back, and tested for sperm.

The contrast medium was visually monitored by fluoroscopy as it advanced through the seminal track. After an initial bolus injection of contrast medium, enough to opacify the vas deferens down to the external inguinal ring, injection was stopped and the contrast was allowed to flow spontaneously down the vas deferens. If necessary, injection was resumed until the contrast medium reached the tail of the epididymis or resistance was met.

The seminal vesicle was opacified to variable degrees in most cases. The dye also flowed back around the catheter to opacify the prostatic urethra and the urinary bladder. The vas deferens was opacified as far as was patent.

In two cases, the vas deferens was opacified down to the epididymal tubule (Fig. 3). In one patient who had undergone hernioplasty, occlusion was shown at the inguinal vas deferens (Fig. 4) on either side. It is to be noted that in one case there was obstruction and the outline of the vas deferens showed an increase in thickness upon continued injection (after the initial bolus), because of dilatation with the accumulating contrast medium. Dilatation of the stricture was attempted by a 5-French balloon catheter, used in cases of coronary artery occlusion. A guide wire was threaded into the vas deferens and monitored by fluoroscopy. Unfortunately, the guide wire could not be negotiated into the stricture. Gradual balloon dilatation of the stricture from without inward failed as well. Despite failure of this intervention, it represents the first trial of scalpel-free restoration of patency. Laparoscopic pelviscrotal vasovasostomy [3] was performed for the latter case in the same setting.

Figure 3

Figure 3

Figure 4

Figure 4

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.

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Results

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.

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Discussion

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 [5].

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 [5].

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 [6].

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 [7]. 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 [7].

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 [8]. 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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References

1. Belker AM, Bennett AH. Applications of microsurgery in urology. Surg Clin North Am. 1988;68:1157–1178
2. Fisch H, Kang YM, Johnson CW, Goluboff ET. Ejaculatory duct obstruction. Curr Opin Urol. 2002;12:509–515
3. Shaeer OK, Shaeer KZ. Laparoscopy-assisted pelvi-scrotal vasovasostomy. Andrologia. 2004;36:311–314
4. Jarow JP, Sharlip ID, Belker AM, Lipshultz LI, Sigman M, Thomas AJ, et al. Best practice policies for male infertility. J Urol. 2002;167:2138–2144
5. Poore RE, Schneider A, DeFranzo AJ, Humphries ST, Woodruff RD, Jarow JP. Comparison of puncture versus vasotomy techniques for vasography in an animal model. J Urol. 1997;158:464–466
6. Goldstein MGoldstein M. Vasography. Surgery of male infertility. 1995 Philadelphia W.B. Saunders Co.:26–32
7. Silber SJ. Evaluation and treatment of male infertility. Clin Obstet Gynecol. 2000;43:854–888
8. Ozgok Y, Tan MO, Kilciler M, Tahmaz L, Kibar Y. Diagnosis and treatment of ejaculatory duct obstruction in male infertility. Eur Urol. 2001;39:24–29
Keywords:

balloon dilatation; transurethral; urethroscope; vas deferens; vasography

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