1 Department of Urology Academic Hospital Nijmegen, P.O. Box 9101, 6500 HB Nijmegen and 2 Department of Urology Academic Hospital Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
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Abstract |
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Key words: male subfertility/prostatic cyst/transurethral deroofing
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Introduction |
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Ejaculatory duct obstruction (EDO) is regarded as one of the treatable causes of male subfertility. EDO is found in 714% of the subfertile male population and can be congenital or acquired (Goldwasser et al., 1985; Pryor and Hendry, 1991
). Normal hormone status and one or more of the following distinct semen abnormalities such as low or absent fructose, decreased sperm motility, decreased ejaculatory volume and oligo- or azoospermia are suggestive for total or partial EDO. The diagnosis of EDO can be confirmed directly by vasography (Banner and Hassler, 1978
) or indirectly by transrectal ultrasonography (TRUS) (Jarow, 1993
). Due to its non-invasive nature TRUS is currently the diagnostic method of choice.
Theoretically, a midline prostatic cyst can be one of the causes of EDO. The cyst, localized in the central zone of the prostate, can compress or displace the ejaculatory ducts to the lateral side (Fisch, 1992). It has been our policy to offer transurethral deroofing of the prostatic cyst to subfertile men with one or more of the following semen abnormalities: decreased seminal volume, decreased motility, oligozoospermia or azoospermia, in order to improve semen quantity and quality and pregnancy rate. In this retrospective study we evaluated the efficacy of this treatment.
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Materials and methods |
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The diagnosis of subfertility based on a median prostatic cyst was based on semen analysis with one or more of the following findings in addition to normal physical examination and normal serum FSH and testosterone: (i) low ejaculate volume (<2 ml) azoospermia; (ii) low or normal ejaculate volume with a sperm concentration <20x106/ml; or (iii) low or normal ejaculate volume with sperm motility <30% (Kim et al., 1997).
Transurethral incision of the midline cyst was performed under local anaesthesia with the patient in the lithotomy position. The roof of the cyst was incised, under TRUS guidance and under direct vision through a Collins hook (Karl Storz GmbH and Co., Tutthingen, Germany). Generally, the prostatic floor had to be incised between the bladder neck and the verumontanum that resulted in complete marsupialization of the cyst. Minimal coagulation was used. A Ch 16 transurethral catheter (Bardex I.C.; Bard Benelux n.v., Olen, Belgium) was introduced in the bladder and removed 24 h post-operatively. Patients were discharged the day after the procedure. There were no complications after transurethral incision of the midline cyst and this procedure was well tolerated by all patients. Semen analyses were obtained 412 weeks postoperatively.
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Results |
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Effect of transurethral incision of the midline prostatic cyst on sperm quality
Sperm concentration did not change in eight patients, decreased in patient no. 4 and increased only in patient no. 10 (Table I). Additionally the percentage of motile spermatozoa and the quality of motility did not change after surgery. A remarkable, but transient, improvement in sperm quality was seen in one patient (no. 6). In the first 3 months following the transurethral incision of the cyst, semen analysis showed dramatic sperm quantity improvement, but eventually the patient developed azoospermia again.
Effect of transurethral incision of the midline prostatic cyst on pregnancy rate
No spontaneous pregnancies occurred following transurethral incision.
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Discussion |
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Historically, ejaculatory duct obstruction was diagnosed by vasography (Pryor and Hendry, 1991; Jarow, 1993
). A complete block in the ejaculatory ducts is conclusive for the diagnosis of total obstruction. The main drawback, however, is the invasiveness of the procedure, and the subsequent risk of iatrogenic occlusion. In contrast, TRUS is readily available, inexpensive and non-invasive. The ultrasonographic diagnosis of EDO is based upon dilation of seminal vesicles or abnormalities such as midline prostatic cysts or calcifications in the region of the ejaculatory ducts. Unfortunately not all patients with EDO have dilated seminal vesicles and, conversely, not all patients with dilated seminal vesicles have EDO (Littup et al., 1988
). Moreover, the functional implication of a midline prostatic cyst or prostatic calcifications cannot be determined by TRUS (Jarow, 1996a
). It provides only circumstantial evidence for obstruction. Nevertheless, at present TRUS has replaced vasography as imaging modality for suspected ejaculatory duct obstruction.
Several treatments for EDO caused by midline prostatic cysts, e.g. transurethral resection of the ejaculatory ducts (TURED), transrectal aspiration together with sclerotherapy, transurethral marsupialization and open surgery of the midline prostatic cyst have been described (Ritchey et al., 1988; Fisch, 1992
; Stricker et al., 1993
; Jarow, 1996b
).
Currently, the standard treatment has become TURED (Fisch, 1992; Mecham et al., 1993
). The overall success rate of TURED has been quite good (Jarow, 1996b
). In the literature more than 100 patients have been described as having had this procedure for subfertility with an improvement of semen parameters seen in 50%. Spontaneous pregnancies occurred in 25% of the cases (Jarow, 1996b
; Netto et al., 1988
). Hendry and Pryor (1992) performed a transurethral incision of a Müllerian cyst in 21 patients, of whom 10 (48%) experienced an undisclosed improvement in semen quality and eight (38%) partners conceived (Hendry and Pryor, 1992
). Dik et al. (1996) described in their series of transurethral marsupialization of medial prostatic cyst in patients with prostatitis-like symptoms, three patients with infertility of whom two demonstrated significant improvement in semen quantity and quality (Dik et al., 1996
). Moreover, eight of the 10 patients with prostatitis-like symptoms who had pre-operatively small volume ejaculation without infertility demonstrated improvement in semen volume after the transurethral marsupialization (Dik et al., 1996
). These results clearly advocate a functional relationship between midline prostatic cysts and low semen volume. Our poor results of transurethral incision of midline prostatic cyst for infertility are therefore surprising. Only five (46%) patients demonstrated an improvement in seminal volume and in one patient improvement of sperm concentration was seen. Sperm motility was not affected in any patient. In our series spontaneous pregnancies did not occur after transurethral deroofing of the midline prostatic cyst.
The diagnosis of subfertility caused by obstruction due to midline prostatic cyst was based on history, physical examination, semen analyses and TRUS. Since vasography was not used in the diagnostic process, a functional relationship between the midline prostatic cyst and obstruction was not established, which may explain our poor results. Functional investigation, i.e. seminal vesiculography or vasography, may still be mandatory to prove the existence of an obstruction and to prove its removal afterwards. Secondly, the midline prostatic cyst was marsupialized and the cyst walls were not resected. The edges may heal together once again thus allowing the obstruction to return. Theoretically, a midline prostatic cyst can cause direct obstruction of the ejaculatory ducts by compression, but secondary fibrosis/stenosis of the ejaculatory ducts might occur on different levels between the ejaculatory duct orifice in the urethra and the epididymal junction. Although marsupialization of the midline cyst might solve the direct obstructive factor, the secondary obstruction might still be present. Digital massage of the seminal vesicles, possibly prior to the operation and injection with a coloured dye, could therefore be helpful to check patency of the ejaculatory ducts following marsupialization of the cyst.
Finally, an improved patient selection might influence pregnancy outcome. Patients with subfertility based only on low semen volume might benefit from improvement of seminal volume because the concomitant increase of pH of the seminal fluid may protect the spermatozoa against the harmful influence of the acid vaginal mucous.
In conclusion, our study suggests a poor efficacy of transurethral deroofing of a midline prostatic cyst alone in subfertile males with low semen volume, oligozoospermia or azoospermia. To improve the results, selective vasography or vesicography prior to an incision to confirm obstruction may be useful despite the potential harmful effects. Moreover, marsupialization of the cyst in combination with a resection of the wall of the cyst might improve the results. Only time will tell if these adjustments will improve the results, in terms of pregnancy rates, of transurethral deroofing of a midline prostatic cyst in subfertile men with low semen volume and/or azoo- or oligozoospermia.
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Notes |
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References |
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Submitted on March 4, 1999; accepted on June 8, 1999.