V3-11: Surgical Management of Ejaculatory Duct Obstruction due to Prostatic Utricular Cyst
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.
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.
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.
While uncommon, ejaculatory duct obstruction due to midline utricular cyst is highly amenable to surgical management with TURED.
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.