Real-time transrectal ultrasound-guided seminal vesiculoscopy for the treatment of patients with persistent hematospermia: A single-center, prospective, observational study

Abstract

This study aimed to describe endoscopic anatomy of the seminal tract and summarize our experience of transutricular seminal vesiculoscopy (TSV) guided by real-time transrectal ultrasonography (TRUS) in managing persistent hematospermia. A total of 281 consecutive patients with persistent hematospermia who underwent TSV with or without real-time TRUS were enrolled in this single-center, prospective, observational study. The median follow-up period was 36.5 (range: 8.0-97.5) months. TSV was successfully performed in 272 (96.8%) patients. The approach of a 4.5/6 F rigid vesiculoscope entering the seminal tract was categorized into four types on the basis of endoscopic presentation of the ejaculatory duct orifice and verumontanum. Seven (2.6%), 74 (27.2%), 64 (23.5%), and 127 (46.7%) patients had Types I (through the ejaculatory duct in the urethra), II (through the ejaculatory duct in the prostatic utricle), III (transutricular fenestration through a thin membrane), and IV (real-time transrectal ultrasound-guided transutricular fenestration) approach, respectively. In patients who successfully underwent surgery, bleeding occurred in the seminal vesicle in 249 (91.5%) patients. Seminal vesiculitis, calculus in the prostatic utricle, calculus in the ejaculatory duct, calculus in the seminal vesicle, prostatic utricle cysts, and seminal vesicle cysts were observed in 213 (78.3%), 96 (35.3%), 22 (8.1%), 81 (29.8%), 25 (9.2%), and 11 (4.0%) patients, respectively. Hematospermia was alleviated or disappeared in 244 (89.7%) patients 12 months after surgery. Fifteen patients had recurrent hematospermia, and the median time to recurrence was 7.5 (range: 2.0-18.5) months. TSV guided by TRUS may contribute to successful postoperative outcomes in managing persistent hematospermia.

Keywords: persistent hematospermia; seminal vesiculoscopy; transrectal ultrasound.

Figure 1

Flowchart of the surgery. DRE: digital rectal examination.

Figure 2

Endoscopic view of verumontanum: (a) prostatic utricle orifice and ejaculation duct orifices by cystoscopy; (b) hematospermia from the ejaculation duct orifice by squeezing seminal vesicle; (c) hematospermia from the prostatic utricle orifice by squeezing seminal vesicle; and (d) posterior urethral bleeding while squeezing seminal vesicle.

Figure 3

(a) Right ejaculation duct orifice could be observed in the urethra; (b) under the guidance of a Zebra guide-wire to enter ejaculation duct in Type I patients; the orifice of the ejaculatory duct was observed in the (c) right and (d) left lateral walls of prostatic utricle in Type II patients; the seminal vesicle and the prostatic utricle were only separated by a thin layer of membrane-like tissue located (e) in the anterior lateral wall of the prostatic utricle and (f) on the lateroposterior aspect of the utricle wall in Type III patients.

Figure 4

The surgical path was established under real-time TRUS guidance in Type IV patients. (a) Nonmembrane-like junctions between the prostate utricle and seminal vesicle; (b) endoscopic view in prostatic utricle postoperatively; (c) image of real-time TRUS during operation. TRUS: transrectal ultrasonography.

Figure 5

Perioperative findings in transutricular seminal vesiculoscopy. (a) Normal seminal vesicle; (b) inflammatory changes in the seminal vesicle; (c) calculus in the seminal vesicle; (d) calculus in the ejaculatory duct.

Figure 6

(a) Endoscopic view of prostatic utricle cyst; (b) preoperative magnetic resonance imaging of prostatic utricle cyst; (c) endoscopic view of seminal vesicle cyst; (d) preoperative magnetic resonance imaging of seminal vesicle cyst.