Transrectal ultrasonography-guided echo-enhanced seminal vesiculography

BJU International (1999), 84, 521–523

P O I NT O F T E C HN I QU E

Transrectal ultrasonography-guided echo-enhanced seminal vesiculography R. M. KILLI, A. P OURB AG HER and B. SEMERCI * Departments of Radiology and *Urology, Ege University, School of Medicine, Bornova, Izmir, Turkey

Indications

a

Distal ductal abnormalities, including congenital defects and obstructive disorders, are infrequently diagnosed causes of male infertility in a small fraction (1–2%) of all men [1,2]. It is important to identify this group of patients because these abnormalities are potentially curable causes of infertility [3]. The aim of this study was to assess the use of a saccharide microparticle echoenhancement suspension in patients with infertility, as a less-invasive method of evaluating the patency of the ejaculatory ducts and prostatic urethra.

B

Method Fifteen patients with clinical and laboratory evidence of ejaculatory duct obstruction (EDO) were included in the study. They were all examined with TRUS and microbubble echo-enhanced seminal vesiculography (EESV, using saccharide particles, code SH U 508 A, Schering AG, Berlin, Germany) performed using the TRUS-guided seminal vesicle puncture technique. The saccharidebased echo-enhancing agent is supplied in vials as a coarse granular powder. The granules are macroaggregates of almost pure galactose microparticles (99.9% pure galactose, 0.01% palmitic acid) and provide reproducible concentrations of stabilized air microbubbles. The agent is prepared for use by adding distilled water and immediately agitated for 5–10 s. The suspension is then allowed to stand in the vial for 2 min before use, during which time larger bubbles dissolve or rise to the top of the vial. All patients were given a cleansing enema 3–4 h before the examination and medication with anticoagulants was terminated 48 h beforehand. Prophylactic antibiotics (400 mg of norfloxacin) were given orally 1 h before the procedure, followed by three 400 mg doses every 12 h. Diagnostic axial and sagittal TRUS was performed with the patient in the left lateral decubitus position, using commercially available ultrasound equipment (Toshiba SSA-270 A, Tokyo, Japan) operating with 6 MHz and 7.5 MHz biplanar transducers. Under TRUS guidance each seminal vesicle was identified © 1999 BJU International

b

B

SV

US

P

Fig. 1. Diagrammatic representation of the sagittal (a) and coronal (b) view of transrectal puncture of a seminal vesicle for echoenhanced seminal vesiculography. Bladder (B), prostate gland (P), seminal vesicle (SV), urethra (arrows) and ejaculatory duct (arrowheads) are indicated.

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POINT OF TECHNIQUE

on the transverse plane and punctured with an 18 G, 25 cm-long needle (Fig. 1a,b and Fig. 2). Seminal vesicle fluid was routinely aspirated and sperm was evaluated microscopically. An 11 mL bolus of microparticles (300 mg/mL) was then administrated under real-time ultrasonographic guidance. Patency of the ipsilateral ejaculatory duct was confirmed by directly visualizing the contrast solution as it flowed through the seminal vesicle, the ampulla of the vas deferens and the ejaculatory duct, and then passed into the prostatic urethra and bladder (Fig. 3). The procedure was then repeated with puncture of the contralateral seminal vesicle. The mean time of diagnostic TRUS was 5–10 min. TRUS-guided EESV, performed in all patients, required 25–30 min of operator time. In all cases, dynamic images were recorded on videotape. TRUS-guided EESV was technically successful in 15 patients, and for visualizing the seminal vesicles, ejaculatory ducts and prostatic urethra was successful in all 15 patients. Anaesthetics were unnecessary and patient discomfort was minimal. There were no major complications, including infection and septicaemia, associated with use of the TRUS-guided puncture technique. Minor complications, e.g. haematuria and haemospermia, occurred in six patients; all bleeding ceased spontaneously.

Comparison with other methods In the absence of neurological dysfunction, diabetes mellitus and retrograde ejaculation, typical semenrelated findings, e.g. azoospermia, low ejaculate volume and absent fructose, should be accepted as showing complete EDO [4]. In the presence of partial EDO patients may have a normal to low ejaculate volume, normal or reduced sperm count, or abnormal sperm motility [4,5].

Perineal pain and discomfort, haematospermia, epididymal pain and pain on ejaculation have also been reported in patients with EDO. There have been five previously reported methods of confirming suspected EDO, i.e. vasography, cystoscopic cannulation of the ejaculatory ducts, MRI, TRUS and TRUS-guided X-ray contrast-agent seminal vesiculography. Vasography, which is still considered the gold standard, is an expensive and invasive procedure that often requires anaesthesia, and has an unquantified risk of vasal stricture formation [6]. Cystoscopic cannulation of the ejaculatory ducts with retrograde infusion of contrast medium is currently not used because of technical diBculties [7]. MRI with endorectal coils can provide a highly detailed anatomical depiction of ejaculatory ducts and is less operatordependent than the other imaging modalities. However, its use is limited by cost and availability [8]. TRUS has been considered as an initial diagnostic modality [3]. EDO is often associated with seminal vesicle dilatation; however, the latter does not occur in every patient and a patient with clinical findings suggestive of obstruction with normal TRUS must still undergo vasography and testicular biopsy [9]. TRUS-guided seminal vesiculography with X-ray contrast agents can be performed on an outpatient basis with no need for anaesthesia. It also less invasive and technically easier than vasography, avoids direct vasal manipulation and therefore would be expected to reduce the potential complications of vasography [10]. However, this technique has important disadvantages, such as radiation exposure and the need for X-ray contrast media. TRUS-guided EESV oCers all the advantages of X-ray contrast agent seminal vesiculography. The present method also has additional advantages, including ease of examination, absence of radiation, no risk of allergy to the X-ray contrast medium and easier availability for multiple follow-up examinations. Therefore, we recommend TRUS-guided EESV for evaluating suspected EDO and in the follow-up of patients with infertility problems previously treated by other methods.

References

Fig. 2. TRUS-guided seminal vesicle puncture; a transverse transrectal ultrasonogram shows the hyperechoic needle tip (arrowhead) in the right seminal vesicle.

1 Jarow JP. Role of ultrasonography in the evaluation of the infertile man. Semin Urol 1994; 12: 274–82 2 Carter SSC, Shinohara K, Lipshultz LI. Transrectal ultrasonography in disorders of the seminal vesicles and ejaculatory ducts. Urol Clin N Am 1989; 16: 773–88 3 Kuligowska E, Fenlon HM. Transrectal US in male infertility: spectrum of findings and role in patient care. Radiology 1998; 207: 173–81 4 Pryor JP, Hendry WF. Ejaculatory duct obstruction in subfertile males: analysis of 87 patients. Fertil Ster 1991; 56: 725–30 5 Meacham RB, Hellerstein DK, Lipshultz LI. Evaluation and © 1999 BJU International 84, 521–523

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Fig. 3. Normal TRUS echo-enhanced seminal vesiculography. a, a transverse ultrasonogram showing echo contrast material to opacify the right seminal vesicle. b, A sagittal ultrasonogram showing the prostate and right seminal vesicle before injection with echo-enhanced material. c,d Sagittal ultrasonogram showing the opacification of the right and left ejaculatory ducts (arrowhead), prostatic urethra (arrows) and bladder, during echo-enhanced material injection through the needle.

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treatment of ejaculatory duct obstruction in the infertile male. Fertil Ster 1993; 59: 393–7 Poore RE, Schneider A, DeFranzo AJ, Humphries ST, WoodruC RD, Jarow JP. Comparison of puncture versus vasostomy techniques for vasography in an animal model. J Urol 1997; 158: 464–6 Riedenklau E, Buch JP, Jarow JP. Diagnosis of vasal obstruction with seminal vesiculography: an alternative to vasography in select patients. Fertil Steril 1995; 64: 1224–7 Parsons RB, Fisher AM, Bar-Chama N, Mitty HA. MR imaging in male infertility. Radiographics 1997; 17: 627–37 Jarow JP. Transrectal ultrasonography of infertile men. Fertil Steril 1993; 60: 1035–9

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10 Jones TR, Zagoria JR, Jarow JP. Transrectal US-guided seminal vesiculography. Radiology 1997; 205: 276–8

Authors R.M. Killi, MD, Associate Professor in Radiology. A. Pourbagher, MD, Radiologist. B. Semerci, MD, Associate Professor in Urology. Correspondence: Dr R.M. Killi, Ege University, School of Medicine, Department of Radiology, 35100, Bornova, Izmir, Turkey.