The authors would like to thank the second affiliated hospital of KMMU for providing cases and medical records related to this work. There is no funding support for this study.

The surgical method described in this paper has been approved by the Ethics Committee of the Second Affiliated Hospital of Kunming Medical University, and the use of patient surgical videos has been authorized. Informed consent was obtained from the patients, and patient data was used for presentation.
1. Instruments for operation
<ol>
	<li>Ensure that the display camera system and holmium laser are working properly.</li>
</ol>
2. Preparation fo...

Seminal Vesiculoscope Laser-Assisted Surgery to Treat Ejaculatory Duct Blockage

<ol>
	<li>Avellino, G. J., Lipshultz, L. I., Sigman, M., Hwang, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transurethral+resection+of+the+ejaculatory+ducts:+etiology+of+obstruction+and+surgical+treatment+options.">Transurethral resection of the ejaculatory ducts: etiology of obstruction and surgical treatment options.</a> Fertil Steril. 111 (3), 427-443 (2019).</li><li>Modgil, V., Rai, S., Ralph, D. J., Muneer, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=An+update+on+the+diagnosis+and+management+of+ejaculatory+duct+obstruction.">An update on the diagnosis and management of ejaculatory duct obstruction.</a> Nat Rev Urol. 13 (1), 13-20 (2016).</li><li>Paick, J., Kim, S. H., Kim, S. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ejaculatory+duct+obstruction+in+infertile+men.">Ejaculatory duct obstruction in infertile men.</a> BJU Int. 85 (6), 720-724 (2000).</li><li>Wang, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transurethral+seminal+vesiculoscopy+using+a+6F+vesiculoscope+for+ejaculatory+duct+obstruction:+initial+experience.">Transurethral seminal vesiculoscopy using a 6F vesiculoscope for ejaculatory duct obstruction: initial experience.</a> J Androl. 33 (4), 637-643 (2012).</li><li>Galloway, M., Woods, R., Nicholson, S., Foggin, J., Elliott, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=An+audit+of+waiting+times+in+a+haematology+clinic+before+and+after+the+introduction+of+point-of-care+testing.">An audit of waiting times in a haematology clinic before and after the introduction of point-of-care testing.</a> Clin Lab Haematol. 21 (3), 201-205 (1999).</li><li>WD, Z., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+effect+analysis+of+two+surgical+methods+for+the+treatment+of+ejaculatory+duct+obstruction.">Clinical effect analysis of two surgical methods for the treatment of ejaculatory duct obstruction.</a> Chinese J Androl. 4, 43-45 (2013).</li><li>Halpern, E. J., Hirsch, I. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sonographically+guided+transurethral+laser+incision+of+a+M&#252;llerian+duct+cyst+for+treatment+of+ejaculatory+duct+obstruction.">Sonographically guided transurethral laser incision of a M&#252;llerian duct cyst for treatment of ejaculatory duct obstruction.</a> AJR. Am J Roentgenol. 175 (3), 777-778 (2000).</li><li>Oh, T. H., Seo, I. Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+treatment+for+persistent+hematospermia:+a+novel+technique+using+a+holmium+laser.">Endoscopic treatment for persistent hematospermia: a novel technique using a holmium laser.</a> Scand J Surg. 105 (3), 174-177 (2016).</li><li>Lee, J. Y., Diaz, R. R., Choi, Y. D., Cho, K. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hybrid+method+of+transurethral+resection+of+ejaculatory+ducts+using+holmium:+yttriumaluminium+garnet+laser+on+complete+ejaculatory+duct+obstruction.">Hybrid method of transurethral resection of ejaculatory ducts using holmium: yttriumaluminium garnet laser on complete ejaculatory duct obstruction.</a> Yonsei Med J. 54 (4), 1062-1065 (2013).</li><li>Guo, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Role+of+MRI+in+assessment+of+ejaculatory+duct+obstruction.">Role of MRI in assessment of ejaculatory duct obstruction.</a> J Xray Sci Technol. 21 (1), 141-146 (2013).</li><li>Heshmat, S., Lo, K. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evaluation+and+treatment+of+ejaculatory+duct+obstruction+in+infertile+men.">Evaluation and treatment of ejaculatory duct obstruction in infertile men.</a> Can J Urol. 13 (Suppl 1), 18-21 (2006).</li><li>Tu, X. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transurethral+bipolar+plasma+kinetic+resection+of+ejaculatory+duct+for+treatment+of+ejaculatory+duct+obstruction.">Transurethral bipolar plasma kinetic resection of ejaculatory duct for treatment of ejaculatory duct obstruction.</a> J Xray Sci Technol. 21 (2), 293-302 (2013).</li><li>El-Assmy, A., El-Tholoth, H., Abouelkheir, R. T., Abou-El-Ghar, M. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transurethral+resection+of+ejaculatory+duct+in+infertile+men:+outcome+and+predictors+of+success.">Transurethral resection of ejaculatory duct in infertile men: outcome and predictors of success.</a> Int Urol Nephrol. 44 (6), 1623-1630 (2012).</li><li>Faydaci, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effectiveness+of+doxazosin+on+erectile+dysfunction+in+patients+with+lower+urinary+tract+symptoms.">Effectiveness of doxazosin on erectile dysfunction in patients with lower urinary tract symptoms.</a> Int Urol Nephrol. 43 (3), 619-624 (2011).</li><li>McQuaid, J. W., Tanrikut, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ejaculatory+duct+obstruction:+current+diagnosis+and+treatment.">Ejaculatory duct obstruction: current diagnosis and treatment.</a> Curr Urol Rep. 14 (4), 291-297 (2013).</li><li>Liu, Z. Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transurethral+seminal+vesiculoscopy+in+the+diagnosis+and+treatment+of+persistent+or+recurrent+hemospermia:+a+single-institution+experience.">Transurethral seminal vesiculoscopy in the diagnosis and treatment of persistent or recurrent hemospermia: a single-institution experience.</a> Asian J Androl. 11 (5), 566-570 (2009).</li><li>Guo, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+application+of+pediatric+ureteroscope+for+seminal+vesiculoscopy.">The application of pediatric ureteroscope for seminal vesiculoscopy.</a> Minim Invasive Surg. 2015, 946147 (2015).</li><li>Xu, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Novel+methods+for+the+diagnosis+and+treatment+of+ejaculatory+duct+obstruction.">Novel methods for the diagnosis and treatment of ejaculatory duct obstruction.</a> BJU Int. 108 (2), 263-266 (2011).</li><li>Enikeev, D., Shariat, S. F., Taratkin, M., Glybochko, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+changing+role+of+lasers+in+urologic+surgery.">The changing role of lasers in urologic surgery.</a> Curr Opin Urol. 30 (1), 24-29 (2020).</li></ol>

TURED is a primary surgical approach to treat ejaculatory duct obstruction caused by the ejaculatory duct cyst, and its main operation mode is to reveal the ejaculatory duct opening after the excision of cysts with an electric incision to relieve the pressure and dreg the seminal canal11. The study subjects were asked about their medical history during the visit, and all had normal sexual activity frequency (1-2 times per week) and no sexual dysfunction or hematospermia. The preoperative semen exa...

Ejaculatory duct obstruction is a rare disease of the male reproductive system, with a reported incidence of 1%-5%1,2. Ejaculatory duct cysts represent the predominant cause of ejaculatory duct obstruction. Semen examination in typical EDO patients reveals four distinctive characteristics: 1. Semen volume less than 2 mL, with a direct correlation between obstruction severity and decreased volume; 2. Oligospermia, with bilateral complete obstruction resulting in azoospermia; 3. Decreased pH value of semen; 4. Reduced levels of seminal plasma fructose, sometimes even dropping to 0 mM/L3. Male infertility caused by EDO can be treated with surgery and is less effective with conservative treatment4. In the past, the main method was transurethral resection of the ejaculatory duct. Although this approach boasts benefits like reduced trauma and fewer intraoperative complications, the surgical removal of the verumontanum disrupts the normal physiological structure of the distal ejaculatory duct. This, in turn, increases the postoperative risk of complications such as urinary reflux, epididymitis, retrograde ejaculation, and urinary incontinence5. At the same time, heat production during the operation may lead to the injury of the ejaculatory duct, seminal vesicle, and even rectum, and the thermal effect of the electric incision may cause new obstruction6.
The verumontanum stands as a crucial anatomical element within the male reproductive system, ensuring the precise and regulated discharge of semen during ejaculation while also helping to prevent retrograde flow. Whether the disadvantages of TURED can be ameliorated by preserving the seminal caruncle is unclear. Several studies have attempted to utilize laser-assisted endoscopy for the treatment of EDO while preserving verumontanum2,7,8,9. Although the surgical approaches varied, post-operative semen recovery was notably successful with minimal complications. This indicates that preserving the epididymal head may be beneficial. However, the method they used is relatively complex and does not intervene in the healthy ejaculatory duct, which may increase the risk of recurrence. Therefore, we present a simple and effective surgical method.
In this study, the seminal vesiculoscope was guided into the ejaculatory duct cyst on the affected side by a wire guide. Then, the holmium laser was used to enlarge the ejaculatory duct opening on the affected side to ensure that it had a sufficiently large outflow channel.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Camera system</td>
			<td>Karl Storz, Germany</td>
			<td>TC200EN</td>
			<td>Endoscopic camera system</td>
		</tr>
		<tr>
			<td>Fr18 Cathete</td>
			<td>Zhanjiang City Shida Industrial Co., Ltd.</td>
			<td>2660476</td>
			<td>Drainage of urine</td>
		</tr>
		<tr>
			<td>Fr6/7.5 vesiculoscope</td>
			<td>Richard Wolf, germany</td>
			<td>8702.534</td>
			<td>Operative procedure</td>
		</tr>
		<tr>
			<td>iodophor</td>
			<td>Shanghai Likang Disinfectant Hi-Tech Co., Ltd.</td>
			<td>31005102</td>
			<td>Skin disinfection</td>
		</tr>
		<tr>
			<td>Nitinol Guidewire 0.035&#34;</td>
			<td>C. R Bard, Inc. Covington, GA&#160;</td>
			<td>150NFS35</td>
			<td>Guide</td>
		</tr>
		<tr>
			<td>Propofol</td>
			<td>Sichuan Kelun Pharmaceutical Research Institute Co., Ltd.</td>
			<td>H20203571</td>
			<td>Induction and maintenance of anesthesia</td>
		</tr>
		<tr>
			<td>Remifentanil</td>
			<td>Yichang Humanwell Pharmaceuticals CO,Ltd.</td>
			<td>H20030200</td>
			<td>Maintenance of anesthesia</td>
		</tr>
		<tr>
			<td>Rocuronium bromide</td>
			<td>Zhejiang Huahai&#160; Pharmaceuticals CO,Ltd.</td>
			<td>H20183264</td>
			<td>Induction and maintenance of anesthesia</td>
		</tr>
		<tr>
			<td>Sevoflurane</td>
			<td>Jiangsu Hengrui Pharmaceuticals Co., Ltd.</td>
			<td>H20070172</td>
			<td>Maintenance of anesthesia</td>
		</tr>
		<tr>
			<td>Slimline EZ 200</td>
			<td>LUMENIS, USA</td>
			<td>0642-393-01</td>
			<td>Dissect capsule wall</td>
		</tr>
		<tr>
			<td>Sodium Chloride Physiological Solution</td>
			<td>Hua Ren MEDICAL TECHNOLOGY CO. Ltd.</td>
			<td>H20034093</td>
			<td>Flushing fluid</td>
		</tr>
		<tr>
			<td>Sufentanil</td>
			<td>Yichang Humanwell Pharmaceuticals CO,Ltd.</td>
			<td>H20054171</td>
			<td>Induction and maintenance of anesthesia</td>
		</tr>
		<tr>
			<td>Syringe 50 mL&#160;</td>
			<td>Double Pigeon Group Co. Ltd.</td>
			<td>20163141179</td>
			<td>Inject 0.9% sodium chloride solution into the vesiculoscope</td>
		</tr>
		<tr>
			<td>VersaPulse PowerSuite 100W Laser System</td>
			<td>LUMENIS, Germany</td>
			<td>PS.INT.100W</td>
			<td>Provide energy</td>
		</tr>
	</tbody>
</table>

treatment of ejaculatory duct obstruction by seminal vesiculoscopy assisted flow modification

Transurethral resection of ejaculatory duct (TURED) is a primary surgical approach to treat ejaculatory duct obstruction (EDO) caused by the ejaculatory duct cyst. Intraoperative excision of the verumontanum is usually required to expose the ejaculatory ducts. However, preserving the verumontanum structure allows for a better simulation of normal physiological anatomy. Maintaining the verumontanum may increase the risk of postoperative distal ejaculatory duct scarring, leading to recurrent obstruction or reduced semen volume. Therefore, we attempted a novel technique that preserves the verumontanum, which is relatively easier and safer compared to TURED. The following were the procedural steps: 1. A 6F seminal vesiculoscope was introduced through the external urethral orifice to the vicinity of the verumontanum, locating the opening of the affected-side ejaculatory duct and introducing a guidewire into the cyst. This successful step preserved the verumontanum, maximizing the retention of the anti-reflux mechanism in the distal ejaculatory duct. 2. The holmium laser enlarged the affected-side ejaculatory duct opening to 5 mm, decreasing the likelihood of postoperative closure of the ejaculatory duct opening and simplifying the procedure. 3. A window was created within the cyst to access the contralateral seminal vesicle, and then a holmium laser was used to burn and dilate the opening to 5 mm, redirecting the contralateral ejaculatory duct into the cystic cavity. This modification preserved the opening of the healthy-side ejaculatory duct and provided a new outflow passage for semen, reducing the risk of decreased semen volume postoperatively. The patients experienced no complications postoperatively, had shorter hospital stays, and showed improvement in semen volume. Hence, this surgical approach is simple yet effective.

Author Spotlight: Advanced Treatment of Seminal Duct Blockage Employing Endoscopy-Mediated Semen Channel Refluviation 

Treatment of Ejaculatory Duct Obstruction by Seminal Vesiculoscopy Assisted Flow Modification

The scope of this study is mainly the clinical effect of seminal duct division assisted by vesiculoscope. In the treatment of seminal duct obstruction caused by seminal duct cysts. We clarify that this procedure employs seminal channel It's a very effective surgical method.The main challenge currently is that the incidence of ejaculatory duct obstruction caused by ejaculatory duct cysts is very low. And it is difficult to accumulate enough patients to conduct a large number of controlled studies with other surgical procedures. Compared with other surgical methods the method can preserve the distal anatomical structure of the seminal even better.And is less likely to cause complications of abnormal ejaculation. Abnormal lubrication. And the loss, has a lower increased risk rate of obstruction.In the future, we'll focus on improving the endoscopic technology. Even more slender and clear endoscopes for the diagnosis and the treatment of seminal disease.

A total of 5 patients were enrolled in this study, ranging in age from 27 to 34 years (median 31 years), with a disease course of 6 to 15 months (mean 9 months). Follow-up was 12 to 48 months (mean 24.8 months). All patients successfully completed the operation. The average operation time was 26 min and the average hospital stay was 2 days. All 5 cases had unilateral EDO and contralateral seminal vesicle dilatation. The demographic information, incorporating preoperative and postoperative data, pertaining to the patients...

Watch this Scientific Journal Video about Advanced Treatment of Seminal Duct Blockage Employing Endoscopy-Mediated Semen Channel Refluviation at JoVE.com

This protocol introduces the clinical application of seminal vesicle endoscopy combined with holmium laser in the treatment of ejaculatory duct obstruction caused by ejaculatory duct cyst.

Transurethral resection of ejaculatory duct (TURED) is a primary surgical approach to treat ejaculatory duct obstruction (EDO) caused by the ejaculatory ...