作者要感谢KMMU第二附属医院提供与这项工作相关的病例和医疗记录。这项研究没有资金支持。

本文所述手术方法已获得昆明医科大学附属第二医院伦理委员会批准，患者手术视频的使用已授权。从患者那里获得知情同意书，并使用患者数据进行介绍。
1. 操作仪器
<ol><li>确保显示摄像头系统和钬激光器工作正常。</li>
</ol>2. 操作准备
<ol><li>使用以下纳入标准选择本研究的参与者。<ol><li>所有被诊断患有无精子症或少精子症并同意手术的患者。</li>
		<li>精液体积小于 1.5 mL，pH<7.2。精浆果糖 ≤13 μM/单次射精。</li>
		<li>磁共振成像（MRI）显示射精管区域有囊肿，双侧精囊腺肿大（图1）。 注意：很难通过成像准确识别前列腺囊肿和射精管囊肿。当精囊扩张的宽度大于 17 mm10 时，我们通常通过手术确认诊断。</li>
		<li>性激素水平在正常范围内。睾丸体积大于 15 mL（单个睾丸体积）。 注意：睾丸体积 >15 mL 的目的是排除由某些睾丸因素引起的无精子症。使用超声报告数据和 Lambert 公式测量睾丸体积：长 x 宽 x 高 x 0.71。</li>
		<li>没有影响手术安全性的疾病，如高血压和高血糖控制不佳、呼吸系统疾病等。</li>
	</ol></li>
	<li>使用以下排除标准将参与者排除在本研究之外。<ol><li>有尿道狭窄、急性尿路感染、严重凝血障碍或其他麻醉禁忌症的患者。</li>
		<li>睾丸体积小于 12 mL。</li>
	</ol></li>
	<li>手术前 30 分钟静脉注射抗生素以防止感染。通常，使用 1.5 g 头孢呋辛钠和 100 mL 0.9% 氯化钠溶液。</li>
</ol>3. 操作程序
<ol><li>使用舒芬太尼 （0.3 μg/kg）、丙泊酚 （2 mg/kg） 和罗库溴铵 （0.8 mg/kg） 将患者置于截石术中进行麻醉诱导。药物起效后进行气管插管，连接麻醉机进行机械通气。</li>
	<li>用异丙酚（2mg / kg / h），瑞芬太尼（0.15μg/ kg / min）和2%七氟醚维持，以达到BIS值40-60。间歇性注射罗库溴铵以促进正性肌力松弛。用碘水对下腹部和会阴区域进行 3 次消毒。</li>
	<li>将精囊镜连接到显示系统。将内窥镜插入尿道外口，小心地将其推进到后尿道。尿道粘膜看起来光滑而微红，证实了尿道在视野内的准确定位并延伸到后尿道。</li>
	<li>如果成功，检查尿道的凸起结构（称为精丘）是否可见。在精髓丘的两侧，检查射精管的两个小开口（图2A）。</li>
	<li>引导一根电线 （Bard） 穿过患侧的射精管开口，进入射精管囊肿。在手术过程中观察充满浑浊液体的重要区域（图2B）。</li>
	<li>用生理盐水冲洗囊肿，直至视力清晰，检查精管是否有异常开口。通过异常的射精管囊肿开口进入同侧精囊，显示多个蜂窝状导管腔（图2C）。</li>
	<li>使用 40 W 钬激光，将射精管的直径扩大到约 5 mm，促进改善冲洗液的循环并提供更清晰的视野（图 2D）。</li>
	<li>沿尿流方向切开射精管口，可能有利于保留抗尿反流机制。</li>
	<li>识别并探索患侧异常射精管开口的对称位置。</li>
	<li>进入健康侧的精囊进行进一步探索。轻轻将其插入囊肿左下方和右侧的精囊中。需要注意的是，确切的位置可能会有所不同（图2E）。</li>
	<li>使用钬激光精确切开和扩大对侧人工开口，使内窥镜顺利通过。这标志着手术的关键终点，两侧输精管中的精子通过受影响侧射精管的开口有效释放（图2F）。</li>
	<li>浸泡 Fr18 导管并用生理氯化钠连续冲洗，以防止血凝块阻塞导管。</li>
</ol>4. 术后护理
<ol><li>术后第1天， 连续冲洗膀胱6小时，并根据需要补充葡萄糖和电解质。</li>
	<li>在手术后第2 天拔 除导管。确保患者在手术后没有明显的疼痛;相反，他们能够忍受导管的主要不适，无需药物即可控制。术后不要对没有预先存在感染的患者使用抗生素。住院2天。</li>
	<li>指导患者增加饮水量，尿频，出院后尽快射精，目标是每周1-2次。此外，密切观察精液量。</li>
</ol>5. 跟进
<ol><li>在手术后第 3个月进行精液分析，以确保满足呕吐时间要求，并在3个月后主要通过电话访谈进行随访。</li>
	<li>使用自动精子活力测试仪和自动精液血浆生化仪进行精液样本。将手术前获得的精液分析结果与术后第 3 个月的精液分析结果进行比较。</li>
</ol>6. 统计分析
<ol><li>使用GraphPad软件分析结果，并表示为平均值±标准差。 使用Shapiro-Wilk检验进行正态性检验。如果术前和术后差异呈正态分布，则使用配对 t 检验进行分析;否则，请使用非参数检验 （Mann-Whitney）。通过配对 t 检验分析术前和术后数据之间的差异。当P<0.05时，统计学差异显著。</li>
</ol>

精囊镜激光辅助手术治疗射精管阻塞

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作者声明他们没有竞争利益。

TURED是治疗射精管囊肿引起的射精管阻塞的主要手术方法，其主要手术方式是用电切口切除囊肿后，以释放压力并渣滓精管11。研究对象在访问期间被问及他们的病史，并且都有正常的性活动频率（每周 1-2 次），没有性功能障碍或血精症。术前精液检查显示，均有精子，但精子数量少于正常值，精液量减少。结合患者的睾丸体积、精浆果糖和影像学检查，足以支持精膜远端不完?...

射精管梗阻是男性生殖系统的一种罕见疾病，据报道发病率为 1%-5%1,2。射精管囊肿是射精管阻塞的主要原因。典型EDO患者的精液检查显示四个显着特征：1.精液量小于2 mL，梗阻严重程度与精液量减少直接相关;2.少精子症，双侧完全梗阻导致无精子症;3.精液pH值降低;4. 精浆果糖水平降低，有时甚至降至 0 mM/L3.EDO引起的男性不育症可以通过手术治疗，保守治疗效果较差4。过去，主要方法是经尿道切除射精管。尽管这种方法具有减少创伤和减少术中并发症等好处，但手术切除藰膜会破坏远端射精管的正常生理结构。这反过来又增加了术后并发症的风险，如尿流、附睾炎、逆行射精和尿失禁5。同时，手术过程中的热量产生可能导致射精管、精囊甚至直肠的损伤，电切口的热效应可能会引起新的梗阻6。
verumontanum 是男性生殖系统中至关重要的解剖元件，确保射精过程中精液的精确和有序排出，同时也有助于防止逆行流动。目前尚不清楚TURED的缺点是否可以通过保留痈来改善。一些研究试图利用激光辅助内窥镜治疗 EDO，同时保留 verumontanum 2,7,8,9。尽管手术方法各不相同，但术后精液恢复非常成功，并发症极少。这表明保留附睾头可能是有益的。然而，他们使用的方法相对复杂，不会干预健康的射精管，这可能会增加复发的风险。因此，我们提出了一种简单有效的手术方法。
在这项研究中，精囊镜通过导线器引导进入患侧的射精管囊肿。然后，使用钬激光扩大患侧射精管开口，以确保其具有足够大的流出通道。

<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

经尿道射精管切除术 （TURED） 是治疗射精管囊肿引起的射精管阻塞 （EDO） 的主要手术方法。通常需要术中切除verumontanum以暴露射精管。然而，保留verumontanum结构可以更好地模拟正常的生理解剖结构。维持藜膜可能会增加术后远端射精管瘢痕形成的风险，导致复发性梗阻或精液量减少。因此，我们尝试了一种保留verumontanum的新技术，与TURED相比，它相对更容易，更安全。以下是程序步骤：1.通过尿道外口将6F精囊镜引入verumontanum附近，定位患侧射精管的开口，并将导丝引入囊肿。这一成功的步骤保留了verumontanum，最大限度地保留了远端射精管中的抗反流机制。2.钬激光将患侧射精管开口扩大至5mm，降低术后射精管开口闭合的可能性，简化手术过程。3.在囊肿内创建一个窗口以进入对侧精囊，然后使用钬激光将开口燃烧并扩张至5毫米，将对侧射精管重定向到囊腔。这种修改保留了健康侧射精管的开口，并为精液提供了新的流出通道，降低了术后精液量减少的风险。患者术后无并发症，住院时间较短，精液量有所改善。因此，这种手术方法简单而有效。

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.

作者聚焦： 采用内窥镜介导的精液通道再激流治疗精管阻塞的先进治疗 

精囊镜辅助血流调整治疗射精管梗阻

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.

本研究共纳入 5 名患者，年龄从 27 岁到 34 岁不等（中位数为 31 岁），病程为 6 至 15 个月（平均 9 个月）。随访时间为 12 至 48 个月（平均 24.8 个月）。所有患者均顺利完成手术。平均手术时间为26分钟，平均住院时间为2天。5例均出现单侧EDO和对侧精囊扩张。与患者有关的人口统计信息，包括术前和术后数据，如表1所示。精囊镜检查手术后 1 个月射精管的代表性图像已在补充?...

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

本方案介绍了精囊内镜联合钬激光治疗射精管囊肿引起的射精管梗阻的临床应用。

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

本研究的范围主要是膀胱镜辅助精管分裂的临床效果。在治疗精管囊肿引起的精管梗阻。我们澄清说，该手术采用通道，这是一种非常有效的手术方法。目前的主要挑战是射精管囊肿引起的射精管阻塞的发生率非常低。并且很难积累足够的患者来与其他外科手术进行大量对照研究。与其他手术方法相比，该方法可以更好地保留的远端解剖结构。并且不太可能引起异常射精的并发症。润滑异常。而损失，阻塞的风险增加率较低。未来，我们将专注于改进内窥镜技术。更纤细、更清晰的内窥镜，用于精髓疾病的诊断和治疗。

treatment-ejaculatory-duct-obstruction-seminal-vesiculoscopy-assisted

Research

JoVE Journal

Medicine

Treatment of Ejaculatory Duct Obstruction by Seminal Vesiculoscopy Assisted Flow Modification

1.7K 次观看.  The Second Affiliated Hospital of Kunming Medical University. 本研究的范围主要是膀胱镜辅助精管分裂的临床效果。在治疗精管囊肿引起的精管梗阻。我们澄清说，该手术采用通道，这是一种非常有效的手术方法。目前的主要挑战是射精管囊肿引起的射精管阻塞的发生率非常低。并且很难积累足够的患者来与其他外科手术进行大量对照研究。与其他手术方法相比，该方法可以更好地保留的远端解剖结构。并且不太可能引起异...

视频: 作者聚焦： 采用内窥镜介导的精液通道再激流治疗精管阻塞的先进治疗 

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.

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.

科研

医学

Application of Seminal Vesiculoscopy and Holmium Laser to Treat Ejaculatory Duct Blockage Caused by Cysts

To begin, position the patient in lithotomy for anesthesia induction. Perform tracheal intubation to support breathing. Inject rocuronium bromide intermittently for inotropic relaxation.Disinfect the lower abdomen and the perineal area three times with iodophor. Connect the seminal vesiculoscope to the display system and insert the endoscope through the external urethral opening. Then carefully advance it towards the posterior urethra.To confirm the accurate position, observe the smooth and reddish urethral mucosa. Note the visibility of the colliculus seminalis and spot the two small openings of the ejaculatory ducts on either side. Guide a wire to the ejaculatory duct cyst through the opening on the affected side to reach the area filled with cloudy fluid.After flushing the cyst with saline, look for abnormal opening in the seminal canal. Then enter the ipsilateral seminal vesicle through the abnormal ejaculatory duct cyst opening, revealing multiple honeycombed ductal lumens. Using a 40-watt holmium laser, expand the ejaculatory duct diameter.To preserve the anti-urine reflux mechanism, cut the ejaculatory duct opening along the direction of urine flow. Explore the symmetrical position of the abnormal ejaculatory duct opening on the affected side as well as the seminal vesicle of the healthy side. Then gently insert the wire into the seminal vesicle at the lower left and right of the cyst.Finally using the holmium laser, incise and widen the contralateral artificial opening. To prevent blood clots from blocking, indwell an 18-French catheter and rinse it continuously with physiological saline. Postoperative examination after a month showed the open ejaculatory duct on the affected side and the preserved verumontanum.Endoscopy confirmed the presence of lateral ductus openings within the ejaculatory cyst. The semen parameters of patients improved significantly in the third month after the surgery.

作者聚焦： 采用内窥镜介导的精液通道再激流治疗精管阻塞的先进治疗

作者聚焦：采用内窥镜介导的精液通道再激流治疗精管阻塞的先进治疗