AJR 2000; 175:777-778
© American Roentgen Ray Society
Sonographically Guided Transurethral Laser Incision of a Müllerian Duct Cyst for Treatment of Ejaculatory Duct Obstruction
Ethan J. Halpern1 and
Irvin H. Hirsch
1
Both authors: Jefferson Prostate Imaging Center, Departments of Radiology and
Urology, Thomas Jefferson University, 132 S. 10th St., Philadelphia, PA
19107-5244.
Received December 29, 1999;
accepted after revision December 3, 2000.
Address correspondence to E. J. Halpern.
Introduction
Cystic lesions of the prostate are often asymptomatic but may present with
lower urinary tract obstructive symptoms or obstruction of the ejaculatory
ducts. We describe the use of transrectal sonography to guide laser incision
of a müllerian duct cyst through the urethral
wall for treatment of ejaculatory duct obstruction. Sonography was used to
define the precise location of the cyst to choose the level of the urethral
incision. On the basis of sonographic localization, the incision was performed
in a manner that spared the ejaculatory ducts.
Subject and Methods
A 35-year-old man presented with a primary complaint of infertility.
Preliminary history and physical examination revealed reduced volume of
ejaculate and oligospermia. Scrotal exploration revealed epididymal tubular
dilatation. Testicular biopsy revealed normal spermatogenesis. Vasography
suggested ejaculatory duct dilatation. Transrectal sonography showed a 14
x 9 x 10 mm midline cyst in the posterior aspect of the prostate,
above the level of the verumontanum (Fig.
1A). This cyst was associated with ductal ectasia of the seminal
vesicles and dilatation of the vasa deferentia with a luminal diameter of 5 mm
(Figs. 1B and
1C).
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Fig. 1B. —35-year-old infertile man with ejaculatory duct obstruction caused
by müllerian duct cyst of prostate. Transverse
sonogram reveals ductal ectasia of both seminal vesicles. Note dilated vasa
deferentia (cursors).
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Fig. 1C. —35-year-old infertile man with ejaculatory duct obstruction caused
by müllerian duct cyst of prostate. Sagittal
sonogram of base of prostate shows dilated vas deferens (VAS) and seminal
vesicle (SV). Compressed seminal ejaculatory duct (ED) appears as thin
hypoechoic line adjacent to cyst (CYST).
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Under laryngeal mask anesthesia, the patient was placed in the dorsal
lithotomy position. Cystourethroscopy revealed a normal bulbous and membranous
urethra. The ejaculatory duct orifices were visualized on either side of the
verumontanum. Sonographic guidance was provided for a transurethral incision
into the cyst. Distention of the urethra with saline solution permitted
visualization of the scope as it was advanced
(Fig. 1D) and sonographic
delineation of the verumontanum (Fig.
1E). Using the Contact: NdYAG laser with an MD-3 chisel tip
(Surgical Laser Technologies: Montgomeryville, PA), an inverted V incision was
made over the verumontanum above the level of the ejaculatory ducts
(Fig. 1F).
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Fig. 1D. —35-year-old infertile man with ejaculatory duct obstruction caused
by müllerian duct cyst of prostate. Sagittal
sonogram reveals scope (S) that has been advanced to level of verumontanum
(V). Note distended urethra (U) and müllerian
cyst (C).
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Fig. 1E. —35-year-old infertile man with ejaculatory duct obstruction caused
by müllerian duct cyst of prostate. Transverse
sonogram shows distended urethra with clearly delineated verumontanum
(arrows).
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Fig. 1F. —35-year-old infertile man with ejaculatory duct obstruction caused
by müllerian duct cyst of prostate. Sonogram
obtained during laser incision shows air bubbles entering cyst. Arrows
indicate laser tip.
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Results
As the cyst was incised, milky white fluid was expressed from incision and
extruded freely with decompression of the cyst
(Fig. 1G). Postoperative semen
analysis showed a normalization of semen volume.
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Fig. 1G. —35-year-old infertile man with ejaculatory duct obstruction caused
by müllerian duct cyst of prostate. Transverse
sonogram obtained after procedure reveals almost complete collapse of the
cyst.
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Discussion
Cystic lesions of the prostate are classified on the basis of location and
contents [1].
Müllerian duct cysts arise in the midline,
either within the posterior aspect of the prostate or extending behind the
prostate and bladder neck. Although they are commonly asymptomatic, these
cysts can result in infertility caused by ejaculatory duct obstruction
[2]. Transrectal sonography is
useful for the diagnosis of ejaculatory duct obstruction
[3,4,5,6].
Although transrectal sonography is often used to guide prostate biopsy and has
been reported for therapeutic intervention for prostatic cysts
[5,
6], we are not aware of any
previous report showing the use of transrectal sonography to guide
transurethral laser surgery. Our study shows definite advantages of
intraoperative sonography to guide laser incision of the urethra. The
underlying cyst was not visible using the cystoscope but was easily targeted
using sonography. Furthermore, the ejaculatory ducts were identified on
sonography, and the laser incision was directed to avoid damage to these
structures. Although the verumontanum is not generally visible with
sonography, the infusion of saline solution into the urethra provided
excellent visualization of the verumontanum. Finally, sonography was useful to
document decompression of the cyst.
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Introduction
Subject and Methods
