Surgery For Male Infertility (TURED - Trans Uretheral Resection of Ejaculatory Ducts) скачать в хорошем качестве

Surgery For Male Infertility (TURED - Trans Uretheral Resection of Ejaculatory Ducts)

Transurethral resection of the ejaculatory ducts is performed in the outpatient setting. Following the administration of light general or regional Anesthesia and a single dose of a broad-spectrum antibiotic, the patient is placed in the dorsal Lithotomy position with a rectal drape. Formal cystourethroscopy is performed. Careful examination is made of the areas lateral to the verumontanum within the prostatic urethra to visualize either ejaculatory duct orifice. A small resectoscope of 24 French size and electrocautery loop are inserted and the verumontanum is resected in the midline. The resection is performed with pure cutting current to minimize cauterization of the delicate ejaculatory ducts. Often, several passes of the cutting loop are required to visualize the ejaculatory duct openings within the prostate. This can mean relatively deep dissection in a small prostate gland, a situation that can make even an experienced transurethral surgeon feel uneasy. At the correct level of resection, cloudy, milky fluid can usually be seen effluxing from the opened ducts. After resection, large bleeding blood vessels are lightly cauterized, with care taken to avoid fulguration of the duct openings. Because the area of resection is at the prostatic apex, near both the external urethral sphincter and the rectum, careful and constant positioning of the resectoscope is essential. A finger placed in the rectum can help avoid rectal injuries and assist in keeping the resectoscope tip proximal to the external sphincter. A small Foley catheter is placed for 24 to 48 hours and removed on an outpatient basis. Oral antibiotics are given while the catheter is in place. After such treatment for infertility, intercourse is resumed after 7 days, and a formal semen analysis is checked as early as 2 weeks and then at regular intervals thereafter, until semen quality stabilizes. Several useful aids can ensure that the resection is performed safely and completely. With an endoscopic needle, the milky ejaculatory duct fluid can be sampled transurethrally during the procedure and inspected with microscopy for sperm. The use of simultaneous, real-time TRUS during the resection is a valuable addition to this procedure. The exact location of the lesion to be resected can be determined by TRUS and the depth of resection continuously assessed during the resection. Similarly, TRUS can be used to guide the instillation of indigo carmine or methylene blue into the seminal vesicles before the resection. The dye is subsequently visualized on relief of obstruction. More recently, transurethral endoscopy and vesiculoscopy have been used to both diagnose and treat hematospermia and ejaculatory duct obstruction. This procedure is completed by passing 6 French or 7 French ureteroscope retrograde through the orifice of the verumontanum over a guide wire. The ejaculatory duct orifices are then visualized and the membrane covering the orifices is punctured with a guide wire. The ureteroscope is passed into the seminal vesicles. After this procedure, levofloxacin wash is directly injected into the seminal vesicles, and a Foley catheter is left for 24 hours.