Since the first application of endoscopy for examining the interior of the seminal vesicle ex vivo by Shimada et al. in 1996, this new method for observing SV directly had attracted the attention of the andrologists and urologists. Nowadays, the vesiculoscope has been used in some large hospitals. However, there remain many surgeons beginning to operate this procedure, for whom transurethral seminal vesiculoscopy (TUSV) is an advanced but challenging procedure. The present study reported some tricks and details devoting to how to use TUSV, but it is not sufficient enough. Therefore, we focused on sharing our experience and putting forward some views after at least 10 years’ application of TUSV.
Transurethral seminal vesiculoscopy has been recommended as the first-line diagnostic modality in hematospermia patients because of its real-time images and low cost. Besides, TUSV is also helpful for therapy.
Xing et al. concluded that TUSV was superior to TRUS for diagnosis, especially for lesions with stones and obstruction. It can also be used to treat recurrent hematospermia and ejaculatory duct obstruction caused by stones or cysts by facilitating removal of calculi, elimination of obstruction and drainage of infection. Liu et al. reported that the hematospermia symptom in 94.4% patients was completely treated and alleviated. Liu et al. reported that hematospermia was alleviated in 89% patients. During the long history of application, it was confirmed to be an effective procedure for both diagnosis and treatment, without severe complications.
In the current study, the improvement rate of hematospermia was 80.56% and the recurrence rate was 6.12%, comparable to similar studies reported in the literature[4,5]. The reason why our improvement rate of hematospermia was relatively lower than other studies may be the relatively longer duration of hematospermia in enrolled patients. In the meantime, to our knowledge, our median follow-up period of 3.38 years was the longest. For this reason, we are surprised that there were no long-term complications. Our findings provide more powerful evidence supporting the safety and efficiency of TUSV.
We would like to highlight two additional points:
First, we want to name one of approaches of TUSV (Wu’ method) to capture the attention of surgeons and to promote application of this method. In the present articles all over the world, we find four ways to treat hematospermia surgically, including a method of transurethral resection of the ejaculatory duct (TURED) and three methods of TUSV. In our concept, we don’t divide TURED into TUSV, due to differences of surgical instrument of vesiculoscope (usually 24-Fr vs. 4.5/6.5-Fr; combine with an electrocautery loop vs. only a scope) and surgical procedure (resection vs. only blunt operation).
We are trying to describe four methods of treating hematospermia as follows: when the opening of the ejaculatory duct is observed from the urethra, inserting into this natural orifice (the first way) is the first choice; whereas in other patients, when the opening is not identified clearly, there are two methods.
First, some surgeons applied TURED (the second way) to observe the covered ejaculatory duct openings. The probable complications of retrograde ejaculation and urinary reflux limited the widely application of this method. At present, surgeons hardly use TURED to locate the opening of the ejaculatory duct exclusively, while some surgeons try to treat patients with Mullerian duct cyst.In addition, surgeons can insert into the verumontanum orifice and establish a surgical path through the ejaculatory duct (the third way) or SV (the fourth way) directly. The only difference between these two approaches is the puncture site (the inner wall of the utricle entrance or the laterposterior aspect of the utricle wall). Anyway, the most important factors are safety and efficacy depending on which method should be used firstly.
We can evaluate safety on the basis of anatomical structure. Nguyen et al.  reported the ejaculatory duct and SV consist of three similar histological layers, including a columnar epithelium, a collagenous coat and a muscular layer. The most surprising finding was that all these three layers become thin as the duct proceeds distally, especially the almost disappearing muscular layer. It is not difficult to conclude that the more distal area we puncture, the fewer tissues we destroy. Li et al. reported that the opening of the ejaculatory duct was covered by the valves that needs to be protected in order to prevent urinary reflux into the ejaculatory ducts. This finding may explain why TURED causes these complications of retrograde ejaculation and urinary reflux.
After approximately 10 years’ application of rigid vesiculoscope, we recommend an approach (Wu’method) through the distal ejaculatory duct, not inserting into the opening of the ejaculatory duct, passing the inner wall of the utricle entrance. The key procedure of this method is to tentatively scratch the entrance of the inner wall of the utricle entrance using the former endoscope. Then, the membrane-like tissue is identified under the monitor. After setting up this tissue, the passageway can be detected and used for entering the ejaculatory duct. Because of the process of the creating and setting up the membrane-like tissue, similar to the action of setting up a curtain or quilt, we would like to call this method the uncover-curtainmethod. In our experience, we found that the success rate of this method was high and the outcomes were good. We emphasize this approach by detailed introduction of seminal tracts and try to make a standard for TUSV so as to encourage its use.
Second, the complications of sexual function are important to discuss. To the best of our knowledge, this study is the first research paying attention to sexual dysfunction after this surgery. The follow-up results showed that 12 patients seemed to suffer sexual dysfunction, including the tendency of premature ejaculation and erectile dysfunction. After we investigated the specific surgical approaches of these 12 patients, we surprisingly discovered that all of them had been treated by puncturing using a guidewire through the SV. This fact triggers our thinking to one guess whether this approach would cause more sexual function influence than other two approaches. Sexuality, as an inherent need for human beings, attracts the attention of both patients and doctors. For this reason, we should concentrate on researching the potential relationship between the operation by puncturing using a guidewire through SV and sexual dysfunction. In case this kind of operation can cause sexual dysfunction, we should identify the specific mechanism and countermeasures to prevent these complications by abandoning or improving this method of TUSV. Therefore, our next purpose is to prepare a study to investigate this potential relationship.
There are some limitations in this study. First, its retrospective design invites recall bias. The results of the postoperative outcome are judged by the view of the patients solely. Besides, most patients lacked semen analyses both before and after surgery, due to most patients (always have one or more kids) without the desire to fertile and the expensive price of semen related tests. However, we will collect some younger patients and acquire their semen analyses before and after surgery in the future, because of its effect to verify validity of TUSV. Second, the situation of sexual dysfunction lacks of evaluation of some scales and other examinations, including IIEF-5 or penile Doppler USG investigation. Third, hematospermia is usually a self-limiting disease and the natural course might interfere with the complete remission and improvement rates. However, in this study, patient who have a long history of hematospermia and have been ineffective after long-term treatment were enrolled. In addition, of 16 patients who refused surgery (10 patients before 2011 and 6 patients in this study), only 1 patient recovered within 3 years after a long-term follow-up. Although the probability of natural recovery of our patients is low, it cannot be ruled out that a small number of patients were cured by themselves. Fourthly, we found that the performing of TUSV in patients with single intraoperative finding (only hemorrhage) was more effective than performing in patients with various intraoperative findings (both hemorrhage and stones), which perfectly meet clinical prognosis. However, P>0.05, because of the few number of total cases. Therefore, further verification is needed. Conclusions
TUSV may be an effective and safe procedure for treating recurrent hematospermia by blocking the vicious cycle of stasis, stones and seminal vesiculitis. The anatomy of the distal seminal tract should be understood more deeply and Wu’method (uncover-curtainmethod) needs to be promoted to verify its universality and safety. Besides, the complications of the function dysfunction should be discussed in the future in multi-center clinical trials.