Men with fructose-negative azoospermia, low semen volume, and at least one palpable vas deferens have either a congenital vasal anomaly or obstruction of the ejaculatory duct. Digital rectal examination may reveal a midline cystic structure. Transrectal sonography has revolutionized the diagnosis and treatment of ejaculatory duct obstruction. If a midline cystic lesion or dilated ejaculatory ducts and seminal vesicles are visualized sonographically, we may ask our sonographer to aspirate 2–3 cm of fluid and instill methylene blue. The aspirate is examined microscopically and if sperm are found, transurethral resection (TUR) of the ejaculatory duct is performed without need for prior vasography as the presence of sperm indicates that at least one side is not obstructed more proximally and that the cyst or dilated ejaculatory duct communicates with a nonobstructed vas. The instillation of methylene blue assists in localizing the opening of the ejaculatory duct and confirms that resection has entered the system. Transrectal aspiration should be performed immediately prior to anticipated surgery and should employ the same bowel prep and antibiotic prophylaxis used for transrectal prostate biopsy. If no sperm are found in the aspirate, vasography is necessary. This is performed as previously described. If no sperm are found in the vas, vasoepididymostomy is performed at the same sitting.
If ejaculatory duct obstruction is confirmed by vasography employing a 50% water-soluble contrast media, the umbilical artery catheters used for vasography stents are left in place so that a dilute methylene blue solution can be injected by the assistant during resection. The resectoscope, with the 24-Fr cutting loop, is engaged with a finger placed in the rectum providing anterior displacement of the posterior lobe of the prostate. The ejaculatory ducts course between the bladder neck and the verumontanum and exit at the level of and along the lateral aspect of the verumontanum. Resection should be carried out in this region with great care taken to preserve the bladder neck proximally, the striated sphincter distally, and the rectal mucosa posteriorly, Efflux of methylene blue from dilated orifices confirms adequate resection.
Avoid excessive coagulation. If formal vasography is performed, the hemivasotomies are closed employing microsurgical technique. A Foley catheter is left overnight and the patient should receive a 5- to 7-day course of antibiotics.