AB205. Clinical analysis of the characterization of magnetic resonance imaging and endoscopic therapy in refractory hematospermia

Objectives: To assess the etiological diagnostic value of magnetic resonance imaging (MRI) by analysis of the pelvic MRI manifestations or characteristic changes around the ejaculatory duct area and to evaluate the therapeutic effect of transurethral minimally invasive endoscopic treatment in the persistent and refractory hematospermia patients who are ineffective to the conservative treatment.

Methods: The morphological features and characteristic changes around the area of the bilateral seminal vesicles (SV) and ejaculatory duct (ED) in 76 patients with persistent and refractory hematospermia as well as 41 adult males who performed the MRI but did not have urinary reproductive system diseases (as the healthy control group) were retrospectively analyzed. All the 76 patients followed by undergoing transurethral minimally invasive endoscopic examination and treatment based on the MRI imaging characteristic. The therapeutic effect was followed up, analyzed and summarized.

Results: Based on the analysis to the normal morphological features of the bilateral SVs and ED areas of pelvic MRI images in 41 cases of health adult men, it was found that 88.2% (67/76) patients with persistent and refractory hematospermia showed typical and characteristic changes in the ED and SVs area in MRI imaging. The main characteristic changes are: (I) 61.8% (47/76) patients showed the signal intensity changes in seminal vesicle, in which 24 patients with old hemorrhage showed middle to high signal intensity on both T1-weighted images (T1WI) and T2-weighted images (T2WI), while the other 23 patients with fresh hemorrhage showed high signal intensity on T1WI)and low signal intensity on T2WI; (II) 34.2% (26/76) patients showed significant cystic dilatation (the width of SV is bigger than 1.7 cm or the diameter of the inner tubular structure is bigger than 5 mm) in unilateral or bilateral SV, with or without the internal signal intensity changes; (III) 36.8% (28/76) patients showed the formation of cysts in the ejaculatory area such as prostatic utricular cysts (PUC) in 27.6% (21/76) patients, Müllerian duct cysts (MDC) in 3.9% (3/76) patients, Ejaculatory duct cysts (EDC) in 3.9% (3/76) patients, and an Seminal vesicle cyst (SVC) in 1.3% (1/76) patients. 11.8% (9/76) patients did not show any obvious abnormal changes in MRI imaging. All the patients were successfully performed observation, dilation, incision or irrigation to their ejaculatory duct and related area under the transurethral endoscopy. No obvious complications were found during and after the surgeries. The biopsies were performed in some of the patients and the pathology confirmed that all the tissue from SV only have non-specific chronic inflammation. No tumor was found in the area of prostate, ED and SV. All the patients were followed-up for 3-36 months (average 18 months). The hematospermia and their related symptoms in most of all of them were disappeared after surgery, except for two patients experienced a recurrence of hematospermia after 5 and 11 months of surgery. The two patients underwent the same treatment again as described above, and recovered during the followed-up period. The urination and ejaculation are usually as well as before surgery. Only two old patients complained about that the orgasm and pleasant sensation slightly decreased, the other 97.4% (74/76) patients have normal orgasm and pleasant sensation after surgery.

Conclusions: The etiology of the most cases of the refractory hematospermia can be distinguished using the three-dimensional MRI imaging. Typical abnormalities observed on MR images are signal intensity, SV volume changes and cyst formation. MRI has significant etiological diagnostic value and provides reliable information for the subsequent treatment of patients with persistent and refractory hematospermia. The transurethral endoscopic technique such as the dilatation of the ED, incision of the verumontanum or distal ejaculatory duct, incision or excision of the cyst in this region is a simple, safe, reliable and effective treatment method for the patients with persistent and refractory hematospermia.

Keywords: Hematospermia; magnetic resonance imaging; etiology; minimally invasive surgery; endoscopy; seminal vesiculoscopy