Transurethral Seminal Vesiculoscopy: A Breakthrough in Diagnosing and Treating Seminal Tract Disorders

Introduction

Hematospermia (blood in the semen) and ejaculatory duct obstruction (EDO) are conditions that cause significant distress to affected men. Hematospermia, while often benign and self-limiting, can be persistent and refractory to conservative treatment in a substantial number of patients. EDO, on the other hand, is a surgically correctable cause of male infertility, accounting for 1-5% of obstructive azoospermia cases (Achermann and Esteves, 2021) [1].

For decades, the deep pelvic location of the seminal vesicles made them one of the most challenging organs to access surgically. Traditional open or laparoscopic approaches required extensive dissection with significant risks of bleeding and damage to surrounding structures. The advent of Transurethral Seminal Vesiculoscopy (TSV) in 1998, when Yang et al. first successfully performed endoscopic examination of the seminal vesicles, fundamentally changed the management paradigm for seminal tract disorders (Yang et al., 1998) [2].

Dr. Chui Ka Lun, Specialist in Urology and a pioneer in introducing advanced urological techniques to Hong Kong, brought TSV to the territory as part of his commitment to providing patients with the most advanced minimally invasive options available. As a National Security Education Mentor and advocate for Greater Bay Area medical integration, Dr. Chui has been instrumental in bridging medical innovations between mainland China and Hong Kong, leading delegations of Hong Kong physicians to visit mainland hospitals and encouraging multi-site practice in the GBA region.

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What Is Transurethral Seminal Vesiculoscopy?

Transurethral Seminal Vesiculoscopy (TSV) is a minimally invasive endoscopic procedure that provides direct visualisation of the entire seminal tract, from the ejaculatory ducts through to the seminal vesicles. Using an ultra-thin endoscope (typically 4.5-6.5 French rigid ureteroscope or a flexible ureteroscope), the surgeon navigates through the natural urethral opening, past the verumontanum, through the prostatic utricle, and into the ejaculatory ducts to reach the seminal vesicles.

The procedure serves a dual purpose: it is both diagnostic and therapeutic. During a single session, the surgeon can directly visualise pathology such as stones, cysts, blood clots, mucosal inflammation, and strictures, while simultaneously performing therapeutic interventions including stone fragmentation with holmium laser, cyst drainage, lavage of infected material, and dilation of stenotic segments.

The landmark study by Chen et al. (2018) at Shanghai Changhai Hospital, the largest published series to date, demonstrated that TSV was successfully performed in 381 out of 419 patients (90.9%), with hematospermia alleviated or resolved in 85.0% of cases within three months of surgery [3].

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Indications for Seminal Vesiculoscopy

TSV is indicated for a range of seminal tract disorders where conservative management has failed or where direct visualisation is required for accurate diagnosis.

Refractory Hematospermia

The most common indication for TSV is persistent or recurrent hematospermia that has not responded to at least three months of conservative treatment including antibiotics, anti-inflammatory medications, and alpha-blockers. In the study by Liao et al. (2019), which analysed 305 cases of refractory hematospermia, TSV was found to be safe and effective, with the ability to identify the underlying cause in the vast majority of cases [4].

Ejaculatory Duct Obstruction (EDO)

EDO is a surgically correctable cause of male infertility. Patients typically present with low ejaculate volume, azoospermia or severe oligospermia, acidic seminal pH, and absent fructose. TSV offers a minimally invasive alternative to transurethral resection of the ejaculatory duct (TURED), with the critical advantage of preserving the anti-reflux mechanism of the ejaculatory ducts. In a 2025 prospective cohort study by Omar et al., seminal vesiculoscopy achieved successful sperm retrieval in 9 out of 14 patients with confirmed EDO, with 4 patients achieving natural conception within one year (Omar et al., 2025) [5].

Seminal Vesicle Stones

Stones within the seminal vesicles or ejaculatory ducts are a significant cause of refractory hematospermia. TSV allows direct visualisation and fragmentation of these stones using holmium laser lithotripsy, with immediate lavage and clearance. The study by Yao et al. (2023) demonstrated that the presence of seminal tract stones or cysts was a significant predictor of favourable postoperative outcomes (OR 0.244, P = 0.010) [6].

Seminal Vesicle Cysts and Chronic Seminal Vesiculitis

Cysts within the seminal tract can cause obstruction, pain, and hematospermia. TSV enables precise cyst drainage and marsupialisation under direct vision. Chronic seminal vesiculitis with accumulated infected material can be thoroughly lavaged during the procedure.

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The Surgical Technique

Patient Preparation

The patient is instructed to abstain from sexual activity for three days before the procedure. Preoperative imaging with MRI of the seminal vesicles is essential, as MRI demonstrates a higher positive rate for detecting stones (particularly protein-based stones) and blood accumulation compared to transrectal ultrasound (TRUS) [6]. The procedure is performed under general or spinal anaesthesia with the patient in the lithotomy position.

Step-by-Step Procedure

Step 1: Urethral and Bladder Inspection. A 4.5/6.5F rigid ureteroscope is introduced through the urethra into the bladder using normal saline as the irrigation solution. The urethra and bladder are carefully inspected for stones, diverticula, and tumours.

Step 2: Verumontanum Identification. The endoscope is retracted to the verumontanum, the anatomical landmark on the posterior urethra. The normal appearance and shape of the verumontanum are assessed, and the openings of the prostatic utricle and ejaculatory duct orifices are identified.

Step 3: Access to the Seminal Vesicle. The surgeon selects the optimal approach based on the patency of the ejaculatory duct orifice. Three approaches are available, listed in order of preference:

Data from Yao et al., 2023 [6]

The natural orifice approach (Method A) is always preferred when feasible, as it preserves the original anatomical structure, minimises interference with seminal tract fluid dynamics, and achieves the lowest recurrence rate.

Step 4: Seminal Vesicle Exploration and Treatment. Once inside the seminal vesicle cavity, the surgeon systematically examines for bleeding, stones, cysts, old blood clots, and mucosal lesions. In the Chen et al. (2018) series, intraoperative findings included seminal vesicle bleeding in 95.0% of patients, ejaculatory duct stenosis or obstruction in 81.9%, mucosal lesions in 54.9%, and calculi in 5.0% [3].

Step 5: Therapeutic Interventions. Based on findings, the following interventions may be performed:

• Stone fragmentation using holmium laser lithotripsy, crushing stones into powder followed by thorough irrigation and clearance
• Cyst drainage and marsupialisation for seminal vesicle or ejaculatory duct cysts
• Lavage with normal saline to remove blood clots, infected material, and debris
• Stricture dilation for ejaculatory duct stenosis
• Bacterial culture of seminal vesicle flushing fluid for targeted antibiotic therapy

Step 6: Bilateral Examination. After completing the examination and treatment of one side, the endoscope is withdrawn to the prostatic utricle and redirected to the contralateral seminal vesicle. In the Chen et al. series, 42.65% of patients had bilateral involvement [3].

Step 7: Completion. After confirming no active bleeding, a 16F three-chamber silicone urinary catheter is placed. The catheter is typically removed within 24-48 hours.

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Clinical Outcomes and Evidence

Technical Success Rate

Across multiple large series, TSV demonstrates consistently high technical success rates. The following table summarises key outcome data from landmark studies:

Hematospermia Outcomes

For the primary indication of refractory hematospermia, TSV achieves resolution or significant improvement in approximately 85% of patients within three months. The recurrence rate varies by surgical approach, with the natural orifice method achieving the lowest rate of 24.4% at one year (Yao et al., 2023) [6].

Fertility Outcomes

For patients with ejaculatory duct obstruction, TSV offers promising fertility outcomes. The Omar et al. (2025) prospective study demonstrated significant improvements in seminal parameters following the procedure, with mean ejaculate volume increasing to 1.96 mL, sperm concentration reaching 16.9 million/mL, and motility improving to 19.1%. Four out of fourteen patients (28.6%) achieved natural conception within one year [5].

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TSV vs. TURED: Why Vesiculoscopy Is Superior

Transurethral resection of the ejaculatory duct (TURED) has been the traditional surgical approach for ejaculatory duct obstruction. However, TSV offers several critical advantages:

The 2025 AUA abstract by Omar et al. specifically concluded that "ESMT and seminal vesiculoscopy are promising, less invasive alternatives to TURED, preserving ejaculatory function with similar success and fewer complications" [5].

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Complications and Safety Profile

TSV has an excellent safety profile. Across all major published series, serious complications are exceedingly rare.

Common (self-limiting):

• Transient hematuria (resolves within 1-3 days)
• Transient hematospermia (may persist for 1-4 weeks, considered normal)

Rare:

• Epididymitis (reported in 2 out of 419 patients in the Chen et al. series; resolved with 3-7 days of intravenous antibiotics) [3]

Very rare:

• Retrograde ejaculation (reported in 1 out of 419 patients, specifically associated with transurethral resection of the verumontanum, which is no longer routinely performed) [3]

Not reported in any major series:

• Seminal vesicle perforation
• Erectile dysfunction
• Urinary reflux into ejaculatory duct
• Rectourethral fistula
• Urinary incontinence

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Recovery Timeline

TSV is increasingly performed as a day surgery procedure. The study by Cui et al. (2020) specifically demonstrated the feasibility and efficacy of TSV as a day surgery procedure with a 95.7% successful insertion rate [7].

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Who Is a Candidate for Seminal Vesiculoscopy?

Ideal Candidates

You may be a candidate for TSV if you experience any of the following:

1. Persistent hematospermia lasting more than three months despite antibiotic and anti-inflammatory treatment
2. Recurrent hematospermia with multiple episodes over months or years
3. Male infertility with suspected ejaculatory duct obstruction (low volume, azoospermia, acidic pH)
4. Seminal vesicle stones identified on MRI or transrectal ultrasound
5. Chronic pelvic pain associated with seminal vesiculitis unresponsive to medical therapy

Contraindications

TSV may not be suitable for patients with:

• Active urinary tract infection (must be treated first)
• Congenital abnormalities of the seminal tract identified on preoperative imaging
• Genitourinary tract tumours confirmed by MRI
• Systemic bleeding disorders
• Severe seminal vesicle atrophy or deformity (may result in technical failure)

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Frequently Asked Questions

Is the procedure painful?

TSV is performed under general or spinal anaesthesia, so you will not feel any pain during the procedure. After the procedure, most patients experience only mild discomfort that is well controlled with standard pain medications. The majority of patients describe the recovery as significantly less painful than they anticipated.

How long does the procedure take?

The procedure typically takes 30-60 minutes, depending on the complexity of the findings and whether therapeutic interventions such as stone fragmentation are required. Bilateral procedures may take slightly longer.

Will I need to stay in hospital?

TSV is increasingly performed as a day surgery procedure. Most patients are discharged within 24 hours of the procedure. In some cases, an overnight stay may be recommended for observation.

Will the procedure affect my sexual function?

TSV is specifically designed to preserve sexual and ejaculatory function. Unlike TURED, which disrupts the anti-reflux mechanism of the ejaculatory ducts, TSV navigates through natural orifices without resecting tissue. The risk of retrograde ejaculation is extremely low (less than 0.3% in published series) and is specifically associated with verumontanum resection, which is no longer routinely performed.

What are the chances of hematospermia recurring?

The recurrence rate depends on the surgical approach and underlying pathology. Using the preferred natural orifice approach, the one-year recurrence rate is approximately 24%, which is significantly lower than the 44-50% rates seen with more invasive approaches. Patients with seminal tract stones or cysts have the most favourable prognosis.

Can this procedure help with infertility?

Yes. For patients with ejaculatory duct obstruction causing infertility, TSV can restore the patency of the ejaculatory ducts and improve seminal parameters. In the Omar et al. (2025) study, 64% of patients had successful sperm retrieval, and 28.6% achieved natural conception within one year.

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Why Choose Hong Kong for Seminal Vesiculoscopy?

Hong Kong offers a unique combination of advantages for international patients seeking advanced urological procedures. The territory's world-class medical infrastructure, internationally trained urologists, and strategic location make it an ideal destination for medical tourism from the GCC region.

Dr. Chui Ka Lun is one of the few urologists in Hong Kong who has introduced and performs all three advanced minimally invasive urological procedures: HoLEP (Holmium Laser Enucleation of the Prostate), Transperineal Prostate Biopsy, and Transurethral Seminal Vesiculoscopy. His comprehensive expertise means that patients can receive a complete diagnostic workup and treatment plan under the care of a single specialist.

Beyond his clinical practice, Dr. Chui is actively involved in charitable medical initiatives, having spearheaded the HKFTU Specialist Clinic's charitable joint replacement programme "Walk With You, Stand Up Together" (與你同行站起來). He also leads delegations of Hong Kong physicians to visit mainland Chinese hospitals, promoting medical development awareness and encouraging multi-site practice across the Greater Bay Area.

For GCC patients, Hong Kong offers visa-free entry, direct flights from major Gulf cities, bilingual medical staff, halal dining options, and prayer facilities, ensuring a comfortable and culturally sensitive medical tourism experience.

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References

1. Achermann APP, Esteves SC. Diagnosis and management of infertility due to ejaculatory duct obstruction. Int Braz J Urol. 2021;47(4):868-881.
2. Yang SC, et al. Transurethral seminal vesiculoscopy. J Endourol. 1998;12:S59.
3. Chen R, et al. Transurethral seminal vesiculoscopy for recurrent hemospermia: experience from 419 patients. Asian J Androl. 2018;20(5):438-441.
4. Liao LG, et al. Etiology of 305 cases of refractory hematospermia and therapeutic efficacy of transurethral seminal vesiculoscopy. Sci Rep. 2019;9:5797.
5. Omar M, et al. The outcome of transurethral seminal vesiculoscopy regulated by Endoscopic Seminal Vesicle Milking Test in treating ejaculatory duct obstruction. Arab J Urol. 2025.
6. Yao RJ, et al. Efficacy of various surgical approaches in treating hematospermia using transurethral seminal vesiculoscopy. BMC Surg. 2023;23:385.
7. Cui B, et al. Efficacy and feasibility of day surgery using transurethral seminal vesiculoscopy. Transl Androl Urol. 2020;10(1):34-42.
8. Liu ZY, et al. Transurethral seminal vesiculoscopy in the diagnosis and treatment of seminal vesicle stones. Chin Med J. 2009;122(13):1540-1542.
9. Neto FTL, et al. Management of ejaculatory duct obstruction by seminal vesiculoscopy: case report and literature review. JBRA Assist Reprod. 2020;24(3):354-358.
10. Zhang W, et al. Efficacy analysis of ejaculatory duct obstruction treated with seminal vesiculoscopy. Front Surg. 2022;9:1031739.