Transurethral Resection of the Ejaculatory Ducts (TURED)


Men with obstruction of the ejaculatory ducts can present with low or normal volume ejaculate with either few, poorly motile sperm or entirely no sperm.  When these findings are repeatable on semen analysis, a specialized ultrasound of the seminal vesicles is recommended.  The seminal vesicles are aspirated for sperm to confirm the presence of an obstruction in their transit.


Transurethral Resection of the Ejaculatory Ducts Resources



Patient Education Guide to Transurethral Resection of the Ejaculatory Ducts

Transurethral Resection of the Ejaculatory Ducts Patient Education Guide


Introduction:


  • You have chosen to have a transurethral resection of the ejaculatory ducts (TURED). This sheet is to help you understand your surgery, what will happen in the hospital and what you can expect when you go home. Below you can find your plan of care from your doctor.

About Ejaculatory Duct Obstruction:


  • In men with azoospermia (no sperm in the ejaculate) or severe oligospermia (few sperm in the ejaculate) and decreased semen volumes, an obstruction may be present where the ejaculatory ducts empty into the urethra.  This may be due to stenosis or scarring of the ducts, stones, or ejaculatory ducts cysts.  A transrectal ultrasound provides an image of the seminal vesicles and ejaculatory ducts.  Obstructed seminal vesicles are often dilated, and aspiration of the obstructed fluid is performed to assess for sperm, which if present, suggests the presence of an obstruction.  Once an obstruction has been confirmed at within the ejaculatory ducts, a transurethral procedure may be performed to “unroof” or open the ejaculatory ducts and allow the passage of sperm into the ejaculate.

About The Surgery:


  • A general anesthetic is given to the patient and a repeat transrectal ultrasound is performed.  The seminal vesicles are visualized similarly to the seminal vesicle ultrasound and aspiration.  A dye is instilled into the vesicles and patient is then placed into the lithotomy position (lying on your back with legs in stirrups).  A cystoscope is inserted through the end of the penis and passed to the level of the ejaculatory duct under direct vision using a camera.  The obstruction is then resected with a cutting loop passed through the inside of the cystoscope, restoring patency to the ejaculatory duct.  The patency is confirmed with visualization of the previously instilled dye seen flowing from the resection site.  A catheter may be left left in the bladder for at least 48 hours to prevent any bleeding that can block the flow of urine.  Studies have demonstrated an average improvement in semen volume of 83%, sperm concentration 62.5%, and natural pregnancy rate of 25% following a TURED procedure.

Before Surgery:


  • You may need to have an evaluation before surgery at UF Health Shands Hospital on the 1st floor. The evaluation is made up of a physical exam, chest X-ray, blood tests, urine tests, an Electrocardiogram and other tests necessary for your health and safety before surgery. At the time, you will be able to ask questions about your medications and hospital care. You will be told about which medications you should take and which you should not take before surgery. Please bring your medications in their original bottles to the before surgery evaluation.
  • If you take medications that cause clotting of the blood such as Coumadin, Plavix, Aspirin, Vitamin E, fish oil, or any NSAID (i.e.: Motrin®, Aleve®, Advil®, ibuprofen), these medications should be reported to your doctor and the person giving you medications. For your safety, these types of medication should not be taken for a least a week before surgery.
  • The day before your surgery, you may eat a light breakfast (no later than 11 a.m.). After breakfast, begin drinking clear liquids (Sprite®, 7up®, ginger ale, apple juice, tea, Jell-O®, ice pops, Gatorade®, chicken or beef broth) for the rest of the day then nothing by mouth after midnight.
  • The morning of your procedure, self-administer a Fleet’s enema for bowel preparation.  You may eat and drink normally afterwards.
  • To find out what time you need to be at UF Health on the day of your surgery call (352) 265-0023 between the hours of 7 p.m. and 11 p.m. the day before surgery.

The Day of Surgery:


  • On the day of surgery, you will get to UF Health at the time you were told. The check-in area is on the 1st floor at the Ambulatory Surgery Check-In desk. You will be taken to the before surgery holding area next to the operating room.
  • Once you are taken into the operating room and the surgery starts, the family can call from the Surgery waiting area on the first floor and get updates from the operating room every 1-2 hours. Your family members must be prepared to wait.
  • The surgery itself takes about 1 hour.  However, it takes at least 1-2 hours to get you ready for the surgery, and you will spend anywhere from 1-2 hours after surgery in the recovery room.  
  • You may have a catheter in your bladder for 48-72 hours after surgery.  This is to help tamponade any bleeding from the resection site.  It’s not uncommon to have blood in the urine for several days following your TURED procedure, since cauterization of the resection site is used sparingly to maintain patency of the ejaculatory ducts.
  • After surgery, the doctor or a member of the surgery team will talk to your family either in person or by phone. At least one family member should stay in the Surgery Waiting Area on the first floor at all times for the entire surgery so that your doctor can locate them and give them an update on your condition once the surgery is over. If none of your family members are in the waiting area then your doctor will not know where to find them.

Care You Should Perform at Home:


  • Foley Catheter:
    • A Foley catheter may be placed at the end of the procedure.  The purpose of the catheter is to tamponade any bleeding from the resection site and to remove urine from your bladder. The catheter will not fall out due to the inflated water balloon at the tip of the catheter in your bladder. Although it is difficult to pull out with the balloon inflated, you should try not to accidentally pull on the tubing to prevent injury to the surgical site.
    • The catheter is connected to a bag that holds the urine.  You will be given 2 bags when you leave the hospital. One bag is a leg bag that can be attached to your thigh area for use under long, loose pants. The larger bag (also called an ‘overnight’ bag) can hold more and should be used at night or while hanging out at home. Either bag should be kept hanging lower than your bladder for it to drain correctly and prevent pressure of urine into your bladder.
  • The Following are Some Tips about your Foley Catheter:
    • Sometimes the catheter in the bladder causes discomfort and bleeding. It is common to see some blood or bloody fluid mixed with urine draining from the catheter.
    • Until the catheter is taken out, it is important to drink at least more fluids than you normally do to increase the amount of urine and to prevent blood clots in the urine.
    • Even with the catheter in place, some urine, mucus and blood can leak around the catheter. This happens more commonly after a bowel movement. You can clean your catheter with warm soapy water daily.
    • You may put some antibiotic ointment at the tip of the penis where the catheter exits several times a day to help wet and protect the area.
    • When changing from the large (overnight) bag to the leg bag, first wash your hands well with warm soapy water. Then clean the connections with alcohol, let them dry, and then switch them.
    • Rarely, the catheter may clog and stop draining. Always make sure urine is collecting in your drainage bag. In the rare chance that it is not, call your doctor as you may need to be to go the clinic or go to the emergency room to have your catheter cleaned out.
    • Rarely, some men have swelling and bruising of their scrotum and penis after surgery. This is not a problem and usually goes away within a couple of weeks. Some people would rather wear briefs or a jock strap for support. You may also elevate your scrotum and testicles when lying down by putting a rolled washcloth or towel
      under them.
    • It is not rare to feel some twinges or sharp pains in your penis or scrotum while the Catheter is in place.
  • Catheter Removal:
    • Your catheter will be removed at a brief follow-up visit after surgery or by your local physician about 48-72 hours after surgery. At this visit, we will do a ‘voiding trial’ where we put water in your bladder through the catheter. We then remove the catheter and ask you to try and empty your bladder. A quick scan will be done in the clinic to see if you have properly emptied your bladder. If you are unable to empty your bladder, it is possible that another catheter will need to be placed.

Medications Following Surgery:


  • You will be prescribed a pain medication for breakthrough pain and an antibiotic which you will take for 3-5 days depending on your prescription.
  • Take pain medication as in the instructions for severe pain but use ibuprofen or naproxen for mild to moderate pain
  • A non-narcotic approach is ideal and proven to provide excellent pain relief along with practical measures such as supportive underwear and intermittent icing).
  • If you feel that your pain is poorly controlled despite practical measures and your prescribed medications, please call our office to discuss the next steps.
  • If you are taking fertility medications such as HCG, FSH, Vitamin E, CoQ, L-carnitine, or vitamin C, you may continue these following surgery.
  • If you are on blood thinners, be sure to confirm it is okay to resume this medication prior to restarting.

Recovery Following Surgery:


  • Please take your medications as prescribed, whether it be your as needed pain medication or your scheduled antibiotics. You are anticipated to have discomfort following your surgery; however, we want you to have a speedy recovery and not be limited by pain.
  • You may notice some swelling in the scrotum as well as black and blue bruising in the surgical areas.  This is common and no reason to worry.  If the swelling continues or you have new onset discomfort different from shortly after surgery, call the office to discuss with our staff.
  • You may notice blood in your ejaculate for up to 1 month following your procedure.  This is not uncommon and should not be cause for alarm.
  • Avoid lifting anything heavier than 10 pounds for the first 2 weeks following surgery.  You may return to work as previously instructed.
  • Abstain from all sexual activity including masturbation until you are seen for your postop follow-up.

Your Follow Up Visit:


  • If you have a catheter, your first post-operative follow-up will be 48-72 hours after your surgery for your catheter removal.  This may be with a nurse or physician associate.
  • Your first appointment with your surgeon will be about two weeks after your surgery.
  • At this visit, you will have a post-surgical check as well as review your recovery course.
  • The next visit afterwards will be 3 months from surgery.  At that time, you will undergo an updated semen analysis.  At that time, make sure to have at least 2-3 days of abstinence since your last ejaculation.

Call Your Doctor If You Have:


  • Trouble urinating or cannot urinate
  • A fever of 102 degrees Fahrenheit or higher
  • Pain that gets worse or does not improve with medication
  • Uncontrolled nausea and vomiting
  • Pain or swelling in your legs
  • Chills and body shakes
  • Active bleeding, increased redness or drainage, or unusual swelling in the area of the incision
  • Any allergic reaction to your prescribed medication.

During work hours (8 a.m.-5 p.m. Monday – Friday) call: UF Health Urology Clinic at 352-265-8240.

AFTER HOURS OR WEEKENDS CALL:
UF Health Shands operator at 352-265-0111 and ask the operator for the urology resident on-call
.


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