| BACKGROUND and OBJECTIVECongenital absence of vas deferens(CAVD)was considered to be a rare disease before.Approximately 1.3% of all infertile men have congenital bilateral absence of vas deferens(CBAVD),and 1% of all men have congenital unilateral absence of vas deferens(CUAVD).The morbidity statistics have rarely been described in China yet.In our department,1631 infertile men were detected by US during 2014-2015 and 46 CAVDs were diagnosed combined with physical examination and semen analysis.The diagnostic rate increased gradually from our experience.Some studies established an association between CAVD and a presence of a cystic fibrosis transmembrane conductance regulator.The vas deferens(VD),seminal vesical(SV)and epididymis(EP)have the same embryological origination,so CAVD often associated with SV and EP anomalies.The status of SVs for men of CAVD by transrectal ultrasonography(TRUS)indicates a large variability of the morphology in the literature[3]and the classification has not been established.The dysplasia of EP in azzospermia has been described in the literature.However,the images of EP in CAVD were not fully studied.Scrotal ultrasonography(US)and TRUS have been widely used as a convenient and cheap modality for evaluate the male reproductive system obstruction.It is known that US is capable of visualizing VD and the sonographic appearance has been described.But weather US can evaluate CAVD or not has rarely been researched.The aim of this retrospective study is to evaluate the usefulness of US in CAVD by describing the imaging characters of CAVD and the correlation with EP and SV anomalies.Meanwhile we tried to evaluated the value of scrotal and transrectal ultrasonography in etiological diagnosis of obstructive azoospermia,and the rolr in differential diagnosis between obstructive azoospermia ands nonobstructive azoospermia.MATERIAL and METHODSGroup 1: 5 patients aged from 38 to 69 years old were detected by scrotal US before orchiectomy resulting from prostatic cancer or testiculoma.Evaluate the images of the spermatic cord segment of vas deferens and measured the internal and external diameter of VD in longitudinal planes of the segment above the testicle.During the surgery,10 spermatic cord specimens were cut out.Make sure the specimens contained complete structures of spermatic cord.Scanned the specimens immediately through ultrasound gel after surgeries.Evaluated the ultrasonographic features of the VD and measured the internal and external diameter of VD in longitudinal planes.Compare the US findings with the preoperative US,including the position in the spermatic,the lumen and the diameter.Group 2: 50 males aged from 19-46 years old without any history of infertility or scrotal disease were involved in as the normal group.All the spermatic cord segment of vas deferens could be cleared palpated during scrotal examination.Scrotal ultrasonography was performed with the patient in the supine position.The spermatic cord segment of vas deferens was scaned continuously in both transverse and longitudinal planes from the epididymal tail to the inguen.Measured the internal and external diameter of vas deferens in longitudinal planes of the segment above the testicle.Because this segment is easy to palpated and not easy to be covered by the testicle and epididymis.Doppler images were performed to distinguish the vas deferens from the vessels in the spermatic cord.In some cases,the vas deferens especially the lumen could not be clearly detected because of the inappropriate location.We used two fingers to hold the vas deferens,detected with the other hand at the same time.Right and left size measurements were compared using Student T test.The means and SDs were calculated in millimeters.Calculate the testicular volume of both sides by using the formula of length×height×width×0.71 ml.Group 3 : 46 male patients aged from 22 to 47 years old visited the clinic of the Infertility Department in our hospital were involved in this study.According to the World Health Organization(WHO),infertility was defined as the inability to initiate a pregnancy after 1 year of unprotected intercourse,and all 46 patients met WHO diagnostic criteria for infertility.Semen analyses of normal ejaculate were first performed twice by our laboratory,as per WHO guidelines,to confirm azoospermia.These patients were presumptively diagnosed as congenital absence of vas deferens based on the physical examination by the same urologist with a work experience above five years.If 1 or 2 sides of the VD could not be palpated in the scrotums,the further semen analysis was performed including the followings: an examination of semen volume,PH and fructose.All the 46 patients presented with hemospermia,low semen volumes,low PH and fructose negative.Meanwhile the semen could not solidified sponteneously.Scrotal high resolution ultrasonograph was used to evaluated the existence of the vas deferens and the morphologic changes of the epididymises.Color Doppler image was performed to distinguish the vascular structure.We defined CAVD if the spermatic cord segment of VD could not be found by high resolution ultrasound.Transrectal ultrasonography was performed with the patient in the left lateral decubitus position,and the ampulla segment of vas deferenses,seminal vesicles,and ejaculatory ducts were examined in a systemic manner in both transverse and longitudinal planes.Calculate the testicular volume of both sides by using the formula of length×height×width×0.71 ml.Group 4 : 48 male patients aged from 28 to 49 years old visited the clinic of the Infertility Department in our hospital were involved in this study.all 46 patients met WHO diagnostic criteria for infertility.Semen analyses of normal ejaculate were first performed twice by our laboratory,as per WHO guidelines,to confirm azoospermia.These patients were presumptively diagnosed as other types of azoospermia based on the physical examination by the same urologist with a work experience above five years,all bilateral spermatic code segment of vas deferens of 48 patients were clearly palpable.(33 of them were obstructive azoospermia and 16 of them were nonobstructive azoospermia based on the testicular biopsy followed.)Then transrectal ultrasonography was used to evaluated the existence and the morphologic changes of seminal vesicles and ampulla segment of vas deferens.Scrotal high resolution ultrasonograph was used to evaluated the existence and the morphologic changes of vas deferens and epididymis.Color Doppler image was performed to distinguish the vascular structure.Calculate the testicular volume of both sides by using the formula of length×height×width×0.71 ml.The volume were compared with other groups using t test.A TOSHIBA medical ultrasound scanner typed APLIO 500 was used to perform TRUS and high resolution studies.A linear-array transducer typed PLT-805 AT was used for all scrotal examination with the following settings: center frequency 8MHz,dynamic range90 d B.A intralumen transducer typed PVT-661 VT was used for all TRUS with the following settings: center frequency 6MHz,dynamic range 90 d B.Congenital absence of vas deferens were classified into the three following categories:1:congenital bilateral absence of vas deferens,which was defined by the bilateral absence of any of the three segment: the spermatic cord segment,the epididymal segment and the ampulla segment.2 : congenital unilateral absence of vas deferens,which was defined by the unilateral absence of any of the three segment,meanwhile the contralateral vas deferens could be detected.3: congenital partial absence of vas deferens,which was defined by the partial absence of the three segment,some segment can still be detected.The anomalies of epididymis were classified into the following categories:total absence、absence of epididymal body and tail 、short epididymal body and tail、net-like ectasia、tube-like ectasia、mass-like lesion.The anomalies of seminal vesicles were classified into the following categories : absence and hypoplasia.The seminal vesicle was defined as hypoplasia when the image showed a hypoechoic trabs.Finally,we determined whether or not there was an inflammatory cyst of the ejaculatory duct,which manifested as a cystic anechoic structure filled with debris,in the distal genital duct.We didnot distinguish between left and right inflammatory cysts of the ejaculatory duct because location could not be reliably identified on transrectal ultrasonography scanseter.The differences in abnormal ultrasonography findings between the congenital absence of vas deferens and other types of obstructive azoospermia were analyzed by Χ2test.The differences in abnormal ultrasonography findings between nonobstructive azoospermia and obstructive azoospermia were analyzed by Χ2test after we incorporating the congenital absence of vas deferens into the obstructive azoospermia.Testicular volume in normal group was compared with that in azoospermia by means of t test.RESULTSGroup 1: 5 specimens from orchiectomy showed the ultrasonographic feature that was indentical with the vas deferens in vivo before surgery and the diameter was the same too.The image of VD was a cord like structure with two parallel linear reflectors representing the internal walls of the lumen surrounded by a thick,hypoechoic and mostly muscular wall in longitudinal plane.In transverse plane,VD showed a "target" like appearance.No significant difference of the diameter were found between the specimens and the vas deferens in vivo.Group 2: All spermatic segment of vas deferens could be indentified bilaterally in the normal group of 50 cases.The vas deferens showed a straight and very hypoechoic tube located laterally in the spermatic cord.The sonographic features were different with other cord like structures such as arteries and veins including the following points:(1)The VD located in an individual fiber sheath lied laterally in the spermatic cord.(2)The image of vessels showed some anechoic,irregular and bent tubes compared to the VD.(3)The vessels collapse during external compression by the transducer,whereas the VD does not change due to the thick muscular wall.(4)We could detect doppler flow in the vessels,but the VD was lack of flow.The external diameter on the right side was2.15±0.26mm(ranged from 1.6 to 2.7mm)and the left side was 2.16±0.23mm(ranged from 1.7 to 2.6mm).The internal diameter on the right side was 0.39±0.09mm(ranged from 0.2 to 0.5mm)and the left side was 0.41±0.09mm(ranged from 0.3 to 0.6mm).No statistically significant deference was found between the left and right measurements in the 50 normal cases.The testicular volume was 21.85±3.03 ml.Group 3: In all 46 cases with a presumptive diagnosis of CAVD,45 cases were found absent vas deferens,1 case was diagnosis as maldevelopment with the image of thin vas without lumen,but all the three segment could be detected.In the 45 cases,43 cases were found bilateral absence of vas deferens;2 cases were found unilateral absence of vas deferens;9 cases were partial absence of vas deferens.The coincidence rate with clinical presumptive diagnosis was 97.8%.Combined the 45 cases with the 2 cases of partial absence of vas deferens,we totally diagnosis 47 cases of congenital absence of vas deferens.All the absent cases accompanied with the anomalies of seminal vesicle and epididymis,including 43 cases of epididymal abnormality,the highest incidence rate(95.7%)of which was short epididymal body and tail;47 cases of seminal vesicle abnormality,the highest incidence rate(85.1%)of which was absence;4 cases of ejaculatary cyst.44 cases(93.6%)combined of two or more abnormalities.The testicular volume was 22.75±4.33 ml.Group 4: 2 cases of this group were diagnosed as partial absence of vas deferens,so we moved the 2 cases to the vas deferens group.Then we bring 1 case which diagnosed as vas deferens maldevelopment in group 3 into group 4.So we totally had 47 azoospermia cases except for the congenital absence of vas deferens.These 47 cases divided into 30 obstructive azoospermia cases and 17 nonobstructive azoospermia cases according to testicular biopsy.19 cases with abnormal images were found In the 30 obstructive azoospermia cases,including 7 cases(23.3%)of epididymal mass-like lesion、8 cases(26.7%)of epididymal tube-likeectasia、4 cases(13.3%)of ejaculative cyst.11 cases without abnormal images were found in the 30 cases.The testicular volume was22.46±2.53 ml.5 cases(70.6%)of abnormal images and 12 cases(41.7%)without abnormal images were found in the 17 nonobstructive azoospermia cases,including 3casesof epididymal mass-like lesion and 2 cases of ejaculative cyst.The testicular volume was 18.35±5.32 ml.All 94 cases in group3 and group 4 divided into 77 obstructive azoospermia cases(including 47 congenital absence of vas deferens diagnosed with ultrasonography and30 cases with other types of obstructive azoospermia)and 17 nonobstructive azoospermia cases.In the 77 cases,ultrasonography diagnosed 66 cases according to the abnormal images,the diagnostic accordance rate was 85.7%,11 cases without abnormal images could not be diagnosed by ultrasonography.We misdiagnosed 5 cases as obstructive azoospermia according to the abnormal images,the misdiagnosis rate was29.4%.These 5 cases were diagnosed as nonobstructive azoospermia finally.The testicular volume was bigger in the 77 obstructive azoospermia cases than the 17 nonobstructive azoospermia,the difference was statistically significant(P<0.05).The difference of abnormal images between the 2 group was statistically significant(P<0.05).We only found epididymal epididymal mass-like lesion and ejaculative cyst in the 17 nonobstructive azoospermia cases.We found scrotal ultrasonography data in accordance with obstructive etiology in 63 of77 patients,for a sensitivity of 81.8% and specificity of 82.4%,and for a a sensitivity of17.6% and specificity of 18.2% in accordance with nonobstructive etiology.The transrectal ultrasonography data with obstructive etiology in 64 of 77 patients was found for a sensitivity of 83.1% and specificity of 88.2%,for a sensitivity of 11.8% and specificity of 16.9% with nonobstructive etiology.The scrotal combined with transrectal ultrasonography data with obstructive etiology in 70 of 77 patients was for a sensitivity of 90.9% and specificity of 94.1%,for a sensitivity of 5.9% and specificity of 9.1% with nonobstructive etiology.Ultrasonography was an effective imaging modality in the diagnosis of obstructive azoospermia than in the diagnosis of nonobstructive azoospermia(P<0.05)and combined the scrotal and transrectal ultrasonograpyh was more effective than use alone(P<0.05).CONCLUSIONS The spermatic cord segment of vas deferens can be detected by ultrasonography.Ultrasonography provide a valuable diagnosis of congenital absence of vas deferens.Seminal vesicle and epididymis anomalies often associated with congenital absence of vas deferens by ultrasonography.The scrotal and transrectal ultrasonography are effective image modalities in the differential diagnosis of congenital absence of vas deferens and other type of obstructive azoospermia based on the various abnormal images.The value in nonobstructive azoospermia is not clear yet. |
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