Editorial Comment on: An Innovative Technique of Transurethral Seminal Vesiculoscopy with Ultrasonic Lithotripter for Severe,Persistent Hematospermia by Zhang et al .

In this report, Dr. Zhang et al. describe a novel and interesting endoscopic approach to tackle a previously difficult-to-treat, although mostly benign, condition, hematospermia. For the purposes of this study, they opted to only include patients with “persistent severe” hematospermia, which they defined as occurring more than six times or lasting >6 months and failing a 4-week course of antibiotic therapy. Before inclusion, all patients underwent urinary testing, including microbiology, serum testing for complete blood count, coagulation factors and prostate specific antigen, imaging by way of transrectal ultrasonography, computed tomography or magnetic resonance imaging, and cystoscopy and biopsy as needed. Once all nonseminal tract disorders were excluded, patients were recommended to proceed with transurethral seminal vesiculoscopy (TSV). Depending on the treating physician's preference, patients underwent TSV with either water irrigation±Holmium laser lithotripsy (group A) or TSV with ultrasonic lithotripsy (group B). A urethral catheter was placed postoperatively and removed 24 hours later.

Procedural efficacy was defined as a combination of absence of recurrence after 1 year of follow-up, resolution of symptoms, and negative transrectal ultrasonography 4 weeks postoperatively. At median follow-up times of 28 and 31 months, all 14 patients in group B had no evidence of recurrence (1 patient underwent a staged approach), 1/16 patients in group A had an aborted procedure because of bleeding, and 2/16 patients had recurrence of their disease. There were no major complications in each group. Accordingly, the authors concluded that TSV with ultrasonic lithotripsy confers a better overall outcome and recommended its use in this subset of patients.

The study did not, however, address whether this intervention had any negative impact on ejaculatory function (volume, quality, direction [retrograde vs antegrade], and time to ejaculation) or sexual function. Similarly, little is known as to whether ultrasonic lithotripsy in proximity to genital structures may have any downstream detrimental effects on semen analysis parameters and quality. These issues need to be better evaluated before any generalized adoption of this technique.

Finally, although preliminary results from this retrospective, nonrandomized, pilot study seem promising, further large prospective studies are needed to better assess the overall safety and efficacy of TSV with ultrasonic lithotripsy, particularly considering the benign nature of hematospermia treated in this cohort.