Transurethral Resection of Ejaculatory Duct Cyst Following High-Intensity Focused Ultrasound for Prostate Cancer

M. West, K. Vazquez, Y. Katlowitz, D. Silver, A. Schulman

High-intensity focused ultrasound, Ejaculatory duct cyst, Dysorgasmia

Introduction:
High-intensity focused ultrasound (HIFU) treatment for localized prostate cancer has been associated with adverse events common to focal therapy, including urinary incontinence and erectile dysfunction. However, there are also lesser-known adverse events related to the anatomic changes produced by HIFU.

Objectives:
We present the case of a symptomatic ejaculatory duct cyst following HIFU and the management thereof.

Methods:
Medical records and intraoperative video footage were reviewed and developed into a video describing transurethral resection of an ejaculatory duct cyst that occurred following HIFU treatment for prostate cancer.

Results:
The patient complained of dysuria, obstructive voiding symptoms, and dysorgasmia approximately 1.5 years following his HIFU treatment. Digital rectal exam revealed a soft paramedian lesion. Prostate magnetic resonance imaging (MRI) confirmed a lesion in the treatment bed, likely representing an ejaculatory duct cyst. The patient underwent transurethral resection of the cyst. Real-time intraoperative ultrasound was used to guide the resection. Prostate tissue was resected above the cyst as visualized on ultrasound until the cyst was entered as evidenced by drainage of cyst fluid. The cyst was then completely unroofed and visualized to be nearly completely resolved on ultrasound. Following the resection, the patient’s voiding and ejaculatory symptoms resolved.

Conclusions:
Focal prostate cancer treatments, including HIFU, cause alterations in prostatic anatomy. Hence, imaging is especially important in this patient population when the patient complains of obstructive voiding symptoms and dysorgasmia. A transurethral, image-guided approach to drainage of post-HIFU ejaculatory duct cysts is feasible in selected cases.

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