Purpose: Ejaculatory duct obstruction (EDO) is one of the few surgically treatable causes of azoospermia. Approximately 1% – 5% of men lose their fertility as a result. Transurethral resection of the ejaculatory duct (TURED) has become a classic treatment for ejaculatory duct obstruction. In this paper, we investigate the feasibility and efficacy of real-time transrectal ultrasound monitoring during TURED. Methods: From July 2006 to June 2007, 11 male patients with ejaculatory duct obstructive azoospermia, aged 26-42(32±4.6) years, with no pregnancy for 1-13(4.8±2.3) years after marriage, were admitted to our hospital and followed up. 5 of the 11 patients had no obvious conscious symptoms; 2 had a history of genitourinary tract infection. The patients had a history of genitourinary tract infection; 3 cases of hematospermia, 3 cases of vague pain or discomfort in the perineum, scrotum and testes, and 2 cases of painful ejaculation. The patients were all male infertility patients who had been married for more than 1 year and had been diagnosed with azoospermia by more than 3 semen examinations. Spousal infertility was excluded by examination. The secondary sexual characteristics were obvious on physical examination, no abnormalities were detected in the penis, and at least one testicle and vas deferens could be retrieved without abnormalities. Sex hormones: LH 4.21-7.23 (5.3±1.2) IU/L, FSH 8.41-9.95 (8.9±0.8) IU/L, PRL 24.09-27.38 (25.3±2.1) IU/L. Semen examination: no sperm. Single ejaculate volume 0.1-2.2 ml, semen pH <7.2, seminal plasma fructose (-). Mature sperm production in the testis was confirmed by epididymal/testicular puncture or testicular biopsy. Preoperative TRUS revealed: dilatation of seminal vesicles > 1.5 cm; cyst formation of 5-22 (15±7) mm near or off the midline of the seminal frenulum with dilatation of the ejaculatory duct; and stone formation in the lumen of the ejaculatory duct in three cases. Group A (6 cases) was randomly divided into two groups: Group A (6 cases): intraoperative vas deferens puncture was performed immediately to inject melanoma fluid, and the assistant reached into the index finger to squeeze the prostate and seminal vesicles during the operation to observe whether there was melanoma fluid flowing out of the surgical wound in order to grasp the depth and scope of electrodesiccation; Group B (5 cases): electrodesiccation was performed according to the location and depth of the cyst under real-time monitoring by transrectal ultrasound during the operation. Postoperatively, all were left with F18 three-lumen catheter for continuous bladder irrigation for 12-36 hours until the disappearance of meatus hematuria, and intravenous or oral antibiotics for 7-10 days. RESULTS: The mean operative time was 45 min in group A, significantly higher than 25 min in group B (P=0.008), and the postoperative bladder irrigation time was 30 hours in group A, significantly higher than 18 hours in group B (P=0.024); 11 patients were followed up for 1-12 months after surgery, and there was no significant difference between the two groups. 3 patients with ejaculation pain and hematuria had their symptoms relieved and disappeared after surgery, and 2 cases developed epididymitis, which was cured after antibiotic treatment. Eight cases (72.7%) had different degrees of improvement in postoperative semen examination, and all of them appeared after 2 months postoperatively: single ejaculate volume rose to: 1.7-4.2 (2.9±0.9) ml, pH 6.5-7.8 (7.4±0.5), seminal plasma fructose (+). 5 cases (45.5%) had spermatozoa in the reexamined semen, and none of the patients had yet patients made their wives pregnant. Conclusion: Trans-urethral ejaculatory ductotomy with real-time monitoring by transrectal ultrasound can effectively relieve ejaculatory duct obstruction with accurate intraoperative positioning, short operative time, little damage to prostate tissue, avoiding damage to the external urethral sphincter and rectum, and fast postoperative recovery, which is worth promoting.