Abstract Primary diseases of the seminal vesicle are rare. Most seminal vesicle cysts are congenital, and two-thirds are associated with renal dysplasia or agenesis and ectopic ureter opening into the seminal vesicle. Acquired cysts may be due to genitourinary infections, surgical prostate resection or ejaculatory duct lithiasis. We report a case of video laparoscopic ablation of seminal vesicle cysts.
Seminal vesicle cysts are rare lesions that can be either congenital or acquired.1 The majority remain asymptomatic. However, those cysts that become symptomatic usually require surgical management for alleviation of symptoms. Open surgery has been considered the definitive form of treatment. Although these procedures have produced excellent results, they can be associated with significant morbidity, such as rectal and bladder wall injury, ureteral injury, injury to the erectile neurovascular bundle and pelvic urinoma.2 With advances in laparoscopic equipment and experience it was natural to extend this approach to the seminal vesicle cyst. To date, due to the rarity of this lesion, only 10 cases of laparoscopic excision have been reported.
We report the eleventh case, of a laparoscopic seminal vesicle cyst excision.
A 78-year-old man presented with urinary frequency, nocturia, dribbling, reduced force of urinary stream, and an episode of acute urinary retention. The past medical history is significant for prostate adenocarcinoma discovered upon transurethral resection of the prostate in January 1999. The patient was placed on estramustine with a prostate-specific antigen (PSA) of 5.9 ng/mL. Digital rectal examination revealed a large cystic mass in the area of the left seminal vesicle with no definable limits. Routine blood and urinary laboratory studies were normal. Ultrasonography showed a solid hypoehoic, well-defined and homogeneous tumor between the bladder and rectum. Excretory urography demonstrated elevation of the bladder on the left side. (Fig. 1). Both kidneys were normal. Pelvic magnetic resonance imaging confirmed the presence of 7.7 cm × 6.8 cm left pelvic mass consistent with a seminal vesicle cyst (Fig. 2), which was confirmed on computed tomography (CT) scan (Fig. 3). Six month before the final procedure, transrectal aspiration of the cyst fluid was performed successfully and sent for culture, biochemical testing, and cytology. The aspirated fluid did not contain urine, was sterile, and was full of sperm cells. The cyst recurred 2 months after the initial aspiration.
Video laparoscopic excision of the cyst was performed with the patient under general anaesthesia. A Foley catheter was placed to drain the bladder. Transperitoneal access was achieved through four laparoscopic ports, including a 12 mm port at the umbilicus, a 12 mm port in the midline suprapubic area and 5 mm port on the left and right sides later to the rectoabdominal muscles and a short distance below the umbilicus, respectively.
The surgical table was placed in the Trendelenburg position, the bladder was retracted anteriorly, and the cyst was easily identified by a transverse incision in the retrovesical peritoneum. The left vas deferens was identified and dissected medially to the ampulla, and was used as a guide to the seminal vesicle. The dilated seminal vesicle was initially punctured and emptied. It was then opened to facilitate dissection from the surrounding structures. Finally, it was clipped and excised at the level of the ipsilateral ejaculatory duct. The entire cystic specimen was extracted through the 12-mm port.
The total operative time was 190 min, and blood loss was minimal. The patient was discharged from the hospital on the second postoperative day and did not present with any complaints or complications thereafter. Pathologic examination revealed focal erosion of the overlying epithelium with concurrent evidence of a moderate degree of a non-specific infectious process and the development of fibrosis.
The reproductive and renal systems are embryologically derived from the mesonephric duct. Anomalies of the seminal vesicles are commonly associated with abnormalities of other structures derived from the mesonephric duct, for example the vas deferens, kidney and ureter. One well recognized association is seminal vesicle cyst and ipsilateral renal agenesis.3 Mostly these cysts are asymptomatic and treatment is unnecessary. When symptoms occur they are varied and include perineal pain, scrotal pain, pain on defecation, dysuria, urinary frequency and urgency, and pain on ejaculation. Bladder outlet obstruction and ureteral obstruction have been observed, as have recurrent urinary tract infection, epididymitis and chronic prostatitis.4
The diagnosis of a seminal vesicle cyst is usually made in adulthood in the third to fifth decades of life.5,6 A mechanism of cyst formation is thought to be the build-up of seminal vesicle fluid due to an abnormal or obliterated ejaculatory duct.7
Physical examination may demonstrate an indurated, tender epididymis and ductus deferens, which is evidence of chronic epididymitis or obstruction, or a palpable cystic mass associated with the seminal vesicle on digital rectal examination, as in our case. Alternatively physical examination may show no physical findings, underscoring the need for maintaining a high index of suspicion for this disease entity in appropriate patients.
Abdominopelvic and transrectal ultrasound is the most useful initial diagnostic tool for long-standing pelvic pain and other suspicious historical or physical findings5,8,9 Subsequently CT can be performed to evaluate concurrent renal abnormalities and further define any pathological pelvic process. Additional studies, including excretory urography (IVP), MRI and seminovesiculography, may be selectively needed to differentiate a seminal vesicle cyst from another type of müllerian or wolffian duct cyst, seminal vesicle or rectal carcinoma, liposarcoma, leiomyoma or an abscess in the cul-de-sac.6 Cystoscopy may identify an absent ipsilateral hemitrigone, intravesical cyst protrusion and any other anatomical abnormality of the bladder.
Open surgery has been considered the definitive form of treatment. Although these procedures have produced excellent results, they can be associated with significant morbidity, such as rectal and bladder wall injury, ureteral injury, to the erectile neurovascular bundle and pelvic urinoma.2
In 1993, Kavoussi et al. described the principles of laparoscopic surgery on normal seminal vesicles in patients with prostate cancer.10 Although video laparoscopy is still a new technique, it is considered an alternative approach to treat most seminal vesicles as well as other retrovesical diseases. The technique is less invasive and shows satisfactory preliminary results.
The transperitoneal laparoscopic approach provides straightforward access and excellent visualization of the retrovesical seminal vesicles. Its blood supply can be meticulously controlled and the seminal vesicles can be cleanly dissected free of the bladder, prostate and overlying peritoneum without entering the bladder or rectum.
To date, due to the rarity of this lesion, only 10 cases of laparoscopic excision have been reported.6,11–13 Among these reports the average laparoscopic operative time has been 192 min, with an average hospital stay of 2.2 days (see Table 1). At follow up of 2 months to 15 years all patients have remained asymptomatic. In these few reported cases there have been no injuries to adjacent structures and no major complications.
Table 1. Current reported experience with laparoscopic seminal vesicle cyst excision
In conclusion, recent reports have demonstrated the feasibility and effectiveness of the laparoscopic approach for excision of a seminal vesicle cyst. We propose laparoscopy as the treatment of choice for the management of symptomatic seminal vesicle cysts even if sizable because of its minimal invasiveness and short postoperative hospitalization.