Vol. 116, December Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
CYST OF SEMINAL VESICLE WITH IPSILATERAL RENAL AGENESIS AND ECTOPIC URETER: CASE REPORT HAROLD A. FUSELIER, JR.*
AND
DENNIS H. PETERS
From the Department of Urology, Ochsner Medical Institutions, New Orleans, Louisiana
ABSTRACT
of the seminal vesicle and renal with an A ureter. Nineteen other with similar anomalies are reviewed. The usual age at 1~he onset of the time of maximal is between 20 and 28 years, uu,~,,v,0,0 is established the mass in the area urogra1n. Treatn1ent consists of or transurethrnl --a,,.,,~,-.a.,.~ of the report of a cyst of a seminal vesicle with renal v1as in 1914 Zinner. 1 Since that time 18 other cases have been 2-1s The collection in a single publication was 7 cases reported Donohue and Greenslade. 14 Only 5 of 19 reported patients had an ectopic ureter into the cyst Herein we report the sixth such case. CASE REPORT
A student had left epididymitis 1 week following treatment for gonococcal urethritis. During evaluation at another hospital an excretory urogram (IVP) demonstrated a radiolucent filling defect in the bladder, a non-functioning right kidney and compensatory hypertrophy of the left kidney 1, A). A cystogram and cystoscopy confirmed the presence of an extravesical mass but failed to disclose the cause. An exploratory operation was advised but the patient sought a second opinion. The patient came to this clinic 2 weeks later with recurrent left was instituted. The additional information was that he had an occasional sensation of incomplete emptying of the bladder. Physical examination was unremarkable except for an indurated, tender, left epididymis. The right vas deferens and epididymis were normal. Prostatic examination was unremarkable with secretions containing 8 to 10 white blood cells. The seminal vesicles were not palpable. Urinalysis, SMA-12 and complete blood count were normal. Renal camera study using iodohippurate sodium revealed an enlarged, solitary, left kidney. With the patient under anesthesia a retrograde urethrogram and cystogram revealed the filling defect in the bladder. During cystoscopy the right ureteral orifice and hemitrigone could not be identified and a 5 to 6 cm. smooth, rounded, extravesical mass was present in the area of the right hemitrigone. The left ureteral orifice was normal. The cyst was unroofed with a resectoscope and 200 to 250 ml. tan, turbid fluid containing sperm was obtained. A panendoscope was then introduced into the cyst and an ectopic ureteral orifice was visualized. A retrograde ureterogram confirmed the presence of a blind-ending ureter to the L4 level (fig. 1, : A right vasogram confirmed the presence of a semmal vesicle cyst. Two days later a right ureteroseminal es11:111ecc,1rrtv was done through a midline incision 2). Extravesical and intravesical approaches were used to resect the cyst. Convalescence was uneventful. Accepted for publicatio:1 Niay * Requests for Oehsner Orleans, Loaisi.a.nc.
D!SCUSSJON
The clinical
of a cyst in the seminal vesicie can be 17 of In a thorough of 4 weeks the mesonephric duct makes a sharp bend before entering the cloaca. It is at this that the ureteral primordium appears. The seminal from the-m1csc,ne,pr1nc duct in of 13 weeks. and incorporation of the ,us"u"'""'"' duct into the urogenital sinus cause of the ureter ar.id the mesonephric duct so that the latter takes a more medial and lower and opens into that part of the urogenital sinus that becomes the prostatic urethra. If there is failure at this stage the ureter will open into one of the derivatives of the mesonephric duct, including the epididymis, vas deferens, ejaculation duct and seminal vesicle. Agenesis of the kidney results from incomplete development of the ureteral bud. In the cases reported the ages of the patients from 18 to 41 years, with between 20 and 28 years. The peak age at onset of symptoms is during the time of maximal All of the patients were white. There was approximately equal distribution between the right and left sides, and in l was the condition bilateral. The initial complaints in the majority of cases were lower urinary tract symptoms and perineal discomfort. Three patients were asymptomatic and the anomaly was found during routine rectal examination. Other initial complaints were epididymitis, hematuria and infertility. A frequent complaint was perinea! discomfort after ejaculation. A mas~ in ~he area of the seminal vesicle was palpable on rectal exammat10n in 16 patients and absent in only 3, including our patient. Usu"ally, diagnosis is established by history, physical examination and IVP. Other studies that are helpful include cystoscopy, angiography, renal camera studies and, most important, a vasoseminal vesiculogram. Aspiration of the cyst and examination of its contents can be extremely helpful. The findings in all of the patients who had cystoscopic examination included an absent hemitrigone and ureteral orifice on the involved side and, frequently, an extravesical mass encroaching on the bladder. Several courses of treatment are recommended. Open excision of the seminal vesicle cyst is nrPt,,rr,on if the symptoms are severe or if other modes of ,~,,v, have failed. This procedure was used in 12 of 20 cases, • u • v i c • - · u ~ or transrectal of the cyst is ucca;;itJIJ.,,u sufficient, as was the case in 2 patients. Transurethral unroofing of the cyst was used in 3 with results and conseivative 0 ""
vvas
15-JA :.¥effe:cson I-Iwy.; ()f
ths 20 cases
11reter
into the serrtinal
834
FUSELIER AND PETERS
FIG. 1. A, IVP demonstrates absent right kidney and filling defect in bladder, with compensatory hypertrophy on left side. B, retrograde ureterogram reveals ectopic ureter.
Seminal Vesicle
FIG. 2. A, schematic diagram of findings in patient. B, schematic diagram of findings in posterior view
icle cyst in 6, absent in 6 and the existence or location of the ureter was unknown in the others. Many of the patients were fertile and had 2 or more children. Differential diagnosis of such lesions includes relatively few entities: walled-off abscess in the cul-de-sac from a leaking diverticulum of the colon, leiomyoma of the bladder wall with degenerative changes, malignant lesions of the rectum involving the bladder, cysts of the miillerian duct remnant, wolffian duct remnant cysts and a cyst of the utricle. REFERENCES
1. Zinner, A.: Ein Fall von intravesikaler Samenblasenzyste. Wein. med. Wochenschr., 64: 605, 1914. 2. Beeby, D. I.: Seminal vesical cyst associated with ipsilateral renal agenesis: case report and review of literature. J. Urol., 112: 120, 1974.
3. Heetderks, D. R., Jr. and Dalambre, L. C.: Cyst of the seminal vesicle. J. Urol., 93: 725, 1965. 4. Hart, J.B.: A case of cyst of the seminal vesicle. J. Urol., 96: 247, 1966. 5. Kimchi, D. and Wiesenfeld, A.: Cyst of seminal vesicle associated with ipsilateral renal agenesis: case report. J. Urol., 89: 906, 1963. 6. Hart, J. B.: A case of cyst or hydrops of the seminal vesicle. J. Urol., 86: 137, 1961. 7. Dickinson, K. M.: Ectopic ureter entering a seminal vesicle. Brit. J. Surg., 50: 858, 1963. 8. Greenbaum, E. and Pearman, R. 0.: Vasovesiculography: cyst of the seminal vesicle associated with the agenesis of the ipsilateral kidney. Radiology, 98: 363, 1971. 9. Harbitz, T. B. and Liavl'tg, I.: Urogenital malformation with cyst of the seminal vesicle, ipsilateral dilated ureter, and renal agenesis. Report of a case and review of the literature. Scand. J. Urol.
CYST OF SEMINAL VESICLE WITH IPSILATERAL RENAL AGENESIS AND ECTOPIC URETER
Nephrol., 2: 217, 1968. 10. Levisay, G. L., Holder, J. and Weigel, J. W.: Ureteral ectopia associated with seminal vesicle cyst and ipsilateral renal agenesis. Radiology, 114: 575, 1975. 11. Korobkin, M. and Cooperman, L. R.: Vesiculographic findings in cysts of the seminal vesicle. Radiology, 114: 571, 1975. 12. Furtado, A. J. L.: Three cases of cystic seminal vesicle associated with unilateral renal agenesis. Brit. J. Urol., 45: 536, 1973. 13. Meiraz, D., Fischelovitch, J. and Lazebnik, J.: Agenesis of the kidney associated with congenital malformation of the seminal
vesicle. Brit. J. Urol., 45: 541, 1973. 14. Donohue, R. E. and Greenslade, N. F.: Seminal vesical cyst and ipsilateral renal agenesis. Urology, 2: 66, 1973. 15. Reddy, Y. N. and Winter, C. C.: Cyst of the seminal vesicle: a case report and review of the literature. J. Urol., 108: 134, 1972. 16. Davidson, A. C. and Beard, J. H.: Seminal vesical cyst: in association with ipsilateral renal agenesis and lumbar scoliosis. South. Med. J., 62: 608, 1969. 17. Arey, L.B.: Developmental Anatomy, 7th ed. Philadelphia: W. B. Saunders Co., 1965.
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
CYST OF SEMINAL VESICLE WITH IPSILATERAL RENAL AGENESIS AND ECTOPIC URETER: CASE REPORT HAROLD A. FUSELIER, JR.*
AND
DENNIS H. PETERS
From the Department of Urology, Ochsner Medical Institutions, New Orleans, Louisiana
ABSTRACT
of the seminal vesicle and renal with an A ureter. Nineteen other with similar anomalies are reviewed. The usual age at 1~he onset of the time of maximal is between 20 and 28 years, uu,~,,v,0,0 is established the mass in the area urogra1n. Treatn1ent consists of or transurethrnl --a,,.,,~,-.a.,.~ of the report of a cyst of a seminal vesicle with renal v1as in 1914 Zinner. 1 Since that time 18 other cases have been 2-1s The collection in a single publication was 7 cases reported Donohue and Greenslade. 14 Only 5 of 19 reported patients had an ectopic ureter into the cyst Herein we report the sixth such case. CASE REPORT
A student had left epididymitis 1 week following treatment for gonococcal urethritis. During evaluation at another hospital an excretory urogram (IVP) demonstrated a radiolucent filling defect in the bladder, a non-functioning right kidney and compensatory hypertrophy of the left kidney 1, A). A cystogram and cystoscopy confirmed the presence of an extravesical mass but failed to disclose the cause. An exploratory operation was advised but the patient sought a second opinion. The patient came to this clinic 2 weeks later with recurrent left was instituted. The additional information was that he had an occasional sensation of incomplete emptying of the bladder. Physical examination was unremarkable except for an indurated, tender, left epididymis. The right vas deferens and epididymis were normal. Prostatic examination was unremarkable with secretions containing 8 to 10 white blood cells. The seminal vesicles were not palpable. Urinalysis, SMA-12 and complete blood count were normal. Renal camera study using iodohippurate sodium revealed an enlarged, solitary, left kidney. With the patient under anesthesia a retrograde urethrogram and cystogram revealed the filling defect in the bladder. During cystoscopy the right ureteral orifice and hemitrigone could not be identified and a 5 to 6 cm. smooth, rounded, extravesical mass was present in the area of the right hemitrigone. The left ureteral orifice was normal. The cyst was unroofed with a resectoscope and 200 to 250 ml. tan, turbid fluid containing sperm was obtained. A panendoscope was then introduced into the cyst and an ectopic ureteral orifice was visualized. A retrograde ureterogram confirmed the presence of a blind-ending ureter to the L4 level (fig. 1, : A right vasogram confirmed the presence of a semmal vesicle cyst. Two days later a right ureteroseminal es11:111ecc,1rrtv was done through a midline incision 2). Extravesical and intravesical approaches were used to resect the cyst. Convalescence was uneventful. Accepted for publicatio:1 Niay * Requests for Oehsner Orleans, Loaisi.a.nc.
D!SCUSSJON
The clinical
of a cyst in the seminal vesicie can be 17 of In a thorough of 4 weeks the mesonephric duct makes a sharp bend before entering the cloaca. It is at this that the ureteral primordium appears. The seminal from the-m1csc,ne,pr1nc duct in of 13 weeks. and incorporation of the ,us"u"'""'"' duct into the urogenital sinus cause of the ureter ar.id the mesonephric duct so that the latter takes a more medial and lower and opens into that part of the urogenital sinus that becomes the prostatic urethra. If there is failure at this stage the ureter will open into one of the derivatives of the mesonephric duct, including the epididymis, vas deferens, ejaculation duct and seminal vesicle. Agenesis of the kidney results from incomplete development of the ureteral bud. In the cases reported the ages of the patients from 18 to 41 years, with between 20 and 28 years. The peak age at onset of symptoms is during the time of maximal All of the patients were white. There was approximately equal distribution between the right and left sides, and in l was the condition bilateral. The initial complaints in the majority of cases were lower urinary tract symptoms and perineal discomfort. Three patients were asymptomatic and the anomaly was found during routine rectal examination. Other initial complaints were epididymitis, hematuria and infertility. A frequent complaint was perinea! discomfort after ejaculation. A mas~ in ~he area of the seminal vesicle was palpable on rectal exammat10n in 16 patients and absent in only 3, including our patient. Usu"ally, diagnosis is established by history, physical examination and IVP. Other studies that are helpful include cystoscopy, angiography, renal camera studies and, most important, a vasoseminal vesiculogram. Aspiration of the cyst and examination of its contents can be extremely helpful. The findings in all of the patients who had cystoscopic examination included an absent hemitrigone and ureteral orifice on the involved side and, frequently, an extravesical mass encroaching on the bladder. Several courses of treatment are recommended. Open excision of the seminal vesicle cyst is nrPt,,rr,on if the symptoms are severe or if other modes of ,~,,v, have failed. This procedure was used in 12 of 20 cases, • u • v i c • - · u ~ or transrectal of the cyst is ucca;;itJIJ.,,u sufficient, as was the case in 2 patients. Transurethral unroofing of the cyst was used in 3 with results and conseivative 0 ""
vvas
15-JA :.¥effe:cson I-Iwy.; ()f
ths 20 cases
11reter
into the serrtinal
834
FUSELIER AND PETERS
FIG. 1. A, IVP demonstrates absent right kidney and filling defect in bladder, with compensatory hypertrophy on left side. B, retrograde ureterogram reveals ectopic ureter.
Seminal Vesicle
FIG. 2. A, schematic diagram of findings in patient. B, schematic diagram of findings in posterior view
icle cyst in 6, absent in 6 and the existence or location of the ureter was unknown in the others. Many of the patients were fertile and had 2 or more children. Differential diagnosis of such lesions includes relatively few entities: walled-off abscess in the cul-de-sac from a leaking diverticulum of the colon, leiomyoma of the bladder wall with degenerative changes, malignant lesions of the rectum involving the bladder, cysts of the miillerian duct remnant, wolffian duct remnant cysts and a cyst of the utricle. REFERENCES
1. Zinner, A.: Ein Fall von intravesikaler Samenblasenzyste. Wein. med. Wochenschr., 64: 605, 1914. 2. Beeby, D. I.: Seminal vesical cyst associated with ipsilateral renal agenesis: case report and review of literature. J. Urol., 112: 120, 1974.
3. Heetderks, D. R., Jr. and Dalambre, L. C.: Cyst of the seminal vesicle. J. Urol., 93: 725, 1965. 4. Hart, J.B.: A case of cyst of the seminal vesicle. J. Urol., 96: 247, 1966. 5. Kimchi, D. and Wiesenfeld, A.: Cyst of seminal vesicle associated with ipsilateral renal agenesis: case report. J. Urol., 89: 906, 1963. 6. Hart, J. B.: A case of cyst or hydrops of the seminal vesicle. J. Urol., 86: 137, 1961. 7. Dickinson, K. M.: Ectopic ureter entering a seminal vesicle. Brit. J. Surg., 50: 858, 1963. 8. Greenbaum, E. and Pearman, R. 0.: Vasovesiculography: cyst of the seminal vesicle associated with the agenesis of the ipsilateral kidney. Radiology, 98: 363, 1971. 9. Harbitz, T. B. and Liavl'tg, I.: Urogenital malformation with cyst of the seminal vesicle, ipsilateral dilated ureter, and renal agenesis. Report of a case and review of the literature. Scand. J. Urol.
CYST OF SEMINAL VESICLE WITH IPSILATERAL RENAL AGENESIS AND ECTOPIC URETER
Nephrol., 2: 217, 1968. 10. Levisay, G. L., Holder, J. and Weigel, J. W.: Ureteral ectopia associated with seminal vesicle cyst and ipsilateral renal agenesis. Radiology, 114: 575, 1975. 11. Korobkin, M. and Cooperman, L. R.: Vesiculographic findings in cysts of the seminal vesicle. Radiology, 114: 571, 1975. 12. Furtado, A. J. L.: Three cases of cystic seminal vesicle associated with unilateral renal agenesis. Brit. J. Urol., 45: 536, 1973. 13. Meiraz, D., Fischelovitch, J. and Lazebnik, J.: Agenesis of the kidney associated with congenital malformation of the seminal
vesicle. Brit. J. Urol., 45: 541, 1973. 14. Donohue, R. E. and Greenslade, N. F.: Seminal vesical cyst and ipsilateral renal agenesis. Urology, 2: 66, 1973. 15. Reddy, Y. N. and Winter, C. C.: Cyst of the seminal vesicle: a case report and review of the literature. J. Urol., 108: 134, 1972. 16. Davidson, A. C. and Beard, J. H.: Seminal vesical cyst: in association with ipsilateral renal agenesis and lumbar scoliosis. South. Med. J., 62: 608, 1969. 17. Arey, L.B.: Developmental Anatomy, 7th ed. Philadelphia: W. B. Saunders Co., 1965.
