Images in Clinical Urology Seminal Vesicle Cyst With Ipsilateral Renal Agenesis and Ectopic Ureter (Zinner Syndrome) Peter Haddock and Joseph R. Wagner The symptomatic presentation of seminal vesicle cysts with ipsilateral renal agenesis and ectopic ureter (Zinner syndrome) is rare. Patients are typically diagnosed at the third or the fourth decade of life and often present with infertility. Although the diagnosis can generally be made with magnetic resonance imaging, cystography can also be useful in indeterminate cases. We report on the unusual case of an 18-year-old man who presented with pelvic pain that was intensified by ejaculation. Computed tomography and magnetic resonance imaging revealed a cystic structure in the area of the right seminal vesicle that was successfully excised robotically without complications. UROLOGY 85: e41ee42, 2015. 2015 Elsevier Inc.
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Figure 1. Coronal T2-weighted magnetic resonance imaging demonstrating the right seminal vesicle cyst (arrow). Left kidney was unremarkable. No right kidney or renal remnant was seen.
n 18-year-old man presented with pelvic pain exacerbated with ejaculation. Digital rectal examination was unremarkable. The right epididymis and vas were dilated. Computed tomography and magnetic resonance imaging demonstrated a cystic structure near the right seminal vesicle and an absent right kidney (Fig. 1). Renal scan showed no activity on the right side. Semen analysis and urinalysis were unremarkable. Cystourethroscopy, retrograde pyelography, transrectal ultrasonography, and transrectal cyst aspiration (injected with 30% Hypaque [diatrizoate meglumine, GE Healthcare, Little Chalfont, UK] and 5 cc indigo carmine) were performed. The urethra was visualized for efflux and radiographic images obtained. Cyst injection demonstrated an ectopic ureter leading to a renal remnant. Blue efflux was observed at the verumontanum (Fig. 2). An immediate computed tomography scan illustrated the renal remnant near the iliac vessels (Fig. 3). The proximal renal remnant, ectopic ureter, and seminal vesicle cyst were resected robotically en bloc with no complications. Radiographic imaging, retrograde pyelography, and transrectal ultrasonography with cystography are useful in evaluating a cystic mass in the area of the seminal vesicle. An undiagnosed ectopic ureter at surgery could result in a freely leaking transected ureter or obstructed renal remnant due to a clipped ureter, and cystography may help avoid this undesirable outcome. Robotic resection appears to be well suited for these patients.1-5
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Urology Division, Hartford Healthcare Medical Group, Hartford, CT Address correspondence to: Peter Haddock, Ph.D., Urology Division, Hartford Healthcare Medical Group, Suite 416, 4th Floor, 85 Seymour Street, Hartford, CT 06106. E-mail: [email protected] Submitted: February 2, 2015, accepted (with revisions): February 16, 2015
ª 2015 Elsevier Inc. All Rights Reserved
http://dx.doi.org/10.1016/j.urology.2015.02.015 0090-4295/15
e41
Figure 3. Computed tomography scan demonstrating renal remnant near right iliac vessels.
References 1. Pereira BJ, Sousa L, Azinhais P, et al. Zinner’s syndrome: an up-todate review of the literature based on a clinical case. Andrologia. 2009;41:322-330. 2. Livingston L, Larson CR. Seminal vesicle cyst with ipsilateral renal agenesis. AJR Am J Roentgenol. 2000;175:177-180. 3. Gianna P, Giuseppe PG. Mayer-Rokitansky-K€uster-Hauser syndrome and the Zinner syndrome, female and male malformation of reproductive system: are two separate entities? J Chin Clin Med. 2007;2:11. 4. Selli C, Cavalleri S, De Maria M, et al. Robot-assisted removal of a large seminal vesicle cyst with ipsilateral renal agenesis associated with an ectopic ureter and a M€ullerian cyst of the vas deferens. Urology. 2008;71:1226.e5-1226.e7. 5. Allaparthi S, Blute RD Jr. Novel application of da Vinci robotic system in patients of Zinners syndrome—case report and review of literature. Can J Urol. 2010;17:5109-5113.
Figure 2. Seminal vesicle cyst injected with 30% Hypaque mixed with 5 cc of indigo carmine. Reflux is seen up an ectopic ureter (superior arrow) and efflux out of verumontanum (inferior arrow).
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UROLOGY 85 (5), 2015
A
Figure 1. Coronal T2-weighted magnetic resonance imaging demonstrating the right seminal vesicle cyst (arrow). Left kidney was unremarkable. No right kidney or renal remnant was seen.
n 18-year-old man presented with pelvic pain exacerbated with ejaculation. Digital rectal examination was unremarkable. The right epididymis and vas were dilated. Computed tomography and magnetic resonance imaging demonstrated a cystic structure near the right seminal vesicle and an absent right kidney (Fig. 1). Renal scan showed no activity on the right side. Semen analysis and urinalysis were unremarkable. Cystourethroscopy, retrograde pyelography, transrectal ultrasonography, and transrectal cyst aspiration (injected with 30% Hypaque [diatrizoate meglumine, GE Healthcare, Little Chalfont, UK] and 5 cc indigo carmine) were performed. The urethra was visualized for efflux and radiographic images obtained. Cyst injection demonstrated an ectopic ureter leading to a renal remnant. Blue efflux was observed at the verumontanum (Fig. 2). An immediate computed tomography scan illustrated the renal remnant near the iliac vessels (Fig. 3). The proximal renal remnant, ectopic ureter, and seminal vesicle cyst were resected robotically en bloc with no complications. Radiographic imaging, retrograde pyelography, and transrectal ultrasonography with cystography are useful in evaluating a cystic mass in the area of the seminal vesicle. An undiagnosed ectopic ureter at surgery could result in a freely leaking transected ureter or obstructed renal remnant due to a clipped ureter, and cystography may help avoid this undesirable outcome. Robotic resection appears to be well suited for these patients.1-5
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Urology Division, Hartford Healthcare Medical Group, Hartford, CT Address correspondence to: Peter Haddock, Ph.D., Urology Division, Hartford Healthcare Medical Group, Suite 416, 4th Floor, 85 Seymour Street, Hartford, CT 06106. E-mail: [email protected] Submitted: February 2, 2015, accepted (with revisions): February 16, 2015
ª 2015 Elsevier Inc. All Rights Reserved
http://dx.doi.org/10.1016/j.urology.2015.02.015 0090-4295/15
e41
Figure 3. Computed tomography scan demonstrating renal remnant near right iliac vessels.
References 1. Pereira BJ, Sousa L, Azinhais P, et al. Zinner’s syndrome: an up-todate review of the literature based on a clinical case. Andrologia. 2009;41:322-330. 2. Livingston L, Larson CR. Seminal vesicle cyst with ipsilateral renal agenesis. AJR Am J Roentgenol. 2000;175:177-180. 3. Gianna P, Giuseppe PG. Mayer-Rokitansky-K€uster-Hauser syndrome and the Zinner syndrome, female and male malformation of reproductive system: are two separate entities? J Chin Clin Med. 2007;2:11. 4. Selli C, Cavalleri S, De Maria M, et al. Robot-assisted removal of a large seminal vesicle cyst with ipsilateral renal agenesis associated with an ectopic ureter and a M€ullerian cyst of the vas deferens. Urology. 2008;71:1226.e5-1226.e7. 5. Allaparthi S, Blute RD Jr. Novel application of da Vinci robotic system in patients of Zinners syndrome—case report and review of literature. Can J Urol. 2010;17:5109-5113.
Figure 2. Seminal vesicle cyst injected with 30% Hypaque mixed with 5 cc of indigo carmine. Reflux is seen up an ectopic ureter (superior arrow) and efflux out of verumontanum (inferior arrow).
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UROLOGY 85 (5), 2015
