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CASE REPORT
Year : 2021  |  Volume : 48  |  Issue : 1  |  Page : 38-40

Laparoscopic removal of congenital seminal vesicle cyst in a preadolescent male: A unique case report


1 Department of Urology, Sentini Hospitals, Vijayawada, Andhra Pradesh, India
2 Department of Urology, Narayana Medical College, Nellore, Andhra Pradesh, India
3 Department of Radiology, Sentini Hospitals, Vijayawada, Andhra Pradesh, India
4 Department of Anaesthesiology, Sentini Hospitals, Vijayawada, Andhra Pradesh, India
5 Department of Pulmonology, Sentini Hospitals, Vijayawada, Andhra Pradesh, India

Date of Submission20-Apr-2020
Date of Acceptance18-Jul-2020
Date of Web Publication5-May-2021

Correspondence Address:
Dr. G Ajay Kumar
Door No. 54-15-5 B and C Ring Road, Beside Vinayak Theatre, Vijayawada - 520 008, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jss.JSS_29_20

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  Abstract 


Zinner syndrome refers to the triad of ipsilateral renal agenesis, seminal vesicle cysts, and ejaculatory duct obstruction. Ipsilateral renal agenesis may be associated with seminal vesicle cysts in 70% of cases, but a remnant ureteral bud has been shown to coexist in only 27% of these cases. While some patients may remain asymptomatic and are discovered incidentally, others present with symptoms related to seminal vesicle cysts or ejaculatory duct obstruction, voiding, or ejaculatory difficulty, or pain. Symptomatic cases are very rare in the preadolescent age group. The uniqueness of our case report is that the patient is a 16-year-old male with suprapubic discomfort who was diagnosed with left seminal vesicle cyst (Zinner syndrome) and was successfully managed by laparoscopic resection. To our knowledge, none of the case reports were published in such age group.

Keywords: Ejaculatory duct obstruction, laparoscopy, renal agenesis, seminal vesicle cyst


How to cite this article:
Kumar G A, Reddy M N, Babu B S, Kumar A L, Sindhuri A. Laparoscopic removal of congenital seminal vesicle cyst in a preadolescent male: A unique case report. J Sci Soc 2021;48:38-40

How to cite this URL:
Kumar G A, Reddy M N, Babu B S, Kumar A L, Sindhuri A. Laparoscopic removal of congenital seminal vesicle cyst in a preadolescent male: A unique case report. J Sci Soc [serial online] 2021 [cited 2021 Jun 17];48:38-40. Available from: https://www.jscisociety.com/text.asp?2021/48/1/38/315451




  Introduction Top


Zinner syndrome is a triad of Müllerian duct abnormality comprising unilateral renal agenesis, ipsilateral seminal vesicle cyst, and ejaculatory duct obstruction.[1] The patients are usually diagnosed at the third or fourth decade of life and often present with infertility.[2],[3] To date, slightly >200 cases of Zinner syndrome have been described in literature based on imaging and pathologic examinations.

The treatment of choice for symptomatic seminal vesicle cysts is surgical resection. Other methods, such as transrectal or transurethral puncture, aspiration, or transurethral resection of the seminal colliculus and vas deferens, carry the risk of recurrent cysts.[4] Open surgery is not easy because of the location of the seminal vesicles deep beneath the bladder[5] and the possibility of damage to the bladder and rectum. We describe a case of a seminal vesicle cyst in a patient with Zinner syndrome who underwent laparoscopic surgery. The uniqueness of our case illustrated in this article is in terms of early age of presentation during preadolescence with predominantly urinary symptoms.


  Case Report Top


A 16-year-old boy presented with dysuria, increased frequency of micturition, and intermittent pain in the suprapubic region for 1 year. Urine analysis was within normal limits. Complete blood cell count, serum biochemistry, and coagulation profile were within normal limits. Semen analysis showed ejaculate volume of <2 ml, sperm count of 17 million/ml, alkaline pH, and fructose of 1.0 g/L. Hormone analysis showed luteinizing hormone, follicle-stimulating hormone, and testosterone within normal limits. Ultrasonography (USG) revealed a fluid-filled space located behind the bladder on the left side [Figure 1]a. Computed tomography (CT) of kidneys, ureters, and bladder axial view (plain and contrast) [Figure 1]b and magnetic resonance imaging (MRI) of the pelvis – axial and sagittal views [Figure 1]c and [Figure 1]d – confirmed the presence of a left seminal vesicle cyst with a diameter of 5.5 cm × 4.5 cm × 3.8 cm and other two small cysts measuring 3.5 cm × 3.5 cm × 3 cm each with ejaculatory duct obstruction and ipsilateral renal agenesis. In view of the above-mentioned clinical and radiological findings, the diagnosis of Zinner syndrome was made. DTPA (Diethylenetriamine pentaacetate) renogram was done, with no function of the left renal unit [Figure 1]e.
Figure 1: (a) Ultrasonography showing a fluid-filled space located behind the bladder on the left side (b) Computed tomography of kidneys, ureters, and bladder axial view (plain and contrast) showing left seminal vesicle cyst with a diameter of 5.5 cm × 4.5 cm × 3.8 cm and other two small cysts measuring 3.5 cm × 3.5 cm × 3 cm each with ejaculatory duct obstruction (c) Magnetic resonance imaging pelvis – axial view – showing left seminal vesicle cyst with a diameter of 5.5 cm × 4.5 cm × 3.8 cm and other two small cysts measuring 3.5 cm × 3.5 cm × 3 cm each with ejaculatory duct obstruction (d) Magnetic resonance imaging pelvis – sagittal view – showing left seminal vesicle cyst with a diameter of 5.5 cm × 4.5 cm × 3.8 cm and other two small cysts measuring 3.5 cm × 3.5 cm × 3 cm each (e) DTPA (Diethylenetriamine pentaacetate) renogram done, with no function of the left renal unit (f) Left seminal vesicle cyst formations were located after removal of the fat layer (g) The seminal vesicle being excised, using a harmonic scalpel (h) The seminal vesicle being excised using bipolar coagulation (i) Blood vessels reaching the bottom of the seminal vesicle were clipped (j) The excised cyst specimen

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The procedure was performed with a laparoscopic technique by transperitoneal approach. The patient was placed in the Trendelenburg position, and a 14 Fr Foley catheter was inserted into the urinary bladder. Three trocars were inserted. Trocar 1 (10 mm) was placed below the umbilicus for a 0° optic. Trocars 2 and 3 of 5 mm each were placed in both the iliac regions at the midclavicular level. Initially, the urinary bladder was lifted up to reveal the vesicorectal recess. The peritoneum was then incised between the bladder and the rectum. Left seminal vesicle cyst formations were located after the removal of the fat layer [Figure 1]f. The seminal vesicle cyst was excised, using a harmonic scalpel [Figure 1]g with bipolar coagulation [Figure 1]h. Blood vessels reaching the bottom of the seminal vesicle were clipped [Figure 1]i. The resected left seminal vesicle cyst specimen is depicted in [Figure 1]j.

A 16 Fr drain was placed in the pelvis and fixed. Port closure was done. The procedure lasted 90 min, and the estimated blood loss was 45 mL. The patient was discharged home on the 3rd postoperative day, and there were no postoperative complications. His preoperative symptoms completely resolved after surgery. Histopathological examination confirmed the presence of a seminal vesicle cyst. The patient is on close follow-up for 2 years and is symptom free.


  Discussion Top


Zinner syndrome refers to the triad of ipsilateral renal agenesis, seminal vesicle cysts, and ejaculatory duct obstruction.[1] The common embryological origin of the mesonephric duct and the ureteral bud leads to the associated anomalous development of the genital and urinary tracts, including obstruction of the ejaculatory duct, seminal vesicle cysts, and ipsilateral renal agenesis. The ureteral bud arises from the dorsal aspect of the distal mesonephric duct and extends in a cranial direction to meet the metanephric blastema, which will form the adult kidney. Normal development of the kidney requires the ureteral bud to meet the metanephric blastema and induce its differentiation. Abnormal development can result from faults at various stages of embryogenesis. An insult during the first trimester adversely affects the embryogenesis of kidney, ureter, seminal vesicle, and vas deferens.[6] Maldevelopment of the distal part of the mesonephric duct leads to atresia of the ejaculatory duct (leading to the obstruction and cystic dilation of seminal vesicle) and abnormal ureteral budding (leading to renal agenesis or dysplasia). The obstruction at the level of ejaculatory duct can also be due to cysts in the prostatic utricle, as in our case, and can lead to gradual accumulation of secretions in the seminal vesicle with consequent cyst formation.

Most patients remain asymptomatic till the second to fourth decade of life, relating to the period of highest sexual and reproductive activity.[7] The clinical presentation relates to the size of the seminal vesicles. Cysts <5 cm in diameter are often diagnosed incidentally on abdominal or digital rectal examination. Symptoms arise following progressive dilation of the seminal vesicles due to accumulation of secretions following insufficient drainage secondary to ejaculatory duct atresia.[8] The seminal vesicles are located directly posterior to the bladder, and therefore enlarged cysts can cause bladder irritation, leading to symptoms of dysuria, recurrent urinary tract infections, infertility, painful ejaculation, epididymitis, and prostatitis.[9],[10],[11] Large cysts can also cause bladder outlet or colonic obstruction.

A spectrum of imaging techniques may be used in the diagnostic workup of this condition. These include intravenous urography, transrectal USG, CT scanning, cystoscopy, and MRI.

Treatment of this syndrome can be decided according to the existing symptoms. If the symptoms are mild, percutaneous drainage, or transrectal or transurethral aspiration of the ureterocele or seminal vesicle cyst, is suitable. However, these approaches were reported to have poor therapeutic effects with a high probability of recurrence and the exposure of a young patient to the possible need to repeat the procedure.[4] Various invasive techniques have been proposed for the operative management of seminal vesicle diseases. Historically, open surgery performed through a transvesical, retrovesical, transperineal, or transcoccygeal route has been considered to be the definitive treatment option because of the high success rate reported, but the related morbidity is also considerable. Transurethral resection with unroofing has been reserved for smaller lesions in close contact with the prostate, and is associated with a significant failure rate. Recently, laparoscopic surgery appears to be the most suitable surgical treatment. Carmignani et al.[12] described the first laparoscopic excision of a seminal vesicle cyst associated with ipsilateral renal agenesis, and about twenty cases of laparoscopic excision have been reported to date. Laparoscopic surgery has the advantages of direct access to the seminal vesicle with excellent images in the deep and retrovesical fields, with minimal invasiveness compared to open resection.


  Conclusion Top


The diagnosis of a seminal vesicle cyst with renal agenesis and stenosis of the vas deferens is suggestive of the very rare condition of Zinner syndrome. A good expertise is needed, for management of such cases by laparoscopy. Compared with the open technique, laparoscopic surgery is safe and in our opinion, provides a quick relief in the postoperative period to the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Zinner A. Ein fall von intravesikaler samenblasenzyste. Wien Med Wochenschr 1914;64:605.  Back to cited text no. 1
    
2.
Livingston L, Larsen CR. Seminal vesicle cyst with ipsilateral renal agenesis. AJR Am J Roentgenol 2000;175:177-80.  Back to cited text no. 2
    
3.
Gianna P, Giuseppe PG. Mayer-Rokitansky-Küster-Hauser syndrome and the Zinner syndrome, female and male malformation of reproductive system: Are two separate entities? J Chinese Clin Med 2007;2:11.  Back to cited text no. 3
    
4.
Jang KD, Choi KH, Yang SC, Jang WS, Jang JY, Han WK. Laparoendoscopic single-site surgery (LESS) for excision of a seminal vesicle cyst associated with ipsilateral renal agenesis. Korean J Urol 2011;52:431-3.  Back to cited text no. 4
    
5.
Ahallal Y, Tazi MF, Khallouk A, Elammari J, Elfassi MJ, Farih MH. Conservative management of a congenital seminal vesicle cyst associated with ipsilateral renal agenesis revealed by cystitis: One case report. Case Rep Urol 2011;2011:125753.  Back to cited text no. 5
    
6.
McCallum TJ, Milunsky JM, Munarriz R, Carson R, Sadeghi-Nejad H, Oates RD. Unilateral renal agenesis associated with congenital bilateral absence of the vas deferens: Phenotypic findings and genetic considerations. Hum Reprod 2001;16:282-8.  Back to cited text no. 6
    
7.
Rappe BJ, Meuleman EJ, Debruyne FM. Seminal vesicle cyst with ipsilateral renal agenesis. Urol Int 1993;50:54-6.  Back to cited text no. 7
    
8.
Kao CC, Wu CJ, Sun GH, Yu DS, Chen HI, Chang SY, et al. Congenital seminal vesicle cyst associated with ipsilateral renal agenesis mimicking bladder outlet obstruction: A case report and review of the literature. Kaohsiung J Med Sci 2010;26:30-4.  Back to cited text no. 8
    
9.
Kenney PJ, Leeson MD. Congenital anomalies of the seminal vesicles: Spectrum of computed tomographic findings. Radiology 1983;149:247-51.  Back to cited text no. 9
    
10.
Beeby DI. Seminal vesicle cyst associated with ipsilateral renal agenesis: Case report and review of literature. J Urol 1974;112:120-2.  Back to cited text no. 10
    
11.
Levisay GL, Holder J, Weigel JW. Ureteral ectopia associated with seminal vesicle cyst and ipsilateral renal agenesis. Radiology 1975;114:575-6.  Back to cited text no. 11
    
12.
Carmignani G, Gallucci M, Puppo P, De Stefani S, Simonato A, Maffezzini M. Video laparoscopic excision of a seminal vesicle cyst associated with ipsilateral renal agenesis. J Urol 1995;153:437-9.  Back to cited text no. 12
    


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