Vesiculographic Findings in Cysts of the Seminal Vesicle 1
Diagnostic Radiology
Melvyn Korobkln, M.D., 2 and Lawrence R. Cooperman, M.D. Vasoseminal vesiculography showed medial displacement and stretching of the ampulla of the vas deferens in 3 patients with cysts of the seminal vesicle. In 2 a nonopacified mass separated the ampulla from the ipsilateral seminal vesicle. All 3 patients were managed without surgical intervention. If such a vesiculographic pattern is seen in a patient with a paraprostatic mass, the contents of the mass should be aspirated and contrast material injected to document its cystic nature. INDEX TERMS:
Seminal Vesicles, cysts- Vas Deferens, abnormalities
Radiology 114:571-574, March 1975
seminal vesicle are thought to be rare (1, 5). They can be asymptomatic and remain undiscovered until a routine rectal examination is performed, or they may lead to symptoms in the urinary tract or abnormalities of ejaculation (5). Although the cyst may be an isolated abnormality, it is frequently associated with ipsilateral renal agenesis (1-3, 5, 6, 8). Surgical excision is advocated by many urologists; however, some cysts can be treated by simple aspiration. For this reason, we believe that the spectrum of radiographic features of seminal vesicle cysts seen at vasoseminal vesiculography should be clearly defined for urologists and radiologists who may need to employ this uncommon examination. Three of our patients studied by this method demonstrated medial displacement and stretching of the ampulla of the vas deferens, a finding not reported previously in this condition. In 2 cases a nonopacified mass was found between the ampulla and the ipsilateral seminal vesicle. while in the third patient the mass pressed these two structures together.
C
YSTS OF THE
CASE REPORTS CASE I: A soft, cystic, movable, nontender mass 2-3 cm in diameter was discovered above the left lobe of the prostate in a 27-yearold man during a routine physical examination. The patient had no urinary or rectal symptoms. Proctoscopy, barium enema examination, and retrograde urethrography were normal. Excretory urography revealed absence of the left kidney and hypertrophy of the right kidney. At cystoscopy, the entire left half of the trigone of the bladder was absent and the left ureteral orifice was not identified. Attempts were made to catheterize the left ejaculatory duct, but the catheter always passed into the right ejaculatory duct and contrast material showed only the normal right seminal vesicle. Digital pressure on the mass through the rectum with a cystoscope in place revealed a local pressure deformity on the bladder where the trigone would normally be. Rectal examination 2 weeks later showed no change in the mass. Left vasoseminal vesiculography demonstrated a mass causing arcing and medial dlsplacement of the ampulla of
the vas deferens and part of the seminal vesicle, pressing the two structures together (Fig. 1, A). Although the mass was not opacified at first, it filled with contrast material on delayed films (Fig. 1, B). CASE II: A mass was seen apparently arising from the left lobe of the prostate in a 36-year-old man on a routine physical examination. It was rope-like in consistency and slightly tender in the region of the left seminal vesicle. The prostate was normal. Urinalysis, excretory urography, and barium enema examination were normal. There were no genitourinary symptoms nor a history of abnormalities. Vasoseminal vesiculography showed separation of the left seminal vesicle from the ampulla by a mass about 3 cm in diameter (Fig. 2). The orifices of the ejaculatory ducts appeared normal on cystoscopic examination. Transperineal biopsy of the mass with a Hutchinson needle was performed with simultaneous palpation through the rectum. Numerous biopsy specimens showed smooth and striated muscle, normal seminal vesicle mucosa, and, in one specimen, a few prostatic glandular elements. On subsequent visits, the patient was asymptomatic and the mass was somewhat smaller. He did not return for further follow-up. CASE III: A 53-y~~r-old man complained of mild pain in the right lower quadrant and right flank of 2 months duration. There were no urinary symptoms. Rectal examination revealed a tender mass over the right lobe of the prostate. Proctoscopy, urinalysis, excretory urography, and cystoscopy were normal. The urethra and ejaculatory ducts were unremarkable. On bilateral vasoseminal vesiculography, the left side was normal but the right seminal vesicle was separated from the ampulla by a mass (Fig. 3" A). Transrectal biopsy of the mass using a Franklin modification of the Vim-Silverman needle was attempted, but the mass disappeared. Histological examination of the biopsy specimens revealed fibromuscular and fatty tissue with no evidence of malignancy or inflammation. The patient was discharged but continued to have pain in the right lower quadrant and right flank, with some hematospermia. On subsequent examination, the mass was again palpable. A Vim-Silverman needle was inserted into the mass transrectally and 2 ml of mucoid material was aspirated; the mass simultaneously decreased in size. Upon injecting 2 ml of contrast material, the mass immediately increased to a palpable size. Films taken immediately thereafter showed opacification of the cyst (Fig. 3, B). Reaspiration resulted in
1 From the Department of Radiology, University of California School of Medicine, San Francisco, Calif. Accepted for publication in November 1974. 2 James Picker Foundation Scholar in Radiolcgical Research. sjh
571
572
MELVYN KOROBKIN AND LAWRENCE
R. COOPERMAN
March 1975
Fig. 1. CASE I. left seminal vesiculogram. A. The distal portion of the vas deferens and part of the seminal vesicle are pressed together. stretched. and displaced across the midline. B. Delayed films show a multiloculated mass filled with contrast material.
disappearance of both the mass and contrast material on repeat radiographs. Microscopic examination of the cystic fluid revealed numerous macrophages and erythrocytes with no epithelial cells. On subsequent visits, the patient had no further symptoms, the urine remained clear, and rectal examination showed only slight induration above the right lobe of the prostate with no definite cyst or other pal. pable mass.
DISCUSSION
Fig. 2. CASE II. Left seminal vesiculogram . The ampulla of the vas deferens is stretched and separated from the opacified segment of the seminal vesicle .
The recent abundance of isolated case reports (2, 5, 6, 8) and our own experience with 3 patients within 12 months suggest that cysts of the seminal vesicle may be more common than previously thought. In our opinion, vasoseminal vesiculography is the most helpful examination in the preoperative diagnosis of such a paraprostatic mass and is usually superior to retrograde injection of the ejaculatory ducts. Few vesiculographic features indicative of a seminal vesicle cyst have been described (2, 5, 6, 8). Most authors have reported the accumulation of contrast material within a unilocular or multilocular compartment near the ampulla of the vas deferens; however, it is not clear from published descriptions and radiographs whether normal portions of the seminal vesicle were also present and what anatomical relationship these might have had to the ampulla. In the frontal projection, the seminal vesicles are normally set at an angle of 50 0_60 0 with the horizontal (7), in close proximity to the ampulla of the vas deferens . The ampulla curves gently as it passes medial to the seminal vesicle and terminates in the vertically oriented ejaculatory duct. In 2 of our patients, the seminal vesi-
Vol . 114
VESICULOGRAPHIC FINDINGS IN CYSTS OF THE SEMINAL VESICLE
573
Diagnostic Radiology
Fig. 3 CASE III. Bilateral seminal vesiculograms . A. The ampulla of the right vas deferens is separated from the right seminal vesicle by a small mass . Note the normal close apposition of the left seminal vesicle to the vas deferens . 8 . The cyst is outlined by contrast material injected following transrectal needle aspiration .
cle and ampulla were abnormally separated , with the ampulla appearing to be stretched around a mass situated between it and the seminal vesicle (Fig. 4). In the third patient, the mass was lateral to both the ampulla and part of the seminal vesicle . In CASE I, delayed vesiculograms demonstrated eventual filling of the cyst by contrast material. In CASE II, the transperineal biopsy specimen demonstrated smooth muscle , fibrous tissue, and seminal vesicle epithelium. In CASE III, transrectal aspiration and direct injection of contrast material confirmed the cystic nature of the mass . Vasoseminal vesiculography can help exclude several cystic lesions that may be confused with cysts of the seminal vesicle on routine examination . Remnants of the mullerian duct course medial to the ampulla of the vas deferens; with cystic enlargement, the ampulla is displaced inferiorly and laterally, resulting in compression against the adjacent seminal vesicle (4). A similar vesiculographic pattern has been reported in 2 patients with retention cysts of the prostate gland; curvilinear lateral deviation of both ejaculatory ducts was demonstrated by vasoseminal vesiculography (9). A cyst originating from the vas deferens or a mesonephric duct remnant and separate from the seminal vesicle might produce the same appearance described in our patients, but this similarity is of no practical significance. The radiographic diagnosis of a seminal vesicle cyst, whether based on the indirect signs described here or on filling of a cystic structure by contrast material, remains a presumptive diagnosis. It is possible that a rare solid tumor , either primary or secondary, might encroach upon the vasoseminal structures and produce an appearance similar to that described in our patients ,
11--
-
+-EJACUl ATORY DUCT
Fig. 4. Left: Diagram of the normal relationship between the seminal vesicle and the ampulla of the vas deferens . Right: Separation of these two structures produced by a seminal vesicle cyst.
and the vesiculographic findings in one such case have been reported (10). Although the clinical and vesiculographic features seen in our CASE II are most suggestive of a seminal vesicle cyst , the presence of smooth muscle cells in the biopsy specimen makes it impossible to completely exclude leiomyoma. As with benign cysts of the kidney, there is no convincing evidence that routine surgical exploration is indicated in all cystic lesions of the male pelvis. In an asymptomatic patient, it is probably unnecessary to re sort to surgical documentation of the precise nature of a cystic lesion separating the ampulla from the seminal
574
MELVYN KOROBKIN AND LAWRENCE
vesicle or pressing them together. In CASE II, the mass was discovered only on routine physical examination and was not treated but still decreased in size. In CASE III, the cyst remained asymptomatic and unchanged in size for 6 months; aspiration resulted in disappearance of both the mass and the associated symptoms. Surgical intervention should probably be reserved for those cases in which symptoms are not relieved by simple aspiration or in which the physical findings and vesiculographic abnormalities are not characteristic of seminal vesicle cysts. CASE I is another example of the frequent association of unilateral renal agenesis with ipsilateral cysts of the seminal vesicle. Both the ureter and the seminal vesicle originate as buds from the embryologic mesonephric (wolffian) duct. Because normal development of the kidney depends on junction of the ureteral bud with the metanephrogenic cap, faulty development of the ureter can result in renal agenesis. Similarly, development of the bladder trigone and seminal vesicle is intimately associated with normal attachment and alterations in position of the distal mesonephric duct at the site where it joins the cloaca. Presumably, maldevelopment of the distal mesonephric duct during the first days or weeks of fetal life can cause not only seminal vesicle cysts but hemitrigone and ipsilateral renal agenesis. Any patient with a seminal vesicle cyst should be evaluated for possible renal agenesis; conversely, patients with a solitary kidney should be studied for genital tract abnormalities.
R. COOPERMAN
March 1975
ACKNOWLEDGMENT: The authors wish to thank Dr. Gerald Olson, Redwood City, Calif., for permission to report these cases, clinical data, and helpful suggestions. Department of Radiology University of California School of Medicine San Francisco, Calif. 94143
REFERENCES 1. Donohue RE, Greenslade NF: Seminal vesicle cyst and ipsilateral renal agenesis. Urology 2:66-69, Jul 1973 2. Greenbaum E, Pearman RO: Vasovesiculography: cyst of the seminal vesicle associated with agenesis of the ipsilateral kidney. Radiology 98:363-364, Feb 1971 3. Harbitz TB, Liavag 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 Nephrol 2: 217-222, 196B 4. Landes RR, Ransom CL: Mullerian duct cysts. J Urol 61: 1OB9-1 093, Jun 1949 5. Linhares Furtado AJ: Three cases of cystic seminal vesicle associated with unilateral renal agenesis. Br J Urol 45:536-540, 1973 6. Meiraz D, Fischelovitch J, Lazebnik J: Agenesis of the kidney associated with congenital malformation of the seminal vesicle. Br J Urol 45:541-544, 1973 7. Ney C, Friedenberg RN: Radiographic Atlas of the Genitourinary System. Philadelphia, Lippincott, 1966, pp 5BO-597 B. Reddy YN, Winter CC: Cyst of the seminal vesicle: a case report and review of the literature. J UroI108:134-135, Jul1972 9. Rieser C, Griffin TL: Cysts of the prostate. J Urol 91:282286, Mar 1964 10. Smith BA, Webb EA, Price WE: Carcinoma of the seminal vesicle. J UroI97:743-750, Apr 1967
(See also page 693)
Diagnostic Radiology
Melvyn Korobkln, M.D., 2 and Lawrence R. Cooperman, M.D. Vasoseminal vesiculography showed medial displacement and stretching of the ampulla of the vas deferens in 3 patients with cysts of the seminal vesicle. In 2 a nonopacified mass separated the ampulla from the ipsilateral seminal vesicle. All 3 patients were managed without surgical intervention. If such a vesiculographic pattern is seen in a patient with a paraprostatic mass, the contents of the mass should be aspirated and contrast material injected to document its cystic nature. INDEX TERMS:
Seminal Vesicles, cysts- Vas Deferens, abnormalities
Radiology 114:571-574, March 1975
seminal vesicle are thought to be rare (1, 5). They can be asymptomatic and remain undiscovered until a routine rectal examination is performed, or they may lead to symptoms in the urinary tract or abnormalities of ejaculation (5). Although the cyst may be an isolated abnormality, it is frequently associated with ipsilateral renal agenesis (1-3, 5, 6, 8). Surgical excision is advocated by many urologists; however, some cysts can be treated by simple aspiration. For this reason, we believe that the spectrum of radiographic features of seminal vesicle cysts seen at vasoseminal vesiculography should be clearly defined for urologists and radiologists who may need to employ this uncommon examination. Three of our patients studied by this method demonstrated medial displacement and stretching of the ampulla of the vas deferens, a finding not reported previously in this condition. In 2 cases a nonopacified mass was found between the ampulla and the ipsilateral seminal vesicle. while in the third patient the mass pressed these two structures together.
C
YSTS OF THE
CASE REPORTS CASE I: A soft, cystic, movable, nontender mass 2-3 cm in diameter was discovered above the left lobe of the prostate in a 27-yearold man during a routine physical examination. The patient had no urinary or rectal symptoms. Proctoscopy, barium enema examination, and retrograde urethrography were normal. Excretory urography revealed absence of the left kidney and hypertrophy of the right kidney. At cystoscopy, the entire left half of the trigone of the bladder was absent and the left ureteral orifice was not identified. Attempts were made to catheterize the left ejaculatory duct, but the catheter always passed into the right ejaculatory duct and contrast material showed only the normal right seminal vesicle. Digital pressure on the mass through the rectum with a cystoscope in place revealed a local pressure deformity on the bladder where the trigone would normally be. Rectal examination 2 weeks later showed no change in the mass. Left vasoseminal vesiculography demonstrated a mass causing arcing and medial dlsplacement of the ampulla of
the vas deferens and part of the seminal vesicle, pressing the two structures together (Fig. 1, A). Although the mass was not opacified at first, it filled with contrast material on delayed films (Fig. 1, B). CASE II: A mass was seen apparently arising from the left lobe of the prostate in a 36-year-old man on a routine physical examination. It was rope-like in consistency and slightly tender in the region of the left seminal vesicle. The prostate was normal. Urinalysis, excretory urography, and barium enema examination were normal. There were no genitourinary symptoms nor a history of abnormalities. Vasoseminal vesiculography showed separation of the left seminal vesicle from the ampulla by a mass about 3 cm in diameter (Fig. 2). The orifices of the ejaculatory ducts appeared normal on cystoscopic examination. Transperineal biopsy of the mass with a Hutchinson needle was performed with simultaneous palpation through the rectum. Numerous biopsy specimens showed smooth and striated muscle, normal seminal vesicle mucosa, and, in one specimen, a few prostatic glandular elements. On subsequent visits, the patient was asymptomatic and the mass was somewhat smaller. He did not return for further follow-up. CASE III: A 53-y~~r-old man complained of mild pain in the right lower quadrant and right flank of 2 months duration. There were no urinary symptoms. Rectal examination revealed a tender mass over the right lobe of the prostate. Proctoscopy, urinalysis, excretory urography, and cystoscopy were normal. The urethra and ejaculatory ducts were unremarkable. On bilateral vasoseminal vesiculography, the left side was normal but the right seminal vesicle was separated from the ampulla by a mass (Fig. 3" A). Transrectal biopsy of the mass using a Franklin modification of the Vim-Silverman needle was attempted, but the mass disappeared. Histological examination of the biopsy specimens revealed fibromuscular and fatty tissue with no evidence of malignancy or inflammation. The patient was discharged but continued to have pain in the right lower quadrant and right flank, with some hematospermia. On subsequent examination, the mass was again palpable. A Vim-Silverman needle was inserted into the mass transrectally and 2 ml of mucoid material was aspirated; the mass simultaneously decreased in size. Upon injecting 2 ml of contrast material, the mass immediately increased to a palpable size. Films taken immediately thereafter showed opacification of the cyst (Fig. 3, B). Reaspiration resulted in
1 From the Department of Radiology, University of California School of Medicine, San Francisco, Calif. Accepted for publication in November 1974. 2 James Picker Foundation Scholar in Radiolcgical Research. sjh
571
572
MELVYN KOROBKIN AND LAWRENCE
R. COOPERMAN
March 1975
Fig. 1. CASE I. left seminal vesiculogram. A. The distal portion of the vas deferens and part of the seminal vesicle are pressed together. stretched. and displaced across the midline. B. Delayed films show a multiloculated mass filled with contrast material.
disappearance of both the mass and contrast material on repeat radiographs. Microscopic examination of the cystic fluid revealed numerous macrophages and erythrocytes with no epithelial cells. On subsequent visits, the patient had no further symptoms, the urine remained clear, and rectal examination showed only slight induration above the right lobe of the prostate with no definite cyst or other pal. pable mass.
DISCUSSION
Fig. 2. CASE II. Left seminal vesiculogram . The ampulla of the vas deferens is stretched and separated from the opacified segment of the seminal vesicle .
The recent abundance of isolated case reports (2, 5, 6, 8) and our own experience with 3 patients within 12 months suggest that cysts of the seminal vesicle may be more common than previously thought. In our opinion, vasoseminal vesiculography is the most helpful examination in the preoperative diagnosis of such a paraprostatic mass and is usually superior to retrograde injection of the ejaculatory ducts. Few vesiculographic features indicative of a seminal vesicle cyst have been described (2, 5, 6, 8). Most authors have reported the accumulation of contrast material within a unilocular or multilocular compartment near the ampulla of the vas deferens; however, it is not clear from published descriptions and radiographs whether normal portions of the seminal vesicle were also present and what anatomical relationship these might have had to the ampulla. In the frontal projection, the seminal vesicles are normally set at an angle of 50 0_60 0 with the horizontal (7), in close proximity to the ampulla of the vas deferens . The ampulla curves gently as it passes medial to the seminal vesicle and terminates in the vertically oriented ejaculatory duct. In 2 of our patients, the seminal vesi-
Vol . 114
VESICULOGRAPHIC FINDINGS IN CYSTS OF THE SEMINAL VESICLE
573
Diagnostic Radiology
Fig. 3 CASE III. Bilateral seminal vesiculograms . A. The ampulla of the right vas deferens is separated from the right seminal vesicle by a small mass . Note the normal close apposition of the left seminal vesicle to the vas deferens . 8 . The cyst is outlined by contrast material injected following transrectal needle aspiration .
cle and ampulla were abnormally separated , with the ampulla appearing to be stretched around a mass situated between it and the seminal vesicle (Fig. 4). In the third patient, the mass was lateral to both the ampulla and part of the seminal vesicle . In CASE I, delayed vesiculograms demonstrated eventual filling of the cyst by contrast material. In CASE II, the transperineal biopsy specimen demonstrated smooth muscle , fibrous tissue, and seminal vesicle epithelium. In CASE III, transrectal aspiration and direct injection of contrast material confirmed the cystic nature of the mass . Vasoseminal vesiculography can help exclude several cystic lesions that may be confused with cysts of the seminal vesicle on routine examination . Remnants of the mullerian duct course medial to the ampulla of the vas deferens; with cystic enlargement, the ampulla is displaced inferiorly and laterally, resulting in compression against the adjacent seminal vesicle (4). A similar vesiculographic pattern has been reported in 2 patients with retention cysts of the prostate gland; curvilinear lateral deviation of both ejaculatory ducts was demonstrated by vasoseminal vesiculography (9). A cyst originating from the vas deferens or a mesonephric duct remnant and separate from the seminal vesicle might produce the same appearance described in our patients, but this similarity is of no practical significance. The radiographic diagnosis of a seminal vesicle cyst, whether based on the indirect signs described here or on filling of a cystic structure by contrast material, remains a presumptive diagnosis. It is possible that a rare solid tumor , either primary or secondary, might encroach upon the vasoseminal structures and produce an appearance similar to that described in our patients ,
11--
-
+-EJACUl ATORY DUCT
Fig. 4. Left: Diagram of the normal relationship between the seminal vesicle and the ampulla of the vas deferens . Right: Separation of these two structures produced by a seminal vesicle cyst.
and the vesiculographic findings in one such case have been reported (10). Although the clinical and vesiculographic features seen in our CASE II are most suggestive of a seminal vesicle cyst , the presence of smooth muscle cells in the biopsy specimen makes it impossible to completely exclude leiomyoma. As with benign cysts of the kidney, there is no convincing evidence that routine surgical exploration is indicated in all cystic lesions of the male pelvis. In an asymptomatic patient, it is probably unnecessary to re sort to surgical documentation of the precise nature of a cystic lesion separating the ampulla from the seminal
574
MELVYN KOROBKIN AND LAWRENCE
vesicle or pressing them together. In CASE II, the mass was discovered only on routine physical examination and was not treated but still decreased in size. In CASE III, the cyst remained asymptomatic and unchanged in size for 6 months; aspiration resulted in disappearance of both the mass and the associated symptoms. Surgical intervention should probably be reserved for those cases in which symptoms are not relieved by simple aspiration or in which the physical findings and vesiculographic abnormalities are not characteristic of seminal vesicle cysts. CASE I is another example of the frequent association of unilateral renal agenesis with ipsilateral cysts of the seminal vesicle. Both the ureter and the seminal vesicle originate as buds from the embryologic mesonephric (wolffian) duct. Because normal development of the kidney depends on junction of the ureteral bud with the metanephrogenic cap, faulty development of the ureter can result in renal agenesis. Similarly, development of the bladder trigone and seminal vesicle is intimately associated with normal attachment and alterations in position of the distal mesonephric duct at the site where it joins the cloaca. Presumably, maldevelopment of the distal mesonephric duct during the first days or weeks of fetal life can cause not only seminal vesicle cysts but hemitrigone and ipsilateral renal agenesis. Any patient with a seminal vesicle cyst should be evaluated for possible renal agenesis; conversely, patients with a solitary kidney should be studied for genital tract abnormalities.
R. COOPERMAN
March 1975
ACKNOWLEDGMENT: The authors wish to thank Dr. Gerald Olson, Redwood City, Calif., for permission to report these cases, clinical data, and helpful suggestions. Department of Radiology University of California School of Medicine San Francisco, Calif. 94143
REFERENCES 1. Donohue RE, Greenslade NF: Seminal vesicle cyst and ipsilateral renal agenesis. Urology 2:66-69, Jul 1973 2. Greenbaum E, Pearman RO: Vasovesiculography: cyst of the seminal vesicle associated with agenesis of the ipsilateral kidney. Radiology 98:363-364, Feb 1971 3. Harbitz TB, Liavag 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 Nephrol 2: 217-222, 196B 4. Landes RR, Ransom CL: Mullerian duct cysts. J Urol 61: 1OB9-1 093, Jun 1949 5. Linhares Furtado AJ: Three cases of cystic seminal vesicle associated with unilateral renal agenesis. Br J Urol 45:536-540, 1973 6. Meiraz D, Fischelovitch J, Lazebnik J: Agenesis of the kidney associated with congenital malformation of the seminal vesicle. Br J Urol 45:541-544, 1973 7. Ney C, Friedenberg RN: Radiographic Atlas of the Genitourinary System. Philadelphia, Lippincott, 1966, pp 5BO-597 B. Reddy YN, Winter CC: Cyst of the seminal vesicle: a case report and review of the literature. J UroI108:134-135, Jul1972 9. Rieser C, Griffin TL: Cysts of the prostate. J Urol 91:282286, Mar 1964 10. Smith BA, Webb EA, Price WE: Carcinoma of the seminal vesicle. J UroI97:743-750, Apr 1967
(See also page 693)
