Laparoscopic excision of huge seminal vesicle cyst in Zinner syndrome

Abstract

This is the case of a 45-year-old male who presented with dysuria and gross hematuria. Ultrasonography and computed tomography revealed an enormous pelvic cystic lesion and a right nephromegaly but an invisible left kidney. Using the imaging findings, the patient was diagnosed with Zinner syndrome. Transperitoneal laparoscopic excision of the cyst was performed for symptom relief. At post-treatment, the symptoms disappeared, and sexual function remained. Seminal vesicle cysts have been commonly reported in previous studies but rarely in this case. Furthermore, most previous studies have documented surgical excision of <10 cm cysts. However, a ∼12.5-cm seminal vesicle cyst was excised with the laparoscopic method without any perioperative complication in this case.

Introduction

Seminal vesicle cyst is a rare congenital disease with only 100 cases currently reported. Ipsilateral seminal vesicle cysts, ejaculatory duct obstruction, and unilateral renal agenesis are considered the triad of mesonephric duct anomalies diagnosed as Zinner syndrome [1]. This rare malformation occurred during improper embryogenesis of the urinary and reproductive systems between 4 and 7 weeks of gestation. If the ureteral bud originated too cranially, which would result in an ectopic ureteral orifice, the dysplastic or completely absent kidney would be noted [2]. Thereafter, the abnormal ejaculatory duct causes the accumulation of seminal vesicle fluid [1].

Initially, it remains asymptomatic and is commonly diagnosed during the third to fifth decades of life when enlarged seminal vesicles compress [3]. Most symptoms are nonspecific, including irritative symptoms such as lower urinary tract symptoms, perineal pain, painful ejaculation, and epididymitis, and even up to 45% of infertility was reported [4]. Thus, it is considered as the male counterpart of the Mayer–Rokitansky–Küster–Hauser female syndrome [5].

Here, we present the case of a male patient with an enormous seminal vesical cyst diagnosed as Zinner syndrome who was successfully treated with laparoscopic excision of the cyst.

Case report

A 45-year-old male patient presented to the emergency department due to dysuria with gross hematuria for 3 days. Meanwhile, irritative voiding symptoms (urgency and frequency) have been observed. A protrusion developed in the lower abdomen in a full bladder. Physical examination revealed lower abdominal distension with right costovertebral angle knocking tenderness. Protract sonography illustrated an enormous pelvic cystic lesion and a right nephromegaly but an invisible left kidney. The following abdominal computed tomography revealed left kidney dysgenesis, right ureterovesical stone with hydroureteronephrosis (Fig. 1), and an enormous pelvic cystic lesion (∼12.5 cm) abutted the prostate (Fig. 2), the characteristics consistent with Zinner syndrome. Then, transperitoneal laparoscopic excision of the cyst and right ureterorenoscopic stone manipulation were performed smoothly. The patient was placed in the supine position, and laparoscopic surgery was performed using the 5-trocar method. After excising the seminal vesicle cyst (Fig. 3, Fig. 4), the patient was repositioned in a modified lithotomy position for endoscopic surgery. A total of 1000 ml of brownish watery fluid was drained from the cyst; however, no left hemitrigone was detected during cystoscopy. The left hemitrigone was not found, and a 0.5-cm yellowish stone was observed in the right lower third of the ureter, which was fragmented with a pneumatic lithoclast. The surgery lasted for 240 minutes with minimal blood loss. No operative complication occurred or transfusion was performed. The patient was discharged uneventfully on postoperative day 5. The pathology report showed a left seminal vesicle cyst with calcification. Then, the patient was lost to follow-up for ∼1.5 years. When the patient revisited the outpatient department, no deterioration of sexual function was observed. Moreover, transrectal ultrasonography showed no recurrence of the cyst.

Fig. 1.

Seminal vesicle cyst, dysgenesis of left kidney and right UVJ stone (arrow).

Fig. 2.

A large seminal vesicle cyst (about 12.5cm) compress bladder to right side with restriction in capacity (Foley balloon noted).

Fig. 3.

Appearance of seminal vesicle cyst during laparoscopic resection.

Fig. 4.

The gross appearance of seminal vesical cyst after resection.

Discussion

Seminal vesicle cyst is a rare disease with a prevalence of 0.005% in men [6]. Zinner first reported that these cysts would coexist with unilateral renal agenesis and ejaculatory duct obstruction in 1914 [6]. Therefore, Zinner syndrome, ipsilateral seminal vesicle cyst, and ejaculatory duct obstruction were considered when the triad was fulfilled. It was commonly diagnosed in men aged 20-50 years [7].

Its most common symptoms are the size of the cyst and the consequent effects of the compressed surrounding organ. A <5-cm cyst is mostly asymptomatic. However, previous studies have reported that irritable symptoms, including dysuria and frequency, always occur [2]. Similarly, our case presented with irritable symptoms and lower abdominal distension in a full bladder.

However, seminal vesicle cysts should be differentiated from other pelvic cystic lesions based on their location and appearance. Zinner syndrome is generally associated with seminal vesicle cysts located in the paramedian region, that is, round, larger, and tubulosaccular-shaped cysts with irregular margins [8].

A digital rectal examination could be performed and could demonstrate an indurated, tender epididymis, and ductus deferens or palpable cystic mass [2]. For the laboratory survey, patients may show positive prostatic secretion or ejaculate culture and even elevated serological markers of chronic inflammation [9].

Ultrasonography (transabdominal or transrectal) can be used as the initial diagnostic tool. Transabdominal ultrasound was more acceptable but lesser comfortable for patients [1]. However, transrectal ultrasound would provide a more detailed visualization of seminal vesicle cysts and could be used during follow-ups [3].

To obtain more details regarding the relationship of cysts with the surrounding organs, magnetic resonance imaging (MRI) or computed tomography (CT) is more appropriate [7]. MRI is a better tool for accurately defining anatomic relationships and is radiation-free when surgeons plan to excise seminal vesicle cysts laparoscopically. It appears as an inverted teardrop shape on sagittal coronal images with hypointensity in T1 and hyperintensity in T2 [8]. Cystoscopy could also be used to evaluate the anatomic position of the lower urinary tract with the cyst [2].

Surgery is indicated when symptoms occur or cysts are larger. The surgical method, an open or laparoscopic approach, would be selected based on the complexity of the cyst. Previously, open surgeries result in excellent outcomes but are always associated with a higher rate of morbidities, especially erectile dysfunction and injury of the surrounding organs [10]. Additionally, a less-invasive treatment, such as cyst aspiration or transurethral resection, has been reported but commonly results in recurrence and increased risk of infection [7,11]. Thus, these treatments may be used as the initial management of small or caudally located seminal vesicle cysts. As in our case, the seminal vesicle cyst is enormous and cranially located; thus, the laparoscopic approach provided straightforward access, excellent visualization, minimal blood loss, and minimal postoperative morbidity.

Conclusion

Zinner syndrome is a congenital disease rarely occurring in males manifesting as unilateral renal agenesis, ipsilateral seminal vesicle cyst, and obstructed ejaculation duct. Physical examination cannot always provide the exact diagnosis. Therefore, imaging studies such as MRI or CT provide comprehensive visualization of the cyst for future surgical planning and diagnosis. Only Zinner syndrome with symptomatic seminal vesicle cyst was treated. Compared to the open technique, laparoscopic excision of the seminal vesicle cyst is an effective treatment with a low morbidity rate and rapid overall recovery.

Patient consent

Informed consent to prepare and publish this case report was obtained from the patient. Personal identifiers were not used in the case report.