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Seminal vesicle (SV) cysts are rare, benign lesions. Most of them are congenital in origin and are usually diagnosed incidentally due to extensive imaging. When symptomatic, surgical excision is recommended.
We describe the case of a 17.2 cm seminal vesicle cyst removed using a transperitoneal, robotic-assisted laparoscopic approach in a 45-year old male with lower urinary tract symptoms and no other genitourinary abnormality.
Laparoscopic excision of seminal vesicle cysts is a minimal invasive alternative to the open technique with single-center studies reporting high success rates. With the advent of the robotic platform, urologists have shifted to this approach especially for confined anatomical spaces such as the pelvis. To our knowledge this is the largest seminal vesicle cyst described in the literature that has been managed by minimally invasive surgery.
With the advantage of combined 3D vision and wristed instrumentation, excision of large seminal vesicle cysts by robotic assisted laparoscopic approach is feasible, safe and regarded as a natural continuity of conventional laparoscopy. Previous experience in Robotic assisted laparoscopic prostatectomy (RALP) especially in the posterior dissection technique is recommended.
Seminal vesicle (SV) cysts are rare lesions that may be congenital or acquired. Most of them are congenital in origin and are almost always solitary. They are believed to be secondary to obstruction of the ejaculatory duct, caused by maldevelopment of the distal portion of the mesonephric duct. Hence, they are associated with genitourinary anomalies, the most frequent of which is ipsilateral renal agenesis. On the other hand, acquired cysts have been associated with benign prostatic enlargement, prostatic surgery, and malignancy.1 Diagnosis of SV cysts has become more common in recent years and it is unclear whether this represents a true increase in incidence or simply a higher incidental pick up rate due to the more prolific use of imaging. While many cases of SV cysts require no intervention, surgical excision is the treatment of choice for symptomatic patients. With the advent of minimally invasive platforms, open vesiculectomy is no longer the only surgical approach that can be utilized.2,3 Herein, we report a case of a large seminal vesicle cyst causing mechanical displacement of the bladder and subsequent lower urinary tract obstruction, managed by robotic-assisted laparoscopic vesiculectomy.
A 45-year old male patient presented to our clinic with a 1-year history of storage lower urinary tract symptoms, dysuria, and intermittent pelvic pain. Digital rectal examination revealed a cystic mass in the region of the prostate, too large to define its boundaries. Abdominal examination revealed a suprapubic mass, consistent with a palpable bladder. Urinalysis and blood tests were unremarkable. Ultrasonography showed a 17.2 cm cyst originating from the right SV with a thin wall containing two smaller multiseptated cystic lobules. The SV cyst occupied the majority of the pelvis, pushing the bladder cephalad. Computed tomography (CT) and magnetic resonance imaging (MRI) confirmed the finding and excluded coexisting pathology (Fig. 1). Cystoscopy demonstrated extrinsic compression and displacement of the bladder but orthotopic and patent ureteral orifices. Transrectal ultrasound (TRUS) guidance was used to aspirate cyst fluid for microscopy, culture, and cytology, plus obtain a wall biopsy; these investigations were negative for malignancy.
Robotic-assisted laparoscopic seminal vesiculectomy was performed at our center after appropriate anesthesia, draping, and docking, with the patient in a 30-degree Trendelenburg position and catheterized. We used a transperitoneal 3-arm approach with a 0-degree lens, an approach used extensively by us and others for robotic-assisted radical prostatectomy (RARP).4 However, due to the size of the cyst, the ports were placed 5 cm more cephalad than is standard for RARP, and an additional 5 mm laparoscopic assistant port was placed on the left side between the camera port and the left robotic arm. Standard robotic and laparoscopic instrumentation as used in RARP were employed. Intraoperative multiple biopsies from macroscopically suspicious areas of the cyst were sent for frozen sections. After confirming that the lesion was benign, a transverse incision of the retrovesical peritoneum was made just above the cyst. Lateral dissection was possible after aspirating the fluid content of the cyst (Fig. 2). Countertraction via the assistant ports was applied to aid the robotic dissection adjacent to the cyst. Care was taken not to injure the rectum during dissection due to dense adhesions between it and the cyst wall (Fig. 3). The ureters were mobilized bilaterally after identification aided by the use of vessel loops. The neurovascular bundles were approached in an athermal, traction-free manner, to preserve potency, and any bleeding was managed by use of intracorporeal robotic suturing. At the end of the operation, hemostasis was confirmed and no drain was required. A laparoscopic entrapment bag was used to retrieve the specimen by extending the incision of the camera port (Fig. 4). Console time for this case was 56 min, and there were no intraoperative complications, with minimal bleeding (estimated blood loss of 25 cm3). Convalescence was uneventful, the urethral catheter was removed on the first postoperative day, and the patient was discharged after a successful trial of void. The histopathology report revealed mucinous cystadenoma in the seminal vesicle.
Seminal vesicle cysts, although rare, occur in young men and can be associated with other genitourinary conditions such as renal agenesis, infertility, hematospermia, genitourinary infection, and adult polycystic kidney disease. The advent of TRUS, CT and MRI has made this benign discovery more frequent. In the case described herein, no concurrent pathology was evident on preoperative imaging or during surgery. The majority of patients with a SV cyst are asymptomatic; however, they may present with lower urinary tract symptoms including dysuria, urinary frequency, painful ejaculation, perineal or pelvic pain, hematospermia, recurrent prostatitis, and epididymitis.2,3
Various techniques for the operative management of symptomatic SV cysts have been proposed. Conventional surgery performed through a transperineal, transabdominal, or even transcoccygeal, approach have been described but are associated with considerable morbidity and postoperative pain. These treatments are invasive and technically demanding due to limited visualization of the operative field. While endoscopic treatments such as TRUS-guided aspiration or transurethral resection with de-roofing are less morbid, they are also accompanied by significant failure rates and thus are reserved mainly for smaller lesions.2 Recently, laparoscopic access to the SVs has been added to the urologist's armamentarium due to familiarity with the anatomy as a result of the establishment of laparoscopic prostatectomy. In 1993, Kavoussi et al. first described the principles of laparoscopic approach to the SVs and suggested that it could be used to treat primary retrovesical lesions.5 Since then, apart from sporadic case reports of laparoscopic SV cyst excision, single-center studies have been reported with high success rates, minimal blood loss, quick convalescence, and minimal postoperative pain.6–8
The robotic platform offers certain distinct advantages over conventional laparoscopy, such as stereoscopic, magnified vision and endo-wristed instrumentation, allowing for more precise dissection especially in confined areas such as the pelvis. Five cases of robotic SV excision and one single-center study with 6 patients including 4 with SV cyst excision, have been reported in the literature to date.9–14 The estimated blood loss ranged from 5 to 50 cm3, operative time ranged from 120 to 231 min, and in most cases the patient was discharged the first or second postoperative day; the only reported complications were transient brachial palsy due to patient positioning13 and a single case of a self-limiting small pelvic hematoma.9 We perform RARP at our institution using the posterior approach to the dissection of the seminal vesicles and vasa deferentia,4 which makes the retrovesical anatomy familiar to the surgeon.
To our knowledge this is the largest seminal vesicle cyst described in the literature that was managed by a minimally invasive approach. Due to this fact, certain modifications were introduced in our case to facilitate dissection. All ports were placed more cephalad and an additional assistant port was utilized on the left side to aid in mobilization of the ipsilateral ureter and retraction of the rectum. The risk of injury to adjacent organs was greatly reduced by keeping the dissection adherent to the SV cyst. When further dissection was not possible, puncture of the cyst and aspiration of its contents made visualization of the surrounding structures possible. Vessel loops were slung around both ureters to aid identification and avoid inadvertent injury during dissection of the lateral limits of the cyst. Finally, meticulous athermal, traction-free dissection of the neurovascular bundles was employed in an effort to preserve potency.
Excision of large seminal vesicle cysts by a robotic-assisted laparoscopic approach is feasible and safe, with the advantages of combined 3D vision and endo-wristed instrumentation over conventional laparoscopy. Morbidity, blood loss, and convalescence are minimal. Due to the rarity of retrovesical pathology, previous experience in RALP, especially in the posterior approach technique, is recommended.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
Achilles Ploumidis, writing; Prasanna Sooriakumaran, writing; Prodromos Philippou, data collection; Peter Wiklund, study design, data analysis