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.