Mark W. Ball, MD
Arthur L. Burnett, II, MD, MBA, FACS
BASICS
DESCRIPTION
• The most common seminal vesicle (SV) masses are secondary malignancies
• Cystic masses are the 2nd most common, followed by primary seminal vesical malignancies.
• Cysts
– Rare; either congenital or acquired
– Age at diagnosis, 20–50 yr
– Usually unilateral; size varies considerably from small (5 mm) to huge cysts that fill the pelvis.
• Neoplasms
– Primary malignant neoplasms of the seminal vesicles are exceedingly rare
– SV solid mass is more likely from local invasion by another malignancy such as prostate cancer
EPIDEMIOLOGY
Incidence
• Cysts: Incidence peaks at age 20–30 yr.
• Primary SV malignancy: Exceedingly rare. Only case reports and small series reported.
Prevalence
N/A
RISK FACTORS
• Secondary malignancies
• Prior transurethral surgery causing scarring at the ejaculatory duct
Genetics
• SV formation occurs at the 12th wk of gestation. Abnormal branching of the ureteral bud from the mesonephric duct can disrupt SV formation and result in an ectopic ureteral orifice:
– The abnormal ureter and metanephrogenic blastema results in a dysplastic kidney.
• A basement membrane defect that is seen in multiple organs (as in autosomal dominant polycystic kidney disease [ADPKD]) is believed to also affect SV cysts.
PATHOPHYSIOLOGY
• Normal anatomy:
– SVs are elongated, flat, paired structures that lie between the rectum and bladder, superior to the prostate.
– Mean normal length is 3.1 cm and width is 1.5 cm; contributes 50–80% of total seminal ejaculatory volume
– Blood supply: Vesiculodeferential artery, a branch of the umbilical artery
• Cystic disease of the SVs can be either congenital or acquired; congenital cysts are associated with anomalies of the ipsilateral mesonephric duct.
• Acquired SV cysts result from ejaculatory duct obstruction, inflammation, or other abnormality.
• Cysts are filled with seminal fluid (nonmotile spermatozoa, red and white blood cells, and epithelial cells).
• Congenital SV cysts are typically associated with an ipsilateral ectopic ureter and/or ipsilateral renal abnormalities:
– Lesions <5 cm are rarely symptomatic.
– Lesions >12 cm have been described as giant cysts and are often associated with symptoms related to bladder outlet or colonic obstruction.
• In men, 30% of ectopic ureters insert into the SV.
• 3 patterns of spread of prostate cancer into SV
– Direct spread along the ejaculatory duct
– Prostatic capsular perforation followed by extension into the periprostatic tissues and the SV
– Isolated deposits
• Direct invasion of the SVs can also occur in malignancies of the bladder and rectum
ASSOCIATED CONDITIONS
• Bladder cancer
• Ectopic ureter
• Ipsilateral renal dysplasia or agenesis
• Prostate cancer
• Rectal cancer
GENERAL PREVENTION
N/A
DIAGNOSIS
HISTORY
• Most SV cysts are asymptomatic
• When symptomatic, typical symptoms are:
– Dysuria, irritative voiding
– Perineal discomfort
– Recurrent epididymitis
– Painful ejaculation
– Hematuria
– Hematospermia
– Infertility
• Determine history of other malignancy such as prostate, bladder, or rectal cancer.
PHYSICAL EXAM
ALERT
Normal seminal vesicles are not palpable on DRE. A palpable SV is abnormal.
• SV tumors are often palpable and nontender hard areas on digital rectal exam (DRE), just cranial to the base of the prostate.
• Primary tumors are usually unilateral and not contiguous with the prostate.
• Secondary tumors are usually bilateral and contiguous with a prostate or bladder tumor.
• SV cysts (when large) can usually be palpated on DRE as a ballotable mass.
• Indurated and/or tender epididymis and ductus deferens: Evidence of chronic epididymitis or obstruction
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Low semen volume and lack of fructose and liquefaction implies SV absence or ejaculatory duct occlusion.
• PSA elevation may suggest prostate cancer.
Imaging
• TRUS (transrectal ultrasound):
– 1st-line imaging for suspected SV abnormality or SV mass on DRE
– SV cystic lesions: Echopenic center with echogenic luminal folds
– SV tumors: Isoechoic to the prostate, but hyperechoic to normal SV
• CT:
– SV tumors: Enlarged SV, with a high-attenuation lesion and a normal bladder and prostate. Can be cystic if there is significant tumor necrosis
– Cannot distinguish benign from malignant tumors. Obliterated tissue planes suggest a secondary tumor by direct extension
• MRI:
– Cannot distinguish benign from malignant tumors
– SV cyst: T1, low signal intensity; T2, unilocular smooth wall with uniform high intensity and well-defined margin
– Hemorrhagic SV cyst: High intensity on both T1 and T2; heterogeneous intensity
Diagnostic Procedures/Surgery
• Cystoscopy
– Hemitrigone with absent ipsilateral orifice
– Intravesical cyst protrusion often noted with congenital SV cysts
• TRUS-guided needle placement for SV aspiration or biopsy for pathologic diagnosis
• Vasovesiculography: Limited value and use today in imaging the SV. Can help determine duct obstruction in azoospermic men; also helps distinguish SV cyst from a müllerian or other wolffian duct cyst
Pathologic Findings
Most primary SV masses are benign and rarely neoplastic.
DIFFERENTIAL DIAGNOSIS
• Müllerian duct cysts and ejaculatory duct cysts:
– Both are midline in location
– Spermatozoa in the aspirate may differentiate seminal vesicle cysts from müllerian duct cysts
• Prostatic cysts
• Diverticulosis of the ampulla of the vas deferens
• Ectopic ureterocele
• SV calcifications/masses can occur from chronic bilharziasis, TB, or old bacterial abscess (commonly from colonic flora):
– Symptoms may include hematospermia, infertility, and pelvic pain
• SV cysts:
– Seminal vesiculitis: SV infection is uncommon:
May occur as a consequence of prostatitis or epididymitis
– SV abscess: Best imaged on MRI or US.
Predisposing factors include diabetes or chronic catheterization
Patients often have pelvic pain, fullness, and fever
– SV calculi: Often present with pain, infection, or hematospermia; usually the result of infection and ejaculatory duct obstruction
– Congenital vs. acquired cysts: Congenital cysts are typically associated with ipsilateral ectopic ureter and/or ipsilateral renal dysplasia
• Benign SV tumors:
– Papillary adenoma or cystadenoma: Middle-aged men; mimics a simple cyst in presentation and on imaging
– Amyloid: Subendothelial deposits of amyloid:
Usually presents in the elderly
Often concomitant with bladder or prostate cancer
– Other rare tumors: Carcinoid
• Mixed SV tumors are extremely rare:
– Only 15 cases reported
– Variously described as cystadenoma, cystomyoma, low-grade phyllodes tumor, benign mesen-chymoma, adenomyosis, and mesonephric hamartoma
• Malignant SV tumors:
– Most SV neoplasms are from secondary invasion from prostate, bladder, or rectal cancer, or lymphoma:
Direct extension into the SV can often be mistaken for primary SV cancer
– Primary adenocarcinoma of the SV:
Age >50 yr; incidence is rare
Serum PSA and PAP are normal, and CEA elevated.
Stains positive for CA125 and negative for PSA
– Primary sarcoma:
Extremely rare aggressive tumor; usually diagnosed late in disease course
Variants: Leiomyosarcoma, angiosarcoma, and müllerian adenosarcoma
TREATMENT
GENERAL MEASURES
• Asymptomatic cystic lesions do not require any specific intervention. Imaging of the urinary tract may reveal renal agenesis.
• Solid lesions require biopsy.
• Adjuvant therapy has no demonstrated efficacy in primary malignancy of the SV.
MEDICATION
First Line
Seminal vesiculitis is treated with standard antibiotic regimens used to treat prostatitis (eg, ciprofloxacin, ofloxacin)
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Symptomatic cysts
– For small cysts, percutaneous transperineal or TRUS-guided aspiration/drainage (cysts typically recur)
– Marsupialization (unroof into the prostate/bladder by TUR or TUI)
– Laparoscopic or robotic-assisted laparoscopic excision. Laparoscopy has good efficacy with minimized morbidity (1)
– Open surgical excision (by the transperineal, coccygeal, intravesical vesical, or retroperitoneal routes) is rarely performed today
– If associated with a congenital ectopic ureter and dysplastic kidney: An ipsilateral nephroureterectomy, along with the SV, should be performed
– SV duct stones: Lithopaxy is feasible in select patients via a ureteroscope
• SV tumors
– All solid or noncystic SV masses on TRUS should undergo a US-guided biopsy:
If tumor is confirmed: Further stage with CT and/or MRI
– Enlarging asymptomatic benign tumors are treated with simple seminal vesiculectomy
– Historically, small benign tumors were excised transperineally or retrovesically, and large tumors, transvesically or transcoccygeally
– Today, excisions are typically by transperitoneal laparoscopy (case series are small)
– A diagnosis of malignancy (large in size or poorly differentiated) warrants radical cystoprostatectomy and regional lymph node dissection, en bloc with adherent surrounding structures
– SV invasion by another malignancy: Directed at the primary tumor type
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
N/A
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• Primary SV malignancies due to their rarity, typically present at an advanced stage and are diagnosed late.
• Local invasion of SVs by secondary cancers are a poor prognostic sign.
COMPLICATIONS
ED can occur after SV excision since the neurovascular bundle lies lateral to the tip of the SV.
FOLLOW-UP
Patient Monitoring
Asymptomatic benign tumors: Close follow-up with DRE and TRUS. After radical surgery for malignancy, no clear follow-up consensus exists.
Patient Resources
N/A
REFERENCE
1. Cherullo EE, Meraney AM, Bernstein LH, et al. Laparoscopic management of congenital seminal vesical cysts associated with ipsilateral renal agenesis. J Urol. 2002;167:1263–1267.
ADDITIONAL READING
Van den Ouden D, Blom JH, Bangma C, et al. Diagnosis and management of seminal vesical cysts associated with ipsilateral renal agenesis: A pooled analysis of 52 cases. Eur Urol. 1998;33:433–440.
See Also (Topic, Algorithm, Media)
• Prostate Nodule
• Renal Dysplasia, Hypodysplasia, and Hypoplasia
• Renal Ectopia
• Seminal Vesicle, Amyloidosis
• Seminal Vesicle, Mass and Cysts Image 
• Seminal Vesiculitis (Pyospermia)
CODES
ICD9
• 198.82 Secondary malignant neoplasm of genital organs
• 608.0 Seminal vesiculitis
• 608.89 Other specified disorders of male genital organs
ICD10
• C79.82 Secondary malignant neoplasm of genital organs
• N49.0 Inflammatory disorders of seminal vesicle
• N50.8 Other specified disorders of male genital organs
CLINICAL/SURGICAL PEARLS
• Seminal vesical masses are most commonly secondary malignancies.
• During seminal vesiculectomy, limit cautery during dissection to limit damage to the neurovascular bundle.
• Asymptomatic cystic lesions should be observed.