Laparoscopic excision of left seminal vesicle
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This document describes a case of recurrent hematospermia (blood in semen) in a 47-year-old male that was treated with laparoscopic excision of the left seminal vesicle. Initial conservative management and investigations revealed hemorrhage in the left seminal vesicle on MRI. The patient underwent cystoscopy, seminal vesiculoscopy, and laparoscopic excision of the left seminal vesicle. Post-operatively, the hematospermia resolved however the patient later developed a retrovesical abscess that improved with aspiration. Follow-up 8 months later showed no recurrence of symptoms and normal sexual function.
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Laparoscopic excision of left seminal vesicle
- 1. Laparosopic management of recurrent hematospermia Dr Santosh Agrawal MCh ( Urology), FIAGES, FALS Fellow Robotic Surgery ( Roswell Park Cancer institute Buffalo, NY, USA)
- 2. • Blood in the semen • Usually self limiting • Recurrent and persistent hematospermia – needs evaluation
- 3. Index case • 47/Male • C/C - blood in the semen since 2 months, present in each ejaculate, not associated with pain or urinary symptoms - No urinary complaints • Past H/O - No h/o hypertension, tuberculosis, antiplatlet or anticoagulant • No h/o any scrotal, inguinal or prostate surgery • Pers. H/O - Non alcoholic & smoker • O/E - Conscious & oriented – Vitals - Tº - Afebrile , P- 78/min , B.P.- 130/80 mmhg – P/A - Soft , Non-tender, bilateral testes, vas , epid normal – P/R - No abnormality detected • No prostatic or supra prostati mass felt, prostate benign feel non tender • Seminal vesicle not felt/non tender
- 4. Investigations Hb – 15.5 TLC- 7100 Platlet- 2.2 M/Cc Urine R/M = RBC- nil , 1 – 2 pus cells. Urine C/S = No growth Semen Analysis = full of RBC’s present S.PSA = 1.24 ng /ml Urine AFB – All the 3 samples negative USG- Scrotum • B/L testes normal • B/L epididymis – no abnormality • B/L - no Varicocele
- 5. TRUS • B/L – SV- normal size, shape & echotexture. • Prostate - normal in size & shape = 12.7 ml • Periurethral area appears normal. • Central zone of prostate shows normal echotexture . • Peripheral zone appears normal with slightly hyperechoic texture . • Few tiny calcific foci in bilateral ejaculatory duct course with in the central zone .
- 6. Management Conservative management for 2 months on OPD basis – antibiotic and anti inflammatory •Show bood coming out from left ejaculatory duct Cystoscopy and seminal vesiculoscopy attempted Again one month of conservative management advised No relief in hematospermia Psychological stress , anxiety /depressive symptoms Cystocopy/seminal vesiculoscopy /seminal vesiculetomy advised
- 7. MRI- Pelvis MRI pelvis study including prostate reveals no significant abnormality , except for hemorrhage in left SV Right Left
- 8. Surgery • Cystoscopy and seminal vesiculoscopy Laparoscopic Excision of left Seminal Vesicle C 5 10 Bladder
- 10. Post-Operative • Operative time = 130 min • Blood loss = 50 ml • No intraoperative complications • Drain removal – POD 3 • Foleys Removal – POD 2 • Discharge – POD 4
- 11. HPE • Two soft tissue pieces & vas deferens – SV- showing few cystically dilated ducts with calcified secretion, luminal papillae showing proliferation of blood vessels with congestion. – No evidence of inflammatory change • Section from vas show inflammatory cells & RBC in lumen • Impression : Obstructive pathology – Seminal vesicle
- 12. Follow up • Devoloped fever dysuria and perineal pain after 15 days • USG – showed collection in retro vesicle space • Transrectal aspiration was done. • Patient immediately improved • Post op 8 month- no hematospermia, sexual funtion ok.
- 13. Discussion • < 40 years – almost always benign • >40 years – usually benign, rarely associated with malignency
- 15. Etiology Idiopathic Congenital • Seminal vesicle/ED CYST Inflammation • Urethritis, prostatitis,epididymitis • TB, CMV, HIV Obstruction • Duct obstruction • Calculi • cyst Malignency • Prostate, SV, epididymis Vascular malformation • Prostatic varices, hemangioma • Excessive sex, masterbation Trauma • Prostate biopsy • Blunt trauma • Post haemorroid injection Systemic cause • Hypertension • Haemophilia • Bleeding disorder • Cirrosis • amyloidosis
- 16. Etiology Prostate •After prostate biopsy •Post TURP •Prosatitis •Prostate cancer •Prostate varices •Dilated prostatic utricle Seminal vesicle • Infection • Cyst • Ejaculatery duct cyst • Calculi • tumor Urethra • Polyp • Urethritis • Tumor • Stricture Epididymis and testes Systemic cause • Uncontrolled HTN • Bleeding diathesis
- 17. Work up • History • Physical examination • Investigation – CBC, coagulation profile – Urine routine and culture – Semen analysis and culture – Serum PSA – TRUS – MRI
- 18. Seminal Vessel Endoscopy • Yang et al described a technique in which a 6F or 9F rigid ureteroscope is used to gain access to the prostatic utricle or ejaculatory ducts. • In this manner, the scope is used to visually inspect the seminal vesicles, and a biopsy specimen may then be obtained from any abnormal area. In a study of this procedure by Yang et al, seminal vesicle hemorrhage was found in 62% of patients, and calculi were found in 16%.
- 19. What next? If seminal vesiculoscopy fails
- 20. Thank you
Editor's Notes
- Hematospermia is defined as blood in the semen. While often perceived as a symptom of little significance, blood in the ejaculate can cause great concern to the men who experience it. The condition is common, and many episodes go unnoticed; therefore, the prevalence of hematospermia remains unknown. In most patients with hematospermia, the condition is self-limited and no further diagnostic workup is needed; however, in some patients, hematospermia may be the first indicator of other urologic diseases
- A good patient history that concentrates on pelvic instrumentation, trauma, infection, and bleeding disorders often helps to narrow the differential diagnoses associated with hematospermia.Most patients have more than one episode, occurring over weeks to months. While no uniformly accepted definition of chronic hematospermia has been determined, blood in the ejaculate that persists for more than 10 ejaculations requires further evaluation. While some authorities use duration (ie, months) as a guideline, the discrepancy in the frequency of ejaculations among men renders this approach less reliable.Patient age is important. In patients younger than 40 years, urogenital infections are the most common cause of hematospermia, and a simple, focused workup is often sufficient. In men older than 40 years with persistent hematospermia or associated symptoms such as hematuria, excluding urogenital malignancy is essential.[3]Next Section: Physical
- Hematospermia is usually associated with inflammatory conditions of the seminal vesicles or prostate. The condition is often self-limited and resolves within 1-2 months. If hematospermia persists beyond 2 months, further workup is recommended to determine the cause. In approximately half the cases, the etiology is declared idiopathic. However, this may reflect an incomplete evaluation. Consider the following in the genital examination:The penis should be carefully inspected to rule out any lesions that may bleed and contribute to the ejaculate. The vasa should be palpated along their entire course to ensure their presence and to rule out any induration or nodularity. Any nodularity in the absence of prior vasal surgery (including vasectomy) should raise concern for a tuberculous infection of the vasa. Alternatively, nodules within the vas rarely represent extension of prostatic or bladder malignancies. Upon digital rectal examination (DRE), special attention should be given to the seminal vesicles and the presence of any midline masses. The seminal vesicles are routinely nonpalpable structures. If they are palpable, this generally indicates significant underlying pathology. In older men (>50 y), specific attention should also be given to the prostate because hematospermia is occasionally a harbinger of prostate cancer.
- The most recent data suggest that seminal vesicle and ejaculatory duct cysts or hemorrhagic lesions account for most identifiable causes of hemospermia. Fifty-two of 86 men in a recent study were found to have lesions in association with hemospermia. Of these men, 51 had some type of seminal vesicle, ejaculatory duct, or prostatic benign or hemorrhagic lesion. Only one case of prostate cancer was identified.[9]
- Worischeck and Parra evaluated 26 patients with hematospermia using TRUS. They found abnormalities in 92% of patients, which included dilatated seminal vesicles (30%), ejaculatory duct cysts (15%), ejaculatory duct calculi (15%), seminal vesicle calculi (15%), and müllerian duct remnants (7%). No ultrasonographic evidence of malignancy was found. In a study by Raviv et al of 115 consecutive patients with hematospermia who were evaluated with TRUS, all the patients were found to have an abnormality, almost all of them benign. In 10 patients a 12-core TRUS-guided biopsy of the prostate was taken; none of the samples were positive for tumor. Three large series have evaluated the utility of TRUS in the investigation of patients with chronic hematospermia. In a study of 52 patients, Etherington et al found a significant number of patients with prostatic calculi and abnormalities of the seminal vesicles, including calculi, dilatation, cysts, abnormal lobulation, and asymmetry.[1
- Persistent hematospermia (>3 mo) without an antecedent cause or persistent hematospermia associated with an abnormality on ultrasonography or MRI may prompt further evaluation.