ROBOT-ASSISTED LAPAROSCOPIC VESICULECTOMY FOR LARGE SEMINAL VESICLE CYSTOADENOMA: A CASE REPORT AND REVIEW OF THE LITERATURE

Case Report: A 47-year-old patient was referred to our centre for gross hematuria, mild dysuria and other lower urinary tract symptoms (LUTS). Past medical history was unremarkable and no co-morbidities were present. Digital rectal examination (DRE) revealed, cranially to the prostate, a tense-elastic mass with undefined upper and lateral boundaries. Prostate-specific antigen (PSA) level was 1.7 ng/ml. Physical examination and laboratory tests were otherwise normal. Trans-abdominal ultrasound showed no lesions or abnormalities in the upper urinary tract; high-resolution trans-rectal ultrasound (TRUS) confirmed the presence of a multisepted, solid-cystic pelvic mass occupying the retrovesicle space. An office cystoscopy showed no lesions within the bladder. Pelvic magnetic resonance imaging (MRI) confirmed the presence of a retrovesicle, 6.0×4.5 cm well-defined pseudo-nodular mass, arising from the right seminal vesicle (SV) and vas deferens (VD) (Figure 1). TRUS-guided prostatic and SVs biopsies showed no neoplastic proliferation in all the samples from both the prostate and the mass. The patient was then scheduled for robot-assisted laparoscopic vesiculectomy (RALV). After a transversal incision of the peritoneum at the level of the Douglas pouch, a voluminous mass, firmly adherent to the surrounding tissues, was found. The plane between the mass, the rectum and the bladder was carefully developed until the tumor was completely released from the surrounding adhesions. The left VD and SV were preserved during the dissection. The neuro-vascular bundles (NVBs) were approached bilaterally in an athermal, traction-free manner in order to preserve continence and potency. The specimen was then removed intact through the camera port by using a retrieval bag. Accurate hemostatic control was achieved and a tube drain was positioned. Console time and estimated blood loss were, respectively, 120 minutes and 50 cc; no intraoperative complications were recorded. The postoperative course was uneventful and the patient was discharged on the fourth postoperative day with normal blood tests and spontaneous voiding. A two-year follow-up showed no evidence of disease recurrence. At present, the patient is free of symptoms with full preservation of continence and potency. Histopathological examination revealed a 7.0×4.5×4.5 cm cystic SV cystoadenoma (Figure 2). No significant cytologic atypia, mitotic activity or necrosis were present. The proliferation index was <1%. Review of the Literature: A systematic review of the English-language literature was performed using the Medline, Embase and Web of Science databases up to December 2014. Twenty case reports have been published in literature on SV cystoadenoma (Table I). Median patient age and median tumor diameter were 49 years (inter-quartile range (IQR)=42-51) and 7.0 cm (IQR 5.0-12.0), respectively. No perioperative complications were reported in all the published series. Local recurrence occurred in 2 cases (10%) after 2 and 3 years, respectively. The differential use of diagnostic investigations and surgical approaches for SV cystoadenoma in the published series is shown in Figure 3. Discussion and Conclusion: Primary tumors of SVs are very rare and the differential diagnosis must be based on a multimodality approach. Most cases of SV cystoadenoma were managed with open surgery through transvesicle/retrovesicle approaches or radical cysto-prostatovesiculectomy. To date, minimally-invasive seminal vesiculectomy (MISV) is increasingly used for the treatment of beginning diseases of SVs achieving optimal oncologi and functional results. Therefore, they could be considered the new gold standard for the treatment of such rare diseases.c