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Müllerian Duct Cysts
THE JOURNAL OF UROLOGY
Vol. 64, No. 6, December 19 0 Printed in U.S.A.
MULLERIAN DUCT CYSTS FREDERICK A. LLOYD
AND
DOVELL BOXNETT
From the Department of Urology of the Northwestern University 1vfedical School, Chicago, Ill.
Retroprostatic cysts in the midline usually arise from rests of the mullerian duct. Englisch in 1875 was the first to recognize their origin, and he demonstrated a cord of fibrous tissue ·with an epithelial lined channel extending from the cyst through the prostate to the colliculus. The normal remnants of the mullerian duct in the adult male are the appendix testis from its proximal end and the prostatic utricle from its distal end. As stated by Hennessey, if the duct were to persist in the adult it would extend from the appendix testis in a groove between the testicle and epididymis, up the spermatic cord, through the abdominal inguinal ring, and finally come to lie between the vas deferens and the bladder, where it would join with the duct from the opposite side. The ducts would be incorporated in the musculature of the bladder wall, passing through the prostate to end in the utricle. Cysts may form from abnormal remnants anywhere along the course of the duct. Because of the intimate incorporation of the duct in the muscular wall of the bladder and in the prostate, retroprostatic mullerian duct cysts are usually so closely attached to the bladder wall, the prostate, and even the seminal vesicles that their clean surgical removal may be difficult or even impossible. These cysts may vary in size from small dilatations of the utricle to huge masses the size of a football or even larger and containing up to five litres of fluid. They may be unilocular or multilocular, and the contents may vary from a pale clear, to a grayish red, to a chocolate-colored fluid, which upon microscopic and chemical examination may reveal erythrocytes, leukocytes, albumin, cholesterin, and fat. The wall of the cyst usually consists of laminated collagenic connective tissue which may contain some smooth muscle fibers. The anterior wall of the cyst and the posterior wall of the bladder are so intimately connected as to form one structure. The cyst may be lined with a low cuboidal or flattened epithelium. Kot infrequently there is no evidence of any epithelial lining. Occasionally the inner surface may show evidence of necrosis. As the attachment of the cyst to the prostate is approached the cystic tumor becomes a solid one, which, upon microscopic examination, reveals numerous spaces lined with a low cuboidal to a stratified epithelium (Begg), and sometimes containing coagulated colloid (Coppridge). Most of the patients are in the third decade of life. According to Englisch, however, these cysts of the utricle may appear in the newborn and cause retention of urine. Then following forceful urination or urpture of the cyst by instrumentation a yellowish, mucoid secretion appears from the urethral meatus. Impotence and pain on ejaculation are among the symptoms described. As the cyst increases in size, difficulty on voiding and retention of urine are common Read at annual meeting, North Central Section, American l:rological Association, Grand Rapids, Mich., October 8, 1949.
777
778
FREDERICK A. LLOYD AND DOVELL BO::XNETT
findings. In the case of the larger cysts, dislocation of the pelvic organs occurs and pressure upon the rectum may result. Compression of the bladder may reduce its capacity and give rise to extreme frequency. In the case of the huge cyst described by Guiteras, however, abdominal pain was the only symptom. With small cysts of the utricle alone, the rectal findings may be negative. On endoscopic examination the cyst is seen to bulge into the prostatic urethra. When the cyst is larger and extends up behind the bladder into the trigonum recto-vesicale, a fluctuant, globular mass is palpable in the midline above the prostate which is otherwise normal to the examining finger (Lubash). As the cyst increases in size the impression is gained of a soft, symmetrical enlargement of the prostate. In the case of the very large cysts described by Begg, Fiske, Guiteras, Coppridge, and Smith, a large midline abdominal tumor is palpable which gives the impression of a greatly overdistended urinary bladder. Upon catheterization only a small quantity of urine is obtained and the mass does not decrease in size. Cystoscopy is usually difficult or impossible due to compression of the bladder by the cyst. Upon rectal examination a tense, globular mass which seems to be jammed down into and occupy the entire pelvis is felt. The prostate and seminal vesicles cannot be made out clearly. If the utricle can be catheterized the cyst may be demonstrated radiographically and the diagnosis is confirmed. This has been accomplished in 3 of the reported cases, including the one described by Landes and Ransom. This is probably the most valuable diagnostic procedure and should be attempted in every suspected case. Begg, Hallock, Deming, Coppridge, and others agree that complete surgical removal of mullerian duct cysts may be difficult or impossible because of fusion with the bladder. In only the cases of Hallock, Deming, Hennessey, and McKenna and Kieffer was complete surgical removal possible. In McKenna and Kieffer's case, part of the prostate and the seminal vesicles -were removed with the cyst. In Hennessey's case removal was accomplished only with great difficulty and in two stages. In other instances mere drainage, or partial removal with packing or electrocoagulation of the inaccessible portion, has been used with varying success. In the absence of an epithelial lining, repeated aspirations may result in a cure as in the cases of Smith and Fiske. Small cysts of the utricle may be treated by endoscopic incision and electrocoagulation. Cysts of the mullerian duct are said to be rare because of the relatively infrequent clinical reports. Landes and Ransom collected 15 cases from the literature and added one of their own. It would seem to us from a perusal of the clinical and pathological literature that the actual count would be above 40 cases if the smaller cysts of the utricle were included. In addition many reports of large cyst of the seminal vesicle (Smith, Guiteras, Fiske) are actually cases of mullerian duct cyst. Spermatozoa are never found in mullerian duct cysts. They are not uncommonly present in cysts of the seminal vesicle. Cysts of the seminal vesicle are very rare and should be so reported only if confirmed anatomically.
MULLERIAN D-CCT CYSTS
779
CASE REPORT
A 26 year old Negro was admitted to the Hines Hospital on May 20, 1949. He had been perfectly well until 6 months previously when he developed bilateral epididymitis. At the same time he had noticed difficulty in starting the urinary stream, slight dysuria, and frequency and nocturia. The symptoms were progressive, and during the previous month he had developed some perinea! pain and suprapubic discomfort when the bladder was full. Examination of the external genitalia revealed epididymides which were thickened to 1.5 cm., firm, and not tender. Rectal examination showed a greatly enlarged prostate which was smooth and soft, and not tender. Neither seminal vesicle was palpable. A No. 18 Tiemann catheter was passed without obstruction and 150 cc clear residual urine was obtained. It contained only an occasional clump of leukocytes and the culture was negative. Except for a slight leukocytosis (10,500), the blood count, blood chemistry, including phosphatase determinations, and the Kahn test gave negative findings. An x-ray of the chest revealed shadows suggestive of sarcoidosis. The excretory urogram was negative. On cystoscopy the bladder capacity was normal. The internal urethral orifice was thrown up into large folds and the prostate projected deeply into the bladder. The overlying mucosa was reddened and edematous. This reddening and edema extended well up onto the trigone and the floor of the bladder, obscuring the ureteral orifices. Under the impression that we were dealing with a prostatic tumor, probably a sarcoma, we undertook a transurethral biopsy of the prostate and bladder neck. About 10 gm. tissue was removed. Histologic examination revealed merely chronic inflammatory changes and cystitis cystica. On June 13, 1949 a perinea! punch biopsy was attempted with the Huffman punch. The trocar was inserted deep into the mass. When the stylet was removed 100 cc of opalescent fluid drained out and the mass disappeared. Culture of the fluid revealed A. aerogenes and E. freundi. Rectal examination now revealed a prostate of normal size. Two weeks later the mass had recurred. Aspiration again yielded about 60 cc fluid, but when an attempt was made to inject skiodan, the needle became dislodged and the medium entered the urinary bladder. On July 15, 1949 the prostatic utricle was catheterized with a No. 4 ureteral catheter which was passed with ease to a depth of 4 cm. About 60 cc of skiodan was injected. The cyst was clearly outlined and thus identified as a mullerian duct cyst (fig. 1). On July 22, 1949, the bladder ,vas extraperitonealized through a midline suprapubic incision and drawn forward. Our intention was to proceed behind the bladder to identify and, if possible, extirpate the cyst. The perivesical tissues everywhere showed the results of previous inflammatory changes in the form of severe liposclerosis and fibrosis. After a long and tedious sharp dissection, during which the cyst could not be found, and during which the bladder was
780
FREDERICK A. LLOYD AND DOVELL BONNE'rT
opened for better orientation, a Pezzer catheter was left in the bladder and the wound closed.
FIG. 1. A, demonstration of cyst following catheterization of utricle and injection of skiodan. B, right oblique view with simultaneous urethrogram and air cystogram.
FIG. 2. Operative specimen including cyst wall, both seminal vesicles, and part of pros-
tate.
On August 15, 1949, rectal examination revealed a hard, irregular mass extending above the region of the prostate and well beyond the reach of the examining finger.
MULLERIAN DUCT CYSTS
781
On August 17, 1949, perineal exploration was carried out. A hard, irregular mass the size of a pear was exposed which was closely adherent to the prostate. This ,vas removed in several pieces, with great difficulty, and mainly by sharp dissection. In the process both seminal vesicles and part of the prostate were excised. As the dissection progressed a flat piece of tissue, evidently part of the cyst wall, and about 4 cm. square, was seen attached to the posterior bladder wall. Excision of this resulted in an opening in the bladder. After suture of the bladder and prostatic urethra, the wound was closed in the usual manner, after leaving in a small gauze pack. The specimen consisted of 4 separate pieces of tissue, including part of the prostate and both seminal vesicles (fig. 2). On histologic examination the cyst wall consisted mainly of connective tissue which showed considerable chronic inflammatory change. No epithelial lining was found. The postoperative convalescence was uneventful. At the last examination 2 months after the operation the patient was voiding with ease, and except for a slight perineal tenderness on sitting down, he felt perfectly well. Rectal examination revealed a prostate of normal size. SUMMARY
A miillerian duct cyst is reported. The cyst was demonstrated radiographically after catheterization of the utricle. The removal of the cyst was accomplished only with great difficulty through a perineal approach after a previous failure through a suprapubic incision. Complete excision required removal of both seminal vesicles, part of the prostate, and a small area of the posterior wall of the bladder.
104 S. :Vl~ichigan Ave., Chicago 3, Ill. REFERENCES BEGG, R. C.: Massive cystadenoma of Mtiller's duct causing retention of urine. Brit. J. Urol., 8: 105, 1936. BosHAMER, K.: Utrikelcysten. Ztschr. f. Urol., 29: 542, 1935. CoPPRIDGE, W. M.: Mullerian duct cysts. South. Med. J., 32: 248, 1939. CuLBURTSON, L. R.: Mullerian duct cyst. J. Urol., 58: 134, 1947. CULVER, H. AND BAKER, W. J.: Extravesical tumors in the male causing interference with urination Trans. Amer. Assoc. G. U. Surg., 21: 285, 1928. DEMING, C. L. AND BERNEIKE, R.R.: Mullerian duct cysts. J. Urol., 51: 563, 1944. EMMETT, J. J,. AND BRAASCH, W. F.: Cysts of the prostate gland. J. Urol., 36: 236, 1936. ENGLISCH: Uber Cysten on der hinteren Blasenwand bei Mannern. JVIed. Jahrb., Vienna, 1875. FISKE, A. L.: A cyst of the right vesicula seminalis. Aspiration by rectum. Ann. Surg., 28: 652, 1898. .. VoN GAZA, W.: Uber Chronische Spermatocystitis und uber eine Cyste des persistierenden Mullerschen Gariges. Arch f. ldin. Chir., 126: 502, 1923. GurTERAS, R.: A case of sero-purulent cyst, probably of the right seminal vesicle. Lancet, London,2:74, 1894. HALLOCK, L.A.: Hemorrhagic cyst of prostate gland. Am. J. Cancer, 15: 2331, 1931. HELLER, J. AND SrRINZ, 0.: Beitriige zur vergleichenden und pathologischen Anatomie des Colliculus Seminalis. Ztschr. f. urol. Chir., 7: 196, 1921. HENNESSEY, R. A.: Mullerian duct cyst. J. Urol., 42: 1042, 1939. HOWARD, F. S.: Hypospadias with enlargement of prostatic utricle. Surg., Gynec. and Obst., 86: 307, 1948.
782
FREDERICK A. LLOYD AND DOVELL BONNETT
HUGGINS, C. B.: The syndrome of diverticulum of the spermatic system in the neighborhood of the prostate obstructing the neck of the urinary bladder. J. Urol., 24: 100, 1930. KLOTZ, H. G.: Endoscopic studies including cysts of the colliculus sominalis. N. Y. Med. J., 61: 99, 1895. LANDES, R.R. AND RANSOM, C. L.: Mullerian duct cysts. J. Urol., 61: 1089, 1949. LUBASH, S.: Cyst of prostatic utricle. Am. J. Surg., 7: 123, 1929. McKENNA, C. M. AND KIEFFER, J. H.: Congenital enlargement of the prostatic utricle with inclusion of ejaculatory ducts and seminal vesicles. Trans. Amer. Assoc. G. U. Surg., 32: 305, 1939. MICHALov, N. A.: Cyste des Mullerschen Ganges. Ztschr. f. Urol. 2: 848, 1908. MooRE, R. A._:_ Pathology of the prostatic utricle. Arch. Path., 23: 517, 1937. PETERS, H.: Uber Heterotopien des Colom opithels an der Urnierenleiste mcnschlicher Embryonen. Ein Beitrag zur Entwichklungs-geschichte des Mi.illerschen Ganges. Ztschr. f. Anat., 86: 348, 1928. SMITH, N. R.: Hydrocele of seminal vesicle. Lancet, London, 2: 558, 1872. SMITH. E. AND STRASBERG, A.: Mullerian duct cyst in a male. Canad. Med. Assoc. J., 52: 160, 1945. SPRINGER, C.: Zur Kenntniss der Cystcnbildung aus dem Utriculus Prostaticus. Heilk. 19: 459, 1898. WESSON, M. B.: Cysts of the prostate and urethra. J. Urol., 13: 605, 1925. ZINNER, A.: Ein Fall von intravesikaler Samenblasen cyste. Verhandl. d. deutsch. Gesellsch. f. Urol., 4: 384, 1913.
Vol. 64, No. 6, December 19 0 Printed in U.S.A.
MULLERIAN DUCT CYSTS FREDERICK A. LLOYD
AND
DOVELL BOXNETT
From the Department of Urology of the Northwestern University 1vfedical School, Chicago, Ill.
Retroprostatic cysts in the midline usually arise from rests of the mullerian duct. Englisch in 1875 was the first to recognize their origin, and he demonstrated a cord of fibrous tissue ·with an epithelial lined channel extending from the cyst through the prostate to the colliculus. The normal remnants of the mullerian duct in the adult male are the appendix testis from its proximal end and the prostatic utricle from its distal end. As stated by Hennessey, if the duct were to persist in the adult it would extend from the appendix testis in a groove between the testicle and epididymis, up the spermatic cord, through the abdominal inguinal ring, and finally come to lie between the vas deferens and the bladder, where it would join with the duct from the opposite side. The ducts would be incorporated in the musculature of the bladder wall, passing through the prostate to end in the utricle. Cysts may form from abnormal remnants anywhere along the course of the duct. Because of the intimate incorporation of the duct in the muscular wall of the bladder and in the prostate, retroprostatic mullerian duct cysts are usually so closely attached to the bladder wall, the prostate, and even the seminal vesicles that their clean surgical removal may be difficult or even impossible. These cysts may vary in size from small dilatations of the utricle to huge masses the size of a football or even larger and containing up to five litres of fluid. They may be unilocular or multilocular, and the contents may vary from a pale clear, to a grayish red, to a chocolate-colored fluid, which upon microscopic and chemical examination may reveal erythrocytes, leukocytes, albumin, cholesterin, and fat. The wall of the cyst usually consists of laminated collagenic connective tissue which may contain some smooth muscle fibers. The anterior wall of the cyst and the posterior wall of the bladder are so intimately connected as to form one structure. The cyst may be lined with a low cuboidal or flattened epithelium. Kot infrequently there is no evidence of any epithelial lining. Occasionally the inner surface may show evidence of necrosis. As the attachment of the cyst to the prostate is approached the cystic tumor becomes a solid one, which, upon microscopic examination, reveals numerous spaces lined with a low cuboidal to a stratified epithelium (Begg), and sometimes containing coagulated colloid (Coppridge). Most of the patients are in the third decade of life. According to Englisch, however, these cysts of the utricle may appear in the newborn and cause retention of urine. Then following forceful urination or urpture of the cyst by instrumentation a yellowish, mucoid secretion appears from the urethral meatus. Impotence and pain on ejaculation are among the symptoms described. As the cyst increases in size, difficulty on voiding and retention of urine are common Read at annual meeting, North Central Section, American l:rological Association, Grand Rapids, Mich., October 8, 1949.
777
778
FREDERICK A. LLOYD AND DOVELL BO::XNETT
findings. In the case of the larger cysts, dislocation of the pelvic organs occurs and pressure upon the rectum may result. Compression of the bladder may reduce its capacity and give rise to extreme frequency. In the case of the huge cyst described by Guiteras, however, abdominal pain was the only symptom. With small cysts of the utricle alone, the rectal findings may be negative. On endoscopic examination the cyst is seen to bulge into the prostatic urethra. When the cyst is larger and extends up behind the bladder into the trigonum recto-vesicale, a fluctuant, globular mass is palpable in the midline above the prostate which is otherwise normal to the examining finger (Lubash). As the cyst increases in size the impression is gained of a soft, symmetrical enlargement of the prostate. In the case of the very large cysts described by Begg, Fiske, Guiteras, Coppridge, and Smith, a large midline abdominal tumor is palpable which gives the impression of a greatly overdistended urinary bladder. Upon catheterization only a small quantity of urine is obtained and the mass does not decrease in size. Cystoscopy is usually difficult or impossible due to compression of the bladder by the cyst. Upon rectal examination a tense, globular mass which seems to be jammed down into and occupy the entire pelvis is felt. The prostate and seminal vesicles cannot be made out clearly. If the utricle can be catheterized the cyst may be demonstrated radiographically and the diagnosis is confirmed. This has been accomplished in 3 of the reported cases, including the one described by Landes and Ransom. This is probably the most valuable diagnostic procedure and should be attempted in every suspected case. Begg, Hallock, Deming, Coppridge, and others agree that complete surgical removal of mullerian duct cysts may be difficult or impossible because of fusion with the bladder. In only the cases of Hallock, Deming, Hennessey, and McKenna and Kieffer was complete surgical removal possible. In McKenna and Kieffer's case, part of the prostate and the seminal vesicles -were removed with the cyst. In Hennessey's case removal was accomplished only with great difficulty and in two stages. In other instances mere drainage, or partial removal with packing or electrocoagulation of the inaccessible portion, has been used with varying success. In the absence of an epithelial lining, repeated aspirations may result in a cure as in the cases of Smith and Fiske. Small cysts of the utricle may be treated by endoscopic incision and electrocoagulation. Cysts of the mullerian duct are said to be rare because of the relatively infrequent clinical reports. Landes and Ransom collected 15 cases from the literature and added one of their own. It would seem to us from a perusal of the clinical and pathological literature that the actual count would be above 40 cases if the smaller cysts of the utricle were included. In addition many reports of large cyst of the seminal vesicle (Smith, Guiteras, Fiske) are actually cases of mullerian duct cyst. Spermatozoa are never found in mullerian duct cysts. They are not uncommonly present in cysts of the seminal vesicle. Cysts of the seminal vesicle are very rare and should be so reported only if confirmed anatomically.
MULLERIAN D-CCT CYSTS
779
CASE REPORT
A 26 year old Negro was admitted to the Hines Hospital on May 20, 1949. He had been perfectly well until 6 months previously when he developed bilateral epididymitis. At the same time he had noticed difficulty in starting the urinary stream, slight dysuria, and frequency and nocturia. The symptoms were progressive, and during the previous month he had developed some perinea! pain and suprapubic discomfort when the bladder was full. Examination of the external genitalia revealed epididymides which were thickened to 1.5 cm., firm, and not tender. Rectal examination showed a greatly enlarged prostate which was smooth and soft, and not tender. Neither seminal vesicle was palpable. A No. 18 Tiemann catheter was passed without obstruction and 150 cc clear residual urine was obtained. It contained only an occasional clump of leukocytes and the culture was negative. Except for a slight leukocytosis (10,500), the blood count, blood chemistry, including phosphatase determinations, and the Kahn test gave negative findings. An x-ray of the chest revealed shadows suggestive of sarcoidosis. The excretory urogram was negative. On cystoscopy the bladder capacity was normal. The internal urethral orifice was thrown up into large folds and the prostate projected deeply into the bladder. The overlying mucosa was reddened and edematous. This reddening and edema extended well up onto the trigone and the floor of the bladder, obscuring the ureteral orifices. Under the impression that we were dealing with a prostatic tumor, probably a sarcoma, we undertook a transurethral biopsy of the prostate and bladder neck. About 10 gm. tissue was removed. Histologic examination revealed merely chronic inflammatory changes and cystitis cystica. On June 13, 1949 a perinea! punch biopsy was attempted with the Huffman punch. The trocar was inserted deep into the mass. When the stylet was removed 100 cc of opalescent fluid drained out and the mass disappeared. Culture of the fluid revealed A. aerogenes and E. freundi. Rectal examination now revealed a prostate of normal size. Two weeks later the mass had recurred. Aspiration again yielded about 60 cc fluid, but when an attempt was made to inject skiodan, the needle became dislodged and the medium entered the urinary bladder. On July 15, 1949 the prostatic utricle was catheterized with a No. 4 ureteral catheter which was passed with ease to a depth of 4 cm. About 60 cc of skiodan was injected. The cyst was clearly outlined and thus identified as a mullerian duct cyst (fig. 1). On July 22, 1949, the bladder ,vas extraperitonealized through a midline suprapubic incision and drawn forward. Our intention was to proceed behind the bladder to identify and, if possible, extirpate the cyst. The perivesical tissues everywhere showed the results of previous inflammatory changes in the form of severe liposclerosis and fibrosis. After a long and tedious sharp dissection, during which the cyst could not be found, and during which the bladder was
780
FREDERICK A. LLOYD AND DOVELL BONNE'rT
opened for better orientation, a Pezzer catheter was left in the bladder and the wound closed.
FIG. 1. A, demonstration of cyst following catheterization of utricle and injection of skiodan. B, right oblique view with simultaneous urethrogram and air cystogram.
FIG. 2. Operative specimen including cyst wall, both seminal vesicles, and part of pros-
tate.
On August 15, 1949, rectal examination revealed a hard, irregular mass extending above the region of the prostate and well beyond the reach of the examining finger.
MULLERIAN DUCT CYSTS
781
On August 17, 1949, perineal exploration was carried out. A hard, irregular mass the size of a pear was exposed which was closely adherent to the prostate. This ,vas removed in several pieces, with great difficulty, and mainly by sharp dissection. In the process both seminal vesicles and part of the prostate were excised. As the dissection progressed a flat piece of tissue, evidently part of the cyst wall, and about 4 cm. square, was seen attached to the posterior bladder wall. Excision of this resulted in an opening in the bladder. After suture of the bladder and prostatic urethra, the wound was closed in the usual manner, after leaving in a small gauze pack. The specimen consisted of 4 separate pieces of tissue, including part of the prostate and both seminal vesicles (fig. 2). On histologic examination the cyst wall consisted mainly of connective tissue which showed considerable chronic inflammatory change. No epithelial lining was found. The postoperative convalescence was uneventful. At the last examination 2 months after the operation the patient was voiding with ease, and except for a slight perineal tenderness on sitting down, he felt perfectly well. Rectal examination revealed a prostate of normal size. SUMMARY
A miillerian duct cyst is reported. The cyst was demonstrated radiographically after catheterization of the utricle. The removal of the cyst was accomplished only with great difficulty through a perineal approach after a previous failure through a suprapubic incision. Complete excision required removal of both seminal vesicles, part of the prostate, and a small area of the posterior wall of the bladder.
104 S. :Vl~ichigan Ave., Chicago 3, Ill. REFERENCES BEGG, R. C.: Massive cystadenoma of Mtiller's duct causing retention of urine. Brit. J. Urol., 8: 105, 1936. BosHAMER, K.: Utrikelcysten. Ztschr. f. Urol., 29: 542, 1935. CoPPRIDGE, W. M.: Mullerian duct cysts. South. Med. J., 32: 248, 1939. CuLBURTSON, L. R.: Mullerian duct cyst. J. Urol., 58: 134, 1947. CULVER, H. AND BAKER, W. J.: Extravesical tumors in the male causing interference with urination Trans. Amer. Assoc. G. U. Surg., 21: 285, 1928. DEMING, C. L. AND BERNEIKE, R.R.: Mullerian duct cysts. J. Urol., 51: 563, 1944. EMMETT, J. J,. AND BRAASCH, W. F.: Cysts of the prostate gland. J. Urol., 36: 236, 1936. ENGLISCH: Uber Cysten on der hinteren Blasenwand bei Mannern. JVIed. Jahrb., Vienna, 1875. FISKE, A. L.: A cyst of the right vesicula seminalis. Aspiration by rectum. Ann. Surg., 28: 652, 1898. .. VoN GAZA, W.: Uber Chronische Spermatocystitis und uber eine Cyste des persistierenden Mullerschen Gariges. Arch f. ldin. Chir., 126: 502, 1923. GurTERAS, R.: A case of sero-purulent cyst, probably of the right seminal vesicle. Lancet, London,2:74, 1894. HALLOCK, L.A.: Hemorrhagic cyst of prostate gland. Am. J. Cancer, 15: 2331, 1931. HELLER, J. AND SrRINZ, 0.: Beitriige zur vergleichenden und pathologischen Anatomie des Colliculus Seminalis. Ztschr. f. urol. Chir., 7: 196, 1921. HENNESSEY, R. A.: Mullerian duct cyst. J. Urol., 42: 1042, 1939. HOWARD, F. S.: Hypospadias with enlargement of prostatic utricle. Surg., Gynec. and Obst., 86: 307, 1948.
782
FREDERICK A. LLOYD AND DOVELL BONNETT
HUGGINS, C. B.: The syndrome of diverticulum of the spermatic system in the neighborhood of the prostate obstructing the neck of the urinary bladder. J. Urol., 24: 100, 1930. KLOTZ, H. G.: Endoscopic studies including cysts of the colliculus sominalis. N. Y. Med. J., 61: 99, 1895. LANDES, R.R. AND RANSOM, C. L.: Mullerian duct cysts. J. Urol., 61: 1089, 1949. LUBASH, S.: Cyst of prostatic utricle. Am. J. Surg., 7: 123, 1929. McKENNA, C. M. AND KIEFFER, J. H.: Congenital enlargement of the prostatic utricle with inclusion of ejaculatory ducts and seminal vesicles. Trans. Amer. Assoc. G. U. Surg., 32: 305, 1939. MICHALov, N. A.: Cyste des Mullerschen Ganges. Ztschr. f. Urol. 2: 848, 1908. MooRE, R. A._:_ Pathology of the prostatic utricle. Arch. Path., 23: 517, 1937. PETERS, H.: Uber Heterotopien des Colom opithels an der Urnierenleiste mcnschlicher Embryonen. Ein Beitrag zur Entwichklungs-geschichte des Mi.illerschen Ganges. Ztschr. f. Anat., 86: 348, 1928. SMITH, N. R.: Hydrocele of seminal vesicle. Lancet, London, 2: 558, 1872. SMITH. E. AND STRASBERG, A.: Mullerian duct cyst in a male. Canad. Med. Assoc. J., 52: 160, 1945. SPRINGER, C.: Zur Kenntniss der Cystcnbildung aus dem Utriculus Prostaticus. Heilk. 19: 459, 1898. WESSON, M. B.: Cysts of the prostate and urethra. J. Urol., 13: 605, 1925. ZINNER, A.: Ein Fall von intravesikaler Samenblasen cyste. Verhandl. d. deutsch. Gesellsch. f. Urol., 4: 384, 1913.