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Spermatozoa-Containing Simple Cysts of the Rete Testis
0022-5347/89/1426-1572$02.00/0 Vol. 142, December Printed in U. S. A.
THE JOURNAL OF UROLOGY
Copyright © 1989 by AMERICAN UROLOGICAL ASSOCIATION, INC.
SPERMATOZOA-CONTAINING SIMPLE CYSTS OF THE RETE TESTIS BRUCE R. YALOWITZ, JOHN N. EBLE* AND DAVID C. WILKS From the Department of Pathology and Laboratory for Experimental Oncology, Indiana University School of Medicine and Laboratory Service, Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, and Department of Urology, Munster Community Hospital, Munster, Indiana
ABSTRACT
Simple cysts of the testis are rare benign lesions of uncertain etiology. We report 2 spermatozoacontaining cysts of the rete testis found incidentally in the left testicle of a 56-year-old man evaluated by ultrasound for hydrocele. The presence of spermatozoa in the cyst fluid has not been observed previously and confirms the connection of the cysts with the seminiferous tubular system. (J. Urol., 142: 1572-1573, 1989) Simple cysts of the testis are rare lesions that are of clinical concern because the principal differential diagnosis is cystic neoplasm. Only a few examples have been reported previously.1-7 The finding of spermatozoa in the cyst fluid in our case sheds light. on the anatomical origin of this type of cyst and suggests criteria for classification. CASE REPORT
Urological consultation was obtained to evaluate scrotal enlargement found on physical examination in a 56-year-old man. The patient had a long history of progressive mild scrotal discomfort. He denied any history of scrotal trauma, pain, or infection of the epididymis or testis proper. The left hemiscrotum was greatly enlarged and a cystic mass was palpable superior to the testis. No intratesticular mass was palpable. There also was a 2 cm. spermatocele on the right side. Ultrasonography of the left hemiscrotum showed a 6 X 4 cm. multiloculated cystic mass superior to the testis, as well as multiple hypoechoic cystic cavities with internal echoes within the testis (fig. 1). Left inguinal exploration was performed to treat the symptomatic spermatocele and to evaluate the intratesticular lesions seen by ultrasound. Exploration confirmed the presence of the spermatocele and a small hydrocele. Drainage of these lesions permitted palpation of a discrete, hard, 1 cm. intratesticular mass at the upper pole of the testis. Radical orchiectomy was performed. Pathological findings. Dissection of the testis revealed 2, 1 cm. cystic structures embedded in the testicular parenchyma and attached to the mediastinum testis in the area of the rete testis. The cysts had smooth internal surfaces and were filled with fluid. A multiloculated spermatocele was present in the epididymis. Microscopically, the cyst walls were dense fibrous tissue and the surrounding seminiferous tubules were atrophic (fig. 2, A). The lining epithelium varied from cuboidal to flat (fig. 2, B). There were no mitotic figures nor any vacuolation of the epithelium. The rete testis was dilated and its lining was an epithelium similar to that which lined the cysts. A cytological preparation of the fluid from the cysts showed the presence of many mature spermatozoa.
types of simple nonneoplastic cysts of the testis has been blurred by incomplete observations of the anatomical relationships and contents. Based on our case, and the case reported by Tejada and Eble 1 it is apparent that cysts of the rete testis can be distinguished from tunica albuginea cysts by the location within the testis, communication with the tubular system, type of lining epithelium and attachment to the rete testis (see table). A helpful confirmatory finding is the presence of spermatozoa in the cyst fluid. In our case neither the history nor anatomical findings supported trauma or infection as the etiology. The cysts occurred in the upper pole attached to the mediastinum testis and appeared to arise from the rete testis. The location and relationship to the rete testis were similar to those of the cyst described by Tejada and Eble, l except that the lesion in our case was associated with a spermatocele. The finding of sperm in the cyst fluid in our case confirms the connection of the lumens with that of the system of seminiferous tubules. This
DISCUSSION
Cysts of the testis may arise in the tunica albuginea (the most common type), rete testis and testicular parenchyma. The latter 2 types are rare. Previously, the distinction among the Accepted for publication June 21, 1989. * Requests for reprints: Laboratory Service (113), Roudebush Veterans Administration Medical Center, 1481 W. Tenth St., Indianapolis, Indiana 46202-2884.
FIG. 1. Ultrasonogram of longitudinal s~ction of testis demonstrates cysts with internal echoes within testicular parenchyma and spermatocele cavities at upper right side.
1572
Intratesticular Cyst Type Tunica albuginea Rete testis Parenchymal simple
Communication to Tubular System No Yes No
No Yes No
Location Within tunica albuginea Mediastinum testis Entirely within testicular parenchyma, not connected to tunica albuor rete testis
finding highlights the distinction between cysts of the tunica albuginea, which are not connected to the tubular system, and cysts of the rete testis, which are so connected. Ultrasound can be helpful to diagnose testicular cysts. Leung6 and Gooding8 and their associates found cysts in approximately 9% of the asymptomatic men but the nature of the cysts was not confirmed by other means and the significance of these ultrasonographic reports is unclear. In our case ultrasonography confirmed the spermatocele and demonstrated the intratesticular cysts but it could not rule out malignancy for at least 1 area of suspicious hypoechogenicity with internal echoes. The previously used diagnostic category of simple cysts of the testis is less precise than the anatomical findings often warrant. Intratesticular simple cysts can be categorized with more precision if they are classified as tunica albuginea cysts, rete testis cysts and parenchymal cysts based on the criteria in the table. REFERENCES
1. Tejada, E. and Eble, J. N.: Simple cyst of the rete testis. J. Urol.,
FIG. 2. A, partially collapsed cyst lined by epithelium and surrounded by loose fibrous condensation. Note atrophy of adjacent seminiferous tubules. & E, reduced from X100. B, epithelial lining of cysts consisted of low cuboidal and flattened cells. Collapse of cyst during dissection resulted in apposition of its walls. & E, reduced from X400.
139: 376, 1988. 2. Takihara, H., Valvo, J. R., Tokuhara, and Cockett, T. K.: Intratesticular cysts. Urology, 20: 80, 1982. 3. Jenkins, R. H. and Deming, C. L.: Cysts of the testicle. New Engl. J. Med., 213: 57,1935. 4. Tosi, S. E. and Richardson, J. R., Jr.: Simple cyst of the testis: case report and review of the literature. J. Urol., 473, 1975. 5. Schmidt, S. S.: Congenital simple cyst of the testis: a hitherto undescribed lesion. J. Urol., 96: 236, 1966. 6. Leung, M. L., Gooding, G. A. W. and Williams, R. D.: Highresolution sonography of scrotal contents in asymptomatic subjects. Amer. J. Roentgen., 161, 1984. 7. Petersen, R. 0.: Testis. In: Urologic Pathology. Philadelphia: J. B. Lippincott Co., chapt. 6, p. 1986. 8. Gooding, G. A. W., Leonhardt, and Stein, R.: Testicular cysts: US findings. Radiology, 537, 1987.
THE JOURNAL OF UROLOGY
Copyright © 1989 by AMERICAN UROLOGICAL ASSOCIATION, INC.
SPERMATOZOA-CONTAINING SIMPLE CYSTS OF THE RETE TESTIS BRUCE R. YALOWITZ, JOHN N. EBLE* AND DAVID C. WILKS From the Department of Pathology and Laboratory for Experimental Oncology, Indiana University School of Medicine and Laboratory Service, Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, and Department of Urology, Munster Community Hospital, Munster, Indiana
ABSTRACT
Simple cysts of the testis are rare benign lesions of uncertain etiology. We report 2 spermatozoacontaining cysts of the rete testis found incidentally in the left testicle of a 56-year-old man evaluated by ultrasound for hydrocele. The presence of spermatozoa in the cyst fluid has not been observed previously and confirms the connection of the cysts with the seminiferous tubular system. (J. Urol., 142: 1572-1573, 1989) Simple cysts of the testis are rare lesions that are of clinical concern because the principal differential diagnosis is cystic neoplasm. Only a few examples have been reported previously.1-7 The finding of spermatozoa in the cyst fluid in our case sheds light. on the anatomical origin of this type of cyst and suggests criteria for classification. CASE REPORT
Urological consultation was obtained to evaluate scrotal enlargement found on physical examination in a 56-year-old man. The patient had a long history of progressive mild scrotal discomfort. He denied any history of scrotal trauma, pain, or infection of the epididymis or testis proper. The left hemiscrotum was greatly enlarged and a cystic mass was palpable superior to the testis. No intratesticular mass was palpable. There also was a 2 cm. spermatocele on the right side. Ultrasonography of the left hemiscrotum showed a 6 X 4 cm. multiloculated cystic mass superior to the testis, as well as multiple hypoechoic cystic cavities with internal echoes within the testis (fig. 1). Left inguinal exploration was performed to treat the symptomatic spermatocele and to evaluate the intratesticular lesions seen by ultrasound. Exploration confirmed the presence of the spermatocele and a small hydrocele. Drainage of these lesions permitted palpation of a discrete, hard, 1 cm. intratesticular mass at the upper pole of the testis. Radical orchiectomy was performed. Pathological findings. Dissection of the testis revealed 2, 1 cm. cystic structures embedded in the testicular parenchyma and attached to the mediastinum testis in the area of the rete testis. The cysts had smooth internal surfaces and were filled with fluid. A multiloculated spermatocele was present in the epididymis. Microscopically, the cyst walls were dense fibrous tissue and the surrounding seminiferous tubules were atrophic (fig. 2, A). The lining epithelium varied from cuboidal to flat (fig. 2, B). There were no mitotic figures nor any vacuolation of the epithelium. The rete testis was dilated and its lining was an epithelium similar to that which lined the cysts. A cytological preparation of the fluid from the cysts showed the presence of many mature spermatozoa.
types of simple nonneoplastic cysts of the testis has been blurred by incomplete observations of the anatomical relationships and contents. Based on our case, and the case reported by Tejada and Eble 1 it is apparent that cysts of the rete testis can be distinguished from tunica albuginea cysts by the location within the testis, communication with the tubular system, type of lining epithelium and attachment to the rete testis (see table). A helpful confirmatory finding is the presence of spermatozoa in the cyst fluid. In our case neither the history nor anatomical findings supported trauma or infection as the etiology. The cysts occurred in the upper pole attached to the mediastinum testis and appeared to arise from the rete testis. The location and relationship to the rete testis were similar to those of the cyst described by Tejada and Eble, l except that the lesion in our case was associated with a spermatocele. The finding of sperm in the cyst fluid in our case confirms the connection of the lumens with that of the system of seminiferous tubules. This
DISCUSSION
Cysts of the testis may arise in the tunica albuginea (the most common type), rete testis and testicular parenchyma. The latter 2 types are rare. Previously, the distinction among the Accepted for publication June 21, 1989. * Requests for reprints: Laboratory Service (113), Roudebush Veterans Administration Medical Center, 1481 W. Tenth St., Indianapolis, Indiana 46202-2884.
FIG. 1. Ultrasonogram of longitudinal s~ction of testis demonstrates cysts with internal echoes within testicular parenchyma and spermatocele cavities at upper right side.
1572
Intratesticular Cyst Type Tunica albuginea Rete testis Parenchymal simple
Communication to Tubular System No Yes No
No Yes No
Location Within tunica albuginea Mediastinum testis Entirely within testicular parenchyma, not connected to tunica albuor rete testis
finding highlights the distinction between cysts of the tunica albuginea, which are not connected to the tubular system, and cysts of the rete testis, which are so connected. Ultrasound can be helpful to diagnose testicular cysts. Leung6 and Gooding8 and their associates found cysts in approximately 9% of the asymptomatic men but the nature of the cysts was not confirmed by other means and the significance of these ultrasonographic reports is unclear. In our case ultrasonography confirmed the spermatocele and demonstrated the intratesticular cysts but it could not rule out malignancy for at least 1 area of suspicious hypoechogenicity with internal echoes. The previously used diagnostic category of simple cysts of the testis is less precise than the anatomical findings often warrant. Intratesticular simple cysts can be categorized with more precision if they are classified as tunica albuginea cysts, rete testis cysts and parenchymal cysts based on the criteria in the table. REFERENCES
1. Tejada, E. and Eble, J. N.: Simple cyst of the rete testis. J. Urol.,
FIG. 2. A, partially collapsed cyst lined by epithelium and surrounded by loose fibrous condensation. Note atrophy of adjacent seminiferous tubules. & E, reduced from X100. B, epithelial lining of cysts consisted of low cuboidal and flattened cells. Collapse of cyst during dissection resulted in apposition of its walls. & E, reduced from X400.
139: 376, 1988. 2. Takihara, H., Valvo, J. R., Tokuhara, and Cockett, T. K.: Intratesticular cysts. Urology, 20: 80, 1982. 3. Jenkins, R. H. and Deming, C. L.: Cysts of the testicle. New Engl. J. Med., 213: 57,1935. 4. Tosi, S. E. and Richardson, J. R., Jr.: Simple cyst of the testis: case report and review of the literature. J. Urol., 473, 1975. 5. Schmidt, S. S.: Congenital simple cyst of the testis: a hitherto undescribed lesion. J. Urol., 96: 236, 1966. 6. Leung, M. L., Gooding, G. A. W. and Williams, R. D.: Highresolution sonography of scrotal contents in asymptomatic subjects. Amer. J. Roentgen., 161, 1984. 7. Petersen, R. 0.: Testis. In: Urologic Pathology. Philadelphia: J. B. Lippincott Co., chapt. 6, p. 1986. 8. Gooding, G. A. W., Leonhardt, and Stein, R.: Testicular cysts: US findings. Radiology, 537, 1987.