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Ureteral Ectopia Opening into the Seminal Vesicle1
URETERAL ECTOPIA OPENING INTO THE SEMINAL VESICLE1 WILLIAM J. ENGEL From the Cleveland Clinic, Cleveland, Ohio
Cases of ureteral ectopia opening into the seminal vesicle are of interest not only as curiosities but because their reporting stimulates consideration and further recognition of the condition in surgical diagnosis. Riba, Schmidlapp, and Bosworth last year reported a case diagnosed clinically and could find only 4 others which had been recognized during life. Thirty-two autopsy cases were collected. The case to be reported was diagnosed clinically, and further interest is afforded by the fact that the patient sought consultation because of sterility, the circumstances of which are rather unusual. CASE REPORT
A man, aged 21, consulted me in March 1947, because of sterility. He had been married for 9 months and there had been no conception. His wife had been found to be normal. Of particular interest in his history was the fact that, although he experienced a normal orgasm, at no time had an emission of semen ever been observed either at the time of coitus or with nocturnal dreams. The patient had no urinary complaints. The clinical history and general physical examination disclosed nothing abnormal. Rectal examination revealed a soft, symmetrical prostate of average size. The left vesicle was rather soft and compressible but was otherwise not remarkable. Massage of the prostate yielded no secretion. The urinalysis and blood studies were negative. A preliminary x-ray film of the abdomen was negative. The intravenous urogram showed prompt function from the right kidney. This kidney was large, the kidney pelvis visualized well and was normal (fig. 1, A). At no time during the urogram series was any dye visualized on the left side. Microscopic examination of a post-coital urine specimen revealed 10 to 20 spermatozoa, mostly nonmotile. ner high power field. A McCarthy panendoscope was passed without difficulty. The right ureteral orifice was in the usual position and appeared normal. The left half of the trigone was thrown into rounded, cystic elevations which covered the area normally occupied by the left ureteral orifice and extended out to the vesical neck, producing some encroachment (fig. 1, B). Upon withdrawal of the instrument into the prostatic urethra, considerable increased engorgement was noted. The verumontanum was enlarged and edematous, and immediately proximal to the verumontanum and to the left of the midline was an irregular, dark, cavernous opening (fig. 2, A). Curiosity led me to explore this with a ureteral catheter, and it was found that the catheter passed out of sight into this cavity (fig. 2, B). 1 Read at annual meeting, American Association of Genito-Urinary Surgeons, Absecon, N. J., June 7, 1947.
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URETERAL ECTOPIA OPENING INTO SEMINAL VESICLE
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Twenty per cent skiodan was injected into the catheter, and the film shown in figure 2, C was obtained. It will be seen that the ureteral catheter became coiled in a large, lobulated cystic dilatation of the seminal vesicle, and from this there emerged a dilated ureter extending up to a hypoplastic kidney lying in normal position.
Fm. 1. A, Cystoscopic view, showing multilocular cystic elevation in region of bladder normally occupied by left ureter al orifice. B, Urethroscopic view of posterior urethra showing cavernous opening on left between verumontanum and vesical neck.
Fm. 2. A, Intravenous urogram film, showing absence of function in left kidney. Compensatory enlargement of right kidney. B, Showing ureteral catheter coiled in dilated, cystic left seminal vesicle. C, Opaque medium injected into catheter, outlining cystic dilatation of seminal vesicle with dilated ureter emptying into it. Kidney is hypoplastic.
The diagnosis was left renal hypoplasia with ureteral ectopia opening into the seminal vesicle, which showed cystic dilatation. The detailed embryologic explanation of this anomaly has been reviewed in several published articles. In brieC, it is due to failure of the normal shifting of the terminal portion of the wolffian ducts and the ureteric bud. When this development is faulty the ureter may remain attached to the lower end of the wolffian duct as the result of which the ureter may open into any organ or structure derived from the terminal portion of this duct. Thus the opening may
48
WILLIAM J. ENGEL
occur abnormally in the ductus deferens, seminal vesicle, ejaculatory duct, or the posterior urethra. Thom lists the following incidence of these various locations: prostatic urethra, 33; seminal vesicle, 17; vas deferens, 6; ejaculatory duct, 5. Associated developmental anomalies are frequently observed, and this patient had a hypoplastic nonfunctioning kidney in addition to the ectopic ureter. In the 20 cases collected by McKirdie and Polkey the kidney was absent in 6, rudimentary in 10, and cystic in 3. Reduplication of the ureter is common, only 1 of the 2 usually being ectopic, however. There is no recorded case of bilateral ectopic opening into the seminal vesicle and no explanation for the recorded preference for the left side. (Of 23 cases tabulated by Hamer et al., 16 were on the left, 7 on the right. McKirdie and Polkey reported 20 cases, 14 on the left, 6 on the right.) The case here presented has, in addition, a cyst of the seminal vesicle. This is demonstrated radiographically by the multilocular cystic dilatation of the vesicle, and a cystic elevation of the left half of the trigone was seen by cystoscopy. This case, therefore, corresponds to the one reported by Hamer, Mertz and Wishard. Deming has suggested that the most likely explanation for cysts of the seminal vesicle is antecedent stenosis of the ejaculatory duct. In our case the findings suggest that the cyst ruptured into the prostatic urethra, giving rise to the rather large, cavernous opening seen on urethroscopic examination. Our case differs from the other recognized clinically in that all other reported cases had pyuria, and urinary symptoms were present in all but 1. It will be noted that this patient had no urinary symptoms, and his urine was microscopically negative. His complaint was sterility due to inability to ejaculate. I believe the explanation is that the opening in the posterior urethra permits the semen to reflux into the cavity formed by the cyst of the vesicle and the dilated ureter. This explanation presupposes that the right vesicle and ejaculatory duct are functionally normal, evidence for which is supplied by the finding of sperm in a post-coital urine specimen. Operation has been advised for this patient. A seminal vesiculectomy and ureteronephrectomy is indicated to correct the anomaly, and it would seem that hope of correcting the sterility lies in closure of the opening in the prostatic urethra. 2 SUMMARY
A case of ureteral ectopia opening into the left seminal vesicle is presented in which a preoperative clinical diagnosis was made. Only 5 other cases diagnosed clinically have been reported. In addition to the ureteral anomaly this patient had a hypoplastic kidney and a multilocular cyst of the seminal vesicle. Sterility due to inability to ejaculate was the complaint which brought the patient for examination. We believe this inability is due to the reflux of semen into the dilated, cystic vesicle. 2 The patient has since returned for operation and the above findings confirmed. A cystic seminal vesicle was removed and a ureteronephrectomy performed. Convalescence was uneventful but we cannot yet report any effect upon the patient's sterility.
URETERAL ECTOPIA OPENING INTO SEMINAL VESICLE
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REFERENCES ABESHOUSE, B. S.: Uretera1 ectopia: report of rare case of ectopic ureter opening in uterus and review of literature. Urol. & Cutan. Rev., 47: 447--465, 1943. CULVER, H.: Extravesical ureteral opening into genital tract in male. Trans. Am. Assoc. Genito-Urin. Surg., 30: 295-300, 1937. DEMING, C. L.: Cyst of seminal vesicle. Trans. Am. Assoc. Genito-Urin. Surg., 28: 301312, 1935. FURNISS, H. D.: Supernumerary ureters with extravesical openings. J. Urol., 37: 341360, 1937. HAMER, H. G., MERTZ, H. 0. AND WISHARD, W. N., JR.: Opening of ureter into seminal vesicle; report of case diagnosed clinically. Trans. Am. Assoc. Genito-Urin. Surg., 30: 301-307, 1937. McKrnDIE, M. AND PoLKEY, H.J.: Extravesical ureteral opening into seminal vesicle. J. Urol., 37: 706-714, 1937. RrnA, L. W., ScHMIDLAPP, C. J. AND BoswORTH, N. L.: Ectopic ureter draining into seminal vesicle. J. Urol., 56: 332-338, 1946.
Cases of ureteral ectopia opening into the seminal vesicle are of interest not only as curiosities but because their reporting stimulates consideration and further recognition of the condition in surgical diagnosis. Riba, Schmidlapp, and Bosworth last year reported a case diagnosed clinically and could find only 4 others which had been recognized during life. Thirty-two autopsy cases were collected. The case to be reported was diagnosed clinically, and further interest is afforded by the fact that the patient sought consultation because of sterility, the circumstances of which are rather unusual. CASE REPORT
A man, aged 21, consulted me in March 1947, because of sterility. He had been married for 9 months and there had been no conception. His wife had been found to be normal. Of particular interest in his history was the fact that, although he experienced a normal orgasm, at no time had an emission of semen ever been observed either at the time of coitus or with nocturnal dreams. The patient had no urinary complaints. The clinical history and general physical examination disclosed nothing abnormal. Rectal examination revealed a soft, symmetrical prostate of average size. The left vesicle was rather soft and compressible but was otherwise not remarkable. Massage of the prostate yielded no secretion. The urinalysis and blood studies were negative. A preliminary x-ray film of the abdomen was negative. The intravenous urogram showed prompt function from the right kidney. This kidney was large, the kidney pelvis visualized well and was normal (fig. 1, A). At no time during the urogram series was any dye visualized on the left side. Microscopic examination of a post-coital urine specimen revealed 10 to 20 spermatozoa, mostly nonmotile. ner high power field. A McCarthy panendoscope was passed without difficulty. The right ureteral orifice was in the usual position and appeared normal. The left half of the trigone was thrown into rounded, cystic elevations which covered the area normally occupied by the left ureteral orifice and extended out to the vesical neck, producing some encroachment (fig. 1, B). Upon withdrawal of the instrument into the prostatic urethra, considerable increased engorgement was noted. The verumontanum was enlarged and edematous, and immediately proximal to the verumontanum and to the left of the midline was an irregular, dark, cavernous opening (fig. 2, A). Curiosity led me to explore this with a ureteral catheter, and it was found that the catheter passed out of sight into this cavity (fig. 2, B). 1 Read at annual meeting, American Association of Genito-Urinary Surgeons, Absecon, N. J., June 7, 1947.
46
URETERAL ECTOPIA OPENING INTO SEMINAL VESICLE
47
Twenty per cent skiodan was injected into the catheter, and the film shown in figure 2, C was obtained. It will be seen that the ureteral catheter became coiled in a large, lobulated cystic dilatation of the seminal vesicle, and from this there emerged a dilated ureter extending up to a hypoplastic kidney lying in normal position.
Fm. 1. A, Cystoscopic view, showing multilocular cystic elevation in region of bladder normally occupied by left ureter al orifice. B, Urethroscopic view of posterior urethra showing cavernous opening on left between verumontanum and vesical neck.
Fm. 2. A, Intravenous urogram film, showing absence of function in left kidney. Compensatory enlargement of right kidney. B, Showing ureteral catheter coiled in dilated, cystic left seminal vesicle. C, Opaque medium injected into catheter, outlining cystic dilatation of seminal vesicle with dilated ureter emptying into it. Kidney is hypoplastic.
The diagnosis was left renal hypoplasia with ureteral ectopia opening into the seminal vesicle, which showed cystic dilatation. The detailed embryologic explanation of this anomaly has been reviewed in several published articles. In brieC, it is due to failure of the normal shifting of the terminal portion of the wolffian ducts and the ureteric bud. When this development is faulty the ureter may remain attached to the lower end of the wolffian duct as the result of which the ureter may open into any organ or structure derived from the terminal portion of this duct. Thus the opening may
48
WILLIAM J. ENGEL
occur abnormally in the ductus deferens, seminal vesicle, ejaculatory duct, or the posterior urethra. Thom lists the following incidence of these various locations: prostatic urethra, 33; seminal vesicle, 17; vas deferens, 6; ejaculatory duct, 5. Associated developmental anomalies are frequently observed, and this patient had a hypoplastic nonfunctioning kidney in addition to the ectopic ureter. In the 20 cases collected by McKirdie and Polkey the kidney was absent in 6, rudimentary in 10, and cystic in 3. Reduplication of the ureter is common, only 1 of the 2 usually being ectopic, however. There is no recorded case of bilateral ectopic opening into the seminal vesicle and no explanation for the recorded preference for the left side. (Of 23 cases tabulated by Hamer et al., 16 were on the left, 7 on the right. McKirdie and Polkey reported 20 cases, 14 on the left, 6 on the right.) The case here presented has, in addition, a cyst of the seminal vesicle. This is demonstrated radiographically by the multilocular cystic dilatation of the vesicle, and a cystic elevation of the left half of the trigone was seen by cystoscopy. This case, therefore, corresponds to the one reported by Hamer, Mertz and Wishard. Deming has suggested that the most likely explanation for cysts of the seminal vesicle is antecedent stenosis of the ejaculatory duct. In our case the findings suggest that the cyst ruptured into the prostatic urethra, giving rise to the rather large, cavernous opening seen on urethroscopic examination. Our case differs from the other recognized clinically in that all other reported cases had pyuria, and urinary symptoms were present in all but 1. It will be noted that this patient had no urinary symptoms, and his urine was microscopically negative. His complaint was sterility due to inability to ejaculate. I believe the explanation is that the opening in the posterior urethra permits the semen to reflux into the cavity formed by the cyst of the vesicle and the dilated ureter. This explanation presupposes that the right vesicle and ejaculatory duct are functionally normal, evidence for which is supplied by the finding of sperm in a post-coital urine specimen. Operation has been advised for this patient. A seminal vesiculectomy and ureteronephrectomy is indicated to correct the anomaly, and it would seem that hope of correcting the sterility lies in closure of the opening in the prostatic urethra. 2 SUMMARY
A case of ureteral ectopia opening into the left seminal vesicle is presented in which a preoperative clinical diagnosis was made. Only 5 other cases diagnosed clinically have been reported. In addition to the ureteral anomaly this patient had a hypoplastic kidney and a multilocular cyst of the seminal vesicle. Sterility due to inability to ejaculate was the complaint which brought the patient for examination. We believe this inability is due to the reflux of semen into the dilated, cystic vesicle. 2 The patient has since returned for operation and the above findings confirmed. A cystic seminal vesicle was removed and a ureteronephrectomy performed. Convalescence was uneventful but we cannot yet report any effect upon the patient's sterility.
URETERAL ECTOPIA OPENING INTO SEMINAL VESICLE
49
REFERENCES ABESHOUSE, B. S.: Uretera1 ectopia: report of rare case of ectopic ureter opening in uterus and review of literature. Urol. & Cutan. Rev., 47: 447--465, 1943. CULVER, H.: Extravesical ureteral opening into genital tract in male. Trans. Am. Assoc. Genito-Urin. Surg., 30: 295-300, 1937. DEMING, C. L.: Cyst of seminal vesicle. Trans. Am. Assoc. Genito-Urin. Surg., 28: 301312, 1935. FURNISS, H. D.: Supernumerary ureters with extravesical openings. J. Urol., 37: 341360, 1937. HAMER, H. G., MERTZ, H. 0. AND WISHARD, W. N., JR.: Opening of ureter into seminal vesicle; report of case diagnosed clinically. Trans. Am. Assoc. Genito-Urin. Surg., 30: 301-307, 1937. McKrnDIE, M. AND PoLKEY, H.J.: Extravesical ureteral opening into seminal vesicle. J. Urol., 37: 706-714, 1937. RrnA, L. W., ScHMIDLAPP, C. J. AND BoswORTH, N. L.: Ectopic ureter draining into seminal vesicle. J. Urol., 56: 332-338, 1946.