THE JOURNAL OF UROLOGY
Vol. 75, No. 1, January 1956 Printed in U.S.A.
ECTOPIC URETER OPENING INTO A SEMINAL VESICLE ALBERT E. GOLDSTEIN
From the Department of Urology, Sinai Hospital of Baltimore, Md.
Anomalies of the urinary tract comprise approximately ten per cent of all congenital malformations (Campbell). One of the rare types of the genitourinary tract anomalies is an ectopic ureter opening into a seminal vesicle. This unusual anomaly has been previously reported and diagnosed clinically on only 9 occasions (table 1). In addition, 32 cases were found at autopsy. The embryological explanation has been reviewed by others and understood by us in the following manner. Between the fifth and sixth weeks of fetal life, the cloaca is divided by a frontal fold into a dorsal rectal and ventral urogenital segment. The renal collecting system is formed by a posterior budding from the wolffian duct which empties into the urogenital segment. The wolffian duct and ureter are ultimately completely separated from each other as the former forms the posterior urethra, vas deferens, epididymis, and seminal vesicles; the orifice of the latter is carried upward into the lateral angle of the trigone. Thus failure of complete separation of these two structures results in connection of the systems which is manifested by various types of ectopic ureteral openings into structures of the seminal tract. Our case is the tenth reported one of an ectopic ureter opening into a seminal vesicle which was diagnosed clinically. We believe, because of its rarity and the unusual method of diagnosis, that it worthy of a report. CASE REPORT
A 42-year-old white man was admitted to the Sinai Hospital of Baltimore, February 8, 1954, with the chief complaints of dribbling at the end of urination, voiding with a spray-like stream, and diminution in the strength of his stream. These symptoms had been present for over three years. The patient had three cystoscopic examinations prior to this admission; the diagnosis was agenesis of the right kidney and a cyst of the seminal vesicle on the right. The patient had been to another clinic because of sterility. Otherwise, his past history was noncon tri bu tory. On physical examination the right testicle was smaller than the left; rectal examination revealed the prostate to be normal. A fullness was palpated in the region of the right seminal vesicle. The patient had a cystoscopic examination on February 9, 1954. A lobulated globular mass, situated in the region of the right side of the trigone and protruding upon the right posterolateral aspect of the bladder neck, was found. The left ureteral orifice appeared normal; the right ureteral orifice was not visualized. Indigo carmine, which had been injected intravenously, appeared on the left side in 6 minutes and in good concentration. There was no evidence of dye coming from the region of the right side of the bladder or from the posterior urethra. Read at annual meeting, Mid-Atlantic Section of American Urological Association, Atlantic City, N. J. April 14-16, 1955. * Present address: Denver, Colo. 57
Day, R. F., 1924
1. Cases of ectopic iireter opening into seminal vesicle which were diagnosed clinically
Method of Diagnosis
Cond. of Kidney
Severe left lumbar Catheterization of open-1· Surgical removal of Hydronephrosis pain following fall ing in posterior urethra. kidney and ureter. and pyo(pyuria) Pyelograms nephrosis
----------~1--1--------- ----------~ ------------~ ------------ ----------
Pyuria found on in-I I.V .P. revealed opening surance exam.
Hamer, H. G., Mcrtz,I 25 N. 0. and Wishard, W. N., Jr., 1937
Riba, L. W., Schmid-I 19 lapp, C. J., Bosworth, :N. L., Hl46
Engel, W. J., 1948
Culver, Hany, 1937
Hamilton, G. R. andl 20 Peyton, A. B., 1950
Meisel, H.J., 1952
Cystic mass in bladderj Endoscopic drainage punctured & catheter passed
Not visualized by x-ray
Severe left flank pain! Ejaculatory ducts cathe-1 Surgical removal ofl Hydronephrotic following injury terized. kid., uret. & sem. double kidney (pyuria) ves. (upper) Sterile
Unable to conceive
Opening in post. urethral None. Advised sur-1 Hypoplastic catheterized & x-ray gery studies carried out.
Rt. upper abdominal Cystic mass in bladder Surgical removal ofl Hypoplastic kidney, ureter & pain & hematuria punctured with electrode. Catheter passed sem. ves. followed blow to for pyelo. V asoseminal right abdomen. vesiculogram
ectopicj None required
Squeezing sensation! Vasoseminal vesiculogra-1 Surgical removal ofl Hypoplastic in rectum phy kid., ureter & sem. ves.
Pasquier, C. M. andl 26 Womack, R. N., 1953
O'Malley, ,T. F. andl 27 Bumgarner, J. E., 1955
Fertile I Hematuria spermia
Goldstein, A. E. andl 42 Heller, E., 1955 I
Cystic mass in blad. punc- Surgical removal ofl Hypoplastic kid., uret. & sem. tured with electrode. Cath. passed for pyelo. ves. V asoseminal vesiculogram hema-1 Excretory urography
Difficulty passingl Vasoseminal urine. Split stream raphy
Anti- I Hypoplastic
vesiculog-j Surgical removal ofl Hypoplastic kid., uret. & sem. 1 ves.
~ B 0 0
zi"l P:i B
ECTOPIC URETER OPENING INTO SEMINAL VESICLE
Fm. 1. A, seminal vesiculogram made after injecting 1.5 cc 30 per cent urokon on each side. Note normal seminal vesicle on left. Ampulla of right vas deferens is dilated. Right seminal vesicle is abnormal and much enlarged. Right ejaculatory duct is obstructed. B, film taken after 10 cc 70 per cent urokon had been injected on right side. Note tortuous, dilated, globular structure leading from dilated seminal vesicle, probably right ureter. C, 150-minute retention film. Note that dye extends into dilated ureter to level of right sacroiliac joint.
It was suspected that the seat of the process was in the region of the right seminal vesicle, and therefore a bilateral vasoseminal vesiculogram was made by means of exposing the vas on each side in the upper part of the scrotum. A hypodermic needle was inserted into the lumen of each vas and 70 per cent urokon sodium injected. The first seminal vesiculogram was taken after 1.5 cc of dye was injected on each side. It revealed a normal left seminal vesicle and a dilated ampulla of the vas along with a deformed vesicle on the right (fig. 1, A). The second vesiculogram was taken after 10 cc of dye was injected on the right. The contrast medium entered a dilated, tortuous, lobulated channel in the region of the right seminal vesicle (fig. 1, B). A 150-minute retention film revealed the progression of dye into a dilated, curved channel which extended to the level of the right sacroiliac joint (fig. 1, C). The 24-hour retention film revealed retained dye in the previously described area along with further progression of dye up to the level of the fifth lumbar vertebra on the right which appeared to be a dilated right ureter. An excretory urogram taken at the same time showed a normal left upper urinary tract with a filling defect in the right side of the bladder (fig. 2). These findings, together with the cystoscopic picture, were indicative of an ectopic ureteral opening into the right seminal vesicle with a hypoplastic right kidney and right hydroureter. On February 16, 1954, an exploratory operation was carried out. The lower portion of the right ureter was exposed through a right Gibson incision. It was found to be dilated below the region of the fourth lumbar vertebra and normal above that point. The ureter was dissected down to the posterior wall of the bladder where a cystic, lobulated, globular mass was found. This mass was posterior to the bladder and was a continuation of the ureter. A cystotomy was performed during the dissection; it was noted that the right ureter did not communicate with the bladder. Further dissection exposed a large right seminal vesicle which was not distorted in appearance. The ureter opened into the ampulla of the seminal vesicle. The right seminal vesicle was removed with the pelvic portion of the vas deferens. The ureter was freed from its attachments to the seminal vesicle and bladder wall and was brought out through the incision. Since the
ALBERT E. GOLDSTEIN AND EUGENE HELLER
Fm. 2. Twenty-four-hour retention film coupled with an 8-minute excretory urogram. Note normal left kidney, filling defect on right side of bladder, dye in right seminal vesicle and lower end of right ureter extending to level of lumbosacral joint on right side.
general condition of the patient was not too satisfactory, a second operation was decided upon for removal of the right kidney. The specimen was allowed to remain intact on the abdomen. One week later on February 23, 1954, a hypoplastic right kidney, in normal position, was removed, with the attached dilated ureter and seminal vesicle through a right flank incision (fig. 3, A and B). The patient had a bothersome postoperative course because of various allergic manifestations. At the time of discharge from the hospital, his urinary complaints had been alleviated. Cases of an ectopic ureter opening into a seminal vesicle found at autopsy were reviewed by McKirdie and Polkey also by others. Hamer, Mertz, and Wishard, Jr., reporting later, added two more cases found at autopsy and one discovered clinically. Riba, Schmidlapp, and Bosworth in 1946 reviewed the literature on this anomaly and included ectopic ureteral openings in other parts of the seminal tract. They found 36 cases in all; of these, thirty-two were noted at autopsy and four clinically. In 10 cases the ureter drained into the vas deferens or ejaculatory duct. It is interesting to note that of the 32 cases reported at autopsy the condition occurred 21 times on the left and 10 times on the right side; the ectopic ureter was single in 26 cases and reduplicated in 6 cases. The corresponding kidney was rudimentary in 14 cases, absent in ten, fibrosed in two, normal in one, and was a double one in three. Day, in 1924, diagnosed this entity by means of catheterization of an opening seen in the posterior urethra. In 19:37, Culver found the ectopic opening on an excretory urogram which had been done as part of a study for pyuria. Hamer,
ECTOPIC URETER OPENING INTO SEMINAL VESICLE
Fm. 3. A, gross specimen of hypoplastic kidney and its three extrarenal divisions of ureter which are probably calyces. Kidney measured 3.5 by 2 cm. B, entire gross specimen of hypoplastic kidney, dilated lower half of ureter, dilated seminal vesicle and section of vas deferens.
Mertz, and Wishard, Jr., in 1937, catheterized an opening in a bladder "cyst" which had been created by cystoscopic scissors and through this performed the diagnostic pyelogram. As the persistent pyuria following nephrectomy cleared after prolonged stripping of the right seminal vesicle, they assumed that the hydroureter emptied into the right vesicle. Riha, Schmidlapp, and Bosworth, after two exploratory operations with excision of the upper pole of the double kidney, diagnosed the primary process by means of catheterizing the ejaculatory ducts and taking vesiculograms. Engel, in 1948, diagnosed this entity by means of catheterizing an opening found in the posterior urethra and performing radiographic studies subsequently. Hamilton and Peyton, in 1950, punctured a "cystic mass" in the bladder with an electrode and passed a ureteral catheter through the opening; subsequent pyelograms revealed the pathologic entity. In this particular case, vasoseminal vesiculography was done as a diagnostic check. In 1952, Meisel diagnosed this condition by means of vasoseminal vesiculography. Pasquier and Womack, in 1953, diagnosed the condition in exactly the same manner as Hamilton and Peyton. They confirmed their diagnosis by means of catheterizing the vas deferens and performing seminal vesiculograms. In February 1955 O'Malley and Bumgarner reported an additional case, diagnosed by excretory urography. In their case the dye was seen to have filled the left seminal vesicle after it left the ureter.
ALBERT E. GOLDSTEIN AND EUGENE HELLER DISCUSSION
In reviewing the case presentations of the subject under discussion, certain diagnostic features stand out. In 6 cases a globular mass was found in the bladder on cystoscopy. The corresponding ureteral orifice was absent in all but O'Malley and Bumgarner's case; a nonfunctioning kidney was present in six. On rectal examination a fullness or mass was found on the affected side five times (rectal examination was not mentioned in 5 cases). The corresponding kidney was pathologic in all cases but O'Malley's. His case demonstrated hypoplasia without pathological change. The pathologic entity includes hypoplasia six times, hydronephrosis two, and double kidney in two. Although sterility was not constant enough to be a diagnostic factor, it was present in 2 cases. Pyuria was found in 6 patients. It is apparent that the diagnostic picture is not constant in all cases. Nonvisualization of the kidney in the presence of a globular mass in the bladder, occupying one side of the trigone, is an important observation. The absence of the corresponding ureteral orifice and a fullness or mass in the region of the seminal vesicle of the involved side should cause one to suspect an ectopic ureter opening into that structure. If the entity is not thought of, the diagnosis might be missed. SUMMARY
A brief review of ectopic ureter opening into a seminal vesicle is presented. A review of those cases which were diagnosed clinically is included. The diagnosis can invariably be made by seminal vesiculography. The diagnosis of a congenital absent kidney should be followed by vasoseminal vesiculograms in search of an ectopic ureter opening into the seminal structures. Six of the ten reported cases showed renal hypoplasia on the same side. The tenth case clinically diagnosed is presented in detail. Addendum: Since the preparation of our paper, one more case has been reported by Doctors Gartman and Cline (U. S. Armed Forces Med. J., 5: 16681671, 1954).
3505 N. Charles St., Baltimore 18, Md. (A. E. G.) REFERENCES CAMPBELL, M.: Clinical Pediatric Urology. Philadelphia: W. B. Saunders Co., 1951, pp. 215--216. CULVER, H.: Extravesical ureteral opening into the genital tract in a male. Trans. Am. Assoc. of Genito. Urin. Surg., 30: 295, 1937. DAY, R. F.: Ectopic opening of the ureter in the male with report of a case. J. Urol., 11: 239, 1924. ENGEL, W. J.: Ureteral ectopic opening into the seminal vesicle. J. Urol., 60: 46, 1948. HAMER, H. G., MERTZ, H. 0. AND WISHARD, W. N. Jr.: Opening of the ureter into the seminal vesicle Trans. Am. Assoc. Genito-Urin. Surg., 30: 301, 1937. HAMILTON, G. R. AND PEYTON, A. B.: Ureter opening into seminal vesicle complicated by traumatic rupture of only functioning kidney. J. Urol., 64: 71, 1950. McKIRDIE, M. AND PoLKEY, H.J.: Extravesical ureteral opening into the seminal vesicle. J. Urol., 37: 706, 1937. MEISEL, H.J.: Ectopic ureter opening into a seminal vesicle. J. Urol., 68: 579, 1952. O'MALLEY, J. F. AND BUMGARNER, J.E.: Ureteral ectopia. J. Urol., 73: 235, 1955. PASQUIER, C. M. AND WOMACK, R. K.: Ectopic opening of ureter into seminal vesicle. J. Urol., 70: 164, 1953. RrnA, L. W., ScHMIDLAPP, C. G. AND BoswoRTH, M. L.: Ectopic ureter draining into the seminal vesicle. J. Urol., 66: 332, 1946.