THE .JOURNAL OF UROLOGY
Vol 68, No. 3, September 1952 Printed in U.S.A.
ECTOPIC URETER OPENING INTO A SEMINAL VESICLE HERMAN J. MEISEL From the Veterans Administration Hospital, Fort Howard, Md.
Termination of the ureter in the seminal vesicle is a rare anomaly. Riba et al., including 1 instance of their own, reported 27 such instances. Subsequently Engel reported a single instance. Of the 28 instances, twenty-two were found at autopsy. In only six was a clinical diagnosis made and therapy applied. The present instance is the seventh* such to be reported. CASE REPORT
R. F. H. (R-24614), a 28 year old, married white man was admitted to the Veterans Administration Hospital, Fort Howard, Maryland complaining of a painful "squeezing" sensation in his rectum for about 3 weeks. A vague discomfort had been present in the rectum for about 3 months. He had been treated for "prostatitis" without effect previous to admission. There had been no urinary or genital symptoms. His sexual life had been normal and he had fathered one daughter, aged three. The remainder of the history was noncontributory. Physical examination was negative except for the rectal findings. The prostate was of normal size, shape and consistency. A soft, almost cystic, irregular, slightly tender mass bulged into the rectal lumen above the prostate. The right border of the mass was sharply defined and the lower border was continuous with the upper margin of the prostate, but the left border extended laterally and upward, higher than could be reached with the examining finger. Routine examination of the blood and urine was normal. Cultural studies of the urine were negative. Roentgenograms of the chest and abdomen, barium studies of the colon, and cystogram were not unusual. Proctoscopy showed the mucosa over the mass to be freely movable and normal in appearance. Excretory urography showed a normal right urinary tract, but there was no evidence of function on the left (fig. 1, A). Seminal vesiculography was done under local anesthesia by isolating the vasa in the scrotum, and injecting each vas in a retrograde manner with 15 cc of 35 per cent diodrast. Rectal palpation during this procedure demonstrated increasing distention of the mass previously described, giving presumptive evidence that the mass ·was seminal vesicle. Roentgenograms revealed a normal right seminal vesicle, and a tremendously dilated, coiled, left vesicle (fig. 1, B). At cystoscopy, a moderate elevation of the trigone was found. The orifice of the right ureter was displaced upward and laterally but was easily catheterized. Reviewed in the Veterans Administration and published with the approval of the Chief Medical Director. The statements and conclusions published by the author are the result of his own study and do not necessarily reflect the opinion or policy of the Veterans Administration. * Since the preparation of this article, another instance has been published (Hamilton, G. R. and Peyton, A. B.: J. Urol. 64: 731-735, 1950). The present instance is therefore the eighth reported clinical case. 579
HERMAN J. MEISEL
The left ureteral orifice could not be found and indigo carmine appeared only from the right ureteral orifice. The posterior urethra and verumontanum were normal. The diagnostic possibilities seemed limited to 1) agenesis of the left kidney with accompanying left seminal vesiculitis, and 2) an atrophic left kidney with an ectopic ureter emptying into the left seminal vesicle. The latter diagnosis was considered more likely. On April 13, 1950 an exploratory procedure was done through a left lumbar incision in the lateral position under spinal anesthesia. An almost completely atrophic kidney, measuring 5 by 2 by 0.4 cm., and consisting of a cap of fibrous tissue surrounding a small pelvis was found in the usual position. A hypoplastic renal artery about 3 mm. in diameter was present. The ureter, which proximally appeared fairly normal, became thickened and distended distally until it entered a tremendously enlarged, coiled, nodular and elongated seminal vesicle. The
[. Frn. 1. A, excretory urogram showing absence of function on left. B, seminal vesiculography. Note enlarged left vesicle and faint outline of diverticulum. C, roentgenogram taken at operation after injecting ureter with diodrast. Note outlining of organs as compared to operative specimen.
kidney and ureter were freed completely and placed in the lower portion of the wound which was then closed. The patient was turned to the supine position and a left lower pararectus incision of the lower abdominal wall was made. The kidney and ureter, freed from above, were exposed retroperitoneally and delivered into the wound. The ureter and seminal vesicle were followed retrovesically where a large, distended cyst, or diverticulum, of the seminal vesicle was found. Dissection was continued to the ejaculatory duct. At this point a needle was inserted in the ureter, 15 cc of dark brown fluid was aspirated, 35 per cent diodrast was injected and a roentgenogram taken (fig. 1, C). The vas deferens and ejaculatory duct were divided and the specimen removed intact. The course was uneventful and the patient was discharged on the twelfth day following operation. A sperm specimen obtained on the day of discharge was normal in every respect and contained 197 million sperm per cubic centimeter. At follow-up examination six months later, the patient was asymptomatic and had had normal sexual relationships.
The pathologist (Wm. B. VandeGrift, M.D.) reported that the kidney, measuring 5 by 2 by 0.5 cm., had a contracted pelvis. The ureter, approximately 15 cm. long and 1 cm. in diameter, opened into a dilated seminal vesicle about 15 cm. in length. A diverticulum, 8 cm. long and 2 cm. wide, with a thick wall was found at the lower margin of the seminal vesicle. The opening of the vas deferens was between the seminal vesicle and its diverticulum. See figure 2. Microscopically, the tissue described grossly as kidney consisted of smooth muscle, nerves and fibrous tissue, containing occasional small and large tubules filled with debris and lined by deeply staining pseudostratified cells containing mucus. Glomeruli were not demonstrated. The epithelium of the ureter, semina Kidney
Semi nol vesicle
Fm. 2. A, Operative specimen, unopened. B, operative specimen, opened.
vesicle, cyst of the vesicle and the vas deferens was of the pseudostratified columnar or transitional type. The submucosa was infiltrated with lymphocytes, plasma cells and eosinophiles with little evidence of fibrosis. DISCUSSION
The ectopic opening of the ureter into the seminal vesicle is due to an anomalous development of the ureter. The lower end of the ureter, which develops by a budding process from the wolflian duct, normally is absorbed into the vesico-urethral anlage. The ureter becomes entirely separate from the wolflian duct which is the anlage of the male genital tract. When the ureter remains attached to the wolflian duct, the ureter may open into any of the derivatives of
HERMAN J. MEISlDL
the duct. The openings of a series of ectopic ureters is listed by Thomas: prostatic urethra 33, seminal vesicle 17, vas deferens 6 and ejaculatory duct 5. The present instance, in addition to the anomalous displacement of the ureteral orifice, exhibited the associated lesions of 1) hypertrophy and dilatation of the seminal vesicle, 2) diverticulum of the seminal vesicle and 3) hypoplastic, nonfunctioning kidney. As a cause of diverticula or cysts of the vesicle, Deming has postulated an antecedent stenosis of the ejaculatory duct which would seem to be a satisfactory explanation. The hypoplastic kidney found in this instance is commonly associated with ureteral ectopia, particularly of this type. Of 20 cases reported by McKirdie and Polkey, the kidney was absent in six, rudimentary in eleven and cystic in three. Of the six previously reported cases, all but one had pyuria with associated urinary symptoms. This isolated instance of Engel was discovered during an investigation for sterility. The patient had a cavernous opening in the posterior urethra which proved to be a cystic seminal vesicle. Engel postulated regurgitation of semen into the vesicle as the cause of sterility. He stated that "a cystic seminal vesicle was removed and ureteronephrectomy performed," but how this was done was not described. Of the five other cases, in one, operation was not done, while in the others, multiple operations and prolonged treatment were required. Our case differs from those previously reported in several particulars. Pyuria and urinary symptoms were absent. The presenting and only complaint was "squeezing in the rectum," a symptom previously unreported. Also unreported is the ballooning out of the seminal vesicle, as felt rectally, during vesiculography. We believe that this unusual clinical sign may be useful in evaluating the nature of masses in and around the prostate. In our opinion, the diagnosis can be made clinically, if its possibility is kept in mind, and the following procedures done: Excretory urography which will usually demonstrate a nonfunctioning kidney. Cystoscopy which will show elevation of the trigone and absence of the ureteral orifice on the side of the nonfunctioning kidney. Seminal vesiculography either by catheterizing the ejaculatory duct, or by injecting the vas in the scrotum, which will demonstrate an enlarged vesicle, a cystic dilatation of the vesicle, or a diverticulum, and may visualize the entrance of the ectopic ureter. Rectal palpation which may reveal a mass at the site of a vesicle, and will demonstrate ballooning during vesiculography. The indicated therapy is complete excision of the seminal vesicle and nephroureterectomy. It is conceivable that a functioning kidney may exist with such an anomaly, in which case the ureter might be transplanted into the bladder, and only the vesicle excised. There was no particular difficulty experienced in approaching the seminal vesicle from above and behind the bladder in this operation, and the use of this approach would seem to be justified by the possibility of saving an occasional functioning kidney.
The seventh clinical case of an ectopic ureter opening into a seminal vesicle has been presented. Associated lesions included a hypoplastic, nonfunctioning kidney, a large diverticulum of the seminal vesicle, and a stenosis of the ejaculatory duct. Cure was effected by removal of the kidney, ureter and seminal vesicle in one stage. REFERENCES DEMING, C. L.: Cyst of seminal vesicle. Trans. Am. Assoc. Genito-Urin. Surg., 28: 301-312, 1935. ENGEL, W. J.: Ureteral ectopic opening into seminal vesicle. J. Urol., 60: 46-49, 1948. JYicKmDIE, M., AND PoLKEY, H. J.: Extravesical ureteral opening into seminal vesicle. J. Urol., 37: 706-714, 1937. RrnA, L. W., ScHMIDLAPP, C. J. AND BoswOR'rH, N. L.: Ectopic ureter draining into seminal vesicle. J. Urol., 56: 332-338, 1946.