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Juliano RV, Juliano CAB, Costa ACDM, Machado MT, Wroclawski ER
Case Report
Seminal vesicle stone treated by laparoscopic surgery: report of
the first Brazilian case
Cálculo de vesícula seminal tratado por cirurgia videolaparoscópica: relato do primeiro caso brasileiro
Roberto Vaz Juliano1, César Augusto Braz Juliano2, Ana Carolina Duarte Martins Costa3, Marcos Tobias
Machado4, Eric Roger Wroclawski5
ABSTRACT
The seminal vesicle stone is a rare condition, with few cases reported in
the international literature and no report found in the Brazilian literature,
especially considering videolaparoscopic treatment. The importance of
diagnosis is related to the fact that the seminal vesicle stone can be
implicated in the pathogenesis of type II or III prostatitis. We present
a case of a 36-year-old male who complained of perineal pain and
persistent pollakiuria despite adequate clinical treatment. Bilateral
seminal vesicle stones were diagnosed by CAT-scan and transrectal
echography. The laparoscopic seminal vesiculotomy resulted in complete
relief of symptoms and infection control in a six-year follow-up.
Keywords: Seminal vesicles/surgery; Vesical calculi/surgery;
Laparoscopy; Prostatitis
RESUMO
A ocorrência de cálculo de vesícula seminal é uma entidade rara, com
poucos relatos na literatura mundial, sendo ainda mais escassos artigos
sobre o tratamento videolaparoscópico. A importância do diagnóstico
está relacionada ao fato de o cálculo de vesícula seminal ser um fator
na gênese da prostatite e ter relação com dor perineal e na ejaculação,
simulando quadro de prostatite sem infecção demonstrável. Relatamos
o caso de um paciente de 36 anos com quadro de dor perineal e
polaciúria persistente, apesar de tratamento clínico adequado. A
tomografia e a ecografia transretal diagnosticaram cálculo de istmo
de vesícula seminal bilateral. A vesiculectomia seminal bilateral por
laparoscopia resultou em remissão da sintomatologia e controle da
infecção em seguimento de seis anos.
Descritores: Glândulas seminais/cirurgia; Cálculos vesicais/cirurgia;
Laparoscopia; Prostatite
INTRODUCTION
Pelvic perineal pain with irritating vesical symptoms
refers to a clinical entity known as prostatitis, which
is classified by the National Institutes of Health
(USA) as: type I – acute bacterial prostatitis; type II
– chronic bacterial prostatitis and type III – chronic
pain with no demonstrable bacterial infection. Type
II and III prostatites present no fever and there are
several treatment options. Type II prostatitis is treated
with antibiotics for a prolonged period (over 60 days)
and type III, particularly type IIIb, in which there
are no bacteria and no increase in leukocyte count in
the prostatovesicular fluid, requires antibiotics, antiinflammatory agents, alpha-blockers, immunomodulators,
hormone therapy, alopurinol, phytotherapeutic agents,
pelvic floor physical therapy, biofeedback, myorelaxants,
prostate massage, thermotherapy and psychotherapy,
among other treatments. These multiple treatment
options demonstrate difficulties faced by physicians in
understanding the pathogenesis and establishing an
effective therapy in many cases. Ultrasound findings of
prostate calcification and seminal vesicle abnormalities
are indicative signs, but do not determine the presence
of prostatitis(1). In this report we describe the case of
a patient with seminal vesicle stone, which is a rare
condition and could be the cause of prostatitis symptoms,
mainly if we consider that excising the vesicles represented
cure. There are few reports in the literature about this
condition(2-6).
1
Responsible for the Division of Laparoscopy and Experimental Surgery, Department of Urology, Faculdade de Medicina do ABC – FMABC, Santo André (SP), Brazil.
2
Medical undergraduate student – 6th year – at the Faculdade de Ciências Médicas da Santa Casa de Misericórdia de São Paulo – FCMSMSP, São Paulo (SP), Brazil.
3
Medical undergraduate student – 6th year – Faculdade de Ciências Médicas da Santa Casa de Misericórdia de São Paulo – FCMSMSP, São Paulo (SP), Brazil.
4
Assistant lecturer at the Department of Urology at the Faculdade de Medicina do ABC – FMABC, Santo André (SP), Brazil.
5
Regent Professor, Department of Urology at the Faculdade de Medicina do ABC – FMABC, Santo André (SP), Brazil.
Corresponding author: Roberto Vaz Juliano – Rua Espírito Santo, 55 – ap. 131 – Aclimação – CEP 01526-020 – São Paulo (SP), Brazil – Tel.: 11 3141-9586 – e-mail: [email protected]
Received on Sep 27, 2006 – Accepted on Mar 24, 2007
einstein. 2007; 5(4):372-374
Seminal vesicle stone treated by laparoscopic surgery: report of the first Brazilian case
CASE REPORT
A 36-year-old white patient, married and with two children (11
and 15-years old), presented perineal and hypogastric pain as
from January 1999, which irradiated to the anus and penile
root, with nocturia (twice per night) and significant pain
during ejaculation that made him avoid intercourse. Upon
digital rectal examination, the prostate had normal size and
consistence and was painless. Sperm culture showed presence
of Escherichia coli and he initiated treatment with trimetropin
and sulfametoxazole for 90 days. This caused sterilization of
the prostatovesicular fluid, but the symptoms remained. He
tried analgesic, anti-inflammatory and phytotherapeutical
agents and alphablockers, however with no improvement.
Echography was performed and showed normal urinary tract
with no calculi and cystoscopy with biopsy revealed normal
bladder mucosa. Helicoidal computed tomography showed
bilateral seminal vesicle calculi (Figure 1). After a one-year
unsuccessful clinical treatment we decided to perform a
bilateral laparoscopic vesiculectomy.
Figure 1. CT image of the seminal vesicles with calculi (arrows)
He was submitted to surgery on September 28, 2000
by means of five punctures in an inverted V pattern
(Figure 2); in that, the vertex was in the navel, where
the optics was introduced. The peritoneum was opened
in the posterior cul-de-sac and the seminal vesicles
were dissected and excised (Figures 3 and 4).
Figure 2. Chart showing the punctures for seminal vesicle surgery. Scars after 20 days
(arrow in the 10-mm long umbilical puncture, other punctures were 5-mm long)
373
Figure 3. Dissection of the seminal vesicles by laparoscopy
The patient progressed well and was discharged on
the second postoperative day, with complete relief of
symptoms, no perineal pain, nocturia or discomfort
during intercourse up to September 2006. He remains
married and has a stable marital relation.
DISCUSSION
The complaints of perineal pain irradiating to the
hypogastrium, anus and penile root associated to
irritating bladder symptoms and low urinary obstruction
syndrome suggest a diagnosis of prostatitis. A negative
culture of prostatovesicular fluid suggests the presence
of a chronic pelvic pain syndrome called prostatodynia
or type III prostatitis(2). The clinical treatment of these
conditions very often fails or results in recurrence of
symptoms probably because we do not clearly know their
pathogenesis and etiology. The pathogenesis of pain in
chronic prostatitis and chronic pelvic pain syndrome has
not been fully understood and there are multicausal and
multifactorial mechanisms involved, such as the toxic effect
of sterile urine reflux to the prostate, infection, trauma
or even immunological mechanisms that trigger a series
of inflammatory, neuropathic and immunological events,
which eventually cause symptoms(7). Other risk factors for
prostate infection include unprotected anal intercourse,
phimosis(8), blood group and urethral manipulation(9).
There is clearly a new fact in the case described
– seminal vesicle calculus – that has a potential irritating
and obstructive action as a causal factor. Although rare,
the diagnosis of seminal vesicle stone must be considered
in these cases and the videolaparoscopic treatment leads
to cure with lower morbidity as compared to conventional
surgery(5). In case of desire of future fertilization and need
to remove both seminal vesicles, patients should be oriented
to store sperm since they may develop infertility.
einstein. 2007; 5(4):372-374
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Juliano RV, Juliano CAB, Costa ACDM, Machado MT, Wroclawski ER
making diagnosis in such cases. Videolaparoscopic
treatment results in cure with low morbidity.
REFERENCES
1. Ludwig M, Weidner W, Schroeder-Printzen I, Zimmermann O, Ringert
RH. Transrectal prostatic sonography as a useful diagnostic means for patients
with chronic prostatitis or prostatodynia. Br J Urol. 1994;73(6):664-8.
2. Namjoshi SP. Large bilateral star-shaped calculi in the seminal vesicles. J
Postgrad Med. 2002;48(2):122-3.
3. Li YK. Diagnosis and management of large seminal vesicle stones. Br J Urol.
1991;68(3):322-3.
4. Wilkinson AG. Case report: calculus in the seminal vesicle. Pediatr Radiol.
1993;23(4):327.
Figure 4. Aspect of the surgical specimen
CONCLUSION
The diagnosis of seminal vesicle stone should be
considered in patients with recurrent chronic prostatitis
and type III prostatitis. Transrectal echography and
computed tomography should be ordered to help in
einstein. 2007; 5(4):372-374
5. Özgök Y, Kilciler M, Aydur E, Saglam M, Irkilata HC, Erduran D. Endoscopic
seminal vesicle stone removal. Urology. 2005;65(3):591.
6. Barros D, Catéra R, Herrera M, Medel R, Podestá M. Quiste de vesícula seminal
con litiasis. Rev Argent Urol. 2003;68(1):43-7.
7. Krieger JN, Nyberg LJ, Nickel JC. NIH consensus definition and classification
of prostatitis. JAMA. 1999;282(3):236-7.
8. Nickel JC. Prostatitis: lessons from the 20th century. BJU Int. 2000;85(2):179-85.
9. Van Howe RS. Circumcision and infectious diseases revisited. Pediatr Infect Dis
J. 1998;17(1):1-6. Review.