Adenocarcinoma in a müllerian duct cyst

Insights into enlarged prostatic utricles and Müllerian duct system remnants associated with posterior hypospadias

INTRODUCTION

The prostatic utricle (PU) consists of the caudal remnant of the Müllerian duct and the urogenital sinus. The term "vagina masculina" is used if other Müllerian structures are associated with the PU. This work aims to investigate the incidence, management, and follow up of enlarged PUs and Müllerian remnants in males with posterior hypospadias.

PATIENTS AND METHODS

This study presents a retrospective review of cases presented with posterior hypospadias over a 5-year period. Prior to hypospadias repair, retrograde urethrograms were used to investigate enlarged PU. Subsequently, they were classified according to the Ikoma score and further assessed by karyotyping and cystoscope. Surgical excision was indicated in cases with symptomatic utricles or vagina masculina.

RESULTS

Thirty patients were included in the study in the period between 2015 and 2020 (Table). All cases were asymptomatic initially. Twelve patients were diagnosed with enlarged PU; three of them had vagina masculina. One case with perineal hypospadias had a separate perineal opening for PU. Following hypospadias repair, three of the eight cases treated conservatively turned symptomatic.

DISCUSSION

The incidence of enlarged PU and Müllerian remnants varied among different studies. However, it increased as the severity of hypospadias increased. Preoperative urethrogram was helpful in the diagnosis and classification of PU, but it had its limitations. Cystoscope was more advantageous in diagnosing vagina masculina. Although most cases were asymptomatic, some turned symptomatic after hypospadias repair. Some cases with perineal hypospadias had PU with a separate perineal opening.

CONCLUSION

The incidence of enlarged PUs or Müllerian remnants was 40%. Although cases were asymptomatic before hypospadias surgery, some cases turned into symptomatic after hypospadias repair. In some cases, the PU or Müllerian remnants had a separate perineal opening. They can be classified as a particular form of Ikoma grade III necessitating surgical intervention.

[Robotic-assisted resection of a symptomatic Müllerian duct cyst]

Cysts in the lesser pelvis are a rare disease and most often an incidental finding from routine diagnostic investigation. Published information is controversial. These cysts are distinguished by localisation, content of the cyst and accompanying anatomical anomalies. In this case, we report a 33 years old man who presented to our clinic due to a large retrovesical cyst. Because of lower abdominal pain and problems with defecation, the cyst was diagnosed by ultrasound. Further radiological diagnostic testing confirmed the presence of a retrovesical cyst of unknown malignancy, which was retrospectively evaluated as a Müllerian duct cyst. Due to symptoms and potential malignancy of the cyst, the decision was made to perform surgery. With the help of the operation robot, this benign cyst was safely and completely removed. In a follow-up, the patient presented free of symptoms and sonographically there was no sign of recurrence. Therefore robotic-assisted resection is a safe procedure to treat large symptomatic Müllerian duct cysts.

The Risk of Malignant Degeneration of Müllerian Derivatives in PMDS: A Review of the Literature

Persistent Müllerian Duct Syndrome (PMDS) is a rare autosomal recessive disorder of sex development characterized by the presence of fallopian tubes, uterus and upper one-third of the vagina in individuals with XY genotype and normal male phenotype. The main complications of PMDS are infertility and the rare risk of malignant degeneration of both testicular and Müllerian derivatives. We report the case of a 49-year-old man who, during repair of an incisional hernia, was incidentally found to have a uterine-like structure posterior to the bladder. In the past at the age of 18 months, he had undergone bilateral orchidopexies for bilateral cryptorchidism. The intraoperative decision was to preserve the uterine-like structure and make a more accurate diagnosis postoperatively. Evaluation revealed an XY chromosome and imaging consistent with PMDS. The patient was informed about the risk of neoplastic transformation of the residual Müller ducts and was offered surgical treatment, which he declined. Subsequent follow-up imaging studies, including testicular and pelvic ultrasound, were negative for findings suggestive of malignant testicular and Mullerian derivative degeneration. A review of the international literature showed that, when a decision is taken to remove the Mullerian derivatives, laparoscopy and especially robotic surgery allow for the successful removal of Müllerian derivatives. Whenever the removal of these structures is not possible or the patient refuses to undergo surgery, it is necessary to inform the patient of the need for adequate follow-up. Patients should undergo regular pelvic imaging examination and MRI might be a better method for that purpose.

Hematuria in an Adolescent Boy With Long-Standing Prostatic Utricle Cyst-An Ominous Sign

The prostatic utricle cyst is usually an asymptomatic enlargement of the persistent remnant of Mullerian duct in males, especially seen associated with hypospadias and usually needs no active intervention. However occasionally they can become symptomatic and can present with complaints of impotence, ejaculatory pain, difficult voiding, urinary retention and abdominal pain. Hematuria is a rare symptom in such patients and is usually due to infection. However rarely it can be a harbinger of a more sinister complication like a malignancy. Herein, we present an adolescent boy with hematuria due to malignant degeneration in a long-standing prostatic utricle cyst.

[3-Tesla MRI of rare large cystic prostate carcinoma]

Magnetic resonance imaging of rare cystic prostate cancers using multiparametric MRI (mp-MRI, 3 Tesla) shows, especially in solid tumor masses, the criteria of ESUR-MR classification with a PI-RADS >3 ("probably malignant"). In association with additional morphological evidence of intracystic hemorrhage and evidence of villous tumor nodules and irregular septa on the cyst wall, further malignancy criteria are met. MRI complementary to TRUS may be useful for targeted biopsy in solid tumor areas.

The management of the persistent Müllerian duct syndrome

OBJECTIVES

To report the findings and management of patients with persistent Müllerian duct syndrome (PMDS).

PATIENTS AND METHODS

Nineteen phenotypically male patients (aged 8 months to 27 years) presented with testicular maldescent. All of them had normal male external genitalia. Two of them had had a previous diagnosis of persistent Müllerian structures. All patients were karyotyped, and had a hormonal profile, diagnostic laparoscopy, retrograde urethrocystogram, gonadal biopsies, and surgical management according to the findings. The follow-up was based on a clinical examination, abdominal ultrasonography (US) and scrotal colour-Doppler US at 3 and 6 months after surgery, and every 6 months thereafter.

RESULTS

Diagnostic laparoscopy showed the presence of persistent Müllerian structures in all 19 patients. All patients had a normal male karyotype (46XY). Ten patients had a laparoscopic excision of their Müllerian structures while the remaining nine patients had their Müllerian structures left in place. No malignant changes were found in the excised Müllerian tissues. Of the 37 gonadal biopsies taken, 31 (84%) indicated normal testes.

CONCLUSIONS

The incidence and prevalence of PMDS are not well estimated. Müllerian structures should be removed whenever possible to avoid the risk of malignant transformation. The early diagnosis of PMDS makes possible the excision of Müllerian structures and a primary orchidopexy. A long-term follow-up is needed for patients with intact Müllerian structures and magnetic resonance imaging might be a better method than US for that purpose. Most of the patients had normal testicular histology, which might allow fertility.

[Ejaculatory system cysts: a case report]

INTRODUCTION

Male pelvic floor cysts are a rare clinical entity that include: Wolffian duct remnants, Müllerian duct remnants, cysts of the seminal vesicles, prostate and ejaculatory duct/vas deferens cysts.


CASE REPORT

We report the clinical case of a 21-year-old male patient with a history of previous surgery in childhood and more precisely: partial colectomy for congenital megacolon, removal of dysplastic right kidney and subsequent surgical adhesiolysis for bowel obstruction.
 At 17, the patient was submitted to MRI for groin pain with an incidental finding of a cystic mass at the level of the right seminal vesicle. Consequently, a TUR-ED was performed at another urology unit, for a suspected seminal vesicle ectasia, without resolution of pain symptoms. The patient was referred to us for persistent genitourinary infections, ejaculation disorder and episodes of gross hematuria. An additional MRI confirmed the presence of a cystic mass of 5,5 cm with a suspected opening into prostatic urethra. Urethrocystoscopy and urethrocystography retrograde confirmed this anatomical communication. For the persistence of the symptoms we performed retropubic surgical exeresis of the mass, with a histopathological finding of benign cyst of the vas deferens.
 Two major postoperative complications were reported: a pelvic hematoma that required surgical exploration and a urinary extravasation at the level of prostatic urethra, which resolved with prolonged urethral catheterization.


CONCLUSIONS

Male pelvic floor cysts are a rare disease with a complex clinical and therapeutic management. A correct diagnosis is based on clinical signs and symptoms together with imaging studies of the pelvic region. The high risk of erectile dysfunction and ejaculatory disorders correlated to a surgical approach, recommend a treatment of these lesions only for symptomatic cases.

Persistent Müllerian duct syndrome: lessons learned from managing a series of eight patients over a 10-year period and review of literature regarding malignant risk from the Müllerian remnants

Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Approximately 200 cases of persistent Müllerian duct syndrome have been reported over the last 50 years and most authors suggest leaving the Müllerian remnant in situ because of the difficulty in dissection and the presumed absence of risk of malignancy. However, with increasing reports of Müllerian malignancies emerging, we report our 10-year experience of managing patients with persistent Müllerian duct syndrome, with removal of müllerian remnants. This case series shows that there is an increased risk of Müllerian malignancy that was previously unknown. With the laparoscopic approach, orchidopexy with simultaneous removal of Müllerian remnants could be accomplished with minimal surgical trauma and the benefit of no malignancy risk in the future. This is a new technique that has not been previously performed. Considering the current evidence of malignancy in the Müllerian remnant, surgeons would need to discuss with families about removal of remnants or long-term monitoring.

OBJECTIVES

• To describe the presentation and management of eight patients with persistent Müllerian duct syndrome (PMDS) seen over a 10-year period at our tertiary centre. • To review the literature of Müllerian malignancies reported in PMDS.

PATIENTS AND METHODS

• The hospital records of eight patients with PMDS were retrospectively reviewed between 2001 and 2011. • Extensive PubMed searches for PMDS and Müllerian malignancy were performed.

RESULTS

• Eleven cases with PMDS and malignancy of the Müllerian remnants were identified. • From our own PMDS series: five males presented with bilateral undescended testes and three had unilateral undescended testis. • We found that the Müllerian remnants could be removed by laparoscopy and three patients had simultaneous laparoscopic removal of the Müllerian structures and laparoscopic orchidopexy.

CONCLUSIONS

• The principle aim of orchidopexy with simultaneous laparoscopic removal of the Müllerian structures can be accomplished with minimal surgical trauma and the benefit of no malignancy risk in the future. • Surgeons should consider excision of the Müllerian remnants where possible.

Squamous cell carcinoma of the enlarged prostatic utricle in an adult

A 39-year-old man with gross terminal hematuria and urethral discharge for 5 months was found to have a partial cystic and partial solid mass above the normal site of prostate, which was confirmed by magnetic resonance imaging (MRI) and transrectal ultrasonagraphy. A radical resection of the tumor was performed, and classical squamous cell carcinoma was confirmed by pathologic assay.

[3 T MRI of the prostate in patients with symptomatic prostatic utricle cyst]

Cystic lesions of the prostate are rare and often asymptomatic. Medial cysts are conventionally divided into so-called Müllerian duct cysts and prostatic utricle cysts which seems rather questionable in light of recent studies. We report a case of a patient with a 10-year history of dysuria. Diagnostic imaging was performed using 3 T prostate MRI with a body coil. Because of the potential risk of retrograde ejaculation with subsequent infertility and of incontinence by the transurethral resection, the interventional therapy of his utricle cyst was abandoned.

Cysts of the ejaculatory system: a report of two cases

We report two cases of rare cystic dilatations of the ejaculatory system. In case 1, a 6-month-old boy was referred to us for the management of recurrent epididymo-orchitis (E-O) complicating open drainage and a colostomy was performed elsewhere for a purulent rectal discharge thought to be rectal duplication. Diagnostic imaging showed a retrovesical cyst. Urethrocystoscopy showed a swelling of the verumontanum. No fistula was seen between the cyst and rectum on colonoscopy. At laparotomy, both ejaculatory ducts and seminal vesicles were found to be fused into a mass with cystic dilatation of the ejaculatory duct. Intraoperative histopathology of the cyst identified a metaplastic epithelial lesion. The cyst was excised with bilateral vasoligation. Since surgery, 8 years ago, urination and defecation have been normal. In case 2, a 4-month-old boy presented with fever and a swollen right scrotum. Ultrasonography showed a retrovesical cyst. Right grade IV vesicoureteral reflux diagnosed on voiding cystourethrography was treated by ureter reimplantation (Cohen) but complicated by recurrent E-O. Urethrocystoscopy with retrograde contrast via the utriculus showed that the cyst opened on the verumontanum, that both ejaculatory ducts opened into the cyst, and there was reflux into the right vas deferens. Right vasoligation alone was performed through a scrotal approach. Although the cyst was not excised, there has been no recurrence of E-O nor enlargement of the cyst for 6 years. Cysts of the ejaculatory system should be considered in the etiology of recurrent E-O in prepubertal children and a high index of awareness is recommended.

Persistent Müllerian duct syndrome: a surgical approach

Laparoscopy revealed a left inguinal testis and a right abdominal testis. Surgery revealed uterus-like structures. The bilateral testes showed primitive testis without ovarian tissue. Physical examination showed a normal and an empty scrotum with a nonpalpable gonad. Chromosome analysis revealed 46,XY. Pathological findings demonstrated the immature testis and the immature uterus.

Management of müllerian duct remnants

OBJECTIVES

To describe the presentation and radiologic investigation of 6 patients who had persistent müllerian duct remnants (MDRs) in association with severe hypospadias and to review the long-term results of surgical management using the transtrigonal approach.

METHODS

The hospital records of 6 patients who had MDRs and who underwent transvesical transtrigonal excision were reviewed and long-term assessment of urinary control and continence was made by interview.

RESULTS

One patient presented in the newborn period with clinically palpable MDRs and five others escaped detection until after the hypospadias repair, despite ultrasonography of the pelvis specifically looking for MDRs. All had undescended testis with severe hypospadias. The karyotype was 45XO/46XY in five and 46XY in one. The most consistently useful examinations were voiding cystourethrography and magnetic resonance imaging. The excision was transtrigonal in each case. Early or late postoperative complications were not encountered in any of our patients. Gonadal histologic examination showed streak gonad in four and a dysgenetic testis in one. Histopathologic examination showed rudimentary uterus and fallopian tubes in 4 patients and a cystic structure lined with squamous and columnar epithelium in 2 patients. No areas of metaplasia were noted. Bladder emptying was normal after surgery.

CONCLUSIONS

Ultrasound examination alone is not always sufficient to diagnose MDRs, which may be responsible for symptoms after hypospadias surgery. The transtrigonal approach provided excellent visualization and access to MDRs and prostatic urethra.

Diagnosis and treatment of midline prostatic cysts

We report three patients with midline prostatic cysts (simple, n=1; complex, n=2) that presented with low ejaculate volume and hematospermia. Transrectal ultrasound (TRUS) revealed a midline prostatic cystic structure that could represent either an ejaculatory duct cyst or a Müllerian duct cyst. In one patient, the ejaculatory duct cyst was confirmed by identification of spermatozoa at microscopic analysis of fluid obtained by TRUS-guided needle aspiration. The two other patients underwent transurethral incision of the cyst with complete resolution of symptoms.

Tubulocystic clear cell adenocarcinoma arising within the prostate

Neoplasms resembling ovarian common epithelial-type tumors, including clear cell adenocarcinomas, rarely occur in the lower urinary tract of men. When they do, they develop in the urethra or urinary bladder. We report a case of such a tumor arising within the prostate of a 47-year-old man. The tumor was a cystic mass in the left posterolateral region of the prostate. Histologically, the tumor was chiefly composed of tubulocystic and papillary glands lined by glycogen-rich, cuboidal or hobnail cells with clear to eosinophilic cytoplasm. The tumor cells were strongly positive for pan-cytokeratin, low molecular weight cytokeratin, and epithelial membrane antigen, and focally positive for high molecular weight keratin. The tumor did not immunohistochemically express prostate-specific antigen (PSA) and prostatic acid phosphatase. Serologically, the patient had increased levels of CA125 instead of PSA. The clinical as well as the pathologic features are consistent with a clear cell adenocarcinoma as seen in the female genital tract rather than a typical prostatic adenocarcinoma.

Primary seminal vesicle carcinoma: an immunohistochemical analysis of four cases

Primary adenocarcinoma of the seminal vesicles is an extremely rare neoplasm. Because prompt diagnosis and treatment are associated with improved long-term survival, accurate recognition of this neoplasm is important, particularly when evaluating limited biopsy material. Immunohistochemistry can be used to rule out neoplasms that commonly invade the seminal vesicles, such as prostatic adenocarcinoma. Previous reports have shown that seminal vesicle adenocarcinoma (SVCA) is negative for prostate-specific antigen (PSA) and prostate-specific acid phosphatase (PAP); however, little else is known of its immunophenotype. Consequently, we evaluated the utility of cancer antigen 125 (CA-125) and cytokeratin (CK) subsets 7 and 20 for distinguishing SVCA from other neoplasms that enter the differential diagnosis. Four cases of SVCA-three cases of bladder adenocarcinoma and a rare case of adenocarcinoma arising in a mullerian duct cyst-were immunostained for CA-125, CK7, and CK20. Three of four cases of SVCA were CA-125 positive and CK7 positive. All four cases were CK20 negative. All bladder adenocarcinomas and the mullerian duct cyst adenocarcinoma were CK7 positive and negative for CA-125 and CK20. In addition, CA-125 immunostaining was performed in neoplasms that commonly invade the seminal vesicles, including prostatic adenocarcinoma (n = 40), bladder transitional cell carcinoma (n = 32), and rectal adenocarcinoma (n = 10), and all were negative for this antigen. In conclusion, the present study has shown that the CK7-positive, CK20-negative, CA-125-positive, PSA/PAP-negative immunophenotype of papillary SVCA is unique and can be used in conjunction with histomorphology to distinguish it from other tumors that enter the differential diagnosis, including prostatic adenocarcinoma (CA-125 negative, PSA/PAP positive), bladder transitional cell carcinoma (CK20 positive, CA-125 negative), rectal adenocarcinoma (CA-125 negative, CK7 negative, CK20 positive), bladder adenocarcinoma (CA-125 negative), and adenocarcinoma arising in a mullerian duct cyst (CA-125 negative).

Laparoscopic management of persistent Müllerian duct remnants associated with an abdominal testis

In recent years, laparoscopy has evolved from a purely diagnostic procedure in the management of nonpalpable testis to a definitive therapeutic intervention. Additional genital malformations occur in association with cryptorchidism, but reports of laparoscopic management of such entities do not exist. Herein, we describe the laparoscopic removal of persistent Müllerian duct remnants (uterus and round ligament) in combination with an orchiectomy of an abnormally small abdominal testis. This technique expands the versatility of laparoscopic management of cryptorchidism to include the resection of associated congenital anomalies.

Surgical management of persistent müllerian duct syndrome

OBJECTIVES

To describe the optimal surgical management of the testes and müllerian duct structures in patients with persistent müllerian duct syndrome.

METHODS

We performed a comprehensive Medline literature search regarding the surgical management of persistent müllerian duct syndrome and extracted information regarding the etiology, pathogenesis, and treatment of this disorder. We specifically assessed the risks of retained müllerian structures versus surgical excision of the infantile uterus and fallopian tubes. Using this information, we formulated a comprehensive strategy for the management of patients with persistent müllerian duct syndrome. An illustrative case is described.

RESULTS

No malignant degeneration of persistent müllerian structures has been reported. The risk of testicular neoplasia in persistent müllerian duct syndrome approximates the risk of neoplasia in other intra-abdominal gonads. Fertility has rarely been reported although virilization is unaffected. Surgical excision of the infantile uterus and fallopian tubes risks damage to vasa deferentia and the deferential blood supply to the testis.

CONCLUSIONS

Surgical excision of persistent müllerian duct structure may result in ischemic and/or traumatic damage to the vasa deferentia and testes. Optimal surgical management is orchiopexy leaving the uterus and fallopian tubes in situ. Meticulous proximal salpingectomy and hysterectomy is indicated only in patients whose müllerian structures limit intrascrotal placement of the tests. Orchiectomy is indicated for testes that cannot be mobilized to a palpable location.

Squamous cell carcinoma in a Müllerian duct cyst: report of a case

A 36-year-old man presented with a pelvic mass which proved to be a Müllerian duct cyst. The cyst was determined to be squamous cell carcinoma which involved the rectum and the bladder. A total pelvic exenteration was carried out for complete resection.

Exophytic papillary prostatic duct adenocarcinoma with endometrioid features, occurring in prostatic urethra after TURP

We present an eighty-three-year-old man with an exophytic lesion in the prostatic cavity, diagnosed three years after transurethral resection of the prostate, and extending into the bladder. Histopathologically, the tumor was recognized as a papillary ductal adenocarcinoma (primary duct type) with endometrioid features, probably associated with prostatic adenomatous polyp. Acinic adenocarcinoma was absent. The lesion was treated by deep transurethral resection with objective follow-up results after six months. Review of the literature concerning history, embryology, possible pathogenesis, differential diagnosis, and treatment options is included.