Congenital Seminal Vesicle Cyst and Ipsilateral Renal Agenesis (Zinner Syndrome): A Rare Association and Its Evolution from Early Childhood to Adolescence

Zinner syndrome in pediatric patients: rare disease leading to challenging management

Introduction

Zinner syndrome (ZS) is the association of seminal vesicle cysts, ipsilateral ejaculatory duct obstruction, and ipsilateral renal agenesis. This condition is very rare in children and both diagnosis and treatment may be challenging. We reviewed the clinical presentation and treatment describing our experience with a series of three patients.

Methods

From January 2016 to January 2021, three patients (patients 1, 2, and 3) with symptomatic ZS, aged 2, 15, and 17 years, respectively, were diagnosed and treated. All three patients were symptomatic, manifesting pelvic pain and dysuria. The diagnosis was made by physical examination, ultrasonography, and abdominopelvic MRI. Patient 1 underwent open surgery, while for patients 2 and 3, laparoscopic excision was performed.

Results

The renal agenesis regarded the left side in patients 1 and 3, and the right side in patient 2. In all cases, the cystic complex was excised. The mean operating time was 4 h and the mean hospitalization time was 5 days (range 4-6 days). The mean follow-up period was 5 years (range 2-5 years). Patients 1 and 3 showed a complete resolution of the symptoms during postoperative follow-up. In patient 2, clinical symptoms relapsed because of the persistence of a 9 mm cyst requiring a redo laparoscopic excision.

Conclusions

Seminal vesicle cyst with ipsilateral renal agenesis, even if rare in pediatric age, should be suspected in young male patients presenting with pelvic cystic masses, pelvic pain, dysuria, and ipsilateral renal absence. Conservative management should be reversed to asymptomatic patients. Surgical treatment is mandatory in symptomatic cases and the preferred approach is minimally invasive surgery to magnify the operating field to spare anatomical structures, primarily the contralateral vas deferens. Radicality is crucial to avoid the persistence of symptoms and the need for reintervention.

A rare presentation of Zinner syndrome as recurrent epididymitis: A case report

Zinner syndrome is a rare congenital malformation characterized by ipsilateral renal agenesis, atresia of the ejaculatory duct, and cystic distension of the seminal vesicles. Symptoms typically arise in adolescence or adulthood and may include painful urination, perineal discomfort, and post-ejaculatory pain. Diagnosis, often made between the ages of 20 and 50 years, involves differentiating Zinner syndrome from other cystic disorders using techniques such as cystoscopy, MRI, intravenous urography, and transrectal ultrasound. Treatment varies based on symptom severity, ranging from conservative approaches to invasive surgeries. Regular follow-up is essential to identify complications and preserve fertility. Herein, we present a 27-year-old male with recurrent scrotal swelling and erythema incidentally diagnosed with Zinner syndrome. The patient had a history of recurrent epididymitis and was found to have cystic dilatation of the seminal vesicle, ipsilateral renal agenesis, and obstruction of the left ejaculatory duct on imaging. Given the patient's mild symptoms, he was managed conservatively with antibiotics and pain medication, resulting in significant improvement.

Retrovesical cysts in boys—case series and literature review

Background

Retrovesical cysts present with varying etiologies. We initiated this study to provide insights into retrovesical cysts in boys through a case series and systematic literature review and to aid in treatment alternatives.

Materials and methods

Case series of seven patients from the in-hospital register with a systematic literature review on retrovesical cysts in children.

Results

We identified seven patients from the in-hospital register during 2005–2020 and eighty-two patients from the literature review. The literature review showed that children’s retrovesical cysts are mainly asymptomatic before puberty. Those detected earlier in childhood present mostly with renal abnormalities. In our series, retrovesical cysts derived from three distinct etiologies with different treatment modalities. Asymptomatic cysts do not need excision and are to be followed up through puberty, but in the case of an ectopic ureter, nephroureterectomy is optional. Symptomatic retrovesical cysts may demand surgical excision. Ultrasonography is usually sufficient for diagnosis, but MRI provides better anatomical delineation and aids in surgical planning.

Conclusions

Retrovesical cysts in boys are benign conditions associated with abnormal development of the ureter and kidney. Ultrasonography is sufficient for diagnosis, with MRI giving further detail for surgical planning. Treatment consists of cyst excision, heminephrectomy/nephrectomy, transurethral canalization, or excision of prostatic utricle, depending on etiology. Asymptomatic cases are to be followed up through puberty, but in cases of an ectopic ureter, nephroureterectomy is preferred.

Zinner syndrome in children: clinical presentation, imaging findings, diagnosis, and outcome

BACKGROUND

Zinner syndrome (ZS), the association of congenital seminal vesicle cyst (SVC) and ipsilateral kidney anomalies, is rarely diagnosed in childhood. This study aimed to assess presentation, imaging findings, management, and outcome of pediatric ZS.

METHODS

Sixteen children with ZS were diagnosed and managed at our hospital from 2003 to 2021. We reviewed the medical records to collect data on initial symptoms, results of imaging studies, complications, operation, and follow-up.

RESULTS

Ultrasound was used in all 16 cases as initial diagnostic tool. Fourteen patients were asymptomatic at diagnosis: these were transferred from obstetricians or pediatricians for evaluation of the prenatally or postnatally detected ultrasonic kidney anomalies. SVCs were incidentally noted on ultrasonography. The other two cases initially presented with urinary tract infection (UTI). Kidney anomalies included multicystic dysplastic kidney in 3 and kidney agenesis in 13 patients. Eleven (68.7%) patients had ipsilateral ectopic ureters entering SVC. Four (36.4%) patients had a reflux from urethra into SVC (urethro-cystic reflux) on voiding cystourethrography. Ten (62.5%) patients remained asymptomatic over a mean of 58 months (range, 7-216 months), two patients developed lower urinary tract dysfunction, and five patients had UTIs. Two boys needed SVC removal, and SVC had disappeared in two patients after 2.5-4 years of follow-up.

CONCLUSIONS

Unilateral kidney hypodysplasia with ectopic ureter inserting into the ipsilateral SVC is a characteristic sign for diagnosis of ZS. In our case series, ZS was mainly asymptomatic. Urethro-cystic reflux was associated with UTIs in young infants. SVC removal was rarely required. A higher resolution version of the Graphical abstract is available as Supplementary information.

[And there was Zinner's syndrome-a rare differential diagnosis]

Zinner's syndrome is a rare congenital abnormality of the Wolffian ducts in male patients. It consists of the triad of renal agenesis, ipsilateral seminal vesicle dilatation, and obstruction of the ejaculatory duct. Symptoms often occur after puberty and can include hematospermia, painful ejaculation, dysuria, and local discomfort. We present the case of a 15-year-old patient with this rare condition who was treated surgically after the diagnosis was confirmed.

A Triad of Unilateral Renal Dysgenesis with Ipsilateral Seminal Vesical and Ejaculatory Duct Obstruction: An Uncommon Urogenital Congenital Anomaly, Zinner Syndrome-A Case Report

Zinner syndrome is a rare congenital anomaly of the urogenital system resulting from an in utero insult during the first trimester. This entity comprises a triad of unilateral renal agenesis/dysgenesis with ipsilateral seminal vesical and ejaculatory duct obstruction. This combination of urinary and genital abnormalities occurs because of the closely related embryological origin of these structures from the distal mesonephric (Wolffian) duct. Nearly 200 cases of seminal vesical cysts with ipsilateral renal agenesis have been reported in the literature. The affected person generally presents in early adulthood when the reproductive activity commences. In this report, we present a case of a 22-year-old male with complaints of painful ejaculation.

Long-Term Surveillance and Laparoscopic Management of Zinner Syndrome

Zinner syndrome was first described in 1914 and represents the triad of unilateral renal agenesis and ipsilateral seminal vesicle cyst and ipsilateral ejaculatory duct obstruction. Seminal vesicle cysts are often asymptomatic but can also present with pain, haematospermia, or other lower urinary tract symptoms. Treatment strategies include observation and surgical excision. We present the laparoscopic management of an enlarged seminal vesicle cyst, consistent with Zinner syndrome, 14 years after the initial diagnosis. A 58-year-old male patient was diagnosed with a left-sided seminal vesicle cyst while undergoing assessment for renal transplant due to progressively worsening renal function in his solitary right kidney. The otherwise asymptomatic cyst enlarged from the time of initial diagnosis in 2004 (11.3 cm × 9.7 cm × 13.1 cm) to nearly double the size in 2018 (12.8 cm × 11.9 cm × 14.2 cm). This cyst size ultimately precluded renal transplant, and the patient was referred for excision. Laparoscopic excision of the cyst was performed, histopathology confirmed seminal vesicle cyst tissue, and there has been no recurrence of the cyst to date. The patient remains active on the renal transplant waitlist. Zinner syndrome is a rare syndrome, with the seminal vesicle cysts being managed by observation or surgical excision. We report the longest documented observation of a seminal vesicle cyst, culminating in a safe and successful laparoscopic excision.

Zinner syndrome and infertility─a literature review based on a clinical case

Zinner syndrome (ZS) is a rare congenital malformation associated with seminal vesicle cysts, ejaculatory duct obstruction, and ipsilateral renal agenesis. The main treatment focus so far has been on symptomatic patients. Therefore, surgery has been reserved for these patients, and surgical treatment is mainly aimed at pain relief. ZS seems to be frequently associated with infertility, but diagnosing is challenging, particularly during adolescence. This literature review of ZS and infertility is based on the medical report of one adolescent patient.

Incidental imaging findings suggesting Zinner syndrome in a young patient with pulmonary embolism: A case report

A triad of seminal vesical cyst, ipsilateral renal agenesis and ipsilateral ejaculatory duct obstruction is known as Zinner Syndrome. First described in 1914, only about 200 cases have been reported in literature. Usually it stays undiagnosed until the second to third decade of life due to lack of symptoms or nonspecific symptoms such as lower urinary tract symptoms, dysuria or painful ejaculation. In this report we present the case of a 22-year-old patient with a Zinner syndrome as an incidental finding and underlie a review of literature to show the main clinical and imaging implications.

Incidental finding of Zinner syndrome in a Greek military recruit: a case report of a rare clinical entity

BACKGROUND

Zinner syndrome represents a rare congenital malformation of the urinary tract. It comprises a constellation of Wolffian duct anomalies and is almost exclusively encountered as a classic triad of seminal vesicle cysts, ejaculatory duct obstruction and renal agenesis. Patients can be either asymptomatic or symptomatic. Recently, minimally invasive surgical techniques have emerged, superseding traditional surgery for select symptomatic cases. Our case highlights the finding of a rare clinical syndrome that was incidentally detected during a routine mass screening of military recruits in the Greek Armed Forces.

CASE PRESENTATION

Herein, we present a case of a 19-year-old male who reported having a solitary right kidney when examined in a military training center of Northern Greece. No additional clinical information was available; thus, referral to a tertiary urology department for further investigation ensued. Imaging studies, namely, computed tomography and magnetic resonance imaging, revealed left renal aplasia, multiple left seminal vesicle cysts, and ejaculatory duct obstruction. Laboratory values and urinalysis were within normal range. Semen analysis was significant for cryptozoospermia. Our patient remained asymptomatic during the entire hospitalization. Long-term follow-up was recommended. Nevertheless, he declined further investigation and sought treatment in a private practice setting.

CONCLUSIONS

This article aims to present the incidental diagnosis of a rare syndrome in a military setting. Population screening conducted in the armed forces permits the identification of undiagnosed diseases that warrant further investigation. To the best of our knowledge, this was the first report of Zinner syndrome in a military recruit and the second case cited of a Greek patient in the published literature. Regular follow-up is the key to timely intervention in conservatively managed cases.

Zinner Syndrome in Pediatric Age: Issues in the Diagnosis and Treatment of a Rare Malformation Complex

Zinner syndrome (ZS) is the association of congenital seminal vesicle cysts and ipsilateral upper urinary tract anomalies, such as multicystic displastic kidney (MCDK). This condition is rare in pediatric age and both diagnosis and treatment are challenging. The aim of this study was to analyze the issues in diagnosis, management, and treatment of ZS in pediatric age. The medical records of two patients with ZS were examined. Furthermore, a review of the literature on this topic in pediatric age was performed. In our experience the diagnosis of ZS was incidentally achieved in the first months of life, as a consequence of studies performed for a prenatal diagnosis of MCDK. The first patient presented unspecific and transient symptoms, the second infant was completely asymptomatic. They were conservatively treated, with a long-term follow-up planned at least until adolescence. Fifty cases of ZS in pediatric age have been reported in the literature up to now. Only 12/50 were diagnosed in the first year of life. The diagnosis was demanding, as the clinical presentation was unspecific and the results at imaging studies needed a differential diagnosis with other retrovesical masses. More than 80% of these cases were asymptomatic at long-term follow-up. Therefore, a conservative management of ZS has been accepted for asymptomatic or poorly symptomatic patients, with occasional, transient, and unspecific symptoms, such as urinary tract infections or orchyepididimytis. As the surgical management is challenging, it is proposed only in those symptomatic patients. In conclusion, ZS is rare in pediatric age. However, it should be considered in the differential diagnosis of cystic masses within the pelvis in males with ipsilateral renal anomalies. A conservative treatment with a long-term follow-up is a safe option in the management of asymptomatic or poorly symptomatic patients, thus reserving the surgical approach only in those cases with symptoms.