Seminal vesicle abscesses associated with ipsilateral multicystic dysplastic kidney in an infant

Pediatric Zinner syndrome variants: Case series with newer insights into pathogenesis in early childhood

INTRODUCTION

Zinner Syndrome (ZS) is a rare congenital disorder characterized by seminal vesicle cysts (SVC) and ipsilateral upper urinary tract abnormalities, mainly due to developmental anomalies of the mesonephric duct. This series highlights our institutional experience with pediatric ZS, with a review of the current literature offering insights into its etiopathogenesis in early childhood.

MATERIAL AND METHODS

A retrospective case review of pediatric ZS diagnosed at our institution from 2019 to 2023, alongside a comprehensive literature review.

RESULTS

Four pediatric ZS cases were identified, a neonate, an infant and two older (pre-pubertal) children, presenting with recurrent epididymo-orchitis and/or UTIs. The two older children had duplex systems, both undergoing curative upper moiety heminephrectomy; the infant underwent nephroureterectomy and the neonate is under observation, asymptomatic for past 18 months.

DISCUSSION

When Zinner identified the link between unilateral renal agenesis and ipsilateral SVC in 1914, the condition's embryological basis was attributed to incorrect ureteric bud migration from the mesonephric duct, failing to stimulate the metanephros, leading to renal agenesis/dysplasia and this disruption was hypothesized to obstruct seminal vesicle drainage, causing cyst formation. Another theory suggests anomalous development of the distal mesonephric duct leading to ejaculatory duct atresia/stenosis which results in cystic enlargement of the seminal vesicles which, in turn, leads to aberrant ureteral budding, resulting in renal malformations. It is our belief that the SVCs, that are typically problematic in adolescence/adulthood due to secretion accumulation, sometimes manifest in childhood due to urinary reflux into the seminal vesicles, leading to epididymo-orchitis or UTIs. This contrasts with adult pathogenesis, where ejaculatory duct obstruction predominates. Hence, treatment leans towards a conservative approach for asymptomatic cases, with surgery reserved for symptomatic children. The scope of this case series is limited by the rare nature of ZS in prepubertal children (41 published cases in English literature), preventing a comprehensive understanding of its untreated natural history and restricting the formulation of generalized recommendations.

CONCLUSION

The variability in presentation of ZS in children necessitates a tailored approach. Unlike adults, where ejaculatory duct obstruction is the common cause, pediatric ZS symptoms mainly stem from urethra-cystic reflux, leading to recurrent infections.

Acute diffuse peritonitis secondary to a seminal vesicle abscess: A case report

BACKGROUND

Seminal vesicle abscess (SVA) is the manifestation of a relatively rare urinary system infection. In response to urinary system inflammation, an abscess forms in special locations. However, acute diffuse peritonitis (ADP) induced by SVA is unusual.

CASE SUMMARY

We report a case of a left SVA in a male patient complicated with pelvic abscess, ADP, multiple organ dysfunction syndrome, infectious shock, bacteremia, and acute appendiceal extraserous suppurative inflammation as a result of a long-term indwelling urinary catheter. The patient received a course of morinidazole + cefminol antibiotics but showed no obvious relief, so the perineal SVA underwent puncture drainage and abdominal abscess drainage + appendectomy was performed. The operations were successful. After the operation, anti-infection, anti-shock, and nutritional support treatments were continued and various laboratory indicators were regularly reviewed. The patient was discharged from the hospital after recovery. This disease is a challenge for the clinician because of the unusual spreading path of the abscess. Moreover, appropriate intervention and adequate drainage of abdominal and pelvic lesions are necessary, especially when the primary focus cannot be determined.

CONCLUSION

The etiology of ADP varies, but acute peritonitis secondary to SVA is very rare. In this patient, the left SVA not only affected the adjacent prostate and bladder but also spread retrogradely through the vas deferens, forming a pelvic abscess in the loose tissues of the extraperitoneal fascia layer. Inflammation involving the peritoneal layer led to ascites and pus accumulation in the abdominal cavity, and appendix involvement led to extraserous suppurative inflammation. In clinical practice, surgeons need to consider the results of various laboratory tests and imaging examinations to make comprehensive judgments involving the diagnosis and treatment plan.

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.

Transperitoneal Laparoscopic Unroofing versus Fenestration Under Seminal Vesiculoscopy for Seminal Vesicle Cyst, a Multi-Institutional Retrospective Cohort Study

Background

To illustrate the transperitoneal laparoscopic unroofing (TLU) and compare the efficacy and safety of TLU to fenestration under seminal vesiculoscopy (FUSV) in treating symptomatic seminal vesicle cyst (SVC).

Methods

We retrospectively reviewed all patients with symptomatic SVC who underwent TLU or FUSV between 2008 and 2020 at 3 institutions in Hunan. The two groups were evaluated with reference to radiological failure-free survival (R-FFS), fertility outcome, symptoms, and complications at a median 33.5-month follow-up.

Results

Of the 98 males, 58 (59.2%) received TLU, and 40 (40.8%) underwent FUSV. Baseline characteristics were comparable. Semen analysis, prostatitis-like symptoms, and the maximum diameter of cyst were partially improved after both surgeries at 12-month follow-up. The TLU groups suggested a higher incidence rate of fertility for SVC patients with comorbid infertility compared with the FUSV group (82.4% vs 70.3%, p = 0.041), as well as better R-FFS of cysts at five-year follow-up (Log rank test, p = 0.021). In addition, the number of patients with NIH-CPSI (National Institutes of Health Chronic Prostatitis Symptom Index) scores higher than 15 decreased more significantly after TLU (p = 0.004). Except for hematospermia within 3 months, no significant difference in adverse events was observed in the two groups during the long-term follow-up.

Conclusion

TLU was superior for patients with large and symptomatic SVC to FUSV, with more relieved symptoms, better R-FFS of cysts and fertility outcomes.

Registration Number of Clinical Trial

ChiCTR2100053850 in Chinese Clinical Trial Registry Platform (ChiCTR).