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The seminal vesicles were first described by Fallopius in 1561 (Brewster, 1985) as paired male organs. Primary pathology within the seminal

vesicles is rare, but secondary lesions are more common.In the past, insufficient imaging methods led to infrequent definition of eitherprimary or secondary seminal vesicle pathology. The use of ultrasonography, computed tomography (CT), and magnetic resonance

imaging (MRI) has improved diagnostic visibility and facilitated the diagnosis and treatment of seminal vesicle pathology.The necessitof surgical intervention is rare but includes congenital cysts with infection and/or obstruction causing infertility, ureteral ectopy into a seminalvesicle with resultant obstruction or dysplasia of the ipsilateral kidney, and primary tumors, either benign or malignant. Surgical access to theseminal vesicles is mostly via routes familiar to the urologic surgeon, but surgery on the seminal vesicles alone (without adjacent organ removal)a unique challenge.

Embryology

Normal Development

An understanding of the normal embryologic development of the seminal vesicles is necessary for the diagnosis and treatment of diseasesinvolving these structures. The seminal vesicle, a strictly male organ (no female homologue), develops as a dorsolateral bulbous swellin

of the distal mesonephric duct at approximately 12 fetal weeks(Arey, 1965; Brewster, 1985). Initially, the cloaca is subdivided by downward

growth of the urorectal septum into the posterior anal canal and the anterior urogenital sinus ( Fig. 1091A). The division is completed around the

seventh week. The mesonephric duct (wolffian duct) is thus included in an area called the vesicourethral canal within the urogenital sinus. Theureter is a bud originating from the mesonephric duct at 4 weeks that eventually attains a separate opening into the bladder by absorption andcranial migration (Fig. 1091B). The mesonephric duct becomes the vas deferens, which normally drains into the urethra at the ejaculatory duct

where it is surrounded by the prostatic glands. Separate symmetrical buds extend from the distal mesonephric duct just proximal to theejaculatory duct at approximately 12 weeks to form the seminal vesicles(Fig. 1091C).

Embryologic Abnormalities

Developmental anomalies form by alteration of this orderly process. If the ureteral bud arises too far cranially on the mesonephric duct, it will beabsorbed late. This results in failure to meet the metanephric blastema, thus leading to renal dysplasia or agenesis and causing the ureter to ente

ectopically anywhere along the vas deferens or posterior urethra (Tanagho, 1976; MacDonald, 1986). Gordonand Kessler (1972) showed tha50% of ectopic ureters in males enter the posterior urethra, whereas 30% join the seminal vesicle. The remainder enter the vas deferenor the ejaculatory ducts. Because formation of the seminal vesicles occurs at week 12 of embryogenesis, an alteration in ureteral buddevelopment from the mesonephric duct may have an impact on formation of the seminal vesicles. There is an association between absence ofthe seminal vesicle and ipsilateral renal anomalies. This is discussed later.

Physiology

The physiologic role of the seminal vesicle is not entirely known; however, the secreted fluid is important in the motility and metabolism ofejaculated sperm. The secretions from the seminal vesicle contribute approximately 50% to 80% of the ejaculate volume, with an averagvolume of 2.5 mL and a pH in the neutral to alkaline range.Seminal vesicle secretions primarily contain carbohydrates such as fructose, anecessary component for sperm motility, and prostaglandins E, A, B, and F, as well as a coagulation factor (Tauberet al, 1975, Tauberet al,

1976). A 52-kDa protein, semenogelin 1, has been identified. It is postulated that this is a sperm motility inhibitor and is cleaved by a proteolytic

enzyme, prostate-specific antigen (PSA), after ejaculation (Robertand Gagnon, 1999).

Anatomy

General Description

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The normal adult seminal vesicle is 5 to 10 cm in length and 3 to 5 cm in diameter. The volume capacity of the seminal vesicle averages 13 mL.The right gland is slightly larger than the left in one third of men, but the size of both decreases with advancing age ( Redman, 1987). There are

three major anatomic types; the most common type contains one central canal with minimal tortuosity and only a few side branches (Aboul-Azm

1979). The major canalof the seminal vesicle empties into the ejaculatory duct (average length of 2.2 cm) at the terminal portion of the vasdeferens within the prostate. Histologically, the ejaculatory ducts are a continuation of the seminal vesicles. However, the thick muscle wall of theseminal vesicle is not present within the ejaculatory duct. Normal ejaculatory duct luminal and wall dimensions are remarkably uniform amongmen. Statistically, a luminal diameter of greater than 2.3 mm defines a dilated system (Nguyenet al, 1996).

Vasculature and Innervation

The blood supply to the seminal vesicle is from the vesiculodeferential artery, a branch of the umbilical artery(Braithwaite, 1952).

Occasionally, the inferior vesicle artery provides a communicating vessel. Venous drainage is from the vesiculodeferential veins and theinferior vesical plexus. The seminal vesicles are innervated by the pelvic nerve and the hypogastric nerve. The hypogastric nerve sends bothadrenergic and cholinergic fibers to the seminal vesicles (Mawhinneyand Tarry, 1991). Lymphatic drainage is via the internal iliac nodes.

Diagnosis

The diagnosis of seminal vesicle neoplasms can be difficult because they often do not cause symptoms until late in their course.General symptoms that may occur include urinary retention, dysuria, hematuria, or hematospermia. A mass is often palpable above the prostateand is usually not tender. Transrectal ultrasound (TRUS) is usually the next step in diagnosis and may be accompanied by needle aspiration orbiopsy for diagnosis. CT or MRI would then be appropriate to stage the patient. Because prostate cancer may be mistaken for primary seminalvesicle cancer, serum PSA and prostatic acid phosphatase (PAP), as well as tissue immunohistochemical stains for both enzymes, should, ifpositive, help define the prostate as the site of primary malignancy.

Physical Examination and Laboratory Testing

Physical diagnosis and vasography were once the only diagnostic tools available for studying the seminal vesicle. TRUS, CT, and MRIhave each added substantially to examination and diagnosis of pathologic conditions of the seminal vesicle.

The normal seminal vesicle and adjacent ducts are not palpable in the normal male.On rectal examination, the area directly craniad to thebase of the prostate where the seminal vesicles reside is soft and nondescript. The seminal vesicles lie anterior to the surrounding relatively thickand inelastic two layers of Denonvilliers' fascia, but no anatomic detail of the vesicles or ducts is usually appreciated by palpation even if theglands are asymmetric. The area immediately above the prostate on rectal examination may be enlarged and relatively compressible in thepresence of a seminal vesicle cyst or solid and firm if there is a seminal vesicle tumor. These lesions may compress the bladder base anteriorlyinstead and, thus, may not be readily palpable. Secondary involvement of the seminal vesicle from prostate or bladder pathology is palpated ashard areas above the prostate but may not be absolutely definable on physical examination.

Laboratory examination of seminal vesicle fluid requires obtaining a semen sample and testing directly for exclusively seminal vesicle excretionssuch as fructose, and indirectly by measuring the volume and observing liquefaction of the semen sample. A low semen volume and a lack ofboth fructose and liquefaction implies either absent seminal vesicles or ejaculatory duct obstruction. Although the terminal portion of theejaculate originates from the seminal vesicles, split ejaculate bacterial cultures are more likely contaminated by multiple other sites along the lowurinary tract and, thus, are not useful for localizing the site of infection (Stamey, 1980). TRUS-guided perineal aspiration cultures and abscess

drainage have been successful, however (Leeet al, 1986).

Ultrasound

Ultrasound (US), by either the transabdominal or the transrectal (preferred) route, has become one of the most accurate methods ofevaluating the seminal vesicle. The advent of probes with high resolution at short focal lengths has allowed rapid, noninvasive, inexpensive, anaccurate seminal vesicle examination in an outpatient setting.

The normal seminal vesicle on TRUS is an elongated, flat, paired structure between the rectum and the bladder just superior to theprostate (Fig. 1092).The seminal vesicle appears predominantly symmetrical and is smooth with apparent saccularity. The center of the

seminal vesicle is echopenic, with occasional areas of increased echogenicity relating to luminal folds within the vesicle itself (Carteret al, 1989)

The ampulla of the vas can usually be seen, particularly near the prostate, as a tortuous tube on sagittal scans. The ejaculatory duct may also beseen within the substance of the prostate. The verumontanum is characteristically seen as a more densely echoic structure in the midline at thetermination of the ejaculatory ducts. Although sagittal images are best for examining the length of seminal vesicles and adjacent ductulaanatomy, transaxial scans are best for detecting symmetry and volume.TRUS of the seminal vesicles does not require any specialpreparation, although a half-full bladder allows easier differentiation of the vesicles and adjacent structures.

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Abnormal findings on TRUS include seminal vesicle aplasia, atrophy, obstruction, or cyst formation.Aplasia and atrophy are commonlyassociated with infertility in up to 2.5% of infertile men (Carteret al, 1989). TRUS-guided seminal vesiculography is a technique that couples US

with radiography to evaluate male-factor infertility secondary to obstruction. Seminal vesiculography helps image the distal male reproductive tra(vas deferens, seminal vesicles, ejaculatory ducts) and has been found to be an improvement over standard vasography ( Joneset al, 1997).

Findings consistent with obstruction include anteroposterior diameter more than 15 mm, length longer than 35 mm, andlarge anechoic areascontaining sperm on aspiration (Jarow, 1996; Colpiet al, 1997).

Cysts, although quite rare, may be congenital and associated with an ipsilateral ectopic ureter and/or an aplastic kidney, or acquired as a result oobstruction after transurethral prostatectomy. However, in one study, 5% of men screened for prostate cancer were found to have asymptomaticcystic dilation of the seminal vesicles (Wesselset al, 1992). The majority of patients with a seminal vesicle cyst are asymptomatic; however, they

may present with urinary tract symptoms including dysuria, painful ejaculation, hematospermia, or recurrent epididymitis. US reveals these cysticlesions to be anechoic masses within the substance of the seminal vesicle or larger anechoic saccular lesions that might rise out of the pelvis andisplace the bladder and other pelvic structures (Steersand Corriere, 1986). Ultrasonography can be used to guide needle placement for drainag

or contrast studies to more fully delineate the lesion (Shabsighet al, 1989). US has also been used to attempt to differentiate inflammatory

conditions of the seminal vesicle; however, other than calcifications with chronic bilharziasis, TRUS findings in patients with chronicprostatourethritis or prostatodynia are relatively nonspecific (Littrupet al, 1988).

Sonographic findings of a tumor within the seminal vesicle depend on whether the tumor is primary or secondary. Primary tumors areusually unilateral, whereas secondary tumors more likely involve both seminal vesicles and may be difficult to distinguish as to their origin (i.e.,from the rectum, bladder, or prostate). The TRUS image of a solid tumor is isoechoic to the prostate but relatively hyperechoic with respect to thenormal seminal vesicle. There are no image characteristics indicative of benign versus malignant or primary versus secondary tumors,except that primary tumors are commonly unilateral and tend not to be contiguous with the prostate, whereas prostate cancer invading the seminvesicle may be at the base of both seminal vesicles and contiguous with the prostate tumor. US-guided transrectal or perineal aspirationcytologies or core biopsies can be useful to pathologically diagnose a seminal vesicle neoplasm.

Computed Tomography

CT is a considerable improvement over conventional radiography for evaluation of the pelvis. Evaluation of seminal vesicle pathology by CT,however, has not been systematically studied. Silvermanand colleagues (1985) reviewed a group of 50 patients with normal seminal vesicles by

CT and determined that mean length was 3.1 cm, width 1.5 cm, and overall area 3.6 cm. The volume tended to decrease with age, and the shapvaried from ovoid (70%) to tubular (20%) to rounded (10%). The seminal vesicles were symmetrical in 67% of those studied. The seminalvesicles themselves are medium contrast structures (similar to muscle) routinely seen directly below the bladder.The surroundingDenonvilliers' fascia is not discernible on CT. Goldsteinand Schlossberg (1988) studied CT in patients who had absent vas deferens and found

that not all had absent seminal vesicles; they concluded that CT was accurate for detection of the presence of seminal vesicles. CT has beenused to detect congenital anomalies, and perhaps this may be its best use in seminal vesicle diagnosis (Fig. 1093). Cystic structures

have CT attenuation numbers (Hounsfield units) from 0 to 10 like most clear fluid-filled structures, although the density may be higher secondaryto debris, pus, or hemorrhage.

Tumor within the seminal vesicle is readily seen on CT as an enlarged vesicle with a higher CT attenuation number in the area of thetumor mass than in normal seminal vesicle and with a normal bladder and prostate(Fig. 1094). The lesion may be cystic, however, as a

result of tumor necrosis (Kinget al, 1989). CT cannot distinguish between benign and malignant tumors and cannot routinely distinguish

between primary and secondary tumors,although tissue planes are usually obliterated by secondary tumors invading from prostate or rectum(Sussmanet al, 1986). Inflammatory masses in the seminal vesicles, such as tuberculosis or old bacterial abscesses, can be calcified (Pateland

Wilbur, 1987; Schwartzet al, 1988; Birnbaumet al, 1990) and thus distinguished from tumors, although a history of infection and related

symptoms can usually be elicited. A long-term history of diabetes mellitus has also been associated with seminal vesicle calcification (Kinget al,

1989).

Magnetic Resonance Imaging

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Although MRI is not, in general, more sensitive than CT or US for diagnosis,the anatomic relationships are more clearly seen, multiplanarimaging is readily available, and the minimal amount of fat in the pelvis and the characteristics of the MR phenomenon (T1- and T2-weightedimage) allow for more definitive diagnosis of cystic lesions and more accurate staging of solid neoplasms in the pelvis.Normally, theanatomic relationships of the seminal vesicles are similar to those shown on CT except that on T1-weighted images, seminal vesicles are oflow signal intensity, which increases substantially on T2-weighted images (Fig. 1095).This is thought to be secondary to the secretions

present in the ductular lumen of the seminal vesicle. The surrounding Denonvilliers' fascia is of low intensity on both T1- and T2-weighted imagesIn general, T2-weighted images have signal intensities that are lower than that of fat in prepubertal children, similar to or higher than that of fat inadults, and similar to or lower than that of fat in patients older than 70 years. Endocrine and radiation therapy influence the size and intensity of tseminal vesicles (Secafet al, 1991). Seminal vesicle cysts are similar to cysts in other locations in that the T1-weighted image is of low intensity

but the T2-weighted image is that of a unilocular smooth wall with a uniform high intensity and well-defined margin ( Gevenoiset al, 1990; Hihara

al, 1993). Hemorrhagic cysts have highintensity signal on both T1- and T2-weighted images (Sueet al, 1989). Seminal vesiculitis shows

decreased signal intensity on T1-weighted image, whereas T2-weighted image intensity is higher than that of both fat and the normal seminalvesicle.

MRI of seminal vesicle tumors shows a heterogeneous mass with a medium intensity on T1-weighted image and a heterogeneous intensity on Tweighted image. There has been no systematic MRI study of seminal vesicle tumors, and MRI cannot distinguish between benign and malignantsolid masses within the seminal vesicle.

Patients with a suspected seminal vesicle abnormality or mass felt on rectal examination should first have TRUS. If the mass is solid annoncystic, a transperineal or TRUS-guided biopsy is a reasonable next step. If the tumor is confirmed, a CT scan should be done next for stagingpurposes; MRI is necessary only to confirm the hemorrhagic nature of the mass or to more definitively stage the extent of the mass to contiguousorgans within the pelvis. Definitive treatment for most seminal vesicle lesions, however, can be appropriately determined without MRI.

Vasography

Vasography,accomplished either by transurethral contrast injection at the seminal colliculus or by surgical exposure of the scrotal vas followed contrast injection, was once the preferred means to image the seminal vesicles (Fig. 1096).Transurethral routes of injection were often

unsuccessful owing to the length of time, special equipment, and expertise required. Antegrade injection through the surgically exposed vas ishighly successful, particularly in evaluating duct obstruction in azoospermic individuals or those with prior surgical trauma (Al-Omariet al, 1985).

Vasography does not, however, provide accurate demonstration of the pathology of the seminal vesicles in patients with vesiculitis,cysts, or tumors(Dunnicket al, 1982; Kinget al, 1989). Direct transrectal needle seminal vesiculography has also been reported as a method f

diagnosis or drug delivery but is not recommended for routine cases (Meyeret al, 1979; Fuseet al, 1988).

Pathology

Congenital Lesions

Agenesis of the Seminal Vesicles

Unilateral agenesis of the seminal vesicles is not uncommon, with an incidence of 0.6% to 1%. It may be associated with unilateralabsence of the vas deferens, as well as ipsilateral renal anomalies (Fig. 1097). This is thought to result from an embryologic insult before

the separation of the ureteral bud from the mesonephric duct, which typically occurs at 7 weeks' gestation. It is felt that if the insult occurs after 7weeks' gestation, then the seminal vesicle anomaly may not be associated with renal agenesis (Halland Oates, 1993). The frequency of

associated renal anomalies varies, but in one series, 79% of patients with absence of a seminal vesicle and/or vas deferens had ipsilateral renalagenesis, 12% ipsilateral renal abnormalities, and only 9% had normal kidneys bilaterally ( Donohueand Fauver, 1989).

Bilateral absence of the seminal vesicles is frequently found in association with congenital bilateral absence of the vas deferens

(CBAVD).This is commonly associated with a mutation of the cystic fibrosis transmembrane receptor (CFTR). Seventy to eighty percent of menwith bilateral absence of the vas and/or seminal vesicles are carriers for the genetic mutation associated with cystic fibrosis (Anguianoet al, 199

Chillonet al, 1995). Conversely, 80% to 95% of men with cystic fibrosis have bilateral absence of the vas deferens or seminal vesicles ( Holsclaw

et al, 1971; Boatet al, 1989). In men who have genitourinary anomalies with CBAVD/seminal vesicle agenesis, the incidence of CFTR mutation

extremely low (de la Tailleet al, 1998). However, lack of a vas deferens does not necessarily imply an absent seminal vesicle unless the ipsilate

ureter is also not present (Goldsteinand Schlossberg, 1988). Seminal vesicle agenesis requires no treatment.

Obstruction of the Seminal Vesicles

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Whereas absence of the seminal vesicles may be asymptomatic, obstruction is frequently associated with symptoms. Unilateral obstruction maybe due to entrance of an ectopic ureter, leading to infection of the obstructed organ. The kidney associated with the ectopic ureter is frequentlydysplastic. Obstruction may also be due to local invasion of bladder or prostate cancer (Fig. 1098). Bilateral obstruction (Fig. 1099) is frequent

associated with infertility (Donohueand Fauver, 1989; Halland Oates, 1993). Several authors have described diagnosis of obstruction with the

use of TRUS and aspiration/injection of the seminal vesicles (Joneset al, 1997; Orhanet al, 1999; Seifmanet al, 1999). This is covered in furthe

detail in the chapter on male infertility.

Infection

Vesiculitis

Infection of the seminal vesicles is an uncommon problem in the United States. In less developed countries, tuberculosis and schistosomiasisremain common causes of seminal vesicle masses, abscesses, and calcification. Chronic bacterial vesiculitis is rare and difficult to diagnose;however, transrectal/perineal needle aspiration for diagnosis or treatment of abscesses has been successful. Bacterial infections are commondue to colonic flora and are thought to be secondary to bacterial prostatitis.In the distant past, bilateral seminal vesiculectomy was used atreatment for infections of the seminal vesicle, but today, selected systemic antibiotics are usually curative, obviating surgery (Gutierrezet al,

1994). Occasionally, chronic bacterial seminal vesiculitis may require surgical removal to eliminate symptoms and to prevent recurrent septicemiAny of the surgical approaches to be described subsequently would be appropriate ( Indudharaet al, 1991).

Abscess

Abscesses of the seminal vesicles usually have an unknown etiology, although predisposing factors include diabetes mellitus, chroniindwelling catheter, and endoscopic manipulation.Signs and symptoms vary but are typically related to inflammation. Conservative drainagevia a percutaneous route is occasionally successful, but most abscesses of the seminal vesicles require open drainage (Gutierrezet al, 1994;

Koreet al, 1994). Imaging of the abscess is best accomplished with MRI, owing to the high fluid content of the seminal vesicles. In contrast to the

normal hypointense T1-weighted image, inflammation results in a less intense image. The normally hyperintense signal found on a T2-weightedimage is increased further with inflammation. The use of systemic gadolinium/diethylenetriamine pentaacetic acid offers better enhancement andvisualization (Chandraet al, 1991; Doringeret al, 1991).

Calculi

Stones within the seminal vesicles are usually related to obstruction, infection, or both(Li, 1991; Wilkinson, 1993). Patients usually prese

with either pain or infection related to the stone, although hematospermia or infertility can be the presenting complaint. Treatment requiresremoval of the stone, usually through an open vesiculectomy. Adjuvant treatment with antibiotics may be necessary, particularly in cases ofsystemic infection.

Masses

Most masses within the seminal vesicles are not neoplastic. Tumors of the seminal vesicles are extremely rare. Benign primary tumorare the most common, including papillary adenoma, cystadenoma, fibroma, and leiomyoma (Mostofiand Price, 1973; Lundhuset al, 1984;

Narayana, 1985; Mazuret al, 1987; Bullock, 1988). Simple cysts of the seminal vesicleare seen not uncommonly and may be associated w

other genitourinary anomalies, such as ipsilateral renal agenesis or malformation (Lynchand Flannigan, 1992; Sheihet al, 1993).

Seminal Vesicle Cysts

Cysts of the seminal vesicles (see Fig. 1099) may be either congenital or acquired(Kinget al, 1991) and are felt to be due to obstructio

of the ejaculatory duct(Heaneyet al, 1987; Connet al, 1992). Numerous authors have reported an association between seminal vesicle

cysts and other abnormalities, including renal agenesis(Kimchiand Wiesenfeld, 1963; Roehrbornet al, 1986), infertility(Nazliet al, 1994),hematospermia(Mayersakand Viviano, 1992; Wanget al, 1993), and genitourinary infection(Beeby, 1974; Roehrbornet al, 1986; Lynchan

Flannigan, 1992).

Others have reported an association between seminal vesicle cysts and adult polycystic kidney disease (Alpernet al, 1991; Hiharaet al, 1993;

Hendryet al, 1998). In contrast to typical benign cysts, some feel that the pathogenesis of these cysts associated with polycystic kidney disease

due to a general defect in the basement membrane of multiple organs, including the seminal vesicles. One report cited the presence of seminalvesicle cysts in 60% of patients with polycystic kidney disease (Danaciet al, 1998). These authors, as well as others, recommend that all patient

with cysts of the seminal vesicles have imaging of their kidneys to rule out polycystic kidney disease (Alpernet al, 1991; Danaciet al, 1998;

Hendryet al, 1998).

Unless these cystic lesions are symptomatic, treatment is not usually necessary(Suryaet al, 1988). If the lesion causes symptoms,

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percutaneous transperineal drainage of the cysts with TRUS guidance can be successful (Kirkaliet al, 1991; Wanget al, 1993); if not, open

surgical excision may be necessary. If an ectopic ureter is present, a nephroureterectomy, including removal of the seminal vesicle, should becurative.

Benign

Papillary Adenoma/Cystadenoma

These may mimic simple seminal vesicle cysts in their presentation and imaging. They generally occur in middle-aged men and involve one sideonly one case of bilateral involvement has been reported (Mazuret al, 1987). Some feel that it originates from embryologic remnants (Tocket al

1991; Mazzucchelliet al, 1992; Ranschaertet al, 1992). Open surgical removal is the treatment of choice because preoperative diagnosis is rare

made.

Amyloid of the Seminal Vesicles

Subepithelial deposits of amyloid in the seminal vesicles have been reported in 4% to 17% of male autopsies, with an incidence up to20% in men older than 76 years(Pitkanenet al, 1983; Ramchandaniet al, 1993). Because of increased incidence in the older population, it is

frequently present concomitant with other conditions, such as bladder or prostate cancer. Therefore, it is possible to misinterpret enlargement ofthe seminal vesicles from senile amyloidosis as carcinomatous invasion. MRI of the pelvis can usually distinguish tumor invasion, although notwith complete accuracy (Kajiet al, 1992). In contrast to senile amyloidosis, the systemic form of amyloidosis may involve multiple organ systems

with amyloid deposits in the blood vessels and muscle cells as opposed to the subepithelium (Coyneand Kenly, 1993). If patients are

asymptomatic, no treatment is necessary.

Malignant

The main difficulty encountered with seminal vesicle neoplasms is determining that they are, in fact, primary within the seminalvesicles. Indeed, it is more common for carcinoma of the bladder, adenocarcinoma of the prostate, lymphoma, or rectal carcinoma to secondarilinvolve the seminal vesicle (Mostofiand Price, 1973; Jakseet al, 1987; Roet al, 1987).

Very few primary tumors of the seminal vesicles have been reported. This is due in part to the paucity of symptoms and the lack of detection onphysical examination for small, benign tumors; it was also once due to the lack of diagnostic imaging capable of accurately depicting the seminalvesicles. It is surprising that a tumor arising from an analogue similar to that of the prostate and responding to similar hormonal influences has sofew recognized pathologic conditions. Perhaps the extremely low proliferative activity of seminal vesicle epithelium partly accounts for this (Meye

et al, 1982).

Adenocarcinoma

Characteristics of a primary seminal vesicle adenocarcinoma include (1) occurrence in patients older than 50 years; (2) tumor usually extendinglocally into prostate and bladder and/or rectum; (3) commonly, prostatic and/or ureteral obstruction; (4) pathology revealing a mucin-producingpapillary or anaplastic carcinoma that may also contain lipofuscin in a patient with no other pelvic primary tumor; (5) normal serum markers forprostate cancer (PSA, PAP); and (6) elevated serum carcinoembryonic antigen (Mostofiand Price, 1973; Bensonet al, 1984; Tanakaet al, 1987

Chinoyand Kulkarni, 1993). Positive staining for cancer antigen 125 has been reported and may be useful to distinguish this from other

adenocarcinomas, such as that of the prostate or bladder (Ohmoriet al, 1994; Ormsbyet al, 2000).

Sarcoma

Sarcomas of the seminal vesicles have been reported by various authors and are extremely rare.They are usually diagnosed late in thecourse of the disease. There are no distinguishing features except for biopsy findings (Bensonet al, 1984; Chiouet al, 1985; Schnedet al, 1986

Tanakaet al, 1987; Daviset al, 1988; Kawaharaet al, 1988). These include leiomyosarcoma (Amirkhan, 1994) and angiosarcoma (Lamontet al

1991), as well as mllerian adenosarcoma-like tumor (Laurilaet al, 1992). These all display aggressive behavior. Treatment is similar to that for

carcinoma, with radical extirpation yielding varying results.

Other Pathology

Other pathology includes hydatid cyst(Kuyumcuogluet al, 1991) and carcinoid(Soyeret al, 1991). Other primary malignant tumors of the

seminal vesicles that have been reported include cystosarcoma phyllodes(Fain, 1993) and primary seminoma(Adachiet al, 1991). Hydatid

disease affecting the seminal vesicles can cause hematospermia, infertility, infection, or pain. Carcinoid of the seminal vesicle appearshomogeneous with intense enhancement on CT. On MRI, hypointense images are demonstrated on both T1- and T2-weighted images, with T2-weighted images demonstrating heterogeneity (Soyeret al, 1991).

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Treatment

If a solid lesion identified in the seminal vesicle shows no evidence of local spread and is benign on biopsy, treatment depends onsymptoms.If the patient is asymptomatic, close follow-up consisting of repeat rectal examination and TRUS to determine subsequent growth ofthe tumor is reasonable, although it may be difficult to be certain the tumor is not malignant. If the mass enlarges or if the patient has symptomsreferable to the mass, simple seminal vesiculectomy is advisable. This may be accomplished through one of several routes described later.

If the mass is quite large, is solid, and has questionable margins, or if the biopsy shows malignant columnar or poorly differentiated carcinoma

cells, the treatment of choice is quite different. Because fewer than 10 cases of primary tumors of the seminal vesicles have been treated aany one institution, it is difficult to define optimal treatment with any degree of certainty. Radical excision, which usually includes acystoprostatectomy with pelvic lymphadenectomy, is the treatment of choice unless the tumor is extremely small.This recommendation isbased on the extensive nature of the majority of the cancers when detected. The excision may include the rectum (total pelvic exenteration) if it isthought to be invading the surrounding structures. Adjuvant therapy has no proven efficacy, although the only long-term survivors in the literaturehad radical surgery with subsequent pelvic radiation therapy or androgen deprivation therapy. No chemotherapeutic regimen is known to beefficacious.

Surgery

Surgical approaches to the seminal vesicle have varied considerably since the first seminal vesicle was removed by Ullmann in 1889 ( de Assis,

1952). Descriptions of large series (up to 700 by one surgeon) of seminal vesiculectomies have been describedmost for tuberculosis orsuspected inflammation. Today, seminal vesiculectomy is rarely necessary. The most useful open surgical methods include transperineal,

similar to radical perineal prostatectomy; transvesical, achieved by incising through the posterior bladder wall; paravesical; retrovesical; ortranscoccygeal. The choice of surgical approach depends partly on the characteristics of the lesion to be treated but probably more on theexperience and expertise of the surgeon. For the most part, congenital lesions require an abdominal approach so that the ipsilateral kidnecan be dealt with concomitantly, if necessary. Benign or very small malignancies could be approached perineally; however, the risk ofimpotence is high even if a nerve-sparing approach is attempted. Larger benign tumors or cysts are best handled by an anterior abdominalapproach, although a transcoccygeal method may be as useful. Patients with malignancy require radical extirpation, which commonly includescysto-prostato-seminal vesiculectomy and pelvic lymphadenectomy. This operation is no different from a routine procedure for bladder cancer anthus, is not described here.

Indications

Most surgeries on seminal vesicles are in conjunction with radical surgical treatment of pelvic neoplasmssuch as bladder, prostate, orurethral cancer and, occasionally, with treatment of rectal cancer. The indications and surgical principles entailed for treatment of these conditionare detailed in other chapters in this book.

Treatments of conditions of the seminal vesicles alone are limited to (1) transperineal/transvesical aspiration of seminal vesicle cysts orabscesses, (2) transurethral unroofing of seminal vesicle cysts or abscesses, (3) laparoscopic dissection, and (4) open resection of one or bothseminal vesicles.

Preoperative Preparation

Preoperative preparation for open seminal vesicle surgery depends on the extent of the pathology and the planned incision.Transperineal, transcoccygeal, and transvesical approaches should be prefaced by a complete bowel preparation. We use a mechanicalpreparation with GoLYTELY orally the evening before surgery, followed by the standard antibiotic regimen, including oral neomycin/erythromycinThis is in anticipation of the uncommon, but not unlikely, possibility of a rectal laceration. A prophylactic systemic antibiotic of choice isadministered perioperatively (i.e., immediately before surgery and for 36 hours after). Some method of attempted prevention of phlebothrombosisin the legs, such as use of intermittent compression stockings during and immediately after surgery, is advisable. The blood loss expected from

seminal vesicle surgery depends on the surgical approach used. One to two units should be prepared for perineal and transcoccygeal approacheand two to three units for an anterior approach. Autologous blood can be obtained because these operations are rarely emergencies.

Open Surgical Techniques

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Indications for an open technique are uncommon; however, we include the following descriptions for historical interest as well as completeness othis chapter.

Patients with chronic seminal vesiculitis or a small benign tumor of the seminal vesicle can have a seminal vesiculectomy via theperineal route,similar to a radical perineal prostatectomy. Large benign tumors or cysts require removal through either an anterior incisioor a transcoccygeal approachbecause the perineal route limits the ability to reach more than a few centimeters craniad to the bladder neck or physically remove large masses through the relatively small opening.

Patients with an ectopic ureter into a seminal vesicle cyst require an anterior approachso that the kidney, ureter, and seminal vesicle canbe removed completely. We prefer a midline incision so that the kidney and ureter can be approached transperitoneally after mobilizing the colonThe ureter can then be followed and dissected from the bladder in a paravesical approach, similar to performing a nephroureterectomy forurothelial cancer.

Transperineal Approach

The transperineal approach follows the standard positioning and incision described for a radical perineal prostatectomy.To find theseminal vesicles above the prostate, the rectal wall needs to be dissected free and released higher on the base of the prostate and seminalvesicles than is usually necessary for initiation of radical prostatectomy. The incision in Denonvilliers' fascia is then made either transversely, jusabove the level of the base of the seminal vesicles on the prostate (Fig. 10910), or vertically, if attempting to save the neurovascular bundles

responsible for potency (Weldonand Tavel, 1988). In this latter case, Denonvilliers' fascia is carefully dissected laterally away from the underlyin

seminal vesicle and ampulla of the vas so as not to tear the longitudinal tissue carrying the neurovascular bundle. The dissection at the base ofthe seminal vesicle may be enhanced by posterior traction on a Lowsley tractor placed through the urethra into the bladder, thus elevating theprostate and putting tension on Denonvilliers' fascia. The two ampullae of the vas deferens should easily be dissected directly above the prostate

and just under Denonvilliers' fascia. They are somewhat friable but can be clipped with metal clips (not placed too tightly) if necessary. In the caof a simple seminal vesicle cyst or small adenoma, the vas can be spared, and the dissection then proceeds to the vesicle of concern . If threason for surgery is cancer or recurrent infection, a wider resection, including the ampulla of the vas, may be advisable.If the diagnosis benign, the dissection can begin directly on the seminal vesicle. There is usually an easily dissected plane that can be found along the seminavesicle, surrounding retroperitoneal tissue, and Denonvilliers' fascia. After dissection around the seminal vesicle at the base of the prostate, it isusually possible to pass a right-angle clamp around the seminal vesicle and use an absorbable 20 suture to ligate the stump of the seminalvesicle directly on the prostate. A second tie or clip on the distal seminal vesicle will keep the secretions from obscuring the field after the vesiclecut across, which is the next step. Although some surgeons may prefer to attempt to dissect out the seminal vesicle completely before ligating itsentry into the prostate, this makes the operation more difficult and lengthy and serves no useful purpose when the seminal vesicle is beingremoved for a benign condition. Once the seminal vesicle has been ligated and cut across at the base, an Allis clamp can be used on the cut edgto put counter-traction on the seminal vesicle so that spreading dissection with Metzenbaum scissors can free the seminal vesicle from thesurrounding tissue. The vascular pedicle is usually encountered within 1 cm of the distal tip, and, after it is ligated with metal clips and cut acrossthe organ can be removed. The wound is then closed in layers exactly as outlined for a radical perineal prostatectomy. A Penrose drain is left inthe bed of the seminal vesicle and removed within 24 hours if no drainage is noted.

The perineal approach is extremely well tolerated by patients and affords them minimal blood loss, early ambulation, and minimalpostoperative pain.Because there is no urethral anastomosis, patients may be ready for discharge within 24 to 48 hours. Intraoperativecomplications primarily entail inadvertent rectal wall laceration, although it is possible to lacerate the trigone area of the bladder or the ipsilateralureter during deep dissection of the distal tip of the seminal vesicle. If an adequate bowel preparation has been given preoperatively and no grosfecal contamination is seen, a two-layer closure of the rectum using a running mucosal layer of 30 absorbable suture and a submucosal layer ointerrupted 40 silk is usually sufficient. Anal dilation before awakening the patient may be useful. A large laceration and/or fecal contaminationshould cause consideration of a temporary colostomy, although such a measure has not been necessary in our experience. If a bladder injury isnoted, it should be closed in two layers with absorbable suture as in any bladder incision and a urethral catheter left indwelling for 7 to 10 dayspostoperatively. If a ureteral injury occurs, an attempt to place a self-retaining (double-J) catheter should be made and the ureter then repairedwith absorbable suture. If the ureter cannot be catheterized, flexible cystoscopy and retrograde placement of a ureteral stent should be performeon the table with the stent left in place for 10 to 14 days postoperatively.

Transvesical Approach

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The transvesical approach to the seminal vesicle has been described by numerous authors(Walkerand Bowles, 1968; Politanoet al,

1975). A midline extraperitoneal suprapubic incision is made up to the umbilicus, and the rectus muscles are separated on the midline. Retzius'space is opened by downward displacement of the transverse fascia on the pubis, and an Omni retractor is placed to expose the anterior bladdewall. Care is taken during this dissection to not injure the epigastric vessels on either side of the pubis. The bladder is opened longitudinallyapproximately 7 to 10 cm, ending 2 to 3 cm away from the bladder neck. Moist 4 8 sponges are placed on the bladder wall laterally and at thedome of the bladder, and specialized blades are placed to put the open bladder on stretch. Although it is not absolutely necessary, it is preferableto place long 8 F feeding tubes in the ureters at this point for definition of the orifices and to help with identification of the subtrigonal ureters toprevent their injury later in the dissection. Using a Bovie cutting stylet, a vertical incision is made through the trigone on the posterior midlineapproximately 5 cm in length (Fig. 10911A). Alternatively, a transverse incision just above the bladder neck can be used, but it is not preferred

(Fig. 10911B). The vertical incision is deepened through the bladder muscle, and the ampullae of the vas should be recognized directly beneath

the bladder neck. They can be dissected by scissors down to their entrance into the prostate and then either ligated and divided or left intactdepending on the pathology, as described in the perineal approach. Just lateral to the ampullae on the prostate base, the seminal vesicles shouldbe identified and the plane surrounding them entered easily unless there has been prior inflammatory disease. The seminal vesicles should beencircled and dissected completely free. Metal clips should be placed on the vascular pedicle and a 20 chromic tie on the distal end at theprostate. A clip is placed across the proximal end of the vas to prevent seminal vesicle contents from obscuring the field, and then the vesicle istransected and removed. If there is a moderate-sized cyst, the dissection is more involved but is usually made simple because the perivesicalplane is usually more pronounced. The plane may be very difficult to establish if there was prior vesiculitis, and in this instance the ureteralcatheters are a welcome safeguardcare must be taken not to dissect completely through Denonvilliers' fascia posteriorly and into the rectum.The posterior bladder incision is then closed with a running 20 absorbable suture in the muscle layer followed by a running 40 absorbablesuture in the mucosal layer. The ureteral stents and 4 8 sponges are removed, a 20-F uretheral catheter is placed, and the anterior bladder wais closed as the posterior wall was. Suprapubic tube placement is an option, but is not necessary. A suction drain is placed through a separatestab incision and positioned in the prevesical space away from the suture line. The drain is left for 2 to 3 days and then removed when thedrainage has proved not to be urine and is less than 50 mL/day. The urethral catheter is removed in 5 to 7 days. Early ambulation is the rule, andthe patient is usually discharged within 3 to 5 days after surgery.

This approach is more prone to blood loss and ureteral injury than the perineal approach, but a rectal laceration is much less likely.These complications are handled as described previously.

Paravesical Approach

The paravesical incision is used in children, when there is a large unilateral cyst that lies lateral to and above the bladder, and whennephroureterectomy is required.A midline or Pfannenstiel's extraperitoneal suprapubic incision is made. The bladder is finger-dissected awayfrom the lateral pelvic sidewall on the affected side. The vas deferens is identified, placed on tension, and dissected down toward the base of thebladder. If the seminal vesicle mass is distended, it should be visible rather quickly as the vas comes close to the bladder posteriorly. Placing acatheter in the bladder and emptying it usually allows the plane between the bladder and the cyst to be readily identified. The plane is incised witscissors, and the seminal vesicle cyst is carefully dissected away sharply. When the tip of the cyst is clearly identified, a 10 chromic suture isplaced into it to provide traction, making further dissection easier. As the dissection proceeds, it must be remembered that the ureter crosses thevas and must be identified to prevent its injury. In addition, the superior vesicle artery and perhaps the inferior vesicle artery may be sacrificed to

gain access to the base of the seminal vesicle. This will cause no harm and should be done without major concern. As the dissection proceeds,the bladder is progressively rolled over medially, and the mass is dissected away from the bladder laterally. The plane is easily maintained withsharp dissection. Any vessels feeding the seminal vesicles should be suture ligated or metal clipped. As the prostate is approached, cautionmust be used to stay directly on the mass so as not to injure the neurovascular bundle lying just lateral to the seminal vesicle.At theprostate base, the neck of the seminal vesicle is encircled and ligated with a 20 absorbable suture. A clamp is placed across just distal to the tieand the seminal vesicle is severed. There may be no need to clip the vas. A suction drain is placed in the bed of the seminal vesicle and broughtout through a separate stab incision. The wound is then closed in layers. Postoperative care is as previously described, except with this approacthe drain can be removed within 24 hours if there is no drainage, and the urethral catheter can be removed within 24 hours. The patient may bedischarged within 2 to 3 days. Complications include ureteral injury and excessive blood loss. If the principles outlined earlier are followed, theseare unlikely events.

Retrovesical Approach

The retrovesical approach should be considered in patients requiring bilateral excision of small seminal vesicle cysts or benign mass

(de Assis, 1952). A midline suprapubic incision is made into the peritoneal space. A catheter is placed, and the urine is evacuated. The reflectionof the peritoneum over the rectum at the posterior bladder wall is incised transversely, with care taken not to incise into the rectum ( Fig. 10912A

The bladder is peeled back from the rectum progressively with sharp dissection until the ampullae of the vasa and the tips of the seminal vesiclescome into view (Fig. 10912B). The seminal vesicles are dissected down to the base of the prostate, much as described in the transvesical

approach, and the neck of the seminal vesicle is ligated and divided bilaterally. The ampullae are usually not taken unless necessary ( Fig.

10912C). A suction drain is left in the area posterior to the bladder and brought out as before. Postoperative care is as per the description for a

paravesical resection. Complications include rectal injury, bladder laceration, and hemorrhage. In this situation, a rectal injury would be within theperitoneum well above the levator ani muscles. After a two-layer closure as before, strong consideration should be given to placement of omentuover the closure between the bladder base and the rectum, as well as to a temporary colostomy.

Transcoccygeal Approach

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The transcoccygeal approach may not be familiar to most urologic surgeons and is unlikely to be a common choice owing to fear of rectal injuryand impotence . In individuals for whom the perineal or supine position may be difficult to maintain, or who have had multiplesuprapubic or perineal surgeries, the transcoccygeal approach may be very useful.The patient is placed on the table, ventral side down(prone) and in a relative jackknife position (Kreagerand Jordan, 1965). The incision is made in an "L" shape from midway on the sacrum (10 cm

from the tip of the coccyx) and angled at the tip of the coccyx down the gluteal cleft within 3 cm of the anus ( Fig. 10913A). The incision is carrie

down to the lateral side of the coccyx, which is dissected free from the underlying rectum and eventually totally removed (Fig. 10913B). The

gluteus maximus muscle layers are moved aside, and the rectosigmoid is encountered and dissected carefully from the underside of the sacrumWith careful dissection, the lateral wall of the rectum on the side of the lesion is dissected medially from the levator ani muscle and surroundingtissue until the prostate is encountered (Fig. 10913C). It is possible that the neurovascular bundle will be recognized from this approach; if the

dissection is unilateral, injury may be of little consequence. Once the prostate is palpated, dissection of the tissue directly superior to the base onthe midline should reveal the ampulla of the vas and, lateral to it, the seminal vesicle ( Fig. 10913D). If difficulty dissecting the rectum away from

the prostate is encountered, a finger in the anus via an O'Connor sheath will allow the correct plane to be determined. Dissection and removal ofthe seminal vesicles should follow the principles outlined previously. A Penrose drain should be left in the area, exiting through a separate stabincision at closure. The rectum should be carefully scrutinized for injury, and, if found, closed in two layers as previously described. The wound isclosed in layers as well. Postoperative care does not differ from that previously described; similar to the perineal approach, the patient should haa rapid and easy recovery. The drain should be removed within 2 to 3 days if there is no drainage.

Endoscopic Treatment

Transurethral Resection

If the cyst or abscess is adjacent to the prostate(not in the middle or distal end of the seminal vesicle), it may be possible to unroof the

cavity with a deep transurethral resectioninto the prostatic substance just distal to the bladder neck at the 5- or 7-o'clock position (FryeandLoughlin, 1988; deLichtenberg and Hvidt, 1989). However, urinary reflux, with resultant postvoid dribbling, and infection are potential

complications (Goluboffet al, 1995). Several groups have reported on endoscopic treatment of seminal vesicle abscesses using semirigid

ureteroscopes (Razviand Denstedt, 1995; Shimadaand Yoshida, 1996; Okuboet al, 1998). Another report detailed drainage of a seminal vesicl

cyst cystoscopically with an incision using a Collins knife (Gonzalezand Dalton, 1998).

Laparoscopic Surgery

Most laparoscopic surgery performed on seminal vesicles has been in conjunction with radical prostatectomy.The laparoscopicapproach allows for greater visualization, particularly of the vasculature and the tip of the seminal vesicle. Drawbacks include the need for atransperitoneal approach and the increase in operative time (Kavoussiet al, 1993). More recently, laparoscopic radical retropubic prostatectomie

have been accomplished (Guillonneauand Vallancien, 1999). Although there is a steep learning curve, those who have used this method

extensively suggest that operative times, blood loss, and catheter removal times have all decreased (Guillonneauet al, 2000; vanVelhoven et a

2000). This approach allows for complete excision of the seminal vesicles with minimal posterior dissection. Excision of benign symptomaticseminal vesicle cysts has been accomplished laparoscopically inboth adults and children (Carmignaniet al, 1995; Ikariet al, 1999).

Medical/Radiologic Treatment

Small seminal vesicle cysts obstructing ejaculatory ducts or causing local symptoms should undergo an initial attempt at transperineor TRUS-guided aspiration.If this is not successful because the cyst reaccumulates, consideration could be given to reaspiration with injectiona sclerosing solution such as tetracycline. Similarly, an abscess in the seminal vesicle could be aspirated for culture and drained, perhaps evenwith a short-term indwelling catheter via a transperineal or transvesical percutaneous route using TRUS or CT guidance ( Fryeand Loughlin, 198

Shabsighet al, 1989; Gutierrezet al, 1994). Direct irrigation of the cavity and subsequent antibiotic injection may be curative (Foxet al, 1988;

Fuseet al, 1988).

Conclusion

The seminal vesicles are difficult organs to access, but they fortunately have a small number of primary pathologic conditions. There are very fewreasons to operate solely on the seminal vesicles, but when the indications are appropriate, the approach and surgical principles are notparticularly different from those of other pelvic conditions more frequently encountered by the urologic surgeon.

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