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