Robotic unilateral seminal vesiculectomy for chronic hematospermia

Abstract

Hematospermia is typically self-limited and warrants no surgical intervention. However, chronic hematospermia requires investigation and treatment depending on etiology. We present an unusual case of chronic hematospermia for 5 years in a 22-year-old patient, which failed conservative medical management. MRI was conducted which revealed left seminal vesicle (SV) distended with blood and a normal right SV. He was treated with robotic unilateral seminal vesiculectomy (RUSV). At 6 months follow-up, ejaculation was normal and hematospermia resolved. Therefore, RUSV is a valid option for chronic hematospermia and can preserve normal ejaculatory function, particularly if the SV responsible for the hematospermia is lateralized.

1 Introduction

Hematospermia is defined as the presence of blood in semen. Several etiologies for hematospermia exist including infections, inflammation, tumors, ejaculatory duct obstruction, seminal vesicle (SV) cysts, lithiasis, vascular aberrations of accessory sex glands, trauma, and iatrogenic causes. Transient hematospermia is typically self-limited and warrants no surgical intervention. However, chronic hematospermia is quite concerning for the patient and will require further investigation and appropriate treatment depending on the etiology. ^, We report here an unusual case of chronic hematospermia for 5 years in a 22-year-old patient, which failed conservative medical management and was treated eventually by robotic-assisted laparoscopic unilateral seminal vesiculectomy in the absence of SV cyst.

2 Case presentation

This is a healthy 22-year-old gentleman who presented with chronic hematospermia for 5 years. This has been a consistent problem, present with every ejaculation. It has severely and negatively affected his sexual life. He has no chronic medical issues apart from major depressive disorder for which he takes Trazodone and Escitalopram. He has had no previous surgeries. Interestingly, he has a congenitally absent left kidney. He denies previous sexually transmitted illnesses (STIs). The patient has denied urinary symptoms or urethral discharge at any point, and he has adequate erections for sexual intercourse without any concern for erectile dysfunction. General physical examination and genital/prostate examination are within the normal limits without any notable findings.

In attempts to address his hematospermia, the patient has received multiple courses of antibiotics (Doxycycline, Trimethoprim/Sulfamethoxazole, and Fluoroquinolones) without benefit over the past several years. A trial of Finasteride was offered but the patient declined this due to concern of possible sexual side effects at his young age.

Other aspects of his work-up after presentation including labs and imaging. Serum creatinine was normal. Urinalysis, urine culture, Chlamydia/gonorrhea, and other STI tests came back negative. An ultrasound of the scrotum was performed which was unremarkable. Given the plethora of negative tests and persistent symptoms, it was agreed upon to perform a cystoscopy which was also unremarkable. At this point, Magnetic Resonance Imaging (MRI) of the pelvis was ordered and showed no evidence of tumors, cysts, or vascular abnormalities; and revealed distension of the left SV with blood. The right SV was normal ( Fig. 1 ).

The options of treatment were discussed with the patient and given the chronicity of the condition and its negative effect on his sexual life. Several treatment options were discussed with the patient. TRUS-guided SV puncture with drug instillation, TRUS-guided cyst aspiration and transurethral resection with deroofing were discussed as less morbid interventions but associated with higher failure rate. He opted for surgical removal of the left SV, despite potential for higher morbidity and potential impotence or ejaculatory dysfunction, due to his many year struggle with the condition. This was performed as a robotic-assisted laparoscopic left seminal vesiculectomy.

2.1 Technique of the primary procedure

The patient underwent standard induction, position preparation and draping. He was placed in the 30-degree Trendelenburg position. An Xi DaVinci robot was utilized with port placement identical to that of a robotic prostatectomy. After access was obtained and we had visualization, the small bowel was mobilized cranially. The sigmoid colon was then mobilized, exposing the cul-de-sac. The left SV was exposed and mobilized using blunt dissection and bipolar cautery to avoid neurovascular injury. The SV was traced back and dissected to the base of seminal vesicle duct. The duct of the SV was then ligated using 2-0 Monocryl suture ( Fig. 2 ). Transection was completed sharply, and the SV was then sent for pathologic examination. Additional examination and hemostasis using bipolar cautery and hemostatic agents. The peritoneum was then closed over the operative field once packed with SURGIFLO ® Hemostatic Matrix mixed with thrombin.