LARGE HEMORRHAGIC: CYST OF THE PROSTATE GLAND

LARGE HEMORRHAGIC: CYST OF THE
PROSTATE GLAND
LEONARD A. HALLOCK, M.D.
(From the Squier Uroloqicul Clinic, Presbyterian Hospital, Colurnbiu UniuersilU, Nc.w
York City)
Excluding echinococcus cysts, large retroprostatic and retrovesical cysts of the male pelvis are rarely encountered. Of those
that have been reported in the literature, none is clear as t o the
true derivation. It is for these reasons that this case may prove
of interest.
REVIEWOF
THE
LITERATURE
Wesson in 1924 thoroughly reviewed the literature on cysts of
the prostate and urethra. He collected 55 reported cases, to
which he added 4 of his own. Since that time 11 more cases have
been cited, making a total of 70 cases up to the year 1931 (Ryall,
Keyes, Andre, Papin and Verliac, Altman, Mandel, Roberts,
and Fritz, quoted by Altman). I n none of these cases reported since
1924, and including Wesson’s four cases, were the cysts of any
appreciable size nor were they located behind the prostate or
bladder, with the exception of those of Roberts, Papin and Verliac,
Altman, and Fritz. Roberts’ case proved to be a cyst within the
prostate, originating from one of the glands. Papin and Verliac
found a small midline multilocular retroprostatic cyst of a vegetating or papillary adenomatous nature which they believed was
derived from the glands within the prostate. I n contrast to these
two cases, Altman and Fritz each described a unilocular cyst the
size of a hazelnut encroaching upon the posterior aspect of the
prostate in its midline, its muscular walls intermingling with those
of the seminal vesicles.
I n 1908, W. Liebi, in presenting his retroprostatic cavernous
cyst in the nature of a lymphangioma-the only case of its kind
noted up t o his time-discussed and classified retroprostatic and
retrovesical cysts according to location and type as follows:
2331
2332
LEONARD A . HALLOCK
I. Epithelial cysts in the prostate
(a) Those within the prostate
( b ) Those from the prostatic utricle
11. Retrovesical epithelial cysts
( a ) All cysts attached to the prostate, epithelial in
character and behind the bladder, except
( b ) dermoid cysts
111. Retrovesical endothelial cysts
IV. Echinococcus cysts
Excluding cysts within the prostate, dermoid, endothelial, and
echinococcus cysts, the rarity of reported retroprostatic and
retrovesical cysts in the male pelvis is marked. Seventeen cases
in all are noted: 8 of these cysts are cited as large cysts, I) as small.
The derivation of the 8 large cysts is, indeed, not clear in any case.
J. Spence, in 1865, was one of the first t o call attention to a large
cyst behind the bladder in the male pelvis. The cyst was punctured and later became infected. After death, upon exploring the
pus-filled cavity, it was found t o lead t o the floor of the urethra
through the prostate gland. This was believed to be a cyst of the
prostate. N. R. Smith, in 1872, described a ‘‘hydrocoele of the
seminal vesicle.” He found a very large cyst between the rectum
and bladder in the midline. It has been thought that this was a
cyst of the prostate rather than the seminal vesicle (Belfield).
Rolfe, Guitkras, Fisk, Damski, and Greenberg reported cases of
large retroprostatic cysts which were thought t o come either from
the prostate or from the seminal vesicles. Huggins, in 1930,
demonstrated that a diverticulum of the spermatic system should
be considered in some of these cases.
The origin of the small cysts is much clearer than that of the
larger cysts. I n 1874 Englisch demonstrated their true nature for
the first time. He presented five historic and classic cases in
which he showed midline retroprostatic cysts, each the size of a
hazelnut, in old as well as young persons. On the dead body he
was able to dissect these cysts out so as t o reveal a fibrous attachment coursing through the mid-section of the prostate as far as the
colliculus. Especially in his second case, in a man aged forty, he
cites evidence that midline retroprostatic cysts are usually derived
from mullerian rests. On the basis of these findings of Englisch
and the work of Meyer, Altman presented his case of a small
midline retroprostatic cyst as being derived from mullerian anlnge.
HEMORRHAGIC CYST O F PROSTATE GLAND
2333
Bosscha (Guelliot), Luksch, Priesel, a n d Fritz have noted similar
cases of small retrovesicd cysts.
CASE REPORT
E. C., a young man of Austrian parentage, aged nineteen, entered
the Squier Urological Clinic on June 10, 1930. For ten days he had had
a watery sanguineous discharge from the urethra following all his bowel
movements. A year earlier he had noticed that he had become somewhat
constipated and that more straining was required to produce stools than
formerly. At this time, also, a sense of pressure had developed in the
rectum. He had no urinary symptoms except for the occasional occurrence of a few drops of blood in the urine. The nocturnal emissions were
normal in appearance. The patient had lost no weight and had felt
exceptionally well for many years.
The family history and past history were irrelevant.
The general physical examination of this patient gave strikingly
negative results. He was well developed and nourished and of good
color. A rectal examination was the means of localizing the pathology.
The prostate felt normal in size, shape, consistency, and position. I n
the midline, just off and above the prostate, was a round, smooth mass,
non-tender and “without heat,” about the size of an orange, protruding
into the rectum. This mass, palpated bimanually through the abdominal
wall, was elastic and semifluctuant in nature. Although freely movable
within the pelvis, it was fixed a t one point, the middle and posterior
aspect of the prostate. The rectal wall was freely movable everywhere.
No other masses, as glands or indurated tissue, were felt. The seminal
vesicles were identified high up, running along the postero-lateral walls
of the mass. They were not indurated or fixed. Occasionally, upon
palpation of this mass, a small amount of serosanguineous fluid would
exude from the urethra.
Laboratory and x-ray examinations were done to help clarify the
nature of this tumor in the pelvis. A complete blood count, including a
blood smear, a complete study of the blood chemistry, a blood Wassermann test, three complete stool examinations, three twenty-four-hour
urine examinations for tubercle bacilli, and several routine urine examinations showed nothing of significance, An x-ray of the chest showed
a flat right diaphragm with obliteration of the costophrenic sinus.
Roentgenograms of the upper and lower genito-urinary tract were
negative. An x-ray report on the colon, following a barium enema, read
as follows: “There is some diminution in the shadow of the barium in
the rectum. The colon is well filled with some leakage through the
ileocecal valve. There is no defect, and no evidence of a tumor involving
the intestinal tract. There is apparent pressure on the contents of the
rectum. Following evacuation, the colon empties about half its contents.” (Fig. 1.)
The fluid obtained by the patient from the urethra following a
bowel movement varied in amount. Sometimes there was just enough
2334
FIQ. 1.
LEONARD A. HALLOCK
ROENTQENOQRAM
OF COLON, SHOWINQ
BARIUM
IN THE
DIMINUTION
IN THE
RECTUM
SHADOW OF T H E
wit.h which t o make a smear, a t other times as much as four C.C. It
was watery in nature, containing a variable amount of blood and mucus.
Microscopically there were seen many red blood cells along with old
degenerated cells, which were interpreted as epithelial cells. There were
no organisms and no tubercle bacilli. A culture of this fluid produced
no growth.
A complete cystoscopic examination was done, The floor of the
HEMORRHAGIC CYST O F PROSTATE GLAND
2335
bladder was found to be pushed up and the ureteral orifices set high
upward and well backward. Both renal pelves were catheterized
together, and a normal peristaltic flow of hazy urine was obtained from
both sides. The laboratory report on the ureteral specimens was the
same for both kidneys: appearance, cloudy; reaction, acid; red blood
cells, many; white blood cells, occasional; urea, 0.60 per cent; tubercle
bacilli, none. Bilateral pyelographic x-rays of the kidneys revealed
normal pelves and ureters.
FIQ.2.
DIAQRAMMATIC DRAWINQ
OF CYST AS
SEENAT OPERATION
An examination of the prostatic urethra showed a normal verumontanum with normal orifices of the utricle and ejaculatory ducts.
No other openings were noted. Even with pressure made by bimanual
palpation of the pelvic tumor and a urethroscope in the urethra, no clue
could be found as to how or from whence the serosanguineous fluid might
have escaped into the urethra.
A preoperative diagnosis of cyst and sarcoma of the prostate gland
was made.
The operation for the exploration of this tumor of the pelvis was
done by Dr. J. Bentley Squier. A midline suprapubic incision was made
2336
LEONARD A. HALLOCK
over the bladder, which was exposed and freed on all sides, so that it
could be pulled up and out of the pelvis on top of the symphysis pubis.
Both ureters and the seminal vesicles with their vasa deferentia were
separately identified, freed, and exposed in their entire length within
the pelvis. Directly in the midline, lying free within the pelvis, opposite
the posterior wall and neck of the bladder, there was found a cystic
tumor about the size and shape of a large orange (Fig. 2). When this
cyst was separat,ed from the overlying peritoneum, fascia, bladder, and
seminal vesicles with their vasa deferentia, it was broken, and a large
amount of serosanguineous fluid gushed forth. The main attachment
VIEW
FXQ.3. HIQH-POWER
OF THE
CYSTWALL AND ITS EPITHELIAL
LINING
of the cyst, which consisted of a thick fibrous cord, was traced downward
directly in the midline tjo the very capsule and substance of the prostate,
where a complete severance was made. This done, the bladder was
replaced within the pelvis in its original site and fixed in place by sewing
the lateral pelvic fascia to the sides of the bladder and the pelvic urachal
fold of tissue to the top and back of the bladder wall, thus forming two
lateral attachments and one posterior for the bladder.
The specimen obtained a t operation consisted of a spherical sac
measuring 15 cm. in diameter. Its wall, 0.5 cm. in thickness, was
composed of a fibrous, leathery structure, the inner side of which revealed
n smooth and injected surface.
The fluid collected directly from the cyst was found t o be identical in
every way with that from the urethra, except that the former contained
no mucus.
Many microscopic sections were made of the cyst wall, all of which
HEMORRHAGIC CYST OF PROSTATE GLAND
2337
revealed a structure consist,ing of two definite layers. The outer layer
was composed of compact, interlacing bundles of collagenous connectivetissue in which were scattered many blood vessels, most numerous at
the outermost surface. I n sections prepared with Mallory’s connective
tissue stain no muscle cells were differentiated. This fibrous tissue
layer was covered on its inside by a low cuboidal, non-ciliated epithelium,
the cells of which contained large vesicular nuclei (Fig. 3). There was a
distinct basement membrane present. The capillary net underlying
this epithelium was quite extensive and in many places formed dilat,ed
sinuses engorged with blood cells (Fig. 4).
F I ~4.. HIQH-POWER
VIEWBHOWINQ BLOODSINUSIN THE EPITHELIAL
LININQOF THE CYST
Serial sections made of t h a t portion of the sac attached t o the prostate
revealed a duct-like structure lined by non-ciliated epithelium similar
to that lining the entire cyst wall. The epithelium, however, was thrown
up into papillary folds containing many small blood vessels. The outer
layer of the wall of the duct was composed entirely of connective tissue
(Fig. 5 ) .
The convalescence of this patient was smooth and uneventful, Hc
left the hospital with his wound entirely healed twenty-five days after
2338
LEONARD A. HALLOCK
the operation. The serosanguineous urethral discharge, constipation,
and sense of rectal pressure have not been present for one year.
COMMENT
To prove the true derivation of this large cystic tumor found
in a male pelvis is not possible; only an hypothesis may be ventured. The tumor is a cyst arising from some embryonic rest,
and, since the number of structures in this region during embryonic
life is large, the possibilities for the origin of the cyst are many.
FIG.5. LOW-POWER
VIEW BHOWINQDUCT-LIKE
STRUCTURE
I N THE FIBROUS
ATTACHMENT
OF THE CYSTTO THE PROSTATE
One must consider the mullerian ducts, the wolffian ducts, the
mesonephros, an accessory ureter, an accessory seminal vesicle,
and an aberrant accessory prostatic lobule. All these structures
are microscopically similar in the embryonic stage and differ only
in their minute anatomical relationships. The latter are not
available in this case. If at operation it had been possible to dissect out the fibrous attachment of this cyst to the prostate, as
Englisch did post mortem in 1874, the origin of this cyst could
have been determined a t least more exactly if not altogether
accurately. However, it is known that the cyst, lying free and
unattached to bladder, ureters, seminal vesicles and their vasa
HEMORRHAGIC CYST OF PROSTATE GLAND
2339
deferentia, in the retroperitoneal space between the rectum and
bladder, was exactly in the midline position. Further, it is known
that it had one attachment only, and that that attachment consisted of a fibrous band of tissue which buried and lost itself in the
very mid-section of the prostate gland on its postero-cephalad
aspect. It is for these reasons that one feels justified in believing
that the derivation was from a remnant of a mullerian duct.
CONCLUSION
A case of a large hemorrhagic retroprostatic and retrovesical
cyst of the prostate gland has been reported. I t is believed that
this cyst had its origin in a remnant of a mullerian duct.
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2340
LEONARD A . HALLOCK
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