Purpose
Mullerian duct cysts (MDC) are embryonic rudiments formed from abnormal Mullerian duct regression and subsequent saccular dilatation, located in the midline retroperitoneal space between the scrotum and prostatic utricle. Although 60% of MDCs present asymptomatically, larger cysts may cause a diverse range of genitourinary symptoms including but, not exclusively, urinary obstruction, frequency, urgency, pain, hematospermia, genitourinary tract infections and infertility. Historically, asymptomatic MDCs are managed through active surveillance while smaller cysts have been treated with minimally invasive procedures. Larger cysts may require more complex and invasive procedures.
We present the 1st ever case report of RARP with a large MDC.
Due to its unique nature and the deficiency in the literature, we hope this case report will prove to be a useful reference for urologic surgeons undertaking similar cases in the future.
Materials and Methods
A 58-year-old male presented with obstructive lower urinary tract symptoms (LUTS) and a previous history of basal cell carcinoma. The patient’s prostate-specific antigen (PSA) was 35 ng/mL and digital rectal examination (DRE) displayed a clinical staging of T2b on the right lobe. A magnetic resonance imaging (MRI) was performed and revealed a 28-cc prostate with a 21 mm PI-RADS 5 lesion on both the peripheral and transitional zones of the right lobe. There was significant capsular involvement, right seminal vesicle base invasion and a 62 mm cyst in the left seminal vesicle. All biopsies from the right lobe were ISUP Grade Group 5 and one sample from the left lobe was positive for ISUP Grade Group 5. A decision was made to perform a robot-assisted radical prostatectomy (RARP) with extended lymphadenectomy and a trimodal treatment option.
Results
Procedure took a total of 221 mins with a robot consult time of 201 minutes. There was 300cc of blood loss, no post-operative complications and the patient was discharged 2 days later. At the 1-month postoperative consultation, the patient continued androgen deprivation therapy (ADT), had a PSA <0.05 ng/mL and good urinary flow requiring 2-3 pads per day.
The final report showed a 23 mL, T3b, ISUP Grade Group 5 lesion involving both lobes of the prostate with a focal margin of 0.1 mm on the right lobe and a confirmed diagnosis of Mullerian duct cyst.
Conclusion
Based on the findings of our case, we concluded that a robot-assisted radical prostatectomy (RARP) in a patient with a large Mullerian duct cyst is a safe and feasible procedure.