Medical Mystery: A blockage too big to remove

A 27-year-old man was retaining urine, and required catheterization for relief. His lower abdomen had slowly been growing more and more distended, and he was increasingly constipated.

He had a very rare condition called a giant seminal vesicle cyst, slowly filling up his pelvis. Surgery to remove the cyst already had been attempted three times at different hospitals around Philadelphia, but each time it was deemed impossible to remove.

The seminal vesicles are tube-like glands attached to the prostate, situated between the rectum and bladder, that make most of the content of semen.

Although such cysts are not cancer, they are dangerous because of their potential size. By the time he came to our office, this young man's cyst was 23 centimeters, or 10.5 inches in length, filling the area from his rectum to above his belly button.

To make matters worse, one of his kidneys had shut down. He was in the early stages of kidney failure because the mass was blocking drainage of his kidneys.

His previous surgeons concluded that in order to remove this mass, he would need a total pelvic exenteration - a radical procedure in which the rectum, bladder, and prostate all are removed. He would have to live with two permanent drainage ostomies on his abdominal wall hooked to bags to empty his stool and urine.

The young man would never have an erection, urinate, or have a bowel movement. Nor could he father any more children. It was horrible news, especially for a young man who was not diagnosed with cancer.

Was there a less radical way to remove the cyst?

After reviewing his MRIs and examining him, I was doubtful I could remove this young man's cyst. He already had a full midline incision that had been used in the three prior surgical attempts, and his colon had been damaged in one of those efforts.

What I could feel of the mass was so large, it was almost as if he were pregnant. Going back in would be extremely challenging and risky if his bowel, nerves, or major blood vessels were injured.

But it was also clear that his options were limited.

I suggested something counterintuitive.

Instead of repeating the open surgical procedures that already had been attempted due to the size of the cyst, I would try removing it using minimally invasive, robotic surgery. In such procedures, we make several small incisions to insert tiny cameras and surgical instruments.

Three-dimensional, high-definition visualization allows us to approach unique, complex cases all the time. But we knew this would be an especially difficult case. I had heard of and read about cysts like this young man's, but had not attempted this exact procedure before.

My team and I cautiously proceeded, knowing that we would likely encounter any number of challenges. It took nearly 15 grueling hours with only bathroom and water breaks, but we were able to meticulously separate the entire mass, while sparing all of the patient's other organs. Once it was freed, the mass was placed into a surgical bag, and we slipped it out of him through a three-inch incision.

Two weeks after surgery, he came in for a post-operative checkup. "I finally feel normal!" he exclaimed.

He made a full recovery with all of his vital functions intact and today he is living a normal and active life. His condition, thought to be either congenital or a result of a blockage of the ejaculatory duct, is thankfully rare. But the lesson here applies to any serious medical condition: I encourage all of you to take control of your health by doing your due diligence. Often this requires a second or third opinion, asking tough questions, and thoroughly understanding all available options.

Daniel D. Eun, M.D., is chief of robotic surgery and director of minimally invasive robotic urologic oncology and reconstructive surgery at Temple University Hospital, and professor of urology at the Lewis Katz School of Medicine at Temple University.