HYDATID DISEASE is endemic in some regions of the

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1 JOURNL OF ENDOUROLOGY Volume 19, Number 3, pril 2005 Mary nn Liebert, Inc. Laparoscopic Excision of Prostatic Hydatid Cyst: Case Report and Review of Literature HMDY. El-KPPNY, M.D., 1 HMED R. El-NHS, M.D., 1 and HL. El-NHS, M.D. 2 STRCT It is rare for hydatid disease to be encountered primarily in the urogenital system or retroperitoneum. Moreover, prostatic involvement is extremely rare. We present a case report of prostatic hydatid cyst that was treated with laparoscopic excision. We reviewed diagnosis and management of hydatid disease of the urogenital tract. INTRODUCTION HYDTID DISESE is endemic in some regions of the world such as the Middle East, South merica, East frica, Turkey, ustralia, and New Zealand. 1 Involvement of the urogenital tract by the disease is rare (2% 4%). The kidneys are the most commonly involved urinary organs. 2 Pelvic hydatid disease affecting the seminal vesicles or the prostate is extremely rare. 3,4 Open surgical management has been the treatment of choice in most cases. 2,5,6 In this report, we present the technique of laparoscopic excision of prostatic hydatid cyst together with a review of the literature on different methods of diagnosis and management of hydatid disease of the urinary tract. CSE REPORT 38-year-old man was referred to our center with urine retention. He had been complaining of difficulty of micturition, weak stream, frequency, and urgency for 1.5 years. He had lived in the southwest region of the Kingdom of Saudi rabia for 5 years, where he was subjected to transurethral resection of a prostatic cyst 1.5 years ago. The procedure was complicated by shock necessitating ICU monitoring. He noticed passage of soft grape-like material in the urine for 1 month following this procedure. bdominal examination of the patient showed a large cystic mass. Digital rectal examination revealed a cystic mass that was continuous with the abdominal one. Pelvic ultrasonography showed a large pelvic cyst displacing the bladder upward. transurethral Foley catheter was placed to relieve retention. n MRI scan of the abdomen and pelvis documented the presence of large cyst ( cm) situated below the bladder in the prostatic area. It displaced the bladder upward and anteriorly and the rectum posteriorly. The characteristic daughter cyst was seen in the inferior part of the wall (Fig. 1). n MR urogram revealed bilateral hydroureteronephrosis down to the bladder (Fig. 2). The antihelminthic drug albendazole (10 mg/kg per day) was administered for 2 weeks followed by transperitoneal laparoscopic excision of the cyst. Mechanical and antibiotic bowel preparation started 2 days before surgery. Low-molecular-weight heparin was initiated the night preceding the procedure and continued for 10 days. Under general anesthesia, the patient was placed supine with his legs flexed and abducted and the head down (Fig. 3). nasogastric tube and a Foley catheter were fixed. four-port transperitoneal approach was employed (Fig. 3). The ports were arranged in a fan array. t first, the pelvic cavity was inspected for the presence of small cysts undetected by preoperative imaging. The bladder was identified anterior to the cyst by instillation of saline through the urethral catheter. Then 2% Formalin was injected into the cyst cavity as a scolecidal agent, followed by aspiration of the cyst fluid. The posterior peritoneum covering the cyst was then incised, and the cyst wall was opened, accompanied by immediate suction of the residual fluid to avoid peritoneal spillage. Next, the cyst wall was completely excised with special attention to removal of the germinal layer of the cyst from the prostate to avoid recurrence. Finally, the cyst wall was removed in an Endocatch II ag. The procedure was completed in 60 minutes with no intraoperative complications, and a tube drain was left for 48 hours. The postoperative course was uneventful, with minimal pain that was relieved with a non- 1 Urology and Nephrology Center and 2 Department of Parasitology, Faculty of Medicine, Mansoura, Egypt. 290

2 LPROSCOPIC EXCISION OF PROSTTIC HYDTID CYST 291 C FIG. 1. Magnetic resonance images of lesion. () Coronal T 2 -weighted image of pelvis and abdomen showing pelvic cyst (C) with daughter cyst (DC) at its inferior wall to right. () xial T 2 -weighted image showing pelvic cyst (C) compressing bladder (DC daughter cyst; bladder). (C) Sagittal T 2 - weighted image showing pelvic cyst (C) displacing bladder () upward and anteriorly and rectum (R) posteriorly. (DC daughter cyst). steroidal anti-inflammatory drug. The urethral catheter was removed after 1 day, and the patient voided well with no residual urine. The patient was discharged from the hospital after 2 days. Symptom-free recovery was completed in 2 weeks. Histopathologic examination of the cyst wall revealed an inner nucleated germinal layer which contained scoleces of the parasite and an outer non-nucleated laminated layer (Fig. 4). lbendazole was administered for 6 weeks postoperatively. Follow-up ultrasonography after 6 months revealed no pelvic cysts and disappearance of hydronephrosis. n MRI scan after 1 year revealed development of a new cyst measuring cm in the left seminal vesicle (Fig. 5). The patient was advised to receive oral albendazole for 6 months to 1 year for treatment of the recurrent infestation. DISCUSSION FIG. 2. Static MRU image showing pelvic cyst compressing both ureters causing bilateral hydroureteronephrosis. Hydatid cystic disease is a parasitic infestation caused by the larval form of Echinococcus granulosus. The adult worm inhabits the small intestine of dogs, cattle, sheep, and pigs. Infective eggs excreted in the feces of the definitive hosts are ingested by humans (the intermediate host). Ingested eggs hatch in the duodenum; the embryos penetrate the intestinal mucosa and enter the portal system. 7 Hydatidosis can be present in all parts of the human body, but the organs most affected are the liver (65%) and lungs (25%). Renal involvement develops in only 2% to 4% of cases. 6,7 Echinococcus larvae may reach the

3 292 EL-KPPNY ET L. FIG. 4. Photomicrography of section of cyst wall. () Inner germinal layer with formed scolex (H&E, original magnification 200). () Outer non-nucleated laminated layer (H&E; original magnification 400). FIG. 3. Technique. () Patient position. () Port distribution. Two ports (Nos. 1 and 2) are 10 mm, and two (Nos. 3 and 4) are 5 mm. kidneys through the blood stream, lymphatic system, or direct inoculation. 8 Involvement of the pelvic organs such as the prostate and seminal vesicles has also been reported in sporadic cases. 3,4 Hydatid embryos may reach the pelvis through the portal system from the liver or through lymphatic drainage of the gastrointestinal tract. 9 Hydatid disease usually affects patients between the third and fifth decades of life who live in endemic areas. 8 There are no specific symptoms and signs, and hydatid disease may remain silent for years. Symptoms develop when the cyst exerts pressure on tissue. The most common symptoms of renal hydatidosis are a palpable mass, flank pain, hematuria, malaise, fever, and hydaturia. 2,6 In prostatic infection, the usual presentations FIG. 5. Sagittal T 2 -weighted MR image showing small cyst (C) ( cm) in area of left seminal vesicle ( bladder).

4 LPROSCOPIC EXCISION OF PROSTTIC HYDTID CYST 293 are lower urinary-tract symptoms and urine retention. 4,9 Storage symptoms in our patient were secondary to compression of the bladder by the large cyst, which decreased its functional capacity; while voiding symptoms such as urine retention were attributable to infravesical obstruction through compression of the prostatic urethra. Hydaturia is a pathognomonic sign. It involves passage of grape-like material in the urine, which results from a connection between the cyst and urinary system. This could occur secondary to spontaneous rupture of the cyst into the renal collecting system or after iatrogenic resection of part of the cyst wall through the urethra in case of prostatic involvement, as occurred in our patient. 4,6 Diagnosis is usually based on a combination of imaging techniques and immune diagnostic tests such as the Casoni (intradermal), Weinberg (complement fixation), and indirect hemagglutination. However, these serologic tests are not specific for hydatid disease, and their role is an adjunct to diagnostic imaging. 10 Radiologic studies such as ultrasonography, CT, or MRI have a more important place in the preoperative diagnosis. Cysts may be unilocular or multilocular, thin or thick walled, and with homogenous contents or a fluid fluid interface. characteristic appearance of localized thickening of the mother cyst wall is caused by daughter cysts. Then, as they gradually mature, new cysts form, giving the appearance of a multilocular cyst. 3 Curvilinear calcification on plain film and distortion of the renal collecting system by the cyst on intravenous urography usually mandate further evaluation by CT or MRI for accurate localization of the cyst as well as its wall and internal structures. 3,6 Differential diagnosis of a large hydatid cyst in the pelvis should include Müllerian-duct cyst, cyst of vas deferens, cyst of the ejaculatory duct, bladder diverticulum, dilated seminal vesicles secondary to infection or obstruction and, less frequently, cystadenoma of the prostate. 11 In our case, we relied on the characteristic radiologic appearance of the cyst and daughter cysts in the preoperative diagnosis in conjunction with the high clinical suspicion. Open surgery remains the most commonly employed approach for the management of hydatid disease. Removal of the intact cyst offers the fewest complications and the best prognosis. For renal involvement, total or partial nephrectomy is the preferred choice of treatment. However, cyst enucleation or marsupialization has also been described. 5,6 If the preoperative evaluation reveals isolated disease, a retroperitoneal approach should be performed to avoid disseminating the disease into the peritoneal cavity. The transperitoneal approach can be used with extrarenal involvement. Recently, percutaneous management of renal hydatidosis was described. The technique entails percutaneous puncture of the cyst, aspiration of cyst fluid, introduction of a scolecidal agent, and reaspiration and has provided a useful alternative to surgery. 13 Intraoperative spillage of the cyst contents may cause serious complications, including allergic reaction such as anaphylaxis and even death. Our patient developed shock (probably secondary to an anaphylactic reaction) during transurethral resection of the cyst wall 1.5 years before referral to our center. Moreover, dissemination of scoleces in the operative field may lead to rapid recurrence of multiple cysts. Therefore, packing the area surrounding the cyst with povidone iodine-soaked sponges was advised to avoid complications and recurrence. 2 In open surgery, the cyst could be removed intact, but during laparoscopy, a large cyst should be opened. Therefore, the cyst cavity should be filled with scolecidal agents in cases where intraoperative opening of the cyst is anticipated. One of the following agents can be used: 2% Formalin, 30% sodium chloride, 1% iodine, or 0.5% silver nitrate. 12 Systemic antihelmenthic therapy such as albendazole can be used in cases in which spillage is suspected. It is given for 1 to 2 weeks before surgery and for several weeks thereafter. The aim is to provide sufficient antihelminthic cover in the body to prevent recurrence of the cyst. 14 Laparoscopic treatment of a hepatic hydatid cyst was previously reported. 15 To the best of our knowledge, we present the first report of laparoscopic excision of a prostatic hydatid cyst. The key steps in avoiding anaphylaxis as well as recurrence are systemic administration of antihelminthic, injection of a scolecidal agent, aspiration of the cyst contents before opening it, suction of any residual fluid inside the cavity as soon as the cyst is opened, and removal of all the germinal layer of the cyst wall. The recurrence rate of hydatid cyst is reported to range from 3% to 10% after surgical management, while a 50% recurrence rate is observed after percutaneous aspiration. 16,17 These reports have demonstrated the importance of complete excision of the cyst wall to decrease the recurrence rate. Laparoscopic excision provided the advantage of complete removal of the cyst wall in a minimally invasive fashion. In our case, recurrence was observed after 1 year at another site (seminal vesicle). The cause may have been reinfestation, because the patient returned to work in the endemic area, whereas cysts that develop after spillage will be multiple and intraperitoneal and appear early after excision of the first cyst. Medical treatment of recurrent hydatid disease was reported to provide promising results. 18 We advised medical treatment for the patient because the cyst new is small, causing no clinical manifestation, and he is exposed to the risk of reinfestation. CONCLUSION Laparoscopic excision of prostatic hydatid cyst is feasible and safe. REFERENCES 1. Schantz PM, Chai J, Craig PS. Epidemiology and control of hydatid disease. In: Thompson RC, Lymberg J (eds): Echinococcus and Hydatid Disease. Wallingford: C International, 1995, pp Gogus C, Safak M, altaci S, Turkolmez K. Isolated renal hydatosis: Experience with 20 cases. J Urol 2003;169: Saglam M, Tasar M, ulakbasi N, Tayfun C, Somuncu I: TRUS, CT and MRI findings of hydatid disease of seminal vesicles. Eur Radiol 1998;8: Houston W. Primary hydatid cyst of the prostate gland. J Urol 1975;113: Poulios C. Echinococcal disease of the urinary tract: Review of the management of 7 cases. J Urol 1991;145: ngulo JC, Sanchez-Chapado M, Diego, Escribano J, Tamayo JC, Martin L. Renal echinococcus: Clinical study of 34 cases. J Urol 1997;157: Thompson RC. Echinococcosis. In Gillespie SH, Pearson RD (eds): Principles and Practice of Clinical Parasitology. Chichester: John Wiley & Sons, 2001, pp

5 ragona F, Ficandio G, Serrata V, Fiorentini L. Renal hydatid disease: Report of 9 cases and discussion of urologic diagnostic procedures. Urol Radiol 1984;6: Ptasznik R, Hennessy OF. Pelvic hydatid disease presenting as acute urine retention. r J Radiol 1988;61: Shetty SD, l-saigh, Ibrahim I, Malatani T, Palil KP. Hydatid disease of the urinary tract: Evaluation of diagnostic methods. r J Urol 199;269: Lim DJ, Hayden RT, Murad T, Nemcek, Dalton DP. Multilocular prostatic cystadenoma presenting as a large complex pelvic cystic mass. J Urol 1993;149: uckley RJ, Smith S, Herschorn S, Comisarow RH, arkin M. Echinococcal disease of the kidney presenting as a renal filling defect. J Urol 1985;133: aijal SS, asarge N, Srinadh ES, Mittal R, Kumar. Percutaneous management of renal hydatidosis: minimally invasive therapeutic option. J Urol 1995;153: Tryfonas GJ, vtzoglou PP, Chaidos C, Zioutis J, Gavopoulos S, Limas C. Renal hydatid disease: Diagnosis and treatment. J Pediatr Surg 1993;28: EL-KPPNY ET L. 15. Xie JM, Gao Y, Shi LS, Tang ZJ. Experience with laparoscopic treatment of hepatic hydatid cyst. Di Yi Jun Yi Da Xue Xue ao 2003;23: gaoglu N, Turkyilmaz S, rslan MK. Surgical treatment of hydatid cyst of the liver. r J Surg 2003;90: Wang Y, Zhang X, artholomot, et al. Classification, follow-up and recurrence of hepatic cystic echinococcosis using ultrasound images. Trans R Soc Trop Med Hyg 2003;97: Chai J, Menghebat, Wei J, et al. Observations on clinical efficacy of albendazole emulsion in 264 cases of hepatic cystic echinococcosis. Parasitol Int 2004;53:3 10. ddress reprint requests to: hmed R. El-Nahas, M.D. Urology and Nephrology Center Mansoura University Mansoura, Egypt ar_el_nahas@yahoo.com