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DOI:10.2214/AJR.04.1770
AJR 2006; 186:539-546
© American Roentgen Ray Society

Clinical Observations

Retained Seminal Vesicles After Radical Prostatectomy: Frequency, MRI Characteristics, and Clinical Relevance

Tamar Sella1,2, Lawrence H. Schwartz1 and Hedvig Hricak1

1 Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., Room C-278, New York, NY 10021.
2 Department of Radiology, Hadassah University Hospital, Jerusalem, Israel.

Received November 15, 2004; accepted after revision January 31, 2005.

 
Supported by grant R01 CA76423 from the National Institutes of Health.

Address correspondence to H. Hricak.


Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
OBJECTIVE. Changes after radical prostatectomy (RP) may present potential pitfalls in the interpretation of pelvic MRI studies in post-RP patients. One such change is retained seminal vesicles (SVs). The purpose of this study was to characterize the MRI features and evaluate the frequency of retained SV remnants in patients after RP.

CONCLUSION. Retained SV remnants are a common finding after RP. Most are fibrotic distal tips. Recognition of SV remnants may prevent their misinterpretation as local recurrences.

Keywords: genitourinary imaging • MRI • oncologic imaging • pelvic imaging • prostate cancer


Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Adenocarcinoma of the prostate is the most frequently diagnosed visceral cancer of men in the United States, whose lifetime risk of being diagnosed with the disease is one (17%) in six [1]. Most cases of the disease are diagnosed at an early stage, with approximately 86% being of a local or regional stage [2]. Radical prostatectomy (RP) is currently the most common first-line therapy for localized prostate cancer [3, 4].

The most common procedure for surgical excision of the prostate gland is retropubic RP [5]. Additional approaches for prostatectomy include the perineal approach and laparoscopy [6, 7]. In attempts to improve postsurgical morbidity, various modifications to the classic surgical procedures have been introduced. These include nerve sparing, sural nerve transplantation, partial or complete urethral sparing, seminal vesicle (SV) sparing, bladder neck sparing, and others [8-11].

The incidence of elevated prostate-specific antigen after retropubic RP ranges from 15% to 53% [12-17]. Such biochemical failure could be due to prostate-specific antigen-only relapse, local recurrence in the postprostatectomy bed, or distant metastases. Clinical nomograms are widely used to statistically predict whether a recurrence is more likely local or metastatic [14, 18, 19]. Imaging plays a central role in evaluating for metastatic disease. Imaging studies, specifically MRI studies, are gaining popularity for detection and localization of local recurrence after prostatectomy [20, 21]. Differences in surgical technique cause a variety of postsurgical changes in the pelvis. Some of these may present potential pitfalls in the interpretation of postprostatectomy MR images. Of particular interest are retained SV remnants [22]. SV remnants do not produce prostate-specific antigen [23]; however, their presence can be confusing on clinical examination and imaging studies. The purpose of this study was to evaluate the frequency and to characterize the MRI features of retained SV remnants on pelvic MRI in postprostatectomy patients.


Materials and Methods
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 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
A search of the Memorial Sloan-Kettering Cancer Center (MSKCC) database revealed 270 consecutive patients who underwent pelvic MRI between January 1, 2000, and October 15, 2004, after RP for adenocarcinoma of the prostate. MRI was indicated to evaluate a rising blood serum level of prostate-specific antigen in 259 patients, to assess for residual disease in light of positive surgical margins in six patients, to evaluate a palpable abnormality in three patients, and to evaluate postsurgical incontinence in two patients. Surgical reports documented an open RP in 263 patients and laparoscopic resection in two. The surgical report was not available for five patients. An SV-sparing procedure was described in the surgical reports of two of 265 patients. Complete pathology reports were available for 250 of 270 patients, all of which mentioned the SVs in addition to the prostate. Patient age at time of diagnosis ranged from 40 to 75 years (mean, 59.5 years). The interval between surgery and the time of MRI; the institution where surgery was performed; and, when available, the individual surgeons were recorded.

All MR images were obtained on a 1.5-T whole-body MRI scanner (Signa, GE Healthcare). Patients were supine when examined. The body coil was used for excitation, and a pelvic phased-array coil (Signa CV/i, GE Healthcare) with (n = 255) or without (n = 15) a commercially available balloon-covered expandable endorectal coil (MRInnervu, Medrad) was used for signal reception. Thin-section, high-spatial-resolution axial and coronal T2-weighted, fast spin-echo images of the postprostatectomy fossa were obtained (TR/effective TE, 5,000/96; echo-train length, 16; slice thickness, 3 mm; interslice gap, 0 mm; field of view, 14 cm; matrix, 256 x 192; frequency direction, anteroposterior [to prevent obscuration of the ureterovesical anastomosis by artifacts from motion of the endorectal coil]; number of excitations, 3; acquisition times, 6 min 50 sec axial and 4 min 10 sec coronal). Examinations performed later than November 2002 (n = 140) also included a high-resolution small-field-of-view sagittal sequence, with the same parameters (acquisition time, 3 min 20 sec).


Figure 1
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  		Fig. 1A —60-year-old man 12 years after radical prostatectomy for prostate adenocarcinoma. B = bladder, R = rectum. T2-weighted axial endorectal-coil MR image shows multiple surgical clips with susceptibility artifact in region of seminal vesicles (arrows). This artifact makes it difficult to assess images for retained seminal vesicle remnants.

 


Figure 2
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  		Fig. 1B —60-year-old man 12 years after radical prostatectomy for prostate adenocarcinoma. B = bladder, R = rectum. Axial CT scan, acquired 1 month earlier, confirms metallic nature of these clips.

 
The MRI studies were analyzed retrospectively, checking for the presence or absence of SV remnants in each patient. If a patient had undergone a number of MRI examinations, the earliest postoperative examination was used for evaluation, with later scans referred to for follow-up. Retained SV remnants were evaluated for location, size, and signal intensity. SV remnants were recorded as complete if the entire SV was retained, partial if less than half an SV was retained, or lateral if only a small portion of SV was retained in a relatively lateral position. SV remnants were categorized as fluid-filled if they showed high signal intensity on T2-weighted images (similar to the signal intensity of fluid, as in normal pretreated SVs) or low signal if the T2-weighted images showed a signal intensity similar to that of adjacent pelvic muscles. In addition, small low-signal-intensity masses in a lateral position in the postprostatectomy fossa were separately recorded as "suggestive of retained low-signal-intensity SV tips." When presurgical pelvic MR images were available, the location of the retained SV remnant or of the suggestion of retained fibrotic SV tips was correlated to that of the preoperative SVs. This study did not evaluate the frequency of local recurrences of prostate cancer within retained SV portions, because that subject has been reported previously [21].

All scans were interpreted by a single reviewer with more than 10 years of experience with prostate MRI scans. The reviewer was unaware of the institution or of the surgeon. Analysis was performed on the T2-weighted axial images, and findings were confirmed on the T2-weighted coronal and sagittal images, when available. The stumps of the ductus deferens were identified individually as well.

Descriptive statistics were used to analyze the results. The institutional review board of MSKCC approved this retrospective study and did not require informed consent.


Results
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 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Of the 270 patients, seven were excluded from analysis: five because of abundant clip artifacts on MR images, limiting adequate evaluation (Figs. 1A and 1B), and two because of large, recurrent masses in the location of the SVs, limiting the ability to characterize the retained SV. Thus, 263 patients were included in this study. SV remnants were found on MRI in 52 (20%) of 263 patients. In the 52 patients with definite SV remnants on MRI, these were bilateral in 41 patients (79%) and unilateral in 11 (21%). Completely retained SVs were seen in 15 (29%) of 52 patients (Figs. 2A, 2B, and 2C), partial SVs were retained in 27 patients (52%), and only the distal lateral portions of SVs were retained in 10 patients (19%) (Fig. 3). Overall, 93 SV remnants were found in these 52 patients. Forty-nine (53%) of the 93 SV remnants showed low signal intensity on MRI; 44 (47%) were convoluted, fluid-filled remnants (Figs. 4A, 4B, and 4C). Small low-signal-intensity masses in a lateral position in the postprostatectomy fossa, which were highly suggestive of retained fibrotic lateral SV tips, were found in 99 (38%) of 263 patients (Figs. 5A and 5B). These masses were bilateral in 76 (77%) of 99 patients and unilateral in 23 (23%). By definition, all these masses were of low signal intensity on T2-weighted images. Findings are summarized in Table 1.


Figure 3
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  		Fig. 2A —61-year-old man with Gleason grade 8 prostate cancer 6 months after radical retropubic prostatectomy. R = rectum, B = bladder. T2-weighted axial (A), coronal (B), and sagittal (C) endorectal-coil MR images show bilaterally complete, intact, retained seminal vesicles (arrows). Remnants show convoluted structure characteristic of normal seminal vesicles. Tubules show high signal intensity on T2-weighted images, indicating their fluid content. Ductus deferens (asterisks, A and B) are also noted.

 

Figure 4
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  		Fig. 2B —61-year-old man with Gleason grade 8 prostate cancer 6 months after radical retropubic prostatectomy. R = rectum, B = bladder. T2-weighted axial (A), coronal (B), and sagittal (C) endorectal-coil MR images show bilaterally complete, intact, retained seminal vesicles (arrows). Remnants show convoluted structure characteristic of normal seminal vesicles. Tubules show high signal intensity on T2-weighted images, indicating their fluid content. Ductus deferens (asterisks, A and B) are also noted.

 

Figure 5
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  		Fig. 2C —61-year-old man with Gleason grade 8 prostate cancer 6 months after radical retropubic prostatectomy. R = rectum, B = bladder. T2-weighted axial (A), coronal (B), and sagittal (C) endorectal-coil MR images show bilaterally complete, intact, retained seminal vesicles (arrows). Remnants show convoluted structure characteristic of normal seminal vesicles. Tubules show high signal intensity on T2-weighted images, indicating their fluid content. Ductus deferens (asterisks, A and B) are also noted.

 

Figure 6
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  		Fig. 3 —46-year-old man with Gleason grade 8 prostate cancer 10 months after retropubic radical prostatectomy. T2-weighted axial endorectal-coil MR image shows retained low-signal-intensity lateral portion of seminal vesicle on left (arrows). Medial to seminal vesicle remnant, adjacent to rectum, is soft-tissue mass of intermediate signal intensity (asterisk), suggestive of local recurrence. Transrectal sonography-guided biopsy of mass showed prostatic adenocarcinoma. Configuration and signal intensity differ between presumably fibrotic seminal vesicle remnant and local recurrence. Seminal vesicle remnant is of lower signal intensity (similar to adjacent pelvic muscles) and has irregular, convoluted shape. B = bladder, R = rectum, M = muscles.

 

Figure 7
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  		Fig. 4A —64-year-old man with Gleason grade 6 prostate cancer 60 months after retropubic radical prostatectomy. R = rectum, B = bladder. T2-weighted axial (A) and coronal (B) endorectal-coil MR images show unilaterally retained right seminal vesicle tip (solid arrow). Seminal vesicle remnant is fluid-filled and intact. Left ductus deferens stump (open arrow, A) is also visualized.

 

Figure 8
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  		Fig. 4B —64-year-old man with Gleason grade 6 prostate cancer 60 months after retropubic radical prostatectomy. R = rectum, B = bladder. T2-weighted axial (A) and coronal (B) endorectal-coil MR images show unilaterally retained right seminal vesicle tip (solid arrow). Seminal vesicle remnant is fluid-filled and intact. Left ductus deferens stump (open arrow, A) is also visualized.

 

Figure 9
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  		Fig. 4C —64-year-old man with Gleason grade 6 prostate cancer 60 months after retropubic radical prostatectomy. R = rectum, B = bladder. Axial CT image shows soft-tissue mass (arrow) on right, between bladder and rectum, correlating with retained seminal vesicle.

 

Figure 10
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  		Fig. 5A —56-year-old man with Gleason grade 7 prostate cancer 86 months after retropubic radical prostatectomy. B = bladder, R = rectum, M = muscles. T2-weighted axial (A) and coronal (B) endorectal-coil MR images show bilaterally symmetric low-signal-intensity masses situated where tips of seminal vesicles were presurgically. These masses are suggestive of retained tips of seminal vesicles (arrows) and show low signal intensity similar to that of adjacent pelvic muscles, suggestive of fibrosis. As seminal vesicles undergo fibrosis, they tend to pull down along lateral rectal wall. Low signal intensity, bilaterality, and symmetry of these remnants distinguish them from local recurrence of prostate cancer.

 

Figure 11
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  		Fig. 5B —56-year-old man with Gleason grade 7 prostate cancer 86 months after retropubic radical prostatectomy. B = bladder, R = rectum, M = muscles. T2-weighted axial (A) and coronal (B) endorectal-coil MR images show bilaterally symmetric low-signal-intensity masses situated where tips of seminal vesicles were presurgically. These masses are suggestive of retained tips of seminal vesicles (arrows) and show low signal intensity similar to that of adjacent pelvic muscles, suggestive of fibrosis. As seminal vesicles undergo fibrosis, they tend to pull down along lateral rectal wall. Low signal intensity, bilaterality, and symmetry of these remnants distinguish them from local recurrence of prostate cancer.

 

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  		TABLE 1: Characteristics of Retained Seminal Vesicles (SVs) in 52 Patients

 

Thirty-two (21%) of the 151 patients with retained SV remnants or a suggestion of retained fibrotic SV tips had a preoperative pelvic MRI study available for review. The location of the remnants in the pelvis was similar to the location of the preoperative SVs in all these patients (Figs. 6A and 6B); all remnants were well differentiated from the stumps of the ductus deferens.


Figure 12
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  		Fig. 6A —50-year-old man with Gleason grade 8 prostate cancer. B = bladder, R = rectum. T2-weighted axial endorectal-coil MR images before (A) and 15 months after (B) retropubic radical prostatectomy. Normal seminal vesicles are noted before surgery (black arrows, A). Bilateral low-signal-intensity seminal vesicle remnants are noted (white arrows, B) in similar position in pelvis after surgery.

 

Figure 13
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  		Fig. 6B —50-year-old man with Gleason grade 8 prostate cancer. B = bladder, R = rectum. T2-weighted axial endorectal-coil MR images before (A) and 15 months after (B) retropubic radical prostatectomy. Normal seminal vesicles are noted before surgery (black arrows, A). Bilateral low-signal-intensity seminal vesicle remnants are noted (white arrows, B) in similar position in pelvis after surgery.

 
One hundred ninety (72%) of the 263 patients underwent surgery at a single institution, by 11 different surgeons. The remainder (28%) were referral patients from 27 other institutions. The average time from surgery to MRI was 39.8 months, and the range was 2-179 months (median, 28 months). The average time from surgery to MRI in patients with low-signal-intensity SV remnants or a suggestion of retained fibrotic SV tips was 39.4 months (range, 2-179 months; median, 28 months; n = 119); in patients with fluid-filled SV remnants, the average interval was 41.5 months (range, 3-144 months; median, 26.5 months; n = 32).

Forty-four fluid-filled convoluted SV remnants were retained in 32 patients. Ten of these patients underwent follow-up MRI examinations, with a total of 12 fluid-filled SV remnants. Six (50%) of these 12 SV remnants showed an interval decrease in size and were of low signal intensity on follow-up examination, suggesting fibrosis (Figs. 7A and 7B). The average interval between the examinations was 29 months (range, 16-53 months; n = 6). Of the six patients with low-signal-intensity SVs on followup, two received pelvic radiation therapy and three began receiving hormonal treatment during the interval between the MRI examinations.


Figure 14
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  		Fig. 7A —65-year-old man with Gleason grade 7 prostate cancer. B = bladder, R = rectum. T2-weighted sagittal endorectal-coil MR image obtained 20 months after retropubic radical prostatectomy shows complete, intact, retained seminal vesicle (arrow).

 

Figure 15
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  		Fig. 7B —65-year-old man with Gleason grade 7 prostate cancer. B = bladder, R = rectum. Image of same site 16 months later shows smaller seminal vesicle of lower signal intensity (arrow), suggestive of fibrosis. In interval, patient received hormonal therapy for rising level of prostate-specific antigen.

 


Discussion
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 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
SVs are symmetric fluid-filled glands that produce and secrete fluid to the ejaculate. The production of seminal fluid requires the presence of SVs and is maintained by androgen secretion [24]. SVs arise bilaterally at the base of the prostate, close to the bladder neck. Each SV consists of a single tube coiled on itself, generally about 5 cm in length. SVs may extend superiorly to the ureterovesical junctions or they may reflect inferiorly, with the tips embedded toward the prostatic capsule. The MRI appearance of the SVs has been well described. On T1-weighted images, SVs normally are of homogeneous, intermediate signal intensity, similar to that of the adjacent pelvic muscles. On T2-weighted images, the appearance of SVs varies, depending on the fluid content at the time of imaging. Generally, the outer fibromuscular sheet and the convoluted inner walls are of low signal intensity, in contrast to the high-signal-intensity fluid within the ducts, giving a typically "grape-like" appearance [25]. The SVs lie close to the bladder neck, the prostatic pedicles, the neurovascular bundles, and branches of the penile vasculature. These structures are in part responsible for the vascular supply and innervation of the trigone, the neobladder neck, the posterior urethra, and the penis. Damage to any of these structures potentially could result in impotence or incontinence. The traditional technique of retropubic RP includes complete dissection and removal of the SVs. A number of authors [10, 26, 27] have suggested that complete removal may not be necessary for patients in whom no gross evidence of tumor involvement of the SVs is identified during surgery. These authors commented that dissecting the SVs to a lesser extent, leaving portions intact, may prevent injury to vital vascular and neural structures and thus result in a better chance of continence and potency, with minimal risk of leaving behind residual tumor.

The incidence of retained SVs after retropubic RP has not been described. Our study showed that SV remnants were detected in 52 (20%) of 263 of the patients examined, with an additional 99 patients (38%) having findings suggestive of retained fibrotic SV tips. In 22 (8%) of the patients examined, the seminal vesicles were retained at more than half their presurgical size. As shown in our study, this appearance may persist for years after surgery. SV remnants showing low signal intensity on T2-weighted images ranged from intermediate to low signal intensity, compared with the signal intensity of water. The decreased signal intensity is assumed to be related to differing degrees of fibrosis, as shown in our limited group of patients who had follow-up MRI examinations. In addition, we identified many patients with bilaterally symmetric low-signal-intensity lesions in the lateral aspect of the prostatectomy fossa, resembling and suggestive of fibrotic retained lateral portions of SVs. Low-signal-intensity, presumably fibrotic, SV remnants and a suggestion of retained fibrotic SV tips are found most commonly in the superolateral aspects of the prostatectomy fossa. The mechanism of fibrosis is not known, and factors affecting this process have not yet been identified. Presumably, this fibrosis may be related to injury of the innervation or vascular supply of the SVs; alternatively, the fibrosis may be related to androgen-deprivation therapy or radiation therapy. In our study, no specific findings suggested that fibrosis was a factor of time. To determine whether this suggestion is true, further investigation is needed into the temporal changes of retained SV remnants over time.

As opposed to residual prostatic tissue, retained SVs do not secrete prostate-specific antigen [23, 28]. They may, however, pose a diagnostic challenge for postsurgical followup of patients. When the SVs undergo fibrosis, they tend to pull down along the lateral aspects of the rectum. In this location, they may be palpated on digital rectal examination as small firm nodules and may be mistaken for a local recurrence. In addition, retained SVs may appear on CT as a soft-tissue mass in the prostatectomy fossa and, again, may be mistaken for a local recurrence. Finally, retained SV remnants are a potential site for local recurrence. A recent study showed the site of local recurrence to be within retained SVs in 21.5% of patients in whom MRI depicted local recurrences [21]. Thus, if a patient is to be treated with salvage radiation therapy for a pelvic recurrence after prostatectomy, it may be important to recognize retained portions of SVs to include them in the radiation field.

All the pathology reports we reviewed mentioned SVs as part of the specimen, yet in 25% of the patients in this study for whom the pathology report was available, complete or partial SVs were noted on MR images. Thus, if an MRI finding is suggestive of a retained SV, this consideration should not be affected by the pathology report. This is true also for patients with retained SV tips, because in those patients, the pathologist really does review SV tissue but cannot know whether the SV was removed entirely.

Because SV remnants are not considered to be pathologic, they do not undergo biopsy or resection; therefore, our findings lack pathologic correlation to prove that they indeed represented remnants of SVs. When the SV remnants were fluid-filled, the MRI appearance of convoluted fluid-filled tubules was identical to that of preoperative SVs. When they were fibrotic, we relied on the bilateral symmetric nature of the finding and the location in the surgical bed to make the diagnosis, and if a clear determination was not possible by MR appearance alone, we classified them as suggestive of retained SV. Signal intensity and configuration helped in differentiating fibrotic SV remnants from a local recurrence of prostate cancer. The lack of pathologic proof is a limitation of this study, inherent to its nature. Most patients in this study were referred for MRI because, clinically, they were suspected of having a local recurrence. This poses a potential selection bias for our patient population; however, this bias is inherent to the nature of our study, because only rarely do postprostatectomy patients undergo MRI for any other reason.

The exact number of SV-sparing procedures is not available in this study because of incomplete surgical reports. These were due to some referral patients who underwent surgery elsewhere and a few patients who underwent surgery many years before the MRI was performed, making acquisition of clinical data difficult at times. However, whether an SV remnant was retained intentionally does not affect the clinical and radiologic implications it may have.

In conclusion, with increasing interest in MRI of the postprostatectomy fossa, it is important for radiologists to become acquainted with the spectrum of postsurgical alterations that they may encounter on these studies. Retained SV remnants are a common finding that must be recognized to prevent misinterpretation as a local recurrence. We suggest reporting this finding as part of the standard report of a postprostatectomy pelvic MRI examination for the benefit of clinicians and radiologists involved in the patient's treatment.


References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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