Presentation
Painful micturition and right testicular pain for 3 days.
Patient Data
The right kidney is not visualized, likely renal agenesis.
The right kidney is not visualized, likely renal agenesis.
Dilated blind ended atretic right ureter is seen starting at L4-5 level being dilated and tortuous with ectopic insertion into the right seminal vesicle forming a sizable cyst protruding through the posterolateral wall of the urinary bladder at the expected location of right vesicoureteric junction. Its fluid content shows hyperintense signal on T1 and mild decreased T2 signal, possibly due to hemorrhagic content or a high proteinaceous component and likely representing an obstructed ureterocele.
Dilated right ejaculatory duct, representing obstruction. It is seen communicating with the cystic lesion.
Normal left kidney with relative compensatory hypertrophy and normal left ureter.
Right kidney: not visualized.
Left kidney: shows adequate perfusion followed by appropriate parenchymal uptake. Spontaneous excretion of the tracer is noted around 6 minutes post injection followed by adequate response to Lasix administration at 10 minutes. Minimal residual tracer activity is noted at the end of the study.
There is normal left ureter opacification and urinary bladder filling, with non-opacification of the cystic structure seen within the left paramedian aspect of urinary bladder shadow, reflecting no communication with the left ureter.
Time-Activity-Curve (T.A.C.):
Right T.A.C.: not visualized.
Left T.A.C.: adequate first phase followed by uprising second phase and then spontaneous third washout phase slightly accelerated by Lasix injection.
Quantitative analysis:
Right kidney split function = 0%
Left kidney split function = 100%
Normalized GFR = 117 mL/min.
Case Discussion
These imaging studies show right renal agenesis, right lower ureteric remnant with communication to seminal vesicle cystic lesion and obstructed ejaculatory duct.
A triad of seminal vesicle cyst, ipsilateral renal agenesis, and ipsilateral ejaculatory duct obstruction is known as Zinner syndrome. It is a mesonephric duct anomaly, that usually presents in adulthood with urinary tract symptoms, infertility or painful ejaculation. MRI is considered the best modality for confirming the diagnosis, especially in demonstrating the communication of the cystic lesion and seminal vesicle. Patients should be screened for infertility as it has a high association with azoospermia 1,2.
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