What is the recommended treatment for a patient with a prostatic cyst?

Treatment of Prostatic Cysts

Transurethral unroofing or deroofing of the prostatic cyst is the recommended first-line treatment for symptomatic prostatic cysts, particularly those located near the bladder neck or prostatic urethra causing urinary obstruction.

Diagnosis and Evaluation

• Imaging: Transrectal ultrasonography (TRUS) is the primary diagnostic tool for prostatic cysts 1

  • Provides real-time visualization of cyst location, size, and relationship to surrounding structures
  • Can guide aspiration procedures if needed

• Additional imaging:

  • MRI offers better soft tissue contrast and is valuable for accurate characterization of prostatic cysts 2
  • Helps differentiate prostatic cysts from other pathologies

• Clinical presentation:

  • Many prostatic cysts are asymptomatic and discovered incidentally
  • Symptomatic cysts typically present with:
    • Lower urinary tract symptoms (LUTS)
    • Urinary retention
    • Weak urinary stream
    • Frequent urination
    • Sensation of incomplete emptying 3, 4

Treatment Algorithm

1. Asymptomatic Prostatic Cysts

• Recommendation: Watchful waiting/observation
  • Regular follow-up with PSA and imaging as appropriate 5
  • No intervention needed if the cyst is not causing symptoms

2. Symptomatic Prostatic Cysts

• Location-based approach:

  a) For cysts near prostatic urethra or bladder neck:

  • First-line: Transurethral unroofing/deroofing 4
    • Procedure duration: 30-50 minutes
    • Minimal blood loss (20-70 ml)
    • High success rate for symptom resolution

  b) For larger cysts or those located deeper/behind prostatic urethra:

  • First-line: Laparoscopic excision 2
    • Procedure duration: 100-150 minutes
    • Minimal blood loss (30-50 ml)
    • Excellent outcomes with minimal invasiveness

  c) For recurrent cysts after minimally invasive treatment:

  • Consider definitive laparoscopic surgery with marsupialisation 3

3. Minimally Invasive Options

• Transperineal needle aspiration:
  • Can be both diagnostic and potentially therapeutic 1
  • May be considered for initial management in select cases
  • Higher risk of recurrence compared to surgical options

Follow-up and Monitoring

• Post-procedure follow-up should include:
  • Assessment of symptom resolution
  • Urinary function evaluation
  • Imaging (ultrasound) to confirm cyst resolution
  • Long-term follow-up (3-12 months) to monitor for recurrence 2

Important Considerations

• Prostatic cysts may recur after minimally invasive procedures, requiring more definitive treatment 3
• Complete removal of cysts carries risk of damage to adjacent structures
• Marsupialisation technique improves clinical outcomes in complex cases 3
• Transurethral resection has shown successful resolution of voiding symptoms in patients with prostatic cysts around the bladder neck 4

While the evidence for prostatic cyst management is limited in current guidelines, the available research strongly supports transurethral unroofing as the first-line approach for symptomatic cysts, with laparoscopic excision reserved for larger or recurrent cysts. This approach balances effective symptom resolution with minimal invasiveness and complications.