Treatment of Prostatic Cysts
Transurethral unroofing or deroofing of the prostatic cyst is the recommended first-line treatment for symptomatic prostatic cysts, particularly those arising near the bladder neck or prostatic urethra that cause urinary symptoms.
Diagnostic Evaluation
Before determining treatment, proper evaluation is essential:
- Transrectal ultrasonography (TRUS) is the primary diagnostic tool for prostatic cysts 1
- MRI provides excellent imaging for accurate depiction of prostatic cysts and their relationship to surrounding structures 2
- Cystoscopy may be performed to visualize cysts that protrude into the urethra or bladder neck 3
Treatment Algorithm Based on Symptoms and Cyst Characteristics
1. Asymptomatic Prostatic Cysts
- Watchful waiting with periodic monitoring is appropriate
- No intervention required unless symptoms develop
2. Symptomatic Prostatic Cysts
Symptoms typically include:
- Lower urinary tract symptoms (LUTS)
- Urinary retention
- Weak urinary stream
- Frequent urination
- Post-void residual sensation 4
Treatment options based on cyst location and size:
A. Small to Medium Cysts Near Prostatic Urethra or Bladder Neck:
- First-line: Transurethral unroofing/deroofing 3
- Procedure time: 30-50 minutes
- Minimal bleeding (20-70 ml)
- Rapid recovery
- Effective for resolving voiding symptoms
B. Larger Cysts or Those Located Behind Prostatic Urethra:
- First-line: Laparoscopic excision 2
- Procedure time: 100-150 minutes
- Minimal bleeding (30-50 ml)
- Safe and effective with fewer complications
- Rapid recovery
C. Alternative Minimally Invasive Options:
- Transperineal needle aspiration under TRUS guidance 1
- May be both diagnostic and therapeutic
- Consider for patients who are poor surgical candidates
- Higher risk of recurrence compared to surgical options
Follow-up and Monitoring
After treatment:
- Follow-up at 3-6 months with symptom assessment
- Imaging (TRUS or MRI) to confirm resolution
- Long-term monitoring may be necessary as recurrence is possible, particularly after minimally invasive procedures 4
Important Considerations
- Recurrence is a significant challenge after minimally invasive interventions 4
- Complete cyst removal risks damage to adjacent structures; marsupialisation (unroofing) often provides better clinical outcomes 4
- For recurrent cysts after minimally invasive treatment, laparoscopic surgery should be considered 4
Special Situations
For prostatic cysts causing infertility (rather than urinary symptoms), the treatment approach should still follow the same principles, with the goal of preserving reproductive function.
Pitfalls to Avoid
- Misdiagnosis: Prostatic cysts must be differentiated from other cystic lesions in the region (müllerian duct cysts, seminal vesicle cysts, ejaculatory duct cysts)
- Inadequate imaging: Both TRUS and MRI should be utilized for complete characterization
- Incomplete treatment: Partial unroofing may lead to recurrence
While the evidence for prostatic cyst management is limited to case reports and small case series, the consistent successful outcomes with transurethral unroofing for symptomatic cysts near the urethra or bladder neck make this the recommended first-line approach for improving morbidity and quality of life.