To report a case of primary seminal vesicle adenocarcinoma (PSVA) presenting with persistent hematospermia as the initial symptom to enhance awareness of this disease.

The data of the patient with PSVA initially presenting with persistent hematospermia treated in our hospital was retrospectively analyzed, with a review of its management strategies and prognostic features based on literature. The 40-years-old patient underwent transurethral seminal vesiculoscopy at an external hospital after failed conservative treatment for persistent hematospermia. Three months postoperatively, hematospermia persisted with new-onset intermittent initial gross hematuria upon waking. The patient was transferred to our center for repeat seminal vesiculoscopy, which revealed hemorrhagic bilateral seminal vesicles and a cauliflower-like mass in the left seminal vesicle. Pathological examination of biopsied tissue confirmed seminal vesicle adenocarcinoma. Subsequent contrast-enhanced MRI and PET/CT revealed left seminal vesicle adenocarcinoma with ipsilateral pelvic lymph node metastasis. The patient underwent robot-assisted laparoscopic radical seminal vesiculectomy with prostatectomy and pelvic lymphadenectomy.

Histopathology confirmed bilateral PSVA infiltrating the prostate, with metastatic adenocarcinoma in the left external iliac lymph node. Follow-up PET/CT at 6 months postoperatively showed no recurrence. One year later, repeat PET/CT and MRI demonstrated right pelvic lymph node metastasis without local recurrence at the primary resection site. Salvage right pelvic lymphadenectomy was performed followed by adjuvant chemoradiotherapy. Follow-up PET/CT scan 1.5 years postoperatively demonstrated tumor recurrence in the right pelvic surgical bed. The patient is currently under ongoing follow-up.

PSVA is an exceptionally rare malignancy with aggressive biological behavior and poor prognosis. Clinically, it most frequently manifests with persistent hematospermia with or without concomitant hematuria as the initial symptom. Due to its exceedingly low incidence, misdiagnosis is common, necessitating heightened clinical vigilance. Radical surgical resection constitutes the cornerstone of treatment. Adjuvant therapies such as chemotherapy or radiotherapy may be considered postoperatively, though their therapeutic outcomes warrant further investigation. Postoperative recurrence remains frequent, mandating close long-term surveillance.