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Surgical treatment of utricular cyst in male child
SURGICAL TREATMENT OF UTRICULAR CYST IN MALE CHILD UMESH
B. PATIL,
M.D.,
F.R.C.S.
From the Department of Urology, State University Hospital of the Upstate Medical Center, Syracuse, New York
ABSTRACT -A simple technique for management of utricular cyst is presented. Essentially the technique consists of putting a Fogarty balloon catheter in the cyst through a perineal urethrostomy and injlating the balloon to fill the cyst completely. Using a miniature resectoscope, the septum between the cyst wall and prostatic urethra is resected widely until the Fogarty balloon is completely visualized in the prostatic urethra.
Utricular cysts are a relatively uncommon genital anomaly. Approximately 60 patients been treated with open surgical procedures. report a simple endoscopic treatment for anomaly.
conhave We this
Case Report A sixteen-month-old black boy was admitted to the emergency pediatric surgical service with a history of painful swelling of the right testicle of two days’ duration. The child was afebrile at the time, and he had no history of urinary tract infection. On physical examination the left testis was normal, and the right was tender, firm and at a higher level than the left. Urinalysis showed 2 to 3 white blood cells and no red blood cells. The white blood count was 10,000. Hematocrit was 35. In view of these signs and symptoms a diagnosis of acute torsion of the right testis was made. At exploration of the testis acute epididymitis was found. On the fourth postoperative day voiding cystourethrogram revealed a cyst arising from the prostatic urethra, and attached to it by a small duct. The right vas deferens also was seen to be filled. The remainder of the urethra was normal. There was no evidence of ureteral reflux, and the
UROLOGY
/ DECEMBER
1975 / VOLUME
VI, NUMBER 6
bladder was normal (Figs. 1A and 2A). Intravenous pyelogram was normal. At cystourethroscopy an opening in the verumontanum was seen. On compressing the cyst with a finger in the rectum, pus exuded through the opening. A ureteral 4 F catheter was introduced into the cyst, and 1 cc. of contrast material was injected to delineate the cyst. It was approximately 8 mm. long and 4 mm. wide (Fig. 1B). After fortyeight hours of antibiotic therapy definitive treatment was carried out. The patient was anesthetized and placed in the lithotomy position. Perineal urethrostomy was performed. Through a cystoscope a 4-Fogarty catheter was passed through the opening at the top of the verumontanum and inflated with 0.5 cc. sterile water. A 14 F Iglesias resectoscope was introduced along the side of the Fogarty catheter into the bladder. The Fogarty balloon was seen bulging into the prostatic urethra being separated from it by a thin septum of prostatic tissue. With the cutting current, two loops of tissue were resected so that the balloon of the Fogarty catheter could be seen in the prostatic urethra (Fig. 2B,C). No bleeding occurred at the time of surgery. An 8 Foley catheter was left in the bladder for forty-eight hours. The patient tolerated the procedure well, and convalescence was uneventful.
719
Two weeks postoperatively voiding cystourethrogram showed a large communication between the utricular cyst and the prostatic urethra (Figs. 2D and 3). The patient could void freely with good urinary control. At follow-up three months later the child had no recurrence of urinary tract infection nor evidence of recurrent epididymitis. Comment The miillerian duct at an early period of male development is a large structure; and, in the adult, ifit failed to degenerate, it would follow the course of the vas deferens from the side of the testicle through the inguinal canal, and would then pass through the substance of the prostate gland medial to the ejaculatory ducts, to join its mate to form the utricle.’ Many patients with utricular cysts have associated hypospadias, true or pseudo hermaphroditism, undescended testis, or deficient development of the perineum and scrotum.2 Since utricular cysts are congenital in origin, the majority appear in childhood. Generally, patients presented with evidence of urinary tract infection, stone formation in the utricle, difficulty in micturition3 or abscess in the inguinal region as reported by McKenna. 4 Since the cysts are small, generally they cannot be diagnosed by physical examination alone and
720
radiologic examination is essential to visualize them. In the .majority of cases voiding cystourethrography does not visualize the cyst. However, in our case the cyst was shown by voiding cystourethrography. Usually, catheterization of the opening in the verumontanum was needed to show the size and the relationship to the vas deferens and seminal vesicle as described by Gullamo and Sundberg.5 In our case the right vas deferens communicated with the cyst. In the past the treatment of these cysts has been surgical excision by either the suprapubic route as described by Spence6 or the perineal route. If one uses the perineal route in a child, there is the possibility of the child being impotent in later life. On the other hand, if one uses the retro- or suprapubic route, the internal sphincteric mechanism can easily be damaged while obtaining exposure, and this may lead to retrograde ejaculation. The endoscopic technique avoids these potential hazards. By putting in a Fogarty catheter, the cyst wall can be delineated as can the landmarks of the bladder neck and the external sphincter. By resection with a miniature resectoscope distal to the bladder neck and proximal to the verumontanum, a wide communication can be developed. The balloon of the catheter is rubber, and being a nonconductor of electricity, damage to other parts of the prostatic urethra is prevented.
UROLOGY
/ DECEMBER1975
/ VOLUMEVI,
NUMBER6
FIGURE 2. Diagrams showing (A) utricular cyst; and (B) 3-Fogarty catheter being passed through perineal urethrostomy with balloon of catheterfilling utricular cyst. (C) Miniature resectoscope is introduced into bladder along side Fogarty catheter; cutting loop of resectoscope is in contact with prostatic urethra adjacent to balloon. with prostatic urethra. (0) After resection of segment of prostatic urethra, cyst has wide communication
721 UROLOGY
/ DECEMBER1975
/ VOLUMEV1,
NUMBER6
The technique is simple and has much morbidity than .open surgical procedures.
less
Slocum-Dickson Medical Group 430 Court Street Utica, New York 13502
References
FIGURE 3. Postoperative voiding cystourethrogram demonstrating wide communication between cyst and prostatic urethra; leakage of dye through perineal urethrostomy site.
722
1. PATTEN, B. M.: Human Embryology, New York, McGraw-Hill Book Company, 1958, p. 469. of the 2. HOWARD, F. S.: Hypospadius with enlargement prostatic utricle, Surg. Gynecol. Obstet. 86: 307 (1948). as a cause of 3. POLSE, S. : Prostatic utricular enlargement vesicle outlet obstruction in children, J. Urol. 100:329 (1968). 4. MCKENNA, C. M.: Congenital enlargement of the prostatic utricle with inclusion of the ejaculatory ducts and seminal vesicles, Trans. Am. Assoc. Genitourin. Surg. 32: 305 (1939). A method for 5. GULLAMO, A., and SUNDBERG, J.: roentgen examination of posterior urethra, prostatic ducts and utricle, Acta Radiol. 48: 241 (1957). Retropubic approach to cyst of prostatic 6. SPENCE, H.: utricle, J. Urol. 79: 308 (1958).
UROLOGY
I
DECEMBER
1975 /
VOLUME VI, NUMBER 6
B. PATIL,
M.D.,
F.R.C.S.
From the Department of Urology, State University Hospital of the Upstate Medical Center, Syracuse, New York
ABSTRACT -A simple technique for management of utricular cyst is presented. Essentially the technique consists of putting a Fogarty balloon catheter in the cyst through a perineal urethrostomy and injlating the balloon to fill the cyst completely. Using a miniature resectoscope, the septum between the cyst wall and prostatic urethra is resected widely until the Fogarty balloon is completely visualized in the prostatic urethra.
Utricular cysts are a relatively uncommon genital anomaly. Approximately 60 patients been treated with open surgical procedures. report a simple endoscopic treatment for anomaly.
conhave We this
Case Report A sixteen-month-old black boy was admitted to the emergency pediatric surgical service with a history of painful swelling of the right testicle of two days’ duration. The child was afebrile at the time, and he had no history of urinary tract infection. On physical examination the left testis was normal, and the right was tender, firm and at a higher level than the left. Urinalysis showed 2 to 3 white blood cells and no red blood cells. The white blood count was 10,000. Hematocrit was 35. In view of these signs and symptoms a diagnosis of acute torsion of the right testis was made. At exploration of the testis acute epididymitis was found. On the fourth postoperative day voiding cystourethrogram revealed a cyst arising from the prostatic urethra, and attached to it by a small duct. The right vas deferens also was seen to be filled. The remainder of the urethra was normal. There was no evidence of ureteral reflux, and the
UROLOGY
/ DECEMBER
1975 / VOLUME
VI, NUMBER 6
bladder was normal (Figs. 1A and 2A). Intravenous pyelogram was normal. At cystourethroscopy an opening in the verumontanum was seen. On compressing the cyst with a finger in the rectum, pus exuded through the opening. A ureteral 4 F catheter was introduced into the cyst, and 1 cc. of contrast material was injected to delineate the cyst. It was approximately 8 mm. long and 4 mm. wide (Fig. 1B). After fortyeight hours of antibiotic therapy definitive treatment was carried out. The patient was anesthetized and placed in the lithotomy position. Perineal urethrostomy was performed. Through a cystoscope a 4-Fogarty catheter was passed through the opening at the top of the verumontanum and inflated with 0.5 cc. sterile water. A 14 F Iglesias resectoscope was introduced along the side of the Fogarty catheter into the bladder. The Fogarty balloon was seen bulging into the prostatic urethra being separated from it by a thin septum of prostatic tissue. With the cutting current, two loops of tissue were resected so that the balloon of the Fogarty catheter could be seen in the prostatic urethra (Fig. 2B,C). No bleeding occurred at the time of surgery. An 8 Foley catheter was left in the bladder for forty-eight hours. The patient tolerated the procedure well, and convalescence was uneventful.
719
Two weeks postoperatively voiding cystourethrogram showed a large communication between the utricular cyst and the prostatic urethra (Figs. 2D and 3). The patient could void freely with good urinary control. At follow-up three months later the child had no recurrence of urinary tract infection nor evidence of recurrent epididymitis. Comment The miillerian duct at an early period of male development is a large structure; and, in the adult, ifit failed to degenerate, it would follow the course of the vas deferens from the side of the testicle through the inguinal canal, and would then pass through the substance of the prostate gland medial to the ejaculatory ducts, to join its mate to form the utricle.’ Many patients with utricular cysts have associated hypospadias, true or pseudo hermaphroditism, undescended testis, or deficient development of the perineum and scrotum.2 Since utricular cysts are congenital in origin, the majority appear in childhood. Generally, patients presented with evidence of urinary tract infection, stone formation in the utricle, difficulty in micturition3 or abscess in the inguinal region as reported by McKenna. 4 Since the cysts are small, generally they cannot be diagnosed by physical examination alone and
720
radiologic examination is essential to visualize them. In the .majority of cases voiding cystourethrography does not visualize the cyst. However, in our case the cyst was shown by voiding cystourethrography. Usually, catheterization of the opening in the verumontanum was needed to show the size and the relationship to the vas deferens and seminal vesicle as described by Gullamo and Sundberg.5 In our case the right vas deferens communicated with the cyst. In the past the treatment of these cysts has been surgical excision by either the suprapubic route as described by Spence6 or the perineal route. If one uses the perineal route in a child, there is the possibility of the child being impotent in later life. On the other hand, if one uses the retro- or suprapubic route, the internal sphincteric mechanism can easily be damaged while obtaining exposure, and this may lead to retrograde ejaculation. The endoscopic technique avoids these potential hazards. By putting in a Fogarty catheter, the cyst wall can be delineated as can the landmarks of the bladder neck and the external sphincter. By resection with a miniature resectoscope distal to the bladder neck and proximal to the verumontanum, a wide communication can be developed. The balloon of the catheter is rubber, and being a nonconductor of electricity, damage to other parts of the prostatic urethra is prevented.
UROLOGY
/ DECEMBER1975
/ VOLUMEVI,
NUMBER6
FIGURE 2. Diagrams showing (A) utricular cyst; and (B) 3-Fogarty catheter being passed through perineal urethrostomy with balloon of catheterfilling utricular cyst. (C) Miniature resectoscope is introduced into bladder along side Fogarty catheter; cutting loop of resectoscope is in contact with prostatic urethra adjacent to balloon. with prostatic urethra. (0) After resection of segment of prostatic urethra, cyst has wide communication
721 UROLOGY
/ DECEMBER1975
/ VOLUMEV1,
NUMBER6
The technique is simple and has much morbidity than .open surgical procedures.
less
Slocum-Dickson Medical Group 430 Court Street Utica, New York 13502
References
FIGURE 3. Postoperative voiding cystourethrogram demonstrating wide communication between cyst and prostatic urethra; leakage of dye through perineal urethrostomy site.
722
1. PATTEN, B. M.: Human Embryology, New York, McGraw-Hill Book Company, 1958, p. 469. of the 2. HOWARD, F. S.: Hypospadius with enlargement prostatic utricle, Surg. Gynecol. Obstet. 86: 307 (1948). as a cause of 3. POLSE, S. : Prostatic utricular enlargement vesicle outlet obstruction in children, J. Urol. 100:329 (1968). 4. MCKENNA, C. M.: Congenital enlargement of the prostatic utricle with inclusion of the ejaculatory ducts and seminal vesicles, Trans. Am. Assoc. Genitourin. Surg. 32: 305 (1939). A method for 5. GULLAMO, A., and SUNDBERG, J.: roentgen examination of posterior urethra, prostatic ducts and utricle, Acta Radiol. 48: 241 (1957). Retropubic approach to cyst of prostatic 6. SPENCE, H.: utricle, J. Urol. 79: 308 (1958).
UROLOGY
I
DECEMBER
1975 /
VOLUME VI, NUMBER 6