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Vesicoperineal Accessory Urethra
GD22-5347 /?8/1201~0255(t02. 00/0 TP2 ,.JDUR.NAL {)F UROLOGY
Copyright © 197S by The Vlillia;T1s & \'TilkiY1s Co.
VESICOPERINEAL ACCESSORY URETHRA KENNETH L GLASSBERG,* ROBERT SCHWARZ
AND
JACK 0. HALLER
From the Departments of Urology and Radiology, State University of New York, Downstate Medical Center, Brooklyn, New York, and the Department of Urology, Alder Hey Children's Hospital, Liverpool, England
ABSTRACT
A previously undescribed form of accessory urethra was found in 2 boys. In each the supernumerary urethra originated from the bladder, just anterior to the vesical neck, passed anterior to the prostate and crossed the normal urethra. In 1 case the channel ended blindly and in the other it opened on the posterior aspect of the scrotum. In the recent literature 2 large series of patients with urethral duplication have been reviewed. 1. 2 In neither of these, nor in any previous report, has there been a case of vesicoperineal accessory urethra. Herein we report on 2 boys with this lesion. CASE REPORTS
Case 1. A. A., a 14-year-old boy, was referred to Alder Hey
Children's Hospital because of a 2-year history of perinea! dribbling of urine. The dribbling was noted mostly when the boy first got out of bed in the morning, in addition to a few drops when he voided. He was otherwise completely continent. Neither the boy nor the parents had ever noticed any perineal or scrotal inflammation or swelling and there was no history of injury.
uneventful and the boy has remained dry. Histological examination of the lower portion of the tract showed a lining of squamous epithelium. The proximal end was unsuitable for study. The portion of the prostate and bladder neck excised with the tract revealed no abnormality. There were no inflammatory changes. Case 2. R. S., a 7-year-old boy, was referred to the Downstate Medical Center because of a history of gross hematuria and pain when voiding. Physical examination was unremarkable. Urinalysis revealed many pus cells and 4 to 6 red blood cells per high power field. Culture yielded a significant growth of Escherichia coli. An excretory urogram was normal. A voiding cystourethrogram demonstrated mild ureteral reflux on the left side and an accessory urethra, which originated from the bladder anterior and to the right of the bladder neck.
FIG. 1. Case 1. A, probe demonstrates cutaneous opening of accessory tract at base of scrotum. B, voiding cystourethrog:ram shows accessory tract originating anteriorly at bladder neck and crossing normal urethra to terminate in posterior position.
On examination the only abnormality was a small fistulous opening on the posterior aspect of the scrotum just to the left of the midline (fig. 1, A). The urine was clear and sterile. A voiding cystourethrogram showed a tract arising from the bladder to the left and anterior to the bladder neck, which crossed the normal urethra before terminating on the scrotal skin (fig. 1, B). At cystoscopy the proximal orifice of the tract could not be identified but when blue dye was injected into the scrotal orifice it appeared in the bladder. The tract was excised by a combined abdominal and perineal approach (fig. 2). From the left side of the bladder neck it passed anterior to the prostate and through the pelvic floor. Convalescence was Accepted for publication October 21, 1977. * Requests for reprints: Department of Urology, State University of New York, Downstate Medical Center, 450 Clarkson Ave., Brooklyn, New York 11203. 255
It crossed posteriorly, crossing the normal urethra, and ended blindly in a bulbous dilatation just in front of the anal canal (fig. 3). At operation the tract was isolated and divided anterior to the prostate. Its lumen was too narrow to allow catheterization but urine flowed freely from the proximal cut end. Both ends were fulgurated. No attempt was made to dissect the distal portion of the tract. Subsequently, the patient has been free of symptoms. DISCUSSION
Although it is likely that the accessory urethras in our patients were of developmental origin the anatomy of the condition does not allow a ready embryological explanation. In the older boy the urinary leakage had been present for only 2 years, which suggested that the scrotal fistula may have been a secondary development. Perhaps the tract was blind
256
GLASSBERG, SCHWARZ AND HALLER
FIG. 3. Voiding cystourethrogram in case 2 demonstrates anterior origin of accessory tract and blind-ending distal perinea! pouch.
and Bloomberg3 in that the accessory urethra originated from the bladder and not the urethra, and the true urethra was normal and not hypoplastic. The vesical origin of the accessory urethra differentiates the condition from the urethroscrotal fistula reported by Redman and Rountree. 4 Simple division of the accessory urethra near its origin was sufficient to produce a symptomatic cure in case 2. It is possible that the same technique might have been equally effective in case 1 and that excision of the tract was unnecessary. Either of these cases alone might be regarded as merely a medical curiosity. However, the occurrence of similar lesions in 2 patients leads us to suggest that future classifications of urethral duplication should include the rare entity of vesicoperineal accessory urethra in the male. FIG. 2. Dissection of distal tract via perineum in case 1
initially, as in the younger boy, but infection led to abscess formation and ultimate communication with the exterior. Alternatively, there may have been a minute complete tract from the outset, which underwent growth changes when the patient was 12 years old and then permitted urinary leakage. The fact that the lower portion of the tract was lined with squamous epithelium and not granulation tissue tends to support the latter concept. The vesicoperineal accessory urethra in our patients differed from the Y-duplication of the urethra described by Williams
Mr. J. Herbert Johnston and Dr. Keith Waterhouse allowed us to report their cases and provided valuable advice. REFERENCES
1. Williams, D. I. and Kenawi, M. M.: Urethral duplications in the
male. Eur. Ural., 1: 209, 1975. 2. Effmann, E. L., Lebowitz, R. L. and Colodny, A.H.: Duplication of the urethra. Radiology, 119: 179, 1976. 3. Williams, D. I. and Bloomberg, S.: Bifid urethra with pre-anal accessory track (Y duplication). Brit. J. Ural., 47: 877, 1976. 4. Redman, J. F. and Rountree, G. A.: Congenital urethral scrotal fistula. Urology, 9: 310, 1977.
Copyright © 197S by The Vlillia;T1s & \'TilkiY1s Co.
VESICOPERINEAL ACCESSORY URETHRA KENNETH L GLASSBERG,* ROBERT SCHWARZ
AND
JACK 0. HALLER
From the Departments of Urology and Radiology, State University of New York, Downstate Medical Center, Brooklyn, New York, and the Department of Urology, Alder Hey Children's Hospital, Liverpool, England
ABSTRACT
A previously undescribed form of accessory urethra was found in 2 boys. In each the supernumerary urethra originated from the bladder, just anterior to the vesical neck, passed anterior to the prostate and crossed the normal urethra. In 1 case the channel ended blindly and in the other it opened on the posterior aspect of the scrotum. In the recent literature 2 large series of patients with urethral duplication have been reviewed. 1. 2 In neither of these, nor in any previous report, has there been a case of vesicoperineal accessory urethra. Herein we report on 2 boys with this lesion. CASE REPORTS
Case 1. A. A., a 14-year-old boy, was referred to Alder Hey
Children's Hospital because of a 2-year history of perinea! dribbling of urine. The dribbling was noted mostly when the boy first got out of bed in the morning, in addition to a few drops when he voided. He was otherwise completely continent. Neither the boy nor the parents had ever noticed any perineal or scrotal inflammation or swelling and there was no history of injury.
uneventful and the boy has remained dry. Histological examination of the lower portion of the tract showed a lining of squamous epithelium. The proximal end was unsuitable for study. The portion of the prostate and bladder neck excised with the tract revealed no abnormality. There were no inflammatory changes. Case 2. R. S., a 7-year-old boy, was referred to the Downstate Medical Center because of a history of gross hematuria and pain when voiding. Physical examination was unremarkable. Urinalysis revealed many pus cells and 4 to 6 red blood cells per high power field. Culture yielded a significant growth of Escherichia coli. An excretory urogram was normal. A voiding cystourethrogram demonstrated mild ureteral reflux on the left side and an accessory urethra, which originated from the bladder anterior and to the right of the bladder neck.
FIG. 1. Case 1. A, probe demonstrates cutaneous opening of accessory tract at base of scrotum. B, voiding cystourethrog:ram shows accessory tract originating anteriorly at bladder neck and crossing normal urethra to terminate in posterior position.
On examination the only abnormality was a small fistulous opening on the posterior aspect of the scrotum just to the left of the midline (fig. 1, A). The urine was clear and sterile. A voiding cystourethrogram showed a tract arising from the bladder to the left and anterior to the bladder neck, which crossed the normal urethra before terminating on the scrotal skin (fig. 1, B). At cystoscopy the proximal orifice of the tract could not be identified but when blue dye was injected into the scrotal orifice it appeared in the bladder. The tract was excised by a combined abdominal and perineal approach (fig. 2). From the left side of the bladder neck it passed anterior to the prostate and through the pelvic floor. Convalescence was Accepted for publication October 21, 1977. * Requests for reprints: Department of Urology, State University of New York, Downstate Medical Center, 450 Clarkson Ave., Brooklyn, New York 11203. 255
It crossed posteriorly, crossing the normal urethra, and ended blindly in a bulbous dilatation just in front of the anal canal (fig. 3). At operation the tract was isolated and divided anterior to the prostate. Its lumen was too narrow to allow catheterization but urine flowed freely from the proximal cut end. Both ends were fulgurated. No attempt was made to dissect the distal portion of the tract. Subsequently, the patient has been free of symptoms. DISCUSSION
Although it is likely that the accessory urethras in our patients were of developmental origin the anatomy of the condition does not allow a ready embryological explanation. In the older boy the urinary leakage had been present for only 2 years, which suggested that the scrotal fistula may have been a secondary development. Perhaps the tract was blind
256
GLASSBERG, SCHWARZ AND HALLER
FIG. 3. Voiding cystourethrogram in case 2 demonstrates anterior origin of accessory tract and blind-ending distal perinea! pouch.
and Bloomberg3 in that the accessory urethra originated from the bladder and not the urethra, and the true urethra was normal and not hypoplastic. The vesical origin of the accessory urethra differentiates the condition from the urethroscrotal fistula reported by Redman and Rountree. 4 Simple division of the accessory urethra near its origin was sufficient to produce a symptomatic cure in case 2. It is possible that the same technique might have been equally effective in case 1 and that excision of the tract was unnecessary. Either of these cases alone might be regarded as merely a medical curiosity. However, the occurrence of similar lesions in 2 patients leads us to suggest that future classifications of urethral duplication should include the rare entity of vesicoperineal accessory urethra in the male. FIG. 2. Dissection of distal tract via perineum in case 1
initially, as in the younger boy, but infection led to abscess formation and ultimate communication with the exterior. Alternatively, there may have been a minute complete tract from the outset, which underwent growth changes when the patient was 12 years old and then permitted urinary leakage. The fact that the lower portion of the tract was lined with squamous epithelium and not granulation tissue tends to support the latter concept. The vesicoperineal accessory urethra in our patients differed from the Y-duplication of the urethra described by Williams
Mr. J. Herbert Johnston and Dr. Keith Waterhouse allowed us to report their cases and provided valuable advice. REFERENCES
1. Williams, D. I. and Kenawi, M. M.: Urethral duplications in the
male. Eur. Ural., 1: 209, 1975. 2. Effmann, E. L., Lebowitz, R. L. and Colodny, A.H.: Duplication of the urethra. Radiology, 119: 179, 1976. 3. Williams, D. I. and Bloomberg, S.: Bifid urethra with pre-anal accessory track (Y duplication). Brit. J. Ural., 47: 877, 1976. 4. Redman, J. F. and Rountree, G. A.: Congenital urethral scrotal fistula. Urology, 9: 310, 1977.