- Email: [email protected]
Cystoscopic-assisted laparoscopic excision of prostatic utricle
+
MODEL
Journal of Pediatric Urology (2017) xx, 1e2
Video Bank
Cystoscopic-assisted laparoscopic excision of prostatic utricle* Ibrahim A. Mostafa a, Mark N. Woodward a, Mohamed S. Shalaby a,b a
Department of Paediatric Surgery, Bristol Royal Hospital for Children, Bristol, UK
b
Department of Paediatric Surgery, Ain Shams University, Cairo, Egypt Correspondence to: M.S. Shalaby, Department of Paediatric Surgery, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol BS2 8BJ, UK [email protected] (M.S. Shalaby) Keywords Prostatic utricle; Utricle; Utriculus; Cystoscopic assisted laparoscopic excision; Mullerian duct remnant Received 8 July 2017 Accepted 14 September 2017 Available online xxx
*
Summary We present a video of our technique for resection of a large prostatic utricle (PU) in a patient who presented initially with disordered sexual development. His karyotype was 46XY, and phenotypically had penoscrotal hypospadias, bifid scrotum, and retractile right testis. An initial micturating cystourethrogram (MCUG) demonstrated the utricle but failed to cannulate the bladder. Being asymptomatic, we carried out staged repair of his hypospadias. Later, he started to have recurrent epididymo-orchitis with resistance to multiple antibiotics. Examination under anaesthesia was done and ruled out meatal or neo-urethral strictures. A subsequent MCUG
demonstrated the large utricle and its relation to the bladder. We carried out a cystoscopic-assisted laparoscopic excision. There has been no consensus about the best surgical approach to resect a PU and most known procedures involved extensive pelvic dissection and carried a significant risk of damage to the pelvic nerves. The laparoscopic approach seems to be promising in this field as it provides proper view of the deep pelvis with reasonable magnification, less dissection and shorter postoperative pain and scarring. Cystoscopic assistance in this technique was a great addition to provide counter-traction movement and facilitate proper dissection.
Prostatic utricle (PU) is not a common pathology. Most cases are seen within a triad of proximal hypospadias, cryptorchidism, and PU [1]. It is an enlarged midline diverticulum arising from the posterior urethra in males, between the two ejaculatory ducts on the verumontanum [2]. Embryologically, it represents the caudal end of the Mu ¨llerian duct that regresses in boys by the effect of the Mu ¨llerian inhibiting factor. Failure of regression results in a PU, hence, the common association with disorders of sexual development [3]. Most cases are asymptomatic. However, about 29% of patients may present clinically with lower urinary tract symptoms, postvoid dribbling, urethral discharge, recurrent urinary tract infections, epididymo-orchitis, stones, secondary incontinence cause by trapping of urine in the pouch, and retention of urine. Surgical excision is the gold standard but is only offered to symptomatic patients [2]. Being such a rare condition, and given its challenging anatomical position, there has been no consensus about the best surgical approach to resect a PU. Many surgical approaches have been described, most of them mandating extensive pelvic dissection and carrying the risk of damage to pelvic structures. Abdominal transperitoneal, perineal, and
combined abdomino-perineal approaches have been described in the past. More recently, anterior sagittal, posterior sagittal transrectal, and rectum-retraction techniques have been advocated. Additionally, suprapubic extravesical and transvesical transtrigonal procedures have been described [3]. The latter gained popularity as being more advantageous in exposing the neck of the PU and facilitating better dissection and complete resection [1]. With evolution of the minimally invasive surgeries, Yeung et al. [4], reported the first series of four cases who successfully underwent laparoscopic excision of PU. They recruited three ports and stitched the bladder to the anterior abdominal wall by a transcutaneous stitch. They used intra-corporeal stitching to close the urethral stump. Their results were promising. Since then, few reports have been published mentioning the advantages of the laparoscopic techniques, with some variations in the number of ports used, the way of cannulating the utricle and creating traction on the bladder. The laparoscopic technique is becoming the procedure of choice in these cases. Jia et al. [2] reported a retrospective comparison between open transvesical approach and laparoscopic approach, which involved a total of 14
This video was presented at the International Pediatric Endosurgery Group (IPEG) 2017 annual congress in London.
https://doi.org/10.1016/j.jpurol.2017.09.024 1477-5131/ª 2017 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Mostafa IA, et al., Cystoscopic-assisted laparoscopic excision of prostatic utricle, Journal of Pediatric Urology (2017), https://doi.org/10.1016/j.jpurol.2017.09.024
+
MODEL
2 patients. They concluded that the laparoscopic technique provided shorter operative time, hospital stay, and catheter duration, as well as better cosmetic outcome. Preoperatively, we had detailed counselling with the parents regarding the possibility of insertion of the vas into the PU and how this can be managed. We highlighted the options of either preserving the vas at the extent of complete PU excision versus vasectomy and complete excision. We highlighted that division of the vas will only be carried out if it is inserted in the PU and cannot be fully separated from it. The parents opted for vasectomy and complete PU excision. We hereby present a video for our technique, using three ports and a bladder hitching stitch. The utricle was scoped and the scope was left in situ to facilitate mobilizing the PU and creating a counter-traction movement. Careful dissection of both vasa differentia was carried out, this revealed intra-utricular insertion of both vasa, hence both were divided to facilitate complete excision of the PU as per the preoperative discussion with the parents. Postoperative MCUG demonstrated no remnants and the patient has been asymptomatic since then. We believe that cystoscopic counter-traction is an important adjunct to facilitate complete laparoscopic excision of the PU. The options of vasectomy to allow complete excision of the PU versus leaving a residual stump and preserving the vas is a crucial aspect in counselling the parents preoperatively if it is inserted in the PU and cannot be separated from it completely.
I.A. Mostafa et al.
Conflict of interest None.
Funding None.
Appendix A. Supplementary data Supplementary data related to this article can be found at https://doi.org/10.1016/j.jpurol.2017.09.024.
References [1] Benedetto V Di, Bagnara V, Guys JM, Meyrat JM, Monfort G. A transvesical approach to Mu ¨llerian duct remnants. Pediatr Surg Int 1997;12:151e4. [2] Jia W, Chang Liu G, Yu Zhang L, Quan Wen Y, Fu W, Hua Hu J, et al. Comparison of laparoscopic excision versus open transvesical excision for symptomatic prostatic utricle in children. J Pediatr Surg 2016;51:1597e601. [3] Ramachandra M, Bendre PS, Redkar RG, Taide DV. Isolated prostatic utricle. J Indian Assoc Pediatr Surg 2009;14:228e9. [4] Yeung CK, Sihoe JDY, Tam YH, Lee KH. Laparoscopic excision of prostatic utricles in children. BJU Int 2001;87:505e8.
Please cite this article in press as: Mostafa IA, et al., Cystoscopic-assisted laparoscopic excision of prostatic utricle, Journal of Pediatric Urology (2017), https://doi.org/10.1016/j.jpurol.2017.09.024
MODEL
Journal of Pediatric Urology (2017) xx, 1e2
Video Bank
Cystoscopic-assisted laparoscopic excision of prostatic utricle* Ibrahim A. Mostafa a, Mark N. Woodward a, Mohamed S. Shalaby a,b a
Department of Paediatric Surgery, Bristol Royal Hospital for Children, Bristol, UK
b
Department of Paediatric Surgery, Ain Shams University, Cairo, Egypt Correspondence to: M.S. Shalaby, Department of Paediatric Surgery, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol BS2 8BJ, UK [email protected] (M.S. Shalaby) Keywords Prostatic utricle; Utricle; Utriculus; Cystoscopic assisted laparoscopic excision; Mullerian duct remnant Received 8 July 2017 Accepted 14 September 2017 Available online xxx
*
Summary We present a video of our technique for resection of a large prostatic utricle (PU) in a patient who presented initially with disordered sexual development. His karyotype was 46XY, and phenotypically had penoscrotal hypospadias, bifid scrotum, and retractile right testis. An initial micturating cystourethrogram (MCUG) demonstrated the utricle but failed to cannulate the bladder. Being asymptomatic, we carried out staged repair of his hypospadias. Later, he started to have recurrent epididymo-orchitis with resistance to multiple antibiotics. Examination under anaesthesia was done and ruled out meatal or neo-urethral strictures. A subsequent MCUG
demonstrated the large utricle and its relation to the bladder. We carried out a cystoscopic-assisted laparoscopic excision. There has been no consensus about the best surgical approach to resect a PU and most known procedures involved extensive pelvic dissection and carried a significant risk of damage to the pelvic nerves. The laparoscopic approach seems to be promising in this field as it provides proper view of the deep pelvis with reasonable magnification, less dissection and shorter postoperative pain and scarring. Cystoscopic assistance in this technique was a great addition to provide counter-traction movement and facilitate proper dissection.
Prostatic utricle (PU) is not a common pathology. Most cases are seen within a triad of proximal hypospadias, cryptorchidism, and PU [1]. It is an enlarged midline diverticulum arising from the posterior urethra in males, between the two ejaculatory ducts on the verumontanum [2]. Embryologically, it represents the caudal end of the Mu ¨llerian duct that regresses in boys by the effect of the Mu ¨llerian inhibiting factor. Failure of regression results in a PU, hence, the common association with disorders of sexual development [3]. Most cases are asymptomatic. However, about 29% of patients may present clinically with lower urinary tract symptoms, postvoid dribbling, urethral discharge, recurrent urinary tract infections, epididymo-orchitis, stones, secondary incontinence cause by trapping of urine in the pouch, and retention of urine. Surgical excision is the gold standard but is only offered to symptomatic patients [2]. Being such a rare condition, and given its challenging anatomical position, there has been no consensus about the best surgical approach to resect a PU. Many surgical approaches have been described, most of them mandating extensive pelvic dissection and carrying the risk of damage to pelvic structures. Abdominal transperitoneal, perineal, and
combined abdomino-perineal approaches have been described in the past. More recently, anterior sagittal, posterior sagittal transrectal, and rectum-retraction techniques have been advocated. Additionally, suprapubic extravesical and transvesical transtrigonal procedures have been described [3]. The latter gained popularity as being more advantageous in exposing the neck of the PU and facilitating better dissection and complete resection [1]. With evolution of the minimally invasive surgeries, Yeung et al. [4], reported the first series of four cases who successfully underwent laparoscopic excision of PU. They recruited three ports and stitched the bladder to the anterior abdominal wall by a transcutaneous stitch. They used intra-corporeal stitching to close the urethral stump. Their results were promising. Since then, few reports have been published mentioning the advantages of the laparoscopic techniques, with some variations in the number of ports used, the way of cannulating the utricle and creating traction on the bladder. The laparoscopic technique is becoming the procedure of choice in these cases. Jia et al. [2] reported a retrospective comparison between open transvesical approach and laparoscopic approach, which involved a total of 14
This video was presented at the International Pediatric Endosurgery Group (IPEG) 2017 annual congress in London.
https://doi.org/10.1016/j.jpurol.2017.09.024 1477-5131/ª 2017 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Mostafa IA, et al., Cystoscopic-assisted laparoscopic excision of prostatic utricle, Journal of Pediatric Urology (2017), https://doi.org/10.1016/j.jpurol.2017.09.024
+
MODEL
2 patients. They concluded that the laparoscopic technique provided shorter operative time, hospital stay, and catheter duration, as well as better cosmetic outcome. Preoperatively, we had detailed counselling with the parents regarding the possibility of insertion of the vas into the PU and how this can be managed. We highlighted the options of either preserving the vas at the extent of complete PU excision versus vasectomy and complete excision. We highlighted that division of the vas will only be carried out if it is inserted in the PU and cannot be fully separated from it. The parents opted for vasectomy and complete PU excision. We hereby present a video for our technique, using three ports and a bladder hitching stitch. The utricle was scoped and the scope was left in situ to facilitate mobilizing the PU and creating a counter-traction movement. Careful dissection of both vasa differentia was carried out, this revealed intra-utricular insertion of both vasa, hence both were divided to facilitate complete excision of the PU as per the preoperative discussion with the parents. Postoperative MCUG demonstrated no remnants and the patient has been asymptomatic since then. We believe that cystoscopic counter-traction is an important adjunct to facilitate complete laparoscopic excision of the PU. The options of vasectomy to allow complete excision of the PU versus leaving a residual stump and preserving the vas is a crucial aspect in counselling the parents preoperatively if it is inserted in the PU and cannot be separated from it completely.
I.A. Mostafa et al.
Conflict of interest None.
Funding None.
Appendix A. Supplementary data Supplementary data related to this article can be found at https://doi.org/10.1016/j.jpurol.2017.09.024.
References [1] Benedetto V Di, Bagnara V, Guys JM, Meyrat JM, Monfort G. A transvesical approach to Mu ¨llerian duct remnants. Pediatr Surg Int 1997;12:151e4. [2] Jia W, Chang Liu G, Yu Zhang L, Quan Wen Y, Fu W, Hua Hu J, et al. Comparison of laparoscopic excision versus open transvesical excision for symptomatic prostatic utricle in children. J Pediatr Surg 2016;51:1597e601. [3] Ramachandra M, Bendre PS, Redkar RG, Taide DV. Isolated prostatic utricle. J Indian Assoc Pediatr Surg 2009;14:228e9. [4] Yeung CK, Sihoe JDY, Tam YH, Lee KH. Laparoscopic excision of prostatic utricles in children. BJU Int 2001;87:505e8.
Please cite this article in press as: Mostafa IA, et al., Cystoscopic-assisted laparoscopic excision of prostatic utricle, Journal of Pediatric Urology (2017), https://doi.org/10.1016/j.jpurol.2017.09.024