Laparoscopic removal of müllerian duct remnants in boys

Surgical treatment for prostatic utricle cyst in children: A single-center report of 15 patients

OBJECTIVES

To report our single-center experience of the management of children with prostatic utricle cysts.

METHODS

We retrospectively analyzed 15 children who were incidentally found to have a prostatic utricle cyst and were admitted to our department between October 2013 and August 2020. Clinical characteristics and management were collected and catalogued.

RESULTS

Recurrent genitourinary tract infections were the most frequent complaint, and two-thirds of patients also had hypospadias. A connection between the posterior urethra and the prostatic utricle cyst was found in all cases. Two patients directly had their progressively enlarging prostatic utricle cyst resected laparoscopically. Endoscopic techniques were used in 13 patients, two of whom underwent laparoscopic excision for repeated symptoms. The mean (range) follow-up period was 34.9 (2-82) months. No recurrences were observed in four patients who underwent prostatic utricle cyst excision and eight patients who received endoscopic treatment. Three patients had recurrent symptoms after endoscopic treatment and were managed by nonsurgical treatment.

CONCLUSIONS

Prostatic utricle cyst is a rare disease which can cause recurrent genitourinary tract infections. Extra attention should be paid to evaluation for prostatic utricle cyst in children with external genital anomalies. Retrograde urethrogram and magnetic resonance imaging are useful tools with which to distinguish prostatic utricle cyst from other cystic lesions that are located in the midline pelvis in male patients. Individualized treatment is appropriate when considering fertility preservation, recurrences and malignancy. Laparoscopic excision is feasible for symptomatic and large prostatic utricle cyst. Regular long-term monitoring is recommended for all patients with prostatic utricle cyst.

Cystoscopic Management of Prostatic Utricles

In this case series (n = 7) on prostatic utricles (PU), retention of urine was seen in 5 of 7, urinary tract infection (4 of 7), recurrent epidydymo-orchitis (3 of 7), and scrotal sinus (1 of 7). Voiding cystourethrogram established diagnosis in 3 of 7 patients while CT/MRI in 4 of 7 patients. Four patients were primarily managed by cystoscopic widening of mouth of PU. Three with large PU underwent initial open (2) or laparoscopic (1) excision but later warranted cystoscopic widening for residual PU. Excision (open/laparoscopic) has risk of damage to adjacent structures (nerves/vas/seminal vesicles) or leaving behind a residual PU. Cystoscopic management (primary/salvage) has less morbidity and relieves recurrent symptoms due to stasis of urine in PU.

Laparoscopic management of Müllerian duct remnants in the paediatric age: Evidence and outcome analysis

Background:

This study performed a literature analysis to determine outcomes of laparoscopic management in Müllerian duct remnants (MDRs).

Patients and Methods:

Literature was searched for terms ‘Müllerian’ ‘duct’ ‘remnants’ and ‘laparoscopy'. Primary end points were age at surgery, laparoscopic technique, intraoperative complications and postoperative morbidity.

Results:

The search revealed 10 articles (2003–2014) and included 23 patients with mean age of 1.5 years (0.5–18) at surgery. All patients were 46XY, n = 1 normal male karyotype with two cell lines. Explorative laparoscopy was performed in n = 2 and surgical management in n = 21. The 5-port technique was used in n = 10, 3-port in n = 9 and robot-assisted laparoscopic approach in n = 1 (n = 1 technique not described). Complete MDRs removal in n = 9, complete dissection and MDRs neck ligation with endoscopic loops in n = 11 and n = 1 uterus and cervix were split in the midline. After MDRs removal, there were n = 2 bilateral orchidopexy, n = 3 unilateral orchidopexy, n = 1 Fowler–Stephens stage-I and n = 1 orchiectomy. Mean operative time was 193 min (120–334), and there were no intraoperative complications. Mean follow-up was 20.5 months (3–54) and morbidity included 1 prostatic diverticula. There were 13 associations with hypospadias, of which 3 had mixed gonads and 3 bilateral cryptorchidism. Other associations were unilateral cryptorchidism and incarcerated inguinal hernia n = 1, right renal agenesis and left hydronephrosis n = 1 and n = 2 with transverse testicular ectopy.

Conclusion:

This MDRs analysis suggests that the laparoscopic approach is an effective and safe method of treatment as no intraoperative complication has reported, and there is low morbidity in the long-term follow-up.

Laparoscopic management of müllerian duct cysts in infants

PURPOSE

The aim of the study was to demonstrate the feasibility of laparoscopic excision of pelvic müllerian duct cysts (MDCs) in infants.

PATIENTS AND METHODS

Three-month-old female and 13-month-old male infants presented with frequent episodes of urinary retention and were found to have large retrovesical cystic pelvic masses. Preoperative workup including abdominopelvic ultrasonography and computed tomographic scan showed bilateral hydroureteronephrosis in the baby girl and a single left anatomical kidney with hydroureteronephrosis in the baby boy, caused by the pressure effect of the mass. The pelvic mass in both infants was excised via transperitoneal laparoscopy via a retrovesical approach.

RESULTS

The operative times were 140 minutes in case 1 and 160 minutes in case 2. Excellent laparoscopic visualization and magnification allowed meticulous dissection of the mass from the pelvic organs in both cases. In the female infant, a 5 × 5-cm collection located retrovesically was found 3 weeks after the operation. It contained serosanguinous fluid that was percutaneously aspirated under ultrasound guidance. Histopathologic examination showed the pelvic mass to be an MDC in both patients. Postoperative abdominopelvic sonography at 3 months showed no recurrence of the mass and resolution of hydroureteronephrosis. In the male infant, a urodynamic study 3 months after the operation showed normal bladder dynamics. No voiding difficulty was noted in regular follow-up visits at the time of this writing (7 months postoperatively).

CONCLUSION

Laparoscopic excision of pelvic MDCs in infants is technically feasible. It is a demanding and rarely reported procedure that offers excellent surgical exposure. Longer follow-up is necessary to see if this procedure will offer less morbidity than the open techniques.

Consensus in Guidelines for Evaluation of DSD by the Texas Children's Hospital Multidisciplinary Gender Medicine Team

The Gender Medicine Team (GMT), comprised of members with expertise in endocrinology, ethics, genetics, gynecology, pediatric surgery, psychology, and urology, at Texas Children's Hospital and Baylor College of Medicine formed a task force to formulate a consensus statement on practice guidelines for managing disorders of sexual differentiation (DSD) and for making sex assignments. The GMT task force reviewed published evidence and incorporated findings from clinical experience. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to assess the quality of evidence presented in the literature for establishing evidence-based guidelines. The task force presents a consensus statement regarding specific diagnostic and therapeutic issues in the management of individuals who present with DSD. The consensus statement includes recommendations for (1) laboratory workup, (2) acute management, (3) sex assignment in an ethical framework that includes education and involvement of the parents, and (4) surgical management.

A single base pair mutation encoding a premature stop codon in the MIS type II receptor is responsible for canine persistent Müllerian duct syndrome

Müllerian inhibiting substance (MIS), a secreted glycoprotein in the transforming growth factor-beta family of growth factors, mediates regression of the Müllerian ducts during embryonic sex differentiation in males. In persistent Müllerian duct syndrome (PMDS), rather than undergoing involution, the Müllerian ducts persist in males, giving rise to the uterus, fallopian tubes, and upper vagina. Genetic defects in MIS or its receptor (MISRII) have been identified in patients with PMDS. The phenotype in the canine model of PMDS derived from the miniature schnauzer breed is strikingly similar to that of human patients. In this model, PMDS is inherited as a sex-limited autosomal recessive trait. Previous studies indicated that a defect in the MIS receptor or its downstream signaling pathway was likely to be causative of the canine syndrome. In this study, the canine PMDS phenotype and clinical sequelae are described in detail. Affected and unaffected members of this pedigree are genotyped, identifying a single base pair substitution in MISRII that introduces a stop codon in exon 3. The homozygous mutation terminates translation at 80 amino acids, eliminating much of the extracellular domain and the entire transmembrane and intracellular signaling domains. Findings in this model could enable insights to be garnered from correlation of detailed clinical descriptions with molecular defects, which are not otherwise possible in the human syndrome.

Ectopic opening of the vas deferens into a Müllerian duct cyst

Two consecutive cases of ectopic opening of the vas deferens into Müllerian duct cysts are presented, with descriptions of the presentation, physical examination, radiographic and ultrasonographic images, surgical findings and treatment undertaken. In both cases, ablation of the cyst and ligature of the vas deferens was the technique employed. Both patients are currently well, with normal urinary flow and no urinary tract infections, 3 years after surgery. Ectopic opening of the vas deferens into Müllerian duct cysts is a rare entity but should always be considered when a child presents with purulent urinary discharge and abdominal tumor. Surgery is the only treatment recommended.

Hernia uterus inguinale: a proposed algorithm using the laparoscopic approach

The authors present a case of hernia uteri inguinale, or the presence of Mullerian duct structures in an inguinal hernia. This entity presents in phenotypic males presumably secondary to defects in the action of the Mullerian inhibiting substance and presents a pediatric surgeon with management dilemmas. The long-term complications associated with the gonads if left intact include the risk of malignancy and infertility. We describe the use of the laparoscopic technique in the management of this condition and propose an algorithm for the management of this condition.

Pediatric laparoscopic surgery--Indian scenario

Laparpscopic Surgery/Minimally Invasive Surgery (MIS) in children have witnessed tremendous progress in the last decade. Presently, there are extensive applications of this novel technique and several advanced level intricate surgeries have been done safely in small children. This is a brief overview of the common indications and utility of MIS in pediatric practice in the Indian Scenario. We discuss some common clinical settings like recurrent abdominal pain, Impalpable testis, intersex disorders Empyema, Thoracis etc., where MIS has had a significant benefit. We also present our experience of MIS in children without using any sophisticated equipment like the harmonic scalpel, endo-staplers etc. MIS has come to stay and it will definitely have lasting impact on surgical problems in children.