Classification of enlarged prostatic utricle in patients with hypospadias

Clinical Application of Ureteroscope-Assisted Laparoscopic Surgery for Prostatic Utricle in Children

Purpose: To investigate the use of ureteroscope-assisted laparoscopic surgery (UALS) in treating symptomatic prostatic utricle (PU) in children. Materials and Methods: Data on surgically treated cases of PU at the Department of Urology in Hunan Children's Hospital between September 2014 and September 2022 were retrospectively collected and analyzed. The diagnosis was confirmed by cystourethroscopy followed by ureteroscopy, and PU was excised by ureteroscope-assisted laparoscopy. Results: A total of 21 patients with PU were enrolled in this study. The median age of the patients at surgery was 8.1 (4.6-11.5) years. Karyotyping was available for 15 children: 13 (86.7%) were 46XY, 1 (6.7%) was 45X/46XY, and 1 (6.7%) was 45X/46XY/47XYY. The median length of the PU was 5.0 (4.1-7.1) cm. Nineteen patients underwent only ureteroscope-assisted laparoscopic excision, whereas 2 also had a perineal incision. All excisions were successfully performed. The median intraoperative blood loss was 25.0 (20.0-37.5) mL. The median hospital stay and follow-up durations were 18.0 (14.5-25.0) days and 24.0 (13.5-49.0) months, respectively. The patients reported no postoperative clinical symptoms. Conclusion: UALS allows for accurate patient positioning and thorough exposure of the anatomical structures, and it is a safe, effective, and minimally invasive treatment for PU in children.

Insights into enlarged prostatic utricles and Müllerian duct system remnants associated with posterior hypospadias

INTRODUCTION

The prostatic utricle (PU) consists of the caudal remnant of the Müllerian duct and the urogenital sinus. The term "vagina masculina" is used if other Müllerian structures are associated with the PU. This work aims to investigate the incidence, management, and follow up of enlarged PUs and Müllerian remnants in males with posterior hypospadias.

PATIENTS AND METHODS

This study presents a retrospective review of cases presented with posterior hypospadias over a 5-year period. Prior to hypospadias repair, retrograde urethrograms were used to investigate enlarged PU. Subsequently, they were classified according to the Ikoma score and further assessed by karyotyping and cystoscope. Surgical excision was indicated in cases with symptomatic utricles or vagina masculina.

RESULTS

Thirty patients were included in the study in the period between 2015 and 2020 (Table). All cases were asymptomatic initially. Twelve patients were diagnosed with enlarged PU; three of them had vagina masculina. One case with perineal hypospadias had a separate perineal opening for PU. Following hypospadias repair, three of the eight cases treated conservatively turned symptomatic.

DISCUSSION

The incidence of enlarged PU and Müllerian remnants varied among different studies. However, it increased as the severity of hypospadias increased. Preoperative urethrogram was helpful in the diagnosis and classification of PU, but it had its limitations. Cystoscope was more advantageous in diagnosing vagina masculina. Although most cases were asymptomatic, some turned symptomatic after hypospadias repair. Some cases with perineal hypospadias had PU with a separate perineal opening.

CONCLUSION

The incidence of enlarged PUs or Müllerian remnants was 40%. Although cases were asymptomatic before hypospadias surgery, some cases turned into symptomatic after hypospadias repair. In some cases, the PU or Müllerian remnants had a separate perineal opening. They can be classified as a particular form of Ikoma grade III necessitating surgical intervention.

Enlarged prostatic utricle and vagina masculinus in boys with disorders of sex development

PURPOSE

To determine the prevalence, radiological characteristics, and clinical symptomatology of enlarged prostatic utricles and vagina masculinus in boys with disorders of sex development.

METHODS

Over 10 years (from February 2012 to March 2022), 102 boys with severe hypospadias underwent voiding cystourethrography. All patients presented with disorders of sex development and Y material in the karyotype (46,XY karyotype, 46,XY/45,X mosaic, etc.). The age of the patients at the first examination ranged from 4 days to 27 months (mean age 2.7 months).

RESULTS

Voiding cystourethrography revealed the presence of a cyst posterior to the urethra in 66 patients (64.7% of cases). There were 15 cases of "vagina masculinus" and 51 of enlarged prostatic utricles. These dilations were classified according to the Ikoma classification and cyst size. In more than 2/3 of cases, the cysts were small (less than 20 mm), and in less than 8% of cases, these cysts were large. In addition, retrograde opacification revealed the presence of vesicoureteral reflux in 20% of boys with a male vagina. The most severe hypospadias with a scrotal or perineal meatus are most at risk of developing an enlarged prostatic utricle, and 80% of patients with Ikoma Grade III had a scrotal or perineal meatus.

CONCLUSION

This study shows that the prevalence of enlarged prostatic utricles and vagina masculinus is high in patients with severe hypospadias. Therefore, their search should be systematic, and for clinical and therapeutic interest, the enlarged prostatic utricles should be classified according to cyst size.

Clinical spectrum and management options for prostatic utricle in children

PURPOSE

Prostatic utricle (PU) has been described in children with hypospadias, posterior urethral valves (PUV), variances of sex characteristics and normal external genitalia. Intervention may be required in symptomatic cases, but clinical characteristics vary, requiring individualisation of management. We describe our experience with this condition.

METHODS

Retrospective review of males noted to have PU on cystoscopy (2009-2020) at a single centre. Presentation, management and outcomes were recorded (Variances of sex characteristics excluded).

RESULTS

Of 1060 male children who underwent cystoscopy for various reasons, PU was recorded in 36 (3.4%), indications for cystoscopy being hypospadias in 28, PUV in 3, urinary tract infections (UTI) in 3 and hydronephrosis in 2. Six (16.7%) developed epididymo-orchitis. All 6 had Ikoma Grade II PU. Case 1 (16 years,UTI) was managed with intravenous antibiotics. Case 2 (8 years,hypospadias) underwent laying open of urethral stricture. Case 3 (5 years,PUV) underwent laparoscopic PU excision. Cases 4 and 5 (3 and 6 years, hypospadias) underwent cystoscopic injection of bulking agent near the insertion of the vasa. Case 6 (3 years,hypospadias) underwent laparoscopic PU excision with vasal disconnection (vasal openings at dome of utricle rather than base) following failed endoscopic management. Median follow-up was 36 (0-206) months. All remained asymptomatic with normal testicular volumes for age at current follow-up.

CONCLUSION

Multiple treatment options to address a symptomatic PU have been described and enable surgeons to individualise treatment based on clinical circumstances. It is important to identify variations in anatomy of vasal connection to PU to plan appropriate management.

LEVEL OF EVIDENCE

IV (Retrospective study).

Urinary retention in adult hypospadias patient resolved by unroofing of a mildly enlarged prostatic utricle

INTRODUCTION

A prostatic utricle is a congenital saccular indentation in the prostatic urethra and frequently enlarged in hypospadias patients. We present a case of urinary retention associated with a mildly enlarged utricle.

CASE PRESENTATION

A 20-year-old male, who underwent multiple repair procedures for hypospadias during childhood, was referred to us for dysuria. Retrograde urethrogram, voiding cystourethrogram, and cystoscopy results revealed only a mildly enlarged prostatic utricle, with no apparent lower urinary tract obstruction or urethral valves. A meatotomy was performed under suspicion of meatal stenosis, though urinary retention occurred following that procedure. Transrectal ultrasonography revealed flapping of the prostatic urethra floor over the utricle. Transurethral unroofing of the utricle relieved the dysuria.

CONCLUSION

A mildly enlarged prostatic utricle can cause dysuria. To the best of our knowledge, no case similar to the present has been previously reported.

Koyanagi- Snow-Hayashi Urethroplasty in Severe Hypospadias Repair: Between Hope and Reality

OBJECTIVE

To present the results of Koyanagi-Snow-Hayashi urethroplasty in severe hypospadias repair.

METHODS

From June 2015 to December 2019, 43 patients with severe hypospadias associated with curvature underwent Koyanagi- Snow-Hayashi urethroplasty. All patients were treated for the first time and by a single surgeon. Thirty-five patients included in this study presented a form of disorders of sex development. The age of the patients at surgery varied from 12 to 120 months (mean age 21 months ± 6 months). The median follow-up was 28 months (range, 5-65 months).

RESULTS

Functional and esthetic results were satisfactory with a straight and excellent appearance of the penis, without any complications in only ten patients (23%). While 30 of 43 patients (70 %) required additional procedures. Postoperative complications encountered in our patients were dominated by fistulas which were found in 17 of 43 patients (39.5%). Among them, 3 fistulas appeared in the penile shaft between 11 and 28 days and disappeared spontaneously. While proximal fistulas have been required surgical repair. Diverticulum seemed to be a significant complication of this technique, it was found in 4 of 43 (9%). This study also revealed the presence of a peculiar complication for this procedure, urethral meatus in the shape of fish lips.

CONCLUSION

The use of Koyanagi-Snow-Hayashi urethroplasty in severe hypospadias repair gives a complete penile straightening in all cases. However, Despite the modifications added by Snow and Hayashi to Koyanagi urethroplasty to improve the vascular supply of the flap, the rate of complications encountered with this technique remains high.

K. P, Shetty J, Patil N. Symptomatic prostatic utricle: various approaches for treatment

Background

Pediatric presentations of a prostatic utricle have received only little attention. The incidence of symptomatic prostatic utricle has been reported but most cases are asymptomatic. The purpose of this study is to highlight the various clinical presentations and surgical approaches to treat a symptomatic prostatic utricle.

Results

This study includes a series of 7 cases over a period of 5 years. The diagnosis of prostatic was made on the basis of clinical presentations, ultrasonography, micturating cystourethrogram, and cystoscopy.

Of the 7 patients, the newborn patient had antenatally detected abdominal cystic mass which presented with postnatal urinary retention, 5 patients had various urinary complaints, and 1 older child with disorder of sexual differentiation (DSD) had urinary incontinence. Depending upon the grade of prostatic utricle, treatment was done in the form of laparoscopic-assisted excision in 1, laparotomy and excision in 1, perineal excision in 2, and cystoscopic fulguration in 3 patients. Postoperative period was uneventful. All the patients were followed for a period of 1–2 years. Most of them were asymptomatic except one child who had recurrent episodes of epidydimo orchitis which was treated conservatively, and he was also asymptomatic at the end of 1 year. Five patients who had associated hypospadias were observed for one year for any urinary complaints before they underwent definitive repair for hypospadias.

Conclusion

Prostatic utricle is a vestigial remnant of müllerian duct most commonly associated with posterior hypospadias. High index of suspicion for prostatic utricle in cases with recurrent urinary complaints helps in timely detection and appropriate treatment can prevent further complications. Cystoscopy and micturating cytourethrogram remains the gold standard for diagnosis.

Cystoscopy-Guided Laparoscopic Excision of Prostatic Utricle: Report of a Case

Prostatic utricle (PU) is incomplete regression of Müllerian duct and may cause recurrent urinary tract infections (UTIs), stone formation, postvoid dribbling, and recurrent epididymitis. Although surgical excision is recommended to avoid complications, surgical access to PU has been challenging. Cystoscopy-guided laparoscopic management of PU in a 3-year-old boy is reported to discuss use of other endoscopic aids in the surgical treatment of PU. He was admitted with disordered sexual development with karyotype of 47,XYY/46,XY and has been experiencing recurrent UTIs. Voiding cystourethrogram (VCU) demonstrated large PU (IKOMA II). Cystoscopy was performed confirming PU and the cystoscope was left in situ to aid laparoscopic exploration after bladder was emptied. A 5-mm umbilical port and two 5-mm ports in both lower quadrants were inserted. The peritoneum was dissected behind bladder. The cystoscope in PU was used as guidance in identification and dissection of PU. The vas deferens was identified and could be secured. The neck of PU was ligated with surgiloop. PU was retrieved from umbilical port. Postoperative VCU revealed normal posterior urethra. He has been free of UTIs for the last 6 months. Laparoscopy is safe and feasible alternative in surgical management of PU, by providing good visual exposure, easy dissection in deep pelvis, and improved cosmesis. The cystoscopic guidance is an important aid in identification and dissection of PU.

A 30-year retrospective study of rare ectopic seminal tract opening cases

Ectopic seminal tract opening is a rare congenital malformation. Until recently, there has been a lack of comprehensive reporting on the condition. The purpose of this retrospective study is to summarize the experience of diagnosis and treatment of this condition based on 28 clinical practice cases throughout the past 30 years. We conducted auxiliary examinations on such patients including routine tests, imaging examinations, and endoscopy. Among these 28 cases, there were ectopic opening of vas deferens into enlarged prostatic utricles (6 cases); ejaculatory ducts into enlarged prostatic utricles, Müllerian ducts cysts, and urethras (18 cases, 2 cases, and 1 case, respectively); and ectopic opening of the unilateral vas deferens and the contralateral ejaculatory duct into enlarged prostatic utricle (1 case). The size of the enlarged prostatic utricle, the type of ectopic seminal tract opening, and the opening's location effectively assisted in the selection of clinical treatment methods, including transurethral fenestration of the utricle, transurethral cold-knife incision, open operation, laparoscopic operation, and conservative treatment. Satisfactory effect was achieved during follow-up. In conclusion, a definite diagnosis and personalized treatment are especially important for patients with ectopic seminal tract opening.

The prostatic utricle: An under-recognized condition resulting in significant morbidity in boys with both hypospadias and normal external genitalia

INTRODUCTION

Pediatric presentations of a prostatic utricle have received only scant attention. Though recognized with increased frequency in boys with hypospadias, little is described about their incidence and potential for morbidity in boys with normal external genitalia.

METHODS

We initially reviewed a cohort of 64 patients with hypospadias seen over a 3-year period to determine the frequency of investigative lower urinary tract studies and utricle identification. Children with disorders of sexual differentiation were excluded from this review. A subsequent group of 70 boys with hypospadias and 23 boys with normal external genitalia presenting with lower urinary tract symptoms (LUTS) who were found to have an unsuspected utricle were reviewed. This comparative group was investigated since symptomatology was the indication for evaluation, contrasting with those in the hypospadias group who were investigated because of hypospadias presence alone.

RESULTS

In our initial review of 64 patients only 24 (37.5%) underwent an investigative study and six (9.4%) had a utricle. Three (50%) required surgical excision, allowing their hypospadias repair to proceed. Results in the subsequent group with hypospadias confirmed these findings with increased rates of investigation and identification. The boys with normal external male genitalia all required surgery since symptoms were the result of the utricle alone. Penile pain with voiding, hematuria, epididymitis, and urinary infection were the most common causes for interventions.

CONCLUSIONS

The prostatic utricle should be considered as a cause of morbidity in boys with both normal external genitalia and those with hypospadias. Endoscopic or radiological evaluation (see Figure) should be undertaken in all boys with proximal hypospadias, boys with hypospadias and associated cryptorchidism, and those with hypospadias with associated urinary symptoms. Boys with normal external genitalia with lower urinary tract symptoms not explained with imaging should undergo cystoscopy, as an unidentified unsuspected utricle may be the underlying cause.

Comparison of laparoscopic excision versus open transvesical excision for symptomatic prostatic utricle in children

PURPOSE

The aims of this study were to report our clinical experience with laparoscopic excision (LE) and to compare the outcomes of LE versus open transvesical excision (OTE) for the management of prostatic utricle (PU) in children.

PATIENTS AND METHODS

This was a retrospective single-center study of 14 children who underwent OTE or LE for managing symptomatic PU between April 2003 and December 2014. Age, utricle size, operative time, estimated blood loss, duration of hospital stay, indwelling time of the urethral catheter, presence of residual postoperative utricular stump, and complications were compared between the two groups.

RESULTS

There were no significant differences in age or utricle size between the two groups. Compared to the OTE group, the LE group experienced shorter operative times, lower estimated blood losses, and shorter hospital stays. Indwelling time of the urethral catheter was nearly 8days in the OTE group and 6days in the LE group. All patients had a follow-up visit between 6months and 2years after surgery. Two patients in the OTE group had transient UTI. Postoperative VCUG showed minimal residual utricular stump for 3 patients in the OTE group. However, no patient in either group required further operative therapy.

CONCLUSIONS

LE is a safe and feasible procedure for symptomatic PU in children. Compared to OTE, LE can provide minimally invasive access for achieving good exposure with good short-term outcomes.

[Caudal migration of the verumontanum and enlargement of the utricle in hypospadias]

Hypospadias is one of the morphological and functional alterations of the internal urogenital organs under the influence of androgen deficiency. In the time period 1974-1998 a total of 823 cases of hypospadias were surgically treated and the findings of the preoperative X-ray diagnostics with micturating cystourethrogram (MCU) and urethrocystogram (UCG) as well as urethrocystoscopy were analyzed. A caudal migration of the verumontanum could be detected in 55% of cases with hypospadias (453/823) and in 79% (322/403) of middle grade (penoscrotal) and high grade (scrotoperineal) cases of hypospadias. Enlargement of the utricle was present in 31.5% (259/823) cases of hypospadias and in 46.2% (186/423) of middle grade (penoscrotal) and high grade (scrotoperineal) cases of hypospadias.

Monosymptomatic Persistent Hematospermia due to Rarely Encountered Prostatic Utricle Stones

We present a young patient who had hematospermia which was unresponsive to repeated medical therapies. In this patient prostatic utricle stones were detected via pelvic and transrectal ultrasonography, the presence of the stones was confirmed by transurethral fenestration, and persistent hematospermia disappeared following surgical excision. Thus, we conclude that prostatic utricle stones might have caused hematospermia in this young patient, who had no additional pathology likely to be responsible for this condition.

A patient with a unique frameshift mutation in GPC3, causing Simpson-Golabi-Behmel syndrome, presenting with craniosynostosis, penoscrotal hypospadias, and a large prostatic utricle

We present a Hispanic male with the clinical and molecular diagnosis of Simpson-Golabi-Behmel syndrome (SGBS). The patient was born with multiple anomalies not entirely typical of SGBS patients, including penoscrotal hypospadias, a large prostatic utricle, and left coronal craniosynostosis. In addition, he demonstrated endocrine anomalies including a low random cortisol level suspicious for adrenal insufficiency and low testosterone level. To our knowledge, this is the first report of a prostatic utricle in SGBS and the second report of craniosynostosis. The unique disease-causing mutation likely arose de novo in the mother. It is a deletion-insertion that leads to a frameshift at the p.p. S359 [corrected] residue of GPC3 and a premature stop codon after five more amino acids. p. S359 [corrected] is the same residue that is normally cleaved by the Furin convertase, although the significance of this novel mutation with respect to the patient's multiple anomalies is unknown. We present this case as the perinatal course of a patient with unique features of SGBS and a confirmed molecular diagnosis.

Isolated prostatic utricle

Complete excision of a prostatic utricle through posterior sagittal rectum retracting approach is reported in an infant.

Hypospadias

Hypospadias results from abnormal development of the penis that leaves the urethral meatus proximal to its normal glanular position anywhere along the penile shaft, scrotum, or perineum. A spectrum of abnormalities, including ventral curvature of the penis (chordee), a hooded incomplete prepuce, and an abortive corpora spongiosum, are commonly associated with hypospadias. Advances in understanding of the causes of hypospadias and current approaches to the correction of hypospadias to provide a cosmetically and functionally satisfactory repair are the focus of this article.

Successful treatment of recurrent epididymo-orchitis: Laparoscopic excision of the prostatic utricle

Prostatic utricle presenting with recurrent epididymo-orchitis is not uncommon. Excision of prostatic utricle is the treatment of choice. The various techniques described in literature suffer from the disadvantages of incomplete excision due to poor view. We report the successful laparoscopic excision of prostatic utricle in childhood.

Inflammatory tumour of the prostate in a 4-year-old boy

An inflammatory tumour of the prostate is very rare in young boys without genital anomalies. We report a 4.5-year-old boy presenting with pollakisuria, dysuria, secondary urinary incontinence and decreased urine stream. Ultrasonography, magnetic resonance imaging and transrectal tumour biopsy justified the diagnosis of an inflammatory tumour of the prostate with a size of 5x3x5cm. Under antibiotic therapy the clinical symptoms disappeared within 6weeks. Three months later ultrasonography revealed a normal prostate with a residual midline cyst of 3x4mm. Follow-up examinations for 2years did not show any evidence of relapse. We believe that the inflammatory tumour can be explained by the embryologic development of the prostate and the persistence of an intraprostatic cyst.

Antenatally detected double prostatic utricle found in a neonate with ambiguous genitalia

Although enlarged prostatic utricle is usually seen in patients with hypospadias and disorders of sex development, double utricle has not been reported without unilateral renal dysplasia and Wolffian duct anomaly. We present an unusual case of antenatally detected large pelvic cyst, which turned out to be one of double prostatic utricles in a neonate with ambiguous genitalia. The possibility of enlarged utricle should be considered in the differential diagnosis of antenatally detected pelvic cysts in neonates with ambiguous genitalia.

Current concepts in hypospadias surgery

Anatomical anomalies in hypospadias are an abnormal ventral opening of the urethral meatus, abnormal ventral curvature of the penis and abnormal distribution of the foreskin around the glans with a ventrally deficient hooded foreskin. The techniques of hypospadias surgery continue to evolve. The current standard of care for hypospadias repair includes not only a functional penis adequate for sexual intercourse and urethral reconstruction offering the ability to stand to urinate, but also a satisfactory cosmetic result. Tubularized incised plate repair has been the mainstay for distal hypospadias. In cases of proximal hypospadias, one-stage repairs such as the Duckett repair or the Koyanagi repair have been well established, while two-stage repairs remain important alternatives. Whether dorsal plication or ventral lengthening should be used to correct penile curvature is still controversial, and long-term results are required. Efforts have been made in this decade to improve cosmetic appearance, constructing a slit-like meatus or performing foreskin reconstruction, and to prevent onerous complications.

Clear cell adenocarcinoma of the prostatic utricle in an adolescent

We present a case of a 16-year-old boy with a primary clear cell adenocarcinoma of the prostatic utricle. The patient presented with a 6-month history of intermittent, nonpainful, gross hematuria and an associated right renal agenesis. Radiographic studies revealed the presence of a solid and cystic mass between the bladder neck and the cranium of the prostate. Serum tests, including prostate-specific antigen, carcinoembryonic antigen, CA-19-9, and human chorionic gonadotropin, were performed and found to be within normal limits. A surgical resection of the mass including prostate and seminal vesicles was performed. Grossly, a polypoid exophytic tumor was present at the prostatic utricle. Histologically, the tumor shows the classical clear cell morphology reminiscent of the so-called mesonephric adenocarcinomas. At clinical follow-up, the patient is alive and well 18 months after surgical resection. The present case highlights an unusual phenomenon of the development of an unusual form of adenocarcinoma in an adolescent.

Hypospadias

Hypospadias results from abnormal development of the penis that leaves the urethral meatus proximal to its normal glanular position anywhere along the penile shaft,scrotum, or perineum. Hypospadiology is an evolving and expanding discipline that remains at the forefront of pediatric surgical innovation. Although modern experiments have begun to yield a deeper understanding of the genetic, hormonal, and environmental basis of hypospadias, the quest for a surgical procedure that consistently results in a straight penis with a normally placed glanular meatus has challenged surgeons for over two centuries. This article focuses on the advances in the understanding of the etiology of hypospadias and the current approaches to the correction of hypospadias.

Laparoscopic removal of müllerian duct remnants in boys

PURPOSE

Müllerian duct remnants (MDRs) are present in a male pseudohermaphroditic form characterized by failure of the müllerian duct to regress due to insufficient production or peripheral action of müllerian inhibiting substance. The MDR can be asymptomatic but it often results in infections, stones and voiding troubles. Furthermore, it may develop into a neoplasm. Therefore, surgery is mandatory for large MDRs and symptomatic patients. Laparoscopic removal is described.

MATERIALS AND METHODS

Six males were treated from February 1998 to February 2003. Age at surgery was between 3 and 18 years (mean 8.6). All patients showed severe hypospadias and 2 had mixed gonadal dysgenesis with ambiguous genitalia. Three patients presented with urogenital infections and all had a large MDR. Laparoscopic procedures, which were preceded by cystoscopy, were performed using a 10 mm umbilical trocar for the camera and 3, 5 mm trocars for instruments placed in the suprapubic region and iliac fossa bilaterally. The remnants were ligated with endoscopic loops or an endoscopic GIA stapler and cut.

RESULTS

Mean operative time was 2 hours. We noted no complications. In 2 cases there was deferential ectopia and in another of mixed gonadal dysgenesis bilateral gonadectomy was performed because of the risk of degeneration. Feeding started on postoperative day 1 and the patients were discharged home on day 5. After a followup of 8 months to 4 years all boys were healthy.

CONCLUSIONS

Multiple approaches are used in traditional surgery, often leading to complications. Laparoscopy improves the view, decreases surgical risk and operative time, avoids large scars and allows more rapid hospital discharge.

Laparoscopic approach to müllerian derivatives in a male with mixed gonadal dysgenesis

Müllerian derivatives are a frequent finding in patients with external genital ambiguity. In cases in which their removal is indicated, traditional surgical approaches are both invasive and associated with risks. We report a case of mixed gonadal dysgenesis in which a large prostatic utricle was successfully removed via laparoscopy.

Comparison between ultrasonography and retrograde urethrography for detection of prostatic utricle associated with hypospadias

OBJECTIVES

To evaluate the practical application and limitation of ultrasonography and retrograde urethrography in detecting prostatic utricle associated with hypospadias.

METHODS

Between 1995 and 1999, 80 patients with hypospadias, 1 month to 16 years of age (mean age 3 years, 6 months), underwent ultrasonography and retrograde urethrography to detect the prostatic utricle.

RESULTS

Of the 80 patients examined, the prostatic utricle was found in a total of 36 patients (45.0%) by ultrasonography and/or retrograde urethrography. Ultrasonography revealed the prostatic utricle in 27 (75%) of the 36 patients; in 6 of the 27, it was not detected by retrograde urethrography. Retrograde urethrography revealed the prostatic utricle in 30 (83%) of the 36 patients; in 9 of the 30, it was not visualized by ultrasonography. Retrograde urethrography was slightly more sensitive in detecting the prostatic utricle than was ultrasonography. In the remaining 44 patients, the prostatic utricle was not detected by either examination method.

CONCLUSIONS

Although retrograde urethrography is considered the most useful method for detecting any degree of the prostatic utricle, we recommend routine ultrasonography because it is noninvasive, painless, and simple.

Histopathological study of the müllerian duct remnant: clarification of disease categories and terminology

PURPOSE

We determined by histopathological studies whether there is an etiological difference in 2 distinct categories of müllerian duct remnant diseases. In addition, we clarified the nomenclature of these diseases.

MATERIALS AND METHODS

We recently performed radical prostatectomy in a patient with prostate cancer associated incidentally with a so-called müllerian duct cyst in the prostatic midline. The specimen was examined by pathological and immunohistochemical testing with special attention to the relationship of the cyst and utricle. We also investigated the histology of so-called enlarged prostatic utricles or vagina masculinus extirpated from patients with severe hypospadias or intersex disorder.

RESULTS

The round cyst removed with the prostate seemed to arise from the verumontanum and it contained fluid with a high concentration of prostate specific antigen. Histological and immunohistochemical examination of its lining epithelium demonstrated that cyst characteristics were identical to those of the prostatic utricle. On the other hand, pouches extirpated from patients with pediatric problems were lined by squamous epithelium.

CONCLUSIONS

The so-called müllerian duct cyst appeared to originate from the prostatic utricle, and so should be termed a utricular cyst or cystic utricle. Conversely the so-called enlarged prostatic utricle should be termed a vagina masculinus or male vagina. The term müllerian duct remnant, which would include these 2 abnormalities, may usefully be replaced by the term utricular abnormalities.

Surgical treatment of the Müllerian duct remnants

BACKGROUND

Persistent Müllerian duct tissue in male individuals may result in an enlarged prostatic utricle (utricular cysts and utricle) or a Müllerian duct cysts, either distinctively or synonymously. In intersex patients Müllerian duct remnants (MDR) are an usual occurrence. Surgical excision is the definitive treatment of symptomatic remnants, as well as during the reconstruction of intersexual genitalia. Many approaches have been described. The authors review their experience in intersex patients.

METHODS

From 1986 to 1999, the authors treated 111 patients with intersex disorders. The records of 47 patients raised as boys with MDR were reviewed. Based on the symptoms and the size of the remnants, in 32 patients the structures were removed. In 13 patients extirpation was done by perineal approach, in 9 by transperitoneal approach, and in the remaining 9 patients the combined abdominal and perineal approach were undertaken. In one patient the large prostatic utricle was extirpated by a posterior sagittal pararectal approach. Perineal approach was mainly used in younger asymptomatic children, with the prostatic utricle disclosed incidentally during genitography because of intersex disorders. Operation was performed only in cases in which the prostatic utricle was observed by cystoscopy or identified by Fogarty balloon catheter introduction into the prostatic utricle. In older patients these structures were discovered frequently after failed urethroplasty, or after symptoms of urinary infection, urinary retention, or epididymitis. We elected to use the transperitoneal approach based on the extension of these structures into the pelvis. The average age of patients at the time of surgery was 8.6 years, with a range of 1 to 30 years.

RESULTS

There were no rectal or bladder injuries during surgery. An older patient had temporary impotence after abdomino-perineal extirpation. The lack of ejaculation, seen in 5 patients, was related to frequent intra-utricular termination of the vas deferens. Posterior sagittal pararectal approach certainly enabled complete exposure and exact visualization of all structures, with considerably decreased bleeding. If gonadal biopsy or gonadectomy were necessary, the transperitoneal approach could not be avoided.

CONCLUSIONS

Surgical treatment of MDR in intersex patients varies according to the size of the utricle, and a double approach is often necessary. A high degree of success may be achieved with minimal morbidity. J Pediatr Surg 36:870-876.

Müllerian duct remnants: surgical management and fertility issues

PURPOSE

We reviewed our experience with mullerian duct remnants, also known as prostatic utricular and mullerian duct cysts, to advance further the understanding of the surgical management of these challenging congenital anomalies. The indications, merits and disadvantages of each surgical approach are presented, and the effects of mullerian duct remnants and their treatment on future fertility are discussed.

MATERIALS AND METHODS

We reviewed the records of 26 patients 1 month to 19 years old with mullerian duct remnants who were seen between January 1984 and October 1998. Clinical presentation included perineoscrotal hypospadias in 10 cases, urinary retention and/or difficult voiding in 7, urinary tract infection in 6, acute scrotum in 2, and recurrent hemospermia and dysuria in 1.

RESULTS

Of the 26 patients 13 required surgical intervention for various symptoms and to correct large diverticula. The surgical approach was transvesical transtrigonal in 8 cases, extravesical in 2, perineal in 2 and posterior sagittal in 1. Transurethral fulguration was performed in 2 cases. The initial surgical approach was successful in 11 of the 13 patients. One patient required conversion to a transvesical transtrigonal approach due to inadequate exposure during attempted perineal excision. Two cases treated with transurethral fulguration failed to resolve completely, and in 1 excision was required using the transvesical transtrigonal technique. A total of 13 patients were treated nonoperatively, including 10 in whom the condition was discovered incidentally during screening for perineoscrotal hypospadias. In 5 of the 10 patients urinary tract infection subsequently developed and they were maintained on long-term chemoprophylaxis.

CONCLUSIONS

By tailoring the surgical approach to the type of mullerian duct remnant and the relevant anatomical relationships a high degree of success may be achieved with minimal morbidity.

Surgical treatment of intersex disorders

Despite the progress made in understanding the factors regulating sexual differentiation, infants born with ambiguous genitalia face significant problems. The authors reviewed a group of 84 children with ambiguous genitalia managed surgically between 1986 and 1993. The most frequent condition was male pseudohermaphroditism (PM) (58%); 31% had female pseudohermaphroditism. Fifty-seven percent of patients were raised as males and 43% as females. In each group of patients, feminine and masculine reconstructive operations were performed. In only 31% of PM and 60% of PF cases was the diagnosis made within the first 2 months of life. In 41% of PF and 40% of PM patients, treatment was begun before the second year of life, which we consider an acceptable time. The timing and type of vaginoplasty were determined by the point of entry of the vagina into the urogenital sinus. Of the 29 patients reared as females, 22 required perineal vaginoplasty, had pull-through vaginoplasty, and 2 had colovaginoplasty. Since 1986, we have applied Mollard's clitoroplasty, which preserves the neurovascular bundle and is important for experiencing orgasm. Seventeen percent of patients with feminization procedures experienced complications. The optimal time for masculinization procedures is 2 years of age, after obligatory testosterone treatment. If there is utriculus prostaticus (UP) type II or III, it is removed before urethroplasty. This is not done for UP types 0 and 1. In PM cases, the number of feminization and masculinization operations was 2.1 and 4.05 per patient, respectively. It is easier to make a vagina than a phallus, not taking into consideration dimensions, aesthetics, or capability of erection of the phallus.(ABSTRACT TRUNCATED AT 250 WORDS)

Megautricles: embryogenic hypothesis

We present 4 cases of megautricle emphasizing the relationship between it and the ejaculatory ducts. We develop an embryogenic hypothesis to explain the different forms of megautricles in relation to the seminal pathway.

Testicular Function in Patients with Hypospadias Associated with Enlarged Prostatic Utricle

Of 485 patients with hypospadias who underwent urethrography, enlarged prostatic utricles were found in 173 (35.7%). Utricles with a higher grade of enlargement were seen mainly in patients with a severe degree of hypospadias. Serum testosterone levels before and after 3 days' treatment with human chorionic gonadotrophin were determined by radioimmunoassay in 97 prepubertal boys with hypospadias and enlarged prostatic utricles. Lower levels of serum testosterone were found after hormonal stimulation in 22 patients with high grade utricular enlargement when compared with 5 controls and 75 patients with low grade enlargement; the difference was statistically significant. This finding supports the hypothesis that utricular enlargement may be due to androgenic insufficiency during the critical period of organogenesis.

Caudal migration of the verumontanum

The location anomaly of the verumontanum has not been described in the literature. We confirmed that the verumontanum was located either in the sphincteric or bulbous urethra in 61 of 477 patients with hypospadias (12.8%) through endoscopic examination and urethorgraphy. There was a patient with bilateral cryptorchidism who had distal location of the verumontanum. The patients with hypospadias and caudal migration of the verumontanum showed significantly low response of testosterone to human chorionic gonadotropin stimulation compared with normal controls. The incidence of caudal migration of the verumontanum was higher in the patients with a severe degree of hypospadias than in those with mild hypospadias. These results suggest that distal location of the verumontanum may be the result of an insufficient action of androgens during the period of critical sexual differentiation in the male embryo. We call this phenomenon caudal migration of the verumontanum, which seems to be a new clinical entity.

Management of müllerian duct remnants in the male patient

We evaluated 36 patients for müllerian duct remnants that were manifest in several forms. The most common type was an enlarged prostatic utricle communicating with the urethra in 22 younger patients, which was associated with hypospadias or intersex disorders in more than 90 per cent of the cases. A cystic müllerian duct remnant was the other configuration noted in 14 older patients who had normal external genitalia and often presented with a rectal mass. The diagnostic evaluation consists of voiding cystourethrography, retrograde urethrography and cystoscopy. Other useful imaging techniques are ultrasonography and computerized tomography. Careful delineation of the anatomy of the lower urinary and genital tracts will help to plan surgical therapy. Suprapubic excision was the most frequent operation and it was successful in all 18 patients in whom it was performed.

Surgical treatment for enlarged prostatic utricle and vagina masculina in patients with hypospadias

Fourteen patients with hypospadias were treated surgically for either an enlarged prostatic utricle (6) or vagina masculina (8). Six vaginae masculinae were removed by an extravesical abdominal approach. One enlarged prostatic utricle was removed by the perineal approach. Three enlarged utricles were removed by an abdominoperineal approach. The transtrigonal approach was recently used for three enlarged utricles and one vagina masculina in four patients. Surgical results in these 14 patients were satisfactory. One post-operative complication of transient mild bilateral vesicoureteric reflux was seen after a transtrigonal removal of an enlarged utricle. Potency was not affected in any approaches in four patients who were older than 12 years. The transtrigonal approach was found to be the best for good exposure of the lesion.