Y-type urethral duplication in children: Management strategy at our center

Progressive Dilatation as a Successful Treatment for Y Duplication of Urethra: A case report

Duplication of urethra is a rare congenital anomaly; a Y-shaped urethral duplication is the rarest variant and lacks a standardised treatment plan. We report a nine-year-old male patient with a Y-duplication of urethra diagnosed during neonatal age who presented to a tertiary care teaching hospital in India in 2018. The patient had undergone a vesicostomy on the seventh day of life for passing urine per anus and was lost to follow-up thereafter. At eight years of age, there was a failed attempt at disconnection of the duplicated urethral tract from the anus after colostomy. The patient was managed successfully by progressive dilatation of the orthotopic urethra, which required multiple stages, followed by separation of the urethra from the rectum. At three-years follow-up the patient was continent and asymptomatic.

Congenital anterior urethrocutaneous fistulas with chordee: A case report

Congenital anterior urethrocutanous fistula is a rare genitourinary malformation with unknown etiology and may present as an isolated form or in association with hypospadias or chordee. We describe a case of congenital anterior urethrocutanous fistula with chordee variants in a 5-year-old boy. The patient successfully underwent chordectomy and urethroplasty with no adverse outcomes. We report a review of the literature about the etiology and surgical intervention especially with chordee variants. The congenital anterior urethrocutanous fistula is a rare anomaly with unkown etiopathogenesis.

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A 5-year-old boy admitted with passage urine from an abnormal opening in ventral surface of the penis and a distal patent urethra.

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Chordectomy and urethroplasty was performed.

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Surgical approach for criptospadias has 90 % success rate.

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Imaging investigation may help to decide the best treatment options.

Working classification and the quest for an effective, reconstructive management strategy in Y duplication of male urethra

INTRODUCTION

Y-duplication is a rare subtype of urethral duplication whose surgical correction has traditionally yielded less than satisfactory results. Herein we report 18 patients, 17 of whom have completed successful urethral reconstruction.

MATERIALS AND METHODS

A retrospective analysis was done on 18 children who have undergone repair of Y-duplication urethra in two tertiary care institutes from 2013 to 2020. The various subtypes encountered were classified in order to develop a rationale for reconstruction based on the underlying pathology. The various modalities used for reconstruction and the outcomes of the repair were studied. All but one boy voided mainly via the posterior (ventral) channel opening in the ano-rectum or perineum. These boys had the urethral reconstruction incorporating the healthy proximal ventral urethra at its origin. Further reconstruction up to the glans tip depended on the degree of dorsal (orthotropic) urethral patency, which forms the basis of our classification into Types I (completely stenotic), II (penile urethra patent), III (penile and bulbar urethra patent) and IV (fully patent dorsal urethra).

RESULTS

Reconstruction resulting in voiding via a glanular or coronal meatus was completed in 17 boys. One boy is awaiting further surgery while being dependent on Mitrofanoff CIC. While urethral continuity could be achieved using patent segments of native urethra alone into two boys (Types II and III), all other children needed a neo-urethral segment to replace (Type I) or supplement (Type II) the dorsal urethra. Neo urethra was constructed from a tubularized preputial island flap (n = 11), Monti tube constructed from ileum (n = 3) or sigmoid colon (n = 4). A perineal operative exposure alone sufficed in 9, while the rest required an additional trans pubic approach. The only boy with Type IV anomaly underwent excision of the ventral urethral limb. Three boys with initially elevated serum creatinine have normal levels after reconstruction.

CONCLUSION

Successful reconstruction of boys with Y- duplication of the urethra entailed elucidation of anatomical variations, adequate operative exposure (trans pubic and/or perineal) and innovative utilisation of local and/or distant tissues (preputial island flap, ileal/sigmoid Monti tubes).

Congenital Y-urethra - A diagnostic and therapeutic challenge

BACKGROUND

For the Y-subtype of urethral duplications expression and nomenclature vary, as treatment recommendations do.

OBJECTIVE

To raise awareness of the variety and variable terminology of Y-type duplication of the urethra, and to discuss the diagnostic work-up in light of options for or against surgical reconstruction.

MATERIALS AND METHODS

Five patients with congenital Y-urethra were treated in four institutions within 15 years (2004-2019). While patients were managed in our respective institution with some exchange of experience, all available data were shared and evaluated for this review.

RESULTS

The age at initial presentation was 1 day-6 months. In three patients the Y-urethra was found together with an anorectal malformation (ARM). With the focus on reconstruction rather than suprapubic diversion the orthotopic urethra was restored in the majority of patients using either single-step or staged approaches while the accessory urethral limb was incorporated. This was successful despite additional procedures aiming at ARM reconstruction. The patients void spontaneously and do control urine and bowels. One patient underwent kidney transplantation as a consequence of associated renal anomalies while reconstructive attempts regarding his urethral anomaly failed. In two patients, uncertainty in recognizing the pathology delayed a purposive treatment.

DISCUSSION

For this rare anomaly the terminology in the literature merges and suggestions for the treatment differ. Success in four out five patients supports an approach which makes use of the accessory ventral track to restore the orthotopic urethra. Since some patients present as a neonatal emergency with concomitant problems such as ARM, a basic understanding of the variable pathology is required.

CONCLUSION

The cases of Y-urethra reported herein demonstrate that correct allocation at the initial presentation or at least prior to first surgical steps will preserve the chance for physiologic micturition and urinary continence. Timing of surgery has to be done in the context of associated malformations and is not an emergency as long as proper bladder drainage is ensured. However, relocation of the accessory track requires several procedures bearing risks of complications short and long-term. This may be an argument to consider any therapeutic strategy against other options such as postponed treatment or permanent suprapubic diversion. Evidence-based guidelines are lacking.

Congenital Anterior Urethrocutaneous Fistula with a Persistent Urethral Groove

Congenital anterior urethrocutaneous fistula (CAUF) is a rare penile anomaly with only 63 cases reported in the literature. The anomaly can present in isolation or in association with chordee or hypospadias. We report the case of an 8-month-old boy with CAUF that resembles the embryological urethral groove. On examination, a wide urethral groove was noted to cover the midshaft of the penis with a well formed urethra extending proximally and distally and with a normal glandular anatomy, a wide glandular meatus, and a complete foreskin. The urethral groove was tubularized and covered in layers. Surgery was complicated with early superficial skin dehiscence not affecting the urethral repair.

Refashioning of the skin was then performed. A satisfactory aesthetic and functional outcome was observed at 7 years' follow-up. Defining the anatomy of CAUF and distal urethra is key in management of these children.

Urethral duplication-Epidemiology, diagnosis, and treatment in a case series of 19 patients

BACKGROUND

Urethral duplications are rare congenital anomalies of the urinary tract. Because of their rare occurrence, evidence about epidemiology, diagnosis and treatment is limited.

OBJECTIVE

The aim of this study was to describe the characteristics, presentation, and treatment of a single large cohort of patients.

STUDY DESIGN

The authors describe a cohort of 19 consecutive patients with urethral duplications treated at a single referral institution over a 15-year period. Type of duplication, comorbidities, diagnosis, and treatments are described.

RESULTS

68% of the patients were male, and the age at diagnosis ranged from 0 days to 120 months. The most common type of urethral duplication in this cohort of patients was IIA-2 according to Effmann (26%). Diagnosis was made by healthcare providers in 90% and by the children's mothers in 10% of the patients. Furthermore, 10% of patients presented with urinary tract infections. Only 26% of the patients did not have associated diseases or disorders. Fifteen (79%) patients were treated surgically, with a mean number of 2 (standard deviation 1.6) surgeries per patient. Surgeries were performed ranging between 2 days and 10 years of age.

DISCUSSION

The authors report one of the largest cohorts of patients with urethral duplication. There was a male preponderance, urinary tract infections were rare, and most patients had associated disorders, which is in line with previous reports. In this cohort, most duplications were discovered by healthcare providers, and a small number of patients did not undergo surgical treatment. The broad spectrum of duplications could be confirmed with type IIA-2 being the most common type. The mean number of two procedures per patient was low compared with previous reports.

Urodynamic performance in boys with Y-type urethral duplication

PURPOSE

The aim of this study was to elucidate the urodynamic features of patients with Y-type urethral duplication.

METHODS

Patients with Y-type urethral duplication were retrospectively analyzed. Clinical presentation, urodynamic findings, surgical methods, and treatment outcomes were reviewed.

RESULTS

From 2014 to 2016, six boys were diagnosed with Y-type urethral duplication at our institution. All patients underwent urodynamic testing. Urodynamic testing in patient 1 and 2 revealed detrusor pressure as 100cmH2O and 88cmH2O in the voiding stage, while urinary flow rate were 0ml/s and 2.8ml/s with volume of residual urine as 300ml and 110ml respectively, which consistent with the typical urodynamic of lower urinary tract obstruction. Patient 1, 3, 4 and 6 showed impaired bladder compliance as 7.5ml/H2O, 12ml/H2O, 6ml/H2O and 6ml/H2O respectively. Patient 5 and 6 also showed maximum urethral pressure as 110cmH2O and 125cmH2O with maximum urethral closure pressure as 103cmH2O and 110cmH2O respectively in the resting state.

CONCLUSIONS

Y-type urethral duplication is one potential cause of lower urinary tract obstruction, as seen in the abnormal urodynamic findings in our patients. Further studies are needed to elucidate the characteristics of this rare condition and determine optimal surgical management.

TYPE OF STUDY

Retrospective case series.

LEVEL OF EVIDENCE

Level 4 observational study without controls.

Fate of males with urethral "Y-duplication": 40-year long follow-up in 8 patients

PURPOSE

The spectrum of male urethral duplication is heterogeneous and it includes the Y-duplication. The malformation is rare and there is only a few case series reported in the literature. The management of Y-forms remains challenging for the surgeon and the long-term follow-up is still scarcely investigated. We report our 40-year experience in the management of patients with Y-duplication.

MATERIALS AND METHODS

We conducted a restrospective analysis collecting information of patients with urethral Y-duplication treated at our department from April 1975 to April 2015. We investigated long-term effects of surgery by using a questionnaire.

RESULTS

Ten male patients with Y-duplication came to our attention. One was treated conservatively, seven underwent surgery and two were lost. Surgery consisted of removal of the ectopic branch (via perineal or ASTRA/anterior sagittal trans-rectal approach approach) and reconstruction of the orthotopic urethra. Post-operative complications included stenosis and infections. Long-term results are influenced by associated anomalies and significant problems (incontinence, urinary tract infections and orchiepididimitis) have been reported.

CONCLUSIONS

Y-duplication (or λ-duplication, as we prefer calling it) is a particular form of urethral duplication. The management of patients should be based upon the identification of the functional channel. The removal of the ectopic channel with ASTRA approach is safe and feasible. On the other hand, the reconstruction of the anterior urethra (when steno-atresic) is more challenging and justifies the need for many procedures. The P.A.D.U.A. (progressive augmentation by dilating the anterior urethra) technique was not effective. Skin tube grafts were responsible for infections ("hairy urethra"). BMFG (bladder mucosa free graft) urethroplasty is a good alternative, although associated with well-known complications. Associated anomalies influence long-term outcomes. Clinical study with type IV level of evidence.

Hindgut Duplication: A Unique Case of Six Perineal Openings

Complete hindgut duplication is a rare and intriguing entity, often coupled with genitourinary abnormalities and neural tube defects. The diagnosis demands a thorough clinical exam and radiological workup. Timely recognition and expeditious treatment of these patients can lead to a better quality of life. We present a case of a 10-month-old female with complete hindgut duplication and associated genitourinary duplication treated with surgical intervention.