Case report and literature review

INTRODUCTION AND CLINICAL IMPORTANCE

Urethral duplication is a congenital anomaly characterized by the partial or full development of an auxiliary urethra as a second urethral channel varying in extent and location. The course of treatment for urethral duplication should be individualized for each patient based on the type of anomaly and the existence of symptoms. In most cases, if the ventral orthotopic urethra is normal, excision of the dorsal auxiliary urethra is almost always curative.

CASE PRESENTATION

We report a case of a 13-year-old boy who presented with recurrent urinary tract infection, occasionally having drops of urine at an external pin hole meatal opening on the dorsum of the penile shaft. Several investigations were performed to confirm the presence of the dorsal accessory urethra. The patient underwent complete excision of the accessory urethra, and 12 weeks post-surgery the patient was completely asymptomatic.

DISCUSSION

Urethral duplications are rare anomalies. These anomalies have been classified in various ways in the literature, including sagittal and lateral duplications, dorsal and ventral duplications. The sagittal plane is where the majority of urethral duplications occur. Based on the anatomic variation, clinical presentation and severity of the anomaly, urethral duplication treatment should be customized for each patient. An asymptomatic child may require no specific treatment. Total surgical excision of the dorsal accessory urethra appears to offer the best curative solution.

CONCLUSION

Excision of the dorsal accessory urethra is usually curative when the ventral orthotopic urethra is normal. Thorough investigation before surgery is mandatory to determine the type of urethral duplication. The most common diagnostic procedures for urethral duplications include cystoscopy, KUB ultrasonography, and micturating cystourethrography. These procedures can help plan surgery, prevent complications such as neurovascular bundle injuries and urine incontinence, and improve patient self-esteem and quality of life.

Urethro-urethrostomy for urethral duplication (Type IIA1) in a 3-years-old boy: Surgical approach

INTRODUCTION

To report a novel maneuver of end-to-side urethro-urethrostomy for managing Type IIA1 urethral duplication (UD).

MATERIALS AND METHODS

A 3-years-old boy was referred to our institute for abnormal appearance of genitalia. Physical examination revealed an epispadiac meatus on the dorsum of the penile shaft, in addition to the orthotopic meatus at the tip of glans. He can void through both urethrae with continence (grade I). Voiding cystourethrography and the cystoscopy confirmed the Type IIA1 UD with two urethrae arising independently from the bladder neck. A novel maneuver of end-to-side urethro-urethrostomy transferring the dorsal urethra through the corpus cavernosa and anastomosing it to the posterior wall of the ventral urethra was successfully performed.

RESULTS

The urethral catheter was removed 2 weeks postoperatively. Neither urethral stricture nor fistula was noticed. After 1 year of followed-up, the boy can void fluently with continence (grade I). The Qmax was 10.4 ml/s.

CONCLUSION

Our maneuver of end-to-side urethro-urethrostomy for managing Type IIA1 UD was safe and effective, especially for the continent cases with the ectopic meatus on the penile shaft.

Type IIB urethral duplication in adult: A case report

Urethral duplication are rare anomalies of the lower urinary tract consisting of partial or complete development of an accessory urethra that common in males than female. The exact embryological mechanism for this condition remain unclear, it is thought to relate to a disruption of development of the lateral folds of Rathke during hindgut development. There are 3 types based on Effman's classification. Diagnosis of urethral duplication, a genital examination has to performed and confirmed by micturating cytourethrography and retrograde urethrography. The authors presented a case of 67-year-old man complaining of dysuria, who was diagnosed with urethral duplication Effman Classification type IIB accompanied by bulbar urethral stricture and diverticula and multiple bladder diverticula after performing retrograde urethrography and micturating cystourethrography. This is an extremely rare type of duplication of the urethra (type IIB) with late presentation. Further study may be required regarding the surgical management.

Anorectal malformation, urethral duplication, occult spinal dysraphism (ARM-UD-OSD): a challenging uncommon association

PURPOSE

Urethral duplication (UD) is a rare malformation, which can be associated with other anomalies, like anorectal malformations (ARM). ARM has been described with occult spinal dysraphism (OSD). No ARM-UD-OSD combination has been reported.

AIM

To share our experience and to discuss the management of ARM-UD-OSD association.

METHODS

We retrospectively reviewed records of five boys with UD. Four of these had ARM-UD-OSD association. ARM was the first diagnosis in all; OSD and UD was detected during screening for associated malformation.

RESULTS

All patients underwent ARM correction, 3 after colostomy. All reached fecal continence, 3 are performing bowel management. Three patients underwent UD surgical correction. Because of symptoms' worsening, 2 children had detethering surgery. At a mean follow-up of 9.5 years, all patients have normal renal function, 3 are on clean intermittent catheterization (CIC) for neurogenic bladder (1 has a cystostomy, another one an appendicostomy).

CONCLUSIONS

UD and OSD should be considered in patients with ARM. Children with these conditions associated must be centralized in a third-level Center and management carefully planned; in particular, urethral reconstruction should be weighed, considering CIC could be required. Suspicion of neurogenic bladder must be present in OSD patient.

Urethral duplication as cause of incontinence in a 5-years-old female: Surgical approach

INTRODUCTION

Duplication of the urethra is a rare congenital anomaly in females which, if left unidentified, might cause refractory urinary incontinence. This video demonstrates its identification and treatment.

PATIENT & METHODS

A 5-year-old female was referred for primary refractory diurnal incontinence without any dry moment since birth. Initial clinical examination showed permanent urine leakage from an opening cranial to the clitoris. Ultrasound did not show any bladder or kidney abnormalities. A diagnostic cystoscopy under anesthesia revealed an accessory meatus located cranially to the orthotopic meatus and to the clitoris.

RESULTS

Lying in dorsal decubitus under general anesthesia, catheters were inserted in respectively the orthotopic and accessory meatus. The accessory meatus and urethra were dissected away into the bladder dome from a circumferential skin incision. Defects were closed and bladder drainage per urethram was left in situ for 10 days. P ostoperative recovery was uncomplicated. Complete resolution of the incontinence was immediately achieved at catheter removal. Daytime and night-time continence are observed with 3 years follow-up.

CONCLUSION

Urethral duplication is a rare finding in females but should be excluded during the workup of primary incontinence. In girls with isolated urethral duplication, resection of the accessory urethra is the best surgical option.

Robotic-assisted laparoscopic repair of a congenital rectourethral fistula with duplicated urethra

OBJECTIVE

To describe our experience with robot-assisted laparoscopic transperitoneal repair of a congenital rectourethral fistula in a pediatric patient with a urethral duplication.

METHODS

The patient is a 2-year-old male with a past medical history of Tetralogy of Fallot presenting with a febrile urinary tract infection (UTI). He was diagnosed with urethral duplication and a rectourethral fistula by voiding cystourethrogram (VCUG). The parents were counseled on various options and agreed to proceed with a robotic repair.

RESULTS

Robotic-assisted transperitoneal rectourethral fistula repair was performed. The procedure time was 229 min with an estimated blood loss (EBL) of 15 mL. His postoperative course was unremarkable. At his 2-week follow-up, the urethral catheter was removed and the patient was voiding normally and having normal bowel movements.

CONCLUSION

Congenital rectourethral fistula with urethral duplication is a rare anomaly with only a few reports in the literature. Pediatric robotic-assisted transperitoneal rectourethral fistula repair is a technically feasible approach in infants with minimal morbidity that allows for excellent visualization and avoids open repair.

Duplicate urethra communicating with seminal vesicles: A rare case report

Urethral duplication is a rare congenital anomaly. A rare variety of accessory urethra communicating with the right seminal vesicle is reported, this is a case report of a 46-year-old male who manifested as semen discharge from the ectopic opening of the urethra, and abnormal discharge of secretions in the near future. After conservative treatment with antibiotics, the symptoms disappeared. The classification, diagnosis, and treatment for this anomaly are discussed.

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.

Urethral duplication in male children: A study of 12 cases

PURPOSE

To present our experience in urethral duplication focusing on detailed surgical management.

METHODS

We retrospectively reviewed the records of 12 male patients treated for urethral duplication between 2005 and 2017. Evaluations included ultrasound, retrograde urethrography, cystoscopy, and voiding cystourethrography.

RESULTS

The age at presentation ranged from birth to 11 years. All 12 cases were classified using the Effmann classification. Case 1-4 patients with type I underwent excision of the dorsal accessory urethra by stripping technique. In case 5 patient(type IA) with two adjacent apical urethras, the septum was opened to form a single channel. Case 6 patient with type IB underwent visual internal urethrotomy near bulbous urethra to combine urethra into one channel. Five patients classified as type II (one with a type IIA1, and four with type IIA2 urethras). Urethral duplication was incidentally found during epispadias repair in case 7 patient with type IIA1, which was corrected by ventral plication, and excision of the dorsal epispadial urethra with stripping technique just below pubic bone. Case 8 patient with type IIA2 also required dorsal urethral excision with stripping technique. The two Y-type patients (case 10, 11) underwent urethrourethrostomy with a single-stage buccal mucosa tube graft, followed by repetitive surgeries owing to urethral stricture. One type III patient presented with penile inflammation and suprapubic pain, and underwent excision of both the dorsal urethra and nonfunctional anterior bladder.

CONCLUSIONS

Urethral duplication requires individualized surgical approaches based on the anatomical and functional characteristics. Because prognosis is variable depending on type and accompanied anomalies, these should be taken into account when planning a comprehensive workup and surgical management.

LEVEL OF EVIDENCE

Level IV.

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.

Epispadias associated with urethral duplication: Our practice

•

Urethral duplication is one of the rarely found congenital anomalies in the genitals.

•

An epispadias is a malformation of the penis in which the urethra ends in an opening on the upper aspect of the penis.

•

In this article we have reported three years old male patient with incomplete urethral duplication and epispadias.

Introduction

Urethral duplication and epispadias are one of the rare anomalies of the genitourinary system. Sometimes, urethral duplication can also be associated with anorectal malformations, epispadias, hypospadias, bladder doubling, bladder exstrophy and other urinary excretory system anomalies.

Presentation of case

In this article we report three years old male patient with incomplete urethral duplication and epispadias. During our examination there was detected the second - accessory urethra along with the main urethra on the dorsal surface of the penile. The accessory urethra was stripped from the surrounding tissues to the root of the penile and it became apparent that the accessory urethra was merged into the main urethra at the same level. The accessory urethra was closed by suturing and removed from that part. Then, by using 7.0 pds thread there was performed urethroplasty.

Discussions

Urethral duplication is one of the rarely found congenital anomalies in the genitals. Duplications in the sagittal plane can be complete or incomplete, dorsal or ventral, and may be associated with other congenital urogenital anomalies. An epispadias is a rare type of malformation of the penis in which the urethra ends in an opening on the upper aspect of the penis. Despite the fact that there are many considerations about their embryology, the reason of appearance of these anomalies is still unknown.

Conclusions

While planning of surgical treatment of such common anomalies along with the good cosmetic results the lower urinary excretory system functions should be considered as well.

Congenital prepubic sinus with dorsal penile curvature: a case report and literature review

Background

Congenital prepubic sinus (CPS) is a rare congenital anomaly and widely thought to be a variant of urethral duplication. Histological examination of this case gives a clue to this theory. CPS with dorsal penile curvature has been reported in previous publications, but their procedures to correct the curvature are different from this case.

Case presentation

A 10-year-old boy complained of the pain in the dorsal base of the penis. Physical examination revealed an accessory meatus located in the midline of the dorsal proximal penis and moderate dorsal penile curvature with deficient dorsal foreskin. Imaging examination showed that the meatus did not communicate with either normal urethra or urinary bladder, and ended blindly at the level of the symphysis pubis. The intact 4-cm-long sinus was completely separated and excised. Penile curvature was corrected after the dorsal proximal fibrous cord was detached. Histological examination confirmed the diagnosis of urethral duplication.

Conclusions

The histological result of this case supports the theory that CPS is a variant of the dorsal urethra. Moreover, this case indicates that the curvature in patients with CPS may be caused by the dorsal fibrous cord at the beginning and the operation should be conducted at an early age to avoid further development of the curvature during puberty.

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.

Y-type urethral duplication with rectal implantation of the urethra: Which is the best approach?

INTRODUCTION

Y-type urethral duplication describes the condition in which a functional urethra is implanted in the rectum, and there is also a dysplastic topic urethra which produces mostly urinary dribbling. These patients are at risk of urinary tract complications and UTI. We aimed to present the surgical steps of a case treated by ASTRA approach in which we separated the urethra from the rectum and created a perineal urethrostomy.

MATERIAL AND METHODS

We treated a 5-month-old boy with Y-type (IIA-2) urethral duplication, in whom the orthotopic urethra was patent just in the penile segment. The patient had urinary flow per anus and minimal dribbling through the orthotopic urethra. We performed a combined cystoscopy with retrograde urethrogram and managed to catheterize the dysplastic urethra with a guide-wire that showed ectopic implantation in the prostatic urethra, below the bladder neck. We performed an ASTRA procedure to separate the urethra from the rectum. The urethral stump was further mobilized to the perineum and anastomosed to a perineal skin flap to create a stoma and minimize the risk of stricture.

RESULTS

The patient was followed at 2 month-intervals, and at 6 months follow-up had an excellent outcome.

CONCLUSION

The ASTRA approach proved to be an excellent alternative for Y-type urethral duplication with functional urethra implanted in the rectum. We believe that further efforts to reconstruct the urethra should be avoided, with a better and simpler option being to create a definitive perineal urethrostomy.

Case of urethral duplication seen by voiding urosonography

A 3-month-old premature male infant with imperforate anus and hypospadias underwent contrast-enhanced voiding urosonography (ceVUS) followed by voiding cystourethrography (VCUG). Images from the ceVUS demonstrated a distinct linearity arising dorsally from the posterior urethra that partially opacified with contrast. VCUG confirmed a urethral duplication. To our knowledge, this exceedingly rare anomaly has yet to be reported by ceVUS.

The anterior sagittal transrectal approach (ASTRA) for cases associated with rectal implantation of the urethra: A retrospective review of six cases

INTRODUCTION

Severe genital abnormalities such as urogenital sinus and urethral duplication with ectopic urethra in the rectum represent a major challenge in reconstructive urology.

OBJECTIVE

We aimed to review our cases presenting with functional ectopic urethra implanted in the rectum that were treated through an ASTRA approach.

METHODS

We reviewed the medical records of all patients who had undergone an ASTRA approach from 2005-2016. We collected data with interest to primary diagnosis, clinical presentation, additional procedure, immediate clinical outcome, complications, bowel habits after surgery, voiding and bladder emptying pattern and long term follow-up.

RESULTS

Since 2005, we treated 6 cases using this method, consisting of 3 patients with congenital aphallia and 3 with Y-type urethral duplication. Two aphallia patients underwent De Castro's neophalloplasty with simultaneous anastomosis of proximal urethra to a tubed buccal mucosa neourethra and one had a neophalloplasty with transverse skin flaps and primary perineal urethrostomy. Two patients with Y-type urethral duplication had a complete urethroplasty performed (one end-to-end anastomosis and a two-stage repair). Last patient had a definitive perineal urethrostomy. At mean follow-up of 83.5 meses, only one patient voids through the urethra, four have a Mitrofanoff channel and two have a perineal urethrostomy. Immediate follow-up was uneventful and none of our patients had any bowel complications nor fecal incontinence.

DISCUSSION

Domini et al. were the first proponents of the anterior sagittal transanorectal approach (ASTRA) as an alternative to classic Peña approach. Later, De Castro popularized specifically this technique as a relevant part of his neophalloplasty procedure to treat congenital aphallia. We did not find in this series any complications related to ASTRA technique in regards to bowel habits, fecal incontinence or infection but most of cases we tried to create a new anterior urethra and connect to the proximal stump failed. Moreover, we are skeptic to support simultaneous urethral repair when there is a dysplastic bulbar segment between the proximal stump and the end of the penile urethra normally at penoscrotal junction area by urethral duplication. Treatment at two-stages is also prone to fail in the midterm. At end, most of them will have either a Mitrofanoff or perineal urethral stoma as shown in our data.

CONCLUSION

The ASTRA approach proved to be useful for cases of rectal implantation of the urethra. No complications related to anterior sphincter incision were documented. We believe it should be regarded as the treatment of choice for cases alike ours.

The Association of Congenital Urethral Duplication and Double Megalourethra

Background:

Urethral duplication and megalourethra are rare urethral anomalies. However, the concomitance of urethral duplication and double megalourethra has not been reported previously.

Case Report:

A newborn was presented with penile swelling during voiding. Physical examination revealed a retractable foreskin and two external meatus of a double urethra. Retrograde urethrography demonstrated two complete megalourethras. Urethro-urethrostomy and urethroplasty were performed when the patient was 10 months old. The patient was followed up for one year without any urinary problems and has good cosmetics and urinary continence.

Conclusion:

The concomitance of these two rare anomalies and more importantly its surgical treatment makes this case report unique and valuable.

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.

Glans duplication: In-depth review and proposal of a new classification

BACKGROUND

Diphallia is a very uncommon malformation, and glans duplication (GD) is its rarest form. In this last group, patients normally present with esthetic/sexual complaints or obstructed voiding late in life after pubertal genital development. Associated malformations are uncommon and relatively mild in those cases.

METHODS

After a case presented, we present herein an extensive review of GD, as the disease is rare, and there is very little about its treatment and there are diverse approaches to address the condition.

RESULTS

After an extensive review of the available literature, we carefully analyzed each published case to describe specific aspects of their clinical presentation (age, main complaint, voiding/urethral problems, and individual anatomy) and treatment.

CONCLUSION

This review allowed us to propose a new classification for diphallia into four groups (true diphallia, hemiphallus, pseudodiphallia, and partial duplication), considering embryological, anatomical, clinical, and therapeutic implications (see Fig. 1). Glans duplications present as esthetic/sexual cases or show abnormal voiding patterns caused by urethral associated abnormalities. Reconstructive techniques may be simple (resection of a hypoplastic accessory glans + urethra) or relatively complex (glans and/or urethral reconstruction).

Hypospadiac Duplication of Anterior Urethra-a Rare Congenital Anomaly

Duplication of the urethra is a complex and rarely seen congenital anomaly with three anatomic variants: epispadiac (dorsal), hypospadiac (ventral), and Y-type. We report here a case of hypospadiac duplication of anterior urethra with dorsal blind ending urethra in a 9-year-old boy who presented with complaint of passing urine from the ventral aspect of penis.

Practical and functional classification of the double urethra: A variable, complex and fascinating malformation observed in 20 patients

INTRODUCTION

Urethral duplication is a rare and variable malformation of the urinary tract, with non-univocal and complex management. In addition, different classification schemes have been proposed, but none have considered all the possible variants.

OBJECTIVE

To report experience with the management of 20 urethral duplication patients and propose a classification of this anomaly.

MATERIALS AND METHODS

A retrospective analysis collecting information regarding 20 patients (Table) with urethral duplication treated at a single institution over the past 40 years. Three females and 17 males were treated: two had vesico-urethral duplication, eight had urethral duplication with a single bladder, and eight had 'λ' duplication.

RESULTS

Immediate postoperative complications included urethral dehiescence (n = 1) and urethral stenosis (n = 2). The progressive augmentation by dilating the urethra (PADUA) technique was ineffective. During follow-up, the following were recorded: urinary incontinence (n = 2), urinary tract infection (n = 3), hypertension (n = 3) and erectile dysfunction (n = 1). All patients were satisfied with the aesthetic result.

DISCUSSION

Urethral duplication is a rare anomaly with male preponderance. Four types of duplication were described, on the basis of anatomy and management: vesical and urethral duplication (type 1), urethral duplication with single bladder (type 2), 'λ-type' duplication (type 3) and 'miscellanea' (multiple urethral channels, spindle urethra, other female forms, type 4). A full description of the malformation and surgical approach was given for each type. The advantages of the classification were compared with the literature.

CONCLUSIONS

The proposed classification should be a useful tool, based on the required surgical approach, even if surgery should be tailored to the patient. It is important to restore the anatomy and achieve urinary continence. Surgery can be challenging and a multi-step process, especially in cases of 'λ' duplications.

Urethral duplication in girls: Three cases associating an accessory epispadiac urethra and a main hypospadiac urethra

INTRODUCTION

Urethral duplication is extremely rare in girls, with less than 40 cases reported so far. Most of them present as a prepubic sinus. Literature is scare regarding aetiology, classification and management in other forms. This study presents three cases of sagittal urethral duplication in girls presenting a main hypospadiac urethra and an accessory epispadiac urethra.

PATIENTS AND METHODS

Medical records were retrospectively reviewed of three girls with urethral duplication managed over a 30-year period at a single institution. Circumstances of diagnosis, management and outcomes were analysed.

RESULTS

The oldest case presented as a neonatal retrovesical mass with an accessory clitoral stream, whereas the two more recent cases presented with antenatal hydrocolpos and bilateral ureterohydronephrosis. Cases 1 and 3 had an incomplete duplication, while Case 2 had a complete form. In Case 3, the duplication was associated with a urogenital sinus and an anteriorly placed anus. Management involved resection of the epispadiac accessory urethra to achieve continence, with dilatation and/or mobilisation of the hypospadiac one. All girls are now aged >5 years old and are continent, and one is old enough to have normal menstruation. Renal function is normal in all. The summary table presents the schematic anatomical description as shown on micturating cystourethrogram and endoscopy, as well as the management for each patient.

DISCUSSION

Step-by-step management is necessary in urethral duplication. The neonatal emergency is to release the urinary tract compression by evacuating urinary retention or hydrocolpos. Later in infancy, decision has to be taken regarding the urethras. If the resection of the epispadiac accessory urethra seems acceptable to achieve continence, the attitude towards the hypospadiac channel is more controversial and should be individualised. Embryologic and aetiopathogenic pathways are still missing to uniformly characterise the malformation.

CONCLUSION

Paediatric urologists should remember that there is a wide spectrum of urethral duplication in girls, and that various presentations exist beside the more classic prepubic sinus.

Urethral duplication--a wide spectrum of anomalies

OBJECTIVE

Urethral duplications are rare lower urinary tract anomalies, with multiple anatomical variants described. This paper aims to separate this complex anomaly into different diseases, each with distinct clinical forms according to the disturbance during embryogenesis, yet noting a few similarities that may be helpful in their management. The classification system of urethral duplication is also discussed.

MATERIAL AND METHODS

Twelve urethral duplication cases over a 14-year period were reviewed. Clinical presentation, the imaging studies used to ascertain anatomical details, type of urethral duplication and surgical correction used in the treatment of patients are presented.

RESULTS

Nine patients had urethral duplication in the sagittal plane and three patients in the coronal plane. Of the patients with sagittal urethral duplication, 3 had pre pubic sinus, 3 had epispadiac urethral duplication, 1 had a dorsal urethral duplication deviated from the midline and 2 had hypospadiac urethral duplication. All the patients with coronal urethral duplication had associated bladder duplication. The surgical correction of the patients with sagittal urethral duplication included excision of the pre pubic sinus, excision of the duplicated urethra, and urethroplasty. Excision of the hemibladders' septum and closure of one bladder neck was the treatment for patients with coronal urethral duplication and bladder duplication.

CONCLUSION

Urethral duplication is a complex anomaly and the different manifestations probably have different embryological origins. Each group, sagittal or coronal, has a few similarities that may be helpful in their management, although every diagnosed case presents a unique anatomy and surgical treatment must be individualized.

Diphallus: report on six cases and review of the literature

BACKGROUND

Diphallus is an extremely rare anomaly. Numerous associated genitourinary, gastrointestinal and other anomalies have been described with diphallus. These patients need several investigations, and finally surgical intervention.

CASES PRESENTATION

In this report we discuss six patients with diphallus which evaluated retrospectively. Five patients had complete diphallia, and one had bifid diphallus. Meatus was normal in 3, hypospadiac in 2, and epispadiac in one patient. The most common associated anomaly was bifid scrotum (5 cases), and other common anomalies consisted of bladder duplication (3 cases), imperforate anus (2 cases), and hypospadias (2 cases). Phalloplasty was performed for all but one.

CONCLUSION

All the patients with urethral duplication have to be evaluated carefully because of the high incidence of other systemic anomalies.