Robot-assisted Prostatic Utricle Reconstruction Using the Carrel Patch Principle to Preserve Fertility
Nicolas Fernandez, MD PhD1, Xinyuan Zhang, MD2.
1Seattle Children's Hospital, Seattle, WA, USA, 2University of Washington, Seattle, WA, USA.
BACKGROUND: Prostatic utricle (PU) with normal external genitalia is an uncommon congenital anomaly. Very few cases present with symptoms and only 14% develop epididymitis. This rare presentation warrants evaluation of possible involvement of the ejaculatory ducts. Robot-assisted utricle resection has been demonstrated to be feasible and safe. Impact on future fertility has been scarcely explored. Injury of the vas deferens during PU resection may negatively impacts fertility.
METHODS: We hereby present a case of PU resection and reconstruction using a Carrel patch like principle to preserve fertility.
RESULTS: A five-month-old uncircumcised male presents with right-sided testicular swelling. Testicular ultrasound showed orchitis and a large retrovesical hypoechoic cystic lesion consistent with a large PU. Urine culture was positive for Klebsiella oxytoca and patient responded well with oral antibiotics for 14 days. A voiding cystourethrogram was performed and confirmed a large prostatic utricle. A second episode of orchitis occurred 5 months later despite being on prophylactic antibiotics and the decision was made to proceed with surgical resection.
Robot-assisted PU resection was performed at 13 months of age with a weight of 10 kg. Port placement included umbilical access for the camera and two 4 mm-apart lateral ports on each side following a horizontal distribution. A hitch stitch was used to hold the bladder. Dissection of the utricle was guided by flexible cystoscopy and intraoperative ultrasound. Visible bilateral seminal vesical orifices were identified at the junction with the urethra. The vas deferens were seen draining at the neck of the PU making complete circumferential resection feasible without compromising the integrity of the vasa. To preserve fertility, a PU flap including drainage of both seminal vesicles was preserved and anastomosed to the edges of the resected PU following a Carrel patch principle. Cystoscopy confirmed no compromise of the urethra. Foley catheter was left in place. Operative time was 3.5 hours with an estimated blood loss of 5 ml. Postoperative course was uncomplicated and the patient was discharged on postoperative day two. A month later, exam under anesthesia, circumcision, cystoscopy and cystogram demonstrated no contrast extravasation with otherwise normal anatomy. With the scope located at the PU ostium, a small residual cavity with retrograde contrast going into the vas deferens was seen. Foley catheter was then removed. A year after the procedure, patient remained asymptomatic with no recurrence of urinary tract infections and is undergoing normal potty-training process.
CONCLUSIONS: Reconstruction of PU is technically feasible and should be considered when future fertility can be compromised. After a one-year follow-up, it is important to continue to monitor long-term. Possible complications like fistula development, infection recurrence, urethral injury and incontinence should be thoroughly discussed with parents.
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