Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA; Department of Urology, University of Washington.
Department of Urology, University of Washington.
Urology. 2023 Jun;176:249-250. doi: 10.1016/j.urology.2023.03.008. Epub 2023 Mar 28.
Prostatic utricle (PU) with normal external genitalia is an uncommon congenital anomaly. About 14% develop epididymitis. This rare presentation should warn involvement of the ejaculatory ducts. Minimally invasive robot-assisted utricle resection is the preferred method.
To describe a novel approach to PU, we hereby present the video of a case with PU resection and reconstruction using a Carrel patch principle to preserve fertility.
A 5-month-old male presented with right side testicular orchitis and a large retrovesical hypoechoic cystic lesion. Urine culture was positive. He responded well to oral antibiotics. A voiding urethrocystogram confirmed a large PU. A breakthrough orchitis occurred 5 months later and the decision to proceed with surgical resection was made. Robot-assisted PU resection was performed at 13 months of age and 10 kg. Dissection of the utricle was guided with a flexible cystoscope and intraoperative ultrasound. Both vas deferens were seen draining at the neck of the PU making complete circumferential resection not feasible without compromising the integrity of both seminal vesicles and vas deferens. To preserve fertility, a PU flap including both seminal vesicles was preserved and anastomosed to the edges of the resected PU following the Carrel patch principle. Postoperative course was not complicated, and patient was discharged home on second postoperative day. A month later, exam under anesthesia, circumcision, cystoscopy, and cystogram demonstrated no contrast extravasation with otherwise normal anatomy. Foley catheter was then removed. A year after the procedure patient has been asymptomatic with no new infection recurrence and normal potty-training process.
Symptomatic isolated PU is an uncommon presentation. Impact of recurrent orchitis on future fertility is possible. Complete resection is difficult in cases where the vas deferens enters the PU at its base crossing the midline. Our novel approach to preserve fertility using the Carrel patch principle is feasible thanks to better visibility and exposure enhancement provided robotically. Prior open attempts demonstrated be technically difficult given the deep and anterior location of the PU. To our knowledge, this is the first time such procedure is reported. The use of cystoscopy and intraoperative ultrasonography are also valuable tools.
Reconstruction of PU is technically feasible and should be considered when risk of future infertility can be compromised. After a 1-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.
具有正常外生殖器的前列腺囊（PU）是一种罕见的先天性异常。约 14%的患者会发生附睾炎。这种罕见的表现应警惕射精管受累。微创机器人辅助的前列腺囊切除术是首选方法。
为了描述一种前列腺囊的新方法，我们在此展示一例使用 Carrel 补片原则进行前列腺囊切除和重建的视频，以保留生育能力。
一名 5 个月大的男性因右侧睾丸附睾炎和一个大的膀胱后低回声囊性病变就诊。尿液培养阳性。他对口服抗生素反应良好。排尿性尿道膀胱造影证实有一个大的前列腺囊。5 个月后发生突破性睾丸炎，决定进行手术切除。在 13 个月大、体重 10 公斤时，进行机器人辅助前列腺囊切除术。在柔性膀胱镜和术中超声的引导下，对前列腺囊进行解剖。双侧输精管均可见在前列腺囊颈部引流，为了不损害双侧精囊和输精管的完整性，不能进行完全环形切除。为了保留生育能力，采用 Carrel 补片原则，保留包括双侧精囊的前列腺囊皮瓣，并将其吻合到切除的前列腺囊边缘。术后过程无并发症，患者于术后第 2 天出院回家。术后 1 个月，全麻下检查、包皮环切术、膀胱镜检查和膀胱造影显示无造影剂外渗，解剖结构正常。然后拔除 Foley 导管。手术后 1 年，患者无症状，无新发感染复发，正常如厕训练过程。
症状性孤立性前列腺囊是一种罕见的表现。复发性睾丸炎对未来生育能力的影响是可能的。在输精管在前列腺囊底部进入，穿过中线的情况下，完全切除是困难的。由于前列腺囊的位置深且靠前，我们采用 Carrel 补片原则保留生育能力的新方法是可行的，这得益于机器人提供的更好的可视性和增强的暴露。之前的开放性尝试表明，由于前列腺囊的深在和靠前的位置，技术上很困难。据我们所知，这是首次报道此类手术。膀胱镜和术中超声的使用也是有价值的工具。
前列腺囊重建在技术上是可行的，当未来生育能力可能受到影响时，应考虑进行重建。在 1 年的随访后，继续长期监测很重要。应与家长充分讨论可能的并发症，如瘘管形成、感染复发、尿道损伤和尿失禁。
