Y-duplication of the male urethra: use of anterior anorectal wall for posterior urethral lengthening

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.

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.

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.

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

Aims:

Report of seven children with Y-type urethral duplication (YUD).

Materials and Methods:

(A) Four staged operations were performed in patients having extensive perineal dissection (for rectourinary fistula separation and anterior mobilization of ventral urethra (VU)), tension rectocutaneous anastomosis, and children who were not toilet trained). These stages are (1) diversion sigmoid colostomy with anterior mobilization of VU as perineal urethrostomy via anterior sagittal approach; (2) Orthotopic urethral (OU) reconstruction; (3) anastomosis of OU and perineal urethra; (4) colostomy closure with management of complications. (B) The patients having VU onto the perineum underwent single stage urethral reconstruction.

Results:

The VU was urethrorectal/urethroanal in five and urethroperineal in two. Low anorectal malformation and upper urinary tract anomalies were present in 57.1% (4/7) and 14.7% (1/7) patients, respectively. Buccal mucosa free graft, transverse inner preputial flap, and perineal skin were tubularized for OU reconstruction. Mean age at 1^st , 2^nd , 3^rd , and 4^th surgery was 5 ± 0.78, 28 ± 0.78, 36 ± 0.78, 49 ± 0.78 months respectively. Three patients needed surgery for complications (urethrocutaneous fistula in two and urethral diverticulum in one) in a mean 3.12 ± 0.34 years of follow-up. Final uroflowmetry and fecal continence were good in all patients.

Conclusions:

The YUD is a difficult entity to manage. Although, staged procedure appears to be time consuming, but good and promising results can be achieved by staging the procedure.

Use of ileum in reconstruction of the congenitally abnormal posterior urethra in two children

The construction of a posterior urethra when a healthy anterior urethra is not available is surgically challenging. We describe two children in whom the posterior urethra was constructed from a segment of ileum. Both children had a satisfactory outcome; one has been followed up for 10 years and one for 1 year.