Duplication of the urethra

Disorder of sexual development, urinary bladder duplication, pancake kidney and neural tube defect

Congenital malformations of the urogenital system with fully developed duplications, such as urinary bladder, are sporadic. They are often present in the setting of endogenous molecular disbalance, such as steroid metabolism disturbances. Other rare manifestations of hormonal disbalance present as intersex conditions in which the individual has karyotype-specific internal genital organs with opposite-sex signs of the external genitalia, known as ambiguous genitalia. Congenital variations and malformations are often fully recognized and understood during radiological exams. Herein we present a unique case of a 2-month-old baby with female chromosomal sex and ambiguous genitalia together with the manifestation of several anatomical malformations: urinary bladder duplication in the coronal plane, pancake kidney with supernumerary renal arteries, 2 ureters and neural tube defect. Despite their low incidence rate, knowledge of such malformations is paramount for correct diagnosis and treatment in such cases.

Female pseudohermaphroditism with urethral duplication: A delayed presentation in adulthood

Female pseudohermaphroditism with urethral duplication presenting as urinary retention in adulthood is extremely rare. We report the case of a 26-year-old female who had multiple failed attempts of per urethral catheterization during a planned cesarean section. She had labial fusion and clitoral hypertrophy with a phallic urethra and underwent labial separation with urethral reconstruction.

Urethral duplication type influences on the complications rate and number of surgical procedures

Introduction:

Urethral duplication is rare. Characterized by the presence of two urethral channels. This anomaly presents a great variety of clinical findings that depend on the type of duplication that often is associated with other anomalies.

Material and Methods:

We report thirteen boys with urethral duplication managed in our institution between 1988-2015. Clinical findings, associated anomalies, treatment of urethral duplication and our results are described. Patients were classified according to Effmann classification.

Results:

Mean patient's age was 38.3±34.7 months (3-136 months). Mean follow-up was 7.7±3.4 years (3y8m-14y2m). Type II A2 was the most common pattern (8/13 patients, 61.5%), followed by type IA (3/13 patients, 23%) and IIA1 (2/13 patients, 15.3%). The most frequent clinical manifestations were urinary tract infections (UTI) observed in 11/13 patients (84.6%) and anal urinary leakage, found in 7/13 patients (53.8%). Associated anomalies were found in 9/13 patients (69.2%).

Required surgeries were 3.53±2.84 procedures per patient. Considering groups: Type IIA2 4.25±3.28, type IIA1 4±1.41 and type IA 1.33±0.57 needed procedures per patient. Complications rate were 0% for type IA, 50% for type IIA1 and 75% for type IIA2.

Conclusions:

Patients with incomplete duplication (type I A or I B) can totally be asymptomatic, with no need of surgical correction. Type IIA2 is the most complex form of duplication to correct and multiple procedures might be required because of the very hypoplastic orthotopic dorsal urethral tissue. Surgical treatment should be individualized and parents should be advised on complications and need of multiple surgeries according to urethral duplication type.

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.

The double urethra: revisiting the surgical classification

AIM

The aim of this article was to describe our experience with 14 patients with double urethra.

PATIENTS AND METHODS

We retrospectively examined the patients' records including their clinical presentations, investigations, operative findings, and outcome. In addition to Effmann's classification, we used a newly proposed classification that depends on the orientation of the double urethral channels.

RESULTS

During the last 15 years, 18 patients were diagnosed to have double urethra at our pediatric surgical unit. We excluded four patients with 'Y-type' urethral duplication. The remaining 14 patients were divided into either sagittal or collateral duplication. Their age at presentation ranged from the neonatal period to 9 years. The sagittal urethral duplication included 12 male patients. All patients had two urethral channels, one above the other. The dorsal urethral channel was always characterized by poor function and ectopic course. The ventral channel was always the more functioning urethra, with a normal course from the urinary bladder to end either at an orthotopic meatus (subgroup A), or more proximally in a hypospadiac location (subgroup B). The collateral urethral duplication included two patients. Both patients were associated with duplication of the urinary bladder and the external genitalia as a part of caudal duplication syndrome. In this group, both urethrae had comparable function, lying side by side, and each draining a separate urinary bladder.

CONCLUSION

The double urethra is a diverse spectrum comprising different pathologies. Our proposed classification system of duplicated urethras is clinically relevant as it guides surgical management and allows prognostication of outcome.

Urethral duplication: cases of ventral and dorsal complete duplication and review of the literature

Urethral duplication is a rare congenital anomaly, with multiple described anatomical variants. Duplications in the sagittal plane can be complete or partial, dorsal or ventral, and may be associated with other congenital urogenital anomalies. The anatomy of the duplication should be defined, and the functional urethra identified prior to any corrective surgical intervention. Correction aims to restore normal cosmesis, provide functional voiding and maintain continence. We describe two cases of urethral duplication in the sagittal plane, outline our approach to surgical correction, and review the literature.

Complete duplication of bladder and urethra in a sagittal plane in a male infant: case report and literature review

Complete duplication of the bladder and urethra is a rare entity. It may occur in the coronal and sagittal planes, and is often associated with other organ system anomalies, in particular of the gastrointestinal tract. We report an unusual variant of sagittal duplication of the bladder, in a male, associated with rudimentary hindgut duplication, and review the literature pertaining to this unusual anomaly.

Intermittent bladder urinary retention in a young woman: an unusual presentation of partial urethral duplication

A singular case of female accessory urethra associated to a mobile bladder stone with an unusual clinical presentation is reported. The role of perineal ultrasound is emphasized as a useful diagnostic tool to study female urethra in a static and dynamic setting, including cases of partial or complete urethral duplication.

Y-type urethral duplication: an unusual variant of a rare anomaly

Urethral duplications are rare anomalies. We present a 3-year-old continent boy passing urine since birth per anus while voiding from penis. Micturating cystourethrogram, retrograde urethrogram and cystoscopy revealed a Y connection between the posterior urethra and anal canal. The accessory channel was excised by a perineal approach. Histopathology revealed that the tract was lined by transitional epithelium, proving that it was indeed a case of urethral duplication; hence, we suggest that all urethroanal fistulas are not variants of anorectal malformations. Certain of these fistulas should be considered as variants of Y-type urethral duplication even if the orthotopic urethra is normal.

[Urethral duplication in boys: report of 4 cases]

Urethral duplication is a rare anomaly, affecting mainly boys. The clinical presentation varies because of the different anatomical patterns of this abnormality. We report 4 cases of urethral duplication in children. An epispadiac duplication was present in 1 case, hypospadiac duplication in 1 case, Y-duplication in 1 case and a congenital prepubic sinus in the last case. The pre-operative probe was based on urethrocystography and fistulography. The surgical management included excision of the duplicated urethra in 3 cases. Transurethral incision of the intra-urethral septum was performed in the case of hypospadiac duplication. The characteristics of male urethral duplication are reviewed.

A rare association of urogenital duplication and anorectal malformation

An unusual case of urogenital duplication in association with anorectal malformation is presented. A 3-year-old girl was referred to the authors' hospital with double vagina, double urethra, double sacrum, double ureters on the right side, multiple vertebral anomalies, together with anorectal malformation. Successful surgical reconstruction was performed.

Anomalies of the distal ureter, bladder, and urethra in children: embryologic, radiologic, and pathologic features

Congenital anomalies of the lower urinary tract are a significant cause of morbidity in infancy. Radiologic investigation is an important source of clinical information in lower urinary tract disorders but should not inconvenience the patient, expose the patient to unnecessary radiation, or delay surgical correction. In pediatric patients with suspected underlying urologic structural anomalies, screening ultrasonography is commonly the initial diagnostic study. If dilatation of the urinary tract is confirmed, voiding cystourethrography is performed to determine the presence of vesicoureteral reflux (VUR) and other causes of upper tract dilatation. If VUR is confirmed, follow-up with nuclear cystography or echo-enhanced cystosonography may be performed. If VUR is excluded, nuclear diuresis renography is the primary test for differentiating between obstructed and nonobstructed megaureter. Intravenous urography can be used to specifically identify an area of obstruction and to determine the presence of duplex collecting systems and a ureterocele. Computed tomography and magnetic resonance (MR) imaging are unsuitable for general screening but provide superb anatomic detail and added diagnostic specificity. MR imaging is mandatory in the evaluation of associated spinal anomalies. MR urography can demonstrate ectopic extravesical ureteric insertions, thereby providing a global view of the malformation. Familiarity with anomalies of the lower urinary tract is essential for correct diagnosis and appropriate management.

Benign symmetric lipomatosis with myelomeningocele in an adolescent: An uncommon association-case report

The authors report an unusual localization of symmetric adipose tumors associated with spinal dysraphism. Initially, the patient underwent a closure of the lumbosacral myelomeningocele. At that time, the tumors were not evident and remained undiscovered up until puberty. However, during puberty, the symmetric lipomatous masses grew at the perineal region. Except the patient's age, all findings and the clinical picture supported the diagnosis of a benign symmetric lipomatosis (BSL). To the authors' knowledge, the following case has not been described previously.