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

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.

Duplication of urethra: A case report from Nepal

Urethral duplication is uncommon with few cases reported in the literature. We report a case in which a patient presented with discharge from proximal part of penis since childhood and recent history of infection. The diagnosis of pre-pubic sinus was made and complete excision of the sinus tract was done.

Case report: Post-surgical complication in a case of urethral duplication in a dog

Urethral duplication is a rare anomaly observed in veterinary medicine. The surgical techniques described therein are associated with an uneventful recovery. The authors describe a major surgical complication after the correction of urethral duplication in a 2-year-old male Yorkshire terrier. After surgical correction using the perineal approach, the patient developed pollakiuria and urinary retention due to a valve effect caused by the remnant of the dorsal opening of the ectopic urethra. A second procedure, using an abdominopelvic approach, successfully corrected the complication by intraluminal correction of the dorsal urethral wall.

Missed urethral duplication associated with hypospadias, post-hypospadias repair urethral stenosis, and recurrent urinary tract infections in an adult: a case report

Background

Duplication of urethra is a very rare congenital disorder. Several types of this anomaly have been reported around the world, and are also discussed in this report. However, the mechanism of this anomaly is still unclear.

Case

A 45-year-old Persian man with a complaint of recurrent urinary tract infection was referred to our clinic. He had a history of repairing penoscrotal hypospadias in childhood along with obstructive and irritating symptoms in adolescence. On his last voiding cystourethrogram and retrograde urethrogram, stenosis was observed in the proximal bulbar urethra along with a double urethra in the dorsal region of the main urethra. The double urethra was removed with operation, and he was followed for 1 month after surgery. He had no complaints of recurrence or urinary incontinence.

Conclusions

This report shows the different classification systems, types of double urethra, and approach and management, which mainly involves surgery; however, surgical management should be done according to the anatomical findings of the abnormality.

Partial urethral duplication in a cat

CASE DESCRIPTION

A 3-year-old neutered male domestic shorthair cat with a history of urethral obstruction was evaluated at a veterinary referral center for acute onset of hunched posture and signs of discomfort on being handled. No evidence of urethral obstruction was found; signs initially responded to medical management, but the cat was presented to the primary care veterinarian < 48 hours after the initial examination with signs suggesting urethral obstruction.

CLINICAL FINDINGS

No urinary calculi were detected radiographically. Attempted urinary catheter placement was unsuccessful, and the cat was returned to the referral center for evaluation and treatment of suspected urethral obstruction. Hematologic evaluation revealed hyperglobulinemia and leukocytosis; the cat was febrile, its prepuce was swollen, and its urinary bladder was soft but could not be manually expressed.

TREATMENT AND OUTCOME

A urinary catheter was placed; urinalysis revealed hematuria, leukocyturia, and bacteriuria. Medical management included analgesic, antimicrobial, urethral antispasmodic, and IV fluid treatment. Positive-contrast cystourethrography results were equivocal for a congenital anomaly versus urethral rupture. Contrast-enhanced CT revealed a sinus communicating with the dorsal aspect of the urethra, and urethral rupture was ruled out. Partial urethral duplication was confirmed surgically; perineal urethrostomy was performed, creating an opening to the accessory urethra, and the strictured orthotopic urethra was ligated. Four weeks after surgery, the cat was doing well.

CLINICAL RELEVANCE

This case highlighted the importance of advanced imaging to distinguish between urethral rupture and a congenital malformation in a cat with signs of lower urinary tract disease. This approach was pivotal to appropriate diagnosis and management and a favorable outcome for the patient.

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

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

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

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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.

Urethral Duplication in Children: Experience of Twenty Cases

Background and Objective

Urethral duplication is a rare congenital anomaly having multiple anatomical variants and varied presentations. Multiple surgical techniques have been described for this anomaly, and no surgical technique is ideal. The aim of this study was to present our experience of twenty cases of urethral duplication in the management of this anomaly.

Materials and Methods

Retrospectively over a period of 10 years from 2006 to 2016, records of all urethral duplications were reviewed. All available records were evaluated for clinical presentation, imaging studies (micturating cystourethrogram, retrograde urethrogram, ultrasonography, and cystourethroscopy), and classified according to the Effmann's classification. The intraoperative details, outcome, and follow-up (including cystoscopy and contrast studies) were noted.

Results

There were 20 patients of urethral duplications. Age of patients ranged from 3 months to 9 years with a mean age of 4.6 years. The details of management, outcome, and follow-up were obtained.

Conclusion

Management varies with the symptoms and the severity of the anomaly. Y-type urethral duplication is more complex and challenging and requires extensive urethral reconstruction. Combined use of the bladder and buccal mucosa for reconstruction gives better results than bladder mucosa alone.

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.

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.

Congenital prepubic sinus (an epispadiac variant of dorsal urethral duplication) with dorsal penile curvature in an adult man: a rare association

Urethral duplication is among a very rare congenital disorder with multiple anatomical variants reported. Urethral duplication of complete type is usually diagnosed during childhood with urinary incontinence or double urinary stream as common presentation. However, patients with incomplete urethral duplication usually present with intermittent mucous discharge from the accessory urethral opening. A 20-year-old man presented to us with intermittent mucous discharge from the accessory opening along with dorsal penile curvature making sexual intercourse very difficult. The epispadiac urethral tract with proximal fibrous tract was excised, and the dorsal penile curvature was corrected by ventral plication, implicating that the fibrous cord may be the causative factor for the development of dorsal curvature.

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.

Diagnosing urethral duplication including a novel radiological diagnostic algorithm

Until this 24 -year -old male was sexually active, the small dimple on his penile glans had never required any consideration. However, persistent focal irritation during sexual intercourse compelled him to pursue medical attention. Following urological consultation he was referred for imaging evaluation that demonstrated urethral duplication. After determining the subtype classification, urologic repair was successfully completed without complication. Urethral duplication is an exceedingly rare genitourinary anatomic anomaly with a variety of presentations and symptomatology. The vast majority of urethral duplications are diagnosed within the paediatric and adolescent populations. Although urethral duplication is managed by urologists, imaging identification of the particular subtype is critical for proper management planning. A thorough review of existing literature on the classification strategies and diagnostic criteria is discussed. Owing to the scarcity of clinical experience, a wide variety of diagnostic approaches are described. These often include unnecessary radiation, invasiveness and cost. A strategic and efficient diagnostic algorithm is included to guide future imaging evaluation of suspected urethral duplication. This provides the essential clinical information, while minimis ing radiation, invasiveness and cost.

Urethral Duplication with Two Hypospadic Meati-An Unusual Variant

Duplication of the urethra is a rare congenital anomaly, with approximately 300 cases reported in the literature. We report a unique case of this condition in a male infant. This case differs from the classical Effman type II-A2 duplication because of the presence of two hypospadic urethral meati, as opposed to a ventral or dorsal accessory meatus with a normally positioned distal urethra. The patient underwent a single-stage repair consisting of a proximal urethra-urethral anastomosis and distal urethral tubularization at 21 months of age with excellent results in terms of both function and cosmesis.

[Epispadias and urethral duplication]

Epispadias is the mildest form of the exstrophy-epispadias complex and rarely occurs in an isolated form. The characteristic clinical sign is a mucosal strip on the penile dorsum. Clinically, epispadias presents with urinary incontinence. Primary surgical correction is recommended at the age of 12 months and should only be performed at a specialized center. During follow-up, further bladder neck surgery may be necessary. Despite a functional and cosmetically appealing penis, psychosocial and psychosexual development of the affected individuals can severely be affected. The incidence of urethral duplication remains unclear. Several classifications reflect the anatomical variation. The clinical presentation depends on the continuity of the duplicated urethra and its relationship to the sphincteric mechanism. In addition to clinical examination, a voiding cysturethrography is part of the basic diagnostic workup. After endoscopic examination an individual operative approach can be defined.

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--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.