Extraperitoneal Pelvic laparoscopic disconnection of accessory urethra from normal urethra in a case of urethral duplication
A 10-year-old boy presented with stress incontinence, splaying of urinary stream, and dorsal curvature of the penis. He had an intact foreskin, which, when retracted, revealed a dorsally grooved glans with two meati: one at the tip and the other smaller one at the corona. The prepuce itself was reverse aligned with the frenulum being dorsal, as in epispadias. A catheter could be passed independently through both meati into the bladder. Kidneys and the bladder were not palpable. He passed urine from both meati. Pelvic X ray, ultrasound for kidneys and the blood biochemistry were normal. Complete urethral duplication was the diagnosis.\nFirst surgery: Cystoscopy, correction of chordee, repair of glans, rearrangement of foreskin and partial excision of the dorsal urethra. On cystoscopy, the ventral urethra, bladder neck and posterior urethra were normal. A tube passed through the dorsal urethra was seen entering the ventral urethra at the posterior urethra just opposite the veru. Penis was degloved and chordee corrected by ventral Nesbitt. The dorsal accessory urethra was partially excised in the distal shaft and glans repaired to achieve a conical glans with normal coronal collar. The remaining stump of the dorsal urethra was fixed to the shaft skin proximally. The skin was re-arranged to give a circumcised appearance []. Post-operatively he passed urine through both the meati but finger occlusion of the dorsal meatus produced one stream through the normal meatus.\nSecond surgery performed after 1 year: Through a suprapubic 10 mm port the prevesical space was developed with finger dissection and CO2 insufflation. Two 5 mm ports were inserted as shown in (inset). In the space of Retzius the accessory urethra was identified as it entered the normal urethra at the prostate. The normal urethra was safeguarded by a transurethral catheter. The accessory urethra was severed from the normal urethra using bipolar cautery and scissors []. A drain was left through the left port site. The ports were removed and the linea alba repaired. The distal stump of the accessory urethra was obliterated by cautery ablation of the mucosa with monopolar electrode passed through the meatus []. The drain and catheter were removed on 3rd and 10th days, respectively. He passed urine through a single stream and his cosmetic appearance was satisfactory. He is well in 3 year follow up with maintained upper tracts.