Vas Deferens-Sparing Laparoscopic Removal of a Large Prostatic Utricle—Video Display and Technical Report, Highlighting Anatomical Considerations

Abstract

Introduction and Aim: A large prostatic utricle (PU) is difficult to remove, when symptomatic, thus indicated, because of its proximity and adherence to the vas deferens, on each side and the occasional ectopic vasal opening into the utricle. Inadvertent vasectomy or deliberately transecting the vas deferens, on one or both sides, is often inevitable, leading to infertility. This work offers an insight into the pertinent surgical anatomy and the aforementioned challenges, as well as a modification of technique in children. Clinical Presentation: A case of a then 4-year-old boy, with penoscrotal hypospadias and a large PU, complicated with recurrent urinary tract infections (UTIs), after a staged hypospadias repair is reported. The hypospadias repair was deemed effective, as judged by cystoscopy. During subsequent laparoscopy, we found the vas deferens bilaterally entering a high point into the PU fundus and running along its wall. Surgical Technique: Definitively, a cystoscopy-assisted laparoscopic technique was performed. The PU was bihalved, then a tubular structure was eventually constructed, from the wall of the utricle on each lateral edge, as an extension of the vas deferens, thus preserving it running towards the urethra and connected to the ejaculatory pathways. The bulky central part of the utricle was discarded. Progress: Recovery was uneventful. The patient was discharged on the next morning and remains asymptomatic for >1 year after surgery. Conclusion: This technique allows for preservation of the vas deferens while excising the main bulk of the utricle. Prospects of sperm delivery are thus kept, as the primary goal of preventing UTIs is fulfilled. A spermatogram could be obtained in the future, when age permits, to confirm this, as it is still not possible during childhood. Authors' Contributions: Both authors share authorship and contribution. Both authors shared the surgical care of the reported patient and acquisition, analysis, and interpretation of the data. Both authors contributed to the literature review, drafted and produced the article then responded to the peer reviewers' critique. The article has been read and approved by both authors. The requirements for authorship as stated in the Instructions to the Authors have been met. Each author believes that the article represents honest work. Ethics Declaration and Consent for Publication: This report followed the principles of the Declaration of Helsinki. It was conducted under the auspices of a university/teaching medical center, which operates under directives allowing utilization of nonidentifiable clinical data. Consent for any clinically indicated surgical procedure or medical intervention followed the standard informed and written documentation, which entails parental consent for sharing the data/findings for educational purposes. Availability of Data and Material: The data and material for this study are available and stored confidentially. No competing financial interests exist. Funding: No funding was received for this article. Runtime of video: 5 mins A preliminary abstract/summary related to this study was presented at the European Society of Paediatric Endoscopic Surgeons, Online Conference, on September 18, 2020, ESPES 2020, Xth Annual Meeting, E-congress (Part 2), hosted at IRCAD France. https://www.espes.eu/media/content/2020_09_15_Abstract_booK.pdf and as a poster at the 20th BAPES Annual Scientific Meeting (virtual), on November 5th–6th, hosted in London. https://www.bapes.org.uk/london2020posters