V573: Robotic Excision of the Symptomatic Prostatic Utricle: An Ideal Application of Technology
VideoIntroduction and Objectives
Laparoscopic excision of symptomatic prostatic utricles has been suggested as the ideal approach for the narrow pediatric male pelvis. It obviates the need for trigone splitting with the transvesical approach, rectum splitting with posterior sagittal approaches, or incomplete excision with perineal approaches. We present a case of robotic assisted laparoscopic excision of a symptomatic prostatic utricle in a child with mixed gonadal dysgenesis.
A 4 year old boy with history of scrotal hypospadias and 45XO/46XY karyotype presented with recurrent urinary tract infections. His surgical history was remarkable for streak gonadectomy and tubularized preputial island flap urethroplasty in infancy. VCUG revealed a patent hypospadias repair, no significant diverticulum and large prostatic utricle. Cystoscopy confirmed an infected utricle with long, narrow neck. After appropriate antibiotic course, surgical excision of the utricle was planned.
Initial cystoscopy allowed placement of a 4Fr Fogarty catheter over a wire into the utricle and another 8Fr catheter within the bladder. Using the da Vinci® Si Surgical System, a 3-port pelvic approach with 5mm assistant port was chosen with patient in dorsal lithotomy position. The peritoneum was incised over the posterior bladder wall just above the catheter impression within the prostatic utricle. Retrovesical dissection was completed surrounding the utricle, preserving the posterior peritoneal reflection. Vasa were not associated with the utricle. The utricle stalk was suture ligated and transected near the pelvic floor at the level of prostatic urethra. Procedure duration was 182 minutes including cystoscopy, with minimal blood loss and hospital discharge on post op day 1. VCUG was performed one week postoperatively, confirming obliteration of the utricle cavity and the urethral catheter was removed. The patient has been free of urinary tract infection for one year of follow up.
Robotic-assisted laparoscopic utricle excision offers similar safety and efficacy to a pure laparoscopic approach. Since robotic assistance enhances laparoscopic magnification, robotic utricle excision may also improve identification of the ureters, associated Wolffian structures or anatomic variants. Combined with its advantage in a narrow pelvis, we feel robotic assistance for utricle excision is an ideal application of medical technology.