Robot-Assisted Prostatic Utricle Reconstruction Using the Carrel Patch Principle to Preserve Fertility

Prostatic utricle (PU) with normal external genitalia is an uncommon congenital anomaly. About 14% develop epididymitis. This rare presentation should warn involvement of the ejaculatory ducts. Minimally invasive robot-assisted utricle resection is the preferred method.

To describe a novel approach to PU, we hereby present the video of a case with PU resection and reconstruction using a Carrel patch principle to preserve fertility.

A 5-month-old male presented with right side testicular orchitis and a large retrovesical hypoechoic cystic lesion. Urine culture was positive. He responded well to oral antibiotics. A voiding urethrocystogram confirmed a large PU. A breakthrough orchitis occurred 5 months later and the decision to proceed with surgical resection was made. Robot-assisted PU resection was performed at 13 months of age and 10 kg. Dissection of the utricle was guided with a flexible cystoscope and intraoperative ultrasound. Both vas deferens were seen draining at the neck of the PU making complete circumferential resection not feasible without compromising the integrity of both seminal vesicles and vas deferens. To preserve fertility, a PU flap including both seminal vesicles was preserved and anastomosed to the edges of the resected PU following the Carrel patch principle. Postoperative course was not complicated, and patient was discharged home on second postoperative day. A month later, exam under anesthesia, circumcision, cystoscopy, and cystogram demonstrated no contrast extravasation with otherwise normal anatomy. Foley catheter was then removed. A year after the procedure patient has been asymptomatic with no new infection recurrence and normal potty-training process.

Symptomatic isolated PU is an uncommon presentation. Impact of recurrent orchitis on future fertility is possible. Complete resection is difficult in cases where the vas deferens enters the PU at its base crossing the midline. Our novel approach to preserve fertility using the Carrel patch principle is feasible thanks to better visibility and exposure enhancement provided robotically. Prior open attempts demonstrated be technically difficult given the deep and anterior location of the PU. To our knowledge, this is the first time such procedure is reported. The use of cystoscopy and intraoperative ultrasonography are also valuable tools.

Reconstruction of PU is technically feasible and should be considered when risk of future infertility can be compromised. After a 1-year follow-up, it is important to continue to monitor long-term. Possible complications like fistula development, infection recurrence, urethral injury and incontinence should be thoroughly discussed with parents.