|Year : 2016 | Volume
| Issue : 1 | Page : 54-56
Acquired male urethral diverticulum: Report of two cases
Sachin Madhukar Bote, Venkat Arjunrao Gite, Ayub Karam Nabi Siddiqui, Saurabh R Patil, Jayant V Nikose
Department of Urology, Grant Medical College (GGMC) and Sir Jamshedjee Jeejeebhoy (J.J.) Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||28-Jul-2016|
Dr. Sachin Madhukar Bote
1283/21, Wani Plot, Agalgaon Road, Barshi, District: Solapur - 413 401, Maharashtra
Source of Support: None, Conflict of Interest: None
Urethral diverticulum (UD) was first described by Hey in 1805. Two third of UD are acquired and up to a third may be congenital. While UD are more common in women secondary to poor anatomical support of the urethra, it is rarely seen in men. Acquired UD in men may be seen after urethroplasty, after hypospadias repair when flaps are used. We report two cases of acquired UD in male children secondary to catheterization and after hypospadias surgery respectively.
Keywords: Acquired urethral diverticulum, post-hypospadias urethra-cutaneous fistula, urethral stricture, urethrocutaneous fistula
|How to cite this article:|
Bote SM, Gite VA, Siddiqui AK, Patil SR, Nikose JV. Acquired male urethral diverticulum: Report of two cases. Arch Int Surg 2016;6:54-6
| Introduction|| |
Urethral diverticulum (UD) was first described by Hey in 1805. Two third of UD are acquired and up to a third may be congenital. UD are more common in women secondary to poor anatomical support of the urethra. Acquired UD is unusual in men but may be seen after urethroplasty, after hypospadias repair when flaps are used. To our knowledge, there is no reported prevalence of male UD in medical literature. We report two cases of acquired UD in men secondary to catheterization in first and after hypospadias surgery in the second one.
| Case Report|| |
A 10-year-old boy who underwent hypospadias repair at the age of 3 years for penoscrotal hypospadias elsewhere and presented to us with mid-penile urethrocutaneous fistula. Details of repair were not available, as it was done outside. He developed penile mid-shaft fistula and was lost to follow-up from the referral center for 61/2 years.
On examination, the external urethral meatus was stenosed with a narrow fistulous opening at the mid-penile shaft. There was no visible or palpable mass along the ventral aspect of the penis except the fistula of size 0.6 cm × 0.6 cm in the mid-penile region. After routine evaluation, the patient was planned for the repair of after hypospadias urethracutaneous fistula.
On urethroscopy with integrated ureterorenoscope (URS) of size 8Fr under anesthesia was found to have diverticulum proximal to the external urethral meatus. Intraoperatively, after dissecting the fistulous tract and raising skin flaps, we found a large UD on the ventral aspect of the penis [Figure 1]. Diverticulum was excised after dissecting it all around [Figure 2]. After excision of the diverticulum, the native urethral plate was found to be made up of the skin. Retubularization was done using the flaps of the remnant of diverticulum, over 8Fr feeding tube was done with Vicryl 6-0 in a continuous manner. The second layer closure was done using subcutaneous tissue. Skin flaps were closed with Vicryl 5-0 in an intermittent manner.
Feeding tube was removed after 15 days. The patient voided well with good stream and had an alternate day meatal calibration. Ascending Urethrogram (ASU) was done after 6 weeks, showing normal urethral lumen with no diverticulum or narrowing [Figure 3].
A 12-year-old boy was admitted in the surgery department for a degloving injury of his right foot after a railway accident. The patient was treated with local wound debridement and subsequent skin grafting. As the patient was not ambulatory due to railway accident, the patient was on per urethral catheter for 6 months and the catheter was changed every month. After a few days following the removal of catheter, the patient developed an abscess at the penoscrotal region that burst spontaneously. The patient subsequently started leaking urine from the penoscrotal region during micturition. He then had urinary drainage by suprapubic cystostomy (SPC). He was reevaluated after 6 weeks and was found to have a small compressible swelling on the ventral aspect of his penis at the penoscrotal region [Figure 4]. On clinical examination, urethrocutaneous fistula was found to be healed. His RUG was suggestive of UD. The patient underwent open excision of the diverticulum and urethroplasty with tunica vaginalis flap cover as a second layer over an 8 Fr Foley catheter. The patient voided with adequate stream after removal of urethral catheter. His RUG, on follow-up at 6 weeks, was normal.
| Discussion|| |
A UD is a saccular dilatation extending from and contiguous with the true urethral lumen. Presenting symptoms of UD in a male are often related to inadequate drainage leading to urinary stasis, recurrent urinary tract infections (UTIs), stone formation, urinary leakage, incontinence, or a palpable penoscrotal mass. Congenital UD are lined by epithelium with full-thickness involvement of the urethral wall. In contrast, acquired UD are lined by epithelium and granulation tissue, and the UD wall lacks smooth muscle fibers.
Mechanisms for acquired male UD: One mechanism is related to obstruction and increased urethral pressure with subsequent herniation of the urethral epithelium, as seen in our first case. This is seen in patients with a complex urological history involving previous reconstructive procedures for hypospadias, urethral stricture, and trauma or incontinence. The second mechanism is a result of constant pressure distributed on the penoscrotal angle, causing chronic urethral ischemia, and induces urethral fibrosis and scar formation, as seen in our second case.
For the evaluation of UD, clinical examination  is equally important as imaging. Magnetic resonance imaging, RUG,, and urethroscopy are useful in diagnosis. Ultrasonography is additionally useful in evaluation.
A small asymptomatic UD can be managed nonoperatively with post-void manual compression of the diverticulum to eliminate urinary stasis., For symptomatic, large UD, excision and urethroplasty is acceptable treatment. The goal of urethral diverticulectomy surgery is to excise the UD, restore urethral continuity, and provide additional tissue to reinforce the repair to minimize the development of urethrocutaneous fistula or recurrence of the condition.
In case of postoperative urethrocutaneous fistula, it is better to have ASU or examination under anesthesia with urethroscopy prior to surgical repair to rule out stricture/stone/diverticulum.
Follow-up can be done by clinical examination, RUG.
| Conclusion|| |
In conclusion, acquired UD in the male is rare. Retrograde urethrography may be considered a gold standard in diagnosis and should be included as a part of preoperative work-up in cases of urethrocutaneous fistula developing after hypospadias repair surgery.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]