Fig. 15.1
Port placement for excision of prostatic utricle using four ports
The ureters and vas deferens are identified. The peritoneal reflection is incised transversely posterior to the bladder. A hitch stitch can be used to retract the bladder anteriorly. Alternatively, an additional working port may be placed in the suprapubic midline to aid with retraction. The presence of a balloon within the utricle significantly aids in identifying a smaller utricle and distinguishing it from the prostate, particularly when manipulated by an assistant.
The utricle is mobilized circumferentially with judicious use of needlepoint electrocautery, and the neck of the utricle is exposed. Great care is taken to avoid injury to the vas deferens and adjacent rectum. Occasionally, it is not possible to excise the whole utricle without damaging the vas deferens. In these patients, it is prudent to leave some of the utricle behind. The occlusion balloon is deflated and catheter is removed. The neck of the utricle is then ligated or transected and closed with an absorbable suture. The Foley catheter can be helpful in identifying the urethral lumen. The resected utricle is then removed through a working port or through a port site incision, which may be enlarged if necessary.
Postoperative Management/Complications
The Foley catheter remains in place for several days. A voiding cystourethrogram may be performed prior to removal of the catheter.
If there is concern for development of a urethral stricture, a retrograde urethrogram may be indicated.
Results
Author Remarks
A wide variety of surgical approaches for excision of prostatic utricles has been reported, including a transvesical approach with marsupialization between the top of the cyst and the bladder [6], transperitoneal transtrigonal approach [12], perineal approach [7, 12], and transrectal approaches [13, 14]. Endoscopic treatments have been limited to unroofing infected cysts or removal of small remnants [15, 16]. The reported success rate and morbidity of these operations appear to be significantly worse compared to recent laparoscopic series, though the number of cases is small.
Robotic-assisted laparoscopy may also be utilized. At this point, it is unclear if the benefits of improved articulation and three-dimensional viewing outweigh the additional procedural costs of this technology.
References
1.
Glenister TW. The development of the utricle and the so called “middle” or “median” lobe of the human prostate. J Anat. 1962;96:443–55.PubMedCentralPubMed
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