Prostatic utricles (PU) are rarely found in boys with a history of severe hypospadias or disorders of sex development, either during preoperative evaluation with a voiding cystogram or at any time due to recurrent non-febrile urinary tract infections. Surgical excision seems to prevent further urinary tract infections but has the potential of damaging the vas deferens.
Prostatic Utricles, the Vas Deferens, and Fertility
It is not clear whether the vas deferens enters the PU or just travels alongside its wall. If the vas deferens drains into the PU, it would seem impossible to both remove the PU and preserve vas patency without trying to re-anastomose the cut end of the vas directly to the urethra. Potential for fertility will probably be nil with a vas deferens connected directly to the urethra due to the lack of seminal and prostatic fluid. The authors of this study considered the option of reimplantation of the vas but thought it would not work and decided not to do it for their patients.
If the vas deferens, on the other hand, runs in the wall of the PU but does not enter the PU, the PU wall could be preserved and only the neck of the utricle — where it joins the urethra — closed with a purse string suture.
In this article that includes a video, the authors show how the vas was divided during the excision of the PU.
The authors of this other report, describe a few ways of avoiding vas injury during open or laparoscopic excision of a PU:
- Leaving a small PU cuff adjacent to the urethra
- Leaving a strip of PU along the course of the vas
Jia et al start their laparoscopic excision by first dissecting and protecting the vas deferens. They leave part of the PU wall attached to the vas to prevent injury or ligation to the vas.
In this study, 5 patients were found to be unable to ejaculate after PU removal due to intra-utricular termination of the vas deferens.
There are appears to be no reports regarding the future potential for fertility among patients that underwent excision of a PU.
I have encountered 3 PU, all in patients status post severe hypospadias repairs with associated disorders of sex development and abnormal karyotypes. They all had recurrent non-febrile urinary tract infections. All 3 were successfully excised laparoscopically robotically-assisted with no more urinary infections after the surgery. None of these patients had a visible seminal vesicle.
In the first patient, the PU was not seen until after the postvoid images of the VCUG. Pathologic examination of the PU did not reveal the presence of seminal vesicle or vas deferens:
The second patient’s pathology also did not reveal any seminal vesicle or vas:
The last patient pathology again did not show any vas or seminal vesicle present in the specimen. This is the video of his surgery:
PU are very rare and usually found in patients with hypospadias and disorders of sex development. Robotic excision of PU is straight forward with very short recovery compared to open abdominal or perineal approaches. Although attention to the vas during surgery seems warranted, current methods to avoid vas injury have not proven to help with fertility. Most of these patients are unlikely to be able to ejaculate normally.