Chapter 175

Excision of Utricular (Mullerian Duct) Cyst

Palpate rectally for a midline mass. Use ultrasonography or lumen by thorough endoscopic fulguration of the walls of
MRI to detect the cyst and help determine its size. Because the cyst. To detect a connection with the vasa deferentia,
cysts open into the posterior urethra, secure a voiding cys- insert a ureteral catheter into the cyst and inject contrast
tourethrogram to evaluate size. In older children assess the medium. Resort to vasography if necessary.
caliber of the ostium by endoscopy. Try to obliterate the

TRANSVESICAL APPROACH

Figure 175-1. Make a transverse or vertical lower abdominal incision. (Avoid a perineal approach because of the risk
of compromising potency.) Open the bladder and expose the trigone. Place a ring retractor with four blades. Insert
an infant feeding tube into each ureter (not shown). Make a vertical incision in the midline through the trigone and
posterior bladder wall that extends almost to the vesical neck. Insert stay sutures to hold the incision open. With blunt
dissection, expose the anterior wall of the cyst. Use tenotomy scissors to dissect the cyst to its entrance into the posterior
urethra. Avoid the orifices of the vasa. Remove the retractor blade at the caudal end of the bladder incision to expose
the bladder neck and allow dissection of the cyst to its entrance into the posterior urethra, with or without enlarging it if
necessary.
Close the urethra with a running inner layer and an interrupted outer layer of 4-0 polyglycolic suture. Approximate
the trigone in two layers. Insert a urethral catheter and a suprapubic tube to remain, with the ureteral catheters, for a
week. Close the bladder and the incision.
If the vasa are transected, implant them into the bladder with a nonrefluxing technique, realizing that the prospect of
fertility is reduced.
The same approach can be used for a refluxing residual stump of an ectopic ureter after heminephrectomy (see
Chapter 28). Use this same approach to avoid the more extensive and possibly damaging dissection required from the
previously discussed procedure. An alternative is the transrectal posterior sagittal approach (see Chapter 78). Note:
A similar technique is useful for urethrorectal fistula tracts remaining after repair of high imperforate anus.

870

Downloaded for zdr ant (dunnie@abv.bg) at ClinicalKey Global Flex Package Trial from ClinicalKey.com by Elsevier on October 30, 2017.
For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved.
 Chapter 175 n EXCISION OF UTRICULAR (MULLERIAN DUCT) CYST 871

JACK S. ELDER
Commentary by

Utricular, or mullerian duct, cysts are most common in boys with penoscrotal or perineal hypospadias and in intersex con-
ditions. These cysts vary in size and usually are asymptomatic. However, selected individuals may experience dysuria,
perineal discomfort, urinary tract infection, epididymitis, lower abdominal mass, obstructive symptoms, hematuria, inconti-
nence, reduced semen volume, or oligospermia. By definition, these cysts should communicate only with the prostatic ure-
thra. In the literature, however, are reports of mullerian duct cysts that communicate with the vasa deferentia. These latter
cysts more appropriately are termed genital duct, or ejaculatory duct, cysts.
Utricular cysts often are palpable on rectal examination. They should be apparent on imaging studies, such as transrectal
retrograde urethrogram, or voiding cystourethrogram, which should be done to evaluate the cyst size. Endoscopy is indi-
cated to determine whether the ostium of the cyst is narrow. In addition, a small ureteral catheter should be inserted into
the cyst and contrast injected to determine whether the vasa deferentia enter it. In selected cases, it is necessary to perform
vasography to learn whether there is communication with the cyst.
Although the ostium of the cyst may be incised endoscopically, signs and symptoms often are not relieved. Consequently,
an open surgical approach usually is necessary. The perineal approach should be avoided because of the risk of iatrogenic
impotence.
The transtrigonal approach provides the best exposure. After opening the bladder, a Denis Browne retractor is placed.
Ureteral catheters or pediatric feeding tubes should be inserted into the ureteral orifices. Next, the trigone is incised in the
midline with the cautery. Stay sutures should be placed in the edges of the trigone. The utricle should be immediately appar-
ent and can be dissected out with tenotomy scissors. Extreme care should be taken to avoid the vasa. The cyst may be dis-
sected to its communication with the urethra. At times, opening the cyst is helpful in its mobilization. The urethra should be
closed over a urethral catheter with a fine, running, imbricating polyglycolic acid stitch for the inner layer and interrupted
sutures in the outer layer. Generally, no drainage of the retrovesical space is necessary. The trigone should be closed in two
layers with nonabsorbable suture. I think it is preferable to leave a urethral catheter, a suprapubic tube, and ureteral catheters
for 7 to 10 days postoperatively. If the vasa enter the cyst, they will need to be transected. Ideally, they should be implanted
into the bladder; usually this can be accomplished in a nonrefluxing manner. However, subsequent fertility would seem
unlikely, even with current methods of retrieving sperm from the bladder.
Although this approach has been used mainly for genital duct cysts, it also may be used in excising remnants of fistulous
tracts in children born with high imperforate anus.

LAPAROSCOPIC EXCISION With the electrocautery, incise the peritoneal reflection

starting immediately behind the bladder. Identify the utri-
Induce general anesthesia, and place the boy in the lithot- cle by the transmitted light from the panendoscope in the
omy position with leg support. Cannulate the utricle pan- bladder. Have your assistant manipulate the panendoscope
endoscopically, and leave the instrument in place for for countertraction. Visualize and protect the ureters.
identification and for facilitating mobilization. Insert a Mobilize the utricle completely with the 5-mm
5-mm port into the bladder from above the umbilicus, ­electronic scalpel and divide it at its junction with the ure-
and two 3- to 5-mm working ports in the right and left thra. Close the defect with fine absorbable sutures or use
mid-­abdomen. Hitch the bladder dome to the anterior ultrasonic coagulation. Remove the specimen through
abdominal wall with a 4-0 polydioxanone suture inserted the camera port. Leave a urethral catheter in place for
percutaneously under vision. 3 days.

CRAIG PETERS
Commentary by

Laparoscopic exposure of the retrovesical space is excellent and offers a much less morbid approach to utricular cysts or
mullerian remnants than the traditional transvesical approach. Robotic assistance is now being used to enhance visual-
ization, manipulation, and suturing. We have not found that a cystoscope is needed, as the cysts are readily visible with
extraperitoneal dissection. A rectal decompression tube can facilitate exposure. In the cases where the contralateral vas is
adherent to the wall of the cyst, leaving a strip of the cyst wall with the vas protects against injury. The mucosa of the cyst
wall can be fulgurated to prevent reformation of the cyst. We close with suture any communication with the urethra and do
not always leave a bladder catheter.

Downloaded for zdr ant (dunnie@abv.bg) at ClinicalKey Global Flex Package Trial from ClinicalKey.com by Elsevier on October 30, 2017.
For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved.