treatment involves excision of the accessory urethra usually through a suprapubic open approach . we report a novel use of extra peritoneal pelvic laparoscopic approach to disconnect accessory urethra from normal urethra in complete urethral duplication .
a 10-year - old boy presented with stress incontinence , splaying of urinary stream , and dorsal curvature of the penis .
he had an intact foreskin , which , when retracted , revealed a dorsally grooved glans with two meati : one at the tip and the other smaller one at the corona .
the prepuce itself was reverse aligned with the frenulum being dorsal , as in epispadias .
first surgery : cystoscopy , correction of chordee , repair of glans , rearrangement of foreskin and partial excision of the dorsal urethra .
on cystoscopy , the ventral urethra , bladder neck and posterior urethra were normal . a tube passed through the dorsal urethra was seen entering the ventral urethra at the posterior urethra just opposite the veru .
the dorsal accessory urethra was partially excised in the distal shaft and glans repaired to achieve a conical glans with normal coronal collar .
the skin was re - arranged to give a circumcised appearance [ figure 1 ] .
post - operatively he passed urine through both the meati but finger occlusion of the dorsal meatus produced one stream through the normal meatus .
chordee has been corrected second surgery performed after 1 year : through a suprapubic 10 mm port the prevesical space was developed with finger dissection and co2 insufflation .
two 5 mm ports were inserted as shown in figure 2a ( inset ) . in the space of retzius the accessory urethra was identified as it entered the normal urethra at the prostate .
the accessory urethra was severed from the normal urethra using bipolar cautery and scissors [ figure 2a ] .
the distal stump of the accessory urethra was obliterated by cautery ablation of the mucosa with monopolar electrode passed through the meatus [ figure 2b ] .
inset shows port placement schematic diagram showing mucosal excision of the distal portion of the accessory urethra
first surgery : cystoscopy , correction of chordee , repair of glans , rearrangement of foreskin and partial excision of the dorsal urethra . on cystoscopy , the ventral urethra , bladder neck and posterior urethra were normal .
a tube passed through the dorsal urethra was seen entering the ventral urethra at the posterior urethra just opposite the veru .
the dorsal accessory urethra was partially excised in the distal shaft and glans repaired to achieve a conical glans with normal coronal collar .
the skin was re - arranged to give a circumcised appearance [ figure 1 ] .
post - operatively he passed urine through both the meati but finger occlusion of the dorsal meatus produced one stream through the normal meatus .
chordee has been corrected second surgery performed after 1 year : through a suprapubic 10 mm port the prevesical space was developed with finger dissection and co2 insufflation .
two 5 mm ports were inserted as shown in figure 2a ( inset ) . in the space of retzius the accessory urethra was identified as it entered the normal urethra at the prostate .
the accessory urethra was severed from the normal urethra using bipolar cautery and scissors [ figure 2a ] .
the distal stump of the accessory urethra was obliterated by cautery ablation of the mucosa with monopolar electrode passed through the meatus [ figure 2b ] .
inset shows port placement schematic diagram showing mucosal excision of the distal portion of the accessory urethra
urethral duplications usually occur as an isolated deformity in males , the two urethra lying one behind the other in a sagittal plane .
usually the normally placed ventral urethra is more functional and contains the sphincter mechanism and verumontanum .
our case had an incomplete epispadic sagittal duplication as per william 's classification . however , as per effmann classification it falls into complete patent duplication type ii ( a2 ) .
surgery to excise the accessory urethra has traditionally involved a combined suprapubic and penile approach to deal with the proximal end and the distal end , respectively .
the key step is suprapubic disconnection of the accessory urethra from the good ventral urethra through dissection in the retropubic space .
this is technically difficult due to limited space , and risk of venous bleeding from a rich prostatic venous plexus , and carries a risk of damage to the normal urethra , sphincter mechanism and the nerves .
however , it would have been a major undertaking considering the length of the tract and its course between the corpora cavernosa .
it would have been technically difficult to reach under the pubic bone to completely excise the distal portion .
the laparoscopic pre - peritoneal approach has been used in adults for excision of benign prostatic enlargement and in partial cystectomy for bladder pheochromocytoma .
the reported advantages are minimal bleeding , a reduced transfusion rate , shorter hospitalization , reduced morbidity and faster recovery .
. however , the pre - peritoneal laparoscopic approach for disconnection of accessory urethra has not been described in children to the best of our knowledge .
insufflations of gas then result in pressure dissection which creates more space to insert working ports .
the visualization of accessory and the main urethra is easy as the view is magnified , free from bleeding and well  retracted  .
since this is probably the first case report of such a procedure in urethral duplication , there is no available data in the literature about dealing with the stump .
however , there is now sizable experience with laparoscopic pull thru for anorectal malformations with several authors leaving the stump of rectourethral fistula open with no ill effects .
transfixation , suture closure and closure by an endo - loop are other options . identification of the good urethra was a key safety step . in case of difficulty
 we report an extraperitoneal pelvic laparoscopic approach to disconnect accessory urethra from normal urethra in complete urethral duplication . 
 first stage consisted of chordee correction , partial excision of the accessory urethra and glansplasty . in the second stage the remaining accessory urethra was disconnected from the normal urethra through a pre - peritoneal minimal access approach to the retropubic space . 
 the remaining distal mucosa was ablated using monopolar cautery . 
INTRODUCTION
CASE REPORT
Surgical treatment
DISCUSSION