Surgical treatment of the Mullerian duct remnants

Background: Persistent Mullerian duct tissue in male individuals may result in an enlarged prostatic utricle (utricular cysts and utricle) or a muller ian duct cysts, either distinctively or synonymously. In intersex patients mullerian duct remnants (MDR) are an usual occurrence. Surgical excision is the definitive treatment of symptomatic remnants, as well as during the re construction of intersexual genitalia. Many approaches have been described. The authors review their experience in intersex patients. Methods: From 1986 to 1999, the authors treated 111 patients with intersex disorders. The records of 47 patients raised as boys with MDR were reviewed . Based on the symptoms and the size of the remnants, in 32 patients the st ructures were removed. In 13 patients extirpation was done by perineal appr oach, in 9 by transperitoneal approach, and in the remaining 9 patients the combined abdominal and perineal approach were undertaken. In one patient t he large prostatic utricle was extirpated by a posterior sagittal pararecta l approach. Perineal approach was mainly used in younger asymptomatic child ren, with the prostatic utricle disclosed incidentally during genitography because of intersex disorders. Operation was performed only in cases in whi ch the prostatic utricle was observed by cystoscopy or identified by Fogart y balloon catheter introduction into the prostatic utricle. In older patien ts these structures were discovered frequently after failed urethroplasty, or after symptoms of urinary infection, urinary retention, or epididymitis. We elected to use the transperitoneal approach based on the extension of t hese structures into the pelvis. The average age of patients at the time of surgery was 8.6 years, with a range of 1 to 30 years. Results: There were no rectal or bladder injuries during surgery. An older patient had temporary impotence after abdomino-perineal extirpation. The la ck of ejaculation, seen in 5 patients, was related to frequent intra-utricu lar termination of the vas deferens. Posterior sagittal pararectal approach certainly enabled complete exposure and exact visualization of all structu res, with considerably decreased bleeding. If gonadal biopsy or gonadectomy were necessary, the transperitoneal approach could not be avoided, Conclusions: Surgical treatment of MDR in intersex patients varies accordin g to the size of the utricle, and a double approach is often necessary. A h igh degree of success may be achieved with minimal morbidity, J Pediatr Sur g 36:870-876. Copyright (C) 2001 by W.B. Saunders Company.