Urethral reconstruction in aphallia using transpubic exposure and colonic Monti neo-urethra – an addition to the De Castro reconstruction

Extended summary Introduction Fashioning a functioning neo urethra in a boy with aphallia is one of the unsolved problems in this condition. Aim We present our technique and outcome of operative exposure and neo urethral construction in four aphallic boys. Materials and methods Retrospective study of the records of four aphallic boys operated in the period 2015-2019 was undertaken. The demographics, presentation, operative procedure, current follow up and voiding outcome was noted. Results The neo phallus was constructed by the De Castro technique in four aphallic boys aged 1 – 8 years. Pre operative assessment revealed bladder outflow obstruction in two and urinary incontinence in one boy. The operative exposure afforded after reflection of the De Castro flap was utilized in doing a limited pubic symphysiectomy. This exposed the bladder neck, urethra and the urethral termination into the ano rectum. The healthy native urethra was isolated by disconnecting it from its ano rectal termination and a neo urethra constructed from a segment of proximal sigmoid colon by its reconfiguration into a Monti type tube. The neo urethra was then anastomosed to the native urethra and laid within the bed of the De Castro flap so as to reach the neo phallic termination. The De Castro flap was then tubularized over the neo urethra to form the new phallus. Appendicular or ileal Monti Mitrofanoff was also added to the reconstruction. Three boys are voiding well. One boy had a partial bladder outflow obstruction resulting from operative correction of incontinence and is dry on intermittent catheterization. Follow up was for 1-4 years and upper tracts are stable or improved. Conclusion We describe the transpubic approach to the construction of a reliable neo urethra in the form of a Monti tube from the sigmoid colon in four boys with aphallia. We believe this to be a useful addition to the De Castro procedure for neo phallic construction.