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Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
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LETTERS TO THE EDITOR
Year : 2023  |  Volume : 28  |  Issue : 3  |  Page : 266-267
 

Isolated urethral varices: An unusual cause of hematuria after urethroplasty


1 Department of Paediatric Surgery, Narayana Health Hospitals, Bengaluru, Karnataka, India
2 Department of Urology, Narayana Health Hospitals, Bengaluru, Karnataka, India

Date of Submission11-Jan-2023
Date of Decision05-Feb-2023
Date of Acceptance05-Feb-2023
Date of Web Publication02-May-2023

Correspondence Address:
M M Zameer
Villa No. B 05, Ajmera Villows, Electronic City, Bangalore - 560 100, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaps.jiaps_6_23

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How to cite this article:
Zameer M M, Vinay C, Kulkarni P, Rao S. Isolated urethral varices: An unusual cause of hematuria after urethroplasty. J Indian Assoc Pediatr Surg 2023;28:266-7

How to cite this URL:
Zameer M M, Vinay C, Kulkarni P, Rao S. Isolated urethral varices: An unusual cause of hematuria after urethroplasty. J Indian Assoc Pediatr Surg [serial online] 2023 [cited 2023 May 31];28:266-7. Available from: https://www.jiaps.com/text.asp?2023/28/3/266/375526




Sir,

Urethral varices, especially after hypospadias repair, are an extremely rare entity. We report an 11-year-old boy with isolated urethral varices presenting with painless hematuria 6 years after urethroplasty.

Eleven-year-old boy presented to us with a history of painless hematuria for 1 month. The hematuria was significant with the passage of clots. It was not associated with fever or pain abdomen. He had undergone Snodgrass urethroplasty for mid-penile hypospadias at the age of 6 years. Posthypospadias uroflowmetry showed good urinary stream (flow >18 ml/min) with no signs of stricture. On examination, the urethroplasty wound had healed well with the meatus at the tip, and no obvious abnormality was noted. There was no fall in hemoglobin. Ultrasound abdomen and pelvis were normal. Doppler of the pelvis did not show any abnormal vascular malformation. Urine microscopy showed plenty of RBCs with no pus cells. The urine culture was sterile. Cystoscopy revealed varices in the penile urethra at 12 and 9 o' clock positions [Figure 1], with the rest of the urethra appearing normal with no signs of inflammation. The bladder was normal, with no evidence of stone or cystitis or any vascular malformation. The urethral varices were cauterized endoscopically with Bugbee electrode [Figure 2]. The child's symptoms settled. At 6 months follow-up, the child is doing well, passing urine in the good stream with no hematuria.
Figure 1: Varices seen at 12 and 9 o' clock position

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Figure 2: Varices electrocoagulated

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Hematuria in children is common. It is mostly due to urinary tract infection (UTI), urethral polyps, stones, bladder lesions like eosinophilic cystitis, hemangioma, or malignancy.[1] Urethral varices are extremely rare in children. Urethral varices as a cause of hematospermia have been reported in adults.[2] Urethral venous malformations are rare in children and are mostly associated with syndromes like Klippel-Trenaunay Syndrome.[3] Here also, they are not isolated but have venous malformations in the bladder, pelvic organs, and in retroperitoneum. Hematuria after hypospadias surgery (Urethroplasty) is known and is mostly due to associated UTI. Urethral varicose veins in children and those presenting after urethroplasty are extremely rare and this may be due to abnormal neovascularization postsurgery. It may be a totally unrelated associated pathology as well.

Children with urethral varicosities usually present with painless hematuria. Evaluation includes urine examination (microscopy and culture) to rule out UTI. Ultrasound KUB is done to look for any structural abnormality. Further imaging like contrast-enhanced computed tomography abdomen and pelvis is indicated if there is a suspicion of malignancy or venous malformations in conditions like Klippel–Trenaunay Syndrome. Cysto-urethroscopy is the diagnostic tool for urethral varicose veins. Endoscopic cauterization/electrocoagulation is the treatment of choice. Extreme care needs to be taken during the fulguration in order not to damage the urethra to avoid the sequelae of urethral stricture. Neodymium:neodymium: yttrium-aluminium-garnet laser is a better option as the area where energy is applied is highly defined in the laser. With a smaller depth of penetration and a wavelength near the absorption of water, Holmium, Erbium, and Thulium lasers are very suitable for urethral varices.[4]

To conclude, urethral varicose veins is a very rare cause for hematuria, especially after hypospadias surgery. Cysto–urethroscopy clinches the diagnosis. Endoscopic electrocoagulation is a safe and effective modality of treatment option for urethral varices.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Malkan AD, Loh A, Bahrami A, Navid F, Coleman J, Green DM, et al. An approach to renal masses in pediatrics. Pediatrics 2015;135:142-58.  Back to cited text no. 1
    
2.
Papp GK, Kopa Z, Szabó F, Erdei E. Aetiology of haemospermia. Andrologia 2003;35:317-20.  Back to cited text no. 2
    
3.
Tepeler A, Yeşilolva Y, Kılınç A, Aktoz T, Onen A. A mild and rare form of Klippel-Trenaunay syndrome presenting with urethral bleeding due to penile hemangioma. Urology 2011;77:463-5.  Back to cited text no. 3
    
4.
Pierre SA, Albala DM. The future of lasers in urology. World J Urol 2007;25:275-83.  Back to cited text no. 4
    


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