L N S C3: a proposed classification system for female urethral diverticula

Urethral Diverticulum During Pregnancy Managed With Primum Non Nocere Principle: Conservative Treatment During Pregnancy and Diverticulectomy After Child Birth

OBJECTIVE

To report our referral single institution experience of the management of urethral diverticulum (UD) in female during pregnancy (UDp), which is a rare condition, not standardized and sparsely reported in the current literature.

METHODS

The charts of 12 female patients treated for UDp between 2010 and 2020 were screened retrospectively. Baseline demographics, management strategies, delivery complications, and surgical outcomes were specifically analyzed and compared to our historical cohort of UD patients (n = 54).

RESULTS

Overall, 7/12 (58%) patients were primiparous and 5/12 (42%) had previous pregnancy with no history of UD. Symptoms at diagnosis were respectively urinary tract infections (7/12, 58%), urethral purulent discharge (6/12, 50%), vaginal bulging (4/12, 33%), and dyspareunia (4/12, 33%). Compared to UD outside pregnancy, UDp patients were younger and were more likely to bear asymptomatic UD. Conservative management until delivery was elected in all patients. Vaginal delivery was possible in all but one patient. There was not any reported infectious mother-to-child transmission. Diverticulectomy through vaginal route were performed 3 months after delivery. Low-grade Clavien Dindo complications were reported in up to 25% (3/12) of the cases. No recurrence was reported.

CONCLUSION

Our report showed UDp could be managed conservatively during pregnancy without jeopardizing vaginal delivery and increasing infectious mother-to-child transmission. Surgical diverticulectomy could safely be performed after child birth using similar technique and care pathways generally used for the management of UD outside pregnancy.

Urethral Masses

Urethral and periurethral masses in women include both benign and malignant entities that can be difficult to clinically differentiate. Primary urethral carcinoma is rare and the optimal treatment modality may vary depending on the stage at presentation. Because cancer-free survival is poor, clinicians shouldhave a high index of suspicion when evaluating a urethral mass. Some benign-appearing urethral masses may be safely observed. Surgical resection is an effective option that should be used based on patient preference and symptoms, and for suspicious lesions.

Transurethral endoscopic extensive incision of complex urethral diverticula in symptomatic women: case series in a single center experience with long-term follow-up

BACKGROUND

Urethral diverticula (UD) affect 1-6% of adult women. Complex UD are rare, but can be challenging to manage. To evaluate the efficacy and safety of transurethral endoscopic extensive incision of complex UD in symptomatic women.

MATERIALS AND METHODS

We retrospectively evaluated 22 female patients with complex UD who underwent transurethral endoscopic extensive incision management in our hospital. This technique was completed by one experienced surgeon over a 7-year period between August 2012 and July 2019. The surgical technique involved placing the patient in a lithotomy position, inserting the needle electrode endoscopically, and incising the tented roof of the UD from its orifice until the entire roof had been opened widely. Outcome data included complete symptom resolution rate, imaging data, de novo stress urinary incontinence (SUI), recurrence, short-term and long-term complications. Cure was defined as decreased UD volume on postoperative magnetic resonance imaging and no post-voiding urinary retention in the diverticular cavity, with symptom resolution.

RESULTS

The initial symptom-resolution rate after 37.0 (27.0, 50.0) months' follow-up was 81.80% (18/22) and the de novo SUI rate was 13.60% (3/22). No patients required additional operations after conservative therapy. There was no symptomatic or imaging recurrence, and no short-term complications.

CONCLUSION

Transurethral endoscopic extensive incision was an effective and safe treatment for symptomatic female complex UD. Its symptom-resolution rate and de novo SUI rate might be superior to the conventional transvaginal approach. Moreover, it was less invasive and easier to conduct, with fewer complications.

Transvaginal management of symptomatic complex urethral diverticula by definite closure of diverticula and robust reconstruction of the urethra

Background

Management of complex urethral diverticula (UDs) is challenging not only for the ostia detection and urethral reconstruction in surgery but also for the high risk of postoperative complications. We aimed to present the experience of surgical management for UDs by transvaginal partial diverticulectomy and urethral reconstruction.

Methods

The database of medical record library was retrospectively searched for patients underwent partial diverticulectomy for symptomatic complex UDs. During the surgical procedure, the cystourethroscopy was firstly performed to locate the diverticular ostium. The surgeon exposed and opened the diverticulum along its maximum axis. The surgeon recorded the location of ostia where saline solution flowed out, when one assistant pressed suprapubic region to increase inner-pressure of bladder and urethra. We focused on definite closure of diverticular ostia and robust urethral reconstruction.

Results

The present study included 39 patients with mean age of 45 years. There were 28 patients, 23 patients and 21 patients suffering from recurrent urinary infection, frequency and urgency. Ten patients had stress urinary incontinence. All of the 39 patients had complex UDs because of U-shaped diverticula (24/39) and circumferential diverticula (15/39). Multiloculated UDs were detected in 17 out of 39 patients. During the median follow-up time of 2.0 (1.0-12.0) years, there was no case of de novo urinary incontinence. However, 2 patients still had mild stress urinary incontinence without additional treatment. At postoperative 3 months, five patients had para-urethral cysts with the size ranging from 0.3 to 0.4 cm, which were absorbed in follow-up.

Conclusions

The method of transvaginal partial diverticulectomy, definite closure of diverticular ostium, and layered reconstruction of the urethra is a feasible surgical alternative for UDs.

Surgical Outcomes of Primary and Recurrent Female Urethral Diverticula

OBJECTIVE

To evaluate the surgical outcomes of female urethral diverticulectomy.

MATERIALS AND METHODS

We retrospectively analyzed the medical records of 68 patients with symptomatic urethral diverticula (UD) with at least 1 year of follow-up data following transvaginal urethral diverticulectomy conducted by a single surgeon. The presence of UD was confirmed by a preoperative magnetic resonance imaging (MRI). According to MRI findings, the UDs were classified as simple, U-shaped, or circumferential. Cure was defined as the absence of residual diverticulum on a postoperative MRI with a resolution of symptoms.

RESULTS

There were 27 cases (39.7%) of simple, 16 cases (23.5%) of U-shaped, and 25 cases (36.8%) of circumferential diverticula. The initial cure rate for UD was 77.9%. According to configuration, the cure rates for simple, U-shaped, and circumferential diverticula were 100%, 75.0%, and 64.0%, respectively (P = .043). Of the 15 patients with UD recurrence, 4 did not require reoperation because of symptom resolution. Of the 11 cases that underwent a second operation, 8 patients were cured: 7 via a Martius labial fat pad interposition (MLFI) procedure and 1 via simple excision without MLFI. The overall cure rate was 92.6%. The circumferential configuration was an independent factor for a lower cure rate (odds ratio, 7.97; 95% confidence interval, 1.14-55.69).

CONCLUSION

Transvaginal diverticulectomy is an effective treatment for female UD. The success rate of an initial surgery was significantly lower for UDs with circumferential configurations than for simple or U-shaped UDs. Regardless of the initial configuration, MLFI is a good treatment option for recurrent or persistent diverticula.

Surgical management of urethral diverticula in women: a systematic review

Urethral diverticula (UD) are pouch-like outgrowths of the urethral lumen and surgery is by far the most common approach in symptomatic patients. The aim of this systematic review was to evaluate surgical techniques and outcomes in adult women with urethral diverticula. Our secondary objective was to determine the types of study designs. A systematic review of the literature was conducted. Medline, Cinahl and Embase were used as data sources. One hundred and eight studies, including 1,947 patients, remained for final analysis. We summarised 40 single case reports and 68 case series. Overall, transvaginal resection of the UD ± reconstruction was performed in the majority of patients (84 %), followed by marsupialisation (3.8 %) and transurethral endoscopic unroofing (2.0 %). Various other surgical techniques were reported in 181 out of 1,858 cases (9.7 %). Nineteen studies, dealing with 584 patients in all, evaluated a combination of vaginal diverticulectomy with an additional surgical procedure. Fifty-six out of 108 studies (52 %) documented the resolution of symptoms, describing 717 out of 1,044 patients in all being completely symptom-free after surgery. Only 50 out of 108 studies (46.2 %) provided detailed information on the length of follow-up, but showed a poor reporting standard regarding prognosis. Complications were studied only selectively. Because of the inconsistency of these data, it was impossible to analyse them collectively. There were no comparative studies on the different types of surgery in women with urethral diverticula. Overall, the non-comparative nature of the current evidence on the surgical management of UD does not allow any accurate estimation of success and complication rates.

Urethral diverticula in women

Female urethral diverticula are rare, benign epithelium-lined outpouchings of the female urethra. Patients can present with a multitude of symptoms, most commonly urinary incontinence, recurrent UTIs and dyspareunia. These presenting symptoms are often confused with other diagnoses leading to delayed diagnosis or misdiagnosis. Diagnosis and preoperative assessment of bladder function is most accurate using a combination of clinical examination, T2-weighted postvoid MRI and videocystometrography. Best treatment is by vaginal excision, a procedure with a very low recurrence rate and high patient acceptability. Excision also results in high cure rates for associated dyspareunia, UTI and voiding dysfunction. Pre-existing urodynamically proven stress urinary incontinence (USUI) resolves in 50% of patients after excision of the diverticulum with Martius labial fat pad interposition without the need for further treatment. Potential adverse effects after surgery are new-onset USUI, urethrovaginal fistula and urethral stricture. The rate of onset of these potential adverse effects is low and related to the preoperative appearance of the diverticulum on an MRI scan and the complexity of the diverticulum.

Urethral Diverticulum in Young Nulliparous with Unusual Presentation

CASE

We highlight a case of chronic skenitis leading to the formation of Urethral diverticulum. A young nulliparous woman presented with dysuria, intermittent hematuria and a 3 cm cystic swelling adjacent to the left distal urethra. Aspiration of the cyst was done initially. Excisional biopsy was followed when it recurred. Urethral diverticulum was revealed when the excisional operation traced up to left distal urethral wall. The cystic swelling urethral diverticulum was completely enucleated.

OUTCOME

The pathology report showed fibrous tissue with cystic spaces lined by squamous epithelium with inflammation, which was consistent with a urethral diverticulum.

CONCLUSION

The presenting symptoms and signs of female urethral diverticulum are often diverse and easily overlooked, we have to keep in mind that cases with unusual age, location and presentation can also exist.

Management of symptomatic urethral diverticula in women: a single-centre experience

BACKGROUND

Urethral diverticula (UDs) affect between 1% and 6% of adult women. A total of 1.4% of women with stress urinary incontinence (SUI) have a UD. Clinically significant diverticula are rare and can be challenging to manage.

OBJECTIVE

To review results of surgery on UDs in a single surgical centre.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively evaluated a group of 89 patients with symptomatic UDs referred for surgical intervention to one teaching hospital. Data were from two surgeons over an 8-yr period between October 2004 and November 2012. Follow-up period ranged from 3 mo to 20 mo, and all patients were physically reviewed postoperatively in an outpatient setting.

INTERVENTION

The surgical technique involved placing the patient prone, ureteric catheterisation, dissection and removal of the diverticulum, and layered closure. Where a large defect was present following excision, a Martius flap was interposed.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Outcome data collected included symptomatic cure, continence, de novo SUI, early versus late complications, and recurrence.

RESULTS AND LIMITATIONS

Early complications included one urinary tract infection and one Martius graft infection, both requiring intravenous antibiotics. Overall, 72% of patients were dry and cured postoperatively; 13 patients had de novo SUI following surgery. Those with bothersome SUI went on to have an autologous sling at 6 mo. All were dry; three (23%) required clean intermittent self-catheterisation. Three patients had a recurrent residual diverticulum (3.4%) following surgery. One chose conservative management. The other two had a redo diverticulectomy performed via a dorsal approach. They have recovered well and are dry. Two (2.2%) diverticula revealed unexpected abnormal pathology. The first was a leiomyoma; the second was a squamous cell carcinoma requiring further surgery.

CONCLUSIONS

The recommended preoperative imaging is postvoid sagittal magnetic resonance imaging and appropriate use of urodynamic assessment at baseline. The 72% dry rate (including a number with preoperative incontinence) is comparable with the literature as is the development of de novo SUI in 15% of patients. There is a small risk of unexpected tumours (2%).

PATIENT SUMMARY

A urethral diverticulum should be excluded as a diagnosis in anyone troubled by symptoms of a swelling of the urethra often associated with discomfort, pain on intercourse, urinary dribbling after passing urine, and/or recurrent urinary infections. In these circumstances patients should seek advice from their doctors and consider referral for a specialist assessment. If the diagnosis is made and the problem is symptomatic, surgery is likely to resolve the problem but should be carried out in a specialist centre with expertise in the management of this condition.

Female urethral diverticulum presenting with acute urinary retention: Reporting the largest diverticulum with review of literature

Female urethral diverticulum is a rare entity with diverse spectrum of clinical manifestations. It is a very rare cause of bladder outlet obstruction and should be considered as a differential diagnosis in females presenting with acute urinary retention associated with a vaginal mass. Strong clinical suspicion combined with thorough physical examination and focused radiological investigations are vital for its diagnosis. Herein we report a case of giant urethral diverticulum presenting with acute urinary retention in a young female. It was managed by excision and urethral closure, and is the largest urethral diverticulum reported till date in the literature.

Recurrent pseudodiverticula of female urethra: five-year experience

OBJECTIVES

To report our experience of transvaginal diverticulectomy with pubovaginal sling placement in a series of 32 women with recurrent urethral pseudodiverticula.

METHODS

A total of 32 women underwent surgical repair from January 2000 to June 2007. Of the 32 women, 12 had undergone other concomitant previous urethral surgery, predominantly for stress urinary incontinence. Transvaginal excision of the diverticulum and concomitant pubovaginal sling placement were performed routinely. The women were evaluated postoperatively for symptom relief, anatomic result, and postoperative continence status at 1, 6, and 12 months and annually thereafter. Pelvic magnetic resonance imaging was repeated after 1 year.

RESULTS

The mean follow-up was 4.3 years. In all cases, the voiding urethrogram after catheter removal showed a good urethral shape with an absence of urinary leaks. At the postoperative urodynamic investigation, 27 patients had an unobstructed and 5 an equivocal Blaivas-Groutz nomogram. Three patients (20%) reported a persistent degree of stress urinary incontinence, including 2 with grade 1 stress urinary incontinence and 1 with mixed incontinence. Two patients presented with clinically evident diverticulum recurrence, and in 1 patient, an intraurethral diverticulum, was found at the 1-year magnetic resonance imaging examination.

CONCLUSIONS

A pubovaginal sling added routinely to all diverticulectomy procedures offers significant support to the urethral repair and/or prevention of urinary incontinence, including in recurrent cases, and does not increase the risk of erosion into the urethra or fistula formation.

Urethral diverticula: a review and an update

Likely originating from the periurethral glands, female urethral diverticula (UD) are an uncommon but fascinating clinical entity. UD are variable in their presentation and the diagnosis is sometimes difficult and delayed. Modern imaging modalities such as surface coil and endoluminal magnetic resonance imaging (MRI) have added to the diagnostic armamentarium but have also furthered our understanding of UD. Accurate preoperative characterization of the often complex anatomical patterns seen on these imaging studies including saddlebag and circumferential urethral involvement, as well as complete evaluation of associated voiding dysfunction such as complete evaluation of associated voiding dysfunction such as urinary incontinence often impacts contemporary surgical management.

Female Urethral Diverticulum: 26-Year Followup of a Large Series

PURPOSE

Female urethral diverticulum is an acquired condition associated with distressing and chronic symptoms. Surgery sometimes represents a technical challenge and various complications may follow treatment. We present the results of a retrospective analysis in a large personal series operated on during a 26-year period.

MATERIALS AND METHODS

A total of 68 women underwent surgery. The medical records of all women were reviewed and a followup telephone interview was conducted by an investigator not involved in the care of the patients. There were 64 women available for the interview who were questioned using a standard questionnaire.

RESULTS

In the majority of patients the postoperative course was uneventful and no complications were encountered. However, a relative stricture of the urethra developed in 1 woman and fistulas developed in 4. In 1 patient the fistula was small and distal, and was left without further surgery. Although diverticulum recurred in 11 patients and urinary incontinence of varying degrees was rather common, as was dyspareunia, 59 patients (92%) would still recommend surgery to a friend having symptoms of the severity they had experienced themselves.

CONCLUSIONS

Residual symptoms were surprisingly common in the long term. However, most of them were tolerable and it is noteworthy that almost all patients found the operation quite worthwhile when looking back to their preoperative situation. It was evident that repeated surgery frequently resulted in various sequela. The first operation is the golden opportunity for long-term success and a lesson to be learned is that operations for female urethral diverticulum would preferably be centralized to a limited number of surgeons.

Female urethral diverticula

Urethral diverticula are frequently under-diagnosed. The pathogenesis of this condition is poorly understood, and these lesions represent a spectrum of disorders ranging from isolated suburethral cysts to herniation of the urethral lining into the vaginal mucosa. Women with this disorder frequently complain of a host of symptoms referable to the lower urinary and genital tracts. Accurate diagnosis is based on history and clinical evaluation. Perineal ultrasound and MRI are often helpful. Repeated courses of antibiotics and urethral dilatation often fail to resolve the problem, and definitive intervention usually requires surgical excision to provide relief. This chapter describes the current management of this condition, and it heralds a re-look at the patho-aetiology in view of recent MRI findings of symptomatic non-communicating microcystic lesions.

[The female urethral diverticula: apropos of 21 cases]

PURPOSE

Our goal is to study the clinical, radiological and therapeutic particularity of the female urethral diverticula via a retrospective study of 21 cases.

PATIENT AND METHODS

Twenty one females, with a mean age of 37 years (range 15 to 62 years) presenting an urethral diverticula, were treated between 1988 and 2000. Clinical examination made diagnosis in all cases. Cystorethrography shown a direct image of diverticula in 100% of cases and intravenous Pyelography in only 24% of cases. The urethral diverticula was excised via a transvaginal approach in all cases.

RESULTS

Eighteen patients had favourable immediate outcome. Three patients presented an urethrovaginal fistula treated surgically in one case and by bladder drainage in one case. The last patient refused treatment and she was lost to follow-up. After a median follow-up of 54 months (range 18 to 120) only three patients have some urinary urgency that was treated by anticholinergics.

CONCLUSION

Female urethral diverticula is a rare disease, the diagnosis is easy and only surgical excision gives good results.

Urethral pathology

In the present review the eligible data on urethral pathologies are critically analysed, with special attention given to unresolved controversies in this topic. The entities discussed are as follows: female circumcision as a ritualistic tradition, with many associated complications; prostatourethritis and urethral syndrome; urethral diverticula as an overlooked rare pathology in urological practice; urethrorectal fistula; pelvic fracture urethral injuries and its current standard treatment algorithm; and urethral strictures and new endoscopic or surgical reconstructive techniques.

Experience with the management of urethral diverticulum in 63 women

The presentation and management are reviewed of 63 women with urethral diverticulum seen at a single institution in 10 years. Of the women 36 (61.9%) had urinary incontinence as a presenting symptom and 20 (31.7%) had incontinence as the only presenting complaint. Diverticula were suspected in 57 cases (90.5%) based on the presence of a periurethral mass during pelvic examination. Investigations included voiding cystourethrogram, excretory urogram, urodynamic studies and recently transvaginal ultrasound. Voiding cystourethrography adequately demonstrated the diverticulum in 60 of the 63 women (95.2%). Urodynamic studies performed in 58 women revealed abnormal findings in 36 (62%), including genuine stress urinary incontinence in 28 (48.3%). The location/number/size/configuration, communication, continence classification was used to define the characteristics of the diverticula. Seven women either refused operation or had small asymptomatic diverticula not requiring treatment. Transvaginal diverticulectomy was performed using a 3-layer closure in 56 women. Concomitant bladder neck suspension was performed in 27 women with documented stress urinary incontinence and/or urethral hypermobility. With a mean followup of 70 months (range 6 to 136) 48 women (85.7%) were completely relieved of the presenting complaint. Complications of diverticulectomy included 2 small distal recurrent diverticula, 1 urethrovaginal fistula and 6 transient early urinary tract infections. None of the women had urethral stricture or recurrent urinary tract infection. Six women (22.2%) who underwent diverticulectomy and bladder neck suspension, and 3 (10.3%) treated with diverticulectomy alone had minimal urinary incontinence requiring less than 2 pads a day.