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

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.

A diagnostic conundrum: Is it a periurethral diverticulum/cyst or a bulking agent (Bulkamid)?

INTRODUCTION

Urethral bulking agents are commonly used to manage female stress urinary incontinence (SUI) as they have been suggested to be safe, efficacious, and a minimally invasive surgical option. Bulkamid is a newer bulking agent that has been introduced and promoted in the market for use. It is non-particulate in nature with high tissue biocompatibility, and consequently, it is difficult to differentiate between Bulkamid and a periurethral cyst on magnetic resonance imaging (MRI). This, therefore, presents a diagnostic dilemma.

METHODS AND MATERIALS

Here we describe two cases with previous injections of Bulkamid referred to our Centre for management of a presumed periurethral diverticulum based on MRI findings. Both patients were reviewed and examined in outpatient clinics with MRI findings discussed at MDT, further imaging was required.

RESULTS

We found that a limited noncontrast computed tomography (CT) pelvis, followed by a voiding cystometrogram (VCMG), and then a repeat limited noncontrast CT pelvis effectively differentiated between Bulkamid and these presumed periurethral diverticulae. The theory behind this was that during micturition, the contrast would pass through to the urethral diverticulum and appear as high-density (bright) material within the periurethral region (the pre-VCMG was required to prove that any high-density material was due to the contrast and not pre-existing high-contrast material).

CONCLUSION

A CT scan done in conjunction with a VCMG is likely to be more effective in differentiating between Bulkamid and a true periurethral diverticulum than an MRI scan. Appropriate diagnostic evaluation of periurethral lesions can lead to time-saving and cost-effective patient management as this will bypass the need for unnecessary investigations and possible unwarranted surgical intervention.

A prospective cohort trial evaluating sexual function after urethral diverticulectomy

OBJECTIVE

Dyspareunia is a main symptom of urethral diverticulum in the female population, reported up to 60% of patients. Pain may cease after diverticulectomy as published in previous retrospective studies. To date scarce or no data exists on the postoperative outcome in terms of sexual function. The present study wants to quantify sexual function and evaluate lower urinary tract symptoms in sexually active patients after resection of urethral diverticulum.

STUDY DESIGN

In this prospective cohort trial at a tertiary referral center, we evaluated 40 female patients who presented with symptomatic urethral diverticulum and were sexually active. All of them underwent a standardized surgical procedure with inverted U-shape colpotomy between 2008 and 2018. The patients completed the Female Sexual Function Index (FSFI), which is determined by the mean score of the different domains, and underwent urodynamic assessment both at baseline examination before surgery and 12 months postoperatively. For statistical analysis, we conducted a paired Wilcoxon rank sum test analyzing the non-normally distributed non-parametric variables of the female sexual function index.

RESULTS

In two patients a malignancy was found in postoperative histology and received a different therapeutical approach. They have been excluded from statistical analysis. Sexual function improved in all domains (n = 38): total score (Z = -5.4, P < 0.000), satisfaction (Z = -5.3, P < 0.000), pain (Z = -5.4, P < 0.000), arousal (Z = -2.6, P = 0.010), lubrication (Z = -2.4, P = 0.020), desire (Z = -2.6, P = 0.009) and orgasm (Z = -2.2, P = 0.029). Maximum urethral closure pressure deteriorated from 39 to 36 cmH2O (P = 0.0008) and residual urine increased from 10 ml to 20 ml after surgery (P = 0.0019). No statistical significance is found for bladder capacity and free urinary flow.

CONCLUSIONS

All domains of the female sexual function index improved. Patients' bothersome symptoms, mainly pain may cease and sexual satisfaction increases, which is reassuring concerning patients' preoperative consent. We should be aware that occasionally an unexpected malignancy may be detected and it is mandatory to examine all excised tissue histologically. Lower urinary tract function remains clinically unchanged, although maximum urethral closure pressure deteriorated and postvoid residual increased though not being clinically significant.

Does a tailored magnetic resonance imaging technique affect the surgical planning and outcomes for different cystic urethral and periurethral swellings in females? Seven years tertiary center experience

PURPOSE

To evaluate the use of magnetic resonance imaging (MRI) in preoperative delineation and surgical planning for the management of female urethral and periurethral cystic vaginal swellings, with emphasis on postoperative surgical outcomes.

MATERIALS AND METHODS

This is a retrospective analysis of females complaining of periurethral and urethral cystic swellings referred to our tertiary center, who underwent MRI for preoperative planning in the period from January 2014 till January 2021, with a total number of 57 patients. Data retrieved from the medical records included: patients' demographics, presenting symptoms and signs, preoperative radiological investigations, duration of symptoms, previous surgical intervention, detailed intraoperative data, postoperative complications, and postoperative follow-up.

RESULTS

Urethral diverticulum was the commonest cystic lesion representing (64.9%) followed by Skene gland cysts in 14%, Mullerian cysts in 7%, Gartner cysts in 3.5%, and dermoid inclusion cysts in 10.5%. MRI precisely diagnosed the various pathological entities and anatomical complex lesions prior to surgery. This was confirmed after surgery and pathology analysis. All patients were followed up with a mean duration of 35 months, without any evidence of recurrence.

CONCLUSION

MRI as a standalone imaging technique is mandatory for diagnosis of all urethral and periurethral cystic lesions, as it offers the most accurate diagnostic modality for delineation of these lesions and hence aids in the preoperative surgical planning, aiming to avoid recurrence and improving surgical outcomes.

Pathophysiology and Management of Long-term Complications After Transvaginal Urethral Diverticulectomy

Female urethral diverticulum (UD) is a rare and benign condition that presents as an epithelium-lined outpouching of the urethra. It has various symptoms, of which incontinence in the form of postmicturition dribble is the most common. The gold standard for the diagnosis of UD is magnetic resonance imaging, and the treatment of choice is transvaginal diverticulectomy. Despite the high success rate of transvaginal diverticulectomy, postoperative complications such as de novo stress urinary incontinence (SUI), recurrence, urethrovaginal fistula, recurrent urinary tract infections, newly-onset urgency, and urethral stricture can occur. De novo SUI is thought to result from weakening of the anatomical support of the urethra and bladder neck or damage to the urethral sphincter mechanism during diverticulectomy. It can be managed conservatively or may require surgical treatment such as a pubovaginal sling, Burch colposuspension, or urethral bulking agent injection. Concomitant SUI can be managed by concurrent or staged anti-incontinence surgery. Recurrent UD may be a newly formed diverticulum or the result of a remnant diverticulum from the previous diverticulectomy. In cases of recurrent UD requiring surgical repair, placing a rectus fascia pubovaginal sling may be an effective method to improve the surgical outcome. Urethrovaginal fistula is a rare, but devastating complication after urethral diverticulectomy; applying a Martius flap during fistula repair may improve the likelihood of a successful result. Malignancies in UD are rarely reported, and anterior pelvic exenteration is the recommended management in such cases.

Correlation between symptoms and imaging findings including pelvic floor ultrasound to improve the symptom-based diagnosis of female urethral diverticulum (CHECK-UD study)

INTRODUCTION AND HYPOTHESIS

The objective was to establish a model to predict the presence of a female urethral diverticulum (UD) based on symptoms.

METHODS

A prospective CHECK-UD study (check of female urethral diverticulum) was conducted. Female patients presenting with symptoms such as lower urinary tract symptoms (LUTS), postmicturition dribble or urinary incontinence (UI), dyspareunia or pain in the pelvic area, and recurrent urinary tract infection (UTI) treated between 2015 and 2020 were included. The association between each symptom variable and the positive finding of UD was evaluated by multivariate logistic regression adjusting for age, body mass index (BMI), vaginal deliveries, previous surgery for SUI, previous pelvic surgery, and microscopic hematuria. A predictive model for the presence of UD was then created.

RESULTS

In total, 189 female patients with a minimum of one symptom were enrolled. Pelvic floor ultrasound revealed the presence of UD in 66 out of 189 (34.92%). Of the four symptoms, the combinations "LUTS + postmicturition dribble + UTI," "postmicturition dribble + LUTS," and "UTI + LUTS" were most significantly related to positive findings and had a higher positive prognostic value for the diagnosis of UD than each individual symptom alone (OR = 13.78 [95% CI: 6.95-16.35], p < 0.001; OR = 9.94 [95% CI: 4.60-12.2], p < 0.05; and OR = 5.78 [95% CI: 1.58-6.98] p = 0.05) respectively.

CONCLUSION

Based on our model, the combination "LUTS + postmicturition dribble + UTI" seems to be the most sensitive combination of clinical symptoms predicting the positive finding of UD. This model could be used for patient counseling and for the identification of patients with UD.

Stress Urinary Incontinence After Urethral Diverticulum Repair Without Concomitant Anti-Incontinence Procedure

OBJECTIVE

To review the rates of persistent and de novo stress urinary incontinence (SUI) following urethral diverticulum (UD) repairs performed without concomitant SUI surgical procedures.

METHODS

Following IRB approval, charts of women who underwent UD excision by three FPMRS surgeons were reviewed. Data collected from the electronic medical record included demographic information, preoperative symptoms and evaluation (validated questionnaires [UDI-6, QoL]), imaging studies, operative details, post-operative symptoms, and subsequent surgical interventions. Excluded were women with <6 months follow-up or concomitant pubovaginal sling placement. SUI was diagnosed by patient report, and UD was confirmed by preoperative magnetic resonance imaging or voiding cystourethrogram. The primary outcome was defined as the rate of SUI following UD repair. Secondary outcomes included resolution of pre-operative SUI, rate of self-reported secondary SUI, and SUI surgical intervention post-UD repair.

RESULTS

From 2003-2018, 61 of 67 women met study criteria. SUI pre-UD repair was reported in 31 of 61 (51%). During UD repair, 3 patients underwent Martius flap interposition. Post-UD repair, 18/61 (30%) reported SUI. Persistent SUI was present in 14 of 31 (45%), and de novo SUI occurred in 4 of 30 (13%). Postoperative responses revealed statistically significant improvements in QoL and most questions of UDI-6 at median 18 months. SUI was surgically managed in 3 patients using bulking agent injections (2) and autologous fascial sling placement (1). Overall, 3 of 61 (5%) underwent SUI intervention post-UD repair.

CONCLUSION

Without prophylactic SUI corrective procedures performed during UD repair, we observed a low rate of de novo SUI, and only 5% with bothersome SUI opting for surgical intervention.

Robotic assisted proximal dorsal urethral diverticulectomy

INTRODUCTION AND HYPOTHESIS

Urethral diverticula are rare but clinically significant entities among female patients. Ventrally located, mid-to distal, simple or horseshoe diverticula are most commonly observed and are usually repaired via a transvaginal approach with varying levels of difficulty but high success rates. Dorsally (anteriorly) located urethral diverticula are more challenging to repair secondary to the need to access the side of the urethra opposite the vaginal lumen, abutting the external urethral sphincter. Unique proximal anatomy in the case presented led to careful consideration of the surgical options.

METHODS

We present a review of techniques reported in the literature and a video demonstrating our technique for transabdominal robot-assisted laparoscopic excision of a large, dorsal, very proximally located, crescenteric urethral diverticulum in a patient who initially presented with urosepsis.

RESULTS

Robotic-assisted excision of the urethral diverticulum was accomplished in 3:27 h with an estimated blood loss of 50 cc. Vaginal counter-incision was not necessary. The patient's postoperative course was uneventful. Postoperative voiding cystourethrogram prior to suprapubic catheter removal revealed a well-healed repair without extravasation. At 6-month follow-up, she denied any de novo lower urinary tract symptoms such as urinary incontinence, post-void dribbling, urinary tract infection or urinary hesitancy.

CONCLUSIONS

Dorsal urethral diverticulum in women, particularly when very proximal, can present a diagnostic and surgical challenge for reconstructive pelvic surgeons. The robotic approach to urethral diverticulectomy is feasible for a proximal dorsal urethral diverticulum which lies cephalad to the pubic symphysis. This or other laparoscopic applications may also be considered as an adjunct to the standard vaginal approach for complex urethral diverticuli with a proximal dorsal component.

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.

The Modified Prone Jack-knife Position for the Excision of Female Urethral Diverticula

BACKGROUND

Female urethral diverticula (UD) are an uncommon and often overlooked aetiology in women presenting with lower urinary tract symptoms, urethral pain, and recurrent urinary tract infection. With increasing awareness, appropriate imaging is more commonly undertaken with consideration given to surgical management.

OBJECTIVE

The video presented demonstrates the technique for excising large and/or complex UD using a modified prone jack-knife position-a position that offers excellent surgical access and allows the surgeon to operate in a more ergonomic position.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective review of the data on patients undergoing excision of UD at a tertiary referral unit was performed.

SURGICAL PROCEDURE

Urethral and suprapubic catheters (±insertion of ureteric stents) were placed in supine position. UD excised in the modified prone jack-knife position (±placement of a Martius flap).

MEASUREMENTS

Subjective cure rate, recurrence rate, rates of postoperative urinary incontinence, need for secondary incontinence procedure, and postoperative complications were measured.

RESULTS AND LIMITATIONS

A total of 121 patients were operated on in the study period. The mean follow-up time was 10 mo (range 3-40). The most frequent presenting symptoms included a vaginal mass (n = 76, 63%), followed by dysuria (n = 72, 60%) and pelvic pain (n = 71, 59%). An identifiable aetiological factor was present in 45 patients, including traumatic vaginal delivery (18, 15%), prior periurethral surgery (17, 14%), and urethral dilatation (10, 8%). All patients underwent postvoiding magnetic resonance imaging (MRI) to confirm the diagnosis and plan surgery. UD ranged in maximum diameter from 8 to 48 mm, with a mean of 43 mm (standard deviation 9.24). The most common anatomical location was midurethral (55, 46%), followed by distal (36, 30%), proximal (25, 21%), and full length (5, 4%). Most UDs were single in configuration (74%), followed by multiloculated (15%), saddle shaped (7%), and circumferential (5%). On preoperative videourodynamics, 17 (14%) had stress urinary incontinence. UD excision was undertaken in the modified prone jack-knife position in all cases. A Martius flap was utilised in 36 (30%). The median postoperative postvoiding residual was 26 ml (interquartile range 0-40). In total, 88 (73%) patients were continent postoperatively and 16 (13%) experienced de novo stress urinary incontinence. Of the 37 with pre-existing stress incontinence symptoms, 20 (54%) were continent after operation. A total of 14 patients had subsequent autologous fascial sling at 6 mo. In total, five symptomatic recurrences occurred (4%); of these patients, three elected to undergo surgical excision, all of whom had symptom resolution and were continent after operation. A total of 11 patients (9%) experienced a Clavien-Dindo grade I-II complication within 90 d after operation. Five patients complained of dyspareunia, which resolved by 6 mo.

CONCLUSIONS

The modified prone jack-knife position facilitates excellent access for excision of both simple and complex UDs. This positioning of the patient is not widely recognised amongst urologists. Using this approach, there were low rates of symptomatic recurrence and de novo stress incontinence at medium-term follow-up. Associated urinary incontinence resolves in over half of patients following UD excision; hence, we advocate deferring any incontinence procedure until after the results of surgery are established.

PATIENT SUMMARY

Surgical removal of urethral outpouching (diverticula) in women is challenging due to its potential to damage the nearby sphincter muscle, which controls continence, or the urethra tube. Placement of patients on their front, rather than on their back, provides excellent access for the surgical removal of urethral diverticula. With this approach, we achieved excellent rates of cure and low rates of urinary incontinence at an average follow-up of 10 mo.

Transvaginal surgical repair of large urethral diverticula with bipedicle double-opposing flaps of the periurethral fascia

PURPOSE

The aims of this study were to describe a novel technique for transvaginal repair of large (> 4 cm) female urethral diverticulum (UD) using bipedicle double-opposing flaps of the periurethral fascia and to evaluate long-term follow-up.

METHODS

The medical records of 29 women who underwent transvaginal excision of UD at our institution were reviewed retrospectively. Seventeen cases with UD > 4 cm were included in the study. Cystourethroscopy was performed at the beginning of the surgery, and in 60% of cases the orifice of the diverticulum was identified. An inverted-U incision was performed at the vaginal anterior wall. The periurethral fascia was incised longitudinal at the midline and parallel to the urethra. The diverticular sac was dissected and resected. The neck of the diverticulum was closed with 4/0 vicryl suture. The periurethral fascia was sutured using bipedicle double-opposing flaps with interrupted 3/0 vircyl suture. The vaginal mucosa was sutured with 2/0 vicryl continuous suture.

RESULTS

All 17 women with large UD were operated on using bipedicle double-opposing flaps of the periurethral fascia. Follow-up of 5 ± 2.4 years yielded no recurrence and no other late complications.

CONCLUSION

Using bipedicle double-opposing flaps of the periurethral fascia during transvaginal excision of large UD is safe and effective.

Hybrid Sling for the Treatment of Concomitant Female Urethral Complex Diverticula and Stress Urinary Incontinence

This study aims to present an alternative technique with the use of a transobturator hybrid sling (autologous fascia lata with a synthetic sling) in two patients with complex urethral diverticulum (CUD), urinary stress incontinence (SUI) and a large incisional infraumbilical hernia. Staged procedures could be performed, but considering the risk of persistence or worsening SUI, and no standard management strategy of SUI associated with CUD; simultaneous treatment was proposed. It is preferable to use autologous materials in such cases. However, the presence of incisional hernia protruded with its content covering the suprapubic area prohibits the retropubic sling technique due to visceral lesion risk. The diverticulum and SUI were repairs in the same surgery using a hybrid transobturator. The technique used for obtaining the fascia lata followed the literature, and a 6 cm segment was acquired. The patients were re-prepared in a lithotomy fashion, and diverticulectomy was performed. The segment of fascia lata was fixed to the mesh and sling was manipulated so that its middle part (fascia) rested directly below the urethra. After 6 months post-operatively, patients referred significant improvement in urinary symptoms. Patients have not had any storage symptoms, International Consultation on Incontinence Questionnaire – Short Form = zero, no SUI, and have not had any mesh-related complications. In conclusion, the present study evaluated a new technique for the treatment of CUD with SUI in a particular clinical scenario. Other studies with extended follow-up periods and larger sample sizes should be performed in this subset of patients.

A multicenter retrospective cohort study comparing urethral diverticulectomy with and without pubovaginal sling

BACKGROUND

Urethral diverticulum is a rare entity and requires a high suspicion for diagnosis based on symptoms and physical exam with confirmation by imaging. A common presenting symptom is stress urinary incontinence (SUI). The recommended treatment is surgical excision with urethral diverticulectomy. Postoperatively, approximately 37% of patients may have persistent and 16% may have de novo SUI. An autologous fascial pubovaginal sling (PVS) placed at the time of urethral diverticulectomy (UD) has the potential to prevent and treat postoperative SUI. However, little has been published about the safety and efficacy of a concomitant pubovaginal sling.

OBJECTIVE

The objective of this study was to compare the clinical presentation, outcomes, complications, and diverticulum recurrence rates in women who underwent a urethral diverticulectomy with vs without a concurrent pubovaginal sling.

STUDY DESIGN

This multicenter, retrospective cohort study included women who underwent a urethral diverticulectomy between January 1, 2000, and December 31, 2016. Study participants were identified by Current Procedure Terminology codes, and their records were reviewed for demographics, medical or surgical history, symptoms, preoperative testing, concomitant surgeries, and postoperative outcomes. Symptoms, recurrence rates, and complications were compared between women with and without a concomitant pubovaginal sling. The primary outcome was the presence of postoperative stress urinary incontinence symptoms. Based on a stress urinary incontinence rate of 50% with no pubovaginal sling and 10% with a pubovaginal sling, we needed a sample size of 141 participants who underwent diverticulectomy without a pubovaginal sling and 8 participants with a pubovaginal sling to achieve 83% power with P<.05.

RESULTS

We identified 485 diverticulectomy cases from 11 institutions who met the inclusion criteria; of these, 96 (19.7%) cases had a concomitant pubovaginal sling. Women with a pubovaginal sling were older than those without a pubovaginal sling (53 years vs 46 years; P<.001), and a greater number of women with pubovaginal sling had undergone diverticulectomy previously (31% vs 8%; P<.001). Postoperative follow-up period (14.6±26.9 months) was similar between the groups. The pubovaginal sling group had greater preoperative stress urinary incontinence (71% vs 33%; P<.0001), dysuria (47% vs 30%; P=.002), and recurrent urinary tract infection (49% vs 33%; P=.004). The addition of a pubovaginal sling at the time of diverticulectomy significantly improved the odds of stress urinary incontinence resolution after adjusting for prior diverticulectomy, prior incontinence surgery, age, race, and parity (adjusted odds ratio, 2.27; 95% confidence interval, 1.02-5.03; P=.043). It was not significantly protective against de novo stress urinary incontinence (adjusted odds ratio, 0.86; 95% confidence interval, 0.25-2.92; P=.807). Concomitant pubovaginal sling increased the odds of postoperative short-term (<6 weeks) urinary retention (adjusted odds ratio, 2.5; 95% confidence interval, 1.04-6.22; P=.039) and long-term urinary retention (>6 weeks) (adjusted odds ratio, 6.98; 95% confidence interval, 2.20-22.11; P=.001), as well as recurrent urinary tract infections (adjusted odds ratio, 3.27; 95% confidence interval, 1.26-7.76; P=.013). There was no significant risk to develop a de novo overactive bladder (adjusted odds ratio, 1.48; 95% confidence interval, 0.56-3.91; P=.423) or urgency urinary incontinence (adjusted odds ratio, 1.47; 95% confidence interval, 0.71-3.06; P=.30). A concomitant pubovaginal sling was not protective against a recurrent diverticulum (adjusted odds ratio, 1.38; 95% confidence interval, 0.67-2.82; P=.374). Overall, the diverticulum recurrence rate was 10.1% and did not differ between the groups.

CONCLUSION

This large retrospective cohort study demonstrated a greater resolution of stress urinary incontinence with the addition of a pubovaginal sling at the time of a urethral diverticulectomy. There was a considerable risk of postoperative urinary retention and recurrent urinary tract infections in the pubovaginal sling group.

The risk of stress incontinence after urethral surgery in women

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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.

Circumferential urethral diverticulum: a surgical conundrum

INTRODUCTION AND HYPOTHESIS

Excision of a circumferential diverticulum may be challenging as its extension into the dorsal aspect of the urethra makes access complicated.

METHODS

A 69-year-old woman with a history of Stage 3C ovarian cancer on chemotherapy presented with a 3-week history of severe dysuria and suprapubic pain. T2-weighted pelvic magnetic resonance imaging (MRI) showed a circumferential diverticulum extending over the dorsal midurethra without evidence of urethral communication. As conservative measures including bladder instillations failed, she underwent surgical excision of this multilocular circumferential diverticulum. The diverticulum was identified and excised in segments. To achieve optimal excision, we incised around and dorsal to the urethral meatus into the retropubic area. Finally, a communicating tract from the ventral loculation of the diverticulum to the urethra was identified. The communication was obliterated, and the urethra was repaired in two layers and reinforced with a fibromuscular flap. The fluid tight seal was confirmed by retrograde filling of the bladder and cystourethroscopy.

RESULTS

The patient was symptom free at 6-week and 6-month visits.

CONCLUSION

This video highlights the steps required to successfully excise a complex circumferential diverticulum that extends over the dorsal midurethra and has a communication with the urethral lumen.

A 10-Year Case Series of Surgically Managed Periurethral Masses at a Single Tertiary Care Institution

OBJECTIVE

This study aimed to present the evaluation, diagnoses, and surgical management of symptomatic periurethral masses of women at an academic institution.

METHODS

This study is an institutional review board-approved retrospective case series of women who presented with a symptomatic periurethral mass and scheduled for surgery within the Department of Urology and Female Pelvic Medicine and Reconstructive Surgery over a 10-year period (October 2003-July 2014).

RESULTS

Fifty-nine women (mean age, 46 years; range, 22-73 years) were evaluated during the study period. Final pathology revealed 38 (64%) urethral diverticula and 21 (36%) from other benign etiologies. Of the 38 urethral diverticula, 2 (5%) were associated with adenocarcinoma and 4 (11%) with previous bulking agents. Of the 21 nondiverticula, there were 7 (12%) Skene duct cysts/abscesses, 3 (5%) Gartner duct cysts, 2 (3%) vaginal wall inclusion cysts, 2 (3%) bulking agents, 2 (3%) urethral polyps, and one (2%) of each of the following: leiomyoma, angiomyofibroblastoma, redundant vaginal mucosa epithelium, suture abscess, and encapsulated mesh remnant. Fifty-seven women underwent surgical excision (97%), and 2 elected observation. Most (78%) reported resolution of symptoms after excision. Of the patients surgically managed, 7% had postoperative stress urinary incontinence and 12% had persistent lower urinary tract symptoms. Of the 38 women with urethral diverticula, 17% had recurrence and were more likely to have multiple diverticula (44% vs 8%, P = 0.03).

CONCLUSION

Although urethral diverticulum was the most common cause of a periurethral mass, final pathology revealed a variety of benign diagnoses in more than one-third of cases, demonstrating the importance of a thorough investigation for accurate diagnosis.

Urethral diverticulum: A systematic review

Objective: To present a review of the current literature regarding the presentation, diagnosis, and treatment of female urethral diverticula (UD).

Methods: A systematic search of the PubMed database was performed to identify studies evaluating female UD. Article titles, abstracts and full-text manuscripts were screened to identify relevant studies, which then underwent data extraction and analysis.

Results: In all, 50 studies evaluating the presentation, diagnosis and treatment of female UD were deemed relevant for inclusion. Almost all studies were retrospective single-arm case series. Female UD are outpouchings of the urethral lumen into the surrounding connective tissue. The presentation of female UD is diverse and can range from incidental findings to lower urinary tract symptoms, frequent urinary tract infections, dyspareunia, urinary incontinence (UI), or malignancy. Repair of UD begins with an accurate assessment and diagnosis, which should include adequate radiographic imaging, usually including magnetic resonance imaging. Once the diagnosis is confirmed, the usual treatment is surgical excision and reconstruction, most often through a transvaginal approach. The principles of transvaginal urethral diverticulectomy include: removal of the entire urethral diverticulum wall, watertight closure of the urethra, multi-layered and non-overlapping closure of surrounding tissue with absorbable suture, and preservation or creation of continence. Results of surgical repair are usually excellent, although long-term recurrence of these lesions may occur. Complications of urethral diverticulectomy include urethrovaginal fistula, UI, and rarely urethral stricture.

Conclusion: Whilst urethral diverticulectomy excision and reconstruction is a challenging procedure, it is ultimately satisfying for the patient and the surgeon when relief of bothersome symptoms is achieved. Adherence to principles of reconstructive surgery is important to ensure a satisfactory result.

Abbreviations: PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; UD: urethral diverticulum/diverticula; UI: urinary incontinence; US: ultrasonography; VCUG: voiding cystourethrogram

Preoperative Transurethral Contrast-Enhanced Ultrasonography in the Diagnosis of Female Urethral Diverticula

OBJECTIVES

To explore the value of transurethral contrast-enhanced ultrasonography (CEUS) in the diagnosis and evaluation of female urethral diverticula.

METHODS

This study prospectively enrolled 35 women with periurethral cystic lesions, who underwent preoperative transurethral CEUS at our single center between April 2015 and May 2017. The diagnosis of a urethral diverticulum was made by the detection of microbubbles inside the lesion. Data regarding the structure and ostia of the diverticula were collected and then compared with intraoperative findings.

RESULTS

The median (interquartile range) age of the 35 patients was 43 (34-48) years. The most common manifestations were dysuria (43%) and palpable masses (40%). On transurethral CEUS, 20 patients were found to have urethral diverticula. The diverticula involved the proximal, mid, and distal urethra with different sizes. The shapes of the diverticula were simple in 4 patients (20%), U shaped in 8 patients (40%), and circumferential in 8 patients (40%). A total of 23 ostia were identified. Seventeen women (85%) had 1 ostium, and 3 women (15%) had 2 ostia. Twenty-one diverticular ostia (91%) were located from the 3- to 9-o'clock positions. The median (interquartile range) distance from the diverticular ostia to the bladder neck was 20 (9-31) mm. During surgery, all US presentations correlated well with surgical findings, and 21 patients were confirmed to have urethral diverticula. The transurethral CEUS had sensitivity of 95% and specificity of 100%.

CONCLUSIONS

Transurethral CEUS is an effective method for identifying the structure and ostium of female urethral diverticula. It may have a potential role in preoperative planning and surgical management.

Managing female urethral diverticulum with a standardized technique using a pacifier-trick artifice to facilitate dissection

INTRODUCTION AND HYPOTHESIS

Managing urethral diverticula is challenging because of recurrence rate and postoperative complications. Herein, we report a standardized, single-institution experience of surgical treatment of urethral diverticula in women.

METHODS

The medical record of 37 female patients treated for urethral diverticula between 2005 and 2017 in a single institution were reviewed. All patients were operated in a standardized genupectoral position using a technical artifice called the pacifier trick to inflate diverticula throughout the procedure and facilitate its dissection. Symptoms at diagnosis, imaging findings, surgical parameters, postoperative complications, and recurrence rates were collected and are presented.

RESULTS

Median age was 39 ± 11 (range 21-67) years. At diagnosis, recurrent urinary tract infections (UTI) (67%), vaginal mass (46%), pelvic pain (43%), dyspareunia (27%), and urinary incontinence (UI) (24%) were the most commonly reported symptoms. Median operative time was 98 ± 31 (range 40-150) min. After a mean follow-up of 1 year, recurrence occurred in one (3%) patient. Immediate de novo postoperative UI decreased from 27% immediately after surgery to 3% after pelvic physical therapy. Pathological analyses found no malignant histology.

CONCLUSIONS

Surgical management of urethral diverticula in women is technically demanding. With our standardized pacifier-trick technique, satisfying anatomical and functional results were achieved.

The treatment of complex female urethral pathology

Lower urinary tract symptoms (LUTS) in women produce significant bother. Common conditions causing LUTS in women include urinary tract infections, overactive bladder, and stress incontinence. Urethral diverticulae and female urethral strictures are rare pathologies. They can cause symptoms, which can mimic commoner conditions, leading to delay in diagnosis and unnecessary delay in treatment. In this article, we discuss in detail the definition, symptoms, epidemiology, pathogenesis, diagnosis, and treatment option for these two conditions. Further understanding of these conditions will aid in the proper diagnosis and prevent delay in management.

Female Urethral Diverticulum: Presentation, Diagnosis, and Predictors of Outcomes After Surgery

INTRODUCTION AND HYPOTHESIS

To report on clinical presentation, diagnosis, and outcomes after treatment of female urethral diverticulum (UD).

METHODS

Using a record linkage system, women with a new diagnosis of UD at Mayo Clinic from January 1, 1980, through December 31, 2011, were identified. The presenting symptoms, clinical characteristics, diagnosis, and management of women presenting with UD were recorded. Outcomes after surgery were assessed using survival analysis. All statistical analyses were 2-sided and P values less than 0.05 were considered significant. Statistical analysis was done using SAS version 9.2 and JMP version 9.0 (SAS Institute Inc.).

RESULTS

A total of 164 cases were identified. Median age at diagnosis was 46 years (range, 21-83). The most common presenting symptom was recurrent urinary tract infection (98, 59.8%), followed by urinary incontinence (81, 49.4%), dysuria (62, 37.8%), dyspareunia (37, 22.6%), and hematuria (15, 9.1%). Examination revealed vaginal mass in 55 (33.5%) of the women. A significant trend was noted toward an increase in use of both magnetic resonance imaging and computed tomography (P < 0.001) along with a progressive decrease in use of urethrogram (P < 0.001) for diagnosis of UD over the years. Among 114 women who underwent surgical treatment for UD, 14(12.3%) women presented with recurrent UD and the 5-year recurrence rate after surgery for UD was 23.4% (95% confidence interval, 13.9-37.0) and a reoperation rate of 17.0% (95% confidence interval, 8.8-30.2) at 5 years.

CONCLUSIONS

Female UD is a rare and unique condition. Clinical presentation is usually nonspecific, and magnetic resonance imaging is commonly used for confirming the diagnosis. Recurrence is not uncommon, and repeat surgical intervention might be needed.

Preliminary report on the effect of urethral diverticulum magnetic resonance imaging configuration on the incidence of new onset urodynamic stress urinary incontinence following excision

Context:

Excision of urethral diverticulum in females has been reported to be associated with new onset urodynamic stress urinary incontinence (USUI) in up to 49%.

Aims:

We have assessed the incidence of new onset USUI in all patients having urethral diverticulum excision with Martius fat pad interposition under the care of a single surgeon between May 1, 2007, and December 1, 2011. The incidence of new onset USUI has been correlated with the preoperative magnetic resonance imaging (MRI) appearance of the urethral diverticulum.

Patients and Methods:

All 33 patients (mean age 42) having urethral diverticulum with Martius fat pad interposition had prospective data tabulated on demographics, preoperative MRI appearance, and pre- and post-operative videocystometrogram.

Statistical Analysis Used:

Statistical analysis was performed by Chi-squared and Fisher's exact.

Results:

Of the 33 patients, 10 (30%) had preoperative USUI and have been excluded from this study. Other preoperative urodynamic findings included idiopathic detrusor overactivity in ten (30%) and bladder outflow obstruction in five (16%). Two (10%) of the patients had a simple diverticulum, 16 (73%) had a horseshoe diverticulum, and 5 (17%) had a circumferential diverticulum. The rate of new onset USUI was 0% for simple, 6% for saddle, and 20% for circumferential.

Conclusions:

New onset USUI occurs in 9% of patients having excision of urethral diverticulum with Martius fat pad interposition. The incidence appears to increase with increasing complexity of urethral diverticulum on preoperative MRI – rising from 0% following simple urethral diverticulum excision to 20% following circumferential diverticulum excision.

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.

Ultrasound imaging in urogynecology - state of the art 2016

The role of ultrasound imaging in urogynecology is not clearly defined. Despite significant developments in visualization techniques and interpretation of images, pelvic ultrasound is still more a tool for research than for clinical practice. Structures of the lower genitourinary tract and pelvic floor can be visualized from different approaches: transperineal, introital, transvaginal, abdominal or endoanal. According to contemporary guidelines and recommendations, the role of ultrasound in urogynecology is limited to the measurement of post-void residue. However, in many instances, including planning and audit of surgical procedures, management of recurrences or complications, ultrasound may be proposed as the initial examination of choice. Ultrasound may be used for assessment of bladder neck mobility before anti-incontinence procedures. On rare occasions it is helpful in recognition of pathologies mimicking vaginal prolapse such as vaginal cyst, urethral diverticula or rectal intussusception. In patients subjected to suburethral slings, causes of surgery failure or postsurgical voiding dysfunctions can be revealed by imaging. Many reports link the location of a tape close to the bladder neck to unfavorable outcomes of sling surgery. Some postoperative complications, such as urinary retention, mesh malposition, hematoma, or urinary tract injury, can be diagnosed by ultrasound. On the other hand, the clinical value of some applications of ultrasound in urogynecology, for example measurement of the bladder wall thickness as a marker of detrusor overactivity, has not been proved.

Urethral diverticulectomy with Martius labial fat pad interposition improves symptom resolution and reduces recurrence

OBJECTIVE

To assess the presenting features and medium-term symptomatic outcomes in women having excision of urethral diverticulum with Martius labial fat pad (MLFP) interposition.

PATIENTS AND METHODS

We reviewed our prospective database of all female patients having excision of a symptomatic urethral diverticulum between 2007 and 2015. Data on demographics, presenting symptoms and clinical features were collected, as well as postoperative outcomes.

RESULTS

In all, 70 women with a mean (range) age of 46.5 (24-77) years underwent excision of urethral diverticulum with MLFP interposition. The commonest presenting symptoms were a urethral mass (69%), urethral pain (61%), and dysuria (57%). Pre-existing stress urinary incontinence (SUI) was present in 41% (29) of the women. After surgery, at a mean (SD) of 18.9 (16.4) months follow-up (median 14 months), complete excision of urethral diverticulum was achieved in all the women, with resolution of urethral mass, dysuria and dyspareunia in all, and urethral pain in 81%. Immediately after surgery, 10 (24%) patients reported de novo SUI, which resolved with time and pelvic floor muscle training such that at 12 months only five (12%) reported continued SUI. There was one symptomatic diverticulum recurrence (1.4%).

CONCLUSIONS

The commonest presenting symptom of a female urethral diverticulum is urethral pain followed by dysuria and dyspareunia. Surgical excision with MLFP interposition results in complete resolution of symptoms in most women. The incidence of persistent de novo SUI in an expert high-volume centre is 12%.

Female Urethral Diverticulum: Current Diagnosis and Management

While urethral diverticulum (UD) affects less than 20 per 1,000,000 women overall, it is thought to represent 1.4% of women with incontinence presenting to urology practices. It is hypothesized to evolve from periurethral glands that become obstructed, infected, and dilated over time, and patients typically present with dyspareunia, bothersome lower urinary tract symptoms (LUTS), and/or recurrent UTIs. In many patients, a periurethral mass can be appreciated on exam. In recent years, magnetic resonance imaging (MRI) has become the imaging test of choice for diagnosis of UD, but ultrasound (US) is a readily available alternative and provides good specificity at a lower cost. Surgical excision of the diverticulum with tension-free, water-tight, three-layer closure continues to be the mainstay of treatment of UD with most studies reporting cure rates of >90%. Concomitant treatment of preexisting stress incontinence with autologous fascial pubovaginal sling can be used at the time of diverticulectomy to avoid a secondary procedure. However, since secondary anti-incontinence procedures are needed in only a small number of patients, up-front stress incontinence treatment may result in significant overtreatment, and staged anti-incontinence procedures continue to be a reasonable option for patients with persistent bothersome stress urinary incontinence (SUI) after diverticulectomy.

Urethral Diverticulum in Women: Retrospective Case Series

PURPOSE

We present the management of 17 cases of urethral diverticulum in our department. We describe the various clinical presentations of urethral diverticulum, which may mimic other pelvic floor disorders and result in diagnostic delay.

MATERIALS AND METHODS

We reviewed 17 cases of urethral diverticulum presented to the urogynaecology department between January 2006 and February 2011 retrospectively. Patient demographics, history, clinical evaluation, diagnostic modalities, and management plans were reviewed. All of them underwent Magnetic Resonance Imaging (MRI) prior to the procedure.

RESULTS

The mean time from onset of symptoms to diagnosis of a urethral diverticulum was 24 ± 5.6 months. MRI identified the urethral diverticulum in all cases while voiding cystourethrography confirmed the diagnosis in 4 (23.5 %). They have been divided into two groups: Group A, (4-6 mm largest axis range) 5 (29.41 %) cases; Group B, (6-33 mm largest axis range) 12(70.59 %). All in Group A were symptomatic with recurrent Urinary Tract Infection (UTI), whereas only 8 (66.6 %) in Group B were symptomatic. Transvaginal diverticulectomy was done in 12 women who were symptomatic (70.5 %). Postoperative evaluation revealed complete resolution of symptoms, such as recurrent UTI, dysuria, and dyspareunia. One patient was unsure of surgery, while conservative approach was opted for asymptomatic patients 4 (23.5 %). The use of preoperative MRI altered the management in 2 (11.7 %) women.

CONCLUSION

The diagnosis of urethral diverticulum should be considered in women with recurrent UTI, dysuria, dyspareunia, and irritative voiding symptoms not responding to conservative therapy.

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.

Patient Characteristics and Perioperative Outcomes of Female Urethral Diverticulectomy: Analysis of a Multi-Institutional Prospective Database

OBJECTIVE

To assess the patient and perioperative characteristics of urethral diverticulectomy using a large multi-institutional prospectively collected database.

MATERIALS AND METHODS

Female patients were identified using the American College of Surgeons National Surgical Quality Improvement Program participant user files (2007-2012) and current procedural terminology codes for urethral diverticulectomy (53,230). Preoperative variables and 30-day complications were examined.

RESULTS

Urethral diverticulectomies were performed on 122 females during the study period. The cohort was relatively healthy; 80% of patients had an American Society of Anesthesiologists score of 1 or 2. The majority of procedures were performed in an outpatient setting (82%). The median procedure length was 77.5 minutes (interquartile range: 50.5-112.5), and the median length of stay was 0 days (interquartile range: 0-1). The overall 30-day complication rate was 3.3% (n = 4): 3 patients developed urinary tract infections (UTIs) and 1 patient developed both a UTI and a superficial wound infection.

CONCLUSION

To our knowledge, our study represents the largest multi-institutional cohort of patients having undergone urethral diverticulectomy. The patients requiring this intervention were relatively healthy, and the procedure itself was short, allowing most patients to be discharged within 24 hours. The 30-day complication rate was very low, with UTI being the most common complication. Thus, patients can continue to be confidently counseled that urethral diverticulectomy is a safe procedure with very few perioperative complications.