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Schaaf AL, Lee YS, Myers AA, Schommer J, Gonzalez G, Chen A, Petrou S. Complex Urethral Diverticulectomy: Is a Synchronous Prophylactic Autologous Fascial Sling Needed? UROGYNECOLOGY (PHILADELPHIA, PA.) 2023; 29:330-335. [PMID: 37235804 DOI: 10.1097/spv.0000000000001311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
IMPORTANCE Urethral diverticulectomy is performed with or without concomitant pubovaginal sling (PVS). Patients with complex UD are more frequently offered concomitant PVS. However, there is paucity of literature comparing postoperative incontinence rates for patients with simple versus complex UD. OBJECTIVE The objective of this study is to examine postoperative stress urinary incontinence (SUI) rates after Urethral Diverticulectomy without concomitant PVS for both complex and simple cases. STUDY DESIGN A retrospective cohort study was conducted among 55 patients who underwent Urethral Diverticulectomy from 2007 to 2021. Preoperative SUI was patient-reported and confirmed with cough stress test result. Complex cases were defined as circumferential or horseshoe configurations, prior diverticulectomy, and/or anti-incontinence procedure. Primary outcome was postoperative SUI. Secondary outcome was interval PVS. Complex and simple cases were compared using the Fisher exact test. RESULTS Median age was 49 years (interquartile range, 36-58 years). Median follow-up was 5.4 months (IQR, 2-24 months). Thirty of 55 (55%) cases were simple, and 25 of 55 (45%) complex. Preoperative SUI was present in 19/57 (35%) (11 complex vs 8 simple, P = 0.25). Stress urinary incontinence persisted postoperatively in 10 of 19 (52%) (6 complex vs 4 simple, P = 0.48). De novo SUI occurred in 7 of 55, 12% (4 complex vs 3 simple, P = 0.68). Overall, 17 of 55 (31%) patients had postoperative SUI (10 complex vs 7 simple, P = 0.24). Of those, 8 of 17 underwent subsequent PVS placement (P = 0.71) and 9 of 17 had resolution of pad use after physical therapy (P = 0.27). CONCLUSIONS We did not find evidence of an association between complexity and postoperative SUI. Age at surgery and preoperative frequency were the strongest predictors of postoperative SUI in this cohort. Our findings suggest successful complex urethral diverticulum repair does not require concomitant PVS.
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Affiliation(s)
| | | | | | | | | | - Anita Chen
- Department of Gynecology, Mayo Clinic, Jacksonville, FL
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Mauler D, Khan A, Wolter C. Contemporary Characterization of Urethral Diverticulum. CURRENT BLADDER DYSFUNCTION REPORTS 2022. [DOI: 10.1007/s11884-021-00639-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Chavez JA, Fuentes JL, Christie AL, Alhalabi F, Carmel ME, Lemack GE, Zimmern PE. Stress Urinary Incontinence After Urethral Diverticulum Repair Without Concomitant Anti-Incontinence Procedure. Urology 2021; 154:103-108. [PMID: 33852920 DOI: 10.1016/j.urology.2021.03.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/28/2021] [Accepted: 03/29/2021] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Jacqueline A Chavez
- Department of Urology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9110
| | - Jorge L Fuentes
- Department of Urology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9110
| | - Alana L Christie
- Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, 6000 Harry Hines Blvd, Dallas, TX 75390-8852
| | - Feras Alhalabi
- Department of Urology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9110
| | - Maude E Carmel
- Department of Urology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9110
| | - Gary E Lemack
- Department of Urology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9110
| | - Philippe E Zimmern
- Department of Urology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390-9110.
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Osman NI, Mangir N, Reeves FA, Franco A, Ricci E, Inman R, Chapple CR. The Modified Prone Jack-knife Position for the Excision of Female Urethral Diverticula. Eur Urol 2020; 79:290-297. [PMID: 33279306 DOI: 10.1016/j.eururo.2020.11.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 11/10/2020] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Nadir I Osman
- Department of Urology, Royal Hallamshire Hospital, Sheffield, UK.
| | - Naside Mangir
- Department of Urology, Hacettepe University School of Medicine, Sıhhiye, Ankara, Turkey
| | - Felicity A Reeves
- Functional, Female and Restorative urology (Fellow), University College Hospital, London, UK
| | | | - Ester Ricci
- Department of Maternal, Infantile and Urological Sciences, University of Naples Frederico II, Naples, Italy
| | - Richard Inman
- Department of Urology, Royal Hallamshire Hospital, Sheffield, UK
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Dykes N, Dwyer P, Rosamilia A, Zilberlicht A. Video and review of the surgical management of recurrent urethral diverticulum. Int Urogynecol J 2020; 31:2679-2681. [DOI: 10.1007/s00192-020-04357-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 05/20/2020] [Indexed: 10/24/2022]
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Mukhtar BMB, Solomon E, Naaseri S, Aughwane P, Pakzad M, Hamid R, Ockrim JL, Greenwell TJ. Urethral diverticula in women are associated with increased urethra‐sphincter complex volumes: A potential role for high‐tone nonrelaxing sphincter in their etiology? Neurourol Urodyn 2019; 38:1859-1865. [DOI: 10.1002/nau.24080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 05/29/2019] [Indexed: 11/07/2022]
Affiliation(s)
| | - Eskinder Solomon
- Evelina London Children's HospitalSt. Thomas’ Hospital London UK
| | - Sahar Naaseri
- Department of RadiologyUCLH at Westmoreland Street London UK
| | - Paul Aughwane
- Department of RadiologyUCLH at Westmoreland Street London UK
| | - Mahreen Pakzad
- Department of UrologyUCLH at Westmoreland Street London UK
| | - Rizwan Hamid
- Department of UrologyUCLH at Westmoreland Street London UK
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Barratt R, Malde S, Pakzad M, Hamid R, Ockrim J, Greenwell T. The incidence and outcomes of urodynamic stress urinary incontinence in female patients with urethral diverticulum. Neurourol Urodyn 2019; 38:1889-1900. [DOI: 10.1002/nau.24090] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 05/27/2019] [Indexed: 11/11/2022]
Affiliation(s)
| | - Sachin Malde
- Department of UrologyGuys and St Thomas’ NHS Foundation Trust London UK
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Seth JH, Naaseri S, Solomon E, Pakzad M, Hamid R, Ockrim J, Greenwell TJ. Correlation of MRI features of urethral diverticulum and pre- and post-operative stress urinary incontinence. Neurourol Urodyn 2018; 38:180-186. [DOI: 10.1002/nau.23820] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 08/11/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Jai H. Seth
- Department of Urology; University College London Hospitals NHS Foundation Trust at Westmoreland Street; Marylebone London
| | - Sahar Naaseri
- Department of Urology; University College London Hospitals NHS Foundation Trust at Westmoreland Street; Marylebone London
| | - Eskinder Solomon
- Department of Urology; University College London Hospitals NHS Foundation Trust at Westmoreland Street; Marylebone London
| | - Mahreen Pakzad
- Department of Urology; University College London Hospitals NHS Foundation Trust at Westmoreland Street; Marylebone London
| | - Rizwan Hamid
- Department of Urology; University College London Hospitals NHS Foundation Trust at Westmoreland Street; Marylebone London
| | - Jeremy Ockrim
- Department of Urology; University College London Hospitals NHS Foundation Trust at Westmoreland Street; Marylebone London
| | - Tamsin J. Greenwell
- Department of Urology; University College London Hospitals NHS Foundation Trust at Westmoreland Street; Marylebone London
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Aldamanhori R, Inman R. The treatment of complex female urethral pathology. Asian J Urol 2018; 5:160-163. [PMID: 29988837 PMCID: PMC6032816 DOI: 10.1016/j.ajur.2018.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 05/19/2017] [Accepted: 06/03/2017] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Reem Aldamanhori
- Department of Urology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Richard Inman
- Department of Urology, Royal Hallamshire Hospital, Sheffield, UK
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Malde S, Naaseri S, Kavia R, Pakzad M, Hamid R, Ockrim J, Greenwell TJ. Preliminary report on the effect of urethral diverticulum magnetic resonance imaging configuration on the incidence of new onset urodynamic stress urinary incontinence following excision. Urol Ann 2017; 9:321-323. [PMID: 29118531 PMCID: PMC5656954 DOI: 10.4103/ua.ua_13_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Sachin Malde
- Department of Urology, University College Hospital, London, UK
| | - Sahar Naaseri
- Department of Urology, University College Hospital, London, UK
| | - Rajesh Kavia
- Department of Urology, University College Hospital, London, UK
| | - Mahreen Pakzad
- Department of Urology, University College Hospital, London, UK
| | - Rizwan Hamid
- Department of Urology, University College Hospital, London, UK
| | - Jeremy Ockrim
- Department of Urology, University College Hospital, London, UK
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Ko KJ, Suh YS, Kim TH, Lee HS, Cho WJ, Han DH, Lee KS. Surgical Outcomes of Primary and Recurrent Female Urethral Diverticula. Urology 2017; 105:181-185. [PMID: 28283414 DOI: 10.1016/j.urology.2017.02.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 02/26/2017] [Accepted: 02/28/2017] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Kwang Jin Ko
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yoon Seok Suh
- Department of Urology, Center for Prostate Cancer, Research Institute and Hospital of the National Cancer Center, Goyang, Republic of Korea
| | - Tae Heon Kim
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyo Serk Lee
- Department of Urology, Cheil General Hospital and Women's Healthcare Center, Dankook University College of Medicine, Seoul, Republic of Korea
| | - Won Jin Cho
- Department of Urology, Chosun University Hospital, Chosun University School of Medicine, Gwangju, Republic of Korea
| | - Deok Hyun Han
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyu-Sung Lee
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Department of Medical Device Management & Research, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea.
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