Transurethral incision of urethral diverticulum in the female

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.

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%.

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.

Usefulness of diagnosis by the urethroscopy under anesthesia and effect of transurethral electrocoagulation in symptomatic female urethral diverticula

OBJECTIVE

We report accurate diagnosis and simple treatment of female urethral diverticula.

PATIENTS AND METHODS

When routine urologic evaluation suggested a urethral diverticulum, urethroscopy was performed with the patient under anesthesia with palpation by an intravaginal finger and transurethral catheterization to seek the orifice of the lesion. When a diverticulum was detected, transurethral electrocoagulation was performed regardless of the lesion size.

RESULTS

Urethral diverticula were detected in 18 of 30 women examined (60%), with the maximum size being that of the tip of the little finger (about 10 mm in diameter). Transurethral electrocoagulation was performed. The postoperative course was uneventful in all patients, who were discharged from the hospital a day after surgery.

CONCLUSIONS

Careful urethroscopy under anesthesia is a useful diagnostic tool, and transurethral electrocoagulation may be one of the best first choices of treatment for female urethral diverticula.

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.