Shlomo Raz1
(1)
Division of Pelvic Medicine and Reconstructive Surgery, UCLA School of Medicine, Los Angeles, CA, USA
Electronic supplementary material
The online version of this chapter (doi:10.1007/978-1-4939-2941-2_4) contains supplementary material, which is available to authorized users.
Keywords
Urethral diverticulaDiagnosisExcision of urethral diverticula
Urethral diverticula result in most cases from inflammatory conditions of the periurethral glands. Most are the result of repeated infection and obstruction of the periurethral glands. Initially, a suburethral cyst is formed by both the inflammatory process of infection and by the pressures created within an obstructed periurethral gland. These cysts subsequently rupture into the urethral lumen. The resulting draining abscess cavity is eventually epithelialized, and thus a urethral diverticulum is formed. Very rarely, they are congenital or traumatic following urethroscopy or urethrotomy. Open surgical procedures such as anterior colporrhaphy or sling procedures surgery may damage the periurethral fascia and create a traction diverticulum.
Diverticula are usually posterior and lateral and are located in the mid or distal third of the urethra. They may be single or multiple, and the urethral communications may be wide or very narrow. Very rarely, urethral diverticula will occur in the anterior urethra or the proximal third. Distal urethral diverticula may originate from an obstructed Skene’s gland draining into the urethral meatus. Circumferential diverticula are not uncommon and their excision requires a delicate and complex reconstruction.
4.1 Surgical Indications and Procedures
Surgery is indicated in patients with significant symptoms related to the presence of the diverticulum. These symptoms include recurrent urinary tract infections, severe pain, dyspareunia, frequency, urgency, and post-voiding dribbling. It is not uncommon to have stress urinary incontinence and urethral hypermobility in conjunction with urethral diverticula.
Surgical options include (1) transurethral incision of the diverticular communication, transforming a narrow mouth into a wide mouth; (2) marsupialization of the diverticular sac into the vagina by incision of the urethrovaginal septum; and (3) excision of the diverticula. In this chapter, we discuss only our technique for surgical excision of large urethral diverticula.
4.2 Diagnosis
On physical examination, the urethra may be tender, and manual compression may lead to the expression of purulent material from the external meatus. A cystic or soft mass of the anterior vaginal wall can be found (Fig. 4.1). The presence of urethral hypermobility and stress incontinence should be documented prior to surgery. The preoperative diagnosis of stress incontinence may warrant a combined operation to correct diverticula and the stress incontinence. In the presence of a large diverticulum, urine is commonly accumulated in the area, making the diagnosis of stress incontinence difficult. We prefer not to perform simultaneous anti-incontinence procedures at the time of removal of a large diverticulum.
Fig. 4.1
(a) Large anterior cystic, tender mass present in a patient with pain and recurrent urinary tract infection resulting from a large, infected urethral diverticulum. (b) Comparison of a cystoscope and a urethroscope. As the arrows show in the cystoscope the optics are located at the end of the scope, and the inflow of fluid is a few centimeters behind the optics. In a urethroscope, the lens in the urethroscope are 15 degress and the inflow of fluid is at the same level as the lens, facilitating direct urethral observation and distension. (c) Cystoscopic view of a small urethral defect communicating with a large urethral diverticulum
Endoscopic evaluation of the urethra should be done routinely to assess the urethral coaptation and the location of the mouth of the diverticulum and to rule out any other pathology (such as tumors or stones) in patients with hematuria. Endoscopy is better done using a urethroscope with a zero-degree lens and a sheath with a very short beak, allowing the entire urethra to be distended for adequate visualization. Constant water flow and bladder neck occlusion at the time of urethroscopy enhance the yield of the test (Fig. 4.2). At the time of endoscopy, the urethra is compressed in order to look for the presence of any active drainage of pus from the mouth of the diverticulum.
Fig. 4.2
Compression of the bladder neck at the time of urethroscopy facilitates urethral distension and direct observation
The post-void film of a CT urogram will often reveal a collection of contrast in the subvesical area (Fig. 4.3). A voiding cystogram in the oblique position is often a reliable diagnostic tool (Fig. 4.4). This study will define the location, size, and number of diverticula. In the past, positive-pressure urethrography using a double-balloon catheter was used in difficult cases (Fig. 4.5). In some cases, direct injection of contrast material into a cystic mass in the anterior vaginal wall can help to better define a diverticular collection (Fig. 4.6). MRI is the gold standard for visualization of urethral diverticula (Figs. 4.7, 4.8, and 4.9). It will define without the use of radiation the location, the contents, the size, and the extension around the urethral mucosa. Ultrasound of the urethra can be a helpful tool to assess the extension and location of diverticula.
Fig. 4.3
Post-void film of a CT urogram shows several collections of contrast at the bladder base, representing multiple urethral diverticula
Fig. 4.4
Large diverticula seen during the voiding phase of a cystogram. A large collection of contrast in the mid- and distal urethra is seen
Fig. 4.5
A double-balloon positive-pressure urethrogram shows midurethral diverticula. This study is now rarely done
Fig. 4.6
Direct injection of contrast in a patient with a mass in the anterior vaginal wall makes it possible to drain and image a large anterior diverticulum
Fig. 4.7
Axial MRI of a patient with posterior urethral diverticula (arrow). The content of the diverticula has a darker fluid level owing to pus and an infected collection. The arrow point to the darker fluid level created by the pus collection
Fig. 4.8
Sagittal midpelvic T2 MRI in a patient with a large urethral diverticulum. The collection extends to the bladder neck and trigone
Fig. 4.9
Axial MRI of the pelvis showing a large, circumferential, urethral diverticulum. In the center of the diverticulum, the urethral sphincteric unit is seen with small residual attachments to the anterior and the posterior wall of the diverticulum
4.3 Surgical Technique
Figures 4.10, 4.11, 4.12, 4.13, 4.14, 4.15, 4.16, 4.17, 4.18, 4.19, 4.20, 4.21, 4.22, 4.23, 4.24, 4.25, 4.26, 4.27, 4.28, and 4.29 show the procedure used for surgical excision of a large urethral diverticulum. After the procedure is completed, a vaginal pack is placed and the Foley catheters are connected to a drainage bag.
Fig. 4.10
Exposure of the anterior vaginal wall in a patient suffering from a diverticulum of the urethra. A large cystic mass is seen. A ring retractor and hooks help in the surgical exposure, and a Foley catheter has been placed
Fig. 4.11
(a) Diagram of the exposure of the anterior vaginal wall. (b) An inverted U incision is made and extended distally to the diverticulum so that normal vaginal tissue will cover the area of the reconstruction when the vaginal wall is closed
Fig. 4.12
An inverted U flap has been prepared, extending proximal to the bladder neck
Fig. 4.13
(a) The anterior vaginal wall flap is reflected posteriorly, exposing the periurethral fascia. Care is taken to avoid any perforation or entry into this fascia. The broken line marks the site of incision of the periurethral fascia. (b) A transverse superficial incision of the periurethral fascia is initiated laterally and is extended to the contralateral side. Care is taken not to enter the wall of the diverticulum at this time. (c) The periurethral fascia has been reflected with one superior and one inferior flap, exposing the wall of the diverticulum
Fig. 4.14
Diagram showing the transverse incision of the periurethral fascia. Dissection of the periurethral fascia will expose the wall of the diverticulum
Fig. 4.15
The periurethral fascia is incised transversely over the area of the diverticulum. This fascia may be found to be very attenuated in patients with large diverticula. Two flaps (superior and inferior) are created by dissection of the periurethral fascia proximally and distally to the incision. The wall of the diverticulum is seen. The arrows point to the upper and lower edges of the incised periurethral fascia
Fig. 4.16
Diagram showing the dissection of the diverticulum from the periurethral fascia and urethral wall
Fig. 4.17
The wall of the diverticulum is opened, and the inner wall of the diverticulum is exposed
Fig. 4.18
After the catheter is removed, diluted indigo carmine is directly injected to reveal the communication of the diverticulum with the urethra
Fig. 4.19
(a) Using sharp dissection, the wall of the diverticular sac is freed from the surrounding structures. The communication to the urethral lumen is isolated and excised flush to the urethral wall. The lumen of the urethra and the indwelling catheter must be seen. In cases of severe inflammatory reaction, the sac may be very thin, adherent, and friable, requiring first the opening of the diverticulum and then the excision of the sac. It is important that all of the diverticular sac and the urethral communication be completely excised and that the urethral mucosa and the indwelling catheter are seen. (b) In cases of extensive or circumferential diverticula, it is best to divide the diverticulum in two, with each half dissected from the lateral and posterior wall to the urethra in order to remove the whole sac. A right-angle clamp is seen behind the urethral wall after excision of a circumferential diverticulum
Fig. 4.20
(a) After excision of the wall of the diverticulum, the urethral communication and the Foley catheter are seen. (b) Diagram of the exposed urethral wall after excision of the diverticulum. The indwelling catheter is in place
Fig. 4.21
(a) Diagram of the growth of a urethral diverticulum between the two layers (endopelvic and periurethral) of the urethropelvic fascia. (b) Opening the periurethral fascia exposes the wall of the diverticulum. (c) After excision of the urethral diverticulum, a defect of the urethral wall is seen. This defect will be closed with two layers of delayed absorbable sutures. (d) The wall of the urethra has been closed. Sutures will approximate the endopelvic and periurethral walls in order to seal completely the defect created by the removal of the diverticulum. All dead space is sealed in order to prevent urinary leakage and possible recurrence
Fig. 4.22
The urethral wall has been closed with running and interrupted #4-0 delayed absorbable sutures in a vertical direction. The closure should be watertight and tension-free. A Foley catheter (14 Fr) is commonly used
Fig. 4.23
(a) The superior and inferior edges of the incised periurethral fascia are exposed. (b) Diagram of the closure of the periurethral fascia. No dead space should be left in the periurethral area after the removal of the sac
Fig. 4.24
Figure-of-eight delayed absorbable sutures incorporate the superior edge of the periurethral and endopelvic fasciae and the inferior edge of the endopelvic fascia. In cases of circumferential diverticula, a separate layer of closure is used. The figure-of-eight sutures will incorporate the endopelvic fascia posterior and lateral to the diverticulum so all the dead space is sealed, reducing the chances of leakage of urine and recurrence
Fig. 4.25
The complete placement of the periurethral fascia sutures is seen. The sutures will include the urethral wall in the middle. With each application of the sutures, the catheter is moved back and forth to ensure that it is not included in the suture line
Fig. 4.26
The transverse closure of the periurethral fascia has been completed
Fig. 4.27
Diagram of the advancement of the anterior vaginal flap covering distal to the area of the transverse closure of the periurethral fascia
Fig. 4.28
The advancement of the vaginal flap has been completed, covering the area of the reconstruction
Fig. 4.29
Diagram of the three lines of sutures used in the procedure: vertical closure of the urethral wall, horizontal closure of the periurethral fascia, and the advancement of new vaginal tissue covering the area of reconstruction
4.4 Postoperative Care
The procedure is usually done as an outpatient surgery. Oral antibiotics are continued as indicated. The packing is removed 2 h after surgery. The patient may be discharged home after recovery from anesthesia. The urethral catheter is removed 2–3 weeks after surgery, and a voiding cystogram is performed through the suprapubic catheter. If the result is normal, the suprapubic catheter is removed.
4.5 Intraoperative Complications
Bleeding in the form of profuse oozing is not uncommon, particularly in patients with active infection and abscess formation. A vaginal packing should control this oozing.
Difficulty in closing the urethral mucosa because a large defect was created during the excision of the diverticulum may require further exposure of the urethral wall, with the closure performed over a 5–8-Fr feeding tube. We have not encountered urethral strictures following this procedure. An end-to-end anastomosis of the proximal urethral wall to the distal wall is rarely necessary.
If closure is difficult because of severely inflamed or poor-quality tissue, a fibro-fatty labial (Martius) flap can be used between the periurethral fascia and the vaginal wall. In this situation, a suprapubic catheter should be placed.
The finding of a large periurethral abscess may require a staged procedure in which the abscess is drained and the excision of the diverticulum is performed as a secondary procedure.
A large proximal urethral diverticulum may extend into the trigone, and bladder or ureteric injury may occur. Instillation of indigo carmine into the bladder will ensure bladder integrity, and cystoscopy after intravenous indigo carmine may be performed in selected cases to rule out ureteric injury.
4.6 Postoperative Complications
Proper antibiotic therapy before surgery is mandatory. Reconstructive surgery in patients with active urinary and diverticular infection may lead to fistula formation and recurrent diverticula.
Important factors in operative success and avoidance of fistula formation include a watertight closure, precise dissection, and anatomical closure of the urethral layers, avoiding overlapping lines of suture. Urethrovaginal fistula formation is the most difficult complication of diverticula surgery and should be treated after a reasonable period of healing.
Anterior vaginal infection is rare and responds well to antibiotics. If an abscess is formed, surgical drainage is required in spite of the potential damage to the repair.
Recurrent urethral diverticula may occur, especially in patients with active urethral infection, difficult dissection, tension of the suture lines, or postoperative difficulties with catheter drainage. Secondary surgery should be performed after a prudent period of observation.
Stress incontinence before surgery should be well documented and could be corrected (in selected cases) at the time of diverticula excision. Secondary stress urinary incontinence not present prior to surgery is rare, developing as a result of the dissection of the urethral structures. Severe incontinence due to a nonfunctional sphincter may arise after extensive dissection of the urethral wall. Surgery for this condition may require an autologous fascial sling.
Suggested Reading
Davis HJ, TeLinde RW. Urethral diverticula: an assay of 121 cases. J Urol. 1958;80:34–9.PubMed
Eilber KS, Raz S. Benign cystic lesions of the vagina: a literature review. J Urol. 2003;170(3):717–22.CrossRefPubMed
Ganabathi K, Leach GE, Zimmern PE, Dmochowski R. Experience with the management of urethral diverticulum in 63 women. J Urol. 1994;152(5 Pt 1):1445–52.PubMed
Lee RA. Diverticulum of the urethra: clinical presentation, diagnosis, and management. Clin Obstet Gynecol. 1984;27(2):490–8.CrossRefPubMed
Nickles SW, Ikwuezunma G, MacLachlan L, El-Zawahry A, Rames R, Rovner E. Simple vs complex urethral diverticulum: presentation and outcomes. Urology. 2014;84(6):1516–20.CrossRefPubMed
Reeves FA, Inman RD, Chapple CR. Management of symptomatic urethral diverticula in women: a single-centre experience. Eur Urol. 2014;66:164–72.CrossRefPubMed