Excision of urethral diverticulum remains an uncommon surgery, at least in part because of failure to make a diagnosis. The classical triad of dysuria, dyspareunia and dribbling of urine, is found in a minority of women. A high index of suspicion and careful examination of the anterior vaginal wall in women with unexplained urinary symptoms remains the key to making a diagnosis. High resolution MR imaging is the best for ascertaining anatomical detailsand relationship with the urethra. Preoperative treatment of infection and resolution of inflammation is important.
Symptomatic urethral diverticula need surgical management. While marsupialization or internal urethrotomy may be appropriate in select situations, a vast majority of patients need surgical excision. Preoperative counseling must include a discussion regarding the possibilities of recurrence, stress incontinence, urethro-vaginal fistula and urinary infection.
Under spinal anesthesia, in the lithotomy position, a U-shaped vaginal flap is elevated. If the mucosa overlying the diverticulum is very unhealthy, an ellipse is excised. We do not routinely inject saline. Dissection proceeds on the shiny layer underlying the mucosa to allow flap mobilization sufficient for subsequent closure.
Underlying the vaginal mucosa is the peri-urethral fascia that covers the diverticulum. Careful preservation of this well-defined tissue is of critical importance in obtaining a sound closure [Figure 1]. The fascia is opened transversely using sharp dissection. All tissue superficial to the diverticulum is lifted up along with the fascial flaps allowing for thick, well-vascularized flap development.
Figure 1: Careful dissection and preservation of periurethral fascia is a key step
The diverticulum is dissected up to its connection with the urethra using gentle traction on the diverticular wall. The diverticulum is opened and it's interior is carefully inspected to define the communication with the urethra and see for any associated abnormality. The diverticular wall is carefully excised back to the urethra.
Closure is performed using continuous fine 4-0 absorbable polyglactin sutures over a catheter usually vertically. The periurethral fascia is then closed horizontally over the urethra minimizing dead space. In case the tissues are tenuous, one may interpose a labial fat pad between the vaginal wall and the periurethral fascia. The vagina is closed using 3-0 polyglactin and an overnight pack is placed. The catheter is left for 3 weeks. Postoperative dye studies are reserved for complex reconstructions.
This lady had an uneventful recovery with complete resolution of symptoms. Two years following the repair she conceived and delivered by an electiveCaesarian section done for obstetric indications. At 30months, she continues to do well.
This technique has been used by the authors in six women aged 24 to 57 (mean 35) years with urethral diverticula since 2006. None of these patients developed a fistula, incontinence or recurrence at a mean follow up of 34 (8-80) months. The average operating time was 96 ± 22 (60-150) minutes. A labial fat pad was interposed in one woman with a large multiloculated diverticulum in whom the closure was deemed insecure. The technique of excision of diverticulum with careful preservation of the periurethral fascia followed by non-overlapping layered closure is a reliable method of managing urethral diverticula in women.