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294 Challenging Concepts in Urological Surgery
https://t.me/med1917
The main risk of urethral diverticulum excision is de novo or worsening SUI in 10– 30%. The risk
of SUI is higher with larger and more extensive horseshoe diverticula and repeat surgery. The SUI
improves and can be managed in the majority of patients with conservative measures. Due to
the complexity of this lady’s recurrent diverticulum including the horseshoe configuration with
dorsal extension around the urethra, and the urethrolysis required to deal with the obstructive
rectus fascia sling, the patient was advised her risk of significant postoperative SUI was 20– 30%.
Expert comment
Concomitant anti- incontinence
procedures
We do not perform concomitant
anti- incontinence procedures at
the time of urethral diverticulum
surgery, as the majority do not
require further intervention, and
the placement of a fascial sling or
colposuspension sutures around
a fragile (healing) urethra has
potential risk. The morbidity of
Martius fat pad harvest is low.
In our series of >130 patients,
significant clinical issues with labial
dissymmetry or discomfort were
much less than 5%.
She was told that she had a 10– 15% risk of eventually requiring further salvage surgery for SUI at
12 months.
The patient was informed that at our institution a Martius labial fat pad interposition is performed in the majority of urethral diverticula excisions to cover the urethral
reconstruction and fill the defect. The risk of labial infection/ abscess is <2%. Martius
harvest can cause labial dissymmetry and discomfort. However, 80% of women find
the cosmesis excellent or very good and <1% unsatisfactory. Labial discomfort generally settles with gentle massage of the wound, with persistence in <5%.
patient was given the British Association of Urological Surgeons patient information
sheets on excision of urethral diverticulum to complement the information provided
in her clinic letter.
The patient opted for surgical excision of the recurrent urethral diverticulum,
urethrolysis, and Martius fat pad interposition.
In experienced hands, nearly all diverticula can be accessed and excised from a ventral approach
through the anterior vaginal wall. Even those with circumferential configuration can be accessed from
this incision, mobilizing the urethra as required, without the necessity for a dorsal approach to drop
the urethra.
● The procedure is performed with the patient in steep lithotomy.
● A preliminary cystourethroscopy is performed to assess the urethra and bladder, which were
unremarkable. Urethral diverticular os are not often identified and was not seen in this case.
A CH16 urethral catheter was inserted.
● The anterior vaginal wall was infiltrated with 10 mL of 0.5% Xylocaine® with 1 in 200,000 adrenaline.
A midline anterior vaginal wall incision was made, centred over the urethral diverticulum, and
dissection of the periurethral tissue from the vaginal aspect of the diverticulum was performed.
A large near- circumferential dorsal diverticulum was identified (Figure 30.2a).
● The plane between the urethra and the inner aspect of the diverticulum was then developed and
the horseshoe diverticulum was completely dissected from dorsum to ventrum and excised in two
halves (Figure 30.2b).
● The 5 o’clock opening into urethra was closed with a 5/ 0 Vicryl® in two layers (Figure 30.2c) and
this was leak tested with Instillagel™ injected into the urethra using a 10 mL syringe attached to a
20- gauge Venflon™.
● A Martius labial fat pad was harvested on its inferolateral pedicle with the superior pedicle ligated.
The Martius fat pad was tunnelled into the vaginal defect and secured around the urethra with 6 ×
4/ 0 Vicryl® (Figure 30.3a,b).
● The fat pad donor site was closed in layers with 3/ 0 Vicryl® over a minivac drain. The vagina was
closed with 3/ 0 Vicryl® (Figure 30.3c) and a Hibitane™- soaked vaginal pack was used to give vaginal
compression for 48 hours.
● The procedure is covered by enoxaparin and three doses of perioperative antibiotics.
● The vaginal pack and labial drain were removed at 48 hours and the patient was discharged once
comfortable on oral analgesia.
● A pericatheter urethrogram was organized 3 to 4 weeks postoperatively to ensure the urethra had
healed and the catheter was removed.
17
Clinical tip Surgical technique
18,19
The
Figure 30.2 Exposure, dissection, and excision of the urethral diverticulum. (a) A large near- circumferential
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dorsal diverticulum. (b) Horseshoe diverticulum bivalved. The urethral opening (os) can be seen at 7 o’clock.
(c) The 5 o’clock opening into urethra was closed with a 5/ 0 Vicryl® in two layers.
Figure 30.3 Martius labial fat pad interposition. (a) Martius labial fat pad was harvested on its
inferolateral pedicle with the superior pedicle ligated and tunnelled into the vaginal defect. (b) Martius
fat pad interposition and secured around the urethra with 6 × 4/ 0 Vicryl®. (c) Final appearance.
Expert comment Surgical excision and reconstruction
In the majority of cases, the dissection to remove the diverticulum leaves a urethral defect
(differentiating a diverticulum from a paraurethral cyst), which can be primary repaired using finegauge Vicryl®. We test this repair to ensure that it is ‘watertight’ using Instillagel™ to retrograde fill the
urethra using a CH20 Venflon™.
We are enthusiasts for the use of Martius fat pad interposition for much of our vaginal surgery
including vesicovaginal fistulae and urethral diverticula. The fat pad is easy to harvest and interpose
between the urethral repair and the vagina closure. The use of the Martius fat pad has reduced our
failure (fistula) rate to <1%. In addition, the preservation of a distinct plane between the urethra and
vagina allows much simpler access for salvage (incontinence) surgery. We have been able to salvage
>90% of stress incontinent (10– 20% of complex) patients with autologous slings or rarely an artificial
urinary sphincter.
At 3 months, the patient was voiding well, and her preoperative vaginal pain had
completely settled. She did complain of mild SUI (one pad). She was referred for
pelvic floor exercises and her SUI improved over the next 9 months. At 12 months she
was infection free, dry, and sexually active. She was delighted with the resolution of
her symptoms.
295Case 30 Urethral diverticulum
Evidence base Management
of urethral diverticulum
Between 1805 and 1954, only
17 cases of urethral diverticulum
in women were described in
the medical literature. Davis and
Telinde published the defining
series of 121 cases of urethral
diverticula in 1958. Since that time,
the literature and knowledge of this
rare but important condition has
blossomed. We would recommend
recent reviews by O’Connor
et al. (2018),20 Bodner- Adler
et al. (2016),21 and Crescenze and
Goldman (2015).
Future directions Surgical
options
About 150 new cases of urethral
diverticula are diagnosed in the
UK each year (Hospital Episode
Statistics data 2016– 2017). Further
analysis is required to define
which patients could be safely
managed by excision and urethral
reconstruction alone, and which
patients would be best served
by concomitant Martius fat pad
interposition. It seems sensible that
patients with a higher risk of SUI
and thus secondary intervention
would have Martius fat pads placed
Expert comment
Centralization of complex
urethral diverticula
Most urethral diverticula are
treated by surgeons (urologists and
urogynaecologists) with limited
experience of this delicate and
often challenging surgery. There is
general acceptance that rare and
complex conditions should be
centralized in expert centres and
specialist commissioning is now
developing along these lines.
22
296 Challenging Concepts in Urological Surgery
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A final word from the expert
Urethral diverticula are a rare diagnosis but cause substantive morbidity and distress. Many
patients suffer debilitating lower urinary tract symptoms and pain for years before the diagnosis
is thought of and diagnosed.
In expert hands, surgical excision and urethral reconstruction is successful in well over 90%
of cases, with alleviation of the distressful symptom complex that this condition causes. The
main risk of stress incontinence can be marginalized by the judicious use of the Martius fat pad
interposition and subsequent salvage anti- incontinence procedures.
In the era in which the complications of interventions for SUI are becoming more apparent,
long- term BOO from bulking agents, mesh tapes, and slings may be shown to be a significant
contributory factor in the aetiology and development of urethral diverticula.
The centralization of complex female urology and concentration of surgical experience in
specialist centres will lead to greater understanding and better functional outcomes for women
with urethral diverticula.
References
1. Andersen MJ. The incidence of diverticula in the female urethra. J Urol. 1967;98(1):96– 98.
2. El- Nasher SA, Bacon MM, Kim- Fine S, Weaver AL, Gebhart JB, Klingele CJ. Incidence
of female urethral diverticulum: a population- based analysis and literature review. Int
Urogynecol J. 2014;25(1):73– 79.
3. Ockrim JL, Allen DJ, Shah PJ, Greenwell TJ. A tertiary experience of urethral diverticulectomy: diagnosis, imaging and surgical outcomes. BJU Int.
2009;103(11):1550– 1554.
4. Hey W. Collection of pus in the vagina. In: Practical Observations in Surgery. Philadelphia,
PA: James Humphreys; 1805:303– 305.
5. Davis HJ, Telinde RW. Urethral diverticula: an assay of 121 cases. J Urol. 1958;80(1):34– 39.
6. Tsivian M, Tsivian A, Schreiber L, Sidi AA, Koren R. Female urethral diverticulum: a pathological insight. Int Urogynecol J Pelvic Floor Dysfunct. 2009;20(8):957– 960.
7. Routh A. Urethral diverticulum. Br Med J. 1890;8:360– 365.
8. Cocco AE, MacLennan GT. Unusual female suburethral mass lesions. J Urol.
2005;174(3):1106.
9. Clemens JQ, Bushman W. Urethral diverticulum following collagen injection. J Urol.
2001;166(2):626.
10. Kumar D, Kaufman MR, Dmochowski RR. Case reports: periurethral bulking agents and
presumed urethral diverticula. Int Urogynecol J. 2011;22(8):1039– 1043.
11. Athanasopoulos A, McGuire EJ. Urethral diverticulum: a new complication associated with
tension- free vaginal tape. Urol Int. 2008;81(4):480– 482.
12. Hammad FT. TVT can also cause urethral diverticulum. Int Urogynecol J Pelvic Floor
Dysfunct. 2007;18(4):467– 469.
13. Greenwell TJ, Spilotros M. Urethral diverticula in women. Nat Rev Urol.
2015;12(12):671– 680.
14. Solomon E, Yasmin H, Duffy M, Malde S, Ockrim J, Greenwell T. Concordance
of urodynamic definitions of female bladder outlet obstruction. Eur Urol Suppl.
2017;16(3):e1965– e1966.
15. Spence HM, Duckett JW Jr. Diverticulum of the female urethra: clinical aspects and presentation of a simple operative technique for cure. J Urol. 1970;104(3):432– 437.
16. Malde S, Sihra N, Naaser S, et al. Urethral diverticulectomy with Martius labial fat
https://t.me/med1917
pad interposition improved symptom resolution and reduces recurrence. BJU Int.
2017;119(1):158– 163.
17. Malde S, Naaseri S, Kavia R, et al. 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(4):321– 324.
18. Malde S, Pakzad M, Spilotros M, et al. The uses and outcomes of the Martius fat pad in
urology. World J Urol. 2017;35(3):473– 478.
19. Wilson A, Pillay S, Greenwell TJ. How and why to take a Martius labial interpositional flap
in female urology. TAU 2017;6 (Supp 2):S81– S87.
20. O’Connor E, Iatropoulou D, Hashimoto S, Takahashi S, Ho DH, Greenwell T. Urethral diverticulum carcinoma in females— a case series and review of the English and Japanese literature. Transl Androl Urol. 2018;7(4):703– 729.
21. Bodner- Adler B, Halpern K, Hanzal E. Surgical management of urethral diverticula in
women: a systematic review. Int Urogynecol J. 2016;27(7):993– 1001.
22. Crescenze IM, Goldman HB. Female urethral diverticulum: current diagnosis and management. Curr Urol Rep. 2015;16(10):71.
297Case 30 Urethral diverticulum
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31
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CASE
Management of
ketamine- induced bilateral
upper urinary tract injury
Ishtiakul G. Rizvi
Expert commentary Mohammed Belal
Case history
A 25- year- old male was admitted with signs of sepsis and acute kidney injury (AKI)
on 26 October 2015. His vital signs were stable with one spike of temperature (38°C)
on admission.
His blood parameters were reported as creatinine 517 μmol/ L, estimated glomerular
filtration rate (eGFR) 12 mL/ min/ 1.73 m2, C- reactive protein 298 mg/ L, white blood
cell count 15.5 × 109/ L, and normal coagulation profile; however, an ultrasound scan
(USS) of the urinary tract showed bilateral hydronephrosis. He underwent emergency
bilateral nephrostomy insertion under general anaesthesia (GA) by the interventional
radiology team because he was unable to tolerate the procedure under local anaesthesia or sedation.
His past medical history included mental behaviour disorder, ketamine- induced
cystitis, and he is a known case of a chronic ketamine abuser. He has allergies to latex,
tramadol, dust, and talcum powder and he is also known for having a very low pain
threshold.
He underwent multiple endoscopic and percutaneous urological interventions
including a complex reconstructive urological procedure (clam ileocystoplasty and
Mitrofanoff procedure on 23 January 2015) due to ketamine- induced lower urinary
tract injury.
Learning point Ketamine
Ketamine is an N- methyl- D- aspartate antagonist. It is metabolized in the liver to become an active
form – norketamine, that is excreted in the urinary system. It has been used as an anaesthetic and
analgesic agent since the 1960s.1 It is also considered as a treatment option for major depression,2
treatment- resistant depression,3 bipolar affective disorder,4 and pain. It has strong psychostimulant
properties and its usage as a recreational drug was first reported in the 1970s.5 Nowadays, ketamine
is a common recreational street drug and its usage increased from 0.8% (in 2007– 2008) to 2.1%
(in 2010– 2011) among young people in the UK aged between 16 and 24 years.
6
The patient was initially referred in June 2009 for severe storage lower urinary
tract symptoms with a history of chronic ketamine abuse. However, his renal function was normal and imaging showed no evidence of obstructive uropathy. Rigid
300 Challenging Concepts in Urological Surgery
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cystoscopy under GA revealed inflamed bladder mucosa, ulceration, and bleeding
on contact and bladder biopsy reported active inflammation. These findings were
discussed with him in detail and he was offered bladder instillation therapy for
symptom management.
He was strongly advised to stop using ketamine and was warned that progression
of the disease would cause further bothersome urinary symptoms unless he stopped
using ketamine. The potential consideration of bladder removal in case of failed medical management was mentioned. The patient refused to accept any forms of management (including medical management or bladder instillation) and was discharged
back to community care.
In April 2013, the patient was re- referred to urology for the investigation of haematuria. A computed tomography scan revealed left hydronephrosis; his renal function
was normal (eGFR >90 mL/ min/ 1.73 m2). However, a mercaptoacetyltriglycine
(MAG3) renogram (May 2013) reported poor drainage of the left kidney and video
urodynamics (July 2013) showed a small- capacity bladder, loss of compliance, with
evidence of detrusor overactivity. Rigid cystoscopy with retrograde study (September
2013) demonstrated a small bladder capacity of 100 mL, petechial haemorrhage, and
left hydronephrosis with left hydroureter. All of these findings were discussed in the
local functional urology multidisciplinary team meeting.
The patient refused to accept simple cystectomy and urinary diversion with ileal
conduit and its associated adverse effects on fertility and erectile function. Therefore,
a clam ileocystoplasty with a Mitrofanoff was offered. Furthermore, he also declined
to perform urethral self- catheterization but agreed to do self- catheterization via a
Mitrofanoff. He was also strongly advised regarding stoppage or abstinence of ketamine for at least 6 months prior to the surgical intervention.
Expert comment Surveillance and compliance
The importance of regular surveillance from 2009 onwards could have been helpful in monitoring
disease progression, avoid potential complication and making decision of early intervention. Therefore
regular surveillance either by general practitioner or primary team, early social support, education
about fatal consequence of ketamine abuse and take measures to abstinence from ketamine abuse
are essential. It will be helpful not only to abstinence from ketamine abuse but also helpful to avoid
disease progression and/ or its serious consequences. However, compliance of the patient is an
important issue.
Learning point Ketamine abuse
Ketamine abuse leads to serious urological conditions and the most common presentation is
ketamine- associated ulcerative cystitis (severe lower urinary tract symptoms with dysuria, frequency,
urgency, and haematuria).7 However, a limited number of cases have been reported previously
in the published literature regarding ketamine’s effects throughout the urinary tract or upper tract
involvement. Nevertheless, it is a complex and increasingly prevalent challenging clinical condition.
The management of ketamine induced upper tract injury requires a holistic and multidisciplinary
approach.
The patient developed AKI and sepsis in July 2014 prior to the planned surgical
procedure (clam ileocystoplasty and Mitrofanoff) and imaging revealed worsening
left hydronephrosis. His MAG3 renogram showed an obstructed left kidney and poor
drainage of the right kidney. Therefore, he underwent emergency bilateral nephrostomy
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tube insertion under GA for the drainage of both kidneys.
Expert comment Monitoring of the abstinence of ketamine usage
Aggressive holistic management (including involvement of the general practitioner, the community
nurse, psychiatric team and social support) is necessary for the regular monitoring of the abstinence
of ketamine usage. It is also essential to educate the patient about the consequence of continuous
ketamine abuse. It will be helpful not only to reduce the incidence of admission with deteriorating
urinary symptoms or renal function and improvement of the patient’s compliance but also to proceed
on the further medical and surgical intervention within the expected time.
The patient underwent clam ileocystoplasty with ileal chimney and Mitrofanoff
formation and bilateral ureteric reimplantation in January 2015 following abstinence
of ketamine usage for >6 months while maintaining his bilateral nephrostomy tubes
in situ. His bilateral nephrostogram in February 2015 reported no obvious obstruction
on the left side but slow flow of contrast on the right side. He was discharged with
bilateral nephrostomy tubes in situ but clamped for observation.
Clinical tip Ileal chimney
In this particular case, an ileal chimney was made along with the clam ileocystoplasty procedure
in anticipation of future reconstructive procedures (if disease progressed to the upper urinary tract
or renal pelvis), such as formation of ileal conduit. It is important and necessary to plan ahead about
further or future reconstructive procedure in advance because sometimes patient require multiple
surgical interventions when there is an evidence of disease progression or no improvement or
worsening of symptoms. Therefore the necessity of thinking ahead in reconstructive functional urology
procedure is essential.
301Case 31 Management of ketamine-induced bilateral upper urinary tract injury
The patient failed to perform self- catheterization via his Mitrofanoff due to stenosis
of the Mitrofanoff channel within a few weeks of the procedure (March 2015). He
needed an emergency rigid cystoscopy with suprapubic catheter insertion due to a
failed trial of Mitrofanoff dilatation and failed retrograde bilateral ureteric stent reinsertion under GA. Subsequently, bilateral antegrade stent insertion was performed by the
interventional radiology team to allow free drainage of both kidneys.
Bilateral ureteric stents were removed on 23 October 2015 (creatinine 136 μmol/ L
and eGFR 55 mL/ min/ 1.73 m2) following improvement of his renal function. However,
he subsequently developed AKI and signs of sepsis on 26 October 2015 (creatinine 517
μmol/ L, eGFR 12 mL/ min/ 1.73 m2, C- reactive protein 296 mg/ L). His USS reported
bilateral hydronephrosis and he required emergency bilateral nephrostomy tube insertion on 26 October 2015.
Expert comment Disease progression
Progression of the disease may occur despite cessation of ketamine usage and therefore necessity of
keeping bilateral nephrostomy tube in situ with a plan of regular change until consideration of any
major reconstructive procedure. This particular patient had bilateral ureteric stents including resonant
(metallic) stent, however ureteric stents failed to drain both kidneys effectively which led to repeated
hospital admissions with AKI or blocked nephrostomies, with signs of urosepsis requiring changes or
re- insertion of nephrostomy tubes.
302 Challenging Concepts in Urological Surgery
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Figure 31.1 Bilateral resonant stents in situ.
Rigid cystoscopy and bilateral retrograde resonant (metallic) ureteric stents were
inserted under GA in January 2016 due to bilateral pelviureteric junction obstruction
reported on nephrostogram (Figure 31.1). He was discharged after removal of both
nephrostomy tubes following the procedure with improved stable renal function (creatinine 146 μmol/ L and eGFR 51 mL/ min/ 1.73 m2).
Expert comment Disease progression and further surgery
There is an evidence of disease progression because the patient developed bilateral hydronephrosis
with AKI despite having bilateral resonant (metallic) ureteric stents in situ. It was proven that bilateral
ureteric stent failed to ensure effective drainage of both kidneys and the patient required emergency
nephrostomy tube insertion for the improvement of renal function and ensure effective drainage of
the renal system. Therefore, the necessity of further reconstructive surgery was paramount.
The patient was readmitted with AKI (creatinine 317 μmol/ L, eGFR 21 mL/ min/
1.73 m2) and USS reported bilateral hydronephrosis (March 2016) despite having bilateral resonant ureteric stents. Subsequently, he had emergency bilateral nephrostomy
insertion (March 2016) by the interventional radiology team (Figure 31.2).
The patient was discharged with bilateral nephrostomies (3- monthly changes) until
a further planned reconstructive procedure was made. He had further admissions
due to urosepsis and required changes of bilateral nephrostomies due to blockage or
dislodgement.
Finally, the patient underwent ileal segmental anastomosis with a continuous isoperistaltic ileal segment running from the left renal pelvis to the right renal pelvis and
an anastomosis to the end of the previous ileal chimney (Figure 31.3) in February 2017.
It is similar to a roux- en- Y configuration and bilateral nephrostomies were left on free
303Case 31 Management of ketamine-induced bilateral upper urinary tract injury
Anastamosis of right renal
Inferior
Aorta
of the small bowel segment
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Figure 31.2 Bilateral nephrostogram showing evidence of obstruction at the pelviureteric junction
bilaterally. There is visualization of the renal pelvis and no evidence of contrast passing into both ureters
despite having bilateral resonant (metallic) ureteric stents.
pelvis to the continuous
small bowel segment
Anastamosis of right end
of small bowel segment
with previous chimney
Chimney of the augmentation
cytoplasty
mesenteric
artery
Anastamosis of left renal
pelvis with the left end
U-loop of small bowel segment
underneath the inferior mesenteric
artery
Previous small bowel segment
used for augmentation cytoplasty
Previous joining line native bladder
with small bowel segment
(augmentation cytoplasty)
Native bladder
Figure 31.3 Schematic diagram of the complex reconstructive procedure.
Courtesy: University Hospitals Birmingham illustration department, Andrew Dakin.
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