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92
L. M. Conroy and O. L. Westney
urodynamic stress urinary incontinence: ef­cacy and adverse effects at 13-years follow-up. Neurourol Urodyn. 2020;39(5):1423–9. https://doi.
org/10.1002/nau.24358.
21. Kokanali MK, Doğanay M, Aksakal O, Cavkaytar S, Topçu HO, Özer İ. Risk factors for mesh erosion after vaginal sling procedures for urinary incontinence. Eur J Obstet Gynecol Reprod Biol. 2014;177:146–50.
https://doi.org/10.1016/j.ejogrb.2014.03.039.
22. de Leval J.Novel surgical technique for the treatment of female stress urinary incontinence: transobturator vaginal tape inside-out. Eur Urol. 2003;44(6):724–30.
https://doi.org/10.1016/j.eururo.2003.09.003.
23. Richter HE, Albo ME, Zyczynski HM, Kenton K, Norton PA, Sirls LT, et al. Retropubic versus tran­sobturator midurethral slings for stress incontinence. N Engl J Med. 2010;362(22):2066–76. https://doi.
org/10.1056/NEJMoa0912658.
24. Schierlitz L, Dwyer PL, Rosamilia A, Murray C, Thomas E, De Souza A, etal. Three-year follow-up of tension-free vaginal tape compared with transobtu­rator tape in women with stress urinary incontinence and intrinsic sphincter deciency. Obstet Gynecol. 2012;119(2 Pt 1):321–7. https://doi.org/10.1097/
AOG.0b013e31823dfc73.
25. Mock S, Angelle J, Reynolds WS, Osborn DJ, Dmochowski RR, Gomelsky A. Contemporary comparison between retropubic midurethral sling and autologous pubovaginal sling for stress urinary incontinence after the FDA advisory notication. Urology. 2015;85(2):321–5. https://doi.org/10.1016/j.
urology.2014.10.017.
26. Plagakis S, Tse V.The autologous pubovaginal fascial sling: an update in 2019. Low Urin Tract Symptoms. 2020;12(1):2–7. https://doi.org/10.1111/luts.12281.
27. Niknejad K, Plzak LS, Staskin DR, Loughlin KR. Autologous and synthetic urethral slings for female incontinence. Urol Clin North Am. 2002;29(3):597–611. https://doi.org/10.1016/
s0094- 0143(02)00074- 5.
28. Dmochowski RR, Blaivas JM, Gormley EA, Juma S, Karram MM, Lightner DJ, etal. Update of AUA guideline on the surgical management of female stress urinary incontinence. J Urol. 2010;183(5):1906–14.
https://doi.org/10.1016/j.juro.2010.02.2369.
29. Athanasopoulos A, Gyftopoulos K, McGuire EJ. Efcacy and preoperative prognostic fac­tors of autologous fascia rectus sling for treatment of female stress urinary incontinence. Urology.
2011;78(5):1034–8. https://doi.org/10.1016/j.
urology.2011.05.069.
30. Kim S, Wong DG, Lee D, Christie AL, Zimmern PE.Very long-term follow-up of autologous pubovag­inal fascia slings in women with stress urinary incon­tinence. Int Urogynecol J. 2022;33(4):821–8. https://
doi.org/10.1007/s00192- 021- 04737- 7.
31. Khan ZA, Nambiar A, Morley R, Chapple CR, Emery SJ, Lucas MG.Long-term follow-up of a multicentre randomised controlled trial comparing tension-free vaginal tape, xenograft and autologous fascial slings for the treatment of stress urinary incontinence in women. BJU Int. 2015;115(6):968–77. https://doi.
org/10.1111/bju.12851.
32. Shariaghdas F, Mirzaei M, Daneshpajooh A, Narouie B.Long-term results of tension-free vaginal tape and pubovaginal sling in the treatment of stress urinary incontinence in female patients. Clin Exp Obstet Gynecol. 2017;44(1):44–7.
33. Hartigan SM, Chapple CR, Dmochowski RR.Retropubic suspension surgery for incontinence in women Campbell-Walsh-Wein urology. 12th ed. Elsevier Inc.; 2021. p.2756–75.
34. Burch JC. Urethrovaginal xation to Cooper’s liga­ment for correction of stress incontinence, cystocele, and prolapse. Am J Obstet Gynecol. 1961;81:281–90.
https://doi.org/10.1016/s0002- 9378(16)36367- 0.
35. Freites J, Stewart F, Omar MI, Mashayekhi A, Agur WI. Laparoscopic colposuspension for uri­nary incontinence in women. Cochrane Database Syst Rev. 2019;12(12):CD002239. https://doi.
org/10.1002/14651858.CD002239.pub4.
36. Lapitan MCM, Cody JD, Mashayekhi A. Open retropubic colposuspension for urinary incon­tinence in women. Cochrane Database Syst Rev. 2017;7(7):CD002912. https://doi.
org/10.1002/14651858.CD002912.pub7.
37. Brubaker L, Richter HE, Norton PA, Albo M, Zyczynski HM, Chai TC, et al. 5-year continence rates, satisfaction and adverse events of burch ure­thropexy and fascial sling surgery for urinary incon­tinence. J Urol. 2012;187(4):1324–30. https://doi.
org/10.1016/j.juro.2011.11.087.
38. Albo ME, Richter HE, Brubaker L, Norton P, Kraus SR, Zimmern PE, etal. Burch colposuspension ver­sus fascial sling to reduce urinary stress incontinence. N Engl J Med. 2007;356(21):2143–55. https://doi.
org/10.1056/NEJMoa070416.

Urethral Diverticulectomy

RichardLee andLeoDreyfuss
9
Pathophysiology ofaUrethral Diverticulum (UD)
The exact etiology of a urethral diverticulum is unclear. While there are reports of congenital urethral diverticula in females and males, it is accepted that most urethral diverticula are acquired in adulthood [1, 2]. Urethral diverticula are thought to arise from the periurethral glands, located in the posterolateral mid- to distal ure­thra. The pathophysiologic process behind the formation of urethral diverticula is likely related to infection, which can lead to abscess formation within the periurethral glands. Recurrent infec­tion causes submucosal tracking of the abscess within the periurethral fascia, which eventually ruptures into the urethral lumen, creating the characteristic ostium.
The most common location of urethral diver­ticula is the distal two-thirds of the ventral ure­thra. This corresponds to the location of most
periurethral glands, supporting the aforemen­tioned pathophysiologic hypothesis (Fig. 9.1). One-third of diverticula, however, are found in the proximal portion of the urethra, and expan­sion of the diverticula can occur anteriorly or extend circumferentially [3].
Surgical pathology following excision most often reveals a benign histology, although inam­matory changes are common. Premalignant changes can be seen in 10–20% of specimens. Malignancy within a urethral diverticulum is rare. Adenocarcinoma is the most common malignant pathology seen, in contrast to urethral carcinoma, where squamous cell carcinoma is more common [4, 5]. Urethral diverticula may contain stones caused by urinary stasis. Their size and location are variable; urethral diverticula can extend anywhere within the periurethral fas­cia, and may extend circumferentially or in a horseshoe orientation. Multiple diverticula may be present [5, 6].
R. Lee (*) · L. Dreyfuss Department of Urology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA e-mail: ril9010@med.cornell.edu; ldd9009@nyp.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025 M. Hoffman et al. (eds.), Major Complications of Female Pelvic Surgery,
https://doi.org/10.1007/978-3-031-66772-5_9
93
94
Diver
diverticulum
Fig. 9.1 Sagittal view of the female pelvis with the urethral diverticulum distal to the urethral sphincter. Adapted from EAU 2016 [51]
R. Lee and L. Dreyfuss
Urethra
Urethral
sphincter
Os of
ticulum
Periurethral
fascia
Prevalence andPresentation
Presentation is variable. Patients tend to be in the third to sixth decade of life. Incidence is esti­mated to be between 1 and 6% [7, 8]. The most common presenting symptoms are a vaginal lump, pain in the area of the diverticulum, dys­uria, and dyspareunia. Post-void dribbling, recur­rent urinary tract infections (UTIs), and urethral discharge can also be present [9, 10]. The classic “three D’s” (discharge, dyspareunia, and drib­bling) are found in only 5% of patients [11].

Diagnosis

According to Davis and Telinde, “The most important single diagnostic instrument for the discovery of suburethral diverticula is a high index of suspicion” [12]. Patients presenting with
Urethral
Vagina Rectum
the above symptoms should undergo a thorough history and physical exam. Physical exam may reveal a uctuant bulge over the anterior vaginal wall. Occasionally, rm palpation of this mass may result in expression of purulent debris from the urethra. Urine studies should be obtained and sent for culture to guide perioperative antimicrobial coverage. Cystourethroscopy can be performed to visualize the ostium of the diver­ticulum. Multiple ostia may be present and are commonly located posterolaterally at the 4 and 8 o’clock position but can be visualized in a minor­ity of patients.
Numerous imaging studies have been employed in the diagnosis of urethral diverticula. Double balloon positive pressure urethrography (PPU) is considered the historic gold standard for diagnosis and characterization of UDs but is rarely used. If the patient is able to void, a void­ing cystourethrogram (VCUG) can be used to
9 Urethral Diverticulectomy
95
diagnose the presence of a UD, which will opacify with contrast during voiding. Transvaginal ultrasound can provide useful infor­mation regarding the size and location of a UD but is operator-dependent and does not produce detailed images. Magnetic resonance imaging (MRI) is commonly employed as the standard imaging modality for diagnosis of UDs with good performance compared to the gold standard PPU [13].
Dierential Diagnosis
Periurethral masses that may be mistaken for ure­thral diverticula include vaginal leiomyoma, Skene’s gland abnormalities, Gartner duct abnor­malities, vaginal wall cysts, urethral prolapse, urethral caruncle, or periurethral bulking agents. Careful history and physical exam can help dif­ferentiate urethral diverticula from these distinct entities [3].
Indications forRepair
Excision of urethral diverticula may be offered to symptomatic patients who desire surgical inter­vention. It is important to counsel patients whose primary complaint is pain that concurrent condi­tions, particularly pelvic oor dysfunction or lower urinary tract symptoms (LUTSs), may exist and may not resolve following diverticulec­tomy. While progression to carcinoma has been reported, it is considered a rare entity; prophylac­tic urethral diverticulectomy in an asymptomatic patient for the sole intent of avoiding a malig­nancy is not necessary. However, patients who desire nonoperative management must be coun­seled on the low risk of malignancy, which may not be seen on diagnostic imaging [4, 5, 14]. Conservative management is an option for patients with UDs; recurrent UTIs and stress uri­nary incontinence (SUI) can be managed with prophylactic antibiotics and pelvic oor physical therapy (PFPT), respectively, but no guidance exists for periodic screening of patients with ure­thral diverticula for malignancy.

Surgical Management

Multiple surgical techniques for the manage­ment of urethral diverticula have been reported [15–18]. Currently, the two most widely used techniques are transvaginal marsupialization and excision and reconstruction, with the latter being far more common. Despite the over­whelming popularity of this technique, there is insufcient evidence to compare differences in outcomes and complications between various procedures [19].
Transvaginal marsupialization is an option for distal urethral diverticula. Originally described by Spence and Duckett, marsupial­ization may be faster and lead to less blood loss than excision and reconstruction. Briey, the procedure involves placement of one blade of a Metzenbaum scissors into the urethra and incision into the diverticulum and anterior vag­inal wall to create a “generous meatotomy” [16]. However, extension of the incision too far proximally may lead to damage of the external sphincter and cause incontinence or to devel­opment of a “pseudoseptum” between the ure­thra and anterior bladder wall. This may cause dyspareunia and limit the classic marsupializa­tion technique to the distal diverticula in patients who are not sexually active. Recently, a variation of the Spence and Duckett proce­dure has been described for distal diverticula involving an incision directly on the diverticu­lar ostium followed by marsupialization, allowing the area to drain into the vagina. This technique may offer the benets of the tradi­tional Spence and Duckett technique while minimizing the risks of long-term dyspareunia or incontinence [20].
For patients with complicated urethral diver­ticula, such as those undergoing repeat surgeries, or for those with complex or circumferential diverticula, variations in surgical technique have been described with favorable results. These include use of xenogenic grafts, lateral vaginal aps, urethroplasty with remnants of the diver­ticular sac, end-to-end urethroplasty following diverticulectomy, and the transabdominal robot­assisted laparoscopic approach [21–24].
96
Urethral suture
R. Lee and L. Dreyfuss
Excision andReconstruction
Excision and reconstruction is the most com­monly used technique for excision of urethral diverticula, although there is insufcient evi­dence to compare the rates of complications and outcomes between different techniques [19]. Basic surgical principles can be employed to optimize outcomes and minimize complications; vaginal wall aps dissected out with preserved blood supply, periurethral fascia preserved as separate layer, and the ostium neck and diverticu­lum wall completely excised. Closure should be performed in a watertight manner with minimal overlapping of sutures. Topical estrogen can be administered for 4–6weeks preoperatively if the patient is postmenopausal to improve vascular supply to the tissue. Preoperative, culture- specic antibiotics should be given if the patient has a history of recurrent urinary tract infections.
The procedure is carried out in the dorsal lithotomy position with a Foley catheter placed. An inverted-U incision is made with special con­sideration to make the proximal portion of the “U” (toward the bladder neck) wide to preserve proximal blood supply. During dissection, the periurethral facia should be preserved as it is an essential layer to close with following removal of diverticular sac. Once the periurethral tissue plane around the diverticulum is developed, a horizontal incision can be made on the diverticu­lum taking care to not violate the sac. The diverticulum is then dissected free of the periure­thral tissue to the ostium origin on the urethra and then excised. The entire mucosal surface of the diverticulum should be removed in order to pre­vent recurrence. Following excision, the Foley catheter can be seen through the defect and a tension- free closure is performed using multiple layers of absorbable sutures (Fig.9.2). Following
Vaginal
wall suture
Periurethral
fascia suture
Fig. 9.2 Diagram of a multilayered closure of (from deep to supercial) a urethral defect, the periurethral fascia, and the vaginal epithelium. The minimal overlapping of suture lines should be noted. Adapted from Ref. [52]
9 Urethral Diverticulectomy
97
closure, the Foley catheter is removed and diluted methylene blue is gently injected into the urethra with a catheter tip syringe to ensure watertight closure.
It is essential to avoid dead space by securing the periurethral fascial aps. Deep to the vaginal wall, brofatty labial aps can be used to prevent risk of wound breakdown or stula with a low rate of complication. Use of a Martius ap is safe but can result in pain, dyspareunia, hematoma, or abscess requiring drainage [25–27].

Complications Following Urethral Diverticulectomy

Short-term complications (<30 days) following urethral diverticulectomy include urinary tract infections (1–10%), soft tissue infections (<1%), and bleeding requiring transfusion (<1%) [28–30].
Long-term complications include lower uri­nary tract symptoms (frequency, dysuria, 10%) and pain (11%). There have been reports of an overactive bladder following urethral diverticu­lectomy, which can be managed with medical therapy [29, 31]. De novo SUI can occur in up to 17% of patients following urethral diverticulec­tomy [10, 32]. Vesicovaginal stulas and urethral strictures are rare outcomes following surgery [23, 30, 33]. Residual or recurrent urethral diver­ticula are found at rates as high as 10–16% post­operatively, and this is related to the complexity of the diverticulum [3, 6, 34–36].

Stress Urinary Incontinence

Stress urinary incontinence deserves special attention in the context of UD as one of the hall­mark symptoms of UD, post-void dribbling can easily be mistaken for SUI.SUI can also be diag-
nosed as a separate entity during preoperative evaluation. It can also arise de novo as a compli­cation of diverticulectomy. It is important to dis­cuss SUI separately in the context of each of these distinct presentations.
Concurrent SUI withaUrethral Diverticulum
For patients who present with SUI in the set­ting of a urethral diverticulum, an accurate diagnosis is important, as leakage of accumu­lated urine from the diverticulum can be mis­taken for SUI. Diagnosticians can manually empty out the diverticulum and ask the patient to cough as a means of elucidating the pres­ence of SUI [37].
Urodynamic evaluation can be conducted preoperatively to delineate symptomatology in patients with a urethral diverticulum. Video uro­dynamics (VUD) is preferred as a voiding cys­tourethrogram (VCUG) can allow for visualization of the diverticulum. SUI can be found during urodynamic evaluation in up to 50% of patients presenting with a urethral diver­ticulum [29, 38].
Patients who present preoperatively with SUI may be offered anti-incontinence surgery at the time of diverticulectomy. It is also reasonable to defer treatment of SUI and reevaluate symptoms following diverticulectomy. A retrospective anal­ysis by Greiman etal. showed that 8 of 15 patients who underwent urethral diverticulectomy with­out simultaneous placement of an autologous pubovaginal sling saw resolution of SUI follow­ing surgery, compared to 20 of 24 patients who had simultaneous sling placement [39]. The staged approach can be particularly helpful for patients for whom differentiation between SUI and urethral post-void dribbling cannot be achieved. Caution should be taken for placement
98
R. Lee and L. Dreyfuss
of slings for proximal diverticula as increased intraurethral pressure with Valsalva can cause rupture of the suture line leading to stula formation.

De Novo SUI

De novo SUI following urethral diverticulectomy can occur in up to 17% of patients. A recent pro­spective series of 100 patients who underwent video urodynamics prior to diverticulectomy with modied Martius interposition has found the rate of de novo SUI to be 16% [10, 32]. Risk factors for de novo SUI include diverticulum size (>30mm), proximal location, and complex con­guration of the diverticulum on preoperative imaging [9, 40, 41]. Limited contemporary data suggest that simultaneous autologous sling place­ment at the time of diverticulectomy is safe and may reduce the risk of post-procedural SUI [39]. The decision to offer concurrent SUI treatment should be balanced with the risk of complications such as urinary retention, urinary urgency, and recurrent UTIs [31, 39, 42, 43]. Importantly, con- comitant use of synthetic mid-urethral slings should be avoided due to the risk of erosion of the graft into the urethra [44]. Additionally, it has been advised that concomitant sling surgery should be avoided in patients with contraindica­tions to pubovaginal slings, including pure urgency incontinence, primary bladder neck obstruction, urethral stricture, and a poorly con­tractile or acontractile bladder with urinary reten­tion [45].
Management of de novo SUI can be either conservative or interventional. Conservative management of postoperative SUI includes pel­vic oor muscle training (PFMT), and it can be expected that the majority of patients who develop de novo SUI following diverticulectomy will improve without the need for surgical inter­vention [32]. In the series published by Barratt
et al., 12 of 16 patients with de novo SUI saw resolution of symptoms with 3months of pelvic oor physical therapy [10]. The remaining four patients underwent video urodynamics (VUDS), demonstrating distal stricture in one patient, detrusor overactivity in one patient, and SUI in two patients.
Surgical management of de novo SUI may be necessary for a minority (4–10%) of patients who undergo diverticulectomy [9, 32, 46]. Treatment options include bulking agents or autologous fascia mid-urethral slings. It must be stressed again that synthetic materials should never be used in management of patients with SUI following urethral diverticulectomy due to the risk of urethral erosion [44]. It is unknown whether the risk of erosion decreases with time or whether synthetic materials may be used in patients with a remote history of urethral diverticulectomy.

Urethrovaginal Fistula

Fistula formation following diverticulectomy is reported in 0–6% of patients. Risk factors for stula formation include surgery on a recurrent diverticulum, complexity of the diverticulum, overlapping suture lines, tension on the incision, poor mobilization of aps, or poor tissue quality [6, 47]. Urethrovaginal stula formation distal to the external urinary sphincter can be mildly symptomatic, presenting with double voiding or vaginal voiding. Urethrovaginal stulae proxi­mal to the external urinary sphincter may result in continuous leakage of urine (Fig. 9.3) [33]. Repair of stula should be delayed until at least 3–6 months following index surgery to allow time for tissue regrowth [48]. Use of brofatty labial (Martius) aps is recommended at the time of repair. As discussed earlier, a Martius ap may be used at the time of urethral diver­ticulectomy and may reduce the risk of stula
Urethrovaginal
Vagina
9 Urethral Diverticulectomy
Rectum
Uterus
Bladder
fistula
Urethra
Fig. 9.3 Sagittal view of the female pelvis with a ureterovesical stula. Adapted from Ref. [53]
99
formation with minimal added postoperative risk [25–27].

Urethral Stricture

Urethral stricture is a rare complication follow­ing diverticulectomy and is found in 0–2% of patients postoperatively. It may be associated with excision of complex diverticula, particularly if end-to-end urethroplasty is performed [23]. Presenting symptoms include slow stream, high post-void residual, or recurrent UTIs. Urethral strictures can be managed with balloon dilation, meatotomy, or urethroplasty or conservatively with clean intermittent catheterization [6, 33, 49].

Recurrent Urethral Diverticulum

Many patients will experience temporary symp­toms following urethral diverticulectomy, includ­ing pain, dysuria, urgency, and urinary leakage. The majority of these patients will improve spon­taneously without intervention [9]. Persistent symptoms following diverticulectomy should
raise concern for a residual or recurrent diverticu­lum and prompt repeat imaging.
Diverticular recurrence is common and can be found in 2–16% of patients postoperatively [6, 9,
30, 49]. Recurrences are believed to arise from
residual dead space or incomplete excision of the diverticular sac [50], and recurrence rates are higher for patients with a history of prior urethral diverticulectomy. Ingber reported 122 patients with urethral diverticulectomy that underwent excision and found that, of the 110 patients with­out prior urethral diverticulectomy, the rate of recurrence was 9.1%, compared to 25% (3 of 12) of patients who were undergoing surgery for a recurrence. Patients with a history of any pelvic surgery were also more likely to experience residual or recurrent diverticula (p<0.001) [35].
It is believed that the complexity of the diver­ticulum affects outcomes. Han et al. report a series of 30 women with simple or complex (C­or U-shaped) diverticula. Notably, 0/17 patients with simple diverticula experienced recurrence and 7/13 patients with complex diverticula recurred [34]. Conversely, a series of 43 patients that underwent diverticulectomy for simple (n=32) or complex (n=11) diverticula found no
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difference in the rates of recurrent diverticula between the two groups [49]. Recurrent divertic­ula can be managed similarly to de novo diver­ticula; asymptomatic recurrences can be managed with observation while symptomatic recurrences can be treated with repeat diverticulectomy with good results [9].

Conclusions

Urethral diverticula represent a benign condition with potential morbid implications for quality of life. When indicated, surgical intervention can lead to resolution of symptoms. However, com­plications can arise. With a careful surgical tech­nique and proper selection, complications can be minimized and outcomes improved.

References

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3. Rovner ES.Bladder and female urethral diverticula. In: Partin AW, editor. Campbell walsh wein urology. Elsevier; 2021.
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15. Spencer WF, Streem SB.Diverticulum of the female urethral roof managed endoscopically. J Urol. 1987;138(1):147–8.
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17. Saito S.Usefulness of diagnosis by the urethroscopy under anesthesia and effect of transurethral electroco­agulation in symptomatic female urethral diverticula. J Endourol. 2000;14(5):455–7.
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