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Urethral Diverticulum: Treatment
Updated: Mar 19, 2009
Treatment
Medical Therapy
Urethral diverticulum is, for all intents and purposes, a surgical disorder. Treatment of recurrent UTIs with appropriate antibiotic therapy can be utilized preoperatively as a temporizing measure or in patients who are unable or unwilling to undergo surgery. Urethral dilation sometimes can be used in this capacity as well. Antibiotic therapy and urethral dilation, however, does not result in cure of the problem.
Expectant management is appropriate for small, asymptomatic diverticula. In several surgical series of patients with urethral diverticulum, small numbers of minimally symptomatic patients have declined surgical management. Unfortunately, the ongoing management and progress of these patients has not been well documented.
Finally, ultrasonic lithotripsy has been used in a few cases to break up large stones within diverticula, followed by urethroscopic extraction of the fragments. Definitive surgical treatment of the diverticula was accomplished several months later.
Surgical Therapy
Surgery is the mainstay of therapy for urethral diverticulum. The choice of surgical procedure depends largely on the location of the diverticulum along the urethra. Simple marsupialization may be appropriate for diverticula with ostia emptying into the distal one third of the urethra, although not all authorities advocate this approach. If the ostium of the diverticulum lies distal to the urethral rhabdosphincter, then incision into the posterior urethral wall to achieve exteriorization of the diverticular sac is thought to have no adverse effect on continence.
Diverticula involving the middle or proximal one third of the urethra are treated most effectively with either total excision or partial ablation. Each procedure has advocates; however, partial ablation generally is considered simpler and less likely to result in urethrovaginal fistula. This especially may be true if significant peridiverticular inflammation is present, if the sac is adherent to the posterior urethra, or if tissue planes are obscured. A third, more conservative approach has been described for use under these adverse surgical conditions. This technique involves a small transvaginal incision into the sac of the diverticulum followed by copious irrigation with an antiseptic solution and packing of the diverticular lumen with Oxycel. The resultant extensive fibrosis is thought to close the diverticulum from within.
With either total excision or partial ablation, the diverticulum is approached surgically through a vaginal incision. Transverse or midline vertical vaginal incisions both have been used with good results. Some surgeons have advocated an inverted horseshoe-shaped incision, with the line of the incision away from the anticipated underlying suture lines that will close the urethra and periurethral connective tissue. Avoiding superimposed suture lines is thought to lower the incidence of postoperative fistula formation; however, this concept never has been proven. Probably more important than the choice of vaginal incision are the basic principles of tension-free meticulous layered closure and good hemostasis. Finally, a semilunar submeatal incision has been described. With this technique, the diverticular neck and sac are approached by way of dissection beneath and parallel to the urethra. Experience with this incision is limited, but reported results have been favorable.
Optimal surgical treatment of patients with diverticula associated with malignancy has yet to be determined. In patients with the diagnosis made prior to surgery, treatment can be wide local excision (urethrectomy) followed by local radiation. Anterior exenteration is reserved for local recurrences. Some patients have been treated primarily with anterior exenteration and diversion. Cure rates at 0.5-2 years of follow-up have been high (87%) but at the cost of high morbidity. If the diagnosis is made after diverticulectomy, postoperative radiation therapy is an option versus anterior exenteration and urinary diversion.
Difficulties with surgical excision can arise in a variety of circumstances. Surgical planes can be obliterated by the sequelae of chronic and acute infection. Bleeding may obscure visualization. Rupture of the diverticular sac or inability to keep the sac distended can be a significant impediment to complete dissection and excision. Friability of the diverticular wall may impair dissection further. Unexpected intraoperative findings, such as multiple or complex diverticula, can prolong and complicate any procedure. The surgeon must be patient, meticulous, and resourceful in order to achieve the best possible outcomes.
Preoperative Details
Preoperative planning for surgical correction of urethral diverticula revolves around meticulous characterization of the lesions themselves. Knowledge of the size, location, adjacent anatomy, and other pertinent characteristics are important factors in choosing and executing a successful procedure. In 1993, Leach et al devised a classification system, in part, to aid surgeons in preoperative planning.19 The system was derived from their experience with evaluation and surgical treatment of 61 patients over 10 years. A secondary purpose of the classification system was to provide a standard means of describing urethral diverticula for the purpose of comparative research. Known as L/N/S/C3, the classification system is as follows:
- L refers to location (distal, mid, or proximal urethra, with or without extension beneath the bladder neck).
- N refers to number of diverticula (single or multiple).
- S refers to size in centimeters.
- C3 refers to configuration (C1 is single, multiloculated, or saddle shaped), communication (C2 is site of communication with the urethral lumen described as distal, mid, or proximal), and continence (C3 is the presence or absence of genuine stress incontinence).
The location of diverticula along the urethra can be ascertained on physical examination in conjunction with imaging studies, such as VCUG or positive-pressure urethrography. The number, size, and configuration usually can be determined via radiographic techniques. Recently, newer modalities, such as US and MRI, have been used. Communication with the urethra often can be determined on urethroscopy. Positive-pressure urethroscopy by way of digital occlusion at the level of the bladder neck can help dilate ostia that are difficult to locate. Additionally, transvaginal injection of dye into the diverticulum can help identify the site of communication with the urethra during urethroscopy.
In patients who report urinary incontinence, urodynamics are indicated prior to surgery. Identifying patients with genuine stress incontinence due to urethral hypermobility is especially important. Genuine stress incontinence can be difficult to differentiate from paradoxical incontinence due to stress-induced emptying of the diverticulum. If genuine stress incontinence is diagnosed, surgical repair of the diverticulum can be combined with a procedure to limit bladder neck mobility. Reports of successfully combining diverticulum excision and needle urethropexy or suburethral sling procedures can be found in the literature. Urethral pressure profilometry may be helpful in identifying the location of the diverticular ostium along the functional length of the urethra.
Finally, in order to ensure the highest possible chance of safe, successful surgery, the surgical field should be free of acute infection. Treat UTIs on the basis of culture and sensitivities. In cases of abscess formation, initiate broad-spectrum antibiotic coverage, and, in most instances, perform a drainage procedure of some kind. Postpone definitive surgery until after the infection is cleared. Marsupialization procedures may be the only exception to this rule because drainage and definitive treatment are accomplished simultaneously.
A realistic preoperative discussion between surgeon and patient should take place. In addition to discussing the usual risks and complications of surgery in general, mention the following procedure-specific complications:
- Recurrent or persistent diverticula
- Urethrovaginal fistula (especially with complete diverticulectomy)
- Postoperative stress incontinence
- Urethral pain syndrome
Intraoperative Details
Simple marsupialization (the Spence procedure)
Spence and Duckett first described surgical treatment of female urethral diverticula by marsupialization in 1970.1 Their intent was to devise a simple procedure with less morbidity and fewer complications than diverticulectomy. They reported on 9 cases, achieving a 100% success rate. In 1975, Lichtman and Robertson subsequently reported on 8 additional cases.20 They, too, experienced a 100% cure rate at 6-12 months of follow-up, with no new cases of urinary incontinence. They did not treat any cases of urethral diverticula with ostia at or near the bladder neck. They recommended marsupialization only for patients with diverticular ostia in the middle or distal one third of the urethra. Since that report, others have recommended using this procedure only for diverticula limited to the distal one third of the urethra due to concern over damaging the striated urethral sphincter complex.
The Spence procedure is carried out with the patient in the dorsal lithotomy position. The bladder is emptied with a catheter, and the vagina and vulva are prepared for surgery. A straight Mayo scissors is used for the initial incision. One blade is placed in the urethra and the second blade rests along the anterior vagina beneath the posterior wall of the urethra in the midline. The initial incision is made with the intent of entering the diverticular sac. The length of the incision is individualized in order to achieve this goal. Once entry into the sac is accomplished, the remainder of the diverticular sac can be opened by extending the original incision using Mayo scissors or a scalpel. Next, the urethral and diverticular epithelium is sewn to the edges of the incised vaginal epithelium using a continuous running stitch of 3 or 4 absorbable suture.
The urinary tract epithelium is exteriorized by what has been called a large posterior meatotomy. No catheter is placed postoperatively, and the patient is encouraged to resume spontaneous voiding as soon as she recovers from anesthesia. Most patients can be discharged in 24 hours or less.
Partial ablation or partial diverticulectomy
Partial ablation, as described by Leon Tancer, MD, involves a midline vertical incision of the vaginal mucosa over the diverticulum. The peridiverticular connective tissue over the diverticulum itself is exposed (see Media file 5). Next, the periurethral connective tissue over the sac is incised and mobilized as flaps. This tissue is widely mobilized on all sides of the diverticulum. The diverticular sac then is dissected free and entered (see Media file 6). The body of the sac is excised.
A small metallic probe can be used to locate the ostia. A cuff of tissue is left around the probe as the bulk of the diverticular epithelium is excised (see Media file 7). No attempt is made to excise the diverticulum flush with the urethra or to dissect close to the junction with the urethra. Tissue is closed over the neck in several layers if possible. The periurethral connective tissue flaps are closed in an overlapping, vest-over-pants fashion (see Media file 8). Finally, the mucosa is reapproximated (see Media file 9). Fine absorbable suture is used throughout. An indwelling urinary catheter, either urethral or suprapubic, is left in place for 5-7 days.
Urethral diverticulectomy
Urethral diverticulectomy is a more extensive procedure in terms of the dissection of the diverticular sac. Some surgeons inflate the diverticulum using a double balloon catheter in order to facilitate identification and dissection and to avoid entry in the sac. The vaginal incision is made. Surgeons advocate longitudinal, transverse, and inverted U-shaped incisions. Periurethral connective tissue is incised and mobilized into flaps completely around the diverticulum.
Next, the diverticulum itself is completely dissected, including the neck, but it is not entered if possible. The sac is excised flush with the urethra. The urethra is closed longitudinally over a catheter with fine absorbable suture. Some surgeons recommend transverse closure of the urethra in order to minimize the chance of urethral stricture. The validity of this recommendation has never been tested. Next, the connective tissue flaps are closed in overlapping fashion to avoid superimposed suture lines. A vest-over-pants closure often is used.
The vaginal mucosa is sutured to complete the procedure.
Transurethral techniques
Transurethral surgical therapy for urethral diverticula has been reported sporadically in the literature since 1970, largely in the form of case reports and small case series. In 1970, Davis and Robinson described a technique of transurethral resection of the roof of the diverticulum with fulguration of the lining of the sac. In 1979, Lapides reported on a simplified urethroscopically guided transurethral procedure in which the diverticular ostium was enlarged via a linear incision using a specially designed knife electrode.21 No tissue was removed with this technique, and the epithelial lining of the diverticulum was not excised or fulgurated. More recently, a similar technique was developed in which an incision to widen the ostia was performed using a cold-knife urethrotome urethroscopically. Finally, a nonendoscopic method of widening of the ostia with small vascular scissors under direct visualization has been described.
This procedure, which seems most applicable to distal diverticula, relies on direct visualization of the ostia with the aid of expression of pus, insertion of small metallic probes, and, if needed, a small posterior meatotomy.
Transurethral procedures appear to work by decompression of the diverticulum and drainage of purulent material. Decompression also may improve local blood flow and, as a result, improve local defenses against infection. After such procedures, urine flows freely across the floor of the diverticulum due to the enlarged opening. Symptomatic relief is nearly immediate, and complications have been few. The possible advantages of transurethral procedures may include the following:
- Low morbidity and complication rates
- Shorter operation
- Shorter hospital stay
- Technical ease
- Adaptability of the technique to different locations along the urethra and multiple diverticula
Despite these proposed advantages and the excellent record reported in the few available studies, widespread acceptance of this approach is lacking. Continued research and experience with these techniques will help define their role in the armamentarium of the genitourinary tract surgeon.
Most recently, resection of complex dorsal (anterior) and circumferential diverticula has been described via complete urethral division and partial urethrectomy and primary repair. The urethral division is used to gain access to the dorsal wall of the diverticulum, increasing the chances of complete excision or ablation. The urethra is reconstructed by direct end-to-end reapproximation over a catheter. In some cases, tubularization of the dorsal wall of the diverticulum was used to construct a neourethral segment if deemed necessary. In addition, Martius grafts and pubovaginal slings were used in selected patients. The authors describe the use of eMRI for preoperative identification and mapping of these complex lesions prior to surgery.
Postoperatively, all 9 patients in this series reported resolution of pain complaints. One patient experienced mild stress incontinence and one patient reported persistent urgency and urge incontinence. Additional complications included 1 urethrovaginal fistula and 1 urethral stricture. Of note, 8 of the 9 patients had undergone prior attempts at surgical repair. Given the relatively high rate of failed surgical treatment with these types of diverticula, this more aggressive surgical approach may be justified; however, more experience is needed. Referring patients with dorsal or circumferential diverticula to surgeons with experience with complicated urethral reconstruction may be prudent.17
Adjunctive procedures and techniques
Excision or partial ablation of urethral diverticula can be challenging surgical endeavors. Difficult surgical conditions can lead to suboptimal results and excessive complications. Incomplete dissection of complicated or inflamed diverticula can lead to incomplete excision of the epithelium-lined sac, resulting in recurrence. Thin and poorly vascularized tissue at the repair site can predispose to development of urethrovaginal fistula. Several ingenious techniques have been devised in order to minimize these problems.
Intraoperative distention of the diverticulum can enhance surgical dissection. The double balloon catheter can be used intraoperatively for this purpose. Injection of dye, coagulum, or other materials transvaginally into the diverticulum has been described as well. Finally, traction on a Foley catheter with a balloon located at the bladder neck can be used to close the ostium of a proximally located diverticulum. This maneuver can enhance the ability to distend the diverticula with injected materials by preventing leakage through the ostia.
Use of intraoperative endoluminal US as an aid to surgical dissection was reported on in a series of 8 patients with urethral diverticula.22 Catheter-based transducers of 6.2F or 9F at 12.5 or 20 MHz, respectively, were utilized. Potential intraoperative information gained from this technique includes improved identification of the size, configuration, and orientation of the diverticulum. Also, an estimate of the degree of peridiverticular inflammation, thickness of the sac wall, and intraluminal distances can be obtained. The role of this imaging modality in the intraoperative management of urethral diverticula has yet to be determined; however, it may be of some benefit in difficult cases.
Transurethral catheterization of diverticular ostia with a fine pigtail catheter over a guide wire has been described. The catheter, in this case report, was used to irrigate and drain an acutely infected complex diverticulum with a poorly draining loculation. After a series of treatments and resolution of the acute infection, the catheter was left in place as a dissection guide during surgical excision of this multiloculated lesion. The same group also reported the use of a small pediatric Foley catheter to guide dissection after inadvertent intraoperative rupture of a thin-walled diverticulum. The catheter was introduced through the defect in the diverticular wall after cutting off the tip. The balloon then was inflated in order to distend the collapsed cavity.
A bulbocavernosus fat pad interposition, the Martius operation, can be used to enhance blood supply, increase tissue thickness, and buffer dead space following excision procedures. The technique involves making a full-length incision over the labia majus longitudinally. The fat pad is gathered up in a series of Babcock clamps and isolated by sharp dissection. The superior pole of the fat pad is freed after the anterior branches of the internal pudendal artery are suture ligated. The suture around the freed superior end of the graft is left long.
A tunnel is created connecting the vulvar and suburethral vaginal incisions using a clamp. The graft pedicle is pulled through the tunnel by grasping the long suture end at the superior pole. The fat pad then is fixed by suture to the area overlying the repaired urethra. The vagina is closed over the graft. The donor site is closed with deep stitches to eliminate dead space and gain hemostasis. The vulvar skin is closed with simple interrupted sutures or a running subcuticular stitch.
Recently, posterior pole disarticulation and mobilization of the graft has been used in cases where anterior vaginal tissue support is needed. In this manner, the graft can be sutured in place under less tension. The chance of vascular compromise to the graft may be less significant with this approach. Another method of increasing tissue vascularity and thickness is through the use of a bipedicled vaginal flap. A transverse vaginal incision is used to perform the diverticulectomy. The flap is created and then fixed to the repair site. The flap is buried beneath the transverse vaginal closure. In a small case series, no cases of vaginal retention cysts were reported.
Postoperative Details
Postoperative care of patients surgically treated for urethral diverticula may differ from case to case depending on the specifics of the procedure(s) performed. Generally, vaginal packing is avoided or limited to one day. Stool softeners may be prescribed in order to avoid straining.
With simple marsupialization procedures, urinary catheterization usually is not needed, and most patients resume voiding promptly. Tancer recommends urinary drainage for 5-7 days by either the transurethral or suprapubic route following partial ablation. Similarly, many surgeons drain the bladder for 5-7 days following diverticulectomy; however, some authors have recommended drainage for as long as 5 weeks via a transurethral catheter. No definitive reports exist in the literature to guide catheter management. One author suggested that longer periods of drainage should be considered if more than one diverticulum was excised or the diverticulum was located at the bladder neck. Also, concomitant surgery for stress incontinence may affect catheter management decisions.
Most patients with uncomplicated repairs are ready for discharge in 24-48 hours. Patients with more complicated surgeries or who require additional procedures may have more prolonged hospital stays.
Follow-up
Short-term postoperative follow-up revolves around close surveillance for complications, such as infection, hematoma, urethrovaginal fistula formation, stress incontinence, urethral stricture, and urethral pain syndromes. Submit excised tissue for pathologic examination. Unexpected early carcinomas have been diagnosed solely on the basis of examination of the pathologic specimen.
Long-term follow-up of patients surgically treated for urethral diverticulum involves surveillance for recurrence. Recurrences, even several years after surgery, have been reported.
For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center. Also, see eMedicine's patient education article Bladder Control Problems.
Complications
The types of complications observed following surgery for urethral diverticulum are partly related to the type of lesion treated and the particular operation utilized. For example, postoperative stress incontinence appears to be more common after surgery for proximal and bladder neck diverticula. Urethrovaginal fistula occurs more commonly after complete diverticulectomy than after partial ablation. Overall complication rates for surgical treatment of urethral diverticula have been reported to range from 5-46%. Common complications reported following surgery for urethral diverticulum include the following:
- Recurrence or persistence of diverticula
- Urethrovaginal fistula
- Vesicovaginal fistula
- Urethral stricture
- Urethral pain syndrome
- New-onset or persistent stress incontinence
- Missed carcinoma
- UTI
- Hemorrhage or hematoma formation
In one series of 70 patients undergoing mostly diverticulectomy from 1955-1979, the cases were divided into 3 groups based on the location of the lesion along the urethra. With diverticula of the proximal one third of the urethra, the main complication was recurrence (33%), indicating difficulty with complete sac excision. Mid urethral diverticula excision resulted in fistula formation in 4 of 26 cases (15.4%). Recurrence was observed in 31% and stricture in 3.8% of cases. Distal urethral diverticula had the lowest postoperative complication rates, with no fistulas and 2 out of 17 cases recurring 1-6 years after surgery.23
One hundred and eight patients at the Mayo Clinic were treated over 15 years with complete diverticulectomy. Low complication rates in this series can be attributed to meticulous surgical technique. Reported complications included urethrovaginal fistula (0.9%), urethral pain syndrome (1.8%), recurrent UTIs (0.9%), immediate postoperative urinary incontinence (1.8%), delayed (>2 y) urinary incontinence (13%), recurrent diverticulum in less than 1 year (3.7%), and recurrent diverticulum after longer than 1 year (5.6%). Of note, the author found that most recurrences were at the same location as the original diverticulum. This finding suggests that most recurrences are the result of incomplete excision of the sac or remaining local weakness in the urethral wall rather than the formation of entirely new lesions.
In 1994, in series of 63 patients over 10 years, complication rates for complete diverticulectomy were less than those previously reported. Urethrovaginal fistulas and recurrences were observed in 1.6% and 3.2% of the cases, respectively. No cases of vesicovaginal fistula were reported. UTIs occurred postoperatively in 9.5% of cases. Twenty-two percent of women who had genuine stress incontinence and urethral diverticulum had persistent stress incontinence despite treatment with bladder neck suspension at the same surgery. The degree of incontinence was reported as requiring less than 2 pads per day. About 10% of patients undergoing diverticulectomy alone developed mild de novo stress incontinence in this series.24
In another retrospective review of 50 cases without preoperative stress incontinence or concurrent incontinence surgery, 50% developed stress incontinence after diverticulum repair. Most of these were mild cases and only 10% sought subsequent surgery for stress incontinence.
In a series of 25 patients, 16% developed postoperative de novo stress incontinence. The cases were described as mild with only 1 out of 4 requiring surgical treatment. Risk factors for the development of de novo stress incontinence in this series were a diverticulum larger than 30 mm and proximal urethral location.25
Tancer et al (1983) reported no cases of recurrence, fistula formation, or stress incontinence in their series of 34 patients treated with partial ablation. Follow-up was from 4 months to 10 years. This group attributed most of the serious complications from excision procedures to overzealous attempts to completely remove the diverticular sac and neck.26
Marsupialization procedures, if limited to treatment of distal diverticula only, should have low complication rates. In a review of 17 cases treated in this manner, no cases of fistula formation, recurrence, stricture, or recurrent UTIs occurred. One case of mild, new-onset stress incontinence was noted.
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Further Reading
Keywords
urethral diverticulum, suburethral diverticulum, urethral diverticula, chronic cystitis, cystitis glandularis, glandular metaplasia, focal hyperplasia, pseudodiverticulum, paraurethral glands, obstruction of paraurethral ducts, suburethral cysts
