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Urethral Diverticula Treatment & Management

  • Author: Sandip P Vasavada, MD; Chief Editor: Edward David Kim, MD, FACS  more...
 
Updated: Dec 01, 2015
 

Medical Therapy

Surgery is the current treatment of choice for urethral diverticula. To date, no known medical therapy exists for successful treatment of urethral diverticulum. Long-term low-dose antibiotic therapy may allow resolution of localized symptoms, but the anatomic abnormality remains. Treat infected urethral diverticula with appropriate antibiotics prior to surgery.

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Surgical Therapy

Multiple open surgical and endoscopic approaches have been described for the treatment of urethral diverticula. They include transurethral saucerization of the diverticulum, marsupialization of the diverticular sac into the vagina, and excision of the diverticulum.[6]

Transurethral saucerization of the urethral diverticulum involves incising the opening of the diverticulum to convert a narrow neck into a wide neck. In general, reserve this for distal diverticula because more proximal incision of the urethral wall may compromise continence.

The marsupialization of a diverticulum is performed by incising the urethrovaginal septum. It is essentially a generous meatotomy, which may result in vaginal voiding. As with endoscopic saucerization, overzealous incision or treatment of mid or proximal diverticula with this technique may result in urinary incontinence. This technique should be reserved for distal diverticula, although definitive reconstruction likely yields a better functional outcome. Distal marsupialization may lead to spraying of the urine stream and dyspareunia.

Numerous techniques are available for transvaginal excision. A popular transvaginal technique uses a vaginal flap. This technique allows complete excision of the diverticulum, closure of the urethral communication, reinforced coverage with periurethral fascia, and closure of the anterior vaginal wall. It allows a secure 3-layer closure without overlapping suture lines. See intraoperative images below.

The anterior vaginal wall and the periurethral fas The anterior vaginal wall and the periurethral fascia have been dissected off, exposing the urethral diverticulum.
The urethral diverticulum has been excised sharply The urethral diverticulum has been excised sharply. Foley catheter is visible through the neck of the diverticulum.
The urethral diverticulum is closed in 3 layers wi The urethral diverticulum is closed in 3 layers with nonoverlapping suture lines. The vaginal wall is closed.

For correction of coexisting stress urinary incontinence, a simultaneous pubovaginal sling or bladder neck suspension may be performed.[7]

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Preoperative Details

Prior to surgery, proper antibiotic therapy is mandatory. Reconstructive surgery in a patient with active urinary and diverticular infection may lead to urethrovaginal fistula formation or recurrent diverticula. Preoperative counseling should include discussion of possible complications such as infection, bleeding, recurrent diverticulum, urethrovaginal fistula, and urinary incontinence.

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Intraoperative Details

After general anesthesia is induced, place the patient in the lithotomy position. Sterilely prepare and drape the lower abdomen and genitalia. A percutaneous suprapubic catheter is often placed; many surgeons forego the suprapubic tube. After infiltrating the anterior vaginal wall with sodium chloride solution, make a U-shaped incision.

Mobilize the anterior vaginal wall flap to expose the diverticulum. Take care to prevent premature violation of the periurethral fascia or the diverticulum.

Transversely incise the periurethral fascia. Develop proximal and distal flaps of periurethral fascia and reflect them off the underlying diverticulum.

Dissect the diverticulum circumferentially down to its urethral communication and excise it completely. In the case of a very large diverticulum, the proximal portion may be left and the inner surface electrocauterized to destroy any epithelial elements.

Close the urethral defect vertically without tension using a running 3-0 or 4-0 absorbable suture incorporating both mucosal and muscular layers of the urethral wall.

Transversely reapproximate the periurethral fascia with a 2-0 or 3-0 absorbable suture constituting the second layer of closure to ensure that no dead space is left over the urethral repair. Planned interposition of a biological sling or Martius flap is performed before the third layer is started. The third layer of closure is the vaginal wall, which is closed with a running 2-0 absorbable suture.

Place an antibiotic-soaked vaginal pack and place both the suprapubic and urethral catheters to sterile drainage. The use of routine suprapubic tube drainage is left to surgeon discretion, but most experts have reserved suprapubic tube drainage for larger or more complex and extensive diverticula.

Important factors in operative success include precise anatomic dissection, a watertight closure, and closure in multiple layers. Avoid overlapping suture lines.

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Postoperative Details

Continue intravenous antibiotics for 24 hours postoperatively, followed by oral antibiotics until the catheters are removed. Belladonna and opium (B&O) suppositories or oral anticholinergics prevent bladder spasms.

The morning after the operation, remove the vaginal packing. The patient is usually discharged home the following day with both catheters still indwelling.

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Follow-up

Perform voiding cystourethrography 10-14 days postoperatively.

Discontinue anticholinergics 24 hours before the voiding study.

Remove the urethral catheter and instill the contrast into the bladder via the suprapubic catheter. If the surgeon elected not to place a suprapubic catheter, then place the contrast via the urethral catheter.

Carefully observe the urethra fluoroscopically during voiding. If no extravasation is observed and the patient empties the bladder to completion, remove the suprapubic tube. If the postvoid residual is more than 100 mL, leave the suprapubic catheter in place, intermittently unclamping it to drain the residual urine and perform residual urine checks until the bladder is satisfactorily emptying.

Some patients may present with extravasation during the first voiding study. If extravasation is observed, ideally more time is given to achieve optimal healing so the suprapubic catheter is placed to gravity drainage. Do not replace the urethral catheter. Perform repeat voiding cystourethrography in 7-10 days.

For patient education resources, see the Kidneys and Urinary System Center, as well as Bladder Control Problems.

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Complications

Patients with active diverticular infection may experience profuse bleeding during vaginal dissection. A large defect created during excision of a large diverticulum may result in urethral strictures. A large proximal diverticulum that extends under the trigone and bladder neck may result in the risk of ureteric injury. Operating on patients with active infection may lead to fistula formation. Urethrovaginal fistula formation is the most difficult complication of diverticular surgery. If it occurs, repair the fistula after an adequate period of healing, but usually several weeks to 3 months minimum healing should suffice.

Anterior vaginal infection is unusual but responds well to antibiotics. If a suburethral abscess forms, surgical drainage is required. If urethral diverticulum recurs, perform secondary surgery after a prudent period of observation. Secondary stress incontinence not present prior to surgical therapy may develop and is more likely in patients who undergo extensive dissection of the urethral wall or its lateral attachments or in the setting of large or proximal diverticula.

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Outcome and Prognosis

The success rate of urethral diverticulectomy has a range of 86-100%. Complications reported in the literature include the following:

  • Recurrent diverticulum (1-29%)
  • Stress incontinence (1.7-16%)
  • Urethral stricture (0-5%)
  • Recurrent urinary tract infection (0-31%)
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Contributor Information and Disclosures
Author

Sandip P Vasavada, MD Physician, Associate Professor of Surgery, Cleveland Clinic Lerner College of Medicine, Center for Female Urology and Genitourinary Reconstructive Surgery, The Glickman Urological and Kidney Institute; Joint Appointment with Women's Institute, Cleveland Clinic

Sandip P Vasavada, MD is a member of the following medical societies: American Urological Association, Engineering and Urology Society, American Urogynecologic Society, International Continence Society, Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Medtronic, Allergan and Axonics<br/>Received ownership interest from NDI Medical, LLC for review panel membership; Received consulting fee from allergan for speaking and teaching; Received consulting fee from medtronic for speaking and teaching; Received consulting fee from boston scientific for consulting.

Coauthor(s)

Raymond R Rackley, MD Professor of Surgery, Cleveland Clinic Lerner College of Medicine; Staff Physician, Center for Neurourology, Female Pelvic Health and Female Reconstructive Surgery, Glickman Urological Institute, Cleveland Clinic, Beachwood Family Health Center, and Willoughby Hills Family Health Center; Director, The Urothelial Biology Laboratory, Lerner Research Institute, Cleveland Clinic

Raymond R Rackley, MD is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Mark Jeffrey Noble, MD Consulting Staff, Urologic Institute, Cleveland Clinic Foundation

Mark Jeffrey Noble, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Kansas Medical Society, Sigma Xi, Society of University Urologists, SWOG

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.

Additional Contributors

Allen Donald Seftel, MD Professor of Urology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School; Head, Division of Urology, Director, Urology Residency Training Program, Cooper University Hospital

Allen Donald Seftel, MD is a member of the following medical societies: American Urological Association

Disclosure: Received consulting fee from lilly for consulting; Received consulting fee from abbott for consulting; Received consulting fee from auxilium for consulting; Received consulting fee from actient for consulting; Received honoraria from journal of urology for board membership; Received consulting fee from endo for consulting.

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The urethral diverticulum is shown as spherical mass at the distal urethra.
Voiding cystourethrogram reveals contrast pooling in a urethral diverticulum. The urethral diverticulum is located well away from the bladder neck at the distal urethra.
The anterior vaginal wall and the periurethral fascia have been dissected off, exposing the urethral diverticulum.
The urethral diverticulum has been excised sharply. Foley catheter is visible through the neck of the diverticulum.
The urethral diverticulum is closed in 3 layers with nonoverlapping suture lines. The vaginal wall is closed.
 
 
 
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