V1-11: A Surgical Video Guide for a 6-Step Excision of Complex/Horseshoe Urethral Diverticula

Video

Introductions and Objectives
The true incidence of urethral diverticula is unknown, but it has been estimated at 0.6%-6.0%. Etiology is thought to arise from secondary obstruction of periurethral glands. The cure rate with excision has been estimated at 70-97%; however, surgical excision can be complicated by anatomical and functional outcomes. In this video, we present a 6-step technique for successful surgical excision of complex urethral diverticulum that minimizes risk of complications.

Methods
A 49 year old female was referred with complaints of pelvic pain, dysuria, postvoid dribbling and dyspareunia. A complete medical and surgical history was obtained. Physical exam revealed a 4 cm fluctuant periurethral mass on the anterior vaginal wall. The urethral meatus was not displaced. A pelvic MRI demonstrated a 4.7 cm x 4 cm complex horseshoe shaped mass surrounding the urethra consistent with a urethral diverticulum.

Results
The patient was consented for elective diverticulectomy using a vaginal approach which was performed without complication. Technical points which are emphasized in the video include the following: 1) optimal vaginal exposure, 2) maximal ventral dissection of the diverticulum first to expose the bivalve surface, 3) meticulous dorsal dissection of the diverticulum to develop a periurethral plane, 4) circumferential demonstration of the extent of the lateral horns or extensions of the diverticulum, 5) complete removal, and 6) a tension-free multilayer closure of the surgical field. Following successful excision, our postoperative care pathway included discharge the following day and urethral catheter removal after three weeks. Final pathology was consistent with a urethral diverticulum with benign tissue showing acute and chronic inflammation. At three month follow up, history and pelvic exam revealed no evidence of incontinence or dyspareunia.

Conclusions
Excision of urethral diverticula can be challenging, especially with a horseshoe shape or circumferential anatomy. The literature suggests that recurrence rates are higher with circumferential diverticula. Therefore, the goal of this video is to emphasize key technical points which may aid in ensuring complete excision without complications.

Funding: none