Outcomes of Surgery of Female Urethral Diverticula Classified Using Magnetic Resonance Imaging

doi:10.1016/j.eururo.2007.01.103

European Urology

Volume 51, Issue 6, June 2007, Pages 1664-1670

https://doi.org/10.1016/j.eururo.2007.01.103 Get rights and content

Abstract

Objectives

We evaluated the surgical outcomes of transvaginal diverticulectomies classified using magnetic resonance imaging (MRI).

Methods

We evaluated 30 women (mean age: 46.4 yr; range: 31–73 yr) who were followed up for at least 12 mo after urethral diverticulectomies (mean follow-up: 29 mo; range: 12–93 mo). Characteristics of urethral diverticula were confirmed before surgery by MRI. Diverticula were classified as simple, U-shaped, or circumferential according to MRI features. Transvaginal excisions of urethral diverticula were performed using vaginal flaps and three-layer closures. Cure was defined as the absence of a diverticulum and symptoms.

Results

Seventeen cases (57%) had simple diverticula, three (10%) had U-shaped diverticula, and 10 (33%) had circumferential diverticula. After the first operation, 23 cases (77%) were cured. None of the simple diverticula recurred, but 33% of the U-shaped and 60% of the circumferential diverticula did recur. Of the seven recurrent cases, three did not require a second operation because their symptoms resolved. Of the four cases that underwent a second operation, three were cured and one was cured after two additional operations. The success rate for circumferential diverticula after initial diverticulectomies was less than that of simple or U-shaped diverticula (p < 0.05). Location, size, and multiplicity of urethral diverticula did not affect the surgical outcome (p > 0.05).

Conclusions

Transvaginal diverticulectomy is effective for treatment of female urethral diverticula. For circumferential urethral diverticula, however, surgical procedures should be adapted to achieve complete resections of the diverticulum.

Introduction

Female urethral diverticulum (UD) is uncommon and is present in 0.6–6% of the population [1], [2]. The majority of cases present during the third to fifth decade of life, but cases of neonates and young female subjects have been reported [3]. It is difficult to diagnose female UDs because of the wide range of nonspecific symptoms and because 3–20% of patients are asymptomatic [1], [4], [5]. Several treatment methods have been described for symptomatic UDs. Although transvaginal diverticulectomy is an effective procedure [3], [4], [6], it is generally considered difficult because of the normal anatomic fusion of the urethra to the anterior vaginal wall, the lack of cleavage planes, and the involvement of the UD with the urethral sphincter mechanism. Consequently, this treatment is sometimes unsuccessful, resulting in a persistent symptomatic UD or other complications such as urethrovesical fistulae or stress urinary incontinence (SUI) [7].

We evaluated the surgical outcomes of transvaginal diverticulectomy according to the classification using MRI and identified preoperative factors that affect the success of the procedure.

Section snippets

Methods

Five years prior to this study, 35 patients underwent urethral diverticulectomies at our institution. We conducted a review of the medical records of 30 women who were followed up for at least 12 mo after surgery. Preoperative evaluation included a thorough medical history, physical examination, urinalysis, and cystourethroscopy. Radiological imaging, including transvaginal ultrasonography (USG) and pelvis magnetic resonance imaging (MRI) using a surface coil, was performed to confirm the

Results

The mean age of patients who underwent diverticulectomy was 46.4 yr (range: 31–73 yr). The mean duration of symptoms at the time of presentation was 26.6 mo (range: 1 mo to 10 yr). The presentations were diverse. The most common symptom was dysuria (11 patients, 37%). We observed palpable vaginal masses in seven patients (23%), postvoid dribbling in six patients (20%), SUI in six patients (20%), pus discharge from the urethra in five patients (17%), and perineal pain in five patients (17%).

Discussion

All 30 cases of UD were cured by urethral diverticulectomy. The cure rate after the first operation was 77% and depended on the configuration of the UD as defined by MRI.

Female UD is an uncommon surgical entity. It was first described by Hey in 1805 [8] and was rarely reported until the introduction of positive-pressure urethrography in 1956 [9], [10]. Female UD can be diagnosed using a combination of the patient’s history, physical examination, cystourethroscopy, and imaging. However,

Conclusions

The transvaginal approach for diverticulectomy is effective for treatment of female UD. However, the success rate of UDs with circumferential configurations according to MRI was significantly lower than that of simple or U-shaped UDs. This is most likely because complete resection of circumferential UDs is difficult. In cases of circumferential UDs, the surgical procedure must be adapted to achieve complete resection and layered closure.

Conflicts of interest

Authors disclose that they do not have any commercial relationship such as consultancies, stock ownership or other equity interests, patents received and/or pending, or any commercial relationship which might be in any way considered related to this submitted article.

References (22)

A.M. Aspera et al.
Contemporary evaluation and management of the female urethral diverticulum
Urol Clin North Am
(2002)
K. Ganabathi et al.
Experience with the management of urethral diverticulum in 63 women
J Urol
(1994)
A. Gómez Gallo et al.
Giant lithiasis in a female urethral diverticulum
Eur Urol
(2007)
W.W. Leng et al.
Management of female urethral diverticula: a new classification
J Urol
(1998)
H.J. Davis et al.
Urethral diverticula: an assay of 121 cases
J Urol
(1958)
D.S. Blander et al.
Endoluminal magnetic resonance imaging in the evaluation of urethral diverticula in women
Urology
(2001)
L.J. Romanzi et al.
Urethral diverticulum in women: diverse presentations resulting in diagnostic delay and mismanagement
J Urol
(2000)
J.D. Neitlich et al.
Detection of urethral diverticula in women: comparison of a high resolution fast spin echo technique with double balloon urethrography
J Urol
(1998)
M. Ellik
Diverticulum of the female urethra: a new method of ablation
J Urol
(1957)
B.L. Davis et al.
Diverticula of the female urethra: assay of 120 cases
J Urol
(1970)

J. Lapides

Transurethral treatment of urethral diverticula in women

J Urol

(1979)

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The female urethra is a short tubular structure surrounded by a number of complex and closely associated pelvic structures. This presents challenges to the clinical diagnosis of urethral and periurethral pathologies. Magnetic resonance imaging (MRI) provides the opportunity for detailed assessment of the female urethra due to its excellent soft tissue differentiation and superior contrast resolution. Comprehensive evaluation of urethral and periurethral pathologies is essential for characterization of both benign and malignant etiologies and plays a critical role in diagnosis and management.
Surgical Outcomes of Primary and Recurrent Female Urethral Diverticula
2017, Urology
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This study also confirmed circumferential configuration as the sole independent factor of a lower cure rate. This study was conducted over a longer period of time with more patients, yet the results were consistent with those of our prior study.5 Previous studies have consistently reported highly diverse factors related to UD recurrence.
To evaluate the surgical outcomes of female urethral diverticulectomy.
We retrospectively analyzed the medical records of 68 patients with symptomatic urethral diverticula (UD) with at least 1 year of follow-up data following transvaginal urethral diverticulectomy conducted by a single surgeon. The presence of UD was confirmed by a preoperative magnetic resonance imaging (MRI). According to MRI findings, the UDs were classified as simple, U-shaped, or circumferential. Cure was defined as the absence of residual diverticulum on a postoperative MRI with a resolution of symptoms.
There were 27 cases (39.7%) of simple, 16 cases (23.5%) of U-shaped, and 25 cases (36.8%) of circumferential diverticula. The initial cure rate for UD was 77.9%. According to configuration, the cure rates for simple, U-shaped, and circumferential diverticula were 100%, 75.0%, and 64.0%, respectively (P = .043). Of the 15 patients with UD recurrence, 4 did not require reoperation because of symptom resolution. Of the 11 cases that underwent a second operation, 8 patients were cured: 7 via a Martius labial fat pad interposition (MLFI) procedure and 1 via simple excision without MLFI. The overall cure rate was 92.6%. The circumferential configuration was an independent factor for a lower cure rate (odds ratio, 7.97; 95% confidence interval, 1.14-55.69).
Transvaginal diverticulectomy is an effective treatment for female UD. The success rate of an initial surgery was significantly lower for UDs with circumferential configurations than for simple or U-shaped UDs. Regardless of the initial configuration, MLFI is a good treatment option for recurrent or persistent diverticula.
ACR appropriateness criteria pelvic floor dysfunction
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Imaging can assess for urethral diverticulum, vaginal wall cyst, or mass [42]. The size and complexity of a urethral diverticulum and its relationship to surrounding anatomy on MRI can affect surgical management [43-45]. The distinction between a urethral diverticulum and a Skene gland cyst or a vaginal wall cyst alters the surgical approach, and risk of complication, and can be made in most cases with MRI [46-48]. (
Pelvic floor dysfunction is a common and potentially complex condition. Imaging can complement physical examination by revealing clinically occult abnormalities and clarifying the nature of the pelvic floor defects present. Imaging can add value in preoperative management for patients with a complex clinical presentation, and in postoperative management of patients suspected to have recurrent pelvic floor dysfunction or a surgical complication. Imaging findings are only clinically relevant if the patient is symptomatic. Several imaging modalities have a potential role in evaluating patients; the choice of modality depends on the patient’s symptoms, the clinical information desired, and the usefulness of the test.
The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions; they are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals, and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
Simple vs complex urethral diverticulum: Presentation and outcomes
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Of the 2 recurrences in the complex cohort, 1 patient elected to undergo repeat operation, whereas the other patient was minimally symptomatic and elected not to undergo further treatment. This recurrence rate of 18% in the complex group is consistent with recurrence rates published in the literature.16,20,21 It is also important to note that these “recurrences” may be due to new UD formation and not necessarily failure.
To determine whether complex anatomic configurations of urethral diverticula (UD), namely circumferential UD (cUD), present differently or confer a worse prognosis as compared with simple UD (sUD).
After institutional review board approval, a retrospective review of patients who underwent transvaginal urethral diverticulectomy at a single institution over an 8-year period was performed. A total of 43 patients were identified, of which 11 were found to have cUD. These lesions were repaired with complete division of the urethra to access the dorsally located portion of the UD, followed by end-to-end anastomosis for urethral reconstruction with a Martius flap and/or autologous fascial pubovaginal sling performed as needed. Presenting symptoms and surgical outcomes were reviewed.
Mean age was 50.9 years in the cUD vs 52.7 years in the sUD. Patients with cUD were more likely to present with stress urinary incontinence than those with sUD (90.9% vs 56.3%; P = .04). There was no statistical difference in the rate of preoperative urgency, pelvic pain and/or dyspareunia, postvoid dribbling, and urinary tract infection. Postoperatively, patients with cUD were more likely to have a urinary tract infection (27% vs 3%; P = .2); otherwise, rates of postoperative results were similar.
Urethral transection and end-to-end anastomosis for the repair of complex UD is a feasible approach and results in similar clinical outcomes compared with the repair of sUD.
Imaging of the female urethral diverticulum
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Additionally, the high cost of MRI remains a deterrent to its use as a first-line imaging study in the investigation of suspected urethral diverticulum. Asymptomatic women can be managed conservatively, whereas a standard therapy for symptomatic women is surgical excision, diverticulectomy, with cure rates ranging from 70–97% in the reported literature.3,10,21 The reoperation rate for primary urethral diverticulum repair in a contemporary series was approximately 9%.3
Female urethral diverticulum is a localized out-pouching of the urethra that is becoming increasingly prevalent, but often poses a diagnostic challenge. Traditionally, conventional voiding cystourethrography has been used to make the preoperative diagnosis. With the development of higher-resolution images acquired through ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI), the anatomy and various abnormalities of the female urethra can be better elucidated. This article focuses on the imaging features of female urethral diverticulum, with emphasis on diagnostic pearls, particularly using MRI. Female urethral diverticulum can be best identified by their location in the posterolateral urethra and by their communication with the urethral lumen. Improved imaging techniques combined with increased physician awareness of urethral diverticulum will lead to more prompt and accurate diagnosis of this entity, leading to better treatment of affected patients.
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Female Urology – IncontinenceOutcomes of Surgery of Female Urethral Diverticula Classified Using Magnetic Resonance Imaging

Abstract

Objectives

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Conclusions

Conflicts of interest

Urol Clin North Am

J Urol

Eur Urol

J Urol

J Urol

Urology

J Urol

J Urol

J Urol

J Urol

J Urol

Female Urology – Incontinence
Outcomes of Surgery of Female Urethral Diverticula Classified Using Magnetic Resonance Imaging