1. Urethral Diverticula Eric S. Rovner, M.D.
Medical University of South Carolina
Charleston, South Carolina

2. Urethral Diverticulum
Diverticulum forms within
the urethropelvic ligament
lined by epithelium (usually) 2

3. Glands located within submucosa
and inner longitudinal SM of urethra
Periurethral glands
Bladder lumen
Urethral lumen

4. Urethral Diverticula: Pathophysiology*
-Obstruction of paraurethral ducts/glands
……dilation
-Abscess formation (?)
-Rupture back into urethral lumen
-Residual epithelialized cavity with narrow neck
Bladder
Urethra
*Routh, 1890

5. Urethral Diverticula: Diagnosis
History:
-pain, UTI, dyspareunia, post-void dribbling, etc.
Physical examination:
-tender anterior vaginal wall mass with urethral discharge upon palpation
(Imaging)

6. Urethral Diverticula: Imaging
Why image ?
Confirm clinical diagnosis:
Skene’s gland cyst, leiomyoma, prolapse, etc.
Anatomy
location
sphincter/bladder neck
size/complexity/urethral involvement
ostia
Other: stones, tumor, etc.

7. Urethral Diverticula Imaging modalities in 2011:
PPU (Double balloon): rarely done, invasive
VCUG:
Invasive, painful
must void to image UD
ostia must be patent to image UD
poor stream will underestimate size, loculations(?)
Transvaginal Ultrasound
operator dependent
images lack precise “surgical anatomy”
MRI

8. Urethral Diverticula and MRI
Surface coil
Hricak, et. al., Radiology, 178:527, 1991 (9 patients)
Kim, et. al., AJR, 161:809, 1993 (16 patients)
Neitlich, et. al.., J. Urol., 159:408, 1998 (6 patients)
Endoluminal coil (endovaginal, endorectal)
Siegelman, et. al., Radiographics, 17:349, 1997
Blander, Rovner, et. al., Urology, 53:818, 1999 (case report)
Blander, Rovner, et al,Urology 57: 660, 2001 (27 patients)
Other imaging includes MRI. Penn reported the first series of patients using endoluminal technology. Would like to explore this in some detail

9. Endoluminal coil Area of interest is adjacent to coil
Improved resolution/contrast
Axial
Sagittal
Pubis
Urethra UD
Vaginal coil

10. Excision of Urethral Diverticula
Principles
-preservation of the periurethral fascia
-closure of dead space
-multi-layered closure
-identify and excise the neck or ostia
-remove entire sac (mucosa)
-preserve or create continence 13

11. Incision Headlight Magnification Lone Star retractor Injectable saline
Wide based anterior vaginal wall flap

12. Opening periurethral fascia
Transverse incision
Avoid early entry into UD

13. Dissection of UD Dissect within leaves of periurethral fasica to ostia
May partially resect urethral wall

14. Removal of UD sac Remove as much sac as possible
Should see foley catheter once UD removed

15. Urethral closure
4.0 double armed SAS interrupted or running to close ostia
Check closure with periurethral injection of saline with 14 g angiocath in urethral meatus

16. Reapproximation periurethral fascia
3.0 SAS
Martius flap if fascia deficient

17. Closure
2.0 SAS
Vaginal packing
7-10 d VCUG