1. Evaluation and Management of Urethral Diverticula Howard B. Goldman, MD Section of Female Pelvic Medicine and Reconstructive Surgery Glickman Urologic and Kidney Institute The Cleveland Clinic Lerner College of Medicine Case Western Reserve University

2. 32 yo woman referred for cystocele No pain No voiding complaints Has noticed a vaginal bulge for 6 months G 1 P 1 - vaginal

4. urethra

5. Urethral Diverticulum Defect in the periurethral fascia with an outpouching of mucosa –Infection within periurethral glands – Obstruction and abscess formation – Rupture into urethral lumen  outpouchings Typically located dorsally and laterally Most common in 3 rd to 5 th decades of life

6. Presentation “Dysuria, Dyspareunia and Dribbling” Recurrent UTIs Urethral pain, pelvic pain, vag wall tenderness Purulent drainage per urethra Overactive bladder complaints: urgency, frequency, incontinence Romanzi et al. (J Urol, 2000): diverse presentations, mimics other disorders

7. Evaluation History and physical exam Careful palpation of distal anterior vaginal wall –Milk the urethra and observe meatus Cystoscopy Radiographic evaluation –Voiding cystourethrography (VCUG) –Ultrasonography (transvaginal, endourethral) –MRI ? Urodynamics - fluoro –Evaluate for stress urinary incontinence

8. VCUG Radiographic study of choice for years Voiding and post-void views important –Many patients cannot void on the table Blander et al. (Urology 2001): MRI and VCUG –VCUG missed 7% of diverticula and underestimated size and complexity

9. VCUG tic

10. Ultrasonography Transvaginal, endoluminal Relatively inexpensive, good visualization Operator dependant Siegel et al.: VCUG vs ultrasound. 13/15 diverticula detected with both modalities, but US showed extent and location better

11. Urethral diverticulum - US transurethral tic neck

12. CT vs MRI

13. Urethral diverticulum axial MRI

14. Urethral Diverticuli Management: –Conservative treatment measures: antibiotics, anticholinergics, anesthetics, etc.. Acutely or for very small tics –Operative Spence procedure –Very distal diverticulum Excision SUI considerations

15. Prepare Vaginal Wall Flap

16. Inicise Periurethral Fascial Tic

17. Prepare Periurethral Fascial Flaps Periurethral fascia flaps

18. Dissect Out and Excise Tic

19. Identify Ostium

20. Close Ostium

21. Closure of Dead Space

22. Periurethral Fascial Defect Closure

23. Close with Vaginal Wall Flap *Avoid overlapping suture lines

24. 32 yo woman referred for cystocele No pain No voiding complaints Has noticed a vaginal bulge for 6 months G 1 P 1 - vaginal

28. urethra

31. Urethral diverticulum axial MRI -saggital

36. ostium

37. Martius flap

38. Management of Stress Incontinence Faerber et al: simultaneous diverticulectomy and sling, no complications, no erosions, no SUI Vasavada et al: 5 diverticulectomies, xenograft tissue for sling, no erosions, no SUI Some controversy over whether to place sling at time of diverticulectomy – if place – never use synthetic mesh

39. Postoperative management Urethral catheter for 14 days VCUG?? complications: –stress incontinence (de novo) –urethrovaginal fistula –recurrence –Evaluate path specimen

40. 4/5 (80%) with Invasive adenoca had history of urinary retention

41. Long Term f/u of Diverticulum Recurrence N=122 50 month avg f/u 10.7% had surgery for recurrence –Risk factors Proximal diverticulum Multiple diverticula Prior vaginal or urethral surgery 26% persistent pain/discomfort with voiding 39% UTI in prior year Ingber et al, J Urol, 2011

42. Conclusions Diagnosis of urethral diverticula may be difficult High index of suspicion MRI is the gold standard for evaluation of suspect diverticula Surgery is the mainstay of therapy Careful exposure of all layers allows proper reconstruction Majority successfully treated