Urethral diverticulum

Question 1

risk of cancer developing in diverticulum

Answer 1

If conservative treatment is adopted, warn patients of the small (1–6%) risk of cancer developing within the diverticulum.

Question 2

history

Answer 2

Carefully question and investigate patients for co-existing voiding dysfunction and urinary incontinence.

Question 3

management incontinenc

Answer 3

Following appropriate counselling, address bothersome stress urinary incontinence at the time of urethral diverticulectomy with concomitant non-synthetic sling.
Weak
Counsel patients regarding the possibility of de novo or persistent lower urinary tract symptoms including urinary incontinence despite technically successful urethral diverticulectomy.

Question 4

definition urethral diverticulum

Answer 4

focal outpouchins of the urethra into the surrounding periurethral tissues

Question 5

age of urethral diverticulum

Answer 5

3rd to fifth decade

Question 6

prevalence in women with luts

Answer 6

up to 40%

Question 7

aetiology diverticulum

Answer 7

follows anatomical location periurethral glans at 3 or 9 oclock in middle and distal third urethra
occur due to acute infection of paraurethral glands
duct formation and abscess
relapsing or persistant infection causes weakening of urethral wall adjacent to gland and rupture into urethral lumen and epithelialisation of tract

Question 8

location of ostia

Answer 8

classicaly at 6 ocklock

Question 9

complications diverticular

tyypes of cancer

Answer 9

enoplastic transformation which may be benign or malignant - 60% adeno, 30% tcc, 10% scc
10% risk formation stones

Question 10

classical triad of diverticulum

Answer 10

dysuria
dyspareunia
dribbling

Question 11

diverticulum how much of wall

Answer 11

entire urethral wall or only by mucosa

Question 12

how many present with recurrent uti

Answer 12

1/3 due to stasis in the diverticilum

Question 13

other symptoms

Answer 13

stress or urgency incontinence
voiding luts
urinary retention
anterior vaginal wall pain and swelling
urethral discharge
urethral bleeding sign of malignant change or stone

relapsing remitting course
but most will be asymptomatic

Question 14

differential diagnosis anterior wall mass

Answer 14

mullerian remnant cyst
ureterocele
abscess
neoplasm
gartner duct cyst
skene gland cyst or abscess
vaginal inclusion cyst

Question 15

diagnosis

Answer 15

cystoscopy with finger on vagina to express pus
MCUG but will need generate enough pressure to fill ostia
MRI T2 weight image
T2-weighted MRI is the preferred modality, which shows increased signal intensity in diverticulum that contrasts well to the surrounding tissues
It is important not only to request sagittal as well as coronal views, but also to stress that the MRI scan should be performed as a post-voiding study; failure to do so will result in a number of diverticula being ‘missed’.

Question 16

conservative treatment

Answer 16

Conservative measures, in addition to just observation, include milking the diverticulum after voids to avoid urinary stagnation, and low dose prophylactic antibiotics to prevent infections

Question 17

surgery

Answer 17

the most common approach is transvaginal excision with reconstruction of the urethra
This should only be carried out in experienced hands as future continence will depend on the integrity of the sphincter mechanism

Question 18

complications surgery

Answer 18

Patients should be warned about the potential risks of surgery including fistula formation, dyspareunia, and postoperative incontinence

Urinary incontinence
Urethrovaginal fistula
Urethral stricture
Recurrent urethral diverticulum
Recurrent UTI
Bladder ureteric injury
Vaginal narrowing  scarring leading to dyspareunia

Question 19

principles closure

Answer 19

The general principles of excision can be summarized to include:

1. (i) Mobilization of well-vascularized vaginal skin flap(s); anterior vaginal wall flap
2. (ii) Complete excision of the urethral communication and diverticulum; identification of neck of the diverticulum or osia
3. (iii) Preservation of urethral anatomy and function; preservation of periurethral fascia
4. (iv) Watertight tension-free closure of urethra;
5. (v) Closure in multiple layers with non-overlapping suture lines. Absorbable sutures (Martius flap graft)

Question 20

blood supply martius fat pad

Answer 20

Blood supply threefold
Branches of external pudendal supply the graft superiorly and anteriorly
Obdurator braches enter fraft as its lateral border
Inferior labial artery and vein supply graft interirly
So can be mobilised superiorly or inferiorly

Question 21

stress incontinence postop
how many have stress pre op
how manyd evelop SUI post op

Answer 21

An important preoperative consideration is the presence of stress incontinence (found in up to 50% of patients).21
Some advocate concomitant incontinence surgery,22 whereas we favour a staged approach as resolution of symptoms may occur after excision and also as sling placement risks erosion.5
Stress incontinence develops in up 16% of patients postoperatively.23 It is associated with the excision of larger, circumferential or saddlebag lesions, probably due to the risk of sphincter injury.

Question 22

when is de novo SUI more common 2

Answer 22

De novo SUI seems to be more common in proximal and in large size (> 30 mm) diverticula.

Question 23

when is de novo SUI more common 2

Answer 23

De novo SUI seems to be more common in proximal and in large size (> 30 mm) diverticula.