Giant Urethral Diverticulum in an Adult Male: A Complication of the Artificial Urinary Sphincter

Abstract

Urethral diverticulum in the male is a rare entity that may be congenital or acquired. An acquired diverticulum usually results from infection, urethral stricture or trauma.1 Patients typically present with symptoms of urinary incontinence, dysuria, perineal pain, or a mass on the ventral aspect of the genitalia or perineum. We report a case of a large male urethral diverticulum occurring after placement of an artificial urinary sphincter (AUS). CASE REPORT A 70-year-old male underwent radical retropubic prostatectomy for adenocarcinoma of the prostate in 1997. Postoperatively, incontinence and erectile dysfunction developed, and in 1999 the patient underwent placement of an inflatable penile prosthesis and AUS. During the following 2 to 3 years he experienced progressive left scrotal swelling, intermittent dysuria, recurrent urinary tract infections and microhematuria. He was treated with long-term antibiotic therapy. Ultimately, radiographic evaluation demonstrated urethral extravasation with associated urinoma. The AUS was removed and the urinoma drained. A urethral catheter was left indwelling. He was subsequently evaluated after the catheter had been indwelling for 3 months. A repeat retrograde urethrogram at that time revealed persistent extravasation of contrast material from the bulbous urethra. Physical examination showed passage of urine from the meatus around the urethral catheter with palpation of the visibly enlarged scrotum. Voiding cystourethrogram (VCUG) demonstrated a large urethral diverticulum filling the scrotum during the voiding phase (fig. 1). Flexible cystoscopy confirmed an opening within the mid bulbous urethra leading into an extensive smooth walled diverticulum. The patient underwent surgical exploration in the exaggerated lithotomy position. An 18Fr soft silicone catheter was placed through the urethra and into the bladder. A midline perineal and scrotal incision was made. The large diverticulum was identified and dissected from the surrounding tissues. After it was free ventrally and laterally the diverticulum was opened to expose better its communication with the urethra (fig. 2). After complete resection of the diverticulum the urethra was closed with interrupted 4-zero polydioxanone sutures. The operative wound was then closed in layers and drained. VCUG 2 weeks postoperatively revealed a nicely patent urethra without extravasation. The patient was to be considered for a repeat AUS after approximately 6 months.