Excision Of Urethral Diverticulum Research Articles

MP74-01 CHARACTERISATION OF FEMALE URETHRAL STRICTURES

You have accessJournal of UrologyCME1 Apr 2023MP74-01 CHARACTERISATION OF FEMALE URETHRAL STRICTURES Elizabeth Day, Helena Gresty, Anthony Noah, Richard Nobrega, Jeremy Ockrim, and Tamsin Greenwell Elizabeth DayElizabeth Day More articles by this author , Helena GrestyHelena Gresty More articles by this author , Anthony NoahAnthony Noah More articles by this author , Richard NobregaRichard Nobrega More articles by this author , Jeremy OckrimJeremy Ockrim More articles by this author , and Tamsin GreenwellTamsin Greenwell More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003348.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Female urethral stricture (FUS) is rare. We have assessed the history, imaging and urodynamic characteristics of all women seeking urethroplasty for recurrent symptomatic strictures. METHODS: A retrospective review of 63 consecutive women (median age 50.5 years, range 25-71) with recurrent or refractory FUS undergoing urethroplasty since June 2012. Data was analysed for symptom profile, aetiology and previous therapy. MRI, videourodynamic (VUDS) and examination findings provided stricture length and site. RESULTS: Median duration of symptoms was 60 months (range 24-456). The commonest symptoms were poor flow 61 (97%), frequency 48 (76%), nocturia 46 (73%), urgency 44 (70%), recurrent UTI 41 (65%) and urethral pain 40 (63%). The commonest causes of FUS are, unknown in 37 (59.7%), urethral instrumentation/catheterisation in 7 (11.1%), urethral diverticulum excision in 4 (6%), radiotherapy in 3 (4.7%), none relaxing sphincter in 3 (4.7%) and lichen planus in 2 (3.2%). The women had had a median of 5 previous urethral dilatations (range 0-33). 38 (60%) had been performing ISC for a mean of 24 months (range 6-120) and 31 (82%) found it painful. Pre-operative MRI pelvis was performed in 56 (89%) and revealed a concentrically thickened urethra in 35 (63%), urethral diverticulum in 4 (6%), an absent/fibrotic urethra in 4 (6%), and no abnormalities in 13 (21%). Pre-operative VUDS were performed in 57 (90%). Bladder outflow obstruction (BOO) was seen in 56 (98%). Preoperatively median Qmax was 5 mls/s (range 0-24), median Pdet Q max was 70 cm H2O (range 0-165) and median Solomon-Greenwell BOOIf was 51.4 (range -24.2-156.2) (where BOOIf >5 =>50% chance of BOO). Other findings included detrusor overactivity in 22 (39%) and stress urinary incontinence in 7 (12%).Median stricture length was 2.0 cm (range 0.5-4.0 cm) and the commonest sites were mid-distal in 20 (32%) and distal in 19 (30%). 53 (84%) had ventral onlay buccal mucosal graft urethroplasty, 6 (10%) had ventral vaginal flap urethroplasty, 2 (3%) had ventral onlay labial minora flap urethroplasty and 1 (1.5%) had a ventral vaginal graft urethroplasty – with stricture free status in 55 (87%) at last follow-up (median 39 months, range 4-112). CONCLUSIONS: Poor flow is present in almost all women with FUS. The majority will also have irritative LUTS, recurrent UTIs and urethral pain. VUDS and MRI are useful pre-operatively to characterise the stricture. Definitive treatment with urethroplasty should be considered earlier once endoscopic management has failed. Source of Funding: Nil © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1069 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Elizabeth Day More articles by this author Helena Gresty More articles by this author Anthony Noah More articles by this author Richard Nobrega More articles by this author Jeremy Ockrim More articles by this author Tamsin Greenwell More articles by this author Expand All Advertisement PDF downloadLoading ...

Stress urinary incontinence following urethral diverticulum excision: Incidence and management

Stress urinary incontinence following urethral diverticulum excision: Incidence and management

MP56-04 THE PRESENTATION, MANAGEMENT AND OUTCOME OF FEMALE URETHRAL DIVERTICULUM SURGERY – DIFFERENT BUT EQUALLY EFFECTIVE EITHER SIDE OF THE POND

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: Urethral Reconstruction (including Stricture, Diverticulum) III (MP56)1 Sep 2021MP56-04 THE PRESENTATION, MANAGEMENT AND OUTCOME OF FEMALE URETHRAL DIVERTICULUM SURGERY – DIFFERENT BUT EQUALLY EFFECTIVE EITHER SIDE OF THE POND Rachel Barratt, Catherine Culp, Helena Gresty, Jeremy Ockrim, Eric Rovner, and Tamsin Greenwell Rachel BarrattRachel Barratt More articles by this author , Catherine CulpCatherine Culp More articles by this author , Helena GrestyHelena Gresty More articles by this author , Jeremy OckrimJeremy Ockrim More articles by this author , Eric RovnerEric Rovner More articles by this author , and Tamsin GreenwellTamsin Greenwell More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002086.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To assess symptomatic and functional outcomes of urethral diverticulum excision in women and to compare management and outcomes at 2 high volume centres – 1 in the UK and 1 in the USA. METHODS: Retrospective review of the notes and imaging of all female patients having excision of a symptomatic urethral diverticulum between 2004 and 2018 for symptomatic urethral diverticulum. Data on patient demographics, urethral diverticulum characteristics and outcomes in particular symptomatic resolution, diverticulum recurrence and persistent/new onset urinary incontinece were noted.Statistical analysis was by Students T -Test and Chi-Squared. Significance was taken as P< 0.05. RESULTS: 191 women median age 45 years (range 19-78) had excision of their urethral diverticulum +/- Martius Fat Pad Interposition (N= 131) during the study period. 21(11%) patients had a simultaneous pubovaginal sling (PVS) or mid-urethral tape (MUT). 169 (88%) had preoperative pelvic MRI, 134 (79.2%) had pre-operative video-urodynamics and 124 (65%) had a complex urethral diverticulum.2 (1%) women had symptomatic and 3 (1.5%) had asymptomatic (on MRI only) urethral diverticulum recurrence at a mean follow-up of 24.2 months (range 0-156). Urinary incontinence was present in 164 (85.8%) pre-operatively and 64(33.5%) post-operatively; 32 (16.8%) of whom rated their incontinence as mild. Other symptomatic outcomes are detailed in Table 1: *P < 0.05 CONCLUSIONS: The commonest symptoms of urethral diverticulum are lump in the vagina, urethral or vaginal pain and dysuria. Following excision, the majority of symptoms resolve with urethral discharge most likely and frequency/urgency least likely to resolve. There are significant differences in outcomes for post-micturition dribble, urethral or vaginal pain, poor flow, recurrent UTIs and frequency/urgency between the 2 centres which most likely represent patient and diverticulum factors rather than treatment factors. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e970-e970 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rachel Barratt More articles by this author Catherine Culp More articles by this author Helena Gresty More articles by this author Jeremy Ockrim More articles by this author Eric Rovner More articles by this author Tamsin Greenwell More articles by this author Expand All Advertisement Loading ...

Robotic assisted retrovesical approach to prostatic utricle excision and other complex pelvic pathology in children is safe and feasible

Excision of the prostatic utricle has been a challenging surgical problem due to the location deep in the pelvis between the rectum and bladder. Robotic-assisted laparoscopic surgery allows minimally invasive access to this location. To describe the robotic surgical outcomes and important techniques associated with robotic excision of the prostatic utricle and explain how these techniques apply to similar pediatric pelvic pathology. Retrospective chart evaluation of patients treated at a single institution with robotic excision of a prostatic utricle as well as two other patients in which the similar approach was employed. 4 patients underwent robotic excision of a prostatic utricle. A fifth patient underwent excision of urethral diverticulum that was the remnant of an ectopic ureter. The sixth patient had a high urogenital sinus that required laparoscopic assisted vaginoplasty approached in a similar manner to the above listed cases. Mean age at surgery was 35.5 months for the utricle patients. Mean follow-up duration for the utricle patients was 30.75 months. Average hospital stay for the utricle patients was one day. In the utricle patients one patient developed transient urinary retention and one had a postoperative urinary tract infection. Concomitant cystoscopy used in the two non-utricle patients was a key step in defining the proper location of dissection. Robotic-assisted laparoscopic retrovesical excision of the prostatic utricle is a safe operation that requires a skill set that can be readily applied to other complex pelvic pathology such as the ectopic ureter, urethral diverticulum, and urogenital sinus. Concomitant cystoscopy can aid significantly in defining the location and limits of dissection.

Stress Urinary Incontinence After Urethral Diverticulum Repair Without Concomitant Anti-Incontinence Procedure

ObjectiveTo review the rates of persistent and de novo stress urinary incontinence (SUI) following urethral diverticulum (UD) repairs performed without concomitant SUI surgical procedures. MethodsFollowing IRB approval, charts of women who underwent UD excision by three FPMRS surgeons were reviewed. Data collected from the electronic medical record included demographic information, preoperative symptoms and evaluation (validated questionnaires [UDI-6, QoL]), imaging studies, operative details, post-operative symptoms, and subsequent surgical interventions. Excluded were women with <6 months follow-up or concomitant pubovaginal sling placement. SUI was diagnosed by patient report, and UD was confirmed by preoperative magnetic resonance imaging or voiding cystourethrogram. The primary outcome was defined as the rate of SUI following UD repair. Secondary outcomes included resolution of pre-operative SUI, rate of self-reported secondary SUI, and SUI surgical intervention post-UD repair. ResultsFrom 2003-2018, 61 of 67 women met study criteria. SUI pre-UD repair was reported in 31 of 61 (51%). During UD repair, 3 patients underwent Martius flap interposition. Post-UD repair, 18/61 (30%) reported SUI. Persistent SUI was present in 14 of 31 (45%), and de novo SUI occurred in 4 of 30 (13%). Postoperative responses revealed statistically significant improvements in QoL and most questions of UDI-6 at median 18 months. SUI was surgically managed in 3 patients using bulking agent injections (2) and autologous fascial sling placement (1). Overall, 3 of 61 (5%) underwent SUI intervention post-UD repair. ConclusionWithout prophylactic SUI corrective procedures performed during UD repair, we observed a low rate of de novo SUI, and only 5% with bothersome SUI opting for surgical intervention.

Comparison of Supine and Prone Positioning in Female Patients Undergoing Urethral Diverticulum Excision

Comparison of Supine and Prone Positioning in Female Patients Undergoing Urethral Diverticulum Excision

The Modified Prone Jack-knife Position for the Excision of Female Urethral Diverticula

BackgroundFemale urethral diverticula (UD) are an uncommon and often overlooked aetiology in women presenting with lower urinary tract symptoms, urethral pain, and recurrent urinary tract infection. With increasing awareness, appropriate imaging is more commonly undertaken with consideration given to surgical management. ObjectiveThe video presented demonstrates the technique for excising large and/or complex UD using a modified prone jack-knife position—a position that offers excellent surgical access and allows the surgeon to operate in a more ergonomic position. Design, setting, and participantsA retrospective review of the data on patients undergoing excision of UD at a tertiary referral unit was performed. Surgical procedureUrethral and suprapubic catheters (±insertion of ureteric stents) were placed in supine position. UD excised in the modified prone jack-knife position (±placement of a Martius flap). MeasurementsSubjective cure rate, recurrence rate, rates of postoperative urinary incontinence, need for secondary incontinence procedure, and postoperative complications were measured. Results and limitationsA total of 121 patients were operated on in the study period. The mean follow-up time was 10 mo (range 3–40). The most frequent presenting symptoms included a vaginal mass (n = 76, 63%), followed by dysuria (n = 72, 60%) and pelvic pain (n = 71, 59%). An identifiable aetiological factor was present in 45 patients, including traumatic vaginal delivery (18, 15%), prior periurethral surgery (17, 14%), and urethral dilatation (10, 8%). All patients underwent postvoiding magnetic resonance imaging (MRI) to confirm the diagnosis and plan surgery. UD ranged in maximum diameter from 8 to 48 mm, with a mean of 43 mm (standard deviation 9.24). The most common anatomical location was midurethral (55, 46%), followed by distal (36, 30%), proximal (25, 21%), and full length (5, 4%). Most UDs were single in configuration (74%), followed by multiloculated (15%), saddle shaped (7%), and circumferential (5%). On preoperative videourodynamics, 17 (14%) had stress urinary incontinence. UD excision was undertaken in the modified prone jack-knife position in all cases. A Martius flap was utilised in 36 (30%). The median postoperative postvoiding residual was 26 ml (interquartile range 0–40). In total, 88 (73%) patients were continent postoperatively and 16 (13%) experienced de novo stress urinary incontinence. Of the 37 with pre-existing stress incontinence symptoms, 20 (54%) were continent after operation. A total of 14 patients had subsequent autologous fascial sling at 6 mo. In total, five symptomatic recurrences occurred (4%); of these patients, three elected to undergo surgical excision, all of whom had symptom resolution and were continent after operation. A total of 11 patients (9%) experienced a Clavien-Dindo grade I–II complication within 90 d after operation. Five patients complained of dyspareunia, which resolved by 6 mo. ConclusionsThe modified prone jack-knife position facilitates excellent access for excision of both simple and complex UDs. This positioning of the patient is not widely recognised amongst urologists. Using this approach, there were low rates of symptomatic recurrence and de novo stress incontinence at medium-term follow-up. Associated urinary incontinence resolves in over half of patients following UD excision; hence, we advocate deferring any incontinence procedure until after the results of surgery are established. Patient summarySurgical removal of urethral outpouching (diverticula) in women is challenging due to its potential to damage the nearby sphincter muscle, which controls continence, or the urethra tube. Placement of patients on their front, rather than on their back, provides excellent access for the surgical removal of urethral diverticula. With this approach, we achieved excellent rates of cure and low rates of urinary incontinence at an average follow-up of 10 mo.

Transvaginal surgical repair of large urethral diverticula with bipedicle double-opposing flaps of the periurethral fascia.

The aims of this study were to describe a novel technique for transvaginal repair of large (> 4cm) female urethral diverticulum (UD) using bipedicle double-opposing flaps of the periurethral fascia and to evaluate long-term follow-up. The medical records of 29 women who underwent transvaginal excision of UD at our institution were reviewed retrospectively. Seventeen cases with UD > 4cm were included in the study. Cystourethroscopy was performed at the beginning of the surgery, and in 60% of cases the orifice of the diverticulum was identified. An inverted-U incision was performed at the vaginal anterior wall. The periurethral fascia was incised longitudinal at the midline and parallel to the urethra. The diverticular sac was dissected and resected. The neck of the diverticulum was closed with 4/0 vicryl suture. The periurethral fascia was sutured using bipedicle double-opposing flaps with interrupted 3/0 vircyl suture. The vaginal mucosa was sutured with 2/0 vicryl continuous suture. All 17 women with large UD were operated on using bipedicle double-opposing flaps of the periurethral fascia. Follow-up of 5 ± 2.4years yielded no recurrence and no other late complications. Using bipedicle double-opposing flaps of the periurethral fascia during transvaginal excision of large UD is safe and effective.

708 - Continence outcomes after urethral diverticulum excision

708 - Continence outcomes after urethral diverticulum excision

699 - Pre-operative MRI findings and predictors of De Novo stress urinary incontinence after urethral diverticulum excision

699 - Pre-operative MRI findings and predictors of De Novo stress urinary incontinence after urethral diverticulum excision

The incidence and outcomes of urodynamic stress urinary incontinence in female patients with urethral diverticulum

To assess the incidence and management of urodynamic stress urinary incontinence (USUI) in women undergoing transvaginal excision of a urethral diverticulum (UD) at our institution. A prospective database, capturing patients undergoing urethral diverticulectomy over a 9-year period (May 2007 to August 2016), was reviewed focusing on USUI and subsequent management. One hundred patients underwent UD excision (with modified Martius labial fat-pad flap interposition). Preoperative magnetic resonance imaging data, available in 90 patients, demonstrated that 80% had complex diverticula. Complete urodynamic data were available for 93 patients. Preoperatively, 27 patients (29%) had USUI of which 16 patients resolved with either UD excision alone (n = 8) or 3 months of pelvic floor muscle therapy (PFMT) (n = 8). All 11 with persistent postoperative USUI had video urodynamics (VUDs) confirming Blaivas type 3 USUI. Six patients had a rectus fascial pubovaginal sling (RFPVS) with success in five (83.3%) while five had a mid-urethral obturator tape (MUT-O) with 100% success. Sixteen patients developed de novo stress urinary incontinence (SUI) postoperatively, with resolution after PFMT in 12 (75%). VUDS identified USUI (Blaivas type 3) in two (of the remaining four) patients, managed successfully with MUT-O (n = 1) and RFPVS (n = 1). Preoperative USUI is present in 29% with UD. Postoperatively, 35.5% (n = 33) have pre-existing (19) or de novo (14) SUI, of which 60.6% (n = 20) resolves after 12 months of conservative management. Surgery for USUI is required in 13 (13.9%), with cure in 92.3%. This supports our practice to excise UD primarily and delay USUI surgery, therefore, avoiding overtreatment for the majority.

Correlation of MRI features of urethral diverticulum and pre- and post-operative stress urinary incontinence.

The complexity of urethral diverticulectomy depends on location, size, and degree of circumferential involvement. MRI features were examined to predict functional outcome after surgery for urethral diverticulum (UD). A prospectively acquired database was of all patients who have had surgical excision of UD at a tertiary center since 2004 was reviewed. Particular focus was pre- and post-operative urodynamically proven stress urinary incontinence (USUI), and pre-operative MRI features. MRI parameters included diverticular volume, degree of circumferential involvement around the urethra, distance of the Os of UD to bladder neck and urethral length. Students t-test and Mann-Whitney U-test were used to compare rates of de novo USUI. There were 100 patients (mean age 45.8 yrs), who had excision of UD since 2004, with a minimum follow-up of 10 months (range 10-112 months). Full MRI data was available for 83 patients. Fourteen were of simple configuration (16.8%), 32 were horseshoe (38.6%), and 37 (44.6%) were circumferential. Twenty-five (25%) patients had pre-operative USUI, while 12 (12%) patients developed de novo USUI post-excision. While, the majority of patients with de novo USUI (67%) had >270° circumferential involvement of urethra, the pre-operative diverticular volume did not predict the likelihood of USUI developing (P = 0.3). A shorter urethral length was associated with pre-operative USUI. 25% of all patients had pre-op USUI, and diverticular volume and urethral length was significantly smaller in this group. The majority of patients with de novo USUI had complex diverticula configuration with higher baseline circumferential angle around urethra, with 67% of angle's between 270 and 360°.

Preliminary report on the effect of urethral diverticulum magnetic resonance imaging configuration on the incidence of new onset urodynamic stress urinary incontinence following excision.

Context:Excision of urethral diverticulum in females has been reported to be associated with new onset urodynamic stress urinary incontinence (USUI) in up to 49%.Aims:We have assessed the incidence of new onset USUI in all patients having urethral diverticulum excision with Martius fat pad interposition under the care of a single surgeon between May 1, 2007, and December 1, 2011. The incidence of new onset USUI has been correlated with the preoperative magnetic resonance imaging (MRI) appearance of the urethral diverticulum.Patients and Methods:All 33 patients (mean age 42) having urethral diverticulum with Martius fat pad interposition had prospective data tabulated on demographics, preoperative MRI appearance, and pre- and post-operative videocystometrogram.Statistical Analysis Used:Statistical analysis was performed by Chi-squared and Fisher's exact.Results:Of the 33 patients, 10 (30%) had preoperative USUI and have been excluded from this study. Other preoperative urodynamic findings included idiopathic detrusor overactivity in ten (30%) and bladder outflow obstruction in five (16%). Two (10%) of the patients had a simple diverticulum, 16 (73%) had a horseshoe diverticulum, and 5 (17%) had a circumferential diverticulum. The rate of new onset USUI was 0% for simple, 6% for saddle, and 20% for circumferential.Conclusions:New onset USUI occurs in 9% of patients having excision of urethral diverticulum with Martius fat pad interposition. The incidence appears to increase with increasing complexity of urethral diverticulum on preoperative MRI – rising from 0% following simple urethral diverticulum excision to 20% following circumferential diverticulum excision.

Urethral diverticulectomy with Martius labial fat pad interposition improves symptom resolution and reduces recurrence.

To assess the presenting features and medium-term symptomatic outcomes in women having excision of urethral diverticulum with Martius labial fat pad (MLFP) interposition. We reviewed our prospective database of all female patients having excision of a symptomatic urethral diverticulum between 2007 and 2015. Data on demographics, presenting symptoms and clinical features were collected, as well as postoperative outcomes. In all, 70 women with a mean (range) age of 46.5 (24-77) years underwent excision of urethral diverticulum with MLFP interposition. The commonest presenting symptoms were a urethral mass (69%), urethral pain (61%), and dysuria (57%). Pre-existing stress urinary incontinence (SUI) was present in 41% (29) of the women. After surgery, at a mean (SD) of 18.9 (16.4) months follow-up (median 14 months), complete excision of urethral diverticulum was achieved in all the women, with resolution of urethral mass, dysuria and dyspareunia in all, and urethral pain in 81%. Immediately after surgery, 10 (24%) patients reported de novo SUI, which resolved with time and pelvic floor muscle training such that at 12 months only five (12%) reported continued SUI. There was one symptomatic diverticulum recurrence (1.4%). The commonest presenting symptom of a female urethral diverticulum is urethral pain followed by dysuria and dyspareunia. Surgical excision with MLFP interposition results in complete resolution of symptoms in most women. The incidence of persistent de novo SUI in an expert high-volume centre is 12%.

The uses and outcomes of the Martius fat pad in female urology.

To assess the indications, morbidity, efficacy and outcomes of Martius fat pad (MFP) interposition in reconstructive female urology. Data on 159 women with MFP interposition as part of their primary procedure between 2 September 2005 and 2 July 2015 were prospectively collected. Patient demographics and the indications for MFP interposition along with the outcomes of their primary procedures and short- and long-term complications related to the MFP, along with patient reported perception of post-operative appearance, were noted. The main indications for MFP interposition were urethral diverticulum excision (74), vaginal repair of vesicovaginal fistula (VVF) (43), removal and repair of urethral erosion of mid-urethral tape (MUT) (24), female urethroplasty for stricture (12), vaginal closure of bladder neck for complex end-stage stress urinary incontinence (USUI) (4) and as a MUT wrap for protection of urethra and vagina in women with fragile urethras (2). The majority of patients (127 or 79%) rated the post-operative appearance of their labia as good or excellent. Only 1 patient (0.6%) felt the post-operative appearance was unsatisfactory. There were 2 post-harvest labial haematoma (1.25%), 1 labial wound infection in an overweight diabetic patient (0.6%) and no other significant short- or long-term complications. MFP interposition is associated with good cosmesis and a very low complication rate (<2%). It appears to lower new onset post-procedure USUI, prevent erosion in the 'fragile' urethra and improve outcomes following repair of post-surgery VVF/UVF. MFP is a versatile and effective tool in the female urologists' armamentarium.

MP65-18 FEMALE URETHRAL DIVERTICULA: CORRELATION OF MRI FINDINGS WITH PRE-OPERATIVE SIGNS AND SYMPTOMS OR POST-OPERATIVE OUTCOMES

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Female Incontinence: Therapy II1 Apr 2016MP65-18 FEMALE URETHRAL DIVERTICULA: CORRELATION OF MRI FINDINGS WITH PRE-OPERATIVE SIGNS AND SYMPTOMS OR POST-OPERATIVE OUTCOMES Nima Baradaran, Leah Chiles, Drew Freilich, William Rawls, Lindsey Cox, Ross Rames, and Eric Rovner Nima BaradaranNima Baradaran More articles by this author , Leah ChilesLeah Chiles More articles by this author , Drew FreilichDrew Freilich More articles by this author , William RawlsWilliam Rawls More articles by this author , Lindsey CoxLindsey Cox More articles by this author , Ross RamesRoss Rames More articles by this author , and Eric RovnerEric Rovner More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1229AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Pelvic MRI (pMRI) provides excellent anatomic delineation of urethral diverticula (UD) and is routinely utilized for preoperative planning and patient counselling. Determining whether preoperative pMRI findings are correlated with severity of the condition or postoperative success is the objective of this study. METHODS After IRB approval, records of adult females who underwent transvaginal excision of UD (TVUD) at our institution between 2004 and 2014 were retrospectively reviewed. Clinical characteristics before and after TVUD including lower urinary tract symptoms, incontinence status, dyspareunia, postvoid dribbling, and urinary tract infections were reviewed and correlated with preoperative pMRI findings. MRI characteristics included UD configuration (simple, saddlebag, or circumferential), size, location (proximal, mid, or distal urethra), and number of UD. An autologous fascia pubovaginal sling was placed at the time of UD excision if stress urinary incontinence was present preoperatively. RESULTS 58 patients underwent TVUD of which 49 patients had available data on preoperative pMRI. Three patients had a previous TVUD at other institutions. UD was located in the proximal urethra in 36%, midurethra in 43%, and distal urethra in 6%. Four (8%) patients had panurethral involvement. Median (range) size of the UD on largest dimension was 2.5cm (0.5-6.7). UD configuration was simple in 37%, saddlebag in 37%, and circumferential in 24% of cases. Size, configuration, and location of UD on pMRI were not predictive of symptoms at presentation or symptom severity. However, distal and pan-urethral UD were correlated with presence of vaginal mass on physical examination (p=0.04). Larger UD size (>3 cm) was associated with higher intraoperative blood loss (450cc vs. 200cc, p<0.001) as was placement of a concomitant sling at the time of TVUD (275cc vs. 200cc, p=0.03). Complete resolution of UD on voiding cystourethrogram was achieved postoperatively in 65% of patients however only 3 (5%) patients required subsequent surgical intervention for persistent UD. There was no correlation with preoperative pMRI characteristics and resolution of UD on postoperative imaging. CONCLUSIONS Although pMRI provides valuable anatomical information for surgical planning, preoperative pMRI findings are not correlated with patients’ presenting symptoms, signs, or postoperative outcomes. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e871 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Nima Baradaran More articles by this author Leah Chiles More articles by this author Drew Freilich More articles by this author William Rawls More articles by this author Lindsey Cox More articles by this author Ross Rames More articles by this author Eric Rovner More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1167 Excision of urethral diverticula in women: Risk factors for recurrence and de novo stress urinary incontinence

1167 Excision of urethral diverticula in women: Risk factors for recurrence and de novo stress urinary incontinence

Excision of urethral diverticulum in a 24 year old woman.

Excision of urethral diverticulum in a 24 year old woman.

1846 THE EFFECT OF MRI CONFIGURATION ON NEW ONSET URODYNAMIC STRESS URINARY INCONTINENCE FOLLOWING URETHRAL DIVERTICULUM EXCISION

INTRODUCTION AND OBJECTIVES: Excision of urethral diverticulum in females is associated with new onset urodynamic stress urinary incontinence (USUI) in up to 65%. We have assessed the incidence of new onset USUI in all patients having urethral diverticulum excision with Martius fat pad interposition under the care of a single surgeon between 1/5/2007 and 1/9/2012 and correlated this with the pre-operative MRI appearance of the urethral diverticulum. METHODS: 39 patients of median age 43, having urethral diverticulum with Martius fat pad interposition had prospective data tabulated on: demographics, pre-operative MRI appearance and pre and post-operative VCMG. RESULTS: Of these 39 patients, 12 (31%) had pre-operative USUI and are not included in this study. Other pre-operative urodynamic findings included IDO in 9 (23 %) and BOO in 17 (44%). The details regarding the incidence of new onset USUI in the remaining 27 patients are as tabulated. CONCLUSIONS: New onset USUI occurs in 11% of patients having excision of urethral diverticulum with Martius fat pad interposition. The incidence appears to increase with increasing complexity of urethral diverticulum on pre-operative MRI rising from 0% following simple urethral diverticulum excision to 22% following circumferential diverticulum excision.

Anterior Urethral Valves: Not Such a Benign Condition…

Purpose: Anterior urethral valves (AUVs) is an unusual cause of congenital obstruction of the male urethra, being 15–30 times less common than posterior urethral valves (PUVs). It has been suggested that patients with congenital anterior urethral obstruction have a better prognosis than those with PUV, with less hydronephrosis, and a lower incidence of chronic renal insufficiency (5 vs. 30%). The long-term prognosis of AUVs is not clear in the literature. In this report we describe our experience and long-term follow up of patients with anterior urethral valve.Materials and Methods: We retrospectively identified 13 patients who presented with the diagnosis of AUVs in our institutions between January 1994 and June 2012. Two patients were excluded: one patient had no follow up after intervention; the other had a follow up <1 year. From the 11 patients included, we evaluated the gestational age, prenatal and postnatal ultrasound findings, voiding cystourethrogram findings, age upon valve ablation, micturition pattern, creatinine, and clinical follow up.Results: Between 1994 and 2012 we evaluated 150 patients with the diagnosis of urethral valves. Of this group, 11 patients (7.3%) had AUVs and an adequate follow up. Mean follow up is 6.3 years (2.5–12 years). Five (45.4%) patients had prenatal diagnosis of AUV. The most common prenatal ultrasonographic finding was bilateral hydronephrosis and distended bladder. One patient showed a large perineal cystic mass, which was confirmed to be a dilated anterior urethra. The mean gestational age was 37.6 weeks (27–40 WGA). Postnatally, 90% had trabeculated bladder, 80% hydronephrosis, and 40% renal dysplasia. The most common clinical presentation was urinary tract infection in five patients (45.4%), followed by weak urinary stream found in four patients (36.3%). The age at initial surgical intervention ranged between 7 days and 13 years. Seven (63.6%) patients had primary transurethral valve resection or laser ablation and three patients (27.2%) had primary vesicostomies. One boy (9.1%) had penile urethrostomy with excision of urethral diverticulum. Two (18.2%) patients developed end-stage renal disease.Conclusion: Anterior urethral valve is a rare congenital entity affecting the genitourinary system in males. Early urinary tract obstruction resulted in end-stage renal disease in 18% of our patient population. In our series, the complication rate and the evolution to renal failure are high and similar to patients with PUV. In patients with AUVs we recommend long-term follow up and close evaluation of patient’s bladder and renal function.