Urethral Diverticula In Women Research Articles

Симптомокомплекс дивертикула уретры у женщин.

Introduction. Urethral diverticulum in women is one of the rarest urological diseases, its frequency ranges from 0.02 to 6%. Urethral diverticulum clinically manifests itself in patients between the third and fourth decades of life and its diagnosis is often difficult because urethral diverticulum can mimic other pelvic floor diseases. Often, incorrect diagnosis leads to the prescription of erroneous treatment for recurrent urinary infection, overactive bladder, urinary incontinence, chronic pelvic pain, etc. The aim of this article is to determine the correlation between the topographic-anatomical parameters of the diverticulum, clinical manifestations and results of surgical treatment. Methods and materials. For the purposes of the study, 50 patients with urethral diverticulum were included in the study. All patients were examined and operated on at the Department of Urology of A.I. Yevdokimov Moscow State University of Medicine and Density, on the basis of the S.I. Spasokukotsky State Clinical Hospital in the 3rd and 4th urological departments in the period 2019 to 2022. The duration of postoperative follow–up is 2 years. The results of the study were statistically processed. Results. Most often, patients with urethral diverticulum experience the classic triad of symptoms: dysuria, dispareunia, dribbling, as well as symptoms associated with an infectious-inflammatory process in the bladder and urethra. Analysis of symptoms showed that their presence and severity do not correlate with the size of the diverticulum. A statistically significant relationship was revealed between the size of the urethral diverticulum and the presence of postoperative complications. The larger the diverticulum, the higher the chance of complications in the postoperative period. The location of the urethral diverticulum does not affect the development of complications in the postoperative period. Conclusions. Based on the results of the study and analysis of the data obtained, the dependence of the frequency of complications (periodic increase in body temperature, weak stream during urination and stress form of urinary incontinence) after diverticulectomy via vaginal access on the size of the urethral diverticulum can be traced.

Characterization of Urethral Diverticula in Women.

Urethral diverticulum is a rare, yet important condition for the female pelvic surgeon. We aimed to characterize the women who have been seen for this condition across the three Mayo Clinic locations. Medical record review was performed for patients across all three Mayo Clinic sites (Rochester, Arizona, Florida) that had International Classification of Diseases, Ninth Revision, (ICD-9) and International Classification of Diseases, Tenth Revision, (ICD-10) codes corresponding to urethral diverticulum (ICD-9, 599.2; ICD-10, N36.1). We also performed a review of patients who underwent urethral diverticulectomy via Current Procedural Terminology (CPT) code 53235. Data were available for patients from June 1, 2003, to October 5, 2018. Patients were classified by age, etiology, presenting symptomatology, location, treatment, pathology, and postoperative outcomes. Four hundred forty-seven women met initial coding criteria for urethral diverticula, with 228 women having documented urethral diverticula. The most common presentations were irritative voiding symptoms (93) and infections (92). The most common diagnostic modality was radiographic imaging (198/228) with magnetic resonance imaging accounting for 157 cases. Etiology was unknown in the majority of cases (181/228). Of women who were diagnosed, 172 underwent diverticulectomy with 51 concurrent urethral sling placements. Final pathology demonstrated 2 cases of malignancy. Postoperative follow-up ranged from 0 months to 15 years (mean, 1.4 years; median, 4 months). Forty-three patients had persistent urinary symptoms after diverticulectomy with stress incontinence being the most common. Eight patients underwent subsequent sling placement. Fourteen patients had recurrence. This appears to be the largest reported series on female urethral diverticula, a rare yet important entity that requires special consideration. Most surgical cases found resolution of symptoms after diverticulectomy. Importantly, less than 2% of urethral diverticula were associated with malignancy.

Robotic assisted proximal dorsal urethral diverticulectomy.

Urethral diverticula are rare but clinically significant entities among female patients. Ventrally located, mid-to distal, simple or horseshoe diverticula are most commonly observed and are usually repaired via a transvaginal approach with varying levels of difficulty but high success rates. Dorsally (anteriorly) located urethral diverticula are more challenging to repair secondary to the need to access the side of the urethra opposite the vaginal lumen, abutting the external urethral sphincter. Unique proximal anatomy in the case presented led to careful consideration of the surgical options. We present a review of techniques reported in the literature and a video demonstrating our technique for transabdominal robot-assisted laparoscopic excision of a large, dorsal, very proximally located, crescenteric urethral diverticulum in a patient who initially presented with urosepsis. Robotic-assisted excision of the urethral diverticulum was accomplished in 3:27h with an estimated blood loss of 50cc. Vaginal counter-incision was not necessary. The patient's postoperative course was uneventful. Postoperative voiding cystourethrogram prior to suprapubic catheter removal revealed a well-healed repair without extravasation. At 6-month follow-up, she denied any de novo lower urinary tract symptoms such as urinary incontinence, post-void dribbling, urinary tract infection or urinary hesitancy. Dorsal urethral diverticulum in women, particularly when very proximal, can present a diagnostic and surgical challenge for reconstructive pelvic surgeons. The robotic approach to urethral diverticulectomy is feasible for a proximal dorsal urethral diverticulum which lies cephalad to the pubic symphysis. This or other laparoscopic applications may also be considered as an adjunct to the standard vaginal approach for complex urethral diverticuli with a proximal dorsal component.

Urethral diverticula in women are associated with increased urethra-sphincter complex volumes: A potential role for high-tone nonrelaxing sphincter in their etiology?

Functional obstruction secondary to a high-tone nonrelaxing sphincter (HTNRS) may lead to the formation of a proximal-to-mid-urethral diverticulum (pmUD) in patients without a history of anatomical obstruction, vaginal delivery, vaginal and/or urethral surgery, or periurethral gland infection, that is, a functional pmUD (fpmUD). We used measurements of the urethra-sphincter complex volume (USCv) as a proxy for the maximal urethral closure pressure to evaluate this potential etiological factor. We compared 17 consecutive women with fpmUD (mean age ± SD of 49.4 ± 13.2 years) with a control group consisting of 24 age-matched women (mean age: 50.8 ± 11.2 years) with no previous urological symptoms having MRI for posthysterectomy vesicovaginal fistula, and in all 71 women (mean age: 48.1 ± 11.6 years) with classical urethral diverticulum (cpmUD) referred in the same time period. The urethra-sphincter complex was measured using T2-weighted MRI and OsiriX© was then used to determine the USCv. The mean USCv of the fpmUD group was 10.01 ± 6.97 cm3 . The mean USCv of the cpmUD was 5.19 ± 1.19 cm 3 and for the control group was 3.92 ± 1.60 cm 3 . There was a high statistically significant (P = .01) difference between the USCv in the fpmUD group and the USCv of both the cpmUD and the control groups. Women with fpmUD demonstrated USCv that were significantly higher than those in women with cpmUD and the control group. These findings suggest that high pressure in the proximal urethra during voiding secondary to a HTNRS may contribute to the formation of urethral diverticula.

Imaging Features and Complications of Female Urethral Diverticula

A female urethral diverticulum is a focal outpouching of the urethra into the urethrovaginal potential space.1 The reported incidence of urethral diverticula in women is approximately 1% to 6%, with the diagnosis typically occurring between the third and sixth decades of life.2 In symptomatic women, the classic clinical triad of dysuria, dyspareunia, and postvoid dribbling is present (the “three Ds”).1 However, women with urethral diverticula are more commonly asymptomatic or present with an array of nonspecific genitourinary symptoms such as urinary frequency and urgency, chronic or recurrent urinary tract infections, hematuria, and stress or urge incontinence. More atypical presentations include urinary retention, urethral pain, purulent urethral discharge, pelvic or suprapubic pain, or a tender mass.1 , 3 Because of the varied clinical presentation, a urethral diverticulum should be considered in all women with unexplained lower genitourinary tract symptoms.3 Other differential diagnoses for women presenting with unexplained lower genitourinary symptoms include interstitial cystitis, urethral syndrome (ie, urinary urgency and frequency with negative urine cultures); Skene's gland abscess; Gartner duct cyst; ectopic ureterocele; periurethral fibrosis; urethrocele; endometrioma; urethral or vaginal neoplasm; and collagen bulking agents used for the treatment of stress urinary incontinence.1 , 3 The correct diagnosis of a urethral diverticulum is critical, as potential complicating features include recurrent infection, calculus formation, and intradiverticular malignancy.2 Moreover, late diagnosis of urethral diverticulum is associated with high risk of postoperative complications, high recurrence rate after surgery, and, if malignancy is present, early metastases.1

Managing female urethral diverticulum with a standardized technique using a pacifier-trick artifice to facilitate dissection.

Managing urethral diverticula is challenging because of recurrence rate and postoperative complications. Herein, we report a standardized, single-institution experience of surgical treatment of urethral diverticula in women. The medical record of 37 female patients treated for urethral diverticula between 2005 and 2017 in a single institution were reviewed. All patients were operated in a standardized genupectoral position using a technical artifice called the pacifier trick to inflate diverticula throughout the procedure and facilitate its dissection. Symptoms at diagnosis, imaging findings, surgical parameters, postoperative complications, and recurrence rates were collected and are presented. Median age was 39 ± 11 (range 21-67) years. At diagnosis, recurrent urinary tract infections (UTI) (67%), vaginal mass (46%), pelvic pain (43%), dyspareunia (27%), and urinary incontinence (UI) (24%) were the most commonly reported symptoms. Median operative time was 98 ± 31 (range 40-150) min. After a mean follow-up of 1year, recurrence occurred in one (3%) patient. Immediate de novo postoperative UI decreased from 27% immediately after surgery to 3% after pelvic physical therapy. Pathological analyses found no malignant histology. Surgical management of urethral diverticula in women is technically demanding. With our standardized pacifier-trick technique, satisfying anatomical and functional results were achieved.

Urethral Diverticula in Women: Comparison of Ultrasound and Magnetic Resonance Imaging

Urethral Diverticula in Women: Comparison of Ultrasound and Magnetic Resonance Imaging

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

Surgical management of urethral diverticula in women: a systematic review

Urethral diverticula (UD) are pouch-like outgrowths of the urethral lumen and surgery is by far the most common approach in symptomatic patients. The aim of this systematic review was to evaluate surgical techniques and outcomes in adult women with urethral diverticula. Our secondary objective was to determine the types of study designs. A systematic review of the literature was conducted. Medline, Cinahl and Embase were used as data sources. One hundred and eight studies, including 1,947 patients, remained for final analysis. We summarised 40 single case reports and 68 case series. Overall, transvaginal resection of the UD ± reconstruction was performed in the majority of patients (84%), followed by marsupialisation (3.8%) and transurethral endoscopic unroofing (2.0%). Various other surgical techniques were reported in 181 out of 1,858 cases (9.7%). Nineteen studies, dealing with 584 patients in all, evaluated a combination of vaginal diverticulectomy with an additional surgical procedure. Fifty-six out of 108 studies (52%) documented the resolution of symptoms, describing 717 out of 1,044 patients in all being completely symptom-free after surgery. Only 50 out of 108 studies (46.2%) provided detailed information on the length of follow-up, but showed a poor reporting standard regarding prognosis. Complications were studied only selectively. Because of the inconsistency of these data, it was impossible to analyse them collectively. There were no comparative studies on the different types of surgery in women with urethral diverticula. Overall, the non-comparative nature of the current evidence on the surgical management of UD does not allow any accurate estimation of success and complication rates.

Urethral diverticula in women.

Female urethral diverticula are rare, benign epithelium-lined outpouchings of the female urethra. Patients can present with a multitude of symptoms, most commonly urinary incontinence, recurrent UTIs and dyspareunia. These presenting symptoms are often confused with other diagnoses leading to delayed diagnosis or misdiagnosis. Diagnosis and preoperative assessment of bladder function is most accurate using a combination of clinical examination, T2-weighted postvoid MRI and videocystometrography. Best treatment is by vaginal excision, a procedure with a very low recurrence rate and high patient acceptability. Excision also results in high cure rates for associated dyspareunia, UTI and voiding dysfunction. Pre-existing urodynamically proven stress urinary incontinence (USUI) resolves in 50% of patients after excision of the diverticulum with Martius labial fat pad interposition without the need for further treatment. Potential adverse effects after surgery are new-onset USUI, urethrovaginal fistula and urethral stricture. The rate of onset of these potential adverse effects is low and related to the preoperative appearance of the diverticulum on an MRI scan and the complexity of the diverticulum.

Urethral Diverticulum in Women: Retrospective Case Series.

We present the management of 17 cases of urethral diverticulum in our department. We describe the various clinical presentations of urethral diverticulum, which may mimic other pelvic floor disorders and result in diagnostic delay. We reviewed 17 cases of urethral diverticulum presented to the urogynaecology department between January 2006 and February 2011 retrospectively. Patient demographics, history, clinical evaluation, diagnostic modalities, and management plans were reviewed. All of them underwent Magnetic Resonance Imaging (MRI) prior to the procedure. The mean time from onset of symptoms to diagnosis of a urethral diverticulum was 24±5.6months. MRI identified the urethral diverticulum in all cases while voiding cystourethrography confirmed the diagnosis in 4 (23.5%). They have been divided into two groups: Group A, (4-6mm largest axis range) 5 (29.41%) cases; Group B, (6-33mm largest axis range) 12(70.59%). All in Group A were symptomatic with recurrent Urinary Tract Infection (UTI), whereas only 8 (66.6%) in Group B were symptomatic. Transvaginal diverticulectomy was done in 12 women who were symptomatic (70.5%). Postoperative evaluation revealed complete resolution of symptoms, such as recurrent UTI, dysuria, and dyspareunia. One patient was unsure of surgery, while conservative approach was opted for asymptomatic patients 4 (23.5%). The use of preoperative MRI altered the management in 2 (11.7%) women. The diagnosis of urethral diverticulum should be considered in women with recurrent UTI, dysuria, dyspareunia, and irritative voiding symptoms not responding to conservative therapy.

Pathologic Outcomes following Urethral Diverticulectomy in Women.

Purpose. Although most urethral diverticula in women are benign, there is a subset of patients who develop malignant changes. Limited studies report the pathologic findings associated with this relatively rare entity. We describe the clinicopathologic findings of women who underwent urethral diverticulectomy. Methods. A consecutive series of 29 women who underwent surgical resection of a urethral diverticulum were identified between 1992 and 2013. Clinical and radiographic data was collected by retrospective review of patient medical records. All pathological slides were rereviewed by a single urologic pathologist. Results. Of the 14 women with clinical data, 9 (64%) presented with urgency, 7 (50%) with urinary frequency, 3 (21%) with urinary incontinence, and 3 (21%) with dysuria. Mean diverticular size was 2.3 (±1.4) cm. Although one patient (3%) had invasive adenocarcinoma on final pathology, the remaining 28 cases (97%) demonstrated benign features. The most common findings were inflammation (55%) and nephrogenic adenoma (21%). Conclusions. Although most urethral diverticula in women are benign, there is a subset of patients who develop malignancy in association with the diverticulum. In this series, 97% of cases had a benign histology. These findings are important when counseling patients regarding treatment options.

Female urethral diverticulum

; C-reactive protein, 2.3 mg/dL. Urinalysis demons-trated microscopic pyuria (50-75 white blood cells/high power field). Transabdominal ultrasonography disclosed a complex cystic mass on the base of the urinary bladder. Voiding cystourethrogram showed contrast material filling the urethral diverticulum (UD) that encircled the urethral lumen (Figure-1). Coronal and axial T2-weighted MR images demons-trated a circumferential high-signal intensity, fluid--filled lesion with fluid-debris level and confirmed the diagnosis of UD (Figure-2). Cystourethroscopy showed two orifices of the UD (Figure-3). Transvagi-nal diverticulectomy was performed and postopera-tive course was uneventful. A UD is a focal outpouching of the urethra and usually occurs in women in the 3rd-7th decade of life, with an estimated prevalence of 0.6-6% (1). The vast majority of UDs are from acquired causes, with the most widely accepted theory involving rup-ture of a chronically obstructed and infected periu-rethral gland into the urethral lumen. Risk factors for acquired UDs include repeated infection of the pe-riurethral glands, vaginal birth trauma, trauma from the prior vaginal or urethral procedures (1). The classic presentation of UD has been des-cribed historically as the “three Ds”: dysuria, dys-pareunia, and dribbling (post-void). The most useful imaging modality for UDs is MRI (2). MRI plays an important role in the diagnosis of UDs and ideally provides the surgeon with preoperative information regarding location, number, size, configuration, and communication of the UDs. Although MRI is the best preoperative diagnostic tool for evaluating the UDs, the old standby double balloon pressure urethrogra-phy (adding sky-blue or brilliant green as staining agent) is of great value of intraoperative identifica-tion of these compound diverticular sacks and facili-tating their resection (3). Complications associated with UDs include recurrent infection, urinary incontinence, calculus formation, and development of intradiverticular neoplasm. Clinicians should be aware of the possibility of a UD in women with unexplained

535 Double balloon urethrography for diagnosing urethral diverticula in women – is it still relevant in the 21st century?

535 Double balloon urethrography for diagnosing urethral diverticula in women – is it still relevant in the 21st century?

Urethral diverticula in women: discrepancies between magnetic resonance imaging and surgical findings

AJR Am J Roentgenol. 2010; 194: W316-22.Objective: The objective of our study was to determine the relationship between the apparent diffusion coef-ficient (ADC) value on diffusion-weighted imaging (DWI) and Gleason score of prostate cancer and percentage of tumor involvement on prostate core biopsy. Materials and Methods: We performed a retrospective study of 57 patients with biopsy-proven prostate cancer who underwent endorectal MRI with DWI between July 2007 and March 2008. Regions of interest (ROIs) were drawn on ADC maps at sites of visible tumor on DW images and ADC maps. A hierarchic mixed linear model was used to compare the ADC value of prostate cancer with the Gleason score and the percentage of tumor on core biopsy. Results: Eighty-one sites of biopsy-proven prostate cancer were visible on DW images and ADC maps. The least-squares mean ADC for disease with a Gleason score of 6 was 0.860 x 10(-3) mm(2)/s (standard error of the mean [SEM], 0.036); Gleason score of 7, 0.702 x 10(-3) mm(2)/s (SEM, 0.030); Gleason score of 8, 0.672 x 10(-3) mm(2)/s (SEM, 0.057); and Gleason score of 9, 0.686 x 10(-3) mm(2)/s (SEM, 0.067). Differ-ences between the mean ADC values for a prostate tumor with a Gleason score of 6 and one with a Gleason score of 7 (p = 0.0096) and for a prostate tumor with a Gleason score of 6 and one with a Gleason score of 8 (p = 0.0460) were significant. Comparison between the ADC and percentage of tumor on core biopsy showed a mean ADC decrease of 0.006 (range, 0.004-0.008 x 10(-3) mm(2)/s) for every 1% increase in tumor in the core biopsy specimen. Conclusion: DWI may help differentiate between low-risk (Gleason score, 6) and intermediate-risk (Gleason score, 7) prostate cancer and between low-risk (Gleason score, 6) and high-risk (Gleason score > 7) prostate cancer. There is an inverse relationship between the ADC and the percentage of tumor involvement on prostate core biopsies.

Urethral Diverticula in Women: Discrepancies Between Magnetic Resonance Imaging and Surgical Findings

Some groups consider magnetic resonance imaging the gold standard to diagnose urethral diverticula with up to 100% reported sensitivity. We describe cases contradicting this paradigm and identify reasons for discrepancies. We searched a database for women who underwent urethral diverticulum surgery from 1998 to 2008 and also underwent preoperative magnetic resonance imaging. Images were reviewed by a blinded panel of urologists and a radiologist. They came to consensus on the presence or absence, site and anatomy of urethral diverticulum or cancer, and compared operative findings. Discrepancies were classified as errors in urethral diverticulum or cancer diagnosis and errors in urethral diverticulum anatomy or site. Of 76 patients who underwent diverticulectomy 41 also underwent magnetic resonance imaging, of whom 10 (24.4%) had a discrepancy between magnetic resonance imaging and surgical findings. In 6 of these cases there were diagnosis errors and diverticula were not seen on magnetic resonance imaging in 3. One urethral diverticulum each was misdiagnosed as Bartholin's cyst and as a typical post-collagen injection appearance. A sterile abscess was incorrectly diagnosed as a urethral diverticulum. In 2 patients magnetic resonance imaging did not detect cancer within the diverticulum. A major discrepancy in anatomy made intraoperative decision making difficult in 2 patients. In cases clinically suspicious for urethral diverticulum magnetic resonance imaging had a 24.4% error rate. Serious consequences are failure to detect cancer and suboptimal treatment for urethral diverticulum. The reason for the high magnetic resonance imaging accuracy rate in other series may be that in the absence of radiological confirmation some surgeons may choose not to perform surgery. Magnetic resonance imaging is useful to assess urethral diverticula but physicians should be aware of its limitations.

Female urethral diverticulectomy: a new surgical approach

AbstractThe authors review the different surgical approaches used for treatment of urethral diverticulum in women before describing an easy method for complete excision. This technique should help to avoid the difficulties in identifying the walls and hence decrease the risk of complications related to dissection, such as incontinence or fistula formation. Copyright © 2009 Wiley Interface Ltd

Imaging of Female Urethral Diverticulum: An Update

Female urethral diverticulum is an uncommon pathologic entity and can manifest with a variety of symptoms involving the lower urinary tract. Selection of the appropriate imaging modality is critical in establishing the diagnosis. Urethrography has traditionally been used in the evaluation of urethral diverticulum but provides only intraluminal information. Ultrasonography is advantageous in that it does not involve ionizing radiation and has the capacity to help detect a diverticulum without contrast agent filling. Multidetector computed tomographic (CT) voiding urethrography yields urethral images during micturition. In addition, the diverticulum and diverticular orifice can be visualized on two- and three-dimensional reformatted CT images. Interactive virtual urethroscopy provides simulated visualization of the intraluminal anatomy and the diverticular orifice. New magnetic resonance imaging techniques that make use of a surface or endoluminal coil have higher diagnostic accuracy and can delineate the diverticular cavity and help detect related complications. Clinicians should consider the possibility of a urethral diverticulum in women with chronic or recurrent lower urinary tract symptoms. Moreover, because female urethral diverticulum is becoming more prevalent in clinical practice, radiologists should be familiar with its imaging features and with the imaging techniques that are optimal for its evaluation.

Urinary Symptoms Before and After Female Urethral Diverticulectomy—Can We Predict De Novo Stress Urinary Incontinence?

We assessed preoperative and postoperative urinary symptoms, and determined risk factors for de novo stress urinary incontinence after transvaginal urethral diverticulectomy. We reviewed the case records of 25 consecutive women who had transvaginal urethral diverticulectomy. Urinary symptoms were documented before and after surgery with a structured history and examination pro forma. Demographic, clinical and imaging parameters were reviewed to determine any association with preoperative and postoperative symptoms as well as possible risk factors for postoperative stress urinary incontinence. The most common presenting symptoms were urinary urgency and frequency (60%), and dyspareunia (56%). On physical examination the most common findings were a tender anterior vaginal wall mass (88%) and urethral discharge (40%). At a mean followup of 15.1 +/- 14.9 months (median 12) the rate of urgency-frequency symptoms and dyspareunia decreased significantly from 60% to 16% and from 56% to 8%, respectively. All the patients who had urge incontinence were cured of this symptom after the operation. De novo stress urinary incontinence developed in 4 patients (16%) postoperatively, and it was mild and only necessitated surgical treatment in 1 patient. A diverticulum larger than 30 mm and proximal urethral location were significant factors (p <0.05) for the development of de novo stress urinary incontinence. Irritative bladder symptoms are common in woman with urethral diverticulum and usually resolve after surgical excision. Stress urinary incontinence developed immediately after the operation, and had a significant association with a proximal urethral location and ultrasonically measured size greater than 30 mm.

Urethral Diverticulum with Endometriosis

The differential diagnosis for women presenting with chronic genitou-rinary symptoms is extensive. Urethral diverticulum has long been thought to be responsible for these symptoms in some women. Although the etiology of urethral diverticulum in women is unclear, a number of different theories have been advanced for the formation of diverticula including either a congenital or acquired etiology. A few cases of acquired urethral diverticulum have been reported that resulted from endome-triosis; however, there have been no such cases reported in Korea. We recently treated a 58-year-old woman who presented with complaints of a protruding mass through the vaginal wall. A diagnosis of urethral diverticulum secondary to endometriosis was finally made. The patient underwent surgical repair. Here we report this case and review the medical literature.