From the Guidelines
A urethral diverticulectomy is a surgical procedure that involves removing a urethral diverticulum, which is an outpouching or sac that forms along the urethral wall, and the steps for this procedure include patient preparation, surgical approach, diverticulum excision, and postoperative care. The procedure typically begins with the patient under general or regional anesthesia in the dorsal lithotomy position. First, the surgeon places a Foley catheter to identify the urethra and may inject methylene blue dye to help visualize the diverticulum 1.
Preoperative Considerations
Before proceeding with the surgical management of a urethral diverticulum, the physician should provide an appropriate antibiotic to reduce surgical site infections, and preoperative urine cultures are recommended to guide antibiotic choice, as stated in the American Urological Association guideline 1. Active UTIs must be treated before urethral diverticulectomy intervention.
Surgical Approach
An inverted U-shaped or midline vaginal incision is made, and the vaginal wall is dissected from the periurethral fascia. The surgeon then identifies the diverticulum and carefully dissects it from surrounding tissues while preserving the urethral integrity. Once isolated, the diverticulum is excised completely, and the urethral wall is closed in layers using absorbable sutures. The periurethral fascia is then reconstructed, and the vaginal wall is closed.
Postoperative Care
The Foley catheter remains in place for 7-14 days postoperatively to allow healing, as mentioned in the postoperative care section of the guideline 1. Potential complications include urinary incontinence, urethrovaginal fistula, urethral stricture, and recurrence of the diverticulum. Patients typically require antibiotics perioperatively and should avoid sexual activity for 4-6 weeks after surgery. Complete excision is crucial as incomplete removal can lead to recurrence, and careful dissection helps preserve urethral function and continence.
Follow-Up
Follow-up care is essential to monitor for potential complications and recurrence, although the optimal postoperative surveillance protocol has not been established, as noted in the follow-up section of the guideline 1. Some centers use a flexible cystoscope to confirm lack of recurrence, while others rely on absence of lower urinary tract symptoms, low PVR, a non-flattened urinary flow pattern on uroflow, and peak urine flow > 15 ml/second to define patients free from clinically significant stricture recurrence.
Patient Selection
Patient selection and proper choice of surgical procedure are paramount to maximize the chance of successful outcome in the treatment of urethral diverticulum, considering factors such as stricture etiology, location, and severity; prior treatment; comorbidity; presence of lichen sclerosus (LS); and patient preference, as outlined in the patient selection section of the guideline 1.
From the Research
Urethral Diverticulectomy Procedure
The steps for a urethral diverticulectomy procedure can be outlined as follows:
- Placement of the patient in a prone position 2
- Ureteric catheterization to ensure the ureters are protected during the procedure 2
- Dissection and removal of the diverticulum 2, 3, 4
- Layered closure of the urethra to prevent leakage and promote healing 2, 4
- In some cases, a Martius flap may be interposed to reinforce the repair and prevent recurrence 2
- Definite closure of the diverticular ostium and robust reconstruction of the urethra 4
Preoperative and Postoperative Care
Preoperative imaging, such as postvoid sagittal magnetic resonance imaging, and urodynamic assessment may be recommended to evaluate the diverticulum and assess urinary function 2, 3 Postoperative care may include follow-up appointments to monitor for complications, such as urinary tract infections, and to assess the success of the procedure 2, 5
Surgical Techniques
Various surgical techniques have been described, including transvaginal resection of the diverticulum, marsupialization, and transurethral endoscopic unroofing 5 The choice of technique may depend on the size, location, and complexity of the diverticulum, as well as the surgeon's preference and experience 3, 4