What is the preferred surgical approach for treating urethral diverticulum, transvaginal excision or distal marsupialization?

Transvaginal Excision is the Preferred Surgical Approach for Urethral Diverticulum

Transvaginal urethral diverticulectomy should be considered the standard of care and preferred surgical approach for most urethral diverticula, while distal marsupialization should be reserved specifically for diverticula located in the distal third of the urethra.

Surgical Approach Selection Based on Anatomical Location

The optimal surgical approach for urethral diverticula depends primarily on the anatomical location:

Transvaginal Excision

• Primary indication: Urethral diverticula located in the middle and proximal two-thirds of the urethra 1
• Advantages:
  • Complete removal of the diverticular sac
  • Lower recurrence rates
  • Appropriate for complex or large diverticula
  • Better preservation of urethral integrity
• Technique: Involves careful dissection of the diverticular sac from surrounding tissues, complete excision, and layered closure

Distal Marsupialization (Spence-Duckett Procedure)

• Primary indication: Diverticula located in the distal third of the urethra 2
• Advantages:
  • High success rate (reported 93% in long-term follow-up) 3
  • Lower risk of complications
  • Technically less challenging
  • Shorter operative time
• Technique: Involves incision into the diverticulum from the urethral lumen and marsupialization of the diverticular sac to create a wider opening 4

Outcomes and Complications

Transvaginal Excision

• Success rate: Approximately 72% complete symptom resolution 1
• Potential complications:
  • De novo stress urinary incontinence (higher risk compared to marsupialization)
  • Urethrovaginal fistula
  • Urethral stricture
  • Recurrence

Distal Marsupialization

• Success rate: Up to 93% in long-term follow-up 3
• Complications:
  • Mild stress urinary incontinence (reported in about 5% of cases) 3
  • Urethral stricture (rare)
  • Risk of urethral shortening with traditional technique 4

Modified Approaches

Recent innovations have improved both techniques:

1. Modified Spence-Duckett procedure: Reduces risks of urethral shortening while maintaining efficacy for distal diverticula 4

2. Transurethral endoscopic extensive incision: An alternative approach for complex diverticula with reported 81.8% symptom resolution and 13.6% de novo SUI rate 5

3. Jackknife prone reverse-lithotomy position: Improves surgical exposure for transvaginal excision, potentially reducing complications 6

Practical Considerations for Surgical Decision-Making

1. Preoperative imaging: MRI or ultrasound is essential to map the exact location and extent of the diverticulum 4

2. Size and complexity: Larger, complex, or multilocular diverticula generally require transvaginal excision

3. Proximity to continence mechanism: Diverticula near the mid-urethra require special care during surgery to prevent incontinence 4

4. Pathologic examination: Always indicated due to 6-9% risk of malignancy in urethral diverticula 4

Conclusion

While both surgical approaches have their merits, the anatomical location of the urethral diverticulum should be the primary determinant in selecting the appropriate surgical technique. Transvaginal excision remains the gold standard for most urethral diverticula, particularly those in the middle and proximal urethra, while distal marsupialization should be considered for diverticula confined to the distal third of the urethra.