What is the initial approach to managing a patient with a periurethral diverticulum?

Management of Periurethral Diverticulum

The initial approach to managing a patient with a periurethral diverticulum should include diagnostic imaging (preferably MRI) followed by appropriate urinary drainage, with surgical excision being the definitive treatment for symptomatic cases. 1

Diagnostic Evaluation

• Imaging: Postvoid sagittal magnetic resonance imaging (MRI) is the recommended preoperative imaging modality for accurate assessment of diverticulum size, location, and extent 1
• Additional studies:
  • Voiding cystourethrogram is an effective technique for demonstrating the diverticulum and differentiating it from other suburethral masses 2
  • Urodynamic assessment may be appropriate at baseline to evaluate for associated urinary symptoms 1

Initial Management

1. Urinary drainage: Obtain urinary drainage as soon as possible, similar to the approach for traumatic urethral injuries 3

   • Options include urethral catheterization or suprapubic catheter placement if urethral catheterization is not feasible

2. Antibiotic therapy:

   • Indicated for cases with active infection
   • Important given the high association between periurethral diverticula and prior infections 2

Definitive Management

Surgical Approach

For symptomatic periurethral diverticula, surgical excision (diverticulectomy) is the treatment of choice, with a 72% rate of complete symptom resolution 1:

1. Surgical technique options:

   • Traditional diverticulectomy: Involves placing the patient prone, ureteric catheterization, dissection and removal of the diverticulum, and layered closure 1
   • For large defects: Consider Martius flap interposition 1
   • For distal urethral diverticula: Modified Spence-Duckett procedure may be considered, involving incision from the ostium down the posterior aspect of the urethra and excision of the diverticular sac prior to marsupialization 4

2. Special considerations:

   • Location of the diverticulum is critical - care must be taken to avoid disruption of the continence mechanism at the mid-urethra 4
   • Pathologic examination of excised tissue is essential as 2-9% of urethral diverticula may contain unexpected malignancy 1, 4, 5

Post-Surgical Follow-up

• Physical examination in an outpatient setting 1
• Monitor for potential complications:
  • De novo stress urinary incontinence (occurs in approximately 15% of cases) 1
  • Recurrence (approximately 3.4% of cases) 1
  • Infection (urinary tract or graft infection) 1

Complications and Management

• De novo stress urinary incontinence: May require autologous sling placement after 6 months if bothersome 1
• Recurrent diverticulum: May require redo diverticulectomy via a dorsal approach 1
• Persistent infection: Warrants further investigation for other etiologic factors or presence of a new/recurrent diverticulum 2

Important Considerations

• Surgical management should be performed in specialized centers with expertise in managing this condition 1
• Patients with persistent urinary tract infections after surgery (53% of cases) require further investigation 2
• For patients with diverticula containing calculi, surgical approach via vaginal route with local extraction of calculi and subsequent diverticulectomy is effective 6

The management approach should be tailored based on the size, location, and symptoms associated with the periurethral diverticulum, with surgical excision offering the best chance for symptom resolution in symptomatic patients.