Is distal marsupialization (surgical procedure) warranted for urethral diverticulum (abnormal pouch in the urethra)?

Distal Marsupialization for Urethral Diverticulum

Distal marsupialization is warranted for urethral diverticulum when the diverticulum is located in the distal urethra and the patient is symptomatic. This surgical approach offers excellent outcomes with low morbidity for appropriately selected patients.

Indications for Surgical Management

• Symptomatic urethral diverticula requiring intervention include those presenting with:
  • Recurrent urinary tract infections 1
  • Dysuria and urinary frequency 1
  • Dyspareunia 1
  • Post-void dribbling or incontinence 1, 2
  • Vaginal bulge or mass 3

Diagnostic Evaluation

• MRI is the preferred imaging modality for urethral diverticula as it:

  • Accurately assesses the structure and complexity of the diverticulum 4
  • Allows for precise surgical planning 4
  • Provides superior soft tissue resolution compared to other imaging methods 4
  • Maps the location and extent of urethral involvement 3

• Double-balloon urethrography has been replaced by MRI at most institutions but may be considered when MRI is unavailable 4

Surgical Approach Selection

• For distal urethral diverticula:
  • Marsupialization (Spence-Duckett procedure) is appropriate for diverticula located in the distal urethra 3, 5
  • Complete excision with primary repair is preferred for diverticula in other locations 3
  • Care must be taken to avoid disruption of the continence mechanism at the mid-urethra 3

Marsupialization Technique

• The traditional Spence-Duckett procedure involves:

  • Insertion of one blade of scissors in the urethra with incision into the diverticulum 3
  • Extension of the incision to the anterior vaginal wall 3
  • Marsupialization of the diverticular sac to the vaginal mucosa 6

• Modified approaches may include:

  • Incision from the ostium down the posterior aspect of the urethra 3
  • Excision of the diverticular sac prior to marsupialization for improved cosmesis 3
  • Leaving a portion of the diverticular floor intact to avoid extensive subtrigonal dissection 6

Outcomes and Complications

• Success rates for marsupialization are high:

  • Long-term studies show approximately 93% of patients report successful outcomes 5
  • Postoperative voiding cystourethrography typically shows normal results 5
  • Symptomatic relief is achieved in the majority of patients 5

• Potential complications include:

  • De novo stress urinary incontinence (approximately 15% of cases) 1
  • Urinary tract infections (rare when properly performed) 5
  • Urethral stricture (rare complication) 5
  • Recurrence rate of approximately 3-4% 1

Special Considerations

• Pathologic examination of excised tissue is important as:

  • Cancers can originate from urethral diverticula (6-9% prevalence) 3
  • Other abnormal pathology such as leiomyoma may be present 1

• The traditional Spence-Duckett technique may cause urethral shortening, so modified approaches may be preferred for improved cosmesis and functional outcomes 3

• For male patients with urethral diverticula:

  • Different management approaches may be required 2
  • Conservative management may be appropriate for small, asymptomatic diverticula that can be manually emptied 2

Follow-up Care

• Postoperative follow-up should include:
  • Physical examination in an outpatient setting 1
  • Assessment for symptom resolution 1
  • Evaluation for continence 1
  • Monitoring for recurrence 1

Distal marsupialization remains an effective surgical option for symptomatic distal urethral diverticula with high success rates and low morbidity when performed by experienced surgeons.