A tertiary experience of urethral diverticulectomy: diagnosis, imaging and surgical outcomes.

OBJECTIVE To review the outcomes of consecutive patients referred with urethral diverticula to a tertiary centre; to investigate the diagnostic, imaging and surgical factors relevant to success. PATIENTS AND METHODS A retrospective case note review of 30 consecutive patients treated between January 1999-2007 was performed and data retrieved on demographics, presenting symptoms, preoperative imaging, surgical technique, outcomes and need for further intervention. RESULTS All patients were tertiary referrals, four after failed local repairs. The mean (range) interval between initial presentation and repair was 48 (1-264) months. Only seven patients (23%) had all three symptoms of the classical triad of dysuria, dyspareunia and dribble, whilst 23% did not have any of these symptoms. Transvaginal ultrasonography showed the diverticulum in six of nine patients, voiding cysto-urethrography (VCUG) in 13 of 18 patients (72%) and magnetic resonance imaging (MRI) in all 11 patients assessed. MRI accurately imaged diverticular configuration, whilst VCUG assessed detrusor and sphincteric function. Twenty-nine (97%) patients were cured of their diverticulum; all 19 patients with simple diverticula were cured at first attempt, whilst 17 procedures were performed on the 11 patients with complex diverticula. Twenty of 24 (83%) repairs were successful using three-layered closure, 9 of 11 using Martius interposition, and one using bulbospongiosus muscle interposition. There were three primary repair failures; two circumferential diverticula repaired with Martius interposition and one partial horseshoe diverticulum repaired without interposition had partial recurrences. Both were subsequently repaired successfully. One patient with chronic urethral pain from multiple, infected recurrences was eventually diverted. A pubovaginal sling procedure was required in only one (3.3%) patient with persistent pre-existing stress urinary incontinence (SUI). CONCLUSIONS The presentation of urethral diverticula is diverse and diagnosis frequently delayed. The most useful preoperative imaging is MRI and VCUG to assess diverticular anatomy and detrusor/urethral function, respectively. In simple cases, transvaginal excision with three-layer closure is curative, whilst more extensive, persistent or SUI-associated diverticula require Martius fat interposition. Sling procedures can be deferred until the results of primary excision are assessed.