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Urethral Diverticula

Urethral Diverticula. Eric S. Rovner, M.D. Medical University of South Carolina Charleston, South Carolina. Diverticulum forms within the urethropelvic ligament lined by epithelium (usually). Urethral Diverticulum. Glands located within submucosa and inner longitudinal SM of urethra.

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Urethral Diverticula

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  1. Urethral Diverticula Eric S. Rovner, M.D. Medical University of South Carolina Charleston, South Carolina

  2. Diverticulum forms within the urethropelvic ligament lined by epithelium (usually) Urethral Diverticulum

  3. Glands located within submucosa and inner longitudinal SM of urethra Periurethral glands Bladder lumen Urethral lumen

  4. Urethral Diverticula: Pathophysiology* -Obstruction of paraurethral ducts/glands ……dilation -Abscess formation (?) -Rupture back into urethral lumen -Residual epithelialized cavity with narrow neck Bladder Urethra *Routh, 1890

  5. Urethral Diverticula: Diagnosis History: -pain, UTI, dyspareunia, post-void dribbling, etc. Physical examination: -tender anterior vaginal wall mass with urethral discharge upon palpation (Imaging)

  6. Urethral Diverticula: Imaging • Why image ? • Confirm clinical diagnosis: • Skene’s gland cyst, leiomyoma, prolapse, etc. • Anatomy • location • sphincter/bladder neck • size/complexity/urethral involvement • ostia • Other: stones, tumor, etc.

  7. Urethral Diverticula Imaging modalities in 2011: • PPU (Double balloon): rarely done, invasive • VCUG: • Invasive, painful • must void to image UD • ostia must be patent to image UD • poor stream will underestimate size, loculations(?) • Transvaginal Ultrasound • operator dependent • images lack precise “surgical anatomy” • MRI

  8. Urethral Diverticula and MRI • Surface coil • Hricak, et. al., Radiology, 178:527, 1991 (9 patients) • Kim, et. al., AJR, 161:809, 1993 (16 patients) • Neitlich, et. al.., J. Urol., 159:408, 1998 (6 patients) • Endoluminal coil (endovaginal, endorectal) • Siegelman, et. al., Radiographics, 17:349, 1997 • Blander, Rovner, et. al., Urology, 53:818, 1999 (case report) • Blander, Rovner, et al,Urology 57: 660, 2001 (27 patients)

  9. Endoluminal coil • Area of interest is adjacent to coil • Improved resolution/contrast Axial Sagittal Pubis Urethra UD Vaginal coil

  10. Excision ofUrethral Diverticula Principles -preservation of the periurethral fascia -closure of dead space -multi-layered closure -identify and excise the neck or ostia -remove entire sac (mucosa) -preserve or create continence

  11. Incision • Headlight • Magnification • Lone Star retractor • Injectable saline • Wide based anterior vaginal wall flap

  12. Opening periurethral fascia • Transverse incision • Avoid early entry into UD

  13. Dissection of UD • Dissect within leaves of periurethral fasica to ostia • May partially resect urethral wall

  14. Removal of UD sac • Remove as much sac as possible • Should see foley catheter once UD removed

  15. Urethral closure • 4.0 double armed SAS interrupted or running to close ostia • Check closure with periurethral injection of saline with 14 g angiocath in urethral meatus

  16. Reapproximation periurethral fascia • 3.0 SAS • Martius flap if fascia deficient

  17. Closure 2.0 SAS Vaginal packing 7-10 d VCUG

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