Surgical Management of a Recurrent Urethral Diverticulum Urethral diverticulum have an estimated incidence of up to almost 5% in the female population. They can be congenital or acquired and may present with a wide variety of symptoms. The most common surgical procedure performed is a transvaginal resection with a tension-free, water-tight, multi-layer closure. However, recurrent diverticulum have been reported in up to 24% of cases after primary repair. A Martius labial fat pad interposition can be used to prevent fistula formation and reduce the risk of recurrent diverticulum, especially in secondary repair. We present the case of a 40-year-old woman who presented with stress urinary incontinence, recurrent urinary tract infections, dyspareunia, and urethral pain. She had a background history of two previous excisions of urethral diverticulum, one of which involved the use of a Martius labial fat pad interposition. A 4D ultrasound scan identified a 2cm urethral diverticulum which was confirmed on subsequent urethrogram and MRI. This video demonstrates a surgical technique of repairing the recurrent diverticulum with mobilization and repositioning of the previously placed Martius fat pad. A diagnostic cystourethroscopy is performed with a 0° scope and SASHI sheath. Multiple small openings can be seen through a paper-thin urethral wall into the diverticulum from the right side of the mid-urethra. A midline incision is made in the vaginal mucosa with lateral dissection into the retropubic space and the mucosa is dissected off the previously placed labial fat pad. The fat pad is dissected off the urethra and diverticulum and mobilized laterally to the left side with care in order to prevent devascularization. A Brandley-Scott retractor is used to facilitate visualization and access. The diverticulum sac is opened at the thinnest point. The diverticulum is seen extending up into the right retropubic space. A probe is used to identify the openings from the diverticulum into the urethra and the openings are joined to create one larger defect. The diverticulum mucosa was excised and sent for histology. The urethral mucosa was closed with a 4-0 Vicryl in a continuous fashion. The top and bottom sutures are tagged to mark the boundaries of the incision. A second layer closure is performed and a tension-free closure is ensured. A repeat Cysto-urethroscopy is performed to ensure that the urethral closure is watertight. A further two layers of closure are performed incorporating the diverticular wall in order to provide additional support to the repair. The Martius labial fat pad is placed over the entire length of the repair and sutured into position. This is then attached to the back of the vaginal mucosa. The vaginal wall is then closed with interrupted sutures. A size 14 urethral catheter was placed at the conclusion of surgery. This was removed two weeks post-operatively and the patient was able to void efficiently. At six weeks post-operatively the patient reported urinary urgency and at nine weeks she reported urethral pain. Clinical examination confirmed a well-healed surgical site and a 4D ultrasound scan at 12 weeks found an intact urethra with no diverticulum. Repair of a recurrent urethral diverticulum can be a difficult procedure due to scarring and loss of natural tissue planes. A zero-degree scope should be utilised in order to visualise the urethral defect. Complete excision of the urethral diverticulum is not necessary in a complex case of recurrence as the fibrous wall can be incorporated in the multi-layer closure in order to facilitate a tension-free repair. A previously placed Martius labial fat pad can be mobilised and repositioned successfully. This procedure should only be performed by surgeons with experience in such complex repairs in order to optimise the surgical outcome.

surgical management

urethral diverticulum

transvaginal resection

Martius labial fat pad interposition

recurrent symptoms