Go ahead and get started this evening. Welcome, everyone, to the Connecticut Community Webinar series. I'm Dr. Lauren Zipf, and I'll be moderating tonight. Before we begin, I do want to share that we'll take questions at the end of the presentation, but you can submit them at any time typing into the Q&A section. And we'll be going with tonight's webinar, titled Conundrums in Urethral Diverticulum, presented by Dr. Sandeep Vasavada. Dr. Vasavada serves as the Urologist Director for the Center of Female Urology and Reconstructive Pelvic Surgery at the Cleveland Clinic Glickman Urological Institute. He's also a professor of surgery at the Cleveland Clinic Werner College of Medicine, and has a joint appointment with Women's Institute. He's the Miller Endowed Chair of Female Pelvic Health at Glickman Urology, the Cleveland Clinic. And Dr. Vasavada has published numerous manuscripts and book chapters in the area of voiding dysfunction and urinary incontinence. He's been named top doc in Philadelphia and Cleveland magazines for over 15 years. He's lectured and demonstrated surgical techniques around the world in over 20 countries. And Dr. Vasavada is a reviewer for seven major journals in the field of urology, urogynecology, and voiding dysfunction. He served on the American Board of Urology Exam Committee, and has helped author AUA guidelines in overactive bladder and stressed urinary incontinence for the country. Dr. Vasavada's main clinical interests lie in the area of urinary incontinence, pelvic border prolapse, and complex reconstruction of the lower urinary tract, and management of complications in vaginal and lower urinary tract surgery. His current research interests are in the field of refractory bladder overactivity and neuromodulation, and peer pathways for optimizing peer and patients undergoing incontinence and prolapse surgery. Dr. Vasavada serves with a section of urogynecology on the NIH pelvic floor disorders network. And we are honored to have him present this evening. So without further ado, I'll turn it over to Dr. Vasavada. Great, thanks, Lauren. Great to see you, as always. So listen, thank you so much for asking me to speak on this subject. This is perhaps one of the most fun subjects I speak on. It's been an odd sort of passion I've developed over years now in practice. It's not a common entity, but when it comes up, it's kind of like, wow, how would I manage that? And what would I do about this? And there's a number of twists and turns for a lot of us that we've dealt with. And certainly, I've had my share. And I guess I'll be hopefully sharing maybe some thoughts. I'd love to say wisdom as well, but something to the effect that lessons learned over the last several years really doing these urethral diverticula in every fashion, from simple to really the most complex. So I wanted to go into, again, what I entitled as conundrums, so all these different little twists and turns. That said, bear with me as I go through the talk, because there's a lot of areas where there's a fair amount of overlap. And to that end, sometimes we'll be moving back and forth through different areas of subject within the context of these diverticular complications or subtle nuances. So again, bear with me as we go through the talk, because we will move back and forth and around within that. So without too much further ado, I don't have any relevant disclosures. So some of our objectives today is to basically go through the relevant surgical techniques. I won't go into huge, huge details, because I'm speaking with a fairly educated audience here. But in terms of some of the basic surgical techniques, we'll go over that. As I mentioned, we'll go through some of the nuances of both the evaluation and the management of urethral diverticula, as well as how to follow those patients up. Certainly some of the complications, because this is the tough stuff that we deal with, and want to go through, again, some aspects that I've kind of learned over the years. And then this last line, if I make you a little uncomfortable with how you evaluate and manage diverticulum patients, I will have achieved my job today. So this is that subtle aspect to urethral diverticulum evaluation management surgery that we just don't know. And there's just not hard data. I can impart to you some thoughts. I'd love to say backed up with data. Some of it is. Some of it's just experience. But suffice to say, we'll talk about that. And hopefully, again, you guys will have plenty of questions. I'm happy to answer through. So some of the basics. Most of you guys know this. Back when we were doing the original grandfathering for the FPMRS boards, and I gave the talk on urethral diverticula. And you can tell, we've gone through so many subjects in FPMRS. And we were going through so many different things. And then I get up there to talk about something a little bit more esoteric. And I just said, guys, there's only five concepts that they can really possibly even test on. And as we went through that, I'd say, listen, wake up. If you're asleep, this is a potentially testable concept. People wrote it down. Every single one of them that year was on the board's exam. And people thought I had some insider knowledge. I did not. This was just only things that they could possibly ask within the context of urethral diverticula. So again, just sort of an odd coincidence or not. So what is a diverticulum? We know it's the normal periurethral fascial structure. There's two leaves of the endopelvic fascia. And basically, between this is where the diverticula develop. There's like a little outpouching. And then the diverticulum fills with urine. And as that continues to expand, it can go to one side. It can go suburethral. It can go circumferential. And these are all the things that we'll talk about. Most commonly, we definitely see it in the third to sixth decades. I'd say, in my experience, most of them would have been younger patients on the tune of 20s and 30s, some in the 40s, less often as they're older. But we certainly do see them occasionally. And we should talk about some things that your antennae should go up when there's a patient who's in their 60s and presents with a diverticulum and what kind of symptoms may be more worrisome. The true prevalence isn't really known, but the estimated incidence between one and 6%, I mean, that's a wildly high number, 6% of females. I don't think it's that high, but I suspect it's more significant and a higher number than we perhaps believe. Again, etiology itself, really not founded in fact. We believe that it's the periurethral glands that somehow get obstructed. And after they get obstructed, they kind of furrow a hole, urine fills into it, and then it kind of continues to expand. It does make sense because the periurethral glands tend to be really in the mid to distal urethral location. So that's where we see most diverticula. I see less often are they very proximal, but if they start in the mid urethra, they can dissect proximally. So their origin might be in the mid urethra, but then they dissect proximally. And those are the more difficult ones. And recurrent infections, especially when patients get recurrent UTIs, there's a thought that some of these could actually go into the urethra, in which case, again, these urethral glands get obstructed and then ultimately fill with urine and then continue to develop as a symptomatic diverticulum. The continued flow of the urine then, stasis when urine doesn't clear out, infections can develop there as well, and they can become profoundly symptomatic as they get more mature. Other risk factors that we've seen, as I mentioned, infection background, it's hard to really pull that together. So you have someone in their 30s or 40s, did you have problems with UTIs? Like, eh, I had a few here and there. I mean, nothing that they really recall as a profound history, strongly suggested that that was the etiology and pathogenesis of their diverticulum. African-American descent, no question, we've seen that as being a higher incidence than other Caucasian groups. Some congenitally developed diverticula, again, not a common thing that we certainly see. Trauma, again, there's a lot of obstetricians on the phone. You would know this better than I would from forceps delivery, but to my understanding, it's going to be a pretty big misadventure to develop a diverticulum from a traumatic vaginal delivery. Urethral injectables, that's an interesting one because it's kind of a chicken or the egg. Did someone inject an injectable into the diverticulum and then someone realized that later on down the line, or was it the diverticulum, they had some stress incontinence, and then that was sort of the actual criteria. So it's really hard to tell which one is which. The presentation has been interesting because the traditional ones we all talk about, the three Ds, dysuria, dyspareunia, and dribbling, I'll say I really see that in a minority of cases. More often than not, we'll see the UTIs, overactive bladder symptoms, pain, less often periodontal discharge per urethra. So more often in our practice is maybe a little bit of incontinence, but the dysuria, dyspareunia, yes. OAB symptoms and recurrent UTIs, I think that's perhaps the majority that we see. But the very presentations are really there, and that's what this last paper, when Laurie Romancy was a fellow with Jerry Blavis wrote, 20 years ago now, patients had seen a ton of physicians, everyone's shaking their shoulders, shrugging their shoulders and saying, I have no idea. They'll have multiple scopes and everything else, but you need to keep that index of suspicion. And so that's something you'll always be mindful of in a patient with a suspect diverticulum. So what kind of things do we know? As I mentioned, diagnosis takes a high index of suspicion. Many patients do present without symptoms. And so this may be an incidentally detected diverticulum at the time of an exam or a women's health exam. Evaluations probably done with MRI is the best way. We would all probably agree to that in 2020. I don't think there's anything close to getting the resolution and the spatial descriptions that we can get with MRI. So I think it's been extremely helpful, if not almost mandatory. I think the belief is a complete excision of the diverticulum is necessary. And we'll talk about some of the subtle nuances with that. Somewhere, some people have mentioned, no, you don't really need to close the ostium. Makes absolutely no sense to me why anyone would even say that. You should close the ostium because that could be the pathogenesis for a recurrent diverticulum. So again, very important. And then follow up after surgery. I ask myself this all the time, and I've been really, over the last several years, pushing my patients to come in, to follow with us every year. Maybe just a quick exam, talk about symptoms, and a few other things. But I've been really pushing them, especially the older patients. Some of the conundrums that we're gonna talk about though is the natural history of maybe asymptomatic diverticula, or how that plays into your thought process, certainly in the relation of abnormal pathologic findings, and most specifically cancer. Recurrent diverticula, we'll talk about stress incontinence, fistulas, and some other kind of oddball complications. But as I mentioned earlier, I'd love to say there's a lot of data behind everything I'm talking about. There's not much consensus on these areas, so it's still somewhat controversial. So let's talk very briefly about the basic technique of urethral diverticulectomy. So I'm just gonna show you this video. I'm gonna move forward, because a lot of the background is pretty standard stuff. But I'm gonna go to about two minutes and 30 seconds here. And so. Shows the large diverticulum, indicated by a red arrow, surrounding the urethra, indicated by a yellow arrow. There is also a thickened levitory rind, surrounding the diverticular loop. Satural T2-weighted imaging, again, demonstrates the large diverticulum. Plans for surgical incision were made. In preparing for such, the RA tract was first sterilized with a course of therapeutic antibiotics. Thereafter, surgery was pursued with the goal of complete surgical incision of the diverticulum and its fibrous rind, with multiple-layered closure. Marking for inverted U-incision with its apex just proximal to the urethral meatus was made. Care was taken to ensure a wide base was given to the plaque to preserve the vascular supply of its most distal aspect. Hydrodissection, using lidocaine with epinephrine, was then used to raise the vaginal wall from the plate of the periurethral tissues. The incision was then made sharply, and the vaginal wall plaque dissected free. Dissection was continued in both sharp and blunt fashions. Exposure of the periurethral fascia overlying the diverticulum was then achieved in a circumferential fashion on both sides. The extent of the diverticulum was then reassessed. A transverse incision was then marked on the periurethral fascia. The incision was made. So I think this is one of the important points that I think most people overlook, is that they see the diverticulum, they took down their flap, let's go, let's go enter it. That's a mistake because this is where a small incision in the transverse direction allows you to reflect the periurethral fascia, and the diverticulum is within the fascia. So that's what, it's a very good reconstructive layer, and also from the pathogenesis of diverticula, the diverticulum is within the leaves of this, so it allows you to reconstruct that area nicely, and then also prevent your recurrences. So I would always highlight that, literally like a one-cell layer dissection across as you do that. Thereafter, flaps of the periurethral fascia were developed. Care was taken to preserve the periurethral fascia as a separate layer to aid in reconstruction of the diverticular tract during closure. Dissection was carried further around the diverticulum, which, consistent with imaging, was noted to be large and nearly circumferential. Repositioning of the ring retractor hooks to aid in visualization and exposure is necessary throughout the dissection. Care was taken at this point to avoid entering the diverticulum to facilitate its separation from surrounding tissue. The extent of the diverticulum was again reassessed. At this time, the diverticulum wasn't sized to enable it to complete incision. Reinspection of the diverticulum and further incision were then carried out. Publization of all aspects of the diverticulum were undertaken to ensure its complete removal. The ostium of the diverticulum was then easily visible. Further dissection and incision were performed. All material excised is sent for pathologic analysis due to the possibility of neoplastic transformation. Inspection of the remaining urethra and diverticulum incision bed were performed. A multi-layer closure is then performed, starting with the urethral mucosa and urethral wall, an absorbable 3-0-0 solution, followed by a 3-0-0 solution, followed by a 3-0-0 solution, followed by a 3-0-0 solution, followed by a 3-0-0 solution, followed by a 3-0-0 solution, followed by a 3-0-0 solution, followed by a 3-0-0 solution, followed by a 3-0-0 solution, followed by a 3-0-0 solution, followed by a 3-0-0 solution, followed by a 3-0-0 solution, followed by a 3-0-0 solution, followed by a 3-0-0 solution, followed by a 3-0-0 solution, followed by a 3-0-0 solution, followed by a 3-0-0 solution, followed by a 3-0-0 solution, followed by a 3-0-0 solution, followed by a 3-0-0 solution, And then at that point, we take down some of our hooks, And then at that point, we take down some of our hooks, so we allow exposure to that last little bit of periurethral fascial flaps, so we allow exposure to that last little bit of periurethral fascial flaps, the original flaps that we developed, the original flaps that we developed, and then use that for closure from that point on. and then use that for closure from that point on. Thereafter, again using an absorbable 3-0 suture, Thereafter, again using an absorbable 3-0 suture, the periurethral fascial layer is closed over the urethra the periurethral fascial layer is closed over the urethra in a horizontal manner, with care taken to do so and not overlap the suture lines. Based upon the quality of the reconstructive tissues, Based upon the quality of the reconstructive tissues, a Martius flap could be placed at the surgeon's discretion. a Martius flap could be placed at the surgeon's discretion. This is not necessary in this case. Finally, the vaginal mucosal flap was advanced over the periurethral fascial closure Finally, the vaginal mucosal flap was advanced over the periurethral fascial closure and re-approximated using a tube. and re-approximated using a tube. So at that point, we're done. Rotate the vaginal wall flap over, do any trimming you have to, Rotate the vaginal wall flap over, do any trimming you have to, and then we're done. That's pretty standard for these techniques, and again, we'll go into nuances of circumferential tics and again, we'll go into nuances of circumferential tics and how we approach it, perhaps differently in some cases, and different things. But for the average diverticulum, we'll typically approach it in that sort of a fashion. So again, let's go back to some of the symptoms I mentioned earlier, of wide variety. Some of these patients may be asymptomatic, and when those patients come in, so this is a lady who had her OB visit, or a gynecologic visit rather, and then someone's like, you know, I think I see something here, and she's one of us as specialists, you know, we ask ourselves like, okay, she has no problems, she has no UTIs, no pain, no discomfort, nothing, just an incidentally detected diverticulum, what do we do with that? And how do we follow these mostly? And that's something I still ask myself on a routine basis. Do we look at them differently if they're small, if they're big? How are they, you know, depending on age? And we'll talk about that as we go through some of the cancer aspects. Microhematuria, you know, makes me pause, not that I expect anything from a diverticulum, but we're going to work those patients up like we do in most of our patients with microhematuria. So cystoscopy and CT urograms are some way to evaluate those types of patients. And then can we use, you know, imaging or cystoscopy to help us? And so, you know, you take a look at this, this is something more obvious, so this is a cystoscope view of a diverticulum. You can see rather proximal extents are just outside of the bladder neck, and it's just going right down to a rather large concavity. If you can get a good view inside, you can assure yourself, I don't see anything that looks like a cancer within there. But you can't always do that. In fact, I'd say much less often can you usually do that where you can look inside of the diverticulum and see it well. But it helps us to identify where the ostium is because prospectively when I'm going to fix that lady surgically, I can find the ostium and close it. And I know in this case, last case is a view, she's at a 7 o'clock location, so once I cut through the diverticulum, I can close the ostium at 7 o'clock and know I'm comfortable going forth. So let's talk about a few cases. So a 38-year-old female, pretty routine, incidentally detected urethral diverticulum, originally thought it was a cysticeal, no urinary symptoms or anything else, urinalysis was negative, she had imaging, and you can see this, circumferential, almost circumferential diverticulum. So you have to ask yourself, is she going to leave her? It's a pretty big tick, is it going to go away? Probably not. Is she going to become symptomatic later? Possibly, but not guaranteed. And, you know, can you help an asymptomatic patient get better? That's the last big question I have to always ask myself, can you help an asymptomatic patient get better? Let's change gears. Case 2, 61-year-old female with a routine pelvic exam, cystic, suburethral mesh, no symptoms, she's got a little fluctuance on exam, which is good. Doesn't have any micro-hematuria or anything. Observation, MRI, cystoscopy, all different things you could do. She had an MRI, you can see the diverticulum here, so urethra is up here, you can see air fluid level, not uncommon, and the horns are starting to go around to the sides of the urethra. And they mentioned it as a 1.2 centimeter saddlebag suburethral diverticulum. Our protocol at the clinic involves the use of intravenous gadolinium. I don't know if you need to do that routinely, but sometimes they look to see if there's anything that enhances and the surrounding soft tissues, which may suggest cancers and bad things. But in her case, it looked pretty good. Cystoscopy, she had a small ostium, couldn't get the scope actually into it. Plan was to follow up yearly. Like, okay, you're not symptomatic. You're doing pretty well. She wasn't comfortable with that. It eventually came back eight months later. So we operated on her. Path from the operation was adenocarcinoma. Hmm. So that's a tough one. So now I have a management dilemma as to what to do with that lady. So changing gears, presentation, the atypical presentations, when someone's got hematuria, gross hematuria especially, retention is the big one. If you have a patient with a diverticulum and urinary retention, in my book, it's cancer until proven otherwise. You really need to evaluate those patients for that. They can have stones. We know that that can happen. They can actually push on the urethra, find that can create obstructive voiding symptoms. But boy, if they have emptying problems and you know they have a diverticulum, I'm very worried and very concerned that they could have cancer within that. And most of the cancers tend to be adenocarcinoma, less often transitional, even less often squamous cell. So the glandular origin of these is why adenocarcinoma is the most common. So that was a board's question seven years ago when we did our original certification for the FPMRS boards. It's one of the only questions you can really ask. Many patients can be asymptomatic and still have cancer, but I would suggest to you if they have the emptying problems cancer until proven otherwise. MRI, a variety of ways you can do it, but most people have pretty standard sequences. You should consult with your radiologist to make sure they have that. Now we're happy to share with you our Cleveland Clinic protocols. I don't think there's anything unique to that, but I think that you need to make sure your radiologist is comfortable reading these and how to protocol these patients. Because the last thing you want to do is have someone have just any generic MRI and they missed the urethra and don't get the right type of views. I had a lady who had an MRI of the pelvis for another reason, I think osteitis or osteomyelitis. Very unclear, but nothing that really had to do with the urinary system. She came to us with severe urethral pain and everything else. I couldn't feel anything on exam. And my worry was no question that she had a diverticulum. But I called the radiologist. I'm like, listen, she had an MRI like two months ago. And this was the protocol sequence. And would I be missing? Because I don't see anything on the study. And they said, you absolutely could miss that. So you should have her repeated protocol it the way we do with the MRI urethral protocol. And let's see, came back. Sure as could be big diverticulum. I don't know how it could be missed on the other MRI study, Cleveland Clinic as well. But suffice to say, you know, thankfully, you know, I had no other source for urethral pain. And, you know, ultimately managed her and the rest is history. So that can come up too. So make sure it's properly protocoled. You know, typically the T2 lights up bright white. One trick I always tell the patients too is not to empty their bladder. But if they can urinate just a little bit, like they're urinating to a Dixie cup, that would be sufficient. Because then that may enhance the diverticulum. And then the gadolinium contrast in my view is optional. And our radiologists like to do it because they feel that they get additional information from again, adjacent soft tissue enhancement. Contraindications like usual, we know. Cystic masses, vaginal wall MRIs. You know, all these things can show a variety of pathologies. You can see these here and here in different views. And what we did, you know, years ago is when we did look pathologically at all the patients. So we've had a ton of diverticuli over the years. And this is a 10 year old plus study. Neil Thomas, one of our former residents led. And with that, Donna Hansel, who's one of our pathologists at the time, reviewed all these. And we had a number of adenocarcinomas that came up all more or less incidentally. So when we looked at the pathology, you know, the rate was about five plus percent. So not insignificant. So something you need to be mindful of. Can it happen? Yeah. Does it happen all the time? No. So I'm not here to tell you that, but just something to be mindful of. Cancers within diverticula, it probably is on the tune of about 5%. Most commonly, as I mentioned earlier, adenocarcinoma. Premalignant lesions. I don't know if we really have enough information. If I had a pathologist on the line here today, they would laugh if we said a controversy of nephrogenic adenoma. It's not premalignant. I see that 20% of the time when we do a pathology specimen from the urethral diverticula. That is not worrisome in any respect. True urethral cancers, whoops, are rare and any urologist around the line will know. Squamous cells, transitional cells, less often, but it can happen. We just don't know the ideal way to manage these patients. And this is something you'll have to individualize with your cancer specialist. The standard has been an anterior exoneration. So doing a wide excision around the urethra as well as obviously taking the anterior vaginal wall, bladder, urethra, plus, minus, having to move the uterus, tubes, ovaries, et cetera, and some form of diversion and lymph node dissection. Some people have published on radiation therapy and observation, but not really great studies on any of those. So looking at a lady like this, 67-year-old, recurring UTIs, hematuria. Maybe I'm a little worried. Known history of a diverticulum, no symptoms. Eh, just kind of keep an eye on it. Now she comes back in with bloody discharge from her urethra, anterior vaginal wall tenderness, no masses, prolapse, or fluctuance. She had gross mass effect on her cystoscopy and tumor throughout. And you can see this is a rather large cancer within a urethral diverticulum. On the cystoscopy, you can see these big fluffy areas coming in, invading in the urethra. So that was a problem and she needed to ultimately have a major exonerative operation. So the question we ask is that a cancer within the diverticulum or did that come first and then someone kind of figured out maybe there's a diverticulum there. No one knows, no one knows. Cystectomy and urethrectomy, and this lady already had this now for her management and she's actually doing okay. Can diverticular remnants develop into cancer? No idea. Our default has always been to say, obviously remove any and all diverticulum tissue. I learned this years ago at a patient who I managed her diverticulum and went back when I was in Philadelphia before I moved back to Cleveland Clinic. She had, she came back into the emergency room six, seven years after her surgery, young lady at the time. And during her attention, ER couldn't get a catheter in, called urology, they couldn't get a catheter in. Someone ultimately scoped one in, but one of my colleagues who was there kind of said something's not right here and took her to the operating room and then ended up doing biopsies in that area, found cancer. And so the implication is clearly a diverticular remnant that perhaps developed into cancer and even in our hands. So it can happen. So the questions I always ask myself, is that more common if in the circumferential diverticulum? Well, you've got areas you probably are not getting all of, and I'm worried about that. So that's something as to how I approach my circumferential tics nowadays. Can you access all parts of the diverticulum? I don't know, it's hard. Can you cauterize those areas where you don't really think you excised it, but maybe you're just killing some of the tissue left? Okay, I can live with that. I've even thought about using like an argon beam coagulator, which has a very low depth of penetration, but it would clearly fry any of the tissues in and around that, so long as you don't damage the urethra. But I also worry about kind of a bunch of necrotic junk and developing an abscess or anything in that space. So it's something to be mindful of if you do decide to do that. 71-year-old lady now, urethral diverticulum five years ago, path was negative, post-diabetes, UG negative, represented with voiding difficulty, so retention. Ultimately was started on ISC at an outside facility, but she couldn't do it, it was just too difficult. Came in here with a Foley catheter, and right when I knew that, and I knew she'd had a diverticulectomy in the past, I was like, oh no, this is bad. Fingers in the anterior vaginal wall, I'm like, oh great, it's all firm and hard and indurated. I knew what was going on, and she had a cancer within the diverticulum as well. Really, really hard and firm, multilaculated area that was real big, and she ended up again getting an anterior exoneration. The incidence of this is probably low, unknown if it's primarily the cause or secondarily. I don't mean to scare patients when they ask me like, hey, I just want to keep an eye on this. I don't have any problems, only is there any harm in waiting and watching? Well, if you opt for surveillance, careful follow-up is no question necessary. Here's the kicker. MRI has missed a lot of these, and so that's where I really worry that we don't have a good, easy way of following these patients going forth. When we looked at our series, the cancer series I showed you from the pathology years ago, I took all those specimens, meaning that they're MR numbers rather, and took them to the radiologist and said, hey, listen, can you just re-review these ones with me? Sure, let's look at them, and so as we looked at them, I said, do you see anything worrisome? Like, no, nothing at all diverticulum standard stuff. I said, what if I told you that these were all cancers on this path specimen? Oh, wow, let's look at it again, and he looked at it again, he's like, no, I mean, gadolinium enhancement didn't happen in any of them. So in other words, there was no way preoperatively to detect is there a cancer within that. Sometimes it's more obvious, but certainly many times not. So MRI to follow these patients is not reliable enough. I think an exam, plus minus MRI, et cetera, but if it's seen on an MRI, it might be too late because we're only gonna see it when it starts to get outside of the walls of the urethra oftentimes, so that's something. Exam alone is unreliable, so really there's no good way to guide anyone to say like, here's how you should follow patients. Again, one of the real challenges, I would love to have given you my two cents. Yeah, I do tend to examine these patients. More than anything, following symptoms and anything else is perhaps the best I can do. I think it would be excessive to do a repeat MRI every year on someone who's otherwise young and pretty healthy and minimally symptomatic, but I can't fault someone if they wanted to. Circumferential diverticula, again, this is when it goes all the way around. These are hard. These are hard surgeries. These are hard to fix at the time. There are complications and stress incontinence and all these other things come up much more often, so I'm very worried for a patient when I have to do a circumferential diverticula. I tend to get a lot of these. I like it and I hate it both. It's just the challenge of being in a tertiary care referral center. One of my colleagues really felt that he got great results. Eric Rovner is a very good surgeon and he would actually, and I've kind of taken his lead on this, going through the urethra, literally bisecting the urethra, getting around the diverticulum then so I can get all the back parts, the dorsal parts to it, and then I'll do an end-to-end urethroplasty. I just did one a couple months ago and ultimately she did great, but at the time, it's a very difficult operation to get around and many times the diverticulum itself has thinned out the tissues so much that your reconstruction is sometimes quite challenging. But in his series, his outcomes were no different when he did that level of an extensive urethroplasty and urethral reconstruction as when he just did more simple saddlebags and other tics. So again, pictures here of circumferential urethral diverticulitis. You can imagine, you got a lot of work to have to do to get all the way around the urethra, excise all this flush and then keep an intact urethra somehow or another. So that's where I will transvaginally go right through the urethra, get around the back wall. Now I have a perfect visualization of the back, get everything else I want and then do an end-to-end urethroplasty to fix that. And that's something that we've done a lot of. So I think that's been the same case for anterior diverticula. So these are ones that are really almost exclusively above the urethra. On examination, sometimes a fellow will be like, I don't feel anything. I'm like, well, you shouldn't feel anything because there's nothing suburethral because we have the MRI that shows you it's all, in this case, from nine o'clock to three o'clock all the way around, but there's nothing in the suburethral portion. So that's going to be much, much more difficult. The rates of incontinence are no question higher. You're doing a much more extensive dissection. You're freeing up a lot of those tissue spaces. Begs the question, should you sling these patients? There's definitely a higher rate of incontinence, but it's not a guarantee. So I don't know if it's really necessary to always do a sling, but it's something I definitely discuss with the patient preoperatively. Maybe a Martius flap. And we'll talk about some of the series from the UK, how they've been looking at that because they like to do a Martius flap rather routinely on a lot of the more complicated diverticula. But no question, if you don't do anything, the recurrence rates are definitely higher. Again, no surprise. You have more spaces from which it's occurring again. If you have a little bit of extravasation and leak, then that can be, again, the start to another diverticulum formation. So recurrences, though, no one really knows. There's people who've looked at their series. Probably between 5% and 15% is fairly accurate. We've quoted about 8%, and I think I'd say it's about accurate. Maybe it's a little higher even because I don't get any simple ones. But how do you define this? I mean, I'm not routinely doing MRIs on follow-ups on these patients. No news is good news. I don't want to ask for trouble or look for trouble. So if that patient's doing well, I don't know if I really care to routinely study patients. So again, we're going to do that prompted based on symptoms alone, but more likely symptomatic in the proximal and circumferential ticks than the mid-to-distal urethral ticks and so forth. So what can we do to minimize the recurrences? As I mentioned earlier, prospectively identifying each layer, closing the ostium very well, making sure you have a good watertight closure. And I will do negative VCUGs until I get a negative VCUG, I should say. So VCUG at two to three weeks, making sure you get a good voiding phase. There's a leak or extravasation, I'm going to put that catheter back in. That lady is not happy with me. And I tell them up front, I'm like, listen, you may not like me, but I need to make sure I get a good, solid, watertight closure. Otherwise, we're just going to be at risk for a recurrence. So again, one of the challenging things that we always have to deal with sometimes. The Martius flap, this is what Tamsin Greenwell and her group in London have done and really talked about is using almost routine Martius flaps. Well, at the very least, it's going to occupy the space. So can a diverticulum recur when the space is kind of plugged up by fat? I suspect no. It's a little bit excessive to do it on most diverticula, but maybe on the more proximal or complicated ones, most certainly on poor quality tissues, we'll do that in. But I don't know if you need to do that routinely. So I don't really advocate for that. These are painful procedures for the patient. They really, you know, there's a little bit of disfigurement that they'll notice for some time. Sometimes it's very bothersome, but the pain is not insignificant. And so you can't really prep a patient for that level of pain and discomfort in one side of the labia. It takes sometimes several weeks to go away. If it does recur, obviously based on symptoms, so let's say someone did an MRI, and you're like, okay, well, why'd you do the MRI? Okay, I don't know, but if they had symptoms, hopefully that was the reason they did the MRI. UTIs, pain, recurrence of their original symptoms. I mentioned the cancer issue notwithstanding. This is another lady, little different. She had three prior urethral diverticulectomies. One was attempted robotically. I have no idea what that means or how that was done. She was getting recurrent culture documented UTIs. She was driving her infectious disease doctor crazy. The urologist was like, I'm done with you. I can't do any. Very nice, normal lady. Didn't really make sense. She was getting pink lines. And, you know, we looked for, their urologist looked for all these other sources. Like, I have nothing I can hang my hat on as another source. She didn't have some weird, you know, upper tract, you know, anatomic abnormality or stone or anything, nothing. So he's like, listen, this is all we've got. And that was this MRI. So she's got this thing that I would submit to you. It was probably, you know, half the size of my pinky nail. And in two little spots, which I might say is well within the range of normal. So if you were probably to do MRIs routinely on patients after these surgeries, I suspect you're gonna see that that's, an MRI like this could come up not infrequently. Six millimeters, so I mentioned that. But she flew in from Montana and she said, like, you gotta, I gotta do something. I didn't come here to visit Cleveland. Like, okay, we'll do it. I talked to a couple of friends of mine. They're like, yeah, what do you have to lose? I mean, you know, it can only help her. I said, yeah, I have to lose a 40 year old lady who's now incontinent and has a fistula. So we know the complications. But at the same time, we elected to do it. We fixed her. I resected the entire lateral wall. Like I needed to make sure, because I wasn't gonna find this little thing. As I mentioned, that's, you know, half the size of my pinky nail. But in the end, we did that, reconstructed her in layers. Post-op BCG is negative. Called me to thank me. She's like, I haven't had a UTI in like three months. And I was in and out of the hospital with PICC lines. So I can't really make sense of it. You know, a diverticulum that small, causing her that level of UTIs and recurrent UTIs. And again, needing PICC lines for her antibiotics routinely. But it comes up. Again, odd cases come up as well. And I won't go into to dwell on that too much. Let's talk a little bit about complications of diverticulectomy. I mentioned fistula formation. That's probably still the more worrisome one. Stress incontinence. We mentioned recurrences. Strictures, I think, should be uncommon, but they do happen. I've had to manage those. And I'll show you a case or two of that. But I think more often than not, it's urethral vaginal fistula and stress incontinence that we see. Stress incontinence, it might be part of their original presenting symptoms. So remember, you have to differentiate dribbling from stress incontinence. And that's a hard one. So that's where I'll do a cystoscopy, have the lady bear down. If I see incontinence simultaneous to the push or cough, all right, then it's stress incontinence. At the same time, if it's something that happens later, seconds later or not, I might think that it's more likely to be post-void dribbling, which I can remedy with correction of the diverticulum. But we know the incidence is not insignificant, seven to a whopping 49%. So we don't really know what to do. I mean, should we sling everyone? Okay. And so I'll just preface this by saying not using a synthetic sling at the time of a reconstruction. We wrote that in our guidelines. We don't need a randomized controlled trial to show that. Doesn't make any sense. So if you're gonna do this, it would be with a fascia sling, or I guess some form of biological should you desire to do that. You can say sling no one. And that's just staging patients who are more symptomatic. I tend to do most of that. If someone has preexistence stress incontinence, okay, I'm only gonna strip the tissues around the urethra even more. I'm pretty sure I'm coming back. I might as well just spend the extra half hour, 45 minutes and just do it all at the same time. And nowadays I'm just doing more fascia lata harvests. So I'm doing fascia lata slings. And so, we can do that at the beginning or later on and do that. Or we can, in cases like this, more likely than not, we'll just do it through the rectus fascia approach. But anyway, then fixing those people. Get any variety of ways you can do the sling either rectus fascia, fascia lata. You know, several series were done in the past. I like the second line. So if you're planning a fascial sling, you should pass the sutures before the diverticulum repair. So then you can perform the cystoscopy. Because if you do all this reconstruction and then anastomosis or even fix a big ostium and all the defects, I don't wanna be shoving some rigid cystoscope through that to see if I perf the bladder in the course of passing her sling trocars. So I like the idea of passing the sutures or at least the sling trocars back before I did too much else. So it makes some sense to me. But if the patient develops a recurrence, now I got the sling underneath there. That's ugly, it's a mess. So that's where sometimes I'm a little bit more pragmatic in my thinking and saying, well, let's stage some of these or she's at a lower risk. Let's hold off on hers. Let's kind of keep an eye on this. Maybe she's not gonna be that bad, et cetera, et cetera. And then voiding dysfunction, the same. She has emptying issues. Is it because of my sling? Okay, that happens not infrequently after fascia slings. Or is it because she has a diverticulum recurrence? We know we can see that. And if she has voiding dysfunction, God, I don't know if I want her doing self-gath through a fresh repair. That's really not advisable in any situation. So things I worry about. I like this. This is something, Rob Goodman, I think the AUGS Fellows Consortium did a really nice kind of retrospective look of the concomitant pubovaginal sling with urethral diverticulectomies. And what they found is really the sling did help a lot of these patients. Again, not a randomized trial or anything, but when they looked at a rather large experience, patients who had diverticulectomy and slings tend to do better in terms of urge, stress incontinence, UTIs, a lot of things. So patients did better when they had that. Again, there's just some subtle nuances, a few things we don't really know, to what extent the diverticulum was, what kind of symptoms they have predating all that. And one of the challenges with some of these retrospective looks. But again, I think it was a valuable addition to the literature. This is another paper, a nice one. Looking again, retrospectively, 15-month follow-ups, not tremendous, but not bad. Two patients with pre-op SUI, one got a concomitant sling, four patients afterwards had de novo SUI, myelosomes, some people got TBTs after all that, but they were more at-risk patients, proximal and enlarged diverticula, they didn't notice that. Our series with this, again, well over 10 years ago, 50 patients that we looked at, we didn't do any concomitant stress incontinence procedures on any of them. But when we looked at kind of, how much are you having for leakage? 50% had none, but when you look at, had a little bit to moderate, now we're starting to get up there, 40 plus percent had some to moderate leakage. So it is something you need to counsel them on, that they may need something to be done for that later on down the line. Many of them still had a subsequent sling done at a later time. We did occasionally some synthetic slings on the follow-up. So a little different in that situation than doing it simultaneous, where I'd never do a synthetic sling, I would only do a fascia sling in those cases. But I think nowadays I'd probably do more fascia slings in patients like that. Again, other patients, again, in their more pragmatic approach that they feel, that if they treated stress incontinence, they would have over-treated a lot of these patients. So they tend to not routinely do slings, which probably makes sense, because a lot of these are doing Martius flaps and to add a sling on top of that, like I wouldn't do it either. So I'd probably wait and see if she had stress incontinence that was bothersome enough that one needed to do something there. Urethra vaginal fistula, some of the last few things we'll talk about. Again, this is tough. This is a 43-year-old lady, symptomatic tick at an outside hospital, had a three to four centimeter bilobed circumferential tick at the proximal urethra. She had a non-overlapping suture line. Everything looked great. At a month, she had insensate urinary incontinence. Five months, just pouring out, failed all conservative measures. Her thing was tough because when we examined her, her urethra was obliterated. They couldn't pass a catheter and she had a urethra vaginal fistula proximal to that. So she became obstructed distally, blew up proximally, developed a urethra vaginal fistula. Again, this is a tough repair. She still had a recurrent tick, a little bit there. And then the fistula was also identified ultimately. So she had this proximal fistula, obliterated urethra. This was one of the tougher cases I've done. So I had to do a transvaginal repair of the fistula. Well, fine, we do those, no big deal. But I had to split open the entire urethra, had a buckle onlay. So one of my reconstructive colleagues, Dr. Wood, helped me. She got some buckle graft and then we put that on top of the urethra and then a Martius flap on top of all that, reconstructed everything. She did fine from the fistula standpoint. We fixed her for that. And these are some of the pictures. So you can see here after we finally got continuity, urethral defect was still there, excised any of the fistula and a little bit of remnant diverticulum. And then did this buckle onlay graft. And then ultimately her post-op BCG looked great. But then she developed stress incontinence. Surprise, surprise. She'd been through so much over the last probably year and change with her diverticulectomy and then the R surgery that she's like, Dr. Asabna, would you mind if I just hold off on doing anything further for my incontinence? I was like, I'd be very happy for you to do that. So we waited and honestly, I haven't seen her back in several months. So I'm hoping she's doing okay. But if not, she's probably living with some of her stress incontinence. So again, real tough case. This is another interesting twist. Sometimes comes up when we're doing slings, synthetic slings, right? We all do those all the time. There's a little poochiness right around that area of the mid and proximal urethra like, it's probably fine. You kind of think, okay, this is probably okay. And then there's that time like, I wonder if that's something, I don't know if I want to just go ahead and do my usual subdueasal dissection for a sling, synthetic sling at that. But I think in some of these cases, we've seen this. So everything looked good, placed the sling. And then later on comes the CS for cystoscopy. You can see mesh across the base, an obvious diverticulum around this. And I think it was just kind of a bad luck situation where she had probably a sling that went through a diverticulum. And maybe her diverticulum was the theology of her leakage or dribbling even. It may not have been as much a typical index stress incontinence. So in these cases, we have to excise the mesh, fix the diverticulum, reconstruct the urethra. So a fair amount of work to do. So again, just sometimes just bad luck. So all of us, we think about these things, but just be proactive when you're looking at the patient's anatomy, making sure you don't feel anything soft, fluctuant. If you're worried, it's not the worst thing in the world to do an MRI in advance of a sling because you don't want to find out the hard way like these cases. Again, it's just bad luck. Again, other examples of bad luck. This is a lady who had a durasphere injection, probably into the diverticulum. She got this big mass and phlegmon around that. But again, is it a chicken or the egg? We have no idea. Sling through a circumferential tick. Again, similar situation. Came back after the sling was doing well, then had voiding dysfunction that developed with time. The time course just didn't make any sense because if she's going to have sling-related outlet obstructive symptoms, it's going to happen pretty much upfront. And she was doing fine for a little while and then progressively developed symptoms. And then again, an MRI showed this. And so we had to, again, incise her sling. She had a fascia sling. Incised it, removed the diverticulum recurrence, and then it took the ends of the sling and kind of brought those back together again and then monitor for symptoms. So she actually did pretty well. Voiding dysfunction, reoperation rates, not insignificant. Again, 10% in our series. Recurrence rates, pain, UTIs, things like that. It's not uncommon for patients to have some of that. So I can't guarantee that they don't have a recurrent tick, but our belief is it's a smaller group of that that actually have that. So the last thing is, what have I learned over the last 15 years of doing these? I think selective management, it's really been, mainstay has been symptom-based direction. We use these buzzwords of shared decision-making and stuff. And this is certainly one of them. It's not me lecturing the patient. You should do this, have it this way. Because if she's asymptomatic or minimally symptomatic and you do something and now she's got a fistula and it's stressing confidence, like I'm the bad guy and I didn't need to be that. So I need to make sure that we're appropriately discussing besides the usual risks and benefits, but that she's understanding that we may not make a whole lot of things better, but what are we trying to achieve? If it's prevention of cancer down the line or something like that, this is where it comes in. But the risks can be kind of high either way you look at it. Continuous follow-up, I've been doing that much more. I've been asking my patients to come in once a year. Quick exam, we follow up with a UTI, something else. Is there something else that's going to prompt me to do an MRI or repeat imaging? I think that's where I think about it. What else have I learned? These anterior circumferential tics. I used to really always prospectively approach it from the sides. I've been now routinely going right through the urethra. It just made a big difference for me. I credit Eric Rovner in South Carolina for that. But I think it really has allowed me to get all the diverticulum out. I'm much more comfortable. And then I'm not shredding the urethra and then a nice endoenurethroplasty. Some of you might think that's a little over and above what you'd normally do, and maybe, but it's really not that hard. And you do these things for other reconstructions. So just simple suturing, and usually you can do a pretty good job for that. I think in these smokers, steroid patients, poor quality tissues, circumferential tics, I'm maybe getting a little bit more liberal with using a Martius flap than I was several years ago. So it's something, again, I've kind of changed my tune to with time. So last conclusion is really just, hopefully you appreciate, your MRI is still the gold standard. If there's any questions, get an MRI of the urethra. Make sure you have a solid protocol in place in your hospitals, because that's going to be very important. Prospective development of the layers. I showed in the video, we're very methodical with each layer, because that's going to help me reconstructively, minimize my complications, minimize fistula formation for sure, and really allow, hopefully minimize the recurrences. So that's how I tend to at least use the mindset of trying to prospectively develop each layer as we do that to reconstruct. And then really thinking about these asymptomatic diverticulum patients and how you want to follow them, kind of go over things to keep an eye out for and things like that, so that those patients don't come back with any worrisome or problematic scenarios. Handful of references, happy to share it with anyone. So I'm happy to answer any questions the group has. Thank you so much for your time and attention on a fall evening like this. So Lauren, any questions I'm happy to field from the chat room or wherever you think. Yes, great. Thank you so much. This is a really interesting discussion of such tricky, complex cases. And we do have a couple of minutes for questions and a few questions that have been submitted. So for the rest of our participants, if you have any further, please feel free to put them in the chat or the Q&A to me. Our first question we have, and some of these are related, is that from Dr. Janaz Birzandi asking about post-op foley management. So she's seen a lot of varying practices from surgeon to surgeon and is asking kind of what your take on best practices for that would be. Yeah, it's hard to say best practice. I can just tell you what I do. And I think many of my colleagues who do, a fair amount of diverticulum, my friend Eric Rovner in South Carolina does very similarly. Most of us probably leave a urethral foley for two weeks. I used to do suprapubic tubes because I was worried if there's any other issues, I'm gonna need to keep a urethral catheter anyway, because I need to make sure we have a watertight repair. I don't want any urine flowing through an otherwise complicated repair. So I'll usually leave it for two weeks, get a post-op VCUG. So then catheter comes out. So right, they get the cystogram phase, they fill up their bladder, remove the catheter, and then we get them to void on the table, which is always challenging. But we need to get that aspect of the study. And so once that happens, if we have no evidence of any leak, the catheter stays out. If there is a leak, then they're gonna come out to the office. Okay, Mrs. Smith, you still have a leak on your X-ray. You're gonna hate me, but I'm gonna have to put that catheter back in. And hopefully we've prepped them in advance that they're gonna potentially need that. And I think along those same lines, Dr. Leakin-Harris also asked, and do you always do the post-op VCUG just to clarify that recommendation kind of even in a straightforward case, I should say. Yeah, that's a good question. Honestly, I got away from that several years ago, when I say several years, many years ago. And I just say, oh, you know what? We got a good repair. It's watertight. Everything will be fine. Because a lot of times we're getting these extravasations. Some old series used to say you could see extravasation on the post-op VCUG well over 50% of the time. Wow, like 50% that I'm keeping a lot of Foley's in for a long period of time. And again, that patient comes in, they're already hating you because they've had a Foley, especially the young women for two weeks. And if they're a smoker, in my practice, I do three weeks. So they already hate me. And now to say, I'm gonna put this back in. They really love me then. So these are questions I would have to ask. So I tried going without them as long, meaning not doing the VCUGs and just saying, take it out. I think my recurrence rate started to creep up a bit. And so to that end, I have gone back to doing a VCUG till I get a negative VCUG and then take the catheters out after that. So I kind of learned my lesson the hard way. Yeah, thank you for that one. One other question here is, do you use your dynamics to determine kind of that preoperative or pre-existing stress incontinence versus the diverticulum dribbling? Yeah, so great question on the use of your dynamics in these patients. Yeah, I mean, we're always gonna say, absolutely. Here's my challenge. On the your dynamics table, it's hard to detect stress incontinence when there's a setting of a diverticulum, right? And in other words, you see something dribble out, something leak out per urethra. It's really hard to tell, right? I mean, especially if the lazy lower overweight, you gotta spread her legs. Can you see that? That's without video fluoroscopy, even with video fluoroscopy, it's still hard to see. So I would submit to you a cystoscopy is more beneficial because my face is right there, at least scope, distance, glasses, shields, right? Have her bear down and see if I see the leakage simultaneous with the Valsalva or cough maneuver versus a dribble, which may or may not happen. So again, that's what it would be more, I think easier to detect stress incontinence than to do a your dynamics study in my book. But no one can fault you for doing your dynamics for sure. Okay, we're gonna make a case for Dr. Jessica Rogers here. She has a lady who's come in, complained of AIDS to 9 out of 10, I don't see any signs. I'm assuming she's a local urologist who did a cystoscopy of biopsies, saw inflammatory reaction in biopsies, her with a finding or a pathology of polyploid cystitis and foreign body reactions. She has a history of macroplasticity over a few years ago by a different provider. And they thought that may have been the macroplastic reaction that the outside urologist had biopsied. So then she turns to Dr. Rogers for her opinion about your pelvic pain. And on the exam, there is, it sounds like tenderness to poppy, you've got a 0.5 centimeter nodule. So you obtained that your MRI and the MRI showed a thickened bladder wall and your reasonable diverticulum of 1.6 centimeters now. So she comments that she hasn't seen a diverticulum like this cause such significant pain. This is, you know, 8 to 9 out of 10 pain routinely. So do you tend to see severe pain in those cases? Yeah, that's a good question. You know, and tough. The good news is there's radiology literature that very well defines the criteria differentiating a macroplastic or durosphere or collagen and other injectable agents. We haven't heard about bulk of it yet because it just got approved. But point being is that they can differentiate that well from a true diverticulum. So that could be defined in advance. So I guess my guess is here that it's a microplastic diverticulum or mass. Does that cause pain? I mean, the thickened bladder wall, I'm worried more about obstruction because maybe they obstructed her with the macroplastic. So is it pain? Does the pain get relieved with voiding? Because again, she's obstructed really more than anything. And assuming you've already ruled out other non-urologic causes of pelvic pain, which we know that that's the pain to all of our existences. So to that end, I might make sure everything else is taken care of. There's nothing else going on that we believe is a source or cause. I would approach it. I would go ahead and remove it. It's not going to get better with time and you got to just tell her, hey, listen, there's some risks, but you can find it. And, but I think, I suspect it's probably the macroplastic. Maybe they just over-injected it. I don't use macroplastic. One of my colleagues does. But I do worry about injectables causing problems. Severe eight to nine out of 10 pain, nah. We'll see obstructive voiding, yes. We'll see dribbling, yes. X, Y, Z, but not that. It's uncommon. It's another conundrum. Yeah, thank you. One last question is about kind of the supramedial approach or alternative anterior tics or circumferential tics. Do you ever do that as opposed to kind of bisecting and doing that? Yeah, great question. So supramedially, you know, if you're just doing an anterior tic, boom, you're right there. Why do I not do it on the circumferential? I think I feel like I've got this whole thing hanging in the breeze, which it would be. And not to say I'm going to still have a lot of anterior support because I'm taking a lot of it down, even if I dissect through going from the ventral, but I need to do a lot of ventral work anyway. So in those cases, but if it was a purely anterior tic, I've done those with a supramedial incision. It's really pretty quick access. You know, you got to just stay right on top of the urethra. I still question, where's the ostium? The ostium's almost always five and seven. So I feel like I'm going to have to slide down to the sides at some point anyway. So I'm a little cautious about saying it's just a supramedial approach. I haven't done that, honestly, in many years. Same time, a purely anterior tic, I rarely see that. Circumferential, unfortunately, often. Well, thank you so much. You're getting a lot of thank yous from all our participants, too. So also on behalf of the Alls Education Committee, we all want to thank Dr. Vassava and all of our participants for joining us tonight. And we do have another upcoming webinar next month on statistics, presented by Dr. Jennifer Ruth. So thank you all for a lovely evening. I'll see you next month. Sounds good. Thanks. Thanks for asking me. Take care. Bye.

urology

female pelvic surgery

urethral diverticula

individualized management

transurethral approach

end-to-end urethroplasty

Martius flap

recurrence rates

complications

synthetic slings