Our patient is a 21-year-old Gravida 1, Para 1, who is 3 months postpartum and presents with a persistent suburethral mass. She was first referred by her obstetrician at 36 weeks gestation. Surgical management is delayed until the postpartum period. A standard of care in pregnancy for these types of masses is conservative. The patient represents in the postpartum period with a mask and denies having any pain, dysuria or incontinence and only endorses having some white discharge from the area. On exam, the patient is noted to have normal anatomy with the exception of a 2 by 2 centimeter suburethral mass that is non-tender but expresses white purulent material upon palpation. The differential diagnosis of suburethral mass includes the following. Urethral diverticulum, urethrocele, Skene's gland abscess, Gartner's duct cyst, ectopic ureter, vaginal wall inclusion cyst, urethral carcinoma, vaginal carcinoma, vaginal fibroma, leiomyoma, leiomyosarcoma. While this list is long, the physical exam and evaluation can help differentiate between these diagnoses. Symptoms of urethral diverticula vary amongst patients. The history of urinary tract infections, stress urinary incontinence, urgency and frequency, and incomplete voiding are some of the most common presenting symptoms. In 1965, Hoffman and Adams described the classic symptom triad of urethral diverticula known as the three Ds, which includes post-void dribbling, dyspareunia, and dysuria. All of these symptoms are nonspecific, however, when accompanied by the presence of a suburethral mass are more suggestive of a urethral diverticulum. An MRI is obtained for this patient to better characterize the mass. Imaging reveals that there are two adjacent cystic structures measuring 0.7 by 0.5 by 0.8 centimeters on the right and 1.1 by 0.9 by 1.2 centimeters on the superior left along the posterior distal aspect of the urethra. The left cystic lesion demonstrates continuity with the urethra and appears to have a narrow communication with the more inferior and right cystic lesion. These imaging findings are consistent with either a solitary bilobed urethral diverticulum or two separate adjacent diverticula. Surgical options for the treatment of urethral diverticula include marsupialization of the diverticulum, endoscopic transurethral incision of the diverticulum, and transvaginal excision of the diverticulum. After thorough counseling, a decision was made to proceed with transvaginal excision of the diverticulum, which is usually our surgical treatment of choice. The patient is taken to the operating room. After the patient is prepped and draped, a cystourethroscopy is performed. Once the bladder is inspected, the urethra is examined to see if the communicating neck of the diverticulum can be identified. A 16 French Foley catheter is inserted inside of the bladder and the bladder is allowed to drain continuously throughout the case. A Lone Star ring retractor with hooks is used for retraction and visualization of the anterior vaginal wall, which reveals a cystic mass in the distal urethra. An inverted U incision is outlined with a marking pen, up to near the distal aspect of the urethra and just proximal to the urethral meatus. A prepared solution of lidocaine with 1 to 200,000 epinephrine is then injected into the anterior vaginal wall to facilitate dissection and hemostasis. The marked area is incised with a scalpel. The anterior vaginal wall flap is dissected with the metzenbaum scissors. Care is taken to keep the flap dissection superficial over the periurethral fascia in order to avoid entrance into the urethral diverticulum, but thick enough to allow for adequate reconstruction at the time of closure. The Lone Star hooks are then advanced to retract the edges of the anterior vaginal wall. The borders of the diverticulum are identified. The periurethral fascia is opened transversely over the diverticulum. The periurethral fascia is dissected off of the underlying diverticulum using the metzenbaum scissors, and this is done carefully in order to help preserve each layer, which will help facilitate closure once the diverticulum has been excised. The dissection is easier when the diverticulum is still full of fluid, but can still be done precisely if the diverticulum is entered, which is the case here. During the dissection, it becomes apparent that this diverticulum is solitary and bilobed, and not two separate diverticula. The communicating neck is identified during the dissection. Once the diverticulum sac has been freed from the surrounding periurethral tissue and the lumen is identified, it is grasped and gentle traction is applied, and the thick wall of the sac is dissected off of the spongy tissue of the urethral wall until the entire sac can be removed. The neck of the diverticulum can be identified on the urethra with the Foley catheter in place. The sac can be passed off as pathology specimen. Again, the neck is identified within the diverticulum. Hemostasis within the perifacial layer is achieved with several figure of eight stitches using 3-0 absorbable suture. The urethral communication site is identified and closed with fine absorbable suture in an interrupted fashion. If a urethrotomy is made at the time of dissection, the site is closed in a similar fashion. To ensure that closure is watertight and that there are no urethral defects, the Foley catheter bulb is deflated and the Foley is backed out of the urethra until the tip of the catheter is at the distal portion of the urethra. The catheter is then retrograde filled with normal saline to confirm that there is no leakage from the repaired defect. Once this is confirmed, the Foley catheter is reinserted into the bladder and left in place. The periurethral fascia is then closed transversely adjacent to the urethra to close the dead space and to prevent recurrence of the diverticulum. Fine absorbable suture is also used for this closure and the sutures are placed in a single or figure of eight interrupted fashion. The excess anterior vaginal wall is trimmed and the anterior vaginal flap is advanced forward to cover the area of reconstruction. It is closed using a number 2-0 absorbable suture in a running or interrupted fashion. Care should be taken to construct a tension-free closure to allow for adequate healing. The transurethral catheter is left in place for continuous drainage for 14 days. The patient is discharged home within 23 hours of surgery with a plan for a 7-day postoperative visit followed by a 14-day visit for a retrograde trial avoid. The most recognized complications after urethral diverticular surgery include the following. Urethrovaginal fistula, urethral diverticular recurrence, de novo stress urinary incontinence, recurrent urinary tract infections, urethral strictures. In patients who present with concomitant stress urinary incontinence, an important consideration is concomitant management of this incontinence at the time of diverticulum excision. In these patients, pubovaginal sling can be successfully performed at the time of urethral diverticulectomy. It is not recommended to use a synthetic graft in these cases as the risk of graft erosion is high in the setting of urethral reconstruction. There are three components to successful management of the urethral diverticulum. Evaluation is the first important component. Analyzing a patient's constellation of symptoms, if there are any, correlating them with the physical exam, and choosing the right imaging modality are key to good management. Next, choosing the correct surgical procedure is very important. And third, adherence to the principles of surgical reconstruction and practicing meticulous surgical technique will cure the diverticulum and prevent complications and recurrences. For more information, visit www.fema.gov

suburethral mass

urethral diverticulum

transvaginal excision

MRI

complications