This is a 50-year-old female who presented initially for the management of a recurrent urethral diverticulum. When first evaluated, she was noted to have an indwelling catheter for six months prior to presentation. The catheter was placed due to severe incontinence refractory to multiple surgical procedures. The anterior vaginal wall was very scarred. There was evidence of minimal anterior wall mobility, and the leak point pressure on urodynamics was 10 to 15 centimeters of water. Pertinent surgical history includes a birch, a prior MMK, a TOT, a TVT, a urethral diverticulectomy, and coaptive injections. The case starts by careful inspection of the vagina, and this demonstrates the presence of exposed mesh from either of the previous slings. Assessment of the severity of leakage is then performed intraoperatively, and it's evident that any compression or movement in the vagina results in urinary leakage. Cystoscopy performed thereafter shows the presence of the diverticulum to be at 6 o'clock relative to the urethral lumen. The surgical plan includes removing the sling material from the vagina and extensive urethral lysis to perform a diverticulectomy to mobilize a marsh's fat graft from the right labium to harvest a 10 by 2 centimeter piece of rectus fascia and position that as a pubofaginal sling. We proceed with infiltrating the vaginal tissue with lidocaine and epinephrine, followed by the release of a flap of tissue overlaying the slings in suspected diverticulum site. In this case, we use the inverted U-shape technique. The flap is initially demarcated with cautery and then released with the help of Smeyer's scissors. The mass of the slings is noted to be incorporated in the vaginal tissue. Next, the diverticulum is identified and resected all the way up to its urethral connection. During the dissection, a suture is located within the wall of the diverticulum. A stone is identified at the suture knot. Due to incorporation of the mesh into the vaginal tissue, that piece gets excised. Next, the arms of the slings are excised as high as accessible as possible. This picture demonstrates the mesh excised as well as the suture with the stone. In this view, the urethral diverticulum is exposed and carefully dissected and excised. In this view, the foley can be seen through the urethral defect. This defect needs to be approximated and sutured closed while ensuring that the urethra is not strictured during the repair. Next step would be to assess urethral integrity throughout the length of the urethra. In this case, a very distal urethrovaginal fistula is noted and repaired. The edges of the fistula are trimmed and the opening is closed with multiple layers of sutures. Next, the spaces for the pubovaginal sling need to be created with the help of a male scissors and then extended digitally. The rectus fascia strip is harvested and prepared for insertion by attaching ethabond sutures to both edges and then positioning it with the help of stamy needles. Next is the harvesting of the marsh's fat pad. In this case, we elected to access the fat pad directly through the hair-covered area on the labia majus. We demarcated the incision and accessed it with a scalpel and released the graft with the help of cautery while ensuring the persistence of a blood supply to the graft. The graft is then passed through an opening made in the vaginal wall and placed between the rectus fascia sling and the suture-closed diverticular opening in the urethra. After the sling is tightened and well-positioned and the vagina is closed, cystoscopy is performed to confirm urethral integrity.

urethral diverticulum

incontinence

surgical procedure

pubofaginal sling

urethrovaginal fistula