Tonight's webinar is titled Urethral Diverticulum from Straightforward to Complex, and our speaker today is Dr. Benjamin Brucker. Dr. Brucker is a distinguished clinician, surgeon, and academic urogynecologist currently practicing in New York City. He earned his undergraduate degree with honors from Cornell before embarking on his medical journey at the University of Penn School of Medicine. It was during medical education they discovered his interest in how various conditions affect the urinary bladder. This led to his residency and fellowship, and he finished his fellowship at FPMRS at the NYU Angone Health, one of the first fully integrated programs blending female urology and urogynecology. He's demonstrated an aptitude for research and publishing in high-impact journals, and has presented his findings at national and international conferences. Dr. Brucker is an active member with numerous professional societies, including AUA and SUFU, OGS, and ICS. He has held numerous committee titles and serves on various professional society committees. He was also a founding member of the SUFU Research Network and continues to be involved with this productive multi-center academic endeavor. He has served as course director and course faculty at countless educational courses, and currently he holds the position with the AUA on the Data Committee and on the AUA Public Policy Council. He now serves as a division director for urogynecology and neurourology in the departments of urology and obstetrics and gynecology, and he's also the program director of the Urogyne Fellowship. His dedication to teaching and mentoring the next generation of clinicians to care for women with pelvic floor disorders such as incontinence, prolapse, and abnormalities of the urethra is very evident. So we're very excited to have him here. This presentation is going to run for about 45 minutes, with the last 15 minutes of the webinar dedicated to Q&A. Before we begin, just a few housekeeping items. AUGS designates this live activity for a maximum of one CME credit. To claim your credit, you must log into the AUGS eLearning portal and complete the evaluation following the completion of the webinar. The webinar is being recorded and live streamed. A recording of the webinar will be made available in the AUGS eLearning portal. Please use the Q&A features of the Zoom to ask any of the speakers questions, and we'll answer at the end of the presentation. Use the chat feature if you have any technical issues, AUGS staff will be monitoring the chat and can assist. Let's begin. Great. Thank you so much for the kind introduction. Thank you for inviting me to talk. I'm very excited at all educational opportunities, and it's great to hear that so many of you have logged on, I'm sure, after busy days or busy weeks. And the title of the talk, as was mentioned, will be urethral diverticulum from straightforward to complex, and very excited to be with you all this evening. As was mentioned, we'll talk for about 45 minutes, 50 minutes. The only real guidance I had was, make sure you have some videos in there. Dr. Stewart, one of my partners and I were talking about what to present, and she said to put videos in, so I promised her I would. Here are my disclosures, which you'll see, I'm not sure that there are any true conflicts here, but I do also want to take a moment to thank Tashi Chester with the AUGS educational division, who did really a great job tracking me down to hand in what I needed to hand in, and made sure that I was on time and that I'm logged on here today. So our objectives today will review the pertinent anatomy pathophysiology of urethral diverticulum. I then want to make sure that we explore the workup and the diagnosis of female urethral diverticulum. We'll explain and demonstrate the surgical steps, principles of urethral diverticulum treatment, and then talk about some other treatment considerations, and then questions with an exclamation point to make sure that you realize we welcome them and we want them. So to start, we'll sort of pull a couple of slides from a intro to urogynecology lecture and anatomy lecture, and sort of focus in on the female urethra. It is, I think, an organ that's obviously vitally critical to the bladder and urinary function, but I think it is sometimes really not so well understood. And I don't know that I'll give you all the answers. I don't know that we know all the answers of the female urethra, but it is nice to look at some cross sections of the female urethra and look at how delicate the actual urethra is. You see at that darker urethra, and then we can see that we have tissue around it, the rhabdo-sphincter RS labeled, hopefully you can see my pointer over here. And then there are some other structures, the ventral urethral fascia, and I even put in the pubo-vesicle ligaments, and whether these ligaments are real ligaments or not real ligaments, whether they exist or not, certainly that's debatable, but I think it's always something that when you look at the anatomy, you learn something new. So for example, this little small area or the tissue raphe, the dorsal connective tissue is actually an area the first couple of times I put together urethral lectures, I didn't realize it was there, but certainly always fun to know about the organ that you're going to be operating on or deciding to observe. So when we talk about the anatomy and we give a lecture, we have to realize that depending on where we are in the urethra, there are going to be different muscle groups and things that contribute to continence and urethral function. So this is a nice schematic borrowed and adapted from functional anatomy of the female pelvic floor, but I like it because as we go from zero to 100, that's the length of the urethra, we see that there are different portions of the urethra, the intramural portion, the mid-urethra, the urogenital diaphragm, and then the distal urethra, and we see that there's an internal urethra, the medial detrusor loop, sort of bladder neck type tissue, striated urogenital sphincter and smooth muscle, compressor urethra as we go more distal and so forth, and then finally the bulbar cavernosus muscle, which we don't always think of as necessarily a urethral tissue. But if I had to sort of pick one anatomy slide and one that I had to sort of put in and say, hey, this is really important for the understanding of urethral diverticulum, it's this slide or depiction of the female urethra, and it's really calling out the periurethral glands. The periurethral glands secrete mucin, which protect the urethra from the irritative and toxic effect of urine. That's from Tam and Gris Greenwald who put together a very nice review on urethral diverticulum in women in Nature Reviews, and if we look at the actual glands and the picture on the right, as you're looking at the screen, show that these periurethral glands sort of branch off the urethra, and this is really thought to be the potential place where diverticulum form. You can imagine an irritation and inflammation and abscess that can form in a little gland that ruptures, and now we're left with a small outpouching from the urethra. Important to realize, and if you think about in your practices or what you've seen or what you've read, where we find urethral diverticulum, they're usually going to mean the distal two-thirds of the urethra, rare to see something very proximally based, and usually it's going to be the three and nine o'clock position. I'll call out one of the orifices of a periurethral duct, which is the Skeen's gland, and you can see that it really is quite similar, if not identical, to what might sort of cause a periurethral gland to turn into a urethral diverticulum, but just where the opening or the os is will vary, and we'll talk about that in the differential in a little bit. So I think that's sort of the most important of the anatomy slides to look at. So I want to talk a little bit about the female urethral diverticulum, and it is always fun to put together a talk because we get to look at the history and some historic papers. William Hay first identified the female urethral diverticulum in 1805, so not too long ago, and really a paucity of case reports in the ensuing 50-plus years. And then we have a paper many years later in 1958 that reported a series of 121 women. And I put this up here a little bit to say, hey, are things different, are they not different? When we have research meetings and we look at papers and figures and graphs, it is fun to see how far we've come really as just a medical community, but I do like what they presented here. And they said, look, the cases are getting more common. I'm not sure that that really is that the incidence was truly increasing versus we were just actually finding more patients that had them aware of the diagnosis. And then what are the things we can look at to say, does this matter for the development of this condition, which we may not know why it's happening. So we look at sort of number of pregnancies, and then we look at cases and the age of patients when they developed symptoms and when a diagnosis was made. And as you'd expect, you get symptoms first, and then finally a couple of years later. So the curve is shifted a little bit to the right and really focusing in on that 40-year-old range. Again, we'll talk about some of the epidemiology today. And the second page here from this old paper does show the different complaints that the patients had, how many patients had frequency dysuria, some of the things that we talk about and we'll talk about. And then very similar to the presentation I'm going to give you tonight, we'll talk about the epidemiology and the actual symptoms people had and how common they are. And then we'll talk about the diagnosis. And we can see that things like physical exam obviously were able to diagnose a lot of diverticulum back at the time the paper was published. They did have cystoscopy, which was also useful, and then urethrography. So it is fun to see how some of these things are quite similar to what's done today. So the who, what, when, and why. It's thought that globally somewhere between 0.2 and 6% of women have urethral diverticulum. And what we see is depending on the population you're looking at, you're going to get different sort of rates or sort of estimates of the incidence of urethral diverticulum. And this was from a couple of years ago, an international urogynecology paper published showing that if we looked at population-based studies or population-based data sets, the incidence is actually a little lower. If we looked at medical things for, let's say, a single institution, this was Mayo admissions versus a gynecologic admission versus a urologic admission. There may be some difference in incidence. But it is something that you have to think about because we are subspecialists and we have clinics and we see lots of patients with lower urinary tract symptoms. And one of the estimates based on the paper was 40% of women with unexplained LUTs in a specialty clinic ended up having a urethral diverticulum. I certainly don't think that that reflects in my practice, but again, depending on what we're looking at and what sort of symptoms and how we're classifying, you can understand that this is something that we need to have a high index of suspicion for. There are, I think, lots of women that have urethral diverticulum, generally speaking, somewhere between 30 and 60 years old. And the histology epithelial lining, usually squamous with some columnar, combined squamous and columnar cuboidal, but never transitional. So I'm not sure, but I sort of, I think there are certain facts and test questions that are easy to ask based on, hey, what's the histology? Can you have transitional cell? So based on this, I'd say, no, I would answer it's not transitional cell. But we do know that a lot of the urethral diverticulum and histology do show inflammation. And we'll talk a little bit toward the end about why urethral diverticulum are something we may want to address and may want to address with an excision because of some potential malignant degeneration or sort of inflammation, chronic inflammation that can lead to more problems. Again, not that it's every patient and certainly observation may be appropriate, which we'll talk about in a little bit. The wall of the diverticulum is composed of fibrous collagen. So what is the presentation and diagnosis? And I would sort of pose to you guys or ask the question, and if you wanted to, we can play where you type it into the Q&A, but what's the sort of the three D's of urethral diverticulum? And I can give you a moment to think about it and maybe jot it down or think about it. If you don't type it in, that's fine. But we talked about the three D's a lot when I was in medical school and residency, and it is always amazing to realize that dysuria, dyspareunia, and dribbling only occur in 23% of patients. So I think someone had put in an answer here, so you got it right. But what's actually nice about this review is they look at some of the symptoms separately and say, hey, what about dysuria alone? About 30% of patients. There are some things like the post-micturition dribbling, which are actually fairly common. So that's something that certainly when I hear someone describe, I have some swelling or a lump in the vagina, vaginal swelling, or post-void dribbling, my index of suspicion does go up for diverticulum. And then there are things that are very rare, which we'll talk a little bit more about when we talk about the diagnosis of diverticulum, like acute urinary retention. You know, it's something that it's there, it's listed as a potential presenting symptoms, but certainly not all that common. So if we think a little bit about the workup and sort of the first part of this is just the request to say, hey, have an index of suspicion. If you're seeing patients and you start to say some of these words and frequency and urinary tract infections and all sorts of things, you need to think, hey, could it be a diverticulum? I do see, definitely keep the questions coming. I'm going to get to some of the approaches surgically for the large diverticulum and the circumferential diverticulum. So definitely we'll get to those. But in terms of the workup itself, you have a high index of suspicion and take a history. Sometimes it's very important. And we'll talk when we get into the differential diagnosis, why history is really quite critical. Physical exam, certainly it can help confirm a diagnosis. If I push on the urethra, I feel a blottable area. I see a little bit of milky discharge come out of the urethra. Patient has a little discomfort that really gives me a lot of suspicion that says, hey, you know what, I'm confirming it. And then there are other times when you have a patient with urinary symptoms and you might push on the urethra and you sort of have. And I think that might be something like a diverticulum. Let's get some more tests. So what are the more tests that we can get? And we'll talk about each of these in a couple of slides. But cystoscopy, urethroscopy, VCUG, positive pressure urethrography, video urodynamics, ultrasound, CAT scan, and MRI. So that's really, I think, it on the workup itself. But what is the differential diagnosis? So as we're considering urethral diverticulum, we want to get in and sort of talk about the surgical correction of it. But it's important to realize what else can be going on. There are things like anterior vaginal wall prolapse, there's Skeen's glands, which we talked a little bit about, vaginal cysts, even things like ectopic ureters. Someone's having some dribbling or some leakage and you look in, you see something and lo and behold, they have an ectopic ureter in the vaginal wall. Again, pretty rare finding, but something we want to know. We can have sort of fibroids, periurethral fibroids, melanoma, fibroepithelial polyps, caracals, a whole slew of things. I'll mention sort of the idea of vaginal cancers and urethral carcinomas. Those are things that we really do want to identify. But I put in bold here prior bulking. And I think it's really important to realize that when we're dealing with women that have had potentially bulking procedures, that's something we need to realize can look an awful lot like a urethral diverticulum on certain imaging studies. There are going to be symptoms that can sort of masquerade as a diverticulum. So someone says, I'm having post-void dribbling and lo and behold, it turns out, nah, it's actually stress incontinence or urgency incontinence. So all things that we do need to consider. And this is one on that differential diagnosis. It's always fun to put up an image and say, hey, guess what this is? I'm sure many of you are well aware. We have, and we sort of hinted at this before, a gland that's sitting periurethrally, but it's really distally sort of located. And I think really the hallmark feature is that it's displacing the meatus. So if you guessed it correctly, this is in fact the Skeen's gland versus a urethral diverticulum, but mechanistically actually quite similar. So this was a lovely pictograph that describes the exam and what you might see on the exam and where you feel some of these cystic areas, what they may be. And the Skeen's gland labeled as SD, you can see very distal on the urethra. And then sort of what we all gather here today for the urethral diverticulum, UD, sort of in that under the urethral area, there are things like Gardner's ducts, which are often a little bit more superior and a bit more posterior. Then we have vaginal inclusion cysts, which may be in the sort of the vaginal wall. And then finally, things like Bartholin cysts, which I think we all will realize, hey, these are separate, but you have to realize when a referring doc or a patient is describing something, these are things that actually can masquerade a little bit like a diverticulum. So cystoscopy, obviously a tremendously useful tool. And we don't often talk about how to do a urethroscopy, but the os of a diverticulum can be seen in nearly 80% of cases, but you have to use the tool appropriately. So we want to make sure we're using a 30 degree lens. I use a 70 degree lens when I'm looking for patency of the ureters and I'm doing a cystosyl repair, but I make sure I have a 30 degree lens when I'm looking in the urethra. And the other thing I'll mention is if you see how the scope is set up, there's actually a big gap underneath where the fluid will come out before you actually get to the camera. So this is not an ideal setup to look in the urethra. There are urethrascopes that are slightly different. I will say I don't have one of these. So what I do when I'm doing my cystoscopy, and I'll show a little video here, is I'm actually occluding the urethra with my finger and I'm occluding the bottom portion of the scope. So you can see a nice wide open urethra. So we can see something like this small os. The problem is it's not going to tell me how large or complex the diverticulum or diverticulum are, but it will give me an idea, okay, when I'm surgically approaching this, how is it going to actually close up at the end of the day? So if we look at other diagnostic tools, we have VCUG. Again, some of the historic data would say that we can diagnose diverticulum in 60% of cases. Sensitivity in one study was sort of suggested at 65%, so it's okay. But then we have another exam, which is called a positive pressure urethroscopy. There is a comment about a rigid hysteroscope working well, and I think that that's exactly the point that I'm getting at, which is certain things are better to look in the urethra. We also sometimes use, there's a rigid urethroscope in one of our ORs that we use, and the idea is just realize the limitation. Sometimes it is even easier with a flexible, like nice flexible scope in the office than the rigid scope that you're using sometimes in the OR, but I think that Elizabeth Takas, if I pronounced that wrong, forgive me, made a great suggestion on the hysteroscope. So the positive pressure urethroscopy is an interesting thing because it really is much better at detecting these things. The sensitivity was quoted at up to 90%, and I'll ask show of hands how many of you have ever done one of these, and I would imagine looking out in the audience, there are not many hands that go up. This is actually a balloon that has sort of two balloons on it. There's a little port on the side. The pictograph shows how we actually fill the diverticulum, but it's uncomfortable. It's invasive. It's difficult to do, and then we also have some normal variations, which is if you put enough pressure on those little periurethral glands and ducts, they may fill, and then we may sort of be finding things that we really don't want to find or that are not actually significant. Video urodynamics. This is a video urodynamic done for a woman that was having urinary symptoms, and this was from an atlas, Jerry Blavis, who's, you know, done a lot with urodynamics, and video urodynamics, patient 64. The urodynamics showed detrusor overactivity. The detrusor pressure was actually very elevated. The flow was pretty, you know, garbage, and it turns out that this is a patient that was diagnosed with an obstruction, but further, you can see on the fluoroscopic image, there was some contrast that looked like it was filling a diverticulum. So, in this older series, the etiology of urethral obstruction, it was quoted at urethral diverticulum of 4% of obstruction cases. Again, that's not something that reflects necessarily in more modern series or in my practice, but it is something that can occur. Depends how often you're doing urodynamics or not or when in your practice you're going to use them, and certainly whether you use video urodynamics or not, this may or may not be a good point. I'll bring up here just because I think it's a good time to say that video urodynamic can be helpful in other ways. I don't know that I necessarily use it to diagnose a diverticulum, but this is a really nice illustration, which is very clearly arrows pointing to the diverticulum, but video urodynamics in this situation can actually help tell me whether a patient that's complaining of leakage of urine is really having stress incontinence because of some issue, bladder neck, urethra, urethral sphincter, or support, or if this is really just that post-void dribbling or the diverticulum draining out, and sometimes as you fill the bladder with contrast, you have the patient cough before the diverticulum fills, you can see that, yeah, they have actual stress incontinence versus someone that, let's say, doesn't have that, and then after they're done voiding, you have them cough again and the diverticulum empties out. So I think, again, video urodynamics, the accuracy was quoted here, but it's more important to illustrate the point of the value of the urodynamics in another way. Ultrasound is another tool that's used. Endourethral ultrasound has excellent diagnostic accuracy, but it's costly. It's not really very commonly done, and I sort of mentioned that I don't use ultrasound in my practice for urethral diverticulum, but I do use it. This is just an image in our clinic for urethral stricture, so I use ultrasound, but not necessarily to diagnose the diverticulum, and certainly the advantage of ultrasound is obviously there's no radiation, and we might be able to actually see where the os is, but I think it takes a little bit more skill and potentially things like endourethral probes, etc., so I don't think very commonly used. What about CAT scan? Once in a while, we'll get a patient that has a CAT scan for blood in the urine or hematuria evaluation or for some other cause, and they'll say, hey, we see something in the urethra. We think it's urethral diverticulum. You'll see a cystic mass. Make sure you look at your imaging to try to figure out if it's there or not. There is some advantage to sort of see in certain contrast-enhanced images whether this is something more concerning for a neoplasm or not. Again, fairly uncommon, but 3D reconstructions can be useful, and some such studies have shown high diagnostic accuracy. Again, not my favorite study because of the various things that we mentioned, and now comes to MRI. This is really superb at looking at soft tissue delineating the urethral anatomy. It can be done with sort of surface normal coils or endoluminal coils. Again, something that years ago was maybe more important. Now, as MRI has gotten better, I think less important, but usually evaluate with a T2-weighted image. Look at the orthogonal planes, and there may be some cost-prohibitive ways of doing this that, honestly, I don't really find that necessary. Now, I think the MRI is considered a reference or standard for diagnosing urethral diverticulum with a lot of groups reporting near 100% sensitivity in detecting the urethral diverticulum. If we look at some of those historic numbers versus some of the numbers now, obviously, things are different. I think MRI is better than the 70%, but again, it gives you just a bit of a comparison to say there are some things like the urethrography that work well, but are just not so practical or commonly done. So, the first sort of audience response, case one and case two, MRI findings, will poll the audience, but these are other things that we may find on imaging. So, any guesses as to case one, if you want to type it in, you can. I can see some of them. I can't see others. Or case two, and I'll show you just for the sake of time, but if you wanted to, we got bulking. So, great. I don't want to, we'll leave it anonymous, but bulking sort of. So, everyone got it. We have bulking on the left-hand side, really nice circumferential sort of circles on each side. So, that's a bulking agent. Certainly, I don't want to tell a patient, look, I have to take a diverticulum out when it's a bulking agent. I may still need to take the bulking agent out depending on the clinical story. And then here we have adenocarcinoma. Again, it's going to be more irregular, maybe enhancement, et cetera. And this is just another interesting case. We don't often use plain film, but wow, what a cool case. It had a stone in it, and someone could actually see the stone in the diverticulum on a plain film, ended up having an excision. They were concerned that it was metastatic disease. There was an ovarian mass, but again, not so commonly used. So, in the second half of the lecture, we want to talk about the treatments, and I'll go quickly through some of these, but this is sort of the to-do list. You know, we can observe, we can use an incision, fulguration. I put an asterisk next to those because I've been doing this, you know, long enough that I've heard or talked to a bunch of people, and I've never actually seen or heard people using transurethral incisions or fulgurations. Not that I'm knocking it. If you use it, that's okay, but I just don't have that in my practice. Marsupialization, also pretty uncommonly used when I talked to colleagues around the country and around the world, but there may be some situations where useful, and then bolded and underlined the diverticulectomy and reconstruction. We'll talk about sort of an interesting way of approaching really that circumferential diverticulum. I know there's a question in the queue about that, and then some of the other sort of more odd approaches, like a robotic approach. So, urethral diverticulectomy. I don't want to take a lot of time to talk about the incision, but I do think you need to consider how you're going to approach anything, and when I see a diverticulum in the distal or mid or even proximal urethra, I'm an inverted U fan. I think it's going to allow me to make sure that my suture lines are non-overlapping, and I usually try to bring the apex of the U to the area or a little bit distal to the area of interest or the diverticulum. I think the fellows that I work with will probably find it annoying that I still mark the vaginal wall for them or I mark it or have them mark it, but I just think it actually helps quite a bit. You mark twice, cut once, and I think you need to consider the closure in terms of where you put the lines, how you're going to sort of put your retractors in, and this is sort of showing a lone star retractor, which is, I think, very useful to have some fixed retraction during this. Hydrodissection. I don't want to take too much time to talk about it because I think we all use this, but the one thing I will say, and whenever, you know, we're doing these procedures, we want to make sure that we're getting the tissue to sort of hydrodissect and separate, but I don't want to necessarily inject directly into the diverticulum, the mass or the cyst or whatever it is, so sometimes it does take a little bit of finesse to do the injection appropriately. So really quickly, just showing the inverted U. This was a patient that had a redo procedure, but again, the lidocaine with epinephrine here being used, and then a little bit of an older video, but you can see sort of the idea of the inverted U, and this is going to allow me to advance tissue up and over. For the sake of time, I'll fast forward a little bit, but I also think what's important to realize, and often when I'm working with younger surgeons or less experienced surgeons, everyone wants to go right at the diverticulum right away, and what I would say is set yourself up for the end and make sure you know sort of what you're going to be closing because it's way easier to do it now than when everything's out and then you're rushing or something gets a little bit bloody. So again, just take the time to make your incisions and set up your closure flaps, which is often what I'll say in most reconstructive type surgeries. So now sort of the entree, the urethral diverticulectomy, you can see that we're making an inverted U incision. We have fixed retraction catheter in. I had done a cystoscopy prior to look for where the os was, and you can see that we have sort of the inverted U peeled back, and this is a really nice diverticulum to take photos of because it's pretty obvious. Now you can see, and hopefully it projects okay, that there's sort of a little layer here again that we're going to try to peel off, and that fascial layer or pseudofascial layer does exist, often using a blade to excise, and we'll go through this in a little bit more detail. Now I have the diverticulum. I have my sort of hole in the urethra. We're going to close the hole in the urethra. Multi-layer closure, which you'll see in a video in a couple of seconds, but just illustrating here nicely in a cartoon, showing that we want things to be non-overlapping. So this is the video of the urethral diverticulectomy, and I'll sort of fast forward. The MRI shows a little diverticulum on the right side, but you can see again urethroscopy quite useful, and I want to show you sort of live what it looks like, and this is sort of a nice picture because it's pretty obvious. So I love being able to see this because then when I do my dissection and I'm worrying about, hey, am I going to find the ass, remember that closing the ass is really quite critical. So I've done my inverted U. I've started my incision. I'm using my finger underneath the vaginal flap to make sure that I'm getting in the right plane. I want to make sure that I don't take everything off with the vaginal flap, so sort of start with a thinner flap, or if you make it a little thicker incision, then sort of slowly peel it off, and you can see we're now beginning to see this periurethral fascia, and I'm trying to figure out, hey, exactly where this is. So now I've actually taken a persona blade and made an incision, a little bit of this stuff, you know, around the edges, which you can see here, which will give me a nice second layer closure, and now I have the actual diverticulum. I got it on a stalk, and I knew exactly where I was going based on the MRI, and now I'm putting a little bit of saline in the urethra through an angiocath, and you can see the urine squirting out. Now I'm using a cystoscope, and this is really just to show you guys, not for any other reason, but that's a lacrimal duct probe, and I'm pushing into the diverticulum so you can actually see it. So that's me below and above, and the idea is I don't want to close what I think is the ass and leave the ass open and then have a recurrent or persistent diverticulum, and you can see that for something like this, this might not be so exciting because it probably takes one stitch or two stitches to close the urethra, but the principle is the same. I'm using a vicral stitch. I'm actually closing the urethra. I do leave tags if it's a sort of longer incision just to make sure I have them, and now really I think the crux of this to prevent things like fistula, which we'll briefly talk about if we have time, I'm going to actually close the next layer, and then finally the vaginal epithelium will be closed or the vaginal wall as well. So if we think about diverticulum, we can think about simple diverticulum. Those are easy. Those are the ones I want to show you. I don't want to show you the complicated ones that are hard to film, but we can classify, and this was an old classification, simple, saddlebag, or circumferential, and Eric Rovner and one of my mentors, Alan Wien, had put together sort of a discussion, which is going to be, I think, one of the interesting ways of using, I guess, this complex imaging to say, hey, maybe we do need to do it a little bit more. So there was a question about the suture type and size. Again, I'll use a 4-0 usually for something as small as that, a vicral stitch, and then as I go to the next layer, probably a 3-0 and then a 2-0 or an depending on the vaginal thickness, and the needles are variable, but something appropriate and small, usually not using a cutting needle, but there's a 4-0 on an RB1, depending on the brand that you guys use. So Dr. Rovner and Dr. Wien had published this, which was sort of showing diverticulum as one of the questions is asking. We got this big circumferential diverticulum, and they're basically in the diverticulum. So the green here is the diverticulum. It's open, looking at the urethra floating, and then this loop is passed behind, actually, the urethra in the diverticulum space. And I think that you need to be sort of ready and prepared to do something like this. Again, more of a reason to do an MRI, see what you're getting into, and I don't think that this is needed. I'll give you some tips and tricks in a couple of minutes of other ways of avoiding this, but it is nice to see the technique where now with the vessel loop behind the actual urethra, you can take the urethra, there's one end up here and one end down here, and this is sort of the still intact urethra, and actually incise it. Again, not for the faint of heart, but you incise the urethra completely. Now you're looking into the cavity directly. You can take out all the diverticular tissue you want, and then this doesn't project as well, but this is a Martius fat flap that comes across. So I just put a circle here for each of the ends of the urethra now totally transected. Oh my gosh, we put in a little bit of a vaginal fat flap and then close the urethra down together. So again, I think that that is something that can be done, and I think Dr. Robner had then published several years later a retrospective review looking at these complex or sort of complicated diverticulum used using this end-to-end anastomosis with a Martius fat flap or an autologous fascial sling, and they classified the complex diverticulum as 75% around or more. The age of presentation was pretty similar. Interestingly, the complex diverticulum presented with more SUI than the sort of simple straightforward cases, and it turns out that the operative results were similar with urethral transection saying it's a feasible approach, but certainly should be something that's well thought out and sort of you're comfortable doing. One of the other approaches that I think is interesting, and I don't think we see lots of cases where this is useful, but this was a nice case published just last year in a pediatric patient who has a diverticulum that really is almost in the in the retropubic space here. So we talk about how usually they track down and we're on the vaginal wall, vaginal flap, but this was one that tracked up, and so you can understand now the anatomy a little bit more looking down in the pelvis, A being the diverticulum dissected away from the urethra, which is B, and then the bladder over here, and obviously this is a easier dissection if it is in this location, but it would be really quite hard to manage and heal if, let's say, one of the os, or if the os was sort of in the on the vaginal side, so I think can be used. And another case just to say, hey, this is, you know, something that people are describing, robotic-assisted laparoscopic anterior urethral diverticulectomy, and this was a patient that ended up with an abscess in a diverticulum, or the diverticulum abscess sort of ruptured and was sort of involving the pubic symphysis. So again, more reason in these cases to maybe approach it from an anterior approach. Getting sort of on to some of the weirder or less common ways of treating diverticulum is marsupialization, the spence operation, so the issues I see with this is we're not removing the at-risk tissue, there's going to be urethral shortening and hypospatic urethra, but you can imagine coming in with a scissor basically cutting from the meatus down to the diverticulum, sewing the edges together, or sewing the edges, and I think that there are probably few clinical scenarios where I'd suggest you do that, but useful to know, and there are always going to be exceptions. So what are some of the additional considerations and things that you may need to do? I think it's important to realize that we have this complex diverticulum. I don't know how many of you want to do an end-to-end anastomosis of a female urethra and then have to sort of be obliged to put in a martial spat flap, but I think to get to spaces that are behind the urethra, we often can use something like perforating into the endopelvic fascia, getting into the retropubic space, and I think that that can be useful for the larger diverticulums or those that have a dorsal component, and this is just really a video showing the sort of perforation with emets, the bladders drained. Obviously, I don't want to go into the diverticulum, but if I can actually mobilize the urethra, you can understand how it actually may be beneficial, and this is sort of a case, a different case, but I put it up here to show the mobility of the urethra and how we actually can almost get or can get behind the urethra. This was a patient that needed a urethralysis for other cause, so a midline incision, a little bit different, but you can see by sort of freeing all the scar tissue around the urethra, that was the retropubic stitch, but lysing all this now with the urethra sort of isolated and a Penrose drain around it, it's going to be much easier for me to get the diverticulum around back, and so again, if you needed surgical tips and tricks to how to deal with the harder, more complicated diverticulum. Sometimes you need to get a little bit more aggressive with how you mobilize the urethra. And you can see here, there's quite a bit of mobility. Obviously, I'm a lot more nervous in this patient about the possibility of stress incontinence if this is a diverticulum. This was a lady that was obstructed, so a different scenario altogether, but I think reasonable to talk about. I do wanna sort of move. I know that there are some questions I'm answering during, so I'll take a couple of more minutes, and we may shorten the Q&A a little bit, but I love the questions. I'll sort of maybe pause on the pregnancy and after delivery, because I think that is something that does come up now and again. But I think we have sort of additional considerations with the stress incontinence. And if we look at things and guidelines, clinical principles, the answer is we don't want this to happen. We don't want holes in the urethra and mesh in the urethra. We know that in general, mesh and urethral closures don't work well. So we do know that in certain situations, we will need to or want to treat stress incontinence, and we're gonna really elect to use something that is an autologous graph rather than something like a synthetic graph. But what about stress incontinence after urethral diverticulum without an anti-incontinence procedure? And this was a nice publication really answering that question, where stress incontinence pre-urodynamics was reported in about half of patients. And post-repair, some of the repairs done with a Marcia's flap of 61 women, it persisted in about 45% of women, and there was new stress incontinence in 31% of women. So the answer here was without prophylactic SUI corrective procedures during a urethral diverticular repair, we observe a low rate of de novo SUI with only 5% of bothersome SUIs opting for surgical intervention. So I think you need to realize that there may be some limitations in terms of using just this methodology to say, hey, we're not gonna do it. I think you need to consider what the patient's presenting complaint is. And certainly for a patient that's having complaints of SUI and has a bigger diverticulum more challenging, I do not mind using something like autologous fascia as a graft or sort of a bit of tissue to cover and potentially correct. Otherwise staging it, I think this paper says is fairly reasonable. So we do know that there are some reasons for the preoperative urodynamic, things like larger diverticulum, more proximal location and complex, which I had alluded to before. And if we are going to consider doing a tissue interposition, let's take just a couple of minutes to talk about what tissue we can use. So if we look at tissue like a Marcia's fat flap, which we'll talk about an autologous sling, there are advantages to some of these, for example, in patients with poor wound healing, redo cases, really concerned about closure where it's under tension or I don't like how it looks or are we having difficulty getting the urethra back together? Marcia's fat flap can be great, certainly with the dividing the urethra, putting some tissue to help that heal, I think makes a lot of sense. And then again, the autologous sling for the patient that is really quite concerned for stress incontinence, we can use that or use it as actual treatment. And buccal mucose again, rarely used, but if you had a huge defect and you couldn't close it and didn't wanna narrow it, I think that would be another option. We have another question, tips and tricks for optimizing urethral to promote adequate healing and fistula formation. So I think we'll talk a little bit about that and I think this sort of factors in the idea of how do we prevent things like getting fistulas, which is a potential complication. I think that adequate catheter drainage is hugely important and you gotta realize this catheter is gonna be in for a while. I do like big catheters, but I like happy patients. So usually a 14 or 16 French, there have been patients with more extensive diverticular resections or sort of urethral work where I would actually even consider something like a suprapubic tube if necessary. But I think that that's not the routine use. I think that you need to make sure that you're doing all the right counseling in terms of people stopping smoking, making sure that we've maximized the patient's overall health and diabetes and A1C. In terms of the post-op VCUG, I've gone back and forth. I think I was a very strong VCUG sort of advocate. I think that probably Dr. Stewart in some journal club told me, hey, we don't necessarily need to do it in a very evidence-based way. And I now probably do fewer VCUGs. I think it comes down to how nervous are you, how sort of confident are you at the repair. But I don't have any data to put up here and say, hey, you should or shouldn't, but certainly it's worth talking. And if we have some time, we can certainly get some more Q&A. I did wanna show just a skin flap. This is one that can be used if we did develop, for example, some issue with a urethral vaginal fistula and we repaired it. And there was some deficiency of the vaginal anterior wall tissue. Or if you don't want the skin on it and you just want the Marcia's fat flap, that's fine too. You just exclude or don't make that ellipse. You just go straight up and down. And usually using BOVI to sort of free up a bit of the fat flap, which I think can be quite useful. And I think that when we are considering things and just as this is playing, like a stricture formation in the urethra, that's when you can consider using sort of different suture lines. So not necessarily closing longitudinally, but sort of horizontally may be more effective. And I think even things like the buccal mucosa if necessary, but thankfully not so common if we can actually do the dissection and get it down. Most of the osses I think are relatively small. And here again, you can see a nice piece of fat here with the tissue that we can lay across or utilize for a more complicated repair with the vaginal closure. The rectus fascial harvest. I know that there was an Oggs educational discussion not too long ago on fascial sling, but just to remind you that there are different ways of harvesting the rectus fascia. And when we're dealing with the diverticulum, again, I sometimes have diverticulum where I will want to put tissue or another layer on top, or it's quite complicated or they're wet already. And so this is a really nice way of being able to not only give some more tissue, to give some more tissue, but potentially protect them or correct their stress incontinence. And I think that the harvest is something that, again, for another talk, we could take a little bit more time talking about, but it gives you just an idea of things to think about. And then you may have seen also the Crawford fascial stripper. So another way of getting a little bit in a less invasive way. So just a little pocket on the patient's thigh, and I'm using the stripper to actually get a bit of tissue. So just another consideration. So in terms of the additional considerations, I would say the long-term complications, there are things like stress incontinence, and some will say, hey, low rates, others even quote it up to 49%. Remembering, depending on how you're defining or how you're actually saying, hey, is this stress incontinence? Is it not? Is it bothering patients? Is it not? These numbers are gonna vary. Persistent dysuria can occur. And these are things, I think, in the counseling that we would talk about. Is there something like a fistula that can form or urethral stricture? Again, things that were alluded to in some of the questions that can happen. And I think it's good surgical principle and sort of appropriate counseling that'll work. So the pregnancy question that came up about how do we deal with diverticulum in pregnancy? You know, again, I think that it's going to be complicated and tricky. It's gonna really depend on the clinical scenario. You know, there are times when they may be not so bothersome and, or the question is about asymptomatic bacteria and we can use antibiotics to suppress. Certainly postpartum, if we can wait and let tissue heal and let estrogen levels come back to normal, I think the repair will be better. Sometimes there are other vaginal cysts at play. And again, I don't know if there's a specific question about a recommendation, what to do, pregnancy postpartum, but generally my rule is I don't wanna deal with it during pregnancy if I don't have to. Sounds like there was probably reason or rationale to push to do this and something to certainly consider. So just a slide or two on the urethral vaginal fistula. Again, this would be a bad outcome after a urethral diverticulectomy. You know, you gotta make sure that your flaps are well vascularized. You gotta make sure that there's nothing else that's going to be contributing. But if you do end up with a fistula, thankfully they can be repaired. This is just sort of showing the steps. And I think we can certainly consider using, certainly consider using that fat flap on top. There are a couple of questions coming in. I think I'll just, there are like two more slides and then we'll have plenty of time for that. So what's the treatment dilemma with diverticulum? And this is where the question is, it's asymptomatic and it's incidentally found. Do we need to do anything about it? That's ultimately going to be the patient's choice. We don't have a lot of data and putting this talk together, I didn't find a lot of data on the natural history. Otherwise I would have presented it. But we also know that there are reports of progression to malignancy. And one of the numbers that gets quoted that's a little bit scary is up to 9%. So in general, I think this is tissue that can be chronically inflamed. We don't want to necessarily leave chronically inflamed or irritated tissue. I can't tell you for certain. And then there are some times when you see an MRI that shows a little thickening or there's a calcification on a CAT scan, which would be reasons to say, hey, I do want to be more aggressive in excision. And this is not a real dilemma. This is what my recommendation is. And I think it's okay to make that recommendation. So just concluding before the questions, we have sort of a high index of suspicion. That's how we'll find it. I think that there are going to be lots of horses out there, lots of simple diverticulum out there, and then there are going to be some zebras. And I think we need to realize that you need to listen for the hoof prints or hoof sort of beats first, and then you got to sort of dial in and say, hey, is this straightforward or not? So we're prepared. Make sure you're not treating bulking, especially if it's asymptomatic. I see so many referrals for diverticulum, patients asymptomatic. I look at the MRI. I say, yeah, it does look like it's a diverticulum. Have you ever had any surgeries on your urethra or bulking? And they say, I had a urethra bulking two years ago. Did it work? Yeah, it's working great. My bladder's emptying. You don't need to do anything. MRI is really helpful. I think you got that in the beginning part of the talk. Video urodynamics I do like if it's something that's going to help me understand what's causing the leakage or LUTs. And it's really not so clear, but obviously if my exam says diverticulum, I'm going to want to get that MRI anyway to really confirm the number and the location, help me tune in. And then we have sort of the basics, which is a multi-layer closure, non-overlapping suture lines, and then appropriately draining and flapping as necessary. So that is all I have prepared. Our moderator is back on, and I think there are a couple of more questions. So I don't know if you have any questions or parting words. No, thank you. That was fantastic. I think you answered most of the questions that are in the chat. The one that maybe you didn't answer, it says, if you do a staged incontinence procedure later, would you use synthetic mesh or consider urethral bulking? So really good question. And staging this is fine. I think it's okay. Again, you have a straightforward, like the video I showed, easy diverticulum or relatively straightforward. Maybe we're going to actually say, hey, we'll leave it for another day. I think it is something that's reasonable to once you're done consider whether you'd put a synthetic sling in or autologous sling, again, depending on the situation and the duration. I wouldn't say it's a never. I probably would have a little bit of a bias towards saying, hey, I'm going to put an autologous sling. I'm a little nervous that I'm not going to be able to dissect as easily after the diverticulum. Is the patient very atrophied? Is the tissue very scarred? Those are things that I would consider. So I would say maybe not a never with appropriate counseling but my bias would be for an autologous fascial sling. And bulking, I think is something that is reasonable as well. I don't think I'd have as much concern about bulking if someone did have stress incontinence after a diverticulectomy. I agree. And I think you answered a lot of questions about pregnancy and delivery. I'm not sure if this question is specifically asking would you consider removal immediately after delivery versus- Yeah, I mean, I think if there was no reason to immediately remove it, I probably would not. I think that, you know, I want to make sure that I think the first time you repair a diverticulum is the best chance you have of fixing it. And so I would say, I'm not sure that it would be a big deal to have a patient come back for it. There was a question about hormonal therapy. I do have most of my post-menopausal women on hormonal therapy, right? If they're seeing me for LUTs, they're seeing me for recurrent urinary tract infections. I, you know, I don't think there's a lot of data for diverticulum and hormonal therapy. So I, you know, I'm hesitant to make a strong recommendation but I would say, I don't think it hurts. And I think that some of those more complicated cases certainly you use everything you can. There was also a question about approaching a woman in her twenties to thirties with a rapidly growing suburethral cyst, increasing pain. So yeah, I mean, I think diverticular abscess versus like an infected diverticulum, that is something that we see. I think we sometimes will see Skene's glands do this. You know, patient has horrible pain. I felt something, they come in, there's nothing there. You know, keep an index of suspicion, have them come back, have them come back, you know, time and time again so you can examine them, maybe you catch it but that may be somewhere where an MRI or something more subtle can help determine what it is. So hopefully you'll be able to figure that out. And then with urethral diverticulectomy, the risk of stricture. Yeah, you know, I think there is a risk of stricture. I think Dr. Stewart had asked a question about that. You know, sometimes there's a big defect but try to keep the, you know, the actual urethral work as minimal as possible. So I try to do everything to get everything down to one single little neck of the diverticulum. The idea of just sort of, you know, taking the diverticulum off and leaving a big hole in the urethra, I don't love doing that if I don't have to. And the reality is sometimes you're going to get into the diverticulum and then you're gonna work from the inside. I do try to take all the wall of the diverticulum out but then I sort of see where the hole is and then I can work from the outside again toward that actual hole in the urethra. And I think new onset urethral diverticulum. So I think symptoms will start. It's sometimes hard to know when symptoms start because they can be so vague and so varied. And, you know, something like recurrent urinary tract infections. Yeah, maybe some of the women we're seeing in our thirties have recurrent urinary tract infections because of a little diverticulum or an infected Skene's gland. And so I think it is something that we will see symptoms earlier. That's why we have to have a high index of suspicion. Looks like one more question. What are your thoughts on the recent case series on marsupialization of any type of urethral diverticulum? Yeah, again, I'm not someone that does marsupialization per se. I think that, you know, for distal lesions, maybe I do, I shouldn't say I never do them, where you just sort of will do a wedge resection of the diverticulum, but it's gotta be pretty distal. So if you imagine like a Skene's gland that's sort of sitting just periurethrally, instead of actually trying to find an os, if you take a little piece out and there's a small wedge that's, you know, a defect, I'm okay with that in some patients. I just don't like making the meat is harder for women to catheterize, just in case they ever need to do them. Probably, you know, I have lots of patients with other conditions that catheterize and I'm always fearful, gosh, I don't wanna make it any harder, God forbid something else happens. But I think the idea of marsupialization, certainly the concept of being able to monitor a diverticulum or if there's bloody discharge or something going on, I think it really depends on the location and the type and sort of the patient's wishes. And then there was a question on cadaveric dermis instead of autologous fascia. You know, at least for diverticulum, I would say, you know, not something that I've routinely used, I would prefer autologous fascia. The same for just my anti-incontinence surgeries, I usually prefer autologous fascia versus a cadaveric dermis. So that's sort of why I'm borrowing for that. But, you know, if you needed something and it's better than nothing, sure, I think that's reasonable. And then the tips for the horseshoe diverticulum, you know, I think I was alluding a little bit to the idea that sometimes you're gonna get into the diverticulum and those horseshoes, depending on where they are and how they are, I think you take as much, leave the diverticulum as full as possible. Make sure as you're taking things off, you're very clear as to, you know, what's diverticulum, what's tissue, I need to close the diverticulum because the horseshoes are pretty large. And then sort of when we eventually get into the diverticulum, I think we wanna actually find that us, make sure we're closing the us and then the rest is fairly, you know, straightforward. So it's all about exposure. It's all about, you know, suction and light and seeing what you can see, feeling confident about the urethra so that you can, you know, make sure that you get everything out that you wanna get out and then repair it accordingly. And I wish I could tell you every one of my cases goes as nicely as a video, but the reality is sometimes they can be difficult. So make sure you prepare appropriately and, you know, counsel well as well. Well, what a great talk. On behalf of Oggs, I'd like to thank our great faculty today for this excellent webinar and be sure to register for our upcoming webinars. In February, we have the Oggs Coding Webinar Series and on March 6th, Dr. Melanie Meister will be presenting a webinar titled Pelvic Floor Myofascial Pain and Dysfunction. So follow Oggs on Twitter and Instagram or check our website for information on all upcoming webinars. Thank you guys and have a great evening. Thanks everyone. Thanks Oggs Education, Dr. Stewart and the rest of the crew. It was a lot of fun. Thanks again.

urethral diverticulum

diagnosis

treatment options

female urethra

urinary symptoms

surgical treatment

complications

stress urinary incontinence

individualized care