NEUROLOGY & FEMALE UROLOGY

Recurrent pseudodiverticula of female urethra: five-year experience
Migliari R, Pistolesi D, D’Urso L, Muto G
U.O.C. Urologia, Ospedale S. Giovanni Bosco, Torino, Italy
Urology. 2009; 73: 1218-22

• Objectives: To report our experience of transvaginal diverticulectomy with pubovaginal sling placement in a series of 32 women with recurrent urethral pseudodiverticula.
• Methods: A total of 32 women underwent surgical repair from January 2000 to June 2007. Of the 32 women, 12 had undergone other concomitant previous urethral surgery, predominantly for stress urinary incontinence. Transvaginal excision of the diverticulum and concomitant pubovaginal sling placement were performed routinely. The women were evaluated postoperatively for symptom relief, anatomic result, and postoperative continence status at 1, 6, and 12 months and annually thereafter. Pelvic magnetic resonance imaging was repeated after 1 year.
• Results: The mean follow-up was 4.3 years. In all cases, the voiding urethrogram after catheter removal showed a good urethral shape with an absence of urinary leaks. At the postoperative urodynamic investigation, 27 patients had an unobstructed and 5 an equivocal Blaivas-Groutz nomogram. Three patients (20%) reported a persistent degree of stress urinary incontinence, including 2 with grade 1 stress urinary incontinence and 1 with mixed incontinence. Two patients presented with clinically evident diverticulum recurrence, and in 1 patient, an intraurethral diverticulum, was found at the 1-year magnetic resonance imaging examination.
• Conclusions: A pubovaginal sling added routinely to all diverticulectomy procedures offers significant support to the urethral repair and/or prevention of urinary incontinence, including in recurrent cases, and does not increase the risk of erosion into the urethra or fistula formation.

• Editorial Comment
  The authors review a very large series of recurrent urethro-diverticula (32 women). Of note is that aside from performing the actual diverticulectomy all patients underwent a concomitant suburethral sling. With a good length of follow-up (mean = 4.3 years) they found that 80% of the patients were dry with 3 patients reporting persistent stress urinary incontinence. There was no notation that the synchronous suburethral sling increased the risk of erosion or fistula formation. In addition, the surgeons felt that the pubovaginal sling well buttressed the urethral repair and helped limit stress urinary incontinence.
  This manuscript is very impressive with regards to the number of patients treated with recurrent urethral diverticula. The patients all underwent an autologous fascial sling but still had a 20% persistent degree of stress urinary incontinence. Almost half the patients (n = 15) had stress urinary incontinence preoperatively. Their patient population suffered no de novo incidence of stress urinary incontinence with patients reporting stress incontinence being from the population sub group that had the malady preoperatively. That they had a 0% de novo incidence of stress urinary incontinence is worth noting in view that other authors report 10 - 20% new onset incidence of stress urinary incontinence after a urethral diverticulectomy (1). It is worthwhile reviewing the paper by Kobi, et al. secondary to their discussion of prediction of new onset stress urinary incontinence before and after urethral diverticulectomy and their comments on a prophylactic operation and comparing it to this work. The authors only used a Martius flap four times in their operation. Some surgeons would be more inclined to use a Martius flap to a greater degree on this impressive re-do population. I think it is worthwhile to note than when using the Martius flap, most surgeons may place the Martius flap between the urethral proper and the pubovaginal sling. It has been noted previously that the use of the Martius flap will not impact the long-term cosmetic appearance of the external vagina (2).
  

References

1. Stav K, Dwyer PL, Rosamilia A, Chao F: Urinary symptoms before and after female urethral diverticulectomy--can we predict de novo stress urinary incontinence? J Urol. 2008; 180: 2088-90.
2. Petrou SP, Jones J, Parra RO: Martius flap harvest site: patient self-perception. J Urol. 2002; 167: 2098-9.

Dr. Steven P. Petrou
Professor of Urology, Associate Dean
Mayo School of Graduate Medical Education
Jacksonville, Florida, USA
E-mail: petrou.steven@mayo.edu