NEUROUROLOGY & FEMALE UROLOGY

Urethral diverticula in 90 female patients: a study with emphasis on neoplastic alterations
Thomas AA, Rackley RR, Lee U, Goldman HB, Vasavada SP, Hansel DE
Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
J Urol. 2008; 180: 2463-7

• Purpose: Urethral diverticula are uncommon and occur predominantly in women. We examined a large series of female urethral diverticula to determine associated neoplastic alterations and subsequent clinical outcomes.
• Materials and Methods: All pathological evaluations of female urethral diverticulectomies performed at our institution between 1981 and 2007 were retrospectively reviewed and the clinicopathological features were correlated.
• Results: During this period 90 women underwent urethral diverticulectomy at our institution. Patient age was 24 to 78 years (mean 45). The most common clinical finding was urinary incontinence (29 of 78 women or 37%). Diverticular size was 0.3 to 5.0 cm (mean 1.7). Neoplastic alterations identified in 5 patients (6%) were glandular in nature, including 1 clear cell and 4 invasive adenocarcinomas. Superficial changes associated with invasive carcinoma included villous adenoma in 1 case, intestinal metaplasia in 2 and high grade dysplasia in 3. An additional 3 patients had extensive intestinal metaplasia. Of the 90 patients the remaining 82 demonstrated benign findings, including nephrogenic adenoma in 10 (11%). All 5 patients with invasive carcinoma underwent anterior pelvic exenteration with urinary diversion. In 2 patients with invasive adenocarcinoma metastatic disease subsequently developed, of which they died.
• Conclusions: Although most cases of surgically resected diverticula demonstrate benign features, approximately 10% show atypical glandular findings, including invasive adenocarcinoma. Due to the risk of malignancy in a subset of patients careful clinical examination and followup are warranted in all patients to exclude neoplastic disease.
  
  
• Editorial Comment
  The authors report on an impressive numerical series of 90 patients who underwent urethral diverticulectomy. The most common associated clinical finding with the urethral diverticulum was urinary incontinence. Pathologic evaluation of the resected tissue revealed 10% with atypical glandular findings; consequently, the authors urged the readership to have careful follow-up in those patients secondary to the association with invasive adenocarcinoma.
  This large series on urethral diverticula warrants reading and review by those actively involved in female urology. Though the most common clinical finding associated with urethral diverticulum was urinary incontinence, 4 out of the 5 patients who had a carcinoma of the involved urethral diverticulum presented with urinary retention. In addition, the authors noted that a review of the position of nephrogenic adenomas throughout the urothelial tract identified a higher prevalence in the urethral diverticulum. This would be something to keep in mind on evaluating a urethral diverticulum that is associated with a submucosal mass. The high mortality rate quoted in this series for patients with invasive adenocarcinoma involving a urethral diverticulum highlights the importance of close follow-up in those patients that have atypical glandular findings on pathologic analysis of the resected diverticulum.

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