NEUROUROLOGY & FEMALE UROLOGY

Urinary symptoms before and after female urethral diverticulectomy--can we predict de novo stress urinary incontinence?
Stav K, Dwyer PL, Rosamilia A, Chao F
Department of Urogynaecology, Mercy Hospital for Women, Melbourne, Australia
J Urol. 2008; 180: 2088-90

• Purpose: We assessed preoperative and postoperative urinary symptoms, and determined risk factors for de novo stress urinary incontinence after transvaginal urethral diverticulectomy.
• Materials and Methods: We reviewed the case records of 25 consecutive women who had transvaginal urethral diverticulectomy. Urinary symptoms were documented before and after surgery with a structured history and examination pro forma. Demographic, clinical and imaging parameters were reviewed to determine any association with preoperative and postoperative symptoms as well as possible risk factors for postoperative stress urinary incontinence.
• Results: The most common presenting symptoms were urinary urgency and frequency (60%), and dyspareunia (56%). On physical examination the most common findings were a tender anterior vaginal wall mass (88%) and urethral discharge (40%). At a mean followup of 15.1 +/- 14.9 months (median 12) the rate of urgency-frequency symptoms and dyspareunia decreased significantly from 60% to 16% and from 56% to 8%, respectively. All the patients who had urge incontinence were cured of this symptom after the operation. De novo stress urinary incontinence developed in 4 patients (16%) postoperatively, and it was mild and only necessitated surgical treatment in 1 patient. A diverticulum larger than 30 mm and proximal urethral location were significant factors (p < 0.05) for the development of de novo stress urinary incontinence.
• Conclusions: Irritative bladder symptoms are common in woman with urethral diverticulum and usually resolve after surgical excision. Stress urinary incontinence developed immediately after the operation, and had a significant association with a proximal urethral location and ultrasonically measured size greater than 30 mm.
  
  
• Editorial Comment
  The authors review their experience of 25 consecutive women who underwent a transvaginal urethral diverticulectomy. Special emphasis was placed on presenting signs and symptoms as well as the postoperative incidence of de novo stress urinary incontinence. The authors found that diverticuluae of a size > 30 mm and with a proximal urethral location had a higher association with postoperative stress urinary incontinence. The surgeons noted that all the patients who had urge incontinence were relieved of that symptom with the operation.
  The authors shed light on their thoughts on urethral diverticulectomy especially with regards to symptoms and signs before and after the surgery. Of interest is that none of the patients appears to have had a preoperative MRI but were diagnosed by ultrasound. They did note that double balloon positive pressure urethrography also identified the diverticulum well when used (in 14 of the 25 patients) but cystourethroscopy could only identify the diverticular orifice in less than half of the patient population (44%). The authors reported a 16% de novo incidence of stress urinary incontinence and did not recommend a prophylactic anti-incontinence operation even for those patients meeting the criteria that were identified in the manuscript. Their median follow up was approximately 12 months. One wonders whether the incidence of de novo stress urinary incontinence will be higher if this population of patients is revisited in two or three years from this time and the subsequent recommendation of no prophylactic surgery will change.

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