Diagnosis and reconstruction of the dorsal or circumferential urethral diverticulum

Uncommonly a saddlebag urethral diverticulum (UD) may extend circumferentially around the urethra dorsally or anteriorly with compromise of the adjacent tissues. Excision of the entire mucosalized surface of this type of UD may leave an extensive gap in the urethra. Unfortunately the full extent of a saddlebag UD is often not appreciated on preoperative imaging and it is only discovered intraoperatively when potential reconstructive flaps have already been compromised. The advent of endoluminal magnetic resonance imaging (eMRI) has provided outstanding preoperative staging that has greatly aided in the successful reconstruction of the cases. We present our experience with the diagnosis and reconstruction of these complex UDs.

A review of 41 patients with UD at a single institution revealed 9 with circumferential involvement of the urethra confirmed on eMRI. All patients had voiding cystourethrography as the initial diagnostic modality. Four of the 9 patients had had at least 1 prior attempt at surgical repair elsewhere. Presenting symptoms included severe pain in 7 of the 9 patients, recurrent cystitis in 7, a vaginal mass in 2 and mixed urinary incontinence in 6. Eight of the 9 patients had undergone attempted surgical repair. Surgical reconstruction consisted of complete division of the urethra to access the dorsal wall of the UD with partial urethrectomy. Urethral continuity was restored by end-to-end urethroplasty in 5 patients and by tubularizing the dorsal (anterior) wall of the UD to construct a neourethral segment in 3. A Martius flap and pubovaginal sling were used selectively. Postoperatively voiding cystourethrography was performed in all patients to document absence of the UD. Self-administered patient questionnaires were completed preoperatively and postoperatively.

All patients report subjective relief of pain. Six of 8 patients did not use pads for incontinence. One patient used 2 to 3 pads daily for stress urinary incontinence symptoms and 1 had persistent urgency with rare incontinence, for which she used 1 pad daily. Complications included a distal urethrovaginal fistula in 1 patient and urethral stricture in 1.

Circumferential UD is an unusual problem. However, with the use of eMRI as a diagnostic and staging modality the incidence may be higher than previously realized. Preoperative knowledge of the extent of the UD is helpful in ensuring complete excision of the UD and optimizing urethral reconstruction. We conclude that excision and reconstruction of the circumferential UD is possible with excellent symptomatic and anatomical results.