Circumferential urethral diverticulum: a surgical conundrum

Excision of a circumferential diverticulum may be challenging as its extension into the dorsal aspect of the urethra makes access complicated.

A 69-year-old woman with a history of Stage 3C ovarian cancer on chemotherapy presented with a 3-week history of severe dysuria and suprapubic pain. T2-weighted pelvic magnetic resonance imaging (MRI) showed a circumferential diverticulum extending over the dorsal midurethra without evidence of urethral communication. As conservative measures including bladder instillations failed, she underwent surgical excision of this multilocular circumferential diverticulum. The diverticulum was identified and excised in segments. To achieve optimal excision, we incised around and dorsal to the urethral meatus into the retropubic area. Finally, a communicating tract from the ventral loculation of the diverticulum to the urethra was identified. The communication was obliterated, and the urethra was repaired in two layers and reinforced with a fibromuscular flap. The fluid tight seal was confirmed by retrograde filling of the bladder and cystourethroscopy.

The patient was symptom free at 6-week and 6-month visits.

This video highlights the steps required to successfully excise a complex circumferential diverticulum that extends over the dorsal midurethra and has a communication with the urethral lumen.