Objective: To present a review of the current literature regarding the presentation, diagnosis, and treatment of female urethral diverticula (UD). Methods: A systematic search of the PubMed database was performed to identify studies evaluating female UD. Article titles, abstracts and full-text manuscripts were screened to identify relevant studies, which then underwent data extraction and analysis. Results: In all, 50 studies evaluating the presentation, diagnosis and treatment of female UD were deemed relevant for inclusion. Almost all studies were retrospective single-arm case series. Female UD are outpouchings of the urethral lumen into the surrounding connective tissue. The presentation of female UD is diverse and can range from incidental findings to lower urinary tract symptoms, frequent urinary tract infections, dyspareunia, urinary incontinence (UI), or malignancy. Repair of UD begins with an accurate assessment and diagnosis, which should include adequate radiographic imaging, usually including magnetic resonance imaging. Once the diagnosis is confirmed, the usual treatment is surgical excision and reconstruction, most often through a transvaginal approach. The principles of transvaginal urethral diverticulectomy include: removal of the entire urethral diverticulum wall, watertight closure of the urethra, multi-layered and non-overlapping closure of surrounding tissue with absorbable suture, and preservation or creation of continence. Results of surgical repair are usually excellent, although long-term recurrence of these lesions may occur. Complications of urethral diverticulectomy include urethrovaginal fistula, UI, and rarely urethral stricture. Conclusion: Whilst urethral diverticulectomy excision and reconstruction is a challenging procedure, it is ultimately satisfying for the patient and the surgeon when relief of bothersome symptoms is achieved. Adherence to principles of reconstructive surgery is important to ensure a satisfactory result.

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Aims: To identify risk factors for urinary retention following AdVance™ Sling placement using preoperative urodynamic studies to evaluate bladder contractility. Methods: A multi-institutional retrospective review of patients who underwent an AdVance Sling for post-prostatectomy stress urinary incontinence from 2007 to 2019 was performed. Acute urinary retention (AUR) was defined as the complete inability to void or elevated post-void residual (PVR) leading to catheter placement or the initiation of intermittent catheterization at the first void trial postoperatively. Bladder contractility was evaluated based on preoperative urodynamics. Results: Of the 391 patients in this study, 55 (14.1%) experienced AUR, and 6 patients (1.5%) had chronic urinary retention with a median follow-up of 18.1 months. In total, 303 patients (77.5%) underwent preoperative urodynamics, and there was no significant difference between average PdetQmax (26.4 vs. 27.4 cmH 2 O), Qmax (16.6 vs. 16.2 ml/s), PVR (19.9 vs. 28.1 ml), bladder contractility index (108 vs. 103) for patients with or without AUR following AdVance Sling. Impaired bladder contractility preoperatively was not predictive of AUR. Time to postoperative urethral catheter removal was predictive of AUR (odds ratio, 0.83; 95% confidence interval, 0.73-0.94; p = .003). Conclusions: Chronic urinary retention after AdVance Sling placement is uncommon and acute retention is generally self-limiting. No demographic or urodynamic factors were predictive of AUR. Patients who developed AUR were more likely to have their void trials within 2 days following AdVance Sling placement versus longer initial catheterization periods, suggesting that a longer duration of postoperative catheterization may reduce the occurrence of AUR.

Incontinence related to sphincter weakness is a potential complication of radical prostatectomy. The ATOMS (Adjustable Trans-Obturator Male System) is selfanchoring trans-obturator device, which features a non-circumferential adjustable hydraulic cushion first introduced to Canada in 2014. We aim to assess the efficacy and safety of the ATOMS sling in a multi-centered setting.METHODS: We reviewed postoperative outcomes from 8 Canadian centers in male patients undergoing treatment with ATOMS for post-prostatectomy incontinence. The primary outcomes were mean pad change and continence defined as requiring 1 pad postoperatively for patients requiring 2 pads preoperatively, and 0 pads for those requiring 1 pad preoperatively. Secondary outcomes included patient satisfaction, improvement, and 90-day complications. Other patient demographics including age, obesity (BMI35), comorbidities, concurrent radiotherapy, previous incontinence surgery, previous urethral stenosis and type of prostatectomy were also examined. Improvement in continence (mean change and absolute change in pads/day) were calculated with t-tests. Patient satisfaction, continence and surgical complications were evaluated with descriptive statistics and Chi-square.RESULTS: A total of 160 patients with a mean age of 70.5 years were enrolled with a mean follow-up of 9.5 months. Pre-operatively mean pad use was 4.4 pads/day (1-10). Initial post-operative pad use was 1.5 pads/day (0-6) before cushion adjustment (p<0.0001) and 0.9 pads/day (0-6) following adjustments (p<0.0001). 58.3% patients underwent adjustment with a mean of 1.4 adjustments (0-7) for a total mean volume of 11.3 mL (0-31). Overall continence rate was 80.0% while 87.8% of patients experienced >50% improvement and 86.3% of patients were satisfied with the results of surgery. Although patients with concurrent radiotherapy did not differ by pre-operative pad usage (4.6 vs. 4.1; p¼0.17) they were less likely to be continent (62.5% vs. 87.9%; p<0.0001), improved (77.1% vs. 92.6%; p¼0.01) and satisfied (69.8% vs. 93.2%; p<0.0001). 22.3% (n¼35) of patients experienced 90-day complications (any Clavien grade) mostly Clavien I (17.8%) with 4.4% (n¼7) of patients experiencing Clavien III complications primarily related to the injection port.CONCLUSIONS: The ATOMS is a safe and efficacious device for the treatment of post prostatectomy incontinence even in the setting of severe incontinence. Patients with concurrent radiotherapy respond to treatment but are less likely to be continent, improved or satisfied.

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