Patients’ Perspectives: Outcomes of Modified Marsupialization for Treatment of Female Urethral Diverticula

Abstract

rethral diverticula are rare, affecting 20:1,000,000 women per year and accounting for 84% of female periurethral masses. 1,2 The "3-D's" triad-dysuria, postvoid dribbling, and dyspareunia -is cited, but recurrent urinary tract infections, urinary incontinence (UI), and pain are more common presentations. 3 Urethral diverticula are simple or complex. 4 A diverticulum is complex when it is proximal or mainly anterior to the urethra, is loculated, has a diameter >3 cm, is horseshoe-shaped or circumferential, has >1 diverticulum, or there is a history of pelvic surgery. Complex diverticula increase the risk of recurrence and postoperative complications. 1,3,5 The standard treatment of female urethral diverticula is surgery, most commonly urethral diverticulectomy, although marsupialization and transurethral diverticulotomy are described. [6][7][8] Aspiration or diverticulotomy procedures are typically reserved for women with severe pain or abscesses, or when elective surgery risks are high. Traditional diverticulectomy has considerable morbidity, including the following: de novo stress UI (SUI; 1. 7%-33%), urethrovaginal fistula (0.9%-8.3%), urethral stricture (0%-5. 2%), recurrence (2%-16%) with reoperation (2%-13%), and prolonged catheter use. 1,9 First described in 1970, the Spence-Duckett procedure (SDP) was used for mid-to-distal urethral diverticula, creating a urethral meatotomy to the diverticular ostia. 8 Roehrborn 10 described the largest and most recent case series of women treated with SDP and found the procedure highly successful with low morbidity-the most common complication being SUI. Urinary incontinence may occur if a diverticulum is proximal to urethral sphincter or if the bladder neck is incompetent. Other risk factors for de novo SUI include the following: extensive tissue dissection, damaging the urethral sphincter mechanism, or denervation injury. 11 Unlike the SDP or other modified procedures, our technique does not create a urethral meatotomy; instead, we incise the suburethral anterior vaginal wall, and the diverticular sac is then marsupialized to the vaginal epithelium, leaving the ostium open. 8,12 (Fig. 1, Fig. 2; Video, Supplemental Digital Content 1, marsupialization surgical technique, http://links.lww.com/FPMRS/A360).Patient candidacy for or modern surgical outcomes after marsupialization techniques for the treatment of female urethral diverticula are ill-defined, and the literature is overall limited. The primary objective of this retrospective case series was to describe a novel surgical technique to