Complications of Female Incontinence and Pelvic Reconstructive Surgery (Current Clinical Urology) 2nd ed.

13. Complications of Urethral Diverticulectomy

Alienor S. Gilchrist1 and Eric S. Rovner 

(1)

Department of Urology, Medical University of South Carolina, 96 Jonathan Lucas Street, CSB 644, Charleston, SC 29425, USA

Eric S. Rovner

Email: rovnere@musc.edu

Abstract

Urethral diverticulum (UD) is a rare condition and frequently can present diagnostic dilemmas to the clinician [1]. Once the correct diagnosis is made, surgical excision is the mainstay of definitive treatment. Although surgical treatment of urethral diverticula includes marsupialization, designed for a distal diverticula ostium, this review will focus on complications from the transvaginal approach for mid and proximal urethral diverticulum excision, as has been previously described. A full discussion of urethral diverticulectomy surgical technique is beyond the scope of this chapter, but specific points will be discussed where appropriate.

Introduction

Urethral diverticulum (UD) is a rare condition and frequently can present diagnostic dilemmas to the clinician [1]. Once the correct diagnosis is made, surgical excision is the mainstay of definitive treatment. Although surgical treatment of urethral diverticula includes marsupialization, designed for a distal diverticula ostium, this review will focus on complications from the transvaginal approach for mid and proximal urethral diverticulum excision, as has been previously described. A full discussion of urethral diverticulectomy surgical technique is beyond the scope of this chapter, but specific points will be discussed where appropriate.

Prevention of Complications

Although most complications are treatable and reversible, the optimal scenario is to prevent or minimize potential for adverse outcomes. This process begins in the preoperative period, initiated during the diagnostic evaluation and work-up. The typical evaluation of patients with a suspected UD consists of a history, physical examination, cystourethroscopy, and appropriate imaging, including voiding cystourethrograpy and magnetic resonance imaging as clinically indicated. For patients with lower urinary tract symptoms or incontinence, videourodynamic studies may be utilized to evaluate for the presence of stress incontinence, voiding dysfunction, and specifically for the presence of a closed, competent bladder neck at rest. With the presence of stress incontinence or an incompetent bladder neck, patients can be offered concomitant placement of an autologous fascial sling at the time of UD excision. Urine cytology, when positive, can assist in making the correct diagnosis of malignancy; however, negative cytology cannot rule out malignancy. In all cases, UDs should be sent for permanent pathologic evaluation following excision to evaluate for malignant tissue. Preoperative urine cultures are obtained to appropriately tailor preoperative antibiotics and decrease the risks of intraoperative and postoperative infection. The differential diagnosis of periurethral masses (Table 13.1) is extensive and includes Skene’s gland abscess (Fig. 13.1), vaginal leiomyoma [2], and primary urethral cancer. Therefore, the importance of a correct diagnosis prior to undertaking surgical excision cannot be overemphasized.

Table 13.1

Differential diagnosis of a periurethral masses

Leiomyoma

Skene’s gland abnormalities

Gartner’s duct abnormalities

Vaginal wall cysts

Urethral mucosal prolapse

Urethral caruncle

Periurethral bulking agents

Malignancy

Endometriosis

A213469_1_En_13_Fig1_HTML.jpg

Fig. 13.1

Skene’s gland abscess

Intraoperative Complications

Intraoperative complications related to anterior compartment vaginal surgery have been previously described and include, but are not limited to, bleeding and injury to the urinary tract.

Bleeding

The risk of bleeding during surgery can be minimized, but not entirely eliminated by good operative technique. Multiple blood vessels traverse the deep pelvis including large venous channels in the retropubic space. Named vessels in the obturator fossa along the pelvic sidewall including the iliac vessels and within the vascular pedicle of the bladder are at risk for injury, especially during passage of trocars or needles for concomitant pubovaginal sling. Major vascular injury can quickly lead to life-threatening hemorrhage if not recognized intraoperatively and may result in large retropubic hematomas postoperatively [34]. Bleeding during the harvest of an adjuvant Martius flap is usually easily visualized and controlled with a combination of cautery, suture ligature, and direct compression. Labial hematomas have been reported with postoperative bleeding [5].

Bleeding during UD surgery can be problematic at times. The initial dissection of the vaginal flap from the underlying periurethral fascia should be associated with minimal bleeding. Bleeding encountered during this early dissection may indicate an excessively deep and incorrect surgical plane. In this circumstance, immediate recognition and reevaluation is necessary to avoid inadvertent entry into the urethral diverticulum or urinary tract and to minimize bleeding. Following identification of this situation, dissection should proceed in the proper surgical plane; in reoperative surgery, however, this may be difficult to identify.

Another common site of bleeding during transvaginal UD surgery occurs when traversing the endopelvic fascia for placement of a pubovaginal sling. Entry into the retropubic space from the transvaginal side or placement of the suprapubic needles or trocars from the abdominal side may be associated with copious bleeding as the endopelvic fascia is perforated. If the bleeding continues and is brisk, the vagina can be packed. It can be very helpful to manually elevate the anterior vaginal wall and compress it anteriorly against the posterior symphysis pubis for several minutes using the surgeon’s hand, sponge stick, or a retractor. These maneuvers will effectively tamponade bleeding in the retropubic space. Packing and compression will result in adequate control in the majority of cases; if not, the surgeon should expeditiously complete the procedure, close the incisions, and pack the vagina [6]. Brisk bleeding that does not respond to manual compression for an extended period of time may suggest a major vessel injury and mandates retropubic exploration.

Urinary Tract Injury

Urethra

The Foley catheter is usually seen following complete excision of UD. The urethra can be reconstructed over as small as a 14F Foley catheter without long-term risk of urethral stricture and should be closed in a watertight fashion with absorbable suture [7]. The closure should be tension-free. Uncommonly, a UD may extend circumferentially around the urethra and require segmental resection of the involved portion of the urethra and complex reconstruction [89].

Ureter

Ureteral injury during UD surgery is rare, but may occur with a large or proximal UD extending beyond the bladder neck and below the trigone. In these instances, cystoscopic placement of ureteric catheters prior to the dissection may aid in ureteral identification. Virtually all of these injuries can be identified by intraoperative cystoscopy. The administration of intravenous vital dyes such as indigo carmine permits obvious visualization of ureteral efflux confirming ureteral patency. Suspected ureteral injuries are confirmed by retrograde pyeloureterography. Ureteral transection requires ureteroneocystostomy.

Bladder

Intraoperative bladder injury may occur during dissection of a large UD extending proximal to the bladder neck and under the bladder (Fig. 13.2), or alternatively, may occur with passage of a ligature carrier through the retropubic space if placing a pubovaginal sling.

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Fig. 13.2

Urethral diverticulum extending below trigone

Injury to the bladder during UD excision is diagnosed intraoperatively by careful endoscopic examination of the bladder and bladder neck with a 70° lens following UD dissection and/or passage of the ligature carrier. The bladder should be filled and then examined to ensure that a small injury does not go unrecognized in a fold of the bladder wall.

To avoid injury during ligature carrier passage, the urethra should be clearly palpated, the bladder drained, and the pelvic anatomy well delineated. If a bladder injury is noted intraoperatively, the ligature carrier should be removed and reinserted. Bladder perforation from a ligature carrier usually does not require primary closure.

Injury to the bladder floor during UD dissection requires cystoscopic examination to assess the extent of the injury and intravenous dyes should be administered to confirm ureteral integrity. Small cystotomies may be closed in layers with absorbable sutures transvaginally. More extensive injuries involving the trigone or more proximal bladder may require transabdominal repair. Postoperative drainage of the bladder with a Foley will help avoid urinoma, fistula formation, and pelvic abscess.

Postoperative Complications

Careful adherence to the principles of transvaginal urethral diverticulectomy should minimize postoperative complications (Table 13.2). Nevertheless, complications may arise (Table 13.3). One small series suggested that large diverticula (>4 cm) or those associated with a lateral or horseshoe configuration may be associated with a greater likelihood of postoperative complications [10]. In a larger series, risk factors for failure or poor functional outcome included horseshoe or circumferential configuration or a previous (failed) surgical intervention. Large or more complex UD typically require greater dissection and more involved reconstruction. Common complications include recurrent urinary tract infections (UTIs), urinary incontinence, or recurrent UD, while urethrovaginal fistula is a more rare but devastating complication.

Table 13.2

Principles of transvaginal urethral diverti­culectomy

Mobilization of a well-vascularized anterior vaginal wall flap(s)

Preservation of the periurethral fascia

Identification and excision of the neck of the UD or ostia

Removal of entire UD wall or sac (mucosa)

Watertight urethral closure

Multilayered, nonoverlapping closure with absorbable suture

Closure of dead space

Preservation or creation of continence

Table 13.3

Complications of transvaginal urethral diverti­culectomy (adapted from Dmochowski [32])

Complication (% range of reported incidence)

Urinary incontinence (1.7–16.1%)

Urethrovaginal fistula (0.9–8.3%)

Urethral stricture (0–5.2%)

Recurrent UD (1–25%)

Recurrent UTI (0–31.3%)

Other

Hypospadias/distal urethral necrosis

Bladder or ureteral injury

Vaginal scarring or narrowing: dyspareunia, etc.

Incontinence

Stress Urinary Incontinence

Patients with preoperative symptomatic stress urinary incontinence (SUI) in association with UD can be offered simultaneous anti-incontinence surgery. Preoperative videourodynamics may be helpful in evaluating the anatomy of the UD, assessing the competence of the bladder neck, and confirming the diagnosis of SUI. In patients with SUI and UD, Ganabathi and others have described excellent results with concomitant needle bladder neck suspension [711], although such needle suspensions are rarely done anymore. More recently, pubovaginal autologous fascial slings have been utilized in patients with UD and SUI with satisfactory outcomes [11213]. The role of synthetic midurethral slings, however, has not been well defined in this population and current AUA guidelines recommend against using synthetic material in this setting [14]. Placement of synthetic material adjacent to a fresh suture line following diverticulectomy in the setting of potentially infected urine may place the patient at higher risk for subsequent urethral erosion and vaginal extrusion of the sling material as well as urethrovaginal fistula formation and foreign body granuloma formation [14].

Significant postoperative de novo SUI may occur in between 7 and 16% of individuals undergoing urethral diverticulectomy surgery without a concomitant anti-incontinence surgery [51516]. However, Lee et al. noted at least minor de novo SUI in 49% of patients following urethral diverticulectomy, the majority of which was minor and did not require additional therapy [17]. Only 10% of these individuals underwent a subsequent SUI operation. Risk factors for de novo SUI may include the size of the diverticulum (>30 mm) and more proximal location [16]. Ljungqvist et al. correlated de novo SUI with wide diverticulum excision in addition to size and location [5]. De novo SUI may arise from the extensive suburethral dissection required for a large UD and the more proximal UD location may compromise the urethral sphincter and bladder neck anatomical support and the sphincter mechanism [16]. Alternatively, large UD at the bladder neck may cause obstruction [18] and occult SUI may be unmasked after removing the obstructing UD [19].

Management of de novo postoperative SUI is undertaken after allowing postsurgical inflam­mation to subside. Autologous pubovaginal sling is a reasonable option in this setting. Synthetic materials such as midurethral polypropylene slings must be used judiciously in this setting, however, as safety data are lacking. Repeat preoperative imaging may be helpful in excluding a recurrent or persistent UD, or urethrovaginal fistula prior to surgery [5].

Urinary Urgency and Urge Incontinence

Stav et al. reported rates of urgency-frequency symptoms decreased significantly postoperatively from 60 to 16% and noted complete resolution of urge incontinence [16]. Other series, however, have demonstrated rates of postoperative urgency of 54% [20] and de novo urge incontinence in 36% of patients [5]. These symptoms may be managed expectantly postoperatively; nonetheless continual symptoms postoperatively may herald UD persistence or recurrence or de novo urethral obstruction. Importantly, urinary incontinence following UD excision should be evaluated to rule out the presence of urethrovaginal or vesicovaginal fistula.

Urethrovaginal Fistula

A urethrovaginal fistula located beyond the sphincteric mechanism should not be associated with symptoms other than perhaps a split urinary stream and/or vaginal voiding. As such, an asymptomatic distal urethrovaginal fistula may not require repair, although some patients may request repair. Conversely, a proximal fistula located at the bladder neck or at the midurethra in patients with an incompetent bladder neck will likely result in considerable symptomatic urinary leakage. These patients should undergo repair with consideration for the use of an adjuvant tissue flap such as a Martius flap to provide a well-vascularized additional tissue layer. The actual timing of the repair relative to the initial procedure is controversial, but should allow for tissue inflammation to subside. Meticulous attention to surgical technique, good hemostasis, avoidance of infection, preservation of the periurethral fascia, and a well-vascularized anterior vaginal wall flap, combined with a multilayered closure and nonoverlapping suture lines, should minimize the potential for postoperative urethrovaginal fistula formation [19].

Recurrent Symptoms

While complete resolution of obstructive and irritative urinary symptoms after UD excision may occur [16], some patients will have persistence or recurrence of their preoperative symptoms postoperatively. Ljungqvist et al. noted reoperation (but not necessarily extent of the primary operation) was the greatest clinical factor associated with residual symptoms postoperatively [5]. These symptoms may be from the surgery itself, and if so, may resolve over time. Alternatively, the finding of a UD following a presumably successful urethral diverticulectomy may occur as a result of incomplete excision of the initial lesion, or as a result of a new UD. Such symptoms should be investigated.

Recurrent Urethral Diverticulum

Recurrence of UD may be due to incomplete removal of the UD, inadequate closure of the urethra, failure to close residual dead space, excessive tension on the repair, infection, or other technical factors [1921]. Lee noted recurrent urethral diverticulum in 8/85 patients at follow-up of between 2 and 15 years from the initial UD resection [22], while Ljungqvist et al. reported recurrence in 11/68 patients over a 26-year follow-up [5]. The risk of recurrence of UD following transvaginal excision may be related to the complexity of the anatomical configuration. Han et al. reported no recurrent UD in 17 patients with simple UD, but of the 10 patients with circumferential UD, recurrence was noted in 6 (60%) [15]. Notably in this series, secondary procedures were not as successful in completely removing the UD. Ockrim et al. similarly cured all 19 patients presenting with simple urethral diverticula on the first attempt, but the 11 patients with complex anatomical configurations required a total of 17 procedures for success [18]. Ingber reported a 10% reoperation rate for UD recurrence which was associated with proximal UD location, multiplicity, and prior urethral vaginal surgery [20]. Recurrent UD after failed prior surgeries may lead to more complex, circumferential involvement [8]. Repeat urethral diverticulectomy surgery can be challenging due to altered anatomy, scarring, and the difficulty in identifying the proper anatomic planes. Prevention of recurrence, especially in reoperative UDs, includes the use of a Martius flap, while MRI remains invaluable in surgical planning to ensure complete excision [1823]. Complications such as fistula and recurrence of the UD are more common in reoperative cases [5].

Urethral Stricture

Urethral strictures are rare following UD excision; Rovner noted urethral stricture in 1/44 patients and Ljungvqist in 1/27 patients [58]. It may result from closing the urethra too tightly or reconstructing it over too small a sound or in one instance, postoperative catheter dislodgement [8]. Additionally, poorly vascularized periurethral tissues can result in ischemic strictures postoperatively. A Martius flap should be considered intraoperatively to provide a healthy graft and assist in stricture prevention. A urethral stricture may be managed postoperatively with urethral dilation. Rarely is open reconstruction with urethroplasty necessary.

Recurrent Urinary Tract Infections

UTIs may persist following UD excision and may be due to recurrence or other etiologies. Ingber et al. found 23% of patients reported having three or more infections in the last year of follow-up after urethral diverticulectomy [20]. In a series of 30 patients, Ockrim found the incidence of recurrent UTIs decreased from 17 to 3% [18]. Recurrent UTI work-up can be undertaken once recurrent UD has been excluded.

Pain

Urethral pain and/or severe pelvic pain was significantly relieved or resolved in all patients following diverticulectomy in one series [8]. Romanzi found resolution of preoperative urethral pain in all but 2 patients postoperatively [1]. Nonetheless, urethral pain may persist despite surgical intervention. Ockrim et al. reported persistent pain in 2 patients, despite repeat diverticulectomy including skeletalizing the urethra [18]. Persistent postoperative urethral and pelvic pain, in the absence of UD recurrence, may be secondary to postsurgical changes, long-standing chronic inflammation of the periurethral tissues from the prior UD, or multifactorial in etiology and may ultimately require a multimodal treatment approach.

Dyspareunia

Dyspareunia is one of the classic presenting symptoms of UD. In two larger series of UD patients with preoperative dyspareunia rates of 54% and 56%, rates dropped to 10% and 8%, respectively [1618]. Persistent or de novo dyspareunia postoperatively may result from postsurgical changes, including vaginal scarring and narrowing, especially in patients undergoing reoperation. Vaginal narrowing can be prevented by harvesting a wide-based vaginal flap, thereby avoiding subsequent devascularization and contracture. Romanzi et al. reported dyspareunia resulting from the Martius flap and labial point tenderness on the harvest side [1]. Patients should be counseled appropriately regarding possible postoperative persistence of this symptom and be well informed of the possible sequelae of the Martius flap harvest. Similar to persistent urethral and pelvic pain, postoperative management of dyspareunia may require a multimodal approach.

Hypospadias/Distal Urethral Necrosis

For those utilizing the Spence-Duckett marsupialization procedure, distal urethral necrosis and/or hypospadias are both possible complications.

Malignant Lesions

Malignant and benign tumors may be found in urethral diverticula. Approximately 10% of urethral diverticulectomy specimens may demonstrate histopathological abnormalities including metaplasia, dysplasia, or frank carcinoma which require long-term follow-up or additional therapy [24]. The most common malignant pathology in UD is adenocarcinoma, followed by transitional cell and squamous cell carcinomas [2425], which is in direct contrast to primary urethral carcinoma in which the primary histologic type is squamous cell carcinoma. Nonexcisional therapy of UD such as marsupialization or endoscopic incision can be combined with a biopsy to rule out malignancy [26]. Although it is interesting to speculate, it has not been conclusively demonstrated that any particular preoperative imaging modality such as ultrasound or MRI can reliably and prospectively diagnose a small malignancy arising in a UD [27]. There is no consensus on proper treatment in these cases, and recurrence rates are high with local treatment alone [25]. When considering curative therapy, it is unclear whether extensive surgery including cystourethrectomy with or without adjuvant external beam radiotherapy is superior to local excision followed by radiotherapy [28]. However, pelvic exenteration may offer the highest likelihood of prolonged disease-free interval [29].

Stones

Calculi within UD are not uncommon and may be diagnosed in 4–10% of cases [13031] and are most likely due to urinary stasis and/or infection. This may be suspected by physical exam findings or noted incidentally on preoperative imaging. The presence of a stone will not significantly alter the evaluation or surgical approach and it can be removed with the UD specimen at the time of surgery.

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