HHS Public Access Author manuscript Author Manuscript
Female Pelvic Med Reconstr Surg. Author manuscript; available in PMC 2017 March 27. Published in final edited form as:
Female Pelvic Med Reconstr Surg. 2016 ; 22(6): 447–452. doi:10.1097/SPV.0000000000000312.
Female Urethral Diverticulum: Presentation, Diagnosis, and Predictors of Outcomes After Surgery Sherif A. El-Nashar, MS, MBBCh*,†, Ruchira Singh, MBBS*, Melissa M. Bacon, DO‡, Shunaha Kim-Fine, MD, MS§, John A. Occhino, MD, MS*, John B. Gebhart, MD, MS*, and Christopher J. Klingele, MD, MS*
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*Division
of Gynecologic Surgery, Mayo Clinic, Rochester, MN
†Division
of Female Pelvic Medicine and Reconstructive Surgery, University Hospitals, Cleveland,
OH ‡Department
of Obstetrics and Gynecology, Michigan State University, Sparrow Hospital, Lansing,
MI §Department
of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
Abstract Introduction and Hypothesis—To report on clinical presentation, diagnosis, and outcomes after treatment of female urethral diverticulum (UD).
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Methods—Using a record linkage system, women with a new diagnosis of UD at Mayo Clinic from January 1, 1980, through December 31, 2011, were identified. The presenting symptoms, clinical characteristics, diagnosis, and management of women presenting with UD were recorded. Outcomes after surgery were assessed using survival analysis. All statistical analyses were 2-sided and P values less than 0.05 were considered significant. Statistical analysis was done using SAS version 9.2 and JMP version 9.0 (SAS Institute Inc.).
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Results—A total of 164 cases were identified. Median age at diagnosis was 46 years (range, 21– 83). The most common presenting symptom was recurrent urinary tract infection (98, 59.8%), followed by urinary incontinence (81, 49.4%), dysuria (62, 37.8%), dyspareunia (37, 22.6%), and hematuria (15, 9.1%). Examination revealed vaginal mass in 55 (33.5%) of the women. A significant trend was noted toward an increase in use of both magnetic resonance imaging and computed tomography (P < 0.001) along with a progressive decrease in use of urethrogram (P < 0.001) for diagnosis of UD over the years. Among 114 women who underwent surgical treatment for UD, 14(12.3%) women presented with recurrent UD and the 5-year recurrence rate after
Reprints: Dr. Christopher J. Klingele, Division of Gynecologic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905. ([email protected]). This paper was presented at the AUGS 34th Annual Scientific Meeting in Las Vegas, Nevada. J.B.G.: Advisory board of Astora American Medical Systems, and royalties from UpToDate Inc and Elsevier. The other authors have declared they have no conflicts of interest. S.A.E.-N. participated in design, data collection, data analysis and article writing. R.S. participated in data collection, article writing, and article preparation. M.M.B. participated in design, data collection, and article writing. S.K.-F. participated in data analysis, article writing, and article preparation. J.A.O. participated in interpretation of data and article reviewing. J.B.G. participated in design, interpretation of data, and article reviewing. C.J.K. participated in design, interpretation of data, and article reviewing.
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surgery for UD was 23.4% (95% confidence interval, 13.9–37.0) and a reoperation rate of 17.0% (95% confidence interval, 8.8–30.2) at 5 years. Conclusions—Female UD is a rare and unique condition. Clinical presentation is usually nonspecific, and magnetic resonance imaging is commonly used for confirming the diagnosis. Recurrence is not uncommon, and repeat surgical intervention might be needed. Keywords urethra; diverticulum; diagnosis; female
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Female urethral diverticulum (UD) is a rare and unique clinical entity with an annual incidence of 17.9 per 1,000,000(0.02%) per year.1 Urethral diverticulum can be congenital or acquired. The diagnosis of UD may be suggested by a thorough clinical history and physical examination but often imaging is required to confirm the findings of clinical evaluation.2–4 As a consequence of delayed diagnosis, women may encounter several complications, such as recurrent urinary tract infections, stone formation, and more rarely, malignancy.2 Treatment options for UD can range from conservative management to extensive surgery including diverticulectomy, martius flap, and rectus fascia pubovaginal sling surgery.5 The main aim was to report on the outcomes surgical management of UD. We also reported on the presentation and diagnostic modalities in those patients. We believe this study shall provide an insight about the trends in diagnosis and surgical treatment and its outcomes of UD.
MATERIALS AND METHODS Author Manuscript
This is an observational study that included women who underwent surgery for UD at Mayo Clinic from January 1, 1980, through December 31, 2011. This study was approved by Mayo Clinic Institutional Review Board. The article is written in accordance with The Strengthening the Reporting of Observational Studies in Epidemiology Statement.6
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An electronic record linkage system was used to identify the women who received a new diagnosis of UD from January 1, 1980, through December 31, 2011. Only female patients who were 18 years or older at the time of their initial diagnosis were included. We conducted a search using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. The codes used were: 599.2 for diagnosis of “urethral diverticulum,” 599.5 for diagnosis of “prolapsed urethral mucosa,” and 599.84 which include “other specified disorder of the urethra.”7 Another search was also performed using the following Hospital International Classification of Diseases Adapted codes: 05994110 for “rupture, urethra, nontraumatic”; 05994210 for “prolapse, urethra, nos”; 05994300 for “sacculation, urethra”; 05994310 for “outpouching urethra (cystic)”; 05994320 for “diverticulum, urethral”; 05994710 for “cyst, urethra”; and 05994712 for “cyst, urethral gland.” Verification of the retrieved cases was conducted through chart review. The details can be found in our previously published study describing the incidence of UD with 16 patients who were used in the prior epidemiologic incidence publication were included in this study.1
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Data on patient demographics, clinical presentation, diagnostic testing, and management were abstracted on all included women. For the subgroup of women who underwent surgery for UD, operative reports were reviewed and details about the surgical approach, intraoperative and postoperative complications, and concomitant procedures performed were reported. Outcomes after surgery including recurrence of UD and reoperation for recurrence after surgery were assessed. The primary outcome was recurrence of UD, which was defined by the presence of UD as detected on clinical examination and confirmed by radiologic imaging after primary surgery. The temporal trends in the type of radiologic imaging used to diagnose UD were studied. The outcomes after surgery were also compared over the different time intervals during the study period. In women who underwent a concomitant or an interval anti-incontinence procedure, the clinical presentation at baseline, indication of anti-incontinence surgery, and effect on postoperative urinary incontinence was noted. Finally, the factors that were thought to affect the recurrence of UD after primary surgery, such as demographic variables, presenting symptoms and signs, and timing of surgery, were compared between women with and without recurrent UD. Logistic regression was used to identify factors predicting recurrence of UD after primary surgery.
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Statistical Methods
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Normally distributed continuous variables were reported as mean and standard deviation, whereas median and range were used to report non-normally distributed continuous variables. Categorical variables were reported as number and percent (%). Among the women who underwent surgical treatment, the cumulative incidence of subsequent surgery for treating UD was calculated using the Kaplan-Meier method. The time to event was selected to adjust for the difference in the duration of follow-up between different subgroups and to compare outcomes of surgery before and after 2000. Logistic regression models were used to identify independent predictors of reoperation for recurrent UD after primary surgery. All variables that had an odds ratio of less than 0.2 in the univariate analyses were considered for the multivariate regression along with all known risk factors that were reported in the literature. We also consider the year of the surgery in the analysis to represent the changes in clinical and surgical practices. All statistical tests were 2-sided, and P values less than 0.05 were considered statistically significant. Statistical analysis was performed using JMP version 10.0 (SAS Institute Inc, Carey, NC).
RESULTS Identification of the Study Cohort
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From January 1, 1980, through December 31, 2011, a total of 595 women, aged 18 years or older, were identified as having an International Classification of Diseases, Ninth Revision, Clinical Modification or Hospital International Classification of Diseases Adapted diagnosis code suggestive of UD. The diagnosis of UD was verified in 182 women after chart review. Of these, 164 women were newly diagnosed UD and were included in the current study. Presentation and Diagnosis of UD The median age at diagnosis was 46 years (range, 21–83). The most common presentation was recurrent urinary tract infection (UTI) reported in 98 (59.8%) women, followed by
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urinary incontinence in 81 (49.4%), dysuria in 62 (37.8%), dyspareunia in 37 (22.6%), and hematuria in 15 (9.1%) women. Among the 81 (49.4%) women who had urinary incontinence, 16 (9.9%) had stress urinary incontinence, 12 (7.3%) had urgency urge incontinence and 53 (32.3%) had mixed urinary incontinence. Physical examination revealed vaginal mass in 55 (33.5%) of the women (Table 1).
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In 9 (5.5%) women, the diagnosis of UD was made intraoperatively. These women were undergoing surgery for other indications (hysterectomy for endometrial cancer in one, and cystectomy with urinary diversion surgery in one, and stress urinary incontinence in 7 women,). The remaining 155 women were diagnosed before surgery. The following imaging modalities were used to confirm the diagnosis of UD: double-balloon urethrogram in 58 (37.4%) women, magnetic resonance imaging (MRI) in 52 (33.5%) women, and computed tomography (CT) in 16 (10.3 %) women. A significant trend was noted toward an increase in the use of both MRI and CT (P < 0.001) to diagnose UD over the period of the study. Magnetic resonance imaging was used as the confirmatory test in 32 (53.3%) of 60 women for diagnosing UD between the years 2000 and 2011. With the shift toward MRI, there was a significant trend in progressive decrease in the use of urethrogram (P < 0.001) for diagnosis of UD, which was the most prevalent diagnostic modality in the 1980s. Thirty-one (51.7%) of 50 women underwent double balloon urethrogram to confirm the diagnosis of UD in the 1980s as compared with only 10 (16.7%) of 60 women after the year 2000. An image of a saddle-shaped UD, which was diagnosed by MRI is shown in Figure 1. Treatment for UD
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Of the 164 women that were included, 50 (30.5%) women were treated conservatively and did not require surgical management at the time of consultation. The remaining 114 (69.5%) women underwent surgical treatment. Of the 114 women who underwent surgery, information on follow-up was available for 82 (71.9%) women. Of these, 72 women who had follow-up documented at least for 6 months after surgery. The median duration of follow-up for patients who had surgery was 12.4 months (range, 0–324.6 months). Patients’ entire charts were reviewed to collect data on follow-up visits for all urinary problems. For those patients who had conservative management, only 3 (6%) of 50 had follow up within the Mayo Clinic Medical Records, and the remaining 47 (94%) were only seen for a consultation and did not continue care at our institution.
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Transvaginal diverticulectomy was the most common procedure performed in 95 (83.3%) women (Fig. 2), followed by marsupialization of the distal diverticulum in 17 (14.9%) women (Fig. 3), and transabdominal diverticulectomy in 2 (1.8%) women. Surgeries were performed by urologist in 62 (54.4%) cases and by a gynecologic surgeon in 52 (45.6%) cases. A Martius fat pad flap was used in 9 (7.9%) cases and urethral reconstruction was required in 18 (15.8%) cases. The decision for performing a Martius fat pad flap was made due to the extensive nature of dissection and the lack of adequate periurethral fibromuscular tissue needed to perform a layered closure. One of the 9 cases with Martius fat pad flap also involved urethral reconstruction. The intraoperative and postoperative complications of surgery included urethrotomy in 8 (7.0%), urethrovaginal fistula in 1 (0.9%), urethral stricture in 1 (0.9%), and persistent pain in 7 (6.1%) women.
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Stress Urinary Incontinence and Incontinence-Related Surgery
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A concomitant procedure for treating incontinence was performed in 21 (18.4%) women. The autologous rectus fascia pubovaginal sling was the most common anti-incontinence procedure performed (16, 76.2%), followed by Marshall-Marchetti-Krantz (4, 19%) and cadaveric fascia pubovaginal sling (1, 4.8%). Among the 21 women who underwent concomitant anti-incontinence procedure, 8 had stress urinary incontinence, 8 had stress predominant mixed urinary incontinence, 1 had urgency urinary incontinence, and 4 women did not report any urinary incontinence at baseline. In these 4 women, the decision to perform an anti-incontinence procedure was made intraoperatively in view of extensive periurethral dissection that involved the sphincter mechanism. In these 21 patients, followup data were available on 16 (76.1%) women with a mean follow-up duration of 25.7 (SD = 16.8) months.
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Eighty-four women did not present with symptoms of urinary incontinence at baseline. Forty-nine women in this cohort underwent surgery for UD, and 35 women were treated conservatively. Of the 49 women undergoing surgery, 4 underwent concomitant antiincontinence sling procedure as indicated before. Among the 45 women who did not have baseline urinary incontinence and did not undergo a concomitant anti-incontinence procedure, information on follow-up after surgery was available in 27 (60%) women. Three women (11.1%) reported de novo postoperative urinary incontinence, and only 1 (3.7%) had to undergo a sling procedure for stress urinary incontinence. The remaining 23 women (85.2%) had continued follow-up with no evidence of stress urinary incontinence requiring evaluation or treatment. Recurrence and Recurrence-Related Reoperations After Primary Surgery
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One hundred fourteen women underwent surgery for treatment of UD, and 14 (12.3%) women presented with recurrent UD postoperatively. In majority of the women (11, 9.64%), the recurrences were diagnosed within 5 years of the primary surgery. Repeat surgery for recurrence of UD was performed in 10 (8.8%) women. The cumulative rate of recurrent UD was 23.4% (95% confidence interval [CI], 13.9–37.0), and the cumulative rate of reoperation for recurrent UD was 17.0% (95% CI, 8.8–30.2) at 5 years, respectively (Figs. 4A and B). Repeat transvaginal urethral diverticulectomy was performed in 8 women, and 2 women underwent marsupialization of UD as their secondary surgery. The concomitant procedures that were performed with transvaginal urethral diverticulectomy were: autologous rectus fascia pubovaginal sling in 2 cases, and Martius fat pad flap and incidental urethrotomy with urethral repair in 1 case. The 5-year cumulative rate of recurrent UD was higher for women who underwent surgery before the year 2000 as compared with women who underwent surgery after the year 2000 (27.8%; 95% CI, 14.2–44.8 for surgery performed before 2000 vs 17.1%; 95% CI, 4.6, 47.1 for surgery performed after 2000). However, the difference was not statistically significant (P = 0.269) (Table 2). The 5-year cumulative rate of re-operation for recurrent UD was significantly lower if the primary surgery was performed after 2000 as compared to women in whom the primary surgery was performed before 2000 (P = 0.021). (Table 2).
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Univariate analyses were conducted in order to evaluate the risk factors predicting recurrence of UD. The presence of dysuria at baseline was the only factor that was associated with an increased risk of recurrent UD after the primary surgery (unadjusted odds ratio, 3.8; 95% CI, 1.1–12.8). The other clinical and demographic factors that have been previously shown to be predict recurrent UD did not reach statistical significance in either univariate analyses or the multivariable analysis (Tables 3 and 4).
DISCUSSION
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This study reports on clinical presentation, diagnosis, and management of 164 cases of female UD from 1980 through 2011 at a single institution. We conducted a systematic review of the published studies in English language in MEDLINE, EMBASE, Cochrane Systematic Reviews, CENTRAL, Web of Science and Scopus databases for studies on “female urethral diverticulum” up to December 31, 2015. This study includes the largest number of women with UD in the last 30 years. Recurrent UTI was the most common presenting complaint in women with UD. Currently, MRI is the criterion standard diagnostic test that is used to confirm the diagnosis of UD. The overall rate of reoperation for recurrent UD was low with 17% of the women requiring surgery within 5 years. Finally, a significant reduction in the reoperation for recurrent UD after the primary surgery was noted for surgeries performed after 2000 as compared with those performed before 2000, which might be attributed to the increased use of MRI in diagnosis and preoperative planning for surgery.
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In agreement with the previous studies, the diagnosis of UD in adults most commonly occurs in the fifth decade of life with the median age of diagnosis of 46 years. One of the clinical characteristics noted previously in the literature is the relatively higher incidence of UD in African American women as compared with the incidence of UD in white women as observed by Menville and Mitchell8 and Davis and Robinson.9 In 2005, Burrows and colleagues10 reported a 3-fold increase in the surgical interventions among African American women as compared with white women. Only 4.9% of the women included in our study were African Americans. This hampered our efforts to study this prior finding and might have been a factor in reducing the overall incidence calculated for Olmsted County of only 17.9 per 1,000,000 (0.02%) per year.1
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The classic triad of “3 Ds” for diagnosis of UD includes dysuria, postvoid dribbling, and dyspareunia11; this was not observed in our study. Recurrent UTI was the most common presenting symptom followed by dysuria, incontinence, and dyspareunia. The diagnosis of UD can be challenging because the symptoms mimic the irritative symptoms as seen with urinary tract infections.12 Reeves and colleagues13 studied a cohort of 89 women with UD over a period of 8 years and reported awareness of vaginal mass to be the most common presenting symptom. In addition to a high index of suspicion from history and physical examination, there are many diagnostic modalities that can increase the probability of identifying a UD. These include voiding cystourethrography, positive pressure urethrography, urethroscopy, endovaginal sonography, transrectal sonography, postvoid radiograph, CT scan, and MRI.14 A trend toward increased use of MRI over the period was observed in our study. This has
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been observed in other studies and currently, MRI is the criterion standard modality for diagnosis of UD.2
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In our cohort, 23.4% women had recurrent UD and 17% required repeat surgery for recurrence. Previous studies have suggested several factors to be associated with the need for repeat surgery for recurrent UD. These include history of previous repair, larger diverticulum (>4 cm), lateral or horseshoe-shaped diverticulum, proximal position, multiple diverticula, and prior pelvic or vaginal surgery.15,16 In our study, we only included primary UD surgeries, so we could not evaluate history of prior surgery of UD as a risk factor. We did not observe location and the size of the UD to be associated with reoperation for recurrence. Interestingly, reoperation for a recurrence was less common in larger UD (>3 cm) in our cohort. This might be explained by the fact that re-operation for recurrence is related to a persistent diverticulum, that could be part of the old UD but was missed in the prior surgery or be just a false observation related to small number of events in our study. Because MRI has higher sensitivity to detect small UD in case of complex or multiple UD as compared with cystourethrogram; the increased use of MRI to diagnose UD may help in preoperative identification of such small lesions. This might explain the lower rates of reoperation for recurrent UD that was noted after 2000, with MRI being the most common diagnostic modality used. However, this theory will need validation by other investigators.
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There is a known association between UD and stress urinary incontinence, and stress urinary incontinence is also a known complication after extensive UD surgery.3,17,18 Unfortunately, due to incomplete follow-up related to continence of the patients included in this study, we could not provide strong evidence to support future practice. However, as shared by Reeves and colleagues,13 in their publication in 2014, there is no current agreement on the best approach for managing stress urinary incontinence and the conduct of a concomitant antiincontinence procedure. In our opinion, this decision has to be individualized based on patient preference and surgeons’ experience until we have more evidence supporting this finding.
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This study is limited by the retrospective design and the lack of data on patient reported outcomes. Due to the nature of the clinical practice in the earlier years of the study, postoperative checkups were not stringently required as compared with current practice. Therefore, no follow-up information was available on 32 of the 114 (28.1%) women who underwent surgery for UD. Nonetheless, follow-up data after surgery was available on the rest of the 82 patients (71.9%). In these 82 women, 10 were only seen once after surgery, 72 had a follow-up more than 6 months with a median follow-up of 12.4 months, and some patients had follow-up data up to 30 years. To address this limitation, we conducted a survival analysis and calculated rates for recurrence and reoperation at 1, 3, and 5 years. In addition, follow-up more than 6 months was available for 12 (85%) of 14 patients with recurrence and 60 (60%) of 100 patients without recurrence which indicates that we may be missing more women with recurrent UD that never came back to our institution for care and may have resulted in higher reported success rate. Another limitation specific to our multiregression analysis for identification of risk factors related to recurrence is the small number of patients who had recurrences (14 of 114). This made the analysis under-powered and limited our ability to include more than 2 risk factors in the final model. We also
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acknowledge that these women may have received subsequent treatment for the condition at a different institution, which may impact our recurrence rates. However, if the patient presented with urinary problems to other specialties within our institution, then the data were collected. Nevertheless, the study duration, including 30 years of data, provided enough numbers to allow an appropriate review of the diagnosis and management of UD in our institution. Finally, this study was conducted in 1 institution in the Upper Midwest, and the results might only be applicable to this specific region of the United States.
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In conclusion, female UD is a rare and unique condition that requires high clinical suspicion for diagnosis and frequently needs multiple surgical interventions for treatment. Good planning for surgery including preoperative MRI might reduce the recurrence and need for reoperation. The results of this study will provide information about the rates of recurrence and reoperation for UD that would be helpful in counselling patients opting to undergo surgery.
Acknowledgments Study data were obtained from the Rochester Epidemiology Project, which is supported by the National Institute on Aging of the National Institutes of Health under Award Number R01AG034676. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
References
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1. El-Nashar SA, Bacon MM, Kim-Fine S, et al. Incidence of female urethral diverticulum: a population-based analysis and literature review. Int Urogynecol J. 2014; 25:73–79. [PubMed: 23857063] 2. Antosh DD, Gutman RE. Diagnosis and management of female urethral diverticulum. Female Pelvic Med Reconstr Surg. 2011; 17:264–271. [PubMed: 22453220] 3. Lee RA. Diverticulum of the female urethra: postoperative complications and results. Obstet Gynecol. 1983; 61:52–58. [PubMed: 6401854] 4. Quiroz, L., Gutman, R. Diagnosis and management of urethral diverticulum in women. In: Brubaker, L., editor. UpToDate. Waltham, MA: UpToDate; 2008. 5. Lee JW, Fynes MM. Female urethral diverticula. Best Pract Res Clin Obstet Gynaecol. 2005; 19:875–893. [PubMed: 16181809] 6. von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007; 370:1453–1457. [PubMed: 18064739] 7. Commission on Professional and Hospital Activities NCfHSUS. H-ICDA; hospital adaptation of ICDA. 2. Ann Arbor, MI: Commission on Professional and Hospital Activities; 1973. 8. Menville JG, Mitchell JD. Diverticulum of the female urethra. J Urol. 1944; 51:411–423. 9. Davis BL, Robinson DG. Diverticula of the female urethra: assay of 120 cases. J Urol. 1970; 104:850–853. [PubMed: 4993407] 10. Tunitsky E, Goldman HB, Ridgeway B. Periurethral mass: a rare and puzzling entity. Obstet Gynecol. 2012; 120:1459–1464. [PubMed: 23168773] 11. Ockrim JL, Allen DJ, Shah PJ, et al. A tertiary experience of urethral diverticulectomy: diagnosis, imaging and surgical outcomes. BJU Int. 2009; 103:1550–1554. [PubMed: 19191783] 12. Ganabathi K, Leach GE, Zimmern PE, et al. Experience with the management of urethral diverticulum in 63 women. J Urol. 1994; 152(5 Pt 1):1445–1452. [PubMed: 7933181] 13. Reeves FA, Inman RD, Chapple CR. Management of symptomatic urethral diverticula in women: a single-centre experience. Eur Urol. 2014; 66:164–172. [PubMed: 24636677]
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14. Patel AK, Chapple CR. Female urethral diverticula. Curr Opin Urol. 2006; 16:248–254. [PubMed: 16770123] 15. Porpiglia F, Destefanis P, Fiori C, et al. Preoperative risk factors for surgery female urethral diverticula. Our experience. Urol Int. 2002; 69:7–11. [PubMed: 12119431] 16. Ingber MS, Firoozi F, Vasavada SP, et al. Surgically corrected urethral diverticula: long-term voiding dysfunction and reoperation rates. Urology. 2011; 77:65–69. [PubMed: 20800882] 17. Mackinnon M, Pratt JH, Pool TL. Diverticulum of the female urethra. Surg Clin North Am. 1959; 39:953–962. [PubMed: 13676011] 18. Spraitz AF Jr, Welch JS. Diverticulum of the female urethra. Am J Obstet Gynecol. 1965; 91:1013–1016. [PubMed: 14268304] 19. Burrows LJ, Howden NL, Meyn L, et al. Surgical procedures for urethral diverticula in women in the United States, 1979–1997. Int Urogynecol J Pelvic Floor Dysfunct. 2005; 16:158–161. [PubMed: 15789149]
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Author Manuscript Author Manuscript FIGURE 1.
Magnetic resonance image of a circumferential urethral diverticulum. This axial T2weighted image shows a saddle-shaped urethral diverticulum.
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FIGURE 2.
Transvaginal diverticulectomy. An 8 french Foley catheter was introduced into the orifice of the diverticulum and was filled with 2 mL of saline. Another Foley catheter was inserted (A), a U vaginal incision was used and a transverse incision of the periurethral tissue was done (B), dissection of the periurethral tissue from the wall of the urethral diverticulum was done (C), complete excision of the diverticular tissue was done (D). Closure of the urethra followed by double layer closure of the periurethral tissues and the vaginal epithelium followed.
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FIGURE 3.
Distal urethral diverticulum (A) surgically treated with distal urethral marsupialization (B).
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Author Manuscript FIGURE 4.
Cumulative rate for recurrence (A) and reoperation for recurrence (B) after primary surgery for treating urethral diverticulum at Mayo from 1980 to 2011.
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TABLE 1
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Baseline Characteristics of Women With Urethral Diverticulum Urethral Diverticulum Cases (N = 164), No. (%) Age: median (range), y
46 (21,83)
Age ≥ 40 y
108 (65.9)
BMI: median (range), BMI ≥ 30
kg/m2
kg/m2
27.8 (18.1,50.1) 46 (28.0)
Race White
142 (86.6)
African American
8 (4.9)
Others
14 (8.5)
Parity, median (range)
2 (0,6)
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Postmenopausal
56 (34.1)
Previous pelvic surgery
56 (34.1)
Recurrent UTI
98 (59.8)
Urinary incontinence
81 (49.4)
Stress
16 (9.9)
Urge
12 (7.3)
Mixed
53 (32.3)
Dysuria
62 (37.8)
Dyspareunia
37 (22.6)
Vaginal mass on examination
55 (33.5)
Diagnosed at time of surgery
9 (5.5)
Preoperative evaluation (% based on 155)
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Urethrogram
58 (37.4)
MRI
52 (33.5)
CT or CT urogram
16 (10.3)
Urodynamic evaluation
40 (25.8)
Cystourethroscopy
121 (78.1)
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Author Manuscript 4.0% (2.0–12.0) 7.4% (4.1–19.8) 17.0% (8.8–30.2)
At 3 y At 5 y
23.4% (13.9–37.0)
At 1 y
At 5 y
Log-rank test in-between groups.
*
Reoperation for recurrence
7.0% (3.0–16.0) 13.9% (7.4–25.0)
At 3 y
Recurrence
N = 114
At 1 y
Year
Outcome
Whole population
17.0% (8.8–30.2)
7.4% (4.1–19.8)
4.0% (2.0–12.0)
27.8% (14.2–44.8)
18.2% (8.8–34.0)
7.0 (2.0–19.8)
N = 70
40 y
9 (64.3%)
63 (63.0%)
1.2 (0.4–4.2)
0.760
Parity > 2
12 (85.7%)
75 (75.0%)
1.8 (0.4–8.8)
0.442
White vs others
13 (92.9%)
89 (89.0%)
1.5 (0.2–12.4)
0.727
BMI, kg/m2 ≤ 30 vs 3 cm vs ≤ 3 cm
2 (14.3%)
18 (18.0%)
0.7 (0.2–3.6)
0.709
UD distal vs others
2 (14.3%)
15 (15.0%)
0.9 (0.2–4.7)
0.944
Surgery done after 2000 vs before 2000
3 (21.4%)
41 (41.0%)
0.4 (0.1–1.5)
0.159
N (%)
BMI, body mass index.
*
Others include multiple UD, complex, horse shoe UD.
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TABLE 4
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Univariate and Multivariate Regression Models for Risk Factors Associated With Recurrence of Urethral Diverticulum After Surgery Risk Factors
Univariate Analysis
Multivariate Analysis*
Dysuria as a presenting symptom
3.8 (1.1–12.8)
4.4 (1.3–17.5)
Vaginal mass identified on examination
0.6 (0.2–1.9)
0.4 (0.1–1.4)
*
Area under the curve for the final multivariate logistic regression model was 0.70.
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Female Pelvic Med Reconstr Surg. Author manuscript; available in PMC 2017 March 27. Published in final edited form as:
Female Pelvic Med Reconstr Surg. 2016 ; 22(6): 447–452. doi:10.1097/SPV.0000000000000312.
Female Urethral Diverticulum: Presentation, Diagnosis, and Predictors of Outcomes After Surgery Sherif A. El-Nashar, MS, MBBCh*,†, Ruchira Singh, MBBS*, Melissa M. Bacon, DO‡, Shunaha Kim-Fine, MD, MS§, John A. Occhino, MD, MS*, John B. Gebhart, MD, MS*, and Christopher J. Klingele, MD, MS*
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*Division
of Gynecologic Surgery, Mayo Clinic, Rochester, MN
†Division
of Female Pelvic Medicine and Reconstructive Surgery, University Hospitals, Cleveland,
OH ‡Department
of Obstetrics and Gynecology, Michigan State University, Sparrow Hospital, Lansing,
MI §Department
of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
Abstract Introduction and Hypothesis—To report on clinical presentation, diagnosis, and outcomes after treatment of female urethral diverticulum (UD).
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Methods—Using a record linkage system, women with a new diagnosis of UD at Mayo Clinic from January 1, 1980, through December 31, 2011, were identified. The presenting symptoms, clinical characteristics, diagnosis, and management of women presenting with UD were recorded. Outcomes after surgery were assessed using survival analysis. All statistical analyses were 2-sided and P values less than 0.05 were considered significant. Statistical analysis was done using SAS version 9.2 and JMP version 9.0 (SAS Institute Inc.).
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Results—A total of 164 cases were identified. Median age at diagnosis was 46 years (range, 21– 83). The most common presenting symptom was recurrent urinary tract infection (98, 59.8%), followed by urinary incontinence (81, 49.4%), dysuria (62, 37.8%), dyspareunia (37, 22.6%), and hematuria (15, 9.1%). Examination revealed vaginal mass in 55 (33.5%) of the women. A significant trend was noted toward an increase in use of both magnetic resonance imaging and computed tomography (P < 0.001) along with a progressive decrease in use of urethrogram (P < 0.001) for diagnosis of UD over the years. Among 114 women who underwent surgical treatment for UD, 14(12.3%) women presented with recurrent UD and the 5-year recurrence rate after
Reprints: Dr. Christopher J. Klingele, Division of Gynecologic Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905. ([email protected]). This paper was presented at the AUGS 34th Annual Scientific Meeting in Las Vegas, Nevada. J.B.G.: Advisory board of Astora American Medical Systems, and royalties from UpToDate Inc and Elsevier. The other authors have declared they have no conflicts of interest. S.A.E.-N. participated in design, data collection, data analysis and article writing. R.S. participated in data collection, article writing, and article preparation. M.M.B. participated in design, data collection, and article writing. S.K.-F. participated in data analysis, article writing, and article preparation. J.A.O. participated in interpretation of data and article reviewing. J.B.G. participated in design, interpretation of data, and article reviewing. C.J.K. participated in design, interpretation of data, and article reviewing.
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surgery for UD was 23.4% (95% confidence interval, 13.9–37.0) and a reoperation rate of 17.0% (95% confidence interval, 8.8–30.2) at 5 years. Conclusions—Female UD is a rare and unique condition. Clinical presentation is usually nonspecific, and magnetic resonance imaging is commonly used for confirming the diagnosis. Recurrence is not uncommon, and repeat surgical intervention might be needed. Keywords urethra; diverticulum; diagnosis; female
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Female urethral diverticulum (UD) is a rare and unique clinical entity with an annual incidence of 17.9 per 1,000,000(0.02%) per year.1 Urethral diverticulum can be congenital or acquired. The diagnosis of UD may be suggested by a thorough clinical history and physical examination but often imaging is required to confirm the findings of clinical evaluation.2–4 As a consequence of delayed diagnosis, women may encounter several complications, such as recurrent urinary tract infections, stone formation, and more rarely, malignancy.2 Treatment options for UD can range from conservative management to extensive surgery including diverticulectomy, martius flap, and rectus fascia pubovaginal sling surgery.5 The main aim was to report on the outcomes surgical management of UD. We also reported on the presentation and diagnostic modalities in those patients. We believe this study shall provide an insight about the trends in diagnosis and surgical treatment and its outcomes of UD.
MATERIALS AND METHODS Author Manuscript
This is an observational study that included women who underwent surgery for UD at Mayo Clinic from January 1, 1980, through December 31, 2011. This study was approved by Mayo Clinic Institutional Review Board. The article is written in accordance with The Strengthening the Reporting of Observational Studies in Epidemiology Statement.6
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An electronic record linkage system was used to identify the women who received a new diagnosis of UD from January 1, 1980, through December 31, 2011. Only female patients who were 18 years or older at the time of their initial diagnosis were included. We conducted a search using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. The codes used were: 599.2 for diagnosis of “urethral diverticulum,” 599.5 for diagnosis of “prolapsed urethral mucosa,” and 599.84 which include “other specified disorder of the urethra.”7 Another search was also performed using the following Hospital International Classification of Diseases Adapted codes: 05994110 for “rupture, urethra, nontraumatic”; 05994210 for “prolapse, urethra, nos”; 05994300 for “sacculation, urethra”; 05994310 for “outpouching urethra (cystic)”; 05994320 for “diverticulum, urethral”; 05994710 for “cyst, urethra”; and 05994712 for “cyst, urethral gland.” Verification of the retrieved cases was conducted through chart review. The details can be found in our previously published study describing the incidence of UD with 16 patients who were used in the prior epidemiologic incidence publication were included in this study.1
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Data on patient demographics, clinical presentation, diagnostic testing, and management were abstracted on all included women. For the subgroup of women who underwent surgery for UD, operative reports were reviewed and details about the surgical approach, intraoperative and postoperative complications, and concomitant procedures performed were reported. Outcomes after surgery including recurrence of UD and reoperation for recurrence after surgery were assessed. The primary outcome was recurrence of UD, which was defined by the presence of UD as detected on clinical examination and confirmed by radiologic imaging after primary surgery. The temporal trends in the type of radiologic imaging used to diagnose UD were studied. The outcomes after surgery were also compared over the different time intervals during the study period. In women who underwent a concomitant or an interval anti-incontinence procedure, the clinical presentation at baseline, indication of anti-incontinence surgery, and effect on postoperative urinary incontinence was noted. Finally, the factors that were thought to affect the recurrence of UD after primary surgery, such as demographic variables, presenting symptoms and signs, and timing of surgery, were compared between women with and without recurrent UD. Logistic regression was used to identify factors predicting recurrence of UD after primary surgery.
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Statistical Methods
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Normally distributed continuous variables were reported as mean and standard deviation, whereas median and range were used to report non-normally distributed continuous variables. Categorical variables were reported as number and percent (%). Among the women who underwent surgical treatment, the cumulative incidence of subsequent surgery for treating UD was calculated using the Kaplan-Meier method. The time to event was selected to adjust for the difference in the duration of follow-up between different subgroups and to compare outcomes of surgery before and after 2000. Logistic regression models were used to identify independent predictors of reoperation for recurrent UD after primary surgery. All variables that had an odds ratio of less than 0.2 in the univariate analyses were considered for the multivariate regression along with all known risk factors that were reported in the literature. We also consider the year of the surgery in the analysis to represent the changes in clinical and surgical practices. All statistical tests were 2-sided, and P values less than 0.05 were considered statistically significant. Statistical analysis was performed using JMP version 10.0 (SAS Institute Inc, Carey, NC).
RESULTS Identification of the Study Cohort
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From January 1, 1980, through December 31, 2011, a total of 595 women, aged 18 years or older, were identified as having an International Classification of Diseases, Ninth Revision, Clinical Modification or Hospital International Classification of Diseases Adapted diagnosis code suggestive of UD. The diagnosis of UD was verified in 182 women after chart review. Of these, 164 women were newly diagnosed UD and were included in the current study. Presentation and Diagnosis of UD The median age at diagnosis was 46 years (range, 21–83). The most common presentation was recurrent urinary tract infection (UTI) reported in 98 (59.8%) women, followed by
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urinary incontinence in 81 (49.4%), dysuria in 62 (37.8%), dyspareunia in 37 (22.6%), and hematuria in 15 (9.1%) women. Among the 81 (49.4%) women who had urinary incontinence, 16 (9.9%) had stress urinary incontinence, 12 (7.3%) had urgency urge incontinence and 53 (32.3%) had mixed urinary incontinence. Physical examination revealed vaginal mass in 55 (33.5%) of the women (Table 1).
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In 9 (5.5%) women, the diagnosis of UD was made intraoperatively. These women were undergoing surgery for other indications (hysterectomy for endometrial cancer in one, and cystectomy with urinary diversion surgery in one, and stress urinary incontinence in 7 women,). The remaining 155 women were diagnosed before surgery. The following imaging modalities were used to confirm the diagnosis of UD: double-balloon urethrogram in 58 (37.4%) women, magnetic resonance imaging (MRI) in 52 (33.5%) women, and computed tomography (CT) in 16 (10.3 %) women. A significant trend was noted toward an increase in the use of both MRI and CT (P < 0.001) to diagnose UD over the period of the study. Magnetic resonance imaging was used as the confirmatory test in 32 (53.3%) of 60 women for diagnosing UD between the years 2000 and 2011. With the shift toward MRI, there was a significant trend in progressive decrease in the use of urethrogram (P < 0.001) for diagnosis of UD, which was the most prevalent diagnostic modality in the 1980s. Thirty-one (51.7%) of 50 women underwent double balloon urethrogram to confirm the diagnosis of UD in the 1980s as compared with only 10 (16.7%) of 60 women after the year 2000. An image of a saddle-shaped UD, which was diagnosed by MRI is shown in Figure 1. Treatment for UD
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Of the 164 women that were included, 50 (30.5%) women were treated conservatively and did not require surgical management at the time of consultation. The remaining 114 (69.5%) women underwent surgical treatment. Of the 114 women who underwent surgery, information on follow-up was available for 82 (71.9%) women. Of these, 72 women who had follow-up documented at least for 6 months after surgery. The median duration of follow-up for patients who had surgery was 12.4 months (range, 0–324.6 months). Patients’ entire charts were reviewed to collect data on follow-up visits for all urinary problems. For those patients who had conservative management, only 3 (6%) of 50 had follow up within the Mayo Clinic Medical Records, and the remaining 47 (94%) were only seen for a consultation and did not continue care at our institution.
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Transvaginal diverticulectomy was the most common procedure performed in 95 (83.3%) women (Fig. 2), followed by marsupialization of the distal diverticulum in 17 (14.9%) women (Fig. 3), and transabdominal diverticulectomy in 2 (1.8%) women. Surgeries were performed by urologist in 62 (54.4%) cases and by a gynecologic surgeon in 52 (45.6%) cases. A Martius fat pad flap was used in 9 (7.9%) cases and urethral reconstruction was required in 18 (15.8%) cases. The decision for performing a Martius fat pad flap was made due to the extensive nature of dissection and the lack of adequate periurethral fibromuscular tissue needed to perform a layered closure. One of the 9 cases with Martius fat pad flap also involved urethral reconstruction. The intraoperative and postoperative complications of surgery included urethrotomy in 8 (7.0%), urethrovaginal fistula in 1 (0.9%), urethral stricture in 1 (0.9%), and persistent pain in 7 (6.1%) women.
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Stress Urinary Incontinence and Incontinence-Related Surgery
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A concomitant procedure for treating incontinence was performed in 21 (18.4%) women. The autologous rectus fascia pubovaginal sling was the most common anti-incontinence procedure performed (16, 76.2%), followed by Marshall-Marchetti-Krantz (4, 19%) and cadaveric fascia pubovaginal sling (1, 4.8%). Among the 21 women who underwent concomitant anti-incontinence procedure, 8 had stress urinary incontinence, 8 had stress predominant mixed urinary incontinence, 1 had urgency urinary incontinence, and 4 women did not report any urinary incontinence at baseline. In these 4 women, the decision to perform an anti-incontinence procedure was made intraoperatively in view of extensive periurethral dissection that involved the sphincter mechanism. In these 21 patients, followup data were available on 16 (76.1%) women with a mean follow-up duration of 25.7 (SD = 16.8) months.
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Eighty-four women did not present with symptoms of urinary incontinence at baseline. Forty-nine women in this cohort underwent surgery for UD, and 35 women were treated conservatively. Of the 49 women undergoing surgery, 4 underwent concomitant antiincontinence sling procedure as indicated before. Among the 45 women who did not have baseline urinary incontinence and did not undergo a concomitant anti-incontinence procedure, information on follow-up after surgery was available in 27 (60%) women. Three women (11.1%) reported de novo postoperative urinary incontinence, and only 1 (3.7%) had to undergo a sling procedure for stress urinary incontinence. The remaining 23 women (85.2%) had continued follow-up with no evidence of stress urinary incontinence requiring evaluation or treatment. Recurrence and Recurrence-Related Reoperations After Primary Surgery
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One hundred fourteen women underwent surgery for treatment of UD, and 14 (12.3%) women presented with recurrent UD postoperatively. In majority of the women (11, 9.64%), the recurrences were diagnosed within 5 years of the primary surgery. Repeat surgery for recurrence of UD was performed in 10 (8.8%) women. The cumulative rate of recurrent UD was 23.4% (95% confidence interval [CI], 13.9–37.0), and the cumulative rate of reoperation for recurrent UD was 17.0% (95% CI, 8.8–30.2) at 5 years, respectively (Figs. 4A and B). Repeat transvaginal urethral diverticulectomy was performed in 8 women, and 2 women underwent marsupialization of UD as their secondary surgery. The concomitant procedures that were performed with transvaginal urethral diverticulectomy were: autologous rectus fascia pubovaginal sling in 2 cases, and Martius fat pad flap and incidental urethrotomy with urethral repair in 1 case. The 5-year cumulative rate of recurrent UD was higher for women who underwent surgery before the year 2000 as compared with women who underwent surgery after the year 2000 (27.8%; 95% CI, 14.2–44.8 for surgery performed before 2000 vs 17.1%; 95% CI, 4.6, 47.1 for surgery performed after 2000). However, the difference was not statistically significant (P = 0.269) (Table 2). The 5-year cumulative rate of re-operation for recurrent UD was significantly lower if the primary surgery was performed after 2000 as compared to women in whom the primary surgery was performed before 2000 (P = 0.021). (Table 2).
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Univariate analyses were conducted in order to evaluate the risk factors predicting recurrence of UD. The presence of dysuria at baseline was the only factor that was associated with an increased risk of recurrent UD after the primary surgery (unadjusted odds ratio, 3.8; 95% CI, 1.1–12.8). The other clinical and demographic factors that have been previously shown to be predict recurrent UD did not reach statistical significance in either univariate analyses or the multivariable analysis (Tables 3 and 4).
DISCUSSION
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This study reports on clinical presentation, diagnosis, and management of 164 cases of female UD from 1980 through 2011 at a single institution. We conducted a systematic review of the published studies in English language in MEDLINE, EMBASE, Cochrane Systematic Reviews, CENTRAL, Web of Science and Scopus databases for studies on “female urethral diverticulum” up to December 31, 2015. This study includes the largest number of women with UD in the last 30 years. Recurrent UTI was the most common presenting complaint in women with UD. Currently, MRI is the criterion standard diagnostic test that is used to confirm the diagnosis of UD. The overall rate of reoperation for recurrent UD was low with 17% of the women requiring surgery within 5 years. Finally, a significant reduction in the reoperation for recurrent UD after the primary surgery was noted for surgeries performed after 2000 as compared with those performed before 2000, which might be attributed to the increased use of MRI in diagnosis and preoperative planning for surgery.
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In agreement with the previous studies, the diagnosis of UD in adults most commonly occurs in the fifth decade of life with the median age of diagnosis of 46 years. One of the clinical characteristics noted previously in the literature is the relatively higher incidence of UD in African American women as compared with the incidence of UD in white women as observed by Menville and Mitchell8 and Davis and Robinson.9 In 2005, Burrows and colleagues10 reported a 3-fold increase in the surgical interventions among African American women as compared with white women. Only 4.9% of the women included in our study were African Americans. This hampered our efforts to study this prior finding and might have been a factor in reducing the overall incidence calculated for Olmsted County of only 17.9 per 1,000,000 (0.02%) per year.1
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The classic triad of “3 Ds” for diagnosis of UD includes dysuria, postvoid dribbling, and dyspareunia11; this was not observed in our study. Recurrent UTI was the most common presenting symptom followed by dysuria, incontinence, and dyspareunia. The diagnosis of UD can be challenging because the symptoms mimic the irritative symptoms as seen with urinary tract infections.12 Reeves and colleagues13 studied a cohort of 89 women with UD over a period of 8 years and reported awareness of vaginal mass to be the most common presenting symptom. In addition to a high index of suspicion from history and physical examination, there are many diagnostic modalities that can increase the probability of identifying a UD. These include voiding cystourethrography, positive pressure urethrography, urethroscopy, endovaginal sonography, transrectal sonography, postvoid radiograph, CT scan, and MRI.14 A trend toward increased use of MRI over the period was observed in our study. This has
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been observed in other studies and currently, MRI is the criterion standard modality for diagnosis of UD.2
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In our cohort, 23.4% women had recurrent UD and 17% required repeat surgery for recurrence. Previous studies have suggested several factors to be associated with the need for repeat surgery for recurrent UD. These include history of previous repair, larger diverticulum (>4 cm), lateral or horseshoe-shaped diverticulum, proximal position, multiple diverticula, and prior pelvic or vaginal surgery.15,16 In our study, we only included primary UD surgeries, so we could not evaluate history of prior surgery of UD as a risk factor. We did not observe location and the size of the UD to be associated with reoperation for recurrence. Interestingly, reoperation for a recurrence was less common in larger UD (>3 cm) in our cohort. This might be explained by the fact that re-operation for recurrence is related to a persistent diverticulum, that could be part of the old UD but was missed in the prior surgery or be just a false observation related to small number of events in our study. Because MRI has higher sensitivity to detect small UD in case of complex or multiple UD as compared with cystourethrogram; the increased use of MRI to diagnose UD may help in preoperative identification of such small lesions. This might explain the lower rates of reoperation for recurrent UD that was noted after 2000, with MRI being the most common diagnostic modality used. However, this theory will need validation by other investigators.
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There is a known association between UD and stress urinary incontinence, and stress urinary incontinence is also a known complication after extensive UD surgery.3,17,18 Unfortunately, due to incomplete follow-up related to continence of the patients included in this study, we could not provide strong evidence to support future practice. However, as shared by Reeves and colleagues,13 in their publication in 2014, there is no current agreement on the best approach for managing stress urinary incontinence and the conduct of a concomitant antiincontinence procedure. In our opinion, this decision has to be individualized based on patient preference and surgeons’ experience until we have more evidence supporting this finding.
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This study is limited by the retrospective design and the lack of data on patient reported outcomes. Due to the nature of the clinical practice in the earlier years of the study, postoperative checkups were not stringently required as compared with current practice. Therefore, no follow-up information was available on 32 of the 114 (28.1%) women who underwent surgery for UD. Nonetheless, follow-up data after surgery was available on the rest of the 82 patients (71.9%). In these 82 women, 10 were only seen once after surgery, 72 had a follow-up more than 6 months with a median follow-up of 12.4 months, and some patients had follow-up data up to 30 years. To address this limitation, we conducted a survival analysis and calculated rates for recurrence and reoperation at 1, 3, and 5 years. In addition, follow-up more than 6 months was available for 12 (85%) of 14 patients with recurrence and 60 (60%) of 100 patients without recurrence which indicates that we may be missing more women with recurrent UD that never came back to our institution for care and may have resulted in higher reported success rate. Another limitation specific to our multiregression analysis for identification of risk factors related to recurrence is the small number of patients who had recurrences (14 of 114). This made the analysis under-powered and limited our ability to include more than 2 risk factors in the final model. We also
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acknowledge that these women may have received subsequent treatment for the condition at a different institution, which may impact our recurrence rates. However, if the patient presented with urinary problems to other specialties within our institution, then the data were collected. Nevertheless, the study duration, including 30 years of data, provided enough numbers to allow an appropriate review of the diagnosis and management of UD in our institution. Finally, this study was conducted in 1 institution in the Upper Midwest, and the results might only be applicable to this specific region of the United States.
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In conclusion, female UD is a rare and unique condition that requires high clinical suspicion for diagnosis and frequently needs multiple surgical interventions for treatment. Good planning for surgery including preoperative MRI might reduce the recurrence and need for reoperation. The results of this study will provide information about the rates of recurrence and reoperation for UD that would be helpful in counselling patients opting to undergo surgery.
Acknowledgments Study data were obtained from the Rochester Epidemiology Project, which is supported by the National Institute on Aging of the National Institutes of Health under Award Number R01AG034676. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
References
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1. El-Nashar SA, Bacon MM, Kim-Fine S, et al. Incidence of female urethral diverticulum: a population-based analysis and literature review. Int Urogynecol J. 2014; 25:73–79. [PubMed: 23857063] 2. Antosh DD, Gutman RE. Diagnosis and management of female urethral diverticulum. Female Pelvic Med Reconstr Surg. 2011; 17:264–271. [PubMed: 22453220] 3. Lee RA. Diverticulum of the female urethra: postoperative complications and results. Obstet Gynecol. 1983; 61:52–58. [PubMed: 6401854] 4. Quiroz, L., Gutman, R. Diagnosis and management of urethral diverticulum in women. In: Brubaker, L., editor. UpToDate. Waltham, MA: UpToDate; 2008. 5. Lee JW, Fynes MM. Female urethral diverticula. Best Pract Res Clin Obstet Gynaecol. 2005; 19:875–893. [PubMed: 16181809] 6. von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007; 370:1453–1457. [PubMed: 18064739] 7. Commission on Professional and Hospital Activities NCfHSUS. H-ICDA; hospital adaptation of ICDA. 2. Ann Arbor, MI: Commission on Professional and Hospital Activities; 1973. 8. Menville JG, Mitchell JD. Diverticulum of the female urethra. J Urol. 1944; 51:411–423. 9. Davis BL, Robinson DG. Diverticula of the female urethra: assay of 120 cases. J Urol. 1970; 104:850–853. [PubMed: 4993407] 10. Tunitsky E, Goldman HB, Ridgeway B. Periurethral mass: a rare and puzzling entity. Obstet Gynecol. 2012; 120:1459–1464. [PubMed: 23168773] 11. Ockrim JL, Allen DJ, Shah PJ, et al. A tertiary experience of urethral diverticulectomy: diagnosis, imaging and surgical outcomes. BJU Int. 2009; 103:1550–1554. [PubMed: 19191783] 12. Ganabathi K, Leach GE, Zimmern PE, et al. Experience with the management of urethral diverticulum in 63 women. J Urol. 1994; 152(5 Pt 1):1445–1452. [PubMed: 7933181] 13. Reeves FA, Inman RD, Chapple CR. Management of symptomatic urethral diverticula in women: a single-centre experience. Eur Urol. 2014; 66:164–172. [PubMed: 24636677]
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14. Patel AK, Chapple CR. Female urethral diverticula. Curr Opin Urol. 2006; 16:248–254. [PubMed: 16770123] 15. Porpiglia F, Destefanis P, Fiori C, et al. Preoperative risk factors for surgery female urethral diverticula. Our experience. Urol Int. 2002; 69:7–11. [PubMed: 12119431] 16. Ingber MS, Firoozi F, Vasavada SP, et al. Surgically corrected urethral diverticula: long-term voiding dysfunction and reoperation rates. Urology. 2011; 77:65–69. [PubMed: 20800882] 17. Mackinnon M, Pratt JH, Pool TL. Diverticulum of the female urethra. Surg Clin North Am. 1959; 39:953–962. [PubMed: 13676011] 18. Spraitz AF Jr, Welch JS. Diverticulum of the female urethra. Am J Obstet Gynecol. 1965; 91:1013–1016. [PubMed: 14268304] 19. Burrows LJ, Howden NL, Meyn L, et al. Surgical procedures for urethral diverticula in women in the United States, 1979–1997. Int Urogynecol J Pelvic Floor Dysfunct. 2005; 16:158–161. [PubMed: 15789149]
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Author Manuscript Author Manuscript FIGURE 1.
Magnetic resonance image of a circumferential urethral diverticulum. This axial T2weighted image shows a saddle-shaped urethral diverticulum.
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FIGURE 2.
Transvaginal diverticulectomy. An 8 french Foley catheter was introduced into the orifice of the diverticulum and was filled with 2 mL of saline. Another Foley catheter was inserted (A), a U vaginal incision was used and a transverse incision of the periurethral tissue was done (B), dissection of the periurethral tissue from the wall of the urethral diverticulum was done (C), complete excision of the diverticular tissue was done (D). Closure of the urethra followed by double layer closure of the periurethral tissues and the vaginal epithelium followed.
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FIGURE 3.
Distal urethral diverticulum (A) surgically treated with distal urethral marsupialization (B).
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Author Manuscript FIGURE 4.
Cumulative rate for recurrence (A) and reoperation for recurrence (B) after primary surgery for treating urethral diverticulum at Mayo from 1980 to 2011.
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TABLE 1
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Baseline Characteristics of Women With Urethral Diverticulum Urethral Diverticulum Cases (N = 164), No. (%) Age: median (range), y
46 (21,83)
Age ≥ 40 y
108 (65.9)
BMI: median (range), BMI ≥ 30
kg/m2
kg/m2
27.8 (18.1,50.1) 46 (28.0)
Race White
142 (86.6)
African American
8 (4.9)
Others
14 (8.5)
Parity, median (range)
2 (0,6)
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Postmenopausal
56 (34.1)
Previous pelvic surgery
56 (34.1)
Recurrent UTI
98 (59.8)
Urinary incontinence
81 (49.4)
Stress
16 (9.9)
Urge
12 (7.3)
Mixed
53 (32.3)
Dysuria
62 (37.8)
Dyspareunia
37 (22.6)
Vaginal mass on examination
55 (33.5)
Diagnosed at time of surgery
9 (5.5)
Preoperative evaluation (% based on 155)
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Urethrogram
58 (37.4)
MRI
52 (33.5)
CT or CT urogram
16 (10.3)
Urodynamic evaluation
40 (25.8)
Cystourethroscopy
121 (78.1)
Author Manuscript Female Pelvic Med Reconstr Surg. Author manuscript; available in PMC 2017 March 27.
Author Manuscript
Author Manuscript
Author Manuscript 4.0% (2.0–12.0) 7.4% (4.1–19.8) 17.0% (8.8–30.2)
At 3 y At 5 y
23.4% (13.9–37.0)
At 1 y
At 5 y
Log-rank test in-between groups.
*
Reoperation for recurrence
7.0% (3.0–16.0) 13.9% (7.4–25.0)
At 3 y
Recurrence
N = 114
At 1 y
Year
Outcome
Whole population
17.0% (8.8–30.2)
7.4% (4.1–19.8)
4.0% (2.0–12.0)
27.8% (14.2–44.8)
18.2% (8.8–34.0)
7.0 (2.0–19.8)
N = 70
40 y
9 (64.3%)
63 (63.0%)
1.2 (0.4–4.2)
0.760
Parity > 2
12 (85.7%)
75 (75.0%)
1.8 (0.4–8.8)
0.442
White vs others
13 (92.9%)
89 (89.0%)
1.5 (0.2–12.4)
0.727
BMI, kg/m2 ≤ 30 vs 3 cm vs ≤ 3 cm
2 (14.3%)
18 (18.0%)
0.7 (0.2–3.6)
0.709
UD distal vs others
2 (14.3%)
15 (15.0%)
0.9 (0.2–4.7)
0.944
Surgery done after 2000 vs before 2000
3 (21.4%)
41 (41.0%)
0.4 (0.1–1.5)
0.159
N (%)
BMI, body mass index.
*
Others include multiple UD, complex, horse shoe UD.
Author Manuscript Author Manuscript Female Pelvic Med Reconstr Surg. Author manuscript; available in PMC 2017 March 27.
El-Nashar et al.
Page 17
TABLE 4
Author Manuscript
Univariate and Multivariate Regression Models for Risk Factors Associated With Recurrence of Urethral Diverticulum After Surgery Risk Factors
Univariate Analysis
Multivariate Analysis*
Dysuria as a presenting symptom
3.8 (1.1–12.8)
4.4 (1.3–17.5)
Vaginal mass identified on examination
0.6 (0.2–1.9)
0.4 (0.1–1.4)
*
Area under the curve for the final multivariate logistic regression model was 0.70.
Author Manuscript Author Manuscript Author Manuscript Female Pelvic Med Reconstr Surg. Author manuscript; available in PMC 2017 March 27.
