Female Urethral Diverticulae: Difference between revisions

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== Background ==

* '''~~~~Definition of female urethral diverticulum: a variably sized~~''' '''~~urine-filled periurethral cystic structure adjacent to the urethra within the confines of the pelvic fascia, connected to the urethra via an ostium'''

* '''Definition of female urethral diverticulum: a variably sized urine-filled periurethral cystic structure adjacent to the urethra within the confines of the pelvic fascia, connected to the urethra via an ostium'''

== Epidemiology ==

Line 68:

=== History and Physical Exam ===

* '''History~~'''~~

** '''Signs and Symptoms'''

==== History ====

***'''Notable for a range of clinical presentations ranging from completely asymptomatic (up to 20% of patients), incidentally noted lesions on physical examination or imaging, to very debilitating, painful vaginal masses associated with incontinence, stones, severe dyspareunia, and/or tumors'''

* '''Signs and Symptoms'''

*** '''Most common symptoms (3):'''

**'''Notable for a range of clinical presentations ranging from completely asymptomatic (up to 20% of patients), incidentally noted lesions on physical examination or imaging, to very debilitating, painful vaginal masses associated with incontinence, stones, severe dyspareunia, and/or tumors'''

***#'''Storage LUTS'''

** '''Most common symptoms (3):'''

***#'''Pain'''

**#'''Storage LUTS'''

***#'''Infection'''

**#'''Pain'''

***##'''Multiple bouts of recurrent cystitis should alert the possibility of a urethral diverticulum'''

**#'''Infection'''

***##* Reinfection, inflammation, and recurrent obstruction of the neck of the cavity are theorized to result in patient symptoms and enlargement of the diverticulum. This expansion occurs most commonly ventrally, resulting in the classic anterior vaginal wall mass palpated on physical examination in some patients with UD. However, it is important to note that these may also expand laterally, or even dorsally, about the urethra. Eventually, the abscess cavity ruptures into the urethral lumen, resulting in the communication between the UD and the urethral lumen.

**#*'''Multiple bouts of recurrent cystitis should alert the possibility of a urethral diverticulum'''

*** '''Other symptoms (8):'''

**#** Reinfection, inflammation, and recurrent obstruction of the neck of the cavity are theorized to result in patient symptoms and enlargement of the diverticulum. This expansion occurs most commonly ventrally, resulting in the classic anterior vaginal wall mass palpated on physical examination in some patients with UD. However, it is important to note that these may also expand laterally, or even dorsally, about the urethra. Eventually, the abscess cavity ruptures into the urethral lumen, resulting in the communication between the UD and the urethral lumen.

***#'''Dysuria'''

** '''Other symptoms (8):'''

***#'''Hematuria'''

**#'''Dysuria'''

***#'''Post-void dribbling'''

**#'''Hematuria'''

***#'''Urinary retention'''

**#'''Post-void dribbling'''

***#'''Incontinence (stress or urge)'''

**#'''Urinary retention'''

***#'''Dyspareunia'''

**#'''Incontinence (stress or urge)'''

***#'''Vaginal mass'''

**#'''Dyspareunia'''

***#*'''Patients may present with complaints of a tender or nontender anterior vaginal wall mass, which upon gentle compression may reveal retained urine or purulent discharge per the urethral meatus.'''

**#'''Vaginal mass'''

***#'''Vaginal discharge'''

**#*'''Patients may present with complaints of a tender or nontender anterior vaginal wall mass, which upon gentle compression may reveal retained urine or purulent discharge per the urethral meatus.'''

***Vaginal pruritis is not a symptom associated with urethral diverticulum

**#'''Vaginal discharge'''

*** '''Size of the UD does not correlate with symptoms'''

**Vaginal pruritis is not a symptom associated with urethral diverticulum

* '''Physical ~~exam'''~~

** '''Size of the UD does not correlate with symptoms'''

** '''Genitals'''

***'''Urethra may be gently “stripped” or “milked” distally in an attempt to express purulent material or urine from within the UD'''

==== Physical Exam ====

* '''Genitals'''

**'''Urethra may be gently “stripped” or “milked” distally in an attempt to express purulent material or urine from within the urethral diverticulum'''

=== Laboratory ===

* '''Urinalysis +/- culture'''

* '''Urinalysis +/- culture'''

[[File:TAJU A 1589748 F0005 OC.jpg|alt=Cystoscopy with visualisation of urethral diverticulum ostium.|thumb|Cystoscopy with visualization of urethral diverticulum ostium at the 4 o’clock position just proximal to the mid-urethral sphincter. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6583718/ Source]]]

=== ~~'''~~Imaging~~'''~~ ===

=== Imaging ===

* '''No single study can be considered the gold standard'''

*'''Options (5)'''

*'''Options (5)'''

*#'''Double-balloon positive pressure urethrography'''

*#'''Double-balloon positive pressure urethrography'''

*#'''VCUG'''

*#'''VCUG'''

*#'''Intravenous urography'''

*#'''Intravenous urography'''

*#'''US'''

*#'''US'''

*#'''MRI'''

*#'''MRI'''

* '''Imaging cannot reliably diagnose malignancy in a urethral diverticulum'''

=== Other ===

* '''~~Endoscopy~~'''

* '''Cystourethroscopy'''

** Patients with UD are often highly symptomatic, and endoscopic examination can be very difficult to initiate or complete without anesthesia.

**Patients with UD are often highly symptomatic, and endoscopic examination can be very difficult to initiate or complete without anesthesia.

** The UD ostium can be very difficult to identify in some patients

** Stones within the urethral diverticulum may be diagnosed 4-10% of the time

== Management: observation vs. intervention ==

Options

*Observation

=== Options ===

*Intervention

#'''Observation'''

**Surgical interventions

#'''Intervention'''

* '''~~Observation~~'''

#*'''Surgical interventions (5):'''

** Very little is known regarding the natural history of untreated UD. For these reasons, and because of the lack of symptoms in selected cases, some patients may not desire surgical therapy.

#*#'''Excision with reconstruction (most common surgical approach)'''

** '''There are reports of malignancy arising in UD. Therefore,''' '''patients should be counselled on the risk of malignancy with nonoperative management'''

#*# '''Marsupialization (transurethral and open)'''

** Patients electing nonoperative management can be treated with low-dose antibacterial suppressants and digital stripping of the anterior vaginal wall following micturition to prevent postvoid dribbling and reduce the risk of UTI resulting from stasis in the UD.

#*# '''Endoscopic unroofing'''

** Whether long-term surveillance is required in these patients, with periodic physical examinations, radiographic imaging, or endoscopic examination, is unknown.

#*# '''Fulguration'''

* '''Intervention~~'''~~

#*# '''Incision and obliteration with oxidized cellulose or polytetrafluoroethylene'''

** '''Symptomatic patients, including those with dysuria, dyspareunia, refractory bothersome postvoid dribbling, recurrent UTIs, and pelvic pain, may be offered surgical excision.'''

** '''The location and competence of the urethral sphincters have important implications when considering surgical repair of UD because of the anatomic overlap of these two entities.'''

==== Observation ====

*** '''Varying degrees of sphincteric compromise may exist prior to intervention because of the location of diverticulum relative to the proximal and distal urinary sphincter mechanisms, or sphincteric compromise may coexist with UD as a result of other factors.'''

* Very little is known regarding the natural history of untreated UD. For these reasons, and because of the lack of symptoms in selected cases, some patients may not desire surgical therapy.

** '''Options:~~'''~~

* '''There are reports of malignancy arising in UD. Therefore,''' '''patients should be counselled on the risk of malignancy with nonoperative management'''

~~***~~ '''Excision with reconstruction (most common surgical approach)'''

* Patients electing nonoperative management can be treated with low-dose antibacterial suppressants and digital stripping of the anterior vaginal wall following micturition to prevent postvoid dribbling and reduce the risk of UTI resulting from stasis in the UD.

~~***~~ '''Marsupialization (transurethral and open)'''

* Whether long-term surveillance is required in these patients, with periodic physical examinations, radiographic imaging, or endoscopic examination, is unknown.

~~***~~ '''Endoscopic unroofing'''

~~***~~ '''Fulguration'''

==== Intervention ====

~~***~~ '''Incision and obliteration with oxidized cellulose or polytetrafluoroethylene'''

** '''Principles ~~of urethral diverticulectomy~~ (8):'''

===== Indications =====

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

**# '''Preservation of the periurethral fascia'''

*'''Symptomatic patients, including those with dysuria, dyspareunia, refractory bothersome postvoid dribbling, recurrent UTIs, and pelvic pain, may be offered surgical excision.'''

**# Identification and excision of the neck, or ostium, of the UD

**# Removal of entire UD wall or sac (mucosa)

===== Options (5): =====

**# Watertight urethral closure

# '''Excision (urethral diverticulectomy) with reconstruction (most common surgical approach)'''

**# Multilayered, nonoverlapping closure with absorbable suture

# '''Marsupialization (transurethral and open)'''

**# Closure of dead space

# '''Endoscopic unroofing'''

**# Preservation or creation of continence

# '''Fulguration'''

** '''Technique'''

# '''Incision and obliteration with oxidized cellulose or polytetrafluoroethylene'''

***'''Successful excision of a urethral diverticulum involves removal of the ostium that connects with the urethral lumen. This often results in direct visualization of the urethral catheter within the urethral lumen during surgery.''' The urethral defect is closed primarily with absorbable suture in a watertight fashion following completion of the removal of the sac.

**** Additional procedures such as buccal mucosal urethroplasty, Martius flap, or vaginal flaps are not necessary to close the urethra.

====== Urethral Diverticulectomy ======

** '''~~Complications~~'''

**# '''Recurrent UTIs'''

* '''Principles (8):'''

**# '''Urinary incontinence'''

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

**# '''Recurrent urethral diverticulum'''

# '''Preservation of the periurethral fascia'''

**# '''Urethrovaginal fistula (uncommon)'''

# Identification and excision of the neck, or ostium, of the UD

** '''Size of diverticulum does correlated with risk of recurrence following surgical repair'''

# Removal of entire UD wall or sac (mucosa)

**Postoperatively, some patients will have persistence or recurrence of their preoperative symptoms.

# Watertight urethral closure

** '''Synthetic materials (e.g., mid-urethral polypropylene mesh) should not be used in an anti-incontinence procedure synchronously with UD surgery because of the potentially increased risk of urethral erosion and infection'''

# Multilayered, nonoverlapping closure with absorbable suture

# Closure of dead space

# Preservation or creation of continence

* '''The location and competence of the urethral sphincters have important implications when considering surgical repair of urethral diverticulectomy because of the anatomic overlap of these two entities.'''

** '''Varying degrees of sphincteric compromise may exist prior to intervention because of the location of diverticulum relative to the proximal and distal urinary sphincter mechanisms, or sphincteric compromise may coexist with UD as a result of other factors.'''

*'''Technique'''

**'''Successful excision of a urethral diverticulum involves removal of the ostium that connects with the urethral lumen. This often results in direct visualization of the urethral catheter within the urethral lumen during surgery.''' The urethral defect is closed primarily with absorbable suture in a watertight fashion following completion of the removal of the sac.

*** Additional procedures such as buccal mucosal urethroplasty, Martius flap, or vaginal flaps are not necessary to close the urethra.

**'''Synthetic materials (e.g., mid-urethral polypropylene mesh) should not be used in an anti-incontinence procedure synchronously with urethral diverticulum surgery because of the potentially increased risk of urethral erosion and infection'''

* '''Adverse Events'''

*# '''Recurrent UTIs'''

*# '''Urinary incontinence'''

*# '''Recurrent urethral diverticulum'''

*# '''Urethrovaginal fistula (uncommon)'''

* '''Size of diverticulum does correlated with risk of recurrence following surgical repair'''

*Postoperatively, some patients will have persistence or recurrence of their preoperative symptoms.

== Questions ==

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* Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 90

*[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6583718/ Greiman, Alyssa K., Jennifer Rolef, and Eric S. Rovner. "Urethral diverticulum: a systematic review." ''Arab journal of urology'' 17.1 (2019): 49-57.]

@@ Line 1: / Line 1: @@
 == Background ==
-* '''<span style="color:#ff0000">Definition of female urethral diverticulum: a variably sized''' '''urine-filled periurethral cystic structure adjacent to the urethra within the confines of the pelvic fascia, connected to the urethra via an ostium'''
+* '''Definition of female urethral diverticulum: a variably sized urine-filled periurethral cystic structure adjacent to the urethra within the confines of the pelvic fascia, connected to the urethra via an ostium'''
 == Epidemiology ==
@@ Line 68: / Line 68: @@
 === History and Physical Exam ===
-* '''History'''
-** '''Signs and Symptoms'''
+==== History ====
-***'''Notable for a range of clinical presentations ranging from completely asymptomatic (up to 20% of patients), incidentally noted lesions on physical examination or imaging, to very debilitating, painful vaginal masses associated with incontinence, stones, severe dyspareunia, and/or tumors'''
+* '''<span style="color:#ff0000">Signs and Symptoms'''
-*** '''Most common symptoms (3):'''
+**'''Notable for a range of clinical presentations ranging from completely asymptomatic (up to 20% of patients), incidentally noted lesions on physical examination or imaging, to very debilitating, painful vaginal masses associated with incontinence, stones, severe dyspareunia, and/or tumors'''
-***#'''Storage LUTS'''
+** '''<span style="color:#ff0000">Most common symptoms (3):'''
-***#'''Pain'''
+**#'''<span style="color:#ff0000">Storage LUTS'''
-***#'''Infection'''
+**#'''<span style="color:#ff0000">Pain'''
-***##'''Multiple bouts of recurrent cystitis should alert the possibility of a urethral diverticulum'''
+**#'''<span style="color:#ff0000">Infection'''
-***##* Reinfection, inflammation, and recurrent obstruction of the neck of the cavity are theorized to result in patient symptoms and enlargement of the diverticulum. This expansion occurs most commonly ventrally, resulting in the classic anterior vaginal wall mass palpated on physical examination in some patients with UD. However, it is important to note that these may also expand laterally, or even dorsally, about the urethra. Eventually, the abscess cavity ruptures into the urethral lumen, resulting in the communication between the UD and the urethral lumen.
+**#*'''<span style="color:#ff0000">Multiple bouts of recurrent cystitis should alert the possibility of a urethral diverticulum'''
-*** '''Other symptoms (8):'''
+**#** Reinfection, inflammation, and recurrent obstruction of the neck of the cavity are theorized to result in patient symptoms and enlargement of the diverticulum. This expansion occurs most commonly ventrally, resulting in the classic anterior vaginal wall mass palpated on physical examination in some patients with UD. However, it is important to note that these may also expand laterally, or even dorsally, about the urethra. Eventually, the abscess cavity ruptures into the urethral lumen, resulting in the communication between the UD and the urethral lumen.
-***#'''Dysuria'''
+** '''<span style="color:#ff0000">Other symptoms (8):'''
-***#'''Hematuria'''
+**#'''<span style="color:#ff0000">Dysuria'''
-***#'''Post-void dribbling'''
+**#'''<span style="color:#ff0000">Hematuria'''
-***#'''Urinary retention'''
+**#'''<span style="color:#ff0000">Post-void dribbling'''
-***#'''Incontinence (stress or urge)'''
+**#'''<span style="color:#ff0000">Urinary retention'''
-***#'''Dyspareunia'''
+**#'''<span style="color:#ff0000">Incontinence (stress or urge)'''
-***#'''Vaginal mass'''
+**#'''<span style="color:#ff0000">Dyspareunia'''
-***#*'''Patients may present with complaints of a tender or nontender anterior vaginal wall mass, which upon gentle compression may reveal retained urine or purulent discharge per the urethral meatus.'''
+**#'''<span style="color:#ff0000">Vaginal mass'''
-***#'''Vaginal discharge'''
+**#*'''Patients may present with complaints of a tender or nontender anterior vaginal wall mass, which upon gentle compression may reveal retained urine or purulent discharge per the urethral meatus.'''
-***Vaginal pruritis is not a symptom associated with urethral diverticulum
+**#'''<span style="color:#ff0000">Vaginal discharge'''
-*** '''Size of the UD does not correlate with symptoms'''
+**Vaginal pruritis is not a symptom associated with urethral diverticulum
-* '''Physical exam'''
+** '''Size of the UD does not correlate with symptoms'''
-** '''Genitals'''
-***'''Urethra may be gently “stripped” or “milked” distally in an attempt to express purulent material or urine from within the UD'''
+==== Physical Exam ====
+* '''<span style="color:#ff0000">Genitals'''
+**'''<span style="color:#ff0000">Urethra may be gently “stripped” or “milked” distally in an attempt to express purulent material or urine from within the urethral diverticulum'''
 === Laboratory ===
-* '''Urinalysis +/- culture'''
+* '''<span style="color:#ff0000">Urinalysis +/- culture'''
+[[File:TAJU A 1589748 F0005 OC.jpg|alt=Cystoscopy with visualisation of urethral diverticulum ostium.|thumb|Cystoscopy with visualization of urethral diverticulum ostium at the 4 o’clock position just proximal to the mid-urethral sphincter. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6583718/ Source]]]
-=== '''Imaging''' ===
+=== Imaging ===
 * '''No single study can be considered the gold standard'''
-*'''Options (5)'''
+*'''<span style="color:#ff0000">Options (5)'''
-*#'''Double-balloon positive pressure urethrography'''
+*#'''<span style="color:#ff0000">Double-balloon positive pressure urethrography'''
-*#'''VCUG'''
+*#'''<span style="color:#ff0000">VCUG'''
-*#'''Intravenous urography'''
+*#'''<span style="color:#ff0000">Intravenous urography'''
-*#'''US'''
+*#'''<span style="color:#ff0000">US'''
-*#'''MRI'''
+*#'''<span style="color:#ff0000">MRI'''
 * '''Imaging cannot reliably diagnose malignancy in a urethral diverticulum'''
 === Other ===
-* '''Endoscopy'''
+* '''<span style="color:#ff0000">Cystourethroscopy'''
-** Patients with UD are often highly symptomatic, and endoscopic examination can be very difficult to initiate or complete without anesthesia.
+**Patients with UD are often highly symptomatic, and endoscopic examination can be very difficult to initiate or complete without anesthesia.
 ** The UD ostium can be very difficult to identify in some patients
 ** Stones within the urethral diverticulum may be diagnosed 4-10% of the time
 == Management: observation vs. intervention ==
-Options
-*Observation
+=== Options ===
-*Intervention
+#'''<span style="color:#ff0000">Observation'''
-**Surgical interventions
+#'''<span style="color:#ff0000">Intervention'''
-* '''Observation'''
+#*'''<span style="color:#ff0000">Surgical interventions (5):'''
-** Very little is known regarding the natural history of untreated UD. For these reasons, and because of the lack of symptoms in selected cases, some patients may not desire surgical therapy.
+#*#'''<span style="color:#ff0000">Excision with reconstruction (most common surgical approach)'''
-** '''There are reports of malignancy arising in UD. Therefore,''' '''patients should be counselled on the risk of malignancy with nonoperative management'''
+#*# '''<span style="color:#ff0000">Marsupialization (transurethral and open)'''
-** Patients electing nonoperative management can be treated with low-dose antibacterial suppressants and digital stripping of the anterior vaginal wall following micturition to prevent postvoid dribbling and reduce the risk of UTI resulting from stasis in the UD.
+#*# '''<span style="color:#ff0000">Endoscopic unroofing'''
-** Whether long-term surveillance is required in these patients, with periodic physical examinations, radiographic imaging, or endoscopic examination, is unknown.
+#*# '''<span style="color:#ff0000">Fulguration'''
-* '''Intervention'''
+#*# '''<span style="color:#ff0000">Incision and obliteration with oxidized cellulose or polytetrafluoroethylene'''
-** '''Symptomatic patients, including those with dysuria, dyspareunia, refractory bothersome postvoid dribbling, recurrent UTIs, and pelvic pain, may be offered surgical excision.'''
-** '''The location and competence of the urethral sphincters have important implications when considering surgical repair of UD because of the anatomic overlap of these two entities.'''
+==== Observation ====
-*** '''Varying degrees of sphincteric compromise may exist prior to intervention because of the location of diverticulum relative to the proximal and distal urinary sphincter mechanisms, or sphincteric compromise may coexist with UD as a result of other factors.'''
+* Very little is known regarding the natural history of untreated UD. For these reasons, and because of the lack of symptoms in selected cases, some patients may not desire surgical therapy.
-** '''Options:'''
+* '''There are reports of malignancy arising in UD. Therefore,''' '''patients should be counselled on the risk of malignancy with nonoperative management'''
-*** '''Excision with reconstruction (most common surgical approach)'''
+* Patients electing nonoperative management can be treated with low-dose antibacterial suppressants and digital stripping of the anterior vaginal wall following micturition to prevent postvoid dribbling and reduce the risk of UTI resulting from stasis in the UD.
-*** '''Marsupialization (transurethral and open)'''
+* Whether long-term surveillance is required in these patients, with periodic physical examinations, radiographic imaging, or endoscopic examination, is unknown.
-*** '''Endoscopic unroofing'''
-*** '''Fulguration'''
+==== Intervention ====
-*** '''Incision and obliteration with oxidized cellulose or polytetrafluoroethylene'''
-** '''Principles of urethral diverticulectomy (8):'''
+===== Indications =====
-**# Mobilization of a well-vascularized anterior vaginal wall flap(s)
-**# '''Preservation of the periurethral fascia'''
+*'''<span style="color:#ff0000">Symptomatic patients, including those with dysuria, dyspareunia, refractory bothersome postvoid dribbling, recurrent UTIs, and pelvic pain, may be offered surgical excision.'''
-**# Identification and excision of the neck, or ostium, of the UD
-**# Removal of entire UD wall or sac (mucosa)
+===== Options (5): =====
-**# Watertight urethral closure
+# '''<span style="color:#ff0000">Excision (urethral diverticulectomy) with reconstruction (most common surgical approach)'''
-**# Multilayered, nonoverlapping closure with absorbable suture
+# '''<span style="color:#ff0000">Marsupialization (transurethral and open)'''
-**# Closure of dead space
+# '''<span style="color:#ff0000">Endoscopic unroofing'''
-**# Preservation or creation of continence
+# '''<span style="color:#ff0000">Fulguration'''
-** '''Technique'''
+# '''<span style="color:#ff0000">Incision and obliteration with oxidized cellulose or polytetrafluoroethylene'''
-***'''Successful excision of a urethral diverticulum involves removal of the ostium that connects with the urethral lumen. This often results in direct visualization of the urethral catheter within the urethral lumen during surgery.''' The urethral defect is closed primarily with absorbable suture in a watertight fashion following completion of the removal of the sac.
-**** Additional procedures such as buccal mucosal urethroplasty, Martius flap, or vaginal flaps are not necessary to close the urethra.
+====== Urethral Diverticulectomy ======
-** '''Complications'''
-**# '''Recurrent UTIs'''
+* '''Principles (8):'''
-**# '''Urinary incontinence'''
+# Mobilization of a well-vascularized anterior vaginal wall flap(s)
-**# '''Recurrent urethral diverticulum'''
+# '''Preservation of the periurethral fascia'''
-**# '''Urethrovaginal fistula (uncommon)'''
+# Identification and excision of the neck, or ostium, of the UD
-** '''Size of diverticulum does correlated with risk of recurrence following surgical repair'''
+# Removal of entire UD wall or sac (mucosa)
-**Postoperatively, some patients will have persistence or recurrence of their preoperative symptoms.
+# Watertight urethral closure
-** '''Synthetic materials (e.g., mid-urethral polypropylene mesh) should not be used in an anti-incontinence procedure synchronously with UD surgery because of the potentially increased risk of urethral erosion and infection'''
+# Multilayered, nonoverlapping closure with absorbable suture
+# Closure of dead space
+# Preservation or creation of continence
+* '''The location and competence of the urethral sphincters have important implications when considering surgical repair of urethral diverticulectomy because of the anatomic overlap of these two entities.'''
+** '''Varying degrees of sphincteric compromise may exist prior to intervention because of the location of diverticulum relative to the proximal and distal urinary sphincter mechanisms, or sphincteric compromise may coexist with UD as a result of other factors.'''
+*'''Technique'''
+**'''Successful excision of a urethral diverticulum involves removal of the ostium that connects with the urethral lumen. This often results in direct visualization of the urethral catheter within the urethral lumen during surgery.''' The urethral defect is closed primarily with absorbable suture in a watertight fashion following completion of the removal of the sac.
+*** Additional procedures such as buccal mucosal urethroplasty, Martius flap, or vaginal flaps are not necessary to close the urethra.
+**'''<span style="color:#ff0000">Synthetic materials (e.g., mid-urethral polypropylene mesh) should not be used in an anti-incontinence procedure synchronously with urethral diverticulum surgery because of the potentially increased risk of urethral erosion and infection'''
+* '''<span style="color:#ff0000">Adverse Events'''
+*# '''<span style="color:#ff0000">Recurrent UTIs'''
+*# '''<span style="color:#ff0000">Urinary incontinence'''
+*# '''<span style="color:#ff0000">Recurrent urethral diverticulum'''
+*# '''<span style="color:#ff0000">Urethrovaginal fistula (uncommon)'''
+* '''Size of diverticulum does correlated with risk of recurrence following surgical repair'''
+*Postoperatively, some patients will have persistence or recurrence of their preoperative symptoms.
 == Questions ==
@@ Line 195: / Line 213: @@
 * Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, chap 90
+*[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6583718/ Greiman, Alyssa K., Jennifer Rolef, and Eric S. Rovner. "Urethral diverticulum: a systematic review." ''Arab journal of urology'' 17.1 (2019): 49-57.]