This is the first large-scale clinical study to specifically focus on female circumferential urethral diverticulum (UD), a rare anatomical variant that encircles the urethra and poses unique surgical challenges. Female UD, with an incidence of 0.02% to 6.00%, often presents with recurrent urinary tract infections, post-void dribbling, and dyspareunia, significantly compromising quality of life. Previous reports suggest that although circumferential UD has a lower incidence, it carries a significantly higher postoperative recurrence rate1. This may be because traditional surgical approaches are difficult to reach all areas in a circumferential UD2,3. To address this, we developed an original surgical technique: transvaginal diverticular wall filling and covering. This technique effectively closes the dorsal urethral diverticulum cavity and reinforces the coverage of the diverticular ostium using demucosalized diverticular wall flaps. This study aims to evaluate the efficacy and safety of this innovative technique in managing circumferential UD.

We retrospectively analyzed 70 female patients diagnosed with circumferential UD who underwent the novel surgical technique between March 2019 and March 2024. Inclusion criteria were imaging-confirmed circumferential UD and complete clinical documentation. Patients with prior reconstructive pelvic surgeries or transvaginal surgeries, and those suffering from uterine prolapse, vaginitis, vaginal tumors, and abnormal coagulation function were excluded. Surgical procedures are as follow: After general anesthesia, the patient is placed in a dorsal lithotomy position. A reverse U-shaped incision is made in the anterior vaginal wall, and the diverticulum wall is carefully exposed. After making a longitudinal incision on the diverticulum wall to release purulent fluid, two pedicled tissue flaps were preserved. Then diverticulum ostium is identified using high-pressure retrograde urethral irrigation, and closed with sutures. The mucosal surface of the diverticulum was ablated using electrocautery. One tissue flap was pulled from the posterior urethra to the opposite side, sutured in place, to fill the diverticular cavity behind the urethra. Another tissue flap was then pulled from the front of the urethra to the opposite side, sutured and fixed to cover the diverticulum ostium. The vaginal wall is then closed (Figure 1). The urethral catheter was retained for 3-4 weeks. All patients were followed up at one month and re-evaluated at 12 months to assess surgical outcomes, recurrence, and complications. Statistical analysis was performed using SPSS 25.0 with p<0.05 considered significant.

The mean age of patients was 46.33 ± 7.90 years, with a mean follow-up duration of 31.27 ± 13.92 months. Preoperative symptoms included recurrent urinary tract infections (59%), vaginal mass (49%), frequency (44%), and dyspareunia (31%). Mean surgery time was 74.81 ± 17.22 minutes. Postoperatively, symptom improvement was achieved in 64 patients (91%). Ten patients (14%) experienced recurrence, four of whom underwent reoperation. Three patients had persistent stress urinary incontinence (SUI) and three developed de novo SUI. Dyspareunia resolved in 86% of pre-affected individuals, and sexual function improved in 66% of the cohort. About 93% of patients reporting satisfaction. No urethrovaginal fistula or urinary retention occurred.

The transvaginal diverticular wall filling and covering technique proved to be a safe and effective alternative to conventional excision methods, particularly for complex circumferential UD. This method achieved excellent long-term outcomes, low recurrence rate, and improved sexual function with a low complication rate.

This study presents the first large-cohort data on the treatment of female circumferential UD using a novel transvaginal filling and covering technique. Long-term efficacy and safety of this procedure is being observed.

Han DH, Jeong YS, Choo MS, Lee KS. Outcomes of surgery of female urethral diverticula classified using magnetic resonance imaging. Eur Urol. 2007;51(6):1664-1670. doi:10.1016/j.eururo.2007.01.103
Mehta S, Suh C, Harmanli O. Circumferential urethral diverticulum: a surgical conundrum. Int Urogynecol J. 2020;31(12):2683-2685. doi:10.1007/s00192-020-04359-5
Crescenze IM, Goldman HB. Female Urethral Diverticulum: Current Diagnosis and Management. Curr Urol Rep. 2015;16(10):71. doi:10.1007/s11934-015-0540-8