Urethral diverticula affect an estimated 0.01–4.7% of female patients [1], with complex forms such as circumferential diverticula representing a subset of these cases. Diverticula symptoms vary, but include urinary frequency, dysuria, dyspareunia, post-void dribbling, vaginal bulge, recurrent urinary tract infections, and hematuria. Circumferential diverticula can pose a significant surgical challenge depending on their size and location. Transvaginal diverticulectomy has been described in the literature, often with a dorsal approach leveraged for anterior access to circumferential diverticula. Urethral transection with end-to-end anastomosis has been reported, with safety and clinical outcomes comparable to those for simple diverticula [2,3].

A 63yo patient was seen for urogynecology consultation after an emergency department visit for severe dysuria. She reported diagnosis of a diverticulum after vaginal delivery over 20 years ago but had remained asymptomatic until 3 months prior to consultation. Her only symptom was severe dysuria with lingering postvoid pain limiting daily activities. Her exam revealed a midline anterior vaginal mass. 

MRI with IV Contrast showed a 3.4cm mid-urethral circumferential diverticulum. Initial management with Pyridium and Atrax provided partial relief. The patient then elected to undergo surgery. The patient was placed in dorsal lithotomy. A large, inverted U incision was made underlaying the diverticulum. After hydrodissection, the vaginal epithelium was then dissected to allow adequate exposure and tension free closure. The periurethral fibromuscular tissue overlaying the diverticulum was then opened transversely at the center of the diverticulum. The fascia was dissected off the diverticulum sharply to allow for the creation of a periurethral flap. The dissection was continued into the bilateral vaginal fornix where the diverticulum extended to the space of Retzius.  

The diverticular sac was opened in the midline and ostium was noted at 6 o’clock. Bilateral diverticular lobes were then dissected off the urethra as laterally as safely possible. The urethra was transected to access the remaining diverticulum anterior to urethra. The remainder to the diverticulum was dissected anteriorly. After completing the excision of the diverticulum, the urethra was reconstructed with an end-to-end anastomosis using multiple 3-0 PDS sutures, working dorsal to ventral. Care was taken to ensure all knots lay outside of urethra. After the urethra was circumferentially closed, the dead space near bilateral pubic rami was closed with interrupted 2-0 PS stitches. Then the overlaying periurethral fascia was closed with care taken to close all dead space, using interrupted 2-0 Vicryl stitches. A urethral leak test performed with no leakage noted. The vaginal flap was then closed using 2-0 Vicryl in a running, locked fashion.

The patient was sent home with a catheter. After 3 weeks, she underwent an x-ray voiding cystourethrogram which was normal with no leakage of contrast noted. She had an uncomplicated post-operative course. At her 8-week post-op visit, she denies concerns with resolution of her pain. She had no incontinence, but mild urgency that was minimally bothersome. She underwent PFPT with improvement in symptoms.

A mid-urethral circumferential diverticulum can be successfully and safely excised transvaginal by utilizing an approach incorporating urethral transection with end-to-end anastomosis.

El-Nashar, S. A., Bacon, M. M., Kim-Fine, S., Weaver, A. L., Gebhart, J. B., & Klingele, C. J. (2014). Incidence of female urethral diverticulum: a population-based analysis and literature review. International urogynecology journal, 25(1), 73-79.?
?  Nickles, S. W., Ikwuezunma, G., MacLachlan, L., El-Zawahry, A., Rames, R., & Rovner, E. (2014). Simple vs complex urethral diverticulum: presentation and outcomes. Urology, 84(6), 1516-1520.
Rovner, E. S., & Wein, A. J. (2003). Diagnosis and reconstruction of the dorsal or circumferential urethral diverticulum. The Journal of urology, 170(1), 82-86.?