Introduction: Resection of complex urethral diverticula in women followed by functional reconstruction is often challenging. Since the diverticulum communicates with the urethra, complete resection always results in a smaller or larger urethral defect. Clearly, such a defect has to be reconstructed. Additionally, care should be taken not to damage the urethral sphincteric mechanism. This is particularly important in case of a (near)circular diverticulum straddling the dorsal (pubic) aspect of the urethra, where the omega-shaped rhabdosfincter is thickest. The aim of this video is to show a technique that obviates extensive dorsal dissection by leaving in situ a short tunnel of the diverticulum which is subsequently plugged with a pulled-through Martius flap to prevent recurrence.
Methods: Preoperative urethroscopy in combination with MRI imaging shows the position of any orifice between urethral lumen and diverticulum. A step-by-step technique of resection of the complex urethral diverticulum is shown with emphasis on important anatomical landmarks. MRI images help to create a road map for the surgery. Surgical steps are illustrated with schematic anatomical drawings. The use of an Auvard speculum and Scott retractor to optimize exposure is shown.
Results: An inverted U-shaped incision of the vaginal wall is made after hydrodissection of the plane between the vaginal wall and the periurethral fascia with lidocaine-adrenalin solution. The periurethral fascia is incised transversely and the diverticulum is released from its surroundings on the ventral and lateral aspect. The diverticulum is lifted of the urethra distally and proximally. Since the diverticulum is ventrally incomplete, first the left sided part is opened and dissected of the urethra until the level of the dorsal “tunnel”. This procedure is repeated on the right side. After threading a vessel loop through the dorsal tunnel, both parts are removed, leaving the dorsal tunnel intact. Any urethral defect is now reconstructed and a Martius flap is pulled through the tunnel and wrapped around the urethra.
Conclusions: Surgical excision of near-circular female urethral diverticulum leaving a short dorsal tunnel in situ, followed by circular urethral wrap with Martius flap, minimizes damage to the rhabdosphincter which is thickest dorsally. The Martius flap pull-through plugs the dorsal tunnel and in this way prevents recurrence. The vascularized Martius flap supports the urethral reconstruction and serves as bulk material in case a fascia sling would be necessary in the presence of de novo stress incontinence.
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