Urethral Diverticulectomy In A Pregnant

Objectives: Urethral diverticulum is a rare complication in pregnancy. Generally, pregnant patients with urethral diverticulum are managed conservatively with surgery performed after delivery. In our video, we demonstrate the successful surgical repair of a symptomatic large urethral diverticulum in a woman who is 25 weeks pregnant.

Methods: We present a video of a 29-year-old G7P5015 who presented with large, symptomatic urethral diverticulum at 23 weeks of pregnancy. A 5 x 4 x 5 cm mass was seen on arising from the distal urethra. After long discussion of the risks and benefits of conservative management versus excision during the second trimester, and after MFM consultation, the patient elected to proceed with surgical excision during the second trimester. Her pregnancy was notable for microcytic anemia. Due to her gestational age of 25 weeks, fetal monitoring was performed throughout the case and was reassuring. Cystoscopy demonstrated normal urethra and bladder. Foley catheter was placed within the bladder. A wide based inverted “U” flap with the apex at the distal third of the vagina was delineated. Lidocaine with epinephrine was used to hydrodissect the sub-epithelial tissue. The sub-epithelial connective tissue was dissected along the predetermined “U” flap. Next, flaps of periurethral fascia were dissected from the diverticular sac. The diverticular sac was dissected from the periurethral fascia and removed. The diverticular ostium was identified, and closed with 2-0 braided suture. Injection of water into the urethra demonstrated a water-tight closure of the diverticular ostium. The periurethral fascia was closed over the urethra in two layers, with the left flap sutured across the urethra and the right flap sutured across the left flap and the urethra. The anterior vaginal wall mucosa was then closed with 2-0 braided suture. Her postoperative course was complicated by regular contractions which did not cause labor and anemia requiring blood transfusion. By post-operative week 7, the surgical site was well healed with no evidence of recurrent diverticulum. She went into spontaneous labor at 40w4d and delivered vaginally with no disruption of the surgical site and no perineal lacerations.

Clinical Relevance: Our video demonstrates the successful surgical removal of urethral diverticulum in a woman who is 25 weeks pregnant. Management of urethral diverticulum during pregnancy generally involves conservative management with antibiotics, aspiration, or incision and drainage. Case reports of urethral diverticulectomy performed during pregnancy generally mandate cesarean section as delivery modality after diverticulum excision. Our video demonstrates that it is possible to manage selective patients definitively during the second trimester while allowing successful vaginal delivery without surgical site complications.