Chapters Transcript Video The Urethral Diverticulum - From Symptoms to Surgical Outcomes Benjamin Brucker, MD So I have the honor to introduce our, uh, ERPs visiting professor, Doctor Bren Brucker. Um, he is a professor at the, um, New York University, NYU, uh, and so he, um, made a trip down to Miami, uh, to spend the day, spend the day with us yesterday and then give us a talk today. So he was born and raised in the historic town of Scarsdale, New York, and he has since returned there. Um, now, um, he completed his undergraduate education at Cornell University in upstate New York, and uh he did his medical school and neurology residency at University of Pennsylvania at Penn with our very own Dr. Alan Ween. Uh, so this was, um, Doctor Ween's, uh, farewell, uh, when he officially retired from Penn, um, the Sufu dedicated a night to him, um, and, uh, Doctor Brucker was obviously in attendance, and he completed his fellowship at NYU and FPRS, and then he joined faculty in 2012. Um, he has been tremendously dedicated toufu. Uh, this is Doctor Vic Nitti, his longtime mentor, um, who was previously at NYU. And another picture over here on the right is when um Dr. Brecker won the Paul Zinki Award in 2022. Um, this award has been around since 1979 and is given to a um Sufu member who has made significant contributions to our field through basic and clinical research. He's currently a member at large for Sufu um executive board, and he chairs several committees, including the early career committee. So he's um has also been very dedicated to teaching. So he's associate residency program director from 2015 to 2018 and he um took over uh the um directorship of the ERPS Fellowship uh and division director of um of ERPS in 2018 after um Doctor Nitty went to uh California. And uh he has been a mentor for a large number of urology residents at NYU who have pursued um our specialty because of him, including our very own Doctor Cyan. So here he's pictured even with her, um, Doctor Palmerola, Doctor Palmerola was his former fellow. So Doctor was his former resident, uh, at NYU and then Doctor Palmerola, um, our new faculty member, was his former fellow at NYU as well. So we have lots of ties to Doctor Brecker, so we're so happy that he's here. Uh, he's done a tremendous amount in research. Um, so when I think of Doctor Barker, I think he's done a great job with, uh, industry relationships. Um, he's been a principal investigator with uh numerous multi-center trials, um, from Botox, um, to different device-based therapies. For neuromodulation. He's authored more than 200 peer reviewed publications, reviews, and book chapters. He's the associate editor of neurourology and Neurodynamics, and really his work has been focused on uh neurologic conditions and pelvic floor dysfunction, and particularly multiple sclerosis and Parkinson's disease. So we want to give a warm welcome. This is yesterday during our didactics uh with uh a jovial uh journal club and case um case discussions and dinner last night uh with Doctor Weed. So, welcome to the you. Thank you so much for being here. All right, um, hopefully everyone can see me. Someone will let me know if I'm not webcasting. So, uh, welcome to everyone that's at home. Um, I really appreciate your waking up and, um, and joining us this morning, and those of you in person, so nice to meet some of you for the first time and good to see many of you again. Um, I'm gonna talk about urethral diverticulum today. Um, when looking at some of the ABU case logs, um, that, um, one of our fellows is looking at, you start to realize that there are certain conditions we've talked about or we know a little bit about, but they're really unfortunately not so common. Um, but no matter what the residents go on to choose to do, whether it's oncology or male sexual health or, um, uh, any male reconstruction, there's still gonna be patients you see that have diverticulum, so hopefully there's something you can take away from this. And for many of my colleagues, certainly the more I can educate them on. Uh, conditions that we treat, then it's a little more streamlined. So, for those of you out there that are really longing for a lecture on PSA, I sit through all the PSA and prostate cancer lectures, um, and that makes me a better urologist and a better clinician for my patients. So you'll have to sit through a little bit of a female urethral diverticulum lecture. My apologies. Um, So here are my disclosures, um, as Katie had mentioned, some of my industry ties, which I think have actually contributed a lot to my understanding of, of many conditions in the neurologic space. Um, and then I would like to review today pertinent anatomy, uh, pathophysiology of urethral diverticulum, explore the workup and diagnostics, and I think for many of you that's sort of maybe where it ends, um, but then for those of you with interest. Then maybe you'll see something in a, in a video or a thought that makes you think about a condition that you treat a little differently. Um, we'll talk about the, uh, surgical steps really so the residents can learn how to do these. So when your esteemed faculty has a diverticulum, you'll say, oh yeah, I remember. And they particularly like when you say, yeah, and Doctor Brucker said to do this. You just have to keep reminding them, right? Or when you're operating with ravine, you say, Well, Katie told us to do that. Um, but, but all kidding aside, we'll talk about some of the other treatment considerations and then I take some questions if we have time. So as Katie had mentioned, I, I'm from Scarsdale. This is, uh, the town of Scarsdale, it's a beautiful old Tudor. So when you mentioned the Revolutionary War, um, certainly, uh, you can see how, uh, yeah, we have the American flag flying and, uh, you know, I'm, I'm a big New York fan. Uh, here just wanted to highlight NYU Langone, uh, for those of you that have been there, you know, the campus, um, you know, on the East River, uh, on the east side of Manhattan, we do have a new campus, and, uh, it is, if you see in that small picture spot, there's a, a huge dog. With a life-size Prius taxicab, uh, balancing on the nose, and some of your, uh, residents have, uh, spent lots of time at NYU, uh, to know how, how pretty the campus is. So that's my welcome invitation if you guys are in town, please stop by, email me, give me a call. We'd love to have you. Um, and then I would be remiss if I did not explain how special it is for me to be here at the U, um, and those are my two children at the University of Miami. Neither of them go there, maybe aspiring to go there one day. Um, but, um, my brother-in-law and sister-in-law and niece, uh, live here and work here. My brother-in-law just came down to visit from the GI floor, uh, to say hello. So, um, it's really special to be here and as Katie had mentioned, the ties are, uh, really pretty profound. Um, this is a picture I found. It's not the most flattering picture. Of me, I think I put on about 15 pounds during my residency, um, but you'll recognize the handsome guy next to me, um, still with an impeccable hairline, Alan Ween, who's an incredible mentor to me and really to all of us, and, and a shining bastion of excellence in the field of urology. Um, and then I have sort of newer friends and colleagues and people that I, uh, rely on, uh, Katie and ravine. Uh, I think this is probably when you had gotten your video Eurodynamic unit, and that's Diane Dorell, who actually ties back to Alan. Diane was actually a Eurodynamics nurse at Penn, um, but how cool that, uh, Katie and Ravin have come and really developed an incredible program in FPMS here at University of Miami. And then, as mentioned before, um, Ricky, I think the newest addition to the division, um, and. Knowing how hard he worked as a fellow and, and everything he's accomplished in, in his career. I, I think what was, I probably considered an outstanding, uh, division is now even more outstanding. So you guys are very lucky. Um, and then some of my newer friends, and again, uh, this was sort of an awesome day yesterday. I was so humbled and honored to talk with the residents, and you guys are an awesome group and want to spend more time with you and get to hear sort of the things you're working on, um, and then definitely had a great evening last night. So, um, with those introductions done, wanted to mention the female urethra, and it's amazing how we talk about the female urethra. Yesterday we were talking about urethral strictures, but how the anatomy of the female urethra and the support mechanisms and continence mechanisms are really very poorly understood. Um, what's scary to me when you look at some of these things is how small, uh, the spaces between the vaginal epithelium and the urethra itself. So even when you're doing something like putting in a mid-urethral sling, I think I mentioned yesterday, it's incredibly scary because it's so close. And I think as you start to realize the deficiency of the tissue in that, uh, ventral area, you start to realize why diverticulums can occur. Um, even things like the ligaments, the pubile vesicle ligaments, uh, this is a controversial topic. Uh, do they really exist or not? Does this give women's urethra the support structure needed for continence? And, you know, I've put up this slide and one of my colleagues at GYN trained, Dr. Stewart said, you know, those don't exist, you know, they've proven they don't exist. And I said, yeah, but I see them. And so again, even things as simple as um As simple as the urethral anatomy are quite complex. Um, yesterday we had a good discussion about continence, and I, I don't need to go through all of the anatomy here, um, but just realizing there are multiple muscular circular layers that exist on the urethra as you work from the bladder neck out to the distal urethra. Um, and thankfully, most of our diverticulum are sort of beyond that. So some of the questions that were asked yesterday about cutting the female urethral stricture, the striated sphincter, uh, usually with the diverticulum lecture, we're. In that area. So diverticulum come from, uh, periaurethral glands. They secrete mucin, and that protects the urethra from irritative and toxic effect of urine. Um, the glands are usually between 3 and 9 o'clock. Aren't we happy that they're not always at 12 o'clock, because surgically it makes it a little bit more favorable for 3 to 9. But I'll talk and if we have a, a little bit of time, uh, some of the mobilization techniques to get those tougher diverticulum out. Um, but it's thought that these glands are, are ul Ultimately the source. Um, I do love looking back historically, um, William Hay, 1805, uh, only 17 cases reported from 1894 to 1954. Uh, you can imagine the sorts of, uh, ability to make these diagnoses. These things must have been really big, really bad, and, and really, uh, uncomfortable for, uh, people to present. Um, but you can see sort of the, the original, uh, series on, on diverticulum and then sort of an updated series, and This comes from that updated series, but what's fun to look at is, you know, like many things in medicine, the more you're aware of it, the more you report on it. So this is the encouragement for the residents, you know, if you have something interesting a finding, publish it, uh, you start to see the numbers, actually, case numbers increase. Um, some of the things that are, are used, um, in terms of like the primary diagnosis is, imagine, you know, in a, in a paper today talking and using like a whole page in a journal article for these like 6, Pie charts that are talking about, uh, you know, was it a palpable mass or it was diagnosed by cystoscopy or urethrography, um, and just seeing how we've really progressed and gotten a lot more sophisticated at our data analysis, but at the same time, um, some of these things are useful, and we'll talk a little bit about the complaints, meaning frequency of urination, 83% of patients back then were complaining, 26% gross hematuria. Um, so those are the historic, uh, papers that are just fun to look at. So what about the who, what, what, when, and why? Um, the numbers of diverticulum are obviously varied from a few small points of a of a percentage point to about 6% globally, um. I think a lot of conditions will vary based on the clinic you are in and what the setting is. Um, so, for example, the incidence really changes if you're talking about a population-based study, uh, versus you're dealing with, let's say, a gynecology clinic or a urology clinic or seeing women with symptoms. And so the smaller sort of um calendar of sort of the calendar periods explain how, um, depending on what your, your demographic is and who you're pulling from study wise, things may change. So if you're in a general urology clinic versus a tertiary referral center, obviously these numbers will vary greatly. Uh, usually it's going to be, um, between the age of 30 and 60, so big range, um, and again, meaning, um, you know, Paris women, women that have had children versus Naliparis, thoughts that maybe that has something to do, who knows. Um, but the histology question really for the in-service examination that the residents take or any of you on the call that might be, uh, thinking to do your lifelong education or. Re-certifying, uh, epithelial line cells, about 40% are squamous, um, and some of these cell types matter for the possibility of malignant degeneration of diverticulum. uh, thankfully not very common, but you see that about 77% of patients or diverticulum specimens will end up having inflammation and a little inflammation, not a big deal, but chronic inflammation is where there's a little bit of concern. Um, most of the walls of the diverticulum will have a fibrinous collagen as well. So when you talk about diverticulum, I remember as a med student learning about the 3 D's, um, uh, dysperunia, dribble, and dysuria. Um, but it's interesting to think about that's how we learn diverticulum, but only 20% of patients actually present with the 3Ds. When you start to look at um some of these other symptoms, things like a vaginal swelling. Or a post-micarish dribble, you can see 60 to 70% of patients will have these things. Um, another condition similar to what we talked about with stricture, where if you don't look for it or at least know it's a diagnosis, you will never find a diverticulum, um, but dysuria alone again, 33%, uh, dysperunia can occur. So very varied symptoms and nothing that comes out as, as much of a smoking gun. A high index of suspicion. Uh, of course, physical exam is very important, um, and it is amazing how, um, you know, the exam can sometimes be a little misleading, something I get sent patients all the time with cystoceles, and I'm told that they have a urethral diverticulum. Um, or, or other sort of vaginal, uh, cysts that will be confirmed as non-diverticulum. Um, so I guess if there's a question, send someone to a specialist because we're happy to look and, and figure out what it is. Um, and then we have a whole lot of other imaging, uh, modality, cystoscopy, BCG, um, positive pressure, urethrography, ultrasound, CAT scan, and MRI, and we'll talk a little bit about those as well. So what is the differential diagnosis? Again, for the residents, um, if we had more time, I'd be. Pimping you a little bit and asking you to answer questions, but I know you guys know this stuff already. Um, we have skins glands, uh, ectopic ureters can present, um, caruncles, prolapsed urethra. And then the one thing that I put in bold, because many of you will see patients, maybe for hematuria or recurrent urinary tract infections, and you have to realize that prior bulking agents can look a whole hell of a lot like a diverticulum. Um, and as we do more and more bulking and there are Some great thoughts about sort of new directions that bulking may go that uh Doctor Amin and I were talking about last evening. Um, but you have to realize that you get an MRI on someone that's had bulking cause you suspect a diverticulum, the last thing you want to do is be in the operating room, cutting it open and saying, that's not a diverticulum. That was the bulking that they had two years ago. Um, so just certainly be careful. And then there are women that will present saying they have stress incontinence or recurrent urinary tract infections that might actually have a diverticulum. Uh, this is, uh, a displaced urethra. Um, you can see the meatus, I'm not sure how well it projects in the room, um, but again, something like that is a skin's gland that's distracting the meatus versus something a little bit more proximal. And this is, I, I like the picture. It's a little bit once you figure out the orientation of it, so superior inferior, anterior, posterior, um, so the The urethra and the urethral diverticulum, what we're talking about here today, um, the skin's gland ducted over here. But as you look at the vagina, there are things that are in the vagina that are cystic structures like a Bartholin's gland cyst. Um, there are vaginal inclusion cysts again in different locations. And then Gardner's duct cysts usually gonna be a little bit more proximal as we talked about where those glands really exist in the female urethra. So I always sort of find it funny to talk to a group of urologists about cystoscopy, although it sounds like a couple of the interns were joking yesterday about not even knowing how to put together a cystoscope yet. Uh, you will learn, but what I wanted to sort of, sorry, that second part of the video wasn't supposed to play, but what I wanted to show you is when you look at a cystoscope, what you'll realize is the actual scope ends a couple of centimeters before the end of the visual, um, the, the optics, and a urethroscope has Sort of a flat rim. If you put your finger underneath the bottom of a cystoscope when you're looking at the female urethra, you can actually distend it because it's very hard with, let's say, a rigid scope like that to see a little os in the urethra. And it turns out that we don't always see the os. Um, you can see in about 80% of cases. So when you're looking for a female urethral diverticulum, turn the water flow on, try to put your, um, you know, pressure up as much as you can so you can see in the urethra. Other diagnostic tools, um, again, I don't use these very commonly, but I thought, as you look historically at the literature, they talk about VCUG with a 65% sensitivity. So it's not to say that you can't sometimes see them. Um, and then the positive, uh, pressure urethrography, um, I, I polled the audience usually if I give a talk on diverticulum about how many of the urologists in the room have actually seen a catheter like this, and it's fewer and fewer. Um, we used to. Need to do more of these things because we didn't have access to things like MRI, um, and it's a really sensitive test, but you can imagine putting this in a woman in a fluoroscopic room and blowing up two balloons and pushing fluid into it to try to occlude the bladder neck, and then have the contrast come out. And the problem is you can have a lot of false positives because if you push hard enough, those little glands that exist will show up. Um, video urodynamics, not traditionally, um, as much of If I suspect a diverticulum, I'm gonna get it. Um, but this was an old Blavis paper, um, that talks about urethral diverticulum being about 4% of his cases of obstruction. So if you see obstruction in a woman and you happen to have video urodynamics, and then you see this little blush on the side of the urethra, um, you can understand how that, um, actually gives you the diagnosis and say, hey, not only is it a diverticulum, but it's actually causing obstruction. Um, I do use video urodynamics when a woman tells me that she has stress urinary incontinence or there's a concern about stress incontinence, um, with the diverticulum, because I wanna understand, is it when they cough, the urine comes from the bladder out the meatus, or is it really, uh, they don't have any stress incontinence, but after the study. When they're done voiding, they have this little pool of urine in the diverticulum, and then they cough and then that leaks out. So concomitant sling, we'll talk a little bit about if we have time, um, but the urodynamics in my mind are used more for looking for stress incontinence rather than diagnosing the diverticulum. We talked yesterday about, uh, ultrasound. I don't really use it for diverticulum, although if you guys have skilled ultrasonographers in your midst, uh, certainly there are papers written about it. Again, uh, a little bit more limited in my practice. Um, CAT scan, we see a lot of CAT scans done for other causes, and this is often when you'll get a referral from a patient that was seen in the ER for something else, and the radiologist picks up on a, um, picks up on a diverticulum. Um, certainly, uh, it has been shown to have some, uh, higher diagnostic accuracy. Uh, the disadvantage is obviously, um, you know, if they're not voiding, maybe hard, maybe it's not filled, uh, maybe it's decompressed, and then obviously the radiation risk. So, MRI is really the mainstay um of diagnosing a diverticulum. I would say at this point, I don't know that I ever take a patient to the operating room for a diver without getting an MRI first. Um, and a lot of the benefits of MRI, um, are in that surgical planning. You'd hate to take out a diverticulum and then have a patient have a second diverticulum, or maybe you don't see where the OS is, but the MRI sort of points you in the direction. Should I be approaching the left side or the right side. Um, and I think that this is now really the standard for diagnosing, um, with several groups reporting 100% sensitivity. Um, in the past, sort of endocoil, um, uh, endoluminal coils, uh, were used, um, but I'm not sure that it's needed as our MRI units have gotten better and better. So I think historically when MRI was not great, even for prostate MRI, I remember, uh, you know, ordering with endorectal coils, and nowadays I don't know that that's uh as commonplace. Um, if you look at the different modalities, again looking historically. Um, you can see back in the day, MRI was only, uh, 70% accurate, um, for diagnosing diverticulum, and there were a lot of other things here, um, like the sonography and transrectal sonography that just don't really exist for us diagnosing diverticulum any longer. Um, and the history and physical exam was not bad at about 33%. So again, I think put it up more for historic purposes, but MRI is really, um, the most important. So, again, we can do an audience response or not, but if you sort of look at, um, these cases and, and we have these three cases, but you know, case one and, and you're sort of trying to figure out what it is, and that's where I wanted to show you that a bulking agent, you can see these sort of circular areas. Very often bulking agents now are put closer to the bladder neck. So if that's the location, if it looks like they're symmetrical or there are multiple of them, I. Do you think you need to think about bulking agents. And then over here, you can see, uh, a little bit more of an irregularity. Um, and again, whether it's a CAT scan or an MRI, you may realize that, uh, patients can develop adenocarcinoma of the urethra, um, and so you don't want to take a patient just for a diverticulectomy and then find out that you need to call your oncology colleagues to, to help out, uh, because the patient needs a much more extensive surgery. Um, there are some other mimicking cases. There are fibroids that have been reported, metastatic lesions, uh, to the urethra, and again, uh, just fun to think about urethral pathology in general, because when you see a woman, you gotta figure out, hey, is this gonna be a fun case to remove a diverticulum and make her better, or is there something else that's going on? So the treatment uh includes, uh, again, like many things in neurology, um, observation, endoscopic approaches, and surgical approaches, um, things like transurethral incision and fulguration, I put a little asterisks next to them because I've never actually seen them done. Um, there are things like marsupializations for very distal diverticulums. I'll show you a photo, uh, explaining it, and then the urethral reconstruction and a couple of other strange approaches, um, that again are not so typical but can be utilized. So, the diverticulectomy, um, again, vaginal incisions, I think important for the residents to think about. Are we making a midline incision or inverted U and the inverted U incision allows us to really have Best exposure to the entirety of the urethra. And when you're operating on the urethra with not a lot of tissue, the idea of fistula or fistula formation is something that's on our minds. So with an inverted you, I can fix my diverticulum and then have a non-overlap lapping suture line. So the suture line of the actual urethrotomy and the edges of this are, uh, off to the side. Um, I think the fellows and residents and maybe everybody makes fun of me that I'm always marking what the marking. Pen, even though it's a simple vaginal incision, I mark it twice and I cut it once. Um, consider closure and access. Um, and I do think a Lone Star is a great option. Hydrodissection, obviously, we want to avoid injecting into the diverticulum. It's always like a oh moment, uh, when you give, uh, a trainee sort of the lidocaine with epinephrine and they go to develop that plane between the diverticulum and the vaginal epithelium, and all of a sudden, you don't see anything. and the, the fluid starts shooting out the meatus, and you realize they went too deep. Um, but I think you can have some bleeding from the injection as well. Um, just wanted to show quickly, um, an inverted U incision just cause it's such an important tool for what we do. Um, and again, here's our injection of the lidocaine with epinephrine, and there's some nice, uh, rays. So I've made the incision. And then the other thing I'll sort of just mention is when you make these incisions, Uh, don't forget, when you start your dissection to get the, the sort of non-flap part dissected up, it's easier to do it in the beginning of the case than waiting for the end of the case. Um, and again, very similar technique if you're putting in a pub of vaginal sling, it's my preferred sort of incision, um, but a Metzenbaum scissor, the Lone Star retractor, the Alice clamps, you gotta get exposure, um, and what a, what a great way of exposing the urethra. So, the actual steps of the diverticulectomy, um, obviously the, um, inverted you again marked, as I promised, I always mark a million times. Uh, we have our flap, we have our diverticulum with sort of the second eventual layer. Uh, sorry if I'm telesttrating with my hand and forgetting about you guys on the, uh, on the Zoom call. Um, and then we have our diverticulum, the diverticulum is removed. We end up having our urethral hole or urethrotomy that gets. Closed, and then the illustration of the non-overlapping suture lines, which is actually quite critical. Um, so here's some video of the diverticulectomy, um, hopefully, um, it presents, uh, OK. Again, as I told you, MRI is done. Here's the os of the diverticulum, so you can actually see it. It's a great picture. Obviously, that's why it makes the video real, the ones that are bad and you're struggling with, we never present. Um, but that's OK, right? I'm, I'm the one that's, uh, hitting the forward button, so I get to choose, uh, what I show you, and you can see here again, our inverted U incision, the diverticulum. Um, and then we have this small little layer between sort of, you know, after you've gone through the vaginal wall, uh, where we're gonna dissect off and, and usually using a fine pickup, um, your assistant is super helpful with suction, uh, and that'll ultimately be our second layer. So here you can see the shell of, of that sort of perurethral fascia, um, and here's the diverticulum being lifted off, um. And then, uh, I, I did end up sort of getting it down to a small area. And this is like a great diverticulum. It's not too big, it's sort of anterior. Um, and then once you get it down, you see that tiny little pinhole. Um, so it was fun to inject a little bit of saline into the urethra, see it squirt out, and then just showing you, and I do this a lot. Maybe in this case, it was more to illustrate for you guys. Um, but I think if you end up thinking you got The os off, you need to look and make sure you actually have it off cause you'd hate to fix what you think is the diverticulum or the OS and then they have a recurrence pretty soon after. So, um, maybe showboating a little bit there in terms of what we're seeing. And then you can understand how the closure is pretty simple. But, um, just to illustrate the point, absorbable suture, we're going to close that. It's water tight after my first layer closure. Uh, there's a second layer that I'm gonna now close over. That. And then if you did need, and we'll talk a little bit about when you might use tissue interposition, you can use tissue interposition, but, you know, after these two layers, and this is a non-smoker, non-radiated patient, uh, pretty straightforward. And then I'm gonna close the vaginal epithelium and vaginal wall, leave a catheter, um, you know, for a couple of maybe a week or two, depending on how your closure goes, and then, uh, the patient can be discharged home. So, um, there are simple and complex diverticulum. I showed you a simple diverticulum, but there are saddlebag diverticulums, and then there are more complicated, um, circumferential diverticulums, um, and uh your own Alan Ween was an author on this journal article that sort of helped classify the different types of diverticulum. Um this is another paper that I think deserves mention, um, again, Allan and Eric Grobner. Had, had discussed, um, actually transecting the urethra completely, uh, in order to get the diverticulum out. So a different surgical technique. Um, and you can understand, it's a little hard to see, but here's the catheter, uh, here's the right angle, uh, at the, uh, dorsal portion of the urethra, and then it's severed. So you have one end here and one end here. The urethra is totally separated. So, again, I don't know that this is something. I use on every case, but if you have a more complicated case, uh, you can see that you can then ultimately lay a piece of fat in and put a urethra back together with a primary anastomosis. Um, simple versus complex, um, 11 were found to have complex, about 75% in the study. Average age about, uh, you know, 50 years in both groups. Um, and what the study concluded was urethral transection and. And anastomosis for repair is a feasible approach with similar outcomes, um, can, you know, and I think very reasonable to say, OK, now we have that in our toolbox. Um, there are other approaches for diverticulectomy that, um, deserve mention. Again, I don't know how commonly we're gonna see these, um, but we have MRI imaging and you can see really a retropubic location of this diverticulum that might be. Very hard to get from a transvaginal approach. Um, and so these authors described actually, uh, taking it out from a robotic approach, and you can see the, um, diverticulum here. Uh, this is another rare situation, pediatric case, um, with a patient that had a diverticulum that ruptured and developed into an abscess, um, and again, a robotic approach is great for anything on the female urethra, um. And I think probably not the common diverticulectomy, but realizing that there are some more complex cases, uh, that you get referred and you're sort of like, oh what do I do with this? Um, the marsupialization, I think, is the idea of just taking a scissor and cutting the urethra and incorporating the actual diverticulum in the incision. Uh, so here's the diverticulum, here's the scissor, and we're just cutting back. Uh, the problem is you make a hyper Spadic or shortened urethra, you can understand how this is not great because you're not removing any tissue that's chronically inflamed. You're not gonna have any pathologic, um, specimen to look at. Um, and again, I would say these are more of the weird and wacky ways of, uh, dealing with the diverticulum, um, but sometimes you do need to be a little bit more creative. Some of the additional considerations, um, you know, a couple of those more complicated. diverticulums, you're not going to be able to reach the os. I showed you like a perfect example, us right in the front, um, but sometimes you do need to really mobilize the urethra to get the os. Um, so this is just the idea of entering into the retropubic space, uh, and here, uh, a video that, um, just sort of shows the popping into the retropubic space with a Metzenbaum scissor, similar to a urethra, to a urethrolysis technique. So freeing up the urethra. And then once we have the urethra freed, um, you can actually pass a Penrose behind it, um, so that you have complete control of the female urethra. And again, it's not always, uh, and this is again for urethrolysis. It's a very similar technique. That's why I'm showing the video with the inverted U. um, but you can imagine, once you mobilize it, you can put a Babcock on the urethra, pull it to the side, and almost get to those 12 o'clock locations if necessary. Um, the other consideration is stress incontinence. The thing that I first would tell anyone on, on sort of the, the zoom or on the call, if you are doing a diverticulectomy or you are doing any urethral reconstruction, uh, the AUA guidelines and common sense and expert opinion says, hey, don't put a mesh, uh, just showing a picture of a mesh complication. And again, not related to this, but if you had a diverticulum, you fixed it and you put a mesh on top of it, that's potentially a bad situation. Um, so avoid using it, um, in those situations. Um, anti-incontinence procedures, do we do them after the diverticulum or not? And what you see sort of in, in this, um, Study looking at um post diverticulum repair, um, preoperatively, 51% had stress incontinence, and then postoperatively uh about a little less than half had persistence and only 13% had de novo. Um, so without prophylactic stress incontinence procedures during diverticulectomy, um, we observed or, or they observed a low rate of de novo SUI with only 5% after the fact going for an intervention. And I think that this is probably multifactorial. Some of those patients that had stress incontinence probably didn't really have stress incontinence, but they had a little bit of dribbling from the diverticulum. So fixing the diverticulum fixes the problem. The other thing that we know is when you do a diverticulectomy, you cause scarring around the urethra. And what does a sling do? A sling causes scarring around the. urethra. And so that may be another reason. So, I think my, my algorithm is, if I suspect that they're definitely really stress incontinence based on my urodynamics, then I'll take the opportunity to put in a pub of vaginal sling or an autologous sling because, hey, they're gonna have stress incontinence anyway, unless they really choose not to. If it's a patient that's radiated or that has some complicated factor. I will opt to put in a sling as another way of tissue coverage or in those cases, maybe a Marti's fat flap. Um, but I, I don't necessarily always fix stress incontinence if it's not going to exist, or if my suspicion is that it's not real. Some of the risk factors for, for preoperative o, stress incontinence were that larger diverticulum, more proximal and more complicated. Um, the flaps, there are things that we use in reconstructive urology, um, on the male and the female side, autologous slings, as I talked about for prevention or treatment. Uh, there are all sorts of martius flaps, buckle mucosal flaps, you know, again, you have this really devastated urethra. It's a huge area. Uh, we've borrowed from our male reconstructive colleagues with the notion of taking some buckcal mucosa, um, and you can put that on, um, and then we also talked a little yesterday about, um, skin island flaps. Just two quick videos, um. A little bit of an older video, as you can tell by the uh the the quality, um, but just showing the harvest sort of a more maximally invasive approach to getting a piece of rectus fascia, um, but for teaching, I think it's great cause you can see what we're trying to do and what the fascia looks like and how you mark it. Just because today we use so many synthetic slings. Again, a lot of urologists out there that may not treat stress incontinence may ultimately still treat diverticulum, so knowing how to harvest rectus fascia, um, a great option, and then, um, You can sort of see we're gonna put our holding stitches, and this is a great way of, of again, correcting the stress incontinence and covering the diverticulum. And then I, I may have shown, or some of you may have seen the video, but a little bit more of a minimally invasive way using a Crawford stripper, so I can use this fascial stripper to get my, um, avoid that big incision on the abdomen. And basically once I developed the little pocket on the, um, on, on the fascia lata, I can slide this fascial stripper down and get a nice piece of fascia, as you can see pulling on an Alice clamp. And now that's a great piece of fascia that I can use to treat stress incontinence or cover. Um, a little less robust, I think, than the rectus fascia for the more devastated urethras, um, but it's nice to be able to, to get there. Um, what about the long term, uh, complications of diverticulum excision? Um, so as I mentioned, there are some that can have, uh, new onset stress incontinence, urinary tract infections. Uh, thankfully, things like stricture and fistula are pretty rare, but as you guys are consenting patients, I think it's important to realize that there are things that can happen. Um, there are cases of fistula that can occur, um, and sort of the way that we repair the fistula, you know, very similar to lots of the other urethral, um, work that we've talked about. Um, and then there's really the big question of what do we do, um, do we treat every patient with a diverticulum or not. Um, and I think the answer that I would sort of put forth would be, you know, if someone's asymptomatic, you need to inform them that we don't really know a lot about the natural history of diverticulum. And there are cases that are reported of malignancy, that chronic inflammation, those squamous cells, um, and ultimately it's going to be a little bit more of that, that patient choice if they're asymptomatic. If they're symptomatic coming in saying, hey, I want this thing removed, or I'm having dysperuna or I'm having dribbling, then it becomes a little bit easier and maybe one of you will come up with a way of, of designing a study where we can really understand how likely is it for these uh diverticulum to progress into a malignancy, which is obviously devastating. Um, one of your colleagues just got back from a, uh, African safari. Uh, we were looking at pictures early this morning over a coffee, um, but, uh, you know, again, it's the question of if, if you're, if you hear, you know, hoofprints or or what is it, if you hear of uh horse horse horse's hooves, uh, you, you gotta sort of think that it's horses, but sometimes it can be a zebra. Um I hopefully have shown you that diverticulum doesn't need to be a zebra, it can be just a normal part of your basic evaluation. Uh, make sure that you are not treating bulking. I think that's really important. Um, an MRI, if there's any question, it's very easy to get an MRI, but do put on the MRI indication that you're looking for urethral diverticulum so that they can focus on that area. Um, do video urodynamics if there is in fact leakage or you suspect leakage or there's lower urinary tract symptoms, um, and then keep with. Basic surgically, which are the multi-layer closures, the non-overlapping suture lines, catheter drainage, and then ultimately consider, uh, flaps if needed. Um, and with that, uh, there's my email in case there are questions. Uh, I think the 7 train, uh, the Empire State Building in the background, and then, uh, that cost me a pretty penny in the University of Miami, uh, gift store, my son. Didn't want just one, but he needed 4, foam fingers to root on the hurricanes. So with that, I'll, I'll pause and I'll, uh, thank you guys again for your hospitality, um, the good weather, um, and, uh, and your attention, and, and a great conversation with the residents. You guys did an awesome job yesterday and it was fun that we got to relax a little bit last evening, and I'll take any questions if you have them. And some for that. very You're all there they no amount of like. They still are having the ligament you would find a regional divers they recommend that. Yeah, I think it's probably pretty rare because I guess either they're gonna get into the diverticulum when they're putting in the sling and then I'm called for a different problem altogether, um. And I don't know that in my treatment algorithm for like, I had a sling and I'm still having leakage if I necessarily on physical exam, didn't feel a diverticulum if I get an MRI in everyone. Uh those are patients like sling and have stress incontinence, probably getting video urodynamics on them. Um, so maybe I'd find it, but I can't say I've encountered someone where that's been the reason why they've had persistent leakage. Although you start to look for anatomic problems, you know, when things are not making sense, so maybe a cystoscopy would do it, um, or maybe a video urodynamic would find it. Yeah. Other question, yeah, Ricky. What's your thoughts on walking after you do the diverticulectomy. Yeah, you mean like like 3 months later, a woman comes back after diverticulectomy and has incontinence. So I think it's fine. I think my little concern is she's had a diverticulum, you know diverticulum can recur. Um, the question is also like what's my other option? So she has stress incontinence. Am I OK with the fascial sling? Yes, I'm OK with the synthetic sling. I think I might be, but I'm also a little bit worried, worried like it's not at the same time and it's been repaired. Um, I guess bulking may be reasonable. I think low risk. I think you have to have the discussion and there's gotta be a good reason. Um, I still would have a bias for an autologous sling post diverticulectomy. I mean, look, if a woman says, I had a diverticulectomy 25 years ago, um, and we image and everything's fine, you know, look, the sling incision shouldn't be a big deal, but what if you get into it and then she's not For an autologous sling or she doesn't have sort of on the consent form, the, the harvest. So I think I'd be pretty conservative in most of these patients and say, I'll, I'll default to an autologous sling, um, but not unreasonable if you thought, hey, let's bulk her or let's put a synthetic or a mini sling or something like that. But you know, you gotta investigate and I guess to that point, what if I did the diverticulectomy and then she comes back with what we think is stress incontinence? Do I trust that it's stress incontinence or is it a diverticulum? So those might be patients where you do get another MRI to say, I've treated the diverticulum. Um, and, and then it's sometimes tricky. You get a little pseudo diverticulum or a little out pouching. So at that point, then you're really treating the symptoms that she has. So there may be symptoms that she has of leakage, and you wanna treat that. The concern about a malignant degeneration is really no longer there because our pathology specimen says inflammation, no cancer. So, what is she symptomatic? Is it really the diverticulum or is it just the stress incontinence? So there are times when you might see a little wisp of something. Obviously, if she has a huge diverticulum, you may go back and actually treat it, but Um, those are the, the tough management choices that you have to make. Do you ever leave like a super pubic tube or you're always kind of like a Yeah, so I, I think super pubic tube is great and I probably, I, I usually say like I've never regretted putting in a super pub, super pubic tube. I've, I've definitely. Regretted not putting one in. Uh, you're 2 weeks out, the patient's not the greatest wound healing. I do a lot of VCUGs before I pull the catheter. I do the VCG. There's a little leak, and then I gotta tell this woman who's 40 years old, you need to wear the catheter for another week. And she's like, I'm coming up to 3 weeks with the catheter. My urethra's raw and hurting. And you're sort of like, ah, so so now should I take you and put in a suprapubic tube. So I think if you get a sense that it's more complicated, or if you're putting in a pubil vaginal sling at the same time, which is gonna further potentially cause some voiding dysfunction, suprapubic tube is not a horrible option, um, just because then at 2 weeks, if there's a little extra, but I can drain them from above, might not be a big deal to get the catheter out, let it just continue to heal on its own without voiding through the urethra, so. That's another good question. Awesome. Great. Great. Thank you guys, and I hope everyone has a great day. For those of you online that I, I didn't get to meet, um, I look forward to, uh, to meeting with you at some point in the future. Um, and Emma, thank you for all your uh logistical arrangements and being on top of everything. Uh, she did tell me that I was not the most delinquent and worst at responding to her emails, so I think she was just being kind, but thanks. Great talk. All right, thanks guys. Published October 9, 2025 Created by
