Case Report: Robotic-assisted Proximal Dorsal Urethral Diverticulectomy

Urethral diverticula (UD) in women are rare outpouchings of the urethral lumen into surrounding connective tissue. Most are located on the ventrolateral, mid to distal urethra, where the periurethral glands dominate. Far less commonly, the UD is proximal and dorsal (anterior); this is more difficult to repair because of the need to access the side of the urethra opposite the vaginal lumen, abutting the external urethral sphincter.

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Sarah Mozafarpour, MD, clinical fellow in surgery in the Department of Urology at Massachusetts General Hospital, Mass General Urologist Elise J.B. De, MD, and colleagues recently described a robotic-assisted retropubic approach to transabdominal laparoscopy in a 38-year-old woman with a large, dorsal, very proximally located UD. Their report appears in the International Urogynecology Journal.

History and Physical Examination

The patient initially presented to the emergency department with urosepsis. She reported a six-month history of lower urinary tract symptoms, recurrent urinary tract infection, gross hematuria and dull abdominal pain. A computerized tomography scan revealed a UD with a 7-mm stone in the posterior left lateral aspect. The patient was discharged on antibiotics and referred to outpatient urology.

Physical examination in the clinic revealed a subtly cystic proximal urethra. Urodynamic testing demonstrated bladder outlet obstruction referable to the diverticulum. Magnetic resonance imaging (MRI) confirmed a large (2.5 cm × 1.6 cm) crescent-shaped left anterior UD at the proximal urethra. The entirety of the diverticulum was cephalad to the level of the pubic bone, and the urethra appeared elongated with an elevated bladder neck.

Standard vaginal dissection was deemed feasible, but a robotic-assisted retropubic approach was chosen to facilitate complete excision of the diverticulum and minimize the potential for urethral and external urethral sphincter compromise.

Surgery

During the office visit, the patient fainted after catheter placement for urodynamics, so cystoscopy was performed in the operating room. It revealed the diverticular ostium to be at the left ventrolateral aspect of the proximal urethra.

The robotic approach to urethral diverticulectomy is described in the article, and an accompanying video gives detailed instruction. The principal advantages of the approach were:

• Excellent direct visualization for identifying the diverticular neck
• Minimal need for dissection along the urethra and avoidance of the external sphincter to minimize the risks of fistula formation and recurrent urinary incontinence, respectively
• It was possible to cover the repair with a thick layer of omentum
• The procedure was technically straightforward and was accomplished in 3:27 hours with an estimated blood loss of 50 cc. Vaginal counter-incision was unnecessary

Postoperative Course

The patient recovered uneventfully without recurrence of lower urinary tract symptoms. Voiding cystourethrogram on postoperative day 13 revealed a well-healed repair without extravasation. There was no pathologic evidence of malignancy.

Commentary

Though challenging, a dorsal UD is typically repaired vaginally. The technique described here is feasible when a retropubic approach may improve access. It and other laparoscopic applications may also be considered as an adjunct to the standard vaginal approach for any UD with a component that is both dorsal and proximal.

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