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Case Report a Case of Urethral Diverticulum with Surgical Repair Using Cadaveric Pericardial Tissue

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Case Report a Case of Urethral Diverticulum with Surgical Repair Using Cadaveric Pericardial Tissue Hindawi Case Reports in Urology Volume 2018, Article ID 6183618, 5 pages https://doi.org/10.1155/2018/6183618 Case Report A Case of Urethral Diverticulum with Surgical Repair Using Cadaveric Pericardial Tissue Loren Custer, Morris Jessop, Stanley Zaslau ,andRobertShapiro West Virginia University, Department of OB/GYN, Morgantown, WV, USA Correspondence should be addressed to Robert Shapiro; [email protected] Received 1 May 2018; Revised 4 September 2018; Accepted 24 September 2018; Published 4 November 2018 Academic Editor: Fumitaka Koga Copyright © 2018 Loren Custer et al. Tis is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. A urethral diverticulum is a relatively uncommon fnding. Te estimated prevalence is approximately 1-5% in the general population. While the defnitive treatment is surgical correction, there are limited studies guiding the best approach to repair. Tis is the case of a 48-year-old female who initially presented with vaginal discharge, dysuria, and dyspareunia. MRI revealed the diagnosis of suspected urethral diverticulum. Te patient was treated with surgical correction with the aid of needle localization prior to the procedure. Afer the diverticulum was excised, the resulting defect in the urethra was successfully closed with cadaveric pericardial tissue. A urethral diverticulum should be considered in the diferential diagnosis when a patient presents with symptoms such as recurrent urinary tract infections (UTIs) vaginal mass, dysuria, dyspareunia, or vaginal discharge. Te use of cadaveric tissue augments the surgical technique for repair. 1. Introduction MRI, however, can give additional information such as if a mass were present within the diverticula [10]. A urethral diverticulum is defned as an abnormal outpouch- Treatment is indicated if the patient is experiencing both- ing of the urethral mucosa into the adjacent tissue. As noted ersome symptoms or if malignancy is suspected. Transvaginal above, the prevalence is approximately 1-5% in the general diverticulectomy and urethral repair is the current procedure population [1] and the incidence is estimated to be less than of choice. Te reported success rate is approximately 70- 0.02 percent per year [2]. Tis condition is found more 86% [13]. Tere are several known postoperative complica- commonly in women than men and usually occurs between tions reported in the literature including urethral stricture, 20and60yearsold[3].Tereareseveraltheoriestoexplain ureterovaginal fstula, stress incontinence, and recurrent the cause of these diverticula. One proposed theory is that UTIs [14]. Te risk of complications increases with repeat of chronic infection/infammation of the periurethral glands procedures [15]. resulting in abscess formation that can communicate with the urethral lumen [3]. Another proposed theory is that 2. Case Presentation trauma via either surgical procedures (ex sling procedures), physical injury, or child birth may cause formation of urethral Tisisthecaseofa48-year-oldG2P2002whooriginally diverticula later in life [4–6]. Other known risk factors presented to our ofce in March 2016 with vaginal discharge, include African American race [1] and female gender [3]. dysuria, and dyspareunia. She had previously been evaluated Te classic triad of symptoms reported in the literature by her primary care physician (PCP) where a small cyst is postvoid dribble, dyspareunia, and dysuria [7]. Other on the anterior vaginal wall was drained. She had received common presenting symptoms include recurrent urinary antibiotic treatment without relief of her symptoms. Her tract infections, urethral stones, and tender vaginal mass [7, past medical history was signifcant for multiple sclerosis, 8]. Te current standard for diagnosis is by MRI [9–11]. Tere Crohn’s disease, and anxiety/depression. Her surgical history have also been studies utilizing transvaginal ultrasound [12]. was signifcant for cesarean section × 2, bilateral tubal 2 Case Reports in Urology Urethral diverticulum Figure 1: Pelvic MRI, axial view of urethral diverticulum. Urethral diverticulum with free fluid level Figure 2: Pelvic MRI, sagittal view of urethral diverticulum. ligation, polypropylene midurethral sling procedure, and In January 2017, patient returned with vaginal discharge, cholecystectomy. On physical examination, she was noted to status post “vaginal cyst drainage” again with her PCP, along have a small anterior vaginal wall fold near the urethra. MRI with antibiotic therapy. MRI was repeated and signifcant for showed a cystic mass posterolateral to the urethra measuring persistence of the cystic mass/diverticulum noted on prior 2.1 × 1.7 × 2.3 cm likely representing a urethral diverticulum. MRI. Her symptoms however improved afer antibiotic ther- Te mass had signs of infection/infammation (Figures 1 and apy. Further treatment was subsequently delayed due to lef 2). Of note, the patient also had a long history of abnormal breast discharge and subsequent diagnosis of a breast mass. uterine bleeding and was found to have fbroids on MRI. In October 2017, patient returned with 2-week history She underwent hysterectomy with concurrent repair of the of dysuria along with persistent discharge and urinary drib- urethral diverticulum. bling. MRI was repeated and signifcant for slight increase In June 2016, she underwent total abdominal hysterec- in size of the urethral diverticulum. Te case was discussed tomy, bilateral salpingectomy, and adhesiolysis. Afer the hys- with our staf in interventional radiology. Tey ofered needle terectomy was complete, excision of her previous midurethral localization of the diverticulum prior to attempting repeat sling was also performed due to the patient’s chronic excision. groin pain and recurrent UTIs. Approximately 2 cm of the In January 2018, the patient underwent the following pro- polypropylene mesh was freed from the periurethral space cedure: transvaginal ultrasound was used to identify a “thick and partially excised to the inferior pubic rami bilaterally. walled diverticulum” and a 5 French catheter needle was At the time of excision, no diverticulum was able to be placed into this cavity. A small wire was then passed through identifed and only an area of infammation was visualized. the catheter and into the diverticulum for localization. Te A 20 gauge spinal needle was passed through that area in catheter was removed and the wire was then secured to the an attempt to aspirate fuid, but no fuid was able to be patient’s thigh. A u-shaped incision was then made, proximal retrieved. Cystoscopy was also performed and no ostia or to the urethra. Afer the vaginal epithelium was dissected communication suggestive of a diverticulum was visualized. away, the diverticulum was easily identifed using the guide Postoperatively, patient had no complications. Although the wire (Figure 3). Te diverticulum was incised longitudinally diverticulum was not able to be isolated and repaired, the and purulent material was subsequently drained. Te diver- patient initially had improvement of her symptoms. ticulum was dissected laterally and anteriorly away from the Case Reports in Urology 3 Foley catheter Needle guide wire Urethral diverticulum Figure 3: Urethral diverticulum isolated with needle localization. 3. Discussion Given the rare occurrence of urethral diverticula, there is ofen a delay in detection leading to persistent symptoms, such as postvoid dribble, dyspareunia, or vaginal discharge, especially if the patient had prior pelvic surgery. [16]. A delay in diagnosis occurred with our patient as well. She had received several courses of antibiotic treatment and localized aspiration prior to presenting to our clinic. Tis may have contributed to the inability to fnd the urethral diverticulum during the frst surgery. Te lack of an acute Figure 4: Urethral diverticulum, afer removal. infection within the diverticulum likely made it too small to recognize. Isolation of the diverticulum during surgical exploration becomes easier if a vaginal mass (usually along the anterior vaginal wall) is palpable or visible. urethra and subsequently removed. Figure 4 illustrates the Te cause of this patient’surethral diverticulum is difcult size of the diverticulum. Afer the diverticulum was removed, to ascertain. It is notable that our patient had a history there was an approximately 1 cm defect in the urethra due of a prior polypropylene midurethral sling procedure. Te to a previous communication between the two areas. Tis authors speculate increased intraurethral pressure resulting was repaired with 3-0 vicryl; however, due to the chronic from the placement of the polypropylene sling could have infammation, the tissue was weak and a leak was noted afer caused the diverticulum to form. Tis is not a novel theory as repair, evident afer methylene blue dye injection. Terefore, other case reports have been published on urethral diverticula the defect was reopened and reapproximated with 3-0 vicryl. associated with prior urethral sling surgery [17]. However, Tis time, cadaveric pericardium was anchored over the frst no clear evidence exists citing urethral diverticulum as a layer of repair. Te cadaveric pericardium was soaked in complication of sling surgery. Moreover, it is difcult to normal saline for rehydration per package insert instructions. excludethepossibilitythepatientmighthavehadaverysmall Te vaginal epithelium
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