A 35-year-old woman consulted for terminal limp or "drooling micturition", dyspareunia and recurrent urinary infections.
Intravenous urography and voiding cystography showed findings consistent with urethral diverticulum.
The patient complained of urinary frequency and nocturia three to four times.
Occasionally he had had isolated episodes of stress urinary incontinence, so he used a daily protective pad.
She had urinary urgency and occasional urge incontinence.
There was no evidence of interconnected bladder voiding or incomplete bladder pressure sensation.
He had no hematuria or signs of genitourinary cancer.
Normal intestinal rhythm.
No previous female sexual dysfunction until the present dyspareunia that affects their sexual life.
No neurological pathological history.
Medical and surgical history: Hypercholesterolemia.
Asthma in childhood.
Occasional lumbosacro pain
Laparoscopic cholecystectomy two years ago.
Two cesarean sections, the last 12 years ago.
In antihypertensive treatment with atenolol, chlortalidone and amyllium.
No known allergies.
No diabetes.
Do not smoke or drink.
Physical location: Morbid obesity.
Good general health.
Head, neck and cardio-pulmonary location without pathological findings.
Tuberculosis: 140/100.
Abdomen blando, obese, non-painful, not hepatomegaly.
pelvic cyst compatible in dorsal lithotomy position: Relatively narrow vaginal introitus; bulging in the suburethral area near the bladder neck and middle urethra of approximately 2.5 cm in diameter, diverting,
No pus was obtained when pressured.
No stress incontinence was observed.
1.
Magnetic resonance imaging (MRI) of the pelvis was performed in T1 axial, T2 axial, T2 gray images on both right and left sides.
Two liquid formations were found in the pelvis.
The largest measured 3.4 cm in its longitudinal axis, in the right parasagittal area, the second collection measured 1 cm in its longitudinal axis.
The formation of a cm in diameter was of the same characteristics and was between the middle parasagittal and sagittal areas.
It was not possible to document a relationship with the urethra in the other sequences.
The impression was of a large urethral diverticulum of at least 3.5 x 2.5 cm, however, it could not be ruled out that the smallest collection was a cyst of the Barino gland.
1.
Flexible cystourethroscopy under anesthesia showed a large urethral diverticulum at 10 mm from the bladder neck.
At compression, there was no drainage through the urethra.
Cystourethroscopy with 12 and 70 degrees optics showed two ostium in the middle urethra at 7 o'clock.
The ostium was a few millimeters apart.
The rest of the urethra showed no abnormalities.
Macroscopically, the diverticulum did not compromise the bladder neck or deform the trigone.
Cystoscopy showed both normal and orthotopic ureteral orifices.
No alterations were found in the rest of the bladder.
The diagnostic impression was a complex urethral diverticulum with two ostia at 7 o'clock in the cystoscopy time in the middle urethra.
A urethral resection was indicated.
The patient was previously informed of the risks of the procedure, including urethrovaginal fistula, urethral stricture, urinary incontinence and possible subsequent reconstructive surgery.
Procedure
General anesthesia.
Lithotomy position.
Sterilization and preparation of the external genital field in the usual manner.
Sedative fixators on the minor lips to expose the anterior vaginal wall.
Anterograde placement of a 16 French supra-plus cystostomy tube was performed using Lowsley's grading system.
The balloon of this catheter was inflated 7 ml of sterile water and left as drainage seriously throughout the operation.
Placement of a 16 Fr Foley urethral catheter in the urinary bladder
Cystoscopy confirmed the preoperative diagnosis.
The anterior vaginal wall was infiltrated with a total of 15 ml of saline solution containing lidocaine and epinephrine.
An incision was made in the urethra and a flap of the anterior vaginal wall was dissected until the periurethral fascia was exposed.
A horizontal incision was made in the periurethral fascia and a plane between the urethral diverticulum and the periurethral fascia was carefully dissected.
The diverticulum wall was thick and indurated.
The diverticulum was dissected to the level of its own neck.
The diverticular neck was dissected just at the tip of the urethra, exposing the previously placed Foley urethral catheter.
The urethra edges were approached by continuously sutured the urethral mucosa with 3-0 Vycril.
In the horizontal plane periurethral fascia was excised with loose points of Vicryl.
Anterior vaginal flap was used as the last layer.
Since there was an excess of anterior vaginal wall tissue that would recombine the diverticulum, the excess was removed and anterior vaginal incision was closed with continuous 2-0 Vicryl suture.
The Foley urethral catheter was left in place and the suprapump cystotomy became severe.
To point out the great difficulty of dissection of the diverticulum that was measured 4 cm in length, mainly due to the difficulty to dissect the entire path to the neck of the diverticulum.
Pathological report: Tissue fragment of 4.0 x 2.0 x 0.5 cm and another tissue fragment of 2.0 x 1.0 x 0.5 cm compatible with complex urethral diverticulum, with chronic inflammation covering dense connective tissue.