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Urethral Diverticulectomy

Urethral diverticulectomy excises the diverticular sac, closes the urethral communication, and reinforces the repair with multilayer closure (± Martius interposition) to minimize fistula and recurrence. Most cases are female and approached transvaginally; rare male diverticula are typically post-urethroplasty / stricture and approached perineally with reconstruction tailored to the resulting urethral defect length.[1][2][3]

For the diagnostic workup of a periurethral mass, see Female Urethral & Periurethral Masses and Urethral Diverticulum (Female). For interposition flap principles, see Martius Flap (foundations).

Epidemiology and Etiology​

Urethral diverticula (UD) are epithelium-lined outpouchings of the urethral mucosa, affecting 1–6% of adult women.[2][3] The dominant etiologic theory is chronic infection / abscess of the periurethral (Skene's) glands rupturing into the urethral lumen.[2][4] Identifiable risk factors: traumatic vaginal delivery (15%), prior periurethral surgery (14%), urethral dilation (8%).[5]

In men, UD are typically acquired, associated with urethral stricture, prior urethroplasty, trauma, or prolonged catheterization.[16][17]

Clinical Presentation​

The classic "3 Ds" (dysuria, dyspareunia, dribbling) are present together in only ~ 5% and are no longer reliable as a diagnostic triad.[7] Most common symptoms: recurrent UTI (23–70%), SUI (38–60%), dyspareunia (12–60%), vaginal mass (52–63%), dysuria (18–60%), post-void dribbling, pelvic pain. Up to 21% are asymptomatic.[7][8] The strongest predictive symptom cluster is LUTS + post-micturition dribbling + recurrent UTI (OR 13.78).[9] Tender anterior vaginal wall mass is the most common physical finding; expression of purulent / mucoid material from the urethra on compression is pathognomonic.[7]

Imaging and Diagnosis​

MRI (post-void T2-weighted) is the gold standard for size, location, configuration (simple / U-shaped / saddle / circumferential), and sphincter relationship.[2][3][10][12] A 24.4% MRI-vs-surgical discrepancy has been reported, including missed intra-diverticular cancer.[13]

ModalitySensitivity / utility
MRI (T2 post-void)Gold standard; configuration + sphincter relationship[2][3]
Pelvic floor ultrasoundSensitivity 94%, specificity 100%; non-invasive first-line[14]
VCUGSensitivity 44–78%; complementary detrusor / sphincter info[10][14][15]
Double-balloon positive-pressure urethrographySensitivity 100% in one series; more sensitive than VCUG[15]

Configuration — most common location is midurethral 46% (distal 30%, proximal 21%).[5] Circumferential UD (> 75% urethral involvement) is the strongest independent predictor of recurrence (OR 7.97) and lower initial cure rates.[16][17]

Indications​

  • Symptomatic UD — recurrent UTIs, pain, dyspareunia, incontinence, voiding dysfunction.[3]
  • Asymptomatic / minimally symptomatic small UD may be observed with post-void manual decompression.[16]
  • All excised specimens to pathology — malignancy (predominantly adenocarcinoma) found in 2–9%.[2][4][18]

Preoperative Preparation​

  • MRI reviewed to plan approach (supine vs prone), Martius need, and urethral-transection requirement for circumferential disease.[1][2][3]
  • Videourodynamics / VCUG to assess detrusor function and pre-existing SUI (14–41%).[1][2]
  • Treat any active UTI to completion before surgery.
  • Consent for de-novo SUI (13–21%), recurrence (2–10%), urethrovaginal fistula, urethral stricture, and the 2–9% malignancy risk.[1][5][6]
  • Perioperative antibiotic prophylaxis per protocol.

Technique 1 — Standard Transvaginal Excision with Three-Layer Closure (84% of cases[7])​

Dorsal lithotomy.[8][1][2]

  1. Setup — 16–18 Fr urethral Foley as a stent / guide; ± SPC for postop drainage.
  2. Cystourethroscopy — identify the diverticular ostium (success ~ 60%), assess number / location, exclude intra-urethral pathology.[8] A guidewire / ureteric catheter into the diverticulum aids intraoperative identification.
  3. Hydrodissection + vaginal incision — dilute vasopressin or 1:200,000 epinephrine for hemostasis; inverted-U incision (preferred) or midline longitudinal over the mass.[8][1]
  4. Vaginal flap elevation — develop the plane between vaginal wall and periurethral fascia; raise lateral flaps wide enough for a tension-free three-layer closure. Maintain flap thickness for blood supply.
  5. Periurethral fascia incision — midline longitudinal; preserve fascial flaps as the critical second layer.[8]
  6. Diverticular sac dissection — sharp + blunt circumferential mobilization; identify the neck. Keep the urethral catheter as a palpable guide to avoid urethrotomy. Adherent / previously-infected sacs require meticulous sharp dissection.
  7. Sac excision — amputate at the neck; excise the entire sac (incomplete excision is the most common recurrence cause). Send for pathology.[9][10]
  8. Layer 1 — urethral mucosa — interrupted or running 4-0 polyglactin; transverse closure to avoid lumen narrowing; watertight (test with saline / methylene blue via the Foley).[8]
  9. Layer 2 — periurethral fascia — interrupted 3-0 polyglactin in a direction perpendicular to layer 1 (the cardinal three-layer principle). For UD > 4 cm, use bipedicle double-opposing fascial flaps (Lask) — left and right fascial flaps advanced and overlapped for a double-thickness layer.[8][19]
  10. Layer 3 — vaginal wall — running 2-0 polyglactin in a third orientation; tension-free; trim redundancy as needed.[8]
  11. Final check — retrograde fill ± end-of-case cystourethroscopy for patency / watertightness.[11]

Technique 2 — Modified Prone Jack-Knife (Chapple / Osman, Sheffield)​

Provides superior gravity-assisted exposure for large or complex UD.[1][5]

  1. Supine phase — cystourethroscopy; place urethral Foley, suprapubic catheter, and 5 Fr ureteric stents for proximal / large UD to protect the orifices.
  2. Reposition prone jack-knife — hips flexed over a break / bolster; buttocks taped apart; surgeon seated with direct view of the anterior vaginal wall.
  3. Dissection / excision / closure — identical principles to Technique 1 (steps 3–11).
  4. Martius flap — used in 30% of the Sheffield cohort; ipsilateral labium majus harvest, subcutaneous tunnel, interposed between fascial and vaginal layers.

Outcomes (n = 121) — 73% continence, 4% recurrence, 13% de-novo SUI, 9% Clavien-Dindo I–II.[1]

Technique 3 — Bipedicle Double-Opposing Fascial Flaps (Lask, for UD > 4 cm)​

Same setup as Technique 1; the modification is at Layer 2:[19]

  • After urethral mucosal closure, the periurethral fascia is incised midline-longitudinally and the two fascial flaps (each on its lateral pedicle) are advanced and overlapped in opposite directions with interrupted 3-0 Vicryl, producing a robust double-thickness fascial layer.
  • Outcomes (n = 17, UD > 4 cm) — 0% recurrence at mean 5 yr.

Technique 4 — Circumferential / Dorsal UD: Urethral Transection and Reconstruction​

Circumferential UD has initial cure of only 64% vs 100% for simple disease.[10] The dorsal component cannot be reached through a standard ventral approach without urethral transection.[12][13]

Rovner / Nickles steps:

  1. Standard vaginal incision and flap elevation.
  2. Complete urethral transection at the level of the diverticulum to access the dorsal wall.
  3. Excise the entire mucosalized surface (partial urethrectomy as needed).
  4. Reconstruction — end-to-end anastomosis when feasible; tubularization of the dorsal diverticular wall to substitute a urethral segment when the dorsal tissue is healthy enough.[12]
  5. Selective Martius interposition for tissue reinforcement.
  6. Selective pubovaginal sling when transection compromises the sphincter.

Outcomes — all subjective pain relief; 6 / 8 pad-free; 1 fistula, 1 stricture.[12]

Mehta alternative — segmental excision without formal transection, incising around / dorsal to the meatus into the retropubic space to access the dorsal component, followed by two-layer urethral repair reinforced with a fibromuscular flap.[11]

Technique 5 — Marsupialization (Spence-Duckett, distal UD only)​

Reserved for distal UD that does not involve the continence mechanism at the midurethra.[6][14]

Classic — Metzenbaum scissors (one blade in urethra, one in diverticulum); incise through the posterior urethral wall and anterior vaginal wall from ostium to meatus; marsupialize diverticular mucosa to vaginal epithelium.

Modified (Welch) — same incision; excise the sac before marsupialization to reduce urethral shortening and improve cosmesis.[6]

Limitation — essentially a generous meatotomy; risk of urethral shortening and cosmetic deformity. Ginsburg / Genadry confined marsupialization to UD in the lower third of the urethra; formal excision for the upper two-thirds.[14]

Technique 6 — Partial Excision / Symptomatic-to-Asymptomatic Conversion​

Conservative alternative for complex UD where complete excision carries high morbidity, or for poor surgical candidates.[15]

  • Mean OR time 75.7 ± 28.9 min; mean EBL 25.5 ± 10.7 mL; median catheterization 15 d.
  • Symptom cure 76.2%; complications mostly Clavien I–II.

Technique 7 — Male Urethral Diverticulectomy​

Approach is perineal or penile depending on diverticulum location (most are bulbar or pendulous).[16][17]

  • Mobilize the urethra; identify the diverticulum.
  • Excise the sac; assess resulting urethral defect length.
  • Reconstruction by defect length:
    • < 4 cm: primary closure or end-to-end anastomosis.
    • ≥ 4 cm: substitution urethroplasty with buccal mucosa graft or penile skin flap (7 / 13 in Alphs).[17]
  • Multilayer closure with dartos / spongiosal coverage.
  • Outcomes — 92% (12 / 13) success at intermediate follow-up, 42% mostly minor complications (Alphs); 91% recurrence-free at 2.3 yr (Cinman).[16][17]

Outcomes Summary​

OutcomeReported rate
Overall cure (transvaginal excision)83–97%[1][2][3][5]
Initial cure — simple UD97–100%[3][5]
Initial cure — circumferential UD64–83%[3][10]
Cure after reoperation92–97%[3][5]
Recurrence (overall)4–10% (primary up to 22%)[1][2][3][10]
De-novo SUI4–21% (most series 13–16%)[1][2][5][18]
Resolution of pre-existing SUI~ 50%[1]
Urethrovaginal fistula~ 2%[1]
Unexpected malignancy in specimen2–2.5%[5][6]

Concomitant Anti-Incontinence Procedure​

Bradley 2020 multicenter retrospective (n = 485): concomitant pubovaginal sling improved SUI resolution (aOR 2.27) but increased long-term retention (OR 6.98) and recurrent UTI (OR 3.27).[20] Most experts defer anti-incontinence surgery for ≥ 6 months because pre-existing SUI resolves in ~ 50% after diverticulectomy alone.[1][2][3]

Postoperative Management​

  • Urethral catheter 10–21 days (median 14–15 d).[1][15]
  • SPC (if placed) clamped at urethral catheter removal; removed once voiding with acceptable PVR confirmed.
  • Voiding trial; PVR (median 26 mL in Sheffield).[1]
  • 6-week clinical exam; 3–6 mo repeat MRI / US to confirm absence of residual / recurrent UD; 6–12 mo final assessment — consider autologous fascial PVS for persistent bothersome SUI.[1][5]
  • Pelvic-floor muscle training postoperatively. De-novo SUI 13–24% early, resolves to ~ 12–13% at 12 mo with conservative management.[1][18]

Technical Pearls and Pitfalls​

  • Three-layer closure with perpendicular suture lines is the single most important principle — overlapping suture lines drive fistula.[2][4][9]
  • Martius alone does not prevent recurrence — meticulous urethral repair is the real determinant.[9]
  • Circumferential configuration is the strongest independent predictor of recurrence (OR 7.97).[10]
  • Convert to urethral transection if the dorsal component cannot be adequately accessed ventrally.[12][13]
  • Avoid excessive cautery near the urethra — thermal injury → delayed necrosis / fistula.
  • Preserve periurethral fascia as much as possible — it is the second layer and supports the continence mechanism.
  • A previously placed Martius can be re-mobilized and repositioned for recurrent repair, avoiding contralateral harvest.[9]
  • End-of-case cystourethroscopy confirms patency and watertightness.[11]

Videos​

Urethral Diverticulectomy: Surgical Demonstration
Dr Deeksha Pandey, Urogynecology for Beginners (2024)

References​

1. Osman NI, Mangir N, Reeves FA, et al. The modified prone jack-knife position for the excision of female urethral diverticula. Eur Urol. 2021;79(2):290-297. doi:10.1016/j.eururo.2020.11.016.

2. Ockrim JL, Allen DJ, Shah PJ, Greenwell TJ. A tertiary experience of urethral diverticulectomy: diagnosis, imaging and surgical outcomes. BJU Int. 2009;103(11):1550-1554. doi:10.1111/j.1464-410X.2009.08348.x.

3. Greenwell TJ, Spilotros M. Urethral diverticula in women. Nat Rev Urol. 2015;12(12):671-680. doi:10.1038/nrurol.2015.230.

4. Ganabathi K, Leach GE, Zimmern PE, Dmochowski R. Experience with the management of urethral diverticulum in 63 women. J Urol. 1994;152(5 Pt 1):1445-1452. doi:10.1016/s0022-5347(17)32442-4.

5. Reeves FA, Inman RD, Chapple CR. Management of symptomatic urethral diverticula in women: a single-centre experience. Eur Urol. 2014;66(1):164-172. doi:10.1016/j.eururo.2014.02.041.

6. Welch EK, Dengler KL, Welgoss JA. Urethral diverticulum marsupialization with modified Spence-Duckett procedure. Urology. 2023;176:248. doi:10.1016/j.urology.2023.02.040.

7. Baradaran N, Chiles LR, Freilich DA, et al. Female urethral diverticula in the contemporary era: is the classic triad of the "3Ds" still relevant? Urology. 2016;94:53-56. doi:10.1016/j.urology.2016.04.005.

8. Pincus JB, Laudano M, Leegant A, Downing K. Female urethral diverticula: diagnosis, pathology, and surgical outcomes at an academic, urban medical center. Urology. 2019;128:42-46. doi:10.1016/j.urology.2018.12.052.

9. Dykes N, Dwyer P, Rosamilia A, Zilberlicht A. Video and review of the surgical management of recurrent urethral diverticulum. Int Urogynecol J. 2020;31(12):2679-2681. doi:10.1007/s00192-020-04357-7.

10. Ko KJ, Suh YS, Kim TH, et al. Surgical outcomes of primary and recurrent female urethral diverticula. Urology. 2017;105:181-185. doi:10.1016/j.urology.2017.02.040.

11. Mehta S, Suh C, Harmanli O. Circumferential urethral diverticulum: a surgical conundrum. Int Urogynecol J. 2020;31(12):2683-2685. doi:10.1007/s00192-020-04359-5.

12. Rovner ES, Wein AJ. Diagnosis and reconstruction of the dorsal or circumferential urethral diverticulum. J Urol. 2003;170(1):82-86; discussion 86. doi:10.1097/01.ju.0000067291.70172.b5.

13. Chung DE, Purohit RS, Girshman J, Blaivas JG. Urethral diverticula in women: discrepancies between magnetic resonance imaging and surgical findings. J Urol. 2010;183(6):2265-2269. doi:10.1016/j.juro.2010.02.016.

14. Ginsburg D, Genadry R. Suburethral diverticulum: classification and therapeutic considerations. Obstet Gynecol. 1983;61(6):685-688.

15. Chen X, Ang X, Xu X, et al. Experience in conversion of symptomatic urethral diverticulum to asymptomatic status through surgery. Sci Rep. 2025;15(1):7533. doi:10.1038/s41598-025-90748-z.

16. Cinman NM, McAninch JW, Glass AS, Zaid UB, Breyer BN. Acquired male urethral diverticula: presentation, diagnosis and management. J Urol. 2012;188(4):1204-1208. doi:10.1016/j.juro.2012.06.036.

17. Alphs HH, Meeks JJ, Casey JT, Gonzalez CM. Surgical reconstruction of the male urethral diverticulum. Urology. 2010;76(2):471-475. doi:10.1016/j.urology.2009.11.080.

18. Malde S, Sihra N, Naaseri S, et al. Urethral diverticulectomy with Martius labial fat pad interposition improves symptom resolution and reduces recurrence. BJU Int. 2017;119(1):158-163. doi:10.1111/bju.13579.

19. Lask A, Rappaport YH, Neheman A, et al. Transvaginal surgical repair of large urethral diverticula with bipedicle double-opposing flaps of the periurethral fascia. Int Urogynecol J. 2021;32(11):2969-2973. doi:10.1007/s00192-020-04486-z.

20. Bradley SE, Leach DA, Panza J, et al. A multicenter retrospective cohort study comparing urethral diverticulectomy with and without pubovaginal sling. Am J Obstet Gynecol. 2020;223(2):273.e1-273.e9. doi:10.1016/j.ajog.2020.06.002.