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OBJECTIVE: Female urethral diverticulum (UD), an evagination of the urethral mucosa into the surrounding connective tissue, is extremely rare in pregnancy. No clear guidelines on the optimal management of UD have been established, except for a common conservative approach. Here, we discuss how to manage UD with pregnancy. CASE REPORT: A 39-year-old gravida 4, para 0, abortion 3 (G4P0A3) woman at 34+0 gestational weeks (GW) visited our outpatient department with a 6-cm septate vaginal mass. Transvaginal ultrasound sonography (TVUS) revealed a 5.5 x 4.9-cm multicystic mass, which was confirmed as UD with pelvic MRI. She was admitted because of preterm labor. A cesarean section was performed at 36+5 GW due to a previous myomectomy, and a healthy male baby was born. UD was still observed in the patient two months after delivery. Periurethral diverticulectomy was performed, and pathological analysis revealed UD with chronic inflammation and edema. CONCLUSION: Previous reports and our case report show that UD can develop during pregnancy and that pelvic MRI is suitable for its accurate diagnosis. Vaginal delivery is possible in pregnant women with the small size of the UD. UD aspiration can permit vaginal delivery in a few cases; however, pus can occur at the aspirated site after the operation. If UD is still observed after delivery, urethral diverticulectomy is recommended.

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Introduction: A Urethral diverticulum can be defined as sac-like dilation lined with epithelial tissue, which may be congenital or acquired. It usually develops in the penoscrotal angle region but can also be observed in the penile urethra. It usually occurs in female teenagers. This report aims to discuss a male infant with a large urethral diverticulum. Case presentation: A 5-month-old male presented to the urological department at Sulaimani Teaching Hospital with a penile swelling that had been noticeable since birth. Clinical examination revealed a ventral cystic penile shaft swelling, which would fill with fluid during urination. A urethrocystoscopy was performed and showed a wide cystic ventral diverticulum. Diverticulectomy was performed as a surgical approach to remove the diverticulum. Discussion: Congenital anterior urethral diverticulum is an uncommon condition that typically begins in early life. It can manifest with various symptoms, like recurrent infections of the urinary tract, painful urination, and post-void urine dribbling. Diagnosis involves imaging, with urethrocystoscopy, to rule out other potential diagnoses. Different surgical techniques exist that show promising results in preventing recurrence. The current case involved diverticulectomy and multi-layered wound closure with a dartos flap. Conclusion: Large anterior diverticulum in early infancy is rare but possible; operation is the preferred intervention method.

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OBJECTIVE: To provide a consensus document for the management of benign female urethral lesions. METHODS: The British Association of Urological Surgeons (BAUS) Female, Neurological and Urodynamic Urology (FNUU) Section created a consensus document to guide the management of the commonest of urethral swellings using expert consensus with a modified Delphi technique. RESULTS: Benign urethral lesions in females can include urethral mucosal prolapse, urethral caruncle, Skene's gland cysts and urethral diverticulum. They can present in a variety of ways including haematuria, lower urinary tract symptoms and voiding dysfunction, and can initially be overlooked or not recognised, resulting in delayed management. CONCLUSION: This consensus statement led by the FNUU Section of the BAUS, in consultation with BAUS members and consultants working in units throughout the UK, aimed to create a comprehensive and pragmatic management pathway for the assessment, investigation and treatment of benign urethral lesions in females.

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This article delves into the diagnostic implications of the female prostate sign, a distinctive radiological sign observed in magnetic resonance imaging of female patients with substantial urethral diverticula. We discuss the association of this sign with urethral diverticula, emphasizing its mimetic resemblance to prostatic hypertrophy observed in older males. Through a comprehensive review of clinical presentations, diagnostic imaging advancements, and treatment modalities, our article underscores the significance of magnetic resonance imaging as a superior diagnostic tool. Our findings support the enhanced recognition and understanding of the female prostate sign among healthcare professionals, facilitating accurate diagnoses and informed management of urethral diverticula.

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INTRODUCTION AND HYPOTHESIS: This video illustrates a rare surgical case involving a urethral diverticulum, urethrovaginal fistula, and mesh erosion. METHODS: We present a 58-year-old patient attending a tertiary care center with a suspected urethrovaginal fistula. Her concerns included stress urinary incontinence (SUI), recurrent urinary tract infection, and vaginal pain. The surgical history was notable for the placement of two different mesh slings during the same procedure to treat SUI. Preoperative evaluation and findings are illustrated in detail. The video uses a high-definition surgical camera to emphasize the initial intraoperative evaluation with localization of the fistula and diverticulum. We then demonstrate the approach to the dissection with the goal of ensuring complete resection of the diverticulum, fistula, and mesh, while preserving healthy tissue for subsequent closure. The utilization of unique and specialized tools for each portion of the procedure is also illustrated. A layered vaginal closure, including a Martius flap, is created to prevent recurrence. RESULTS: The surgery was accomplished without complications. CONCLUSIONS: To our knowledge, concomitant findings of a urethral diverticulum, urethrovaginal fistula, and mesh erosion are unique in the literature. We postulate that this triad could have resulted from the mesh burden in this particular patient.

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Acquired urethral diverticula (UD) in males is an uncommon entity, and it is rarely reported after an open simple prostatectomy or transurethral resection of the prostate. Here, we report a unique case of a UD presenting after holmium laser enucleation of the prostate (HoLEP) in a 69-year-old male with a prostate of 372 g who had five episodes of urine retention over one year despite combined medical treatment with tamsulosin 0.8 mg and finasteride 5 mg. The patient also has elevated prostate-specific antigen (PSA) with five negative prostate biopsies over the last few years. The procedure lasted six hours with difficult morcellation due to beach balls that took 3.5 hours. There were no intraoperative complications. However, he continued to have mixed urine incontinence and recurrent (six) episodes of urinary tract infection (UTI) in the first postoperative year. On evaluation, his urodynamic study did not reproduce stress urinary incontinence (SUI); however, cystoscopy and retrograde urethrogram diagnosed a 6-cm UD in the bulbar penile urethra with penoscrotal mass. The patient underwent urethral diverticulectomy and urethroplasty with a buccal mucosa graft to correct the defect. Six months after his urethral reconstruction, he continued to have mixed urine incontinence needing two pads/day. Although male UD is a rare condition, our case report seeks to heighten awareness of such a potential rare complication in men with recurrent UTIs and refractory urinary incontinence after prolonged HoLEP for extremely large prostates.

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INTRODUCTION: Urethral diverticulum (UD) is a saccular dilatation of the urethral wall, continuous with the true urethral lumen. It is categorized etiologically into congenital and acquired. The etiology of an acquired urethral diverticulum is thought to be secondary to trauma. The gold standard imaging modalities for diagnosis of UD are retrograde urethrogram (RGU) and micturating cystourethrogram (MCU). Management options include: nonoperative treatment, minimally invasive and open surgeries. Open surgeries comprise a primary anastomosis or, Substitution urethroplasty after UD excision, with the aim of excising the diverticulum, reestablishing the continuity of the urethra, and prevent urethrocutaneous fistula formation. We present a case of urethral diverticulum and bulbar urethral stricture successfully managed by surgical excision of UD and substitution urethroplasty. CASE PRESENTATION: We report a case of a 32-year-old man who had lower urinary tract symptoms following a traumatic urethral catheterization. Investigations done in a peripheral hospital revealed a short, bulbar urethral stricture and direct visual internal urethrotomy (DVIU) was done. Later he presented to us with urine retention, whereupon emergency suprapubic cystostomy was performed. After serial investigations, urethral diverticulectomy followed by single stage urethroplasty with ventral onlay buccal mucosa graft was done. He was followed for 12 months with good surgical outcome. DISCUSSION: The development of Acquired UD has been attributed to several possible factors: pelvic fractures, urethral strictures, straddle injuries, long-term urethral catheterization, endoscopic direct injuries, lower urinary tract infections, and urethral surgeries. Depending on the presentation and investigation findings, management of UD is planned. Conservative management is possible for uncomplicated asymptomatic UD if the patient consents to follow-up. Surgery to remove the diverticulum and urethral reconstruction are required for complicated symptomatic UD; these procedures vary from patient to patient and are individualized. CONCLUSION: It is important to base the choice to do surgery on the clinical presentation. Whether a concurrent urethral stricture is present is a critical factor in deciding on the best course of surgical treatment. In our case we opted to perform a substitution urethroplasty with ventral onlay buccal mucosa graft as our patient had a long bulbar urethral stricture proximal to the diverticulum.

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Long-term complications of hypospadias surgery can lead to urethral diverticula, causing issues like stone formation, incomplete voiding, and infections. We present a case: a 45-year-old male, who underwent two-stage penile hypospadias repair at age three, now experiencing lower urinary obstruction symptoms. Urethroscopy revealed urethral stenosis and stone formation within the diverticulum. After successful stone removal without diverticulum excision, a urethrotomy was performed. Early stricture detection post-hypospadias repair, through routine calibration, is vital for efficient treatment. Urethral diverticulum with stone formation in adult males post-hypospadias surgery is rare. Efficient management typically involves stone removal and a simple urethrotomy, minimizing surgical interventions.

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Post-hypospadias repair, hair growth within the urethra, and subsequent hair bezoar formation can lead to significant complications, including urinary tract infections (UTIs) and urinary flow obstruction. Using hair-bearing skin in hypospadias repair can cause these complications. We report a 55-year-old male who underwent two-stage penile hypospadias repair at age three, presenting with recurrent UTIs and lower urinary tract obstruction symptoms. Urethroscopy identified a hair bezoar in a wide-mouth diverticulum of the penile urethra. Post-extraction of the hair bezoar using a rigid cystoscope, transcutaneous neodymium-doped yttrium aluminum garnet (ND:YAG) laser epilation was employed to ablate urethral diverticular hair follicles. Hair bezoars in the urethra, although rare in modern practice, may obstruct urine flow and act as a nidus for UTIs. Transcutaneous ND:YAG laser has emerged as a minimally invasive technique, offering a simple, effective solution for urethral hair removal with minimal complications. Transcutaneous ND:YAG laser epilation serves as a viable first-line treatment for urethral hair follicles following hypospadias repair, emphasizing its significance in preventing recurrent complications in such patients.

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Male urethral diverticulum is an uncommon condition typically caused by previous surgeries, inflammation, or trauma. There are very few case reports of primary male urethral diverticulum, with only one report linking it to ejaculatory problems. In this report, we present a rare case of congenital male urethral diverticulum who presented with lower urinary tract symptoms and anejaculation that was successfully treated through open urethral diverticulectomy.

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Teaching Point: Female urethral diverticulum is a rare condition that is often a diagnostic challenge; magnetic resonance imaging (MRI) is efficient to confirm the diagnosis (especially if endovaginal ultrasound is inconclusive), to assess the diverticulum prior to surgery, and to detect related complications including intra-diverticular neoplasm.

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Nephrogenic adenoma is a benign lesion of the urothelial tract characterized by tubules surrounded by thick, hyalinized basement membranes. There is a great variety of architectural patterns within nephrogenic adenomas, including patterns that mimic malignancy, such as focal clear or hobnail cells, areas of significant nuclear atypia, mitosis, and isolated cystic changes. This represents a diagnostic pitfall, where a malignant lesion can be mistaken for a nephrogenic adenoma, leading to a delay in diagnosis and treatment that adversely affects the outcome. In this case report, we describe a nephrogenic adenoma arising in a female urethral diverticulum and discuss the differential diagnosis, which includes clear cell carcinomas, microcystic variant urothelial carcinomas, and Skene's gland cysts.

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Introduction: Urethral clear cell carcinoma is rare and often arises from a urethral diverticulum and rarely from the Müllerian duct. However, an explanation for this correlation remains unknown. Case presentation: We report the case of a 46-year-old woman who presented with hypermenorrhea. Magnetic resonance imaging revealed a papillary tumor in a cystic lesion in the dorsal urethra. We performed a robot-assisted radical cystourethrectomy and created an ileal conduit. Since pathological findings revealed microvascular and lymphovascular invasions around the urethra, adjuvant radiation therapy was administered. The patient showed no signs of recurrence or metastasis after treatment. Conclusion: We report a case of clear cell carcinoma in a female urethral diverticulum originating from a Müllerian duct cyst. While postoperative radiation therapy has been shown to produce a good outcome in carcinoma cases similar to this one, we recommend that a radical cystourethrectomy be performed.

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INTRODUCTION AND HYPOTHESIS: A 31-year-old patient with a history of fetal sacrococcygeal teratoma requiring tumor resection and pelvic reconstruction in infancy presented with a 3-year history of recurrent vulvar abscesses and voiding dysfunction. Magnetic resonance imaging demonstrated a fluid collection posterior to the pubic bone and inferior to the bladder. The objective was to demonstrate the key steps in the resection and repair of an anterior urethral diverticulum via robot-assisted laparoscopic approach. METHODS: Cystoscopy followed by robot-assisted laparoscopic retropubic dissection was used for resection of an anterior urethral diverticulum followed by urethral reconstruction. RESULTS: Cystoscopy revealed a large anterior cavity at the midpoint of the urethra consistent with an anterior urethral diverticulum. This likely tracked inferiorly toward her vulva during repeated episodes of infection expressing through her recurrent abscesses. Retropubic space exploration revealed dense fibrotic tissue adherent to the underside of the pubic tubercule contiguous with the anterior urethral diverticulum, which was successfully resected. CONCLUSIONS: Female anterior urethral diverticulum is a rare entity. A robot-assisted laparoscopic approach can be safely utilized to identify and resect an anterior urethral diverticulum. Key points include optimization of port placement, use of a council-tip catheter to facilitate bladder drainage in the setting of distorted pelvic anatomy, and multi-layered tension-free urethral closure with flap placement.

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BACKGROUND: A posterior urethral diverticulum (PUD) is a serious postoperative complication after anorectal malformation correction. Complete resection is technical demanding because of limited retrourethral working space deep in the pelvis. OBJECTIVE: We pioneered the single-incision laparoscopic approach for PUD excision and evaluated the efficacy. DESIGN, SETTING, AND PARTICIPANTS: Twenty-six PUD patients undergoing redo surgeries between June 2011 and June 2021 were reviewed. SURGICAL PROCEDURE: A series of transabdominal retraction sutures were placed through the PUD to facilitate dissection. The contents were evacuated to create a working space. Distal PUD dissection was carried along the submucosal layer to prevent injury of the urethra/pelvic nerve complex. The rectal mucosa was peeled off from the junction site for complete PUD excision. The muscular cuff of the distal rectum was then oversewn. MEASUREMENTS: Operative time, postoperative recovery, and complications were assessed. RESULTS AND LIMITATIONS: The mean age of redo surgery was 2.46 yr. The average operative duration was 2.35 h. The mean postoperative hospital stay, resumption of full diet, and bowel movement were 10.23, 2.15, and 1.54 d, respectively. The median follow-up period was 46 mo (12-132 mo). No remnant of PUD, recurrent fistula, or urinary leak was detected. None of the patients had difficulty in urination, urinary dribbling, urinary tract infection, constipation, or soiling. All patients retained morning erection, and two postpubertal patients had ejaculations. CONCLUSIONS: Our single-incision laparoscopic redo surgery provides an effective approach for PUD excision. It minimizes complications. It also preserves urinary and bowel continence and sexual function. PATIENT SUMMARY: Complete resection of a posterior urethral diverticulum (PUD) in anorectal malformation is technically demanding because of limited retrourethral working space in the deep pelvis. The outcomes of single-incision laparoscopic PUD excision were satisfactory.

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INTRODUCTION AND HYPOTHESIS: The purpose of this study was to evaluate the sensitivity and specificity of pelvic floor ultrasound (PFUS) in the diagnostic work-up of female urethral diverticulum (UD) and to compare results of PFUS with voiding cystourethrogram (VCUG). METHODS: We retrospectively reviewed our database of patients, who received VCUG and PFUS for the diagnosis of UD. A total of 196 consecutive female patients with a minimum of one symptom, such as a lower urinary tract symptom (LUTS), postmicturition dribble, dyspareunia and recurrent urinary tract infection (UTI) who underwent initial diagnostics with VCUG and PFUS were selected. Diagnostic performance of both procedures, which included size, complexity, echogenicity. and content were compared. RESULTS: Recurrent UTI and LUTS were the most common symptoms, which were present in 165 (84%) and 163 patients (83%) respectively. Final diagnosis of UD was based on PFUS and VCUG findings in 69 (35%) and 58 (30%) cases respectively. Based on our study cohort, the sensitivity of PFUS in detecting UD was significantly higher than that of VCUG: 94% (IQR: 89-97) versus 78% (IQR: 73-85, p<0.01), with a trend toward higher specificity: 100% (IQR: 94-100) versus 84% (IQR: 78-84, p=0.05). Enabling direct UD visualisation, PFUS was associated with a positive predictive value (PPV) of 100% (IQR: 97-100) and a negative predictive value (NPV) of 88% (IQR: 78-95), whereas VCUG had an inferior accuracy with a PPV of 84 (IQR: 80-84) and a NPV of 68 (IQR: 62-79). CONCLUSIONS: In clinical practice, VCUG has a lower sensitivity than PFUS. Based on these results, we recommend the usage of dynamic PFUS as part of a non-invasive work-up.

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Congenital anterior urethral diverticulum is a rare entity that can occur at any age but exceptionally in adults. Its diagnosis is suspected clinically by obstructive symptoms of the lower urinary tract most often associated with a penoscrotal ball. Its management consists of a diverticulectomy associated or not with a urethroplasty depending on the size of the diverticulum. We discuss through a case report the clinical and therapeutic aspects of this rare entity.

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OBJECTIVE: To report the management for a urethral diverticulum presenting with pure stress urinary incontinence (SUI). CASE REPORT: A 67-year-old postmenopausal woman resorted to urogynecological outpatient department for the treatment of bothersome SUI. She denied other lower urinary tract symptoms and previous pelvic surgeries. On examination, there was stage I anterior vaginal wall prolapse. Urinalysis showed negative findings. Urodynamic studies revealed negative findings. An ultrasound disclosed a complex paraurethral lesion and no urethral hypermobility. A magnetic resonance image of the pelvis revealed a 4-cm circumferential urethral diverticulum. A urethral diverticulectomy was performed. Histopathological examination confirmed the diagnosis of urethral diverticulum. The patient recovered uneventfully and reported freedom from SUI postoperatively. CONCLUSION: In women deemed uncomplicated stress urinary incontinence after undertaking a holistic urogynecological evaluation including detailed clinical history, physical examination, and urodynamic studies, further image studies investigating lower urinary tract is required for disclosing other rare conditions that necessitate different management from anti-incontinence surgery.

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A rare case of male urethral diverticulum presents in this article. A 34-year-old man was referred to our clinic because of post-void dribbling. The retrograde cystogram and cystoscopy confirmed a 3 cm urethral diverticulum in the penile urethra without having urethra stricture. Open surgical repair was scheduled to excise urethral diverticulum and restore urethral continuity. Corpus spongiosum and dartus fascia was used to reinforce the repair.