Female urethral diverticulum is a rare condition which affects less than 1% of adult women every year [1]. It is often difficult to diagnose, and most women do not present with the classic triad of dysuria, dyspareunia and post-void dribbling. The most commonly used repair technique is transvaginal resection of the diverticulum, with or without reconstruction. However, other methods such as marsupialisation and transurethral endoscopic de-roofing have also been described [2].

A retrospective review of female patients who had surgery at our institution (Singapore General Hospital) for urethral diverticulum from 2008 to 2018 was performed. Demographic, clinical presentation as well as peri- and post-operative data such as duration of surgery, post-operative complications, length of stay, post-operative catheter duration, symptomatic cure and recurrence were retrieved and analysed.

We also present a step-by-step instructional video of transvaginal urethral diverticulum excision and Martius interposition flap reconstruction in a 70-year-old patient with a 2.6 cm circumferential diverticulum at the mid-urethra with several calculi within.

15 women had urethral diverticulum excision performed at our institution over 10 years, all through a transvaginal approach. The mean age was 48.5 (range 21-70) years and the most common presenting symptoms were the presence of a vaginal lump (46.7%), followed by dysuria (20%) and perineal pain (20%). All patients in our series had a single diverticulum with a mean size of 30.7 (range 15–70) mm. 

Five patients received a Martius labial interposition flap reconstruction, while ten had transvaginal diverticulum excision only. Two patients from the cohort (13.3%) had Clavien Grade II & above complications. There was no recurrence reported in all patients within a mean follow-up of 11.2 months and histological examination of all diverticula revealed benign pathology.

The mean length of stay and post-operative catheter duration were 2.5 and 11.5 days respectively. Patients who underwent a Martius labial interposition flap had 1.9 times longer length of stay and post-operative catheter duration as compared to those who did not (p<0.05 for both). There was no difference in mean diverticulum size for in the patients who underwent a Martius labial interposition flap as compared to those who did not (33.3 vs 29.1 mm; p=0.58). Additionally, there were also no difference in complication rates between both groups (p=0.62).

The presentation of urethral diverticulum is varied, and the clinician should have a high index of suspicion for diagnosis in patients who present with pyuria or urinary tract infection. Transvaginal excision is an effective surgical option for repair with minimal morbidity. The addition of a Martius labial interposition flap is a viable adjunct procedure but may increase the length of hospital stay.

El-Nashar SA, Bacon MM, Kim-Fine S, Weaver AL, Gebhart JB, Klingele CJ. Incidence of female urethral diverticulum: a population-based analysis and literature review. International Urogynecology Journal. 2014;25(1):73-9.
Bodner-Adler B, Halpern K, Hanzal E. Surgical management of urethral diverticula in women: a systematic review. International urogynecology journal. 2016;27(7):993-1001.