Urethral Diverticulum Excision and Placement of Autologous Fascia Lata Sling

Abstract

Video Objective To show the repair of an uncommon urogynecological pathology, and to illustrate a case where an autologous fascial graft is placed for management of stress urinary incontinence. Setting The patient is a 59-year-old with abdominal pain, urinary incontinence, incomplete bladder emptying, and hematuria. She has a complex past medical and surgical history. Pre-operative urodynamic testing showed genuine stress urinary incontinence, and office cystoscopy was unremarkable. Imaging demonstrated a urethral diverticulum containing multiple stones. The patient proceeded to the operating room for excision of the diverticulum and placement of an autologous sling. Interventions Fascia lata from patient s right thigh was harvested and prepared with polypropylene sutures at each end. Cystourethroscopy identified the diverticulum opening in the posterior mid urethra. The anterior vaginal mucosa was incised and the pubocervical fascia was dissected. The bulge of the urethral diverticulum was identified. Entry into the diverticulum was encountered during the dissection, and multiple stones were removed. The entire diverticular sac was dissected from the posterior urethra and pubocervical fascia. The urethral wall was reapproximated. The periurethral fibromuscularis was closed in a vest-over-pants fashion in order to avoid overlapping suture line with the urethral closure. An abdominal incision was made above the pubic symphysis. Needle trocars were passed vaginally through retropubic space. The polypropylene stitches on the fascial lata graft were threaded through the needles and pulled onto the abdomen, placing the sling in place. The sutures were then sewn through the rectus fascia and tied in the midline. Final cystourethroscopy confirmed patent ureteral orifices, normal bladder mucosa, and intact urethral repair. A Foley catheter was replaced and maintained for 4 weeks. A voiding cystogram showed intact bladder and urethra. Conclusion This case depicts a scenario where autologous sling is preferable over synthetic mesh due to decreased risk of erosion when a urethral diverticulum is repaired.