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+A 35-year-old woman consulted for terminal dribbling or "drooling micturition", dyspareunia and repeated urinary tract infections. Intravenous urography and voiding cystography showed findings compatible with urethral diverticulum. The patient had urinary frequency and nocturia 3 to 4 times. Occasionally she had had isolated episodes of stress urinary incontinence, for which she used a daily protective pad. She had urinary urgency and occasional urge incontinence. There was no urinary voiding, no sensation of bladder pressure or incomplete emptying. No haematuria or symptoms or signs of genitourinary cancer. Normal bowel rhythm. No previous female sexual dysfunction until the present dyspareunia affecting her sex life. No neurological pathological history.
+Medical and surgical history: High blood pressure. Asthma in childhood. Occasional lumbosacral pain. Laparoscopic cholecystectomy 2 years ago. Two caesarean sections, the last one 12 years ago. On antihypertensive treatment with atenolol, chlorthalidone and amlodipine. No known allergies. No diabetes. No smoking or drinking.
+Physical examination: Morbid obesity. Good general health. Examination of the head, neck and cardio-pulmonary system with no pathological findings. Blood pressure: 140/100. Abdomen soft, obese, not painful, no hepatosplenomegaly. Pelvic examination in dorsal lithotomy position: relatively narrow vaginal introitus; bulge in the suburethral area near the bladder neck and mid urethra approximately 2.5 cm in diameter, fluctuant, compatible with a urethral diverticulum. No pus was obtained on pressure. No stress incontinence was observed.
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+Magnetic resonance imaging (MRI) of the pelvis was performed on axial T1, axial T2, fatty T2 sequences in both right and left images. Two liquid formations were found in the pelvis. The larger one measured 3.4 cm in its longitudinal axis, in the right parasagittal area, the second collection measured 1 cm in its longitudinal axis. The one cm diameter formation had the same characteristics and was located between the parasagittal and mid-sagittal area. A relationship to the urethra could not be documented in the other sequences. The impression was of a large urethral diverticulum, at least 3.5 x 2.5 cm, however, it could not be ruled out that the smaller collection was a Bartholin's gland cyst.
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+Flexible cystourethroscopy under anaesthesia revealed a large urethral diverticulum 10 mm from the bladder neck. On compression, there was no drainage from the urethra.
+At cystourethroscopy with 12 and 70 degree optics, two ostia were found in the mid urethra at 7 o'clock cystoscopic time. The ostia were within a few millimetres of each other. The rest of the urethra was unaltered. Macroscopically, the diverticulum did not involve the bladder neck, nor did it deform the trigone. Cystoscopy showed both ureteral orifices to be normal and orthotopic. No alterations were found in the rest of the bladder. The diagnostic impression was of complex urethral diverticulum with two ostia at 7 o'clock cystoscopic time in the middle urethra.
+A urethral diverticulectomy 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 anaesthesia. Lithotomy position. Sterilisation and preparation of the external genitalia field in the usual way. Silk fixation stitches in the labia minora to expose the anterior vaginal wall. Antegrade placement of a 16 French suprapubic cystostomy tube using the Lowsley retractor. The balloon of this catheter was inflated with 7 ml of sterile water and left as a gravity drain for the duration of the operation. Placement of a 16 Fr Foley urethral catheter into the urinary bladder. Cystoscopy was performed confirming the preoperative diagnosis. The anterior vaginal wall was infiltrated with a total of 15 ml of saline containing lidocaine and epinephrine. An inverted U-shaped incision was made 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. It should be noted that the wall of the diverticulum was very thick and indurated. The diverticulum was dissected down to the level of its own neck. The diverticular neck was sectioned just flush with the urethra, exposing the previously placed Foley urethral catheter. The edges of the urethra were approximated by suturing the urethral mucosa continuously with 3-0 Vycril. In the horizontal plane the periurethral fascia was reapproximated with loose Vicryl stitches. The anterior vaginal flap was used as the final layer. As there was excess anterior vaginal wall tissue overlying the diverticulum, the excess was trimmed and the anterior vaginal incision was closed with continuous 2-0 Vicryl suture. The Foley urethral catheter was left in place and the suprapubic cystotomy was left draining under gravity. It should be noted that dissection of the diverticulum, which was 4 cm in length, was very difficult, mainly due to the difficulty of dissecting the entire length of the diverticulum up to the neck of the diverticulum. Pathology report: Tissue fragment measuring 4.0 x 2.0 x 0.5 cm and another tissue fragment measuring 2.0 x 1.0 x 0.5 cm compatible with complex urethral diverticulum, with chronic inflammation covering dense connective tissue.
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