Suburethral Diverticulectomy via the Double-Breasted Closure Technique

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Vagina and Urethra

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McIndoe Vaginoplasty for Neovagina

Rectovaginal Fistula Repair

Reconstruction of the Urethra

Marsupialization of a Suburethral Diverticulum by the Spence Operation

Suburethral Diverticulum via the Double-Breasted Closure Technique

Urethrovaginal Fistula Repair via the Double-Breasted Closure Technique

Goebell-Stoeckel Fascia Lata Sling Operation for Urinary Incontinence

Transection of Goebell-Stoeckel Fascia Strap

Rectovaginal Fistula Repair via Musset-Poitout-Noble Perineotomy

Sigmoid Neovagina

Suburethral Diverticulectomy via the Double-Breasted Closure Technique

Suburethral diverticula may be discovered in patients evaluated for recurrent or chronic urinary tract infections. The diverticula formation can be congenital or secondary to trauma of the female urethra.

The purpose of the operation is to remove the diverticulum and close the urethra without producing a stricture. This procedure should be utilized only for diverticula located in the middle and proximal thirds of the urethra. Suburethral diverticula in the distal one-third of the urethra are managed effectively by the Spence operation.

Physiologic Changes. A source of chronic infection that is also a potential site of urethral stone formation is removed.

Points of Caution. After excision of the suburethral diverticulum, adequate mobilization of the surrounding tissues must be made to close the wound without tension and reduce the chance of urethral stricture. If the tissue is brought together under tension, necrosis can occur, and a fistula may develop.

Technique

Figure 1 is a sagittal section of the female bladder, urethra, and vagina, showing a suburethral diverticulum. Diverticula can be diagnosed either by urethroscopy or with the use of a Davis double-balloon catheter in which x-ray contrast media is injected under pressure.

This special catheter entraps x-ray contrast dye between the two inflated balloons, forcing dye into a diverticulum. A lateral x-ray film can demonstrate the diverticulum.

The patient is placed in the dorsal lithotomy position, and the perineum is prepped and draped in the usual fashion. A uterine sound has passed through the urethra into the bladder. The vaginal mucosa is opened over the suspected diverticulum. Figure 2 shows the vaginal mucosa, pubovesical cervical fascia, and the urethral mucosa.

The urethral mucosa is closed over the diverticulum with a running monofilament 4-0 synthetic absorbable suture. The sutures should be placed with the uterine sound in position to prevent stricture of the urethra. Notice that the pubovesical cervical (PVC) fascia has been developed into 2-3 cm-wide flaps of fascia. The vaginal mucosa has been dissected laterally and is held laterally with Allis clamps.

The double-breasted closure technique is performed with monofilament delayed synthetic absorbable suture. The right pubovesical cervical fascia flap is sutured across to the base of the opposite pubovesical cervical fascia flap. It is best to place all these sutures prior to tying them. This will allow more accurate placement of the sutures.

Note that the vaginal mucosa is retracted laterally. On the patient's left, the opposite pubovesical cervical fascia is retracted out of the suture line.

The left pubovesical cervical fascia flap is now sutured over the right pubovesical cervical fascia flap in a double-breasted fashion with monofilament delayed synthetic absorbable suture used.

The vaginal mucosa is closed in the midline with 2-0 synthetic absorbable suture. Catheter drainage should be continuous for 1 week. This can be accomplished with a suprapubic Foley catheter or a transurethral Foley catheter.