Background Urethral diverticulum is an uncommon complication after hypospadias repair and presents as ballooning of the penile urethra with associated lower urinary tract symptoms. We report our experience with surgical repair.
Methods We reviewed records of 44 patients (2-29 years old) operated by a single surgeon between 2007 - 2018 who underwent operative repair of urethral diverticulum and were gleaned from our database of 583 patients who underwent revision or repeat hypospadias repair.
Results Most patients in the cohort were referred or self-referred (42/44). There were 4 adult patients aged 20-29 years old, who developed symptoms 2-3 years prior to referral. Diverticulum formation was noted in 37 children with onset ranging 1.5-4 years (median 2.75 years). The most common primary repair was staged Byar skin-flap repair (n=26), island-onlay preputial flaps (n=4), redo Thiersch-Duplay repairs (n=3) and tubed mucosal grafts (n=2). Surgical records unavailable in 5 children. Voiding dysfunction was prevalent (21/40 children). 11 patients had history of culture-proven urinary tract infections (UTI). All 44 patients had terminal or subterminal meatus, and only 3 children had meatal stenosis. Surgical repair is shown in Figure 1, the diverticular walls are de-epithelialized and wrapped over the urethroplasty for mechanical support. In resurfacing, the thinned/stretched skin over the diverticulum was avoided, and Z-plasties used to achieve tension-free skin closure and define the penoscrotal junction. Office follow-up ranged from 6 months to 7 years (median 2 years). 4 children developed UTI after repair, and 3 had ongoing dysfunctional voiding and constipation. One child developed proximal and meatal strictures and was corrected at another institution. All patients reported normal urinary stream without post-void dripping compared with preoperative urinary flows. None developed diverticulum recurrence or fistula formation.
Conclusions In this series, meatal stenosis was an uncommon cause of diverticulum formation. We hypothesize the compliance differential between normal glandular tissue and tubed skin flaps, or mucosal graft can unmask the mechanical weakness of the neourethra resulting in diverticulum formation. This is supported by the high proportion of patients with voiding dysfunction in our cohort. The etiology in the 4 adults is unclear. The principles for our diverticular repair emphasize maximal mechanical support to compensate for the non-spongiosum neourethra. This surgical technique proved to be highly successful with no recurrent diverticulum, fistula, or stricture formation.
Figure 1: 1A - Pre-operative VCUG showing urethral diverticulum and high pressure vesico-ureteral reflux and posterior urethral dilation. Bladder trabeculation noted at cystoscopy. 1B - Urethral calibration with 12 Fr sound. 1C - Urethral diverticulum is distended. 1D - Diverticulum incision is made lateral to midline and urethroplasty marked. 1E - Urethroplasty and de-epithelialization of the walls of the diverticulum. 1F - Right diverticulum wall wrapped over urethroplasty. 1G - Left wall of diverticulum is wrapped in double-breasted fashion. 1H - Coverage by a third layer of dartos flap and resurfacing the repair. 1I - Post operative VCUG.
