Preoperative CT voiding cystourethrography using 16-multidetector CT in female urethral diverticulum

Preoperative Transurethral Contrast-Enhanced Ultrasonography in the Diagnosis of Female Urethral Diverticula

OBJECTIVES

To explore the value of transurethral contrast-enhanced ultrasonography (CEUS) in the diagnosis and evaluation of female urethral diverticula.

METHODS

This study prospectively enrolled 35 women with periurethral cystic lesions, who underwent preoperative transurethral CEUS at our single center between April 2015 and May 2017. The diagnosis of a urethral diverticulum was made by the detection of microbubbles inside the lesion. Data regarding the structure and ostia of the diverticula were collected and then compared with intraoperative findings.

RESULTS

The median (interquartile range) age of the 35 patients was 43 (34-48) years. The most common manifestations were dysuria (43%) and palpable masses (40%). On transurethral CEUS, 20 patients were found to have urethral diverticula. The diverticula involved the proximal, mid, and distal urethra with different sizes. The shapes of the diverticula were simple in 4 patients (20%), U shaped in 8 patients (40%), and circumferential in 8 patients (40%). A total of 23 ostia were identified. Seventeen women (85%) had 1 ostium, and 3 women (15%) had 2 ostia. Twenty-one diverticular ostia (91%) were located from the 3- to 9-o'clock positions. The median (interquartile range) distance from the diverticular ostia to the bladder neck was 20 (9-31) mm. During surgery, all US presentations correlated well with surgical findings, and 21 patients were confirmed to have urethral diverticula. The transurethral CEUS had sensitivity of 95% and specificity of 100%.

CONCLUSIONS

Transurethral CEUS is an effective method for identifying the structure and ostium of female urethral diverticula. It may have a potential role in preoperative planning and surgical management.

Female urethral diverticula: An elusive pathology that can cause significant problems

Female urethral diverticula are a rare pathology, although thought to be under-diagnosed. They can present with a large variety of symptoms, and can be complicated by stones or malignancy. Magnetic resonance imaging is widely accepted to be the best form of imaging for this condition, although voiding cystourethrogram studies are helpful in providing information on bladder function. Symptomatic patients should be treated surgically through urethral diverticulectomy.

Level of evidence: Not applicable for this multicentre audit.

Preoperative 3D and 4D-CT imaging using 640-Multislice CT (640-MSCT) in diagnosis of female urethral diverticulum

Objective

To determine the sensitivity and specificity of 640-Multislice CT (640-MSCT) in diagnosing the female UD.

Materials and methods

We investigated 16 patients with symptomatic UDs preoperatively in our hospital from August 2010 to March 2016. The patients’ average age was 38.8 years. All patients were performed 640-MSCT of pelvis; then, 3D and 4D images were reconstructed preoperatively.

Results

In 3D and 4D-CT images, out of 16 patients, thirteen patients had one ostium, two had 2 ostia and one had 3 ostia. Out of those thirteen patients, eight patients’ ostia were located at 5 o’clock and five patients’ at 7 o’clock. Patients with 2 ostia location were at 5 and 6 o’clock and 5 and 7 o’clock, respectively. Patients with 3 ostia location were at 5, 6 and 7 o’clock. The mean distance from the bladder neck to the ostia was 22.5 mm. The shape of UD was out-pouching in 11 patients (68.8%), U-shaped in four patients (25.0%) and circumferential in 1 patient (6.2%). The CT findings were confirmed by surgical findings.

Conclusions

640-MSCT is a useful tool in identifying UD’s shape and ostium (including number, location) before operation. Preoperative 640-MSCT should be an adaptable modality for clinically suspected UD patients.

Advances in knowledge

Several imaging methods have been used to diagnose female UD. 640-MSCT may be more suitable to diagnose it for its higher sensitivity and specificity in diagnosis of female UD, especially in identifying UD’s shape and number and location of ostium.

Urethral diverticula in women

Female urethral diverticula are rare, benign epithelium-lined outpouchings of the female urethra. Patients can present with a multitude of symptoms, most commonly urinary incontinence, recurrent UTIs and dyspareunia. These presenting symptoms are often confused with other diagnoses leading to delayed diagnosis or misdiagnosis. Diagnosis and preoperative assessment of bladder function is most accurate using a combination of clinical examination, T2-weighted postvoid MRI and videocystometrography. Best treatment is by vaginal excision, a procedure with a very low recurrence rate and high patient acceptability. Excision also results in high cure rates for associated dyspareunia, UTI and voiding dysfunction. Pre-existing urodynamically proven stress urinary incontinence (USUI) resolves in 50% of patients after excision of the diverticulum with Martius labial fat pad interposition without the need for further treatment. Potential adverse effects after surgery are new-onset USUI, urethrovaginal fistula and urethral stricture. The rate of onset of these potential adverse effects is low and related to the preoperative appearance of the diverticulum on an MRI scan and the complexity of the diverticulum.