It is well recognized that certain conditions such as urethral stricture, blunt trauma and infection are associated with UD development. As evidenced by our experience, there is a significant iatrogenic association.
Three suspected mechanisms exist for acquired male UDs. One mechanism is related to obstruction and increased urethral pressure with subsequent herniation of the urethral epithelium. This tends to occur in patients with a complex urological history often involving previous reconstructive procedures for hypospadias, urethral stricture and trauma or incontinence.8
The second mechanism is a result of constant pressure distributed on the penoscrotal angle, which causes chronic urethral ischemia and induces urethral fibrosis and scar formation. This sometimes applies to male patients with an indwelling urethral catheter.7
The third mechanism incorporates anorectal malformation repair with UD occurring in 12% to 18% of cases.9,10
A UD develops from a retained portion of the urethral fistula and balloons out as more urine is sequestered in the herniated structure. It is suggested that a posterior sagittal surgical approach for the repair of anorectal malformation may lead to a decrease in the UD rate.
It is well accepted that the gold standard for evaluating a UD in a female involves magnetic resonance imaging.11
While there are reports of magnetic resonance imaging used to evaluate male urethral diverticula,12
fluoroscopic modalities in conjunction with urethral ultrasonography provide excellent details of the UD. These studies demonstrate UD location, volume, neck size and other urethral pathology. Patients with urological hardware should be evaluated with cystoscopy to rule out urethral obstruction and erosion.
While many patients who present with symptoms related to the UD require surgical correction, UD treatment should be individually based. Consideration should be given to the size and thickness of the UD wall, integrity of the corpus spongiosum, concomitant urethral pathology and symptoms. As evidenced by our experience, a small asymptomatic UD can be managed nonoperatively with post-void manual compression of the diverticulum to eliminate urinary stasis.13
In this study 7 patients were successfully treated in a conservative manner and avoided surgery for the UD at a mean of 3.2 years of followup. Patients treated nonoperatively may require prophylactic antibiotic consumption to keep the urine sterile. They also warrant close followup with the possibility of surgery at a later date should the condition progress.
We believe that endoscopic management of a UD is not curative and has a likelihood of failure with a need for reoperation. While it may be a technically easier option, there is an association with UD recurrence and risk of urethrocutaneous fistula.7
Endoscopic UD unroofing is also inadvisable when the surrounding supportive tissue is deficient, when a large poorly draining cavity is likely to remain or when the UD is too thick for adequate incision.14
Since many patients with an acquired UD underwent prior urethral surgery with the risk of compromised surrounding tissue support, integrity and scarring, patients in this series who were considered surgical candidates were treated with more definitive operations with UD excision and urethral reconstruction.
If nonoperative treatment is not appropriate, an open procedure must be considered. The goal of urethral diverticulectomy surgery is to excise the UD, restore urethral continuity and provide additional tissue to reinforce the repair to minimize the development of a urethrocutaneous fistula. The simplest surgical option to achieve these goals should be selected.
While local urethral and penile flaps were used in this cohort without any buccal mucosal grafts, extragenital grafts can be used, especially for larger defects of the urethral lumen.15,16
If the urethral defect is large, extragenital grafts can placed ventral to avoid fistula formation and relapses derived from simple closure techniques.17
Grafts obtained from hair bearing skin should be avoided.
Urinary diversion can be a suitable option for patients with neurogenic bladder, especially those who may need frequent urethral catheterization for bladder drainage. For patients in whom urethral reconstruction is expected to be nonreconstructable (those with multiple surgeries, anatomical abnormalities or extensive fibrosis from prostatic or pelvic radiation), urinary diversion remains an option.
Strengths of this study include the relatively large size of the cohort and the spectrum of management options. Not all male patients who present with a UD need surgical treatment. However, in some patients urinary diversion may be the most efficient definitive treatment option, although with its own inherent risks.
Patient followup may be limited, secondary to patients being referred back to care by local urologists. Since many patients lived a significant distance away and were referred to our tertiary care center, after the patient was considered clinically stable the choice was given to resume care with a local urologist. This resulted in a shorter followup. However, there is a significant likelihood that if symptoms were to recur in these patients, they would return to our center for additional care.