Female urethral diverticulum is a rare condition and occurs in 1-6% of women. Recurrence after surgery, although, is common, occurring at a rate of 8-20%.
 It usually affects women between the third and seventh decade of life,  but it can appear at any age. Usually, it presents as a bulge underneath  the urethra, lined by urethral mucosa. Factors associated with major complications are horseshoe-shaped and circumferential diverticula, size over 3-4 cm, and proximal location.
The classic triad of symptoms is: dysuria, dribbling, and dyspareunia, but it presents in only 5% of women. The most common symptoms are recurrent urinary tract infection, dysuria, and a vaginal mass.
A high suspicion associated with an image exam is necessary for the diagnosis. Voiding cystourethrography and Magnetic Resonance Imaging (MRI) are considered the most used diagnostic methods, with increasing evidence that MRI is the most sensitive radiological examination for the diagnosis of the urethral diverticulum and has great value for surgical planning7. 
The urethral diverticulectomy can be done by vaginal or abdominal approach. The choice depends mainly on the surgeon’s expertise and diverticulum location, and the vaginal one is usually prefered. 
The aim of this video is to present a stepwise laparoscopic approach of recurrent urethral diverticulum.

A 42 year-old female reported recurrent urinary tract infection and chronic pelvic pain. She was submitted to a vaginal diverticulectomy six months before, presenting new episodes of recurrent urinary tract infections and chronic pelvic pain. Magnetic resonance showed a urethral diverticulum involving the urethra circumferentially. 
The procedure was done under general anesthesia, in trendlemburg position with open legs in semi-litothomy. We placed five trocars: one at the midline, above the umbilicus, two pararectal, and two medial to the anterior superior iliac spine. We decided on a laparoscopic approach to avoid the risks associated with vaginal technique including transection of the urethra. A 16 French urethral Foley catheter was inserted and the cuff helps to identify bladder boundaries. The diverticula sac was identified and opened to identify the diverticulum boundaries in order to excise it. This approach was chosen due to adherences identified between the diverticulum and surrounding tissues caused by the previous procedure and recurrent infections.  Digital vaginal manipulation and an intraoperative cystoscopy helped to identify the neck of the diverticulum, at 4 o’clock position. The diverticula was freed flush with the wall of the urethra. A ureteral catheter was used to help expose the urethral defect which was sutured with 3-0 caprofyl stitches in a watertight fashion without any tension. A Jackson Pratt drain was located to watch for leaks. A 16Fr urethral catheter was maintained for 2 weeks.

The drain was withdrawn and the patient was discharged on the first postoperative day. The urethral catheter was removed after 14 days. At the follow-up six months later, she was satisfied, with no urinary tract infections recurrence or local complications.

In circumferential diverticula, the laparoscopic approach allows direct access, avoiding transection of the urethra. In this case, it proved to be an efficient and safe option, which can be carried out with widely available resources.

Greiman AK, Rolef J, Rovner ES. Urethral diverticulum: a systematic review. Arab J Urol 2019;17(1):49–57.
Ingber MS, Firoozi F, Vasavada SP, Ching CB, Goldman HB, Moore CK, Rackley RR. Surgically corrected urethral diverticula: long-term voiding dysfunction and reoperation rates. Urology 2011;77:65-69.
Vaidya RV, Olson K, Wolter C, Khan A. Characterization of Urethral Diverticula in Women. Female Pelvic Med Reconstr Surg. 2022 Jan 1;28(1):54-56. doi: 10.1097/SPV.0000000000001060. PMID: 34978545.

Continence 2S2 (2022) 100399
DOI: 10.1016/j.cont.2022.100399