Hybrid Sling for the Treatment of Concomitant Female Urethral Complex Diverticula and Stress Urinary Incontinence

Figures & data

Figure 1 Magnetic resonance images showing a large incisional hernia with the presence of bowel (A, arrows) and omentum (B, arrows).

Figure 2 Magnetic resonance image of the pelvis.

Notes: (A) Axial slice demonstrating a complex urethral diverticulum. The small arrow points to the diverticulum lumen. The broad arrow indicates to the urethra. (B) Axial slice of the caudal area of the urethral diverticulum.

Figure 3 Image of the patient’s abdomen in the standing position demonstrates an incisional hernia projecting from the umbilical scar to the pubic symphysis.

Figure 4 Transvaginal ultrasound axial view shows complex urethral diverticulum as hypoechoic region around urethra.

Figure 5 Voiding cystourethrogram shows a complex multilocular diverticulum filled with contrast agent at the level of the midurethra.

Notes: (A) Anteroposterior image; (B) oblique image.

Figure 6 Image of two 2-cm horizontal incisions (over the iliotibial band and 6 cm above the patella) with the fascia lata strip.

Figure 7 Images demonstrating diverticulectomy.

Notes: (A) UD (urethral diverticulum) dissected (broad arrow) and vaginal wall opened (small arrow). (B) UD resected and Foley catheter (broad arrow) and vaginal wall (small arrow). (C) Closure in three layers (urethral mucosa, pubocervical fascia – broad arrow; and vagina – small arrow).

Figure 8 Final aspect of the procedure.

Notes: The synthetic extension of the sling establishes the correct allocation through the obturator fascia. Conversely, the autologous segment decreases the risk of extrusion or erosion.

Table 1 One-Year Post-Operative Assessment Voiding Function

Patient	Flow Rate - Qmax	PVR	Vaginal Exam	ICIQ-Short Form	OAB-v8
1	20 mL/sec Bell-shaped	20 mL	No extrusion	0, no pads	2
2	19 mL/sec Bell-shaped	30 mL	No extrusion	0, no pads	2

Abbreviations: PVR, post-void residual; ICIQ, International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form; OAB-v8, overactive bladder-validated 8-question.

Table 2 Literature Review of Concomitant SUI and Diverticulum Repair

Author	N	Mean F/U (Months)	Cure SUI (%)	Improved SUI (%)	Fistula	De Novo Urgency	UD Recurrence	Urinary Retention (>4 Weeks)
Swierzewski and McGuire^Citation15	07	17	100	–	0		1	NR
Faerber^Citation13	32	25	88	12	0	2	2	0
*Migliari et al^Citation14	16	51	80	NR	0	1	2	0
Romanzi et al^Citation16	14	39	100	–	0	1	NR	NR
Enemchukwu et al^Citation6	38	56	100	23	0	NR	1	1

Note: *Recurrent pseudodiverticulum.

Abbreviations: F/U, follow-up; NR, not directly reported; SUI, stress urinary incontinence; UD, urethral diverticulum.

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