Urethral diverticulectomy in the female is a challenging extirpative and reconstructive undertaking that is most often approached vaginally. Infected urethral diverticula cause significant morbidity, pain, and debilitation and are often difficult to diagnose clinically.  MRI studies not only help make the diagnosis, but are extremely helpful in planning the surgical excision.   The most challenging urethral diverticula are those that are located in a proximal location, close to the bladder and at the 12-O’clock position, right underneath the pubic symphysis.  Often reconstruction of the urethra is necessary and these delicate procedures are made much more difficult if not impossible in this location.  The open retropubic approach is another way to access this particular situation, but is still made challenging  by limited working space under the pubic bone, particularly in the obese patients.  We hypothesize that the robotic surgical approach may improve visibility and dexterity in these challenging cases. A video is the best way for the experienced reconstructive surgeon to determine if visibility and dexterity are indeed improved. So we present the video for the experienced reader’s own judgement.

After approval by the Institutional Review Board for protection of Human Subjects, a prospective database was queried and two patients with robotic approach for diverticulum excision were identified.  Each patient had been offered traditional combined vaginal and retropubic approach due to the challenging location of the diverticulum and both were offered robotic approach and consented to this.

Two patients were identified with diverticula in the 12-o’clock position, patient #1 exhibited a 360 degree diverticulum measuring 2cm at the widest axial measurement located proximally less than 1cm from the bladder neck and extending under the pubic symphysis.  She was obese and this was further complicated by mixed urinary incontinence preoperatively with obvious stress urinary incontinence component on physical exam.  She requested a fascia lata pubovaginal sling at the time of diverticulectomy.  She was 48 years of age at the time of surgery. Patient #2 exhibited a horseshoe 240 degree configuration measuring 2.7cm at the widest axial point also less than 1cm from the bladder neck, extending under the pubic bone, with a large component at the 12-O’clock location. She was 51 years of age at the time of surgery. Both went for surgery without complication.  At the 3 week post operative visit, retrograde urethrogram revealed no leak or extravasation at the urethral repair site. Both patients reported being continent of urine at the most recent follow up visit. Both reported being pain free since the time of surgery.  Preoperative MRI images will be shown in the video.   Patient #1 has 2 months follow up and Patient #2 has 4 months follow up.

Small sample size and short follow up limit the reader’s ability to make quantitative comparison with the traditional combined vaginal and retropubic approach for these challenging patients.  The experienced reconstructive surgeon will recognize that  diverticula behind the pubic symphysis cannot easily  be compared with slightly simpler diverticula that do not extend to this area.  The reader will also note the superior visibility and fine dexterity for suturing the urethra if necessary. The video demonstrates the first published robotic approach to urethral diverticula and will provide qualitative evidence to support the hypothesis. 
Robotic urethral diverticulum repair in the female can be accomplished safely with excellent visibility and dexterity in a challenging space.