Sequelae of Urethral Trauma

INTRODUCTION: Urethral injury following obstetrics and gynecology procedures are not well described in the literature. Urethral diverticulum is a known complication of urethral trauma. There are two case reports and one case series reviewing urethral diverticulum as a possible complication of tension-free vaginal tape surgery. In the obstetrics field, urethral injury is described in the setting of tears following vaginal delivery. OBJECTIVE: To describe iatrogenic urethral trauma and demonstrate the surgical technique of urethral reconstruction. METHODS: Case Series Report. First patient is a 34-year-old G3P1011 at 38 weeks 2 days who underwent induction of labor in the setting of gestational diabetes with a large for gestational age fetus. During the second stage of labor, there were multiple failed attempts of Foley placement. Infant was delivered by cesarean section due to non-reassuring fetal heart tones. During c-section, distended bladder was noted and Foley was not draining. Urology was consulted and cystoscopy illustrated deep urethral injury. Second patient is a 45-year-old P1 with history of pelvic angiomyxoma incidentally found at time of midurethral sling surgery with normal cystoscopy findings. During cancer surveillance MRI, an urethral defect was identified with patient describing postvoid dribbling. Cystoscopy noted large urethral opening into the defect. MRI and cystoscopy findings were consistent with diverticulum, and suspected prior urethral trauma was considered as possible etiology. This patient underwent removal of the midurethral sling, resection of the urethral diverticulum, and primary reconstruction of the urethra. An inverted U-incision was made at the suburethral location. The midurethral sling was resected to bilateral pubic symphysis locations. The urethral defect was identified and redundant urethral mucosa resected. Primary repair was performed and noted to be water-tight. Multiple layers of the surrounding endopelvic fascia was used to overlay the urethral incision prior to closure of the vaginal epithelium. Postoperatively, a Foley catheter was placed for 1 week and a voiding trial was successful. RESULTS: Following urethral reconstruction, at 6 weeks post-op, patient reported voiding without restriction and denied urinary dribbling, stress urinary incontinence, and urinary frequency or urgency. There was no evidence of urethrovaginal fistula and Foley catheter was passed without difficulty. CONCLUSIONS: Urethral diverticulum may occur from obstruction of periurethral glands, but urethral trauma can also be an etiology and may differ in presentation with a large urethral opening to the defect. Difficult catheter placement should be documented in case of future lower urinary tract symptoms to aid in diagnosis.