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Pre- and Postoperative Evaluation of Urethral Diverticulum

¹ Department of Radiology, University of Pittsburgh Medical Center, Presbyterian Campus, 200 Lothrop St., Rm. 3950, CHP MT, UPMC, Pittsburgh, PA 15213.
² Institute of Radiology, University of Udine, Udine, Italy.

View larger version (36K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1 —Pathogenesis of urethral diverticulum. A, Infection of distal Skene's gland drains into urethra. B and C, Ductal obstruction leads to formation of suburethral cyst or abscess (B) that eventually ruptures into urethral lumen (C).

View larger version (112K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —55-year-old woman with urethral diverticulum who underwent diverticulectomy. Voiding phase of voiding cystourethrography (VCUG) shows contrast material filling urinary diverticulum (arrowheads) that encircles urethral lumen (arrow). Filling started on right lateral aspect of urethra and extended to fill remaining diverticulum.

View larger version (78K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —55-year-old woman with urethral diverticulum who underwent diverticulectomy. Voiding phase of VCUG after diverticulum resection shows normal appearance of urethra (arrow).

View larger version (92K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —46-year-old woman with urethral diverticulum who presented with dysuria and palpable mass on anterior wall of vagina. Transverse translabial color-flow sonogram shows complex cystic lesion anterior to vagina, representing palpable mass (outlined by calipers).

View larger version (123K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —46-year-old woman with urethral diverticulum who presented with dysuria and palpable mass on anterior wall of vagina. Sagittal translabial sonogram after insertion of Foley catheter (arrow) shows anechoic lesions (arrowheads) encircling urethral lumen. B = Foley balloon in urinary bladder.

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C —46-year-old woman with urethral diverticulum who presented with dysuria and palpable mass on anterior wall of vagina. Transverse contrast-enhanced CT scan shows fluid-filled diverticular sac (asterisk) in enlarged urethra. Mucosal and submucosal component of urethra is displaced to left (arrow).

View larger version (172K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3D —46-year-old woman with urethral diverticulum who presented with dysuria and palpable mass on anterior wall of vagina. Coronal (D) and transverse (E) fast spin-echo T2-weighted MR images confirm diagnosis of high-signal-intensity, fluid-filled diverticulum (asterisk) with fluid-debris level (white arrow, E). Note displaced urethra (black arrow) and anterior septation (arrowhead, E).

View larger version (147K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3E —46-year-old woman with urethral diverticulum who presented with dysuria and palpable mass on anterior wall of vagina. Coronal (D) and transverse (E) fast spin-echo T2-weighted MR images confirm diagnosis of high-signal-intensity, fluid-filled diverticulum (asterisk) with fluid-debris level (white arrow, E). Note displaced urethra (black arrow) and anterior septation (arrowhead, E).

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —38-year-old woman with urethral diverticulum who presented with recurrent urinary tract infections. EV = endovaginal probe. (Courtesy of Bae KT, Pittsburgh, PA) Sagittal fast spin-echo T2-weighted endovaginal MR image shows high-signal-intensity, fluid-filled diverticulum (asterisk) in posterior aspect of urethra (arrow) that contains multiple thin septations (arrowheads). Note elevation of bladder dome by diverticulum. B = urinary bladder.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —38-year-old woman with urethral diverticulum who presented with recurrent urinary tract infections. EV = endovaginal probe. (Courtesy of Bae KT, Pittsburgh, PA) Transverse unenhanced (B) and gadolinium-enhanced (C) gradient-echo T1-weighted endovaginal MR images show enhancement of urethral tissues (arrow) and posterior septation (arrowhead) of diverticulum (asterisk).

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C —38-year-old woman with urethral diverticulum who presented with recurrent urinary tract infections. EV = endovaginal probe. (Courtesy of Bae KT, Pittsburgh, PA) Transverse unenhanced (B) and gadolinium-enhanced (C) gradient-echo T1-weighted endovaginal MR images show enhancement of urethral tissues (arrow) and posterior septation (arrowhead) of diverticulum (asterisk).

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5 —46-year-old woman with urethral diverticulum who presented with urinary frequency and painful mass in anterior wall of vagina. Transverse contrast-enhanced CT scan of pelvis shows multiple dependent calculi (arrowheads) within fluid-filled urethral diverticulum (asterisk) that displaces urethra (arrow) to the right.

View larger version (78K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —Typical anatomic locations of urethral diverticulum, Gartner's cyst, and Bartholin's gland cyst. Axial illustration through bladder neck, upper vagina, and rectum depicts Gartner's cyst in anterolateral or anterior wall of proximal third of vagina.

View larger version (117K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —Typical anatomic locations of urethral diverticulum, Gartner's cyst, and Bartholin's gland cyst. Axial illustration at or below inferior ramus, distal urethra, lower vagina, and anus depicts Bartholin's gland cyst in posterolateral wall of lower vagina at level of introitus. Anteriorly, crescent-shaped cystic structure containing fluid-fluid level encircles and connects to distal urethra via narrow orifice, which is consistent with urethral diverticulum.

View larger version (113K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —32-year-old woman with Gartner's cyst who presented with dysuria and dyspareunia. Transverse fast spin-echo T2-weighted MR image with fat suppression shows well-defined high-signal-intensity fluid-filled rounded mass (asterisk) arising from right anterolateral wall of upper vagina and displacing high-signal-intensity vaginal mucosa (arrow) to the left. Mass was clearly separate from urethra.

View larger version (155K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —32-year-old woman with Gartner's cyst who presented with dysuria and dyspareunia. Sagittal fast spin-echo T2-weighted MR image shows fluid-filled mass (asterisk) displacing vaginal mucosa posteriorly (white arrow). Urethra (black arrow) is displaced anteriorly.

View larger version (162K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A —31-year-old woman with Bartholin's gland cyst that presented as mass in posterolateral introitus. Urethral diverticulum was incidentally discovered. V = vagina. Transverse fast spin-echo T2-weighted MR image shows high-signal-intensity fluid-filled urethral diverticulum (arrow) with neck (arrowhead) connecting to urethra.

View larger version (162K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B —31-year-old woman with Bartholin's gland cyst that presented as mass in posterolateral introitus. Urethral diverticulum was incidentally discovered. V = vagina. Transverse (B) and coronal (C) fast spin-echo T2-weighted MR images show lobulated septate cystic mass (arrow) representing Bartholin's gland cyst and located posterolaterally in left lower third of vagina below symphysis pubis and immediately inferior to urethral diverticulum. Arrowheads in C indicate lateral fornices of vagina.

View larger version (169K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8C —31-year-old woman with Bartholin's gland cyst that presented as mass in posterolateral introitus. Urethral diverticulum was incidentally discovered. V = vagina. Transverse (B) and coronal (C) fast spin-echo T2-weighted MR images show lobulated septate cystic mass (arrow) representing Bartholin's gland cyst and located posterolaterally in left lower third of vagina below symphysis pubis and immediately inferior to urethral diverticulum. Arrowheads in C indicate lateral fornices of vagina.

View larger version (121K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A —50-year-old woman with high-grade squamous cell carcinoma (SCC) of urethra causing dysuria. EV = endovaginal probe. (Courtesy of Bae KT, Pittsburgh, PA) Transverse unenhanced (A) and gadolinium-enhanced (B) gradient-echo T1-weighted endovaginal MR images show intermediate-signal-intensity urethral mass (asterisk, A) that enhances heterogeneously (asterisk, B). Urethroscopy and biopsy confirmed SCC. Arrow indicates Foley catheter in urethra.

View larger version (114K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B —50-year-old woman with high-grade squamous cell carcinoma (SCC) of urethra causing dysuria. EV = endovaginal probe. (Courtesy of Bae KT, Pittsburgh, PA) Transverse unenhanced (A) and gadolinium-enhanced (B) gradient-echo T1-weighted endovaginal MR images show intermediate-signal-intensity urethral mass (asterisk, A) that enhances heterogeneously (asterisk, B). Urethroscopy and biopsy confirmed SCC. Arrow indicates Foley catheter in urethra.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9C —50-year-old woman with high-grade squamous cell carcinoma (SCC) of urethra causing dysuria. EV = endovaginal probe. (Courtesy of Bae KT, Pittsburgh, PA) Transverse gadolinium-enhanced gradient-echo T1-weighted endovaginal MR image shows anterior vaginal wall invasion (white arrow). Black arrow indicates Foley catheter in urethra.

View larger version (147K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A —52-year-old woman with development of adenocarcinoma in remnant urethral diverticulum 4 years after resection. V = vagina. Transverse unenhanced T1-weighted MR image shows intermediate-signal-intensity urethral mass (asterisk) in known remnant diverticulum. Note fatty tissue (arrow) in urethrovaginal space resulting from Martius flap (labial fat interposed between urethra and vagina), a normal postprocedural finding.

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B —52-year-old woman with development of adenocarcinoma in remnant urethral diverticulum 4 years after resection. V = vagina. Transverse gadolinium-enhanced T1-weighted MR image confirms lesion appearing as circumferential enhancing mass (asterisk). Surgery confirmed diagnosis of adenocarcinoma. Note susceptibility artifact from remote diverticular resection (arrowhead). Again noted is surgically interposed fat (arrow) between urethra and enhancing vagina.

View larger version (148K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11A —49-year-old woman with recurrence of urethral diverticulum and interval increase in size that is causing recurrent urinary tract infections. Coronal fast spin-echo T2-weighted MR image obtained before diverticulectomy shows high-signal-intensity fluid-filled urethral diverticulum (asterisk) and urethra (arrow).

View larger version (113K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11B —49-year-old woman with recurrence of urethral diverticulum and interval increase in size that is causing recurrent urinary tract infections. Voiding cystourethrography performed in immediate postoperative period shows linear contrast collection (arrowhead) to right of urethral lumen (arrow), representing residual diverticular neck.

View larger version (136K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11C —49-year-old woman with recurrence of urethral diverticulum and interval increase in size that is causing recurrent urinary tract infections. Transverse (C) and sagittal (D) fast spin-echo T2-weighted MR images obtained 16 (C) and 24 (D) months after diverticulectomy show recurrent fluid-filled right posterolateral diverticulum with progressive increase in size of diverticular sac (asterisks) and displacement of urethra to left (arrow, C) and anteriorly (arrow, D). Note septation in diverticular sac (arrowhead, D).

View larger version (172K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11D —49-year-old woman with recurrence of urethral diverticulum and interval increase in size that is causing recurrent urinary tract infections. Transverse (C) and sagittal (D) fast spin-echo T2-weighted MR images obtained 16 (C) and 24 (D) months after diverticulectomy show recurrent fluid-filled right posterolateral diverticulum with progressive increase in size of diverticular sac (asterisks) and displacement of urethra to left (arrow, C) and anteriorly (arrow, D). Note septation in diverticular sac (arrowhead, D).

View larger version (113K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12A —39-year-old woman with asymptomatic urethral diverticular recurrence. Voiding cystourethrography performed in immediate postoperative period appears unremarkable.

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12B —39-year-old woman with asymptomatic urethral diverticular recurrence. Pelvic sonograms obtained 4 months after diverticulectomy for evaluation of ovaries show incidental cystic lesion (outlined by calipers) anterior to vagina. V = vagina, SAG = sagittal, TRV = transverse.

View larger version (114K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12C —39-year-old woman with asymptomatic urethral diverticular recurrence. Pelvic sonograms obtained 4 months after diverticulectomy for evaluation of ovaries show incidental cystic lesion (outlined by calipers) anterior to vagina. V = vagina, SAG = sagittal, TRV = transverse.

View larger version (147K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12D —39-year-old woman with asymptomatic urethral diverticular recurrence. Coronal (D) and transverse (E) fast spin-echo T2-weighted MR images confirm recurrence of small high-signal-intensity diverticulum (open arrow) with fluid-filled neck (arrowhead, D) connecting to urethra (solid arrow). V = vagina.

View larger version (169K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12E —39-year-old woman with asymptomatic urethral diverticular recurrence. Coronal (D) and transverse (E) fast spin-echo T2-weighted MR images confirm recurrence of small high-signal-intensity diverticulum (open arrow) with fluid-filled neck (arrowhead, D) connecting to urethra (solid arrow). V = vagina.

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