Urethral diverticulum is rare, affecting <0.02% of women. When ventrally located, it is accessible via the anterior vaginal wall. Dorsal, proximal, circumferential, or horseshoe female urethra diverticula present more challenging dissection. In the case presented, the urethral diverticulum was dorsal and proximal. Rather than standard vaginal options including transection of the urethra, suprameatal incision, and the open retropubic “above and below” approach, a robotic assisted retropubic approach allowed the best access.

A 38 yo female presented with fever and a 6 month history of LUTS, post void dribbling, and recurrent UTIs. CT scan then MRI revealed a 2.5 x 1.6 cm crescenteric left dorsal urethral diverticulum at the proximal urethra with stone formation, cephalad to the pubic bone, with an elevated bladder neck. Urodynamics demonstrated bladder outlet obstruction. The patient was formally consented for the robotic approach including consent for video. Incisions were made lateral to the medial umbilical ligaments and the bladder was dropped from the anterior abdominal wall. The space of Retzius was developed. A combination of sharp and blunt dissection were used to mobilize the diverticulum circumferentially. Digital vaginal manipulation and movement of the foley balloon further defined the planes. The os was encountered in the left ventral aspect of the urethra as was consistent with cystoscopy. The urethra was repaired using a running 3-0 Vicryl suture. The suture line was watertight on testing with methylene blue. A SPTube was placed using laparoscopic guidance. The omentum was secured to the pubic peri-ostium and anterior bladder neck.

Operative time was 3:27 h and estimated blood loss 50 cc. Surgical finding includes a left lateral ventral ostium with the diverticulum wrapping dorsally, proximal to the pelvic diaphragm and endopelvic fascia.  Post-op voiding cystourethrogram showed good healing without extravasation. The patient is currently dry with complete resolution of symptoms.

Robotic approach to urethral diverticulectomy is feasible for proximal dorsal diverticuli cephalad to the pubic symphysis. This method could be considered as an adjunct for other complex urethral diverticuli with a proximal dorsal component.