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Injection of autologous fat has been used for many years to correct cosmetic surgical defects. More recently, autologous fat injection has been applied to the treatment of urinary incontinence. The background and technique of periurethral fat injection are described in this article. The technique is safe, and preliminary results are encouraging in women with intrinsic sphincter deficiency. Long term follow-up and comparative trials will determine the ultimate utility of periurethral fat injection for the treatment of women with intrinsic sphincter deficiency.

The diagnosis and successful treatment of female urethral diverticulum can be facilitated by a heightened clinical awareness coupled with appropriate evaluation and perioperative management. In particular, it is important to address all the preoperative factors to avoid complications de treatment such as recurrence of the diverticulum or urethro-vaginal fistula. The authors also report their clinical experience of evaluating 59 women with urethral diverticula over the last 11 years and describe the technique and complications of diverticulectomy in 49 women.

The presentation and management are reviewed of 63 women with urethral diverticulum seen at a single institution in 10 years. Of the women 36 (61.9%) had urinary incontinence as a presenting symptom and 20 (31.7%) had incontinence as the only presenting complaint. Diverticula were suspected in 57 cases (90.5%) based on the presence of a periurethral mass during pelvic examination. Investigations included voiding cystourethrogram, excretory urogram, urodynamic studies and recently transvaginal ultrasound. Voiding cystourethrography adequately demonstrated the diverticulum in 60 of the 63 women (95.2%). Urodynamic studies performed in 58 women revealed abnormal findings in 36 (62%), including genuine stress urinary incontinence in 28 (48.3%). The location/number/size/configuration, communication, continence classification was used to define the characteristics of the diverticula. Seven women either refused operation or had small asymptomatic diverticula not requiring treatment. Transvaginal diverticulectomy was performed using a 3-layer closure in 56 women. Concomitant bladder neck suspension was performed in 27 women with documented stress urinary incontinence and/or urethral hypermobility. With a mean followup of 70 months (range 6 to 136) 48 women (85.7%) were completely relieved of the presenting complaint. Complications of diverticulectomy included 2 small distal recurrent diverticula, 1 urethrovaginal fistula and 6 transient early urinary tract infections. None of the women had urethral stricture or recurrent urinary tract infection. Six women (22.2%) who underwent diverticulectomy and bladder neck suspension, and 3 (10.3%) treated with diverticulectomy alone had minimal urinary incontinence requiring less than 2 pads a day.

No descriptive criteria for the preoperative classification of female urethral diverticula have been proposed. Consequently, alternative therapies and different treatment series are not easily compared. Since 1982 the authors have evaluated 61 women with urethral diverticula and have identified those preoperative factors critical to an organized surgical approach to urethral diverticula. From this experience, a simple, comprehensive classification system for female urethral diverticula is proposed. The classification system is called L/N/S/C3. Each letter of the system represents a different characteristic of urethral diverticula. L = Location, the site of the diverticulum, i.e., distal, mid, or proximal urethra, with or without extension beneath the bladder neck. N = Number, whether single or multiple diverticula are present. S = Size, expressed in centimeters (cm). C3 = Configuration, Communication, and Continence Configuration (C1) describes whether we diverticulum is single, multiloculated, or saddle shaped. Communication (C2) indicates the site of communication with the urethral lumen, i.e., distal, mid, or proximal urethra. Continence (C3) is the presence of genuine stress urinary incontinence. Adhering to this format provides the surgeon a systematic means of approaching a urethral diverticulum and thus may minimize postoperative complications. Finally, the authors encourage other surgeons reporting series of urethral diverticula to adopt this system so that standard terminology may allow accurate comparison of surgical results.

Most urethrovaginal fistulas are iatrogenic and, like other urinary fistulas, significantly reduce the quality of the affected individual's life. The Martius labial fat pad graft facilitates the urologic care of these women.

Urinary incontinence is frequently associated with a urethral diverticulum in female patients. Preoperative evaluation including a thorough history and physical examination, voiding cystourethrogram, urethroscopy, and urodynamic studies can diagnose both the urethral diverticulum and any concomitant bladder-urethral dysfunction. Preoperative recognition of stress urinary incontinence or patients at risk for this problem postoperatively permits effective treatment with concomitant transvaginal bladder neck suspension and urethral diverticulectomy.