The Foley catheter is usually seen following complete excision of UD at the location of the entry of the ostium into the urethra. The urethra can be reconstructed over as small as a 14F Foley catheter without long-term risk of urethral stricture, and should be closed in a watertight fashion with absorbable suture [9]. The closure should be tension free. Uncommonly, a UD may extend circumferentially around the urethra and require transection of the involved portion of the urethra and complex reconstruction [10, 11].

Ureteral injury during UD surgery is rare, but may occur with a large or proximal UD extending beyond the bladder neck and posterior to the bladder trigone. In these instances, cystoscopic placement of ureteric catheters prior to the dissection may aid in ureteral identification. Virtually all of these injuries can be identified by intraoperative cystoscopy. The administration of intravenous vital dyes such as indigo carmine permits obvious visualization of ureteral efflux confirming ureteral patency. With limited availability of indigo carmine, preoperative oral phenazopyridine, 50 % dextrose solution for bladder filling, or intraoperative intravenous 10% fluorescein can be used as alternatives [12, 13]. Suspected ureteral injuries are confirmed by retrograde pyeloureterography. Ureteral transection requires ureteroneocystostomy. Inadvertent ureteral obstruction by sutures can also be recognized with cystoscopic confirmation of ureteral patency. If obstruction is suspected, offending sutures can be identified and removed, and placement of a temporary indwelling ureteral stent should be considered.

Intraoperative bladder injury may occur during dissection of a large UD extending proximal to the bladder neck and inferior to the bladder (Fig. 20.2), or alternatively, may occur with passage of a ligature carrier through the retropubic space if placing a pubovaginal sling.

Injury to the bladder during UD excision is diagnosed intraoperatively by careful endoscopic examination of the bladder and bladder neck with a 70° lens or a flexible cystoscope with retroflexion following UD dissection and/or passage of the ligature carrier. The bladder should be filled and then examined to ensure that a small injury does not go unrecognized in a fold of the bladder wall.

To avoid injury during ligature carrier passage, the urethra should be clearly palpated, the bladder drained, and the pelvic anatomy well delineated. If a bladder injury is noted intraoperatively, the ligature carrier should be removed and reinserted. Bladder perforation from a ligature carrier usually does not require primary closure.

Injury to the bladder floor during UD dissection requires cystoscopic examination to assess the extent of the injury and intravenous dyes should be administered to confirm ureteral integrity. Small cystotomies may be closed in layers with absorbable sutures transvaginally. More extensive injuries involving the trigone or more proximal bladder may require transabdominal repair. Postoperative drainage of the bladder with a Foley catheter will help avoid urinoma, fistula formation, and pelvic abscess.

Patients with preoperative symptomatic stress urinary incontinence (SUI) in association with UD can be offered simultaneous anti-incontinence surgery. Preoperative videourodynamics may be helpful in evaluating the anatomy of the UD, assessing the competence of the bladder neck, and confirming the diagnosis of SUI. In patients with SUI and UD, Ganabathi and others have described excellent results with concomitant needle bladder neck suspension [9, 18], although such needle suspensions are rarely done in contemporary practice. More recently, pubovaginal autologous fascial slings have been utilized in patients with UD and SUI with satisfactory outcomes [1, 17, 19, 20]. The role of synthetic midurethral slings, however, has not been well defined in this population and current AUA guidelines recommend against using synthetic material in this setting [21]. Placement of synthetic material adjacent to a fresh suture line following diverticulectomy in the setting of potentially infected urine may place the patient at higher risk for subsequent urethral erosion and vaginal extrusion of the sling material as well as urethrovaginal fistula formation and foreign body granuloma formation [21].

Significant postoperative de novo SUI may occur in between 7 and 16 % of individuals undergoing urethral diverticulectomy surgery without a concomitant anti-incontinence surgery [7, 22, 23]. However, Lee and colleagues noted at least minor de novo SUI in 49 % of patients following urethral diverticulectomy, the majority of which was minor and did not require additional therapy [24]. Only 10 % of these individuals underwent a subsequent SUI operation. Risk factors for de novo SUI may include the size of the diverticulum (>30 mm) and more proximal location [23]. Ljungqvist and colleagues correlated de novo SUI with wide diverticulum excision in addition to size and location [7]. Popat and Zimmern [25] reported long-term follow-up for 12 women with horseshoe diverticula who underwent diverticulectomy using a urethral preservation technique. Four patients had stress incontinence preoperatively, two had residual stress incontinence, one went on to have treatment with collagen injection [25]. Nickles and coworkers report de novo SUI in 1/11 (9.1 %) after complex UD repair and 1/32 simple UD repairs, noting a significantly higher rate of concomitant PV sling with complex repair [16]. De novo SUI may arise from the extensive suburethral or circumferential dissection required for a large UD, and the more proximal UD location may compromise the urethral sphincter and bladder neck anatomical support and/or the sphincter mechanism [23]. Alternatively, large UD at the bladder neck may cause obstruction [26] and occult SUI may be unmasked after removing the obstructing UD [27].

Management of de novo postoperative SUI is undertaken after allowing postsurgical inflammation to subside. Autologous pubovaginal sling is a reasonable option in this setting. Synthetic materials such as midurethral polypropylene slings must be used judiciously in this setting, however, as safety data are lacking. Repeat preoperative imaging may be helpful in excluding a recurrent or persistent UD, or urethrovaginal fistula prior to surgery for incontinence [7].