Bladder Diverticulectomy



Bladder Diverticulectomy


SARAH FRAUMANN FARIS

SAM S. CHANG



Bladder diverticula are the herniation of the bladder mucosa through the detrusor muscle fibers and are classified as either congenital or acquired. Congenital diverticula are postulated to be due to an inadequately developed or thin muscular wall, which is especially vulnerable near the intravesical ureter resulting in a common association with vesicoureteral reflux (1). Bladder diverticula are more common in males, typically present <10 years old and are often solitary and in smoothwalled bladders on cystoscopic examination. In contrast, acquired bladder diverticula are secondary to the elevated intravesical pressures generated as a result of bladder outlet obstruction. The most common causes of outlet obstruction include benign prostatic hyperplasia, urethral stricture disease, bladder neck contracture, posterior urethral valves, and neurogenic voiding dysfunction such as detrusor sphincter dyssynergia. They typically present in males >60 years old and are often multiple and found in association with bladder trabeculation (2).

Diverticula are typically located in the weakest points of the bladder including the ureteral hiatus (paraureteral or
Hutch diverticulum) and both posterolateral walls (1,2,3). The diverticular wall is composed of mucosa, subepithelial connective tissue or lamina propria, occasional muscle fibers, and adventitial tissue, and at times, a fibrous capsule or pseudocapsule may be present (Figs. 21.1 and 21.2) (2,4).






FIGURE 21.1 Posterior view of bladder and diverticulum: ampulla of vas deferens (1), ureters (2 and 2′), posterior longitudinal bundle of the outer layer of the detrusor (3), diverticulum (4), and circular fibers of the middle layer of the detrusor around the diverticular neck (5).




INDICATIONS FOR SURGERY

All underlying urologic abnormalities should be addressed concomitantly or prior to definitive surgical treatment of a bladder diverticulum to prevent recurrence. Patients who have improved bladder emptying and symptomatology after relief of outlet obstruction can be managed expectantly with surveillance. In patients who have significantly impaired bladder contractility on preoperative urodynamics, persistently poor bladder emptying after relief of obstruction, or who are unable or unwilling to undergo surgical treatment of the bladder diverticulum, clean intermittent catheterization (CIC) or an indwelling catheter can be effective treatment options (2). In these patients, and in the absence of future complicating factors, surveillance of the bladder diverticulum with cystoscopy and urine cytology, and monitoring of the upper tracts with renal ultrasound and renal function, may be all that is required.







FIGURE 21.3 Contrast-enhanced CT scan demonstrating a large posteriorly based bladder diverticulum seen on (A) transverse and (B) sagittal images.

Indications for surgical intervention include chronic infections, stones, persistent symptoms, upper urinary tract deterioration from vesicoureteral reflux or obstruction, diverticular rupture, and malignancy (2). Additionally, we recommend simultaneous resection of all poorly emptying bladder diverticula to improve voiding if a patient is scheduled for an open prostatectomy, cystolithotomy, ureteroneocystostomy, or YV plasty of the bladder neck.

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Apr 24, 2020 | Posted by in UROLOGY | Comments Off on Bladder Diverticulectomy
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