In this article Dr Ashwin Mallaya, Consultant in Urology at Sir Ganga Ram Hospital, New Delhi talks about when and how to treat the Bladder Diverticula.
Congenital diverticula are present by birth and are often due to a focal defect in the detrusor muscle from where the mucosa herniates and are usually solitary and are located near the ureteral orifices. On the other hand, in adults, the diverticula usually develop secondary to bladder outlet obstruction. Not all bladder diverticula will require treatment. Small uncomplicated diverticula that may be present along with bladder outflow obstruction will remain silent and continue to do so after relief of the bladder outflow obstruction. Bladder diverticlula that are progressively growing in size and become symptomatic in the form of lower abdominal pain/hematuria or develop complications like recurrent UTI, stone formation, development of malignancy or urinary retention deserve to be treated.
Evaluation: In addition to urine routine and cross sectional imaging a cystoscopy is recommended to examine the mucosal surface of the diverticulum as well as the neck of the diverticulum and signs of bladder outlet obstruction.
Treatment options:
Observation: Treat the bladder outflow obstruction medically or surgically and observe the behaviour of the diverticulum periodically by imaging and cystoscopy.
Endoscopic treatment: Incision/Resection of bladder diverticular neck in order to help better drainage from the diverticulum. Low risk tumours within the diverticulum can be managed endoscopically
Bladder diverticulectomy: Open/Laparoscopic/Robot assisted is necessary in case of large diverticula, tumour within or high volume retention.
Tips and tricks during Diverticulectomy
Cystoscopy and procedure for Bladder outflow obstruction (TURP/BNI) is advisable prior to diverticulectomy even if it has been performed earlier.
Scoring of diverticular neck with diathermy helps identify it easily during a minimally invasive approach (lap/Robotics)
Insertion of a ureteric catheter/stent is useful in cases where there could be likelihood of ureteric injury on either side or possible need for ureteric reimplantation.
Drain removal is generally done once less than 50 ml of serous drainage. Catheter removal after 8-10 days after a cystogram confirms no leakage of contrast.
When to treat Bladder Diverticula | |
Indication | Description |
Symptomatic Diverticulum | Recurrent UTI, Hematuria, Voiding difficulty |
Complications | Stone, Suspected malignancy, Significant BOO |
Large or growing diverticulum | Increased risk of future complications |
Concomittant bladder outflow management has to be done either prior to diverticulectomy or simultaneously in same sitting depending on severity of symptoms and complicated nature of diverticulum |
Surgical approaches to treat bladder diverticulum | ||
Approach | Advantages | Disadvantages |
Transurethral resection | Minimally Invasive, short recovery | Limited to small diverticula |
Open Diverticluectomy | Direct access, effective for large diverticula, ureteral reimplant, lymphadenectomy if indicated | Blood loss, pain,Longer recovery time |
Laparoscopic diverticulectomy | Minimally invasive, can deal simultaneously with ureteral reimplant and lymphadenectomy quick recovery | Requires advanced surgical skills |
Robot assisted diverticulectomy | High precision, minimally invasive, can deal simultaneously with ureteral reimplant and lymphadenectomy | High cost and availability |
Commentaires