From the Guidelines
Surgery is not recommended solely for the presence of an asymptomatic bladder diverticulum. When considering the management of a bladder diverticulum, it's crucial to prioritize the patient's symptoms and overall quality of life. According to the American Urological Association (AUA) guideline 1, surgery is indicated for specific complications such as renal insufficiency, refractory urinary retention, recurrent urinary tract infections, or gross hematuria due to benign prostatic hyperplasia (BPH).
Key Considerations
- The presence of a bladder diverticulum itself is not an absolute indication for surgery unless it is causing symptoms or complications.
- Evaluation for bladder outlet obstruction (BOO) should be considered in patients with a bladder diverticulum, as this can be a contributing factor to the development of symptoms 1.
- Treatment of the underlying cause, such as BPH, may alleviate symptoms associated with the diverticulum.
- Surgical removal of the diverticulum (diverticulectomy) may be necessary in cases of persistent infections, large diverticula causing emptying problems, or suspected cancer within the diverticulum.
Approach to Management
- Asymptomatic diverticula generally require no treatment beyond monitoring.
- Symptomatic cases require addressing the underlying cause and may necessitate surgical intervention if complications arise or if the diverticulum is causing significant symptoms.
- The choice of surgical approach (open, laparoscopic, or robotic) depends on the size, location, and specific characteristics of the diverticulum, as well as the patient's overall health status. Given the potential for complications and the importance of individualized patient care, a thorough assessment and consideration of the patient's specific situation are necessary before making a decision regarding the management of a bladder diverticulum 1.
From the Research
Definition and Prevalence of Bladder Diverticulum
- Bladder diverticula are common enough to be encountered by most urologists in practice, but are reported less frequently in the literature than they were 50 years ago 2.
- A spontaneous rupture of the bladder diverticulum in an adult patient is extremely rare 3.
Diagnosis and Evaluation
- Cystoscopy, computed tomography with contrast, urodynamic studies, cytology, and voiding cystourethrography play important roles in informing the clinician about bladder diverticula 2.
- Urodynamic evaluation can reveal varying findings like bladder outlet obstruction (BOO), poor compliance, and equivocal readings in patients with bladder diverticula 4.
Treatment Options
- Some patients with bladder diverticula can be managed nonoperatively, whereas others will need surgical intervention consisting of bladder outlet reduction and possibly removal of the diverticulum itself 2.
- Robotic bladder diverticulectomy (RBD) is a safe and effective procedure in carefully selected patients with refractory lower urinary symptoms and UTIs, showing good postoperative and functional outcomes 4.
- Conservative management with urinary catheterization, antibiotics, and/or percutaneous peritoneal drainage may be an alternative for spontaneous intraperitoneal bladder rupture in some cases, but close observation is required and surgical intervention is the first option 3.
- Surgical repair of primary isolated bladder diverticula (PIBD) larger than 3 cm is associated with improvement of voiding dysfunction and elimination of UTIs 5.
- Laparoscopic approach is a promising alternative to classical surgery for bladder diverticulectomy, with minimal operative bleeding and a smaller incision 6.
Indications and Outcomes
- The presence of a large diverticulum can have a complex effect on bladder dynamics 4.
- Patients with PIBD larger than 3 cm are more likely to develop UTIs and have functional lower urinary tract symptoms, and disorders of bladder storage or emptying 5.
- RBD can improve post-void residual (PVR) and International Prostate Symptom Score (IPSS) in patients with refractory lower urinary symptoms and UTIs 4.