Management of Bladder Diverticula
The management of bladder diverticula should be based on symptoms, complications, and underlying etiology, with asymptomatic diverticula generally not requiring surgical intervention unless associated with specific complications.
Diagnostic Evaluation
Imaging studies are essential for proper evaluation:
- CT urography (CTU) or MR urography (MRU) are usually appropriate with sensitivity of 98% and specificity of 99% for detecting bladder diverticula 1
- Cystoscopy to directly visualize the diverticulum and rule out malignancy
- Voiding cystourethrography to assess the size and location of diverticula
Urodynamic studies to evaluate for bladder outlet obstruction (BOO), which is often the underlying cause of bladder diverticula
Management Algorithm
1. Asymptomatic Bladder Diverticula
- Observation is recommended for asymptomatic bladder diverticula 1
- Regular follow-up with periodic imaging to monitor for growth or development of complications
- Clinicians should not perform surgery solely for the presence of an asymptomatic bladder diverticulum 1
2. Symptomatic Bladder Diverticula
A. Management of Underlying Causes
- Treat bladder outlet obstruction if present:
- Medical therapy for BPH (if applicable)
- Surgical options for BOO:
- Transurethral resection of prostate (TURP) for BPH-related obstruction 1
- Other appropriate procedures based on etiology of obstruction
B. Indications for Surgical Intervention
Surgery is recommended for bladder diverticula associated with:
- Recurrent urinary tract infections
- Bladder stones
- Gross hematuria
- Malignancy within the diverticulum
- Vesicoureteral reflux
- Urinary retention
- Large diverticula causing significant symptoms 1
3. Complicated Bladder Diverticula
A. Diverticula with Malignancy
- Radical cystectomy is typically recommended for invasive carcinoma in a bladder diverticulum 1, 2
- Partial cystectomy may be considered for select cases with localized disease 2
- For superficial tumors confined to the diverticulum, transurethral resection with close surveillance may be appropriate 2
B. Diverticula with Rupture
- Surgical repair is generally recommended for intraperitoneal rupture of bladder diverticulum
- Conservative management with urinary catheterization and antibiotics may be considered in high-risk surgical patients 3
Surgical Approaches for Diverticulectomy
- Open diverticulectomy - traditional approach with excellent outcomes
- Laparoscopic diverticulectomy - minimally invasive option with reduced morbidity 4
- Robotic-assisted diverticulectomy - offers improved visualization and precision 5
Special Considerations
Pediatric Bladder Diverticula
- Large bladder diverticula in children often require surgical intervention
- Transvesical diverticulectomy is effective and can be combined with ureteral reimplantation if needed 6
- In neonates with urinary retention, staged approach with initial vesicostomy followed by diverticulectomy may be safer 6
Elderly or High-Risk Patients
- Conservative management may be appropriate for patients with significant comorbidities
- Catheter drainage may provide symptomatic relief when surgery is contraindicated
Follow-up Recommendations
- Regular cystoscopic surveillance for patients with history of bladder diverticula, especially if risk factors for malignancy exist
- Periodic imaging to assess for recurrence or development of new diverticula
- Urodynamic studies to evaluate resolution of bladder outlet obstruction if that was the underlying cause
Pitfalls and Caveats
- Failure to address underlying bladder outlet obstruction may lead to recurrence of diverticula
- Bladder diverticula can harbor occult malignancy, requiring thorough evaluation before management decisions
- Diverticulectomy without addressing underlying BOO is likely to result in treatment failure
- Patients with bladder diverticula should be evaluated for vesicoureteral reflux, especially if recurrent UTIs are present
By following this structured approach to the management of bladder diverticula, clinicians can provide appropriate care based on patient-specific factors and the presence of complications.