What is the management approach for a diverticulum of the bladder?

Management of Bladder Diverticulum

Bladder diverticula should be surgically treated when they cause complications such as recurrent UTIs, bladder stones, or progressive bladder dysfunction, while asymptomatic diverticula without complications do not require surgical intervention. 1

Diagnosis and Evaluation

Imaging

• First-line imaging: CT urography (CTU) or MR urography (MRU) are usually appropriate for evaluation of bladder diverticula 1
• Alternative options:
  • Ultrasound of the bladder can be employed to evaluate for bladder diverticula detection 1
  • Cystography can delineate bladder diverticula but has been largely supplanted by CT 1
  • Voiding cystourethrography when diverticulum is at/near ureteral orifice to evaluate for vesicoureteral reflux 1

Clinical Assessment

• Evaluate for symptoms:
  • Recurrent urinary tract infections (UTIs)
  • Incomplete bladder emptying
  • Hematuria
  • Bladder stones
  • Lower urinary tract symptoms

Management Algorithm

1. Asymptomatic Bladder Diverticula

• Recommendation: Observation without surgical intervention
• Evidence: "Clinicians should not perform surgery solely for the presence of an asymptomatic bladder diverticulum" 1
• Rationale: The presence of a bladder diverticulum alone is not an absolute indication for surgery unless associated with complications

2. Symptomatic Bladder Diverticula

• Surgical indications (any of the following):
  • Recurrent UTIs clearly due to bladder diverticulum
  • Recurrent gross hematuria due to diverticulum
  • Bladder stones associated with diverticulum
  • Progressive bladder dysfunction
  • Renal insufficiency due to bladder outlet obstruction with diverticulum

3. Bladder Diverticula with Bladder Outlet Obstruction

• Approach: Treat the underlying bladder outlet obstruction first, then reassess the diverticulum
• For BPH-related obstruction:
  • TURP (monopolar or bipolar) for moderate-sized prostates 1
  • Simple prostatectomy (open, laparoscopic, or robotic) for large prostates 1

4. Surgical Options for Diverticulectomy

• Open diverticulectomy: Traditional approach, especially for large or complex diverticula
• Laparoscopic diverticulectomy: Minimally invasive option with good outcomes 2
• Robotic diverticulectomy: Newer approach with advantages of minimally invasive surgery 3
• Endoscopic management: Fulguration of diverticulum mucosa using the Orandi technique may be considered for patients unfit for more extensive surgery 4

Special Considerations

Size-Based Management (Pediatric Evidence)

While primarily from pediatric literature, size considerations may be relevant:

• Diverticula <3 cm: May be managed conservatively with observation if asymptomatic 5
• Diverticula >3 cm: More likely to cause urodynamic abnormalities, recurrent UTIs, and voiding dysfunction, often requiring surgical intervention 5

Pre-operative Assessment

• Urodynamic studies to assess bladder function and outlet obstruction
• Cystoscopy to evaluate diverticulum location, size, and relationship to ureteral orifices
• Urine cytology to rule out malignancy within the diverticulum

Post-Treatment Follow-up

• Regular assessment for symptom resolution
• Post-void residual measurement to ensure adequate emptying
• Surveillance for recurrent UTIs
• Imaging follow-up to assess diverticulum resolution (if treated) or stability (if observed)

Pitfalls and Caveats

1. Failure to address underlying bladder outlet obstruction may lead to recurrence of diverticulum
2. Diverticula near ureteral orifices require careful surgical planning to avoid ureteral injury
3. Large diverticula may contain malignancy and should be thoroughly evaluated before treatment
4. Endoscopic management alone may be insufficient for large diverticula with significant symptoms

By following this structured approach to bladder diverticula management, clinicians can ensure appropriate treatment while avoiding unnecessary surgical intervention in asymptomatic cases.