What is the management approach for bladder diverticulum?

Management of Bladder Diverticulum

Surgical intervention is the treatment of choice for symptomatic bladder diverticula causing recurrent urinary tract infections or incomplete bladder emptying, with robotic-assisted approaches being preferred when available due to favorable outcomes and shorter recovery times. 1

Diagnosis and Evaluation

• CT urography (CTU) or MR urography (MRU) are usually appropriate for evaluation of bladder diverticula, with both considered equivalent alternatives depending on availability 2
• Cystoscopy should be considered alongside imaging for comprehensive evaluation of recurrent complicated UTIs or patients with known risk factors 2
• Ultrasound of the bladder can be employed to evaluate for bladder diverticula detection, particularly in initial screening 2
• MRI provides excellent soft-tissue contrast and is particularly useful for evaluating the structure and complexity of urinary tract diverticula 2

Management Algorithm

Conservative Management

• Asymptomatic bladder diverticula generally do not require intervention 1
• Treatment of underlying bladder outlet obstruction (if present) may be sufficient to manage symptoms in some cases 3
• Regular monitoring for complications is recommended for patients managed conservatively 1

Indications for Surgical Intervention

• Recurrent urinary tract infections despite appropriate antibiotic therapy 4, 1
• Incomplete bladder emptying with significant post-void residual 4, 5
• Large diverticula causing urinary stasis 3
• Presence of stones or tumors within the diverticulum 1
• Vesicoureteral reflux associated with the diverticulum 1

Surgical Approaches

1. Robot-Assisted Diverticulectomy (Preferred)

   • Offers advantages of minimally invasive surgery with improved visualization and precision 1, 6
   • Can be performed via:
     • Transvesical approach: Provides direct access to the diverticulum and facilitates simultaneous treatment of bladder outlet obstruction 6
     • Extravesical approach: Suitable for diverticula located away from critical structures 1
   • Associated with shorter hospitalization (median 3 days) and catheterization time (median 2 days) 6

2. Laparoscopic Diverticulectomy

   • Viable alternative when robotic assistance is unavailable 3, 5
   • Laparoendoscopic single-site surgery (LESS) approach may offer improved cosmetic results 5
   • Average operative time ranges from 130-160 minutes with minimal blood loss 3, 5

3. Open Surgical Diverticulectomy

   • Reserved for complex cases or when minimally invasive approaches are contraindicated 1
   • Can be performed via extravesical, intravesical, or combined approaches 3

4. Endoscopic Management

   • Endoscopic incision of diverticular neck and fulguration of the mucosa 1
   • Primarily considered for elderly or frail patients with high surgical risk 1
   • Limited to smaller diverticula 3

Perioperative Considerations

• Ureteral catheterization on the side of the diverticulum is recommended to prevent ureteral injury during surgery 3, 5
• Placement of urethral catheter with balloon inflation in the diverticulum under fluoroscopic guidance can aid in identification during surgery 5
• Postoperative cystography is recommended before catheter removal to ensure absence of urinary leakage 5, 6

Special Considerations

• When intradiverticular tumors are present, management decisions between transurethral resection, partial cystectomy, or radical cystectomy should be based on tumor stage and grade 1
• Simultaneous treatment of bladder outlet obstruction (e.g., transurethral resection of prostate or adenomectomy) should be performed when indicated 3, 6
• Careful pathological evaluation is essential as the lack of muscular layer in diverticular wall may lead to underestimation of tumor invasion 1

Outcomes and Follow-up

• Surgical success rates are high with minimal recurrence when performed by experienced surgeons 1, 6
• Follow-up should include cystography, uroflowmetry, and ultrasonography measurement of post-void residual urine 5
• Significant improvement in post-void residual volumes can be expected after successful treatment (median decline of 120 mL) 6