What is the best course of treatment for a patient with a 3 cm bladder diverticula and bladder outlet obstruction (BOO) confirmed by cystoscopy and CT Urography?

Treatment of 3 cm Bladder Diverticulum with Bladder Outlet Obstruction

The primary treatment should be surgical intervention addressing both the bladder diverticulum and the underlying bladder outlet obstruction, with robot-assisted laparoscopic diverticulectomy combined with treatment of the BOO (typically TURP or simple prostatectomy) being the preferred approach. 1, 2, 3

Rationale for Surgical Intervention

The AUA guidelines explicitly state that surgery is indicated for patients with bladder outlet obstruction causing refractory urinary retention, recurrent urinary tract infections, or other complications. 1 Importantly, clinicians should not perform surgery solely for an asymptomatic bladder diverticulum; however, when BOO is confirmed (as in this case with cystoscopy findings), evaluation and treatment of the obstruction is mandatory. 1

The presence of a 3 cm diverticulum with confirmed BOO creates a clinical scenario where:

• The diverticulum is likely symptomatic given the BOO findings 2
• Medical management alone will not address the anatomical abnormality 4
• Risk of complications (recurrent UTIs, incomplete emptying, upper tract deterioration) is significant 4, 2

Recommended Surgical Approach

Primary Option: Robot-Assisted Laparoscopic Surgery

Robot-assisted laparoscopic diverticulectomy with concurrent treatment of BOO should be the preferred approach when robotic expertise is available. 2, 3

The transvesical approach offers specific advantages:

• Direct visualization of diverticular orifice and bladder neck 3
• Simultaneous access to treat prostatic obstruction if present 3
• Short catheterization time (median 2 days) and hospital stay (median 3 days) 3
• Minimal blood loss (median 250 mL) 3
• No relapses reported in recent series 3

Alternative Surgical Options

If robotic surgery is unavailable:

• Laparoscopic diverticulectomy (extravesical or transvesical approach) with concurrent endoscopic treatment of BOO 5, 6
• Open diverticulectomy remains the gold standard when minimally invasive expertise is lacking 7, 2

Treatment of Concurrent BOO

The underlying cause of BOO must be addressed simultaneously:

• TURP (monopolar or bipolar) for prostatic obstruction 1
• Simple prostatectomy (open, laparoscopic, or robotic) for large prostates 1
• The choice depends on prostate size and surgeon expertise 1

Endoscopic Alternative for Selected Patients

Endoscopic incision of the diverticular neck with fulguration may be considered only in elderly, frail patients who cannot tolerate major surgery. 2 However, this approach:

• Is less definitive than surgical excision 2
• Should not be first-line in surgical candidates 2
• Still requires treatment of the underlying BOO 1

Critical Pre-Operative Considerations

Complete the Diagnostic Workup

• Obtain post-void residual measurement to quantify incomplete emptying 1
• Perform voiding cystourethrography if the diverticulum is near a ureteral orifice to evaluate for vesicoureteral reflux 1, 4
• Calculate prostate volume from CT urography to guide BOO treatment approach 1
• Exclude malignancy - bladder diverticula carry a 2-10% risk of harboring urothelial carcinoma 2

Patient Counseling

Counsel the patient about sexual side effects of surgical intervention, including ejaculatory dysfunction and potential worsening of erectile dysfunction. 1 This is particularly important given the strong relationship between LUTS/BPH and sexual dysfunction. 1

Common Pitfalls to Avoid

• Do not treat this as simple recurrent UTI - anatomical abnormalities with BOO require surgical correction, not just antimicrobial therapy 4
• Do not perform diverticulectomy without addressing the BOO - failure to treat the underlying obstruction will lead to recurrence 1, 7
• Do not rely on non-diagnostic uroflowmetry - the low voided volume makes interpretation unreliable; clinical findings and cystoscopy already confirm BOO 1
• Do not delay surgery in appropriate candidates - the combination of symptomatic diverticulum and BOO warrants definitive treatment to prevent complications including upper tract deterioration 4, 2