What is the management plan for a patient with cystitis, benign prostatic hyperplasia (BPH), urinary bladder diverticulum, cystolithiases, bilateral renal cortical cysts, and an indeterminate liver nodule?

Management of Bladder Outlet Obstruction from BPH with Bladder Diverticulum and Cystolithiasis

This patient requires urgent urological referral for surgical intervention—specifically transurethral resection of the prostate (TURP) combined with endoscopic stone removal—because the CT findings of bladder wall thickening with trabeculations, large bladder diverticulum (11.7 cm), multiple bladder stones, and prostatomegaly (51 grams) with intravesical extension represent absolute indications for surgery to prevent progression to renal insufficiency, recurrent infections, and acute urinary retention. 1

Immediate Management Priorities

Assess for Surgical Indications (Present in This Case)

The AUA guidelines identify bladder stones secondary to BPH as an indication for surgical management, particularly when associated with bladder outlet obstruction 1. This patient demonstrates multiple high-risk features:

• Large bladder diverticulum (11.7 cm) with bladder wall thickening and trabeculations indicating chronic outlet obstruction 1, 2
• Multiple cystolithiases (bladder stones up to 0.5 cm with calcific densities +624 HU) 1
• Significant prostatomegaly (51 grams) with intravesical extension causing obstruction 1
• Markedly distended bladder suggesting impaired emptying and urinary stasis 2

Rule Out Active Infection Before Surgery

Obtain urinalysis and urine culture immediately to exclude active urinary tract infection, as asymptomatic bacteriuria must be screened for and treated before TURP 3. Urinary stasis in bladder diverticula predisposes to recurrent UTI and makes bacterial eradication difficult 2, 4.

Definitive Surgical Treatment

Combined Endoscopic Approach

The optimal surgical strategy is TURP combined with endoscopic management of bladder stones and the bladder diverticulum in a single procedure 5, 6. This approach addresses:

• TURP for prostatic obstruction: Removes the obstructing prostatic tissue causing bladder outlet obstruction 1
• Endoscopic stone removal: Eliminates bladder calculi that formed secondary to urinary stasis 6
• Endoscopic fulguration of diverticulum mucosa (Orandi technique): Can achieve near-complete resolution of large bladder diverticula without requiring open diverticulectomy 5

Timing and Preoperative Preparation

If active UTI is present, initiate targeted antibiotic therapy based on culture results and provide urgent drainage (bladder catheterization) before definitive surgery 2. Fluoroquinolones (ciprofloxacin) or third-generation cephalosporins are appropriate empirical choices pending culture results 1.

Antibiotic prophylaxis should be administered before TURP based on local pathogen prevalence and individual antibiotic susceptibility 3.

Why Medical Management Alone Is Inadequate

While alpha-blockers (tamsulosin, alfuzosin) and 5-alpha-reductase inhibitors (finasteride) are appropriate for uncomplicated BPH 1, 7, 8, this patient has developed serious complications of BPH that constitute absolute indications for surgery 1:

• Bladder stones clearly due to BPH 1
• Large bladder diverticulum (>5 cm) with evidence of progressive bladder dysfunction 1, 4
• Risk of recurrent UTI from urinary stasis 2, 3

One retrospective study showed that 78% of selected patients with bladder stones could avoid TURP with medical management after stone removal 6, but those patients had serum creatinine ≤1.6 mg/dL, no hydronephrosis, and no acute retention history. Even in that favorable cohort, 17.4% developed recurrent calculi and 21.7% developed UTI 6. This patient's large diverticulum and severe bladder changes indicate more advanced disease requiring definitive surgical correction.

Management of Incidental Findings

Renal Cortical Cysts (Bosniak 1)

Simple renal cysts (3.2 cm right, 1.2 cm left) require no intervention and no routine follow-up imaging 1.

Indeterminate Liver Nodule (0.9 cm, Segment VIII)

This requires dedicated liver imaging with contrast-enhanced MRI or multiphase CT to characterize the nodule, as size <1 cm makes definitive characterization difficult on non-contrast CT 1. This evaluation can proceed after addressing the urgent urological issues.

Colonic Diverticulosis

Uncomplicated diverticulosis without CT evidence of diverticulitis requires no acute intervention.

Postoperative Follow-Up

After TURP and stone removal, monitor for:

• Postvoid residual urine volume to confirm adequate bladder emptying (target <50 mL) 5
• Recurrent UTI through periodic urinalysis 3
• Stone recurrence with imaging if symptoms develop 6
• Serum creatinine to ensure no progression to renal insufficiency 1

Cystoscopy at 3-month intervals initially, then every 6 months if negative, to monitor for bladder changes and ensure diverticulum resolution 5.