Saudi J Kidney Dis Transpl 2009;20(3):474-475

2009 Saudi Center for Organ Transplantation

Case Report


Bilateral Large Diverticulae of Urinary Bladder

Sanjay Pandey, Vijay Agarwal, Shashank Mishra, S.K. Thakur

Department of Surgery, Subharti Medical College, Meerut, India

Introduction

Bladder diverticulum is an outpouching of the
mucosa through the muscular wall of the bla-
dder, which may be congenital or acquired.
Bladder diverticulae in children and adults is
reported to be approximately 1.7% and 1 to 6%
respectively.
1
In adults, most often they occur
as a result of outlet obstruction, frequently
prostatic hypertrophy. Occasionally, when a
diverticulum encompasses the ureteral orifice
in the setting of a neurogenic bladder and
vesico-ureteral reflux, it is termed a Hutch
diverticulum.
1

Case Report

A 65 year old male presented with increased
diurnal frequency and difficulty in micturition,
frequent attacks of urinary tract infection and
episodes of near retention for the last one and
half years. Clinically he had prostate enlarge-
ment on per-rectal examination. Plain X-ray
KUB revealed multiple calculi in the pelvic
region. Ultrasonography confirmed the pre-
sence of multiple bladder calculi with bilateral
large diverticulae, enlarged prostate, and sig-
nificant residual urine with out hydronephro-
sis. Intravenous urography with voiding cysto-
graphy revealed two large diverticulae on
either side of normal ureters with multiple cal-
culi in bladder and diverticulae (Figure 1).
Preoperative Cystoscopy revealed enlarged
prostate, trabeculations and sacculations with
cystitis and bilateral narrow opening of diver-
ticulae superolateral to ureteric orifices. Bila-
teral ureteric stenting was done peroperatively
with combined intravesical and extravesical
diverticulectomy accompanied by removal of
stones and packing of diverticulum. Suprapubic
transvesical enucleation of prostate was also
done. Glycine irrigation through Foleys triway
catheter continued for 48 hours with unevent-
ful post-operative period. Prevesical drain was
removed on 4
th
and Foleys catheter removed
on 14
th
post-operative day.

Discussion

Bladder diverticulae can be congenital or ac-
quired. Acquired diverticulae are of two types-
pulsion or traction type. Acquired diverticulae
are rare in women. Congenital bladder diverti-
culae is usually solitary and seen in boys
Correspondence to:

Dr. S.K. Thakur
Department of Surgery
Subharti Medical College
Delhi-Haridwar Bypass Road
Meerut- 250002,India
E-mail: thakur_sk@rediffmail.com
Saudi Journal
of Kidney Diseases
and Transplantation
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younger than 10 years. On Cystoscopy, smooth
walled bladder is seen. Causes could be as
follows- congenital weakness at the level of
ureterovesical junction; aberrant voiding dyna-
mics or anatomy as in Prune-belly syndrome
or posterior urethral valve where diverticulum
is usually located at the dome of bladder. This
variety is also associated with various conge-
nital syndromes such as Menkes syndrome,
Williams syndrome and Ehlers-Danlos syn-
drome.
1

Acquired bladder diverticulum usually occurs
in males more than 60 years of age. Diverti-
culae are often multiple and usually occur on
the lateral bladder walls On Cystoscopy, there
are usually multiple openings with significant
bladder trabeculations. Causes could be a bla-
dder outlet obstruction, neurogenic vesico-ure-
thral dysfunction or Iatrogenic.
1,2
Large diver-
ticulae often displace the bladder and/or ure-
ters. Diverticulae narrow necks are slow to
empty and likely to have urinary stasis and
infection.
2

Repeated infections, hematuria due to stone
in the diverticulum and passing of urine twice,
once from the bladder, followed by emptying
of the diverticulum (Pis en deux) are the usual
presenting features. Metaplasia and tumor can
also occur in the diverticulum with a like-
lihood of spread beyond the bladder since the
diverticulum wall consists only of urothelium
without muscle.
1,3,4

Bladder diverticulae can be evaluated with
excretory urography with pre- and post-void
films, Ultrasonography, CT scan and Cystos-
copy.
1
Indications for surgery in a case of bla-
dder diverticulum include- persistent or recu-
rrent urinary infection, presence of stones in a
diverticulum, development of tumor in a diver-
ticulum, lower urinary tract symptoms, voi-
ding dysfunction and vesicoureteral reflux due
to diverticulum or ureteral obstruction.
1,2

Small size diverticulum resolves with relief
of bladder outlet obstruction wheras surgery is
needed in large size diverticulum if sympto-
matic. Surgical options include transurethral
cystoscopic or open surgical management by
either Transvesical or combined extravesical
and intravesical approach or Tubeless diverti-
culectomy either by Laparoscopic or trans-
abdominal approach.
1-4

Acknowledgement

We are thankful to the medical superintendent
Subharti Medical College, Meerut, for giving
us the permission to publish this case report.

References

1. Wein AJ, Kavoussi LR, Novick AC. Campbell-
Walsh, Urology 9
th
Edition, 2006 W.B. Saunders:
2361-2371.
2. Faramarzi-Roques R, calvet C, Gataeu T,
Ballanger PH. Surgical treatment of bladder
diverticula: laparoscopic approach.. J Endourol
2004;18(1):69-72.
3. Pizzi P, Castillo O, Carvajal D, Vitagliano G,
Hidalgo F. Transperitoneal laparoscopic bladder
diverticulectomy. Arch Esp Urol 2006;59(8):
805-8.
4. Abdel-Hakim AM, El-Feel A, Abouel-Fettouh
H, Saad I. Laparoscopic vesical diverticulectomy.
J Endourol 2007;21(1):85-9.



Figure 1. 15 min. IVU film showing diverticulae
and radioluscent shadows of stones
Bilateral large diverticulae of urinary bladder 475
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