CLINICAL CASE
Laparoscopic resection
of symptomatic bladder
diverticulum
Gutfrajnd-Feldmann RE,1 Kibanov V,2 González-Domínguez M.3
• ABSTRACT
Bladder diverticula are herniations of the mucosa
through the muscular bladder wall. Traditionally,
symptomatic bladder diverticula are resected by
means of conventional open surgery. However, the
development of minimally invasive surgical techniques
has made this operation possible using endourologic,
laparoscopic or robotic procedures.
The case of a 28-year-old female patient
diagnosed with left perimeatal bladder diverticulum
and managed with laparoscopic diverticulectomy
with excellent functional as well as cosmetic results
is presented.
To the best of the authors’ knowledge this is the first
case of laparoscopic diverticulectomy reported in Mexico.
Key words: bladder diverticulum, laparoscopic
diverticulectomy, Mexico.
1 Hospital Ángeles de Las Lomas, Huixquilucan, Mexico State.
2 Hospital Español, Mexico City. 3 Centro Médico Nacional La Raza,
Mexico City.
• RESUMEN
Los divertículos vesicales son herniaciones de la mucosa
a través de la pared muscular de la vejiga. De manera tra-
dicional, los divertículos vesicales sintomáticos se resecan
con procedimientos quirúrgicos convencionales a cielo
abierto. Sin embargo, el desarrollo de las técnicas qui-
rúrgicas de mínima invasión posibilita la práctica de esta
operación mediante procedimientos endourológicos, lapa-
roscópicos o robóticos.
Se presenta el caso de una paciente femenina de 28
años de edad con diagnóstico de divertículo vesical peri-
meatal izquierdo, sometida a diverticulectomía mediante
laparoscopia con excelentes resultados, funcionales y cos-
méticos.
Hasta donde tienen noticia los autores, éste es el pri-
mer caso de diverticulectomía laparoscópica informado en
México.
Palabras clave: divertículo vesical, diverticulectomía la-
paroscópica, México.
Corresponding author: Dr. Ricardo Gutfrajnd Feldmann. Hospital Án-
geles de Las Lomas. Consultorio # P.B. 001. Av. Vialidad de la Ba-
rranca s/n. Col. Valle de las Palmas C.P. 52763. Huixquilucan, Esta-
do de México. Telephone and Fax: + (52) 55-5246-9760. Email:
urología@yahoo.com
Rev Mex Urol 2009;69(5):247-250 247
 Gutfrajnd-Feldmann RE et al. Laparoscopic resection of symptomatic bladder diverticulum
Image 1. Bladder diverticulum with sediment and pus. Double-J catheter draining very clouded urine from the left kidney.
• INTRODUCTION
Bladder diverticula are herniations of the mucosa through
the muscular wall of the urinary bladder. Depending
on their size and location, they can cause ureteral
obstruction, urinary flow obstruction (incomplete
bladder voiding), recurrent infection or vesicoureteral
reflux. Bladder diverticula are usually found lateral or
superior to the ureteral openings since they are the
weakest tissular areas of the bladder wall.1
Traditionally, symptomatic bladder diverticula
have been resected by means of conventional open
surgery. However, the development of laparoscopic,
endourologic and robotic techniques has brought about
their use in treating different pathologies, including
bladder diverticula. Laparoscopic diverticulectomy
can be performed trans- or extraperitoneally.2-4 The
authors describe their initial experience in performing
laparoscopic transperitoneal diverticulectomy. This is
the first such report in Mexico.
• CLINICAL CASE
The patient is a 28-year-old woman with a history
of dysuria, urinary frequency and straining of long
progression, recurrent urinary tract infection and
2 episodes of acute (left) pyelonephritis meriting
hospitalization. Urinalysis showed leukocyturia and
urine cultures were positive for different gram-negative
bacteria over a period of several years.
Patient had undergone previous studies including
cystography that had diagnosed bladder diverticulum
but stated that those studies had been lost.
Urethrocystoscopy was then ordered which revealed a
left-side bladder diverticulum where the ureteral meatus
and intramural portion of the left ureter formed part of
248 Rev Mex Urol 2009;69(5):247-250
the inner surface of the diverticulum. This was filled with
pus and sediment. There were no apparent calculi or
other lesions within the diverticulum. Double-J catheter
was put in place resulting in exit of cloudy urine from the
left kidney (Image 1).
After a 4- week wait for antibiotic treatment to be fully
effective, laparoscopic diverticulectomy was performed.
The patient was placed in the modified lithotomy position
and given balanced general anesthesia. Laparoscopic
approach consisted of four 5 mm ports at the umbilical
location, the suprapubic midline, the right iliac fossa
and the left iliac fossa. Simultaneous flexible cystoscopy
was done, visualizing the diverticulum through bladder
transillumination with the flexible cystoscope placed in
the bladder interior. Diverticulum was exposed with a
peritoneal incision. After circumferential dissection of
the diverticular neck was carried out, diverticulectomy
was completed by sectioning the neck around the
flexible cystoscope (Image 2). Bladder opening
was sutured at two planes with 3-0 vicryl. Antireflux
mechanism was created by tunneling the terminal
portion of the ureter. Hermetic bladder closure was
verified by hydro pneumatic test, placing drain under
direct vision. Resected diverticulum was removed and
sent to the laboratory for anatomopathological study.
The surgical area was checked by cystoscope after the
procedure (Image 3) and 18 F Foley catheter was put
in place, completing the operation. Total time in surgery
was 145 minutes, with no incidents or accidents and a
minimum of bleeding (<100 ml). Patient was released 48
hours later, after prior drain removal. Foley catheter was
removed 7 days later. Control urethrocystoscopy and
double-J catheter removal were carried out at 9 weeks,
corroborating cicatrization zone. Cosmetic results
were excellent. Follow-up care was carried out during
 Gutfrajnd-Feldmann RE et al. Laparoscopic resection of symptomatic bladder diverticulum
Image 2. Flexible cystoscope can be seen entering the abdominal cavity
from the bladder once the diverticulum was resected. Diverticular neck
resection.
4 months with persistently negative urine cultures and
complete post-urinary voiding demonstrated through
ultrasonography.
• DISCUSSION
Clinically significant bladder diverticulum is rare. The
majority of diverticula are secondary to urinary flow
obstruction. Medical treatment criteria are not well-
defined. Surgical treatment is clearly indicated in patients
that present with persistent urinary symptomatology,
recurrent infection, bladder calculi, urethral obstruction
or malignancy within the diverticulum.5
Current surgical techniques include conventional
open surgery6 (intravesical, extravesical and combined),
endoscopic surgery7 (fulguration or resection of the
diverticular neck), laparoscopic surgery that can
be transperitoneal8 or extraperitoneal3 and, more
recently, robot-assisted laparoscopy that adds
3-dimensional visualization and articulated tweezers
enabling movement at all angles.9
The most frequent diverticular site is the area
anterolateral to the ureteral opening and the proximity
Image 3. Cystoscopic revision after completion of laparoscopic
diverticulectomy.
to this opening often makes reimplantation necessary.9
In 1992 Parra et al were the first to report laparoscopic
transperitoneal bladder diverticulectomy but they stated
that the proximity of the diverticulum to the ureter
was a contraindication for the laparoscopic approach.8
However, as minimally invasive surgical techniques
have progressed, this consideration is no longer an
impediment to safely carrying out laparoscopic ureteral
reimplant. 8,9
In the present case, the variables of time in surgery,
amount of bleeding and postoperative recuperation
time were all within the parameters cited in the
literature reviewed and functional and cosmetic results
were also good.
Traditional open surgery is safe and provides good
results, but the laparoscopic approach in selected
patients presenting with the same pathology can
provide even better cosmetic results and a quicker
return to normal activities for the patient. However, its
higher cost and greater necessity of technological and
human resources make the laparoscopic approach to
bladder diverticulum treatment an indication in only
very select cases.
It can be concluded that the laparoscopic approach
to bladder diverticulum treatment is feasible and
safe providing results comparable to those of
conventional surgery. However, this approach
demands adequate technological equipment and
a well-trained surgical team with the laparoscopic
skills necessary to achieve access, dissection and
suturing. There are published prospective studies
on a reduced number of patients that evaluate the
actual benefits of this technique. 10
Rev Mex Urol 2009;69(5):247-250 249
 Gutfrajnd-Feldmann RE et al. Laparoscopic resection of symptomatic bladder diverticulum
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