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Bladder Diverticulectomy: Surgical Technique and Complications

Indications for Bladder Diverticulectomy

Common indications are Large bladder diverticula with significant residual urine, recurrent infections, or urinary bladder stone formation. The cause of bladder diverticula in adults is usually subvesical obstruction, which should be treated beforehand or during diverticulectomy.

Contraindications

Contraindications for planned surgery are coagulation disorders, untreated urinary tract infection, bladder cancer, and high surgical risk due to comorbidities.

Surgical Techniques for Bladder Diverticulectomy

Preoperative Patient Preparation

• Exclusion or treatment of a urinary tract infection
• Perioperative antibiotic prophylaxis
• Supine position with slight hyperextension of the lumbar spine
• Disinfection and draping of the abdomen and genitals.
• Insert a transurethral catheter and fill the bladder with 200–300 ml
• For laparoscopic diverticulectomy: perform cystoscopy and insert a catheter balloon into the diverticulum with the help of a guide wire (inflate with 50 ml), good fixation of the patient to the operating table with a belt across the chest, pelvis and calves with arms resting on the table to enable a Trendelenburg position.

Surgical Approach

Lower midline incision or Pfannenstiel incision are used for open diverticulectomy, especially if adenomectomy of the prostate or ureteral reimplantation is planned at the same time. A laparoscopic approach is a good option for extravesical diverticulectomy without the need for ureteral reimplantation or simple prostatectomy.

Transvesical Diverticulectomy:

A transvesical diverticulectomy is used to treat small and medium-sized bladder diverticula, especially during transvesical adenomectomy of the prostate. After cystotomy, the mucosa of the diverticulum is grasped through the diverticular neck and inverted into the bladder. The diverticular neck is incised circumferentially. The diverticulum is resected, and the bladder is closed in two layers. If the diverticulum cannot be pulled into they bladder due to adhesions, the diverticulum is tamponaded with compresses and an extravesical diverticulectomy is attempted. The cystostomy is closed in two layers, test the closure with a bladder filling.

Extravesical diverticulectomy:

An extravesical diverticulectomy is suitable for the treatment of large bladder diverticula. The extravesical identification of the diverticulum can be difficult; a catheter balloon is used to mark the diverticulum (see patient preparation and fig. laparoscopic diverticulectomy and open diverticulectomy). Incise the peritoneum over the diverticulum and dissect the diverticular wall. Lateral or ventral diverticula can be treated with an extraperitoneal approach. After complete mobilization of the diverticulum, the bladder filling is removed and the diverticula neck is circumferentially incised, with careful attention paid to the ureter and the ductus deferens. If the ureter opens into the diverticulum, ureteral reimplantation is necessary at the same time. Place stay sutures cranial and caudal to the diverticular neck. Reposition of the bladder catheter into the bladder after complete resection of the diverticulum. Close the bladder defects with two layers and test the closure with a bladder filling.

Care after Bladder Diverticulectomy

General measures:

Early mobilization, analgesics, thrombosis prophylaxis, laboratory tests (hemoglobin, creatinine), regular physical examination of the abdomen and incision wound.

Analgesics:

Use a combination of NSAIDs and opioids.

Drains and Catheters:

• The pelvic drain is removed if the daily drainage volume is below 50 ml.
• Bladder catheter for five days; consider cystography for complicated cases.

Complications of Diverticulectomy

Urinary tract infection, bleeding requiring intervention or transfusion, wound infection, urinoma, ureteral injury, thrombosis, pulmonary embolism.

References

  Deutsche Version: Offen chirurgische und laparoskopische Harnblasendivertikelresektion