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Laparoscopic bladder diverticulectomy

LAPAROSCOPIC BLADDER DIVERTICULECTOMY FOR LARGE BLADDER DIVERTICULUM: A CASE REPORT Yung-Shun Juan, Ching-Chia Li,1 Jung-Tsung Shen,1 Mei-Yu Jang, Wen-Jeng Wu,1 Chii-Jye Wang, and Chun-Hsiung Huang1 Department of Urology, Kaohsiung Municipal Hsiao-Kang Hospital, and 1 Department of Urology, Kaohsiung Medical University, Kaohsiung, Taiwan.

Bladder diverticula are herniations of the bladder mucosa through the bladder wall musculature. Acquired bladder diverticula are the result of outlet obstruction, mostly benign prostate enlargement, infections, or urethral stricture. Traditionally, bladder diverticulum was excised by the open method. However, the laparoscopic technique has been widely used to treat many urologic diseases, including bladder diverticulum. Laparoscopic diverticulectomy can be performed transperitoneally or extraperitoneally. We report our initial experience with laparoscopic transperitoneal diverticulectomy for a large bladder diverticulum caused by bladder outlet obstruction. The patient had satisfactory micturition and was discharged on the eighth postoperative day.

Key Words: bladder diverticulum, laparoscopy (Kaohsiung J Med Sci 2004;20:563–6)

Bladder diverticula are herniations of the bladder mucosa through the bladder wall musculature. Depending on the size and location, bladder diverticula may cause ureteral obstruction, bladder outlet obstruction, or vesicoureteral reflux. Bladder diverticula most commonly occur lateral and superior to the ureteral orifices [1]. Many techniques for bladder diverticulectomy have been described, including transperitoneal [2–4] and extraperitoneal laparoscopic bladder diverticulectomy [5], as well as open [6] and transurethral techniques [7]. However, larger diverticula have not typically been treated using a laparoscopic technique or transurethral approach. The chance of ureteral injury increases because the normal anatomic relationship of the ureter to the bladder may be severely distorted by the diverticulum. We report our experience with transperitoneal laparoscopic bladder diverticulectomy and describe the surgical

Received: June 8, 2004 Accepted: July 8, 2004 Address correspondence and reprint requests to: Dr. Yung-Shun Juan, Department of Urology, Kaohsiung Municipal Hsiao-Kang Hospital, 482 Shan-Ming Road, Kaohsiung 812, Taiwan. E-mail: [email protected] Kaohsiung J Med Sci November 2004 • Vol 20 • No 11 © 2004 Elsevier. All rights reserved.

technique to avoid ureteral injury during the laparoscopic procedure.

CASE PRESENTATION An 85-year-old male with a long history of dysuria, pain on micturition, and cloudy urine denied any significant medical history except that he had undergone transurethral resection of the prostate 3 years prior to this presentation. Urinalysis showed pyuria, and urine cultures were positive for Pseudomonas aeruginosa. Cystogram revealed multiple small bladder diverticula and a giant posterior diverticulum (Figure). Abdominal sonography showed a small right renal cyst and a huge posterior bladder diverticulum. Cystoscopy revealed multiple small bladder diverticula, marked urinary bladder trabeculation, and a large right diverticulum just lateral to the right ureteral orifice. The prostatic urethra appeared relatively unobstructed. Closer examination of the diverticulum revealed no stones or mucosal lesion inside. Preoperatively, the patient underwent mechanical and antibiotic bowel preparation. After induction of general 563

Y.S. Juan, C.C. Li, J.T. Shen, et al

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B

Figure. (A) Preoperative cystogram shows a large right bladder diverticulum (arrow) and irregular bladder wall. (B) Lateral preoperative cystogram also demonstrates a large lateral and posterior bladder diverticulum.

anesthesia, the patient was placed in the dorsal lithotomy position. A Veress needle was inserted and pneumoperitoneum was attained through a subumbilical port. Two other trocars (12 and 5 mm) were introduced in a fan pattern. Cystoscopic examination was performed simultaneously. Having identified the diverticulum with the assistance of transillumination from the cystoscope, an incision was made in the peritoneum and the diverticulum was exposed. The peritoneum was dissected from the bladder using a combination of blunt and sharp dissection. After circumferential dissection of the diverticulum neck, the diverticulectomy was completed by sectioning the neck around the cystoscope. A single-layer suture of 2-0 Vicryl was used to close the bladder opening. The bladder was filled with saline to confirm a watertight closure, and a drain was placed under direct vision. The resected diverticulum was removed through the 12 mm port. At the end of the procedure, all catheters were removed and a 20F threeway Foley catheter was inserted into the bladder for drainage. The patient resumed a regular diet on postoperative day 3. There were no early or late complications. Cystography performed 7 days postoperatively showed no evidence of extravasation. He had satisfactory micturition after ure564

thral catheter removal and was discharged on the eighth postoperative day.

DISCUSSION Bladder diverticula are herniations of the bladder mucosa through the bladder wall musculature. Diverticula can be wide- or narrow-mouthed, according to the size of the musculature defect. The size of diverticular openings has functional implications because narrow-mouthed diverticula often empty poorly. Stasis of urine within diverticula can also lead to stone formation or epithelial dysplasia. Depending on the size and location, bladder diverticula may cause ureteral obstruction, bladder outlet obstruction, or vesicoureteral reflux [1]. This anatomic location, close to the insertion of the ureter in the bladder, is important because large diverticula can impinge upon or distort the ureteral orifices. Many diverticula that are related to obstruction spontaneously resolve after relief or correction of the obstruction. In our case, however, the large diverticula persisted after transurethral resection of the prostate and caused symptoms of dysuria, pain on micturition, and cloudy urine after surgery. Kaohsiung J Med Sci November 2004 • Vol 20 • No 11

Laparoscopic bladder diverticulectomy

The goal of bladder diverticulectomy is successful excision of the bladder diverticulum without harming surrounding organs. Until recently, open extravesical [6] or transvesical [8] approaches have been most widely accepted, although transurethral techniques have also been described. Transurethral approaches to excise or fulgurate a bladder diverticulum replace open surgery with endoscopy, facilitating concurrent endoscopic resection or incision of the prostate [7]. However, these procedures are commonly limited to diverticula that are no larger than 300 mL. The laparoscopic technique has been widely used to treat many urologic diseases, including bladder diverticulum. Laparoscopic diverticulectomy can be performed transperitoneally [2,3] or extraperitoneally [5]. The most critical step in laparoscopic diverticulectomy is the initial highlighting of the diverticulum. Several approaches have been described that can help in the laparoscopic identification of the diverticulum and its dissection. Transillumination is effective in guiding laparoscopic dissection, but it is not easy to maintain the cystoscope in place [9,10]. We used a transperitoneal approach instead of extraperitoneoscopy. Nadler et al reported that laparoscopic extraperitoneal bladder diverticulectomy is superior to the transperitoneal approach [5]. Advantages of an extraperitoneal approach include avoidance of manipulation or mobilization of intraperitoneal structures, and possible reduction in the chances of postoperative port-site complications, such as hernia formation. In addition, if a postoperative urine leak develops, it would be confined to the extraperitoneal space. Nevertheless, we believe that the transperitoneal approach permits better space for identification and dissection of posterior diverticula and intracorporeal suturing. These advantages result in shorter operative times. Our experience with laparoscopic excision of a simple diverticulum demonstrates that this method can be an attractive alternative to open surgery for patients with diverticula responsible for bladder infection or residual urine. It is especially useful in instances when the diverticulum has a narrow neck. Limitations to this approach are,

Kaohsiung J Med Sci November 2004 • Vol 20 • No 11

potentially, diverticula involving a ureter or in an inaccessible location.

CONCLUSION For the symptomatic patient with a large bladder diverticulum, treatment can be chosen from a wide range of procedures, including open diverticulectomy, endoscopic transurethral resection and fulguration, and laparoscopic bladder diverticulectomy. From our experience, laparoscopic transperitoneal diverticulectomy provides the surgeon with a safe, effective, and minimally invasive procedure for large diverticulum.

REFERENCES 1. Fox M, Power RF, Bruce AW. Diverticulum of the bladder – presentation and evaluation of treatment of 115 cases. Br J Urol 1962;34:286–98. 2. Porpiglia F, Tarabuzzi R, Cossu M, et al. Sequential transurethral resection of the prostate and laparoscopic bladder diverticulectomy: comparison with open surgery. Urology 2002;60:1045–9. 3. Porpiglia F, Tarabuzzi R, Cossu M, et al. Is laparoscopic bladder diverticulectomy after transurethral resection of the prostate safe and effective? Comparison with open surgery. J Endourol 2004;18:73–6. 4. Khonsari S, Lee DI, Basillote JB, et al. Intraoperative catheter management during laparoscopic excision of a giant bladder diverticulum. J Laparoendosc Adv Surg Tech A 2004;14:47–50. 5. Nadler RB, Pearle MS, McDougall EM, et al. Laparoscopic extraperitoneal bladder diverticulectomy: initial experience. Urology 1995;45:524–7. 6. Blacklock AR, Geddes JR, Shaw RE. The treatment of large bladder diverticula. Br J Urol 1983;55:17–20. 7. Clayman RV, Shahin S, Reddy P, et al. Transurethral treatment of bladder diverticula. Alternative to open diverticulectomy. Urology 1984;23:573–7. 8. Firstater M, Farkas A. Transvesical submucosal diverticulectomy. Experience with 48 cases. Urology 1977;10:436–8. 9. Parra RO, Jones JP, Andrus CH, et al. Laparoscopic diverticulectomy: preliminary report of a new approach for the treatment of bladder diverticulum. J Urol 1992;148:869–71. 10. Parra RO, Boullier JA. Endocavitary (laparoscopic) bladder surgery. Semin Urol 1992;10:213–21.

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