Bladder diverticulum

Bladder diverticulum - epidemiology, presentation, evaluation, and management

1. Seminar Bladder diverticula - Dr. Abhishek Pandey

2. Introduction Bladder diverticulum → herniation of bladder mucosa between fibres of detrusor muscles Diverticular wall – Urothelium Lamina Propria Adventitia Fibrous capsule ( pseudocapsule ) – plane for excision Variably sized neck / ostium

3. Epidemiology 90% in Adults M : F = 9 : 1 (in both adult & pediatric) Classified as – Congenital Diverticula Acquired (Secondary) Diverticula – 2° to BOO/NGB Iatrogenic – following cystotomy / ureteral re-implantation Hutch Diverticulum – Superolateral to ureteral orifice sparing trigone + NGB + VUR

4. Classification Congenital Acquired/Secondary Childhood (<10yr – 1.7% incidence) Adults (>60yr) Congenital detrusor weakness BOO / NGB Solitary, Larger Multiple Smooth walled bladder Trabeculated thickened bladder 90% peri -VUJ Most common peri -VUJ 60% Syndromic /NGB/BOO 70% a/w Prostatism No association with malignancy 0.8 – 10% prevalence

5. Congenital Diverticula - Associations Bladder wall weakness – Syndromic associations Menkes syndrome (Kinky hair / Copper deficiency) Williams syndrome Ehler–Danlos syndrome Fetal alcohol syndrome BOO Prune–belly syndrome Posterior urethral valves

6. Presentation & Evaluation Congenital → m/c presentation – UTI (due to stasis) Acquired – non-specific symptoms (UTI/ hematuria / LUTS) → incidentally detected Mass effect in lower abdomen & pelvis Urine – R/M, C/S, & Cytology Cystoscopy Imaging of lower & upper urinary tract

7. Imaging Fluid-filled structure adjacent to bladder – d/d Mullerian cyst Urachal cyst Ectopic ureter / Ureterocele Post-op changes – lymphocele Cellules→Saccules→Bladder diverticula (radiological continuum – arbitrary, size related)

8. MCU MCU with AP, lateral & oblique views – Location, size & anatomy of diverticulum Associated VUR – 13% association with Congenital Emptying of diverticulum with voiding Trabeculated bladder wall Smooth diverticular wall

9. Anomalous Voiding into Diverticulum

10. Lower tract Cross-sectional Imaging Diverticulum anatomy – esp. if Assess for mass in diverticulum Surrounding Anatomy – Ureters , Rectum

11. Bladder wall thickening Asymmetric wall thickening Symmetric wall thickening

12. Diverticular mass

13. Large diverticulum - Distorted anatomy

14. MRI

15. Upper tract Imaging Hematuria evaluation / suspected malignancy Silent HUN – 7% Pediatric diverticula – upto 30% associated upper tract anomalies – Renal scarring/dysplasia, HUN HUN causes – Obstruction – related to Underlying pathology Diverticulum itself VUR

16. HUN – relieved by TURP

17. IVU – Medial ureteral deviation

18. UDS Role in adult patients (2°diverticula) ( Vedio UDS) Failure to treat underlying urodynamic anomaly at surgery → Complications & recurrence Correcting urodynamic anomaly → resolution Findings – BOO, ↓contractility, ↑PVR, DO Pressure sink effect – bladder emptying into diverticulum → falsely ↓contractility

19. Endoscopy Diverticular stone, mass Biopsy abnormal epithelium (perforation risk) Flexible cystoscope Cytology from diverticulum Surveillance Diverticular mass

20. Para- ureteral Diverticulum Lateral wall Diverticulum

21. Malignancy Diverticular malignant growth – 0.8 to 10% TCC in 70-80% > SCC in 20-25% Exclusively in Adults – peak ages 65-75yr Lack of deep muscles → stage progression Survival – Superficial disease 83% ± 9% Extra- diverticular disease 45% ± 14% TUR difficult & pathological staging inaccurate

22. Management

23. Management Options Surveillance – Cytology + Cystoscopy Endoscopic Mx – Diverticular neck TUR ± mucosal fulguration in poor surgical candidates Surgical Mx - Trans- vesical Bladder Diverticulectomy – small diverticulum with no adhesions / inflammation Combined intravesical-extravesical approach – large, with peri-diverticular inflammation

24. Trans- vesical Bladder Diverticulectomy

25. Combined intravesical-extravesical bladder diverticulectomy

26. Complications Ureteral Injury Partial transection – primary repair + stent Complete transection – reimplantation Urinary extravasation / Fistula Bleeding Infection

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28. Thank You

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