Giant bladder diverticulum: A case report and review of the literature

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The bladder mucosa may herniate due to weak or low muscle structure of the bladder wall (congenital), infravesical obstruction, or increased intra-bladder pressure due to neurogenic disorders (acquired) or previous surgery. This condition is called bladder diverticulum. Here we present a case of giant bladder diverticulum and review of the current literature.

A giant bladder diverticulum measuring 17x13x10 cm and connecting to the bladder with an approximately 15 mm ostium was detected through the computed tomography (CT) scan of a 73-year-old male patient presenting with lower urinary tract symptoms. A cystoscopic evaluation was performed right after this, both prostate lobes were closing the bladder neck and the ostium between the bladder and diverticulum was visually identified. Open diverticulectomy was performed after transurethral prostate resection.

Giant bladder diverticulum may present with different symptoms. Although minimally invasive techniques (endoscopic, laparoscopic and robot-assisted) can be applied effectively, open surgical treatment is still a valid option.

Introduction

Bladder diverticulum is defined as herniation of the bladder mucosa from a weak part of the muscularis propria layer in the bladder wall. Its incidence is approximately 1.7% and 1-6% in children and adults, respectively [1].

Case Report

A 73-year-old male patient presented to our outpatient clinic with long-lasting severe lower urinary tract symptoms (LUTS) and abdominal distention. Of the LUTS, storage symptoms were prominent. Although he had undergone internal urethrotomy for urethral stenosis 20 years ago and had been receiving alpha-blocker treatment for eight years, his complaints persisted. On physical examination, there was a palpable swelling in the abdomen extending from the  pubic symphysis to the epigastrium and was consistent with the globe vesicle (Figure 1). Urethral foley was inserted and 2000 cc of urine was drained. Renal function tests were normal. Abdominal ultrasonography revealed a giant cystic lesion extending from pelvic region to epigastrium. Upon this, an abdominopelvic computed tomography (CT) was performed and it showed a 17x13x10 cm size diverticulum, filling the left half of the pelvis almost completely, extending to the level of the L3 vertebra, compressing the bladder and prostate to the right, and attaching to the left lateral wall of the bladder with an approximately 15 mm ostium (Figures 2A and 2B). Then, transurethral prostate resection and open diverticulectomy operation was made and applied (Figure 3).

Together with our case, we summarized 18 cases of giant bladder diverticulum detected in adult patients in the literature since 1957 (Table 1).

Discussion

Bladder diverticulum is basically divided into two classes as congenital and acquired. It can also be seen as iatrogenic [2]. Congenital diverticulum usually occurs at the ureterovesical junction or among the hypertrophic muscle bundles where the muscle tissue is poor in amount. They are usually asymptomatic and incidentally detected. [3]. These diverticulae are seen to peak during childhood, especially before the age of 10 years. This presentation can also be seen in elderly patients. Indeed, in an 83-year-old case published by Oliveira et al. in 2017, the patient was diagnosed with bilateral hydronephrosis secondary to urinary retention and acute renal failure [4]. The imaging and physical examination findings of our case were also consistent with urinary obstruction in the form of a vesical globe. Congenital diverticulae are usually seen in males, are solitary and larger than acquired ones. It is mostly localized to the posterolateral of the ureteric orifice. Acquired diverticula are often secondary to a bladder outlet obstruction or neurogenic vesicourethral dysfunction. It is frequently seen in men over 60 years of age and secondary to prostate enlargement by aging. They are mostly multiple and typically associated with marked bladder trabeculation [2]. Our case is also male as 16 of the 18 cases that we reviewed fromt the literature (Table 1). 

The acquired type is usually narrow-mouthed and is more prone to stasis and infection than the wide-mouthed type (congenital type), since the urine in it slowly drains into the bladder [5]. Bladder diverticulum may become larger than the bladder itself by expanding when the bladder is emptied. According to the literature research, the largest bladder diverticulum recorded so far is the 27x21 cm giant diverticulum presented by Kumar et al. [6].

Acquired bladder diverticula usually do not cause symptoms. Many bladder diverticulum are detected incidentally during radiological or endoscopic examination of nonspecific LUTS, hematuria or infectious conditions [7]. Although they are very rare, they may cause gastrointestinal obstruction and acute abdomen. Mirow et al. operated their patient due to an acute abdomen, a giant bladder diverticulum was detected intraoperatively and diverticulectomy was performed [3]. 

Abdominal ultrasonography (USG) and contrasted abdominopelvic CT are frequently preferred methods for determining the size, location, accompanying pathologies of the diverticulum and dilatation secondary to renal obstruction. Voiding cystourethrogram may provide valuable information, especially accompanying vesicoureteral reflux. Cystoscopic examination of bladder diverticula for stone and tumor, cytology sample from the diverticulum and biopsy of abnormal mucosal areas are recommended [2]. Sometimes diverticula can cause recurrent urinary tract infections (up to 68%), malignant intradiverticular tumors (2-20%), vesicoureteral reflux or ureteral obstructions (5-15%), and spontaneous rupture [7]. The absence of muscle structure in the wall of the bladder diverticulum paves the way for a faster invasion of an intradiverticular tumor into the perivesical adipose tissue. Grade is more important than stage in these tumors.  Abdominal complaints were present in 10 of 18 cases in Table 1, while LUTS were present in the remaining 8 just as in our case. In the case of Kaneko et al., neural-induced syncope was accompanied by chronic urinary retention [8].

Treatment options for bladder diverticula include follow-up or surgery (endoscopic, laparoscopic, robotic or open). Endoscopic treatment can be applied to elderly patients who are not good candidates for open surgery, who will undergo endoscopic prostate surgery and who have a diverticular drainage disorder. The aim is to resect the diverticulum neck with a Collins knife or resectoscope loop, to dilate the narrow neck and to ensure complete emptying during voiding. Open prostatectomy and transvesical diverticulectomy can be performed in the same session in cases with large prostate and obstruction. Combined intravesical / extravesical approach should be preferred in cases with large diverticulum, peridiverticular inflammation and/or coexistence of ureteral pseudodiverticula [2]. Transurethral resection of the prostate and open diverticulectomy was performed in our case. Of the 18 cases reviewed, 9 had open diverticulectomy, 3 had endoscopic treatment, and 1 had reduction cystoplasty. One patient was followed up and treatment methods of 4 patients were unspecified. All authors performed extravesical diverticulectomy except Kwan et al. They chose intravesical approach [9]. 

Indications for surgical treatment of bladder diverticula are persistent and recurrent urinary tract infections, the presence of stones or tumors in the diverticulum, vesicocutaneous fistula, LUTS, and the presence of vesicoureteral reflux [2]. In our case, the indication for surgical treatment was severe LUTS with storage symptoms at the forefront.

Consequently, giant bladder diverticula may present with different symptoms. Endoscopic treatment can be applied effectively and open surgery is still a valid option.

Scientific Responsibility Statement 

The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.

Animal and human rights statement

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.

Conflict of interest

None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.

References

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2. Chang JCY, Hsu TF, How CK. Acute Urine Retention With Two Giant Urinary Bladder Diverticula. The J Emergency Med.  2015; 48(2): 39-40.

3. Akbulut S, Cakabay B, Sezgin A, Isen K, Senol A. Giant vesical diverticulum: A rare cause of defecation disturbance. World J Gastroenterol.  2009; 15(31): 3957-59.

4. Oliveira PS, Oliveira TR, Martinho D, Lopes T. Hutch bladder diverticulum - unusual cause of adult obstructive uropathy. Arch Ital Urol Androl. 2017; 89(2):162-3.

5. Stephens FD. The vesicoureteral hiatus and paraureteral diverticula. J Urol. 1979; 121:786–91.   

6. Kumar S, Jayant K, Barapatra Y, Rani J, Agrawal S. Giant Urinary Bladder Diverticula presenting as Epigastric Mass and Dyspepsia. Nephrourol Mon. 2014; 6(4):e18918.      

7. Izumi J, Hirano H, Kato T, Ito T, Kinoshita K, Wakabayashi T. CT findings of spontaneous intraperitoneal rupture of the urinary bladder: two case reports. Jpn J Radiol. 2012; 30(3) : 284 -7.

8. Kaneko N, Kawasaki T, Boku H, Kamitani T. Syncope in a Patient with Giant Bladder Diverticulum. Intern Med. 2012; 51: 1935-36.

9. Kwan DJ, Lowe FC. Congenital Bladder Diverticulum: An Unusual Presentation with Abdominal Mass, Urinary Retention, and Renal Failure in a Young Adult. Urol Radiol. 1992; 14(3):194-6. 

10. Adachi M, Nakada T, Suzuki H, Hirano J, Kawamura S, Ishii N, et al. Successful Repair of Huge Bladder Diverticulum with a Transurethral Fulguration. Urol Int. 1991;46:87-89.

11. Lu HC, Lu CL. Giant Urinary Bladder Diverticulum Mimicking Intra-Abdominal Cyst. Am J Med Sci.2010; 339(2):205.

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14. Braga A, Serati M, Vitelli A, Caccia G. Occasional finding of giant bladder diverticulum that simulated an ovarian cyst: A case report and literature review. J. Obstet. Gynaecol. Res.2016; 42(3): 235-8.

Additional Info

  • Recieved: 2020-02-08
  • Accepted: 2020-03-09
  • Published Online: 2020-03-12
  • Printed: 2020-04-01
  • DOI: 10.4328/ACAM.20132
  • Author: Samet Senel, Yalcin Kizilkan, Suleyman Bulut, Binhan Kagan Aktas
  • Identifier: Corresponding Author ORCID ID: https://orcid.org/0000-0003-2280-4192
  • Index Page: S89-92
  • How to Cite: Samet Senel, Yalcin Kizilkan, Suleyman Bulut, Binhan Kagan Aktas. Giant bladder diverticulum: A case report and review of the literature. Ann Clin Anal Med 2020;11(Suppl 1): S89-92
  • Running Title: Giant bladder diverticulum
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