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GIANT BLADDER DIVERTICULUM

Satish R Ranka *, Anand Iyer**, Girish Bakshi**,Chetan V Kantharia***, S A Bhaama****, R D Bapat*****
*Medical Officer; **Resident in Surgery; ***Associate Professor; ****Lecturer in Surgery; *****Head of Department of Surgery; Department of General Surgery, Seth GS Medical College and KEM Hospital, Mumbai, India.

Bladder diverticulum is a well known entity. We report a case of giant bladder diverticulum with review of literature.

INTRODUCTION

Bladder diverticulum is a known entity. In acquired cases it is secondary to bladder outlet obstruction or a weak muscle wall. Symptomatic diverticulum requires treatment. Malignant potentials of these diverticulum is also to be kept in mind if long standing.

CASE REPORT

A 55 year man presented to the Surgical OPD with complains of hesitancy, intermittency and frequency since 4 months. He also gave history of intermittent haematuria. On physical examination bladder was palpable till the umbilicus and prostate was enlarged on per rectal examination. Ultrasound revealed a bladder diverticulum on the right side and a post void residual urine of 400 ml. IVU and CT scan confirmed our diagnosis (Figs. 1 and 2). The renal function on right side was markedly reduced so a renal scan was performed which showed 20% function in right kidney. Blood, urine and prostate specific antigen were normal. Cystoscopy revealed a large diverticulum on right side with non visualisation of the ureteric orifice on right side. There also was median lobe enlargement of prostate. The bladder mucosa was normal and there was no stone or tumour seen. Patient underwent diverticulectomy with ureteric reimplantation and transuretheral resection of prostate in same sitting. Patient was discharged after suture removal and removal of catheter.

DISCUSSION

By definition bladder diverticulum is protrusion of bladder mucosa through its muscular layer.

Bladder diverticula are classified as:

Congenital : Seen rarely and are usually associated with posterior urethral valves or neurogenic bladder.[1]

Acquired or Pulsion diverticulum : Secondary to bladder outlet obstruction.[2]

Traction Diverticulum : In this condition a portion of bladder protrudes through the inguinal or femoral hernial orifice.

Fig. 1
Fig. 1 : Intravenous urography showing the giant bladder diverticulum.


Fig. 2
Fig. 2 : CT scan of the patient depicting the diverticulum posterior to the bladder on the right side.

Small diverticulum do not cause problem but a large one may pose some problems.[3] It may give rise to complications like recurrent urinary tract infection, vesical calculi and obstruction. Ureteral obstruction as was the case in our patient may lead to hydronephrosis and hamper renal function. Rarely a neoplasm (< 5%) may develop due to chronic irritation.[4] Sarcomatoid changes are also reported.[5] Patient may present with haematuria (30%) or double micturition classically. It can also present as an acute abdomen due to its rupture.[6] Ultrasound, intravenous urography, cystoscopy are routinely performed. A contrast enhanced CT scan, urodymamic studies may also be performed. All diverticulum do not require treatment in absence of infection or other complications if the causative factor is removed. Combined intravesical and extravesical diverticulectomy is the standard surgery with relieving of the obstructive factor in same sitting or before it. Endoscopic transvesical-transurethral approach to close the mouth of diverticulum is also reported.[7]

ACKNOWLEDGEMENT

We would like to thank the Dean, Seth GS Medical College and KEM Hospital for allowing us to publish this case report and Mr. Rakesh Rathod of DM Rathod and Co for their Technical support.


REFERENCES
  1. Pieretti RV, Pieretti-Vanmarcke RV. Congenital bladder diverticula in children. Journal of Paediatric Surgery 1999; 34 (3) : 468-73.
  2. John P Gearhart, Robert D Jeffs. Campbells Urology 6th Edition. WB Sanders Co, Philadelphia. 1992; 2 : 1814-15.
  3. Melekos MD, Asbach HW, Barbalias GA. Vesical Diverticulum : Etiology, Diagnosis, Tumorigenesis and Treatment : Analysis of 74 cases. Urology 1987; 15 : 453.
  4. Charles V Mann, Russell RCG, Norman S William. In : Bailey and Love’s Short Practice of Surgery 22nd Edition 1995, Chapman and Hal Medical, London. 1995; 955-56.
  5. Kim MY, Jeon YS, Suh CH, et al. Sarcomatoid carcinoma arising from the diverticulum of the urinary bladder dome. American Journal of Roentgenology May 1999; 172 (5) : 1454-5.
  6. Jorion JL, Michel M. Spontaneous rupture of bladder diverticula in a girl with Ehlers-Danlos syndrome. Journal of Paediatric Surgery 1999; 34 (3) : 483-4.
  7. Okamura K, Watanabe H, Iwasaki A, et al. Closure of mouth of bladder diverticulum via Endoscopic transvesico-transurethral approach. Journal of Endourology 1999; 13 (2) : 123-6.

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