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

4. 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

5. 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

6. 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

7. 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

8. 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)

9. 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

10. Anomalous Voiding into Diverticulum

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

12. Bladder wall thickening
Asymmetric wall thickening
Symmetric wall thickening

13. Diverticular mass

14. Large diverticulum - Distorted anatomy

15. MRI

16. 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

17. HUN – relieved by TURP

18. IVU – Medial ureteral deviation

19. 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

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

21. Para-ureteral Diverticulum
Lateral wall Diverticulum

22. 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

23. Management

26. 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

27. Trans-vesical Bladder Diverticulectomy

30. Combined intravesical-extravesical
bladder diverticulectomy

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

32. A
• A

33. Thank You

34. A
• A