LAPARASCOPIC DIVERTICULECTOMY/BLADDER

Bladder diverticulae represent a herniation of the bladder urothelium through the muscularis propria of the bladder wall. They are located adjacent to and connect with the bladder lumen through a narrow neck or ostium.3 On histologic examination, the diverticular wall is composed of mucosa, lamina propria, scattered thin muscle fibers, an adventitial layer, and, in some cases, a fibrous capsule or pseudocapsule.4,5 Because diverticulae contain only scattered thin muscle fibers, they do not empty their contents effectively during bladder emptying, leaving residual urine within the bladder which results in their characteristic findings on both endoscopic and radiologic examination. Bladder diverticulae may be classified as either congenital or acquired.

Treatment of bladder diverticulae depends primarily on first identifying and treating the cause of the diverticulum which is most commonly bladder outlet obstruction due to BPH, urethral stricture, voiding dysfunction, or neurogenic bladder.3 This may be performed prior to management of the diverticulum or concurrently with treatment of diverticulum. If the former approach is pursued and results in improved emptying of the diverticulum with corresponding resolution of symptoms and complications, then treatment of the diverticulum itself may not be required. As such, indications to treat bladder diverticulae include persistent symptoms, infections, obstruction (of the ureter or the bladder neck), vesicoureteral reflux, stones or malignant disease within the diverticulum. If an indication to treat is present, treatment options include observation, endoscopic management, or surgical excision using either the open or laparoscopic approaches

Laparoscopic bladder diverticulectomy represents a minimally invasive alternative to the open approach and can be performed either transperitoneally or extraperitoneally.18 Laparoscopic diverticulectomy employs the same principles of the open approach which include: 1.) Complete mobilization of the diverticular sac and neck; 2.) Excision of the diverticulum; and 3.) Precise double-layer bladder closure.19 Treatment of bladder outlet obstruction, if not already achieved, can be performed either immediately before or after diverticulectomy.20 It should be noted, however, that case series suggest that a staged approach of endoscopic outlet management followed by laparoscopic diverticulectomy results in faster recovery, lower blood loss, and comparable outcomes compared with the combined open approach.20 Robotic-assisted laparoscopic diverticulectomy also adheres to these treatment principles and The transperitoneal technique of laparoscopic bladder diverticulectomy involves ten steps: 1.) Individual cystoscopic catheterization of the ureters, the bladder, and the diverticulum itself; 2.) Insufflation of the peritoneal cavity; 3.) Insertion of four or five transperitoneal laparoscopic ports; 4.) Selective distension of the diverticulum; 5.) Incision of the peritoneum over the diverticulum; 6.) Identification and preservation of the ureters; 7.) Circumscription of the neck and excision of the diverticulum at its ostium; 8.) Double-layer bladder closure; 9.) Distension of the bladder to confirm closure; and 10.) Placement of a perivesical drain and urethral (or suprapubic) catheter.