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Pediatr Surg Int (2009) 25:1117–1121

DOI 10.1007/s00383-009-2470-3

ORIGINAL ARTICLE

Lower urinary tract obstruction secondary to congenital bladder


diverticula in infants
Arbinder Kumar Singal Æ V. V. S. S. Chandrasekharam

Accepted: 12 August 2009 / Published online: 2 September 2009


Ó Springer-Verlag 2009

Abstract VCUG can help in diagnosis. Primary definitive repair can be


Purpose Congenital primary bladder diverticulum is a undertaken even in first few months of life with good results.
rare condition and may present with urinary infection;
other forms of presentation are rare. We present a series of Keywords Bladder diverticulum  Urinary retention 
infants who presented with urinary retention secondary to Infant  Lower urinary tract obstruction
large primary bladder diverticulum.
Methods Seven infants were evaluated for symptoms of
lower urinary tract obstruction. All seven were infant boys; Introduction
three were neonates. Investigations included ultrasono-
gram, voiding cystourethrogram (VCUG) and cystoscopy. Bladder diverticula in children most often occur secondary
Results Six infants had single large diverticulum while one to infravesical obstruction or neurogenic bladder and in
had bilateral diverticula. VCUG was diagnostic in all cases children with connective tissue disorders. In addition,
demonstrating the mechanism of obstruction clearly except paraureteric (Hutch) diverticulae may be seen in children
one where bilateral diverticula was diagnosed only on cys- with vesicoureteric reflux. However, true congenital pri-
toscopy prior to definitive surgery. Five children (including mary bladder diverticulae are rare in children. Such di-
one neonate) underwent successful definitive repair con- verticulae occur almost exclusively in boys and usually
sisting of diverticulectomy and ureteral re-implant while two present with recurrent urinary tract infection. Presentation
neonates were planned for a staged correction. One neonate with obstructive symptoms in form of urinary retention or
later in the series underwent definitive primary repair as straining and poor stream is rarer still [1–9]. However, it is
bladder was good sized. All five children have done well important to entertain this possibility in boys presenting
after definitive repair at a follow-up of 6–72 months. with urinary retention to avoid misdiagnosis and confusion.
Conclusion Primary bladder diverticulum in infants may We report a series of infants who presented with urinary
present with lower urinary obstructive symptoms indistin- retention secondary to congenital primary bladder diver-
guishable from posterior urethral valves. A carefully done ticulae. To our knowledge, this is the largest series of its
kind in English literature.
A. K. Singal
MGM’s New Bombay Hospital, Vashi and MGM University
of Health Sciences, Navi Mumbai 400703, India Materials and methods
A. K. Singal (&)
RH-5, O-26, Sector-7, Vashi, Navi Mumbai 400703, Seven boys (age range 7 days–11 months) presented with
Maharashtra, India lower urinary tract obstructive symptoms and were evalu-
e-mail: arbinders@gmail.com; arbinders@yahoo.com ated (Table 1). Three (40%) were less than a month old at
presentation. Six of the seven children had a single large
V. V. S. S. Chandrasekharam
Rainbow Children’s Hospital and Mahavir Hospital & Research diverticulum in the bladder (4 right sided and 2 left sided)
Centre, Hyderabad, AP, India while one boy had bilateral large diverticulae. None of the

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Table 1 Clinical details of all seven infants


S. no. Age Presenting Catheterization USG Palpable mass VUR Therapy FU (months)
complaints

1 1 year Retention 2 BH, div. Yes Ipsilateral Primary div. excision 72


seen and reimplantation
2 11 months Poor stream 1 UH, div. No Ipsilateral Primary div. excision 30
seen and reimplantation
3a 6 months Poor stream and 2 BH, div. Yes None Primary single-stage 12
retention seen excision of both div.,
bilateral ureteric
reimplantation
4 7 days Retention 1 BH, div. Yes None Vesicostomy Awaiting
seen definitive
surgery
5 5 months Retention 3 UH div. No Ipsilateral Primary div. excision 9
not seen and ureteric
reimplantation
6 10 days Retention 1 BH, div. Yes Ipsilateral Vesicostomy Awaiting
seen definitive
surgery
7 30 days Retention 1 BH, div. seen Yes Ipsilateral Primary div. excision 6
and re-implantation
UH Unilateral hydronephrosis, BH bilateral hydronephrosis, div. diverticulum
a
Bilateral diverticula were initially missed on VCUG as only one was seen due to overlapping on a lateral image. Cystoscopy showed bilateral
involvement

children had received antenatal diagnosis. Clinical exami- Results


nation revealed a large suprapubic cystic mass corre-
sponding to the thick-walled distended bladder in five Five of the seven children (including one 1-month-old
infants and in one newborn a separate mass could be pal- child and the child with bilateral diverticulae) underwent
pated corresponding to the distended diverticulum. History cystoscopy and primary transvesical excision of the di-
of urinary retention necessitating catheterization could be verticulae with reimplantation of ipsilateral ureter (with
elicited in all the patients and some boys had been cathe- ureteric tapering in 4). In the child with bilateral divertic-
terized more than once. Serum creatinine was within nor- ulae, both the ureters had to be reimplanted. All the
mal range for all the infants and none had urine infection at diverticula had a constant site of origin from posterolateral
presentation on urine analysis. Ultrasonogram (USG) bladder wall close to the ureteric hiatus. At a mean follow-
revealed varying degrees of hydronephrosis in all seven up of 26 months (range 6–72), all five children are
and it was bilateral in 5/7. Diverticulum could be seen in 6/ asymptomatic and follow-up USG demonstrated complete
7 as a fluid filled mass behind the bladder. VCUG was done or near-complete resolution of the hydronephrosis and
in all the cases and special emphasis was placed on lateral insignificant post-void residue. Two neonates underwent
and oblique films during filling and voiding phases. vesicostomy as the initial procedure and are awaiting the
Diverticulum could be well seen in all the patients and definitive procedure at 1 year of age (Table 1).
under fluoroscopy; the diverticulum was seen to enlarge
with voiding and compress the bladder outlet from behind,
thus resulting in bladder outlet obstruction (Figs. 1, 2, 3, 4). Discussion
Vesicoureteric reflux into the ipsilateral ureter was seen in
5/7 children. There was no contralateral reflux in any child. Bladder diverticula in children may be congenital or
In the 7-month-old child with bilateral diverticulae, bilat- acquired. Acquired diverticula are commonly seen with
eral involvement was missed out on initial VCUG as on the obstructive problems such as posterior urethral valves, in
lateral film the diverticulae got superimposed (Fig. 2) The patients suffering from neuropathic bladders or in children
diagnosis of bilateral diverticulae was only made at cys- with connective tissue disorders [1–9]. Primary bladder
toscopy prior to the open surgery. diverticulum unassociated with above-mentioned disorders

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Fig. 1 a VCUG showing large


bladder diverticulum in Case 1.
b Voiding film with retrograde
filling of the anterior urethra
demonstrates compression of
posterior urethra by enlarging
diverticulum at attempts to void

Fig. 3 VCUG of Case 4 showing large diverticulum lifting the


bladder out of pelvis as it enlarges behind the bladder. Note the
elevation of bladder neck and stretching of posterior urethra

Primary diverticulum in a girl child has been encountered


Fig. 2 VCUG of Case 3 showing a large bladder diverticulum in
Case 3. On cystoscopy, the child had bilateral diverticula. On only twice [7, 9]. Shukla et al. recently reported a girl with
retrospective review, the other side diverticulum can be faintly seen Ehler–Danlos syndrome who presented with urinary
through the bladder as denser contrast shadow retention secondary to bladder diverticulum [7].
Congenital bladder diverticula may be asymptomatic or
is a rare entity and is generally confined to male children may present with recurrent urinary tract infection or uri-
[1, 2, 9]. The etiology of such a primary diverticulum is nary obstruction. The latter presentation is rare; less than
inherent weakness in the bladder musculature with the 25 such cases have been reported so far in literature mostly
most common location being the posterolateral bladder as individual case reports [2, 4, 5, 9, 10]. Unlike some other
wall just above the ureteric hiatus [1, 3]. The sac wall series, all the patients in the present series are infants which
consists of bladder mucosa with some muscle fibers only. makes this series unique because the diagnosis and surgical

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re-implantation necessary. Thus, transvesical diverticulec-


tomy remains a preferred approach as re-implantation can
be performed concomitantly. The procedure has been well
illustrated by Kelalis [11] and also in a recent paper [9].
For reasons of safety and technical difficulty, in neonates
presenting with large bladder diverticulum a staged
approach including initially a diversion in form of a vesi-
costomy and later reconstruction at 1 year of age is gen-
erally advised [9]. Two of the newborns initially in the
present series with retentive symptoms were also diverted
(vesicostomy) as the bladder was deemed to be too small
for any formal reconstruction (Table 1). As the experience
grew, later in the series we elected to perform a definitive
surgery even in the 30-day-old infant (Case 7). We made
this decision after we observed that even in very large
diverticula the neck is always small and protrudes through
a small detrusor defect. Further, the reflux on VCUG in this
Fig. 4 VCUG of Case 5 showing giant bladder diverticulum child showed the ureter to be normal sized without the need
overlapping the bladder. Note the angulation of bladder neck and for tapering. Thus, we thought it would be worthwhile to
stretching of posterior urethra do a single-stage definitive procedure and this was easily
performed in the young baby. The ipsilateral ureter was
placed between the repaired detrusor and the mucosa thus
management of these lesions is much more challenging at achieving successful nonrefluxing re-implantation in a
this young age [8–10]. Retention is secondary to mechan- small bladder. The infant has completed 6 months of
ical distortion of the bladder outlet because of angulation uneventful follow-up and is voiding well with good stream.
and compression of the bladder neck and posterior urethra The hydronephrosis has disappeared and there is minimal
by the large diverticulum. Due to a thin wall and low post-void residue on USG.
pressures, these diverticula enlarge during micturition and In the present series, we also report the second case in
cause retention, which further balloons up the diverticu- English literature of a child with bilateral primary blad-
lum, thus worsening the obstruction. In the present series, der diverticulae. As mentioned earlier, the final diagnosis
such a phenomenon could be clearly demonstrated during of bilateral involvement was made on cystoscopy which
voiding cystography under fluoroscopic guidance (Figs. 1, we routinely do before any bladder surgery. The excision
2, 3, 4). In fact, in a newborn (Case 4) with acute retention, of two large diverticulae with reimplantation of large
the bladder was almost lifted out of the pelvis by the ureters in an infant bladder is a difficult surgical exer-
enlarging diverticulum (Fig. 3). cise. We approached this child also intravesically and
Incidentally discovered asymptomatic small diverticula avoided extravesical approach because bilateral extrave-
do not require any management, though the ones that retain sical dissection around the region of the ureteric hiatus
contrast post-void should be viewed with concern. could have resulted in neurogenic bladder. The basic
According to Verghese et al., criteria for surgery should principle is to dissect close to the wall of the divertic-
include persistent or recurrent urinary tract infection, ulum. The child is asymptomatic 6 months after surgery
interference with bladder emptying or outlet obstruction with USG demonstrating normal kidneys and no post-
and ureteral obstruction or reflux [6]. In the present series void residue.
all the children had huge diverticula which presented with In conclusion, congenital bladder diverticula may be a
lower urinary tract obstruction mandating management. rare cause of lower urinary tract obstructive symptoms in
Giant bladder diverticula is the term used when the diam- male infants and needs to be distinguished from more
eter is more than 1/3 of the bladder diameter [7, 9]. Our ubiquitous posterior urethral valves. Our series is the
patients had diverticula which were equal to or larger than largest till date and stresses on proper evaluation in form a
the bladder itself (Figs. 1, 2, 3, 4). carefully done VCUG to establish diagnosis and cystos-
In symptomatic children, diverticulectomy is the pro- copy prior to surgery to further aid in delineating the
cedure of choice. It can be done by extravesical, intraves- anatomy well. Outcome is excellent after a definitive repair
ical or combined approach with good results [2, 5, 6]. In which includes diverticulectomy and/or ureteric re-
most cases, there is associated reflux or the ureteric hiatus implantation and this can be done with good results even in
is involved by the diverticulum, making ipsilateral ureteric first few months of life or in bilateral cases.

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