Excision of Vesical Diverticulum CHAPTER
Dena Engel
Bladder diverticula are the result of herniation of the bladder
mucosa through the detrusor wall. Because of the lack of muscu-
laris tissue around the diverticula, they usually empty poorly or
incompletely. Urinary stasis, inflammation, and resultant infec-
tion can occur. A fibrous pseudocapsule often encases the bladder
diverticulum. Inflammation also creates an environment at risk
for malignancy. Bladder cancer within any diverticulum has a
poorer prognosis because of the lack of muscularis, which can
result in early tumor infiltration.
Many diverticula are often asymptomatic, and most are never
diagnosed. Typical presenting symptoms include hematuria,
infection, and lower urinary tract symptoms. Bladder diverticula
are either congenital or acquired and can occur at any age but are
usually detected in middle or older age. Men are more commonly
affected than women.
Congenital diverticula are commonly a consequence of an
inherent detrusor weakness. They are typically solitary, lateral, and
posterior to the ureteral orifice and occur without evidence of
outflow obstruction. They can enlarge and encroach upon the
ureteral orifice and cause either ureteral obstruction or reflux.
Surgical intervention may be required in cases of recurrent infec-
tions, vesicoureteral reflux, ureteral obstruction, or bladder neck
obstruction.
Acquired diverticula commonly occur in patients with bladder
outlet obstruction, neurogenic voiding dysfunction, or impaired
bladder compliance. Significant bladder trabeculations and hyper-
trophied detrusor muscles increase the propensity for diverticula
to occur. The increased intravesical pressure causes mucosa to
protrude between hypertrophied muscle bundles.
Asymptomatic patients may be followed conservatively with
urine cultures, urine cytology, and endoscopic surveillance. Symp-
tomatic patients may require surgical intervention. Complications
of bladder diverticula include persistent infection, stone forma-
tion, ureteral obstruction, and urinary retention. Traditionally
surgical repairs have been done with open procedures. In recent
years, laparoscopic and robotic diverticulectomy repairs have
become more common.
PREOPERATIVE MANAGEMENT
A voiding cystourethrogram is recommended to assess the number,
size, location, concurrent reflux, and emptying of the diverticu-
lum with voiding. Cystourethroscopy is also advisable to deter-
mine location of the ureteral orifices in association with the
diverticulum and to assess for mucosal abnormalities. If the ure-
teral orifices are involved, ureteral reimplantation at the time of
diverticulectomy may be needed. Upper tract imaging with intra-
venous pyelography, ultrasonography, or computed tomography
urography should be performed assessing for hydronephrosis or
ureteral obstruction.
The underlying abnormality causing the diverticula should
be addressed either before or during surgical treatment of the
diverticula. In some cases, treatment of the underlying urologic
abnormality will result in symptom resolution, and no further
treatment is needed for the diverticula. Urodynamics should be
considered to aid in identification of any underlying functional
abnormality.
52
Patient should have a clean urinalysis and urine culture before
any surgical procedure or placed on appropriate antibiotics pre-
operatively. Preoperative medical clearance for surgery is per-
formed to minimize surgical risk.
COMBINED INTRAVESICAL AND
EXTRAVESICAL APPROACH
The combined approach is ideal for patients with a larger diver-
ticulum or fibrosis or inflammation surrounding the diverticula.
1. Place the patient in the supine position with the pelvis over
the kidney rest and in slight extension. Prep and drape the
penis and urethra into the field. Insert a 22-Fr Foley catheter
and partially fill the bladder. Cover the penis and urethra and
catheter with a towel.
2. Make a lower midline extraperitoneal incision (Fig. 52.1, A)
3. Incise the linea alba. Enter the abdomen between the recti
and separate them. Divide the transversalis fascia with scissors
and move laterally. Push the peritoneal fold upward, revealing
the perivesical fact. Place a self-retaining retractor, such as a
Bookwalter retractor, for optimal exposure. Through the
Foley catheter, fill the bladder to capacity with sterile water.
Develop the retropubic space (Fig. 52.1, B).
4. Place two stay sutures in the detrusor wall well above the
pubic symphysis. Ensure that there is adequate suction in
hand. Incise the detrusor muscle in a vertical fashion between
the stay sutures using electrocautery. Use the suction to
remove the excess irrigation.
5. Adjust the retractors as necessary to reveal the diverticulum
and ureteral orifices. Place ureteral catheters to aid in avoid-
ing ureteral injury if necessary.
6. Locate and incise the mucosa at the diverticula neck circum-
ferentially with electrocautery. Place a finger in the diverticu-
lum (Fig. 52.2, A). Using a finger for traction, bring the
diverticula neck outside the bladder so the diverticulum can
be palpated anteriorly through the wound. Dissect the overly-
ing tissue to expose the anterior portion the diverticula neck.
Dissect the perivesical tissue away from the bladder wall
down to the palpable fingertip (Fig. 52.2, B). Incise the
anterior portion of the diverticular neck around the finger
(Fig. 52.3).
7. Use fine Allis clamps to grasp the urothelium edges and
progressively dissect the neck of the diverticulum circumfer-
entially from the bladder (Fig. 52.4).
8. After the diverticular neck has been freed from the mucosa,
mobilize and dissect the walls of the diverticulum from the
capsule until it can be completely removed (Fig. 52.5). These
steps are carried out carefully to make identification of the
mucosa and detrusor layers easier at the time of closure of
the bladder defect. When the diverticulum is densely adher-
ent to the capsule, portions may be left in situ. There is no
need to leave a drain in the diverticular cavity.
9. Close the bladder wall at the diverticular mouth in two layers,
ensuring closure of the muscularis serosal layer to prevent
recurrent diverticulum (Fig. 52.6).
10. If needed, place a suprapubic catheter or a large Foley catheter
in the bladder with a cystotomy in through the abdominal
385
386 SECTION 8 Bladder: Excision
FIGURE 52.1 (A) Lower midline extraperitoneal incision. (B) Development of the retropubic space.
wall. Suture in place with the bladder with an absorbable
purse-string suture secured to the skin (Fig. 52.7).
11. Close the bladder in two layers using 3-0 Vicryl and the
mucosa and a 2-0 Vicryl on the detrusor layer. The mucosal
layers closed first with a running suture. Close the detrusor
and serosal layers, also using a running suture. Test the closure
by filling the bladder with sterile water.
12. Placed a Penrose or closed-suction drain near the bladder
closure, exiting next to the wound. Stitch in place to the
skin with a nonabsorbable suture to prevent inadvertent
removal.
13. Close the fascia with zero polydioxanone suture (PDS). Skin
closure is by surgeon preference.
14. Leave a catheter to drainage for 8 to 10 days. Obtain a cys-
togram before catheter removal.
INTRAVESICAL APPROACH
The intravesical approach is ideal for smaller diverticula.
1. Place the patient in the supine position with the pelvis over
the kidney rest and in slight extension. Prep and drape the
penis and urethra into the field. Insert a 22-Fr Foley catheter
and partially fill the bladder. Cover the penis and urethra and
catheter with a towel.
2. Make a lower midline extraperitoneal incision (see Fig. 52.1).
3. Incise the linea alba. Enter the abdomen between the recti
and separate them. Divide the transversalis fascia with scissors
and moved laterally. Push the peritoneal fold upward, reveal-
ing the perivesical fact. Place a self-retaining retractor, such
as a Bookwalter retractor, for optimal exposure. Through the
Foley catheter, fill the bladder to capacity with sterile water.
Develop the retropubic space.
4. Place two stay sutures in the detrusor wall well above the
pubic symphysis. Ensure that there is adequate suction in
hand. Incise the detrusor muscle in a vertical fashion between
the stay sutures using electrocautery. Use the suction to
remove the excess irrigation.
5. Place a retractor to visualize the diverticulum. Pass a curved
Allis clamp through the neck to the base of the diverticulum,
which is grasped and everted back into the bladder (Fig.
52.8). Incise the mucosa of the diverticular neck circumfer-
entially. Remove the diverticulum (Fig. 52.9).
 CHAPTER 52 Excision of Vesical Diverticulum 387

FIGURE 52.2 (A) Exposure of the diverticular neck. (B) Dissection of the perivesical tissue away
from the bladder wall.

A B
FIGURE 52.3 (A, B) Incision of the diverticular neck.
388 SECTION 8 Bladder: Excision

FIGURE 52.4 Dissection of the neck of the diverticulum

circumferentially from the bladder.

FIGURE 52.6 Closure of the bladder wall.

FIGURE 52.5 Dissection of the walls of the diverticulum from

the capsule.

a. If the diverticulum cannot be everted into the bladder, a

submucosal excision may be performed.
b. Using electrocautery, incise the mucosa circumferentially
around the diverticulum neck. Place traction on the neck
with an Allis clamp, dissecting a plane between the diver-
ticula and surrounding capsule. Continue to mobilize the
diverticulum from the capsule until the diverticulum can
be delivered into the bladder lumen. When the diverticu-
lum has been completely freed from the capsule, remove
it from the bladder.
c. If the diverticulum is located near the trigone, insertion
of urethral catheters can be helpful to avoid damage to the
ureters.
6. Close the bladder wall at the diverticular defect in two layers,
ensuring closure of the muscular and serosal layer to prevent
recurrent diverticulum.
FIGURE 52.7 Placement of a catheter.
7. If needed, place a suprapubic catheter or a large Foley catheter
in the bladder with a cystotomy in through the abdominal
wall. Suture in place with the bladder with an absorbable
purse-string suture secured to the skin (see Fig. 52.7).
8. Close the bladder in two layers using 3-0 Vicryl on the
mucosa and 2-0 Vicryl and the detrusor layer. The mucosal
layer is closed first with a running suture. Close the detrusor
and serosal layer also using a running suture (Fig. 52.10). Test
closure by filling the bladder with sterile water.

9. Place a Penrose or closed-suction drain near the bladder
closure, exiting next to the wound. Stitch and placed to the
skin with a known double suture to prevent inadvertent
removal.
10. Close the fascia with zero PDS. Skin closure is by surgeon
preference.
11. Leave the catheter to drainage for 8 to 10 days. Obtain a
cystogram before catheter removal.
FIGURE 52.8 Intravesical approach: eversion of diverticulum
back into the bladder.
FIGURE 52.9 Intravesical approach: removal of diverticulum.
CHAPTER 52 Excision of Vesical Diverticulum 389
ROBOTIC AND LAPAROSCOPIC DIVERTICULECTOMY
1. The patient is placed in supine position or low lithotomy
position. Perform cystoscopy. Ureteral catheters or stents can
be placed if the diverticulum is in the proximity to the
ureters. Place a Foley catheter and fill the bladder by gravity
with sterile water.
2. Place ports: Pneumoperitoneum is obtained either by Veress
needle or open Hassan access. A 12-mm trochar is placed
supraumbilically for the camera port. Three robotic 8-mm
trocars are placed. Two robotic ports are placed in the left
abdomen approximately 10 cm away from each other and the
camera port. A right-sided robotic port is placed 10 cm from
the camera trocar. A 12-mm assistant port is placed on the
right side 7 cm superior-lateral to the right robotic port.
Laparoscopic ports can be placed accordingly.
3. Place the patient in an exaggerated Trendelenburg position.
4. Docking the robot can be done between the legs or side
docking. Side docking on the patient’s left aids when the
assistant is on the right. Intraoperative cystoscopy is helpful
in locating the bladder diverticulum and easier to perform
when the robot has been docked at the side, allowing for
better pelvic access. When side docking is performed, place
the robot at the patient’s knee.
5. Incise the peritoneal peritoneum over the diverticulum trans-
versely. To aid with the visualization of the diverticulum, a
flexible cystoscope advanced transurethrally into the diver-
ticulum will illuminate the diverticular walls.
6. Dissect a plane between the peritoneum and the perivesical
fat. Identify the ipsilateral ureter and dissected away from the
diverticulum. If the ureter is involved, ureteral refluxing reim-
plantation may be appropriate.
390 SECTION 8 Bladder: Excision

7. Dissect the diverticulum down to the diverticular neck. Tran-

sect the diverticulum directly at its neck. Place the diverticu-
lum in specimen bag and remove the diverticulum through
a trocar site.
8. Close the mouth of the diverticulum in two layers with 3-0
absorbable running suture.
9. Remove the ureteral catheters if placed. Place an 18-Fr Foley
catheter into the bladder and distend with sterile water to test
the anastomosis.
10. Place a closed suction drain through the 8-mm robotic trocar
and secured place with a nonabsorbable stitch at the skin.
11. Close the fascia and skin per surgeon preference.
12. Keep the catheter to drainage for 8 to 10 days. Obtain a
cystogram before catheter removal.

FIGURE 52.10 Intravesical approach: closure of the bladder.
SUGGESTED READINGS
Davidiuk AJ, Meschia C, Young PR, et al. Robotic-assisted
diverticulectomy: assessment of outcomes and modifications of
technique. Urology. 2015;85:1347.
Myer EG, Wagner JP. Robotic-assisted laparoscopic bladder
diverticulectomy. J Urol. 2007;178:2406.
Nadler RB, Pearle MS, McDougall EM, et al. Laparoscopic extraperitoneal
diverticulectomy: initial experience. Urology. 1995;45:524.
Wein AJ. Campbell-Walsh urology. 10th ed. Philadelphia: Saunders; 2012.