










































This is an open access article under the terms of a license that permits non-commercial use, provided the original work is properly cited.  
© 2022 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Key Words Competing Interests Article Information

Bladder tumours, bladder cancer,  
robot-assisted surgery,  
bladder diverticula

None declared. Received on April 7, 2022 
Accepted on April 30, 2022 
This article has been peer reviewed.

Soc Int Urol J. 2022;3(5):303–313

DOI: 10.48083/JCLW6772

Intra-Diverticular Bladder Tumours:  
How to Manage Rationally

Mohammed Lotfi Amer,1,2 Hassan Mumtaz,2 Beth Russell,2 Jason Gan,2 Zahra Rehman,2  
Rajesh Nair,2 Ramesh Thurairaja,2 Muhammad Shamim Khan2

1 Tanta University Faculty of Medicine, Urology, Tanta, Egypt  
2 Guy's and St Thomas' NHS Foundation Trust, Urology, London, United Kingdom

Abstract

Objective To report changing practice in the management of intra-diverticular bladder tumours.

Methods We undertook a review of all intra-diverticular bladder tumours in our prospectively maintained 
institutional database.

Results A total of 28 patients (male = 27, female = 1) with a median age of 71 years (IQR 61 to 76) were diagnosed 
with intra-diverticular bladder tumours (IDBT) between March 2013 and February 2021. Fourteen had visible and 
3 had non-visible haematuria, while 11 patients had lower urinary tract symptoms. Median axial diameter of  
the diverticula was 46 mm (IQR 35 to 69), and median neck diameter was 9 mm (IQR 7 to 11). All patients had  
CT-urography and 5 patients also had an MRI. Surgical treatment consisted of diverticulectomy (n = 11), diverticulectomy 
and ipsilateral ureteric reimplantation (n = 11), radical cystectomy and ileal conduit (n = 4), or radical cystectomy  
and orthotopic bladder (n = 2). Eleven patients had open procedures, and 17 had robotic assisted surgery.

Final pathological stages were T0 (n = 2), Ta (n = 5), T1 (n = 7), T3a (n = 8) and T3b (n = 6). Twenty-four patients 
had urothelial carcinoma (including one nested variant and 4 with squamous differentiation) and 2 had small cell 
carcinoma. Three patients had neoadjuvant systemic chemotherapy, 2 had intravesical bacillus Calmette-Guerin 
(BCG) with mitomycin, and one had BCG monotherapy preoperatively. Five patients had adjuvant systemic 
chemotherapy while 7 had adjuvant intravesical therapies. Mean follow-up period was 37.8 months (±25.3). Mean 
recurrence-free survival was 61.5% (CI 45.7 to 77.4) and mean overall survival 71.6 % (CI 57.4 to 85.8). Ten patients 
(37%) died of cancer.

Conclusion Management of intra-diverticular bladder tumours is evolving. Bladder-sparing approaches are 
gaining popularity. Robot-assisted diverticulectomy is preferable as it reduces the morbidity resulting from treatment.

Introduction

Intra-diverticular bladder tumours (IDBT) are rare, accounting for approximately 1.5% of all bladder tumours. The 
first report of a diverticular tumour in the English literature was in 1896[1]. Studies published since then have been 
either case reports or small case series from various centres.

The most common histological type is urothelial carcinoma[2]. The challenges in managing IDBT are multifacto-
rial and involve all stages including initial diagnosis, resection/biopsy pathological staging, and subsequent treatment.

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Historically, IDBT have been perceived to be associ-
ated with poor prognosis. The possible reasons include 
anatomical factors ie, lack of muscle layer, late presen-
tation, delay in diagnosis due to limited access to digital 
imaging, and delayed treatment[3,4].

Because of the rarity of the IDBT, there is no univer-
sally accepted management algorithm. Recommen-
dations for management of IDBT were published by 
Cancer Committee of the French Association of Urology 
in 2012[2]; however, because of changing surgical prac-
tice, these guidelines require revision.

We report a series of 28 patients managed in our 
centre over the last 8 years. Their management reflects 
the increasing adoption of robotic approach for excision 
of the diverticula ± reimplantation of ureters and radi-
cal cystectomy when required. An algorithm is proposed 
for the most rational management of this rare group of 
tumours (Appendix 1).

Materials and Methods
We reviewed the prospectively maintained institutional 
database to identify all patients with IDBT who were 
managed in our department between March 2013 and 
February 2022. All patients provided informed consent 
for use of their data with preservation of confidentiality. 
As our institutional data are prospectively maintained 
with approval of local and institutional governance, 
ethics committee approval was not required. The data 
collated included demographics, presenting symptoms, 
results of investigations including histology, neoadjuvant 
t herapy, t y pe of procedure, surg ica l approach, 
postoperative oncological and functional outcomes, 
adjuvant therapy, recurrences and their management, 
and estimated recurrence-free and overall survival.

Statistical Analysis
For continuous data with normal distribution, variables 
are presented as mean ± standard deviation (SD). For 
continuous data with skewed distribution, variables 
are presented as median ± interquartile range (IQR). 
Kaplan-Meier analysis and the log-rank tests were used 
to depict time to events during follow-up. Statistical 
significance was set at P < 0.05. All statistical analysis 
was performed using SPSS version 26 software (IBM 
SPSS Statistics, IBM Corp., Armonk, NY).

Robot-Assisted Bladder Diverticulectomy
T h e  s t e p s  i n  t h e  r o b o t- a s s i s t e d  pr o c e du r e 
diver t icu lectomy involve a n init ia l c ystoscopic 
examination to re-assess the bladder. It is advisable to 
mark the periphery of the diverticulum with a Colling’s 
knife, aiming for a 1 cm surgical margin to act as guide 
for adequate oncological clearance. An appropriate 
length and diameter stent should be inserted in the 
ipsilateral ureter.

We use a 6 port transperitoneal approach. Once the 
diverticulum is identified it should be dissected from all 
sides until the neck is clearly defined. The bladder should 
be emptied before the neck of the diverticulum is opened 
to avoid spillage of the fluid to reduce the risk of cancer 
cell implantation.

The diverticular neck should be opened at the  
12 o’clock position initially to prevent spillover of any 
residual f luid in the diverticulum. Previously placed 
diathermy marks should be followed to circumcise the 
diverticulum. It is important not to mobilize the blad-
der anteriorly during the procedure, as this makes 
subsequent dissection very difficult. Once excision is 
complete, the specimen must be placed in the appro-
priate size bag immediately. The defect in the bladder 
should be closed with V-Loc sutures in a single layer.  
If the ipsilateral ureter must be transected for complete 
removal of the tumour, it should be re-implanted over 
an appropriate length double-J stent. Bilateral standard 
lymphadenectomy should then be performed. A drain 
may be left in the pelvis. A cystogram should be obtained 
7 to 10 days after surgery and the catheter removed if 
this is satisfactory.

Results
A total of 28 patients were identified from the database: 
27 males and 1 female. The median age was 71 years 
(IQR 61 to 76), and the median Charlson comorbidity 
index was 5 (IQR 4 to 7). The median body mass index 
was 26 (IQR 24.1 to 27.3). Fourteen patients presented 
with visible and 3 with non-visible haematuria, and 11 
patients presented with lower urinary tract symptoms. 
Six had previous transurethral resection of the prostate 
(TURP), 3 had prior bladder neck incision (BNI), and 6 
were on clean intermittent self-catheterisation (CISC) 
for incomplete bladder emptying.

Median axial diameter of the diverticula was 46 mm 
(IQR 35 to 69) and neck diameter 9 mm (IQR 7 to 11). All 
patients had CT-urography, but 5 patients additionally 
had magnetic resonance imaging (MRI) of the bladder 
for precise staging. Twenty-seven patients had resec-
tion biopsies, and one had diverticulectomy without 
prior tumour biopsy as the lesion was highly vascular 
and subsequently proved to be a small cell diverticular 
tumour.

Definitive surgical management consisted of divert-
iculectomy (n = 11), diverticulectomy and ipsilateral 
ureteric reimplantation (n = 11), radical cystectomy and 
ileal conduit (n = 4), and radical cystectomy and orthot-
opic bladder substitution (n = 2). Three patients did not 
have lymphadenectomy because of poor general health; 
14 had ipsilateral and 11 bilateral pelvic lymphadenec-
tomy. Eleven patients had open procedures and 17 had 
robot-assisted surgery. Surgeries were done by 3 expert 

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consultants with special interest in bladder cancer. The 
median operative time was 230 minutes (IQR 180 to 
290), the median estimated blood loss was 200mL (IQR 
100 to 300) and the median length of stay was 4 days 
(IQR 3 to 6).

There were 23 postoperative complications; 20/23 
(86%) of which were low-grade complications (Clavien-
Dindo grade 1 or 2). Three major complications (ie, 
Clavien-Dindo grade ≥ 3) occurred mainly in those who 
had radical cystectomy. The list of complications and 
their management is shown in Table 1.

On final histological examination, 2 patients had 
no residual tumour (T0); however, one had dysplasia 
and the other’s specimen showed extensive keratiniz-
ing metaplasia. The pathologic stage of the tumours 
in the remainder was as follows: pTa (n = 5), pT1  
(n = 7), pT3a (n = 8), pT3b (n = 6). Tumours in 24 patients 
were urothelial carcinoma including nested variant in 
1 patient and squamous differentiation in 4, and 2 had 
small cell carcinoma.

The risk of clinical under-staging is well documented, 
and this occurred in 2 of the 6 patients in the radical 
cystectomy subgroup: the first was clinically staged as 

cT1 and was upstaged to pT3, while the other was cTa in 
clinical staging and upstaged to pT1 on final histology 
(Table 2).

Of 22 patients undergoing diverticulectomy, 4 were 
staged ascTa, 11 as cT1 and 4 as cT3. The final stage in 12 
of these patients was in concordance with initial clinical 
stage, 7 were upstaged and 3 were downstaged (Table 3).

Three patients had systemic neoadjuvant chemother-
apy for clinically locally advanced disease with only 
partial response. One patient had intravesical bacillus 
Calmette-Guerin (BCG) monotherapy before referral to 
our centre, and 2 had sequential intravesical mitomycin 
and BCG therapy.

Five patients had adjuvant systemic chemotherapy 
(for locally advanced disease on final histology), and  
7 patients had adjuvant intravesical BCG and sequential 
electromotive drug administration mitomycin induc-
tion, followed by maintenance BCG after diverticulec-
tomy[5].

Eleven patients who underwent bladder-preserv-
ing surgery had normal voiding patterns postopera-
tively. Eleven others had ongoing lower urinary tract 
symptoms after surgery. Four patients were on medi-

TABLE 1. 

Complications and their management 

Postoperative complications Number of patients Management Clavien-Dindo grade

Urinary infection 2 Course of antibiotics 2

Migrated stents 1 Exploration to reposition stents 3b

Bleeding 1 Transfusion 2

Pyrexia due to small pelvic collection 2 IV antibiotics + antipyretics 2

Hospital acquired pneumonia 2 IV Antibiotics and chest physiotherapy 2

Nausea and bloating 5 antiemetics 1

Neuropraxia of the medial side of thigh 1 Medical TTT for neuropathy like B12 1

Postoperative ileus 3 NGT and antiemetics, Bowel stimulants 2

Hypotension and bradycardia 1 Antiarrhythmics 1

High drain output 2 Low creatinine content/ drain for 3 more days 1

Ileus, aspiration, and pulmonary oedema 1 ITU management 4a

Small bowel obstruction 1 Laparotomy + adhesiolysis 3b

Scrotal swelling 1 Scrotal support+ analgesics 1

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TABLE 3. 

Diverticulectomy: pathological data 

TURBT 
histology 

Clinical stage  
(with imaging)

Final histology

G3 T1 + CIS T1N0 G2 Ta Nx                 

G3 T1 + CIS T1N0
G3 T1 N0 +  

(squamous differentiation)

G3 T1 T1N0 G3 T3a N0                

G2 T1 T1N0 G2 T3a N0                   

G2 Ta TaN0 G2 Ta N0                    

G3 T1 T3N0
G3 T3b N0 +  

(squamous differentiation)

G2 Ta TaN0 G2 Ta N0               

G3 Ta TaN0 G3 T1 N0

G3 T1 T3N1 G3 T3a N0

G3 T1 T1N0
G3 T3a N0+ 

(squamous differentiation) 

G3 Ta TaN0  G3 Ta N0             

Not performed T3N0
G3 T3a Nx  

(small cell variant)  

G3 T1 T1N0
G3 T3b N0 

(small cell variant)           

G3 T1 T1N0
G3 T3b N0   

(nested variant)           

G3 T1 T1N0 G3 T1 N0

G3 T3 T3N0 G3 T3a N0

G2 T1 T1N0 G3 PT3a N0 

Not performed TxN0 T0 N0- dysplasia

G3 T1 T1N0 G3 T1 N0

G3 T1 T1N0 G3 T1 N0

G2 Ta TaN0 T0N0

G3 T1 T1N0
G3 T1+  

(squamous differentiation)

cal treatment while 7 patients underwent surgeries for 
bladder outlet obstruction later (TURP in 4 and BNI in 
3). Finally, 6 patients had to continue to perform CISC, 
including 3 of after outlet surgery.

Mean follow-up was 37.8 ± 25.3 months. The esti-
mated mean recurrence-free survival for this cohort was 
61.8% (CI 46.0 to 77.6) (Figure 1). Recurrences and their 
management are listed in Table 4. Radical surgery did 
not seem to add therapeutic benefit in recurrent locally 
advanced disease. The estimated mean overall survival 
was 71.6 % (CI 57.4 to 85.8) (Figure 2). Ten patients (37%) 
died of cancer. By Kaplan-Meier estimate there was 
no significant difference in recurrence-free survival in 
patients who underwent open surgery versus those who 
had robot-assisted surgery (log-rank P = 0.57) (Figure 3).

Discussion
Appendix 1 shows an algorithm that  summarizes our 
approach to the management of IDBT. There are 3 key 
factors to be taken into consideration in the management 
of these tumours: (1) tumour factors, (2) diverticular 
factors, and (3) patient factors.

Diverticular anatomy is particularly important. 
Difficulties may arise in the initial identification of the 
tumour as tumour in a diverticulum with narrow neck 
may be missed. Furthermore, the neck of the diverticu-
lum may not be wide enough to allow the passage of the 
scope into the cavity of the diverticulum. The size and 
location in the bladder may also make the diverticulum 
inaccessible for thorough internal inspection particu-
larly with a rigid cystoscope. Similar factors may limit 
resection of tumour in a diverticulum. A thin-walled 
diverticulum increases the risk of perforation, and a 
large or deep tumour may preclude complete clearance 

TABLE 2. 

Radical cystectomy: pathological data 

TURBT 
histology 

Clinical stage 
(with imaging)

Cystectomy histology

G3 T1 T1N1
G3 T3b N1   

(squamous differentiation)

G3 T1 T3N0 G3 T3b N0

G3 Ta + CIS TaN0 G3 T1 N0

G3 T1 T1N0 G3 T1 N0

G3 T1 + CIS T3N0 G3 T3a N0

G3 T1 T3N0 G3 T3b N0

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TABLE 4. 

Tumour recurrences and their management

Preoperative 
clinical stage

Neoadjuvant 
therapy

Initial  
operation

Final  
histology

Adjuvant 
therapy

Site and 
histology of 
recurrence 

Management 
of the  

recurrence
Follow-up

G3 T1 N0 No
Robotic 

diverticulectomy+ 
bilateral PLND

G3 T3 N0
Systemic 

chemotherapy
Bladder 

CIS

TURBT BCG + 
EMDA MMC 

induction 
and BCG 

maintenance

28 months/ 
alive

G3 T1 N0

Local 
intravesical 
MMC + BCG 

induction

Open 
Diverticulectomy 

+ Ureteric 
reimplantation+ 

Ipsilateral 
Lymphadenectomy

G3 T3 N0 
(nested 
variant)

Systemic 
chemotherapy

Bladder 
G3T1

Salvage 
cystectomy

61 months/ 
alive

G3 T1 N0 No

Robotic 
Diverticulectomy 

+ Ureteric 
reimplantation+ 

Ipsilateral 
Lymphadenectomy

G3 T1 N0

Intravesical 
EMDA 

MMC+BCG 
maintenance

Bladder 
G3 T1+ Cis

Unfit for 
salvage 

cystectomy, 
managed 

endoscopically

27 months/
dead

G3 T1 N0 No

Robotic 
Diverticulectomy 

+ Ureteric 
reimplantation+ 

Ipsilateral 
Lymphadenectomy

G3 T1 
(squamous  

differentiation)
No

Bladder 
CIS

Salvage 
cystectomy

27 months/
alive

without risk of perforation and local spillage of the 
tumour.

Prognostically, the absence of the muscle layer allows 
diverticular tumours to spread locally or metastasize 
more readily than non-diverticular bladder tumours. 
High-grade diverticular tumours are likely to invade the 
peri-diverticular fat because of lack of detrusor muscle 
barrier, and are potentially associated with a worse 
outcome.

Because of the structural differences of the divertic-
ulum, the standard bladder cancer staging system is not 
applicable to the IDBT. Diverticular tumour staging 
distinguishes non-invasive (Tis/Ta), superficially inva-
sive (T1), and extra-vesical (T3) disease as well as tumours 
invading adjacent structures (T4) (Figure 4) [6].

FIGURE. 1

continued on page 308

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TABLE 4. 

Tumour recurrences and their management

Preoperative 
clinical stage

Neoadjuvant 
therapy

Initial  
operation

Final  
histology

Adjuvant 
therapy

Site and 
histology of 
recurrence 

Management 
of the  

recurrence
Follow-up

G3 T1 N1
Systemic 

chemotherapy

Open radical 
cystectomy+ Bilateral 

PLND+ Orthotopic 
neobladder

G3 T3 N1 
(squamous  

differentiation)

Systemic  
chemotherapy

Orthotopic 
neobladder

Excision of 
orthotopic 

neobladder and 
IC formation+ 

adjuvant 
systemic 

chemotherapy

11 months/ 
dead

G3 T1 N0 No

Robotic radical 
cysto-prostatectomy 

+ Bilateral 
PLND+   Orthotopic 

neobladder

G3 T3 N0 No
Orthotopic 
neobladder

Palliative 
Radiation

12 months/
dead

G3 T3 N0
Systemic 

chemotherapy

Robotic 
Radical Cysto-

prostatectomy+ 
lymphadenectomy 

+Ileal conduit 
diversion

G3 T3 N0 No
Local in the 
hemipelvis

Palliative 
Radiation

7 months/
dead

G3 T3 N0 
(squamous 

differentiation)
No

Open 
diverticulectomy + 
Bilateral-Ureteric 

reimplantation 
Bilateral PLND

G3 T3 N0 
(squamous  

differentiation)
No

Bone  
metastasis 

(rib)

Palliative 
Radiation

8 months/
dead

G3 T1 N0 No

Open 
Diverticulectomy+ 

Bilateral PLND 
+ Ureteric 

reimplantation

G3 T3 N0 No
Bladder 

with liver 
metastasis

Palliative 
Symptomatic 
management

55 months/
alive

G3 T3 N0 No

Open 
Diverticulectomy+ 

Bilateral PLND 
+ Ureteric 

reimplantation

G3 T3 N0 No
Liver 

metastasis

Palliative 
Symptomatic 
management

4 months/
dead

, Cont’d 

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Management options range from tumour resection 
followed by adjuvant intravesical chemotherapy or bacil-
lus Calmette-Guerin (BCG) immunotherapy to divert-
iculectomy / partial cystectomy and radical cystectomy 
for high-grade tumours. Radical cystectomy is appro-
priate for patients with concomitant high-grade or 
extensive disease of any grade with or without voiding 
dysfunction.

The evolution in management has seen a shift from 
radical surgery for all to a more targeted approach in 
which a significant number have been managed with 
diverticulectomy / partial cystectomy with good long-
term oncological outcomes, as well as preservation of 
patient quality of life. Endoscopic management is most 
suitable for patients with low-grade non-invasive disease 
in a wide-neck diverticulum that can be completely 
resected, provided the main bladder is either clear or has 
minimal low-grade non-invasive disease. After complete 
tumour resection, patients should be given intravesical 
chemotherapy or immunotherapy as appropriate.

Bladder-preserving surgery with diverticulectomy, 
with or without ipsilateral ureteric reimplantation and 
pelvic lymphadenectomy is suitable for patients with 
tumours that cannot be resected endoscopically because 
of the bulk or poor access to the diverticulum irrespec-
tive of tumour grade. Diverticulectomy should not be 
offered to patients with high-grade tumours or CIS else-
where in the bladder.

Traditionally, bladder diverticulectomy has been 
performed by an open surgical approach. Bourgi et 
al. reported a series of 17 patients from their centre[7]. 
One had endoscopic resection, 11 had open diverti-
culectomy and 5 had radical cystectomy. Nine patients 
(81.81%) were disease free after a mean of 33.63 months. 
One required radical cystectomy 6 months after divert-
iculectomy for recurrent high-grade tumour. One 
patient developed lymph node metastases 10 months 
after diverticulectomy and underwent palliative chemo-
therapy. Five of 7 patients (71%) with invasive tumours 
treated with diverticulectomy alone were disease free at 
the end of the follow-up[7].

Golijanin et al. published a series of 39 patients with 
IDBT: 13 (33%) had non-invasive disease; 13 (33%) had 
cT1 tumours; and 13 (33%) had cT3 disease. Actuarial 
5-year disease-specific survival for the cohort was 72% 
(+/- 5.4%), but this varied widely by stage. Mode of treat-
ment of cT1 tumours did not correlate with outcome in 
this series; in a multivariate model, clinical staging was 
the only independent predictor of outcome[8].

Sallami et al. reported 32 cases of IDBT. Clinical eval-
uation showed cTa stage in 16 patients, cT1 stage in 8 
patients, and ≥cT3 tumours in 8 patients. With an aver-
age follow-up of 27 months, 7 recurrences were found 

FIGURE. 2

FIGURE. 3

FIGURE. 4

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in the group of non-invasive tumours, including 3 cases 
of progression to invasive disease. Patients with high-
grade invasive tumours were treated with radical cystec-
tomy[9]. Myer and Wagner reported the first series of  
5 patients who underwent robot-assisted bladder divert-
iculectomy for symptoms[10]. Length of stay was 3 days 
(range 1 to 6).

Radical cystectomy would be the treatment of 
choice for patients with high-grade IDBT and concom-
itant high-grade tumour elsewhere in the bladder. The 
same would be offered to a patient with severe voiding 
dysfunction or if the patient prefers radical surgery for 
maximal oncological safety. With the widespread adop-
tion of robotic technology, it has become possible to 
minimise the trauma of surgery and the morbidity of 
diverticulectomy. In our centre with extensive experi-
ence in robotic surgery, robot-assisted diverticulectomy 
has become the standard of care in the management of 
these patients in recent years.

Other issues to consider in the management of IDBT 
are voiding function, protection of the ureters, and 
patient preference. Acquired diverticula are usually 
secondary to bladder outlet obstruction. Incomplete 
bladder emptying, due to obstruction or to atonic blad-
der, is common. When the bladder is involved with 
multifocal tumours it is better to consider radical surgery 
to address both oncological and functional issues unless 
the patient is keen to persist in CISC, although patients 
should be advised against this. Those with IBDT only 
but with outflow obstruction need either transurethral 
resection or bladder neck incision as appropriate after 
a urodynamic study post diverticulectomy. The ipsilat-
eral ureter is at risk of injury during dissection of the 
diverticulum or may be draining into the diverticu-
lum. Hence, the ipsilateral ureter should be protected by 
stenting during dissection of the diverticulum, or if it is 
not possible to salvage the ureter, a reimplantation over a 
double-J stent should be performed.

In 2018, a series of 115 patients was reported that 
included patients from 11 European centres (thus 
averaging about 10 patients per centre)[11]. The study 
suffers from a degree of heterogeneity due to the diverse 
management approaches in various centres. However, 
with a median follow-up of 5 years (95% confidence 
interval [CI] 4.0 to 6.2), it has shed light on few aspects of 
managing IDBT and highlighted the current limitations 
of staging investigations[11]. Moreover, it has provided 
some reassurance that bladder-sparing approach 
in carefully selected patients can yield equivalent 
oncological outcomes to radical cystectomy. Although 

radical cystectomy may offer oncological benefit, it 
comes at the high cost of living with urinary diversion 
and a high risk of losing sexual function. Therefore, the 
management should be tailored to the individual patient 
according to the volume and stage of the disease, status 
of the bladder, voiding function, and patient preference. 
On the basis of our experience and previously published 
series, we make the following recommendations:

1. Prognosis is largely dependent on the stage, grade, 
and bulk of the tumour rather than the extent of 
surgery. Hence, when appropriate (absence of CIS 
or multifocal tumours/ normal voiding function), 
bladder preservation with meticulous follow-up 
should be the preferred treatment.

2. When considering radical surgery, particularly in 
locally advanced tumours or histological variants 
with poor prognosis, it is advisable to avoid complex 
reconstruction.

3. Lymphadenectomy should be bilateral rather than 
ipsilateral on the side of tumour, although we have 
not come across any lymph node metastasis on 
the contralateral side in patients having ipsilateral 
lymph node dissection.

4. Patients should be counselled about the possibility 
of needing completion cystectomy in the case of 
adverse final pathology or subsequent recurrences.

5. Robot-assisted diverticulectomy has the advantages 
of minimal blood loss, shorter hospital-stay, and 
minimal would complications. Hence, this approach 
should be offered in centres with surgical expertise. 
Should a patient require completion cystectomy, this 
can also be performed using the robotic approach.

Limitations of the current study are low number 
of cases, heterogeneous cohort, and short follow-up, 
including patients who were treated in the past couple of 
years. Therefore, more organized multicentre experience 
would be helpful to confirm the results.

Conclusion
Management of intra-diverticular bladder tumours is 

evolving. There is a shift from radical surgery for all to 
a more selective approach tailored to individual needs. 
The spectrum of procedures required lends itself to a 
robotic approach, and this should be applied where 
possible to reduce the surgical morbidity.

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T. Sequential bacillus Calmet te-Guérin/electromotive drug 
administration of mitomycin C as the standard intravesical regimen 
in high risk nonmuscle invasive bladder cancer: 2-year outcomes.  
J Urol.2016;195(6):1697-1703. doi: 10.1016/j.juro.2016.01.103. Epub 
2016 Feb 2.

6. Walker NF, Gan C, Olsburgh J, Khan MS. Diagnosis and management 
of intradiverticular bladder tumours. Nat Rev Urol.2014;11(7):383-390. 
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7. Bourgi A, Ayoub E, Merhej S. Diverticulectomy in the management of 
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Published online 2016 Mar 15.

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311SIUJ.ORG SIUJ  •  Volume 3, Number 5  •  September 2022

Intra-Diverticular Bladder Tumours: How to Manage Rationally

http://SIUJ.org


Treatment 
Options

Bladder sparing surgery 
(Diverticulectomy/ partial 

cystectomy ± reimplantation 
of the ureter(s)/unilateral or 
bilateral PLND ± IVC OR IVI

Radical cystectomy+ 
PLND +/- adjuvant 

systemic chemotherapy 
or local radiotherapy

LV LG IDBT but with 
difficult angle/ 

inaccessible location/ 
narrow neck

Endoscopic management + 
IVC/IVI +or- endoscopic 

management of IVO 
(BNI/TURP)

LV LG IDBT wide 
diverticcular neck

LV HG IDBT + No 
synchronous bladder 

tumours or extensive CIS

High volume / High 
risk of perforation

HV HG IDBT

Synchronous bladder 
tumours/extensive 

CIS

High volume / High 
risk of perforation

VH

NVH + LUTS
Recurrent 

UTI

Symptoms of bladder 
tumour and/or IVO/BPH:

GHG2

MRI pelvis

Laboratory 
investigations

Status of the 
urethra/prostate

Bladder mapping 
(associated tumours)

Accessibility to 
the tumour

Tissue sampling 
and HPE

In
ve

st
ig

at
io

ns

Cystoscopy 
(rigid/flexible) ± 
biopsy/resection

Tumour Factors

Stage

State of LNs

Synchronous 
bladder 
tumours

Histology

Size and neck 
diameter

Number

Location 
and relation 

to the UO

Age

Associated 
diseases 

(BPH/ PCa)

Patient 
preference

Diverticular Factors

Patient Factors

Comorbidities/
CCI/ Renal function

APPENDIX 1. 

Algorithm of management of IDBT

312 SIUJ  •  Volume 3, Number 5  •  September 2022 SIUJ.ORG

ORIGINAL RESEARCH

http://SIUJ.org


Treatment 
Options

Bladder sparing surgery 
(Diverticulectomy/ partial 

cystectomy ± reimplantation 
of the ureter(s)/unilateral or 
bilateral PLND ± IVC OR IVI

Radical cystectomy+ 
PLND +/- adjuvant 

systemic chemotherapy 
or local radiotherapy

LV LG IDBT but with 
difficult angle/ 

inaccessible location/ 
narrow neck

Endoscopic management + 
IVC/IVI +or- endoscopic 

management of IVO 
(BNI/TURP)

LV LG IDBT wide 
diverticcular neck

LV HG IDBT + No 
synchronous bladder 

tumours or extensive CIS

High volume / High 
risk of perforation

HV HG IDBT

Synchronous bladder 
tumours/extensive 

CIS

High volume / High 
risk of perforation

VH

NVH + LUTS
Recurrent 

UTI

Symptoms of bladder 
tumour and/or IVO/BPH:

GHG2

MRI pelvis

Laboratory 
investigations

Status of the 
urethra/prostate

Bladder mapping 
(associated tumours)

Accessibility to 
the tumour

Tissue sampling 
and HPE

In
ve

st
ig

at
io

ns

Cystoscopy 
(rigid/flexible) ± 
biopsy/resection

Tumour Factors

Stage

State of LNs

Synchronous 
bladder 
tumours

Histology

Size and neck 
diameter

Number

Location 
and relation 

to the UO

Age

Associated 
diseases 

(BPH/ PCa)

Patient 
preference

Diverticular Factors

Patient Factors

Comorbidities/
CCI/ Renal function

BNI Bladder neck incision

BPH Benign prostatic hyperplasia

CCI Charlton comorbidity index

CECT Contrast enhanced CT

CIS Carcinoma in situ

e-GFR Estimated glomerular filtration rate

HG High grade

HN Hydronephrosis

HPE Histopathological examination

HV High volume

IDBT Intra-diverticular bladder tumour

IVC Intra-vesical chemotherapy

IVI Intra-vesical immunotherapy

IVO Infra-vesical obstruction

LG Low grade

LN Lymph node

LV Low volume

LUTs Lower urinary tract symptoms

MRI Magnetic resonance imaging

NAC Neoadjuvant chemotherapy

NVH Nonvisible haematuria

PLND Pelvic lymph node dissection

PCa Prostate cancer

UO Ureteric orifice

UTI Urinary tract infection

VH Visible haematuria

313SIUJ.ORG SIUJ  •  Volume 3, Number 5  •  September 2022

Intra-Diverticular Bladder Tumours: How to Manage Rationally

http://SIUJ.org

