Point of Technique Diverticulocystoplasty in a Case with Decreased Bladder Capacity TABIBI A, NOURALIZADEH A Department of Urology, Shaheed Labbafinejad Hospital, Shaheed Beheshti University of Medical Sciences,Tehran, Iran KEY WORDS: diverticulocystoplasty, diverticulum, bladder capacity 51 Urology Journal UNRC/IUA Vol. 2, 51-52 Spring 2004 Printed in IRAN Introduction Bladder diverticula are often asymptomatic, but in some cases they become symptomatic and lead to calculus formation, urinary tract infection, vesi- coureteral reflux, and urethral obstruction. Surgical intervention and diverticulectomy is required in such cases.(1) We described our experi- ence in the treatment of a patient with large diver- ticulum. Case Report A 17-year-old boy with a chief complaint of dis- comfort in hypogastrium and urinary retention was evaluated. He had a history of frequency, urgency, and nocturia, without urinary infection or incontinence. Physical examination revealed a relatively large palpable mass, in the lower abdom- inal area, from the umbilicus to the pelvis. Biochemical laboratory studies were normal. Ultrasonography showed normal kidneys, but a thickened bladder wall and a cystic mass with smooth wall containing liquid. The bladder was longitudinally stretched and had a large diverticu- lum in VCUG (fig. 1). Vesicoureteral reflux was not present. A large amount of residual urine in the diverticulum was seen in the post void film. Cystoscopy was performed and showed a severe trabeculated and low-capacity bladder. Furthermore, 2 cm above the right ureteral orifice a diverticulum opening measured 1.5 cm × 1.5 cm was seen. Cystometry was not applicable due to low capac- ity bladder which was influenced by diverticulum pressure and the resultant pop off mechanism. Indwelling urethral could not reduce the size of the diverticulum. Due to the lowered bladder capacity, we decided to perform augmentation cystoplasty using diver- ticulum. The bladder was accessed with a lower midline incison. The bladder was opened longitu- dinally and 500CC urine was drained from the diverticulum. Afterwards, the bladder and divertic- ulum were incised longitudinally on the adjacent walls and they were sutured to each other preced- ing by cystostomy and urethral catheter fixation. Finally, a spherical vesicle was achieved. The patient was discharged after two weeks. Urethral catheter was removed after three weeks. Urinary residue was checked following proper voiding which was not significant; thus, the cys- tostomy was removed too. VCUG was done three months later (fig. 2). Follow-up has been continued Accepted for publication in July 2003 FIG 1. Low capacity bladder with a large diverticu- lum on its right side (VCUG) DIVERTICULOCYSTOPLASTY IN A CASE WITH DECREASED BLADDER CAPACITY every six months by renal and vesical ultrasonog- raphy, and biochemistry studies. The patient has been using intermittent catheterization in order to drain urine since then. Discussion Most bladder diverticula in young adults are sin- gle and associated with a small bladder. Voiding disorders are common in bladder diverticulum.(1) They are often located laterally above the ureter orifice. Diagnosis is made by cystography, particu- larly with post void film. Surgery is warranted if recurrent infection, urethral and ureteral obstruc- tion, or reflux develops. Diverticulum can be sec- ondary to obstructive neurogenic bladder. Several treatments have been introduced for diverticula including laparoscopic, endoscopic, and open sur- gical approaches.(2-4) Izquierdo and colleagues per- formed urodynamic studies in 11 cases with con- genital bladder diverticulum of whom 8 had vesi- coureteral dysfunction. Urodynamics were normal in all following operation, so that they concluded that functional changes were due to diverticulum and reflux.(5) Because of urinary retention and a large mass in the pelvis and abdomen, surgical approach was necessary in this patient. On the other hand, diverticulectomy could possibly lead to higher bladder pressure, incontinence, and upper tract damages since the bladder had a lowered capacity and thickened trabeculated wall. Hence, we decid- ed to perform augmentation using diverticulum itself, taking into account its advantages compared to intestinal tissue. To our knowledge, we have reported the first case of diverticulocystoplasty, and according to the last follow-up outcomes, it was successful. References 1. Gearhart PJ. Exstrophy, epispadias and other bladder anomalies. In: Walsh PC, Retik AB, editors. Campbell's Urology. Philadelphia: WB Saunders; 2002. p. 2189. 2. Porpiglia F, Tarabuzzi R, Cossu M, et al. Sequential transurethral resection of the prostate and laparoscopic bladder diverticulectomy: comparison with open surgery. Urology 2002; 60(6): 1045-9. 3. Yu TJ. Extravesical deverticuloplasty for repair of a parau- reteral diverticulum and the associated refluxing ureter. J Urol 2002; 168(3): 1135-7. 4. Martov AG, Moskalev AIU, et al. Endoscopic treatment of bladder diverticula. Urologiia 2001;(6):40-4. 5. Izuierdo MCR, Mialdea LR, Navascues AJ, et al. Functional changes in the bladder of children with primary bladder diverticulum. Arch Esp Urol 1997 Jul-Aug; 50(6): 661-7. 52 FIG 2. VCUG three months after diverticulocysto- plasty