Laparoscopic bladder diverticulectomy

The description of the laparoscopic bladder diverticulectomy covers all aspects of the surgical procedure used for the management of bladder diverticula. Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exposure, dissection, closure of bladder, end of procedure. Consequently, this operating technique is well standardized for the management of this condition.

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Laparoscopic   bladder   diverticulectomy

Authors
C Saussine, H Lang
Abstract
The description of the laparoscopic bladder diverticulectomy covers all aspects of the surgical procedure used for the management of bladder diverticula.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exposure, dissection, closure of bladder, end of procedure.
Consequently, this operating technique is well standardized for the management of this condition.
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2002-11
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E-publication
WeBSurg.com, Nov 2002;2(11).
URL: http://www.websurg.com/doi-ot02en294.htm

Laparoscopic   bladder   diverticulectomy

1. Introduction
Bladder diverticula are herniations of the bladder mucosa through the detrusor muscle. They can be congenital, but are usually acquired. Acquired diverticula are the result of a high intravesical pressure secondary to an outlet obstruction. This obstruction is most often secondary to benign prostatic hyperplasia, but can also be caused by urethral stenosis and neurogenic bladder-sphincter dysfunction. Whenever possible, the diverticulum and its cause are treated concurrently.
Conventionally, bladder diverticula are treated surgically, via an extraperitoneal extravesical or transvesical approach. Surgery is generally required when the diverticula cause complications. In the presence of an adenoma, the diverticulectomy is combined with a prostatectomy. As prostatic adenomas are increasingly being treated by endoscopic resection, endoscopic treatment of diverticula has also developed (Orandi, 1977).
The morbidity of endoscopic treatment of bladder diverticula is low. However, the results in terms of complete disappearance of the diverticula are not always satisfactory (Errando Smet et al., 1996).
With the development of laparoscopy, the first cases of bladder diverticula operated on via transperitoneal laparoscopy (Parra et al., 1992; Das, 1992) or extraperitoneal laparoscopy (Nadler et al., 1995) were reported. The low morbidity of laparoscopic treatment has made this approach a preferred alternative to open surgery (Iselin et al., 1996).

2. Anatomy
1. Bladder musculature
2. Bladder mucosa
3. Muscular trabeculae
4. Diverticulum
5. Neck of diverticulum
6. Stagnant urinary residue
The bladder is a hollow muscular reservoir, the wall of which is composed of a mucosa and a musculature. When the bladder muscle hypertrophies because of an outflow obstruction, muscular trabeculation occurs. Herniation of the mucosa can develop between these trabeculae, leading to the formation of a diverticulum. Diverticula can also develop congenitally.
The most common localization of congenital bladder diverticula is posterolateral to the ureteral orifices. Acquired diverticula can develop on all parts of the bladder wall, but are most often found on the posterior and lateral walls.
3. Indications
Indications and contraindications
Surgery is indicated for symptomatic and complicated diverticula. The most common symptoms of diverticula are micturition occurring twice in rapid succession and the sensation of incomplete bladder emptying. Complications are linked to post-void residual urine leading to urinary infection, and intradiverticular lithiasis.
The discovery of an intradiverticular tumor is not uncommon. These should not be treated as diverticula, but as bladder tumors. They constitute a contraindication to the laparoscopic approach.

Contraindications are those for general anesthesia.

Preoperative management:
The patient’s urine must be sterile. The usual preoperative examinations include ultrasound and cystoscopy that identifies the site of the diverticulum, its location in relation to the ureteral orifices, the size of its neck, and its contents (stones, tumors).
4. Operating room set-up
• Patient
- supine, lithotomy position for intraoperative cystoscopy;
- arms tucked along the body;
- 30° Trendelenburg position.
• Team
1. The surgeon stands to the left of the patient.
2. The first assistant stands to the right of the patient.
3. The second assistant is positioned between the patient’s legs. He or she manipulates the cystoscope.
4. The scrub nurse stands to the left of the surgeon.
• Equipment
1. Rigid or flexible cystoscope, or resectoscope if a combined treatment for the cause of the diverticulum is planned, with video camera and screen.
2. Laparoscopic unit (screen, insufflator, electrocautery)
5. Trocar placement
• Landmarks
Four trocars are used. The landmarks are as follows:
- the umbilicus;
- the pubis;
- the right and left anterior superior iliac spines.
• Transperitoneal approach
Trocar A (10-12 mm) is placed below the umbilicus with an open technique. It can also be placed after creating a pneumoperitoneum with a Veress needle. The other trocars are placed under direct vision.
Trocar B (5 mm) is placed halfway between the pubis and the umbilicus, on the midline.
Trocar C (5 mm) is placed in the right lower quadrant, 2 to 3 cm medial to the anterior superior iliac spine.
Trocar D (5 mm) is placed in the left lower quadrant, 2 to 3 cm medial to the anterior superior iliac spine.
• Extraperitoneal approach
• Open trocar placement
1. Umbilicus
2. Exposure of anterior fascia of rectus abdominis muscles
3. Incision of anterior fascia of rectus abdominis muscles
4. Rectus abdominis muscle
5. Anterior fascia of rectus abdominis muscles
6. Penetration of preperitoneal retropubic space
For the extraperitoneal approach, the umbilical trocar is placed with an open technique, but without opening the peritoneum. To do this, the anterior fascia of the rectus abdominis muscles is incised transversally. Using scissors, and remaining posterior to the muscles, the surgeon sweeps aside the connective tissues to penetrate into the preperitoneal retropubic space.
• Trocars A and B
1. Opening of anterior fascia of rectus abdominis muscles
2. Posterior fascia of rectus abdominis muscles
3. Arcuate line
4. Peritoneum
The space that is created is enlarged laterally to allow for the insertion of trocar A (10-12 mm). Insufflation is performed through this trocar and, combined with gentle lateral movements of the laparoscope, the space is made large enough for the insertion of trocar B, midway between the umbilicus and the pubis.
• Trocars C and D
1. Epigastric vessels
2. Rectus abdominis muscles
3. Bladder
4. Peritoneum after clearing of attachments
Scissors introduced through trocar B help clear away the attachments between the peritoneum and the posterior surface of the rectus muscles until trocars C and D can be inserted. The peritoneum is dissected free until the epigastric vessels can be seen.
Trocar C (5 mm) is placed 2-3 cm medial to the right anterior superior iliac spine.
Trocar D (5 mm) is placed 2-3 cm medial to the left anterior superior iliac spine.
6. Instruments
• Instruments
1. Monopolar scissors
2. Bipolar grasper
3. Grasper
4. One or two needle holders
5. Retrieval bag in case of very large diverticulum
6. Suction device
• Instruments/trocars
1. The monopolar scissors and one needle holder are held in the surgeon’s right hand, and introduced through trocar B. The bipolar grasper, the second needle holder, and the grasper are held in the surgeon’s left hand, and introduced through trocar D.
2. The grasper and suction device are held in the assistant’s right hand and introduced through trocar C. The camera is held in the assistant’s left hand and introduced through trocar A.
7. Exposure
• Preparation
The patient is placed in Trendelenburg position. The small bowel loops move cephalad.
With the extraperitoneal approach, the Trendelenburg position can be avoided, as well as all difficulties of exposure linked to the intraperitoneal organs.
• Cystoscopy
The assistant introduces the cystoscope, which can be rigid or flexible, and identifies the diverticulum.
1. If the diverticular neck is wide enough, the cystoscope is placed in the diverticulum.
2. If the diverticular neck is narrow, the assistant positions the cystoscope just in front of it.
The cold light of the cystoscope can be seen by the surgeon from the peritoneal cavity and enables him to identify the exact position of the diverticulum.
When the neck of the diverticulum is near a ureteral meatus, the assistant places a ureteral stent to identify the ureter.
8. Dissection
• Incision of peritoneum
1. Peritoneum
2. Bladder
3. Cystoscope
4. Diverticulum
5. Incision
The surgeon incises the peritoneum opposite the cold light source with monopolar scissors. The size of this incision is proportional to the size of the diverticulum.
When the diverticulum is very lateral or posterior, the surgeon must identify the vas deferens and ureters to avoid injuries to these structures.
This step is not required in the extraperitoneal approach.
• Dissection of diverticulum
1. Bladder
2. Neck of the diverticulum
3. Diverticulum
The dissection is carried out progressively, until the entire diverticulum is dissected free, and its neck is identified.
In the extraperitoneal approach, this dissection may be relatively long and difficult, especially if the diverticulum is posterior.
• Division of neck
The bladder is incised at the level of the neck of the diverticulum in order to resect the diverticulum completely. Prior to this step, the bladder must be emptied through the cystoscope. The suction device is used to complete the voiding of the bladder.
In difficult cases, the surgeon may have to open the diverticulum and perform the division of the neck from inside the diverticulum (Rozenberg et al., 1994).
The diverticulum is removed in one or several pieces through one of the trocars, or left aside in the paracolic gutter if a retrieval bag is needed for its extraction.
• Danger
1. Mucosa of diverticulum
2. Recurrence
The mucosa of the diverticulum must be completely resected in order to reapproximate and suture the muscular wall of the bladder correctly, and to prevent a postoperative fistula or recurrence.
9. Closure of bladder
• Closure
The bladder is closed in 1 layer with an absorbable running suture. The use of a mechanical stapler has been described (Nadler et al., 1995).
• Extraction
The diverticulum is extracted through a 5 mm trocar, except in the case of a thick wall, in which case a retrieval bag can be used through trocar A.
10. End of procedure
For both transperitoneal and extraperitoneal approaches, the retropubic space must be drained with a closed suction drain.
Drainage of the peritoneal cavity is usually not necessary.
The trocars are removed under visual control.
A urinary catheter is left is place for 5 to 7 days.
The ureteral stent is left in place if the dissection was performed near the ureter. In these cases, the surgeon usually uses a double-J stent for 2 to 3 weeks. It is removed during the postoperative visit.
11. Conclusion
Laparoscopic bladder diverticulectomy is a relatively simple procedure with rare indications. Complications include ureteral injuries and poor closure of the vesical wall that may lead to urinary peritonitis. These complications can be prevented by using double-J ureteral stents and by mastering laparoscopic suturing and knot tying.
12. Reference
Das S. Laparoscopic removal of bladder diverticulum. J Urol 1992;148:1837-9.
Errando Smet C, Laguna Pes P, Salvador Bayarri J, Vicente Rodriguez J. Cirugia endoscopica del
diverticulo vesical. Actas Urol Esp 1996;20:783-5.
Iselin CE, Winfield HN, Rohner S, Graber P. Sequential laparoscopic bladder diverticulectomy and
transurethral resection of the prostate. J Endourol 1996;10:545-9.
Nadler RB, Pearle MS, McDougall EM, Clayman RV. Laparoscopic extraperitoneal bladder
diverticulectomy: initial experience. Urology 1995;45:524-7.
Orandi A. Transurethral fulguration of bladder diverticulum: new procedure. Urology 1977;10:30-2.
Parra RO, Jones JP, Andrus CH, Hagood PG. Laparoscopic diverticulectomy: preliminary report of a new
approach for the treatment of bladder diverticulum. J Urol 1992;148:869-71.
Rozenberg H, Abdelkader T, Hussein AA. Exérèse par coelioscopie d'un volumineux diverticule vésical.
Prog Urol 1994;4:91-4; discussion 93.