© 1991 S. Karger AG, Basel 0042-1138/91/046I-0087S2.75/0
Urol Int 1991;46:87-89
Successful Repair of Huge Bladder Diverticulum with a Transurethral Fulguration Report of a Case Masafumi Adachi, Teruhiro Nakada, Hitoshi Suzuki, Junji Hirano, Shunzo Kawamura, Nobuhisa Ishii, Hiroyuki Watanabe, Hisashi Kaneko, Manabu Ishigooka Department of Urology, Yamagata University, School of Medicine, Yamagata, Japan
Keywords. Bladder diverticulum • Transurethral fulguration Abstract. We present a 68-year-old man with a huge bladder diverticulum associated with benign prostate hyper trophy treated with transurethral fulguration of the diverticular mucosa in combination with transurethral resection of the prostate. The procedure was well tolerated by the patient and unfavorable symptoms faded after this proce dure. Follow-up cystogram demonstrated remarkable reduction of the diverticulum.
Introduction Orandi [1] introduced the noninvasive procedure for transurethral fulguration of the bladder diverticulum. Additional information on this method in combination with electrochemical lithotripsy of bladder stones has been provided by daym an et al. [2]. We report on 1 patient in whom the transurethral fulguration of the bladder diverticulum plus transurethral prostatectomy was successfully performed. Case Report
Fig. 1. Cystogram showing a huge diverticulum (D) and a con tracted bladder (B).
isms. Routine blood and blood chemistries were within normal lim its. The phenolsulfophthalein test showed 10% of injected dye in 15 min and 69% total in 2 h.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/24/2018 9:26:47 PM
A 77-year-old man presented in July 1986 with hesitancy in ini tiating voiding, dysuria and occasional interruption of the urinary stream. A course of penicillin was prescribed but 1 week later simi lar symptoms recurred and interruption of urinary flow was re peatedly detected. His past history was not remarkable. No other members of the family are similarly affected. On admission, he was of somewhat smaller than normal stature. Other physical findings were unremarkable. Cystoscopy revealed prominent protrusion of the middle lobe of the prostate and a huge solitary diverticulum on the left lateral wall of the bladder. Cystogram of this patinet con firmed the presence of the diverticulum as well as hyperplastic pros tate configuration (fig. 1). Ultrasound examination of the upper abdomen and an intravenous urogram revealed normal kidneys and distal ureters. Urinalysis showed a specific gravity of 1.015. a pH of 7.0 and a trace of albumin. The sediment contained a few red blood cells, 20-30 white blood cells and 4 hyaline casts per high-power field. A urine culture grew abundant Staphylococcus albus organ-
Adachi/Nakada/Suzuki/Hirano/Kawamura/Ishii/Watanabe/Kaneko/Ishigooka
88
Fig. 2. a One week after trans urethral fulgulation of the bladder diverticulum, cystogram demon strating 79% decrease in size of the diverticulum, b Three months after the procedure, 93 % decrease in size of the diverticulum. See figure 1 for explanations. Each cystogram was taken by instillation of 300 ml of contrast medium. Then volume of diverticulum was calculated as el lipsoid.
Spinal anesthesia worked well for this procedure. After the loca tion of the diverticulum was confirmed by cystoscopy, Le Fort metal sounds from 22 to 28 French in size were introduced. The operator located the resectoscope inside the diverticulum.The tip of the resectoscope was then extended and the fulguration initiated from the apex of the diverticulum to the surrounding diverticular wall in a whorl manner with the coagulation current set at 4.5. The mucosal layer perceptibility etiolates and shrivels. As the diverticulum neck had been too narrow to comprise the cystoscope, the tissues of the diverticular orifice and its surrounding bladder mucosa had been fulgurated by the roller electrode before the fulguration of the div erticular inside lesion. The resectoscope (TU-196 SI Takei, Japan) and a roller electrode (TU-L97 Takei, Japan) were optimal for per forming these procedures. Periodic checking of the lateral margins of the vesical neck and noting of the position of the ureteric orifices are important to evade resecting the trigone. After the transurethral fulguration of the diverticular mucosa had been achieved, transure thral prostatic resection was done. At the end of the surgical proce dure, an intravenous injection of 20 mg of furosemide was adminis tered which could be duplicated in the next 30 min to ensure a valid diuresis. No irrigation should be performed unless the Foley cathe ter is plugged.
Results Four days after the transurethral fulguration of the vesical diverticulum and transurethral resection of the prostate, the Foley catheter was removed. Postoperatively, the patient suffered from acute bilateral epididy mitis, which was treated successfully with antibiotics. Detrusor hyperreflexia was caused by the reduction of
postoperative urinary incontinence; however, this tem poral bladder disturbance was completely cured 1 week after removal of the indwelling catheter. One week after the procedure, cystogram demonstrated a 79% reduction in the volume of the diverticulum (fig. 2). Three weeks and 3 months after the procedure, the sizes of the diver ticula had decreased by 85 and 93%, respectively (fig. 2). Symptoms of chronic cystitis resulted in marked im provement 2 weeks after the transurethral operation. Follow-up cystograms have demonstrated no recur rences, and no additional operations have been neces sary. Postoperatively, detrusor function was successfully improved (fig. 3) and voiding dysfunction was taken away.
Discussion Intraoperative bleeding can sometimes be very trou blesome and transurethral prostatectomy occasionally accompanies this untoward phenomenon. In order to keep good visibility, we had fulgurated the vesical diver ticulum first, then transurethral prostatectomy was per formed. Similar surgical procedures have also been ad vocated by other investigators [2], When the neck of the diverticulum is too tight to admit the instrument, Clayman et al. [2] proposed to stretch the roller electrode directly across the neck and the cutting current is set at 4, after which the roller is drawn back across the tissues of the mouth of the diverticulum, daym an et al. [2] used
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/24/2018 9:26:47 PM
Method of Transurethral Fulguration
Transurethral Fulguration of Bladder Diverticulum
the roller electrode to incise all 4 quadrants. In our case, we did not cut the neck of the diverticulum but fulgu rated the mouth of the diverticulum and its surrounding bladder mucosa. This appeared to decrease intra- or postoperative hemorrhage. When the bladder mucosa or prostatic capsule is perforated early in the surgical pro cedure, the irrigating fluid can be assimilated into the circulation in large quantities [3], Such unfavorable phe nomena will cause hypervolemia and hypovolemia [3]. Under spinal anesthesia, the patient will become agi tated, blood pressure will gradually rise, and the pulse rate will decrease. This should be noticed early and treated quickly and a high index of suspicion on the part of the operating surgeon can reduce the risk of this prob lem. Vitale and Woodside [4] have performed transure thral resection of the diverticular neck in 6 patients. The indications for surgery in 3 patients were unfavorable diverticular evacuation with urine stasis and recurrent infection [4], In 1 patient, resection was performed con comitant with a transurethral resection of the prostate. Two patients had resections a few years after transure thral resection of the prostate. As long ago as 1943, Hartung and Flocks [5] performed transurethral diverticulotomy in 22 patients with successful results in many patients. More recently, Posta [6] reported a good out come of transurethral resection of the neck of the diver ticulum in 8 of 10 cases. Orandi [ 1] treated 14 patients with bladder diverticula with transurethral fulguration of the mucosa. According to Vitale and Woodside [4], the method introduced by Orandi [1] maintains the
sphincter function of the neck of the diverticulum allow ing persistent residual urine. Subsequently, they con cluded that the fulguration procedure was less desirable than resection of the neck of the diverticulum [4], Trans urethral fulguration or incision of vesical diverticula associated with transurethral resection of the prostate has some advantages in respect to safety, cost-effective ness and bleeding in comparison with open diverticulectomy. In addition, it is of considerable practical signifi cance in this study that progressive widening of the neck of the diverticulum can be achieved a few weeks after the fulguration. As mentioned previously [2, 7], the most difficult problem concerning surgery in this procedure is the pres ence of bladder tumor. If bladder cancer is located in the diverticulum or in the vincinity of the neck of the diver ticulum, this surgical technique is contraindicated. Al though this transurethral fulguration procedure was per formed successfully, we followed this patient for only 10 months. A long follow-up must be pursued in the fu ture.
References 1 Orandi A: Transurethral fulguration of bladder diverticulum: New procedure. Urology 1977;10:30-32. 2 daym an RV, Shahin S, Reddy P, Fraley EE: Transurethral treatment of bladder diverticula. Urology 1984;23:573-577. 3 Straffon RA: Transurethral prostatectomy; in Stewart BH (ed): Operative Urology - Lower Urinary Tract, Pelvic Structures and Male Reproductive System. Baltimore, Williams & Wilkins, 1982, pp 179-191. 4 Vitale PJ, Woodside JR: Management of bladder diverticula by transurethral resection: Re-evaluation of an old technique. J Urol 1979;122:744-745. 5 Hartung W, Flocks RH: Diverticulum of the bladder. A method of roentgen examination and clinical findings in 200 cases. Radi ology 1943;41:363-370. 6 Posta B: Transurethral electroresection of the diverticular neck: Incisions, technique, results and analysis of ten surgical cases. Int Urol Nephrol 1977;9:297-302. 7 Redman JF, McGinnis TB, Bissada NK: Management of neo plasms in vesical diverticula. Urology 1976;12:492-494.
Received: March 5, 1990 Accepted after revision: April 19, 1990 Dr. Masafumi Adachi Department of Urology Yamagata University School of Medicine 2-2-2-Iida-Nishi Yamagata-shi 990-23 (Japan)
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/24/2018 9:26:47 PM
Fig. 3. a Preoperative uroflowmetry showing low levels of urine flow and average flow rate, b postoperative uroflowmetry showing remarkable improvement in urine flow.
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Urol Int 1991;46:87-89
Successful Repair of Huge Bladder Diverticulum with a Transurethral Fulguration Report of a Case Masafumi Adachi, Teruhiro Nakada, Hitoshi Suzuki, Junji Hirano, Shunzo Kawamura, Nobuhisa Ishii, Hiroyuki Watanabe, Hisashi Kaneko, Manabu Ishigooka Department of Urology, Yamagata University, School of Medicine, Yamagata, Japan
Keywords. Bladder diverticulum • Transurethral fulguration Abstract. We present a 68-year-old man with a huge bladder diverticulum associated with benign prostate hyper trophy treated with transurethral fulguration of the diverticular mucosa in combination with transurethral resection of the prostate. The procedure was well tolerated by the patient and unfavorable symptoms faded after this proce dure. Follow-up cystogram demonstrated remarkable reduction of the diverticulum.
Introduction Orandi [1] introduced the noninvasive procedure for transurethral fulguration of the bladder diverticulum. Additional information on this method in combination with electrochemical lithotripsy of bladder stones has been provided by daym an et al. [2]. We report on 1 patient in whom the transurethral fulguration of the bladder diverticulum plus transurethral prostatectomy was successfully performed. Case Report
Fig. 1. Cystogram showing a huge diverticulum (D) and a con tracted bladder (B).
isms. Routine blood and blood chemistries were within normal lim its. The phenolsulfophthalein test showed 10% of injected dye in 15 min and 69% total in 2 h.
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/24/2018 9:26:47 PM
A 77-year-old man presented in July 1986 with hesitancy in ini tiating voiding, dysuria and occasional interruption of the urinary stream. A course of penicillin was prescribed but 1 week later simi lar symptoms recurred and interruption of urinary flow was re peatedly detected. His past history was not remarkable. No other members of the family are similarly affected. On admission, he was of somewhat smaller than normal stature. Other physical findings were unremarkable. Cystoscopy revealed prominent protrusion of the middle lobe of the prostate and a huge solitary diverticulum on the left lateral wall of the bladder. Cystogram of this patinet con firmed the presence of the diverticulum as well as hyperplastic pros tate configuration (fig. 1). Ultrasound examination of the upper abdomen and an intravenous urogram revealed normal kidneys and distal ureters. Urinalysis showed a specific gravity of 1.015. a pH of 7.0 and a trace of albumin. The sediment contained a few red blood cells, 20-30 white blood cells and 4 hyaline casts per high-power field. A urine culture grew abundant Staphylococcus albus organ-
Adachi/Nakada/Suzuki/Hirano/Kawamura/Ishii/Watanabe/Kaneko/Ishigooka
88
Fig. 2. a One week after trans urethral fulgulation of the bladder diverticulum, cystogram demon strating 79% decrease in size of the diverticulum, b Three months after the procedure, 93 % decrease in size of the diverticulum. See figure 1 for explanations. Each cystogram was taken by instillation of 300 ml of contrast medium. Then volume of diverticulum was calculated as el lipsoid.
Spinal anesthesia worked well for this procedure. After the loca tion of the diverticulum was confirmed by cystoscopy, Le Fort metal sounds from 22 to 28 French in size were introduced. The operator located the resectoscope inside the diverticulum.The tip of the resectoscope was then extended and the fulguration initiated from the apex of the diverticulum to the surrounding diverticular wall in a whorl manner with the coagulation current set at 4.5. The mucosal layer perceptibility etiolates and shrivels. As the diverticulum neck had been too narrow to comprise the cystoscope, the tissues of the diverticular orifice and its surrounding bladder mucosa had been fulgurated by the roller electrode before the fulguration of the div erticular inside lesion. The resectoscope (TU-196 SI Takei, Japan) and a roller electrode (TU-L97 Takei, Japan) were optimal for per forming these procedures. Periodic checking of the lateral margins of the vesical neck and noting of the position of the ureteric orifices are important to evade resecting the trigone. After the transurethral fulguration of the diverticular mucosa had been achieved, transure thral prostatic resection was done. At the end of the surgical proce dure, an intravenous injection of 20 mg of furosemide was adminis tered which could be duplicated in the next 30 min to ensure a valid diuresis. No irrigation should be performed unless the Foley cathe ter is plugged.
Results Four days after the transurethral fulguration of the vesical diverticulum and transurethral resection of the prostate, the Foley catheter was removed. Postoperatively, the patient suffered from acute bilateral epididy mitis, which was treated successfully with antibiotics. Detrusor hyperreflexia was caused by the reduction of
postoperative urinary incontinence; however, this tem poral bladder disturbance was completely cured 1 week after removal of the indwelling catheter. One week after the procedure, cystogram demonstrated a 79% reduction in the volume of the diverticulum (fig. 2). Three weeks and 3 months after the procedure, the sizes of the diver ticula had decreased by 85 and 93%, respectively (fig. 2). Symptoms of chronic cystitis resulted in marked im provement 2 weeks after the transurethral operation. Follow-up cystograms have demonstrated no recur rences, and no additional operations have been neces sary. Postoperatively, detrusor function was successfully improved (fig. 3) and voiding dysfunction was taken away.
Discussion Intraoperative bleeding can sometimes be very trou blesome and transurethral prostatectomy occasionally accompanies this untoward phenomenon. In order to keep good visibility, we had fulgurated the vesical diver ticulum first, then transurethral prostatectomy was per formed. Similar surgical procedures have also been ad vocated by other investigators [2], When the neck of the diverticulum is too tight to admit the instrument, Clayman et al. [2] proposed to stretch the roller electrode directly across the neck and the cutting current is set at 4, after which the roller is drawn back across the tissues of the mouth of the diverticulum, daym an et al. [2] used
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/24/2018 9:26:47 PM
Method of Transurethral Fulguration
Transurethral Fulguration of Bladder Diverticulum
the roller electrode to incise all 4 quadrants. In our case, we did not cut the neck of the diverticulum but fulgu rated the mouth of the diverticulum and its surrounding bladder mucosa. This appeared to decrease intra- or postoperative hemorrhage. When the bladder mucosa or prostatic capsule is perforated early in the surgical pro cedure, the irrigating fluid can be assimilated into the circulation in large quantities [3], Such unfavorable phe nomena will cause hypervolemia and hypovolemia [3]. Under spinal anesthesia, the patient will become agi tated, blood pressure will gradually rise, and the pulse rate will decrease. This should be noticed early and treated quickly and a high index of suspicion on the part of the operating surgeon can reduce the risk of this prob lem. Vitale and Woodside [4] have performed transure thral resection of the diverticular neck in 6 patients. The indications for surgery in 3 patients were unfavorable diverticular evacuation with urine stasis and recurrent infection [4], In 1 patient, resection was performed con comitant with a transurethral resection of the prostate. Two patients had resections a few years after transure thral resection of the prostate. As long ago as 1943, Hartung and Flocks [5] performed transurethral diverticulotomy in 22 patients with successful results in many patients. More recently, Posta [6] reported a good out come of transurethral resection of the neck of the diver ticulum in 8 of 10 cases. Orandi [ 1] treated 14 patients with bladder diverticula with transurethral fulguration of the mucosa. According to Vitale and Woodside [4], the method introduced by Orandi [1] maintains the
sphincter function of the neck of the diverticulum allow ing persistent residual urine. Subsequently, they con cluded that the fulguration procedure was less desirable than resection of the neck of the diverticulum [4], Trans urethral fulguration or incision of vesical diverticula associated with transurethral resection of the prostate has some advantages in respect to safety, cost-effective ness and bleeding in comparison with open diverticulectomy. In addition, it is of considerable practical signifi cance in this study that progressive widening of the neck of the diverticulum can be achieved a few weeks after the fulguration. As mentioned previously [2, 7], the most difficult problem concerning surgery in this procedure is the pres ence of bladder tumor. If bladder cancer is located in the diverticulum or in the vincinity of the neck of the diver ticulum, this surgical technique is contraindicated. Al though this transurethral fulguration procedure was per formed successfully, we followed this patient for only 10 months. A long follow-up must be pursued in the fu ture.
References 1 Orandi A: Transurethral fulguration of bladder diverticulum: New procedure. Urology 1977;10:30-32. 2 daym an RV, Shahin S, Reddy P, Fraley EE: Transurethral treatment of bladder diverticula. Urology 1984;23:573-577. 3 Straffon RA: Transurethral prostatectomy; in Stewart BH (ed): Operative Urology - Lower Urinary Tract, Pelvic Structures and Male Reproductive System. Baltimore, Williams & Wilkins, 1982, pp 179-191. 4 Vitale PJ, Woodside JR: Management of bladder diverticula by transurethral resection: Re-evaluation of an old technique. J Urol 1979;122:744-745. 5 Hartung W, Flocks RH: Diverticulum of the bladder. A method of roentgen examination and clinical findings in 200 cases. Radi ology 1943;41:363-370. 6 Posta B: Transurethral electroresection of the diverticular neck: Incisions, technique, results and analysis of ten surgical cases. Int Urol Nephrol 1977;9:297-302. 7 Redman JF, McGinnis TB, Bissada NK: Management of neo plasms in vesical diverticula. Urology 1976;12:492-494.
Received: March 5, 1990 Accepted after revision: April 19, 1990 Dr. Masafumi Adachi Department of Urology Yamagata University School of Medicine 2-2-2-Iida-Nishi Yamagata-shi 990-23 (Japan)
Downloaded by: Univ. of California Santa Barbara 128.111.121.42 - 3/24/2018 9:26:47 PM
Fig. 3. a Preoperative uroflowmetry showing low levels of urine flow and average flow rate, b postoperative uroflowmetry showing remarkable improvement in urine flow.
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