Editing Bladder Diverticulae (section)

== Management ==

=== Options ===
*'''<span style="color:#ff0000">Surveillance'''
*'''<span style="color:#ff0000">Surgery (endoscopic, open, laparoscopic, robotic)'''
*'''<span style="color:#ff0000">Catheterization'''

==== Surveillance ====
* '''Suitable for adult patients with minimal symptoms and no complicating factors'''
* '''Patients should be counseled regarding the potentially increased risk of malignancy''' and the need for periodic reassessment as well as the unpredictable course and potentially aggressive nature of malignancy if subsequently found in this setting.
** '''The''' '''association between bladder diverticula and bladder cancer has been attributed to urinary stasis and to chronic inflammation''' that is often found on pathologic examination of bladder diverticulum tissue.
** Historically, prophylactic surgical treatment was done for all bladder diverticula, including asymptomatic and minimally symptomatic lesions. However, more recently it has been suggested that such management is not warranted, and observation with careful follow-up and periodic endoscopic surveillance is acceptable in asymptomatic individuals without evidence of dysplastic or malignant changes
* '''The optimal schedule and type of surveillance for those individuals choosing observation is not well defined but consists of:'''
** '''<span style="color:#ff0000">Periodic reassessment of symptoms'''
** '''<span style="color:#ff0000">Urine studies (including cytology)'''
** '''<span style="color:#ff0000">Endoscopic examination of the lower urinary tract'''

==== Surgery ====
* '''<span style="color:#ff0000">Indications for intervention of bladder diverticulae (5):'''
*# '''<span style="color:#ff0000">Stones in diverticulum'''
*# '''<span style="color:#ff0000">Upper urinary tract deterioration as a result of obstruction or reflux'''
*# '''<span style="color:#ff0000">Persistent symptoms not otherwise responsive to medical therapy'''
*# '''<span style="color:#ff0000">Recurrent UTI'''
*# '''<span style="color:#ff0000">Carcinoma or premalignant change'''
*#* '''Neoplasms within a bladder diverticulum are associated with poor prognosis''' because of the potential for rapid transmural involvement of invasive bladder cancer and extravesical extension due to the bladder diverticulum wall lacking a well-developed muscularis propria layer
*#* The lack of a defined muscular wall risks early dissemination of tumor cells into an extravesical location during transurethral resection of these lesions and makes precise pathologic staging difficult. Because pathologic staging following transurethral resection is difficult and often inaccurate, consideration should be given to the possibility of early extravesical disease extension owing to the lack of a defined muscularis propria and '''an aggressive approach to these tumors has been suggested.'''
*#** '''***2015 CUA NMIBC Guidelines include “invasive tumours involving bladder diverticula” as indication for timely cystectomy'''
** '''Size of the diverticulum does not correlate with symptoms or complications (UTI or malignancy) and therefore cannot be used as an absolute indication to proceed with surgery'''
**'''In patients with bladder diverticulum secondary to bladder outlet obstruction, management of bladder outlet obstruction should occur prior to or concomitant with treatment of the bladder diverticulum.''' Whether such procedures should be done concomitantly or staged is controversial

===== Endoscopic surgical management =====
* '''Transurethral resection of the diverticular neck may be combined with fulguration of the entire urothelial lining of the diverticulum'''
** The neck of the diverticulum is incised using the resectoscope loop or Collins knife. Incisions are carried down to the muscular fibers of the bladder at the level of the ostium of the diverticulum. Circumferential resection of the entire neck may be performed.
** Fulguration of the lining of the diverticulum should result in obliteration of the diverticulum or a considerable reduction in its size.
* '''May be considered in:'''
** '''Elderly or comorbid'''
** '''Those who are not good candidates for open operative approach'''
** '''Those undergoing TURP in whom there is an associated poorly draining diverticulectomy'''

===== Open/laparoscopic/robotic surgical management =====
* '''<span style="color:#ff0000">Careful dissection is required during excision of the diverticulum to avoid ureteral injury</span>''', because many bladder diverticula are located adjacent to the ureter or may be adherent to it. Ureteral stents are often placed preoperatively or intraoperatively to facilitate dissection and avoid ureteric injury
*Open
**Usually performed through a transvesical, extra-peritoneal approach
* '''Adverse Events'''
** '''Intra-operative:'''
*** '''Ureteral injury'''
*** '''Bleeding'''
*** '''Injury to adjacent organ'''
** '''Early post-operative'''
*** '''Bleeding'''
*** '''UTI'''
*** '''Prolonged urinary extravasation postoperatively'''
** '''Late-post-operative:'''
*** '''Urinary fistula'''

==== Catheterization ====
* '''Patients who have poor bladder emptying following relief of obstruction and remain symptomatic, or those who are unable or unwilling to undergo surgical excision of the bladder diverticulum,''' '''may be effectively treated with CIC or an indwelling catheter'''.