Congenital Vesical Diverticulum in a 38-year-old Female

A 38-year-old female with a history of psychiatric illness presents with irritative urological symptoms and is diagnosed as having a large congenital vesical diverticulum (Hutch diverticulum). An overview of the aetiology, classification and complications of diverticula together with indications for and management of bladder diverticula is discussed. This is the first documented case of a very large symptomatic congenital diverticulum in a female presenting in the third decade of life and emphasizes the importance of ultrasound in irritative urological symptoms resistant to medication.     

Management of vesical diverticula

Vesical diverticula refer to hernias of the vesical mucous membrane in the detrusor. The diverticulum wall is therefore constituted by the chorion urothelium. The muscular dehiscence that is at the origin of the diverticulum may be either congenital or degenerative. Two important complications of the diverticulum-that are sometimes interwoven-may occur: a draining defect (responsible for infections, lithiasis, and functional signs of the lower urinary tract), and the development of an urothelial tumour in the diverticulum cavity. For such complicated diverticula, surgery is indicated, by endoscopic or retropubic approach. Results may be excellent, provided the surgical intervention focuses at the same time on the management of the associated sub-vesical obstacle in case of acquired diverticulum.     

Primary congenital bladder diverticula in boys.

Three male patients ranging in age at diagnosis from eight to seventeen years were found to have presumed primary congenital bladder diverticula. All 3 patients had a solitary documented urinary tract infection (Staphylococcus 2, Escherichia coli 1), 1 patient presented with gross hematuria, and in 1 patient the diverticulum was an incidental finding. In all cases, there was no radiologic evidence on voiding cystourethrography of physiologic or anatomic ureteral or bladder outlet obstruction. In a nine-year-old boy there was ipsilateral renal agenesis, an intra-abdominal undescended testis, and an atretic ureter arising from the diverticulum. The older boy had Ehlers-Danlos syndrome. If the diverticulum is enlarging, compromises the ureterovesical valve mechanism, or by virtue of incomplete bladder emptying is believed to promote urinary tract infection, it should be removed. A surgically conservative course is followed in the Ehlers-Danlos syndrome because of the bleeding tendency and tissue abnormalities.     

Management of neoplasms in vesical diverticula.

Two cases of neoplasms occurring in vesical diverticula are presented, and the pertinent literature is reviewed. It is suggested that a patient with a neoplasm in a vesical diverticulum be staged by surgical exploration and be accorded the same aggressive management as any patient with an infiltrating vesical neoplasm.     

膀胱憩室的手术治疗

作者总结３１例膀胱憩室的手术治疗结果，并介绍一种处理巨大膀胱憩室的简易手术。多数憩室继发于膀胱流出道梗阻。憩室内并发肿瘤７例，结石形成９例。膀胱憩室多由膀胱造影或Ｂ超诊断。憩室切除常采用膀胱内外联合入路。本组２６例手术同时处理膀胱出口梗阻和膀胱憩室。获得随访的２３例中，２１例尿路症状消失。７例憩室肿瘤患者中，５例在两年半内死亡，余２例分别存活２年和６年。本组２例巨大膀胱憩室行经膀胱内憩室旷置术，无并发症，膀胱造影无异常。作者认为，膀胱憩室的治疗应依据每个患者的情况而选用不同的手术方式。对位于膀胱后下方，粘连广泛的巨大憩室，宜采用经膀胱内入路憩室旷置术。     

Giant diverticulum of the bladder. A case report]

Vesical diverticula are a common pathology of the urinary bladder, generally secondary to cervico-urethral obstruction. Frequency of giant diverticula is not reported in the literature. The Authors present a case of giant vesical diverticulum (20 x 30 cm in diameter) due to prostatic adenoma in which any referable symptomatology was absent. The Authors debate the reasons for which progressive development of the diverticulum has been related with the improvement of the frequency and urgency previously presented by the patient.     

Bladder diverticula

Bladder diverticula are of two different types: 1. Those due to abnormal embryonal evolution giving rise to abnormalities, deviations or arrest in development. To this group belong the well-known diverticula of the urachus. But apart from these there exist other, less recognized diverticula probably due to evagination of the embryonal epithelium of the bladder: they are the supratrigonal diverticula, those located in the centre of the vesical dome, and some varieties of paraureteral diverticula. A diverticulum is described into which the ureter ends; probably because of excessive ascension of the embryonal ureter. 2. Those which are not due to abnormalities of development or so-called acquired diverticula. There are two varieties in this group; the foetal diverticulum arising in the second half of pregnancy and diverticula formed after birth, which make up the majority. In the genesis of acquired diverticula, both predisposing causes (weak spots of the vesical wall) and determinant causes (any pathology causing prostatism and increase of the intravesical pressure) should be considered. This mechanism of formation is evident in the acquired diverticula after birth, and also in the foetal diverticula, since the urine contained in the bladder is evacuated to the amniotic cavity through actual micturition. It is possible that in this stage there already exist obstacles to urination. It is, therefore, proper to say that the same causes produce the same effects in all stages of life.     

Etiopathogenesis and classification of esophageal diverticula

The classification and etiopathogenesis of esophageal diverticula is discussed on the basis of our experience with the surgical management of 74 such diverticula (51 parapharyngeal, 7 thoracic, 167 epiphrenic). Parapharyngeal diverticula always represent true diverticula, their walls comprising muscular tissue as well as mucosa and submucosa. A causal relationship between esophageal reflux disease and Zenker's diverticulum has not yet been proved. Thoracic diverticula are probably more often of a congenital than traction origin. Epiphrenic diverticula result either from hypertonia of the lower esophageal sphincter (esophageal achalasia) or, if the latter functions normally, are of congenital origin. Traction etiology can in special cases be due to the presence of a leiomyoma in the esophageal wall.     

Congenital bladder diverticulum in a 28-year-old male: A rare cause of urinary retention

Congenital vesical diverticulum causing urinary retention in adults is very uncommon. Herein we describe the case of a 28-year-old male patient presenting with retention of urine due to a large diverticulum. The mechanism by which a diverticulum causes retention is discussed along with the features which distinguish a congenital from an acquired vesical diverticulum.     

Bladder diverticulum, a congenital disease of children and adults

Genetically all diverticula are congenital and arise from the zone between trigone and detrusor which is susceptible to embryonal disturbances. The climax of the morbidity is in the first and sixth decennium. In both cases, the diverticulum is caused by infravesical obstruction which is congenital in the first group and acquired in the second. The morbidity in the male patient is characteristically higher than in the female. Morphologically, we differentiate between small, medium sized and large diverticula with a gradually increasing morbidity, depending on the size of the diverticulum and involvement of the ipsilateral ureter. The musculature of the diverticular wall is deficient. Pathophysiologically, the growth of a diverticulum depends on three stimuli: an intrinsic one, the exposure to micturitional pressures and a coincidental infravesical obstruction. The micturition has lost its efficiency and is incomplete. The urine in the diverticulum empties incompletely into the urinary bladder. Correlated pathologies include reflux and tendencies towards chronic inflammation and malignant degeneration. Therapeutically, an endoscopic incision of a narrow diverticular neck should be considered first. If this is not sufficient diverticulectomy should be considered next and this is the treatment of choice for large diverticula. No treatment is necessary for small diverticula. If a paraostial diverticulum in children causes reflux of marked degree, the reflux should be operated on by an extravesical approach, sinking the diverticulum into the urinary bladder and eliminating the diverticulum this way.     

A case of giant vesical diverticula causing defecation disturbance

Cases of giant vesical diverticula that cause defecation disturbance are very rare. A 67-year-old man with such a condition was admitted to our hospital complaining of pollakiuria , nycturia , retardation, two-phase urination and defecation disturbance which began about 7 years earlier. A goose-egg-sized tumor touched above the hen-egg-sized prostate and the tumor disappeared after urination. X-ray examinations revealed that defecation disturbance was caused when the sigmoid colon was oppressed by the giant diverticulum. After diverticulectomy and prostatectomy the vesical symptoms and defecation disturbance completely subsided.     

Urinary retention caused by a large bladder diverticulum: a simple method of diverticulectomy

We report on a 63-year-old man with persistent urinary retention owing to a large bladder diverticulum. To our knowledge this is the second case reported in the literature. A simple technique for excision of large vesical diverticula is described.     

Tumour in a giant bladder diverticulum: A case report and review of literature

We report an unusual case of a transitional cell carcinoma arising in a bladder diverticulum presenting as a giant abdominal mass and acute urinary retention. We have reviewed the literature and discuss the aetiology, diagnosis, and treatment of tumours arising in vesical diverticula.     

A case of isolated congenital diverticulum of the left ventricule

Congenital diverticulum of the left ventricule is rare congenital cardiac malformation and is classified as muscular and fibrous. Muscular diverticula are usually accompanied with other cardiac and extracardiac malformations. 8 years old boy involved with muscular left ventricular diverticulum with no other congenital anomalies underwent resection of diverticulum. The cardiopulmonary bypass was required because it was not feasible to apply a clamp, to the neck of the diverticulum. Congenital diverticulum of the heart should be resected as soon as possible because of crisis of spontaneous rupture and systemic embolization. However, the assessment of cardiac arrhythmias and hemodynamic changes caused by clamping of the diverticulum during operation is necessary.     

Voiding inability after transurethral resection of a bladder diverticulum

Following transurethral resection of the opening of a large bladder diverticulum a 62-year-old man was in complete urinary retention. The reason was the considerable vent created by altering the hydrodynamics. The complication was resolved only after conventional vesical diverticulectomy. A warning is issued against the use of transurethral treatment of large bladder diverticula.     

Urinary bladder diverticula and the Ehlers-Danlos syndrome in children

Two large bladder diverticula that induced severe micturition disturbances were surgically removed in a 5-year-old boy with Ehlers-Danlos syndrome (EDS). One year after surgery, a new, asymptomatic diverticulum developed. This case is discussed in the light of nine similar cases that have already been published. It is concluded that EDS diverticula form a distinct group characterized by postoperative recurrence. They are not due to vesicourethral obstruction but probably result from an anomaly of the vesical wall. They are responsible for micturition difficulties and urinary tract infections. Their unavoidable recurrence means that surgery should be restricted only to symptomatic patients.     

Vesical diverticula: etiology, diagnosis, tumorigenesis, and treatment. Analysis of 74 cases

A thirteen-year review of bladder diverticula was undertaken and 74 cases were identified. In 8 patients primary neoplasms arose in the diverticula, and their treatment included diverticulectomy or partial cystectomy with or without postoperative irradiation, irradiation only, and transurethral resection of the tumor combined with fulguration of the diverticular wall and postoperative bladder instillations with doxorubicin or thiotepa solutions. Early diagnosis with additional visualization of the interior of vesical diverticulum is mandatory, since carcinoma arising in it has a poor prognosis.     

膀胱憩室癌5例报告

目的：探讨膀胱憩室癌的临床特征，提高其诊治水平。方法：对5例膀胱憩室癌患者均行CT和膀胱镜检查确诊。3例行根治性膀胱全切、尿流改道手术．2例行膀胱部分切除术。结果：病理诊断移行细胞癌2例，鳞状细胞癌2例，恶性神经鞘瘤1例。3例于术后2个月内死亡，均为非移行性细胞癌；另外2例术后随访10个月，无局部复发和远处转移。结论：CT和膀胱镜检查是确诊膀胱憩室癌的重要方法；膀胱憩室癌的临床分期不同，预后明显不同，非移行细胞癌病理类型有早期浸润行为．预后差。     

An atypical bladder diverticulum presented with recurrent peritonitis: case report

Bladder diverticula develop from congenital detrusor muscle defect and frequently present with urinary tract infection, which occurs as a result of urinary stasis in the diverticula. Different clinical presentations, such as bladder outlet obstruction, cyanosis of the lower extremities, intestinal obstruction, ureteral obstruction (which may occur due to direct diverticular compression), and peritonitis due to spontaneous rupture of the diverticula, were reported previously. Here, we report a case with the diagnosis of bladder diverticulum that caused recurrent generalized peritonitis without perforation and mimicked perforated appendicitis.