Robotic Bladder Diverticulectomy with Concomitant Holmium Laser Enucleation of the Prostate

Abstract

Clinical History:

A 69-year-old male patient was referred to our office for chronic lower urinary tract symptoms (LUTS), recurrent UTIs, and hydronephrosis. Outside records revealed a post-void residual of 401 ml and an AUA Symptom Score of 19 managed with clean intermittent catheterization.

Physical Exam:

Physical exam was non-revealing for any overt signs of pathology.

Diagnosis:

Delayed phase CT imaging revealed mild bilateral hydroureteronephrosis with medial displacement of the right ureter due to a large right sided bladder diverticulum. There was significant bladder wall thickening consistent with chronic outlet obstruction and an enlarged prostate estimated at 40cc’s. While this patient did not undergo urodynamics, we will frequently obtain urodynamics on these patients both pre- and postoperatively.

Intervention:

The patient was counseled on treatment options and elected to proceed with Robotic Bladder Diverticulectomy with Concomitant Holmium Laser Enucleation of the Prostate (HoLEP). At our institution, our endourologists can perform HoLEP with lower operative times than a robotic simple prostatectomy with equivalent postoperative results, so we choose to perform HoLEP at the time of diverticulectomy. ¹ Endoscopic evaluation of the bladder also allows identification of the ureteral orifices and placement of localizing ureteral stents before treatment of the diverticulum. However, when HoLEP is not available, concomitant robotic simple prostatectomy is an option as well for these patients.

Outcomes:

The patient did well overnight and was discharged on postoperative day 1 (POD 1). His Foley catheter was removed on POD7 and he was able to void. Pathology showed 23 g of prostate tissue removed along with an 8.5 cm diverticulum. Through 1 year of follow-up the patient had no further incidence of UTI and resolution of hydronephrosis. This outcome is consistent with a larger cohort of 40 patients from our institution who underwent bladder diverticulectomy with or without concomitant outlet procedure. Findings from this group indicated a significant reduction in recurrent UTI’s (58% vs. 12.5% p < 0.01) and post-void residual volume (302 ml vs. 134 ml p = 0.02). Our findings indicate that in select patients, bladder diverticulectomy can be performed with concomitant HoLEP to address LUTS symptoms related to both the diverticulum itself, and the BPH induced chronic outlet obstruction that results in diverticulum formation.

Disclosure: We know of no conflicts of interest for this publication, and we did not receive financial support for this work. This article has been reviewed and approved for submission by all named authors listed on this article. All authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.

Runtime of video: 7 min 58 sec.