The large bladder diverticulum in children

Large bladder diverticulae, i.e. with a diameter measuring at least one-third of the bladder diameter on voiding cystourethrography, constitute an unusual but serious cause of obstructive uropathy in childhood. Their operative management entails meticulous reconstruction of the lower urinary tract. We report our experience with the management and long-term outcome of large bladder diverticulae in children during a 20-year period.

Twenty-two children (21 boys and 1 girl) aged 13 days to 14 years old (median age 2 years) at diagnosis of a large bladder diverticulum were treated in our department between April 1982 and December 2001. Presenting symptoms were: acute pyelonephritis in 10 patients, acute or chronic urinary retention in five, recurrent non-febrile bacteriuria in four and macroscopic hematuria in one patient. In the remaining two cases the diverticulae were diagnosed incidentally. Vesicoureteral reflux due to incorporation of the ureter within the diverticulum occurred in three children (four ureters). Transvesical diverticulectomy was performed as primary treatment in 20 patients. In the remaining two who presented at the age of 2 weeks with acute retention, cutaneous vesicostomy was the primary management followed after 1 year by diverticulectomy. Diverticulectomy was combined with ureteral reimplantation in 14 ureters (four refluxing and 10 non-refluxing) which were incorporated within the diverticular sac. In two children with bladder-neck hypertrophy, a bladder neck incision was additionally performed.

There were two postoperative complications. In one case of bladder-neck stenosis with a thick trabeculated bladder ureterovesical obstruction occurred following ureteral reimplantation. Another patient presented with severe hematuria and clot retention, which was controlled by clot evacuation, continuous bladder irrigation and administration of factor VIII. In the five patients with retention preoperatively, complete bladder emptying was achieved postoperatively. Seventeen patients who at their last follow up had reached school age had a normal uroflow and normal voiding patterns. None of the patients had recurrence of the diverticulum, and all have remained free of urinary infection postoperatively during a mean (range) follow-up period of 16 (2-20) years.

Large bladder diverticulae present a serious urological problem in childhood. Urinary infection and urinary retention are the most common presenting symptoms. Transvesical diverticulectomy is a reliable technique for surgical treatment, and can effectively be combined with ureteral reimplantation or with the management of associated bladder-neck pathology whenever necessary. In neonates a staged approach with primary cutaneous vesicostomy followed by diverticulectomy is recommended as a safer but equally effective treatment.