Diverticulectomy reimplantation

Bladder diverticulectomy reimplantation

Diverticulectomy with reimplantation of the ureter is a rare urological procedure and at the time of writing, there are very few reports of this technique being used in adults. In these situations, simple diverticulectomy may interfere with the urine drainage from the kidney and therefore the ureter is reimplanted in the bladder.

What Is a Bladder Diverticulum?

It is the evagination of the bladder wall where urine can be retained. It could be:

• Congenital (from birth)
• Acquired – An acquired diverticulum is a result of chronic bladder outlet obstruction.

Surgical removal should be done for a giant and symptomatic diverticulum.

Benefits 

• Complete removal of the diverticulum 
• Restoration of normal urine flow 
• Prevention of kidney damage 
• Relief from recurrent UTIs and urinary retention.

Ureteric reimplantation diverticulectomy

Ureteric reimplantation with bladder diverticulectomy is a single-stage urological procedure indicated when a bladder diverticulum involves or endangers the ureteric orifice. The aim is to excise the diverticulum without compromising urine flow from the kidney to the bladder.

Indications for the Combined Procedure

This operation is recommended for a patient with:

• Bladder diverticulum with the ureter opening within the diverticulum

Large or symptomatic diverticulum causing:

• Recurrent urinary tract infections
• Urinary retention
• Stone formation
• Vesicoureteral reflex
• Hydroureteronephrosis due to obstruction
• Risk of ureteric injury during diverticulectomy

Diverticulectomy reimplantation procedure

This surgery may be combined with a ureter reimplantation when the ureter opens into or is closely adherent to the diverticulum; this ensures a normal flow of urine thereby protecting the kidney from potential damage.

Preoperative Preparation

• Blood tests, urine culture 
• Imaging CT scan of urinary system
• Antibiotics if infection is present
• Bowel preparation for open approaches in some cases

Procedure:

Anaesthesia & Positioning

• General anaesthesia
• Patient supine; lower abdomen is prepped and draped.

Bladder Access

• Open, laparoscopic or robot technique

Diverticulum identified and mobilized

• Diverticulectomy in the bladder neck is performed for persistent symptoms
• The diverticular sac is meticulously isolated on electrocautery

Neck of diverticulum excised

• Bladder wall ready to be closed

Ureteric Mobilization

• Ureter carefully isolated
• If diverticulum involves ureteric orifice, ureter is divided close to bladder entry

Ureteric Reimplantation

• There is a new submucosal tunnel in the normal bladder wall
• Ureter is implanted by antireflux technique 
• Double-J stent is placed to keep patency of ureter.

Bladder Closure

• Watertight closure in 2 layers
• Other: Foley catheter left in bladder

Postoperative Care

• Foley catheter: 7–14 days
• DJ stent:··6 weeks before removal
• Hospital stay: 3–7 days
• Recovery: Return to normal activity in 4–6 weeks
• Pain control, antibiotic and hydration

Laparoscopic diverticulectomy reimplantation

It is a type of endoscopic procedure done when a bladder diverticulum involves the ureteric orifice. Laparoscopy provides enhanced visualization, less pain, shorter hospitalization and faster resumption of daily activities in comparison with laparotomy. 

Patient Positioning 

• Supine or lithotomy position 
• Trendelenburg tilt (head down) to facilitate bowel away from the bladder 
• Pneumoperitoneum established 

Port Placement 

• 5-12 mm of 3-4 laparoscopic ports 
• Camera port usually supraumbilical 
• Working ports placed laterally on lower abdomen 

Diverticulum Identification 

• Bladder and diverticulum are dissected off surrounding tissues 
• Identifying the diverticular neck carefully 

Diverticulectomy 

• Diverticular sac excised 
• Avoid injury to surrounding structures 
• Bladder wall prepared for repair 

Ureteric Mobilization 

• Ureter meticulously dissected up to bladder entry 
• Diverticulum sometimes requires division of ureter at bladder 

Ureteric Reimplantation

• A submucosal tunnel is formed in normal bladder 
• Ureter implanted by Lich–Gregoir (extravesical) or Politano–Leadbetter (intravesical) technique 
• Double-J stent inserted to keep it patent and prevent obstruction 

Bladder Closure 

• Watertight closure in 2 layers with absorbable sutures 
• Ensure no urine leak 

Completion 

• Ports removed 
• Pneumoperitoneum released 
• Foley catheter inserted 

Laparoscopic Method Benefits

• Minimal postoperative pain 
• Faster recovery and shorter hospital stay 
• Reduced blood loss 
• Better visualization of ureter and bladder anatomy

Robotic diverticulectomy reimplantation

A robotic aided minimally invasive surgery to are the bladder diverticulum and to reimplant the ureter if it lies within or close to the diverticulum. Robotic systems provide high accuracy, enhanced visualization and suturing in confined spaces and therefore are very suitable for complex procedures.

Robotic Method Benefits

• Excellent 3D visualization
• Dissection is performed meticulously around ureter and bladder
• Precisely stitched for closure of bladder and ureteric reimplantation
• Blood loss is minimal
• Shorter hospital stay and more rapid convalescence
• Lower risk of complications than with open surgery

Diverticulectomy reimplantation recovery

Recovery is also dependent on the surgical technique (open, laparoscopic or robotic), age of the patient and comorbidities. 

Postoperative Care

Hospital stay:

• Open surgery: 5–7 days
• Laparoscopic/robotic: 2–5 days
• Surveillance: Vital signs, urine flow, drainage, any evidence of infection 
• Pain control: IV or oral reflect or analgesics
• Antibiotics: To prevent UTIs

Urinary Catheter

• Foley catheter: Left in place for 7–14 days
• Goal: Bladder kept decompressed to facilitate healing of bladder wall
• Prevent infection: Take good care of your catheter

Ureteric Stent (Double-J Stent)

• Introduced during surgery to open the ureter
• Generally taken out after 4–6 weeks
• Stent can help to avoid obstruction or leakage at the site of a ureteric reimplantation

Pain and Activity

• Mild discomfort around incision/ports
• Progressive return to normal daily activities in 4-6 weeks
• Do not heavy lift or strenuous exercise until you get permission from your doctor

Diet

• Liquids first, progress to soft diet as tolerated
• Drinking enough fluid is necessary to prevent infection and stimulate healing

Follow-Up

• Postoperative imaging: Ultrasound or VCUG to assess a ureteric patency and no leakage
• Urine tests: Follow infection
• Regular follow-up to monitor kidney function

Diverticulectomy reimplantation complications

While this process is ordinarily safe, complications can arise, including mild and severe forms. The risk varies with the age of the patient, the size of the diverticulum, the involvement of the ureter and the type of surgery.

Urinary Complications

• Urine leak
• Urinary tract infection
• Hematuria

Ureteric Complications

• Ureteric obstruction or stricture
• Ureteric injury

Vesicoureteral Reflux

Bladder Complications

• Bladder spasms or urgency
• Incomplete bladder emptying

General Surgical Complications

• Bleeding or hematoma
• Infection
• Injury to surrounding organs

Best hospital for diverticulectomy reimplantation India

• Artemis Hospital, Gurgaon
• Medanta-The Medicity, Gurgaon
• Fortis Memorial Research Institute, Gurgaon
• Max Hospital, Saket

Conclusion

Diverticulectomy with ureteric reimplantation under is operatively feasible and well tolerated in patients with vesical diverticula involving the ureteric orifice or associated with significant urological morbidity. Whether open, laparoscopic, or robotic, the procedure is done to:

• Excise the diverticulum entirely
• Reestablishnden obstructed urine from the kidney to the bladder
• To stop infections, reflux and/or kidney damage

The benefits of the minimally invasive (laparoscopic/robotic) approach are reduced blood loss, decreased length of stay in the hospital, faster recovery and precise ureteric reimplantation. With proper patient selection, the technique having been matured and careful aftercare, the long-term prospects are good for most patients. 

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FAQ

Will kidney function improve? 

• Yes. In general, if the surgery is performed prior to irreversible kidney damage, kidney function stabilizes or improves following surgery.

Is the procedure permanent? 

• Now with the healing done, the normal function of the bladder and ureters is reestablished and the patient is one of the fortunate ones for whom recurrence is not likely.

Can children have this specific surgery? 

• Yes Pediatric diverticula are commonly congenital and associated with reflux. Robotic or open approaches are frequently performed in children with excellent results.

Will I have urinary problems after the surgery? 

• You may experience temporary bladder spasms, urgency, or mild hematuria but typically these will resolve within a few weeks. It is worth noting that long-term urinary outcomes tend to be favourable.

Can you operate on both at the same time? 

• Yes. It is possible to perform bilateral diverticulectomy with ureteric reimplantation when both ureters are involved.