Suprapubic Transvesical Laparoendoscopic Single-Port Bladder Diverticulectomy: Points of Technique with Medium-Term Surgical Outcomes

Introduction

B ladder diverticula encompass herniations of the mucosal layer through detrusor muscle fibers. They may be either congenital or acquired. Acquired diverticula form mostly as a result of the obstruction of the bladder outlet, most commonly in older men with benign prostatic hyperplasia.

Although diverticula are most often asymptomatic, such conditions as urinary tract infections (UTI), bladder/diverticular calculi, tumors, or significant postvoid residual (PVR) may be an indication for surgical treatment. ^1,2 In this context, various techniques, including open, endoscopic, laparoscopic, and robot-assisted approaches, have been applied. They were performed either trans- or extraperitoneally. ^{2 –6}

Although they differ, the accesses mostly follow the same principles of the open approach: (1) Mobilization of the diverticular sac and neck; (2) extraction of the diverticulum; and (3) suturing of the bladder wall defect. ⁷

Treatment of patients with bladder outlet obstruction, if not already achieved, can be managed either in staged or combined approaches, with comparable results. ⁸ Case series indicate the potential advantage of the staged procedure of transurethral resection of the prostate (TURP) followed by laparoscopic diverticulectomy, in terms of blood loss and recovery time. ⁸

The variation of classic transperitoneal access is transvesical laparoscopic diverticulectomy introduced by Pansadoro and associates. ⁹ In this technique, three trocars are inserted directly into the bladder, and after establishing a pneumovesicum, a diverticulectomy is performed. No port is inserted into the peritoneal cavity; this maneuver reduces the risk of inadvertent intestinal injury. ⁹ To further reduce the morbidity associated with multiport laparoscopic surgery, Stolzenburg and colleagues ¹⁰ performed a series of transvesical bladder diverticulectomies using the single port introduced in the umbiliculus. In this technique, an extravesical closure of the bladder opening was needed.

The newest approach that further minimizes tissue manipulation is transvesical laparoendoscopic single-port (T-LESS) surgery introduced in 2011. ¹¹

This study assesses the clinical results of an initial series of five patients who were treated with the T-LESS technique after a minimum of 7 months of follow-up.

Patients and Methods

From March 2011 to February 2012, we operated on five men with mean age of 66 years (range 61–76 years) for symptomatic bladder diverticula, using the T-LESS approach. All patients were qualified for the treatment because of PVR urine volumes of greater than 80 mL, complicated by recurrent UTI, or an intradiverticular superficial neoplasm.

All men presented a history of benign prostatic hyperplasia treated with alpha-blockers. The detailed description of the material is presented in Table 1.

The patients' diagnoses were made by ultrasonography and cystoscopy or intravenous urography, and there were diverticula with a median diameter of 5.1 cm. The average PVR volume and maximum flow rate were 110 mL and 17.6 mL/s, respectively.

In four patients, recurrent UTI associated with increased PVR were the main indications for surgery. In one patient, the procedure was performed because of a recurrent, intradiverticular, low-grade malignancy located close to the diverticular ostium.

After obtaining written informed consent, the patients were operated on in a similar manner following the steps described below:

1. Placement of the patient in the lithotomy position

OPEN IN VIEWER

FIG. 1.

The use of a single port device and standard laparoscopic instruments. (A) The TriPort+ device; (B) dissection of a diverticular neck; (C) closure of the bladder wall defect with the standard laparoscopic instruments.

In all procedures, we used a standard, 0-degree or 30-degree optic (Olympus, Germany), and standard, rigid, monopolar laparoscopic instruments. No sophisticated optics or armamentaria were applied. Blind transurethral insertion of graspers accompanied each procedure. The careful introduction of the instrument through the urethra and the visual control of its passage through the internal urethral ostium are essential for the safe performance of this maneuver.

Despite this, we were concerned that, after introducing graspers through the urethra, the gas leakage would make it difficult or impossible to complete the procedure. In fact, we noticed no gas leak through the urethra even if a laparoscopic instrument was inserted. The patients were treated postoperatively with courses of antibiotics (quinolones or cephalosporins), mostly based on the results of urine culture. Patients were discharged on the second to fourth days after the operation and were advised to attend follow-up after 6 weeks, and every 3 months thereafter.

Results

In all five patients, the procedures were completed successfully, and no blood loss or complications were observed. The operative time ranged from 80 to 175 minutes (Table 2). The need for the administration of analgesics was minimal. Pathology examination confirmed the complete removal of all diverticula. In patient 3, a 1-cm in diameter, low-grade urothelial carcinoma was revealed, but with no positive margins.

All the patients presented a decreased PVR (<40 mL) at the 6-week follow-up. The urinalysis and bacteriologic urine assessment were negative in all cases, except that of patient 4, in whom Enterococcus faecalis was identified. A course of antibiotics was administered successfully for this patient.

In three patients, we did not observe any abnormalities in the paravesical space, but in the other two, we noticed the progressive involution of small hematomas located in the postdiverticulectomy area. No hematomas were found in those men at the 6-month follow-up. Patient 3 was regularly investigated cystoscopically every 3 months, and no neoplastic recurrence has been observed. Four patients are continuing treatment with alpha-blockers. None of them needed ablative procedures for benign prostatic hyperplasia. After 11 months in patient 4, we found a small recurrent diverticulum.

Discussion

To date, the consensus on what approach is the best for bladder diverticulectomy has not been established.

Mostly, the diverticula are removed via extravesical or intravesical access, using either the open or laparoscopic approaches. At present, laparoscopic, robot-assisted, and single-port procedures tend to replace open surgery, with comparable results. ^{4,5,10 –13}

Moreover, endoscopic management may be appropriate for patients with small diverticula, during the simultaneous treatment for bladder outlet obstruction and/or for those who are poor candidates for an extirpative approach. ^14,15

In 2011, single access techniques, such as transperitoneal or transvesical LESS diverticulectomies, were introduced to reduce the morbidity associated with standard laparoscopy and to improve the cosmetic outcome. ^10,11

In the comparison of laparoscopic and open bladder diverticulectomy, based on the most numerous number of patients (25 patients), the laparoscopic group had a longer operative time (4 hours vs 2 hours and 16 minutes), but was superior in terms of blood loss, postoperative analgesic requirements, and hospital stay (3.2 vs 9.6 days). ¹² Abdel-Hakim and coworkers ⁴ presented a series of 13 laparoscopic patients with the mean operative time of 265 minutes. Robotic surgery seems to prevail over classic laparoscopy, presenting a shorter mean operative time (console time), ranging from 83 to 194 minutes. ^5,16 Nevertheless, in patients reported by Tareen and colleagues, ¹⁶ the use of a Collins knife with transurethral resectoscope for incising the diverticular ostium and the simultaneous need for undocking the robot might lengthen significantly the operative time.

In all of our cases, we used the hook electrode introduced through the TriPort. When the diverticular sack is tracked by the grasper introduced transurethrally, or via the single-port, dissection of extravesical adhesions with the hook electrode is easy and safe because of the perfect exposure of the structures. We consider that such maneuvers facilitate dissection, improve visualization, which is crucial to avoid ureteral injury and to obtain proper hemostasis, and may decrease the operative time. In our group of patients, the operative time was shorter than in either the laparoscopic or most robotic series, and comparable to that achieved in open diverticulectomies.

The duration of postoperative bladder catheterization is rather debatable. Abdel-Hakim and associates ⁴ removed urethral catheters after 7 to 14 days, and Tareen and coworkers ¹⁶ withdrew them between postoperative days 5 and 14. These authors performed cystography before catheter removal.

In our series, the bladder drainage with the urethral Foley catheter was established for 4 to 7 days. It was sufficient in all cases, although the catheterization period may probably be decreased to 2 days. ¹³ No postoperative cystography was applied in those patients. An ultrasonographic examination was performed before the patients were discharged to ensure that there was no hydronephrosis or paravesical urinary leakage.

Further differences of our method are those relating to ureteral and diverticular catheterization. An ipsilateral ureteral catheterization is advised in several articles. ^4,5,7 Because of excellent visualization inside the bladder, we did not perform this maneuver in all the patients, but only in one whose diverticular neck was close to the ureteral orifice. Moreover, because of the nature of the technique, we did not have to identify the diverticula by insertion of a Foley catheter or by cystoscopic transillumination, both of which were commonly performed when other approaches were used. ^3,6,7,10,17

The literature on the assessment of medium- or long-term results of the management of diverticula is scarce. We found only one article presenting data of medium-term observation. Martov and colleagues ¹⁵ reported that in 13 of 29 patients, after 6 to 48 months of follow-up, the transurethral endoscopic incision of the bladder diverticulum was successful, but in the remaining 16 patients, the diverticula were diminished. In our group, we observed a small recurrent diverticulum in one patient after 1 year of follow-up. In our opinion, this may be expected because of the pathophysiology of the disease and/or persistent bladder outlet obstruction. For this patient, we have considered TURP; however, the patient was satisfied with conservative treatment.

The T-LESS diverticulectomy is as safe and efficient as other minimally invasive techniques. We were encouraged to apply this technique, because it was a natural translation from the transperitoneal or transvesical laparoscopic multiport approaches to a likely less invasive access.

This is all the more important in the context of the Laparo-Endoscopic Single-Site Surgery Consortium for Assessment and Research consensus, which predicts an increase in the number of procedures that may be performed with the LESS access up to 50% during a period of 5 years. ¹⁸

We consider that the newest achievements in the technology of endoscopic instruments, which can be potentially applied in T-LESS procedures, will enable the surgeon to remove most bladder diverticula using this technique, especially if the diverticula are located typically near the bladder fundus. At present, however, the T-LESS approach seems to be unfit for cases with diverticula presenting in the bladder dome or those with a wide ostium.

The T-LESS provides the same benefits as the laparoscopic approach in terms of blood loss, postoperative analgesic requirements, and hospital stay, but the operative time is comparable to that achieved during open or endoscopic surgery. The other advantages of T-LESS are the use of standard laparoscopic instruments, excellent visualization inside the bladder, and easier identification of the diverticulum.

The disadvantages of the procedure are the relatively small operative field and clashing of the instruments. The disadvantages may be reduced, however, when newer sophisticated instruments are introduced.

The authors realize that the presented number of patients is relatively small, but as instruments and our experience evolve, we expect that further observations will confirm the benefits of this method compared with other minimally invasive techniques.

Conclusions

T-LESS bladder diverticulectomy is a safe, effective, reproducible and minimally invasive procedure. Further studies, experience, and development of new technologies are necessary, however, to facilitate the establishment of this method.