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CASE REPORT
Year : 2002  |  Volume : 19  |  Issue : 1  |  Page : 84-86
 

Bladder outlet obstruction due to con­genital bladder diverticulum: Case report and review of literature


Department of Pediatric Surgery, K.M.C., Manipal and K.M.C., Mangalore, India

Correspondence Address:
Vijay Kumar
Department of Pediatric Surgery, KMC, Manipal - 576 119
India
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   Abstract 

Acute urinary retention in infancy, due to a congenital bladder diverticulum (CBD) is rare. The literature is scanty on the subject. We report 2 such cases. In both of them the ureters were opening directly into the dive rticulitin. One of them had a complete duplex system on the left side, which is the first reported of its kind, with both ureters of the duplex system opening into the diverticulum.


Keywords: Bladder Diverticulum; Bladder Outlet Obstruc-tion; Duplex System


How to cite this article:
Sadashiva Rao P, Kumar V, Rao P. Bladder outlet obstruction due to con­genital bladder diverticulum: Case report and review of literature. Indian J Urol 2002;19:84-6

How to cite this URL:
Sadashiva Rao P, Kumar V, Rao P. Bladder outlet obstruction due to con­genital bladder diverticulum: Case report and review of literature. Indian J Urol [serial online] 2002 [cited 2014 Apr 23];19:84-6. Available from: http://www.indianjurol.com/text.asp?2002/19/1/84/20301



   Introduction Top


Congenital bladder diverticulum (CBD), almost always seen in boys. rarely leads to complications. It has got var­ied presentations like bladder outlet obstruction, ureteral obstruction, urinary tract infection. incontinence, etc. [1],[2] It can be associated with other urological problems like du­plex system. [3]


   Case Reports Top


Case 1: An 8-month-old male child presented with the history of dysuria, fever of 4 days and urinary retention of one day duration. From the age of 1th months, patient had intermittent episodes of dysuria with fever. At admission, the acute retention was relieved by catheterization and draining 300 ml of urine (expected bladder capacity-70ml). Abdominal ultrasound and micturating cystourethrogram showed a large diverticulum arising from the posterola­teral wall of the bladder on the left side and descending down to obstruct the bladder neck.

No vesicoureteric reflux was detected. Intravenous uro­gram showed normal right ureter and medially displaced left ureter. Cystoscopy showed diverticulum opening at the left corner of the trigone. Right ureteric orifice was normal but left ureteric orifice was not seen. On exploration, the diverticulum was seen to arise from the left side of the blad­der wall extending posterocaudally. Duplex system was seen on the left side with stenotic upper moiety orifice opening on the lip of the diverticulum and lower moiety orifice of normal size opening proximally on the medial wall of the diverticulum. The diverticulum was excised by combined intra- and extravesical approach and Politano Leadbetter's reimplantation of ureters in single sheath was carried out. Child is healthy with a follow-up of more than 4 years.

Case 2 : A 3-month-old male child presented with acute retention of urine of 2 days duration for which he was catheterized. Child had a similar episode 2 weeks prior to admission with dysuria. Urine analysis showed 20-25 WBCs/HPF and the culture was sterile. Abdominal ultra­sound detected a diverticulum arising from the posterola­teral wall of the bladder on left side, enlarging caudally, to compress the bladder neck. Micturating cystoure­throgram confirmed the sonology findings and did not show any vesicoureteric reflux. Intravenous pyelogram showed minimally functioning left kidney. On cytoscopy, mild trebaculation and the diverticular opening on the left corner of the trigone was visualized whereas the left ureteric orifice could not be made out. The right ureteric orifice was normal. The diverticulum was excised by both intra- and extravesical approach and Politano Leadbetter's reimplantation of left ureter was done. The child is healthy with a follow-up of 3 years.


   Comments Top


Congenital bladder diverticulum (CBD) rarely leads to complications and presenting with an outlet obstruction is unusual. CBD almost always occurs in males and are usu­ally solitary [4],[5] and they commonly present with urinary tract infection. [2],[5] Congenital weakness of the musculature near the ureteric orifice is a universally accepted cause for these diverticula. Bauer et al proposed that trigone and the rest of the bladder have different embryological ori­gin. which results in the weakness at the point of continu­ity (i.e., at ureteric orifices). [6] Johnson et al describes that the diverticula occur due to muscular deficiency at the ureteric insertion into the trigone. [7] As the diverticulum enlarges the ureteric orifice gets incorporated into it. [4],[7] These diverticula may obstruct the outlet or ureter and may lead to recurrent urinary tract infection, reflux, stone formation, urinary incontinence, etc. [1],[2] During the detrustor contraction, as the diverticulum fills, the urethra gets ob­structed and more urine flows into the diverticulum fur­ther pressing the posterior urethra. [9] Urethral obstruction due to a CBD was described first by Schiff and Lytton in 1970 and majority of them presented in infancy. [1],[9] Mic­turating cystourethrogram in both oblique views and cys­toscopy are the best tools for diagnosing this condition. The distorted anatomy due to large diverticulum, failure of diverticulo-ureteric reflux and the poor function of the affected kidney/moiety of the duplex kidney all contrib­uted to the difficulties in establishing the complete ana­tomical configuration ; in our first case. Even though ureteric orifice is in its abnormal position, reflux was not seen in more than 50% of the reported cases, especially when the diverticulum was unilateral with outlet obstruc­tion. Though different approaches have been described for bladder diverticulectomy, combined intra and extra­vesical approach was found to be more convenient. [10]


   Conclusions Top


Congenital diverticulum though rare should be consid­ered as a possibility in infants with lower urinary tract obstruction. Its association with a duplex system is even rarer and ours appears to be the first to be reported in Eng­lish literature. Surgical excision of the diverticulum with reimplantation of the ureter results in complete cure and the prognosis appears to be good.

 
   References Top

1.Sheldon CA. Essig KA. Congenital bladder diverticulum causing bladder outlet obstruction: Case report and review of literature. Pediatr Su g Int. 1994; 9: 141.  Back to cited text no. 1    
2.Pieretti RV, Pieretti RV-Vanmarcke. Congenital bladder diverticula in children. J Pediatr Surg 1999; 34(3): 468.  Back to cited text no. 2    
3.Beasley SW, Kelly JH. Inverted Y duplication of the ureter in asso­ciation with ureterocele and bladder diverticulum. J Urol 1986; 136(4): 899.  Back to cited text no. 3    
4.Gearhart JP, Jeffs RD. Exstrophy epispadias complex and bladder anomalies. In Campbell's Urology, 7 th edition. Walsh PC, Retik AB, Vaughan ED Jr and Wein A J (eds). Philadelphia, WB Saunders company, 1998:2: 1939-90.  Back to cited text no. 4    
5.Lione PM and Gonzales ET Jr. Congenital bladder diverticula causing ureteral obstruction. Urol 1985; 25(3): 273.  Back to cited text no. 5    
6.Bauer SB and Retik AB. Bladder diverticula in infants and children. Urol 1974: 3(6): 712.  Back to cited text no. 6    
7.Johnson JH. Bladder disorders. In Pediatric Urology: William DI, Johnston JH (eds.). London, Butterworth Scientific. 1982; 225-237.   Back to cited text no. 7    
8.Taylor WN, Alton D, Togu i A, Churchill BM, Schillinger JF. Bladder diverticula causing posterior urethral obstruction in children. J Urol 1979: 122(3): 415.  Back to cited text no. 8    
9.Parrott TS, Bastuba M. Giant bladder diverticulum causing ure­thral obstruction in an infant. Br J Urol 1992: 69(5): 545.  Back to cited text no. 9    
10.Verghese M, Belman AB. Urinary retention secondary to congeni­tal bladder diverticula in infants. J Urol 1984: 132(6): 1186.  Back to cited text no. 10    




 

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    Abstract
    Introduction
    Case Reports
    Comments
    Conclusions
    References

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