Radical Cystectomy for Intradiverticular Bladder Carcinoma: A Case Report

Abstract

Herniation of bladder mucosa through the bladder wall muscle layer is known as bladder diverticulum. The incidence of bladder diverticulum is 1.7. About 0.8 to 10% of the urinary bladder diverticulum develops carcinoma. Transitional cell carcinoma is the most common. Painless hematuria is the most common clinical presentation. Different imaging modalities along with cystoscopy are the key to accurate diagnosis and staging. High grade multifocal urothelial carcinoma in the bladder diverticulum is better managed by radical cystectomy and standard pelvic lymph node dissection with an ileal conduit. Here we report a case of a 66-year old gentleman of high grade multifocal urothelial carcinoma in bladder diverticulum managed with radical cystectomy and standard pelvic lymph node dissection with an ileal conduit. Such cases have been addressed adequately in the literature, but we did not find such cases from our country.

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JNMA I VOL 59 I ISSUE 242 I October 2021
CASE REPORT J Nepal Med Assoc 2021;59(242):1069-71
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BY
doi: 10.31729/jnma.6228
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BY
______________________________________
Correspondence: Dr. Anil Kumar Sah, Department of
Urology, Nepal Mediciti Hospital, Bhainsepati, Lalitpur, Nepal.
Email: anil.frens@gmail.com, Phone: +977- 9851224609.
Radical Cystectomy for Intradiverticular Bladder Carcinoma: A Case
Report
Anil Kumar Sah,1 Bipin Maharjan,1 Mahesh Bahadur Adhikari,1 Reena Rana,2 Sunila Basnet,2 Rajesh Panth,2
Gopi Aryal2
1Department of Urology, Nepal Mediciti Hospital, Bhainsepati, Lalitpur Nepal, 2Department of Pathology, Nepal
Mediciti Hospital, Bhainsepati, Lalitpur, Nepal.
ABSTRACT
Herniation of bladder mucosa through the bladder wall muscle layer is known as bladder diverticulum.
The incidence of bladder diverticulum is 1.7. About 0.8 to 10% of the urinary bladder diverticulum
develops carcinoma. Transitional cell carcinoma is the most common. Painless hematuria is the
most common clinical presentation. Different imaging modalities along with cystoscopy are the
key to accurate diagnosis and staging. High grade multifocal urothelial carcinoma in the bladder
diverticulum is better managed by radical cystectomy and standard pelvic lymph node dissection
with an ileal conduit. Here we report a case of a 66-year old gentleman of high grade multifocal
urothelial carcinoma in bladder diverticulum managed with radical cystectomy and standard pelvic
lymph node dissection with an ileal conduit. Such cases have been addressed adequately in the
literature, but we did not nd such cases from our country.
Keywords: bladder; cystectomy; diverticulum; radical; urothelial carcinoma.
INTRODUCTION
Out pouching of the bladder mucosa through the weak
part of the urinary bladder muscular layer is known as
bladder diverticulum.1,2 Its incidence is not rare at all.3
Chronic irritation and inammation secondary to urinary
stasis in the diverticulum are responsible for neoplastic
changes. Radical cystectomy is indicated for high-grade
tumours and is a safe and effective procedure in the
treatment of diverticular tumours.1 We reported a case
of a 66-year gentleman who presented with painless
hematuria and was later diagnosed with high-grade
multifocal bladder diverticulum urothelial carcinoma
which was successfully managed with radical
cystectomy and standard pelvic lymph node dissection
with an ileal conduit.
CASE REPORT
A 66-years male presented with painless occasional
gross hematuria for 6months with the poor ow of
urine, intermittency, abdominal straining and incomplete
voiding. He was a known case of hypertension and
enlarged prostate under medications. The bladder
was palpable. Prostate was enlarged, rm, non-tender
and non-nodular on digital rectal examination. His
haemoglobin level was 12.1gm/dl with a normal kidney
function test. Urine analysis showed plenty of red
blood cells, pus cells 1-2/hpf with no bacterial growth
on culture. Abdominal sonography showed a polypoidal
hypoechoic lesion measuring 2.17x1.2cm with
vascular pedicle was seen arising from the anterior non-
dependent portion of bladder diverticulum measuring
10.5x8.9cm (Figure 1).
Figure 1. Pre-operative USG showing a polypoidal
hypoechoic mass from the bladder diverticulum.

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The prostate is enlarged in size and measures
5.7x5.1x3.5cm which corresponds to approximately
56.1grams in weight. Foley catheterization failed.
On cystourethroscopy 1.5x1.5cm impacted urethral
calculus was seen in the prostatic fossa. Pushback of
the calculus in the urinary bladder failed. Therefore,
pneumatic lithotripsy was done in the same region.
There were multiple trabeculations, sacculations and a
large diverticulum in the UB wall in the right lateral wall
with multiple sessile growths and a 1.5x1.5cm size
pedunculated growth inside the diverticulum.
Multiple biopsies were taken from the growths and
random cold cup biopsy was taken from the proper
urinary bladder wall. Histopathology came as high-
grade inltrating (lamina propria) urothelial carcinoma
from the bladder diverticulum and normal ndings from
the bladder wall. CT abdomen showed 10.7mm wall
thickness of urinary bladder with a large diverticulum
measuring 9.69x4.55cm arising from the right lateral
aspect of UB. There was enhancing polypoidal lesions
of 13.2x11.4mm arising from the anterosuperior aspect
of this diverticulum (Figure 2).
Figure 2. CT Scan showing a polypoidal enhancing
mass arising from the bladder diverticulum.
Options of bladder preservative surgery and radical
cystectomy with urinary diversion were discussed with
the patients and the family. Finally, radical cystectomy
and standard pelvic lymph node dissection (PLND) with
ileal conduit were done. It was urothelial carcinoma
inltrating the lamina propria. There was no evidence of
detrusor muscle in the specimen (Figure 3). The patient
progressed well post-operatively and he is doing well
currently on follow up.
Figure 3. Histopathology showing urothelial carcinoma
inltrating the lamina propria with no evidence of
detrusor muscle in the specimen.
DISCUSSION
Urinary bladder diverticulum (BD) is an out-pouching of
the bladder mucosa through the weak bladder muscle
(detrusor muscle) either congenital or acquired, which
may be complicated with inammation, calculus,
infection, and malignancy.1 The incidence of bladder
diverticulum is approximately 1.7% in children and 6%
in adults.2
Acquired diverticulum occurs as a result of raised
intravesical pressure due to bladder outlet obstruction
through a series of changes like trabeculations and
sacculations.3 Congenital diverticulum is usually
single that occurs as a result of the disarray of the
detrusor bres within the musculature of the bladder
wall and is associated with vesicoureteric reux and
hydronephrosis. BD usually occurs in close proximity to
the ureteric orices.4
Chronic irritation and inammation, secondary to urinary
stasis due to lack of contractility of the diverticulum are
responsible for dysplasia, leukoplakia, and squamous
metaplasia. These changes are seen in almost 80% of
BD.5
The incidence of BD tumour is 0.8 to 10%, usually
occurs in the aged patients with bladder outlet
obstruction, rarely on congenital diverticula. Transitional
Cell Carcinoma (TCC) is the most common histological
variety constituting 70-80%, followed by Squamous
Cell Carcinoma (SCC) which is about 20-25% of all BD
tumours. TCC along with SCC is reported in 2% of all
tumours while adenocarcinoma constitutes the other
2% of these BD tumours.6 Painless hematuria, which
accounts for about 90% is the most common clinical
presentation of BD tumours, as in ordinary bladder
tumours.7
Ultrasonography is particularly helpful in patients with
contraindicated cystoscopy or unsuccessful radiographic
contrast examinations due to small diverticulum ostium
or occlusive tumours. However, diverticula located
along with the dome or in the neck of the bladder may
be more difcult to identify sonographically. BD tumours
are moderately echogenic, non-shadowing mass along
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JNMA I VOL 59 I ISSUE 242 I October 2021
the wall of the diverticulum on the sonogram.
Diagnosis and staging rely on CT imaging. However,
its role is limited by its inability to resolve the different
layers of the bladder wall. MRI provides a better gross
assessment of tumour depth especially when done with
Gadolinium.8
Since the wall of the BD is thin, there is a high probability
of penetration of the wall by diverticular tumours.9
Staging of the BD tumour is difcult because of the
lack of muscle layer in the diverticulum. Indeed, some
authors suggest skipping the T2 stage altogether when
staging diverticular tumours whereas some authors
suggest T1 as muscle-invasive.
Transurethral resection of the tumour is indicated in low
grade, low volume Ta, Tis or T1 tumours with wide
diverticular necks. It is technically challenging. It is
difcult to access the diverticulum owing to a narrow
neck or an acute angle of entry. There is a potential risk
of bladder perforation & tumour dissemination.9
Diverticulectomy or Partial Cystectomy is indicated
in low grade, large volume tumours with narrow
diverticular necks and high-grade unifocal tumours.
Partial cystectomy with PLND, followed by adjuvant
intravesical immunotherapy or systemic chemotherapy,
is advisable in patients with high-grade T1 tumours.9
Radical Cystectomy is indicated for locally advanced
tumours, high-grade tumours, multifocal exophytic
tumours, extensive CIS and multifocal disease with
poor bladder function. It is a safe & effective procedure
in the treatment of diverticular tumours.
Series of studies suggest that there is a high rate
of recurrence and poor prognosis for diverticular
tumours. But the newer study suggests complete
tumour resection with partial cystectomy results in
5-year disease-specic survival rates of around 70%.1
Complete removal is feasible for the tumours conned
to the bladder diverticulum and close surveillance
ensues.1
The ways of presentation and the modalities of the
diagnosis of bladder diverticular tumours are similar to
those of regular bladder tumours. Radical cystectomy
with standard pelvic lymph node dissection is effectively
justied for the management of high grade multifocal
urothelial carcinoma of the bladder diverticulum.
Consent: JNMA Case Report Consent Form was signed
by the patient and the original article is attached with
the patient’s chart.
Conict of Interest: None.
Sah et al. Radical Cystectomy for Intradiverticular Bladder Carcinoma: A Case Report
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