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Transurethral treatment of bladder diverticula alternative to open diverticulectomy
TRANSURETHRAL
TREATMENT
OF
BLADDER
DIVERTICULA
Alternative
to Open Diverticulectomy
RALPH
V CLAYMAN,
SALEM
SHAHIN,
PRATAP REDDY, ELWIN
M.D.
M.D. M.D.
E. FRALEY,
From the Department of Minnesota Medical
M.D. of Urologic Surgery, School, Minneapolis,
Universit) Minnesota
ABSTRACT-Since October, 1980, we have used transurethralfulguration of the diverticular mucosa and incision of the diverticular neck in combination with electrohydraulic lithotripsy of bladder stones and transurethral prostatic resection to treat all aspects of diverticula in 11 patients. In comparing the results u;ith those of open diverticulectom y. we found the transurethral procedure to be equally effective while being safer, faster, and less expensive.
The treatment of bladder diverticula traditionally has required open operation. However, Orandi’ has described his favorable experience with transurethral fulguration of diverticular mucosa, and Vitale and Woodside have reported successful transurethral incision of the diverticular neck. We have used these transurethral techniques in combination with electrohydraulic lithotripsy of bladder stones and transurethral prostatic resection to manage all aspects of bladder diverticula in 11 patients. Material
and Methods
Pa tien ts Between October, 1980, and March, 1982, 11 patients underwent transurethral treatment for bladder diverticula at our hospitals. Of the 6 patients who required treatment for diverticula alone. 4 presented with s!rmptoms of bladder outlet obstruction and 1 had a history of recurrent urinary tract infection. The diameter of
UROL&:Y
/ JUNE 1984 ! VOLUME
XXIII,NUMBER6
1. Transurethral I;ersus open diverticulectomy
TABLE
Clinical Data No. of patients Age (yr)* Operating room time (hr) * Estimated blood loss (ml)* Hospitalization (days) * Residual urine (ml) * Preoperativel! Postoperativel! Complications
Follow-up cystogram
Diverticulectom! Open Transurethral 6: 1.25 <50
14 63 2.6 425
8
19.6
62 8 None
300 7Fi Confusion (1); bilat. reflux (1); transient fever (3) No diverticula (8)
No diverticula (5); 75% decrease in volume (1)
Small diverticula (2)
*Average.
573
1. Method o_f transurethral fulguration. (a) Note spiral motion of electrode and beginning at resectoscope. furthest point and moving toward bladder: (b) muscular neck of dicerticulum being incised with roller electrode and cutting current. (c) Area just beneath the diverticular neck has been exposed by incision of neck and can now bc fulgurated. FI(:UHK
the diverticulum ranged from 2 to 7 cm (Table I). Of the 5 patients who also underwent transurethral prostatic resection, all presented with obstructive symptoms. The diameter of the
Transurethral diverticulectomy TABLE II. and prostatectomy versus open diverticulectomy and suprapubic prostatectomy Clinical Data
Transurethral
5 66 Age (yr)* Operating room time (hr)* 1.9 Estimated blood loss (ml)* 460 Tissue 41 resected (Gm) * Hospitalization (days) * 9 Residual urine (ml) * Preoperatively 1857 Postoperatively 32 Complications Transient unilateral reflux No. of patients
Follow-up cystogram
Open 13 68 2.5
diverticulum ranged from 9.0 to 14.9 cm (Table II). To compare the open and closed approaches to bladder diverticula, we reviewed the medical charts of all patients who had undergone open diverticulectomy at our hospitals between 1970 and 1980. Of the 14 who underwent diverticulectomy alone, 7 had symptoms of bladder outlet obstruction and 7 had a history of recurrent urinary tract infection (Table I). Of the patients who underwent suprapubic prostatectomy also, 12 presented with obstructive symptoms and 4 had a history of recurrent urinary tract infection (Table II).
1,650 36 15
400 20 Fatal pulmonary (1) embolus (1); fever (2) No diverticula (2) No diverticula (8) 75-90 % decrease in volume (2); 98 % decrease in volume (1)
Transurethral fulguration of diverticular mucosa and incision of diverticular neck The continuous-flow resectoscope is best suited to these procedures, because with this instrument the position of the diverticular mucosa relative to the surgeon does not change. A small roller electrode (ACMI) is used. The resectoscope is placed inside the diverticulum, and the mucosa is examined for carcinomatous lesions. With the coagulation current set at 4.5, fulguration begins at the apex of the diverticulum and moves in a spiral (Fig. 1A). *
*Average. tMeasured in 3 patients.
574
UROLOGY
/ JUNE 1984 / VOLUME XXIII, NUMBER 6
Frcrx~ 2. (A) Plain radiograph of pelvis shows calcific densities (diverticular calculi} on patient’s right. (B) Stones that were fragmented with 9-F lithotriptor probe superimposed on cystogram of large retrovesical diverticulum from which they came. (C) Cystogram immediately after procedure shows 90 per cent decrease in diverticular volume and marked widening of diverticular neck without extravasation.
Short bursts of coagulating current are used to preclude damage to surrounding structures and to minimize obturator nerve spasm. The mucosal lining visibly whitens and shrinks. If the diverticular neck is too tight to admit the cystoscope, the roller electrode is extended across the neck and the cutting current is set at 4, after which the roller is drawn back across the tissues of the mouth of the diverticulum. After all portions of the diverticulum have been fulgurated, a prostatectomy may be performed. We prefer to fulgurate the diverticulum first, because it is then easier to evacuate the prostatic chips and because the visibility is better. The roller electrode is then used to incise all four quadrants (Fig. 1B) unless the ureteral orifice is part of one of the quadrants; then we incise only the three quadrants distal to the ureteral orifice. These cuts are carried into the deeper vesical muscle fibers to ablate an)’ sphincteric action present in the diverticular neck. The roller electrode is then used to fulgurate any previously inaccessible portions of the diverticulum to reduce the diverticulum as much as possible and to ensure the emptying of any remnant (Fig. 1C).
A three-way Foley Alcock catheter is introduced. The container of irrigating fluid is hung no higher than 20 cm above the bedside to avoid undue pressure on the obliterated diverticulum. After three to five days, a voiding cystourethrogram is obtained; if the appearance is acceptable, the catheter is removed. Electrohydraulic
lithotrip@
transurethral fulguration of In 2 patients, diverticula and destruction of calculi were performed in a single session. For this part of the procedure, 116 normal saline is used as the irrigating fluid. The stones are pulled from the diverticulum into the bladder (it may be necessary to incise the neck of the diverticulum first). An adaptor is placed on the resectoscope to allow passage of the 9-F probe of the SD-l electrohydraulic lithotriptor. * The tip of the probe is positioned 1 mm from the stone and 25 mm
FIGURE 3. (A) Cystogram of patient with 14.9-cm diverticulum; bladder is on patient’s left. (B) Cystogram immediately after procedure shows 75 per cent reduction in diverticular volume and &de connection with bladder. (C) Custogram six months later: diverticulum has continued to decrease in size and nou; is < 5 per cent of its driginal”volume; residual urine is 20 ml.
from the resectoscope lens and discharged at a pulse frequency of 50 to 100 cycles per second. Results Treatment resection
of dizjerticula
without
prostatic
cellent results (Table I). Combination prostatectomy
with
no significant
of treatment
morbidity
for diverticula
with
The average operating time was 1.25 hours (Table I). In 3 patients, incision of the bladder neck was necessary to treat outlet obstruction; and in 1 patient, several calculi were destroyed by electrohydraulic lithotripsy. Cystograms made immediately after the procedure revealed no extravasation and showed a 90 to 100 per cent reduction in diverticular size in 4 cases and a 75 per cent reduction in the other 2 (Fig. 2). Follow-up cystography two to nineteen months after the procedure showed no recurrences. Of the 2 patients whose diverticula were not entirely obliterated, the lesion had disappeared in 1 by four months postprocedure. The other patient has not returned for follow-up. Intravenous urography in 4 patients revealed no damage to the ipsilateral ureter, and no patient has complained of flank discomfort. One patient later required transurethral prostatic resection. In comparison with open diverticulectomy, the transurethral procedure required half as much operating time and reduced the length of the hospital stay 60 per cent while providing ex-
The average operating time was 1.9 hours. In the 3 patients with the largest diverticula (9.014.9 cm), there was a 75 per cent reduction in the size of the lesion. Cystograms made immediately after the procedure showed no extravasation, with virtually complete obliteration of the diverticula in the 2 patients with small diverticula. Follow-up cystograms one to nine months after the procedure showed no recurrences. The diverticular remnant showed no change in 1 patient. In another, the size of the diverticulum (original diameter 14.9 cm) had decreased 75 per cent at one week and 98 per cent at three months (Fig. 3). This patient’s residual urine volume was 20 ml. The other patient with a postoperative remnant has not returned for follow-up. In comparision with open diverticulectomy and prostatectomy, the transurethral procedure shortened the operating time approximately one half hour, reduced the length of hospitalization 33 per cent, and decreased the average blood loss 66 per cent while providing similar results (Table II).
576
UROLOGY
/ JUNE 1984
/
VOLUME
XXIII,
NUMBER
6
Comment Most bladder diverticula are associated with bladder outlet obstruction. Diverticula occur in 1.4 to 13 per cent of patients with outlet obstruction, most commonly those with prostatic hyperplasia (60% of cases of diverticula) or bladder neck contracture (35% of cases).4 In our series, one half of the patients undergoing open diverticulectomy alone either had a history of transurethral prostatic resection or required this procedure in the immediate perioperative period, and among our 11 patients who underwent transurethral diverticular ablation, 9 required either prostatic resection or incision of the bladder neck. The indications for treating bladder diverticula are several. For example, large diverticula that fail to empty are liable to many complications. Urinary. tract infection is the most common and may lead to peridiverticulitis. More serious complications include stones (16% of patients) and either squamous cell or transitional cell carcinoma (3-7 % ) .5 7 Spontaneous rupture of bladder diverticula has been reported in 6 patients, in 4 of whom it led to fatal peritonitis.” Since the first open diverticulectomy was performed in 1897, various open approaches have been advocated, all of which have significant morbidity* and mortality rates (15-26% and 2. S-4 % . respectively). The complications include cerebral vascular accidents, deep vein thrombosis, hemorrhage, and pelvic abscesses.“g When open prostatectomy is added to the procedure, the blood loss, morbidity, and mortality all increase. Orandi’ introduced his method of transurethral fulguration of bladder diverticular mucosa in 1977. Follovv-up of the 19 patients at three to forty-nine months showed complete obliteration of the lesion in 55 per cent and a significant decrease in size in another 40 per cent. The procedure vvas ineffective in only 1 patient, and there were no untoward effects in any’ patient. There havre been no recurrences.“’
UROI,OG\r
JIJNE
1984
VOLUME
XXIII,
NUMBER
6
Our technique combines Hartung and Flocks’4 transurethral incision of the diverticular neck with Orandi’s’ technique of transurethral fulguration of diverticular mucosa. It was successful in 11 patients with diverticula as large as 14.9 cm. Follovv-up cystograms have shown no recurrences, and no further surgical treatment has been required. The only. contraindication to this technique is the presence of a carcinomatous lesion in the diverticulum or the rare instance in which the ureteral orifice or tunnel is part of the diverticular vvall.” In sum, transurethral fulguration and incision of vesical diverticula, in conjunction with electrohydraulic lithotripsy, of stones and transurethral resection of the prostate as required, is a safe, expeditious, and cost-effective method for treating these lesions. In comparison with open diverticulectomy, the procedure markedlyreduces the operating time, intraoperative blood loss, length of hospitalization, and morbidity. Box 394, University Hospitals Minneapolis, Minnesota 55455 (DR. CLAYMAN)
References 1. Orandi A: Transurethral fulguration of bladder diverticw lum: new procedure. Urology 10: 30 (1977). 2. Vitale PJ, and Whiteside JR: Managemment of bladder diverticula by transurethral resection: re-evaluation of an old technique, J Urol 122: 744 (1979). 3. Rainey .4M: Electrohydraulic c)-stolithotripsp Urology 7: 379 (1976). 4. Hartung W, and Flocks RH: Diverticulum of the bladder: a method of roentgen examination and roentgen and clinical findings in 200 cases, Radiology 41: 363 (1943). 5. Fox M, Power RF, and Bruce AW: Diverticulum of the bladder: presentation and evaluation of treatment in 115 cases. Br J Ural 34: 286 (1962). 6. M&lean P and Kelalis P: Bladder diverticulum in the male, ihid 40: 321 (1968). 7. Redman JF, McGinnis TB, and Bissada NK: Management of neoplasms in vesical diverticula, Urology 7: 492 (1976). 8. Mitchell RJ, and Hamilton SGI: Spontaneous perforation of diverticula. Br J Surg 58: 712 (1971). 9. Wesselhoeft CW Jr, et al: Pathogenesis and surgical treatment of diverticulum of the urinar! bladder. Surg Gvnecol Obstrt 116: 719 (1963). 10. Orandi A: Personal communication. 1979.
577
TREATMENT
OF
BLADDER
DIVERTICULA
Alternative
to Open Diverticulectomy
RALPH
V CLAYMAN,
SALEM
SHAHIN,
PRATAP REDDY, ELWIN
M.D.
M.D. M.D.
E. FRALEY,
From the Department of Minnesota Medical
M.D. of Urologic Surgery, School, Minneapolis,
Universit) Minnesota
ABSTRACT-Since October, 1980, we have used transurethralfulguration of the diverticular mucosa and incision of the diverticular neck in combination with electrohydraulic lithotripsy of bladder stones and transurethral prostatic resection to treat all aspects of diverticula in 11 patients. In comparing the results u;ith those of open diverticulectom y. we found the transurethral procedure to be equally effective while being safer, faster, and less expensive.
The treatment of bladder diverticula traditionally has required open operation. However, Orandi’ has described his favorable experience with transurethral fulguration of diverticular mucosa, and Vitale and Woodside have reported successful transurethral incision of the diverticular neck. We have used these transurethral techniques in combination with electrohydraulic lithotripsy of bladder stones and transurethral prostatic resection to manage all aspects of bladder diverticula in 11 patients. Material
and Methods
Pa tien ts Between October, 1980, and March, 1982, 11 patients underwent transurethral treatment for bladder diverticula at our hospitals. Of the 6 patients who required treatment for diverticula alone. 4 presented with s!rmptoms of bladder outlet obstruction and 1 had a history of recurrent urinary tract infection. The diameter of
UROL&:Y
/ JUNE 1984 ! VOLUME
XXIII,NUMBER6
1. Transurethral I;ersus open diverticulectomy
TABLE
Clinical Data No. of patients Age (yr)* Operating room time (hr) * Estimated blood loss (ml)* Hospitalization (days) * Residual urine (ml) * Preoperativel! Postoperativel! Complications
Follow-up cystogram
Diverticulectom! Open Transurethral 6: 1.25 <50
14 63 2.6 425
8
19.6
62 8 None
300 7Fi Confusion (1); bilat. reflux (1); transient fever (3) No diverticula (8)
No diverticula (5); 75% decrease in volume (1)
Small diverticula (2)
*Average.
573
1. Method o_f transurethral fulguration. (a) Note spiral motion of electrode and beginning at resectoscope. furthest point and moving toward bladder: (b) muscular neck of dicerticulum being incised with roller electrode and cutting current. (c) Area just beneath the diverticular neck has been exposed by incision of neck and can now bc fulgurated. FI(:UHK
the diverticulum ranged from 2 to 7 cm (Table I). Of the 5 patients who also underwent transurethral prostatic resection, all presented with obstructive symptoms. The diameter of the
Transurethral diverticulectomy TABLE II. and prostatectomy versus open diverticulectomy and suprapubic prostatectomy Clinical Data
Transurethral
5 66 Age (yr)* Operating room time (hr)* 1.9 Estimated blood loss (ml)* 460 Tissue 41 resected (Gm) * Hospitalization (days) * 9 Residual urine (ml) * Preoperatively 1857 Postoperatively 32 Complications Transient unilateral reflux No. of patients
Follow-up cystogram
Open 13 68 2.5
diverticulum ranged from 9.0 to 14.9 cm (Table II). To compare the open and closed approaches to bladder diverticula, we reviewed the medical charts of all patients who had undergone open diverticulectomy at our hospitals between 1970 and 1980. Of the 14 who underwent diverticulectomy alone, 7 had symptoms of bladder outlet obstruction and 7 had a history of recurrent urinary tract infection (Table I). Of the patients who underwent suprapubic prostatectomy also, 12 presented with obstructive symptoms and 4 had a history of recurrent urinary tract infection (Table II).
1,650 36 15
400 20 Fatal pulmonary (1) embolus (1); fever (2) No diverticula (2) No diverticula (8) 75-90 % decrease in volume (2); 98 % decrease in volume (1)
Transurethral fulguration of diverticular mucosa and incision of diverticular neck The continuous-flow resectoscope is best suited to these procedures, because with this instrument the position of the diverticular mucosa relative to the surgeon does not change. A small roller electrode (ACMI) is used. The resectoscope is placed inside the diverticulum, and the mucosa is examined for carcinomatous lesions. With the coagulation current set at 4.5, fulguration begins at the apex of the diverticulum and moves in a spiral (Fig. 1A). *
*Average. tMeasured in 3 patients.
574
UROLOGY
/ JUNE 1984 / VOLUME XXIII, NUMBER 6
Frcrx~ 2. (A) Plain radiograph of pelvis shows calcific densities (diverticular calculi} on patient’s right. (B) Stones that were fragmented with 9-F lithotriptor probe superimposed on cystogram of large retrovesical diverticulum from which they came. (C) Cystogram immediately after procedure shows 90 per cent decrease in diverticular volume and marked widening of diverticular neck without extravasation.
Short bursts of coagulating current are used to preclude damage to surrounding structures and to minimize obturator nerve spasm. The mucosal lining visibly whitens and shrinks. If the diverticular neck is too tight to admit the cystoscope, the roller electrode is extended across the neck and the cutting current is set at 4, after which the roller is drawn back across the tissues of the mouth of the diverticulum. After all portions of the diverticulum have been fulgurated, a prostatectomy may be performed. We prefer to fulgurate the diverticulum first, because it is then easier to evacuate the prostatic chips and because the visibility is better. The roller electrode is then used to incise all four quadrants (Fig. 1B) unless the ureteral orifice is part of one of the quadrants; then we incise only the three quadrants distal to the ureteral orifice. These cuts are carried into the deeper vesical muscle fibers to ablate an)’ sphincteric action present in the diverticular neck. The roller electrode is then used to fulgurate any previously inaccessible portions of the diverticulum to reduce the diverticulum as much as possible and to ensure the emptying of any remnant (Fig. 1C).
A three-way Foley Alcock catheter is introduced. The container of irrigating fluid is hung no higher than 20 cm above the bedside to avoid undue pressure on the obliterated diverticulum. After three to five days, a voiding cystourethrogram is obtained; if the appearance is acceptable, the catheter is removed. Electrohydraulic
lithotrip@
transurethral fulguration of In 2 patients, diverticula and destruction of calculi were performed in a single session. For this part of the procedure, 116 normal saline is used as the irrigating fluid. The stones are pulled from the diverticulum into the bladder (it may be necessary to incise the neck of the diverticulum first). An adaptor is placed on the resectoscope to allow passage of the 9-F probe of the SD-l electrohydraulic lithotriptor. * The tip of the probe is positioned 1 mm from the stone and 25 mm
FIGURE 3. (A) Cystogram of patient with 14.9-cm diverticulum; bladder is on patient’s left. (B) Cystogram immediately after procedure shows 75 per cent reduction in diverticular volume and &de connection with bladder. (C) Custogram six months later: diverticulum has continued to decrease in size and nou; is < 5 per cent of its driginal”volume; residual urine is 20 ml.
from the resectoscope lens and discharged at a pulse frequency of 50 to 100 cycles per second. Results Treatment resection
of dizjerticula
without
prostatic
cellent results (Table I). Combination prostatectomy
with
no significant
of treatment
morbidity
for diverticula
with
The average operating time was 1.25 hours (Table I). In 3 patients, incision of the bladder neck was necessary to treat outlet obstruction; and in 1 patient, several calculi were destroyed by electrohydraulic lithotripsy. Cystograms made immediately after the procedure revealed no extravasation and showed a 90 to 100 per cent reduction in diverticular size in 4 cases and a 75 per cent reduction in the other 2 (Fig. 2). Follow-up cystography two to nineteen months after the procedure showed no recurrences. Of the 2 patients whose diverticula were not entirely obliterated, the lesion had disappeared in 1 by four months postprocedure. The other patient has not returned for follow-up. Intravenous urography in 4 patients revealed no damage to the ipsilateral ureter, and no patient has complained of flank discomfort. One patient later required transurethral prostatic resection. In comparison with open diverticulectomy, the transurethral procedure required half as much operating time and reduced the length of the hospital stay 60 per cent while providing ex-
The average operating time was 1.9 hours. In the 3 patients with the largest diverticula (9.014.9 cm), there was a 75 per cent reduction in the size of the lesion. Cystograms made immediately after the procedure showed no extravasation, with virtually complete obliteration of the diverticula in the 2 patients with small diverticula. Follow-up cystograms one to nine months after the procedure showed no recurrences. The diverticular remnant showed no change in 1 patient. In another, the size of the diverticulum (original diameter 14.9 cm) had decreased 75 per cent at one week and 98 per cent at three months (Fig. 3). This patient’s residual urine volume was 20 ml. The other patient with a postoperative remnant has not returned for follow-up. In comparision with open diverticulectomy and prostatectomy, the transurethral procedure shortened the operating time approximately one half hour, reduced the length of hospitalization 33 per cent, and decreased the average blood loss 66 per cent while providing similar results (Table II).
576
UROLOGY
/ JUNE 1984
/
VOLUME
XXIII,
NUMBER
6
Comment Most bladder diverticula are associated with bladder outlet obstruction. Diverticula occur in 1.4 to 13 per cent of patients with outlet obstruction, most commonly those with prostatic hyperplasia (60% of cases of diverticula) or bladder neck contracture (35% of cases).4 In our series, one half of the patients undergoing open diverticulectomy alone either had a history of transurethral prostatic resection or required this procedure in the immediate perioperative period, and among our 11 patients who underwent transurethral diverticular ablation, 9 required either prostatic resection or incision of the bladder neck. The indications for treating bladder diverticula are several. For example, large diverticula that fail to empty are liable to many complications. Urinary. tract infection is the most common and may lead to peridiverticulitis. More serious complications include stones (16% of patients) and either squamous cell or transitional cell carcinoma (3-7 % ) .5 7 Spontaneous rupture of bladder diverticula has been reported in 6 patients, in 4 of whom it led to fatal peritonitis.” Since the first open diverticulectomy was performed in 1897, various open approaches have been advocated, all of which have significant morbidity* and mortality rates (15-26% and 2. S-4 % . respectively). The complications include cerebral vascular accidents, deep vein thrombosis, hemorrhage, and pelvic abscesses.“g When open prostatectomy is added to the procedure, the blood loss, morbidity, and mortality all increase. Orandi’ introduced his method of transurethral fulguration of bladder diverticular mucosa in 1977. Follovv-up of the 19 patients at three to forty-nine months showed complete obliteration of the lesion in 55 per cent and a significant decrease in size in another 40 per cent. The procedure vvas ineffective in only 1 patient, and there were no untoward effects in any’ patient. There havre been no recurrences.“’
UROI,OG\r
JIJNE
1984
VOLUME
XXIII,
NUMBER
6
Our technique combines Hartung and Flocks’4 transurethral incision of the diverticular neck with Orandi’s’ technique of transurethral fulguration of diverticular mucosa. It was successful in 11 patients with diverticula as large as 14.9 cm. Follovv-up cystograms have shown no recurrences, and no further surgical treatment has been required. The only. contraindication to this technique is the presence of a carcinomatous lesion in the diverticulum or the rare instance in which the ureteral orifice or tunnel is part of the diverticular vvall.” In sum, transurethral fulguration and incision of vesical diverticula, in conjunction with electrohydraulic lithotripsy, of stones and transurethral resection of the prostate as required, is a safe, expeditious, and cost-effective method for treating these lesions. In comparison with open diverticulectomy, the procedure markedlyreduces the operating time, intraoperative blood loss, length of hospitalization, and morbidity. Box 394, University Hospitals Minneapolis, Minnesota 55455 (DR. CLAYMAN)
References 1. Orandi A: Transurethral fulguration of bladder diverticw lum: new procedure. Urology 10: 30 (1977). 2. Vitale PJ, and Whiteside JR: Managemment of bladder diverticula by transurethral resection: re-evaluation of an old technique, J Urol 122: 744 (1979). 3. Rainey .4M: Electrohydraulic c)-stolithotripsp Urology 7: 379 (1976). 4. Hartung W, and Flocks RH: Diverticulum of the bladder: a method of roentgen examination and roentgen and clinical findings in 200 cases, Radiology 41: 363 (1943). 5. Fox M, Power RF, and Bruce AW: Diverticulum of the bladder: presentation and evaluation of treatment in 115 cases. Br J Ural 34: 286 (1962). 6. M&lean P and Kelalis P: Bladder diverticulum in the male, ihid 40: 321 (1968). 7. Redman JF, McGinnis TB, and Bissada NK: Management of neoplasms in vesical diverticula, Urology 7: 492 (1976). 8. Mitchell RJ, and Hamilton SGI: Spontaneous perforation of diverticula. Br J Surg 58: 712 (1971). 9. Wesselhoeft CW Jr, et al: Pathogenesis and surgical treatment of diverticulum of the urinar! bladder. Surg Gvnecol Obstrt 116: 719 (1963). 10. Orandi A: Personal communication. 1979.
577