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Vesical diverticula: Etiology, diagnosis, tumorigenesis, and treatment
VESICAL DIVERTICULA: TUMORIGENESIS,
ETIOLOGY,
DIAGNOSIS,
AND TREATMENT
Analysis of 74 Cases MICHAEL
D. MELEKOS,
HANS W ASBACH, GEORGE
M.D.
M.D.
A. BARBALIAS,
M.D.
From the Department of Urology, Patras University, School of Medicine, Patras, Greece
ABSTRACT-A thirteen-year review of bladder diverticula was undertaken and 74 cases were identified. In 8 patients primary neoplasms arose in the diverticula, and their treatment included diverticulectomy or partial cystectomy with or without postoperative irradiation, irradiation only, and transurethral resection of the tumor combined with fulguration of the diverticular wall and postoperative bladder instillations with doxorubicin or thiotepa solutions. Early diagnosis with additional visualization of the interior of vesical diverticulum is mandatory, since carcinoma arising in it has a poor prognosis.
Bladder diverticula frequently are small, asymptomatic, and require no treatment. Others, however, may cause significant morbidity, such as infection, stone formation, and possible diverticular wall metaplasia which may lead to carcinoma within themelm The incidence of neoplasms in a vesical diverticulum varies from 0.8 to 10 per cent. 1-s Although the accepted treatment includes open surgical procedures such as diverticulectomy and partial or total cystectomy, we resected the tumors transurethrally and fulgurated the diverticular wall in 3 cases, using bladder instillations with doxorubicin or thiotepa postoperatively. Herein we review our experience with vesical diverticula in general, and report on 8 patients with neoplasms arising in them and their proposed treatment. Material and Methods We analyzed, retrospectively, a series of 74 patients with vesical diverticula seen between 1973-1985. Of these patients, 13 men had vesi-
UROLOGY
/ NOVEMBER
1987
i
VOLUME
cal neoplasms, both in the diverticula (8 cases) and elsewhere in the bladder (5 cases). In 12 patients the coexisting tumors were of the same histologic type. In 1 patient bladder tumors were identified in a vesical diverticulum (of squamous cell type) and in an intravesical location (of transitional cell type). Results The average age of the 74 patients (including 1 female) with bladder diverticula was sixtynine years, of the 13 patients with concomitant vesical tumors seventy-two, and of those 8 with neoplasms arising in the diverticula seventyfour years. Hematuria was the cardinal symptom in the 13 patients with vesical tumors. In particular, hematuria was present in 87.5 per cent of the patients with neoplasms occurring in the diverticula and in 100 per cent of those having tumors elsewhere in the bladder. Urinary tract infection (UTI) with pyuria was present in 53 patients with vesical diverticula (71.6%). In
XXX, KUMBER S
453
FIGURE 1. (A) Cystographic portion of intravenous pyelogram showing paraureteral diverticulum at left side of bladder. Large arrows show course of left lower ureter; small arrows show site of tumor. (B) Plain film demonstrates many small stones in right side of bladder (like mud), and larger stone on left side (arrow). (C) Same patient as (B). Cystographic portion of intravenous pyelogram showing large diverticulum at left with filling deject (arrow), which was in fact tumor within diverticulum. Note displacement of ipsilateral lower ureter.
particular, UT1 and pyuria were present in 75 per cent of the patients having neoplasms arising in the diverticula, in 60 per cent of those having tumors elsewhere in the bladder, and in 60.6 per cent of those having diverticula only. The diagnosis of the vesical diverticula was usually made at cystoscopy, during radiologic examination of the urinary tract, or at both. Of the 74 cases, 54 had either an intravenous pyelogram or cystogram, 49 demonstrating a diverticulum. Filling defect (tumors) in a vesical diverticulum was detected in 5 of the 8 cases (Fig. lA, C). In the other 3 patients, tumors were detected at cystoscopy. However, the presence of intradiverticular neoplasms was established only at cystoscopy. Of the 74 patients with vesical diverticula, 7 had stones of different sizes in them (9.4%). It was noteworthy that a patient with a stone in a large diverticulum suffered also from invasive grade IV squamous cell carcinoma in the diverticulum (Fig. lB, C) and a concomitant neoplasm of lower grade (grade II) elsewhere in the bladder. The origin of the diverticula is shown in Table I. Histopathologic examinations of the tumors occurring in the vesical diverticula revealed invasion of the whole diverticular wall in 4 cases and superficial invasion of the wall in
454
the other 4. The tumor in one of those 4 cases with complete wall invasion was a grade IV squamous cell carcinoma and was proved to infiltrate the perivesical tissues. In that same case, as it has been already mentioned, the concomitant tumor elsewhere in the bladder was a grade II transitional cell carcinoma. The neoplasm in the 3 remaining cases with complete invasion of the diverticular wall was a grade III transitional cell carcinoma. In the other 4 cases with superficial wall invasion, the tumors were papillary in appearance and of transitional cell type; two were of grade I and two of grade II. Of the patients with vesical diverticula, 60 underwent either open surgery (diverticulectomy or partial cystectomy) or transurethral TABLE I.
Origin of vesical diverticula PatientsNo. Per Cent
Benign prostatic hyperplasia (BPH) Vesical neck contracture (BNC) Urethral stricture Urethral stricture combined with either BPH or BNC Neurogenic None (no obvious cause) TOTALS
60 6 2
81.1 8.1 2.7
1 1 74
1.35 1.35 100
UROLOGY / NOVEMBER1987 / VOLUMEXXX, NUMBER5
TABLE II. Pts.
Grade
1
I I
Primary and recurrent diverticular tumors, treatment, and survival of patients
Primary Neoplasm Treatment
Grade
4 5 6
II II III III
TUR + thiotepa instillations TUR + doxorubicin and thiotepa instillations Diverticulectomy Partial cystectomy Diverticulectomy TUR + doxorubicin instillations
7
III
Diverticulectomy
. .
8
IV
Irradiation
. .
2 3
resection (TUR) of diverticular neck. In the majority of the cases, the procedures were accompanied with correction of the coexisting subvesical obstruction. TUR was the treatment of choice for those patients who had tumors not in the diverticula but elsewhere in the bladder. In patients who had been selected to undergo TUR of the diverticulum, the size of the latter was smaller than 2.5 cm. It must be noted that in many of the aforementioned cases, besides the TUR of the diverticular neck, a fulguration of the diverticular wall also has been undertaken, according to Orandi’s technique.e Regarding the 8 patients with neoplasms within the diverticula, 3 underwent diverticulectomies. Of these, 1 patient had a grade II and 2 patients a grade III transitional cell carcinoma. In this group of patients who had been treated with diverticulectomies, recurrent tumors of higher grade developed in 2 and were managed with TUR plus irradiation with 6,500 rad; however, they died of their disease within two and three years, respectively. The third patient of that group died of metastatic disease (liver metastases) before local bladder recurrences could be detected (Table II). The patient with infiltrative diverticular squamous cell carcinoma, underwent a TUR of the concomitant grade II transitional cell neoplasm, followed by irradiation of the bladder with 7,000 rad. He is still alive, since his disease was recently detected, but the prognosis is considered poor (follow-up only 4 months). A patient with a grade II transitional cell carcinoma was managed with partial cystectomy. There was no recurrent tumor development in the next three years. Three patients were treated with TUR of the neoplasms occurring within the diverticula,
Recurrent Neoplasm Treatment
Outcome
. . . .
No recurrence No recurrence
Alive Alive
III
TUR + irradiation No recurrence TUR + irradiation TUR + doxorubicin instillation + irradiation Me&static disease (liver metastases) . .
Dead Alive Dead Dead
iv III
Dead Alive, but poor prognosis
while at the same time the diverticular wall was fulgurated. In one of them, who had a grade I tumor not penetrating the lamina propria, the TUR was followed forty-eight hours postoperatively by intravesical instillation of 60 mg thiotepa, which was repeated once weekly for six weeks and then once every month for three months. Since no recurrent tumor was evident, a TUR of the prostatic adenoma together with TUR of the diverticular neck was then undertaken. There was also no recurrent tumor in the next two years. In the second patient, who also had a grade I nonpenetrating the lamina propria transitional cell tumor and severe irritative and obstructive urinary symptoms secondary to benign prostatic hypertrophy, a preliminary TUR of prostatic adenoma was performed with synchronous resection of the diverticular neck. Seven weeks later a TUR of the diverticular neoplasm was undertaken, while the mucosa of the diverticulum was fulgurated. Here again, forty-eight hours postoperatively, a single dose of 60 mg thiotepa was instilled. Two weeks later doxorubicin instillations of 50 mg each, once every two weeks were started. After the fourth dose, however, doxorubicin was discontinued since chemical cystitis developed. As soon as irritation had subsided and even though there was no evidence of recurrent tumor cystoscopically, thiotepa bladder instillations of 60 mg weekly were started and continued (once weekly) for the next five weeks. There was also no tumor recurrence in eighteen months. In the third and last patient, whose tumor proved to be a grade III invasive carcinoma, TUR of the neoplasm and fulguration of the diverticular wall were undertaken. Again a single dose of 60 mg thiotepa, forty-eight hours
UROLOGY / NOVEMBER1987 / VOLUMEXXX, NUMBER5
455
postoperatively, was instilled and followed thereafter with 60 mg doxorubicin instillations, once every month for the next six months. However, tumor recurrence was seen in three different intravesical sites. The patient was treated with TUR combined with doxorubicin instillations and irradiation of the bladder, but he died of his disease within two years (Table II). Comment Vesical diverticula may be congenital or acquired, but by far the latter are the most common. Acquired diverticula are secondary to lower urinary tract obstruction and can be seen in both adults and children. In the adult population, bladder diverticula are seen more commonly in men.‘O In our series 81 per cent of the patients had benign prostatic hyperplasia as a causative factor, and the average age in men with diverticula was sixty-nine years. The incidence of vesical tumors not in the diverticulum but elsewhere in the bladder was 6.7 per cent, while stones or neoplasms within the vesical diverticula were present in 9.4 and 10.8 per cent, respectively. The association of carcinoma occurring in bladder diverticula has been known for many years and is now receiving greater attention. A search in the literature reveals that neoplasms arising in a vesical diverticulum vary from 0.8 to as high as 10 per cent.1-8 However, this incidence must be falsely high since many small diverticula may not have been reported in the charts and an unknown proportion of bladder diverticula remains undiagnosed because they cause no symptoms. l l It is assumed that stagnant urine within the diverticulum allows urinary carcinogens to promote chronic mucosal irritation secondary to infection and calculus formation. These factors predispose the urothelium to malignant degeneration. 23 There has been a disparity between clinically or cystoscopically examined diverticula, and the pathology specimens. Gerridzen and Futter4 have found that in 80 per cent of examined diverticula the histopathology of the diverticular wall revealed chronic inflammation and squamous metaplasia. Neoplasms arising in a vesical diverticulum present a problem in management, and the overall survival rate is poor1*2,5JJ2-14since these tumors are often of high grade and the thin
456
diverticular wall which contains no muscular fibers (or occasionally only a small amount of smooth muscle) facilitates earlier penetration of carcinoma. Therefore, the main factor affecting survival appears to be the grade of the tumor and the absence or presence of invasion of the lamina propria. In our series, only 3 patients who are still alive had low infiltrative diverticular tumors, while, on the other hand, 4 patients who died of their disease had highgrade and/or invasive neoplasms in the vesical diverticula. The patient with a high-grade squamous cell carcinoma is considered to have a worse prognosis. In 3 patients we resected the diverticular neck and the tumor within the diverticulum transurethrally, having in that way destroyed the sphincteric action of the diverticular neck and eliminated stasis. In addition, having fulgurated the entire diverticular wall according to Orandi’s technique, we succeeded not only in shrinkage of the bladder diverticulum but also in destroying potential new sites of tumor growth. The latter may be explained by the thermal deleterious effect of the fulgurating current on the tumor cells. Postoperative instillation of chemotherapeutic agents was used to reduce the possible tumor recurrences. However, recurrent bladder tumors, not at the fulgurated site but elsewhere in the bladder, developed in 1 of these patients. This transurethral method is considered suitable in the aged or debilitated patient in whom open diverticulectomy poses a definite surgical risk. Patients who refuse open surgery also might be considered for the procedure. Of course, due to our limited number of patients, it is not possible to draw any definite conclusions. We would like to suggest, however, that the Orandi technique combined with tumor and diverticular neck resection could prove to be an easily performed and possibly effective method in treating these patients, provided the tumors are of low grade and there is no invasion of the lamina propria. Because of the possibility of carcinoma arising in the diverticular wall and its poor prognosis, various authors have proposed either prophylactic diverticulectomy or, in cases of diverticular carcinoma, total cystectomy, with or without postoperative radiotherapy.2s4J3 In conclusion we would like to reemphasize the importance of looking into the interior of a vesical diverticulum regardless of the proposed treatment. Finally, we think that the Orandi
UROLOGY
/ NOVEMBER
1987
i
VOLUME
XXX, NUMBER 5
technique of transurethral fulguration of the diverticular wall deserves more attention since it represents a safe, quick, and effective way to treat these patients. Rio, Patras, Greece (DR. BARBALIAS) References 1. Knappenberger ST, Usan AC, and Melicow MM: Primary neoplasms occurring in vesical diverticula. A report of 18 cases, J Urol 83: 153 (1969). 2. Kelalis PP, and McLean P: The treatment of diverticulum of bladder, ibid 98: 349 (1967). 3. Peterson LJ, Paulson DF, and Glenn JF: The histopathology of vesical diverticula. ibid 110: 62 (1973). 4. Gerridzen GR,‘and Futter GN: Ten-year review of vesical diverticula, Urology 20: 33 (1982).
UROLOGY
/ NOVEMBER
1987
5. Micic S, and Ilic V: Incidence of neoplasm in vesical diverticula, J Ural 129: 734 (1983). 6. Fox M, Power RF, and Bruce AW: Diverticulum of the bladder. Presentation and evaluation of treatment of 115 cases, Br J Urol 34: 286 (1962). 7. McLean P and Kelalis PP: Bladder diverticulum in the male, ibid 40: 321 (1968). 8. Faysal HM, and Freiha SF: Primary neoplasm in vesical divericula, ibid 53: 141 (1981). 9. Orandi A: Transurethral fulguration of bladder diverticulum. New procedure, Urology 10: 30 (1977). 10. Barret MD, Malek SR, and Kelalis PP: Observations on vesical diverticulum in childhood, J Urol 116: 234 (1976). 11. Fellows GJ: The association between vesical carcinoma and diverticulum of the bladder, Eur Urol 4: 185 (1978). 12. Boylan RN, Greene LF, and McDonald JR: Epithelial neoplasms arising in diverticula of the urinary bladder, J Urol 65: 1041 (1951). 13. Siegel WH: Neoplasms in bladder diverticula, Urology 4: 411 (1974). 14. Redman JF, McGinnis TB, and Bissada NK: Management of neoplasms in vesical diverticula, ibid 7: 492 (1976).
/ VOLUME XXX, NUMBER 5
457
ETIOLOGY,
DIAGNOSIS,
AND TREATMENT
Analysis of 74 Cases MICHAEL
D. MELEKOS,
HANS W ASBACH, GEORGE
M.D.
M.D.
A. BARBALIAS,
M.D.
From the Department of Urology, Patras University, School of Medicine, Patras, Greece
ABSTRACT-A thirteen-year review of bladder diverticula was undertaken and 74 cases were identified. In 8 patients primary neoplasms arose in the diverticula, and their treatment included diverticulectomy or partial cystectomy with or without postoperative irradiation, irradiation only, and transurethral resection of the tumor combined with fulguration of the diverticular wall and postoperative bladder instillations with doxorubicin or thiotepa solutions. Early diagnosis with additional visualization of the interior of vesical diverticulum is mandatory, since carcinoma arising in it has a poor prognosis.
Bladder diverticula frequently are small, asymptomatic, and require no treatment. Others, however, may cause significant morbidity, such as infection, stone formation, and possible diverticular wall metaplasia which may lead to carcinoma within themelm The incidence of neoplasms in a vesical diverticulum varies from 0.8 to 10 per cent. 1-s Although the accepted treatment includes open surgical procedures such as diverticulectomy and partial or total cystectomy, we resected the tumors transurethrally and fulgurated the diverticular wall in 3 cases, using bladder instillations with doxorubicin or thiotepa postoperatively. Herein we review our experience with vesical diverticula in general, and report on 8 patients with neoplasms arising in them and their proposed treatment. Material and Methods We analyzed, retrospectively, a series of 74 patients with vesical diverticula seen between 1973-1985. Of these patients, 13 men had vesi-
UROLOGY
/ NOVEMBER
1987
i
VOLUME
cal neoplasms, both in the diverticula (8 cases) and elsewhere in the bladder (5 cases). In 12 patients the coexisting tumors were of the same histologic type. In 1 patient bladder tumors were identified in a vesical diverticulum (of squamous cell type) and in an intravesical location (of transitional cell type). Results The average age of the 74 patients (including 1 female) with bladder diverticula was sixtynine years, of the 13 patients with concomitant vesical tumors seventy-two, and of those 8 with neoplasms arising in the diverticula seventyfour years. Hematuria was the cardinal symptom in the 13 patients with vesical tumors. In particular, hematuria was present in 87.5 per cent of the patients with neoplasms occurring in the diverticula and in 100 per cent of those having tumors elsewhere in the bladder. Urinary tract infection (UTI) with pyuria was present in 53 patients with vesical diverticula (71.6%). In
XXX, KUMBER S
453
FIGURE 1. (A) Cystographic portion of intravenous pyelogram showing paraureteral diverticulum at left side of bladder. Large arrows show course of left lower ureter; small arrows show site of tumor. (B) Plain film demonstrates many small stones in right side of bladder (like mud), and larger stone on left side (arrow). (C) Same patient as (B). Cystographic portion of intravenous pyelogram showing large diverticulum at left with filling deject (arrow), which was in fact tumor within diverticulum. Note displacement of ipsilateral lower ureter.
particular, UT1 and pyuria were present in 75 per cent of the patients having neoplasms arising in the diverticula, in 60 per cent of those having tumors elsewhere in the bladder, and in 60.6 per cent of those having diverticula only. The diagnosis of the vesical diverticula was usually made at cystoscopy, during radiologic examination of the urinary tract, or at both. Of the 74 cases, 54 had either an intravenous pyelogram or cystogram, 49 demonstrating a diverticulum. Filling defect (tumors) in a vesical diverticulum was detected in 5 of the 8 cases (Fig. lA, C). In the other 3 patients, tumors were detected at cystoscopy. However, the presence of intradiverticular neoplasms was established only at cystoscopy. Of the 74 patients with vesical diverticula, 7 had stones of different sizes in them (9.4%). It was noteworthy that a patient with a stone in a large diverticulum suffered also from invasive grade IV squamous cell carcinoma in the diverticulum (Fig. lB, C) and a concomitant neoplasm of lower grade (grade II) elsewhere in the bladder. The origin of the diverticula is shown in Table I. Histopathologic examinations of the tumors occurring in the vesical diverticula revealed invasion of the whole diverticular wall in 4 cases and superficial invasion of the wall in
454
the other 4. The tumor in one of those 4 cases with complete wall invasion was a grade IV squamous cell carcinoma and was proved to infiltrate the perivesical tissues. In that same case, as it has been already mentioned, the concomitant tumor elsewhere in the bladder was a grade II transitional cell carcinoma. The neoplasm in the 3 remaining cases with complete invasion of the diverticular wall was a grade III transitional cell carcinoma. In the other 4 cases with superficial wall invasion, the tumors were papillary in appearance and of transitional cell type; two were of grade I and two of grade II. Of the patients with vesical diverticula, 60 underwent either open surgery (diverticulectomy or partial cystectomy) or transurethral TABLE I.
Origin of vesical diverticula PatientsNo. Per Cent
Benign prostatic hyperplasia (BPH) Vesical neck contracture (BNC) Urethral stricture Urethral stricture combined with either BPH or BNC Neurogenic None (no obvious cause) TOTALS
60 6 2
81.1 8.1 2.7
1 1 74
1.35 1.35 100
UROLOGY / NOVEMBER1987 / VOLUMEXXX, NUMBER5
TABLE II. Pts.
Grade
1
I I
Primary and recurrent diverticular tumors, treatment, and survival of patients
Primary Neoplasm Treatment
Grade
4 5 6
II II III III
TUR + thiotepa instillations TUR + doxorubicin and thiotepa instillations Diverticulectomy Partial cystectomy Diverticulectomy TUR + doxorubicin instillations
7
III
Diverticulectomy
. .
8
IV
Irradiation
. .
2 3
resection (TUR) of diverticular neck. In the majority of the cases, the procedures were accompanied with correction of the coexisting subvesical obstruction. TUR was the treatment of choice for those patients who had tumors not in the diverticula but elsewhere in the bladder. In patients who had been selected to undergo TUR of the diverticulum, the size of the latter was smaller than 2.5 cm. It must be noted that in many of the aforementioned cases, besides the TUR of the diverticular neck, a fulguration of the diverticular wall also has been undertaken, according to Orandi’s technique.e Regarding the 8 patients with neoplasms within the diverticula, 3 underwent diverticulectomies. Of these, 1 patient had a grade II and 2 patients a grade III transitional cell carcinoma. In this group of patients who had been treated with diverticulectomies, recurrent tumors of higher grade developed in 2 and were managed with TUR plus irradiation with 6,500 rad; however, they died of their disease within two and three years, respectively. The third patient of that group died of metastatic disease (liver metastases) before local bladder recurrences could be detected (Table II). The patient with infiltrative diverticular squamous cell carcinoma, underwent a TUR of the concomitant grade II transitional cell neoplasm, followed by irradiation of the bladder with 7,000 rad. He is still alive, since his disease was recently detected, but the prognosis is considered poor (follow-up only 4 months). A patient with a grade II transitional cell carcinoma was managed with partial cystectomy. There was no recurrent tumor development in the next three years. Three patients were treated with TUR of the neoplasms occurring within the diverticula,
Recurrent Neoplasm Treatment
Outcome
. . . .
No recurrence No recurrence
Alive Alive
III
TUR + irradiation No recurrence TUR + irradiation TUR + doxorubicin instillation + irradiation Me&static disease (liver metastases) . .
Dead Alive Dead Dead
iv III
Dead Alive, but poor prognosis
while at the same time the diverticular wall was fulgurated. In one of them, who had a grade I tumor not penetrating the lamina propria, the TUR was followed forty-eight hours postoperatively by intravesical instillation of 60 mg thiotepa, which was repeated once weekly for six weeks and then once every month for three months. Since no recurrent tumor was evident, a TUR of the prostatic adenoma together with TUR of the diverticular neck was then undertaken. There was also no recurrent tumor in the next two years. In the second patient, who also had a grade I nonpenetrating the lamina propria transitional cell tumor and severe irritative and obstructive urinary symptoms secondary to benign prostatic hypertrophy, a preliminary TUR of prostatic adenoma was performed with synchronous resection of the diverticular neck. Seven weeks later a TUR of the diverticular neoplasm was undertaken, while the mucosa of the diverticulum was fulgurated. Here again, forty-eight hours postoperatively, a single dose of 60 mg thiotepa was instilled. Two weeks later doxorubicin instillations of 50 mg each, once every two weeks were started. After the fourth dose, however, doxorubicin was discontinued since chemical cystitis developed. As soon as irritation had subsided and even though there was no evidence of recurrent tumor cystoscopically, thiotepa bladder instillations of 60 mg weekly were started and continued (once weekly) for the next five weeks. There was also no tumor recurrence in eighteen months. In the third and last patient, whose tumor proved to be a grade III invasive carcinoma, TUR of the neoplasm and fulguration of the diverticular wall were undertaken. Again a single dose of 60 mg thiotepa, forty-eight hours
UROLOGY / NOVEMBER1987 / VOLUMEXXX, NUMBER5
455
postoperatively, was instilled and followed thereafter with 60 mg doxorubicin instillations, once every month for the next six months. However, tumor recurrence was seen in three different intravesical sites. The patient was treated with TUR combined with doxorubicin instillations and irradiation of the bladder, but he died of his disease within two years (Table II). Comment Vesical diverticula may be congenital or acquired, but by far the latter are the most common. Acquired diverticula are secondary to lower urinary tract obstruction and can be seen in both adults and children. In the adult population, bladder diverticula are seen more commonly in men.‘O In our series 81 per cent of the patients had benign prostatic hyperplasia as a causative factor, and the average age in men with diverticula was sixty-nine years. The incidence of vesical tumors not in the diverticulum but elsewhere in the bladder was 6.7 per cent, while stones or neoplasms within the vesical diverticula were present in 9.4 and 10.8 per cent, respectively. The association of carcinoma occurring in bladder diverticula has been known for many years and is now receiving greater attention. A search in the literature reveals that neoplasms arising in a vesical diverticulum vary from 0.8 to as high as 10 per cent.1-8 However, this incidence must be falsely high since many small diverticula may not have been reported in the charts and an unknown proportion of bladder diverticula remains undiagnosed because they cause no symptoms. l l It is assumed that stagnant urine within the diverticulum allows urinary carcinogens to promote chronic mucosal irritation secondary to infection and calculus formation. These factors predispose the urothelium to malignant degeneration. 23 There has been a disparity between clinically or cystoscopically examined diverticula, and the pathology specimens. Gerridzen and Futter4 have found that in 80 per cent of examined diverticula the histopathology of the diverticular wall revealed chronic inflammation and squamous metaplasia. Neoplasms arising in a vesical diverticulum present a problem in management, and the overall survival rate is poor1*2,5JJ2-14since these tumors are often of high grade and the thin
456
diverticular wall which contains no muscular fibers (or occasionally only a small amount of smooth muscle) facilitates earlier penetration of carcinoma. Therefore, the main factor affecting survival appears to be the grade of the tumor and the absence or presence of invasion of the lamina propria. In our series, only 3 patients who are still alive had low infiltrative diverticular tumors, while, on the other hand, 4 patients who died of their disease had highgrade and/or invasive neoplasms in the vesical diverticula. The patient with a high-grade squamous cell carcinoma is considered to have a worse prognosis. In 3 patients we resected the diverticular neck and the tumor within the diverticulum transurethrally, having in that way destroyed the sphincteric action of the diverticular neck and eliminated stasis. In addition, having fulgurated the entire diverticular wall according to Orandi’s technique, we succeeded not only in shrinkage of the bladder diverticulum but also in destroying potential new sites of tumor growth. The latter may be explained by the thermal deleterious effect of the fulgurating current on the tumor cells. Postoperative instillation of chemotherapeutic agents was used to reduce the possible tumor recurrences. However, recurrent bladder tumors, not at the fulgurated site but elsewhere in the bladder, developed in 1 of these patients. This transurethral method is considered suitable in the aged or debilitated patient in whom open diverticulectomy poses a definite surgical risk. Patients who refuse open surgery also might be considered for the procedure. Of course, due to our limited number of patients, it is not possible to draw any definite conclusions. We would like to suggest, however, that the Orandi technique combined with tumor and diverticular neck resection could prove to be an easily performed and possibly effective method in treating these patients, provided the tumors are of low grade and there is no invasion of the lamina propria. Because of the possibility of carcinoma arising in the diverticular wall and its poor prognosis, various authors have proposed either prophylactic diverticulectomy or, in cases of diverticular carcinoma, total cystectomy, with or without postoperative radiotherapy.2s4J3 In conclusion we would like to reemphasize the importance of looking into the interior of a vesical diverticulum regardless of the proposed treatment. Finally, we think that the Orandi
UROLOGY
/ NOVEMBER
1987
i
VOLUME
XXX, NUMBER 5
technique of transurethral fulguration of the diverticular wall deserves more attention since it represents a safe, quick, and effective way to treat these patients. Rio, Patras, Greece (DR. BARBALIAS) References 1. Knappenberger ST, Usan AC, and Melicow MM: Primary neoplasms occurring in vesical diverticula. A report of 18 cases, J Urol 83: 153 (1969). 2. Kelalis PP, and McLean P: The treatment of diverticulum of bladder, ibid 98: 349 (1967). 3. Peterson LJ, Paulson DF, and Glenn JF: The histopathology of vesical diverticula. ibid 110: 62 (1973). 4. Gerridzen GR,‘and Futter GN: Ten-year review of vesical diverticula, Urology 20: 33 (1982).
UROLOGY
/ NOVEMBER
1987
5. Micic S, and Ilic V: Incidence of neoplasm in vesical diverticula, J Ural 129: 734 (1983). 6. Fox M, Power RF, and Bruce AW: Diverticulum of the bladder. Presentation and evaluation of treatment of 115 cases, Br J Urol 34: 286 (1962). 7. McLean P and Kelalis PP: Bladder diverticulum in the male, ibid 40: 321 (1968). 8. Faysal HM, and Freiha SF: Primary neoplasm in vesical divericula, ibid 53: 141 (1981). 9. Orandi A: Transurethral fulguration of bladder diverticulum. New procedure, Urology 10: 30 (1977). 10. Barret MD, Malek SR, and Kelalis PP: Observations on vesical diverticulum in childhood, J Urol 116: 234 (1976). 11. Fellows GJ: The association between vesical carcinoma and diverticulum of the bladder, Eur Urol 4: 185 (1978). 12. Boylan RN, Greene LF, and McDonald JR: Epithelial neoplasms arising in diverticula of the urinary bladder, J Urol 65: 1041 (1951). 13. Siegel WH: Neoplasms in bladder diverticula, Urology 4: 411 (1974). 14. Redman JF, McGinnis TB, and Bissada NK: Management of neoplasms in vesical diverticula, ibid 7: 492 (1976).
/ VOLUME XXX, NUMBER 5
457