Size Of Diverticulum Research Articles

Per-oral endoscopic myotomy for esophageal diverticula with or without esophageal motility disorders

Mid-esophageal and epiphrenic diverticula (MED) can be associated with esophageal motility disorders. Per-oral endoscopic myotomy (POEM) is an established treatment for esophageal motility disorders that has also been introduced for the treatment of MED. Data were prospectively collected from patients with MED treated with POEM at our institution. When esophageal motility disorders were present, myotomy was performed extending the myotomy to the lower esophageal sphincter (LES) to treat the motility dysfunction associated with the diverticulum. In the absence of esophageal motility disorder, POEM was performed without including the LES in the myotomy to achieve diverticulotomy. Four patients were treated with POEM for MED between April 2017 and March 2018. The patients suffered from distal esophageal spasm, jackhammer esophagus or esophago-gastric junction outflow obstruction. One patient had no esophageal motility disorder. Diverticulum size was 3 cm in one case and 6 cm in the others. Preoperative Eckardt scores ranged from 6 to 8. No life-threatening complications were reported. Intraoperative pneumoperitoneum was described in two cases and one patient experienced aspiration pneumonia. The patients with motility disorders were asymptomatic at 6-8 months follow-up. The patient without documented underlying esophageal motility disorder had an Eckardt score of 3 at 9-months follow-up. Two cases of gastro-esophageal reflux were successfully managed with proton pump inhibitors. In the case of MED and esophageal motility disorder, POEM permitted treatment of the underlying cause of the diverticulum, achieving favorable early clinical outcomes. In the absence of motility disorder, POEM was feasible with promising early outcomes, and could be a valid alternative to surgical diverticulectomy in selected patients.

Endoscopic submucosal dissection in management of colorectal tumors near or involving a diverticulum: a retrospective case series.

Background and study aims Surgery is the standard treatment for colon tumors associated with diverticulum. U se of endoscopic submucosal dissection (ESD) to treat such tumors is controversial. The aim of this study was to assess the safety and feasibility of ESD in treating superficial colorectal tumors situated near or involving diverticulum. Patients and methods Consecutive patients from two referral centers who had colorectal tumors near or involving diverticulum treated by ESD were retrospectively studied. Clinicopathological characteristics and clinical outcomes were analyzed. Results Of the 12 patients studied, six had tumors near diverticulum and six had tumors involving diverticulum. The overall en-bloc R0 resection rate, median tumor size and procedure time were 67 %, 26.5 mm (range, 15 – 80 mm) and 110 minutes (range, 50 – 220 minutes), respectively. For tumors near diverticulum group, the en-bloc R0 resection rate was 100 % and no adverse events (AEs) or residual/recurrent tumors were observed. In contrast, for intradiverticular tumors group, the en-bloc R0 resection rate was low at 33 %, and one AE (perforation) was observed. The diverticula were ≥ 6 mm in diameter in the patients with incomplete resection. However, all but one diverticulum was unrecognized before ESD. Two residual tumors were detected at the 12-month surveillance and one required surgery. Conclusions This case series indicates that ESD is safe and feasible for treating colorectal tumors near a diverticulum and might be feasible for tumors involving a diverticulum smaller than 6 mm. Selection for smaller diverticulum size may contribute to higher en-bloc R0 resection rates.

Endoscopic treatment of Zenker's diverticulum with Ligasure: simple, safe and effective.

Background and study aims Zenker's diverticulum may cause disabling symptoms, especially in the elderly. Treatment has changed in recent decades from open surgery to management with flexible endoscopy, resulting in lower morbidity and mortality. The goal of this study was to present the largest series, with the longest follow-up, of patients with Zenker's diverticulum receiving outpatient treatment with flexible endoscopy using a diverticuloscope and Ligasure (Covidien, Minneapolis, Minnesota, United States), a device that allows tissue sealing and coagulation of vessels before cutting the septum between the diverticulum and esophagus. Patients and methods We performed 79 diverticulotomies in 69 patients (65.2 % male, mean age 73.4 years). The mean diverticulum size was 2.8 cm. In three cases with a diverticulum ≤ 1.5 cm, the diverticuloscope could not be placed. Results The technical success was 95.83 % and the clinical success 96.7 %: 84 % of the 56 patients followed for a mean of 34.6 months (24 – 64 months) had no dysphagia. The recurrence rate was 10.4 %, with a good response to a second diverticulotomy at 12 months (IQR: 11.5 – 17) in most cases. The most severe complications were two microperforations, resolved with conservative treatment, and one case of delayed bleeding endoscopically-controlled with a clip. Conclusions Diverticulotomy of the esophageal-diverticular septum with Ligasure is an outpatient endoscopic technique that is simple, effective in the long term and very safe for the treatment of patients with Zenker's diverticulum. In symptomatic recurrences, a second procedure was equally safe and effective in most patients.

Isolated Internal Auditory Canal Diverticula: A Normal Anatomic Variant Not Associated with Sensorineural Hearing Loss.

Bony internal auditory canal diverticula are relatively common, occurring in approximately 5% of temporal bone CTs. Internal auditory canal diverticula have historically been considered incidental; however, a recent publication reported that internal auditory canal diverticula are associated with sensorineural hearing loss. The objective of this study was to further characterize this potential association in a large cohort of patients. A total of 1759 patients undergoing high-resolution temporal bone CT were collected during a 6-year interval, and audiometric data were obtained from those with internal auditory canal diverticula. To assess any association of isolated internal auditory canal diverticula with sensorineural hearing loss, we excluded from further analysis patients with concomitant otosclerosis and bilateral diverticula and those without audiometric data, leaving 22 index cases. Audiometric data for the ear with a diverticulum was compared with that in the contralateral ear, to serve as an internal control. Of 1759 patients, 82 (4.7%) had either unilateral (n = 33, 40%) or bilateral (n = 49, 60%) internal auditory canal diverticula. The co-incidence of otosclerosis and internal auditory canal diverticula was 34% (n = 28). There was no correlation between patient age and diverticulum size on either side. Among the index cases with isolated unilateral internal auditory canal diverticula and complete audiometric data, word recognition scores and the prevalence and severity of sensorineural hearing loss were not significantly different comparing the internal auditory canal diverticulum side to its contralateral control. This study did not find a statistically significant association between ears with internal auditory canal diverticula and worsening sensorineural hearing loss or word recognition. Internal auditory canal diverticula most likely represent a normal anatomic variant in ears without otosclerosis.

The Sensitivity of Cross-Sectional Imaging for Identifying Periampullary Diverticula

Introduction: Periampullary diverticula can make ERCP challenging due to unusual papilla position and distorted anatomy. Pre-ERCP CT or MRI, may help define anatomy, localize pathology, and identify periampullary diverticula. It is unclear whether technological advancements have led to improved radiographic sensitivity of periampullary diverticula or if adequate documentation is performed. Our aim was to determine the sensitivity of imaging in identifying duodenal diverticula as seen during ERCP. Methods: This is a retrospective study of 106 patients noted to have periampullary diverticula during ERCP between June 2014 and November 2017 at a single, large-volume academic center. The presence of duodenal diverticula noted on CT or MRI prior to ERCP was recorded. Age, gender, and diverticulum characteristics including number, size, and ampullary involvement were recorded. Successful cannulation was noted. The association between diverticula detection on imaging with diverticulum size, ampullary involvement, and biliary dilatation was determined using a Fisher's exact test. Results: A total 3289 ERCPs were performed in the study period, in which 106 patients were noted to have periampullary diverticula on ERCP. Of these 106 patients, 31 had CT, 52 had MRI, and 23 had both. Detection rate of diverticula on CT or MRI was 25.7% (28/106). Most patients had a single diverticulum (n=96, 88.1%) and ampullary involvement (n=76, 69.7%). Biliary ductal dilatation was noted on imaging in 68.7% (57/83). For the 23 individuals who underwent both CT and MRI, there was a 17.4% discordance rate. Diverticula were detected on CT or MRI in 18 of 51 (35.2%) patients with large diverticula, and 9 of 54 (16.7%) small/medium-sized diverticula (p=0.044). There was also a significant difference in detection of diverticula between patients with versus without a dilated bile duct (28.1% vs. 23.1%, p=0.0001). No significant difference was seen in detection of diverticula with or without ampullary involvement (28.9% vs. 20.0%, p=0.467).1154_A Figure 1. Patient characteristics, diverticulum qualities, procedural details, and indication for ERCPConclusion: The sensitivity of cross-sectional imaging for detecting duodenal diverticula among patients undergoing ERCP remains low despite advancements in imaging. There was a statistically significant difference in sensitivity of diverticulum detection based upon diverticulum size and biliary dilatation, but not ampullary involvement. This study highlights the potential to improve detection of periampullary diverticula by radiologists, which may impact pre-procedural planning and outcomes.1154_B Figure 2. Differences in diverticula detection on cross-sectional imaging by imaging modality, diverticulum size, ampullary involvement, or bile duct dilatation

The Plication Technique to Enhance the Endoscopic Approach to Zenker's Diverticulum.

Endoscopic stapler approaches to Zenker's diverticulum often yield a persistent diverticulum and recurrent dysphagia up to 20%. A novel technique to reduce the postoperative diverticulum is described. Eight consecutive patients with Zenker's diverticulum who underwent endoscopic stapler diverticulotomy had adjunctive endoscopic plication of the diverticulum wall to functionally reduce the residual diverticulum size. On postoperative esophagram, there was no visible diverticulum in 4 of 7 patients (57%). The remaining 3 patients had a reduction in common wall of 76%, 50%, and 40% with a mean postoperative size of 1.0 cm. All patients had resolution or significant improvement in dysphagia. There were no complications or recurrences at a mean follow-up of 6.3 months. As an adjunct to endoscopic treatment of Zenker's diverticulum, the plication technique can reduce diverticulum size. Further studies will determine if the plication technique affects long-term recurrence of endoscopic stapler approaches.

A novel endoscopic grading system for prediction of disease-related outcomes in patients with diverticulosis

BackgroundWe describe a simple endoscopic grading system of diverticular disease for the assessment of disease severity and prediction of outcomes. MethodsA retrospective analysis of prospectively maintained colonoscopy database was conducted. A single endoscopist prospectively graded disease severity according to the number and size of diverticula, the degree of muscular hypertrophy and rigidity of the sigmoid colon. Results762 patients were included in the analysis. Mean patient age was 70 years (range 37–97). Endoscopic severity of diverticulosis was predictive of the need for surgery, with 2% in the mild-moderate, 12% in the severe and 33% in the acute group (p < 0001). Time to surgery showed correlation to severity grade, with mean periods of 107.5 months in the moderate group vs. 3 and 2.5 months in the severe and acute group (p < 0001). The mean follow up was 11 years. ConclusionSurgeons should consider using endoscopic grading as an adjunct to clinical management decisions.

Long-Term Outcomes of Laparoendoscopic Single-Site Nephrolithotomy for Caliceal Diverticular Calculi: A Case Series.

To evaluate the outcomes of laparoendoscopic single-site nephrolithotomy (LESS-NL) for symptomatic caliceal diverticular calculi. From November 2009 to March 2014, 11 cases of LESS-NL with a homemade single-port device for caliceal diverticular calculi were performed by a single experienced laparoscopic surgeon. All patients were assessed at postoperative 1 month, 1 year, and 3 years for symptom-free status and by CT for stone-free and caliceal diverticular obliteration status. All complications were categorized by the Clavien-Dindo classification. Demographic parameters and postoperative outcomes were retrospectively analyzed. All procedures were effectively performed without conversion to open or conventional laparoscopic surgery. Median patient age was 53 years (range 22-73), and median diverticular size was 26 mm (range 15-58). Six patients (54.5%) had multiple stones, and five patients (45.5%) had a single stone; median stone size was 20.6 mm (range 12.1-66.4). The transperitoneal approach was used in seven patients (63.6%) and retroperitoneal approach in four patients (36.4%). Median operative time was 161 minutes (range 110-250), median estimated blood loss was 50 mL (range 20-400), and median hospital stay was 4 days (range 3-6). An additional needlescopic instrument was used in five cases (45.5%). There were three cases (27.3%) of grade I complications (two postoperative fever, one ileus), and no intraoperative or major complications. Median visual analog scale score significantly improved by discharge day (from 4.9 preoperatively to 1.4; p = 0.003). After a median follow-up of 38 months (range 36-41), all patients were symptom free with no evidence of stone or caliceal diverticulum on imaging. LESS-NL is a safe, feasible, and definitive treatment option for symptomatic caliceal diverticular calculi.

Endoscopic needle-knife treatment for symptomatic esophageal Zenker's diverticulum: A meta-analysis and systematic review.

The aim of this study was to assess the efficacy and safety following endoscopic management of Zenker's diverticulum (ZD) using a needle-knife technique. A systematic search of PubMed, Embase and Cochrane library databases was performed. All original studies reporting efficacy and safety of needle-knife technique for treatment of ZD were included. Pooled event rates across studies were expressed with summative statistics. Main outcomes, such as rates of immediate symptomatic response (ISR), adverse events and recurrence, were extracted, pooled and analyzed. Heterogeneity among studies was assessed using the R statistic. The random effects model was used and results were expressed with forest plots and summative statistics. Thirteen studies included 589 patients were enrolled. Pooled event rates for ISR, overall complication, bleeding and perforation were 88% (95% confidence interval [CI] 79-94%), 13% (95% CI 8-22%), 5% (95% CI 3-10%) and 7% (95% CI 4-12%), respectively. The pooled data demonstrated an overall recurrence rate of 14% (95% CI 9-21%). Diverticulum size of at least 4 cm and less than 4 cm demonstrated pooled adverse event rates of 17% (95% CI 10-27%) and 7% (95% CI 2-18%), respectively. When using diverticuloscope as an accessory, pooled ISR and adverse events rates were 84% (95% CI 58-95%) and 10% (95% CI 3-26%), respectively. Flexible endoscopic procedures using needle-knife offers a relatively safe and effective treatment of symptomatic ZD, especially for ZD of <4 cm in diameter.

Holmium laser enucleation of the prostate is an effective treatment in patients with concomitant bladder diverticula and outlet obstruction.

Bladder diverticula can be congenital or secondary to benign prostatic hyperplasia with bladder outlet obstruction, and be a source of high postvoid residuals prompting surgical intervention. We sought to evaluate the outcomes of patients with bladder diverticula undergoing holmium laser enucleation of the prostate (HoLEP) for bladder outlet obstruction. We retrospectively reviewed HoLEP patients with at least one bladder diverticulum at two high volume institutions. All cases were performed in similar fashion. Preoperative, perioperative, and postoperative patient variables were obtained and assessed. Of 2746 HoLEP patients, 51 were diagnosed with bladder diverticula before surgery. Mean prostate size was 80.8±50.0g and mean diverticulum size (largest if multiple) was 5.5±2.6cm. Preoperatively, urinary retention requiring catheterization was present in 28 (55%) patients. In the remainder, mean preoperative AUASI was 19.7, peak flow 7.2ml/s, and post-void residual (PVR) 365ml. At most recent follow-up (mean 12.2months), mean total AUASI was 8.6, peak flow 27.1ml/s, and PVR 145ml with 71, 276, and 221% improvement, respectively. All patients were voiding and none required catheterization. Only three (6%) patients required diverticulectomy at a mean of 15.2months after HoLEP for the following indications: hematuria (one patient)and urinary retention(two patients). HoLEP is an effective method of outlet obstruction treatment in patients with bladder diverticula. Most patients, even with large diverticula, do not require further treatment after the outlet obstruction has been relieved and can avoid more invasive surgical interventions.

Percutaneous Management of Stone Containing Calyceal Diverticula: Associated Factors and Outcomes

We evaluated the outcomes of percutaneous treatment and metabolic evaluation of calyceal diverticula with associated stones. We retrospectively identified 51 patients with a calyceal diverticulum in our prospectively maintained percutaneous nephrolithotomy database. Patients with complete data were separated into 14 with stones isolated to the diverticulum and 15 with renal stones in and outside the diverticulum. A total of 571 patients with renal stones but no diverticulum were used for comparison. Statistical differences were assessed using the chi-square test and the t-test. Patients with stones isolated to the diverticulum were younger (44 vs 54 years, p = 0.024), had a lower body mass index (23.2 vs 27 kg/m2, p = 0.032) and were more often female (71% vs 44%, p = 0.046) compared to patients with renal stones but no diverticulum. Calyceal diverticula were anterior in 19 of 29 cases and in the upper pole in 15. Average diverticular size was 2.5 cm with a 1.5 cm stone burden. Percutaneous treatment was successful in 96% of patients with a 4% complication rate. The diverticular neck was dilated in 22 of 51 patients (43%). During 5-year followup in the 51 patients there was 1 stone recurrence, which was managed by ureteroscopy, while 46 and 5 patients showed complete absence and reduction of the diverticulum, respectively. Of the calyceal diverticular stones 82% contained calcium phosphate compared to only 33% in patients with renal stones but no diverticulum. All patients with a diverticulum had at least 1 metabolic derangement. Percutaneous treatment of calyceal diverticula is safe and effective regardless of size or location, including anterior diverticula. Infundibular neck dilation does not appear to be necessary. There are metabolic abnormalities in a significant proportion of patients with a calyceal diverticulum.

Functional results in endoscopic Zenker's diverticulum surgery

ObjectivesThe main objective of this retrospective study was to assess functional results in endoscopic Zenker's diverticulum surgery. The secondary objectives were to assess safety, identify recurrence risk factors, and determine optimal management of recurrence. Material and methodsFrom 2000 to 2014, 50 patients underwent endoscopic surgery for marsupialization of Zenker's diverticulum. Regurgitation and dysphagia were assessed on the FOIS scale, pre- and post-operatively. Recurrences and complications rates were determined retrospectively at a minimum 18 months’ follow-up. ResultsRegurgitation and dysphagia improved in respectively 96% and 86% of patients. There was a 12% rate of complications, mostly minor. Mean hospital stay and time to return to oral feeding were 2.0 and 1.3 days respectively. Nine patients (18%) showed recurrence of symptoms, requiring revision surgery at a mean 2.7 years, performed endoscopically in the majority of cases. Only one recurrence risk factor was identified: small diverticulum size. ConclusionEndoscopic Zenker's diverticulum surgery provided functional improvement in most cases. Safe and effective, it is currently the treatment of choice for Zenker's diverticulum.

Normal fluoroscopic appearance status post-successful endoscopic Zenker diverticulotomy.

Endoscopic Zenker diverticulotomy (EZD) is a primary treatment for Zenker diverticulum (ZD). During EZD, the diverticulum is not excised, and interpretation of postoperative videofluoroscopic swallow study (VFSS) is challenging. The purpose of this investigation was to describe normal VFSS findings status post-successful EZD. The charts of all patients with ZD treated at our center between October 01, 2011, and May 30, 2014, were abstracted. Outcome measures included recidivistic diverticulum size, Eating Assessment Tool-10 (EAT-10), penetration aspiration scale, pharyngeal constriction ratio (PCR), and pharyngoesophageal segment (PES) opening. Twenty patients met inclusion criteria. The mean age was 70.5 (± 13) years. Seventy percent of the patients were male. Mean EAT-10 decreased 72.1% from 17.9 (± 8.2) to 5 (± 6.9) (P < 0.0001), and diverticulum size decreased 50.9% from 1.96 cm (± 0.68) to 0.96 cm (± 0.57) (P < 0.001). The PCR improved 33.6% from 0.17 (± 0.13) to 0.11 (± 0.11) (P < 0.001). Mean PES opening increased 61.6% from 0.53 cm (± 0.3544) to 0.86 cm (± 0.29) in lateral view and increased 40.0% from 1.00 cm (± 0.54) to 1.39 cm (± 0.46) in anteroposterior view (P < 0.001). VFSS following successful EZD demonstrates an approximate 50% reduction in diverticulum size and significant improvement in PCR and PES opening. These data provide a framework for the expected fluoroscopic outcomes of successful diverticulotomy. 4. Laryngoscope, 127:1762-1766, 2017.

Management of renal caliceal diverticular stones: A decade of experience.

Objective:The objective of this study is to evaluate our methods for management of renal caliceal diverticular stones (CDS).Materials and Methods:We conducted a retrospective study from January 2005 to July 2015 and included patients who were treated for renal CDS. Patients were evaluated for treatment modality, puncture site (in case percutaneous nephrolithotomy [PCNL] attempted), operative time, stone clearance rate, and complications. During PCNL, if the infundibulum was found to connect the diverticulum to the calyx, then a double J stent was placed. No attempt was made to dilate the diverticular neck or to create a neoinfundibulum.Results:Twenty-four patients were treated for CDS during the study period. Two patients underwent shockwave lithotripsy, and 22 were managed by PCNL. Mean stone size was 16.37 mm (range: 6–35 mm) and mean diverticulum size was 20.62 mm (range: 12–37 mm). No fulguration was done in initial 17 patients, while fulguration by Holmium Laser was performed in the last five cases treated with PCNL. Mean operative time was 70.31 min (range: 47–90 min). Mean follow-up was 34 months, diverticulum resolved in 14 patients and reduced in size in 7 patients.Conclusion:Caliceal diverticular calculi can be treated most efficiently by PCNL. Stone-guided puncture and no attempt to dilate or create neoinfundibulum reduces operative time and morbidity while yielding high stone-free rate.

Laparoscopic diverticulectomy: A systemized technique

ObjectivesTo present an original technique for laparoscopic vesical diverticulectomy without the need of dissecting the diverticular wall, thereby making the procedure safe and significantly simpler. Material and methodsFour patients were operated from September 2014 and April 2016. The diagnosis was made by ultrasonography in all cases, and the study included blood and urine analyses with urine cultures, urine cytology, contrast-enhanced CT scans, prostate symptom questionnaire (International Prostate Symptom Score), flowmetry and cystoscopy. One case required transurethral prostate resection at first. ResultsThe medium age of the patients was 64 years (range: 56–71). The medium diverticulum size was 4cm (range: 3–6). The location was retrotrigonal in all cases, on the left side in 2 cases, right retromeatic in 1 case and near the midline in 1 case. The medium surgical time was 146mins (range, 120–180), being shorter in each new case. There were no significant bleeding, complications or conversion to open surgery in any of the cases. The postoperative period had no incidences. The hospital stay was 3 days in 3 cases and 48hrs in the other case (medium, 3.5 days). The catheter was withdrawn in the outpatient clinic at 14 days. ConclusionsThe initial experience with the technique described above shows it to be safe and reproducible, with similar results to other current laparoscopic techniques. Avoiding the dissection of the diverticular wall significantly reduces the technical difficulty of the procedure.

Diverticulectomía laparoscópica: técnica sistematizada

ObjectivesTo present an original technique for laparoscopic vesical diverticulectomy without the need for dissecting the diverticular wall, thereby making the procedure safe and significantly simpler. Material and methodsFour patients were operated on between September 2014 and April 2016. The diagnosis was made by ultrasonography in all cases, and the study included blood and urine analyses with urine cultures, urine cytology, contrast-enhanced CT scans, prostate symptom questionnaire (International Prostate Symptom Score), flowmetry and cystoscopy. One case required transurethral prostate resection in a first time. ResultsThe mean age of the patients was 64 years (range: 56-71). The mean diverticulum size was 4cm (range: 3-6). The location was retrotrigonal in all cases, on the left side in 2 cases, right retromeatic in 1 case and near the midline in 1 case. The mean surgical time was 146min (range, 120-180), shortening for each new case. There were no significant bleeding, complications or conversion to open surgery in any of the cases. The postoperative period had no incidences. The hospital stay was 3 days in 3 cases and 48h in the other case (mean, 3.5 days). The catheter was withdrawn in the outpatient clinic at 14 days. ConclusionsThe initial experience with the technique described above shows it to be safe and reproducible, with results similar to other current laparoscopic techniques. Avoiding the dissection of the diverticular wall significantly reduces the technical difficulty of the procedure.

Robot-assisted partial cystectomy: perioperative outcomes and early oncological efficacy.

To report on patients undergoing robot-assisted partial cystectomy (RAPC), focusing on perioperative outcomes over a range of clinical, anatomical and pathological variables, as well as the overall oncological efficacy of this approach. We retrospectively reviewed all patients who underwent RAPC by a single surgeon between 2005 and 2015. We identified 29 patients who underwent surgery for definitive management of a primary bladder tumour. Clinicopathological data and perioperative variables were recorded. Continuous variables were compared using the Student's t-test. Prediction of perioperative outcomes for those undergoing RAPC for intra-diverticular neoplasms was done using univariate logistic regression. Survival was estimated using the Kaplan-Meier method. The median (interquartile range) patient age was 75 (65-81) years, 18 patients (62.1%) had an American Society of Anesthesiologists classification of ≥3, and 10 patients (34.5%) had a history of prior abdominal surgery. The median estimated blood loss (EBL) was 50 mL and the median length of stay (LOS) was 1 day. Two patients (6.9%) had a perioperative complication and five (17.9%) a post-discharge complication at ≤90 days, all of which were minor. The positive surgical margin rate was 3.6% and in those with muscle-invasive disease a median of 12 lymph nodes were removed. Neither the size of diverticulum nor the need for ureteric re-implantation was predictive of LOS, EBL, or complication (P > 0.05). We did not encounter any wound, port site, or unusual recurrence patterns to suggest the technical factors of a robotic approach influenced oncological outcomes. The 5-year overall and recurrence-free survival rates were 79% and 68%, respectively. RAPC confers the ability to achieve favourable outcomes with low morbidity and reduced hospital stays. Oncological efficacy compares favourably with the published literature. For experienced surgeons, this may represent the optimal surgical approach for organ-preserving bladder surgery.

V2-09 ELECTROVAPORIZATION OF LARGE BLADDER DIVERTICULUM

You have accessJournal of UrologyFemale Voiding Dysfunction1 Apr 2016V2-09 ELECTROVAPORIZATION OF LARGE BLADDER DIVERTICULUM Ryan Chandhoke, Bilal Farhan, and Gamal Ghoniem Ryan ChandhokeRyan Chandhoke More articles by this author , Bilal FarhanBilal Farhan More articles by this author , and Gamal GhoniemGamal Ghoniem More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2663AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES A bladder diverticulum which causes urinary complications requires intervention. There are several options for treatment. This is a case where we used a minimally invasive transurethral technique with electrovaporization of the diverticular mucosa as the primary treatment for an acquired bladder diverticulum due to an obstructive pubovaginal sling in a female patient. METHODS A 63-year-old female presented to our institution in 2013 with complaints of incomplete bladder emptying, difficulty of urination with voiding only in a bent-over position, pelvic pain, and recurrent urinary tract infection (UTI). Her past surgical history included vaginal hysterectomy, rectocele repair with perineoplasty, placement of a pubovaginal sling with autologous fascia, and cystocele repair at an outside institution in 2001. Pelvic examination was unremarkable. Flexible cystoscopy revealed a normal urethra and a large left lateral wall diverticulum. The mouth of the diverticulum was wide and showed no abnormalities. Fluorourodynamic images re-demonstrated the large diverticulum which balllooned during voiding. The bladder emptied to completion while the diverticulum retained the contrast. The diagnosis was that of bladder outlet obstruction at the mid-urethral level. Follow up residual urine measurements showed higher volumes of 400mL which could be attributed to the growing diverticulum. The patient underwent partial urethrolysis with excision of the fascial sling. Her urination became easier and did not require changing position. She continued, however, to have incomplete bladder emptying and recurrent UTI due to the diverticulum. Electrovaporization was performed of the entire diverticular mucosa utilizing a bipolar button vaporization electrode. Only the coagulation setting was used at a power of 160 watts. There was no evidence of bleeding or perforation during the operation. Total electrovaporization time lasted thirty minutes. An indwelling urethral catheter was placed at the end of the case and left in for a total of six weeks. RESULTS The patient did well postoperatively. Voiding cystourethrogram at six weeks showed a significant reduction in diverticular size. The Foley catheter was removed and the patient was able to void without difficulty with minimal residual urine and no urinary tract infections. CONCLUSIONS Electrovaproization of a bladder diverticulum is a minimally invasive technique with similar clinical outcome to open and laparoscopic diverticulectomy. Its ease of surgery with a faster operating and recovery time exemplifies its usefulness in the clinical setting. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e182 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Ryan Chandhoke More articles by this author Bilal Farhan More articles by this author Gamal Ghoniem More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Magnetic resonance enterography/enteroclysis in acquired small bowel diverticulitis and small bowel diverticulosis.

Small bowel (SB) diverticulosis is a rare disorder that may entail serious complications, including SB diverticulitis. Both are often missed in imaging. Magnetic resonance enterography/enteroclysis (MRE) is increasingly used to assess SB disease; awareness of the appearance of SB diverticulitis is essential to ensure appropriate management. Our aim was to systematically describe imaging characteristics of SB diverticulosis and diverticulitis in MRE. This retrospective, HIPAA-compliant study identified 186 patients with suspected SB diverticulosis/diverticulitis in medical databases of two tertiary medical centres between 2005 and 2011. Patients with surgically confirmed diagnoses of SB diverticulosis/diverticulitis were included. Two observers analyzed MR images for the presence, location, number, and size of diverticula, wall thickness, and mural and extramural patterns of inflammation. Seven patients were recruited. MRI analysis showed multiple diverticula in all (100%). Diverticular size ranged from 0.5 to 6cm. Prevalence of diverticula was higher in the proximal than the distal SB (jejunum 86%, ileum 57%, distal ileum43%). Diverticulitis occurred in 3/7 patients (43%) showing asymmetric bowel wall thickening and focal mesenteric inflammation. SB diverticulitis demonstrates characteristic MRE imaging features to distinguish this rare disorder from more common diseases. Asymmetric, focal mesenteric and mural inflammation and presence of multiple diverticula are keys to diagnosis. • Small bowel diverticulosis and diverticulitis is rare and often missed in imaging • Acquired small bowel diverticula are variable in size and number • Small bowel diverticulitis demonstrates characteristic features on MR enterography/enteroclysis • A focal or segmental asymmetric small bowel inflammation should prompt the search for diverticula.

Pediatric calyceal diverticulum treatment: An experience with endoscopic and laparoscopic approaches

The symptomatic calyceal diverticulum is a rare event in the pediatric population. In adults, surgical options include ureteroscopy, percutaneous ablation, and laparoscopic decortication but there is a lack of experience in the literature with these techniques. We present our experience with both the ureteroscopic and laparoscopic approach to treating the pediatric calyceal diverticulum. We performed a retrospective case series looking at patients who underwent treatment for calyceal diverticulum at our institution from January 2009 to May 2014. We reviewed patient demographics, indications for intervention, radiographic appearance, type of intervention, and perioperative outcomes. Ureteroscopic approach included dilation of infundibulum and ablation of diverticular cavity. Laparoscopic approach included ablation of the diverticulum with argon diathermy with or without surgical closure of the ostium. There were 13 patients who underwent 15 procedures for symptomatic calyceal diverticulum (Table). Median age was 11 years. Indications for intervention were: pain and increasing size of diverticulum (8/15, 55%), hematuria (3/15, 20%), UTI (3/15, 20%), and calculi (1/15, 5%). 11/15 (73%) procedures were managed endoscopically and 4/15 (27%) were managed with laparoscopic decortication. Ureteral stent was left in all patients for a mean duration of 51 days (15-120 days). Follow up imaging at median of 2.1 years (0.5-4 years) revealed an initial success rate of 85% (11/13 patients). Two patients failed initial intervention (persistent pain/increasing size) necessitating successful secondary minimally invasive procedures. There were 2 (13%) complications: a perinephric hematoma post endoscopic ablation which resolved spontaneously and a deep venous thrombosis in a patient with a coagulation disorder in the laparoscopic group. Limitations of our study include its retrospective design, lack of standardization of the treatment approach amongst the four treating surgeons, and the small number of patients requiring intervention for this relatively rare diagnosis. Our study is the largest to date in the pediatric population and is the first to report outcomes with ureteroscopic management of the calyceal diverticulum. We found that the pediatric calyceal diverticulum can be successfully treated in a minimally invasive manner. The endoscopic approach should be the first line option for patients with small, endophytic diverticula, particularly those located in the upper and mid pole. The laparoscopic approach is more invasive but should be considered for large diverticula that are exophytic with thin overlying parenchyma.