Dr JOY NARAYAN CHAKRABORTY

MS, DNB Urology, DNB Surgery, FRCS Edinburgh.

Vi v a To p i c
FRCS England, FRCS Urology, FHEA Bladder Cancer 7
Postgraduate Tutor in Surgical & Urological
Sciences, Edinburgh University, UK

BCa in a Diverticulum

CONTACT
urologicacademy@gmail.com
A 68 year-old-male presents with recent onset, intermittent visible and painless haematuria. There is no history of
pneumaturia, fecaluria or urethral secretions. No significant medical history except mild hypertension that is well-
controlled by medication. He is non-smoker and works in a office.

How would you investigate him further?

How would you investigate him further?

2-ww Haematuria clinic

• Urine Culture / Cytology

• Baseline blood tests
• Flexible Cystoscopy
• Imaging - > USS
Ultrasound reveals a large diverticulum of 62 x 45 mm, on the right wall,
occupied by a "tumour" of 3.6 x 2.7 cm with a heterogenous hypoechoic
mass. Doppler study shows, internal blood flow.

There is a large post void residual.

f - Cystoscopy findings ?
What are the things you look for in a diverticular tumour ?
Flexible cystoscopy reveals a tumour in a diverticulum
at the posterolateral wall of the bladder.

Things to see for during f-cystoscopy:

1. Size & Number of tumour inside the diverticulum

2. Tumour morphology (sessile, broad base?,
papillary?)
3. Primary or secondary diverticulum?
4. Location of diverticulum relating to the ureteric
orifice
5. Any tumour elsewhere in the bladder
3. Size of diverticular neck

What should be the next step?

What should be the next step?

• CT urography
• CT abdomen and Chest
• MRI pelvis

• Uroflowmetry and ask for any functional bladder problem: The diverticulum may be congenital or due to a
functional bladder problem - the latter may impact on management and possible reconstructive options in the
event of cystectomy and so should be investigated as well.
CTU ?
CTU demonstrated a large diverticulum (Polypoid filling defect) on the right posterolateral side of the bladder
measuring 8.1 ×3.3 ×5.7 cm. The diverticulum was in communication with the bladder lumen via a narrow neck, 0.6
cm in diameter. The diverticulum shows contrast uptake and slow washout.
No significant abdominopelvic lymph nodes are observed. CT chest is clear.
MRI Pelvis ?
MRI Pelvis

Coronal plane, T2-weighted image; Sagittal plane, Fat-saturated T2-weighted image; Axial plane, T2-weighted image; Axial
plane, DWI; Axial plane, ADC map. cT3

What should be the next step in his management?

What should be the next step in his management?

• MRI pelvis and bladder area if not already done (If a tumour is seen in a diverticulum at initial diagnostic flexible
cystoscopy a MRI scan may give more accurate staging imaging in addition to a CT urogram for upper tract staging. It
is important to get this imaging prior to any resection otherwise there will be artefact.)

• Rigid cystoscopy and TURBT

What are the precautions should you take for the TUR of a diverticular tumour ?
What are the precautions should you take for the TUR of a diverticular tumour ?

1. Assess the diverticular neck, to accommodate the resectoscope and loop movement
2. Cautious resection: thin diverticular wall, no Muscularis mucosae –> risk of perforation. Too deep biopsy may prove
risky. Short bursts of bipolar energy is advisable.
3. Careful about the ureteric orifice, especially in cases of congenital (Hutch) diverticulum
4. Careful inspection of other diverticula in the bladder for any undetected lesion
5. Accurate assess of the rest of the bladder to properly stage the disease. i.e.
Is the tumour in the diverticulum solitary?
Is there multifocal CIS?
Is there disease around the diverticulum neck?
6. Mapping biopsies of the whole bladder to rule out CIS
What are the special issues in performing resection of tumour in a diverticulum and what else would you like to do
at the time of TURBT?

• Narrow diverticular mouth may pose problem for a good inspection and TURBT
• Risk of perforation
• No muscle in the diverticulum-so need to avoid deeper resection.
• Random biopsies from the surrounding bladder (to rule out CIS in the rest of the bladder)
• Risk of injury to the ureteric orifice
After discussing the options, we decided to perform a transurethral resection.
You perform transurethral resection of the tumour and random biopsies of the surrounding bladder.

Histology findings ?
Papillary formations lined with atypical urothelial cells. Adjacent urothelium displaying carcinoma in situ (CIS).
Peridiverticular adipose tissue involvement; solid nests of atypical urothelial cells invading adipose tissue, there is CIS in
the rest of the bladder in the random biopsies. pT3, High grade, G3, No LVI, No PNI.
On histology the tumour is an UC and there is CIS on random biopsies, perivesical fat involved. Patient post-void
residual is 270 ml.

What would you recommend to the patient? And why ?

What would you recommend to the patient? And why ?

Radical Cystectomy is the best option (INDICATIONS : Variant histology, multifocal CIS, PT3, HG UC on histology, +ve CIS
in the rest of the bladder, Dysfunctional bladder

What are the key factors to be taken into consideration in the management of these tumours ?
What are the key factors to be taken into consideration in the management of these tumours ?

There are 3 key factors to be taken into consideration in the management of these tumours:

(1) Tumour factors

(2) Diverticular factors
(3) Patient factors

Diverticular Factors

1. The initial identification of the tumour as tumour in a diverticulum with narrow neck may be missed. The neck of
the diverticulum may not be wide enough to allow the passage of the scope into the cavity of the diverticulum.
The size and location in the bladder may also make the diverticulum inaccessible for thorough internal inspection
particularly with a rigid cystoscope. Similar factors may limit resection of tumour in a diverticulum.

3. A thin-walled diverticulum increases the risk of perforation, and a large or deep tumour may preclude complete
clearance without risk of perforation and local spillage of the tumour.
Tumour factors

1. Prognostically, the absence of the muscle layer allows diverticular tumours to spread locally or metastasize
more readily than non-diverticular bladder tumours. High-grade diverticular tumours are likely to invade the peri-
diverticular fat because of lack of detrusor muscle barrier, and are potentially associated with a worse outcome.

2. Because of the structural differences of the diverticulum, the standard bladder cancer staging system is not
applicable to the IDBT. Diverticular tumour staging distinguishes non-invasive (Tis/Ta), superficially invasive
(T1), and extra-vesical (T3) disease as well as tumours invading adjacent structures (T4).

What are the management options you would offer a patient with IDBT ?
Management options

It ranges from

1. Endoscopic management : Tumour resection followed by adjuvant intravesical chemotherapy or bacillus Calmette-
Guerin (BCG) immunotherapy
2. Bladder preserving approach: Diverticulectomy / Partial cystectomy
3. Radical cystectomy

For high-grade tumours, radical cystectomy is appropriate for patients with concomitant high-grade or extensive
disease of any grade with or without voiding dysfunction.

Bladder-preserving surgery with diverticulectomy, with or without ipsilateral ureteric reimplantation and
pelvic lymphadenectomy is suitable for patients with tumours that cannot be resected endoscopically because of the
bulk or poor access to the diverticulum irrespective of tumour grade. Diverticulectomy should not be
offered to patients with high-grade tumours or CIS elsewhere in the bladder.

When would you prefer a Endoscopic management ?

Endoscopic management

It is most suitable for patients with

a. Low-grade, non-invasive disease in a wide-neck diverticulum that can be completely resected
b. either clear or minimal low-grade non-invasive disease of the main bladder.

** After complete TU tumour resection, patients should be given intravesical chemotherapy or immunotherapy as
appropriate. I give a course of mitomycin C or BCG for low grade pTa diverticular tumours, even if they are small and
solitary as I want to minimise risk of recurrence. However, diligent surveillance with cystoscopy and MRI is critical. For
high grade T1 tumours in a diverticulum I would recommend cystectomy or diverticulectomy (unless significant
comorbidities and with the considerations re-bladder mapping as mentioned above).

Challenges Of Endoscopic approach

1. Lack of a muscle layer makes resection challenging due to a higher risk of perforation. In addition, HG-T1 tumours
may actually be a T3 lesion, due to the lack of muscle layer and therefore a cystectomy or diverticulectomy would often
be the first line choice of treatment for HG-T1 diverticular tumours.
2. There is concern as to how well intravesical treatment may get into diverticula and therefore how effective
intravesical treatment may be.
Bladder-preserving surgery

Diverticulectomy / Partial cystectomy (Lap/Robotic), with or without ipsilateral ureteric reimplantation and PLND is
suitable for

a. Diverticular tumours that cannot be resected endoscopically because of the bulk or poor access to the diverticulum
irrespective of tumour grade.
b. Absence of HG tumours or CIS elsewhere in the bladder.

** The French guidelines (Neuzillet Y et al, Prog Urol 2012;22:495-502) state diverticulectomy as an option.

Precautions for PC

1. Very careful to avoid "tumour spillage"

2. Make sure there is not cancerous field change elsewhere in the bladder (If diverticulectomy is to be performed you
need to ensure the rest of the bladder is clear of cancer with a careful cystoscopy and negative mapping biopsies)
[Voskuilen CS et al, Eur Urol Focus 2020;6:1226-1232].

How would you choose between RC and PC in a Diverticular tumour ?

How would you choose between RC and PC in a Diverticular tumour ?

Radical cystectomy would be the treatment of choice for

1. Patients with HG IDBT and concomitant multifocal HG-tumour elsewhere in the bladder
2. Patient with severe voiding dysfunction
3. If the patient prefers radical surgery for maximal oncological safety.
 Bladder diverticular tumour
LG, Ta, T1, UC, No variant histology, TUR + Intravesical therapy
No LN, No CIS elsewhere
Local staging:
MRI (before TUR)
TURBT with mapping Bx (must)

HG, >T2 UC +/- LN Diverticulectomy/

Factors to be considered No variant histology Partial cystectomy +/-
TNM stage No CIS elsewhere or CIS limited to LND
Grade diverticulum only
Size of tumour Narrow diverticular neck
Size of diverticular neck Thick diverticular wall
Presence of CIS / multifocal tumours
Location relative to the ureteric orifice
Patient preference
HG, >T2 UC +/- LN Radical cystectomy
Variant histology
CIS elsewhere in the bladder
Narrow diverticular neck
Thick diverticular wall

Does the presence of CIS within the bladder affect the outcome after PC ?
Does the presence of CIS within the bladder affect the outcome after PC ?

• CIS confined to the BD does not affect the treatment outcome after Partial cystectomy
• However, if there is CIS in the rest of the bladder, radical cystectomy should be the option.

[# Voskuilen CS, Seiler R, Rink M, Poyet C, Noon AP, Roghmann F, Necchi A, Aziz A, Lavollé A, Young MJ, Marks P. Urothelial carcinoma
in bladder diverticula: a multicenter analysis of characteristics and clinical outcomes. European urology focus. 2020 Nov 15;6(6):1226-
32].
How would you counsel a patient before PC in a diverticular tumour ?

1. 5-year OS is more or less same for RC vs PC: 64%

2. Tumour upgradation to T3 rate is 33%, and a completion cystectomy may be necessary in case there is
upgradation/T3.
3. Risk of tumour spillage is there
4. Risk of ureteric injury and the need for ureteric reimplantation
5. In case of BOO, the need for outlet surgery after UDS
6. In case of atonic bladder, need for CIC

What are the other non-tumour issues to consider in the management of IDBT ?
Non-tumour issues to consider in the management of IDBT

Other issues to consider in the management of IDBT are

1. Voiding function
2. Protection of the ureters
3. Patient preference.

** The ipsilateral ureter is at risk of injury during dissection of the diverticulum or may be draining into the
diverticulum. Hence, the ipsilateral ureter should be protected by stenting during dissection of the diverticulum, or if it
is not possible to salvage the ureter, a reimplantation over a double-J stent should be performed.
Counselling points for Radical surgery for IDBT

1. Prognosis is largely dependent on the stage, grade, and bulk of the tumour rather than the extent of
surgery. Hence, when appropriate (absence of CIS or multifocal tumours/ normal voiding function),
bladder preservation with meticulous follow-up should be the preferred treatment.
2. When considering radical surgery, particularly in locally advanced tumours or histological variants
with poor prognosis, it is advisable to avoid complex reconstruction.
3. Lymphadenectomy should be bilateral rather than ipsilateral on the side of tumour, although we have
not come across any lymph node metastasis on the contralateral side in patients having ipsilateral
lymph node dissection.
4. Patients should be counselled about the possibility of needing completion cystectomy in the case of
adverse final pathology or subsequent recurrences.
5. Robot-assisted diverticulectomy has the advantages of minimal blood loss, shorter hospital-stay, and
minimal would complications. Hence, this approach should be offered in centres with surgical expertise.
Should a patient require completion cystectomy, this can also be performed using the robotic approach.

# Amer ML, Mumtaz H, Russell B, Gan J, Rehman Z, Nair R, Thurairaja R, Khan MS. Intra-Diverticular Bladder Tumours: How to Manage
Rationally. Société Internationale d'Urologie Journal. 2022 Sep 15;3(5):303-13.
• Upstaging 55% patients with cTa/is/1
• PSM after PC or RC: 9% after PC, 6% after RC.

• After Partial cystectomy PSM 9%

After Radical cystectomy PSM 6%

• 5-year OS : 63%
For <pT2: 86%
For >pT2: 51%

• 5-year OS after PC: 66%

5-year OS after RC: 62%

• NAC: better OS
Variant histology, PSMs, Extravesical disease (>T2): Poor OS

No statistically significant OS between patients treated with PC or RC (HR: 0.94)

What does the standard guidelines say regarding the treatment of UCBD ?
What does the standard guidelines say regarding the treatment of UCBD ?

Current guidelines on BC management do not state any recommendations regrading UCBD.

However, ‘French association of urology’ states that:

• Partial cystectomy with PLND is a treatment option for unifocal tumours confined to BD without concomitant CIS and
with a maximum stage of T3.

[# Rouprêt M, Neuzillet Y, Masson-Lecomte A, Colin P, Compérat E, Dubosq F, Houédé N, Larré S, Pignot G, Puech P, Roumiguié M.
Recommandations en onco-urologie 2016-2018 du CCAFU: Tumeurs de la vessie. Progrès en Urologie. 2016 Nov 1;27:S67-91].

What are the difficulties in histological interpretation / staging of diverticular tumours?

What are the difficulties in histological interpretation / staging of diverticular tumours?

Lack of muscle in the diverticulum -> pT1 may be pT3

Is there any T2 stage in UCBD ? Why some of the histopathological in UCBD came as pT2 stage ?
Why some of the histopathological in UCBD came as pT2 stage ?
Is there any T2 stage in UCBD ? Why some of the histopathological in UCBD came as pT2 stage ?

As there is no Muscularis propria in BD, T2 stage should not be used in TNM staging of a diverticular tumour
(AJCC on cancer TNM classification).

[# Brierley JD, Gospodarowicz MK, Wittekind C, editors. TNM classification of malignant tumours. John Wiley & Sons; 2017 Jan
17.]

Why some of the histopathological in UCBD came as pT2 stage ?

• There may be small amount of muscularis propria in diverticular neck.

• Histopathological reports often show that UCBD often associated with a hypertrophic layer of Muscularis
mucosae. As this layer morphologically resembles Muscularis propria, there may be confusion in reporting.

What are the basic differences between UC in a bladder diverticulum and other UC ?
What are the basic differences between UC in a bladder diverticulum and other UC ?

• No T2 stage (as there is no Muscularis propria)

• High upstaging rate in UCBD (55%) compared to other Non-diverticular UC (32-40%)
• Treatment decision can not be made solely on the basis of TURBT report (potential underestimation)

What is the rate of pathological upstaging from ‘Organ confined’ to ‘Extra-diverticular’ disease ?
What is the rate of pathological upstaging from ‘Organ confined’ to ‘Extra-diverticular’ disease ?

• 55% patients who are staged as cTa/is/1 by TURBT is seen to have actually >T2 disease in RC specimen.
(compared to 30% in non-diverticular disease)

# Hu B, Satkunasivam R, Schuckman A, Miranda G, Cai J, Daneshmand S. Urothelial carcinoma in bladder diverticula: outcomes after
radical cystectomy. World journal of urology. 2015 Oct;33:1397-402.

How to manage a case of diverticular tumour with bladder dysfunction?

How to manage a case of diverticular tumour with bladder dysfunction?

• Incomplete bladder emptying, due to obstruction or to atonic bladder, is common. When the bladder is involved
with multifocal tumours it is better to consider Radical cystectomy to address both oncological and functional issues
unless the patient is keen to preserve his bladder and agrees to CISC, although patients should be advised against
this.

• In case of voiding dysfunction before PC, Those with IBDT only but with BOO need either TUR or BNI as appropriate
after a UDS post diverticulectomy.
Although 68, he is quite fit and wishes to discuss continent urinary diversions.
How would you counsel him about various choices?

Incontinent: Conduit or Cutaneous Ureterostomy

Continent: Orthotopic / Mitroffanoff /Mainz-II

Discuss pros & cons of each.

He opts to have ileal conduit urinary diversion.

What short and long term complications will you explain to him after this type of diversion?
Early complications:

Ischaemia

Ileus

Bowel Anastomotic leak

Urinary leak-1-3%

Bowel obstruction
Delayed complications

Para-stomal hernia 4.5-31%

Stomal retraction 0-31%
Upper Tract Deterioration 30%
UTI 0-23%
Stomal stenosis 0-15%
Bowel complications 5-10%
Stomal bleeding 0-8%
 Delayed complications

Uretero-ileal obstruction 0-14%

Redundant loop 0-13%
Stones 0-9%
Incisional hernia 3-5%
Metabolic 0-1%

# Wood DN, Allen SE, Greenwell TJ, Shah PJR. Stomal Complications of Ileal Conduit are Significantly Higher when formed for Women with Intractable
Urinary Incontinence. In press. J Urol 2004.
Madersbacher S, Schmidt J, Eberle JM et al. Long-term outcome of ileal conduit diversion. J Urol. 2003 Mar;169(3):985-90.
So we completed the surgery with a radical cystoprostatectomy + lymphadenectomy + urinary diversion. The
postoperative period passed without incidents. On 27.06.2016 the patient was being discharged. The resulting
pathology was UC pT3a N0 R0.
The majority of diverticular bladder tumours are urothelial cell cancer (TCC) although urinary stasis and inflammation in
the diverticulum are possible causative factors which one might assume would lead to squamous cell carcinoma.
Articles on diverticular bladder tumours / pathology can be found at Idrees MT et al Hum Pathol 2013;44:1223-32 and
Kong MX et al Urology 2013;82:142-7.

# Raheem OA, Besharatian B, Hickey DP. Surgical management of bladder transitional cell carcinoma in a vesicular
diverticulum: case report. Canadian Urological Association Journal. 2011 Aug;5(4):E60.

Matković A, Ferenc T, Jurjević N, Brkić F, Kavur L, Jurenec F, Mužinić D, Vidjak V. Urothelial carcinoma in a urinary
bladder diverticulum: A case report and review of the literature. Radiology Case Reports. 2023 Mar 1;18(3):1169-74.